1
|
Sheikh SR, Patel NJ, Recinos VMR. Safety and Technical Efficacy of Pediatric Brainstem Biopsies: An Updated Meta-Analysis of 1000+ Children. World Neurosurg 2024; 189:428-438.e2. [PMID: 38968995 DOI: 10.1016/j.wneu.2024.06.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/28/2024] [Accepted: 06/29/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Brainstem tumors represent ∼10% of pediatric brain tumors, ∼80% of these are diffuse midline glioma. Given invariably poor prognosis in diffuse midline glioma, there continues to be immense variation worldwide in performing biopsy of these lesions. Several contemporary studies in recent years have provided new data to elucidate the safety profile of biopsy and an updated meta-analysis is thus indicated. METHODS We found 29 studies of pediatric brainstem biopsy in the last 20 years (2003-2023, 1002 children). We applied meta-analysis of proportions using a random-effects model to generate point estimates, confidence intervals, and measures of heterogeneity. RESULTS Eighty-seven percent of procedures were stereotactic needle biopsies (of these, 62% with a frame, 14% without frame, and 24% robotic.) Biopsy resulted in a histological diagnosis ("technical yield") in 96.8% of cases (95% CI 95.4-98.2). Temporary complications were seen in 6% (95 CI 4-8), with the most common neurological complications being 1) cranial nerve dysfunction, 2) worsening or new ataxia, and 3) limb weakness. Permanent complications (excluding death) were seen in 1% (95% CI 0.5-2), most commonly including cranial nerve dysfunction and limb weakness. Five deaths were reported in the entire pooled cohort of 1002 children (0.5%). CONCLUSIONS When counseling families on the merits of brainstem biopsy in children, it is reasonable to state that permanent morbidity is rare (<2%). If biopsy is performed specifically to facilitate enrollment in clinical trials requiring a molecular diagnosis, the risks of biopsy outlined here should be weighed against potential benefits of trial enrollment.
Collapse
Affiliation(s)
| | - Neha J Patel
- Department of Pediatric Hematology-Oncology and Blood & Marrow Transplant, Cleveland Clinic, Cleveland, Ohio, USA
| | | |
Collapse
|
2
|
Coleman C, Chen K, Lu A, Seashore E, Stoller S, Davis T, Braunstein S, Gupta N, Mueller S. Interdisciplinary care of children with diffuse midline glioma. Neoplasia 2022; 35:100851. [PMID: 36410226 PMCID: PMC9676429 DOI: 10.1016/j.neo.2022.100851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/10/2022] [Accepted: 10/22/2022] [Indexed: 11/19/2022] Open
Abstract
Diffuse Midline Glioma (DMG) which includes Diffuse Intrinsic Pontine Glioma (DIPG) is an infiltrative tumor of the midline structures of the central nervous system that demonstrates an aggressive pattern of growth and has no known curative treatment. As these tumors progress, children experience ongoing neurological decline including inability to ambulate, swallow and communicate effectively. We propose that optimal care for patients with DMG should involve a specialized team experienced in caring for the multifaceted needs of these patients and their families. Herein we review the roles and evidence to support early involvement of a specialized interdisciplinary team and outline our views on best practices for these challenging tumors.
Collapse
Affiliation(s)
- Christina Coleman
- Department of Pediatrics, University of California, San Francisco, United States
| | - Katherine Chen
- Department of Radiation Oncology, University of California, San Francisco, United States
| | - Alex Lu
- Department of Neurological Surgery, University of California, San Francisco, United States
| | - Elizabeth Seashore
- Department of Pediatrics, University of California, San Francisco, United States
| | - Schuyler Stoller
- Department of Neurology, University of California, San Francisco, United States
| | - Taron Davis
- Department of Orthopedic Surgery, University of California, San Francisco, United States
| | - Steve Braunstein
- Department of Radiation Oncology, University of California, San Francisco, United States
| | - Nalin Gupta
- Department of Pediatrics, University of California, San Francisco, United States,Department of Neurological Surgery, University of California, San Francisco, United States
| | - Sabine Mueller
- Department of Pediatrics, University of California, San Francisco, United States,Department of Neurological Surgery, University of California, San Francisco, United States,Department of Neurology, University of California, San Francisco, United States,Department of Pediatrics, University of Zurich, Zurich, Switzerland,Corresponding author at: Departments of Neurology, Neurosurgery and Pediatrics, University of California, San Francisco, Sandler Neuroscience Building, 675 Nelson Rising Lane, San Francisco, CA 94148, United States.
| |
Collapse
|
3
|
A microRNA Prognostic Signature in Patients with Diffuse Intrinsic Pontine Gliomas through Non-Invasive Liquid Biopsy. Cancers (Basel) 2022; 14:cancers14174307. [PMID: 36077842 PMCID: PMC9454461 DOI: 10.3390/cancers14174307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/29/2022] [Accepted: 08/31/2022] [Indexed: 11/25/2022] Open
Abstract
Simple Summary Diffuse intrinsic pontine glioma (DIPG) is a neuro-radiologically defined tumor of the brainstem, primarily affecting children, with most diagnoses occurring between 5 and 7 years of age. Surgical removal in DIPGs is not feasible. Subsequent tumor progression is almost universal and no biomarker for predicting the course of the disease has entered into clinical practice so far. Under these premises, it is essential to develop reliable biomarkers that are able to improve outcomes and stratify patients using non-invasive methods to determine tumor profiles. We designed a study assessing circulating miRNA expression by a high-throughput platform and divided patients into training and validation phases in order to disclose a potential signature with clinical impact. Our results for the first time have proved the usefulness of blood-circulating nucleic acids as powerful, easy-to-assay molecular markers of disease status in DIPG. Abstract Diffuse midline gliomas (DMGs) originate in the thalamus, brainstem, cerebellum and spine. This entity includes tumors that infiltrate the pons, called diffuse intrinsic pontine gliomas (DIPGs), with a rapid onset and devastating neurological symptoms. Since surgical removal in DIPGs is not feasible, the purpose of this study was to profile circulating miRNA expression in DIPG patients in an effort to identify a non-invasive prognostic signature with clinical impact. Using a high-throughput platform, miRNA expression was profiled in serum samples collected at the time of MRI diagnosis and prior to radiation and/or systemic therapy from 47 patients enrolled in clinical studies, combining nimotuzumab and vinorelbine with concomitant radiation. With progression-free survival as the primary endpoint, a semi-supervised learning approach was used to identify a signature that was also tested taking overall survival as the clinical endpoint. A signature comprising 13 circulating miRNAs was identified in the training set (n = 23) as being able to stratify patients by risk of disease progression (log-rank p = 0.00014; HR = 7.99, 95% CI 2.38–26.87). When challenged in a separate validation set (n = 24), it confirmed its ability to predict progression (log-rank p = 0.00026; HR = 5.51, 95% CI 2.03–14.9). The value of our signature was also confirmed when overall survival was considered (log-rank p = 0.0021, HR = 4.12, 95% CI 1.57–10.8). We have identified and validated a prognostic marker based on the expression of 13 circulating miRNAs that can shed light on a patient’s risk of progression. This is the first demonstration of the usefulness of nucleic acids circulating in the blood as powerful, easy-to-assay molecular markers of disease status in DIPG. This study provides Class II evidence that a signature based on 13 circulating miRNAs is associated with the risk of disease progression.
Collapse
|
4
|
Radlanski K, Hartwig M, Kordes U. Coping with Diffuse Intrinsic Pontine Glioma in Children - Findings from an Interview Study on Bereaved Parents. KLINISCHE PADIATRIE 2022; 234:374-381. [PMID: 35654395 DOI: 10.1055/a-1816-6552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Diffuse midline glioma (DMG) is the most common malignant glioma in early childhood with median survival of only eleven months. This retrospective interview study investigates specific coping strategies and needs of affected parents. PATIENTS 13 interviews with parents of seven children who died from DMG at the age of five to 16 years were conducted in 2016. METHOD The used method is a problem-oriented guided interview with consecutive content and evaluating structuring analysis according to Mayring. RESULTS Major inductive category was whether the parents had talked to their children about their upcoming death. All parents stated overall satisfaction and comfort regarding their palliative care. Lack of psycho-social support in families was successfully addressed by involving palliative care. CONCLUSIONS Retrospective interview studies in this context are feasible. Early involvement of the palliative care team may relieve burden from affected parents. Open communication about death proved helpful for all involved parties, it may facilitate acceptance of terminal illness and alleviate guilt in parents.Concepts for an open and empowering communication within families and between treatment site and families need continuing adjustment. The Palliative care team may also have a key role regarding early phase trials and molecular studies.
Collapse
Affiliation(s)
- Kalinka Radlanski
- Radiation Oncology and Radiotherapy, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Maite Hartwig
- Zentrum für Kinderschmerztherapie, delfin-kids, Hamburg, Germany
| | - Uwe Kordes
- Pediatric Hematology and Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| |
Collapse
|
5
|
Development of a clinical scale for assessment of patients with diffuse intrinsic pontine glioma (DIPG) receiving experimental therapy: the PONScore. J Neurooncol 2020; 149:263-272. [PMID: 32902768 DOI: 10.1007/s11060-020-03594-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/08/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Monitoring neurological side-effects in experimental therapy for diffuse intrinsic pontine glioma (DIPG) can be challenging. We aimed to develop a neurological scale that could be used by non-specialists to quantify neurological changes during experimental treatment of DIPG. METHODS We developed the Pontine Observational Neurological Score (PONScore) to measure signs and symptoms of DIPG by adapting validated assessment scales of neurological signs and symptoms in children. We developed a prototype score, taught it to paediatric intensive care nursing staff, who used the Score to assess children receiving awake pontine infusion of chemotherapy for treatment of DIPG. We used their feedback to develop the PONScore. Points are allocated for headache, ophthalmoplegia, facial and tongue weakness, dysarthria, paraesthesia, limb weakness and dysmetria with increasing scores reflecting increasing disability. The PONScore was administered every hour during awake pontine infusion. Correlation and agreement calculations between nursing staff, as non-specialists, and a specialist rater were performed in 30 infusions in 6 children (aged 8-11). Changes in PONScore versus volume of infusion are described in a further 55 infusions in 8 children (aged 3-11). RESULTS The PONScore demonstrated excellent intra-rater reliability with an intra-class co-efficient of 0.98 (95% CI 0.97-0.99; p-value < 0.001) between a specialist and non-specialist raters with strong correlation between scores and a Spearman correlation coefficient of 0.985 (p < 0.001). PONScores increased from 3.3 to 5.7 (p-value < 0.001) during infusion reflecting accumulation of neurological signs and symptoms during infusion. CONCLUSIONS We describe a novel neurological scale that can be used by non-specialists to describe acute neurological changes in children receiving experimental therapy for DIPG. Prospective validation as part of a clinical trial is required.
Collapse
|
6
|
Abstract
Even though the treatment of childhood cancer has evolved significantly in recent decades, aggressive central nervous system (CNS) tumors are still a leading cause of morbidity and mortality in this population. Consequently, the identification of molecular targets that can be incorporated into diagnostic practice, effectively predict prognosis, follow treatment response, and materialize into potential targeted therapeutic approaches are still warranted. Since the first evidence of the participation of miRNAs in cancer development and progression 20 years ago, notable progress has been made in the basic understanding of the contribution of their dysregulation as epigenetic driver of tumorigenesis. Nevertheless, among the plethora of articles in the literature, microRNA profiling of pediatric tumors are scarce. This article gives an overview of the recent advances in the diagnostic/prognostic potential of miRNAs in a selection of pediatric CNS tumors: medulloblastoma, ependymoma, pilocytic astrocytoma, glioblastoma, diffuse intrinsic pontine glioma, atypical teratoid/rhabdoid tumors, and choroid plexus tumors.
Collapse
|
7
|
Kuzan-Fischer CM, Souweidane MM. The intersect of neurosurgery with diffuse intrinsic pontine glioma. J Neurosurg Pediatr 2019; 24:611-621. [PMID: 31786541 DOI: 10.3171/2019.5.peds18376] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 05/02/2019] [Indexed: 11/06/2022]
Abstract
An invited article highlighting diffuse intrinsic pontine glioma (DIPG) to celebrate the 75th Anniversary of the Journal of Neurosurgery, a journal known to define surgical nuance and enterprise, is paradoxical since DIPG has long been relegated to surgical abandonment. More recently, however, the neurosurgeon is emerging as a critical stakeholder given our role in tissue sampling, collaborative scientific research, and therapeutic drug delivery. The foundation for this revival lies in an expanding reliance on tissue accession for understanding tumor biology, available funding to fuel research, and strides with interventional drug delivery.
Collapse
Affiliation(s)
| | - Mark M Souweidane
- Departments of1Neurological Surgery and
- 2Pediatrics, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York; and
- 3Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
8
|
Ahrendsen JT, Filbin MG, Chi SN, Manley PE, Wright KD, Bandopadhayay P, Clymer JR, Yeo KK, Kieran MW, Jones R, Lidov HG, Ligon KL, Alexandrescu S. Increasing value of autopsies in patients with brain tumors in the molecular era. J Neurooncol 2019; 145:349-355. [PMID: 31571114 DOI: 10.1007/s11060-019-03302-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 09/24/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Pediatric brain tumors are associated with high morbidity and mortality, in part due to insufficient understanding of tumor biology. With limited tissue allocation for research from surgical specimens, a key barrier to improving biological understanding, brain tumor autopsies have become an increasingly valuable resource. This study reviews the brain tumor autopsy practice at our institution and describes specific emerging research utilization patterns beyond the clinical autopsy report. METHODS We performed a retrospective analysis of brain tumor autopsies at Boston Children's Hospital (BCH) between 2007 and 2017 and reviewed their consents, neuropathology reports and final diagnoses. We reviewed the method of tissue triaging for research consented autopsies (bioregistry, frozen and fresh tissue) and documented their specific uses. RESULTS Ninety-six deaths at BCH were due to brain tumors; 56 autopsies were performed (58.3%), of which 49 (87.5%) were consented for research. Tumor mapping was performed on all cases and tissue was allocated for DNA- and RNA-based sequencing studies (published and ongoing). Three tissue allocations with a postmortem interval of 8 h or less resulted in successful cell lines. Tissue from 14 autopsies was contributed to the National DIPG Registry. CONCLUSION Our institutional pediatric brain tumor autopsy clinical experience demonstrates the increased utility and wide utilization of autopsy-derived tissue for multiple types of research. These results support the increased efforts to obtain research consent for brain tumor autopsy and active collection of unfixed autopsy material in the molecular era.
Collapse
Affiliation(s)
- Jared T Ahrendsen
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, USA
| | - Mariella G Filbin
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, USA
| | - Susan N Chi
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, USA
| | - Peter E Manley
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, USA
| | - Karen D Wright
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, USA
| | | | - Jessica R Clymer
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, USA
| | - Kee Kiat Yeo
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, USA
| | - Mark W Kieran
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, USA.,Brystol Meyers Squibb, New York, USA
| | - Robert Jones
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, USA
| | - Hart G Lidov
- Department of Pathology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA, 02215, USA
| | - Keith L Ligon
- Department of Pathology, Brigham and Women's Hospital, Boston, USA.,Department of Pathology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA, 02215, USA
| | - Sanda Alexandrescu
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, USA. .,Department of Pathology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA, 02215, USA.
| |
Collapse
|
9
|
Pfaff E, El Damaty A, Balasubramanian GP, Blattner-Johnson M, Worst BC, Stark S, Witt H, Pajtler KW, van Tilburg CM, Witt R, Milde T, Jakobs M, Fiesel P, Frühwald MC, Hernáiz Driever P, Thomale UW, Schuhmann MU, Metzler M, Bochennek K, Simon T, Dürken M, Karremann M, Knirsch S, Ebinger M, von Bueren AO, Pietsch T, Herold-Mende C, Reuss DE, Kiening K, Lichter P, Eggert A, Kramm CM, Pfister SM, Jones DT, Bächli H, Witt O. Brainstem biopsy in pediatric diffuse intrinsic pontine glioma in the era of precision medicine: the INFORM study experience. Eur J Cancer 2019; 114:27-35. [DOI: 10.1016/j.ejca.2019.03.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 03/23/2019] [Indexed: 02/09/2023]
|
10
|
Abstract
Acute kidney injury (AKI) is a highly heterogeneous, common, and potentially devastating condition associated with markedly increased hospital length of stay, cost, mortality, and morbidity. Expanding the role for kidney biopsies in AKI may offer fresh insights into disease heterogeneity, molecular mechanisms, and therapeutic targets. A number of challenges face investigators and clinicians considering research biopsies in AKI: ensuring patient safety, ensuring the ethical conduct of research studies, and maximizing the scientific yield of the kidney tissue obtained. The societal benefits of research that lead to novel strategies for preventing and treating AKI would be enormous. Rethinking our current approach to the role of kidney biopsy for AKI diagnosis and research may be a major step toward the promise of personalized medicine in nephrology.
Collapse
Affiliation(s)
- Sushrut S Waikar
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA.
| | - Gearoid M McMahon
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
11
|
Lin GL, Nagaraja S, Filbin MG, Suvà ML, Vogel H, Monje M. Non-inflammatory tumor microenvironment of diffuse intrinsic pontine glioma. Acta Neuropathol Commun 2018; 6:51. [PMID: 29954445 PMCID: PMC6022714 DOI: 10.1186/s40478-018-0553-x] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 06/07/2018] [Indexed: 01/05/2023] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is a universally fatal malignancy of the childhood central nervous system, with a median overall survival of 9-11 months. We have previously shown that primary DIPG tissue contains numerous tumor-associated macrophages, and substantial work has demonstrated a significant pathological role for adult glioma-associated macrophages. However, work over the past decade has highlighted many molecular and genomic differences between pediatric and adult high-grade gliomas. Thus, we directly compared inflammatory characteristics of DIPG and adult glioblastoma (GBM). We found that the leukocyte (CD45+) compartment in primary DIPG tissue samples is predominantly composed of CD11b + macrophages, with very few CD3+ T-lymphocytes. In contrast, T-lymphocytes are more abundant in adult GBM tissue samples. RNA sequencing of macrophages isolated from primary tumor samples revealed that DIPG- and adult GBM-associated macrophages both express gene programs related to ECM remodeling and angiogenesis, but DIPG-associated macrophages express substantially fewer inflammatory factors than their adult GBM counterparts. Examining the secretome of glioma cells, we found that patient-derived DIPG cell cultures secrete markedly fewer cytokines and chemokines than patient-derived adult GBM cultures. Concordantly, bulk and single-cell RNA sequencing data indicates low to absent expression of chemokines and cytokines in DIPG. Together, these observations suggest that the inflammatory milieu of the DIPG tumor microenvironment is fundamentally different than adult GBM. The low intrinsic inflammatory signature of DIPG cells may contribute to the lack of lymphocytes and non-inflammatory phenotype of DIPG-associated microglia/macrophages. Understanding the glioma subtype-specific inflammatory milieu may inform the design and application of immunotherapy-based treatments.
Collapse
Affiliation(s)
- Grant L Lin
- Department of Neurology, Stanford University, Stanford, CA, 94305, USA
| | - Surya Nagaraja
- Department of Neurology, Stanford University, Stanford, CA, 94305, USA
| | - Mariella G Filbin
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center and Harvard Medical School, Boston, MA, USA
| | - Mario L Suvà
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Klarman Cell Observatory, Broad Institute of Harvard and Massachussetts Institute of Technology (MIT), Cambridge, MA, 02142, USA
| | - Hannes Vogel
- Department of Neurology, Stanford University, Stanford, CA, 94305, USA
- Department of Pathology, Stanford University, Stanford, CA, 94305, USA
- Department of Pediatrics, Stanford University, Stanford, CA, 94305, USA
| | - Michelle Monje
- Department of Neurology, Stanford University, Stanford, CA, 94305, USA.
- Department of Pathology, Stanford University, Stanford, CA, 94305, USA.
- Department of Pediatrics, Stanford University, Stanford, CA, 94305, USA.
| |
Collapse
|
12
|
Diffuse intrinsic pontine gliomas (DIPG) at recurrence: is there a window to test new therapies in some patients? J Neurooncol 2017; 137:111-118. [PMID: 29198053 DOI: 10.1007/s11060-017-2702-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 11/24/2017] [Indexed: 02/08/2023]
Abstract
Children with diffuse intrinsic pontine glioma (DIPG) need new and more efficient treatments. They can be developed at relapse or at diagnosis, but therefore they must be combined with radiotherapy. Survival of children after recurrence and its predictors were studied to inform the possibility to design early phase clinical trials for DIPG at this stage. Among 142 DIPG patients treated between 1998 and 2014, 114 had biopsy-proven DIPG with histone H3 status available for 83. We defined as long survivors' patients who survived more than 3 months after relapse which corresponds to the minimal life expectancy requested for phase I/II trials. Factors influencing post-relapse survival were accordingly compared between short and long-term survivors after relapse. Fifty-seven percent of patients were considered long survivors and 70% of them had a Lansky Play Scale (LPS) above 50% at relapse. Patients who became steroids-independent after initial treatment for at least 2 months had better survival after relapse (3.7 versus 2.6 months, p = 0.001). LPS above 50% at relapse was correlated with better survival after relapse (3.8 versus 1.8 months, p < 0.001). Patients with H3.1 mutation survived longer after relapse (4.9 versus 2.7 months, p = 0.007). Patients who received a second radiotherapy at the time of relapse had an improved survival (7.5 versus 4 months, p = 0.001). In the two-way ANOVA analysis, steroid-independence and LPS predicted survival best and the type of histone H3 (H3.1 or H3.3) mutated did not improve prediction. Survival of many DIPG patients after relapse over 3 months would make possible to propose specific trials for this condition. Steroid-independence, H3 mutation status and LPS should be considered to predict eligibility.
Collapse
|
13
|
Baugh J, Bartels U, Leach J, Jones B, Chaney B, Warren KE, Kirkendall J, Doughman R, Hawkins C, Miles L, Fuller C, Hassall T, Bouffet E, Lane A, Hargrave D, Grill J, Hoffman LM, Jones C, Towbin A, Savage SA, Monje M, Li XN, Ziegler DS, Veldhuijzen van Zanten S, Kramm CM, van Vuurden DG, Fouladi M. The international diffuse intrinsic pontine glioma registry: an infrastructure to accelerate collaborative research for an orphan disease. J Neurooncol 2017; 132:323-331. [PMID: 28093680 PMCID: PMC6343830 DOI: 10.1007/s11060-017-2372-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 01/03/2017] [Indexed: 10/20/2022]
Abstract
Diffuse intrinsic pontine glioma (DIPG), a rare, often fatal childhood brain tumor, remains a major therapeutic challenge. In 2012, investigators, funded by the DIPG Collaborative (a philanthropic partnership among 29 private foundations), launched the International DIPG Registry (IDIPGR) to advance understanding of DIPG. Comprised of comprehensive deidentified but linked clinical, imaging, histopathological, and genomic repositories, the IDIPGR uses standardized case report forms for uniform data collection; serial imaging and histopathology are centrally reviewed by IDIPGR neuro-radiologists and neuro-pathologists, respectively. Tissue and genomic data, and cell cultures derived from autopsies coordinated by the IDIPGR are available to investigators for studies approved by the Scientific Advisory Committee. From April 2012 to December 2016, 670 patients diagnosed with DIPG have been enrolled from 55 participating institutions in the US, Canada, Australia and New Zealand. The radiology repository contains 3558 studies from 448 patients. The pathology repository contains tissue on 81 patients with another 98 samples available for submission. Fresh DIPG tissue from seven autopsies has been sent to investigators to develop primary cell cultures. The bioinformatics repository contains next-generation sequencing data on 66 tumors. Nine projects using data/tissue from the IDIPGR by 13 principle investigators from around the world are now underway. The IDIPGR, a successful alliance among philanthropic agencies and investigators, has developed and maintained a highly collaborative, hypothesis-driven research infrastructure for interdisciplinary and translational projects in DIPG to improve diagnosis, response assessment, treatment and outcome for patients.
Collapse
Affiliation(s)
- Joshua Baugh
- Brain Tumor Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA
| | - Ute Bartels
- Hospital for Sick Children, Toronto, ON, Canada
| | - James Leach
- Brain Tumor Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA
| | - Blaise Jones
- Brain Tumor Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA
| | - Brooklyn Chaney
- Brain Tumor Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA
| | - Katherine E Warren
- National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jenavieve Kirkendall
- Brain Tumor Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA
| | - Renee Doughman
- Brain Tumor Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA
| | | | - Lili Miles
- Brain Tumor Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA
| | - Christine Fuller
- Brain Tumor Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA
| | - Tim Hassall
- Lady Cilento Children's Hospital, Brisbane, Australia
| | | | - Adam Lane
- Brain Tumor Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA
| | - Darren Hargrave
- Great Ormond Street Hospital for Children NHS Trust, London, UK
| | | | - Lindsey M Hoffman
- Brain Tumor Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA
| | | | - Alex Towbin
- Brain Tumor Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA
| | - Sharon A Savage
- National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Michelle Monje
- Stanford University and Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | | | - David S Ziegler
- Sydney Children's Hospital, Randwick, NSW, Australia
- Children's Cancer Institute, University of New South Wales, Kensington, Australia
| | | | | | | | - Maryam Fouladi
- Brain Tumor Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA.
| |
Collapse
|
14
|
Abstract
Diffuse Intrinsic Pontine Glioma (DIPG) is a childhood brainstem tumor that carries a universally fatal prognosis. Because surgical resection is not a viable treatment strategy and biopsy is not routinely performed, the availability of patient samples for research is limited. Consequently, efforts to study this disease have been challenged by a paucity of faithful disease models. To address this need, we describe here a protocol for the rapid processing of post-mortem autopsy tissue samples in order to generate durable patient-derived cell culture models that can be used in in vitro assays or in vivo orthotopic xenograft experiments. These models can be used to screen for potential drug targets and to study fundamental pathobiological processes within DIPG. This protocol can further be extended to analyze and isolate tumor and microenvironmental cells using Fluorescence-activated Cell Sorting (FACS), which enables subsequent analysis of gene expression, protein expression, or epigenetic modifications of DNA at the bulk cell or single cell level. Finally, this protocol can also be adapted to generate patient-derived cultures for other central nervous system tumors.
Collapse
Affiliation(s)
- Grant L Lin
- Graduate Program in Neuroscience, Department of Neurology, Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine
| | - Michelle Monje
- Departments of Neurology, Neurosurgery, Pathology and Pediatrics, Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine;
| |
Collapse
|
15
|
Carai A, Mastronuzzi A, De Benedictis A, Messina R, Cacchione A, Miele E, Randi F, Esposito G, Trezza A, Colafati GS, Savioli A, Locatelli F, Marras CE. Robot-Assisted Stereotactic Biopsy of Diffuse Intrinsic Pontine Glioma: A Single-Center Experience. World Neurosurg 2017; 101:584-588. [PMID: 28254596 DOI: 10.1016/j.wneu.2017.02.088] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/16/2017] [Accepted: 02/17/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Diffuse intrinsic pontine glioma (DIPG) is a childhood tumor with a dismal prognosis. Emerging molecular signatures have paved the way for stereotactic biopsy in selected centers. We present our experience in DIPG stereotactic needle biopsy using the Robotic Stereotactic-Assisted system (ROSA) in a series of consecutive pediatric patients. METHODS All stereotactic biopsy procedures for DIPG performed during the last year at our institution were considered. All procedures were carried out using the ROSA surgical assistant through a precoronary approach. All children underwent a postoperative computed tomography scan to document possible surgical complications and confirm the site of biopsy. Postoperative clinical changes were recorded to test morbidity of the procedure. RESULTS In the last year, we performed 7 pontine needle biopsies. Specimens were diagnostic and useful for molecular analysis in all cases. No surgical complications were observed. One child showed a transient neurologic worsening related to the biopsy that resolved within 2 weeks. The combination of the precoronary approach and use of the stereotactic ROSA system allowed single-session surgeries in all cases. CONCLUSIONS Pontine biopsy for DIPG is a safe procedure in selected centers. The advantages of the single-session procedure we described might be of particular interest in the pediatric setting.
Collapse
Affiliation(s)
- Andrea Carai
- Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Angela Mastronuzzi
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandro De Benedictis
- Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Raffaella Messina
- Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Antonella Cacchione
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Evelina Miele
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Franco Randi
- Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giacomo Esposito
- Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy; Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrea Trezza
- Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy; Neurosurgery, Department of Surgery and Translational Medicine, Milan Center for Neuroscience, University of Milano Bicocca, San Gerardo Hospital, Monza, Italy
| | | | - Alessandra Savioli
- Intensive Care Unit, Department of Emergency, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Franco Locatelli
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy; Department of Pediatric Science, University of Pavia, Pavia, Italy
| | - Carlo Efisio Marras
- Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| |
Collapse
|
16
|
Survival rates and prognostic predictors of high grade brain stem gliomas in childhood: a systematic review and meta-analysis. J Neurooncol 2017; 135:13-20. [PMID: 28681244 PMCID: PMC5658459 DOI: 10.1007/s11060-017-2546-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 06/27/2017] [Indexed: 11/03/2022]
Abstract
Diagnosis of a pediatric high grade brain stem glioma is devastating with dismal outcomes. This systematic review and meta-analysis was undertaken to determine the survival rates and assess potential prognostic factors including selected interventions. Studies included involved pediatric participants with high grade brain stem gliomas diagnosed by magnetic resonance imaging or biopsy reporting overall survival rates. Meta-analysis was undertaken using a binomial random effects model. Sixty-five studies (2336 participants) were included. Meta-analysis showed 1 year overall survival (OS) of 41% (95% confidence interval (CI) 38-44%, I-sq 52%, 2083 participants), 2 year OS of 15.3% (95% confidence interval 12-20%, I-sq 73.1%, 1329 participants) and 3 year OS of 7.3% (95% confidence interval 5.2-10%, I-sq 26%, 584 participants). Meta-analyses of median overall survival results was not possible due to the lack of reported measures of variance. Subgroup analysis comparing date of study, classification of tumor, use of temozolomide, non-standard interventions or phase 1/2 versus other studies demonstrated no difference in survival outcomes. There was insufficient data to undertake subgroup meta-analysis of patient age, duration of symptoms, K27M histone mutations and AVCR1 mutations. Survival outcomes of high grade brain stem gliomas have remained very poor, and do not clearly vary according to classification, phase of study or use of different therapeutic interventions. Future studies should harmonize outcome and prognostic variable reporting to enable accurate meta-analysis and better exploration of prognosis.
Collapse
|
17
|
Kieran MW, Goumnerova LC, Prados M, Gupta N. Biopsy for diffuse intrinsic pontine glioma: a reappraisal. J Neurosurg Pediatr 2016; 18:390-1. [PMID: 27153377 DOI: 10.3171/2015.6.peds15374] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
18
|
Pre-radiation chemotherapy improves survival in pediatric diffuse intrinsic pontine gliomas. Childs Nerv Syst 2016; 32:1415-23. [PMID: 27379495 DOI: 10.1007/s00381-016-3153-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 06/19/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND The median survival of patients with diffuse intrinsic pontine glioma (DIPG) remains less than 1 year. The BSG 98 pre-irradiation chemotherapy protocol showed a significant increase in overall survival. In contrast to current treatment strategies, patients did not have to undergo surgical stereotactic biopsy, which can sometimes lead to complications, to be included in this protocol. MATERIALS AND METHODS We retrospectively reviewed all the cases of DIPG that were treated in our department from September 15, 2004 to September 15, 2014. We compared the group of patients who followed our BSG 98 protocol to those who were treated with new targeted therapy protocols where systematic biopsy was required. RESULTS Patients in the BSG 98 protocol were treated with BCNU, cisplatin, and methotrexate, followed by radiation at disease progression. Targeted therapy protocols included radiation therapy along with treatment by erlotinib, cilengitide, or an association of nimotuzumab and vinblastine. Sixteen patients were treated with the BSG 98 protocol, and 9 patients were treated with new targeted therapy protocols. Median overall survival was significantly higher in the BSG 98 group compared to the targeted therapy group (16.1 months (95 % CI, 10.4-19.0) vs 8.8 months (95 % CI 1.4-12.3); p = 0.0003). An increase in the median progression-free survival was observed (respectively, 8.6 vs 3.0 months; p = 0.113). CONCLUSION The present study confirms that the BSG 98 protocol is one of the most effective current treatment strategies for DIPG. It may be used as the control arm in randomized trials investigating the use of innovative treatments and may be proposed to families who are averse to biopsy.
Collapse
|
19
|
Pierre-Aurélien B, Alexandru S, Federico DR, Justyna K, Carmine M, Didier F. Diffuse Intrinsic Pontine Glioma in Children: Document or Treat? World Neurosurg 2016; 93:485.e11-4. [PMID: 27422681 DOI: 10.1016/j.wneu.2016.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 07/05/2016] [Accepted: 07/05/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND The place of stereotactic biopsies in the management of diffuse intrinsic pontine gliomas (DIPGs) in children has changed over the years. Nonetheless, stereotactic biopsy remains a surgical procedure with its risks. One complication that has not been reported previously in case of a biopsy of a DIPG is metastatic seeding along the tract of the biopsy. We report the first 2 cases in the literature. CASE DESCRIPTION One 8-year-old and one 9-year-old boy were admitted for a typical DIPG. Parents choose to be included into a research protocol that required a stereotactic biopsy. The biopsy was performed in both cases without any intraoperative complications, and they both received their treatment according to protocol. Unfortunately, 3 and 1 months respectively after the biopsy, their clinical condition deteriorated. MRI showed a metastatic seeding along the tract of the biopsy, and both patients died of disease progression. CONCLUSIONS The era of targeted therapy with molecular and genomic discoveries has paved the way to a research protocol that requires a biopsy from the patient. The reported complications have never been described before. The purpose of this paper is not to suggest that no biopsy should be performed when a DIPG is suspected. For now, biopsy remains investigational, because no benefit in survival could be drawn so far for any patient. This subject deserves honest discussion with the children and their parents.
Collapse
Affiliation(s)
| | - Szathmari Alexandru
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, Lyon Cedex, France
| | - Di Rocco Federico
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, Lyon Cedex, France
| | - Kanold Justyna
- Pediatric Haematology and Oncology Unit, University Hospital, Clermont-Ferrand, France; INSERM-CIC 1405, CRECHE Unit, Clermont-Ferrand, France; Auvergne University, Clermont1 University, Faculty of Medicine, Clermont-Ferrand, France
| | - Mottolese Carmine
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, Lyon Cedex, France
| | - Frappaz Didier
- Pediatric Institutes of Haematology-Oncology, Lyon, France
| |
Collapse
|
20
|
Abstract
Great progress has been made in many areas of pediatric oncology. However, tumors of the central nervous system (CNS) remain a significant challenge. A recent explosion of data has led to an opportunity to understand better the molecular basis of these diseases and is already providing a foundation for the pursuit of rationally chosen therapeutics targeting relevant molecular pathways. The molecular biology of pediatric brain tumors is shifting from a singular focus on basic scientific discovery to a platform upon which insights are being translated into therapies.
Collapse
|
21
|
Goodwin CR, Xu R, Iyer R, Sankey EW, Liu A, Abu-Bonsrah N, Sarabia-Estrada R, Frazier JL, Sciubba DM, Jallo GI. Local delivery methods of therapeutic agents in the treatment of diffuse intrinsic brainstem gliomas. Clin Neurol Neurosurg 2016; 142:120-127. [PMID: 26849840 DOI: 10.1016/j.clineuro.2016.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 01/05/2016] [Indexed: 10/22/2022]
Abstract
Brainstem gliomas comprise 10-20% of all pediatric central nervous system (CNS) tumors and diffuse intrinsic pontine gliomas (DIPGs) account for the majority of these lesions. DIPG is a rapidly progressive disease with almost universally fatal outcomes and a median survival less than 12 months. Current standard-of-care treatment for DIPG includes radiation therapy, but its long-term survival effects are still under debate. Clinical trials investigating the efficacy of systemic administration of various therapeutic agents have been associated with disappointing outcomes. Recent efforts have focused on improvements in chemotherapeutic agents employed and in methods of localized and targeted drug delivery. This review provides an update on current preclinical and clinical studies investigating treatment options for brainstem gliomas.
Collapse
Affiliation(s)
- C Rory Goodwin
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - Risheng Xu
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - Rajiv Iyer
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - Eric W Sankey
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - Ann Liu
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - Nancy Abu-Bonsrah
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - Rachel Sarabia-Estrada
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - James L Frazier
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - Daniel M Sciubba
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - George I Jallo
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA.
| |
Collapse
|
22
|
Hoffman LM, DeWire M, Ryall S, Buczkowicz P, Leach J, Miles L, Ramani A, Brudno M, Kumar SS, Drissi R, Dexheimer P, Salloum R, Chow L, Hummel T, Stevenson C, Lu QR, Jones B, Witte D, Aronow B, Hawkins CE, Fouladi M. Spatial genomic heterogeneity in diffuse intrinsic pontine and midline high-grade glioma: implications for diagnostic biopsy and targeted therapeutics. Acta Neuropathol Commun 2016; 4:1. [PMID: 26727948 PMCID: PMC4700584 DOI: 10.1186/s40478-015-0269-0] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 12/20/2015] [Indexed: 11/20/2022] Open
Abstract
Introduction Diffuse intrinsic pontine glioma (DIPG) and midline high-grade glioma (mHGG) are lethal childhood brain tumors. Spatial genomic heterogeneity has been well-described in adult HGG but has not been comprehensively characterized in pediatric HGG. We performed whole exome sequencing on 38-matched primary, contiguous, and metastatic tumor sites from eight children with DIPG (n = 7) or mHGG (n = 1) collected using a unique MRI-guided autopsy protocol. Validation was performed using Sanger sequencing, Droplet Digital polymerase-chain reaction, immunohistochemistry, and fluorescent in-situ hybridization. Results Median age at diagnosis was 6.1 years (range: 2.9–23.3 years). Median overall survival was 13.2 months (range: 11.2–32.2 months). Contiguous tumor infiltration and distant metastases were observed in seven and six patients, respectively, including leptomeningeal dissemination in three DIPGs. Histopathological heterogeneity was evident in seven patients, including intra-pontine heterogeneity in two DIPGs, ranging from World Health Organization grade II to IV astrocytoma. We found conservation of heterozygous K27M mutations in H3F3A (n = 4) or HIST1H3B (n = 3) across all primary, contiguous, and metastatic tumor sites in all DIPGs. ACVR1 (n = 2), PIK3CA (n = 2), FGFR1 (n = 2), and MET (n = 1) were also intra-tumorally conserved. ACVR1 was co-mutated with HIST1H3B (n = 2). In contrast, PDGFRA amplification and mutation were spatially heterogeneous, as were mutations in BCOR (n = 1), ATRX (n = 2), and MYC (n = 1). TP53 aberrations (n = 3 patients) varied by type and location between primary and metastatic tumors sites but were intra-tumorally conserved. Conclusion Spatial conservation of prognostically-relevant and therapeutically-targetable somatic mutations in DIPG and mHGG contrasts the significant heterogeneity of driver mutations seen in adult HGG and supports uniform implementation of diagnostic biopsy in DIPG and mHGG to classify molecular risk groups and guide therapeutic strategy. Electronic supplementary material The online version of this article (doi:10.1186/s40478-015-0269-0) contains supplementary material, which is available to authorized users.
Collapse
|
23
|
Vanan MI, Eisenstat DD. DIPG in Children - What Can We Learn from the Past? Front Oncol 2015; 5:237. [PMID: 26557503 PMCID: PMC4617108 DOI: 10.3389/fonc.2015.00237] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 10/08/2015] [Indexed: 02/02/2023] Open
Abstract
Brainstem tumors represent 10–15% of pediatric central nervous system tumors and diffuse intrinsic pontine glioma (DIPG) is the most common brainstem tumor of childhood. DIPG is almost uniformly fatal and is the leading cause of brain tumor-related death in children. To date, radiation therapy (RT) is the only form of treatment that offers a transient benefit in DIPG. Chemotherapeutic strategies including multi-agent neoadjuvant chemotherapy, concurrent chemotherapy with RT, and adjuvant chemotherapy have not provided any survival advantage. To overcome the restrictive ability of the intact blood–brain barrier (BBB) in DIPG, several alternative drug delivery strategies have been proposed but have met with minimal success. Targeted therapies either alone or in combination with RT have also not improved survival. Five decades of unsuccessful therapies coupled with recent advances in the genetics and biology of DIPG have taught us several important lessons (1). DIPG is a heterogeneous group of tumors that are biologically distinct from other pediatric and adult high grade gliomas (HGG). Adapting chemotherapy and targeted therapies that are used in pediatric or adult HGG for the treatment of DIPG should be abandoned (2). Biopsy of DIPG is relatively safe and informative and should be considered in the context of multicenter clinical trials (3). DIPG probably represents a whole brain disease so regular neuraxis imaging is important at diagnosis and during therapy (4). BBB permeability is of major concern in DIPG and overcoming this barrier may ensure that drugs reach the tumor (5). Recent development of DIPG tumor models should help us accurately identify and validate therapeutic targets and small molecule inhibitors in the treatment of this deadly tumor.
Collapse
Affiliation(s)
- Magimairajan Issai Vanan
- Department of Pediatrics and Child Health, University of Manitoba , Winnipeg, MB , Canada ; Department of Biochemistry and Medical Genetics, University of Manitoba , Winnipeg, MB , Canada
| | - David D Eisenstat
- Department of Pediatrics, University of Alberta , Edmonton, AB , Canada ; Department of Medical Genetics, University of Alberta , Edmonton, AB , Canada ; Department of Oncology, University of Alberta , Edmonton, AB , Canada
| |
Collapse
|
24
|
Puget S, Beccaria K, Blauwblomme T, Roujeau T, James S, Grill J, Zerah M, Varlet P, Sainte-Rose C. Biopsy in a series of 130 pediatric diffuse intrinsic Pontine gliomas. Childs Nerv Syst 2015; 31:1773-80. [PMID: 26351229 DOI: 10.1007/s00381-015-2832-1] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/09/2015] [Indexed: 01/06/2023]
Abstract
PURPOSE Diffuse intrinsic pontine glioma (DIPG) is the most severe pediatric solid tumor, with no significant improvement in the past 50 years. Possible reasons for failure to make therapeutic progress include poor understanding of the underlying molecular biology due to lack of tumor material. METHODS We performed a prospective analysis of children with typical appearance of DIPG who had a stereotactic biopsy in our unit since 2002. Technical approach, complications, histopathological results, and samples processing are exposed. The literature on this subject is discussed. RESULTS Reviewing our own 130 cases of DIPG biopsies and previous published data, these procedures appear to have a diagnostic yield and morbidity rates similar to those reported for other brain locations (3.9 % of transient morbidity in our series). In addition, the quality and the quantity of the material obtained allow to (1) confirm the diagnosis, (2) reveal that WHO grading was useless to predict outcome, and (3) perform an extended molecular screen, including biomarkers study and the development of preclinical models. Recent studies reveal that DIPG may comprise more than one biological entity and a unique oncogenesis involving mutations never described in other types of cancers, i.e., histones H3 K27M and activin receptor ACVR1. CONCLUSION Stereotactic biopsies of DIPG can be considered as a safe procedure in well-trained neurosurgical teams and could be incorporated in protocols. It is a unique opportunity to integrate DIPG biopsies in clinical practice and use the biology at diagnosis to drive the introduction of innovative targeted therapies, in combination with radiotherapy.
Collapse
Affiliation(s)
- Stephanie Puget
- Department of Pediatric Neurosurgery, Necker Enfants Malades Hospital, 149 rue de Sèvres, 75015, Paris, France. .,Sorbonne Paris Cité, Université Paris Descartes, Paris, France. .,UMR CNRS 8203 "Vectorologie et Thérapeutiques Anticancéreuses", Département de Cancérologie de l'Enfant et de l'Adolescent, Institut de Cancérologie Gustave Roussy, 114 rue Edouard Vaillant, 94805, Villejuif cedex, France.
| | - Kevin Beccaria
- Department of Pediatric Neurosurgery, Necker Enfants Malades Hospital, 149 rue de Sèvres, 75015, Paris, France.,Sorbonne Paris Cité, Université Paris Descartes, Paris, France
| | - Thomas Blauwblomme
- Department of Pediatric Neurosurgery, Necker Enfants Malades Hospital, 149 rue de Sèvres, 75015, Paris, France.,Sorbonne Paris Cité, Université Paris Descartes, Paris, France
| | - Thomas Roujeau
- Department of Pediatric Neurosurgery, Necker Enfants Malades Hospital, 149 rue de Sèvres, 75015, Paris, France.,Sorbonne Paris Cité, Université Paris Descartes, Paris, France
| | - Syril James
- Department of Pediatric Neurosurgery, Necker Enfants Malades Hospital, 149 rue de Sèvres, 75015, Paris, France.,Sorbonne Paris Cité, Université Paris Descartes, Paris, France
| | - Jacques Grill
- Department of Pediatric and Adolescent Oncology and CNRS UMR 8203 "Vectorology and Anticancer Therapeutics", Gustave Roussy Cancer Institute, Universite Paris Sud, 114 rue Edouard Vaillant, 94805, Villejuif, France
| | - Michel Zerah
- Department of Pediatric Neurosurgery, Necker Enfants Malades Hospital, 149 rue de Sèvres, 75015, Paris, France.,Sorbonne Paris Cité, Université Paris Descartes, Paris, France
| | - Pascale Varlet
- Department of Neuropathology, Sainte-Anne Hospital, 1 rue Cabanis, 75014, Paris, France
| | - Christian Sainte-Rose
- Department of Pediatric Neurosurgery, Necker Enfants Malades Hospital, 149 rue de Sèvres, 75015, Paris, France.,Sorbonne Paris Cité, Université Paris Descartes, Paris, France
| |
Collapse
|
25
|
Pediatric brainstem gliomas: new understanding leads to potential new treatments for two very different tumors. Curr Oncol Rep 2015; 17:436. [PMID: 25702179 DOI: 10.1007/s11912-014-0436-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Pediatric brainstem gliomas include low-grade focal brainstem gliomas (FBSG) and high-grade diffuse intrinsic pontine gliomas (DIPG). These tumors share a crucial and eloquent area of the brain as their location, which carries common challenges for treatment. Otherwise, though, these two diseases are very different in terms of presentation, biology, treatment, and prognosis. FBSG usually present with greater than 3 months of symptoms, while DIPG are usually diagnosed within 3 months of symptom onset. Surgery remains the preferred initial treatment for FBSG, with chemotherapy used for persistent, recurrent, or inoperable disease; conversely, radiation is the only known effective treatment for DIPG. Recent developments in biological understanding of both tumors have led to new treatment possibilities. In FBSG, two genetic changes related to BRAF characterize the majority of tumors, and key differences in their biological effects are informing strategies for targeted chemotherapy use. In DIPG, widespread histone H3 and ACVR1 mutations have led to new hope for effective targeted treatments. FBSG has an excellent prognosis, while the long-term survival rate of DIPG tragically remains near zero. In this review, we cover the epidemiology, biology, presentation, imaging characteristics, multimodality treatment, and prognosis of FBSG and DIPG, with a focus on recent biological discoveries.
Collapse
|
26
|
Kaye EC, Baker JN, Broniscer A. Management of diffuse intrinsic pontine glioma in children: current and future strategies for improving prognosis. CNS Oncol 2015; 3:421-31. [PMID: 25438813 DOI: 10.2217/cns.14.47] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is one of the deadliest pediatric central nervous system cancers in spite of treatment with radiation therapy, the current standard of care. The outcome of affected children remains dismal despite multiple clinical trials that investigated radiation therapy combined with chemotherapy. Recently, multiple genome-wide studies unveiled the distinct molecular characteristics of DIPGs and preclinical models of DIPG were developed to mimic the human disease. Both of these accomplishments have generated tremendous progress in the research of new therapies for children with DIPG. Here we review some of these promising new strategies.
Collapse
Affiliation(s)
- Erica C Kaye
- Department of Oncology, St Jude Children's Research Hospital; 262 Danny Thomas Place, Mail Stop 260, Memphis, TN 38105, USA
| | | | | |
Collapse
|
27
|
Buczkowicz P, Hawkins C. Pathology, Molecular Genetics, and Epigenetics of Diffuse Intrinsic Pontine Glioma. Front Oncol 2015; 5:147. [PMID: 26175967 PMCID: PMC4485076 DOI: 10.3389/fonc.2015.00147] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 06/16/2015] [Indexed: 11/13/2022] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is a devastating pediatric brain cancer with no effective therapy. Histological similarity of DIPG to supratentorial high-grade astrocytomas of adults has led to assumptions that these entities possess similar underlying molecular properties and therefore similar therapeutic responses to standard therapies. The failure of all clinical trials in the last 30 years to improve DIPG patient outcome has suggested otherwise. Recent studies employing next-generation sequencing and microarray technologies have provided a breadth of evidence highlighting the unique molecular genetics and epigenetics of this cancer, distinguishing it from both adult and pediatric cerebral high-grade astrocytomas. This review describes the most common molecular genetic and epigenetic signatures of DIPG in the context of molecular subgroups and histopathological diagnosis, including this tumor entity's unique mutational landscape, copy number alterations, and structural variants, as well as epigenetic changes on the global DNA and histone levels. The increased knowledge of DIPG biology and histopathology has opened doors to new diagnostic and therapeutic avenues.
Collapse
Affiliation(s)
- Pawel Buczkowicz
- Division of Pathology, The Hospital for Sick Children , Toronto, ON , Canada ; The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children , Toronto, ON , Canada
| | - Cynthia Hawkins
- Division of Pathology, The Hospital for Sick Children , Toronto, ON , Canada ; The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children , Toronto, ON , Canada ; Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto , Toronto, ON , Canada
| |
Collapse
|