1
|
Shariff N, Moreno AS, Bennett J, Ramaswamy V, Das A, Liu AP, Huang A, Tabori U, Hawkins C, Dirks P, Bouffet E, Keilty DM, Millar BA, Hodgson DC, Tsang DS. Re-irradiation for children with diffuse intrinsic pontine glioma and diffuse midline glioma. Radiother Oncol 2025; 207:110865. [PMID: 40139463 DOI: 10.1016/j.radonc.2025.110865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2024] [Revised: 02/26/2025] [Accepted: 03/09/2025] [Indexed: 03/29/2025]
Abstract
BACKGROUND AND PURPOSE Diffuse intrinsic pontine glioma (DIPG) and diffuse midline glioma (DMG) are incurable brain malignancies. In this study, we report one of the largest known single-institution cohorts of DIPG/DMG patients undergoing re-irradiation (RT2) to evaluate its effect on survival. MATERIALS AND METHODS Children aged less than 18 years treated for DIPG/DMG with initial fractionated photon radiotherapy (RT1) and had subsequent recurrence were retrospectively reviewed. Patients treated with or without RT2 were compared. The primary outcomes were overall survival (OS) from time of recurrence after RT1, and from start of RT2 (for the RT2 group). RESULTS A total of 118 children were included, 39 of whom received RT2. Children treated with RT2 had superior OS, with 6-month OS of 66 % vs 22 % in those who did not undergo RT2 (p < 0.0001). Median survivals were 6.9 months for the RT2 group vs 2.7 months for RT1 only. Median time from RT1 to RT2 was 7.7 months; patients with a greater than 1-year latent time between RT1 and RT2 had longer OS from start of RT2 (median 10.9 months vs 5.5 months, p = 0.023). 61 % of those treated with RT2 experienced improvement of neurologic symptoms post-RT2. Multivariate analysis identified younger age, adverse imaging findings on the 4-week post-RT1 reassessment MRI (including pseudoprogression), and the absence of RT2 as poor prognostic factors for OS. CONCLUSION Re-irradiation was associated with improved survival and neurological recovery in children with recurrent DIPG and DMG. There is a need to identify novel biomarkers to better select patients who respond best to RT2.
Collapse
Affiliation(s)
- Nisha Shariff
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada; Department of Clinical Oncology, University Malaya Medical Centre, Malaysia
| | - Alejandro S Moreno
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Julie Bennett
- Division of Haematology/Oncology, Hospital for Sick Children, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, Hospital for Sick Children, Canada
| | - Anirban Das
- Division of Haematology/Oncology, Hospital for Sick Children, Canada
| | - Anthony P Liu
- Division of Haematology/Oncology, Hospital for Sick Children, Canada
| | - Annie Huang
- Division of Haematology/Oncology, Hospital for Sick Children, Canada
| | - Uri Tabori
- Division of Haematology/Oncology, Hospital for Sick Children, Canada
| | - Cynthia Hawkins
- Department of Paediatric Laboratory Medicine, Hospital for Sick Children, Canada
| | - Peter Dirks
- Division of Neurosurgery, Hospital for Sick Children, Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, Hospital for Sick Children, Canada
| | - Dana M Keilty
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Barbara-Ann Millar
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada
| | - David C Hodgson
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada.
| |
Collapse
|
2
|
Jouglar E, de Marzi L, Verrelle P, Créhange G, Ferrand R, Doz F, Prezado Y, Paoletti X. From pre-clinical studies to human treatment with proton-minibeam radiation therapy: adapted Idea, Development, Exploration, Assessment and Long-term evaluation (IDEAL) framework for innovation in radiotherapy. Clin Transl Radiat Oncol 2025; 52:100932. [PMID: 40124645 PMCID: PMC11928333 DOI: 10.1016/j.ctro.2025.100932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2024] [Revised: 01/24/2025] [Accepted: 02/10/2025] [Indexed: 03/25/2025] Open
Abstract
The implementation and spread of new radiation therapy (RT) techniques are often rushed through before or without high-quality proof of a clinical benefit. The framework for phase 1, 2 and 3 trials, ideally designed for pharmaceutical evaluation, is not always appropriate for RT interventions. The IDEAL framework is a five-step process initially developed to enable the rapid implementation of surgical innovations while limiting risks for patients. IDEAL was subsequently adapted to RT. Proton-minibeam radiation therapy (pMBRT) is an innovative RT approach, using an array of parallel thin beams resulting in an outstanding increase in the therapeutic ratio. Cumulative preclinical evidence showed pMBRT was superior to standard RT regarding brain tolerance and provided equivalent or better local control in several glioblastoma models. We decided to adapt IDEAL to pMBRT to accelerate the implementation of this promising new technique in clinical care and present here some examples of possible upcoming studies.
Collapse
Affiliation(s)
- Emmanuel Jouglar
- Institut Curie, PSL Research University, Department of Radiation Oncology - Paris and Orsay Protontherapy Center, Paris, France
- Paris-Saclay University, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, Orsay, France
| | - Ludovic de Marzi
- Institut Curie, PSL Research University, Department of Radiation Oncology - Paris and Orsay Protontherapy Center, Paris, France
- Institut Curie, PSL Research University, Inserm U1288, Laboratoire d’Imagerie Translationnelle en Oncologie (LITO), Orsay, France
| | - Pierre Verrelle
- Institut Curie, PSL Research University, CNRS UMR9187, Inserm U1196, Orsay, France
| | - Gilles Créhange
- Institut Curie, PSL Research University, Department of Radiation Oncology - Paris and Orsay Protontherapy Center, Paris, France
- Institut Curie, PSL Research University, Inserm U1288, Laboratoire d’Imagerie Translationnelle en Oncologie (LITO), Orsay, France
| | - Regis Ferrand
- Institut Curie, PSL Research University, Department of Radiation Oncology - Paris and Orsay Protontherapy Center, Paris, France
| | - François Doz
- SIREDO Centre (Care, Innovation and Research in Pediatric, Adolescent and Young Adults Oncology), Institut Curie, Paris and University Paris Cité, Paris, France
| | - Yolanda Prezado
- Paris-Saclay University, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, Orsay, France
| | - Xavier Paoletti
- Institut Curie, PSL Research University, Biostatistic Unit, Paris, France
| |
Collapse
|
3
|
Zaghloul MS, Bishr MK, Refaat A, Hemaly AE, Ayadi MA, Ahmed S, Maher E, Todary ES. Re-Irradiation for the Progressive Pediatric Diffuse Intrinsic Pontine Glioma: A Report on 109 Children From a Single Center. Pediatr Blood Cancer 2025; 72:e31587. [PMID: 39905588 DOI: 10.1002/pbc.31587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2024] [Revised: 01/10/2025] [Accepted: 01/27/2025] [Indexed: 02/06/2025]
Abstract
BACKGROUND Diffuse intrinsic pontine glioma (DIPG) is a challenging pediatric tumor that frequently progresses within the first year following local radiotherapy. However, several small studies have suggested that re-irradiation may improve quality of life and extend overall survival. PATIENTS AND METHODS This retrospective study included 109 children who experienced disease progression ≥3 months after their initial radiotherapy, and subsequently received re-irradiation at a single institution. These patients were compared with a cohort of 60 children, meeting the same criteria, who were treated before adopting the re-irradiation policy and received only the best supportive care (BSC). Most of the re-irradiated children (94%) received first radiation dose as hypofractionation (39 Gy/13 fractions). RESULTS The re-irradiation group demonstrated significantly higher overall survival (OS) rates after the first progression, with a 6-month OS of 42% (95% CI: 34%-53%) compared to 16% (95% CI: 8.9%-32%) in the BSC group (p < 0.001). Re-irradiation reduced the hazard of death by more than half (HR = 0.45, p < 0.001). Clinical response (p < 0.001) and radiological response (p = 0.016) were significant predictors of improved survival. While the time from initial radiotherapy to progression (p = 0.059) and higher re-irradiation doses (p = 0.074) were associated with improved OS, these factors did not reach statistical significance but may represent potential prognostic indicators. CONCLUSION Re-irradiation improved the OS in children with progression of DIPG and alleviated their signs and symptoms.
Collapse
Affiliation(s)
- Mohamed Saad Zaghloul
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
- Radiation Oncology Department, Children's Cancer Hospital, Cairo, Egypt
| | - Mai K Bishr
- The Institute of Cancer Research, London, UK
| | - Amal Refaat
- Radiology Department, National Cancer Institute, Cairo University, Cairo, Egypt
- Radiology Department, Children's Cancer Hospital, Cairo, Egypt
| | - Ahmed El Hemaly
- Pediatric Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
- Pediatric Oncology Department, Children's Cancer Hospital, Cairo, Egypt
| | - Moatssem Al Ayadi
- Pediatric Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
- Pediatric Oncology Department, Children's Cancer Hospital, Cairo, Egypt
| | - Soha Ahmed
- Clinical Oncology Department, Suez University, Suez, Egypt
| | - Eslam Maher
- Clinical Research Department, Children's Cancer Hospital, Cairo, Egypt
| | - Engy S Todary
- Radiation Oncology Department, Children's Cancer Hospital, Cairo, Egypt
| |
Collapse
|
4
|
Kahvecioglu A, Cengiz M, Burca Aydin G, Tezer Kutluk M, Coban Cifci G, Yazici G. Re-irradiation in progressive diffuse infiltrative pontine glioma in children and young adults. Strahlenther Onkol 2025:10.1007/s00066-025-02394-z. [PMID: 40131412 DOI: 10.1007/s00066-025-02394-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2024] [Accepted: 03/05/2025] [Indexed: 03/27/2025]
Abstract
PURPOSE This study aims to assess oncological outcomes in children and young adults with diffuse infiltrative pontine glioma (DIPG) who have progressed after initial radiotherapy (RT), with an emphasis on the role of re-irradiation. METHODS Data from 33 patients aged 25 years or younger with progressive disease after initial RT were retrospectively analyzed. RESULTS The median age at diagnosis was 8 years (range 4-24 years), and the median initial RT dose was 54 Gy (range 39-54 Gy). The median time between initial RT and progression was 8 months (range 3-40 months). In addition to systemic therapy, 15 patients (46%) received re-irradiation due to progression, with a median dose of 23.4 Gy (range 19.8-36 Gy), while 18 patients (54%) were treated with systemic therapy alone. In patients who received re-irradiation after progression, the 1‑year post-progression overall survival (OS) was significantly higher compared to those treated with systemic therapy alone (27% vs. 0%, p = 0.01). Among the 15 re-irradiated patients, 9 out of 12 with available data (75%) showed improvement in neurological symptoms following re-irradiation. No patient exhibited acute or late RT-related ≥ grade 3 toxicity. CONCLUSION Palliative re-irradiation in children and young adults with progressive DIPG after initial RT provides an approximately 3‑month OS benefit and clinical improvement without significant toxicity and should be considered as a standard-of-care approach.
Collapse
Affiliation(s)
- Alper Kahvecioglu
- Faculty of Medicine, Department of Radiation Oncology, Hacettepe University, Sihhiye, 06100, Ankara, Turkey
| | - Mustafa Cengiz
- Faculty of Medicine, Department of Radiation Oncology, Hacettepe University, Sihhiye, 06100, Ankara, Turkey
| | - Guzide Burca Aydin
- Faculty of Medicine, Department of Pediatric Oncology, Hacettepe University, Sihhiye, 06100, Ankara, Turkey
| | - Mustafa Tezer Kutluk
- Faculty of Medicine, Department of Pediatric Oncology, Hacettepe University, Sihhiye, 06100, Ankara, Turkey
| | - Gokcen Coban Cifci
- Faculty of Medicine, Department of Radiology, Hacettepe University, Sihhiye, 06100, Ankara, Turkey
| | - Gozde Yazici
- Faculty of Medicine, Department of Radiation Oncology, Hacettepe University, Sihhiye, 06100, Ankara, Turkey.
| |
Collapse
|
5
|
Wawrzuta D, Chojnacka M, Drogosiewicz M, Pędziwiatr K, Dembowska-Bagińska B. Reirradiation for diffuse intrinsic pontine glioma: prognostic radiomic factors at progression. Strahlenther Onkol 2024; 200:797-804. [PMID: 38748214 PMCID: PMC11343881 DOI: 10.1007/s00066-024-02241-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 04/23/2024] [Indexed: 08/24/2024]
Abstract
PURPOSE Diffuse intrinsic pontine glioma (DIPG) is a lethal pediatric brain tumor. Radiation therapy (RT) is the standard treatment, with reirradiation considered in case of progression. However, the prognostic factors for reirradiation are not well understood. This study aims to investigate the outcomes of DIPG patients undergoing reirradiation and identify clinical and radiomic prognostic factors. METHODS We conducted a retrospective analysis of patients with DIPG who underwent reirradiation at our institution between January 2016 and December 2023. Using PyRadiomics, we extracted radiomic features of tumors at the time of progression from FLAIR MRI images and collected clinical data. We used the least absolute shrinkage and selection operator (lasso) for Cox's proportional hazard model with leave-one-out cross-validation to select optimal prognostic factors for survival after reirradiation. RESULTS The study included 18 patients who underwent reirradiation at first progression, receiving a total dose of 20 Gy or 24 Gy in 2‑Gy fractions. Reirradiation was well tolerated, with no severe toxicity. Most patients (78%) showed neurological improvement after treatment. Median survival after progression was 29.2 weeks. The Cox model demonstrated a concordance of 0.81 (95% CI: 0.75-0.88), revealing that tumor sphericity and structural gray-level heterogeneity in FLAIR MRI images were associated with longer survival of reirradiated patients. CONCLUSION Reirradiation is a safe and effective approach for patients with DIPG. MRI-based radiomic models could be helpful in predicting survival after reirradiation.
Collapse
Affiliation(s)
- Dominik Wawrzuta
- Department of Radiation Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Wawelska 15B, 02-034, Warsaw, Poland.
| | - Marzanna Chojnacka
- Department of Radiation Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Wawelska 15B, 02-034, Warsaw, Poland
| | - Monika Drogosiewicz
- Department of Oncology, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730, Warsaw, Poland
| | - Katarzyna Pędziwiatr
- Department of Radiation Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Wawelska 15B, 02-034, Warsaw, Poland
| | - Bożenna Dembowska-Bagińska
- Department of Oncology, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730, Warsaw, Poland
| |
Collapse
|
6
|
Mankuzhy NP, Tringale KR, Dunkel IJ, Farouk Sait S, Souweidane MM, Khakoo Y, Karajannis MA, Wolden S. Hypofractionated re-irradiation for diffuse intrinsic pontine glioma. Pediatr Blood Cancer 2024; 71:e30929. [PMID: 38430472 PMCID: PMC11791744 DOI: 10.1002/pbc.30929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Re-irradiation (reRT) increases survival in locally recurrent diffuse intrinsic pontine glioma (DIPG). There is no standard dose and fractionation for reRT, but conventional fractionation (CF) is typically used. We report our institutional experience of reRT for DIPG, which includes hypofractionation (HF). METHODS We reviewed pediatric patients treated with brainstem reRT for DIPG at our institution from 2012 to 2022. Patients were grouped by HF or CF. Outcomes included steroid use, and overall survival (OS) was measured from both diagnosis and start of reRT. RESULTS Of 22 patients who received reRT for DIPG, two did not complete their course due to clinical decline. Of the 20 who completed reRT, the dose was 20-30 Gy in 2-Gy fractions (n = 6) and 30-36 Gy in 3-Gy fractions (n = 14). Median age was 5 years (range: 3-14), median interval since initial RT was 8 months (range: 3-20), and 12 received concurrent bevacizumab. Median OS from diagnosis was 18 months [95% confidence interval: 17-24]. Median OS from start of reRT for HF versus CF was 8.2 and 7.5 months, respectively (p = .20). Thirteen (93%) in the HF group and three (75%) in the CF group tapered pre-treatment steroid dose down or off within 2 months after reRT due to clinical improvement. There was no significant difference in steroid taper between HF and CF (p = .4). No patients developed radionecrosis. CONCLUSION reRT with HF achieved survival duration comparable to published outcomes and effectively palliated symptoms. Future investigation of this regimen in the context of new systemic therapies and upfront HF is warranted.
Collapse
Affiliation(s)
- Nikhil P Mankuzhy
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kathryn R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ira J Dunkel
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sameer Farouk Sait
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mark M Souweidane
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yasmin Khakoo
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Matthias A Karajannis
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| |
Collapse
|
7
|
Damodharan S, Abbott A, Kellar K, Zhao Q, Dey M. Molecular Characterization and Treatment Approaches for Pediatric H3 K27-Altered Diffuse Midline Glioma: Integrated Systematic Review of Individual Clinical Trial Participant Data. Cancers (Basel) 2023; 15:3478. [PMID: 37444588 PMCID: PMC10340772 DOI: 10.3390/cancers15133478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/30/2023] [Accepted: 07/01/2023] [Indexed: 07/15/2023] Open
Abstract
Diffuse midline glioma (DMG), H3 K27-altered are highly aggressive, incurable central nervous system (CNS) tumors. The current standard palliative treatment is radiotherapy, with most children succumbing to the disease in less than one year from the time of diagnosis. Over the past decade, there have been significant advancements in our understanding of these heterogeneous tumors at the molecular level. As a result, most of the newer clinical trials offered utilize more targeted approaches with information derived from the tumor biopsy. In this systematic review, we used individual participant data from seven recent clinical trials published over the past five years that met our inclusion and exclusion criteria to analyze factors that influence overall survival (OS). We found that the most prominent genetic alterations H3.3 (H3F3A) and TP53 were associated with worse OS and that ACVR had a protective effect. In addition, re-irradiation was the only statistically significant treatment modality that showed any survival benefit. Our findings highlight some important characteristics of DMG, H3 K27-altered and their effects on OS along with the importance of continuing to review clinical trial data to improve our therapies for these fatal tumors.
Collapse
Affiliation(s)
- Sudarshawn Damodharan
- Department of Pediatrics, Division of Pediatric Hematology, Oncology and Bone Marrow Transplant, School of Medicine & Public Health, University of Wisconsin, Madison, WI 53792, USA;
| | - Alexandra Abbott
- Department of Neurosurgery, School of Medicine & Public Health, University of Wisconsin, UW Carbone Cancer Center, Madison, WI 53792, USA; (A.A.); (K.K.)
| | - Kaitlyn Kellar
- Department of Neurosurgery, School of Medicine & Public Health, University of Wisconsin, UW Carbone Cancer Center, Madison, WI 53792, USA; (A.A.); (K.K.)
| | - Qianqian Zhao
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53792, USA;
| | - Mahua Dey
- Department of Neurosurgery, School of Medicine & Public Health, University of Wisconsin, UW Carbone Cancer Center, Madison, WI 53792, USA; (A.A.); (K.K.)
| |
Collapse
|
8
|
Zaghloul MS, Hunter A, Mostafa AG, Parkes J. Re-irradiation for recurrent/progressive pediatric brain tumors: from radiobiology to clinical outcomes. Expert Rev Anticancer Ther 2023; 23:709-717. [PMID: 37194207 DOI: 10.1080/14737140.2023.2215439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 05/15/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION Brain tumors are the most common solid tumors in children. Neurosurgical excision, radiotherapy, and/or chemotherapy represent the standard of care in most histopathological types of pediatric central nervous system (CNS) tumors. Even though the successful cure rate is reasonable, some patients may develop recurrence locally or within the neuroaxis. AREA COVERED The management of these recurrences is not easy; however, significant advances in neurosurgery, radiation techniques, radiobiology, and the introduction of newer biological therapies, have improved the results of their salvage treatment. In many cases, salvage re-irradiation is feasible and has achieved encouraging results. The results of re-irradiation depend upon several factors. These factors include tumor type, extent of the second surgery, tumor volume, location of the recurrence, time that elapses between the initial treatment, the combination with other treatment agents, relapse, and the initial response to radiotherapy. EXPERT OPINION Reviewing the radiobiological basis and clinical outcome of pediatric brain re-irradiation revealed that re-irradiation is safe, feasible, and indicated for recurrent/progressive different tumor types such as; ependymoma, medulloblastoma, diffuse intrinsic pontine glioma (DIPG) and glioblastoma. It is now considered part of the treatment armamentarium for these patients. The challenges and clinical results in treating recurrent pediatric brain tumors were highly documented.
Collapse
Affiliation(s)
- Mohamed S Zaghloul
- Radiation Oncology department. National Cancer Institute, Cairo University & Children's Cancer Hospital, Cairo, Egypt
| | - Alistair Hunter
- Division of Radiobiology, Radiation Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Ayatullah G Mostafa
- Department of Radiology, Faculty of Medicine, Egypt and Department of Diagnostic Imaging, Cairo University, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jeannette Parkes
- Radiation Oncology Department, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
9
|
Huang WH, Huang TY, Lin CM, Mu PF, Lee YY, Liu SH, Hsu SM, Chen YW. Salvage boron neutron capture therapy for pediatric patients with recurrent diffuse midline glioma. Childs Nerv Syst 2023; 39:1529-1536. [PMID: 36821007 DOI: 10.1007/s00381-023-05850-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/14/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE Pediatric diffuse malignant glioma located in the brainstem was officially named "diffuse midline glioma" (DMG) by the World Health Organization in 2016. For this disease, radical surgery is not beneficial, and the only major treatment strategy is radiotherapy. However, the dose limitations to brainstem tissue mean that treatment by radiotherapy can only control and not eradicate the tumors, and there is no effective treatment for recurrence, resulting in short overall survival of 6-12 months. This paper reports our experience with boron neutron capture therapy (BNCT), a new treatment process, and its efficacy in treating children with recurrent DMG. METHODS From September 2019 to July 2022, we treated 6 children affected by recurrent DMG. With the collaboration of Taipei Veteran General Hospital (TVGH) and National Tsing-Hua University (NTHU), each patient received two sessions of BNCT within 1 month. RESULTS Among the six patients, three showed partial response and the rest had stable disease after the treatment. The overall survival and recurrence-free survival duration after treatment were 6.39 and 4.35 months, respectively. None of the patients developed severe side effects, and only one patient developed brain necrosis, which was most likely resulted from previous hypofractionated radiotherapy received. CONCLUSION BNCT elicited sufficient tumor response with low normal tissue toxicity; it may benefit vulnerable pediatric patients with DMG.
Collapse
Affiliation(s)
- Wei-Hsuan Huang
- Department of Radiation Oncology, MacKay Memorial Hospital, Taipei City, Taiwan
- Medical Physics and Radiation Measurements Laboratory, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Ting-Yu Huang
- Department of Nursing, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Chun-Mei Lin
- Department of Nursing, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Pei-Fan Mu
- College of Nursing, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Yi-Yen Lee
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Shih-Hua Liu
- Department of Radiation Oncology, MacKay Memorial Hospital, Taipei City, Taiwan
| | - Shih-Ming Hsu
- Medical Physics and Radiation Measurements Laboratory, National Yang Ming Chiao Tung University, Taipei City, Taiwan.
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei City, Taiwan.
| | - Yi-Wei Chen
- Division of Radiotherapy, Department of Oncology, Taipei Veterans General Hospital, Taipei City, Taiwan.
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan.
- Department of Medical Imaging and Radiological Technology, Yuanpei University of Medical Technology, Hsinchu City, Taiwan.
- School of Medicine, National Tsing Hua University, Hsinchu City, Taiwan.
| |
Collapse
|
10
|
Vallero SG, Bertero L, Morana G, Sciortino P, Bertin D, Mussano A, Ricci FS, Peretta P, Fagioli F. Pediatric diffuse midline glioma H3K27- altered: A complex clinical and biological landscape behind a neatly defined tumor type. Front Oncol 2023; 12:1082062. [PMID: 36727064 PMCID: PMC9885151 DOI: 10.3389/fonc.2022.1082062] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/23/2022] [Indexed: 01/18/2023] Open
Abstract
The 2021 World Health Organization Classification of Tumors of the Central Nervous System, Fifth Edition (WHO-CNS5), has strengthened the concept of tumor grade as a combination of histologic features and molecular alterations. The WHO-CNS5 tumor type "Diffuse midline glioma, H3K27-altered," classified within the family of "Pediatric-type diffuse high-grade gliomas," incarnates an ideally perfect integrated diagnosis in which location, histology, and genetics clearly define a specific tumor entity. It tries to evenly characterize a group of neoplasms that occur primarily in children and midline structures and that have a dismal prognosis. Such a well-defined pathological categorization has strongly influenced the pediatric oncology community, leading to the uniform treatment of most cases of H3K27-altered diffuse midline gliomas (DMG), based on the simplification that the mutation overrides the histological, radiological, and clinical characteristics of such tumors. Indeed, multiple studies have described pediatric H3K27-altered DMG as incurable tumors. However, in biology and clinical practice, exceptions are frequent and complexity is the rule. First of all, H3K27 mutations have also been found in non-diffuse gliomas. On the other hand, a minority of DMGs are H3K27 wild-type but have a similarly poor prognosis. Furthermore, adult-type tumors may rarely occur in children, and differences in prognosis have emerged between adult and pediatric H3K27-altered DMGs. As well, tumor location can determine differences in the outcome: patients with thalamic and spinal DMG have significantly better survival. Finally, other concomitant molecular alterations in H3K27 gliomas have been shown to influence prognosis. So, when such additional mutations are found, which one should we focus on in order to make the correct clinical decision? Our review of the current literature on pediatric diffuse midline H3K27-altered DMG tries to address such questions. Indeed, H3K27 status has become a fundamental supplement to the histological grading of pediatric gliomas; however, it might not be sufficient alone to exhaustively define the complex biological behavior of DMG in children and might not represent an indication for a unique treatment strategy across all patients, irrespective of age, additional molecular alterations, and tumor location.
Collapse
Affiliation(s)
- Stefano Gabriele Vallero
- Pediatric Oncohematology Division, Regina Margherita Children’s Hospital, Azienda Ospedaliera Universitaria (AOU) Città della Salute e della Scienza, Turin, Italy,*Correspondence: Stefano Gabriele Vallero,
| | - Luca Bertero
- Pathology Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giovanni Morana
- Neuroradiology Unit, Department of Neuroscience, University of Turin, Turin, Italy
| | - Paola Sciortino
- Department of Neuroradiology, Azienda Ospedaliera Universitaria (AOU) Città della Salute e della Scienza, Turin, Italy
| | - Daniele Bertin
- Pediatric Oncohematology Division, Regina Margherita Children’s Hospital, Azienda Ospedaliera Universitaria (AOU) Città della Salute e della Scienza, Turin, Italy
| | - Anna Mussano
- Radiotherapy Unit, Regina Margherita Children’s Hospital, Azienda Ospedaliera Universitaria (AOU) Città della Salute e della Scienza, Turin, Italy
| | - Federica Silvia Ricci
- Child and Adolescent Neuropsychiatry Division, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Paola Peretta
- Pediatric Neurosurgery Division, Regina Margherita Children’s Hospital, Azienda Ospedaliera Universitaria (AOU) Città della Salute e della Scienza, Turin, Italy
| | - Franca Fagioli
- Pediatric Oncohematology Division, Regina Margherita Children’s Hospital, Azienda Ospedaliera Universitaria (AOU) Città della Salute e della Scienza, Turin, Italy,Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| |
Collapse
|