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Margol AS, Molinaro AM, Onar-Thomas A, Resnick A, Hanson D, Kieran M, Mishra-Kalyani P, Rivera D, Barone A, Arons D, Meehan C, Prados M. Use of External Control Cohorts in Pediatric Brain Tumor Clinical Trials. J Clin Oncol 2024; 42:1340-1343. [PMID: 38394473 DOI: 10.1200/jco.23.01084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 11/18/2023] [Accepted: 01/03/2024] [Indexed: 02/25/2024] Open
Abstract
Why, when, and how to consider external control cohorts in pediatric brain tumor clinical trials.
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Affiliation(s)
- Ashley S Margol
- Keck School of Medicine of University of Southern California, Cancer and Blood Disease Institute at Children's Hospital Los Angeles, Los Angeles, CA
| | - Annette M Molinaro
- Division of Biomedical Statistics and Informatics, Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | | | - Adam Resnick
- Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Derek Hanson
- Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack, NJ
| | | | | | | | - Amy Barone
- US Food and Drug Administration, Washington, DC
| | | | | | - Michael Prados
- Departments of Neurosurgery and Pediatrics, University of California, San Francisco, San Francisco, CA
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Mueller S, Kline C, Stoller S, Lundy S, Christopher L, Reddy AT, Banerjee A, Cooney TM, Raber S, Hoffman C, Luks T, Wembacher-Schroeder E, Lummel N, Zhang Y, Bonner ER, Nazarian J, Molinaro AM, Prados M, Villanueva-Meyer JE, Gupta N. PNOC015: Repeated convection-enhanced delivery of MTX110 (aqueous panobinostat) in children with newly diagnosed diffuse intrinsic pontine glioma. Neuro Oncol 2023; 25:2074-2086. [PMID: 37318058 PMCID: PMC10628948 DOI: 10.1093/neuonc/noad105] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND The objective of this study was to determine the safety, tolerability, and distribution of MTX110 (aqueous panobinostat) delivered by convection-enhanced delivery (CED) in patients with newly diagnosed diffuse intrinsic pontine glioma (DIPG) who completed focal radiation therapy (RT). METHODS Patients with DIPG (2-21 years) were enrolled after RT. CED of MTX110 combined with gadoteridol was completed across 7 dose levels (DL) (30-90 µM; volumes ranging from 3 mL to 2 consecutive doses of 6 mL). An accelerated dose escalation design was used. Distribution of infusate was monitored with real-time MR imaging. Repeat CED was performed every 4-8 weeks. Quality-of-life (QoL) assessments were obtained at baseline, every 3 months on therapy, and end of therapy. RESULTS Between May 2018 and March 2020, 7 patients who received a total of 48 CED infusions, were enrolled (median age 8 years, range 5-21). Three patients experienced dose-limited toxicities. Four grade 3 treatment-related adverse events were observed. Most toxicities were transient new or worsening neurologic function. Median overall survival (OS) was 26.1 months (95% confidence interval: 14.8-not reached). Progression-free survival was 4-14 months (median, 7). Cumulative percentage of tumor coverage for combined CED infusions per patient ranged from 35.6% to 81.0%. Increased CED infusions were negatively associated with self-reported QoL assessments. CONCLUSION Repeat CED of MTX110 with real-time imaging with gadoteridol is tolerable for patients with DIPG. Median OS of 26.1 months compares favorably with historical data for children with DIPG. The results support further investigation of this strategy in a larger cohort.
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Affiliation(s)
- Sabine Mueller
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Department of Pediatrics, University of Zurich, Zurich, Switzerland
| | - Cassie Kline
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Schuyler Stoller
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Shannon Lundy
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Lauren Christopher
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Alyssa T Reddy
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Anu Banerjee
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Tabitha M Cooney
- Department of Pediatric Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorder Center, Boston, Massachusetts, USA
| | - Shannon Raber
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Carly Hoffman
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Tracy Luks
- Department of Radiology, University of California, San Francisco, San Francisco, California, USA
| | | | | | - Yalan Zhang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Erin R Bonner
- Center for Genetic Medicine Research, Children’s National Medical Center, Washington, DC, USA
| | - Javad Nazarian
- Department of Pediatrics, University of Zurich, Zurich, Switzerland
- Center for Genetic Medicine Research, Children’s National Medical Center, Washington, DC, USA
| | - Annette M Molinaro
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Michael Prados
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Javier E Villanueva-Meyer
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Department of Radiology, University of California, San Francisco, San Francisco, California, USA
| | - Nalin Gupta
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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Parsels LA, Wahl DR, Koschmann C, Morgan MA, Zhang Q. Developing H3K27M mutant selective radiosensitization strategies in diffuse intrinsic pontine glioma. Neoplasia 2023; 37:100881. [PMID: 36724689 PMCID: PMC9918797 DOI: 10.1016/j.neo.2023.100881] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/13/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023]
Abstract
Diffuse intrinsic pontine glioma (DIPG) is a rare but highly lethal pediatric and adolescent tumor located in the pons of the brainstem. DIPGs harbor unique and specific pathological and molecular alterations, such as the hallmark lysine 27-to-methionine (H3K27M) mutation in histone H3, which lead to global changes in the epigenetic landscape and drive tumorigenesis. While fractionated radiotherapy, the current standard of care, improves symptoms and delays tumor progression, DIPGs inevitably recur, and despite extensive efforts chemotherapy-driven radiosensitization strategies have failed to improve survival. Advances in our understanding of the role of epigenetics in the cellular response to radiation-induced DNA damage, however, offer new opportunities to develop combinational therapeutic strategies selective for DIPGs expressing H3K27M. In this review, we provide an overview of preclinical studies that explore potential radiosensitization strategies targeting the unique epigenetic landscape of H3K27M mutant DIPG. We further discuss opportunities to selectively radiosensitize DIPG through strategic inhibition of the radiation-induced DNA damage response. Finally, we discuss the potential for using radiation to induce anti-tumor immune responses that may be potentiated in DIPG by radiosensitizing-therapeutic strategies.
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Affiliation(s)
- Leslie A Parsels
- Department of Radiation Oncology, Rogel Cancer Center, University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI, 48109, USA
| | - Daniel R Wahl
- Department of Radiation Oncology, Rogel Cancer Center, University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI, 48109, USA
| | - Carl Koschmann
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Meredith A Morgan
- Department of Radiation Oncology, Rogel Cancer Center, University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI, 48109, USA.
| | - Qiang Zhang
- Department of Radiation Oncology, Rogel Cancer Center, University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI, 48109, USA.
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Boscencu R, Radulea N, Manda G, Machado IF, Socoteanu RP, Lupuliasa D, Burloiu AM, Mihai DP, Ferreira LFV. Porphyrin Macrocycles: General Properties and Theranostic Potential. Molecules 2023; 28:molecules28031149. [PMID: 36770816 PMCID: PMC9919320 DOI: 10.3390/molecules28031149] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/26/2023] Open
Abstract
Despite specialists' efforts to find the best solutions for cancer diagnosis and therapy, this pathology remains the biggest health threat in the world. Global statistics concerning deaths associated with cancer are alarming; therefore, it is necessary to intensify interdisciplinary research in order to identify efficient strategies for cancer diagnosis and therapy, by using new molecules with optimal therapeutic potential and minimal adverse effects. This review focuses on studies of porphyrin macrocycles with regard to their structural and spectral profiles relevant to their applicability in efficient cancer diagnosis and therapy. Furthermore, we present a critical overview of the main commercial formulations, followed by short descriptions of some strategies approached in the development of third-generation photosensitizers.
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Affiliation(s)
- Rica Boscencu
- Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia, 020956 Bucharest, Romania
- Correspondence: (R.B.); (R.P.S.); (A.M.B.); (L.F.V.F.)
| | - Natalia Radulea
- Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia, 020956 Bucharest, Romania
| | - Gina Manda
- “Victor Babeş” National Institute of Pathology, 050096 Bucharest, Romania
| | - Isabel Ferreira Machado
- Polytechnic Institute of Portalegre, 7300-110 Portalegre, Portugal
- BSIRG—Biospectroscopy and Interfaces Research Group, iBB-Institute for Bioengineering and Biosciences, Instituto Superior Técnico and Associate Laboratory i4HB—Institute for Health and Bioeconomy at Instituto Superior Técnico, Universidade de Lisboa, 1049-001 Lisboa, Portugal
| | - Radu Petre Socoteanu
- “Ilie Murgulescu” Institute of Physical Chemistry, Romanian Academy, 060021 Bucharest, Romania
- Correspondence: (R.B.); (R.P.S.); (A.M.B.); (L.F.V.F.)
| | - Dumitru Lupuliasa
- Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia, 020956 Bucharest, Romania
| | - Andreea Mihaela Burloiu
- Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia, 020956 Bucharest, Romania
- Correspondence: (R.B.); (R.P.S.); (A.M.B.); (L.F.V.F.)
| | - Dragos Paul Mihai
- Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia, 020956 Bucharest, Romania
| | - Luis Filipe Vieira Ferreira
- BSIRG—Biospectroscopy and Interfaces Research Group, iBB-Institute for Bioengineering and Biosciences, Instituto Superior Técnico and Associate Laboratory i4HB—Institute for Health and Bioeconomy at Instituto Superior Técnico, Universidade de Lisboa, 1049-001 Lisboa, Portugal
- Correspondence: (R.B.); (R.P.S.); (A.M.B.); (L.F.V.F.)
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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.
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Di Ruscio V, Del Baldo G, Fabozzi F, Vinci M, Cacchione A, de Billy E, Megaro G, Carai A, Mastronuzzi A. Pediatric Diffuse Midline Gliomas: An Unfinished Puzzle. Diagnostics (Basel) 2022; 12:diagnostics12092064. [PMID: 36140466 PMCID: PMC9497626 DOI: 10.3390/diagnostics12092064] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/22/2022] [Indexed: 11/15/2022] Open
Abstract
Diffuse midline glioma (DMG) is a heterogeneous group of aggressive pediatric brain tumors with a fatal prognosis. The biological hallmark in the major part of the cases is H3K27 alteration. Prognosis remains poor, with median survival ranging from 9 to 12 months from diagnosis. Clinical and radiological prognostic factors only partially change the progression-free survival but they do not improve the overall survival. Despite efforts, there is currently no curative therapy for DMG. Radiotherapy remains the standard treatment with only transitory benefits. No chemotherapeutic regimens were found to significantly improve the prognosis. In the new era of a deeper integration between histological and molecular findings, potential new approaches are currently under investigation. The entire international scientific community is trying to target DMG on different aspects. The therapeutic strategies involve targeting epigenetic alterations, such as methylation and acetylation status, as well as identifying new molecular pathways that regulate oncogenic proliferation; immunotherapy approaches too are an interesting point of research in the oncology field, and the possibility of driving the immune system against tumor cells has currently been evaluated in several clinical trials, with promising preliminary results. Moreover, thanks to nanotechnology amelioration, the development of innovative delivery approaches to overcross a hostile tumor microenvironment and an almost intact blood–brain barrier could potentially change tumor responses to different treatments. In this review, we provide a comprehensive overview of available and potential new treatments that are worldwide under investigation, with the intent that patient- and tumor-specific treatment could change the biological inauspicious history of this disease.
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Affiliation(s)
- Valentina Di Ruscio
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Giada Del Baldo
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Francesco Fabozzi
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
- Department of Pediatrics, University of Rome Tor Vergata, 00165 Rome, Italy
| | - Maria Vinci
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Antonella Cacchione
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Emmanuel de Billy
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Giacomina Megaro
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Andrea Carai
- Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Angela Mastronuzzi
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
- Faculty of Medicine and Surgery, Saint Camillus International University of Health Sciences, 00131 Rome, Italy
- Correspondence:
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Mueller S, Cooney T, Yang X, Pal S, Ermoian R, Gajjar A, Liu X, Prem K, Minard CG, Reid JM, Nelson M, Haas-Kogan D, Fox E, Weigel BJ. Wee1 kinase inhibitor adavosertib with radiation in newly diagnosed diffuse intrinsic pontine glioma: A Children's Oncology Group phase I consortium study. Neurooncol Adv 2022; 4:vdac073. [PMID: 35733515 PMCID: PMC9209747 DOI: 10.1093/noajnl/vdac073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background Children with diffuse intrinsic pontine gliomas (DIPG) have a dismal prognosis. Adavosertib (AZD1775) is an orally available, blood-brain barrier penetrant, Wee1 kinase inhibitor. Preclinical efficacy against DIPG is heightened by radiation induced replication stress. Methods Using a rolling six design, 7 adavosertib dose levels (DLs) (50 mg/m2 alternating weeks, 50 mg/m2 alternating with weeks of every other day, 50 mg/m2, then 95, 130, 160, 200 mg/m2) were assessed. Adavosertib was only given on days of cranial radiation therapy (CRT).The duration of CRT (54 Gy over 30 fractions; 6 weeks) constituted the dose limiting toxicity (DLT) period. Endpoints included tolerability, pharmacokinetics, overall survival (OS) and peripheral blood γH2AX levels as a marker of DNA damage. Results A total of 46 eligible patients with newly diagnosed DIPG [median (range) age 6 (3-21) years; 52% female] were enrolled. The recommend phase 2 dose (RP2D) of adavosertib was 200 mg/m2/d during days of CRT. Dose limiting toxicity included ALT elevation (n = 1, DL4) and neutropenia (n = 1, DL7). The mean Tmax, T1/2 and Clp on Day 1 were 2 h, 4.4 h, and 45.2 L/hr/m2, respectively. Modest accumulation of adavosertib was observed comparing day 5 versus day 1 AUC0-8h (accumulation ratio = 1.6). OS was 11.1 months (95% CI: 9.4, 12.5) and did not differ from historical control. Conclusion Adavosertib in combination with CRT is well tolerated in children with newly diagnosed DIPG, however, compared to historical controls, did not improve OS. These results can inform future trial design in children with high-risk cancer.
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Affiliation(s)
- Sabine Mueller
- Department of Neurology, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Tabitha Cooney
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Xiaodong Yang
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Sharmistha Pal
- Department of Radiation Oncology, Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ralph Ermoian
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington
| | - Amar Gajjar
- St. Jude Children’s Research Hospital, Memphis, Tenesse
| | - Xiaowei Liu
- Children’s Oncology Group, Monrovia, California
| | - Komal Prem
- Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Charles G Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Joel M Reid
- Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Marvin Nelson
- Children’s Hospital Los Angeles, Radiology, Keck USC School of Medicine, Los Angeles, California
| | - Daphne Haas-Kogan
- Department of Radiation Oncology, Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Fox
- St. Jude Children’s Research Hospital, Memphis, Tenesse
| | - Brenda J Weigel
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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Childhood Malignant Brain Tumors: Balancing the Bench and Bedside. Cancers (Basel) 2021; 13:cancers13236099. [PMID: 34885207 PMCID: PMC8656510 DOI: 10.3390/cancers13236099] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/29/2021] [Accepted: 11/29/2021] [Indexed: 01/28/2023] Open
Abstract
Simple Summary Brain tumors remain the most common childhood solid tumors, accounting for approximately 25% of all pediatric cancers. They also represent the most common cause of cancer-related illness and death in this age group. Recent years have witnessed an evolution in our understanding of the biological underpinnings of many childhood brain tumors, potentially improving survival through both improved risk group allocation for patients to provide appropriate treatment intensity, and novel therapeutic breakthroughs. This review aims to summarize the molecular landscape, current trial-based standards of care, novel treatments being explored and future challenges for the three most common childhood malignant brain tumors—medulloblastomas, high-grade gliomas and ependymomas. Abstract Brain tumors are the leading cause of childhood cancer deaths in developed countries. They also represent the most common solid tumor in this age group, accounting for approximately one-quarter of all pediatric cancers. Developments in neuro-imaging, neurosurgical techniques, adjuvant therapy and supportive care have improved survival rates for certain tumors, allowing a future focus on optimizing cure, whilst minimizing long-term adverse effects. Recent times have witnessed a rapid evolution in the molecular characterization of several of the common pediatric brain tumors, allowing unique clinical and biological patient subgroups to be identified. However, a resulting paradigm shift in both translational therapy and subsequent survival for many of these tumors remains elusive, while recurrence remains a great clinical challenge. This review will provide an insight into the key molecular developments and global co-operative trial results for the most common malignant pediatric brain tumors (medulloblastoma, high-grade gliomas and ependymoma), highlighting potential future directions for management, including novel therapeutic options, and critical challenges that remain unsolved.
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Price G, Bouras A, Hambardzumyan D, Hadjipanayis CG. Current knowledge on the immune microenvironment and emerging immunotherapies in diffuse midline glioma. EBioMedicine 2021; 69:103453. [PMID: 34157482 PMCID: PMC8220552 DOI: 10.1016/j.ebiom.2021.103453] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 12/29/2022] Open
Abstract
Diffuse midline glioma (DMG) is an incurable malignancy with the highest mortality rate among pediatric brain tumors. While radiotherapy and chemotherapy are the most common treatments, these modalities have limited promise. Due to their diffuse nature in critical areas of the brain, the prognosis of DMG remains dismal. DMGs are characterized by unique phenotypic heterogeneity and histological features. Mutations of H3K27M, TP53, and ACVR1 drive DMG tumorigenesis. Histological artifacts include pseudopalisading necrosis and vascular endothelial proliferation. Mouse models that recapitulate human DMG have been used to study key driver mutations and the tumor microenvironment. DMG consists of a largely immunologically cold tumor microenvironment that lacks immune cell infiltration, immunosuppressive factors, and immune surveillance. While tumor-associated macrophages are the most abundant immune cell population, there is reduced T lymphocyte infiltration. Immunotherapies can stimulate the immune system to find, attack, and eliminate cancer cells. However, it is critical to understand the immune microenvironment of DMG before designing immunotherapies since differences in the microenvironment influence treatment efficacy. To this end, our review aims to overview the immune microenvironment of DMG, discuss emerging insights about the immune landscape that drives disease pathophysiology, and present recent findings and new opportunities for therapeutic discovery.
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Affiliation(s)
- Gabrielle Price
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai,10 Union Square East, 5th Floor, Suite 5E, New York, NY 10003, USA; Department of Oncological Sciences, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Nash Family Department of Neuroscience, Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Alexandros Bouras
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai,10 Union Square East, 5th Floor, Suite 5E, New York, NY 10003, USA; Department of Oncological Sciences, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dolores Hambardzumyan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai,10 Union Square East, 5th Floor, Suite 5E, New York, NY 10003, USA; Department of Oncological Sciences, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Constantinos G Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai,10 Union Square East, 5th Floor, Suite 5E, New York, NY 10003, USA; Department of Oncological Sciences, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Metselaar DS, du Chatinier A, Stuiver I, Kaspers GJL, Hulleman E. Radiosensitization in Pediatric High-Grade Glioma: Targets, Resistance and Developments. Front Oncol 2021; 11:662209. [PMID: 33869066 PMCID: PMC8047603 DOI: 10.3389/fonc.2021.662209] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/17/2021] [Indexed: 12/25/2022] Open
Abstract
Pediatric high-grade gliomas (pHGG) are the leading cause of cancer-related death in children. These epigenetically dysregulated tumors often harbor mutations in genes encoding histone 3, which contributes to a stem cell-like, therapy-resistant phenotype. Furthermore, pHGG are characterized by a diffuse growth pattern, which, together with their delicate location, makes complete surgical resection often impossible. Radiation therapy (RT) is part of the standard therapy against pHGG and generally the only modality, apart from surgery, to provide symptom relief and a delay in tumor progression. However, as a single treatment modality, RT still offers no chance for a cure. As with most therapeutic approaches, irradiated cancer cells often acquire resistance mechanisms that permit survival or stimulate regrowth after treatment, thereby limiting the efficacy of RT. Various preclinical studies have investigated radiosensitizers in pHGG models, without leading to an improved clinical outcome for these patients. However, our recently improved molecular understanding of pHGG generates new opportunities to (re-)evaluate radiosensitizers in these malignancies. Furthermore, the use of radio-enhancing agents has several benefits in pHGG compared to other cancers, which will be discussed here. This review provides an overview and a critical evaluation of the radiosensitization strategies that have been studied to date in pHGG, thereby providing a framework for improving radiosensitivity of these rapidly fatal brain tumors.
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Affiliation(s)
- Dennis S Metselaar
- Department of Neuro-oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands.,Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Oncology, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Aimée du Chatinier
- Department of Neuro-oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Iris Stuiver
- Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Oncology, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Gertjan J L Kaspers
- Department of Neuro-oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands.,Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Oncology, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Esther Hulleman
- Department of Neuro-oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
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11
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Williams JR, Young CC, Vitanza NA, McGrath M, Feroze AH, Browd SR, Hauptman JS. Progress in diffuse intrinsic pontine glioma: advocating for stereotactic biopsy in the standard of care. Neurosurg Focus 2021; 48:E4. [PMID: 31896081 DOI: 10.3171/2019.9.focus19745] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 09/20/2019] [Indexed: 11/06/2022]
Abstract
Diffuse intrinsic pontine glioma (DIPG) is a universally fatal pediatric brainstem tumor affecting approximately 300 children in the US annually. Median survival is less than 1 year, and radiation therapy has been the mainstay of treatment for decades. Recent advances in the biological understanding of the disease have identified the H3K27M mutation in nearly 80% of DIPGs, leading to the 2016 WHO classification of diffuse midline glioma H3K27M-mutant, a grade IV brainstem tumor. Developments in epigenetic targeting of transcriptional tendencies have yielded potential molecular targets for clinical trials. Chimeric antigen receptor T cell therapy has also shown preclinical promise. Recent clinical studies, including prospective trials, have demonstrated the safety and feasibility of pediatric brainstem biopsy in the setting of DIPG and other brainstem tumors. Given developments in the ability to analyze DIPG tumor tissue to deepen biological understanding of this disease and develop new therapies for treatment, together with the increased safety of stereotactic brainstem biopsy, the authors present a case for offering biopsy to all children with suspected DIPG. They also present their standard operative techniques for image-guided, frameless stereotactic biopsy.
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Affiliation(s)
- John R Williams
- 1Department of Neurological Surgery, University of Washington
| | | | - Nicholas A Vitanza
- 2Division of Hematology/Oncology, Department of Pediatrics, Seattle Children's Hospital; and
| | | | | | - Samuel R Browd
- 3Division of Neurosurgery, Seattle Children's Hospital, Seattle, Washington
| | - Jason S Hauptman
- 3Division of Neurosurgery, Seattle Children's Hospital, Seattle, Washington
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12
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Radio-Resistance and DNA Repair in Pediatric Diffuse Midline Gliomas. Cancers (Basel) 2020; 12:cancers12102813. [PMID: 33007840 PMCID: PMC7600397 DOI: 10.3390/cancers12102813] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/27/2020] [Accepted: 09/28/2020] [Indexed: 12/15/2022] Open
Abstract
Malignant gliomas (MG) are among the most prevalent and lethal primary intrinsic brain tumors. Although radiotherapy (RT) is the most effective nonsurgical therapy, recurrence is universal. Dysregulated DNA damage response pathway (DDR) signaling, rampant genomic instability, and radio-resistance are among the hallmarks of MGs, with current therapies only offering palliation. A subgroup of pediatric high-grade gliomas (pHGG) is characterized by H3K27M mutation, which drives global loss of di- and trimethylation of histone H3K27. Here, we review the most recent literature and discuss the key studies dissecting the molecular biology of H3K27M-mutated gliomas in children. We speculate that the aberrant activation and/or deactivation of some of the key components of DDR may be synthetically lethal to H3K27M mutation and thus can open novel avenues for effective therapeutic interventions for patients suffering from this deadly disease.
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13
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Choi J, Kim G, Cho SB, Im HJ. Radiosensitizing high-Z metal nanoparticles for enhanced radiotherapy of glioblastoma multiforme. J Nanobiotechnology 2020; 18:122. [PMID: 32883290 PMCID: PMC7470617 DOI: 10.1186/s12951-020-00684-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/28/2020] [Indexed: 12/13/2022] Open
Abstract
Radiotherapy is an essential step during the treatment of glioblastoma multiforme (GBM), one of the most lethal malignancies. The survival in patients with GBM was improved by the current standard of care for GBM established in 2005 but has stagnated since then. Since GBM is a radioresistant malignancy and the most of GBM recurrences occur in the radiotherapy field, increasing the effectiveness of radiotherapy using high-Z metal nanoparticles (NPs) has recently attracted attention. This review summarizes the progress in radiotherapy approaches for the current treatment of GBM, the physical and biological mechanisms of radiosensitization through high-Z metal NPs, and the results of studies on radiosensitization in the in vitro and in vivo GBM models using high-Z metal NPs to date.
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Affiliation(s)
- Jinyeong Choi
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Republic of Korea
| | - Gaeun Kim
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Republic of Korea
| | - Su Bin Cho
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Republic of Korea
| | - Hyung-Jun Im
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Republic of Korea.
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14
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Convection Enhanced Delivery for Diffuse Intrinsic Pontine Glioma: Review of a Single Institution Experience. Pharmaceutics 2020; 12:pharmaceutics12070660. [PMID: 32674336 PMCID: PMC7407112 DOI: 10.3390/pharmaceutics12070660] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/11/2020] [Accepted: 07/13/2020] [Indexed: 01/24/2023] Open
Abstract
Diffuse intrinsic pontine gliomas (DIPGs) are a pontine subtype of diffuse midline gliomas (DMGs), primary central nervous system (CNS) tumors of childhood that carry a terrible prognosis. Because of the highly infiltrative growth pattern and the anatomical position, cytoreductive surgery is not an option. An initial response to radiation therapy is invariably followed by recurrence; mortality occurs approximately 11 months after diagnosis. The development of novel therapeutics with great preclinical promise has been hindered by the tightly regulated blood-brain barrier (BBB), which segregates the tumor comportment from the systemic circulation. One possible solution to this obstacle is the use of convection enhanced delivery (CED), a local delivery strategy that bypasses the BBB by direct infusion into the tumor through a small caliber cannula. We have recently shown CED to be safe in children with DIPG (NCT01502917). In this review, we discuss our experience with CED, its advantages, and technical advancements that are occurring in the field. We also highlight hurdles that will likely need to be overcome in demonstrating clinical benefit with this therapeutic strategy.
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15
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Fonseca A, Afzal S, Bowes L, Crooks B, Larouche V, Jabado N, Perreault S, Johnston DL, Zelcer S, Fleming A, Scheinemann K, Silva M, Vanan MI, Mpofu C, Wilson B, Eisenstat DD, Lafay-Cousin L, Hukin J, Hawkins C, Bartels U, Bouffet E. Pontine gliomas a 10-year population-based study: a report from The Canadian Paediatric Brain Tumour Consortium (CPBTC). J Neurooncol 2020; 149:45-54. [PMID: 32632896 DOI: 10.1007/s11060-020-03568-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/22/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Diffuse intrinsic pontine gliomas (DIPG) are midline gliomas that arise from the pons and the majority are lethal within a few months after diagnosis. Due to the lack of histological diagnosis the epidemiology of DIPG is not completely understood. The aim of this report is to provide population-based data to characterize the descriptive epidemiology of this condition in Canadian children. PATIENTS AND METHODS A national retrospective study of children and adolescents diagnosed with DIPG between 2000 and 2010 was undertaken. All cases underwent central review to determine clinical and radiological diagnostic characteristics. Crude incidence figures were calculated using age-adjusted (0-17 year) population data from Statistics Canada. Survival analyses were performed using the Kaplan-Meier method. RESULTS A total of 163 patients with pontine lesions were identified. Central review determined one-hundred and forty-three patients who met clinical, radiological and/or histological criteria for diagnosis. We estimate an incidence rate of 1.9 DIPG/1,000,000 children/year in the Canadian population over a 10 years period. Median age at diagnosis was 6.8 years and 50.3% of patients were female. Most patients presented with cranial nerve palsies (76%) and ataxia (66%). Despite typical clinical and radiological characteristics, histological confirmation reported three lesions to be low-grade gliomas and three were diagnosed as CNS embryonal tumor not otherwise specified (NOS). CONCLUSIONS Our study highlights the challenges associated with epidemiology studies on DIPG and the importance of central review for incidence rate estimations. It emphasizes that tissue biopsies are required for accurate histological and molecular diagnosis in patients presenting with pontine lesions and reinforces the limitations of radiological and clinical diagnosis in DIPG. Likewise, it underscores the urgent need to increase the availability and accessibility to clinical trials.
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Affiliation(s)
- Adriana Fonseca
- Division of Haematology Oncology, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, M5G 1X8, Canada.
| | - Samina Afzal
- IWK Health Center, Dalhousie University, Halifax, B3K 6R8, Canada.,Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Lynette Bowes
- Janeway Child Health Center, Memorial University, St. John's, A1B 3V6, Canada
| | - Bruce Crooks
- IWK Health Center, Dalhousie University, Halifax, B3K 6R8, Canada
| | - Valerie Larouche
- CHU de Québec- Université Laval, Laval University, Québec, G1V 4G2, Canada
| | - Nada Jabado
- Montreal Children's Hospital, McGill University, Montreal, H4A 3J1, Canada
| | - Sebastien Perreault
- Centre Hospitalier Universitaire Sainte, Justine, Université de Montreal, Montreal, H3T 1C5, Canada
| | - Donna L Johnston
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, K1H 8L1, Canada
| | - Shayna Zelcer
- London Health Sciences Children's Hospital, Western University, London, N6A 5A5, Canada
| | - Adam Fleming
- McMaster Children's Hospital, McMaster University, Hamilton, L8P 1H1, Canada
| | - Katrin Scheinemann
- McMaster Children's Hospital, McMaster University, Hamilton, L8P 1H1, Canada.,Department of Pediatrics, Kantonsspital Aarau, Aarau, Switzerland.,University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Mariana Silva
- Kingston General Hospital, Queens University, Kingston, K7L 2V7, Canada
| | - Magimairajan Issai Vanan
- Cancer Care Manitoba, Pediatrics and Child Health, University of Manitoba, Winnipeg, R3E 0V9, Canada
| | - Chris Mpofu
- Jim Pattison Children's Hospital, University of Saskatchewan, Saskatoon, S7N 0W8, Canada
| | - Beverly Wilson
- Stollery Children's Hospital, University of Alberta, Edmonton, T6G 2B7, Canada
| | - David D Eisenstat
- Stollery Children's Hospital, University of Alberta, Edmonton, T6G 2B7, Canada
| | - Lucie Lafay-Cousin
- Alberta Children's Hospital, University of Calgary, Calgary, T3B 6A8, Canada
| | - Juliette Hukin
- BC Children's Hospital, University of British Columbia, Vancouver, V6H 3N1, Canada
| | - Cynthia Hawkins
- Division of Haematology Oncology, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, M5G 1X8, Canada
| | - Ute Bartels
- Division of Haematology Oncology, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, M5G 1X8, Canada
| | - Eric Bouffet
- Division of Haematology Oncology, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, M5G 1X8, Canada
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16
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Felker J, Broniscer A. Improving long-term survival in diffuse intrinsic pontine glioma. Expert Rev Neurother 2020; 20:647-658. [PMID: 32543245 DOI: 10.1080/14737175.2020.1775584] [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] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Diffuse intrinsic pontine glioma (DIPG) is an almost universally fatal pediatric brain cancer. There has been no improvement in event-free survival (EFS) or overall survival (OS) despite immense effort through a multitude of clinical trials to find a cure. Recently, there has been a surge in the knowledge of DIPG biology, including the discovery of a recurrent H3F3A mutation in over 80% of these tumors. AREAS COVERED The authors review the most recent approaches to diagnosis and treatment of DIPG including chemotherapy, biologics, surgical approaches, and immunotherapy. EXPERT OPINION The authors propose four main opportunities to improve long-term survival. First, patients should be enrolled in scientifically sound clinical trials that include molecularly profiling either via stereotactic biopsy or liquid biopsy. Second, clinical trials should include more innovative endpoints other than traditional EFS and OS such as MRI/PET imaging findings combined with surrogates of activity (e.g. serial liquid biopsies) to better ascertain biologically active treatments. Third, innovative clinical trial approaches are needed to help allow for the rapid development of combination therapies to be tested. Finally, effort should be concentrated on reversing the effects of the histone mutation, as this malfunctioning development program seems to be key to DIPG relentlessness.
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Affiliation(s)
- James Felker
- Department of Pediatrics, University of Pittsburgh School of Medicine , Pittsburgh, PA, USA.,Pediatric Neuro-Oncology, UPMC Children's Hospital of Pittsburgh , Pittsburgh, PA, USA
| | - Alberto Broniscer
- Department of Pediatrics, University of Pittsburgh School of Medicine , Pittsburgh, PA, USA.,Pediatric Neuro-Oncology, UPMC Children's Hospital of Pittsburgh , Pittsburgh, PA, USA
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17
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Rashed WM, Maher E, Adel M, Saber O, Zaghloul MS. Pediatric diffuse intrinsic pontine glioma: where do we stand? Cancer Metastasis Rev 2020; 38:759-770. [PMID: 31802357 DOI: 10.1007/s10555-019-09824-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pediatric diffuse intrinsic pontine glioma (DIPG) represents approximately 20% of all pediatric CNS tumors. However, disease outcomes are dismal with a median survival of less than 1 year and a 2-year overall survival rate of less than 10%. Despite extensive efforts to improve survival outcomes, progress towards clinical improvement has been largely stagnant throughout the last 4 decades. Focal radiotherapy remains the standard of care with no promising single-agent alternatives and no evidence for improvement with the addition of a long list of systemic therapies. A better understanding of the biology of DIPG, though not easy due to obstacles in obtaining pathological material to study, is promising for the development of specific individualized treatment for this fatal disease. Recent studies have found epigenetic mutations to be successful predictors and prognostic factors for developing future management policies. The aim of this review is to give a global overview about the epidemiology, diagnosis, and treatment of DIPG. We further examine the controversial biopsy and autopsy issue that is unique to DIPG and assess the subsequent impact this issue has on the research efforts and clinical management of DIPG.
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Affiliation(s)
- Wafaa M Rashed
- Research Department, Children's Cancer Hospital Egypt, Cairo, 57357, Egypt.
| | - Eslam Maher
- Research Department, Children's Cancer Hospital Egypt, Cairo, 57357, Egypt
| | - Mohamed Adel
- Armed Forces College of Medicine (AFCM), Cairo, Egypt
| | - Ossama Saber
- Armed Forces College of Medicine (AFCM), Cairo, Egypt
| | - Mohamed Saad Zaghloul
- Radiotherapy Department, National Cancer Institute, Cairo University & Children's Cancer Hospital, Cairo, 57357, Egypt.
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18
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Diffuse Intrinsic Pontine Glioma: From Diagnosis to Next-Generation Clinical Trials. Curr Treat Options Neurol 2019; 21:37. [PMID: 31290035 DOI: 10.1007/s11940-019-0577-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE OF REVIEW This review of diffuse intrinsic pontine glioma (DIPG) provides clinical background, a systematic approach to diagnosis and initial care, and synthesizes historical, modern, and future directions for treatment. We present evidence supporting neurosurgical biopsy, early palliative care involvement, limitation of glucocorticoid use, and the leveraging of preclinical DIPG models as a pipeline to next-generation clinical trials. RECENT FINDINGS New molecular understanding of pediatric high-grade gliomas has led to the reclassification of DIPG as one member of a family of diffuse gliomas occurring in the midline of the central nervous system that exhibit pathognomonic mutations in genes encoding histone 3 (H3 K27M). DIPG remains a clinically relevant term, though diagnostically the 80% of DIPG cases that exhibit the H3 K27M mutation have been reclassified as diffuse midline glioma, H3 K27M-mutant. Re-irradiation has been shown to be well-tolerated and of potential benefit. Epigenetic targeting of transcriptional dependencies in preclinical models is fueling molecularly targeted clinical trials. Chimeric antigen receptor T cell immunotherapy has also demonstrated efficacy in preclinical models and provides a promising new clinical strategy. DIPG is a universally fatal, epigenetically driven tumor of the pons that is considered part of a broader class of diffuse midline gliomas sharing H3 K27M mutations. Radiation remains the standard of care, single-agent temozolomide is not recommended, and glucocorticoids should be used only sparingly. A rapid evolution of understanding in the chromatin, signaling, and immunological biology of DIPG may soon result in clinical breakthroughs.
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19
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Srinivas US, Tan BWQ, Vellayappan BA, Jeyasekharan AD. ROS and the DNA damage response in cancer. Redox Biol 2019; 25:101084. [PMID: 30612957 PMCID: PMC6859528 DOI: 10.1016/j.redox.2018.101084] [Citation(s) in RCA: 978] [Impact Index Per Article: 195.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/12/2018] [Accepted: 12/17/2018] [Indexed: 12/14/2022] Open
Abstract
Reactive oxygen species (ROS) are a group of short-lived, highly reactive, oxygen-containing molecules that can induce DNA damage and affect the DNA damage response (DDR). There is unequivocal pre-clinical and clinical evidence that ROS influence the genotoxic stress caused by chemotherapeutics agents and ionizing radiation. Recent studies have provided mechanistic insight into how ROS can also influence the cellular response to DNA damage caused by genotoxic therapy, especially in the context of Double Strand Breaks (DSBs). This has led to the clinical evaluation of agents modulating ROS in combination with genotoxic therapy for cancer, with mixed success so far. These studies point to context dependent outcomes with ROS modulator combinations with Chemotherapy and radiotherapy, indicating a need for additional pre-clinical research in the field. In this review, we discuss the current knowledge on the effect of ROS in the DNA damage response, and its clinical relevance.
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Affiliation(s)
| | - Bryce W Q Tan
- Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | | | - Anand D Jeyasekharan
- Cancer Science Institute of Singapore, National University of Singapore, Singapore; Department of Haematology-Oncology, National University Hospital, Singapore.
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20
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Role of Radiation Therapy in the Management of Diffuse Intrinsic Pontine Glioma: A Systematic Review. Adv Radiat Oncol 2019; 4:520-531. [PMID: 31360809 PMCID: PMC6639749 DOI: 10.1016/j.adro.2019.03.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 03/20/2019] [Indexed: 01/05/2023] Open
Abstract
Purpose Diffuse intrinsic pontine glioma (DIPG) is the most aggressive primary pediatric brain tumor, with <10% of children surviving 2 years. Radiation therapy (RT) remains the mainstay of treatment, but there is a great clinical need for improvements and advancements in treatment strategies. The aim of this systematic review was to identify all available studies in which RT was used to treat patients with DIPG. Methods and Materials A literature search for studies published up to March 10, 2018 was conducted using the PubMed database. We identified 384 articles using search items “diffuse intrinsic pontine glioma” and 221 articles using search items “diffuse brainstem glioma radiotherapy.” Included studies were prospective and retrospective series that reported outcomes of DIPG treatment with RT. Results We identified 49 studies (1286 patients) using upfront conventionally fractionated RT, 5 studies (92 patients) using hypofractionated RT, and 8 studies (348 patients) using hyperfractionated RT. The mean median overall survival (OS) was 12.0 months, 10.2 months, and 7.9 months in patients who received conventional, hyperfractionated, and hypofractionated RT regimens, respectively. Patients undergoing radiosensitizing therapy had a mean median OS of 11.5 months, and patients who did not receive concomitant systemic therapy had an OS of 9.4 months. In patients who received salvage RT, the mean median OS from initial diagnosis was 16.3 months. Conclusions As one of the largest systematic reviews examining RT for DIPG, this report may serve as a useful tool to help clinicians choose the most appropriate treatment approach, while also providing a platform for future investigations into the utility of RT and systemic therapy.
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21
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Baskaran R, Lee J, Yang SG. Clinical development of photodynamic agents and therapeutic applications. Biomater Res 2018; 22:25. [PMID: 30275968 PMCID: PMC6158913 DOI: 10.1186/s40824-018-0140-z] [Citation(s) in RCA: 275] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/11/2018] [Indexed: 12/20/2022] Open
Abstract
Background Photodynamic therapy (PDT) is photo-treatment of malignant or benign diseases using photosensitizing agents, light, and oxygen which generates cytotoxic reactive oxygens and induces tumour regressions. Several photodynamic treatments have been extensively studied and the photosensitizers (PS) are key to their biological efficacy, while laser and oxygen allow to appropriate and flexible delivery for treatment of diseases. Introduction In presence of oxygen and the specific light triggering, PS is activated from its ground state into an excited singlet state, generates reactive oxygen species (ROS) and induces apoptosis of cancer tissues. Those PS can be divided by its specific efficiency of ROS generation, absorption wavelength and chemical structure. Main body Up to dates, several PS were approved for clinical applications or under clinical trials. Photofrin® is the first clinically approved photosensitizer for the treatment of cancer. The second generation of PS, Porfimer sodium (Photofrin®), Temoporfin (Foscan®), Motexafin lutetium, Palladium bacteriopheophorbide, Purlytin®, Verteporfin (Visudyne®), Talaporfin (Laserphyrin®) are clinically approved or under-clinical trials. Now, third generation of PS, which can dramatically improve cancer-targeting efficiency by chemical modification, nano-delivery system or antibody conjugation, are extensively studied for clinical development. Conclusion Here, we discuss up-to-date information on FDA-approved photodynamic agents, the clinical benefits of these agents. However, PDT is still dearth for the treatment of diseases in specifically deep tissue cancer. Next generation PS will be addressed in the future for PDT. We also provide clinical unmet need for the design of new photosensitizers.
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Affiliation(s)
- Rengarajan Baskaran
- World Class Smart Lab, Department of New Drug Development, Inha University College of Medicine, 366, Seohae-daero, Jung-gu, Incheon, 22332 Republic of Korea
| | - Junghan Lee
- World Class Smart Lab, Department of New Drug Development, Inha University College of Medicine, 366, Seohae-daero, Jung-gu, Incheon, 22332 Republic of Korea
| | - Su-Geun Yang
- World Class Smart Lab, Department of New Drug Development, Inha University College of Medicine, 366, Seohae-daero, Jung-gu, Incheon, 22332 Republic of Korea
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22
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Mathew RK, Rutka JT. Diffuse Intrinsic Pontine Glioma : Clinical Features, Molecular Genetics, and Novel Targeted Therapeutics. J Korean Neurosurg Soc 2018; 61:343-351. [PMID: 29742880 PMCID: PMC5957322 DOI: 10.3340/jkns.2018.0008] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 01/21/2018] [Indexed: 12/18/2022] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is a deadly paediatric brain cancer. Transient response to radiation, ineffective chemotherapeutic agents and aggressive biology result in rapid progression of symptoms and a dismal prognosis. Increased availability of tumour tissue has enabled the identification of histone gene aberrations, genetic driver mutations and methylation changes, which have resulted in molecular and phenotypic subgrouping. However, many of the underlying mechanisms of DIPG oncogenesis remain unexplained. It is hoped that more representative in vitro and preclinical models–using both xenografted material and genetically engineered mice–will enable the development of novel chemotherapeutic agents and strategies for targeted drug delivery. This review provides a clinical overview of DIPG, the barriers to progress in developing effective treatment, updates on drug development and preclinical models, and an introduction to new technologies aimed at enhancing drug delivery.
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Affiliation(s)
- Ryan K Mathew
- Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada.,Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK.,Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
| | - James T Rutka
- Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
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23
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Kilburn LB, Kocak M, Baxter P, Poussaint TY, Paulino AC, McIntyre C, Lemenuel-Diot A, Lopez-Diaz C, Kun L, Chintagumpala M, Su JM, Broniscer A, Baker JN, Hwang EI, Fouladi M, Boyett JM, Blaney SM. A pediatric brain tumor consortium phase II trial of capecitabine rapidly disintegrating tablets with concomitant radiation therapy in children with newly diagnosed diffuse intrinsic pontine gliomas. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26832. [PMID: 29090526 PMCID: PMC5774861 DOI: 10.1002/pbc.26832] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 08/16/2017] [Accepted: 08/18/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND We conducted a phase II study of oral capecitabine rapidly disintegrating tablets given concurrently with radiation therapy (RT) to assess progression-free survival (PFS) in children with newly diagnosed diffuse intrinsic pontine gliomas (DIPG). PATIENTS AND METHODS Children 3-17 years with newly diagnosed DIPG were eligible. Capecitabine, 650 mg/m2 /dose BID (maximum tolerated dose [MTD] in children with concurrent radiation), was administered for 9 weeks starting the first day of RT. Following a 2-week break, three courses of capecitabine, 1,250 mg/m2 /dose BID for 14 days followed by a 7-day rest, were administered. As prospectively designed, 10 evaluable patients treated at the MTD on the phase I trial were included in the phase II analyses. The design was based on comparison of the PFS distribution to a contemporary historical control (n = 140) with 90% power to detect a 15% absolute improvement in the 1-year PFS with a type-1 error rate, α = 0.10. RESULTS Forty-four patients were evaluable for the phase II objectives. Capecitabine and RT was well tolerated with low-grade palmar plantar erythrodyesthesia, increased alanine aminotransferase, cytopenias, and vomiting the most commonly reported toxicities. Findings were significant for earlier progression with 1-year PFS of 7.21% (SE = 3.47%) in the capecitabine-treated cohort versus 15.59% (SE = 3.05%) in the historical control (P = 0.007), but there was no difference for overall survival (OS) distributions (P = 0.30). Tumor enhancement at diagnosis was associated with shorter PFS and OS. Capecitabine was rapidly absorbed and converted to its metabolites. CONCLUSION Capecitabine did not improve the outcome for children with newly diagnosed DIPG.
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Affiliation(s)
- Lindsay B. Kilburn
- Center for Cancer and Blood Disorders, Children’s National Medical Center, Washington, DC
| | - Mehmet Kocak
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Patricia Baxter
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston TX
| | - Tina Young Poussaint
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston MA
| | - Arnold C. Paulino
- Department of Radiation Oncology MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Larry Kun
- Department of Radiological Sciences, St. Jude Children’s Research Hospital Memphis, TN
| | | | - Jack M Su
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston TX
| | - Alberto Broniscer
- Department of Oncology St. Jude Children’s Research Hospital, Memphis, TN,Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, TN
| | - Justin N. Baker
- Department of Oncology St. Jude Children’s Research Hospital, Memphis, TN
| | - Eugene I. Hwang
- Center for Cancer and Blood Disorders, Children’s National Medical Center, Washington, DC
| | - Maryam Fouladi
- Division of Hematology/Oncology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - James M. Boyett
- Department of Biostatistics, Operations and Biostatistics Center for PBTC St. Jude Children’s Research Hospital, Memphis, TN
| | - Susan M. Blaney
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston TX
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Kengen J, Deglasse JP, Neveu MA, Mignion L, Desmet C, Gourgue F, Jonas JC, Gallez B, Jordan BF. Biomarkers of tumour redox status in response to modulations of glutathione and thioredoxin antioxidant pathways. Free Radic Res 2018; 52:256-266. [DOI: 10.1080/10715762.2018.1427236] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Julie Kengen
- Louvain Drug Research Institute, Biomedical Magnetic Resonance Group, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Jean-Philippe Deglasse
- Institute of Experimental and Clinical Research, Pole of Endocrinology, Diabetes and Nutrition, Université Catholique de Louvain, Brussels, Belgium
| | - Marie-Aline Neveu
- Louvain Drug Research Institute, Biomedical Magnetic Resonance Group, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Lionel Mignion
- Louvain Drug Research Institute, Biomedical Magnetic Resonance Group, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Céline Desmet
- Louvain Drug Research Institute, Biomedical Magnetic Resonance Group, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Florian Gourgue
- Louvain Drug Research Institute, Biomedical Magnetic Resonance Group, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Jean-Christophe Jonas
- Institute of Experimental and Clinical Research, Pole of Endocrinology, Diabetes and Nutrition, Université Catholique de Louvain, Brussels, Belgium
| | - Bernard Gallez
- Louvain Drug Research Institute, Biomedical Magnetic Resonance Group, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Bénédicte F. Jordan
- Louvain Drug Research Institute, Biomedical Magnetic Resonance Group, Université Catholique de Louvain (UCL), Brussels, Belgium
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Patay Z, Merchant TE, Nguyen R, Pierson CR, Onar-Thomas A, Broniscer A. Treatment-Related Noncontiguous Radiologic Changes in Children With Diffuse Intrinsic Pontine Glioma Treated With Expanded Irradiation Fields and Antiangiogenic Therapy. Int J Radiat Oncol Biol Phys 2017; 99:1295-1305. [PMID: 29165288 DOI: 10.1016/j.ijrobp.2017.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 06/02/2017] [Accepted: 08/16/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE We previously reported the cases of 3 children with diffuse intrinsic pontine glioma (DIPG) in whom noncontiguous treatment-related abnormalities (NCTRAs) developed in the brain after expanded-field radiation therapy (RT). To investigate the occurrence and putative mechanism of NCTRAs, we reviewed brain magnetic resonance imaging studies of patients with DIPG treated in 2 consecutive phase I clinical trials (trials 1 and 2). METHODS AND MATERIALS The 55 children included in these trials received small-molecule inhibitors: vandetanib in trial 1 (n=32; mean age 6.4 years) and vandetanib and dasatinib in trial 2 (n=23; mean age 5.8 years). The patients also received conformal 3-dimensional RT (cumulative dose 54 Gy). For patients enrolled in trial 1, the clinical target volume (CTV) was expanded by 1 cm from the gross tumor volume. In trial 2, the expansion to form the CTV was 2 to 3 cm. A review of imaging studies was performed from the initial diagnosis through the end of progression-free survival. The imaging findings were grouped into 5 categories according to the presence, absence, location, extent, and putative mechanism of NCTRAs. Statistical analysis was performed to evaluate the association between covariates and NCTRA, cohort characterization, and survival comparisons. RESULTS Overall survival was similar in both studies (P=.74). NCTRAs developed in 9 patients (39%) treated in trial 2 but in none treated in trial 1. The NCTRAs included T2-weighted hyperintensities with (n=3; radiation necrosis) or without (n=5) contrast uptake, supratentorial leukoencephalopathy (n=2), and ischemic stroke (n=1). All NCTRAs, except for 1, occurred within the CTV. Compared with nonaffected patients, patients with a NCTRA were younger (P=.003) and had had larger relative brain volumes exposed to doses >20 Gy. CONCLUSIONS The imaging features of NCTRAs suggest that their development is secondary to synergistic steno-occlusive vascular effects induced by the combination of RT, an expanded CTV, potent antiangiogenic therapy, young age, and, in 1 case, a genetic predisposition.
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Affiliation(s)
- Zoltan Patay
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, Tennessee.
| | - Thomas E Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Rosa Nguyen
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Christopher R Pierson
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Pathology, The Ohio State University College of Medicine, Columbus, Ohio; Department of Biomedical Education and Anatomy, The Ohio State University College of Medicine, Columbus, Ohio
| | - Arzu Onar-Thomas
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Alberto Broniscer
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee; Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
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Long W, Yi Y, Chen S, Cao Q, Zhao W, Liu Q. Potential New Therapies for Pediatric Diffuse Intrinsic Pontine Glioma. Front Pharmacol 2017; 8:495. [PMID: 28790919 PMCID: PMC5525007 DOI: 10.3389/fphar.2017.00495] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 07/11/2017] [Indexed: 12/20/2022] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is an extensively invasive malignancy with infiltration into other regions of the brainstem. Although large numbers of specific targeted therapies have been tested, no significant progress has been made in treating these high-grade gliomas. Therefore, the identification of new therapeutic approaches is of great importance for the development of more effective treatments. This article reviews the conventional therapies and new potential therapeutic approaches for DIPG, including epigenetic therapy, immunotherapy, and the combination of stem cells with nanoparticle delivery systems.
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Affiliation(s)
- Wenyong Long
- Department of Neurosurgery, Xiangya Hospital, Central South UniversityChangsha, China
| | - Yang Yi
- Key Laboratory for Stem Cells and Tissue Engineering, Ministry of Education, Sun Yat-sen UniversityGuangzhou, China.,Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-sen UniversityGuangzhou, China
| | - Shen Chen
- Key Laboratory for Stem Cells and Tissue Engineering, Ministry of Education, Sun Yat-sen UniversityGuangzhou, China.,Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-sen UniversityGuangzhou, China
| | - Qi Cao
- Center for Inflammation and Epigenetics, Houston Methodist Research Institute, HoustonTX, United States
| | - Wei Zhao
- Key Laboratory for Stem Cells and Tissue Engineering, Ministry of Education, Sun Yat-sen UniversityGuangzhou, China.,Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-sen UniversityGuangzhou, China
| | - Qing Liu
- Department of Neurosurgery, Xiangya Hospital, Central South UniversityChangsha, China
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Infinger LK, Stevenson CB. Re-Examining the Need for Tissue Diagnosis in Pediatric Diffuse Intrinsic Pontine Gliomas: A Review. Curr Neuropharmacol 2017; 15:129-133. [PMID: 27109746 PMCID: PMC5327458 DOI: 10.2174/1570159x14666160425114024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 12/18/2014] [Accepted: 02/08/2016] [Indexed: 01/24/2023] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is a malignant brain tumor of childhood that carries an extremely poor prognosis. There are ~200-300 new cases diagnosed each year, [1, 2] and little progress has been made in changing the prognosis and outcome of the tumor since it was first documented in the literature in 1926 [3]. The median overall survival is 8-11 months [4], with an overall survival rate of 30% at 1 year, and less than 10% at 2 years [4]. This review will provide background information on DIPGs, a historical look at the trends in caring for DIPG, and current trends in diagnosis and treatment. By changing the way we care for these terminal tumors, we can work towards having a better understanding of the underlying molecular biology, and attempt to develop better chemotherapeutic tools to combat the disease.
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Affiliation(s)
| | - Charles B. Stevenson
- Cincinnati Children’s Hospital Medical Center, Division of Pediatric Neurosurgery, USA
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Hennika T, Becher OJ. Diffuse Intrinsic Pontine Glioma: Time for Cautious Optimism. J Child Neurol 2016; 31:1377-85. [PMID: 26374787 PMCID: PMC6025797 DOI: 10.1177/0883073815601495] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 07/20/2015] [Indexed: 01/03/2023]
Abstract
Diffuse intrinsic pontine glioma is a lethal brain cancer that arises in the pons of children. The median survival for children with diffuse intrinsic pontine glioma is less than 1 year from diagnosis, and no improvement in survival has been realized in more than 30 years. Currently, the standard of care for diffuse intrinsic pontine glioma is focal radiation therapy, which provides only temporary relief. Recent genomic analysis of tumors from biopsies and autopsies, have resulted in the discovery of K27M H3.3/H3.1 mutations in 80% and ACVR1 mutations in 25% of diffuse intrinsic pontine gliomas, providing renewed hope for future success in identifying effective therapies. In addition, as stereotactic tumor biopsies at diagnosis at specialized centers have been demonstrated to be safe, biopsies have now been incorporated into several prospective clinical trials. This article summarizes the epidemiology, clinical presentation, diagnosis, prognosis, molecular genetics, current treatment, and future therapeutic directions for diffuse intrinsic pontine glioma.
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Affiliation(s)
- Tammy Hennika
- Department of Pediatrics Duke University Medical Center, Durham, NC, USA Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA
| | - Oren J Becher
- Department of Pediatrics Duke University Medical Center, Durham, NC, USA Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA Department of Pathology, Duke University Medical Center, Durham, NC, USA
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Lee MJ. Overview of CNS Gliomas in Childhood. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2016. [DOI: 10.15264/cpho.2016.23.1.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Mee Jeong Lee
- Department of Pediatrics, Dankook University College of Medicine, Cheonan, Korea
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Qiu L, Zhang F, Shi Y, Bai Z, Wang J, Li Y, Lee D, Ingraham C, Feng X, Yang X. Gliomas: Motexafin Gadolinium-enhanced Molecular MR Imaging and Optical Imaging for Potential Intraoperative Delineation of Tumor Margins. Radiology 2015; 279:400-9. [PMID: 26599802 DOI: 10.1148/radiol.2015150895] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To investigate the possibility of using motexafin gadolinium (MGd)-enhanced molecular magnetic resonance (MR) imaging and optical imaging to identify the true margins of gliomas. MATERIALS AND METHODS The animal protocol was approved by the institutional animal care and use committee. Thirty-six Sprague-Dawley rats with gliomas were randomized into six groups of six rats. Five groups were euthanized 15, 30, 60, 120, and 240 minutes after intravenous administration of 6 mg/kg of MGd, while one group received only saline solution as a control group. After craniotomy, optical imaging and T1-weighted MR imaging were performed to identify the tumor margins. One-way analysis of variance was used to compare optical photon intensity and MR imaging signal-to-noise ratios. Histologic analysis was performed to confirm the intracellular uptake of MGd by tumor cells and to correlate the tumor margins delineated on both optical and MR images. RESULTS Both optical imaging and T1-weighted MR imaging showed tumor margins. The highest optical photon intensity (2.6 × 10(8) photons per second per mm(2) ± 2.3 × 10(7); analysis of variance, P < .001) and MR signal-to-noise ratio (77.61 ± 2.52; analysis of variance, P = .006) were reached at 15-30 minutes after administration of MGd, with continued tumor visibility at 2-4 hours. Examination with confocal microscopy allowed confirmation that the fluorescence of optical images and MR imaging T1 enhancement exclusively originated from MGd that accumulated in the cytoplasm of tumor cells. CONCLUSION MGd-enhanced optical and MR imaging can allow determination of glioma tumor margins at the optimal time of 15-120 minutes after administration of MGd. Clinical application of these results may allow complete removal of gliomas in a hybrid surgical setting in which intraoperative optical and MR imaging are available.
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Affiliation(s)
- Longhua Qiu
- From the Image-Guided Biomolecular Intervention Research, Department of Radiology, University of Washington School of Medicine, 850 Republican St, Seattle, WA 98109 (L.Q., F.Z., Y.S., Z.B., J.W., Y.L., D.L., C.I., X.Y.); and Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China (L.Q., X.F.)
| | - Feng Zhang
- From the Image-Guided Biomolecular Intervention Research, Department of Radiology, University of Washington School of Medicine, 850 Republican St, Seattle, WA 98109 (L.Q., F.Z., Y.S., Z.B., J.W., Y.L., D.L., C.I., X.Y.); and Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China (L.Q., X.F.)
| | - Yaoping Shi
- From the Image-Guided Biomolecular Intervention Research, Department of Radiology, University of Washington School of Medicine, 850 Republican St, Seattle, WA 98109 (L.Q., F.Z., Y.S., Z.B., J.W., Y.L., D.L., C.I., X.Y.); and Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China (L.Q., X.F.)
| | - Zhibin Bai
- From the Image-Guided Biomolecular Intervention Research, Department of Radiology, University of Washington School of Medicine, 850 Republican St, Seattle, WA 98109 (L.Q., F.Z., Y.S., Z.B., J.W., Y.L., D.L., C.I., X.Y.); and Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China (L.Q., X.F.)
| | - Jianfeng Wang
- From the Image-Guided Biomolecular Intervention Research, Department of Radiology, University of Washington School of Medicine, 850 Republican St, Seattle, WA 98109 (L.Q., F.Z., Y.S., Z.B., J.W., Y.L., D.L., C.I., X.Y.); and Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China (L.Q., X.F.)
| | - Yonggang Li
- From the Image-Guided Biomolecular Intervention Research, Department of Radiology, University of Washington School of Medicine, 850 Republican St, Seattle, WA 98109 (L.Q., F.Z., Y.S., Z.B., J.W., Y.L., D.L., C.I., X.Y.); and Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China (L.Q., X.F.)
| | - Donghoon Lee
- From the Image-Guided Biomolecular Intervention Research, Department of Radiology, University of Washington School of Medicine, 850 Republican St, Seattle, WA 98109 (L.Q., F.Z., Y.S., Z.B., J.W., Y.L., D.L., C.I., X.Y.); and Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China (L.Q., X.F.)
| | - Christopher Ingraham
- From the Image-Guided Biomolecular Intervention Research, Department of Radiology, University of Washington School of Medicine, 850 Republican St, Seattle, WA 98109 (L.Q., F.Z., Y.S., Z.B., J.W., Y.L., D.L., C.I., X.Y.); and Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China (L.Q., X.F.)
| | - Xiaoyuan Feng
- From the Image-Guided Biomolecular Intervention Research, Department of Radiology, University of Washington School of Medicine, 850 Republican St, Seattle, WA 98109 (L.Q., F.Z., Y.S., Z.B., J.W., Y.L., D.L., C.I., X.Y.); and Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China (L.Q., X.F.)
| | - Xiaoming Yang
- From the Image-Guided Biomolecular Intervention Research, Department of Radiology, University of Washington School of Medicine, 850 Republican St, Seattle, WA 98109 (L.Q., F.Z., Y.S., Z.B., J.W., Y.L., D.L., C.I., X.Y.); and Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China (L.Q., X.F.)
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Gajjar A, Bowers DC, Karajannis MA, Leary S, Witt H, Gottardo NG. Pediatric Brain Tumors: Innovative Genomic Information Is Transforming the Diagnostic and Clinical Landscape. J Clin Oncol 2015; 33:2986-98. [PMID: 26304884 DOI: 10.1200/jco.2014.59.9217] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Pediatric neuro-oncology has undergone an exciting and dramatic transformation during the past 5 years. This article summarizes data from collaborative group and institutional trials that have advanced the science of pediatric brain tumors and survival of patients with these tumors. Advanced genomic analysis of the entire spectrum of pediatric brain tumors has heralded an era in which stakeholders in the pediatric neuro-oncology community are being challenged to reconsider their current research and diagnostic and treatment strategies. The incorporation of this new information into the next-generation treatment protocols will unleash new challenges. This review succinctly summarizes the key advances in our understanding of the common pediatric brain tumors (ie, medulloblastoma, low- and high-grade gliomas, diffuse intrinsic pontine glioma, and ependymoma) and some selected rare tumors (ie, atypical teratoid/rhabdoid tumor and CNS primitive neuroectodermal tumor). The potential impact of this new information on future clinical protocols also is discussed. Cutting-edge genomics technologies and the information gained from such studies are facilitating the identification of molecularly defined subgroups within patients with particular pediatric brain tumors. The number of evaluable patients in each subgroup is small, particularly in the subgroups of rare diseases. Therefore, international collaboration will be crucial to draw meaningful conclusions about novel approaches to treating pediatric brain tumors.
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Affiliation(s)
- Amar Gajjar
- Amar Gajjar, St Jude Children's Research Hospital, Memphis, TN; Daniel C. Bowers, University of Texas Southwestern Medical Center, Dallas, TX; Matthias A. Karajannis, New York University (NYU) Perlmutter Cancer Center and NYU Langone Medical Center, New York, NY; Sarah Leary, University of Washington School of Medicine and Fred Hutchinson Cancer Research Center, Seattle, WA; Hendrik Witt, German Cancer Research Center and University of Heidelberg, Heidelberg, Germany; and Nicholas G. Gottardo, Princess Margaret Hospital for Children and The University of Western Australia, Perth, Western Australia, Australia.
| | - Daniel C Bowers
- Amar Gajjar, St Jude Children's Research Hospital, Memphis, TN; Daniel C. Bowers, University of Texas Southwestern Medical Center, Dallas, TX; Matthias A. Karajannis, New York University (NYU) Perlmutter Cancer Center and NYU Langone Medical Center, New York, NY; Sarah Leary, University of Washington School of Medicine and Fred Hutchinson Cancer Research Center, Seattle, WA; Hendrik Witt, German Cancer Research Center and University of Heidelberg, Heidelberg, Germany; and Nicholas G. Gottardo, Princess Margaret Hospital for Children and The University of Western Australia, Perth, Western Australia, Australia
| | - Matthias A Karajannis
- Amar Gajjar, St Jude Children's Research Hospital, Memphis, TN; Daniel C. Bowers, University of Texas Southwestern Medical Center, Dallas, TX; Matthias A. Karajannis, New York University (NYU) Perlmutter Cancer Center and NYU Langone Medical Center, New York, NY; Sarah Leary, University of Washington School of Medicine and Fred Hutchinson Cancer Research Center, Seattle, WA; Hendrik Witt, German Cancer Research Center and University of Heidelberg, Heidelberg, Germany; and Nicholas G. Gottardo, Princess Margaret Hospital for Children and The University of Western Australia, Perth, Western Australia, Australia
| | - Sarah Leary
- Amar Gajjar, St Jude Children's Research Hospital, Memphis, TN; Daniel C. Bowers, University of Texas Southwestern Medical Center, Dallas, TX; Matthias A. Karajannis, New York University (NYU) Perlmutter Cancer Center and NYU Langone Medical Center, New York, NY; Sarah Leary, University of Washington School of Medicine and Fred Hutchinson Cancer Research Center, Seattle, WA; Hendrik Witt, German Cancer Research Center and University of Heidelberg, Heidelberg, Germany; and Nicholas G. Gottardo, Princess Margaret Hospital for Children and The University of Western Australia, Perth, Western Australia, Australia
| | - Hendrik Witt
- Amar Gajjar, St Jude Children's Research Hospital, Memphis, TN; Daniel C. Bowers, University of Texas Southwestern Medical Center, Dallas, TX; Matthias A. Karajannis, New York University (NYU) Perlmutter Cancer Center and NYU Langone Medical Center, New York, NY; Sarah Leary, University of Washington School of Medicine and Fred Hutchinson Cancer Research Center, Seattle, WA; Hendrik Witt, German Cancer Research Center and University of Heidelberg, Heidelberg, Germany; and Nicholas G. Gottardo, Princess Margaret Hospital for Children and The University of Western Australia, Perth, Western Australia, Australia
| | - Nicholas G Gottardo
- Amar Gajjar, St Jude Children's Research Hospital, Memphis, TN; Daniel C. Bowers, University of Texas Southwestern Medical Center, Dallas, TX; Matthias A. Karajannis, New York University (NYU) Perlmutter Cancer Center and NYU Langone Medical Center, New York, NY; Sarah Leary, University of Washington School of Medicine and Fred Hutchinson Cancer Research Center, Seattle, WA; Hendrik Witt, German Cancer Research Center and University of Heidelberg, Heidelberg, Germany; and Nicholas G. Gottardo, Princess Margaret Hospital for Children and The University of Western Australia, Perth, Western Australia, Australia
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Abstract
Diffuse intrinsic pontine gliomas (DIPGs) are a fairly common pediatric brain tumor, and children with these tumors have a dismal prognosis. They generally are diagnosed within the first decade of life, and due to their location within the pons, these tumors are not surgically resectable. The median survival for children with DIPGs is less than 1 year, in spite of decades of clinical trial development of unique approaches to radiation therapy and chemotherapy. Novel therapies are under investigation for these deadly tumors. As clinicians and researchers make a concerted effort to obtain tumor tissue, the molecular signals of these tumors are being investigated in an attempt to uncover targetable therapies for DIPGs. In addition, direct application of chemotherapies into the tumor (convection-enhanced delivery) is being investigated as a novel delivery system for treatment of DIPGs. Overall, DIPGs require creative thinking and a disciplined approach for development of a therapy that can improve the prognosis for these unfortunate children.
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Affiliation(s)
- Amy Lee Bredlau
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA; Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA.
| | - David N Korones
- Department of Pediatrics, University of Rochester, Rochester, New York, USA; Department of Palliative Care, University of Rochester, Rochester, New York, USA
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Kardeh S, Ashkani-Esfahani S, Alizadeh AM. Paradoxical action of reactive oxygen species in creation and therapy of cancer. Eur J Pharmacol 2014; 735:150-68. [DOI: 10.1016/j.ejphar.2014.04.023] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 04/04/2014] [Accepted: 04/09/2014] [Indexed: 02/07/2023]
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Robison NJ, Kieran MW. Diffuse intrinsic pontine glioma: a reassessment. J Neurooncol 2014; 119:7-15. [PMID: 24792486 DOI: 10.1007/s11060-014-1448-8] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 04/13/2014] [Indexed: 11/25/2022]
Abstract
Diffuse intrinsic pontine glioma (DIPG) is a disease of childhood whose abysmal prognosis has remained unchanged for over 50 years. Biologic investigation has been stymied by lack of pretreatment tissue, as biopsy has been reserved for atypical cases. Recent advances in surgical and molecular-analytic techniques have increased the safety and potential utility of biopsy; brainstem biopsy has now been incorporated into several prospective clinical trials. These and other recent efforts have yielded new insights into DIPG molecular pathogenesis, and opened new avenues for investigation.
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Affiliation(s)
- Nathan J Robison
- Pediatric Neuro-Oncology Program, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, 4650 W Sunset Blvd, MS#54, Los Angeles, CA, 90027, USA,
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Martin V, Moyal É, Delannes M, Padovani L, Sunyach MP, Feuvret L, Dhermain F, Noël G, Laprie A. Radiothérapie des tumeurs cérébrales : quelles marges ? Cancer Radiother 2013; 17:434-43. [DOI: 10.1016/j.canrad.2013.07.136] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 07/09/2013] [Indexed: 01/15/2023]
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Abstract
Brainstem gliomas (BGs) are a heterogenous group of gliomas that occur predominately in children. They can be separated into groups on the basis of anatomy and clinical behavior: diffuse intrinsic pontine glioma (DIPG), exophytic medullary glioma, and tectal glioma. DIPG is the commonest BG. Median age at onset is 6.5 years and median survival is less than 1 year. Adults with DIPG survive longer, suggesting a less aggressive and biologically different tumor from that in children. Patients present with cranial nerve dysfunction, long tract signs, or ataxia, either in isolation or in combination. Magnetic resonance imaging shows an infiltrative lesion occupying most of the pons and contrast enhancement is usually not prominent. Standard treatment is fractionated radiotherapy. Platelet-derived growth factor receptor alpha and epidermal growth factor receptor mutations have been identified. Inhibitors of these growth factor receptors are being evaluated in clinical trials. Exophytic medullary and tectal gliomas are relatively indolent tumors that can often be followed closely without treatment.
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Affiliation(s)
- Sean A Grimm
- Department of Neurology, University of Minnesota Medical School, Minneapolis, MN 55455, USA
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Gajjar A, Packer RJ, Foreman N, Cohen K, Haas-Kogan D, Merchant TE. Children's Oncology Group's 2013 blueprint for research: central nervous system tumors. Pediatr Blood Cancer 2013; 60:1022-6. [PMID: 23255213 PMCID: PMC4184243 DOI: 10.1002/pbc.24427] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 11/09/2012] [Indexed: 12/29/2022]
Abstract
In the US, approximately 2,500 children are diagnosed annually with brain tumors. Their survival ranges from >90% to <10%. For children with medulloblastoma, the most common malignant brain tumor, 5-year survival ranges from >80% (standard-risk) to 60% (high-risk). For those with high-grade gliomas (HGGs) including diffuse intrinsic pontine gliomas, 5-year survival remains <10%. Sixty-five percent patients with ependymoma are cured after surgery and radiation therapy depending on the degree of resection and histopathology of the tumor. Phase II trials for brain tumors will investigate agents that act on cMET, PDGFRA, or EZH2 in HGG, DIPG, or medulloblastoma, respectively. Phase III trials will explore risk-based therapy stratification guided by molecular and clinical traits of children with medulloblastoma or ependymoma.
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Affiliation(s)
- Amar Gajjar
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
| | - Roger J. Packer
- Brain Tumor Institute, Children's National, Washington, District of Columbia
| | - N.K. Foreman
- Department of Pediatrics, University of Colorado, Denver
| | - Kenneth Cohen
- Oncology and Pediatrics, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
| | - Daphne Haas-Kogan
- Department of Radiation Oncology, Helen Diller Comprehensive Cancer Center, San Francisco, California
| | - Thomas E. Merchant
- Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee
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Abstract
OPINION STATEMENT Gliomas are the most common brain tumor in children and represent nearly 50 % of all pediatric central nervous system (CNS) tumors. They are a heterogeneous group of diseases, ranging from highly malignant and frequently fatal to histologically benign and curable by surgery alone. A uniform treatment approach to these tumors is not practical, due to their histological and biological heterogeneity. Low-grade gliomas (LGGs) are best treated with maximally safe surgical resection, generally achievable for hemispheric or cerebellar locations. Patients with deep midline, optic pathway/hypothalamic, and brain stem locations should undergo subtotal resection or biopsy only. If a complete resection is not feasible, subtotal resection followed by adjuvant chemotherapy or radiotherapy is the standard approach; however, observation alone with serial neuroimaging is used in some asymptomatic, surgically inaccessible lesions. Chemotherapy is used first-line in cases of residual or progressive disease, to avoid or delay radiation therapy and its associated side effects. Regimens demonstrating objective responses and increased progression free survival (PFS) include carboplatin and vincristine (CV), thioguanine/procarbazine/CCNU/vincristine (TPCV), or weekly vinblastine. High-grade gliomas (HGGs) are less common in children than in adults, though are similar in their aggressive clinical behavior, resistance to therapy, and dismal outcomes. There is not a single "standard of care" therapy for non-metastatic HGGs, but generally accepted is an aggressive attempt at a complete surgical resection, followed by multimodality therapy with focal radiation and chemotherapy. The use of temozolomide (TMZ) during and following radiotherapy is common, though it appeared not to improve the outcome in a cooperative group clinical trial when compared to an historical control cohort. The angiogenesis inhibitor bevacizumab, used alone or in combination with irinotecan, is also commonly used as maintenance therapy after radiation. Current trials are prospectively comparing TMZ to newer agents (vorinostat, bevacizumab) in a randomized phase II trial. Brainstem gliomas are a unique category of childhood gliomas. Approximately 80 % of childhood brainstem gliomas arise within the pons as diffuse intrinsic pontine gliomas (DIPG). When biopsied, these are usually HGGs and carry a dismal prognosis. Standard therapy is focal radiation (54-58 Gy), preferably on a clinical trial testing concurrent chemotherapy or biologic agent. No standard chemotherapy agent has impacted survival. The remaining 20 % of brainstem gliomas are low-grade, arise in the midbrain, dorsal medulla, or cervicomedullary junction, and are indolent in nature with a much better prognosis. Improvement in the outcome of all childhood gliomas will require increased knowledge of the underlying biology of these tumors, in order to treat with more biologically based and precise therapies.
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Affiliation(s)
- Jane E Minturn
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, 3501 Civic Center Boulevard, CTRB 4028, Philadelphia, PA, 19104, USA
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