Inhomogeneities in radiotherapy dose distributions covering the vertebrae in children can produce long-term spinal problems, including kyphosis, lordosis, scoliosis, and hypoplasia. In the published literature, many often interrelated variables have been reported to affect the extent of potential radiotherapy damage to the spine. Articles published in the 2D and 3D radiotherapy era instructed radiation oncologists to avoid dose inhomogeneity over growing vertebrae. However, in the present era of highly conformal radiotherapy, steep dose gradients over at-risk structures can be generated and thus less harm is caused to patients. In this report, paediatric radiation oncologists from leading centres in 11 European countries have produced recommendations on how to approach dose coverage for target volumes that are adjacent to vertebrae to minimise the risk of long-term spinal problems. Based on available information, it is advised that homogeneous vertebral radiotherapy doses should be delivered in children who have not yet finished the pubertal growth spurt. If dose fall-off within vertebrae cannot be avoided, acceptable dose gradients for different age groups are detailed here. Vertebral delineation should include all primary ossification centres and growth plates, and therefore include at least the vertebral body and arch. For partial spinal radiotherapy, the number of irradiated vertebrae should be restricted as much as achievable, particularly at the thoracic level in young children (<6 years old). There is a need for multicentre research on vertebral radiotherapy dose distributions for children, but until more valid data become available, these recommendations can provide a basis for daily practice for radiation oncologists who have patients that require vertebral radiotherapy.

Bristol Haematology and Oncology Centre University Hospitals Bristol NHS Foundation Trust Bristol UK

Danish Centre for Particle Therapy Aarhus University Hospital Aarhus Denmark

Department of Oncology Cambridge University Hospitals Cambridge UK

Department of Oncology Clatterbridge Cancer Centre Liverpool UK

Department of Oncology Oslo University Hospital Oslo Norway

Department of Particle Therapy University Hospital Essen West German Proton Therapy Centre Essen West German Cancer Center German Cancer Consortium Essen Germany

Department of Radiation Oncology Academic Medical Center Amsterdam Netherlands

Department of Radiation Oncology Assistance Publique Hôpitaux de Marseille Marseille France

Department of Radiation Oncology Centre François Baclesse Caen France

Department of Radiation Oncology Centre Léon Bérard Lyon France

Department of Radiation Oncology Ghent University Hospital Ghent Belgium

Department of Radiation Oncology Gustave Roussy Villejuif France

Department of Radiation Oncology Institut Claudius Regaud Institut Universitaire du Cancer de Toulouse Oncopole Toulouse France; Toulouse NeuroImaging Center ToNIC INSERM Université Toulouse 3 Paul Sabatier Toulouse France

Department of Radiation Oncology Institut Curie Paris and Orsay France

Department of Radiation Oncology Medical Center Hamburg Eppendorf Hamburg Germany

Department of Radiation Oncology Radboud University Medical Center Nijmegen Netherlands

Department of Radiation Oncology Saarland University Hospital Homburg Germany

Department of Radiation Oncology Universität Klinik für Strahlentherapie und Strahlenbiologie Vienna Austria

Department of Radiation Oncology University Medical Center Utrecht Utrecht Netherlands

Department of Radiation Oncology University Medical Center Utrecht Utrecht Netherlands; Princess Maxima Center for Pediatric Oncology Utrecht Netherlands

Department of Radiation Oncology University of Leipzig Leipzig Germany

Department of Radiotherapy Royal Marsden Hospital Sutton UK

Hospital Universitari de la Vall d'Hebron Barcelona Spain

Manchester Academic Health Science Centre University of Manchester The Christie NHS Foundation Trust Manchester UK; The Children's Brain Tumour Research Network University of Manchester Royal Manchester Children's Hospital Manchester UK

Pediatric Radiotherapy Unit Fondazione IRCCS Istituto Nazionale dei Tumori Milan Italy

Princess Maxima Center for Pediatric Oncology Utrecht Netherlands

Proton Therapy Center Czech Prague Czech Republic

Proton Therapy Center Santa Chiara Hospital Trento Italy

Radiotherapy Department Istituto Oncologico Veneto IRCCS Padua Italy

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