Germ Cell Tumor of the Brain
Overview
A germ cell tumor develops from cells primitive developing cells in the embryo that should migrate and create the reproductive system.
- Germ cell tumors in the brain are very rare.
- They are usually treated with surgery, but radiation therapy and chemotherapy may also be used, if completely removing the tumor removal surgically isn’t possible.
- Certain germ cell tumors release measurable substances into the blood. These tumor markers can be tested to follow the tumor’s response to treatment.
As you read further, you will find general information about germ cell tumors in the brain.
How Dana-Farber/Children’s Hospital Cancer Center approaches germ cell tumors of the brain
We understand that you may have a lot of questions when your child is diagnosed with acute a germ cell tumor of the brain. Is it dangerous? Will it affect my child long-term? What do we do next? We’ve tried to provide some answers to those questions here, and our experts can explain your child’s condition fully.
We hold a weekly brain tumor clinic for newly diagnosed patients currently receiving treatment. Each time you come for an appointment, you meet with every specialist on your child’s team, from your pediatric neuro-oncologist, neurologist and neurosurgeon, to your pediatric endocrinologist, psycho-oncologist and school liaison.
Dana-Farber/Children’s Hospital Cancer Center’s Pediatric Brian Tumor Program offers the following services:
- Access to high-tech resources, like the intra-operative MRI, which allows our pediatric neurosurgeons to visualize the tumor as they operate with MRI scans. This means they can remove as much of the tumor as possible, and sometimes eliminate additional surgeries.
- Expert neuropathological review, using advanced molecular diagnostic testing, to identify your child’s exact type of tumor. This information helps predict which treatments are more likely to work.
- Access to unique Phase I clinical trials, from our own investigators, the Children’s Oncology Group and the Pediatric Oncology Experimental Therapeutics Investigators Consortium. Studies offer treatment options beyond standard therapy.
- Ongoing care from pediatric neurologists familiar with the early symptoms and side effects of brain tumors and their treatments.
- Access to one of the nation’s few dedicated pediatric brain tumor survivorship programs. This weekly clinic offers ongoing care to manage late effects caused by your child’s tumor or the treatment they received.
In-depth
What is a germ cell tumor of the brain?
A germ cell tumor develops from cells primitive developing cells in the embryo that should migrate and create the reproductive system.
What causes a germ cell tumor of the brain?
Usually germ cells migrate to the gonads during fetal development and become an egg in the female ovaries or sperm in a man’s testes. If they don’t move to the right area, they begin to multiply in areas where they shouldn’t be.
- Most germ cell tumors occur outside the brain, in the chest or abdomen.
- Germ cell tumors in the brain are most commonly found in the pineal and suprasellar regions.
- They account for about 2 percent of all pediatric brain tumors.
- Around half of these tumors occur in young people between ages 10 and 20.
What are the symptoms of germ cell tumors in the brain?
Symptoms vary depending on size and location of tumor. This tumor can block the normal flow of depending on size and location of tumor. Sometimes the tumor may block the normal flow of the cerebral spinal fluid (CSF), causing increased pressure on the brain (hydrocephalus) and enlargement of the skull and a variety of symptoms. Common symptoms may include:
- headaches ( especially upon awakening).
- nausea and vomiting (especially upon awakening).
- lethargy and irritability.
- problems feeding or walking.
- enlarged head size or fontanels, the soft "spot" that occurs before the bones in the head become solid, in infants.
For germ cell tumors found in other areas of the brain, common symptoms may include:
- vision loss
- hormone abnormalities
The symptoms of a brain tumor may resemble other conditions or medical problems, ranging from the simple to the serious. Always consult your child's physician for diagnosis and treatment.
What are the different kinds of germ cell tumors in the brain?
Germ cell tumors are a widely varied group of tumors. They range from very low grade or benign to highly malignant or aggressively growing cancers.
- Germinomas are the most common form of germ cell tumors in the brain.
- Teratomas range from mature to immature and even malignant.
- Mixed non-germinomas contain cancerous, or malignant, forms of these tumors, including:
- embryonal carcinoma
- choriocarcinoma
- endodermal sinus [yolk sac] tumors
The prognosis and treatment of each of these depends on their location, size, and other characteristics.
Tests
How are germ cell tumors in the brain diagnosed?
Diagnostic procedures for germ cell tumors, like other brain tumors, determine the exact type of tumor and whether the tumor has spread. These may include a:
- physical exam to test neurologic function including: reflexes, muscle strength, eye and mouth movement, coordination, and alertness.
- magnetic resonance imaging (MRI) to produce detailed images of organs and structures within the brain and/or spine.
- computerized tomography scan (also called a CT or CAT scan) to capture a detailed view of the brain, in some cases.
- Biopsy or tissue sample from the tumor to provide definitive information about the type of tumor. This is collected during surgery.
- lumbar puncture (spinal tap) to remove a small sample of cerebrospinal fluid (CSF) and determine if any tumor cells have started to spread. In young children, this procedure is safely performed under sedation, and is less difficult and less painful than placing an intravenous (IV) catheter.
- Blood tests to measure if markers exist. Certain germ cell tumors release measurable substances into the blood and CSF (e.g. alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (B-HCG)). These tumor markers can be repeatedly tested to follow the response of a tumor to treatment.
Treatment & care
At Dana-Farber/Children’s Hospital Cancer Center, we know how difficult a diagnosis of germ cell tumors can be, both for your child and for your whole family. That’s why our physicians are focused on family-centered care: From your first visit, you’ll work with a team of professionals who are committed to supporting all of your family’s physical and psychosocial needs. We’ll work with you to create a care plan that’s best for your child.
What are the treatments for a germ cell tumors of the brain?
Treatment may include the following, alone or in combination.
Surgery
Usually first step of treatment is surgery: a pediatric neurosurgeon removes as much of the tumor as possible while preserving your child’s neurological function. Tumor specimens are examined by neuropathologists.
- Surgery is usually limited to well encapsulated teratomas, a particular tumor that includes all three cellular layers of germ cells, or in the case of blocked CSF flow.
- Complete resection or surgical removal of the entire tumor is ideal when possible. However, tumor location and other characteristics may limit removal to a partial or sub-total resection.
- A biopsy is the surgical removal of a sample of the tumor for diagnostic purposes. This is frequently done if the tumor is in an area with sensitive structures around it that may be injured during removal.
Ventriculo-peritoneal shunt (VP shunt)
When a tumor causes blockage of cerebral spinal fluid (CSF) flow, special tubing can be surgically implanted in the ventricles to drain excess CSF into the abdomen. This bypasses the tumor blockage and relieves symptoms of hydrocephalus, the build up of fluid inside the skull.
Radiation therapy
Precisely targeted and dosed radiation is used to kill cancer cells left behind after surgery. This treatment is important to control the local growth of tumor.
- Tumors that are not likely to spread receive radiation only to the tumor and the area surrounding it.
- If we determine the tumor is more likely to spread beyond its original tumor location, radiation to other parts of the brain and spinal cord may be recommended.
- If the tumor has spread, radiation to the whole brain and spinal cord are used to treat certain germ cell tumors.
Chemotherapy
Chemotherapy is a drug that interferes with the cancer cell’s ability to grow or reproduce. Chemotherapy before surgery may help shrink the tumor, making it possible to remove.
- Different groups of chemotherapy drugs work in different ways to fight cancer cells and shrink tumors.
- Often, a combination of chemotherapy drugs is used.
- Certain chemotherapy drugs may be given in a specific order depending on the type of cancer it is being used to treat.
While chemotherapy can be quite effective in treating certain cancers, the agents don’t differentiate normal healthy cells from cancer cells. Because of this, there can be many adverse side effects during treatment. Being able to anticipate these side effects can help the care team, parents, and child prepare, and, in some cases, prevent these symptoms from occurring, if possible.
Chemotherapy is systemic treatment, meaning it is introduced to the bloodstream and travels throughout the body to kill cancer cells. Chemotherapy can be given:
- as a pill to swallow.
- as an injection into the muscle or fat tissue.
- Intravenously, directly to the bloodstream (also called IV).
- Intrathecally, which means directly delivering the chemotherapy into the spinal column with a needle.
What is the expected prognosis after treatment for my child?
Outcomes vary widely, depending on the precise type of germ cell tumor your child has. In general, germinomas are cured in greater than 85 percent of cases with combined treatment.
- Mature teratomas are curable with complete resection alone.
- Immature teratomas usually require additional therapy.
- Other germ cell tumors, the mixed and malignant types, are more difficult to treat.
What is the recommended long-term care for my child?
Children treated for a germ cell tumor in the brain should visit a survivorship clinic every year to:
- manage disease complications
- screen for early recurrence of tumor
- manage late effects of treatment
A typical follow-up visit may include some or all of the following:
- a physical exam
- laboratory testing
- imaging scans
Through the Stop and Shop Family Pediatric Neuro-Oncology Outcomes Clinic as Dana-Farber Cancer Institute, children are able to meet with their neurosurgeon, radiation oncologist, pediatric neuro-oncologist and neurologists at the same follow-up visit.
- Endocrinologists, neuro-psychologists, alternative/complementary therapy specialists, and school liaison and psychosocial personnel from the pediatric brain tumor team are also available.
- In addition, children needing rehabilitation may meet with speech, physical, and occupational therapists during and after treatments.
Research & innovations
The pediatric neurosurgeons at Dana-Farber/Children’s Hospital Cancer Center have access to the most recent technological advances such as the intra-operative MRI, which allow them to visualize the tumor as they operate with MRI scans, so they can remove as much of the tumor as possible.
We also have access to high-tech imaging, such as PET, CT and functional MRI, which enable us to understand exactly where the tumor tissue is, and to map out surgeries and treatments that minimize risk to healthy brain tissue.
Our pediatric neuropathologists see hundreds of tissue samples each year, giving them in-depth knowledge of tissue subtypes so you receive a quick and accurate diagnosis.
What is the latest research on germ cell tumors?
Dana-Farber/Children’s Hospital Cancer Care is a member of the Pediatric Oncology Therapeutic Experimental Investigators Consortium (POETIC), a collaborative clinical research group offering experimental therapies to patients with relapsed or refractory disease. It is also the New England Phase I Center of the Children’s Oncology Group. Children with progressive/recurrent gangliogliomas may be eligible for experimental therapies available through these consortiums.
Participation in any clinical trial is completely voluntary: We will take care to fully explain all elements of the treatment plan prior to the start of the trial, and you may remove your child from the medical study at any time.
Purpose of This PDQ Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of select childhood brain and spinal cord tumors. It also provides links to the other PDQ childhood brain and spinal cord tumor summaries. This summary is reviewed regularly and updated as necessary by the PDQ Pediatric Treatment Editorial Board.
Information about the following is included in this summary:
- Classification of childhood brain and spinal cord tumors.
- General approach to care for childhood brain tumor patients.
- Stage information about select childhood brain and spinal cord tumors, and links to the other PDQ childhood brain and spinal cord tumor summaries.
- Treatment options about select childhood brain and spinal cord tumors, and links to the other PDQ childhood brain and spinal cord tumor summaries.
This summary is intended as a resource to inform and assist clinicians and other health professionals who care for pediatric cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
In this summary, treatments are described as “standard” or “conventional” and “under clinical evaluation.” These designations should not be used as a basis for reimbursement determinations.
This summary is also available in a patient version, which is written in less technical language, and in Spanish.
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General Information
Note: Separate PDQ summaries on Childhood Astrocytomas Treatment, Childhood Central Nervous System Atypical Teratoid/Rhabdoid Tumor Treatment, Childhood Brain Stem Glioma Treatment, Childhood Central Nervous System Embryonal Tumors Treatment, Childhood Ependymoma Treatment, and Childhood Craniopharyngioma Treatment are also available.
The National Cancer Institute (NCI) provides the PDQ pediatric cancer information treatment summaries as a public service to increase the availability of evidence-based cancer information to health professionals, patients, and the public.
Information about ongoing clinical trials is available from the NCI Web site.
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Classification of Brain Tumors
Primary brain tumors are a diverse group of diseases that together constitute
the most common solid tumor in childhood. Between 2,500 and 3,500 children are diagnosed in the United States each year. Immunohistochemical analysis,
cytogenetic and molecular genetic findings, and measures of mitotic activity
are increasingly used in tumor diagnosis and classification, and will likely alter classification and nomenclature in the future.
The classification of childhood brain tumors is based on histology and location.[1] Tumors are classically categorized as infratentorial, supratentorial, sellar, or suprasellar.
Common
infratentorial (posterior fossa) tumors include:
- Cerebellar astrocytomas (usually pilocytic but also fibrillary and, less frequently,
high-grade).
- Medulloblastomas (primitive neuroectodermal tumors [PNETs]).
- Ependymomas (cellular, papillary, clear cell, tanycytic, or anaplastic).
- Brain stem gliomas are typically diffuse intrinsic pontine gliomas or diffuse intrinsic high-grade tumors that are diagnosed neuroradiographically without biopsy. Focal, tectal, and exophytic cervicomedullary tumors are generally low-grade tumors.
- Atypical teratoid/rhabdoid tumors.
Supratentorial tumors include:
- Low-grade cerebral hemispheric astrocytomas (grade 1 [pilocytic] or grade 2).
- High-grade or malignant astrocytomas (anaplastic astrocytomas, glioblastomas
multiforme [grade 3 or grade 4]).
- Mixed gliomas (low-grade or high-grade).
- Oligodendrogliomas (low-grade or high-grade).
- PNETs (including cerebral neuroblastomas, pineoblastomas, and ependymoblastomas).
- Atypical teratoid/rhabdoid tumors.
- Ependymomas (cellular or anaplastic).
- Meningiomas.
- Choroid plexus tumors (papillomas and carcinomas).
- Pineal parenchymal tumors (pineocytomas, mixed pineal
parenchymal tumors, and pineal parenchymal tumors of intermediate differentiation).
- Neuronal and mixed neuronal glial tumors (gangliogliomas, desmoplastic
infantile gangliogliomas, and dysembryoplastic neuroepithelial tumors).
- Metastasis (rare) from extraneural malignancies.
Sellar or suprasellar tumors include:
- Craniopharyngiomas.
- Diencephalic astrocytomas (central tumors involving the chiasm, hypothalamus, and/or thalamus) that are generally low-grade
(including astrocytomas, grade 1 [pilocytic] or grade 2).
- Germ cell tumors (germinomas or nongerminomatous).
References:
Kleihues P, Cavenee WK, eds.: Pathology and Genetics of Tumours of the Nervous System. Lyon, France: International Agency for Research on Cancer, 2000.
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Classification of Spinal Cord Tumors
Primary central nervous system spinal cord tumors comprise approximately
1% to 2% of all childhood nervous system tumors.[1][2][3] As is the case for
primary brain tumors, such lesions are histologically heterogeneous.
Approximately 70% of all intramedullary spinal cord tumors will be low-grade
astrocytomas and/or gangliogliomas. Other tumor types that occur include
ependymomas (refer to the PDQ summary on Childhood Ependymoma Treatment for more information), higher-grade glial tumors, and (rarely) primitive neuroectodermal
tumors (refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information). Myxopapillary ependymomas have a tendency to develop in the conus
and cauda equina regions. Symptoms and signs of spinal cord tumors are highly
dependent on the location of the tumor and its extent; some low-grade spinal
cord tumors are associated with large cysts that extend rostrally and caudally. At times it is impossible to
distinguish a tumor that arises in the medulla from a tumor that arises in
the upper cervical cord.
The classification of spinal cord tumors is based on histopathologic
characteristics of the tumor and does not differ from that of primary brain
tumors.[1][2][3]
References:
Constantini S, Miller DC, Allen JC, et al.: Radical excision of intramedullary spinal cord tumors: surgical morbidity and long-term follow-up evaluation in 164 children and young adults. J Neurosurg 93 (2 Suppl): 183-93, 2000.
Bouffet E, Pierre-Kahn A, Marchal JC, et al.: Prognostic factors in pediatric spinal cord astrocytoma. Cancer 83 (11): 2391-9, 1998.
Hardison HH, Packer RJ, Rorke LB, et al.: Outcome of children with primary intramedullary spinal cord tumors. Childs Nerv Syst 3 (2): 89-92, 1987.
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General Approach to Care for Children with Brain and Spinal Cord Tumors
Important concepts that should be understood by those treating and caring for a
child who has a brain or spinal cord tumor include the following:
- The cause of most childhood brain tumors remains unknown.[1][2][3]
- Selection of an appropriate therapy can only occur if the correct
diagnosis is made and the stage of the disease is accurately determined.
- Children with primary brain or spinal cord tumors represent a major therapy challenge that,
for optimal results, requires the coordinated efforts of pediatric specialists
in fields such as neurosurgery, neuropathology,
radiation oncology, pediatric oncology, neuro-oncology, neurology, rehabilitation, neuroradiology, endocrinology, and
psychology, who have special expertise in the care of patients with these
diseases.[4][5][6] For example, radiation therapy of pediatric brain tumors is very technically demanding and should be carried out in centers that have experience in this area.
- For most childhood brain and spinal cord tumors, the optimal treatment regimen
has not been determined. Children who have brain and spinal cord tumors should be
considered for enrollment in a clinical trial when an appropriate study
is available. Such clinical trials are being carried out by institutions
and cooperative groups.
Many of the improvements in survival in childhood cancer have been made as a result of clinical trials that have attempted to improve on the best accepted therapy available. Information about ongoing clinical trials is available from the NCI
Web site.
- While more than 50% of children diagnosed with brain tumors will survive more than 5
years from diagnosis, survival rates are wide-ranging depending on tumor type and stage. Long-term sequelae related to the initial presence of the tumor and subsequent treatment are common.[7][8][9] For more information about possible long-term or late effects, refer to the PDQ summary on Late Effects of Treatment for Childhood Cancer.
- Guidelines for pediatric cancer centers and their role in the treatment
of pediatric patients with cancer have been outlined by the American
Academy of Pediatrics.[10]
References:
Kuijten RR, Bunin GR: Risk factors for childhood brain tumors. Cancer Epidemiol Biomarkers Prev 2 (3): 277-88, 1993 May-Jun.
Kuijten RR, Strom SS, Rorke LB, et al.: Family history of cancer and seizures in young children with brain tumors: a report from the Childrens Cancer Group (United States and Canada). Cancer Causes Control 4 (5): 455-64, 1993.
Fisher JL, Schwartzbaum JA, Wrensch M, et al.: Epidemiology of brain tumors. Neurol Clin 25 (4): 867-90, vii, 2007.
Strother DR, Poplack IF, Fisher PG, et al.: Tumors of the central nervous system. In: Pizzo PA, Poplack DG, eds.: Principles and Practice of Pediatric Oncology. 4th ed. Philadelphia, Pa: Lippincott, Williams and Wilkins, 2002, pp 751-824.
Pollack IF: Brain tumors in children. N Engl J Med 331 (22): 1500-7, 1994.
Cohen ME, Duffner PK, eds.: Brain Tumors in Children: Principles of Diagnosis and Treatment. 2nd ed. New York: Raven Press, 1994.
Ris MD, Packer R, Goldwein J, et al.: Intellectual outcome after reduced-dose radiation therapy plus adjuvant chemotherapy for medulloblastoma: a Children's Cancer Group study. J Clin Oncol 19 (15): 3470-6, 2001.
Johnson DL, McCabe MA, Nicholson HS, et al.: Quality of long-term survival in young children with medulloblastoma. J Neurosurg 80 (6): 1004-10, 1994.
Packer RJ, Sutton LN, Goldwein JW, et al.: Improved survival with the use of adjuvant chemotherapy in the treatment of medulloblastoma. J Neurosurg 74 (3): 433-40, 1991.
Guidelines for the pediatric cancer center and role of such centers in diagnosis and treatment. American Academy of Pediatrics Section Statement Section on Hematology/Oncology. Pediatrics 99 (1): 139-41, 1997.
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Stage Information
Childhood Astrocytoma
Childhood astrocytomas are classified as low-grade or high-grade.
Childhood Low-Grade Astrocytomas:
- Pilocytic astrocytoma.
- Diffuse fibrillary astrocytoma.
Childhood High-Grade Astrocytomas:
- Anaplastic astrocytoma.
- Glioblastoma multiforme.
Refer to the PDQ summary on Childhood Astrocytomas Treatment for more information.
Childhood Central Nervous System (CNS) Atypical Teratoid/Rhabdoid Tumor
Refer to the PDQ summary on Childhood Central Nervous System Atypical Teratoid/Rhabdoid Tumor Treatment for more information.
Childhood Brain Stem Glioma
Childhood brain stem gliomas include:
- Diffuse intrinsic pontine gliomas.
- Focal or low-grade brain stem gliomas.
Refer to the PDQ summary on Childhood Brain Stem Glioma Treatment for more information.
Childhood CNS Embryonal Tumors
Childhood CNS embryonal tumors include:
- CNS atypical teratoid/rhabdoid tumors. (Refer to the PDQ summary on Childhood Central Nervous System Atypical Teratoid/Rhabdoid Tumor Treatment for more information.)
- Ependymoblastomas.
- Medulloblastomas.
- Medulloepitheliomas.
- Pineal parenchymal tumors of intermediate differentiation.
- Pineoblastomas.
- Supratentorial primitive neuroectodermal tumors.
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Childhood CNS Germ Cell Tumors
Childhood CNS germ cell tumors include:
- Germinomas.
- Embryonal yolk sac tumors.
- Choriocarcinomas.
- Immature teratomas.
- Mature teratomas.
- Teratomas with malignant transformation.
- Mixed germ cell tumors.
- Nongerminomatous germ cell tumors.
Germ cell brain tumors usually arise in the pineal or suprasellar regions.
Histologic subtypes include teratomas (both mature and immature), germinomas,
choriocarcinomas, and nongerminomatous germ cell tumors (i.e., embryonal cell
carcinoma, yolk cell or endodermal sinus tumors, and mixed germ cell tumors). These tumors have a
propensity for subarachnoid spread. Every patient with a germinoma or
malignant germ cell tumor should be evaluated with diagnostic imaging of the
spinal cord and whole brain. The best method for evaluating spinal cord
subarachnoid metastasis is magnetic resonance imaging with gadolinium enhancement. Cerebrospinal
fluid CSF) should be examined cytologically and levels of alpha-fetoprotein (AFP)
and human chorionic gonadotropin (HCG) determined. AFP and/or HCG may be
elevated in the serum of such patients. Prognosis is related to histology;
patients with pure germinoma have a more favorable outcome than those with
nongerminomatous germ cell tumors (nongerminomas).[1][2]
Childhood Craniopharyngioma
Refer to the PDQ summary on Childhood Craniopharyngioma Treatment for more information.
Childhood Ependymoma
Refer to the PDQ summary on Childhood Ependymoma Treatment for more information.
Childhood Ependymoblastoma
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Childhood Malignant Glioma
Refer to the PDQ summary on Childhood Astrocytomas Treatment for more information.
Childhood Medulloblastoma
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more
information.
Childhood Medulloepithelioma
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Childhood Pineal Parenchymal Tumors
Childhood pineal parenchymal tumors include:
- Pineoblastomas.
- Pineocytomas.
- Pineal parenchymal tumors of intermediate differentiation.
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Childhood Spinal Cord Tumors
There is no uniformly accepted staging system for childhood primary spinal cord
tumors. These tumors are classified based on their location within the spinal
cord and histology. Low-grade spinal cord tumors rarely disseminate elsewhere
in the nervous system; however, higher grade tumors may disseminate.[3][4]
Despite this, because of the location of the tumor and concerns over causing
further neurologic deterioration by CSF attainment, routine
lumbar spinal punctures are not indicated in the evaluation of a child with a
spinal cord tumor. For high-grade glial spinal cord tumors, and possibly lower
grade tumors and ependymomas, (refer to the PDQ summary on Childhood Ependymoma Treatment for more information) neuroimaging of the entire neuroaxis (brain and
entire spine) is indicated at the time of diagnosis for determination of extent
of disease.
Childhood Supratentorial Primitive Neuroectodermal Tumors
Childhood supratentorial primitive neuroectodermal tumors include:
- Primitive neuroectodermal tumors.
- Cerebral neuroblastomas.
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
References:
Matsutani M, Sano K, Takakura K, et al.: Primary intracranial germ cell tumors: a clinical analysis of 153 histologically verified cases. J Neurosurg 86 (3): 446-55, 1997.
Balmaceda C, Modak S, Finlay J: Central nervous system germ cell tumors. Semin Oncol 25 (2): 243-50, 1998.
Constantini S, Miller DC, Allen JC, et al.: Radical excision of intramedullary spinal cord tumors: surgical morbidity and long-term follow-up evaluation in 164 children and young adults. J Neurosurg 93 (2 Suppl): 183-93, 2000.
Bouffet E, Pierre-Kahn A, Marchal JC, et al.: Prognostic factors in pediatric spinal cord astrocytoma. Cancer 83 (11): 2391-9, 1998.
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Treatment Option Overview
Many of the improvements in survival in childhood cancer have been made as a
result of clinical trials that have attempted to improve on the best
accepted therapy available. Clinical trials in pediatrics are designed to compare new
therapy with therapy that is currently accepted as standard. This comparison
may be done in a randomized study of two treatment arms or by evaluating a
single new treatment and comparing the results with those previously obtained
with existing therapy.
Because of the relative rarity of cancer in children, all patients with brain
and spinal cord tumors should be considered for entry into a clinical trial. To determine and
implement optimum treatment, treatment planning by a multidisciplinary team of
cancer specialists who have experience treating childhood brain tumors is
required. Radiation therapy of pediatric brain tumors is very technically demanding and should be carried out in centers that have experience in this
area to ensure optimal results.
Debilitating effects on growth and neurologic development have frequently been
observed following radiation therapy, especially in younger children.[1][2][3]
Secondary tumors have increasingly been diagnosed in long-term survivors.[4]
For this reason, the role of chemotherapy in allowing a delay or reduction in the
administration of radiation therapy is under study, and preliminary results
suggest that chemotherapy can be used to delay, limit, and sometimes obviate, the need
for radiation therapy in children with benign and malignant lesions.[5][6][7]
Long-term management of these patients is complex and requires a
multidisciplinary approach.
References:
Ris MD, Packer R, Goldwein J, et al.: Intellectual outcome after reduced-dose radiation therapy plus adjuvant chemotherapy for medulloblastoma: a Children's Cancer Group study. J Clin Oncol 19 (15): 3470-6, 2001.
Johnson DL, McCabe MA, Nicholson HS, et al.: Quality of long-term survival in young children with medulloblastoma. J Neurosurg 80 (6): 1004-10, 1994.
Packer RJ, Sutton LN, Goldwein JW, et al.: Improved survival with the use of adjuvant chemotherapy in the treatment of medulloblastoma. J Neurosurg 74 (3): 433-40, 1991.
Jenkin D: Long-term survival of children with brain tumors. Oncology (Huntingt) 10 (5): 715-9; discussion 720, 722, 728, 1996.
Duffner PK, Horowitz ME, Krischer JP, et al.: Postoperative chemotherapy and delayed radiation in children less than three years of age with malignant brain tumors. N Engl J Med 328 (24): 1725-31, 1993.
Packer RJ, Lange B, Ater J, et al.: Carboplatin and vincristine for recurrent and newly diagnosed low-grade gliomas of childhood. J Clin Oncol 11 (5): 850-6, 1993.
Mason WP, Grovas A, Halpern S, et al.: Intensive chemotherapy and bone marrow rescue for young children with newly diagnosed malignant brain tumors. J Clin Oncol 16 (1): 210-21, 1998.
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Treatment of Newly Diagnosed Childhood Brain and Spinal Cord Tumors
Childhood Astrocytoma
Childhood astrocytomas are classified as low-grade or high-grade.
Childhood Low-Grade Astrocytomas:
- Pilocytic astrocytoma.
- Diffuse fibrillary astrocytoma.
Childhood High-Grade Astrocytomas:
- Anaplastic astrocytoma.
- Glioblastoma multiforme.
Refer to the PDQ summary on Childhood Astrocytomas Treatment for more information.
Childhood Central Nervous System (CNS) Atypical Teratoid/Rhabdoid Tumor
Refer to the PDQ summary on Childhood Central Nervous System Atypical Teratoid/Rhabdoid Tumor Treatment for more information.
Childhood Brain Stem Glioma
Childhood brain stem gliomas include:
- Diffuse intrinsic pontine gliomas.
- Focal or low-grade brain stem gliomas.
Refer to the PDQ summary on Childhood Brain Stem Glioma Treatment for more
information
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
childhood brain stem glioma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood CNS Embryonal Tumors
Childhood CNS embryonal tumors include:
- CNS atypical teratoid/rhabdoid tumors. (Refer to the PDQ summary on Childhood Central Nervous System Atypical Teratoid/Rhabdoid Tumor Treatment for more information.)
- Ependymoblastomas.
- Medulloblastomas.
- Medulloepitheliomas.
- Pineal parenchymal tumors of intermediate differentiation.
- Pineoblastomas.
- Supratentorial primitive neuroectodermal tumors.
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
childhood embryonal tumor. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood CNS Germ Cell Tumors
Childhood CNS germ cell tumors include:
- Germinomas.
- Embryonal yolk sac tumors.
- Choriocarcinomas.
- Immature teratomas.
- Mature teratomas.
- Teratomas with malignant transformation.
- Mixed germ cell tumors.
- Nongerminomatous germ cell tumors.
Surgery, other than biopsy to establish the diagnosis, rarely plays a role in the
treatment of CNS germinomas. The role of surgical
resection for nongerminomatous germ cell tumors and teratomas remains to be
defined.[1] For germinomas, irradiation with doses of 45 Gy to 54 Gy to the
tumor and 21 Gy to 36 Gy to the whole brain and spine is usually curative. In
selected cases, germinoma can be effectively treated with ventricular field radiation
therapy and at lower dose levels (30–36 Gy) following response to chemotherapy.[1] Although experience with
pre-irradiation chemotherapy has shown that most of these tumors
respond to cyclophosphamide and platinum-containing drugs, the definitive role
of chemotherapy has yet to be determined.[1] Disseminated germinomas are treated with craniospinal
irradiation,[2][3] alone or in combination with chemotherapy. The usual dose to the
tumor is 45 Gy to 54 Gy with 27 Gy to 36 Gy to the whole brain and spine. Although nongerminomatous germ cell tumors (e.g., embryonal carcinomas, yolk cell tumors, and mixed germ cell tumors) may respond
to chemotherapeutic agents (e.g., cisplatin or carboplatin, etoposide,
cyclophosphamide, and vinblastine) as do such histologies outside of the CNS,
optimal combination of agents, and the timing of chemotherapy in relation to radiation therapy
remains to be determined.[4][5][6]
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
childhood central nervous system germ cell tumor. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood Craniopharyngioma
Refer to the PDQ summary on Childhood Craniopharyngioma Treatment for more information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
childhood craniopharyngioma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood Ependymoma
Refer to the PDQ summary on Childhood Ependymoma Treatment for more
information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
newly diagnosed childhood ependymoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood Ependymoblastoma
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
childhood ependymoblastoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood Malignant Glioma
Refer to the PDQ summary on Childhood Astrocytomas Treatment for more information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
childhood cerebral astrocytoma/malignant glioma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood Medulloblastoma
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more
information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
untreated childhood medulloblastoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood Medulloepithelioma
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
childhood medulloepithelioma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood Pineal Parenchymal Tumors
Childhood pineal parenchymal tumors include:
- Pineoblastomas.
- Pineocytomas.
- Pineal parenchymal tumors of intermediate differentiation.
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
childhood pineal parenchymal tumor. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood Spinal Cord Tumors
The optimal treatment for intrinsic/intramedullary glial spinal cord tumors has
not been determined by prospective randomized trials. Therapeutic options
include surgery alone, surgery plus local radiation therapy, and possibly
adjuvant chemotherapy in selected cases.[7][8] Extensive surgical resections
are technically possible for many patients with intramedullary spinal cord
tumors, but may result in worsening neurologic status in at least 10%
of cases.[7][8] Surgery is usually indicated at least to determine the type of
tumor present; for low-grade glial tumors this may be the only treatment
required.[7] In one recent series of 164 children and young adults with
intramedullary low-grade glial tumors or ganglioglial spinal cord tumors, 70%
were controlled for 5 years after extensive surgical resections.[7] Radiation therapy has been demonstrated to control disease in some patients with
low-grade glial tumors after subtotal resections.[8][9][10] The role of
chemotherapy for spinal cord tumors is poorly characterized, but some very
young children with low-grade glial tumors have been successfully treated with
a carboplatin and vincristine drug regimen.[11] Outcomes for patients with
high-grade glial tumors have been extremely poor; most
develop progressive disease within 3 years of treatment with surgery,
radiation, and/or chemotherapy.[7][9][10]
The optimal treatment for children with spinal ependymomas has not been well characterized (refer to the PDQ summary on Childhood Ependymoma Treatment for more information). As is the case for glial tumors, treatment options
predominantly consist of either surgery alone or surgery followed by local
radiation therapy.[7][8] Management of primitive neuroectodermal tumors of the
spinal cord is also not well delineated, and most patients are treated on
treatment protocols designed for children with high-risk medulloblastoma.
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
childhood spinal cord neoplasm. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood Supratentorial Primitive Neuroectodermal Tumors
Childhood supratentorial primitive neuroectodermal tumors include:
- Primitive neuroectodermal tumors.
- Cerebral Neuroblastomas.
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
childhood supratentorial primitive neuroectodermal tumor. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
References:
Matsutani M, Sano K, Takakura K, et al.: Primary intracranial germ cell tumors: a clinical analysis of 153 histologically verified cases. J Neurosurg 86 (3): 446-55, 1997.
Dearnaley DP, A'Hern RP, Whittaker S, et al.: Pineal and CNS germ cell tumors: Royal Marsden Hospital experience 1962-1987. Int J Radiat Oncol Biol Phys 18 (4): 773-81, 1990.
Linstadt D, Wara WM, Edwards MS, et al.: Radiotherapy of primary intracranial germinomas: the case against routine craniospinal irradiation. Int J Radiat Oncol Biol Phys 15 (2): 291-7, 1988.
Balmaceda C, Heller G, Rosenblum M, et al.: Chemotherapy without irradiation--a novel approach for newly diagnosed CNS germ cell tumors: results of an international cooperative trial. The First International Central Nervous System Germ Cell Tumor Study. J Clin Oncol 14 (11): 2908-15, 1996.
Bouffet E, Baranzelli MC, Patte C, et al.: Combined treatment modality for intracranial germinomas: results of a multicentre SFOP experience. Société Française d'Oncologie Pédiatrique. Br J Cancer 79 (7-8): 1199-204, 1999.
Robertson PL, DaRosso RC, Allen JC: Improved prognosis of intracranial non-germinoma germ cell tumors with multimodality therapy. J Neurooncol 32 (1): 71-80, 1997.
Constantini S, Miller DC, Allen JC, et al.: Radical excision of intramedullary spinal cord tumors: surgical morbidity and long-term follow-up evaluation in 164 children and young adults. J Neurosurg 93 (2 Suppl): 183-93, 2000.
Bouffet E, Pierre-Kahn A, Marchal JC, et al.: Prognostic factors in pediatric spinal cord astrocytoma. Cancer 83 (11): 2391-9, 1998.
Hardison HH, Packer RJ, Rorke LB, et al.: Outcome of children with primary intramedullary spinal cord tumors. Childs Nerv Syst 3 (2): 89-92, 1987.
O'Sullivan C, Jenkin RD, Doherty MA, et al.: Spinal cord tumors in children: long-term results of combined surgical and radiation treatment. J Neurosurg 81 (4): 507-12, 1994.
Hassall TE, Mitchell AE, Ashley DM: Carboplatin chemotherapy for progressive intramedullary spinal cord low-grade gliomas in children: three case studies and a review of the literature. Neuro-oncol 3 (4): 251-7, 2001.
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Treatment of Recurrent Childhood Brain and Spinal Cord Tumors
Recurrence is not uncommon in both low-grade and malignant childhood brain tumors
and may occur many years after initial treatment.[1] Disease may occur at the
primary tumor site or, especially in malignant tumors, at noncontiguous central
nervous system (CNS) sites. Systemic relapse is rare but may occur. At time of
recurrence, a complete evaluation for extent of relapse is indicated for all
malignant tumors and, at times, for lower-grade lesions. Biopsy or surgical
re-resection may be necessary for confirmation of relapse; other entities,
such as secondary tumor and treatment-related brain necrosis, may be clinically
indistinguishable from tumor recurrence. The need for surgical intervention
must be individualized based on the initial tumor type, the length of time
between initial treatment and the reappearance of the lesion, and the clinical
picture.
Childhood Astrocytoma
Childhood astrocytomas are classified as low-grade or high-grade.
Childhood Low-Grade Astrocytomas:
- Pilocytic astrocytoma.
- Diffuse fibrillary astrocytoma.
Childhood High-Grade Astrocytomas:
- Anaplastic astrocytoma.
- Glioblastoma multiforme.
Refer to the PDQ summary on Childhood Astrocytomas Treatment for more information.
Childhood Central Nervous System (CNS) Atypical Teratoid/Rhabdoid Tumor
Refer to the PDQ summary on Childhood Central Nervous System Atypical Teratoid/Rhabdoid Tumor Treatment for more information.
Childhood Brain Stem Glioma
Childhood brain stem gliomas include:
- Diffuse intrinsic pontine gliomas.
- Focal or low-grade brain stem gliomas.
Refer to the PDQ summary on Childhood Brain Stem Glioma Treatment for more
information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
recurrent childhood brain stem glioma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
CNS Tumors in Children Aged 3 Years and Younger
Studies have addressed the treatment of infants who have progressive disease in
spite of chemotherapy. Approaches that have been used include further surgery,
chemotherapy, local and/or craniospinal radiation therapy, high-dose chemotherapy
supported by autologous stem cell rescue, or combinations of chemotherapy and
radiation therapy. Overall salvage rates have been less than optimal, but a
subgroup of children, primarily those with localized disease at the time of
relapse, may experience prolonged disease control and possible cure with
treatment after recurrence.[2][3][4][5][6][7] For children aged 2 years and younger, the use of high-dose craniospinal irradiation has been associated with poor neurocognitive outcome. Treatment for young children with multiple
recurrent and/or disseminated brain tumors is even more problematic and entry
into phase I and phase II trials is indicated to identify more effective and less
toxic agents.
Childhood CNS Embryonal Tumors
Childhood CNS embryonal tumors include:
- CNS atypical teratoid/rhabdoid tumors. (Refer to the PDQ summary on Childhood Central Nervous System Atypical Teratoid/Rhabdoid Tumor Treatment for more information.)
- Ependymoblastomas.
- Medulloblastomas.
- Medulloepitheliomas.
- Pineal parenchymal tumors of intermediate differentiation.
- Pineoblastomas.
- Supratentorial primitive neuroectodermal tumors.
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Childhood CNS Germ Cell Tumors
Childhood CNS germ cell tumors include:
- Germinomas.
- Embryonal yolk sac tumors.
- Choriocarcinomas.
- Immature teratomas.
- Mature teratomas.
- Teratomas with malignant transformation.
- Mixed germ cell tumors.
- Nongerminomatous germ cell tumors.
Germ cell tumors may be chemoresponsive. Patients may benefit from the types
of agents that are used to treat germ cell tumors in other locations; these agents include cisplatin, etoposide, and cyclophosphamide. Patients with recurrent germ cell tumors for whom the
standard chemotherapy options have failed may be entered into phase I and phase
II studies that are designed to determine the activity and toxic effects of
agents new to the treatment of this tumor.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
childhood central nervous system germ cell tumor. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood Craniopharyngioma
Refer to the PDQ summary on Childhood Craniopharyngioma Treatment for more information.
Childhood Ependymoma
Refer to the PDQ summary on Childhood Ependymoma Treatment for more information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
recurrent childhood ependymoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood Ependymoblastoma
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Childhood Low-Grade Glial Tumors
Surgical resection, radiation therapy (especially if not previously given),
and chemotherapy may result in prolonged disease stabilization for children
with recurrent low-grade tumors. Resection is an option for those patients
with a surgically accessible lesion and has the advantage of documenting the
histology of the recurrent tumor. Radiation therapy, if not previously given,
may result in tumor shrinkage and long-term disease control.
Chemotherapy with drugs such as carboplatin and vincristine has recently been
shown to result in tumor shrinkage and disease control for children with
low-grade glial neoplasms.[8] Similar results have been demonstrated for
hypothalamic and chiasmatic tumors treated with etoposide.[9] Entry into phase
I and phase II trials is indicated to identify more effective and less toxic
agents.
Childhood Medulloblastoma
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
recurrent childhood medulloblastoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood Medulloepithelioma
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
childhood medulloepithelioma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood Pineal Parenchymal Tumors
Childhood pineal parenchymal tumors include:
- Pineoblastomas.
- Pineocytomas.
- Pineal parenchymal tumors of intermediate differentiation.
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
recurrent childhood pineoblastoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood Spinal Cord Tumors
At the time of recurrence, low-grade spinal cord glial tumors can be
treated with re-resection with or without the use of radiation therapy.
Recurrent low-grade and high-grade tumors which cannot be re-resected can be
treated on protocols designed for histologically similar brain tumors.
For more information, refer to the PDQ summaries on Childhood Ependymoma Treatment and Childhood Central Nervous System Embryonal Tumors Treatment.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
recurrent childhood spinal cord neoplasm. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Childhood Supratentorial Primitive Neuroectodermal Tumors
Childhood suprantentorial primitive neuroectodermal tumors include:
- Primitive neuroectodermal tumors.
- Cerebral neuroblastomas.
Refer to the PDQ summary on Childhood Central Nervous System Embryonal Tumors Treatment for more information.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
recurrent childhood supratentorial primitive neuroectodermal tumor. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
References:
Jenkin D, Greenberg M, Hoffman H, et al.: Brain tumors in children: long-term survival after radiation treatment. Int J Radiat Oncol Biol Phys 31 (3): 445-51, 1995.
Fisher PG, Needle MN, Cnaan A, et al.: Salvage therapy after postoperative chemotherapy for primary brain tumors in infants and very young children. Cancer 83 (3): 566-74, 1998.
Walter AW, Mulhern RK, Gajjar A, et al.: Survival and neurodevelopmental outcome of young children with medulloblastoma at St Jude Children's Research Hospital. J Clin Oncol 17 (12): 3720-8, 1999.
Goldwein JW, Glauser TA, Packer RJ, et al.: Recurrent intracranial ependymomas in children. Survival, patterns of failure, and prognostic factors. Cancer 66 (3): 557-63, 1990.
Dupuis-Girod S, Hartmann O, Benhamou E, et al.: Will high dose chemotherapy followed by autologous bone marrow transplantation supplant cranio-spinal irradiation in young children treated for medulloblastoma? J Neurooncol 27 (1): 87-98, 1996.
Dunkel IJ, Boyett JM, Yates A, et al.: High-dose carboplatin, thiotepa, and etoposide with autologous stem-cell rescue for patients with recurrent medulloblastoma. Children's Cancer Group. J Clin Oncol 16 (1): 222-8, 1998.
Guruangan S, Dunkel IJ, Goldman S, et al.: Myeloablative chemotherapy with autologous bone marrow rescue in young children with recurrent malignant brain tumors. J Clin Oncol 16 (7): 2486-93, 1998.
Packer RJ, Lange B, Ater J, et al.: Carboplatin and vincristine for recurrent and newly diagnosed low-grade gliomas of childhood. J Clin Oncol 11 (5): 850-6, 1993.
Chamberlain MC, Grafe MR: Recurrent chiasmatic-hypothalamic glioma treated with oral etoposide. J Clin Oncol 13 (8): 2072-6, 1995.
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About PDQ
Additional PDQ Summaries
Important:
This information is intended mainly for use by doctors and other health care professionals. If you have questions about this topic, you can ask your doctor, or call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).
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This information is provided by the National Cancer Institute.
This information was last updated on October 14, 2009.