15 maart 2005: N Engl J Med. 2005;352:978-986, 1036-1038

Na nieuwe studieresultaten lijkt het advies/protocol voor het behandelen van kinderen met een medulloblastoom - hersentumor - te zijn om alleen chemo te geven en niet te bestralen. Er zat geen significant verschil in het risico op een recidief tussen kinderen die behandeld waren met of chemo of bestraling, maar bij de kinderen die waren bestraald gaf dit wel verschil in cognitieve beschadigingen bij kinderen die geen recidief ontwikkelden maar dus op latere leeftijd meer last hadden van ernstige bijwerkingen van die bestraling. Hier het abstract van deze studie en kort commentaar erbij van Medscape

Children With Medulloblastoma Should Probably Be Treated Only With Chemotherapy After Surgery

March 11, 2005 — Children with medulloblastoma should be treated with chemotherapy alone after surgery, reserving radiotherapy for salvage or for those who relapse, according to the results of a study published in the March 10 issue of the New England Journal of Medicine.

"The prognosis for young children with medulloblastoma is poor, and survivors are at high risk for cognitive deficits," write Stefan Rutkowski, MD, from the University of Würzburg in Germany, and colleagues. "Some patients have been cured by postoperative chemotherapy alone, but survival rates after chemotherapy, with or without radiotherapy, remain unsatisfactory at 25 to 45 percent."

After surgery, 43 children received three cycles of intravenous chemotherapy with cyclophosphamide, vincristine, methotrexate, carboplatin, and etoposide and intraventricular methotrexate. If a complete remission was achieved, treatment was terminated.

Five-year progression-free survival rates were 82% ± 9% in 17 children who had complete resection, 50% ± 13% in 14 patients with residual tumor, and 33% ± 14% in 12 patients with macroscopic metastases. The five-year overall survival rates were 93% ± 6%, 56% ± 14%, and 38% ± 15%, respectively. Five-year progression-free survival rates and five-year overall survival rates in 31 patients without macroscopic metastases were 68% ± 8% and 77% ± 8%.

Independent prognostic factors for tumor relapse and survival were desmoplastic histology, metastatic disease, and age younger than two years. Treatment strategies at relapse were successful in 8 (50%) of 16 patients, and there were no major instances of unexpected toxicity. Magnetic resonance imaging revealed asymptomatic leukoencephalopathy in 19 (83%) of 23 children. After treatment, the mean IQ was significantly lower than that of healthy control subjects of similar age, but higher than that of patients in an earlier study who had received radiotherapy.

"Postoperative chemotherapy alone is a promising treatment for medulloblastoma in young children without metastases," the authors write. "Results are especially promising for patients without initial metastases, in whom radiotherapy should be reserved for salvage strategies at relapse."

The German Cancer Aid, the German Children's Cancer Foundation, and the Association of Parents for Children with Cancer, Würzburg, Germany, supported this study and some of its authors.

In an accompanying editorial, Lisa M. DeAngelis, MD, from Memorial Sloan-Kettering Cancer Center in New York, NY, note that "the severe side effects associated with neuraxis irradiation in the very young make it an unacceptable therapeutic option." However, this study showed that the use of a vigorous combination chemotherapy regimen resulted in an excellent outcome and allowed two thirds of patients who had no evidence of macroscopic metastases to avoid radiotherapy.

"We still have a long way to go in the treatment of malignant brain tumors, but progress will come only through clinical research, and we must encourage our patients to participate," Dr. DeAngelis writes.

N Engl J Med. 2005;352:978-986, 1036-1038


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