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Truffaux N, Philippe C, Paulsson J, Andreiuolo F, Guerrini-Rousseau L, Cornilleau G, Le Dret L, Richon C, Lacroix L, Puget S, Geoerger B, Vassal G, Östman A, Grill J. Preclinical evaluation of dasatinib alone and in combination with cabozantinib for the treatment of diffuse intrinsic pontine glioma. Neuro Oncol 2014; 17:953-64. [PMID: 25534822 DOI: 10.1093/neuonc/nou330] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 11/12/2014] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Platelet-derived growth factor receptor A is altered by amplification and/or mutation in diffuse intrinsic pontine glioma (DIPG). We explored in vitro on new DIPG models the efficacy of dasatinib, a multi-tyrosine kinase inhibitor targeting this receptor. METHODS Gene expression profiles were generated from 41 DIPGs biopsied at diagnosis and compared with the signature associated with sensitivity/resistance to dasatinib. A panel of 12 new DIPG cell lines were established from biopsy at diagnosis, serially passaged, and characterized by gene expression analyses. Effects of dasatinib (1-10 μM) on proliferation, invasion, and cytotoxicity were determined on 4 of these cell lines using live-cell imaging and flow cytometry assays. Downstream signaling and receptor tyrosine kinases (RTKs) were assessed by western blot and phospho-RTK array. The effect of the combination with the c-Met inhibitor cabozantinib was studied on cellular growth and invasion analyzed by the Chou-Talaly method. RESULTS DIPG primary tumors and cell lines exhibited the gene expression signature of sensitivity to dasatinib. Dasatinib reduced proliferation (half-maximal inhibitory concentration = 10-100 nM) and invasion (30%-60% reduction) at 100 nM in 4/4 cultures and induced apoptosis in 1 of 4 DIPG cell lines. Activity of downstream effectors of dasatinib targets including activin receptor 1 was strongly reduced. Since multiple RTKs were activated simultaneously in DIPG cell lines, including c-Met, which can be also amplified in DIPG, the benefit of the combination of dasatinib with cabozantinib was explored for its synergistic effects on proliferation and migration/invasion in these cell lines. CONCLUSION Dasatinib exhibits antitumor effects in vitro that could be increased by the combination with another RTK inhibitor targeting c-Met.
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Affiliation(s)
- Nathalène Truffaux
- CNRS UMR 8203 Vectorology and Anticancer Therapeutics, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (N.T., C.P., F.A., L.G.-R., G.C., L.L.-D., B.G., G.V., J.G.); Functional Genomics Unit, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (C.R.); Translational Research Laboratory and Biobank, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Inserm U981, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Medical Biology and Pathology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (B.G., J.G.); Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden (J.P., A.Ö.); Department of Neurosurgery, Necker-Sick Children Hospital, Paris Descartes University, Paris, France (S.P.)
| | - Cathy Philippe
- CNRS UMR 8203 Vectorology and Anticancer Therapeutics, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (N.T., C.P., F.A., L.G.-R., G.C., L.L.-D., B.G., G.V., J.G.); Functional Genomics Unit, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (C.R.); Translational Research Laboratory and Biobank, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Inserm U981, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Medical Biology and Pathology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (B.G., J.G.); Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden (J.P., A.Ö.); Department of Neurosurgery, Necker-Sick Children Hospital, Paris Descartes University, Paris, France (S.P.)
| | - Janna Paulsson
- CNRS UMR 8203 Vectorology and Anticancer Therapeutics, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (N.T., C.P., F.A., L.G.-R., G.C., L.L.-D., B.G., G.V., J.G.); Functional Genomics Unit, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (C.R.); Translational Research Laboratory and Biobank, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Inserm U981, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Medical Biology and Pathology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (B.G., J.G.); Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden (J.P., A.Ö.); Department of Neurosurgery, Necker-Sick Children Hospital, Paris Descartes University, Paris, France (S.P.)
| | - Felipe Andreiuolo
- CNRS UMR 8203 Vectorology and Anticancer Therapeutics, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (N.T., C.P., F.A., L.G.-R., G.C., L.L.-D., B.G., G.V., J.G.); Functional Genomics Unit, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (C.R.); Translational Research Laboratory and Biobank, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Inserm U981, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Medical Biology and Pathology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (B.G., J.G.); Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden (J.P., A.Ö.); Department of Neurosurgery, Necker-Sick Children Hospital, Paris Descartes University, Paris, France (S.P.)
| | - Léa Guerrini-Rousseau
- CNRS UMR 8203 Vectorology and Anticancer Therapeutics, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (N.T., C.P., F.A., L.G.-R., G.C., L.L.-D., B.G., G.V., J.G.); Functional Genomics Unit, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (C.R.); Translational Research Laboratory and Biobank, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Inserm U981, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Medical Biology and Pathology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (B.G., J.G.); Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden (J.P., A.Ö.); Department of Neurosurgery, Necker-Sick Children Hospital, Paris Descartes University, Paris, France (S.P.)
| | - Gaétan Cornilleau
- CNRS UMR 8203 Vectorology and Anticancer Therapeutics, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (N.T., C.P., F.A., L.G.-R., G.C., L.L.-D., B.G., G.V., J.G.); Functional Genomics Unit, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (C.R.); Translational Research Laboratory and Biobank, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Inserm U981, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Medical Biology and Pathology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (B.G., J.G.); Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden (J.P., A.Ö.); Department of Neurosurgery, Necker-Sick Children Hospital, Paris Descartes University, Paris, France (S.P.)
| | - Ludivine Le Dret
- CNRS UMR 8203 Vectorology and Anticancer Therapeutics, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (N.T., C.P., F.A., L.G.-R., G.C., L.L.-D., B.G., G.V., J.G.); Functional Genomics Unit, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (C.R.); Translational Research Laboratory and Biobank, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Inserm U981, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Medical Biology and Pathology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (B.G., J.G.); Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden (J.P., A.Ö.); Department of Neurosurgery, Necker-Sick Children Hospital, Paris Descartes University, Paris, France (S.P.)
| | - Catherine Richon
- CNRS UMR 8203 Vectorology and Anticancer Therapeutics, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (N.T., C.P., F.A., L.G.-R., G.C., L.L.-D., B.G., G.V., J.G.); Functional Genomics Unit, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (C.R.); Translational Research Laboratory and Biobank, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Inserm U981, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Medical Biology and Pathology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (B.G., J.G.); Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden (J.P., A.Ö.); Department of Neurosurgery, Necker-Sick Children Hospital, Paris Descartes University, Paris, France (S.P.)
| | - Ludovic Lacroix
- CNRS UMR 8203 Vectorology and Anticancer Therapeutics, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (N.T., C.P., F.A., L.G.-R., G.C., L.L.-D., B.G., G.V., J.G.); Functional Genomics Unit, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (C.R.); Translational Research Laboratory and Biobank, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Inserm U981, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Medical Biology and Pathology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (B.G., J.G.); Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden (J.P., A.Ö.); Department of Neurosurgery, Necker-Sick Children Hospital, Paris Descartes University, Paris, France (S.P.)
| | - Stéphanie Puget
- CNRS UMR 8203 Vectorology and Anticancer Therapeutics, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (N.T., C.P., F.A., L.G.-R., G.C., L.L.-D., B.G., G.V., J.G.); Functional Genomics Unit, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (C.R.); Translational Research Laboratory and Biobank, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Inserm U981, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Medical Biology and Pathology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (B.G., J.G.); Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden (J.P., A.Ö.); Department of Neurosurgery, Necker-Sick Children Hospital, Paris Descartes University, Paris, France (S.P.)
| | - Birgit Geoerger
- CNRS UMR 8203 Vectorology and Anticancer Therapeutics, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (N.T., C.P., F.A., L.G.-R., G.C., L.L.-D., B.G., G.V., J.G.); Functional Genomics Unit, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (C.R.); Translational Research Laboratory and Biobank, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Inserm U981, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Medical Biology and Pathology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (B.G., J.G.); Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden (J.P., A.Ö.); Department of Neurosurgery, Necker-Sick Children Hospital, Paris Descartes University, Paris, France (S.P.)
| | - Gilles Vassal
- CNRS UMR 8203 Vectorology and Anticancer Therapeutics, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (N.T., C.P., F.A., L.G.-R., G.C., L.L.-D., B.G., G.V., J.G.); Functional Genomics Unit, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (C.R.); Translational Research Laboratory and Biobank, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Inserm U981, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Medical Biology and Pathology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (B.G., J.G.); Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden (J.P., A.Ö.); Department of Neurosurgery, Necker-Sick Children Hospital, Paris Descartes University, Paris, France (S.P.)
| | - Arne Östman
- CNRS UMR 8203 Vectorology and Anticancer Therapeutics, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (N.T., C.P., F.A., L.G.-R., G.C., L.L.-D., B.G., G.V., J.G.); Functional Genomics Unit, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (C.R.); Translational Research Laboratory and Biobank, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Inserm U981, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Medical Biology and Pathology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (B.G., J.G.); Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden (J.P., A.Ö.); Department of Neurosurgery, Necker-Sick Children Hospital, Paris Descartes University, Paris, France (S.P.)
| | - Jacques Grill
- CNRS UMR 8203 Vectorology and Anticancer Therapeutics, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (N.T., C.P., F.A., L.G.-R., G.C., L.L.-D., B.G., G.V., J.G.); Functional Genomics Unit, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (C.R.); Translational Research Laboratory and Biobank, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Inserm U981, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Medical Biology and Pathology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (L.L.); Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, Paris XI University, Villejuif, France (B.G., J.G.); Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden (J.P., A.Ö.); Department of Neurosurgery, Necker-Sick Children Hospital, Paris Descartes University, Paris, France (S.P.)
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Adamski J, Tabori U, Bouffet E. Advances in the Management of Paediatric High-Grade Glioma. Curr Oncol Rep 2014; 16:414. [DOI: 10.1007/s11912-014-0414-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Pautier P, Locher C, Robert C, Deroussent A, Flament C, Le Cesne A, Rey A, Bahleda R, Ribrag V, Soria JC, Vassal G, Eggermont A, Zitvogel L, Chaput N, Paci A. Phase I clinical trial combining imatinib mesylate and IL-2 in refractory cancer patients: IL-2 interferes with the pharmacokinetics of imatinib mesylate. Oncoimmunology 2014; 2:e23079. [PMID: 23525192 PMCID: PMC3601177 DOI: 10.4161/onci.23079] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Imatinib mesylate (IM) is a small molecule inhibitor of protein tyrosine kinases. In addition to its direct effect on malignant cells, it has been suggested IM may activate of natural killer (NK) cells, hence exerting immunomodulatory functions. In preclinical settings, improved antitumor responses have been observed when IM and interleukin-2 (IL-2), a cytokine that enhances NK cells functions, were combined. The goals of this study were to determine the maximum tolerated dose (MTD) of IL-2 combined with IM at a constant dose of 400 mg, the pharmacokinetics of IM and IL-2, as well as toxicity and clinical efficacy of this immunotherapeutic regimen in patients affected by advanced tumors. The treatment consisted in 50 mg/day cyclophosphamide from 21 d before the initiation of IM throughout the first IM cycle (from D-21 to D14), 400 mg/day IM for 14 d (D1 to D14) combined with escalating doses of IL-2 (3, 6, 9 and 12 MIU/day) from days 10 to 14. This treatment was administered at three week intervals to 17 patients. Common side effects of the combination were mild to moderate, including fever, chills, fatigue, nausea and hepatic enzyme elevation. IL-2 dose level II, 6 MIU/day, was determined as the MTD with the following dose-limiting toxicities: systemic capillary leak syndrome, fatigue and anorexia. Pharmacokinetic studies revealed that the area under the curve and the maximum concentration of IM and its main metabolite CGP74588 increased significantly when IM was concomitantly administered with IL-2. In contrast, IM did not modulate IL-2 pharmacokinetics. No objective responses were observed. The best response obtained was stable disease in 8/17 (median duration: 12 weeks). Finally, IL-2 augmented the impregnation of IM and its metabolite. The combination of IM (400 mg/day) and IL-2 (6 MIU/day) in tumors that express IM targets warrants further investigation.
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Affiliation(s)
- Patricia Pautier
- Département de Médecine; Institut de Cancérologie Gustave Roussy; Villejuif, France
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Vanan MI, Eisenstat DD. Management of high-grade gliomas in the pediatric patient: Past, present, and future. Neurooncol Pract 2014; 1:145-157. [PMID: 26034626 DOI: 10.1093/nop/npu022] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Indexed: 11/12/2022] Open
Abstract
High-grade gliomas (HGGs) constitute ∼15% of all primary brain tumors in children and adolescents. Routine histopathological diagnosis is based on tissue obtained from biopsy or, preferably, from the resected tumor itself. The majority of pediatric HGGs are clinically and biologically distinct from histologically similar adult malignant gliomas; these differences may explain the disparate responses to therapy and clinical outcomes when comparing children and adults with HGG. The recently proposed integrated genomic classification identifies 6 distinct biological subgroups of glioblastoma (GBM) throughout the age spectrum. Driver mutations in genes affecting histone H3.3 (K27M and G34R/V) coupled with mutations involving specific proteins (TP53, ATRX, DAXX, SETD2, ACVR1, FGFR1, NTRK) induce defects in chromatin remodeling and may play a central role in the genesis of many pediatric HGGs. Current clinical practice in pediatric HGGs includes surgical resection followed by radiation therapy (in children aged > 3 years) with concurrent and adjuvant chemotherapy with temozolomide. However, these multimodality treatment strategies have had a minimal impact on improving survival. Ongoing clinical trials are investigating new molecular targets, chemoradiation sensitization strategies, and immunotherapy. Future clinical trials of pediatric HGG will incorporate the distinction between GBM molecular subgroups and stratify patients using group-specific biomarkers.
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Affiliation(s)
- Magimairajan Issai Vanan
- Section of Pediatric Hematology/Oncology/BMT, CancerCare Manitoba, Departments of Pediatrics & Child Health and Biochemistry & Medical Genetics , University of Manitoba , Winnipeg, Manitoba , Canada (M.I.V.); Division of Hematology/Oncology and Palliative Care, Stollery Children's Hospital, Departments of Pediatrics, Medical Genetics and Oncology , University of Alberta , Edmonton, Alberta , Canada (D.D.E.)
| | - David D Eisenstat
- Section of Pediatric Hematology/Oncology/BMT, CancerCare Manitoba, Departments of Pediatrics & Child Health and Biochemistry & Medical Genetics , University of Manitoba , Winnipeg, Manitoba , Canada (M.I.V.); Division of Hematology/Oncology and Palliative Care, Stollery Children's Hospital, Departments of Pediatrics, Medical Genetics and Oncology , University of Alberta , Edmonton, Alberta , Canada (D.D.E.)
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Pai Panandiker AS, Wong JK, Nedelka MA, Wu S, Gajjar A, Broniscer A. Effect of time from diagnosis to start of radiotherapy on children with diffuse intrinsic pontine glioma. Pediatr Blood Cancer 2014; 61:1180-3. [PMID: 24482196 PMCID: PMC4378861 DOI: 10.1002/pbc.24971] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 01/07/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND Children with diffuse intrinsic pontine glioma (DIPG) continue to have poor outcomes, and radiotherapy (RT) is the only temporarily effective treatment. In this retrospective analysis, we studied the effect of time from diagnosis to start of RT on event-free survival (EFS) and overall survival (OS) in children with DIPG. METHODS Records of children (n = 95) with DIPG treated with RT at a single institution between April 1999 and September 2009 were analyzed. RT was delivered at doses of 54.0-55.8 Gy at 1.8 Gy per fraction, and children were followed prospectively. The effect of gender, race, interruption during treatment course, age at diagnosis, duration of symptoms prior to diagnosis, use of protocol-based chemotherapy, and time from diagnosis to initiation of RT on EFS and OS was assessed by the Cox proportional hazards model. RESULTS Time as a continuous variable from diagnosis to start of RT did not affect outcome. Time dichotomized to ≤14 days significantly affected OS (hazard ratio [HR] = 1.70, P = 0.014) and race other than white or black affected EFS (HR = 2.32, P = 0.017). The 95 patients had a 6-month EFS and OS of 60 ± 5% and 94.7 ± 2.3%, respectively, and a 12-month EFS and OS of 11.6 ± 3.1% and 49.5 ± 5%, respectively. CONCLUSIONS Time as a continuous variable did not affect OS or EFS in our cohort; however, children treated within 2 weeks of diagnosis had poor outcomes. Although rapid initiation of RT is desirable, our findings do not support intensive efforts aimed at shortening delays from diagnosis to start of RT.
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Affiliation(s)
- Atmaram S. Pai Panandiker
- Department of Radiological Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee,Corresponding author: Atmaram S. Pai Panandiker, MD, Department of Radiological Sciences, Mail Stop 220, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678, Phone: 901-595-3226; Fax: 901-595-3113;
| | - J. Karen Wong
- Department of Radiological Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Michele A. Nedelka
- Department of Radiological Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Shengjie Wu
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Amar Gajjar
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Alberto Broniscer
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
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Iasonos A, O'Quigley J. Adaptive dose-finding studies: a review of model-guided phase I clinical trials. J Clin Oncol 2014; 32:2505-11. [PMID: 24982451 DOI: 10.1200/jco.2013.54.6051] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE We provide a comprehensive review of adaptive phase I clinical trials in oncology that used a statistical model to guide dose escalation to identify the maximum-tolerated dose (MTD). We describe the clinical setting, practical implications, and safety of such applications, with the aim of understanding how these designs work in practice. METHODS We identified 53 phase I trials published between January 2003 and September 2013 that used the continual reassessment method (CRM), CRM using escalation with overdose control, or time-to-event CRM for late-onset toxicities. Study characteristics, design parameters, dose-limiting toxicity (DLT) definition, DLT rate, patient-dose allocation, overdose, underdose, sample size, and trial duration were abstracted from each study. In addition, we examined all studies in terms of safety, and we outlined the reasons why escalations occur and under what circumstances. RESULTS On average, trials accrued 25 to 35 patients over a 2-year period and tested five dose levels. The average DLT rate was 18%, which is lower than in previous reports, whereas all levels above the MTD had an average DLT rate of 36%. On average, 39% of patients were treated at the MTD, and 74% were treated at either the MTD or an adjacent level (one level above or below). CONCLUSION This review of completed phase I studies confirms the safety and generalizability of model-guided, adaptive dose-escalation designs, and it provides an approach for using, interpreting, and understanding such designs to guide dose escalation in phase I trials.
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Affiliation(s)
- Alexia Iasonos
- Alexia Iasonos, Memorial Sloan Kettering Cancer Center, New York, NY; and John O'Quigley, Université Paris VI, Paris, France.
| | - John O'Quigley
- Alexia Iasonos, Memorial Sloan Kettering Cancer Center, New York, NY; and John O'Quigley, Université Paris VI, Paris, France
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Pollack IF, Jakacki RI, Butterfield LH, Hamilton RL, Panigrahy A, Potter DM, Connelly AK, Dibridge SA, Whiteside TL, Okada H. Antigen-specific immune responses and clinical outcome after vaccination with glioma-associated antigen peptides and polyinosinic-polycytidylic acid stabilized by lysine and carboxymethylcellulose in children with newly diagnosed malignant brainstem and nonbrainstem gliomas. J Clin Oncol 2014; 32:2050-8. [PMID: 24888813 DOI: 10.1200/jco.2013.54.0526] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Diffuse brainstem gliomas (BSGs) and other high-grade gliomas (HGGs) of childhood carry a dismal prognosis despite current treatments, and new therapies are needed. Having identified a series of glioma-associated antigens (GAAs) commonly overexpressed in pediatric gliomas, we initiated a pilot study of subcutaneous vaccinations with GAA epitope peptides in HLA-A2-positive children with newly diagnosed BSG and HGG. PATIENTS AND METHODS GAAs were EphA2, interleukin-13 receptor alpha 2 (IL-13Rα2), and survivin, and their peptide epitopes were emulsified in Montanide-ISA-51 and given every 3 weeks with intramuscular polyinosinic-polycytidylic acid stabilized by lysine and carboxymethylcellulose for eight courses, followed by booster vaccinations every 6 weeks. Primary end points were safety and T-cell responses against vaccine-targeted GAA epitopes. Treatment response was evaluated clinically and by magnetic resonance imaging. RESULTS Twenty-six children were enrolled, 14 with newly diagnosed BSG treated with irradiation and 12 with newly diagnosed BSG or HGG treated with irradiation and concurrent chemotherapy. No dose-limiting non-CNS toxicity was encountered. Five children had symptomatic pseudoprogression, which responded to dexamethasone and was associated with prolonged survival. Only two patients had progressive disease during the first two vaccine courses; 19 had stable disease, two had partial responses, one had a minor response, and two had prolonged disease-free status after surgery. Enzyme-linked immunosorbent spot analysis in 21 children showed positive anti-GAA immune responses in 13: to IL-13Rα2 in 10, EphA2 in 11, and survivin in three. CONCLUSION GAA peptide vaccination in children with gliomas is generally well tolerated and has preliminary evidence of immunologic and clinical responses. Careful monitoring and management of pseudoprogression is essential.
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Affiliation(s)
- Ian F Pollack
- All authors: University of Pittsburgh, Pittsburgh, PA.
| | | | | | | | | | | | | | | | | | - Hideho Okada
- All authors: University of Pittsburgh, Pittsburgh, PA
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Robison NJ, Kieran MW. Diffuse intrinsic pontine glioma: a reassessment. J Neurooncol 2014; 119:7-15. [PMID: 24792486 DOI: 10.1007/s11060-014-1448-8] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 04/13/2014] [Indexed: 11/25/2022]
Abstract
Diffuse intrinsic pontine glioma (DIPG) is a disease of childhood whose abysmal prognosis has remained unchanged for over 50 years. Biologic investigation has been stymied by lack of pretreatment tissue, as biopsy has been reserved for atypical cases. Recent advances in surgical and molecular-analytic techniques have increased the safety and potential utility of biopsy; brainstem biopsy has now been incorporated into several prospective clinical trials. These and other recent efforts have yielded new insights into DIPG molecular pathogenesis, and opened new avenues for investigation.
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Affiliation(s)
- Nathan J Robison
- Pediatric Neuro-Oncology Program, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, 4650 W Sunset Blvd, MS#54, Los Angeles, CA, 90027, USA,
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Sie M, den Dunnen WF, Hoving EW, de Bont ES. Anti-angiogenic therapy in pediatric brain tumors: An effective strategy? Crit Rev Oncol Hematol 2014; 89:418-32. [DOI: 10.1016/j.critrevonc.2013.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 08/10/2013] [Accepted: 09/27/2013] [Indexed: 12/15/2022] Open
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Abstract
The prognosis for children with diffuse intrinsic pontine gliomas (DIPGs) is dismal. Although DIPGs constitute only 10-15 % of all pediatric brain tumors, they are the main cause of death in this group with a median survival of less than 12 months. Standard therapy involves radiotherapy, which produces transient neurologic improvement. Despite several clinical trials having been conducted, including trials on targeted agents to assess their efficacy, there is no clear improvement in prognosis. However, knowledge of DIPG biology is increasing, mainly as a result of research using biopsy and autopsy samples. In this review, we discuss recent studies in which systemic therapy was administered prior to, concomitantly with, or after radiotherapy. The discussion also includes novel therapeutic options in DIPG. Continuing multimodal and multitargeted therapies might lead to an improvement in the dismal prognosis of the disease.
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Affiliation(s)
- Rejin Kebudi
- Istanbul University Cerrahpasa Medical Faculty Pediatric Hematology-Oncology, P.C: 34090, Millet Street, Capa, Istanbul, Turkey,
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61
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Zaky W, Wellner M, Brown RJ, Blüml S, Finlay JL, Dhall G. Treatment of children with diffuse intrinsic pontine gliomas with chemoradiotherapy followed by a combination of temozolomide, irinotecan, and bevacizumab. Pediatr Hematol Oncol 2013; 30:623-32. [PMID: 24050762 DOI: 10.3109/08880018.2013.829895] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Diffuse intrinsic pontine gliomas (DIPG) are inoperable and highly resistant tumors to chemotherapy and irradiation. DIPG has the worst prognosis among all pediatric brain tumors and the overwhelming majority of patients die within 6-18 months after diagnosis. METHODS We retrospectively reviewed the charts of six DIPG patients treated with chemoradiotherapy (daily carboplatin and oral etoposide in five patients and temozolomide in one patient) followed by maintenance chemotherapy consisting of irinotecan, temozolomide, and bevacizumab at our institution between January 2007 until December 2007. RESULTS Event-free survival (EFS) and overall survival (OS) were 10.4 ± 3.08 and 14.6 ± 3.55 months, respectively. Side effects in the patients included hypertension in two, abdominal cramping and diarrhea in four, and neutropenia in five patients. CONCLUSIONS This augmented regimen was associated with increased but tolerable toxicity and a modest increase in EFS and OS when compared with published literature in patients with DIPG (median EFS and OS of 6.1 and 9.6 months, respectively). More effective therapies are desperately needed.
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Affiliation(s)
- Wafik Zaky
- 1Department of Pediatrics, Division of Pediatric Hematology and Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
Brainstem gliomas (BGs) are a heterogenous group of gliomas that occur predominately in children. They can be separated into groups on the basis of anatomy and clinical behavior: diffuse intrinsic pontine glioma (DIPG), exophytic medullary glioma, and tectal glioma. DIPG is the commonest BG. Median age at onset is 6.5 years and median survival is less than 1 year. Adults with DIPG survive longer, suggesting a less aggressive and biologically different tumor from that in children. Patients present with cranial nerve dysfunction, long tract signs, or ataxia, either in isolation or in combination. Magnetic resonance imaging shows an infiltrative lesion occupying most of the pons and contrast enhancement is usually not prominent. Standard treatment is fractionated radiotherapy. Platelet-derived growth factor receptor alpha and epidermal growth factor receptor mutations have been identified. Inhibitors of these growth factor receptors are being evaluated in clinical trials. Exophytic medullary and tectal gliomas are relatively indolent tumors that can often be followed closely without treatment.
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Affiliation(s)
- Sean A Grimm
- Department of Neurology, University of Minnesota Medical School, Minneapolis, MN 55455, USA
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63
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Wu L, Li X, Janagam DR, Lowe TL. Overcoming the blood-brain barrier in chemotherapy treatment of pediatric brain tumors. Pharm Res 2013; 31:531-40. [PMID: 23996470 DOI: 10.1007/s11095-013-1196-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 08/21/2013] [Indexed: 12/19/2022]
Abstract
Pediatric brain tumors are most common cancers in childhood and among the leading causes of death in children. Chemotherapy has been used as adjuvant (i.e. after) or neoadjuvant (i.e. before) therapy to surgery and radiotherapy for the management of pediatric brain tumors for more than four decades and gained more attention in the recent two decades. Although chemotherapy has demonstrated its effectiveness in the management of some pediatric brain tumors, failure or inactiveness of chemotherapy is commonly met in the clinics and clinical trials. Some of these failures might be attributed to the blood-brain barrier (BBB), limiting the penetration of systemically administered chemotherapeutics into pediatric brain tumors. Therefore, various strategies have been developed and used to address this issue. Herein, we review different methods reported in the literature to circumvent the BBB for enhancing the present of chemotherapeutics in the brain to treat pediatric brain tumors.
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Affiliation(s)
- Linfeng Wu
- Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, 38163, USA
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Clinico-radiologic characteristics of long-term survivors of diffuse intrinsic pontine glioma. J Neurooncol 2013; 114:339-44. [PMID: 23813229 DOI: 10.1007/s11060-013-1189-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 06/22/2013] [Indexed: 10/26/2022]
Abstract
Diffuse intrinsic pontine glioma (DIPG) is the deadliest central nervous system tumor in children. The survival of affected children has remained poor despite treatment with radiation therapy (RT) with or without chemotherapy. We reviewed the medical records of all surviving patients with DIPG treated at our institution between October 1, 1992 and May 31, 2011. Blinded central radiologic review of the magnetic resonance imaging at diagnosis of all surviving patients and 15 controls with DIPG was performed. All surviving patients underwent neurocognitive assessment during follow-up. Five (2.6 %) of 191 patients treated during the study period were surviving at a median of 9.3 years from their diagnosis (range 5.3-13.2 years). Two patients were younger than 3 years, one lacked signs of pontine cranial nerve involvement, and three had longer duration of symptoms at diagnosis. One patient had a radiologically atypical tumor and one had a tumor originating in the medulla. All five patients received RT. Chemotherapy was variable among these patients. Neurocognitive assessments were obtained after a median interval of 7.1 years. Three of four patients who underwent a detailed evaluation showed cognitive function in the borderline or mental retardation range. Two patients experienced disease progression at 8.8 and 13 years after diagnosis. A minority of children with DIPG experienced long-term survival with currently available therapies. These patients remained at high risk for tumor progression even after long follow-ups. Four of our long-term survivors had clinical and radiologic characteristics at diagnosis associated with improved outcome.
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Premkumar DR, Jane EP, Foster KA, Pollack IF. Survivin inhibitor YM-155 sensitizes tumor necrosis factor- related apoptosis-inducing ligand-resistant glioma cells to apoptosis through Mcl-1 downregulation and by engaging the mitochondrial death pathway. J Pharmacol Exp Ther 2013; 346:201-10. [PMID: 23740602 DOI: 10.1124/jpet.113.204743] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Induction of apoptosis by the death ligand tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is a promising antitumor therapy. However, not all tumor cells are sensitive to TRAIL, highlighting the need for strategies to overcome TRAIL resistance. Inhibitor of apoptosis family member survivin is constitutively activated in various cancers and blocks apoptotic signaling. Recently, we demonstrated that YM-155 [3-(2-methoxyethyl)-2-methyl-4,9-dioxo-1-(pyrazin-2-ylmethyl)-4,9-dihydro-3H-naphtho[2,3-d]imidazol-1-ium bromide], a small molecule inhibitor, downregulates not only survivin in gliomas but also myeloid cell leukemia sequence 1 (Mcl-1), and it upregulates proapoptotic Noxa levels. Because Mcl-1 and survivin are critical mediators of resistance to various anticancer therapies, we questioned whether YM-155 could sensitize resistant glioma cells to TRAIL. To address this hypothesis, we combined YM-155 with TRAIL and examined the effects on cell survival and apoptotic signaling. TRAIL or YM-155 individually induced minimal killing in highly resistant U373 and LNZ308 cell lines, but combining TRAIL with YM-155 triggered a synergistic proapoptotic response, mediated through mitochondrial dysfunction via activation of caspases-8, -9, -7, -3, poly-ADP-ribose polymerase, and Bid. Apoptosis induced by combination treatments was blocked by caspase-8 and pan-caspase inhibitors. In addition, knockdown of Mcl-1 by RNA interference overcame apoptotic resistance to TRAIL. Conversely, silencing Noxa by RNA interference reduced the combined effects of YM-155 and TRAIL on apoptosis. Mechanistically, these findings indicate that YM-155 plays a role in counteracting glioma cell resistance to TRAIL-induced apoptosis by downregulating Mcl-1 and survivin and amplifying mitochondrial signaling through intrinsic and extrinsic apoptotic pathways. The significantly enhanced antitumor activity of the combination of YM-155 and TRAIL may have applications for therapy of malignant glioma.
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Affiliation(s)
- Daniel R Premkumar
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
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66
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Abstract
OPINION STATEMENT Gliomas are the most common brain tumor in children and represent nearly 50 % of all pediatric central nervous system (CNS) tumors. They are a heterogeneous group of diseases, ranging from highly malignant and frequently fatal to histologically benign and curable by surgery alone. A uniform treatment approach to these tumors is not practical, due to their histological and biological heterogeneity. Low-grade gliomas (LGGs) are best treated with maximally safe surgical resection, generally achievable for hemispheric or cerebellar locations. Patients with deep midline, optic pathway/hypothalamic, and brain stem locations should undergo subtotal resection or biopsy only. If a complete resection is not feasible, subtotal resection followed by adjuvant chemotherapy or radiotherapy is the standard approach; however, observation alone with serial neuroimaging is used in some asymptomatic, surgically inaccessible lesions. Chemotherapy is used first-line in cases of residual or progressive disease, to avoid or delay radiation therapy and its associated side effects. Regimens demonstrating objective responses and increased progression free survival (PFS) include carboplatin and vincristine (CV), thioguanine/procarbazine/CCNU/vincristine (TPCV), or weekly vinblastine. High-grade gliomas (HGGs) are less common in children than in adults, though are similar in their aggressive clinical behavior, resistance to therapy, and dismal outcomes. There is not a single "standard of care" therapy for non-metastatic HGGs, but generally accepted is an aggressive attempt at a complete surgical resection, followed by multimodality therapy with focal radiation and chemotherapy. The use of temozolomide (TMZ) during and following radiotherapy is common, though it appeared not to improve the outcome in a cooperative group clinical trial when compared to an historical control cohort. The angiogenesis inhibitor bevacizumab, used alone or in combination with irinotecan, is also commonly used as maintenance therapy after radiation. Current trials are prospectively comparing TMZ to newer agents (vorinostat, bevacizumab) in a randomized phase II trial. Brainstem gliomas are a unique category of childhood gliomas. Approximately 80 % of childhood brainstem gliomas arise within the pons as diffuse intrinsic pontine gliomas (DIPG). When biopsied, these are usually HGGs and carry a dismal prognosis. Standard therapy is focal radiation (54-58 Gy), preferably on a clinical trial testing concurrent chemotherapy or biologic agent. No standard chemotherapy agent has impacted survival. The remaining 20 % of brainstem gliomas are low-grade, arise in the midbrain, dorsal medulla, or cervicomedullary junction, and are indolent in nature with a much better prognosis. Improvement in the outcome of all childhood gliomas will require increased knowledge of the underlying biology of these tumors, in order to treat with more biologically based and precise therapies.
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Affiliation(s)
- Jane E Minturn
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, 3501 Civic Center Boulevard, CTRB 4028, Philadelphia, PA, 19104, USA
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Broniscer A, Baker SD, Wetmore C, Pai Panandiker AS, Huang J, Davidoff AM, Onar-Thomas A, Panetta JC, Chin TK, Merchant TE, Baker JN, Kaste SC, Gajjar A, Stewart CF. Phase I trial, pharmacokinetics, and pharmacodynamics of vandetanib and dasatinib in children with newly diagnosed diffuse intrinsic pontine glioma. Clin Cancer Res 2013; 19:3050-8. [PMID: 23536435 DOI: 10.1158/1078-0432.ccr-13-0306] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE Testing of promising drug combinations is crucial in the treatment of diffuse intrinsic pontine glioma (DIPG). As the VEGF and platelet-derived growth factor (PDGF) pathways are critical in gliomas, we evaluated the safety, maximum tolerated dose (MTD), pharmacokinetics, and pharmacodynamics of vandetanib, a VEGFR-2 inhibitor, combined with dasatinib, a potent PDGFR inhibitor, during and after radiotherapy in children with newly diagnosed DIPG. EXPERIMENTAL DESIGN Dasatinib was started concurrently with radiotherapy. Vandetanib was started 8 days later. We tested increasing doses of vandetanib (65 and 85 mg/m(2) once daily) and dasatinib (65 and 85 mg/m(2) twice daily). Dose-limiting toxicities were evaluated during the first 6 weeks of therapy. Plasma pharmacokinetics was obtained on days 8 and 42 ± 3 in all patients and concomitantly with cerebrospinal fluid (CSF) when possible. Inhibition of targets of dasatinib in peripheral blood mononuclear cells (PBMC) was evaluated. RESULTS Twenty-five patients were treated. Treatment was well tolerated. The median duration of treatment was 184 days. Diarrhea was the most significant toxicity. Three patients experienced substantial myelosuppression. The steady-state plasma pharmacokinetics of vandetanib was comparable with previous studies. Although the plasma exposure to dasatinib decreased from days 8 to 42, it remained similar to adult studies. CSF to plasma exposure of vandetanib and dasatinib were approximately 2% in 2 patients. Phosphorylated 70S6K decreased during therapy in PBMCs. CONCLUSIONS The MTD of vandetanib and dasatinib in combination was 65 mg/m(2) for each drug. Other studies are underway to test dasatinib and other PDGFR inhibitors alone or in combination for this deadly cancer.
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Affiliation(s)
- Alberto Broniscer
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA.
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Jansen MHA, Kaspers GJ. A new era for children with diffuse intrinsic pontine glioma: hope for cure? Expert Rev Anticancer Ther 2013; 12:1109-12. [PMID: 23098109 DOI: 10.1586/era.12.95] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Primary glial brain tumors account for the majority of primary brain tumors in children. They are classified as low-grade gliomas (LGG) or high-grade gliomas (HGG), based on specific pathologic characteristics of the tumor, resulting in disparate clinical prognoses. Surgery is a mainstay of treatment for HGG, although it is not curative, and adjuvant therapy is required. Temozolomide, an oral imidazotetrazine prodrug, while considered standard of care for adult HGG, has not shown the same degree of benefit in the treatment of pediatric HGG. There are significant biologic differences that exist between adult and pediatric HGG, and targets specifically aimed at the biology in the pediatric population are required. Novel and specific therapies currently being investigated for pediatric HGG include small molecule inhibitors of epidermal growth factor receptor, platelet-derived growth factor receptor, histone deacetylase, the RAS/AKT pathway, telomerase, integrin, insulin-like growth factor receptor, and γ-secretase. Surgery is also the mainstay for LGG. There are defined front-line, multiagent chemotherapy regimens, but there are few proven second-line chemotherapy options for refractory patients. Approaches such as the inhibition of the mammalian target of rapamycin pathway, inhibition of MEK1 and 2, as well as BRAF, are discussed. Further research is required to understand the biology of pediatric gliomas as well as the use of molecularly targeted agents, especially in patients with surgically unresectable tumors.
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70
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Warren KE. Diffuse intrinsic pontine glioma: poised for progress. Front Oncol 2012; 2:205. [PMID: 23293772 PMCID: PMC3531714 DOI: 10.3389/fonc.2012.00205] [Citation(s) in RCA: 186] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 12/11/2012] [Indexed: 12/21/2022] Open
Abstract
Diffuse intrinsic pontine gliomas (DIPGs) are amongst the most challenging tumors to treat. Surgery is not an option, the effects of radiation therapy are temporary, and no chemotherapeutic agent has demonstrated significant efficacy. Numerous clinical trials of new agents and novel therapeutic approaches have been performed over the course of several decades in efforts to improve the outcome of children with DIPG, yet without success. The diagnosis of DIPG is based on radiographic findings in the setting of a typical clinical presentation, and tissue is not routinely obtained as the standard of care. The paradigm for treating children with these tumors has been based on that for supratentorial high-grade gliomas in adults as the biology of these lesions were presumed to be similar. However, recent pivotal studies demonstrate that DIPGs appear to be their own entity. Simply identifying this fact releases a number of constraints and opens opportunities for biologic investigation of these lesions, setting the stage to move forward in identifying DIPG-specific treatments. This review will summarize the current state of knowledge of DIPG, discuss obstacles to therapy, and summarize results of recent biologic studies.
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Affiliation(s)
- Katherine E Warren
- Pediatric Neuro-Oncology Section, Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health Bethesda, MD, USA
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71
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Bradley KA, Zhou T, McNall-Knapp RY, Jakacki RI, Levy AS, Vezina G, Pollack IF. Motexafin-gadolinium and involved field radiation therapy for intrinsic pontine glioma of childhood: a children's oncology group phase 2 study. Int J Radiat Oncol Biol Phys 2012; 85:e55-60. [PMID: 23092726 DOI: 10.1016/j.ijrobp.2012.09.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 08/31/2012] [Accepted: 09/04/2012] [Indexed: 01/08/2023]
Abstract
PURPOSE To evaluate the effects on 1-year event-free survival (EFS) and overall survival (OS) of combining motexafin and gadolinium (MGd), a potent radiosensitizer, with daily fractionated radiation therapy in children with newly diagnosed intrinsic pontine gliomas. METHODS AND MATERIALS Patients with newly diagnosed intrinsic pontine glioma were treated with MGd daily for 5 consecutive days each week, for a total of 30 doses. Patients received a 5- to 10-min intravenous bolus of MGd, 4.4 mg/kg/day, given 2 to 5 h prior to standard dose irradiation. Radiation therapy was administered at a daily dose of 1.8 Gy for 30 treatments over 6 weeks. The total dose was 54 Gy. RESULTS Sixty eligible children received MGd daily, concurrent with 6 weeks of radiation therapy. The estimated 1-year EFS was 18%±5%, and the estimated 1-year OS was 53%±6.5%. The most common grade 3 to 4 toxicities were lymphopenia, transient elevation of liver transaminases, and hypertension. CONCLUSIONS Compared to historical controls, the addition of MGd to a standard 6-week course of radiation did not improve the survival of pediatric patients with newly diagnosed intrinsic pontine gliomas.
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Affiliation(s)
- Kristin A Bradley
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53792, USA.
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Heath JA, Zacharoulis S, Kieran MW. Pediatric neuro-oncology: current status and future directions. Asia Pac J Clin Oncol 2012; 8:223-31. [PMID: 22897924 DOI: 10.1111/j.1743-7563.2012.01558.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Tumors of the central nervous system (CNS) are the most common solid malignancies in childhood and are the leading cause of cancer-related death in this age group. While an ongoing improvement in overall prognosis has been achieved in the last few decades, current therapeutic approaches still confer significant morbidities, especially for the very young. The traditional strategies of surgery, radiotherapy and conventional cytotoxic chemotherapy need to be further refined while newer approaches, including molecularly targeted agents, hold the promise of better responses, improved outcomes and reduced toxicities. This article discusses treatment standards, the focus of current clinical investigations and the future promise of novel, biologically based approaches for the most common pediatric CNS tumors: primitive neuroectodermal tumors including medulloblastomas, ependymomas and astrocytomas (both low-grade and high-grade glioma).
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Affiliation(s)
- John A Heath
- Children's Cancer Centre, Royal Children's Hospital, Melbourne, Victoria, Australia.
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73
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Abstract
High-grade gliomas (HGGs) are malignant tumors and typically include glioblastoma multiforme and anaplastic astrocytoma subtypes. Brainstem gliomas and ependymomas are separate entities with respect to clinical presentation, treatment, prognosis, and outcome in comparison with supratentorial HGGs. In children, these tumors account for 3% to 7% of newly diagnosed brain tumors and 20% of all diagnoses of pediatric supratentorial brain tumors. These neoplasms are highly proliferative and mitotically active and of glial origin. This article reviews clinical, diagnostic, and pathologic features of HGG and current treatments and potential future therapies specific to pediatric patients with HGGs.
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Affiliation(s)
- Tene A Cage
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94143-0112, USA.
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Jones C, Perryman L, Hargrave D. Paediatric and adult malignant glioma: close relatives or distant cousins? Nat Rev Clin Oncol 2012; 9:400-13. [PMID: 22641364 DOI: 10.1038/nrclinonc.2012.87] [Citation(s) in RCA: 143] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Gliomas in children differ from their adult counterparts by their distribution of histological grade, site of presentation and rate of malignant transformation. Although rare in the paediatric population, patients with high-grade gliomas have, for the most part, a comparably dismal clinical outcome to older patients with morphologically similar lesions. Molecular profiling data have begun to reveal the major genetic alterations underpinning these malignant tumours in children. Indeed, the accumulation of large datasets on adult high-grade glioma has revealed key biological differences between the adult and paediatric disease. Furthermore, subclassifications within the childhood age group can be made depending on age at diagnosis and tumour site. However, challenges remain on how to reconcile clinical data from adult patients to tailor novel treatment strategies specifically for paediatric patients.
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Affiliation(s)
- Chris Jones
- Divisions of Molecular Pathology and Cancer Therapeutics, The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, UK
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Wells EM, Rao AAN, Scafidi J, Packer RJ. Neurotoxicity of biologically targeted agents in pediatric cancer trials. Pediatr Neurol 2012; 46:212-21. [PMID: 22490765 PMCID: PMC3626408 DOI: 10.1016/j.pediatrneurol.2012.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 02/10/2012] [Indexed: 02/07/2023]
Abstract
Biologically targeted agents offer the promise of delivering specific anticancer effects while limiting damage to healthy tissue, including the central and peripheral nervous systems. During the past 5-10 years, these agents were examined in preclinical and adult clinical trials, and are used with increasing frequency in children with cancer. This review evaluates current knowledge about neurotoxicity from biologically targeted anticancer agents, particularly those in pediatric clinical trials. For each drug, neurotoxicity data are reviewed in adult (particularly studies of brain tumors) and pediatric studies when available. Overall, these agents are well tolerated, with few serious neurotoxic effects. Data from younger patients are limited, and more neurotoxicity may occur in the pediatric population because these agents target pathways that control not only tumorigenesis but also neural maturation. Further investigation is needed into long-term neurologic effects, particularly in children.
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Affiliation(s)
- Elizabeth M. Wells
- Brain Tumor Institute, Children's National Medical Center, Washington, DC
- Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, Washington, DC
- Department of Neurology and Pediatrics, George Washington University, Washington, DC
| | - Amulya A. Nageswara Rao
- Brain Tumor Institute, Children's National Medical Center, Washington, DC
- Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, Washington, DC
- Department of Neurology and Pediatrics, George Washington University, Washington, DC
- Division of Pediatric Hematology/Oncology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joseph Scafidi
- Brain Tumor Institute, Children's National Medical Center, Washington, DC
- Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, Washington, DC
- Department of Neurology and Pediatrics, George Washington University, Washington, DC
| | - Roger J. Packer
- Brain Tumor Institute, Children's National Medical Center, Washington, DC
- Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, Washington, DC
- Department of Neurology and Pediatrics, George Washington University, Washington, DC
- Communications should be addressed to: Dr. Packer; Department of Neurology; Children's National Medical Center; 111 Michigan Avenue NW; Washington, DC 20010.
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Nageswara Rao AA, Scafidi J, Wells EM, Packer RJ. Biologically targeted therapeutics in pediatric brain tumors. Pediatr Neurol 2012; 46:203-11. [PMID: 22490764 PMCID: PMC3654250 DOI: 10.1016/j.pediatrneurol.2012.02.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 02/10/2012] [Indexed: 01/10/2023]
Abstract
Pediatric brain tumors are often difficult to cure and involve significant morbidity when treated with traditional treatment modalities, including neurosurgery, conventional chemotherapy, and radiotherapy. During the past two decades, a clearer understanding of tumorigenesis, molecular growth pathways, and immune mechanisms in the pathogenesis of cancer has opened up promising avenues for therapy. Pediatric clinical trials with novel biologic agents are underway to treat various pediatric brain tumors, including high and low grade gliomas and embryonal tumors. As the therapeutic potential of these agents undergoes evaluation, their toxicity profiles are also becoming better understood. These agents have potentially better central nervous system penetration and lower toxicity profiles compared with conventional chemotherapy. In infants and younger children, biologic agents may prove to be of equal or greater efficacy compared with traditional chemotherapy and radiation therapy, and may reduce the deleterious side effects of traditional therapeutics on the developing brain. Molecular pathways implicated in pediatric brain tumors, agents that target these pathways, and current clinical trials are reviewed. Associated neurologic toxicities will be discussed subsequently. Considerable work is needed to establish the efficacy of these agents alone and in combination, but pediatric neurologists should be aware of these agents and their rationale.
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Affiliation(s)
- Amulya A. Nageswara Rao
- Division of Pediatric Hematology/Oncology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota,Department of Neurology and Pediatrics, George Washington University, Washington, DC,Brain Tumor Institute, Children’s National Medical Center, Washington, DC,Center for Neuroscience and Behavioral Medicine, Children’s National Medical Center, Washington, DC
| | - Joseph Scafidi
- Department of Neurology and Pediatrics, George Washington University, Washington, DC,Brain Tumor Institute, Children’s National Medical Center, Washington, DC,Center for Neuroscience and Behavioral Medicine, Children’s National Medical Center, Washington, DC
| | - Elizabeth M. Wells
- Department of Neurology and Pediatrics, George Washington University, Washington, DC,Brain Tumor Institute, Children’s National Medical Center, Washington, DC,Center for Neuroscience and Behavioral Medicine, Children’s National Medical Center, Washington, DC
| | - Roger J. Packer
- Department of Neurology and Pediatrics, George Washington University, Washington, DC,Brain Tumor Institute, Children’s National Medical Center, Washington, DC,Center for Neuroscience and Behavioral Medicine, Children’s National Medical Center, Washington, DC,Communications should be addressed to: Dr. Packer; Department of Neurology; Children’s National Medical Center; 111 Michigan Avenue NW; Washington, DC 20010.
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Kawakami C, Inoue A, Takitani K, Tsuji M, Wakai K, Tamai H. Imatinib mesylate treatment for platelet-derived growth factor receptor alfa-positive choroid plexus carcinoma. Clin Pract 2012; 2:e49. [PMID: 24765448 PMCID: PMC3981291 DOI: 10.4081/cp.2012.e49] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 12/31/2011] [Accepted: 04/13/2012] [Indexed: 11/30/2022] Open
Abstract
We herein report a female child with choroid plexus carcinoma treated with standard dose of imatinib at disease recurrence. This patient failed initial twice-surgical resections, central nervous system (CNS) irradiation, and adjuvant chemotherapies and high-dose thiotepa and melphalan with auto peripheral blood stem cell rescue. Finally, imatinib treatment was undergone as a palliative setting, however the tumor did not reduce and the patient died of tumor bleedings. We consider that the reasons for the failure are as follows: i) adequate CNS level of imatinib were not obtained because of the blood brain barrier, ii) the lack of platelet-derived growth factor receptor beta expression in our case may have a crucial role.
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Affiliation(s)
- Chihiro Kawakami
- Department of Pediatrics, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Akiko Inoue
- Department of Pediatrics, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Kimitaka Takitani
- Department of Pediatrics, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Motomu Tsuji
- Department of Pathology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Kimiko Wakai
- Department of Laboratory Medicine, Gunnma Childrens' Medical Center, Shibukawa, Gunnma, Japan
| | - Hiroshi Tamai
- Department of Pediatrics, Osaka Medical College, Takatsuki, Osaka, Japan
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Reyes-Botero G, Mokhtari K, Martin-Duverneuil N, Delattre JY, Laigle-Donadey F. Adult brainstem gliomas. Oncologist 2012; 17:388-97. [PMID: 22382458 DOI: 10.1634/theoncologist.2011-0335] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Brainstem gliomas are uncommon in adults and account for only 1%-2% of intracranial gliomas. They represent a heterogeneous group of tumors that differ from those found in their pediatric counterparts. In adults, a low-grade phenotype predominates, which is a feature that likely explains their better prognosis compared to that in children. Because biopsies are rarely performed, classifications based on the radiological aspect of magnetic resonance imaging results have been proposed to establish treatment strategies and to determine outcomes: (a) diffuse intrinsic low-grade, (b) enhancing malignant glioma, (c) focal tectal gliomas, and (d) exophytic gliomas. Despite significant advances in neuroradiology techniques, a purely radiological classification remains imperfect in the absence of a histological diagnosis. Whereas a biopsy may often be reasonably avoided in the diffuse nonenhancing forms, obtaining histological proof seems necessary in many contrast-enhanced brainstem lesions because of the wide variety of differential diagnoses in adults. Conventional radiotherapy is the standard treatment for diffuse intrinsic low-grade brainstem gliomas in adults (the median survival is 5 years). In malignant brainstem gliomas, radiotherapy is the standard treatment. However, the possible benefit of combined radiotherapy and chemotherapy (temozolomide or other agents) has not been thoroughly evaluated in adults. The role of anti-angiogenic therapies in brainstem gliomas remains to be defined. A better understanding of the biology of these tumors is of primary importance for identifying homogeneous subgroups and for improving therapy options and outcomes.
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Affiliation(s)
- German Reyes-Botero
- Service de Neurologie 2-Division Mazarin, Groupe Hospitalier Pitié-Salpêtrière, 47-83 boulevard de l'Hôpital, 75013 Paris, France
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Puget S, Philippe C, Bax DA, Job B, Varlet P, Junier MP, Andreiuolo F, Carvalho D, Reis R, Guerrini-Rousseau L, Roujeau T, Dessen P, Richon C, Lazar V, Le Teuff G, Sainte-Rose C, Geoerger B, Vassal G, Jones C, Grill J. Mesenchymal transition and PDGFRA amplification/mutation are key distinct oncogenic events in pediatric diffuse intrinsic pontine gliomas. PLoS One 2012; 7:e30313. [PMID: 22389665 PMCID: PMC3289615 DOI: 10.1371/journal.pone.0030313] [Citation(s) in RCA: 177] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 12/15/2011] [Indexed: 12/17/2022] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is one of the most frequent malignant pediatric brain tumor and its prognosis is universaly fatal. No significant improvement has been made in last thirty years over the standard treatment with radiotherapy. To address the paucity of understanding of DIPGs, we have carried out integrated molecular profiling of a large series of samples obtained with stereotactic biopsy at diagnosis. While chromosomal imbalances did not distinguish DIPG and supratentorial tumors on CGHarrays, gene expression profiling revealed clear differences between them, with brainstem gliomas resembling midline/thalamic tumours, indicating a closely-related origin. Two distinct subgroups of DIPG were identified. The first subgroup displayed mesenchymal and pro-angiogenic characteristics, with stem cell markers enrichment consistent with the possibility to grow tumor stem cells from these biopsies. The other subgroup displayed oligodendroglial features, and appeared largely driven by PDGFRA, in particular through amplification and/or novel missense mutations in the extracellular domain. Patients in this later group had a significantly worse outcome with an hazard ratio for early deaths, ie before 10 months, 8 fold greater that the ones in the other subgroup (p = 0.041, Cox regression model). The worse outcome of patients with the oligodendroglial type of tumors was confirmed on a series of 55 paraffin-embedded biopsy samples at diagnosis (median OS of 7.73 versus 12.37 months, p = 0.045, log-rank test). Two distinct transcriptional subclasses of DIPG with specific genomic alterations can be defined at diagnosis by oligodendroglial differentiation or mesenchymal transition, respectively. Classifying these tumors by signal transduction pathway activation and by mutation in pathway member genes may be particularily valuable for the development of targeted therapies.
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Affiliation(s)
- Stephanie Puget
- Department of Neurosurgery, Necker-Sick Children Hospital, University Paris V Descartes, Paris, France
- Unite Mixte de Recherche 8203 du Centre National de la Recherche Scientifique «Vectorology and Anticancer Therapeutics», Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Cathy Philippe
- Unite Mixte de Recherche 8203 du Centre National de la Recherche Scientifique «Vectorology and Anticancer Therapeutics», Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Dorine A. Bax
- Section of Pediatric Oncology, The Institute of Cancer Research/Royal Marsden Hospital, Sutton, Surrey, United Kingdom
| | - Bastien Job
- Formation de Recherche en Evolution 2939 du Centre National de la Recherche Scientifique, Integrated Research Cancer Institute in Villejuif, University Paris XI, Villejuif, France
| | - Pascale Varlet
- Team Glial Plasticity, Unite Mixte de Recherche 894 de l'Institut National de la Santé et de la Recherche Medicale and Department of Neuropathology, Sainte-Anne Hospital, University Paris V Descartes, Paris, France
| | - Marie-Pierre Junier
- Team Glial Plasticity, Unite Mixte de Recherche 894 de l'Institut National de la Santé et de la Recherche Medicale and Department of Neuropathology, Sainte-Anne Hospital, University Paris V Descartes, Paris, France
| | - Felipe Andreiuolo
- Unite Mixte de Recherche 8203 du Centre National de la Recherche Scientifique «Vectorology and Anticancer Therapeutics», Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Dina Carvalho
- Section of Pediatric Oncology, The Institute of Cancer Research/Royal Marsden Hospital, Sutton, Surrey, United Kingdom
- Life and Health Sciences Research Institute, University Do Minho, Braga, Portugal
- Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
| | - Ricardo Reis
- Life and Health Sciences Research Institute, University Do Minho, Braga, Portugal
| | - Lea Guerrini-Rousseau
- Unite Mixte de Recherche 8203 du Centre National de la Recherche Scientifique «Vectorology and Anticancer Therapeutics», Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Thomas Roujeau
- Department of Neurosurgery, Necker-Sick Children Hospital, University Paris V Descartes, Paris, France
| | - Philippe Dessen
- Formation de Recherche en Evolution 2939 du Centre National de la Recherche Scientifique, Integrated Research Cancer Institute in Villejuif, University Paris XI, Villejuif, France
| | - Catherine Richon
- Functional Genomics Unit, Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Vladimir Lazar
- Functional Genomics Unit, Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Gwenael Le Teuff
- Department of Biostatistics and Epidemiology, Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Christian Sainte-Rose
- Department of Neurosurgery, Necker-Sick Children Hospital, University Paris V Descartes, Paris, France
| | - Birgit Geoerger
- Unite Mixte de Recherche 8203 du Centre National de la Recherche Scientifique «Vectorology and Anticancer Therapeutics», Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
- Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Gilles Vassal
- Unite Mixte de Recherche 8203 du Centre National de la Recherche Scientifique «Vectorology and Anticancer Therapeutics», Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Chris Jones
- Section of Pediatric Oncology, The Institute of Cancer Research/Royal Marsden Hospital, Sutton, Surrey, United Kingdom
| | - Jacques Grill
- Unite Mixte de Recherche 8203 du Centre National de la Recherche Scientifique «Vectorology and Anticancer Therapeutics», Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
- Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
- * E-mail:
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80
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Jansen M, van Vuurden D, Vandertop W, Kaspers G. Diffuse intrinsic pontine gliomas: A systematic update on clinical trials and biology. Cancer Treat Rev 2012; 38:27-35. [DOI: 10.1016/j.ctrv.2011.06.007] [Citation(s) in RCA: 170] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 05/17/2011] [Accepted: 06/25/2011] [Indexed: 11/28/2022]
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General and neurological complications of targeted therapy. HANDBOOK OF CLINICAL NEUROLOGY 2012; 105:937-45. [PMID: 22230543 DOI: 10.1016/b978-0-444-53502-3.00033-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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83
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Niyazi M, Maihoefer C, Krause M, Rödel C, Budach W, Belka C. Radiotherapy and "new" drugs-new side effects? Radiat Oncol 2011; 6:177. [PMID: 22188921 PMCID: PMC3266653 DOI: 10.1186/1748-717x-6-177] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 12/21/2011] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Targeted drugs have augmented the cancer treatment armamentarium. Based on the molecular specificity, it was initially believed that these drugs had significantly less side effects. However, currently it is accepted that all of these agents have their specific side effects. Based on the given multimodal approach, special emphasis has to be placed on putative interactions of conventional cytostatic drugs, targeted agents and other modalities. The interaction of targeted drugs with radiation harbours special risks, since the awareness for interactions and even synergistic toxicities is lacking. At present, only limited is data available regarding combinations of targeted drugs and radiotherapy. This review gives an overview on the current knowledge on such combined treatments. MATERIALS AND METHODS Using the following MESH headings and combinations of these terms pubmed database was searched: Radiotherapy AND cetuximab/trastuzumab/panitumumab/nimotuzumab, bevacizumab, sunitinib/sorafenib/lapatinib/gefitinib/erlotinib/sirolimus, thalidomide/lenalidomide as well as erythropoietin. For citation crosscheck the ISI web of science database was used employing the same search terms. RESULTS Several classes of targeted substances may be distinguished: Small molecules including kinase inhibitors and specific inhibitors, antibodies, and anti-angiogenic agents. Combination of these agents with radiotherapy may lead to specific toxicities or negatively influence the efficacy of RT. Though there is only little information on the interaction of molecular targeted radiation and radiotherapy in clinical settings, several critical incidents are reported. CONCLUSIONS The addition of molecular targeted drugs to conventional radiotherapy outside of approved regimens or clinical trials warrants a careful consideration especially when used in conjunction in hypo-fractionated regimens. Clinical trials are urgently needed in order to address the open question in regard to efficacy, early and late toxicity.
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Affiliation(s)
- Maximilian Niyazi
- Department of Radiation Oncology, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 München, Germany
| | - Cornelius Maihoefer
- Department of Radiation Oncology, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 München, Germany
| | - Mechthild Krause
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Claus Rödel
- Klinik für Strahlentherapie und Onkologie, Johann Wolfgang Goethe Universität Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Wilfried Budach
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Heinrich Heine Universität Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Claus Belka
- Department of Radiation Oncology, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 München, Germany
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84
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Warren KE, Killian K, Suuriniemi M, Wang Y, Quezado M, Meltzer PS. Genomic aberrations in pediatric diffuse intrinsic pontine gliomas. Neuro Oncol 2011; 14:326-32. [PMID: 22064882 DOI: 10.1093/neuonc/nor190] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Diagnostic biopsy is not routinely performed for children with diffuse intrinsic pontine glioma (DIPG). Consequently, our understanding of DIPG biology is hindered by limited tissue availability. We performed comparative genomic hybridization (CGH) on autopsy specimens to examine the feasibility of determining DNA genomic copy number aberrations on formalin-fixed, paraffin-embedded (FFPE) blocks. Histology on FFPE blocks obtained from autopsy of pediatric patients with DIPG was reviewed. Regions were marked for processing, and DNA was extracted from the tissue core, labeled by chemical coupling with Cy5, and hybridized to 105K oligonucleotide CGH arrays. After hybridization and washing, arrays were scanned, and data segmented and processed with Nexus software. Twenty-two samples from 13 subjects were obtained. Histologic variability was noted. CGH was successfully performed on 18 of 22 samples, representing 11 of 13 subjects. All demonstrated DNA copy number abnormalities. High copy number amplification of known oncogenes and homozygous deletions of known tumor suppressor genes were observed. Additional regions of high copy number amplification and homozygous deletion and geographical variations in the CGH patterns were found. CGH performed on FFPE tissue obtained from autopsy yields satisfactory results. This sample set from patients with DIPG was highly informative, with the majority of specimens showing ≥1 abnormality related to a known cancer gene. Aberrations in candidate drug targets were observed. This study establishes the feasibility of genomic DNA analysis from DIPG autopsy material, identifies several targets for which molecular targeted therapy exists, and suggests significant heterogeneity among patients with DIPG.
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Affiliation(s)
- Katherine E Warren
- National Cancer Institute, Pediatric Oncology Branch, Pediatric Neuro-Oncology Section, Bldg 10 CRC, Rm 1W-5750, Bethesda, MD 20892-1104, USA.
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Nicolaides TP, Li H, Solomon DA, Hariono S, Hashizume R, Barkovich K, Baker SJ, Paugh BS, Jones C, Forshew T, Hindley GF, Hodgson JG, Kim JS, Rowitch DH, Weiss WA, Waldman TA, James CD. Targeted therapy for BRAFV600E malignant astrocytoma. Clin Cancer Res 2011; 17:7595-604. [PMID: 22038996 DOI: 10.1158/1078-0432.ccr-11-1456] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Malignant astrocytomas (MA) are aggressive central nervous system tumors with poor prognosis. Activating mutation of BRAF (BRAF(V600E)) has been reported in a subset of these tumors, especially in children. We have investigated the incidence of BRAF(V600E) in additional pediatric patient cohorts and examined the effects of BRAF blockade in preclinical models of BRAF(V600E) and wild-type BRAF MA. EXPERIMENTAL DESIGN BRAF(V600E) mutation status was examined in two pediatric MA patient cohorts. For functional studies, BRAF(V600E) MA cell lines were used to investigate the effects of BRAF shRNA knockdown in vitro, and to investigate BRAF pharmacologic inhibition in vitro and in vivo. RESULTS BRAF(V600E) mutations were identified in 11 and 10% of MAs from two distinct series of tumors (six of 58 cases total). BRAF was expressed in all MA cell lines examined, among which BRAF(V600E) was identified in four instances. Using the BRAF(V600E)-specific inhibitor PLX4720, pharmacologic blockade of BRAF revealed preferential antiproliferative activity against BRAF(V600E) mutant cells in vitro, in contrast to the use of shRNA-mediated knockdown of BRAF, which inhibited cell growth of glioma cell lines regardless of BRAF mutation status. Using orthotopic MA xenografts, we show that PLX4720 treatment decreases tumor growth and increases overall survival in mice-bearing BRAF(V600E) mutant xenografts, while being ineffective, and possibly tumor promoting, against xenografts with wild-type BRAF. CONCLUSIONS Our results indicate a 10% incidence of activating BRAF(V600E) among pediatric MAs. With regard to implications for therapy, our results support evaluation of BRAF(V600E)-specific inhibitors for treating BRAF(V600E) MA patients.
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86
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Rossig C, Juergens H, Berdel WE. New targets and targeted drugs for the treatment of cancer: an outlook to pediatric oncology. Pediatr Hematol Oncol 2011; 28:539-55. [PMID: 21936619 DOI: 10.3109/08880018.2011.613094] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Novel drugs and treatment modalities are urgently needed to further improve survival of children with cancer. In medical oncology, an increased understanding of the molecular basis of cancer is driving the development of new drugs that target relevant signaling pathways in cancer cells and tumor microenvironment. Small-molecule modulators of signal transduction and monoclonal antibodies against various cellular targets have been approved in adult cancers in recent years. These drugs are now starting to be considered for the use in children. Despite the biological differences between adult and pediatric cancers, common cellular pathways have emerged from experimental research. Thus, insights into clinical experience with molecular targeted drugs in adults may help to accelerate progress in pediatric oncology. Here, the authors review molecules and pathways for which drugs are approved for adult cancer treatment and provide links to existing and potential applications in pediatric oncology.
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Affiliation(s)
- Claudia Rossig
- Department of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany.
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87
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MacDonald TJ, Aguilera D, Kramm CM. Treatment of high-grade glioma in children and adolescents. Neuro Oncol 2011; 13:1049-58. [PMID: 21784756 PMCID: PMC3177659 DOI: 10.1093/neuonc/nor092] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 05/20/2011] [Indexed: 12/15/2022] Open
Abstract
Pediatric high-grade gliomas (HGGs)--including glioblastoma multiforme, anaplastic astrocytoma, and diffuse intrinsic pontine glioma--are difficult to treat and are associated with an extremely poor prognosis. There are no effective chemotherapeutic regimens for the treatment of pediatric HGG, but many new treatment options are in active investigation. There are crucial molecular differences between adult and pediatric HGG such that results from adult clinical trials cannot simply be extrapolated to children. Molecular markers overexpressed in pediatric HGG include PDGFRα and P53. Amplification of EGFR is observed, but to a lesser degree than in adult HGG. Potential molecular targets and new therapies in development for pediatric HGG are described in this review. Research into bevacizumab in pediatric HGG indicates that its activity is less than that observed in adult HGG. Similarly, tipifarnib was found to have minimal activity in pediatric HGG, whereas gefitinib has shown greater effects. After promising phase I findings in children with primary CNS tumors, the integrin inhibitor cilengitide is being investigated in a phase II trial in pediatric HGG. Studies are also ongoing in pediatric HGG with 2 EGFR inhibitors: cetuximab and nimotuzumab. Other novel treatment modalities under investigation include dendritic cell-based vaccinations, boron neutron capture therapy, and telomerase inhibition. While the results of these trials are keenly awaited, the current belief is that multimodal therapy holds the greatest promise. Research efforts should be directed toward building multitherapeutic regimens that are well tolerated and that offer the greatest antitumor activity in the setting of pediatric HGG.
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Affiliation(s)
- T J MacDonald
- Aflac Cancer Center and Blood Disorders Service, Children's Healthcare of Atlanta, Emory University School of Medicine, Emory Children's Center, 2015 Uppergate Drive, Suite 442, Atlanta, GA 30322 USA.
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Paugh BS, Broniscer A, Qu C, Miller CP, Zhang J, Tatevossian RG, Olson JM, Geyer JR, Chi SN, da Silva NS, Onar-Thomas A, Baker JN, Gajjar A, Ellison DW, Baker SJ. Genome-wide analyses identify recurrent amplifications of receptor tyrosine kinases and cell-cycle regulatory genes in diffuse intrinsic pontine glioma. J Clin Oncol 2011; 29:3999-4006. [PMID: 21931021 DOI: 10.1200/jco.2011.35.5677] [Citation(s) in RCA: 238] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Long-term survival for children with diffuse intrinsic pontine glioma (DIPG) is less than 10%, and new therapeutic targets are urgently required. We evaluated a large cohort of DIPGs to identify recurrent genomic abnormalities and gene expression signatures underlying DIPG. PATIENTS AND METHODS Single-nucleotide polymorphism arrays were used to compare the frequencies of genomic copy number abnormalities in 43 DIPGs and eight low-grade brainstem gliomas with data from adult and pediatric (non-DIPG) glioblastomas, and expression profiles were evaluated using gene expression arrays for 27 DIPGs, six low-grade brainstem gliomas, and 66 nonbrainstem low-grade gliomas. RESULTS Frequencies of specific large-scale and focal imbalances varied significantly between DIPGs and nonbrainstem pediatric glioblastomas. Focal amplifications of genes within the receptor tyrosine kinase-Ras-phosphoinositide 3-kinase signaling pathway were found in 47% of DIPGs, the most common of which involved PDGFRA and MET. Thirty percent of DIPGs contained focal amplifications of cell-cycle regulatory genes controlling retinoblastoma protein (RB) phosphorylation, and 21% had concurrent amplification of genes from both pathways. Some tumors showed heterogeneity in amplification patterns. DIPGs showed distinct gene expression signatures related to developmental processes compared with nonbrainstem pediatric high-grade gliomas, whereas expression signatures of low-grade brainstem and nonbrainstem gliomas were similar. CONCLUSION DIPGs comprise a molecularly related but distinct subgroup of pediatric gliomas. Genomic studies suggest that targeted inhibition of receptor tyrosine kinases and RB regulatory proteins may be useful therapies for DIPG.
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Affiliation(s)
- Barbara S Paugh
- St Jude Children's Research Hospital, Memphis, TN 38105, USA
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Proceedings of the diffuse intrinsic pontine glioma (DIPG) Toronto Think Tank: advancing basic and translational research and cooperation in DIPG. J Neurooncol 2011; 105:119-25. [DOI: 10.1007/s11060-011-0704-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 08/16/2011] [Indexed: 10/17/2022]
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90
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Pollack IF. Multidisciplinary management of childhood brain tumors: a review of outcomes, recent advances, and challenges. J Neurosurg Pediatr 2011; 8:135-48. [PMID: 21806354 DOI: 10.3171/2011.5.peds1178] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECT Brain tumors are the most common category of childhood solid tumors. In the 1970s and 1980s, treatment protocols for benign tumors focused almost exclusively on surgery, with radiation treatment as a salvage modality, whereas the management of malignant tumors employed a combination of surgery, radiation therapy, and chemotherapy, with therapeutic approaches such as "8-in-1" chemotherapy often applied across histological tumor subsets that are now recognized to be prognostically distinct. During the ensuing years, treatment has become increasingly refined, based on clinical and, more recently, molecular factors, which have supported risk-adapted treatment stratification. The goal of this report is to provide an overview of recent progress in the field. METHODS A review of the literature was undertaken to examine recent advances in the management of the most common childhood brain tumor subsets, and in particular to identify instances in which molecular categorization and treatment stratification offer evidence or promise for improving outcome. RESULTS For both medulloblastomas and infant tumors, refinements in clinical and molecular stratification have already facilitated efforts to achieve risk-adapted treatment planning. Current treatment strategies for children with these tumors focus on improving outcome for tumor subsets that have historically been relatively resistant to therapy and reducing treatment-related sequelae for children with therapy-responsive tumors. Recent advances in molecular categorization offer the promise of further refinements in future studies. For children with ependymomas and low-grade gliomas, clinical risk stratification has facilitated tailored approaches to therapy, with improvement of disease control and concomitant reduction in treatment sequelae, and recent discoveries have identified promising therapeutic targets for molecularly based therapy. In contrast, the prognosis remains poor for children with diffuse intrinsic pontine gliomas and other high-grade gliomas, despite recent identification of biological correlates of tumor prognosis and elucidation of molecular substrates of tumor development. CONCLUSIONS Advances in the clinical and molecular stratification for many types of childhood brain tumors have provided a foundation for risk-adapted treatment planning and improvements in outcome. In some instances, molecular characterization approaches have also yielded insights into new therapeutic targets. For other tumor types, outcome remains discouraging, although new information regarding the biological features critical to tumorigenesis are being translated into novel therapeutic approaches that hold promise for future improvements.
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Affiliation(s)
- Ian F Pollack
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Dubois SG, Shusterman S, Ingle AM, Ahern CH, Reid JM, Wu B, Baruchel S, Glade-Bender J, Ivy P, Grier HE, Adamson PC, Blaney SM. Phase I and pharmacokinetic study of sunitinib in pediatric patients with refractory solid tumors: a children's oncology group study. Clin Cancer Res 2011; 17:5113-22. [PMID: 21690570 DOI: 10.1158/1078-0432.ccr-11-0237] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE Sunitinib is an oral multitargeted receptor tyrosine kinase inhibitor. The purpose of this study was to determine the recommended phase 2 dose, pharmacokinetics, pharmacodynamic effects, and preliminary antitumor activity of sunitinib in a pediatric population. EXPERIMENTAL DESIGN Patients who were 2 to 21 years of age with refractory solid tumors were eligible if they had measurable or evaluable disease and met baseline organ function requirements. Patients received sunitinib once daily for 28 days followed by a 14-day break between each cycle. Dose levels of 15 and 20 mg/m(2)/d were evaluated, with dose escalation based on a 3 + 3 design. Sunitinib pharmacokinetics and biomarkers of angiogenesis were also evaluated during the first cycle. RESULTS Twenty-three patients were treated (median age 13.9 years; range, 3.9-20.6 years). The most common toxicities were neutropenia, thrombocytopenia, elevated liver transaminases, gastrointestinal symptoms, and fatigue. Two patients developed dose-limiting reductions in cardiac ejection fraction prompting a protocol amendment to exclude patients with previous exposure to anthracyclines or cardiac radiation. In patients without these cardiac risk factors, the maximum tolerated dose (MTD) was 15 mg/m(2)/d. Steady-state plasma concentrations were reached by day 7. No objective responses were observed. Four patients with sarcoma and glioma had stable disease for 2 to 9 cycles. CONCLUSIONS Cardiac toxicity precluded determination of a recommended dose for pediatric patients with previous anthracycline or cardiac radiation exposure. The MTD of sunitinib for patients without risk factors for cardiac toxicity is 15 mg/m(2)/d for 28 days followed by a 14-day break.
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Affiliation(s)
- Steven G Dubois
- Department of Pediatrics, University of California, San Francisco School of Medicine, San Francisco, CA 94143-0106, USA.
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[Indications and current development of new targeted therapies in pediatric oncology]. Bull Cancer 2011; 98:527-39. [PMID: 21596652 DOI: 10.1684/bdc.2011.1358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Progresses performed in pediatric oncology during the last 30 years allowed to obtain about 70 to 80% healing rates. These progresses are the result of the optimization of the cytotoxic chemotherapies protocols used at standard and high doses, as well as the improvement of the local treatment. Most of the new anticancer treatments currently in developmental stage are based on targeted therapies, acting against numerous tumor cell abnormalities, like growth factors et their receptors, cell proliferation-inducing factors, molecules involved in DNA repair, cell death inducers, tumor invasion and angiogenesis. They are widely used in adult patients since 10 years and they are being more and more employed in children with cancer. The aim of this article is to review the main indications of these new targeted drugs in pediatric oncology and the new developments of these drugs.
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94
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Cohen KJ, Heideman RL, Zhou T, Holmes EJ, Lavey RS, Bouffet E, Pollack IF. Temozolomide in the treatment of children with newly diagnosed diffuse intrinsic pontine gliomas: a report from the Children's Oncology Group. Neuro Oncol 2011; 13:410-6. [PMID: 21345842 DOI: 10.1093/neuonc/noq205] [Citation(s) in RCA: 209] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
An open-label phase II study (ACNS0126) testing the efficacy of chemoradiotherapy with temozolomide (TMZ) followed by adjuvant TMZ was conducted by the Children's Oncology Group. During the period from July 6, 2004 through September 6, 2005, 63 children with newly diagnosed diffuse intrinsic pontine glioma (DIPG) were enrolled in the study. All patients received TMZ at a dosage of 90 mg/m(2)/day for 42 days to a dose of 59.4 Gy. Four weeks following irradiation, TMZ was given at a dosage of 200 mg/m(2)/day for 5 days every 28 days, for a total of 10 cycles. The primary objective of the statistical analysis was to determine whether the current treatment produced a 1-year event-free survival (EFS) rate higher than the historical baseline of 21.9% observed in CCG-9941. The mean 1-year EFS (± standard deviation) was 14% ± 4.5%, compared with 21.9% ± 5% for CCG-9941. The P value of the test of comparison of 1-year EFS, based on a 1-sided, 1-sample test of proportions, was .96. There was no evidence that temozolomide produced a 1-year EFS rate higher than 21.9%. The mean 1-year OS (± standard deviation) was 40% ± 6.5%, compared with 32% ± 6% for CCG-9941. The median time to death was 9.6 months. Chemoradiotherapy with TMZ followed by adjuvant TMZ is not more effective than previously reported regimens for the treatment of children with DIPG.
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Affiliation(s)
- Kenneth J Cohen
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD 21287, USA.
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Pollack IF, Stewart CF, Kocak M, Poussaint TY, Broniscer A, Banerjee A, Douglas JG, Kun LE, Boyett JM, Geyer JR. A phase II study of gefitinib and irradiation in children with newly diagnosed brainstem gliomas: a report from the Pediatric Brain Tumor Consortium. Neuro Oncol 2011; 13:290-7. [PMID: 21292687 DOI: 10.1093/neuonc/noq199] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This phase II study was designed to assess the safety and efficacy of gefitinib given with and following radiation therapy in children newly diagnosed with a poor prognosis brainstem glioma. Eligible patients were those with a previously untreated nondisseminated diffuse intrinsic brainstem glioma. Histological confirmation was not required, provided patients had a characteristic clinical history and MRI findings. Treatment consisted of gefitinib, administered orally, 250 mg/m(2)/day, during standard external beam radiotherapy, continuing for up to 13 monthly courses in the absence of disease progression or unacceptable toxicity. Toxicities, particularly intratumoral hemorrhage, were monitored. Pharmacokinetics and investigational imaging studies were performed in consenting patients. Forty-three eligible patients were included in the study. Therapy was well tolerated; only 4 patients were withdrawn from the study for dose-limiting toxicity after receiving therapy for 6, 9, 17, and 24 weeks. The 12- and 24-month progression-free survival rates were 20.9 ±5.6 % and 9.3 ±4%, respectively. Overall survival rates were 56.4 ±7.6% and 19.6 ±5.9%, respectively, which appear nominally superior to other contemporaneous Pediatric Brain Tumor Consortium trials. Three patients remain progression-free survivors with ≥36 months follow-up. The observation that a subset of children with this generally fatal tumor experienced long-term progression-free survival, coupled with recent observations regarding the molecular features of brainstem gliomas, raises the possibility that prospective molecular characterization may allow enrichment of treatment responders and improvement in outcome results in future studies of biologically targeted agents.
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Affiliation(s)
- Ian F Pollack
- Department of Neurosurgery, Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
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Bellanti F, Kågedal B, Della Pasqua O. Do pharmacokinetic polymorphisms explain treatment failure in high-risk patients with neuroblastoma? Eur J Clin Pharmacol 2011; 67 Suppl 1:87-107. [PMID: 21287160 PMCID: PMC3112027 DOI: 10.1007/s00228-010-0966-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Accepted: 11/27/2010] [Indexed: 12/30/2022]
Abstract
PURPOSE Neuroblastoma is the most common extracranial solid tumour in childhood. It accounts for 15% of all paediatric oncology deaths. In the last few decades, improvement in treatment outcome for high-risk patients has not occurred, with an overall survival rate <30-40%. Many reasons may account for such a low survival rate. The aim of this review is to evaluate whether pharmacogenetic factors can explain treatment failure in neuroblastoma. METHODS A literature search based on PubMed's database Medical Subject Headings (MeSH) was performed to retrieve all pertinent publications on current treatment options and new classes of drugs under investigation. One hundred and fifty-eight articles wer reviewed, and relevant data were extracted and summarised. RESULTS AND CONCLUSIONS Few of the large number of polymorphisms identified thus far showed an effect on pharmacokinetics that could be considered clinically relevant. Despite their clinical relevance, none of the single nucleotide polymorphisms (SNPs) investigated can explain treatment failure. These findings seem to reflect the clinical context in which anti-tumour drugs are used, i.e. in combination with multimodal therapy. In addition, many pharmacogenetic studies did not assess (differences in) drug exposure, which could contribute to explaining pharmacogenetic associations. Furthermore, it remains unclear whether the significant activity of new drugs on different neuroblastoma cell lines translates into clinical efficacy, irrespective of resistance or myelocytomatosis viral related oncogene, neuroblastoma derived (MYCN) amplification. Elucidation of the clinical role of pharmacogenetic factors in the treatment of neuroblastoma demands an integrated pharmacokinetic-pharmacodynamic approach to the analysis of treatment response data.
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Affiliation(s)
- Francesco Bellanti
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands
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Moreno L, Chesler L, Hargrave D, Eccles SA, Pearson ADJ. Preclinical drug development for childhood cancer. Expert Opin Drug Discov 2010; 6:49-64. [DOI: 10.1517/17460441.2011.537652] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Geoerger B, Hargrave D, Thomas F, Ndiaye A, Frappaz D, Andreiuolo F, Varlet P, Aerts I, Riccardi R, Jaspan T, Chatelut E, Le Deley MC, Paoletti X, Saint-Rose C, Leblond P, Morland B, Gentet JC, Méresse V, Vassal G. Innovative Therapies for Children with Cancer pediatric phase I study of erlotinib in brainstem glioma and relapsing/refractory brain tumors. Neuro Oncol 2010; 13:109-18. [PMID: 20974795 DOI: 10.1093/neuonc/noq141] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
This multicenter phase I study aimed to establish the recommended dose (RD) of the epidermal growth factor receptor (EGFR) inhibitor erlotinib, given as monotherapy or with radiotherapy to children with malignant brain tumors. Group 1 included patients with refractory or relapsing brain tumors receiving erlotinib alone, and group 2 included newly diagnosed patients with brainstem gliomas receiving radiotherapy and erlotinib. A conventional 3 + 3 dose escalation and a continual reassessment method, respectively, were utilized in 4 dose levels: 75, 100, 125, and 150 mg/m² per day. Fifty-one children were enrolled (30 and 21, respectively); 50 received treatment. The RD of erlotinib was 125 mg/m² per day as monotherapy or in combination with radiotherapy. Overall, 230 adverse events in 44 patients were possibly treatment related (216, grades 1 and 2; 9, grade 3; 1, grade 4; 4, grade 5). Dermatologic and neurologic symptoms were common; intratumoral hemorrhage was confirmed in 3 patients. In group 1, 8 of 29 patients (28%) had stable disease with tumor regression approaching 50% in a malignant glioma and an anaplastic oligoastrocytoma. In group 2, overall survival was 12.0 months. EGFR overexpression by immunohistochemistry was found in 17 of 38 (45%) tumor samples analyzed, with a partial gain of 7p11.2 in 1 glioblastoma; phosphate and tensin homolog loss was frequent in brainstem glioma (15 of 19). Mean (95% CI) apparent clearance and volume of distribution for erlotinib were 4.0 L/h (3.4-4.5 L/h) and 98.6 L (69.8-127.0 L), respectively, and were independent of the dose level; mean half-life was 16.6 hours. Thus, erlotinib 125 mg/m² per day has an acceptable tolerability profile in pediatric patients with brain tumors and can be combined with radiotherapy.
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Affiliation(s)
- Birgit Geoerger
- Department of Pediatrics, UPRES EA 3535 Pharmacology and New Treatments with Cancer, Institut Gustave Roussy, 94805 Villejuif, France.
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Broniscer A, Baker JN, Tagen M, Onar-Thomas A, Gilbertson RJ, Davidoff AM, Pai Panandiker AS, Panandiker AP, Leung W, Chin TK, Stewart CF, Kocak M, Rowland C, Merchant TE, Kaste SC, Gajjar A. Phase I study of vandetanib during and after radiotherapy in children with diffuse intrinsic pontine glioma. J Clin Oncol 2010; 28:4762-8. [PMID: 20921456 DOI: 10.1200/jco.2010.30.3545] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the safety, maximum-tolerated dose, pharmacokinetics, and pharmacodynamics of vandetanib, an oral vascular endothelial growth factor receptor 2 (VEGFR2) and epidermal growth factor receptor inhibitor, administered once daily during and after radiotherapy in children with newly diagnosed diffuse intrinsic pontine glioma. PATIENTS AND METHODS Radiotherapy was administered as 1.8-Gy fractions (total cumulative dose of 54 Gy). Vandetanib was administered concurrently with radiotherapy for a maximum of 2 years. Dose-limiting toxicities (DLTs) were evaluated during the first 6 weeks of therapy. Pharmacokinetic studies were obtained for all patients. Plasma angiogenic factors and VEGFR2 phosphorylation in mononuclear cells were analyzed before and during therapy. RESULTS Twenty-one patients were administered 50 (n = 3), 65 (n = 3), 85 (n = 3), 110 (n = 6), and 145 mg/m(2) (n = 6) of vandetanib. Only one patient developed DLT (grade 3 diarrhea) at dosage level 5. An expanded cohort of patients were treated at dosage levels 4 (n = 10) and 5 (n = 4); two patients developed grade 4 hypertension and posterior reversible encephalopathy syndrome while also receiving high-dose dexamethasone. Despite significant interpatient variability, exposure to vandetanib increased with higher dosage levels. The bivariable analysis of vascular endothelial growth factor (VEGF) before and during therapy showed that patients with higher levels of VEGF before therapy had a longer progression-free survival (PFS; P = .022), whereas patients with increases in VEGF during treatment had a shorter PFS (P = .0015). VEGFR2 phosphorylation was inhibited on day 8 or 29 of therapy compared with baseline (P = .039). CONCLUSION The recommended phase II dose of vandetanib in children is 145 mg/m(2) per day. Close monitoring and management of hypertension is required, particularly for patients receiving corticosteroids.
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Löbel U, Sedlacik J, Sabin ND, Kocak M, Broniscer A, Hillenbrand CM, Patay Z. Three-dimensional susceptibility-weighted imaging and two-dimensional T2*-weighted gradient-echo imaging of intratumoral hemorrhages in pediatric diffuse intrinsic pontine glioma. Neuroradiology 2010; 52:1167-77. [PMID: 20878319 DOI: 10.1007/s00234-010-0771-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Accepted: 09/03/2010] [Indexed: 02/07/2023]
Abstract
INTRODUCTION We compared the sensitivity and specificity of T2*-weighted gradient-echo imaging (T2*-GRE) and susceptibility-weighted imaging (SWI) in determining prevalence and cumulative incidence of intratumoral hemorrhages in children with diffuse intrinsic pontine glioma (DIPG) undergoing antiangiogenic and radiation therapy. METHODS Patients were recruited from an institutional review board-approved prospective phase I trial of vandetanib administered in combination with radiation therapy. Patient consent was obtained before enrollment. Consecutive T2*-GRE and SWI exams of 17 patients (F/M: 9/8; age 3-17 years) were evaluated. Two reviewers (R1 and R2) determined the number and size of hemorrhages at baseline and multiple follow-ups (92 scans, mean 5.4/patient). Statistical analyses were performed using descriptive statistics, graphical tools, and mixed-effects Poisson regression models. RESULTS Prevalence of hemorrhages at diagnosis was 41% and 47%; the cumulative incidences of hemorrhages at 6 months by T2*-GRE and SWI were 82% and 88%, respectively. Hemorrhages were mostly petechial; 9.7% of lesions on T2*-GRE and 5.2% on SWI were hematomas (>5 mm). SWI identified significantly more hemorrhages than T2*-GRE did. Lesions were missed or misinterpreted in 36/39 (R1/R2) scans by T2*-GRE and 9/3 scans (R1/R2) by SWI. Hemorrhages had no clinically significant neurological correlates in patients. CONCLUSIONS SWI is more sensitive than T2*-GRE in detecting hemorrhages and differentiating them from calcification, necrosis, and artifacts. Also, petechial hemorrhages are more common in DIPG at diagnosis than previously believed and their number increases during the course of treatment; hematomas are rare.
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Affiliation(s)
- Ulrike Löbel
- Department of Radiological Sciences, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Mail Stop 220, Memphis, TN 38105, USA
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