Medulloblastoma medical therapy: Difference between revisions

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==Overview==
==Overview==
Risk stratification determines the protocol of management used for medulloblastoma patients. Radiotherapy is the mainstay of treatment for medulloblastoma. Radiotherapy for medulloblastoma must be started within the 6 weeks period following surgery. Adjunctive chemotherapy is also required for the management of certain medulloblastoma patients.<ref name="pmid22622599">{{cite journal| author=von Hoff K, Rutkowski S| title=Medulloblastoma. | journal=Curr Treat Options Neurol | year= 2012 | volume= 14 | issue= 4 | pages= 416-26 | pmid=22622599 | doi=10.1007/s11940-012-0183-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22622599  }} </ref><ref name="N"> Clinical Practice Guidelines in Oncology Central Nervous System Cancers. National Comprehensive Cancer Network.(2015) http://www.lecba-rakoviny.cz/dokumenty/NCCN_Guidelines_cns_2011.pdf Accessed on September,25 2015</ref>
Risk stratification determines the protocol of management used for medulloblastoma patients. Radiotherapy is the mainstay of treatment for medulloblastoma. Radiotherapy for medulloblastoma must be started within the 6 weeks period following surgery. Adjunctive chemotherapy is also required for the management of certain medulloblastoma patients. Recommended chemotherapeutic regimens used for the management of standard risk medulloblastoma patients include a combination of [[lomustine]], [[vincristine]], and [[cisplatin]].<ref name="pmid22622599">{{cite journal| author=von Hoff K, Rutkowski S| title=Medulloblastoma. | journal=Curr Treat Options Neurol | year= 2012 | volume= 14 | issue= 4 | pages= 416-26 | pmid=22622599 | doi=10.1007/s11940-012-0183-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22622599  }} </ref><ref name="N"> Clinical Practice Guidelines in Oncology Central Nervous System Cancers. National Comprehensive Cancer Network.(2015) http://www.lecba-rakoviny.cz/dokumenty/NCCN_Guidelines_cns_2011.pdf Accessed on September,25 2015</ref>


==Medical Therapy==
==Medical Therapy==
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<br>
<br>
{{Family tree/start}}
{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01=<div style="width: 20em; padding:1em;">'''Optimal surgical excision'''</div>}}
{{Family tree | | | | A01 | | | |A01=<div style="width: 15em; padding:1em;">'''Optimal surgical excision'''</div>}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01=<div style="width: 20em; padding:)0.5em;">'''Histopathological analysis and detailed staging'''</div>}}
{{Family tree | | | | B01 | | | |B01=<div style="width: 15em; padding:)0.5em;">'''Histopathological analysis and detailed staging'''</div>}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01=<div style="width: 20em; padding:0.5;">'''[[#Risk Stratification|Risk stratification]]'''</div>}}
{{Family tree | | | | B01 | | | |B01=<div style="width: 15em; padding:0.5;">'''[[#Risk Stratification|Risk stratification]]'''</div>}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{familytree  | | | | Y01 | | | | | | | | | | Y01=<div style="width: 20em; padding:0.5em;">'''Radiotherapy and chemotherapy'''
{{familytree  | | | | Y01 | | | | | | | | | | Y01=<div style="width: 20em; padding:0.5em;">'''Radiotherapy and chemotherapy'''
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{{familytree  | | X01 | |  X02 | | | | | | |X01='''Standard risk patients'''| X02='''High risk patients'''}}
{{familytree  | | X01 | |  X02 | | | | | | |X01='''Standard risk patients'''| X02='''High risk patients'''}}
{{familytree|boxstyle= border-top: 0px;| | A01 | |  A03 | | | | | | |A01=<div style="width: 20em; padding:1em;">
{{familytree|boxstyle= border-top: 0px;| | A01 | |  A03 | | | | | | |A01=<div style="width: 20em; padding:1em;">
'''Craniospinal radiation <u>OR</u> Concurrent chemoradiotherapy followed by [[#Chemotherapy|chemotherapeutic regimens]]'''</div>|A03=<div style="width: 20em; padding:1em;">|A03=<div style="width: 20em; padding:1em;">
'''Craniospinal radiation <br>{{or}}<br> Chemoradiotherapy followed by additional [[#Chemotherapy|chemotherapy]]'''</div>|A03=<div style="width: 15em; padding:1em;">|A03=<div style="width: 15em; padding:1em;">
'''[[#Radiation Therapy|Craniospinal radiation]] followed by chemotherapeutic regimens'''</div>}}
'''[[#Radiation Therapy|Craniospinal radiation]] followed by chemotherapy'''</div>}}
{{Family tree/end}}
{{Family tree/end}}
<br>




===Risk Stratification===
===Risk Stratification===
* Risk stratification determines the protocol of management used for medulloblastoma patients.<ref name="pmid23245832">{{cite journal| author=Bartlett F, Kortmann R, Saran F| title=Medulloblastoma. | journal=Clin Oncol (R Coll Radiol) | year= 2013 | volume= 25 | issue= 1 | pages= 36-45 | pmid=23245832 | doi=10.1016/j.clon.2012.09.008 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23245832  }} </ref><ref name="b">Medulloblastoma staging. Wikibooks(2015) https://en.wikibooks.org/wiki/Radiation_Oncology/Medulloblastoma/Staging Accessed on September, 28th 2015)</ref>
* Risk stratification determines the protocol of management used for medulloblastoma patients.<ref name="pmid23245832">{{cite journal| author=Bartlett F, Kortmann R, Saran F| title=Medulloblastoma. | journal=Clin Oncol (R Coll Radiol) | year= 2013 | volume= 25 | issue= 1 | pages= 36-45 | pmid=23245832 | doi=10.1016/j.clon.2012.09.008 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23245832  }} </ref><ref name="b">Medulloblastoma staging. Wikibooks(2015) https://en.wikibooks.org/wiki/Radiation_Oncology/Medulloblastoma/Staging Accessed on September, 28 2015)</ref>


* The table below demonstrates the risk stratification criteria for medulloblastoma patients:
* The table below demonstrates the risk stratification for medulloblastoma patients:


{| style="border: 0px; font-size: 90%; margin: 3px; width: 1000px"
{| style="border: 0px; font-size: 90%; margin: 3px; width: 1000px"
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| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
:::M1-M3 stage '''or''' presence of [[leptomeningeal]] seeding
:::M1-M3 stage '''or''' presence of [[leptomeningeal]] seeding
|-
| style="background: #CEDCED; width: 150px; padding:7px;" | '''Management Protocol'''
| style="background: #CEDCED; width: 400px; text-align:center; padding:7px;" |Craniospinal radiation  <br>{{or}}<br>  Chemoradiotherapy followed by additional chemotherapy
| style="background: #CEDCED; width: 450px; text-align:center; padding:7px;" |Craniospinal radiation followed by chemotherapy
|}
|}


===Radiation Therapy===
===Radiation Therapy===
* Radiotherapy is the mainstay of treatment for medulloblastoma.<ref name="pmid23245832">{{cite journal| author=Bartlett F, Kortmann R, Saran F| title=Medulloblastoma. | journal=Clin Oncol (R Coll Radiol) | year= 2013 | volume= 25 | issue= 1 | pages= 36-45 | pmid=23245832 | doi=10.1016/j.clon.2012.09.008 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23245832  }} </ref>
* Radiotherapy is the mainstay of treatment for medulloblastoma.
* Radiotherapy for medulloblastoma must be started within the 6 weeks period following surgery.
* [[Radiotherapy]] for medulloblastoma must be started within the 6 weeks period following surgery.
* The main radiotherapy techniques used in the management of medulloblastoma patients include:
* The main radiotherapy techniques used in the management of medulloblastoma patients include:
:* Conventional radiotherapy technique
:* Conventional radiotherapy technique
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:* Three dimensional radiotherapy technique
:* Three dimensional radiotherapy technique
* Three dimensional radiotherapy technique demonstrated better outcomes when compared to conventional and intensity modulated radiotherapy techniques.
* Three dimensional radiotherapy technique demonstrated better outcomes when compared to conventional and intensity modulated radiotherapy techniques.
* The radiotherapy dose is adjusted according to the risk stratification of medulloblastoma patients.
* The dose of radiation is adjusted according to the risk stratification of medulloblastoma patients.
* As medulloblastoma tends to spread along the cerebrospinal fluid, it is recommended to deliver a craniospinal irradiation with a boost to the posterior fossa.
* As medulloblastoma tends to spread along the [[cerebrospinal fluid]], it is recommended to deliver a craniospinal irradiation with a boost to the posterior fossa.
* Side effects of radiotherapy may include:
* Side effects of radiotherapy may include:
:* Altered cognitive level
:* Altered [[cognitive]] level
:* Deafness
:* [[Deafness]]
:* Endocrinopathies
:* Endocrinopathies<ref name="pmid23245832">{{cite journal| author=Bartlett F, Kortmann R, Saran F| title=Medulloblastoma. | journal=Clin Oncol (R Coll Radiol) | year= 2013 | volume= 25 | issue= 1 | pages= 36-45 | pmid=23245832 | doi=10.1016/j.clon.2012.09.008 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23245832  }} </ref>


===Chemotherapy===
===Chemotherapy===
* Adjunctive chemotherapy is required for the management of medulloblastoma patients.<ref name="pmid22622599">{{cite journal| author=von Hoff K, Rutkowski S| title=Medulloblastoma. | journal=Curr Treat Options Neurol | year= 2012 | volume= 14 | issue= 4 | pages= 416-26 | pmid=22622599 | doi=10.1007/s11940-012-0183-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22622599  }} </ref><ref name="N"> Clinical Practice Guidelines in Oncology Central Nervous System Cancers. National Comprehensive Cancer Network.(2015) http://www.lecba-rakoviny.cz/dokumenty/NCCN_Guidelines_cns_2011.pdf Accessed on September,25 2015</ref>
* Adjunctive chemotherapy is required for the management of medulloblastoma patients.
* Recommended chemotherapeutic regimens used for the management of standard risk medulloblastoma patients include a combination of [[lomustine]] {{and}} [[vincristine]] {{and}}   [[cisplatin]]
* Recommended chemotherapeutic regimens used for the management of '''standard''' risk medulloblastoma patients include a combination of [[lomustine]] {{and}} [[vincristine]] {{and}} [[cisplatin]]
* Other chemotheuraptic agents that may be used for the management of high risk medulloblastoma patients iclude:
* Other chemotheuraptic agents that may be used for the management of '''high''' risk medulloblastoma patients include:
:* [[Cyclophosphamide]]
:* [[Cyclophosphamide]]
:* [[Carboplatin]]
:* [[Carboplatin]]
:* [[Etoposide]]
:* [[Etoposide]]
:* [[Temozolomide]]
:* [[Temozolomide]]<ref name="pmid22622599">{{cite journal| author=von Hoff K, Rutkowski S| title=Medulloblastoma. | journal=Curr Treat Options Neurol | year= 2012 | volume= 14 | issue= 4 | pages= 416-26 | pmid=22622599 | doi=10.1007/s11940-012-0183-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22622599  }} </ref><ref name="N"> Clinical Practice Guidelines in Oncology Central Nervous System Cancers. National Comprehensive Cancer Network.(2015) http://www.lecba-rakoviny.cz/dokumenty/NCCN_Guidelines_cns_2011.pdf Accessed on September,25 2015</ref>


==References==
==References==
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Latest revision as of 02:34, 27 November 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Haytham Allaham, M.D. [2]

Overview

Risk stratification determines the protocol of management used for medulloblastoma patients. Radiotherapy is the mainstay of treatment for medulloblastoma. Radiotherapy for medulloblastoma must be started within the 6 weeks period following surgery. Adjunctive chemotherapy is also required for the management of certain medulloblastoma patients. Recommended chemotherapeutic regimens used for the management of standard risk medulloblastoma patients include a combination of lomustine, vincristine, and cisplatin.[1][2]

Medical Therapy

  • The algorithm below summarizes the management approach for medulloblastoma patients:[1][2]


 
 
 
Optimal surgical excision
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Histopathological analysis and detailed staging
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Radiotherapy and chemotherapy administered according to the risk stratification criteria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Standard risk patients
 
High risk patients
 
 
 
 
 
 
 
Craniospinal radiation
OR
Chemoradiotherapy followed by additional chemotherapy
 
Craniospinal radiation followed by chemotherapy
 
 
 
 
 
 


Risk Stratification

  • Risk stratification determines the protocol of management used for medulloblastoma patients.[3][4]
  • The table below demonstrates the risk stratification for medulloblastoma patients:
Parameters Standard Risk Group High Risk Group

Age

Patients older than 3 years of age
Patients younger than 3 years of age

Extent of previous surgical resection

<1.5 cm² residual tumor after resection
Subtotal resection or >1.5 cm² residual tumor after resection

Tumor stage

M0 stage confirmed by MRI and CSF sampling
M1-M3 stage or presence of leptomeningeal seeding
Management Protocol Craniospinal radiation
OR
Chemoradiotherapy followed by additional chemotherapy 		Craniospinal radiation followed by chemotherapy

Radiation Therapy

  • Radiotherapy is the mainstay of treatment for medulloblastoma.
  • Radiotherapy for medulloblastoma must be started within the 6 weeks period following surgery.
  • The main radiotherapy techniques used in the management of medulloblastoma patients include:
  • Conventional radiotherapy technique
  • Intensity modulated radiotherapy technique
  • Three dimensional radiotherapy technique
  • Three dimensional radiotherapy technique demonstrated better outcomes when compared to conventional and intensity modulated radiotherapy techniques.
  • The dose of radiation is adjusted according to the risk stratification of medulloblastoma patients.
  • As medulloblastoma tends to spread along the cerebrospinal fluid, it is recommended to deliver a craniospinal irradiation with a boost to the posterior fossa.
  • Side effects of radiotherapy may include:

Chemotherapy

  • Adjunctive chemotherapy is required for the management of medulloblastoma patients.
  • Recommended chemotherapeutic regimens used for the management of standard risk medulloblastoma patients include a combination of lomustine AND vincristine AND cisplatin
  • Other chemotheuraptic agents that may be used for the management of high risk medulloblastoma patients include:

References

  1. ↑ 1.0 1.1 1.2 von Hoff K, Rutkowski S (2012). "Medulloblastoma". Curr Treat Options Neurol. 14 (4): 416–26. doi:10.1007/s11940-012-0183-8. PMID 22622599.
  2. ↑ 2.0 2.1 2.2 Clinical Practice Guidelines in Oncology Central Nervous System Cancers. National Comprehensive Cancer Network.(2015) http://www.lecba-rakoviny.cz/dokumenty/NCCN_Guidelines_cns_2011.pdf Accessed on September,25 2015
  3. ↑ 3.0 3.1 Bartlett F, Kortmann R, Saran F (2013). "Medulloblastoma". Clin Oncol (R Coll Radiol). 25 (1): 36–45. doi:10.1016/j.clon.2012.09.008. PMID 23245832.
  4. ↑ Medulloblastoma staging. Wikibooks(2015) https://en.wikibooks.org/wiki/Radiation_Oncology/Medulloblastoma/Staging Accessed on September, 28 2015)


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