The Necessity of Cranial Radiation in Pediatric Leukemia Treatment

Q: The Necessity of Cranial Radiation in Pediatric Leukemia Treatment

Mr. <br>Apple： Indeed, cranial radiation therapy can lead to various side effects in children in terms of cognitive function, attention, height, endocrine function, and bone density. <br>An alternative approach is to use what you referred to as Triple IT and High Dose Methotrexat

The Necessity of Cranial Radiation Therapy in Pediatric Leukemia Patients

Dear Doctor,
My daughter is five years old and was diagnosed with Acute Lymphoblastic Leukemia (ALL) last year.
At the time of diagnosis, her white blood cell count was approximately 170,000, and she exhibited signs of liver and spleen involvement.
According to the TPOG classification, my daughter is categorized as Very High Risk, so she is undergoing the TPOG-ALL-VHR-2002 treatment protocol.
She responded very well to the steroids used during the induction phase, and before receiving her first dose of Idarubicin (IDA) and Vincristine (VCR), her blast count had already decreased to 3%.
She has now completed the Reinduction phase and is preparing to enter the Continuation phase of treatment.
During this period, she has undergone 10 Triple Intrathecal (IT) treatments, and examinations of the central nervous system (CNS) have not detected any blasts, including at the time of diagnosis.
Since the TPOG-ALL-VHR-2002 protocol requires cranial radiation at the beginning of the Continuation phase, I understand that cranial radiation can have a certain degree of impact on a child's IQ.
Recent publications from advanced medical institutions suggest that cranial radiation should only be administered to children at specific high risk.
Therefore, I would like to ask the following two questions:
1.
What is the extent of the impact of 18 Gy cranial radiation on a child's IQ? What are the potential remedial measures?
2.
Is it possible for my daughter to avoid cranial radiation? If so, what alternative options are available?
I have already discussed this issue with my daughter's attending physician, who enthusiastically explained the benefits and drawbacks and strongly recommended that we proceed with radiation therapy.
However, for the sake of my daughter's future quality of life, I would still like to obtain professional opinions from other physicians.
Thank you.

Pinggu, 30~39 year old female. Ask Date: 2005/07/19

Dr. Fan Sheng reply Oncology

Mr.
Apple: Indeed, cranial radiation therapy can lead to various side effects in children in terms of cognitive function, attention, height, endocrine function, and bone density.
An alternative approach is to use what you referred to as Triple IT and High Dose Methotrexate therapy.
Reports indicating that this method can replace cranial radiation therapy while achieving similar efficacy can be found in the following three articles: 1.
Leukemia 2000;14(12):2267-752.
J Clin Oncol 2001;19(7):1935-423.
Pediatr Blood Cancer 2004;42(1):24-9.
In relation to this trend, the following paper is a review: 4.
Curr Opin Oncol 2003;15(1):23-35.
Treatment plans in Taiwan are designed based on foreign literature, but the latest plans in the United States also attempt to avoid cranial radiation therapy, as described in the following article: 5.
Ann Hematol 2004;83 Supple 1:S124-6.
I recommend printing the above literature from a medical library and discussing it with your child's primary oncologist.
I wish you a satisfactory solution.
Good luck!

Reply Date: 2005/07/19

More Info

The necessity of cranial radiation in the treatment of pediatric leukemia, particularly in cases of Acute Lymphoblastic Leukemia (ALL), is a complex and nuanced topic. Your daughter's situation, being classified as Very High Risk due to her initial white blood cell count and organ involvement, certainly warrants careful consideration of treatment options.

1. Impact of Cranial Radiation on Cognitive Function: Studies have shown that cranial radiation therapy (CRT) can have significant effects on cognitive development in children. Specifically, doses around 18 Gy have been associated with declines in IQ, attention, and memory. The degree of cognitive impairment can vary based on several factors, including the child's age at the time of treatment, the total dose of radiation, and the specific areas of the brain that are irradiated. Children who receive CRT at a younger age tend to be at a higher risk for long-term cognitive deficits.
Remediation strategies for cognitive deficits post-CRT may include educational interventions, cognitive rehabilitation, and supportive therapies. Early intervention is crucial, as it can help mitigate some of the cognitive impacts. Programs tailored to address learning difficulties and cognitive challenges can be beneficial.

2. Alternatives to Cranial Radiation: Given the advancements in leukemia treatment, particularly in high-risk ALL, there are alternative strategies that may be considered. The use of intrathecal chemotherapy (Triple IT) and high-dose methotrexate has shown promise in reducing the need for cranial radiation while still effectively managing the risk of central nervous system (CNS) relapse. Research indicates that these methods can provide adequate CNS prophylaxis without the associated cognitive risks of CRT.
Recent studies have suggested that cranial radiation may be reserved for specific high-risk populations, particularly those with evidence of CNS involvement at diagnosis or those who do not respond adequately to chemotherapy. Since your daughter's CNS evaluations have shown no evidence of blasts, this may support the argument for considering alternatives to cranial radiation.

It is essential to have an open dialogue with your daughter's healthcare team about these concerns. Discussing the potential cognitive impacts and exploring alternative treatment options, such as intensified chemotherapy regimens, can help you make an informed decision. Additionally, consulting with a pediatric oncologist who specializes in leukemia and has experience with high-risk protocols may provide further insights into the best course of action for your daughter.

In conclusion, while cranial radiation has traditionally been a part of treatment for high-risk ALL, emerging evidence suggests that it may not be necessary for all patients, especially those who respond well to chemotherapy and have no CNS involvement. The decision should be made collaboratively with your healthcare team, considering both the potential benefits and risks, as well as your daughter's long-term quality of life.

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