Fatal brain stem necrosis after standard posterior fossa radiation and aggressive chemotherapy for metastatic medulloblastoma.
A 3-year-old girl received conventional-dose external beam posterior fossa irradiation (5400 cGy in 30 fractions over 40 days) for good-risk medulloblastoma. Soon thereafter, she experienced an extraneural (occipital scar, cervical lymph nodes) and central nervous system (CNS) recurrence. Intensive cisplatin and cyclophosphamide chemotherapy led to rapid disappearance of the extraneural disease. Methotrexate was administered via a ventricular reservoir. After 2 months of chemotherapy, CNS toxicity progressed rapidly from ataxia to paraplegia to quadriplegia to central respiratory failure. Radiographic scans and autopsy material revealed brain stem necrosis. This unusual toxicity raises concern about the safety of aggressive systemic chemotherapy and intrathecal therapy, when given after conventional radiotherapy.
Department of Hematology/Oncology, Children's Hospital of St. Paul, Minnesota 55102.
J
J
Watterson
S C
SC
Simonton
L B
LB
Rorke
R J
RJ
Packer
T H
TH
Kim
R H
RH
Spiegel
J R
JR
Priest
D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects*; D001933:Brain Stem / Q000187:drug effects / Q000473:pathology* / Q000528:radiation effects; D002528:Cerebellar Neoplasms / Q000188:drug therapy* / Q000532:radiotherapy*; D002675:Child, Preschool; D002945:Cisplatin / Q000008:administration & dosage / Q000009:adverse effects; D003131:Combined Modality Therapy; D016371:Cranial Irradiation / Q000009:adverse effects*; D003520:Cyclophosphamide / Q000008:administration & dosage / Q000009:adverse effects; D005260:Female; D006801:Humans; D008527:Medulloblastoma / Q000188:drug therapy* / Q000532:radiotherapy*; D008727:Methotrexate / Q000008:administration & dosage / Q000009:adverse effects; D009336:Necrosis; D009364:Neoplasm Recurrence, Local / Q000188:drug therapy* / Q000532:radiotherapy*; D011882:Radiotherapy, High-Energy / Q000009:adverse effects
D003520:Cyclophosphamide; D002945:Cisplatin; D008727:Methotrexate