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Posterior fossa treatment

The interesting and commendable comparisons of conventional, conformal and intensity-modulated coplanar radiotherapy plans for posterior fossa treatment of medulloblastoma patients [1] confirm the widely held doubts about application of intensity-modulated radiotherapy (IMRT) techniques in children. The associated "dose bath" effect obtained with IMRT could be deleterious not only to growing tissues in terms of deleterious functional effects but also there is the potential enhanced increased risk of stochastic effects such as induction of second malignancy [2].

This treatment planning exercise will be informative to British radiotherapy centres that possess the techniques used in the study, although there is a risk of complacency because of our characteristic insular approach to radiotherapy. The availability of more sophisticated proton beams abroad allows for better dose distributions than those demonstrated. The French group (Paris/Orsay) are developing a cochlear sparing technique [3] and at the Northeast Proton Therapy Centre (Boston), sparing of spinal exit dose to include only 0.7 cm of the vertebral body has now been achieved, with good in vivo verification in terms of the delineation of bone marrow changes on MRI [4].

We British are accustomed to shortages and severe economic constraints in healthcare, but the time has arrived to consider offering the best available treatment based on improvements in physical dose distributions, particularly to our children. I would encourage our most highly specialist centres to obtain proton therapy planning software so that the appropriate isodose comparisons can be made in individual cases. This will allow clinicians and parents of children to be better informed of the potential advantages. It can only be a matter of time before Government will decide to invest in high energy particle therapy within the UK, but in the meantime we should strive to educate ourselves and prepare for such necessary developments.

Yours etc.,

B Jones

Department of Clinical Oncology, Queen Elizabeth University Hospital, Birmingham B15 2TH

Received for publication October 28, 2004. Accepted for publication November 3, 2004.

References

1. Breen SL, Kehagioglou P, Usher C, Plowman PN. A comparison of conventional, conformal and intensity-modulated coplanar radiotherapy plans for posterior fossa treatment. Br J Radiology 2004;77:768–74.[Abstract/Free Full Text]
2. Miralbell R, Lomax A, Cella L, Schneider U. Potential reduction of the incidence of radiation-induced second cancers by using proton beams in the treatment of pediatric tumors. Int J Radiat Oncol Biol Phys 2002;54:824–9.[CrossRef][Medline]
3. Jones B, Rosenberg I. Particle Therapy Co-operative Oncology Group (PTCOG 40) Meeting, Institute Curie 2004. Br J Radiol 2005;78:99–102.[Free Full Text]
4. Adams J, Liebsch NJ (personal communication, October 2004).

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P N Plowman and C Usher
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