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Perwein T, Giese B, Nussbaumer G, von Bueren AO, van Buiren M, Benesch M, Kramm CM. How I treat recurrent pediatric high-grade glioma (pHGG): a Europe-wide survey study. J Neurooncol 2023; 161:525-538. [PMID: 36720762 PMCID: PMC9992031 DOI: 10.1007/s11060-023-04241-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/05/2023] [Indexed: 02/02/2023]
Abstract
PURPOSE As there is no standard of care treatment for recurrent/progressing pediatric high-grade gliomas (pHGG), we aimed to gain an overview of different treatment strategies. METHODS In a web-based questionnaire, members of the SIOPE-BTG and the GPOH were surveyed on therapeutic options in four case scenarios (children/adolescents with recurrent/progressing HGG). RESULTS 139 clinicians with experience in pediatric neuro-oncology from 22 European countries participated in the survey. Most respondents preferred further oncological treatment in three out of four cases and chose palliative care in one case with marked symptoms. Depending on the case, 8-92% would initiate a re-resection (preferably hemispheric pHGG), combined with molecular diagnostics. Throughout all case scenarios, 55-77% recommended (re-)irradiation, preferably local radiotherapy > 20 Gy. Most respondents would participate in clinical trials and use targeted therapy (79-99%), depending on molecular genetic findings (BRAF alterations: BRAF/MEK inhibitor, 64-88%; EGFR overexpression: anti-EGFR treatment, 46%; CDKN2A deletion: CDK inhibitor, 18%; SMARCB1 deletion: EZH2 inhibitor, 12%). 31-72% would administer chemotherapy (CCNU, 17%; PCV, 8%; temozolomide, 19%; oral etoposide/trofosfamide, 8%), and 20-69% proposed immunotherapy (checkpoint inhibitors, 30%; tumor vaccines, 16%). Depending on the individual case, respondents would also include bevacizumab (6-18%), HDAC inhibitors (4-15%), tumor-treating fields (1-26%), and intraventricular chemotherapy (4-24%). CONCLUSION In each case, experts would combine conventional multimodal treatment concepts, including re-irradiation, with targeted therapy based on molecular genetic findings. International cooperative trials combining a (chemo-)therapy backbone with targeted therapy approaches for defined subgroups may help to gain valid clinical data and improve treatment in pediatric patients with recurrent/progressing HGG.
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Affiliation(s)
- Thomas Perwein
- Division of Pediatric Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036, Graz, Austria.
| | - Barbara Giese
- Division of Pediatric Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036, Graz, Austria
| | - Gunther Nussbaumer
- Division of Pediatric Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036, Graz, Austria
| | - André O von Bueren
- Department of Pediatrics, Obstetrics and Gynecology, Division of Pediatric Hematology and Oncology, University Hospital of Geneva, Geneva, Switzerland
- Cansearch Research Platform for Pediatric Oncology and Hematology, Faculty of Medicine, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland
| | - Miriam van Buiren
- Department of Pediatric Hematology and Oncology, Center for Pediatrics, Medical Center, University of Freiburg, Freiburg, Germany
| | - Martin Benesch
- Division of Pediatric Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036, Graz, Austria
| | - Christof Maria Kramm
- Division of Pediatric Hematology and Oncology, University Medical Center Göttingen, Göttingen, Germany
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Schmidt T, Agkatsev S, Feldheim J, Oster C, Blau T, Sure U, Keyvani K, Kleinschnitz C, Stuschke M, Herrmann K, Deuschl C, Scheffler B, Kebir S, Glas M, Lazaridis L. Feasibility and tolerability of trofosfamide and etoposide in progressive glioblastoma. Neurooncol Adv 2023; 5:vdad090. [PMID: 37547266 PMCID: PMC10403750 DOI: 10.1093/noajnl/vdad090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Background Standard of care treatment options at glioblastoma relapse are still not well defined. Few studies indicate that the combination of trofosfamide plus etoposide may be feasible in pediatric glioblastoma patients. In this retrospective analysis, we determined tolerability and feasibility of combined trofosfamide plus etoposide treatment at disease recurrence of adult glioblastoma patients. Methods We collected clinicopathological data from adult progressive glioblastoma patients treated with the combination of trofosfamide and etoposide for more than four weeks (one course). A cohort of patients receiving empiric treatment at the investigators' discretion balanced for tumor entity and canonical prognostic factors served as control. Results A total of n = 22 progressive glioblastoma patients were eligible for this analysis. Median progression-free survival (3.1 vs 2.3 months, HR: 1.961, 95% CI: 0.9724-3.9560, P = .0274) and median overall survival (9.0 vs 5.7 months, HR: 4.687, 95% CI: 2.034-10.800, P = .0003) were significantly prolonged compared to the control cohort (n = 17). In a multivariable Cox regression analysis, treatment with trofosfamide plus etoposide emerged as a significant prognostic marker regarding progression-free and overall survival. We observed high-grade adverse events in n = 16/22 (73%) patients with hematotoxicity comprising the majority of adverse events (n = 15/16, 94%). Lymphopenia was by far the most commonly observed hematotoxic adverse event (n = 11/15, 73%). Conclusions This study provides first indication that the combination of trofosfamide plus etoposide is safe in adult glioblastoma patients. The observed survival outcomes might suggest potential beneficial effects. Our data provide a reasonable rationale for follow-up of a larger cohort in a prospective trial.
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Affiliation(s)
- Teresa Schmidt
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
- DKFZ-Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK); German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sarina Agkatsev
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Jonas Feldheim
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
- DKFZ-Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK); German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christoph Oster
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
- DKFZ-Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK); German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Tobias Blau
- DKFZ-Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK); German Cancer Research Center (DKFZ), Heidelberg, Germany
- Institute of Neuropathology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Kathy Keyvani
- Institute of Neuropathology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Martin Stuschke
- Department of Radiotherapy, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Björn Scheffler
- DKFZ-Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK); German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sied Kebir
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
- DKFZ-Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK); German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martin Glas
- Corresponding Author: Prof. Dr. Martin Glas, Department of Neurology, Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Hufelandstr. 55, Essen, 45147, Germany ()
| | - Lazaros Lazaridis
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
- DKFZ-Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK); German Cancer Research Center (DKFZ), Heidelberg, Germany
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High-Grade Gliomas in Children-A Multi-Institutional Polish Study. Cancers (Basel) 2021; 13:cancers13092062. [PMID: 33923337 PMCID: PMC8123180 DOI: 10.3390/cancers13092062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/07/2021] [Accepted: 04/22/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary High-grade gliomas constitute less than 5% of pediatric brain tumors. Due to the rarity of such a diagnosis, the lack of consensus about the best therapeutic approach, and the difficulty in conducting prospective trials; a retrospective multi-institutional analysis, such as the one presented in this article, is needed. We carried out the survival analysis of children diagnosed and treated with high-grade gliomas in seven major polish institutions. The assessment of the outcome of 82 consecutive patients with grade III and grade IV tumors was performed and showed a 5-year overall survival of only 30%. The extent of resection, immediate temozolomide-based chemotherapy, and radical radiotherapy were found as factors positively influencing survival. Abstract Due to the rarity of high-grade gliomas (HGG) in children, data on this topic are scarce. The study aimed to investigate the long-term results of treatment of children with HGG and to identify factors related to better survival. We performed a retrospective analysis of patients treated for HGG who had the main tumor located outside the brainstem. The evaluation of factors that correlated with better survival was performed with the Cox proportional-hazard model. Survival was estimated with the Kaplan–Meier method. The study group consisted of 82 consecutive patients. All of them underwent surgery as primary treatment. Chemotherapy was applied in 93% of children with one third treated with temozolomide. After or during the systemic treatment, 79% of them received radiotherapy with a median dose of 54 Gy. Median follow-up was 122 months, and during that time, 59 patients died. One-, 2-, 5-, and 10-year overall survival was 78%, 48%, 30% and 17%, respectively. Patients with radical (R0) resection and temozolomide-based chemotherapy had better overall survival. Progression-free survival was better in patients after R0 resection and radical radiotherapy. The best outcome in HGG patients was observed in patients after R0 resection with immediate postoperative temozolomide-based chemotherapy and radical radiotherapy.
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Randomised phase II trial of trofosfamide vs. doxorubicin in elderly patients with untreated metastatic soft-tissue sarcoma. Eur J Cancer 2020; 124:152-160. [DOI: 10.1016/j.ejca.2019.10.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/02/2019] [Accepted: 10/06/2019] [Indexed: 11/22/2022]
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5
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Karremann M, Gielen GH, Hoffmann M, Wiese M, Colditz N, Warmuth-Metz M, Bison B, Claviez A, van Vuurden DG, von Bueren AO, Gessi M, Kühnle I, Hans VH, Benesch M, Sturm D, Kortmann RD, Waha A, Pietsch T, Kramm CM. Diffuse high-grade gliomas with H3 K27M mutations carry a dismal prognosis independent of tumor location. Neuro Oncol 2019; 20:123-131. [PMID: 29016894 DOI: 10.1093/neuonc/nox149] [Citation(s) in RCA: 177] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background The novel entity of "diffuse midline glioma, H3 K27M-mutant" has been defined in the 2016 revision of the World Health Organization (WHO) classification of tumors of the central nervous system (CNS). Tumors of this entity arise in CNS midline structures of predominantly pediatric patients and are associated with an overall dismal prognosis. They are defined by K27M mutations in H3F3A or HIST1H3B/C, encoding for histone 3 variants H3.3 and H3.1, respectively, which are considered hallmark events driving gliomagenesis. Methods Here, we characterized 85 centrally reviewed diffuse gliomas on midline locations enrolled in the nationwide pediatric German HIT-HGG registry regarding tumor site, histone 3 mutational status, WHO grade, age, sex, and extent of tumor resection. Results We found 56 H3.3 K27M-mutant tumors (66%), 6 H3.1 K27M-mutant tumors (7%), and 23 H3-wildtype tumors (27%). H3 K27M-mutant gliomas shared an aggressive clinical course independent of their anatomic location. Multivariate regression analysis confirmed the significant impact of the H3 K27M mutation as the only independent parameter predictive of overall survival (P = 0.009). In H3 K27M-mutant tumors, neither anatomic midline location nor histopathological grading nor extent of tumor resection had an influence on survival. Conclusion These results substantiate the clinical significance of considering diffuse midline glioma, H3 K27M-mutant, as a distinct entity corresponding to WHO grade IV, carrying a universally fatal prognosis.
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Affiliation(s)
- Michael Karremann
- Department of Pediatric and Adolescent Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Gerrit H Gielen
- Department of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Marion Hoffmann
- Division of Pediatric Hematology and Oncology, University Medical Center Goettingen, Goettingen, Germany.,Department of Child and Adolescent Health, University Medical Center Goettingen, Goettingen, Germany
| | - Maria Wiese
- Division of Pediatric Hematology and Oncology, University Medical Center Goettingen, Goettingen, Germany.,Department of Child and Adolescent Health, University Medical Center Goettingen, Goettingen, Germany
| | - Niclas Colditz
- Division of Pediatric Hematology and Oncology, University Medical Center Goettingen, Goettingen, Germany.,Department of Child and Adolescent Health, University Medical Center Goettingen, Goettingen, Germany
| | - Monika Warmuth-Metz
- Department of Neuroradiology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Brigitte Bison
- Department of Neuroradiology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Alexander Claviez
- Department of Pediatrics, Schleswig-Holstein Medical University in Kiel, Kiel, Germany
| | - Dannis G van Vuurden
- Department of Pediatrics, VU University Medical Center, Amsterdam, Netherlands.,Division of Oncology/Hematology, VU University Medical Center, Amsterdam, Netherlands
| | - André O von Bueren
- Division of Pediatric Hematology and Oncology, University Medical Center Goettingen, Goettingen, Germany.,Department of Child and Adolescent Health, University Medical Center Goettingen, Goettingen, Germany.,Department of Pediatrics and Adolescent Medicine, University Hospital of Geneva, Geneva, Switzerland.,Division of Pediatric Hematology and Oncology, University Hospital of Geneva, Geneva, Switzerland
| | - Marco Gessi
- Department of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Ingrid Kühnle
- Division of Pediatric Hematology and Oncology, University Medical Center Goettingen, Goettingen, Germany.,Department of Child and Adolescent Health, University Medical Center Goettingen, Goettingen, Germany
| | - Volkmar H Hans
- Department of Pathology, Universitätsmedizin Greifswald, Greifswald, Germany.,Institute of Neuropathology, Evangelisches Krankenhaus Bielefeld, Bielefeld, Germany
| | - Martin Benesch
- Division of Pediatric Hematology and Oncology, Medical University Graz, Graz, Austria.,Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
| | - Dominik Sturm
- Division of Pediatric Neurooncology, German Cancer Research Center Heidelberg, Heidelberg, Germany
| | - Rolf-Dieter Kortmann
- Department of Radiotherapy and Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - Andreas Waha
- Department of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Torsten Pietsch
- Department of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Christof M Kramm
- Division of Pediatric Hematology and Oncology, University Medical Center Goettingen, Goettingen, Germany.,Department of Child and Adolescent Health, University Medical Center Goettingen, Goettingen, Germany
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Witte HM, Riecke A, Mayer T, Bartscht T, Rades D, Lehnert H, Merz H, Fetscher S, Biersack H, Gebauer N. Trofosfamide in the treatment of elderly or frail patients with diffuse large B-cell lymphoma. J Cancer Res Clin Oncol 2018; 145:129-136. [PMID: 30327940 DOI: 10.1007/s00432-018-2772-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 10/11/2018] [Indexed: 01/10/2023]
Abstract
PURPOSE The introduction of immunochemotherapy has led to a significant improvement in treatment results and prognosis of diffuse large B-cell non-Hodgkins lymphoma (DLBCL) both at initial diagnosis and in relapse. Trofosfamide, an oxazaphosphorine derivative, has been utilized as alternative treatment option for patients with lymphoproliferative diseases unsuitable for conventional chemotherapy agents and protocols because of age, comorbidity, or poor performance score. While data on the activity and safety of single-agent trofosfamide have been published, the potential value of this agent in immunochemotherapy in combination with anti-CD20 antibodies such as rituximab has not been investigated to our knowledge. METHODS Safety and therapeutic effectiveness of trofosfamide given orally at a dose of 50 mg twice daily alone, or in combination with standard-dose rituximab, was investigated in a cohort of elderly and/or highly comorbid patients with histologically confirmed primary or secondary DLBCL. RESULTS Treatment with trofosfamide in this combination setting was generally well tolerated with no treatment-related deaths and manageable side effects, most of which were WHO class I-II; the most clinically relevant toxicity was cytopenia. 19 of 21 examined patients responded to therapy with 11 of 21 (52.4%) achieving a complete remission (CR). Median overall and progression-free survival (OS and PFS) in the CR-group was 14 and 9 months, respectively. In the subgroup with trofosfamide-based first-line therapy, 7 of 10 (70%) achieved CR and median PFS was not reached. CONCLUSIONS Immunochemotherapy with rituximab and trofosfamide (RT) is safe and effective in elderly and poor-performance patients with DLBCL. Response rates are comparable to most commonly used primary and salvage treatment protocols. The potential value of TR regimen in both first-line and relapsed/refractory DLCBL merits further investigation and is probably underestimated.
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Affiliation(s)
- Hanno M Witte
- Department of Haematology and Oncology, University Hospital of Schleswig-Holstein (UKSH), Ratzeburger Allee 160, 23538, Lübeck, Germany.
- Department of Haematology and Oncology, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany.
| | - Armin Riecke
- Department of Haematology and Oncology, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | - Thomas Mayer
- Department of Haematology and Oncology, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | - Tobias Bartscht
- Department of Haematology and Oncology, University Hospital of Schleswig-Holstein (UKSH), Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Dirk Rades
- Department of Radiation Oncology, University Hospital of Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Hendrik Lehnert
- Department of Internal Medicine I, University Hospital of Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Hartmut Merz
- Reference Center for Lymph Node Pathology and Haematopathology, Lübeck, Germany
| | | | - Harald Biersack
- Department of Haematology and Oncology, University Hospital of Schleswig-Holstein (UKSH), Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Niklas Gebauer
- Department of Haematology and Oncology, University Hospital of Schleswig-Holstein (UKSH), Ratzeburger Allee 160, 23538, Lübeck, Germany
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Bavle A, Chintagumpala M. Pediatric high-grade glioma: a review of biology, prognosis, and treatment. ACTA ACUST UNITED AC 2018. [DOI: 10.1007/s13566-018-0344-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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8
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High-grade glioma in very young children: a rare and particular patient population. Oncotarget 2017; 8:64564-64578. [PMID: 28969094 PMCID: PMC5610026 DOI: 10.18632/oncotarget.18478] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 05/17/2017] [Indexed: 01/05/2023] Open
Abstract
In the past years, pediatric high-grade gliomas (HGG) have been the focus of several research articles and reviews, given the recent discoveries on the genetic and molecular levels pointing out a clinico-biological uniqueness of the pediatric population compared to their adult counterparts with HGG. On the other hand, there are only scarce data about HGG in very young children (below 3 years of age at diagnosis) due to their relatively low incidence. However, the few available data suggest further distinction of this very rare subgroup from older children and adults at several levels including their molecular and biological characteristics, their treatment management, as well as their outcome. This review summarizes and discusses the current available knowledge on the epidemiological, neuropathological, genetic and molecular data of this subpopulation. We discuss these findings and differences compared to older patients suffering from the same histologic disease. In addition, we highlight the particular clinical and neuro-radiological findings in this specific subgroup of patients as well as their current management approaches and treatment outcomes.
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9
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Karremann M, Krämer N, Hoffmann M, Wiese M, Beilken A, Corbacioglu S, Dilloo D, Driever PH, Scheurlen W, Kulozik A, Gielen GH, von Bueren AO, Dürken M, Kramm CM. Haematological malignancies following temozolomide treatment for paediatric high-grade glioma. Eur J Cancer 2017; 81:1-8. [PMID: 28586748 DOI: 10.1016/j.ejca.2017.04.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 04/25/2017] [Accepted: 04/28/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Temozolomide (TMZ) is widely used in high-grade glioma (HGG). There is a major concern of treatment-induced secondary haematological malignancies (SHMs). Due to the poor overall survival of HGG patients, the true incidence is yet elusive. Thus, the aim of this study was to determine the risk of SHMs following TMZ in paediatric HGG. METHODS We analysed 487 patients from the HIT-HGG database of the German-speaking Society of Pediatric Oncology and Hematology with follow up beyond 1 year. RESULTS The incidence of SHM was 7.7 ± 3.2% at 10 years. No SHM occurred in 194 patients after first-line TMZ therapy, but four out of 131 patients treated with TMZ for relapse following first-line multiagent chemotherapy experienced SHM (20% at 10 years; p = 0.041). SHMs occurred in two out of 162 patients who underwent multiagent chemotherapy without TMZ (4.1% at 10 years). Gender, patient age and acute haematological toxicity during treatment did not affect the incidence of SHMs. CONCLUSION Data of our cohort do not indicate an increased risk of SHM following TMZ treatment when compared to previous chemotherapy regimen. However, if TMZ is administered as a second-line treatment following conventional chemotherapy regimen, the risk might be disproportionately increasing.
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Affiliation(s)
- Michael Karremann
- Department of Pediatric and Adolescent Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Nadja Krämer
- Department of Pediatric and Adolescent Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marion Hoffmann
- Division of Pediatric Hematology and Oncology, Department of Child and Adolescent Health, University Medical Center Göttingen, Göttingen, Germany
| | - Maria Wiese
- Division of Pediatric Hematology and Oncology, Department of Child and Adolescent Health, University Medical Center Göttingen, Göttingen, Germany
| | - Andreas Beilken
- Department of Pediatric Hematology and Oncology, Medical School Hannover, Hannover, Germany
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Regensburg, Children's Hospital Regensburg, Regensburg, Germany
| | - Dagmar Dilloo
- Department of Pediatric Hematology and Oncology, Center for Child and Adolescent Medicine, Rheinische Friedrich-Wilhelms University, Bonn, Germany
| | - Pablo Hernáiz Driever
- Department of Pediatric Oncology/Hematology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Wolfram Scheurlen
- Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany
| | - Andreas Kulozik
- Department of Pediatric Hematology, Oncology and Immunology, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Gerrit H Gielen
- Department of Neuropathology, University Hospital Bonn, 53105 Bonn, Germany
| | - André O von Bueren
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, University Hospital of Geneva, Geneva, Switzerland
| | - Matthias Dürken
- Department of Pediatric and Adolescent Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christof M Kramm
- Division of Pediatric Hematology and Oncology, Department of Child and Adolescent Health, University Medical Center Göttingen, Göttingen, Germany
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Karremann M, Hoffmann M, Benesch M, Kwiecien R, von Bueren AO, Kramm CM. Secondary Solid Malignancies After High-Grade Glioma Treatment in Pediatric Patients. Pediatr Hematol Oncol 2016; 32:467-73. [PMID: 26237586 DOI: 10.3109/08880018.2015.1050615] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Due to the poor survival in high-grade glioma (HGG), secondary solid malignancies (SSM) following pediatric HGG are scarce. The authors present the experience from the HIT-HGG database in Germany, Austria, and Switzerland. Five out of 1228 pediatric HGG patients developed a SSM following a latency of 29-122 months from primary HGG diagnosis. In 4 patients, the SSM may be attributed to previous radiotherapy or a tumor predisposition syndrome, reflected by a markedly increased cumulative incidence rate of SSM in patients with tumor predisposition. Survival was devastating, since none of the patients survived beyond 18 months from SSM diagnosis.
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Affiliation(s)
- Michael Karremann
- a Department of Pediatric and Adolescent Medicine, University Medical Center Mannheim, Medical Faculty Mannheim , Heidelberg University , Mannheim, Germany
| | - Marion Hoffmann
- b Division of Pediatric Hematology and Oncology, Department of Child and Adolescent Health , University Medical Center Göttingen , Göttingen, Germany
| | - Martin Benesch
- c Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine , Medical University Graz , Graz, Austria
| | - Robert Kwiecien
- d Institute of Biostatistics and Clinical Research , University of Münster , Münster, Germany
| | - André O von Bueren
- b Division of Pediatric Hematology and Oncology, Department of Child and Adolescent Health , University Medical Center Göttingen , Göttingen, Germany
| | - Christof M Kramm
- b Division of Pediatric Hematology and Oncology, Department of Child and Adolescent Health , University Medical Center Göttingen , Göttingen, Germany
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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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Bode U, Zimmermann M, Moser O, Rutkowski S, Warmuth-Metz M, Pietsch T, Kortmann RD, Faldum A, Fleischhack G. Treatment of recurrent primitive neuroectodermal tumors (PNET) in children and adolescents with high-dose chemotherapy (HDC) and stem cell support: results of the HITREZ 97 multicentre trial. J Neurooncol 2014; 120:635-42. [PMID: 25179451 DOI: 10.1007/s11060-014-1598-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 08/19/2014] [Indexed: 11/29/2022]
Abstract
Early studies with high-dose chemotherapy for treatment of relapsed cerebral PNET had shown modest efficacy but considerable toxicity. The HIT97 national trial tested a nonrandomized but stratified relapse protocol using either intensive chemotherapy, potentially high dose, or oral chemotherapy. 72 patients (59 disseminated) whose primary treatment had been surgery (97 %), radiotherapy (88 %), and/or chemotherapy (95 %) were enrolled in the intensive chemotherapy arm at diagnosis of relapse or resistance. As a window for this study they received two courses of a 96-hour infusion with carboplatin and etoposide. A response (complete or partial remission) was documented by MRI. Responders received two more cycles of this therapy and stem cell collection, before they received HDC (carboplatin, etoposide, thiotepa) and stem cell support. All possibilities of local therapy were to be explored and applied. After two courses of chemotherapy there was a 52 % response rate (41/72 patients). The median PFS and OS for all 72 patients were 11.6 and 21.1 months. Patients with medulloblastoma had a longer PFS and OS (12.6 and 22.6 months) than those with other PNETs (3.1 and 12.3 months). Favourable prognostic features were no new signs of clinical impairment and localised disease at relapse diagnosis. For the 27 patients who received HDC the median PFS and OS were 8.4 and 20.2 months, respectively. HDC did not benefit patients with resistant cerebral PNET and was associated with profound haematological and mucosal toxicity (90-100 % grade III, IV), infections (50 % grade III and IV) and severe ototoxicity (50 % grade III, 12.5 % grade IV). Treatment related mortality was 8 %. There was low long-term survival and only 2/72 patients are in continuous remission. Adding HDC in patients who responded to the initial courses of chemotherapy did not improve survival. Patients with relapsed cerebral PNET who respond to conventional chemotherapy do not profit from further augmentation to HDC.
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Affiliation(s)
- U Bode
- Department of Pediatrics, Hematology/Oncology, Children`s Hospital, University of Bonn, Adenauerallee 119, 53113, Bonn, Germany,
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13
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Karremann M, Rausche U, Roth D, Kühn A, Pietsch T, Gielen GH, Warmuth-Metz M, Kortmann RD, Straeter R, Gnekow A, Wolff JEA, Kramm CM. Cerebellar location may predict an unfavourable prognosis in paediatric high-grade glioma. Br J Cancer 2013; 109:844-51. [PMID: 23868007 PMCID: PMC3749574 DOI: 10.1038/bjc.2013.404] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 06/26/2013] [Accepted: 06/27/2013] [Indexed: 01/11/2023] Open
Abstract
Background: High-grade glioma (HGG) of the cerebellum accounts for only 5% of paediatric HGG. Since little is known about these tumours, the present study aimed at their further characterisation. Methods: Twenty-nine paediatric patients with centrally reviewed cerebellar HGG were identified from the HIT-GBM/HIT-HGG database. Clinical and epidemiological data were compared with those of 180 paediatric patients with cortical HGG. Results: Patients with cerebellar tumours were younger (median age of 7.6 vs 11.7 years, P=0.028), but both groups did not differ significantly with regard to gender, tumour predisposing syndromes, secondary HGG, primary metastasis, tumour grading, extent of tumour resection, chemotherapy regimen, or radiotherapy. Except for an increased incidence of anaplastic pilocytic astrocytoma (APA) in the cerebellar subset (20.7% vs 3.3% P<0.001), histological entities were similarly distributed in both groups. As expected, tumour grading had a prognostic relevance on survival. Compared with cortical HGG, overall survival in the cerebellar location was significantly worse (median overall survival: 0.92±0.02 vs 2.03±0.32 years; P=0.0064), and tumour location in the cerebellum had an independent poor prognostic significance as shown by Cox-regression analysis (P=0.019). Conclusion: High-grade glioma represents a group of tumours with an obviously site-specific heterogeneity associated with a worse survival in cerebellar location.
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Affiliation(s)
- M Karremann
- Department of Paediatric and Adolescent Medicine, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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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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Affiliation(s)
- Christine Marosi
- Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria.
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Wolff JE, Rytting ME, Vats TS, Zage PE, Ater JL, Woo S, Kuttesch J, Ketonen L, Mahajan A. Treatment of recurrent diffuse intrinsic pontine glioma: the MD Anderson Cancer Center experience. J Neurooncol 2011; 106:391-7. [PMID: 21858608 DOI: 10.1007/s11060-011-0677-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 07/30/2011] [Indexed: 01/27/2023]
Abstract
Recurrent diffuse intrinsic pontine gliomas (DIPG) are traditionally treated with palliative care since no effective treatments have been described for these tumors. Recently, clinical studies have been emerging, and individualized treatment is attempted more frequently. However, an informative way to compare the treatment outcomes has not been established, and historical control data are missing for recurrent disease. We conducted a retrospective chart review of patients with recurrent DIPG treated between 1998 and 2010. Response progression-free survival and possible influencing factors were evaluated. Thirty-one patients were identified who were treated in 61 treatment attempts using 26 treatment elements in 31 different regimens. The most frequently used drugs were etoposide (14), bevacizumab (13), irinotecan (13), nimotuzumab (13), and valproic acid (13). Seven patients had repeat radiation therapy to the primary tumor. Response was recorded after 58 treatment attempts and was comprised of 0 treatment attempts with complete responses, 7 with partial responses, 20 with stable diseases, and 31 with progressive diseases The median progression-free survival after treatment start was 0.16 years (2 months) and was found to be correlated to the prior time to progression but not to the number of previous treatment attempts. Repeat radiation resulted in the highest response rates (4/7), and the longest progression-free survival. These data provide a basis to plan future clinical trials for recurrent DIPG. Repeat radiation therapy should be tested in a prospective clinical study.
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Affiliation(s)
- Johannes E Wolff
- Department of Pediatrics, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Box 87, Houston, TX 77030, USA.
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Kramm CM, Butenhoff S, Rausche U, Warmuth-Metz M, Kortmann RD, Pietsch T, Gnekow A, Jorch N, Janssen G, Berthold F, Wolff JE. Thalamic high-grade gliomas in children: a distinct clinical subset? Neuro Oncol 2011; 13:680-9. [PMID: 21636712 PMCID: PMC3107103 DOI: 10.1093/neuonc/nor045] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Accepted: 02/11/2011] [Indexed: 11/13/2022] Open
Abstract
Pediatric high-grade gliomas (HGGs) of the thalamic region account for up to 13% of pediatric HGGs and usually result in only anecdotal long-term survival. Because very little is known about these tumors, we aimed to further characterize them. In our series of 99 pediatric thalamic HGGs, there were no significant differences in survival between patients with tumors affecting the thalamus alone (including bithalamic lesions) and patients with tumors affecting the thalamus plus adjacent structures. Tumor resection (event-free survival/overall survival) and an early treatment response to radiotherapy/chemotherapy (event-free survival) had independent prognostic significance, as shown by Kaplan-Meier and multivariate Cox regression analyses. When we compared clinical characteristics and outcomes of pediatric thalamic HGG with those of pediatric (nonthalamic) supratentorial (n = 177) as well as pediatric pontine HGG (including diffuse intrinsic pontine gliomas; n = 234), we found that thalamic HGG shared more similarities with pontine than with supratentorial HGG, but overall, it appeared to represent a clinically distinct subgroup of pediatric HGG. The varying extent of tumor resection in the different tumor localizations may play some role in the observed clinical differences, as shown by multivariate Cox regression analyses, but the tumor site itself was also identified as an independent prognostic parameter. Thus, an additional location-specific effect on survival and/or tumor biology, despite different neurosurgical accessibility, has to be considered. Therefore, future investigations should try to further characterize the obviously site-specific heterogeneity of pediatric HGG on a molecular genetic basis.
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Affiliation(s)
- Christof M Kramm
- University Children's Hospital, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120 Halle, Germany.
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Wolff JEA, Mohiuddin K, Jorch N, Graf N, Wagner S, Vats T, Gnekow A. Measuring performance status in pediatric patients with brain tumors--experience of the HIT-GBM-C protocol. Pediatr Blood Cancer 2010; 55:520-4. [PMID: 20658624 DOI: 10.1002/pbc.22566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Measuring the quality of life or performance status in pediatric neurooncology has proven a challenge. Here, we report in a treatment protocol for pediatric patients with high-grade glioma and diffuse intrinsic pontine glioma. PROCEDURE The Fertigkeitenskala Münster-Heidelberg (FMH) is a 56-item quantitative measure of health status. The number of yes answers is transformed to age-dependent percentiles. Physicians were also asked the patients' health status by their own judgment on a 1-5 scale: normal, mild handicap, age-normal activity severely reduced but patient not in bed, in bed, and in ICU. RESULTS Assessments were available from 50 of 97 eligible patients. For 22 patients both questionnaire and the physicians score obtained. At the beginning of the treatment, only 5 patients scored over 40 FMH%, and 4 of these survived. Of 16 patients who initially scored less than 40 FMH%, 15 died. During later assessments, most FMH measures became gradually worse. FMH scores improved in three patients. The physician's judgment was documented at diagnosis and during treatment (n = 50). Per physician, 22% of the patients were normal before chemotherapy, decreasing to 16% in the middle of the protocol. At diagnosis only 16% of patients had severely reduced activity, which increased to 30.6% in the middle of the protocol. The FMH% correlated well with the physicians' judgments (P < 0.005). CONCLUSION The FMH scale is easily obtained and provides a valid assessment of health status. Patients with poor performance at diagnosis had a poorer prognosis.
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Affiliation(s)
- Johannes E A Wolff
- Division of Pediatrics, Section of Pediatric Neuro-oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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High dose methotrexate for pediatric high grade glioma: results of the HIT-GBM-D pilot study. J Neurooncol 2010; 102:433-42. [PMID: 20694800 DOI: 10.1007/s11060-010-0334-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 07/21/2010] [Indexed: 01/09/2023]
Abstract
We conducted a phase II study to test methotrexate (5 g/m(2)), as a single agent prior to radiochemotherapy for pediatric high-grade glioma and diffuse intrinsic pontine glioma. Thirty patients (19 male, median age 10.8) were enrolled. Tumors were located as follows: cortex 10, pons 7, other 13. Tumor resection was classified as gross total in 6, subtotal in 6, partial in 4, biopsy in 11 and not performed in 3. WHO grading of the histology was: IV: 11, III: 12 and II: 3. Patients received methotrexate 5 g/m(2) in 24-hour infusions on days 1 and 15. Subsequently 54 Gy radiation was administered with simultaneous chemotherapy including cisplatin, etoposide, vincristine and ifosfamide as previously described. Eight 6-weeks cycles of maintenance chemotherapy consisted of vincristine 1.5 mg/m(2) on days 1, 8 and 15; lomustine 100 mg/m(2) on day 2 and prednisone 40 mg/kg on days 1-17. Event-free survival rates in the whole group of 30 patients were: 43, 20, and 13% after 1, 2 and 5 years, respectively. The response evaluation after methotrexate was available in 19 of the 24 patients who started treatment with measurable disease: CR: 0, PR: 1, SD 18, PD: 0. After radiochemotherapy the response of 24 patients with measurable disease was CR: 1, PR 10, SD 12, PD 1. Both response and event-free survival were superior to the control group of 330 patients treated in various protocols of the same cooperative group. In subgroup analyses the use of dexamethasone during early treatment was linked to poor event free survival. Giving two cycles of high-dose methotrexate prior to radiochemotherapy was feasible, and the approach was taken forward to a randomized phase III trial.
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Wolff JEA, Driever PH, Erdlenbruch B, Kortmann RD, Rutkowski S, Pietsch T, Parker C, Metz MW, Gnekow A, Kramm CM. Intensive chemotherapy improves survival in pediatric high-grade glioma after gross total resection: results of the HIT-GBM-C protocol. Cancer 2010; 116:705-12. [PMID: 19957326 DOI: 10.1002/cncr.24730] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The authors hypothesized that intensified chemotherapy in protocol HIT-GBM-C would increase survival of pediatric patients with high-grade glioma (HGG) and diffuse intrinsic pontine glioma (DIPG). METHODS Pediatric patients with newly diagnosed HGG and DIPG were treated with standard fractionated radiation and simultaneous chemotherapy (cisplatin 20 mg/m2 x 5 days, etoposide 100 mg/m2 x 3 days, and vincristine, and 1 cycle of cisplatin + etoposide + ifosfamide 1.5 g/m x 5 days [PEI] during the last week of radiation). Subsequent maintenance chemotherapy included further cycles of PEI in Weeks 10, 14, 18, 22, 26, and 30, followed by oral valproic acid. RESULTS Ninety-seven (pons, 37; nonpons, 60) patients (median age, 10 years; grade IV histology, 35) were treated. Resection was complete in 21 patients, partial in 29, biopsy only in 26, and not performed in 21. Overall survival rates were 91% (standard error of the mean [SE] +/- 3%), 56%, and 19% at 6, 12, and 60 months after diagnosis, respectively. When compared with previous protocols, there was no significant benefit for patients with residual tumor, but the 5-year overall survival rate for patients with complete resection treated on HIT-GBM-C was 63% +/- 12% SE, compared with 17% +/- 10% SE for the historical control group (P = .003, log-rank test). CONCLUSIONS HIT-GBM-C chemotherapy after complete tumor resection was superior to previous protocols.
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Affiliation(s)
- Johannes E A Wolff
- Department of Pediatrics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Hales RK, Shokek O, Burger PC, Paynter NP, Chaichana KL, Quiñones-Hinojosa A, Jallo GI, Cohen KJ, Song DY, Carson BS, Wharam MD. Prognostic factors in pediatric high-grade astrocytoma: the importance of accurate pathologic diagnosis. J Neurooncol 2009; 99:65-71. [PMID: 20043190 DOI: 10.1007/s11060-009-0102-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Accepted: 12/14/2009] [Indexed: 10/20/2022]
Abstract
To characterize a population of pediatric high-grade astrocytoma (HGA) patients by confirming the proportion with a correct diagnosis, and determine prognostic factors for survival in a subset diagnosed with uniform pathologic criteria. Sixty-three children diagnosed with HGA were treated at the Johns Hopkins Hospital between 1977 and 2004. A single neuropathologist (P.C.B.) reviewed all available histologic samples (n = 48). Log-rank analysis was used to compare survival by patient, tumor, and treatment factors. Median follow-up was 16 months for all patients and 155 months (minimum 54 months) for surviving patients. Median survival for all patients (n = 63) was 14 months with 10 long-term survivors (survival >48 months). At initial diagnosis, 27 patients were grade III (43%) and 36 grade IV (57%). Forty-eight patients had pathology slides available for review, including seven of ten long-term surviving patients. Four patients had non-HGA pathology, all of whom were long term survivors. The remaining 44 patients with confirmed HGG had a median survival of 14 months and prognostic analysis was confined to these patients. On multivariate analysis, five factors were associated with inferior survival: performance status (Lansky) <80% (13 vs. 15 months), bilaterality (13 vs. 19 months), parietal lobe location (13 vs. 16 months), resection less than gross total (13 vs. 22 months), and radiotherapy dose <50 Gy (9 vs. 16 months). Among patients with more than one of the five adverse factors (n = 27), median survival and proportion of long-term survivors were 12.9 months and 0%, compared with 41.4 months and 18% for patients with 0-1 adverse factors (n = 17). In an historical cohort of children with HGA, the potential for long term survival was confined to the subset with less than two of the following adverse prognostic factors: low performance status, bilaterality, parietal lobe site, less than gross total resection, and radiotherapy dose <50 Gy. Pathologic misdiagnosis should be suspected in patients who are long term survivors of a pediatric high grade astrocytoma.
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Affiliation(s)
- Russell K Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, 401 North Broadway, Suite 1440, Baltimore, MD 21231, USA.
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Christiansen SR, Broniscer A, Panetta JC, Stewart CF. Pharmacokinetics of erlotinib for the treatment of high-grade glioma in a pediatric patient with cystic fibrosis: case report and review of the literature. Pharmacotherapy 2009; 29:858-66. [PMID: 19558260 DOI: 10.1592/phco.29.7.858] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A 12-year-old girl with cystic fibrosis was diagnosed with a high-grade glioma after radiographic and biopsy results confirmed the primary intracranial lesion. She was treated with single-agent erlotinib during and after daily localized radiation therapy. Pharmacokinetic studies were conducted to assess the effect of pancreatic enzyme deficiency and intestinal malabsorption secondary to cystic fibrosis on the bioavailability of orally administered erlotinib, a lipophilic drug. Pharmacokinetic analysis of plasma samples from days 1 and 8 demonstrated that absorption of oral erlotinib was not affected by the patient's cystic fibrosis when the drug was given concomitantly with pancreatic enzyme replacement. When pediatric patients with cystic fibrosis are receiving erlotinib or other lipophilic oral drugs, continued supplementation of pancreatic enzymes is recommended, with therapeutic drug monitoring of plasma drug concentrations when feasible, and close observation for therapeutic responses and adverse effects.
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Affiliation(s)
- Shannon R Christiansen
- Department of Pharmaceutical Services, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA
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Karremann M, Butenhoff S, Rausche U, Pietsch T, Wolff JEA, Kramm CM. Pediatric giant cell glioblastoma: New insights into a rare tumor entity. Neuro Oncol 2008; 11:323-9. [PMID: 19050301 DOI: 10.1215/15228517-2008-099] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Little is known about giant cell glioblastoma (GCG) in pediatric patients. The present study identified 18 pediatric patients with centrally reviewed GCG from the HIT-GBM database of the Gesellschaft für Paediatrische Onkologie und Haematologie in Germany, Austria, and Switzerland. Clinical and epidemiological data were compared with those of 178 pediatric patients with centrally reviewed glioblastoma multiforme (GBM) from the same database. In this unique series, median age, male preference, and median clinical history did not differ significantly between pediatric GCG and GBM patients. GCG showed a stronger predilection for cerebral hemispheres than did GBM, which may only partly explain the higher percentage of gross total tumor resections in GCG patients. Most surprising, the widely distributed hypothesis that GCG may imply a better prognosis than GBM could not be substantiated for our pediatric series. Future studies with larger patient numbers and molecular pathological analyses are still needed to corroborate the present findings and further elucidate the biology of GCG in children.
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Affiliation(s)
- Michael Karremann
- Department of Pediatrics and Adolescent Medicine, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06120 Halle, Germany
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Anaplastic ganglioglioma in children. J Neurooncol 2008; 92:157-63. [DOI: 10.1007/s11060-008-9747-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2008] [Accepted: 11/17/2008] [Indexed: 10/21/2022]
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Wolff JEA, Kramm C, Kortmann RD, Pietsch T, Rutkowski S, Jorch N, Gnekow A, Driever PH. Valproic acid was well tolerated in heavily pretreated pediatric patients with high-grade glioma. J Neurooncol 2008; 90:309-14. [PMID: 18679579 DOI: 10.1007/s11060-008-9662-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Accepted: 07/22/2008] [Indexed: 12/27/2022]
Abstract
Valproic acid (VPA) inhibits histone deacetylase and has been reported to induce apoptosis in glioma. We report 44 heavily pretreated pediatric patients with high-grade glioma or diffuse intrinsic pontine glioma who received VPA as oral continues maintenance treatment with individual dose adaptation. The tumor status when starting the drug was: no measurable disease in 12, measurable but stable disease in 12, and measurable progressive disease in 22 patients. Average trough blood levels of VPA were 99 mg/l. The most frequent complaint was somnolence (three patients), but no severe toxicity was reported. One relapse patient responded, early progression of disease was observed in three frontline patients and in six relapsed patients. Median overall survival duration for all patients was 1.33 years, with large differences between first-line (5-year overall survival, 44%) and relapse therapy (5-year overall survival, 14%). This shows that valproate is safe in this patient population. The moderate tumor efficacy encourages studying the drug further as an element of multi-agent protocols.
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Affiliation(s)
- Johannes E A Wolff
- Children's Cancer Hospital, Department of Pediatrics, Unit 87, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA.
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Subpopulations of malignant gliomas in pediatric patients: analysis of the HIT-GBM database. J Neurooncol 2008; 87:155-64. [DOI: 10.1007/s11060-007-9495-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Accepted: 10/29/2007] [Indexed: 10/22/2022]
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Roujeau T, Machado G, Garnett MR, Miquel C, Puget S, Geoerger B, Grill J, Boddaert N, Di Rocco F, Zerah M, Sainte-Rose C. Stereotactic biopsy of diffuse pontine lesions in children. J Neurosurg 2007; 107:1-4. [PMID: 17647306 DOI: 10.3171/ped-07/07/001] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Empirical radiotherapy is the current treatment for children with diffuse pontine lesions that have imaging characteristics of an infiltrative malignant astrocytoma. The use of chemotherapeutic agents is, however, currently under investigation in the treatment of these tumors. To be included into a trial, patients need a definitive histological diagnosis. The authors present their prospective study of the stereotactic biopsy of these lesions during a 4-year period. METHODS A suboccipital, transcerebellar approach was used to obtain biopsy samples in 24 children. RESULTS Two patients suffered deficits. Both had a transient (< 2 months) new cranial nerve palsy; one of these patients also experienced an exacerbation of a preoperative hemiparesis. No patient died during the perioperative period. A histological diagnosis was made in all 24 patients as follows: 22 had a malignant infiltrative astrocytoma, one had a low-grade astrocytoma, and one had a pilocytic astrocytoma. The diagnosis of the latter two patients affected the initial treatment after the biopsy. CONCLUSIONS The findings of this study imply that stereotactic biopsy sampling of a diffuse pontine tumor is a safe procedure, is associated with minimal morbidity, and has a high diagnostic yield. A nonmalignant tumor was identified in two of the 24 patients in whom the imaging findings were characteristic of a malignant infiltrative astrocytoma. With the advent of new treatment protocols, stereotactic biopsy sampling, which would allow specific tumor characterization of diffuse pontine lesions, may become standard.
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Affiliation(s)
- Thomas Roujeau
- Department of Pediatric Neurosurgery, Hôpital Necker-Enfants Malades, Paris, France
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Wagner S, Peters O, Fels C, Janssen G, Liebeskind AK, Sauerbrey A, Suttorp M, Hau P, Wolff JEA. Pegylated-liposomal doxorubicin and oral topotecan in eight children with relapsed high-grade malignant brain tumors. J Neurooncol 2007; 86:175-81. [PMID: 17641821 DOI: 10.1007/s11060-007-9444-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Accepted: 06/13/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND The combination of topoisomerase I and II chemotherapeutic agents has shown promising preclinical synergistic effects in the treatment of high-grade malignant brain tumors such as high-grade gliomas and choroid plexus carcinomas. To confirm the effectiveness of this treatment combination and determine its possible toxicity, we conducted a retrospective review of the charts of children who received the therapy. METHODS Patients with relapsed malignant brain tumors who were given an individualized treatment of pegylated (PEG)-liposomal doxorubicin and topotecan were included in our study. PEG-liposomal doxorubicin was given intravenously at a dosage of 30-40 mg/m(2) over 4 h once every 4 weeks. Additionally, an intravenous formulation of topotecan was given orally twice daily and was increased on an individual basis from a starting dosage of 0.3 mg/m(2) per application to a total daily dosage of 0.6 mg/m(2). RESULTS Eight patients were included. The main toxicity (NCI-CTC) after three cycles of the combination therapy was grade IV hematotoxicity (n = 3); grade III hematotoxicity (n = 2), grade III stomatitis (n = 1), grade III infection (n = 2), grade III diarrhea (n = 1); and grade II dermatitis (n = 1). In four patients, stable disease was achieved for 9, 23, more than 24, and more than 48 weeks, respectively. CONCLUSION The schedule of PEG-liposomal doxorubicin with 30-40 mg/m(2) every 4 weeks in combination with oral topotecan resulted in tumor response, but the toxicity was high. An individualized increasing dose of PEG-liposomal doxorubicin 10-20 mg/m(2) every two weeks is now recommended.
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Affiliation(s)
- Sabine Wagner
- Department of Pediatric Oncology, Krankenhaus der Barmherzigen Brüder, Klinik St. Hedwig, Steinmetzstrasse 1-3, Regensburg, Germany.
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Classen CF, Warmuth-Metz M, Papke K, Trotter A, Wolff JEA, Wagner S. Late response to radiochemotherapy in pediatric glioblastoma: report on two patients treated according to HIT-GBM protocols. Pediatr Hematol Oncol 2006; 23:631-7. [PMID: 17065139 DOI: 10.1080/08880010600951088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
High-grade gliomas in children are rare and the best treatment is undetermined. The German language group study HIT-GBM compares various induction protocols for subsequent patient cohorts. Currently, cisplatinum, etoposide, ifosfamide, and vincristine are given simultaneously with extended-field radiotherapy. Imaging is done 3 weeks after to define treatment response, followed by 6-weekly controls during consolidation with lomustine, vincristine, and prednisone. The authors report on 2 patients with incompletely resected glioblastoma multiforme in which response was lacking 3 weeks after radiochemotherapy but became evident 12 weeks later. This suggests that later time points are required to assess induction protocol response.
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Affiliation(s)
- C F Classen
- Children's Hospital, Wedau Kliniken, Klinikum Duisburg, Duisburg, Germany.
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Wagner S, Benesch M, Berthold F, Gnekow AK, Rutkowski S, Sträter R, Warmuth-Metz M, Kortmann RD, Pietsch T, Wolff JEA. Secondary dissemination in children with high-grade malignant gliomas and diffuse intrinsic pontine gliomas. Br J Cancer 2006; 95:991-7. [PMID: 17047647 PMCID: PMC2360717 DOI: 10.1038/sj.bjc.6603402] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In children, treatment regimen for high-grade gliomas (HGG) and diffuse intrinsic pontine gliomas (DIPG) are generally not stratified according to disease stage. The hypothesis was that secondary disseminating disease (SDD) in children with HGG is related to an even worse outcome. Description of SDD pattern was performed. In total, 270 children with newly diagnosed HGG or DIPG were eligible for retrospective analysis of SDD. Medical and computer records of these patients were reviewed for demographic characteristics, sites of dissemination, prognostic variables. Forty-six (17%) of the 270 patients had developed SDD. The median time to SDD was 8.2 months. The median overall survival (OS) after dissemination was 3.2 months. The SDD was located parenchymal in the supratentorial (34.8%), infratentorial (6.5%), supratentorial and infratentorial (19.6%), spinal (10.9%), spinal and cerebral (6.5%) regions of the CNS, or leptomeningeal (21.7%). For HGG patients, the median OS was shorter among patients with SDD than among patients without SDD (1.02 vs 1.41 years, P=0.0495). In the group of patients with SDD, patients with cerebrospinal fluid dissemination had a worse outcome compared with patients with parenchymal metastases. Summarising, SDD is a negative prognostic factor for patients with HGG outside the pons. Treatment stratification should be considered.
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Affiliation(s)
- S Wagner
- Department of Pediatric Hematology and Oncology, Klinik St Hedwig, University of Regensburg, Regensburg, Germany.
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Wagner S, Csatary CM, Gosztonyi G, Koch HC, Hartmann C, Peters O, Hernáiz-Driever P, Théallier-Janko A, Zintl F, Längler A, Wolff JEA, Csatary LK. Combined treatment of pediatric high-grade glioma with the oncolytic viral strain MTH-68/H and oral valproic acid. APMIS 2006; 114:731-43. [PMID: 17004977 DOI: 10.1111/j.1600-0463.2006.apm_516.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The case of a 12-year-old boy with anaplastic astrocytoma of the left thalamus is reported. Postoperative irradiation and chemotherapy could not repress tumor progression; therefore, treatment was undertaken with an oncolytic virus, MTH-68/H, an attenuated strain of Newcastle disease virus (NDV), and valproic acid (VPA), an antiepileptic drug, which also has antineoplastic properties. This treatment resulted in a far-reaching regression of the thalamic glioma, but 4 months later a new tumor manifestation, an extension of the thalamic tumor, appeared in the wall of the IVth ventricle, which required a second neurosurgical intervention. Under continuous MTH-68/H - VPA administration the thalamic tumor remained under control, but the rhombencephalic one progressed relentlessly and led to the fatal outcome. In the final stage, a third tumor manifestation appeared in the left temporal lobe. The possible reasons for the antagonistic behavior of the three manifestations of the same type of glioma to the initially most successful therapy are discussed. The comparative histological study of the thalamic and rhombencephalic tumor manifestations revealed that MTH-68/H treatment induces, similar to in vitro observations, a massive apoptotic tumor cell decline. In the rhombencephalic tumor, in and around the declining tumor cells, NDV antigen could be demonstrated immunohistochemically, and virus particles have been found in the cytoplasm of tumor cells at electron microscopic investigation. These findings document that the oncolytic effect of MTH-68/H treatment is the direct consequence of virus presence and replication in the neoplastic cells. This is the first demonstration of NDV constituents in an MTH-68/H -treated glioma.
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Affiliation(s)
- Sabine Wagner
- Dept. of Pediatric Oncology, Krankenhaus der Barmherzigen Brüder, Klinik St. Hedwig, University of Regensburg
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Broniscer A, Chintagumpala M, Fouladi M, Krasin MJ, Kocak M, Bowers DC, Iacono LC, Merchant TE, Stewart CF, Houghton PJ, Kun LE, Ledet D, Gajjar A. Temozolomide after radiotherapy for newly diagnosed high-grade glioma and unfavorable low-grade glioma in children. J Neurooncol 2006; 76:313-9. [PMID: 16200343 DOI: 10.1007/s11060-005-7409-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Chemotherapy is commonly used in the treatment of children with high-grade glioma, although its usefulness is uncertain. We conducted a multi-institutional study to evaluate the efficacy of temozolomide given after radiotherapy in children with newly diagnosed high-grade glioma and unfavorable low-grade glioma (gliomatosis cerebri or bithalamic involvement). Optional window therapy of intravenous irinotecan (10 doses of 20 mg/m2 per cycle x 2) was given over 6 weeks. The 5-day schedule of temozolomide (200 mg/m2 per day) started 4 weeks after the completion of radiotherapy and continued for a total of 6 cycles. Thirty-one eligible patients (median age: 12.3 years) participated. Tumors most commonly involved cerebral hemispheres (n = 13, 42%) and thalamus (n = 14, 45%). Whereas six patients underwent radical resection, the remainder had limited surgery, including biopsy (n = 14, 45%). The predominant histologic diagnoses were glioblastoma multiforme (n = 15, 48%) and anaplastic astrocytoma (n = 10, 32%). Two patients had bithalamic grade II astrocytoma. Twenty-seven patients received radiotherapy (median dose: 59.4 Gy), including craniospinal irradiation in 3 because of leptomeningeal spread. Four patients did not receive radiotherapy in this study because of consent withdrawn (n = 2), toxicity during window therapy (n = 1), or at the physician's discretion (n = 1). Twenty-three patients received 112 cycles of temozolomide therapy. The 2-year progression-free and overall survival estimates were 11 +/- 5% and 21 +/- 7%, respectively. Although the heterogeneity of prognostic factors in our patients made assessment of treatment outcome more difficult, the addition of 6 cycles of temozolomide after radiotherapy did not seem to alter the poor outcome of these patients.
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Affiliation(s)
- Alberto Broniscer
- Department of Hematology-Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA.
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Massimino M, Biassoni V. Use of high-dose chemotherapy in front-line therapy of childhood malignant glioma. Expert Rev Anticancer Ther 2006; 6:709-17. [PMID: 16759162 DOI: 10.1586/14737140.6.5.709] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Brain tumors are the second most common cancer in pediatric patients and the main cause from death of malignant tumors in this age group. High-grade or malignant glioma, among which anaplastic astrocytomas and glioblastoma are the most prevalent histotypes, represent 10% of pediatric brain tumors and, taken as a whole, are the second most frequent malignant histotype after medulloblastoma. Apart from complete excision followed by full-dose local radiotherapy, chemotherapy appears to provide some benefit to the final outcome. Different trials have explored the role of high-dose chemotherapy that, theoretically, could give an advantage to these patients by overcoming the blood-brain barrier, cell chemoresistance and inducing a wider number of responses. However, it is still doubtful if more responses translate into better outcome and it is not fully understood which patients can experience a true benefit from this treatment strategy. New protocols under evaluation include new agents with specific biological targets, multiple cycles of high-dose chemotherapy, and vaccination, as an immunotherapeutic approach.
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Affiliation(s)
- Maura Massimino
- Pediatric Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori, 20133 Milan, Italy.
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Biassoni V, Casanova M, Spreafico F, Gandola L, Massimino M. A Case of Relapsing Glioblastoma Multiforme Responding to Vinorelbine. J Neurooncol 2006; 80:195-201. [PMID: 16670944 DOI: 10.1007/s11060-006-9176-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2005] [Accepted: 04/07/2006] [Indexed: 10/24/2022]
Abstract
Childhood malignant gliomas are rare and their clinical behavior is almost as aggressive as in adults: they resist treatment, progress rapidly and often spread. Therapeutic strategies at relapse deserve an experimental approach, since none of the conventional-dose treatments have demonstrated a clear superiority over the others and no randomized trials have proved that high-dose chemotherapy is better than conventional treatment. Vinorelbine is a semi-synthetic vinca alkaloid with an in vitro and in vivo experimentally proven broad spectrum of activity, including against malignant brain glioma. We report our experience with a 19-year-old girl with glioblastoma multiforme (GBM) of the deep temporal region recurring 6 months after completing an intensive treatment that included preradiation chemotherapy (chemotherapy as a preradiation "sandwich" phase) with a myeloablative course of thiotepa, tumor bed radiotherapy and postradiation maintenance chemotherapy. The GBM proved fully responsive to intravenous vinorelbine, with a subsequent progression-free interval lasting more than 24 months. This case report suggests that vinorelbine is effective against high-grade pediatric glioma and, since this evidence has only one precedent in the literature (and given the generally poor prognosis for this tumor), even this single success seems worth reporting.
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Affiliation(s)
- V Biassoni
- Department of Pediatric, Istituto Nazionale per lo Studio e la Cura dei Tumori, 20133, Milan, Italy.
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Wolff JEA, Wagner S, Reinert C, Gnekow A, Kortmann RD, Kühl J, Van Gool SW. Maintenance treatment with interferon-gamma and low-dose cyclophosphamide for pediatric high-grade glioma. J Neurooncol 2006; 79:315-21. [PMID: 16645718 DOI: 10.1007/s11060-006-9147-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Accepted: 03/13/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND The prognosis of high-grade glioma in children is poor. PURPOSE Interferon-gamma may increase the immune surveillance of glioma cells. Earlier clinical evidence had shown that low dose cyclophosphamide (CPM) increased immune response. METHODS After induction treatment with simultaneous radiation and chemotherapy, patients were treated with individually increasing interferon-gamma (IFN-gamma) doses starting from 25 microg/m2/d s.c. increasing up to a maximum of 175 microg/m2/d within 7 weeks. Cyclophosphamide was given at 300 mg/m2 i.v. every 21 days. Forty pediatric glioma patients were enrolled (median age: 8.5 year, male: n = 22). Tumor locations included cerebral cortex (n = 8), basal ganglia (n = 4), brainstem (n = 24), cerebellum (n = 3), spinal cord (n = 1). Histologies were GBM (n = 14), AA (n = 14), LGG (n = 2, diffuse intrinsic pontine glioma). There was grade IV toxicity for thrombocytopenia (10%) and leucopenia (2.5%), grade III toxicity for central nervous (2.5%) and hepatic (5%) side effects, no toxic death. The observation time of the six surviving patients was: 1.2, 1.9, 4.2, 4.4, 4.6 and 4.7 years respectively. The median overall survival (1 year) was not significantly different from a historical control group (0.8 years). The survival of pontine gliomas appeared even inferior when compared to the previous protocol (n.s.). CONCLUSION Maintenance treatment with IFN-gamma and low dose CPM has no sufficient beneficial effect for the treatment of high-grade glioma.
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Affiliation(s)
- Johannes E A Wolff
- Department of Pediatrics, MD Anderson Cancer Center, Unit 87, University of Texas, 1515 Holcombe Blvd, Houston, TX 77030, USA.
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Wagner S, Warmuth-Metz M, Emser A, Gnekow AK, Sträter R, Rutkowski S, Jorch N, Schmid HJ, Berthold F, Graf N, Kortmann RD, Pietsch T, Sörensen N, Peters O, Wolff JEA. Treatment options in childhood pontine gliomas. J Neurooncol 2006; 79:281-7. [PMID: 16598416 DOI: 10.1007/s11060-006-9133-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2005] [Accepted: 02/06/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pontine gliomas are the subgroup of brainstem gliomas with the worst prognosis. Controversial treatment approaches are discussed. PATIENTS AND METHODS Data of children with pontine gliomas treated in different prospective multi-center studies who were registered in the HIT-GBM database were pooled and analyzed addressing prognostic factors and the relevance of intensive treatment using contingency tables, Kaplan-Meier curves and Cox regression analyses. RESULTS From 1983 to 2001, 153 patients (74 males, 79 females, mean age: 8.1 years) with pontine gliomas were registered. Twenty-one tumors were low-grade and 60 were high-grade gliomas (72 undefined histology: 67 no surgery, 5 incomplete data). Sixteen tumors were partially resected, and 125 were irradiated. Ninety children received chemotherapy according to the "HIT-GBM" protocols ("Hirntumor-Glioblastoma multiforme"). The one-year overall survival rate (1YOS) of all patients with pontine glioma was 39.9+/-4.3%. None of the surviving patients had an observation time longer than 3.9 years. Favorable prognostic factors seemed to be age younger than 4 years, low-grade histology and smaller tumor. All three major treatment modalities including resection, irradiation and chemotherapy had prognostic relevance in univariable analysis. Chemotherapy remained beneficial, even if the analysis was restricted to the subgroup of irradiated tumors (1YOS 45.8+/-5.4% vs. 34.4+/-13.5%, P=0.030). CONCLUSION Irradiation is an effective element for the treatment of pontine gliomas. Intensive chemotherapy seems to be important in achieving a better OS.
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Affiliation(s)
- Sabine Wagner
- Department of Pediatric Oncology, Krankenhaus der Barmherzigen Brüder Klinik St. Hedwig, Regensburg, Germany.
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Benesch M, Wagner S, Berthold F, Wolff JEA. Primary dissemination of high-grade gliomas in children: experiences from four studies of the Pediatric Oncology and Hematology Society of the German Language Group (GPOH). J Neurooncol 2005; 72:179-83. [PMID: 15925999 DOI: 10.1007/s11060-004-3546-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Clinical data on central nervous system (CNS) dissemination of high-grade gliomas (HGG) at initial presentation in children are rare. PATIENTS AND METHODS We conducted a retrospective data analysis of all patients enrolled into four consecutive HGG protocols of the Pediatric Oncology and Hematology Society of the German Language Group (GPOH) to determine the incidence of primary CNS dissemination of HGG and to describe clinical characteristics and outcome of children with HGG who were diagnosed with CNS dissemination at initial presentation. 546 patients with newly diagnosed HGG (n=348) or diffuse intrinsic pontine gliomas (n=198) were enrolled in these four studies. Data concerning tumor dissemination are available from 324 patients. RESULTS A total of 10 patients (3.1%) (anaplastic astrocytoma: n=3, glioblastoma multiforme: n=6, diffuse intrinsic pontine glioma: n=1) had primary tumor dissemination. Median age at diagnosis was 9.3 years (range: 0.3-21.3 years). The most frequent primary tumor sites were the cortex (n=4), followed by the ventricles (n=2), cerebellum (n=1), spinal cord (n=1), and pons (n=1). One patient had diffuse gliomatosis cerebri. Following surgery eight patients received local radiotherapy and eight additional chemotherapy. At a median follow-up of 10 months (range: 0.05-3 years) four patients are alive. None is disease-free. Median progression-free and overall survival was 0.8 years (95% CI 0.2-1.4) and 1.5 years (95% CI 0.67-2.29) for patients with primary tumor dissemination, respectively, with no statistically significant differences between the group with and the group without primary tumor dissemination. CONCLUSIONS Initial diagnostic evaluation should include complete CNS imaging as well as cerebrospinal fluid examination in all patients with HGG. As prognosis of children with HGG and primary CNS dissemination was not inferior to patients without dissemination in our population, these patients should be treated in the same way as patients without primary CNS dissemination.
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Affiliation(s)
- Martin Benesch
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescence Medicine, Medical University of Graz, Auenbruggerplatz 30, A-8036, Graz, Austria.
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Nieto Y. DNA-binding agents. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/s0921-4410(04)22008-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
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Latz D, Nassar N, Frank R. Trofosfamide in the Palliative Treatment of Cancer: A Review of the Literature. Oncol Res Treat 2004; 27:572-6. [PMID: 15591719 DOI: 10.1159/000081342] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Trofosfamide is an alkylating agent that is derived from the oxazaphoshorines. It has found application in a broad spectrum of malignancies in the last three decades. The main indications for application were in the palliative situation and as maintenance therapy. Good results were reported from the treatment of non-Hodgkin's lymphomas and soft tissue sarcomas. A lot of small studies and casuistic contributions are available giving treatment results of several solid carcinomas (malignant gliomas, ovarian, lung and prostate cancer, and others). Due to its oral formulation and good tolerability trofosfamide is an attractive candidate for the palliative situation because treatment on an outpatient basis is possible. However, there is still a lack of randomized clinical studies with trofosfamide. Thus, evidence-based conclusions on the therapeutic value of the drug cannot be drawn. In the future, phase III trials should be undertaken.
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Affiliation(s)
- D Latz
- Radiologische Gemeinschaftspraxis am Klinikum Coburg, Abteilung Radioonkologie, Coburg, Germany.
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Rutkowski S, De Vleeschouwer S, Kaempgen E, Wolff JEA, Kühl J, Demaerel P, Warmuth-Metz M, Flamen P, Van Calenbergh F, Plets C, Sörensen N, Opitz A, Van Gool SW. Surgery and adjuvant dendritic cell-based tumour vaccination for patients with relapsed malignant glioma, a feasibility study. Br J Cancer 2004; 91:1656-62. [PMID: 15477864 PMCID: PMC2409960 DOI: 10.1038/sj.bjc.6602195] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Patients with relapsed malignant glioma have a poor prognosis. We developed a strategy of vaccination using autologous mature dendritic cells loaded with autologous tumour homogenate. In total, 12 patients with a median age of 36 years (range: 11–78) were treated. All had relapsing malignant glioma. After surgery, vaccines were given at weeks 1 and 3, and later every 4 weeks. A median of 5 (range: 2–7) vaccines was given. There were no serious adverse events except in one patient with gross residual tumour prior to vaccination, who repetitively developed vaccine-related peritumoral oedema. Minor toxicities were recorded in four out of 12 patients. In six patients with postoperative residual tumour, vaccination induced one stable disease during 8 weeks, and one partial response. Two of six patients with complete resection are in CCR for 3 years. Tumour vaccination for patients with relapsed malignant glioma is feasible and likely beneficial for patients with minimal residual tumour burden.
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Affiliation(s)
- S Rutkowski
- Department of Pediatric Oncology, Children's Hospital, University of Wuerzburg, Josef-Schneider-Str. 2, D-97080 Wuerzburg, Germany
| | - S De Vleeschouwer
- Laboratory of Experimental Immunology, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
- Department of Neurosurgery, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
| | - E Kaempgen
- Department of Dermatology, University of Erlangen, Hartmennstrasse 14, D-91052 Erlangen, Germany
| | - J E A Wolff
- Department of Pediatric Oncology, St Hedwig, University of Regensburg, Steinmetzstr. 1-3, D-93049 Regensburg, Germany
| | - J Kühl
- Department of Pediatric Oncology, Children's Hospital, University of Wuerzburg, Josef-Schneider-Str. 2, D-97080 Wuerzburg, Germany
| | - P Demaerel
- Department of Radiology, University Hospital Gasthuisberg, Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - M Warmuth-Metz
- Department of Neuroradiology, University of Wuerzburg, Josef-Schneider-Str. 11, D-97080 Wuerzburg, Germany
| | - P Flamen
- Department of Nuclear Medicine, Jules Bordet Institute, Héger-Bordetstraat 1, B-1000 Brussel, Belgium
| | - F Van Calenbergh
- Department of Neurosurgery, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
| | - C Plets
- Department of Neurosurgery, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
| | - N Sörensen
- Department of Pediatric Neurosurgery, University of Wuerzburg, Josef-Schneider-Str. 11, D-97080 Wuerzburg, Germany
| | - A Opitz
- Department of Transfusion Medicine, University of Wuerzburg, Josef-Schneider-Str. 2, D-97080 Wuerzburg, Germany
| | - S W Van Gool
- Laboratory of Experimental Immunology, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
- Department of Pediatrics, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
- University hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium. E-mail:
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Makis A, Polychronopoulou S, Haidas S. Osteosarcoma as a second tumor after treatment for primary non-Hodgkin's lymphoma in a child with ataxia-telangiectasia: presentation of a case and review of possible pathogenetic mechanisms. J Pediatr Hematol Oncol 2004; 26:444-6. [PMID: 15218420 DOI: 10.1097/00043426-200407000-00009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Patients with ataxia-telangiectasia (A-T) and cancer are exposed to additional toxicity due to their underlying inability to repair chemotherapy-induced DNA damage. The authors report the development of osteosarcoma as a second neoplasia in a child with A-T who was treated, without being irradiated, for non-Hodgkin's lymphoma as a primary malignancy. This is the first report of osteosarcoma associated with A-T. The authors postulate that the mechanisms of carcinogenesis are common and independent of the different histopathology categories of these two neoplasias, and the underlying "canvas" of the A-T mutated gene was further triggered by chemotherapy, leading to the development of a second malignancy.
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Affiliation(s)
- Alexandros Makis
- Department of Pediatric Hematology/Oncology, Aghia Sophia Children's Hospital, Athens, Greece.
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Wagner S, Erdlenbruch B, Längler A, Gnekow A, Kühl J, Albani M, Völpel S, Bucsky P, Emser A, Peters O, Wolff JEA. Oral topotecan in children with recurrent or progressive high-grade glioma: a Phase I/II study by the German Society for Pediatric Oncology and Hematology. Cancer 2004; 100:1750-7. [PMID: 15073866 DOI: 10.1002/cncr.20168] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Continuous oral treatment with topotecan may be more effective than the typical 1-day and 5-day treatment schedules. In previous studies of continuous treatment with topotecan, increased intestinal side effects were reported in adult patients; however, the experience in pediatric patients and patients with high-grade glioma is quite limited. METHODS Thirty-two pediatric patients with recurrent high-grade glioma (16 females and 16 males; median age, 9.5 years) were enrolled in the current Phase I/II study. Tumor locations included the cerebral cortex (n = 5), pons (n = 18), and other sites (n = 9). An injectable formulation of topotecan was administered orally, in ice-cold orange juice, once daily. The starting dose of 0.4 mg/m(2) per day was escalated on a patient-by-patient basis. At each patient's maximum dose, blood samples were obtained for the determination of plasma hydroxytopotecan and topotecan lactone concentrations and for the calculation of pharmacokinetic quantities. RESULTS The toxicity criteria for a maximum tolerated topotecan dose were met in only 19 patients. The primary toxicity type was hematologic. The median maximum tolerated dose was 0.9 mg/m(2) per day (n = 19). The calculated maximum total plasma topotecan concentration was 3.8 ng/mL (n = 7), with an area under the concentration-time curve of 38.4 ng. hours/mL and a half-life of 4.1 hours, which would result in the complete disappearance of topotecan from the plasma after 12 hours. Objective responses were observed in 2 of 13 evaluable patients and lasted for 2.5 and 9 months, respectively (continuous clinical remission, 1 of 14 patients; partial response, 2 of 14 patients; stable disease, 7 of 14 patients; progressive disease, 4 of 14 patients). CONCLUSIONS Oral topotecan (median dose, 0.9 mg/m(2) per day) administered once daily was well tolerated and somewhat effective in children with recurrent high-grade glioma. A schedule in which the daily dose is split so that dosing is performed twice daily may be superior to the current schedule.
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Affiliation(s)
- Sabine Wagner
- Department of Pediatric Oncology, Krankenhaus der Barmherzigen Brüder, Klinik St. Hedwig, Regensburg, Germany.
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Edick MJ, Gajjar A, Mahmoud HH, van de Poll MEC, Harrison PL, Panetta JC, Rivera GK, Ribeiro RC, Sandlund JT, Boyett JM, Pui CH, Relling MV. Pharmacokinetics and pharmacodynamics of oral etoposide in children with relapsed or refractory acute lymphoblastic leukemia. J Clin Oncol 2003; 21:1340-6. [PMID: 12663724 DOI: 10.1200/jco.2003.06.083] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To study the pharmacokinetics and pharmacodynamics of once- versus twice-daily oral etoposide in children with relapsed or refractory acute lymphoblastic leukemia (ALL). PATIENTS AND METHODS Fifty-eight patients were randomly assigned to etoposide at 50 mg/m(2)/d with once- versus twice-daily doses for 22 days. On day 8, vincristine, asparaginase, and dexamethasone were started. Etoposide pharmacokinetics and pharmacodynamics were studied for 47, 28, and 26 patients on day 1, 8, and 22, respectively, of remission reinduction therapy. RESULTS Of 48 patients with pharmacokinetic data, 42 (87.5%) achieved complete remission, three (6.3%) failed to achieve remission, and three (6.3%) died during induction. Median etoposide day 8 area under concentration-time curve (AUC) and cumulative AUC tended to be greater (P =.06 and P =.07, respectively) in patients (n = 23) who achieved complete remission (24 and 522 micro mol/L x h, respectively) than in patients (n = 3) who did not (14 and 303 micro mol/L x h, respectively). Three of eight patients with plasma concentrations exceeding 1.7 micro M (1 micro g/mL) for more than 8 hours daily, compared with one of 20 patients with concentrations exceeding 1.7 micro M for <or= 8 hours daily, were unable to receive all 22 days of etoposide because of toxicity. There was no difference in the AUC at day 1 or day 8 with once- versus twice-daily doses (P =.55 and P =.86, respectively). CONCLUSION A pharmacodynamic relationship exists between systemic etoposide exposure and response to therapy when oral etoposide is used as part of remission induction regimens for relapsed or refractory childhood ALL.
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Affiliation(s)
- Mathew J Edick
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, and College of Pharmacy, The University of Tennessee, Memphis 38105, USA
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Nieto Y. DNA-binding agents. ACTA ACUST UNITED AC 2003; 21:171-209. [PMID: 15338745 DOI: 10.1016/s0921-4410(03)21008-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- Yago Nieto
- University of Colorado Bone Marrow, Transplant Program, Denver 80262, USA.
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Wolff JEA, Westphal S, Mölenkamp G, Gnekow A, Warmuth-Metz M, Rating D, Kuehl J. Treatment of paediatric pontine glioma with oral trophosphamide and etoposide. Br J Cancer 2002; 87:945-9. [PMID: 12434281 PMCID: PMC2364312 DOI: 10.1038/sj.bjc.6600552] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2002] [Revised: 06/13/2002] [Accepted: 07/15/2002] [Indexed: 11/30/2022] Open
Abstract
To evaluate the overall survival of paediatric patients with pontine gliomas treated with oral trophosphamide and etoposide. Patients between 3 and 17 years of age with either typical diffuse pontine glioma on MRI or histologically proven anaplastic astrocytoma/glioblastoma multiforme located in the pons, were eligible. Treatment consisted of oral trophosphamide 100 mg x m(-2) x day(-1) combined with oral etoposide at 25 mg x m(-2) x day(-1) starting simultaneously with conventional radiation. Twenty patients were enrolled (median age 6 years, male : female=9 : 11). Surgical procedures included: no surgery: five, open biopsy: three, stereotactic biopsy: six, partial resection: three, and sub-total resection: three. Histological diagnoses included pilocytic astrocytoma: one, astrocytoma with no other specification: three, anaplastic astrocytoma: three, glioblastoma multiforme: eight, no histology: five. The most frequent side effects were haematologic and gastrointestinal. There was no toxic death. The response to combined treatment in 12 evaluable patients was: complete response: 0, partial response: three, stable disease: four, and progressive disease: five. All tumours progressed locally and all patients died. The overall median survival was 8 months. The overall survival rates at 1 and 4 years were: 0.4 and 0.05 respectively. This was not different from a control group of patients documented in the same population. Oral trophosphamide in combination with etoposide did not improve survival of pontine glioma patients. The treatment was well tolerated and should be evaluated for more chemoresponsive paediatric malignancies.
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Affiliation(s)
- J E A Wolff
- St. Hedwigs Klinik, Hämato/Onkologie, Steinmetzstr. 1-3, 93049 Regensburg, Germany.
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Doz F, Neuenschwander S, Bouffet E, Gentet JC, Schneider P, Kalifa C, Mechinaud F, Chastagner P, De Lumley L, Sariban E, Plantaz D, Mosseri V, Bours D, Alapetite C, Zucker JM. Carboplatin before and during radiation therapy for the treatment of malignant brain stem tumours: a study by the Société Française d'Oncologie Pédiatrique. Eur J Cancer 2002; 38:815-9. [PMID: 11937316 DOI: 10.1016/s0959-8049(02)00029-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Childhood malignant brain stem tumours have a very poor prognosis with a median survival of 9 months despite radiotherapy. No chemotherapy has improved survival. However, carboplatin has been reported to have activity in glial tumours as well as antitumour synergy with radiation. Our aims were to test the response rate of these tumours to carboplatin alone and to evaluate the efficacy on survival of carboplatin alone followed by concurrent carboplatin and radiotherapy. Patients younger than 16 years with typical clinical and radiological presentation of infiltrating brain stem tumour, as well as histologically-documented cases in the atypical forms, were eligible. Two courses of carboplatin (1050 mg/m2 over 3 days) were administered initially. This treatment was followed by a chemoradiotherapy phase including five weekly carboplatin courses (200 mg/m2) and conventional radiotherapy. 38 eligible patients were included. No tumour response was observed after the initial phase. This schedule of first-line carboplatin followed by concurrent carboplatin and radiotherapy did not improve survival.
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Affiliation(s)
- F Doz
- Département d'Oncologie Pédiatrique, Institut Curie, 26 rue d'Ulm, 75248 Paris Cedex 05, France.
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Wolff JEA, Gnekow AK, Kortmann RD, Pietsch T, Urban C, Graf N, Kühl J. Preradiation chemotherapy for pediatric patients with high-grade glioma. Cancer 2002; 94:264-71. [PMID: 11815986 DOI: 10.1002/cncr.10114] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND To evaluate the feasibility and efficacy of intensive chemotherapy given prior to irradiation in pediatric patients with malignant glioma, the Society of Pediatric Oncology in Germany started a randomized trial in 1991. The high-grade glioma strata had to be closed because of insufficient patient accrual. The follow-up data from these patients are reported. METHODS Fifty-two patients with World Health Organization (WHO) Grade 4 malignant glioma (n = 27 patients) or with WHO Grade 3 anaplastic astrocytoma (n = 25 patients) between the ages of 3 years and 17 years were available for analysis. The tumor locations were supratentorial in 42 patients, the cerebellum in 8 patients, and the spinal cord in 2 patients (the brainstem was excluded). Tumor surgeries were biopsy in 10 patients, partial resection in 5 patients, subtotal resection in 10 patients, and macroscopic total resection in 21 patients. Patients received either 54 grays of irradiation (n = 22 patients) followed by chemotherapy with lomustine, vincristine, and cisplatin (maintenance chemotherapy) or sandwich chemotherapy (n = 30 patients), which consisted of ifosfamide, etoposide, methotrexate, cisplatin, and cytosine arabinoside followed by irradiation. RESULTS The extent of resection was the most important prognostic factor. The median survival was 5.2 years for patients who underwent tumor resection of > or = 90% compared with 1.3 years for patients who underwent less than complete resection (P < 0.0005). After undergoing macroscopic total resection, sandwich chemotherapy (n = 15 patients) resulted in better overall survival (median, 5.2 years) compared with the maintenance protocol (n = 16 patients; median survival, 1.9 years; P = 0.015). A Cox multivariate regression analysis showed better survival for female patients (P = 0.025), WHO Grade 3 disease (P = 0.016), tumor resection of > or = 90% (P = 0.003), irradiation with > or = 54 grays (P = 0.003), and sandwich chemotherapy (P = 0.006). CONCLUSIONS These data suggest that early, intensive chemotherapy increases survival rates in patients with malignant glioma who undergo complete resection.
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Affiliation(s)
- Johannes E A Wolff
- Department of Hematology/Oncology, Klinik St. Hedwig, Regensburg, Germany.
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