Pediatr Blood Cancer 2014;61:1520
LETTER TO THE EDITOR Stereotactic Body Radiation Therapy (SBRT) for an Isolated Bone Metastasis in an Adolescent Male With Nasopharyngeal Carcinoma To the Editor: Stereotactic Body Radiation Therapy (SBRT) allows for the delivery of high biologically effective dose (BED) of radiation to small, well-defined targets using 1 to 5 radiotherapy fractions. While its use in adult patients with early stage, non-small cell lung carcinoma and those with oligometastasis is well documented [1–3], there is limited information regarding its use in children [4,5]. We describe a case of an isolated bone metastasis treated with SBRT in a 12-year-old male with WHO Grade 3 nasopharyngeal carcinoma. Initial computerized tomography (CT) and magnetic resonance scan of the head and neck showed a mass within the nasopharynx and bilateral cervical nodal metastasis. Bone scan (Fig. 1A) showed osteoblastic activity in the left pelvis, and MRI confirmed the left iliac lesion. Although the differential diagnosis included osteoid osteoma, the lesion was most consistent for a metastatic focus of nasopharyngeal carcinoma. The patient was given three cycles of induction chemotherapy with 5-fluorouracil (5-FU) (1,000 mg/m2/day 4 days) and cisplatin (80 mg/m2/dose). The lesion showed significant improvement on both bone scan and MRI after induction therapy, providing clinical confirmation of metastatic disease. Cisplatin (100 mg/m2/dose q 21 days 2 doses, followed by a dose-reduction to 50 mg/m2/dose) was then given along with intensity modulated radiation therapy (61.2 Gy in 34 fractions over 6.8 weeks) to the nasopharynx and bilateral neck. After completion of chemoradiation, the left iliac bony metastasis received 40 Gy in 5 fractions, delivered every other day for 1.5 weeks using SBRT. Currently he is 4 years after completion of therapy, doing well without any evidence of progression. There has been no late complication such as bowel injury or bone fracture. A bone scan performed 3 years after SBRT (Fig. 1B) confirms sustained local control of the solitary iliac metastatic disease site. Radiotherapy doses traditionally used to target bone metastasis have a low BED and are more consistent with palliative rather than curative intent. Two of the most common regimens for bone
metastases have been 30 Gy in 10 fractions (BED, 39) and 8 Gy in 1 fraction (BED, 14.4). The dose (40 Gy in 5 fractions) we delivered to the iliac bone metastasis had a BED of 72, which is the same BED as delivering 60 Gy in 30 fractions, biologically very similar to what our patient received to the nasopharynx and cervical nodal disease. Several studies have confirmed the high efficacy and safety of SBRT for oligometastatic disease [2–3]. Only two publications exist in children. One is a review article with a Ewing sarcoma patient treated with SBRT for an isolated pulmonary metastasis after whole lung irradiation and salvage chemotherapy [4]. The other is an abstract of 27 osseous and pulmonary sites treated with SBRT in metastatic bone sarcoma. Five local failures occurred; however, median follow-up was only 7.4 months [5]. Future studies are needed to assess the efficacy and safety of SBRT in the pediatric population, given the limited literature that is currently available.
ACKNOWLEDGMENTS CUL is supported by a Sidney Kimmel Foundation for Cancer Research Scholar Award. Benjamin Farnia, BA Bin S. Teh, MD Department of Radiation Oncology Houston Methodist Hospital Houston, Texas Chrystal U. Louis, MD Department of Pediatrics Baylor College of Medicine Houston, Texas Arnold C. Paulino, MD Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas Department of Pediatrics, Baylor College of Medicine Houston, Texas
REFERENCES 1. Chang JY, Roth JA. Stereotactic body radiation therapy for stage I non-small cell lung cancer. Thorac Surg Clin 2007;17:251–259. 2. Milano MT, Katz AW, Muhs AG, et al. A prospective pilot study of curative-intent stereotactic body radiation therapy in patients with 5 or fewer oligometastatic lesions. Cancer 2008;112:650–658. 3. Muacevic A, Kufeld M, Rist C, et al. Safety and feasibility of image-guided robotic radiosurgery for patients with limited bone metastases of prostate cancer. Urol Oncol 2013;31:455–460. 4. Siddiqui F, Kunos CA, Paulino AC. Stereotactic body radiation therapy in head and neck, gynecologic and pediatric malignancies. J Radiat Oncol 2012;1:31–42. 5. Brown LC, Lester RA, Haddock MG, et al. Stereotactic body radiation therapy (SBRT) for pediatric bone tumors. Int J Radiat Oncol Biol Phys 2013;87S:S71
Conflict of interest: CUL holds patents with or receives royalties from Cell Medica. Fig. 1. Bone scan images (A) prior to stereotactic body radiotherapy (SBRT) (B) 3 years after SBRT showing resolution of uptake in the left iliac bone lesion. R: right side.
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2014 Wiley Periodicals, Inc. DOI 10.1002/pbc.24963 Published online 4 February 2014 in Wiley Online Library (wileyonlinelibrary.com).
Correspondence to: Arnold Paulino, Department of Pediatrics, Baylor College of Medicine, Houston, TX. E-mail: [email protected]
Received 18 December 2013; Accepted 6 January 2014
LETTER TO THE EDITOR Stereotactic Body Radiation Therapy (SBRT) for an Isolated Bone Metastasis in an Adolescent Male With Nasopharyngeal Carcinoma To the Editor: Stereotactic Body Radiation Therapy (SBRT) allows for the delivery of high biologically effective dose (BED) of radiation to small, well-defined targets using 1 to 5 radiotherapy fractions. While its use in adult patients with early stage, non-small cell lung carcinoma and those with oligometastasis is well documented [1–3], there is limited information regarding its use in children [4,5]. We describe a case of an isolated bone metastasis treated with SBRT in a 12-year-old male with WHO Grade 3 nasopharyngeal carcinoma. Initial computerized tomography (CT) and magnetic resonance scan of the head and neck showed a mass within the nasopharynx and bilateral cervical nodal metastasis. Bone scan (Fig. 1A) showed osteoblastic activity in the left pelvis, and MRI confirmed the left iliac lesion. Although the differential diagnosis included osteoid osteoma, the lesion was most consistent for a metastatic focus of nasopharyngeal carcinoma. The patient was given three cycles of induction chemotherapy with 5-fluorouracil (5-FU) (1,000 mg/m2/day 4 days) and cisplatin (80 mg/m2/dose). The lesion showed significant improvement on both bone scan and MRI after induction therapy, providing clinical confirmation of metastatic disease. Cisplatin (100 mg/m2/dose q 21 days 2 doses, followed by a dose-reduction to 50 mg/m2/dose) was then given along with intensity modulated radiation therapy (61.2 Gy in 34 fractions over 6.8 weeks) to the nasopharynx and bilateral neck. After completion of chemoradiation, the left iliac bony metastasis received 40 Gy in 5 fractions, delivered every other day for 1.5 weeks using SBRT. Currently he is 4 years after completion of therapy, doing well without any evidence of progression. There has been no late complication such as bowel injury or bone fracture. A bone scan performed 3 years after SBRT (Fig. 1B) confirms sustained local control of the solitary iliac metastatic disease site. Radiotherapy doses traditionally used to target bone metastasis have a low BED and are more consistent with palliative rather than curative intent. Two of the most common regimens for bone
metastases have been 30 Gy in 10 fractions (BED, 39) and 8 Gy in 1 fraction (BED, 14.4). The dose (40 Gy in 5 fractions) we delivered to the iliac bone metastasis had a BED of 72, which is the same BED as delivering 60 Gy in 30 fractions, biologically very similar to what our patient received to the nasopharynx and cervical nodal disease. Several studies have confirmed the high efficacy and safety of SBRT for oligometastatic disease [2–3]. Only two publications exist in children. One is a review article with a Ewing sarcoma patient treated with SBRT for an isolated pulmonary metastasis after whole lung irradiation and salvage chemotherapy [4]. The other is an abstract of 27 osseous and pulmonary sites treated with SBRT in metastatic bone sarcoma. Five local failures occurred; however, median follow-up was only 7.4 months [5]. Future studies are needed to assess the efficacy and safety of SBRT in the pediatric population, given the limited literature that is currently available.
ACKNOWLEDGMENTS CUL is supported by a Sidney Kimmel Foundation for Cancer Research Scholar Award. Benjamin Farnia, BA Bin S. Teh, MD Department of Radiation Oncology Houston Methodist Hospital Houston, Texas Chrystal U. Louis, MD Department of Pediatrics Baylor College of Medicine Houston, Texas Arnold C. Paulino, MD Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas Department of Pediatrics, Baylor College of Medicine Houston, Texas
REFERENCES 1. Chang JY, Roth JA. Stereotactic body radiation therapy for stage I non-small cell lung cancer. Thorac Surg Clin 2007;17:251–259. 2. Milano MT, Katz AW, Muhs AG, et al. A prospective pilot study of curative-intent stereotactic body radiation therapy in patients with 5 or fewer oligometastatic lesions. Cancer 2008;112:650–658. 3. Muacevic A, Kufeld M, Rist C, et al. Safety and feasibility of image-guided robotic radiosurgery for patients with limited bone metastases of prostate cancer. Urol Oncol 2013;31:455–460. 4. Siddiqui F, Kunos CA, Paulino AC. Stereotactic body radiation therapy in head and neck, gynecologic and pediatric malignancies. J Radiat Oncol 2012;1:31–42. 5. Brown LC, Lester RA, Haddock MG, et al. Stereotactic body radiation therapy (SBRT) for pediatric bone tumors. Int J Radiat Oncol Biol Phys 2013;87S:S71
Conflict of interest: CUL holds patents with or receives royalties from Cell Medica. Fig. 1. Bone scan images (A) prior to stereotactic body radiotherapy (SBRT) (B) 3 years after SBRT showing resolution of uptake in the left iliac bone lesion. R: right side.
C
2014 Wiley Periodicals, Inc. DOI 10.1002/pbc.24963 Published online 4 February 2014 in Wiley Online Library (wileyonlinelibrary.com).
Correspondence to: Arnold Paulino, Department of Pediatrics, Baylor College of Medicine, Houston, TX. E-mail: [email protected]
Received 18 December 2013; Accepted 6 January 2014
