The NIH pediatric/young adult chordoma clinic and natural history study: Making advances in a very rare tumor

BACKGROUND

Chordomas are rare tumors arising from the skull base and spine, with approximately 20 pediatric chordoma cases in the Unitedn States per year. The natural history and optimal treatment of pediatric chordomas, especially poorly differentiated and dedifferentiated subtypes, is incompletely understood. Herein, we present findings from our first National Cancer Institute (NCI) chordoma clinic and a retrospective analysis of published cases of pediatric poorly differentiated chordomas (PDC) and dedifferentiated chordomas (DC).

METHODS

Patients less than 40 years old with chordoma were enrolled on the NCI Natural History and Biospecimens Acquisitions Study for Children and Adults with Rare Solid Tumors protocol (NCT03739827). Chordoma experts reviewed patient records, evaluated patients, and provided treatment recommendations. Patient-reported outcomes, biospecimens, and volumetric tumor analyses were collected. A literature review for pediatric PDC and DC was conducted.

RESULTS

Twelve patients (median age: 14 years) attended the clinic, including four patients with active disease and three patients with PDC responsive to systemic therapy. Consensus treatment, management, and recommendations were provided to patients. Literature review returned 45 pediatric cases of PDC or DC with variable treatments and outcomes.

CONCLUSIONS

A multidisciplinary expert clinic was feasible and successful in improving understanding of pediatric chordoma. While multimodal approaches have all been employed, treatment for PDC has been inconsistent and a recommended standardized treatment approach has not been defined. Centralized efforts, inclusive of specialized chordoma-focused clinics, natural history studies, and prospective analyses will help in the standardization of care for this challenging disease.

Patient reported outcomes in adult patients with neuroendocrine neoplasms

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Background: Neuroendocrine neoplasm (NEN) is a broad term that includes both neuroendocrine tumors (NETs) and neuroendocrine carcinomas (NECs). These rare malignancies most often occur in the gastrointestinal tract, pancreas, lung, adrenal medulla, and thyroid. Clinical symptoms depend upon several factors including tumor location, length of time since diagnosis, secretion of hormones, and tumor growth. Physical symptoms may include fatigue, gastrointestinal complaints, shortness of breath, and fluctuations in blood pressure, weight, and appetite. Patient reported outcomes (PROs) are critical in understanding the clinical spectrum of patients with NENs including their physical and social-emotional response to disease course and treatments. The aim of the current study was to assess physical, social, and emotional domains of PROs amongst a cohort of adult participants with NENs over time. Methods: Patients were enrolled on an ongoing NIH natural history study (NCT03739827). Annual PROs were electronically administered to adult participants (≥18 years) using the PRO Measurement Information System (PROMIS) forms for Anxiety, Depression, Fatigue, Mobility, Upper Extremity, Pain Interference, Cognitive Function, and Emotional Support ( www.nihpromis.org ). PROMIS forms are standardized on a T-Scale with a mean of 50 and a standard deviation of 10. Pain intensity was assessed from 0 (no pain) to 10 (worst pain imaginable) using the Numeric Rating Scale for Pain (NRS) (Wolters, 2013). The Pain Interference Index (PII) was used to assess the impact of pain on daily functioning on a 7-point Likert scale (Martin et al., 2015). Results: A total of 49 out of 85 patients provided completed PROs: 47 NET and 2 NEC. Mean (M) age was 58.8 years and 61.2% of the sample was female. Amongst NET patients (n = 47), primary tumor locations were the small bowel (45.7%), pancreas (21.7%), and lungs (13.0%). Other primary sites (19.6%) included the appendix, rectum, thyroid, kidney, and prostate. 46.8% had metastatic disease. Fatigue was the primary symptom complaint; 34% of NET patients reported fatigue in the moderate to severe range (Mean: 54.1; Standard Deviation: 11.2). Self-perceived mobility (M:47.4; SD: 9.1) and pain interference (M: 51.8; SD: 9.0) were a moderate concern for 19.1% and 17.0% of patients, respectively. At follow-up, 24 patients have returned PROs to date. Fatigue and mobility remained prevalent concerns; 29.1% of patients reported moderate to severe fatigue and 25% reported moderate concerns with mobility. Challenges with upper extremity mobility were endorsed by 20.8% of the sample. Conclusions: Our prospective and comprehensive PRO assessment confirms previously reported fatigue as the most prevalent symptom in patients with NET. Assessment of PROs over time will inform the development of clinical interventions and assessment of their impact on patient quality of life and functioning.

The Fourth International Symposium on Genetic Disorders of the Ras/MAPK pathway

The RASopathies are a group of disorders due to variations of genes associated with the Ras/MAPK pathway. Some of the RASopathies include neurofibromatosis type 1 (NF1), Noonan syndrome, Noonan syndrome with multiple lentigines, cardiofaciocutaneous (CFC) syndrome, Costello syndrome, Legius syndrome, and capillary malformation-arteriovenous malformation (CM-AVM) syndrome. In combination, the RASopathies are a frequent group of genetic disorders. This report summarizes the proceedings of the 4th International Symposium on Genetic Disorders of the Ras/MAPK pathway and highlights gaps in the field. © 2016 Wiley Periodicals, Inc.

Developing therapies for rare tumors: opportunities, challenges and progress

Introduction

Rare tumors account for one fourth of adult tumors; in children, rare tumors represent approximately 15-20% of childhood malignancies, thus accounting for a significant burden of disease. The rarity of these individual diseases creates many challenges, from developing a thorough understanding of the disease pathophysiology, clinical characterization, to the conduct of meaningful clinical trials and eventually the development of effective therapies.

Areas covered

Despite these challenges, substantial advances have been made in recent years including the development of novel clinical trial designs and endpoints including molecularly driven treatment trials that have resulted in approval of novel therapies for rare diseases. Collaboration amongst basic and clinical researchers, patient advocacy groups, industry and regulatory agencies has proven successful in select cases and holds promise for future progress in the treatment of rare tumors. In this review, we will highlight several examples of trials for rare tumors, with a focus on examples from pediatric oncology, where strong, nationwide collaborative groups have existed for many years.

Expert opinion

Future progress in developing therapies for rare tumors will depend not only on continued scientific advances, but also on collaboration between investigators from various disciplines, institutions, regulatory agencies and patient advocacy groups.

Cold plasma selectivity and the possibility of a paradigm shift in cancer therapy

Background:

Plasma is an ionised gas that is typically generated in high-temperature laboratory conditions. However, recent progress in atmospheric plasmas has led to the creation of cold plasmas with ion temperature close to room temperature.

Methods:

Both in-vitro and in-vivo studies revealed that cold plasmas selectively kill cancer cells.

Results:

We show that: (a) cold plasma application selectively eradicates cancer cells in vitro without damaging normal cells; and (b) significantly reduces tumour size in vivo. It is shown that reactive oxygen species metabolism and oxidative stress responsive genes are deregulated.

Conclusion:

The development of cold plasma tumour ablation has the potential of shifting the current paradigm of cancer treatment and enabling the transformation of cancer treatment technologies by utilisation of another state of matter.