Challenges of delivering bi-daily general anaesthetic for hyperfractionated accelerated proton beam therapy for high-risk medulloblastoma

BackgroundHyperfractionated accelerated radiotherapy (HART) is being evaluated as part of the SIOP-HRMB trial for children with high-risk medulloblastoma (HRMB).In the UK, proton beam therapy (PBT) is the standard of care for HRMB.Delivery of HART using PBT in young J o u r n a l P r e -p r o o f children commonly requires bi-daily general anaesthesia (GA), introducing unique clinical and logistical challenges that have not been previously reported. MethodsWe describe a UK multi-centre case series of five children with HRMB treated with bi-daily PBT under GA within the SIOP-HRMB trial.Four patients were treated at The Christie NHS Foundation Trust, Manchester and one at University College London Hospitals NHS Foundation Trust, London.Challenges related to nutrition, treatment logistics, management of treatment interruptions, and anaesthetic considerations were evaluated. ResultsAll the patients completed the planned radiotherapy.Treatment interruptions occurred due to intercurrent illness or cyclotron downtime but were managed using compensatory strategies, including weekend treatments and, in one case, dose escalation following trial approval.Four patients experienced less than 5% weight loss during treatment, and one patient lost 7.2% of their body weight.Nutritional support required enteral feeding and intravenous hydration.Acute toxicities were consistent with those expected after craniospinal irradiation.No serious anaesthetic complications were observed. ConclusionsHART delivered with PBT under twice-daily GA is feasible within the UK NHS, but it imposes substantial nutritional, logistical, and anaesthetic challenges.The issues discussed provide guidance to other centres considering bi-daily radiotherapy, including PBT under anaesthesia in paediatric patients.