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Kong BY, Sim HW, Nowak AK, Yip S, Barnes EH, Day BW, Buckland ME, Verhaak R, Johns T, Robinson C, Thomas MA, Giardina T, Lwin Z, Scott AM, Parkinson J, Jeffree R, Lourenco RDA, Hovey EJ, Cher LM, Kichendasse G, Khasraw M, Hall M, Tu E, Amanuel B, Koh ES, Gan HK. LUMOS - Low and Intermediate Grade Glioma Umbrella Study of Molecular Guided TherapieS at relapse: Protocol for a pilot study. BMJ Open 2021; 11:e054075. [PMID: 37185327 PMCID: PMC8719186 DOI: 10.1136/bmjopen-2021-054075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction Grades 2 and 3 gliomas (G2/3 gliomas), when combined, are the second largest group of malignant brain tumours in adults. The outcomes for G2/3 gliomas at progression approach the dismal outcomes for glioblastoma (GBM), yet there is a paucity of trials for Australian patients with relapsed G2/3 gliomas compared with patients with GBM. LUMOS will be a pilot umbrella study for patients with relapsed G2/3 gliomas that aims to match patients to targeted therapies based on molecular screening with contemporaneous tumour tissue. Participants in whom no actionable or no druggable mutation is found, or in whom the matching drug is not available, will form a comparator arm and receive standard of care chemotherapy. The objective of the LUMOS trial is to assess the feasibility of this approach in a multicentre study across five sites in Australia, with a view to establishing a national molecular screening platform for patient treatment guided by the mutational analysis of contemporaneous tissue biopsies Methods and analysis This study will be a multicentre pilot study enrolling patients with recurrent grade 2/3 gliomas that have previously been treated with radiotherapy and chemotherapy at diagnosis or at first relapse. Contemporaneous tumour tissue at the time of first relapse, defined as tissue obtained within 6 months of relapse and without subsequent intervening therapy, will be obtained from patients. Molecular screening will be performed by targeted next-generation sequencing at the reference laboratory (PathWest, Perth, Australia). RNA and DNA will be extracted from representative formalin-fixed paraffin embedded tissue scrolls or microdissected from sections on glass slides tissue sections following a review of the histology by pathologists. Extracted nucleic acid will be quantified by Qubit Fluorometric Quantitation (Thermo Fisher Scientific). Library preparation and targeted capture will be performed using the TruSight Tumor 170 (TST170) kit and samples sequenced on NextSeq 550 (Illumina) using NextSeq V.2.5 hi output reagents, according to the manufacturer’s instructions. Data analysis will be performed using the Illumina BaseSpace TST170 app v1.02 and a custom tertiary pipeline, implemented within the Clinical Genomics Workspace software platform from PierianDx (also refer to section 3.2). Primary outcomes for the study will be the number of patients enrolled and the number of patients who complete molecular screening. Secondary outcomes will include the proportion of screened patients enrolled; proportion of patients who complete molecular screening; the turn-around time of molecular screening; and the value of a brain tumour specific multi-disciplinary tumour board, called the molecular tumour advisory panel as measured by the proportion of patients in whom the treatment recommendation was refined compared with the recommendations from the automated bioinformatics platform of the reference laboratory testing. Ethics and dissemination The study was approved by the lead Human Research Ethics Committee of the Sydney Local Health District: Protocol No. X19-0383. The study will be conducted in accordance with the principles of the Declaration of Helsinki 2013, guidelines for Good Clinical Practice and the National Health and Medical Research Council National Statement on Ethical Conduct in Human Research (2007, updated 2018 and as amended periodically). Results will be disseminated using a range of media channels including newsletters, social media, scientific conferences and peer-reviewed publications. Trial registration number ACTRN12620000087954; Pre-results.
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Affiliation(s)
- Benjamin Y Kong
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
- Department of Medical Oncology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Hao-Wen Sim
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- Kinghorn Cancer Centre, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- St Vincent's Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Anna K Nowak
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Sonia Yip
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | | | - Bryan W Day
- School of Biomedical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
- Sid Faithfull Brain Cancer Laboratory, Cell and Molecular Biology Department, QIMR Berghofer, Herston, Queensland, Australia
| | - Michael E Buckland
- Department of Neuropathology, Brain and Mind Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Roel Verhaak
- The Jackson Laboratory for Genomic Medicine, Farmington, Connecticut, USA
| | - Terrance Johns
- Oncogenic Signalling Laboratory, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Cleo Robinson
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Nedlands, Western Australia, Australia
| | - Marc A Thomas
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Nedlands, Western Australia, Australia
| | - Tindaro Giardina
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Nedlands, Western Australia, Australia
| | - Zarnie Lwin
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Andrew M Scott
- Department of Molecular Imaging and Therapy, Austin Health, Heidelberg, Victoria, Australia
- Olivia Newton-John Cancer Research Institute, Heidelberg, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- School of Cancer Medicine, La Trobe University, Melbourne, Victoria, Australia
| | - Jonathon Parkinson
- Department of Neurosurgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Rosalind Jeffree
- Department of Neurosurgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- University of Queensland School of Medicine, Herston, Queensland, Australia
| | - Richard de Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology, Ultimo, New South Wales, Australia
| | - Elizabeth J Hovey
- Department of Medical Oncology, Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Randwick, New South Wales, Australia
| | - Lawrence M Cher
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
| | - Ganessan Kichendasse
- Department of Clinical Pharmacology, College of Medicine and Public Health, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Department of Medical Oncology, Flinders Centre for Innovation in Cancer, Bedford Park, South Australia, Australia
| | - Mustafa Khasraw
- Preston Robert Tisch Brain Tumor Center at Duke, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Merryn Hall
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Emily Tu
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Benhur Amanuel
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Nedlands, Western Australia, Australia
| | - Eng-Siew Koh
- Faculty of Medicine, University of New South Wales, Randwick, New South Wales, Australia
- Department of Radiation Oncology, Liverpool Cancer Therapy Centre, Liverpool, New South Wales, Australia
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Hui K Gan
- Olivia Newton-John Cancer Research Institute, Heidelberg, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- School of Cancer Medicine, La Trobe University, Melbourne, Victoria, Australia
- Department of Medical Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg, Victoria, Australia
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Lapointe S, Perry A, Butowski NA. Primary brain tumours in adults. Lancet 2018; 392:432-446. [PMID: 30060998 DOI: 10.1016/s0140-6736(18)30990-5] [Citation(s) in RCA: 745] [Impact Index Per Article: 124.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/05/2018] [Accepted: 04/23/2018] [Indexed: 12/11/2022]
Abstract
Primary CNS tumours refer to a heterogeneous group of tumours arising from cells within the CNS, and can be benign or malignant. Malignant primary brain tumours remain among the most difficult cancers to treat, with a 5 year overall survival no greater than 35%. The most common malignant primary brain tumours in adults are gliomas. Recent advances in molecular biology have improved understanding of glioma pathogenesis, and several clinically significant genetic alterations have been described. A number of these (IDH, 1p/19q codeletion, H3 Lys27Met, and RELA-fusion) are now combined with histology in the revised 2016 WHO classification of CNS tumours. It is likely that understanding such molecular alterations will contribute to the diagnosis, grading, and treatment of brain tumours. This progress in genomics, along with significant advances in cancer and CNS immunology, has defined a new era in neuro-oncology and holds promise for diagntic and therapeutic improvement. The challenge at present is to translate these advances into effective treatments. Current efforts are focused on developing molecular targeted therapies, immunotherapies, gene therapies, and novel drug-delivery technologies. Results with single-agent therapies have been disappointing so far, and combination therapies seem to be required to achieve a broad and durable antitumour response. Biomarker-targeted clinical trials could improve efficiencies of therapeutic development.
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Affiliation(s)
- Sarah Lapointe
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Arie Perry
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, CA, USA
| | - Nicholas A Butowski
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.
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Chamberlain MC. Salvage therapy with lomustine for temozolomide refractory recurrent anaplastic astrocytoma: a retrospective study. J Neurooncol 2015; 122:329-38. [PMID: 25563816 DOI: 10.1007/s11060-014-1714-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/24/2014] [Indexed: 01/06/2023]
Abstract
There is no standard therapy for recurrent anaplastic astrocytoma (AA). Assess response and toxicity of lomustine (CCNU) in recurrent AA following prior surgery, radiotherapy and TMZ in a retrospective case series. Thirty-five adults (18 males; 17 females: median age 42.5 years) with TMZ refractory recurrent AA were treated with lomustine. Seven patients were treated at 1st recurrence and 28 patients were treated at 2nd recurrence. Prior salvage therapy included re-resection in 19, TMZ in 20 and radiotherapy in 7. A cycle of lomustine was defined as 110 mg/m(2) on day 1 only administered once every 6-8 weeks. Success of treatment was defined as progression free survival at 6 months of 40 % or better. Grade 3 or 4 toxicities included anemia (14 patients), constipation (1), fatigue (4), lymphopenia (5), nausea/vomiting (2), neutropenia (8) and thrombocytopenia (10). No grade five toxicities were seen. The median number of cycles of therapy was 3 (range 1-6). Best radiographic response was progressive disease in 14 (40 %), stable disease in 19 (54 %) and partial response in 2 (5.7 %). Median progression free survival (PFS) was 4.5 months (range 1.5-12 months), 6-month PFS was 40 % and 12 month PFS was 11.4 %. Median survival after onset of CCNU was 9.5 months (range 2.5-15 months). Median overall survival was 2.7 years (range 1.7-4.3). In this small retrospective series of patients with recurrent AA refractory to TMZ, lomustine appears to have modest single agent with manageable toxicity. Confirmation in a larger series of similar patients is required.
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Affiliation(s)
- Marc C Chamberlain
- Division of Neuro-Oncology, Department of Neurology and Neurological Surgery, University of Washington/Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, 825 Eastlake Ave E, MS: G4-940, Seattle, WA, 98109, USA,
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Ajaz M, Jefferies S, Brazil L, Watts C, Chalmers A. Current and investigational drug strategies for glioblastoma. Clin Oncol (R Coll Radiol) 2014; 26:419-30. [PMID: 24768122 DOI: 10.1016/j.clon.2014.03.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 03/27/2014] [Indexed: 11/21/2022]
Abstract
Medical treatments for glioblastoma face several challenges. Lipophilic alkylators remain the mainstay of treatment, emphasising the primacy of good blood-brain barrier penetration. Temozolomide has emerged as a major contributor to improved patient survival. The roles of procarbazine and vincristine in the procarbazine, lomustine and vincristine (PCV) schedule have attracted scrutiny and several lines of evidence now support the use of lomustine as effective single-agent therapy. Bevacizumab has had a convoluted development history, but clearly now has no major role in first-line treatment, and may even be detrimental to quality of life in this setting. In later disease, clinically meaningful benefits are achievable in some patients, but more impressively the combination of bevacizumab and lomustine shows early promise. Over the last decade, investigational strategies in glioblastoma have largely subscribed to the targeted kinase inhibitor paradigm and have mostly failed. Low prevalence dominant driver lesions such as the FGFR-TACC fusion may represent a niche role for this agent class. Immunological, metabolic and radiosensitising approaches are being pursued and offer more generalised efficacy. Finally, trial design is a crucial consideration. Progress in clinical glioblastoma research would be greatly facilitated by improved methodologies incorporating: (i) routine pharmacokinetic and pharmacodynamic assessments by preoperative dosing; and (ii) multi-stage, multi-arm protocols incorporating new therapy approaches and high-resolution biology in order to guide necessary improvements in science.
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Affiliation(s)
- M Ajaz
- Surrey Cancer Research Institute, University of Surrey, Guildford, UK.
| | - S Jefferies
- Oncology Centre, Addenbrooke's Hospital, Cambridge, UK
| | - L Brazil
- Guy's, St Thomas' and King's College Hospitals, London, UK
| | - C Watts
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - A Chalmers
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
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Nabors LB, Ammirati M, Bierman PJ, Brem H, Butowski N, Chamberlain MC, DeAngelis LM, Fenstermaker RA, Friedman A, Gilbert MR, Hesser D, Holdhoff M, Junck L, Lawson R, Loeffler JS, Maor MH, Moots PL, Morrison T, Mrugala MM, Newton HB, Portnow J, Raizer JJ, Recht L, Shrieve DC, Sills AK, Tran D, Tran N, Vrionis FD, Wen PY, McMillian N, Ho M. Central nervous system cancers. J Natl Compr Canc Netw 2014; 11:1114-51. [PMID: 24029126 DOI: 10.6004/jnccn.2013.0132] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Primary and metastatic tumors of the central nervous system are a heterogeneous group of neoplasms with varied outcomes and management strategies. Recently, improved survival observed in 2 randomized clinical trials established combined chemotherapy and radiation as the new standard for treating patients with pure or mixed anaplastic oligodendroglioma harboring the 1p/19q codeletion. For metastatic disease, increasing evidence supports the efficacy of stereotactic radiosurgery in treating patients with multiple metastatic lesions but low overall tumor volume. These guidelines provide recommendations on the diagnosis and management of this group of diseases based on clinical evidence and panel consensus. This version includes expert advice on the management of low-grade infiltrative astrocytomas, oligodendrogliomas, anaplastic gliomas, glioblastomas, medulloblastomas, supratentorial primitive neuroectodermal tumors, and brain metastases. The full online version, available at NCCN. org, contains recommendations on additional subtypes.
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Giglio P, Dhamne M, Hess KR, Gilbert MR, Groves MD, Levin VA, Kang SL, Ictech SE, Liu V, Colman H, Conrad CA, Loghin M, de Groot J, Yung WKA, Puduvalli VK. Phase 2 trial of irinotecan and thalidomide in adults with recurrent anaplastic glioma. Cancer 2011; 118:3599-606. [PMID: 22086614 DOI: 10.1002/cncr.26663] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 10/07/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND Therapeutic options for patients with anaplastic gliomas (AGs) are limited despite better insights into glioma biology. The authors previously reported improved outcome in patients with recurrent glioblastoma treated with thalidomide and irinotecan compared with historical controls. Here, results of the AG arm of the study are reported, using this drug combination. METHODS Adults with recurrent AG previously treated with radiation therapy, with Karnofsky performance score ≥70, adequate organ function and not on enzyme-inducing anticonvulsants were enrolled. Treatment was in 6-week cycles with irinotecan at 125 mg/m(2) weekly for 4 weeks followed by 2 weeks off, and thalidomide at 100 mg daily increased to 400 mg/day as tolerated. The primary endpoint was progression-free survival rate at 6 months (PFS-6), and the secondary endpoints were overall survival (OS) and response rate (RR). RESULTS In 39 eligible patients, PFS-6 for the intent-to-treat population was 36% (95% confidence interval [CI] = 21%, 53%), median PFS was 13 weeks (95% CI = 6%, 28%) and RR was 10%(95% CI = 3%, 24%). Radiological findings included 2 complete and 2 partial responses and 17 stable disease. Median OS from study registration was 62 weeks, (95% CI = 51, 144). Treatment-related toxicities (grade 3 or higher) included neutropenia, diarrhea, nausea, and fatigue; 6 patients experienced venous thromboembolism. Four deaths were attributable to treatment-related toxicities: 1 from pulmonary embolism, 2 from colitis, and 1 from urosepsis. CONCLUSIONS The combination of thalidomide and irinotecan did not achieve sufficient efficacy to warrant further investigation against AG, although a subset of patients experienced prolonged PFS/OS. A trial of the more potent thalidomide analogue, lenalidomide, in combination with irinotecan against AG is currently ongoing.
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Affiliation(s)
- Pierre Giglio
- Department of Neuro-oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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