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Roosen M, Odé Z, Bunt J, Kool M. The oncogenic fusion landscape in pediatric CNS neoplasms. Acta Neuropathol 2022; 143:427-451. [PMID: 35169893 PMCID: PMC8960661 DOI: 10.1007/s00401-022-02405-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/31/2022] [Accepted: 01/31/2022] [Indexed: 01/09/2023]
Abstract
Pediatric neoplasms in the central nervous system (CNS) are the leading cause of cancer-related deaths in children. Recent developments in molecular analyses have greatly contributed to a more accurate diagnosis and risk stratification of CNS tumors. Additionally, sequencing studies have identified various, often entity specific, tumor-driving events. In contrast to adult tumors, which often harbor multiple mutated oncogenic drivers, the number of mutated genes in pediatric cancers is much lower and many tumors can have a single oncogenic driver. Moreover, in children, much more than in adults, fusion proteins play an important role in driving tumorigenesis, and many different fusions have been identified as potential driver events in pediatric CNS neoplasms. However, a comprehensive overview of all the different reported oncogenic fusion proteins in pediatric CNS neoplasms is still lacking. A better understanding of the fusion proteins detected in these tumors and of the molecular mechanisms how these proteins drive tumorigenesis, could improve diagnosis and further benefit translational research into targeted therapies necessary to treat these distinct entities. In this review, we discuss the different oncogenic fusions reported in pediatric CNS neoplasms and their structure to create an overview of the variety of oncogenic fusion proteins to date, the tumor entities they occur in and their proposed mode of action.
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Affiliation(s)
- Mieke Roosen
- Princess Máxima Center for Pediatric Oncology, 3584CS, Utrecht, The Netherlands
| | - Zelda Odé
- Princess Máxima Center for Pediatric Oncology, 3584CS, Utrecht, The Netherlands
| | - Jens Bunt
- Princess Máxima Center for Pediatric Oncology, 3584CS, Utrecht, The Netherlands
| | - Marcel Kool
- Princess Máxima Center for Pediatric Oncology, 3584CS, Utrecht, The Netherlands.
- Hopp Children's Cancer Center (KiTZ), 69120, Heidelberg, Germany.
- Division of Pediatric Neurooncology, German Cancer Research Center DKFZ and German Cancer Consortium DKTK, 69120, Heidelberg, Germany.
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2
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Fangusaro J, Cefalo MG, Garré ML, Marshall LV, Massimino M, Benettaib B, Biserna N, Poon J, Quan J, Conlin E, Lewandowski J, Simcock M, Jeste N, Hargrave DR, Doz F, Warren KE. Phase 2 Study of Pomalidomide (CC-4047) Monotherapy for Children and Young Adults With Recurrent or Progressive Primary Brain Tumors. Front Oncol 2021; 11:660892. [PMID: 34168987 PMCID: PMC8218626 DOI: 10.3389/fonc.2021.660892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/23/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Treatment of recurrent primary pediatric brain tumors remains a major challenge, with most children succumbing to their disease. We conducted a prospective phase 2 study investigating the safety and efficacy of pomalidomide (POM) in children and young adults with recurrent and progressive primary brain tumors. Methods Patients with recurrent and progressive high-grade glioma (HGG), diffuse intrinsic pontine glioma (DIPG), ependymoma, or medulloblastoma received POM 2.6 mg/m2/day (the recommended phase 2 dose [RP2D]) on days 1-21 of a 28-day cycle. A Simon's Optimal 2-stage design was used to determine efficacy. Primary endpoints included objective response (OR) and long-term stable disease (LTSD) rates. Secondary endpoints included duration of response, progression-free survival (PFS), overall survival (OS), and safety. Results 46 patients were evaluable for response (HGG, n = 19; DIPG, ependymoma, and medulloblastoma, n = 9 each). Two patients with HGG achieved OR or LTSD (10.5% [95% CI, 1.3%-33.1%]; 1 partial response and 1 LTSD) and 1 patient with ependymoma had LTSD (11.1% [95% CI, 0.3%-48.2%]). There were no ORs or LTSD in the DIPG or medulloblastoma cohorts. The median PFS for patients with HGG, DIPG, ependymoma, and medulloblastoma was 7.86, 11.29, 8.43, and 8.43 weeks, respectively. Median OS was 5.06, 3.78, 12.02, and 11.60 months, respectively. Neutropenia was the most common grade 3/4 adverse event. Conclusions Treatment with POM monotherapy did not meet the primary measure of success in any cohort. Future studies are needed to evaluate if POM would show efficacy in tumors with specific molecular signatures or in combination with other anticancer agents. Clinical Trial Registration ClinicalTrials.gov, identifier NCT03257631; EudraCT, identifier 2016-002903-25.
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Affiliation(s)
- Jason Fangusaro
- Department of Pediatrics, Children's Healthcare of Atlanta and Aflac Cancer Center at Emory University Medical School, Atlanta, GA, United States
| | - Maria Giuseppina Cefalo
- Department of Hematology/Oncology and Stem Cell Transplantation, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | | | - Lynley V Marshall
- Children and Young People's Unit, The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom
| | - Maura Massimino
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Noha Biserna
- Bristol Myers Squibb, Princeton, NJ, United States
| | | | - Jackie Quan
- Bristol Myers Squibb, Princeton, NJ, United States
| | - Erin Conlin
- Bristol Myers Squibb, Princeton, NJ, United States
| | | | | | - Neelum Jeste
- Bristol Myers Squibb, Princeton, NJ, United States
| | - Darren R Hargrave
- Pediatric Oncology Unit, UCL Great Ormond Street Hospital for Children, London, United Kingdom
| | - François Doz
- Department of Pediatric Oncology, Institut Curie and University of Paris, Paris, France
| | - Katherine E Warren
- National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
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3
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Peeters SM, Muftuoglu Y, Na B, Daniels DJ, Wang AC. Pediatric Gliomas: Molecular Landscape and Emerging Targets. Neurosurg Clin N Am 2021; 32:181-190. [PMID: 33781501 DOI: 10.1016/j.nec.2020.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Next-generation sequencing of pediatric gliomas has revealed the importance of molecular genetic characterization in understanding the biology underlying these tumors and a breadth of potential therapeutic targets. Promising targeted therapies include mTOR inhibitors for subependymal giant cell astrocytomas in tuberous sclerosis, BRAF and MEK inhibitors mainly for low-grade gliomas, and MEK inhibitors for NF1-deficient BRAF:KIAA fusion tumors. Challenges in developing targeted molecular therapies include significant intratumoral and intertumoral heterogeneity, highly varied mechanisms of treatment resistance and immune escape, adequacy of tumor penetrance, and sensitivity of brain to treatment-related toxicities.
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Affiliation(s)
- Sophie M Peeters
- Department of Neurosurgery, University of California Los Angeles, 300 Stein Plaza, Suite #520, Los Angeles, CA 90095, USA
| | - Yagmur Muftuoglu
- Department of Neurosurgery, University of California Los Angeles, 300 Stein Plaza, Suite #520, Los Angeles, CA 90095, USA
| | - Brian Na
- Department of Pediatrics, Division of Hematology/Oncology, University of California Los Angeles, 200 UCLA Medical Plaza, Suite 265, Los Angeles, CA 90095, USA
| | - David J Daniels
- Department of Neurosurgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Anthony C Wang
- Department of Neurosurgery, University of California Los Angeles, 300 Stein Plaza, Suite #520, Los Angeles, CA 90095, USA.
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4
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Nix JS, Blakeley J, Rodriguez FJ. An update on the central nervous system manifestations of neurofibromatosis type 1. Acta Neuropathol 2020; 139:625-641. [PMID: 30963251 DOI: 10.1007/s00401-019-02002-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/30/2019] [Accepted: 04/01/2019] [Indexed: 02/06/2023]
Abstract
Neurofibromatosis 1 (NF1) is an autosomal dominant genetic disorder that presents with variable phenotypes as a result of mutations in the neurofibromatosis type 1 (NF1) gene and subsequently, abnormal function of the protein product, neurofibromin. Patients with NF1 are at increased risk for central nervous system (CNS) manifestations including structural, functional, and neoplastic disease. The mechanisms underlying the varied manifestations of NF1 are incompletely understood, but the loss of functional neurofibromin, resulting in sustained activation of the oncoprotein RAS, is responsible for tumorigenesis throughout the body, including the CNS. Much of our understanding of NF1-related CNS manifestations is from a combination of data from animal models and natural history studies of people with NF1 and CNS disease. Data from animal models suggest the importance of both Nf1 mutations and somatic genetic alterations, such as Tp53 loss, for development of neoplasms, as well as the role of the timing of the acquisition of such alterations on the variability of CNS manifestations. A variety of non-neoplastic structural (macrocephaly, hydrocephalus, aqueductal stenosis, and vasculopathy) and functional (epilepsy, impaired cognition, attention deficits, and autism spectrum disorder) abnormalities occur with variable frequency in individuals with NF1. In addition, there is increasing evidence that similar appearing CNS neoplasms in people with and without the NF1 syndrome are due to distinct oncogenic pathways. Gliomas in people with NF1 show alterations in the RAS/MAPK pathway, generally in the absence of BRAF alterations (common to sporadic pilocytic astrocytomas) or IDH or histone H3 mutations (common to diffuse gliomas subsets). A subset of low-grade astrocytomas in these patients remain difficult to classify using standard criteria, and occasionally demonstrate morphologic features resembling subependymal giant cell astrocytomas that afflict patients with tuberous sclerosis complex ("SEGA-like astrocytomas"). There is also emerging evidence that NF1-associated high-grade astrocytomas have frequent co-existing alterations such as ATRX mutations and an alternative lengthening of telomeres (ALT) phenotype responsible for unique biologic properties. Ongoing efforts are seeking to improve diagnostic accuracy for CNS neoplasms in the setting of NF1 versus sporadic tumors. In addition, MEK inhibitors, which act on the RAS/MAPK pathway, continue to be studied as rational targets for the treatment of NF1-associated tumors, including CNS tumors.
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5
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Walter AW, Kandula VVR, Shah N. Larotrectinib imaging response in low-grade glioma. Pediatr Blood Cancer 2020; 67:e28002. [PMID: 31544356 DOI: 10.1002/pbc.28002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/01/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Andrew W Walter
- Divisions of Pediatric Hematology/Oncology, Department of Imaging, A. I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Vinay V R Kandula
- Divisions of Pediatric Hematology/Oncology, Department of Imaging, A. I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Nidhi Shah
- Pediatric Hematology/Oncology, Penn State College of Medicine, Hershey, Pennsylvania, USA
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6
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Mitogenic and progenitor gene programmes in single pilocytic astrocytoma cells. Nat Commun 2019; 10:3731. [PMID: 31427603 PMCID: PMC6700116 DOI: 10.1038/s41467-019-11493-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 07/10/2019] [Indexed: 01/28/2023] Open
Abstract
Pilocytic astrocytoma (PA), the most common childhood brain tumor, is a low-grade glioma with a single driver BRAF rearrangement. Here, we perform scRNAseq in six PAs using methods that enabled detection of the rearrangement. When compared to higher-grade gliomas, a strikingly higher proportion of the PA cancer cells exhibit a differentiated, astrocyte-like phenotype. A smaller proportion of cells exhibit a progenitor-like phenotype with evidence of proliferation. These express a mitogen-activated protein kinase (MAPK) programme that was absent from higher-grade gliomas. Immune cells, especially microglia, comprise 40% of all cells in the PAs and account for differences in bulk expression profiles between tumor locations and subtypes. These data indicate that MAPK signaling is restricted to relatively undifferentiated cancer cells in PA, with implications for investigational therapies directed at this pathway. Pilocytic astrocytoma is a low-grade pediatric glioma, characterized by a single BRAF rearrangement. Here, Reitman and colleagues use single-cell RNA sequencing to reveal molecular hallmarks of the disease that might be targeted therapeutically.
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7
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Cooney T, Yeo KK, Kline C, Prados M, Haas-Kogan D, Chi S, Mueller S. Neuro-Oncology Practice Clinical Debate: targeted therapy vs conventional chemotherapy in pediatric low-grade glioma. Neurooncol Pract 2019; 7:4-10. [PMID: 32257279 DOI: 10.1093/nop/npz033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The treatment of children with low-grade glioma has evolved over the last several decades, beginning initially with focal radiotherapy, which has now been largely replaced by systemic treatment with conventional chemotherapy agents or more recently molecularly targeted therapeutics. A consensus standard of care is not well defined, leaving clinicians and parents to choose from an increasing number of options, often without complete information concerning the associated risks and benefits. Issues critical to this topic include timing of interventions (when to treat), preservation of neurological function (goals of treatment), choice of initial therapy strategy (conventional cytotoxic chemotherapy vs molecularly targeted therapy), duration of treatment (how long, and what clinical or imaging endpoints to consider), and perhaps most important, risk reduction relative to anticipated benefit. The groups from the University of California, San Francisco and Dana Farber Cancer Institute, moderated by Michael Prados, herein debate the merits of cytotoxic chemotherapy and targeted therapeutics as initial treatment strategies in pediatric low-grade glioma, a topic discussed daily in Tumor Boards across the United States and abroad. Prospective, randomized, phase 3 trials comparing the 2 strategies, conducted within homogenous disease settings, with consistently evaluated functional and imaging endpoints, are not available to guide the risks/benefit discussion. As is often the case in rare biologically diverse diseases, in a vulnerable population, therapy decisions are frequently based on incomplete data, physician experience, bias to some degree, and patient/family preference.
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Affiliation(s)
- Tabitha Cooney
- Department of Pediatrics, University of California, San Francisco
| | - Kee Kiat Yeo
- Dana Farber Cancer Institute, Boston, MA.,Boston Children's Hospital, MA.,Harvard Medical School, Boston MA
| | - Cassie Kline
- Department of Pediatrics, University of California, San Francisco.,Department of Neurology, University of California, San Francisco
| | - Michael Prados
- Department of Neurology, University of California, San Francisco.,Department of Neurosurgery, University of California, San Francisco
| | - Daphne Haas-Kogan
- Boston Children's Hospital, MA.,Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston MA
| | - Susan Chi
- Dana Farber Cancer Institute, Boston, MA.,Boston Children's Hospital, MA.,Harvard Medical School, Boston MA
| | - Sabine Mueller
- Department of Pediatrics, University of California, San Francisco.,Department of Neurology, University of California, San Francisco.,Department of Neurosurgery, University of California, San Francisco.,Children's Hospital University of Zürich, Oncology, Switzerland
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8
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Miklja Z, Pasternak A, Stallard S, Nicolaides T, Kline-Nunnally C, Cole B, Beroukhim R, Bandopadhayay P, Chi S, Ramkissoon SH, Mullan B, Bruzek AK, Gauthier A, Garcia T, Atchison C, Marini B, Fouladi M, Parsons DW, Leary S, Mueller S, Ligon KL, Koschmann C. Molecular profiling and targeted therapy in pediatric gliomas: review and consensus recommendations. Neuro Oncol 2019; 21:968-980. [PMID: 30805642 PMCID: PMC6682212 DOI: 10.1093/neuonc/noz022] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
As the field of neuro-oncology makes headway in uncovering the key oncogenic drivers in pediatric glioma, the role of precision diagnostics and therapies continues to rapidly evolve with important implications for the standard of care for clinical management of these patients. Four studies at major academic centers were published in the last year outlining the clinically integrated molecular profiling and targeting of pediatric brain tumors; all 4 demonstrated the feasibility and utility of incorporating sequencing into the care of children with brain tumors, in particular for children and young adults with glioma. Based on synthesis of the data from these studies and others, we provide consensus recommendations for the integration of precision diagnostics and therapeutics into the practice of pediatric neuro-oncology. Our primary consensus recommendation is that next-generation sequencing should be routinely included in the workup of most pediatric gliomas.
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Affiliation(s)
- Zachary Miklja
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Amy Pasternak
- University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | | | | | - Cassie Kline-Nunnally
- University of California San Francisco (UCSF) Benioff Children’s Hospital, San Francisco, California
| | - Bonnie Cole
- Seattle Children’s Hospital/University of Washington (UW), Seattle, Washington
| | | | | | - Susan Chi
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Shakti H Ramkissoon
- Foundation Medicine, Morrisville, North Carolina
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Brendan Mullan
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Amy K Bruzek
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Taylor Garcia
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Bernard Marini
- University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | | | | | - Sarah Leary
- Seattle Children’s Hospital/University of Washington (UW), Seattle, Washington
| | - Sabine Mueller
- University of California San Francisco (UCSF) Benioff Children’s Hospital, San Francisco, California
| | - Keith L Ligon
- Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
| | - Carl Koschmann
- University of Michigan Medical School, Ann Arbor, Michigan
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9
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Abstract
PURPOSE OF REVIEW Pediatric low-grade gliomas (pLGGs) have been treated with similar therapies for the last 30 years. Recent biological insights have allowed a new generation of targeted therapies to be developed for these diverse tumors. At the same time, technological advances may redefine the late toxicities associated with radiation therapy. Understanding recent developments in pLGG therapy is essential to the management of these common pediatric tumors. RECENT FINDINGS It is now well understood that aberrations of the mitogen-activated protein kinase pathway are key to oncogenesis in low-grade gliomas. This understanding, along with the development of available targeted agents, have heralded a new era of understanding and treatment for these patients. Promising, sustained responses are now being seen in early phase trials among patients with multiply recurrent/progressive disease. Also, newer and highly conformal radiation approaches such as proton beam radiotherapy maintain efficacy of radiation but limit radiation-associated toxicities. SUMMARY Novel therapies offer the potential for tumor control with greatly reduced toxicities. However, late effects of these therapies are just now being explored. Improved radiation approaches and targeted agents have the potential to redefine traditional therapy for pLGG.
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10
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Wagner LM, Myseros JS, Lukins DE, Willen CM, Packer RJ. Targeted therapy for infants with diencephalic syndrome: A case report and review of management strategies. Pediatr Blood Cancer 2018; 65:e26917. [PMID: 29369501 DOI: 10.1002/pbc.26917] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 10/30/2017] [Accepted: 11/06/2017] [Indexed: 02/04/2023]
Abstract
Young children with emaciation caused by a hypothalamic glioma are considered to have diencephalic syndrome (DS), which is often poorly controlled with conventional treatment. We describe an infant with DS whose tumor progressed following chemotherapy. Biopsy was performed for molecular testing and demonstrated a BRAF fusion. Treatment with the MEK inhibitor trametinib for 18 months resulted in reduction of tumor size, normalization of his weight curve, and marked neurodevelopmental improvement. Our results build on earlier reports of using targeted agents for low-grade glioma, and we review the evolving management strategy for such patients in the era of precision medicine.
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Affiliation(s)
- Lars M Wagner
- Division of Pediatric Hematology/Oncology, Kentucky Children's Hospital, University of Kentucky, Lexington, Kentucky
| | - John S Myseros
- Division of Neurosurgery, Children's National Health System, George Washington University, Washington, District of Columbia
| | - Douglas E Lukins
- Department of Radiology, Kentucky Children's Hospital, University of Kentucky, Lexington, Kentucky
| | - Christi M Willen
- Department of Ophthalmology, Kentucky Children's Hospital, University of Kentucky, Lexington, Kentucky
| | - Roger J Packer
- Department of Neurology, Children's National Health System, George Washington University, Washington, District of Columbia.,Center for Neuroscience and Behavioral Medicine, Children's National Health System, George Washington University, Washington, District of Columbia
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