Re-Irradiation for Diffuse Intrinsic Pontine Glioma with 3 Gy per Fraction

PURPOSE/OBJECTIVE(S)

Radiotherapy (RT) improves survival in pediatric diffuse intrinsic pontine glioma (DIPG). After recurrence, re-irradiation (re-RT) offers palliation of symptoms and extends life in patients after exhaustion of investigational options and clinical decline. Practice patterns vary in dose and fractionation for re-RT, with majority of reported cases treated with conventional fractionation. Given radiobiologic rationale for hypofractionation in glioblastoma, we hypothesized that treatment with 3 Gy per fraction is safe and effective for re-RT to the brainstem for DIPG.

MATERIALS/METHODS

We identified patients at our institution, ages 1-25, treated with re-RT to the brainstem for DIPG from 2012-2022. Patient demographics, treatment details, and clinical outcomes were reviewed from the medical record. Analysis was completed in R 4.2.2 using Kaplan-Meier method with log-rank test for survival estimates and Fisher's exact test for categorical variables.

RESULTS

A total of 22 patients received re-RT for DIPG. All patients had received 54-59.4 Gy with conventional fractionation at the time of diagnosis. Re-RT dose was initially 20-24 Gy in 2-Gy fractions (n = 6) and continued at 30-36 Gy in 3-Gy fractions (n = 14). Two patients did not complete re-RT due to continued clinical decline from disease progression after 1-2 fractions. Of the 20 that completed re-RT, 11 were female, median age was 5 years (3-14), median interval since initial RT was 8 months (3-20), 12 (60%) received concurrent bevacizumab, and OS from diagnosis was 18 months. Median OS from start of re-RT for patients treated with 3 Gy per fraction was 8.2 months and 13 (93%) clinically improved to taper pre-treatment steroid dose down (n = 9) or off (n = 4) within 2 months after re-RT. For those treated with 2 Gy per fraction, median OS from re-RT was 7.5 months and 3 (75%) improved to taper steroids down (n = 2) or off (n = 1). Overall, 2 patients were not on steroids, 2 were maintained at same steroid dose, and 0 required increase from pre-treatment steroid dose within 6 weeks after re-RT. There was no significant difference in OS from re-RT (p = 0.2) or steroid taper (p = 0.4) between fractionation groups. No patients developed radionecrosis of normal brain tissue.

CONCLUSION

Patients receiving re-RT achieved extended survival comparable to published outcomes and majority experienced clinical improvement to allow steroid taper. While radionecrosis is a reported risk in prior published series, our experience demonstrates the safety and effectiveness of using 3 Gy per fraction to 30-36 Gy for meaningful palliation in this population.

ADC Histogram Analysis of Pediatric Low-Grade Glioma Treated with Selumetinib: A Report from the Pediatric Brain Tumor Consortium

BACKGROUND AND PURPOSE

Selumetinib is a promising MAP (mitogen-activated protein) kinase (MEK) 1/2 inhibitor treatment for pediatric low-grade gliomas. We hypothesized that MR imaging-derived ADC histogram metrics would be associated with survival and response to treatment with selumetinib.

MATERIALS AND METHODS

Children with recurrent, refractory, or progressive pediatric low-grade gliomas who had World Health Organization grade I pilocytic astrocytoma with KIAA1549-BRAF fusion or the BRAF V600E mutation (stratum 1), neurofibromatosis type 1-associated pediatric low-grade gliomas (stratum 3), or sporadic non-neurofibromatosis type 1 optic pathway and hypothalamic glioma (OPHG) (stratum 4) were treated with selumetinib for up to 2 years. Quantitative ADC histogram metrics were analyzed for total and enhancing tumor volumes at baseline and during treatment.

RESULTS

Each stratum comprised 25 patients. Stratum 1 responders showed lower values of SD of baseline ADC_total as well as a larger decrease with time on treatment in ADC_total mean, mode, and median compared with nonresponders. Stratum 3 responders showed a greater longitudinal decrease in ADC_total. In stratum 4, higher baseline ADC_total skewness and kurtosis were associated with shorter progression-free survival. When all 3 strata were combined, responders showed a greater decrease with time in ADC_total mode and median. Compared with sporadic OPHG, neurofibromatosis type 1-associated OPHG had lower values of ADC_total mean, mode, and median as well as ADC_enhancement mean and median and higher values of ADC_total skewness and kurtosis at baseline. The longitudinal decrease in ADC_total median during treatment was significantly greater in sporadic OPHG compared with neurofibromatosis type 1-associated OPHG.

CONCLUSIONS

ADC histogram metrics are associated with progression-free survival and response to treatment with selumetinib in pediatric low-grade gliomas.

Advanced integrated mouse YAC map including BAC framework

Functional characterization of the mouse genome requires the availability of a comprehensive physical map to obtain molecular access to chromosomal regions of interest. Positional cloning remains a crucial way of linking phenotype with particular genes. A key step and frequent stumbling block in positional cloning is making a contig of a genetically defined candidate region. The most efficient first step is isolating YAC (Yeast Artificial Chromosome) clones. A robust, detailed YAC contig map is thus an important tool. Employing Interspersed Repetitive Sequence (IRS)-PCR genomics, we have generated an advanced second-generation YAC contig map of the mouse genome that doubles both the depth of clones and the density of markers available. In addition to the primarily YAC-based map, we located 1942 BAC (Bacterial Artificial Chromosome) clones. This allows us to present for the first time a dense framework of BACs spanning the genome of the mouse, which, for instance, can serve as a nucleus for genomic sequencing. Four large-insert mouse YAC libraries from three different strains are included in our data, and our analysis incorporates the data of Hunter et al. and Nusbaum et al. There is a total of 20,205 markers on the final map, 12,033 from our own data, and a total of 56,093 YACs, of which 44,401 are positive for more than one marker.

Complex probes for high-throughput parallel genetic mapping of genomic mouse BAC clones

We describe a novel approach for the identification and mapping of polymorphic markers. Amplicons are generated by ligation of double-stranded adaptor molecules to genomic DNA cleaved with a restriction enzyme. Using primers that extend beyond the restriction site, reduced-complexity subsets of fragments are generated by PCR. Differences in the composition of complex probes generated from DNA of different strains are revealed through hybridization against high-density filter grids of large-insert genomic clones. Genetic mapping of genomic clones is achieved by hybridizing complex probes derived from backcross animals against the polymorphic clones. The mouse was chosen as a model system to test the feasibility of this technique because of the general availability of backcross resources and genomic libraries. Nevertheless, we would expect the method to be of particular use to generate markers for species that have not yet been extensively studied, because a substantial number of easy-to-use markers can be recruited in a relatively short period of time.

Septicemia and septic shock in pediatric patients: 140 consecutive cases on a pediatric hematology-oncology service

PURPOSE

This report describes the incidence of septic shock in pediatric hematology-oncology patients with positive blood cultures and investigates parameters of potential use in early diagnosis of gram-negative (GN) bacteremia and septic shock.

PATIENTS

In a 12-month period, 140 consecutive episodes of septicemia (135 bacterial and 5 fungal) were seen in 100 patients. The absolute neutrophil count (ANC) was > 500/microl in 89 episodes (65%).

RESULTS

Septic shock developed in patients with positive blood cultures with an overall incidence of approximately 19%. Of the 12 bacteremic patients who required transfer to the intensive care unit, 83% had a GN isolate recovered. The incidence of septic shock was not significantly lower in the group of patients with ANC > 500/microl. Low serum bicarbonate correlated with GN infection in patients with bacteremia.

CONCLUSIONS

GN organisms were the major cause of septic shock in a group of pediatric hematology-oncology patients with positive blood cultures although they were recovered less frequently than gram-positive organisms. In our study, non-neutropenic patients with indwelling catheters were at approximately the same risk for GN shock as neutropenic patients. Monitoring blood carbon dioxide content may be useful in the early diagnosis of GN infection.

Minimal truncation of the c-myb gene product in rapid-onset B-cell lymphoma

Oncogenic activation of c-myb by insertional mutagenesis has been implicated in rapid-onset B-cell lymphomas induced by the nonacute avian leukosis virus EU-8. In these tumors, proviruses are integrated either upstream of the c-myb coding region or within the first intron of c-myb. Tumors with either type of integration contained identical chimeric mRNAs in which the viral 5' splice site was juxtaposed to the 3' splice site of c-myb exon 2 and myb exon 1 was eliminated. Both classes of integrations generated truncated Myb proteins that were indistinguishable by Western analysis. In contrast to most other examples of c-myb activation, the truncation consisted of only 20 N-terminal amino acids and did not disrupt either the DNA binding domain near the N terminus or the negative regulatory domain near the C terminus of Myb. The significance of the 20-amino-acid Myb truncation to tumorigenesis was tested by infection of chicken embryos with retroviral vectors expressing different myb gene products. While virus expressing either wild-type c-myb or c-myb mutated at the N-terminal casein kinase II sites was only weakly oncogenic at 10 weeks, the minimally truncated myb virus induced a high incidence of rapid-onset tumors, including B-cell lymphomas, sarcomas, and adenocarcinomas.

Genetic determinant of rapid-onset B-cell lymphoma by avian leukosis virus

Infection of 10 day-old chicken embryos with the recombinant avian leukosis virus (ALV) EU-8 induces a high incidence of rapid-onset B-cell lymphoma by insertional activation of the c-myb gene. LR-9, a related ALV with differences from EU-8 in the gag and pol genes, induces rapid-onset lymphoma at only a low incidence. To localize the viral determinant(s) responsible for this biologic difference, we constructed and tested a series of reciprocal chimeras between EU-8 and LR-9 ALVs. The ability to induce rapid-onset lymphoma efficiently was localized to a 925-nucleotide (nt) region of the EU-8 gag gene. Sequence analysis of the region revealed a 42-nt deletion in EU-8 relative to LR-9, as well as some single-nucleotide changes. A mutant virus, delta LR-9, constructed by deleting these 42 nt from LR-9, also induced rapid-onset lymphoma at a high frequency, confirming the biologic significance of this deletion. This deletion removed nt 735 to 776, which lies within a cis-acting RNA element that negatively regulates splicing (NRS). The deletion was shown to cause an increase in splicing efficiency, which may lead to increased production of a truncated myb gene product from an ALV-myb readthrough RNA.

Rapid induction of B-cell lymphomas by avian leukosis virus

Avian leukosis viruses (ALVs) that induce rapid B-cell lymphomas integrate into the c-myb gene and produce an ALV-myb read-through RNA, which is spliced to produce a truncated Myb protein. The genetic determinants of such recombinant ALVs have been mapped to a 42-nt deletion within the gag gene. This deletion increases splicing efficiency since it is located within a negative regulator of splicing. We propose that the deletion leads to increased production of Myb protein by increasing splicing of an ALV-myb pre-mRNA.