Evaluation of prevalence and outcomes of serial tyrosine kinase inhibitor use in pediatric patients with advanced solid tumors

PURPOSE

Multitargeted tyrosine kinase inhibitors (mTKIs) are increasingly utilized in the treatment of pediatric sarcomas and other solid tumors. It is unknown whether serial treatment with multiple TKIs provides a benefit and which patients are most likely to benefit from mTKI rechallenge.

METHODS

We performed a retrospective cohort study of pediatric cancer patients who received serial mTKI therapy off-study between 2007 and 2020 as either monotherapy or combination therapy. We report patient characteristics, clinical outcomes, dosing patterns, and treatment-associated toxicity.

RESULTS

The study cohort included 25 patients. The overall prevalence of serial mTKI therapy among all patients treated for sarcoma at our institution was 3.7%, and the response rate to second mTKI was 9%. Median 6-month progression-free survival (PFS) and overall survival (OS) from start of second mTKI were 42.1% (95% CI: 20.4%-62.5%) and 79.1% (95% CI: 57.0%-90.8%), respectively. Patients who had received 4 months or more (n = 11) of therapy with first mTKI had significantly longer PFS versus those who received less than 4 months (n = 11; p = .001). Thirty-three percent of patients discontinued second mTKI due to toxicity. Six (40%) of 15 patients who discontinued the first mTKI due to progression had either a partial response or stable disease on the second mTKI.

CONCLUSIONS

We observed a low response rate to mTKI rechallenge. However, we identified patients who had been treated with first mTKI for  ≥4 months as more likely to have prolonged stable disease with second mTKI. Several patients had a response or stable disease on the second mTKI despite having progressed on the first mTKI. Though toxicity was common, only a minority of patients discontinued the second mTKI due to toxicity.

Broken tails in Holstein dairy cattle: A cross-sectional study

Dairy cows are regularly handled when moved to the milking parlor and during other routine procedures. Low-stress handling methods are important in avoiding negative welfare states for dairy cattle. Tail twisting is used by some handlers to prompt cattle movement. However, when used inappropriately with excessive force, tail twisting can lead to a broken tail. The aim of this cross-sectional study was to determine cow-level factors that may be associated with the prevalence of broken tails in dairy cattle. A subset of 229 Holstein dairy cows (68 primiparous and 161 multiparous) at a single dairy were assessed for broken tails from the larger herd (N = 1,356). Tails were visually assessed for the presence of fractures by a single trained observer. A tail was classified as unfractured if it laid straight when at rest and as fractured if there were deviations in the tail when at rest. Poisson regression models were used to identify associations between cow-level characteristics and broken tails and compute adjusted prevalence ratios (PR). The prevalence of broken tails was 45.8% (105/229) at the time of assessment. Multiparous cows had a greater prevalence of broken tails than primiparous cows [PR = 1.70; 95% confidence interval (CI): 1.11-2.59]. The prevalence of broken tails was also greater for cows treated for mastitis ≥2 times than cows treated once for mastitis (PR = 1.84; 95% CI: 1.08-3.13) and cows never treated for mastitis (PR = 1.36; 95% CI: 1.02-1.82). Results from this study indicated that the longer a cow was present on the farm and the more times she was treated for mastitis, the more likely she was to experience a broken tail. These findings suggest that the relationship between dairy cow handling, health, and welfare is a multifactorial issue.

Immunotherapy approaches for the treatment of diffuse midline gliomas

Diffuse midline gliomas (DMG) are a highly aggressive and universally fatal subgroup of pediatric tumors responsible for the majority of childhood brain tumor deaths. Median overall survival is less than 12 months with a 90% mortality rate at 2 years from diagnosis. Research into the underlying tumor biology and numerous clinical trials have done little to change the invariably poor prognosis. Continued development of novel, efficacious therapeutic options for DMGs remains a critically important area of active investigation. Given that DMGs are not amenable to surgical resection, have only limited response to radiation, and are refractory to traditional chemotherapy, immunotherapy has emerged as a promising alternative treatment modality. This review summarizes the various immunotherapy-based treatments for DMG as well as their specific limitations. We explore the use of cell-based therapies, oncolytic virotherapy or immunovirotherapy, immune checkpoint inhibition, and immunomodulatory vaccination strategies, and highlight the recent clinical success of anti-GD2 CAR-T therapy in diffuse intrinsic pontine glioma (DIPG) patients. Finally, we address the challenges faced in translating preclinical and early phase clinical trial data into effective standardized treatment for DMG patients.

Standard clinical approaches and emerging modalities for glioblastoma imaging

Glioblastoma (GBM) is the most common primary adult intracranial malignancy and carries a dismal prognosis despite an aggressive multimodal treatment regimen that consists of surgical resection, radiation, and adjuvant chemotherapy. Radiographic evaluation, largely informed by magnetic resonance imaging (MRI), is a critical component of initial diagnosis, surgical planning, and post-treatment monitoring. However, conventional MRI does not provide information regarding tumor microvasculature, necrosis, or neoangiogenesis. In addition, traditional MRI imaging can be further confounded by treatment-related effects such as pseudoprogression, radiation necrosis, and/or pseudoresponse(s) that preclude clinicians from making fully informed decisions when structuring a therapeutic approach. A myriad of novel imaging modalities have been developed to address these deficits. Herein, we provide a clinically oriented review of standard techniques for imaging GBM and highlight emerging technologies utilized in disease characterization and therapeutic development.

Therapeutic cancer vaccines for pediatric malignancies: advances, challenges, and emerging technologies

Though outcomes for pediatric cancer patients have significantly improved over the past several decades, too many children still experience poor outcomes and survivors suffer lifelong, debilitating late effects after conventional chemotherapy, radiation, and surgical treatment. Consequently, there has been a renewed focus on developing novel targeted therapies to improve survival outcomes. Cancer vaccines are a promising type of immunotherapy that leverage the immune system to mediate targeted, tumor-specific killing through recognition of tumor antigens, thereby minimizing off-target toxicity. As such, cancer vaccines are orthogonal to conventional cancer treatments and can therefore be used alone or in combination with other therapeutic modalities to maximize efficacy. To date, cancer vaccination has remained largely understudied in the pediatric population. In this review, we discuss the different types of tumor antigens and vaccine technologies (dendritic cells, peptides, nucleic acids, and viral vectors) evaluated in clinical trials, with a focus on those used in children. We conclude with perspectives on how advances in combination therapies, tumor antigen (eg, neoantigen) selection, and vaccine platform optimization can be translated into clinical practice to improve outcomes for children with cancer.

Trends in conditional survival and predictors of late death in neuroblastoma

PURPOSE

Significant advances in the treatment of neuroblastoma have been made in the past several decades. There are scant data examining how these improvements have changed over time and differentially affected conditional survival among high-risk and non-high-risk patient groups.

METHODS

We conducted a retrospective cohort study using the Surveillance, Epidemiology, and End Results database. We analyzed clinical characteristics and survival outcomes for 4717 neuroblastoma patients. Kaplan-Meier methods were used to estimate overall survival (OS) and conditional overall survival (COS) with estimates compared between groups using log-rank tests.

RESULTS

Five-year OS was 41.46% (95% CI 38.77-44.13) for the high-risk group and 91.13% (95% CI 89.49-92.53) for the non-high-risk group. Both groups saw significant improvements in OS by decade (P < .001). Five-year COS among 1-year survivors was 52.69% (CI 49.54-55.73) for the high-risk group and 96.75% (95% CI 95.57-97.62) for the non-high-risk group. One-year survivors in the high-risk group showed a statistically significant improvement in COS over time. No difference in COS was observed among 5-year high-risk survivors. In the high-risk and non-high-risk groups, 82% and 32% of late deaths were attributable to cancer, respectively. Statistically significant adverse prognostic factors for late death were age ≥ 1 year at diagnosis, metastatic disease, and nonthoracic primary site (P = .001).

CONCLUSIONS

Improvements in COS over time have largely benefited high-risk patients, though they are still at higher risk for late death due to cancer when compared to non-high-risk patients. Age, stage, and primary site, but not treatment decade, influence outcomes among 5-year survivors.

Corpus Callosotomy for Refractory Epilepsy in Aicardi Syndrome: Case Report and Focused Review of the Literature

BACKGROUND

Aicardi syndrome is a severe neurodevelopmental disorder that occurs primarily in females and is characterized by seizures, agenesis of the corpus callosum, and chorioretinal lacunae, which occur together in the majority of affected individuals. Seizures begin in infancy and tend to progress in intensity and are often refractory to standard multimodal medication treatments.

CASE DESCRIPTION

We present here a unique case of a 12-year-old girl with partial agenesis of the corpus callosum who underwent a corpus callosotomy for treatment of medically refractory epilepsy. In so doing, we also review the literature with regard to the neurosurgical management of these unique patients.

CONCLUSIONS

For the subset of children who present with partial, rather than complete, agenesis of the corpus callosum, corpus callosotomy should be considered as a treatment option to reduce seizure burden.

Rapid functional genetics of the oligodendrocyte lineage using pluripotent stem cells

Oligodendrocyte dysfunction underlies many neurological disorders, but rapid assessment of mutation-specific effects in these cells has been impractical. To enable functional genetics in oligodendrocytes, here we report a highly efficient method for generating oligodendrocytes and their progenitors from mouse embryonic and induced pluripotent stem cells, independent of mouse strain or mutational status. We demonstrate that this approach, when combined with genome engineering, provides a powerful platform for the expeditious study of genotype-phenotype relationships in oligodendrocytes.

Striatal neurons directly converted from Huntington's disease patient fibroblasts recapitulate age-associated disease phenotypes

In Huntington's disease (HD), expansion of CAG codons in the huntingtin gene (HTT) leads to the aberrant formation of protein aggregates and the differential degeneration of striatal medium spiny neurons (MSNs). Modeling HD using patient-specific MSNs has been challenging, as neurons differentiated from induced pluripotent stem cells are free of aggregates and lack an overt cell death phenotype. Here we generated MSNs from HD patient fibroblasts through microRNA-based direct neuronal conversion, bypassing the induction of pluripotency and retaining age signatures of the original fibroblasts. We found that patient MSNs consistently exhibited mutant HTT (mHTT) aggregates, mHTT-dependent DNA damage, mitochondrial dysfunction and spontaneous degeneration in culture over time. We further provide evidence that erasure of age stored in starting fibroblasts or neuronal conversion of presymptomatic HD patient fibroblasts results in differential manifestation of cellular phenotypes associated with HD, highlighting the importance of age in modeling late-onset neurological disorders.

Interminable treatment in patients who appear healthy

Treatment interminability among nonpsychotic psychiatric patients is a subject not well understood. Those who treat such patients are often nagged by a feeling that they are somehow failing, especially if the patient has a history of personal achievement. The authors describe three such patients and propose that they exemplify a type of pseudomaturation. common features in the accounts of their childhood suggest a failure in the separation-individuation phase of development. The authors theorize that this failure first contributed to the development of psychiatric symptoms during adulthood and then to interminability in treatment.

Candidates' evaluation of psychoanalytic supervision

The origins, methods, results, and discussions of a project undertaken by the advanced candidates at the Denver Institute for Psychoanalysis have been described. This project was designed to examine the supervisory process and to compile a consensual critique of individual supervisors from the candidate's point of view. We have included vignettes of supervisory experiences. It became our purpose to: (1) Develop a set of criteria by which the strengths and weaknesses of supervisors can be evaluated, (2) Involve the candidate in assessing his own learning needs, (3) Promote the objective assignment of supervisors, an assignment determined by the patient's problems, the candidate's learning needs, and the supervisor's varying capacities and abilities to effectively understand these problems and deal with these needs, (4) Expand the supervisory process to include what we felt were often unconscious or hiterto unacceptable issues, such as the function and use of countertransference, and the detection and open discussion of transference dilemmas between analyst and both patient and supervisor, (5) Stimulate dialogue at all levels of psychoanalytic education on the patient-analyst-supervisor relational system.