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Ependymoma

 

 

Late Effects

Late Effects of Radiation Therapy (RT):

  • Occur 90 days to many years after RT 

Late Effects depend very much on:

  • Age of the child at therapy:
    • The younger the child, the more pronounced the toxicity is likely to be
  • Dose of RT:
    • Higher dose associated with increased toxicity
    • Ependymoma is generally treated with high dose posterior fossa RT
  • RT treatment field extent:
    • Craniospinal RT more damaging than focal field
  • Concurrent chemotherapy increases toxicity

Ependymoma in children is usually treated with high dose RT to the posterior fossa alone.  Craniospinal RT has been rarely used to treat ependymoma in the past 10 to 20 years and is now reserved only for those children who present with metastatic disease to the craniospinal axis.

Summary of Late Effects after posterior fossa RT for Ependymoma:

Therapy Late Toxicity

Posterior fossa RT

Neurocognitive problems:

  • Poor short term memory
  • Difficulty with executive function

Depression:

  • Usually related to multiple long-term health problems and neurocognitive dysfunction

Hearing loss:

  • Direct RT related damage to the cochlea
  • Compounded sometimes by previous cisplatin

Pituitary and hypothalamic dysfunction:

There will be significant scatter to the pituitary with a high risk of endocrinopathy

Increased risk for cerebrovascular events (strokes):

  • RT effect on cerebral vasculature

Increased risk of second neoplasms:

Sparse growth of hair:

  • Affects posterior fossa where high dose RT is given

Hypoplasia (reduced growth) of occipital region and upper cervical spine

Ataxia:

  • Chronic ataxia can occur as a result of cerebellar atrophy

Thyroid damage is very common due to scattered RT  from the posterior fossa field:

 

Summary of Late Effects after craniospinal RT for Ependymoma:

Therapy Late Toxicity

Craniospinal

RT (cranial portion of RT field)

Neurocognitive problems:

  • Poor short term memory
  • Difficulty with executive function

Depression:

  • Usually related to multiple long-term health problems and neurocognitive dysfunction

Hearing loss:

  • Direct RT related damage to the cochlea
  • Compounded sometimes by previous cisplatin

Pituitary and hypothalamic dysfunction:

Increased risk for cerebrovascular events (strokes):

  • RT effect on cerebral vasculature

Increased risk of second neoplasms:

Cataracts:

  • Lens of the eye very sensitive to RT

Sparse growth of scalp hair:

  • Especially affects posterior fossa where "boost" of extra RT is given

Hypoplasia of occipital region and reduced growth of upper cervical spine:

  • Due to posterior fossa boost

Ataxia:

  • Chronic ataxia can occur as a result of cerebellar atrophy
  • related to posterior fossa boost

Craniospinal

RT (spinal portion of RT field)

Thyroid damage is very common due to the "exit"

dose of the spinal field:

Spinal damage from RT effect on spinal growth:

  • Short sitting height (and therefore total height)
  • Scoliosis and kyphosis of spine leading to pain
  • Increased risk of early spinal arthritis and osteoporosis

Infertility:

  • Exit dose from lower end of spinal field damages ovaries or testicles

Cardiac damage:

  • Valvular stenosis from exit RT exit dose (rare)

Damage to bone marrow reserve:

  • After craniospinal RT, it is very difficult to tolerate further intensive chemotherapy
  • Bone marrow reserve is permanently damaged

 

Summary of Late Effects after Surgery for Ependymoma:

Therapy Late Toxicity
Surgical resection of tumor

Cerebellar mutism:

  • Less common in ependymoma than medulloblastoma, but may occur

 

Summary of Late Effects after Chemotherapy for Ependymoma:

Therapy Late Toxicity
Chemotherapy

Cisplatin associated with:

Vincristine associated with:

Alkylating agents associated with:

  • Infertility
  • Second malignancies

Etoposide associated with:

  • Secondary AML (short latent period sometimes within 2 - 3 years after Rx)

 

 

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