MP 8.01.28

High-dose Chemotherapy with Hematopoietic Stem-cell Support for Primitive Neuroectodermal Tumors (PNET) of the CNS and Ependymoma

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Medical Policy
Section Therapy	Original Policy Date 12/1/98	Last Review Status/Date Reviewed with literature search/5:2008
Issue 5:2008		Return to Medical Policy Index

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Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.

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Description

Policy

Policy Guidelines

Benefit Application

Rationale

Primitive Neuroectodermal Tumors (PNETs) of the CNS

Initial therapy of CNS PNETs focuses on neurosurgical resection, plus radiation therapy with or without adjuvant conventional-dose chemotherapy; 60% of children survive 5 years or more with this approach. In patients with residual tumor or recurrent disease, further surgery or radiation therapy usually is not an option, and conventional chemotherapy rarely is successful. Therefore, HDC for CNS PNET has focused primarily on residual or recurrent disease. The most common CNS PNET is medulloblastoma, and thus, most studies focus on this diagnosis.

This policy was initially based on a literature search for studies published through 1999. No comparative trials were found. The largest case series included 23 patients with recurrent medulloblastoma treated with high-dose carboplatin, thiotepa, and etoposide. (1) Seven patients were event-free survivors at a median of 54 months, with overall survival estimated at 46% at 36 months. In contrast, the median survival after recurrent medulloblastoma treated with conventional therapy may be as low as 5 months. HDC was expected to be most effective with minimal disease burden. Thus, Dunkel and colleagues suggested increased surveillance for recurrence, or aggressive surgical debunking at the time of recurrence. (1) The authors also acknowledged the potential for effects of patient selection bias on their results, since not all patients eligible for the protocol were enrolled.

Other CNS PNETs are uncommon and include pinealblastoma, ependymoblastoma, and central neuroblastoma. There were few data regarding high-dose therapy for these rare tumors, although it was thought that the results with medulloblastoma may be extrapolated to other PNETs.

An updated literature search was conducted in May 2002 for studies published since 1999. The only new data were from a study including 53 patients with newly diagnosed medulloblastoma or supratentorial PNETs, 19 of whom had high-risk disease and 34 had average-risk disease. (2) After surgery and radiotherapy, the study used 4 cycles of HDC with cyclophosphamide, cisplatin, and vincristine, followed by autologous stem-cell support. Patients with high-risk disease also received topotecan between surgery and radiotherapy. Early actuarial analysis of outcomes yielded estimates of 94% progression-free survival at 2 years for average-risk patients and 74% for high-risk patients.

Subsequent updated literature searches identified no new randomized clinical trial publications that would alter the policy statement. Two recent clinical series report outcomes in children with newly diagnosed medulloblastoma or PNET. In the first study (n=134 cases), following maximum tumor resection, all patients received risk-adapted craniospinal radiotherapy followed by 4 cycles of cyclophosphamide-based HDC with autologous stem-cell rescue. (5) After resection, patients were classified as having average-risk disease (<1.5 cm2 residual tumor and no metastatic disease) or high-risk disease (>1.5 cm2 residual tumor or metastatic disease localized to the neuraxis). Five-year overall survival (OS) was 85% (95% CI: 75–94) among the average-risk cases and 70% (95% CI 54-84) in the high-risk patients. Five-year event-free survival (EFS) was 83% (95% CI: 73–93) and 70% (95% CI: 55–85) for average- and high-risk patients, respectively. No treatment-related deaths were reported. These results provide further support for the use of dose-intensive chemotherapy in high-risk medulloblastoma cases. In the second series, single or tandem double HDC with autologous stem-cell rescue was administered to 25 children with newly diagnosed high-risk or relapsed medulloblastoma or PNET following surgical resection. (6) Three-year EFS for patients in CR or PR and less than PR at first HDC was 67% or 16.7%, respectively. For 19 cases in CR or PR at first HDC, 3-year EFS was 89% in the tandem double group and 44% in the single HDC group, respectively. Four treatment-related deaths occurred, and in 4 of 8 young children craniospinal radiotherapy was successfully withheld without relapse. These results also suggest HDC may improve the survival of children with newly diagnosed high-risk medulloblastomas or PNET, but further study in RCTs is needed to establish the role of the tandem approach.
2008 Update
As of April 2008, the National Cancer Institute (NCI) Physician Data Query (PDQ®) database lists the following ongoing Phase III randomized clinical trials for PNETs:

• Phase III study of radiotherapy, high-dose cisplatin, vincristine, and cyclophosphamide, and autologous stem-cell rescue in patients with newly diagnosed medulloblastoma, supratentorial primitive neuroectodermal tumor, or atypical teratoid rhabdoid tumor (SJCRH-SJMB03).
  Estimated date of completion 8/2010
• Phase III pilot study of induction chemotherapy followed by consolidation myeloablative chemotherapy comprising thiotepa and carboplatin with or without etoposide and autologous hematopoietic stem cell rescue in pediatric patients with previously untreated malignant brain tumors (CHLA-HEAD-START-III).
  Active as of 4/22/2008
• Phase III randomized study of intensive induction chemotherapy comprising vincristine, etoposide, cyclophosphamide and cisplatin in combination with high-dose methotrexate and leucovorin calcium followed by consolidation chemotherapy comprising carboplatin and thiotepa and peripheral blood stem cell rescue compared to the complete response rate in patients given the same regimen without high-dose methotrexate and leucovorin calcium (COG-ACNS0334)
  Active as of 4/22/2008- estimated completion 10/2007

The 2007/8 (v.1.2008) National Comprehensive Cancer Network Guidelines on Central Nervous System Cancers do not address high-dose chemotherapy with stem-cell support for PNET of the CNS. (7)

Ependymoma

Initial treatment of ependymoma consists of maximal surgical resection followed by radiotherapy. Chemotherapy usually does not play a role in the initial treatment of ependymoma. However, disease relapse is common, typically occurring at the site of origin. Treatment of recurrence is problematic; further surgical resection or radiation therapy is usually not possible. Given the poor response to conventional-dose chemotherapy, HDC has been investigated as a possible salvage therapy. Literature published through 1999 regarding HDC for ependymoma consisted primarily of small case series. For example, Mason and colleagues reported on a case series of 15 patients with recurrent ependymoma. (8) Five patients died of treatment-related toxicities, 8 died from progressive disease, 1 died of unrelated causes. After 25 months, 1 patient remains alive, but with tumor recurrence. The authors concluded that their high-dose regimen of thiotepa and etoposide was not an effective treatment of ependymoma. Grill and colleagues similarly reported a disappointing experience in 16 children treated with a thiotepa-based high-dose regimen. (9)
Updated literature searches failed to identify new randomized, controlled trial data on outcomes of HDC with hematopoietic stem-cell support for patients with ependymoma. A small series reported 5-year EFS of 12% (+ 6%) and OS of 38% (+10%) among 29 children younger than 10 years of age who received HDC and autologous SCT following intensive induction chemotherapy to treat newly diagnosed ependymoma (10). Importantly, radiation-free survival was only 8% (+ 5%) in these cases. Although limited in size, these series results further suggest HDC with SCT is not superior to other previously reported chemotherapeutic approaches.

2008 Update
An updated literature search was conducted through April 2008. No reports of clinical trials were found that would alter the policy statement.
Patients with ependymoma are eligible to participate in the CHLA-HEAD-START-III trial (noted in the previous section).
The 2007/8 National Comprehensive Cancer Network Guidelines on Central Nervous System Tumors do not address HDC with stem-cell support for ependymoma in the pediatric population. (7)

 

References:

1. Childhood Ependymoma Treatment - National Cancer Institute Physician Data Query (PDQ®) Database Modified 04/09/2008. Available online at http://www.cancer.gov/cancertopics/pdq/treatment/childependymoma/HealthProfessional. Last accessed April 2008.
2. Childhood Central Nervous System Embryonal Tumors – National Cancer Institute Physician Data Query (PDQ®) Modified 04/03/2008. Available online at http://www.cancer.gov/cancertopics/pdq/treatment/childCNSembryonal/healthprofessional. Last accessed April 2008.
3. Dunkel IJ, Boyett JM, Yates A et al. High-dose carboplatin, thiotepa, and etoposide with autologous stem-cell rescue for patients with recurrent medulloblastoma. Children’s Cancer Group. J Clin Oncol 1998; 16(1):222-8.
4. Strother D, Ashley D, Kellie SJ et al. Feasibility of four consecutive high-dose chemotherapy cycles with stem-cell rescue for patients with newly diagnosed medulloblastoma or supratentorial primitive neuroectodermal tumor after craniospinal radiotherapy: results of a collaborative study. J Clin Oncol 2001;19(10):2696-704.
5. Gajjar A, Chintagumpala M, Ashley D et al. Risk-adapted craniospinal radiotherapy followed by high-dose chemotherapy and stem-cell rescue in children with newly diagnosed medulloblastoma (St Jude Medulloblastoma-96): long-term results from a prospective, multicentre trial. Lancet Oncol 2006; 7(10):813-20.
6. Sung KW, Yoo KH, Cho EJ et al. High-dose chemotherapy and autologous stem cell rescue in children with newly diagnosed high-risk or relapsed medulloblastoma or supratentorial primitive neuroectodermal tumor. Pediatr Blood Cancer 2007; 48(4):408-15. 
7. Central Nervous System Cancers. Practice Guidelines in Oncology. National Comprehensive Cancer Network Guidelines. v.2.2005. http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf.
8. Mason WP, Goldman S, Yates AJ et al. Survival following intensive chemotherapy with bone marrow reconstitution for children with recurrent intracranial ependymoma: a report of the Children’s Cancer Group. J NeuroOncol 1998; 37(2):135-43.
9. Grill J, Kalifa C, Doz F et al. A high-dose busulfan-thiotepa combination followed by autologous bone marrow transplantation in childhood recurrent ependymoma. A phase-II study. Pediatr Neurosurg 1996; 25(1):7-12.
10. Zacharoulis S, Levy A, Chi SN et al. Outcome for young children newly diagnosed with ependymoma, treated with intensive induction chemotherapy followed by myeloablative chemotherapy and autologous stem cell rescue. Pediatr Blood Cancer 2007; 49(1):34-40.

Index

Policy History

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