Subsequent MRI of pediatric patients after an adverse reaction to Gadolinium-based contrast agents.

BACKGROUND:Gadolinium-based contrast agent (GBCA)-enhanced magnetic resonance imaging (MRI) scans often must be used repeatedly in pediatric oncologic patients. Although GBCAs are usually well tolerated, severe and life-threatening allergic reactions might occur, which can result in overly cautions adherence to special precautions in patients. PURPOSE:To evaluate the management of the reported GBCA-associated adverse reactions in subsequent contrast-enhanced MRIs in pediatric patients, distinguishing non-allergic and allergic reactions. MATERIALS AND METHODS:In this retrospective, cross-sectional study, consecutive pediatric neurooncological patients who underwent GBCA-enhanced MRI at our university hospital, between 2007 and 2016, were eligible. The patients' history was evaluated with regard to any adverse events after GBCA administration. In a subset of patients with reported adverse reactions, the institutional premedication regime or an allergy work-up in clinical practice were performed, using either skin-prick tests or intravenous provocation tests in a double-blind procedure. RESULTS:Included were 8156 contrast-enhanced MRI scans in 2109 patients. Nineteen acute adverse events (19/8156; 0.23%) in 17 patients (17/2109; 0.81%) were reported. Despite a premedication regime in 14 patients, three patients (3/14; 21.4%) reported a breakthrough reaction. None of the 12 patients who underwent skin-prick tests or intravenous provocation tests showed allergic reactions. At least one well-tolerated GBCA was identified in almost every tested patient. CONCLUSION:A fast-track allergy work-up can help to distinguish non-allergic and allergic reactions and to identify a well-tolerated GBCA, thus avoiding unnecessary premedication for subsequent GBCA administrations

Pharmacokinetics of Bevacizumab in Three Patients Under the Age of 3 Years with CNS Malignancies

Background Bevacizumab is a recombinant antibody that is increasingly used in pediatric malignancies. The pharmacokinetics of bevacizumab in pediatric patients have been shown to be influenced by tumor localization and body weight. In this report, we present data on the pharmacokinetics and safety of bevacizumab in children under the age of 3 years with central nervous system (CNS) malignancies. Methods Three patients (mean age 22 months) were treated with intravenous bevacizumab 10 mg/kg every 2 weeks. In total, 20 trough and peak bevacizumab concentrations of 10 treatment cycles were obtained at steady state. Results Bevacizumab was generally well-tolerated in this age group. The mean trough concentration was 127 29 g/ml (range 77155), and the mean peak concentration was 149 13 g/ml (range 113157). Trough and peak levels were stable upon repeated treatment cycles in the same patient. In contrast, we determined strong interindividual variations in trough levels. Whereas the plasma concentration of the oldest patient matched the prediction of a previously published model, younger patients showed markedly higher trough levels. Conclusions Serum peak concentrations of bevacizumab in children under the age of 3 years with CNS malignancies are in a similar magnitude to that found in older children and adults. Thus, a dosing schedule of bevacizumab 10 mg/kg every 2 weeks can be considered sufficient and safe, even in very young children. We further show that very young children with CNS malignancies show a markedly reduced plasma clearance, possibly related to lower body weight or differences in clearance mechanisms of antibodies.(VLID)482317

Laser ablation-inductively coupled plasma time-of-flight mass spectrometry imaging of trace elements at the single-cell level for clinical practice

In this work, a combination of routine clinical practice and stateof-the-art laser ablation-inductively coupled plasma time-of-flight mass spectrometry (LA-ICP-TOFMS) imaging is presented for multielement analysis of single cells on clinical samples. More specifically, routinely drawn blood thin films of a patient undergoing treatment with the anticancer drug cisplatin were studied. The presented label-free approach enabled rapid analysis of hundreds of cells at the single-cell level within a few minutes without additional tailored sample preparation. The employed low-dispersion LA setup is based on the tube-type COBALT ablation cell in combination with the aerosol rapid introduction system (ARTS) providing pixel-resolved imaging at 250-500 Hz for biological sample material. In order to cope with the short transient signals of only a few milliseconds delivered by the laser ablation setup, an( )icpTOF 2R TOF-based ICP-MS instrument was used for analysis, which has a mass coverage of m/z = 14-256. Leukocytes and erythrocytes, imaged with a laser beam of 4 mu m and pixel interspacing of 2 mu m, were differentiated on the basis of their intrinsic trace-elemental pattern. Overall, red blood cells displayed high iron intensities, whereas individual white blood cells were characterized by their high phosphorus content and increased sulfur signal. Unsupervised multivariate statistical analysis was applied to the data set. Principal component plots showed a clear clustering of leukocytes versus erythrocytes. The approach allowed studying not only the drug distribution between plasma and cells but also, for the first time, the preferential accumulation of platinum in different blood cell types without the need of cell fixation and labeling. Extracellular hotspots of platinum were observed, whereas only a small fraction of platinum was associated with erythrocytes. The investigation demonstrates the potential of low-dispersion LA-ICP-TOFMS as a rapid and powerful tool for label-free single-cell imaging in the clinical context

Does the interval from tumour surgery to radiotherapy influence survival in paediatric high grade glioma?

Purpose Paediatric high grade glioma (pHGG) are rare. Following maximum safe resection, children >3 years with HGG receive radiotherapy as standard of care. Whether the interval from tumour surgery to radiotherapy (ISRT) influences survival is disputed in adults with glioblastoma, data for children are lacking. This retrospective single-centre analysis investigates a possible impact of ISRT on survival in paediatric patients with HGG. Methods Survival was analysed in patients aged 319 years with non-pontine HGG. Results Thirty-eight patients were included (female:male 19:19) with a median age of 11.0 years (3.417.7). Seventeen patients had grade 3 and 21 grade 4 glioma. Gross total resection was achieved in 26.3%, partial resection in 36.8% and 36.8% underwent biopsy only. All patients received concomitant and adjuvant chemotherapy. Fifty percent (n=19) started irradiation 17 days (median interval 12 days [range 517]), 50% thereafter (median 28 days [range 1978]). More patients with grade 4 tumours were irradiated shortly after surgery. ISRT (as a continuous variable and dichotomised into two groups by the median ISRT of 18 days) did not significantly influence overall survival (OS) or progression-free survival (PFS). Higher extent of resection (EOR), lower tumour grade as well as chemotherapy with temozolomide had a significant positive impact on OS and PFS in univariate analysis and (except for the effect of temozolomide on PFS) also in multivariable analysis. Conclusions ISRT did not influence survival in pHGG. In view of upcoming targeted treatment options in pHGG the present data suggest that it is safe to perform molecular analyses within a 4-week timeframe before radiotherapy.(VLID)358222

Prospective Evaluation of Kidney Function in Long-Term Survivors of Pediatric CNS Tumors

Purpose: Numerous acute effects of chemotherapeutics on kidney function are well described. However, data on the long-term effects of chemotherapy in the growing population of childhood central nervous system (CNS) tumor survivors is limited. We aimed to evaluate the kidney function of a cohort of long-term CNS tumor survivors treated with different standard chemotherapeutic regimens. Methods: Patients treated for a CNS tumor were prospectively evaluated up to 12 years after completion of their therapy. Examination of kidney function was performed during routine follow-up visits. Blood pressure and blood and urine parameters were analyzed for kidney function evaluation. Glomerular function was assessed by calculating the estimated glomerular filtration rate (eGFR), tubular functions were analyzed by measuring serum electrolytes, bicarbonate and phosphate reabsorption, and proteinuria was assessed by calculating the protein/creatinine ratio and phosphate reabsorption. Results: None of the 65 patients evaluated suffered from clinically relevant kidney impairment (eGFR < 90 mL/min/L, 73 m2). There was no association between chemotherapy dose and eGFR. Only two patients showed mild signs of tubulopathy and 11 patients were diagnosed with elevated blood pressure. Conclusion: With adequate supportive measures, such as sufficient hydration according to chemotherapy protocol guidelines, as well as avoidance or close monitoring of additional nephrotoxic medication, impaired kidney function is rare in CNS tumor survivors treated with standard chemotherapy. Nonetheless, long-term follow-up is essential for early detection of mild impairment of kidney function

Pharmacokinetics of metronomic temozolomide in cerebrospinal fluid of children with malignant central nervous system tumors

Purpose Although temozolomide is widely used in the treatment of childhood central nervous system (CNS) tumors, information on its pharmacokinetic profile in the brain or cerebrospinal fluid (CSF) is sparse. This study aimed at investigating whether measurable and clinically relevant concentrations of temozolomide are reached and maintained in CSF for continuous oral administration in pediatric patients. A population pharmacokinetic model was developed to quantify CSF penetration of temozolomide. Methods Eleven pediatric CNS tumor patients (aged 4-14 years) treated with oral temozolomide using a metronomic schedule (24-77 mg/m(2)/day) were included. Temozolomide concentrations in 28 plasma samples and 64 CSF samples were analyzed by high-performance liquid chromatography. Population pharmacokinetic modeling and simulations were performed using non-linear mixed effects modeling (NONMEM 7.4.2). Results Median temozolomide concentrations in plasma and CSF were 0.96 (range 0.24-5.99) mu g/ml and 0.37 (0.06-1.76) mu g/ml, respectively. A two-compartment model (central/plasma [1], CSF [2]) with first-order absorption, first-order elimination, and a transit compartment between CSF and plasma adequately described the data. Population mean estimates for clearance (CL) and the volume of distribution in the central compartment (V-c) were 3.29 L/h (95% confidence interval (CI) 2.58-3.95) and 10.5 L (8.17-14.32), respectively. Based on simulations, we found a median area under the concentration vs. time curve ratio (AUC(CSF) / AUC(plasma) ratio) of 37%. Conclusion Metronomic oral temozolomide penetrates into the CSF in pediatric patients, with even higher concentration levels compared to adults