Survivors of brain tumors in childhood experience adverse sequelae that are greater in prevalence and severity than those encountered by survivors of all other forms of cancer in early life, reflected in a burden of morbidity by instruments measuring health-related quality of life (HRQL). However, there are few studies of the change in HRQL over time in such populations. Patients who were above 5 years of age, at least 2 years from completion of therapy, and able to communicate in English were eligible for study of HRQL by the Health Utilities Index HUI2 and HUI3 at study entry, and again 5 and 10 years later. An initial cohort of 40 patients was reduced to 37 and 25 at the second and third time points, respectively, although only 1 death occurred during the study. HRQL showed a progressive decline over the decade, reaching conventional levels of clinical significance for the sizes of the changes. Median scores for HUI2 were 0.93, 0.90, and 0.88; and for HUI3 were 0.88, 0.85, and 0.77 at baseline, 5, and 10 years, respectively. The serial decline in HRQL demands further examination and an exploration of potential targets for therapeutic intervention.

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Idiopathic trigeminal neuralgia (TN) is a rare condition causing severe facial pain along the trigeminal nerve. Variants include typical TN (TTN), atypical facial pain syndromes (AFP) and facial pain associated with multiple sclerosis (FPMS). Historically, the primary treatment is pharmacological, with surgery being reserved for patients with refractory pain. Stereotactic radiosurgery (SRS) has recently emerged as a non-invasive alternative to surgery. Here, we report the largest Canadian single-institution experience utilizing SRS in the functional management of TN. We performed a retrospective review of all patients with TN treated with SRS at our institution. Collected data included patient demographics, TN characteristics and SRS details, as well as treatment outcomes including pain response, medication changes, toxicities and new MRI findings. To maximize validity, variables were entered a priori into a prospective database during the initial consultation and subsequent follow-up visits to our radiosurgery clinic. Between July 2011 and January 2014, 25 patients were treated on our radiosurgery unit. All patients received single fraction SRS of 60 Gy prescribed to a 6 mm long segment of the trigeminal nerve root within the prepontine cistern, beginning 3 mm distal to the ipsilateral brainstem. Maximum point dose within the target was limited to 75 Gy and the brainstem maximum point dose was limited to 37.5 Gy. Median age was 69 years (41-84) and median duration of symptoms was 7 years (1-25). Fourteen patients had TTN, 5 had AFP and 6 had FPMS. More than half (54%) the cohort had TN involving a single branch of the trigeminal nerve, with the maxillary branch most commonly involved (36% of all cases). 25% of patients had 2 branches involved while 21% cited pain in all 3 branches. Eighteen patients had previously used medication alone, while 7 had undergone a surgical procedure. Twenty-one patients completed at least one follow-up visit, with a median time from SRS of 4 months (1.5-5.1). At first follow-up, 42%, 42%, 8% and 8% of patients experienced complete resolution, partial improvement, no change and worsening of their TN, respectively. 36% of patients were medication free, 36% remained unchanged, 18% had a dose reduction and 9% had a dose increase. Median time from SRS to pain response was 14 days (1-60). No serious (≥ grade 3) acute toxicities were observed. 18% of patients did report worsening facial paresthesias. Ten patients had post-SRS MRI, with a median time from SRS of 4.6 months (1.9-14.1). Two (20%) were noted to have new enhancement within the treated area. The use of SRS in the management of TN is safe and effective. Mature follow-up is required to evaluate important long-term clinical outcomes including sustained pain response and toxicity profile.

Intensity modulated radiation therapy (IMRT) is a mainstay treatment for primary head and neck cancers. There are limited radiation treatment options for patients presenting with extensive high risk or recurrent head and neck disease. We present a series of these patients to assess the feasibility of the use of SBRT in both settings. SBRT is used to increase the biologic equivalent dose received by the tumor volume while avoiding excess dose to critical organs at risk (OAR) located within close proximity to the gross tumor volume (GTV). SBRT was given upfront as lone modality, as a boost after sub-radical IMRT dosing, or alone after recurrence. A prospectively collected database was retrospectively analyzed. Between March 2012 and January 2013, eight patients were treated with SBRT to head and neck tumors. An internally reviewed care path for SBRT in the upfront and recurrent setting was used to define treatment parameters including dose limitations to OAR. GTV was defined as residual tumor or high risk postoperative bed, clinical target volume (CTV) was defined as GTV with a margin of 0-1mm for in situ disease or 2mm for surgical bed, and no margin was given for planning target volume (PTV). Endpoints assessed were dose delivered to critical organs at risk, local disease control, and RT related morbidity. Age at diagnosis ranged from 17 to 95 years of age. 75% of the patients were male. Pathologies included squamous cell carcinoma (n = 4), adenoid cystic (n = 1), atypical pleomorphic adenoma (n = 1), spindle cell (n = 1), and paraganglioma (n = 1). In 5 patients IMRT (range, 44-59.4 Gy) and SBRT (18 Gy in 3 fractions or 25 Gy in 5 fractions) were used upfront with radical intent. One Patient received SBRT alone (25 Gy in 5 fractions) for curative treatment. Two patients were treated with SBRT (25 Gy in 5 fractions) in the recurrent setting. Median follow-up was 4 months after the completion of SBRT. No acute grade III toxicities or above were recorded. One patient developed a grade II neurosensory event in the form of trigeminal neuralgia 3 months after SBRT in the setting of radical surgery and IMRT as well. Radiographically, local tumor control was accomplished in 100% of patients to date. SBRT allows for the achievement of radical equivalent doses to tumor volume while sparing adjacent critical structures both in the setting of high risk disease or re-irradiation for recurrence in the head and neck. To date, our data suggests SBRT may be used with minimal adverse events and good tumor control yet more information is needed to further define the role of SBRT in head and neck cancers.

Local recurrence represents a significant challenge in the management of patients with glioblastoma multiforme. Salvage treatment options are limited by lack of clinical efficacy. Recent studies have demonstrated a significant response rate and acceptable toxicity with the use of fractionated stereotactic radiosurgery in this patient population. Our primary objective was to determine the efficacy and toxicity of fractionated stereotactic radiosurgery combined with concurrent temozolomide chemotherapy as a salvage treatment for recurrent glioblastoma multiforme. We prospectively collected treatment and outcome data for patients having fractionated stereotactic radiosurgery for locally recurrent glioblastoma multiforme after radical radiotherapy. Eligible patients had a maximum recurrence diameter of 60 mm without causing significant mass effect. The gross tumor volume was defined as the enhancing lesion on an enhanced fine-slice T1 (spin-lattice) magnetic resonance imaging, and a circumferential setup margin of 1 mm was used to define the planning target volume. All patients were treated using robotic radiosurgery with three dose/fractionation schedules ranging from 25 to 35 Gy in five fractions, depending on the maximum tumor diameter. Concurrent temozolomide 75 mg/m(2) was prescribed to all patients. Tumor response was judged using the Macdonald criteria, and toxicity was assessed using the CTCAE (Common Terminology Criteria for Adverse Events). A total of 31 patients were enrolled in this study. The median overall survival was 9 months, and progression-free survival was 7 months. The 6-month progression-free survival was 60% with a 95% confidence interval of 43%-77%. The a priori stratification factor of small tumor diameter was shown to predict overall survival, while time to recurrence was not predictive of progression-free or overall survival. Three patients experienced grade 3 acute toxicity that responded to increased steroid dosing. One patient experienced a grade 4 acute toxicity that did not respond to increased steroids but did respond to anti-angiogenic therapy. Fractionated stereotactic radiosurgery with concurrent temozolomide has shown good short-term clinical and radiologic control with manageable acute toxicity. This regimen appears to provide superior efficacy to either temozolomide or fractionated radiosurgery alone. The results of this study support the continued evaluation of this regimen.

By minimising the effect of irradiation on surrounding tissue, intensity-modulated radiation therapy (IMRT) can deliver higher, more effective doses to the targeted tumour site, minimising treatment-related morbidity and possibly improving cancer control and cure. A multidisciplinary IMRT Expert Panel was convened to develop the organisational standards for the delivery of IMRT. The systematic literature search used MEDLINE, EMBASE, the Cochrane Database, the National Guidelines Clearing House and the Health Technology Assessment Database. An environmental scan of unpublished literature used the Google™ search engine to review the websites of key organisations, cancer agencies/centres and vendor sites in Canada, the USA, Australia and Europe. In total, 22 relevant guidance documents were identified; 12 from the published literature and 10 from the environmental scan. Professional and organisational standards for the provision of IMRT were developed through the analysis of this evidence and the consensus opinion of the IMRT Expert Panel. The resulting standards address the following domains: planning of new IMRT programmes, practice setting requirements, tools, devices and equipment requirements; professional training requirements; role of personnel; and requirements for quality assurance and safety. Here the IMRT Expert Panel offers organisational and professional standards for the delivery of IMRT, with the intent of promoting innovation, improving access and enhancing patient care.

6043 Background: Greater participation by patients in health care decision-making and public concerns about WT led Cancer Care Ontario (CCO) to post radiation WT by cancer type and treatment centre on its website http://www.cancercare.on.ca anticipating patients and referring physicians (MDs) would use WT information to access facilities with shorter waits. The availability of more radiation treatment facilities in Southern Ontario provides patients and MDs with more options for location of treatment. Methods: The usefulness of this approach was evaluated by an on-line survey, patient focus groups, physician interviews and usability lab testing. Results: 1,043 on-line surveys were completed by patients/family members (35%), media (24%) and others, including health professionals (HP) and administrators (AD). HP found the information useful and clear but patients were less satisfied, wanting information on the effect of WT on their illness. 45 individuals (40 treated patients, 5 family) participated in 8 geographically dispersed focus groups. Facilitator-led conversations were recorded, transcribed verbatim and content grouped in themes by 4 researchers. Most patients were unaware of the CCO WT information. Patients indicated that MDs should have and use WT information and determine speed of access to care based on urgency of condition. Patients would accept MD advice to travel to a more distant treatment facility but patients questioned why WT existed and why health care system not managed more efficiently. 15 MD phone interviews indicated MDs were distrustful of WT data, did not use the web data for referral, preferring usual practice patterns. MDs were reluctant to share WT information with patients for fear of creating unnecessary anxiety. AD found data useful as a stimulus for performance improvement. Usability lab testing uncovered numerous user preferences for redesign of the site, including its content. Conclusions: Current Ontario patients and MDs are not ‘consumers’ of WT information but AD see value in this information for system improvement. As society increasingly uses the internet as an information resource, future patients and MDs will likely utilize WT information in the decision-making for location of care. Supported by Cancer Care Ontario and grant 03110 from the Change Foundation. No significant financial relationships to disclose.

There is an evident need to measure the comprehensive burden of morbidity experienced by survivors of brain tumours in childhood. To this end, a questionnaire based on the Health Utilities Index mark 2 (HUI2) and mark 3 (HUI3) systems was completed independently for a cohort of such children by their parents, by a nurse, by physicians and by a selected group of the children themselves. Each of the HUI2 and HUI3 systems consists of a multi-attribute health status classification scheme linked to a preference function which provides utility scores for levels within single attributes (domains of health) and for global health states. All eligible families (n = 44) participated. Even cognitively impaired children of at least 9.5 years of age could complete the questionnaire. The greatest burden of morbidity, occurring in two-thirds of children, was in the attribute of cognition. Surprisingly, almost one-third of children experienced pain. Global health status was lowest in children who underwent radiotherapy before the age of 5 years and the corresponding utility scores were related inversely to the volume irradiated. Children with demonstrable disease had lower scores than those in whom disease was not evident. There was a high level of agreement (intraclass correlation coefficients > 0.5) on formal assessment of inter-rater reliability for global health-related quality of life utility scores. The usefulness of measures of health status and health-related quality of life, in children surviving brain tumours, has been demonstrated by this study.

Puroose: To determine the prognostic significance of histologic grading in oligodendrogliomas.And to assess the role of postoperative radiotherapy in low-grade tumors and adjuvant chemotherapy in anaplastic tumors.Methods and Materials: The records of 38 consecutive patients with the diagnosis of oligodendroglioma were studied.Histologic grade was based on the Smith System and adjusted for the Kemohan's variables.Treatment of low-grade tnmors consisted of surgery or surgery plus postoperative radiotherapy.High-grade tumors, anaplastic and malignant, had surgeq and postoperative radiotherapy with or without adjuvant chemotherapy.&p& 23 patients with low-grade tumors showed improved S-year progression-free survival compared to 15 patients with high-grade tumors (74% and 27% respectively), and improved overall 5-year survival (70% compared to 27%).Of the low-grade group, 16 patients receiving postoperative radiotherapy showed improved 5-year progression-free survival compared to 7 patients who did not receive adjuvant radiation (80% and 24% respectively).The overall 5-year survival was similar (86%).10 patients of the high-grade group had anaplastic oligodendrogliomas.5 patients receiving adjuvant chemotherapy showed improved 5-year progression-free survival compared to 5 patients not receiving adjuvant chemotherapy (60% and 20% respectively).The overall 5-year survival was similar (40%).The remaining 5 patients of the high-grade group had malignant oligodendrogliomas.These received adjuvant chemotherapy and had similar overall survival and progression-tke survival, ie: 40% at 5 years.Conclusion: High-grade oligodendroglimas have worse prognosis than low-grade tumors.postoperative radiotherapy may offer some benefit prolonging time to progression of low-grade tumors.Similarly adjuvant chemotherapy may prolong time to progression of anaplastic oligcdendrogliomas.Prospective randomized clinical trials are needed to more Molly assess these issues.

The poor prognosis for primary cerebral lymphoma following conventional radiation therapy has generally been attributed to high local relapse rates despite initial local control. Hyperfractionated radiation therapy may improve the therapeutic ratio by allowing higher total radiation doses to be prescribed without exceeding the radiation tolerance of the central nervous system (CNS). Eight patients entered a study of hyperfractionated whole brain irradiation (HWBI) between October 1988 and May 1991. The prescribed dose was 64.8 Gy in 54 fractions over 5.5 weeks. All patients were followed clinically and with computed tomographic scanning. Additional investigations to discriminate between lymphoma recurrence and radionecrosis included magnetic resonance imaging (MRI), thallium-201 single photon emission computed tomography (SPECT), and immunocytological examination of the cerebrospinal fluid (CSF). A complete remission as seen on CT scan was achieved in all cases. The overall median survival was 102 weeks. Six patients initially deteriorated neurologically without evidence of tumour recurrence. Three patients have died without evidence of recurrence at 18, 62 and 128 weeks. As of 31 May 1992, three patients remain alive, two with radiation brain injury at 147 and 184 weeks. Treatment toxicity prompted study closure in September 1991. The hyperfractionation regimen used is reported by others to be free from significant morbidity. The pathogenesis of cerebral lymphomas (diffuse disease, angiotropism, subependymal involvement) may adversely affect CNS radiation tolerance.