title: Hyperfractionated craniospinal radiation therapy for primitive neuroectodermal tumors: early results of a pilot study.
abstract: OBJECTIVE
  To report the early results of hyperfractionated craniospinal radiation therapy with and without adjuvant chemotherapy for primitive neuroectodermal brain tumors (PNETs).
  
  
  METHODS
  Thirty-nine patients with PNETs were classified as good-risk (23) or poor-risk (16), based on postoperative magnetic resonance imaging and a cytological examination of cerebrospinal fluid. All patients received hyperfractionated craniospinal radiation therapy; poor-risk patients subsequently received adjuvant chemotherapy with cisplatin, lomustine, and vincristine. The first six patients received 72 Gy to the primary tumor site and 24 Gy to the rest of the craniospinal axis. Subsequent patients received 30 Gy to the craniospinal axis.
  
  
  RESULTS
  During a median of 1.9 years of follow-up (range 4 months to 3.5 years), there have been ten treatment failures in 39 patients, five in the good-risk group and five in the poor-risk group. Three failures occurred in the primary tumor site in areas that received 72 Gy; two were in poor-risk patients with residual disease after surgery; one was in a good-risk patient who had a gross total resection. Three failures occurred in the spine and craniospinal fluid of patients treated with 24 Gy. Four occurred in areas treated to 30 Gy; two of these were in areas thought to be undertreated because of treatment planning errors. Adjuvant chemotherapy was difficult to give to poor-risk patients because of poor bone marrow recovery, even with relatively low doses of lomustine (75 mg/m2).
  
  
  CONCLUSIONS
  We think a dose of 24 Gy to the craniospinal axis is inappropriate because three of the six patients who received it had treatment failures outside the primary site. Whether 30 Gy is an appropriate dose for good-risk patients is still unclear. Even after a dose of 30 Gy, chemotherapy was difficult to give; this potentially limits the impact of adjuvant chemotherapy in poor-risk patients. Further follow-up is necessary to evaluate the use of hyperfractionated radiation therapy alone or with chemotherapy in patients with PNETs.
authors.affiliation: Neuro-Oncology Service, School of Medicine, University of California, San Francisco.
authors.forename: M D
authors.initials: MD
authors.lastname: Prados
authors.forename: W M
authors.initials: WM
authors.lastname: Wara
authors.forename: M S
authors.initials: MS
authors.lastname: Edwards
authors.forename: P H
authors.initials: PH
authors.lastname: Cogen
mesh_terms: D000293:Adolescent; D000328:Adult; D001932:Brain Neoplasms / Q000532:radiotherapy*; D017024:Chemotherapy, Adjuvant / Q000009:adverse effects; D002648:Child; D002675:Child, Preschool; D016371:Cranial Irradiation; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018242:Neuroectodermal Tumors, Primitive / Q000532:radiotherapy*; D010865:Pilot Projects; D011879:Radiotherapy Dosage; D013116:Spinal Cord / Q000528:radiation effects*