Pediatric disorders: Viewpoint—fractionated radiotherapy

Abstract

There has been an evolution in multimodality therapy for children with brain tumors and the use of fractionated irradiation during the past 20 years. This highlights the benefit of pediatric clinical trials and data-driven research. There is strong evidence that the primary role of radiation therapy has been secured for low-grade glioma and craniopharyngioma and that adjuvant irradiation is pivotal in achieving high rates of tumor control for children with ependymoma, medulloblastoma, and other tumors. The era of 3-dimensional (3D) radiation therapy planning has provided valuable information about disease control and patterns of failure and the contribution of radiation dose and the irradiated volume to the risk of complications. Newer methods of irradiation appear to preserve function in most patients and overall the rate of treatment complications has been acceptable leading to the use of irradiation even in the very young. The current level of success has invited reappraisal of the use of other modalities and the sequencing of treatment as investigators continue to investigate whether the targeted volume for radiotherapy may be further reduced without affecting the rate or pattern of failure. Based on 3D dose-volume data, investigators are now able to estimate the risk of neurological, endocrine, and cognitive effects in children with brain tumors and this information is being used to optimize therapy. Recent trials have been designed with the combined goal of improving disease control and eliminating side effects; future trials will take advantage of tumor biology to improve risk-stratification and test the role of novel agents.​