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Brassesco MS, Roberto GM, Delsin LE, Baldissera GC, Medeiros M, Umezawa K, Tone LG. A foretaste for pediatric glioblastoma therapy: targeting the NF-kB pathway with DHMEQ. Childs Nerv Syst 2023; 39:1519-1528. [PMID: 36807999 DOI: 10.1007/s00381-023-05878-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 02/09/2023] [Indexed: 02/20/2023]
Abstract
PURPOSE While pediatric glioblastomas are molecularly distinct from adult counterparts, the activation of NF-kB is partially shared by both subsets, playing key roles in tumor propagation and treatment response. RESULTS We show that, in vitro, dehydroxymethylepoxyquinomicin (DHMEQ) impairs growth and invasiveness. Xenograft response to the drug alone varied according to the model, being more effective in KNS42-derived tumors. In combination, SF188-derived tumors were more sensitive to temozolomide while KNS42-derived tumors responded better to the combination with radiotherapy, with continued tumor regression. CONCLUSION Taken together, our results strengthen the potential usefulness of NF-kB inhibition in future therapeutic strategies to overcome this incurable disease.
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Affiliation(s)
- María Sol Brassesco
- Department of Biology, Faculty of Philosophy, Sciences and Letters at Ribeirão Preto, University of São Paulo, Av. Bandeirantes, 3900, Bairro Monte Alegre, CEP 14040-901, Ribeirão Preto, SP, Brazil.
| | - Gabriela Molinari Roberto
- Department of Biology, Faculty of Philosophy, Sciences and Letters at Ribeirão Preto, University of São Paulo, Av. Bandeirantes, 3900, Bairro Monte Alegre, CEP 14040-901, Ribeirão Preto, SP, Brazil
| | - Lara Elis Delsin
- Department of Biology, Faculty of Philosophy, Sciences and Letters at Ribeirão Preto, University of São Paulo, Av. Bandeirantes, 3900, Bairro Monte Alegre, CEP 14040-901, Ribeirão Preto, SP, Brazil
| | - Gabriel Carlos Baldissera
- Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Mariana Medeiros
- Department of Cell Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Kazuo Umezawa
- Department of Molecular Target Medicine, Aichi Medical University School of Medicine, Aichi, Japan
| | - Luiz Gonzaga Tone
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
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Schmidt T, Agkatsev S, Feldheim J, Oster C, Blau T, Sure U, Keyvani K, Kleinschnitz C, Stuschke M, Herrmann K, Deuschl C, Scheffler B, Kebir S, Glas M, Lazaridis L. Feasibility and tolerability of trofosfamide and etoposide in progressive glioblastoma. Neurooncol Adv 2023; 5:vdad090. [PMID: 37547266 PMCID: PMC10403750 DOI: 10.1093/noajnl/vdad090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Background Standard of care treatment options at glioblastoma relapse are still not well defined. Few studies indicate that the combination of trofosfamide plus etoposide may be feasible in pediatric glioblastoma patients. In this retrospective analysis, we determined tolerability and feasibility of combined trofosfamide plus etoposide treatment at disease recurrence of adult glioblastoma patients. Methods We collected clinicopathological data from adult progressive glioblastoma patients treated with the combination of trofosfamide and etoposide for more than four weeks (one course). A cohort of patients receiving empiric treatment at the investigators' discretion balanced for tumor entity and canonical prognostic factors served as control. Results A total of n = 22 progressive glioblastoma patients were eligible for this analysis. Median progression-free survival (3.1 vs 2.3 months, HR: 1.961, 95% CI: 0.9724-3.9560, P = .0274) and median overall survival (9.0 vs 5.7 months, HR: 4.687, 95% CI: 2.034-10.800, P = .0003) were significantly prolonged compared to the control cohort (n = 17). In a multivariable Cox regression analysis, treatment with trofosfamide plus etoposide emerged as a significant prognostic marker regarding progression-free and overall survival. We observed high-grade adverse events in n = 16/22 (73%) patients with hematotoxicity comprising the majority of adverse events (n = 15/16, 94%). Lymphopenia was by far the most commonly observed hematotoxic adverse event (n = 11/15, 73%). Conclusions This study provides first indication that the combination of trofosfamide plus etoposide is safe in adult glioblastoma patients. The observed survival outcomes might suggest potential beneficial effects. Our data provide a reasonable rationale for follow-up of a larger cohort in a prospective trial.
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Affiliation(s)
- Teresa Schmidt
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
- DKFZ-Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK); German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sarina Agkatsev
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Jonas Feldheim
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
- DKFZ-Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK); German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christoph Oster
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
- DKFZ-Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK); German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Tobias Blau
- DKFZ-Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK); German Cancer Research Center (DKFZ), Heidelberg, Germany
- Institute of Neuropathology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Kathy Keyvani
- Institute of Neuropathology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Martin Stuschke
- Department of Radiotherapy, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
| | - Björn Scheffler
- DKFZ-Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK); German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sied Kebir
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
- DKFZ-Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK); German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martin Glas
- Corresponding Author: Prof. Dr. Martin Glas, Department of Neurology, Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Hufelandstr. 55, Essen, 45147, Germany ()
| | - Lazaros Lazaridis
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Medicine Essen, Essen, Germany
- DKFZ-Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Medicine Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK); German Cancer Research Center (DKFZ), Heidelberg, Germany
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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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Luzzi S, Giotta Lucifero A, Brambilla I, Semeria Mantelli S, Mosconi M, Foiadelli T, Savasta S. Targeting the medulloblastoma: a molecular-based approach. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:79-100. [PMID: 32608377 PMCID: PMC7975825 DOI: 10.23750/abm.v91i7-s.9958] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 06/01/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The lack of success of standard therapies for medulloblastoma has highlighted the need to plan a new therapeutic approach. The purpose of this article is to provide an overview of the novel treatment strategies based on the molecular characterization and risk categories of the medulloblastoma, also focusing on up-to-date relevant clinical trials and the challenges in translating tailored approaches into clinical practice. METHODS An online search of the literature was carried out on the PubMed/MEDLINE and ClinicalTrials.gov websites about molecular classification of medulloblastomas, ongoing clinical trials and new treatment strategies. Only articles in the English language and published in the last five years were selected. The research was refined based on the best match and relevance. RESULTS A total 58 articles and 51 clinical trials were analyzed. Trials were of phase I, II, and I/II in 55%, 33% and 12% of the cases, respectively. Target and adoptive immunotherapies were the treatment strategies for newly diagnosed and recurrent medulloblastoma in 71% and 29% of the cases, respectively. CONCLUSION Efforts are focused on the fine-tuning of target therapies and immunotherapies, including agents directed to specific pathways, engineered T-cells and oncoviruses. The blood-brain barrier, chemoresistance, the tumor microenvironment and cancer stem cells are the main translational challenges to be overcome in order to optimize medulloblastoma treatment, reduce the long-term morbidity and increase the overall survival.
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Affiliation(s)
- Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Ilaria Brambilla
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, Uni-versity of Pavia, Pavia, Italy.
| | - Simona Semeria Mantelli
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, Uni-versity of Pavia, Pavia, Italy.
| | - Mario Mosconi
- Orthopaedic and Traumatology Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Thomas Foiadelli
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, Uni-versity of Pavia, Pavia, Italy.
| | - Salvatore Savasta
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, Uni-versity of Pavia, Pavia, Italy.
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Nikolaev A, Fiveash JB, Yang ES. Combined Targeting of Mutant p53 and Jumonji Family Histone Demethylase Augments Therapeutic Efficacy of Radiation in H3K27M DIPG. Int J Mol Sci 2020; 21:ijms21020490. [PMID: 31940975 PMCID: PMC7014308 DOI: 10.3390/ijms21020490] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 12/27/2019] [Accepted: 01/08/2020] [Indexed: 01/15/2023] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is an aggressive pediatric brainstem tumor with a 5-year survival of <1%. Up to 80% of the DIPG tumors contain a specific K27M mutation in one of the two genes encoding histone H3 (H3K27M). Furthermore, p53 mutations found in >70–80% of H3K27M DIPG, and mutant p53 status is associated with a decreased response to radiation treatment and worse overall prognosis. Recent evidence indicates that H3K27M mutation disrupts tri-methylation at H3K27 leading to aberrant gene expression. Jumonji family histone demethylases collaborates with H3K27 mutation in DIPG by erasing H3K27 trimethylation and thus contributing to derepression of genes involved in tumorigenesis. Since the first line of treatment for pediatric DIPG is fractionated radiation, we investigated the effects of Jumonji demethylase inhibition with GSK-J4, and mutant p53 targeting/oxidative stress induction with APR-246, on radio-sensitization of human H3K27M DIPG cells. Both APR-246 and GSK-J4 displayed growth inhibitory effects as single agents in H3K27M DIPG cells. Furthermore, both of these agents elicited mild radiosensitizing effects in human DIPG cells (sensitizer enhancement ratios (SERs) of 1.12 and 1.35, respectively; p < 0.05). Strikingly, a combination of APR-246 and GSK-J4 displayed a significant enhancement of radiosensitization, with SER of 1.50 (p < 0.05) at sub-micro-molar concentrations of the drugs (0.5 μM). The molecular mechanism of the observed radiosensitization appears to involve DNA damage repair deficiency triggered by APR-246/GSK-J4, leading to the induction of apoptotic cell death. Thus, a therapeutic approach of combined targeting of mutant p53, oxidative stress induction, and Jumonji demethylase inhibition with radiation in DIPG warrants further investigation.
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Role of Radiation Therapy in the Management of Diffuse Intrinsic Pontine Glioma: A Systematic Review. Adv Radiat Oncol 2019; 4:520-531. [PMID: 31360809 PMCID: PMC6639749 DOI: 10.1016/j.adro.2019.03.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 03/20/2019] [Indexed: 01/05/2023] Open
Abstract
Purpose Diffuse intrinsic pontine glioma (DIPG) is the most aggressive primary pediatric brain tumor, with <10% of children surviving 2 years. Radiation therapy (RT) remains the mainstay of treatment, but there is a great clinical need for improvements and advancements in treatment strategies. The aim of this systematic review was to identify all available studies in which RT was used to treat patients with DIPG. Methods and Materials A literature search for studies published up to March 10, 2018 was conducted using the PubMed database. We identified 384 articles using search items “diffuse intrinsic pontine glioma” and 221 articles using search items “diffuse brainstem glioma radiotherapy.” Included studies were prospective and retrospective series that reported outcomes of DIPG treatment with RT. Results We identified 49 studies (1286 patients) using upfront conventionally fractionated RT, 5 studies (92 patients) using hypofractionated RT, and 8 studies (348 patients) using hyperfractionated RT. The mean median overall survival (OS) was 12.0 months, 10.2 months, and 7.9 months in patients who received conventional, hyperfractionated, and hypofractionated RT regimens, respectively. Patients undergoing radiosensitizing therapy had a mean median OS of 11.5 months, and patients who did not receive concomitant systemic therapy had an OS of 9.4 months. In patients who received salvage RT, the mean median OS from initial diagnosis was 16.3 months. Conclusions As one of the largest systematic reviews examining RT for DIPG, this report may serve as a useful tool to help clinicians choose the most appropriate treatment approach, while also providing a platform for future investigations into the utility of RT and systemic therapy.
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Bavle A, Chintagumpala M. Pediatric high-grade glioma: a review of biology, prognosis, and treatment. ACTA ACUST UNITED AC 2018. [DOI: 10.1007/s13566-018-0344-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Abstract
Brainstem gliomas are not nearly as common in adults as they are in children. They are likely the final common consequence not of a single disease process but of several. They can be difficult to diagnose, and are challenging to treat. Clinical studies of this diagnosis are few and generally small. Because of these factors, our understanding of the biology of adult brainstem glioma is incomplete. However, the knowledge base is growing and progress is being made. In this article, we review the current state of knowledge for brainstem glioma in adults and identify key areas for which additional information is required.
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Affiliation(s)
- Jethro Hu
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Santosh Kesari
- Department of Translational Neuro-Oncology and Neurotherapeutics, John Wayne Cancer Institute, Pacific Neuroscience Institute, Providence Saint John's Health Center , Santa Monica, CA , USA
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Goodwin CR, Xu R, Iyer R, Sankey EW, Liu A, Abu-Bonsrah N, Sarabia-Estrada R, Frazier JL, Sciubba DM, Jallo GI. Local delivery methods of therapeutic agents in the treatment of diffuse intrinsic brainstem gliomas. Clin Neurol Neurosurg 2016; 142:120-127. [PMID: 26849840 DOI: 10.1016/j.clineuro.2016.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 01/05/2016] [Indexed: 10/22/2022]
Abstract
Brainstem gliomas comprise 10-20% of all pediatric central nervous system (CNS) tumors and diffuse intrinsic pontine gliomas (DIPGs) account for the majority of these lesions. DIPG is a rapidly progressive disease with almost universally fatal outcomes and a median survival less than 12 months. Current standard-of-care treatment for DIPG includes radiation therapy, but its long-term survival effects are still under debate. Clinical trials investigating the efficacy of systemic administration of various therapeutic agents have been associated with disappointing outcomes. Recent efforts have focused on improvements in chemotherapeutic agents employed and in methods of localized and targeted drug delivery. This review provides an update on current preclinical and clinical studies investigating treatment options for brainstem gliomas.
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Affiliation(s)
- C Rory Goodwin
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - Risheng Xu
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - Rajiv Iyer
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - Eric W Sankey
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - Ann Liu
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - Nancy Abu-Bonsrah
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - Rachel Sarabia-Estrada
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - James L Frazier
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - Daniel M Sciubba
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA
| | - George I Jallo
- The Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore, MD, USA.
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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 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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Bartels U, Wolff J, Gore L, Dunkel I, Gilheeney S, Allen J, Goldman S, Yalon M, Packer RJ, Korones DN, Smith A, Cohen K, Kuttesch J, Strother D, Baruchel S, Gammon J, Kowalski M, Bouffet E. Phase 2 study of safety and efficacy of nimotuzumab in pediatric patients with progressive diffuse intrinsic pontine glioma. Neuro Oncol 2014; 16:1554-9. [PMID: 24847085 DOI: 10.1093/neuonc/nou091] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The prognosis of diffuse intrinsic pontine glioma (DIPG) remains poor, with no drug proven to be effective. METHODS Patients with clinically and radiologically confirmed, centrally reviewed DIPG, who had failed standard first-line therapy were eligible for this multicenter phase II trial. The anti-epidermal growth factor receptor (EGFR) antibody, nimotuzumab (150 mg/m(2)), was administered intravenously once weekly from weeks 1 to 7 and once every 2 weeks from weeks 8 to 18. Response evaluation was based on clinical and MRI assessments. Patients with partial response (PR) or stable disease (SD) were allowed to continue nimotuzumab. RESULTS Forty-four patients received at least one dose of nimotuzumab (male/female, 20/24; median age, 6.0 years; range, 3.0-17.0 years). All had received prior radiotherapy. Treatment was well tolerated. Eighteen children experienced serious adverse events (SAEs). The majority of SAEs were associated with disease progression. Nineteen patients completed 8 weeks (W8) of treatment: There were 2 PRs, 6 SDs, and 11 progressions. Five patients completed 18 weeks (W18) of treatment: 1 of 2 patients with PR at W8 remained in PR at W18, and 3 of 6 children with SD at W8 maintained SD at W18. Time to progression following initiation of nimotuzumab for the 4 patients with SD or better at W18 was 119, 157, 182 and 335 days, respectively. Median survival time was 3.2 months. Two patients lived 663 and 481 days from the start of nimotuzumab. CONCLUSIONS Modest activity of nimotuzumab in DIPG, which has been shown previously, was confirmed: A small subset of DIPG patients appeared to benefit from anti-EGFR antibody treatment.
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Affiliation(s)
- Ute Bartels
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - Johannes Wolff
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - Lia Gore
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - Ira Dunkel
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - Stephen Gilheeney
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - Jeffrey Allen
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - Stewart Goldman
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - Michal Yalon
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - Roger J Packer
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - David N Korones
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - Amy Smith
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - Kenneth Cohen
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - John Kuttesch
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - Douglas Strother
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - Sylvain Baruchel
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - Janet Gammon
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - Mark Kowalski
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
| | - Eric Bouffet
- The Hospital for Sick Children, Toronto, Ontario, Canada (U.B., S.B., J.G., E.B.); The MD Anderson Cancer Center, Houston, Texas (J.W.); Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado (L.G.); Memorial Sloan Kettering Cancer Center, New York, New York (I.D., S.G.); NYU Langone Medical Center, New York, New York (J.A.); Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.G.); Sheba Medical Center, Tel Hashomer, Israel (M.Y.); Children's National Medical Center, Washington, DC (R.J.P.); University of Rochester Medical Center, Rochester, New York (D.N.K.); University of Florida, Gainesville, Florida (A.S.); Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (K.C.); Vanderbilt Children Hospital, Nashville, Tenneessee (J.K.); Alberta Children's Hospital, Calgary, Alberta, Canada (D.S.); YM Biosciences Inc, Mississauga, Ontario, Canada (M.K.)
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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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Blesa JMG, Mollá SB, Esparcia MF, Ortells JMS, Godoy MP, Das AM, Magan BM, Pulla MP, Sanchez JL, Canales JBL, Candel VA. Durable complete remission of a brainstem glioma treated with a combination of bevacizumab and cetuximab. Case Rep Oncol 2012; 5:676-81. [PMID: 23341811 PMCID: PMC3551399 DOI: 10.1159/000341852] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Treatment of a relapsed glioma is a clinical challenge nowadays. New active treatments are required to treat these difficult diseases. Here we present a durable complete remission of a relapsed glioblastoma that has achieved a complete radiologic response with the combination of cetuximab and bevacizumab, in a third-line setting, that has offered a progression-free survival of 20 months. We consider here both potential mechanisms for the explanation of this result. First, the potential target of the cancer stem cells (CSCs) with these two antibodies, and second, the potential recruitment of the immune system to directly pursue the CSCs.
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Proceedings of the diffuse intrinsic pontine glioma (DIPG) Toronto Think Tank: advancing basic and translational research and cooperation in DIPG. J Neurooncol 2011; 105:119-25. [DOI: 10.1007/s11060-011-0704-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 08/16/2011] [Indexed: 10/17/2022]
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Diffuse intrinsic pontine glioma-current status and future strategies. Childs Nerv Syst 2011; 27:1391-7. [PMID: 21533575 DOI: 10.1007/s00381-011-1468-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 04/15/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Diffuse intrinsic pontine gliomas which constitute 15% of all childhood brain tumors are inoperable and response to radiation and chemotherapy has not improved long-term survival. Due to lack of newer effective therapies, mean survival after diagnosis has remained less than 12 months. Trials investigating chemotherapy and/or radiation have proven disappointing. As biopsy of these tumors are rarely performed due to the high eloquence of the brain stem, information about the pathology and biology remains elusive hindering development of novel biologic agents. Poor access of most chemotherapeutic agents to these tumors due to the blood-brain barrier continues to undermine therapeutic efficacy. Thus, to date, we remain at a virtual standstill in our attempts to improve the prognosis of children with these tumors. METHODS An extensive review of the literature was performed concerning children with diffuse brain stem gliomas including clinical trials, evolving molecular biology, and newer therapeutic endeavors. CONCLUSION A pivotal approach in improving the prognosis of these tumors should include the initiation of biopsy and encouraging families to consider autopsy to study the molecular biology. This will help in redefining this tumor by its molecular signature and profiling targeted therapy. Continued advances should be pursued in neuroimaging technology including identifying surrogate markers of early disease progression. Defining strategies to enhance local delivery of drugs into tumors with the help of newer surgical techniques are important. Exhaustive research in all these aspects as a multidisciplinary approach could provide hope to children with these fatal tumors.
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Wolff JE, Rytting ME, Vats TS, Zage PE, Ater JL, Woo S, Kuttesch J, Ketonen L, Mahajan A. Treatment of recurrent diffuse intrinsic pontine glioma: the MD Anderson Cancer Center experience. J Neurooncol 2011; 106:391-7. [PMID: 21858608 DOI: 10.1007/s11060-011-0677-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 07/30/2011] [Indexed: 01/27/2023]
Abstract
Recurrent diffuse intrinsic pontine gliomas (DIPG) are traditionally treated with palliative care since no effective treatments have been described for these tumors. Recently, clinical studies have been emerging, and individualized treatment is attempted more frequently. However, an informative way to compare the treatment outcomes has not been established, and historical control data are missing for recurrent disease. We conducted a retrospective chart review of patients with recurrent DIPG treated between 1998 and 2010. Response progression-free survival and possible influencing factors were evaluated. Thirty-one patients were identified who were treated in 61 treatment attempts using 26 treatment elements in 31 different regimens. The most frequently used drugs were etoposide (14), bevacizumab (13), irinotecan (13), nimotuzumab (13), and valproic acid (13). Seven patients had repeat radiation therapy to the primary tumor. Response was recorded after 58 treatment attempts and was comprised of 0 treatment attempts with complete responses, 7 with partial responses, 20 with stable diseases, and 31 with progressive diseases The median progression-free survival after treatment start was 0.16 years (2 months) and was found to be correlated to the prior time to progression but not to the number of previous treatment attempts. Repeat radiation resulted in the highest response rates (4/7), and the longest progression-free survival. These data provide a basis to plan future clinical trials for recurrent DIPG. Repeat radiation therapy should be tested in a prospective clinical study.
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Affiliation(s)
- Johannes E Wolff
- Department of Pediatrics, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Box 87, Houston, TX 77030, USA.
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Wolff JEA, Mohiuddin K, Jorch N, Graf N, Wagner S, Vats T, Gnekow A. Measuring performance status in pediatric patients with brain tumors--experience of the HIT-GBM-C protocol. Pediatr Blood Cancer 2010; 55:520-4. [PMID: 20658624 DOI: 10.1002/pbc.22566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Measuring the quality of life or performance status in pediatric neurooncology has proven a challenge. Here, we report in a treatment protocol for pediatric patients with high-grade glioma and diffuse intrinsic pontine glioma. PROCEDURE The Fertigkeitenskala Münster-Heidelberg (FMH) is a 56-item quantitative measure of health status. The number of yes answers is transformed to age-dependent percentiles. Physicians were also asked the patients' health status by their own judgment on a 1-5 scale: normal, mild handicap, age-normal activity severely reduced but patient not in bed, in bed, and in ICU. RESULTS Assessments were available from 50 of 97 eligible patients. For 22 patients both questionnaire and the physicians score obtained. At the beginning of the treatment, only 5 patients scored over 40 FMH%, and 4 of these survived. Of 16 patients who initially scored less than 40 FMH%, 15 died. During later assessments, most FMH measures became gradually worse. FMH scores improved in three patients. The physician's judgment was documented at diagnosis and during treatment (n = 50). Per physician, 22% of the patients were normal before chemotherapy, decreasing to 16% in the middle of the protocol. At diagnosis only 16% of patients had severely reduced activity, which increased to 30.6% in the middle of the protocol. The FMH% correlated well with the physicians' judgments (P < 0.005). CONCLUSION The FMH scale is easily obtained and provides a valid assessment of health status. Patients with poor performance at diagnosis had a poorer prognosis.
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Affiliation(s)
- Johannes E A Wolff
- Division of Pediatrics, Section of Pediatric Neuro-oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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High dose methotrexate for pediatric high grade glioma: results of the HIT-GBM-D pilot study. J Neurooncol 2010; 102:433-42. [PMID: 20694800 DOI: 10.1007/s11060-010-0334-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 07/21/2010] [Indexed: 01/09/2023]
Abstract
We conducted a phase II study to test methotrexate (5 g/m(2)), as a single agent prior to radiochemotherapy for pediatric high-grade glioma and diffuse intrinsic pontine glioma. Thirty patients (19 male, median age 10.8) were enrolled. Tumors were located as follows: cortex 10, pons 7, other 13. Tumor resection was classified as gross total in 6, subtotal in 6, partial in 4, biopsy in 11 and not performed in 3. WHO grading of the histology was: IV: 11, III: 12 and II: 3. Patients received methotrexate 5 g/m(2) in 24-hour infusions on days 1 and 15. Subsequently 54 Gy radiation was administered with simultaneous chemotherapy including cisplatin, etoposide, vincristine and ifosfamide as previously described. Eight 6-weeks cycles of maintenance chemotherapy consisted of vincristine 1.5 mg/m(2) on days 1, 8 and 15; lomustine 100 mg/m(2) on day 2 and prednisone 40 mg/kg on days 1-17. Event-free survival rates in the whole group of 30 patients were: 43, 20, and 13% after 1, 2 and 5 years, respectively. The response evaluation after methotrexate was available in 19 of the 24 patients who started treatment with measurable disease: CR: 0, PR: 1, SD 18, PD: 0. After radiochemotherapy the response of 24 patients with measurable disease was CR: 1, PR 10, SD 12, PD 1. Both response and event-free survival were superior to the control group of 330 patients treated in various protocols of the same cooperative group. In subgroup analyses the use of dexamethasone during early treatment was linked to poor event free survival. Giving two cycles of high-dose methotrexate prior to radiochemotherapy was feasible, and the approach was taken forward to a randomized phase III trial.
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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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Wolff JEA, Driever PH, Erdlenbruch B, Kortmann RD, Rutkowski S, Pietsch T, Parker C, Metz MW, Gnekow A, Kramm CM. Intensive chemotherapy improves survival in pediatric high-grade glioma after gross total resection: results of the HIT-GBM-C protocol. Cancer 2010; 116:705-12. [PMID: 19957326 DOI: 10.1002/cncr.24730] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The authors hypothesized that intensified chemotherapy in protocol HIT-GBM-C would increase survival of pediatric patients with high-grade glioma (HGG) and diffuse intrinsic pontine glioma (DIPG). METHODS Pediatric patients with newly diagnosed HGG and DIPG were treated with standard fractionated radiation and simultaneous chemotherapy (cisplatin 20 mg/m2 x 5 days, etoposide 100 mg/m2 x 3 days, and vincristine, and 1 cycle of cisplatin + etoposide + ifosfamide 1.5 g/m x 5 days [PEI] during the last week of radiation). Subsequent maintenance chemotherapy included further cycles of PEI in Weeks 10, 14, 18, 22, 26, and 30, followed by oral valproic acid. RESULTS Ninety-seven (pons, 37; nonpons, 60) patients (median age, 10 years; grade IV histology, 35) were treated. Resection was complete in 21 patients, partial in 29, biopsy only in 26, and not performed in 21. Overall survival rates were 91% (standard error of the mean [SE] +/- 3%), 56%, and 19% at 6, 12, and 60 months after diagnosis, respectively. When compared with previous protocols, there was no significant benefit for patients with residual tumor, but the 5-year overall survival rate for patients with complete resection treated on HIT-GBM-C was 63% +/- 12% SE, compared with 17% +/- 10% SE for the historical control group (P = .003, log-rank test). CONCLUSIONS HIT-GBM-C chemotherapy after complete tumor resection was superior to previous protocols.
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Affiliation(s)
- Johannes E A Wolff
- Department of Pediatrics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Leblond P, Vinchon M, Bernier-Chastagner V, Chastagner P. [Diffuse intrinsic brain stem glioma in children: current treatment and future directions]. Arch Pediatr 2009; 17:159-65. [PMID: 20018494 DOI: 10.1016/j.arcped.2009.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Revised: 08/11/2009] [Accepted: 11/08/2009] [Indexed: 11/19/2022]
Abstract
Despite the numerous clinical trials undertaken, the prognosis of children with diffuse brain stem glioma remains very poor. This review examines the different strategies for the treatment of malignant brain stem glioma such as radiation therapy, concurrent radiochemotherapy, and classical cytotoxic drugs, with a particular focus on the novel targeted and antiangiogenic drugs recently introduced in pediatric oncology. The strategy using integrin inhibitors is discussed.
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Affiliation(s)
- P Leblond
- Unité d'oncologie pédiatrique, centre Oscar-Lambret, 59020 Lille cedex, France.
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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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Bevacizumab and irinotecan treatment for progressive diffuse brainstem glioma: case report. J Neurooncol 2009; 93:409-12. [DOI: 10.1007/s11060-008-9782-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Accepted: 12/30/2008] [Indexed: 10/21/2022]
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Wolff JEA, Kramm C, Kortmann RD, Pietsch T, Rutkowski S, Jorch N, Gnekow A, Driever PH. Valproic acid was well tolerated in heavily pretreated pediatric patients with high-grade glioma. J Neurooncol 2008; 90:309-14. [PMID: 18679579 DOI: 10.1007/s11060-008-9662-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Accepted: 07/22/2008] [Indexed: 12/27/2022]
Abstract
Valproic acid (VPA) inhibits histone deacetylase and has been reported to induce apoptosis in glioma. We report 44 heavily pretreated pediatric patients with high-grade glioma or diffuse intrinsic pontine glioma who received VPA as oral continues maintenance treatment with individual dose adaptation. The tumor status when starting the drug was: no measurable disease in 12, measurable but stable disease in 12, and measurable progressive disease in 22 patients. Average trough blood levels of VPA were 99 mg/l. The most frequent complaint was somnolence (three patients), but no severe toxicity was reported. One relapse patient responded, early progression of disease was observed in three frontline patients and in six relapsed patients. Median overall survival duration for all patients was 1.33 years, with large differences between first-line (5-year overall survival, 44%) and relapse therapy (5-year overall survival, 14%). This shows that valproate is safe in this patient population. The moderate tumor efficacy encourages studying the drug further as an element of multi-agent protocols.
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Affiliation(s)
- Johannes E A Wolff
- Children's Cancer Hospital, Department of Pediatrics, Unit 87, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA.
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27
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Sirachainan N, Pakakasama S, Visudithbhan A, Chiamchanya S, Tuntiyatorn L, Dhanachai M, Laothamatas J, Hongeng S. Concurrent radiotherapy with temozolomide followed by adjuvant temozolomide and cis-retinoic acid in children with diffuse intrinsic pontine glioma. Neuro Oncol 2008; 10:577-82. [PMID: 18559468 DOI: 10.1215/15228517-2008-025] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The prognosis of children with diffuse intrinsic pontine glioma (DIPG) is very poor. Radiotherapy remains the standard treatment for these patients, but the median survival time is only 9 months. Currently, the use of concurrent radiotherapy with temozolomide (TMZ) has become the standard care for adult patients with malignant gliomas. We therefore investigated this approach in 12 children diagnosed with DIPG. The treatment protocol consisted of concurrent radiotherapy at a dose of 55.8-59.4 Gy at the tumor site with TMZ (75 mg/m(2)/day) for 6 weeks followed by TMZ (200 mg/m(2)/day) for 5 days with cis-retinoic acid (100 mg/m(2)/day) for 21 days with a 28-day cycle after concurrent radiotherapy. Ten of the 12 patients had a clinical response after the completion of concurrent radiotherapy. Seven patients had a partial response, four had stable disease, and one had progressive disease. At the time of the report, 9 of the 12 patients had died of tumor progression, one patient was alive with tumor progression, and two patients were alive with continuous partial response and clinical improvement. The median time to progression was 10.2 +/- 3.0 months (95% confidence interval [CI], 4.2-16.1 months). One-year progression-free survival was 41.7% +/- 14.2%. The median survival time was 13.5 +/- 3.6 months (95% CI, 6.4-20.5 months). One-year overall survival was 58% +/- 14.2%. The patients who had a partial response after completion of concurrent radiotherapy had a longer survival time (p = 0.036) than did the other patients (those with stable or progressive disease). We conclude that the regimen of concurrent radiotherapy and TMZ should be considered for further investigation in a larger series of patients.
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Affiliation(s)
- Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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28
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Subpopulations of malignant gliomas in pediatric patients: analysis of the HIT-GBM database. J Neurooncol 2008; 87:155-64. [DOI: 10.1007/s11060-007-9495-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Accepted: 10/29/2007] [Indexed: 10/22/2022]
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Radbill AE, Reddy AT, Markert JM, Wyss JM, Pike MM, Akella NS, Bharara N, Gillespie GY. Effects of G207, a conditionally replication-competent oncolytic herpes simplex virus, on the developing mammalian brain. J Neurovirol 2007; 13:118-29. [PMID: 17505980 DOI: 10.1080/13550280601187177] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Viral oncolytic therapy for malignant brain tumors involves local intratumoral delivery of a genetically engineered virus with tumor cell-specific lytic activity. Promising preliminary results have been achieved in preclinical models with G207, a replication-competent herpes simplex virus type 1 constructed with multiple directed mutations. Although the safety of G207 has been demonstrated in adults, application of viral oncolytic therapy to children with brain tumors has been delayed because of previous lack of data concerning the impact of a replication-competent oncolytic virus on the developing mammalian brain. In this study there was no significant difference in long-term physical development, cognitive performance, or exploratory behaviors between mice that received intracerebral inoculation of G207 or control saline at 4 days of age. However, histological examination and magnetic resonance imaging revealed frequent unilateral ventriculomegaly ipsilateral to the site of injection in only the G207 group. These results suggest that although it is unlikely that G207 will have significant adverse effects on neurodevelopmental outcomes of pediatric patients with brain tumors, an initial study of G207 in children should exclude those patients with tumors in or near the ventricular system as well as patients less than 2 years of age. Furthermore, patients in such a study will need to be closely monitored for the development of hydrocephalus.
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Affiliation(s)
- Andrew E Radbill
- Department of Cardiology, Children's Hospital Boston, Boston, Massachusetts 02115, USA.
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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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Wagner S, Benesch M, Berthold F, Gnekow AK, Rutkowski S, Sträter R, Warmuth-Metz M, Kortmann RD, Pietsch T, Wolff JEA. Secondary dissemination in children with high-grade malignant gliomas and diffuse intrinsic pontine gliomas. Br J Cancer 2006; 95:991-7. [PMID: 17047647 PMCID: PMC2360717 DOI: 10.1038/sj.bjc.6603402] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In children, treatment regimen for high-grade gliomas (HGG) and diffuse intrinsic pontine gliomas (DIPG) are generally not stratified according to disease stage. The hypothesis was that secondary disseminating disease (SDD) in children with HGG is related to an even worse outcome. Description of SDD pattern was performed. In total, 270 children with newly diagnosed HGG or DIPG were eligible for retrospective analysis of SDD. Medical and computer records of these patients were reviewed for demographic characteristics, sites of dissemination, prognostic variables. Forty-six (17%) of the 270 patients had developed SDD. The median time to SDD was 8.2 months. The median overall survival (OS) after dissemination was 3.2 months. The SDD was located parenchymal in the supratentorial (34.8%), infratentorial (6.5%), supratentorial and infratentorial (19.6%), spinal (10.9%), spinal and cerebral (6.5%) regions of the CNS, or leptomeningeal (21.7%). For HGG patients, the median OS was shorter among patients with SDD than among patients without SDD (1.02 vs 1.41 years, P=0.0495). In the group of patients with SDD, patients with cerebrospinal fluid dissemination had a worse outcome compared with patients with parenchymal metastases. Summarising, SDD is a negative prognostic factor for patients with HGG outside the pons. Treatment stratification should be considered.
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Affiliation(s)
- S Wagner
- Department of Pediatric Hematology and Oncology, Klinik St Hedwig, University of Regensburg, Regensburg, Germany.
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Wolff JEA, Wagner S, Reinert C, Gnekow A, Kortmann RD, Kühl J, Van Gool SW. Maintenance treatment with interferon-gamma and low-dose cyclophosphamide for pediatric high-grade glioma. J Neurooncol 2006; 79:315-21. [PMID: 16645718 DOI: 10.1007/s11060-006-9147-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Accepted: 03/13/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND The prognosis of high-grade glioma in children is poor. PURPOSE Interferon-gamma may increase the immune surveillance of glioma cells. Earlier clinical evidence had shown that low dose cyclophosphamide (CPM) increased immune response. METHODS After induction treatment with simultaneous radiation and chemotherapy, patients were treated with individually increasing interferon-gamma (IFN-gamma) doses starting from 25 microg/m2/d s.c. increasing up to a maximum of 175 microg/m2/d within 7 weeks. Cyclophosphamide was given at 300 mg/m2 i.v. every 21 days. Forty pediatric glioma patients were enrolled (median age: 8.5 year, male: n = 22). Tumor locations included cerebral cortex (n = 8), basal ganglia (n = 4), brainstem (n = 24), cerebellum (n = 3), spinal cord (n = 1). Histologies were GBM (n = 14), AA (n = 14), LGG (n = 2, diffuse intrinsic pontine glioma). There was grade IV toxicity for thrombocytopenia (10%) and leucopenia (2.5%), grade III toxicity for central nervous (2.5%) and hepatic (5%) side effects, no toxic death. The observation time of the six surviving patients was: 1.2, 1.9, 4.2, 4.4, 4.6 and 4.7 years respectively. The median overall survival (1 year) was not significantly different from a historical control group (0.8 years). The survival of pontine gliomas appeared even inferior when compared to the previous protocol (n.s.). CONCLUSION Maintenance treatment with IFN-gamma and low dose CPM has no sufficient beneficial effect for the treatment of high-grade glioma.
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Affiliation(s)
- Johannes E A Wolff
- Department of Pediatrics, MD Anderson Cancer Center, Unit 87, University of Texas, 1515 Holcombe Blvd, Houston, TX 77030, USA.
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Wagner S, Warmuth-Metz M, Emser A, Gnekow AK, Sträter R, Rutkowski S, Jorch N, Schmid HJ, Berthold F, Graf N, Kortmann RD, Pietsch T, Sörensen N, Peters O, Wolff JEA. Treatment options in childhood pontine gliomas. J Neurooncol 2006; 79:281-7. [PMID: 16598416 DOI: 10.1007/s11060-006-9133-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2005] [Accepted: 02/06/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pontine gliomas are the subgroup of brainstem gliomas with the worst prognosis. Controversial treatment approaches are discussed. PATIENTS AND METHODS Data of children with pontine gliomas treated in different prospective multi-center studies who were registered in the HIT-GBM database were pooled and analyzed addressing prognostic factors and the relevance of intensive treatment using contingency tables, Kaplan-Meier curves and Cox regression analyses. RESULTS From 1983 to 2001, 153 patients (74 males, 79 females, mean age: 8.1 years) with pontine gliomas were registered. Twenty-one tumors were low-grade and 60 were high-grade gliomas (72 undefined histology: 67 no surgery, 5 incomplete data). Sixteen tumors were partially resected, and 125 were irradiated. Ninety children received chemotherapy according to the "HIT-GBM" protocols ("Hirntumor-Glioblastoma multiforme"). The one-year overall survival rate (1YOS) of all patients with pontine glioma was 39.9+/-4.3%. None of the surviving patients had an observation time longer than 3.9 years. Favorable prognostic factors seemed to be age younger than 4 years, low-grade histology and smaller tumor. All three major treatment modalities including resection, irradiation and chemotherapy had prognostic relevance in univariable analysis. Chemotherapy remained beneficial, even if the analysis was restricted to the subgroup of irradiated tumors (1YOS 45.8+/-5.4% vs. 34.4+/-13.5%, P=0.030). CONCLUSION Irradiation is an effective element for the treatment of pontine gliomas. Intensive chemotherapy seems to be important in achieving a better OS.
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Affiliation(s)
- Sabine Wagner
- Department of Pediatric Oncology, Krankenhaus der Barmherzigen Brüder Klinik St. Hedwig, Regensburg, Germany.
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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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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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Benesch M, Wagner S, Berthold F, Wolff JEA. Primary dissemination of high-grade gliomas in children: experiences from four studies of the Pediatric Oncology and Hematology Society of the German Language Group (GPOH). J Neurooncol 2005; 72:179-83. [PMID: 15925999 DOI: 10.1007/s11060-004-3546-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Clinical data on central nervous system (CNS) dissemination of high-grade gliomas (HGG) at initial presentation in children are rare. PATIENTS AND METHODS We conducted a retrospective data analysis of all patients enrolled into four consecutive HGG protocols of the Pediatric Oncology and Hematology Society of the German Language Group (GPOH) to determine the incidence of primary CNS dissemination of HGG and to describe clinical characteristics and outcome of children with HGG who were diagnosed with CNS dissemination at initial presentation. 546 patients with newly diagnosed HGG (n=348) or diffuse intrinsic pontine gliomas (n=198) were enrolled in these four studies. Data concerning tumor dissemination are available from 324 patients. RESULTS A total of 10 patients (3.1%) (anaplastic astrocytoma: n=3, glioblastoma multiforme: n=6, diffuse intrinsic pontine glioma: n=1) had primary tumor dissemination. Median age at diagnosis was 9.3 years (range: 0.3-21.3 years). The most frequent primary tumor sites were the cortex (n=4), followed by the ventricles (n=2), cerebellum (n=1), spinal cord (n=1), and pons (n=1). One patient had diffuse gliomatosis cerebri. Following surgery eight patients received local radiotherapy and eight additional chemotherapy. At a median follow-up of 10 months (range: 0.05-3 years) four patients are alive. None is disease-free. Median progression-free and overall survival was 0.8 years (95% CI 0.2-1.4) and 1.5 years (95% CI 0.67-2.29) for patients with primary tumor dissemination, respectively, with no statistically significant differences between the group with and the group without primary tumor dissemination. CONCLUSIONS Initial diagnostic evaluation should include complete CNS imaging as well as cerebrospinal fluid examination in all patients with HGG. As prognosis of children with HGG and primary CNS dissemination was not inferior to patients without dissemination in our population, these patients should be treated in the same way as patients without primary CNS dissemination.
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Affiliation(s)
- Martin Benesch
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescence Medicine, Medical University of Graz, Auenbruggerplatz 30, A-8036, Graz, Austria.
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Ashby LS, Pueschel JK, Shapiro WR. Central nervous system tumors. CANCER CHEMOTHERAPY AND BIOLOGICAL RESPONSE MODIFIERS 2005; 22:605-41. [PMID: 16110631 DOI: 10.1016/s0921-4410(04)22027-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- Lynn S Ashby
- Barrow Neurological Institute, Phoenix, AZ 85013, USA.
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Al-Batran SE, Atmaca A, Bert F, Jäger D, Frisch C, Neumann A, Orth J, Knuth A, Jäger E. Dose escalation study for defining the maximum tolerated dose of continuous oral trofosfamide in pretreated patients with metastatic lung cancer. Oncol Res Treat 2004; 27:534-8. [PMID: 15591711 DOI: 10.1159/000081334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Trofosfamide is increasingly used in the treatment of patients with several types of malignancies. However, the optimal dose of trofosfamide for patients with advanced cancer has not been systematically investigated yet. The aim of this study was to define the maximum tolerated dose (MTD) of continuous oral trofosfamide. PATIENTS AND METHODS 16 patients with advanced lung cancer (14 nonsmall cell lung cancer, 2 small cell lung cancer; 10 male, 6 female; median age 64 years (range 46-82); median Karnofsky status 70%; median number of organs involved 3 (range 1-6)) were enrolled. All patients were previously treated with chemotherapy (median 2x, range 1-6) and 8/16 (50%) with radiotherapy. Patients received trofosfamide p.o. administered in 3 doses per day for 3 weeks (1 cycle) using a 3-patient-cohort dose-escalation strategy. Toxicities were graded according to the WHO Criteria. RESULTS Patients received a median of 2 cycles of trofosfamide (range 1-4) at 3 dose levels (90, 125, and 175 mg/m2). Grade 3 and 4 neutropenia, anemia, and thrombocytopenia were observed in 20, 13.3, and 6.6%, respectively. Dose-limiting toxicities during the first cycle were grade 3 muscle weakness and anorexia observed in 1/6 patients in cohort 1 (trofosfamide 90 mg/m2), grade 3 neutropenia in 1/6, and encephalopathy in 1/6 patients in cohort 3 (trofosfamide 175 mg/m2). Therefore, the dose level of 125 mg/m2 was defined as the MTD. CONCLUSION Trofosfamide at 125 mg/m2 administered in 3 doses per day was well tolerated. This dose level is recommended for further clinical studies.
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Latz D, Nassar N, Frank R. Trofosfamide in the Palliative Treatment of Cancer: A Review of the Literature. Oncol Res Treat 2004; 27:572-6. [PMID: 15591719 DOI: 10.1159/000081342] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Trofosfamide is an alkylating agent that is derived from the oxazaphoshorines. It has found application in a broad spectrum of malignancies in the last three decades. The main indications for application were in the palliative situation and as maintenance therapy. Good results were reported from the treatment of non-Hodgkin's lymphomas and soft tissue sarcomas. A lot of small studies and casuistic contributions are available giving treatment results of several solid carcinomas (malignant gliomas, ovarian, lung and prostate cancer, and others). Due to its oral formulation and good tolerability trofosfamide is an attractive candidate for the palliative situation because treatment on an outpatient basis is possible. However, there is still a lack of randomized clinical studies with trofosfamide. Thus, evidence-based conclusions on the therapeutic value of the drug cannot be drawn. In the future, phase III trials should be undertaken.
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Affiliation(s)
- D Latz
- Radiologische Gemeinschaftspraxis am Klinikum Coburg, Abteilung Radioonkologie, Coburg, Germany.
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Peters O, Gnekow AK, Rating D, Wolff JEA. Impact of location on outcome in children with low-grade oligodendroglioma. Pediatr Blood Cancer 2004; 43:250-6. [PMID: 15266409 DOI: 10.1002/pbc.20111] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Childhood low-grade oligodendroglioma (WHO grade II) are rare. No controlled pediatric study has been published, to generate high level evidence for the best treatment. Therefore, we retrospectively analyzed data available from pediatric patients. PROCEDURE We pooled data from two prospective German multicentre studies (HIT-DOK and HIT-LGG). Eligibility criteria were: (1) primary neoplasm, (2) histology of pure oligodendroglioma WHO grade II, (3) intracranial location, (4) age <18 years, (5) date of diagnosis: 1990-2002, (6) observation time >6 months. The outcome was analyzed by using the SPSS-software. RESULTS Nineteen boys and 13 girls were eligible (median age 10.3 years). The tumor locations included: 26 peripheral tumors (23 cerebral hemisphere, 3 cerebellum), and 6 central tumors (4 thalamus, 1 frontal mesencephalon, 1 basal ganglia). Resections were classified as complete in 18 (14 cerebral hemispheres, 3 cerebellum, 1 thalamus) and less than complete in 14 patients (3 subtotal resections, 8 partial resections, 3 biopsy). The 5-year event-free survival (EFS) and overall survival (OS) rates of all patients were 81.3 and 84.4%, respectively (median observation time 3.8 years). All of the 26 children with peripheral tumors were alive with no tumor progression, but five of six patients with central tumors died of disease (median time to death 1.6 years). This survival difference was statistically significant for EFS (P < 0.0001) and OS (P < 0.0001). The difference between completely resected versus incompletely resected tumors was far less striking (P > 0.06). CONCLUSIONS The outcome of children with centrally located low-grade oligodendroglioma is particularly poor, while tumors of the cerebral hemispheres and cerebellum carry an excellent prognosis, even with minor tumor resection.
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Affiliation(s)
- Ove Peters
- Department of Pediatric Oncology and Hematology, St. Hedwig Children's Hospital Regensburg, Germany.
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Broniscer A, Gajjar A. Supratentorial high-grade astrocytoma and diffuse brainstem glioma: two challenges for the pediatric oncologist. Oncologist 2004; 9:197-206. [PMID: 15047924 DOI: 10.1634/theoncologist.9-2-197] [Citation(s) in RCA: 171] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pediatric high-grade gliomas represent a heterogeneous group of tumors that accounts for 15%-20% of all pediatric central nervous system tumors. These neoplasms predominantly involve the supratentorial hemispheres or the pons, in which case the tumors are usually called diffuse brainstem gliomas. The diagnosis of supratentorial neoplasms is dependent on their histologic appearance. The maximum possible surgical resection is always attempted since the degree of surgical resection is the main prognostic factor for these patients. Older children (>3 years) with supratentorial neoplasms undergo a multimodality treatment comprised of surgical resection, radiation therapy, and chemotherapy. The addition of chemotherapy seems to improve the survival of a subset of these children, particularly those with glioblastoma multiforme. However, 2-year survival rates remain poor for children with supratentorial neoplasms, ranging from 10%-30%. The diagnosis of a diffuse brainstem glioma is based upon typical imaging, dispensing with the need for surgery in the majority of cases. Radiation therapy is the mainstay of treatment for children with diffuse brainstem gliomas. The role of chemotherapy for these children is not clear, and it is, in general, employed in the context of an investigational study. Less than 10% of children with diffuse brainstem gliomas survive 2 years. Because the outcome for patients with either type of tumor is poor when standard multimodality therapy is used, these children are ideal candidates for innovative treatment approaches.
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Affiliation(s)
- Alberto Broniscer
- Division of Neuro-Oncology, Department of Hematology-Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA.
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Weber F, Dietl B, Wolff J, Peters O, Altmeppen J, Taeger K. [Anaesthesia for radiation therapy of brain tumours in children. A multidisciplinary challenge]. Anaesthesist 2004; 53:717-22. [PMID: 15221121 DOI: 10.1007/s00101-004-0712-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Radiation therapy of childhood intracranial malignancies is always a challenge for radiation oncologists, anaesthetists and paediatric oncologists. Detailed knowledge of the course of the disease prior to radiation therapy and a critical evaluation of the child's actual physical status are mandatory in each case. Furthermore the anaesthetist should be informed about the child's individual preferences and aversions. The optimum prearrangement of the radiation therapy is of paramount importance. Interdisciplinary communication structures which must always involve the child's parents have to be established. Perfect adjustment of the mask that fixes the head during each radiation procedure is necessary to give the child the possibility to breathe spontaneously without an endotracheal tube or a laryngeal mask. Two case reports highlight these aspects of the complex procedure of paediatric radiation therapy which are relevant for the anaesthetist.
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Affiliation(s)
- F Weber
- Klinik für Anästhesiologie, Klinikum der Universität Regensburg.
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Abstract
Primary brain tumors are the most common solid neoplasms of childhood. The diagnosis of brain tumors in the general pediatric population remains challenging. Nevertheless, it is clear that refinements in imaging, surgical technique, and adjunctive therapies have led to longer survival and an improving quality of life in children with brain tumors.
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Affiliation(s)
- Cormac O Maher
- Department of Neurosurgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Abstract
Brainstem gliomas have been increasingly understood in the last two decades and they are nowadays regarded as an heterogeneous group of tumors with tendency towards the pediatric age, where they account for 10-20% of brain neoplasms. Besides the well known diffuse tumor, several subtypes, with a different biological behaviour, amenable to surgical resection and better prognosis, have been identified, giving rise to many classifications and terms. In the other way, attention has been recently paid to adult brainstem gliomas in contrast to pediatric tumors. Based on a review of the literature, we describe the different subtypes of brainstem gliomas, with particular interest on therapeutic approaches and differences between pediatric and adult tumors, employing iconography from our series.
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Affiliation(s)
- P Sousa
- Servicio de Neurocirugía Pedíatrica, Hospital Doce de Octubre. Madrid. Spain
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