Arnold C. Paulino, MD

Bone metastases are a common feature of many solid cancers, especially those originating from the prostate, breast, lung, kidney, melanoma, and other sites. Up to 80% of patients with these cancers will develop painful bony disease during the course of their disease.

Brain metastases from renal cell carcinoma (RCC) cause significant morbidity and mortality. More effective treatment approaches are needed. Traditionally, whole-brain radiotherapy has been used for palliation. With advances in radiation oncology, stereotactic radiosurgery and hypofractionated stereotactic radiotherapy have been utilized for RCC brain metastases, producing excellent outcomes. This review details the role of radiotherapy in various subgroups of patients with RCC brain metastases as well as the associated toxicities and outcomes. Newer radiosensitizers (eg, motexafin gadolinium [Xcytrin]) and chemotherapeutic agents (eg, temozolomide [Temodar]) used in combination with radiotherapy will also be discussed.

The manuscript by Jubran et albrings to light the many controversiessurrounding the managementof intracranial germ cell tumors.Perhaps the most controversialissues are the roles of radiotherapyand chemotherapy in the treatment ofpure germinoma and nongerminomatousgerm cell tumor (NGGCT).

The fusion of 18-fluorodeoxyglucose (FDG) positron-emission tomography(PET) with computed tomography (CT) offers both anatomicand physiologic delineation of head and neck cancers. PET-CT is usefulin the staging of head and neck carcinomas and may identify unsuspecteddistant metastasis that may alter treatment. PET-CT may alsohelp in target volume delineation during radiotherapy (RT) treatmentplanning. Better characterization of the target may improve local controlas well as spare normal tissues from RT sequelae.

Dr. Merchant provides a comprehensive overview of intracranial ependymoma in children. As he points out, most of the current information regarding childhood intracranial ependymoma has come from single-institution retrospective reviews. Of the prognostic indicators mentioned in the article, both young age and subtotal resection are widely accepted. Children less than 3 years old have a worse prognosis than older children, possibly because of more aggressive tumor biology, reluctance to give postoperative radiotherapy, or use of lower doses of radiotherapy. Regarding the degree of surgical resection, assessment by postoperative imaging is more important than the neurosurgeon’s perspective on whether a gross total or subtotal resection has been performed.[1,2]

Intracranial germinomas are uncommon tumors. In the past, patients have traditionally been diagnosed with a trial of focal radiotherapy without biopsy. If the tumor was radiosensitive, it was presumed to be a germinoma.

Although craniospinal irradiation has been employed in children with medulloblastoma for the past 40 years, many issues concerning its use have been raised and examined, and some continue to be debated. Careful radiation technique includes adequate irradiation of the neuraxis with special attention to the cribriform plate region and termination of the thecal sac. Conventional-dose craniospinal radiation therapy, in combination with chemotherapy, is currently recommended for patients with high-risk medulloblastoma. The appropriate dose of radiation to the craniospinal axis when this modality is combined with chemotherapy for low-risk medulloblastoma remains to be defined. Long-term results of hyperfractionated radiation therapy are likewise awaited. In an effort to decrease late toxicity to the immature central nervous system, radiation therapy can be delayed in a proportion of infants by administering chemotherapy after maximal tumor debulking. [ONCOLOGY 11(6):813-823, 1997]

Significant advances have been made in the treatment of children with Wilms' tumor. Whereas 50 years ago overall survival was less than 10%, current survival estimates approach 90%. This progress has been made