Diffuse Intrinsic Pontine Glioma Clinical Trial
Official title:
Biological Medicine for Diffuse Intrinsic Pontine Glioma (DIPG) Eradication
Diffuse Intrinsic Pontine Gliomas (DIPG) appear almost exclusively in children and
adolescents, representing 15 to 20% of posterior fossa tumours. Even if it is one of the most
common malignant brain tumours, there are only 30 to 40 new cases per year in France. Their
clinical presentation is stereotyped with a short clinical history and a unique MRI
appearance that was usually considered as sufficient to establish the diagnosis. The
prognosis of DIPG is always unfavourable; median overall survival is 9 to 10 months in
general and most patients will die within two years after diagnosis (Kaplan 1996,Hargrave
2006). Malignant gliomas infiltrating the brainstem represent the greatest challenge of
paediatric oncology; despite numerous collaborative studies performed, patients' survival has
not significantly increased in thirty years (Hargrave 2009). There is no validated prognostic
factor. There is currently no validated treatment except radiotherapy.
Several targeted agents have been tested in DIPG (Pollack 2007 Haas-Kogan 2008, Geoerger,
2011), without knowing whether the target was present in the tumour. A critical review of the
paradigms of these trials tells us that there are long term survivors in these studies that
is to say patients who may have benefited from the tested therapy, but they are few. So far,
the new therapies that have been tried were evaluated one after the other in search of a
treatment that would be effective for all patients, measuring the treatment effect on median
survival. They were all rejected as ineffective. However the investigators can challenge the
endpoint to evaluate efficacy in these trials as the existence of long term survivors (> 18
months, for example) and their number should not been ignored, especially if targeted
therapies are considered. The investigators propose a paradigm shift in the choice of
treatment; the issue raised would be to give to each patient the treatment associated with
the highest likelihood of efficacy based on the specific biological tumour profile.
The development of targeted therapies for malignant gliomas infiltrating the brainstem has
been hampered by the absence of biological data. It is therefore crucial to better understand
the biology of these tumours. Despite the safety of the biopsy in brainstem tumours, most
teams of paediatric neurosurgery limit the use of stereotactic biopsy only for clinically or
radiologically unusual forms. Until recently, there has been no systematic genetic study at
diagnosis to date and the few available data were confounded by the inclusion of autopsies or
clinically and radiologically unusual cases (Louis, 1993; Gilbertson 2003; Okada, 2008;
Zarghooni 2010; Broniscer, 2010; Wu, 2012 and Schwartzentruber, 2012).
French teams gathered in the French Society of Paediatric Oncology and the European
consortium "Innovative Therapies in Children with Cancer (ITCC)" decided a few years ago to
perform biopsies of these tumours for diagnostic confirmation and to ensure the presence of
certain therapeutic targets prior to a possible inclusion in a trial evaluating a targeted
therapy (Geoerger, 2009; Geoerger, 2010). Part of this experiment was reported by the team of
the Necker Hospital in Paris, confirming the low rate of complications of stereotactic biopsy
procedure (Roujeau, 2007). The biopsy specimen analysis allowed practicing
immunohistochemical, genomic (CGHarray), gene expression (transcriptome) and direct
sequencing of candidate genes studies.
In this study, the majority of patients will receive a treatment assumed to specifically
target a biological abnormality identified on the biopsy. More importantly, patients will not
receive a drug for which the identified target is absent.
In this first step of the protocol, the patients will thus be allocated to one of the three
treatment groups as follows:
- If the tumor overexpresses EGFR without PTEN loss of expression, patients may receive
erlotinib or dasatinib allocated by randomization (R1 randomisation).
- If the tumor shows loss of PTEN expression without EGFR overexpression, patients may
receive everolimus or dasatinib allocated by randomisation (R2 randomisation).
- If the tumor shows both EGFR overexpression and loss of PTEN expression, patients may
receive erlotinib, everolimus or dasatinib by randomisation (R3 randomisation).
- If the tumor shows neither EGFR overexpression nor loss of PTEN expression (a very rare
situation in our experience), patients will receive dasatinib (no randomisation).
- If the biopsy assessment is not contributive, the treatment will be allocated by
randomisation between erlotinib, everolimus and dasatinib (R3 randomisation).
n/a
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