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Moreira DC, Qaddoumi I, Spiller S, Bouldin TW, Davidson A, Saba-Silva N, Sullivan DV, Tanaka R, Wagner AS, Wood M, Klimo P, Job G, Devidas M, Li X, Gajjar A, Robinson GW, Chiang J. Comprehensive analysis of MYB/MYBL1-altered pediatric-type diffuse low-grade glioma. Neuro Oncol 2024; 26:1327-1334. [PMID: 38466086 PMCID: PMC11226882 DOI: 10.1093/neuonc/noae048] [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: 10/18/2023] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND Pediatric-type diffuse low-grade gliomas (pLGG) harboring recurrent genetic alterations involving MYB or MYBL1 are closely related tumors. Detailed treatment and outcome data of large cohorts are still limited. This study aimed to comprehensively evaluate pLGG with these alterations to define optimal therapeutic strategies. METHODS We retrospectively reviewed details of pLGG with MYB or MYBL1 alterations from patients treated or referred for pathologic review at St. Jude Children's Research Hospital. Tumor specimens were centrally reviewed, and clinical data were collated. RESULTS Thirty-three patients (18 male; median age, 5 years) were identified. Two tumors had MYBL1 alterations; 31 had MYB alterations, MYB::QKI fusion being the most common (n = 10, 30%). Most tumors were in the cerebral hemispheres (n = 22, 67%). Two patients (6%) had metastasis at diagnosis. The median follow-up was 6.1 years. The 5-year event-free survival (EFS) rate was 81.3% ± 8.3%; the 5-year overall survival (OS) rate was 96.4% ± 4.1%. Patients receiving a near-total or gross-total resection had a 5-year EFS of 100%; those receiving a biopsy or subtotal resection had a 5-year EFS rate of 56.6% ± 15.2% (P < .01). No difference in EFS was observed based on location, histology, or molecular alterations. However, the tumors that progressed or metastasized may have distinct methylation profiles with evidence of activation of the MAPK and PI3K/AKT/mTOR pathways. CONCLUSIONS pLGG with MYB/MYBL1 alterations have good outcomes. Our findings suggest that surgical resectability is a crucial determinant of EFS. Further characterization is required to identify optimal treatment strategies for progressive tumors.
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Affiliation(s)
- Daniel C Moreira
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Ibrahim Qaddoumi
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Susan Spiller
- Department of Pediatric Hematology/Oncology, East Tennessee Children’s Hospital, Knoxville, Tennessee, USA
| | - Thomas W Bouldin
- Department of Pathology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Alan Davidson
- Department of Pediatric Hematology/Oncology, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - Nasjla Saba-Silva
- Department of Pediatric Oncology, Grupo de Apoio ao Adolescente e à Criança com Câncer (GRAACC), São Paulo, Brazil
| | - Daniel V Sullivan
- Department of Pathology, University of California San Francisco, San Francisco, California, USA
| | - Ryuma Tanaka
- Department of Pediatric Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Aaron S Wagner
- Department of Pathology, Orlando Health, Orlando, Florida, USA
| | - Matthew Wood
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Paul Klimo
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Neurosurgery, Le Bonheur Children’s Hospital, Memphis, Tennessee, USA
| | - Godwin Job
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Xiaoyu Li
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Amar Gajjar
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Giles W Robinson
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Jason Chiang
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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Joh-Carnella N, Bauman G, Yock TI, Zelcer S, Youkhanna S, Cacciotti C. Case report: Pediatric low-grade gliomas: a fine balance between treatment options, timing of therapy, symptom management and quality of life. Front Oncol 2024; 14:1366251. [PMID: 38912055 PMCID: PMC11190070 DOI: 10.3389/fonc.2024.1366251] [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: 01/05/2024] [Accepted: 05/28/2024] [Indexed: 06/25/2024] Open
Abstract
Introduction Pediatric low-grade gliomas (pLGG) are the most common brain tumor in children and encompass a wide range of histologies. Treatment may pose challenges, especially in those incompletely resected or those with multiple recurrence or progression. Case description We report the clinical course of a girl diagnosed with pilocytic astrocytoma and profound hydrocephalus at age 12 years treated with subtotal resection, vinblastine chemotherapy, and focal proton radiotherapy. After radiotherapy the tumor increased in enhancement temporarily with subsequent resolution consistent with pseudoprogression. Despite improvement in imaging and radiographic local control, the patient continues to have challenges with headaches, visual and auditory concerns, stroke-like symptoms, and poor quality of life. Conclusion pLGG have excellent long-term survival; thus, treatments should focus on maintaining disease control and limiting long-term toxicities. Various treatment options exist including surgery, chemotherapy, targeted agents, and radiation therapy. Given the morbidity associated with pLGG, individualized treatment approaches are necessary, with a multi-disciplinary approach to care focused on minimizing treatment side effects, and promoting optimal quality of life for patients.
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Affiliation(s)
| | - Glenn Bauman
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre & Western University, London, ON, Canada
| | - Torunn I. Yock
- Department of Pediatric Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Shayna Zelcer
- Division of Hematology/Oncology, Department of Pediatrics, London Health Sciences Centre & Western University, London, ON, Canada
| | - Sabin Youkhanna
- Department Radiation Oncology, London Regional Cancer Centre, London, ON, Canada
| | - Chantel Cacciotti
- Division of Hematology/Oncology, Department of Pediatrics, London Health Sciences Centre & Western University, London, ON, Canada
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Ramírez-Melo JL, Moreira DC, Orozco-Alvarado AL, Sánchez-Zubieta F, Navarro-Martín del Campo RM. Challenges in treating children with optic pathway gliomas: an 18-year experience from a middle-income country. Front Oncol 2024; 14:1329729. [PMID: 38414749 PMCID: PMC10898851 DOI: 10.3389/fonc.2024.1329729] [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: 10/29/2023] [Accepted: 01/05/2024] [Indexed: 02/29/2024] Open
Abstract
Introduction Patients with optic pathway gliomas (OPG) have good survival rates although their long-term quality of life can be affected by the tumor or treatment-related morbidity. This retrospective study sought to describe the clinical presentation and outcomes of children with OPG at a tertiary center in Mexico. Methods Consecutive patients <18 years-of-age with newly diagnosed OPG between January 2002 and December 2020 at the Hospital Civil de Guadalajara Dr. Juan I. Menchaca in Guadalajara, Mexico were included. Results Thirty patients were identified with a median age of six years. The most frequent clinical manifestations were loss of visual acuity (40%) and headaches (23%). Neurofibromatosis-1 was found in 23.3% of the patients. Surgery, either biopsy or resection, was done in 20 of 30 patients. Two patients died shortly after initial surgery. The 5-year event-free survival (EFS) was 79.3% ± 10.8% and the 5-year overall survival was 89.5% ± 6.9%. Lower EFS was associated with age less than 3 years, intracranial hypertension at presentation, and diencephalic syndrome. Patients who received surgery as first-line treatment had a 3.1 times greater risk of achieving a performance score of less than 90 points at 6 months after diagnosis (p=0.006). Of 10 patients with vision testing, 5 had improvement in visual acuity, 4 had no changes, and one patient showed worsening. Conclusion Our data suggests that favorable outcomes can be achieved with OPG in low- and middle-income countries, although a high rate of surgical complications was described leading to a lower overall survival. These data can be used prospectively to optimize treatment at this institute and other middle-income countries through a comprehensive, multidisciplinary approach.
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Affiliation(s)
- Jorge Luis Ramírez-Melo
- Pediatric Oncology and Hematology Service, Hospital Civil de Guadalajara Dr. Juan I. Menchaca, Guadalajara, Mexico
| | - Daniel C. Moreira
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Ana Luisa Orozco-Alvarado
- Pediatric Oncology and Hematology Service, Hospital Civil de Guadalajara Dr. Juan I. Menchaca, Guadalajara, Mexico
| | - Fernando Sánchez-Zubieta
- Pediatric Oncology and Hematology Service, Hospital Civil de Guadalajara Dr. Juan I. Menchaca, Guadalajara, Mexico
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Haas-Kogan DA, Aboian MS, Minturn JE, Leary SE, Abdelbaki MS, Goldman S, Elster JD, Kraya A, Lueder MR, Ramakrishnan D, von Reppert M, Liu KX, Rokita JL, Resnick AC, Solomon DA, Phillips JJ, Prados M, Molinaro AM, Waszak SM, Mueller S. Everolimus for Children With Recurrent or Progressive Low-Grade Glioma: Results From the Phase II PNOC001 Trial. J Clin Oncol 2024; 42:441-451. [PMID: 37978951 PMCID: PMC10824388 DOI: 10.1200/jco.23.01838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/09/2023] [Accepted: 10/17/2023] [Indexed: 11/19/2023] Open
Abstract
PURPOSE The PNOC001 phase II single-arm trial sought to estimate progression-free survival (PFS) associated with everolimus therapy for progressive/recurrent pediatric low-grade glioma (pLGG) on the basis of phosphatidylinositol 3-kinase (PI3K)/AKT/mammalian target of rapamycin (mTOR) pathway activation as measured by phosphorylated-ribosomal protein S6 and to identify prognostic and predictive biomarkers. PATIENTS AND METHODS Patients, age 3-21 years, with progressive/recurrent pLGG received everolimus orally, 5 mg/m2 once daily. Frequency of driver gene alterations was compared among independent pLGG cohorts of newly diagnosed and progressive/recurrent patients. PFS at 6 months (primary end point) and median PFS (secondary end point) were estimated for association with everolimus therapy. RESULTS Between 2012 and 2019, 65 subjects with progressive/recurrent pLGG (median age, 9.6 years; range, 3.0-19.9; 46% female) were enrolled, with a median follow-up of 57.5 months. The 6-month PFS was 67.4% (95% CI, 60.0 to 80.0) and median PFS was 11.1 months (95% CI, 7.6 to 19.8). Hypertriglyceridemia was the most common grade ≥3 adverse event. PI3K/AKT/mTOR pathway activation did not correlate with clinical outcomes (6-month PFS, active 68.4% v nonactive 63.3%; median PFS, active 11.2 months v nonactive 11.1 months; P = .80). Rare/novel KIAA1549::BRAF fusion breakpoints were most frequent in supratentorial midline pilocytic astrocytomas, in patients with progressive/recurrent disease, and correlated with poor clinical outcomes (median PFS, rare/novel KIAA1549::BRAF fusion breakpoints 6.1 months v common KIAA1549::BRAF fusion breakpoints 16.7 months; P < .05). Multivariate analysis confirmed their independent risk factor status for disease progression in PNOC001 and other, independent cohorts. Additionally, rare pathogenic germline variants in homologous recombination genes were identified in 6.8% of PNOC001 patients. CONCLUSION Everolimus is a well-tolerated therapy for progressive/recurrent pLGGs. Rare/novel KIAA1549::BRAF fusion breakpoints may define biomarkers for progressive disease and should be assessed in future clinical trials.
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Affiliation(s)
- Daphne A. Haas-Kogan
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Mariam S. Aboian
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT
| | - Jane E. Minturn
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sarah E.S. Leary
- Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, WA
- Department of Pediatrics, University of Washington, Seattle, WA
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA
| | - Mohamed S. Abdelbaki
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO
| | - Stewart Goldman
- Phoenix Children's Hospital, Phoenix, AZ
- University of Arizona College of Medicine, Phoenix, AZ
| | - Jennifer D. Elster
- Division of Hematology Oncology, Department of Pediatrics, Rady Children's Hospital, University of California, San Diego, San Diego, CA
| | - Adam Kraya
- Division of Neurosurgery, Center for Data-Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Matthew R. Lueder
- Division of Neurosurgery, Center for Data-Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Divya Ramakrishnan
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT
| | - Marc von Reppert
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT
- University of Leipzig, Leipzig, Germany
| | - Kevin X. Liu
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jo Lynne Rokita
- Division of Neurosurgery, Center for Data-Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Adam C. Resnick
- Division of Neurosurgery, Center for Data-Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David A. Solomon
- Department of Pathology, University of California, San Francisco, San Francisco, CA
| | - Joanna J. Phillips
- Department of Pathology, University of California, San Francisco, San Francisco, CA
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael Prados
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Annette M. Molinaro
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Sebastian M. Waszak
- Laboratory of Computational Neuro-Oncology, Swiss Institute for Experimental Cancer Research, School of Life Sciences, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
- Department of Neurology, University of California, San Francisco, San Francisco, CA
- Centre for Molecular Medicine Norway (NCMM), Nordic EMBL Partnership, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Sabine Mueller
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
- Department of Neurology, University of California, San Francisco, San Francisco, CA
- Department of Pediatrics, University of Zurich, Zurich, Switzerland
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5
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Na B, Shah S, Nghiemphu PL. Cancer Predisposition Syndromes in Neuro-oncology. Semin Neurol 2024; 44:16-25. [PMID: 38096910 DOI: 10.1055/s-0043-1777702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Although most primary central and peripheral nervous system (NS) tumors occur sporadically, there are a subset that may arise in the context of a cancer predisposition syndrome. These syndromes occur due to a pathogenic mutation in a gene that normally functions as a tumor suppressor. With increased understanding of the molecular pathogenesis of these tumors, more people have been identified with a cancer predisposition syndrome. Identification is crucial, as this informs surveillance, diagnosis, and treatment options. Moreover, relatives can also be identified through genetic testing. Although there are many cancer predisposition syndromes that increase the risk of NS tumors, in this review, we focus on three of the most common cancer predisposition syndromes, neurofibromatosis type 1, neurofibromatosis type 2, and tuberous sclerosis complex type 1 and type 2, emphasizing the clinical manifestations, surveillance guidelines, and treatment options.
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Affiliation(s)
- Brian Na
- Department of Neurology, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Shilp Shah
- Department of Bioengineering, UCLA Samueli School of Engineering, Los Angeles, California
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Liu KX, Haas-Kogan DA, Elhalawani H. Radiotherapy for Primary Pediatric Central Nervous System Malignancies: Current Treatment Paradigms and Future Directions. Pediatr Neurosurg 2023; 58:356-366. [PMID: 37703864 DOI: 10.1159/000533777] [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: 12/25/2022] [Accepted: 08/21/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Central nervous system tumors are the most common solid tumors in childhood. Treatment paradigms for pediatric central nervous system malignancies depend on elements including tumor histology, age of patient, and stage of disease. Radiotherapy is an important modality of treatment for many pediatric central nervous system malignancies. SUMMARY While radiation contributes to excellent overall survival rates for many patients, radiation also carries significant risks of long-term side effects including neurocognitive decline, hearing loss, growth impairment, neuroendocrine dysfunction, strokes, and secondary malignancies. In recent decades, clinical trials have demonstrated that with better imaging and staging along with more sophisticated radiation planning and treatment set-up verification, smaller treatment volumes can be utilized without decrement in survival. Furthermore, the development of intensity-modulated radiotherapy and proton-beam radiotherapy has greatly improved conformality of radiation. KEY MESSAGES Recent changes in radiation treatment paradigms have decreased risks of short- and long-term toxicity for common histologies and in different age groups. Future studies will continue to develop novel radiation regimens to improve outcomes in aggressive central nervous system tumors, integrate molecular subtypes to tailor radiation treatment, and decrease radiation-associated toxicity for long-term survivors.
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Affiliation(s)
- Kevin X Liu
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hesham Elhalawani
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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7
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Damodharan S, Puccetti D. Pediatric Central Nervous System Tumor Overview and Emerging Treatment Considerations. Brain Sci 2023; 13:1106. [PMID: 37509034 PMCID: PMC10377074 DOI: 10.3390/brainsci13071106] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
Pediatric central nervous system (CNS) tumors are the most common solid tumor in children, with the majority being glial in origin. These tumors are classified by the World Health Organization (WHO) as either being low grade (WHO grade 1 and 2) or high grade (WHO grade 3 and 4). Our knowledge of the molecular landscape of pediatric brain tumors has advanced over the last decade, which has led to newer categorizations along with an expansion of therapeutic targets and options. In this review, we will give an overview of common CNS tumors seen in children along with a focus on treatment options and future considerations.
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Affiliation(s)
- Sudarshawn Damodharan
- Department of Pediatrics, Division of Pediatric Hematology, Oncology and Bone Marrow Transplant, University of Wisconsin School of Medicine & Public Health, Madison, WI 53792, USA
| | - Diane Puccetti
- Department of Pediatrics, Division of Pediatric Hematology, Oncology and Bone Marrow Transplant, University of Wisconsin School of Medicine & Public Health, Madison, WI 53792, USA
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8
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Rajagopal R, Khan M, Lethbridge R, Lee G, Lee S, Dyke J, Fabian V, McGrath A, Taylor M, Jacoby P, Endersby R, Nagabushan S, Gottardo NG. Long-term outcomes of symptomatic optic pathway glioma: 32-year experience at a single Western Australian tertiary pediatric oncology center. Front Oncol 2023; 13:1157909. [PMID: 37519788 PMCID: PMC10379632 DOI: 10.3389/fonc.2023.1157909] [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: 02/03/2023] [Accepted: 06/27/2023] [Indexed: 08/01/2023] Open
Abstract
Introduction Optic pathway gliomas (OPGs) are associated with significant risk of visual and endocrine morbidity, but data on long-term outcomes in symptomatic patients is sparse. This study reviews the clinical course, disease progression, survival outcomes and long-term sequelae in pediatric patients with symptomatic OPGs in our institution over three decades. Methods Retrospective review of patients with symptomatic OPG treated in a single tertiary pediatric oncology center from 1984 to 2016. Results A total of 37 patients were diagnosed with symptomatic OPG. Decreased visual acuity was the commonest presenting symptom (75.7%). Surgical intervention was performed in 62.2%; 56.5% underwent biopsy, 26.1% surgical debulking and 17.4% had orbital decompression with cystic fenestration and cosmetic optic nerve excision at different treatment intervals. CSF diversion was performed in 47.8% patients. Histopathologic examination confirmed 86% to be pilocytic astrocytoma and 1 ganglioglioma. 46% received chemotherapy and 48% had radiotherapy, at different intervals. Median follow-up was 13.74 years. In NF1 patients, overall survival (OS) was 100% at 5 years and 55.6 ± 24.8% at 25 years while progression-free-survival (PFS) was 50 ± 15.8% at 5 and 20 years. In non-NF1 patients, OS was 96.2 ± 3.8% at 5 years and 87.4 ± 9% at 25-years. 5-year PFS was 53.8 ± 9.8% and 25-year PFS was 49.0 ± 10%. Cumulative PFS was 53 ± 8.3% at 5 years and 49.7 ± 8.4% at 20 years while cumulative OS was 97.2 ± 2.7% at 5 years and 77.5 ± 10.8% at 25 years. 59.5% patients developed post-operative endocrinopathy. Long-term vision was normal in 8.1%, improved in 13.5%, stabilized in 40.5% but worsened in 37.8% patients. Three patients treated with radiotherapy developed second brain tumors. Conclusion 25-year OS in this cohort was 77.5% but survivorship carried significant long-term morbidities including radiation-induced second malignant brain tumors.
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Affiliation(s)
- Revathi Rajagopal
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, TN, United States
| | - Mumtaz Khan
- Department of Anesthesia, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Robert Lethbridge
- School of Pediatrics and Child Health, University of Western Australia, Perth, WA, Australia
| | - Gabriel Lee
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Sharon Lee
- Department of Neurosurgery, Perth Children’s Hospital, Perth, WA, Australia
| | - Jason Dyke
- Department of Neuropathology, Royal Perth Hospital, Perth, WA, Australia
| | - Vicki Fabian
- Department of Neuropathology, Royal Perth Hospital, Perth, WA, Australia
| | - Alycea McGrath
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Mandy Taylor
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Peter Jacoby
- Department of Biostatistics, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - Raelene Endersby
- Brain Tumor Research Program, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - Sumanth Nagabushan
- Kids Cancer Centre, Sydney Children’s Hospital, Sydney, NSW, Australia
- School of Women’s and Children’s Health, University of New South Wales, Sydney, NSW, Australia
| | - Nicholas G. Gottardo
- Brain Tumor Research Program, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
- Department of Pediatric and Adolescent Oncology and Hematology, Perth Children’s Hospital, Perth, WA, Australia
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9
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Cipri S, Del Baldo G, Fabozzi F, Boccuto L, Carai A, Mastronuzzi A. Unlocking the power of precision medicine for pediatric low-grade gliomas: molecular characterization for targeted therapies with enhanced safety and efficacy. Front Oncol 2023; 13:1204829. [PMID: 37397394 PMCID: PMC10311254 DOI: 10.3389/fonc.2023.1204829] [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: 04/12/2023] [Accepted: 06/01/2023] [Indexed: 07/04/2023] Open
Abstract
In the past decade significant advancements have been made in the discovery of targetable lesions in pediatric low-grade gliomas (pLGGs). These tumors account for 30-50% of all pediatric brain tumors with generally a favorable prognosis. The latest 2021 WHO classification of pLGGs places a strong emphasis on molecular characterization for significant implications on prognosis, diagnosis, management, and the potential target treatment. With the technological advances and new applications in molecular diagnostics, the molecular characterization of pLGGs has revealed that tumors that appear similar under a microscope can have different genetic and molecular characteristics. Therefore, the new classification system divides pLGGs into several distinct subtypes based on these characteristics, enabling a more accurate strategy for diagnosis and personalized therapy based on the specific genetic and molecular abnormalities present in each tumor. This approach holds great promise for improving outcomes for patients with pLGGs, highlighting the importance of the recent breakthroughs in the discovery of targetable lesions.
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Affiliation(s)
- Selene Cipri
- Department of Hematology/Oncology, Cell Therapy, Gene Therapies and Hemopoietic Transplant, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Giada Del Baldo
- Department of Hematology/Oncology, Cell Therapy, Gene Therapies and Hemopoietic Transplant, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesco Fabozzi
- Department of Hematology/Oncology, Cell Therapy, Gene Therapies and Hemopoietic Transplant, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Luigi Boccuto
- Healthcare Genetics Program, School of Nursing, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC, United States
| | - Andrea Carai
- Department of Neurosciences, Neurosurgery Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Angela Mastronuzzi
- Department of Hematology/Oncology, Cell Therapy, Gene Therapies and Hemopoietic Transplant, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
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10
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Moreira DC, Lam CG, Bhakta N, Boop FA, Chiang J, Merchant TE, Rodriguez-Galindo C, Gajjar A, Qaddoumi I. Tackling Pediatric Low-Grade Gliomas: A Global Perspective. JCO Glob Oncol 2023; 9:e2300017. [PMID: 37043711 DOI: 10.1200/go.23.00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Affiliation(s)
- Daniel C Moreira
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Catherine G Lam
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Nickhill Bhakta
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Frederick A Boop
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Jason Chiang
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN
| | - Thomas E Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Amar Gajjar
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Ibrahim Qaddoumi
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
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11
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Phuong C, Qiu B, Mueller S, Braunstein SE. Precision based approach to tailoring radiotherapy in the multidisciplinary management of pediatric central nervous system tumors. JOURNAL OF THE NATIONAL CANCER CENTER 2023. [DOI: 10.1016/j.jncc.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
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12
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Grippin AJ, McGovern SL. Proton therapy for pediatric diencephalic tumors. Front Oncol 2023; 13:1123082. [PMID: 37213290 PMCID: PMC10196353 DOI: 10.3389/fonc.2023.1123082] [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: 12/13/2022] [Accepted: 03/03/2023] [Indexed: 05/23/2023] Open
Abstract
Diencephalic tumors tend to be low grade tumors located near several critical structures, including the optic nerves, optic chiasm, pituitary, hypothalamus, Circle of Willis, and hippocampi. In children, damage to these structures can impact physical and cognitive development over time. Thus, the goal of radiotherapy is to maximize long term survival while minimizing late effects, including endocrine disruption leading to precocious puberty, height loss, hypogonadotropic hypogonadism, and primary amenorrhea; visual disruption including blindness; and vascular damage resulting in cerebral vasculopathy. Compared to photon therapy, proton therapy offers the potential to decrease unnecessary dose to these critical structures while maintaining adequate dose to the tumor. In this article, we review the acute and chronic toxicities associated with radiation for pediatric diencephalic tumors, focusing on the use of proton therapy to minimize treatment-related morbidity. Emerging strategies to further reduce radiation dose to critical structures will also be considered.
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13
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Single-agent Bevacizumab in the Treatment of Symptomatic Newly Diagnosed and Recurrent/Refractory Pediatric Cervicomedullary Brainstem Low-grade Gliomas: A Single Institutional Experience. J Pediatr Hematol Oncol 2023; 45:e21-e25. [PMID: 35426868 DOI: 10.1097/mph.0000000000002462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/08/2022] [Indexed: 02/03/2023]
Abstract
Bevacizumab-based therapies have been utilized as single or combination therapy of refractory/recurrent pediatric low-grade gliomas. Its efficacy for symptomatic cervicomedullary low-grade gliomas (cmLGGs) in the upfront and the recurrent setting is less known. We report our retrospective single institutional experience from 2015 to 2021 with single-agent bevacizumab for symptomatic cmLGG. Six consecutive patients (4 female, ages 2 to 12 y) with newly diagnosed (n=3) and recurrent/refractory (n=3) symptomatic nondisseminated cmLGG (5/6 biopsy-proven, 2 BRAFV600E, 2 BRAF-KIAA1549) were treated with single-agent bevacizumab. All demonstrated radiographic response most pronounced on post-gadolinium T1-weighted magnetic resonance imaging (2 complete, 4 partial) at a median of 8 weeks (range: 2 to 12 wk). Clinical response was seen in all patients with improvement in cranial nerve abnormalities (3 recurrent/refractory, 1 newly diagnosed), strength (2 recurrent/refractory, 2 newly diagnosed), pain (2 recurrent/refractory), and anorexia (1 newly diagnosed). Four patients (2 recurrent/refractory, 2 newly diagnosed) experienced disease progression on subsequent adjunct therapies, 2 of which (the 2 newly diagnosed patients) are currently being rechallenged. At a mean follow-up of 7 months, all patients are clinically stable without disease progression. Single-agent bevacizumab may be effective in the management of symptomatic newly diagnosed and recurrent/refractory cmLGG and warrants further evaluation in a clinical trial setting.
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14
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Jujui-Eam A, Sirachainan N, Hongeng S, Hansasuta A, Boongird A, Tritanon O, Dhanachai M, Swangsilpa T, Ruangkanchanasetr R, Worawongsakul R, Puataweepong P. Long-term treatment outcomes of pediatric low-grade gliomas treated at a university-based hospital. Childs Nerv Syst 2022; 39:1173-1182. [PMID: 36574012 DOI: 10.1007/s00381-022-05809-9] [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: 08/08/2022] [Accepted: 12/14/2022] [Indexed: 12/28/2022]
Abstract
PURPOSE A multimodality approach is generally considered for pediatric low-grade gliomas (LGG); however, the optimal management remains uncertain. The objective of the study was to evaluate treatment outcomes of pediatric LGG, focusing on long-term survival and factors related to outcomes. METHODS A retrospective review of 77 pediatric LGG cases treated at Ramathibodi Hospital, Thailand between 2000 and 2018 was performed. The inclusion criteria were all pediatric LGG cases aged ≤ 15 years. Diffuse intrinsic pontine gliomas and spinal cord tumors were excluded. RESULTS The median follow-up time was 8.2 years (range, 0.6-19.7). The median age at diagnosis was 6.2 years (interquartile range, 3.6-11.4). Treatments modality included tumor surgery (93%), chemotherapy (40%), and radiation therapy (14%). The 10-year overall survival (OS) and 10-year progression-free survival were 94% and 59%, respectively, for the entire cohort. The 10-year OS was 100% in three subgroups of patients: pilocytic subtype, WHO grade 1 tumors, and recipient of gross total resection. After multivariable analysis, no tumor surgery had a significantly unfavorable influence on overall survival. CONCLUSIONS With a multimodality approach, pediatric LGGs had excellent outcome. Gross total resection is the standard primary treatment. Chemotherapy is the alternative standard treatment in incomplete resection cases, unresectable patients, or patients with progressive disease. Radiation therapy should be reserved as a salvage treatment option because of late complications that usually affect patients' quality of life.
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Affiliation(s)
- Apisak Jujui-Eam
- Radiation Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, 10400, Bangkok, Thailand
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suradej Hongeng
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ake Hansasuta
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Atthaporn Boongird
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Oranan Tritanon
- Radiation Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, 10400, Bangkok, Thailand
| | - Mantana Dhanachai
- Radiation Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, 10400, Bangkok, Thailand
| | - Thiti Swangsilpa
- Radiation Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, 10400, Bangkok, Thailand
| | - Rawee Ruangkanchanasetr
- Radiation Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, 10400, Bangkok, Thailand
| | - Rasin Worawongsakul
- Radiation Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, 10400, Bangkok, Thailand
| | - Putipun Puataweepong
- Radiation Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, 10400, Bangkok, Thailand.
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15
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Manoharan N, Liu KX, Mueller S, Haas-Kogan DA, Bandopadhayay P. Pediatric low-grade glioma: Targeted therapeutics and clinical trials in the molecular era. Neoplasia 2022; 36:100857. [PMID: 36566593 PMCID: PMC9803951 DOI: 10.1016/j.neo.2022.100857] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 12/25/2022] Open
Abstract
pLGGs are a group of tumors for which the era of molecular diagnostics has truly shifted treatment paradigms and patient care. The discovery that this group of tumors is driven by single-gene alterations/fusions in the MAPK pathway has resulted in relatively rapid translation into targeted therapy options for patients with this often chronic disease. This translation has been facilitated through efforts of multiple collaboratives and consortia and has led to the development of clinical trials testing the role of targeted therapies in pLGG. Although these developments represent promise, many questions remain regarding these therapies including their long-term toxicities and their potential effects on the natural history of pLGG.
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Affiliation(s)
- Neevika Manoharan
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW 2031, Australia,School of Women's and Children's Health, UNSW Sydney, Kensington, NSW, Australia
| | - Kevin X. Liu
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Sabine Mueller
- Department of Neurology, Neurosurgery and Pediatrics, University of California San Francisco, San Francisco, CA, USA,Department of Pediatrics, University of Zurich, Switzerland
| | - Daphne A. Haas-Kogan
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Pratiti Bandopadhayay
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, 450 Brookline Avenue, Boston, MA 02215, USA,Corresponding author.
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16
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Use of Trametinib in Children and Young Adults With Progressive Low-Grade Glioma and Glioneuronal Tumors. J Pediatr Hematol Oncol 2022; 45:e464-e470. [PMID: 36730221 DOI: 10.1097/mph.0000000000002598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/26/2022] [Indexed: 02/03/2023]
Abstract
Low-grade gliomas/glioneuronal tumors comprise one-third of all pediatric-type CNS tumors. These tumors are generally caused by activating mutations in the mitogen-activated protein kinase (MAPK) pathway. Targeted drugs, such as trametinib, have shown promise in other cancers and are being utilized in low-grade gliomas. A retrospective chart review was conducted to evaluate radiographic response, visual outcomes, tolerability, and durability of response in progressive circumscribed low-grade gliomas treated with trametinib. Eleven patients were treated with trametinib. The best radiographic response was 2/11 partial response, 3/11 minor response, 3/11 stable disease, and 3/13 progressive disease. In the patients with partial or minor response, the best response was seen after longer durations of therapy; 4 of 5 best responses occurred after at least 9 months of therapy with a median of 21 months. Patients with optic pathway tumors showed at least stable vision throughout treatment, with 3 having improved vision on treatment. Trametinib is effective and well-tolerated in patients with progressive low-grade glioma. Best responses were seen after a longer duration of therapy in those with a positive response. Patients with optic pathway lesions showed stable to improved vision while on treatment.
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17
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Management of Optic Pathway Glioma: A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14194781. [PMID: 36230704 PMCID: PMC9563939 DOI: 10.3390/cancers14194781] [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: 09/01/2022] [Revised: 09/25/2022] [Accepted: 09/26/2022] [Indexed: 11/17/2022] Open
Abstract
Background: OPG accounts for 3−5% of childhood central nervous system (CNS) tumors and about 2% of pediatric glial lesions. Methods: Article selection was performed by searching PubMed, Web of Science, and Cochrane databases. Results: The pooled mortality rate was 0.12 (95%CI 0.09−0.14). Due to the unrepresentative data, improved and not changed outcomes were classified as favorable outcomes and worsened as unfavorable. Meta-analyses were performed to determine the rate of clinical and radiological favorable outcomes. In terms of visual assessment, the pooled rate of a favorable outcome in chemotherapy, radiotherapy, and surgery was 0.74, 0.81, and 0.65, respectively, and the overall pooled rate of the favorable outcome was 0.75 (95%CI 0.70−0.80). In terms of radiological assessment, the rate of a favorable outcome following chemotherapy, radiotherapy, and surgery was 0.71, 0.74, and 0.67, respectively, and the overall pooled rate of the favorable outcome is 0.71 (95%CI 0.65−0.77). The subgroup analysis revealed no significant difference in the rate of clinical and radiological favorable outcomes between the different treatment modalities (p > 0.05). Conclusion: Our analyses showed that each therapeutic modality represents viable treatment options to achieve remission for these patients.
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18
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Zuccato JA, Algan O, Nair VJ, Gunter T, Glenn CA, Dunn IF, Fung KM, Shultz DB, Zadeh G, Laperriere N, Tsang DS. Resection and radiotherapy for intracranial ependymoma: a multiinstitutional 50-year experience. J Neurosurg 2022; 137:525-532. [PMID: 34952512 DOI: 10.3171/2021.9.jns211299] [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: 05/25/2021] [Accepted: 09/30/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Maximal safe resection is the standard-of-care treatment for adults with intracranial ependymoma. The value of adjuvant radiotherapy remains unclear as these tumors are rare and current data are limited to a few retrospective cohort studies. In this study, the authors assembled a cohort of patients across multiple international institutions to assess the utility of adjuvant radiotherapy in this patient population. METHODS Adults with intracranial ependymoma managed surgically at the University Health Network in Toronto, Canada, the University of Oklahoma Health Sciences Center in Oklahoma City, Oklahoma, and The Ottawa Hospital in Ottawa, Canada, were included in this study. The primary end points were progression-free survival (PFS) and overall survival (OS). Clinicopathological variables were assessed in univariate and multivariate Cox proportional hazard models for prognostic significance of PFS and OS. RESULTS A total of 122 patients diagnosed between 1968 and 2019 were identified for inclusion. The majority of patients had grade II ependymomas on histopathology (78%) that were infratentorially located (71%), underwent gross-total (GTR) or near-total resection (NTR; 55%), and were treated with adjuvant radiotherapy (67%). A volumetric analysis of the extent of resection in 49 patients with available tumor volume data supported the accuracy of the categorical GTR, NTR, and subtotal resection (STR) groups utilized. Independent statistically significant predictors of poorer PFS in the multivariate analysis included STR or biopsy (vs GTR/NTR; HR 5.4, 95% confidence interval [CI] 2.4-11.0, p < 0.0001) and not receiving adjuvant radiotherapy; cranial (HR 0.5, 95% CI 0.2-1.1) and craniospinal (HR 0.2, 95% CI 0.04-0.5) adjuvant radiotherapy regimens improved PFS (p = 0.0147). Predictors of poorer OS in the multivariate analysis were grade III histopathology (vs grade II: HR 5.7, 95% CI 1.6-20.2, p = 0.0064) and undergoing a biopsy/STR (vs GTR/NTR: HR 9.8, 95% CI 3.2-30.1, p = 0.0001). CONCLUSIONS The results of this 50-year experience in treating adult intracranial ependymomas confirm an important role for maximal safe resection (ideally GTR or NTR) and demonstrate that adjuvant radiotherapy improves PFS. This work will guide future studies as testing for molecular ependymoma alterations become incorporated into routine clinical practice.
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Affiliation(s)
- Jeffrey A Zuccato
- 1Division of Neurosurgery, University Health Network, University of Toronto, Ontario, Canada
| | - Ozer Algan
- 2Department of Radiation Oncology, Peggy and Charles Stephenson Oklahoma Cancer Center
| | - Vimoj J Nair
- 3Department of Radiation Oncology, The Ottawa Hospital, University of Ottawa, Ontario, Canada; and
| | - Tyler Gunter
- 2Department of Radiation Oncology, Peggy and Charles Stephenson Oklahoma Cancer Center
| | | | | | - Kar-Ming Fung
- 5Department of Pathology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - David B Shultz
- 6Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- 1Division of Neurosurgery, University Health Network, University of Toronto, Ontario, Canada
| | - Normand Laperriere
- 6Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Derek S Tsang
- 6Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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19
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Kim N, Lim DH. Recent Updates on Radiation Therapy for Pediatric Optic Pathway Glioma. Brain Tumor Res Treat 2022; 10:94-100. [PMID: 35545828 PMCID: PMC9098980 DOI: 10.14791/btrt.2022.0003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 11/25/2022] Open
Abstract
Optic pathway glioma (OPG) is a rare tumor located in optic nerve, optic tract, or optic chiasm. Treatment options for OPG include surgery, radiation therapy (RT), and chemotherapy. Although RT may provide favorable long-term outcomes in manner of either adjuvant or salvage aim, chemotherapy-first approach is increasingly performed due to possible late effects of RT. Proton beam RT may allow normal tissue sparing of radiation exposure compared to conventional X-ray treatment. Therefore, proton beam RT is expected to reduce complications from RT. This review discusses the recent updates on oncologic outcomes of OPG, late toxicities following RT, and compares the outcomes between X-ray treatment and proton beam RT.
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Affiliation(s)
- Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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20
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Nardone V, Desideri I, D’Ambrosio L, Morelli I, Visani L, Di Giorgio E, Guida C, Clemente A, Belfiore MP, Cioce F, Spadafora M, Vinciguerra C, Mansi L, Reginelli A, Cappabianca S. Nuclear medicine and radiotherapy in the clinical management of glioblastoma patients. Clin Transl Imaging 2022. [DOI: 10.1007/s40336-022-00495-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract
Introduction
The aim of the narrative review was to analyse the applications of nuclear medicine (NM) techniques such as PET/CT with different tracers in combination with radiotherapy for the clinical management of glioblastoma patients.
Materials and methods
Key references were derived from a PubMed query. Hand searching and clinicaltrials.gov were also used.
Results
This paper contains a narrative report and a critical discussion of NM approaches in combination with radiotherapy in glioma patients.
Conclusions
NM can provide the Radiation Oncologist several aids that can be useful in the clinical management of glioblastoma patients. At the same, these results need to be validated in prospective and multicenter trials.
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21
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The role of irinotecan-bevacizumab as rescue regimen in children with low-grade gliomas: a retrospective nationwide study in 72 patients. J Neurooncol 2022; 157:355-364. [PMID: 35239111 DOI: 10.1007/s11060-022-03970-4] [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: 11/09/2021] [Accepted: 02/15/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION At least half of children with low-grade glioma (LGG) treated with first line chemotherapy experience a relapse/progression and may therefore need a second-line chemotherapy. Irinotecan-bevacizumab has been recommended in this setting in France after encouraging results of pilot studies. We performed a retrospective analysis to define the efficacy, toxicity and predictors for response to the combination on a larger cohort. METHODS We reviewed the files from children < 19 years of age with progressive or refractory LGG treated between 2009 and 2016 in 7 French centers with this combination. RESULTS 72 patients (median age 7.8 years [range 1-19]) received a median of 16 courses (range 3-30). The median duration of treatment was 9 months (range 1.4-16.2). 96% of patients experienced at least disease stabilization. The 6-month and 2-year progression-free survivals (PFS) were 91.7% [IC 95% 85.5-98.3] and 38.2% [IC 95% 28.2-51.8] respectively. No progression occurred after treatment in 18 patients with a median follow-up of 35.6 months (range 7.6-75.9 months). Younger patients had a worse PFS (p = 0.005). Prior chemoresistance, NF1 status, duration of treatment, histopathology or radiologic response did not predict response. The most frequent toxicities related to bevacizumab included grades 1-2 proteinuria in 21, epistaxis in 10, fatigue in 12 and hypertension in 8 while gastro-intestinal toxicity was the most frequent side effect related to irinotecan. CONCLUSIONS Bevacizumab-irinotecan has the potential of disease control clinically and radiographically in children with recurrent LGG whatever their previous characteristics; in many cases however these responses are not sustained, especially in younger children.
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22
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Rady MR, Enayet AE, Refaat A, Taha H, Said W, Maher E, Beltagy MAE. Management and outcome of pediatric brainstem and cerebellar peduncular low-grade gliomas: a retrospective analysis of 62 cases. Childs Nerv Syst 2022; 38:565-575. [PMID: 34787716 DOI: 10.1007/s00381-021-05405-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This study was designed to present our experience and recommendations regarding the management of pediatric brainstem and peduncular low-grade gliomas (LGGs). METHODS Retrospective analysis was performed for pathologically proven brainstem or cerebellar peduncular LGGs in patients admitted between 2014 and 2019. These lesions were classified into the dorsal exophytic, focal brainstem, cervicomedullary, lower peduncular, and upper peduncular groups, and this classification was the basis for the surgical approach for the lesions. RESULTS Sixty-two pediatric patients were included, and their distribution among the aforementioned groups were as follows: 12, 12, 3, 16, and 19 cases in the dorsal exophytic, focal brainstem, cervicomedullary, upper peduncular, and lower peduncular groups, respectively. Stereotactic biopsy was performed for all cases in the focal brainstem group, whereas other groups underwent open excision. Gross total resection (GTR) was achieved in 20 cases (40%), near-total resection (NTR) was achieved in 17 cases (34%), and subtotal resection (STR) was achieved in 13 cases (26%). The extent of GTR and NTR for the upper peduncular, lower peduncular, dorsal exophytic, and cervicomedullary groups were 81.2%, 68.4%,75%, and 66.6%, respectively. Then, 32 cases received chemotherapy. The 3- and 5-year progression-free survival rates were 95% (95% confidence interval (CI) 89.5-100%) and 90.3% (95% CI 79.9-100%), respectively. A significant difference in the 3-year progression-free survival rate was observed between the GTR and NTR groups (p = 0.06; 100% vs. 88.2% (95% CI 72.9-100%)). CONCLUSION Surgery plays a definitive curative role in grossly resected cases. Additionally, the role of surgical debulking should be considered, even if GTR is impossible. Meanwhile, chemotherapy showed a beneficial role in patients with focal brainstem lesions and progressive lesions, those with STR, and some patients with NTR.
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Affiliation(s)
- Mohamed Reda Rady
- Neurosurgery Department, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt.,Neurosurgery Department, Children's Cancer Hospital Egypt (CCHE, 57357), Cairo, Egypt
| | - Abd Elrhman Enayet
- Neurosurgery Department, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt.,Neurosurgery Department, Children's Cancer Hospital Egypt (CCHE, 57357), Cairo, Egypt
| | - Amal Refaat
- Radiodiagnosis department, Children's Cancer Hospital Egypt, Cairo, 57357, Egypt
| | - Hala Taha
- Clinical Pathology Department, Children's Cancer Hospital Egypt (CCHE, Cairo, 57357), Egypt
| | - Waleed Said
- Pediatric Oncology Department, Children's Cancer Hospital Egypt (CCHE, Cairo, 57357), Egypt
| | - Eslam Maher
- Research Department, Children's Cancer Hospital Egypt (CCHE, Cairo, 57357), Egypt
| | - Mohamed A El Beltagy
- Neurosurgery Department, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt. .,Neurosurgery Department, Children's Cancer Hospital Egypt (CCHE, 57357), Cairo, Egypt.
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23
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Rios JD, Velummailum R, Bennett J, Nobre L, Tsang DS, Bouffet E, Hawkins C, Tabori U, Denburg A, Pechlivanoglou P. Clinical and economic impact of molecular testing for BRAF fusion in pediatric low-grade Glioma. BMC Pediatr 2022; 22:13. [PMID: 34980048 PMCID: PMC8722113 DOI: 10.1186/s12887-021-03069-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 12/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background Treatment personalization via tumor molecular testing holds promise for improving outcomes for patients with pediatric low-grade glioma (PLGG). We evaluate the health economic impact of employing tumor molecular testing to guide treatment for patients diagnosed with PLGG, particularly the avoidance of radiation therapy (RT) for patients with BRAF-fusion. Methods We performed a model-based cost-utility analysis comparing two strategies: molecular testing to determine BRAF fusion status at diagnosis against no molecular testing. We developed a microsimulation to model the lifetime health and cost outcomes (in quality-adjusted life years (QALYs) and 2018 CAD, respectively) for a simulated cohort of 100,000 patients newly diagnosed with PLGG after their initial surgery. Results The life expectancy after diagnosis for individuals who did not receive molecular testing was 39.01 (95% Confidence Intervals (CI): 32.94;44.38) years and 40.08 (95% CI: 33.19;45.76) years for those who received testing. Our findings indicate that patients who received molecular testing at diagnosis experienced a 0.38 (95% CI: 0.08;0.77) gain in QALYs and $1384 (95% CI: $-3486; $1204) reduction in costs over their lifetime. Cost and QALY benefits were driven primarily by the avoidance of long-term adverse events (stroke, secondary neoplasms) associated with unnecessary use of radiation. Conclusions We demonstrate the clinical benefit and cost-effectiveness of molecular testing in guiding the decision to provide RT in PLGG. While our results do not consider the impact of targeted therapies, this work is an example of the value of simulation modeling in assessing the long-term costs and benefits of precision oncology interventions for childhood cancer, which can aid decision-making about health system reimbursement. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-03069-1.
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Affiliation(s)
- Juan David Rios
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, 11th Floor - L4 East, Toronto, ON, M5G 0A4, Canada
| | - Russanthy Velummailum
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, 11th Floor - L4 East, Toronto, ON, M5G 0A4, Canada
| | - Julie Bennett
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Liana Nobre
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Derek S Tsang
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Cynthia Hawkins
- Department of Pathology, Hospital for Sick Children, Toronto, ON, Canada
| | - Uri Tabori
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Avram Denburg
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, 11th Floor - L4 East, Toronto, ON, M5G 0A4, Canada.,Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Petros Pechlivanoglou
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, 11th Floor - L4 East, Toronto, ON, M5G 0A4, Canada. .,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
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24
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Jumah F, Abou-Al-Shaar H, Mallela AN, Wiley CA, Lunsford LD. Gamma Knife Radiosurgery in the Management of Hypothalamic Glioma: A Case Report with Long-Term Follow-Up. Pediatr Neurosurg 2022; 57:118-126. [PMID: 34969032 DOI: 10.1159/000521732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 12/27/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Optic pathway/hypothalamic gliomas are rare pediatric brain tumors. The management paradigm for these challenging tumors includes chemotherapy, radiotherapy, or surgical resection, but the optimal management strategy remains elusive. Gamma knife radiosurgery (GKRS) has emerged as a promising treatment for such lesions as documented by a small number of cases in the literature. CASE PRESENTATION We present a rare case of hypothalamic glioma in a 13-year-old girl who was referred to our service due to growth of an incidentally diagnosed hypothalamic lesion following head injury at the age of 8 years. The lesion demonstrated hypointensity on T1- and hyperintensity on T2-weighted imaging without contrast enhancement. Given the growth of the lesion on serial imaging, a stereotactic biopsy was performed demonstrating low-grade glioma. The patient underwent GKRS treatment with a marginal dose of 15 Gy at 50% isodose line for a tumor volume of 2.2 mL. Annual radiological surveillance over the next 17 years demonstrated a gradual shrinkage of the lesion until it completely disappeared. The patient is currently a healthy 31-year-old female without any visual, endocrine, or neurocognitive deficits. CONCLUSION The outcome obtained after extended follow-up in our patient highlights the safety and efficacy of GKRS in the management of hypothalamic gliomas in pediatrics, which in turn can avoid potentially serious complications of surgery in this vulnerable patient population, especially in this sensitive location.
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Affiliation(s)
- Fareed Jumah
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School & University Hospital, Rutgers-New Jersey Medical School, New Brunswick, New Jersey, USA,
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arka N Mallela
- Department of Neurological Surgery, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Clayton A Wiley
- Division of Neuropathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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25
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Giotta Lucifero A, Elbabaa SK, Baldoncini M, Bruno N, Savasta S, Marseglia GL, Luzzi S. Novel "T-Dimension" Therapies for Pediatric Optic Pathway Glioma: A Timely, Targeted, and Tailored Treatment Trend. Pediatr Neurosurg 2022; 57:161-174. [PMID: 35588700 DOI: 10.1159/000524873] [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: 05/18/2021] [Accepted: 04/26/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Novel targeted and tailored therapies can substantially improve the prognosis for optic pathway glioma (OPG), especially when implemented in a timely manner. However, their tremendous potential remains underestimated. Therefore, in this study, we provide an updated overview of the clinical trials, current trends, and future perspectives for OPG's novel therapeutic strategies. METHODS We completed an extensive literature review using the PubMed, MEDLINE, and ClinicalTrials.gov databases. We analyzed and reported the data following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Thioguanine, procarbazine, lomustine, and vincristine/vinblastine, as well as cisplatin-etoposide, provided excellent results in advanced-phase trials. Selumetinib and trametinib, two oral MEK inhibitors, have been approved for recurrent or refractory OPGs in association with the angiogenetic inhibitor bevacizumab. Among the mTOR inhibitors, everolimus and sirolimus showed the best results. Stereotactic radiosurgery and proton beam radiation therapy have advantages over conventional radiotherapy regimens. Timely treatment is imperative for acute visual symptoms with evidence of tumor progression. This latest evidence can help define a novel "T-Dimension" for pediatric OPG therapies. CONCLUSION The novel "T-Dimension" for pediatric OPGs is based on recent evidence-based treatments, including combination chemotherapy regimens, molecular targeted therapies, stereotactic radiosurgery, and proton beam radiation therapy. Additional clinical trials are essential for validating each of these new therapies.
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Affiliation(s)
- Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Samer K Elbabaa
- Department of Pediatric Neurosurgery, Leon Pediatric Neuroscience Center of Excellence, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Matias Baldoncini
- Laboratory of Neuroanatomic Microsurgical-LaNeMic-II Division of Anatomy, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Nunzio Bruno
- Division of Neurosurgery, Azienda Ospedaliero Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Salvatore Savasta
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Gian Luigi Marseglia
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
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26
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Shen CJ, Terezakis SA. The Evolving Role of Radiotherapy for Pediatric Cancers With Advancements in Molecular Tumor Characterization and Targeted Therapies. Front Oncol 2021; 11:679701. [PMID: 34604027 PMCID: PMC8481883 DOI: 10.3389/fonc.2021.679701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 08/26/2021] [Indexed: 12/14/2022] Open
Abstract
Ongoing rapid advances in molecular diagnostics, precision imaging, and development of targeted therapies have resulted in a constantly evolving landscape for treatment of pediatric cancers. Radiotherapy remains a critical element of the therapeutic toolbox, and its role in the era of precision medicine continues to adapt and undergo re-evaluation. Here, we review emerging strategies for combining radiotherapy with novel targeted systemic therapies (for example, for pediatric gliomas or soft tissue sarcomas), modifying use or intensity of radiotherapy when appropriate via molecular diagnostics that allow better characterization and individualization of each patient’s treatments (for example, de-intensification of radiotherapy in WNT subgroup medulloblastoma), as well as exploring more effective targeted systemic therapies that may allow omission or delay of radiotherapy. Many of these strategies are still under investigation but highlight the importance of continued pre-clinical and clinical studies evaluating the role of radiotherapy in this era of precision oncology.
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Affiliation(s)
- Colette J Shen
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC, United States
| | - Stephanie A Terezakis
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, United States
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27
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Heitzer AM, Kahalley LS, Minard CG, Stafford C, Grosshans DR, Okcu MF, Raghubar KP, Gragert M, McCurdy M, Warren EH, Gomez J, Ris MD, Paulino AC, Chintagumpala M. Treatment age and neurocognitive outcomes following proton beam radiotherapy for pediatric low- and intermediate-grade gliomas. Pediatr Blood Cancer 2021; 68:e29096. [PMID: 34019329 PMCID: PMC9040342 DOI: 10.1002/pbc.29096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/12/2021] [Accepted: 04/16/2021] [Indexed: 11/11/2022]
Abstract
The relationship between age and neurocognitive functioning following proton beam radiotherapy (PRT) in low- and intermediate-grade gliomas (LIGG) has yet to be examined. Eighteen LIGG patients treated with PRT were prospectively enrolled and received annual neurocognitive evaluations of perceptual/verbal reasoning, working memory, and processing speed postradiotherapy. The median age at diagnosis was 8.2 years (range 1.0-14.7) and the median age at PRT was 9.9 years (range 4.2-17.0). Patients' neurocognitive performance did not change on any measure following PRT (p ≥ .142). We did not observe significant changes in cognitive function over time among a small group of LIGG patients treated with PRT.
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Affiliation(s)
- Andrew M. Heitzer
- Psychology Department, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Lisa S. Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Charles G. Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine
| | - Claire Stafford
- Psychology Department, Macalester College, St. Paul, Minnesota
| | - David R. Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
| | - M. Fatih Okcu
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston TX
| | - Kimberly P. Raghubar
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Marsha Gragert
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Mark McCurdy
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Emily H. Warren
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Jocelyn Gomez
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - M. Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
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28
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Aridgides P, Janssens GO, Braunstein S, Campbell S, Poppe M, Murphy E, MacDonald S, Ladra M, Alapetite C, Haas-Kogan D. Gliomas, germ cell tumors, and craniopharyngioma. Pediatr Blood Cancer 2021; 68 Suppl 2:e28401. [PMID: 32960496 DOI: 10.1002/pbc.28401] [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: 01/28/2020] [Revised: 04/22/2020] [Accepted: 04/23/2000] [Indexed: 11/07/2022]
Abstract
This report summarizes the current multimodality treatment approaches for children with low- and high-grade gliomas, germinoma, and nongerminomatous germ cell tumors, and craniopharyngiomas used in the Children's Oncology Group (COG) and the International Society of Pediatric Oncology (SIOP). Treatment recommendations are provided in the context of historical approaches regarding the roles of surgery, radiation, and chemotherapy. Future research strategies for these tumors in both COG and SIOP are also discussed.
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Affiliation(s)
- Paul Aridgides
- Department of Radiation Oncology, SUNY Upstate Medical University, Syracuse, NY, 13210
| | - Geert O Janssens
- Department of Radiation Oncology, University Medical Center Utrecht and Princess Máxima Center for Pediatric Oncology, Utrecht, GA, 3508, The Netherlands
| | - Steve Braunstein
- Department of Radiation Oncology, University of California, Ron Conway Family Gateway Medical Building, 1825 Fourth St. 1st floor M1215, San Francisco, CA, 94115
| | - Shauna Campbell
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Avenue / CA-50, Cleveland, OH, 44195
| | - Matthew Poppe
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, 1950 Circle of Hope, Radiation Oncology, 1570, Salt Lake City, UT, 84112
| | - Erin Murphy
- Department of Radiation Oncology, Cleveland Clinic, Mail Code CA5, 9500 Euclid Avenue, Cleveland, OH, 44195
| | - Shannon MacDonald
- Francis H Burr Proton Therapy Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114
| | - Matthew Ladra
- Department of Radiation Oncology, Johns Hopkins Kimmel Cancer Center, 401 N. Broadway, Weinberg Suite 1440, Baltimore, MD, 21231
| | | | - Daphne Haas-Kogan
- Department of Radiation Oncology, Dana-Farber Cancer Institute, D1622, 450 Brookline Ave, Brookline, MA, 02215
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29
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Trunin YY, Golanov AV, Konovalov AN, Pronin IN, Zagirov RI, Ryzhova MV, Kadyrov SU, Igoshina EN. [Stereotactic irradiation in the complex treatment of patients with intracranial pilocytic astrocytoma]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:34-46. [PMID: 33864667 DOI: 10.17116/neiro20218502134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Complex management of patients with intracranial pilocytic astrocytoma (PA) consists of surgical treatment, drug therapy (mainly in young children) and radiotherapy. For many years, radiotherapy (RT) has been a standard for residual tumors, recurrence or continued growth of PA. Currently, stereotactic radiosurgery and radiotherapy are preferred for PA, because these procedures are characterized by high conformity and selectivity, precise irradiation of tumor with minimal damage to surrounding intact tissues. Stereotaxic approach is very important since PAs are localized near functionally significant and radiosensitive brain structures in most cases. There is significant experience of single-center studies devoted to radiotherapy of patients with PA at the Department of Neuroradiosurgery of the Burdenko Neurosurgery Center. In this research, the authors analyzed the results of stereotactic irradiation of 430 patients with PA for the period from 2005 to 2018.
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Affiliation(s)
| | - A V Golanov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - R I Zagirov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - M V Ryzhova
- Burdenko Neurosurgical Center, Moscow, Russia
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30
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Acharya S, Liu JF, Tatevossian RG, Chiang J, Qaddoumi I, Gajjar A, Walker D, Harreld JH, Merchant TE, Ellison DW. Risk stratification in pediatric low-grade glioma and glioneuronal tumor treated with radiation therapy: an integrated clinicopathologic and molecular analysis. Neuro Oncol 2021; 22:1203-1213. [PMID: 32052049 DOI: 10.1093/neuonc/noaa031] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Management of unresectable pediatric low-grade glioma and glioneuronal tumor (LGG/LGGNT) is controversial. There are no validated prognostic features to guide use of radiation therapy (RT). Our study aimed to identify negative prognostic features in patients treated with RT using clinicopathologic and molecular data and validate these findings in an external dataset. METHODS Children with non-metastatic, biopsy-proven unresectable LGG/LGGNT treated with RT at a single institution between 1997 and 2017 were identified. Recursive partitioning analysis (RPA) was used to stratify patients into low- and high-risk prognostic groups based on overall survival (OS). CNS9702 data were used for validation. RESULTS One hundred and fifty patients met inclusion criteria. Median follow-up was 11.4 years. RPA yielded low- and high-risk groups with 10-year OS of 95.6% versus 76.4% (95% CI: 88.7%-98.4% vs 59.3%-87.1%, P = 0.003), respectively. These risk groups were validated using CNS9702 dataset (n = 48) (4-year OS: low-risk vs high-risk: 100% vs 64%, P < 0.001). High-risk tumors included diffuse astrocytoma or location within thalamus/midbrain. Low-risk tumors included pilocytic astrocytoma/ganglioglioma located outside of the thalamus/midbrain. In the subgroup with known BRAF status (n = 49), risk stratification remained prognostic independently of BRAF alteration (V600E or fusion). Within the high-risk group, delayed RT, defined as RT after at least one line of chemotherapy, was associated with a further decrement in overall survival (P = 0.021). CONCLUSION A high-risk subgroup of patients, defined by diffuse astrocytoma histology or midbrain/thalamus tumor location, have suboptimal long-term survival and might benefit from timely use of RT. These results require validation.
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Affiliation(s)
- Sahaja Acharya
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jo-Fen Liu
- Children's Brain Tumor Research Centre, University of Nottingham, Nottingham, UK
| | - Ruth G Tatevossian
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jason Chiang
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Ibrahim Qaddoumi
- Division of Neuro-Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Amar Gajjar
- Division of Neuro-Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - David Walker
- Children's Brain Tumor Research Centre, University of Nottingham, Nottingham, UK
| | - Julie H Harreld
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Thomas E Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - David W Ellison
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
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31
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Pajavand AM, Sharifi G, Anvari A, Bidari-Zerehpoosh F, Shamsi MA, Nateghinia S, Meybodi TE. Case Report: Chemotherapy Indication in a Case of Neurofibromatosis Type 1 Presenting Optic Pathway Glioma: A One-Year Clinical Case Study Using Differential Tractography Approach. Front Hum Neurosci 2021; 15:620439. [PMID: 33994974 PMCID: PMC8115022 DOI: 10.3389/fnhum.2021.620439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/01/2021] [Indexed: 11/30/2022] Open
Abstract
Neurofibromatosis type 1 (NF1) is associated with peripheral and central nervous system tumors. It is noteworthy that the regions in which these tumors frequently arise are the optic pathways (OPs) and the brainstem. Thus, we decided to trace the procedure of diffusion Magnetic Resonance Imaging (dMRI) alterations along with Short-Wavelength Automated Perimetry (SWAP) examinations of the OPs after surgery and chemotherapy over 1 year, which enabled us to evaluate chemotherapy's efficacy in an NF1 patient with an OP tumor. In this study, a 25-year-old woman with NF1 and left optic radiation (OR) glioma underwent surgery to remove the glioma. Immunohistochemistry (IHC) revealed a Pilocytic Astrocytoma (PA) WHO grade I. Post-operation chemotherapy done using nine treatment cycles of administering Temozolomide (TMZ) for 5 days every 4 weeks. Applying the region of interest (ROI) differential tractography method and SWAP four times every 3 months allowed us to follow the patient's visual acuity alterations longitudinally. The differential deterministic tractography method and statistical analyses enabled us to discover the white matter (WM) tracts anisotropy alterations over time. Furthermore, statistical analyses on the SWAP results along time illustrated possible alterations in visual acuity. Then, we could compare and associate the findings with the SWAP examinations and patient symptoms longitudinally. Statistical analyses of SWAP tests revealed a significant improvement in visual fields, and longitudinal differential tractography showed myelination and dense axonal packing in the left OR after 1 year of treatment. In this study, we examined an old hypothesis suggesting that chemotherapy is more effective than radiotherapy for NF1 patients with OP gliomas (OPGs) because of the radiation side effects on the visual field, cognition, and cerebrovascular complications. Our longitudinal clinical case study involving dMRI and SWAP on a single NF1-OPG patient showed that chemotherapy did not suppress the OP myelination over time. However, it should be noted that this is a clinical case study, and, therefore, the generalization of results is limited. Future investigations might focus on genetic-based imaging, particularly in more cases. Further, meta-analyses are recommended for giving a proper Field Of View (FOV) to researchers as a subtle clue regarding precision medicine.
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Affiliation(s)
- Amir Mohammad Pajavand
- Institute for Cognitive and Brain Sciences, Shahid Beheshti University Government College University, Tehran, Iran.,Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Guive Sharifi
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Anvari
- Department of Radiation Oncology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farahnaz Bidari-Zerehpoosh
- Department of Pathology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad A Shamsi
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeedeh Nateghinia
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Tohid Emami Meybodi
- Functional Neurosurgery Research Center, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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32
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Current Salvage Treatment Strategies for Younger Children (<10 y of Age) With Progressive Low-grade Glioma After Initial Chemotherapy in North America: A Web-based Survey. J Pediatr Hematol Oncol 2021; 43:e141-e145. [PMID: 33235141 DOI: 10.1097/mph.0000000000002017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pediatric low-grade gliomas (LGGs) are the most common brain tumors in children. Treatment of pediatric LGG can often be challenging, particularly when not resectable and refractory or recurrent following standard chemotherapy regimens. There is no current accepted standard of care salvage regimen for progressive LGG after the failure of first-line chemotherapy. A web-based survey was distributed to pediatric cancer centers throughout North America to inquire regarding institutional preferences of salvage treatment strategies after initial chemotherapy for LGG in children less than 10 years of age, as well as molecular testing preferences. Highlights from the survey results were as follows: vincristine/carboplatin (VC) and vinblastine (VBL) were the top 2 preferred salvage regimens for non-BRAF-altered pediatric LGG. BRAF and MEK inhibitors were the most preferred salvage regimens for BRAF V600e-mutated and BRAF fusion-positive pediatric LGG, respectively. VC ranked second. As high as 47.8% of North American centers would use conformal radiation for younger children with non-neurofibromatosis type 1 LGG after failing 2 to 3 chemotherapy regimens. Overall, 87% (87%) of North American institutions obtain some type of routine molecular testing for non-neurofibromatosis type 1-associated pediatric LGG cases. Less than 60% of centers obtain routine H3 K27M molecular testing for pediatric LGG with a midline location.
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Acharya S, Wu S, Ashford JM, Tinkle CL, Lucas JT, Qaddoumi I, Gajjar A, Krasin MJ, Conklin HM, Merchant TE. Association between hippocampal dose and memory in survivors of childhood or adolescent low-grade glioma: a 10-year neurocognitive longitudinal study. Neuro Oncol 2020; 21:1175-1183. [PMID: 30977510 PMCID: PMC7594551 DOI: 10.1093/neuonc/noz068] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Hippocampal avoidance has been suggested as a strategy to reduce short-term memory decline in adults receiving whole-brain radiation therapy (RT). The purpose of this study was to determine whether the hippocampal dose in children and adolescents undergoing RT for low-grade glioma was associated with memory, as measured by verbal recall. Methods Eighty patients aged at least 6 years but less than 21 years with low-grade glioma were treated with RT to 54 Gy on a phase II protocol. Patients underwent age-appropriate cognitive testing at baseline, 6 months posttreatment, yearly through 5 years posttreatment, year 7 or 8, and year 10 posttreatment. Random coefficient models were used to estimate the longitudinal trends in cognitive assessment scores. Results Median neurocognitive follow-up was 9.8 years. There was a significant decline in short-delay recall (slope = −0.01 standard deviation [SD]/year, P < 0.001), total recall (slope = −0.09 SD/y, P = 0.005), and long-delay recall (slope = −0.01 SD/y, P = 0.002). On multivariate regression, after accounting for hydrocephalus, decline in short-delay recall was associated with the volume of right (slope = −0.001 SD/y, P = 0.019) or left hippocampus (slope = −0.001 SD/y, P = 0.025) receiving 40 Gy (V40 Gy). On univariate regression, decline in total recall was only associated with right hippocampal dosimetry (V40 Gy slope = −0.002, P = 0.025). In children <12 years, on univariate regression, decline in long-delay recall was only associated with right (V40 Gy slope = −0.002, P = 0.013) and left (V40 Gy slope = −0.002, P = 0.014) hippocampal dosimetry. Conclusion In this 10-year longitudinal study, greater hippocampal dose was associated with a greater decline in delayed recall. Such findings might be informative for radiation therapy planning, warranting prospective evaluation.
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Affiliation(s)
- Sahaja Acharya
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Shengjie Wu
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Jason M Ashford
- Department of Psychology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Christopher L Tinkle
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - John T Lucas
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Ibrahim Qaddoumi
- Division of Neuro-Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Amar Gajjar
- Division of Neuro-Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Matthew J Krasin
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Heather M Conklin
- Department of Psychology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Thomas E Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
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34
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Bavle A, Srinivasan A, Choudhry F, Anderson M, Confer M, Simpson H, Gavula T, Thompson JS, Clifton S, Gross NL, McNall-Knapp R. Systematic review of the incidence and risk factors for cerebral vasculopathy and stroke after cranial proton and photon radiation for childhood brain tumors. Neurooncol Pract 2020; 8:31-39. [PMID: 33664967 DOI: 10.1093/nop/npaa061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background The aim of our study is to determine the incidence, timing, and risk factors for cerebral vasculopathy after cranial proton and photon radiation for pediatric brain tumors. Methods We performed a single-institution retrospective review of a cohort of children treated with proton radiation for brain tumors. MRA and/or MRI were reviewed for evidence of cerebral vascular stenosis and infarcts. Twenty-one similar studies (17 photon, 4 proton) were identified by systematic literature review. Results For 81 patients with median follow-up of 3 years, the rates of overall and severe vasculopathy were 9.9% and 6.2% respectively, occurring a median of 2 years post radiation. Dose to optic chiasm greater than 45 Gy and suprasellar location were significant risk factors. Results were consistent with 4 prior proton studies (752 patients) that reported incidence of 5% to 6.7%, 1.5 to 3 years post radiation. With significantly longer follow-up (3.7-19 years), 9 studies (1108 patients) with traditional photon radiation reported a higher rate (6.3%-20%) and longer time to vasculopathy (2-28 years). Significant risk factors were neurofibromatosis type 1 (NF-1; rate 7.6%-60%) and suprasellar tumors (9%-20%). In 10 studies with photon radiation (1708 patients), the stroke rate was 2% to 18.8% (2.3-24 years post radiation). Conclusions Childhood brain tumor survivors need screening for vasculopathy after cranial radiation, especially with higher dose to optic chiasm, NF-1, and suprasellar tumors. Prospective studies are needed to identify risk groups, and ideal modality and timing, for screening of this toxicity.
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Affiliation(s)
- Abhishek Bavle
- Children's Blood and Cancer Center, Dell Children's Medical Center of Central Texas, Toronto, Canada
| | - Anand Srinivasan
- Blood and Marrow Transplant Program, Hospital for Sick Children, Toronto, Canada
| | - Farooq Choudhry
- Department of Radiology, University of Oklahoma Health Sciences Center (OUHSC) Oklahoma City, OK, US
| | | | | | - Hilarie Simpson
- Department of Radiation Oncology, University of Kansas School of Medicine, Oklahoma City, OK, US
| | - Theresa Gavula
- Department of Pediatrics, OUHSC, Oklahoma City, OK, US.,Jimmy Everest Section of Pediatric Hematology/Oncology, Oklahoma City, OK, US
| | | | | | - Naina L Gross
- Department of Neurosurgery, OUHSC, Oklahoma City, OK, US
| | - Rene McNall-Knapp
- Department of Pediatrics, OUHSC, Oklahoma City, OK, US.,Jimmy Everest Section of Pediatric Hematology/Oncology, Oklahoma City, OK, US
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Willard VW, Berlin KS, Conklin HM, Merchant TE. Trajectories of psychosocial and cognitive functioning in pediatric patients with brain tumors treated with radiation therapy. Neuro Oncol 2020; 21:678-685. [PMID: 30624746 DOI: 10.1093/neuonc/noz010] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pediatric patients with brain tumors who are treated with radiation therapy (RT) are at risk for neurocognitive and psychosocial late effects. Research to date has primarily examined these outcomes at a group level and in isolation. Advanced statistical techniques allow for person-centered analyses, as well as examination of relationships between domain-specific trajectories. METHODS Patients with brain tumors (craniopharyngioma, ependymoma, low-grade astrocytoma, high-grade astrocytoma) were enrolled on a phase II clinical trial of RT. Three hundred and fifty patients completed serial neurocognitive assessments as part of their treatment monitoring, including pre-RT baseline, 6 months post-RT, and then yearly for 5 years. This secondary analysis focused on outcomes of cognition (estimated IQ, parent-reported attention problems) and psychosocial effects (parent-reported socialization and social problems) post-RT. RESULTS Latent growth curve modeling indicated that estimated IQ and socialization were best served by quadratic models, while attention and social problems were best served by linear models. Growth mixture modeling indicated 3-class models were the best fit for IQ and socialization, and 2-class models for attention and social problems. Baseline IQ and socialization scores were associated, but there was no association over time. Young age at diagnosis and pre-RT treatments (surgery, chemotherapy) were associated with class membership. CONCLUSIONS Person-centered statistical analyses provide rich information regarding the variability in neurocognitive and psychosocial functioning following RT for pediatric brain tumor. While many patients do well over time, a subset are exhibiting significant cognitive and/or psychosocial deficits. Class membership was associated with some medical factors (eg, pre-radiation surgery/chemotherapy, age at diagnosis, shunted hydrocephalus).
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Affiliation(s)
- Victoria W Willard
- Department of Psychology, St Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Heather M Conklin
- Department of Psychology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Thomas E Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
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Trametinib for the treatment of recurrent/progressive pediatric low-grade glioma. J Neurooncol 2020; 149:253-262. [PMID: 32780261 DOI: 10.1007/s11060-020-03592-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/07/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Pediatric low-grade gliomas (pLGGs) are the most common CNS tumor of childhood and comprise a heterogenous group of tumors. Children with progressive pLGG often require numerous treatment modalities including surgery, chemotherapy, rarely radiation therapy and, more recently, molecularly targeted therapy. We describe our institutional experience using the MEK inhibitor, trametinib, for recurrent/progressive pLGGs. METHODS We performed a retrospective, IRB-approved, chart review of all pediatric patients treated with trametinib for recurrent/progressive pLGGs at Dana-Farber/Boston Children's Cancer and Blood Disorder Center between 2016 and 2018. RESULTS Eleven patients were identified, of which 10 were evaluable for response. Median age at commencement of trametinib treatment was 14.7 years (range 7.3-25.9 years). Tumor molecular status included KIAA1549-BRAF fusion (n = 4), NF1 mutation (n = 4), FGFR mutation (n = 1) and CDKN2A loss (n = 1). Median number of prior treatment regimens was 5 (range 1-12). Median duration of treatment with trametinib was 19.2 months (range 3.8-29.8 months). Based on modified RANO criteria, best responses included partial (n = 2), minor response (n = 2) and stable disease (n = 6). Two patients remain on therapy (29.8 and 25.9 months, respectively). The most common toxicities attributable to trametinib were rash, fatigue and gastrointestinal disturbance. Five patients required dose reduction for toxicities. Two patients experienced significant intracranial hemorrhage (ICH) while on trametinib. While it is unclear whether ICH was directly attributable to trametinib, therapy was discontinued. CONCLUSION Trametinib appears to be an effective treatment for patients with recurrent/progressive pLGG. The toxicities of this therapy warrant further investigation, with particular attention to the potential risk for intracranial hemorrhage. Early phase multi-institutional clinical trials are underway.
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Gatto L, Franceschi E, Nunno VD, Tomasello C, Bartolini S, Brandes AA. Glioneuronal tumors: clinicopathological findings and treatment options. FUTURE NEUROLOGY 2020. [DOI: 10.2217/fnl-2020-0003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Glioneuronal tumors are very rare CNS neoplasms that demonstrate neuronal differentiation, composed of mixed glial and neuronal cells. The majority of these lesions are low grade and their correct classification is crucial in order to avoid misidentification as ‘ordinary’ gliomas and prevent inappropriate aggressive treatment; nevertheless, precise diagnosis is a challenge due to phenotypic overlap across different histologic subtype. Surgery is the standard of therapeutic approach; literature concerning the benefit of adjuvant treatments is inconclusive and a globally accepted treatment of recurrence does not exist. Targetable mutations in the genes BRAF and FGFR1/2 are recurrently found in these tumors and could take a promising role in future treatment management.
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Affiliation(s)
- Lidia Gatto
- Department of Medical Oncology, Azienda USL/IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Enrico Franceschi
- Department of Medical Oncology, Azienda USL/IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Vincenzo Di Nunno
- Department of Medical Oncology, Azienda USL/IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Chiara Tomasello
- Department of Neurosciences, University of Messina, Messina, Italy
| | - Stefania Bartolini
- Department of Medical Oncology, Azienda USL/IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Alba Ariela Brandes
- Department of Medical Oncology, Azienda USL/IRCCS Institute of Neurological Sciences, Bologna, Italy
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38
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Elmaraghi C, Bishr MK, Mousa AG, Ahmed S, Refaat A, Elhemaly A, Ayadi ME, Taha H, Maher E, Elbeltagy M, Zaghloul MS. Pediatric low grade focal brainstem glioma: outcomes of different treatment strategies and prognostic factors. Future Oncol 2020; 16:2401-2410. [PMID: 32687387 DOI: 10.2217/fon-2020-0448] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: This study explores the prognostic factors and outcomes of different treatment modalities in focal brain stem glioma (FBSG). Materials & methods: Pediatric FBSG patients diagnosed during 2010-2017 were retrospectively reviewed for clinical and therapeutic data. Results: A total of 71 cases were identified and the median age was 6.4 years. The 5-year overall- and progression-free survival were 74.5 and 70.6%, respectively. Radiotherapy was the main line of treatment (66.2%) and there were no survival differences between radiotherapy, chemotherapy and surveillance groups. Two independent poor prognostic factors were identified on multivariate analysis: age <8 years and cervicomedullary tumor site (p = 0.02 for both). Conclusion: Surveillance, radiotherapy and chemotherapy have comparable clinical outcomes in pediatric FBSG.
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Affiliation(s)
- Caroline Elmaraghi
- Department of Clinical Oncology, Ain Shams University, Cairo, Egypt.,Department of Radiotherapy, Children's Cancer Hospital, CCHE 57357, Egypt
| | - Mai K Bishr
- Department of Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Amr G Mousa
- National Cancer Institute, Cairo University, Cairo, Egypt.,Oncology Center, King Faisal Specialized Hospital & Research Center, Riyadh, Saudi Arabia
| | - Soha Ahmed
- Department of Radiotherapy, Children's Cancer Hospital, CCHE 57357, Egypt.,Department of Clinical Oncology and Nuclear Medicine. Aswan University
| | - Amal Refaat
- National Cancer Institute, Cairo University, Cairo, Egypt.,Department of Radiodiagnosis, Children's Cancer Hospital, CCHE 57357, Egypt
| | - Ahmed Elhemaly
- National Cancer Institute, Cairo University, Cairo, Egypt.,Department of Pediatric Oncology, Children's Cancer Hospital, CCHE 57357, Egypt
| | - Moatasem El Ayadi
- National Cancer Institute, Cairo University, Cairo, Egypt.,Department of Pediatric Oncology, Children's Cancer Hospital, CCHE 57357, Egypt
| | - Hala Taha
- National Cancer Institute, Cairo University, Cairo, Egypt.,Department of Pathology, Children's Cancer Hospital, CCHE 57357, Egypt
| | - Eslam Maher
- Department of Research, Children's Cancer Hospital, CCHE 57357, Egypt
| | - Mohamed Elbeltagy
- Department of Neurosurgery, Children's Cancer Hospital, CCHE 57357, Egypt.,Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed S Zaghloul
- Department of Radiotherapy, Children's Cancer Hospital, CCHE 57357, Egypt.,National Cancer Institute, Cairo University, Cairo, Egypt
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Kandels D, Pietsch T, Bison B, Warmuth-Metz M, Thomale UW, Kortmann RD, Timmermann B, Hernáiz Driever P, Witt O, Schmidt R, Gnekow AK. Loss of efficacy of subsequent nonsurgical therapy after primary treatment failure in pediatric low-grade glioma patients-Report from the German SIOP-LGG 2004 cohort. Int J Cancer 2020; 147:3471-3489. [PMID: 32580249 DOI: 10.1002/ijc.33170] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/02/2020] [Accepted: 06/10/2020] [Indexed: 12/11/2022]
Abstract
First-line treatment of pediatric low-grade glioma using surgery, radio- or chemotherapy fails in a relevant proportion of patients. We analyzed efficacy of subsequent surgical and nonsurgical therapies of the German cohort of the SIOP-LGG 2004 study (2004-2012, 1558 registered patients; median age at diagnosis 7.6 years, median observation time 9.2 years, overall survival 98%/96% at 5/10 years, 15% neurofibromatosis type 1 [NF1]). During follow-up, 1078/1558 patients remained observed without (n = 217), with 1 (n = 707), 2 (n = 124) or 3 to 6 (n = 30) tumor volume reductions; 480/1558 had 1 (n = 332), 2 (n = 80), 3 or more (n = 68) nonsurgical treatment-lines, accompanied by up to 4 tumor-reductive surgeries in 215/480; 265/480 patients never underwent any neurosurgical tumor volume reduction (163/265 optic pathway glioma). Patients with progressing tumors after first-line adjuvant treatment were at increased risk of suffering further progressions. Risk factors were young age (<1 year) at start of treatment, tumor dissemination or progression within 18 months after start of chemotherapy. Progression-free survival rates declined with subsequent treatment-lines, yet remaining higher for patients with NF1. In non-NF1-associated tumors, vinblastine monotherapy vs platinum-based chemotherapy was noticeably less effective when used as second-line treatment. Yet, for the entire cohort, results did not favor a certain sequence of specific treatment options. Rather, all can be aligned as a portfolio of choices which need careful balancing of risks and benefits. Future molecular data may predict long-term tumor biology.
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Affiliation(s)
- Daniela Kandels
- Swabian Children's Cancer Center, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Torsten Pietsch
- Institute of Neuropathology, DGNN Brain Tumor Reference Center, University of Bonn, Bonn, Germany
| | - Brigitte Bison
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany
| | - Monika Warmuth-Metz
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany
| | - Ulrich-Wilhelm Thomale
- Pediatric Neurosurgery, Charité Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | | | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), German Cancer Consortium (DKTK), Essen, Germany
| | - Pablo Hernáiz Driever
- Department of Pediatric Oncology/Hematology, Charité Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Olaf Witt
- Hopp Children's Cancer Center Heidelberg (KiTZ), German Cancer Research Center (DKFZ), and Heidelberg University Hospital, Heidelberg, Germany
| | - René Schmidt
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Astrid K Gnekow
- Swabian Children's Cancer Center, Medical Faculty, University of Augsburg, Augsburg, Germany
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Janssens GO, Mandeville HC, Timmermann B, Maduro JH, Alapetite C, Padovani L, Horan G, Lassen-Ramshad Y, Dieckmann K, Ruebe C, Thorp N, Gandola L, Ajithkumar T, Boterberg T. A rapid review of evidence and recommendations from the SIOPE radiation oncology working group to help mitigate for reduced paediatric radiotherapy capacity during the COVID-19 pandemic or other crises. Radiother Oncol 2020; 148:216-222. [PMID: 32342872 PMCID: PMC7184972 DOI: 10.1016/j.radonc.2020.04.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 04/21/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To derive evidence-based recommendations for the optimal utilisation of resources during unexpected shortage of radiotherapy capacity. METHODS AND MATERIALS We have undertaken a rapid review of published literature on the role of radiotherapy in the multimodality treatment of paediatric cancers governing the European practise of paediatric radiotherapy. The derived data has been discussed with expert paediatric radiation oncologists to derive a hierarchy of recommendations. RESULTS The general recommendations to mitigate the potential detriment of an unexpected shortage of radiotherapy facilities include: (1) maintain current standards of care as long as possible (2) refer to another specialist paediatric radiotherapy department with similar level of expertise (3) prioritise use of existing radiotherapy resources to treat patients with tumours where radiotherapy has the most effect on clinical outcome (4) use chemotherapy to defer the start of radiotherapy where timing of radiotherapy is not expected to be detrimental (5) active surveillance for low-grade tumours if appropriate and (6) consider iso-effective hypofractionated radiotherapy regimens only for selected patients with predicted poor prognosis. The effectiveness of radiotherapy and recommendations for prioritisation of its use for common and challenging paediatric tumours are discussed. CONCLUSION This review provides evidence-based treatment recommendations during unexpected shortage of paediatric radiotherapy facilities. It has wider applications for the optimal utilisation of facilities, to improve clinical outcome in low- and middle-income countries, where limited resources continue to be a challenge.
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Affiliation(s)
- Geert O Janssens
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands; Princess Maxima Centre for Paediatric Oncology, Utrecht, The Netherlands
| | - Henry C Mandeville
- Department of Radiotherapy, The Royal Marsden Hospital, Sutton, United Kingdom; The Institute of Cancer Research, Sutton, United Kingdom
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ) and German Cancer Consortium (DKTK), Germany
| | - John H Maduro
- Princess Maxima Centre for Paediatric Oncology, Utrecht, The Netherlands; Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Claire Alapetite
- Department of Radiation Oncology & Proton Center, Institut Curie, France
| | - Laetitia Padovani
- Aix-Marseille University, Oncology Radiotherapy Department, CRCM Inserm, UMR1068, CNRS UMR7258, AMU UM105, Genome Instability and Carcinogenesis, APHM, France
| | - Gail Horan
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, United Kingdom
| | | | - Karin Dieckmann
- Department of Radiotherapy Medical University Vienna, Austria
| | - Christian Ruebe
- Strahlentherapie und Radioonkologie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Nicky Thorp
- Department of Radiotherapy, The Clatterbridge Cancer Centre, Wirral, United Kingdom; The Proton Beam Therapy Centre, The Christie Hospital, Manchester, United Kingdom
| | - Lorenza Gandola
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Thankamma Ajithkumar
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, United Kingdom.
| | - Tom Boterberg
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
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Wallace D, Taylor DR, Pan H, Hwang S, Lucas JT, Klimo P, Upadhyaya SA, Boop FA. Treatment-related calvarial lesions in pediatric brain tumor survivors. Pediatr Blood Cancer 2020; 67:e28189. [PMID: 32286018 PMCID: PMC8674206 DOI: 10.1002/pbc.28189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 12/12/2019] [Accepted: 12/23/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite improved survival, many pediatric brain tumor survivors receiving radiation therapy (RT) experience late effects. PROCEDURE To study calvarial lesions in this population, we retrospectively reviewed records of patients undergoing neurosurgical evaluation for calvarial bone lesions detected in posttreatment follow-up imaging at St. Jude Children's Research Hospital. Primary tumor diagnosis, treatment, imaging, surgical intervention, and histopathology from patients with radiographic evidence of lesions followed for ≥2 years post-RT were studied. RESULTS For 17 patients with 18 index lesions, median time to lesion manifestation was 2.34 years. Medulloblastoma patients developed lesions at a shorter interval from RT than ependymoma patients (P = .05). Twelve of 14 lesions requiring surgery were benign fibro-osseous or sclerotic. Two malignant lesions distinct from the primary tumor had genetic predisposition to malignancy. CONCLUSION Most calvarial lesions arising post-RT are benign and fibro-osseous. Serial imaging is recommended, and high index of suspicion for malignant lesions is warranted for patients genetically predisposed to cancer.
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Affiliation(s)
- David Wallace
- University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee
| | - Douglas R. Taylor
- Department of Neurosurgery, LeBonheur Children’s Hospital, Memphis, Tennessee
| | - Haitao Pan
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Scott Hwang
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - John T. Lucas
- Department of Radiation Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Paul Klimo
- Department of Neurosurgery, LeBonheur Children’s Hospital, Memphis, Tennessee,Department of Surgery, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Santhosh A. Upadhyaya
- Department of Oncology, Division of Neuro-Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Frederick A. Boop
- Department of Neurosurgery, LeBonheur Children’s Hospital, Memphis, Tennessee,Department of Surgery, St. Jude Children’s Research Hospital, Memphis, Tennessee
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42
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Nobre L, Zapotocky M, Ramaswamy V, Ryall S, Bennett J, Alderete D, Balaguer Guill J, Baroni L, Bartels U, Bavle A, Bornhorst M, Boue DR, Canete A, Chintagumpala M, Coven SL, Cruz O, Dahiya S, Dirks P, Dunkel IJ, Eisenstat D, Faure Conter C, Finch E, Finlay JL, Frappaz D, Garre ML, Gauvain K, Bechensteen AG, Hansford JR, Harting I, Hauser P, Hazrati LN, Huang A, Injac SG, Iurilli V, Karajannis M, Kaur G, Kyncl M, Krskova L, Laperriere N, Larouche V, Lassaletta A, Leary S, Lin F, Mascelli S, McKeown T, Milde T, Morales La Madrid A, Morana G, Morse H, Mushtaq N, Osorio DS, Packer R, Pavelka Z, Quiroga-Cantero E, Rutka J, Sabel M, Salgado D, Solano P, Sterba J, Su J, Sumerauer D, Taylor MD, Toledano H, Tsang DS, Valente Fernandes M, van Landeghem F, van Tilburg CM, Wilson B, Witt O, Zamecnik J, Bouffet E, Hawkins C, Tabori U. Outcomes of BRAF V600E Pediatric Gliomas Treated With Targeted BRAF Inhibition. JCO Precis Oncol 2020; 4:1900298. [PMID: 32923898 DOI: 10.1200/po.19.00298] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2020] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Children with pediatric gliomas harboring a BRAF V600E mutation have poor outcomes with current chemoradiotherapy strategies. Our aim was to study the role of targeted BRAF inhibition in these tumors. PATIENTS AND METHODS We collected clinical, imaging, molecular, and outcome information from patients with BRAF V600E-mutated glioma treated with BRAF inhibition across 29 centers from multiple countries. RESULTS Sixty-seven patients were treated with BRAF inhibition (pediatric low-grade gliomas [PLGGs], n = 56; pediatric high-grade gliomas [PHGGs], n = 11) for up to 5.6 years. Objective responses were observed in 80% of PLGGs, compared with 28% observed with conventional chemotherapy (P < .001). These responses were rapid (median, 4 months) and sustained in 86% of tumors up to 5 years while receiving therapy. After discontinuation of BRAF inhibition, 76.5% (13 of 17) of patients with PLGG experienced rapid progression (median, 2.3 months). However, upon rechallenge with BRAF inhibition, 90% achieved an objective response. Poor prognostic factors in conventional therapies, such as concomitant homozygous deletion of CDKN2A, were not associated with lack of response to BRAF inhibition. In contrast, only 36% of those with PHGG responded to BRAF inhibition, with all but one tumor progressing within 18 months. In PLGG, responses translated to 3-year progression-free survival of 49.6% (95% CI, 35.3% to 69.5%) versus 29.8% (95% CI, 20% to 44.4%) for BRAF inhibition versus chemotherapy, respectively (P = .02). CONCLUSION Use of BRAF inhibition results in robust and durable responses in BRAF V600E-mutated PLGG. Prospective studies are required to determine long-term survival and functional outcomes with BRAF inhibitor therapy in childhood gliomas.
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Affiliation(s)
- Liana Nobre
- Department of Hematology and Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Michal Zapotocky
- Department of Hematology and Oncology, Hospital for Sick Children, Toronto, ON, Canada.,Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Vijay Ramaswamy
- Department of Hematology and Oncology, Hospital for Sick Children, Toronto, ON, Canada.,Developmental and Stem Cell Biology Program, Hospital for Sick Children, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Scott Ryall
- Department of Hematology and Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Julie Bennett
- Department of Hematology and Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Daniel Alderete
- Hospital of Pediatrics SAMIC Prof. Dr Juan P. Garrahan, Buenos Aires, Argentina
| | - Julia Balaguer Guill
- Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | - Lorena Baroni
- Hospital of Pediatrics SAMIC Prof. Dr Juan P. Garrahan, Buenos Aires, Argentina
| | - Ute Bartels
- Department of Hematology and Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Abhishek Bavle
- Jimmy Everest Section of Pediatric Heamatology/Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | | | - Daniel R Boue
- Nationwide Children's Hospital and Ohio State University, Columbus, OH
| | - Adela Canete
- Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | | | - Scott L Coven
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Indiana University, Indianapolis, IN
| | | | - Sonika Dahiya
- Washington University School of Medicine, St Louis, MO
| | - Peter Dirks
- Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children, Toronto, ON, Canada.,Division of Neurosurgery, Hospital for Sick Children, Toronto, ON, Canada
| | - Ira J Dunkel
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - David Eisenstat
- Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | | | - Elizabeth Finch
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jonathan L Finlay
- Nationwide Children's Hospital and Ohio State University, Columbus, OH
| | - Didier Frappaz
- Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France
| | | | - Karen Gauvain
- Washington University School of Medicine, St Louis, MO
| | | | - Jordan R Hansford
- Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Inga Harting
- Hopp Children's Cancer Center Heidelberg, Heidelberg, Germany
| | | | - Lili-Naz Hazrati
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Annie Huang
- Department of Hematology and Oncology, Hospital for Sick Children, Toronto, ON, Canada.,Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children, Toronto, ON, Canada
| | | | | | | | | | - Martin Kyncl
- Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Lenka Krskova
- Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Normand Laperriere
- Department of Hematology and Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | | | | | | | - Frank Lin
- Texas Children's Cancer Center, Houston, TX
| | | | - Tara McKeown
- Department of Hematology and Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Till Milde
- Hopp Children's Cancer Center Heidelberg, Heidelberg, Germany
| | | | | | | | | | - Diana S Osorio
- Nationwide Children's Hospital and Ohio State University, Columbus, OH
| | - Roger Packer
- Children's National Health System, Washington, DC
| | - Zdenek Pavelka
- University Hospital Brno, Masaryk University, and ICRC Brno, Brno, Czech Republic
| | | | - James Rutka
- Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children, Toronto, ON, Canada.,Division of Neurosurgery, Hospital for Sick Children, Toronto, ON, Canada
| | - Magnus Sabel
- Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | | | - Palma Solano
- Hospital Infantil Virgen del Rocío, Sevilla, Spain
| | - Jaroslav Sterba
- University Hospital Brno, Masaryk University, and ICRC Brno, Brno, Czech Republic
| | - Jack Su
- Texas Children's Cancer Center, Houston, TX
| | - David Sumerauer
- Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Michael D Taylor
- Developmental and Stem Cell Biology Program, Hospital for Sick Children, Toronto, ON, Canada.,Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children, Toronto, ON, Canada.,Division of Neurosurgery, Hospital for Sick Children, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Department of Surgery, University of Ontario, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Helen Toledano
- Schneiders Children's Medical Center of Israel, Petah Tikva, Israel
| | - Derek S Tsang
- Department of Hematology and Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | | | | | | | - Bev Wilson
- Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Olaf Witt
- Hopp Children's Cancer Center Heidelberg, Heidelberg, Germany
| | - Josef Zamecnik
- Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Eric Bouffet
- Department of Hematology and Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Cynthia Hawkins
- Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Department of Pediatric Laboratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Uri Tabori
- Department of Hematology and Oncology, Hospital for Sick Children, Toronto, ON, Canada.,Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children, Toronto, ON, Canada
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Margin-Free Fractionated Stereotactic Radiation Therapy for Pediatric Brain Tumors. Pract Radiat Oncol 2020; 10:e485-e494. [PMID: 32428764 DOI: 10.1016/j.prro.2020.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/14/2020] [Accepted: 03/09/2020] [Indexed: 01/05/2023]
Abstract
PURPOSE Conventional radiation therapy (RT) to pediatric brain tumors exposes a large volume of normal brain to unwarranted radiation causing late toxicity. We hypothesized that in well demarcated pediatric tumors lacking microscopic extensions, fractionated stereotactic RT (SRT), without target volume expansions, can reduce high dose normal tissue irradiation without affecting local control. METHODS AND MATERIALS Between 2008 and 2017, 52 pediatric patients with brain tumors were treated using the CyberKnife (CK) with SRT in 180 to 200 cGy per fraction. Thirty representative cases were retrospectively planned for intensity modulated RT (IMRT) with 4-mm PTV expansion. We calculated the volume of normal tissue within the high or intermediate dose region adjacent to the target. Plan quality and radiation dose-volume dosimetry parameters were compared between CK and IMRT plans. We also reported overall survival, progression-free survival (PFS), and local control. RESULTS Tumors included low-grade gliomas (n = 28), craniopharyngiomas (n = 16), and ependymomas (n = 8). The volumes of normal tissue receiving high (≥80% of prescription dose or ≥40 Gy) or intermediate (80% > dose ≥50% of the prescription dose or 40 Gy > dose ≥25 Gy) dose were significantly smaller with CK versus IMRT plans (P < .0001 for all comparisons). With a median follow-up of 3.7 years (range, 0.1-9.0), 3-year local control was 92% for all patients. Eight failures occurred: 1 craniopharyngioma (marginal), 2 ependymomas (both in-field), and 5 low-grade gliomas (2 in-field, 1 marginal, and 2 distant). CONCLUSIONS Fractionated SRT using CK without target volume expansion appears to reduce the volume of irradiated tissue without majorly compromising local control in pediatric demarcated brain tumors. These results are hypothesis generating and should be tested and validated in prospective studies.
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Abstract
Brain tumors constitute the largest source of oncologic mortality in children and low-grade gliomas are among most common pediatric central nervous system tumors. Pediatric low-grade gliomas differ from their counterparts in the adult population in their histopathology, genetics, and standard of care. Over the past decade, an increasingly detailed understanding of the molecular and genetic characteristics of pediatric brain tumors led to tailored therapy directed by integrated phenotypic and genotypic parameters and the availability of an increasing array of molecular-directed therapies. Advances in neuroimaging, conformal radiation therapy, and conventional chemotherapy further improved treatment outcomes. This article reviews the current classification of pediatric low-grade gliomas, their histopathologic and radiographic features, state-of-the-art surgical and adjuvant therapies, and emerging therapies currently under study in clinical trials.
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Ryall S, Tabori U, Hawkins C. Pediatric low-grade glioma in the era of molecular diagnostics. Acta Neuropathol Commun 2020; 8:30. [PMID: 32164789 PMCID: PMC7066826 DOI: 10.1186/s40478-020-00902-z] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 02/21/2020] [Indexed: 12/17/2022] Open
Abstract
Low grade gliomas are the most frequent brain tumors in children and encompass a spectrum of histologic entities which are currently assigned World Health Organisation grades I and II. They differ substantially from their adult counterparts in both their underlying genetic alterations and in the infrequency with which they transform to higher grade tumors. Nonetheless, children with low grade glioma are a therapeutic challenge due to the heterogeneity in their clinical behavior – in particular, those with incomplete surgical resection often suffer repeat progressions with resultant morbidity and, in some cases, mortality. The identification of up-regulation of the RAS–mitogen-activated protein kinase (RAS/MAPK) pathway as a near universal feature of these tumors has led to the development of targeted therapeutics aimed at improving responses while mitigating patient morbidity. Here, we review how molecular information can help to further define the entities which fall under the umbrella of pediatric-type low-grade glioma. In doing so we discuss the specific molecular drivers of pediatric low grade glioma and how to effectively test for them, review the newest therapeutic agents and their utility in treating this disease, and propose a risk-based stratification system that considers both clinical and molecular parameters to aid clinicians in making treatment decisions.
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Greenberger BA, Yock TI. The role of proton therapy in pediatric malignancies: Recent advances and future directions. Semin Oncol 2020; 47:8-22. [PMID: 32139101 DOI: 10.1053/j.seminoncol.2020.02.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 11/11/2022]
Abstract
Proton radiotherapy has promised an advantage in safely treating pediatric malignancies with an increased capability to spare normal tissues, reducing the risk of both acute and late toxicity. The past decade has seen the proliferation of more than 30 proton facilities in the United States, with increased capacity to provide access to approximately 3,000 children per year who will require radiotherapy for their disease. We provide a review of the initial efforts to describe outcomes after proton therapy across the common pediatric disease sites. We discuss the main attempts to assess comparative efficacy between proton and photon radiotherapy concerning toxicity. We also discuss recent efforts of multi-institutional registries aimed at accelerating research to better define the optimal treatment paradigm for children requiring radiotherapy for cure.
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Affiliation(s)
- Benjamin A Greenberger
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, PA
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Francis H. Burr Proton Therapy Center, Boston, MA.
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47
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Bitterman DS, MacDonald SM, Yock TI, Tarbell NJ, Wright KD, Chi SN, Marcus KJ, Haas-Kogan DA. Revisiting the Role of Radiation Therapy for Pediatric Low-Grade Glioma. J Clin Oncol 2019; 37:3335-3339. [PMID: 31498029 PMCID: PMC9798905 DOI: 10.1200/jco.19.01270] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Danielle S. Bitterman
- Harvard Radiation Oncology Program, Boston, MA,Massachusetts General Hospital, Boston, MA,Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA
| | | | | | | | - Karen D. Wright
- Dana-Farber Cancer Institute and Boston Children’s Hospital, Boston, MA
| | - Susan N. Chi
- Dana-Farber Cancer Institute and Boston Children’s Hospital, Boston, MA
| | - Karen J. Marcus
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA
| | - Daphne A. Haas-Kogan
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA,Daphne A. Haas-Kogan, MD, Department of Radiation Oncology, Dana-Farber Cancer Institute, DA-16-22, 450 Brookline Ave, Boston, MA, 02115; e-mail:
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48
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Abstract
In pediatric brain tumors, the intensification of chemotherapy has allowed for a reduction in radiotherapy (RT) volume to an involved field approach, particularly in patients with medulloblastoma. For patients with low-grade gliomas, the trend has remained to delay RT with chemotherapy; however, when RT is used, typically smaller clinical target volume margins are used. For patients with extracranial tumors, intensive chemotherapy to address systemic disease with local control is considered standard. Proton beam therapy shows significant promise in addressing both short-term and long-term toxicities in both central nervous system (CNS) and non-CNS pediatric tumors.
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Affiliation(s)
- Sujith Baliga
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Francis H. Burr Proton Therapy Center, 30 Fruit Street, Boston, MA 02114, USA
| | - Torunn I Yock
- Francis H. Burr Proton Therapy Center, 30 Fruit Street, Boston, MA 02114, USA; Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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Ludmir EB, Mahajan A, Paulino AC, Jones JY, Ketonen LM, Su JM, Grosshans DR, McAleer MF, McGovern SL, Lassen-Ramshad YA, Adesina AM, Dauser RC, Weinberg JS, Chintagumpala MM. Increased risk of pseudoprogression among pediatric low-grade glioma patients treated with proton versus photon radiotherapy. Neuro Oncol 2019; 21:686-695. [PMID: 30753704 PMCID: PMC6502497 DOI: 10.1093/neuonc/noz042] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Pseudoprogression (PsP) is a recognized phenomenon after radiotherapy (RT) for high-grade glioma but is poorly characterized for low-grade glioma (LGG). We sought to characterize PsP for pediatric LGG patients treated with RT, with particular focus on the role of RT modality using photon-based intensity-modulated RT (IMRT) or proton beam therapy (PBT). METHODS Serial MRI scans from 83 pediatric LGG patients managed at 2 institutions between 1998 and 2017 were evaluated. PsP was scored when a progressive lesion subsequently decreased or stabilized for at least a year without therapy. RESULTS Thirty-two patients (39%) were treated with IMRT, and 51 (61%) were treated with PBT. Median RT dose for the cohort was 50.4 Gy(RBE) (range, 45-59.4 Gy[RBE]). PsP was identified in 31 patients (37%), including 8/32 IMRT patients (25%) and 23/51 PBT patients (45%). PBT patients were significantly more likely to have post-RT enlargement (hazard ratio [HR] 2.15, 95% CI: 1.06-4.38, P = 0.048). RT dose >50.4 Gy(RBE) similarly predicted higher rates of PsP (HR 2.61, 95% CI: 1.20-5.68, P = 0.016). Multivariable analysis confirmed the independent effects of RT modality (P = 0.03) and RT dose (P = 0.01) on PsP incidence. Local progression occurred in 10 patients: 7 IMRT patients (22%) and 3 PBT patients (6%), with a trend toward improved local control for PBT patients (HR 0.34, 95% CI: 0.10-1.18, P = 0.099). CONCLUSIONS These data highlight substantial rates of PsP among pediatric LGG patients, particularly those treated with PBT. PsP should be considered when assessing response to RT in LGG patients within the first year after RT.
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Affiliation(s)
- Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anita Mahajan
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Mayo Clinic, Rochester, Minnesota, USA
| | - Arnold C Paulino
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Jeremy Y Jones
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston, Texas, USA
- Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Leena M Ketonen
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jack M Su
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - David R Grosshans
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Susan L McGovern
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Adekunle M Adesina
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Robert C Dauser
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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50
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Pollack IF, Agnihotri S, Broniscer A. Childhood brain tumors: current management, biological insights, and future directions. J Neurosurg Pediatr 2019; 23:261-273. [PMID: 30835699 PMCID: PMC6823600 DOI: 10.3171/2018.10.peds18377] [Citation(s) in RCA: 159] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 10/29/2018] [Indexed: 02/06/2023]
Abstract
Brain tumors are the most common solid tumors in children, and, unfortunately, many subtypes continue to have a suboptimal long-term outcome. During the last several years, however, remarkable advances in our understanding of the molecular underpinnings of these tumors have occurred as a result of high-resolution genomic, epigenetic, and transcriptomic profiling, which have provided insights for improved tumor categorization and molecularly directed therapies. While tumors such as medulloblastomas have been historically grouped into standard- and high-risk categories, it is now recognized that these tumors encompass four or more molecular subsets with distinct clinical and molecular characteristics. Likewise, high-grade glioma, which for decades was considered a single high-risk entity, is now known to comprise multiple subsets of tumors that differ in terms of patient age, tumor location, and prognosis. The situation is even more complex for ependymoma, for which at least nine subsets of tumors have been described. Conversely, the majority of pilocytic astrocytomas appear to result from genetic changes that alter a single, therapeutically targetable molecular pathway. Accordingly, the present era is one in which treatment is evolving from the historical standard of radiation and conventional chemotherapy to a more nuanced approach in which these modalities are applied in a risk-adapted framework and molecularly targeted therapies are implemented to augment or, in some cases, replace conventional therapy. Herein, the authors review advances in the categorization and treatment of several of the more common pediatric brain tumors and discuss current and future directions in tumor management that hold significant promise for patients with these challenging tumors.
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