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Table of Contents    
CASE REPORT
Year : 2020  |  Volume : 68  |  Issue : 1  |  Page : 189-191

India's First Proton Beam Therapy Pediatric Patient


1 Department of Radiation Oncology, Apollo Proton Cancer Center, Chennai, Tamil Nadu, India
2 Department of Medical Physics, Apollo Proton Cancer Center, Chennai, Tamil Nadu, India
3 Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
4 Department of Radiation, Apollo Proton Cancer Center, Chennai, Tamil Nadu, India

Date of Web Publication28-Feb-2020

Correspondence Address:
Dr. Rakesh Jalali
Medical Director and Head of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, 4/661, Dr Vikram Sarabai Instronic Estate 7th St, Tharamani, Chennai - 600 096, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.279686

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 » Abstract 


We recently started India's first proton beam therapy facility. Proton beam therapy because of its unique physical characteristics of minimal exit dose has an unequivocal dosimetric superiority over high-end photon/standard X-ray beam therapy and is particularly advantageous in growing children with curable cancers in view of their very high probability of long-term cures. We hereby report a case of a 7-year-old boy with a craniopharyngioma which had been subtotally resected and was subsequently treated with modern pencil beam proton therapy under high-precision image guidance. This is the first ever child ever to be treated with proton therapy in India.


Keywords: Craniopharyngioma, intensity-modulated proton beam therapy, proton beam therapy
Key Messages: Proton beam therapy offers significant benefit in all paediatric brain tumors. Proton beam therapy has a potential to further improve the quality of life of paediatric brain tumor patients in the long run, thus improving their quality of life.


How to cite this article:
Tonse R, Noufal M P, Deopujari CE, Jalali R. India's First Proton Beam Therapy Pediatric Patient. Neurol India 2020;68:189-91

How to cite this URL:
Tonse R, Noufal M P, Deopujari CE, Jalali R. India's First Proton Beam Therapy Pediatric Patient. Neurol India [serial online] 2020 [cited 2020 Mar 28];68:189-91. Available from: http://www.neurologyindia.com/text.asp?2020/68/1/189/279686




Radiation therapy (RT) forms an integral component in the management of several benign brain tumors. Craniopharyngiomas are one of the most common tumors arising from the pituitary region apart from pituitary adenomas and are seen mainly in children.[1] Conservative surgery and high precision modern conformal radiation therapy are the standard of care in the management of these tumors.[2] The radiation treatment for brain tumors continues to undergo rapid technologic advances with the implementation of highly precise conformal RT techniques being increasingly adopted to minimize the irradiation to the normal brain without compromising radiotherapy doses essential for tumor control. While the recent RT techniques have mitigated several of the long-term challenges, issues such as neuro-cognitive decline continue to exist.[3] As a result, proton beam therapy because of its unique physical characteristics of rapid dose fall, resulting in the reduction of radiation dose to critical structures is increasingly being used as the treatment of choice for pediatric benign brain tumors.[4] We would like to report the nation's first child diagnosed with craniopharyngioma being treated with modern contemporary proton beam therapy.


 » Case History Top


A 7-year old boy presented with complaints of headache, vomiting for six months in 2017. MRI MRI of the brain and CT of the brain showed a solid cystic lesion in the supra-sellar lesion. He first underwent cystic decompression with the ommaya reservoir followed by trans-sphenoidal endoscipic excision. He underwent redo-endoscopic trans-sphenoidal excision of the residual tumor after six days and was discharged. The histopathology revealed it to be craniopharyngioma. He was started on hormonal support and kept on regular follow-up. MRI after 3 months revealed mild residual disease present of the size of 2 × 1.9 × 1.3 cm. He was kept under close follow-up. He started having complaints of headache and an MRI repeated after nine months showed an increase in the size of the residual disease. He came to us to seek an opinion regarding proton beam therapy. Because of the residual disease present and clinical symptoms, he was offered to undergo treatment with proton beam therapy.

The preplanning audit was done among a physician, physicist, and radiation therapy technicians, and the patient positioning was planned. After proper immobilization using customized headrest and 3 clamps open face mold, radiotherapy planning Plain CT scan acquired, which was registered with volumetric planning MRI sequences, for delineation of target and organs at risk (OARs). Preradiotherapy neurocognitive assessment of patient was done by a clinical pediatric psychologist. Preradiotherapy, endocrine evaluation, and the visual assessment were also done as a baseline. After finalization of contours, intensity-modulated proton therapy planning was done to dose 54 GyE in 30 fractions. A 3-field plan was finalized [Figure 1] after quality assurance check as per institutional protocol. Significant reduction of the radiation dose to critical structures such as hippocampi and cochlea was observed. A QA MR and CT imaging were done in between treatment to assess the cyst volume. No change in cyst volume was noticed in either QA imaging. The radiation treatment plan was overlaid on the MRI and CT scan and the results of QA plans were satisfactory. The patient tolerated treatment well and did not have any interruptions during treatment. He came to us for follow-up after six weeks where we repeated an MRI, neuro-cognitive testing, vision testing, and hormonal evaluation. The MRI was suggestive of good response [Figure 2] and he is being kept on regular follow-up.
Figure 1: Representative images of a comparative helical tomotherapy plan (a) with intensity-modulated proton beam therapy plan (b) highlighting the critical structures saved (hippocampus) (c) Dose- volume histogram

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Figure 2: (a) Axial T2 image preproton beam therapy. (b) Axial T1 with contrast image preproton beam therapy. (c) Axial T2 image post 6 weeks proton beam therapy. (d) Axial T1 with contrast image preproton beam therapy

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 » Discussion Top


Radiation treatment for brain tumors continues to undergo rapid technologic advances with the implementation of highly precise conformal radiotherapy techniques. Jalali et al. in a large phase III randomized trial, in which the majority of cases diagnosed with craniopharyngioma, demonstrated that with modern technology tight radiation margins around the tumor can be achieved without compromising on local control and overall survival and demonstrating superior neurocognitive (29% vs 52%; P = 0.02) and neuroendocrine functional (31% vs 51%; P = 0.01) outcomes at 5 years in favor of high-precision fractionated stereotactic conformal RT over conventional RT.[5] In a comparison of proton and photon radiotherapy for pediatric brain tumors, superior outcomes have been demonstrated in several retrospective and prospective series.[6] In addition, relatively small critical normal organs, such as the hypothalamus-pituitary axis, hippocampus, and cochlea, can be preserved significantly with proton therapy when not adjacent to the primary tumor volume. These advantages can result in preservation of intelligence, endocrine function, and hearing. Early and mature data from multiple institutions consistently demonstrate that proton therapy is an effective and well-tolerated radiation therapy modality for patients with craniopharyngioma.[7],[8],[9],[10],[11] Fitzek et al. reported on 15 patients was one of the initial studies on the clinical use of proton therapy for craniopharyngioma; these data provide information on late toxicity, with local control rates at 5 and 10 years to be 93% and 85%, respectively.[8] All patients were able to live independently and none had tumor progression.

With the evolution of proton beam therapy, there have been several technical refinements in the proton machinery and methods of delivery in the last few years, which includes incorporation of pencil beam scanning techniques with a resultant extremely highly conformal intensity-modulated proton beam therapy (IMPT), robust and Monte Carlo optimization, and routine use of modern cone beam based highly precise daily image guidance. All these are the significant advances seen in modern proton therapy centers, which have considerable potential to further enhance the value of this technology.

We have shared our experience of the first child treated at our centers and understand that a follow-up of 6 weeks is too short to comment regarding treatment response. We are collecting the quality of life data, neuro-cognitive evaluation, and endocrine data of all our pediatric patients prospectively and will be presenting the case series in the subsequent manuscript.


 » Conclusion Top


Globally, proton beam therapy is marching to a position of preeminence in the treatment of pediatric brain tumor due to its unprecedented precision for more focused targeting of tumors, less damage to healthy tissue around the tumor, and a lesser chance of hormonal deficiencies and intellectual impairment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Winkfield KM, Tsai HK, Yao X, Larson E, Neuberg D, Pomeroy SL, et al. Long-term clinical outcomes following treatment of childhood craniopharyngioma. Pediatr Blood Cancer 2011;56:1120-6.  Back to cited text no. 1
    
2.
Schoenfeld A, Pekmezci M, Barnes MJ, Tihan T, Gupta N, Lamborn KR, et al. The superiority of conservative resection and adjuvant radiation for craniopharyngiomas. J Neurooncol 2012;108:133-9.  Back to cited text no. 2
    
3.
Merchant TE, Conklin HM, Onar-Thomas A, Boop FA. Longitudinal models of cognitive function in children with craniopharyngioma demonstrate the effect of radiation dose. Int J Radiat Oncol Biol Phys 2013;87:S38-S9.  Back to cited text no. 3
    
4.
Main C, Dandapani M, Pritchard M, Dodds R, Stevens SP, Thorp N, et al. The effectiveness and safety of proton beam radiation therapy in children with malignant central nervous system (CNS) tumours: Protocol for a systematic review. Syst Rev 2016;5:124.  Back to cited text no. 4
    
5.
Jalali R, Gupta T, Goda JS, Goswami S, Shah N, Dutta D, et al. Efficacy of stereotactic conformal radiotherapy vs conventional radiotherapy on benign and low-grade brain tumors: A randomized clinical trial. JAMA Oncol 2017;3:1368-76.  Back to cited text no. 5
    
6.
Gondi V, Yock TI, Mehta MP. Proton therapy for paediatric CNS tumours-improving treatment-related outcomes. Nat Rev Neurol 2016;12:334-45.  Back to cited text no. 6
    
7.
Confer ME, McNall-Knapp R, Gross N. Proton radiation therapy for pediatric craniopharyngiomas: Initial results. Int J Radiat Oncol Biol Phys 2012;84:S635.   Back to cited text no. 7
    
8.
Indelicato DJ, Rotondo R, Flampouri S, Kowalchik K, Sandler E, Aldana P, et al. Proton therapy for craniopharyngioma: Early clinical outcomes. Int J Radiat Oncol Biol Phys 2012;84:S634.  Back to cited text no. 8
    
9.
Fitzek MM, Linggood RM, Adams J, Munzenrider JE. Combined proton and photon irradiation for craniopharyngioma: Long-term results of the early cohort of patients treated at Harvard cyclotron laboratory and Massachusetts general hospital. Int J Radiat Oncol Biol Phys 2006;64:1348-54.  Back to cited text no. 9
    
10.
Winkfield KM, Linsenmeier C, Yock TI, Grant PE, Yeap BY, Butler WE, et al. Surveillance of craniopharyngioma cyst growth in children treated with proton radiotherapy. Int J Radiat Oncol Biol Phys 2009;73:716-21.  Back to cited text no. 10
    
11.
Luu QT, Loredo LN, Archambeau JO, Yonemoto LT, Slater JM, Slater JD. Fractionated proton radiation treatment for pediatric craniopharyngioma: Preliminary report. Cancer J 2006;12:155-9.  Back to cited text no. 11
    


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