Feasibility of high-dose chemotherapy protocols to treat infants with malignant central nervous system tumors: Experience from a middle-income country

Adjuvant therapy for brain tumors in LMICs: A systematic review of barriers and possible solutions

BACKGROUND

Adjuvant therapy is an important tool in the arsenal of brain tumor management and can improve patients' outcomes significantly but low- and middle-income countries (LMICs) often face challenges in provision. Therefore, our study aims to highlight barriers and strategies to adjuvant therapy of brain tumors in low-resource settings.

METHOD

A comprehensive search of literature was conducted using PubMed, CINAHL, Google Scholar, and Scopus, from inception to October 20, 2022. The review included studies on adjuvant therapy for brain tumors in LMICs and identified themes using the National Surgical, Obstetric, and Anesthesia Plan (NSOAP) domains.

RESULTS

32 studies were included in the review. The most reported barriers to adjuvant care were limited access to healthcare (14 %), limited access to chemotherapy and radiation equipment (25 %), and traditional or alternative medications (11 %). Strategies for improvement include improving the availability of specialized radiation oncology training (8 %) and improving access to neuro-diagnostics and neurotherapeutics (12 %). In addition, efforts to subsidize treatment (4 %) and provide financial coverage through the Ministry of Health (4 %) can help to address the high cost of care and improve access to funding for chemotherapy. Finally, establishing documentation systems and registries (16 %), implementing standardized national treatment guidelines (8 %) can help to improve overall care for brain tumor patients in LMICs.

CONCLUSION

A multimodal approach of strategies targeting workforce, infrastructure, service delivery, financing, and information management is needed to improve adjuvant care for brain tumors. International collaboration and partnerships can also play a key role in addressing barriers and improving care in LMICs.

Post-Surgical Prognosis of Patients with Pineoblastoma: A Systematic Review and Individual Patient Data Analysis with Trends over Time

Most of the literature on pineoblastoma consists of case reports and single-institution series. The goal of this systematic review and individual patient data (IPD) analysis was to summarize the existing literature, identify factors associated with overall survival (OS), and provide a contemporary update on prognosis for patients with pineoblastoma. Forty-four studies were identified with 298 patients having IPD. Kaplan-Meier analyses were used to report survival outcomes based on age, tumor metastases, extent of resection (EOR), adjuvant therapy, and publication year. Cox regression was performed to identify independent predictors of time to mortality. Multivariable recursive partitioning analysis was used to identify the most important subgroups associated with mortality. Patients were classified based on publication year before and after the last systematic review on this topic (pre-2012 and 2012 onwards) and compared using univariate and multivariable analyses. This study demonstrates that EOR less-than-gross total resection, metastatic presentation, adjuvant chemotherapy without radiation, and tumor presentation in children less than three years old are associated with poorer prognosis. Since 2012, the 5-year actuarial OS has improved from 32.8% to 56.1%, which remained significant even after accounting for EOR, age, and adjuvant therapy. Pineoblastoma remains a severe rare disease, but survival outcomes are improving.

How do we approach the management of medulloblastoma in young children?

Therapeutic strategies avoiding craniospinal irradiation were developed for young children with medulloblastoma to improve survival while protecting the neurocognitive outcomes of these vulnerable patients. These strategies most commonly rely on high-dose chemotherapy with stem cell rescue or conventional chemotherapy combined with intraventricular chemotherapy or conventional chemotherapy with adjuvant focal irradiation. Over the past decade, our growing understanding of the molecular landscape of medulloblastoma has transformed how we risk stratify and allocate treatment in this young age group. We present the results of the most recent approaches and clinical trials for medulloblastoma of early childhood, according to the different molecular subgroups. Overall, young children with sonic hedgehog medulloblastoma treated with intensive adjuvant chemotherapy achieve excellent survival and can safely be spared from radiotherapy. For patients with group 3 and 4 medulloblastomas, the interplay between molecular alterations and treatment intensity still needs to be further delineated. While recent clinical trials point toward more encouraging survival figure for a sizeable number of them, patients identified with very high-risk feature desperately needs innovative therapies.

Detection of BRAF V600E Mutation in Ganglioglioma and Pilocytic Astrocytoma by Immunohistochemistry and Real-Time PCR-Based Idylla Test

The BRAF V600E mutation is an important oncological target in certain central nervous system (CNS) tumors, for which a possible application of BRAF-targeted therapy grows continuously. In the present study, we aim to determine the prevalence of BRAF V600E mutations in a series of ganglioglioma (GG) and pilocytic astrocytoma (PA) cases. Simultaneously, we decided to verify whether the combination of fully automated tests—BRAF-VE1 immunohistochemistry (IHC) and Idylla BRAF mutation assay—may be useful to accurately predict it in the case of specified CNS tumors. The study included 49 formalin-fixed, paraffin-embedded tissues, of which 15 were GG and 34 PA. Immunohistochemistry with anti-BRAF V600E (VE1) antibody was performed on tissue sections using the VentanaBenchMark ULTRA platform. All positive or equivocal cases on IHC and selected negative ones were further assessed using the Idylla BRAF mutation assay coupled with the Idylla platform. The BRAF-VE1 IHC was positive in 6 (6/49; 12.3%) and negative in 39 samples (39/49; 79.6%). The interpretation of immunostaining results was complicated in 4 cases, of which 1 tested positive for the Idylla BRAF mutation assay. Therefore, the overall positivity rate was 14.3%. This included 2 cases of GG and 5 cases of PA. Our study found that BRAF V600E mutations are moderately frequent in PA and GG and that for these tumor entities, IHC VE1 is suitable for screening purposes, but all negative, equivocal, and weak positive cases should be further tested with molecular biology techniques, of which the Idylla system seems to be a promising tool.