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Li J, Wu A, Kim S. Mechanistic Modeling of Intrathecal Chemotherapy Pharmacokinetics in the Human Central Nervous System. Clin Cancer Res 2024; 30:1397-1408. [PMID: 38289997 PMCID: PMC10984761 DOI: 10.1158/1078-0432.ccr-23-3062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/05/2023] [Accepted: 01/25/2024] [Indexed: 02/01/2024]
Abstract
PURPOSE The pharmacokinetics of intrathecally administered antibody or small-molecule drugs in the human central nervous system (CNS) remains poorly understood. This study aimed to provide mechanistic and quantitative perspectives on the CNS pharmacokinetics of intrathecal chemotherapy, by using a physiologically based pharmacokinetic (PBPK) modeling approach. EXPERIMENTAL DESIGN A novel CNS PBPK model platform was developed and verified, which accounted for the human CNS general anatomy and physiologic processes governing drug distribution and disposition. The model was used to predict CNS pharmacokinetics of antibody (trastuzumab) and small-molecule drugs (methotrexate, abemaciclib, tucatinib) following intraventricular injection or intraventricular 24-hour infusion, and to assess the key determinants of drug penetration into the deep brain parenchyma. RESULTS Intraventricularly administered antibody and small-molecule drugs exhibited distinct temporal and spatial distribution and disposition in human CNS. Both antibody and small-molecule drugs achieved supratherapeutic or therapeutic concentrations in the cerebrospinal fluid (CSF) compartments and adjacent brain tissue. While intrathecal small-molecule drugs penetrated the deep brain parenchyma to a negligible extent, intrathecal antibodies may achieve therapeutic concentrations in the deep brain parenchyma. Intraventricular 24-hour infusion enabled prolonged CNS exposure to therapeutically relevant concentrations while avoiding excessively high and potentially neurotoxic drug concentrations. CONCLUSIONS CNS PBPK modeling, in line with available clinical efficacy data, confirms the therapeutic value of intrathecal chemotherapy with antibody or small-molecule drugs for treating neoplastic meningitis and warrants further clinical investigation of intrathecal antibody drugs to treat brain parenchyma tumors. Compared with intraventricular injection, intraventricular 24-hour infusion may mitigate neurotoxicity while retaining potential efficacy.
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Affiliation(s)
- Jing Li
- Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI 482012
| | - Andrew Wu
- Northville High School, 45700 Six Mile Rd, Northville, MI 48168
| | - Seongho Kim
- Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI 482012
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2
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Meyer AH, Feldsien TM, Mezler M, Untucht C, Venugopalan R, Lefebvre DR. Novel Developments to Enable Treatment of CNS Diseases with Targeted Drug Delivery. Pharmaceutics 2023; 15:pharmaceutics15041100. [PMID: 37111587 PMCID: PMC10145602 DOI: 10.3390/pharmaceutics15041100] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/07/2023] [Accepted: 03/17/2023] [Indexed: 04/29/2023] Open
Abstract
The blood-brain barrier (BBB) is a major hurdle for the development of systemically delivered drugs against diseases of the central nervous system (CNS). Because of this barrier there is still a huge unmet need for the treatment of these diseases, despite years of research efforts across the pharmaceutical industry. Novel therapeutic entities, such as gene therapy and degradomers, have become increasingly popular in recent years, but have not been the focus for CNS indications so far. To unfold their full potential for the treatment of CNS diseases, these therapeutic entities will most likely have to rely on innovative delivery technologies. Here we will describe and assess approaches, both invasive and non-invasive, that can enable, or at least increase, the probability of a successful drug development of such novel therapeutics for CNS indications.
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Affiliation(s)
- Axel H Meyer
- Quantitative, Translational & ADME Sciences, AbbVie Deutschland GmbH & Co. KG, Knollstraße, 67061 Ludwigshafen, Germany
| | - Thomas M Feldsien
- Drug Delivery and Combination Products, Development Sciences, AbbVie Inc., 1 N Waukegan Road, North Chicago, IL 60064, USA
| | - Mario Mezler
- Quantitative, Translational & ADME Sciences, AbbVie Deutschland GmbH & Co. KG, Knollstraße, 67061 Ludwigshafen, Germany
| | - Christopher Untucht
- Neuroscience Discovery, AbbVie Deutschland GmbH & Co. KG, Knollstraße, 67061 Ludwigshafen, Germany
| | - Ramakrishna Venugopalan
- Drug Delivery and Combination Products, Development Sciences, AbbVie Inc., 1 N Waukegan Road, North Chicago, IL 60064, USA
| | - Didier R Lefebvre
- Drug Delivery and Combination Products, Development Sciences, AbbVie Inc., 1 N Waukegan Road, North Chicago, IL 60064, USA
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3
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Butler A, Meijer L, Liu JF, Chohan M, Jalloh I, Macarthur D, Parr M, Wilne S, Wilson S, Walker D, Grundy R, Dandapani M. Evaluating the efficacy and safety of single-agent etoposide intra-CSF chemotherapy in children and young people with relapsed/refractory central nervous system tumours. Childs Nerv Syst 2023; 39:1537-1544. [PMID: 36949251 DOI: 10.1007/s00381-023-05872-w] [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: 01/02/2023] [Accepted: 01/28/2023] [Indexed: 03/24/2023]
Abstract
PURPOSE The aim of the project was to evaluate intra-CSF etoposide administration in a palliative setting for children and young people with relapsed/refractory central nervous system (CNS) tumours, with the primary endpoints being overall survival and progression-free survival time. A safety endpoint was to assess the side effect profile and complications of intra-CSF etoposide. METHODS Thirty-five patients under the age of 30 years (median age: 5.33 years) were enrolled onto the project. The cross-centre study was a service evaluation, with a data collection spreadsheet designed in Nottingham and completed by both Nottingham and Oxford centres. Data was analysed using SPSS, assessing the overall survival and progression-free survival times, as well as the 6-month and 1-year survival rates. RESULTS The median overall survival and progression-free survival times were 10.97 and 5.91 months, respectively. The 6-month and 1-year overall survival rates were 67% and 48%, and the progression-free survival rates were 50% and 22%. Age at the start of intra-CSF therapy was significantly associated with overall survival (P = 0.046), with the 6 + age group having improved overall survival. Treatment type was significantly associated with overall survival (P = 0.012), with etoposide intra-CSF treatment being associated with improved overall survival. Treatment duration was significantly associated with both overall survival (P < 0.001) and progression-free survival (P < 0.001). CONCLUSION Intra-CSF etoposide treatment has shown to increase both overall and progression-free survival significantly, whilst having few side effects and maintaining a good quality of life for patients, reflecting it as a beneficial therapy in the palliative setting.
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Affiliation(s)
- Anna Butler
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Lisethe Meijer
- Department of Neuro-Oncology, Princess Maxima Centre for Paediatric Oncology, Utrecht, The Netherlands
| | - Jo-Fen Liu
- Children's Brain Tumour Research Centre, University of Nottingham, Nottingham, NG7 2RG, UK
| | - Manjit Chohan
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Ibrahim Jalloh
- Cambridge University Hospitals NHS Trust, Cambridge, CB2 0QQ, UK
| | - Donald Macarthur
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Margaret Parr
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Sophie Wilne
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Shaun Wilson
- Oxford University Hospitals NHS Trust, Oxford, OX3 7LE, UK
| | - David Walker
- Children's Brain Tumour Research Centre, University of Nottingham, Nottingham, NG7 2RG, UK
| | - Richard Grundy
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
- Children's Brain Tumour Research Centre, University of Nottingham, Nottingham, NG7 2RG, UK
| | - Madhumita Dandapani
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
- Children's Brain Tumour Research Centre, University of Nottingham, Nottingham, NG7 2RG, UK.
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Retrospective National "Real Life" Experience of the SFCE with the Metronomic MEMMAT and MEMMAT-like Protocol. J Clin Med 2023; 12:jcm12041415. [PMID: 36835950 PMCID: PMC9967517 DOI: 10.3390/jcm12041415] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/02/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Relapses in pediatric high-risk brain tumors remain unmet medical needs. Over the last 15 years, metronomic chemotherapy has gradually emerged as an alternative therapeutic approach. PATIENTS AND METHODS This is a national retrospective study of patients with relapsing pediatric brain tumors treated according to the MEMMAT or MEMMAT-like regimen from 2010 to 2022. Treatment consisted of daily oral thalidomide, fenofibrate, and celecoxib, and alternating 21-day cycles of metronomic etoposide and cyclophosphamide associated with bevacizumab and intraventricular chemotherapy. RESULTS Forty-one patients were included. The most frequent malignancies were medulloblastoma (22) and ATRT (8). Overall, the best responses were CR in eight patients (20%), PR in three patients (7%), and SD in three patients (7%), for a clinical benefit rate of 34%. The median overall survival was 26 months (IC95% = 12.4-42.7), and median EFS was 9.7 months (IC95% = 6.0-18.6). The most frequent grade ¾ toxicities were hematological. Dose had to be adjusted in 27% of the cases. There was no statistical difference in outcome between full or modified MEMMAT. The best setting seems to be when MEMMAT is used as a maintenance and at first relapse. CONCLUSIONS The metronomic MEMMAT combination can lead to sustained control of relapsed high-risk pediatric brain tumors.
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Boutros SW, Kessler K, Unni VK, Raber J. Infusion of etoposide in the CA1 disrupts hippocampal immediate early gene expression and hippocampus-dependent learning. Sci Rep 2022; 12:12834. [PMID: 35896679 PMCID: PMC9329441 DOI: 10.1038/s41598-022-17052-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/20/2022] [Indexed: 11/21/2022] Open
Abstract
Tight regulation of immediate early gene (IEG) expression is important for synaptic plasticity, learning, and memory. Recent work has suggested that DNA double strand breaks (DSBs) may have an adaptive role in post-mitotic cells to induce IEG expression. Physiological activity in cultured neurons as well as behavioral training leads to increased DSBs and subsequent IEG expression. Additionally, infusion of etoposide-a common cancer treatment that induces DSBs-impairs trace fear memory. Here, we assessed the effects of hippocampal infusion of 60 ng of etoposide on IEG expression, learning, and memory in 3-4 month-old C57Bl/6J mice. Etoposide altered expression of the immediate early genes cFos and Arc in the hippocampus and impaired hippocampus-dependent contextual fear memory. These data add to the growing evidence that DSBs play an important role in IEG expression, learning, and memory, opening avenues for developing novel treatment strategies for memory-related disorders.
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Affiliation(s)
- Sydney Weber Boutros
- Department of Behavioral Neuroscience, OHSU, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Kat Kessler
- Department of Behavioral Neuroscience, OHSU, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Vivek K Unni
- Department of Neurology, OHSU, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
- Jungers Center for Neurosciences Research, OHSU Parkinson Center, OHSU, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Jacob Raber
- Department of Behavioral Neuroscience, OHSU, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA.
- Department of Neurology, OHSU, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA.
- Departments of Psychiatry and Radiation Medicine, OHSU, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA.
- Division of Neuroscience, ONPRC, 505 NW 185th Ave, Beaverton, OR, 97006, USA.
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McNeer JL, Schmiegelow K. Management of CNS Disease in Pediatric Acute Lymphoblastic Leukemia. Curr Hematol Malig Rep 2022; 17:1-14. [PMID: 35025035 DOI: 10.1007/s11899-021-00640-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The treatment of acute lymphoblastic leukemia (ALL) is one of the success stories of pediatric oncology, but challenges and questions remain, including the optimal approach to the treatment of central nervous system (CNS) leukemia. It is unclear why some children with ALL develop CNS leukemia and others do not, and there remains debate regarding optimal regimens for prophylaxis, upfront treatment, and the treatment of CNS relapses. These topics are especially important since both cranial radiation therapy (CRT) and intensive intrathecal therapy carry risks of both short- and long-term adverse effects. In this review, we aim to identify areas of ongoing debate on this topic, review the biology of CNS leukemia, and summarize clinical trial data that address some of these questions. RECENT FINDINGS Both retrospective and meta-analyses have demonstrated that few patients with ALL benefit from CRT as a component of CNS-directed treatment for de novo disease, allowing cooperative groups to greatly limit the number of patients undergoing CRT as part of their initial ALL regimens. More recent efforts are focusing on how best to assay for low levels of CNS disease at the time of diagnosis, as well as the biological drivers that may result in CNS leukemia in certain patients. Progress remains to be made in the identification and treatment of CNS leukemia in pediatric ALL. Advancements have occurred to limit the number of children undergoing CRT, but much has yet to be learned to better understand the biology of and risk factors for CNS leukemia, and novel approaches are required to approach CNS relapse of ALL.
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Affiliation(s)
- Jennifer L McNeer
- Section of Pediatric Hematology/Oncology/Stem Cell Transplant, University of Chicago Comer Children's Hospital, 5841 S. Maryland Ave, MC 4060, Chicago, IL, 60637, USA.
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
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7
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Apps JR, Maycock S, Ellison DW, Jaspan T, Ritzmann TA, Macarthur D, Mallucci C, Wheatley K, Veal GJ, Grundy RG, Picton S. Phase II study of intravenous etoposide in patients with relapsed ependymoma (CNS 2001 04). Neurooncol Adv 2022; 4:vdac053. [PMID: 35591977 PMCID: PMC9113139 DOI: 10.1093/noajnl/vdac053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Relapsed ependymoma has a dismal prognosis, and the role of chemotherapy at relapse remains unclear. This study prospectively evaluated the efficacy of intensive intravenous (IV) etoposide in patients less than 21 years of age with relapsed intracranial ependymoma (NCT00278252). Methods This was a single-arm, open-label, phase II trial using Gehan's two-stage design. Patients received IV etoposide 100 mg/m2 on days 1-3, 8-10, and 15-17 of each 28-day cycle, up to maximum of 6 cycles. Primary outcome was radiological response after 3 cycles. Pharmacokinetic analysis was performed in 10 patients. Results Twenty-five patients were enrolled and included in the intention-to-treat (ITT) analysis. Three patients were excluded in per-protocol (PP) analysis. After 3 cycles of etoposide, 5 patients (ITT 20%/PP 23%) had a complete response (CR), partial response (PR), or objective response (OR). Nine patients (ITT 36%/PP 41%,) had a best overall response of CR, PR, or OR. 1-year PFS was 24% in ITT and 23% in PP populations. 1-year OS was 56% and 59%, 5-year OS was 20% and 18%, respectively, in ITT and PP populations. Toxicity was predominantly hematological, with 20/25 patients experiencing a grade 3 or higher hematological adverse event. Conclusions This study confirms the activity of IV etoposide against relapsed ependymoma, however, this is modest, not sustained, and similar to that with oral etoposide, albeit with increased toxicity. These results confirm the dismal prognosis of this disease, provide a rationale to include etoposide within drug combinations, and highlight the need to develop novel treatments for recurrent ependymoma.
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Affiliation(s)
- John R Apps
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Shanna Maycock
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - David W Ellison
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Timothy Jaspan
- Radiology Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Timothy A Ritzmann
- Children’s Brain Tumour Research Centre, Bio-Discovery Institute and Queen’s Medical Centre, University of Nottingham, Nottingham, UK
| | - Donald Macarthur
- Children’s Brain Tumour Research Centre, Bio-Discovery Institute and Queen’s Medical Centre, University of Nottingham, Nottingham, UK
| | - Conor Mallucci
- Department of Neurosurgery, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Gareth J Veal
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
| | - Richard G Grundy
- Children’s Brain Tumour Research Centre, Bio-Discovery Institute and Queen’s Medical Centre, University of Nottingham, Nottingham, UK
| | - Susan Picton
- Department of Paediatric Oncology, Leeds Children’s Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Hill RM, Plasschaert SLA, Timmermann B, Dufour C, Aquilina K, Avula S, Donovan L, Lequin M, Pietsch T, Thomale U, Tippelt S, Wesseling P, Rutkowski S, Clifford SC, Pfister SM, Bailey S, Fleischhack G. Relapsed Medulloblastoma in Pre-Irradiated Patients: Current Practice for Diagnostics and Treatment. Cancers (Basel) 2021; 14:126. [PMID: 35008290 PMCID: PMC8750207 DOI: 10.3390/cancers14010126] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 02/07/2023] Open
Abstract
Relapsed medulloblastoma (rMB) accounts for a considerable, and disproportionate amount of childhood cancer deaths. Recent advances have gone someway to characterising disease biology at relapse including second malignancies that often cannot be distinguished from relapse on imaging alone. Furthermore, there are now multiple international early-phase trials exploring drug-target matches across a range of high-risk/relapsed paediatric tumours. Despite these advances, treatment at relapse in pre-irradiated patients is typically non-curative and focuses on providing life-prolonging and symptom-modifying care that is tailored to the needs and wishes of the individual and their family. Here, we describe the current understanding of prognostic factors at disease relapse such as principal molecular group, adverse molecular biology, and timing of relapse. We provide an overview of the clinical diagnostic process including signs and symptoms, staging investigations, and molecular pathology, followed by a summary of treatment modalities and considerations. Finally, we summarise future directions to progress understanding of treatment resistance and the biological mechanisms underpinning early therapy-refractory and relapsed disease. These initiatives include development of comprehensive and collaborative molecular profiling approaches at relapse, liquid biopsies such as cerebrospinal fluid (CSF) as a biomarker of minimal residual disease (MRD), modelling strategies, and the use of primary tumour material for real-time drug screening approaches.
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Affiliation(s)
- Rebecca M. Hill
- Wolfson Childhood Cancer Research Centre, Newcastle University Centre for Cancer, Newcastle upon Tyne NE1 7RU, UK; (S.C.C.); (S.B.)
| | - Sabine L. A. Plasschaert
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (S.L.A.P.); (M.L.); (P.W.)
| | - Beate Timmermann
- Department of Particle Therapy, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany;
| | - Christelle Dufour
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, 94800 Villejuif, France;
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital, London WC1N 3JH, UK;
| | - Shivaram Avula
- Department of Radiology, Alder Hey Children’s NHS Foundation Trust, Liverpool L12 2AP, UK;
| | - Laura Donovan
- UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK;
| | - Maarten Lequin
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (S.L.A.P.); (M.L.); (P.W.)
| | - Torsten Pietsch
- Institute of Neuropathology, DGNN Brain Tumor Reference Center, University of Bonn, 53127 Bonn, Germany;
| | - Ulrich Thomale
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Stephan Tippelt
- Department of Pediatrics III, Center for Translational Neuro- and Behavioral Sciences (CTNBS), University Hospital of Essen, 45147 Essen, Germany;
| | - Pieter Wesseling
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (S.L.A.P.); (M.L.); (P.W.)
- Department of Pathology, Amsterdam University Medical Centers/VUmc, 1081 HV Amsterdam, The Netherlands
| | - Stefan Rutkowski
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Steven C. Clifford
- Wolfson Childhood Cancer Research Centre, Newcastle University Centre for Cancer, Newcastle upon Tyne NE1 7RU, UK; (S.C.C.); (S.B.)
| | - Stefan M. Pfister
- Hopp Children’s Cancer Center Heidelberg (KiTZ), 69120 Heidelberg, Germany;
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Department of Pediatric Oncology and Hematology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Simon Bailey
- Wolfson Childhood Cancer Research Centre, Newcastle University Centre for Cancer, Newcastle upon Tyne NE1 7RU, UK; (S.C.C.); (S.B.)
| | - Gudrun Fleischhack
- Department of Pediatrics III, Center for Translational Neuro- and Behavioral Sciences (CTNBS), University Hospital of Essen, 45147 Essen, Germany;
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Lau G, Drummond J, Zhukova N, Wood P, Janson L. Triple intraventricular chemotherapy for treatment of relapsed choroid plexus carcinoma. Pediatr Blood Cancer 2021; 68:e29094. [PMID: 34003555 DOI: 10.1002/pbc.29094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/16/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Grace Lau
- Pharmacy Department, Monash Health, Clayton, Victoria, Australia
| | - Julie Drummond
- Pharmacy Department, Monash Health, Clayton, Victoria, Australia
| | - Nataliya Zhukova
- Children's Cancer Centre, Monash Children's Hospital/Monash Health, Clayton, Victoria, Australia.,Centre for Cancer Research, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Paul Wood
- Children's Cancer Centre, Monash Children's Hospital/Monash Health, Clayton, Victoria, Australia.,Centre for Cancer Research, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Paediatrics, Monash University, Victoria, Australia
| | - Lisa Janson
- Pharmacy Department, Monash Health, Clayton, Victoria, Australia
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Naseri Kouzehgarani G, Feldsien T, Engelhard HH, Mirakhur KK, Phipps C, Nimmrich V, Clausznitzer D, Lefebvre DR. Harnessing cerebrospinal fluid circulation for drug delivery to brain tissues. Adv Drug Deliv Rev 2021; 173:20-59. [PMID: 33705875 DOI: 10.1016/j.addr.2021.03.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/10/2021] [Accepted: 03/01/2021] [Indexed: 12/31/2022]
Abstract
Initially thought to be useful only to reach tissues in the immediate vicinity of the CSF circulatory system, CSF circulation is now increasingly viewed as a viable pathway to deliver certain therapeutics deeper into brain tissues. There is emerging evidence that this goal is achievable in the case of large therapeutic proteins, provided conditions are met that are described herein. We show how fluid dynamic modeling helps predict infusion rate and duration to overcome high CSF turnover. We posit that despite model limitations and controversies, fluid dynamic models, pharmacokinetic models, preclinical testing, and a qualitative understanding of the glymphatic system circulation can be used to estimate drug penetration in brain tissues. Lastly, in addition to highlighting landmark scientific and medical literature, we provide practical advice on formulation development, device selection, and pharmacokinetic modeling. Our review of clinical studies suggests a growing interest for intra-CSF delivery, particularly for targeted proteins.
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Cancela MB, Zugbi S, Winter U, Martinez AL, Sampor C, Sgroi M, Francis JH, Garippa R, Abramson DH, Chantada G, Schaiquevich P. A decision process for drug discovery in retinoblastoma. Invest New Drugs 2020; 39:426-441. [PMID: 33200242 DOI: 10.1007/s10637-020-01030-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/28/2020] [Indexed: 11/28/2022]
Abstract
Intraocular retinoblastoma treatment has changed radically over the last decade, leading to a notable improvement in ocular survival. However, eyes that relapse remain difficult to treat, as few alternative active drugs are available. More challenging is the scenario of central nervous system (CNS) metastasis, in which almost no advancements have been made. Both clinical scenarios represent an urgent need for new drugs. Using an integrated multidisciplinary approach, we developed a decision process for prioritizing drug selection for local (intravitreal [IVi], intrathecal/intraventricular [IT/IVt]), systemic, or intra-arterial chemotherapy (IAC) treatment by means of high-throughput pharmacological screening of primary cells from two patients with intraocular tumor and CNS metastasis and a thorough database search to identify clinical and biopharmaceutical data. This process identified 169 compounds to be cytotoxic; only 8 are FDA-approved, lack serious toxicities and available for IVi administration. Four of these agents could also be delivered by IT/IVt. Twelve FDA-approved drugs were identified for systemic delivery as they are able to cross the blood-brain barrier and lack serious adverse events; four drugs are of oral usage and six compounds that lack vesicant or neurotoxicity could be delivered by IAC. We also identified promising compounds in preliminary phases of drug development including inhibitors of survivin, antiapoptotic Bcl-2 family proteins, methyltransferase, and kinesin proteins. This systematic approach may be applied more broadly to prioritize drugs to be repurposed or to identify novel hits for use in retinoblastoma treatment.
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Affiliation(s)
- María Belen Cancela
- Precision Medicine, Hospital de Pediatría JP Garrahan, 1245, Buenos Aires, Argentina.,National Scientific and Technical Research Council, CONICET, 1425, Buenos Aires, Argentina
| | - Santiago Zugbi
- Precision Medicine, Hospital de Pediatría JP Garrahan, 1245, Buenos Aires, Argentina.,National Scientific and Technical Research Council, CONICET, 1425, Buenos Aires, Argentina
| | - Ursula Winter
- Pathology Service, Hospital de Pediatría JP Garrahan, 1245, Buenos Aires, Argentina
| | - Ana Laura Martinez
- Precision Medicine, Hospital de Pediatría JP Garrahan, 1245, Buenos Aires, Argentina
| | - Claudia Sampor
- Hematology-Oncology Service, Hospital de Pediatría JP Garrahan, 1245, Buenos Aires, Argentina
| | - Mariana Sgroi
- Ophthalmology Service, Hospital de Pediatría JP Garrahan, 1245, Buenos Aires, Argentina
| | - Jasmine H Francis
- Ophthalmic Oncology Service, Memorial Sloan-Kettering Institute and Cancer Center, New York, NY, 10065, USA
| | - Ralph Garippa
- Gene Editing And Screening Core facility, Department of Cancer Biology and Genetics, Memorial Sloan-Kettering Institute and Cancer Center, New York, NY, 10065, USA
| | - David H Abramson
- Ophthalmic Oncology Service, Memorial Sloan-Kettering Institute and Cancer Center, New York, NY, 10065, USA
| | - Guillermo Chantada
- Precision Medicine, Hospital de Pediatría JP Garrahan, 1245, Buenos Aires, Argentina.,National Scientific and Technical Research Council, CONICET, 1425, Buenos Aires, Argentina
| | - Paula Schaiquevich
- Precision Medicine, Hospital de Pediatría JP Garrahan, 1245, Buenos Aires, Argentina. .,National Scientific and Technical Research Council, CONICET, 1425, Buenos Aires, Argentina.
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12
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Animasawun RK, Taresco V, Swainson SME, Suksiriworapong J, Walker DA, Garnett MC. Screening and Matching Polymers with Drugs to Improve Drug Incorporation and Retention in Nanoparticles. Mol Pharm 2020; 17:2083-2098. [PMID: 32348676 DOI: 10.1021/acs.molpharmaceut.0c00236] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Key challenges hindering the clinical translation of the use of nanoparticles (NP) for delivery of drugs to tumors are inadequate drug loading and premature drug release. This study focused on understanding the conditions required to produce nanoparticles that can reach their target site with sufficient drug loading and drug retention for effective pharmacological action. Etoposide, etoposide phosphate, and teniposide were screened against modified poly(glycerol) adipate (PGA) based polymers by monitoring drug release from 40% drug in polymer films and using Fourier transform infrared spectroscopy (FTIR) and contact angle measurements to help understand the release results. Polymers were matched with the specific drugs based on the interactions observed. NP were then prepared by an interfacial deposition method. NPs were characterized and resulted in drug loadings ranging from 3.5% and 5%, respectively, for etoposide phosphate and etoposide with PGA modified with stearate (PGA85%C18) up to 13.4% for teniposide with PGA modified with tryptophan (PGA50%Try) and drug release of just 22-35% over 24 h. Assessment of cytotoxicity showed that etoposide nanoparticles with PGA85%C18 were more potent than an equivalent amount of free drug. This screening method to match polymers to drugs to monitor based drug and polymer interactions thus resulted in the formulation of nanoparticles with higher drug loading and slower release and potential for further development for clinical applications.
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Affiliation(s)
- Rashidat K Animasawun
- Division of Molecular Therapeutics and Formulation, School of Pharmacy, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Vincenzo Taresco
- School of Chemistry, University of Nottingham, Nottingham NG7 2RD, United Kingdom
| | - Sadie M E Swainson
- Division of Molecular Therapeutics and Formulation, School of Pharmacy, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Jiraphong Suksiriworapong
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand.,Center of Excellence in Innovative Drug Delivery and Nanomedicine, Faculty of Pharmacy, Mahidol University, 447 Sri-Ayudhaya Road, Ratchathewi, Bangkok 10400, Thailand
| | - David A Walker
- Children's Brain Tumour Research Centre, University of Nottingham, Nottingham, NG7 2RD, United Kingdom
| | - Martin C Garnett
- Division of Molecular Therapeutics and Formulation, School of Pharmacy, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
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13
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Walker DA, Meijer L, Coyle B, Halsey C. Leptomeningeal malignancy of childhood: sharing learning between childhood leukaemia and brain tumour trials. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:242-250. [PMID: 31958415 DOI: 10.1016/s2352-4642(19)30333-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 01/02/2023]
Abstract
Leptomeningeal malignancy complicates childhood cancers, including leukaemias, brain tumours, and solid tumours. In leukaemia, such malignancy is thought to invade leptomeninges via the vascular route. In brain tumours, dissemination from the primary tumour, before or after surgery, via CSF pathways is assumed; however, evidence exists to support the vascular route of dissemination. Success in treating leptomeningeal malignancy represents a rate-limiting step to cure, which has been successfully overcome in leukaemia with intensified systemic therapy combined with intra-CSF therapy, which replaced cranial radiotherapy for many patients. This de-escalated CNS-directed therapy is still associated with some neurotoxicity. The balanced benefit justifies exploration of ways to further de-escalate CNS-directed therapy. For primary brain tumours, standard therapy is craniospinal radiotherapy, but attendant risk of acute and delayed brain injury and endocrine deficiencies compounds post-radiation impairment of spinal growth. Alternative ways of treating leptomeninges by intensifying drug therapy delivered to CSF are being investigated-preliminary evidence suggests improved outcomes. This Review seeks to describe methods of intra-CSF drug delivery and drugs in use, and consider how the technique could be modified and additional drugs might be selected for this route of administration.
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Affiliation(s)
- David A Walker
- Children's Brain Tumour Research Centre, University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK.
| | - Lisethe Meijer
- Department of Paediatric Neuro-Oncology, Prinses Maxima Center for Paediatric Oncology, Bilthoven, Netherlands
| | - Beth Coyle
- Children's Brain Tumour Research Centre, University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK
| | - Christina Halsey
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Abstract
Leptomeningeal metastasis (LM) results from dissemination of cancer cells to both the leptomeninges (pia and arachnoid) and cerebrospinal fluid (CSF) compartment. Breast cancer, lung cancer, and melanoma are the most common solid tumors that cause LM. Recent approval of more active anticancer therapies has resulted in improvement in survival that is partly responsible for an increased incidence of LM. Neurologic deficits, once manifest, are mostly irreversible, and often have a significant impact on patient quality of life. LM-directed therapy is based on symptom palliation, circumscribed use of neurosurgery, limited field radiotherapy, intra-CSF and systemic therapies. Novel methods of detecting LM include detection of CSF circulating tumor cells and tumor cell-free DNA. A recent international guideline for a standardization of response assessment in LM may improve cross-trial comparisons as well as within-trial evaluation of treatment. An increasing number of retrospective studies suggest that molecular-targeted therapy, such as EGFR and ALK inhibitors in lung cancer, trastuzumab in HER2+ breast cancer, and BRAF inhibitors in melanoma, may be effective as part of the multidisciplinary management of LM. Prospective randomized trials with standardized response assessment are needed to further validate these preliminary findings.
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Abstract
Among the various routes of drug administration, perhaps the least studied is intracerebroventricular (ICV) administration. This route has been shown to be particularly useful in administering to the central nervous system (CNS) drugs that do not cross the blood-brain barrier readily. As such, the ICV route is a valuable option for providing therapeutic CNS drug concentrations to treat patients with CNS infectious and neoplastic diseases. This route of drug administration also has the advantage of minimizing systemic toxicity.
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Affiliation(s)
- Arthur J Atkinson
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University Chicago, Illinois, USA
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16
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Qu D, Wang L, Liu M, Shen S, Li T, Liu Y, Huang M, Liu C, Chen Y, Mo R. Oral Nanomedicine Based on Multicomponent Microemulsions for Drug-Resistant Breast Cancer Treatment. Biomacromolecules 2017; 18:1268-1280. [PMID: 28350158 DOI: 10.1021/acs.biomac.7b00011] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Ding Qu
- Affiliated
Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210028, China
- Jiangsu Provincial Academy of Traditional Chinese Medicine, Nanjing 210028, China
| | - Lixiang Wang
- Affiliated
Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210028, China
| | - Meng Liu
- State
Key Laboratory of Natural Medicines and Jiangsu Key Laboratory of
Drug Discovery for Metabolic Diseases, Center of Advanced Pharmaceuticals
and Biomaterials and Center of Drug Discovery, China Pharmaceutical University, Nanjing 210009, China
| | - Shiyang Shen
- State
Key Laboratory of Natural Medicines and Jiangsu Key Laboratory of
Drug Discovery for Metabolic Diseases, Center of Advanced Pharmaceuticals
and Biomaterials and Center of Drug Discovery, China Pharmaceutical University, Nanjing 210009, China
| | - Teng Li
- State
Key Laboratory of Natural Medicines and Jiangsu Key Laboratory of
Drug Discovery for Metabolic Diseases, Center of Advanced Pharmaceuticals
and Biomaterials and Center of Drug Discovery, China Pharmaceutical University, Nanjing 210009, China
| | - Yuping Liu
- Affiliated
Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210028, China
- Jiangsu Provincial Academy of Traditional Chinese Medicine, Nanjing 210028, China
| | - Mengmeng Huang
- Affiliated
Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210028, China
- Jiangsu Provincial Academy of Traditional Chinese Medicine, Nanjing 210028, China
| | - Congyan Liu
- Affiliated
Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210028, China
- Jiangsu Provincial Academy of Traditional Chinese Medicine, Nanjing 210028, China
| | - Yan Chen
- Affiliated
Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210028, China
- Jiangsu Provincial Academy of Traditional Chinese Medicine, Nanjing 210028, China
| | - Ran Mo
- State
Key Laboratory of Natural Medicines and Jiangsu Key Laboratory of
Drug Discovery for Metabolic Diseases, Center of Advanced Pharmaceuticals
and Biomaterials and Center of Drug Discovery, China Pharmaceutical University, Nanjing 210009, China
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17
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Ivanov DP, Al-Rubai AJ, Grabowska AM, Pratten MK. Separating chemotherapy-related developmental neurotoxicity from cytotoxicity in monolayer and neurosphere cultures of human fetal brain cells. Toxicol In Vitro 2016; 37:88-96. [PMID: 27622579 DOI: 10.1016/j.tiv.2016.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 08/01/2016] [Accepted: 09/09/2016] [Indexed: 12/22/2022]
Abstract
Chemotherapy-induced neurotoxicity can reduce the quality of life of patients by affecting their intelligence, senses and mobility. Ten percent of safety-related late-stage clinical failures are due to neurological side effects. Animal models are poor in predicting human neurotoxicity due to interspecies differences and most in vitro assays cannot distinguish neurotoxicity from general cytotoxicity for chemotherapeutics. We developed in vitro assays capable of quantifying the paediatric neurotoxic potential for cytotoxic drugs. Mixed cultures of human fetal brain cells were differentiated in monolayers and as 3D-neurospheres in the presence of non-neurotoxic chemotherapeutics (etoposide, teniposide) or neurotoxicants (methylmercury). The cytotoxic potency towards dividing progenitors versus differentiated neurons and astrocytes was compared using: (1) immunohistochemistry staining and cell counts in monolayers; (2) through quantitative Western blots in neurospheres; and (3) neurosphere migration assays. Etoposide and teniposide, were 5-10 times less toxic to differentiated neurons compared to the mix of all cells in monolayer cultures. In contrast, the neurotoxicant methylmercury did not exhibit selectivity and killed all cells with the same potency. In 3D neurospheres, etoposide and teniposide were 24 to 10 times less active against neurons compared to all cells. These assays can be used prioritise drugs for local drug delivery to brain tumours.
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Affiliation(s)
- Delyan P Ivanov
- Cancer Biology, Division of Cancer and Stem Cells, School of Medicine, Queen's Medical Centre, University of Nottingham, Nottingham, UK.
| | - Abdal-Jabbar Al-Rubai
- School of Life Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK.
| | - Anna M Grabowska
- Cancer Biology, Division of Cancer and Stem Cells, School of Medicine, Queen's Medical Centre, University of Nottingham, Nottingham, UK.
| | - Margaret K Pratten
- School of Life Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK.
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18
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Intraventricular etoposide safety and toxicity profile in children and young adults with refractory or recurrent malignant brain tumors. J Neurooncol 2016; 128:463-71. [PMID: 27147083 DOI: 10.1007/s11060-016-2133-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 04/19/2016] [Indexed: 10/21/2022]
Abstract
Systemic administration of etoposide is effective in treating metastatic, recurrent or refractory brain tumors, but penetration into the cerebrospinal fluid is extremely poor. This study was designed to determine the safety and toxicity profile of intraventricular etoposide administration and was affiliated with the prospective, multicenter, nonblinded, nonrandomized, multi-armed HIT-REZ-97 trial. The study enrolled 68 patients, aged 1.1-34.6 (median age 11 years). Adverse events that could possibly be related to intraventricular etoposide therapy were documented and analyzed. Intraventricular etoposide was simultaneously administered with either oral or intravenous chemotherapy in 426 courses according to three major schedules varying in dosing (0.25-1 mg), frequency of administration (bolus injection, every 12 or 24 h), course duration (5-10 days) and length of interval between courses (2-5 weeks). Potential treatment-related adverse effects included transient headache, seizures, infection of the reservoir, nausea and neuropsychological symptoms. Hematological side effects were not observed. One patient, with history of multiple prior therapies, who received long-term intraventricular and oral etoposide treatment developed acute myeloid leukemia as a secondary malignancy. Overall intraventricular etoposide is well tolerated. The results of this study have warranted a phase II trial to determine the effectiveness of this regimen in disease stages with very limited therapeutic options.
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19
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Park MJ. Durable Response of Leptomeningeal Metastasis of Breast Cancer to Salvage Intrathecal Etoposide After Methotrexate: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:524-7. [PMID: 26258900 PMCID: PMC4535194 DOI: 10.12659/ajcr.894007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patient: Female, 42 Final Diagnosis: Breast cancer with leptomeningeal metastasis Symptoms: Headache Medication: Etoposide Clinical Procedure: Intrathecal chemotherapy Specialty: Oncology
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Affiliation(s)
- Min Jae Park
- Division of Hematology-Oncology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea, South
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20
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Fakhoury M. Drug delivery approaches for the treatment of glioblastoma multiforme. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2015; 44:1365-73. [PMID: 26046399 DOI: 10.3109/21691401.2015.1052467] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
CONTEXT Glioblastoma multiforme (GBM) is by far the most common and aggressive form of glial tumor. It is characterized by a highly proliferative population of cells that invade surrounding tissue and that frequently recur after surgical resection and chemotherapy. Over the last decades, a number of promising novel pharmacological approaches have been investigated, but most of them have failed clinical trials due to some side-effects such as toxicity and poor drug delivery to the brain. The major obstacle in the treatment of GBM is the presence of the blood-brain barrier (BBB). Due to their relatively high molecular weight, most therapeutic drugs fail to cross the BBB from the blood circulation. OBJECTIVE This paper sheds light on the characteristics of GBM and the challenges of current pharmacological treatments. A closer look is given to the role of nanotechnology in the field of drug delivery, and its application in the treatment of brain tumors such as GBM. METHOD For this purpose, effort was made to select the most recent studies using predefined search criteria that included at least one of the following keywords in the PubMed and Medline databases: glioblastoma, drug delivery, blood-brain barrier, nanotechnology, and nanoparticle. CONCLUSION Breakthrough in nanotechnology offers promising applications in cancer therapy and targeted drug delivery. However, more efforts need to be devoted to the development of novel therapeutic strategies that enable the delivery of drugs to desired areas of the brain with limited side-effects and higher therapeutic efficiency.
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Affiliation(s)
- Marc Fakhoury
- a Department of Neurosciences , University of Montreal , Montreal , QC , Canada
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21
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Park MJ. Prolonged response of meningeal carcinomatosis from non-small cell lung cancer to salvage intrathecal etoposide subsequent to failure of first-line methotrexate: a case report and literature review. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:224-7. [PMID: 25879815 PMCID: PMC4407681 DOI: 10.12659/ajcr.894061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Patient: Male, 58 Final Diagnosis: Non-small cell lung cancer with meningeal carcinomatosis Symptoms: Headache Medication: Etoposide Clinical Procedure: Intraventricular chemotherapy Specialty: Oncology
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Affiliation(s)
- Min Jae Park
- Division of Hematology-Oncology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
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22
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Cuervo-Arango I, Reimunde P, Gutiérrez JC, Aransay A, Rivero B, Pérez C, Budke M, Villarejo F. [Choroid plexus tumour treatment at Hospital Infantil Niño Jesús in Madrid: Our experience over the last three decades]. Neurocirugia (Astur) 2015; 26:209-16. [PMID: 25724620 DOI: 10.1016/j.neucir.2015.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 01/03/2015] [Accepted: 01/08/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To review childhood patients with choroid plexus tumors (CPT) who underwent surgery at Hospital Infantil Niño Jesús of Madrid since January 1981 to September 2014. MATERIAL AND METHODS Registered charts were analyzed based on the epidemiology, tumor grade, clinical profile, location, dissemination characteristics, therapy, prognosis and complications. RESULTS Seventeen childhood patients were recorded with CPT. Cases were distributed so that 9 cases were choroid plexus-papilloma (CPP) (52.9%), 2 cases atypical CPP (11.7%) and 6 cases choroid plexus-carcinoma (CPC) (35.2%). Age at diagnosis was less than 2 years in 14 of the 17 patients (82.3%) and the incidence was higher in males (82.3% of the cases). Gross total resection was performed in 16 patients (94.1%). Adjuvant treatment was used in 6 patients (all this cases with CPC) (35.2%). Two of the 17 patients died (11.7%), showing an incidence density of 0.01 deaths/year. CONCLUSIONS Our case series is consistent with previous published in scientific literature regarding epidemiology, tumor grade, clinical presentation, radiological features and therapeutic approach. Gross total resection is considered the therapeutic gold standard for choroid plexus tumors. Chemotherapy and radiotherapy should be used as adjuvant treatment in CPC and recurrent or remaining atypical CPP.
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Affiliation(s)
- Isabel Cuervo-Arango
- Servicio de Neurocirugía, Hospital Universitario Central de Asturias (HUCA), Oviedo, Asturias, España
| | - Pedro Reimunde
- Servicio de Neurocirugía, Hospital Universitario Central de Asturias (HUCA), Oviedo, Asturias, España.
| | - Julio César Gutiérrez
- Servicio de Neurocirugía, Hospital Universitario Central de Asturias (HUCA), Oviedo, Asturias, España
| | - Ana Aransay
- Servicio de Neurocirugía, Hospital Universitario Niño Jesús, Madrid, España
| | - Belén Rivero
- Servicio de Neurocirugía, Hospital Universitario Niño Jesús, Madrid, España
| | - Carlos Pérez
- Servicio de Neurocirugía, Hospital Universitario Niño Jesús, Madrid, España
| | - Marcelo Budke
- Servicio de Neurocirugía, Hospital Universitario Niño Jesús, Madrid, España
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Ivanov DP, Parker TL, Walker DA, Alexander C, Ashford MB, Gellert PR, Garnett MC. In vitro co-culture model of medulloblastoma and human neural stem cells for drug delivery assessment. J Biotechnol 2015; 205:3-13. [PMID: 25592050 DOI: 10.1016/j.jbiotec.2015.01.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 12/22/2014] [Accepted: 01/05/2015] [Indexed: 12/20/2022]
Abstract
Physiologically relevant in vitro models can serve as biological analytical platforms for testing novel treatments and drug delivery systems. We describe the first steps in the development of a 3D human brain tumour co-culture model that includes the interplay between normal and tumour tissue along with nutrient gradients, cell-cell and cell-matrix interactions. The human medulloblastoma cell line UW228-3 and human foetal brain tissue were marked with two supravital fluorescent dyes (CDCFDASE, Celltrace Violet) and cultured together in ultra-low attachment 96-well plates to form reproducible single co-culture spheroids (d = 600 μm, CV% = 10%). Spheroids were treated with model cytotoxic drug etoposide (0.3-100 μM) and the viability of normal and tumour tissue quantified separately using flow cytometry and multiphoton microscopy. Etoposide levels of 10 μM were found to maximise toxicity to tumours (6.5% viability) while stem cells maintained a surviving fraction of 40%. The flexible cell marking procedure and high-throughput compatible protocol make this platform highly transferable to other cell types, primary tissues and personalised screening programs. The model's key anticipated use is for screening and assessment of drug delivery strategies to target brain tumours, and is ready for further developments, e.g. differentiation of stem cells to a range of cell types and more extensive biological validation.
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Affiliation(s)
- Delyan P Ivanov
- School of Pharmacy, University of Nottingham, Nottingham, UK.
| | - Terry L Parker
- Medical School, Queens Medical Centre, University of Nottingham, Nottingham, UK.
| | - David A Walker
- Children's Brain Tumour Research Centre, Queens Medical Centre, University of Nottingham, Nottingham, UK.
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Paidakula S, Kankala S, Kankala RK, Juluru B, Jonnalagadda SB, Lee CH, Vadde R, Vasam CS. Synthesis and biological evaluation of 4β-benzoxazolepodophyllotoxin hybrids as DNA topoisomerase-II targeting anticancer agents. RSC Adv 2015. [DOI: 10.1039/c5ra15366b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A series of new 4β-benzoxazolepodophyllotoxin compounds (9a–j) were prepared and screened for molecular modelling and cytotoxicity against various human tumour cell lines. Cell apoptosis evaluation was performed using Hoechst staining.
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Affiliation(s)
| | - Shravankumar Kankala
- Department of Chemistry
- Kakatiya University
- Warangal
- India
- School of Physics and Chemistry
| | - Ranjith kumar Kankala
- Department of Life Science and Institute of Biotechnology
- National Dong Hwa University
- Hualien
- Taiwan
| | | | | | - Chia-Hung Lee
- Department of Life Science and Institute of Biotechnology
- National Dong Hwa University
- Hualien
- Taiwan
| | | | - Chandra Sekhar Vasam
- Department of Chemistry
- Satavahana University
- India
- Department of Pharmaceutical Chemistry
- Telangana University
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25
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Ivanov DP, Parker TL, Walker DA, Alexander C, Ashford MB, Gellert PR, Garnett MC. Multiplexing spheroid volume, resazurin and acid phosphatase viability assays for high-throughput screening of tumour spheroids and stem cell neurospheres. PLoS One 2014; 9:e103817. [PMID: 25119185 PMCID: PMC4131917 DOI: 10.1371/journal.pone.0103817] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 07/03/2014] [Indexed: 12/31/2022] Open
Abstract
Three-dimensional cell culture has many advantages over monolayer cultures, and spheroids have been hailed as the best current representation of small avascular tumours in vitro. However their adoption in regular screening programs has been hindered by uneven culture growth, poor reproducibility and lack of high-throughput analysis methods for 3D. The objective of this study was to develop a method for a quick and reliable anticancer drug screen in 3D for tumour and human foetal brain tissue in order to investigate drug effectiveness and selective cytotoxic effects. Commercially available ultra-low attachment 96-well round-bottom plates were employed to culture spheroids in a rapid, reproducible manner amenable to automation. A set of three mechanistically different methods for spheroid health assessment (Spheroid volume, metabolic activity and acid phosphatase enzyme activity) were validated against cell numbers in healthy and drug-treated spheroids. An automated open-source ImageJ macro was developed to enable high-throughput volume measurements. Although spheroid volume determination was superior to the other assays, multiplexing it with resazurin reduction and phosphatase activity produced a richer picture of spheroid condition. The ability to distinguish between effects on malignant and the proliferating component of normal brain was tested using etoposide on UW228-3 medulloblastoma cell line and human neural stem cells. At levels below 10 µM etoposide exhibited higher toxicity towards proliferating stem cells, whereas at concentrations above 10 µM the tumour spheroids were affected to a greater extent. The high-throughput assay procedures use ready-made plates, open-source software and are compatible with standard plate readers, therefore offering high predictive power with substantial savings in time and money.
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Affiliation(s)
- Delyan P. Ivanov
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
| | - Terry L. Parker
- Medical School, Queens Medical Centre, University of Nottingham, Nottingham, United Kingdom
| | - David A. Walker
- Children's Brain Tumour Research Centre, Queens Medical Centre, University of Nottingham, Nottingham, United Kingdom
| | - Cameron Alexander
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
| | | | | | - Martin C. Garnett
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
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26
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Le Rhun E, Taillibert S, Chamberlain MC. Carcinomatous meningitis: Leptomeningeal metastases in solid tumors. Surg Neurol Int 2013; 4:S265-88. [PMID: 23717798 PMCID: PMC3656567 DOI: 10.4103/2152-7806.111304] [Citation(s) in RCA: 180] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 04/11/2013] [Indexed: 11/04/2022] Open
Abstract
Leptomeningeal metastasis (LM) results from metastatic spread of cancer to the leptomeninges, giving rise to central nervous system dysfunction. Breast cancer, lung cancer, and melanoma are the most frequent causes of LM among solid tumors in adults. An early diagnosis of LM, before fixed neurologic deficits are manifest, permits earlier and potentially more effective treatment, thus leading to a better quality of life in patients so affected. Apart from a clinical suspicion of LM, diagnosis is dependent upon demonstration of cancer in cerebrospinal fluid (CSF) or radiographic manifestations as revealed by neuraxis imaging. Potentially of use, though not commonly employed, today are use of biomarkers and protein profiling in the CSF. Symptomatic treatment is directed at pain including headache, nausea, and vomiting, whereas more specific LM-directed therapies include intra-CSF chemotherapy, systemic chemotherapy, and site-specific radiotherapy. A special emphasis in the review discusses novel agents including targeted therapies, that may be promising in the future management of LM. These new therapies include anti-epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors erlotinib and gefitinib in nonsmall cell lung cancer, anti-HER2 monoclonal antibody trastuzumab in breast cancer, anti-CTLA4 ipilimumab and anti-BRAF tyrosine kinase inhibitors such as vermurafenib in melanoma, and the antivascular endothelial growth factor monoclonal antibody bevacizumab are currently under investigation in patients with LM. Challenges of managing patients with LM are manifold and include determining the appropriate patients for treatment as well as the optimal route of administration of intra-CSF drug therapy.
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Affiliation(s)
- Emilie Le Rhun
- Breast Unit, Department of Medical Oncology, Centre Oscar Lambret and Department of Neuro Oncology, Roger Salengro Hospital, University Hospital, Lille, France
| | - Sophie Taillibert
- Neurology, Mazarin and Radiation Oncology, Pitié Salpétrière Hospital, University Pierre et Marie Curie, Paris VI, Paris, France
| | - Marc C. Chamberlain
- Neurology and Neurological Surgery, University of Washington, Fred Hutchinson Research Cancer Center, Seattle, WA, USA
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27
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Intra-CSF administration of chemotherapy medications. Cancer Chemother Pharmacol 2012; 70:1-15. [DOI: 10.1007/s00280-012-1893-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 05/11/2012] [Indexed: 10/28/2022]
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28
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Sandberg DI, Peet MM, Johnson MD, Cole P, Koru-Sengul T, Luqman AW. Chemotherapy administration directly into the fourth ventricle in a nonhuman primate model. J Neurosurg Pediatr 2012; 9:530-41. [PMID: 22546032 DOI: 10.3171/2012.1.peds11410] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors hypothesized that chemotherapy infusions directly into the fourth ventricle might potentially play a role in treating malignant fourth ventricular tumors. The study tested the safety and pharmacokinetics of short- and long-term infusions of methotrexate into the fourth ventricle in a new nonhuman primate model. METHODS Six rhesus monkeys underwent posterior fossa craniectomy and catheter insertion into the fourth ventricle. In Group I (3 animals), catheters were externalized, and lumbar drain catheters were placed simultaneously to assess CSF distribution after short-term methotrexate infusions. In 2 animals, methotrexate (0.5 mg) was infused into the fourth ventricle daily for 5 days. Serial CSF and serum methotrexate levels were measured. The third animal had a postoperative neurological deficit, and the experiment was aborted prior to methotrexate administration. In Group II (3 animals), catheters were connected to a subcutaneously placed port for subsequent long-term methotrexate infusions. In 2 animals, 4 cycles of intraventricular methotrexate, each consisting of 4 daily infusions (0.5 mg), were administered over 8 weeks. The third animal received 3 cycles, and then the experiment was terminated due to self-inflicted wound breakdown. All animals underwent detailed neurological evaluations, MRI, and postmortem histological analysis. RESULTS No neurological deficits were noted after intraventricular methotrexate infusions. Magnetic resonance images demonstrated catheter placement within the fourth ventricle and no signal changes in the brainstem or cerebellum. Histologically, two Group I animals, one of which did not receive methotrexate, had several small focal areas of brainstem injury. Two Group II animals had a small (≤ 1-mm) focus of axonal degeneration in the midbrain. Intraventricular and meningeal inflammation was noted in 4 animals after methotrexate infusions (one from Group I and all three from Group II). In all Group II animals, inflammation extended minimally into brainstem parenchyma. Serum methotrexate levels were undetectable or negligible in both groups, ranging from 0.00 to 0.06 μmol/L. In Group I, the mean peak methotrexate level in fourth ventricle CSF exceeded that in the lumbar CSF by greater than 10-fold. Statistically significant differences between fourth ventricle and lumbar AUC (area under the concentration-time curve) were detected at peaks (p = 0.04) but not at troughs (p = 0.50) or at all time collection points (p = 0.12). In Group II, peak fourth ventricle CSF methotrexate levels ranged from 84.62 to 167.89 μmol/L (mean 115.53 ± 15.95 μmol/L [SD]). Trough levels ranged from 0.06 to 0.55 μmol/L (mean 0.22 ± 0.13 μmol/L). CONCLUSIONS Methotrexate can be infused into the fourth ventricle in nonhuman primates without clinical or radiographic evidence of injury. Observed inflammatory and other histological changes had no clinical correlate. This approach may have pharmacokinetic advantages over current treatment paradigms. Further experiments are warranted to determine if fourth ventricular chemotherapy infusions may benefit patients with malignant fourth ventricular tumors.
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Affiliation(s)
- David I Sandberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
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Neoplastic meningitis resulting from hematological malignancies: pharmacokinetic considerations and maximizing outcome. ACTA ACUST UNITED AC 2011; 1:1391-1402. [PMID: 22396850 DOI: 10.4155/cli.11.115] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neoplastic meningitis, also known as leptomeningeal metastases, is a complication of various types of cancer that occurs when tumor cells enter the cerebrospinal fluid (CSF), travel along CSF pathways and grow. Treatment options include drug delivery directly into the CNS or systemic administration for targeted action in the CNS. CNS drug delivery is limited by the blood-brain barrier and the blood-CSF barrier. It may be possible to partially overcome this by using high-dose systemic therapy; however, this is done at the possible expense of increased systemic toxicity. Intra-CSF drug delivery bypasses the blood-brain barrier and allows direct access of the chemotherapeutic agent to the CSF. Because neoplastic meningitis occurs in an increasingly large percentage of all cancer patients, it is imperative to optimize drug delivery to the CSF and meninges. Both the pharmacokinetic profile of the chemotherapeutic agent and the site of administration influence therapeutic efficacy. Achieving prolonged therapeutic cytotoxic drug concentrations and even distribution in the CSF will improve efficacy. In this article we summarize data on the efficacy, safety and outcome of high-dose systemic and intra-CSF treatments.
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Interstitial brachytherapy using stereotactic implanted (125)iodine seeds for recurrent medulloblastoma. Clin Oncol (R Coll Radiol) 2011; 23:532-7. [PMID: 21440428 DOI: 10.1016/j.clon.2011.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 12/24/2010] [Accepted: 02/11/2011] [Indexed: 11/23/2022]
Abstract
AIMS To evaluate the efficacy of interstitial brachytherapy using (125)iodine ((125)I) seeds for the treatment of recurrent multimodal treated medulloblastoma. MATERIALS AND METHODS Between September 1989 and August 2009, 12 patients (female:male=3:9, median age 19 years, range 7-55 years) with 23 recurrent medulloblastomas underwent interstitial brachytherapy using (125)I seeds. Before brachytherapy, all patients underwent microsurgical resection; six patients underwent a combined adjuvant treatment consisting of craniospinal irradiation and chemotherapy; three received craniospinal irradiation alone and two received chemotherapy alone. One patient was treated by surgery alone. The median tumour volume was 4.9ml (range 0.4-44.2ml), the median tumour surface dose 50Gy (range 32-50Gy) and the median implantation time 42 days (range 42-90 days). A median follow-up of 26 months was available (range 5-116 months). RESULTS After brachytherapy, nine of 23 tumours (39%) presented a complete remission, nine (39%) a partial remission and five (22%) stable disease on magnetic resonance images. The neurological status improved in six patients and remained unchanged in four. Two patients deteriorated: one developed spinal metastasis and another a treatment-related adverse radiation effect. Ten patients died due to disseminated disease despite local tumour control. The median survival after treatment was 15 months (range 5-68 months). CONCLUSIONS Our results show a good response of recurrent medulloblastoma after interstitial brachytherapy. High rates of tumour remission were yielded with low rates of treatment-related morbidity. Thus, (125)I seed brachytherapy should be considered as a treatment option for recurrent medulloblastoma.
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Beauchesne P. Intrathecal chemotherapy for treatment of leptomeningeal dissemination of metastatic tumours. Lancet Oncol 2010; 11:871-9. [PMID: 20598636 DOI: 10.1016/s1470-2045(10)70034-6] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Neoplastic meningitis consists of diffuse involvement of the leptomeninges by infiltrating cancer cells, and can be caused by systemic or primary CNS tumours, such as solid cancers or lymphoproliferative malignant disease. Neoplastic meningitis is characterised by multifocal neurological signs and symptoms. Thus, careful neurological examination is needed for diagnosis of secondary diffuse involvement. Survival of patients with neoplastic meningitis is short (3-4 months), although some patients have long-lasting remission. Because most patients with neoplastic meningitis have diffuse systemic disease, treatment is typically palliative. However, more aggressive treatments are available to low-risk patients, which could increase survival. Therefore, identification of low-risk patients is important. Intrathecal chemotherapy is currently the main treatment for patients with neoplastic meningitis, but optimum anticancer chemotherapy is being studied.
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Safety and pharmacokinetic analysis of methotrexate administered directly into the fourth ventricle in a piglet model. J Neurooncol 2010; 100:397-406. [PMID: 20440538 DOI: 10.1007/s11060-010-0210-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 04/14/2010] [Indexed: 10/19/2022]
Abstract
We have developed a piglet model to assess chemotherapy administration directly into the fourth ventricle as a potential treatment for medulloblastoma and other malignant posterior fossa tumors. The objective of this study was to assess safety and pharmacokinetics after methotrexate infusions into the fourth ventricle. Catheters were inserted into the fourth ventricle and lumbar cistern in five piglets. Two milligrams of Methotrexate (MTX) was infused into the fourth ventricle on five consecutive days. Safety was assessed by neurological examination, 4.7 T MRI, and post-mortem pathological analysis. MTX levels in serum and cerebrospinal fluid (CSF) were measured, and area under the concentration-time curve (AUC) was calculated for CSF samples. No neurological deficits were caused by MTX infusions. One piglet died from complications of anesthesia induction for MRI scanning. MRI scans showed accurate catheter placement without signal changes in the brainstem or cerebellum. One piglet had asymptomatic ventriculomegaly. Pathological analysis demonstrated meningitis and choroid plexitis consisting predominantly of CD-3 positive T-lymphocytes in all piglets and a small focal area of subependymal necrosis in one. In all piglets, mean peak MTX level in fourth ventricular CSF exceeded that in lumbar CSF by greater than five-fold. Serum MTX levels were undetectable or negligible. Statistically significant differences between fourth ventricle and lumbar AUC were detected at peaks (P = 0.01) and at all collection time points (P = 0.01) but not at troughs (P = 0.36). MTX can be infused into the fourth ventricle without clinical or radiographic evidence of damage. An inflammatory response without clinical correlate is observed. Significantly higher peak MTX levels are observed in the fourth ventricle than in the lumbar cistern.
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Sandberg DI, Crandall KM, Koru-Sengul T, Padgett KR, Landrum J, Babino D, Petito CK, Solano J, Gonzalez-Brito M, Kuluz JW. Pharmacokinetic analysis of etoposide distribution after administration directly into the fourth ventricle in a piglet model. J Neurooncol 2009; 97:25-32. [PMID: 19688296 DOI: 10.1007/s11060-009-9998-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 08/10/2009] [Indexed: 11/28/2022]
Abstract
We hypothesize that infusion of chemotherapeutic agents directly into the fourth ventricle potentially may play a role in treating malignant posterior fossa brain tumors. Accordingly, we used a piglet model developed in our laboratory to test the safety of etoposide infusions into the fourth ventricle and to study the pharmacokinetics associated with these infusions. In 5 piglets, closed-tip silicone catheters were inserted into the fourth ventricle and lumbar cistern. Five consecutive daily infusions of etoposide (0.5 mg) were administered via the fourth ventricle catheter. Serum and CSF from both catheters were sampled for measurement of etoposide level by reversed-phase high performance liquid chromatography (HPLC). For CSF samples, area under the concentration-time curve (AUC) was calculated. Piglets underwent daily neurological examinations, a 4.7 Tesla MRI scan, and then were sacrificed for post-mortem brain examination. No neurological deficits or signs of meningitis were caused by intraventricular chemotherapy infusions. MRI scans showed catheter placement within the fourth ventricle but no signal changes in the brain stem or cerebellum. In all piglets, the mean fourth ventricular CSF peak etoposide level exceeded the mean peak lumbar etoposide levels by greater than 10-fold. Statistically significant differences between fourth ventricle and lumbar AUC were noted at peaks (DeltaAUC = 3384196 ng h/ml with 95%CI: 1758625, 5009767, P = 0.0044) and at all collection time points (DeltaAUC = 1422977 ng h/ml with 95%CI: 732188, 2113766, P = 0.0046) but not at troughs (DeltaAUC = -29546 ng h/ml (95%CI: -147526, 88434.2, P = 0.5251). Serum etoposide was absent at two and four hours after intraventricular infusions in all animals. Pathological analysis demonstrated meningitis, choroid plexitis, and ependymitis in the fourth and occasionally lateral ventricles. Etoposide can be infused directly into the fourth ventricle without clinical or radiographic evidence of damage. Autopsy examination revealed ventriculitis and meningitis which did not have a clinical correlate. Etoposide does not distribute evenly throughout CSF spaces after administration into the fourth ventricle, and higher peak CSF levels are observed in the fourth ventricle than in the lumbar cistern.
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Affiliation(s)
- David I Sandberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine and Miami Children's Hospital, Ambulatory Care Building Suite 3109, Miami, FL 33155, USA.
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Sandberg DI, Crandall KM, Petito CK, Padgett KR, Landrum J, Babino D, He D, Solano J, Gonzalez-Brito M, Kuluz JW. Chemotherapy administration directly into the fourth ventricle in a new piglet model. Laboratory Investigation. J Neurosurg Pediatr 2008; 1:373-80. [PMID: 18447671 DOI: 10.3171/ped/2008/1/5/373] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors hypothesized that chemotherapy infusions directly into the fourth ventricle may potentially play a role in treating malignant posterior fossa tumors. In this study the safety and pharmacokinetics of etoposide administration into the fourth ventricle was tested using an indwelling catheter in piglets. METHODS A closed-tip silicone lumbar drain catheter was inserted into the fourth ventricle via a posterior fossa craniectomy and 5 daily infusions of etoposide (0.5 mg in 5 animals) or normal saline (in 2 animals) were instilled. Piglets (10-18 kg, 2-3 months of age) underwent daily neurological examinations and 4.7-T magnetic resonance (MR) imaging after the final infusion and were then killed for postmortem examination. Pharmacokinetics were studied using reversed-phase high-performance liquid chromatography on cerebrospinal fluid (CSF) samples at 0.25, 1, 2, 4, 8, 12, and 24 hours after etoposide infusion. Peak and trough CSF etoposide levels were measured for each subsequent infusion. Serum etoposide levels were obtained at 2 and 4 hours after infusion. RESULTS All piglets remained neurologically intact, and MR images demonstrated catheter placement within the fourth ventricle without signal changes in the brainstem or cerebellum. Serum etoposide was absent at 2 and 4 hours after intraventricular infusions. When adequate samples could be obtained for analysis, CSF etoposide levels peaked 15 minutes after infusion and progressively decreased. Cytotoxic levels (> 0.1 microg/ml) were maintained for 5 consecutive peak and trough measurements with 1 exception. Etoposide-related neuropathology included moderate-to-severe T-lymphocytic meningitis and fourth and lateral ventricular choroid plexitis with associated subependymal inflammation. CONCLUSIONS Etoposide can be infused directly into the fourth ventricle without clinical or imaging evidence of damage. Cytotoxic CSF etoposide levels can be maintained for 24 hours with a single daily infusion into the fourth ventricle using an indwelling catheter. Intraventricular etoposide elicits an inflammatory response, the long-term effects of which are as yet undetermined.
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Affiliation(s)
- David I Sandberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine and Miami Children's Hospital, Miami, Florida 33155, USA.
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Abstract
Intrathecal administration of chemotherapy, with or without radiation therapy, is the primary treatment modality for the prevention and treatment of central nervous system (CNS) metastases in patients with leukemia or lymphoma. Although this treatment strategy has been very effective for patients with hematological malignancies, currently available intrathecal agents are relatively ineffective for patients with neoplastic meningitis resulting from an underlying solid or CNS tumor effective. This article provides an overview of some of the practical considerations and limitations associated with intrathecal chemotherapy, and is followed by a comprehensive review of some of the preclinical and early phase clinical trials of novel anticancer agents and treatment strategies using the intrathecal route.
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Affiliation(s)
- Stacie Stapleton
- Pediatric Hematology/Oncology, Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
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Chamberlain MC, Tsao-Wei DD, Groshen S. Phase II trial of intracerebrospinal fluid etoposide in the treatment of neoplastic meningitis. Cancer 2006; 106:2021-7. [PMID: 16583432 DOI: 10.1002/cncr.21828] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The purpose of the current study was to determine the toxicity and response of a fixed dose intracerebrospinal fluid (CSF) etoposide in the treatment of patients with newly diagnosed neoplastic meningitis (NM). NM reportedly occurs in 1% to 5% of patients with known cancer. Currently available treatment options are limited and provide only modest benefit. METHODS Twenty-seven patients (median age, 55 yrs) with clinically and cytologically documented NM received intra-CSF etoposide. Tumor histologies included lung (8 patients), breast (5 patients), primary brain tumor (4 patients), non-Hodgkin lymphoma (4 patients), melanoma (4 patients), colon (1 patient), and prostate (1 patient). Concurrent involved-field radiotherapy (19 of 27 patients) or systemic chemotherapy (17 of 27 patients) was administered based on clinical indications. Etoposide was administered at a fixed dose (0.5 mg every day given 5 days per week every other week for 8 weeks [induction]). Patients were evaluated by CSF cytology and neurologic examination at the conclusion of induction therapy. Responding patients continued to receive etoposide (5 consecutive days every 4 weeks) with monthly evaluations. RESULTS Seven of 27 patients (26%) treated with etoposide had a cytologic response and either stable or improved neurologic status at the conclusion of induction. Eight patients (30%) developed disease progression during induction therapy and did not complete the 8-week induction course of therapy. At the conclusion of induction therapy, 12 patients (44%) had persistently positive CSF cytology, although they were clinically stable. In responding patients, time to neurologic disease progression ranged from 8 weeks to 40 weeks (median, 20 wks). Toxicity manifested as transient chemical arachnoiditis (5 of 27 patients; 13% of all treatment cycles). The 6-month neurologic disease progression-free survival was 11%. CONCLUSIONS Etoposide appears to have modest activity against NM and easily managed toxicity.
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Affiliation(s)
- Marc C Chamberlain
- Department of Interdisciplinary Oncology, Moffitt Cancer Center and Research Institute, Tampa, Florida 33612, USA.
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Huynh GH, Deen DF, Szoka FC. Barriers to carrier mediated drug and gene delivery to brain tumors. J Control Release 2006; 110:236-259. [PMID: 16318895 DOI: 10.1016/j.jconrel.2005.09.053] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2005] [Accepted: 09/29/2005] [Indexed: 01/18/2023]
Abstract
Brain tumor patients face a poor prognosis despite significant advances in tumor imaging, neurosurgery and radiation therapy. Potent chemotherapeutic drugs fail when used to treat brain tumors because biochemical and physiological barriers limit drug delivery into the brain. In the past decade a number of strategies have been introduced to increase drug delivery into the brain parenchyma. In particular, direct drug administration into the brain tumor has shown promising results in both animal models and clinical trials. This technique is well suited for the delivery of liposome and polymer drug carriers, which have the potential to provide a sustained level of drug and to reach cellular targets with improved specificity. We will discuss the current approaches that have been used to increase drug delivery into the brain parenchyma in the context of fluid and solute transport into, through and from the brain, with a focus on liposome and polymer drug carriers.
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Affiliation(s)
- Grace H Huynh
- Joint Graduate Group in Bioengineering, University of California at San Francisco and Berkeley San Francisco, CA 94143-0446, United States
| | - Dennis F Deen
- Brain Tumor Research Center of the Department of Neurological Surgery, University of California at San Francisco, San Francisco, CA 94143-0520, United States
| | - Francis C Szoka
- Joint Graduate Group in Bioengineering, University of California at San Francisco and Berkeley San Francisco, CA 94143-0446, United States; Departments of Pharmaceutical Chemistry and Biopharmaceutical Sciences, University of California at San Francisco, San Francisco, CA 94143-0446, United States.
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Fleischhack G, Jaehde U, Bode U. Pharmacokinetics Following Intraventricular Administration of Chemotherapy in Patients with Neoplastic Meningitis. Clin Pharmacokinet 2005; 44:1-31. [PMID: 15634030 DOI: 10.2165/00003088-200544010-00001] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Intraventricular administration of chemotherapy is one approach to overcoming the limited distribution of anticancer drugs and their active metabolites into the CNS. This form of regional chemotherapy has led to effective treatment of occult and overt meningeal leukaemia in humans. In contrast, the efficacy of this therapy is extremely limited in the treatment of leptomeningeal dissemination of various solid tumours. Pharmacokinetic studies of the commonly intraventricularly applied anticancer agents in humans have demonstrated that, using low drug doses, very high drug concentrations can be achieved in the cerebrospinal fluid (CSF) and relatively high concentrations in the leptomeninges but not in the brain tissue and the plasma. Therefore, this approach is not an effective treatment for bulky disease of brain tissue, and results in minimal systemic toxicity. In comparison with intralumbar administration, lower interpatient variability of CSF drug concentrations and improved clinical efficacy were observed. 'Concentration x time' schedules, i.e. frequent small drug doses over a short period, enable long-term CSF exposure to cytotoxic drug concentrations while avoiding excessively high and potentially neurotoxic drug concentrations. The technique of ventriculolumbar cerebrospinal perfusion delivers continuously high drug concentrations throughout the CSF for several hours, but its widespread use is limited by the technical complexities of this approach. In this article, the dosages, schedules and pharmacokinetic data of routinely used intraventricular agents in humans, e.g. methotrexate, cytarabine, glucocorticoids and thiotepa, are outlined in detail. In addition, pharmacokinetic data of investigational agents for intraventricular administration (diaziquone, DTC 101, mercaptopurine, mafosfamide, etoposide, topotecan, nimustine [ACNU] and bleomycin) are presented. Better understanding of the CSF pharmacology of these drugs is an essential prerequisite for safe, effective administration of these drugs. Investigational efforts are underway to verify the feasibility and efficacy of different dosages, schedules and combination therapies of these new intra-CSF agents. Current and future clinical research should also focus on methods allowing the delivery of tumoricidal drug concentrations for extended periods into the CSF and the brain tissue while minimising neurotoxicity and systemic toxicity (e.g. liposomal drug preparations, monoclonal antibodies, immunotoxins and gene therapy).
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Affiliation(s)
- Gudrun Fleischhack
- Department of Paediatric Haematology/Oncology, University of Bonn, Adenauerallee 119, Bonn, D-53113, Germany.
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Slavc I, Schuller E, Falger J, Günes M, Pillwein K, Czech T, Dietrich W, Rössler K, Dieckmann K, Prayer D, Hainfellner J. Feasibility of long-term intraventricular therapy with mafosfamide (n = 26) and etoposide (n = 11): experience in 26 children with disseminated malignant brain tumors. J Neurooncol 2003; 64:239-47. [PMID: 14558599 DOI: 10.1023/a:1025633704071] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Treatment options for leptomeningeal disseminated brain tumors are limited by the lack of effective drugs for intrathecal therapy of non-hematologic malignancies. We report on our experience with an intraventricular therapy consisting of mafosfamide, a preactivated cyclophosphamide derivative, and etoposide. Between May 1994 and 2002, 26 patients aged 2-19 years with various intensely pretreated disseminated brain tumors received intraventricular mafosfamide via an indwelling subcutaneous reservoir. Twenty-three of them received a dose of 20 mg. Mafosfamide was administered once or twice weekly until remission was achieved and every 2-6 weeks thereafter as maintenance therapy for a total of 736 administrations (2-63/patient). Since March 1998, two patients were switched to receive intraventricular etoposide and nine received etoposide alternating with mafosfamide. Etoposide was given at a dose of 0.5 mg x 5 d every 3-6 weeks for a total of 122 courses (1-29/patient). Immediate toxicities such as transient headaches, nausea, and vomiting occurred with mafosfamide but were manageable with premedication. Etoposide did not cause any discomfort. No long-term toxicities attributable to intrathecal therapy as evidenced by magnetic resonance imaging or neurologic evaluation were observed. Since all patients received some sort of concurrent anti-cancer therapy, the efficacy of intrathecal therapy cannot be assessed independently. However, seven of 13 patients evaluable for response by cerebrospinal fluid (CSF) cytology developed CSF dissemination under systemic chemotherapy and cleared their CSF only after administration of intrathecal mafosfamide. In conclusion, intraventricularly administered mafosfamide at a dose of 20 mg and etoposide at a dose of 0.5 mg x 5 d for patients over 2 years of age are feasible and safe and may produce responses.
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Affiliation(s)
- Irene Slavc
- Department of Pediatrics, University of Vienna, Vienna, Austria.
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