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Akdemir EY, Odia Y, Hall MD, Mehta MP, Kotecha R. An Update on H3K27M-altered Diffuse Midline Glioma: Diagnostic and Therapeutic Challenges in Clinical Practice. Pract Radiat Oncol 2024; 14:443-451. [PMID: 38704025 DOI: 10.1016/j.prro.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 05/06/2024]
Abstract
H3K27-altered diffuse midline glioma (DMG H3K27-altered) is a relatively newly-designated WHO entity which primarily affects the midline structures of the central nervous system (CNS), including the brainstem (predominantly pontine region), thalamus, midbrain, or spinal cord, and primarily affects children and young adults. Despite the proximity of these tumors to eloquent areas in the CNS, novel stereotactic approaches have facilitated the ability to obtain tissue diagnoses without significant morbidity, providing molecular diagnostic information in more than half of patients. Conventionally fractionated radiation therapy to a total dose of 54-60 Gy in 27-30 fractions and 24 Gy in 12 fractions play a crucial role in the definitive treatment of these tumors in the primary and salvage settings, respectively. Hypofractionated regimens may allow for accelerated treatment courses in selected patients without jeopardizing disease control or survival. The decision to add concurrent or adjuvant systemic therapy mainly relies on the physicians' experience without solid evidence in the literature in favor of any particular regimen. Recently, novel agents, such as ONC201 have demonstrated promising oncologic outcomes in progressive/recurrent tumors and are currently under investigation in ongoing randomized trials. Given the scarcity of data and well-established guidelines due to the rare nature of the disease, we provide a contemporary overview on the molecular underpinnings of this disease entity, describe the role of radiotherapy and systemic therapy, and present practice management principles based on the published literature.
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Affiliation(s)
- Eyub Yasar Akdemir
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Yazmin Odia
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Department of Neuro-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida; Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida; Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida; Herbert Wertheim College of Medicine, Florida International University, Miami, Florida.
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Viani GA, Gouveia AG, Arcidiacono F, Marta GN, Hamamura AC, Anselmo P, Barbosa FS, Moraes FY. Efficacy and safety of hypofractionated radiotherapy versus conventional fractionated radiotherapy in diffuse intrinsic pontine glioma: A systematic review and meta-analysis. Rep Pract Oncol Radiother 2024; 29:309-317. [PMID: 39144263 PMCID: PMC11321787 DOI: 10.5603/rpor.100779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 05/16/2024] [Indexed: 08/16/2024] Open
Abstract
Background Diffuse intrinsic pontine glioma (DIPG) stands as the predominant type of brainstem glioma. It is characterized by a notably brief median survival period, with the majority of patients experiencing disease progression within six months following radiation therapy. This systematic review and meta-analysis aims to assess the efficacy and safety of hypofractionated radiotherapy (HFRT) compared to conventionally fractionated radiotherapy (CFRT) in DIPG treatment. Materials and methods A systematic literature search was conducted in four databases, and relevant studies comparing HFRT and CFRT in DIPG were included. Data were extracted and analyzed for overall survival (OS), progression-free survival (PFS), and treatment-related toxicities. Statistical analysis was performed using random-effects models with heterogeneity assessment. Results Five studies met the inclusion criteria, comprising 518 patients. No significant difference in one-year OS was observed between HFRT and CFRT (29% vs. 22%, p = 0.94). The median OS was similar in both treatment groups (9.7 vs. 9.3 months, p = 0.324). Similarly, no significant difference in one-year PFS was found between HFRT and CFRT (19.8% vs. 16.6%, p = 0.82), with comparable median PFS (9.3 vs. 9.4 months, p = 0.20). In meta-regression analysis, there was no association of chemotherapy (p > 0.05) or radiation biologically effective dose (BED) (p > 0.05) regarding OS or PFS outcomes. There were no significant differences in treatment-related toxicities. Conclusions HFRT yields one-year OS and PFS rates similar to CFRT in DIPG, with no significant differences in treatment-related toxicities. Chemotherapy and BED did not affect OS or PFS.
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Affiliation(s)
- Gustavo A Viani
- Department of Medical Imagings, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
| | - Andre G Gouveia
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
- Division of Radiation Oncology, Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | - Gustavo N Marta
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
- Radiation Oncology Department, Hospital Sirio Libanês, São Paulo, Brazil
- Post-Graduation Program, Department of Radiology and Oncology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Ana Carolina Hamamura
- Department of Medical Imagings, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Paola Anselmo
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | - Felipe S Barbosa
- Department of Medical Imagings, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Fabio Y Moraes
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
- Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
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Li S, Zhao Y, Huang H. Clinical characteristics and prognostic factors of adult brainstem gliomas: A retrospective analysis of histologically-proven 40 cases. Medicine (Baltimore) 2024; 103:e37910. [PMID: 38701282 PMCID: PMC11062748 DOI: 10.1097/md.0000000000037910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 03/25/2024] [Indexed: 05/05/2024] Open
Abstract
To illustrate the clinical characteristics and prognostic factors of adult patients pathologically confirmed with brainstem gliomas (BSGs). Clinical data of 40 adult patients pathologically diagnosed with BSGs admitted to Beijing Shijitan Hospital from 2009 to 2022 were recorded and retrospectively analyzed. The primary parameters included relevant symptoms, duration of symptoms, Karnofsky performance status (KPS), tumor location, type of surgical resection, diagnosis, treatment, and survival. Univariate and multivariate analyses were evaluated by Cox regression models. The gliomas were located in the midbrain of 9 patients, in the pons of 14 cases, in the medulla of 5 cases, in the midbrain and pons of 6 cases and invading the medulla and pons of 6 cases, respectively. The proportion of patients with low-grade BSGs was 42.5%. Relevant symptoms consisted of visual disturbance, facial paralysis, dizziness, extremity weakness, ataxia, paresthesia, headache, bucking, dysphagia, dysacousia, nausea, dysphasia, dysosmia, hypomnesia and nystagmus. 23 (57.5%) patients accepted stereotactic biopsy, 17 (42.5%) patients underwent surgical resection. 39 patients received radiotherapy and 34 cases were treated with temozolomide. The median overall survival (OS) of all patients was 26.2 months and 21.5 months for the median progression-free survival (PFS). Both duration of symptoms (P = .007) and tumor grading (P = .002) were the influencing factors for OS, and tumor grading was significantly associated with PFS (P = .001). Duration of symptoms for more than 2 months and low-grade are favorable prognostic factors for adult patients with BSGs.
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Affiliation(s)
- Shan Li
- Department of Oncology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yanjie Zhao
- Department of Oncology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Hongyan Huang
- Department of Oncology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Lo Greco MC, Milazzotto R, Liardo RLE, Foti PV, Palmucci S, Basile A, Pergolizzi S, Spatola C. The Role of Reirradiation in Childhood Progressive Diffuse Intrinsic Pontine Glioma (DIPG): An Ongoing Challenge beyond Radiobiology. Brain Sci 2023; 13:1449. [PMID: 37891817 PMCID: PMC10605436 DOI: 10.3390/brainsci13101449] [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: 08/30/2023] [Revised: 09/26/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023] Open
Abstract
To investigate the clinical impact of multiple courses of irradiation on pediatric patients with progressive diffuse intrinsic pontine glioma (DIPG), we conducted a retrospective case series on three children treated at our institution from 2018 to 2022. All children were candidates to receive systemic therapy with vinorelbine and nimotuzumab. Radiotherapy was administered to a total dose of 54 Gy. At any disease progression, our local tumor board evaluated the possibility of offering a new course of radiotherapy. To determine feasibility and assess toxicity rates, all children underwent clinical and hematological evaluation both during and after the treatment. To assess efficacy, all children performed contrast-enhanced MRI almost quarterly after the end of the treatment. In all children, following any treatment course, neurological improvement (>80%) was associated with a radiological response (41.7-46%). The longest overall survival (24 months) was observed in the child who underwent three courses of radiotherapy, without experiencing significant side effects. Even though it goes beyond the understanding of conventional radiobiology, first and second reirradiation in pediatric patients with progressive DIPG may represent a feasible and safe approach, capable of increasing overall survival and disease-free survival in selected patients and improving their quality of life.
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Affiliation(s)
- Maria Chiara Lo Greco
- Radiation Oncology Unit, Department of Biomedical, Dental and Morphological and Functional Imaging Sciences, University of Messina, 98122 Messina, Italy;
| | - Roberto Milazzotto
- Radiation Oncology Unit, Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy; (R.M.); (R.L.E.L.); (C.S.)
| | - Rocco Luca Emanuele Liardo
- Radiation Oncology Unit, Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy; (R.M.); (R.L.E.L.); (C.S.)
| | - Pietro Valerio Foti
- Radiology I Unit, Department of Medical Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy; (P.V.F.); (S.P.); (A.B.)
| | - Stefano Palmucci
- Radiology I Unit, Department of Medical Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy; (P.V.F.); (S.P.); (A.B.)
| | - Antonio Basile
- Radiology I Unit, Department of Medical Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy; (P.V.F.); (S.P.); (A.B.)
| | - Stefano Pergolizzi
- Radiation Oncology Unit, Department of Biomedical, Dental and Morphological and Functional Imaging Sciences, University of Messina, 98122 Messina, Italy;
| | - Corrado Spatola
- Radiation Oncology Unit, Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy; (R.M.); (R.L.E.L.); (C.S.)
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Miguel Llordes G, Medina Pérez VM, Curto Simón B, Castells-Yus I, Vázquez Sufuentes S, Schuhmacher AJ. Epidemiology, Diagnostic Strategies, and Therapeutic Advances in Diffuse Midline Glioma. J Clin Med 2023; 12:5261. [PMID: 37629304 PMCID: PMC10456112 DOI: 10.3390/jcm12165261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/03/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Object: Diffuse midline glioma (DMG) is a highly aggressive and lethal brain tumor predominantly affecting children and young adults. Previously known as diffuse intrinsic pontine glioma (DIPG) or grade IV brain stem glioma, DMG has recently been reclassified as "diffuse midline glioma" according to the WHO CNS5 nomenclature, expanding the DMG demographic. Limited therapeutic options result in a poor prognosis, despite advances in diagnosis and treatment. Radiotherapy has historically been the primary treatment modality to improve patient survival. Methods: This systematic literature review aims to comprehensively compile information on the diagnosis and treatment of DMG from 1 January 2012 to 31 July 2023. The review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement and utilized databases such as PubMed, Cochrane Library, and SciELO. Results: Currently, molecular classification of DMG plays an increasingly vital role in determining prognosis and treatment options. Emerging therapeutic avenues, including immunomodulatory agents, anti-GD2 CAR T-cell and anti-GD2 CAR-NK therapies, techniques to increase blood-brain barrier permeability, isocitrate dehydrogenase inhibitors, oncolytic and peptide vaccines, are being explored based on the tumor's molecular composition. However, more clinical trials are required to establish solid guidelines for toxicity, dosage, and efficacy. Conclusions: The identification of the H3K27 genetic mutation has led to the reclassification of certain midline tumors, expanding the DMG demographic. The field of DMG research continues to evolve, with encouraging findings that underscore the importance of highly specific and tailored therapeutic strategies to achieve therapeutic success.
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Affiliation(s)
- Gloria Miguel Llordes
- Molecular Oncology Group, Instituto de Investigación Sanitaria Aragón (IIS Aragón), 50009 Zaragoza, Spain
- Pediatric Cancer Center Barcelona, Hospital Sant Joan de Déu, 08950 Barcelona, Spain
| | - Víctor Manuel Medina Pérez
- Molecular Oncology Group, Instituto de Investigación Sanitaria Aragón (IIS Aragón), 50009 Zaragoza, Spain
| | | | - Irene Castells-Yus
- Molecular Oncology Group, Instituto de Investigación Sanitaria Aragón (IIS Aragón), 50009 Zaragoza, Spain
| | | | - Alberto J. Schuhmacher
- Molecular Oncology Group, Instituto de Investigación Sanitaria Aragón (IIS Aragón), 50009 Zaragoza, Spain
- Fundación Aragonesa para la Investigación y el Desarrollo (ARAID), 50018 Zaragoza, Spain
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Noon A, Galban S. Therapeutic avenues for targeting treatment challenges of diffuse midline gliomas. Neoplasia 2023; 40:100899. [PMID: 37030112 PMCID: PMC10119952 DOI: 10.1016/j.neo.2023.100899] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/08/2023]
Abstract
Diffuse midline glioma (DMG) is the leading cause of brain tumor-related deaths in children. DMG typically presents with variable neurologic symptoms between ages 3 and 10. Currently, radiation remains the standard therapy for DMG to halt progression and reduce tumor bulk to minimize symptoms. However, tumors recur in almost 100% of patients and thus, DMG is still considered an incurable cancer with a median survival of 9-12 months. Surgery is generally contraindicated due to the delicate organization of the brainstem, where DMG is located. Despite extensive research efforts, no chemotherapeutic agents, immune therapies, or molecularly targeted therapies have been approved to provide survival benefit. Furthermore, the efficacy of therapies is limited by poor blood-brain barrier penetration and inherent resistance mechanisms of the tumor. However, novel drug delivery approaches, along with recent advances in molecularly targeted therapies and immunotherapies, have advanced to clinical trials and may provide viable future treatment options for DMG patients. This review seeks to evaluate current therapeutics at the preclinical stage and those that have advanced to clinical trials and to discuss the challenges of drug delivery and inherent resistance to these therapies.
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Affiliation(s)
- Aleeha Noon
- College of Medicine, California Northstate University, 9700 W Taron Drive, Elk Grove, CA 95757, USA
| | - Stefanie Galban
- Center for Molecular Imaging, The University of Michigan Medical School, BSRB A502, 109 Zina Pitcher Place, Ann Arbor, MI 48109-2200, USA; Department of Radiology, The University of Michigan Medical School, BSRB A502, 109 Zina Pitcher Place, Ann Arbor, MI 48109-2200, USA; Rogel Cancer Center, The University of Michigan Medical School, 1500 E Medical Center Drive, Ann Arbor, MI 48109, USA.
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7
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Lyu Y, Guo Y, Okeoma CM, Yan Z, Hu N, Li Z, Zhou S, Zhao X, Li J, Wang X. Engineered extracellular vesicles (EVs): Promising diagnostic/therapeutic tools for pediatric high-grade glioma. Biomed Pharmacother 2023; 163:114630. [PMID: 37094548 DOI: 10.1016/j.biopha.2023.114630] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/29/2023] [Accepted: 03/29/2023] [Indexed: 04/26/2023] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is a highly malignant brain tumor that mainly occurs in children with extremely low overall survival. Traditional therapeutic strategies, such as surgical resection and chemotherapy, are not feasible mostly due to the special location and highly diffused features. Radiotherapy turns out to be the standard treatment method but with limited benefits of overall survival. A broad search for novel and targeted therapies is in the progress of both preclinical investigations and clinical trials. Extracellular vesicles (EVs) emerged as a promising diagnostic and therapeutic candidate due to their distinct biocompatibility, excellent cargo-loading-delivery capacity, high biological barrier penetration efficiency, and ease of modification. The utilization of EVs in various diseases as biomarker diagnoses or therapeutic agents is revolutionizing modern medical research and practice. In this review, we will briefly talk about the research development of DIPG, and present a detailed description of EVs in medical applications, with a discussion on the application of engineered peptides on EVs. The possibility of applying EVs as a diagnostic tool and drug delivery system in DIPG is also discussed.
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Affiliation(s)
- Yuan Lyu
- Medical Research Center, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China; Henan Joint International Laboratory of Glioma Metabolism and Microenvironment Research, Henan Provincial Department of Science and Technology, Zhengzhou, Henan 450052, China; Institute of Neuroscience, Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Yupei Guo
- Henan Joint International Laboratory of Glioma Metabolism and Microenvironment Research, Henan Provincial Department of Science and Technology, Zhengzhou, Henan 450052, China; Institute of Neuroscience, Zhengzhou University, Zhengzhou, Henan 450052, China; Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Chioma M Okeoma
- Department of Pathology, Microbiology, and Immunology, New York Medical College, Valhalla, NY 10595-1524, USA
| | - Zhaoyue Yan
- Department of Neurosurgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Nan Hu
- Henan Joint International Laboratory of Glioma Metabolism and Microenvironment Research, Henan Provincial Department of Science and Technology, Zhengzhou, Henan 450052, China; Institute of Neuroscience, Zhengzhou University, Zhengzhou, Henan 450052, China; Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Zian Li
- Henan Joint International Laboratory of Glioma Metabolism and Microenvironment Research, Henan Provincial Department of Science and Technology, Zhengzhou, Henan 450052, China; Institute of Neuroscience, Zhengzhou University, Zhengzhou, Henan 450052, China; Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Shaolong Zhou
- Henan Joint International Laboratory of Glioma Metabolism and Microenvironment Research, Henan Provincial Department of Science and Technology, Zhengzhou, Henan 450052, China; Institute of Neuroscience, Zhengzhou University, Zhengzhou, Henan 450052, China; Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Xin Zhao
- Department of Radiology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Junqi Li
- Medical Research Center, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China; Henan Joint International Laboratory of Glioma Metabolism and Microenvironment Research, Henan Provincial Department of Science and Technology, Zhengzhou, Henan 450052, China; Institute of Neuroscience, Zhengzhou University, Zhengzhou, Henan 450052, China.
| | - Xinjun Wang
- Henan Joint International Laboratory of Glioma Metabolism and Microenvironment Research, Henan Provincial Department of Science and Technology, Zhengzhou, Henan 450052, China; Institute of Neuroscience, Zhengzhou University, Zhengzhou, Henan 450052, China; Department of Neurosurgery, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China.
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Kim HJ, Suh CO. Radiotherapy for Diffuse Intrinsic Pontine Glioma: Insufficient but Indispensable. Brain Tumor Res Treat 2023; 11:79-85. [PMID: 37151149 PMCID: PMC10172015 DOI: 10.14791/btrt.2022.0041] [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: 11/23/2022] [Revised: 12/28/2022] [Accepted: 01/02/2023] [Indexed: 05/09/2023] Open
Abstract
Diffuse intrinsic pontine gliomas (DIPGs) account for 10%-20% of all central nervous system tumors in children and are the leading cause of death in children with brain tumors. Although many clinical trials have been conducted over the past decades, the survival outcome has remained unchanged. Over 90% of children die within 2 years of the diagnosis, and radiotherapy remains the standard treatment to date. To improve the prognosis, hyperfractionated and hypofractionated radiotherapy and/or addition of radiosensitizers have been investigated. However, none of the radiotherapy approaches have shown a survival benefit, and the overall survival of patients with DIPG is approximately 11 months. Here, we comprehensively review the management of DIPG with focus on radiotherapy.
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Affiliation(s)
- Hyun Ju Kim
- Department of Radiation Oncology, Gachon University Gil Hospital, Gachon University College of Medicine, Incheon, Korea
| | - Chang-Ok Suh
- Department of Radiation Oncology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea.
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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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10
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Les essais qui changent les pratiques : le point en 2022. Cancer Radiother 2022; 26:823-833. [DOI: 10.1016/j.canrad.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/06/2022] [Indexed: 11/19/2022]
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Lutz K, Jünger ST, Messing-Jünger M. Essential Management of Pediatric Brain Tumors. CHILDREN 2022; 9:children9040498. [PMID: 35455542 PMCID: PMC9031600 DOI: 10.3390/children9040498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/25/2022] [Accepted: 03/25/2022] [Indexed: 02/02/2023]
Abstract
Brain tumors are the most common solid tumors in children and are associated with high mortality. The most common childhood brain tumors are grouped as low-grade gliomas (LGG), high grade gliomas (HGG), ependymomas, and embryonal tumors, according to the World Health Organization (WHO). Advances in molecular genetics have led to a shift from pure histopathological diagnosis to integrated diagnosis. For the first time, these new criteria were included in the WHO classification published in 2016 and has been further updated in the 2021 edition. Integrated diagnosis is based on molecular genomic similarities of the tumor subclasses, and it can better explain the differences in clinical courses of previously histopathologically identical entities. Important advances have also been made in pediatric neuro-oncology. A growing understanding of the molecular-genetic background of tumorigenesis has improved the diagnostic accuracy. Re-stratification of treatment protocols and the development of targeted therapies will significantly affect overall survival and quality of life. For some pediatric tumors, these advances have significantly improved therapeutic management and prognosis in certain tumor subgroups. Some therapeutic approaches also have serious long-term consequences. Therefore, optimized treatments are greatly needed. Here, we discuss the importance of multidisciplinary collaboration and the role of (pediatric) neurosurgery by briefly describing the most common childhood brain tumors and their currently recognized molecular subgroups.
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Affiliation(s)
- Katharina Lutz
- Neurosurgery Department, Inselspital, 3010 Bern, Switzerland
- Pediatric Neurosurgery, Asklepios Children’s Hospital, 53757 Sankt Augustin, Germany;
- Correspondence:
| | - Stephanie T. Jünger
- Center for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany;
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Zaghloul MS, Nasr A, Tolba M, Refaat A, Youssef A, Moseab A, Enayet A, Arafa O, Maher E, Eldebawy E. Hypofractionated radiotherapy for Diffuse Intrinsic Pontine Glioma (DIPG): A non-inferiority prospective randomized study including 253 children. Int J Radiat Oncol Biol Phys 2022; 113:360-368. [PMID: 35150788 DOI: 10.1016/j.ijrobp.2022.01.054] [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: 10/23/2021] [Revised: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pediatric Diffuse intrinsic pontine glioma (DIPG) is an orfen disease. The study aims at confirming the non-inferiority of hypofractionated (HF) radiotherapy. Identification of the prognostic factors that determine the overall survival (OS) and progression-free survival (PFS) is the secondary objective. METHODS 253 patients were randomized into 3 arms; HF1 receiving 39 Gy /13 fractions, HF2 receiving 45 Gy /15 fractions, and Conventional fractionation (CF) 54 Gy/30 fractions. The OS and PFS were calculated using Kaplan-Meier methods and the non-inferiority was estimated against the CF arm. RESULTS The median OS for the HF1, HF2, and CF were: 9.6, 8.2, and 8.7 months, respectively. The 1-, 1.5-, and 2- year OS were: 34.6 %, 17.9 %, and 10.7 % for HF1, 26.2 %, 13.1, and 4.8 % for HF2 compared to 25.3 %, 12.1 %, and 8.4 % for CF, respectively (p=0.3). The hazard ratio was 0.776 and 1.124 for HF1 and HF2, respectively. Considering the non-inferiority margin (Δ) of 15% and a power of 90%, the lower inferiority confident interval for HF1= -14.34% & HF2= 11.37% (both below Δ) confirming its non-inferiority at 18-months OS. Younger patients (2 - 5 years) have better median OS in the whole cohort (11.6 months), HF1(13.5), and CF (12.1) but not HF2 (6.2) (p=0.003). Furthermore, the overall survival rates at 1-,1.5- and 2- year for Children 2 - 5 years belonging to HF2 arm was lower than that for HF1 and CF arms. However, similar acute and late side effects were reported in the 3 arms. CONCLUSIONS Two Hypofractionated radiotherapy proved to be non-inferior to conventional fractionation. Young age (2 - 5 years) is the only prognostic factor determining both OS and PFS. The young age superiority was lost with a higher hypofractionated RT dose necessitating more caution in applying 45 Gy/15 fractions in younger (2 - 5 years) children.
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Affiliation(s)
- Mohamed S Zaghloul
- Radiation Oncology Department, National Cancer Institute, Cairo University, Egypt; Children's Cancer Hospital, Egypt.
| | - Azza Nasr
- Radiation Oncology Department, National Cancer Institute, Cairo University, Egypt; Children's Cancer Hospital, Egypt
| | | | - Amal Refaat
- Children's Cancer Hospital, Egypt; Radiodiagnosis Department, National Cancer Institute, Cairo University
| | - Ayda Youssef
- Children's Cancer Hospital, Egypt; Radiodiagnosis Department, National Cancer Institute, Cairo University
| | | | - Abdelrahman Enayet
- Children's Cancer Hospital, Egypt; Neurosurgery department, Faculty of Medicine, Cairo University
| | - Omar Arafa
- Children's Cancer Hospital, Egypt; Pediatric Oncology department, National Cancer Institute, Cairo University
| | | | - Eman Eldebawy
- Radiation Oncology Department, National Cancer Institute, Cairo University, Egypt; Children's Cancer Hospital, Egypt
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McKelvey KJ, Hudson AL, Donaghy H, Stoner SP, Wheeler HR, Diakos CI, Howell VM. Differential effects of radiation fractionation regimens on glioblastoma. Radiat Oncol 2022; 17:17. [PMID: 35073960 PMCID: PMC8788072 DOI: 10.1186/s13014-022-01990-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/14/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Radiotherapy (RT) is a mainstay of treatment for patients with glioblastoma (GB). Early clinical trials show that short course hypofractionation showed no survival benefit compared to conventional regimens with or without temozolomide chemotherapy (TMZ) but reduces the number of doses required. Concerns around delayed neurological deficits and reduced cognition from short course hypofractionated RT remain a concern. The aim of this study was to evaluate the effect of increased interfractional time using two different radiation fractionation regimens on GB. METHODS The radiobiological effect of increasing doses 0-20 Gy x-ray photon RT on Gl261 and CT2A GB cell lines was compared by colony forming assay, DNA damage by alkaline comet assay, oxidative stress, DNA damage, cell cycle, and caspase-3/7 by MUSE® flow cytometric analyses, and protein expression by western blot analyses. Conventional (20 Gy/10 fractions) and hypofractionated (20 Gy/4 fractions spaced 72 h apart) RT regimens with and without TMZ (200 mg/kg/day) were performed in syngeneic Gl261 and CT2A intracranial mouse models using the Small Animal Radiation Research Platform (Xstrahl Inc.). RESULTS X-ray photon radiation dose-dependently increased reactive oxygen species, DNA damage, autophagy, and caspase 3/7-mediated apoptotic cell death. While the conventional fractionated dose regimen of 20 Gy/10 f was effective at inducing cell death via the above mechanism, this was exceeded by a 20 Gy/4 f regimen which improved median survival and histopathology in Gl261-tumor bearing mice, and eradicated tumors in CT2A tumors with no additional toxicity. CONCLUSIONS Spacing of hypofractionated RT doses 72 h apart showed increased median survival and tumor control via increased activation of RT-mediated cell death, with no observed increased in radiotoxicity. This supports further exploration of differential RT fractionated regimens in GB clinical trials to reduce delayed neurological radiotoxicity.
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Affiliation(s)
- Kelly J McKelvey
- Bill Walsh Translational Cancer Research Laboratory, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW, 2065, Australia.
| | - Amanda L Hudson
- Bill Walsh Translational Cancer Research Laboratory, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW, 2065, Australia
| | - Heather Donaghy
- Bill Walsh Translational Cancer Research Laboratory, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW, 2065, Australia
| | - Shihani P Stoner
- Bill Walsh Translational Cancer Research Laboratory, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW, 2065, Australia
| | - Helen R Wheeler
- Bill Walsh Translational Cancer Research Laboratory, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW, 2065, Australia
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
- Department of Medical Oncology, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - Connie I Diakos
- Bill Walsh Translational Cancer Research Laboratory, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW, 2065, Australia
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
- Department of Medical Oncology, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - Viive M Howell
- Bill Walsh Translational Cancer Research Laboratory, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW, 2065, Australia
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