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Valvi S, Manoharan N, Mateos MK, Hassall TE, Ziegler DS, McCowage GB, Dun MD, Eisenstat DD, Gottardo NG, Hansford JR. Management of patients with diffuse intrinsic pontine glioma in Australia and New Zealand: Australian and New Zealand Children's Haematology/Oncology Group position statement. Med J Aust 2024; 220:533-538. [PMID: 38699949 DOI: 10.5694/mja2.52295] [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: 08/16/2023] [Accepted: 03/26/2024] [Indexed: 05/05/2024]
Abstract
INTRODUCTION The main mission of the Australian and New Zealand Children's Haematology and Oncology Group (ANZCHOG) is to develop and facilitate local access to the world's leading evidence-based clinical trials for all paediatric cancers, including brain tumours, as soon as practically possible. Diffuse intrinsic pontine gliomas (DIPGs) - a subset of a larger group of tumours now termed diffuse midline glioma, H3K27-altered (DMG) - are paediatric brain cancers with less than 10% survival at two years. In the absence of any proven curative therapies, significant recent advancements have been made in pre-clinical and clinical research, leading many to seek integration of novel therapies early into standard practice. Despite these innovative therapeutic approaches, DIPG remains an incurable disease for which novel surgical, imaging, diagnostic, radiation and systemic therapy approaches are needed. MAIN RECOMMENDATIONS All patients with DIPG should be discussed in multidisciplinary neuro-oncology meetings (including pathologists, neuroradiologists, radiation oncologists, neurosurgeons, medical oncologists) at diagnosis and at relapse or progression. Radiation therapy to the involved field remains the local and international standard of care treatment. Proton therapy does not yield a superior survival outcome compared with photon therapy and patients should undergo radiation therapy with the available modality (photon or proton) at their treatment centre. Patients may receive concurrent chemotherapy or radiation-sensitising agents as part of a clinical trial. Biopsy should be offered to facilitate consideration of experimental therapies and eligibility for clinical trial participation. After radiation therapy, each patient should be managed individually with either observation or considered for enrolment on a clinical trial, if eligible, after full discussion with the family. Re-irradiation can be considered for progressive disease. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINE Every child diagnosed with DIPG should be offered enrolment on a clinical trial where available. Access to investigational drugs without biological rationale outside the clinical trial setting is not supported. In case of potentially actionable target identification with molecular profiling and absence of a suitable clinical trial, rational targeted therapies can be considered through compassionate access programs.
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Affiliation(s)
- Santosh Valvi
- Perth Children's Hospital, Perth, WA
- Telethon Kids Institute, Perth, WA
- University of Western Australia, Perth, WA
| | - Neevika Manoharan
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, Sydney, NSW
- University of New South Wales, Sydney, NSW
| | - Marion K Mateos
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, Sydney, NSW
- University of New South Wales, Sydney, NSW
| | - Timothy Eg Hassall
- Queensland Children's Hospital, Brisbane, QLD
- Frazer Institute, University of Queensland, Brisbane, QLD
| | - David S Ziegler
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, Sydney, NSW
- University of New South Wales, Sydney, NSW
| | | | - Matthew D Dun
- University of Newcastle, Newcastle, NSW
- Hunter Medical Research Institute, Newcastle, NSW
| | - David D Eisenstat
- Children's Cancer Centre, Royal Children's Hospital Melbourne, Melbourne, VIC
- Murdoch Children's Research Institute, Melbourne, VIC
- University of Melbourne, Melbourne, VIC
| | | | - Jordan R Hansford
- Women's and Children's Hospital, Adelaide, SA
- South Australian Health and Medical Research Institute, Adelaide, SA
- University of Adelaide, Adelaide, SA
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Mankuzhy NP, Tringale KR, Dunkel IJ, Farouk Sait S, Souweidane MM, Khakoo Y, Karajannis MA, Wolden S. Hypofractionated re-irradiation for diffuse intrinsic pontine glioma. Pediatr Blood Cancer 2024; 71:e30929. [PMID: 38430472 DOI: 10.1002/pbc.30929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Re-irradiation (reRT) increases survival in locally recurrent diffuse intrinsic pontine glioma (DIPG). There is no standard dose and fractionation for reRT, but conventional fractionation (CF) is typically used. We report our institutional experience of reRT for DIPG, which includes hypofractionation (HF). METHODS We reviewed pediatric patients treated with brainstem reRT for DIPG at our institution from 2012 to 2022. Patients were grouped by HF or CF. Outcomes included steroid use, and overall survival (OS) was measured from both diagnosis and start of reRT. RESULTS Of 22 patients who received reRT for DIPG, two did not complete their course due to clinical decline. Of the 20 who completed reRT, the dose was 20-30 Gy in 2-Gy fractions (n = 6) and 30-36 Gy in 3-Gy fractions (n = 14). Median age was 5 years (range: 3-14), median interval since initial RT was 8 months (range: 3-20), and 12 received concurrent bevacizumab. Median OS from diagnosis was 18 months [95% confidence interval: 17-24]. Median OS from start of reRT for HF versus CF was 8.2 and 7.5 months, respectively (p = .20). Thirteen (93%) in the HF group and three (75%) in the CF group tapered pre-treatment steroid dose down or off within 2 months after reRT due to clinical improvement. There was no significant difference in steroid taper between HF and CF (p = .4). No patients developed radionecrosis. CONCLUSION reRT with HF achieved survival duration comparable to published outcomes and effectively palliated symptoms. Future investigation of this regimen in the context of new systemic therapies and upfront HF is warranted.
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Affiliation(s)
- Nikhil P Mankuzhy
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kathryn R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ira J Dunkel
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sameer Farouk Sait
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mark M Souweidane
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yasmin Khakoo
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Matthias A Karajannis
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Cacciotti C, Wright KD. Advances in Treatment of Diffuse Midline Gliomas. Curr Neurol Neurosci Rep 2023; 23:849-856. [PMID: 37921944 DOI: 10.1007/s11910-023-01317-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 11/05/2023]
Abstract
PURPOSE OF REVIEW Diffuse midline gliomas (DMGs) generally carry a poor prognosis, occur during childhood, and involve midline structures of the central nervous system, including the thalamus, pons, and spinal cord. RECENT FINDINGS To date, irradiation has been shown to be the only beneficial treatment for DMG. Various genetic modifications have been shown to play a role in the pathogenesis of this disease. Current treatment strategies span targeting epigenetic dysregulation, cell cycle, specific genetic alterations, and the immune microenvironment. Herein, we review the complex features of this disease as it relates to current and past therapeutic approaches.
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Affiliation(s)
- Chantel Cacciotti
- Children's Hospital London Health Sciences/Western University, London, ON, Canada.
| | - Karen D Wright
- Dana Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
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Bergengruen PM, Hernaíz Driever P, Budach V, Zips D, Grün A. Second course of re-irradiation in pediatric diffuse intrinsic pontine glioma : A case study. Strahlenther Onkol 2023; 199:773-777. [PMID: 36862153 PMCID: PMC10361911 DOI: 10.1007/s00066-023-02057-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/05/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE Concomitant chemoradiation followed by repeat (dose-deescalated) irradiation has become standard of care in treating childhood diffuse intrinsic pontine glioma (DIPG) during first line treatment and at first progression. Progression after re-irradiation (re-RT) is in most cases symptomatic and either treated systemically with chemotherapy or new innovative approaches including targeted therapy. Alternatively, the patient receives best supportive care. Data on second re-irradiation in DIPG patients with second progression and good performance status are sparse. This is a case report of second short-term re-irradiation to shed further light on this option. METHODS Retrospective case report of a 6-year-old boy with DIPG receiving a second course of re-irradiation (with 21.6 Gy) as part of an individual multimodal approach in a patient with very low symptom burden. RESULTS The second course of re-irradiation was feasible and well tolerated. No acute neurological symptoms or radiation-induced toxicity occurred. Overall survival was 24 months after initial diagnosis. CONCLUSION A second course of re-irradiation can be an additional tool in patients with progressive disease after first- and second-line irradiation. It is unclear whether and to what extent it contributes to progression-free survival prolongation and if-since our patient was asymptomatic-progression-associated neurological deficits can be alleviated.
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Affiliation(s)
- Paula Maria Bergengruen
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Pablo Hernaíz Driever
- Department of Pediatric Oncology and Hematology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Volker Budach
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Daniel Zips
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Arne Grün
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
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Farrukh S, Habib S, Rafaqat A, Sarfraz Z, Sarfraz A, Sarfraz M, Robles-Velasco K, Felix M, Cherrez-Ojeda I. Emerging Therapeutic Strategies for Diffuse Intrinsic Pontine Glioma: A Systematic Review. Healthcare (Basel) 2023; 11:healthcare11040559. [PMID: 36833093 PMCID: PMC9956230 DOI: 10.3390/healthcare11040559] [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] [Received: 11/04/2022] [Revised: 01/19/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Of all central nervous systems tumors, 10-20% are located in the brainstem; diffuse intrinsic pontine glioma (DIPG) is diagnosed in 80% of them. With over five decades of clinical trial testing, there are no established therapeutic options for DIPG. This research article aims to collate recent clinical trial data and provide a landscape for the most promising therapies that have emerged in the past five years. METHODS PubMed/MEDLINE, Web of Science, Scopus, and Cochrane were systematically searched using the following keywords: Diffuse intrinsic pontine glioma, Pontine, Glioma, Treatment, Therapy, Therapeutics, curative, and/or Management. Both adult and pediatric patients with newly diagnosed or progressive DIPG were considered in the clinical trial setting. The risk of bias was assessed using the ROBINS-I tool. RESULTS A total of 22 trials were included reporting the efficacy and safety outcomes among patients. First, five trials reported outcomes of blood-brain barrier bypass via single or repeated-dose intra-arterial therapy or convection-enhanced delivery. Second, external beam radiation regimens were assessed for safety and efficacy in three trials. Third, four trials administered intravenous treatment without using chemotherapeutic regimens. Fourth, eight trials reported the combinations of one or more chemotherapeutic agents. Fifth, immunotherapy was reported in two trials in an adjuvant monotherapy in the post-radiotherapy setting. CONCLUSION This research article captures a clinical picture of the last five years of the direction toward which DIPG research is heading. The article finds that re-irradiation may prolong survival in patients with progressive DIPG; it also instills that insofar palliative radiotherapy has been a key prognostic choice.
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Affiliation(s)
- Shahrukh Farrukh
- Department of Research, Khawaja Muhammad Safdar Medical College, Sialkot 51310, Pakistan
| | - Shagufta Habib
- Department of Research, University Medical and Dental College Faisalabad, Faisalabad 38800, Pakistan
| | - Amna Rafaqat
- Department of Research and Publications, Fatima Jinnah Medical University, Lahore 54000, Pakistan
| | - Zouina Sarfraz
- Department of Research and Publications, Fatima Jinnah Medical University, Lahore 54000, Pakistan
| | - Azza Sarfraz
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi 74000, Pakistan
- Correspondence: (A.S.); (I.C.-O.)
| | | | - Karla Robles-Velasco
- Department of Allergy, Immunology and Pulmonary Medicine, Universidad Espíritu Santo, Samborondón 092301, Ecuador
| | - Miguel Felix
- Department of Internal Medicine, New York City Health + Hospitals, Lincoln, The Bronx, NY 10451, USA
| | - Ivan Cherrez-Ojeda
- Department of Allergy, Immunology and Pulmonary Medicine, Universidad Espíritu Santo, Samborondón 092301, Ecuador
- Correspondence: (A.S.); (I.C.-O.)
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Vallero SG, Bertero L, Morana G, Sciortino P, Bertin D, Mussano A, Ricci FS, Peretta P, Fagioli F. Pediatric diffuse midline glioma H3K27- altered: A complex clinical and biological landscape behind a neatly defined tumor type. Front Oncol 2023; 12:1082062. [PMID: 36727064 PMCID: PMC9885151 DOI: 10.3389/fonc.2022.1082062] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/23/2022] [Indexed: 01/18/2023] Open
Abstract
The 2021 World Health Organization Classification of Tumors of the Central Nervous System, Fifth Edition (WHO-CNS5), has strengthened the concept of tumor grade as a combination of histologic features and molecular alterations. The WHO-CNS5 tumor type "Diffuse midline glioma, H3K27-altered," classified within the family of "Pediatric-type diffuse high-grade gliomas," incarnates an ideally perfect integrated diagnosis in which location, histology, and genetics clearly define a specific tumor entity. It tries to evenly characterize a group of neoplasms that occur primarily in children and midline structures and that have a dismal prognosis. Such a well-defined pathological categorization has strongly influenced the pediatric oncology community, leading to the uniform treatment of most cases of H3K27-altered diffuse midline gliomas (DMG), based on the simplification that the mutation overrides the histological, radiological, and clinical characteristics of such tumors. Indeed, multiple studies have described pediatric H3K27-altered DMG as incurable tumors. However, in biology and clinical practice, exceptions are frequent and complexity is the rule. First of all, H3K27 mutations have also been found in non-diffuse gliomas. On the other hand, a minority of DMGs are H3K27 wild-type but have a similarly poor prognosis. Furthermore, adult-type tumors may rarely occur in children, and differences in prognosis have emerged between adult and pediatric H3K27-altered DMGs. As well, tumor location can determine differences in the outcome: patients with thalamic and spinal DMG have significantly better survival. Finally, other concomitant molecular alterations in H3K27 gliomas have been shown to influence prognosis. So, when such additional mutations are found, which one should we focus on in order to make the correct clinical decision? Our review of the current literature on pediatric diffuse midline H3K27-altered DMG tries to address such questions. Indeed, H3K27 status has become a fundamental supplement to the histological grading of pediatric gliomas; however, it might not be sufficient alone to exhaustively define the complex biological behavior of DMG in children and might not represent an indication for a unique treatment strategy across all patients, irrespective of age, additional molecular alterations, and tumor location.
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Affiliation(s)
- Stefano Gabriele Vallero
- Pediatric Oncohematology Division, Regina Margherita Children’s Hospital, Azienda Ospedaliera Universitaria (AOU) Città della Salute e della Scienza, Turin, Italy,*Correspondence: Stefano Gabriele Vallero,
| | - Luca Bertero
- Pathology Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giovanni Morana
- Neuroradiology Unit, Department of Neuroscience, University of Turin, Turin, Italy
| | - Paola Sciortino
- Department of Neuroradiology, Azienda Ospedaliera Universitaria (AOU) Città della Salute e della Scienza, Turin, Italy
| | - Daniele Bertin
- Pediatric Oncohematology Division, Regina Margherita Children’s Hospital, Azienda Ospedaliera Universitaria (AOU) Città della Salute e della Scienza, Turin, Italy
| | - Anna Mussano
- Radiotherapy Unit, Regina Margherita Children’s Hospital, Azienda Ospedaliera Universitaria (AOU) Città della Salute e della Scienza, Turin, Italy
| | - Federica Silvia Ricci
- Child and Adolescent Neuropsychiatry Division, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Paola Peretta
- Pediatric Neurosurgery Division, Regina Margherita Children’s Hospital, Azienda Ospedaliera Universitaria (AOU) Città della Salute e della Scienza, Turin, Italy
| | - Franca Fagioli
- Pediatric Oncohematology Division, Regina Margherita Children’s Hospital, Azienda Ospedaliera Universitaria (AOU) Città della Salute e della Scienza, Turin, Italy,Department of Public Health and Pediatrics, University of Turin, Turin, Italy
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Di Ruscio V, Del Baldo G, Fabozzi F, Vinci M, Cacchione A, de Billy E, Megaro G, Carai A, Mastronuzzi A. Pediatric Diffuse Midline Gliomas: An Unfinished Puzzle. Diagnostics (Basel) 2022; 12:diagnostics12092064. [PMID: 36140466 PMCID: PMC9497626 DOI: 10.3390/diagnostics12092064] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/22/2022] [Indexed: 11/15/2022] Open
Abstract
Diffuse midline glioma (DMG) is a heterogeneous group of aggressive pediatric brain tumors with a fatal prognosis. The biological hallmark in the major part of the cases is H3K27 alteration. Prognosis remains poor, with median survival ranging from 9 to 12 months from diagnosis. Clinical and radiological prognostic factors only partially change the progression-free survival but they do not improve the overall survival. Despite efforts, there is currently no curative therapy for DMG. Radiotherapy remains the standard treatment with only transitory benefits. No chemotherapeutic regimens were found to significantly improve the prognosis. In the new era of a deeper integration between histological and molecular findings, potential new approaches are currently under investigation. The entire international scientific community is trying to target DMG on different aspects. The therapeutic strategies involve targeting epigenetic alterations, such as methylation and acetylation status, as well as identifying new molecular pathways that regulate oncogenic proliferation; immunotherapy approaches too are an interesting point of research in the oncology field, and the possibility of driving the immune system against tumor cells has currently been evaluated in several clinical trials, with promising preliminary results. Moreover, thanks to nanotechnology amelioration, the development of innovative delivery approaches to overcross a hostile tumor microenvironment and an almost intact blood–brain barrier could potentially change tumor responses to different treatments. In this review, we provide a comprehensive overview of available and potential new treatments that are worldwide under investigation, with the intent that patient- and tumor-specific treatment could change the biological inauspicious history of this disease.
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Affiliation(s)
- Valentina Di Ruscio
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Giada Del Baldo
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Francesco Fabozzi
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
- Department of Pediatrics, University of Rome Tor Vergata, 00165 Rome, Italy
| | - Maria Vinci
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Antonella Cacchione
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Emmanuel de Billy
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Giacomina Megaro
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Andrea Carai
- Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Angela Mastronuzzi
- Department of Onco-Hematology, Cell and Gene Therapies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
- Faculty of Medicine and Surgery, Saint Camillus International University of Health Sciences, 00131 Rome, Italy
- Correspondence:
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Immunogenic Cell Death Enhances Immunotherapy of Diffuse Intrinsic Pontine Glioma: From Preclinical to Clinical Studies. Pharmaceutics 2022; 14:pharmaceutics14091762. [PMID: 36145510 PMCID: PMC9502387 DOI: 10.3390/pharmaceutics14091762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/02/2022] [Accepted: 08/20/2022] [Indexed: 11/16/2022] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is the most lethal tumor involving the pediatric central nervous system. The median survival of children that are diagnosed with DIPG is only 9 to 11 months. More than 200 clinical trials have failed to increase the survival outcomes using conventional cytotoxic or myeloablative chemotherapy. Immunotherapy presents exciting therapeutic opportunities against DIPG that is characterized by unique and heterogeneous features. However, the non-inflammatory DIPG microenvironment greatly limits the role of immunotherapy in DIPG. Encouragingly, the induction of immunogenic cell death, accompanied by the release of damage-associated molecular patterns (DAMPs) shows satisfactory efficacy of immune stimulation and antitumor strategies. This review dwells on the dilemma and advances in immunotherapy for DIPG, and the potential efficacy of immunogenic cell death (ICD) in the immunotherapy of DIPG.
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Massimino M, Vennarini S, Barretta F, Colombo F, Antonelli M, Pollo B, Pignoli E, Pecori E, Alessandro O, Schiavello E, Boschetti L, Podda M, Puma N, Gattuso G, Sironi G, Barzanò E, Nigro O, Bergamaschi L, Chiaravalli S, Luksch R, Meazza C, Spreafico F, Terenziani M, Casanova M, Ferrari A, Chisari M, Pellegrini C, Clerici CA, Modena P, Biassoni V. How ten-years of reirradiation for paediatric high-grade glioma may shed light on first line treatment. J Neurooncol 2022; 159:437-445. [PMID: 35809148 DOI: 10.1007/s11060-022-04079-4] [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: 05/31/2022] [Accepted: 06/25/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Recurrence incidence for paediatric/adolescent high-grade glioma (HGG) exceeds 80%. Reirradiation (reRT) palliates symptoms and delays further progression. Strategies for reRT are scarce: we retrospectively analysed our series to develop rational future approaches. METHODS We re-evaluated MRI + RT plans of 21 relapsed HGG-patients, accrued 2010-2021, aged under 18 years. All underwent surgery and RT + chemotherapy at diagnosis. Pathologic/molecular re-evaluation allowed classification based on WHO 2021 criteria in 20/21 patients. Survival analyses and association with clinical parameters were performed. RESULTS Relapse after 1st RT was local in 12 (7 marginal), 4 disseminated, 5 local + disseminated. Re-RT obtained 8 SD, 1 PR, 1PsPD, 1 mixed response, 10 PD; neurological signs/symptoms improved in 8. Local reRT was given to 12, followed again by 6 local (2 marginal) and 4 local + disseminated second relapses in 10/12 re-evaluated. The 4 with dissemination had 1 whole brain, 2 craniospinal irradiation (CSI), 1 spine reRT and further relapsed with dissemination and local + dissemination in 3/four assessed. Five local + disseminated tumours had 3 CSI, 1 spine reRT, further progressing locally (2), disseminated (1), n.a. (1). Three had a third RT; three were alive at 19.4, 29, 50.3 months after diagnosis. Median times to progression/survival after re-RT were 3.7 months (0.6-16.2 months)/6.9 months (0.6-17.9 months), improved for longer interval between 1st RT and re-RT (P = 0.017) and for non-PD after reRT (P < 0.001). First marginal relapse showed potential association with dissemination after re-RT (P = 0.081). CONCLUSIONS This is the biggest series of re-RT in paediatric HGG. Considering the dissemination observed at relapse, our results could prompt the investigation of different first RT fields in a randomized trial.
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Affiliation(s)
- Maura Massimino
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy.
| | - Sabina Vennarini
- Pediatric Radiotherapy (SV, FC, EP, OA), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Francesco Barretta
- Medical Statistics, Biometry and Bioinformatics (FB), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | | | - Manila Antonelli
- Radiological, Oncological and Anatomo-Pathological Sciences (MA), Department of La Sapienza University, Rome, Italy
| | - Bianca Pollo
- Neuropathology (BP) Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Emanuele Pignoli
- Medical Physics (EP), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Emilia Pecori
- Pediatric Radiotherapy (SV, FC, EP, OA), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Ombretta Alessandro
- Pediatric Radiotherapy (SV, FC, EP, OA), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Elisabetta Schiavello
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Luna Boschetti
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Marta Podda
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Nadia Puma
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Giovanna Gattuso
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Giovanna Sironi
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Elena Barzanò
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Olga Nigro
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Luca Bergamaschi
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Stefano Chiaravalli
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Roberto Luksch
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Cristina Meazza
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Filippo Spreafico
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Monica Terenziani
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Michela Casanova
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Andrea Ferrari
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Marco Chisari
- Pain Therapy and Rehabilitation Units (MC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Chiara Pellegrini
- Pain Therapy and Rehabilitation Units (MC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Carlo Alfredo Clerici
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy.,Hemato-Oncology Department La Statale University, Milan, Italy
| | | | - Veronica Biassoni
- Pediatrics (MM, LB, VB, ES, CAC), Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| |
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