Ory Haisraely

IntroductionWhole lung irradiation (WLI) remains a standard component of therapy for pediatric patients with lung metastases from Wilms tumor, Ewing sarcoma, and rhabdomyosarcoma. While modern techniques such as intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT) offer improved conformality and cardiac sparing compared with traditional anterior–posterior/posterior–anterior (AP/PA) fields, data on pneumonitis in children treated with these approaches are limited. We aimed to evaluate the incidence and predictors of radiation pneumonitis (RP) in pediatric patients receiving WLI with contemporary techniques.MethodsWe retrospectively reviewed pediatric patients (≤18 years) treated with WLI using IMRT, VMAT, or 3D conformal techniques at a single tertiary cancer center between 2010 and 2024. Demographic, clinical, and dosimetric variables were abstracted from electronic medical records and treatment planning systems. Associations between clinical factors, dosimetry, and RP, graded according to CTCAE v6.0, were evaluated using univariable analysis.ResultsSeventy-eight patients received WLI (IMRT: n=22; VMAT: n=33; 3D: n=23). Median age was 7 years (range, 1.5–17 years) at time of WLI, and the median prescribed WLI dose was 12 Gy (range, 10.5–15 Gy).Thoracic/lung boost irradiation was delivered in 16 patients (20.5%), with boost doses ranging from 10.5 to 36 Gy. Tissue diagnosis included Wilms tumor (n=40, 51.3%), Ewing sarcoma (n=24, 30.8%), rhabdomyosarcoma (n=13, 16.7%), and synovial sarcoma (n=1, 1.3%). Six patients (7.6%) developed RP, with only four being symptomatic (grade 2, 5.1%). No grade ≥3 events occurred. RP was significantly associated with receipt of a lung or chest wall boost (p=0.003), while mean lung dose (p=0.53), maximum lung dose (p=0.12), and V20 (p=0.09) were not. RP did not differ significantly across techniques (AP/PA: 4.5%, IMRT: 8.6%, VMAT: 9.1%; p=0.78).ConclusionRP after pediatric WLI was infrequent and mild in this cohort. Lung or chest wall boost emerged as the only variable significantly associated with pneumonitis. IMRT and VMAT were not associated with higher pneumonitis rates compared with conventional 3D/AP-PA techniques, supporting their safe use for WLI.

Background: Childhood scalp irradiation for tinea capitis (TC) increases the long-term risk of intracranial meningiomas. It remains unclear whether prior TC irradiation affects meningiomas’ response to stereotactic radiosurgery (SRS). We compared TC-irradiated and sporadic meningiomas treated with SRS. Methods: Among 539 meningioma patients treated with SRS from 2010 to 2023, 204 met criteria for volumetric analysis (median follow-up 64.6 months, interquartile range [IQR] 32.8-107.8). Of these, 61 (29.9%) had childhood scalp irradiation for TC, while 143 (70.1%) had no prior cranial irradiation. Tumor volumes were measured on T1-weighted gadolinium-enhanced MRI baseline and at last follow-up, or prior to surgery. Treatment response was assessed as percent volume change, as a binary study-defined “good response” (≥29% reduction), and RANO-aligned categories. Predictors of response and surgical intervention were evaluated using multivariable regression. Results: Tinea capitis-irradiated patients were older (median 67.6 vs 62.8 years, P < .001) and more commonly had multiple meningiomas (73.8% vs 11.9%, P < .001) than nonirradiated patients. Baseline tumor volume was similar between groups (P = .516), as was the need for surgical resection (P = .535). Multivariable analysis showed that TC irradiation independently predicted poorer volumetric response (a 38.7% relative volume change, P = .026) and a lower likelihood of achieving the study-defined “good response,” although this was not statistically significant. Tinea capitis irradiation was not associated with progression-free survival. Conclusions: Childhood TC irradiation-related meningiomas are a distinct subgroup characterized by multifocality and reduced volumetric response to SRS. These findings suggest a potentially treatment-resistant phenotype, supporting the need for individualized management.

Introduction: Central nervous system solitary fibrous tumors (cSFTs) are rare, accounting for less than 1% of central nervous system tumors. Treatment guidelines are limited, especially for frail or elderly patients. Gross total resection followed by radiotherapy is recommended for higher grade cases, but the role of hypofractionated (HF) radiotherapy versus standard fractionation (SF) in this population remains unclear. This study evaluates outcomes of HF compared to SF in frail patients with cSFT. Methods: A retrospective analysis of 51 frail patients (age >65, Karnofsky performance status [KPS] <80) with cSFT treated from 2015 to 2023 was performed. Patients received either HF (21 patients) or SF (30 patients). Data extracted included demographics, tumor characteristics, surgical outcomes, radiation regimens, and oncologic outcomes. Descriptive and survival analyses were conducted using the Kaplan-Meier methods, with multivariable analysis via Cox regression models to assess factors influencing local control and overall survival. Results: The median follow-up was 19 months (11–55 months). HF regimens varied from 35–48 Gy in 10–15 fractions, while SF was predominantly 54–60 Gy in 28–30 fractions. Local control was achieved in 76.2% of HF and 80% of SF patients (p = 0.154). No statistical difference in overall survival was observed between HF (18 months) and SF (18 months, p = 0.54). Higher tumor grade (HR = 3.5, p = 0.021) and incomplete resection (HR = 0.72, p = 0.035) negatively impacted local control. KPS ≤50 was associated with reduced survival (HR = 2.3, p = 0.035). Conclusions: HF radiotherapy appears feasible and safe for frail patients with cSFT, providing comparable outcomes to SF. The reduced treatment burden of HF may benefit patients with limited performance status. Further research is needed to guide optimal treatment approaches for this unique population. HF vs. SF radiotherapy in frail and elderly patients with cSFTs.

Whole-brain radiotherapy (WBRT) remains a standard treatment for extensive brain metastases, providing symptom relief and improved progression-free survival (PFS). Re-irradiation is often necessary for recurrent disease, particularly in the cerebellum, which accounts for 10–20% of cases. Cerebellar metastases are associated with distinct symptoms and poorer prognoses compared to supratentorial lesions. This study evaluates the outcomes of cerebellar-only re-irradiation for brain metastases, with or without stereotactic radiosurgery (SRS) for supratentorial lesions. A retrospective analysis of 56 patients treated between 2017 and 2023 was conducted. Patients received cerebellar-only re-irradiation after WBRT. Symptom improvement was assessed three months post-treatment. Statistical analyses included t-tests, Mann-Whitney U tests, and multivariable logistic regression. The cohort’s median age was 53 years, with breast cancer being the most prevalent histology (71%). Symptom improvement occurred in 75% of patients, with relief rates of 84.6% for nausea, 80% for headache, and 58.3% for dizziness. Dexamethasone use decreased in 76.3% of cases. Median PFS was 39.2%, with a six-month overall survival of 50%. Only 1.7% of patients developed symptomatic radiation necrosis. Factors associated with symptom improvement included younger age, extended intervals between WBRT and re-irradiation, and higher equivalent dose in 2 Gy fractions (EQD2). Cerebellar-only re-irradiation is an effective, low-toxicity option for recurrent cerebellar metastases. This approach warrants further validation in prospective studies, particularly in comparison to SRS.

Introduction: Anaplastic meningiomas, categorized as WHO grade 3 tumors, are rare and highly aggressive, accounting for 1-2% of all meningioma cases. Despite aggressive treatment, including surgery and Radiation, they exhibit a high recurrence rate and poor survival outcomes. The aggressive histopathological features emphasize the urgent need for effective management strategies. Methods: A retrospective multi-institutional analysis was conducted on patients with recurrent anaplastic meningioma who underwent re-irradiation between 2017 and 2023. Clinical, dosimetric, and outcome data were collected and analyzed, focusing on local control, progression free survival and treatment-related adverse events. Results: Thirty-four cases were analyzed, with a median follow-up 11 months after re-irradiation. Progression-free survival at 12 months was 61.9%, with higher doses correlating with better outcomes. Concomitant Bevacizumab improves progression-free survival and reduces the risk of radiation necrosis. CDKN2A homozygote deletion correlated with a higher risk of local failure. Symptomatic radiation necrosis occurred in 20.5% of cases, but its incidence was lower with concomitant Bevacizumab treatment. Conclusion: Re-irradiation presents a viable option for recurrent anaplastic meningioma despite the associated risk of radiation necrosis. Higher doses with concomitant Bevacizumab improve clinical outcomes and reduce toxicity. Individualized treatment approaches are necessary, emphasizing the importance of further research to refine management strategies for this challenging disease.