Clinical characteristics and abandonment and outcome of ...

clinical articleJ neurosurg Pediatr 17:49–56, 2016

MedulloblastoMa is a common malignant brain tumor that mainly arises during infancy and childhood. With current multimodality therapy,

children with medulloblastoma in developed countries have good long-term survival, with 5-year overall survival (OS) reported at 65%–71%.8 However, the survival rate is not so encouraging in developing countries,16 and there is a lack of published data about Chinese children with me-dulloblastoma, especially about their treatment status and outcomes. In this study, we retrospectively analyzed the

clinical features and survival data from 67 pediatric cases of medulloblastoma to investigate the underlying reasons for this disparity of outcome.

MethodsPatients

A total of 67 cases involving patients with newly diag-nosed medulloblastoma were included in this study. The patients were admitted to Xinhua Hospital, which is affili-

abbreviations GTR = gross-total resection; OS = overall survival; PFS = progression-free survival; RT = radiotherapy; STR = subtotal resection.subMitted January 31, 2015. accePted May 11, 2015.include when citing Published online October 9, 2015; DOI: 10.3171/2015.5.PEDS1573.

Clinical characteristics and abandonment and outcome of treatment in 67 Chinese children with medulloblastomachen wang, Md,1 Xiao-Jun Yuan, Md, Phd,1 Ma-wei Jiang, Md, Phd,2 and li-Feng wang, Md, Phd3

Departments of 1Pediatric Hematology/Oncology, 2Oncological Radiotherapy, and 3Pathology, Xin Hua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China

obJective The purpose of this study was to explore the clinical features and outcome of medulloblastoma in Chinese children. The authors analyze the reasons that treatment is abandoned and attempt to provide evidence-based recom-mendations for improving the prognosis of medulloblastoma in this population. Methods A total of 67 pediatric cases of newly diagnosed medulloblastoma were included in this study. All of the children were treated at Xinhua Hospital between January 2007 and June 2013. The authors retrospectively analyzed the clinical data, treatment modalities, and outcome. The male-to-female ratio was 2:1, and the patients’ median age at diagnosis was 51.96 months (range 3.96–168.24 months). The median duration of follow-up was 32 months (range 3–70 months). results At the most recent follow-up date, 31 patients (46%) were alive, 30 (45%) had died, and 6 (9%) had been lost to follow-up. The estimated 3-year overall survival and progression-free survival, based on Kaplan-Meier analysis, were 55.1% ± 6.4% and 45.6% ± 6.7%, respectively. Univariate analysis showed that standard-risk group (p = 0.009), postoperative radiotherapy (RT) combined with chemotherapy (p < 0.001), older age (≥ 3 years) at diagnosis (p = 0.010), gross-total resection (p = 0.012), annual family income higher than $3000 (p = 0.033), and living in urban areas (p = 0.008) were favorable prognostic factors. Multivariate analysis revealed that postoperative RT combined with chemo-therapy was an independent prognostic factor (p < 0.001). The treatment abandonment rate in this cohort was 31% (21 of 67 cases).conclusions There was a large gap between the outcome of medulloblastoma in Chinese children and the outcome in Western children. Based on our data, treatment abandonment was the major cause of therapeutic failure. Parents’ misunderstanding of medulloblastoma played a major role in abandonment, followed by financial and transportation dif-ficulties. Establishment of multidisciplinary treatment teams could improve the prognosis of medulloblastoma in Chinese children.http://thejns.org/doi/abs/10.3171/2015.5.PEDS1573KeY words medulloblastoma; prognosis; clinical characteristic; Chinese children; oncology

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ated with Shanghai Jiaotong University School of Medi-cine, from January 2007 to June 2013. All of the children underwent tumor resection or biopsy, and in all cases, the diagnosis of medulloblastoma was made on the basis of pathological examination of tumor specimens in Xinhua Hospital and confirmed by Dr. Adekunle M. Adesina (Texas Children’s Hospital, Houston), who reviewed the sections. Clinical data were collected from the Xinhua Hospital database. All patients were followed up by clinic appointment or telephone interviews. The last follow-up date was October 31, 2014. Data collection and entry were approved by the ethics committee of Xinhua Hospital. The collected data included age, sex, travel time from the patient’s hometown to Xinhua Hospital, annual family income, residence, reason for abandoning treatment, ex-tent of tumor resection, postoperative radiotherapy (RT), postoperative chemotherapy, and clinical outcomes. The patients’ residence was classified as rural or urban de-pending on the recorded address. Travel time, annual fam-ily income, and reasons for treatment abandonment were reported by the patients’ parents via clinic interview or follow-up investigation. We designed a questionnaire to collect data on the reasons for abandoning treatment; par-ents were asked to rank the reasons from most to least important (Table 1).

Risk StratificationPatients with medulloblastoma are generally catego-

rized as being in standard-risk or high-risk groups as defined by the Children’s Cancer Study Group. The stan-dard-risk group is defined as patients who are older than 3 years at diagnosis, without metastatic disease (M0), and have a residual tumor volume less than 1.5 cm; other pa-tients are considered to be in the high-risk group.7

Treatment Modalities and DefinitionsTumor operation followed by craniospinal RT and ad-

juvant chemotherapy is the typical treatment modality for medulloblastoma.3 We assigned patients to one of 3 groups based on treatment. The Op group was defined as patients who had undergone gross-total resection (GTR) or subto-tal resection (STR) but did not receive any adjuvant ther-apy. The Op+RT group comprised patients who received adjuvant RT after resection, and the Op+RT+Chemo group comprised patients who completed all Op, RT, and chemotherapy treatment. In most cases, microdissection was used to resect the primary tumors via a posterior fos-sa craniotomy. Standard RT practice involves the use of craniospinal irradiation (36 Gy, 20 fractions) with a boost to the posterior fossa/primary tumor bed (54 Gy, 10 frac-tions). For patients younger than 3 years of age, RT usually would be delayed until they were older than 3 years. The chemotherapy regimens included a routine combination of lomustine, cisplatin, and vincristine. Adjuvant temozolo-mide was used in a few cases. Treatment was considered to have been abandoned if a patient did not begin a speci-fied treatment course or if the patient missed 4 or more successive weeks of treatment.2

Statistical AnalysisStatistical analysis was performed with the software

IBM SPSS Statistics 18 (IBM Corp.). Survival rates were estimated by means of the Kaplan-Meier method. Overall survival (OS) was calculated as the time from diagnosis to death from any cause or the last follow-up. Progression-free survival (PFS) was calculated as the time from diag-nosis to any of the following: disease progression, tumor recurrence, occurrence of metastatic disease, and death from any cause. Cases in which treatment was abandoned were censored at the date of abandonment. The log-rank test was used for univariate analysis of prognostic vari-ables. Variables with a p value < 0.05 in univariate analy-sis were entered into the multivariate Cox proportional-hazards regression model. Relationships between travel time from the patient’s hometown to the hospital, annual family income, family residence, and treatment abandon-ment were evaluated by chi-square test. A p value < 0.05 was considered to indicate statistical significance. The last follow-up date was October 31, 2014.

resultsPatient Characteristics

A total of 67 patients were in this cohort, including 17 infants or very young children (< 3 years of age) and 50 children between 3 and 16 years of age. The median age at diagnosis was 51.96 months (range 3.96–168.24 months). Forty-five patients (67%) were male, and 22 (33%) were female. The male/female ratio was approximately 2:1. The most common symptoms were those associated with in-tracranial hypertension, such as nausea or vomiting (69%), headache (29%), and cerebellar dysfunctional symptoms such as ataxia (45%) and diplopia (3%). The median pre-diagnostic interval (interval from symptom onset to con-firmed diagnosis) was 1 month (range 4 hours to 2 years). Thirty-seven patients (55.2%) had transferred from one hospital to another more than twice. According to risk group classification, 26 patients (39%) were in the stan-

TABLE 1. The most common reasons for abandoning treatment of medulloblastoma

Rank Reason Score*

1 Child experienced severe side effects during postop therapy & preferred alternative medicine

191

2 Believed that the brain tumor was incurable 1853 Confused information about diagnosis & treatment 1354 Financial difficulties 1054 Transportation difficulties 1056 Child’s condition showed no improvement after initial

treatment88

7 Long-term therapy occupied too much of parents’ time 838 Dissatisfaction w/ the service of health care providers 809 Lack of social support or pressure from social network 77

10 Child’s improved condition after initial treatment made parents think further therapy unnecessary

49

* We scored the abandonment reasons from 1 to 10. If the parents chose a reason as the most important (no. 1 reason), it was given a score of 10 points; the second most important reason was given 9 points, and so on. The scores in this table represent the total number of points given to each of the reasons listed.


Prognosis of medulloblastoma in Chinese children

J neurosurg Pediatr Volume 17 • January 2016 51

dard-risk group, and 41 patients (61%) were in the high-risk group. The patients came from different provinces or regions across China. Thirty-eight (55%) came from poor rural areas, whereas 29 (43%) were from economically prosperous urban areas. Based on the survey, the median annual family income was $2910 (range $500–$7056). Approximately half of the patients’ families (33 families) had an annual income higher than $3000, and half (34 families) had lower than that level. The average total cost of medulloblastoma treatment in Xinhua Hospital was about $19,926 (Fig. 1). The median travel time (by train or bus) from the patient’s hometown to Xinhua Hospital was 6 hours (range 1–16 hours).

Treatment OutcomeAt the final follow-up date, 31 patients (46%) were

alive, 30 (45%) had died, and 6 (9%) had been lost to fol-low-up. In 4 of the 6 cases in which patients were lost to follow-up, the phone numbers that we had from the pa-tients’ initial registration were either wrong or invalid; in the other 2 cases, the parents intentionally disconnected the follow-up calls. As for the treatment modalities, 22 patients had resective surgery (GTR or STR) without ad-junctive treatment and made up the Op group; 9 patients were included in the Op+RT group; and 35 patients in the Op+RT+Chemo group completed all the recommended therapy procedures. In 1 case, the family refused any other treatment after the tumor was diagnosed by biopsy; this patient was not included in any of the 3 treatment groups. In 37 cases (55.2%), the patients had used Chinese medi-cine outside the specialist hospital.

Treatment was abandoned in 21 of 67 cases, resulting in an overall treatment abandonment rate of 31%. The major reasons for abandonment included misunderstand-ings about medulloblastoma and financial or transporta-tion difficulties (Table 1). In 1 case, the cause of treatment abandonment could not be determined.

Survival AnalysisThe median follow-up time was 21 months (range 3–70

months). The estimated 3-year OS and 3-year PFS were 55.1% ± 6.4% and 45.6% ± 6.7%, respectively. Patients old-er than 3 years had higher 3-year OS than younger patients (63.1% ± 7.2% vs 31.37% ± 11.7%, p = 0.010) (Fig. 2A).

The 3-year OS of the standard-risk group was much higher than that of the high-risk group (67.5% ± 7.8% vs 36.3% ± 9.6%, p = 0.009) (Fig. 2B). Patients who received GTR had higher 3-year OS than those who had STR (60.0% ± 6.5% vs 0% ± 0%, p = 0.012). The 3-year OS was higher in the Op+RT+Chemo group than in the Op+RT group (87.8% ± 5.7% vs 59.3% ± 18.5%, p = 0.140) and in the Op group (87.8% ± 5.7% vs 0.00% ± 0.0%, p < 0.001). The 3-year OS was also higher in the OP+RT group than in the Op group (59.3% ± 18.5% vs 0.00% ± 0.0%, p < 0.001) (Fig. 2C). Treatment abandonment greatly affected the 3-year OS (87.8% ± 5.7% for patients with complete treatment vs 25.2% ± 10.7% for those whose treatment was abandoned, p < 0.001) (Fig. 2D). Patients with higher annual family income also had more favorable 3-year OS than patients with lower annual family income (66.5% ± 8.3% vs 42.1% ± 9.3%, p = 0.033) (Fig. 2E). The 3-year OS of urban pa-tients was higher than that of rural patients (71.8% ± 8.5% vs 41.0 ± 8.6%, p = 0.008) (Fig. 2F). However, comparison of 3-year PFS between urban patients and rural patients (p = 0.110) and between patients with higher annual fam-ily income and patients with lower annual family income (p = 0.172) showed no statistically significant difference. The chi-square test showed that annual family income was closely related to the area of residence (p < 0.001). However, treatment abandonment was not correlated with travel time from the patient’s hometown to the hospital (p = 0.051) (Fig. 3), annual family income (p = 0.490) (Fig. 4), or area of residence (p = 0.150) (Fig. 5). Univariate analysis showed that older age (≥ 3 years) at diagnosis (p = 0.010), GTR (p = 0.012), standard-risk-group (p = 0.009), comple-tion of both RT and chemotherapy in addition to surgery (p < 0.001), annual family income higher than $3000 (p = 0.033), and living in urban areas (p = 0.008) were favor-able prognostic factors (Table 2). The above factors were all entered into a multivariate Cox proportional-hazards regression model, which revealed that the combination of postoperative RT and chemotherapy was an independent prognostic factor (p < 0.001). Since establishment of the Xinhua Multidisciplinary Collaboration Group for Pediat-ric Brain Tumors in our hospital in January 2011, the per-centage of patients who completed postoperative RT and chemotherapy increased from 33% (10/30) to 68% (25/37) (p = 0.036). The treatment abandonment rate decreased from 43% (13/30) to 22% (8/37) (p = 0.069).

DiscussionMedulloblastoma is one of the most common primary

CNS tumors in children, with an estimated incidence of 0.5 cases per 100,000 children.3 For children, tumor re-section followed by craniospinal irradiation and adjuvant chemotherapy is the typical treatment modality.3,6 Recent reports from Western countries suggest that, with multi-modal therapy, 5-year OS approaches 85% for patients in the standard-risk group and 60% for those in the high-risk group.5,12 In our cohort of Chinese children, however, the 3-year OS rates of the standard-risk group and high-risk group were only 67.5% ± 7.8% and 36.3 ± 9.6%, respec-tively. Although the medical system in China has been renovated during the last 15 years, there is still a large gap

Fig. 1. Pie chart showing the average cost of medulloblastoma treat-ment in Xinhua Hospital. The overall average cost of approximately $19,926 per patient included $11,276 (57%) for surgery, $4020 (20%) for chemotherapy, and $4630 (23%) for RT.


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between the outcome of medulloblastoma in Chinese chil-dren and children in developed countries. Many reasons are interrelated, such as misunderstandings about brain tumors, high treatment costs, parental socioeconomic sta-tus, shortage of specialists, and lack of a multidisciplinary team. The increasing social mobility and lack of standard-ized medical network make this issue more complicated for Chinese doctors.

In our analysis of clinical data, we found that treat-ment modality was the most significant prognostic factor. Abandonment was the major cause of treatment failure. In developing countries, treatment abandonment could affect up to 50%–60% of children with cancer.2 The rate of aban-donment does seem to be related to the type of cancer. For Wilms’ tumor and Hodgkin’s lymphoma, the treatment abandonment rate is usually 5%–10%. For acute leukemia, the rate varies from 16% to 50%.2 However, we found very little information on treatment abandonment rates for chil-

dren with brain tumors in developing countries.14,15 To our knowledge, our study is the first to report on abandonment of medulloblastoma treatment for children in China. The abandonment rate was 31% in this cohort. Because a large percentage of children with brain tumors are diagnosed and treated in nonspecialist children’s hospitals, this sce-nario might be much worse across China.

The male/female ratio in this cohort was 2:1, which shows a stronger male preponderance than the previously reported ratio of 1.3:1.3 The reports of the sixth Chinese population census released by National Bureau of Statis-tics cite a nationwide male/female ratio of 1.05:1 (http://www.stats.gov.cn/tjsj/pcsj/rkpc/6rp/indexch.htm). In some rural areas of China, people have a traditional preference for boys over girls. We suspected that the increased male preponderance in our study might be due to earlier aban-donment of treatment after initial diagnosis in female chil-dren.

Fig. 2. Kaplan-Meier curves for OS in our patient cohort stratified by age, risk group, treatment modality, treatment abandonment, annual family income, and area of residence. a: The 3-year OS of patients 3 years of age or older was better than that of younger patients (63.1% ± 7.2% vs 31.37% ± 11.7%, p = 0.010). b: The 3-year OS of patients in the standard-risk group was much higher than that of those in the high-risk group (67.5% ± 7.8% vs 36.3% ± 9.6%, p = 0.009). c: The 3-year OS in the Op+RT+Chemo group was higher than that in the Op+RT group (87.8% ± 5.7% vs 59.3% ± 18.5%, p = 0.140) or Op group (87.8% ± 5.7% vs 0.00% ± 0.0%, p < 0.001). The 3-year OS in the Op+RT group was also higher than that in the Op group (59.3% ± 18.5% vs 0.00% ± 0.0%, p < 0.001). d: The 3-year OS of patients who completed the prescribed courses of therapy was better than that of those who did not (87.8% ± 5.7% vs 25.2% ± 10.7%, p < 0.001). e: Patients with higher annual family income also had more favorable 3-year OS than patients with lower annual family income (66.5% ± 8.3% vs. 42.1% ± 9.3%, p = 0.033). F: The 3-year OS was much higher for patients from urban areas than for those from rural areas (71.8% ± 8.5% vs. 41.0 ± 8.6%, p = 0.008).




The median prediagnostic interval in our cohort was 1 month (range 4 hours to 2 years), which was similar to the result of a large cohort in Canada that the median pre-diagnostic interval across all 126 medulloblastoma cases was 4 weeks (range 4–12 weeks).13 It seemed that the Chi-nese parents did not lack awareness of early symptoms of a brain tumor, but before getting appropriate treatment, more than half of our patients (37/67, 55%) had to transfer from one hospital to another more than twice. This sug-gests that China has a serious shortage of pediatric brain tumor specialists.

The treatment protocols for medulloblastoma have not been standardized in China. Our center is one of the major specialist pediatric oncology centers in China, and we use a standardized treatment procedure, including microdis-section, followed by RT and adjuvant chemotherapy. To avoid long-term sequelae, infants and children under the age of 3 years were treated only with chemotherapy after surgery.1 The estimated 3-year OS for children who re-ceived complete courses of chemotherapy and RT, as well as undergoing surgery (the Op+RT+Chemo group), was

87.3% ± 5.4%, which is as good as the results reported by the UK National Registry of Childhood Tumors.8 How-ever, only 52% of the patients (35/67) completed scheduled treatment in our study, 31% (21/67) abandoned the planned therapy, and the other 17% (11/67) did not complete the therapy because of contraindications.

In addition to medical reasons, parental misconcep-tions regarding brain tumors and limited family resources seem to play an important role in abandoning treatment.9,14 We investigated the reasons for abandonment by using a questionnaire. The top 3 reasons (preference for alternative medicine, belief that brain tumors are incurable, and con-fusion regarding the treatment and prognosis of medullo-blastoma) were all related to misunderstandings about me-dulloblastoma and its treatment. The wide use of Chinese medicine might explain the strong preference for alterna-tive medicine. In our cohort, 37 patients (55.2%) had used Chinese medicine outside the specialist hospital. Because of the lack of standardization of Chinese medicine, we do not consider it a professional postoperative treatment. In ad-dition, most parents tended to wish the surgery could cure

Fig. 3. Abandonment rates stratified by travel time from the patients’ hometowns to the hospital. The relationship between aban-donment rate and travel time did not quite achieve statistical significance (p = 0.051).

Fig. 4. Abandonment rates stratified by family income. Families with lower annual income had a greater tendency to abandon treatment, but the relationship was not statistically significant (p = 0.490).


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Fig. 5. Abandonment rates stratified by rural versus urban residence. Families living in rural areas were more likely to abandon treatment, but the relationship was not statistically significant (p = 0.150).

TABLE 2. Prognostic factors in 67 pediatric cases of medulloblastoma

Factor No. of Patients 3-Yr OS (%) p Value 3-Yr PFS (%) p Value

Sex 0.579 0.296 Male 45 57.8 ± 7.6 48.4 ± 8.3 Female 22 49.5 ± 11.4 39.3 ± 11.3Age at diagnosis 0.010 0.006 <3 yrs 17 31.7 ± 11.7 25.7 ± 11.0 ≥3 yrs 50 63.1 ± 7.2 52.4 ± 7.8Risk stratification 0.009 0.014 Standard 41 67.5 ± 7.8 54.3 ± 8.8 High 26 36.3 ± 9.6 32.4 ± 9.4Extent of resection 0.012 0.017 GTR 61 60.0 ± 6.5 49.5 ± 7.0 STR 5 0 ± 0 0 ± 0 Biopsy 1 —CSF dissemination at diagnosis 0.240 0.400 Yes 8 37.5 ± 17.1 37.5 ± 17.1 No 59 57.7 ± 6.8 46.6 ± 7.2Treatment modality Op only 22 0 ± 0 <0.001* 0 ± 0 <0.001* Op+RT 9 59.3 ± 18.5 0.140* 61.0 ± 18.1 0.502* Op+RT+Chemo 35 87.8 ± 5.7 69.1 ± 9.0Completion of therapy <0.001 <0.001 Completion 35 87.8 ± 5.7 69.1 ± 4.0 Abandonment 21 25.2 ± 10.7 26.2 ± 10.8Family annual income 0.033 0.172 >$3000 34 66.5 ± 8.3 52.7 ± 9.1 <$3000 33 42.1 ± 9.3 38.6 ± 9.3Residence 0.008 0.110 Rural 38 41.0 ± 8.6 37.9 ± 8.5 Urban 29 71.8 ± 8.5 56.2 ± 9.7

* Compared with Op+RT+Chemo group.




medulloblastoma completely. If surgery could not remove all the symptoms, they might think postoperative therapy was also useless and unable to save the child. On the other hand, if the child appeared healthy after surgery, parents might think that the disease had been cured and postopera-tive therapy was unnecessary. Therefore, the correction of families’ misconceptions about the treatment process and prognosis of brain tumor might prevent the abandonment of treatment in children with medulloblastoma.

Financial difficulties and transportation to a major care center were also important reasons. We analyzed patients’ annual family income and family residence ar-eas. The average annual family income across China was 18,771 RMB ($2843) in 2013 (data obtained from the of-ficial website of NBS, http://data.stats.gov.cn/workspace/index?m=hgnd). The median annual family income in our cohort was $2910. In light of the high average treatment costs ($19,926), it was reasonable to categorize those pa-tients with an annual family income lower than $3000 as the poor group and the others as the wealthy group. Pa-tients in the poor group had a poorer outcome than patients in the wealthy group (p = 0.033). The family financial sta-tus had a significant relationship with 3-year OS but not with 3-year PFS. This suggests that wealthier families had a stronger tendency to pursue medical treatment in the face of disease progression, and this might result in a transient prolongation of overall survival. Area of residence (rural vs urban) was also correlated with outcome (p = 0.008). Basically, people living in rural areas had lower income (p < 0.001), and they tended to travel long distances to reach a major hospital, which made it more difficult for patients to continue their long-term postoperative therapy. More than half of the patients (37/67, 55%) needed to travel more than 5 hours to get to Xinhua Hospital from their hometown. This suggests that the training of specialists in pediatric brain tumors should be an urgent issue for Chinese health care governors. In addition, parents who lived in rural ar-eas with lower annual incomes often have a lower educa-tional level and limited social resources, which could lead to lack of communication with doctors. As a result, the be-havior of treatment abandonment represents an interaction between family financial difficulties and misunderstand-ings regarding brain tumor. Treatment abandonment is as much a socioeconomic issue as a medical one.

Because standard treatment strategies for CNS tumors have not yet been established, lack of a multidisciplinary team for treatment worsens the situation.10 Initial consulta-tion and multidisciplinary collaboration may have a posi-tive effect on patients’ compliance.4,11 Our multimodality team—consisting of specialists from pediatric neurosur-gery, oncology, radiology, RT, and pathology—was estab-lished in 2011. The doctors from different departments get together to discuss the best remedy for each patient. We enhanced the initial consultation and provided parents with education of brain tumor’s characteristics, treatment, prognosis, and daily care. Parents had close contact with all the pediatric brain tumor specialists during their hospi-talization. With this collaboration, each patient’s condition was discussed and treated cooperatively, and we subse-quently experienced an increase in the treatment comple-tion rate and a decrease in treatment abandonment.

Conclusions With effective interventions to prevent treatment aban-

donment, the outcome of pediatric medulloblastoma could be greatly improved. On the basis of this study, we be-lieve that the following 4 improvements could provide im-portant benefits: 1) training more specialists in pediatric brain tumor to serve patients across our country; 2) having discussions with the children’s parents about the benefits of postoperative therapy at diagnosis to provide them an accurate understanding of RT and chemotherapy; 3) pro-viding close follow-up and making regular contact with patients to reduce the likelihood of treatment abandon-ment; and 4) establishing multidisciplinary teams for com-prehensive treatment. These measures could enhance the compliance and completion rates for children with brain tumors in developing countries. Multicenter studies are still needed to evaluate the long-term outcome of pediatric medulloblastoma in China.

AcknowledgmentsThis project was sponsored by Shanghai Jiaotong University

Kuan-cheng Wang Medical Reward Funds. We are grateful to Dr. Adekunle M. Adesina (Texas Children’s Hospital, Houston, Texas) for reviewing the pathological diagnoses and Dr. Yang Zhao (Department of Pediatric Neurosurgery, Xinhua Hospital, Shanghai, China) for providing surgical information. We are also thankful to Dr. Jingqiu Ma (the English editor of the Journal of Clinical Pediatrics, Shanghai, China) for her critical review of the manuscript.

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DisclosureThe authors report no conflict of interest concerning the materi-als or methods used in this study or the findings specified in this paper.

Author ContributionsConception and design: Yuan. Acquisition of data: C Wang. Analysis and interpretation of data: C Wang. Drafting the article: C Wang. Critically revising the article: Yuan. Reviewed submit-ted version of manuscript: Yuan, Jiang, LF Wang. Approved the final version of the manuscript on behalf of all authors: Yuan. Statistical analysis: C Wang. Administrative/technical/material support: Yuan, Jiang, LF Wang. Study supervision: Yuan.

CorrespondenceXiaojun Yuan, Department of Pediatric Hematology/Oncology, Xinhua Hospital, No. 1665 Kongjiang Rd., Shanghai 200092, China. email: [email protected].


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