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Krystal J, Hanson D, Donnelly D, Atlas M. A phase 1 study of mebendazole with bevacizumab and irinotecan in high-grade gliomas. Pediatr Blood Cancer 2024; 71:e30874. [PMID: 38234020 DOI: 10.1002/pbc.30874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/11/2023] [Accepted: 01/03/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND High-grade gliomas (HGG) have a dismal prognosis despite multimodal therapy. Mebendazole is an anti-helminthic benzimidazole that has demonstrated efficacy in numerous in vitro cancer models, and is able to cross the blood-brain barrier. We conducted a phase 1 trial (NCT01837862) to evaluate the safety of mebendazole in combination with bevacizumab and irinotecan in children and young adults with HGG. OBJECTIVE To determine the maximally tolerated dose of mebendazole when given in combination with bevacizumab and irinotecan in children with HGG; to describe the progression-free survival (PFS) and overall survival (OS) for this group. DESIGN/METHOD Patients between 1 and 21 years of age with HGG were enrolled in a 3 + 3 design to escalating doses of mebendazole in combination with bevacizumab (10 mg/kg/dose) and irinotecan (150 mg/m2 /dose). Subjects were eligible upfront after completion of radiation or at the time of progression. Mebendazole was taken orally twice per day continuously, and bevacizumab and irinotecan were given intravenously on Days 1 and 15 of 28-day cycles. RESULTS Between 2015 and 2020, 10 subjects were enrolled at mebendazole doses of 50 mg/kg/day (n = 3), 100 mg/kg/day (n = 4), and 200 mg/kg/day (n = 3). One subject assigned to 100 mg/kg/day was not evaluable. Seven subjects had a diagnosis of diffuse midline glioma, one subject had anaplastic astrocytoma, and one subject had a spinal HGG. All subjects received radiation. There were no dose-limiting toxicities. The most frequent G3/4 adverse events were neutropenia (n = 3) and lymphopenia (n = 4). The overall response rate was 33%, with two subjects achieving a partial response and one subject achieving a complete response sustained for 10 months. The mean PFS and OS from the start of study treatment were 4.7 and 11.4 months, respectively. CONCLUSION Mebendazole was safe and well tolerated when administered with bevacizumab and irinotecan at doses up to 200 mg/kg/day. Further studies are needed to determine the efficacy of this treatment.
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Affiliation(s)
- Julie Krystal
- Division of Pediatric Hematology-Oncology and Stem Cell Transplant, Cohen Children's Medical Center, New Hyde Park, New York, USA
- Department of Pediatrics, Zucker School of Medicine, Hempstead, New York, USA
| | - Derek Hanson
- Department of Pediatrics, Hackensack Meridian School of Medicine at Seton Hall University, Nutley, New Jersey, USA
- Department of Pediatrics, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Danielle Donnelly
- Division of Pediatric Hematology-Oncology and Stem Cell Transplant, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Mark Atlas
- Division of Pediatric Hematology-Oncology and Stem Cell Transplant, Cohen Children's Medical Center, New Hyde Park, New York, USA
- Department of Pediatrics, Zucker School of Medicine, Hempstead, New York, USA
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Chen S, He Y, Liu J, Wu R, Wang M, Jin A. Dynamic Survival Risk Prognostic Model and Genomic Landscape for Atypical Teratoid/Rhabdoid Tumors: A Population-Based, Real-World Study. Cancers (Basel) 2024; 16:1059. [PMID: 38473416 DOI: 10.3390/cancers16051059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/06/2024] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND An atypical teratoid/rhabdoid tumor (AT/RT) is an uncommon and aggressive pediatric central nervous system neoplasm. However, a universal clinical consensus or reliable prognostic evaluation system for this malignancy is lacking. Our study aimed to develop a risk model based on comprehensive clinical data to assist in clinical decision-making. METHODS We conducted a retrospective study by examining data from the Surveillance, Epidemiology, and End Results (SEER) repository, spanning 2000 to 2019. The external validation cohort was sourced from the Children's Hospital Affiliated to Chongqing Medical University, China. To discern independent factors affecting overall survival (OS) and cancer-specific survival (CSS), we applied Least Absolute Shrinkage and Selection Operator (LASSO) and Random Forest (RF) regression analyses. Based on these factors, we structured nomogram survival predictions and initiated a dynamic online risk-evaluation system. To contrast survival outcomes among diverse treatments, we used propensity score matching (PSM) methodology. Molecular data with the most common mutations in AT/RT were extracted from the Catalogue of Somatic Mutations in Cancer (COSMIC) database. RESULTS The annual incidence of AT/RT showed an increasing trend (APC, 2.86%; 95% CI:0.75-5.01). Our prognostic study included 316 SEER database participants and 27 external validation patients. The entire group had a median OS of 18 months (range 11.5 to 24 months) and median CSS of 21 months (range 11.7 to 29.2). Evaluations involving C-statistics, DCA, and ROC analysis underscored the distinctive capabilities of our prediction model. An analysis via PSM highlighted that individuals undergoing triple therapy (integrating surgery, radiotherapy, and chemotherapy) had discernibly enhanced OS and CSS. The most common mutations of AT/RT identified in the COSMIC database were SMARCB1, BRAF, SMARCA4, NF2, and NRAS. CONCLUSIONS In this study, we devised a predictive model that effectively gauges the prognosis of AT/RT and briefly analyzed its genomic features, which might offer a valuable tool to address existing clinical challenges.
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Affiliation(s)
- Sihao Chen
- Department of Immunology, School of Basic Medical Sciences, Chongqing Medical University, Chongqing 400010, China
- Chongqing Key Laboratory of Tumor Immune Regulation and Immune Intervention, Chongqing 400010, China
| | - Yi He
- Department of Immunology, School of Basic Medical Sciences, Chongqing Medical University, Chongqing 400010, China
- Chongqing Key Laboratory of Tumor Immune Regulation and Immune Intervention, Chongqing 400010, China
| | - Jiao Liu
- Children's Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Ruixin Wu
- Department of Immunology, School of Basic Medical Sciences, Chongqing Medical University, Chongqing 400010, China
- Chongqing Key Laboratory of Tumor Immune Regulation and Immune Intervention, Chongqing 400010, China
| | - Menglei Wang
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing 400010, China
- Department of Pediatrics, Chongqing Health Center for Women and Children, Chongqing 400010, China
| | - Aishun Jin
- Department of Immunology, School of Basic Medical Sciences, Chongqing Medical University, Chongqing 400010, China
- Chongqing Key Laboratory of Tumor Immune Regulation and Immune Intervention, Chongqing 400010, China
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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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Kang X, Xia H, Skudder-Hill L, Yin Y, Wang X. Magnetic Resonance Imaging (MRI) and Positron Emission Tomography (PET)/Computed Tomography Features of Atypical Teratoid/Rhabdoid Tumors: Case Series and Review. J Child Neurol 2022; 37:1003-1009. [PMID: 36417494 DOI: 10.1177/08830738221129968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Purpose: The purpose of this article is to explore the clinical and neuroradiologic properties of atypical teratoid/rhabdoid tumors. Methods: Data from 6 pediatric patients with atypical teratoid/rhabdoid tumors, which mainly contained the features of magnetic resonance imaging (MRI) and positron emission tomography (PET)/computed tomography (CT), was retrospectively analyzed. Follow-up was conducted in all patients through clinic services and/or telephone consultation. Results: The patients included 4 males and 2 females, aged from 3.2 to 83.1 months at the initial diagnosis. All patients had MRI scans. Two patients underwent 18F-fluorodeoxyglucose PET/CT scintigraphy preoperatively and 4 postoperatively. All primary lesions were located in the cranial cavity and the average diameter of lesions was 37.2 mm. Cerebrospinal fluid spread on enhanced T1-weighted images were found in 2 patients. Multiple metastases were found on MRI and PET/CT scans, which were located at cranial cavity, spinal cord, lung and lymph node. The primary and metastatic lesions showed evident uptake of 18F-fluorodeoxyglucose. Two patients underwent total tumor removal, and 4 patients underwent subtotal removal. None of the patients received shunt surgery. Follow-up was performed in all 6 patients. One patient survived event-free 38.4 months after resection. The mean overall survival of the remaining 5 patients was 5.1 months. Conclusion: We identified specific PET/CT and MRI features that can facilitate the recognition of atypical teratoid/rhabdoid tumors prior to biopsy.
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Affiliation(s)
- Xu Kang
- Department of Pediatric Neurosurgery, Xinhua Hospital, 91603Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hongping Xia
- Department of Neonatology, Xinhua Hospital, 91603Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Loren Skudder-Hill
- Department of Pediatric Neurosurgery, 191612The Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Yafu Yin
- Department of Nuclear Medicine, 91603Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaoqiang Wang
- Department of Pediatric Neurosurgery, Xinhua Hospital, 91603Shanghai Jiaotong University School of Medicine, Shanghai, China
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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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Variations in attitudes towards stereotactic biopsy of adult diffuse midline glioma patients: a survey of members of the AANS/CNS Tumor Section. J Neurooncol 2020; 149:161-170. [PMID: 32705457 PMCID: PMC7452882 DOI: 10.1007/s11060-020-03585-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/11/2020] [Indexed: 02/01/2023]
Abstract
Purpose Diffuse midline gliomas are rare midline CNS malignancies that primarily affect children but can also affect adults. While radiation is standard treatment, prognosis remains fatal. Furthermore, due to its sensitive anatomic location, many physicians have been reluctant to perform biopsies without potential for improved prognosis. However, recent advancements in molecular-targeted therapeutics have encouraged greater tissue sampling. While the literature reflects this progress, the landscape of how clinicians actually manage these patients remains unclear. Our goal was to assess the attitudes of current practicing neurosurgical oncologists towards management of adult diffuse midline gliomas, reasons behind their practices, and factors that might influence these practices. Methods We created and distributed a survey with 16 multiple choice and open-ended questions to members of the Tumor Section of the Congress of Neurological Surgeons. Results A total of 81 physicians responded to the survey. Although time since training and volume of glioma patients did not significantly affect the decision to consider clinical trials or to offer biopsy, those that operated on fewer gliomas (< 25/year) were more likely to cite surgical morbidity as the primary reason not to biopsy these midline locations. Further, surgeons with access to more advanced molecular testing were significantly more likely to consider clinical trial eligibility when offering biopsies. Conclusion Factors that affect the management of diffuse midline gliomas and the role of biopsy are relatively uniform across the field, however, there were a few notable differences that reflect the changes within the neuro-oncology field in response to clinical trials. Electronic supplementary material The online version of this article (10.1007/s11060-020-03585-7) contains supplementary material, which is available to authorized users.
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Erker C, Tamrazi B, Poussaint TY, Mueller S, Mata-Mbemba D, Franceschi E, Brandes AA, Rao A, Haworth KB, Wen PY, Goldman S, Vezina G, MacDonald TJ, Dunkel IJ, Morgan PS, Jaspan T, Prados MD, Warren KE. Response assessment in paediatric high-grade glioma: recommendations from the Response Assessment in Pediatric Neuro-Oncology (RAPNO) working group. Lancet Oncol 2020; 21:e317-e329. [PMID: 32502458 DOI: 10.1016/s1470-2045(20)30173-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/05/2020] [Accepted: 03/12/2020] [Indexed: 12/27/2022]
Abstract
Response criteria for paediatric high-grade glioma vary historically and across different cooperative groups. The Response Assessment in Neuro-Oncology working group developed response criteria for adult high-grade glioma, but these were not created to meet the unique challenges in children with the disease. The Response Assessment in Pediatric Neuro-Oncology (RAPNO) working group, consisting of an international panel of paediatric and adult neuro-oncologists, clinicians, radiologists, radiation oncologists, and neurosurgeons, was established to address issues and unique challenges in assessing response in children with CNS tumours. We established a subcommittee to develop response assessment criteria for paediatric high-grade glioma. Current practice and literature were reviewed to identify major challenges in assessing the response of paediatric high-grade gliomas to various treatments. For areas in which scientific investigation was scarce, consensus was reached through an iterative process. RAPNO response assessment recommendations include the use of MRI of the brain and the spine, assessment of clinical status, and the use of corticosteroids or antiangiogenics. Imaging standards for brain and spine are defined. Compared with the recommendations for the management of adult high-grade glioma, for paediatrics there is inclusion of diffusion-weighted imaging and a higher reliance on T2-weighted fluid-attenuated inversion recovery. Consensus recommendations and response definitions have been established and, similar to other RAPNO recommendations, prospective validation in clinical trials is warranted.
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Affiliation(s)
- Craig Erker
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Dalhousie University and IWK Health Centre, Halifax, NS, Canada.
| | - Benita Tamrazi
- Department of Radiology, Keck School of Medicine, University of Southern California and Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Tina Y Poussaint
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA
| | - Sabine Mueller
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA; Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA; Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Daddy Mata-Mbemba
- Department of Diagnostic Imaging, Dalhousie University and IWK Health Centre, Halifax, NS, Canada
| | - Enrico Franceschi
- Department of Medical Oncology, Azienda USL, Bologna, Italy; IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Alba A Brandes
- Department of Medical Oncology, Azienda USL, Bologna, Italy; IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Arvind Rao
- Departments of Computational Medicine and Bioinformatics and Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Kellie B Haworth
- Division of Neuro-Oncology, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Patrick Y Wen
- Center For Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Stewart Goldman
- Department of Haematology, Oncology, Neuro-Oncology, and Stem Cell Transplantation, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Gilbert Vezina
- Department of Radiology, Children's National Medical Center, Washington, DC, USA
| | - Tobey J MacDonald
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Ira J Dunkel
- Department of Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul S Morgan
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK
| | - Tim Jaspan
- Department of Radiology, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK
| | - Michael D Prados
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Katherine E Warren
- Department of Pediatric Oncology, Dana- Farber/Boston Children's Cancer and Blood Disorders Center, Dana-Farber Cancer Institute, Boston, MA, USA
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Abstract
Pediatric central nervous system (CNS) tumors are the most common solid tumors in children and comprise 15% to 20% of all malignancies in children. Presentation, symptoms, and signs depend on tumor location and age of the patient at the time of diagnosis. This article summarizes the common childhood CNS tumors, presentations, classification, and recent updates in treatment approaches due to the increased understanding of the molecular pathogenesis of pediatric brain tumors.
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Affiliation(s)
- Yoko T Udaka
- The Brain Tumor Institute, Center for Neuroscience and Behavioral Medicine, Children's National Health System, 111 Michigan Avenue Northwest, Washington, DC 20010, USA; Division of Oncology, Center for Cancer and Blood Disorders, 111 Michigan Avenue Northwest, Washington, DC 20010, USA
| | - Roger J Packer
- The Brain Tumor Institute, Center for Neuroscience and Behavioral Medicine, Children's National Health System, 111 Michigan Avenue Northwest, Washington, DC 20010, USA; The Brain Tumor Institute, Gilbert Family Neurofibromatosis Institute, Children's National Medical Center, 111 Michigan Avenue Northwest, Washington, DC 20010, USA.
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Pollack IF, Agnihotri S, Broniscer A. Childhood brain tumors: current management, biological insights, and future directions. J Neurosurg Pediatr 2019; 23:261-273. [PMID: 30835699 PMCID: PMC6823600 DOI: 10.3171/2018.10.peds18377] [Citation(s) in RCA: 159] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 10/29/2018] [Indexed: 02/06/2023]
Abstract
Brain tumors are the most common solid tumors in children, and, unfortunately, many subtypes continue to have a suboptimal long-term outcome. During the last several years, however, remarkable advances in our understanding of the molecular underpinnings of these tumors have occurred as a result of high-resolution genomic, epigenetic, and transcriptomic profiling, which have provided insights for improved tumor categorization and molecularly directed therapies. While tumors such as medulloblastomas have been historically grouped into standard- and high-risk categories, it is now recognized that these tumors encompass four or more molecular subsets with distinct clinical and molecular characteristics. Likewise, high-grade glioma, which for decades was considered a single high-risk entity, is now known to comprise multiple subsets of tumors that differ in terms of patient age, tumor location, and prognosis. The situation is even more complex for ependymoma, for which at least nine subsets of tumors have been described. Conversely, the majority of pilocytic astrocytomas appear to result from genetic changes that alter a single, therapeutically targetable molecular pathway. Accordingly, the present era is one in which treatment is evolving from the historical standard of radiation and conventional chemotherapy to a more nuanced approach in which these modalities are applied in a risk-adapted framework and molecularly targeted therapies are implemented to augment or, in some cases, replace conventional therapy. Herein, the authors review advances in the categorization and treatment of several of the more common pediatric brain tumors and discuss current and future directions in tumor management that hold significant promise for patients with these challenging tumors.
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Mizumoto M, Oshiro Y, Yamamoto T, Kohzuki H, Sakurai H. Proton Beam Therapy for Pediatric Brain Tumor. Neurol Med Chir (Tokyo) 2017; 57:343-355. [PMID: 28603224 PMCID: PMC5566707 DOI: 10.2176/nmc.ra.2017-0003] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Cancer is a major cause of childhood death, with central nervous system (CNS) neoplasms being the second most common pediatric malignancy, following hematological cancer. Treatment of pediatric CNS malignancies requires multimodal treatment using a combination of surgery, chemotherapy, and radiotherapy, and advances in these treatments have given favorable results and longer survival. However, treatment-related toxicities have also occurred, particularly for radiotherapy, after which secondary cancer, reduced function of irradiated organs, and retarded growth are significant problems. Proton beam therapy (PBT) is a particle radiotherapy with excellent dose localization that permits treatment of liver and lung cancer by administration of a high dose to the tumor while minimizing damage to surrounding normal tissues. Thus, PBT has the potential advantages for pediatric cancer. In this context, we review the current knowledge on PBT for treatment of pediatric CNS malignancies.
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Affiliation(s)
| | - Yoshiko Oshiro
- Department of Radiation Oncology, University of Tsukuba.,Department of Radiation Oncology, Tsukuba Medical Center Hospital
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Antigen-specific immunoreactivity and clinical outcome following vaccination with glioma-associated antigen peptides in children with recurrent high-grade gliomas: results of a pilot study. J Neurooncol 2016; 130:517-527. [PMID: 27624914 DOI: 10.1007/s11060-016-2245-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 08/21/2016] [Indexed: 12/29/2022]
Abstract
Recurrent high-grade gliomas (HGGs) of childhood have an exceedingly poor prognosis with current therapies. Accordingly, new treatment approaches are needed. We initiated a pilot trial of vaccinations with peptide epitopes derived from glioma-associated antigens (GAAs) overexpressed in these tumors in HLA-A2+ children with recurrent HGG that had progressed after prior treatments. Peptide epitopes for three GAAs (EphA2, IL13Rα2, survivin), emulsified in Montanide-ISA-51, were administered subcutaneously adjacent to intramuscular injections of poly-ICLC every 3 weeks for 8 courses, followed by booster vaccines every 6 weeks. Primary endpoints were safety and T-cell responses against the GAA epitopes, assessed by enzyme-linked immunosorbent spot (ELISPOT) analysis. Treatment response was evaluated clinically and by magnetic resonance imaging. Twelve children were enrolled, 6 with glioblastoma, 5 with anaplastic astrocytoma, and one with malignant gliomatosis cerebri. No dose-limiting non-CNS toxicity was encountered. ELISPOT analysis, in ten children, showed GAA responses in 9: to IL13Rα2 in 4, EphA2 in 9, and survivin in 3. One child had presumed symptomatic pseudoprogression, discontinued vaccine therapy, and responded to subsequent treatment. One other child had a partial response that persisted throughout 2 years of vaccine therapy, and continues at >39 months. Median progression-free survival (PFS) from the start of vaccination was 4.1 months and median overall survival (OS) was 12.9 months. 6-month PFS and OS were 33 and 73 %, respectively. GAA peptide vaccination in children with recurrent malignant gliomas is generally well tolerated, and has preliminary evidence of immunological and modest clinical activity.
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Bouffet E, Allen JC, Boyett JM, Yates A, Gilles F, Burger PC, Davis RL, Becker LE, Pollack IF, Finlay JL. The influence of central review on outcome in malignant gliomas of the spinal cord: the CCG-945 experience. J Neurosurg Pediatr 2016; 17:453-9. [PMID: 26684767 PMCID: PMC5040185 DOI: 10.3171/2015.10.peds1581] [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: 11/06/2022]
Abstract
OBJECT The impact of central pathology review on outcome has been described in pediatric patients with high-grade glioma (HGG). The objective of this report was to analyze the impact of the central pathology review on outcome in the subgroup of patients with institutional diagnosis of HGG of the spinal cord enrolled in the Children's Cancer Group 945 cooperative study. METHODS Five neuropathologists centrally reviewed the pathology of the 18 patients with HGG of the spinal cord who were enrolled in the study. These reviews were independent, and reviewers were blinded to clinical history and outcomes. A consensus diagnosis was established for each patient, based on the outcome of the review. RESULTS Of 18 patients, only 10 were confirmed to have HGG on central review. At a median follow-up of 12 years, event-free and overall survival for all 18 patients was 43.2% ± 13.3% and 50% ± 13.4%, respectively. After central review, 10-year event-free and overall survival for confirmed HGGs and discordant diagnoses was 30% ± 12.5% versus 58.3% ± 18.8% (p = 0.108) and 30% ± 12.5% versus 75% ± 14.2% (p = 0.0757), respectively. CONCLUSIONS The level of discordant diagnoses in children and adolescents with institutional diagnosis of HGG of the spinal cord was 44% in this experience. However, there was no significant difference in outcome between patients with confirmed and discordant diagnosis. This group of tumor deserves a specific attention in future trials.
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Affiliation(s)
- Eric Bouffet
- The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | | | - James M. Boyett
- Biostatistics, Saint Jude Children’s Research Hospital, Memphis, Tennessee
| | - Allen Yates
- Department of Pathology, The Ohio State University, Columbus, Ohio
| | - Floyd Gilles
- Department of Pathology, Children’s Hospital Los Angeles, California
| | - Peter C. Burger
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard L. Davis
- Department of Pathology, University of California, San Francisco, California
| | - Laurence E. Becker
- Department of Pathology, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Ian F. Pollack
- Department of Neurosurgery, Children’s Hospital of Pittsburgh, Pennsylvania
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A pilot study of bevacizumab-based therapy in patients with newly diagnosed high-grade gliomas and diffuse intrinsic pontine gliomas. J Neurooncol 2015; 127:53-61. [PMID: 26626490 DOI: 10.1007/s11060-015-2008-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 11/22/2015] [Indexed: 01/09/2023]
Abstract
Although bevacizumab has not proven effective in adults with newly diagnosed high-grade gliomas (HGG), feasibility in newly diagnosed children with diffuse intrinsic pontine gliomas (DIPG) or HGG has not been reported in a prospective study. In a safety and feasibility study, children and young adults with newly diagnosed HGG received radiotherapy (RT) with bevacizumab (10 mg/kg: days 22, 36) and temozolomide (75-90 mg/m(2)/day for 42 days) followed by bevacizumab (10 mg/kg, days 1, 15), irinotecan (125 mg/m(2), days 1, 15) and temozolomide (150 mg/m(2)/day days 1-5). DIPG patients did not receive temozolomide. Telomerase activity, quality of life (QOL), and functional outcomes were assessed. Among 27 eligible patients (15 DIPG, 12 HGG), median age 10 years (range 3-29 years), 6 discontinued therapy for toxicity: 2 during RT (grade 4 thrombocytopenia, grade 3 hepatotoxicity) and 4 during maintenance therapy (grade 3: thrombosis, hypertension, skin ulceration, and wound dehiscence). Commonest ≥grade 3 toxicities included lymphopenia, neutropenia and leukopenia. Grade 3 hypertension occurred in 2 patients. No intracranial hemorrhages occurred. For DIPG patients, median overall survival (OS) was 10.4 months. For HGG patients, 3-year progression free survival and OS were 33 % (SE ± 14 %) and 50 % (SE ± 14 %), respectively. All 3 tested tumor samples, demonstrated histone H3.3K27M (n = 2 DIPG) or G34R (n = 1 HGG) mutations. QOL scores improved over the course of therapy. A bevacizumab-based regimen is feasible and tolerable in newly diagnosed children and young adults with HGG and DIPG.
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14
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Laprie A, Hu Y, Alapetite C, Carrie C, Habrand JL, Bolle S, Bondiau PY, Ducassou A, Huchet A, Bertozzi AI, Perel Y, Moyal É, Balosso J. Paediatric brain tumours: A review of radiotherapy, state of the art and challenges for the future regarding protontherapy and carbontherapy. Cancer Radiother 2015; 19:775-89. [PMID: 26548600 DOI: 10.1016/j.canrad.2015.05.028] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 05/18/2015] [Accepted: 05/21/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Brain tumours are the most frequent solid tumours in children and the most frequent radiotherapy indications in paediatrics, with frequent late effects: cognitive, osseous, visual, auditory and hormonal. A better protection of healthy tissues by improved beam ballistics, with particle therapy, is expected to decrease significantly late effects without decreasing local control and survival. This article reviews the scientific literature to advocate indications of protontherapy and carbon ion therapy for childhood central nervous system cancer, and estimate the expected therapeutic benefits. MATERIALS AND METHODS A systematic review was performed on paediatric brain tumour treatments using Medline (from 1966 to March of 2014). To be included, clinical trials had to meet the following criteria: age of patients 18 years or younger, treated with radiation, and report of survival. Studies were also selected according to the evidence level. A secondary search of cited references found other studies about cognitive functions, quality of life, the comparison of photon and proton dosimetry showing potential dose escalation and/or sparing of organs at risk with protontherapy; and studies on dosimetric and technical issues related to protontherapy. RESULTS A total of 7051 primary references published were retrieved, among which 40 clinical studies and 60 papers about quality of life, dose distribution and dosimetry were analysed, as well as the ongoing clinical trials. These papers have been summarized and reported in a specific document made available to the participants of a final 1-day workshop. Tumours of the meningeal envelop and bony cranial structures were excluded from the analysis. Protontherapy allows outstanding ballistics to target the tumour area, while substantially decreasing radiation dose to the normal tissues. There are many indications of protontherapy for paediatric brain tumours in curative intent, either for localized treatment of ependymomas, germ-cell tumours, craniopharyngiomas, low-grade gliomas; or panventricular irradiation of pure non-secreting germinoma; or craniospinal irradiation of medulloblastomas and metastatic pure germinomas. Carbon ion therapy is just emerging and may be studied for highly aggressive and radioresistant tumours, as an initial treatment for diffuse brainstem gliomas, and for relapse of high-grade gliomas. CONCLUSION Both protontherapy and carbon ion therapy are promising for paediatric brain tumours. The benefit of decreasing late effects without altering survival has been described for most paediatric brain tumours with protontherapy and is currently assessed in ongoing clinical trials with up-to-date proton devices. Unfortunately, in 2015, only a minority of paediatric patients in France can receive protontherapy due to the lack of equipment.
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Affiliation(s)
- A Laprie
- Université Paul-Sabatier, Toulouse, France; Institut Claudius-Regaud, institut universitaire du cancer de Toulouse (IUCT)-Oncopole, radiation oncology, 1, avenue Irene-Joliot-Curie, 31059 Toulouse, France; Périclès-France-Hadron, Toulouse, France.
| | - Y Hu
- GCS-Étoile-France-Hadron, Lyon, France
| | - C Alapetite
- Institut Curie Paris Orsay (ICPO)-France-Hadron, Orsay, France
| | - C Carrie
- GCS-Étoile-France-Hadron, Lyon, France; Centre Léon-Bérard, Lyon, France
| | - J-L Habrand
- Institut Curie Paris Orsay (ICPO)-France-Hadron, Orsay, France; Université Paris Sud, Orsay, France; Archade-France-Hadron, Caen, France; Centre François-Baclesse, Caen, France; Gustave-Roussy, Villejuif, France
| | - S Bolle
- Institut Curie Paris Orsay (ICPO)-France-Hadron, Orsay, France; Impact-France-Hadron, Nice, France
| | - P-Y Bondiau
- Centre Antoine-Lacassagne, Nice, France; CHU de Bordeaux, Bordeaux, France
| | - A Ducassou
- Institut Claudius-Regaud, institut universitaire du cancer de Toulouse (IUCT)-Oncopole, radiation oncology, 1, avenue Irene-Joliot-Curie, 31059 Toulouse, France; Périclès-France-Hadron, Toulouse, France
| | - A Huchet
- Hôpital des Enfants, Toulouse, France
| | - A-I Bertozzi
- Périclès-France-Hadron, Toulouse, France; Université Grenoble Alpes, Grenoble, France
| | - Y Perel
- Université Grenoble Alpes, Grenoble, France
| | - É Moyal
- Université Paul-Sabatier, Toulouse, France; Institut Claudius-Regaud, institut universitaire du cancer de Toulouse (IUCT)-Oncopole, radiation oncology, 1, avenue Irene-Joliot-Curie, 31059 Toulouse, France; Périclès-France-Hadron, Toulouse, France
| | - J Balosso
- GCS-Étoile-France-Hadron, Lyon, France; CHU de Grenoble, Grenoble, France
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Patterns of progression in pediatric patients with high-grade glioma or diffuse intrinsic pontine glioma treated with Bevacizumab-based therapy at diagnosis. J Neurooncol 2014; 121:591-8. [DOI: 10.1007/s11060-014-1671-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 11/23/2014] [Indexed: 12/11/2022]
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Abt NB, Bydon M, De la Garza-Ramos R, McGovern K, Olivi A, Huang J, Bydon A. Concurrent neoadjuvant chemotherapy is an independent risk factor of stroke, all-cause morbidity, and mortality in patients undergoing brain tumor resection. J Clin Neurosci 2014; 21:1895-900. [DOI: 10.1016/j.jocn.2014.05.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 05/11/2014] [Indexed: 11/30/2022]
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17
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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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Pollack IF, Jakacki RI, Butterfield LH, Hamilton RL, Panigrahy A, Potter DM, Connelly AK, Dibridge SA, Whiteside TL, Okada H. Antigen-specific immune responses and clinical outcome after vaccination with glioma-associated antigen peptides and polyinosinic-polycytidylic acid stabilized by lysine and carboxymethylcellulose in children with newly diagnosed malignant brainstem and nonbrainstem gliomas. J Clin Oncol 2014; 32:2050-8. [PMID: 24888813 DOI: 10.1200/jco.2013.54.0526] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Diffuse brainstem gliomas (BSGs) and other high-grade gliomas (HGGs) of childhood carry a dismal prognosis despite current treatments, and new therapies are needed. Having identified a series of glioma-associated antigens (GAAs) commonly overexpressed in pediatric gliomas, we initiated a pilot study of subcutaneous vaccinations with GAA epitope peptides in HLA-A2-positive children with newly diagnosed BSG and HGG. PATIENTS AND METHODS GAAs were EphA2, interleukin-13 receptor alpha 2 (IL-13Rα2), and survivin, and their peptide epitopes were emulsified in Montanide-ISA-51 and given every 3 weeks with intramuscular polyinosinic-polycytidylic acid stabilized by lysine and carboxymethylcellulose for eight courses, followed by booster vaccinations every 6 weeks. Primary end points were safety and T-cell responses against vaccine-targeted GAA epitopes. Treatment response was evaluated clinically and by magnetic resonance imaging. RESULTS Twenty-six children were enrolled, 14 with newly diagnosed BSG treated with irradiation and 12 with newly diagnosed BSG or HGG treated with irradiation and concurrent chemotherapy. No dose-limiting non-CNS toxicity was encountered. Five children had symptomatic pseudoprogression, which responded to dexamethasone and was associated with prolonged survival. Only two patients had progressive disease during the first two vaccine courses; 19 had stable disease, two had partial responses, one had a minor response, and two had prolonged disease-free status after surgery. Enzyme-linked immunosorbent spot analysis in 21 children showed positive anti-GAA immune responses in 13: to IL-13Rα2 in 10, EphA2 in 11, and survivin in three. CONCLUSION GAA peptide vaccination in children with gliomas is generally well tolerated and has preliminary evidence of immunologic and clinical responses. Careful monitoring and management of pseudoprogression is essential.
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Affiliation(s)
- Ian F Pollack
- All authors: University of Pittsburgh, Pittsburgh, PA.
| | | | | | | | | | | | | | | | | | - Hideho Okada
- All authors: University of Pittsburgh, Pittsburgh, PA
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Mathew RK, O'Kane R, Parslow R, Stiller C, Kenny T, Picton S, Chumas PD. Comparison of survival between the UK and US after surgery for most common pediatric CNS tumors. Neuro Oncol 2014; 16:1137-45. [PMID: 24799454 DOI: 10.1093/neuonc/nou056] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We report a population-based study examining long-term outcomes for common pediatric CNS tumors comparing results from the UK with the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) data set and with the literature. No such international study has previously been reported. METHODS Data between 1996 and 2005 from the UK National Registry of Childhood Tumours (NRCT) and the SEER registry were analyzed. We calculated actuarial survival at each time point from histological diagnosis, with death from any cause as the endpoint. Kaplan-Meier estimation and log-rank testing (Cox proportional hazards regression analysis) were used to calculate survival differences among tumor subtypes, adjusting for age at diagnosis. RESULTS Population-based outcomes for each tumor type are presented. Overall age-adjusted survival, stratifying for histology (combining pilocytic astrocytoma, anaplastic astrocytoma, glioblastoma, primitive neuroectodermal tumor, medulloblastoma, and ependymoma), is significantly lower for NRCT than SEER (hazard ratio 0.71, P < .001) and at 1, 5, and 10 years. Both NRCT and SEER outcomes are worse than those reported from trials. CONCLUSION Analyzing data from comprehensive registries minimizes bias associated with trials and institutional studies. The reasons for the poorer outcomes in children treated in the UK are unclear. Likewise, the differences in outcomes between patients in trials and those not in trials need further investigation. We recommend that all children with CNS tumors be recruited into studies-even if these are observational studies. We also suggest that registries be suitably funded to publish independent outcome data (including morbidity) at both a national and an institutional level.
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Affiliation(s)
- Ryan Koshy Mathew
- Department of Neurosurgery, General Infirmary at Leeds, Leeds, UK (R.K.M.); Department of Neurosurgery, Royal Hospital for Sick Children, Glasgow, UK (R.O.); Division of Epidemiology and Biostatistics, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds, UK (R.P.); Childhood Cancer Research Group, Headington, Oxford, UK (C.S.); National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, University of Southampton, Southampton, UK (T.K.); Department of Paediatric Oncology, General Infirmary at Leeds, Leeds, UK (S.P.); Department of Neurosurgery, General Infirmary at Leeds, Leeds, UK (P.D.C.)
| | - Roddy O'Kane
- Department of Neurosurgery, General Infirmary at Leeds, Leeds, UK (R.K.M.); Department of Neurosurgery, Royal Hospital for Sick Children, Glasgow, UK (R.O.); Division of Epidemiology and Biostatistics, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds, UK (R.P.); Childhood Cancer Research Group, Headington, Oxford, UK (C.S.); National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, University of Southampton, Southampton, UK (T.K.); Department of Paediatric Oncology, General Infirmary at Leeds, Leeds, UK (S.P.); Department of Neurosurgery, General Infirmary at Leeds, Leeds, UK (P.D.C.)
| | - Roger Parslow
- Department of Neurosurgery, General Infirmary at Leeds, Leeds, UK (R.K.M.); Department of Neurosurgery, Royal Hospital for Sick Children, Glasgow, UK (R.O.); Division of Epidemiology and Biostatistics, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds, UK (R.P.); Childhood Cancer Research Group, Headington, Oxford, UK (C.S.); National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, University of Southampton, Southampton, UK (T.K.); Department of Paediatric Oncology, General Infirmary at Leeds, Leeds, UK (S.P.); Department of Neurosurgery, General Infirmary at Leeds, Leeds, UK (P.D.C.)
| | - Charles Stiller
- Department of Neurosurgery, General Infirmary at Leeds, Leeds, UK (R.K.M.); Department of Neurosurgery, Royal Hospital for Sick Children, Glasgow, UK (R.O.); Division of Epidemiology and Biostatistics, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds, UK (R.P.); Childhood Cancer Research Group, Headington, Oxford, UK (C.S.); National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, University of Southampton, Southampton, UK (T.K.); Department of Paediatric Oncology, General Infirmary at Leeds, Leeds, UK (S.P.); Department of Neurosurgery, General Infirmary at Leeds, Leeds, UK (P.D.C.)
| | - Tom Kenny
- Department of Neurosurgery, General Infirmary at Leeds, Leeds, UK (R.K.M.); Department of Neurosurgery, Royal Hospital for Sick Children, Glasgow, UK (R.O.); Division of Epidemiology and Biostatistics, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds, UK (R.P.); Childhood Cancer Research Group, Headington, Oxford, UK (C.S.); National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, University of Southampton, Southampton, UK (T.K.); Department of Paediatric Oncology, General Infirmary at Leeds, Leeds, UK (S.P.); Department of Neurosurgery, General Infirmary at Leeds, Leeds, UK (P.D.C.)
| | - Susan Picton
- Department of Neurosurgery, General Infirmary at Leeds, Leeds, UK (R.K.M.); Department of Neurosurgery, Royal Hospital for Sick Children, Glasgow, UK (R.O.); Division of Epidemiology and Biostatistics, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds, UK (R.P.); Childhood Cancer Research Group, Headington, Oxford, UK (C.S.); National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, University of Southampton, Southampton, UK (T.K.); Department of Paediatric Oncology, General Infirmary at Leeds, Leeds, UK (S.P.); Department of Neurosurgery, General Infirmary at Leeds, Leeds, UK (P.D.C.)
| | - Paul Dominic Chumas
- Department of Neurosurgery, General Infirmary at Leeds, Leeds, UK (R.K.M.); Department of Neurosurgery, Royal Hospital for Sick Children, Glasgow, UK (R.O.); Division of Epidemiology and Biostatistics, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds, UK (R.P.); Childhood Cancer Research Group, Headington, Oxford, UK (C.S.); National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, University of Southampton, Southampton, UK (T.K.); Department of Paediatric Oncology, General Infirmary at Leeds, Leeds, UK (S.P.); Department of Neurosurgery, General Infirmary at Leeds, Leeds, UK (P.D.C.)
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O'Halloran PJ, Farrell M, Caird J, Capra M, O'Brien D. Paediatric spinal glioblastoma: case report and review of therapeutic strategies. Childs Nerv Syst 2013; 29:367-74. [PMID: 23319103 DOI: 10.1007/s00381-013-2023-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 01/03/2013] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Although uncommon, there is significant morbidity and mortality associated with paediatric spinal glioblastoma. The paucity of cases makes treatment options difficult. The current recommended standard of care is biopsy followed by adjuvant chemo-radiotherapy, with emerging data supporting the role of safe gross total resection. OBJECTIVE The purpose of this paper is to provide a single-institution case study and to discuss current and future therapeutic treatment strategies. CASE PRESENTATION A 14-year-old boy presented with a 2-year history of intermittent back pain with recent progressively worsening motor and sensory deficits of the right side. Pre-operative MRI revealed an enhancing intra-medullary tumour extending from C2 to C7. During the operative case, no tumour-cord margin could be identified, and the patient underwent a subtotal excision. Histopathology confirmed glioblastoma. In the subsequent weeks, the patient's clinical condition deteriorated. Adjuvant therapy was declined by the family, and the patient died 9 weeks after initial presentation. CONCLUSION Despite major advances in surgical techniques, peri-operative neuro-imaging as well as chemo-radiotherapy, the prognosis of a paediatric intra-medullary high-grade spinal tumour remains poor. Detailed analysis of our understanding of tumour dynamics in this patient group is important in establishing future therapeutic strategies.
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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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Bode U, Massimino M, Bach F, Zimmermann M, Khuhlaeva E, Westphal M, Fleischhack G. Nimotuzumab treatment of malignant gliomas. Expert Opin Biol Ther 2012; 12:1649-59. [PMID: 23043252 DOI: 10.1517/14712598.2012.733367] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION In spite of new alkylating medication and recently accumulated knowledge about genomics, the prognosis of malignant gliomas remains poor. The introduction of single substances interfering with tumour proliferation dynamics has been disappointing and the lessons learned indicate that a complicated network of proliferation needs time consuming, in-depth analysis in order to more specifically treat now distinguishable subgroups of a disease, which too long was thought of as a uniform entity. AREAS COVERED The clinical trials using the EGFR antibody nimotuzumab in the treatment of malignant gliomas are reviewed. Pending conformation in future studies the antibody might be part of the treatment of MGMT-negative, EGFR-amplified, not completely resected gliomas of adulthood and juvenile DIPG (pontine gliomas). Upcoming genomic results of the different tumour entities may suggest certain combination partners of the antibody. Recent studies of nimotuzumab indicate the reason for the lack of toxicity, which is the most attractive argument for its clinical use besides modest efficacy. EXPERT OPINION We await the final results on the use of the antibody together with vinorelbine and radiation therapy for the therapy of DIPG. Adult patients with MGMT-negative, EGFR amplified, not totally resected GBM may also profit from this combination therapy. TK-inhibitors combined with the antibody and irradiation may be an option for a therapeutic trial in paediatric patients.
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Affiliation(s)
- Udo Bode
- University of Bonn Medical School, Department Paed. Haematology/Oncology, Bonn, Germany.
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Brain tumors in children--current therapies and newer directions. Indian J Pediatr 2012; 79:922-7. [PMID: 22294272 DOI: 10.1007/s12098-012-0689-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 01/11/2012] [Indexed: 10/14/2022]
Abstract
Brain tumors are the second most common malignancy and the major cause of cancer related mortality in children. Though significant advances in neuroimaging, neurosurgery, radiation therapy and chemotherapy have evolved over the years, overall survival rate remains less than 75%. Malignant gliomas, high risk medulloblastoma with recurrence and infant brain tumors continue to be a major cause of therapeutic frustration. Even today diffuse pontine gliomas are universally fatal. Though tumors like low grade glioma have an overall excellent survival, recurrences and progression in eloquent areas pose therapeutic challenges. As research continues to unravel the biology including key molecules and signaling pathways responsible for the oncogenesis of different childhood brain tumors, novel targeted therapies are profiled. Identification of major targets like the Epidermal Growth factor Receptor (EGFR), Platelet Derived Growth Factor Receptor (PDGFR), Vascular Endothelial Growth factor (VEGF) and key signaling pathways like the MAPK and PI3K/Akt/mTOR has enabled us over the recent years to better understand tumor behavior and design tailored therapy. These efforts have improved overall survival of children with brain tumors. This review article discusses the current status of common brain tumors in children and the newer therapeutic approaches.
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Marcus L, Murphy R, Fox E, McCully C, Cruz R, Warren KE, Meyer T, McNiff E, Balis FM, Widemann BC. The plasma and cerebrospinal fluid pharmacokinetics of the platinum analog satraplatin after intravenous administration in non-human primates. Cancer Chemother Pharmacol 2012; 69:247-52. [PMID: 21706317 PMCID: PMC6300136 DOI: 10.1007/s00280-011-1659-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2010] [Accepted: 04/14/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Satraplatin is an orally bioavailable platinum analog with preclinical activity in cisplatin resistant models and clinical activity in adults with refractory cancers. The cerebrospinal fluid (CSF) penetration of cisplatin and carboplatin in non-human primates (NHP) is limited (3.7 and 2.6%, respectively). We evaluated the plasma and CSF pharmacokinetics (PK) of satraplatin after an intravenous (IV) dose in NHP. METHODS Satraplatin (120 mg/m(2)) was administered as 1 h IV infusion in DMSO (5%) and normal saline to 5 NHP. Serial blood and CSF samples were obtained over 48 h. Plasma ultrafiltrate (UF) was immediately prepared by centrifugation. Platinum was quantified in plasma UF and CSF using a validated atomic absorption spectroscopy assay with lower limit of quantification (LLQ) of 0.025 μM in UF and 0.006 μM after concentration in CSF. Pharmacokinetic parameters were estimated using non-compartmental analyses. CSF penetration was calculated from the CSF AUC(0-48h) : plasma UF AUC(0-48h). RESULTS Satraplatin was well tolerated. Median (range) PK parameters in plasma UF were: maximum concentration (C (max)) 8.3 μM (5.7-10.6), area under the curve (AUC(0-48h)) 29.2 μM h (22.6-33.2), clearance 0.36 l/h/kg (0.31-0.37), and t (1/2) 18.8 h (13.4-25). Satraplatin was detected in the CSF of all NHP. Median (range) PK parameters in CSF were: C (max) 0.07 μM (0.02-0.12), AUC(0-48h) 1.2 μM h (0.49-2.43). The median (range) CSF penetration of satraplatin was 4.3% (2.2-7.4). CONCLUSIONS Satraplatin penetration into CSF is similar to that of carboplatin and cisplatin, despite its greater lipophilicity. The development of a phase I trial of satraplatin for refractory childhood solid tumors including brain tumors is in progress.
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Affiliation(s)
- Leigh Marcus
- National Cancer Institute, Pediatric Oncology Branch, 10 Center Drive, Building 10-CRC, Room 1-5742, Bethesda, MD 20892-1101, USA.
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Bhat S, Yadav SP, Suri V, Patir R, Kurkure P, Kellie S, Sachdeva A. Management of childhood brain tumors: consensus report by the Pediatric Hematology Oncology (PHO) Chapter of Indian Academy of Pediatrics (IAP). Indian J Pediatr 2011; 78:1510-9. [PMID: 21695381 DOI: 10.1007/s12098-011-0421-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 04/06/2011] [Indexed: 11/29/2022]
Abstract
Brain tumors are the second most common childhood tumors and remain the leading cause of cancer related deaths in children. Appropriate diagnosis and management of these tumors are essential to improve survival. There are no clinical practical guidelines available for the management of brain tumors in India. This document is a consensus report prepared after a National Consultation on Pediatric Brain Tumors held in Delhi on 06 Nov 2008. The meeting was attended by eminent experts from all over the country, in the fields of Neurosurgery, Radiation Oncology, Pediatric Oncology, Neuropathology, Diagnostic Imaging, Pediatric Endocrinology and Allied Health Professionals. This article highlights that physicians looking after children with brain tumors should work as part of a multidisciplinary team to improve the survival, quality of life, neuro-cognitive outcomes and standards of care for children with brain tumors. Recommendations for when to suspect, diagnostic workup, initial management, long-term follow up and specific management of individual tumors are outlined.
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Affiliation(s)
- Sunil Bhat
- Pediatric Hematology Oncology and BMT Unit, Sir Ganga Ram Hospital, Delhi, India
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MacDonald TJ, Aguilera D, Kramm CM. Treatment of high-grade glioma in children and adolescents. Neuro Oncol 2011; 13:1049-58. [PMID: 21784756 PMCID: PMC3177659 DOI: 10.1093/neuonc/nor092] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 05/20/2011] [Indexed: 12/15/2022] Open
Abstract
Pediatric high-grade gliomas (HGGs)--including glioblastoma multiforme, anaplastic astrocytoma, and diffuse intrinsic pontine glioma--are difficult to treat and are associated with an extremely poor prognosis. There are no effective chemotherapeutic regimens for the treatment of pediatric HGG, but many new treatment options are in active investigation. There are crucial molecular differences between adult and pediatric HGG such that results from adult clinical trials cannot simply be extrapolated to children. Molecular markers overexpressed in pediatric HGG include PDGFRα and P53. Amplification of EGFR is observed, but to a lesser degree than in adult HGG. Potential molecular targets and new therapies in development for pediatric HGG are described in this review. Research into bevacizumab in pediatric HGG indicates that its activity is less than that observed in adult HGG. Similarly, tipifarnib was found to have minimal activity in pediatric HGG, whereas gefitinib has shown greater effects. After promising phase I findings in children with primary CNS tumors, the integrin inhibitor cilengitide is being investigated in a phase II trial in pediatric HGG. Studies are also ongoing in pediatric HGG with 2 EGFR inhibitors: cetuximab and nimotuzumab. Other novel treatment modalities under investigation include dendritic cell-based vaccinations, boron neutron capture therapy, and telomerase inhibition. While the results of these trials are keenly awaited, the current belief is that multimodal therapy holds the greatest promise. Research efforts should be directed toward building multitherapeutic regimens that are well tolerated and that offer the greatest antitumor activity in the setting of pediatric HGG.
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Affiliation(s)
- T J MacDonald
- Aflac Cancer Center and Blood Disorders Service, Children's Healthcare of Atlanta, Emory University School of Medicine, Emory Children's Center, 2015 Uppergate Drive, Suite 442, Atlanta, GA 30322 USA.
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Pollack IF. Multidisciplinary management of childhood brain tumors: a review of outcomes, recent advances, and challenges. J Neurosurg Pediatr 2011; 8:135-48. [PMID: 21806354 DOI: 10.3171/2011.5.peds1178] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECT Brain tumors are the most common category of childhood solid tumors. In the 1970s and 1980s, treatment protocols for benign tumors focused almost exclusively on surgery, with radiation treatment as a salvage modality, whereas the management of malignant tumors employed a combination of surgery, radiation therapy, and chemotherapy, with therapeutic approaches such as "8-in-1" chemotherapy often applied across histological tumor subsets that are now recognized to be prognostically distinct. During the ensuing years, treatment has become increasingly refined, based on clinical and, more recently, molecular factors, which have supported risk-adapted treatment stratification. The goal of this report is to provide an overview of recent progress in the field. METHODS A review of the literature was undertaken to examine recent advances in the management of the most common childhood brain tumor subsets, and in particular to identify instances in which molecular categorization and treatment stratification offer evidence or promise for improving outcome. RESULTS For both medulloblastomas and infant tumors, refinements in clinical and molecular stratification have already facilitated efforts to achieve risk-adapted treatment planning. Current treatment strategies for children with these tumors focus on improving outcome for tumor subsets that have historically been relatively resistant to therapy and reducing treatment-related sequelae for children with therapy-responsive tumors. Recent advances in molecular categorization offer the promise of further refinements in future studies. For children with ependymomas and low-grade gliomas, clinical risk stratification has facilitated tailored approaches to therapy, with improvement of disease control and concomitant reduction in treatment sequelae, and recent discoveries have identified promising therapeutic targets for molecularly based therapy. In contrast, the prognosis remains poor for children with diffuse intrinsic pontine gliomas and other high-grade gliomas, despite recent identification of biological correlates of tumor prognosis and elucidation of molecular substrates of tumor development. CONCLUSIONS Advances in the clinical and molecular stratification for many types of childhood brain tumors have provided a foundation for risk-adapted treatment planning and improvements in outcome. In some instances, molecular characterization approaches have also yielded insights into new therapeutic targets. For other tumor types, outcome remains discouraging, although new information regarding the biological features critical to tumorigenesis are being translated into novel therapeutic approaches that hold promise for future improvements.
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Affiliation(s)
- Ian F Pollack
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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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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Abstract
High-grade gliomas and diffuse brainstem gliomas carry a very poor prognosis despite current therapies, and account together for the largest number of deaths in children with brain tumors. Many of these tumors have been found to overexpress the EGF receptor (EGFR). Nimotuzumab (h-R3) is a humanized monoclonal antibody against the EGFR, and consequently inhibits tyrosine kinase activation. In vitro and in vivo studies have supported the antiproliferative, antiangiogenic, pro-apoptotic and radiosensitizing activities of nimotuzumab. Emerging trials suggest a promising role for nimotuzumab as a therapeutic agent in patients with high-grade gliomas. This review attempts to provide a context for the evolving interest and evidence for nimotuzumab in pediatric glioma.
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Affiliation(s)
- Catherine Lam
- The Hospital for Sick Children, Division for Haematology/Oncology, Toronto, Canada
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Spinal cord astrocytomas: rare but life-threatening tumors in children. JAAPA 2009; 22:37-41. [PMID: 19601448 DOI: 10.1097/01720610-200906000-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mueller S, Chang S. Pediatric brain tumors: current treatment strategies and future therapeutic approaches. Neurotherapeutics 2009; 6:570-86. [PMID: 19560746 PMCID: PMC5084192 DOI: 10.1016/j.nurt.2009.04.006] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Revised: 04/11/2009] [Accepted: 04/13/2009] [Indexed: 01/19/2023] Open
Abstract
Pediatric CNS tumors are the most common solid tumors of childhood and the second most common cancer after hematological malignancies accounting for approximate 20 to 25% of all primary pediatric tumors. With over 3,000 new cases per year in the United States, childhood CNS tumors are the leading cause of death related to cancer in this population. The prognosis for these patients has improved over the last few decades, but current therapies continue to carry a high risk of significant side effects, especially for the very young. Currently a combination of surgery, radiation, and chemotherapy is often used in children greater than 3 years of age. This article will outline current and future therapeutic strategies for the most common pediatric CNS tumors, including primitive neuroectodermal tumors such as medulloblastoma, as well as astrocytomas and ependymomas.
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Affiliation(s)
- Sabine Mueller
- Department of Neurology, Division of Child Neurology, University of San Francisco, San Francisco, California, USA.
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Friedman GK, Pressey JG, Reddy AT, Markert JM, Gillespie GY. Herpes simplex virus oncolytic therapy for pediatric malignancies. Mol Ther 2009; 17:1125-35. [PMID: 19367259 DOI: 10.1038/mt.2009.73] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Despite improving survival rates for children with cancer, a subset of patients exist with disease resistant to traditional therapies such as surgery, chemotherapy, and radiation. These patients require newer, targeted treatments used alone or in combination with more traditional approaches. Oncolytic herpes simplex virus (HSV) is one of these newer therapies that offer promise for several difficult to treat pediatric malignancies. The potential benefit of HSV therapy in pediatric solid tumors including brain tumors, neuroblastomas, and sarcomas is reviewed along with the many challenges that need to be addressed prior to moving oncolytic HSV therapy from the laboratory to the beside in the pediatric population.
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Affiliation(s)
- Gregory K Friedman
- Department of Pediatrics, Children's Hospital of Alabama, University of Alabama at Birmingham, USA.
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Pollack IF. Diagnostic and therapeutic stratification of childhood brain tumors: implications for translational research. J Child Neurol 2008; 23:1179-85. [PMID: 18952584 PMCID: PMC3674757 DOI: 10.1177/0883073808321770] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Recent advances in the categorization of childhood brain tumors have improved risk-based treatment planning. In several instances, new therapeutic strategies that incorporate these advances have resulted in meaningful improvements in progression-free and overall survival. Current studies are directed at further refining therapy based on clinical, biological, and molecular data; testing the effectiveness of a number of novel therapeutic strategies for high-risk tumors; and examining approaches to reduce sequelae of treatment among more favorable-risk tumor subsets. Because multiple tumor subtypes are individually relatively uncommon, most such studies are being conducted by large co-operative groups, such as the Children's Oncology Group, or by smaller brain tumor-focused consortia, such as the Pediatric Brain Tumor Consortium.
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Affiliation(s)
- Ian F. Pollack
- Department of Neurosurgery, Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Abstract
The management of childhood brain tumors, which consist of many different histological subtypes, continues to be a challenge. Outcome, measured not only by survival rates but also by the effects of disease and therapy on quality of life, has improved over the past two decades for some tumor types, most notably medulloblastomas. For others, however, there has been little progress, and quality of life for long-term survivors remains suboptimal. Because of advances in our understanding of the biology underlying childhood brain tumors, treatments may change dramatically in the years ahead. Accordingly, survival rates may improve and long-term sequelae lessen.
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Affiliation(s)
- Roger J. Packer
- Center of Excellence for Neuroscience and Behavioral Medicine, Division of Child Neurology, Children's National Medical Center, Washington, DC
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Thorarinsdottir HK, Santi M, McCarter R, Rushing EJ, Cornelison R, Jales A, MacDonald TJ. Protein expression of platelet-derived growth factor receptor correlates with malignant histology and PTEN with survival in childhood gliomas. Clin Cancer Res 2008; 14:3386-94. [PMID: 18519768 PMCID: PMC2953416 DOI: 10.1158/1078-0432.ccr-07-1616] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE We previously showed that overexpression of epidermal growth factor receptor (EGFR) is associated with malignant grade in childhood glioma. The objective of this study was to determine whether protein expression of EGFR or platelet-derived growth factor receptor (PDGFR) and their active signaling pathways are related to malignant histology, progression of disease, and worse survival. EXPERIMENTAL DESIGN Tissue microarrays were prepared from untreated tumors from 85 new glioma patients [22 high-grade gliomas (HGG) and 63 low-grade gliomas (LGG)] diagnosed at this institution from 1989 to 2004. Immunohistochemistry was used to assess total expression of EGFR, PDGFR beta, and PTEN and expression of phosphorylated EGFR, phosphorylated PDGFR alpha (p-PDGFR alpha), phosphorylated AKT, phosphorylated mitogen-activated protein kinase, and phosphorylated mammalian target of rapamycin. These results were correlated with clinicopathologic data, including extent of initial tumor resection, evidence of dissemination, tumor grade, proliferation index, and survival, as well as with Affymetrix gene expression profiles previously obtained from a subset of these tumors. RESULTS High expression of p-PDGFR alpha, EGFR, PDGFR beta, and phosphorylated EGFR was seen in 85.7%, 80.0%, 78.9%, and 47.4% of HGG and 40.0%, 87.1%, 41.7%, and 30.6% of LGG, respectively. However, high expression of p-PDGFR alpha and PDGFR beta was the only significant association with malignant histology (P = 0.031 and 0.005, respectively); only the loss of PTEN expression was associated with worse overall survival. None of these targets, either alone or in combination, was significantly associated with progression-free survival in either LGG or HGG. CONCLUSIONS High PDGFR protein expression is significantly associated with malignant histology in pediatric gliomas, but it does not represent an independent prognostic factor. Deficient PTEN expression is associated with worse overall survival in HGG.
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Affiliation(s)
| | | | - Robert McCarter
- Division of Biostatistics, Children’s National Medical Center
| | | | - Robert Cornelison
- Institute for Biomedical Sciences, George Washington University
- Cancer Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | | | - Tobey J. MacDonald
- Division of Hematology-Oncology, Children’s National Medical Center
- Institute for Biomedical Sciences, George Washington University
- Center for Cancer and Immunology Research, Children’s Research Institute, Washington, District of Columbia
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Jakacki RI, Yates A, Blaney SM, Zhou T, Timmerman R, Ingle AM, Flom L, Prados MD, Adamson PC, Pollack IF. A phase I trial of temozolomide and lomustine in newly diagnosed high-grade gliomas of childhood. Neuro Oncol 2008; 10:569-76. [PMID: 18497327 DOI: 10.1215/15228517-2008-019] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A phase I trial was conducted to determine the maximum tolerated dose (MTD) of temozolomide given in combination with lomustine in newly diagnosed pediatric patients with high-grade gliomas. Response was assessed following two courses of therapy at the MTD. Temozolomide was administered to cohorts of patients at doses of 100, 125, 160, or 200 mg/m(2) on days 1-5, along with 90 mg/m(2) lomustine on day 1. Two courses of lomustine/temozolomide were given prior to radiation therapy (RT) and up to six courses were administered afterward. Thirty-two patients were enrolled. Dose-limiting myelosuppression was seen in two of three patients enrolled at the 200 mg/m(2) dose level. One of 14 patients in the expanded MTD cohort (160 mg/m(2)) experienced dose-limiting thrombocytopenia. After two courses at the MTD, one patient with a 5-mm enhancing nodule postoperatively had a complete response, one patient with a large residual temporal lobe glioblastoma had a partial response, and eight patients had stable disease. Several patients developed transient radiographic worsening after completing RT. Median 1- and 2-year overall survivals at the MTD were 60% +/- 13% and 40% +/- 13% with a median of 17.6 months. Thirteen of 20 patients (65%) who underwent MRI scans within 6 months prior to death developed metastatic disease. In conclusion, when administered with 90 mg/m(2) lomustine on day 1, the MTD of temozolomide is 160 mg/m(2)/day x 5. Radiographic changes following RT make determination of early tumor progression difficult. Metastatic disease is common prior to death.
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Shih CS, Hale GA, Gronewold L, Tong X, Laningham FH, Gilger EA, Srivastava DK, Kun LE, Gajjar A, Fouladi M. High-dose chemotherapy with autologous stem cell rescue for children with recurrent malignant brain tumors. Cancer 2008; 112:1345-53. [PMID: 18224664 DOI: 10.1002/cncr.23305] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND High-dose chemotherapy (HDCT) with autologous stem cell rescue (ASCR) has been reported to be effective in treating children with recurrent central nervous system (CNS) malignancies. METHODS To evaluate the efficacy and toxicities of HDCT and ASCR, the medical records of 27 children with recurrent CNS malignancies who received such therapy at St. Jude Children's Research Hospital between 1989 and 2004 were reviewed. RESULTS The median age at diagnosis was 4.5 years (range, 0.4-16.6 years) and that at ASCR was 6.7 years (range, 1.1-18.5 years). Diagnoses included medulloblastoma (13 patients), primitive neuroectodermal tumor (3 patients), pineoblastoma (2 patients), atypical teratoid rhabdoid tumor (2 patients), ependymoma (3 patients), anaplastic astrocytoma (2 patients), and glioblastoma multiforme (2 patients). The 5-year overall and progression-free survival (PFS) rates were 28.2% and 18.5%, respectively. The 5-year PFS rate for patients aged<3 years at diagnosis (57.1%) was significantly better than older patients (5.0%) (P=.019). Among the 6 long-term survivors (5 with M0 disease and 1 with M3 disease at diagnosis), 5 received both radiotherapy and HDCT as part of their salvage regimen; 4 were aged<3 years at diagnosis and had received chemotherapy only as part of frontline therapy. Two patients died of transplant-related toxicities; 44% experienced grade 3 or 4 transplant-related toxicities (toxicities were graded according to the National Cancer Institute Common Toxicity Criteria). CONCLUSIONS HDCT with ASCR is not an effective salvage strategy for older children with recurrent CNS malignancies. The significantly better outcome in the younger cohort was most likely related to the use of radiotherapy as part of the salvage strategy.
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Affiliation(s)
- Chie-Schin Shih
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Abstract
Central nervous system (CNS) tumors comprise 15% to 20% of all malignancies occurring in childhood and adolescence. They may present in a myriad of ways, often delaying diagnosis. Symptoms and signs depend on the growth rate of the tumor, its location in the central nervous system (CNS), and the age of the child. This article describes the presentation, diagnosis and management of these tumors.
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Affiliation(s)
- Roger J Packer
- Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, Washington, DC 20010, USA.
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Abstract
PURPOSE OF REVIEW Chemotherapy has gained a larger importance in the management of brain tumours, especially in children. RECENT FINDINGS Converging results were presented in 2005 by the German, French and North-American cooperative groups indicating that a subgroup of young children with medulloblastoma (i.e. those with desmoplastic histology) could be cured with chemotherapy only strategies. The usefulness of high-dose chemotherapy followed by stem-cell transplant was shown not only as salvage strategy but also upfront in high-risk patients with medulloblastoma. Diffuse pontine glioma remains a devastating disease despite numerous attempts to improve on the standard radiotherapy. Targeted therapies have entered the paediatric neuro-oncology field as well. SUMMARY In the most frequent paediatric brain tumors (medulloblastoma and low grade gliomas), the improvements have been impressive in recent years. These patients still await new targeted therapies to lower the burden of treatments and their related side-effects. Most of the brain tumours, however, are rare and the development of specific protocols too slow. Likely, they may have very specific biologic abnormalities that could be efficiently targeted in the near future.
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Affiliation(s)
- Jacques Grill
- Department of Paediatric and Adolescent Oncology, Gustave Roussy Cancerology Institute, Villejuif, France.
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Chastagner P, Kalifa C, Doz F, Bouffet E, Gentet JC, Ruchoux MM, Bracard S, Desandes E, Frappaz D. Outcome of children treated with preradiation chemotherapy for a high-grade glioma: results of a French Society of Pediatric Oncology (SFOP) Pilot Study. Pediatr Blood Cancer 2007; 49:803-7. [PMID: 17096408 DOI: 10.1002/pbc.21051] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND To evaluate the efficacy of BCNU, cisplatin, and vincristine (BCV regimen) in a prospective nonrandomized study among newly diagnosed children with high-grade glioma. PROCEDURE Following surgery, patients received a combination of BCNU + cisplatin + VP16 (BCV), over 3 consecutive days. Patients with residual tumor continued this regimen unless no further improvement was observed on MRI, for a maximum of six courses. Patients who underwent complete surgical resection received six courses of adjuvant BCV. RESULTS Seventy-three patients were enrolled. Out of 66 eligible patients with central pathology review, the diagnosis of high-grade glioma was confirmed in 53 cases. The response rate was 20%. With a median follow-up of 128 months, 5- and 10-year event free survival rates are 16 +/- 9 and 13.3 +/- 9.4%. In univariate analysis, two prognostic factors were statistically significant: extent of resection and tumor location, while macroscopic total resection was the only significant prognostic factor in the multivariate analysis. The response to BCV did not translate into improved event free survival. Interstitial pneumonitis occurred in seven patients, leading to six deaths. CONCLUSION This BCV regimen could not be recommended in the treatment of high-grade gliomas in children, according to its lack of efficacy and its unacceptable pulmonary toxicity.
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Affiliation(s)
- P Chastagner
- Department of Pediatric Oncology, CHU Nancy, Hôpital d'Enfants, Vandoeuvre Lès Nancy, France.
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Carret AS, Tabori U, Crooks B, Hukin J, Odame I, Johnston DL, Keene DL, Freeman C, Bouffet E. Outcome of secondary high-grade glioma in children previously treated for a malignant condition: A study of the Canadian Pediatric Brain Tumour Consortium. Radiother Oncol 2006; 81:33-8. [PMID: 16973227 DOI: 10.1016/j.radonc.2006.08.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2006] [Revised: 07/31/2006] [Accepted: 08/11/2006] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Reports of secondary high-grade glioma (HGG) in survivors of childhood cancer are scarce. The aim of this study was to review the pattern of diagnosis, the treatment, and outcome of secondary pediatric HGG. PATIENTS AND METHODS We performed a multi-center retrospective study among the 17 paediatric institutions participating in the Canadian Pediatric Brain Tumour Consortium (CPBTC). RESULTS We report on 18 patients (14 males, 4 females) treated in childhood for a primary cancer, who subsequently developed a HGG as a second malignancy. All patients had previously received radiation therapy +/- chemotherapy for either acute lymphoblastic leukaemia (n=9) or solid tumour (n=9). All HGG occurred within the previous radiation fields. At the last follow-up, 17 patients have died and the median survival time is 9.75 months. CONCLUSION Although aggressive treatment seems to provide sustained remissions in some patients, the optimal management is still to be defined. Further documentation of such cases is necessary in order to better understand the pathogenesis, the natural history and the prevention of these tumours.
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Affiliation(s)
- Anne-Sophie Carret
- Pediatric Hematology/Oncology, The Montreal Children's Hospital/McGill University Health Center, Que., Canada.
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