1
|
Castex MP, Stefanowicz J, Clement L, Węcławek-Tompol J, Hameury F, Fresneau B, Irtan S, Brunac AC, Januszkiewicz-Lewandowska D, Lacour B, Faure-Conter C, Orbach D. Choriocarcinoma in neonates and infants: A severe but curable disease. Pediatr Blood Cancer 2024; 71:e31124. [PMID: 38814255 DOI: 10.1002/pbc.31124] [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: 03/04/2024] [Revised: 04/13/2024] [Accepted: 05/19/2024] [Indexed: 05/31/2024]
Abstract
Choriocarcinoma in neonates and infants (N-CC) is an extremely rare, but aggressive cancer, frequently observed with concomitant maternal disease. A retrospective, bi-national study of patients treated in France and Poland for infantile choriocarcinoma analysed eight cases of N-CC, median age of 6 weeks. All tumours were diffuse. Six patients received a platinum-based regimen, and five had delayed surgery on residual distant tumour sites. At the end of follow-up, four patients were in complete remission and four had died of the disease. In all but two cases, mothers had simultaneous metastatic choriocarcinoma. Even if the outcome remains poor, patients could be cured with multimodal therapy.
Collapse
Affiliation(s)
- Marie Pierre Castex
- Paediatric Oncology Immunology Haematology Unit, Children's University Hospital, Toulouse, France
| | - Joanna Stefanowicz
- Department of Paediatrics, Haematology and Oncology, Medical University of Gdansk, Gdansk, Poland
| | - Laura Clement
- Paediatric Oncology Immunology Haematology Unit, Children's University Hospital, Toulouse, France
| | - Jadwiga Węcławek-Tompol
- Clinical Department of Paediatric Bone Marrow Transplantation, Oncology and Haematology, Wroclaw Medical University, Wroclaw, Poland
| | - Frederic Hameury
- Department of Paediatric Surgery, Hospices Civils de Lyon, Lyon, France
| | - Brice Fresneau
- Department of Child and Adolescent Oncology, Gustave Roussy, Paris-Saclay University, Paris-Sud University, CESP, INSERM, Villejuif, France
| | - Sabine Irtan
- Department of Visceral and Neonatal Paediatric surgery, Sorbonne University, Trousseau Hospital, APHP, Paris, France
| | | | | | - Brigitte Lacour
- Registre National des cancers de l'Enfant, Registre National des Tumeurs Solides de l'Enfant, CHRU Nancy, Vandœuvre-lès-Nancy, France
- Epidemiology of Childhood and Adolescent Cancers, CRESS, INSERM, UMR1153, Paris-Cité University, Paris, France
| | | | - Daniel Orbach
- SIREDO Oncology Centre (Care, Innovation and Research for Children, Adolescents and Young Adults with Cancer), Institut Curie, PSL University, Paris, France
| |
Collapse
|
2
|
Barnett S, Hellmann F, Parke E, Makin G, Tweddle DA, Osborne C, Hempel G, Veal GJ. Vincristine dosing, drug exposure and therapeutic drug monitoring in neonate and infant cancer patients. Eur J Cancer 2021; 164:127-136. [PMID: 34657763 PMCID: PMC8914346 DOI: 10.1016/j.ejca.2021.09.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/02/2021] [Accepted: 09/16/2021] [Indexed: 01/12/2023]
Abstract
Background The anticancer drug vincristine is associated with potentially dose-limiting side-effects, including neurotoxicity and myelosuppression. However, there currently exists a lack of published clinical pharmacology data relating to its use in neonate and infant patients. We report a study investigating vincristine dosing and drug exposure, alongside the feasibility and impact of a therapeutic drug monitoring treatment approach, in this challenging patient population. Patients and methods Vincristine pharmacokinetic data from a total of 57 childhood cancer patients, including 26 neonates and infants, were used to characterise a population pharmacokinetic model. Vincristine was administered at doses of 0.02–0.05 mg/kg or 0.75–1.5 mg/m2 in neonates and infants aged <1 year or ≤12 kg and doses of 1.5 mg/m2 in older children. Results A two-compartment model provided the best fit for the population analysis. There was no significant difference in vincristine clearance normalised for body surface area between neonates/infants and older children. Lower doses administered to neonates and infants resulted in significantly lower drug exposures (area under the curve [AUC]), compared with older children (p = 0.047). Vincristine doses of <0.05 mg/kg in neonates and infants resulted in significantly lower AUC values than observed in those receiving doses of ≥0.05 mg/kg (p ≤ 0.0001). Therapeutic drug monitoring was shown to be feasible, effective and well tolerated in neonates and infants experiencing suboptimal drug exposures. Conclusion Doses of <0.05 mg/kg should not be used in neonate and infant patients because of a high risk of patients experiencing potentially suboptimal drug exposures. Therapeutic drug monitoring approaches in neonates and infants are supported by the data generated, with a proposed target therapeutic window of 50–100 μg/l∗h. Vincristine dosing and drug exposure was investigated in neonates and infants. Vincristine concentrations were quantified in 210 plasma samples from 57 children. Lower drug exposures were observed in infants and neonates compared with older children. Therapeutic drug monitoring can be used to avoid suboptimal vincristine drug exposures. Vincristine dosing guidance is provided for treatment of neonate and infant patients.
Collapse
Affiliation(s)
- Shelby Barnett
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
| | - Farina Hellmann
- Department of Pharmaceutical and Medical Chemistry, University of Münster, Münster, Germany
| | - Elizabeth Parke
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
| | - Guy Makin
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Royal Manchester Children's Hospital, Manchester, UK
| | - Deborah A Tweddle
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK; Great North Children's Hospital, Newcastle, UK
| | - Caroline Osborne
- Pharmacy Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, University of Münster, Münster, Germany
| | - Gareth J Veal
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK.
| |
Collapse
|
3
|
Barnett S, Errington J, Sludden J, Jamieson D, Poinsignon V, Paci A, Veal GJ. Pharmacokinetics and Pharmacogenetics of Cyclophosphamide in a Neonate and Infant Childhood Cancer Patient Population. Pharmaceuticals (Basel) 2021; 14:ph14030272. [PMID: 33809608 PMCID: PMC8002238 DOI: 10.3390/ph14030272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/10/2021] [Accepted: 03/13/2021] [Indexed: 01/11/2023] Open
Abstract
Infants and young children represent an important but much understudied childhood cancer patient population. The pharmacokinetics and pharmacogenetics of the widely used anticancer prodrug cyclophosphamide were investigated in children <2 years of age. Concentrations of cyclophosphamide and selected metabolites were determined in patients administered cyclophosphamide at doses ranging from 100–1500 mg/m2 (5–75 mg/kg), with various infusion times as determined by the standard treatment regimen that each patient was receiving. Polymorphisms in genes including CYP2B6 and CYP2C19 were investigated. Data generated for cyclophosphamide were analysed using a previously published population pharmacokinetic model. Cyclophosphamide pharmacokinetics was assessed in 111 samples obtained from 25 patients ranging from 4–23 months of age. The average cyclophosphamide clearance for the patients was 46.6 mL/min/m2 (ranging from 9.4–153 mL/min/m2), with marked inter-patient variability observed (CV 41%). No significant differences in cyclophosphamide clearance or exposure (AUC) were observed between patient groups as separated by age or body weight. However, marked differences in drug clearance and metabolism were noted between the current data in children <2 years of age and recently published results from a comparable study conducted by our group in older children, which reported significantly lower cyclophosphamide clearance values and metabolite exposures using the same population pharmacokinetic model for analysis. Whilst this study demonstrates no significant differences in cyclophosphamide clearance in patients <2 years, it highlights large differences in dosing protocols across tumour types. Furthermore, the study suggests marked differences in cyclophosphamide clearance in children less than two years of age as compared to older patients.
Collapse
Affiliation(s)
- Shelby Barnett
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (S.B.); (J.E.); (J.S.); (D.J.)
| | - Julie Errington
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (S.B.); (J.E.); (J.S.); (D.J.)
| | - Julieann Sludden
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (S.B.); (J.E.); (J.S.); (D.J.)
| | - David Jamieson
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (S.B.); (J.E.); (J.S.); (D.J.)
| | - Vianney Poinsignon
- Department of Pharmacology and Drug Analysis, Gustave Roussy Cancer Campus Grand Paris, Université Paris-Sud, 94805 Villejuif, France; (V.P.); (A.P.)
| | - Angelo Paci
- Department of Pharmacology and Drug Analysis, Gustave Roussy Cancer Campus Grand Paris, Université Paris-Sud, 94805 Villejuif, France; (V.P.); (A.P.)
| | - Gareth J. Veal
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (S.B.); (J.E.); (J.S.); (D.J.)
- Correspondence:
| |
Collapse
|
4
|
Ruggiero A, Ariano A, Triarico S, Capozza MA, Romano A, Maurizi P, Mastrangelo S, Attinà G. Cisplatin-induced nephrotoxicity in children: what is the best protective strategy? J Oncol Pharm Pract 2020; 27:180-186. [PMID: 32990190 DOI: 10.1177/1078155220961550] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Platinum compounds, which are considerably effective for the treatment of childhood malignancies, have significantly contributed to the increase in long-term survival of children with cancer. Unfortunately, children receiving cisplatin-based chemotherapy have been known to be at risk for severe disabling adverse effects, such as nephrotoxicity. METHODS A literature research of the MEDLINE PubMed database was conducted to identify articles published between 1980 and 2019 reviewing "Cisplatin AND mannitol." RESULTS The primary pharmacodynamics and clinical characteristics of cisplatin were described, focusing on its renal toxic effects and potential preventive strategies, in order to improve clinical outcomes among children with cancer aged 1 to 14 years. Currently, selecting either hydration alone or hydration plus mannitol for preventing nephrotoxicity has been controversial considering the lack of guidelines to provide treatment recommendations both among adults and children. CONCLUSIONS Appropriate knowledge regarding the pharmacokinetics and toxicological profile of cisplatin may help physicians prevent renal toxicity. Unfortunately, published data regarding the nephroprotective utility of adding mannitol appear to be inconclusive. As such, appropriate hydration remains the main fundamental strategy for reducing the risk of cisplatin-induced nephrotoxicity. Considering the increasing number of children safely cured of their tumours, it is imperative that those treated with cisplatin receive the most appropriate nephroprotective strategy for reducing the negative impact of platinum compounds on quality of life.
Collapse
Affiliation(s)
- Antonio Ruggiero
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Anna Ariano
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Silvia Triarico
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Michele Antonio Capozza
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Alberto Romano
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Palma Maurizi
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Stefano Mastrangelo
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Giorgio Attinà
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| |
Collapse
|
5
|
Romano A, Capozza MA, Mastrangelo S, Maurizi P, Triarico S, Rolesi R, Attinà G, Fetoni AR, Ruggiero A. Assessment and Management of Platinum-Related Ototoxicity in Children Treated for Cancer. Cancers (Basel) 2020; 12:cancers12051266. [PMID: 32429551 PMCID: PMC7281210 DOI: 10.3390/cancers12051266] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 02/07/2023] Open
Abstract
Platinum compounds are a group of chemotherapeutic agents included in many pediatric and adult oncologic treatment protocols. The main platinum compounds are cisplatin, carboplatin, and oxaliplatin. Their use in clinical practice has greatly improved long-term survival of pediatric patients, but they also cause some toxic effects: ototoxicity, myelosuppression, nephrotoxicity, and neurotoxicity. Hearing damage is one of the main toxic effects of platinum compounds, and it derives from the degeneration of hair cells of the ear, which, not having self-renewal capacity, cannot reconstitute themselves. Hearing loss from platinum exposure is typically bilateral, sensorineural, and permanent, and it is caused by the same mechanisms with which platinum acts on neoplastic cells. According to available data from the literature, the optimal timing for the audiological test during and after treatment with platinum compounds is not well defined. Moreover, no substances capable of preventing the onset of hearing loss have been identified.
Collapse
Affiliation(s)
- Alberto Romano
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Universita’ Cattolica Sacro Cuore, 00168 Rome, Italy; (A.R.); (M.A.C.); (S.M.); (P.M.); (S.T.); (G.A.)
| | - Michele Antonio Capozza
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Universita’ Cattolica Sacro Cuore, 00168 Rome, Italy; (A.R.); (M.A.C.); (S.M.); (P.M.); (S.T.); (G.A.)
| | - Stefano Mastrangelo
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Universita’ Cattolica Sacro Cuore, 00168 Rome, Italy; (A.R.); (M.A.C.); (S.M.); (P.M.); (S.T.); (G.A.)
| | - Palma Maurizi
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Universita’ Cattolica Sacro Cuore, 00168 Rome, Italy; (A.R.); (M.A.C.); (S.M.); (P.M.); (S.T.); (G.A.)
| | - Silvia Triarico
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Universita’ Cattolica Sacro Cuore, 00168 Rome, Italy; (A.R.); (M.A.C.); (S.M.); (P.M.); (S.T.); (G.A.)
| | - Rolando Rolesi
- Otolaryngology Division, Fondazione Policlinico Universitario A.Gemelli IRCCS, Universita’ Cattolica Sacro Cuore, 00168 Rome, Italy; (R.R.); (A.R.F.)
| | - Giorgio Attinà
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Universita’ Cattolica Sacro Cuore, 00168 Rome, Italy; (A.R.); (M.A.C.); (S.M.); (P.M.); (S.T.); (G.A.)
| | - Anna Rita Fetoni
- Otolaryngology Division, Fondazione Policlinico Universitario A.Gemelli IRCCS, Universita’ Cattolica Sacro Cuore, 00168 Rome, Italy; (R.R.); (A.R.F.)
| | - Antonio Ruggiero
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Universita’ Cattolica Sacro Cuore, 00168 Rome, Italy; (A.R.); (M.A.C.); (S.M.); (P.M.); (S.T.); (G.A.)
- Correspondence: ; Tel.: +39-06-30155155
| |
Collapse
|
6
|
Franz DN, Lawson JA, Yapici Z, Brandt C, Kohrman MH, Wong M, Milh M, Wiemer-Kruel A, Voi M, Coello N, Cheung W, Grosch K, French JA. Everolimus dosing recommendations for tuberous sclerosis complex-associated refractory seizures. Epilepsia 2018; 59:1188-1197. [PMID: 29727013 PMCID: PMC6033043 DOI: 10.1111/epi.14085] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2018] [Indexed: 01/27/2023]
Abstract
Objective The present analysis examined the exposure‐response relationship by means of the predose everolimus concentration (Cmin) and the seizure response in patients with tuberous sclerosis complex–associated seizures in the EXIST‐3 study. Recommendations have been made for the target Cmin range of everolimus for therapeutic drug monitoring (TDM) and the doses necessary to achieve this target Cmin. Methods A model‐based approach was used to predict patients' daily Cmin. Time‐normalized Cmin (TN‐Cmin) was calculated as the average predicted Cmin in a time interval. TN‐Cmin was used to link exposure to efficacy and safety end points via model‐based approaches. A conditional logistic regression stratified by age subgroup was used to estimate the probability of response in relation to exposure. A multiplicative linear regression model was used to estimate the exposure‐response relationship for seizure frequency (SF). An extended Cox regression model was used to link exposure to the time to first adverse event. Results There was a strong, consistent, and highly significant relationship between everolimus exposure and efficacy, measured by TN‐Cmin and SF, regardless of patient's age and concomitant use of cytochrome P450 3A4 (CYP3A4) inhibitors/inducers. Results of an extended Cox regression analyses indicated that twofold increases in TN‐Cmin were not associated with statistically significant increases in the risk of stomatitis or infections. Significance The recommended TDM is to target everolimus Cmin within a range of 5‐7 ng/mL initially and 5‐15 ng/mL in the event of an inadequate clinical response, and safety is consistent with previous reports. Starting doses depend on age and the concomitant use of CYP3A4/P‐glycoprotein inducers/inhibitors.
Collapse
Affiliation(s)
- David N Franz
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - John A Lawson
- Tuberous Sclerosis Multidisciplinary Management Clinic, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Zuhal Yapici
- Division of Child Neurology, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Michael H Kohrman
- NeuroDevelopmental Science Center, University of Chicago, Chicago, IL, USA
| | - Michael Wong
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Mathieu Milh
- Pediatric Neurology Service, Aix-Marseille University, Marseille, France
| | | | - Maurizio Voi
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Neva Coello
- Novartis Pharmaceuticals AG, Basel, Switzerland
| | - Wing Cheung
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Kai Grosch
- Novartis Pharmaceuticals AG, Basel, Switzerland
| | | |
Collapse
|
7
|
Uppugunduri CRS, Ansari M. Commentary: A Myriad Aberrations on Information of Ontogeny of Drug Metabolizing Enzymes in the Pediatric Population: An Obstacle for Personalizing Drug Therapy in the Pediatric Population. Drug Metab Lett 2016; 10:72-4. [PMID: 26908134 PMCID: PMC5405624 DOI: 10.2174/1872312810666160224143443] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 02/13/2016] [Accepted: 02/22/2016] [Indexed: 11/22/2022]
Abstract
Major lacunae exist in our understanding of how developmental changes in drug biotransformation influence drug's exposure and thus its efficacy and toxicity in children. It is not just about smaller weight in children, which modifies the pattern of the drug's exposure. There are developmental, functional changes in organ systems, liver to body mass ratios, and changes in metabolism. Understanding these changes and conducting studies to obtain data on ontogeny of drug metabolizing enzymes is essential for implementation of personalized dosing schedules in the pediatric population.
Collapse
Affiliation(s)
| | - Marc Ansari
- Department of Pediatrics, Geneva University Hospitals, Geneva, Switzerland.
| |
Collapse
|
8
|
Veal GJ, Errington J, Sastry J, Chisholm J, Brock P, Morgenstern D, Pritchard-Jones K, Chowdhury T. Adaptive dosing of anticancer drugs in neonates: facilitating evidence-based dosing regimens. Cancer Chemother Pharmacol 2016; 77:685-92. [PMID: 26875154 PMCID: PMC4819938 DOI: 10.1007/s00280-016-2975-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 01/19/2016] [Indexed: 11/25/2022]
Abstract
Purpose Selection of the most appropriate chemotherapy dosing regimens for neonates treated within the first weeks of life represents a significant clinical dilemma. Due to a lack of information relating to the clinical pharmacology of anticancer drugs in these challenging patients, current dosing guidelines are based on limited scientific rationale. In the current study, we investigate the utilisation of therapeutic drug monitoring approaches in neonates with localised hepatoblastoma, Wilms’ tumour and stage 4S neuroblastoma, being treated with widely used anticancer drugs. Methods Plasma concentrations of cisplatin, vincristine, etoposide and carboplatin were quantified in two neonates being treated within the first 3 weeks of life and in a 32-week preterm infant treated at a gestational age of 40 weeks. Therapeutic drug monitoring was carried out where appropriate, based on the pharmacokinetic data obtained in conjunction with clinical response and toxicity. Results Treatment of a child aged 2 weeks with a recommended cisplatin dose reduction for weight to 1.8 mg/kg resulted in achievement of unbound cisplatin plasma concentrations of 0.01–0.08 µg/mL, markedly lower than exposures previously reported in infants and older children. A dose increase to 2.7 mg/kg was implemented, leading to the achievement of levels more in-line with those previously reported. This increased dose level was well tolerated over six courses of treatment, resulting in a good response to cisplatin monotherapy and the patient remains in remission at 3.5 years. In contrast, a 50 % vincristine dose reduction for weight in a 3-week-old neonate resulted in plasma concentrations comparable to levels observed in older children, leading to successful treatment and continued remission at 2 years. In a third patient, etoposide and carboplatin clearance values normalised to body weight were comparable to those reported in older children, resulting in comparatively lower exposures following reduced dosing. Conclusions The current report provides unique data on the pharmacokinetics of several widely used anticancer drugs in neonates treated within the first few weeks of life. The provision of these data acts as a useful reference point to support future dosing decisions to be made by clinicians in the treatment of these challenging patients.
Collapse
Affiliation(s)
- Gareth J Veal
- Northern Institute for Cancer Research, Paul O'Gorman Building, Medical School, Framlington Place, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK.
| | - Julie Errington
- Northern Institute for Cancer Research, Paul O'Gorman Building, Medical School, Framlington Place, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Jairam Sastry
- School of Medicine, Glasgow University, Glasgow, G12 8QQ, UK
| | | | | | | | | | | |
Collapse
|
9
|
Ruggiero A, Rizzo D, Trombatore G, Maurizi P, Riccardi R. The ability of mannitol to decrease cisplatin-induced nephrotoxicity in children: real or not? Cancer Chemother Pharmacol 2015; 77:19-26. [PMID: 26589789 DOI: 10.1007/s00280-015-2913-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/06/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Platinum compounds are very effective drugs for the treatment of childhood malignancies, and their use has contributed to an increase in the long-term survival of children with cancer. Unfortunately, the risk of severe disabling effects such as nephrotoxicity is well known among children receiving cisplatin-based chemotherapy. METHODS The main pharmacodynamics and clinical characteristics of cisplatin nephrotoxicity are described in order to explore the real ability of mannitol to prevent cisplatin-related nephrotoxicity. RESULTS Currently, the choice of hydration alone or hydration plus mannitol to prevent nephrotoxicity is controversial. No guidelines are available to provide recommendations on this issue either in adults or in children. CONCLUSIONS Appropriate hydration remains the main fundamental strategy for reducing the risk of cisplatin-induced nephrotoxicity. In conventional treatment regimens employing doses of cisplatin of less than 100 mg/m(2) in patients with normal renal function, pre- and post-hydration (3 l/m(2) at least 12 h pre-cisplatin and 24 h post-cisplatin) alone should be routinely used. In higher doses, pre- and post-hydration plus mannitol should be considered in order to ensure a valid diuresis.
Collapse
Affiliation(s)
- Antonio Ruggiero
- Division of Pediatric Oncology, A. Gemelli Hospital, Catholic University of Rome, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - Daniela Rizzo
- Division of Pediatric Oncology, A. Gemelli Hospital, Catholic University of Rome, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Giovanna Trombatore
- Division of Pediatric Oncology, A. Gemelli Hospital, Catholic University of Rome, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Palma Maurizi
- Division of Pediatric Oncology, A. Gemelli Hospital, Catholic University of Rome, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Riccardo Riccardi
- Division of Pediatric Oncology, A. Gemelli Hospital, Catholic University of Rome, Largo A. Gemelli 8, 00168, Rome, Italy
| |
Collapse
|
10
|
van den Berg H, Paulussen M, Le Teuff G, Judson I, Gelderblom H, Dirksen U, Brennan B, Whelan J, Ladenstein RL, Marec-Berard P, Kruseova J, Hjorth L, Kühne T, Brichard B, Wheatley K, Craft A, Juergens H, Gaspar N, Le Deley MC. Impact of gender on efficacy and acute toxicity of alkylating agent -based chemotherapy in Ewing sarcoma: secondary analysis of the Euro-Ewing99-R1 trial. Eur J Cancer 2015; 51:2453-64. [PMID: 26271204 DOI: 10.1016/j.ejca.2015.06.123] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 04/20/2015] [Accepted: 06/17/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Based on the randomised Euro-EWING99-R1 trial, vincristine, adriamycin, cyclophosphamide (VAC) may be able to replace vincristine, adriamycin, ifosfamide (VAI) in the treatment of standard-risk Ewing sarcoma. However some heterogeneity of treatment effect by gender was observed. The current exploratory study aimed at investigating the influence of gender on treatment efficacy and acute toxicity. PATIENTS AND METHODS Impact of gender on event-free survival (EFS), acute toxicity by course, switches between treatment arms and cumulative dose of alkylating agents was evaluated in multivariable models adjusted for age including terms to test for heterogeneity of treatment effect by gender. The analysis of the EFS was performed on the intention-to-treat population. RESULTS EFS did not significantly differ between the 509 males and 347 females (p=0.33), but an interaction in terms of efficacy was suspected between treatment and gender (p=0.058): VAC was associated with poorer EFS than VAI in males, hazard ratio (HR) (VAC/VAI)=1.37 [95% confidence interval (CI), 0.98-1.90], contrasting with HR=0.81 [95%CI, 0.53-1.24] in females. Severe toxicity was more frequent in females, whatever the toxicity type. Thirty patients switched from VAI to VAC (9/251 males, 4%, and 21/174 females, 12%) mostly due to renal toxicity, and three from VAC to VAI (2/258 males, 0.8%, and 1/173 females, 0.6%). A reduction of alkylating agent cumulative dose >20% was more frequent in females (15% versus 9%, p=0.005), with no major difference between VAC and VAI (10% versus 13%, p=0.15). CONCLUSION Differences of acute toxicity rate and cumulative doses of alkylating agents could not explain the marginal interaction observed in the Euro-EWING99-R1 trial data. Effects of gender-dependent polymorphism/activity of metabolic enzymes (e.g. known for CYP2B6) of ifosfamide versus cyclophosphamide should be explored. External data are required to further evaluate whether there is heterogeneity of alkylating agent effect by gender. TRIAL NUMBERS NCT00987636 and EudraCT 2008-003658-13.
Collapse
Affiliation(s)
- Henk van den Berg
- Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - Michael Paulussen
- Vestische Kinder-und Jugendklinik Datteln, Witten/Herdecke University, Datteln, Germany
| | | | - Ian Judson
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Uta Dirksen
- Department of Paediatric Hematology and Oncology, University Hospital, Muenster, Germany
| | | | | | | | | | - Jarmila Kruseova
- Department of Paediatric Haematology and Oncology, Charles University, Motol Hospital, Prague, Czech Republic
| | - Lars Hjorth
- Skåne University Hospital, Lund University, Lund, Sweden
| | - Thomas Kühne
- University Children's Hospital Basel, Basel, Switzerland
| | | | - Keith Wheatley
- Cancer Research UK, Cancer Trials Unit, University of Birmingham, Birmingham
| | - Alan Craft
- United Kingdom Sir James Spence Institute, Newcastle upon Tyne, United Kingdom
| | - Heribert Juergens
- Department of Paediatric Hematology and Oncology, University Hospital, Muenster, Germany
| | | | - Marie-Cécile Le Deley
- Institute Gustave Roussy, Villejuif, France; Paris-Sud University, Le Kremlin-Bicêtre, France
| |
Collapse
|
11
|
Veal GJ, Errington J, Hayden J, Hobin D, Murphy D, Dommett RM, Tweddle DA, Jenkinson H, Picton S. Carboplatin therapeutic monitoring in preterm and full-term neonates. Eur J Cancer 2015; 51:2022-30. [PMID: 26232270 PMCID: PMC4571926 DOI: 10.1016/j.ejca.2015.07.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 05/12/2015] [Accepted: 07/13/2015] [Indexed: 11/17/2022]
Abstract
Introduction Administration of the most appropriate dose of chemotherapy to neonates is particularly challenging and frequently not standardised based on any scientific rationale. We report the clinical utility of carboplatin therapeutic drug monitoring in preterm and full-term neonates within the first month of life. Methods Carboplatin therapeutic monitoring was performed to achieve target drug exposures area under the plasma concentration–time curve (AUC values) in nine preterm and full-term neonates diagnosed with retinoblastoma or neuroblastoma treated over an 8 year period. Carboplatin was administered over 3 days with therapeutic drug monitoring utilised to target cumulative AUC values of 5.2–7.8 mg/ml min. Results AUC values achieved were within 15% of target values for the individual courses of treatment in all but one patient (12/13 courses of treatment), with dose modifications of up to 215% required to achieve target AUC values, based on initial mg/kg dosing schedules. Carboplatin clearance determined across three consecutive chemotherapy courses in two patients increased from 3.4 to 7.1 ml/min and from 7.2 to 16.5 ml/min, representing increases of 210–230% over several weeks of treatment. Complete remission was observed in 8/9 patients, with no renal toxicity reported and only one patient experiencing ototoxicity. Conclusion The study highlights the benefits of utilising therapeutic drug monitoring to achieve target carboplatin AUC values in preterm and full-term neonates treated within the first few weeks of life, particularly in view of marked increases in drug clearance observed over consecutive chemotherapy courses. In the absence of therapeutic drug monitoring, body-weight based dosing is recommended, with dosing guidance provided for both approaches to inform future treatment.
Collapse
Affiliation(s)
- Gareth J Veal
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne NE2 4HH, UK.
| | - Julie Errington
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - James Hayden
- Alder Hey Children's NHS Trust, Liverpool L12 2AP, UK
| | - David Hobin
- Birmingham Children's Hospital, Birmingham B4 6NH, UK
| | - Dermot Murphy
- Royal Hospital for Sick Children, Glasgow G3 8SJ, UK
| | | | - Deborah A Tweddle
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; Great North Children's Hospital, Newcastle upon Tyne NE1 4LP, UK
| | | | | |
Collapse
|
12
|
P-glycoprotein in the developing human brain: a review of the effects of ontogeny on the safety of opioids in neonates. Ther Drug Monit 2015; 36:699-705. [PMID: 24819966 DOI: 10.1097/ftd.0000000000000087] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The human blood brain barrier is responsible for maintaining brain homeostasis and protecting against potentially toxic substances. The ATP-binding cassette drug efflux protein, P-glycoprotein (P-gp) is a key player in actively extruding a wide range of xenobiotics such as opioids from the brain. Because the blood brain barrier is structurally and functionally immature in neonates, opioids may have a greater penetration to the central nervous system. This may influence the efficacy and safety of opioids in the newborn. Understanding the extent of P-gp's expression in the brain in the embryo, fetus, and newborn will facilitate rational opioid use during pregnancy and the neonatal period. This review aims to summarize the current evidence that associates the ontogeny of P-gp and the susceptibility to opioid-induced adverse respiratory effects in neonates. To date, evidence suggests that the expression of P-gp in the human brain is low at birth, contributing to increased susceptibility.
Collapse
|
13
|
Kasprzak A, Popławska M, Bystrzejewski M, Łabędź O, Grudziński IP. Conjugation of polyethylenimine and its derivatives to carbon-encapsulated iron nanoparticles. RSC Adv 2015. [DOI: 10.1039/c5ra17912b] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Polyethylenimine and its pre-synthesized derivatives were conjugated to carbon-encapsulated iron nanoparticles.
Collapse
Affiliation(s)
- Artur Kasprzak
- Faculty of Chemistry
- Warsaw University of Technology
- 00-664 Warsaw
- Poland
| | | | | | - Olga Łabędź
- Faculty of Chemistry
- University of Warsaw
- 02-093 Warsaw
- Poland
| | | |
Collapse
|
14
|
van Hasselt JGC, van Eijkelenburg NKA, Beijnen JH, Schellens JHM, Huitema ADR. Optimizing drug development of anti-cancer drugs in children using modelling and simulation. Br J Clin Pharmacol 2014; 76:30-47. [PMID: 23216601 DOI: 10.1111/bcp.12062] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 11/30/2012] [Indexed: 01/04/2023] Open
Abstract
Modelling and simulation (M&S)-based approaches have been proposed to support paediatric drug development in order to design and analyze clinical studies efficiently. Development of anti-cancer drugs in the paediatric population is particularly challenging due to ethical and practical constraints. We aimed to review the application of M&S in the development of anti-cancer drugs in the paediatric population, and to identify where M&S-based approaches could provide additional support in paediatric drug development of anti-cancer drugs. A structured literature search on PubMed was performed. The majority of identified M&S-based studies aimed to use population PK modelling approaches to identify determinants of inter-individual variability, in order to optimize dosing regimens and to develop therapeutic drug monitoring strategies. Prospective applications of M&S approaches for PK-bridging studies have scarcely been reported for paediatric oncology. Based on recent developments of M&S in drug development there are several opportunities where M&S could support more informative bridging between children and adults, and increase efficiency of the design and analysis of paediatric clinical trials, which should ultimately lead to further optimization of drug treatment strategies in this population.
Collapse
Affiliation(s)
- Johan G C van Hasselt
- Department of Clinical Pharmacology, Netherlands Cancer Institute; Department of Pharmacy & Pharmacology, Slotervaart Hospital/Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | | | | | | | | |
Collapse
|
15
|
|
16
|
Dempsey DA, Sambol NC, Jacob P, Hoffmann E, Tyndale RF, Fuentes-Afflick E, Benowitz NL. CYP2A6 genotype but not age determines cotinine half-life in infants and children. Clin Pharmacol Ther 2013; 94:400-6. [PMID: 23714690 PMCID: PMC3820275 DOI: 10.1038/clpt.2013.114] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 05/19/2013] [Indexed: 01/08/2023]
Abstract
The formation of cotinine, the main proximate metabolite and a biomarker of nicotine exposure, is mediated primarily by cytochrome P450 (CYP)2A6. Our aim was to determine whether higher cotinine levels in young children exposed to secondhand smoke (SHS) are a result of age-related differences in pharmacokinetics. Forty-nine participants, aged 2-84 months, received oral deuterium-labeled cotinine, with daily urine samples for up to 10 days for cotinine half-life measurement. DNA from saliva was used for CYP2A6 genotyping. The estimate of half-life using a mixed-effect model was 17.9 h (95% confidence interval: 16.5, 19.3), similar to that reported in adults. There was no statistically significant effect of sex, race, age, or weight. Children with normal-activity CYP2A6*1/*1 genotypes had a shorter half-life than those with one or two reduced-activity variant alleles. Our data suggest that higher cotinine levels in SHS-exposed young children as compared with adults are due to greater SHS exposure rather than to different cotinine pharmacokinetics.
Collapse
Affiliation(s)
- D A Dempsey
- Division of Clinical Pharmacology and Experimental Therapeutics, Medical Service, San Francisco General Hospital Medical Center, San Francisco, California, USA
| | | | | | | | | | | | | |
Collapse
|
17
|
van den Anker J, Allegaert K. Clinical pharmacology in neonates and young infants: the benefit of a population-tailored approach. Expert Rev Clin Pharmacol 2012; 5:5-8. [PMID: 22142152 DOI: 10.1586/ecp.11.65] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
18
|
Saghir SA, Khan SA, McCoy AT. Ontogeny of mammalian metabolizing enzymes in humans and animals used in toxicological studies. Crit Rev Toxicol 2012; 42:323-57. [PMID: 22512665 DOI: 10.3109/10408444.2012.674100] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
It is well recognized that expression of enzymes varies during development and growth. However, an in-depth review of this acquired knowledge is needed to translate the understanding of enzyme expression and activity into the prediction of change in effects (e.g. kinetics and toxicity) of xenobiotics with age. Age-related changes in metabolic capacity are critical for understanding and predicting the potential differences resulting from exposure. Such information may be especially useful in the evaluation of the risk of exposure to very low (µg/kg/day or ng/kg/day) levels of environmental chemicals. This review is to better understand the ontogeny of metabolizing enzymes in converting chemicals to either less-toxic metabolite(s) or more toxic products (e.g. reactive intermediate[s]) during stages before birth and during early development (neonate/infant/child). In this review, we evaluated the ontogeny of major "phase I" and "phase II" metabolizing enzymes in humans and commonly used experimental animals (e.g. mouse, rat, and others) in order to fill the information gap.
Collapse
Affiliation(s)
- Shakil Ahmed Saghir
- Toxicology & Environmental Research & Consulting, The Dow Chemical Company, Midland, Michigan, USA.
| | | | | |
Collapse
|
19
|
Abstract
The determination of appropriate dosing regimens for the treatment of infants and very young children with cancer represents a major challenge in paediatric oncology. Whereas dose reductions are commonplace for many chemotherapeutics in this patient group, the appropriateness of dose reductions for drugs is unclear when the limited number of published studies reporting on pharmacokinetics in infant patient populations are considered. Developmental physiological changes, potentially impacting significantly on drug disposition, occur throughout childhood, with a number of important changes observed within the first few weeks from birth. The current review focuses on the developmental physiology of preterm babies and infants and the potential impact of physiological changes on drug disposition, clinical response and toxicity. Dose reductions for a number of important anticancer drugs are compared between tumour types and clinical protocols. Where data exist, differences in pharmacokinetics between infants and older children are highlighted. In addition, the impact of confounding factors relating to the availability of appropriate drug formulations and ethical challenges concerning the conduct of clinical pharmacology studies in infant patient populations are addressed. As many currently used drugs are highly likely to be important in the treatment of cancer in infants and young children for the foreseeable future, it would seem advantageous for appropriately planned population pharmacokinetic studies to be carried out in this patient population.
Collapse
|
20
|
Hutson JR, Weitzman S, Schechter T, Arceci RJ, Kim RB, Finkelstein Y. Pharmacokinetic and pharmacogenetic determinants and considerations in chemotherapy selection and dosing in infants. Expert Opin Drug Metab Toxicol 2012; 8:709-22. [PMID: 22509821 DOI: 10.1517/17425255.2012.680884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION There is a lack of high-quality data regarding optimal chemotherapy dosage regimens among infants. Dosing regimens for chemotherapy during the first year of life are commonly based on empiric recommendations extrapolated from older children; however, balancing efficacy and toxicity is critical as severe adverse drug reactions may lead to treatment failure or reduced adherence to needed medications. AREAS COVERED This review describes pharmacokinetic and pharmacogenetic considerations when administering chemotherapeutic agents to infants. Examples of commonly used agents are provided with practical recommendations for dosing adjustments. EXPERT OPINION Optimal chemotherapy for children and infants in particular has lagged behind the remarkable progress in cancer treatment and it is clear that far more basic and clinical research are needed with respect to the mechanistic basis of age-dependent differences in pharmacokinetic parameters. More recent studies which have combined pharmacokinetic data with clinical toxicity and outcome data have resulted in a number of more evidence-based guidelines at least for the initial chemotherapy dosing; however, at present, the dosing of chemotherapy drugs in neonates and infants remains largely empiric.
Collapse
Affiliation(s)
- Janine R Hutson
- University of Toronto, Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, 555 University Ave, Toronto ON, M5G 1X8, Canada
| | | | | | | | | | | |
Collapse
|