Professor Lai Mingyao/Cai Linbo: Do All Medulloblastoma Cases Require Radiotherapy? What If Children Don't Cooperate with Radiotherapy?

Professor Lai Mingyao/Cai Linbo: Do All Medulloblastoma Cases Require Radiotherapy? What If Children Don't Cooperate with Radiotherapy?

Source: Sunflower Children  

Author: Lai Mingyao  

Editor: Wuxiu  

Date: November 17, 2023  

The "Q&A on Medulloblastoma" column invites experts in the field of pediatric brain tumors to address various questions regarding medulloblastoma. Today we present the 14th edition, and we welcome you to leave your questions in the comments section!  

1. Do all medulloblastoma cases require radiotherapy?  

The treatment of pediatric medulloblastoma is a multidisciplinary approach that requires collaboration among neurosurgeons, neuro-oncologists, and radiation oncologists to achieve optimal treatment outcomes. When considering radiotherapy for medulloblastoma, the child’s age is a primary factor. For children under 3 years old, radiotherapy is generally avoided because their tissues are still developing, which makes them more susceptible to damage from radiation. Additionally, younger children often have lower levels of cooperation. Therefore, the typical approach for this age group is to start with chemotherapy before considering radiotherapy. Current international trends also favor this approach, using chemotherapy first and delaying radiotherapy as long as possible while ensuring effective treatment. However, for patients with metastatic disease, radiotherapy may be administered based on individual circumstances.

For children aged 3 and older, radiotherapy should begin as soon as possible after tumor resection. Generally, this involves whole brain and spinal cord radiotherapy (CSI), followed by targeted treatment of the posterior fossa or local tumor bed. Delaying radiotherapy can lead to poorer prognoses, and the ideal timing to start radiotherapy is within 4 to 6 weeks post-surgery. Prior to radiotherapy, assessments for medulloblastoma patients must be conducted, focusing on whether the tumor has been completely resected, its molecular type, whether it has spread, and the patient's overall postoperative condition. Based on these risk factors, different radiotherapy strategies—including range, dosage, and techniques—are determined.

2. What is the radiotherapy plan for medulloblastoma?  

The radiotherapy plan for pediatric medulloblastoma patients needs to be tailored according to individual circumstances. The comprehensive treatment plan after surgery is developed through multidisciplinary consultations involving neurosurgeons, neuro-oncologists, and radiation oncologists. Current treatment approaches for medulloblastoma are stratified based on the patient’s risk level, with considerations including age, whether the tumor was fully resected, and whether there has been central nervous system dissemination. Most importantly, tumor genetic profiling is a critical factor, as it is believed to significantly influence the patient's prognosis and risk level.

For low-risk pediatric patients, a reduced dose of CSI at 23.4 Gy is used, with the local tumor bed receiving an additional dose of 54-55.8 Gy; administered at 1.8 Gy per session, alongside concurrent or staggered chemotherapy with Vincristine. For high-risk pediatric patients, the CSI dose is escalated to 36 Gy, with the posterior fossa or local tumor bed receiving an additional 54-59.4 Gy; spinal metastases may receive localized treatment up to 45-50.4 Gy; again at 1.8-2 Gy per session, with concurrent chemotherapy required during the radiotherapy period. Overall, the goal is to achieve personalized and precise treatment for children with medulloblastoma, providing appropriate treatment for low-risk groups to avoid unnecessary interventions while ensuring high-intensity treatment for high-risk patients to prevent poor prognoses due to under-treatment.

Thus, the treatment of pediatric medulloblastoma is a systematic endeavor requiring collaboration among neurosurgeons, neuro-oncologists, and radiation oncologists to create a tailored treatment plan that minimizes suffering while maximizing therapeutic outcomes.

3. What age can a child start radiotherapy?  

Generally, for children aged 3 and older, it is recommended to start radiotherapy as soon as possible after surgery. For children under 3 with metastatic tumors, radiotherapy may be considered based on specific clinical circumstances.

4. Do children need anesthesia for radiotherapy?  

In general, children undergoing radiotherapy do not require anesthesia. However, if a child is unable to cooperate post-surgery, and despite psychological counseling and other methods they still cannot comply, anesthesia may be used to ensure that radiotherapy proceeds without delay, as this could impact their prognosis.

5. What if a child doesn’t cooperate with radiotherapy?  

Firstly, parents and healthcare personnel should fully communicate to assess and understand the reasons for the child’s lack of cooperation. For children who experience medical anxiety, caregivers should provide ample love and support, using verbal encouragement and play to gradually alleviate the child's fears about radiotherapy. Throughout this process, parents must remain patient and cooperate with the medical team to support their child during treatment. If cooperation remains elusive, professional psychological assistance should be sought to utilize therapeutic interventions that can help alleviate the child’s fear and promote their willingness to cooperate with treatment.

For children who are unable to cooperate due to postoperative issues or the tumor itself, efforts should be made to identify the reasons for their discomfort and provide targeted interventions to ease their suffering. If necessary, sedatives or anesthesia may be administered to ensure the smooth progression of radiotherapy.  

Formatting | Wu Jun  

Proofreading | Xiuxiu