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Abstract

BACKGROUND:

Compared with traditional photon radiotherapy, proton radiotherapy irradiates less normal tissue and might improve health outcomes associated with photon radiotherapy by reducing toxic effects to normal tissue. We did a trial to assess late complications, acute side-effects, and survival associated with proton radiotherapy in children with medulloblastoma.

METHODS:

In this non-randomised, open-label, single-centre, phase 2 trial, we enrolled patients aged 3-21 years who had medulloblastoma. Patients had craniospinal irradiation of 18-36 Gy radiobiological equivalents (GyRBE) delivered at 1·8 GyRBE per fraction followed by a boost dose. The primary outcome was cumulative incidence of ototoxicity at 3 years, graded with the Pediatric Oncology Group ototoxicity scale (0-4), in the intention-to-treat population. Secondary outcomes were neuroendocrine toxic effects and neurocognitive toxic effects, assessed by intention-to-treat. This study is registered at ClinicalTrials.gov, number NCT00105560.

FINDINGS:

We enrolled 59 patients from May 20, 2003, to Dec 10, 2009: 39 with standard-risk disease, six with intermediate-risk disease, and 14 with high-risk disease. 59 patients received chemotherapy. Median follow-up of survivors was 7·0 years (IQR 5·2-8·6). All patients received the intended doses of proton radiotherapy. The median craniospinal irradiation dose was 23·4 GyRBE (IQR 23·4-27·0) and median boost dose was 54·0 GyRBE (IQR 54·0-54·0). Four (9%) of 45 evaluable patients had grade 3-4 ototoxicity according to Pediatric Oncology Group ototoxicity scale in both ears at follow-up, and three (7%) of 45 patients developed grade 3-4 ototoxicity in one ear, although one later reverted to grade 2. The cumulative incidence of grade 3-4 hearing loss at 3 years was 12% (95% CI 4-25). At 5 years, it was 16% (95% CI 6-29). Pediatric Oncology Group hearing ototoxicity score at a follow-up of 5·0 years (IQR 2·9-6·4) was the same as at baseline or improved by 1 point in 34 (35%) of 98 ears, worsened by 1 point in 21 (21%), worsened by 2 points in 35 (36%), worsened by 3 points in six (6%), and worsened by 4 points in two (2%). Full Scale Intelligence Quotient decreased by 1·5 points (95% CI 0·9-2·1) per year after median follow-up up of 5·2 years (IQR 2·6-6·4), driven by decrements in processing speed and verbal comprehension index. Perceptual reasoning index and working memory did not change significantly. Cumulative incidence of any neuroendocrine deficit at 5 years was 55% (95% CI 41-67), with growth hormone deficit being most common. We recorded no cardiac, pulmonary, or gastrointestinal late toxic effects. 3-year progression-free survival was 83% (95% CI 71-90) for all patients. In post-hoc analyses, 5-year progression-free survival was 80% (95% CI 67-88) and 5-year overall survival was 83% (95% CI 70-90).

INTERPRETATION:

Proton radiotherapy resulted in acceptable toxicity and had similar survival outcomes to those noted with conventional radiotherapy, suggesting that the use of the treatment may be an alternative to photon-based treatments.

FUNDING:

US National Cancer Institute and Massachusetts General Hospital. 

Author information

Yock TI1, Yeap BY2, Ebb DH3, Weyman E4, Eaton BR5, Sherry NA6, Jones RM7, MacDonald SM4, Pulsifer MB8, Lavally B3, Abrams AN9, Huang MS3, Marcus KJ10, Tarbell NJ4.

1Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA. Electronic address: tyock@partners.org.

2Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.

3Department of Pediatric Oncology, Massachusetts General Hospital, Boston, MA, USA.

4Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.

5Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA; Winship Cancer Institute of Emory University, Atlanta, GA, USA.

6Department of Pediatric Endocrinology, Massachusetts General Hospital, Boston, MA, USA.

7Department of Pediatric Neurology, Massachusetts General Hospital, Boston, MA, USA.

8Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.

9Department of Child Psychiatry, Massachusetts General Hospital, Boston, MA, USA.

10Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA.