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Quandt Z, Kim S, Villanueva-Meyer J, Coupe C, Tyrrell JB, Bluestone JA, Anderson MS, Masharani U. SUN-298 Spectrum of Imaging in Immune Checkpoint Inhibitor Induced Hypophysitis. J Endocr Soc 2020. [PMCID: PMC7207307 DOI: 10.1210/jendso/bvaa046.1584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background: Hypophysitis (HP) is a known immune related adverse event of immune checkpoint inhibitors (CPIs), commonly associated with CTLA-4 inhibitors and rarely with PD-1/PD-L1 inhibitors. Prior studies of MRIs at HP diagnosis noted pituitary enlargement with resolution within a few weeks. In this study, we examine MRI changes in patients with CPI-induced HP. Methods: Subjects with biochemical evidence of central hypothyroidism or central adrenal insufficiency and MRIs were reviewed by endocrinology and neuroradiology. MRIs were classified relative to HP diagnosis: baseline (at least 21 days prior), diagnosis (within 21 days), and follow up (over 21 days). Patient characteristics included age at CPI initiation, sex, race/ethnicity, personal and family history of autoimmunity, type of cancer and CPI. Results: Twenty-six subjects met the inclusion criteria. The mean age was 59 years; 62% were male and 86% were non-Hispanic white. Nineteen percent had a personal history and 31% a family history of autoimmunity. Fifty percent had melanoma. At HP diagnosis, 46% were on PD-1/PD-L1 inhibitors, 42% were on combination PD-1/CTLA-4 inhibitors and 12% were on CTLA-4 inhibitors. Median time from CPI initiation to HP diagnosis was 95 days. Time to HP was shorter on a CTLA-4 inhibitor combination or monotherapy (median 82 days) compared to a PD-1/PD-L1 inhibitor monotherapy (median 220 days; Wilcoxon rank sum, p <0.01). Central adrenal insufficiency was present in all patients not yet on steroids. Central hypothyroidism was common (10/19) in those without primary thyroid disease and was not associated with type of CPI (Fisher’s exact, p=0.18). Thirteen subjects had baseline MRIs, 18 had MRIs at HP diagnosis and 13 had MRIs in the follow up period. Baseline MRIs were normal in 12/13; one subject had an enlarged pituitary. At diagnosis, 10 had an enlarged pituitary, 7 a normal pituitary and 1 a partially empty sella. CTLA-4 inhibitor exposure was associated with pituitary enlargement at diagnosis: 9/11 compared to 1/7 on PD-1/PD-L1 inhibitor (Fisher’s exact, p <0.04). Of the subjects who had follow-up MRIs, 3 had an enlarged pituitary, 7 a normal pituitary and 3 a partially empty sella. Follow up imaging did not differ between treatment types (Fisher’s exact, p >0.05). Timing of MRI was significantly associated with pituitary appearance (Fisher’s exact, p <0.01). Conclusion: The MRI appearance of HP presents as a spectrum, from a partially empty sella, normal pituitary to an enlarged pituitary. HP diagnosed in the setting of CTLA-4 inhibitor treatment occurs earlier and is more likely to induce an enlarged pituitary gland compared to PD-1/PD-L1 monotherapy, which occurs later and is associated with a normal appearing MRI at diagnosis. This suggests that the pathogenesis of HP following CPI exposure may vary depending on the type of CPI.
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Susko M, Vasudevan H, Magill S, Calixto-Hope L, Villanueva-Meyer J, Nakamura J, Ann Oberheim-Bush N, Theodosopoulos P, Solomon D, Braunstein S, Sneed P, McDermott M, Raleigh D. MNGI-04. PATTERNS OF FAILURE AND FACTORS INFLUENCING LOCAL RECURRENCE OF MENINGIOMA TREATED WITH POSTOPERATIVE RADIATION THERAPY. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Factors associated with meningioma recurrence after postoperative radiotherapy are poorly understood, and the optimal postoperative radiotherapy target delineation for meningioma is unknown. The objective of this study was to identify factors influencing meningioma recurrence after postoperative radiotherapy to inform patient selection and treatment design.
METHODS
Medical records were retrospectively reviewed for patients who underwent meningioma resection at a single institution between 1991 and 2015. Patients with sufficient tumor tissue for histologic classification and who received postoperative radiation therapy with external beam radiotherapy (EBRT), stereotactic radiosurgery (SRS) or brachytherapy, were included. Local freedom from recurrence (LFFR) was analyzed according to tumor and treatment characteristics using the Kaplan Meier method.
RESULTS
We identified 86 patients with 96 meningiomas who met inclusion criteria. Nineteen meningiomas (20%) were WHO grade I, 56 (58%) were grade II and 21 (22%) were grade III. Forty-one meningiomas (43%) were recurrent, and 55 (57%) were de novo. The postoperative radiotherapy modality was EBRT for 58 patients (60%), SRS for 20 (21%) patients and brachytherapy for 18 (19%) patients. With a median follow up of 4.3 years (IQR 2.1–8.8 years), there were 48 (50%) local failures that occurred a median of 17 months after immediate prior resection (IQR 9–33 months). WHO grade II/III and recurrent meningiomas had worse LFFR (p< 0.001). The 5-year LFFR was 53% after EBRT (95% CI 41–69%), 53% after SRS (95% CI 34–84%) and 15% after brachytherapy (95% CI 3–74%), although meningiomas that were treated with brachytherapy were significantly more likely to have received prior EBRT or SRS (86% versus 29%, p< 0.001).
CONCLUSIONS
These data provide a foundation for understanding patterns of meningioma recurrence after postoperative radiotherapy. Ongoing analyses aim to quantify the relationships between postoperative radiotherapy dose, target delineation and local control of meningioma.
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Villanueva-Meyer J, Autry A, Gordon J, Chen HY, Lafontaine M, Chang S, Xu D, Larson P, Vigneron D, Li Y. NIMG-57. SERIAL HYPERPOLARIZED 13C PYRUVATE AND 1H METABOLIC IMAGING IN RECURRENT HIGH-GRADE GLIOMA. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
INTRODUCTION
Hyperpolarized (HP) 13C MRI is a novel metabolic imaging that allows for real time in vivo probing of pathway-specific metabolic processes relevant to gliomas. The first human brain application reports were published recently. In this study, we characterized longitudinal dynamic and static brain metabolism changes from serial HP 13C and 1H metabolic imaging in a patient with multiply recurrent glioma.
METHODS
Eight dynamic HP 13C imaging, 1H MRI and MRSI examinations were acquired over a period of 15 months in a patient with multiply recurrent glioma that underwent malignant transformation. The patient was imaged after initial tumor debulking, after chemoradiotherapy, at first recurrence, after re-irradiation and anti-angiogentic therapy, and at second recurrence. Ratios of pyruvate-to-lactate and pyruvate-to-bicarbonate were calculated from HP 13C imaging and choline-to-NAA index (CNI) was derived from 1H MRSI. RESULTS/
DISCUSSION
Successful therapies are usually associated with a drop in pyruvate-to-lactate conversion, mediated by different mechanisms from various treatments. We identified three key findings over repeat HP 13C MRIs: 1) a marked response to therapy with a reduction in pyruvate-to-lactate conversion corresponding to associated imaging response to therapy at the primary site of disease. Following chemoradiotherapy, the volume of T2 hyperintensity decreased from 28.21cc to 15.29 cc, and the volume of metabolic abnormality (CNI >3) decreased from 27.84 cc to 10.36 cc. 2) increasing pyruvate-to-lactate conversion in a region of recurrence before morphologic signal abnormality, and 3) a reduction in pyruvate-to-lactate conversion in a recurrent lesion following anti-angiogenic therapy.
CONCLUSION
Here we show that one can reliably image glioma patients using HP 13C MRI alongside standard of care morphologic and physiologic MRI including diffusion, perfusion, and 1H MRSI. Serial HP 13C MRI can be performed in the neuro-oncologic clinical setting and pyruvate-to-lactate metabolism may be useful to monitor treatment response.
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79
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Luks T, Li Y, Alcaide-Leon P, Lafontaine M, Jakary A, Chang S, Villanueva-Meyer J. NIMG-33. TUMOR GROWTH AND MRI TRAJECTORIES IN GRADE II AND III GLIOMA. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
INTRODUCTION
The purpose of this work was to investigate the trajectory of tumor growth and multiparametric MRI characteristics in grade II and III gliomas leading up to the onset of new contrast enhancement or the expansion of FLAIR signal abnormality.
METHODS
Fifty-one grade II and III glioma patients (39 grade II, 12 grade III) underwent serial MR imaging at standard of care timepoints. Multiparametric MR imaging was performed and maps of the apparent diffusion coefficient (ADC) and percentiles (10th, 50th, 90th) from histograms of normalized signal intensities were calculated. Regions of Interest (ROIs) were defined for the entire T2/FLAIR lesion, and when present, the contrast-enhancing (CE) lesion. Serial imaging parameters were acquired for each of these ROIs. Linear rates of change were calculated for CE volume, T2/FLAIR volume, normalized T2 FSE intensity within the FLAIR volume, normalized T2/FLAIR intensity within the FLAIR volume, and normalized median, 10th percentile and 90th% ADC values within the FLAIR volume.
RESULTS
Thirty-nine patients progressed while on study (7 by CE growth, 32 by T2/FLAIR growth), and 12 patients remained stable, according to RANO criteria. In progressed patients, T2/FLAIR volume and T2 FSE intensity increased over time to progression. The rate of T2/FLAIR volume growth was significantly greater in progressed than stable patients (mean = .42, -.07 mL/week, respectively). The rate of normalized T2/FLAIR signal intensity change was also significantly different in progressed than stable patients (mean = -.002, .0035 mL/week). There were no significant interactions with grade or molecular subgroup by WHO criteria. Additionally, 44% (17/39) of progressed patients by RANO criteria were characterized as having stable disease by radiologic assessment.
CONCLUSION
Tumor volumes remain the gold standard for response assessment in lower grade gliomas and there exists a need for standardized measurement as visual assessment for determination of tumor status is inconsistent.
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80
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Alcaide-Leon P, Cluceru J, Luks T, Lupo J, Villanueva-Meyer J. NIMG-51. THE CENTRALLY RESTRICTED DIFFUSION SIGN FOR DIFFERENTIATION BETWEEN TREATMENT-RELATED LESIONS AND TUMOR PROGRESSION IN GLIOMA PATIENTS: A VALIDATION STUDY. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
The aim of the study was to compare the diagnostic accuracy of different diffusion patterns for differentiation between treatment-related lesions and true tumor progression in patients with suspected glioma recurrence.
METHODS
A retrospective analysis of a prospective cohort was conducted. The images of 240 consecutive patients who underwent surgery for suspected glioma recurrence were reviewed for potential inclusion. Exclusion criteria were lack of a ring-enhancing lesion and presence of susceptibility artifact. Final diagnosis was established upon review of histopathology reports. Lesions showing treatment-related changes and less than 25% of viable tumor were considered treatment-related lesions. More than 25% of viable tumor was considered recurrent tumor. A neuroradiologist, blinded to the diagnosis, evaluated the diffusion patterns on preoperative MRI. ROC curve analysis was performed.
RESULTS
One hundred and ten patients were included (26 with treatment-related lesions and 84 with tumor progression). Of 110, 35 showed no reduced diffusion. Fifty patients had reduced diffusion in the solid lesion component (84%, recurrent tumor and 16%, treatment-related lesions). Twenty-five patients showed reduced diffusion within the central necrosis (48%, recurrent tumor and 52%, treatment-related lesions). Most cases with reduced diffusion in the central necrotic region showed mixed pathology with concurrent treatment effect and viable tumor. The AUC for the combined diffusion pattern (reduced diffusion in the solid lesion component vs in the necrotic region) was 0.68 (95%CI=0.55–0.81). The AUC for the traditional diffusion approach (reduced diffusion in the solid lesion component vs no reduced diffusion) was 0.59 (95%CI=0.49–070). No significant differences were found in AUC (p=0.3).
CONCLUSION
Although the existence of centrally reduced diffusion seems to be associated with the presence of treatment effect, it does not significantly increase the diagnostic accuracy of the traditional diffusion evaluation approach. This is most likely related to the high incidence of concurrent recurrent tumor and treatment effect.
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81
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Liu J, Jakary A, Lafontaine M, Wang Y, Xu D, Saloner D, Butowski N, Hess C, Villanueva-Meyer J, Chang S, Lupo J. NIMG-45. 3D SINGLE-SCAN FOR MULTI-CONTRAST-WEIGHTED MRI FOR LESION DETECTION IN PATIENTS WITH GLIOMAS. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
INTRODUCTION
Multi-contrast-weighted (MCW) MRI allows derivation of T1-weighted, T2-weighted, and T2-FLAIR images and their parametric maps. Under current practice, these high-resolution 3D MR images are acquired separately with a total scan time is approximately 30 minutes. The goal of this study was to develop a novel sequence and processing strategy for MCW MRI and lesion detection of gliomas with 1mm isotropic resolution in 6 minutes, which can significantly improve clinical imaging workflow. The proposed whole brain, single-scan method enables the generation of segmented tumor regions that correspond the hyperintense lesion on T2-weighted or T2-FLAIR images (T2L).
METHODS
Our strategy involves using a highly accelerated 3D MRI sequence to achieve whole brain, MCW images that can be jointly segmented with modified k-means clustering. Six patients with enhancing gliomas were scanned with this sequence before the injection of gadolinium, 4 of which also received a repeat scan post-gadolinium. Our automatic segmentation of the T2L and manual definition of the contrast-enhancing lesion (CEL) was compared against manually segmented lesions drawn from conventional anatomical imaging.
RESULTS
Whole-brain MCW MRI was achieved with 1mm isotropic resolution in 6 mins. Grey-matter, white-matter, CSF, and the T2L could be automatically segmented with our clustering method. The resulting automatically-segmented T2L volume was not significantly different between our new sequence and clinically defined regions (average Dice Coefficient=0.81(+/-0.05); p=0.95).
CONCLUSIONS
Our novel, 6-minute scan and processing strategy was able to generate MCW anatomical images and automatically segment grey-matter, white-matter, and T2L volumes that were similar to manual segmentation of conventional anatomical imaging. We are currently extending the automatic segmentation to the CEL. This approach has the potential to improve clinical workflow by allowing time for therapy-specific advanced imaging and providing a noninvasive tool for monitoring tumor evolution. Validation is currently being performed in a larger cohort.
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John Liu S, Vasudevan H, Pekmezci M, Choudhury A, Lien B, Breshears J, Swaney D, Magill S, Lang U, Chen W, Gopinath C, Castro M, Villanueva-Meyer J, Braunstein S, Sneed P, Lim D, Perry A, Krogran N, McDermott M, Berger M, Theodosopoulos P, Raleigh D. GENE-37. VESTIBULAR SCHWANNOMA IS COMPRISED OF NEURAL CREST AND IMMUNE SUBGROUPS. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Vestibular schwannomas (VS) are tumors arising from cranial nerve Schwann cells and show variable outcomes after treatment, including oscillation in size for many years after radiosurgery. To understand the unique biology of VS, we performed multiplatform molecular profiling to develop a single cell atlas of VS and reveal that VS exists on a molecular axis defined by neural crest and immune genes.
METHODS
Sixty-six sporadic VS with available tissue for molecular profiling from 59 consecutive patients at a single institution were included. 850K DNA methylation arrays and RNA sequencing were used to profile both primary (76%) and recurrent (24%) tumors. Single nuclei RNA sequencing of 7 tumors and single cell RNA sequencing of 3 tumors and cell lines were used to define the cellular composition of VS and heterogeneous changes in molecular programs following irradiation. Molecular subtyping was performed by hierarchical clustering of differentially-methylated DNA probes and validated using transcriptomic data. Mechanistic experiments were performed using cultured human schwann cells and human vestibular schwannoma cells, confocal microscopy, CRISPR interference, proteomic mass spectrometry and lymphocyte migration assays.
RESULTS
Multiplatform genomic profiling and machine learning revealed that VS is comprised of two distinct molecular subtypes characterized by heterogeneous cell populations. Neural crest enriched VS express primary cilia and are associated with misactivation of the Hedgehog pathway. Consistently, we find that the Hedgehog pathway antagonist vismodegib blocks the growth of human Schwann cells. Irradiation epigenetically reprograms tumors and cell lines to reduce ciliary length, attenuate Hedgehog signaling, activate senescence pathways, and express cytokines and apolipoproteins that recruit lymphocytes and macrophages to immune enriched VS.
CONCLUSIONS
Our data reveal novel molecular subtypes of VS and establish a framework for understanding how irradiation modifies the epigenome and tumor microenvironment.
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83
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Cluceru J, Nelson S, Molinaro A, Alcaide-Leon P, Olson M, Berger M, Chang S, Phillips J, Nair D, Wen Q, Villanueva-Meyer J, Chunduru P, Cha S, Lupo J. NIMG-42. RECURRENT TUMOR AND TREATMENT-INDUCED EFFECTS HAVE DIFFERENT MR SIGNATURES IN CONTRAST ENHANCING AND NON-ENHANCING LESIONS OF HIGH-GRADE GLIOMAS. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
INTRODUCTION
It is estimated that 25 to 35% of patients experience treatment-induced effects that can mimic recurrent high-grade gliomas. This diagnostic challenge is complicated by the coexistence of treatment-related changes and recurrent tumor within the same lesion which limits the accuracy of classification based on summary metrics of multi-parametric MRI. This study aimed to determine whether different MR features were relevant for distinguishing pathological features of recurrent tumor from the effects of treatment in the contrast enhancing and non-enhancing lesions of recurrent high-grade gliomas.
METHODS
Leveraging our unique dataset of image-guided tissue samples that directly maps pathology to MR characteristics, we analyzed 291 tissue samples (222 recurrent tumor; 69 treatment effect) with known coordinates on imaging from 139 patients that underwent preoperative 3T MRI and surgery for a suspected high-grade recurrent tumor. 8 MR parameter values from perfusion-weighted, diffusion-weighted, and MR spectroscopic imaging at each tissue sample location were tested for association with histopathological outcome using univariate and multivariate generalized estimating equation models for enhancing and non-enhancing tissue samples. Individual cutoff values were determined and evaluated using ROC-Curve analysis with 5-fold cross-validation.
RESULTS
In tissue samples obtained from contrast-enhancing lesions, elevated relative cerebral blood volume (rCBV) was significantly associated with the presence of recurrent tumor (p< 0.03), while increases in normalized choline (nCho) and choline-to-NAA index (CNI) were significantly associated with the presence of recurrent tumor in non-enhancing tissue samples (p< 0.008). Cutoff values of 1.6(rCBV), 2.7(CNI), and 2.1(nCho) had the highest performance.
CONCLUSION
Our results confirm the utility of rCBV in distinguishing the effects of treatment from recurrent tumor within the contrast enhancing lesion. We report a novel finding that metabolic parameters can differentiate recurrent tumor from treatment-related changes in the non-enhancing lesion of high-grade gliomas. These results will help improve future management of patients with suspected recurrence.
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84
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Magill S, Vasudevan H, Seo K, John Liu S, Hilz S, Villanueva-Meyer J, Choudhury A, Demaree B, Lim D, Braunstein S, Ann Oberheim-Bush N, Ullian E, Aghi M, Theodosopoulos P, Sneed P, Abate A, Berger M, McDermott M, Costello J, Raleigh D. TMOD-27. A NEURAL CREST CELL SUBPOPULATION UNDERLIES INTRATUMOR HETEROGENEITY IN MENINGIOMA. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.1126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Meningiomas are the most common primary intracranial tumor, and high grade meningiomas are resistant to most cancer therapies. Intratumor heterogeneity is a recognized source of resistance to treatment in numerous malignancies. Thus, we hypothesized that investigating molecular heterogeneity in meningiomas would elucidate biologic drivers and shed light on tumor evolution and mechanisms of resistance.
METHODS
We collected 86 spatially distinct samples at the time of resection from 13 meningiomas. Seven meningiomas were WHO grade I (46 samples), three were grade II (22 samples), and three were grade III (18 samples). Seven meningiomas were sampled at the time of salvage surgery (48 samples), and 6 were sampled at the time of initial diagnosis (38 samples). We performed multiplatform molecular profiling of these samples to identify drivers of intratumor heterogeneity, and validated our results using meningioma cells co-cultured with human cerebral organoids and RNA sequencing of paired primary and recurrent meningiomas.
RESULTS
Using bulk RNA sequencing, DNA methylation profiling and phylogenetic analysis of spatially distinct samples, we discovered significant transcriptomic, epigenomic and genomic heterogeneity in meningioma. In particular, we identified chromosomal structural alterations and differences in immune and neuronal signaling that underlie clonal evolution in high grade tumors. Using MRI-stratified bulk RNA sequencing, single nuclear RNA sequencing, RNA sequencing of paired primary and recurrent meningiomas, and live cell microscopy and single cell RNA sequencing of meningioma cells in co-culture with human cerebral organoids, we revealed a rare meningioma cell subpopulation with strong transcriptional concordance to the neural crest, a multipotent embryonic tissue that forms the meninges in development.
CONCLUSIONS
These data suggest that misactivation of a developmental cell population underlies intratumor heterogeneity in meningioma and that expression of neural crest and immediate early genes are an important step in meningeal oncogenesis.
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85
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Ramani B, Villanueva-Meyer J, Glastonbury C, Meram E, Walsh K, Taylor J, van Ziffle J, Onodera C, Grenert J, Bollen A, Perry A, Tihan T, Solomon D, Pekmezci M. PATH-66. THE GENOMIC LANDSCAPE OF SPINAL CORD EPENDYMOMA. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
INTRODUCTION
Ependymomas are seen throughout the neural axis but spinal cord is most common in adults. A subset arises in the setting of neurofibromatosis 2, whereas most are sporadic, potentially with somatic NF2 inactivation. The genetic drivers in NF2 wildtype tumors are unknown, as is the spectrum of cooperating genetic alterations.
METHODS
We performed targeted next-generation sequencing (NGS) to assess mutations, rearrangements, and chromosomal copy number alterations in 46 adult spinal cord ependymomas.
RESULTS
The 24 females and 22 males ranged from 20–73 (median 46) years of age. Tumors were in the cervical (n=24), thoracic (n=12), and lumbar (n=10) spinal cord. Nine tumors (20%) harbored truncating NF2 mutations with loss of the remaining wildtype allele, with frequent monosomy 13q. Thirteen NF2-wildtype tumors (28%) showed monosomy 22q with frequent monosomy 13q and trisomy 7, 9, and 12. Seventeen tumors (37%) carried a near-tetraploid genome, likely due to genomic reduplication with frequent preservation of diploidy in chromosomes 13q (77%), 14q (88%), 21q (53%) and 22q (65%). Remaining cases did not show a recurrent pattern, but one harbored focal high-level MYCN amplification. Three of the six recurrences were seen in the last subgroup; however, there was no significant difference for progression-free survival between four subgroups. None of the NF2-mutant tumors were in lumbar spinal cord, but there was no difference for tumor location or patient age between four subgroups.
DISCUSSION
Biallelic NF2 mutational inactivation characterizes only a subset of spinal cord ependymomas, and MYCN amplification is likely a genetic driver in a small subset of NF2 wildtype cases. The high frequency of chromosome 22q loss even in NF2-wildtype tumors raises the possibility of cryptic alterations in the NF2 gene not detected by our panel, or perhaps implicates the presence of another as yet unidentified tumor suppressor gene on chromosome 22q.
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86
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Autry A, Gordon J, Chen HY, Lafontaine M, Villanueva-Meyer J, Chang S, Xu D, Larson P, Vigneron D, Li Y. CBMT-26. SERIAL CHARACTERIZATION OF HYPERPOLARIZED [1-13C]PYRUVATE METABOLISM IN PATIENTS WITH GLIOMA AND THE INFLUENCE OF BEVACIZUMAB. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Treatment-related changes often mimic or mask tumor on standard anatomic imaging, making it difficult to monitor disease recurrence. Hyperpolarized (HP) carbon-13 MR imaging allows for real-time non-invasive measurement of metabolism, which may improve patient surveillance. Here, we focused on characterizing serial HP scans in patients undergoing treatment compared to healthy controls. Serial dynamic HP C-13 MRI scans were performed on 5 patients with recurrent glioma (22 total) and 3 healthy controls (4 total) using an echo-planar imaging sequence (2.88-8cm3 spatial resolution, 3s temporal resolution, 60s), following injection of 0.43mL/kg of 250mM HP [1-13C]pyruvate. Apparent rate constants were modeled for enzymatic conversion of pyruvate-to-lactate (kPL) via cytosolic lactate dehydrogenase and pyruvate-to-bicarbonate (kPB) via mitochondrial pyruvate dehydrogenase and carbonic anhydrase. Regions of interest included normal-appearing white matter (NAWM) and T2-hyperintense lesions (T2L), which were segmented from H-1 MR images and then aligned to the HP data. Carbon voxels containing >30% of NAWM or T2L were included in the analysis. Healthy controls demonstrated consistent kPL and kPB values over 4 scans in NAWM with SD/Mean of 5% and 12%, respectively. Compared to the median kPL-NAWM of 0.022s-1 in controls, the 5 patients had median serial kPL-NAWM values of 0.023, 0.023, 0.023, 0.029, and 0.015s-1, and mean serial ratios of kPL between T2L and NAWM (kPL-T2L/kPL-NAWM) of 1.22, 1.27, 1.05, 1.32, and 1.37s-1, indicating higher values in putative tumor. Median kPB-NAWM in controls was 0.004s-1 and ranged in patients 0.003-0.006s-1. Two patients with >4 serial scans, showed consistent kPL-NAWM over standard-of-care treatment and elevated kPL-T2L within new lesions, but up to 85% increase in kPL-NAWM with bevacizumab, which may be attributed to reduced BBB permeability. Stable patients generally demonstrated consistent kPL-T2L values that were lower compared to progressive patients. Future studies will include multi-parametric 1H imaging analysis in a larger patient population.
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87
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Zhang M, Lazar A, Chan J, Xu C, Anderson A, Villanueva-Meyer J, McDermott M, Melisko M, Sneed P, Morin O, Braunstein S. CMET-35. COMPETING RISKS ANALYSIS OF FACTORS INFLUENCING DEVELOPMENT OF LEPTOMENINGEAL METASTASIS IN BREAST CANCER PATIENTS RECEIVING STEREOTACTIC RADIOSURGERY FOR LIMITED BRAIN METASTASES. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Leptomeningeal metastasis (LM) is a late stage manifestation of advanced breast cancer frequently managed with whole brain radiotherapy (WBRT) and/or intrathecal chemotherapy. A subset of breast cancer patients who undergo stereotactic radiosurgery (SRS) for limited brain metastases (BM) ultimately develop LM. We hypothesized that this subset of high-risk patients may be identified by patient, disease, and/or treatment parameters. Clinical records from 133 breast cancer patients from a single institution who underwent SRS for BM between February 2010 and March 2018 were retrospectively analyzed. Variables including histopathology, BM features, systemic disease burden, and prior treatments were analyzed. Cumulative incidence rates were estimated with death as a competing risk. Dichotomous variable cutoffs were based on the 75th percentile value. In our cohort, 27 (20.3%) patients ultimately developed LM. With a median follow up of 21.2 months after diagnosis of BM, the actuarial rate of LM at 24 months was 15.2% (95% CI, 8.7%-21.7%). Median OS after diagnosis of LM was 7.0 (95% CI, 3.1–15.4) months. There was significantly increased risk of LM with ≥9 vs < 9 BM at BM diagnosis (28.1% vs 10.8% [24-month actuarial risk], subdistribution HR 2.4, p=0.027), and ≥11 vs < 11 cumulative number of BM treated (25.7% vs 11.7% [24-month actuarial risk], subdistribution HR 2.7, p=0.01). Variables not significantly associated with the risk of LM included tumor receptor status (ER, PR, HER2, triple negative), graded prognostic assessment, KPS, extracranial metastases, total BM volume, prior WBRT, or prior surgical resection. Time intervals between SRS treatments immediately preceding LM diagnosis was not significantly different from other time intervals. In conclusion, patients with a larger number of brain metastases at BM diagnosis (≥9) or cumulatively treated (≥11) appear to be at higher risk of developing LM and may benefit from stronger consideration of WBRT, intrathecal chemotherapy, and/or brain-penetrating systemic therapy.
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Liu S, Vasudevan H, Breshears J, Pekmezci M, Villanueva-Meyer J, Lang U, Chen W, Choudhury A, Magill S, Braunstein S, Gopinath C, Nakamura J, Tward A, Sneed P, Perry A, McDermott M, Theodosopoulos P, Raleigh D. Multiplatform Molecular Profiling of Vestibular Schwannoma Reveals Immune Enrichment after Radiosurgery and a Methylation-Based Predictor of Recurrence. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.2415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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89
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Villanueva-Meyer J, Diaz A, Felix A, Braunstein S. RADI-43. ARTERIAL SPIN LABELING PERFUSION MR IMAGING FOR DIFFERENTIATION BETWEEN TUMOR RECURRENCE AND PSEUDOPROGRESSION IN INTRACRANIAL METASTASES FOLLOWING STEREOTACTIC RADIOSURGERY. Neurooncol Adv 2019. [PMCID: PMC7213128 DOI: 10.1093/noajnl/vdz014.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Stereotactic radiosurgery (SRS) is a standard adjuvant treatment for patients with limited intracranial metastatic disease. Transient growth, increased peritumoral edema, and inflammation can be seen in up to a third of these cases following SRS. Unfortunately, this pseudoprogression is often indistinguishable from true progression by morphologic MR imaging thereby complicating patient management. The purpose of this study was to evaluate whether arterial spin labeling (ASL) perfusion can differentiate tumor recurrence from pseudoprogression after SRS. We reviewed patients treated between 2013 and 2018 and identified 24 patients with 43 intracranial metastases who had imaging suggesting progression following SRS and also had ASL perfusion acquired at time of MR imaging. Median imaging follow-up was 11 months (range 3–64 months). Outcome of tumor recurrence or pseudoprogression was confirmed in each case by pathology or subsequent MR imaging. 25 (58%) lesions were classified as tumor recurrence (13, 52% by pathology), while 18 (42%) were classified as pseudoprogression (3, 18% by pathology). ASL perfusion values (normalized cerebral blood flow) were higher in patients with tumor progression (2.1 vs 1.1 ml/min/100g, p=0.003). No significant difference was observed between histology, time from radiotherapy, marginal dose, volume of lesion, or instances of repeat SRS treatments between groups. In conclusion, elevated blood flow by ASL perfusion was closely associated with the diagnosis of tumor recurrence after SRS. Patients with intracranial metastases undergoing SRS may benefit from this short non-contrast sequence at time of follow-up MR imaging.
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90
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Zhang M, Chan J, Xu C, Anderson A, Lazar A, Villanueva-Meyer J, McDermott M, Melisko M, Sneed P, Morin O, Braunstein S. LPTO-05. FACTORS INFLUENCING RISK OF LEPTOMENINGEAL METASTASIS IN BREAST CANCER PATIENTS RECEIVING STEREOTACTIC RADIOSURGERY FOR LIMITED BRAIN METASTASES. Neurooncol Adv 2019. [PMCID: PMC7213244 DOI: 10.1093/noajnl/vdz014.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Leptomeningeal metastasis (LM) is a late stage manifestation of advanced breast cancer frequently managed with whole brain radiotherapy (WBRT) and/or intrathecal chemotherapy. A subset of breast cancer patients who undergo stereotactic radiosurgery (SRS) for limited brain metastases (BM) ultimately develop LM. We hypothesized that this subset of high-risk patients may be identified by patient, disease, and/or treatment parameters. Clinical records from 135 consecutive breast cancer patients from a single institution who underwent SRS for BM between February 2010 and March 2018 were retrospectively analyzed. Diagnosis of LM was determined radiographically and/or by cerebrospinal fluid analysis. Demographic data, clinical history, histopathology, BM features, systemic disease burden, and prior treatments were analyzed with Cox proportional hazards regression. In our cohort, 22 (16.3%) patients ultimately developed LM. With a median follow up of 18.9 (IQR 8.6–38.7) months after diagnosis of BM, the actuarial rate of LM at 18 months was 14.5% (95% CI, 7.0–21.4%). Median OS after diagnosis of LM was 7.3 (95% CI, 3.1–15.4) months. There was significantly increased risk of LM with ≥5 vs < 5 BM at BM diagnosis (33.0% vs 7.5% [18-month actuarial risk], HR 3.5, p=0.0045), and ≥7 vs < 7 cumulative number of BM treated (21.9% vs 11.1% [18-month actuarial risk], HR 2.7, p=0.023). Variables not significantly associated with the risk of LM included tumor receptor status (ER, PR, HER2, triple negative), graded prognostic assessment, KPS, extracranial metastases, total BM volume, prior WBRT, or prior surgical resection. In conclusion, patients with a larger number of brain metastases at BM diagnosis or ≥7 cumulative number of brain metastases treated appear to be at higher risk of developing LM and may benefit from stronger consideration of WBRT, intrathecal chemotherapy, and/or brain-penetrating systemic therapy.
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91
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Liu SJ, Magill S, Vasudevan H, Hilz S, Daggubati V, Villanueva-Meyer J, Choudhury A, Ferris S, Orr B, Bush NAO, Bollen A, McDermott M, Costello J, Raleigh D. EPEN-02. MULTIPLATFORM MOLECULAR PROFILING REVEALS INTRATUMOR HETEROGENEITY IN EPENDYMOMA. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz036.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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92
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Luks T, Li Y, Lafontaine M, Jakary A, Inamdar G, Wahl M, Chang S, Nelson S, Villanueva-Meyer J. NIMG-24. DIFFUSION MRI PRECURSORS TO PROGRESSION IN GRADE II AND III GLIOMA. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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93
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Hara J, Wu A, Villanueva-Meyer J, Valdes G, Daggubati V, Mueller S, Solberg T, Braunstein S, Morin O, Raleigh D. NIMG-67. CLINICAL APPLICATIONS OF QUANTITATIVE THREE-DIMENSIONAL MRI ANALYSIS FOR PEDIATRIC EMBRYONAL BRAIN TUMORS. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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94
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Li Y, Autry A, Gordon J, Crane J, Olson B, Lafontaine M, Park I, Villanueva-Meyer J, Vigneron D, Chang S, Nelson S. NIMG-66. COMPARISON OF STEADY STATE AND DYNAMIC BRAIN METABOLISM BY USING 1H MRSI AND HYPERPOLARIZED [1-13C]PYRUVATE IMAGING IN PATIENTS WITH GLIOMA. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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95
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Buerki R, Lapointe S, Solomon D, J Phillips J, Perry A, Villanueva-Meyer J, Molinaro A, Ann Oberheim Bush N, Taylor J, Butowski N, Chang S, Clarke J. PATH-09. CLINICAL CHARACTERISTICS OF ADULTS WITH H3 K27M-MUTANT GLIOMAS AT UCSF. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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96
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Chen W, Lucas CH, Baal J, Magill S, Wu A, Hara J, Morin O, Gopinath C, Braunstein S, Oberheim Bush NA, McDermott M, Perry A, Solomon D, Villanueva-Meyer J, Raleigh D. MNGI-30. RADIOLOGIC FEATURES ARE PROGNOSTIC FOR CLINICAL OUTCOMES OF CHORDOID MENINGIOMA. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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97
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Morin O, Chen W, Gennatas E, Magill S, Wu A, Valdes G, Perry A, Sneed P, McDermott M, Solberg T, Bush NAO, Braunstein S, Villanueva-Meyer J, Raleigh D. MNGI-23. PREOPERATIVE QUANTITATIVE IMAGING FEATURES ARE PROGNOSTIC FOR MENINGIOMA OUTCOMES. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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98
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Leon PA, Luks T, Lafontaine M, Clarke J, Chang S, Nelson S, Bloch O, Villanueva-Meyer J. ATIM-22. PROGNOSTIC VALUE OF PTEN LOSS IN NEWLY DIAGNOSED GBM PATIENTS TREATED WITH AUTOLOGOUS HEAT SHOCK PROTEIN VACCINE. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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99
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Yu Y, Hilz S, Grimmer M, Solomon D, Choi S, Wahl M, Mazor T, Hong C, Shai A, J Phillips J, Villanueva-Meyer J, McDermott M, Haas-Kogan D, Taylor J, Butowski N, Clarke J, Berger M, Molinaro A, Chang S, Costello J, Oberheim Bush NA. PATH-29. CLINICAL SIGNIFICANCE OF TEMOZOLOMIDE-INDUCED SOMATIC HYPERMUTATION IN INITIALLY LOW-GRADE IDH-MUTANT DIFFUSE GLIOMAS. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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100
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Dalle Ore C, Magill S, Yen A, Shahin M, Lee D, Lucas CH, Viner J, Aghi M, Theodosopoulos P, Raleigh D, Villanueva-Meyer J, McDermott M. MNGI-06. MENINGIOMA METASTASES: INCIDENCE AND SCREENING IN 1203 PATIENTS. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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