Diagnostics and treatment of diffuse intrinsic pontine glioma: where do we stand?

INTRODUCTION: Diffuse intrinsic pontine glioma (DIPG) is a rare clinically, neuro-radiologically, and molecularly defined malignancy of the brainstem with a median overall survival of approximately 11 months. Our aim is to evaluate the current tendency for its treatment in Europe in order to develop (inter)national consensus guidelines. METHODS: Healthcare professionals specialized in DIPG were asked to fill in an online survey with questions regarding usual treatment strategies at diagnosis and at disease progression in their countries and/or their centers, respectively. RESULTS: Seventy-four healthcare professionals responded to the survey, of which 87.8% were pediatric oncologists. Only 13.5% of the respondents biopsy all of their patients, 41.9% biopsy their patients infrequently. More than half of the respondents (54.1%) treated their patients with radiotherapy only at diagnosis, whereas 44.6% preferred radiotherapy combined with chemotherapy. When the disease progresses, treatment strategies became even more diverse, and the tendency for no treatment increased from 1.4% at diagnosis to 77.0% after second progression. 36.5% of the healthcare professionals treat children younger than 3 years differently than older children at diagnosis. This percentage decreased, when the disease progresses. Most of the participants (51.4%) included less than 25% of their patients in clinical trials. CONCLUSION: This survey demonstrates a large heterogeneity of treatment regimens, especially at disease progression. We emphasize the need for international consensus guidelines for the treatment of DIPG, possible by more collaborative clinical trials.

Development of the SIOPE DIPG network, registry and imaging repository: a collaborative effort to optimize research into a rare and lethal disease.

Diffuse intrinsic pontine glioma (DIPG) is a rare and deadly childhood malignancy. After 40 years of mostly single-center, often non-randomized trials with variable patient inclusions, there has been no improvement in survival. It is therefore time for international collaboration in DIPG research, to provide new hope for children, parents and medical professionals fighting DIPG. In a first step towards collaboration, in 2011, a network of biologists and clinicians working in the field of DIPG was established within the European Society for Paediatric Oncology (SIOPE) Brain Tumour Group: the SIOPE DIPG Network. By bringing together biomedical professionals and parents as patient representatives, several collaborative DIPG-related projects have been realized. With help from experts in the fields of information technology, and legal advisors, an international, web-based comprehensive database was developed, The SIOPE DIPG Registry and Imaging Repository, to centrally collect data of DIPG patients. As for April 2016, clinical data as well as MR-scans of 694 patients have been entered into the SIOPE DIPG Registry/Imaging Repository. The median progression free survival is 6.0 months (95% Confidence Interval (CI) 5.6-6.4 months) and the median overall survival is 11.0 months (95% CI 10.5-11.5 months). At two and five years post-diagnosis, 10 and 2% of patients are alive, respectively. The establishment of the SIOPE DIPG Network and SIOPE DIPG Registry means a paradigm shift towards collaborative research into DIPG. This is seen as an essential first step towards understanding the disease, improving care and (ultimately) cure for children with DIPG.

Thiamine responsive megaloblastic anemia syndrome: a novel homozygous SLC19A2 gene mutation identified.

Thiamine responsive megaloblastic anemia syndrome (TRMAS) is a rare autosomal recessive disorder especially in countries where consanguinity is uncommon. Three main features are characteristic of the disease - megaloblastic anemia, early onset deafness, and non-type I diabetes. TRMAS is a Mendelian disorder; a gene SLC19A2 coding high affinity thiamine transporter mediating vitamin B1 uptake through cell membrane has been identified. We present the first patient with TRMAS in Lithuania - a 3-year-old boy born to a non-consanguineous family with a novel homozygous SLC19A2 gene mutation. The patient had insulin dependent diabetes (onset 11 months), respiratory illness (onset 11 months), bilateral profound hearing loss (onset at 7 months, verified at 20 months), refractory anemia (onset 2 years), and decreased vision acuity and photophobia (onset 2.5 years). The psychomotor abilities developed according to age. Phenotypic evaluation did not reveal any dysmorphic features. The clinical diagnosis of TRMAS was suspected and daily supplementation with thiamine 100 mg was started. The condition of the patient markedly improved several days after the initiation of treatment. The results of SLC19A2 gene molecular testing confirmed the clinical diagnosis - novel homozygous c.[205G>T], p.[(Val69Phe)] mutation changing conserved amino acid residue or even interfering the mRNA splicing. Clinical heterogeneity, diverse dynamics, and wide spectrum of symptoms are aggravating factors in the diagnosis. The possibility of treatment demands early recognition of disorder to facilitate the improvement of the patient's condition.

Chemotherapy induced kidney and urinary tract related complications: A study in the Department of Pediatric Oncology and Hematology.

Nephrotoxicity is one of the most severe late-term side effects after chemotherapy. It is important to evaluate the possible risks and provide valuable treatment and follow-up for the patient. METHODS: the data was observed from 50 patients from 0 till 18 years old that were treated for childhood cancer and was collected according to methodological recommendations. RESULTS: 28 boys and 22 girls were included and the average age of all patients when the diagnosis was made was five years. 56% have faced kidney and urinary tract related complications. 75% of those patients have faced nephrotoxicity, 10,71 - urinary tract related complications and 14,29 have faced both - nephrotoxicity and urinary tract related complications. GFR was decreased in one case, increased in three cases and normal in the remaining cases. There was no statistical significance between kidney and urinary tract related complications and patient's age at the time of treatment, type of cancer (except for sarcomas), type of surgery or radiotherapy. Nephrotoxicity had statistical significance to occur more commonly during the first two years after treatment, while urinary tract related complications occurred more frequently during five years after treatment. Doxorubicin and Ifosfamide had statistical significance with kidney-related long-side effect; Lomustine also had a close relation. Chemotherapy drug's cumulative dose also had statistical significance of the same chemotherapy drugs. CONCLUSIONS: this study suggests that chemotherapy drug and its cumulative dosage has the most influence on kidney and urinary tract related complications.

The impact of incomplete registration on survival rate of children with very rare tumors.

Pediatric very rare tumors (VRTs) represent a heterogeneous subset of childhood cancers, with reliable survival estimates depending dramatically on each (un)registered case. The current study aimed to evaluate the number of VRTs among Lithuanian children, to assess the impact of the registration status on survival rates and to track changes in treatment outcomes over the 16-year study period. We performed a population-based retrospective study across children below 18 years old diagnosed with VRTs in Lithuania between the years 2000 and 2015. The identified cases were cross-checked with the Lithuanian Cancer Registry-a population-based epidemiology cancer registry-for the fact of registration and survival status. The overall survival was calculated in relation to the registration status and treatment period. Thirty-seven children with VRTs were identified within the defined time frame. Six of them (16.2%) were not reported to the Lithuanian Cancer Registry at diagnosis. The probability of overall survival at 5 years (OS5y) differed significantly between the registered (n = 31) and unregistered (n = 6) cohorts: 51.6% versus 100%, respectively (p = 0.049). A 5-year survival estimate for children diagnosed with a VRT at the age of 0-14 years differed by 10 percentage points according to the registration completeness: 52.1% calculated for the entire cohort versus 42.1% for registered patients only. The OS5y has not improved over the analyzed period: 61.1% in 2000-2007 versus 57.9% in 2008-2015 (p = 0.805). The survival continued to decline beyond 5 years post-diagnosis due to late cancer-related adverse events: 59.5% of patients were alive at 5 years as compared to 44.3% at 10 years. The OS5y of children affected by VRT was lower than in more common childhood cancers. The survival rate of the unregistered patients may lead to misinterpretation of treatment outcomes. Meticulous registration of VRTs is crucial for correct evaluation of treatment outcomes, especially across small countries with few cases.

The results of the treatment of childhood medulloblastoma with radiotherapy at Kaunas University of Medicine Hospital in 1994-2000.

UNLABELLED: Medulloblastoma, a primitive neuroectodermal tumor growing in cerebellum, is one of the most sensitive to radiation therapy childhood brain tumors, therefore, this method of treatments is justly considered to be the standard for the treatment of medulloblastoma. The outcome of this malignant brain tumor differs in standard and high-risk groups of patients. The aim of the work was to evaluate the survival rate for children with medulloblastoma according to two risk groups. PATIENTS AND METHODS: Eighteen patients aged from 3 to 18 years with histological proven medulloblastoma treated with standard craniospinal and additional posterior fossa radiotherapy were investigated in our study. Nine patients with disseminated and partial removed medulloblastoma were assigned to the high-risk group and other 9 patients with local ant totally removed medulloblastoma were allocated to the standard risk group. RESULTS: Radiological response of medulloblastoma to the radiation therapy was observed in 15 (83.3%) out of 18 patients: complete radiological response was observed in 6 (67%) out of 9 standard-risk patients and in only 1 (11.1%) out of 9 high-risk patients (p<0.05). Medulloblastoma progressed in 15 (83.3%) patients treated with radiation therapy: relapse rate in the high-risk group was 100% and in the standard-risk group--66.7% (p>0.05). The mean time to progression for all patients was 18.2 months: 28.9 months in standard and 7.4 months in high-risk group (p=0.02). The overall survival for all investigated patients was 25.8 months: 37.2 and 14.3 months in the standard and high-risk groups, respectively (p=0.01). Five years progression-free and overall survival rate for all patients was 16.7%: 0% in the high-risk group and 33.3 % in the standard-risk group (p>0.05). CONCLUSION: In our study the difference in survival rate between standard and high-risk patients with medulloblastoma was shown. We observed a statistically significant longer time to progression and better overall survival in the standard-risk group. However, we did not find any significant differences in other survival indices (response, relapse rates, mortality, five years progression- free and overall survival) between those two risk groups.

Treatment of patients of high-risk group of medulloblastoma with the adjuvant lomustine, cisplatin, and vincristine chemotherapy.

UNLABELLED: The prognosis of children with medulloblastoma, primitive neuroectodermal tumor of cerebella, is poor especially in case of disseminated disease. Bad outcome of this disease encouraged the investigators to look for new more effective and safer ways of medulloblastoma treatment that would be able to improve the prognosis and quality of live for children with medulloblastoma. Adjuvant chemotherapy administered after radiotherapy prolongs the time to progression as well as overall survival for high-risk group of medulloblastoma patients, while such results vary little in standard-risk medulloblastoma group. OBJECTIVE: To evaluate effectiveness of adjuvant chemotherapy while treating high-risk medulloblastoma patients. PATIENTS AND METHODS: A total of 18 patients with disseminated and non-totally removed medulloblastoma admitted to high-risk group aged from 3 to 18 years were enrolled in this study. Nine of these patients were treated by radiotherapy alone and the adjuvant chemotherapy with CCNU (lomustine), cisplatinum, and vincristine after radiotherapy was administered to the other nine patients. RESULTS: Full response was determined in all patients of adjuvant chemotherapy group and only in 3 children out of 9 in radiotherapy group (33.3%) (p<0.01). The rate of the relapse was 100% in radiotherapy and 11.1% in adjuvant chemotherapy group that differed statistically reliably in both group patients (p<0.001). Mean time to progression among patients of radiotherapy group was 9+/-2 months and 47+/-8 months among of the patients of adjuvant chemotherapy group (p<0.01). Two years free to progression survival in adjuvant chemotherapy group was 88.9%, in radiotherapy group - 0%. Two-year overall survival in these groups was 71.1 and 22.2%, respectively (p<0.01). CONCLUSION: With this research we proved that adjuvant chemotherapy, prescribed after standard radial (craniospinal and local) treatment, statistically reliably improves survival indices of patients from high risk group and has to be prescribed to all patients from this risk group.