Outcome for metastatic (M+) medulloblastoma (MB) treated with carboplatin during craniospinal radiotherapy (CSRT) followed by cyclophosphamide (CPM) and vincristine (VCR): Preliminary results of COG 99701

2017

Background: The outcome for patients with metastatic medulloblastoma has historically been poor. Carboplatin is both a potent radiosensitizer and has activity against medulloblastoma. In this study, we evaluated the feasibility of administering carboplatin during CSRT and the impact of anaplasia as an independent predictor of outcome. Methods: All patients underwent surgical debulking followed by 36 Gy CSRT with boosts to the posterior fossa and sites of bulk disease. During CSRT, patients received weekly VCR as well as carboplatin doses ranging from 30 mg/m2/dose x 15 to 45 mg/m2/dose x 30 given 1–4 hours prior to each RT fraction, using a Phase I design. G-CSF was given for neutropenia during CSRT. Six weeks after completing chemoradiotherapy, patients received six courses of monthly CPM (2 gm/m2) and VCR. Central pathology review was performed to confirm the diagnosis and assess for anaplasia. Results: 57 patients (median age 7.3 yrs, range 3.1–18.1 years, M/F ratio of 2.6:1) with centrally reviewed M+ MB were enrolled. Thrombocytopenia was dose limiting and 35 mg/m2/dose x 30 was selected as the maximum tolerated carboplatin dose. 20 patients (35%) had severe anaplasia. There was no difference in age, M/F ratio or distribution of M-stage between those with or without anaplasia. Median follow-up for surviving patients is 4.5 yrs. Four-year overall survival (OS) and event-free survival (EFS) for the entire group is 81 ± 5% and 66 ± 6%. Four-year OS is 89 ± 5% for patients without anaplasia vs. 65 ± 11% for those with anaplasia (log-rank p=0.002). Four-year EFS is 76 ± 7% for patients without anaplasia vs. 48 ± 12% for those with anaplasia (log-rank p=0.02). There was no difference in survival based on M-stage. Conclusions: The use of daily carboplatin as a radiosensitizer appears to be a promising strategy for patients with metastatic MB. The presence of anaplasia is a significant negative predictor of outcome.

No significant financial relationships to disclose.

Ranolazine: a novel agent that improves dysfunctional sodium channels

Treatment for coronary heart disease is usually directed at either increasing myocardial oxygen supply or decreasing myocardial oxygen demand. Although combination therapy with beta-blockers, calcium-channel blockers and nitrates are effective, many patients suffer from adverse effects of hypotension and bradycardia. Ranolazine is a novel medication that reduces ischaemia by preventing sodium induced calcium overload in myocardial cells without adversely affecting haemodynamic parameters. This agent is the first in the USA to be approved to treat angina in over 10 years. The purpose of this review is to evaluate the pharmacology, pharmacokinetics, clinical trials for safety and efficacy, precautions, adverse effects, drug interactions, and dosage and administration of ranolazine in the treatment of chronic stable angina and acute coronary syndrome.

A comparison of the effect of reduced illumination and tinted lenses on stereospsis at near

Relative depth may be appreciated with the use of one eye using linear perspective, shadows, parallax and texture as monocular cues to depth. Stereopsis, on the other hand, is the directappreciation of relative depth that requires the use of both eyes to construct a three-dimension-al percept from disparate two-dimensional retinal images. The advantage of stereopsis is with respect to complex visual tasks especially that requiring accurate hand-eye coordination. Tinted lenses are prescribed for a variety of reasons, including but not limited to photophobia, asthenopia, improving colour perception in colour deficient individuals, enhancing cosmesis and protection against glare or harmful radiation and enhancing visual performance as in sports. The aim of this study was to investigate the comparative effects of six specific CR39 tinted spectacle lenses (grade B), and a white CR39 lens, against a no lens condition, on stereoacuity over a range of illumination levels. Illumination was varied with the use of neutral density (ND) filters, while the Titmus Fly Stereotest (TFS) wasused to measure stereoacuity. Participants (n =60) between the ages of 17 - 29 years (mean =23.58; sd = 3.14) were purposively sampled from a clinical practice to participate in this research study.  Using repeated measures ANOVA and appropriate post-hoc multivariate analysis, it was evident that there was a significant decline in stereopsis as the level ofillumination decreased,regardless of tint condition; also there was no statistically significant difference in stereopsis between the no lens and white lens conditions at each level of illumination; and stereopsis wassignificantly superior with the no lens conditioncompared to all six other tint conditions (gradeB), at each level of illumination. These results indicate that stereoacuity, as measured by the TFS, is adversely affected by adecline in retinal illuminance and by the use of tinted lenses. This information could be utilised to advise patients on the performance implications of the six tinted lenses tested with respectto their effects on stereoacuity under different illumination levels.

RTOG 0131: Phase II trial of pre-irradiation and concurrent temozolomide in patients with newly diagnosed anaplastic oligodendrogliomas and mixed anaplastic oligodendrogliomas: Relationship between 1p/19q status and progression-free survival

1517

Background: In a previous report, we showed in patients with newly diagnosed anaplastic oligodendrogliomas (AOs) and mixed anaplastic oligoastrocytomas (MAOs) that temozolomide (TMZ) can be given concurrently with radiation therapy (RT) with acceptable toxicity. We have now evaluated the efficacy of this regimen and correlated durability of response with tumor 1p/19q genotype. Methods: A phase II study was performed to evaluate the use of pre-RT TMZ followed by concurrent RT and TMZ in patients with newly diagnosed AO or MAO. The primary endpoint was to determine the pre-RT TMZ six-month progression rate, and secondary endpoints included progression-free survival and overall survival. Results: 40 eligible patients were entered into the trial. Thirty-two patients completed 6 months of pre-RT TMZ and concurrent RT and TMZ. Of the remaining eight patients, 4 withdrew due to toxicity and 4 other patients withdrew from study without evidence of toxicity or pre-RT progression. 1p/19q data are available in 37 cases; 23 tumors had loss of heterozygosity (LOH) of both 1p and 19q (double-deleted) while 14 tumors had LOH of either 1p or 19q (n = 3), or no LOH (n = 11). To date, 11 patients have experienced tumor progression; 1p/19q data are available for 10 of these cases (2 are double-deleted (2/23 = 9%), 8 have at least one intact chromosome (8/14 = 57%). Kaplan-Meier analysis demonstrates that progression free survival is significantly better for the double-deleted group (median time to progression not reached) than for the intact group (median time to progression = 15.2 months, p = 0.001). Overall survival is 98% (39/40) with a median follow-up of 17.5 months (2.8 - 31.1 months). Conclusions: LOH of both 1p and 19q is strongly correlated with a durable response of AO and MAO to a combined regimen of chemotherapy and radiation therapy. Tumors that are intact at 1p and/or 19q progress early despite an aggressive therapeutic regimen. These results suggest that future clinical trials should be prospectively stratified by tumor 1p/19q genotype.

[Table: see text]

An update of phase II results from RTOG 0211: A phase I/II study of gefitinib with radiotherapy in newly diagnosed glioblastoma

1527

Background: The epidermal growth factor receptor (EGFR) pathway is commonly deregulated in GBMs and its activity has been associated with treatment resistance in preclinical models. Accordingly, the Radiation Therapy Oncology Group (RTOG) recently conducted a Phase I/II study of Gefitinib, an EGFR tyrosine kinase inhibitor, in combination with radiotherapy for newly-diagnosed glioblastoma (GBM) patients. Methods: 178 GBM patients were entered on RTOG 0211 (Phase I: 31 patients and Phase II: 147 patients). The maximum tolerated dose (MTD) of Gefitinib was determined to be 500mg in non-EIACD patients, and the Phase II component of RTOG 0211 was continued at this dose level during radiation and as maintenance for 18 months afterward or until disease progression. Results: 119/147 patients completed treatment per protocol and/or with acceptable deviation. The median survival time for all patients in the study was 11.0 months. Progression-free survival was 5.1 months for all patients. When considering only patients who were treated per protocol, the median survival of RTOG 0211 patients was 11.5 months, compared to 11.0 months for historical controls treated in previous RTOG studies (p=0.14). RPA Class IV patients appeared to derive the greatest benefit from Gefitinib when combined with radiotherapy compared to historical controls, although not reaching statistical significance. Molecular and genetic profiling efforts are underway to determine which GBM patients derive greatest benefit from Gefitinib in the upfront setting, which will be reported at the time of the annual meeting. These include markers such as EGFRvIII and PTEN, which have been recently reported to be associated with response to anti-EGFR agents in the recurrent setting, and members of key signal transduction pathways regulated by EGFR. Conclusions: The observed survival advantage of newly-diagnosed GBM patients treated with Gefitinib in combination with radiotherapy compared to historical controls treated on previous RTOG studies does not reach statistical significance. Molecular and genetic profiling efforts are underway to identify subsets of GBM patients who might derive the greatest benefit from Gefitinib in the upfront setting.

No significant financial relationships to disclose.

Prospective neurocognitive effects and quality of life (QOL) in patients with multiple brain metastases receiving whole brain radiation (WBRT) ± thalidomide on radiation therapy oncology group (RTOG) trial 0118

8589

Background: RTOG 0118 was a randomized trial of WBRT (37.5 Gy/15 fractions) ± thalidomide in patients (pts) with brain metastases, which showed no effect on survival (Knisely et al, ASCO, 2005). This analysis examined the relationship between neurocognitive progression (NCP) and QOL in patients on both arms. Methods: NCP was assessed with the Folstein Mini-Mental Status Exam (MMSE) and QOL with the Spitzer QOL Index (SQLI). Pts with MMSE scores below age/education adjusted cutoff levels were considered to have NCP. T-test and Chi-Square statistics were used to determine significant differences in NCP and QOL between the two treatment arms over time. Results: Of 176 pts, 88 and 92% had SQLI and MMSE scores at baseline (43% were below the MMSE cutoff). Baseline SQLI (but not MMSE) was a significant predictor for OS (p=0.034). From baseline, SQLI and MMSE compliance rates were 74 and 60% at 1–2 months (mo), 37 and 29% at 4 mo, and 21 and 19% at 6 months, respectively. While QOL was stable, those who failed to meet MMSE cutoffs increased by 60% by 6 mo, on both study arms. Although a weak correlation (r=.23) existed at baseline between QOL and MMSE for both the WBRT (0.04) and WBRT/thalidomide (0.058) arms, there was no correlation beyond baseline. Conclusions: Baseline QOL is a significant predictor of OS. While QOL remained essentially stable, the degree of neurocognitive decline (60%) over time is concerning. These findings suggest the importance of these outcome measures in pts with brain metastases and the need for interventions to conserve cognitive status. RTOG is developing a trial to study the role of preventive strategies for NCP in brain metastases.

No significant financial relationships to disclose.

Phase I study of concurrent motexafin gadolinium (MGd) with radiation therapy for children with newly diagnosed brain stem gliomas (BSG): A Children’s Oncology Group study

9014

Background: MGd, a radiosensitizer that selectively accumulates in tumors, generates reactive oxygen species intracellularly. In preclinical experiments, MGd enhances RT-induced apoptosis. Methods: A multi-institutional Phase I dose escalation and pharmacokinetic (PK) study was performed in children with newly diagnosed BSG to determine the maximum tolerated dose (MTD) and dose-limiting toxicities (DLT) of MGd administered i.v. 2 to 5 hours prior to involved field radiotherapy (RT) (1.8 Gy/day, total 54 Gy). Cohort 1 received MGd, 1.7 mg/kg/dose M-F × 3 wks and cohort 2 received the same dose M, W and F × 6 wks. The 6 subsequent cohorts of 3 to 6 pts received MGd M-F × 6 weeks at doses of 1.9, 3.4, 4.4, 5.5, 7.1 and 9.2 mg/kg/dose. Serum for PK analysis, and MRI scans (MGd is detectable by MR), were obtained for analysis of drug accumulation and responses. Results: 44 pts (42 fully evaluable for toxicity) with a median age of 6 years (range 2–20) were enrolled. At the 9.2 mg/kg/dose, 2/2 pts experienced DLT. During subsequent expansion of the 7.1 and 5.5 mg/kg/dose cohorts, DLTs, including transaminitis, hypertension and urticaria, were observed in 2/5 and 2/6 pts. At the MTD of 4.4 mg/kg/dose, 1/6 pts had reversible grade 3 serum transaminase elevations. PK analysis showed biphasic elimination with a terminal t 1/2 of 6.4 h. At the MTD, serum MGd concentrations were >250 ng/ml for 24 h. Serum clearance and steady-state volume of distribution were 0.0243 L/h/kg and 0.162 L/kg. MRI for intra-tumoral MGd distribution is ongoing. One patient had a CR and 4 had a PR. The estimated median survival is 10.3 months (95% confidence interval: 8.1 months-11.5 months). Conclusions: The recommended phase II dose of MGd for children with BSG is 4.4 mg/kg/d administered M-F × 6 weeks with involved field RT. A COG phase II trial is planned.

[Table: see text]

Initial report of Radiation Therapy Oncology Group (RTOG) 9802: Prospective studies in adult low-grade glioma (LGG)

1500

Background: Treatment of adult LGG is controversial. Favorable patients (pts) (age <40 years [yrs] who undergo gross total resection [GTR]) are typically observed. Unfavorable pts (age ≥40 who have subtotal resection [STR] or biopsy [B]) are usually given initial radiation therapy (RT), reserving chemotherapy (historically procarbazine, CCNU and vincristine [PCV]) for recurrence. In 1998, the RTOG, in conjunction with SWOG, NCCTG, and ECOG initiated prospective studies of adult LGG, the results of which are reported herein. Methods: Favorable pts were observed postoperatively in a single arm Phase II study (Arm 1). Unfavorable pts were stratified by age, histology, KPS, and presence/absence of contrast enhancement on preoperative magnetic resonance imaging and randomized to either RT alone (54Gy in 30 fractions to a local treatment field) (Arm 2) or RT followed by 6 cycles of standard dose PCV (Arm 3). Reported results include overall survival (OS) rate, median overall survival time (MOST), progression-free survival (PFS) rate, and median progression-free survival time (MPFST). Survival data are compared using Wilcoxon p-values. Results: A total of 362 eligible/analyzable pts were accrued between 1998 and 2002. Median follow-up time is 4 years. For the 111 favorable pts observed on Arm 1, OS at 2- and 5-yrs is 99% and 94%. PFS at 2- and 5-yrs is 82% and 50%. For the 251 unfavorable pts on Arms 2 (RT alone) and 3 (RT+PCV), there was no difference in OS or PFS. OS at 2- and 5-yrs was 87% and 61% with RT alone versus (vs) 86% and 70% with RT+PCV (p=0.72). MOST was not reached in RT alone pts and was 6.0 yrs in RT+PCV pts. PFS at 2- and 5-yrs was 73% and 39% with RT alone vs 72% and 61% with RT+PCV (p=0.38). MPFST was 4.0 yrs with RT alone vs 6.0 yrs with RT+PCV. Acute grade 3–4 toxicity occurred in 9% of pts who received RT alone, 67% who received RT+PCV (mostly hematologic). There were no treatment deaths on either arm. Conclusions: 5-yr PFS was poor in all three arms ranging from 39% to 61%. Only half of favorable pts were disease-free at 5 yrs. In unfavorable pts, there was no OS advantage with the addition of PCV to RT. Both PFS and MPFST were better with the addition of PCV, but not significantly. Analysis of outcome by 1p19q status is pending.

No significant financial relationships to disclose.

Phase II trial of concomitant low dose temozolomide with external beam radiation (EBRT) followed by 12 months of temozolomide and irinotecan for newly diagnosed glioblastoma (GBM): Preliminary results of RTOG 04–20

1510

Background: Irinotecan and temozolomide compare favorably to regimens tested in recurrent GBM. RTOG 04–20 intensifies the Stupp R, et al. (N Engl J Med. 2005 Mar 10;352(10):987–96) adjuvant regimen, using irinotecan and temozolomide in place of temozolomide alone. Methods: Adult patients with newly diagnosed histologically confirmed, supratentorial GBM were eligible. Subjects began temozolomide 75mg/m2 daily the night before initiation of EBRT, and continued until the final day of RT. Pneumocystis prophylaxis was begun prior to RT and for 2 weeks following RT. Within 6 wks after EBRT, subjects with stable or improved MRI were scheduled to receive temozolomide 150mg/m2 on days 1–5, and irinotecan 200mg/m2 on days 1 and 15 of 28 day cycles × 12. Clinical assessments and post contrast MRI are required prior to EBRT, after RT, and after every 2 treatment cycles. Only nonenzyme inducing anticonvulsants were allowed. Results: Accrual of 170 patients was completed in September 2005 with 140 patients currently evaluable. Median age is 57yr, 80% were RPA class III or IV. Prior to cycle 1 of adjuvant therapy, 32 subjects withdrew (20 progressed, 4 toxicity). Of the first 25 subjects receiving irinotecan, 10 suffered grade 3–4 hematologic toxicities in the initial 3 cycles. The protocol was modified by dose reducing irinotecan to 100mg/m2 in cycle 1, escalating to 150 and 200mg/2 in subsequent cycles only if no dose limiting hematologic toxicity occured. No data is yet available on patients who started adjuvant therapy at the lower dose of irinotecan. Diarrhea and constitutional symptoms are the most common nonhematologic toxicies Conclusions: Irinotecan 200mg/m2 days 1 and 15 with temozolomide 150mg/m2 days 1–5 of 28 day cycles was well tolerated treating recurrent GBM, but this regimen was too myelosuppressive when given after concomitant low dose temozolomide and EBRT. Primary outcome data should be available in late 2006.

[Table: see text]

Secondary Analysis of Radiation Therapy Oncology Group study (RTOG) 9310: An Intergroup Phase II Combined Modality Treatment of Primary Central Nervous System Lymphoma

PURPOSE

To determine whether a lower dose of hyperfractionated whole brain radiation reduces central nervous system morbidity without compromising survival for primary CNS lymphoma (PCNSL) patients receiving combined modality treatment.

MATERIALS AND METHODS

One hundred and two patients received a course of pre-radiation chemotherapy, followed by whole brain radiation, followed by cytosine-arabinoside. Initial radiation dose was 45 Gy/25 fractions (RT) then the study was amended to reduce this dose for complete responders to induction chemotherapy to 36 Gy/30 fractions/3 weeks (HFX). Eighty-two patients received radiotherapy and were evaluable for toxicity analysis (66 RT patients and 16 HFX patients). MMSE scores and survival for the 40 patients who received radiotherapy after complete response to chemotherapy (27 RT and 13 HFX) were compared. There were no notable differences in pre-treatment patient characteristics between the RT and HFX groups.

RESULTS

Neurotoxicity: By 4 years, there were 8/82 (10%) grade 5 neurotoxicities which included 2/16 (13%) grade 5 encephalopathies and 0/27 in the RT group of complete responders to chemotherapy. Survival: There was no statistically significant difference in overall or progression-free survival (PFS) between the chemotherapy-complete responders who received RT and HFX. Cognitive function testing: MMSE scores improved at 8 months across both treatment groups. Analysis of the area under the MMSE curve at 8 months showed no statistically significant difference between RT and HFX groups (P=0.81). Leukoencephalopathy occurred later in the HFX group than in the RT patients.

CONCLUSION

Although the HFX schedule represented a 25% reduction in biologically effective tumor dose in comparison, PFS and overall survival were not significantly affected. The HFX regimen delayed but did not eliminate severe neurotoxicity from chemoradiation in PCNSL patients.