 Hello everyone, greetings from Manipal Hospital Baner Pune, I am Dr. Karan Chanchlani, a radiation oncologist and a neuro-oncologist. Today, we will be discussing about an interesting case of medulloblastoma which is a childhood brain tumor. So, pediatric brain tumors or childhood brain tumors are pose a difficult challenge in the treatment. These tumors typically have a propensity to spread not just locally, they also spread along the entire neuraxis. So, they can spread from brain to the spinal cord or to the other areas of the brain. They are also it is difficult to treat these because they arise in a growing age or a growing brain in which any treatment may actually cause further damage to the growth of the brain and we need to take care of the long term consequences of the treatment. So, coming specifically to this case, this was a 6 year old male child who presented with a small mass inside. So, he presented with headaches and vomiting and then little imbalance and MRI was done wherein he had a mass inside the posterior side of the brain, the cerebellar region and it was radiologically very conclusive of medulloblastoma. So, he was stabilized and then in the pediatric intensivist and the neuro team were involved and contemplated for a neurosurgery. So, typically the surgery for these cases is maximal safe resection. So, looking at the images it was apparent that the child had probably a long standing growth and it had it was very close to the brainstem maybe probably it appeared like infiltrating the brainstem also, but nevertheless with advanced techniques the neurosurgeons were able to remove that tumor completely and we subjected the tumor specimen for surgical pathology and it confirmed medulloblastoma classical variant. Along with that we did certain molecular tests to ascertain the molecular profile of these tumors. So, these days it is classified as wind pathway. So, there are various pathways which have very different prognosis. So, our patient had a favorable pathway called as wind pathway and we could based on the near complete resection that was done and the other assessment on MRI and CSF studies we could ascertain that this patient was of a low risk or average risk medulloblastoma that had been resected completely. So, we planned craniospinal radiation. So, we need to treat the entire neuraxis in the first phase for the initial treatment and then later on plan a focal boost of radiation to the area where the tumor had arise. So, since it was a low risk or average risk medulloblastoma with a favorable profile on molecular studies we decided to go with low dose CSI that is low dose of radiation to the entire neuraxis from brain to spine and the remaining dose was just boosted on the tumor and total it took around 6 weeks to complete the radiation and along with that we had to deliver concurrent chemotherapy as well as some cycles of chemotherapy after the radiation. The main challenge over here is to reduce the doses to the rest of the structures while treating such a large volume. So, your eyes, your oral cavity, thyroid, the entire body structures have received some dose of the radiation. We had one of the few centers wherein we treat with these type of cases with a volumetric approach rather than the conventional field setup approach because conventional field radiations used to have problems with field junction matching and all. So, that is why we have adopted a completely volumetric approach with latest advanced linear accelerator and that is how we could reduce the doses to the subsequent structures. Image guidance was used for matching the target volumes before treatment each day and during the CSI as well as the focal boost area. And this child completed his treatment with hardly any toxicities one of the most dreaded toxicities for these children is in the acute sitting is the fall in the blood counts or neutropenias. So, this child had hardly any neutropenias or any support required additionally the doses to the ear to the eyes were very low and he is on follow up. So, now so far he has not developed any of the toxicities and we hope that this child continues to remain healthy. Usually these type of tumors have excellent prognosis with almost up to 80 to 90 percent 5 year survival. So, we just hope that this kid also enjoys such a good prognosis. Thank you.