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O’Halloran K, Phadnis S, Friedman GK, Metrock K, Davidson TB, Robison NJ, Tamrazi B, Cotter JA, Dhall G, Margol AS. Effective re-induction regimen for children with recurrent medulloblastoma. Neurooncol Adv 2024; 6:vdae070. [PMID: 38863988 PMCID: PMC11165644 DOI: 10.1093/noajnl/vdae070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024] Open
Abstract
Background There is no standard treatment for the recurrence of medulloblastoma, the most common malignant childhood brain tumor, and prognosis remains dismal. In this study, we introduce a regimen that is well-tolerated and effective at inducing remission. Methods The primary objectives of this study were to assess tolerability of the regimen and overall response rate (ORR). A retrospective chart review of patients with recurrent medulloblastoma, treated at two institutions with a re-induction regimen of intravenous irinotecan and cyclophosphamide with oral temozolomide and etoposide, was performed. Demographic, clinicopathologic, toxicity, and response data were collected and analyzed. Results Nine patients were identified. Median age was 5.75 years. Therapy was well-tolerated with no therapy-limiting toxicities and no toxic deaths. Successful stem cell collection was achieved in all 5 patients in whom it was attempted. ORR after 2 cycles was 78%. Three patients had a complete response, 4 patients had a partial response, 1 patient had stable disease, and 1 patient had progressive disease. Four patients are alive with no evidence of disease (NED), 2 patients are alive with disease, 2 patients have died of disease, and 1 patient died of toxicity related to additional therapy (NED at time of death). Conclusions This regimen is well-tolerated and effective. Tumor response was noted in the majority of cases, allowing patients to proceed to additional treatment with no or minimal disease. Further study of this regimen in a clinical trial setting is an important next step.
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Affiliation(s)
- Katrina O’Halloran
- Keck School of Medicine of University of Southern California, Los Angeles, California, USA
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Sheetal Phadnis
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Pediatrics, Children’s of Alabama, Birmingham, Alabama, USA
| | - Gregory K Friedman
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Pediatrics, Children’s of Alabama, Birmingham, Alabama, USA
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katie Metrock
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Pediatrics, Children’s of Alabama, Birmingham, Alabama, USA
| | - Tom B Davidson
- Keck School of Medicine of University of Southern California, Los Angeles, California, USA
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Nathan J Robison
- Keck School of Medicine of University of Southern California, Los Angeles, California, USA
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Benita Tamrazi
- Keck School of Medicine of University of Southern California, Los Angeles, California, USA
- Department of Radiology, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Jennifer A Cotter
- Keck School of Medicine of University of Southern California, Los Angeles, California, USA
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Girish Dhall
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Pediatrics, Children’s of Alabama, Birmingham, Alabama, USA
| | - Ashley S Margol
- Keck School of Medicine of University of Southern California, Los Angeles, California, USA
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California, USA
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Peyrl A, Chocholous M, Sabel M, Lassaletta A, Sterba J, Leblond P, Nysom K, Torsvik I, Chi SN, Perwein T, Jones N, Holm S, Nyman P, Mörse H, Öberg A, Weiler-Wichtl L, Leiss U, Haberler C, Schmook MT, Mayr L, Dieckmann K, Kool M, Gojo J, Azizi AA, André N, Kieran M, Slavc I. Sustained Survival Benefit in Recurrent Medulloblastoma by a Metronomic Antiangiogenic Regimen: A Nonrandomized Controlled Trial. JAMA Oncol 2023; 9:1688-1695. [PMID: 37883081 PMCID: PMC10603581 DOI: 10.1001/jamaoncol.2023.4437] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/27/2023] [Indexed: 10/27/2023]
Abstract
Importance Medulloblastoma recurrence in patients who have previously received irradiation has a dismal prognosis and lacks a standard salvage regimen. Objective To evaluate the response rate of pediatric patients with medulloblastoma recurrence using an antiangiogenic metronomic combinatorial approach (Medulloblastoma European Multitarget Metronomic Anti-Angiogenic Trial [MEMMAT]). Design, Setting, and Participants This phase 2, investigator-initiated, multicenter nonrandomized controlled trial assessed 40 patients with relapsed or refractory medulloblastoma without a ventriculoperitoneal shunt who were younger than 20 years at original diagnosis. Patients were enrolled between April 1, 2014, and March 31, 2021. Interventions Treatment consisted of daily oral thalidomide, fenofibrate, celecoxib, and alternating 21-day cycles of low-dose (metronomic) oral etoposide and cyclophosphamide, supplemented by intravenous bevacizumab and intraventricular therapy consisting of alternating etoposide and cytarabine. Main Outcomes and Measures The primary end point was response after 6 months of antiangiogenic metronomic therapy. Secondary end points included progression-free survival (PFS), overall survival (OS), and quality of life. Adverse events were monitored to assess safety. Results Of the 40 patients (median [range] age at treatment start, 10 [4-17] years; 25 [62.5%] male) prospectively enrolled, 23 (57.5%) achieved disease control after 6 months of treatment, with a response detected in 18 patients (45.0%). Median OS was 25.5 months (range, 10.9-40.0 months), and median PFS was 8.5 months (range, 1.7-15.4 months). Mean (SD) PFS at both 3 and 5 years was 24.6% (7.9%), while mean (SD) OS at 3 and 5 years was 43.6% (8.5%) and 22.6% (8.8%), respectively. No significant differences in PFS or OS were evident based on molecular subgroup analysis or the number of prior recurrences. In patients demonstrating a response, mean (SD) overall 5-year PFS was 49.7% (14.3%), and for patients who remained progression free for the first 12 months of treatment, mean (SD) 5-year PFS was 66.7% (16.1%). Treatment was generally well tolerated. Grade 3 to 4 treatment-related adverse events included myelosuppression, infections, seizures, and headaches. One heavily pretreated patient with a third recurrence died of secondary acute myeloid leukemia. Conclusions and Relevance This feasible and well-tolerated MEMMAT combination regimen demonstrated promising activity in patients with previously irradiated recurrent medulloblastoma. Given these results, this predominantly oral, well-tolerated, and outpatient treatment warrants further evaluation. Trial Registration ClinicalTrials.gov Identifier: NCT01356290.
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Affiliation(s)
- Andreas Peyrl
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Monika Chocholous
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Magnus Sabel
- Childhood Cancer Centre, Queen Silvia Children’s Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Alvaro Lassaletta
- Department of Pediatric Neuro-Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Jaroslav Sterba
- Pediatric Oncology Department, University Hospital Brno, Brno, Czech Republic
| | - Pierre Leblond
- Pediatric Oncology Unit, Oscar Lambret Comprehensive Cancer Center, Lille, France
- Centre Léon Bérard, Institut d’Hématologie et d’Oncologie Pediatrique, Lyon, France
| | - Karsten Nysom
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Ingrid Torsvik
- Department of Paediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Susan N. Chi
- Department of Pediatric Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Thomas Perwein
- Division of Pediatric Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Neil Jones
- Kinderonkologie, Salzburger Universitätsklinikum, Salzburg, Austria
| | - Stefan Holm
- Department of Pediatric Hematology and Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Per Nyman
- Department of Paediatrics, Linköping University Hospital, Linköping, Sweden
| | - Helena Mörse
- Pediatric Cancer Center, Skane University Hospital, Lund, Sweden
| | - Anders Öberg
- Department of Pediatrics, Uppsala University, Uppsala, Sweden
| | - Liesa Weiler-Wichtl
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Ulrike Leiss
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | | | - Maresa T. Schmook
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria
| | - Lisa Mayr
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Karin Dieckmann
- Department of Radio-Oncology, Medical University of Vienna, Vienna, Austria
| | - Marcel Kool
- Hopp Children’s Cancer Center (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Johannes Gojo
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Amedeo A. Azizi
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Nicolas André
- Départment of Pediatric Oncology, Assistance Publique-Hopitaux de Marseille, Marseille, France
- Aix Marseille University, Cancer Research Center of Marseille, Marseille, France
| | - Mark Kieran
- Department of Pediatric Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Irene Slavc
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
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Lazow MA, Palmer JD, Fouladi M, Salloum R. Medulloblastoma in the Modern Era: Review of Contemporary Trials, Molecular Advances, and Updates in Management. Neurotherapeutics 2022; 19:1733-1751. [PMID: 35859223 PMCID: PMC9723091 DOI: 10.1007/s13311-022-01273-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 12/13/2022] Open
Abstract
Critical discoveries over the past two decades have transformed our understanding of medulloblastoma from a single entity into a clinically and biologically heterogeneous disease composed of at least four molecularly distinct subgroups with prognostically and therapeutically relevant genomic signatures. Contemporary clinical trials also have provided valuable insight guiding appropriate treatment strategies. Despite therapeutic and biological advances, medulloblastoma patients across the age spectrum experience tumor- and treatment-related morbidity and mortality. Using an updated risk stratification approach integrating both clinical and molecular features, ongoing research seeks to (1) cautiously reduce therapy and mitigate toxicity in low-average risk patients, and (2) thoughtfully intensify treatment with incorporation of novel, biologically guided agents for patients with high-risk disease. Herein, we review important historical and contemporary studies, discuss management updates, and summarize current knowledge of the biological landscape across unique pediatric, infant, young adult, and relapsed medulloblastoma populations.
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Affiliation(s)
- Margot A Lazow
- Pediatric Brain Tumor Program, Division of Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joshua D Palmer
- The Ohio State University College of Medicine, Columbus, OH, USA
- The James Cancer Centre, Ohio State University, Columbus, OH, USA
| | - Maryam Fouladi
- Pediatric Brain Tumor Program, Division of Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Ralph Salloum
- Pediatric Brain Tumor Program, Division of Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
- The Ohio State University College of Medicine, Columbus, OH, USA.
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Development of a Hospital Compounded, Taste-Masked, Temozolomide Oral Suspension and 5-Year Real-Life Experience in Treating Paediatric Patients. Pharmaceuticals (Basel) 2022; 15:ph15050555. [PMID: 35631381 PMCID: PMC9146721 DOI: 10.3390/ph15050555] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/14/2022] [Accepted: 04/26/2022] [Indexed: 11/16/2022] Open
Abstract
The development of oral pediatric forms by pharmaceutical companies is still insufficient. In fact, many drugs used in paediatric oncology, such as temozolomide, are not labeled and adapted for paediatric use. Temozolomide (TMZ) is an alkylating agent used as the standard of care for many adult and pediatric brain tumours, such as neuroblastoma, glioblastoma and medulloblastoma. The present study was carried out to propose a suitable and palatable formulation of the oral liquid preparation of TMZ. The suspension is composed of TMZ suspended in SyrSpend SF pH 4, as well as TMZ crystallization stabilizing agents and sweetening agents. To reach this formulation, several taste-masking agents were evaluated. Here, we describe the method of preparation of the formation as well as the monocentric population treated with the formulation over a 5–year period. A 20 mg/mL TMZ suspension was developed. TMZ suspension is stable for 6 weeks, stored between 2 and 8 degrees, protected from light, and compatible with nasogastric tubes. Thirty-eight patients participated in the palatability study and choose cola flavour, and 104 patients were treated in Gustave Roussy with the developed suspension; no unexpected event was reported. To conclude, we propose here a new TMZ liquid formulation which is stable for at least 6 weeks and well-tolerated with extensive feedback.
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Pharmacokinetics of metronomic temozolomide in cerebrospinal fluid of children with malignant central nervous system tumors. Cancer Chemother Pharmacol 2022; 89:617-627. [PMID: 35355137 PMCID: PMC9054874 DOI: 10.1007/s00280-022-04424-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/13/2022] [Indexed: 11/24/2022]
Abstract
Purpose Although temozolomide is widely used in the treatment of childhood central nervous system (CNS) tumors, information on its pharmacokinetic profile in the brain or cerebrospinal fluid (CSF) is sparse. This study aimed at investigating whether measurable and clinically relevant concentrations of temozolomide are reached and maintained in CSF for continuous oral administration in pediatric patients. A population pharmacokinetic model was developed to quantify CSF penetration of temozolomide. Methods Eleven pediatric CNS tumor patients (aged 4–14 years) treated with oral temozolomide using a metronomic schedule (24–77 mg/m2/day) were included. Temozolomide concentrations in 28 plasma samples and 64 CSF samples were analyzed by high-performance liquid chromatography. Population pharmacokinetic modeling and simulations were performed using non-linear mixed effects modeling (NONMEM 7.4.2). Results Median temozolomide concentrations in plasma and CSF were 0.96 (range 0.24–5.99) µg/ml and 0.37 (0.06–1.76) µg/ml, respectively. A two-compartment model (central/plasma [1], CSF [2]) with first-order absorption, first-order elimination, and a transit compartment between CSF and plasma adequately described the data. Population mean estimates for clearance (CL) and the volume of distribution in the central compartment (Vc) were 3.29 L/h (95% confidence interval (CI) 2.58–3.95) and 10.5 L (8.17–14.32), respectively. Based on simulations, we found a median area under the concentration vs. time curve ratio (AUCCSF / AUCplasma ratio) of 37%. Conclusion Metronomic oral temozolomide penetrates into the CSF in pediatric patients, with even higher concentration levels compared to adults. Supplementary Information The online version contains supplementary material available at 10.1007/s00280-022-04424-4.
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Local and Systemic Therapy of Recurrent Medulloblastomas in Children and Adolescents: Results of the P-HIT-REZ 2005 Study. Cancers (Basel) 2022; 14:cancers14030471. [PMID: 35158738 PMCID: PMC8833340 DOI: 10.3390/cancers14030471] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/10/2022] [Accepted: 01/14/2022] [Indexed: 12/21/2022] Open
Abstract
Simple Summary A medulloblastoma recurrence is usually associated with an unfavorable prognosis. The German P-HIT-REZ 2005 Study gathered data from patients with relapsed medulloblastomas treated in different, non-randomized therapy arms dependent on preconditions of the patients (previous treatment, comorbidities, relapse pattern), the decision of treating physicians, and the patients’/parents’ choice. A total of 93 evaluable patients with refractory or relapsed medulloblastoma were enrolled. The main aim of this study was to analyze the impact of patient and disease characteristics as well as local and systemic therapies on post-relapse progression-free (PFS) and overall survival (OS). In multivariate analysis, a short time until the first recurrence (<18 months) was the strongest predictor for a worse PFS and OS, which was mainly associated with molecular subgroup 3. Metastatic disease, at relapse, only had a significant impact on OS. Re-biopsy, at relapse, is highly recommended to investigate the histopathological and molecular genetic tumor characteristics and to exclude a secondary malignancy. Abstract Recurrent medulloblastomas are associated with survival rates <10%. Adequate multimodal therapy is being discussed as having a major impact on survival. In this study, 93 patients with recurrent medulloblastoma treated in the German P-HIT-REZ 2005 Study were analyzed for survival (PFS, OS) dependent on patient, disease, and treatment characteristics. The median age at the first recurrence was 10.1 years (IQR: 6.9–16.1). Median PFS and OS, at first recurrence, were 7.9 months (CI: 5.7–10.0) and 18.5 months (CI: 13.6–23.5), respectively. Early relapses/progressions (<18 months, n = 30/93) found mainly in molecular subgroup 3 were associated with markedly worse median PFS (HR: 2.34) and OS (HR: 3.26) in regression analyses. A significant survival advantage was found for the use of volume-reducing surgery as well as radiotherapy. Intravenous chemotherapy with carboplatin and etoposide (ivCHT, n = 28/93) showed improved PFS and OS data and the best objective response rate (ORR) was 66.7% compared to oral temozolomide (oCHT, n = 47/93) which was 34.8%. Intraventricular (n = 43) as well as high-dose chemotherapy (n = 17) at first relapse was not related to a significant survival benefit. Although the results are limited due to a non-randomized study design, they may serve as a basis for future treatment decisions in order to improve the patients’ survival.
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Bailey S, André N, Gandola L, Massimino M, Wheatley K, Gates S, Homer V, Rutkowski S, Clifford SC. Clinical Trials in High-Risk Medulloblastoma: Evolution of the SIOP-Europe HR-MB Trial. Cancers (Basel) 2022; 14:374. [PMID: 35053536 PMCID: PMC8773789 DOI: 10.3390/cancers14020374] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/27/2021] [Accepted: 01/05/2022] [Indexed: 02/06/2023] Open
Abstract
Medulloblastoma patients receive adapted therapies stratified according to their risk-profile. Favourable, standard, and high disease-risk groups are each defined by the status of clinical and pathological risk factors, alongside an evolving repertoire of diagnostic and prognostic biomarkers. Medulloblastoma clinical trials in Europe are coordinated by the International Society for Paediatric Oncology (SIOP-Europe) brain tumour group. Favourable and standard-risk patients are eligible for the SIOP-PNET5-MB clinical trial protocol. In contrast, therapies for high-risk disease worldwide have, to date, encompassed a range of different treatment philosophies, with no clear consensus on approach. Higher radiotherapy doses are typically deployed, delivered either conventionally or in hyper-fractionated/accelerated regimens. Similarly, both standard and high-dose chemotherapies were assessed. However, trials to date in high-risk medulloblastoma have commonly been institutional or national, based on modest cohort sizes, and have not evaluated the relative performance of different strategies in a randomised fashion. We describe the concepts and design of the SIOP-E high-risk medulloblastoma clinical trial (SIOP-HR-MB), the first international biomarker-driven, randomised, clinical trial for high-risk medulloblastoma. SIOP-HR-MB is programmed to recruit >800 patients in 16 countries across Europe; its primary objectives are to assess the relative efficacies of the alternative established regimens. The HR-MB patient population is molecularly and clinically defined, and upfront assessments incorporate a standardised central review of molecular pathology, radiology, and radiotherapy quality assurance. Secondary objectives include the assessment of (i) novel therapies within an upfront 'window' and (ii) therapy-associated neuropsychology, toxicity, and late effects, alongside (iii) the collection of materials for comprehensive integrated studies of biological determinants within the SIOP-HR-MB cohort.
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Affiliation(s)
- Simon Bailey
- Great North Children’s Hospital, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK
- Wolfson Childhood Cancer Research Centre, Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne NE1 7RU, UK;
| | - Nicolas André
- Pediatric Hematology and Oncology Department, Hôpital Pour Enfants de La Timone, AP-HM, 13005 Marseille, France;
- Centre de Recherche en Cancérologie de Marseille, SMARTc Unit, Inserm U1068, Aix Marseille University, 13005 Marseille, France
| | - Lorenza Gandola
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy;
| | - Maura Massimino
- Pediatric Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy;
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birimingham, Birmingham B15 2TT, UK; (K.W.); (S.G.); (V.H.)
| | - Simon Gates
- Cancer Research UK Clinical Trials Unit, University of Birimingham, Birmingham B15 2TT, UK; (K.W.); (S.G.); (V.H.)
| | - Victoria Homer
- Cancer Research UK Clinical Trials Unit, University of Birimingham, Birmingham B15 2TT, UK; (K.W.); (S.G.); (V.H.)
| | - 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 University, Newcastle upon Tyne NE1 7RU, 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: 7] [Impact Index Per Article: 2.3] [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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Steinbügl M, Nemes K, Johann P, Kröncke T, Tüchert S, da Costa MJG, Ebinger M, Schüller U, Sehested A, Hauser P, Reinhard H, Sumerauer D, Hettmer S, Jakob M, Hasselblatt M, Siebert R, Witt O, Gerss J, Kerl K, Frühwald MC. Clinical evidence for a biological effect of epigenetically active decitabine in relapsed or progressive rhabdoid tumors. Pediatr Blood Cancer 2021; 68:e29267. [PMID: 34347371 DOI: 10.1002/pbc.29267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 07/09/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Refined therapy has helped to improve survival rates in rhabdoid tumors (RT). Prognosis for patients with chemoresistant, recurrent, or progressive RT remains dismal. Although decitabine, an epigenetically active agent, has mainly been evaluated in the management of hematologic malignancies in adults, safety in children has also been demonstrated repeatedly. MATERIALS AND METHODS A retrospective series of patients who received decitabine upon relapse or progression following therapy according to the EU-RHAB regimen is presented. Due to the retrospective nature of analyses, response was defined as measurable regression of at least one lesion on imaging. 850k methylation profiling was done whenever tumor tissue was available. RESULTS A total of 22 patients with RT of any anatomical localization were included. Most patients (19/22) presented with metastases. All received low-dose decitabine with or preceding conventional chemotherapy. Patients received a median of two (1-6) courses of decitabine; 27.3% (6/22) demonstrated a radiological response. Molecular analyses revealed increased methylation levels in tumors from responders. No excessive toxicity was observed. Clinical benefits for responders included eligibility for early phase trials or local therapy. Responders showed prolonged time to progression and overall survival. Due to small sample size, statistical correction for survivorship bias demonstrated no significant effect on survival for responders. CONCLUSIONS Patients with RT demonstrate promising signs of antitumor activity after multiagent relapse therapy including decitabine. Analyses of methylation data suggest a specific effect on an epigenetic level. We propose to consider decitabine and other epigenetic drugs as candidates for further clinical investigations in RT.
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Affiliation(s)
- Mona Steinbügl
- University Medical Center Augsburg, Paediatric and Adolescent Medicine, Swabian Children's Cancer Center, Augsburg, Germany
| | - Karolina Nemes
- University Medical Center Augsburg, Paediatric and Adolescent Medicine, Swabian Children's Cancer Center, Augsburg, Germany
| | - Pascal Johann
- University Medical Center Augsburg, Paediatric and Adolescent Medicine, Swabian Children's Cancer Center, Augsburg, Germany.,Hopp Children's Cancer Center Heidelberg (KiTZ), German Cancer Research Center (DKFZ) and Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Kröncke
- Department of Diagnostic and Interventional Radiology, University Medical Center, Augsburg, Germany
| | - Stefanie Tüchert
- Department of Diagnostic and Interventional Radiology, University Medical Center, Augsburg, Germany
| | - Maria Joao Gil da Costa
- Pediatric Hematology and Oncology Division, University Hospital S. João Alameda Hernani Monteiro, Porto, Portugal
| | - Martin Ebinger
- Department of General Pediatrics, Hematology and Oncology, Children's University Hospital, Tübingen, Germany
| | - Ulrich Schüller
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Research Institute Children's Cancer Center Hamburg, Hamburg, Germany.,Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Astrid Sehested
- Department of Paediatrics and Adolescent Medicine Rigshospitalet, Copenhagen, Denmark
| | - Peter Hauser
- Department of Pediatric Oncology, 2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Harald Reinhard
- Department of Pediatrics, Asklepios Kinderklinik Sankt Augustin, Sankt Augustin, Germany
| | - David Sumerauer
- Department of Pediatric Hematology and Oncology, University Hospital Motol, Prague, Czech Republic
| | - Simone Hettmer
- Division of Pediatric Hematology and Oncology, Department of Pediatric and Adolescent Medicine, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Marcus Jakob
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Hospital of Regensburg, Regensburg, Germany
| | - Martin Hasselblatt
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Reiner Siebert
- Institute of Human Genetics, University of Ulm and Ulm University Hospital, Ulm, Germany
| | - Olaf Witt
- Hopp Children's Cancer Center Heidelberg (KiTZ), German Cancer Research Center (DKFZ) and Heidelberg University Hospital, Heidelberg, Germany
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University of Münster, Muenster, Germany
| | - Kornelius Kerl
- Department of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Michael C Frühwald
- University Medical Center Augsburg, Paediatric and Adolescent Medicine, Swabian Children's Cancer Center, Augsburg, Germany
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10
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Frappaz D, Barritault M, Montané L, Laigle-Donadey F, Chinot O, Le Rhun E, Bonneville-Levard A, Hottinger AF, Meyronnet D, Bidaux AS, Garin G, Pérol D. MEVITEM-a phase I/II trial of vismodegib + temozolomide vs temozolomide in patients with recurrent/refractory medulloblastoma with Sonic Hedgehog pathway activation. Neuro Oncol 2021; 23:1949-1960. [PMID: 33825892 PMCID: PMC8563312 DOI: 10.1093/neuonc/noab087] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Vismodegib specifically inhibits Sonic Hedgehog (SHH). We report results of a phase I/II evaluating vismodegib + temozolomide (TMZ) in immunohistochemically defined SHH recurrent/refractory adult medulloblastoma. METHODS TMZ-naïve patients were randomized 2:1 to receive vismodegib + TMZ (arm A) or TMZ (arm B). Patients previously treated with TMZ were enrolled in an exploratory cohort of vismodegib (arm C). If the safety run showed no excessive toxicity, a Simon's 2-stage phase II design was planned to explore the 6-month progression-free survival (PFS-6). Stage II was to proceed if arm A PFS-6 was ≥3/9 at the end of stage I. RESULTS A total of 24 patients were included: arm A (10), arm B (5), and arm C (9). Safety analysis showed no excessive toxicity. At the end of stage I, the PFS-6 of arm A was 20% (2/10 patients, 95% unilateral lower confidence limit: 3.7%) and the study was prematurely terminated. The overall response rates (ORR) were 40% (95% CI, 12.2-73.8) and 20% (95% CI, 0.5-71.6) in arm A and B, respectively. In arm C, PFS-6 was 37.5% (95% CI, 8.8-75.5) and ORR was 22.2% (95% CI, 2.8-60.0). Among 11 patients with an expected sensitivity according to new generation sequencing (NGS), 3 had partial response (PR), 4 remained stable disease (SD) while out of 7 potentially resistant patients, 1 had PR and 1 SD. CONCLUSION The addition of vismodegib to TMZ did not add toxicity but failed to improve PFS-6 in SHH recurrent/refractory medulloblastoma. Prediction of sensitivity to vismodegib needs further refinements.
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Affiliation(s)
| | | | - Laure Montané
- Clinical Research Platform (DRCI) of Centre Léon Bérard, Lyon, France
| | | | - Olivier Chinot
- Neuro-Oncology Unit, La Timone Marseille, Marseille, France
| | - Emilie Le Rhun
- University of Lille, U-1192, F-59000 Lille, Lille, France
- Inserm, U-1192, F-59000 Lille, Lille, France
- General and Stereotaxic Neurosurgery Service, CHU Lille, Lille, France
- Oscar Lambret Center, Lille, France
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | | | - Andreas F Hottinger
- Brain and Spine Tumor Center, Departments of Clinical Neurosciences & Oncology, CHUV Lausanne University Hospital, Lausanne, Switzerland
| | | | | | - Gwenaële Garin
- Clinical Research Platform (DRCI) of Centre Léon Bérard, Lyon, France
| | - David Pérol
- Clinical Research Platform (DRCI) of Centre Léon Bérard, Lyon, France
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11
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Yamauchi T, Kitai R, Arai H, Kidoguchi M, Isozaki M, Kodera T, Yamauchi T, Kikuta KI. Bevacizumab, irinotecan, and temozolomide with re-irradiation in adult recurrent medulloblastoma: A first case report. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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12
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Levy AS, Krailo M, Chi S, Villaluna D, Springer L, Williams-Hughes C, Fouladi M, Gajjar A. Temozolomide with irinotecan versus temozolomide, irinotecan plus bevacizumab for recurrent medulloblastoma of childhood: Report of a COG randomized Phase II screening trial. Pediatr Blood Cancer 2021; 68:e29031. [PMID: 33844469 PMCID: PMC8764558 DOI: 10.1002/pbc.29031] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/17/2021] [Accepted: 03/08/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Approximately 30% of children with medulloblastoma (MB) experience recurrence, which is usually incurable. This study compared the overall survival (OS) of patients receiving temozolomide (TMZ) and irinotecan with that of patients receiving TMZ, irinotecan, and bevacizumab for recurrent MB/central nervous system (CNS) primitive neuroectodermal tumor (PNET). METHODS Patients with relapsed/refractory MB or CNS PNET were randomly assigned to receive TMZ (150 mg/m2 /day PO on days 1-5) and irinotecan (50 mg/m2 /day IV on days 1-5) with or without bevacizumab (10 mg/kg IV on days 1 and 15). RESULTS One hundred five patients were eligible and treated on study. Median OS was 13 months in the standard arm and 19 months with the addition of bevacizumab; median event-free survival (EFS) was 6 months in the standard arm and 9 months with the addition of bevacizumab. The hazard ratio for death from the stratified relative-risk regression model is 0.63. Overall, 23 patients completed 12 courses of planned protocol therapy, 23% (12/52) in the experimental arm with bevacizumab versus 21% (11/53) in the standard arm. Toxicity profiles were comparable in both treatment arms. The estimate of the incidence of feasibility events associated with the bevacizumab arm is three of 52 (5.8%) (95% CI 1.2-16%). Events included myelosuppression, electrolyte abnormalities, diarrhea, and elevated transaminases. One intracranial hemorrhage event was observed in each arm. CONCLUSION The addition of bevacizumab to TMZ/irinotecan significantly reduced the risk of death in children with recurrent MB. The combination was relatively well tolerated in this heavily pretreated cohort. The three-drug regimen demonstrated a sufficient risk reduction to warrant further investigation.
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Affiliation(s)
| | - Mark Krailo
- Department of Preventive Medicine, University of Southern California, Los Angeles CA
| | - Susan Chi
- Dana-Farber/Harvard Cancer Center, Boston, MA
| | | | | | - Chris Williams-Hughes
- Department of Preventive Medicine, University of Southern California, Los Angeles CA
| | - Maryam Fouladi
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Amar Gajjar
- Saint Jude Children’s Research Hospital, Memphis, TN
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13
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Shih HA. An early foray with targeted therapy and inspiring novel approaches to combat adult medulloblastoma. Neuro Oncol 2021; 23:1814-1815. [PMID: 34270765 DOI: 10.1093/neuonc/noab179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Helen A Shih
- Massachusetts General Hospital, Department of Radiation Oncology, Boston, MA
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14
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Adelon J, Dufour C, Foulon S, Masliah Planchon J, Meyronnet D, Bourdeaut F, Palenzuela G, Fouyssac F, Raimbault S, De Carli E, Klein S, Pagnier A, Bertozzi AI, Rome A, David A, Chabaud S, Faure-Conter C. What does a non-response to induction chemotherapy imply in high-risk medulloblastomas? J Neurooncol 2021; 153:425-440. [PMID: 34076831 DOI: 10.1007/s11060-021-03777-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/14/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE High-risk medulloblastomas (HR-MB) may not respond to induction chemotherapy, with either post-induction stable (SD) or progressive disease (PD). There is no consensus regarding their optimal management. METHODS A retrospective, multicentre study investigated patients with non-responder HR-MB treated according to the PNET HR + 5 protocol (NCT00936156) between 01/01/2009 and 31/12/2018. After two courses of etoposide and carboplatin (induction), patients with SD or PD were analyzed. Upon clinician's decision, the PNET HR + 5 protocol was either pursued with tandem high-dose chemotherapy (HDCT) and craniospinal irradiation (CSI) (continuation group) or it was modified (switched group). RESULTS Forty-nine patients were identified. After induction, 37 patients had SD and 12 had PD. The outcomes were better for the SD group: the 5-y PFS and OS were 52% (95% CI 35-67) and 70% (95% CI 51-83), respectively, in the SD group while the 2-y PFS and OS were 17% (95% CI 3-41) and 25% (95% CI 6-50), respectively, in the PD group (p < 0.0001). The PNET HR + 5 strategy was pursued for 3 patients in the PD group, of whom only one survived. In the SD group, it was pursued for 24/37 patients whereas 13 patients received miscellaneous treatments including a 36 Gy CSI in 12 cases. Despite that continuation and switched group were well-balanced for factors impacting the outcomes, the latter were better in the continuation group than in the switched group: the 5-y PFS were 78% (95% CI 54-90) versus 0% (p < 0.001), and the 5-y OS were 78% (95% CI 54-90) versus 56% (95% CI 23-79) (p = 0.0618) respectively. In the SD group, multivariate analysis revealed that MYC amplification, molecular group 3, and a switched strategy were independent prognostic factors for progression. CONCLUSION Patients with post-induction SD may benefit from HDCT and CSI, whereas patients with early PD will require new therapeutic approaches.
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Affiliation(s)
- Jihane Adelon
- Department of Pediatrics, Institut d'Hématologie et d'Oncologie pédiatrique, 1 Place Professeur Joseph Renaut, 69008, Lyon, France.
| | - Christelle Dufour
- Department of Pediatric and Adolescent Oncology, Gustave Roussy Institute, Villejuif, France
| | - Stéphanie Foulon
- Biostatistics and Methodology Unit, Department of Clinical Research and Investigation, Gustave Roussy Institute, Villejuif, France
| | - Julien Masliah Planchon
- INSERM U830, Laboratory of Translational Research in Pediatric Oncology, SIREDO Pediatric Oncology Center, Curie Institute, Paris, France
| | - David Meyronnet
- Department of Neuropathology, Institut de Pathologie Est, Hospices civils de Lyon, Lyon, France
| | - Franck Bourdeaut
- SIREDO Pediatric Oncology Center, Curie Institute, Paris, France
| | - Gilles Palenzuela
- Department of Pediatric Hematology-Oncology, Centre Hospitalo-Universitaire de Montpellier, Montpellier, France
| | - Fanny Fouyssac
- Department of Pediatric Oncology, Children's Hospital, Nancy, France
| | - Sandra Raimbault
- Pediatric Oncology Unit, Oscar Lambret Comprehensive Cancer Center, Lille, France
| | - Emilie De Carli
- Department of Pediatric Oncology, University Hospital, Angers, France
| | - Sébastien Klein
- Department of Pediatric Hematology-Oncology, University Hospital, Besançon, France
| | - Anne Pagnier
- Department of Pediatric Immunohematology and Oncology, University Hospital, Grenoble, France
| | | | - Angélique Rome
- Department of Pediatric Hematology and Oncology, La Timone Children's Hospital, Marseille, France
| | - Audrey David
- Department of Pediatric Hematology and Oncology Unit, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - Sylvie Chabaud
- Clinical Research and Innovation Department, Léon Bérard Cancer Centre, Biostatistics Unit, Lyon, France
| | - Cécile Faure-Conter
- Department of Pediatrics, Institut d'Hématologie et d'Oncologie pédiatrique, 1 Place Professeur Joseph Renaut, 69008, Lyon, France
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15
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Kumar R, Smith KS, Deng M, Terhune C, Robinson GW, Orr BA, Liu APY, Lin T, Billups CA, Chintagumpala M, Bowers DC, Hassall TE, Hansford JR, Khuong-Quang DA, Crawford JR, Bendel AE, Gururangan S, Schroeder K, Bouffet E, Bartels U, Fisher MJ, Cohn R, Partap S, Kellie SJ, McCowage G, Paulino AC, Rutkowski S, Fleischhack G, Dhall G, Klesse LJ, Leary S, Nazarian J, Kool M, Wesseling P, Ryzhova M, Zheludkova O, Golanov AV, McLendon RE, Packer RJ, Dunham C, Hukin J, Fouladi M, Faria CC, Pimentel J, Walter AW, Jabado N, Cho YJ, Perreault S, Croul SE, Zapotocky M, Hawkins C, Tabori U, Taylor MD, Pfister SM, Klimo P, Boop FA, Ellison DW, Merchant TE, Onar-Thomas A, Korshunov A, Jones DTW, Gajjar A, Ramaswamy V, Northcott PA. Clinical Outcomes and Patient-Matched Molecular Composition of Relapsed Medulloblastoma. J Clin Oncol 2021; 39:807-821. [PMID: 33502920 PMCID: PMC8078396 DOI: 10.1200/jco.20.01359] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We sought to investigate clinical outcomes of relapsed medulloblastoma and to compare molecular features between patient-matched diagnostic and relapsed tumors.
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Affiliation(s)
- Rahul Kumar
- Department of Developmental Neurobiology, St Jude Children's Research Hospital, Memphis, TN.,Graduate School of Biomedical Sciences, St Jude Children's Research Hospital, Memphis, TN
| | - Kyle S Smith
- Department of Developmental Neurobiology, St Jude Children's Research Hospital, Memphis, TN
| | - Maximilian Deng
- Pediatric Glioma Research Group, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Colt Terhune
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Giles W Robinson
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Brent A Orr
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN
| | - Anthony P Y Liu
- Department of Developmental Neurobiology, St Jude Children's Research Hospital, Memphis, TN.,Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Tong Lin
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - Catherine A Billups
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | | | - Daniel C Bowers
- Division of Pediatric Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Timothy E Hassall
- Department of Pediatric Oncology, Lady Ciliento Children's Hospital, South Brisbane, Queensland, Australia
| | - Jordan R Hansford
- Department of Haematology and Oncology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Dong Anh Khuong-Quang
- Department of Haematology and Oncology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - John R Crawford
- Department of Neurosciences and Pediatrics, University of California San Diego and Rady Children's Hospital, San Diego, CA
| | - Anne E Bendel
- Department of Hematology-Oncology, Children's Hospital of Minnesota, Minneapolis, MN
| | | | - Kristin Schroeder
- Preston Robert Tisch Brain Tumor Center, Duke University, Durham, NC
| | - Eric Bouffet
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ute Bartels
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Michael J Fisher
- Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Richard Cohn
- Kid's Cancer Centre, Sydney Children's Hospital and School of Woman's and Children's Health, Sydney, New South Wales, Australia
| | - Sonia Partap
- Departments of Neurology and Pediatrics, Stanford University, Palo Alto, CA
| | - Stewart J Kellie
- Department of Pediatric Oncology, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Geoffrey McCowage
- Department of Pediatric Oncology, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Arnold C Paulino
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stefan Rutkowski
- Department of Hematology and Oncology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Girish Dhall
- Division of Pediatric Hematology/Oncology, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Laura J Klesse
- Division of Pediatric Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Sarah Leary
- Department of Hematology-Oncology, Seattle Children's Hospital, Seattle, WA
| | - Javad Nazarian
- Research Center for Genetic Medicine, Children's National Health System, Washington, DC
| | - Marcel Kool
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Pieter Wesseling
- Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Marina Ryzhova
- Department of Neuropathology, NN Burdenko Neurosurgical Institute, Moscow, Russia
| | - Olga Zheludkova
- Department of Neuro-Oncology, Russian Scientific Center of Radiology, Moscow, Russia
| | - Andrey V Golanov
- Department of Neuroradiology, NN Burdenko Neurosurgical Institute, Moscow, Russia
| | - Roger E McLendon
- Department of Pathology, Duke University Medical Center, Durham, NC
| | | | - Christopher Dunham
- Department of Pathology and Laboratory Medicine, Division of Anatomical Pathology, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Juliette Hukin
- Department of Pediatrics, Division of Neurology, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Maryam Fouladi
- Department of Pediatrics, Division of Oncology, Cincinnati Children's Hospital, Cincinnati, OH
| | - Claudia C Faria
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Jose Pimentel
- Department of Neurology, Hospital de Santa Maria, Lisbon, Portugal
| | - Andrew W Walter
- Department of Hematology/Oncology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Nada Jabado
- Department of Pediatrics, Research Institute of the McGill University Health Center, Montreal, Québec, Canada
| | - Yoon-Jae Cho
- Department of Pediatrics, Pediatric Neurology, Oregon Health & Science University, Portland, OR
| | - Sebastien Perreault
- Division of Neurology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada
| | - Sidney E Croul
- Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michal Zapotocky
- Prague Brain Tumor Research Group, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Cynthia Hawkins
- Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Uri Tabori
- Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael D Taylor
- Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stefan M Pfister
- Department of Neuropathology, NN Burdenko Neurosurgical Institute, Moscow, Russia
| | - Paul Klimo
- Division of Pediatric Neurosurgery, Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN
| | - Frederick A Boop
- Division of Pediatric Neurosurgery, Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN
| | - David W Ellison
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN
| | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Arzu Onar-Thomas
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - Andrey Korshunov
- Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - David T W Jones
- Pediatric Glioma Research Group, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Hopp Children's Cancer Center (KiTZ), Heidelberg, Germany
| | - Amar Gajjar
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Vijay Ramaswamy
- Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul A Northcott
- Department of Developmental Neurobiology, St Jude Children's Research Hospital, Memphis, TN
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16
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Eibl T, Hammer A, Yakubov E, Blechschmidt C, Kalisch A, Steiner HH. Medulloblastoma in adults - reviewing the literature from a surgeon's point of view. Aging (Albany NY) 2021; 13:3146-3160. [PMID: 33497354 PMCID: PMC7880386 DOI: 10.18632/aging.202568] [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: 08/03/2020] [Accepted: 01/04/2021] [Indexed: 06/12/2023]
Abstract
Medulloblastoma is a common primary brain tumor in children but it is a rare cancer in adult patients. We reviewed the literature, searching PubMed for articles on this rare tumor entity, with a focus on tumor biology, advanced neurosurgical opportunities for safe tumor resection, and multimodal treatment options. Adult medulloblastoma occurs at a rate of 0.6 per one million people per year. There is a slight disparity between male and female patients, and patients with a fair skin tone are more likely to have a medulloblastoma. Patients present with cerebellar signs and signs of elevated intracranial pressure. Diagnostic efforts should consist of cerebral MRI and MRI of the spinal axis. Cerebrospinal fluid should be investigated to look for tumor dissemination. Medulloblastoma tumors can be classified as classic, desmoplastic, anaplastic, and large cell, according to the WHO tumor classification. Molecular subgroups include WNT, SHH, group 3, and group 4 tumors. Further molecular analyses suggest that there are several subgroups within the four existing subgroups, with significant differences in patient age, frequency of metastatic spread, and patient survival. As molecular markers have started to play an increasing role in determining treatment strategies and prognosis, their importance has increased rapidly. Treatment options include microsurgical tumor resection and radiotherapy and, in addition, chemotherapy that respects the tumor biology of individual patients offers targeted therapeutic approaches. For neurosurgeons, intraoperative imaging and tumor fluorescence may improve resection rates. Disseminated disease, residual tumor after surgery, lower radiation dose, and low Karnofsky performance status are all suggestive of a poor outcome. Extraneural spread occurs only in very few cases. The reported 5-year-survival rates range between 60% and 80% for all adult medulloblastoma patients.
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Affiliation(s)
- Thomas Eibl
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Alexander Hammer
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Eduard Yakubov
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Cristiane Blechschmidt
- Department of Neuropathology, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Alexander Kalisch
- Department of Oncology, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Hans-Herbert Steiner
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
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17
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Abstract
PURPOSE OF REVIEW Molecular subtyping in medulloblastoma (MB) has diagnostic and prognostic values which impact therapy. This paper provides guidance for the clinician caring for pediatric and adult patients with medulloblastoma in the modern era. RECENT FINDINGS Medulloblastoma comprises four molecularly distinct subgroups: wingless activated (WNT), sonic hedgehog activated (SHH), group 3, and group 4. Risk stratification before and after the discovery of molecular subgroups aims at minimizing toxicity by reducing radiation and chemotherapy doses in low-risk patients while maintaining favorable overall survival (OS). The mainstay of newly diagnosed medulloblastoma treatment is surgery, radiation therapy, and chemotherapy, except for children under 6 years of age, where high-dose chemotherapy with autologous stem cell rescue is used to avoid or delay radiotherapy, preventing neurocognitive sequelae. Management of recurrent/refractory medulloblastoma remains a challenge with immunotherapy and small-molecule inhibitors forming the backbone of novel strategies. Recent innovations in medulloblastoma research allow us to better understand pathogenesis and molecular characteristics resulting in advanced risk stratification models, new therapeutic approaches, and overall improved survival and quality of life.
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Affiliation(s)
- Luca Szalontay
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Yasmin Khakoo
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA. .,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA.
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18
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Franceschi E, Hofer S, Brandes AA, Frappaz D, Kortmann RD, Bromberg J, Dangouloff-Ros V, Boddaert N, Hattingen E, Wiestler B, Clifford SC, Figarella-Branger D, Giangaspero F, Haberler C, Pietsch T, Pajtler KW, Pfister SM, Guzman R, Stummer W, Combs SE, Seidel C, Beier D, McCabe MG, Grotzer M, Laigle-Donadey F, Stücklin ASG, Idbaih A, Preusser M, van den Bent M, Weller M, Hau P. EANO-EURACAN clinical practice guideline for diagnosis, treatment, and follow-up of post-pubertal and adult patients with medulloblastoma. Lancet Oncol 2020; 20:e715-e728. [PMID: 31797797 DOI: 10.1016/s1470-2045(19)30669-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/13/2019] [Accepted: 09/02/2019] [Indexed: 12/20/2022]
Abstract
The European Association of Neuro-Oncology (EANO) and EUropean RAre CANcer (EURACAN) guideline provides recommendations for the diagnosis, treatment, and follow-up of post-pubertal and adult patients with medulloblastoma. The guideline is based on the 2016 WHO classification of tumours of the CNS and on scientific developments published since 1980. It aims to provide direction for diagnostic and management decisions, and for limiting unnecessary treatments and cost. In view of the scarcity of data in adults with medulloblastoma, we base our recommendations on adult data when possible, but also include recommendations derived from paediatric data if justified. Our recommendations are a resource for professionals involved in the management of post-pubertal and adult patients with medulloblastoma, for patients and caregivers, and for health-care providers in Europe. The implementation of this guideline requires multidisciplinary structures of care, and defined processes of diagnosis and treatment.
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Affiliation(s)
- Enrico Franceschi
- Department of Medical Oncology, Azienda USL, Bologna, Italy; IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Silvia Hofer
- Division of Medical Oncology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Alba A Brandes
- Department of Medical Oncology, Azienda USL, Bologna, Italy; IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Didier Frappaz
- Department of Neuro-Oncology and Institut d'Hématologie et d'Oncologie Pédiatrique, Centre Léon Bérard, Lyon, France
| | | | - Jacoline Bromberg
- Department of Neuro-Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, Netherlands
| | - Volodia Dangouloff-Ros
- Paediatric Radiology Department, Hôpital Necker Enfants Malades, Paris, France; UMR 1163, Imagine Institute, Paris, France
| | - Nathalie Boddaert
- Paediatric Radiology Department, Hôpital Necker Enfants Malades, Paris, France; UMR 1163, Imagine Institute, Paris, France
| | - Elke Hattingen
- Department of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Benedikt Wiestler
- Department of Neuroradiology, Technical University of Munich Hospital, Munich, Germany
| | - Steven C Clifford
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Dominique Figarella-Branger
- Aix-Marseille Univ, APHM, CNRS, INP, Inst Neurophysiopathol, CHU Timone, Service d'Anatomie Pathologique et de Neuropathologie, Marseille, France
| | - Felice Giangaspero
- Department of Radiological, Oncological and Anatomopathological Sciences, Policlinico Umberto I, Sapienza University, Rome, Italy; IRCCS Neuromed, Mediterranean Neurological Institute, Pozzilli, Italy
| | - Christine Haberler
- Institute of Neurology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Torsten Pietsch
- Department of Neuropathology, DGNN Brain Tumour Reference Center, University of Bonn Medical Center, Bonn, Germany
| | - Kristian W Pajtler
- KiTZ Hopp Children's Cancer Center Heidelberg, Division of Pediatric Neurooncology, DKFZ German Cancer Research Center, DKTK German Cancer Consortium, and Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan M Pfister
- KiTZ Hopp Children's Cancer Center Heidelberg, Division of Pediatric Neurooncology, DKFZ German Cancer Research Center, DKTK German Cancer Consortium, and Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Raphael Guzman
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University Hospital and University Children's Hospital, Basel, Switzerland
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Muenster, Muenster, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany; Institute of Radiation Medicine, Department of Radiation Sciences, Helmholtz Zentrum München, Munich, Germany
| | - Clemens Seidel
- Department of Radiation Oncology, University Hospital Leipzig, Leipzig, Germany
| | - Dagmar Beier
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Martin G McCabe
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Michael Grotzer
- Department of Oncology, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Florence Laigle-Donadey
- Service de Neurologie 2-Mazarin, Hôpitaux Universitaires La Pitié-Salpêtrière-Charles Foix, Paris, France
| | - Ana S Guerreiro Stücklin
- Department of Oncology, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ahmed Idbaih
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, AP-HP, Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, Service de Neurologie 2-Mazarin, Paris, France
| | - Matthias Preusser
- Division of Oncology, Department of Medicine, Medical University of Vienna, Vienna, Austria
| | - Martin van den Bent
- Department of Neuro-Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, Netherlands
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Peter Hau
- Wilhelm Sander-NeuroOncology Unit and Department of Neurology, University Hospital Regensburg, Regensburg, Germany.
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19
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Franceschi E, Frappaz D, Rudà R, Hau P, Preusser M, Houillier C, Lombardi G, Asioli S, Dehais C, Bielle F, Di Nunno V, van den Bent M, Brandes AA, Idbaih A. Rare Primary Central Nervous System Tumors in Adults: An Overview. Front Oncol 2020; 10:996. [PMID: 32676456 PMCID: PMC7333775 DOI: 10.3389/fonc.2020.00996] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/20/2020] [Indexed: 12/15/2022] Open
Abstract
Overall, tumors of primary central nervous system (CNS) are quite common in adults with an incidence rate close to 30 new cases/100,000 inhabitants per year. Significant clinical and biological advances have been accomplished in the most common adult primary CNS tumors (i.e., diffuse gliomas). However, most CNS tumor subtypes are rare with an incidence rate below the threshold defining rare disease of 6.0 new cases/100,000 inhabitants per year. Close to 150 entities of primary CNS tumors have now been identified by the novel integrated histomolecular classification published by the World Health Organization (WHO) and its updates by the c-IMPACT NOW consortium (the Consortium to Inform Molecular and Practical Approaches to CNS Tumor Taxonomy). While these entities can be better classified into smaller groups either by their histomolecular features and/or by their location, assessing their treatment by clinical trials and improving the survival of patients remain challenging. Despite these tumors are rare, research, and advances remain slower compared to diffuse gliomas for instance. In some cases (i.e., ependymoma, medulloblastoma) the understanding is high because single or few driver mutations have been defined. The European Union has launched European Reference Networks (ERNs) dedicated to support advances on the clinical side of rare diseases including rare cancers. The ERN for rare solid adult tumors is termed EURACAN. Within EURACAN, Domain 10 brings together the European patient advocacy groups (ePAGs) and physicians dedicated to improving outcomes in rare primary CNS tumors and also aims at supporting research, care and teaching in the field. In this review, we discuss the relevant biological and clinical characteristics, clinical management of patients, and research directions for the following types of rare primary CNS tumors: medulloblastoma, pineal region tumors, glioneuronal and rare glial tumors, ependymal tumors, grade III meningioma and mesenchymal tumors, primary central nervous system lymphoma, germ cell tumors, spinal cord tumors and rare pituitary tumors.
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Affiliation(s)
- Enrico Franceschi
- Department of Medical Oncology, Azienda USL/IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Didier Frappaz
- Department of Neuro-Oncology and Institut d'Hématologie et d'Oncologie Pédiatrique, Centre Léon Bérard, Lyon, France
| | - Roberta Rudà
- Department of Neuro-Oncology, City of Health and Science and University of Turin, Turin, Italy
| | - Peter Hau
- Wilhelm Sander NeuroOncology-Unit, Department of Neurology, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Caroline Houillier
- Sorbonne Université, IHU, ICM, Service de Neurologie 2-Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Giuseppe Lombardi
- Department of Oncology, Veneto Institute of Oncology-IRCCS, Padua, Italy
| | - Sofia Asioli
- Section of Anatomic Pathology "M. Malpighi", Department of Biomedical and Neuromotor Sciences, Bellaria Hospital, Bologna, Italy
| | - Caroline Dehais
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, AP-HP, Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, Service de Neurologie 2-Mazarin, Paris, France
| | - Franck Bielle
- Department of Neuropathology, Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, AP-HP, Sorbonne Université, SIRIC Curamus, Paris, France
| | - Vincenzo Di Nunno
- Department of Medical Oncology, Azienda USL/IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Martin van den Bent
- The Brain Tumor Center at Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Alba A Brandes
- Department of Medical Oncology, Azienda USL/IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Ahmed Idbaih
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, AP-HP, Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, Service de Neurologie 2-Mazarin, Paris, France
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20
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Abstract
Aggressive pituitary tumors (APTs) represent rare pituitary adenomas (PAs) with local invasion of surrounding tissues, increased risk for multiple recurrence, rapid tumor growth, or resistance to standard therapies. The most common APTs in children and adolescents are giant prolactinomas and somatotropinomas. Few cases of Crooke's cell adenomas, silent corticotroph adenomas and pituitary carcinomas have also been reported in the literature. Pediatric patients with APTs have higher risk of harboring germline genetic defects, most commonly in the MEN1 and AIP genes. Since certain genetic defects confer a more aggressive behavior to PAs, genetic testing should be considered in tumors with young onset and positive family history. The management of pediatric APTs involves usually a combination of standard therapies (surgical, medical, radiation). Newer agents, such as temozolomide, have been used in few cases of pediatric pituitary tumors with promising results. In the elderly, PAs are more commonly non-functioning. Their management often poses dilemmas given the coexistence of age-related comorbidities. However, standard surgical treatment and temozolomide seem to be safe and well tolerated in elderly patients.
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Affiliation(s)
- Christina Tatsi
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, 10 Center Drive, Building 10, NIH-Clinical Research Center, Room 1-3330, MSC1103, Bethesda, MD, 20892, USA
| | - Constantine A Stratakis
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, 10 Center Drive, Building 10, NIH-Clinical Research Center, Room 1-3330, MSC1103, Bethesda, MD, 20892, USA.
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21
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Le Teuff G, Castaneda-Heredia A, Dufour C, Jaspan T, Calmon R, Devos A, McHugh K, Leblond P, Frappaz D, Aerts I, Zwaan CM, Ducassou S, Chastagner P, Verschuur A, Corradini N, Casanova M, Rubie H, Riccardi R, Le Deley MC, Vassal G, Geoerger B. Phase II study of temozolomide and topotecan (TOTEM) in children with relapsed or refractory extracranial and central nervous system tumors including medulloblastoma with post hoc Bayesian analysis: A European ITCC study. Pediatr Blood Cancer 2020; 67:e28032. [PMID: 31595663 DOI: 10.1002/pbc.28032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 09/19/2019] [Accepted: 09/23/2019] [Indexed: 11/06/2022]
Abstract
AIM To assess objective response after two cycles of temozolomide and topotecan (TOTEM) in children with refractory or relapsed miscellaneous extracranial solid and central nervous system (CNS) tumors, including medulloblastoma and primitive neuroectodermal tumors (PNET). PROCEDURE Multicenter, nonrandomized, phase 2 basket trial including children with solid tumors, completed by a one-stage design confirmatory cohort for medulloblastoma, and an exploratory cohort for PNET. Main eligibility criteria were refractory/relapsed measurable disease and no more than two prior treatment lines. Temozolomide was administered orally at 150 mg/m2 /day followed by topotecan at 0.75 mg/m2 /day intravenously for five consecutive days every 28 days. Tumor response was assessed every two cycles according to WHO criteria and reviewed independently. RESULTS Thirty-two patients were enrolled and treated in the miscellaneous solid tumor and 33 in the CNS strata; 20 patients with medulloblastoma and six with PNET were included in the expansion cohorts. The median age at inclusion was 10.0 years (range, 0.9-20.9). In the basket cohorts, confirmed complete and partial responses were observed in one glioma, four medulloblastoma, and one PNET, leading to the extension. The overall objective response rate (ORR) in medulloblastoma was 28% (95% CI, 12.7-47.2) with 1/29 complete and 7/29 partial responses, those for PNET 10% (95% CI, 0.3-44.5). Post hoc Bayesian analysis estimates that the true ORR in medulloblastoma is probably between 20% and 30% and below 20% in PNET. The most common treatment-related toxicities of the combination therapy were hematologic. CONCLUSIONS Temozolomide-topotecan results in significant ORR in children with recurrent and refractory medulloblastoma with a favorable toxicity profile.
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Affiliation(s)
- Gwénaël Le Teuff
- Université Paris-Saclay, Univ Paris-Sud, UVSQ, CESP, INSERM, Villejuif, France.,Gustave Roussy Cancer Center, Université Paris-Saclay, Biostatistics and Epidemiology Unit, Villejuif, France
| | - Alicia Castaneda-Heredia
- Gustave Roussy Cancer Center, Department of Pediatric and Adolescent Oncology, Villejuif, France
| | - Christelle Dufour
- Gustave Roussy Cancer Center, Department of Pediatric and Adolescent Oncology, Villejuif, France
| | - Timothy Jaspan
- University Hospital Nottingham, Nottingham, United Kingdom
| | | | - Annick Devos
- Erasmus MC/Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands
| | - Kieran McHugh
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Pierre Leblond
- Centre Oscar-Lambret, Department of Pediatric Oncology, Lille, France
| | - Didier Frappaz
- Institut d'Hématologie et d'Oncologie pédiatrique, Lyon, France
| | - Isabelle Aerts
- Institut Curie, SIREDO Oncology Center, PSL Research University, Paris, France
| | - Christian M Zwaan
- Erasmus MC/Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands
| | | | | | | | - Nadège Corradini
- Centre Hospitalier Universitaire, Department of Pediatric and Adolescent Oncology, Nantes, France
| | | | | | | | - Marie-Cecile Le Deley
- Université Paris-Saclay, Univ Paris-Sud, UVSQ, CESP, INSERM, Villejuif, France.,Gustave Roussy Cancer Center, Université Paris-Saclay, Biostatistics and Epidemiology Unit, Villejuif, France
| | - Gilles Vassal
- Gustave Roussy Cancer Center, Clinical Research Direction, Université Paris-Saclay, Univ Paris-Sud, Villejuif, France
| | - Birgit Geoerger
- Gustave Roussy Cancer Center, Department of Pediatric and Adolescent Oncology, Villejuif, France.,Université Paris-Saclay, Univ Paris-Sud, CNRS UMR8203, Villejuif, France
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22
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Morano F, Corallo S, Niger M, Barault L, Milione M, Berenato R, Moretto R, Randon G, Antista M, Belfiore A, Raimondi A, Nichetti F, Martinetti A, Battaglia L, Perrone F, Pruneri G, Falcone A, Di Bartolomeo M, de Braud F, Di Nicolantonio F, Cremolini C, Pietrantonio F. Temozolomide and irinotecan (TEMIRI regimen) as salvage treatment of irinotecan-sensitive advanced colorectal cancer patients bearing MGMT methylation. Ann Oncol 2019; 29:1800-1806. [PMID: 29860358 DOI: 10.1093/annonc/mdy197] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background Non-randomized studies showed that temozolomide (TMZ) achieves an average 10% response rate in heavily pretreated metastatic colorectal cancer (mCRC) patients with promoter methylation of the DNA repair gene O6-methylguanine-DNA methyltransferase (MGMT). In this phase II trial, irinotecan and temozolomide (TEMIRI) combination regimen was assessed in irinotecan-sensitive, MGMT methylated/microsatellite stable (MSS) pretreated mCRC patients. Patients and methods Key inclusion criteria were centrally confirmed MGMT methylation by methylation-specific PCR, MSS mCRC, progression after at least two prior chemotherapy regimens for advanced disease and irinotecan-free interval >3 months. TEMIRI (TMZ 150 mg/m2 on days 1-5 plus irinotecan 100 mg/m2 on days 1, 15 q28 days) was administered for six cycles, followed by maintenance with TMZ. The primary end point was overall response rate (ORR). Exploratory translational analyses included MGMT immunohistochemistry (IHC) and methyl-BEAMing (MB). Results Between December 2014 and June 2017, 25 patients were enrolled. The primary end point was met, since six patients achieved a partial response [ORR 24%, 95% confidence interval (CI) 11% to 43%]. At a median follow-up of 15.6 months, median progression-free survival (mPFS) and overall survival (mOS) were 4.4 and 13.8 months, respectively. Only four (16%) patients had ≥ grade 3 (CTCAE 4.0) adverse events. All patients whose cancer was MGMT-positive IHC were non-responders. Consistently, patients with MGMT-negative/low tumors had a significantly longer mPFS than others (6.9 versus 2.0 months; hazard ratio = 0.29, 95% CI 0.02-0.41; P = 0.003) and a non-significant trend for longer mOS. MB testing showed similar accuracy. Conclusions TEMIRI regimen is a safe and active option in pre-treated, irinotecan-sensitive mCRC patients with MGMT methylation.
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Affiliation(s)
- F Morano
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - S Corallo
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - M Niger
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - L Barault
- Department of Oncology, University of Turin, Candiolo, Turin, Italy; Candiolo Cancer Institute - FPO, IRCCS, Candiolo, Turin, Italy
| | - M Milione
- Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - R Berenato
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - R Moretto
- Unit of Medical Oncology 2, Department of Translational Research and New Technologies in Medicine and Surgery, Azienda Ospedaliera-Universitaria Pisana, University of Pisa, Pisa, Italy
| | - G Randon
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - M Antista
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - A Belfiore
- Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - A Raimondi
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - F Nichetti
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - A Martinetti
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - L Battaglia
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - F Perrone
- Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - G Pruneri
- Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Oncology and Hemato-Oncology Department, University of Milan, Milan, Italy
| | - A Falcone
- Unit of Medical Oncology 2, Department of Translational Research and New Technologies in Medicine and Surgery, Azienda Ospedaliera-Universitaria Pisana, University of Pisa, Pisa, Italy
| | - M Di Bartolomeo
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - F de Braud
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Oncology and Hemato-Oncology Department, University of Milan, Milan, Italy
| | - F Di Nicolantonio
- Department of Oncology, University of Turin, Candiolo, Turin, Italy; Candiolo Cancer Institute - FPO, IRCCS, Candiolo, Turin, Italy
| | - C Cremolini
- Unit of Medical Oncology 2, Department of Translational Research and New Technologies in Medicine and Surgery, Azienda Ospedaliera-Universitaria Pisana, University of Pisa, Pisa, Italy
| | - F Pietrantonio
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Oncology and Hemato-Oncology Department, University of Milan, Milan, Italy.
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23
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Clinical Characteristics and Outcome of Children With Relapsed Medulloblastoma: A Retrospective Study at a Single Center in China. J Pediatr Hematol Oncol 2018; 40:598-604. [PMID: 29927794 DOI: 10.1097/mph.0000000000001241] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Relapsed medulloblastoma (MB) has a dire prognosis, and chemotherapy remains the main therapeutic option. We retrospectively analyzed the clinical characteristics and survival rates of 60 Chinese children with relapsed MB. The patients received 11 cycles of chemotherapy in sequence, followed by 12 cycles of oral temozolomide and etoposide. Thirty patients were simultaneously administered intrathecal methotrexate (IT-MTX). The Kaplan-Meier method was used to determine survival rates; the patients' median survival time after relapse was 2.8 years, 5-year progression-free survival (PFS) and overall survival (OS) rates were 26.7%±5.7% and 31.6%±6.9%, respectively. There was no significant difference between these rates according to histology or molecular subgroup. Tumor cells were detected in the cerebrospinal fluid of over 40% of patients; such patients had significantly shorter OS and PFS rates. Patients who received IT-MTX showed significantly longer survival than those who did not (3.73 vs. 2.06 y, respectively, P=0.000); the corresponding 5-year PFS and OS rates were 43.3%±9.0% versus 10.0%±5.5% and 49.5%±11.1% versus 14.6%±6.9%, respectively (P=0.000). In addition, tumor cell-positive cerebrospinal fluid and IT-MTX use significantly influenced PFS and OS in relapsed patients. Taken together, our data show that IT-MTX improves the survival of patients with relapsed MB.
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24
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Hashimoto Y, Penas-Prado M, Zhou S, Wei J, Khatua S, Hodges TR, Sanai N, Xiu J, Gatalica Z, Kim L, Kesari S, Rao G, Spetzler D, Heimberger A. Rethinking medulloblastoma from a targeted therapeutics perspective. J Neurooncol 2018; 139:713-720. [PMID: 29869738 PMCID: PMC6132970 DOI: 10.1007/s11060-018-2917-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/30/2018] [Indexed: 01/23/2023]
Abstract
Introduction Medulloblastoma is an aggressive but potentially curable central nervous system tumor that remains a treatment challenge. Analysis of therapeutic targets can provide opportunities for the selection of agents. Methods Using multiplatform analysis, 36 medulloblastomas were extensively profiled from 2009 to 2015. Immunohistochemistry, next generation sequencing, chromogenic in situ hybridization, and fluorescence in situ hybridization were used to identify overexpressed proteins, immune checkpoint expression, mutations, tumor mutational load, and gene amplifications. Results High expression of MRP1 (89%, 8/9 tumors), TUBB3 (86%, 18/21 tumors), PTEN (85%, 28/33 tumors), TOP2A (84%, 26/31 tumors), thymidylate synthase (TS; 80%, 24/30 tumors), RRM1 (71%, 15/21 tumors), and TOP1 (63%, 19/30 tumors) were found in medulloblastoma. TOP1 was found to be enriched in metastatic tumors (90%; 9/10) relative to posterior fossa cases (50%; 10/20) (p = 0.0485, Fisher exact test), and there was a positive correlation between TOP2A and TOP1 expression (p = 0.0472). PD-1 + T cell tumor infiltration was rare, PD-L1 tumor expression was uncommon, and TML was low, indicating that immune checkpoint inhibitors as a monotherapy should not necessarily be prioritized for therapeutic consideration based on biomarker expression. Gene amplifications such as those of Her2 or EGFR were not found. Several unique mutations were identified, but their rarity indicates large-scale screening efforts would be necessary to identify sufficient patients for clinical trial inclusion. Conclusions Therapeutics are available for several of the frequently expressed targets, providing a justification for their consideration in the setting of medulloblastoma. Electronic supplementary material The online version of this article (10.1007/s11060-018-2917-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yuuri Hashimoto
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Marta Penas-Prado
- Department of Neuro-Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Shouhao Zhou
- Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Jun Wei
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Soumen Khatua
- Department of Pediatrics, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Tiffany R Hodges
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Nader Sanai
- Division of Neurosurgical Oncology, Barrow Neurological Institute, Phoenix, AZ, USA
| | | | | | - Lyndon Kim
- Department of Neurological Surgery and Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Santosh Kesari
- Department of Translational Neurosciences and Neurotherapeutics, Pacific Neuroscience Institute and John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Ganesh Rao
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | | | - Amy Heimberger
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA. .,Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Unit 442, Houston, TX, 77030, USA.
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25
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Kurimoto T, Kondo A, Ogino I, Fujimura J, Arakawa A, Arai H, Shimizu T. Effect of O 6-methylguanine-DNA methyltransferase methylation in medulloblastoma. Mol Clin Oncol 2017; 7:1107-1111. [PMID: 29285383 DOI: 10.3892/mco.2017.1431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 07/04/2017] [Indexed: 11/06/2022] Open
Abstract
Medulloblastoma is a highly malignant brain tumor that predominately affects children and requires multimodal treatment, including chemotherapy with alkylating agents. O6-methylguanine-DNA methyltransferase (MGMT) is a DNA repair enzyme that plays an important role in tumor resistance to alkylating agents. Recent studies demonstrated that MGMT promoter methylation suppresses the expression of MGMT and is associated with favorable outcomes of malignant glioma patients. However, the MGMT methylation status and its prognostic impact on medulloblastoma have not been fully elucidated to date. The objective of the present study was to investigate the association between MGMT status and clinical outcomes of pediatric medulloblastoma patients. The records of 15 patients with medulloblastoma treated at our institution were reviewed, and the methylation status of 18 CpG sites in the MGMT promoter region was determined using bisulfite sequencing analysis. A larger number of methylated CpG sites was identified in 9 patients with complete remission (median, 5 sites; range, 2-9 sites) compared with that in 6 patients with relapse (median, 2 sites, range, 1-4 sites; P=0.041). These results suggest that a higher number of methylated CpG sites in the MGMT promoter region are associated with a favorable outcome of medulloblastoma.
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Affiliation(s)
- Tomoko Kurimoto
- Department of Pediatrics, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan
| | - Akihide Kondo
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo 112-8421, Japan
| | - Ikuko Ogino
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo 112-8421, Japan
| | - Junya Fujimura
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo 112-8421, Japan
| | - Atsushi Arakawa
- Department of Pathology, Juntendo University Faculty of Medicine, Tokyo 112-8421, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo 112-8421, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo 112-8421, Japan
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26
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de Rojas T, Bautista F, Flores M, Igual L, Rubio R, Bardón E, Navarro L, Murillo L, Hladun R, Cañete A, Garcia-Ariza M, Garrido C, Fernández-Teijeiro A, Quiroga E, Calvo C, Llort A, de Prada I, Madero L, Cruz O, Moreno L. Management and outcome of children and adolescents with non-medulloblastoma CNS embryonal tumors in Spain: room for improvement in standards of care. J Neurooncol 2017; 137:205-213. [PMID: 29248974 DOI: 10.1007/s11060-017-2713-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 12/11/2017] [Indexed: 02/07/2023]
Abstract
Non-medulloblastoma CNS embryonal tumors (former PNET/Pineoblastomas) are aggressive malignancies with poor outcome that have been historically treated with medulloblastoma protocols. The purpose of this study is to present a tumor-specific, real-world data cohort of patients with CNS-PNET/PB to analyze quality indicators that can be implemented to improve the outcome of these patients. Patients 0-21 years with CNS-PNET treated in eight large institutions were included. Baseline characteristics, treatment and outcome [progression-free and overall survival (PFS and OS respectively)] were analyzed. From 2005 to 2014, 43 patients fulfilled entry criteria. Median age at diagnosis was 3.6 years (range 0.0-14.7). Histology was pineoblastoma (9%), ependymoblastoma (5%), ETANTR (7%) and PNET (77%). Median duration of the main symptom was 2 weeks (range 0-12). At diagnosis, 28% presented with metastatic disease. Seventeen different protocols were used on frontline treatment; 44% had gross total resection, 42% craniospinal radiotherapy, 86% chemotherapy, and 33% autologous hematopoietic stem cell transplantation (aHSCT). Median follow-up for survivors was 3.5 years (range 1.7-9.3). 3-year PFS was 31.9% (95% CI 17-47%) and OS 35.1% (95% CI 20-50%). Age, extent of resection and radiotherapy were prognostic of PFS and OS in univariate analysis (p < 0.05). Our series shows a dismal outcome for CNS-PNET, especially when compared to patients included in clinical trials. Establishing a common national strategy, implementing referral circuits and collaboration networks, and incorporating new molecular knowledge into routine clinical practice are accessible measures that can improve the outcome of these patients.
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Affiliation(s)
- Teresa de Rojas
- Pediatric Oncology Department, Hospital Niño Jesús, Av. Menéndez Pelayo, 65, 28009, Madrid, Spain
| | - Francisco Bautista
- Pediatric Oncology Department, Hospital Niño Jesús, Av. Menéndez Pelayo, 65, 28009, Madrid, Spain
| | - Miguel Flores
- Pediatric Oncology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Lucía Igual
- Pediatric Oncology Department, Hospital La Fe, Valencia, Spain
| | - Raquel Rubio
- Pediatric Oncology Department, Hospital Cruces, Bilbao, Spain
| | - Eduardo Bardón
- Pediatric Oncology Department, Hospital Gregorio Marañón, Madrid, Spain
| | - Lucía Navarro
- Pediatric Oncology Department, Hospital Virgen del Rocío, Sevilla, Spain
| | - Laura Murillo
- Pediatric Oncology Department, Hospital Miguel Servet, Zaragoza, Spain
| | - Raquel Hladun
- Pediatric Oncology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Adela Cañete
- Pediatric Oncology Department, Hospital La Fe, Valencia, Spain
| | | | - Carmen Garrido
- Pediatric Oncology Department, Hospital Gregorio Marañón, Madrid, Spain
| | | | - Eduardo Quiroga
- Pediatric Oncology Department, Hospital Virgen del Rocío, Sevilla, Spain
| | - Carlota Calvo
- Pediatric Oncology Department, Hospital Miguel Servet, Zaragoza, Spain
| | - Anna Llort
- Pediatric Oncology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Luis Madero
- Pediatric Oncology Department, Hospital Niño Jesús, Av. Menéndez Pelayo, 65, 28009, Madrid, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Ofelia Cruz
- Pediatric Oncology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Lucas Moreno
- Pediatric Oncology Department, Hospital Niño Jesús, Av. Menéndez Pelayo, 65, 28009, Madrid, Spain. .,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.
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Bulbul A, Fahy BN, Xiu J, Rashad S, Mustafa A, Husain H, Hayes-Jordan A. Desmoplastic Small Round Blue Cell Tumor: A Review of Treatment and Potential Therapeutic Genomic Alterations. Sarcoma 2017; 2017:1278268. [PMID: 29225486 PMCID: PMC5687144 DOI: 10.1155/2017/1278268] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 09/17/2017] [Indexed: 02/07/2023] Open
Abstract
Desmoplastic small round blue cell tumors (DSRCTs) originate from a cell with multilineage potential. A molecular hallmark of DSRCT is the EWS-WT1 reciprocal translocation. Ewing sarcoma and DSRCT are treated similarly due to similar oncogene activation pathways, and DSRCT has been represented in very limited numbers in sarcoma studies. Despite aggressive therapy, median survival ranges from 17 to 25 months, and 5-year survival rates remain around 15%, with higher survival reported among those undergoing removal of at least 90% of tumor in the absence of extraperitoneal metastasis. Almost 100% of these tumors contain t(11;22) (p13;q12) translocation, and it is likely that EWS-WT1 functions as a transcription factor possibly through WT1 targets. While there is no standard protocol for this aggressive disease, treatment usually includes the neoadjuvant HD P6 regimen (high-dose cyclophosphamide, doxorubicin, and vincristine (HD-CAV) alternating with ifosfamide and etoposide (IE) chemotherapy combined with aggressively attempted R0 resection). We aimed to review the molecular characteristics of DSRCTs to explore therapeutic opportunities for this extremely rare and aggressive cancer type.
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Affiliation(s)
- Ajaz Bulbul
- Department of Hematology/Oncology, Kymera Independent Physicians, Carlsbad, NM, USA
- Division of Internal Medicine, Department of Hematology/Oncology, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX, USA
| | - Bridget Noel Fahy
- Department of Surgery, University of New Mexico, Albuquerque, NM, USA
| | | | - Sadaf Rashad
- All Saints University School of Medicine, Roseau, Dominica
| | - Asrar Mustafa
- Acharya Shri Chander College of Medical Sciences and Hospital, Jammu, India
| | - Hatim Husain
- Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA
| | - Andrea Hayes-Jordan
- Department of Pediatric Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Bautista F, Fioravantti V, de Rojas T, Carceller F, Madero L, Lassaletta A, Moreno L. Medulloblastoma in children and adolescents: a systematic review of contemporary phase I and II clinical trials and biology update. Cancer Med 2017; 6:2606-2624. [PMID: 28980418 PMCID: PMC5673921 DOI: 10.1002/cam4.1171] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 12/12/2022] Open
Abstract
Survival rates for patients with medulloblastoma have improved in the last decades but for those who relapse outcome is dismal and new approaches are needed. Emerging drugs have been tested in the last two decades within the context of phase I/II trials. In parallel, advances in genetic profiling have permitted to identify key molecular alterations for which new strategies are being developed. We performed a systematic review focused on the design and outcome of early-phase trials evaluating new agents in patients with relapsed medulloblastoma. PubMed, clinicaltrials.gov, and references from selected studies were screened to identify phase I/II studies with reported results between 2000 and 2015 including patients with medulloblastoma aged <18 years. A total of 718 studies were reviewed and 78 satisfied eligibility criteria. Of those, 69% were phase I; 31% phase II. Half evaluated conventional chemotherapeutics and 35% targeted agents. Overall, 662 patients with medulloblastoma/primitive neuroectodermal tumors were included. The study designs and the response assessments were heterogeneous, limiting the comparisons among trials and the correct identification of active drugs. Median (range) objective response rate (ORR) for patients with medulloblastoma in phase I/II studies was 0% (0-100) and 6.5% (0-50), respectively. Temozolomide containing regimens had a median ORR of 16.5% (0-100). Smoothened inhibitors trials had a median ORR of 8% (3-8). Novel drugs have shown limited activity against relapsed medulloblastoma. Temozolomide might serve as backbone for new combinations. Novel and more homogenous trial designs might facilitate the development of new drugs.
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Affiliation(s)
- Francisco Bautista
- CNIO‐HNJ Clinical Research UnitPediatric Oncology, Hematology and Stem Cell Transplant DepartmentHospital Infantil Universitario Niño JesúsAvenida Menéndez Pelayo, 6528009MadridSpain
| | - Victoria Fioravantti
- CNIO‐HNJ Clinical Research UnitPediatric Oncology, Hematology and Stem Cell Transplant DepartmentHospital Infantil Universitario Niño JesúsAvenida Menéndez Pelayo, 6528009MadridSpain
| | - Teresa de Rojas
- CNIO‐HNJ Clinical Research UnitPediatric Oncology, Hematology and Stem Cell Transplant DepartmentHospital Infantil Universitario Niño JesúsAvenida Menéndez Pelayo, 6528009MadridSpain
| | - Fernando Carceller
- Pediatric and Adolescent Drug Development, Children and Young People's UnitThe Royal Marsden NHS Foundation TrustLondonUK
- Division of Clinical Studies and Cancer TherapeuticsThe Institute of Cancer ResearchLondonUK
| | - Luis Madero
- CNIO‐HNJ Clinical Research UnitPediatric Oncology, Hematology and Stem Cell Transplant DepartmentHospital Infantil Universitario Niño JesúsAvenida Menéndez Pelayo, 6528009MadridSpain
| | - Alvaro Lassaletta
- CNIO‐HNJ Clinical Research UnitPediatric Oncology, Hematology and Stem Cell Transplant DepartmentHospital Infantil Universitario Niño JesúsAvenida Menéndez Pelayo, 6528009MadridSpain
| | - Lucas Moreno
- CNIO‐HNJ Clinical Research UnitPediatric Oncology, Hematology and Stem Cell Transplant DepartmentHospital Infantil Universitario Niño JesúsAvenida Menéndez Pelayo, 6528009MadridSpain
- Instituto de Investigación La PrincesaMadridSpain
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Bautista F, Gallego S, Cañete A, Mora J, Díaz de Heredia C, Cruz O, Fernández JM, Rives S, Berlanga P, Hladun R, Juan Ribelles A, Madero L, Ramírez M, Fernández Delgado R, Pérez-Martínez A, Mata C, Llort A, Martín Broto J, Cela ME, Ramírez G, Sábado C, Acha T, Astigarraga I, Sastre A, Muñoz A, Guibelalde M, Moreno L. Early clinical trials in paediatric oncology in Spain: A nationwide perspective. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.anpede.2016.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Esbenshade AJ, Kocak M, Hershon L, Rousseau P, Decarie JC, Shaw S, Burger P, Friedman HS, Gajjar A, Moghrabi A. A Phase II feasibility study of oral etoposide given concurrently with radiotherapy followed by dose intensive adjuvant chemotherapy for children with newly diagnosed high-risk medulloblastoma (protocol POG 9631): A report from the Children's Oncology Group. Pediatr Blood Cancer 2017; 64:10.1002/pbc.26373. [PMID: 28000417 PMCID: PMC5541391 DOI: 10.1002/pbc.26373] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 10/13/2016] [Accepted: 10/25/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Children with high-risk medulloblastoma historically have had a poor prognosis. The Children's Oncology Group completed a Phase II study using oral etoposide given with radiotherapy followed by intensive chemotherapy. PROCEDURE Patients enrolled in the study had high-risk disease defined as ≥1.5 cm2 of residual disease postsurgery or definite evidence of central nervous metastasis. All patients underwent surgery followed by radiotherapy. During radiation, the patients received oral etoposide (21 days on, 7 off) at an initial dose of 50 mg/m2 per day (treatment 1), which was reduced to 35 mg/m2 per day (treatment 2) due to toxicity. After radiotherapy, the patients received chemotherapy with three cycles of cisplatin and oral etoposide, followed by eight courses of cyclophosphamide and vincristine. RESULTS Between November 1998 and October 2002, 53 patients were accrued; 15 received treatment 1 and 38 treatment 2. Forty-seven patients (89%) were eligible. Response to radiation was excellent, with 19 (40.4%) showing complete response, 24 (51.1%) partial response, and four (8.5%) no recorded response. The overall 2- and 5-year progression-free survival (PFS) was 76.6 ± 6% and 70.2 ± 7%, respectively. The 2- and 5-year overall survival (OS) was 80.9 ± 6% and 76.6 ± 6%, respectively. Clinical response postradiation and PFS/OS were not significantly different between the treatment groups. There was a trend toward a difference in 5-year PFS between those without and with metastatic disease (P = 0.072). CONCLUSIONS Oral etoposide was tolerable at 35 mg/m2 (21 days on and 7 days off) when given during full-dose irradiation in patients with high-risk medulloblastoma with encouraging survival data.
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Affiliation(s)
- Adam J. Esbenshade
- Monroe Carrell Jr. Children’s Hospital at Vanderbilt and Vanderbilt Ingram Cancer Center
| | - Mehmet Kocak
- University of Tennessee, Health Science Center, Memphis, TN; Nashville, TN
| | - Linda Hershon
- Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Pierre Rousseau
- Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | | | - Susan Shaw
- State University of New York Upstate Medical University, Syracuse, NY
| | | | | | - Amar Gajjar
- St. Jude Children’s Research Hospital, Memphis, TN
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31
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Bautista F, Gallego S, Cañete A, Mora J, Díaz de Heredia C, Cruz O, Fernández JM, Rives S, Berlanga P, Hladun R, Juan Ribelles A, Madero L, Ramírez M, Fernández Delgado R, Pérez-Martínez A, Mata C, Llort A, Martín Broto J, Cela ME, Ramírez G, Sábado C, Acha T, Astigarraga I, Sastre A, Muñoz A, Guibelalde M, Moreno L. [Early clinical trials in paediatric oncology in Spain: a nationwide perspective]. An Pediatr (Barc) 2017; 87:155-163. [PMID: 28279690 DOI: 10.1016/j.anpedi.2016.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/24/2016] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Cancer is the leading cause of death between the first year of life and adolescence, and some types of diseases are still a major challenge in terms of cure. There is, therefore, a major need for new drugs. Recent findings in cancer biology open the door to the development of targeted therapies against individual molecular changes, as well as immunotherapy. Promising results in adult anti-cancer drug development have not yet been translated into paediatric clinical practice. A report is presented on the activity in early paediatric oncology trials (phase I-II) in Spain. MATERIAL AND METHODS All members of the Spanish Society of Paediatric Haematology Oncology (SEHOP) were contacted in order to identify early clinical trials in paediatric cancer opened between 2005 and 2015. RESULTS A total of 30 trials had been opened in this period: 21 (70%) in solid tumours, and 9 (30%) in malignant haemopathies. A total of 212 patients have been enrolled. The majority was industry sponsored (53%). Since 2010, four centres have joined the international consortium of Innovative Therapies for Children with Cancer (ITCC), which has as its aim to develop novel therapies for paediatric tumours. A significant number of new studies have opened since 2010, improving the treatment opportunities for our children. Results of recently closed trials show the contribution of Spanish investigators, the introduction of molecularly targeted agents, and their benefits. CONCLUSIONS The activity in clinical trials has increased in the years analysed. The SEHOP is committed to develop and participate in collaborative academic trials, in order to help in the advancement and optimisation of existing therapies in paediatric cancer.
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Affiliation(s)
- Francisco Bautista
- Unidad de Investigación Clínica CNIO-HNJ, Servicio de Hematología, Oncología y Trasplante de Progenitores Hematopoyéticos, Hospital Infantil Universitario Niño Jesús, Madrid, España.
| | - Soledad Gallego
- Unidad de Oncología Pediátrica, Hospital Vall d'Hebron, Barcelona, España
| | - Adela Cañete
- Unidad de Oncología Pediátrica, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Jaume Mora
- Unidad de Oncología Pediátrica, Hospital Sant Joan de Déu, Barcelona, España
| | | | - Ofelia Cruz
- Unidad de Oncología Pediátrica, Hospital Sant Joan de Déu, Barcelona, España
| | - José María Fernández
- Unidad de Oncología Pediátrica, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Susana Rives
- Unidad de Oncología Pediátrica, Hospital Sant Joan de Déu, Barcelona, España
| | - Pablo Berlanga
- Unidad de Oncología Pediátrica, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Raquel Hladun
- Unidad de Oncología Pediátrica, Hospital Vall d'Hebron, Barcelona, España
| | - Antonio Juan Ribelles
- Unidad de Oncología Pediátrica, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Luis Madero
- Unidad de Investigación Clínica CNIO-HNJ, Servicio de Hematología, Oncología y Trasplante de Progenitores Hematopoyéticos, Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Manuel Ramírez
- Unidad de Investigación Clínica CNIO-HNJ, Servicio de Hematología, Oncología y Trasplante de Progenitores Hematopoyéticos, Hospital Infantil Universitario Niño Jesús, Madrid, España
| | | | | | - Cristina Mata
- Unidad de Oncología Pediátrica, Hospital Gregorio Marañón, Madrid, España
| | - Anna Llort
- Unidad de Oncología Pediátrica, Hospital Vall d'Hebron, Barcelona, España
| | | | - María Elena Cela
- Unidad de Oncología Pediátrica, Hospital Gregorio Marañón, Madrid, España
| | - Gema Ramírez
- Unidad de Oncología Pediátrica, Hospital Virgen del Rocío, Sevilla, España
| | - Constantino Sábado
- Unidad de Oncología Pediátrica, Hospital Vall d'Hebron, Barcelona, España
| | - Tomás Acha
- Unidad de Oncología Pediátrica, Hospital Carlos Haya, Málaga, España
| | - Itziar Astigarraga
- Unidad de Oncología Pediátrica, Hospital Universitario Cruces, Barakaldo, IIS BioCruces, Universidad del País Vasco (UPV/EHU), España
| | - Ana Sastre
- Unidad de Oncología Pediátrica, Hospital La Paz, Madrid, España
| | - Ascensión Muñoz
- Unidad de Oncología Pediátrica, Hospital Miguel Servet, Zaragoza, España
| | - Mercedes Guibelalde
- Unidad de Oncología Pediátrica, Hospital Universitario Son Espases, Palma de Mallorca, España
| | - Lucas Moreno
- Unidad de Investigación Clínica CNIO-HNJ, Servicio de Hematología, Oncología y Trasplante de Progenitores Hematopoyéticos, Hospital Infantil Universitario Niño Jesús, Madrid, España; Instituto de Investigación La Princesa, Madrid, España
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Daudigeos-Dubus E, Le Dret L, Lanvers-Kaminsky C, Bawa O, Opolon P, Vievard A, Villa I, Pagès M, Bosq J, Vassal G, Zopf D, Geoerger B. Regorafenib: Antitumor Activity upon Mono and Combination Therapy in Preclinical Pediatric Malignancy Models. PLoS One 2015; 10:e0142612. [PMID: 26599335 PMCID: PMC4658168 DOI: 10.1371/journal.pone.0142612] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 10/05/2015] [Indexed: 12/14/2022] Open
Abstract
The multikinase inhibitor regorafenib (BAY 73-4506) exerts both anti-angiogenic and anti-tumorigenic activity in adult solid malignancies mainly advanced colorectal cancer and gastrointestinal stromal tumors. We intended to explore preclinically the potential of regorafenib against solid pediatric malignancies alone and in combination with anticancer agents to guide the pediatric development plan. In vitro effects on cell proliferation were screened against 33 solid tumor cell lines of the Innovative Therapies for Children with Cancer (ITCC) panel covering five pediatric solid malignancies. Regorafenib inhibited cell proliferation with a mean half maximal growth inhibition of 12.5 μmol/L (range 0.7 μmol/L to 28 μmol/L). In vivo, regorafenib was evaluated alone at 10 or 30 mg/kg/d or in combination with radiation, irinotecan or the mitogen-activated protein kinase kinase (MEK) inhibitor refametinib against various tumor types, including patient-derived brain tumor models with an amplified platelet-derived growth factor receptor A (PDGFRA) gene. Regorafenib alone significantly inhibited tumor growth in all xenografts derived from nervous system and connective tissue tumors. Enhanced effects were observed when regorafenib was combined with irradiation and irinotecan against PDGFRA amplified IGRG93 glioma and IGRM57 medulloblastoma respectively, resulting in 100% tumor regressions. Antitumor activity was associated with decreased tumor vascularization, inhibition of PDGFR signaling, and induction of apoptotic cell death. Our work demonstrates that regorafenib exhibits significant antitumor activity in a wide spectrum of preclinical pediatric models through inhibition of angiogenesis and induction of apoptosis. Furthermore, radio- and chemosensitizing effects were observed with DNA damaging agents in PDGFR amplified tumors.
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Affiliation(s)
- Estelle Daudigeos-Dubus
- Université Paris-Sud 11, Vectorology and Anticancer Therapeutics, UMR 8203, Villejuif, France
- CNRS, Vectorology and Anticancer Therapeutics, UMR 8203, Orsay, France
- Gustave Roussy, Vectorology and Anticancer Therapeutics, UMR 8203, Villejuif, France
| | - Ludivine Le Dret
- Université Paris-Sud 11, Vectorology and Anticancer Therapeutics, UMR 8203, Villejuif, France
- CNRS, Vectorology and Anticancer Therapeutics, UMR 8203, Orsay, France
- Gustave Roussy, Vectorology and Anticancer Therapeutics, UMR 8203, Villejuif, France
| | - Claudia Lanvers-Kaminsky
- University Children’s Hospital, Department of Pediatric Hematology and Oncology, Münster, Germany
| | - Olivia Bawa
- PFEP (Plateforme d’évaluation préclinique), Gustave Roussy, Villejuif, France
| | - Paule Opolon
- PFEP (Plateforme d’évaluation préclinique), Gustave Roussy, Villejuif, France
| | | | - Irène Villa
- Pathology Laboratory, Gustave Roussy, Villejuif, France
| | - Mélanie Pagès
- Department of Neuropathology, Sainte-Anne’s Hospital, Paris, France
- Paris Descartes University, Paris, France
| | - Jacques Bosq
- Pathology Laboratory, Gustave Roussy, Villejuif, France
| | - Gilles Vassal
- Université Paris-Sud 11, Vectorology and Anticancer Therapeutics, UMR 8203, Villejuif, France
- CNRS, Vectorology and Anticancer Therapeutics, UMR 8203, Orsay, France
- Gustave Roussy, Vectorology and Anticancer Therapeutics, UMR 8203, Villejuif, France
| | - Dieter Zopf
- Bayer Pharma Aktiengesellschaft, Berlin, Germany
| | - Birgit Geoerger
- Université Paris-Sud 11, Vectorology and Anticancer Therapeutics, UMR 8203, Villejuif, France
- CNRS, Vectorology and Anticancer Therapeutics, UMR 8203, Orsay, France
- Gustave Roussy, Vectorology and Anticancer Therapeutics, UMR 8203, Villejuif, France
- * E-mail:
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Braun S, Bauer I, Pannen B, Werdehausen R. Pretreatment but not subsequent coincubation with midazolam reduces the cytotoxicity of temozolomide in neuroblastoma cells. BMC Anesthesiol 2015; 15:151. [PMID: 26475338 PMCID: PMC4609078 DOI: 10.1186/s12871-015-0135-4] [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] [Received: 07/17/2015] [Accepted: 10/08/2015] [Indexed: 11/23/2022] Open
Abstract
Background Temozolomide (TMZ) induces a G2/M cell cycle arrest and is used for treatment of paediatric tumours, especially neuroblastomas. Patients treated with TMZ frequently receive midazolam for sedation prior to surgery and other interventions. Previous studies suggested both cytoprotective and apoptosis-inducing properties of midazolam. Therefore, the impact of midazolam on TMZ-induced cytotoxicity was investigated in vitro. Methods Human neuroblastoma cells were incubated with midazolam alone, as a pretreatment prior to incubation with TMZ or a coincubation of both. Cell viability and proliferation was analysed (XTT and BrdU assay) after 24 h and flowcytometric cell cycle analysis was performed after 24 and 48 h. Results Midazolam alone increased cell viability at lower concentrations (2, 4, 8, 16 μM), whereas higher concentrations (128, 256, 512 μM) reduced cell viability. Pretreatment with midazolam 6 h prior to TMZ incubation reduced cytotoxic effects (IC25 1005 ± 197 μM; IC50 1676 ± 557 μM; P < 0.05) compared to incubation with TMZ alone (IC25 449 ± 304 μM; IC50 925 ± 196 μM) and reduced the antiproliferative effect of TMZ (1000 μM) by 43.9 % (P < 0.05). In contrast, cytotoxic effects of TMZ were increased (IC75 1175 ± 221 μM vs. 2764 ± 307 μM; P < 0.05) when midazolam pretreatment was followed by coincubation of midazolam and TMZ. Cell cycle analysis revealed increased fractions of cells in G2/M phase after TMZ treatment (100 μM; 48 h), irrespective of midazolam pretreatment. Conclusion Midazolam causes a hormetic dose–response relationship in human neuroblastoma cells. Pretreatment with midazolam reduces the cytotoxic and antiproliferative effects of TMZ without interfering with G2/M cell cycle arrest. In contrast, subsequent midazolam coincubation increases overall cytotoxicity.
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Affiliation(s)
- Sebastian Braun
- Department of Anaesthesiology, University Hospital Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Inge Bauer
- Department of Anaesthesiology, University Hospital Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Benedikt Pannen
- Department of Anaesthesiology, University Hospital Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Robert Werdehausen
- Department of Anaesthesiology, University Hospital Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
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Patients in pediatric phase I and early phase II clinical oncology trials at Gustave Roussy: a 13-year center experience. J Pediatr Hematol Oncol 2015; 37:e102-10. [PMID: 25171452 DOI: 10.1097/mph.0000000000000237] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In the European Union, the pediatric medicines regulation in 2007 modified significantly the access to new agents in pediatric oncology. Early oncology trials are still thought to be associated with limited benefit and substantial risk. We report the characteristics and outcome of patients below 21 years enrolled in investigational trials in the Pediatric and Adolescent Department at Gustave Roussy between January 2000 and December 2012. A total of 235 patients (median age, 10.4 [0.8 to 20.7] y) were included in 26 trials (16 cytotoxic and 10 targeted agents) for a total of 260 inclusions. A total of 117 patients (50%) had brain tumors and 68 (29%) had various soft tissue and bone sarcoma. Thirteen of the 106 patients in a phase I trial experienced dose-limiting toxicity. Main severe toxicity was hematologic; none had toxic death. Grade 3 to 4 toxicities were associated with combination trials, cytotoxic agent, and at least 1 previous line of therapy. Thirty patients (12%) had objective response and 42 (16%) had stable disease for >4 months. Median overall survival was 9.0 months (95% CI, 7.5-10.5) and 73% of patients received further anticancer treatment. Phase I to II pediatric oncology trials are safe, associated with clinical benefit, and can be successfully integrated in current relapse strategies.
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Vassal G, Rousseau R, Blanc P, Moreno L, Bode G, Schwoch S, Schrappe M, Skolnik J, Bergman L, Bradley-Garelik MB, Saha V, Pearson A, Zwierzina H. Creating a unique, multi-stakeholder Paediatric Oncology Platform to improve drug development for children and adolescents with cancer. Eur J Cancer 2014; 51:218-24. [PMID: 25434924 DOI: 10.1016/j.ejca.2014.10.029] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 10/28/2014] [Indexed: 11/26/2022]
Abstract
Seven years after the launch of the European Paediatric Medicine Regulation, limited progress in paediatric oncology drug development remains a major concern amongst stakeholders - academics, industry, regulatory authorities, parents, patients and caregivers. Restricted increases in early phase paediatric oncology trials, legal requirements and regulatory pressure to propose early Paediatric Investigation Plans (PIPs), missed opportunities to explore new drugs potentially relevant for paediatric malignancies, lack of innovative trial designs and no new incentives to develop drugs against specific paediatric targets are some unmet needs. Better access to new anti-cancer drugs for paediatric clinical studies and improved collaboration between stakeholders are essential. The Cancer Drug Development Forum (CDDF), previously Biotherapy Development Association (BDA), with Innovative Therapy for Children with Cancer Consortium (ITCC), European Society for Paediatric Oncology (SIOPE) and European Network for Cancer Research in Children and Adolescents (ENCCA) has created a unique Paediatric Oncology Platform, involving multiple stakeholders and the European Union (EU) Commission, with an urgent remit to improve paediatric oncology drug development. The Paediatric Oncology Platform proposes to recommend immediate changes in the implementation of the Regulation and set the framework for its 2017 revision; initiatives to incentivise drug development against specific paediatric oncology targets, and repositioning of drugs not developed in adults. Underpinning these changes is a strategy for mechanism of action and biology driven selection and prioritisation of potential paediatric indications rather than the current process based on adult cancer indications. Pre-competitive research and drug prioritisation, early portfolio evaluation, cross-industry cooperation and multi-compound/sponsor trials are being explored, from which guidance for innovative trial designs will be provided.
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Affiliation(s)
- Gilles Vassal
- Department of Clinical Research, Institut Gustave Roussy, Paris-Sud University, Paris, France.
| | | | - Patricia Blanc
- Imagine for Margo, 9 Avenue Eric Tabarly, 78112 Fourqueux, France.
| | - Lucas Moreno
- CNIO Centro Nacional de Investigaciones Oncológicas, C/ Melchor Fernández Almagro, 3, E-28029 Madrid, Spain.
| | - Gerlind Bode
- International Confederation of Childhood Cancer Parent Organizations, Schouwstede 2B, 3431 JB Nieuwegein, The Netherlands.
| | - Stefan Schwoch
- Eli Lilly, Erl Wood Manor, Sunninghill Road, Windlesham, Surrey GU20 6PH, UK.
| | - Martin Schrappe
- Department of General Pediatrics, Christian-Albrechts-University and Medical Centre Schleswig-Holstein, Campus Kiel, Schwanenweg 20, D-24105 Kiel, Germany.
| | - Jeffrey Skolnik
- GlaxoSmithKline, 5 Crescent Drive, Philadelphia, PA 19112, USA.
| | - Lothar Bergman
- Medizinische Klinik II, J.W. Goethe Universität, D-60590 Frankfurt, Germany.
| | | | - Vaskar Saha
- Institute of Cancer Sciences, The University of Manchester, Manchester Academic Health Science Centre, 550 Wilmslow Rd, Manchester M20 4BX, UK.
| | - Andy Pearson
- The Institute of Cancer Research, The Royal Marsden NHS Foundation Trust, 15 Cotswold Road, Sutton, London SM2 5NG, UK.
| | - Heinz Zwierzina
- Medizinische Universität Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
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