Received: 20 November 2016 Accepted: 7 December 2016 DOI: 10.1002/pbc.26434 Pediatric Blood & Cancer The American Society of Pediatric Hematology/Oncology LETTER TO THE EDITOR Whole brain radiotherapy with volumetric-modulated arc therapy for pediatric intracranial embryonic carcinoma prevents permanent alopecia Excellent survival outcomes for nongerminomatous germ cell tumors (NGGCT), including embryonic carcinoma, have been achieved with the recent advances in platinum-based multidrug chemotherapy with craniospinal irradiation (CSI) and boost irradiation for the primary tumor. 1–3 However, such intensive chemoradiotherapy occasionally causes severe, although not life-threatening, late adverse events including permanent alopecia. 4,5 Permanent alopecia could negatively affect self-image and self-esteem, leading to a decrease in social interactions. 6 Whole brain irradiation with volumetric-modulated arc therapy (WBI-VMAT) can reduce the dose to hair follicles, and is already applied in adult patients to limit the extent of alopecia. 7 Whether WBI-VMAT can prevent permanent alopecia in pediatric patients has not yet been reported. Herein, we report a 9-year-old female who presented to our hos- pital with a 1-month history of headache. Progressive polydipsia and polyuria were also found, which suggested diabetes insipidus. Cra- nial magnetic resonance imaging (MRI) showed a gadolinium-enhanced mass in the suprasellar region. The examination of cerebrospinal fluid was negative for malignant cells and whole spine MRI did not indicate any dissemination. Laboratory tests showed elevation of serum alpha-fetoprotein (AFP; 49.8 ng/ml) and human chorionic gonadotropin (HCG)- (8.8 mIU/ml). The patient was diagnosed with embryonal carcinoma based on histology of the biopsied tumor tis- sue. The patient received five courses of chemotherapy consisting of cyclophosphamide, cisplatin, and etoposide. Following the first course of chemotherapy, the patient obtained a complete response with nor- malization of serum AFP and HCG- levels. Considering the high rate of local and spinal recurrence, 1 the patient was given CSI of 35.2 Gy in 22 fractions followed by boost irra- diation to the primary tumor of 17 Gy in 10 fractions. The fourth course of chemotherapy and the radiotherapy were started concurrently. The treatment plan for CSI consisted of irradiation to the spinal cord and WBI-VMAT. In the WBI-VMAT plan, the skin structure was defined as a 5 mm-thick region beneath the surface of the skin. Optimization was performed to set doses to the skin as low as possible while main- taining a homogenous dose distribution to the target. As a result, the mean dose to the skin structure was less than 21 Gy (Fig. 1A). The patient received chemoradiotherapy without any serious treatment- related complications. Hair regrowth was first observed 2 months after Abbreviations: AFP, alpha-fetoprotein; CSI, craniospinal irradiation; HCG, human chorionic gonadotropin; MRI, magnetic resonance imaging; NGGCT, nongerminomatous germ cell tumors; Oct3/4, octamer binding transcriptional factor 3/4; VMAT, volumetric-modulated arc therapy; WBI, whole brain irradiation treatment (Fig. 1B–E). To date, the patient is disease-free with com- plete hair regrowth 15 months after treatment (Fig. 1F–I). Radiation-induced permanent alopecia occurs in a dose-dependent manner. 4 As WBI-VMAT was able to reduce the mean dose to the skin structure, it contributed to prompt and complete hair regrowth in the current case. Although WBI-VMAT can reduce the probability of permanent alopecia, this novel technique has some potential disadvantages. Espe- cially, poor quality WBI-VMAT plans may decrease the dose to the sub- arachnoid space immediately beneath the scalp, which increases the risk of meningeal dissemination. 8 Thus, multi-institutional studies are first required to verify the efficacy and accuracy of WBI-VMAT. ACKNOWLEDGMENT We would like to thank all the staff involved for their help with the WBI-VMAT. ETHICS STATEMENT The patient’s parents provided written informed consent for the publi- cation of photographs under the guidelines of the Ethics Committee of Kyoto University Graduate School and Faculty of Medicine. CONFLICTS OF INTEREST The authors have no potential conflicts of interest to declare. Atsushi Iwai and Katsutsugu Umeda Department of Pediatrics, Kyoto University, Kyoto, Japan Megumi Uto Radiation Oncology and Image-Applied Therapy, Kyoto University, Kyoto, Japan Hiroshi Nihira, Koji Kawaguchi, Masamitsu Mikami, Seishiro Nodomi, Satoshi Saida and Hidefumi Hiramatsu Department of Pediatrics, Kyoto University, Kyoto, Japan Kengo Ogura Radiation Oncology and Image-Applied Therapy, Kyoto University, Kyoto, Japan Masahiro Tanji and Yoshiki Arakawa Neurosurgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan Tatsunori Sakamoto Department of Otolaryngology-Head and Neck Surgery, The Tazuke Kohukai Medical Research Institute, Kitano Hospital, Osaka, Japan Pediatr Blood Cancer 2017; 00: e26434 c  2017 Wiley Periodicals, Inc. 1 of 2 wileyonlinelibrary.com/journal/pbc