Clinical studyPrognostic role of chemotherapy, radiotherapy dose, and extent of surgical resection in adult medulloblastoma
Introduction
Although medulloblastoma is one of the most common primary central nervous system tumors in children, it is relatively rare in adults [1]. As compared to pediatric cases, adult medulloblastoma (AM) is characterized by distinct phenotypes, molecular characteristics, patterns of spread, and prognosis [2], [3], [4], [5].
Despite the distinctions between pediatric and AM, many aspects of AM management are extrapolated from the pediatric setting [3], such as the general paradigm of surgical resection followed by radiotherapy (RT) and chemotherapy. The National Comprehensive Cancer Network (NCCN) recommends adjuvant craniospinal RT (CSI) with or without chemotherapy for standard-risk patients, and CSI with concurrent and adjuvant chemotherapy for high-risk patients [6].
Given that AM is a rare neoplasm, it remains unknown whether the extent of resection is a prognostic factor. In pediatric medulloblastoma, emerging data suggest that the degree of resection does not predict for outcomes in most molecular subtypes [7], but this notion has not been well-studied in AM. Additionally, the role of chemotherapy in AM remains relatively under-studied; small reports have produced conflicting results [8], [9], [10]. Given the questionable benefit, some prospective studies have attempted to deliver sequential RT and chemotherapy in efforts to avoid potentially additive toxicities from concurrent therapy [11], [12], [13]. The comparative efficacy of sequential versus concurrent chemoradiotherapy (CRT) is also not well-characterized. Lastly, the dose of CSI in adults is also unresolved, and largely remains extrapolated from pediatric patients as well. Although AM is a rare neoplasm, the goal of the present study was to better address these notions with high-volume data.
Section snippets
Materials & methods
The NCDB is a joint project of the Commission on Cancer (CoC) of the American College of Surgeons and the American Cancer Society, which consists of de-identified information regarding tumor characteristics, patient demographics, and survival for approximately 70% of the US population [14]. All pertinent cases are reported regularly from CoC-accredited centers and compiled into a unified dataset, which is then validated. The data used in the study were derived from a de-identified NCDB file
Results
Supplemental Fig. 1 depicts a flow diagram of patient selection. Altogether, 1144 patients were included (Table 1). Of the 613 patients with available surgical information, 242 (39%) did not undergo surgery, 277 (45%) underwent subtotal resection (STR), and 94 (15%) had gross total resection (GTR). A total of 428 (37.4%) did not receive chemotherapy, 348 (30.4%) received sequential CRT, and 368 (32.2%) underwent concurrent CRT. Of the 711 patients with available RT dose information, 202 (28.4%)
Discussion
Because AM is a rare malignancy, the vast majority of existing studies are generally of smaller sample sizes. This study of a large, contemporary national database revealed no apparent influence of the degree of resection or CSI dose on OS. Chemotherapy may be associated with improved OS in select patients, although it appeared that concurrent CRT did not offer additional benefits with sequential CRT.
Although several smaller retrospective reports demonstrated improved outcomes with greater
Conclusions
This study of a large, contemporary national database of adult medulloblastoma revealed no apparent influence of the degree of resection or CSI dose on OS. Chemotherapy may be associated with improved OS in select patients, although it appeared that concurrent CRT did not offer additional benefits with sequential CRT. These results do not imply causation, and careful patient selection is still recommended.
Funding
There was no research support for this study.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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