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Wiese M, Pohlmeier B, Kubiak K, El-Khouly FE, Sitte M, Carcaboso AM, Baugh JN, Perwein T, Nussbaumer G, Karremann M, Gielen GH, Salinas G, Kramm CM. Boswellic acid formulations are not suitable for treatment of pediatric high-grade glioma due to tumor promoting potential. J Tradit Complement Med 2024; 14:101-108. [PMID: 38223806 PMCID: PMC10785237 DOI: 10.1016/j.jtcme.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 01/16/2024] Open
Abstract
Background and aim Pediatric high-grade gliomas (pedHGG) comprise a very poor prognosis. Thus, parents of affected children are increasingly resorting to complementary and alternative medicine (CAM), among those Boswellia extracts. However, nothing is known about the therapeutic effectiveness of their active substances, Boswellic acids (BA) in pedHGG. Thus, we aimed to investigate if the three main Boswellic acids (BA) present in Boswellia plants, alpha-boswellic acid (α-BA), beta-boswellic acid (β-BA) and 3-acetyl-11-keto-beta-boswellic acid (AKBA) hold any promising potential for treatment of affected pedHGG patients. Experimental procedure Histone 3 (H3)-wildtype and H3.3K27M-mutant pedHGG cell lines were treated with BA, either alone or in combination with radio-chemotherapy with temozolomide. Cell viability, stemness properties, apoptosis, in ovo tumor growth and the transcriptome was investigated upon BA treatment. Results and conclusion Interestingly, α-BA and β-BA treatment promoted certain tumor properties in both pedHGG cells. AKBA treatment reduced cell viability and colony growth accompanied by induction of slight anti-inflammatory effects especially in H3.3K27M-mutant pedHGG cells. However, no effects on apoptosis and in ovo tumor growth were found. In conclusion, besides positive anti-tumor effects of AKBA, tumor promoting effects were observed upon treatment with α-BA and β-BA. Thus, only pure AKBA formulations may be used to exploit any potential positive effects in pedHGG patients. In conclusion, the use of commercially available supplements with a mixture of different BA cannot be recommended due to detrimental effects of certain BA whereas pure AKBA formulations might hold some potential as therapeutic supplement for treatment of pedHGG patients.
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Affiliation(s)
- Maria Wiese
- Division of Pediatric Hematology and Oncology, Department of Child and Adolescent Health, University Medical Center Goettingen, Robert Koch Straße 40, Goettingen, Germany
| | - Bente Pohlmeier
- Division of Pediatric Hematology and Oncology, Department of Child and Adolescent Health, University Medical Center Goettingen, Robert Koch Straße 40, Goettingen, Germany
| | - Klaudia Kubiak
- Division of Pediatric Hematology and Oncology, Department of Child and Adolescent Health, University Medical Center Goettingen, Robert Koch Straße 40, Goettingen, Germany
| | - Fatma E. El-Khouly
- Pediatric Oncology, Emma Children's Hospital, Amsterdam UMC, De Boelelaan 1118 Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Maren Sitte
- Transcriptome and Genome Analysis Laboratory (TAL), Department of Developmental Biochemistry, University Medical Center Goettingen, Justus-von-Liebig-Weg 11, Goettingen, Germany
| | - Angel M. Carcaboso
- Pediatric Hematology and Oncology, Hospital Sant Joan de Deu/Institut de Recerca, Sant Joan de Deu 2, Barcelona, Spain
| | - Joshua N. Baugh
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Thomas Perwein
- Division of Pediatric Hematology-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 38, Graz, Austria
| | - Gunther Nussbaumer
- Division of Pediatric Hematology-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 38, Graz, Austria
| | - Michael Karremann
- Institute of Neuropathology, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Gerrit H. Gielen
- Institute of Neuropathology, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Gabriela Salinas
- Transcriptome and Genome Analysis Laboratory (TAL), Department of Developmental Biochemistry, University Medical Center Goettingen, Justus-von-Liebig-Weg 11, Goettingen, Germany
| | - Christof M. Kramm
- Division of Pediatric Hematology and Oncology, Department of Child and Adolescent Health, University Medical Center Goettingen, Robert Koch Straße 40, Goettingen, Germany
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Perwein T, Giese B, Nussbaumer G, von Bueren AO, van Buiren M, Benesch M, Kramm CM. How I treat recurrent pediatric high-grade glioma (pHGG): a Europe-wide survey study. J Neurooncol 2023; 161:525-538. [PMID: 36720762 PMCID: PMC9992031 DOI: 10.1007/s11060-023-04241-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/05/2023] [Indexed: 02/02/2023]
Abstract
PURPOSE As there is no standard of care treatment for recurrent/progressing pediatric high-grade gliomas (pHGG), we aimed to gain an overview of different treatment strategies. METHODS In a web-based questionnaire, members of the SIOPE-BTG and the GPOH were surveyed on therapeutic options in four case scenarios (children/adolescents with recurrent/progressing HGG). RESULTS 139 clinicians with experience in pediatric neuro-oncology from 22 European countries participated in the survey. Most respondents preferred further oncological treatment in three out of four cases and chose palliative care in one case with marked symptoms. Depending on the case, 8-92% would initiate a re-resection (preferably hemispheric pHGG), combined with molecular diagnostics. Throughout all case scenarios, 55-77% recommended (re-)irradiation, preferably local radiotherapy > 20 Gy. Most respondents would participate in clinical trials and use targeted therapy (79-99%), depending on molecular genetic findings (BRAF alterations: BRAF/MEK inhibitor, 64-88%; EGFR overexpression: anti-EGFR treatment, 46%; CDKN2A deletion: CDK inhibitor, 18%; SMARCB1 deletion: EZH2 inhibitor, 12%). 31-72% would administer chemotherapy (CCNU, 17%; PCV, 8%; temozolomide, 19%; oral etoposide/trofosfamide, 8%), and 20-69% proposed immunotherapy (checkpoint inhibitors, 30%; tumor vaccines, 16%). Depending on the individual case, respondents would also include bevacizumab (6-18%), HDAC inhibitors (4-15%), tumor-treating fields (1-26%), and intraventricular chemotherapy (4-24%). CONCLUSION In each case, experts would combine conventional multimodal treatment concepts, including re-irradiation, with targeted therapy based on molecular genetic findings. International cooperative trials combining a (chemo-)therapy backbone with targeted therapy approaches for defined subgroups may help to gain valid clinical data and improve treatment in pediatric patients with recurrent/progressing HGG.
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Affiliation(s)
- Thomas Perwein
- Division of Pediatric Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036, Graz, Austria.
| | - Barbara Giese
- Division of Pediatric Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036, Graz, Austria
| | - Gunther Nussbaumer
- Division of Pediatric Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036, Graz, Austria
| | - André O von Bueren
- Department of Pediatrics, Obstetrics and Gynecology, Division of Pediatric Hematology and Oncology, University Hospital of Geneva, Geneva, Switzerland
- Cansearch Research Platform for Pediatric Oncology and Hematology, Faculty of Medicine, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland
| | - Miriam van Buiren
- Department of Pediatric Hematology and Oncology, Center for Pediatrics, Medical Center, University of Freiburg, Freiburg, Germany
| | - Martin Benesch
- Division of Pediatric Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036, Graz, Austria
| | - Christof Maria Kramm
- Division of Pediatric Hematology and Oncology, University Medical Center Göttingen, Göttingen, Germany
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Knox AJ, Van Court B, Oweida A, Barsh E, DeSisto J, Flannery P, Lemma R, Chatwin H, Vibhakar R, Dorris K, Serkova NJ, Karam SD, Gilani A, Green AL. A novel preclinical model of craniospinal irradiation in pediatric diffuse midline glioma demonstrates decreased metastatic disease. Front Oncol 2023; 13:1105395. [PMID: 37124531 PMCID: PMC10132465 DOI: 10.3389/fonc.2023.1105395] [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] [Received: 11/22/2022] [Accepted: 03/24/2023] [Indexed: 05/02/2023] Open
Abstract
Background Diffuse midline glioma (DMG) is an aggressive pediatric central nervous system tumor with strong metastatic potential. As localized treatment of the primary tumor improves, metastatic disease is becoming a more important factor in treatment. We hypothesized that we could model craniospinal irradiation (CSI) through a DMG patient-derived xenograft (PDX) model and that CSI would limit metastatic tumor. Methods We used a BT245 murine orthotopic DMG PDX model for this work. We developed a protocol and specialized platform to deliver craniospinal irradiation (CSI) (4 Gy x2 days) with a pontine boost (4 Gy x2 days) and compared metastatic disease by pathology, bioluminescence, and MRI to mice treated with focal radiation only (4 Gy x4 days) or no radiation. Results Mice receiving CSI plus boost showed minimal spinal and brain leptomeningeal metastatic disease by bioluminescence, MRI, and pathology compared to mice receiving radiation to the pons only or no radiation. Conclusion In a DMG PDX model, CSI+boost minimizes tumor dissemination compared to focal radiation. By expanding effective DMG treatment to the entire neuraxis, CSI has potential as a key component to combination, multimodality treatment for DMG designed to achieve long-term survival once novel therapies definitively demonstrate improved local control.
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Affiliation(s)
- Aaron J. Knox
- Morgan Adams Foundation Pediatric Brain Tumor Research Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Benjamin Van Court
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Ayman Oweida
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Elinor Barsh
- Morgan Adams Foundation Pediatric Brain Tumor Research Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - John DeSisto
- Morgan Adams Foundation Pediatric Brain Tumor Research Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Patrick Flannery
- Morgan Adams Foundation Pediatric Brain Tumor Research Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Rakeb Lemma
- Morgan Adams Foundation Pediatric Brain Tumor Research Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Hannah Chatwin
- Morgan Adams Foundation Pediatric Brain Tumor Research Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Rajeev Vibhakar
- Morgan Adams Foundation Pediatric Brain Tumor Research Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Children’s Hospital Colorado, Aurora, CO, United States
| | - Kathleen Dorris
- Morgan Adams Foundation Pediatric Brain Tumor Research Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Children’s Hospital Colorado, Aurora, CO, United States
| | - Natalie J. Serkova
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Sana D. Karam
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Ahmed Gilani
- Children’s Hospital Colorado, Aurora, CO, United States
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Adam L. Green
- Morgan Adams Foundation Pediatric Brain Tumor Research Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Children’s Hospital Colorado, Aurora, CO, United States
- *Correspondence: Adam L. Green,
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Radlanski K, Hartwig M, Kordes U. Coping with Diffuse Intrinsic Pontine Glioma in Children - Findings from an Interview Study on Bereaved Parents. KLINISCHE PADIATRIE 2022; 234:374-381. [PMID: 35654395 DOI: 10.1055/a-1816-6552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Diffuse midline glioma (DMG) is the most common malignant glioma in early childhood with median survival of only eleven months. This retrospective interview study investigates specific coping strategies and needs of affected parents. PATIENTS 13 interviews with parents of seven children who died from DMG at the age of five to 16 years were conducted in 2016. METHOD The used method is a problem-oriented guided interview with consecutive content and evaluating structuring analysis according to Mayring. RESULTS Major inductive category was whether the parents had talked to their children about their upcoming death. All parents stated overall satisfaction and comfort regarding their palliative care. Lack of psycho-social support in families was successfully addressed by involving palliative care. CONCLUSIONS Retrospective interview studies in this context are feasible. Early involvement of the palliative care team may relieve burden from affected parents. Open communication about death proved helpful for all involved parties, it may facilitate acceptance of terminal illness and alleviate guilt in parents.Concepts for an open and empowering communication within families and between treatment site and families need continuing adjustment. The Palliative care team may also have a key role regarding early phase trials and molecular studies.
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Affiliation(s)
- Kalinka Radlanski
- Radiation Oncology and Radiotherapy, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Maite Hartwig
- Zentrum für Kinderschmerztherapie, delfin-kids, Hamburg, Germany
| | - Uwe Kordes
- Pediatric Hematology and Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
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Perez-Somarriba M, Santa-Maria V, Cruz O, Muchart J, Lavarino C, Mico S, Morales La Madrid A. Craniospinal irradiation as a salvage treatment for metastatic relapsed DIPG. Pediatr Blood Cancer 2021; 68:e28762. [PMID: 33063935 DOI: 10.1002/pbc.28762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/28/2020] [Indexed: 12/27/2022]
Affiliation(s)
| | - Vicente Santa-Maria
- Department of Pediatric Oncology, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Ofelia Cruz
- Department of Pediatric Oncology, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Jordi Muchart
- Department of Radiology, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Cinzia Lavarino
- Department of Developmental Tumor Biology Laboratory, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Soraya Mico
- Department of Radiation Oncology, Hospital Vall d'Hebron, Barcelona, Spain
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Shi S, Lu S, Jing X, Liao J, Li Q. The Prognostic Impact of Radiotherapy in Conjunction with Temozolomide in Diffuse Intrinsic Pontine Glioma: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 148:e565-e571. [PMID: 33476781 DOI: 10.1016/j.wneu.2021.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Diffuse intrinsic pontine glioma (DIPG) is a rare and devastating brainstem glioma that occurs predominately in children. To date, the prognostic impact of radiotherapy (RT) in conjunction with temozolomide (TMZ) in DIPG has not been thoroughly analyzed. The aim of this meta-analysis was to analyze the effectiveness of RT quantitatively and precisely in conjunction with TMZ in improving the prognosis of DIPG. METHODS A systematic search of 8 electronic databases was conducted. Articles mainly discussing the prognostic impact of RT in conjunction with TMZ in DIPG were selected. The pooled 1- and 2-year overall survival (OS) and progression-free survival (PFS) were calculated. RESULTS A total of 14 studies fulfilled our inclusion criteria, involving 283 cases of patients with DIPG who were treated with RT in conjunction with TMZ. The pooled 1- and 2-year OS of this treatment was 43% and 11%, respectively. The pooled 1- and 2-year PFS was 20% and 2%, respectively. Subgroup analysis revealed that the heterogeneity remained almost the same in all stratum. Egger's test demonstrated that the possibility of publication bias was low. CONCLUSIONS Requirements of up-to-date evidence on evaluating the prognostic impact of this therapy are urgent.
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Affiliation(s)
- Shuai Shi
- Department of Neurosurgery, Tianjin Medical University, Tianjin, PR China; Department of Neurology, Tianjin Huanhu Hospital, Tianjin, PR China
| | - Shan Lu
- Tianjin Neurosurgical Institute, Tianjin Key Laboratory of Cerebrovascular and Neurodegenerative Diseases, Tianjin, PR China
| | - Xiyue Jing
- Tianjin Neurosurgical Institute, Tianjin Key Laboratory of Cerebrovascular and Neurodegenerative Diseases, Tianjin, PR China
| | - Jianwen Liao
- Tianjin Neurosurgical Institute, Tianjin Key Laboratory of Cerebrovascular and Neurodegenerative Diseases, Tianjin, PR China
| | - Qingguo Li
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, PR China.
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7
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Zhu X, Lazow MA, Schafer A, Bartlett A, Senthil Kumar S, Mishra DK, Dexheimer P, DeWire M, Fuller C, Leach JL, Fouladi M, Drissi R. A pilot radiogenomic study of DIPG reveals distinct subgroups with unique clinical trajectories and therapeutic targets. Acta Neuropathol Commun 2021; 9:14. [PMID: 33431066 PMCID: PMC7798248 DOI: 10.1186/s40478-020-01107-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/14/2020] [Indexed: 01/03/2023] Open
Abstract
An adequate understanding of the relationships between radiographic and genomic features in diffuse intrinsic pontine glioma (DIPG) is essential, especially in the absence of universal biopsy, to further characterize the molecular heterogeneity of this disease and determine which patients are most likely to respond to biologically-driven therapies. Here, a radiogenomics analytic approach was applied to a cohort of 28 patients with DIPG. Tumor size and imaging characteristics from all available serial MRIs were evaluated by a neuro-radiologist, and patients were divided into three radiographic response groups (partial response [PR], stable disease [SD], progressive disease [PD]) based on MRI within 2 months of radiotherapy (RT) completion. Whole genome and RNA sequencing were performed on autopsy tumor specimens. We report several key, therapeutically-relevant findings: (1) Certain radiologic features on first and subsequent post-RT MRIs are associated with worse overall survival, including PD following irradiation as well as present, new, and/or increasing peripheral ring enhancement, necrosis, and diffusion restriction. (2) Upregulation of EMT-related genes and distant tumor spread at autopsy are observed in a subset of DIPG patients who exhibit poorer radiographic response to irradiation and/or higher likelihood of harboring H3F3A mutations, suggesting possible benefit of upfront craniospinal irradiation. (3) Additional genetic aberrations were identified, including DYNC1LI1 mutations in a subgroup of patients with PR on post-RT MRI; further investigation into potential roles in DIPG tumorigenesis and/or treatment sensitivity is necessary. (4) Whereas most DIPG tumors have an immunologically “cold” microenvironment, there appears to be a subset which harbor a more inflammatory genomic profile and/or higher mutational burden, with a trend toward improved overall survival and more favorable radiographic response to irradiation, in whom immunotherapy should be considered. This study has begun elucidating relationships between post-RT radiographic response with DIPG molecular profiles, revealing radiogenomically distinct subgroups with unique clinical trajectories and therapeutic targets.
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Giambattista J, Omene E, Souied O, Hsu FH. Modern Treatments for Gliomas Improve Outcome. CURRENT CANCER THERAPY REVIEWS 2020. [DOI: 10.2174/1573394715666191017153045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Glioma is the most common type of tumor in the central nervous system (CNS). Diagnosis
is through history, physical examination, radiology, histology and molecular profiles. Magnetic
resonance imaging is a standard workup for all CNS tumors. Multidisciplinary team management
is strongly recommended. The management of low-grade gliomas is still controversial
with regards to early surgery, radiotherapy, chemotherapy, or watchful waiting watchful waiting.
Patients with suspected high-grade gliomas should undergo an assessment by neurosurgeons for
the consideration of maximum safe resection to achieve optimal tumor debulking, and to provide
adequate tissue for histologic and molecular diagnosis. Post-operative radiotherapy and/or chemotherapy
are given depending on disease grade and patient performance. Glioblastoma are mostly
considered incurable. Treatment approaches in the elderly, pediatric population and recurrent
gliomas are discussed with the latest updates in the literature. Treatment considerations include
performance status, neurocognitive functioning, and co-morbidities. Important genetic mutations,
clinical trials and guidelines are summarized in this review.
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Affiliation(s)
| | - Egiroh Omene
- Vancouver Cancer Centre, BC Cancer Agency, Columbia, Vancouver, BC, Canada
| | - Osama Souied
- Vancouver Cancer Centre, BC Cancer Agency, Columbia, Vancouver, BC, Canada
| | - Fred H.C. Hsu
- Vancouver Cancer Centre, BC Cancer Agency, Columbia, Vancouver, BC, Canada
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9
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Tinkle CL, Simone B, Chiang J, Li X, Campbell K, Han Y, Li Y, Hover LD, Molitoris JK, Becksfort J, Lucas JT, Patay Z, Baker SJ, Broniscer A, Merchant TE. Defining Optimal Target Volumes of Conformal Radiation Therapy for Diffuse Intrinsic Pontine Glioma. Int J Radiat Oncol Biol Phys 2019; 106:838-847. [PMID: 31785339 DOI: 10.1016/j.ijrobp.2019.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/16/2019] [Accepted: 11/18/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE Optimal radiation therapy (RT) target margins for diffuse intrinsic pontine glioma (DIPG) are unknown. We sought to define disease progression patterns in a contemporary cohort treated with conformal RT using different clinical target volume (CTV) margins. METHODS AND MATERIALS We reviewed 105 patients with newly diagnosed DIPG treated with conformal conventionally fractionated RT at our institution from 2006 to 2014. CTV margins were classified as standard (1 cm) for 60 patients and extended (2-3 cm) for 45 patients. Survival and cumulative incidence of progression in treatment groups were compared by log-rank and Gray's tests, respectively. Cox proportional hazard models identified predictors of survival. RESULTS For 97 patients evaluated with magnetic resonance imaging at progression, the cumulative incidences of isolated local, isolated distant, and synchronous disease progression at 1 year were 62.6%, 12.3%, and 7.2%, respectively, and did not differ significantly according to the CTV margin. Central dosimetric progression (Vprogression95% ≥95%) was observed in 80 of 81 evaluable patients. Median progression-free survival and overall survival (OS) were 7.6 months (95% confidence interval, 6.9-8.2) and 11.3 months (95% confidence interval, 10.0-12.8), respectively, and did not differ significantly according to margin status. DIPG survival prediction risk group (standard vs high, P = .02; intermediate vs high, P = .009) and development of distant metastasis (P = .003) were independent predictors of OS. For the 41 patients (39%) with a pathologic diagnosis, H3.3 K27M mutation was associated with shorter OS (hazard ratio [HR], 0.41; P =.02), whereas H3.1 K27M and ACVR1 mutations were associated with longer OS (HR, 3.56; P =.004 and HR, 2.58; P =.04, respectively). CONCLUSIONS All patients who experienced local failure showed progression within the high-dose volume, and there was no apparent survival or tumor-control benefit to extending the CTV margins beyond 1 cm. Given the increasing use of reirradiation, standardizing the CTV margin to 1 cm may improve retreatment tolerance.
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Affiliation(s)
- Christopher L Tinkle
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.
| | - Brittany Simone
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jason Chiang
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Xiaoyu Li
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Kristen Campbell
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yuanyuan Han
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yimei Li
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Laura D Hover
- Department of Developmental Neurobiology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jason K Molitoris
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jared Becksfort
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - John T Lucas
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Zoltan Patay
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Suzanne J Baker
- Department of Developmental Neurobiology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Alberto Broniscer
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
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10
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Pramanik R, Bakhshi S. Metronomic therapy in pediatric oncology: A snapshot. Pediatr Blood Cancer 2019; 66:e27811. [PMID: 31207063 DOI: 10.1002/pbc.27811] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 12/16/2022]
Abstract
Metronomic chemotherapy transitioned from the bench to bedside in the early 2000s and since then has carved a niche for itself in pediatric oncology. It has been used solely or in combination with other modalities such as radiotherapy, maximum tolerated dose chemotherapy, and targeted agents in adjuvant, palliative, as well as maintenance settings. No wonder, the resulting medical literature is extremely heterogeneous. In this review, the authors review and synthesize the published literature in pediatric metronomics giving a glimpse of its history, varied applications, and evolution of this genre of chemotherapy in pediatric cancers. Limitations, future prospects, and grey areas are also highlighted.
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Affiliation(s)
- Raja Pramanik
- Department of Medical Oncology, Dr. B. R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, Dr. B. R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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11
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O'Leary B, Mandeville HC, Fersht N, Solda F, Mycroft J, Zacharoulis S, Vaidya S, Saran F. Craniospinal irradiation with concomitant and adjuvant temozolomide--a feasibility assessment of toxicity in patients with glioblastoma with a PNET component. J Neurooncol 2016; 127:295-302. [PMID: 26842817 DOI: 10.1007/s11060-015-2033-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 12/26/2015] [Indexed: 12/22/2022]
Abstract
There is no standard treatment for glioblastoma with elements of PNET (GBM-PNET). Conventional treatment for glioblastoma is surgery followed by focal radiotherapy with concurrent temozolomide. Given the increased propensity for neuroaxial metastases seen with GBM-PNETs, craniospinal irradiation (CSI) with temozolomide (TMZ) could be a feasible treatment option but little is known regarding its toxicity. The clinical records of all patients treated at two UK neuro-oncology centres with concurrent CSI and TMZ were examined for details of surgery, radiotherapy, chemotherapy and toxicities related to the CSI-TMZ component of their treatment. Eight patients were treated with CSI-TMZ, the majority (6/8) for GBM-PNET. All patients completed radiotherapy to the craniospinal axis 35-40 Gy in 20-24 daily fractions with a focal boost to the tumour of 14-23.4 Gy in 8-13 daily fractions. Concurrent TMZ was administered at 75 mg/m(2) for seven of the cohort, with the other patient receiving 50 mg/m(2). The most commonly observed non-haematological toxicities were nausea and vomiting, with all patients experiencing at least grade 2 symptoms of either or both. All patients had at least grade 3 lymphopaenia. Two patients experience grade 4 neutropaenia and grade 3 thrombocytopaenia. Three of the eight patients required omission of TMZ for part of their chemoradiotherapy and 3/8 required hospital admission at some point during chemoradiotherapy. The addition of TMZ to CSI did not interrupt radiotherapy. Principal toxicities were neutropaenia, lymphopaenia, thrombocytopaenia, nausea and vomiting. Treatment with CSI-TMZ merits further investigation and may be suitable for patients with tumours at high-risk of metastatic spread throughout the CNS who have TMZ-sensitive pathologies.
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Affiliation(s)
- Ben O'Leary
- The Royal Marsden Hospital NHS Trust, The Royal Marsden Hospital, Fulham Rd, London, SW3 6JJ, UK
- The Institute of Cancer Research, 237 Fulham Rd, London, SW3 6JB, UK
| | - Henry C Mandeville
- The Royal Marsden Hospital NHS Trust, The Royal Marsden Hospital, Fulham Rd, London, SW3 6JJ, UK
| | - Naomi Fersht
- Department of Oncology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - Francesca Solda
- Department of Oncology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - Julie Mycroft
- The Royal Marsden Hospital NHS Trust, The Royal Marsden Hospital, Fulham Rd, London, SW3 6JJ, UK
| | - Stergios Zacharoulis
- The Royal Marsden Hospital NHS Trust, The Royal Marsden Hospital, Fulham Rd, London, SW3 6JJ, UK
| | - Sucheta Vaidya
- The Royal Marsden Hospital NHS Trust, The Royal Marsden Hospital, Fulham Rd, London, SW3 6JJ, UK
| | - Frank Saran
- The Royal Marsden Hospital NHS Trust, The Royal Marsden Hospital, Fulham Rd, London, SW3 6JJ, UK.
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Radiotherapy of spinal cord gliomas : A retrospective mono-institutional analysis. Strahlenther Onkol 2015; 192:139-45. [PMID: 26519080 DOI: 10.1007/s00066-015-0917-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 10/07/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Due to the rarity of spinal cord gliomas, no consensus has been reached regarding the optimal treatment strategy. The aim of the present retrospective study was to identify patient and tumor characteristics and to evaluate the effectiveness of radiotherapy within this setting. PATIENTS AND METHODS Patients diagnosed with spinal cord gliomas between 2003 and 2013 and treated at the Department of Radiation Oncology, University of Munich, were retrospectively analyzed. Overall survival was estimated with the Kaplan-Meier method and univariate analysis was performed by log-rank testing. RESULTS A total of 16 patients were identified. The cohort consisted of seven primary spinal cord gliomas and eight cases of metastases of cerebral gliomas. Median follow-up was 42 months and median total radiation dose was 45.0 Gy. In all, 62.5 % of patients received a simultaneous chemotherapy with temozolomide. The median overall survival was 6 months (95% CI: 0-27.5 months). Surgical resection of the tumor was a significant predictor of improved survival, compared with radiotherapy alone (p = 0.001). Patients with the diagnosis of a primary spinal cord glioma survived significantly longer than those presenting with a metastatic deposit from a cerebral glioma (p < 0.001). A statistically significant dose-response relationship at dose levels of ≥ 45 Gy vs. < 45 Gy could be derived (p < 0.001). Simultaneous chemotherapy did not influence survival outcome. CONCLUSION Despite the aggressive treatment in the present study, the prognosis for spinal cord gliomas was still poor, with a median overall survival of 6 months. To the best of our knowledge, this is the largest study reporting the results of simultaneous chemoradiation in spinal cord gliomas. A combined chemoradiation treatment seems feasible and can be considered as a new treatment option in the management of spinal cord gliomas.
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13
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Vanan MI, Eisenstat DD. DIPG in Children - What Can We Learn from the Past? Front Oncol 2015; 5:237. [PMID: 26557503 PMCID: PMC4617108 DOI: 10.3389/fonc.2015.00237] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 10/08/2015] [Indexed: 02/02/2023] Open
Abstract
Brainstem tumors represent 10–15% of pediatric central nervous system tumors and diffuse intrinsic pontine glioma (DIPG) is the most common brainstem tumor of childhood. DIPG is almost uniformly fatal and is the leading cause of brain tumor-related death in children. To date, radiation therapy (RT) is the only form of treatment that offers a transient benefit in DIPG. Chemotherapeutic strategies including multi-agent neoadjuvant chemotherapy, concurrent chemotherapy with RT, and adjuvant chemotherapy have not provided any survival advantage. To overcome the restrictive ability of the intact blood–brain barrier (BBB) in DIPG, several alternative drug delivery strategies have been proposed but have met with minimal success. Targeted therapies either alone or in combination with RT have also not improved survival. Five decades of unsuccessful therapies coupled with recent advances in the genetics and biology of DIPG have taught us several important lessons (1). DIPG is a heterogeneous group of tumors that are biologically distinct from other pediatric and adult high grade gliomas (HGG). Adapting chemotherapy and targeted therapies that are used in pediatric or adult HGG for the treatment of DIPG should be abandoned (2). Biopsy of DIPG is relatively safe and informative and should be considered in the context of multicenter clinical trials (3). DIPG probably represents a whole brain disease so regular neuraxis imaging is important at diagnosis and during therapy (4). BBB permeability is of major concern in DIPG and overcoming this barrier may ensure that drugs reach the tumor (5). Recent development of DIPG tumor models should help us accurately identify and validate therapeutic targets and small molecule inhibitors in the treatment of this deadly tumor.
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Affiliation(s)
- Magimairajan Issai Vanan
- Department of Pediatrics and Child Health, University of Manitoba , Winnipeg, MB , Canada ; Department of Biochemistry and Medical Genetics, University of Manitoba , Winnipeg, MB , Canada
| | - David D Eisenstat
- Department of Pediatrics, University of Alberta , Edmonton, AB , Canada ; Department of Medical Genetics, University of Alberta , Edmonton, AB , Canada ; Department of Oncology, University of Alberta , Edmonton, AB , Canada
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Buczkowicz P, Hawkins C. Pathology, Molecular Genetics, and Epigenetics of Diffuse Intrinsic Pontine Glioma. Front Oncol 2015; 5:147. [PMID: 26175967 PMCID: PMC4485076 DOI: 10.3389/fonc.2015.00147] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 06/16/2015] [Indexed: 11/13/2022] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is a devastating pediatric brain cancer with no effective therapy. Histological similarity of DIPG to supratentorial high-grade astrocytomas of adults has led to assumptions that these entities possess similar underlying molecular properties and therefore similar therapeutic responses to standard therapies. The failure of all clinical trials in the last 30 years to improve DIPG patient outcome has suggested otherwise. Recent studies employing next-generation sequencing and microarray technologies have provided a breadth of evidence highlighting the unique molecular genetics and epigenetics of this cancer, distinguishing it from both adult and pediatric cerebral high-grade astrocytomas. This review describes the most common molecular genetic and epigenetic signatures of DIPG in the context of molecular subgroups and histopathological diagnosis, including this tumor entity's unique mutational landscape, copy number alterations, and structural variants, as well as epigenetic changes on the global DNA and histone levels. The increased knowledge of DIPG biology and histopathology has opened doors to new diagnostic and therapeutic avenues.
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Affiliation(s)
- Pawel Buczkowicz
- Division of Pathology, The Hospital for Sick Children , Toronto, ON , Canada ; The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children , Toronto, ON , Canada
| | - Cynthia Hawkins
- Division of Pathology, The Hospital for Sick Children , Toronto, ON , Canada ; The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children , Toronto, ON , Canada ; Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto , Toronto, ON , Canada
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Alken SP, D'Urso P, Saran FH. Managing teenage/young adult (TYA) brain tumors: a UK perspective. CNS Oncol 2015; 4:235-46. [PMID: 26118974 DOI: 10.2217/cns.15.14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Tumors of the CNS are among the commonest malignancies occurring in teenage/young adult patients (i.e., those aged between 15 and 24 years). The treatment of this patient population is challenging. Adolescence and young adulthood are a turbulent period of life, with physical, emotional, social and cognitive changes. Best practice advocates their treatment in dedicated teenage/young adult units, with multidisciplinary team input and access to clinical trials. Treatment of CNS malignancies is dependent upon histological subtype and staging, with varying combinations of surgery, radiotherapy and chemotherapy used. Clinical trials directly targeted at this patient population are rare; treatments are based on pediatric protocols as studies have demonstrated improved outcomes in patients (with other malignancies) treated as such. Scope for improvement lies in minimizing patient risk of recurrence and long-term sequelae of treatment. Molecular characterization of tumors may provide further information.
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Affiliation(s)
- Scheryll P Alken
- Department of Neuro Oncology, Royal Marsden Hospital, Sutton, UK
| | - Pietro D'Urso
- Department of Neurosurgery, Salford Royal Hospital Foundation Trust, Salford, UK
| | - Frank H Saran
- Department of Neuro Oncology, Royal Marsden Hospital, Sutton, UK
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Hepatotoxicity after liver irradiation in children and adolescents : results from the RiSK. Strahlenther Onkol 2014; 191:413-20. [PMID: 25487695 DOI: 10.1007/s00066-014-0796-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 11/14/2014] [Indexed: 12/25/2022]
Abstract
AIM The aim of this study was to evaluate acute and late radiotherapy-associated hepatotoxicity in consideration of dose-volume effects and liver function in childhood and adolescence. PATIENTS AND METHODS Since 2001, irradiated children and adolescents in Germany have been prospectively documented in the "Register of Treatment-Associated Late Effects After Radiotherapy of Malignant Diseases in Childhood and Adolescence (RiSK)" using standardized forms. Toxicity was graded according to the Radiation Therapy Oncology Group (RTOG) criteria. RESULTS Until April 2012, 1,392 children and adolescents from 62 radiotherapy centers were recruited. In all, 216 patients underwent irradiation of the liver (median age 9 years, range 1-18 years, 70 patients with total-body irradiation, TBI). For 75 % of patients without TBI, information on acute toxicity of the liver was available: 24 patients had acute toxicity of grade 1-4 (grade 1, 2, and 4, in 20, 3, and 1 patient, respectively), including five patients receiving simultaneous hepatotoxic chemotherapy. Information on late toxicity was documented in 465 forms from 216 patients, with a median follow-up of 2 years. A maximum grade of toxicity of ≥ 0 occurred in 18 patients over time (with grade 1, 2, and 3 toxicity occurring in 15, 2, and 1 patient, respectively), including three patients (17 %) with TBI. One of them received simultaneous hepatotoxic chemotherapy. In multivariable analysis, volume-dose correlations showed no statistically noticeable effect on acute or chronic toxicity. CONCLUSION Only low hepatotoxicity developed in children after irradiation of various abdominal and thoracic tumors. Due to the low radiation doses to the liver (median liver dose = 5 Gy) and the low toxicities that were consecutively observed, dose-volume curves for liver toxicity could not be established. These findings reflect the cautious attitude of radiation oncologists in terms of attributable liver doses in the treatment of the investigated tumor entities. It offers the option of increasing these conservative doses if tumor control is necessary.
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Pietschmann S, von Bueren AO, Henke G, Kerber MJ, Kortmann RD, Müller K. An individual patient data meta-analysis on characteristics, treatments and outcomes of the glioblastoma/gliosarcoma patients with central nervous system metastases reported in literature until 2013. J Neurooncol 2014; 120:451-7. [PMID: 25160993 DOI: 10.1007/s11060-014-1596-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 08/17/2014] [Indexed: 10/24/2022]
Abstract
Dissemination of high-grade gliomas (WHO IV) has been investigated poorly so far. We conducted an extensive analysis of the characteristics, treatments and outcomes of the glioblastoma multiforme (GBM)/gliosarcoma (GS) patients with central nervous system (CNS) metastases reported in literature until April 2013. PubMed and Web of Science searches for peer-reviewed articles pertaining to GBM/GS patients with metastatic disease were conducted using predefined keywords. Additionally, we performed hand search following the references from the selected papers. Cases in which the metastases exclusively occurred outside the CNS were excluded. 110 publications reporting on 189 patients were eligible. There was a significant increase in the number of reported cases over the last decades. We calculated a median overall survival from diagnosis of metastasis (from initial diagnosis of GBM/GS) of 3.0 ± 0.3 (11 ± 0.7) months. On univariate analyses, gender, age, the histological subtype, the time interval between initial diagnosis and the occurrence of metastases and the location of CNS metastasis (intracranial versus spinal and parenchymal versus leptomeningeal, respectively) did not influence survival after diagnosis of metastasis. There was no substantial treatment progress over the recent decades. GBM/GS with CNS metastasis are associated with a dismal prognosis. Crucial treatment progress is not evident. A central registry should be considered to consecutively gain more information about the ideal therapeutic approach.
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Affiliation(s)
- Sophie Pietschmann
- Department for Radiation Oncology, University of Leipzig Medical Center, Stephanstraße 9a, 04103, Leipzig, Germany,
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