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Ozerov SS, Ryzhova MV, Kumirova EV. [Diffuse brainstem tumors in children. Tumor biology and hope for a better outcome. Current state of the problem]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:77-86. [PMID: 34463454 DOI: 10.17116/neiro20218504177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diffuse brainstem tumor is a fatal disease and the main cause of child mortality from neoplasms of central nervous system. So far, no effective therapy has been found for this disease. The authors discuss the modern aspects of clinical data, biology, diagnosis and treatment of patients with diffuse brainstem tumors.
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Affiliation(s)
- S S Ozerov
- Dmitry Rogachev National Medical Research Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - M V Ryzhova
- Burdenko Neurosurgical Center, Moscow, Russia
| | - E V Kumirova
- Dmitry Rogachev National Medical Research Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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Su JM, Kilburn LB, Mansur DB, Krailo M, Buxton A, Adekunle A, Gajjar A, Adamson PC, Weigel B, Fox E, Blaney SM, Fouladi M. Phase 1/2 Trial of Vorinostat and Radiation and Maintenance Vorinostat in Children with Diffuse Intrinsic Pontine Glioma: A Children's Oncology Group Report. Neuro Oncol 2021; 24:655-664. [PMID: 34347089 DOI: 10.1093/neuonc/noab188] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A phase 1/2 trial of vorinostat (suberoylanilide hydroxamic acid), an oral histone deacetylase (HDAC) inhibitor, was conducted in children with newly-diagnosed diffuse intrinsic pontine glioma (DIPG) through the Children's Oncology Group (COG) to: 1) determine the recommended phase 2 dose (RP2D) of vorinostat given concurrently with radiation therapy; 2) document the toxicities of continuing vorinostat as maintenance therapy after radiation; and 3) to determine the efficacy of this regimen by comparing the risk of progression or death with an historical model from past COG trials. METHODS Vorinostat was given once daily, Monday through Friday, during radiation therapy (54 Gy in 30 fractions), and then continued at 230 mg/m 2 daily for a maximum of twelve 28-day cycles. RESULTS Twelve patients enrolled on the phase 1 study; the RP2D of vorinostat given concurrently with radiation was 230 mg/m 2/day, Monday through Friday weekly. The six patients enrolled at the RP2D and an additional 64 patients enrolled onto the phase 2 study contributed to the efficacy assessment. Although vorinostat was well-tolerated, did not interrupt radiation therapy, and was permanently discontinued in only 8.6% of patients due to toxicities, risk for EFS-event was not significantly reduced compared with the target risk derived from historical COG data (p = 0.32; 1-sided). The 1-year EFS was 5.85% (95% CI 1.89 - 13.1%) and 1-year OS was 39.2% (27.8 - 50.5%). CONCLUSIONS Vorinostat given concurrently with radiation followed by vorinostat monotherapy was well tolerated in children with newly-diagnosed DIPG but failed to improve outcome.
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Affiliation(s)
- Jack M Su
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Lindsay B Kilburn
- Children's National Medical Center, Center for Cancer & Blood Disorders, Washington, DC, USA
| | - David B Mansur
- Rainbow Babies and Children's Hospital, Radiation Oncology, Cleveland, OH, USA
| | - Mark Krailo
- Children's Oncology Group, Statistics, Monrovia, CA, USA
| | - Allen Buxton
- Children's Oncology Group, Statistics, Monrovia, CA, USA
| | - Adesina Adekunle
- Texas Children's Hospital, Department of Pathology, Houston, TX, USA
| | - Amar Gajjar
- St. Jude Children's Research Hospital, Department of Oncology, Memphis, TN, USA
| | - Peter C Adamson
- Children's Oncology Group, Global Head, Oncology Department, Cambridge, MA, USA
| | - Brenda Weigel
- University of Minnesota/Masonic Cancer Center, Department of Pediatrics, Hem/Onc/BMT, Minneapolis, MN, USA
| | - Elizabeth Fox
- St. Jude Children's Research Hospital, Department of Oncology, Memphis, TN, USA
| | - Susan M Blaney
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Maryam Fouladi
- Nationwide Children's Hospital, Neuro-Oncology Program, Columbus, OH, USA
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Krishnatry R, Manjali JJ, Chinnaswamy G, Chatterjee A, Goda JS, Janu A, Sahu A, Jalali R, Gupta T. Clinical approach to re-irradiation for recurrent diffuse intrinsic pontine glioma. Jpn J Clin Oncol 2021; 51:762-768. [PMID: 33521824 DOI: 10.1093/jjco/hyab006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/06/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND We present our institutional approach for re-irradiation in diffuse intrinsic pontine glioma and their outcomes. METHODS Consecutive patients of recurrent diffuse intrinsic pontine glioma treated with re-irradiation (January 2015-September 2019) were reviewed retrospectively to describe the clinical-response-based approach followed for the dose and volume decision. Outcomes were defined with clinical and steroid response criteria and survival endpoints included progression-free survival and overall survival as cumulative(c) overall survival and re-irradiation overall survival (re-irradiation starting to death). The Kaplan-Meier method and log-rank test were used for survival analysis. RESULTS Twenty-patient cohort with a median (m) age of 7.5 years, m-progression-free survival of 8.4 months and m-Lansky performance score of 50 received re-irradiation of which 17 (85%) were called clinical responders. The median re-irradiation-overall survival with 39.6-41.4, 43.2 and 45 Gy were 5.8, 7 and 5.3 months, respectively. One-month post-re-irradiation steroid independent status was a significant predictor of better survival outcomes (overall survival, P≤0.004). No ≥ grade 3 toxicities were noticed. Two patients succumbed to intra-tumoral hemorrhage. CONCLUSIONS Higher doses of re-irradiation based on a clinical-response-based approach show improvement in survival and steroid dependence rates with acceptable toxicity. Steroid independent status at 1-month post-re-irradiation predicts better outcomes. Prospective studies may validate this with quality of life data.
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Affiliation(s)
- Rahul Krishnatry
- Department of Radiation Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Jifmi Jose Manjali
- Department of Radiation Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Girish Chinnaswamy
- Department of Pediatric Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Abhishek Chatterjee
- Department of Radiation Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Jayant Sastri Goda
- Department of Radiation Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Amit Janu
- Department of Radiology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Arpita Sahu
- Department of Radiology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Rakesh Jalali
- Department of Radiation Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Tejpal Gupta
- Department of Radiation Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
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Xu Y, Li Q, Ma H, Sun T, Xiang R, Di F. Therapeutic effect and side effects of Bevacizumab combined with Irinotecan in the treatment of paediatric intracranial tumours: Meta-analysis and Systematic Review. J Clin Pharm Ther 2020; 45:1363-1371. [PMID: 32598559 PMCID: PMC7689821 DOI: 10.1111/jcpt.13228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/12/2020] [Accepted: 06/13/2020] [Indexed: 12/19/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Bevacizumab (BVZ) is an angiogenesis inhibitor that often works well with chemotherapeutic drugs for the treatment of solid intracranial tumours in children. This meta-analysis discusses the efficacy and side effects of BVZ combined with irinotecan in the treatment of patients (younger than 21 years of age) with recurrent, progressive or refractory intracranial tumours. METHODS We searched for articles published before 31 October 2018 in PubMed, EMBASE, Cochrane library and Web of Science. We selected relevant literature on the combination of BVZ and irinotecan in the treatment of children with intracranial tumours. Objective response was evaluated by combining partial response (PR), complete response (CR), stable disease (SD) and progressive disease (PD), and survival time was evaluated by combining overall survival (OS) and progression-free survival (PFS); common side effects were also analysed. All data included were obtained from single-arm data, with no control groups. RESULTS AND DISCUSSION A total of 13 studies involving 272 patients were included. We found that out of 41% patients who showed an objective response following the BVZ therapy combined with irinotecan, 28% achieved a PR, 13% achieved a CR, 32% showed a SD, and 43% had a PD; PFS and OS were 6.47 and 11.9 months, respectively; gastrointestinal dysfunction, leukopenia and hypertension were the three most common adverse events, accounting for 36.7%, 33.6% and 22.1%, respectively, whereas musculoskeletal disorders had the lowest occurrence, accounting for 3.9%. WHAT IS NEW AND CONCLUSION BVZ combined with irinotecan-based chemotherapy had a better response and prolonged survival in the treatment of paediatric intracranial tumours than radiation therapy or chemotherapy. Gastrointestinal dysfunction, leukopenia and hypertension were the toxic side effects with the highest incidence.
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Affiliation(s)
- Yan Xu
- Department of NeurosurgeryBeijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Qiang Li
- Department of NeurosurgeryXinle City HospitalXinleHebeiChina
| | - Hai‐Yang Ma
- Department of NeurosurgeryBeijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Tao Sun
- Department of NeurosurgeryBeijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Ruo‐Lan Xiang
- Department of Physiology and PathophysiologyPeking University School of Basic Medical SciencesBeijingChina
| | - Fei Di
- Department of NeurosurgeryBeijing Tiantan HospitalCapital Medical UniversityBeijingChina
- Department of NeurosurgeryZhangJiakou First HospitalZhangjiakouHebeiChina
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Pre-irradiation intensive induction and marrow-ablative consolidation chemotherapy in young children with newly diagnosed high-grade brainstem gliomas: report of the "head-start" I and II clinical trials. J Neurooncol 2018; 140:717-725. [PMID: 30392092 DOI: 10.1007/s11060-018-03003-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/22/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The dismal outcome in children with high-grade brainstem gliomas (BSG) accentuates the need for effective therapeutic strategies. We investigated the role of intensive, including marrow-ablative, chemotherapy regimens in the treatment of young children with newly-diagnosed high-grade BSG. METHODS Between 1991-and-2002, 15 eligible children less than 10 years of age with a diagnosis of high-grade BSG were treated on "Head-Start" I and II protocols (HSI and HSII). Treatment included Induction with 4-5 cycles of one of three intensive chemotherapy regimens followed by Consolidation with one cycle of marrow-ablative chemotherapy (thiotepa, carboplatin and etoposide) with autologous hematopoietic cell rescue (AHCR). Irradiation was required for children over 6 years of age or for those with residual tumor at the end of Consolidation. RESULTS We had two long-term survivors who were found retrospectively to harbor low-grade glial tumors and thus were not included in the survival analysis. Of the remaining 13 patients, the 1-year event-free (EFS) and overall (OS) survival for these children were 31% (95% CI 9-55%) and 38% (95% CI 14-63%), respectively. Median EFS and OS were 6.6 (95% CI 2.7, 12.7) and 8.7 months (95% CI 6.9, 20.9), respectively. Eight patients developed progressive disease during study treatment (seven during Induction and one at the end of Consolidation). Ten children received focal irradiation, five for residual tumor (three following Induction and two following Consolidation) and five due to disease progression. CONCLUSIONS Children with high-grade BSG did not benefit from this intensive chemotherapy strategy administered prior to irradiation.
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Prasad KSV, Ravi D, Pallikonda V, Raman BVS. Clinicopathological Study of Pediatric Posterior Fossa Tumors. J Pediatr Neurosci 2017; 12:245-250. [PMID: 29204199 PMCID: PMC5696661 DOI: 10.4103/jpn.jpn_113_16] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
CONTEXT Brain tumor is one of the most devastating forms of human illness, especially when occurring in the posterior fossa and involving the brainstem. Tumors in the posterior fossa are considered some of the most critical brain lesions. This is primarily due to the limited space within the posterior fossa, as well as the potential involvement of the vital brainstem nuclei. AIMS The aim of this study is to analyze the incidence, clinical features, surgical outcome, complications, and prognosis in a series of 37 pediatric patients with posterior fossa tumors who underwent surgery between September 2012 and January 2015 from the Department of Neurosurgery, King George Hospital, Visakhapatnam (both prospective and retrospective study). MATERIALS AND METHODS A series of 37 cases were treated by the Department of Neurosurgery, King George Hospital, between August 2012 and January 2015. RESULTS Posterior fossa tumors are predominantly seen in children with a peak incidence in the first decade. The most common presenting symptoms are raised intracranial pressure with headache and vomiting. Majority of the tumors are medulloblastomas, ependymomas, and cerebellar astrocytomas. The most common location is the cerebellar vermis, followed by the cerebellar hemispheres, followed by the forth ventricle and then the brainstem.
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Affiliation(s)
| | - D. Ravi
- Department of Neurosurgery, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
| | - Vijay Pallikonda
- Department of Neurosurgery, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
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Vanan MI, Eisenstat DD. DIPG in Children - What Can We Learn from the Past? Front Oncol 2015; 5:237. [PMID: 26557503 PMCID: PMC4617108 DOI: 10.3389/fonc.2015.00237] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 10/08/2015] [Indexed: 02/02/2023] Open
Abstract
Brainstem tumors represent 10–15% of pediatric central nervous system tumors and diffuse intrinsic pontine glioma (DIPG) is the most common brainstem tumor of childhood. DIPG is almost uniformly fatal and is the leading cause of brain tumor-related death in children. To date, radiation therapy (RT) is the only form of treatment that offers a transient benefit in DIPG. Chemotherapeutic strategies including multi-agent neoadjuvant chemotherapy, concurrent chemotherapy with RT, and adjuvant chemotherapy have not provided any survival advantage. To overcome the restrictive ability of the intact blood–brain barrier (BBB) in DIPG, several alternative drug delivery strategies have been proposed but have met with minimal success. Targeted therapies either alone or in combination with RT have also not improved survival. Five decades of unsuccessful therapies coupled with recent advances in the genetics and biology of DIPG have taught us several important lessons (1). DIPG is a heterogeneous group of tumors that are biologically distinct from other pediatric and adult high grade gliomas (HGG). Adapting chemotherapy and targeted therapies that are used in pediatric or adult HGG for the treatment of DIPG should be abandoned (2). Biopsy of DIPG is relatively safe and informative and should be considered in the context of multicenter clinical trials (3). DIPG probably represents a whole brain disease so regular neuraxis imaging is important at diagnosis and during therapy (4). BBB permeability is of major concern in DIPG and overcoming this barrier may ensure that drugs reach the tumor (5). Recent development of DIPG tumor models should help us accurately identify and validate therapeutic targets and small molecule inhibitors in the treatment of this deadly tumor.
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Affiliation(s)
- Magimairajan Issai Vanan
- Department of Pediatrics and Child Health, University of Manitoba , Winnipeg, MB , Canada ; Department of Biochemistry and Medical Genetics, University of Manitoba , Winnipeg, MB , Canada
| | - David D Eisenstat
- Department of Pediatrics, University of Alberta , Edmonton, AB , Canada ; Department of Medical Genetics, University of Alberta , Edmonton, AB , Canada ; Department of Oncology, University of Alberta , Edmonton, AB , Canada
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Abstract
Diffuse intrinsic pontine glioma (DIPG) is an aggressive tumor that is universally fatal, and to-date we are at a virtual standstill in improving its grim prognosis. Dearth of tissue due to rarity of biopsy has precluded understanding the elusive biology and frustration continues in reproducing faithful animal models for translational research. Furthermore the intricate anatomy of the pons has forestalled locoregional therapy and drug penetration. Over the last few years, biopsy-driven targeted therapy, development of vitro and xenograft animal models for therapeutic testing, profiling immunotherapeutic strategies and locoregional infusion of drugs in brain stem tumors, now provide a sense of hope in the years ahead. This review aims to discuss current status and advances in the management of these tumors.
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Affiliation(s)
- Soumen Khatua
- Pediatric Neuro-Oncology, Department of Pediatrics, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 87, Houston, TX 77030, USA
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9
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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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Luther N, Zhou Z, Zanzonico P, Cheung NK, Humm J, Edgar MA, Souweidane MM. The potential of theragnostic ¹²⁴I-8H9 convection-enhanced delivery in diffuse intrinsic pontine glioma. Neuro Oncol 2014; 16:800-6. [PMID: 24526309 DOI: 10.1093/neuonc/not298] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Reasons for failure in prior human glioma convection-enhanced delivery (CED) clinical trials remain unclear. Concentration-dependent volume of distribution (Vd) measurement of CED-infused agents in the human brain is challenging and highlights a potential technical shortcoming. Activity of iodine isotope 124 ((124)I ) in tissue can be directly measured in vivo with high resolution via PET. With the potential therapeutic utility of radioimmunotherapy, we postulate (124)I conjugated to the antiglioma monoclonal antibody 8H9 may serve as a "theragnostic" agent delivered via CED to diffuse intrinsic pontine glioma. METHODS Fifteen rats underwent CED of 0.1-1.0 mCi of (131)I-8H9 to the pons for toxicity evaluation. Six additional rats underwent CED of 10 µCi of (124)I-8H9 to the pons for dosimetry, with serial microPET performed for 1 week. Two primates underwent CED of gadolinium-albumin and 1.0 mCi of (124)I-8H9 to the pons for safety and dosimetry analysis. Serial postoperative PET, blood, and CSF radioactivity counts were performed. RESULTS One rat (1.0 mCi (131)I-8H9 infusion) suffered toxicity necessitating early sacrifice. PET analysis in rats yielded a pontine absorbed dose of 37 Gy/mCi. In primates, no toxicity was observed, and absorbed pontine dose was 3.8 Gy/mCi. Activity decreased 10-fold with 48 h following CED in both animal models. Mean Vd was 0.14 cc(3) (volume of infusion [Vi] to Vd ratio = 14) in the rat and 6.2 cc(3) (Vd/Vi = 9.5) in primate. CONCLUSION The safety and feasibility of (124)I dosimetry following CED via PET is demonstrated, establishing a preclinical framework for a trial evaluating CED of (124)I-8H9 for diffuse intrinsic pontine glioma.
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Affiliation(s)
- Neal Luther
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York (N.L., Z.Z.); Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York (P.Z., J.H.); Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York (N.-K.C.); Department of Pathology, Emory University, Atlanta, Georgia (M.A.E.); Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York (M.M.S.)
| | - Zhiping Zhou
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York (N.L., Z.Z.); Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York (P.Z., J.H.); Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York (N.-K.C.); Department of Pathology, Emory University, Atlanta, Georgia (M.A.E.); Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York (M.M.S.)
| | - Pat Zanzonico
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York (N.L., Z.Z.); Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York (P.Z., J.H.); Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York (N.-K.C.); Department of Pathology, Emory University, Atlanta, Georgia (M.A.E.); Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York (M.M.S.)
| | - Nai-Kong Cheung
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York (N.L., Z.Z.); Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York (P.Z., J.H.); Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York (N.-K.C.); Department of Pathology, Emory University, Atlanta, Georgia (M.A.E.); Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York (M.M.S.)
| | - John Humm
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York (N.L., Z.Z.); Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York (P.Z., J.H.); Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York (N.-K.C.); Department of Pathology, Emory University, Atlanta, Georgia (M.A.E.); Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York (M.M.S.)
| | - Mark A Edgar
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York (N.L., Z.Z.); Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York (P.Z., J.H.); Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York (N.-K.C.); Department of Pathology, Emory University, Atlanta, Georgia (M.A.E.); Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York (M.M.S.)
| | - Mark M Souweidane
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York (N.L., Z.Z.); Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York (P.Z., J.H.); Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York (N.-K.C.); Department of Pathology, Emory University, Atlanta, Georgia (M.A.E.); Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York (M.M.S.)
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Abstract
The prognosis for children with diffuse intrinsic pontine gliomas (DIPGs) is dismal. Although DIPGs constitute only 10-15 % of all pediatric brain tumors, they are the main cause of death in this group with a median survival of less than 12 months. Standard therapy involves radiotherapy, which produces transient neurologic improvement. Despite several clinical trials having been conducted, including trials on targeted agents to assess their efficacy, there is no clear improvement in prognosis. However, knowledge of DIPG biology is increasing, mainly as a result of research using biopsy and autopsy samples. In this review, we discuss recent studies in which systemic therapy was administered prior to, concomitantly with, or after radiotherapy. The discussion also includes novel therapeutic options in DIPG. Continuing multimodal and multitargeted therapies might lead to an improvement in the dismal prognosis of the disease.
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Affiliation(s)
- Rejin Kebudi
- Istanbul University Cerrahpasa Medical Faculty Pediatric Hematology-Oncology, P.C: 34090, Millet Street, Capa, Istanbul, Turkey,
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Zaky W, Wellner M, Brown RJ, Blüml S, Finlay JL, Dhall G. Treatment of children with diffuse intrinsic pontine gliomas with chemoradiotherapy followed by a combination of temozolomide, irinotecan, and bevacizumab. Pediatr Hematol Oncol 2013; 30:623-32. [PMID: 24050762 DOI: 10.3109/08880018.2013.829895] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Diffuse intrinsic pontine gliomas (DIPG) are inoperable and highly resistant tumors to chemotherapy and irradiation. DIPG has the worst prognosis among all pediatric brain tumors and the overwhelming majority of patients die within 6-18 months after diagnosis. METHODS We retrospectively reviewed the charts of six DIPG patients treated with chemoradiotherapy (daily carboplatin and oral etoposide in five patients and temozolomide in one patient) followed by maintenance chemotherapy consisting of irinotecan, temozolomide, and bevacizumab at our institution between January 2007 until December 2007. RESULTS Event-free survival (EFS) and overall survival (OS) were 10.4 ± 3.08 and 14.6 ± 3.55 months, respectively. Side effects in the patients included hypertension in two, abdominal cramping and diarrhea in four, and neutropenia in five patients. CONCLUSIONS This augmented regimen was associated with increased but tolerable toxicity and a modest increase in EFS and OS when compared with published literature in patients with DIPG (median EFS and OS of 6.1 and 9.6 months, respectively). More effective therapies are desperately needed.
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Affiliation(s)
- Wafik Zaky
- 1Department of Pediatrics, Division of Pediatric Hematology and Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Brower JV, Indelicato DJ, Aldana PR, Sandler E, Rotondo R, Mendenhall NP, Marcus RB, Su Z. A treatment planning comparison of highly conformal radiation therapy for pediatric low-grade brainstem gliomas. Acta Oncol 2013; 52:594-9. [PMID: 23421953 PMCID: PMC3665211 DOI: 10.3109/0284186x.2013.767474] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jeffrey V. Brower
- University of Florida Proton Therapy Institute,
Jacksonville, Florida, USA
| | | | - Philipp R. Aldana
- University of Florida Pediatric Neurosurgery Center,
Jacksonville, Florida, USA
| | - Eric Sandler
- Nemours Children’s Clinic,
Jacksonville, Florida, USA
| | - Ronny Rotondo
- University of Florida Proton Therapy Institute,
Jacksonville, Florida, USA
| | | | - Robert B. Marcus
- University of Florida Proton Therapy Institute,
Jacksonville, Florida, USA
| | - Zhong Su
- University of Florida Proton Therapy Institute,
Jacksonville, Florida, USA
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O'Halloran PJ, Farrell M, Caird J, Capra M, O'Brien D. Paediatric spinal glioblastoma: case report and review of therapeutic strategies. Childs Nerv Syst 2013; 29:367-74. [PMID: 23319103 DOI: 10.1007/s00381-013-2023-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 01/03/2013] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Although uncommon, there is significant morbidity and mortality associated with paediatric spinal glioblastoma. The paucity of cases makes treatment options difficult. The current recommended standard of care is biopsy followed by adjuvant chemo-radiotherapy, with emerging data supporting the role of safe gross total resection. OBJECTIVE The purpose of this paper is to provide a single-institution case study and to discuss current and future therapeutic treatment strategies. CASE PRESENTATION A 14-year-old boy presented with a 2-year history of intermittent back pain with recent progressively worsening motor and sensory deficits of the right side. Pre-operative MRI revealed an enhancing intra-medullary tumour extending from C2 to C7. During the operative case, no tumour-cord margin could be identified, and the patient underwent a subtotal excision. Histopathology confirmed glioblastoma. In the subsequent weeks, the patient's clinical condition deteriorated. Adjuvant therapy was declined by the family, and the patient died 9 weeks after initial presentation. CONCLUSION Despite major advances in surgical techniques, peri-operative neuro-imaging as well as chemo-radiotherapy, the prognosis of a paediatric intra-medullary high-grade spinal tumour remains poor. Detailed analysis of our understanding of tumour dynamics in this patient group is important in establishing future therapeutic strategies.
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Goda JS, Dutta D, Raut N, Juvekar SL, Purandare N, Rangarajan V, Arora B, Gupta T, Kurkure P, Jalali R. Can multiparametric MRI and FDG-PET predict outcome in diffuse brainstem glioma? A report from a prospective phase-II study. Pediatr Neurosurg 2013; 49:274-81. [PMID: 25277867 DOI: 10.1159/000366167] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 07/20/2014] [Indexed: 11/19/2022]
Abstract
PURPOSE To study the impact of multiparametric MRI and (18)F-FDG-PET on the outcome of children with diffuse intrinsic pontine gliomas (DIPG). MATERIALS AND METHODS Imaging data from a phase-II prospective therapeutic study in children with newly diagnosed DIPG were considered for evaluation. They included baseline MRI with contrast enhancement before treatment. Functional imaging included MR spectroscopy, MR perfusion and FDG-PET studies. All patients (n = 20) had baseline MRI and 11 patients had FDG-PET. Response was assessed by MRI and PET 4 weeks after therapy. Baseline imaging findings were correlated with survival. Presence or absence of adverse parameters on MRI (heterogeneous contrast enhancement, hyperperfusion or increased choline:NAA ratio) was used to develop a cumulative radiological prognostic index (RPI). Sensitivity and specificity of each imaging modality in tumour grading was estimated. RESULTS The cumulative RPI was able to classify the patients into different grades and was predictive of overall survival (p = 0.02). MR perfusion also predicted survival (p = 0.039). Sensitivity and specificity of MRI and FDG-PET to detect low-grade gliomas were low to moderate (33-66%), but moderate to high in detecting high-grade gliomas (50-100%). Baseline FDG uptake on PET scan did not correlate with survival (p = 0.7). CONCLUSIONS Cumulative RPI was able to classify tumours into different grades and predicted clinical outcome. At baseline, MR hyperperfusion indicated a shorter survival for DIPG patients. Sensitivity and specificity of imaging modalities to detect low-grade gliomas were poor.
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Affiliation(s)
- Jayant S Goda
- Department of Radiation Oncology, Neuro-Oncology Disease Management Group, Tata Memorial Centre, Mumbai, India
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Warren KE. Diffuse intrinsic pontine glioma: poised for progress. Front Oncol 2012; 2:205. [PMID: 23293772 PMCID: PMC3531714 DOI: 10.3389/fonc.2012.00205] [Citation(s) in RCA: 186] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 12/11/2012] [Indexed: 12/21/2022] Open
Abstract
Diffuse intrinsic pontine gliomas (DIPGs) are amongst the most challenging tumors to treat. Surgery is not an option, the effects of radiation therapy are temporary, and no chemotherapeutic agent has demonstrated significant efficacy. Numerous clinical trials of new agents and novel therapeutic approaches have been performed over the course of several decades in efforts to improve the outcome of children with DIPG, yet without success. The diagnosis of DIPG is based on radiographic findings in the setting of a typical clinical presentation, and tissue is not routinely obtained as the standard of care. The paradigm for treating children with these tumors has been based on that for supratentorial high-grade gliomas in adults as the biology of these lesions were presumed to be similar. However, recent pivotal studies demonstrate that DIPGs appear to be their own entity. Simply identifying this fact releases a number of constraints and opens opportunities for biologic investigation of these lesions, setting the stage to move forward in identifying DIPG-specific treatments. This review will summarize the current state of knowledge of DIPG, discuss obstacles to therapy, and summarize results of recent biologic studies.
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Affiliation(s)
- Katherine E Warren
- Pediatric Neuro-Oncology Section, Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health Bethesda, MD, USA
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Bode U, Massimino M, Bach F, Zimmermann M, Khuhlaeva E, Westphal M, Fleischhack G. Nimotuzumab treatment of malignant gliomas. Expert Opin Biol Ther 2012; 12:1649-59. [PMID: 23043252 DOI: 10.1517/14712598.2012.733367] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION In spite of new alkylating medication and recently accumulated knowledge about genomics, the prognosis of malignant gliomas remains poor. The introduction of single substances interfering with tumour proliferation dynamics has been disappointing and the lessons learned indicate that a complicated network of proliferation needs time consuming, in-depth analysis in order to more specifically treat now distinguishable subgroups of a disease, which too long was thought of as a uniform entity. AREAS COVERED The clinical trials using the EGFR antibody nimotuzumab in the treatment of malignant gliomas are reviewed. Pending conformation in future studies the antibody might be part of the treatment of MGMT-negative, EGFR-amplified, not completely resected gliomas of adulthood and juvenile DIPG (pontine gliomas). Upcoming genomic results of the different tumour entities may suggest certain combination partners of the antibody. Recent studies of nimotuzumab indicate the reason for the lack of toxicity, which is the most attractive argument for its clinical use besides modest efficacy. EXPERT OPINION We await the final results on the use of the antibody together with vinorelbine and radiation therapy for the therapy of DIPG. Adult patients with MGMT-negative, EGFR amplified, not totally resected GBM may also profit from this combination therapy. TK-inhibitors combined with the antibody and irradiation may be an option for a therapeutic trial in paediatric patients.
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Affiliation(s)
- Udo Bode
- University of Bonn Medical School, Department Paed. Haematology/Oncology, Bonn, Germany.
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Jansen M, van Vuurden D, Vandertop W, Kaspers G. Diffuse intrinsic pontine gliomas: A systematic update on clinical trials and biology. Cancer Treat Rev 2012; 38:27-35. [DOI: 10.1016/j.ctrv.2011.06.007] [Citation(s) in RCA: 170] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 05/17/2011] [Accepted: 06/25/2011] [Indexed: 11/28/2022]
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MacDonald TJ, Aguilera D, Kramm CM. Treatment of high-grade glioma in children and adolescents. Neuro Oncol 2011; 13:1049-58. [PMID: 21784756 PMCID: PMC3177659 DOI: 10.1093/neuonc/nor092] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 05/20/2011] [Indexed: 12/15/2022] Open
Abstract
Pediatric high-grade gliomas (HGGs)--including glioblastoma multiforme, anaplastic astrocytoma, and diffuse intrinsic pontine glioma--are difficult to treat and are associated with an extremely poor prognosis. There are no effective chemotherapeutic regimens for the treatment of pediatric HGG, but many new treatment options are in active investigation. There are crucial molecular differences between adult and pediatric HGG such that results from adult clinical trials cannot simply be extrapolated to children. Molecular markers overexpressed in pediatric HGG include PDGFRα and P53. Amplification of EGFR is observed, but to a lesser degree than in adult HGG. Potential molecular targets and new therapies in development for pediatric HGG are described in this review. Research into bevacizumab in pediatric HGG indicates that its activity is less than that observed in adult HGG. Similarly, tipifarnib was found to have minimal activity in pediatric HGG, whereas gefitinib has shown greater effects. After promising phase I findings in children with primary CNS tumors, the integrin inhibitor cilengitide is being investigated in a phase II trial in pediatric HGG. Studies are also ongoing in pediatric HGG with 2 EGFR inhibitors: cetuximab and nimotuzumab. Other novel treatment modalities under investigation include dendritic cell-based vaccinations, boron neutron capture therapy, and telomerase inhibition. While the results of these trials are keenly awaited, the current belief is that multimodal therapy holds the greatest promise. Research efforts should be directed toward building multitherapeutic regimens that are well tolerated and that offer the greatest antitumor activity in the setting of pediatric HGG.
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Affiliation(s)
- T J MacDonald
- Aflac Cancer Center and Blood Disorders Service, Children's Healthcare of Atlanta, Emory University School of Medicine, Emory Children's Center, 2015 Uppergate Drive, Suite 442, Atlanta, GA 30322 USA.
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Pollack IF. Multidisciplinary management of childhood brain tumors: a review of outcomes, recent advances, and challenges. J Neurosurg Pediatr 2011; 8:135-48. [PMID: 21806354 DOI: 10.3171/2011.5.peds1178] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECT Brain tumors are the most common category of childhood solid tumors. In the 1970s and 1980s, treatment protocols for benign tumors focused almost exclusively on surgery, with radiation treatment as a salvage modality, whereas the management of malignant tumors employed a combination of surgery, radiation therapy, and chemotherapy, with therapeutic approaches such as "8-in-1" chemotherapy often applied across histological tumor subsets that are now recognized to be prognostically distinct. During the ensuing years, treatment has become increasingly refined, based on clinical and, more recently, molecular factors, which have supported risk-adapted treatment stratification. The goal of this report is to provide an overview of recent progress in the field. METHODS A review of the literature was undertaken to examine recent advances in the management of the most common childhood brain tumor subsets, and in particular to identify instances in which molecular categorization and treatment stratification offer evidence or promise for improving outcome. RESULTS For both medulloblastomas and infant tumors, refinements in clinical and molecular stratification have already facilitated efforts to achieve risk-adapted treatment planning. Current treatment strategies for children with these tumors focus on improving outcome for tumor subsets that have historically been relatively resistant to therapy and reducing treatment-related sequelae for children with therapy-responsive tumors. Recent advances in molecular categorization offer the promise of further refinements in future studies. For children with ependymomas and low-grade gliomas, clinical risk stratification has facilitated tailored approaches to therapy, with improvement of disease control and concomitant reduction in treatment sequelae, and recent discoveries have identified promising therapeutic targets for molecularly based therapy. In contrast, the prognosis remains poor for children with diffuse intrinsic pontine gliomas and other high-grade gliomas, despite recent identification of biological correlates of tumor prognosis and elucidation of molecular substrates of tumor development. CONCLUSIONS Advances in the clinical and molecular stratification for many types of childhood brain tumors have provided a foundation for risk-adapted treatment planning and improvements in outcome. In some instances, molecular characterization approaches have also yielded insights into new therapeutic targets. For other tumor types, outcome remains discouraging, although new information regarding the biological features critical to tumorigenesis are being translated into novel therapeutic approaches that hold promise for future improvements.
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Affiliation(s)
- Ian F Pollack
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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23
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Use of positron emission tomography in the evaluation of diffuse intrinsic brainstem gliomas in children. J Pediatr Hematol Oncol 2011; 33:369-73. [PMID: 21602725 DOI: 10.1097/mph.0b013e31820ad915] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Diffuse intrinsic brainstem gliomas (DIBSGs) in children remain difficult tumors to treat and have a very poor prognosis. Intensifying both chemotherapy and radiation programs have been attempted without success. Positron emission tomography (PET) has been used to differentiate benign from malignant tumors and may predict outcome. OBJECTIVES To determine whether PET can characterize a specific metabolic pattern of DIBSGs and correlate this with patient survival. METHODS We conducted a retrospective review of patients with DIBSGs and PET scans at diagnosis. Data for ¹⁸[F] fluorodeoxyglucose (FDG) and ¹¹C-methionine (CMET) PET scans were collected. Treatment and survival were reviewed. RESULTS We identified 30 patients with DIBSGs, 25 of whom had FDG and/or CMET PET scans. Scans showed both focal and generalized metabolic activity, and the patterns showed no correlation with survival. Patients with both FDG and CMET positive scans had a mean survival of 380 days, whereas those negative for both isotopes had a mean survival of 446 days. CONCLUSIONS There was no specific PET pattern identified in this DIBSG cohort but a trend toward improved survival was noted with absence of FDG and CMET metabolism. Metabolically active areas may suggest potential sites for biopsy. We believe that biopsy is essential for improving therapy for this patient population.
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Cohen KJ, Heideman RL, Zhou T, Holmes EJ, Lavey RS, Bouffet E, Pollack IF. Temozolomide in the treatment of children with newly diagnosed diffuse intrinsic pontine gliomas: a report from the Children's Oncology Group. Neuro Oncol 2011; 13:410-6. [PMID: 21345842 DOI: 10.1093/neuonc/noq205] [Citation(s) in RCA: 189] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
An open-label phase II study (ACNS0126) testing the efficacy of chemoradiotherapy with temozolomide (TMZ) followed by adjuvant TMZ was conducted by the Children's Oncology Group. During the period from July 6, 2004 through September 6, 2005, 63 children with newly diagnosed diffuse intrinsic pontine glioma (DIPG) were enrolled in the study. All patients received TMZ at a dosage of 90 mg/m(2)/day for 42 days to a dose of 59.4 Gy. Four weeks following irradiation, TMZ was given at a dosage of 200 mg/m(2)/day for 5 days every 28 days, for a total of 10 cycles. The primary objective of the statistical analysis was to determine whether the current treatment produced a 1-year event-free survival (EFS) rate higher than the historical baseline of 21.9% observed in CCG-9941. The mean 1-year EFS (± standard deviation) was 14% ± 4.5%, compared with 21.9% ± 5% for CCG-9941. The P value of the test of comparison of 1-year EFS, based on a 1-sided, 1-sample test of proportions, was .96. There was no evidence that temozolomide produced a 1-year EFS rate higher than 21.9%. The mean 1-year OS (± standard deviation) was 40% ± 6.5%, compared with 32% ± 6% for CCG-9941. The median time to death was 9.6 months. Chemoradiotherapy with TMZ followed by adjuvant TMZ is not more effective than previously reported regimens for the treatment of children with DIPG.
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Affiliation(s)
- Kenneth J Cohen
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD 21287, USA.
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Massimino M, Cohen KJ, Finlay JL. Is there a role for myeloablative chemotherapy with autologous hematopoietic cell rescue in the management of childhood high-grade astrocytomas? Pediatr Blood Cancer 2010; 54:641-3. [PMID: 20146219 DOI: 10.1002/pbc.22375] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
High-grade or malignant glioma represent 10% of pediatric brain tumors and are, taken as a whole, the second more frequent malignant histotype after medulloblastoma. Apart from a complete excision followed by full dose local radiotherapy, chemotherapy seems to give some beneficial to final outcome. Different trials have explored the role of high-dose chemotherapy that theoretically could give an advantage to these patients by overcoming blood-brain barrier, tumor cell chemo-resistance and inducing a wider number of responses. It is, however, still doubtful if better responses translate into improved outcome and which patients can have a true beneficial from this treatment strategy.
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Affiliation(s)
- Maura Massimino
- Pediatric Neuro-Oncology at Pediatrics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy.
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Kim CY, Kim SK, Phi JH, Lee MM, Kim IA, Kim IH, Wang KC, Jung HL, Lee MJ, Cho BK. A prospective study of temozolomide plus thalidomide during and after radiation therapy for pediatric diffuse pontine gliomas: preliminary results of the Korean Society for Pediatric Neuro-Oncology study. J Neurooncol 2010; 100:193-8. [PMID: 20309719 DOI: 10.1007/s11060-010-0157-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Accepted: 03/08/2010] [Indexed: 10/19/2022]
Abstract
This prospective study was performed to determine the efficacy and safety of temozolomide (TMZ) plus thalidomide during and after radiation therapy (RT) in pediatric patients with newly diagnosed diffuse pontine glioma (DPG). Seventeen patients with pediatric DPG were enrolled between November 2004 and March 2008. The median age was eight years (range, 3-16 years); seven patients were male and ten were female. With the exception of one glioblastoma case, which was diagnosed via open biopsy, all diagnoses were established using neuroradiological studies. The authors used the Korean Society for Pediatric Neuro-Oncology (KSPNO)-A053 protocol. The mean follow-up period was 12 months (range, 8.5-25 months). Five patients were withdrawn from the study. The rates of response to treatment and survival were analyzed in 12 patients. Ten out of the 12 patients showed a partial response (PR), whereas one patient exhibited stable disease (SD) and another patient had progressive disease (PD). The tumor control rate was 92% (11/12) and the response rate was 83% (10/12). The median progression-free survival (PFS) of the 12 patients was 7.2 months (95% confidence interval (CI), 3.6-10.7). Six-month and twelve-month PFS were 58.3 and 16.7%, respectively. Overall survival (OS) was 12.7 months (95% CI, 10.4-15.1). One and two-year survival were 58.3 and 25%, respectively. The main adverse effect was hematological toxicity, with four patients exhibiting grade 3 or 4 toxicity. All patients tolerated the regimen well enough to continue the adjuvant chemotherapy. No Pneumocystis jiroveci pneumonia was noted. The TMZ plus thalidomide regimen was safe and tolerated well enough to be administered on an outpatient basis. Larger studies are required to demonstrate the efficacy of this regimen.
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Affiliation(s)
- Chae-Yong Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Gyeonggi-do, Korea.
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Michalski A, Bouffet E, Taylor RE, Hargrave D, Walker D, Picton S, Robinson K, Pizer B, Bujkiewicz S. The addition of high-dose tamoxifen to standard radiotherapy does not improve the survival of patients with diffuse intrinsic pontine glioma. J Neurooncol 2010; 100:81-8. [PMID: 20238235 DOI: 10.1007/s11060-010-0141-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Accepted: 02/07/2010] [Indexed: 10/19/2022]
Abstract
The study aimed to examine the tolerability of the combination of radiotherapy and tamoxifen and the effect on median and event free survival as well as collecting data on the use of steroids in this population. 31 patients with diffuse intrinsic pontine glioma, diagnosed on clinical and radiological criteria, were treated with high-dose oral tamoxifen (120 mg/m(2)/day) given concomitantly with standard dose radiotherapy (54 Gy in 1.8 Gy fractions over 6 weeks). Results Tamoxifen was well tolerated with no grade 3 or 4 CTC toxicity reported. At 1 year, the progression free and event free survival were 3.2% (95% CI: 0.2-14.1%), and at 6 months 19.4% (CI: 7.9% to 34.6%). The overall survival at 1 year was 16.1% (CI: 5.9-30.9%) with median survival 6.32 months. In this study, in which tamoxifen was used in conjunction with radiotherapy, progression free survival was shown to be less good when compared with historical data HR = 3.1 (CI: 1.7-5.7). There was no significant reduction in overall survival. The addition of high-dose tamoxifen, although well tolerated, confers no clinical benefit to patients treated with diffuse intrinsic pontine glioma treated with standard radiotherapy.
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Affiliation(s)
- Antony Michalski
- Department of Oncology, Great Ormond Street Hospital, London, WC1N 3JH, England, UK.
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Friedman GK, Pressey JG, Reddy AT, Markert JM, Gillespie GY. Herpes simplex virus oncolytic therapy for pediatric malignancies. Mol Ther 2009; 17:1125-35. [PMID: 19367259 DOI: 10.1038/mt.2009.73] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Despite improving survival rates for children with cancer, a subset of patients exist with disease resistant to traditional therapies such as surgery, chemotherapy, and radiation. These patients require newer, targeted treatments used alone or in combination with more traditional approaches. Oncolytic herpes simplex virus (HSV) is one of these newer therapies that offer promise for several difficult to treat pediatric malignancies. The potential benefit of HSV therapy in pediatric solid tumors including brain tumors, neuroblastomas, and sarcomas is reviewed along with the many challenges that need to be addressed prior to moving oncolytic HSV therapy from the laboratory to the beside in the pediatric population.
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Affiliation(s)
- Gregory K Friedman
- Department of Pediatrics, Children's Hospital of Alabama, University of Alabama at Birmingham, USA.
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Frazier JL, Lee J, Thomale UW, Noggle JC, Cohen KJ, Jallo GI. Treatment of diffuse intrinsic brainstem gliomas: failed approaches and future strategies. J Neurosurg Pediatr 2009; 3:259-69. [PMID: 19338403 DOI: 10.3171/2008.11.peds08281] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Diffuse intrinsic pontine gliomas constitute ~ 60-75% of tumors found within the pediatric brainstem. These malignant lesions present with rapidly progressive symptoms such as cranial nerve, long tract, or cerebellar dysfunctions. Magnetic resonance imaging is usually sufficient to establish the diagnosis and obviates the need for surgical biopsy in most cases. The prognosis of the disease is dismal, and the median survival is < 12 months. Resection is not a viable option. Standard therapy involves radiotherapy, which produces transient neurological improvement with a progression-free survival benefit, but provides no improvement in overall survival. Clinical trials have been conducted to assess the efficacy of chemotherapeutic and biological agents in the treatment of diffuse pontine gliomas. In this review, the authors discuss recent studies in which systemic therapy was administered prior to, concomitantly with, or after radiotherapy. For future perspective, the discussion includes a rationale for stereotactic biopsies as well as possible therapeutic options of local chemotherapy in these lesions.
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Affiliation(s)
- James L Frazier
- Departments of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
During the past 3 decades, chemotherapeutic agents for the treatment of pediatric brain tumors have been extensively evaluated in a myriad of schedules, doses, and combinations. Remarkable advances in outcome have been achieved for certain children, notably those with medulloblastoma, but with a high cost to quality of life. In addition, the success achieved for medulloblastoma is offset by lack of progress for high-grade glioma. Despite intensive investigation, no single chemotherapeutic regimen stands out for children with high-grade glioma, with most succumbing to their disease. Further treatment intensification using conventional nonspecific chemotherapy is more likely to result in additional toxicity without major advances in survival. Genome-wide analysis using microarray technology has contributed significantly to our understanding of tumor biology, shifting the focus onto novel agents that target molecular changes crucial for tumor proliferation or survival. These selective agents are likely to be less toxic to normal cells and more effective.
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Affiliation(s)
- Nicholas G. Gottardo
- Division of Neuro-Oncology, Department of Hematology-Oncology, St Jude Children's Research Hospital, 332 North Lauderdale St, Memphis, Tennessee
| | - Amar Gajjar
- Division of Neuro-Oncology, Department of Hematology-Oncology, St Jude Children's Research Hospital, 332 North Lauderdale St, Memphis, Tennessee
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Pollack IF. Diagnostic and therapeutic stratification of childhood brain tumors: implications for translational research. J Child Neurol 2008; 23:1179-85. [PMID: 18952584 PMCID: PMC3674757 DOI: 10.1177/0883073808321770] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Recent advances in the categorization of childhood brain tumors have improved risk-based treatment planning. In several instances, new therapeutic strategies that incorporate these advances have resulted in meaningful improvements in progression-free and overall survival. Current studies are directed at further refining therapy based on clinical, biological, and molecular data; testing the effectiveness of a number of novel therapeutic strategies for high-risk tumors; and examining approaches to reduce sequelae of treatment among more favorable-risk tumor subsets. Because multiple tumor subtypes are individually relatively uncommon, most such studies are being conducted by large co-operative groups, such as the Children's Oncology Group, or by smaller brain tumor-focused consortia, such as the Pediatric Brain Tumor Consortium.
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Affiliation(s)
- Ian F. Pollack
- Department of Neurosurgery, Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Frappaz D, Schell M, Thiesse P, Marec-Bérard P, Mottolese C, Perol D, Bergeron C, Philip T, Ricci AC, Galand-Desme S, Szathmari A, Carrie C. Preradiation chemotherapy may improve survival in pediatric diffuse intrinsic brainstem gliomas: final results of BSG 98 prospective trial. Neuro Oncol 2008; 10:599-607. [PMID: 18577561 PMCID: PMC2666234 DOI: 10.1215/15228517-2008-029] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2006] [Accepted: 02/25/2008] [Indexed: 11/19/2022] Open
Abstract
Radiation therapy remains the only treatment that provides clinical benefit to children with diffuse brainstem tumors. Their median survival, however, rarely exceeds 9 months. The authors report a prospective trial of frontline chemotherapy aimed at delaying radiation until time of clinical progression. The aim was to investigate the possibility that radiotherapy would maintain its activity in children whose disease progressed after chemotherapy. Twenty-three patients took part in this protocol, the BSG 98 protocol, which consisted of frontline chemotherapy alternating hematotoxic and nonhematotoxic schedules. Each cycle included three courses delivered monthly; the first course was 1,3-bis(2-chloroethyl)-1-nitrosoureacisplatin, and the second and third were high-dose methotrexate. Three patients underwent one cycle; 5 patients each, two and three cycles; and 10 patients, four cycles. Twenty of the 23 patients eventually received local radiation therapy. A historical cohort of 14 patients who received at least local radiation therapy served as controls. Four patients experienced severe iatrogenic infections, and 11 patients required platelet transfusions. Median survival increased significantly in patients participating in the protocol compared to that in the historical controls (17 months, 95% confidence interval [CI], 10-23 months, vs. 9 months, 95% CI, 8-10 months; p = 0.022), though hospitalization was prolonged (57 vs. 25 days, p = 0.001). Although frontline chemotherapy alternating hematotoxic and nonhematotoxic schedules significantly increases overall median survival, its cost from infection and hospitalization deserves honest discussion with the children and their parents.
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Marachelian A, Butturini A, Finlay J. Myeloablative chemotherapy with autologous hematopoietic progenitor cell rescue for childhood central nervous system tumors. Bone Marrow Transplant 2008; 41:167-72. [DOI: 10.1038/sj.bmt.1705953] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Korones DN. Treatment of newly diagnosed diffuse brain stem gliomas in children: in search of the holy grail. Expert Rev Anticancer Ther 2007; 7:663-74. [PMID: 17492930 DOI: 10.1586/14737140.7.5.663] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Diffuse brain stem glioma is the most devastating of pediatric malignancies. Virtually all children with this disease die within 1-2 years of diagnosis. After three decades of exhaustive research, the key to controlling this malignancy still eludes us. Attempts to improve survival using radiation, chemotherapy and biologic agents have yet to culminate in meaningful advances. Recent advances in molecular biology have led to the development of more targeted therapies, which are now being introduced in clinical trials for children with brain stem glioma. As our understanding of the biology of this disease improves, so too will our ability to target it more effectively. Real strides in improving the lives of children with brain stem glioma may finally be within our grasp.
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Affiliation(s)
- David N Korones
- University of Rochester Medical Center, Rochester, NY 14642, USA.
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Hargrave D, Bartels U, Bouffet E. Diffuse brainstem glioma in children: critical review of clinical trials. Lancet Oncol 2006; 7:241-8. [PMID: 16510333 DOI: 10.1016/s1470-2045(06)70615-5] [Citation(s) in RCA: 436] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Diffuse intrinsic brainstem gliomas constitute 15-20% of all CNS tumours in children, and are the main cause of death in children with brain tumours. Many clinical trials have been done over the past three decades, but survival has remained static. More than 90% of children die within 2 years of diagnosis, and conventional fractionated radiation remains the standard treatment. However, median survival differs substantially between clinical trials, suggesting a survival benefit with some strategies. We appraised the consistency between protocols in terms of eligibility criteria, definition and assessment of response and progression, statistical design, and endpoints. Study designs varied substantially, which could explain the differences in outcome, and no treatment has shown a benefit over conventional radiotherapy. However, consistency between protocols (eg, eligibility criteria and outcome measures) is important to measure the progress in management of diffuse pontine gliomas.
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Affiliation(s)
- Darren Hargrave
- Department of Paediatric Oncology, Royal Marsden Hospital, Sutton, Surrey, UK
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Finlay JL, Zacharoulis S. The treatment of high grade gliomas and diffuse intrinsic pontine tumors of childhood and adolescence: a historical - and futuristic - perspective. J Neurooncol 2006; 75:253-66. [PMID: 16195805 DOI: 10.1007/s11060-005-6747-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Pediatric high grade gliomas represent a heterogeneous group of tumors with poor prognoses despite the use of multimodal treatment. Very little progress has been made over the past decades in identifying efficacious therapeutic modalities against both high grade gliomas and diffuse brainstem gliomas in children. The degree of surgical resection is the most important clinical prognostic factor for children with high grade gliomas, and a complete resection should be attempted whenever feasible. The role of radiation therapy in the treatment of older children with high grade gliomas and diffuse brain stem gliomas is undisputed; however the benefit of using radiation for patients less than 6 years of age (with high grade gliomas) might be questionable. Despite the absence of solid evidence to support its use, chemotherapy is routinely used against these tumors. Currently temozolomide is being investigated due to its activity in adult trials and based on preliminary data regarding recurrent disease. A small subgroup of patients can be successfully treated with high dose chemotherapy followed by autologous stem cell rescue. Early trials using this modality in the past had been associated with high morbidity and mortality. High dose chemotherapy with autologous stem cell rescue in selected patients with minimal residual disease, angiogenesis inhibitors, radiosensitizers and other biological modifiers are being currently investigated in phase I/II trials.
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Affiliation(s)
- Jonathan L Finlay
- The Neural Tumors Program, Childrens Center for Cancer and Blood Diseases, Childrens Hospital Los Angeles, USA.
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Bernier-Chastagner V, Grill J, Doz F, Bracard S, Gentet JC, Marie-Cardine A, Luporsi E, Margueritte G, Lejars O, Laithier V, Mechinaud F, Millot F, Kalifa C, Chastagner P. Topotecan as a radiosensitizer in the treatment of children with malignant diffuse brainstem gliomas: results of a French Society of Paediatric Oncology Phase II Study. Cancer 2006; 104:2792-7. [PMID: 16265674 DOI: 10.1002/cncr.21534] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The current Phase II study was conducted to evaluate the survival and toxicity observed in children with newly diagnosed brainstem gliomas who were treated with the daily radiotherapy with topotecan used as a radiosensitizer. METHODS Eligible patients were those ages 3-18 years with previously untreated tumors arising in the pons diagnosed within the previous 6 months. Histologic confirmation was not mandatory provided that the clinical and magnetic resonance imaging findings were typical for a diffusely infiltrating brainstem lesion. Treatment was comprised of a 6-week course of topotecan administered intravenously at a dose of 0.4 mg/m(2)/day over 30 minutes within 1 hour before irradiation. Radiotherapy was comprised of a once-daily treatment of 1.8 grays (Gy) per fraction to a total dose of 54 Gy. RESULTS Thirty-two patients were included in the current study between August 2000 and October 2002. All patients completed the combined treatment in accordance with the treatment design. Only partial responses were observed, occurring in 40% of the patients. The 9-month and 12-month survival rates were 34.4% +/- 8% and 25.5% +/- 8%, respectively. The median duration of survival for these 32 patients was 8.3 months. An intratumoral cystic/necrotic change was observed in five patients, with clinical impairment noted in two patients. One intratumoral hemorrhage occurred during radiotherapy, and was associated with transitory neurologic impairment. CONCLUSIONS The findings of the current study regarding newly diagnosed brainstem glioma patients treated with topotecan given as a radiosensitizing agent did not reproduce the encouraging results obtained in preclinical studies. Therefore, the concomitant combination of topotecan and radiotherapy at this schedule and these doses cannot be recommended for the treatment of patients with brainstem gliomas.
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Abstract
Brain stem tumors are heterogeneous. They range from the diffuse pontine tumors, which are almost invariably fatal despite all known therapies, to lower-grade focal or exophytic tumors that often have a very good prognosis with surgery or observation only. In this article, we review the epidemiology of brain stem tumors and note that diffuse pontine tumors, although rare, are a significant contributor to mortality among pediatric oncology patients. Diagnosis in typical cases is made using a magnetic resonance imaging scan without biopsy. No highly effective standard treatment exists; therefore, inclusion of eligible patients in well-designed clinical research studies is extremely important. If an appropriate trial is not available, conventionally fractionated external beam radiation therapy can provide good short-term palliation to a significant proportion of patients. An important area of preclinical research that may soon be investigated in clinical trials for patients with diffuse pontine tumors is interstitial infusion of therapeutic agents, and the rationale for that approach is described in detail. Lastly, autopsy should be considered for patients who die of diffuse pontine tumors with the goal of obtaining tumor tissue for biological studies that may in the future lead to novel therapies.
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Affiliation(s)
- Ira J Dunkel
- Memorial Sloan-Kettering Cancer Center, Department of Pediatrics, Box 185, 1275 York Avenue, New York, NY 10021, USA.
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Foreman NK, Schissel D, Le T, Strain J, Fleitz J, Quinones R, Giller R. A study of sequential high dose cyclophosphamide and high dose carboplatin with peripheral stem-cell rescue in resistant or recurrent pediatric brain tumors. J Neurooncol 2005; 71:181-7. [PMID: 15690136 DOI: 10.1007/s11060-004-1366-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To determine the maximum tolerated dose (MTD) of carboplatin with autologous hematopoietic stem-cell rescue, in children with poor-prognosis brain tumors. PATIENTS AND METHODS A previously determined dose of cyclophosphamide with stem-cell rescue was used as a first course. In a second course, carboplatin was given for 3 days with stem-cell rescue to 20 children. The starting dose of carboplatin was 400 mg/m2/day with increments of 75 mg/m2/day in subsequent cohorts. Toxicity and tumor response were recorded. RESULTS There were two grade IV toxicities at the dose level of 775 mg/m2/day. There were no toxic deaths. Thus, the MTD of carboplatin was 700 mg/m2/day for 3 days. There were six complete responses (33%, 95% confidence interval [CI], 13-59%), two partial responses (11%; 95% CI, 1-35%), four with stable diseases (22%; 95% CI, 6-48%) and six progressed (33%; 95% CI, 13-59%) out of 18 assessable. Seven of the eight responses were in primitive neuroectodermal tumors (PNETs) or Germinomas. One child with a metastatic anaplastic astrocytoma had a CR. The median duration of tumor response was 10 months (range: 1.5-87 months) with two children disease free at 66 and 87 months. Actuarial survival is 21%. Median follow-up of survivors is 35 months (range: 15-87 months). CONCLUSION The MTD of carboplatin with stem-cell rescue is 700 mg/m2/day for 3 days. Sequential stem-cell supported cyclophosphamide and carboplatin was tolerable in children with brain tumors and produced responses in PNETs and Germinomas.
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Affiliation(s)
- N K Foreman
- The Children's Hospital, Denver, and The University of Colorado, Health Sciences Center, Denver, Colorado 80218, USA.
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Hong S, Kim IH, Wang KC. Outcome and prognostic factors of childhood diffuse brainstem glioma. Cancer Res Treat 2005; 37:109-13. [PMID: 19956489 DOI: 10.4143/crt.2005.37.2.109] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2005] [Accepted: 02/15/2005] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The outcome and prognostic factors of brainstem glioma were evaluated following radiotherapy methods. MATERIALS AND METHODS Between 1986 and 2001, 45 childhood patients with diffuse brainstem glioma were treated. There were 26 boys and 19 girls, with a median age of 7 years (range 3 approximately 18). The histopathological diagnoses were confirmed in 13 patients, which revealed a low-grade glioma in four patients, and high-grade glioma in the other nine. Before 1993, radiation therapy using a regime of 1.8 to 2.0 Gy once a day was performed in 16 cases; thereafter, a regimes of 1.1 or 1.5 Gy twice a day was given in 15 and 14 cases, respectively. Nine patients were treated with adjuvant chemotherapy. The response to the treatment was evaluated by the MRI findings 4 weeks after radiotherapy. RESULTS After radiotherapy, the neurological deficit improved in 42 of the 45 patients (93%). The MRI responses were as follows; partial response 22/39 (56%), minimal to no response in 16/39 (41%) and tumor progression in 1/39 (3%). The median time to disease progression was 7 months, and the median survival was 12 months; the overall survival rate at 1 year was 41%. There was no significant prognostic factor for overall survival. The progression-free survival was influenced by the tumor histology (low grade vs. high grade, p=0.05) in those patients whose pathology was confirmed. CONCLUSION The radiation therapy fractionation schedule did not influence the survival. Low grade histology was a possible favorable prognostic factor of progression-free survival in pediatric brainstem glioma patients.
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Affiliation(s)
- Semie Hong
- Department of Radiation Oncology, Konkuk University College of Medicine, Seoul, Korea
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42
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Occhiogrosso G, Edgar MA, Sandberg DI, Souweidane MM. Prolonged convection-enhanced delivery into the rat brainstem. Neurosurgery 2003; 52:388-93; discussion 393-4. [PMID: 12535369 DOI: 10.1227/01.neu.0000043696.83722.8d] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2002] [Accepted: 09/18/2002] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Prolonged convection-enhanced delivery was used in an attempt to achieve large volumes of distribution (V(d)) in the rat brainstem. Clinical assessment and histological analysis were performed to establish the safety of this approach. METHODS For evaluation of V(d,), 10 rats underwent stereotactic cannula placement into the brainstem. Five rats underwent a 24-hour infusion (volume of infusion [V(i)], 200 microl), and 5 rats underwent a 7-day infusion (V(i), 2 ml) of fluorescein isothiocyanate-dextran. Serial brainstem sections were imaged with ultraviolet illumination, and V(d) was assessed. For assessment of clinical tolerance, 30 additional rats underwent chronic infusions of an isotonic saline solution into the brainstem. Serial neurological examinations were performed, followed by histological analysis after the animals' death. RESULTS No animal demonstrated clinically recognized neurological deficits. Foci of organizing necrosis were limited to the site of infusion and cannula tract. V(d) increased linearly with increasing V(i) (range, 24.8-130.6 mm(3)). Maximal cross sectional area of fluorescence and craniocaudal extent of fluorescence increased with increasing V(i). Fluorescence was detected throughout the entire brainstem beyond the compact area of highly concentrated tracer. CONCLUSION Prolonged convection-enhanced delivery can be applied safely in the rat brainstem with no recognized limitations of V(d) and minimal histological changes beyond the site of infusion. Chronic brainstem infusions may enhance the potential application of convection-enhanced delivery for therapeutic purposes in treating diffuse pontine gliomas.
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Affiliation(s)
- Giuseppe Occhiogrosso
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York 10021, USA
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Wolff JEA, Westphal S, Mölenkamp G, Gnekow A, Warmuth-Metz M, Rating D, Kuehl J. Treatment of paediatric pontine glioma with oral trophosphamide and etoposide. Br J Cancer 2002; 87:945-9. [PMID: 12434281 PMCID: PMC2364312 DOI: 10.1038/sj.bjc.6600552] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2002] [Revised: 06/13/2002] [Accepted: 07/15/2002] [Indexed: 11/30/2022] Open
Abstract
To evaluate the overall survival of paediatric patients with pontine gliomas treated with oral trophosphamide and etoposide. Patients between 3 and 17 years of age with either typical diffuse pontine glioma on MRI or histologically proven anaplastic astrocytoma/glioblastoma multiforme located in the pons, were eligible. Treatment consisted of oral trophosphamide 100 mg x m(-2) x day(-1) combined with oral etoposide at 25 mg x m(-2) x day(-1) starting simultaneously with conventional radiation. Twenty patients were enrolled (median age 6 years, male : female=9 : 11). Surgical procedures included: no surgery: five, open biopsy: three, stereotactic biopsy: six, partial resection: three, and sub-total resection: three. Histological diagnoses included pilocytic astrocytoma: one, astrocytoma with no other specification: three, anaplastic astrocytoma: three, glioblastoma multiforme: eight, no histology: five. The most frequent side effects were haematologic and gastrointestinal. There was no toxic death. The response to combined treatment in 12 evaluable patients was: complete response: 0, partial response: three, stable disease: four, and progressive disease: five. All tumours progressed locally and all patients died. The overall median survival was 8 months. The overall survival rates at 1 and 4 years were: 0.4 and 0.05 respectively. This was not different from a control group of patients documented in the same population. Oral trophosphamide in combination with etoposide did not improve survival of pontine glioma patients. The treatment was well tolerated and should be evaluated for more chemoresponsive paediatric malignancies.
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Affiliation(s)
- J E A Wolff
- St. Hedwigs Klinik, Hämato/Onkologie, Steinmetzstr. 1-3, 93049 Regensburg, Germany.
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44
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Jennings MT, Sposto R, Boyett JM, Vezina LG, Holmes E, Berger MS, Bruggers CS, Bruner JM, Chan KW, Dusenbery KE, Ettinger LJ, Fitz CR, Lafond D, Mandelbaum DE, Massey V, McGuire W, McNeely L, Moulton T, Pollack IF, Shen V. Preradiation chemotherapy in primary high-risk brainstem tumors: phase II study CCG-9941 of the Children's Cancer Group. J Clin Oncol 2002; 20:3431-7. [PMID: 12177103 DOI: 10.1200/jco.2002.04.109] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE This Children's Cancer Group group-wide phase II trial evaluated the efficacy and toxicity of two chemotherapy arms administered before hyperfractionated external-beam radiotherapy (HFEBRT). PATIENTS AND METHODS Thirty-two patients with newly diagnosed brainstem gliomas were randomly assigned to regimen A and 31 to regimen B. Regimen A comprised three courses of carboplatin, etoposide, and vincristine; regimen B comprised cisplatin, etoposide, cyclophosphamide, and vincristine. Both arms included granulocyte colony-stimulating factor. Patients were evaluated by magnetic resonance imaging after induction chemotherapy and HFEBRT at a dose of 72 Gy. RESULTS Ten percent +/- 5% of regimen A patients objectively responded to chemotherapy. For combined induction and radiotherapy, 27% +/- 9% of patients improved. The neuroradiographic response rate for regimen B was 19% +/- 8% for chemotherapy and 23% +/- 9% after HFEBRT. Response rates were not statistically significant between regimens after induction or chemotherapy/HFEBRT. Event-free survival was 17% +/- 5% (estimate +/- SE) at 1 year and 6% +/- 3% at 2 years. Survival was significantly longer among patients who responded to chemotherapy (P <.05). Among patients who received regimen A induction, grades 3 and 4 leukopenia were observed in 50% to 65%, with one toxicity-related death. For regimen B, severe leukopenia occurred in 86% to 100%, with febrile neutropenia in 48% to 60% per course. CONCLUSION Neither chemotherapy regimen meaningfully improved response rate, event-free survival, or overall survival relative to previous series of patients with brainstem gliomas who received radiotherapy with or without chemotherapy.
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Sandberg DI, Edgar MA, Souweidane MM. Effect of hyperosmolar mannitol on convection-enhanced delivery into the rat brain stem. J Neurooncol 2002; 58:187-92. [PMID: 12187954 DOI: 10.1023/a:1016213315548] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Convection-enhanced delivery (CED) can safely achieve high local infusate concentrations within the rat brain stem with predictable distribution volumes. The authors investigated the effects of co-infusion or systemic administration of hyperosmolar mannitol on distribution parameters for infusions into the rat brain stem. METHODS Fifteen rats underwent stereotactic cannula placement into the pontine nucleus oralis (PnO) followed by infusions at a constant rate to a total volume of 1 microl. Five rats underwent infusion of fluorescein isothiocyanate (FITC)-dextran diluted in 20% mannitol. Five rats received an intraperitoneal injection of 20% mannitol 10 min prior to infusion of FITC-dextran diluted in isotonic saline. As a control group, 5 rats underwent infusion of FITC-dextran diluted in isotonic saline without mannitol administration. Serial brain sections were imaged using confocal microscopy with ultraviolet illumination, and distribution volume (Vd) was calculated by computer image analysis. Histologic analysis was performed on adjacent sections. RESULTS Volumes of distribution were not significantly increased by co-infusion of mannitol directly into the brain stem or by systemic mannitol administration compared to infusion without mannitol. Similarly, mannitol administration by either means failed to significantly alter maximal cross-sectional area or cranio-caudal extent of fluorescence. No animal demonstrated a postoperative neurological deficit or histologic evidence of tissue disruption. CONCLUSIONS Neither systemic administration nor co-infusion of hyperosmolar mannitol significantly affects distribution parameters for CED infusions into the rat brain stem.
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Affiliation(s)
- David I Sandberg
- Department of Neurosurgery, Weill Medical College of Cornell University, New York, NY 10021, USA
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Abstract
OBJECT Convection-enhanced delivery (CED) can be used safely to achieve high local infusate concentrations within the brain and spinal cord. The use of CED in the brainstem has not been previously reported and may offer an alternative method for treating diffuse pontine gliomas. In the present study the authors tested CED within the rat brainstem to assess its safety and establish distribution parameters. METHODS Eighteen rats underwent stereotactic cannula placement into the pontine nucleus oralis without subsequent infusions. Twenty rats underwent stereotactic cannula placement followed by infusion of fluorescein isothiocyanate (FITC)-dextran at a constant rate (0.1 microl/minute) until various total volumes of infusion (V(i)s) were reached: 0.5, 1, 2, and 4 microl. Additional rats underwent FITC-dextran infusion (V, 4 microl) and were observed for 48 hours (five animals) or 14 days (five animals). Serial (20-microm thick) brain sections were imaged using confocal microscopy with ultraviolet illumination, and the volume of distribution (Vd) was calculated using computer image analysis. Histological analysis was performed on adjacent sections. No animal exhibited a postoperative neurological deficit, and there was no histological evidence of tissue disruption. The Vd increased linearly (range 15.4-55.8 mm3) along with increasing Vi, with statistically significant correlations for all groups that were compared (p < 0.022). The Va/Vi ratio ranged from 14 to 30.9. The maximum cross-sectional area of fluorescence (range 9.8-20.9 mm2) and the craniocaudal extent of fluorescence (range 2.8-5.1 mm) increased with increasing Vi. CONCLUSIONS Convection-enhanced delivery can be safely applied to the rat brainstem with substantial and predictable V(d)s. This study provides the basis for investigating delivery of various candidate agents for the treatment of diffuse pontine gliomas.
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Affiliation(s)
- David I Sandberg
- Department of Neurosurgery, Weill Medical College of Cornell University, New York, NY, USA
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47
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Dunkel IJ, Finlay JL. High-dose chemotherapy with autologous stem cell rescue for brain tumors. Crit Rev Oncol Hematol 2002; 41:197-204. [PMID: 11856595 DOI: 10.1016/s1040-8428(01)00156-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The use of high-dose chemotherapy with stem cell rescue for malignant brain tumors is reviewed. Promising results have been reported in patients with medulloblastomas, supratentorial PNET's and high-grade astrocytomas. Results thus far have been disappointing for ependymomas and brain stem gliomas. The role of this treatment strategy for other chemotherapy-sensitive tumors such as oligodendrogliomas and central nervous system germ cell tumors has yet to be determined.
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Affiliation(s)
- Ira J Dunkel
- Memorial Sloan-Kettering Cancer Center, Department of Pediatrics, Box 185, 1275 York Avenue, New York, NY 10021, USA.
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Jennings MT, Iyengar S. Pharmacotherapy of malignant astrocytomas of children and adults: current strategies and future trends. CNS Drugs 2002; 15:719-43. [PMID: 11580310 DOI: 10.2165/00023210-200115090-00005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
This article reviews the conceptual progression in the pharmacological therapy of malignant astrocytoma (MA) over the past decade, and its future trends. It is a selective rather than an exhaustive inventory of literature citations. The experience of the Brain Tumour Cooperative Group (BTCG) and earlier phase III trials are summarised to place subsequent phase II and I studies of single and combination agent chemotherapy in perspective. The BTCG experience of the 1970s to 1980s may be summarised to indicate that external beam radiotherapy (EBRT) is therapeutic, although not curative, and not further improved upon by altering fractionation schedules, or the addition of radioenhancers. Whole brain and reduced whole brain EBRT with focal boost were comparable regimens. Nitrosourea-based, adjuvant chemotherapy provided a modest improvement in survival among adult patients, which was comparable with that of other single drugs or multidrug regimes. The multiagent schedules, however, had a correspondingly higher toxicity rate. Intra-arterial administration was associated with significant risk, which conferred no therapeutic advantage. The trend of the past decade has been towards multiagent chemotherapy although its benefit cannot be predicted from the classic prognostic factors. Published experience with investigational trials utilising myeloablative chemotherapy with autologous bone marrow or peripheral blood stem cell haemopoietic support, drug delivery enhancement methods and radiosensitisers is critically reviewed. None of these approaches have achieved wide-spread acceptance in the treatment of adult patients with MA. Greater attention is placed on recent 'chemoradiotherapy' trials, which attempt to integrate and maximise the cytoreductive potential of both modalities. This approach holds promise as an effective means to delay or overcome the evolution of tumour resistance, which is probably one of the dominant determinants of prognosis. However, the efficacy of this approach remains unproven. New chemotherapeutic agents as well as biological response modifiers, protein kinase inhibitors, angiogenesis inhibitors and gene therapy are also discussed; their role in the therapeutic armamentarium has not been defined.
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Affiliation(s)
- M T Jennings
- Vanderbilt Ingram Cancer Center, Vanderbilt Medical School, 2100 Pierce Avenue, Nashville, TN 37205-3375, USA
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Chastagner P, Bouffet E, Grill J, Kalifa C. What have we learnt from previous phase II trials to help in the management of childhood brain tumours? Eur J Cancer 2001; 37:1981-93. [PMID: 11597375 DOI: 10.1016/s0959-8049(01)00251-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Contrary to major advances in cure rates observed for almost all childhood cancers, progress in reducing brain tumour survival rates remains very limited. Although new drug development in oncology is founded on principles outlined in the organised methodology of phase I, II, and III trials, based on rigorous study design using standardised criteria, this approach has been applied very slowly in the field of neuro-oncology. There are multiple explanations for the paucity of well-conducted prospective clinical trials, such as the rarity and the heterogeneity of these tumours, and the reluctance of some investigators to enroll their patients in constraining trials. Data from the past two decades shows that several methodological problems preclude the drawing of any definite conclusions for the majority of drugs assessed. Among them, the necessity of a central neuropathological and neuroradiological review has been highlighted in, at least, two multicentric studies. Changes in histological diagnosis and grade have been reported in a proportion as high as 20%, and changes in response rate in 14% of the cases. This review of phase II trials for brain tumours reveals a wide array of sometimes arbitrary response definitions, that is if response is defined at all, and most series have enrolled small numbers of patients. We report on the different problems encountered in childhood brain tumours in these phase II trials, and their impact on phase III trials.
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Affiliation(s)
- P Chastagner
- Department of Paediatric Oncology, Hôpital d'Enfants, CHU Nancy, 54500, Vandoeuvre, France.
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50
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Papadakis V, Dunkel IJ, Cramer LD, Kramer E, Papadopoulos E, Goldman S, Packer RJ, Willoughby M, Baker D, Garvin J, Strandjord S, Coccia P, Kaplan AM, Klemperer M, Finlay JL. High-dose carmustine, thiotepa and etoposide followed by autologous bone marrow rescue for the treatment of high risk central nervous system tumors. Bone Marrow Transplant 2000; 26:153-60. [PMID: 10918425 DOI: 10.1038/sj.bmt.1702475] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Forty-two patients (29 newly diagnosed) with high grade gliomas (n = 37), medulloblastoma (n = 2) or non-biopsied tumors (n = 3) with supratentorial (n = 24), brain stem (n = 11), posterior fossa (n = 5) or spinal (n = 2) location were eligible for this study with adequate organ function and no bone marrow tumor infiltration. Median patient age was 12.2 years (range, 0.7-46.8). A total of 600 mg/m2 BCNU, 900 mg/m2 thiotepa and 1500 or 750 mg/m2 etoposide (VP-16) was administered followed by autologous bone marrow reinfusion (ABMR). Twenty-one newly diagnosed patients received local irradiation (RT) post ABMR. Nine early deaths were observed (21%), as well as one secondary graft failure. Half of the patients aged 18 years or older experienced toxic deaths, whereas only 15% of patients younger than 18 years experienced toxic death (P = 0.05). Of 25 evaluable newly diagnosed patients, 20% achieved complete remission (CR) and 4% partial remission (PR), while 28% remained in continuing complete remission (CCR) and 44% remained with stable disease prior to RT. Of eight evaluable patients with recurrent disease, one achieved CR and two PR, while one remained in CCR and four with stable disease for 1 to 110.2 months. Overall survival was 36%, 24% and 17% at 1, 2 and 3 years following ABMR, with three newly diagnosed patients and one patient treated for recurrent disease being alive, without disease progression 64.4, 67.0, 86.3 and 110.2 months after ABMR, respectively. The combination of high-dose BCNU/ thiotepa/VP-16 has substantial toxicity but definite activity for high risk CNS tumors. Similar protocols with lower toxicity merit further evaluation in both newly diagnosed and recurrent CNS tumors.
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Affiliation(s)
- V Papadakis
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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