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Tamura R, Yamanobe Y, Fujioka M, Morimoto Y, Fukumura M, Nakaya M, Oishi Y, Sato M, Ueda R, Fujiwara H, Hikichi T, Noji S, Oishi N, Ozawa H, Ogawa K, Kawakami Y, Ohira T, Yoshida K, Toda M. Phase I/II Study of a Vascular Endothelial Growth Factor Receptor Vaccine in Patients With NF2-Related Schwannomatosis. J Clin Oncol 2024; 42:2578-2587. [PMID: 38776485 DOI: 10.1200/jco.23.02376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/15/2024] [Accepted: 03/21/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE The humanized antivascular endothelial growth factor (VEGF) antibody bevacizumab (Bev) is efficacious for the treatment of NF2-related schwannomatosis (NF2), previously known as neurofibromatosis type 2. This study evaluated the safety and efficacy of a VEGF receptor (VEGFR) vaccine containing VEGFR1 and VEGFR2 peptides in patients with NF2 with progressive schwannomas (jRCTs031180184). MATERIALS AND METHODS VEGFR1 and VEGFR2 peptides were injected subcutaneously into infra-axillary and inguinal regions, once a week for 4 weeks and then once a month for 4 months. The primary end point was safety. Secondary end points included tolerability, hearing response, imaging response, and immunologic response. RESULTS Sixteen patients with NF2 with progressive schwannomas completed treatment and were assessed. No severe vaccine-related adverse events occurred. Among the 13 patients with assessable hearing, word recognition score improved in five patients at 6 months and two at 12 months. Progression of average hearing level of pure tone was 0.168 dB/mo during the year of treatment period, whereas long-term progression was 0.364 dB/mo. Among all 16 patients, a partial response was observed in more than one schwannoma in four (including one in which Bev had not been effective), minor response in 5, and stable disease in 4. Both VEGFR1-specific and VEGFR2-specific cytotoxic T lymphocytes (CTLs) were induced in 11 patients. Two years after vaccination, a radiologic response was achieved in nine of 20 assessable schwannomas. CONCLUSION This study demonstrated the safety and preliminary efficacy of VEGFR peptide vaccination in patients with NF2. Memory-induced CTLs after VEGFR vaccination may persistently suppress tumor progression.
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Affiliation(s)
- Ryota Tamura
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiharu Yamanobe
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masato Fujioka
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo, Japan
- Clinical and Translational Research Center, Keio University School of Medicine, Tokyo, Japan
- Department of Molecular Genetics, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yukina Morimoto
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Mariko Fukumura
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Masato Nakaya
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Yumiko Oishi
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Mizuto Sato
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Ryo Ueda
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Hirokazu Fujiwara
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | | | - Shinobu Noji
- Division of Cellular Signaling Institute for Advanced Medical Research, Keio University School of Medicine, Tokyo, Japan
- Laboratory of Cell and Tissue Biology, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Oishi
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyuki Ozawa
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kaoru Ogawa
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yutaka Kawakami
- Division of Cellular Signaling Institute for Advanced Medical Research, Keio University School of Medicine, Tokyo, Japan
- Department of Immunology, International University of Health and Welfare School of Medicine, Narita, Japan
| | - Takayuki Ohira
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
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Plotkin SR, Yohay KH, Nghiemphu PL, Dinh CT, Babovic-Vuksanovic D, Merker VL, Bakker A, Fell G, Trippa L, Blakeley JO. Brigatinib in NF2-Related Schwannomatosis with Progressive Tumors. N Engl J Med 2024; 390:2284-2294. [PMID: 38904277 DOI: 10.1056/nejmoa2400985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
BACKGROUND NF2-related schwannomatosis (NF2-SWN, formerly called neurofibromatosis type 2) is a tumor predisposition syndrome that is manifested by multiple vestibular schwannomas, nonvestibular schwannomas, meningiomas, and ependymomas. The condition is relentlessly progressive with no approved therapies. On the basis of preclinical activity of brigatinib (an inhibitor of multiple tyrosine kinases) in NF2-driven nonvestibular schwannoma and meningioma, data were needed on the use of brigatinib in patients with multiple types of progressive NF2-SWN tumors. METHODS In this phase 2 platform trial with a basket design, patients who were 12 years of age or older with NF2-SWN and progressive tumors were treated with oral brigatinib at a dose of 180 mg daily. A central review committee evaluated one target tumor and up to five nontarget tumors in each patient. The primary outcome was radiographic response in target tumors. Key secondary outcomes were safety, response rate in all tumors, hearing response, and patient-reported outcomes. RESULTS A total of 40 patients (median age, 26 years) with progressive target tumors (10 vestibular schwannomas, 8 nonvestibular schwannomas, 20 meningiomas, and 2 ependymomas) received treatment with brigatinib. After a median follow-up of 10.4 months, the percentage of tumors with a radiographic response was 10% (95% confidence interval [CI], 3 to 24) for target tumors and 23% (95% CI, 16 to 30) for all tumors; meningiomas and nonvestibular schwannomas had the greatest benefit. Annualized growth rates decreased for all tumor types during treatment. Hearing improvement occurred in 35% (95% CI, 20 to 53) of eligible ears. Exploratory analyses suggested a decrease in self-reported pain severity during treatment (-0.013 units per month; 95% CI, -0.002 to -0.029) on a scale from 0 (no pain) to 3 (severe pain). No grade 4 or 5 treatment-related adverse events were reported. CONCLUSIONS Brigatinib treatment resulted in radiographic responses in multiple tumor types and clinical benefit in a heavily pretreated cohort of patients with NF2-SWN. (Funded by the Children's Tumor Foundation and others; INTUITT-NF2 ClinicalTrials.gov number, NCT04374305.).
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Affiliation(s)
- Scott R Plotkin
- From Massachusetts General Hospital and Harvard Medical School (S.R.P., V.L.M.) and the Dana-Farber Cancer Institute (G.F., L.T.) - all in Boston; the NYU Grossman School of Medicine (K.H.Y.) and the Children's Tumor Foundation (A.B.) - both in New York; the University of California, Los Angeles, Los Angeles (P.L.N.); the University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami (C.T.D.); the Mayo Clinic, Rochester, MN (D.B.-V.); and Johns Hopkins University, Baltimore (J.O.B.)
| | - Kaleb H Yohay
- From Massachusetts General Hospital and Harvard Medical School (S.R.P., V.L.M.) and the Dana-Farber Cancer Institute (G.F., L.T.) - all in Boston; the NYU Grossman School of Medicine (K.H.Y.) and the Children's Tumor Foundation (A.B.) - both in New York; the University of California, Los Angeles, Los Angeles (P.L.N.); the University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami (C.T.D.); the Mayo Clinic, Rochester, MN (D.B.-V.); and Johns Hopkins University, Baltimore (J.O.B.)
| | - Phioanh L Nghiemphu
- From Massachusetts General Hospital and Harvard Medical School (S.R.P., V.L.M.) and the Dana-Farber Cancer Institute (G.F., L.T.) - all in Boston; the NYU Grossman School of Medicine (K.H.Y.) and the Children's Tumor Foundation (A.B.) - both in New York; the University of California, Los Angeles, Los Angeles (P.L.N.); the University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami (C.T.D.); the Mayo Clinic, Rochester, MN (D.B.-V.); and Johns Hopkins University, Baltimore (J.O.B.)
| | - Christine T Dinh
- From Massachusetts General Hospital and Harvard Medical School (S.R.P., V.L.M.) and the Dana-Farber Cancer Institute (G.F., L.T.) - all in Boston; the NYU Grossman School of Medicine (K.H.Y.) and the Children's Tumor Foundation (A.B.) - both in New York; the University of California, Los Angeles, Los Angeles (P.L.N.); the University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami (C.T.D.); the Mayo Clinic, Rochester, MN (D.B.-V.); and Johns Hopkins University, Baltimore (J.O.B.)
| | - Dusica Babovic-Vuksanovic
- From Massachusetts General Hospital and Harvard Medical School (S.R.P., V.L.M.) and the Dana-Farber Cancer Institute (G.F., L.T.) - all in Boston; the NYU Grossman School of Medicine (K.H.Y.) and the Children's Tumor Foundation (A.B.) - both in New York; the University of California, Los Angeles, Los Angeles (P.L.N.); the University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami (C.T.D.); the Mayo Clinic, Rochester, MN (D.B.-V.); and Johns Hopkins University, Baltimore (J.O.B.)
| | - Vanessa L Merker
- From Massachusetts General Hospital and Harvard Medical School (S.R.P., V.L.M.) and the Dana-Farber Cancer Institute (G.F., L.T.) - all in Boston; the NYU Grossman School of Medicine (K.H.Y.) and the Children's Tumor Foundation (A.B.) - both in New York; the University of California, Los Angeles, Los Angeles (P.L.N.); the University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami (C.T.D.); the Mayo Clinic, Rochester, MN (D.B.-V.); and Johns Hopkins University, Baltimore (J.O.B.)
| | - Annette Bakker
- From Massachusetts General Hospital and Harvard Medical School (S.R.P., V.L.M.) and the Dana-Farber Cancer Institute (G.F., L.T.) - all in Boston; the NYU Grossman School of Medicine (K.H.Y.) and the Children's Tumor Foundation (A.B.) - both in New York; the University of California, Los Angeles, Los Angeles (P.L.N.); the University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami (C.T.D.); the Mayo Clinic, Rochester, MN (D.B.-V.); and Johns Hopkins University, Baltimore (J.O.B.)
| | - Geoffrey Fell
- From Massachusetts General Hospital and Harvard Medical School (S.R.P., V.L.M.) and the Dana-Farber Cancer Institute (G.F., L.T.) - all in Boston; the NYU Grossman School of Medicine (K.H.Y.) and the Children's Tumor Foundation (A.B.) - both in New York; the University of California, Los Angeles, Los Angeles (P.L.N.); the University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami (C.T.D.); the Mayo Clinic, Rochester, MN (D.B.-V.); and Johns Hopkins University, Baltimore (J.O.B.)
| | - Lorenzo Trippa
- From Massachusetts General Hospital and Harvard Medical School (S.R.P., V.L.M.) and the Dana-Farber Cancer Institute (G.F., L.T.) - all in Boston; the NYU Grossman School of Medicine (K.H.Y.) and the Children's Tumor Foundation (A.B.) - both in New York; the University of California, Los Angeles, Los Angeles (P.L.N.); the University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami (C.T.D.); the Mayo Clinic, Rochester, MN (D.B.-V.); and Johns Hopkins University, Baltimore (J.O.B.)
| | - Jaishri O Blakeley
- From Massachusetts General Hospital and Harvard Medical School (S.R.P., V.L.M.) and the Dana-Farber Cancer Institute (G.F., L.T.) - all in Boston; the NYU Grossman School of Medicine (K.H.Y.) and the Children's Tumor Foundation (A.B.) - both in New York; the University of California, Los Angeles, Los Angeles (P.L.N.); the University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami (C.T.D.); the Mayo Clinic, Rochester, MN (D.B.-V.); and Johns Hopkins University, Baltimore (J.O.B.)
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Shrivastava M, Emmanouil B, Mathew R, Halliday D, Parry A, Halliday J, Mackeith S. Stereotactic Radiosurgery and Radiotherapy for Vestibular Schwannoma in NF2-Related Schwannomatosis. Laryngoscope 2024; 134:2364-2371. [PMID: 37983868 DOI: 10.1002/lary.31180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/11/2023] [Accepted: 10/27/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVES To determine the long-term control rates and hearing outcomes for growing vestibular schwannoma in NF2-related schwannomatosis (NF2) treated with stereotactic radiosurgery (SRS) and fractionated radiotherapy (FRT). METHODS Retrospective review of all patients treated with SRS/FRT between 1986 and2021 from a tertiary NF2 unit. Overall tumor control was defined as: (1) growth control (growth failure was defined as growth in any dimension of 3 millimetres or more from baseline post-SRS/FRT), and (2) treatment control (no need for further intervention). Loss of serviceable hearing was defined as a drop in speech discrimination score below 50% after SRS/FRT. RESULTS There were 81 cases, with a mean duration of follow-up of 125 months. Overall control rate was 72% (58/81), with 80% (65/81) growth control and 74% (60/81) treatment control. There was a 5-year actuarial survival of 77% and 10-year survival of 71%. Forty-three percent (30/69) of cases did not have serviceable hearing at baseline. Of those remaining, 49% (19/39) preserved serviceable hearing during follow-up at a mean of 106 months. Actuarial survival for preservation of serviceable hearing at 5 and 10 years was 69% and 53%. There were poorer outcomes with increasing genetic severity, and with baseline tumor size >3 cm. No cases of SRS/FRT-related malignancy were identified at a mean follow-up of 10 years. CONCLUSION Stereotactic radiosurgery/fractionated radiotherapy are an effective option to treat growing vestibular schwannoma in patients with NF2 with the potential for hearing preservation in a proportion of patients. LEVEL OF EVIDENCE 4-Case Series Laryngoscope, 134:2364-2371, 2024.
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Affiliation(s)
- Manu Shrivastava
- Department of Ear, Nose and Throat Surgery, Oxford University Hospitals, Oxford, UK
| | - Beatrice Emmanouil
- NHS England, Wellington House, London, UK
- Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Rajeev Mathew
- Department of Ear, Nose and Throat Surgery, Oxford University Hospitals, Oxford, UK
| | | | - Allyson Parry
- Department of Neurology, Oxford University Hospitals, Oxford, UK
| | - Jane Halliday
- Department of Neurosurgery, Oxford University Hospitals, Oxford, UK
| | - Samuel Mackeith
- Department of Ear, Nose and Throat Surgery, Oxford University Hospitals, Oxford, UK
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Nguyen HTN, Duhon BH, Kuo HC, Fisher M, Brickey OM, Zhang L, Otero JJ, Prevedello DM, Adunka OF, Ren Y. Matrix metalloproteinase 9: An emerging biomarker for classification of adherent vestibular schwannoma. Neurooncol Adv 2024; 6:vdae058. [PMID: 38887507 PMCID: PMC11181934 DOI: 10.1093/noajnl/vdae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024] Open
Abstract
Background The progression of vestibular schwannoma (VS) is intricately linked with interactions between schwannoma cells and the extracellular matrix. Surgical resection of VS is associated with substantial risks as tumors are adherent to the brainstem and cranial nerves. We evaluate the role of matrix metalloproteinase 9 (MMP9) in VS and explore its potential as a biomarker to classify adherent VS. Methods Transcriptomic analysis of a murine schwannoma allograft model and immunohistochemical analysis of 17 human VS were performed. MMP9 abundance was assessed in mouse and human schwannoma cell lines. Transwell studies were performed to evaluate the effect of MMP9 on schwannoma invasion in vitro. Plasma biomarkers were identified from a multiplexed proteomic analysis in 45 prospective VS patients and validated in primary culture. The therapeutic efficacy of MMP9 inhibition was evaluated in a mouse schwannoma model. Results MMP9 was the most highly upregulated protease in mouse schwannomas and was significantly enriched in adherent VS, particularly around tumor vasculature. High levels of MMP9 were found in plasma of patients with adherent VS. MMP9 outperformed clinical and radiographic variables to classify adherent VS with outstanding discriminatory ability. Human schwannoma cells secreted MMP9 in response to TNF-α which promoted cellular invasion and adhesion protein expression in vitro. Lastly, MMP9 inhibition decreased mouse schwannoma growth in vivo. Conclusions We identify MMP9 as a preoperative biomarker to classify adherent VS. MMP9 may represent a new therapeutic target in adherent VS associated with poor surgical outcomes that lack other viable treatment options.
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Affiliation(s)
- Han T N Nguyen
- Division of Otology, Neurotology, and Cranial Base Surgery, Department of Otolaryngology—Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bailey H Duhon
- Division of Otology, Neurotology, and Cranial Base Surgery, Department of Otolaryngology—Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Hsuan-Chih Kuo
- Division of Otology, Neurotology, and Cranial Base Surgery, Department of Otolaryngology—Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Melanie Fisher
- Division of Otology, Neurotology, and Cranial Base Surgery, Department of Otolaryngology—Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Olivia M Brickey
- Division of Otology, Neurotology, and Cranial Base Surgery, Department of Otolaryngology—Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Lisa Zhang
- Division of Otology, Neurotology, and Cranial Base Surgery, Department of Otolaryngology—Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jose J Otero
- Division of Neuropathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Oliver F Adunka
- Division of Otology, Neurotology, and Cranial Base Surgery, Department of Otolaryngology—Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Yin Ren
- Division of Otology, Neurotology, and Cranial Base Surgery, Department of Otolaryngology—Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Plotkin SR, Allen J, Dhall G, Campian JL, Clapp DW, Fisher MJ, Jain RK, Tonsgard J, Ullrich NJ, Thomas C, Edwards LJ, Korf B, Packer R, Karajannis MA, Blakeley JO. Multicenter, prospective, phase II study of maintenance bevacizumab for children and adults with NF2-related schwannomatosis and progressive vestibular schwannoma. Neuro Oncol 2023; 25:1498-1506. [PMID: 37010875 PMCID: PMC10398799 DOI: 10.1093/neuonc/noad066] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Prospective data on maintenance therapy with bevacizumab for persons with NF2-related schwannomatosis (NF2-SWN) is lacking. In this prospective multicenter phase II study, we evaluated the efficacy, safety, and tolerability of bevacizumab for maintenance therapy in children and adults with NF2-SWN and hearing loss due to vestibular schwannomas (VS). METHODS Following induction therapy, participants received bevacizumab 5 mg/kg every 3 weeks for 18 months. Participants were monitored for changes in hearing, tumor size, and quality of life (QOL), and for adverse events. Hearing loss was defined as a statistically significant decline in word recognition score (WRS) or pure-tone average compared to the study baseline; tumor growth was defined as >20% increase in volume compared to baseline. RESULTS Twenty participants with NF2-SWN (median age 23.5 years; range, 12.5-62.5 years) with hearing loss in the target ear (median WRS 70%, range 2%-94%) received maintenance bevacizumab. Freedom from hearing loss in the target ear was 95% after 48 weeks, 89% after 72 weeks, and 70% after 98 weeks. Freedom from tumor growth in the target VS was 94% after 48 weeks, 89% after 72 weeks, and 89% after 98 weeks. NF2-related QOL remained stable for 98 weeks whereas tinnitus-related distress decreased. Maintenance bevacizumab was well tolerated, with 3 participants (15%) discontinuing treatment due to adverse events. CONCLUSIONS Maintenance bevacizumab (5 mg/kg every 3 weeks) is associated with high rates of hearing and tumor stability during 18 months of follow-up. No new unexpected adverse events related to bevacizumab were identified in this population.
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Affiliation(s)
- Scott R Plotkin
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Girish Dhall
- University of Southern California, Los Angeles, California, USA
| | | | - D Wade Clapp
- University of Indiana, Indianapolis, Indiana, USA
| | - Michael J Fisher
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rakesh K Jain
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | - Bruce Korf
- University of Alabama, Birmingham, Alabama, USA
| | - Roger Packer
- Children’s National Medical Center, Washington, District of Columbia, USA
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Zhao F, Li SW, Zhang S, Li P, Zhao C, Zhao XB, Wang CH, Zhang J, Wang B, Liu PN. Phase II trial of icotinib in adult patients with neurofibromatosis type 2 and progressive vestibular schwannoma. J Neurosurg 2023; 138:1680-1687. [PMID: 36272122 DOI: 10.3171/2022.9.jns22699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 09/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neurofibromatosis type 2 (NF2) is a rare autosomal dominant syndrome associated primarily with bilateral vestibular schwannomas (VSs). Conventional surgical or radiosurgical treatments for VS in NF2 usually result in high risks of hearing loss and facial nerve impairment, while there is no validated medical option to date. This single-institution phase II study evaluated the efficacy and safety of icotinib, an oral epidermal growth factor receptor tyrosine kinase inhibitor, in patients with NF2 and progressive VS. METHODS Icotinib was administered daily at 375 mg orally in a continuous 28-day course for up to 12 courses. The primary endpoint of the study was radiographic response assessed by brain MRI using 3D volumetric tumor analysis and defined as a ≥ 20% decrease in VS volume. Hearing function was evaluated as a secondary endpoint, with response defined as a statistically significant increase in word recognition scores. RESULTS Ten eligible patients with a mean age of 23.8 years were enrolled. One patient (10%) with bilateral tumors experienced an objective radiographic response (-23.58% and -22.01%). Three (43%) of 7 patients met the hearing response criteria. At 12 months, the estimated progression-free survival was 82.0% (95% CI 42.3%-95.5%) for volumetric progression and 69.2% (95% CI 37.3%-87.2%) for hearing progression. Common mild to moderate adverse events included rash (90%), diarrhea (50%), myalgia (20%), and nausea/gastrointestinal pain (20%). CONCLUSIONS Icotinib carries minor toxicity and is associated with radiographic and hearing responses in patients with NF2 and progressive VS.
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Affiliation(s)
- Fu Zhao
- 1Departments of Neurosurgery
- 2Department of Neural Reconstruction, Beijing Neurosurgical Institute, Capital Medical University; and
| | | | | | - Peng Li
- 1Departments of Neurosurgery
| | - Chi Zhao
- 3Department of Neuro-Oncology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | | | - Chun-Hong Wang
- 5Otolaryngology, Beijing Tiantan Hospital, Capital Medical University
| | - Jing Zhang
- 2Department of Neural Reconstruction, Beijing Neurosurgical Institute, Capital Medical University; and
| | - Bo Wang
- 1Departments of Neurosurgery
| | - Pi-Nan Liu
- 1Departments of Neurosurgery
- 2Department of Neural Reconstruction, Beijing Neurosurgical Institute, Capital Medical University; and
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Early prediction of functional prognosis in neurofibromatosis type 2 patients based on genotype-phenotype correlation with targeted deep sequencing. Sci Rep 2022; 12:9543. [PMID: 35681071 PMCID: PMC9184572 DOI: 10.1038/s41598-022-13580-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 05/09/2022] [Indexed: 11/09/2022] Open
Abstract
Regardless of treatment, the clinical progression of neurofibromatosis type 2 (NF2), particularly in terms of hearing, swallowing, and gait, tend to worsen throughout the patients' lives. We performed a retrospective analysis of functional outcomes in Japanese NF2 patients to predict their functional prognosis. We analyzed genotype-phenotype correlation based on genetic data from a cohort of 57 patients with a mean follow-up of 14.5 ± 6.0 years. Their functional outcomes, including hearing, swallowing, and ambulation, were reviewed. Performing a targeted deep sequencing, germline NF2 mutations were identified in 28 patients (49.1%), and mosaic NF2 was identified in 20 patients (20, 35.0%). The functional preservation period and outcome differed significantly depending on clinical/genetic factors. Among these factors, "Truncating", "Mosaic", and "Age of symptom onset ≥ 25" had the most significant effects on functional disability. By applying a combination of an NF2 mutation type/location, and age of symptom onset, we classified different degrees of functional preservation and progression, schwannoma growth rate and total interventions per year per patient. The prediction of detailed functional outcomes in NF2 patients can plan better strategies for life-long disease management and social integration.
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Abstract
OBJECTIVE To assess the efficacy and toxicity of proton radiotherapy in vestibular schwannoma. STUDY DESIGN Retrospective chart review and volumetric MRI-analyses. SETTING Tertiary referral center. PATIENTS Vestibular schwannoma patients treated with protons between 2003 and 2018. INTERVENTION Proton radiotherapy. MAIN OUTCOME MEASURES Tumor control was defined as not requiring salvage treatment. Progressive hearing loss was defined as a decrease in maximum speech discrimination score below the 95% critical difference in reference to the pretreatment score. Hearing assessment includes contralateral hearing and duration of follow-up. Dizziness and/or unsteadiness and facial and trigeminal nerve function were scored. Patients who had surgery prior to proton radiotherapy were separately assessed. RESULTS Of 221 included patients, 136 received single fraction and 85 fractionated proton radiotherapy. Actuarial 5-year local control rate was 96% (95% CI 90-98%). The median radiological follow-up was 4.5 years. Progressive postirradiation speech discrimination score loss occurred in 42% of patients with audiometric follow-up within a year. Facial paresis was found in 5% (usually mild), severe dizziness in 5%, and trigeminal neuralgia in 5% of patients receiving protons as primary treatment. CONCLUSIONS Proton radiotherapy achieves high tumor control with modest side effects aside from hearing loss in vestibular schwannoma patients. Limited and heterogeneous outcome reporting hamper comparisons to the literature. Potential sequelae of radiation therapy impacting vestibular function, cognitive function, and quality of life warrant further evaluation. Subgroups that benefit most from proton radiotherapy should be identified to optimize allocation and counterbalance its costs.
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Amaravathi A, Oblinger JL, Welling DB, Kinghorn AD, Chang LS. Neurofibromatosis: Molecular Pathogenesis and Natural Compounds as Potential Treatments. Front Oncol 2021; 11:698192. [PMID: 34604034 PMCID: PMC8485038 DOI: 10.3389/fonc.2021.698192] [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: 04/20/2021] [Accepted: 09/01/2021] [Indexed: 12/22/2022] Open
Abstract
The neurofibromatosis syndromes, including NF1, NF2, and schwannomatosis, are tumor suppressor syndromes characterized by multiple nervous system tumors, particularly Schwann cell neoplasms. NF-related tumors are mainly treated by surgery, and some of them have been treated by but are refractory to conventional chemotherapy. Recent advances in molecular genetics and genomics alongside the development of multiple animal models have provided a better understanding of NF tumor biology and facilitated target identification and therapeutic evaluation. Many targeted therapies have been evaluated in preclinical models and patients with limited success. One major advance is the FDA approval of the MEK inhibitor selumetinib for the treatment of NF1-associated plexiform neurofibroma. Due to their anti-neoplastic, antioxidant, and anti-inflammatory properties, selected natural compounds could be useful as a primary therapy or as an adjuvant therapy prior to or following surgery and/or radiation for patients with tumor predisposition syndromes, as patients often take them as dietary supplements and for health enhancement purposes. Here we review the natural compounds that have been evaluated in NF models. Some have demonstrated potent anti-tumor effects and may become viable treatments in the future.
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Affiliation(s)
- Anusha Amaravathi
- Center for Childhood Cancer and Blood Diseases, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States.,Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Janet L Oblinger
- Center for Childhood Cancer and Blood Diseases, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - D Bradley Welling
- Department of Otolaryngology Head & Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, and Massachusetts General Hospital, Boston, MA, United States
| | - A Douglas Kinghorn
- Division of Medicinal Chemistry and Pharmacognosy, The Ohio State University College of Pharmacy, Columbus, OH, United States
| | - Long-Sheng Chang
- Center for Childhood Cancer and Blood Diseases, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States.,Department of Otolaryngology-Head & Neck Surgery, The Ohio State University College of Medicine, Columbus, OH, United States
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10
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Thompson HL, Blanton A, Franklin B, Merker VL, Franck KH, Welling DB. Patient Report of Hearing in Neurofibromatosis Type 2: Recommendations for Clinical Trials. Neurology 2021; 97:S64-S72. [PMID: 34230203 PMCID: PMC8594003 DOI: 10.1212/wnl.0000000000012424] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 05/03/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To systematically evaluate published patient-reported outcome measures for the assessment of hearing function and hearing-related quality of life (QoL) and recommend measures selected by the Response Evaluation in Neurofibromatosis and Schwannomatosis International Collaboration (REiNS) as endpoints for clinical trials in neurofibromatosis type 2 (NF2). METHODS The REiNS Patient-Reported Outcomes Working Group systematically evaluated published patient-reported outcome measures of (1) hearing function and (2) hearing-related QoL for individuals with hearing loss of various etiologies using previously published REiNS rating procedures. Ten measures of hearing functioning and 11 measures of hearing-related QoL were reviewed. Measures were numerically scored and compared primarily on their participant characteristics (including participant age range and availability of normative data), item content, psychometric properties, and feasibility for use in clinical trials. RESULTS The Self-Assessment of Communication and the Self-Assessment of Communication-Adolescent were identified as most useful for adult and pediatric populations with NF2, respectively, for the measurement of both hearing function and hearing-related QoL. Measures were selected for their strengths in participant characteristics, item content, psychometric properties, and feasibility for use in clinical trials. CONCLUSIONS REiNS recommends the Self-Assessment of Communication adult and adolescent forms for the assessment of patient-reported hearing function and hearing-related QoL for NF2 clinical trials. Further work is needed to demonstrate the utility of these measures in evaluating pharmacologic or behavioral interventions.
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Affiliation(s)
- Heather L Thompson
- From the Department of Communication Sciences and Disorders (H.L.T.), California State University, Sacramento; Department of Communication Disorders and Sciences (A.B.), SUNY Cortland, NY; REiNS Patient Representative for NF2 (B.F.); Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston (V.L.M.); Center for Healthcare Organization and Implementation Research (CHOIR) (V.L.M.), Edith Nourse Rogers Memorial Veterans Hospital, Bedford; and Departments of Audiology (K.H.F.) and Otolaryngology and Head and Neck Surgery (D.B.W.), Massachusetts Eye and Ear Hospital and Massachusetts General Hospital, Boston.
| | - Ann Blanton
- From the Department of Communication Sciences and Disorders (H.L.T.), California State University, Sacramento; Department of Communication Disorders and Sciences (A.B.), SUNY Cortland, NY; REiNS Patient Representative for NF2 (B.F.); Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston (V.L.M.); Center for Healthcare Organization and Implementation Research (CHOIR) (V.L.M.), Edith Nourse Rogers Memorial Veterans Hospital, Bedford; and Departments of Audiology (K.H.F.) and Otolaryngology and Head and Neck Surgery (D.B.W.), Massachusetts Eye and Ear Hospital and Massachusetts General Hospital, Boston
| | - Barbara Franklin
- From the Department of Communication Sciences and Disorders (H.L.T.), California State University, Sacramento; Department of Communication Disorders and Sciences (A.B.), SUNY Cortland, NY; REiNS Patient Representative for NF2 (B.F.); Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston (V.L.M.); Center for Healthcare Organization and Implementation Research (CHOIR) (V.L.M.), Edith Nourse Rogers Memorial Veterans Hospital, Bedford; and Departments of Audiology (K.H.F.) and Otolaryngology and Head and Neck Surgery (D.B.W.), Massachusetts Eye and Ear Hospital and Massachusetts General Hospital, Boston
| | - Vanessa L Merker
- From the Department of Communication Sciences and Disorders (H.L.T.), California State University, Sacramento; Department of Communication Disorders and Sciences (A.B.), SUNY Cortland, NY; REiNS Patient Representative for NF2 (B.F.); Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston (V.L.M.); Center for Healthcare Organization and Implementation Research (CHOIR) (V.L.M.), Edith Nourse Rogers Memorial Veterans Hospital, Bedford; and Departments of Audiology (K.H.F.) and Otolaryngology and Head and Neck Surgery (D.B.W.), Massachusetts Eye and Ear Hospital and Massachusetts General Hospital, Boston
| | - Kevin H Franck
- From the Department of Communication Sciences and Disorders (H.L.T.), California State University, Sacramento; Department of Communication Disorders and Sciences (A.B.), SUNY Cortland, NY; REiNS Patient Representative for NF2 (B.F.); Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston (V.L.M.); Center for Healthcare Organization and Implementation Research (CHOIR) (V.L.M.), Edith Nourse Rogers Memorial Veterans Hospital, Bedford; and Departments of Audiology (K.H.F.) and Otolaryngology and Head and Neck Surgery (D.B.W.), Massachusetts Eye and Ear Hospital and Massachusetts General Hospital, Boston
| | - D Bradley Welling
- From the Department of Communication Sciences and Disorders (H.L.T.), California State University, Sacramento; Department of Communication Disorders and Sciences (A.B.), SUNY Cortland, NY; REiNS Patient Representative for NF2 (B.F.); Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston (V.L.M.); Center for Healthcare Organization and Implementation Research (CHOIR) (V.L.M.), Edith Nourse Rogers Memorial Veterans Hospital, Bedford; and Departments of Audiology (K.H.F.) and Otolaryngology and Head and Neck Surgery (D.B.W.), Massachusetts Eye and Ear Hospital and Massachusetts General Hospital, Boston
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11
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Gross AM, Plotkin SR, Widemann BC. Neurofibromatosis Clinical Trials-REiNS Collaboration 2020 Recommendations: Looking Back and Moving Ahead. Neurology 2021; 97:S1-S3. [PMID: 34230201 DOI: 10.1212/wnl.0000000000012429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 03/19/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Andrea M Gross
- From the Pediatric Oncology Branch (A.M.G., B.C.W.), Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD; and Department of Neurology and Cancer Center (S.R.P.), Massachusetts General Hospital, Boston.
| | - Scott R Plotkin
- From the Pediatric Oncology Branch (A.M.G., B.C.W.), Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD; and Department of Neurology and Cancer Center (S.R.P.), Massachusetts General Hospital, Boston
| | - Brigitte C Widemann
- From the Pediatric Oncology Branch (A.M.G., B.C.W.), Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD; and Department of Neurology and Cancer Center (S.R.P.), Massachusetts General Hospital, Boston
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12
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Ardern-Holmes S, White C, Bahure S, So S, McCowage G, Hovey E, Troon S, De Souza P, Simes J, Slancar M, Dexter M, Wong M. The Effect of Bevacizumab on Vestibular Schwannoma Related to Neurofibromatosis Type 2. AUSTRALASIAN JOURNAL OF NEUROSCIENCE 2021. [DOI: 10.21307/ajon-2021-002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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13
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Fujii M, Kobayakawa M, Saito K, Inano A, Morita A, Hasegawa M, Mukasa A, Mitsuhara T, Goto T, Yamaguchi S, Tamiya T, Nakatomi H, Oya S, Takahashi F, Sato T, Bakhit M. Rationale and Design of BeatNF2 Trial: A Clinical Trial to Assess the Efficacy and Safety of Bevacizumab in Patients with Neurofibromatosis Type 2 Related Vestibular Schwannoma. ACTA ACUST UNITED AC 2021; 28:726-739. [PMID: 33572546 PMCID: PMC7985777 DOI: 10.3390/curroncol28010071] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 11/16/2022]
Abstract
Simple Summary Neurofibromatosis type 2 (NF2) is a rare genetic hereditary disease characterized by multiple central nervous system tumors, most frequently bilateral vestibular schwannomas (VSs). No chemotherapeutic agents are available for clinical use, and surgery and radiotherapy are the only therapeutic options available now. Still, neither treatment option alleviates hearing loss in patients with NF2 and VS; they may even exacerbate it. However, bevacizumab has been reported to be effective in suppressing the tumor’s growth and has shown unprecedented efficacy in improving hearing. We describe a new ongoing and novel clinical trial, BeatNF2, a randomized, double-blinded, placebo-controlled, multicenter trial to assess bevacizumab’s efficacy and safety in patients with NF2. The study’s primary endpoint is improved hearing function 24 weeks after the beginning of the treatment protocol. Abstract Neurofibromatosis type 2 (NF2) causes bilateral vestibular schwannomas (VSs), leading to deafness. VS is treated by surgery or radiation, but neither treatments prevent hearing loss. Bevacizumab was found to be effective in suppressing the tumor’s growth and may help to improve hearing. We are conducting a randomized, double-blind, multicenter clinical trial to verify the efficacy and safety of bevacizumab in NF2-related VS. The primary objective is to evaluate the efficacy of bevacizumab in improving hearing in the affected ear. One of the secondary objectives is to evaluate bevacizumab’s efficacy in rechallenge treatment in relapsed cases. Sixty patients will randomly receive either bevacizumab or a placebo and will be clinically observed for 48 weeks in the initial intervention phase. In the first half (24 weeks), they will receive either 5 mg/kg of bevacizumab or a placebo drug. In the second half, all patients will receive 5 mg/kg of bevacizumab. If hearing function deteriorated in a patient who had shown improvement during the first phase, a rechallenge dose with bevacizumab would be offered.
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Affiliation(s)
- Masazumi Fujii
- Department of Neurosurgery, Fukushima Medical University, Fukushima 960-1247, Japan; (K.S.); (T.S.); (M.B.)
- Correspondence: ; Tel.: +81-24-547-1268
| | - Masao Kobayakawa
- Medical Research Center, Fukushima Medical University, Fukushima 960-1247, Japan; (M.K.); (A.I.)
| | - Kiyoshi Saito
- Department of Neurosurgery, Fukushima Medical University, Fukushima 960-1247, Japan; (K.S.); (T.S.); (M.B.)
| | - Akihiro Inano
- Medical Research Center, Fukushima Medical University, Fukushima 960-1247, Japan; (M.K.); (A.I.)
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School, Bunkyo-Ku, Tokyo 113-8602, Japan;
| | - Mitsuhiro Hasegawa
- Department of Neurosurgery, Fujita Health University, Toyoake 470-1192, Japan;
| | - Akitake Mukasa
- Department of Neurosurgery, Kumamoto University, Kumamoto 860-8555, Japan;
| | - Takafumi Mitsuhara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 739-8511, Japan;
| | - Takeo Goto
- Department of Neurosurgery, Osaka City University, Osaka 558-8585, Japan;
| | - Shigeru Yamaguchi
- Department of Neurosurgery, Hokkaido University, Sapporo 060-0808, Japan;
| | - Takashi Tamiya
- Department of Neurosurgery, Kagawa University, Takamatsu 760-0016, Japan;
| | - Hirofumi Nakatomi
- Department of Neurosurgery, University of Tokyo, Bunkyo-Ku, Tokyo 113-8654, Japan;
| | - Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Kawagoe 350-8550, Japan;
| | - Fumiaki Takahashi
- Center for Liberal Arts and Sciences, Iwate Medical University, Morioka 020-0023, Japan;
| | - Taku Sato
- Department of Neurosurgery, Fukushima Medical University, Fukushima 960-1247, Japan; (K.S.); (T.S.); (M.B.)
| | - Mudathir Bakhit
- Department of Neurosurgery, Fukushima Medical University, Fukushima 960-1247, Japan; (K.S.); (T.S.); (M.B.)
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14
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Ren Y, Chari DA, Vasilijic S, Welling DB, Stankovic KM. New developments in neurofibromatosis type 2 and vestibular schwannoma. Neurooncol Adv 2020; 3:vdaa153. [PMID: 33604573 PMCID: PMC7881257 DOI: 10.1093/noajnl/vdaa153] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Neurofibromatosis type 2 (NF2) is a rare autosomal dominant disorder characterized by the development of multiple nervous system tumors due to mutation in the NF2 tumor suppressor gene. The hallmark feature of the NF2 syndrome is the development of bilateral vestibular schwannomas (VS). Although there is nearly 100% penetrance by 60 years of age, some patients suffer from a severe form of the disease and develop multiple tumors at an early age, while others are asymptomatic until later in life. Management options for VS include surgery, stereotactic radiation, and observation with serial imaging; however, currently, there are no FDA-approved pharmacotherapies for NF2 or VS. Recent advancements in the molecular biology underlying NF2 have led to a better understanding of the etiology and pathogenesis of VS. These novel signaling pathways may be used to identify targeted therapies for these tumors. This review discusses the clinical features and treatment options for sporadic- and NF2-associated VS, the diagnostic and screening criteria, completed and ongoing clinical trials, quality of life metrics, and opportunities for future research.
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Affiliation(s)
- Yin Ren
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, University of California San Diego School of Medicine, San Diego, California, USA
| | - Divya A Chari
- Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Eaton-Peabody Laboratories and Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Sasa Vasilijic
- Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Eaton-Peabody Laboratories and Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - D Bradley Welling
- Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Eaton-Peabody Laboratories and Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Speech and Hearing Bioscience and Technology Program, Harvard Medical School, Boston, Massachusetts, USA
| | - Konstantina M Stankovic
- Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Eaton-Peabody Laboratories and Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Speech and Hearing Bioscience and Technology Program, Harvard Medical School, Boston, Massachusetts, USA.,Harvard Stem Cell Institute, Harvard University, Cambridge, Massachusetts, USA.,Program in Therapeutic Science, Harvard Medical School, Boston, Massachusetts, USA
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15
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Tamura R, Fujioka M, Morimoto Y, Ohara K, Kosugi K, Oishi Y, Sato M, Ueda R, Fujiwara H, Hikichi T, Noji S, Oishi N, Ogawa K, Kawakami Y, Ohira T, Yoshida K, Toda M. A VEGF receptor vaccine demonstrates preliminary efficacy in neurofibromatosis type 2. Nat Commun 2019; 10:5758. [PMID: 31848332 PMCID: PMC6917794 DOI: 10.1038/s41467-019-13640-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 11/11/2019] [Indexed: 12/14/2022] Open
Abstract
The anti-VEGF antibody bevacizumab has shown efficacy for the treatment of neurofibromatosis type 2 (NF2). Theoretically, vascular endothelial growth factor receptors (VEGFRs)-specific cytotoxic T lymphocytes (CTLs) can kill both tumor vessel cells and tumor cells expressing VEGFRs. Here we show an exploratory clinical study of VEGFRs peptide vaccine in seven patients with progressive NF2-derived schwannomas. Hearing improves in 2/5 assessable patients (40%) as determined by international guidelines, with increases in word recognition scores. Tumor volume reductions of ≥20% are observed in two patients, including one in which bevacizumab had not been effective. There are no severe adverse events related to the vaccine. Both VEGFR1-specific and VEGFR2-specific CTLs are induced in six patients. Surgery is performed after vaccination in two patients, and significant reductions in the expression of VEGFRs in schwannomas are observed. Therefore, this clinical immunotherapy study demonstrates the safety and preliminary efficacy of VEGFRs peptide vaccination in patients with NF2. The anti-vascular endothelial growth factor (VEGF) antibody bevacizumab has shown efficacy for the treatment of neurofibromatosis type 2 (NF2). Here, the authors show that VEGFRs peptide vaccination can improve hearing and reduce tumor volume in NF2 patients, including in previously bevacizumab resistant tumors.
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Affiliation(s)
- Ryota Tamura
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masato Fujioka
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yukina Morimoto
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kentaro Ohara
- Department of Pathology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kenzo Kosugi
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yumiko Oishi
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Mizuto Sato
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Ryo Ueda
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hirokazu Fujiwara
- Department of Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Tetsuro Hikichi
- OncoTherapy Science, Inc., 3-2-1, Sakado, Takatsu-ku, Kawasaki City, Kanagawa, 213-0012, Japan
| | - Shinobu Noji
- Division of Cellular Signaling Institute for Advanced Medical Research, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Naoki Oishi
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kaoru Ogawa
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yutaka Kawakami
- Division of Cellular Signaling Institute for Advanced Medical Research, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Takayuki Ohira
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
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16
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Plotkin SR, Duda DG, Muzikansky A, Allen J, Blakeley J, Rosser T, Campian JL, Clapp DW, Fisher MJ, Tonsgard J, Ullrich N, Thomas C, Cutter G, Korf B, Packer R, Karajannis MA. Multicenter, Prospective, Phase II and Biomarker Study of High-Dose Bevacizumab as Induction Therapy in Patients With Neurofibromatosis Type 2 and Progressive Vestibular Schwannoma. J Clin Oncol 2019; 37:3446-3454. [PMID: 31626572 DOI: 10.1200/jco.19.01367] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Bevacizumab treatment at 7.5 mg/kg every 3 weeks results in improved hearing in approximately 35%-40% of patients with neurofibromatosis type 2 (NF2) and progressive vestibular schwannomas (VSs). However, the optimal dose is unknown. In this multicenter phase II and biomarker study, we evaluated the efficacy and safety of high-dose bevacizumab in pediatric and adult patients with NF2 with progressive VS. PATIENTS AND METHODS Bevacizumab was given for 6 months at 10 mg/kg every 2 weeks, followed by 18 months at 5 mg/kg every 3 weeks. The primary end point was hearing response defined by word recognition score (WRS) at 6 months. Secondary end points included toxicity, radiographic response, quality of life (QOL), and plasma biomarkers. RESULTS Twenty-two participants with NF2 (median age, 23 years) with progressive hearing loss in the target ear (median baseline WRS, 53%) were enrolled. Nine (41%) of 22 participants achieved a hearing response at 6 months (1 of 7 children and 8 of 15 adults; P = .08). Radiographic response was seen in 7 (32%) of 22 patients with VS at 6 months (7 of 15 adults and 0 of 7 children; P = .05). Common mild to moderate adverse events included hypertension, fatigue, headache, and irregular menstruation. Improvement in NF2-related QOL and reduction in tinnitus-related distress were reported in 30% and 60% of participants, respectively. Paradoxically, high-dose bevacizumab treatment was not associated with a significant decrease in free vascular endothelial growth factor but was associated with increased carbonic anhydrase IX, hepatocyte growth factor, placental growth factor, stromal cell-derived factor 1α, and basic fibroblast growth factor concentrations in plasma. CONCLUSION High-dose bevacizumab seems to be no more effective than standard-dose bevacizumab for treatment of patients with NF2 with hearing loss. In contrast to adults, pediatric participants did not experience tumor shrinkage. However, adult and pediatric participants reported similar improvement in QOL during induction. Novel approaches using bevacizumab should be considered for children with NF2.
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Affiliation(s)
| | - Dan G Duda
- Massachusetts General Hospital, Boston, MA
| | | | | | | | - Tena Rosser
- University of Southern California, Los Angeles, CA
| | | | | | | | | | | | | | | | | | - Roger Packer
- Children's National Medical Center, Washington, DC
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17
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Shukla A, Hsu FC, Slobogean B, Langmead S, Lu Y, Blakeley JO, Strowd RE. Association between patient-reported outcomes and objective disease indices in people with NF2. Neurol Clin Pract 2019; 9:322-329. [PMID: 31583187 DOI: 10.1212/cpj.0000000000000648] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/12/2019] [Indexed: 11/15/2022]
Abstract
Objective The association between patient-reported outcomes and currently used clinical trial endpoints, including total vestibular schwannoma (VS) volume and word recognition score (WRS) in neurofibromatosis type 2 (NF2), is not known. Methods A prospective observational study enrolling adult patients with NF2 was conducted at a single specialty center. Measures included: NF2 impact on quality of life (NFTI-QOL), short form (SF)-36; total VS volume, WRS; provider- and patient-reported disease severity (ProvSev, PatSev) measured with an institutionally derived multi-item (e.g., symptom burden, age-of-onset, and fatality-risk) and single-item Likert (mild, moderate, severe) scale. Results Fifty-one patients were enrolled between June 2014 and August 2017. Mean age was 42.1 ± 18.2 years and 37.3% patients were male. Mean WRS was 74.4 ± 37.3%; mean total VS volume was 4.2 ± 5.2 cc. Additional lesions were common including meningioma (79.2%) and spinal ependymoma (39.6%). Mean NFTI-QOL score was 7.6 ± 4.9 and correlated with responses on the SF-36. NFTI-QOL also correlated well with PatSev (r = 0.63, p < 0.001) and both multi- and single-item ProvSev (r = 0.62, p < 0.001; r = 0.52, p < 0.001, respectively). A weak correlation was observed between NFTI-QOL and WRS (r = -0.34, p = 0.0156). There was no correlation with VS volume (r = 0.23, p = 0.15). Conclusions The NFTI-QOL correlated well with multiple measures of disease severity but not commonly accepted endpoints for NF2 clinical trials including total VS volume in this US cohort of patients with NF2. This suggests that the NFTI-QOL captures components of the patient experience not sufficiently represented by objective measures of disease and underscores the important and complementary role of patient-focused measures in therapeutic outcome assessment in people with NF2.
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Affiliation(s)
- Aishwarya Shukla
- Johns Hopkins School of Medicine (AS, BS, SL, JOB), the Johns Hopkins Comprehensive Neurofibromatosis Center, Baltimore, MD; Department of Biostatistics and Data Science (F-CH), Wake Forest School of Medicine, Winston-Salem, NC; Division of Biostatistics and Epidemiology (YL), Weill Cornell Medical College, New York; Department of Neurology (RES), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Neurology (RES), Johns Hopkins School of Medicine, Baltimore, MD
| | - Fang-Chi Hsu
- Johns Hopkins School of Medicine (AS, BS, SL, JOB), the Johns Hopkins Comprehensive Neurofibromatosis Center, Baltimore, MD; Department of Biostatistics and Data Science (F-CH), Wake Forest School of Medicine, Winston-Salem, NC; Division of Biostatistics and Epidemiology (YL), Weill Cornell Medical College, New York; Department of Neurology (RES), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Neurology (RES), Johns Hopkins School of Medicine, Baltimore, MD
| | - Bronwyn Slobogean
- Johns Hopkins School of Medicine (AS, BS, SL, JOB), the Johns Hopkins Comprehensive Neurofibromatosis Center, Baltimore, MD; Department of Biostatistics and Data Science (F-CH), Wake Forest School of Medicine, Winston-Salem, NC; Division of Biostatistics and Epidemiology (YL), Weill Cornell Medical College, New York; Department of Neurology (RES), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Neurology (RES), Johns Hopkins School of Medicine, Baltimore, MD
| | - Shannon Langmead
- Johns Hopkins School of Medicine (AS, BS, SL, JOB), the Johns Hopkins Comprehensive Neurofibromatosis Center, Baltimore, MD; Department of Biostatistics and Data Science (F-CH), Wake Forest School of Medicine, Winston-Salem, NC; Division of Biostatistics and Epidemiology (YL), Weill Cornell Medical College, New York; Department of Neurology (RES), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Neurology (RES), Johns Hopkins School of Medicine, Baltimore, MD
| | - Yao Lu
- Johns Hopkins School of Medicine (AS, BS, SL, JOB), the Johns Hopkins Comprehensive Neurofibromatosis Center, Baltimore, MD; Department of Biostatistics and Data Science (F-CH), Wake Forest School of Medicine, Winston-Salem, NC; Division of Biostatistics and Epidemiology (YL), Weill Cornell Medical College, New York; Department of Neurology (RES), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Neurology (RES), Johns Hopkins School of Medicine, Baltimore, MD
| | - Jaishri O Blakeley
- Johns Hopkins School of Medicine (AS, BS, SL, JOB), the Johns Hopkins Comprehensive Neurofibromatosis Center, Baltimore, MD; Department of Biostatistics and Data Science (F-CH), Wake Forest School of Medicine, Winston-Salem, NC; Division of Biostatistics and Epidemiology (YL), Weill Cornell Medical College, New York; Department of Neurology (RES), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Neurology (RES), Johns Hopkins School of Medicine, Baltimore, MD
| | - Roy E Strowd
- Johns Hopkins School of Medicine (AS, BS, SL, JOB), the Johns Hopkins Comprehensive Neurofibromatosis Center, Baltimore, MD; Department of Biostatistics and Data Science (F-CH), Wake Forest School of Medicine, Winston-Salem, NC; Division of Biostatistics and Epidemiology (YL), Weill Cornell Medical College, New York; Department of Neurology (RES), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Neurology (RES), Johns Hopkins School of Medicine, Baltimore, MD
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Bonne NX, Risoud M, Hoa M, Lemesre PE, Aboukais R, Le Rhun E, Dubrulle F, Baroncini M, Lejeune JP, Vincent C. Hearing Response Following Internal Auditory Canal Decompression in Neurofibromatosis Type 2. Neurosurgery 2019; 85:E560-E567. [DOI: 10.1093/neuros/nyz057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 02/27/2019] [Indexed: 12/28/2022] Open
Abstract
AbstractBACKGROUNDHearing response following an osteodural decompression of the internal auditory canal (IAC) is controversial.OBJECTIVETo evaluate the course of auditory brainstem responses (ABRs) and the early hearing response during the first year following IAC decompression for small to medium-sized vestibular schwannomas occurring in neurofibromatosis type 2 (NF2).METHODSRetrospective chart review of middle fossa craniotomy for IAC osteodural decompression in NF2-related vestibular schwannomas.RESULTSTwelve NF2 patients were operated on from 2011 to 2016 for IAC decompression. All had NF2 according to the Manchester criteria. All had a progressive change of their ABRs documented from the diagnosis of NF2 over a mean period of 6.25 [0.36;10.9] yr. Treatment was proposed to stop hearing progression based on the speech discrimination scores (SDSs; n = 4) or for hearing maintenance (n = 8). In patients with prior hearing progression, hearing responses were observed in 3 of the 4 patients during the first year. One patient kept on progressing. In the hearing maintenance group, the SDSs remained stable. SDSs improved from 85% [20-100] to 92.5% [60-100] on average (n = 12) and from 55% [20-80] to 77.5% [50-100] in the hearing progression group (n = 4). ABRs improved in 4 patients following decompression.CONCLUSIONIAC decompression allows early objective hearing responses in select patients. We suggest that the procedure should be offered to patients with hearing progression based on their SDSs and/or associated progressive increases in their wave III and V latencies on ABRs.
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Affiliation(s)
- Nicolas-Xavier Bonne
- CHU Lille, Otologie et Otoneurologie, Université de Lille, Inserm U1008, Controlled Drug Delivery Systems and Biomaterials, Lille, France
- Université de Lille, Inserm U1192, Protéomique Réponse Inflamatoire Spectrométrie de Masse, PRISM, Lille, France
| | - Michaël Risoud
- CHU Lille, Otologie et Otoneurologie, Université de Lille, Inserm U1008, Controlled Drug Delivery Systems and Biomaterials, Lille, France
| | - Michael Hoa
- Department of Otolaryngology, Georgetown University Hospital, NC, Washington, District of Columbia
| | - Pierre-Emmanuel Lemesre
- CHU Lille, Otologie et Otoneurologie, Université de Lille, Inserm U1008, Controlled Drug Delivery Systems and Biomaterials, Lille, France
| | - Rabih Aboukais
- CHU Lille, Department of General and Stereotaxic Neurosurgery, Lille, France
| | - Emilie Le Rhun
- Université de Lille, Inserm U1192, Protéomique Réponse Inflamatoire Spectrométrie de Masse, PRISM, Lille, France
- CHU Lille, Department of General and Stereotaxic Neurosurgery, Lille, France
| | | | - Marc Baroncini
- CHU Lille, Department of General and Stereotaxic Neurosurgery, Lille, France
| | - Jean-Paul Lejeune
- CHU Lille, Department of General and Stereotaxic Neurosurgery, Lille, France
| | - Christophe Vincent
- CHU Lille, Otologie et Otoneurologie, Université de Lille, Inserm U1008, Controlled Drug Delivery Systems and Biomaterials, Lille, France
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19
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Emmanouil B, Houston R, May A, Ramsden JD, Hanemann CO, Halliday D, Parry A, Mackeith S. Progression of hearing loss in neurofibromatosis type 2 according to genetic severity. Laryngoscope 2018; 129:974-980. [DOI: 10.1002/lary.27586] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 11/12/2022]
Affiliation(s)
| | - Rory Houston
- Department of ENTOxford University Hospitals NHS Foundation Trust Oxford United Kingdom
| | - Anne May
- Oxford NF2 Unit, Neurosciences Oxford United Kingdom
| | - James D. Ramsden
- Department of ENTOxford University Hospitals NHS Foundation Trust Oxford United Kingdom
| | | | - Dorothy Halliday
- Oxford NF2 Unit, Neurosciences Oxford United Kingdom
- Oxford Centre for Genomic MedicineOxford University Hospitals NHS Foundation Trust Oxford United Kingdom
| | - Allyson Parry
- Oxford NF2 Unit, Neurosciences Oxford United Kingdom
| | - Samuel Mackeith
- Oxford NF2 Unit, Neurosciences Oxford United Kingdom
- Department of ENTOxford University Hospitals NHS Foundation Trust Oxford United Kingdom
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20
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Peyre M, Bernardeschi D, Sterkers O, Kalamarides M. Natural history of vestibular schwannomas and hearing loss in NF2 patients. Neurochirurgie 2018; 64:342-347. [DOI: 10.1016/j.neuchi.2015.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/22/2015] [Accepted: 03/29/2015] [Indexed: 10/23/2022]
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21
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Sverak P, Adams ME, Haines SJ, Levine SC, Nascene D, Sommer K, Dusenbery K, Huang TC, Moertel C. Bevacizumab for Hearing Preservation in Neurofibromatosis Type 2: Emphasis on Patient-Reported Outcomes and Toxicities. Otolaryngol Head Neck Surg 2018; 160:526-532. [DOI: 10.1177/0194599818809085] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective Bevacizumab for hearing preservation in patients with neurofibromatosis type 2 (NF2) is an emerging practice. We set out to characterize the effectiveness and toxicity of bevacizumab in our patient group. Study Design Case series with chart review. Setting Tertiary referral center. Subjects and Methods Seventeen consecutive patients with NF2 received bevacizumab treatment for vestibular schwannomas, including 2 patients treated to maintain cochlear implant performance. Volumetric analysis of serial magnetic resonance imaging scans was used to evaluate radiographic response, and hearing response was evaluated with serial audiograms. Patient-reported outcomes were also assessed, including subjective hearing improvement, changes in tinnitus, vertigo, headaches, ear pain, and improvement in ability to communicate via telephone. Results A positive radiographic response occurred in 8 of 17 (47%) patients and the median tumor volume change was a tumor decrease of 19%. A positive hearing response was recorded in 5 of 9 (56%) patients. Two patients had a word recognition score improvement over 40%. There was an approximately 40% improvement in patient-reported outcomes. Primary toxicities included hypertension, proteinuria, dysgeusia, and amenorrhea. Conclusion Bevacizumab treatment was followed by hearing improvement in 56% of patients, while decreased tumor volume was noted in 47%. These outcomes agree favorably with prior reported series. There were significant improvements in patient-reported outcomes that have not been described previously.
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Affiliation(s)
- Pavlina Sverak
- Department of Pediatric Hematology/Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Meredith E. Adams
- Department of Otolaryngology, Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Stephen J. Haines
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Samuel C. Levine
- Department of Otolaryngology, Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - David Nascene
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Katherine Sommer
- Department of Pediatric Hematology/Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tina C. Huang
- Department of Otolaryngology, Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Christopher Moertel
- Department of Pediatric Hematology/Oncology, University of Minnesota, Minneapolis, Minnesota, USA
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22
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Huang V, Bergner AL, Halpin C, Merker VL, Sheridan MR, Widemann B, Blakeley JO, Plotkin SR. Improvement in Patient-reported Hearing After Treatment With Bevacizumab in People With Neurofibromatosis Type 2. Otol Neurotol 2018; 39:632-638. [PMID: 29649040 PMCID: PMC6642810 DOI: 10.1097/mao.0000000000001781] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Assess patient-reported outcomes (PRO) for hearing and tinnitus relative to clinical hearing assessment in people with neurofibromatosis 2 (NF2) associated hearing loss. STUDY DESIGN Prospective, open label, phase-II clinical trial with PRO administered pre-, post-, and after treatment. SETTING Three tertiary referral centers. PATIENTS Fourteen patients with NF2, median age of 30 years (range, 14-79 yr) and progressive hearing loss (median baseline word recognition score, 60%; range, 13-82%). Half of these patients achieved objective hearing response (word recognition score improved beyond the 95% critical difference versus baseline). INTERVENTION Bevacizumab 7.5 mg/kg was administered every 3 weeks for 48 weeks, followed by surveillance for 24 weeks off-drug. MAIN OUTCOME MEASURES Speech, spatial, and qualities of hearing scale (SSQ) and tinnitus reaction questionnaire (TRQ) to assess hearing difficulties in life situations and tinnitus related distress. RESULTS Patient-reported speech understanding and auditory quality improved with bevacizumab treatment and were significantly correlated with word recognition scores, but not pure tone threshold average. There was no change in spatial perception after treatment. Reduction in tinnitus distress after treatment with bevacizumab did not reach statistical significance. CONCLUSION Participants had reductions in hearing difficulty during treatment with bevacizumab, suggesting that patients subjectively experience hearing-related benefit mirroring clinical hearing assessments. We suspect the lack of significant reduction in tinnitus distress is related to small sample size and low intensity of distress in our sample. These data highlight the usefulness of PRO measures to assess benefits of treatment in the setting of NF2-associated hearing loss.
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Affiliation(s)
| | - Amanda L. Bergner
- Johns Hopkins University, Baltimore, MD
- Columbia University, New York, NY
| | - Chris Halpin
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston, MA
| | - Vanessa L. Merker
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston, MA
| | - Monica R. Sheridan
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston, MA
| | | | | | - Scott R. Plotkin
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston, MA
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23
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Abstract
Neurofibromatosis type 1 and type 2, affecting both children and adults, often results in devastating complications. The rapid unravelling of the genetic underpinnings of these unique disorders has led to the development of novel therapies, especially molecular-targeted therapies. To facilitate clinical trial development, the Neurofibromatosis Clinical Trial Consortium (NFCTC) was established in 2006 by the Department of Defense. Over the past decade, the Consortium has successfully completed studies for children and adults with neurofibromatosis type 1 and plexiform neurofibromas, neurocognitive challenges, low-grade gliomas, and malignant peripheral nerve sheath tumors. In addition, a study for children and adults with neurofibromatosis type 2 and acoustic schwannomas is near completion. The NFCTC has now been expanded to 19 sites in the United Stated and Australia. Mechanisms have been put in place to work closely with other consortia, foundations, and industry to expeditiously translate preclinical discoveries into clinical trials.
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Affiliation(s)
- Roger J Packer
- 1 From the Center for Neuroscience and Behavioral Medicine, Children's National Health System, Washington, DC, USA.,2 Gilbert Neurofibromatosis Family Institute, Children's National Health System, Washington, DC, USA.,3 Brain Tumor Institute, Children's National Health System, Washington, DC, USA
| | - Michael J Fisher
- 4 Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gary Cutter
- 5 University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Bruce R Korf
- 5 University of Alabama at Birmingham, Birmingham, AL, USA
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Rosahl S, Bohr C, Lell M, Hamm K, Iro H. Diagnostics and therapy of vestibular schwannomas - an interdisciplinary challenge. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2017; 16:Doc03. [PMID: 29279723 PMCID: PMC5738934 DOI: 10.3205/cto000142] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Vestibular schwannomas (VS) expand slowly in the internal auditory canal, in the cerebellopontine angle, inside the cochlear and the labyrinth. Larger tumors can displace and compress the brainstem. With an annual incidence of 1:100,000 vestibular schwannoma represent 6-7% of all intracranial tumors. In the cerebellopontine angle they are by far the most neoplasm with 90% of all lesions located in this region. Magnetic resonance imaging (MRI), audiometry, and vestibular diagnostics are the mainstays of the clinical workup for patients harboring tumors. The first part of this paper delivers an overview of tumor stages, the most common grading scales for facial nerve function and hearing as well as a short introduction to the examination of vestibular function. Upholding or improving quality of life is the central concern in counseling and treating a patient with vestibular schwannoma. Preservation of neuronal function is essential and the management options - watchful waiting, microsurgery and stereotactic radiation - should be custom-tailored to the individual situation of the patient. Continuing interdisciplinary exchange is important to monitor treatment quality and to improve treatment results. Recently, several articles and reviews have been published on the topic of vestibular schwannoma. On the occasion of the 88th annual meeting of the German Society of Oto-Rhino-Laryngology, Head and Neck surgery a special volume of the journal "HNO" will be printed. Hence this presentation has been designed to deviate from the traditional standard which commonly consists of a pure literature review. The current paper was conceptually woven around a series of interdisciplinary cases that outline examples for every stage of the disease that show characteristic results for management options to date. Systematic clinical decision pathways have been deduced from our experience and from results reported in the literature. These pathways are graphically outlined after the case presentations. Important criteria for decision making are size and growth rate of the tumor, hearing of the patient and the probability of total tumor resection with preservation of hearing and facial nerve function, age and comorbidity of the patient, best possible control of vertigo and tinnitus and last but not least the patient's preference and choice. In addition to this, the experience and the results of a given center with each treatment modality will figure in the decision making process. We will discuss findings that are reported in the literature regarding facial nerve function, hearing, vertigo, tinnitus, and headache and reflect on recent studies on their influence on the patient's quality of life. Vertigo plays an essential role in this framework since it is an independent predictor of quality of life and a patient's dependence on social welfare. Pathognomonic bilateral vestibular schwannomas that occur in patients suffering from neurofibromatosis typ-2 (NF2) differ from spontaneous unilateral tumors in their biologic behavior. Treatment of neurofibromatosis type-2 patients requires a multidisciplinary team, especially because of the multitude of separate intracranial and spinal lesions. Off-label chemotherapy with Bevacizumab can stabilize tumor size of vestibular schwannomas and even improve hearing over longer periods of time. Hearing rehabilitation in NF2 patients can be achieved with cochlear and auditory brainstem implants.
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Affiliation(s)
- Steffen Rosahl
- Department of Neurosurgery, Helios Hospital of Erfurt, Germany
| | - Christopher Bohr
- Department of Otolaryngology, University Hospital of Erlangen, Germany
| | - Michael Lell
- Institute for Radiology and Nuclear Medicine, Hospital of Nuremberg, Germany
| | - Klaus Hamm
- Cyberknife Center of Central Germany, Erfurt, Germany
| | - Heinrich Iro
- Department of Neurosurgery, Helios Hospital of Erfurt, Germany
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25
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Best SR, Ahn J, Langmead S, Dhillon V, Hillel AT, Akst LM, Blakeley JO. Voice and Swallowing Dysfunction in Neurofibromatosis 2. Otolaryngol Head Neck Surg 2017; 158:505-510. [PMID: 29160153 DOI: 10.1177/0194599817741839] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective Neurofibromatosis 2 (NF2) is a neuro-oncologic condition that presents with bilateral vestibular schwannomas of the cerebellopontine angle (CPA). Voice and swallowing impairment can occur from direct involvement or compression of the vagus nerve or as the result of surgical excision of CPA tumors. The objectives in this study are to (1) assess the prevalence of voice and swallowing impairments and (2) analyze the effects of vagal dysfunction in patients with NF2. Study Design Cross-sectional. Setting Academic tertiary care center. Subjects and Methods Patients at a neurofibromatosis center were mailed Voice Handicap Index and Sydney Swallow Questionnaire surveys. Stroboscopic, voice, and swallowing evaluations were performed for patients who elected to participate in screening exams. Results There were high rates of self-assessed and objective voice and swallowing handicaps in this population. Fourteen of 40 (35%) patients had a self-assessed voice handicap, and 20 of 40 (50%) patients had a self-assessed swallow handicap. Vocal fold motion impairment (VFMI) was observed in 22 of 31 (71%) patients examined, with 27 of 62 (44%) possible vocal cords affected. Velopharyngeal insufficiency (45%) and piriform sinus pooling or residue (39%) were seen in a significant percentage of patients. There was a significant relationship between vocal cord motion impairment and CPA surgical intervention ipsilateral to the impairment ( P = .002). The presence of VFMI was strongly associated with voice ( P = .002) and swallowing ( P = .01) impact on quality of life. Conclusion Speech and swallowing impairments are highly prevalent in patients with NF2, cause significant impact on quality of life, and are most commonly related to surgical interventions in the CPA region.
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Affiliation(s)
- Simon R Best
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Julie Ahn
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Shannon Langmead
- 2 Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Vaninder Dhillon
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Alexander T Hillel
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Lee M Akst
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jaishri O Blakeley
- 2 Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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26
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Plotkin SR, Davis SD, Robertson KA, Akshintala S, Allen J, Fisher MJ, Blakeley JO, Widemann BC, Ferner RE, Marcus CL. Sleep and pulmonary outcomes for clinical trials of airway plexiform neurofibromas in NF1. Neurology 2017; 87:S13-20. [PMID: 27527645 DOI: 10.1212/wnl.0000000000002933] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 05/06/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Plexiform neurofibromas (PNs) are complex, benign nerve sheath tumors that occur in approximately 25%-50% of individuals with neurofibromatosis type 1 (NF1). PNs that cause airway compromise or pulmonary dysfunction are uncommon but clinically important. Because improvement in sleep quality or airway function represents direct clinical benefit, measures of sleep and pulmonary function may be more meaningful than tumor size as endpoints in therapeutic clinical trials targeting airway PN. METHODS The Response Evaluation in Neurofibromatosis and Schwannomatosis functional outcomes group reviewed currently available endpoints for sleep and pulmonary outcomes and developed consensus recommendations for response evaluation in NF clinical trials. RESULTS For patients with airway PNs, polysomnography, impulse oscillometry, and spirometry should be performed to identify abnormal function that will be targeted by the agent under clinical investigation. The functional group endorsed the use of the apnea hypopnea index (AHI) as the primary sleep endpoint, and pulmonary resistance at 10 Hz (R10) or forced expiratory volume in 1 or 0.75 seconds (FEV1 or FEV0.75) as primary pulmonary endpoints. The group defined minimum changes in AHI, R10, and FEV1 or FEV0.75 for response criteria. Secondary sleep outcomes include desaturation and hypercapnia during sleep and arousal index. Secondary pulmonary outcomes include pulmonary resistance and reactance measurements at 5, 10, and 20 Hz; forced vital capacity; peak expiratory flow; and forced expiratory flows. CONCLUSIONS These recommended sleep and pulmonary evaluations are intended to provide researchers with a standardized set of clinically meaningful endpoints for response evaluation in trials of NF1-related airway PNs.
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Affiliation(s)
- Scott R Plotkin
- From the Neurology Department and Cancer Center (S.R.P.), Massachusetts General Hospital, Boston; Section of Pediatric Pulmonology, Allergy and Sleep Medicine (S.D.D.), and Stem Cell Transplantation Program (K.A.R.), Riley Children's Hospital, Indiana University School of Medicine, Indianapolis; Pediatric Oncology Branch (S.A., B.C.W.), National Cancer Institute, Bethesda, MD; Division of Pulmonary Medicine (J.A.), Division of Oncology (M.J.F.), and Sleep Center (C.L.M.), Children's Hospital of Philadelphia; Department of Pediatrics (M.J.F.) and Sleep Center (C.L.M.), The Perelman School of Medicine at the University of Pennsylvania (J.A.), Philadelphia; Department of Neurology (J.O.B.), John Hopkins Medical Institute, Baltimore, MD; and Department of Neurology (R.E.F.), Guy's and St. Thomas' NHS Foundation Trust and Institute of Psychiatry, King's College London, UK.
| | - Stephanie D Davis
- From the Neurology Department and Cancer Center (S.R.P.), Massachusetts General Hospital, Boston; Section of Pediatric Pulmonology, Allergy and Sleep Medicine (S.D.D.), and Stem Cell Transplantation Program (K.A.R.), Riley Children's Hospital, Indiana University School of Medicine, Indianapolis; Pediatric Oncology Branch (S.A., B.C.W.), National Cancer Institute, Bethesda, MD; Division of Pulmonary Medicine (J.A.), Division of Oncology (M.J.F.), and Sleep Center (C.L.M.), Children's Hospital of Philadelphia; Department of Pediatrics (M.J.F.) and Sleep Center (C.L.M.), The Perelman School of Medicine at the University of Pennsylvania (J.A.), Philadelphia; Department of Neurology (J.O.B.), John Hopkins Medical Institute, Baltimore, MD; and Department of Neurology (R.E.F.), Guy's and St. Thomas' NHS Foundation Trust and Institute of Psychiatry, King's College London, UK
| | - Kent A Robertson
- From the Neurology Department and Cancer Center (S.R.P.), Massachusetts General Hospital, Boston; Section of Pediatric Pulmonology, Allergy and Sleep Medicine (S.D.D.), and Stem Cell Transplantation Program (K.A.R.), Riley Children's Hospital, Indiana University School of Medicine, Indianapolis; Pediatric Oncology Branch (S.A., B.C.W.), National Cancer Institute, Bethesda, MD; Division of Pulmonary Medicine (J.A.), Division of Oncology (M.J.F.), and Sleep Center (C.L.M.), Children's Hospital of Philadelphia; Department of Pediatrics (M.J.F.) and Sleep Center (C.L.M.), The Perelman School of Medicine at the University of Pennsylvania (J.A.), Philadelphia; Department of Neurology (J.O.B.), John Hopkins Medical Institute, Baltimore, MD; and Department of Neurology (R.E.F.), Guy's and St. Thomas' NHS Foundation Trust and Institute of Psychiatry, King's College London, UK
| | - Srivandana Akshintala
- From the Neurology Department and Cancer Center (S.R.P.), Massachusetts General Hospital, Boston; Section of Pediatric Pulmonology, Allergy and Sleep Medicine (S.D.D.), and Stem Cell Transplantation Program (K.A.R.), Riley Children's Hospital, Indiana University School of Medicine, Indianapolis; Pediatric Oncology Branch (S.A., B.C.W.), National Cancer Institute, Bethesda, MD; Division of Pulmonary Medicine (J.A.), Division of Oncology (M.J.F.), and Sleep Center (C.L.M.), Children's Hospital of Philadelphia; Department of Pediatrics (M.J.F.) and Sleep Center (C.L.M.), The Perelman School of Medicine at the University of Pennsylvania (J.A.), Philadelphia; Department of Neurology (J.O.B.), John Hopkins Medical Institute, Baltimore, MD; and Department of Neurology (R.E.F.), Guy's and St. Thomas' NHS Foundation Trust and Institute of Psychiatry, King's College London, UK
| | - Julian Allen
- From the Neurology Department and Cancer Center (S.R.P.), Massachusetts General Hospital, Boston; Section of Pediatric Pulmonology, Allergy and Sleep Medicine (S.D.D.), and Stem Cell Transplantation Program (K.A.R.), Riley Children's Hospital, Indiana University School of Medicine, Indianapolis; Pediatric Oncology Branch (S.A., B.C.W.), National Cancer Institute, Bethesda, MD; Division of Pulmonary Medicine (J.A.), Division of Oncology (M.J.F.), and Sleep Center (C.L.M.), Children's Hospital of Philadelphia; Department of Pediatrics (M.J.F.) and Sleep Center (C.L.M.), The Perelman School of Medicine at the University of Pennsylvania (J.A.), Philadelphia; Department of Neurology (J.O.B.), John Hopkins Medical Institute, Baltimore, MD; and Department of Neurology (R.E.F.), Guy's and St. Thomas' NHS Foundation Trust and Institute of Psychiatry, King's College London, UK
| | - Michael J Fisher
- From the Neurology Department and Cancer Center (S.R.P.), Massachusetts General Hospital, Boston; Section of Pediatric Pulmonology, Allergy and Sleep Medicine (S.D.D.), and Stem Cell Transplantation Program (K.A.R.), Riley Children's Hospital, Indiana University School of Medicine, Indianapolis; Pediatric Oncology Branch (S.A., B.C.W.), National Cancer Institute, Bethesda, MD; Division of Pulmonary Medicine (J.A.), Division of Oncology (M.J.F.), and Sleep Center (C.L.M.), Children's Hospital of Philadelphia; Department of Pediatrics (M.J.F.) and Sleep Center (C.L.M.), The Perelman School of Medicine at the University of Pennsylvania (J.A.), Philadelphia; Department of Neurology (J.O.B.), John Hopkins Medical Institute, Baltimore, MD; and Department of Neurology (R.E.F.), Guy's and St. Thomas' NHS Foundation Trust and Institute of Psychiatry, King's College London, UK
| | - Jaishri O Blakeley
- From the Neurology Department and Cancer Center (S.R.P.), Massachusetts General Hospital, Boston; Section of Pediatric Pulmonology, Allergy and Sleep Medicine (S.D.D.), and Stem Cell Transplantation Program (K.A.R.), Riley Children's Hospital, Indiana University School of Medicine, Indianapolis; Pediatric Oncology Branch (S.A., B.C.W.), National Cancer Institute, Bethesda, MD; Division of Pulmonary Medicine (J.A.), Division of Oncology (M.J.F.), and Sleep Center (C.L.M.), Children's Hospital of Philadelphia; Department of Pediatrics (M.J.F.) and Sleep Center (C.L.M.), The Perelman School of Medicine at the University of Pennsylvania (J.A.), Philadelphia; Department of Neurology (J.O.B.), John Hopkins Medical Institute, Baltimore, MD; and Department of Neurology (R.E.F.), Guy's and St. Thomas' NHS Foundation Trust and Institute of Psychiatry, King's College London, UK
| | - Brigitte C Widemann
- From the Neurology Department and Cancer Center (S.R.P.), Massachusetts General Hospital, Boston; Section of Pediatric Pulmonology, Allergy and Sleep Medicine (S.D.D.), and Stem Cell Transplantation Program (K.A.R.), Riley Children's Hospital, Indiana University School of Medicine, Indianapolis; Pediatric Oncology Branch (S.A., B.C.W.), National Cancer Institute, Bethesda, MD; Division of Pulmonary Medicine (J.A.), Division of Oncology (M.J.F.), and Sleep Center (C.L.M.), Children's Hospital of Philadelphia; Department of Pediatrics (M.J.F.) and Sleep Center (C.L.M.), The Perelman School of Medicine at the University of Pennsylvania (J.A.), Philadelphia; Department of Neurology (J.O.B.), John Hopkins Medical Institute, Baltimore, MD; and Department of Neurology (R.E.F.), Guy's and St. Thomas' NHS Foundation Trust and Institute of Psychiatry, King's College London, UK
| | - Rosalie E Ferner
- From the Neurology Department and Cancer Center (S.R.P.), Massachusetts General Hospital, Boston; Section of Pediatric Pulmonology, Allergy and Sleep Medicine (S.D.D.), and Stem Cell Transplantation Program (K.A.R.), Riley Children's Hospital, Indiana University School of Medicine, Indianapolis; Pediatric Oncology Branch (S.A., B.C.W.), National Cancer Institute, Bethesda, MD; Division of Pulmonary Medicine (J.A.), Division of Oncology (M.J.F.), and Sleep Center (C.L.M.), Children's Hospital of Philadelphia; Department of Pediatrics (M.J.F.) and Sleep Center (C.L.M.), The Perelman School of Medicine at the University of Pennsylvania (J.A.), Philadelphia; Department of Neurology (J.O.B.), John Hopkins Medical Institute, Baltimore, MD; and Department of Neurology (R.E.F.), Guy's and St. Thomas' NHS Foundation Trust and Institute of Psychiatry, King's College London, UK
| | - Carole L Marcus
- From the Neurology Department and Cancer Center (S.R.P.), Massachusetts General Hospital, Boston; Section of Pediatric Pulmonology, Allergy and Sleep Medicine (S.D.D.), and Stem Cell Transplantation Program (K.A.R.), Riley Children's Hospital, Indiana University School of Medicine, Indianapolis; Pediatric Oncology Branch (S.A., B.C.W.), National Cancer Institute, Bethesda, MD; Division of Pulmonary Medicine (J.A.), Division of Oncology (M.J.F.), and Sleep Center (C.L.M.), Children's Hospital of Philadelphia; Department of Pediatrics (M.J.F.) and Sleep Center (C.L.M.), The Perelman School of Medicine at the University of Pennsylvania (J.A.), Philadelphia; Department of Neurology (J.O.B.), John Hopkins Medical Institute, Baltimore, MD; and Department of Neurology (R.E.F.), Guy's and St. Thomas' NHS Foundation Trust and Institute of Psychiatry, King's College London, UK
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Abstract
Neurofibromatosis type 2 (NF2) is a rare autosomal dominant disorder (incidence 1:33 000-40 000) characterized by formation of central nervous system tumors, due to mutation in the NF2 gene on chromosome 22q12. Vestibular schwannomas are the hallmark lesion, affecting 95% of individuals and typically occur bilaterally. Schwannomas commonly occur on other nerves intracranially and in the spinal compartment, along with meningiomas, ependymomas, and gliomas. Although histologically benign, tumors are associated with significant morbidity due to multiple problems including hearing and vision loss, gait abnormalities, paralysis, pain, and seizures. Risk of early mortality from brainstem compression and other complications is significant. Severity of disease is higher when NF2 presents during childhood. Children have a more variable presentation, which can be associated with significant delays in recognition of the condition. Careful examination of the skin and eyes can identify important clinical signs of NF2 during childhood, allowing timely initiation of disease-specific surveillance and treatment. Monitoring for complications comprises clinical evaluation, along with functional testing including audiology and serial neuroimaging, which together inform decisions regarding treatment. Evidence for disease-specific medical treatment options is increasing, nevertheless most patients will benefit from multimodal treatment including surgery during their lifetime. Patient enrolment in international natural history and treatment trials offers the best opportunity to accelerate our understanding of the complications and optimal treatment of NF2, with a view to improving outcomes for all affected individuals.
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Affiliation(s)
- Simone Ardern-Holmes
- 1 TY Nelson Department of Neurology and Neurosurgery, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Gemma Fisher
- 2 Sydney Children's Hospital, New South Wales, Australia
| | - Kathryn North
- 3 Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
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Avery RA, Katowitz JA, Fisher MJ, Heidary G, Dombi E, Packer RJ, Widemann BC. Orbital/Periorbital Plexiform Neurofibromas in Children with Neurofibromatosis Type 1: Multidisciplinary Recommendations for Care. Ophthalmology 2016; 124:123-132. [PMID: 27817916 DOI: 10.1016/j.ophtha.2016.09.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 09/06/2016] [Accepted: 09/16/2016] [Indexed: 12/13/2022] Open
Abstract
TOPIC Children and adults with neurofibromatosis type 1 (NF1), a common autosomal dominant condition, manifest a variety of ophthalmologic conditions. Plexiform neurofibromas (PNs) involving the eyelid, orbit, periorbital, and facial structures (orbital-periorbital plexiform neurofibroma [OPPN]) can result in significant visual loss in children. Equally important, OPPNs can cause significant alteration in physical appearance secondary to proptosis, ptosis, and facial disfigurement, leading to social embarrassment and decreased self-esteem. CLINICAL RELEVANCE Although NF1 is a relatively common disease in which routine ophthalmologic examinations are required, no formal recommendations for clinical care of children with OPPNs exist. Although medical and surgical interventions have been reported, there are no agreed-on criteria for when OPPNs require therapy and which treatment produces the best outcome. METHODS Because a multidisciplinary team of specialists (oculofacial plastics, pediatric ophthalmology, neuro-ophthalmology, medical genetics, and neuro-oncology) direct management decisions, the absence of a uniform outcome measure that represents visual or aesthetic sequelae complicates the design of evidence-based studies and feasible clinical trials. RESULTS In September 2013, a multidisciplinary task force, composed of pediatric practitioners from tertiary care centers experienced in caring for children with OPPN, was convened to address the lack of clinical care guidelines for children with OPPN. CONCLUSIONS This consensus statement provides recommendations for ophthalmologic monitoring, outlines treatment indications and forthcoming biologic therapy, and discusses challenges to performing clinical trials in this complicated condition.
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Affiliation(s)
- Robert A Avery
- The Gilbert Family Neurofibromatosis Institute, Children's National Health System, Washington, DC; Department of Neurology, Children's National Health System, Washington, DC; Department of Ophthalmology, Children's National Health System, Washington, DC; Center for Neuroscience and Behavior, Children's National Health System, Washington, DC; Division of Ophthalmology, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, Pennsylvania.
| | - James A Katowitz
- Division of Ophthalmology, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael J Fisher
- Division of Oncology, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Gena Heidary
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts
| | - Eva Dombi
- Pediatric Oncology Branch, National Cancer Institute, Bethesda, Maryland
| | - Roger J Packer
- The Gilbert Family Neurofibromatosis Institute, Children's National Health System, Washington, DC; Department of Neurology, Children's National Health System, Washington, DC; The Brain Tumor Institute, Children's National Health System, Washington, DC; Center for Neuroscience and Behavior, Children's National Health System, Washington, DC
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29
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Blakeley JO, Plotkin SR. Therapeutic advances for the tumors associated with neurofibromatosis type 1, type 2, and schwannomatosis. Neuro Oncol 2016; 18:624-38. [PMID: 26851632 PMCID: PMC4827037 DOI: 10.1093/neuonc/nov200] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 08/17/2015] [Indexed: 01/08/2023] Open
Abstract
Neurofibromatosis type 1 (NF1), neurofibromatosis type 2 (NF2), and schwannomatosis (SWN) are tumor-suppressor syndromes. Each syndrome is an orphan disease; however, the tumors that arise within them represent the most common tumors of the nervous system worldwide. Systematic investigation of the pathways impacted by the loss of function of neurofibromin (encoded byNF1) and merlin (encoded byNF2) have led to therapeutic advances for patients with NF1 and NF2. In the syndrome of SWN, the genetic landscape is more complex, with 2 known causative genes (SMARCB1andLZTR1) accounting for up to 50% of familial SWN patients. The understanding of the molecular underpinnings of these syndromes is developing rapidly and offers more therapeutic options for the patients. In addition, common sporadic cancers harbor somatic alterations inNF1(ie, glioblastoma, breast cancer, melanoma),NF2(ie, meningioma, mesothelioma) andSMARCB1(ie, atypical teratoid/rhabdoid tumors) such that advances in management of syndromic tumors may benefit patients both with and without germline mutations. In this review, we discuss the clinical and genetic features of NF1, NF2 and SWN, the therapeutic advances for the tumors that arise within these syndromes and the interaction between these rare tumor syndromes and the common tumors that share these mutations.
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Affiliation(s)
- Jaishri O Blakeley
- Neurology, Neurosurgery and Oncology, Johns Hopkins University, Baltimore, MD (J.O.B.); Neurology, Harvard Medical School, Stephen E. and Catherine Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Boston, MA (S.R.P.)
| | - Scott R Plotkin
- Neurology, Neurosurgery and Oncology, Johns Hopkins University, Baltimore, MD (J.O.B.); Neurology, Harvard Medical School, Stephen E. and Catherine Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Boston, MA (S.R.P.)
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30
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Blakeley JO, Ye X, Duda DG, Halpin CF, Bergner AL, Muzikansky A, Merker VL, Gerstner ER, Fayad LM, Ahlawat S, Jacobs MA, Jain RK, Zalewski C, Dombi E, Widemann BC, Plotkin SR. Efficacy and Biomarker Study of Bevacizumab for Hearing Loss Resulting From Neurofibromatosis Type 2-Associated Vestibular Schwannomas. J Clin Oncol 2016; 34:1669-75. [PMID: 26976425 DOI: 10.1200/jco.2015.64.3817] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Neurofibromatosis type 2 (NF2) is a tumor predisposition syndrome characterized by bilateral vestibular schwannomas (VSs) resulting in deafness and brainstem compression. This study evaluated efficacy and biomarkers of bevacizumab activity for NF2-associated progressive and symptomatic VSs. PATIENTS AND METHODS Bevacizumab 7.5 mg/kg was administered every 3 weeks for 46 weeks, followed by 24 weeks of surveillance after treatment with the drug. The primary end point was hearing response defined by word recognition score (WRS). Secondary end points included toxicity, tolerability, imaging response using volumetric magnetic resonance imaging analysis, durability of response, and imaging and blood biomarkers. RESULTS Fourteen patients (estimated to yield > 90% power to detect an alternative response rate of 50% at alpha level of 0.05) with NF2, with a median age of 30 years (range, 14 to 79 years) and progressive hearing loss in the target ear (median baseline WRS, 60%; range 13% to 82%), were enrolled. The primary end point, confirmed hearing response (improvement maintained ≥ 3 months), occurred in five (36%) of 14 patients (95% CI, 13% to 65%; P < .001). Eight (57%) of 14 patients had transient hearing improvement above the 95% CI for WRS. No patients experienced hearing decline. Radiographic response was seen in six (43%) of 14 target VSs. Three grade 3 adverse events, hypertension (n = 2) and immune-mediated thrombocytopenic purpura (n = 1), were possibly related to bevacizumab. Bevacizumab treatment was associated with decreased free vascular endothelial growth factor (not bound to bevacizumab) and increased placental growth factor in plasma. Hearing responses were inversely associated with baseline plasma hepatocyte growth factor (P = .019). Imaging responses were associated with high baseline tumor vessel permeability and elevated blood levels of vascular endothelial growth factor D and stromal cell-derived factor 1α (P = .037 and .025, respectively). CONCLUSION Bevacizumab treatment resulted in durable hearing response in 36% of patients with NF2 and confirmed progressive VS-associated hearing loss. Imaging and plasma biomarkers showed promising associations with response that should be validated in larger studies.
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Affiliation(s)
- Jaishri O Blakeley
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA.
| | - Xiaobu Ye
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Dan G Duda
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Chris F Halpin
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Amanda L Bergner
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Alona Muzikansky
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Vanessa L Merker
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Elizabeth R Gerstner
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Laura M Fayad
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Shivani Ahlawat
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Michael A Jacobs
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Rakesh K Jain
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Christopher Zalewski
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Eva Dombi
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Brigitte C Widemann
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Scott R Plotkin
- Jaishri O. Blakeley, Xiaobu Ye, Amanda L. Bergner, Laura M. Fayad, Shivani Ahlawat, and Michael A. Jacobs, Johns Hopkins University, Baltimore; Christopher Zalewski, National Institute on Deafness and Other Communication Disorders; Eva Dombi and Brigitte C. Widemann, National Cancer Institute, Bethesda, MD; Dan G. Duda, Alona Muzikansky, Vanessa L. Merker, Elizabeth R. Gerstner, Rakesh K. Jain, and Scott R. Plotkin, Massachusetts General Hospital; and Chris F. Halpin, Massachusetts Eye and Ear Infirmary, Boston, MA
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Aboukais R, Bonne NX, Baroncini M, Zairi F, Schapira S, Vincent C, Lejeune JP. Management of multiple tumors in neurofibromatosis type 2 patients. Neurochirurgie 2015; 64:364-369. [PMID: 26071178 DOI: 10.1016/j.neuchi.2014.11.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 10/15/2014] [Accepted: 11/02/2014] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Neurofibromatosis type 2 is characterized by the presence of bilateral vestibular schwannomas. However, other nervous system tumors may also occur. Therefore, the management of NF2 patients is complex and requires a multidisciplinary discussion in a specialized center. MATERIALS AND METHODS All recent articles concerning tumors other than vestibular schwannoma in NF2 disease were reviewed, using PubMed databases. RESULTS Intracranial meningiomas occur in 50% of NF2 patients, and are often multiple. Surgery remains the main treatment and should be performed in cases of growing tumors. The role of antiangiogenic therapy is currently under evaluation and the role of radiosurgery still remains to be defined in NF2 disease. Spinal tumors occur in about half of NF2 patients. Surgery should be discussed when radiological tumor progression is demonstrated, even if spinal tumors are asymptomatic, in order to preserve neurological function and good quality of life. As regards lower cranial nerve schwannomas, radiosurgery appears to be a more appropriate treatment for growing tumor with a small volume in order to avoid post-operative complications, especially swallowing disorders. Facial nerve schwannomas may appear, on MRI, like vestibular schwannomas. The diagnosis should be suspected when the facial palsy is an early symptom during cerebello-pontine tumor progression. Trigeminal schwannomas are frequent in NF2 disease and fortunately they are often asymptomatic. Among major neurofibromatosis types, peripheral nerve sheath schwannomas are only present in patients with NF2 disease and schwannomatosis. Surgical resection is required when the cutaneous schwannomas is painful or when tumor progression is observed and causes symptoms. CONCLUSION Tumors other than vestibular schwannoma are also associated with a poor prognosis in NF2 patients. Surgery remains the main treatment in most cases. Each treatment decision in NF2 disease requires a complete evaluation of all cranial and spinal locations of the disease in order to establish surgical priorities and strategies.
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Affiliation(s)
- R Aboukais
- Department of Neurosurgery, Lille University Hospital, rue E.-Lainé, 59037 Lille cedex, France.
| | - N-X Bonne
- Department of Otology and Neurotology, Lille University Hospital, rue E.-Lainé, 59037 Lille cedex, France
| | - M Baroncini
- Department of Neurosurgery, Lille University Hospital, rue E.-Lainé, 59037 Lille cedex, France
| | - F Zairi
- Department of Neurosurgery, Lille University Hospital, rue E.-Lainé, 59037 Lille cedex, France
| | - S Schapira
- Department of Otology and Neurotology, Lille University Hospital, rue E.-Lainé, 59037 Lille cedex, France
| | - C Vincent
- Department of Otology and Neurotology, Lille University Hospital, rue E.-Lainé, 59037 Lille cedex, France
| | - J-P Lejeune
- Department of Neurosurgery, Lille University Hospital, rue E.-Lainé, 59037 Lille cedex, France
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