Further Inpatient and Outpatient Care and Transfer
Further inpatient care
Admit patients with medulloblastoma for specific chemotherapy and for complications (eg, neutropenic fever) as a result of therapy.
Further outpatient care
Radiotherapy
Daily outpatient radiotherapy (usual dose fractions of 180 cGy/day) is performed for approximately 6 weeks.
Physical and neurologic examination
Careful monitoring of response and treatment-associated side effects is performed weekly during radiotherapy and at least every 2 weeks during chemotherapy.
Reevaluation immediately before each cycle of chemotherapy is necessary to document resolution of previous treatment-related toxicities.
Following the completion of therapy, assessments are conducted every 3 months for the first 12-18 months, every 6 months for the next 2 years, and then annually, provided no complications have occurred.
Imaging studies
To have an objective measurement of tumor response to therapy, MRI with contrast of the head and spine is performed at the completion of radiotherapy, after every 2-3 cycles of chemotherapy, and at the end of therapy.
Following the completion of therapy, follow up brain and spine imaging studies are conducted every 3 months for the first 12-18 months, every 6 months for the next 2 years, and then annually, provided no complications have occurred. Simultaneous spine imaging is performed
Laboratory studies
Weekly CBC counts are necessary during the initial phase of radiation therapy. Every attempt should be made to maintain the patient’s hemoglobin at or above 10 mg/dL to improve radiation outcomes.
During chemotherapy, once to twice weekly CBC counts may be necessary in anticipation of possible need for red cell and/or platelet transfusions as well as need from granulocyte colony stimulating factor (G-CSF) support to abrogate neutropenic fever admissions. Other labs, namely, liver function studies, electrolytes, renal function, and a hearing test are to be obtained before each cycle of chemotherapy and again at the end of treatment.
A baseline endocrinologic and neuropsychologic evaluation should be performed at the completion of therapy and annually thereafter.
Additional tests for the purposes of monitoring specific investigational protocol treatment-related toxicity (eg, echocardiogram, pulmonary function tests, etc.) may be required according to protocol guidelines.
Transfer
Transfer to centers that can provide appropriate MRI imaging studies, neurosurgical intervention, radiotherapy (particularly proton beam therapy), and chemotherapy may be necessary.
Inpatient & Outpatient Medications
Inpatient medications are dictated by the most current chemotherapeutic protocols available for the treatment of medulloblastoma. See previous section on medications.
All regimens require the concomitant use of anti-emetic agents. Special care should be taken into maximizing the use of anti-emetic agents (e.g. addition of aprepitant) for cisplatin, a highly pro-emetic agent.
Granulocyte colony stimulating factor (GCSF) following chemotherapy may be used in treatment regimens expected to cause marked neutropenia. Intravenous gammaglobulin (IVIG) replacement to keep IgG levels >400 mg/dL is generally use to help prevent infections in infants. It may also be used for patients whose treatment is complicated with viral infections.
Because of the immunosuppressive effects of chemotherapy, trimethoprim sulfamethoxazole are commonly prescribed for prophylaxis against Pneumocystis jiroveci pneumonia until 3-6 months after completion of chemotherapy.
Infants, especially those anticipated to receive high dose chemotherapy and autologous stem cell transplantation, also benefit from additional antifungal prophylaxis with fluconazole (to prevent systemic candidiasis) and palivizumab, a respiratory syncytial virus (RSV) specific passive antibody administered as an injectable medication monthly during the cold season. Autologous stem cell transplantation recipients will also need re-immunized starting 6 months post-transplant.
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MRI showing a medulloblastoma of the cerebellum.
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Section displaying Homer-Wright rosettes and pseudorosettes of a medulloblastoma.
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This section displays a typical medulloblastoma, composed of undifferentiated cells with deeply basophilic nuclei of variable size and shape and little discernible cytoplasm.
Tables
Tumor Stage |
|
T1 |
tumor < 3 cm in diameter |
T2 |
tumor ≥3 cm in diameter |
T3a |
tumor >3 cm and with extension into Aqueduct of Sylvius or foramen of Luschka |
T3b |
tumor >3 cm and with unequivocal extension into brainstem |
T4 |
tumor >3 cm with extension past Aqueduct of Sylvius or down past foramen magnum |
Metastases Stage |
|
M0 |
no evidence of gross subarachnoid or hematogenous metastasis |
M1 |
microscopic tumors cells found in CSF |
M2 |
gross nodular seeding intracranially beyond the primary site (in cerebellar/cerebral subarachnoid space or in third or lateral ventricle) |
M3 |
gross nodular seeding in spinal subarachnoid space |
M4 |
metastasis outside cerebrospinal axis |
