High prevalence of anterior pituitary deficiencies after cranial radiation therapy for skull base meningiomas

International audienceBackground: Cranial irradiation represents one of the first line treatment proposed in skull base meningiomas. While cranial irradiation is associated with a high risk of secondary hypopituitarism, few studies focused on the specific location of skull base meningiomas. Methods: Fifty-two adults receiving photon-beam therapy for skull base meningiomas between 2003 and 2014 in our Institution were included. Anterior pituitary (ACTH, FSH, GH, LH, TSH and prolactin) as well as corresponding peripheral hormones (8 am-Cortisol, IGF-1, fT3, fT4, 17βestradiol or testosterone) were biologically screened before radiotherapy (baseline), then yearly until March 2019. The pituitary gland (PG) was delineated on CT and the mean dose delivered to it was calculated. Results: Mean age at diagnosis was 56 +/− 14 years. Median follow-up was 7 years. Up to 60% of patients developed at least ≥2 pituitary deficiencies, 10 years after radiotherapy. Gonadotroph, thyrotroph, corticotroph and somatotroph deficiencies occurred in 37, 28, 18 and 15% of patients, respectively. Hyperprolactinemia was found in 13% of patients. None patient had only one pituitary deficiency. In the multivariate analysis, a delivered dose to the PG ≥ 50 Gy or a meningioma size ≥40 mm significantly increased the risk of developing hypopituitarism. Conclusions: Over a long-term follow-up, cranial radiation therapy used in skull base meningiomas led to a high prevalence of hypopituitarism, further pronounced in case of tumor ≥4 cm. These results advocate for an annual and prolonged follow-up of the pituitary functions in patients with irradiated skull base meningiomas

Impact de l’âge et radiothérapie: points clés chez les AJA

International audienceWhen using radiation therapy for adolescents and young adults (AYA), paediatricians, adults’ oncologists and radiation oncologists need to keep in mind several particularities through the whole therapeutic process. They embrace the indication, target volumes, prescribed dose, treatment techniques and follow-up. Indeed, the young age and the cancer features that characterised this population influence the modalities of irradiation. This article highlights the key points of AYA care with radiation therapy

Validation of a high performance functional assay for individual radiosensitivity in pediatric oncology: a prospective cohort study (ARPEGE)

Abstract Background Approximately 900 children/adolescents are treated with radiotherapy (RT) every year in France. However, among the 80% of survivors, the cumulative incidence of long-term morbidity – including second malignancies - reach 73.4% thirty years after the cancer diagnosis. Identifying a priori the subjects at risk for RT sequelae is a major challenge of paediatric oncology. Individual radiosensitivity (IRS) of children/adolescents is unknown at this time, probably with large variability depending on the age when considering the changes in metabolic functions throughout growth. We previously retrospectively showed that unrepaired DNA double strand breaks (DSB) as well a delay in the nucleoshuttling of the pATM protein were common features to patients with RT toxicity. We aim to validate a high performance functional assay for IRS prospectively. Methods/design ARPEGE is a prospective open-label, non-randomized multicentre cohort study. We will prospectively recruit 222 children/adolescents who require RT as part of their routine care and follow them during 15 years. Prior RT we will collect blood and skin samples to raise a primary dermal fibroblast line to carry out in blind the IRS assay. As a primary objective, we will determine its discriminating ability to predict the occurrence of unusual early skin, mucous or hematological toxicity. The primary endpoint is the measurement of residual double-strand breaks 24 h after ex vivo radiation assessed with indirect immunofluorescence (γH2AX marker). Secondary endpoints include the determination of pATM foci at 10 min and 1 h (pATM marker) and micronuclei at 24 h. In parallel toxicity including second malignancies will be reported according to NCI-CTCAE v4.0 reference scale three months of the completion of RT then periodically during 15 years. Confusion factors such as irradiated volume, skin phototype, previous chemotherapy regimen, smoking, comorbities (diabetes, immunodeficiency, chronic inflammatory disease...) will be reported. Discussion ARPEGE would be the first study to document the distribution of IRS in the pediatric subpopulation. Screening hypersensitive patients would be a major step forward in the management of cancers, opening a way to personalized pediatric oncology. Trial registration ID-RCB number: 2015-A00975–44, ClinicalTrials.gov Identifier: NCT02827552 Registered 7/6/2016

Synergistic Antitumor Effect between Gefitinib and Fractionated Irradiation in Anaplastic Oligodendrogliomas Cannot Be Predicted by the Egfr Signaling Activity

<div><p>In high-grade gliomas, the identification of patients that could benefit from EGFR inhibitors remains a challenge, hindering the use of these agents. Using xenografts models, we evaluated the antitumor effect of the combined treatment “gefitinib + radiotherapy” and aimed to identify the profile of responsive tumors. Expression of phosphorylated proteins involved in the EGFR-dependent signaling pathways was analyzed in 10 glioma models. We focused on three models of anaplastic oligodendrogliomas (TCG2, TCG3 and TCG4) harboring high levels of phospho-EGFR, phospho-AKT and phospho-MEK1. They were treated with gefitinib (GEF 75 mg/kg/day x 5 days/week, for 2 weeks) and/or fractionated radiotherapy (RT: 5x2Gy/week for 2 weeks). Our results showed that GEF and/or RT induced significant tumor growth delays. However, only the TCG3 xenografts were highly responsive to the combination GEF+RT, with ∼50% of tumor cure. Phosphoproteins analysis five days after treatment onset demonstrated in TCG3 xenografts, but not in TCG2 model, that the EGFR-dependent pathways were inhibited after GEF treatment. Moreover, TCG3-bearing mice receiving GEF monotherapy exhibited a transient beneficial therapeutic response, rapidly followed by tumor regrowth, along with a major vascular remodeling. Taken together, our data evoked an “EGFR-addictive” behavior for TCG3 tumors. This study confirms that combination of gefitinib with fractionated irradiation could be a potent therapeutic strategy for anaplastic oligodendrogliomas harboring EGFR abnormalities but this treatment seems mainly beneficial for “EGFR-addictive” tumors. Unfortunately, neither the usual molecular markers (<i>EGFR</i> amplification, PTEN loss) nor the basal overexpression of phosphoproteins were useful to distinguish this responsive tumor. Evaluating the impact of TKIs on the EGFR-dependent pathways during the treatment might be more relevant, and requires further validation.</p></div

Gefitinib and/or fractionated radiotherapy induced morphological changes in TCG3 glioma xenografts.

<p>Tumors were harvested on D6, 24h after the last treatment fraction. Representative micrographs (<b>A</b>) of TCG3 xenograft sections after saline (CTRL), GEF, RT or GEF+RT treatment (HES staining). (<b>B</b>) The apoptotic index corresponds to the percentage of positively labeled cells for cleaved caspase-3. (<b>C</b>) The proliferative index corresponds to the percentage of tumor cells positively labeled for Ki-67. In order to determine proliferative and apoptotic indexes, a minimum of 1,000 cells were counted for each tumor. Results are expressed as the mean ± SD of at least four tumors.</p

Impact of treatments on VEGF concentration and tumor vasculature in TCG2 and TCG3 models.

<p>Tumors were harvested on days 6 (D6) and 13 (D13), 24 h after the last fraction of saline (CTRL), GEF, RT or GEF+RT treatment. (<b>A</b>) VEGF concentrations measured in tumors by ELISA assay (Day 6). (<b>B</b>) Immunohistochemical detection of the basement membrane of tumor blood vessels based on mouse type IV collagen staining in TCG3 xenografts. (<b>C</b>) The vascular density corresponds to the number of CD31 and type IV collagen positive vessels counted in a field of view (X 200 magnification) for at least four tumors. Results are expressed as the mean ± SD.</p

TCG2, TCG3 and TCG4 tumor characterization for oncogenic alterations commonly found in high-grade gliomas.

1<p>Primary diagnoses (determined in 2001 by a first pathologist according to the WHO classification 2000) were compared to a second opinion (given by an independent pathologist in 2013 according to the WHO classification 2007). AO  =  anaplastic oligodendroglioma.</p><p><i>²</i>EGFR amplification was assessed using CGH array and FISH, leading to consistent results.</p>3<p>The expression of the EGFR variant III was determined by western-blotting.</p>4<p>EGFR protein overexpression was assesed by immunohistochemical detection and compared to non tumor tissue.</p>5<p>Phospho-EGFR expression level was determined using the Bio-plex phosphotrein arrays.</p>6<p>PTEN status was investigated using three techniques: CGH array, qRT-PCR and protein expression analysis by western-blotting, leading to consistent results. (-)  =  PTEN loss.</p>7<p>PIK3CA mutation analysis (exons 9 & 20) was performed using direct sequencing.</p>8<p>IDH1 mutation was assessed by immunohistochemistry;</p>9<p>1p/19q Codeletion was determined using microsatellite analysis for loss of heterozygosity on chromosome 1 and 19q, as previously described. In parallel, IHC studies showed no expression of alpha-internexin.</p>10<p>p53 status was determined by FASAY and confirmed by IHC: WT  =  wild type or MUT  =  Mutated.</p>11<p>MGMT promotor methylation status was evaluated with the methylation specific polymerase chain reaction after DNA modification by sodium bisulfite: M  =  mutated or U  =  unmethylated.</p

Effect of treatments on (A) TCG2 (B) TCG3 and (C) TCG4 tumor growth.

<p>Xenografts-bearing mice were randomly assigned into four therapeutic groups (6–14 mice per group): CTRL (▪), GEF (□), RT (▴) and GEF+RT (▵). Treatments started at D1 and were administered for two consecutive weeks. Results are expressed as the mean tumor volume (± SEM) evolution. In each xenograft model, inset focuses on the mean relative tumor volume (mean RTV) on days 6 (D6) and 13 (D13), as compared to day 1 (D1).</p

EGFR and downstream signaling phosphorylated proteins expression in 10 human malignant glioma xenograft models.

<p>Expression of (<b>A</b>) phosphorylated EGFR (phospho-EGFR) and downstream signaling proteins: (<b>B</b>) phospho-AKT and (<b>C</b>) phospho-MEK1 were measured by BPA assay. For each model, fluorescence intensity values corresponding to 3 independent tumors were plotted and the median was represented by the bar. <i>NTBT: non-tumor brain tissue; a.u.  =  arbitrary units.</i></p

Effect of gefitinib and/or fractionated radiotherapy on phospho-EGFR and downstream phosphoproteins.

<p>On D6, phospho-EGFR (<b>A, B</b>), phospho-AKT (<b>C, D</b>) and phospho-MEK1 (<b>E, F</b>) expression were assessed in TCG2 (<b>A, C, E</b>) and TCG3 (<b>B, D, F</b>) xenograft-bearing mice which received saline (CTRL), GEF, RT or GEF+RT treatments for one week. Expression of phosphoproteins is presented as fluorescence intensity (mean ± SD) measured by BPA assay (a.u.  =  arbitrary units) (n = 6 independent tumors), *<i>p</i><0.05.</p