Pediatric Medulloblastoma Research Articles

Abstract PO-077: Image clustering of brain tumor patients using a deep neural network

Abstract Purpose: The clustering of pediatric patients based on their unlabeled brain magnetic resonance (MR) images reveal the latent features and group structures. It is an unbiased approach to finding image-based markers and risk-stratification for neurocognitive functions. Analyzing large sets of MR images is time-intensive and challenging due to the MR images' high dimensionality and complexity. The extraction of low-dimension informative feature space instead of high-dimension MR image is an effective and fast solution to cluster images accurately. We aimed at developing a feature extraction method using deep learning. Our long-term research goal is to develop a feature extraction model using deep learning to automatically and accurately identify brain regions in association with neurocognitive outcomes. Methods: We used 124 registered fractional anisotropy (FA)-mapped of diffusion tensor (DT) images of pediatric medulloblastoma patients obtained after tumor surgery and before radiation from the SJMB03 clinical trial. First, we developed a 3D convolutional auto-encoder model based on a deep neural network for the voxel-wise analysis of 3D images to produce low-dimensional features, which can reconstruct input images accurately. Then, we applied the density-based clustering model, named OPTICS (Ordering Points To Identify the Clustering Structure), to the features. To train two models, we used a soft and dynamic algorithm to simultaneously combine two loss functions. Distance measure and CAHL (Cluster Assignment Loss Hardening) are used to measure feature learning and clustering performance. Results: Our experiment demonstrates that the proposed models yield results comparable in quality to manual clustering. The model trained regarding using a sufficient dataset and reducing dynamic loss function. Our model can cluster patients precisely and extract representative hidden features of the images, which is much more time- and labor-efficient compared to manual clustering by experts. Conclusions: In this study, we focused on a new feature extraction method and clustering of brain images. Because of the deep neural networks' unique advantages in image processing, we considered a 3D convolutional auto-encoder for the feature extraction part and OPTICS algorithm for the clustering part of the model. This method is highly useful in neuroimaging and neurocognitive research. Citation Format: Hadi Hosseini, Cheng Cheng, John Glass, Gene Reddick, Amar Gajjar, Zhaohua Lu. Image clustering of brain tumor patients using a deep neural network [abstract]. In: Proceedings of the AACR Virtual Special Conference on Artificial Intelligence, Diagnosis, and Imaging; 2021 Jan 13-14. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(5_Suppl):Abstract nr PO-077.

MB-AI-His: Histopathological Diagnosis of Pediatric Medulloblastoma and its Subtypes via AI.

Medulloblastoma (MB) is a dangerous malignant pediatric brain tumor that could lead to death. It is considered the most common pediatric cancerous brain tumor. Precise and timely diagnosis of pediatric MB and its four subtypes (defined by the World Health Organization (WHO)) is essential to decide the appropriate follow-up plan and suitable treatments to prevent its progression and reduce mortality rates. Histopathology is the gold standard modality for the diagnosis of MB and its subtypes, but manual diagnosis via a pathologist is very complicated, needs excessive time, and is subjective to the pathologists’ expertise and skills, which may lead to variability in the diagnosis or misdiagnosis. The main purpose of the paper is to propose a time-efficient and reliable computer-aided diagnosis (CADx), namely MB-AI-His, for the automatic diagnosis of pediatric MB and its subtypes from histopathological images. The main challenge in this work is the lack of datasets available for the diagnosis of pediatric MB and its four subtypes and the limited related work. Related studies are based on either textural analysis or deep learning (DL) feature extraction methods. These studies used individual features to perform the classification task. However, MB-AI-His combines the benefits of DL techniques and textural analysis feature extraction methods through a cascaded manner. First, it uses three DL convolutional neural networks (CNNs), including DenseNet-201, MobileNet, and ResNet-50 CNNs to extract spatial DL features. Next, it extracts time-frequency features from the spatial DL features based on the discrete wavelet transform (DWT), which is a textural analysis method. Finally, MB-AI-His fuses the three spatial-time-frequency features generated from the three CNNs and DWT using the discrete cosine transform (DCT) and principal component analysis (PCA) to produce a time-efficient CADx system. MB-AI-His merges the privileges of different CNN architectures. MB-AI-His has a binary classification level for classifying among normal and abnormal MB images, and a multi-classification level to classify among the four subtypes of MB. The results of MB-AI-His show that it is accurate and reliable for both the binary and multi-class classification levels. It is also a time-efficient system as both the PCA and DCT methods have efficiently reduced the training execution time. The performance of MB-AI-His is compared with related CADx systems, and the comparison verified the powerfulness of MB-AI-His and its outperforming results. Therefore, it can support pathologists in the accurate and reliable diagnosis of MB and its subtypes from histopathological images. It can also reduce the time and cost of the diagnosis procedure which will correspondingly lead to lower death rates.

3D spheroid models of paediatric SHH medulloblastoma mimic tumour biology, drug response and metastatic dissemination

Studying medulloblastoma, the most common malignant paediatric brain tumour, requires simple yet realistic in vitro models. In this study, we optimised a robust, reliable, three-dimensional (3D) culture method for medulloblastoma able to recapitulate the spatial conformation, cell–cell and cell–matrix interactions that exist in vivo and in patient tumours. We show that, when grown under the same stem cell enriching conditions, SHH subgroup medulloblastoma cell lines established tight, highly reproducible 3D spheroids that could be maintained for weeks in culture and formed pathophysiological oxygen gradients. 3D spheroid culture also increased resistance to standard-of-care chemotherapeutic drugs compared to 2D monolayer culture. We exemplify how this model can enhance in vitro therapeutic screening approaches through dual-inhibitor studies and continual monitoring of drug response. Next, we investigated the initial stages of metastatic dissemination using brain-specific hyaluronan hydrogel matrices. RNA sequencing revealed downregulation of cell cycle genes and upregulation of cell movement genes and key fibronectin interactions in migrating cells. Analyses of these upregulated genes in patients showed that their expression correlated with early relapse and overall poor prognosis. Our 3D spheroid model is a significant improvement over current in vitro techniques, providing the medulloblastoma research community with a well-characterised and functionally relevant culture method.

Integrated molecular analysis of adult sonic hedgehog (SHH)-activated medulloblastomas reveals two clinically relevant tumor subsets with VEGFA as potent prognostic indicator.

Up to now, adult medulloblastoma (MB) patients are treated according to the protocols elaborated for pediatric MB although these tumors are different in terms of clinical outcomes and biology. Approximately 70% of adult MB disclose a sonic hedgehog (SHH) molecular signature in contrast to about 30% in pediatric cohorts. In addition, adult SHH-MB (aSHH-MB) are clinically heterogeneous but there is consensus neither on their optimal treatment nor on risk stratification. Thus, the identification of clinically relevant molecular subsets of aSHH-MB and identification of potential treatment targets remains inconclusive. We analyzed 96 samples of institutionally diagnosed aSHH-MB through genome-wide DNA methylation profiling, targeted DNA sequencing, and RNA sequencing to identify molecular subcategories of these tumors and assess their prognostic significance. We defined two aSHH-MB numerically comparable epigenetic subsets with clinical and molecular variability. The subset "aSHH-MBI" (46%/48%) was associated with PTCH1/SMO (54%/46%) mutations, "neuronal" transcriptional signatures, and favorable outcomes after combined radio-chemotherapy (5-year PFS = 80% and OS = 92%). The clinically unfavorable "aSHH-MBII" subset (50%/52%; 5-year PFS = 24% and OS = 45%) disclosed GLI2 amplifications (8%), loss of 10q (22%), and gene expression signatures associated with angiogenesis and embryonal development. aSHH-MBII tumors revealed strong and ubiquitous expression of VEGFA both at transcript and protein levels that was correlated with unfavorable outcome. (1) The histologically uniform aSHH-MB cohort exhibits clear molecular heterogeneity separating these tumors into two molecular subsets (aSHH-MBI and aSHH-MBII), which are associated with different cytogenetics, mutational landscapes, gene expression signatures, and clinical course. (2) VEGFA appears to be a promising biomarker to predict clinical course, which needs further prospective validation as its potential role in the pathogenesis of this subset.

Circulating Lymphocyte Counts Early During Radiation Therapy Are Associated With Recurrence in Pediatric Medulloblastoma.

Decreased peripheral lymphocyte counts are associated with survival after radiation therapy (RT) in several solid tumors, although they appear late during or after the radiation course and often correlate with other clinical factors. Here we investigate if absolute lymphocyte counts (ALCs) are independently associated with recurrence in pediatric medulloblastoma early during RT. We assessed 202 patients with medulloblastoma treated between 2000 and 2016 and analyzed ALC throughout therapy, focusing on both early markers (ALC during week 1 - ALCwk1; grade 3+ Lymphopenia during week 2 - Lymphopeniawk2) and late markers (ALC nadir). Uni- and multivariable regressions were used to assess association of clinical and treatment variables with ALC and of ALC with recurrence. Thirty-six recurrences were observed, with a median time to recurrence of 1.6 years (range, 0.2-10.3) and 7.1 years median follow-up. ALC during RT was associated with induction chemotherapy (P < .001), concurrent carboplatin (P = .009), age (P = .01), and high-risk status (P = .05). On univariable analysis, high-risk disease (hazard ratio = 2.0 [1.06-3.9]; P= .03) and M stage≥1 (hazard ratio = 2.2 [1.1-4.4]) were associated with recurrence risk, as was lower ALC early during RT (ALCwk1, hazard ratio = 0.28 [0.12-0.65]; P = .003; Lymphopeniawk2, hazard ratio = 2.27 [1.1-4.6]; P = .02). Neither baseline ALC nor nadir correlated with outcome. These associations persisted when excluding carboplatin and pre-RT chemotherapy patients, and in the multivariable analysis accounting for confounders lymphocyte counts remained significant (ALCwk1, hazard-ratio = 0.23 [0.09-0.57]; P = .002; Lymphopeniawk2, hazard-ratio = 2.3 [1.1-4.8]; P = .03). ALC during weeks 1 and 2 of RT was associated with recurrence, and low ALC is an independent prognostic factor in medulloblastoma. Strategies to mitigate the risk of radiation-induced lymphopenia should be considered.

Drugging the "Undruggable" MYCN Oncogenic Transcription Factor: Overcoming Previous Obstacles to Impact Childhood Cancers.

Effective treatment of pediatric solid tumors has been hampered by the predominance of currently "undruggable" driver transcription factors. Improving outcomes while decreasing the toxicity of treatment necessitates the development of novel agents that can directly inhibit or degrade these elusive targets. MYCN in pediatric neural-derived tumors, including neuroblastoma and medulloblastoma, is a paradigmatic example of this problem. Attempts to directly and specifically target MYCN have failed due to its similarity to MYC, the unstructured nature of MYC family proteins in their monomeric form, the lack of an understanding of MYCN-interacting proteins and ability to test their relevance in vivo, the inability to obtain structural information on MYCN protein complexes, and the challenges of using traditional small molecules to inhibit protein-protein or protein-DNA interactions. However, there is now promise for directly targeting MYCN based on scientific and technological advances on all of these fronts. Here, we discuss prior challenges and the reasons for renewed optimism in directly targeting this "undruggable" transcription factor, which we hope will lead to improved outcomes for patients with pediatric cancer and create a framework for targeting driver oncoproteins regulating gene transcription.

Small-molecule screen reveals synergy of cell cycle checkpoint kinase inhibitors with DNA-damaging chemotherapies in medulloblastoma.

Medulloblastoma (MB) consists of four core molecular subgroups with distinct clinical features and prognoses. Treatment consists of surgery, followed by radiotherapy and cytotoxic chemotherapy. Despite this intensive approach, outcome remains dismal for patients with certain subtypes of MB, namely, MYC-amplified Group 3 and TP53-mutated SHH. Using high-throughput assays, six human MB cell lines were screened against a library of 3208 unique compounds. We identified 45 effective compounds from the screen and found that cell cycle checkpoint kinase (CHK1/2) inhibition synergistically enhanced the cytotoxic activity of clinically used chemotherapeutics cyclophosphamide, cisplatin, and gemcitabine. To identify the best-in-class inhibitor, multiple CHK1/2 inhibitors were assessed in mice bearing intracranial MB. When combined with DNA-damaging chemotherapeutics, CHK1/2 inhibition reduced tumor burden and increased survival of animals with high-risk MB, across multiple different models. In total, we tested 14 different models, representing distinct MB subgroups, and data were validated in three independent laboratories. Pharmacodynamics studies confirmed central nervous system penetration. In mice, combination treatment significantly increased DNA damage and apoptosis compared to chemotherapy alone, and studies with cultured cells showed that CHK inhibition disrupted chemotherapy-induced cell cycle arrest. Our findings indicated CHK1/2 inhibition, specifically with LY2606368 (prexasertib), has strong chemosensitizing activity in MB that warrants further clinical investigation. Moreover, these data demonstrated that we developed a robust and collaborative preclinical assessment platform that can be used to identify potentially effective new therapies for clinical evaluation for pediatric MB.

Neuroimaging Biomarkers and Neurocognitive Outcomes in Pediatric Medulloblastoma Patients: a Systematic Review.

Medulloblastoma is a malign posterior fossa brain tumor, mostly occurring in childhood. The CNS-directed chemoradiotherapy treatment can be very harmful to the developing brain and functional outcomes of these patients. However, what the underlying neurotoxic mechanisms are remain inconclusive. Hence, this review summarizes the existing literature on the association between advanced neuroimaging and neurocognitive changes in patients that were treated for pediatric medulloblastoma. The PubMed/Medline database was extensively screened for studies investigating the link between cognitive outcomes and multimodal magnetic resonance (MR) imaging in childhood medulloblastoma survivors. A behavioral meta-analysis was performed on the available IQ scores. A total of 649 studies were screened, of which 22 studies were included. Based on this literature review, we conclude medulloblastoma patients to be at risk for white matter volume loss, more frequent white matter lesions, and changes in white matter microstructure. Such microstructural alterations were associated with lower IQ, which reached the clinical cut-off in survivors across studies. Using functional MR scans, changes in activity were observed in cerebellar areas, associated with working memory and processing speed. Finally, cerebral microbleeds were encountered more often, but these were not associated with cognitive outcomes. Regarding intervention studies, computerized cognitive training was associated with changes in prefrontal and cerebellar activation and physical training might result in microstructural and cortical alterations. Hence, to better define the neural targets for interventions in pediatric medulloblastoma patients, this review suggests working towards neuroimaging-based predictions of cognitive outcomes. To reach this goal, large multimodal prospective imaging studies are highly recommended.

A systematic view of pediatric medulloblastoma proteomics-current state of the field and future directions.

Quantitative mass spectrometry (MS)-based approaches have allowed further characterization of medulloblastoma (MB) classification and clinical/biological behavior. By investigating protein expression, as well as the role of post-translational modifications in shaping cellular activity, novel avenues of research will clarify the current subgrouping, providing elements for tumor treatment-new molecular targets and signaling cascades-and introducing serum, urinary, and CSF markers of tumor growth and recurrence. We systematically searched and reviewed original research articles treating MB proteomics on PubMed. Reviews, opinion papers, and abstracts were excluded from the final work. A total of 30 novel articles treating the proteomic characterization of MB were included in our review. Research conducted on tissue samples, cell lines, CSF, and urine, as well as exosome and medullospheres, was considered, to picture a broad view of the different directions MS-based proteomic analysis is moving toward. In this review, we collect, summarize, and interpret the current literature on this topic. Significant progress has been achieved in the last decade in MB characterization, paving the way for further exploration of large biobanks of MB and other tissues that will allow a more systematic understanding of MB functioning and clinical progression.

Meduloblastoma pediatrikoaren pronostikorako markatzaile molekularren identifikazioa

Meduloblastoma klinika eta oinarri molekular heterogeneoa duen minbizia da. Azken urteotan, genoma osoko eta sekuentziazio masiboko teknika molekularren garapenaren ondorioz, meduloblastoma pediatrikoan parte hartzen duten mutazio asko identifikatzea ahalbidetu da. Hortaz, lanaren helburua izan zen meduloblastoma pediatrikoaren pronostikoan edota terapian lagundu dezakeen gene eta mutazio somatikoen panel baten diseinua egitea. Horretarako, meduloblastoma pediatrikoan eragina duten geneei buruzko informazioa duen literaturaren berrikuspen sistematikoa egin zen. Bilaketarako Pubmed datubase bibliografikoa erabili zen, honako termino hauek erabiliz: (Medulloblastoma*) AND («mutation*» OR «genetic alteration*» OR «genetic variation*»). Berrikuspen bibliografikoaren ondoren, hasieran zeuden 588 artikuluetatik 62 artikulutan 197 gene identifikatu ziren. Horietatik, % 2 baino gehiagoko mutazio-maiztasuna zuten 21 gene aurkitu ziren, eta diagnosiaren momentuan balio pronostikoa edo meduloblastoma azpimoten ezaugarri ziren 5 gene (TP53, CTNNB1, PTCH1, SUFU eta KDM6A). Gene horiek analizatuz gero, profil molekularrean oinarritutako tratamendu indibidualizatuak doitu litezke.

The impact of magnetic resonance imaging spectroscopy parameters on differentiating between paediatric medulloblastoma and ependymoma.

IntroductionThe distinction of medulloblastomas and ependymomas plays an important role in the care plans and prognosis of children. We aimed to investigate the role of magnetic resonance spectroscopy (MRS) in the differentiation between medulloblastomas and ependymomas in children.Materials and methodsThe institutional review board approved this prospective study. The brain magnetic resonance imaging protocol including axial multivoxel spectroscopy with a TE of 144 ms was assessed in 49 patients, who were divided into 2 groups: 40 patients with medulloblastomas and 9 patients with ependymomas. Receiver operating characteristic (ROC) curve analysis and the Youden index were utilized to determine the best cut-off, sensitivity, specificity, and area under the curve (AUC) values of the independent spectroscopy parameters.ResultsThe choline level (Cho) and the choline/creatine (Cho/Cr) and choline/N-acetyl aspartate (Cho/NAA) ratios of medulloblastomas were significantly higher than those of ependymomas (p < 0.05). A Cho/NAA cut-off value of 1.24 to predict the diagnosis of medulloblastoma yielded the highest AUC and sensitivity of 80.3% and 97.5%, respectively, while a Cho cut-off value of 4.64 produced the highest specificity value of 88.9%.ConclusionsOur findings suggest that Cho and Cho/NAA derived from MRS could serve as differential factors between paediatric medulloblastomas and ependymomas. Among those, a Cho/NAA cut-off value of 1.24 to predict the diagnosis of medulloblastoma generated the highest accuracy.

Pediatric Medulloblastoma: A Study from Western Region of Saudi Arabia

Objective: Medulloblastoma is the most common malignant brain tumors in children worldwide. It is little known about the characteristics associated with medulloblastoma and the outcome in Saudi Arabia. Therefore, the study was conducted to understand the current status and what should be done for future. Methods: A retrospective chart review of all children (<14 years) who have been diagnosed and managed with medulloblastoma at King Faisal specialist hospital and research center (KFSHRC) in Jeddah, Saudi Arabia from 2011 to 2017. Important epidemiological and clinical Data have been collected and analyzed through descriptive statistics to understand the clinical characteristics and treatment outcomes. In addition, Kaplan-Meier survival analysis was conducted to generate EFS and OS. Results: The obtained results of OS of 73.7% with suggested that lower age (Age ≤ 3), high risk, positive metastasis at presentation, partial resection remained vital and contributed to lower overall survival rate among the patients with P value as follow: (P: 3 years (P<0.001) was the major factor for better survival. Conclusion: As per the observation, the estimated outcome of total cohort was OS 73.7% and EFS 54.8% which are comparable to the developed countries. The age of > 3 years and the complete surgical excision are emerging as the most significant factors affecting OS (80.5%, 88.7%) and EFS (61.2%, 70%). Average risk and negative metastasis had significant OS with p value of 0.04, 0.02 respectively. This study provides an important clue in understanding the importance of the demographic, clinical, and treatment modalities in understanding the prognosis of medulloblastoma. This report will serve as an important resource from Kingdom of Saudi Arabia regarding medulloblastoma survival.

Pediatric Craniospinal Irradiation - The implementation and Use of Normal Tissue Complication Probability in Comparing Photon versus Proton Planning.

Purpose:The preferred radiotherapy treatment for medulloblastoma is craniospinal irradiation (CSI). With the aim of developing the potential to reduce normal tissue dose and associated post-treatment complications with photon and proton radiotherapy techniques for CSI. This report aims to carefully compare and rank treatment planning and dosimetric outcomes for pediatric medulloblastoma patients using normal tissue complication probability (NTCP) formalism between photon (three-dimensional conformal radiotherapy, intensity-modulated radiotherapy [IMRT], volumetric-modulated arc therapy [VMAT], and HT) and proton CSI.Methods and Materials:The treatment data of eight pediatric patients who typically received CSI treatment were used in this study. The patients were 7 years of age on average, with ages ranging from 3 to 11 years. A prescription dose of 3600 cGy was delivered in 20 fractions by the established planning methods. The Niemierko's and Lyman–Kutcher–Burman models were followed to carefully estimate NTCP and compare different treatment plans.Results:The NTCP of VMAT plans in upper and middle thoracic volumes was relatively high compared to helical tomotherapy (HT) and pencil beam scanning (PBS) (all P < 0.05). PBS rather than IMRT and VMAT in the middle thoracic region (P < 0.06) could significantly reduce the NTCP of the heart. PBS significantly reduced NTCP of the lungs and liver (all P < 0.05).Conclusion:The NTCP and tumor control probability (TCP) model-based plan ranking along with dosimetric indices will help the clinical practitioner or medical physicists to choose the best treatment plan for each patient based on their anatomical or clinical challenges.

CRISPR-powered electrochemical microfluidic multiplexed biosensor for target amplification-free miRNA diagnostics

Recently the use of microRNAs (miRNAs) as biomarkers for a multitude of diseases has gained substantial significance for clinical as well as point-of-care diagnostics. Amongst other challenges, however, it holds the central requirement that the concentration of a given miRNA must be evaluated within the context of other factors in order to unambiguously diagnose one specific disease. In terms of the development of diagnostic methods and devices, this implies an inevitable demand for multiplexing in order to be able to gauge the abundance of several components of interest in a patient's sample in parallel. In this study, we design and implement different multiplexed versions of our electrochemical microfluidic biosensor by dividing its channel into subsections, creating four novel chip designs for the amplification-free and simultaneous quantification of up to eight miRNAs on the CRISPR-Biosensor X (‘X’ highlighting the multiplexing aspect of the device). We then use a one-step model assay followed by amperometric readout in combination with a 2-min-stop-flow-protocol to explore the fluidic and mechanical characteristics and limitations of the different versions of the device. The sensor showing the best performance, is subsequently used for the Cas13a-powered proof-of-concept measurement of two miRNAs (miRNA-19b and miRNA-20a) from the miRNA-17–92 cluster, which is dysregulated in the blood of pediatric medulloblastoma patients. Quantification of the latter, alongside simultaneous negative control measurements are accomplished on the same device. We thereby confirm the applicability of our platform to the challenge of amplification-free, parallel detection of multiple nucleic acids.

Evaluation of factors associated with the occurrence of cerebellar mutism syndrome after resection of pediatric medulloblastoma in 3 cases

Evaluation of factors associated with the occurrence of cerebellar mutism syndrome after resection of pediatric medulloblastoma in 3 cases

Особенности предиагностического периода клинических проявлений медуллобластом у детей в Республике Татарстан

The article provides up-to-date information on the first clinical symptoms of brain tumors in children and considers the term «pre-diagnostic symptomatic interval» of pediatric medulloblastoma, which is widely used in foreign pediatric and neuro-oncological practice. The authors publish the results of their own retrospective population study revealing the clinical and epidemiological characteristics of the most frequently detected malignant brain tumors in children — medulloblastomas in the pediatric population of the Republic of Tatarstan. The analysis of the pre-diagnostic symptomatic interval of this pathology was carried out through the prism of the LOWorPAY scheme, recommended by neurooncologists as a guide for early detection of tumors for primary care physicians. A probabilistic model of the clinical symptom complex is proposed, which determines the risk of neoplasm of the central nervous system in children. Its use will help increase the oncological alertness of doctors and systematize the tactics of detecting brain and spinal cord tumors in children on an outpatient basis.

Molecular Subtyping of Paediatric Medulloblastoma by Immunohistochemistry

Four core molecular subgroups of medulloblastomas have recently been introduced disparate by their transcriptional profile, all of which have different prognostic value. We aimed to determine the histological variants and molecular subtypes of medulloblastomas by immunohistochemistry in our population, and to correlate that with clinicopathological parameters. Seventeen patients aged four-month to 14.3 years diagnosed with medulloblastoma were recruited from year 2002 to 2017. All medulloblastomas were assigned to various histological variants and molecular subgroups by immunohistochemistry surrogate markers (YAP-1 and beta catenin). They were then correlated with clinicopathological parameters and outcomes. Classic histology (76.5%) was the commonest, followed by large cell/anaplastic (LCA) (17.6%) and desmoplastic/nodular (DN) variants (59%). The most frequent molecular subgroup was non-SHH/WNT tumours (64.7%), seconded by SHH tumours (35.3%). Among the SHH tumours, 66.7% was classic histology and the remaining 33.3% was LCA variant. Interestingly, one DN histology demonstrated YAP-1 and beta catenin immunonegativity, denoting non-SHH/WNT molecular subgroup. Majority (88.2%) medulloblastomas were at midline 4th ventricle location, including DN variant. Estimated three-year diseasefree- survival (DFS) and overall-survival (OS) was 60% and 86.7%, respectively. Age &lt;3 years at diagnosis, tumour size &gt;5 cm, LCA histology and high risk group were inversely correlated with DFS, with early relapse. Infant &lt;3-year-old had worse OS. Other factors had no significant impact on DFS and OS. We had demonstrated the feasibility of simple immunohistochemistry-based surrogate markers (YAP-1 and beta catenin) to stratify medulloblastomas into distinct molecular subtypes. Prognostic and predictive values of YAP-1 immunomarker in medulloblastomas however await further investigations.

Novel Thiosemicarbazones Sensitize Pediatric Solid Tumor Cell-Types to Conventional Chemotherapeutics through Multiple Molecular Mechanisms.

Simple SummaryCombination of chemotherapeutics for the treatment of childhood cancer can lead to the use of lower cytotoxic drug doses and better therapeutic tolerability (i.e., lower side effects) for patients. We discovered novel molecular targets of two lead thiosemicarbazone agents of the di-2-pyridylketone thiosemicarbazone class. These molecular targets include: cyclooxygenase, the DNA repair protein, O6-methylguanine DNA methyltransferase, mismatch repair proteins, and topoisomerase 2α. This research also identifies promising synergistic interactions of these thiosemicarbazones particularly with the standard chemotherapeutic, celecoxib.Combining low-dose chemotherapies is a strategy for designing less toxic and more potent childhood cancer treatments. We examined the effects of combining the novel thiosemicarbazones, di-2-pyridylketone 4-cyclohexyl-4-methyl-3-thiosemicarbazone (DpC), or its analog, di-2-pyridylketone-4,4-dimethyl-3-thiosemicarbazone (Dp44mT), with the standard chemotherapies, celecoxib (CX), etoposide (ETO), or temozolomide (TMZ). These combinations were analyzed for synergism to inhibit proliferation of three pediatric tumor cell-types, namely osteosarcoma (Saos-2), medulloblastoma (Daoy) and neuroblastoma (SH-SY5Y). In terms of mechanistic dissection, this study discovered novel thiosemicarbazone targets not previously identified and which are important for considering possible drug combinations. In this case, DpC and Dp44mT caused: (1) up-regulation of a major protein target of CX, namely cyclooxygenase-2 (COX-2); (2) down-regulation of the DNA repair protein, O6-methylguanine DNA methyltransferase (MGMT), which is known to affect TMZ resistance; (3) down-regulation of mismatch repair (MMR) proteins, MSH2 and MSH6, in Daoy and SH-SY5Y cells; and (4) down-regulation in all three cell-types of the MMR repair protein, MLH1, and also topoisomerase 2α (Topo2α), the latter of which is an ETO target. While thiosemicarbazones up-regulate the metastasis suppressor, NDRG1, in adult cancers, it is demonstrated herein for the first time that they induce NDRG1 in all three pediatric tumor cell-types, validating its role as a potential target. In fact, siRNA studies indicated that NDRG1 was responsible for MGMT down-regulation that may prevent TMZ resistance. Examining the effects of combining thiosemicarbazones with CX, ETO, or TMZ, the most promising synergism was obtained using CX. Of interest, a positive relationship was observed between NDRG1 expression of the cell-type and the synergistic activity observed in the combination of thiosemicarbazones and CX. These studies identify novel thiosemicarbazone targets relevant to childhood cancer combination chemotherapy.

Platelet-derived growth factor beta is a potent inflammatory driver in paediatric high-grade glioma.

Paediatric high-grade gliomas (HGGs) account for the most brain tumour-related deaths in children and have a median survival of 12-15 months. One promising avenue of research is the development of novel therapies targeting the properties of non-neoplastic cell-types within the tumour such as tumour associated macrophages (TAMs). TAMs are immunosuppressive and promote tumour malignancy in adult HGG; however, in paediatric medulloblastoma, TAMs exhibit anti-tumour properties. Much is known about TAMs in adult HGG, yet little is known about them in the paediatric setting. This raises the question of whether paediatric HGGs possess a distinct constituency of TAMs because of their unique genetic landscapes. Using human paediatric HGG tissue samples and murine models of paediatric HGG, we demonstrate diffuse midline gliomas possess a greater inflammatory gene expression profile compared to hemispheric paediatric HGGs. We also show despite possessing sparse T-cell infiltration, human paediatric HGGs possess high infiltration of IBA1+ TAMs. CD31, PDGFRβ, and PDGFB all strongly correlate with IBA1+ TAM infiltration. To investigate the TAM population, we used the RCAS/tv-a system to recapitulate paediatric HGG in newborn immunocompetent mice. Tumours are induced in Nestin-positive brain cells by PDGFA or PDGFB overexpression with Cdkn2a or Tp53 co-mutations. Tumours driven by PDGFB have a significantly lower median survival compared to PDGFA-driven tumours and have increased TAM infiltration. NanoString and quantitative PCR analysis indicates PDGFB-driven tumours have a highly inflammatory microenvironment characterized by high chemokine expression. In vitro bone marrow-derived monocyte and microglial cultures demonstrate bone marrow-derived monocytes are most responsible for the production of inflammatory signals in the tumour microenvironment in response to PDGFB stimulation. Lastly, using knockout mice deficient for individual chemokines, we demonstrate the feasibility of reducing TAM infiltration and prolonging survival in both PDGFA and PDGFB-driven tumours. We identify CCL3 as a potential key chemokine in these processes in both humans and mice. Together, these studies provide evidence for the potent inflammatory effects PDGFB has in paediatric HGGs.

QOL-01. LONGITUDINAL COMPARISON OF NEUROCOGNITIVE TRAJECTORIES IN PEDIATRIC MEDULLOBLASTOMA PATIENTS TREATED WITH PROTON VERSUS PHOTON RADIOTHERAPY

PURPOSEBy reducing dose to normal brain tissue, proton radiotherapy (PRT) may lessen neurocognitive risk traditionally associated with photon radiotherapy (XRT). We examined change in neurocognitive scores over time in pediatric medulloblastoma patients treated with PRT versus XRT.METHODSNeurocognitive scores from 79 patients (37 PRT, 42 XRT) were examined. Patients were treated between 2007–2018 on the same treatment protocols that differed only by craniospinal modality (PRT versus XRT). Change in scores over time since diagnosis were compared between groups.RESULTSGroups were similar on most demographic/clinical variables: sex (67.1% male), age at diagnosis (mean 8.6 years), CSI dose (median 23.4 Gy), length of follow-up (mean 4.3 years), and parental education (mean 14.3 years). Boost dose (p<0.001) and margin (p=0.001) differed between groups. Adjusting for covariates, the PRT group exhibited superior outcomes in global IQ, perceptual reasoning, and working memory versus the XRT group (all p<0.05). The XRT group exhibited significant decline in global IQ, working memory, and processing speed (all p<0.05). The PRT group exhibited stable scores in all domains except processing speed (p=0.003). Posterior fossa syndrome imparted risk independent of modality.CONCLUSIONThis is the first study comparing neurocognitive trajectories between pediatric patients treated for medulloblastoma with PRT versus XRT on comparable, contemporary protocols. PRT was associated with more favorable neurocognitive outcomes in most domains compared to XRT, although processing speed emerged as vulnerable in both groups. This is the strongest evidence to date of an intellectual sparing advantage with PRT in the treatment of pediatric medulloblastoma.