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Catherine Bollard

Engineering TGFB receptor to enhance NK cells and fight neuroblastoma

Catherine Bollard

“In this study, we have genetically engineered cord blood derived NK cells so that they are not only resistant to the devastating effects of TGFb, but they are not able to become activated in the presence of TGFb,” said, Catherine Bollard, M.B.Ch.B., M.D.

Catherine Bollard, M.B.Ch.B., M.D., and her research team published results showing potential efficacy of a novel cell therapeutic for treatment of pediatric patients with relapsed/refractory neuroblastoma.

The research paper, entitled, “Engineering the TGFβ receptor to Enhance the Therapeutic Potential of Natural Killer Cell as an Immunotherapy for Neuroblastoma,” was published on April 29, 2019 by Clinical Cancer Research and is being recognized for the potential efficacy of the “off the shelf” treatment for patients with relapsed/refractory neuroblastoma.

The researcher’s approach allows them to manipulate Natural Killer (NK) cells, expand and reinfuse them within a patient so they can fight cancer and disease.

“In this study, we have genetically engineered cord blood derived NK cells so that they are not only resistant to the devastating effects of TGFb, but they are not able to become activated in the presence of TGFb,” said, Dr. Bollard, who is the senior corresponding author of the study and director of the Center for Cancer and Immunology Research at the Children’s Research Institute. “In other words, turning the negative effects of TGFb into positive effects enhances the persistence and anti-tumor activity of these tumor-killing NK cells in vivo.”

NK cells are highly cytolytic, and their potent antitumor effects can be rapidly triggered by a lack of human leukocyte antigen (HLA) expression on interacting target cells, as in the case for a majority of solid tumors, including neuroblastoma. With neuroblastoma being a leading cause of pediatric cancer-related deaths, it presents as an ideal candidate for NK cell therapy.

“This manuscript encompasses a significant portion of work, in which we generated genetically-modified NK cells as an enhanced form of immunotherapy for neuroblastoma,” said Rachel Burga, Ph.D., lead author and graduate of the Institute for Biomedical Sciences at George Washington and Children’s National Health System.  “We’re very excited to share our pre-clinical findings which demonstrate the efficacy of approaches to “hijack” the TGFb receptor and target TGFb in the tumor microenvironment.”

She added that the approach will allow for the NK cells to simultaneously resist the immune suppression in the microenvironment and initiate activation to increase their ability to target tumor cells.

Pre-clinical testing and research for this trial began in 2016 and ended in 2019. “The idea came from a Department of Defense award given to Dr. Bollard and Dr. Cruz and they took the idea and reduced it to practice and showed feasibility for pre-clinical trial,” said Rohan Fernandes, Ph.D., assistant professor in the Department of Medicine at George Washington University and senior author on the manuscript.

Fernandes added that the timeframe to start the clinical trial is within the next two to four years at Children’s National.

Additional authors include Rachel A. Burga, Ph.D., Eric Yvon, Rohan Fernandes, Conrad Russell Cruz, and Catherine M. Bollard, M.B.Ch.B., M.D.

Maureen E Lyon

Maureen E. Lyon receives American Cancer Society grant

Maureen E Lyon

Children’s Clinical Health Psychologist Maureen E. Lyon, Ph.D., has received the “Judy White Memorial Clinical Research Pilot Exploratory Projects in Palliative Care of Cancer Patients and their Families” grant from the American Cancer Society (ACS).

Over two years, Lyon will be allotted $144,000 to translate Children’s evidence-based Family-Centered (FACE) pediatric advance care planning (ACP) protocol into Spanish through a process of community-based participatory research for teens with cancer.

Lyon’s research focuses on enabling families to understand their adolescents’ treatment preferences and describing patient-reported palliative care needs for teens with cancer. Ultimately, the research will help identify the wants, values, goals and beliefs of teens with cancer.

Along with the ACS research grant, Lyon and Jessica Thompkins, BSN, R.N., CPN, research nurse coordinator at Children’s National, will present at the Annual Assembly of Hospice & Palliative Medicine conference, March 13-16, 2019 in Orlando, Fla. on data from the current multi-site, five-year randomized clinical trial funded by National Institute of Health/ National Institute of Nursing Research for English-speaking teens with cancer.

During the presentation, they will speak about the effect of FACE ACP on families’ appraisals of caregiving for their teens with cancer and describing advance care planning communication approaches.

Lyon and other researchers at Children’s National look forward to making significant contributions to the science of advance care planning aimed to minimize suffering and enhancing quality of life for young adults. Their contributions give teens a voice in their future medical care and help families “break the ice,” by providing an extra level of support to treating clinicians.

Roger Packer

Roger J. Packer, M.D. presents keynote address for BRAIN 2019

Roger Packer

2019 Otto Lien Da Wong visiting professor in neuro-oncology at BRAIN 2019, Roger J. Packer, M.D. presented the keynote address.

 

More than 400 neurologists, neurosurgeons, pathologists, pediatricians, clinical and basic scientists gathered in Hong Kong for Brain 2019, a conjoint congress of the 3rd Asian Central Nervous System Germ Cell Tumour Conference (CNSGCT), the 9th Interim Meeting of the International Chinese Federation of Neurosurgical Sciences (ICFNS) and the 16th Asia Pacific Multidisciplinary Meeting for Nervous System Diseases (BRAIN) which is also jointly organized by The Chinese University of Hong Kong. This three-day convention discussed advances in pediatric neuro-oncology and neuro-rehabilitation.

Invited as the 2019 Otto Lien Da Wong (OLDW) visiting professor in neuro-oncology, Roger J. Packer, M.D., senior vice president for the Center of Neuroscience and Behavioral Medicine and director at the Gilbert Neurofibromatosis and Brain Tumor Institutes, presented a keynote address titled “Advances in Pediatric Brain Tumors.” Established in 2009, the purpose of the visiting professorship is to advance surgical knowledge and techniques in neuro-oncology between Hong Kong and major medical centers around the world. Dr. Packer was selected from an international field of acclaimed academic surgeons and scholars in the field of neuro-oncology. Two additional presentations included “Pediatric Brain Tumors in Molecular Era: Germ Cell Tumors” as an invited guest of the BRAIN conference and a presentation on “Treatment of Medulloblastoma and PNET” as a session presented by the ICFNS.

In addition to his presentations, Dr. Packer will participate in surgical teaching and scholastic exchange with local surgeons, surgical trainees and medical students.

SIOP logo

Children’s National physicians attend the International Society of Paediatric Oncology in Japan

SIOP logo

From November 16 to 19, medical professionals, clinicians, nurses and oncology patients and families from around the globe gathered for the International Society of Paediatric Oncology (SIOP) in Kyoto, Japan. Pediatric experts in their respective fields Jeffrey Dome, M.D., Ph.D., AeRang Kim, M.D., Ph.D., Steven Hardy, Ph.D., and Karun Sharma, M.D., attended SIOP representing Children’s National. The four-day scientific programme engaged those in pediatric oncology with educational lectures, keynote speakers, tailored sessions for survivors, families and support organizations, free paper sessions, specialist sessions and Meet the Expert talks.

Dr. Kim, an oncologist with the Center for Cancer and Blood Disorders and a member of the solid tumor faculty at Children’s National, presented with Dr. Sharma, director of Interventional Radiology at Children’s, on “Interventional Radiology: Technology and Opportunities” in Meet the Expert talks on both Saturday and Sunday of the programme. They discussed background information, preclinical studies, current, ongoing studies of high-intensity focused ultrasound (HIFU), HIFU in combination with heat sensitive formulated chemotherapy and future directions. In 2017, Children’s National was the first U.S. children’s hospital to successfully use MR-HIFU to treat osteoid osteoma, and is currently accruing on early phase studies evaluating HIFU ablation and HIFU in combination with lyso-thermosensitive liposomal doxorubicin for pediatric patients with refractory/recurrent solid tumors.

Dr. Hardy, a pediatric psychologist in the Center for Cancer and Blood Disorders at Children’s, presented on “Brief Psychosocial Screening to Identify Patients in Need of a Mental Health Treatment Referral in a Childhood Cancer Survivorship Clinic.” In his educational lecture, Dr. Hardy described findings that show a brief mental and behavioral health questionnaire given to patients in the Children’s National survivorship clinic is a sensitive screening tool that can identify patients in need of more formal psychosocial evaluation and treatment. He also presented data supporting the use of a lower threshold of psychological symptoms necessary to trigger discussions about mental health treatment compared to previous reports. The key implication of Dr. Hardy’s work is that survivorship clinics lacking embedded psychology support could adopt this questionnaire, which is publically available and translated into 86 languages, to help identify survivors with mental and behavioral health concerns and ensure appropriate referrals are made.

Dr. Dome, Vice President of the Center for Cancer and Blood Disorders, served on the SIOP Scientific Programme Advisory Committee, which selected the topics for presentation.

SIOP provides an international forum for the sharing of new research and ideas related to pediatric oncology. The annual conference furthers the efforts made towards developing new treatments and cures and opens the conversation, encouraging innovation and collaboration with experts from around the world. Children’s National has taken part in SIOP for many years, most recently hosting the meeting in Washington, D.C., in 2017.

Eugene Hwang

Unexpected heterogeneity in CNS-PNET patients treated as a single entity

Eugene Hwang

“We found that some patients diagnosed with standard tools underwent much more treatment than necessary or intended,” said Eugene Hwang, M.D.

Eugene I. Hwang, M.D., a neuro-oncologist in the Center for Cancer and Blood Disorders, and other researchers at Children’s National Health System, Seattle Children’s Hospital and Research Institute, the Fred Hutchinson Cancer Research Center and the Hopp-Children’s Cancer Center at the NCT Heidelberg recently published the results of a clinical trial focusing on children with histologically diagnosed supratentorial primitive neuroectodermal tumors (CNS-PNET) and pineblastomas (PBLs).

The clinical trial, published online October 17, 2018 in the Journal of Clinical Oncology, included children and adolescents aged 3-22 with these brain cancers who were randomly assigned to receive carboplatin during radiation and/or isotretinoin after the standard intensive therapy (high-dose craniospinal radiation and months of inpatient chemotherapy).  Importantly, because each patient was treated prospectively according to the clinical trial design, the conclusions related to tumor biology were felt to be less affected by varied treatment plans.

“This trial really highlighted the importance of new molecular testing methods in accurately diagnosing some of the brain cancers included in the trial. We found that some patients diagnosed with standard tools underwent much more treatment than necessary or intended.” says Dr. Hwang. “Kids who aren’t receiving the right form of cancer treatment may not get better despite months and months of intensive treatment.”

During this clinical trial, 85 participants with institutionally-diagnosed CNS-PNETs/PBLs were enrolled. Out of the 60 patients with sufficient tissue, 31 were non-pineal in location, 22 of which represented tumors that did not fit in the diagnoses intended for trial inclusion.

The researchers discovered that patient outcomes across each molecularly-diagnosed tumor type were strikingly different. Patients with molecularly-confirmed supratentorial embryonal tumors/PBLs exhibited a five-year event free survival (EFS) and an overall survival rate of 62 percent and 78.5 percent, respectively. However, patients with molecularly-classified high-grade gliomas (HGGs) had a five-year EFS of 5.6 percent and OS of 12 percent, showing no benefit even with the chemotherapy and craniospinal radiation.

Researchers determined that for patients with CNS-PNETs/PBLs, prognosis is considerably better than previously assumed when molecularly-confirmed HGG are removed. Dr. Hwang and co-authors concluded that molecular diagnosis can greatly aid standard pathological diagnostic tools, preventing unnecessary intensive therapy for some patients while enabling more rational treatment for others.

“The findings from our clinical trial have highlighted the immense challenges of histology-based diagnosis for some types of pediatric brain tumors, and the enormous importance this has for children with brain cancer,” Dr. Hwang says. “We hope that ultimately our study will pave the way for molecular profiling to become a standard component of initial diagnosis.”

Jeffrey Dome

The impact of surveillance imaging to detect relapse in Wilms tumor patients

Jeffrey Dome

Dr. Jeffrey Dome, M.D., Ph.D., vice president, Center for Cancer and Blood Disorders.

The Children’s Oncology Group published an article in the Journal of Clinical Oncology looking at the impact that surveillance imaging has on patients with Wilms tumor (WT), the most common kidney cancer in children.

Despite the risks and costs, the use of computed tomography (CT) for routine surveillance to detect recurrence in patients with WT has increased in recent years. The rationale for using CT scans rather than chest x-rays (CXR) and abdominal ultrasounds (US) is that CT scans are more sensitive, thereby enabling recurrences to be detected earlier.

In this study, led by Jeffrey S. Dome, M.D., Ph.D, vice president of the Center for Cancer and Blood Disorders at Children’s National Health System, researchers conducted a retrospective analysis of patients enrolled in the fifth National Wilms Tumor Study (NWTS-5) who experienced relapse to determine if relapse detection with CT scan correlates with improved overall survival compared with relapse detection by CXR or abdominal US.

A total of 281 patients with favorable-histology WT (FHWT) were included in the analysis. The key findings of the study were that:

  • Among patients with relapse after completion of therapy, outcome was improved in patients whose relapse was detected by surveillance imaging rather after signs and symptoms developed.
  • A higher disease burden at relapse, defined by the diameter of the relapsed tumor and the number of sites of relapse, was associated with inferior survival.
  • Relapses detected by CT scan were detected earlier and were smaller on average than relapses detected by CXR or US.
  • However, there was no difference in survival between patients whose relapse was detected by CT versus CXR or US.

An analysis of radiation exposure levels showed that surveillance regimes including CT scans have about seven times the radiation exposure compared to regimens including only CXR and US. Moreover, the cost to detect each recurrence reduced by 50 percent when CXR and US are used for surveillance.

“The results of this study will be practice changing,” said Dr. Dome, one of the doctors leading the clinical trial. “The extra sensitivity that CT scans provide compared to CXR and US do not translate to improved survival and are associated with the downsides of extra radiation exposure, cost and false-positive results that can lead to unnecessary stress and medical interventions,” he added. “Although counter-intuitive, the more sensitive technology is not necessarily better for patients.”

In conclusion, the doctors found that the elimination of CT scans from surveillance programs for unilateral favorable histology Wilms tumor is unlikely to compromise survival. However, it could result in substantially less radiation exposure and lower health care costs. Overall, the risk-benefit ratio associated with imaging modalities should be considered and formally studied for all pediatric cancers.

Learn more about this research in a podcast from the Journal of Clinical Oncology.

Affiliations

Elizabeth A. Mullen, Dana-Farber Cancer Institute/Boston Children’s Cancer and Blood Disorders Center, Boston, MA; Yueh-Yun Chi and Emily Hibbitts, University of Florida, Gainesville, FL; James R. Anderson, Merck Research Laboratories, North Wales, PA; Katarina J. Steacy, University of Maryland Medical Center, Baltimore, MD; James I. Geller, Cincinnati Children’s Hospital Medical Centre, Cincinnati, OH; Daniel M. Green, St Jude Children’s Research Hospital, Memphis, TN; Geetika Khanna, Washington University School of Medicine, St Louis, MO; Marcio H. Malogolowkin, University of California at Davis Comprehensive Cancer Center, Sacramento, CA; Paul E. Grundy, Stollery Children’s Hospital, University of Alberta, Alberta; Conrad V. Fernandez, University, Halifax, Nova Scotia, Canada; and Jeffrey S. Dome, Children’s National Health System, George Washington University School of Medicine and Health Sciences, Washington, D.C.

Tessie October

Effectively expressing empathy to improve ICU care

Tessie October

“Families who feel we’re really listening and care about what they have to say are more likely to feel comfortable as they put their child’s life in our hands a second, third or fourth time,” says Tessie W. October, M.D., M.P.H.

In nearly every intensive care unit (ICU) at every pediatric hospital across the country, physicians hold numerous care conferences with patients’ family members daily. Due to the challenging nature of many these conversations – covering anything from unexpected changes to care plans for critically ill children to whether it’s time to consider withdrawing life support – these talks tend to be highly emotional.

That’s why physician empathy is especially important, says Tessie W. October, M.D., M.P.H., critical care specialist at Children’s National Health System.

Several studies have shown that when families believe that physicians hear, understand or share patients’ or their family’s emotions, patients can achieve better outcomes, Dr. October explains. When families feel like their physicians are truly empathetic, she adds, they’re more likely to share information that’s crucial to providing the best care.

“For the most part, our families do not make one-time visits. They return multiple times because their children are chronically ill,” Dr. October says. “Families who feel we’re really listening and care about what they have to say are more likely to feel comfortable as they put their child’s life in our hands a second, third or fourth time. They’re also less likely to regret decisions made in the hospital, which makes them less likely to experience long-term psychosocial outcomes like depression and anxiety.”

What’s the best way for physicians to show empathy? Dr. October and a multi-institutional research team set out to answer this question in a study published online in JAMA Network Open on July 6, 2018.

With families’ consent, the researchers recorded 68 care conferences that took place at Children’s pediatric ICU (PICU) between Jan. 3, 2013, to Jan. 5, 2017. These conversations were led by 30 physicians specializing in critical care, hematology/oncology and other areas and included 179 family members, including parents.

During these conferences, the most common decision discussed was tracheostomy placement – a surgical procedure that makes an opening in the neck to support breathing – followed by the family’s goals, other surgical procedures or medical treatment. Twenty-two percent of patients whose care was discussed during these conferences died during their hospitalization, highlighting the gravity of many of these talks.

Dr. October and colleagues analyzed each conversation, counting how often the physicians noticed opportunities for empathy and how they made empathetic statements. The researchers were particularly interested in whether empathetic statements were “buried,” which means they were:

  • Followed immediately by medical jargon
  • Followed by a statement beginning with the word “but” that included more factual information or
  • Followed by a second physician interrupting with more medical data.

That compares with “unburied” empathy, which was followed only by a pause that provided the family an opportunity to respond. The research team examined what happened after each type of empathetic comment.

The researchers found that physicians recognized families’ emotional cues 74 percent of the time and made 364 empathetic statements. About 39 percent of these statements were buried. In most of these instances, says Dr. October, the study’s lead author, the buried empathy either stopped the conversation or led to family members responding with a lack of emotion themselves.

After the nearly 62 percent of empathetic statements that were unburied, families tended to answer in ways that revealed their hopes and dreams for the patient, expressed gratitude, agreed with care advice or expressed mourning—information that deepened the conversation and often offered critical information for making shared decisions about a patient’s care.

Physicians missed about 26 percent of opportunities for empathy. This and striving to make more unburied empathetic statements are areas ripe for improvement, Dr. October says.

That’s why she and colleagues are leading efforts to help physicians learn to communicate better at Children’s National. To express empathy more effectively, Dr. October recommends:

  • Slow down and be in the moment. Pay close attention to what patients are saying so you don’t miss their emotional cues and opportunities for empathy.
  • Remember the “NURSE” mnemonic. Empathetic statements should Name the emotion, show Understanding, show Respect, give Support or Explore emotions.
  • Avoid using the word “but” as a transition. When you follow an empathetic statement with “but,” Dr. October says, it cancels out what you said earlier.
  • Don’t be afraid to invite strong emotions. Although it seems counterintuitive, Dr. October says helping patients express strong feelings can help process emotions that are important for decision-making.

In addition to Dr. October, study co-authors include Zoelle B. Dizon, BA, Children’s National; Robert M. Arnold, M.D., University of Pittsburgh Medical Center; and Senior Author, Abby R. Rosenberg, M.D., MS, University of Washington School of Medicine.

Research covered in this story was supported by the National Institutes of Health under grants 5K12HD047349-08 and 1K23HD080902 and the National Center for Advancing Translational Sciences under Clinical and Translational Science Institute at Children’s National Health System grant number UL1TR0001876.

Yuan Zhu

The brain tumor field moves forward with new findings and a research grant

Yuan Zhu

Yuan Zhu, Ph.D., and other experts completed new research findings evaluating the effects of manipulating the growth-promoting signaling pathways in brain tumors associated with adults and children.

This month, experts at Children’s National Health System made great strides in brain tumor research, specifically in gliomas, glioblastomas and medulloblastomas. Led by Yuan Zhu, Ph.D., the scientific director and Gilbert Endowed Professor of the Gilbert Family Neurofibromatosis Institute and Center for Cancer and Immunology Research at Children’s National, the team completed new research findings evaluating the effects of manipulating the growth-promoting signaling pathways in brain tumors associated with adults and children. Dr. Zhu’s research was recently published in Cell Reports and he was also awarded a U.S. Department of Defense (DoD) grant to gain a better understanding of how low-grade gliomas form. Together, this work moves the needle on developing more effective treatments for these debilitating and life-threatening tumors.

The study

In his recently published paper, Dr. Zhu and his colleagues, including Drs. Seckin Akgul and Yinghua Li, studied glioblastomas, the most common brain tumor in adults, and medulloblastomas, the most common brain tumor found in children, in genetically engineered experimental models. Dr. Zhu found that when they removed the p53 gene (the most commonly mutated tumor suppressor gene in human cancers) in the experimental model’s brain, most developed malignant gliomas and glioblastomas, while Sonic Hedgehog (SHH)-subtype (SHH) medulloblastomas were also observed. They further suppressed the Rictor/mTorc2 molecular pathway that is known in the regulation of tumor growth. This action greatly reduced the incidence of malignant gliomas and extended the survival of the models, validating the concept that Rictor/mTorc2 could be a viable drug target for this lethal brain cancer in adults.

The study also found that the same Rictor/mTorc2 molecular pathway serves the opposite function in SHH medulloblastoma formation, acting as a tumor suppressor. Findings suggest that if the same drug treatment is used for treating SHH medulloblastoma in children, it could potentially have an adverse effect and promote growth of the tumors.

Ultimately, the study demonstrates that Rictor/mTORC2 has opposing functions in glioblastomas in adults and SHH medulloblastomas in children. While drug therapies targeting Rictor/mTORC2 may be successful in adults, the findings reveal the risks of treating children with pediatric brain tumors when using the same therapies.

The grant

Continuing the study of brain tumors, Dr. Zhu recently received a $575,000 grant from DoD to research benign gliomas, with the hope of gaining a greater understanding of how the tumors form. Low-grade gliomas, or benign brain tumors, are the most common brain tumors in children. While not lethal like their high-grade counterpart, these tumors can lead to significant neurological defects, permanently impacting a child’s quality of life. Most commonly, the tumor can impair vision, often leading to blindness.

Since the tumors only occur in children under the age of eight, Dr. Zhu believes they are linked to neural stem or progenitor cells that exist in the optic nerve only during development, or when children are under eight-years-old. To test if his hypothesis is correct, Dr. Zhu will develop a preclinical model that mimics human brain tumors to study the development of the optic nerve. If his theory proves correct, Dr. Zhu’s long-term goal is to develop a strategy that prevents the tumor formation from ever occurring, ultimately preventing vision loss in children. The grant begins in July and will run for three years.

 

Brian Rood

Improving the understanding of medulloblastoma

Brian Rood

Brian Rood, M.D., employed quantitative proteomics to tumor samples that led to novel therapeutic targets for Medulloblastoma and other tumors.

In a recently published study, Brian Rood, M.D., a neuro-oncologist at Children’s National Health System, employed quantitative proteomics to tumor samples, a technique that could lead to novel therapeutic targets for medulloblastoma and other tumors in the future.

Currently, many experts use genomic characterization to understand the genetic makeup of cancer cells, which has deepened the field’s collective knowledge of tumor biology. However, it has remained challenging to infer specific information about how the tumors will respond and consequently develop more effective therapies. Medulloblastoma is the most common pediatric, malignant brain tumor. Through Dr. Rood’s research using proteomic analysis, he was able to identify and measure the protein makeup of medulloblastoma, which led to a potential pathway for clinical intervention to treat this life-threatening cancer. The findings were published online June 7, 2018, in Acta Neuropathologica Communications.

“The goal of this research was to find out how these tumor cells function at the protein level, which may ultimately help the field identify drug therapies to stop them,” says Dr. Rood. “The genes of a cancer cell are like a blueprint for a building, but the blueprints aren’t always followed in a cancer cell: Not every active gene will produce its corresponding protein. Proteins do the work of the cell, and understanding them will provide a better overall understanding of a cancer cell’s biology.”

Dr. Rood compared proteomic and genomic data to confirm that genetics do not accurately predict the quantity of proteins. By directly quantitating the proteins and comparing them between different subgroups of the disease, they were able to identify protein-based pathways driving tumor biology. With this information, Dr. Rood was able to demonstrate that medulloblastoma depends on a crucial pathway, the eukaryotic initiation factor 4F protein synthesis pathway, resulting in the identification of a potential target for new treatments in medulloblastoma.

Ultimately, Dr. Rood found that proteomic analysis complements genomic characterization and the two can be used together to create a more complete understanding of tumor biology. Going forward, he hopes proteomic analysis will become common practice for studying all tumors, allowing tumors to be categorized and grouped together by protein makeup to help the field identify more effective therapies for all tumors.

New treatment approach shows promise for patients with stage IV Wilms tumor

The study assessed the benefit of adding two additional chemotherapy agents, cyclophosphamide and etoposide, to the treatment regimen for patients with incomplete lung nodule response or tumor loss of heterozygosity (LOH) at chromosomes 1p and 16q, both associated with interior outcomes in previous studies.

Wilms tumor, which first develops in the kidneys, is the fifth most common cancer in children under 15 years old. While overall outcomes for patients with Wilms tumor are excellent, patients with metastatic disease, with the lung as the most common site of spread, fare worse than patients with localized disease. That’s why a new study showing significantly improved survival rates for patients with stage IV Wilms tumors with lung metastases is making waves in the pediatric oncology community.

The study, “Treatment of Stage IV Favorable Histology Wilms Tumor With Lung Metastases: A Report From the Children’s Oncology Group AREN0533 Study” – recently published in the Journal of Clinical Oncology with Jeffrey Dome, M.D., Ph.D., vice president for the Center for Cancer and Blood Disorders at Children’s National Health System, as the senior author – assessed whether lung radiation therapy, part of the standard treatment in combination with chemotherapy drugs, can be avoided for patients with complete lung nodule response after six weeks of chemotherapy. Conversely, the study assessed the benefit of adding two additional chemotherapy agents, cyclophosphamide and etoposide, to the treatment regimen for patients with incomplete lung nodule response or tumor loss of heterozygosity (LOH) at chromosomes 1p and 16q, both associated with interior outcomes in previous studies. The results show that:

  • The new approach to therapy resulted in a 4-year overall survival rate of 96 percent, compared to 84 percent on the predecessor study.
  • About 40 percent of patients with Wilms tumor and lung metastases can be spared initial upfront lung radiation and still have outstanding survival. This will decrease the long-term risk of heart toxicity and breast cancer.
  • Patients with incomplete lung nodule response after six weeks of therapy with cyclophosphamide and etoposide had significantly better 4-year event-free survival: 89 percent compared with 75 percent that was expected based on historical data.
  • Intensification of therapy for patients with LOH at 1p and 16q was highly effective: 4-year event-free survival rate improved from 66 percent on the previous study to 100 percent.

“These findings will change clinical practice and improve survival for patients with Wilms tumor whose cancer has spread to the lungs” said Dr. Dome. “The risk-adapted approach to treatment based on tumor biology and tumor response provides a framework for future studies as we come one step closer to achieving 100 percent survival without treatment-associated side effects.”

Anthony Sandler

Treatment of neuroblastoma with immunotherapy and vaccine combination shows promise

Anthony Sandler

“Treatment options like these that help the body use its own immune system to fight off cancer are incredibly promising, and we look forward to continuing this work to understand how we can best help our patients and their families,” said Anthony Sandler, M.D.

Despite being the most common extracranial solid tumor found in children and having multiple modes of therapy, neuroblastoma continues to carry a poor prognosis. However, a recent cutting-edge pre-clinical study, PD-L1 checkpoint inhibition and anti-CTLA-4 whole tumor cell vaccination counter adaptive immune resistance: A mouse neuroblastoma model that mimics human disease, published in PLOS Medicine shows the first signs of success in treating high-risk neuroblastoma, a promising step not only for neuroblastoma patients, but potentially for other types of cancer and solid tumors as well. While the research was conducted on mouse models and is in the early stages, the lead author of the study, Anthony Sandler, M.D., senior vice president and surgeon-in-chief of the Joseph E. Robert, Jr., Center for Surgical Care at Children’s National, believes these findings are an encouraging development for the field.

The treatment method combines a novel personalized vaccine and a combination of drugs that target checkpoint inhibitors enabling the immune system to identify and kill cancer cells. When these checkpoints are blocked, it’s similar to taking the brakes off the immune system so that the body’s T cells can be primed by the vaccine, identify the tumor and allow for targeted tumor cell killing. The vaccine then brings in reinforcements to double down on the attack, helping to eradicate the tumor. The vaccine could also be used as a way to prevent recurrence of disease. After a patient has received the vaccine, the T cells would live in the body, remembering the tumor cells, and attack reemerging cancer in a similar way that a flu vaccine helps fight off the flu virus.

“Treatment options like these that help the body use its own immune system to fight off cancer are incredibly promising, and we look forward to continuing this work to understand how we can best help our patients and their families,” said Dr. Sandler.