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Children’s Hospital Los Angeles (CHLA) utilizes surface-guided radiation therapy (SGRT) for almost all sites including head and neck, chest, pelvis, and extremities and for special procedures including stereotactic radiation therapy (SRS), deep inspiration breath hold (DIBH), and craniospinal irradiation (CSI). Implementing SGRT at CHLA was not immediate and took place over the course of a year. During the implementation phase, each treatment site was assessed and the best execution strategy for the region of interest (ROI) was established. SGRT was implemented methodically, starting with chest and abdominal sites, and as we gained experience and confidence, we moved into more complex treatments such as DIBH and CSI. The use of SGRT within the pediatric population has multiple advantages with many benefits overlapping into the adult population as well. Benefits include reduction of setup and kV imaging time and ionizing radiation, elimination of all skin marks, real-time patient monitoring, and safe and efficient treatments in palliative cases with reduction or elimination of anesthesia usage. The benefits extend beyond patients to staff members as well, increasing efficiency and permitting staff to focus on higher cognitive tasks. Unique challenges for SGRT within the pediatric population include fewer body contour variations relative to adults, potential interference of extra monitoring devices and intravenous or nasogastric lines during anesthesia, and the overall decrease in cooperation compared to adults. We were able to address these challenges and found that SGRT can be successfully implemented in the pediatric setting.

BACKGROUND We report the responses, toxicities and long-term outcomes of gemcitabine, paclitaxel and oxaliplatin (GemPOx) regimen administered, in responsive patients, prior to single cycle marrow-ablative chemotherapy (thiotepa, etoposide and carboplatin) with autologous hematopoietic progenitor cell rescue (HDCx+AuHPCR). METHODS Since December 2009, 11 recurrent/refractory patients (10 MMGCT, 1 germinoma; 10 males; mean age 16.5 years, range 7–46 years) have been treated with up to four cycles of gemcitabine (800mg/M2), paclitaxel (170mg/M2) and oxaliplatin (100mg/M2) administered on one day at 14 days intervals. RESULTS All 11 patients were enrolled on a prospective multi-center trial, which was closed in October 2019. Three patients achieved complete remissions (tumor marker and/or imaging studies), five achieved partial remissions, two developed disease progression (PD), and one was withdrawn after one cycle for severe paclitaxel neurotoxicity followed by rapid tumor progression and death. One patient with PD after one cycle had pathologically-confirmed metastatic transformation to pure embryonal rhabdomyosarcoma, and rapidly expired. A second patient, with pure pineal choriocarcinoma, progressed after the second GemPOx cycle, ultimately died of tumor progression. Eight of the 11 responsive patients subsequently underwent HDCx+AuHPCR; five of these received some form of radiotherapy. Seven patients (six MMGCT, one germinoma) are alive and disease-free without recurrence for a mean of 94 months (range 74–118 months) since completion of therapy. CONCLUSION GemPOx is an effective re-induction regimen for patient with recurrent CNS germ cell tumors, with acceptable toxicities; when followed by marrow-ablative chemotherapy and subsequent irradiation/re-irradiation, the regimen produces encouraging long-term disease-free survival.

Background Recurrence occurs in almost 50% of patients with intracranial ependymoma, and their outcome following recurrence is poor. Methods We retrospectively reviewed the medical records of 22 patients with intracranial ependymoma and subsequent relapse(s) (59 recurrences) treated at Children's Hospital Los Angeles or New York University between January 1997 and December 2012. Results Median duration of follow-up was 52 months (7–171 months). Median age at initial diagnosis was 4 years (0.3–19 years) with 8 patients younger than 3 years at presentation. Eleven patients had anaplastic and 11 cellular pathologies. Eighteen patients had infratentorial tumors at diagnosis and 3 (all infratentorial) had metastatic spinal cord involvement at presentation. Cerebrospinal fluid involvement was not identified at diagnosis or relapse. Median time to first recurrence was 16 months (1.3 to 115 months). The number of recurrences in each patient ranged from 1 to 9 (median = 2). Thirty-seven recurrences (63%) were detected asymptomatically by surveillance imaging. Fifteen recurrences (26%) arose outside the initial tumor site. Recurrences were treated by surgical resection (45), with irradiation (30), and with various oral chemotherapies (23) with (7) or without (16) conventional chemotherapy. The 5 and 10 year overall survival rates from first recurrence were 0.37 ± 0.14 and 0.25 ± 0.14. Conclusion Prolonged (5–10 year) survival from first relapse was noted in over one-quarter of our patients. It remains unclear whether early radiographic diagnosis, differing treatment modalities beyond radical surgical resection or possibly unrecognized biological differences contributed towards this prolonged survival. Pediatr Blood Cancer 2014;61:1195–1201. © 2014 Wiley Periodicals, Inc.

Background High-dose chemotherapy with autologous hematopoietic progenitor cell rescue (AuHPCR) for pediatric patients with brain tumors has become an important therapeutic modality to avoid or delay the long-term effects of cranial irradiation. Data on post-AuHPCR infectious complications in this population are lacking. This single institution retrospective review reports the prophylactic practices and infections in the first year following AuHPCR in pediatric patients with brain tumors. Procedure The medical record of patients who underwent AuHPCR for the treatment of a malignant brain tumor at Children's Hospital Los Angeles between 1988 and 2010 were reviewed. Patients without prior irradiation who were free of disease at 1 year without additional chemotherapy were evaluated for all infectious disease complications occurring from time of neutrophil engraftment to 1 year post-AuHPCR. Results Forty-three of the 115 eligible patients were included. The median time to neutrophil engraftment was 11 days (range: 8–43 days), and 20 Grade III/IV (no Grade V) infectious episodes developed in 15 patients (35%). Fourteen episodes of bacteremia (70%) were catheter-related, predominantly gram-negative (71%), and polymicrobial (50%). There were no fungal or pneumocystis infections and only 1 of 25 (4%) at-risk patients developed VZV reactivation. Conclusions These data suggest patients with brain tumors undergoing AuHPCR have few late-occurring non-catheter-related post-transplant infections indicating that prophylaxis practices were sufficient. Central lines should be removed soon after engraftment, but those with central line infections should receive adequate treatment including gram-negative coverage. In addition, only at-risk patients who receive further irradiation may benefit from VZV reaction prophylaxis. Pediatr Blood Cancer 2013;60:2012–2017. © 2013 Wiley Periodicals, Inc.

Recurrence occurs in almost 50% of patients with intracranial ependymoma, and their outcome following recurrence is poor.We retrospectively reviewed the medical records of 22 patients with intracranial ependymoma and subsequent relapse(s) (59 recurrences) treated at Children's Hospital Los Angeles or New York University between January 1997 and December 2012.Median duration of follow-up was 52 months (7-171 months). Median age at initial diagnosis was 4 years (0.3-19 years) with 8 patients younger than 3 years at presentation. Eleven patients had anaplastic and 11 cellular pathologies. Eighteen patients had infratentorial tumors at diagnosis and 3 (all infratentorial) had metastatic spinal cord involvement at presentation. Cerebrospinal fluid involvement was not identified at diagnosis or relapse. Median time to first recurrence was 16 months (1.3 to 115 months). The number of recurrences in each patient ranged from 1 to 9 (median = 2). Thirty-seven recurrences (63%) were detected asymptomatically by surveillance imaging. Fifteen recurrences (26%) arose outside the initial tumor site. Recurrences were treated by surgical resection (45), with irradiation (30), and with various oral chemotherapies (23) with (7) or without (16) conventional chemotherapy. The 5 and 10 year overall survival rates from first recurrence were 0.37 ± 0.14 and 0.25 ± 0.14.Prolonged (5-10 year) survival from first relapse was noted in over one-quarter of our patients. It remains unclear whether early radiographic diagnosis, differing treatment modalities beyond radical surgical resection or possibly unrecognized biological differences contributed towards this prolonged survival.

High-dose chemotherapy with autologous hematopoietic progenitor cell rescue (AuHPCR) for pediatric patients with brain tumors has become an important therapeutic modality to avoid or delay the long-term effects of cranial irradiation. Data on post-AuHPCR infectious complications in this population are lacking. This single institution retrospective review reports the prophylactic practices and infections in the first year following AuHPCR in pediatric patients with brain tumors.The medical record of patients who underwent AuHPCR for the treatment of a malignant brain tumor at Children's Hospital Los Angeles between 1988 and 2010 were reviewed. Patients without prior irradiation who were free of disease at 1 year without additional chemotherapy were evaluated for all infectious disease complications occurring from time of neutrophil engraftment to 1 year post-AuHPCR.Forty-three of the 115 eligible patients were included. The median time to neutrophil engraftment was 11 days (range: 8-43 days), and 20 Grade III/IV (no Grade V) infectious episodes developed in 15 patients (35%). Fourteen episodes of bacteremia (70%) were catheter-related, predominantly gram-negative (71%), and polymicrobial (50%). There were no fungal or pneumocystis infections and only 1 of 25 (4%) at-risk patients developed VZV reactivation.These data suggest patients with brain tumors undergoing AuHPCR have few late-occurring non-catheter-related post-transplant infections indicating that prophylaxis practices were sufficient. Central lines should be removed soon after engraftment, but those with central line infections should receive adequate treatment including gram-negative coverage. In addition, only at-risk patients who receive further irradiation may benefit from VZV reaction prophylaxis.