Hypofractionated Radiation Therapy For Diffuse Intrinsic Pontine Glioma: A Noninferiority Randomized Study Including 253 Children

Abstract

Purpose: Pediatric diffuse intrinsic pontine glioma is an orphen disease. This study aimed to confirm the noninferiority of hypofractionated (HF) radiation therapy. Identification of the prognostic factors that determine the overall survival (OS) and progression-free survival (PFS) was the secondary objective.

Methods and materials: We randomized 253 patients into 3 arms of radiation therapy regimens: HF1, receiving 39 Gy in 13 fractions; HF2, receiving 45 Gy in 15 fractions; and conventional fractionation (CF), receiving 54 Gy in 30 fractions. The OS and PFS were calculated using Kaplan-Meier methods, and the noninferiority was estimated against the CF arm.

Results: The median OS for the HF1, HF2, and CF were 9.6, 8.2, and 8.7 months, respectively. The 1-, 1.5-, and 2-year OS were 34.6%, 17.9%, and 10.7% for HF1; 26.2%, 13.1%, and 4.8% for HF2; and 25.3%, 12.1%, and 8.4% for CF, respectively (P = .3). The hazard ratio was 0.776 and 1.124 for HF1 and HF2, respectively. Considering the noninferiority margin (Δ) of 15% and a power of 90%, the lower inferiority confidence interval for HF1 was -14.34% and for HF2 it was 11.37% (both below Δ), confirming its noninferiority at 18-months OS. Younger patients (2-5 years of age) had better median OS in the whole cohort (11.6 months), HF1 (13.5), and CF (12.1) but not HF2 (6.2) (P = .003). Furthermore, the OS rates at 1, 1.5, and 2 years for children 2 to 5 years of age in the HF2 arm were lower than those in the HF1 and CF arms. However, similar acute and late side effects were reported in the 3 arms.

Conclusions: Two hypofractionated radiation therapy proved to be noninferior to conventional fractionation. Young age (2-5 years) is the only prognostic factor determining both OS and PFS. The young age superiority was lost with a higher hypofractionated radiation therapy dose, necessitating more caution in applying 45 Gy in 15 fractions in younger children (2-5 years of age).