An Evolution in the Use of Radiation

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CR received 2 further cycles

Others received 2 cycles intensified by cyclophosphamide

High initial response rates (78% CR) but 50% of patients experience disease progression or recurrence.

Treatment related mortality approximates 10%

Salvage with reinduction cyclophosphamide and CSI still results in 76% 2 yr survival.

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Approaches to limiting toxicity

Lower total radiation dose while maintaining irradiation volume

Decrease the volume while maintaining dose and use chemotherapy as a substitute for extended-field

Decrease both volume and dose without the use of chemotherapy

Use systemic chemotherapy with both volume and dose reduction

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Radiotherapy of localized intracranial germinoma

Rogers et al reported in Lancet Oncology in July of 2005 on a review of the “modern” literature (published) since 1988 to compare patterns of disease relapse, and cure rates after CSI, reduced –volume irradiation and focal radiation alone.

Most comprehensive review on patterns of relapse after radiotherapy alone for localized intracranial germinomas.

Reported on series published after 1988.

Excluded series

Recurrent disease

Spinal staging not reported

Radiotherapy volumes were not specified

Relapse pattern was not defined

Chemotherapy was used

Patients without histologic verification

Patients with evidence of spinal dissemination

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Radiotherapy of localized intracranial germinoma

Patient Classification

Craniospinal radiotherapy

Whole-brain or whole ventricular radiotherapy plus boost

Radiation of primary tumor alone

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Reduced Volume Irradiation

Whole Brain RT

Whole-ventricular RT

Focal Radiotherapy

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Reduced Volume Irradiation

Whole Brain RT

Whole-ventricular RT

Focal Radiotherapy

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Reduced Volume Irradiation

DVH Brain

WB and WV include dose to 24 Gy followed by a 16 Gy focal boost

Focal RT single 40Gy treatment plan

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Radiotherapy of localized intracranial germinoma

788 patients included

Weighted median age was 13.5 years

Median follow up 6.4 years

Median radiation dose to primary tumor 48.6 Gy.

Relapse rates subdivided into categories based on first relapse

Local with or without other sites