Pediatric DIPG is a devastating malignancy that is associated with a grim prognosis. Data are sorely needed identifying prognostic factors associated with improved overall survival (OS) and progression free survival (PFS). This study randomized 253 patients into three RT arms: (1) 39 Gy/15 fx, (2) 45 Gy/15 fx, (3) 54 Gy/30 fx. By fractionation scheme, median OS was: 9.6, 8.2. and 8.7 months. The 1, 1.5, and 2-year OS rates by RT arm were: 34.6%, 17.9%, 10.7%; 26.2%, 13.1%, 4.8%; 25.3%, 12.1%, 8.4%. The two hypofractionated approaches were noted to be non-inferior to the conventionally fractionated approach for OS at 1.5 years. Younger patients (aged 2-5) were also found to have better median OS with the 39 Gy and 50 Gy (not 45 Gy) treatments. Thus, the two hypofractionated approaches were non-inferior to conventional fractionation. Younger age was the only prognostic factor for OS and PFS; however, this was lost with higher hypofractionated doses, thus 45 Gy/15 fractions should be used cautiously in this age group.

Reference (Pub-Med Link): Zaghloul, M. S., Nasr, A., Tolba, M., et al. (2022). Hypofractionated Radiation Therapy For Diffuse Intrinsic Pontine Glioma: A Noninferiority Randomized Study Including 253 Children. International Journal of Radiation Oncology, Biology, Physics, 113(2), 360–368. https://doi.org/10.1016/j.ijrobp.2022.01.054

Key Institution: Children's Cancer Hospital, Cairo, Egypt

Keywords: Pediatric

This study provides a very important perspective onthe role of Avastin (Bevacizumab) in the optimization of the postoperative management of one of the most common aggressive childhood type of tumors –high-grade gliomas (HGGs). The authors of the study conducted a randomized multi-center open-label investigation in order to assess event-free survival (EFS) and overall survival (OS) rates after a standard radiotherapy (RT) + temozolomide (TMZ) adjuvant TMZ versus RT + TMZ + Bev (Bevacizumab) adjuvant TMZ + BEV.

One of the major strengths of this studyis its randomized multi-institutional international design. Furthermore, given rarity of pediatric malignancies, a total of 116 patients were included for analysis, which is a relatively large number for this disease type. Overall, the study demonstrated that unlike adult high-grade gliomas, addition of Avastin to the standard therapy with RT+TMZ fails to improve EFS or OS in children with newly diagnosed HGG. These findings are an additional strength of the study as they indicate that a mere extrapolation of findings from the respective adult tumors to the pediatric malignancies is not often appropriate, therefore pediatric-specific investigations are paramount to improving care of this unique patient population.

Some of the shortcomings of the study include a short follow-up, heterogeneity of enrolled participants, and low completion rate of one of the key quality of life questionnaires of the investigation.

Overall, this publication contributes significantly to the relatively scarce literature on this important topic in the management of childhood high-grade gliomas, and will serve as a useful resource for both radiation and medical oncologists who care for children with cancer. Furthermore, it provides a platform with which we can guide future investigations.

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Journal & Date: Clinical Oncology 36, no. 10 (April 1 2018) 951-958
Key Institution: International randomized trial (Australasian Children’s Cancer Trials, Innovative Therapies for Children with Cancer, the European Society of Pediatric Oncology
Keywords: Pediatric brain tumors, high-grade glioma, bevacizumab, radiotherapy, temozolomide