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Apps JR, Maycock S, Ellison DW, Jaspan T, Ritzmann TA, Macarthur D, Mallucci C, Wheatley K, Veal GJ, Grundy RG, Picton S. Phase II study of intravenous etoposide in patients with relapsed ependymoma (CNS 2001 04). Neurooncol Adv 2022; 4:vdac053. [PMID: 35591977 PMCID: PMC9113139 DOI: 10.1093/noajnl/vdac053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Relapsed ependymoma has a dismal prognosis, and the role of chemotherapy at relapse remains unclear. This study prospectively evaluated the efficacy of intensive intravenous (IV) etoposide in patients less than 21 years of age with relapsed intracranial ependymoma (NCT00278252). Methods This was a single-arm, open-label, phase II trial using Gehan's two-stage design. Patients received IV etoposide 100 mg/m2 on days 1-3, 8-10, and 15-17 of each 28-day cycle, up to maximum of 6 cycles. Primary outcome was radiological response after 3 cycles. Pharmacokinetic analysis was performed in 10 patients. Results Twenty-five patients were enrolled and included in the intention-to-treat (ITT) analysis. Three patients were excluded in per-protocol (PP) analysis. After 3 cycles of etoposide, 5 patients (ITT 20%/PP 23%) had a complete response (CR), partial response (PR), or objective response (OR). Nine patients (ITT 36%/PP 41%,) had a best overall response of CR, PR, or OR. 1-year PFS was 24% in ITT and 23% in PP populations. 1-year OS was 56% and 59%, 5-year OS was 20% and 18%, respectively, in ITT and PP populations. Toxicity was predominantly hematological, with 20/25 patients experiencing a grade 3 or higher hematological adverse event. Conclusions This study confirms the activity of IV etoposide against relapsed ependymoma, however, this is modest, not sustained, and similar to that with oral etoposide, albeit with increased toxicity. These results confirm the dismal prognosis of this disease, provide a rationale to include etoposide within drug combinations, and highlight the need to develop novel treatments for recurrent ependymoma.
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Affiliation(s)
- John R Apps
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Shanna Maycock
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - David W Ellison
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Timothy Jaspan
- Radiology Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Timothy A Ritzmann
- Children’s Brain Tumour Research Centre, Bio-Discovery Institute and Queen’s Medical Centre, University of Nottingham, Nottingham, UK
| | - Donald Macarthur
- Children’s Brain Tumour Research Centre, Bio-Discovery Institute and Queen’s Medical Centre, University of Nottingham, Nottingham, UK
| | - Conor Mallucci
- Department of Neurosurgery, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Gareth J Veal
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
| | - Richard G Grundy
- Children’s Brain Tumour Research Centre, Bio-Discovery Institute and Queen’s Medical Centre, University of Nottingham, Nottingham, UK
| | - Susan Picton
- Department of Paediatric Oncology, Leeds Children’s Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Fraser J, Wills L, Fardus-Reid F, Irvine L, Elliss-Brookes L, Fern L, Cameron AL, Pritchard-Jones K, Feltbower RG, Shelton J, Stiller C, McCabe MG. Oral etoposide as a single agent in childhood and young adult cancer in England: Still a poorly evaluated palliative treatment. Pediatr Blood Cancer 2021; 68:e29204. [PMID: 34227732 DOI: 10.1002/pbc.29204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 06/04/2021] [Accepted: 06/16/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Oral etoposide is commonly used in palliative treatment of childhood and young adult cancer without robust evidence. We describe a national, unselected cohort of young people in England treated with oral etoposide using routinely collected, population-level data. METHODS Patients aged under 25 years at cancer diagnosis (1995-2017) with a treatment record of single-agent oral etoposide in the Systemic AntiCancer Dataset (SACT, 2012-2018) were identified, linked to national cancer registry data using NHS number and followed to 5 January 2019. Overall survival (OS) was estimated for all tumours combined and by tumour group. A Cox model was applied accounting for age, sex, tumour type, prior and subsequent chemotherapy. RESULTS Total 115 patients were identified during the study period. Mean age was 11.8 years at cancer diagnosis and 15.5 years at treatment with oral etoposide. Median OS was 5.5 months from the start of etoposide; 13 patients survived beyond 2 years. Survival was shortest in patients with osteosarcoma (median survival 3.6 months) and longest in CNS embryonal tumours (15.5 months). Across the cohort, a median of one cycle (range one to nine) of etoposide was delivered. OS correlated significantly with tumour type and prior chemotherapy, but not with other variables. CONCLUSIONS This report is the largest series to date of oral etoposide use in childhood and young adult cancer. Most patients treated in this real world setting died quickly. Despite decades of use, there are still no robust data demonstrating a clear benefit of oral etoposide for survival.
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Affiliation(s)
- Jess Fraser
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, London, UK.,Cancer Research UK, London, UK
| | - Lorna Wills
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, London, UK
| | - Fahmina Fardus-Reid
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, London, UK
| | - Lucy Irvine
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, London, UK
| | - Lucy Elliss-Brookes
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, London, UK
| | - Lorna Fern
- Cancer Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Alison L Cameron
- Bristol Haematology Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Richard G Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, UK
| | | | - Charles Stiller
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, London, UK
| | - Martin G McCabe
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, London, UK.,Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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A Rare Case of Metastatic Primary Peritoneal Ependymoma: A Case Report and Literature Review. Case Rep Oncol Med 2020; 2020:9805847. [PMID: 32879742 PMCID: PMC7448234 DOI: 10.1155/2020/9805847] [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: 01/08/2020] [Revised: 07/07/2020] [Accepted: 07/31/2020] [Indexed: 11/17/2022] Open
Abstract
Background Primary peritoneal ependymoma is an exceedingly rare tumour with only four cases reported in the literature. It typically follows an indolent disease course. We describe a rare case of metastatic primary peritoneal ependymoma which was treated with chemotherapy and radiotherapy resulting in prolonged survival to date for 10 years. Case Presentation. The patient was a 23-year-old female on presentation. She presented with right upper quadrant pain associated with an abdominal mass. Computed tomography demonstrated a large mass displacing the liver. Debulking surgery was done revealing a tumour arising from the peritoneum as well as multiple metastatic pleural and peritoneal nodules. Pathology was consistent with primary peritoneal ependymoma. The patient was then treated with multiple lines of chemotherapy containing etoposide as the backbone. She also received palliative radiotherapy to the thoracic metastases with good and durable response. Conclusion We reported a rare case of metastatic primary peritoneal ependymoma. Etoposide containing the chemotherapy regimen is effective in the treatment of peritoneal ependymoma. Radiotherapy is also effective for palliation of local symptoms with durable response.
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4
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Pramanik R, Bakhshi S. Metronomic therapy in pediatric oncology: A snapshot. Pediatr Blood Cancer 2019; 66:e27811. [PMID: 31207063 DOI: 10.1002/pbc.27811] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 12/16/2022]
Abstract
Metronomic chemotherapy transitioned from the bench to bedside in the early 2000s and since then has carved a niche for itself in pediatric oncology. It has been used solely or in combination with other modalities such as radiotherapy, maximum tolerated dose chemotherapy, and targeted agents in adjuvant, palliative, as well as maintenance settings. No wonder, the resulting medical literature is extremely heterogeneous. In this review, the authors review and synthesize the published literature in pediatric metronomics giving a glimpse of its history, varied applications, and evolution of this genre of chemotherapy in pediatric cancers. Limitations, future prospects, and grey areas are also highlighted.
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Affiliation(s)
- Raja Pramanik
- Department of Medical Oncology, Dr. B. R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, Dr. B. R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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Ferguson SD, Zhou S, Xiu J, Hashimoto Y, Sanai N, Kim L, Kesari S, de Groot J, Spetzler D, Heimberger AB. Ependymomas overexpress chemoresistance and DNA repair-related proteins. Oncotarget 2018; 9:7822-7831. [PMID: 29487694 PMCID: PMC5814261 DOI: 10.18632/oncotarget.23288] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/05/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND After surgery and radiation, treatment options for ependymoma are few making recurrence a challenging issue. Specifically, the efficacy of chemotherapy at recurrence is limited. We performed molecular profiling on a cohort of ependymoma cases in order to uncover therapeutic targets and to elucidate the molecular mechanisms contributing to treatment resistance. RESULTS This ependymoma cohort showed minimal alterations in gene amplifications and mutations but had high expression rates of DNA synthesis and repair enzymes such as RRM1 (47%), ERCC1 (48%), TOPO1 (62%) and class III β-tublin (TUBB3) (57%), which are also all associated with chemoresistance. This cohort also had high expression rates of transporter proteins that mediate multi-drug resistance including BCRP (71%) and MRP1 (43%). Subgroup analyses showed that cranial ependymomas expressed the DNA synthesis enzyme TS significantly more frequently than spinal lesions did (57% versus 15%; p = 0.0328) and that increased TS expression was correlated with increased tumor grade (p = 0.0009). High-grade lesions were also significantly associated with elevated expression of TOP2A (p = 0.0092) and TUBB3 (p = 0.0157). MATERIALS AND METHODS We reviewed the characteristics of 41 ependymomas (21 cranial, 20 spinal; 8 grade I, 11 grade II, 22 grade III) that underwent multiplatform profiling with immunohistochemistry, next-generation sequencing, and in situ hybridization. CONCLUSIONS Ependymomas are enriched with proteins involved in chemoresistance and in DNA synthesis and repair, which is consistent with the meager clinical effectiveness of conventional systemic therapy in ependymoma. Adjuvant therapies that combine conventional chemotherapy with the inhibition of chemoresistance-related proteins may represent a novel treatment paradigm for this difficult disease.
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Affiliation(s)
- Sherise D. Ferguson
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shouhao Zhou
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Yuuri Hashimoto
- Department of Neurosurgery, The University of Texas MD 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
| | - John de Groot
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Spetzler
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy B. Heimberger
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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6
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Single-agent erlotinib versus oral etoposide in patients with recurrent or refractory pediatric ependymoma: a randomized open-label study. J Neurooncol 2016; 129:131-8. [DOI: 10.1007/s11060-016-2155-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 06/01/2016] [Indexed: 11/26/2022]
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Oral etoposide in relapsed or refractory Ewing sarcoma: a monoinstitutional experience in children and adolescents. TUMORI JOURNAL 2015; 102:84-8. [PMID: 26797935 DOI: 10.5301/tj.5000419] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2015] [Indexed: 01/28/2023]
Abstract
AIMS To assess the efficacy and toxicity of low-dose oral etoposide (VP) 16 in relapsing/refractory Ewing sarcoma. METHODS The records of all patients treated at our department between 1989 and 2012 for relapsing/refractory Ewing sarcoma who received oral VP-16 were analyzed. The dose was 40 mg/m2 daily for 21 consecutive days in every 28. Response was assessed after 2/3 cycles according to Response Evaluation Criteria in Solid Tumors 1.0. RESULTS A total of 46 of 58 patients completed at least 2 cycles; 12 suspended the treatment earlier due to rapid disease progression. The patients' median age at diagnosis was 14 years and 25/58 had metastatic disease. All patients received intensive polychemotherapy including VP-16 IV as first- (n = 53) or second-line (n = 5) treatment; 21/58 had myeloablative regimens with peripheral blood stem cell rescue, and 1 underwent allogeneic stem cell transplantation. Oral VP-16 was prescribed as 2nd-, 3rd-, and 4th-line treatment for 19, 27, and 12 patients, respectively. The cycles administered totaled 241 (median 3, mean 4 per patient; range 1-14). A total of 46 of 58 patients were evaluable: 11 responded (9 partial remission, 1 very good partial remission, 1 complete remission) and 10 were stable, the response lasting a mean of 8 months. Hematologic toxicity G3/G4 (in 164/241 evaluable cycles) occurred in 15%, 16%, and 11% of cycles for leukocytes, hemoglobin, and platelets, respectively. There were 5 cases of pneumonia. Two patients developed secondary leukemia after receiving 12 and 14 cycles. CONCLUSIONS Low-dose oral VP-16 may be suitable in a palliative setting with an acceptable toxicity. The risk of secondary leukemia is in line with reports in the literature.
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A Randomized Study on Postrelapse Disease-Free Survival with Adjuvant Mistletoe versus Oral Etoposide in Osteosarcoma Patients. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2014; 2014:210198. [PMID: 24803944 PMCID: PMC3988743 DOI: 10.1155/2014/210198] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 03/02/2014] [Indexed: 12/03/2022]
Abstract
Background. Osteosarcoma is a highly malignant bone tumour. After the second relapse, the 12-month postrelapse disease-free survival (PRDFS) rate decreases below 20%. Oral Etoposide is often used in clinical practice after surgery as an “adjuvant” outside any protocol and with only limited evidence of improved survival. Viscum album fermentatum Pini (Viscum) is an extract of mistletoe plants grown on pine trees for subcutaneous (sc) injection with immunomodulatory activity. Methods. Encouraged by preliminary findings, we conducted a study where osteosarcoma patients free from disease after second metastatic relapse were randomly assigned to Viscum sc or Oral Etoposide. Our goal was to compare 12-month PRDFS rates with an equivalent historical control group. Results. Twenty patients have been enrolled, with a median age of 34 years (range 11–65) and a median follow-up time of 38.5 months (3–73). The median PRDSF is currently 4 months (1–47) in the Etoposide and 39 months (2–73) in the Viscum group. Patients getting Viscum reported a higher quality of life due to lower toxicity. Conclusion. Viscum shows promise as adjuvant treatment in prolonging PRDFS after second relapse in osteosarcoma patients. A larger study is required to conclusively determine efficacy and immunomodulatory mechanisms of Viscum therapy in osteosarcoma patients.
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Abstract
OPINION STATEMENT Survival rates for patients with ependymoma, a glial tumor arising from the ependymal cells lining the ventricles of the brain and spinal cord canal, have changed little during the past decade. Contemporary "standard" therapy for children and adults with ependymoma consists of maximal surgical resection followed by focal irradiation except in cases of disseminated disease. Despite refinements in radiotherapy techniques and improvements in survival for patients with gross totally resected, nonanaplastic disease, many therapeutic challenges remain, especially for patients with unresectable, macroscopic, metastatic, or anaplastic disease. Moreover, radiotherapy to the developing central nervous system, especially in patients younger than age 5 years, can have potential long-term neurocognitive and neuroendocrine sequelae. Chemotherapy has not played a role in most treatment regimens for ependymoma to date, but due to the ongoing therapeutic challenges for a subset of patients, this modality is being reinvestigated in a few ongoing studies. Early recognition of patients who will not respond to primary therapy is imperative to modify treatment regimens, such as intensification with the addition of adjuvant chemotherapy, the use of novel experimental therapies, or their combination. Refinements in patient stratification schemes that are based on a combination of clinical variables and molecular profiles also require improved knowledge of tumor biology. Several molecular alterations have been identified already, some of which may be of prognostic significance. Furthermore, disruption of molecular alterations in signaling pathways involved in the development and maintenance of ependymoma by using novel molecularly targeted therapies may improve outcomes and reduce toxicity for patients with ependymoma.
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10
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Wolf DS, Cohen KJ. Is low and slow the way to go? Metronomic therapy in the treatment of pediatric brain tumors. CNS Oncol 2013; 2:211-3. [DOI: 10.2217/cns.13.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- David S Wolf
- Department of Neurology, The Johns Hopkins Hospital, 1800 Orleans Street, Bloomberg 11379, Baltimore, MD 21287, USA
| | - Kenneth J Cohen
- The Sidney Kidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Hospital, 1800 Orleans Street, Bloomberg 11379, Baltimore, MD 21287, USA
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Abstract
Central nervous system tumors are the most frequent malignant tumor in children and the main cause of death in this age group after traffic accidents. The current estimates are that one adult in 2500 is a survivor of a brain tumor that occurred during childhood. These tumors are particularly heterogeneous in terms of histology/biology, treatment, and outcome. They share, however, a high risk of neurological and cognitive morbidity due to the disease itself and the treatment modalities (radiotherapy, surgery, and chemotherapy). Diagnosis is frequently delayed because symptoms are usually nonspecific at the beginning of the evolution. Posterior fossa is the most frequent site and the tumors present most frequently with signs of intracranial hypertension. Supratentorial tumors are more frequent in infants and in adolescents; seizures are not uncommon, especially for benign tumors. When adjuvant treatment is needed, radiotherapy is usually the mainstay apart from some histologies where chemotherapy may be sufficient: low-grade gliomas, desmoplastic medulloblastomas, malignant glial tumors in infants. Multidisciplinary care is best performed in tertiary care centers and should include early rehabilitation programs soon after surgery.
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Affiliation(s)
- Grill Jacques
- Brain Tumor Program, Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, Villejuif, France.
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Belcher R, Chahal HS, Evanson J, Afshar F, Marino S, Grossman AB. Recurrent pituitary ependymoma: a complex clinical problem. Pituitary 2010; 13:176-82. [PMID: 18704689 DOI: 10.1007/s11102-008-0139-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Ependymomas rarely arise from the region of the pituitary fossa, with only four cases previously reported in the literature. We present a complex case of a recurrent ependymoma of the parasellar region which has been difficult to clinically manage due to its tendency to recurrence. Our patient has had four operations over the last 28 years, with external beam radiotherapy, but still has residual tumor and is currently panhypopituitary and with significant visual loss. We believe there is considerable uncertainty as to the optimal management of any future progression, which seems likely, and are currently considering the use of radiosurgery with careful sparing of the optic chiasm, or possibly the chemotherapeutic agent temozolomide. Our case emphasises the recurrent nature of this rare but difficult tumor.
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Affiliation(s)
- Rosie Belcher
- Department of Endocrinology, Barts and the London School of Medicine, London, UK
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Abstract
The authors provide an update on most issues related to biology, diagnosis, and treatment of children with ependymoma based on a literature review. Ependymoma is the third most common brain tumor in children and overall survival ranges from 24% to 75% at 5 years. The extent of surgical resection remains the principal risk factor that clearly influences outcome. The influence of age, location, grade, or stage has proved to be more controversial. Current standard therapy includes surgical resection and radiotherapy. Chemotherapy has a role in infants to avoid/delay radiotherapy and can be helpful to improve resectability. About half of patients will experience relapse, and outcome is dismal. New radiation modalities, reirradiation, chemotherapy, or targeted agents have been tested with promising results. Results of multi-institutional clinical trials are awaited to determine the best first-line treatment, while results of early phase I/ II trials will explore directed therapies based on new biologic factors.
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Bouffet E, Capra M, Bartels U. Salvage chemotherapy for metastatic and recurrent ependymoma of childhood. Childs Nerv Syst 2009; 25:1293-301. [PMID: 19360417 DOI: 10.1007/s00381-009-0883-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Chemotherapy has limited role in the up-front management of ependymoma. At the time of recurrence, the role of chemotherapy is also ill defined and the choice of chemotherapeutic agents is often arbitrary, based on anecdotal data and personal experience. METHODS The purpose of this review is to describe and critically analyze the published literature on chemotherapy in patients with recurrent and metastatic ependymoma. DISCUSSION The disappointing response rate with single agents (12.9%) and combinations (17.4%) emphasizes the need to re-evaluate the current chemotherapeutic approach of intracranial ependymoma, and biological studies are needed to identify targets that may be considered for clinical trials.
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Affiliation(s)
- Eric Bouffet
- Paediatric Neuro-Oncology Program, The Hospital for Sick Children, 555 University Avenue, Toronto, M5G1X8, Canada.
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15
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Sangra M, Thorp N, May P, Pizer B, Mallucci C. Management strategies for recurrent ependymoma in the paediatric population. Childs Nerv Syst 2009; 25:1283-91. [PMID: 19484246 DOI: 10.1007/s00381-009-0914-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The management of recurrent ependymoma within the paediatric population remains a therapeutic challenge. The options available are varied and patients may have already received prior radio- or chemotherapy. As yet, no consensus exists regarding their optimal treatment. We review the literature and present our contemporary management strategies for this interesting group of patients. RESULTS AND DISCUSSION Survival following recurrence is poor and those prognostic factors that predispose to recurrence include extent of surgical resection and the timing of administration of adjuvant therapy. The extent of resection at re-operation can confer a survival advantage, without a necessary increase in morbidity. Strategies aimed at improving surgical resection at first diagnosis include improving and centralising post-surgical radiological review, defining what are true residuals, and centralising surgical review of incompletely resected tumours. Re-irradiation can improve survival, and with the use of conformal radiation fields need not necessarily lead to neuropsychological damage. Cisplatin and etoposide remain the most effective chemotherapeutic agents to date and with an increase in the understanding of tumour biology this may improve further. Because of the complex nature of this group of patients, decisions regarding their management require the involvement of a paediatric neurosurgeon, paediatric neuro-oncologist and paediatric radiation oncologist.
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Affiliation(s)
- M Sangra
- Department of Neurosurgery, Royal Liverpool Children's Hospital NHS Trust, Liverpool, L12 2AP, UK.
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16
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New chemotherapy strategies and biological agents in the treatment of childhood ependymoma. Childs Nerv Syst 2009; 25:1275-82. [PMID: 19212772 PMCID: PMC2738756 DOI: 10.1007/s00381-009-0809-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Indexed: 02/05/2023]
Abstract
INTRODUCTION With the limited role of current treatment regimens and potential associated side effects of radiation in young children with ependymoma, considerable effort is being focused on new chemotherapeutic strategies and biologic agents. DISCUSSION AND CONCLUSION Identification of those molecular changes underlying the development of ependymoma may, in time, lead to the development of not only novel therapeutic agents, but also specific patient-tailored therapies directed against known cell-signaling pathways.
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Messahel B, Ashley S, Saran F, Ellison D, Ironside J, Phipps K, Cox T, Chong W, Robinson K, Picton S, Pinkerton C, Mallucci C, Macarthur D, Jaspan T, Michalski A, Grundy R. Relapsed intracranial ependymoma in children in the UK: Patterns of relapse, survival and therapeutic outcome. Eur J Cancer 2009; 45:1815-23. [DOI: 10.1016/j.ejca.2009.03.018] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2008] [Revised: 03/08/2009] [Accepted: 03/17/2009] [Indexed: 10/20/2022]
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18
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Liu AK, Foreman NK, Gaspar LE, Trinidad E, Handler MH. Maximally safe resection followed by hypofractionated re-irradiation for locally recurrent ependymoma in children. Pediatr Blood Cancer 2009; 52:804-7. [PMID: 19260098 DOI: 10.1002/pbc.21982] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Treatment failure in children with ependymoma is relatively common, with the majority of events consisting of local failure. Salvage therapy for these children historically had poor results, with repeated local recurrences. To improve these outcomes, we began to offer hypofractionated re-irradiation after resection at first local recurrence. To minimize the duration of therapy, we chose a hypofractionated regimen that has been shown to be well tolerated in adult patients. PROCEDURE We performed a review of the experience at the Children's Hospital in Denver and at the Department of Radiation Oncology at the University of Colorado Denver from 1995 to 2008 with hypofractionated re-irradiation after maximally safe resection in children with locally recurrent ependymoma. RESULTS Six children with locally recurrent ependymoma were seen in that time period. After maximally safe resection, all six received hypofractionated radiation therapy of 24-30 Gy delivered in three fractions. With a median follow-up of 28 months from the time of re-irradiation, all six children are alive with no evidence of disease. Three children had evidence of radiation necrosis, either clinically or based on imaging, but none required significant intervention. CONCLUSIONS Hypofractionated re-irradiation after resection for locally recurrent ependymoma is well tolerated. This approach also appears to provide good local control. Additional follow-up is required to determine the efficacy and potential late effects of hypofractionated re-irradiation in this patient population.
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Affiliation(s)
- Arthur K Liu
- Department of Radiation Oncology, University of Colorado Denver, Aurora, Colorado 80045, USA.
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19
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Samuel DP, Wen PY, Kieran MW. Antiangiogenic (metronomic) chemotherapy for brain tumors: current and future perspectives. Expert Opin Investig Drugs 2009; 18:973-83. [DOI: 10.1517/13543780903025752] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- David P Samuel
- Harvard Medical School, Pediatric Medical Neuro-Oncology, Dana-Farber Cancer Institute and Children's Hospital of Boston, 44 Binney Street, Room SW331, Boston, MA 02115, USA ;
| | - Patrick Y Wen
- Harvard Medical School, Dana-Farber/Brigham and Women's Cancer Center, Room SW430D, 44 Binney Street, Boston, MA 02115, USA
| | - Mark W Kieran
- Harvard Medical School, Pediatric Medical Neuro-Oncology, Dana-Farber Cancer Institute and Children's Hospital of Boston, 44 Binney Street, Room SW331, Boston, MA 02115, USA ;
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20
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Longhi A, Mariani E, Kuehn JJ. A randomized study with adjuvant mistletoe versus oral Etoposide on post relapse disease-free survival in osteosarcoma patients. Eur J Integr Med 2009. [DOI: 10.1016/j.eujim.2009.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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21
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Mack JW, Joffe S, Hilden JM, Watterson J, Moore C, Weeks JC, Wolfe J. Parents' views of cancer-directed therapy for children with no realistic chance for cure. J Clin Oncol 2008; 26:4759-64. [PMID: 18779605 DOI: 10.1200/jco.2007.15.6059] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Previous literature suggests that parents often wish to continue cancer-directed therapy for their children with incurable cancer. We assessed parents' experiences with treatment for their children with cancer and no realistic chance of cure. PATIENTS AND METHODS We administered questionnaires to 141 parents of children with cancer who died after receiving care at one of two cancer centers. Parents were asked whether the child benefited and suffered from treatment administered after the parent recognized that cure was not a realistic expectation, and whether they would recommend cancer-directed therapy to other families of children with advanced cancer. RESULTS Fifty-three (38%) of 141 children received cancer-directed therapy after the parent recognized that the child had no realistic chance for cure. Most of these parents felt that their child had experienced at least some suffering resulting from the therapy (61%, 31 of 51) and little to no benefit (57%, 29 of 51). Fifty-one (38%) of 135 parents overall would recommend standard chemotherapy and 46 (33%) of 140 would recommend experimental chemotherapy to families of children with advanced cancer. Even parents who would not recommend standard chemotherapy generally felt the physician should offer it (91%, 88 of 97). Parents who reported that their children experienced suffering resulting from cancer-directed therapy (odds ratio = 0.46; P = .02) were less likely to recommend standard chemotherapy to other families. CONCLUSION Although many parents choose treatment for their children with incurable cancer, bereaved parents often would not recommend such therapy. Parents who felt their children suffered as a result of cancer treatment were particularly unlikely to recommend it.
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Affiliation(s)
- Jennifer W Mack
- Center for Outcomes and Policy Research and Department of Pediatric Oncology, Dana-Farber Cancer Institute, 44 Binney St, Boston, MA 02115, USA.
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22
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Buccoliero AM, Castiglione F, Rossi Degl'Innocenti D, Paglierani M, Maio V, Gheri CF, Garbini F, Moncini D, Taddei A, Sardi I, Sanzo M, Giordano F, Mussa F, Genitori L, Taddei GL. O6-Methylguanine-DNA-methyltransferase in recurring anaplastic ependymomas: PCR and immunohistochemistry. J Chemother 2008; 20:263-8. [PMID: 18467255 DOI: 10.1179/joc.2008.20.2.263] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Ependymomas are the third most common brain tumor in children. The post surgical management is controversial. There are no convincing data on an effective role for chemotherapy. O(6)-Methylguanine-DNA-Methyltransferase (MGMT) is a DNA repair protein considered to be a chemosensitivity predictor. Hypermethylation of the MGMT gene promoter is an important cause of MGMT inactivation. We evaluated the MGMT gene promoter methylation and the immunohistochemical MGMT protein expression in 12 recurrent anaplastic ependymomas affecting children. Our purpose was to investigate the molecular rationale of the administration of alkylating agents to children affected by recurrent anaplastic ependymomas. All ependymomas lacked MGMT promoter hypermethylation and 9 (75%) showed high MGMT protein expression (>50% tumoral cells). Differences between different recurrences in the same patient were not observed. These results may indicate MGMT as a factor of chemoresistance to alkylating drugs in anaplastic ependymomas and support the uncertainties regarding the actual benefit of chemotherapy for patients with anaplastic ependymomas.
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Affiliation(s)
- A M Buccoliero
- Department of Human Pathology and Oncology, University of Florence, Florence, Italy.
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23
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Choi LMR, Rood B, Kamani N, La Fond D, Packer RJ, Santi MR, Macdonald TJ. Feasibility of metronomic maintenance chemotherapy following high-dose chemotherapy for malignant central nervous system tumors. Pediatr Blood Cancer 2008; 50:970-5. [PMID: 17941070 DOI: 10.1002/pbc.21381] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Children less than 5 years of age with malignant central nervous system (CNS) tumors, continue to have a high rate of morbidity and mortality following administration of conventional therapy. In an attempt to avoid the neurologic sequelae associated with craniospinal radiation, strategies such as high-dose chemotherapy (HDCT) followed by peripheral stem cell rescue have been used successfully. Metronomic chemotherapy has also been reported as a potential new treatment strategy in solid tumors, particularly in adults. PROCEDURE A retrospective chart analysis was performed on 10 patients less than 5 years of age with CNS tumors treated with metronomic chemotherapy shortly after HDCT as part of their clinical care. RESULTS Metronomic chemotherapy was associated with minimal toxicity and all patients maintained a good quality of life. At the time of this report, all 10 patients are alive. Two patients have relapsed, and the remaining eight, including six patients with metastatic disease, continue to have stable clinical and radiographic disease at a mean of 20 months from the time of diagnosis. CONCLUSIONS Metronomic chemotherapy in this patient population is feasible and shows encouraging preliminary results, especially in patients with metastatic disease who have not received craniospinal radiation. Further investigation of this strategy in newly diagnosed patients with CNS tumors is warranted.
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Affiliation(s)
- L Mi Rim Choi
- Division of Hematology and Oncology, Children's National Medical Center, Washington, District of Columbia, USA
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Feun LG, Marini A, Landy H, Markoe A, Heros D, Robles C, Herrera C, Savaraj N. Clinical trial of CPT-11 and VM-26/VP-16 for patients with recurrent malignant brain tumors. J Neurooncol 2006; 82:177-81. [PMID: 17051317 DOI: 10.1007/s11060-006-9261-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2006] [Accepted: 09/01/2006] [Indexed: 11/24/2022]
Abstract
CPT-11 is a potent inhibitor of topoisomerase I and has shown antitumor activity in brain xenografts and in clinical trials in recurrent/progressive malignant glioma. VM-26 and VP-16 are topoisomerase II inhibitors and have also shown activity in phase II trials. We performed a phase II trial of intravenous CPT-11 (125 mg/m2) followed 24 h later by VM-26 (125 mg/m2). VP-16 (125 mg/m2) was later substituted for VM-26 due to drug shortage. For patients on anticonvulsants, the starting dose for all drugs was 150 mg/m2. Drugs were given weekly for 3 weeks followed by 1-week rest. Twenty-five patients were entered into the study. Three patients (12%) had improvement in CAT/MRI brain scans (95% confidence interval 3-31%). Fatigue and myelosuppression, mainly leukopenia, were the main toxicities. This combination of the topoisomerase I inhibitor CPT-11 followed by the topoisomerase II inhibitor, VM-26 or VP-16, has shown modest antitumor activity comparable to that reported for each drug singly. Myelosuppression is the main toxicity when topoisomerase I and II inhibitors are combined together.
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Affiliation(s)
- Lynn G Feun
- Sylvester Comprehensive Cancer Center, University of Miami, and VA Medical Center, Miami, FL 33136, USA.
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Sterba J, Valik D, Mudry P, Kepak T, Pavelka Z, Bajciova V, Zitterbart K, Kadlecova V, Mazanek P. Combined biodifferentiating and antiangiogenic oral metronomic therapy is feasible and effective in relapsed solid tumors in children: single-center pilot study. Oncol Res Treat 2006; 29:308-13. [PMID: 16874014 DOI: 10.1159/000093474] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND To outline an outpatient-based treatment for children with relapsed solid tumors, who already have been extensively pretreated, we defined a 4-drug protocol named COMBAT (combined oral maintenance biodifferentiating and antiangiogenic therapy). Using this protocol, we performed a pilot study to determine its feasibility in children with relapsed and/or high-risk pediatric solid tumors. PATIENTS AND METHODS 22 children received the COMBAT protocol. Treatment consisted of daily celecoxib administration along with daily 13-cisretinoic acid (2 weeks on / 2 weeks off) and cycles of metronomic temozolomide (90 mg/m2 for 42 days) and low-dose etoposide (21 days). The treatment was scheduled for a period of 1 year. RESULTS 9 of the 14 patients assessable for response demonstrated evidence of treatment benefit manifested as prolonged disease stabilization or response. The protocol medication was well tolerated with very good compliance. Only minimal side effects where observed which responded to dose modification or local therapy. CONCLUSIONS The COMBAT regimen is well tolerated by patients with intensive prior therapy including myeloablative regimens. Favorable responses observed in this cohort of patients support the further exploration of this and/or similar strategies in the treatment of pediatric solid tumors.
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Affiliation(s)
- Jaroslav Sterba
- Department of Pediatric Oncology, University Hospital Brno, Czech Republic.
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