Long-term efficacy and toxicity of bevacizumab-based therapy in children with recurrent low-grade gliomas.

BACKGROUND: Because definitive resection or radiotherapy for pediatric low-grade gliomas (LGGs) may be associated with severe and permanent adverse effects, medical management has taken a significant role. Bevacizumab-based therapy has demonstrated encouraging responses; however, longer-term toxicity, response durability and alternative dosing regimens have not been evaluated. PROCEDURE: This was a retrospective review of children with multiply recurrent, progressive LGGs treated with bevacizumab-based therapy and followed for at least 12 months after treatment completion. Toxicity was uniformly graded and imaging was centrally reviewed. RESULTS: All fourteen patients had failed at least two prior treatment regimens; six had dissemination. Patients received initial bevacizumab-based therapy at a median age of 5.3 years (range, 1-12 years). Median treatment duration was 12 months (range, 1-24 months). 12 patients had an objective response; 2 had stable disease. Median time to maximum response was 9 weeks (range, 7-17 weeks). No patients progressed on therapy, although 13/14 progressed after stopping bevacizumab at a median of 5 months. Four patients were re-treated with bevacizumab and all again responded or stabilized. Alternative dosing strategies were effective, including bevacizumab monotherapy and prolonging the dosing interval to 3 weeks. High-grade bevacizumab-related toxicities consisted of grade 3 proteinuria (n = 2), primary inflammatory arthritis (n = 1), and somnolence (n = 1). Toxicities resolved within 6 months of treatment cessation except one case of hypertension. CONCLUSIONS: Bevacizumab-based therapy is successful at inducing rapid LGG response. Patients progressing off-therapy may be successfully re-treated with bevacizumab. Nearly all tumors progress once treatment is discontinued. Toxicities are not insignificant but usually reversible.

Chemically-induced trout model of acute intestinal inflammation using TNBS.

Chemically-induced models of intestinal inflammation are a useful tool for the study of immune responses and inflammation. Although well established in mammals, application of these models is currently limited in teleosts. Based on a variety of factors, including genetic diversity, known toxicological sensitivity, and economic importance, we propose salmonids as a model family of fishes for studying intestinal inflammation. We present a rainbow trout model of chemically-induced intestinal inflammation using 2,4,6-trinitrobenzene sulfonic acid (TNBS), assessed through histological analysis of primary and secondary intestinal folding, enterocyte morphology, goblet cell size and frequency, tissue layer thickness, and immune cell infiltration. Twenty-four hours after treatment with one of three concentrations of TNBS, trout developed classic signs of intestinal inflammation, including notably increased thickness of primary and secondary folds, and increased immune cell infiltration as compared to controls. This study provides a simple, reproducible model of rapid TNBS-induction of moderate intestinal inflammation.

Contrast-enhanced ultrasound imaging for assessment of intestinal inflammation in rainbow trout.

The intestine is essential for nutritional uptake and as a barrier to pathogens. Inflammation of the intestine can result from chemical contaminants, dietary irritants, or disease and may lead to serious health consequences, including reduced growth rates or increased pathogen susceptibility. Traditionally, intestinal inflammation in fish has been detected through histology completed post-mortem through excision and processing of the affected tissue. However, in human clinical settings, tools have been developed to assess intestinal inflammation non-invasively. Contrast-enhanced ultrasound (CEUS) imaging is an important tool for measuring inflammation in patients because it is cost-effective and minimally invasive. Specifically, CEUS allows real-time visualization and quantification of vascular perfusion. Changes in blood flow are typical in areas of inflamed or diseased tissue, and by measuring these changes, it is possible to assess the degree of inflammation. We demonstrate that standard CEUS protocols used for small mammals can be used to quantify vascular perfusion in the intestines of rainbow trout. Our resolution was sufficient to measure a significant difference in perfusion between control and TNBS-inflamed trout intestines, with inflamed intestines showing decreased perfusion. The presence of inflammation in the TNBS-treated intestines was verified ex vivo histologically and was characterized by the thickening of intestinal folds. The minimally invasive nature of CEUS imaging presents the opportunity to evaluate intestinal health in novel ways by allowing for longitudinal observations and avoiding mortality in valuable or at-risk specimens. Recent developments of highly portable, cost-effective CEUS systems will allow broad application of this tool, from industry to research.

Embryonic exposure to predation risk and hatch time variation in fathead minnows.

Organisms are exposed to a wealth of chemical information during their development. Some of these chemical cues indicate present or future dangers, such as the presence of predators that feed on either the developing embryos or their nearby parents. Organisms may use this information to modify their morphology or life-history, including hatching timing, or may retain information about risk until it gains relevance. Previous research has shown predation-induced alterations in hatching among embryonic minnows that were exposed to mechanical-injury-released alarm cues from conspecific embryos. Here, we test whether minnows likewise hatch early in response to alarm cues from injured adult conspecifics. We know that embryonic minnows can detect adult alarm cues and use them to facilitate learned recognition of predators; however, it is unknown whether these adult alarm cues will also induce a change in hatching time. Early hatching may allow animals to rapidly disperse away from potential predators, but late hatching may allow animals to grow and develop structures that allow them to effectively escape when they do hatch. Here, we found here that unlike embryonic fathead minnows (Pimephales promelas) exposed to embryonic cues, embryonic minnows exposed to adult alarm cues do not exhibit early hatching. The ability of embryos to recognize adult alarm cues as a future threat, but not a current one, demonstrates sophisticated ontogenetic specificity in the hatching response of embryonic minnows.

Objective response of multiply recurrent low-grade gliomas to bevacizumab and irinotecan.

BACKGROUND: Chemotherapy has taken on a prominent role in the treatment of pediatric low-grade gliomas not amenable to gross total resections; however, there are few proven effective options for children with multiply recurrent tumors. Bevacizumab, a humanized immunoglobulin, monoclonal antibody that inhibits the activity of vascular endothelial growth factor and irinotecan have been used with some success in adults with malignant gliomas. METHODS: Ten children with multiply recurrent low-grade gliomas were treated with the combination of bevacizumab and irinotecan. Patients received treatment at a median of 5.2 years of age, range 1.5-11.1 years. The majority had diencephalic tumors, three had neurofibromatosis type 1, and two had disseminated disease at the time of treatment. Nine of 10 patients had progressed after three or greater chemotherapy regimens and one also had received radiation therapy. RESULTS: Seven patients had an objective neuroradiographic response, which was a complete response in one, partial response in three, and minor response in three. Clinical improvements were noted in seven, including improved visual acuity (2), improved motor function (2), weight gain in four with a diencephalic syndrome, and reversal of psychomotor retardation (3). Dose-limiting toxicities included transient leukoencephalopathy (1) and grade 3 protienuria (1). Response was durable in the majority of patients and six remain on treatment, for up to 22 months. CONCLUSIONS: Multiply recurrent low-grade gliomas in children are responsive to the combination of bevacizumab and irinotecan. The drug combination has been relatively well tolerated, including in patients with neurofibromatosis type 1, and warrants further study.