PENTEC GUIDELINES FOR PAEDIATRIC RADIOTHERAPY

PENTEC GUIDELINES FOR PAEDIATRIC RADIOTHERAPY

1. PENTEC GUIDELINES DR KANHU CHARAN PATRO MD,DNB(Radiation Oncology),MBA,FICRO,FAROI(USA),PDCR,CEPC HOD,RADIATION ONCOLOGY Mahatma Gandhi Cancer Hospital And Research Institute, Visakhapatnam [email protected] /M- [phone] RGCON 25 th FEB 2023 1

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5. Craniofcialdeformity 5

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14. ADULT VS KID Physical development Cognitive development 14

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16. In pediatric population all are OARs except PTV 16

17. PTV is the priority OAR is the OCD 17

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19. Radiation requirement 19

20. SITUATIONS 20

21. F/UP HEAD &NECK 21

22. F/UP 22

23. LATE EFFECTS 23

24. MULTIDISCIPLINARY 24

25. SPARSE LITERATURE VAGUE RECOOMENDATIONS 25

26. QUANTEC VS PENTEC QUANTEC Quantitative Analyses of Normal Tissue Effects in the Clinic PENTEC Pediatric Normal Tissue Effects in the Clinic 26

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28. PENTEC GOALS With advances in multimodality therapy, childhood cancer cure rates approach 80%. However, both radiotherapy and chemotherapy may cause debilitating or even fatal “late effects” that are critical to understand, mitigate, or prevent Data analysis is challenging due to the influence of both therapeutic and developmental variables. PENTEC (Pediatric Normal Tissue Effects in the Clinic) is a group of physicians, physicists and epidemiologists conducting a critical synthesis of existing literature aiming to: Develop quantitative evidence-based dose/volume guidelines to inform treatment planning and improve outcomes for survivors of radiation therapy for childhood cancers, Describe relevant physics issues specific to pediatric radiotherapy Propose dose-volume-outcome reporting standards to systematically inform future treatment guidelines. 28

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30. PENTEC PUBLICATIONS 30

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33. EPIPHYSIS 33

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40. Ossification centers primary and secondary We recommend that delineation of the vertebrae should include at least the primary ossification centres and growth plates. Therefore, the vertebral body and the vertebral arch should be included There is no need to include secondary ossification centres , as they form after the pubertal growth spurt and induce no substantial growth. 40

41. SOME TIPS ABOUT GROWTH OF SPINE Spine accounts 60% of all sitting heights Dose constraints and dose gradient in vertebra is required Most of the growth reduction seems to be caused by microvascular damage in the proliferative zone of the growth plate Radiotherapy also has a direct effect on proliferating chondroblasts Surviving clones eventually repopulate , and the recovery is indirectly proportional to the radiation dose given Disproportionate growth in sitting height after whole spinal radiotherapy, which they found was most marked in children receiving doses of more than 35 Gy, as opposed to doses of less than 25 Gy. Greatest height impairment was at doses of more than 33 Gy to the entire spine at the age of 11 years or younger for boys and 9 years or younger for girls Lumbar spine was found to be more affected than the cervical or thoracic spine 41

42. VERTEBRAL GROWTH The individual lumbar vertebrae grow at a higher velocity than the thoracic vertebrae (2 mm per year vs 1 mm per year) The posterior elements grow more slowly than the anterior components in the lumbar spine, and vice versa in the thoracic spine, resulting in the adult lordotic and kyphotic curves, respectively 42

43. Scoliosis- LATERAL GRADIENT High risk of scoliosis that is associated with a steep vertebral gradient, with resulting early-onset functional problems, must be balanced against the potential and small increase in risk of future osteoporosis, compaction fractures, or induction of bone sarcoma that is associated with homogeneous dose distributions. The effects of left-right gradients are more clinically relevant than posterior-anterior or craniocaudal gradients 43

44. Anterior posterior gradient in CSI 44

45. Vertebral contouring-entire vertebra 45

46. Vertebral dose gradient SIOP guidelines 46

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48. Kyphoscoliosis 48

49. Endocrinopathies Childhood cancer survivors are at risk for a wide range of treatment-related complications, which may occur many years after therapy, including diabetes and metabolic syndrome. While specific risk factors for metabolic dysfunction, including cranial, abdominal, and total body irradiation , have been identified, the exact mechanisms underlying these derangements remain unclear. Data are similarly lacking on survivor-specific preventive strategies and treatment recommendations for metabolic dysfunction in this high-risk population. Survivors, however, remain at lifelong risk for the development of treatment-related complications, collectively known as “late effects.” Endocrinopathies, which include diabetes mellitus 49

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51. DIABETES 51

52. THE DIABETIC RISK Among 2,520 French-UK survivors of childhood solid cancer or lymphoma, the relative risk of diabetes was 11.5 (95% confidence interval [CI], 3.9-34.0) among survivors who received ≥10 Gy to the pancreatic tail ; risk increased with increasing dose to the tail of the pancreas through 20-29 Gy with subsequent plateau in risk. In contrast, a more recent analysis of 2,264 Hodgkin lymphoma survivors in the Netherlands found that risk of diabetes significantly increased with higher mean radiation doses to the tail without any evident plateau in risk (p<0.001). Survivors treated with ≥ 36 Gy to the para-aortic lymph nodes and spleen, which includes most of the volume of the pancreas, were at highest risk. 52

53. Primary hypothyroidism 53

54. Lens and retina 54

55. RETINOPATHY 55

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57. The optic tract 57

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59. Cochlea 59

60. Medulla 60

61. Neurocognitive 61

62. Hippocampus 62

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66. Radiation myelitis 66

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68. LKB MODEL 68

69. TBI and lung toxicity 69

70. Pulmonary toxicity 70

71. Cardiac toxicity 71

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73. Heart subsegments 73

74. Ovarian toxicity 74

75. Breast hypoplasia 75

76. Xerostomia 76

77. Spermatogenesis 77

78. Ototoxicity 78

79. Cerebrovascular Events  NO DATA 79

80. Renal toxicity NO DATA 80

81. Summary Data is sparse Hope PENTEC will solve in future Care should be taken for vertebral is the part of radiation Anterior posterior gradient in CSI is important Lateral gradient in Wilms tumor/neuroblastoma RT Please take care of the child 81

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