Efficacy of Stereotactic Conformal Radiotherapy vs Conventional Radiotherapy on Benign and Low-Grade Brain Tumors: A Randomized Clinical Trial

Importance Evidence for application of stereotactic and other conformal radiotherapy techniques in treating brain tumors is largely based on data derived from dosimetric, retrospective, or small prospective studies. Therefore, we conducted a randomized clinical trial of stereotactic conformal radiotherapy (SCRT) compared with conventional radiotherapy (ConvRT) evaluating clinically meaningful end points. Objective To compare neurocognitive and endocrine functional outcomes and survival at 5 years in young patients with residual and/or progressive benign or low-grade brain tumors treated with SCRT and ConvRT techniques. Design, Setting, and Participants This phase 3 randomized clinical trial enrolled 200 young patients (ages 3-25 years) with residual or progressive benign or low-grade brain tumors at a single center between April 2001 to March 2012. Patients were randomly allocated (1:1) to either SCRT (n = 104) or ConvRT (n = 96) arms. Interventions Patients were randomly assigned to either high-precision SCRT or ConvRT to a dose of 54 Gy in 30 fractions over 6 weeks. Main Outcomes and Measures Detailed neuropsychological and neuroendocrine assessments were performed at preradiotherapy baseline, at 6 months, and annually thereafter until 5 years on longitudinal follow-up. Change in these functional parameters was compared between the 2 arms as the primary end point and overall survival (OS) as the secondary end point. Results In total, 200 young patients (median [interquartile range] age, 13 [9-17] years; 133 males and 67 females) were enrolled. Mean full-scale or global intelligence quotient (IQ) and performance IQ scores over a period of 5 years were significantly superior in patients treated with SCRT compared with those treated with ConvRT (difference in slope = 1.48; P = .04 vs difference in slope = 1.64; P = .046, respectively). Cumulative incidence of developing new neuroendocrine dysfunction at 5 years was significantly lower in patients treated with SCRT compared with ConvRT (31% vs 51%; P = .01) while developing a new neuroendocrine axis dysfunction in patients with preexisting dysfunction in at least 1 axis at baseline was also significantly lower in the SCRT arm compared with the ConvRT arm (29% vs 52%; P = .02). Five-year OS in SCRT and ConvRT arms was 86% and 91%, respectively (P = .54). Conclusions and Relevance In young patients with residual and/or progressive benign or low-grade brain tumors requiring radiotherapy for long-term tumor control, SCRT compared with ConvRT achieves superior neurocognitive and neuroendocrine functional outcomes over 5 years without compromising survival. Trial Registration clinicaltrials.gov Identifier: NCT00517959

[1]  P. Burger,et al.  Management of pediatric intracranial low-grade gliomas: long-term follow-up after radiation therapy , 2016, Child's Nervous System.

[2]  N. Tarbell,et al.  Early Cognitive Outcomes Following Proton Radiation in Pediatric Patients With Brain and Central Nervous System Tumors. , 2015, International journal of radiation oncology, biology, physics.

[3]  K. Kurian,et al.  Current Understanding of BRAF Alterations in Diagnosis, Prognosis, and Therapeutic Targeting in Pediatric Low-Grade Gliomas , 2015, Front. Oncol..

[4]  T. Merchant,et al.  Prospective evaluation of local control and late effects of conformal radiation therapy in children, adolescents, and young adults with high-grade glioma. , 2014, Neuro-oncology.

[5]  Ching-Jen Chen,et al.  Gamma Knife surgery for craniopharyngioma: report on a 20-year experience. , 2014, Journal of neurosurgery.

[6]  M. Mehta,et al.  Hippocampal dosimetry predicts neurocognitive function impairment after fractionated stereotactic radiotherapy for benign or low-grade adult brain tumors. , 2013, International journal of radiation oncology, biology, physics.

[7]  T. Merchant,et al.  Learning and memory following conformal radiation therapy for pediatric craniopharyngioma and low-grade glioma. , 2012, International journal of radiation oncology, biology, physics.

[8]  T. Pietsch,et al.  Long-term follow-up of the multicenter, multidisciplinary treatment study HIT-LGG-1996 for low-grade glioma in children and adolescents of the German Speaking Society of Pediatric Oncology and Hematology. , 2012, Neuro-oncology.

[9]  Gilbert Vezina,et al.  Randomized study of two chemotherapy regimens for treatment of low-grade glioma in young children: a report from the Children's Oncology Group. , 2012, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[10]  C. Hawkins,et al.  Phase II study of weekly vinblastine in recurrent or refractory pediatric low-grade glioma. , 2012, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[11]  R. Sarin,et al.  Factors influencing neurocognitive outcomes in young patients with benign and low-grade brain tumors treated with stereotactic conformal radiotherapy. , 2010, International journal of radiation oncology, biology, physics.

[12]  T. Merchant,et al.  Phase II trial of conformal radiation therapy for pediatric low-grade glioma. , 2009, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[13]  T. Merchant,et al.  Late effects of conformal radiation therapy for pediatric patients with low-grade glioma: prospective evaluation of cognitive, endocrine, and hearing deficits. , 2009, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[14]  T. Merchant,et al.  Conformal radiotherapy after surgery for paediatric ependymoma: a prospective study. , 2009, The Lancet. Oncology.

[15]  J. Cox,et al.  Should randomized clinical trials be required for proton radiotherapy? , 2008, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[16]  E. Glatstein Fractionated stereotactic conformal radiotherapy following conservative surgery in the control of craniopharyngiomas , 2008 .

[17]  Dirk De Ruysscher,et al.  Proton therapy in clinical practice: current clinical evidence. , 2007, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[18]  Yan Liu,et al.  Late-occurring stroke among long-term survivors of childhood leukemia and brain tumors: a report from the Childhood Cancer Survivor Study. , 2006, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[19]  R. Mulhern,et al.  Phase II trial of conformal radiation therapy for pediatric patients with craniopharyngioma and correlation of surgical factors and radiation dosimetry with change in cognitive function. , 2006, Journal of neurosurgery.

[20]  R. Sarin,et al.  High precision conformal radiotherapy employing conservative margins in childhood benign and low-grade brain tumours. , 2005, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[21]  Maria Werner-Wasik,et al.  Randomized comparison of stereotactic radiosurgery followed by conventional radiotherapy with carmustine to conventional radiotherapy with carmustine for patients with glioblastoma multiforme: report of Radiation Therapy Oncology Group 93-05 protocol. , 2004, International journal of radiation oncology, biology, physics.

[22]  R. Mulhern,et al.  Preliminary results from a phase II trial of conformal radiation therapy and evaluation of radiation-related CNS effects for pediatric patients with localized ependymoma. , 2004, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[23]  V. Khoo,et al.  Stereotactically guided conformal radiotherapy for progressive low-grade gliomas of childhood. , 2002, International journal of radiation oncology, biology, physics.

[24]  L. Cohen,et al.  Memory Deficits among Children with Craniopharyngiomas , 2001, Neurosurgery.

[25]  H. Alheit,et al.  Patient Position Reproducibility in Fractionated Stereotactically Guided Conformal Radiotherapy Using the BrainLab® Mask System , 2001, Strahlentherapie und Onkologie.

[26]  D. Thomas,et al.  Stereotactic conformal radiotherapy for pituitary adenomas: technique and preliminary experience. , 2000, Clinical endocrinology.

[27]  H. Poulsen,et al.  Dosimetry and growth hormone deficiency following cranial irradiation of childhood brain tumors. , 1999, Medical and pediatric oncology.

[28]  A P Warrington,et al.  Optimization of stereotactically-guided conformal treatment planning of sellar and parasellar tumors, based on normal brain dose volume histograms. , 1999, International journal of radiation oncology, biology, physics.

[29]  J. Debus,et al.  Fractionated stereotactic radiotherapy (FSRT) for optic glioma. , 1999, International journal of radiation oncology, biology, physics.

[30]  R. Clayton,et al.  Radiotherapy for non-function pituitary tumours. , 1998, Clinical endocrinology.

[31]  S. Wellek,et al.  Prospective randomised trial of chemotherapy given before radiotherapy in childhood medulloblastoma. International Society of Paediatric Oncology (SIOP) and the (German) Society of Paediatric Oncology (GPO): SIOP II. , 1995, Medical and pediatric oncology.

[32]  Douglas L. Jones ICRU Report 50—Prescribing, Recording and Reporting Photon Beam Therapy , 1994 .

[33]  M Wannenmacher,et al.  Fractionated stereotactically guided radiotherapy of head and neck tumors: a report on clinical use of a new system in 195 cases. , 1993, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[34]  R. Laing,et al.  Stereotactic radiotherapy of irregular targets: a comparison between static conformal beams and non-coplanar arcs. , 1993, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[35]  M. Prados,et al.  Carboplatin and vincristine for recurrent and newly diagnosed low-grade gliomas of childhood. , 1993, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[36]  S. Kramer,et al.  Assessment of the long‐term effects of primary radiation. Therapy for brain tumors in children , 1982, Cancer.