Protontherapy in paediatric skull base and cervical canal chordomas. Long term outcome Jean-Louis Habrand, MD François Baclesse Cancer Center- Caen University, Institut Curie-Proton Therapy Center (ICPO), Orsay, & Institut Gustave Roussy, Villejuif, Fr
Background: notochordal origin
Age-specific incidence rate by histological types Grimer et al, 2013
Epidemiology Adults: 0.08 per 100,000 people M/F SR: 1.8:1 Med age: 60 Y Children-adolescents: < 5% CH (% / 4!) M/F SR: 1:1 Metastases: 9-60% (youngsters +)
Anomical sites adults vs children SITES ADULTS / CHILDREN INTRA CRANIAL 35% vs 54% SPINE 15% vs 23% SACRUM/COCCYX 50% vs 22%
Young vs older children (5 Y) Intra cranial: 61% 72% Spinal: 13.6% 22% Sacral: 25.4% 6% Undiff: 25.4% 9.4% Mets: 45.8% 11.1% OS: 3Y:45.8% 5Y:66.1%
Malignant subtypes Differentiated & undifferentiated (WHO, 2013) Differentiated Undifferentiated Brachyury + + Brachyury - - IHC IHC Flanagan, Yamaguchi, 2013
Altered differentiations Chondroid-like Hepatocyte-like
Benign subtypes: precursors? BNCT*, EP** (WHO, 2013) Intra osseous Mixed with hematopoietic Lack architecture Adipocyte-like cells (colloid material) Low power *Benign Notochordal Cell Tumours **Ecchordosis Physaliphora Spheno-occipitalis High power Flanagan, Yamaguchi, 2013
Protocol Surgical resection, for: - pathology determination - maximal debulking - spacing critical structures from target (+) - in 1 or multiple successive approaches Post op radiotherapy: - within 2 months - using P alone or combined X-P Follow-up: - Physical, MRI ± Pituitary, audiol, visual - Y1-2 : 3 m - Y 2-5: 6 m - Y 5+ : 12 m
Adolescent pt. L.: pre op imaging Choanae C2
Patient L.: post op imaging Op # 1 Op # 2 Minimal residual?
One limitation: Metallic osteosynthesis Occipito-cervical Cervico-thoracic
ICPO renovation (Orsay, 2010)
General anesthesia: required,children < 4Y
Stereotactic alignment: the best set-up 2 2 1 «Rotaplus» program: -Virtual triangles between gold 3 seeds (DRRs)... -Compared with actual position on orthogonal X-Rays 4
Stereotactic alignment : but the most cumbersome
Patient s positioning FIDUCIALS MEDCOM (IBA)
COMBINED PHOTONS/PROTONS Dosi Patient L. AX. 68 GyEq 55GyEq
EXCLUSIVE PROTONS
Population From 07/1996 to 03/2010 34 children/adolescents with cranial/cervical Chordomas Mean age: 13 Y (6-18 Y) M/F SR: 1.4:1
Symptoms at presentation 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Visual Neurol Hydrocephalus ENT Pains Auditory
Quality of resection # (%) R2 33 (97%) R1 1(3%) Total 34 (100%)
Radiotherapy: Total dose (Gy Eq) min Mean Max Tot 60 69.1 72 X 0 30.9 45 P 20 38.3 72
Acute toxicity: cutaneous NO 29% 71% YES
Acute toxicity: Hydrocephalus 41% YES NO 59%
Acute toxicity: mucosal 21% YES 79% NO
Failures Mean Follow-up: 76 m (17-158) 8 local-regional recurrences Including 1 surgical route seeding, & 1 marginal No initial mets
Patient L.: Surgical route seeding
Local failures «profile» FAILURES (8) Pain at presentation: 80% (4/5) Cervical involt: 27% (4/15) M: 80% (4/5) Age: mean 14 Y NON FAILURES (26) Pain at presentation: 14% (4/29) Cervical involt: 21% (4/19) M: 57% (12/21) Age: mean 12 Y
10-Y OS and 10-Y DFS 1,8,6,4,2 10-Y OS = 89% (95%CI:77-100) 10-Y DFS = 76% (95%CI:62-93) 0 N=34 0 20 40 60 80 100 120 140 160 TIME (months)
Late toxicity NEUROLOGICAL 32% 5% VISUAL 29% 50% AUDITORY HORMONAL On 28 evaluable
Late combined toxicity Visual Auditory 0% 28% 7% 0% 7% 14% Hormonal On 28 evaluable
Late radiation-induced severe toxicity HORMONAL AUDITORY NEUROLOGICAL NEUROLOGICAL 4% 4% VISUAL 0% 36% AUDITORY HORMONAL On 28 evaluable
Discussion Is the combination surgery-proton therapy the best?
Méta analyse (Medline, 1999-2008, 807 pts)
Gross total resection 5Y:87% yes 5Y:50% no p.0001 yes 5Y:95% 5Y:71% no p.001
Post op therapy pns pns
Chordomas: Molecular genetic profile
Medical treatment of failing chordomas
Inoperable sacral chordoma Imatinib (400mg/Jr) + Sirolimus (2 mg/jr) Initial + 3 mois
Metastatic chordoma Sirolimus 3m SD Imatinib 6m PR
Conclusion In pediatric chordomas, Proton therapy combined with maximal tumour resection provides : # 90% and 75%, 10 Y OS / DFS Excellent immediate tolerance, despite high dose administered Low long term toxicity, except on pituitary function
Conclusion (cont) Very late failures are possible, and justify extended follow-up Biological agents, chemotherapy, reirradiation using protons, cyberknife, tomotherapy can provide interesting palliations