PRRT with Lu-177 DOTATATE in Treatment-Refractory Progressive Meningioma: Initial Experience from a Tertiary-Care Neuro-Oncology Center

PURPOSE

Refractory and/or recurrent meningiomas have poor outcomes, and the treatment options are limited. Peptide receptor radionuclide therapy (PRRT) has been used in this setting with promising results. We have documented our experience of using intravenous (IV) and intra-arterial (IA) approaches of Lu-177 DOTATATE PRRT.

METHODS

Eight patients with relapsed/refractory high-grade meningioma received PRRT with Lu-177 DOTATATE by IV and an IA route. At least 2 cycles were administered. Time to progression was calculated from the first PRRT session to progression. The response was assessed on MRI using RANO criteria, and visual analysis of uptake was done on Ga-68 DOTANOC PET/CT. Post-therapy dosimetry calculations for estimating the absorbed dose were performed.

RESULTS

Median time to progression was 8.9 months. One patient showed disease progression, whereas seven patients showed stable disease at 4 weeks following 2 cycles of PRRT. Dosimetric analysis showed higher dose and retention time by IA approach. No significant peri-procedural or PRRT associated toxicity was seen.

CONCLUSION

PRRT is a safe and effective therapeutic option for relapsed/refractory meningioma. The IA approach yields better dose delivery and should be routinely practised.

Multitarget Potential Drug Candidates for High-Grade Gliomas Identified by Multiple Reaction Monitoring Coupled with In Silico Drug Repurposing

High-grade gliomas (HGGs) are extremely aggressive primary brain tumors with high mortality rates. Despite notable progress achieved by clinical research and biomarkers emerging from proteomics studies, efficacious drugs and therapeutic targets are limited. This study used targeted proteomics, in silico molecular docking, and simulation-based drug repurposing to identify potential drug candidates for HGGs. Importantly, we performed multiple reaction monitoring (MRM) on differentially expressed proteins with putative roles in the development and progression of HGGs based on our previous work and the published literature. Furthermore, in silico molecular docking-based drug repurposing was performed with a customized library of FDA-approved drugs to identify multitarget-directed ligands. The top drug candidates such as Pazopanib, Icotinib, Entrectinib, Regorafenib, and Cabozantinib were explored for their drug-likeness properties using the SwissADME. Pazopanib exhibited binding affinities with a maximum number of proteins and was considered for molecular dynamic simulations and cell toxicity assays. HGG cell lines showed enhanced cytotoxicity and cell proliferation inhibition with Pazopanib and Temozolomide combinatorial treatment compared to Temozolomide alone. To the best of our knowledge, this is the first study combining MRM with molecular docking and simulation-based drug repurposing to identify potential drug candidates for HGG. While the present study identified five multitarget-directed potential drug candidates, future clinical studies in larger cohorts are crucial to evaluate the efficacy of these molecular candidates. The research strategy and methodology used in the present study offer new avenues for innovation in drug discovery and development which may prove useful, particularly for cancers with low cure rates.

A Retrospective Cohort Study to Evaluate the Outcomes of HIV-Associated High-Grade B-Cell Non-Hodgkin Lymphoma (NHL) Treated with Dose Adjusted EPOCH (+/-R) Regimen

High-grade B-cell NHL's are more common in seropositive patients. They are biologically different from their seronegative counterparts. We report our analysis on our cohort of patients who were treated with DA-EPOCH(+/-R). We retrospectively analyzed treatment-naïve HIV-associated High-grade B-cell NHL patients (aged ≥ 18) treated with DA-EPOCH(+/-R) regimen from 2011 to 2015. Descriptive statistics were summarized with median and range; survival outcomes were analyzed with Kaplan-Meier method. The cohort comprised of 40 patients [DLBCL(19), Burkitt's Lymphoma(16), High-grade B-Cell Lymphoma-Unclassifiable(09), and Plasmablastic Lymphoma(01)] and the median CD4 + T cell count was 202/mm3. CNS prophylaxis was administered with intrathecal methotrexate to 90% of patients. With a median follow-up of 72 months, an estimated 5-year OS was 82.5%, and 5-PFS was 77.5%. There were 9 deaths, and 9 patients had progression. At least 4 cycles of chemotherapy were administered to 35 (93%) patients, with 28 (70%) receiving 6 cycles. Grade 3-4 toxicities were seen in 33 (83%) patients- febrile neutropenia (65%) being the most common followed by mucositis (25%) and peripheral neuropathy (13%). There was no difference in survival based on IPI, CD 4 + T cell count, CDI, or duration of HIV. DA-EPOCH(+/-R) is a highly effective regimen in seropositive high-grade B-cell lymphoma, even in the presence of adverse features.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12288-023-01652-3.

Intracranial disease in pediatric Hodgkin lymphoma-case report and review of literature

Central nervous system (CNS) involvement in Hodgkin lymphoma (HL) is an extremely rare presentation with dismal outcomes according to reported literature. An 8-year-old girl presented to us with complaints of on-off fever, right cervical swelling and bilateral ptosis. Positron emission tomography (PET) showed intracranial extra-axial soft tissue masses in right infero-lateral temporal lobe, sella and bilateral parasellar region along with cervical, mediastinal, axillary, abdominal and inguino-pelvic nodes, liver lesions and extensive marrow lesions involving the axial and appendicular skeleton. Histopathology of the cervical lymph node revealed a diagnosis of classical Hodgkin lymphoma. Child received 2 cycles of OEPA and 4 cycles of COPP followed by radiotherapy to bulky cervical lymph nodes and intracranial lesion. The child has been disease-free for 44 months with no neurological sequalae. Intracranial spread is rare in Hodgkin lymphoma and is associated with inferior outcomes. Due to its rarity, there are no specific treatment guidelines for this entity. The choice of ideal chemotherapeutic agents and role of whole-brain radiotherapy needs further evaluation.

Imaging-Based Patterns of Failure following Re-Irradiation for Recurrent/Progressive High-Grade Glioma

BACKGROUND

Re-irradiation (ReRT) is an effective treatment modality in appropriately selected patients with recurrent/progressive high-grade glioma (HGG). The literature is limited regarding recurrence patterns following ReRT, which was investigated in the current study.

METHODS

Patients with available radiation (RT) contours, dosimetry, and imaging-based evidence of recurrence were included in the retrospective study. All patients were treated with fractionated focal conformal RT. Recurrence was detected on imaging with magnetic resonance imaging (MRI) and/ or amino-acid positron emission tomography (PET), which was co-registered with the RT planning dataset. Failure patterns were classified as central, marginal, and distant if >80%, 20-80%, or <20% of the recurrence volumes were within 95% isodose lines, respectively.

RESULTS

Thirty-seven patients were included in the current analysis. A total of 92% of patients had undergone surgery before ReRT, and 84% received chemotherapy. The median time to recurrence was 9 months. Central, marginal, and distant failures were seen in 27 (73%), 4 (11%), and 6 (16%) patients, respectively. None of the patient-, disease-, or treatment-related factors were significantly different across different recurrence patterns.

CONCLUSION

Failures are seen predominantly within the high-dose region following ReRT in recurrent/ progressive HGG.

Imaging Guidelines and Recommendations for Diagnosis, Surveillance, and Management of Pediatric CNS and Spinal Tumors

Central nervous system (CNS) tumors are the second most common cause of cancer in children when incidence rates of cancer are estimated according to the Indian population dynamics based on 2011 consensus. As per the estimates, CNS tumors account for 20.1% of cancer burden in children aged between 0 and 14 years and 16.8% when 0 to 19 years age group is considered. The most common pediatric brain tumors are astrocytoma and medulloblastoma followed by other embryonal tumors, craniopharyngioma, and ependymal tumors. The incidence of CNS tumors in children from India is similar to the western high-income countries, other than slightly higher incidence of craniopharyngioma in Indian children.

Phase II trial of a novel chemotherapy regimen CVEP (cyclophosphamide, vinblastine, etoposide and prednisolone) for acquired immunodeficiency syndrome (AIDS)-associated lymphomas

Management of acquired immunodeficiency syndrome (AIDS)-related diffuse large B-cell (DLBCL) and plasmablastic lymphomas (PBL) poses significant challenges. The evidence supports use of dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin) with or without rituximab as first-line therapy. The need for central venous access, growth factors and significant toxicities limits its use in resource-constrained settings. To address these challenges, we have developed a novel regimen, CVEP (cyclophosphamide, vinblastine, etoposide, and prednisolone) based on the pharmacodynamic principles of dose-adjusted EPOCH. This single-centre phase II study evaluated the efficacy and safety of CVEP regimen in patients with de novo systemic AIDS-related DLBCL and PBL. The primary objective was complete response (CR) rates as assessed by positron emission tomography-computed tomography. The secondary objectives were incidence of Grade 3/4 toxicities, toxicities requiring hospitalisation, and disease-free survival. From May 2011 to February 2017, 42 patients were enrolled. At the end of therapy the CR rates were 69% (29/42) in the intention-to-treat population and 80.5% (29/36) in evaluable patients. At a median follow-up of 69 months, the 5-year disease-free survival was 65.3%. Out of 217 cycles administered, febrile neutropenia occurred in 19.3% and hospitalisation was required in 18.3% of cycles. There were two treatment-related deaths. The CVEP regimen is an active and safe regimen for AIDS-related DLBCL and PBL.

NCOG-29. INFLUENCE OF RADIATION DOSES TO HIPPOCAMPAL SUBVOLUMES ON MEMORY OUTCOMES IN PITUITARY TUMORS: DOES THE ENTIRE HIPPOCAMPUS NEED TO BE SPARED?

INTRODUCTION

In patients treated with radiation (RT), doses to hippocampus influence neurocognitive outcomes. However, the role of hippocampal subvolumes in memory functioning has not been reported, which prompted the current study.

METHODS

Adults ( &gt; 18 years) with pituitary tumors treated with fractionated RT (45 Gy/ 25 fractions/ 5 weeks) were accrued in the prospective study. Hippocampus was delineated on T1-weighted 3D-FSPGR sequences with 1mm slice thickness. The head, body, and tail of hippocampus were drawn for the current study based on the consensus of two neuroradiologists. The anatomical landmarks were: head (basilar artery to interpeduncular cistern), body (interpeduncular cistern to superior colliculus), and tail (beyond superior colliculus). Memory assessment was done pre-RT and 18 months post-RT by dedicated neuropsychologist using Weschler Memory Scale. The dose-volume parameters (maximum, mean, D10-D100) were extracted from bilateral hippocampus and subvolumes individually, which were correlated with the memory outcomes. Binary endpoints of &gt; 5% drop of memory quotient (MQ) or not at 18 months were used for analysis using an independent t-test or Mann Whitney test as appropriate.

RESULTS

Of 25 patients included in the analysis, 11 had drop of MQ &gt; 5% at 18 months. The left and right hippocampus doses of D10, D20, and D30 were significantly higher in patients with higher memory decline. For the subvolumes, only dose to bilateral head had statistically significant impact on MQ. Mean doses for patients with &gt; 5% MQ drop for left and right heads were 26 Gy and 24 Gy compared to 21 Gy and 19 Gy, respectively, for the other group.

CONCLUSION

Doses to bilateral hippocampus were shown to impact short-term memory. Of the subvolumes, only head appeared significant in memory functioning from the current pilot study, opening a window for exploring stricter dose constraints towards hippocampal head for primary or metastatic brain tumors.

RADT-26. PATTERNS OF RECURRENCE IN PATIENTS TREATED WITH RE-IRRADIATION FOR RECURRENT HIGH-GRADE GLIOMA

Purpose/Objective(s)

Re-irradiation (ReRT) is often used to treat recurrent high grade glioma (HGG). There is limited literature regarding the patterns of recurrence following ReRT, which was investigated in the current study.

Materials/METHODS

Patients with available radiation (RT) contours, dosimetry, and imaging-based evidence of recurrence were included in the retrospective study. All patients were treated with fractionated RT using conformal technique. Recurrence was documented as per decision in tumor board based on imaging with magnetic resonance imaging (MRI) or Flouroethyl-L-Tyrosine (FET) positron emission tomography (PET), which was registered with the planning CT. Failure patterns were classified as in-field, marginal, and out-field as decided by &gt;50% recurrence volume within 95%, 20-95%, and outside 20% isodose lines, respectively.

RESULTS

Study population included 37 patients treated with median dose of 54 Gy (range 50.4-54 Gy). Before ReRT, 92% patients had undergone surgery (biopsy in 3, gross total resection in 9, subtotal resection in 22), 62% received concurrent chemo with ReRT, and 49% received maintenance chemotherapy. Median time to recurrence was 9 months (7-16 months, median 10 and 8 months respectively for in-field and marginal/out-field recurrence). In-field, marginal, and out-field recurrence were seen in 24 (65%), 10 (27%), and 3 (8%), respectively. Recurrence mapping was done using MRI, PET, or both in 27, 3, and 7, respectively. Of 24 patients with in-field recurrence, 8 and 16 had disease volume within gross tumor volume and clinical target volume, respectively. 2 patients had leptomeningeal dissemination (1 with majority of recurrence volume in-field and 1 with marginal failure in addition to metastatic disease).

CONCLUSION

Following ReRT for HGG, the majority of recurrence was in the high dose region, suggesting the use of conservative target volumes. Future studies are required for feasibility of dose-escalation to improve control rates, particularly in patients with long intervals from first course of RT.

TMIC-03. TUMOR INFILTRATING LYMPHOCYTES IN BRAIN METASTASIS: CLINICOPATHOLOGICAL EVALUATION AND COMPARISON WITH PAIRED PRIMARY

INTRODUCTION

Little is known about tumour-infiltrating lymphocytes (TILs) in brain metastasis (BM) and their utility as predictive biomarker for immunotherapy. AIM: To analyze TILs in BM, and correlate with corresponding paired primary (PP).

METHODS

Inclusion: Histologically confirmed BM and PP (2015-2020). Exclusion: Hematological malignancies, spinal cord/meningeal metastasis, pediatric age, slides/blocks not available. Final Nf 277 BM; 64 PP. One H&E slide from both PP &BM assessed for stromal TILs (sTILs) and intratumoral TILs (iTILs) as per International TIL Working Group guidelines.

RESULTS

Median sTILs (10%) were significantly higher than iTILs (1%) in primary and BM (p-value &lt; 0.001). sTILs were mild (&lt;10%) in majority of primary (57.8%) and BM (59.9%), while iTILs were nearly always mild (primary 97.1%; BM 96.9%). Between PP and BM, no change in sTIL category in 48.43%, while conversion in 51.56%, with higher to lower conversion (66.67%) &gt; lower to higher (33.33%). Conversion rate higher for breast (54.3%) &GIT (62.5%) than lung (45.5%) &GUT (40%). In BM, preoperative steroid therapy (PST) showed lower sTILs (≤10%) (p-value= 0.041), and adenocarcinoma histology higher sTILs ( &gt;10%) (p-value= 0.001), while precocious metastasis (p-value= 0.051) and absence of extracranial metastasis (p-value= 0.083) trended towards higher sTILs. Median survival of whole cohort was 20 months (95% CI 14.4-25.68 months). Presence of extracranial metastasis (p-value= 0.01); precocious BM (p-value= 0.007) showed lower overall survival (OS), while adenocarcinoma histology better OS (p-value= 0.029), in both univariate and multivariate analysis. Absence of PST showed longer median survival, though not significant (24.1 vs 19.8months; p-value= 0.19).

CONCLUSIONS

sTILs predominantly show high &gt;low conversion between PP and BM, signifying lowered immune response in BM. Thus, evaluation of sTILs in BM, wherever tissue available, may be indicated if immunotherapy is considered. Parameters with higher sTILs showed longer survival, possibly indicating prognostic role of tumor microenvironment in BM.

NIMG-77. MAGNETIC RESONANCE IMAGING AND AMINO ACID POSITRON EMISSION TOMOGRAPHY IN DIFFERENTIATING TUMOR RECURRENCE FROM RADIATION NECROSIS IN HIGH GRADE GLIOMAS

BACKGROUND AND PURPOSE

Differentiating tumor recurrence (TR) from radiation necrosis (RN) in high grade glioma (HGG) following radiotherapy can be challenging. The ability of conventional magnetic resonance imaging (MRI) to differentiate TR from post-therapeutic effects is often limited. Multiparametric advanced MRI (perfusion) and positron emission tomography (PET) with amino acid tracers, specifically 18F-Fluoroethyl-Tyrosine (FET) can provide relevant additional information on tumor metabolism, which allows for a more accurate diagnosis to differentiate tumor recurrence from radiation necrosis in high grade gliomas.

MATERIALS AND METHODS

Prospective analysis of 62 lesions in 62 patients with HGG who underwent both MRI and FET-PET imaging within three weeks intervals was done independently by a neuroradiologist and nuclear medicine physician. The study was conducted in a tertiary care oncology center between July 2018 and August 2021. Manually segmented regions of interest were placed over the areas of maximum enhancement/suspicion on MRI and FET uptake, which were used to calculate the relative cerebral volume (rCBV) and tumor to background ratios, respectively. Definitive diagnosis (TR versus RN) was made on clinico-radiological follow-up or histopathological report (wherever available).

RESULTS

Out of the 62 lesions that were studied, 46 and 16 had TR and RN, respectively. The sensitivity and specificity for determination of TR in HGG with conventional MRI were 98% and 62.5% respectively, while with FET-PET it was 91% and 87.5% respectively. The PPV , NPV and accuracy for MRI were 88%, 91% , 89% , while for FET-PET it was 95%, 78% and 90% respectively. A combination of MRI and PET parameters (mean target-to-background ratio), demonstrated an increase in diagnostic accuracy to 97%.

CONCLUSION

Cumulative imaging with MRI and FET-PET offers a multiparametric assessment of glioma recurrence that is correlative and complimentary, with higher accuracy and clinical value.

CLRM-12 TITLE: STEREOTACTIC RADIOSURGERY (ADJUVANT OR NEOADJUVANT) COMPARED TO HIPPOCAMPAL AVOIDANCE WHOLE BRAIN RADIATION THERAPY WITH SIMULTANEOUS INTEGRATED BOOST FOR LIMITED BRAIN METASTASES (SRS-CHART): PHASE III OPEN-LABEL PARALLEL-GROUP RANDOMIZED CONTROLLED TRIAL

BACKGROUND

Surgery is indicated for large or symptomatic lesions in patients with limited brain metastasis (BM), followed by adjuvant stereotactic radiosurgery (A-SRS) to the cavity. Emerging evidence suggests promising role of neoadjuvant SRS (NA-SRS) before surgery with potentially lesser risk of leptomeningeal disease (LMD) and radionecrosis (RN). Hippocampal avoidance whole brain radiotherapy (HA-WBRT) results in better neurocognitive outcomes than standard WBRT, and use of simultaneous integrated boost (SIB) to surgical cavity can improve the local control. Absence of high-quality evidence forms the basis of current study comparing these three treatment strategies.

OBJECTIVES

Primary endpoint is 1-year event-free survival (EFS) a composite endpoint comprising any local failure, LMD, DBF, symptomatic RN, or death as events. Other endpoints include individual endpoints and longitudinal neuro-cognitive function and quality-of-life assessment.

METHODS

Target population includes adults with newly diagnosed BM (≤3 lesions) with life expectancy &gt;1 year and one target lesion needing surgery. Patients will be randomized (1:1:1) to A-SRS (control arm) or one of two test arms (NA-SRS or HA-WBRT-SIB). In A-SRS arm, patients will receive single fraction (16-20Gy) or hypofractionated-SRS (24-27Gy/3 fractions or 30-32.5Gy/5 fractions) based on volume and location of cavity and other intact BM. In the test arms, patients will be allocated to either NA-SRS group (single/multi-fraction) followed by surgery within 2 weeks or HA-WBRT (30Gy/10 fractions) with SIB to cavity plus other intact BM (40-50Gy/10 fractions) combined with memantine within 6 weeks of surgery. A sample size of 168 patients is required to prove the superiority of test arms individually compared to the control arm with assumption of 1-year EFS of 43% versus 25% with a hazard ratio of 0.6 (two-sided alpha=0.05, power=80%, and 15% attrition rate).

DISCUSSION

The study will generate level 1 evidence investigating the role of NA-SRS or HA-WBRT-SIB compared to A-SRS in limited brain metastases.

Clinical outcomes and prognostic factors in children with B-cell lymphoblastic lymphoma (LBL) treated according to on modified BFM-90 protocol: Experience from a Tertiary cancer care center in India

Pediatric B-cell lymphoblastic lymphoma (LBL) is a rare entity, and appropriate treatment for pediatric B-cell LBL is not well defined. While intensive ALL type regimens achieve long term survival of 90% across Western co-operative group trials, published data from Asian studies on long term outcomes are scarce. We retrospectively analyzed the data of pediatric B-cell LBL patients treated between January 2010 and December 2017 on a uniform protocol (modified BFM 90). Kaplan-Meier method was used to estimate the survival and Cox regression models to identify prognostic factors. Of 21 patients who received treatment on the modified BFM-90 protocol, 17(81%) were alive in remission, 3(14%) had relapse, and 1(4%) had treatment-related mortality (TRM) while in remission. Two of 3 relapsed patients subsequently expired. With a median follow-up of 66 months (range 6-114), 5-year event free survival (EFS) and overall survival (OS) were 80% (95% CI:71-89%) and 91% (95% CI:85-97%), respectively. While delayed presentation from symptom onset (p=0.030), and partial response at early (D35) interim assessment (p=0.025) had inferior EFS, patients with elevated baseline LDH had a worse OS (p=0.037). Outcomes of pediatric B-cell LBL patients treated on a modified BFM-90 protocol at a single center in India were excellent. In our study, higher disease burden manifested by elevated baseline LDH and delayed presentation (≥3months) and partial interim response portend poorer survival.Supplemental data for this article is available online at https://doi.org/10.1080/08880018.2021.2005725.

Long-Term Clinical Outcomes and Sequelae of Therapy in Early-Stage Orbital Mucosa-Associated Lymphoid Tissue Lymphoma

INTRODUCTION

Orbital mucosa-associated lymphoid tissue (MALT) lymphoma, which are rare and indolent, often present at an early stage. We report the efficacy and safety outcomes of treatment in these patients.

METHODS

We analyzed adult patients with stage IE or IIE orbital MALT lymphoma between 1999 and 2017 treated at our institute. We assessed local control (LC) rates, overall survival (OS), relapse-free survival (RFS) using Kaplan Meier method and the incidence of late toxicities.

RESULTS

Seventy patients were analyzed for clinical outcomes. The median age at diagnosis was 52 years (IQR-45-62 years). Radiotherapy was offered to 97% of patients and the dose ranged from 36 to 45 Gy. Chemotherapy was administered in 5(7.1%) patients. Relapse occurred in 8 patients (local: 2, distant: 6). At a median follow-up of 101 months (IQR-47-146 months), the median OS and RFS was not reached. 8-year OS, RFS and LC rates were 96.5%, 88.5%, 96.7% respectively. Univariate analysis showed age ≤60 years and lacrimal involvement significantly correlated with better OS (P = .01 and .04, respectively). Cataract was the most common sequelae observed in 31 patients (44.3%).

CONCLUSION

Moderate doses of radiotherapy are curative in early-stage orbital MALT lymphoma with favorable clinical outcomes. Lower doses of radiation can reduce the toxicity further, without compromising efficacy.

IMG-13. Role of diffusion weighted imaging of spine in pediatric brain tumors showing diffusion restriction and CSF metastases

INTRODUCTION: Early detection of leptomeningeal metastases (LM) with paediatric brain tumors cases can change the prognosis as well as course of treatment. Conventional MR imaging and CSF (cerebrospinal fluid) analysis plays a vital role in detection of metastases, however, due to certain limitations these can be missed. In our study, diffusion weighed imaging (DWI) of spine was able to bridge this gap and increased the detection rate in MRI equivocal cases in which CSF study was negative. AIMS: To evaluate the incremental value of DWI over the conventional sequences in detection of LM. MATERIALS & METHODS: Paediatric patients with primary brain tumors known to show restriction and propensity for CSF metastasis underwent MRI on 1.5T Philip’s machine. CSF analysis and radiological follow up were used to confirm the diagnosis. RESULTS: Of the 26 patients proven to have LM, linear leptomeningeal metastases (LLP) were seen in 7 patients and nodular leptomeningeal metastases (NLM) were seen in 6 patients and both were seen in 13 patients. Of the 20 patients with LLM, 18 were detected on contrast; however, these were not detected on T2W and DWI except one patient with thick LLP. In 19 patients with NLM, a total of 84 lesions were detected. All were appreciated on contrast with additional 6 lesions which were false positive (FP). Total 96 lesions were detected on T2W, of which 80 were true positive and 16 were FP. About 80 lesions were detected on DWI. Thus, on contrast sequence FP were 6 while on T2W 16 were FP. DISCUSSION: DWI showed a lower FP rate than conventional sequences. CONCLUSION: Contrast sequence remains most reliable sequence for the detection of LM. However, DWI is useful in equivocal cases. The role of DWI in Group 3 and 4 Medulloblastoma with non-enhancing metastases needs to be further explored.

MEDB-27. Clinico-Radiological Outcomes in WNT-pathway Medulloblastoma: Retrospective Single Institutional Audit

BACKGROUND: Medulloblastoma (MB) is a heterogeneous disease comprising 4 molecular subgroups - wingless (WNT), sonic hedgehog, Group 3, and Group 4 tumors - with distinct developmental origins, diverse clinico-demographic characteristics, unique transcriptional profiles, and widely varying outcomes. WNT-MB is associated with the best outcomes (5-year survival &gt;90%) prompting attempts at treatment de-escalation to reduce late toxicity. We undertook a clinical audit of WNT-MB patients treated at our tertiary-care comprehensive cancer centre. METHODS: Patients with molecularly confirmed WNT-MB treated with maximal safe resection followed by post-operative standard-of-care risk-stratified adjuvant radio(chemo)therapy were identified retrospectively via electronic search of the neuro-oncology database. Data regarding clinico-demographic characteristics, histo-molecular features, treatment details, patterns of failure, and survival outcomes was retrieved from electronic medical records and/or hospital case files. Time-to-event outcomes were analyzed using Kaplan-Meier methods and compared with the log-rank test. RESULTS: Between 2004 to 2018, a total of 65 patients of WNT-MB were registered at our institute. Five patients treated on a prospective clinical trial of therapy de-intensification were excluded leaving 60 patients that constitute the present study cohort. Median age at presentation was 12 years (inter-quartile range 9-18 years) with male preponderance (2:1). Six patients (1 post-operative mortality and 5 without adequate details of treatment or outcomes) were excluded from the survival analysis which was restricted to 54 patients. At a median follow-up of 66 months, Kaplan-Meier estimates of 5-year progression-free survival and overall survival were 87.9% and 92.8% respectively. Traditional high-risk features such as age, residual tumor (&gt;1.5cm2) and leptomeningeal metastases (M+) did not emerge as significant prognostic factors for survival in this molecularly-characterized WNT-MB cohort. CONCLUSION: WNT-MB patients have excellent survival outcomes irrespective of traditional high-risk features suggesting the need for more tailored and refined risk-stratification with potential de-intensification of therapy. ACKNOWLEDGEMENTS: Brain Tumor Foundation (BTF) of India

Compliance, adverse events and quality of life of patients in a phase 3 study comparing temozolomide with PCV as adjuvant chemotherapy in grade 2 and 3 glioma

e14010

Background: Both PCV and Temozolomide (TMZ) are options for adjuvant therapy in grade 2 & grade 3 gliomas after maximal safe resection. The RTOG 9802 PCV regimen is not commonly used as it is perceived as a toxic, poorly tolerated regimen. TMZ is often preferred as it is easy to administer and has fewer adverse events. There has been no head-to-head comparison of these regimens, hence we are conducting a study to compare the 2 regimens. Here, we report the adverse event profile, compliance & quality of life (QoL) of patients enrolled in this study. Methods: This is an ongoing phase 3, non-inferiority trial. Adults with grade 2 glioma with high-risk features (age ≥40 years at diagnosis or residual disease ≥1 cm) or grade 3 gliomas, with ECOG PS 0-2 were enrolled. Patients were randomized 2:1 to receive either adjuvant TMZ or PCV after adjuvant focal conformal radiation (RT). In the TMZ arm patients received RT with concurrent TMZ 75 mg/m2/day (max. 49 days) followed by adjuvant TMZ 150 mg/m2/day on days 1-5 of a 28 day cycle for cycle1, & 200 mg/m2/day cycle 2 onwards (max. 12 cycles).In the PCV arm, patients received Procarbazine 60 mg/m2/day on days 8-21, Lomustine (CCNU) 110 mg/m2 on day 1 & Vincristine (VCR) 1.4 mg/m2 on days 8 & 29 of a 56 day cycle (max. 6 cycles). The primary endpoint of the study is progression-free survival. The current analysis focuses on compliance, adverse events (as per CTCAE v4.03) & QoL (EORTC QLQ C-30 & BN-20). Results: This analysis was limited to the first 50 patients who had completed at least 1 year from the start of adjuvant chemotherapy. There were 32 patients in the TMZ arm & 18 patients in the PCV arm. Two patients each in the TMZ & PCV arms did not start adjuvant chemotherapy. Among those who started adjuvant chemotherapy, the completion rates were higher in the TMZ arm (n = 26,86.7%) as compared to the PCV arm (n = 11,68.8%; p = .241). The median number of cycles of TMZ, Procarbazine, CCNU, and VCR were 12, 5.5, 6 and 5.5 respectively. Dose delays were slightly higher in the PCV arm (81.3%) compared to the TMZ arm (73.3%) which was not statistically significant (p = .722). Chemotherapy dose reductions were needed in 11 patients (68.8%) in the PCV arm & only 1 patient (3.3%) in the TMZ arm, this was statistically significant (p = 0.000). Myelosuppression was significantly higher in the PCV arm as compared to the TMZ arm. The incidence of any grade and grade ≥ 3 anemia, neutropenia & thrombocytopenia was significantly higher with PCV. The incidence of grade 3 lymphopenia was significantly higher with PCV (p = .000). Only 2 patients in the PCV arm developed febrile neutropenia. There was no significant difference in the QoL scores between the two arms at various time points. Conclusions: The use of adjuvant PCV is feasible when administered by experienced neuro-medical oncologists with an acceptable compliance and toxicity profile, without adversely impacting the QoL of patients. Clinical trial information: CTRI/2018/07/015056.

Mebendazole in recurrent glioblastoma: Results of a phase 2 randomized study

2029

Background: Recurrent glioblastoma (GBM) has dismal outcomes and limited treatment options. Mebendazole (MBZ) is an anti-helminthic drug with in-vivo and in-vitro activity against glioma cell lines and has been demonstrated to be well tolerated in combination with lomustine (CCNU) and temozolomide (TMZ). In this phase 2 study, we sought to determine whether the addition of MBZ to CCNU or TMZ would improve overall survival (OS) in recurrent GBM. Methods: Adult patients with ECOG PS 0-3, with recurrent glioblastoma who were not eligible for re-radiation, were randomized 1:1 between CCNU-MBZ (n = 44) and TMZ-MBZ (n = 44). The primary endpoint was OS at 9 months, selected to reflect the BELOB trial. A 9-month OS of 55% or more in any arm was hypothesized to warrant further evaluation and a value below 35% was too low to warrant further investigation. Results: At 17.4 months, 68 events for OS analysis had occurred. The 9-month overall survival was 36.6% (95%CI 22.3-51) and 45% (95%CI 29.6-59.2) in the TMZ-MBZ and CCNU-MBZ arms respectively. ECOG PS was the only independent prognostic factor impacting OS (HR-0.478 95%CI 0.268-0.851; P = 0.012). Twenty-three patients (28.6%) enrolled had an ECOG PS 2-3 with inferior outcomes (median OS-5.67, HR-2.092 95%CI 1.175-3.731). Analysis restricted to ECOG PS 0-1 (n = 65) patients revealed a 9-month OS of 39.6% (95% CI 22.4-56.3) and 57.9% (95% CI 38.7-73) in TMZ-MBZ and CCNU-MBZ arms respectively. Grade 3-5 adverse events were seen in 8 (18.6%; n = 43) and 4 (9.5%; n = 42) patients in the TMZ-MBZ and CCNU-MBZ arms respectively. Conclusions: The addition of MBZ to TMZ or CCNU failed to achieve the pre-set benchmark of 55% 9-month OS. This was probably due to 28.6% of patients with poor PS of 2-3. In patients with ECOG PS 0-1, CCNU-MBZ had a 9 month OS of 57.9% and needs to be evaluated further. Clinical trial information: CTRI/2018/01/011542.

Outcomes of COVID-19 and risk factors in patients with cancer

Patients with cancer are at higher risk for adverse coronavirus disease 2019 (COVID-19) outcomes. Here, we studied 1,253 patients with cancer, who were diagnosed with severe acute respiratory syndrome coronavirus 2 at a tertiary referral cancer center in India. Most patients had mild disease; in our settings, recent cancer therapies did not impact COVID-19 outcomes. Advancing age, smoking history, concurrent comorbidities and palliative intent of treatment were independently associated with severe COVID-19 or death. Thus, our study provides useful insights into cancer management during the COVID-19 pandemic.

CTNI-34. TOXICITY PROFILE AND COMPLIANCE OF PATIENTS WITH HIGH RISK GRADE 2 OR GRADE 3 GLIOMAS RECEIVING ADJUVANT PCV VERSUS ADJUVANT TEMOZOLOMIDE

INTRODUCTION

The NCCN recommends either PCV (Procarbazine, CCNU and vincristine) or Temozolomide (TMZ) as adjuvant therapy in high-risk grade 2 & grade 3 gliomas. In this ongoing study we are comparing PCV with TMZ as adjuvant therapy in this setting.

METHODS

This is a randomised phase 3 study that includes patients with high risk (as per RTOG) grade 2 gliomas and grade 3 gliomas after surgery. Patient are randomly assigned in 1: 2 to receive either adjuvant PCV or TMZ after adjuvant RT. The primary end-point is progression-free survival & key secondary end points are overall survival, toxicity and quality of life. The current analysis focuses on the compliance and adverse events seen in patients enrolled till 30th April 2020.

RESULTS

46 patients were enrolled, with 30 patients in TMZ arm. The median age of patients was 37 years (range 23-64). The ECOG PS was 1 in 45 (97.8%) patients and 2 in 1(2.2%) patient at enrolment. The number of patients who have completed all planned cycles of chemotherapy in the PCV arm is 62.5% (10, n=16) as compared to 90% (27, n=30) in the TMZ arm (P=0.047). The incidence of grade 3 or higher adverse events is 68.8% (n=11) in the PCV arm and 16.7% (n=5) in the TMZ arm (P=0.001). The most common grade 3 or higher toxicities noted are lymphopenia in 50% (n=8), neutropenia in 37.5% (n=6), and thrombocytopenia in 25% (n=4) in the PCV arm; while the corresponding numbers in the TMZ arm are 13.3% (n=4), 3.3% (n=1) and 10% (n=3) respectively.

CONCLUSION

In the current study the chemotherapy completion rates are higher with TMZ and it is associated with lower grade 3-4 events, whether this will lead to an improvement in outcomes remains to be seen.

Prognostic significance of 18F-FDG PET/CT parameters in IDH-1 wild-type GBM and correlation with molecular markers

AIM

To assess the prognostic role of metabolic parameters on 18F-FDG PET/CT & correlation with molecular markers in IDH-1 wild-type GBM.

METHODS

A total of 129 patients with brain lesions showing equivocal findings on baseline MRI who were referred for fluoro-deoxy-glucose PET/CT were analyzed. Of these, 50 underwent surgery/biopsy and postoperative histopathological diagnosis of IDH-1 wild-type GBM. SUVmax, metabolic tumor volume (MTV), total lesion glycolysis (TLG) & T/w ratio was calculated. Median metabolic parameters were used for stratification. Overall survival was calculated using Kaplan-Meier method and was compared using log rank test. P value < 0.05 was considered significant. Multivariate analysis was done using Cox proportional hazard model. Correlation between metabolic parameters and molecular markers was done using Mann-Whitney U test.

RESULTS

Median of SUVmax, T/w ratio, MTV, TLG, 18.3, 2.09, 61, 409. Average overall survival (OS) for T/w ratio >2.08 was 5 months, <2.08 was 18 months (P value 0.001). For MTV >61 was 4 months, <61 was 18 months (P value 0.001). Similarly, for TLG >409 was 5 months while for <409 was 19 months (P value 0.001). SUVmax was not significant for OS. In multivariate analysis, age was the statistically significant independent prognostic factor.

CONCLUSION

Metabolic parameters of fluoro-deoxy-glucose PET/CT help in prognosticating IDH-1 wild-type GBM. Higher MiB-1 index correlates with higher T/w ratio and is associated with poor overall survival.

Brain FET PET tumor-to-white mater ratio to differentiate recurrence from post-treatment changes in high-grade gliomas

BACKGROUND AND PURPOSE

Highergrade glial neoplasms undergo standard treatment with surgery, radiotherapy, and alkylating agents. There is often a clinical/neuroimaging dilemma in the post-treatment setting to differentiate disease recurrence from treatment-related changes. FET (fluoro-ethyl-tyrosine) PET has emerged as a molecular imaging modality for cases where MR imaging is inconclusive. This study aims to develop a cutoff on FET PET for differentiating true recurrence from post-treatment changes.

METHODS

We retrospectively analyzed72 patientswith post-treatment grade 3 or 4 brain gliomas. Five to six mCi of ¹⁸ F-FET was injected and static imaging of the brain was performed at 20 min. A tumor-to-white matter (T/Wm) ratio was used as semiquantitative parameter. A T/Wm cutoff of 2.5 was used for image interpretation. Imaging findings were confirmed by either histopathologic diagnosis in a multidisciplinary joint clinic or based on follow-up of clinical and neuroimaging findings.

RESULTS

Forty-one of 72 patients (57%) showed recurrent disease on FET PET. Thirty-five of them were confirmed to have tumor recurrence; six patients showed post-treatment changes. Thirty-one of 72 patients (43%) showed post-treatment changes on FET PET; 27 were confirmed as post-treatment change and four patients had tumor recurrence on subsequent MR imaging. An optimum T/Wm cutoff of 2.65 was derived based on receiver operating characteristic analysis with a sensitivity of 80% and specificity of 87.5%.

CONCLUSION

Static FET PET can be used as problem-solving imaging modality with a T/Wm cutoff of 2.65 to differentiate late recurrence from post-treatment changes in grade 3 or 4 brain gliomas with equivocal MR features.

MiR-592 activates the mTOR kinase, ERK1/ERK2 kinase signaling and imparts neuronal differentiation signature characteristic of group 4 medulloblastoma

Medulloblastoma, a common malignant brain tumor in children, consists of four molecular subgroups WNT, SHH, Group 3 and Group 4. Group 3, Group 4 tumors have an overlap in their expression profiles and genetic alterations but differ significantly in their clinical characteristics, with Group 3 having the worst five-year overall survival of less than 60%. MiR-592 is overexpressed predominantly in Group 4 tumors. MiR-592 expression reduced the anchorage-independent growth, invasion potential, and tumorigenicity of Group 3 medulloblastoma cells. DEPTOR, an endogenous inhibitor of the mTOR kinase, and EML1 were identified as novel targets of miR-592. The miR-592 mediated decrease in the DEPTOR expression levels activated both mTORC1 and mTORC2 complex in medulloblastoma cells. However, the miR-592 expression also decreased the AKT kinase activity, likely to be due to the activation of the inhibitory feedback of the mTOR signaling. MiR-592 expression upregulated several neuronal differentiation-related genes, a characteristic of Group 4 medulloblastoma in Group 3 cell lines. The expression of miR-592 also upregulated the activity of ERK1/ERK2 kinases indicating activation of the MAPK signaling pathway. The inhibition of MAPK signaling by the ERK1/ERK2 inhibitor and mTOR signaling by rapamycin abrogated the miR-592-mediated upregulation of neuronal differentiation-related genes. Group 4 medulloblastomas showed higher activity of the mTOR and MAPK signaling compared to Group 3 tumors. Thus, miR-592 overexpression appears to be a driver event and a determining factor of Group 4 biology, which activates the mTOR and MAPK signaling pathways and thereby imparts its characteristic expression profile of neuronal differentiation-related genes.

Downregulation of ARID1B, a tumor-suppressor in the WNT subgroup medulloblastoma, activates multiple oncogenic signaling pathways

Medulloblastoma, a common pediatric malignant brain tumor, consists of four distinct molecular subgroups WNT, SHH, Group 3, and Group 4. Exome sequencing of 11 WNT subgroup medulloblastomas from an Indian cohort identified mutations in several chromatin modifier genes, including genes of the mammalian SWI/SNF complex. The genome of WNT subgroup tumors is known to be stable except for monosomy 6. Two tumors, having monosomy 6, carried a loss of function mutation in the ARID1B gene located on chromosome 6. ARID1B expression is also lower in the WNT subgroup tumors compared to other subgroups and normal cerebellar tissues that could result in haploinsufficiency. The shRNA-mediated knockdown of ARID1B expression resulted in a significant increase in the malignant potential of medulloblastoma cells. Transcriptome sequencing identified upregulation of several genes encoding cell adhesion proteins, matrix metalloproteases indicating the epithelial-mesenchymal transition. The ARID1B knockdown also upregulated ERK1/ERK2 and PI3K/AKT signaling with a decrease in the expression of several negative regulators of these pathways. The expression of negative regulators of the WNT signaling like TLE1, MDFI, GPX3, ALX4, DLC1, MEST decreased upon ARID1B knockdown resulting in the activation of the canonical WNT signaling pathway. Synthetic lethality has been reported between SWI-SNF complex mutations and EZH2 inhibition, suggesting EZH2 inhibition as a possible therapeutic modality for WNT subgroup medulloblastomas. Thus, the identification of ARID1B as a tumor suppressor and its downregulation resulting in the activation of multiple signaling pathways opens up opportunities for novel therapeutic modalities for the treatment of WNT subgroup medulloblastoma.

Understanding NLRs and AIM2 cellular and molecular signalling in glioblastoma pathophysiology

Gliomas are the most prevalent primary brain tumors with immense clinical heterogeneity, poor prognosis and survival. Gliomas arise from glial cells and are heavily infiltrated with innate immune cells. In India high-grade gliomas or Glioblastomas (GBM) account for 59.5% of CNS tumours. A key challenge for clinical management of GBM is its highly heterogeneous nature-between patients and within a single tumour-making current therapies ineffective. The nucleotide-binding domain, and leucine-rich repeat containing receptors (NLRs) and absent-in-melanoma 2 (AIM2) are innate immune receptors crucial for initiation and progression of several cancers. There is a dearth of reports investigating NLRs and AIM2 in glioma pathology.

We are interested in studying the cellular and molecular contribution of NLRs and AIM2 in malignant gliomas in the Indian subcontinent. We previously reported a data-driven approach to identify NLRs, AIM2 and NLR-associated gene expression in gliomas using The Cancer Genome Atlas (TCGA) patient datasets. However, TCGA data is obtained from diverse populations and cellular diversity within individual tumor tissues remains unexplored. In this study we carried out tumour primary cell culture, human brain immunohistochemistry and proteomic analysis and same patient serum controls (n=100). Our results characterize novel cell specific differential expression and signalling profile of several NLR genes (including NLRP3, NLRP12 and ASC) in microglia, astrocytes, endothelial cells and the tumour cell populations in GBM patient tissue. We provide critical insights into innate immune signalling within the GBM microenvironment and identify key markers for future therapeutic interventions.

Outcomes of Patients with Primary Mediastinal B-Cell Lymphoma Treated with Dose Adjusted R-EPOCH Regimen: A Single Centre Experience

Introduction

Primary Mediastinal B cell lymphoma (PMBCL) is a biologically and clinically distinct subset of diffuse large B cell lymphoma. We analysed the outcomes of our cohort of PMBCL patients treated with Dose adjusted (DA)-R-EPOCH regimen.

Patients and Methods

This is a retrospective analysis of consecutive PMBCL patients who received chemotherapy consisting of DA-R-EPOCH with filgrastim support. Survival analysis was done using Kaplan-Meier method. All calculations were performed using SPSS version 20 for windows.

Results

A total of 43 consecutive suspected PMBCL patients were reviewed for this study, 6 patients were excluded as diagnosis of PMBCL could not be established. All patients except one (97.3%) received 6 cycles of R-DA-EPOCH regimen. Median age of the patients was 27 years (range 15-58). Bulky disease (> 7 cm) was present in 97% patients and 54% patients had extranodal disease. With a median follow up of 40 months, 3-year overall survival was 80.6% (95% CI: 74.0-87.2). The 3-year event free survival was 78.4% (95% CI: 71.6-85.2). There were 6 (16.2%) relapses, 1 (2.7%) primary progression and 7 (23%) deaths. Mediastinal radiotherapy was administered to 17 (45.9%) patients. All the deaths were due to disease progression. Grade III/IV toxicities were seen in 28 (75.7%) patients, febrile neutropenia being the most common one.

Conclusions

DA-R-EPOCH regimen is an effective and tolerable regimen in PMBCL patients even with adverse features.

LINC-12. COMBINED ADULT AND PAEDIATRIC NEURO-ONCOLOGY LONG-TERM SURVIVOR CLINIC EXPERIENCE FROM A TERTIARY CANCER CENTRE IN A LOW-MIDDLE-INCOME COUNTRY

NeuroOncology survivor clinics (NOS) is uncommon in low-middle-income countries. We started combined (paediatric and adult) NOS clinic in our tertiary a cancer centre (Jan-2017) and review here the demographic, clinical-pathological and treatment spectrum for our paediatric (0-18years) and adult (&gt;18years) survivors (&gt;5years since their initial diagnosis) till date. Of total 312 patients registered, 198 (63.5%) were adults while 114 (36.5%) were paediatric at-diagnosis with median age (IQR) at presentation: 34 (23–41) and 9(6 – 13) years respectively. In both groups, only 33% were females. The median (IQR) time since diagnosis was 9 (9–14) and 8 (6–12) years respectively with 60% of paediatric turning into adult survivors. The commonest paediatric tumours were glioma (52, 45.6%), embryonal (34, 29.8%), and ependymoma (12, 10.5%) versus gliomas (114, 57.6%) and benign tumours (42, 21.2%) in adults. The low-grade-glioma comprised 90.4% of all pediatric gliomas and intermediate-grade (90%) in adults. The primary treatment consisted of radiotherapy and chemotherapy in 95% and 43% versus 99% and 36% in adults versus paediatric patients respectively. Temozolomide and multi-drug combinations were the commonest chemotherapy used in adults and paediatrics respectively. Relapse and retreatments were seen in 16.6 and 14% of adults and paediatric patients. There were two deaths each in each group since registration (median 12 months). Although the baseline diagnosis/treatment characteristics are different, survivors of both group had a similar number of retreatments and deaths. Combined survivor clinics may present an interesting and unique opportunity to learn and provide challenging service in this part of the world.

Outcomes of T-lymphoblastic lymphoma treated with pediatric ALL-like protocol

Background

The management of T-lymphoblastic lymphoma (T-LBL) in adults poses uncertainties, including optimal chemotherapy regimen, need for radiotherapy, and the benefit of stem cell transplant. This retrospective case series investigated the efficacy of the pediatric BFM-90 regimen in adult patients and evaluated the role of early response assessment by positron emission tomography with computed tomography (PET-CT) in predicting outcomes.

Methods

Patients aged 15 years or older with T-LBL diagnosed at Tata Memorial Hospital, Mumbai, India were given chemotherapy according to the European BFM-90 protocol (n = 38). The patients were evaluated for early response by interim PET-CT, post-induction and monitored for toxicity and long-term outcomes.

Results

Thirty-eight consecutive patients (median age 23.5 years) were analyzed. After a median follow-up of 33.5 (1-77) months, following induction, 35 out of 38 patients (92.1%) had achieved complete response (CR) on PET-CT. Thirty (78.9%) patients treated according to BFM-90 were alive in first remission. Three-year event-free survival for those with CR on PET-CT was 78%, against no survivors for those who remained PET-positive.

Conclusion

This study demonstrates the feasibility and efficacy of BFM-90 approach in adults with T-LBL. We found an early PET response to be highly predictive of outcome.

Increased toxicities in children with Burkitt lymphoma treated with rituximab: Experience from a tertiary cancer center in India

BACKGROUND

Even though rituximab has emerged as standard of care for the management of high-risk pediatric Burkitt lymphoma (BL), its safety in children from the low-middle-income countries (LMICs) remains to be proven. We herein report our experience of using rituximab in children with BL.

METHODS

All patients diagnosed with BL between January 2015 and December 2017 were treated in a risk-stratified manner with either the modified MCP-842 or modified LMB protocol. Patients with poor response to MCP-842 were switched to the LMB-salvage regimen. In addition, rituximab was given to selected high-risk patients.

RESULT

Forty-two (49.4%) of 85 patients with BL received rituximab. The incidence of febrile neutropenia (90.5% vs 67.4%; P = 0.02), pneumonia (38.1% vs 11.6%; P = 0.005), intensive care unit admissions (54.5% vs 17.6%; P = 0.002), and toxic deaths (26.2% vs 9.3%; P = 0.04) was higher among BL patients who received rituximab. Pneumonia was fatal in 11 of 16 (69%) patients who received rituximab. On multivariate analysis, rituximab continued to be significantly associated with toxic deaths ( OR: 11.45 [95% CI: 1.87-70.07; P = 0.008]). The addition of rituximab to intensive chemotherapy resulted in an inferior one-year event-free survival (49.4% ± 8.1% vs 79.3% ± 6.5%; P = 0.025) and one-year overall survival (63.1% ± 8.5% vs 91.8% ± 4.5%; P = 0.007) with no improvement in one-year relapse-free survival (78.3% ± 7.3% vs 83.9% ± 6.0%; P = 0.817).

CONCLUSION

Rituximab was associated with increased toxicities and toxic deaths in our patients. The potential immunomodulatory effect of rituximab and increased susceptibility to infections in patients from LMICs have to be carefully considered while choosing this drug in the treatment of BL in resource-constrained settings.

Reverse swing-M, phase 1 study of repurposing mebendazole in recurrent high-grade glioma

BACKGROUND

Relapsed high-grade glioma has dismal outcomes. Mebendazole has shown promising activity against glioma in in-vitro and in-vivo studies. Hence, we undertook a phase 1 study to repurpose mebendazole in the treatment of glioblastoma.

METHODS

We conducted a phase 1 study (accelerated titrated design 4) of mebendazole in patients with recurrent glioblastoma (GBM). Patients eligible for re-irradiation were enrolled in arm A1 (radiation with concurrent temozolomide 75 mg/m2 daily during the course of radiation+mebendazole) while patients who were ineligible were enrolled in either arm B1 (CCNU 110 mg/m2 day 1, every 6 weekly + mebendazole) or arm C1 (temozolomide 200 mg/m2 day 1-5, every 4 weekly + mebendazole). The primary endpoint of phase 1 was to identify the MTD of mebendazole in each combination.

FINDINGS

11 patients were enrolled in the whole study. MTD of mebendazole was not reached in arm A1 and C1 and hence the recommended dose for phase 2 was 1600 mg TDS (4800 mg) per day. The MTD of mebendazole in combination with CCNU was 1600 mg TDS (4800 mg) per day and the dose recommended for phase 2 was 800 mg TDS (2400 mg) per day. The three most common adverse events seen in the study were anemia (n = 9, 81.8%), nausea (n = 7, 63.6%), and fatigue (n = 6, 55.5%).

INTERPRETATION

The recommended phase 2 dose of mebendazole is 1600 mg TDS with temozolomide and temozolomide-radiation combination while the dose of 800 mg TDS needs to be used with single-agent CCNU.

Objective assessment of intraoperative tumor fluorescence reveals biological heterogeneity within glioblastomas: a biometric study

PURPOSE

Heterogeneity within GBMs and variability of visualized fluorescence combine to confer practical limitations to the technique of optical imaging. A biometric analysis was planned to objectively ascertain and analyse this phenomenon METHODS: 25 adult glioblastoma subjects undergoing resection were prospectively accrued. Biopsies were taken from various parts of the tumor and safe peritumoral zones. White light (WL) and visualized fluorescence was subjectively recorded. Corresponding histopathology [coalescent (C) or infiltrating (I) tumor] and protoporphyrin-IX (PPIX) levels were assayed.

RESULTS

WL was very sensitive for detecting tumor. SF was more specific and had high positive predictive value for detecting tumor. WF on the other hand had a poor discriminatory efficacy. Mean PPIX levels were 3.0, 2.01 and 0.16 for SF, WF, and NF respectively. WF had a wide variable range of PPIX levels. Within the coalescent tumor areas, there was a variable distribution of fluorescence (both subjective as well as objective PPIX levels) with only 54% samples showing SF and high PPIX. In seven cases this discordance was noted within the same tumor (biological heterogeneity).

CONCLUSIONS

Fluorescence may miss important tumor areas even if objective assessment is used. Histologically similar tumor areas may exhibit contrasting fluorescence properties, a phenomenon which needs further investigation and elucidation of underlying mechanisms which could potentially be manipulated to optimize the utility of fluorescence guidance.

The Th9 Axis Reduces the Oxidative Stress and Promotes the Survival of Malignant T Cells in Cutaneous T-Cell Lymphoma Patients

Immune dysfunction is critical in pathogenesis of cutaneous T-cell lymphoma (CTCL). Few studies have reported abnormal cytokine profile and dysregulated T-cell functions during the onset and progression of certain types of lymphoma. However, the presence of IL9-producing Th9 cells and their role in tumor cell metabolism and survival remain unexplored. With this clinical study, we performed multidimensional blood endotyping of CTCL patients before and after standard photo/chemotherapy and revealed distinct immune hallmarks of the disease. Importantly, there was a higher frequency of "skin homing" Th9 cells in CTCL patients with early (T1 and T2) and advanced-stage disease (T3 and T4). However, advanced-stage CTCL patients had severely impaired frequency of skin-homing Th1 and Th17 cells, indicating attenuated immunity. Treatment of CTCL patients with standard photo/chemotherapy decreased the skin-homing Th9 cells and increased the Th1 and Th17 cells. Interestingly, T cells of CTCL patients express IL9 receptor (IL9R), and there was negligible IL9R expression on T cells of healthy donors. Mechanistically, IL9/IL9R interaction on CD3⁺ T cells of CTCL patients and Jurkat cells reduced oxidative stress, lactic acidosis, and apoptosis and ultimately increased their survival. In conclusion, coexpression of IL9 and IL9R on T cells in CTCL patients indicates the autocrine-positive feedback loop of Th9 axis in promoting the survival of malignant T cells by reducing the oxidative stress. IMPLICATIONS: The critical role of Th9 axis in CTCL pathogenesis indicates that strategies targeting Th9 cells might harbor significant potential in developing robust CTCL therapy.

Favorable outcomes and reduced toxicity with a novel vinblastine-based non-high dose methotrexate (HDMTX) regimen (modified MCP-842) in pediatric anaplastic large cell lymphoma (ALCL): experience from India

Anaplastic large cell lymphoma (ALCL) is a rare form of non-Hodgkin lymphoma (NHL) in children. Most treatment regimens include high-dose methotrexate (HDMTX), which is logistically difficult to administer in resource-limited settings. We evaluated the outcomes of pediatric ALCL patients treated on a uniform protocol (Modified Multicentric Protocol, MCP-842 regimen) at our hospital between January 2005 and December 2016. Of the 68 patients who received treatment on the Modified MCP842 protocol, 46 patients are alive in remission, 11(16%) had disease progression, 9(13%) relapsed after achieving remission, and 5(7%) had treatment-related mortality (TRM). Seventeen of 20 relapsed/progressed patients subsequently expired. With a median follow-up of 55 months (range 2-165 months), the 4-year event-free survival (EFS) and overall survival (OS) are 63% (95% CI of 50-73%) and 70%(95% CI of 57-79%), respectively. An indigenous protocol using vinblastine (without HDMTX and steroids) is feasible in a resource-limited setting and achieves outcomes comparable to regimens incorporating HDMTX, with lower toxicity.

Primary tonsillar tuberculosis masquerading as carcinoma of the tonsil

Primary tuberculosis (TB) of tonsil is a rare form of extra-pulmonary tuberculosis. Most tonsillar TB cases present with coexistent pulmonary tuberculosis. It can simulate tonsillar malignancy and poses a diagnostic challenge. Histopathological examination is often needed for confirmation. Herein, we report a case of primary tonsillar tuberculosis in a 55-year-old gentleman mimicking carcinoma of the tonsil.

Utility of FET-PET in detecting high-grade gliomas presenting with equivocal MR imaging features

High-grade gliomas, metastases, and primary central nervous system lymphoma (PCNSL) are common high-grade brain lesions, which may have overlapping features on magnetic resonance (MR) imaging. Our objective was to assess the utility of 18-fluoride-fluoro-ethyl-tyrosine positron emission tomography (FET-PET) in reliably differentiating between these lesions, by studying their metabolic characteristics. Patients with high-grade brain lesions suspicious for glioma, with overlapping features for metastases and PCNSL were referred for FET-PET by Neuroradiologists from Multidisciplinary Neuro-Oncology Joint Clinic. Tumor-to-contralateral white mater ratio (T/Wm) at 5 and 20 min was derived and compared to histopathology. Receiver operating characteristic curve analysis was used to find the optimal T/Wm cutoff to differentiate between the tumor types. T/Wm was higher for glial tumors compared to nonglial tumors (metastases, PCNSL, tuberculoma, and anaplastic meningioma). A cutoff of 1.9 was derived to reliably diagnose a tumor of glial origin with a sensitivity and specificity of 93.8% and 91%, respectively. FET-PET can be used to diagnose glial tumors presenting as high-grade brain lesions when MR findings show overlapping features for other common high-grade lesions.

P14.50 Clinicopathological spectrum of intracranial germ cell tumors: an Indian tertiary cancer center experience

BACKGROUND

Incidence of intracranial germ cell tumors (ICGCT) in Western literature is low (0.3–0.6 %) as compared to East Asia (3–4 %), & their clinicopathological features are well documented. However, there are scant studies on ICGCT from India.

MATERIAL AND METHODS

Retrospective observational study of all ICGCT histologically diagnosed in our hospital from 2007–2018. Metastasis were excluded. Clinicopathological features were retrieved from hospital’s electronic medical records.

RESULTS

We diagnosed 82 primary ICGCT, forming approx. 0.54 % of all primary brain tumors, & 3.5% of pediatric brain tumors. Age range: 2 months-32 yrs (Median age 14 yrs). M:F ratio: 1.82:1 (53M,29F). Nearly 80% patients were pediatric (<18 yrs), & 8 very young (<3 yrs, 7M1F). Majority were suprasellar & pineal (31/82, 37% each), with one bifocal presentation. Other rarer sites: posterior fossa (4), midbrain (1), corpus callosum (1) & 11 non midline (4 thalamic, 4 frontal, 2 cerebellar, 1 CP angle). Predominant histology was germinoma (G) (51/82, 62%), while non germinomatous (NGGCT) were 31/82 (38%), of which 9 were mixed. Pure teratoma were 11 (9 immature (IT), 2 mature), & 5 pure yolk sac tumor (YST). Interestingly, all very young age group patients (<3 yrs), showed only NGGCT histology (5/8 IT, 3/8 pure YST). In contrast, G histology formed nearly 70% of all patients >3 yrs. Females were associated mainly with G (21/29, 72%). NGGCT were predominantly seen in males (M:F=2.9:1). Also, pure IT (9) were seen only in males. Posterior fossa tumors were all IT (4/4). Spinal tumors were NGGCT (1 mature teratoma, 1 YST). Majority of suprasellar tumors (25/31, 80.6%), other midline locations like corpus callosal, midbrain, & all thalamic tumors were G. However, pineal tumors showed equal distribution of G (15/31) & NGGCT (16/31). Spine screening was positive in 8 patients (6 G, 2 IT)- 7 on MRI and 1 only on CSF cytology. Serum tumor markers were raised in 13/54 cases- 6/34G(17.6%), vs 7/20 NGGCT (35%). CSF tumor markers were raised in 14/34-10/23 G (43.4%), vs 4/11 NGGCT (36.3%). Follow up was available for 37 patients (Duration 3 months-10 yrs, median 2 yrs). On f/u 6/15 (40%) NGGCT showed progression/death, while only 2/32 G relapsed (6.5%). Four deaths in G group were not directly attributable to the tumor.

CONCLUSION

Frequency of ICGCT in our hospital similar to western data rather than Asian, albeit with less striking male preponderance. ICGCT were tumors of 2nd decade & majority occurred in pineal/suprasellar areas. About 2/3rd were pure G on histology, and showed good prognosis. NGGCT were common in infants, males and in posterior fossa. IT were seen exclusively in males and pure YST mainly in males. Although majority of ICGCT are in midline, rarely non midline involvement also occurs, and it’s essential to exclude metastasis before considering primary ICGCT. Expectedly, NGGCT showed poorer prognosis, compared to pure germinomas.

Downregulation of miR-204 expression defines a highly aggressive subset of Group 3/Group 4 medulloblastomas

Genome-wide expression profiling studies have identified four core molecular subgroups of medulloblastoma: WNT, SHH, Group 3 and Group 4. Molecular markers are necessary for accurate risk stratification in the non-WNT subgroups due to the underlying heterogeneity in genetic alterations and overall survival. MiR-204 expression was evaluated in molecularly classified 260 medulloblastomas from an Indian cohort and in 763 medulloblastomas from the MAGIC cohort, SickKids, Canada. Low expression of miR-204 in the Group 3 / Group 4 tumors identify a highly aggressive subset of tumors having poor overall survival, in the two independent cohorts of medulloblastomas. Downregulation of miR-204 expression correlates with poor survival within the Group 4 as well indicating it as a valuable risk-stratification marker in the subgroup. Restoration of miR-204 expression in multiple medulloblastoma cell lines was found to inhibit their anchorage-independent growth, invasion potential and tumorigenicity. IGF2R was identified as a novel target of miR-204. MiR-204 expression resulted in downregulation of both M6PR and IGF2R that transport lysosomal proteases from the Golgi apparatus to the lysosomes. Consistent with this finding, miR-204 expression resulted in reduction in the levels of the lysosomal proteases in medulloblastoma cells. MiR-204 expression also resulted in inhibition of autophagy that is known to be dependent on the lysosomal degradation pathway and LC3B, a known miR-204 target. Treatment with HDAC inhibitors resulted in upregulation of miR-204 expression in medulloblastoma cells, suggesting therapeutic role for these inhibitors in the treatment of medulloblastomas. In summary, miR-204 is not only a valuable risk stratification marker in the combined cohort of Group 3 / Group 4 medulloblastomas as well as in the Group 4 itself, that has paucity of good prognostication markers, but also has therapeutic potential as indicated by its tumor suppressive effect on medulloblastoma cells.

Abstract 2080: Role of differentially expressed micro RNAs in non-WNT, non-SHH medulloblastoma

Medulloblastoma is a common malignant brain tumor in children. It has four distinct molecular subgroups namely WNT, SHH, Group 3 and Group 4. The molecular subgroups differ in their clinical characteristics including age, incidence of metastasis and survival. Group 3 and Group 4 medulloblastomas have overlapping gene expression profile but are distinct in their clinical behavior. Group 3 medulloblastomas have the worst overall survival rates whereas Group 4 medulloblastomas have intermediate survival. Group 3 and Group 4 tumors are not associated with any known signaling pathway and due to their overlapping expression profiles it is often difficult to accurately identify the subgroup, which is very crucial for the appropriate treatment design. MiR-592, located in the intronic region of GRM8 gene, is over expressed in Group 4 medulloblastoma along with its host gene, thus acting as a good marker for Group 4 tumors. MiR-204, on the other hand is expressed from the 6th intron of TRPM3 gene and expressed in some Group 3 and majority of Group 4 medulloblastomas. In order to delineate the role of miR-592 and miR-204 in medulloblastoma biology, effect of expression of these microRNAs on medulloblastoma cell growth and behavior were investigated. The micro RNAs were expressed in a lentiviral mediated inducible manner in Group 3 medulloblastoma cell lines D283, D425 and D341 and their effects on cell proliferation, anchorage-independent growth and invasion potential were studied. MiR-592 expression had marginal effects on the anchorage independent growth potential and the tumorigenic potential of the Group 3 cell line where as miR-204 expression led to significant decrease in the anchorage independent growth, tumorigenic potential, as well as invasion potential of the medulloblastoma cell lines. Further in order to decipher the molecular mechanisms underlying these micro RNA mediated effects, RNA-sequencing analysis of miR-592 and miR-204 expressing medulloblastoma cells were performed to identify genes that are differentially expressed upon micro RNA expression. The results helped us to identify the molecular pathways that are being affected by the micro RNA expression and how they affect the malignant behavior of medulloblastoma cells.

Citation Format: Raikamal Paul, Rakesh Jalali, Epari Sridhar, Aliasagar Moiyadi, Neelam Shirsat. Role of differentially expressed micro RNAs in non-WNT, non-SHH medulloblastoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2080.

Abstract 4148: Role of the photoreceptor gene, CRX (cone-rod homeobox) in pathogenesis of non-WNT, non-SHH medulloblastoma

Central nervous system (CNS) tumours are the second most common cancers diagnosed in children after leukemia and continue to be the leading cause of cancer-related mortality in children. Medulloblastoma (MB) is a highly malignant primary brain tumour that occurs in posterior fossa region of the brain. The current standard treatment regimen includes surgical resection, craniospinal irradiation and adjuvant chemotherapy. Although this has resulted in significant increase in survival, approximately one-third of medulloblastoma patients still die because of the disease. Genome-wide gene expression profiling studies have identified four molecularly distinct subgroups of medulloblastoma namely WNT, SHH, Group 3, and Group 4. Among the four subgroups, Group 3 patients exhibit highest incidence of metastasis and worst overall survival rates. Molecular mechanism underlying the pathogenesis of Group 3 medulloblastomas is not understood. Group 3 tumors often express retina photoreceptor-specific genes like CRX (Cone Rod Homeobox) which is a homeodomain transcription factor and it is essential for the normal development and maintenance of cones and rods cells of the retina. We have noted that this expression is also retained by the medulloblastoma cell lines like D425, D283 and D341 which have characteristics of Group 3 tumours. Downregulation of CRX in these cell lines brought about inhibition of cell proliferation and anchorage-independent growth as studied by soft agar colony formation assay. CRX gene, therefore, seems to act as an oncogene similar to OTX2, another homeobox gene overexpressed in medulloblastomas. Transcriptome profiling and CHIP-seq analysis is being carried out to identify genes regulated by CRX transcription factor to delineate the molecular mechanism underlying the oncogenic role of CRX in medulloblastoma pathogenesis.

Citation Format: Shalaka Masurkar, Aliasagar Moiyadi, Epari Sridhar, Rakesh Jalali, Neelam Shirsat. Role of the photoreceptor gene, CRX (cone-rod homeobox) in pathogenesis of non-WNT, non-SHH medulloblastoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4148.

What you see and what you don't - Utility and pitfalls during fluorescence guided resections of gliomas using 5-aminolevulinic acid

BACKGROUND

Fluorescence guided resections have been increasingly used for malignant gliomas. Despite the high reliability of the technique, there remain some practical limitations.

METHODS

We retrospectively reviewed our experience with 50 consecutive cases of 5-aminolevulinic acid (ALA)-guided resections. Clinico-radiological features and intraoperative variables (pattern and type of fluorescence) were recorded. In a subset (12 cases), we performed annotated biopsies to calculate the diagnostic accuracy of the technique. We recorded and analysed the patterns of excision and residual fluorescence and correlated this with postoperative magnetic resonance imaging (MRI).

RESULTS

Majority of the tumours (92%) were resectable and predominantly enhancing. Though strong fluorescence was seen in most of them, there were 2 cases with a non-enhancing tumor which showed fluorescence. Visualized strong fluorescence had a very high predictive value (100%) for detecting the pathological tissue. However, it was not always possible to resect all the fluorescing tissue. Proximity to critical neuro-vascular structures was the commonest reason for failure to achieve a gross total excision (16 cases). Additionally, there were some cases (5 of 8) where the non-fluorescing residue was resected intraoperatively with the help of ultrasound. Despite the presence of residual fluorescence, overall radiological gross total resection was achieved in 66% cases.

CONCLUSIONS

ALA guided resections are very useful in malignant gliomas, even if these lesions do not enhance signi cantly. Although ALA reliably depicts the tumour intraoperatively, it may not be possible to resect all this tissue completely. Additionally, non-fluorescing tumor may be completely missed out and may require additional imaging tools. Working within the limitations of the technique and using complementary modalities (ultrasound or brain mapping) may be ideal for achieving a radical resection of malignant gliomas.

Story of survival in anaplastic large cell lymphoma - sometimes more than the anaplastic lymphoma kinase status: An evaluation of pathologic prognostic factors in 102 cases

INTRODUCTION

Systemic anaplastic large cell lymphoma (ALCL) accounts for 5%-10% of adult non Hodgkin's lymphoma (NHL) and 10%-30% of childhood NHL. Owing to significant differences in survival and gene expression profile, current WHO classifies ALCL into two distinct entities as anaplastic lymphoma receptor tyrosine kinase (ALK) positive and ALK negative ALCL with ALK expression by tumour as a good prognostic indicator. However, in our institute which is a cancer referral institute, our preliminary experience was that even ALK positive tumours did not fare well as compared to ALK- negative ALCL. So, the current study aims at exploring more clinical and pathological factors impacting survival in ALCL patients.

OBJECTIVE

To study clinical and pathological prognostic factors in cases of ALCL.

METHODS

102 cases of ALCL were retrieved from pathology database. Pathological features and clinical features of these cases were recorded and factors found to impact overall survival (OAS) and disease-free survival (DFS) curves were identified based on univariate and multivariate analysis.

RESULTS

ALK 1 expression was seen in 71/102 (69.6%) cases and was not found to impact OAS or DFS. The 2 year OAS rate for ALK positive patients was 63.5% and DFS rate was 54.4%, while for ALK negative patients, the OAS was 60.5% and DFS was 43.5%. The Ann Arbor stage, performance status, international prognostic index, histological subtype, and the degree of the background inflammatory infiltrate were found to impact the OAS significantly. Increased reactive inflammatory component also negatively impacted DFS. In the multivariate analysis, only the histologic type emerged as significant for OAS.

CONCLUSION

Though ALK plays a role in prognostication of systemic ALCL, advanced stage disease and an inflammatory milieu may modulate the final outcome. We report a study of clinical and pathologic prognostic features in 102 cases of anaplastic large cell lymphoma (ALCL) from a cancer referral institute in India. Anaplastic lymphoma receptor tyrosine kinase (ALK-1) expression was seen in 71/102 (69.6%) cases and was not found to impact overall survival (OAS) or disease-free survival (DFS). The 2-year OAS rate for ALK-positive patients was 63.5% and DFS rate was 54.4%, while for ALK-negative patients, the OAS was 60.5% and DFS was 43.5%. The Ann Arbor stage, performance status, international prognostic index, histological subtype, and the degree of the background inflammatory infiltrate were found to impact the OAS significantly. Increased reactive inflammatory component also negatively impacted DFS. In the multivariate analysis, only the histologic type emerged as significant for OAS. Thus, though ALK plays a role in prognostication of systemic ALCL, advanced stage disease and an inflammatory milieu may modulate the final outcome.

Phosphaturic mesenchymal tumor of the nasal cavity and paranasal sinuses: A clinical curiosity presenting a diagnostic challenge

Phosphaturic mesenchymal tumor (PMT) is a rare mesenchymal neoplasm associated with tumor-induced osteomalacia (TIO) and elevated serum FGF-23. Common in extremities, PMT rarely occurs in sinonasal region. We report a series of sinonasal PMT diagnosed at our institute over a 6-year period. Six cases of sinonasal PMT were identified during this period, of which five presented with features of TIO. Median age of patients was 45.5 years. All six tumors were composed of stellate to spindled cells, with prominent staghorn vasculature in four cases. Typical smudgy matrix was seen in all cases, but only focally; grungy calcification was absent. Accurate diagnosis of PMTs is imperative, as complete excision leads to dramatic resolution of TIO symptoms. Lack of knowledge of this entity prevents clinicians from ordering relevant investigations. Absence of specific morphological features, like grungy calcification, and presentation at atypical locations makes the diagnosis challenging. Awareness of this entity is essential in order to suspect PMT in patients presenting with a soft tissue mass and features of TIO, however unusual the location may be.

Heterogeneous spectrum of childhood and adult SHH medulloblastoma: Clinical, radiogenomic features, patterns of failure and survival

2063

Background: To present SHH pathway driven medulloblastoma (MB) diversities in pediatric and adult patient populations. Methods: 60 patients with SHH-MB seen at our institute during 2009-2015. We assigned 22 predefined radiological features for all MB subgroups including SHH. Outcome data was retrieved from a prospectively maintained database. Results: Median age of entire cohort was 14 years (1-48 years). 29 were adults (a-SHH) and 31 were pediatric SHH (p-SHH). Radiological data available for 39 patients showed a-SHH having lateralised location in 72% cases. Distinct MRI features to predict SHH include mild/moderate contrast enhancement (90%), cystic changes (82%), edema (92%); identical in two age groups. We could predict SHH accurately 95% times. p-SHH were seen to have higher frequency of p53 mutations (70% vs 45%). At median follow-up of 37 months, 25 patients failed [isolated tumor bed (TB) in 10, TB and supratentorially in 2, cranium outside TB in 1, craniospinal in 5 (along with TB), extraneuraxial (ENM) in 5, second primary in 2 (lymphomas)]. 1 and 3 year DFS was 74% (p-SHH) vs 96% (a-SHH) and 58% vs 73% respectively (p-0.19). The failures seen in a-SHH were typically late (10/11 failed > 22 months) as compared to p-SHH (12/14 failing < 24 months). Also location of recurrences was different, with 7 of a-SHH failing at TB and rest 3 developed ENM. Ten of 13 in p-SHH failed beyond TB. Post- recurrence salvage was better in a-SHH compared to p-SHH, 1-year survival of 50% vs 19% (p-0.08). Overall survival at 1 and 3 year 84% and 55% for p-SHH and 100% and 88% for a-SHH respectively (p = 0.04). Histology and tumor location significantly correlated with OS. No significant correlation was seen with CSI dose or chemotherapy. Conclusions: SHH medulloblastoma have unique MRI features and can be predicted up to 95% times pre-operatively. Adult and pediatric SHH MB form extreme diverse groups with different patterns of failure reflecting different tumor kinetics. Adults fail primarily over TB after initial 2 years. Paediatric SHH follow aggressive course with early disseminated recurrences in 1st year. Different treatment modalities may be needed for pediatric and adult SHH MB.