Feasibility of Dose Escalation in Patients With Intracranial Pediatric Ependymoma

Fatima Tensaouti, Anne Ducassou, Léonor Chaltiel, Stéphanie Bolle, Jean Louis Habrand, Claire Alapetite, Bernard Coche-Dequeant, Valérie Bernier, Line Claude, Christian Carrie, Laetitia Padovani, Xavier Muracciole, Stéphane Supiot, Aymeri Huchet, Julie Leseur, Christine Kerr, Grégorie Hangard, Albert Lisbona, Farid Goudjil, Régis Ferrand, Anne Laprie, Fatima Tensaouti, Anne Ducassou, Léonor Chaltiel, Stéphanie Bolle, Jean Louis Habrand, Claire Alapetite, Bernard Coche-Dequeant, Valérie Bernier, Line Claude, Christian Carrie, Laetitia Padovani, Xavier Muracciole, Stéphane Supiot, Aymeri Huchet, Julie Leseur, Christine Kerr, Grégorie Hangard, Albert Lisbona, Farid Goudjil, Régis Ferrand, Anne Laprie

Abstract

Background and purpose: Pediatric ependymoma carries a dismal prognosis, mainly owing to local relapse within RT fields. The current prospective European approach is to increase the radiation dose with a sequential hypofractionated stereotactic boost. In this study, we assessed the possibility of using a simultaneous integrated boost (SIB), comparing VMAT vs. IMPT dose delivery. Material and methods: The cohort included 101 patients. The dose to planning target volume (PTV59.4) was 59.4/1.8 Gy, and the dose to SIB volume (PTV67.6) was 67.6/2.05 Gy. Gross tumor volume (GTV) was defined as the tumor bed plus residual tumor, clinical target volume (CTV59.4) was GTV + 5 mm, and PTV59.4 was CTV59.4 + 3 mm. PTV67.6 was GTV+ 3 mm. After treatment plan optimization, quality indices and doses to target volume and organs at risk (OARs) were extracted and compared with the standard radiation doses that were actually delivered (median = 59.4 Gy [50.4 59.4]). Results: In most cases, the proton treatment resulted in higher quality indices (p < 0.001). Compared with the doses that were initially delivered, mean, and maximum doses to some OARs were no higher with SIB VMAT, and significantly lower with protons (p < 0.001). In the case of posterior fossa tumor, there was a lower dose to the brainstem with protons, in terms of V59 Gy, mean, and near-maximum (D2%) doses. Conclusion: Dose escalation with intensity-modulated proton or photon SIB is feasible in some patients. This approach could be considered for children with unresectable residue or post-operative FLAIR abnormalities, particularly if they have supratentorial tumors. It should not be considered for infratentorial tumors encasing the brainstem or extending to the medulla.

Keywords: boost; ependymoma; intracranial; photon therapy; proton therapy; treatment planning.

Figures

Figure 1
Figure 1
Doses to OARs and near-maximum D2% (top) and mean doses (bottom) as a % of the prescribed target dose. Infratentorial tumor (left panel) and supratentorial tumor (right panel).
Figure 2
Figure 2
Median of mean and near-maximum doses (cGy) to OARs received at treatment (tt) with SIB-VMAT or SIB-PBS in the case of infratentorial tumor. IER, right inner ear; IEL, left inner ear; BS MD, brainstem mean dose; BS NMD, brainstem near-maximum dose; PG, pituitary gland; HR, right hippocampus; HL, left hippocampus; ST, standard treatment.
Figure 3
Figure 3
Median of mean and near-maximum doses (cGy) to OARs received at treatment (tt) with SIB-VMAT or SIB-PBS in the case of supratentorial tumor. BS MD, brainstem mean dose; BS NMD, brainstem near-maximum dose; PG, pituitary gland; HR, right hippocampus; HL, left hippocampus; ST, standard treatment.

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