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Das A, Fernandez NR, Levine A, Bianchi V, Stengs LK, Chung J, Negm L, Dimayacyac JR, Chang Y, Nobre L, Ercan AB, Sanchez-Ramirez S, Sudhaman S, Edwards M, Larouche V, Samuel D, Van Damme A, Gass D, Ziegler DS, Bielack SS, Koschmann C, Zelcer S, Yalon-Oren M, Campino GA, Sarosiek T, Nichols KE, Loret De Mola R, Bielamowicz K, Sabel M, Frojd CA, Wood MD, Glover JM, Lee YY, Vanan M, Adamski JK, Perreault S, Chamdine O, Hjort MA, Zapotocky M, Carceller F, Wright E, Fedorakova I, Lossos A, Tanaka R, Osborn M, Blumenthal DT, Aronson M, Bartels U, Huang A, Ramaswamy V, Malkin D, Shlien A, Villani A, Dirks PB, Pugh TJ, Getz G, Maruvka YE, Tsang DS, Ertl-Wagner B, Hawkins C, Bouffet E, Morgenstern DA, Tabori U. Combined Immunotherapy Improves Outcome for Replication-Repair-Deficient (RRD) High-Grade Glioma Failing Anti-PD-1 Monotherapy: A Report from the International RRD Consortium. Cancer Discov 2024; 14:258-273. [PMID: 37823831 PMCID: PMC10850948 DOI: 10.1158/2159-8290.cd-23-0559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/28/2023] [Accepted: 10/10/2023] [Indexed: 10/13/2023]
Abstract
Immune checkpoint inhibition (ICI) is effective for replication-repair-deficient, high-grade gliomas (RRD-HGG). The clinical/biological impact of immune-directed approaches after failing ICI monotherapy is unknown. We performed an international study on 75 patients treated with anti-PD-1; 20 are progression free (median follow-up, 3.7 years). After second progression/recurrence (n = 55), continuing ICI-based salvage prolonged survival to 11.6 months (n = 38; P < 0.001), particularly for those with extreme mutation burden (P = 0.03). Delayed, sustained responses were observed, associated with changes in mutational spectra and the immune microenvironment. Response to reirradiation was explained by an absence of deleterious postradiation indel signatures (ID8). CTLA4 expression increased over time, and subsequent CTLA4 inhibition resulted in response/stable disease in 75%. RAS-MAPK-pathway inhibition led to the reinvigoration of peripheral immune and radiologic responses. Local (flare) and systemic immune adverse events were frequent (biallelic mismatch-repair deficiency > Lynch syndrome). We provide a mechanistic rationale for the sustained benefit in RRD-HGG from immune-directed/synergistic salvage therapies. Future approaches need to be tailored to patient and tumor biology. SIGNIFICANCE Hypermutant RRD-HGG are susceptible to checkpoint inhibitors beyond initial progression, leading to improved survival when reirradiation and synergistic immune/targeted agents are added. This is driven by their unique biological and immune properties, which evolve over time. Future research should focus on combinatorial regimens that increase patient survival while limiting immune toxicity. This article is featured in Selected Articles from This Issue, p. 201.
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Affiliation(s)
- Anirban Das
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatric Haematology and Oncology, Tata Medical Center, Kolkata, India
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Nicholas R. Fernandez
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Adrian Levine
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Vanessa Bianchi
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Lucie K. Stengs
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Jiil Chung
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Logine Negm
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Jose Rafael Dimayacyac
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Yuan Chang
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Liana Nobre
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Ayse B. Ercan
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Santiago Sanchez-Ramirez
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Sumedha Sudhaman
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Melissa Edwards
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Valerie Larouche
- Pediatric Haematology/Oncology Department, CHU de Québec-Université Laval, Quebec City, Canada
| | - David Samuel
- Department of Paediatric Oncology, Valley Children's Hospital, Madera, California
| | - An Van Damme
- Department of Paediatric Haematology and Oncology, Saint Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - David Gass
- Atrium Health/Levine Children's Hospital, Charlotte, North Carolina
| | - David S. Ziegler
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, Australia
- School of Clinical Medicine, UNSW Sydney, Sydney, Australia
| | - Stefan S. Bielack
- Department of Pediatric Oncology, Hematology and Immunology, Center for Childhood, Adolescent, and Women's Medicine, Stuttgart Cancer Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Carl Koschmann
- Pediatric Hematology/Oncology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Shayna Zelcer
- Department of Pediatrics, London Health Sciences Centre, London, Canada
| | - Michal Yalon-Oren
- Department of Paediatric Haematology-Oncology, Sheba Medical Centre, Ramat Gan, Israel
| | - Gadi Abede Campino
- Department of Paediatric Haematology-Oncology, Sheba Medical Centre, Ramat Gan, Israel
| | | | - Kim E. Nichols
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Kevin Bielamowicz
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, The University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock, Arkansas
| | - Magnus Sabel
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg & Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Charlotta A. Frojd
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Matthew D. Wood
- Neuropathology, Oregon Health & Science University Department of Pathology, Portland, Oregon
| | - Jason M. Glover
- Department of Pediatric Hematology/Oncology, Randall Children's Hospital, Portland, Oregon
| | - Yi-Yen Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Magimairajan Vanan
- Pediatric Hematology-Oncology, CancerCare Manitoba, Winnipeg, Canada
- CancerCare Manitoba Research Institute, Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Jenny K. Adamski
- Neuro-oncology Division, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Sebastien Perreault
- Neurosciences Department, Child Neurology Division, CHU Sainte-Justine, Montreal, Canada
| | - Omar Chamdine
- Pediatric Hematology Oncology, King Fahad Specialist Hospital Dammam, Eastern Province, Saudi Arabia
| | - Magnus Aasved Hjort
- Department of Paediatric Haematology and Oncology, St. Olav's University Hospital, Trondheim, Norway
| | - Michal Zapotocky
- Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, University Hospital Motol, Charles University, Prague, Czech Republic
| | - Fernando Carceller
- Paediatric and Adolescent Neuro-Oncology and Drug Development, The Royal Marsden NHS Foundation Trust & Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Erin Wright
- Division of Neuro-Oncology, Akron Children's Hospital, Akron, Ohio
| | - Ivana Fedorakova
- Clinic of Pediatric Oncology and Hematology, University Children's Hospital, Banská Bystrica, Slovakia
| | - Alexander Lossos
- Department of Oncology, Leslie and Michael Gaffin Centre for Neuro-Oncology, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - Ryuma Tanaka
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Osborn
- Women's and Children's Hospital, North Adelaide, Australia
| | - Deborah T. Blumenthal
- Neuro-Oncology Service, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Melyssa Aronson
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Canada
| | - Ute Bartels
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Annie Huang
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - David Malkin
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Adam Shlien
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Anita Villani
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Peter B. Dirks
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Canada
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Trevor J. Pugh
- Ontario Institute for Cancer Research, Princess Margaret Cancer Centre, Toronto, Canada
| | - Gad Getz
- Broad Institute of Harvard and MIT, Cambridge, Massachusetts
| | | | - Derek S. Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Birgit Ertl-Wagner
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada
| | - Cynthia Hawkins
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Daniel A. Morgenstern
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Uri Tabori
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
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2
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Blandin AF, Giglio R, Graham MS, Garcia G, Malinowski S, Woods JK, Ramkissoon S, Ramkissoon L, Dubois F, Schoolcraft K, Tsai J, Wang D, Jones R, Vogelzang J, Pelton K, Becker S, Watkinson F, Sinai C, Cohen EF, Booker MA, Tolstorukov MY, Haemels V, Goumnerova L, Wright K, Kieran M, Fehnel K, Reardon D, Tauziede-Espariat A, Lulla R, Carcamo B, Chaleff S, Charest A, DeSmet F, Ligon AH, Dubuc A, Pages M, Varlet P, Wen PY, Alexander BM, Chi S, Alexandrescu S, Kittler R, Bachoo R, Bandopadhayay P, Beroukhim R, Ligon KL. ALK Amplification and Rearrangements Are Recurrent Targetable Events in Congenital and Adult Glioblastoma. Clin Cancer Res 2023; 29:2651-2667. [PMID: 36780194 PMCID: PMC10363218 DOI: 10.1158/1078-0432.ccr-21-3521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/31/2022] [Accepted: 02/07/2023] [Indexed: 02/14/2023]
Abstract
PURPOSE Anaplastic lymphoma kinase (ALK) aberrations have been identified in pediatric-type infant gliomas, but their occurrence across age groups, functional effects, and treatment response has not been broadly established. EXPERIMENTAL DESIGN We performed a comprehensive analysis of ALK expression and genomic aberrations in both newly generated and retrospective data from 371 glioblastomas (156 adult, 205 infant/pediatric, and 10 congenital) with in vitro and in vivo validation of aberrations. RESULTS ALK aberrations at the protein or genomic level were detected in 12% of gliomas (45/371) in a wide age range (0-80 years). Recurrent as well as novel ALK fusions (LRRFIP1-ALK, DCTN1-ALK, PRKD3-ALK) were present in 50% (5/10) of congenital/infant, 1.4% (3/205) of pediatric, and 1.9% (3/156) of adult GBMs. ALK fusions were present as the only candidate driver in congenital/infant GBMs and were sometimes focally amplified. In contrast, adult ALK fusions co-occurred with other oncogenic drivers. No activating ALK mutations were identified in any age group. Novel and recurrent ALK rearrangements promoted STAT3 and ERK1/2 pathways and transformation in vitro and in vivo. ALK-fused GBM cellular and mouse models were responsive to ALK inhibitors, including in patient cells derived from a congenital GBM. Relevant to the treatment of infant gliomas, we showed that ALK protein appears minimally expressed in the forebrain at perinatal stages, and no gross effects on perinatal brain development were seen in pregnant mice treated with the ALK inhibitor ceritinib. CONCLUSIONS These findings support use of brain-penetrant ALK inhibitors in clinical trials across infant, pediatric, and adult GBMs. See related commentary by Mack and Bertrand, p. 2567.
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Affiliation(s)
- Anne-Florence Blandin
- Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad institute of Harvard and MIT, Cambridge, MA, USA
| | - Ross Giglio
- Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | | | - Jared K. Woods
- Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad institute of Harvard and MIT, Cambridge, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Frank Dubois
- Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad institute of Harvard and MIT, Cambridge, MA, USA
| | | | - Jessica Tsai
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
| | - Dayle Wang
- Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | | | | | | | | | - Elizabeth F Cohen
- Department of Informatics and Analytics, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Matthew A Booker
- Department of Informatics and Analytics, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Veerle Haemels
- Laboratory for Precision Cancer Medicine, Translational Cell and Tissue Research Unit, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | | | - Karen Wright
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
| | - Mark Kieran
- Day One Biopharmaceuticals, Brisbane, CA 94005
| | - Katie Fehnel
- Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
| | | | | | - Rishi Lulla
- Hasbro Children's Hospital, Providence, RI, USA
| | - Benjamin Carcamo
- Texas Tech University, Health Science Center, Paul L. Foster School of Medicine, El Paso, TX, USA
- El Paso Children's Hospital, El Paso, TX, USA
| | | | - Alain Charest
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Frederik DeSmet
- Laboratory for Precision Cancer Medicine, Translational Cell and Tissue Research Unit, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Azra H. Ligon
- Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
- Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
| | - Adrian Dubuc
- Dana-Farber Cancer Institute, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | - Melanie Pages
- Department of Genetics, Institute Curie, Paris, France. INSERM U830, Laboratory of Translational Research in Pediatric Oncology, SIREDO Pediatric Oncology Center, Institute Curie, Paris, France
| | | | - Patrick Y. Wen
- Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Brian M. Alexander
- Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | - Susan Chi
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
| | - Sanda Alexandrescu
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
| | - Ralf Kittler
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert Bachoo
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Pratiti Bandopadhayay
- Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad institute of Harvard and MIT, Cambridge, MA, USA
- Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
| | - Rameen Beroukhim
- Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad institute of Harvard and MIT, Cambridge, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | - Keith L. Ligon
- Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad institute of Harvard and MIT, Cambridge, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
- Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
- Dana-Farber Cancer Institute, Center for Patient Derived Models (CPDM), Boston, MA, USA
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Rhodes A, Martin S, Toledo-Tamula MA, Loucas C, Glod J, Warren KE, Wolters PL. The neuropsychological profile of children with Diffuse Intrinsic Pontine Glioma (DIPG) before and after radiation therapy: A prospective longitudinal study. Child Neuropsychol 2022:1-25. [DOI: 10.1080/09297049.2022.2144189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Amanda Rhodes
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Staci Martin
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Mary Anne Toledo-Tamula
- Clinical Research Directorate (CRD), Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Caitlyn Loucas
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - John Glod
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Katherine E. Warren
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
- Department of Pediatric Neuro-Oncology, Dana Farber Cancer Institute/Boston Children’s Hospital, Boston, MA, USA
| | - Pamela L. Wolters
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
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Neurobehavioral Impairment in Pediatric Brain Tumor Survivors: A Meta-Analysis. Cancers (Basel) 2022; 14:cancers14133269. [PMID: 35805042 PMCID: PMC9265927 DOI: 10.3390/cancers14133269] [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: 05/31/2022] [Revised: 06/22/2022] [Accepted: 06/30/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose: The neurocognitive outcomes of pediatric brain tumor survivors have been extensively studied but the risk and predictors for neurobehavioral impairment are less clearly defined. We systematically analyzed the rates of emotional, psychosocial, and attention problems in pediatric brain tumor survivors. Methods: PubMed, Web of Science, Embase, Scopus, and Cochrane were searched for articles published between January 2012 to April 2022. Eligible studies reported neurobehavioral outcomes for PBTS aged 2 to <23 years with a brain tumor diagnosis before 18 years of age. A random-effect meta-analysis was performed in R. Results: The search yielded 1187 unique publications, of which 50 were included in the quantitative analysis. The estimated risk of having emotional, psychosocial, and attention problems were 15% (95%CI 10−20%), 12% (95%CI 9−16%), and 12% (95%CI 9−16%), respectively. PBTS were more likely to have emotional difficulties (Hedge’s g = 0.43 [95%CI 0.34−0.52]), psychosocial problems (Hedge’s g = 0.46 [95%CI 0.33−0.58]), and attention problems (Hedge’s g = 0.48 [95%CI 0.34−0.63]) compared to normal/healthy control subjects. There was no significant difference in the rates of neurobehavioral impairment between children with and without history of cranial radiotherapy. Conclusions: PBTS are at elevated risk of neurobehavioral impairment. Neurobehavioral monitoring should be considered as the standard of care for PBTS.
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Ebel F, Greuter L, Guzman R, Soleman J. Transitional Care in Pediatric Brain Tumor Patients: A Systematic Literature Review. CHILDREN (BASEL, SWITZERLAND) 2022; 9:501. [PMID: 35455545 PMCID: PMC9026288 DOI: 10.3390/children9040501] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/05/2022] [Accepted: 03/18/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Due to advances in the treatment of pediatric brain tumors (PBT), an increasing number of patients are experiencing the transition from the pediatric to the adult health care system. This requires efficient transitional models. METHODS We systematically reviewed the literature regarding PBT concerning different transitional models and aspects of the transitional period. For this purpose, PubMed, Medline, and Embase databases were searched systematically through January 2022. RESULTS We reviewed a total of 304 studies, of which 15 were ultimately included. We identified five transition models described within the literature, while the most frequently mentioned ones were the "adult caregiver model" (45.5%), "joint caregiver model" (45.5%), "continued caregiver model" (27.3%), and the "specialized clinic model" (27.3%). During the transition, the most frequent challenges mentioned by the patients were the lack of knowledge about the disease by the adult health care professionals (62.5%) and the difficulty of establishing a new relationship with the new physician, environment, or hospital (37.5%). CONCLUSIONS An efficient transitional model is mandatory for patients with PBT. Continuity in the treatment and care of the patient and their family is essential. For this purpose, in patients with PBT, the "continued caregiver model", and for NF1 and TSC patients, the "specialized clinic model" seems optimal to offer continuity of care. If such models are unavailable, efficient communication with patients, families, and specialists in a multidisciplinary network is even more critical.
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Affiliation(s)
- Florian Ebel
- Department of Neurosurgery, University Hospital of Basel, 4031 Basel, Switzerland; (L.G.); (R.G.); (J.S.)
| | - Ladina Greuter
- Department of Neurosurgery, University Hospital of Basel, 4031 Basel, Switzerland; (L.G.); (R.G.); (J.S.)
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, 4031 Basel, Switzerland; (L.G.); (R.G.); (J.S.)
- Department of Pediatric Neurosurgery, University Children’s Hospital of Basel, 4056 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, 4031 Basel, Switzerland; (L.G.); (R.G.); (J.S.)
- Department of Pediatric Neurosurgery, University Children’s Hospital of Basel, 4056 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
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6
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Larkin T, Das A, Bianchi V, Sudhaman S, Chung J, Alsafwani N, Negm L, Yachnis A, Blatt J, Hawkins C, Bouffet E, Tabori U, Gururangan S. Upfront Adjuvant Immunotherapy of Replication Repair-Deficient Pediatric Glioblastoma With Chemoradiation-Sparing Approach. JCO Precis Oncol 2021; 5:1426-1431. [PMID: 34994637 DOI: 10.1200/po.21.00153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Trisha Larkin
- Department of Pediatrics, UF Health Shands Hospital, Gainesville, FL.,Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Anirban Das
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Vanessa Bianchi
- Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sumedha Sudhaman
- Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jiil Chung
- Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Noor Alsafwani
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Logine Negm
- Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Anthony Yachnis
- Department of Pathology, University of Florida, Gainesville, FL
| | - Jason Blatt
- Department of Neurosurgery and the Preston A. Wells Jr Center for Brain Tumor Therapy, University of Florida, Gainesville, FL
| | - Cynthia Hawkins
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Uri Tabori
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sridharan Gururangan
- Department of Neurosurgery and the Preston A. Wells Jr Center for Brain Tumor Therapy, University of Florida, Gainesville, FL
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7
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Plant-Fox AS, O'Halloran K, Goldman S. Pediatric brain tumors: the era of molecular diagnostics, targeted and immune-based therapeutics, and a focus on long term neurologic sequelae. Curr Probl Cancer 2021; 45:100777. [PMID: 34303558 DOI: 10.1016/j.currproblcancer.2021.100777] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 07/09/2021] [Accepted: 07/09/2021] [Indexed: 11/16/2022]
Abstract
Pediatric brain tumors are the second most common malignancy of childhood after acute leukemia and the number one cause of cancer-related mortality1. Over the past decade, advanced molecular diagnostics have led to the discovery of new molecularly-defined tumor types with prognostic and therapeutic implications. Methylation profiles, whole genome sequencing, and transcriptomics have defined subgroups and revealed heterogeneity within commonly defined tumor entities2,3. These findings have also revealed important differences between adult and pediatric brain tumors of similar histology. The majority of pediatric low grade gliomas (pLGG) are defined by alterations in the mitogen-activated protein kinase (MAPK) pathway including BRAFV600E point mutation, K1AA1549-BRAF fusion, and FGFR1 alterations as opposed to IDH1/2 mutations and 1p/19q co-deletion seen more frequently in adult low grade gliomas4. These findings have led to targeted therapies, namely BRAF and MEK inhibitors, which are currently being evaluated in phase III clinical trials and may soon supplant chemotherapy as standard of care for pLGG's. While targeted therapy trials for pediatric brain tumors have had significant success, immunotherapy remains a challenge in a group of tumors with generally lower mutational burden compared to adult tumors and relatively "cold" immune microenvironment. Despite this, a wide array of immunotherapy trials including vaccine therapies, immune checkpoint blockade, chimeric antigen receptor (CAR) T cells, and viral therapies are on-going. Unique to pediatrics, multiple clinical trials have sought to answer the question of whether the most malignant pediatric brain tumors in the youngest patients can be successfully treated with high dose chemotherapy in lieu of radiation to avoid devastating long-term neurocognitive deficits. Due to the collaborative work of multiple pediatric neuro-oncology consortiums, the recent history of pediatric brain tumor research is one of efficient translation from bench to bedside in a rare group of tumors resulting in significant progress in the field. Here, advances in the areas of molecular characterization, targeted and immune-based therapies, and reduction in long term co-morbidities will be reviewed.
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Affiliation(s)
- Ashley S Plant-Fox
- Ann and Robert H. Lurie Children's Hospital of Chicago. Division of Hematology/Oncology/Stem Cell Transplantation/Neuro-Oncology. Chicago, Illinois.
| | - Katrina O'Halloran
- Children's Hospital of Los Angeles. Division of Hematology/Oncology, Los Angeles, California
| | - Stewart Goldman
- Ann and Robert H. Lurie Children's Hospital of Chicago. Division of Hematology/Oncology/Stem Cell Transplantation/Neuro-Oncology. Chicago, Illinois
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8
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Ellenbogen Y, Yang K, Ajani O. Transition of Care for Children with High-Grade Central Nervous System Tumors. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0040-1716909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractThe increase in survival rates of children with high-grade central nervous system tumors has highlighted the necessity for and challenges associated with transition of care as these children grow into adult life. Late recurrence and treatment effects are some of the conditions that require care after transition. Several models of transition have been proposed in the literature. An effective transition will not only ensure adequate continuity of care but will also include assessment of effectiveness of the transition by health care personnel and the patient/patient's family themselves.
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Affiliation(s)
- Yosef Ellenbogen
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kaiyun Yang
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Olufemi Ajani
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- McMaster University Medical Center and Children's Hospital, Hamilton, Ontario, Canada
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9
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Neumann S, Porritt MJ, Osman AM, Kuhn HG. Cranial irradiation at early postnatal age impairs stroke-induced neural stem/progenitor cell response in the adult brain. Sci Rep 2020; 10:12369. [PMID: 32703986 PMCID: PMC7378832 DOI: 10.1038/s41598-020-69266-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 07/09/2020] [Indexed: 11/29/2022] Open
Abstract
Cranial irradiation (IR) is commonly used to treat primary brain tumors and metastatic diseases. However, cranial IR-treated patients often develop vascular abnormalities later in life that increase their risk for cerebral ischemia. Studies in rodents have demonstrated that IR impairs maintenance of the neural stem/precursor cell (NSPC) pool and depletes neurogenesis. We and others have previously shown that stroke triggers NSPC proliferation in the subventricular zone and migration towards the stroke-injured neocortex. Whether this response is sustained in the irradiated brain remains unknown. Here, we demonstrate that cranial IR in mice at an early postnatal age significantly reduced the number to neuronal progenitors responding to cortical stroke in adults. This was accompanied by a reduced number of microglia/macrophages in the peri-infarct cortex; however, the astrocytic response was not altered. Our findings indicate that IR impairs the endogenous repair capacity in the brain in response to stroke, hence pointing to another side effect of cranial radiotherapy which requires further attention.
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Affiliation(s)
- Susanne Neumann
- Department of Clinical Neuroscience, Institute for Neuroscience and Physiology, University of Gothenburg, Box 436, 405 30, Gothenburg, Sweden.,Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Michelle J Porritt
- Department of Clinical Neuroscience, Institute for Neuroscience and Physiology, University of Gothenburg, Box 436, 405 30, Gothenburg, Sweden
| | - Ahmed M Osman
- Department of Women's and Children's Health, Karolinska Institutet, 171 64, Stockholm, Sweden
| | - H Georg Kuhn
- Department of Clinical Neuroscience, Institute for Neuroscience and Physiology, University of Gothenburg, Box 436, 405 30, Gothenburg, Sweden.
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10
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Howarth A, Madureira PA, Lockwood G, Storer LCD, Grundy R, Rahman R, Pilkington GJ, Hill R. Modulating autophagy as a therapeutic strategy for the treatment of paediatric high-grade glioma. Brain Pathol 2019; 29:707-725. [PMID: 31012506 PMCID: PMC8028648 DOI: 10.1111/bpa.12729] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 04/17/2019] [Indexed: 12/18/2022] Open
Abstract
Paediatric high-grade gliomas (pHGG) represent a therapeutically challenging group of tumors. Despite decades of research, there has been minimal improvement in treatment and the clinical prognosis remains poor. Autophagy, a highly conserved process for recycling metabolic substrates is upregulated in pHGG, promoting tumor progression and evading cell death. There is significant crosstalk between autophagy and a plethora of critical cellular pathways, many of which are dysregulated in pHGG. The following article will discuss our current understanding of autophagy signaling in pHGG and the potential modulation of this network as a therapeutic target.
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Affiliation(s)
- Alison Howarth
- Brain Tumour Research Centre, Institute of Biomedical and Biomolecular Sciences, IBBSUniversity of PortsmouthPortsmouthUK
| | - Patricia A. Madureira
- Brain Tumour Research Centre, Institute of Biomedical and Biomolecular Sciences, IBBSUniversity of PortsmouthPortsmouthUK
- Centre for Biomedical Research (CBMR)University of AlgarveFaroPortugal
| | - George Lockwood
- Children’s Brain Tumour Research Centre, School of Medicine, Queen’s Medical CentreUniversity of NottinghamNottinghamUK
| | - Lisa C. D. Storer
- Children’s Brain Tumour Research Centre, School of Medicine, Queen’s Medical CentreUniversity of NottinghamNottinghamUK
| | - Richard Grundy
- Children’s Brain Tumour Research Centre, School of Medicine, Queen’s Medical CentreUniversity of NottinghamNottinghamUK
| | - Ruman Rahman
- Children’s Brain Tumour Research Centre, School of Medicine, Queen’s Medical CentreUniversity of NottinghamNottinghamUK
| | - Geoffrey J. Pilkington
- Brain Tumour Research Centre, Institute of Biomedical and Biomolecular Sciences, IBBSUniversity of PortsmouthPortsmouthUK
| | - Richard Hill
- Brain Tumour Research Centre, Institute of Biomedical and Biomolecular Sciences, IBBSUniversity of PortsmouthPortsmouthUK
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11
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Valiakhmetova A, Gorelyshev S, Konovalov A, Trunin Y, Savateev A, Kram DE, Severson E, Hemmerich A, Edgerly C, Duncan D, Britt N, Huang RS, Elvin J, Miller V, Ross JS, Gay L, McCorkle J, Rankin A, Erlich RL, Chudnovsky Y, Ramkissoon SH. Treatment of Pediatric Glioblastoma with Combination Olaparib and Temozolomide Demonstrates 2-Year Durable Response. Oncologist 2019; 25:e198-e202. [PMID: 32043779 PMCID: PMC7011619 DOI: 10.1634/theoncologist.2019-0603] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 09/06/2019] [Indexed: 11/17/2022] Open
Abstract
For pediatric patients with high-grade gliomas, standard-of-care treatment includes surgery, chemotherapy, and radiation therapy; however, most patients ultimately succumb to their disease. With advances in genomic characterization of pediatric high-grade gliomas, the use of targeted therapies in combination with current treatment modalities offer the potential to improve survival in this patient population. In this report, we present the case of a 3-year-old girl with glioblastoma who continues to experience an exceptional and durable response (>2 years) to the poly (ADP-ribose) polymerase (PARP) inhibitor olaparib. Our patient presented with persistent and progressive seizure activity that upon workup was the result of a large heterogeneously enhancing, mixed cystic and solid mass in the left frontal-parietal-temporal region. Histopathologic analysis of resected tumor tissue confirmed the diagnosis of glioblastoma, and comprehensive genomic profiling demonstrated absence of any BRAF or H3F3A mutations. Genomic profiling, however, did reveal a probable germline heterozygous BRCA2 Lys3326Ter (K3226*) nonsense variant. After debulking surgery, the patient received standard-of-care treatment with radiation and temozolomide. Nine months later the PARP inhibitor olaparib was administered in combination with temozolomide for 16 cycles. This regimen was well tolerated by the patient and serial imaging showed reduction in tumor size. Since completion of the regimen, the patient remains neurologically intact with no evidence of tumor recurrence. To our knowledge, this represents the first case of a pediatric glioblastoma that maintains a durable response to a therapeutic strategy that included the PARP inhibitor olaparib and more generally highlights the potential clinical utility of incorporating these agents into the treatment of pediatric high-grade gliomas. KEY POINTS: Germline mutations detected in pediatric gliomas may represent a cancer predisposition syndrome. Integrating molecular testing into routine clinical care for pediatric patients with glioma is critical to identify therapeutic targets and patients with a cancer predisposition syndrome. Patients with glioma with defects in DNA repair pathway components (e.g., BRCA1/2) may show increased responsiveness to poly (ADP-ribose) polymerase (PARP) inhibitors. Combining PARP inhibitors with temozolomide (standard-of-care treatment) revealed no adverse events or toxicities over the course of 18 months.
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Affiliation(s)
- Andge Valiakhmetova
- Federal State Autonomous Institution, N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian FederationMoscowRussia
| | - Sergey Gorelyshev
- Federal State Autonomous Institution, N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian FederationMoscowRussia
| | - Alexander Konovalov
- Federal State Autonomous Institution, N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian FederationMoscowRussia
| | - Yuri Trunin
- Federal State Autonomous Institution, N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian FederationMoscowRussia
| | - Alexander Savateev
- Federal State Autonomous Institution, N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian FederationMoscowRussia
| | - David E. Kram
- Section of Pediatric Hematology‐Oncology, Department of Pediatrics, Wake Forest School of MedicineWinston‐SaleNorth CarolinaUSA
- Wake Forest Comprehensive Cancer Center, Wake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Eric Severson
- Foundation Medicine, Inc.MorrisvilleNorth CarolinaUSA
| | | | | | - Daniel Duncan
- Foundation Medicine, Inc.MorrisvilleNorth CarolinaUSA
| | | | | | - Julia Elvin
- Foundation Medicine, Inc.CambridgeMassachusettsUSA
| | | | - Jeffrey S. Ross
- Foundation Medicine, Inc.CambridgeMassachusettsUSA
- Department of Pathology, State University of New York (SUNY) Upstate Medical UniversitySyracuseNew YorkUSA
| | - Laurie Gay
- Foundation Medicine, Inc.CambridgeMassachusettsUSA
| | | | | | | | | | - Shakti H. Ramkissoon
- Wake Forest Comprehensive Cancer Center, Wake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Pathology, Wake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Foundation Medicine, Inc.MorrisvilleNorth CarolinaUSA
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12
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Fronto-limbic white matter microstructure, behavior, and emotion regulation in survivors of pediatric brain tumor. J Neurooncol 2019; 143:483-493. [PMID: 31073964 DOI: 10.1007/s11060-019-03180-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 04/26/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE After treatment, pediatric brain tumor survivors (PBTS) face emotional and behavioral challenges, perhaps due to tumor or treatment-related changes in brain structures involved in emotion regulation, including those with fronto-limbic connections. We hypothesized that relative to healthy controls (HCs), PBTS would exhibit greater difficulties with behavior and emotional functioning, and display reduced mean fractional anisotropy (mFA) in white matter tracts with fronto-limbic connections including the cingulum bundle (CB), inferior fronto-occipital fasciculus (IFOF), and uncinate fasciculus (UF). We further predicted that mFA would account for variance in the relationship between group and emotional/behavioral outcome. METHODS Eleven 8-16 year old PBTS and 14 HCs underwent MRI, including diffusion tensor imaging to assess white matter microstructure. Tractography quantified mFA of selected tracts. Parents rated children's emotional and behavioral functioning. RESULTS Compared to HCs, caregivers of PBTS reported poorer behavioral regulation and greater internalizing and externalizing symptoms. Relative to HCs, PBTS had lower mFA within the bilateral CB, IFOF, and UF (ds = 0.59-1.15). Across groups, several medium-to-large correlations linked tract mFA and increased internalizing, externalizing, and poor behavioral regulation. Tract mFA also accounted for significant variance in the group-outcome association. CONCLUSIONS Reduced mFA in fronto-limbic associated tracts may be associated with reduced behavioral regulation following pediatric brain tumor. PBTS with treatment known to impact white matter may be most susceptible. Research with larger, longitudinal samples should clarify this relationship, allow for multiple mediators across time, and consider factors like tumor and treatment type.
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13
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Arango-Lasprilla JC, Rivera D, Trapp S, Jiménez-Pérez C, Hernández Carrillo CL, Pohlenz Amador S, Vergara-Moragues E, Rodríguez-Agudelo Y, Rodriguez-Irizarry W, García de la Cadena C, Galvao-Carmona A, Galarza-Del-Angel J, Llerena Espezúa X, Torales Cabrera N, Flor-Caravia P, Aguayo Arelis A, Saracostti Schwartzman M, Barranco Casimiro R, Albaladejo-Blázquez N. Symbol Digit Modalities Test: Normative data for Spanish-speaking pediatric population. NeuroRehabilitation 2018; 41:639-647. [PMID: 28946593 DOI: 10.3233/nre-172243] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To generate normative data for the Symbol Digit Modalities Test (SDMT) in Spanish-speaking pediatric populations. METHOD The sample consisted of 4,373 healthy children from nine countries in Latin America (Chile, Cuba, Ecuador, Guatemala, Honduras, Mexico, Paraguay, Peru, and Puerto Rico) and Spain. Each participant was administered the SDMT as part of a larger neuropsychological battery. SDMT scores were normed using multiple linear regressions and standard deviations of residual values. Age, age2, sex, and mean level of parental education (MLPE) were included as predictors in the analyses. RESULTS The final multiple linear regression models showed main effects for age in all countries, such that score increased linearly as a function of age. In addition, age2 had a significant effect in all countries, except in Honduras and Puerto Rico. Models indicated that children whose parent(s) had a MLPE >12 years of education obtained higher score compared to children whose parent(s) had a MLPE ≤12 years for Chile, Guatemala, Mexico, and Spain. Sex affected SDMT score for Paraguay and Spain. CONCLUSIONS This is the largest Spanish-speaking pediatric normative study in the world, and it will allow neuropsychologists from these countries to have a more accurate interpretation of the SDMT with pediatric populations.
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Affiliation(s)
- J C Arango-Lasprilla
- IKERBASQUE, Basque Foundation for Science, Bilbao, Spain.,BioCruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain
| | - D Rivera
- BioCruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain
| | - S Trapp
- Division of Physical Medicine and Rehabilitation, University of Utah, Utah, USA
| | - C Jiménez-Pérez
- CIMCYC-The Mind, Brain and Behaviour Research Centre, Universidad de Granada, Granada, Spain
| | | | - S Pohlenz Amador
- Escuela de Ciencias Psicológicas, Universidad Nacional Autónoma de Honduras, Tegucigalpa, Honduras
| | | | - Y Rodríguez-Agudelo
- Instituto Nacional de Neurología y Neurocirugía, MVS, Ciudad de México, México
| | | | - C García de la Cadena
- Departamento de Psicología, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - A Galvao-Carmona
- Department of Psychology, Universidad Loyola Andalucía, Sevilla, Spain
| | - J Galarza-Del-Angel
- Laboratorio de Psicofisiología, Facultad de Ciencias Humanas, Universidad Autónoma de Baja California, Mexicali, México
| | | | | | - P Flor-Caravia
- Escuela de Psicología, Universidad de Las Américas, Quito, Ecuador
| | - A Aguayo Arelis
- Departamento de investigación, Psicología, Universidad Enrique Díaz de León, Guadalajara, México
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14
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Lieberman NAP, Vitanza NA, Crane CA. Immunotherapy for brain tumors: understanding early successes and limitations. Expert Rev Neurother 2018; 18:251-259. [DOI: 10.1080/14737175.2018.1425617] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Nicole A. P. Lieberman
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Nicholas A. Vitanza
- Division of Hematology/Oncology, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Courtney A. Crane
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA
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15
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Wegenschimmel B, Leiss U, Veigl M, Rosenmayr V, Formann A, Slavc I, Pletschko T. Do we still need IQ-scores? Misleading interpretations of neurocognitive outcome in pediatric patients with medulloblastoma: a retrospective study. J Neurooncol 2017; 135:361-369. [PMID: 28779461 PMCID: PMC5663794 DOI: 10.1007/s11060-017-2582-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/23/2017] [Indexed: 11/26/2022]
Abstract
Over the past decades, many studies used global outcome measures like the IQ when reporting cognitive outcome of pediatric brain tumor patients, assuming that intelligence is a singular and homogeneous construct. In contrast, especially in clinical neuropsychology, the assessment and interpretation of distinct neurocognitive domains emerged as standard. By definition, the full scale IQ (FIQ) is a score attempting to measure intelligence. It is established by calculating the average performance of a number of subtests. Therefore, FIQ depends on the subtests that are used and the influence neurocognitive functions have on these performances. Consequently, the present study investigated the impact of neuropsychological domains on the singular "g-factor" concept and analysed the consequences for interpretation of clinical outcome. The sample consisted of 37 pediatric patients with medulloblastoma, assessed 0-3 years after diagnosis with the Wechsler Intelligence Scales. Information processing speed and visuomotor function were measured by the Trailmaking Test, Form A. Our findings indicate that FIQ was considerably impacted by processing speed and visuomotor coordination, which leaded to an underestimation of the general cognitive performance of many patients. One year after diagnosis, when patients showed the largest norm-deviation, this effect seemed to be at its peak. As already recommended in international guidelines, a comprehensive neuropsychological test battery is necessary to fully understand cognitive outcome. If IQ-tests are used, a detailed subtest analysis with respect to the impact of processing speed seems essential. Otherwise patients may be at risk for wrong decision making, especially in educational guidance.
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Affiliation(s)
- Barbara Wegenschimmel
- Association for the Promotion of Childhood and Adolescent Neurology, Psychiatry, Psychology and Psychotherapy (kjnp3), Vienna, Austria
| | - Ulrike Leiss
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Michaela Veigl
- Neuropsychology Unit, Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Verena Rosenmayr
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | | | - Irene Slavc
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Thomas Pletschko
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria.
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16
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Schulte F, Russell KB, Cullen P, Embry L, Fay-McClymont T, Johnston D, Rosenberg AR, Sung L. Systematic review and meta-analysis of health-related quality of life in pediatric CNS tumor survivors. Pediatr Blood Cancer 2017; 64. [PMID: 28266804 DOI: 10.1002/pbc.26442] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/10/2016] [Accepted: 12/12/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pediatric central nervous system (CNS) tumor survivors are at high risk for numerous late effects including decreased health-related quality of life (HRQOL). Our objective was to summarize studies describing HRQOL in pediatric CNS tumor survivors and compare HRQOL outcomes in studies that included a comparison group. PROCEDURE EMBASE, MEDLINE, and PsychINFO were used to identify relevant articles published until August, 2016. Eligible studies reported outcomes for pediatric CNS tumor survivors diagnosed before age 21, at least 5 years from diagnosis and/or 2 years off therapy and used a standardized measure of HRQOL. All data were abstracted by two reviewers. Random-effects meta-analyses were performed using Review Manager 5.0. RESULTS Of 1,912 unique articles identified, 74 were included in this review. Papers described 29 different HRQOL tools. Meta-analyses compared pediatric CNS tumor survivors to healthy comparisons and other pediatric cancer survivors separately. HRQOL was significantly lower for CNS (n = 797) than healthy comparisons (n = 1,397) (mean difference = -0.54, 95% confidence interval [CI] = -0.72 to -0.35, P < 0.001, I2 = 35%). HRQOL was also significantly lower for CNS (n = 244) than non-CNS survivors (n = 414) (mean difference = -0.56, 95% CI = -0.73 to -0.38, P < 0.00001, I2 = 0%). CONCLUSIONS Pediatric CNS tumor survivors experience worse HRQOL than healthy comparisons and non-CNS cancer survivors. Future HRQOL work should be longitudinal, and/or multisite studies that examine HRQOL by diagnosis and treatment modalities.
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Affiliation(s)
- Fiona Schulte
- Departments of Oncology and Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Haematology, Oncology and Transplant Program, Alberta Children's Hospital Research Institute, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - K Brooke Russell
- Haematology, Oncology and Transplant Program, Alberta Children's Hospital, Calgary, Alberta, Canada.,Departments of Oncology and Psychology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Patricia Cullen
- Loretto Heights School of Nursing, Regis University, Denver, Colorado
| | - Leanne Embry
- Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Taryn Fay-McClymont
- Departments of Oncology and Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Donna Johnston
- Department of Haematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Abby R Rosenberg
- Department of Hematology/Oncology, Seattle Children's Hospital, Seattle, Washington
| | - Lillian Sung
- Department of Haematology/Oncology, SickKids Hospital, Toronto, Ontario, Canada
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17
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Antonini TN, Ris MD, Grosshans DR, Mahajan A, Okcu MF, Chintagumpala M, Paulino A, Child AE, Orobio J, Stancel HH, Kahalley LS. Attention, processing speed, and executive functioning in pediatric brain tumor survivors treated with proton beam radiation therapy. Radiother Oncol 2017; 124:89-97. [PMID: 28655455 DOI: 10.1016/j.radonc.2017.06.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/31/2017] [Accepted: 06/08/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE This study examines attention, processing speed, and executive functioning in pediatric brain tumor survivors treated with proton beam radiation therapy (PBRT). MATERIAL AND METHODS We examined 39 survivors (age 6-19years) who were 3.61years post-PBRT on average. Craniospinal (CSI; n=21) and focal (n=18) subgroups were analyzed. Attention, processing speed, and executive functioning scores were compared to population norms, and clinical/demographic risk factors were examined. RESULTS As a group, survivors treated with focal PBRT exhibited attention, processing speed, and executive functioning that did not differ from population norms (all p>0.05). Performance in the CSI group across attention scales was normative (all p>0.05), but areas of relative weakness were identified on one executive functioning subtest and several processing speed subtests (all p<0.01). CONCLUSIONS Survivors treated with PBRT may exhibit relative resilience in cognitive domains traditionally associated with radiation late effects. Attention, processing speed, and executive functioning remained intact and within normal limits for survivors treated with focal PBRT. Among survivors treated with CSI, a score pattern emerged that was suggestive of difficulties in underlying component skills (i.e., processing speed) rather than true executive dysfunction. No evidence of profound cognitive impairment was found in either group.
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Affiliation(s)
- Tanya N Antonini
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - M Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - David R Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Anita Mahajan
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - M Fatih Okcu
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - Murali Chintagumpala
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - Arnold Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Amanda E Child
- Department of Psychology, University of Houston, Houston, United States
| | - Jessica Orobio
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Heather H Stancel
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Lisa S Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States.
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Espinoza JC, Haley K, Patel N, Dhall G, Gardner S, Allen J, Torkildson J, Cornelius A, Rassekh R, Bedros A, Etzl M, Garvin J, Pradhan K, Corbett R, Sullivan M, McGowage G, Stein D, Jasty R, Sands SA, Ji L, Sposto R, Finlay JL. Outcome of young children with high-grade glioma treated with irradiation-avoiding intensive chemotherapy regimens: Final report of the Head Start II and III trials. Pediatr Blood Cancer 2016; 63:1806-13. [PMID: 27332770 PMCID: PMC5598351 DOI: 10.1002/pbc.26118] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/03/2016] [Accepted: 05/21/2016] [Indexed: 11/08/2022]
Abstract
PURPOSE To report the final analysis of survival outcomes for children with newly diagnosed high-grade glioma (HGG) treated on the "Head Start" (HS) II and III protocols with chemotherapy and intent to avoid irradiation in children <6 years old. PATIENTS AND METHODS Between 1997 and 2009, 32 eligible children were enrolled in HS II and III with anaplastic astrocytoma (AA, n = 19), glioblastoma multiforme (GBM, n = 11), or other HGG (n = 2). Central pathology review was completed on 78% of patients. Patients with predominantly brainstem tumors were excluded. Patients were to be treated with single induction chemotherapy regimen C, comprising four cycles of vincristine, carboplatin, and temozolomide. Following induction, patients underwent marrow-ablative chemotherapy and autologous hematopoietic cell rescue. Irradiation was used for patients with residual tumor after consolidation or >6 years old or at the time of tumor progression. RESULTS The 5-year event-free survival (EFS) and overall survival (OS) for all HGG patients were 25 ± 8% and 36 ± 9%, respectively. The EFS at 5 years for patients with AA and GBM were 24 ± 11% and 30 ± 16%, respectively (P = 0.65). The OS at 5 years for patients with AA and GBM was 34 ± 12% and 35 ± 16%, respectively (P = 0.83). Children <36 months old experienced improved 5-year EFS and OS of 44 ± 17% and 63 ± 17%, compared with children 36-71 months old (31 ± 13% and 38 ± 14%) and children >72 months old (0% and 13 ± 12%). CONCLUSIONS Irradiation-avoiding treatment strategies should be evaluated further in young children with HGG given similar survival rates to older children receiving standard irradiation-containing therapies.
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Affiliation(s)
| | - Kelley Haley
- Children's Hospital Los Angeles, Los Angeles, California
| | - Neha Patel
- Department of pediatrics, University of Wisconsin, Madison, Wisconsin
| | - Girish Dhall
- Children's Hospital Los Angeles, Los Angeles, California
| | - Sharon Gardner
- Department of pediatrics, New York University Medical Center, New York, New York
| | - Jeffrey Allen
- Department of pediatrics, New York University Medical Center, New York, New York
| | | | | | - Rod Rassekh
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Antranik Bedros
- Department of pediatrics, Loma Linda University Medical Center, Loma Linda, California
| | - Morris Etzl
- Phoenix Children's Hospital, Phoenix, Arizona
| | - James Garvin
- Columbia Children's Hospital, New York, New York
| | | | - Robin Corbett
- Department of pediatrics, University of Otago, Christchurch, New Zealand
| | - Michael Sullivan
- Department of pediatrics, University of Otago, Christchurch, New Zealand
| | | | | | | | - Stephen A. Sands
- Department of pediatrics, Columbia University Medical Center, New York, New York
| | - Lingyun Ji
- USC Norris Comprehensive Cancer Center, Los Angeles, California
| | - Richard Sposto
- Children's Hospital Los Angeles, Los Angeles, California
| | - Jonathan L. Finlay
- Department of pediatrics, Division of Hematology, Oncology and BMT, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
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Dessens AB, van Herwerden MC, Aarsen FK, Birnie E, Catsman-Berrevoets CE. Health-related quality of life and emotional problems in children surviving brain tumor treatment: A descriptive study of 2 cohorts. Pediatr Hematol Oncol 2016; 33:282-294. [PMID: 27337046 DOI: 10.1080/08880018.2016.1191101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The survival of childhood brain tumors has improved in the past 30 years, but acquired brain injury due to damage caused by tumor invasion and side effects of different treatment modalities frequently occurs. This study focused on residual impairments, health-related quality of life (HRQoL), and emotional and behavioral problems in 2 cohorts of survivors diagnosed and treated for various types of brain tumors. Survivors in the 2004 cohort visited the Erasmus Medical Centre for standardized follow-up between 2003 and 2004, and in the 2014 cohort, between 2012 and 2014. Data of neurologically impairments of all children were extracted from medical records. Parents and survivors filled out questionnaires on quality of life and emotional and behavioral problems. In both cohorts, approximately 55% of the survivors displayed neurologic impairments. In comparison with the healthy reference group, a reduced parent-reported quality of life was found on the Motor, Cognition, and Autonomy (Cohort 2004) scales. Comparison between the cohorts showed that parents in the 2004 cohort reported a higher HRQoL on the Motor and Cognitive functioning scales. In the 2014 cohort, children reported less negative emotions than healthy children. No increase in emotional or behavioral problems were reported by children in both cohorts, whereas parents reported problems in social functioning and isolation related to a delay in emotional development. Children surviving brain tumor treatment have a reduced quality of life. The authors therefore recommend regular screening of HRQoL and emotional and behavioral problems and referral to specific aftercare.
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Affiliation(s)
- Arianne B Dessens
- a Department of Child and Adolescent Psychiatry and Psychology , Erasmus Medical Centre Rotterdam-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Michael C van Herwerden
- a Department of Child and Adolescent Psychiatry and Psychology , Erasmus Medical Centre Rotterdam-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Femke K Aarsen
- a Department of Child and Adolescent Psychiatry and Psychology , Erasmus Medical Centre Rotterdam-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Erwin Birnie
- b Department of Genetics , University Medical Center Groningen , Groningen , The Netherlands
| | - Coriene E Catsman-Berrevoets
- a Department of Child and Adolescent Psychiatry and Psychology , Erasmus Medical Centre Rotterdam-Sophia Children's Hospital , Rotterdam , The Netherlands
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20
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Social competence in children and young people treated for a brain tumour. Support Care Cancer 2016; 24:4587-95. [PMID: 27312844 DOI: 10.1007/s00520-016-3301-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 06/06/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE The purposes of this study were to provide a multi-informant assessment of social competence in 8-16-year olds treated for a brain tumour (BT) and then to compare these assessment outcomes to peers. METHOD A cross-sectional, mixed (within and between group) design was used to compare a paediatric BT survivor group (n = 33) with an age-matched control group (n = 34) on two multi-informant (self-report, parent, teacher) social competence questionnaires: Social Skills Improvement System (SSIS) and Social Responsiveness Scale (SRS). Demographic factors (age, gender, social economic status (SES), intellectual ability and emotional/behavioural difficulties were investigated as potential non-insult-related risk factors. RESULTS Compared to controls, the BT group was reported to have difficulties in social adjustment, interactions and information processing, on both social competence questionnaire measures by parents and teachers, but not self-report. Social competence scores for the BT group were broadly distributed within the normal-severe clinical range, with 40 % of BT survivors scoring in the clinical range for social competence difficulties on the SRS. Lower intellectual ability and emotional/behavioural difficulties accounted for some of the group differences in social competence, but group effects remained once estimated IQ and emotional/behavioural difficulties were controlled for. CONCLUSIONS Paediatric BT survivors were reported by parents and teachers to have significant difficulties at all three levels of social competence: adjustment, interaction and information processing. The results highlight the importance of routine assessment in clinic settings for social competence and emotional/behavioural difficulties in BT survivors, to promote early identification and to ensure that survivors are referred for appropriate services and intervention as part of their multi-disciplinary care package.
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21
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Jalali R, Rishi A, Goda JS, Sridhar E, Gurav M, Sharma P, Moiyadi A, Shetty P, Gupta T. Clinical outcome and molecular characterization of pediatric glioblastoma treated with postoperative radiotherapy with concurrent and adjuvant temozolomide: a single institutional study of 66 children. Neurooncol Pract 2015; 3:39-47. [PMID: 31579520 DOI: 10.1093/nop/npv024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Indexed: 11/12/2022] Open
Abstract
Background Glioblastoma (GBM) in children is rare. Pediatric GBM have a distinct molecular profile as compared to adult GBM. There are relatively few studies of pediatric GBMs and no standard of care on adjuvant therapy. We aimed to evaluate the clinical outcome and molecular profile of pediatric GBM. Methods and Materials Between 2004 and 2013, 66 consecutive children with histologically proven GBM were identified from our database. The majority of the children underwent maximal safe resection followed by focal radiotherapy with concurrent and adjuvant temozolomide. Immunohistochemical staining was performed for p53, MIB-1 labeling index, MGMT overexpression, and EGFR amplification and isocitrate dehydrogenase (IDH1) R132H point mutation. Survival and impact of possible prognostic factors on outcomes were analyzed. Result Median survival was 15 months. The overall survival rate at 1 year was 62%, at 2 years was 30%, and at 3 years was 27%. Patients with thalamic tumors (P < .001), incompletely resected tumors (P < .00001), and tumors with MIB-1 labeling index >25% (P < .002) had poor overall survival rates. p53 was overexpressed in 74% of patients, MGMT promoter methylation was seen in 37% of patients, IDH1 mutation was seen in 4% of patients, and no patients had EGFR amplification. MGMT methylation and p53 overexpression did not impact survival. Conclusions Clinical outcome of pediatric GBM is similar to that reported for adult GBM. The frequency of p53 overexpression is higher than in adult GBM, while MGMT methylation, IDH1 mutations and EGFR amplification is lower than in adult GBM. MGMT methylation and p53 expression status do not have any prognostic significance.
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Affiliation(s)
- Rakesh Jalali
- Neuro Oncology Group, Tata Memorial Centre, Mumbai, India (R.J., A.R., J.S.G., P.S., T.G.); Molecular Pathology, Tata Memorial Centre, Mumbai, India (E.S., M.G.); Neurosurgery, Tata Memorial Centre, Mumbai, India (A.M., P.S.)
| | - Anupam Rishi
- Neuro Oncology Group, Tata Memorial Centre, Mumbai, India (R.J., A.R., J.S.G., P.S., T.G.); Molecular Pathology, Tata Memorial Centre, Mumbai, India (E.S., M.G.); Neurosurgery, Tata Memorial Centre, Mumbai, India (A.M., P.S.)
| | - Jayant S Goda
- Neuro Oncology Group, Tata Memorial Centre, Mumbai, India (R.J., A.R., J.S.G., P.S., T.G.); Molecular Pathology, Tata Memorial Centre, Mumbai, India (E.S., M.G.); Neurosurgery, Tata Memorial Centre, Mumbai, India (A.M., P.S.)
| | - Epari Sridhar
- Neuro Oncology Group, Tata Memorial Centre, Mumbai, India (R.J., A.R., J.S.G., P.S., T.G.); Molecular Pathology, Tata Memorial Centre, Mumbai, India (E.S., M.G.); Neurosurgery, Tata Memorial Centre, Mumbai, India (A.M., P.S.)
| | - Mamta Gurav
- Neuro Oncology Group, Tata Memorial Centre, Mumbai, India (R.J., A.R., J.S.G., P.S., T.G.); Molecular Pathology, Tata Memorial Centre, Mumbai, India (E.S., M.G.); Neurosurgery, Tata Memorial Centre, Mumbai, India (A.M., P.S.)
| | - Pravin Sharma
- Neuro Oncology Group, Tata Memorial Centre, Mumbai, India (R.J., A.R., J.S.G., P.S., T.G.); Molecular Pathology, Tata Memorial Centre, Mumbai, India (E.S., M.G.); Neurosurgery, Tata Memorial Centre, Mumbai, India (A.M., P.S.)
| | - Aliasgar Moiyadi
- Neuro Oncology Group, Tata Memorial Centre, Mumbai, India (R.J., A.R., J.S.G., P.S., T.G.); Molecular Pathology, Tata Memorial Centre, Mumbai, India (E.S., M.G.); Neurosurgery, Tata Memorial Centre, Mumbai, India (A.M., P.S.)
| | - Prakash Shetty
- Neuro Oncology Group, Tata Memorial Centre, Mumbai, India (R.J., A.R., J.S.G., P.S., T.G.); Molecular Pathology, Tata Memorial Centre, Mumbai, India (E.S., M.G.); Neurosurgery, Tata Memorial Centre, Mumbai, India (A.M., P.S.)
| | - Tejpal Gupta
- Neuro Oncology Group, Tata Memorial Centre, Mumbai, India (R.J., A.R., J.S.G., P.S., T.G.); Molecular Pathology, Tata Memorial Centre, Mumbai, India (E.S., M.G.); Neurosurgery, Tata Memorial Centre, Mumbai, India (A.M., P.S.)
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Olson K, Sands SA. Cognitive training programs for childhood cancer patients and survivors: A critical review and future directions. Child Neuropsychol 2015; 22:509-36. [PMID: 26070928 DOI: 10.1080/09297049.2015.1049941] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A robust literature has developed documenting neurocognitive late effects in survivors of leukemia and central nervous system (CNS) tumors, the most frequent cancer diagnoses of childhood. Patterns of late effects include deficits in attention and concentration, working memory, processing speed, and executive function, as well as other domains. As childhood cancer survivors are living longer, ameliorating deficits both in broad and specific neurocognitive domains has been increasingly recognized as an endeavor of paramount importance. Interventions to improve cognitive functioning were first applied to the field of pediatric oncology in the 1990s, based on strategies used effectively with adults who had sustained a traumatic brain injury (TBI). Compilation and modification of these techniques has led to the development of structured cognitive training programs, with the effectiveness and feasibility of such interventions currently an active area of research. Consequently, the purpose of this critical review is to: (1) review cognitive training programs intended to remediate or prevent neurocognitive deficits in pediatric cancer patients and survivors, (2) critically analyze training program strengths and weaknesses to inform practice, and (3) provide recommendations for future directions of clinical care and research.
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Affiliation(s)
- Katie Olson
- a Children's National Medical Center , Divisions of Hematology and Oncology , Washington , DC , USA
| | - Stephen A Sands
- b Columbia University Medical Center, Herbert Irving Division of Child & Adolescent Oncology , New York , NY , USA
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23
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Long-term psychiatric outcomes in pediatric brain tumor survivors. Childs Nerv Syst 2015; 31:653-63. [PMID: 25726165 DOI: 10.1007/s00381-015-2669-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 02/20/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The increased efficacy of cancer treatments has led to a greater survival rate of patients with pediatric brain cancers. Therefore, it is imperative to explore the long-term consequences of therapies employed to treat pediatric brain tumors. The goal of this study was to provide a review of literature regarding the downstream psychological and psychiatric consequences experienced by adult survivors of pediatric brain cancer as a result of treatment, tumor type, or tumor location. METHODS A PubMed MeSH search and additional online database searches were conducted to include pertinent studies that discussed psychological deficits in childhood brain cancer survivors. The studies included were subjected to data extraction to quantify relevant information for further analysis. RESULTS A total of 17 papers with 5320 pediatric brain tumor patients were incorporated in our review. Mean age at diagnosis (8.13 ± 0.77 years), mean follow-up time (9.98 ± 3.05 years), and male-to-female ratios (1.08:1) were compiled from studies reporting this information. Incidences of depression (19 %), anxiety (20 %), suicidal ideation (10.9 %), schizophrenia and its related psychoses (9.8 %), and behavioral problem (28.7 %) were higher among pediatric brain cancer survivors than in the normal population. Craniospinal radiotherapy and/or surgery corresponded to an increased likelihood of developing adverse deficits. Astrocytomas or other glial tumors were linked to poorer outcomes. CONCLUSION Physicians treating pediatric brain tumor patients should be aware of the possible consequences associated with treatment. Psychiatric monitoring is warranted in survivors of pediatric brain tumors, but further investigation is needed to elucidate late outcomes regarding tumor type and location.
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Unsinn C, Neidert MC, Burkhardt JK, Holzmann D, Grotzer M, Bozinov O. Sellar and parasellar lesions - clinical outcome in 61 children. Clin Neurol Neurosurg 2014; 123:102-8. [PMID: 25012021 DOI: 10.1016/j.clineuro.2014.04.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 03/10/2014] [Accepted: 04/26/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate clinical outcome in a 10-year consecutive series of children operated for sellar and parasellar tumors with special focus on neuropsychology and endocrinology. PATIENTS AND METHODS We analyzed 61 children (30 female) under 18 years of age (mean age 9.9, range 1 month-17 years) operated between 2000 and 2010. Medical records were evaluated retrospectively; postoperative histologic diagnoses included 20 craniopharyngiomas, 17 gliomas, 6 pituitary adenomas and 18 rare tumor entities. RESULTS Of 61 patients, 58 (95%) were still alive at last follow-up. Three patients died, all due to progression of malignant rhabdoid tumors. Postoperative clinical morbidity consisted of endocrinological (66%), visual (60.7%) and other neurological deficits (55.9%) after a mean follow-up of 44 months. When compared to all other tumor entities in this series, craniopharyngiomas were associated with high rates of gross-total resection (p=0.008), frequent progression of residual tumor (p=0.005) scotomas (p=0.013), persistent diabetes insipidus (p<0.001), and panhypopituitarism (p<0.001). Surgically treated gliomas showed higher rates of motor weakness (p=0.004), double vision (p<0.001), and milder forms of endocrinopathy (single hormone deficits, p=0.02). In general, deterioration in school performance was associated with multiple surgeries (p=0.018) and radiotherapy (p=0.021). CONCLUSION Excellent overall survival in these patients is possible, however malignant rhabdoid tumors have a poor prognosis. Aggressive treatment is associated with significant morbidity. Children operated for craniopharyngioma showed an expected high rate of endocrine deterioration, whereas glioma patients had higher incidences of motor weakness and double vision. The treating physicians should be well aware of all these considerable postoperative deficits, especially when facing interdisciplinary management decisions, and for the informed consent discussions with the patient and the parents.
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Affiliation(s)
- Caroline Unsinn
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Jan-Karl Burkhardt
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - David Holzmann
- Department of Otorhinolaryngology, University Hospital Zurich, Zurich, Switzerland
| | - Michael Grotzer
- Department of Oncology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.
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25
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Rooney JW, Laack NN. Pharmacological interventions to treat or prevent neurocognitive decline after brain radiation. CNS Oncol 2013; 2:531-41. [PMID: 25054823 PMCID: PMC6136103 DOI: 10.2217/cns.13.60] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
After surgery, radiation is the most effective treatment for the majority of brain tumors in both children and adults. Although improvements in radiotherapy delivery and targeting have resulted in reduction in neurologic morbidity, radiotherapy is still associated with acute and late toxicities that are dependent on a variety of treatment- and patient-specific variables. Variables of treatment include radiation dose, fractionation, volume, technique, photons or protons, and concomitant or adjuvant chemotherapy. Patient- and tumor-specific variables include tumor type, location and patient age. Side effects of treatment are also variable and can range from mild fatigue to significant memory difficulties and even death. This review will focus on the hypothesized mechanisms of cognitive dysfunction after radiation therapy and will discuss possible intervention strategies including behavioral and pharmacological prevention and treatment.
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Affiliation(s)
- Jessica W Rooney
- Mayo Clinic Department of Radiation Oncology, 200 First Street SW, Rochester, MN 55905, USA
| | - Nadia N Laack
- Mayo Clinic Department of Radiation Oncology, 200 First Street SW, Rochester, MN 55905, USA
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Sung L, Zaoutis T, Ullrich NJ, Johnston D, Dupuis L, Ladas E. Children's Oncology Group's 2013 blueprint for research: cancer control and supportive care. Pediatr Blood Cancer 2013; 60:1027-30. [PMID: 23255159 PMCID: PMC4447629 DOI: 10.1002/pbc.24426] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 11/09/2012] [Indexed: 11/07/2022]
Abstract
In cancer control research, the objective is to reduce overall morbidity and mortality by decreasing acute and delayed treatment-related toxicities in all children with cancer. To date, the Children's Oncology Group (COG) has focused on infection, neurocognition, quality of life (QoL), and nutrition/antiemetics. COG is conducting randomized controlled trials (RCTs) to determine prophylaxis strategies that will reduce infections in high-risk populations. Two RCTs are determining if modafinil or computerized cognitive training improve cognitive functioning in pediatric brain tumor patients. QoL is being assessed in acute leukemia patients. Improved supportive care outcomes will only occur when the most effective interventions are established.
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Affiliation(s)
- Lillian Sung
- Department of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Theo Zaoutis
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nicole J. Ullrich
- Department of Neurology, Boston Children’s Hospital and Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Donna Johnston
- Department of Hematology/Oncology, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Lee Dupuis
- Department of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elena Ladas
- Department of Pediatric Oncology, Columbia University Medical Center, New York, New York
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Armenian SH, Landier W, Hudson MM, Robison LL, Bhatia S. Children's Oncology Group's 2013 blueprint for research: survivorship and outcomes. Pediatr Blood Cancer 2013; 60:1063-8. [PMID: 23255494 PMCID: PMC3799776 DOI: 10.1002/pbc.24422] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 11/07/2012] [Indexed: 12/12/2022]
Abstract
Improvements in the treatment of childhood cancer have resulted in over 360,000 survivors of childhood cancer in the U.S. There is now a heightened recognition of the need to reduce treatment-related sequelae and optimize the quality of life of children treated for cancer. Survivorship studies conducted in the cooperative group setting have provided us with important information on long-term intellectual function, organ toxicity, reproductive outcomes, second cancers, late mortality, and disparities in outcomes. Ongoing health education initiatives have helped standardize the follow-up care for childhood cancer survivors and facilitate the early transfer of health-related information to patients, families, and healthcare providers.
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Affiliation(s)
| | - Wendy Landier
- Department of Population Sciences, City of Hope, Duarte, CA
| | - Melissa M. Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Smita Bhatia
- Department of Population Sciences, City of Hope, Duarte, CA
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Abstract
OPINION STATEMENT Gliomas are the most common brain tumor in children and represent nearly 50 % of all pediatric central nervous system (CNS) tumors. They are a heterogeneous group of diseases, ranging from highly malignant and frequently fatal to histologically benign and curable by surgery alone. A uniform treatment approach to these tumors is not practical, due to their histological and biological heterogeneity. Low-grade gliomas (LGGs) are best treated with maximally safe surgical resection, generally achievable for hemispheric or cerebellar locations. Patients with deep midline, optic pathway/hypothalamic, and brain stem locations should undergo subtotal resection or biopsy only. If a complete resection is not feasible, subtotal resection followed by adjuvant chemotherapy or radiotherapy is the standard approach; however, observation alone with serial neuroimaging is used in some asymptomatic, surgically inaccessible lesions. Chemotherapy is used first-line in cases of residual or progressive disease, to avoid or delay radiation therapy and its associated side effects. Regimens demonstrating objective responses and increased progression free survival (PFS) include carboplatin and vincristine (CV), thioguanine/procarbazine/CCNU/vincristine (TPCV), or weekly vinblastine. High-grade gliomas (HGGs) are less common in children than in adults, though are similar in their aggressive clinical behavior, resistance to therapy, and dismal outcomes. There is not a single "standard of care" therapy for non-metastatic HGGs, but generally accepted is an aggressive attempt at a complete surgical resection, followed by multimodality therapy with focal radiation and chemotherapy. The use of temozolomide (TMZ) during and following radiotherapy is common, though it appeared not to improve the outcome in a cooperative group clinical trial when compared to an historical control cohort. The angiogenesis inhibitor bevacizumab, used alone or in combination with irinotecan, is also commonly used as maintenance therapy after radiation. Current trials are prospectively comparing TMZ to newer agents (vorinostat, bevacizumab) in a randomized phase II trial. Brainstem gliomas are a unique category of childhood gliomas. Approximately 80 % of childhood brainstem gliomas arise within the pons as diffuse intrinsic pontine gliomas (DIPG). When biopsied, these are usually HGGs and carry a dismal prognosis. Standard therapy is focal radiation (54-58 Gy), preferably on a clinical trial testing concurrent chemotherapy or biologic agent. No standard chemotherapy agent has impacted survival. The remaining 20 % of brainstem gliomas are low-grade, arise in the midbrain, dorsal medulla, or cervicomedullary junction, and are indolent in nature with a much better prognosis. Improvement in the outcome of all childhood gliomas will require increased knowledge of the underlying biology of these tumors, in order to treat with more biologically based and precise therapies.
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Affiliation(s)
- Jane E Minturn
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, 3501 Civic Center Boulevard, CTRB 4028, Philadelphia, PA, 19104, USA
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Computerized assessment of cognitive late effects among adolescent brain tumor survivors. J Neurooncol 2013; 113:333-40. [PMID: 23525951 DOI: 10.1007/s11060-013-1123-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 03/16/2013] [Indexed: 10/27/2022]
Abstract
Advantages of computerized assessment of neuropsychological functions include improved standardization and increased reliability of response time variables. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is a computerized battery developed for monitoring recovery following mild brain injuries that assesses attention, memory and processing speed. Despite evidence that core areas of deficit among cancer survivors are those assessed by ImPACT, it has not previously been used with this population. Twenty four childhood brain tumor (BT) survivors treated with conformal radiation therapy (mean age = 15.7 ± 1.6; mean age at irradiation = 9.8 ± 2.5), twenty solid tumor (ST) survivors treated without CNS-directed therapy (mean age = 16.2 ± 1.8) and twenty healthy siblings (mean age = 15.1 ± 1.6 years) were administered an age modified version of ImPACT. Additional computerized measures of working memory and recognition memory were administered. Univariate ANOVAs revealed group differences (p < 0.05) on measures of recognition memory, spatial working memory, processing speed and reaction time, with BT survivors performing significantly worse than ST survivors and siblings. Pearson correlation coefficients revealed significant associations between ImPACT memory tasks and computerized forced choice recognition tasks (rs = 0.30-0.33, p < 0.05). Multiple surgical resections, hydrocephalus and CSF shunt placement most consistently predicted worse ImPACT performance using linear mixed models (p < 0.05). The ImPACT test battery demonstrated sensitivity to cognitive late effects experienced by some BT survivors with clinical predictors of performance consistent with the pediatric oncology literature. Correlations with measures of similar constructs provide evidence for convergent validity. Findings offer initial support for the utility of ImPACT for monitoring of cognitive late effects.
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Kahalley LS, Conklin HM, Tyc VL, Hudson MM, Wilson SJ, Wu S, Xiong X, Hinds PS. Slower processing speed after treatment for pediatric brain tumor and acute lymphoblastic leukemia. Psychooncology 2013; 22:1979-86. [PMID: 23447439 DOI: 10.1002/pon.3255] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 01/11/2013] [Accepted: 01/16/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Acute lymphoblastic leukemia (ALL) and brain tumor (BT) survivors are at risk for post-treatment IQ declines. The extent to which lower scores represent global cognitive decline versus domain-specific impairment remains unclear. This study examined discrepancies between processing speed and estimated IQ (EIQ) scores and identified clinical characteristics associated with score discrepancies in a sample of pediatric cancer survivors. PROCEDURE Survivors (50 ALL, 50 BT) ages 12-17 years completed cognitive testing. The Wechsler Abbreviated Scale of Intelligence provided an untimed measure of general reasoning ability (EIQ). The age-appropriate Wechsler Intelligence Scale provided a Processing Speed Index (PSI) score. Scores were examined and compared. RESULTS Survivors' PSI scores were lower than their EIQ scores (BT t(45) =6.3, p<0.001; ALL t(49) =6.9, p<0.001). For BT survivors, lower PSI scores were associated with history of craniospinal irradiation, t(44) =3.3, p<0.01. For ALL survivors, lower PSI scores were associated with male gender, grade retention, and time since diagnosis, F(3, 46) =10.1, p<0.001. Clinically significant EIQ-PSI score discrepancies were identified in 41.3% of BT and 14.0% of ALL survivors. CONCLUSIONS Many pediatric BT and ALL survivors exhibit slower processing speed than expected for age, whereas general reasoning ability remains largely intact. Risk factors associated with larger EIQ-PSI discrepancies include the following: BT diagnosis, craniospinal irradiation (BT only), male gender, and younger age at diagnosis (ALL only). Grade retention was frequent and associated with lower EIQ scores (both groups) and PSI scores (ALL only). Describing post-treatment cognitive declines using global measures of intellectual ability may underestimate dysfunction or fail to isolate specific underlying deficits contributing to impairment.
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Affiliation(s)
- Lisa S Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX, USA.
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Affiliation(s)
- Katherine E Warren
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Building 10/Room 1-5750, 9000 Rockville Pike, Bethesda, MD, 20892, USA
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Padovani L, André N, Constine LS, Muracciole X. Neurocognitive function after radiotherapy for paediatric brain tumours. Nat Rev Neurol 2012; 8:578-88. [DOI: 10.1038/nrneurol.2012.182] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Ermoian R, Ladra M, Patel S. Children's Oncology Group L991 final study report: Establishing an important benchmark for assessing late effects of trimodality care of pediatric patients treated for high grade gliomas. Transl Pediatr 2012; 1:3-5. [PMID: 26835257 PMCID: PMC4728847 DOI: 10.3978/j.issn.2224-4336.2012.04.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ralph Ermoian
- University of Washington, Department of Radiation Oncology, UWMC Cancer Center, Box 356043, 1959 Pacific Street, Seattle, WA 98195-6043, USA
| | - Matthew Ladra
- University of Washington, Department of Radiation Oncology, UWMC Cancer Center, Box 356043, 1959 Pacific Street, Seattle, WA 98195-6043, USA
| | - Shilpen Patel
- University of Washington, Department of Radiation Oncology, UWMC Cancer Center, Box 356043, 1959 Pacific Street, Seattle, WA 98195-6043, USA
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