Hyperfractionated radiation therapy for brain-stem glioma: a Phase I–II trial

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✓ Fifty-three patients (19 adults and 34 children) harboring brain-stem glioma were treated with hyperfractionated radiation therapy (100 cGy twice a day, 5 days/wk, to a total dose of 7200 cGy). For the entire group, the median time to tumor progression (TTP) was 59 weeks (adults 66 weeks, children 44 weeks) and the median survival time was 74 weeks (adults 92 weeks, children 64 weeks). Statistically significant prognostic factors associated with a decrease in TTP and median survival times (adults < children) were: patient's age, a clinical history of less than 2 months, widespread brain-stem dysfunction, and a diffuse tumor as seen on magnetic resonance imaging. A finding of glioblastoma multiforme at histological analysis was associated with a statistical trend toward poorer survival, but in general tumor histology was not predictive of outcome. No evidence of an increase in acute or delayed radiation toxicity was seen with this fractionation schedule and total dose. This study suggests that hyperfractionation prolongs the TTP and survival time for many patients with brain-stem glioma. However, there remains a group of patients who are only moderately helped by this technique and for whom more aggressive treatment is warranted.

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Figures

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    Outcome of hyperfractionated radiation therapy for brain-stem glioma*

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    Survival data for 53 patients with brain-stem glioma (19 adults and 34 children).

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    Outcome vs. tumor location in patients with hyperfractionated radiation therapy*

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    Time to tumor progression (left) and survival time (right) in patients with focal or diffuse brain-stem glioma.

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    Time to tumor progression (left) and survival time (right) in children with focal or diffuse brain-stem glioma.

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    Time to tumor progression (left) and survival time (right) in adults with focal or diffuse brain-stem glioma.

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    Outcome vs. symptom onset in patients with hyperfractionated radiation therapy*

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    Time to tumor progression (left) and survival time (right) in patients with brain-stem glioma, correlated with the duration of symptoms.

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    Magnetic resonance images in a 6-year-old girl with a clinical history of less than 2 months, bilateral cranial-nerve long-tract and cerebellar dysfunction, and a diffuse tumor. A: Sagittal T1-weighted image of diffuse brain-stem glioma obtained before hyperfractionated radiation therapy B: Same image at completion of a course of 7200 cGy of hyperfractionated radiation therapy. The anatomy of the brain stem is nearly normal. C: Axial T2-weighted image before radiation therapy. D: Same image after completion of a course of 7200 cGy of hyperfractionated radiation therapy.

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    Magnetic resonance (MR) images in a 14-year-old boy with a history of hydrocephalus for 2 years before the diagnosis of a brain-stem glioma was made. Worsening of extraocular motion and headaches resulted in his reevaluation. Left: A sagittal T1-weighted MR image showing collicular plate tumor compromising the fourth ventricle and cerebellum with extension into the posterior thalamus. Histological analysis showed the lesion to be an anaplastic astrocytoma. Center: A sagittal T1-weighted MR image after 2 weeks of hyperfractionated radiation therapy. There is evidence of acute hemorrhage into the tumor bed. Right: A sagittal T1-weighted MR image 3 years after hyperfractionated radiation therapy. There remains only an irregular area in the collicular plate. There is no abnormal signal and no compression of the cerebellum. The aqueduct is not visualized.

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