Medulloblastoma+(Adult)

with a peak at 3 years[2,10] || __Treatment dose guidelines __ __Treatment field parameters __ Cranium Cranium “Helmet” Spine Boost Posterior fossa: Limited Cranial field boost: 1-1.5 cm margin around the GTV [13] [14]  [15]  Cranial field Angle collimator on lateral fields to align posterior aspect of skull, external auditory canal and lateral canthus and/or use custom blocks or MLC Gantry can also be angles 2-3 degrees posterior off lateral to eliminate beam divergence into contralateral eye Spine field Superior border must match the inferior border of the cranial field S3 must be included in the spine field If 2 separate spine fields are needed to encompass length of spine, gap calculation is necessary for superior/inferior field separation [15,16] [17] D2L, Brain PPT, slide 28 ||
 * Epidemiology: || <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%; margin-bottom: 0pt;">Medulloblastoma is the most common central nervous system (CNS) tumor in children from the ages 0-19. This tumor is rarely seen in adults age 20 and greater. As the age increases the likelihood of developing medulloblastoma is reduced significantly. After the age of 50 this tumor rarely occurs. According to Ciurea, “ It is estimated that only 29% of medulloblastomas occur in patients age 20 or older. Sixty two percent of patients are male (61% age <20 and 63% age≥20).” [1] ||
 * Etiology: || <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">“Etiologic factors are unknown; however, there are reported associations with the following syndromes”:
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">- Ataxia-telangiectasia
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">- Rubinstein- Taybi sndrome
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">- Gorlin syndrome
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">- Turoct syndrome
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">- Li- Fraumeni syndrome [1] ||
 * Signs & Symptoms: || [[image:Medulloblastoma[1].jpg width="640" height="306"]] ||
 * Diagnostic Procedures: || * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">Complete History and Work up [2,3]
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">General Physical exam [2,3]
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">Complete Blood work (CBC & chemistries)
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">Complete Neurologic examination- Assess mental status, coordination, reflexes, & motor and cranial nerves [2,3]
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">Opthalmoscopy – check for papilladema associated with ↑ cranial pressure [2]
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">CT Scan of brain with and without contrast shows bony extension for disease if present [2,3]
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">MRI – T1 weighted for anatomy delineation and T2 weighted for edema and tumor localization [2,3]
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">Biopsy – when and where possible depending on location and size. Either stereotactic with needle or open craniotomy.
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">Post Fossa Tumors – Indicate CSF spinal axis staging, (CSF cytology, preoperative Myelogram / MRI) [2,3] ||
 * Histology: || <span style="background-color: transparent; color: #ff0066; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%; text-decoration: none; vertical-align: auto;">Medulloblastomas are considered to be highly cellular neoplasms that are made up of small to medicum hyperchormatic nuclei and a small amount of cytoplasm. The World Health Organization defines them as a grade IV because they are considered to be malignant and invasive tumors. [5] ||
 * Lymph Node Drainage: || ** <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">There are no lymphatic channels in the brain and therefore do not metastasize through the lymphatic system [6] ||
 * Metastatic Spread: || <span style="background-color: transparent; color: #ff0066; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%; text-decoration: none; vertical-align: auto;">Medulloblastoma is known to spread via cerebral spinal fluid and can be determined 30% of the time through presentation. The tumor may infiltrate subpial and parenchymal. Remote metastases are rare. Medulloblastomas may metastasize out of the central nervous system by ventriculoperitoneal shunts or other means. [7] ||
 * Grading: || <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> Graded on a scale of I to IV World Health Organization [WHO] Grading system [8] * Grade I tumors are slow-growing, nonmalignant, and associated with long term survival.
 * <span style="color: #7030a0; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 150%;">Grade II tumors are relatively slow-growing but sometimes recur as higher grade tumors. They can be nonmalignant or malignant.
 * <span style="color: #7030a0; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 150%;">Grade III tumors are malignant and often recur as higher grade tumors.
 * <span style="color: #7030a0; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 150%;">Grade IV tumors reproduce rapidly and are very aggressive malignant tumors. ||
 * Staging: || <span style="color: #7030a0; font-family: 'Times New Roman',Times,serif; font-size: 120%; font-weight: normal;">Chang System [9]
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> T1 : tumor ≤3cm, confined to cerebellum, vermis, roof of 4th ventricle
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> T2: tumor >3cm, invading one adjacent structure or partially filling 4th ventricle
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> T3a: tumor is invading 2 adjacent structures, complete filling 4th ventricle with proximal or distal extension
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> T3b: tumor arising from floor of 4th ventricle and/or brainstem and filling the 4th ventricle
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> T4: Involving 3rd ventricle/ midbrain/upper cervical cord
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> M0: No evidence of gross subarachnoid or hematogenous metastasis
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> M1: Microscopic tumor cells in Cerebrospinal Fluid (CSF)
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> M2: Nodular seeding intracranially beyond primary site ( in cerebellar/cerebral subarachnoid space, 3rd or lateral ventricles)
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> M3: Nodular seeding in spinal subarachnoid space
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> M4: Extraneuraxial metastasis ( outside cerebrospinal axis) ||
 * Radiation Side Effects: || <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Adults tend to experience acute side effects to a greater degree than children.
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Alopecia
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Headaches
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Seizures
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Short term memory deficiency
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Decreased appetite
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Loss of balance and/or trouble walking
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Otitis externa
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Serous otitis media
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Dermatitis
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Hormone dysfunction
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">High tone hearing loss
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Vestibular damage
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Nausea and vomiting
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Fatigue
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Dysphasia
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Secondary tumor
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Death[2,10]
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Neuroendocrine dysfunction[11]
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Neurologic deterioration Can begin 6-12 months following radiation treatment.
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Radiation necrosis Can appear after 6 months following radiation treatment
 * Prognosis: || ** <span style="color: #4f6228; font-family: 'Times New Roman',Times,serif; font-size: 120%;">The three most important prognostic factors are age, performance status, and tumor type. Tumor grade is a stronger factor than size. The average 5 year survival is about 60%. ||
 * Treatments: || __<span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Treatment __
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Initial treatment is corticosteroid or shunting prior to surgery [12]
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Followed by complete surgical resection
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Following surgery Post-op radiation therapy
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Craniospinal axis fields with primary lesion boost
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">No chemotherapy [2]
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Whole sub-arachnoid 160-180cGy per fraction 30-40Gy
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Posterior fossa boost 180cGy per fraction to Total 50-55Gy [2] or 54-55.8Gy [13]
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Hyperfractionated boost to posterior fossa can take to Total of 55-60Gy
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Full CSI 180cGy per fraction 36Gy
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Spinal mets 180cGy per fraction 45-50Gy [13]
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Junction shift every 10Gy
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Superior 1-2 cm flash off cranium
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Inferior C2-C3 interface
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Posterior 1-2 cm flash off cranium
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Anterior 1-2 cm flash off cranium
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Central Axis Pineal region
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Superior 1-2 cm flash off cranium
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Inferior Lowest border of lowest cervical vertebra without treating ipsilateral shoulder
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Posterior 1-2 cm flash off cranium
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Anterior 1-2 cm flash off cranium
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Central Axis Pineal region
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Superior Match the inferior border of the cranial field edge
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Inferior 2 vertebral bodies below the pre-op tumor extension
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Lateral 1 cm lateral to the lateral edge of each ipsilateral pedicle
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Parallel opposed lateral
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Posterior obliques
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Multifield [13]
 * TD5/5: || [[image:5_table[1]_(2).jpg width="560" height="268"]][15] ||

<span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">**Shun** Epidemiology and Etiology <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%;">**Eric** Signs, Symptoms and Diagnostic Procedures <span style="background-color: transparent; color: #4f6228; display: block; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-align: left; text-decoration: none; vertical-align: auto;">**Curtis** Lymph node drainage, Prognosis and TD 5/5 <span style="background-color: #ffffff; color: #ff0066; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; vertical-align: auto;">**Lisa** Histology and Metastatic spread <span style="color: #7030a0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">**Kim** Grading and Staging <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%;">**LaDonna** Radiation side effects and Treatment

<span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">[1] Medulloblastoma. Web site. Available at: []. Accessed May 30th 2011. <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">[2]Chaos KS, Perez CA, Brady KW. //Radiation Oncology-Management Decisions.// 2nd edition. Philadelphia: Lippincott, Williams & Wilkins. 2002 <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">[3] [] accessed 6/1/11 <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">[4] [] accessed 6/1/11 <span style="background-color: transparent; color: #ff0066; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; text-decoration: none; vertical-align: auto;">[5] Medscape Reference. //Medulloblastoma pathology microscopic findings//. Available at: <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">[] <span style="background-color: transparent; color: #ff0066; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; text-decoration: none; vertical-align: auto;">Accessed June 3, 2011 <span style="color: #4f6228; font-family: 'Times New Roman',Times,serif; font-size: 120%;">[6]Washington, Charles, and Dennis Leaver. Principles and Practices of Radiation Therapy. St. Louis, Missouri: Mosby Elsevier, 2010. Print <span style="background-color: transparent; color: #ff0066; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; text-decoration: none; vertical-align: auto;">[7] Medscape Reference. //Medulloblastoma pathology tumor spread and staging//. Available at: <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">[] <span style="background-color: transparent; color: #ff0066; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; text-decoration: none; vertical-align: auto;">Accessed June 3, 2011. <span style="color: #7030a0; font-family: 'Times New Roman',Times,serif; font-size: 120%; margin-bottom: 0pt;">[8]Wikipedia. //WHO Classification//. Available at http://en.wikipedia.org/wiki/WHO <span style="color: #7030a0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">[9]Hansen E, Roach M. //Handbook of Evidence-based Radiation Oncology//. New York:Springer. 2007 <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">[10]American Brain Tumor Association (ABTA). Focusing on tumors: Medulloblastoma. Available at: [] Accessed on May 28, 2011. <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">[11]Merchant, T.E., Happersett, L., Finlay, J.L. and Libel, S.A. (1999) Preliminary results of conformal therapy for medulloblastoma. Neuro-Oncology, July 1999. Available at: [] Accessed on May 28, 2011 <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">[12]University of Wisconsin-LaCrosse, DOS 431 D2L Brain PPT, slide 17 <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">[13] Halperin E, Perez CA, Brady LW. //Perez and Brady's Principles and Practice of Radiation Oncology//. 5th edition. Philadelphia:Lippincott, Williams & Wilkins. 2008 <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">[14]Merchant, T.E., Happersett, L., Finlay, J.L. and Libel, S.A. (1999) Preliminary results of conformal therapy for medulloblastoma. Neuro-Oncology, July 1999. Available at: [] Accessed on May 28, 2011. <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">[15] Khan FM. //Treatment Planning in Radiation Oncology//. 2nd ed. Philadelphia, PA; Lippincott Williams & Wilkins; 2007. <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">[16]Bentel, GC. Radiation therapy planning. 2nd edition. Chapter 10, Treatment planning-central nervous system and pituitary gland. Macmillan Publishing Company; 1992 <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%;">[17]University of Wisconsin-LaCrosse, DOS 431 D2L, Brain PPT, slide 28
 * __References__**