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Vo KT, Sabnis AJ, Williams PM, Roy-Chowdhuri S, Patton DR, Coffey B, Reid JM, Piao J, Saguilig L, Alonzo TA, Berg SL, Jaju A, Fox E, Weigel BJ, Hawkins DS, Mooney MM, Takebe N, Tricoli JV, Janeway KA, Seibel NL, Parsons DW. Phase II Study of Ulixertinib in Children and Young Adults With Tumors Harboring Activating Mitogen-Activated Protein Kinase Pathway Alterations: APEC1621J of the National Cancer Institute-Children's Oncology Group Pediatric MATCH Trial. JCO Precis Oncol 2024; 8:e2400103. [PMID: 38935895 DOI: 10.1200/po.24.00103] [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: 02/16/2024] [Revised: 03/29/2024] [Accepted: 05/06/2024] [Indexed: 06/29/2024] Open
Abstract
PURPOSE The National Cancer Institute-Children's Oncology Group (NCI-COG) Pediatric MATCH trial assigns patients age 1-21 years with refractory malignancies to phase II treatment arms of molecularly targeted therapies on the basis of genetic alterations detected in their tumor. Patients with activating alterations in the mitogen-activated protein kinase pathway were treated with ulixertinib, an extracellular signal-regulated kinase (ERK)1/2 inhibitor. METHODS As there were no previous pediatric data, ulixertinib was initially tested in a dose escalation cohort to establish the recommended phase II dose (RP2D) before proceeding to the phase II cohort. Ulixertinib was administered at 260 mg/m2/dose orally twice a day (dose level 1 [DL1], n = 15) or 350 mg/m2/dose orally twice a day (DL2, n = 5). The primary end point was objective response rate; secondary end points included safety/tolerability and progression-free survival (PFS). RESULTS Twenty patients (median 12 years; range, 5-20) were treated, all evaluable for response. CNS tumors comprised 55% (11/20) of diagnoses, with high-grade glioma and low-grade glioma most common (n = 5 each). All CNS tumors except one harbored BRAF fusions or V600E mutations. Rhabdomyosarcoma (n = 5) was the most frequent non-CNS diagnosis. DL1 was declared the RP2D in the dose escalation cohort after dose-limiting toxicities in Cycle 1 occurred in 1/6 patients at DL1 and 2/5 patients at DL2, including fatigue, anorexia, rash, nausea, vomiting, diarrhea, dehydration, hypoalbuminemia, and hypernatremia. No objective responses were observed. Six-month PFS was 37% (95% CI, 17 to 58). Three patients with BRAF-altered CNS tumors achieved stable disease >6 months. CONCLUSION Ulixertinib, a novel targeted agent with no previous pediatric data, was successfully evaluated in a national precision medicine basket trial. The pediatric RP2D of ulixertinib is 260 mg/m2/dose orally twice a day. Limited single-agent efficacy was observed in a biomarker-selected cohort of refractory pediatric tumors.
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Affiliation(s)
- Kieuhoa T Vo
- Department of Pediatrics, University of California, San Francisco School of Medicine, UCSF Benioff Children's Hospital, San Francisco, CA
| | - Amit J Sabnis
- Department of Pediatrics, University of California, San Francisco School of Medicine, UCSF Benioff Children's Hospital, San Francisco, CA
| | | | | | - David R Patton
- Center for Biomedical Informatics and Information Technology, NCI, NIH, Bethesda, MD
| | - Brent Coffey
- Center for Biomedical Informatics and Information Technology, NCI, NIH, Bethesda, MD
| | | | - Jin Piao
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Todd A Alonzo
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Stacey L Berg
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX
| | - Alok Jaju
- Ann and Robert H. Lurie Children's Hospital, Chicago, IL
| | | | - Brenda J Weigel
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Douglas S Hawkins
- Seattle Children's Hospital and University of Washington, Seattle, WA
| | - Margaret M Mooney
- Division of Cancer Treatment and Diagnosis, Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, MD
| | - Naoko Takebe
- Division of Cancer Treatment and Diagnosis, Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, MD
| | - James V Tricoli
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| | | | - Nita L Seibel
- Division of Cancer Treatment and Diagnosis, Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, MD
| | - D Williams Parsons
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX
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Bahabri A, Abla O. Advances in our understanding of genetic markers and targeted therapies for pediatric LCH. Expert Rev Hematol 2024; 17:223-231. [PMID: 38721670 DOI: 10.1080/17474086.2024.2353772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/07/2024] [Indexed: 05/12/2024]
Abstract
INTRODUCTION Langerhans cell histiocytosis (LCH) is a rare myeloid neoplasm, encompassing a diverse clinical spectrum ranging from localized bone or skin lesions to a multisystemic life-threatening condition. Over the past decade, there has been an expansion in understanding the molecular biology of LCH, which translated into innovative targeted therapeutic approaches. AREAS COVERED In this article, we will review the molecular alterations observed in pediatric LCH and the relationship between these molecular changes and the clinical phenotype, as well as targeted therapies in LCH. EXPERT OPINION Mitogen-activated protein kinase (MAPK) pathway mutation is a hallmark of LCH and is identified in 80% of the cases. Notably, BRAFV600E mutation is seen in ~50-60% of the cases, ~30% has other MAPK pathway mutations, while 15-20% have no detected mutations. While the first line therapeutic approach is vinblastine and prednisone, targeted therapies - specifically BRAF/MEK inhibitors - emerged as a promising second-line salvage strategy, particularly when a mutation is identified. Most patients respond to BRAF/MEK inhibitors but at least 75% reactivate after stopping, however, most patients respond again when restarting inhibitors.
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Affiliation(s)
- Aban Bahabri
- Division of Haematology-Oncology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Division of Haematology-Oncology, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Oussama Abla
- Division of Haematology-Oncology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Morimoto A, Sakamoto K, Kudo K, Shioda Y. [Central nervous system disorders secondary to histiocytoses: neurodegeneration with potential for improvement]. Rinsho Shinkeigaku 2024; 64:85-92. [PMID: 38281751 DOI: 10.5692/clinicalneurol.cn-001899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Histiocytoses, including Langerhans cell histiocytosis (LCH) and Erdheim-Chester disease (ECD), are inflammatory myeloid tumors in which monocyte lineage cells aggregate in various organs, causing tissue damage. Most of these tumors harbor oncogenic mutations in mitogen-activated protein kinase (MAPK) pathway genes, typified by BRAFV600E. Some patients with LCH develop bilateral symmetrical cerebellar lesions and brain atrophy several years after diagnosis when the initial symptoms disappear, leading to cerebellar ataxia and higher cerebral dysfunction. A similar neurological disorder has also been reported in ECD. This neurological disorder can be improved with MAPK inhibitors. When patients with this neurological disorder are identified among neurodegeneration of unknown etiology or histiocytosis patients and treated early with MAPK inhibitors, the disorder can be reversible.
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Affiliation(s)
| | | | - Ko Kudo
- Department of Pediatrics, Hirosaki University School of Medicine
| | - Yoko Shioda
- Children's Cancer Center, National Center for Child Health and Development
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Lei J, Wang W, Lin D, Zhu C, Jia W, Weng W, Liu X, Ma Y, Wang Z, Yang L, He X, He Y, Li Y. Vemurafenib combined with chemotherapy achieved sustained remission in pediatric LCH: a multi-center observational study. J Cancer Res Clin Oncol 2024; 150:12. [PMID: 38231288 PMCID: PMC10794359 DOI: 10.1007/s00432-023-05551-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 12/14/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Langerhans cell histiocytosis (LCH) is a myeloid neoplasia with potentially fatal consequences, and about 2/3 of cases involve the BRAFV600E kinase-activated mutation. Vemurafenib, a BRAF inhibitor, has demonstrated significant clinical improvements in LCH. However, the high relapse rate of LCH following cessation of vemurafenib therapy remains a major challenge, and alternative treatment strategies require further investigation. METHODS In this retrospective multi-center study, we evaluated the efficacy and safety of vemurafenib combined with conventional chemotherapy in patients with severe or refractory LCH. RESULTS Seventeen patients were enrolled in the study, with eleven classified as risk organ involvement (RO +). Six received the combination therapy as the primary treatment, and eleven after being refractory to prior chemotherapy. The overall response rate was 94.1%. Progression-free survival among all 17 patients was 70.6% (12/17) at a median follow-up of 32 months, and relapse-free survival among the 15 patients with discontinuation after a response was 73.3%(11/15) at a median follow-up of 34 months. Five of six patients (83.3%) with myeloid BRAFV600E mutations demonstrated molecular remission. The overall survival rate was 100%. Adverse events were mostly classified as grades 1 or 2. CONCLUSION Our data suggest that the combination of vemurafenib and chemotherapy can achieve sustained clinical and molecular level relief in children with LCH, and side effects are tolerable.
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Affiliation(s)
- Jiaying Lei
- Department of Pediatric Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Wenxia Wang
- Department of Pediatric Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Danna Lin
- Department of Pediatric Hematology and Critical Care Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510280, China
| | - Chengguang Zhu
- Department of Pediatric Hematology and Oncology, Hunan Provincial People's Hospital, Changsha, 410005, China
| | - Wenguang Jia
- The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Wenjun Weng
- Department of Pediatric Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Xiaoshan Liu
- Department of Pediatric Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Yuhan Ma
- Department of Pediatric Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Zhixuan Wang
- Department of Pediatric Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Lihua Yang
- Department of Pediatric Hematology and Critical Care Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510280, China.
| | - Xiangling He
- Department of Pediatric Hematology and Oncology, Hunan Provincial People's Hospital, Changsha, 410005, China.
| | - Yunyan He
- The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China.
| | - Yang Li
- Department of Pediatric Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China.
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Banks SA, Sartori Valinotti JC, Go RS, Abeykoon JP, Goyal G, Young JR, Koster MJ, Vassallo R, Ryu JH, Davidge-Pitts CJ, Ravindran A, Bennani NN, Shah MV, Rech KL, Tobin WO. Neurological Manifestations of Histiocytic Disorders. Curr Neurol Neurosci Rep 2023; 23:277-286. [PMID: 37209319 DOI: 10.1007/s11910-023-01272-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE OF REVIEW Histiocytic disorders, including Erdheim-Chester disease (ECD), Langerhans cell histiocytosis (LCH), and Rosai-Dorfman disease (RDD), are rare neoplasms that may present with a spectrum of neurologic involvement. Diagnostic delay is common due to heterogeneity in presentation and challenging pathology. RECENT FINDINGS Recent advances in the treatment of these diseases targeted towards mutations in the MAP kinase pathway have led to an improved prognosis in these patients with neurologic involvement. It is critical for clinicians to have a high index of suspicion to allow for early targeted treatment and optimize neurologic outcomes. A systematic approach to diagnosis is presented in this article to allow for accurate diagnosis of these rare diseases.
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Affiliation(s)
- Samantha A Banks
- Department of Neurology, Mayo Clinic Rochester, 200 First St SW, Rochester, MN, 55905, USA
| | | | - Ronald S Go
- Division of Hematology, Mayo Clinic Rochester, Rochester, MN, USA
| | | | - Gaurav Goyal
- Division of Hematology-Oncology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jason R Young
- Department of Radiology, Mayo Clinic in Jacksonville, Jacksonville, FL, USA
| | - Matthew J Koster
- Division of Rheumatology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Robert Vassallo
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Jay H Ryu
- Division of Hematology, Mayo Clinic Rochester, Rochester, MN, USA
| | | | - Aishwarya Ravindran
- Division of Laboratory Medicine-Hematopathology, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - N Nora Bennani
- Division of Hematology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Mithun V Shah
- Division of Hematology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Karen L Rech
- Division of Hematopathology, Mayo Clinic Rochester, Rochester, MN, USA
| | - W Oliver Tobin
- Department of Neurology, Mayo Clinic Rochester, 200 First St SW, Rochester, MN, 55905, USA.
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Koh YK, Yoon SH, Kang SH, Kim H, Im HJ, Kim PH, Jung AY, Koh KN. Improvement of Neurodegenerative Disease after Use of Vemurafenib in Refractory BRAF V600E-Mutated Langerhans Cell Histiocytosis: A Case Report. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2022. [DOI: 10.15264/cpho.2022.29.2.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Young Kwon Koh
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Su Hyun Yoon
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Han Kang
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyery Kim
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho Joon Im
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Pyeong Hwa Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ah Young Jung
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung-Nam Koh
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
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