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Johnson TS, MacDonald TJ, Pacholczyk R, Aguilera D, Al-Basheer A, Bajaj M, Bandopadhayay P, Berrong Z, Bouffet E, Castellino RC, Dorris K, Eaton BR, Esiashvili N, Fangusaro JR, Foreman N, Fridlyand D, Giller C, Heger IM, Huang C, Kadom N, Kennedy EP, Manoharan N, Martin W, McDonough C, Parker RS, Ramaswamy V, Ring E, Rojiani A, Sadek RF, Satpathy S, Schniederjan M, Smith A, Smith C, Thomas BE, Vaizer R, Yeo KK, Bhasin MK, Munn DH. Indoximod-based chemo-immunotherapy for pediatric brain tumors: A first-in-children phase I trial. Neuro Oncol 2024; 26:348-361. [PMID: 37715730 PMCID: PMC10836763 DOI: 10.1093/neuonc/noad174] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Recurrent brain tumors are the leading cause of cancer death in children. Indoleamine 2,3-dioxygenase (IDO) is a targetable metabolic checkpoint that, in preclinical models, inhibits anti-tumor immunity following chemotherapy. METHODS We conducted a phase I trial (NCT02502708) of the oral IDO-pathway inhibitor indoximod in children with recurrent brain tumors or newly diagnosed diffuse intrinsic pontine glioma (DIPG). Separate dose-finding arms were performed for indoximod in combination with oral temozolomide (200 mg/m2/day x 5 days in 28-day cycles), or with palliative conformal radiation. Blood samples were collected at baseline and monthly for single-cell RNA-sequencing with paired single-cell T cell receptor sequencing. RESULTS Eighty-one patients were treated with indoximod-based combination therapy. Median follow-up was 52 months (range 39-77 months). Maximum tolerated dose was not reached, and the pediatric dose of indoximod was determined as 19.2 mg/kg/dose, twice daily. Median overall survival was 13.3 months (n = 68, range 0.2-62.7) for all patients with recurrent disease and 14.4 months (n = 13, range 4.7-29.7) for DIPG. The subset of n = 26 patients who showed evidence of objective response (even a partial or mixed response) had over 3-fold longer median OS (25.2 months, range 5.4-61.9, p = 0.006) compared to n = 37 nonresponders (7.3 months, range 0.2-62.7). Four patients remain free of active disease longer than 36 months. Single-cell sequencing confirmed emergence of new circulating CD8 T cell clonotypes with late effector phenotype. CONCLUSIONS Indoximod was well tolerated and could be safely combined with chemotherapy and radiation. Encouraging preliminary evidence of efficacy supports advancing to Phase II/III trials for pediatric brain tumors.
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Affiliation(s)
- Theodore S Johnson
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Tobey J MacDonald
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Rafal Pacholczyk
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Dolly Aguilera
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Ahmad Al-Basheer
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Radiation Oncology, Augusta University, Augusta, Georgia, USA
| | - Manish Bajaj
- Department of Radiology, Augusta University, Augusta, Georgia, USA
| | | | - Zuzana Berrong
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
| | - Eric Bouffet
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Robert C Castellino
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Kathleen Dorris
- Department of Pediatrics, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Bree R Eaton
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Natia Esiashvili
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Jason R Fangusaro
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Nicholas Foreman
- Department of Pediatrics, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Diana Fridlyand
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Cole Giller
- Department of Neurosurgery, Augusta University, Augusta, Georgia, USA
| | - Ian M Heger
- Department of Neurosurgery, Augusta University, Augusta, Georgia, USA
| | - Chenbin Huang
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
| | - Nadja Kadom
- Department of Radiology and Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Eugene P Kennedy
- Lumos Pharma, Inc. (formerly NewLink Genetics Corporation), Austin, Texas, USA
| | - Neevika Manoharan
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - William Martin
- Department of Radiation Oncology, Augusta University, Augusta, Georgia, USA
| | - Colleen McDonough
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Rebecca S Parker
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Vijay Ramaswamy
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Eric Ring
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Amyn Rojiani
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pathology, Augusta University, Augusta, Georgia, USA
| | - Ramses F Sadek
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Population Health Sciences, Augusta University, Augusta, Georgia, USA
| | - Sarthak Satpathy
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
| | - Matthew Schniederjan
- Children’s Healthcare of Atlanta and Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, USA
| | - Amy Smith
- Department of Pediatrics, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Christopher Smith
- Lumos Pharma, Inc. (formerly NewLink Genetics Corporation), Austin, Texas, USA
| | - Beena E Thomas
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Rachel Vaizer
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Kee Kiat Yeo
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Manoj K Bhasin
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
| | - David H Munn
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
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2
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S. Johnson T, Pacholczyk R, Aguilera D, Al-Basheer A, Bajaj M, Berrong Z, Castellino RC, Eaton BR, Esiashvili N, Foreman N, Heger IM, Kennedy EP, Martin W, Ring E, Sadek RF, Smith A, Smith C, Vaizer R, MacDonald TJ, Munn DH. IMMU-04. FIRST-IN-CHILDREN PHASE 1B STUDY USING THE IDO PATHWAY INHIBITOR INDOXIMOD IN COMBINATION WITH RADIATION AND CHEMOTHERAPY FOR CHILDREN WITH NEWLY DIAGNOSED DIPG (NCT02502708, NLG2105). Neuro Oncol 2021. [DOI: 10.1093/neuonc/noab090.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Diffuse intrinsic pontine glioma (DIPG) is a uniformly fatal brain tumor with no available cure. Indoximod blocks the IDO (indoleamine 2,3-dioxygenase) pathway, thereby reversing IDO-mediated immune suppression in the tumor microenvironment.
Methods
Patients aged 3 to 21 years with treatment-naive DIPG were eligible for this phase 1b dose-confirmation study of indoximod. The treatment regimen comprised continuous oral indoximod (38.4 mg/kg/day divided twice daily) with conformal photon radiation (54 Gy in 30 fractions), followed by cycles of indoximod with temozolomide (200 mg/m2/day, days 1–5 in 28-day cycles).
Results
Thirteen patients (median age 9 years, range 5 to 20 years) with DIPG were treated. Median OS was 14.5 months (follow-up ranged 4.8 to 29.3 months), 12-month OS was 61.5% (8/13), and 18-month OS was 30.8% (4/13), with 1 patient remaining in follow-up at the data cutoff. This compared favorably to expected median OS of approximately 10.8 months, 12-month OS of 45.3%, and 18-month OS of 16.2% taken from published historical data from the Pediatric Brain Tumor Consortium. Two patients showed near-complete responses lasting until relapsing after 7.6 months and 13.3 months of study therapy, respectively. Many patients had increased circulating non-classical monocytes (nc-Monos, CD16+, CD14neg, CD33+, HLA-DR+) within the first 3 treatment cycles, and elevation of this early pharmacodynamic marker was predictive of subsequent OS. Patients with nc-Monos >10% (n=7) had median OS of 19 months, whereas patients with nc-Monos below 10% (n=5) had median OS of 7 months (p=0.0047). No patients stopped therapy for toxicity. The most common indoximod-attributed adverse events were thrombocytopenia, neutropenia, nausea, vomiting, dizziness, and fatigue.
Conclusions
Adding indoximod immunotherapy to conventional radiation and chemotherapy for front-line treatment of pediatric patients with DIPG was well-tolerated. Improved outcomes were observed in patients having evidence of pharmacodynamic response. A follow-on phase 2 study is in progress (NCT04049669).
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Affiliation(s)
- Theodore S. Johnson
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | | | - Dolly Aguilera
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Ahmad Al-Basheer
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
- Department of Radiation Oncology, Augusta University, Augusta, GA, USA
| | - Manish Bajaj
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
- Department of Radiology, Augusta University, Augusta, GA, USA
| | - Zuzana Berrong
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
| | - Robert C Castellino
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Bree R Eaton
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Natia Esiashvili
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Nicholas Foreman
- Department of Pediatrics, Children’s Hospital Colorado, Aurora, CO, USA
| | - Ian M Heger
- Pediatric Neurosurgery Program, Medical City Children’s Hospital, Dallas, TX, USA
| | - Eugene P Kennedy
- Lumos Pharma (formerly NewLink Genetics Corporation), Ames, IA, USA
| | - William Martin
- Department of Radiation Oncology, Augusta University, Augusta, GA, USA
| | - Eric Ring
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Ramses F Sadek
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
- Department of Population Health Sciences, Augusta University, Augusta, GA, USA
| | - Amy Smith
- Department of Pediatrics, Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Chris Smith
- Lumos Pharma (formerly NewLink Genetics Corporation), Ames, IA, USA
| | - Rachel Vaizer
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Tobey J MacDonald
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - David H Munn
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
- Department of Pediatrics, Augusta University, Augusta, GA, USA
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East L, Lyon M, Agrawal P, Islam Z, Newell M, Hockman T, Heger IM, Xu H, Kuchinski AM, Gibson RW. Increased Intracranial Pressure Damages Optic Nerve Structural Support. J Neurotrauma 2019; 36:3132-3137. [PMID: 31256706 DOI: 10.1089/neu.2019.6490] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Optic nerve sheath diameter (ONSD) is used clinically as a noninvasive measure for elevated intracranial pressure (ICP). This study had two purposes: to investigate the immediate effects optic nerve sheath (ONS) dilation post-ICP increase on trabecular fibers connecting the optic nerve to the ONS and to document any changes in these fibers 30 days post-increased ICP. In a swine model, ICP was increased by inflating a Foley catheter balloon in the epidural space. Three control pigs received the catheter insertion without inflation (no increase in ICP) and four experimental pigs received the catheter with inflation (increased ICP). The control and two randomly selected pigs with increased ICP were euthanized immediately after the procedure. The two other pigs were euthanized 30 days post-catheter inflation. For all pigs, the ONS was removed and imaged using a scanning electron microscope, calculating percent porosity values. Porosity values for the experimental groups (Immediately measured [IM] μ = 0.5749; Delayed measured [DM] μ = 0.5714) were larger than the control group (μ = 0.4336) and statistically significant (IM vs. Control, p = 0.0018; DM vs. Control, p = 0.0092). There was no significant difference (p = 0.9485) in porosity of the DM group when compared with the IM group. This study demonstrated that the trabecular fibers immediately post-increased ICP (ONS dilation) were more porous than the control and remained statistically different (more porous) after 30 days. These results suggest a structural change that occurs in the ONS with elevations in ICP.
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Affiliation(s)
- Lauren East
- Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Matthew Lyon
- Department of Emergency Medicine, Augusta University, Augusta, Georgia.,Center for Ultrasound Education, Augusta University, Augusta, Georgia
| | - Parth Agrawal
- Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Zulqar Islam
- Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Maegan Newell
- Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Tyler Hockman
- Division of Laboratory Animal Services, Augusta University, Augusta, Georgia
| | - Ian M Heger
- Department of Neurosurgery, Augusta University, Augusta, Georgia
| | - Hongyan Xu
- Department of Population Health Sciences, Augusta University, Augusta, Georgia
| | | | - Robert W Gibson
- Department of Emergency Medicine, Augusta University, Augusta, Georgia
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Viers AG, Nguyen KD, Moon PX, Forseen SE, Heger IM. Pediatric occipital condyle morphometric analysis using computed tomography with evaluation for occipital condyle screw placement. J Neurosurg Pediatr 2019; 23:1-5. [PMID: 30835709 DOI: 10.3171/2019.1.peds18583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 01/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEOccipitocervical fusions in the pediatric population are rare but can be challenging because of the smaller anatomy. The procedure is even more exacting in patients with prior suboccipital craniectomy. A proposed method for occipitocervical fusion in such patients is the use of occipital condyle screws. There is very limited literature evaluating the pediatric occipital condyle for screw placement. The authors examined the occipital condyle in pediatric patients to determine if there was an age cutoff at which condylar screw placement is contraindicated.METHODSThe authors performed a retrospective morphometric analysis of the occipital condyle in 518 pediatric patients aged 1 week-9 years old. Patients in their first decade of life whose occipital condyle was demonstrated on CT imaging in the period from 2009 to 2013 at the Augusta University Medical Center and Children's Hospital of Georgia were eligible for inclusion in this study. Exclusion criteria were an age older than 10 years; traumatic, inflammatory, congenital, or neoplastic lesions of the occipital condyles; and any previous surgery of the occipitocervical junction. Descriptive statistical analysis was performed including calculation of the mean, standard deviation, and confidence intervals for all measurements. Probability values were calculated using the Student t-test with statistical significance determined by p < 0.05.RESULTSOverall, male patients had statistically significantly larger occipital condyles than the female patients, but this difference was not clinically significant. There was no significant difference in left versus right occipital condyles. There were statistically significant differences between age groups with a general trend toward older children having larger occipital condyles. Overall, 20.65% of all patients evaluated had at least one measurement that would prevent occipital condyle screw placement including at least one patient in every age group.CONCLUSIONSOccipital condyle screw fixation is feasible in pediatric patients younger than 10 years. More importantly, all pediatric patients should undergo critical evaluation of the occipital condyle in the axial, sagittal, and coronal planes preoperatively to determine individual suitability for occipital condyle screw placement.
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Affiliation(s)
- Angela G Viers
- 1Department of Neurosurgery, Augusta University Medical Center, Augusta
| | - Khoi D Nguyen
- 1Department of Neurosurgery, Augusta University Medical Center, Augusta
| | - Perounsack X Moon
- 2Philadelphia College of Osteopathic Medicine Georgia Campus, Suwanee; and
| | - Scott E Forseen
- 3Department of Radiology and Imaging, Neuroradiology Section, Augusta, Georgia
| | - Ian M Heger
- 1Department of Neurosurgery, Augusta University Medical Center, Augusta
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5
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Nguyen KD, Viers A, Tuttle JA, Heger IM. 205 Pediatric Occipital Condyle Morphometric Analysis Using Computed Tomography With Evaluation for Occipital Condyle Screw Placement. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy303.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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6
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Johnson TS, Aguilera D, Al-Basheer A, Castellino C, Eaton BR, Esiashvili N, Foreman N, Heger IM, Kennedy EP, Link CJ, Martin W, Ring E, Sadek RF, Smith A, Vahanian NN, MacDonald TJ, Munn DH. IMMU-25. RADIO-IMMUNOTHERAPY USING THE IDO PATHWAY INHIBITOR INDOXIMOD FOR CHILDREN WITH NEWLY-DIAGNOSED DIPG. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy059.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Dolly Aguilera
- Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Craig Castellino
- Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Bree R Eaton
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Natia Esiashvili
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Nicholas Foreman
- Department of Pediatrics, Children’s Hospital Colorado, Aurora, CO, USA
| | - Ian M Heger
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
| | | | | | - William Martin
- Department of Radiation Oncology, Augusta University, Augusta, GA, USA
| | - Eric Ring
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
| | - Ramses F Sadek
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
| | - Amy Smith
- Department of Pediatrics, Arnold Palmer Hospital for Children, Orlando, FL, USA
| | | | - Tobey J MacDonald
- Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - David H Munn
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
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Johnson TS, Aguilera D, Al-Basheer A, Cooksey RM, Eaton BR, Esiashvili N, Firat S, Fiveash JB, Foreman N, Fridlyand D, Friedman GK, Giller CA, Grosshans DR, Heger IM, Kelly M, Kennedy EP, Knipstein J, Kolhe RB, Liu AK, Martin W, Mourad WF, Pacholczyk R, Parker R, Rojiani AM, Sadek RF, Thornton A, Vahanian NN, MacDonald T, Munn D. PDCT-06. RADIO-IMMUNOTHERAPY USING THE IDO-INHIBITOR INDOXIMOD IN COMBINATION WITH RE-IRRADIATION FOR CHILDREN WITH PROGRESSIVE BRAIN TUMORS IN THE PHASE 1 SETTING: AN UPDATED REPORT OF SAFETY AND TOLERABILITY (NCT02502708). Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox168.750] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Felema GG, Bryskin RB, Heger IM, Saswata R. Venous air embolism from Tisseel use during endoscopic cranial vault remodeling for craniosynostosis repair: a case report. Paediatr Anaesth 2013; 23:754-6. [PMID: 23746210 DOI: 10.1111/pan.12180] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2013] [Indexed: 01/05/2023]
Abstract
Venous air embolism (VAE) is a potential complication during cranial vault remodeling requiring early detection and prompt therapeutic intervention. The incidence of VAE has been reported to be as high as 82.6% during open craniectomy for craniosynostosis repair. On the other hand, two separate studies reported a much lower incidence of VAE (8% and 2%) during endoscopic strip craniectomy. As surgical advancements progress, minimally invasive neurosurgical procedures are increasing in the pediatric population with reported benefits of decreased blood loss and need for transfusion, shorter hospital stay, decreased cost, lower morbidity, and mortality. In addition, there is a heightened emphasis on achieving hemostasis, which has led to the use of products such as antifibrinolytics and fibrin sealants. We present a case where a VAE causing significant hemodynamic instability (grade III) ensued immediately following aerosolized fibrin sealant application. Exploration of the potential source of VAE pointed to the high pressure and close proximity (between spray device and tissue) during application of the sealant, likely forcing air into the vascular system.
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Affiliation(s)
- Gohalem G Felema
- Department of Pediatric Anesthesiology, Mayo Clinic/Nemours Children's Clinic, Jacksonville, FL 32207, USA
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9
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Milhorat TH, Capocelli AL, Kotzen RM, Bolognese P, Heger IM, Cottrell JE. Intramedullary pressure in syringomyelia: clinical and pathophysiological correlates of syrinx distension. Neurosurgery 1997; 41:1102-10. [PMID: 9361064 DOI: 10.1097/00006123-199711000-00014] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE The pathophysiological effects of syrinx distension are incompletely understood. Although it is generally assumed that the accumulation of fluid within syrinx cavities can contribute to neurological dysfunction, there are no reports describing intramedullary pressure in syringomyelia. The purpose of the current study was to measure syrinx pressures in patients with progressive clinical deterioration and to correlate these data with neurological deficits and intraoperative physiological findings. METHODS Intramedullary fluid pressure was measured manometrically in 32 patients undergoing syrinx shunting procedures. The data were correlated with syrinx morphology, intraoperative somatosensory evoked potentials, laser Doppler measurements of local spinal cord blood flow (six patients), and neurological findings before and after syrinx decompression. RESULTS Syrinx pressures recorded under atmospheric conditions ranged from 0.5 to 22.0 cm H2O (mean = 7.7 cm). There was a significant elevation of the cardiac pulse (mean = 0.7 cm H2O) and the respiratory pulse (mean = 1.1 cm H2O) that was consistent with raised cerebrospinal fluid pressure. Syrinx pressures decreased to subatmospheric levels after surgical drainage. In 18 of 24 patients with predrainage somatosensory evoked potential abnormalities, syrinx decompression produced a consistent reduction of N20 latencies (mean change = 0.49 ms +/- 0.094 SE right, P = 0.002; 0.61 ms +/- 0.089 SE left, P = 0.001) and a similar but less consistent increase in N20 amplitudes (mean change = 0.17 mV +/- 0.103 SE right, P = 0.115; 0.31 mV +/- 0.097 SE left, P = 0.027). Measurements of local spinal cord blood flow revealed very low baseline values (mean = 12.2 arbitrary units +/- 13.9 standard deviation), which increased to intermediate levels (mean = 144.7 arbitrary units +/- 42.6 standard deviation) after syrinx decompression. Patients with syrinx pressures greater than 7.7 cm H2O tended to have more rapidly progressive symptoms, exhibited greater improvements after shunting, and had a higher incidence of postoperative dysesthetic pain. CONCLUSION The current study is the first to measure intramedullary pressure in a human disease. Evidence is presented that distended syringes are associated with varying levels of raised intramedullary pressure that can accentuate or induce neurological dysfunction by the compression of long tracts, neurons, and the microcirculation. Symptoms referrable to raised intramedullary pressure are potentially reversible by syrinx decompression.
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Affiliation(s)
- T H Milhorat
- Department of Neurosurgery, State University of New York Health Science Center at Brooklyn, USA
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10
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Johnson WD, Bolognese P, Miller JI, Heger IM, Liker MA, Milhorat TH. Continuous postoperative lCBF monitoring in aneurysmal SAH patients using a combined ICP-laser Doppler fiberoptic probe. J Neurosurg Anesthesiol 1996; 8:199-207. [PMID: 8803831 DOI: 10.1097/00008506-199607000-00003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Cerebral vasospasm remains the principal cause of morbidity and mortality following successful clipping of intracranial aneurysms. Current management often requires subjective judgments concerning presumed abnormalities of cerebral blood flow. In this study, a combined intracranial pressure (ICP)-laser Doppler flowmetry (LDF) fiberoptic probe that permits continuous monitoring of local cerebral blood flow (lCBF) was used in the postoperative management of 20 aneurysm patients. Using this probe, lCBF was simultaneously recorded and integrated on a real time basis with other physiological parameters, including ICP, systemic arterial pressure, pulmonary arterial pressure, central venous pressure, and pulse oximetry. The combined probe also provided the ability to obtain precise and detailed information concerning the presence or absence of cerebral autoregulation and CO2 vascular reactivity, and allowed calculation of the cerebral vascular resistance. Continuous monitoring of lCBF in this manner complemented by transcranial Doppler and angiographic data permitted early detection of cerebral ischemia, helped to differentiate cerebral ischemia from edema and hyperemia, was useful in titrating blood pressure and fluid management, provided direct feedback about the effectiveness of instituted therapies, and determined early on when medical management was of no avail and that interventional neuroradiology was indicated. Evidence is presented that the presence of angiographic vasospasm and increased velocities on TCD do not always correlate with ischemia in the microcirculation and that direct measurements of lCBF are often at variance with calculations of cerebral perfusion pressure (CPP).
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Affiliation(s)
- W D Johnson
- Department of Neurosurgery, Health Science Center at Brooklyn, State University New York, Kings County Hospital Center 11203-2098, USA
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11
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Abstract
Laser-Doppler flowmetry (LDF) provides a reliable measurement of local cerebral blood flow (lCBF) as demonstrated by multiple validation studies. This article evaluates the clinical applications of LDF in neurosurgery. With the availability of modified probes, it is possible to carry out LDF monitoring of neurosurgical patients in the intensive care unit. Currently, there are multiple systemic and intracranial parameters that are interactive and separately monitored. A multi-channeled digital data acquisition system allows these data to be compiled in a single computer environment for the interpretation of lCBF changes. Guidelines are suggested for the clinical use of LDF monitoring, and the technical features of monitoring including the interpretation of data are summarized.
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Affiliation(s)
- P Bolognese
- Department of Neurosurgery, State University of New York Health Science Center at Brooklyn 11203
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12
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Abstract
Hindbrain lesions that distort or compress the cervicomedullary junction are commonly associated with syringomyelia. As a basis for discussing pathogenetic mechanisms, the upper end of the central canal of the spinal cord was examined histologically in six aborted fetuses and 14 adults dying of natural causes; the results were correlated with magnetic resonance images in 40 normal subjects. The central canal of the medulla, which extends from the cervicomedullary junction to the fourth ventricle, was found to migrate dorsally, elongate in dorsoventral diameter, and dilate beneath the tip of the obex to form a large, everted aperture. This opening communicates directly with the subarachnoid space through the foramen of Magendie and is indirectly continuous with the main body of the fourth ventricle. In adults, the aperture of the central canal is located approximately 1.0 cm below the tela choroidea inferior and 3.5 cm below the midpoint of the fourth ventricle. Analysis of magnetic resonance imaging scans in 45 patients with syringomyelia and simple hindbrain lesions revealed two patterns of cavity formation: 1) lesions that obstructed the upper end of the central canal or its continuity with the subarachnoid space produced a noncommunicating type of syringomyelia; and 2) lesions that obstructed the basilar cisterns or the foraminal outlets of the fourth ventricle produced a communicating type of syringomyelia (hydromyelia) in association with hydrocephalus. Evidence is presented that syrinxes occurring with hindbrain lesions are not caused by a caudal flow of cerebrospinal fluid from the fourth ventricle into the central canal of the spinal cord.
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Affiliation(s)
- T H Milhorat
- Department of Neurosurgery, State University of New York Health Science Center, Brooklyn
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13
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Abstract
The pathology of hematomyelia was examined in 35 rats following the stereotactic injection of 2 microliters blood into the dorsal columns of the thoracic spinal cord. This experimental model produced a small ball-hemorrhage without associated neurological deficits or significant tissue injury. Histological sections of the whole spinal cord were studied at intervals ranging from 2 hours to 4 months after injection. In acute experiments (2 to 6 hours postinjection), blood was sometimes seen within the lumen of the central canal extending rostrally to the level of the fourth ventricle. Between 24 hours and 3 days, the parenchymal hematoma became consolidated and there was an intense proliferation of microglial cells at the perimeter of the lesion. The cells invaded the hematoma, infiltrated its core, and removed erythrocytes by phagocytosis. Rostral to the lesion, the lumen of the central canal was found to contain varying amounts of fibrin, proteinaceous material, and cellular debris for up to 15 days. These findings were much less prominent in the segments of the canal caudal to the lesion. Healing of the parenchymal hematoma was usually complete within 4 to 6 weeks except for residual hemosiderin-laden microglial cells and focal gliosis at the lesion site. It is concluded that the clearance of atraumatic hematomyelia probably involves two primary mechanisms: 1) phagocytosis of the focal hemorrhage by microglial cells; and 2) drainage of blood products in a rostral direction through the central canal of the spinal cord.
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Affiliation(s)
- T H Milhorat
- Department of Neurosurgery, Division of Neuropathology, State University of New York, Brooklyn
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