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CLINICAL INVESTIGATION Brain
A RETROSPECTIVE STUDY OF SURGERYAND REIRRADIATION FOR RECURRENT
EPENDYMOMA
THOMAS E. MERCHANT, D.O., PH.D., FREDERICK A. BOOP, M.D., LARRY E. KUN , M.D.,
AND ROBERT A. SANFORD, M.D.
Department of Radiological Sciences, Division of Radiation Oncology, St. Jude Children’s Research Hospital, Memphis, TN
Purpose: To report disease control for patients with recurrent ependymoma (EP) treated with surgery and a second
course of radiation therapy (RT2 ).
Patients and Methods: Thirty-eight pediatric patients (median age, 2.7 years) with initially localized EP at the time
of definitive RTunderwent a second course of RT after local (n = 21), metastatic (n = 13), or combined (n = 4) fail-
ure. Reirradiation included radiosurgery (n = 6), focal fractionated reirradiation (n = 13), or craniospinal irradi-
ation (CSI; n = 19).
Results: Initial time to failure was 16 months, and median age at second treatment was 4.8 years. Radiosurgery
resulted in significant brainstem toxicity and one death (median dose, 18 Gy). Progression-free survival ratio
was greater than unity for 4 of 6 patients; there was one long-term survivor. Three of 13 patients treated using focal
fractionated reirradiation (median combined dose, 111.6 Gy) experienced metastasis. The CSI was administered to
12 patients with metastatic failure, 3 patients with local failure, and 4 patients with combined failure. The 4-year
event-free survival rate was 53% ± 20% for 12 patients with metastatic failure treated with CSI. Failure after CSI
was observed in 1 of 3 patients with a history of local failure and 3 of 4 patients with a history of combined failure.
Conclusion: Patients with locally recurrent EP experience durable local tumor control, but remain at risk of metas-
tasis. Patients with metastatic EP failure may receive salvage therapy that includes a component of CSI. Durability
of disease control and long-term effects from this approach require further follow-up. 2008 Elsevier Inc.
Radiotherapy, Re-treatment, Ependymoma, Pediatrics, CNS neoplasms, Toxicity.
INTRODUCTION
Children with ependymoma (EP) for which treatment fails
after surgery and radiation therapy (RT) have few options:
chemotherapy may prolong survival, but is not curative,
and surgeons are reluctant to approach recurrent disease with-
out the backing of effective adjuvant salvage therapy.
Fractionated reirradiation may be a potential treatment for
these patients. However, guidelines have not been estab-
lished, relative benefits and risks are unknown, and most re-
ported reirradiation series included patients with diverse
diagnoses and combined adult and pediatric patients
Single-fraction radiosurgery was used in selected patients
with locally recurrent or metastatic EP with mixed results.
Morbidity was high, and durable disease control was not
clearly shown . Fractionated reirradiation has not been
systematically explored for patients with EP, mainly because
these patients tend to be young and pediatric oncologists are
not familiar with reirradiation as a treatment option.
We identified 38 patients with EP recurrent after previous
surgery and conventionally fractionated RT and subse-
quently treated with radiosurgery, focal fractionated reirra-
diation (FFRT), or craniospinal irradiation (CSI) at our
institution. We reviewed treatment and outcomes for these
patients with the hope of developing guidelines for reirradia-
tion or highlighting the relative risks based on clinical infor-
mation. From a review of the data, three groups emerged to
focus our effort to outline strategies for the use of radiation
as a salvage therapy for patients with EP.
PATIENTS AND METHODS
Thirty-eight patients with EP recurrent after surgery and RT and
subsequently treated by using single-fraction radiosurgery (n = 6),
FFRT (n = 13), and CSI (n = 19) were identified for an institutional
review board–approved retrospective review.
Review of patient information included, at a minimum, date of
birth, diagnosis, surgery, chemotherapy, RT, disease progression
Reprint requests to: Thomas E. Merchant, D.O., Ph.D., Division
of Radiation Oncology, Mail Stop 220, St. Jude Children’s Research
Hospital, 332 North Lauderdale Street, Memphis, TN 38105. Tel:
(901) 495-3604; Fax: (901) 495-3113; E-mail:
Supported in part by Cancer Center Support Grant No. CA21765
from the National Cancer Institute, Research Project Grant No.
RPG-99-252-01-CCE from the American Cancer Society, and the
American Lebanese Syrian Associated Charities.
Presented in part at The Children’s Oncology Group Fall Meet-
ing, Los Angeles, CA, Oct 3–7, 2006.
Conflict of interest: none.
Received Jan 13, 2007, and in revised form Sept 5, 2007.
Accepted for publication Sept 12, 2007.
87
Int. J. Radiation Oncology Biol. Phys., Vol. 71, No. 1, pp. 87–97, 2008
Copyright 2008 Elsevier Inc.
Printed in the USA. All rights reserved
0360-3016/08/$–see front matter
doi:10.1016/j.ijrobp.2007.09.037