A Need for Guidelines

The need for clinical practice guidelines for children undergoing vertebral or perivertebral radiotherapy for cancer led the European Society for Paediatric Oncology’s (SIOPE) radiotherapy working group, representing radiation oncologists from 11 European countries, to undertake a review of the available evidence base.1 They published their consensus recommendations for managing pediatric vertebral radiotherapy dose in The Lancet Oncology.1

The consensus document emphasizes the importance of vertebral radiotherapy doses being homogeneously delivered to children — particularly among “children who have not yet finished the pubertal growth spurt,” reported lead investigator Bianca A. Hoeben, PhD, of the Department of Radiation Oncology at Radboud University Medical Center in the Netherlands, and colleagues.1  


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Pediatric radiation oncology teams “must consider late effects when planning radiotherapy of a spinal or paravertebral target volume,” the authors emphasized.1 “However, the severity of treatment-related damage is challenging to predict as the damage can be affected by many factors, including total radiation dose, fractionation schedule, treatment volume, age of the child, symmetry of the delivered dose over vertebrae, developmental status of the irradiated growth plates, and other treatments such as chemotherapy or surgery, as well as inherent factors such as endocrine abnormalities and bone growth aberrations [associated with] tumor location.”

The SIOPE working group’s recommendations include acceptable dose gradients for children of different age groups when dose fall-off or inhomogeneities cannot be avoided within vertebrae.

“We recommended that between the ages of 0 years and around 6 years, partial irradiation of the spinal column should be limited to approximately seven thoracic vertebrae, particularly for doses of more than 20 Gy, if it is possible to do so without compromising target volume coverage,” Dr Hoeben and colleagues reported.1

The available research base remains relatively immature. The SIOPE radiotherapy working group recommendations therefore represent a tentative framework guideline that “can be reevaluated and updated as more reliable data become available,” the investigators wrote.1

The SIOPE radiotherapy working group recommendations are limited to radiotherapy treatment planning but can be used to inform survivorship plans for children treated for cancers.

References

1. Hoeben BA, Carrie C, Timmermann B, et al. Management of vertebral radiotherapy dose in paediatric patients with cancer: consensus recommendations from the SIOPE radiotherapy working group. Lancet Oncology. 2019;20(3):e155-e166.

2. Jairam V, Roberts KB, Yu JB. Historical trends in the use of radiation therapy for pediatric cancers: 1973-2008. Int J Radiat Oncol Biol Phys. 2013;85(3):e151-e155.

3. Hogeboom C, Grosser S, Guthrie K, et al. Stature loss following treatment for Wilms tumor. Pediatr Blood Cancer. 2001;36(2):295-304.

4. Hudson MM, Ness KK, Gurney JG, et al. Clinical ascertainment of health outcomes among adults treated for childhood cancer. JAMA. 2013;309(22):2371-2381.