Radiotherapy use has the potential to cause serious damage to the nervous system of children with intracranial ependymoma. Chemotherapy treatment can prevent or delay the need for radiotherapy, without compromising the child's chances of survival, according to an article in this weeks The Lancet Oncology (Special Paediatric Oncology Edition).

Intracranial ependymomas are tumors which develop around the lining of the cerebral ventricles. Over 50% of intracranial ependymoma cases occur in children under the age of five years. Health care professionals have a very limited choice of treatments for these children.

The effectiveness of treatment for such young children has to be balanced not only against event-free or overall survival. One has to consider the significant risk of serious and/or irreversible brain damage. Radiotherapy treatment with young children (in the brain) is linked to a long-term reduction in IQ (intelligence quotient), as well as short-term memory loss.

Prof. Richard Grundy, Children's Brain Tumour Research Centre, Queen's Medical Centre and University of Nottingham, Nottingham, UK, and team, carried out a study on 89 ependymoma patients between 1992-2003, they were all children. Nine of these children had secondary cancers at pre-operative imaging. In eighty of them the disease had not spread. They all had as much of their tumors removed as was possible with modern surgery. They then received alternative blocks of myelosuppressive* and non-myelosuppressive* chemotherapy for a one-year intended duration. Radiotherapy treatment was only used if the disease progressed.

* (Myelosuppressive chemotherapy = Treatment which inhibits blood cell production)
* (Non-myelosuppresive chemotherapy = Treatment which targets cancerous cells without specifically inhibiting blood cell production)

Of those who did not develop secondary cancer, 58% received radiotherapy after an average of 20.3 months, while the rest did not receive radiotherapy.

At six years median follow-up of the 80 children:

-- Three years overall survival was 79.3%, event free survival was 47.6%.
-- Five years overall survival was 63.4%, event free survival was 41.8%.

Of the 50 children who relapsed, 90% of them did so because the tumors reappeared in the brain, not some other part of the body. The researchers report that there was no significant difference in event-free or overall survival between children with complete and incomplete surgical resection. They also found that survival did not differ according to histological grade, age at diagnosis, or where the disease was located.

An analysis, which took place later on, found that the nine children who had avoided radiotherapy had normal IQ levels.

The researchers believe that radiotherapy may have been avoided because..

-- ..the chemotherapy programme may have been intense.

-- ..the effect of non-chemotherapy events, such as post-surgical neurotoxicity, intercurrent infections, shunt malfunction and treatment, could also have been vital. This indicates that supportive and preventative care might benefit patients by allowing optimal chemotherapy to be achieved for a higher percentage of children.

"The original aim of avoiding or delaying radiotherapy in children without compromising outcome has been achieved. Our results confirm a role for primary chemotherapy in children with intracranial ependymoma. The results reported here will contribute further to the impetus for collaborative studies in Europe and the US in this very young age group. "Despite these advances, the long-term outlook for children with ependymoma remains unacceptably poor and further therapeutic advances will only come through a better understanding of the underlying tumour biology," the authors conclude.

The Lancet Oncology