Page 1
MoiseDanielpour,M.D.VeraandPaulGuerinFamilyChairinPediatricNeurosurgeryMedicalDirector,PediatricNeurosurgeryandCenterforPediatricNeurosciencesDepartmentofNeurosurgeryandTheRegenerativeMedicineInstituteCedars-SinaiMedicalCenter
Page 2
¡ ConsultantforBiomarinPharmaceuticalsforclinicaldrugtrialforforamenmagnumstenosisinachondroplasia
¡ Noconflictofinterest
Page 3
0 500 1000 1500 2000
CancerRemainsaLeadingCausesofDeathamong1-14Year-OldsU.S.,1991vs.1998
AccidentsCancer*
BirthDefectsHomicide
HeartDiseasesPneu&Influenza
CerebralPalsySuicide
HIVInfectionObstruc.LungDis.
Dis.ofInfancyCerebrovasc.Dis.
SepticemiaViralDiseases
Meningitis
19911998
1991:Ca-ACaJforClinJan-Feb,'951998:Ca-ACaJforClin51:15-36,'01
*includesfatal'benign'tumors
51896325
Page 4
¡ Morethan7000newcasesofchildhoodcancersarediagnosedeachyearintheUnitedStates
¡ CentralNervousSystem(CNS)Tumorsarethemostcommonsolidtumorofchildhood
¡ ThemorbiditycausedbyCNStumorsandtheirtreatmentexceedsthatofmostotherchildhoodcancers
Page 5
¡ EarlydiagnosisandextentofsurgicalresectionofCNStumorsinchildrenarethestrongestpredictorsofincreasedsurvivalorcure§ SignsandSymptoms§ RoleofSurgeryandChemotherapy▪ AdvancesleadingtodecreasedMorbidity
§ PrecisionMedicineandPersonalizedModelingofCancers
§ Advancesinthelaboratory
Page 6
¡ Seizures¡ Ataxia/Dysmetria¡ Vomiting¡ CranialNeuropaties¡ Macrocephaly
§ Nausea§ Headache§ VisualDisturbance§ AlteredMentalStatus§ Pain§ Weakness
Page 7
¡ Occursin84%ofpediatricpatientswithbraintumors
¡ MaybeduetogeneralizedelevatedICP,orcompressionofvagalnucleiorvomitingcentersinflooroffourthventricle
¡ Earlymorningheadachesandvomiting¡ Waxingandwaningsymptomsoftenwithimprovementofheadachesafteremesis
Page 8
¡ Rareearlyindicationofamasslesion:§ Initialpresentationin15%ofchildrenwithsupratentoriallesions
¡ Temporallobemostcommonsitefortumorsproducingseizuresasanearlysign§ Canpresentasabsenceseizures§ Difficulttodetect:staring,Lackofawareness,suddenhaltinactivity,lipsmackingetc.
§ behavioralissuesanddeclineinschoolperformance
Page 9
¡ Gaitdisturbancesmaysuggesteitherabrainstemorcerebellarprocess
¡ Triadoflong-tractsigns,cranialneuropaties,andataxiasuggestsbrainstempathology
¡ Cerebellarlesions§ Midlinelesions=truncalataxia
§ Cerebellarhemisphere=Appendicularataxia
Page 10
¡ Seeninmultipletypesofbraintumors¡ Producedbydirectcompression/invasionor¡ IndirectlyduetoincreasedICP
§ MostcommonlyCNVI▪ Diplopiawithcomplimentarystrabismusorheadtilt
Page 11
¡ MostCommon--Diplopia,asymmetriccranialnervedeficitsanddifficultywalking
¡ HydrocephalusSyndrome--Headaches,vomitingandventriculomegaly
¡ PsychiatricSyndrome1--Apathy,depression,declineinschoolperformanceandmemoryloss
¡ PsychiatricSyndrome2--Behavioralchange,nightmaresandenuresis
¡ StrokeorhemorrhagicSyndrome--Acutestrokelikeonsetofhemiplegia,quadraparesis,intra-nuclearophthalmoplegiaandupbeatnystagmus
¡ --Cerebello-pontineanglepresentationwithinvolvementofcranialnervesV,VIIandataxia
Page 12
¡ Backpaininachildmaybewarningofundelyingspinalcordlesion§ Whenpresentingwithintracranialsignsorsymptomsmayrepresentadropmetastasisfromintracranialtumor
Tumorwithdropmetastasis
Page 13
¡ Weaknessofextremetiescommonlyseenwithsupratentorialtumors
¡ Canbepresentingsignofspinalcordcompression
¡ Otherassociatedsignsandsymptomsmustbeelicitedtodifferentiatebetweenthetwotypesofpresentation
Page 15
¡ YoungchildrencanaccommodatelargetumorswithminimalsignsofraisedICP
¡ PresenceofopensuturesorfrontalbossingisalongstandingsignofincreasedICP.
¡ Imperativetomeasureachild’sheadcircumferenceifanysignsofachangeinmentalstatus,irritabilityorlethargyoccurs.
Page 16
¡ Directinvolvementofvisualpathway§ Opticglioma,hypothalamicgliomas,visualcortexandcraniopharyngioma:visualfieldcuts
§ pinealandtectalplatetumors:perinaud’ssign¡ Papilledemasecondarytoraisedintracranialpressure§ Presentinupto90%ofpatientswithcerebellarastrocytoma
Page 17
¡ Growthdisturbances¡ Precociouspuberty¡ Amenorrhea¡ Hypothyroidism¡ Diabetesinsipidus
Page 18
¡ 42%ofpatientspresentwithhormonaldeficiency(D.I.)andprecociousordelayedpuberty
¡ Ophthalmologicexaminationiscriticalbecausepatientsrarelycomplainofvisualdisturbance
¡ Visualcutsarecommonlyfoundonexam
Page 20
¡ Frequentlypresentwithhormonaldeficiency¡ Over50%presentwithgrowthhormonedeficiency
¡ Over91%ofpatientshavehypopituitarismwithmultiplehormonaldeficiencies
¡ DiabetesInsipidusisalatesignandfrequentlyunderappreciated
Post-op
Pre-op
Page 21
¡ Parinaud’ssign§ Paralysisofupwardgazewithretractionnystagmus,pupillarylight-near
dissociation,lidretraction¡ Raisedintracranialpressure:hydrocephalus¡ Diplopia¡ Diabetesinsipidus¡ Hypopituitarism
Pre-opPost-op
Page 23
0102030405060708090100
resection>90% Residual<1.5cc neurologicalcomplications
GNSDPNSASPN
Page 25
SurgicalResection
Page 26
The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
Page 27
Neuroanatomy Microneurosurgery Imaging
Page 28
PRE-OPERATIVEIMAGE
POST-OPERATIVEIMAGE
BRAINTUMOR
Page 32
¡ Realtimeimages¡ Canaccountforbrainshift¡ Ideallysuitedforuseinchildren
§ Smallersurgicalfield
§ Higherincidenceoflow-gradetumors
§ Donotneedtousetraditionalheadholdingapparatus
Page 33
¡ AFlexibleLaserapplicatorisguidedtointendedtargetedarea
¡ IntheMRIunitaphysicalpreciselymonitorstreatmentusingsoftwaretomeasuretemperaturechange
¡ Laserlightheatsanddestroystargetarea.Temperaturemapsshowextentoftumortissuebeingdestroyed,minimizingriskofdamagetosurroundinghealthytissue
Page 34
¡ DeterminantsofDrugEfficacy§ Sensitivityoftumortothedrug
§ Pharmoracokineticsofthedrug
§ Drug’sabilitytocrosstheBBB§ Abilityoftumorcellstoaccumulateandretainthedrug
§ Abilityofthetumorcellstorepairdamagecausedbythedrug
Page 35
¡ MalignantGlioma§ Increasesthediseasefreesurvivalinbothanaplasticastrocytoma(30%)andGlioblastoma(20%)whenusedfollowingradiotherapyascomparedtothosetreatedwithpostsurgicalradiotherapyalone.
¡ Medulloblastoma§ Upto80%fiveyeardiseasefreesurvivalfollowinggrosstotalresection,radiationandchemotherapycomparedtoabout40%withoutchemotherapy
Page 36
¡ Ependymoma§ Chemotherapoyhasnotimprovedsurvival
¡ Oligodendrogliomas§ Verylittledataexistregardinguseofchemotherapyforchildrenwithnewlydiagnosedorrecurrentdisease
¡ GermCellTumors§ Dependsonthetypeofgermcelltumor
Page 37
Leptomeningealtumor
Chemotherapy
Drop-Mets?
Page 38
TUMORPAINTOptides;targetedtreatmentstokillcacercellswhilesparing
patientsfromtoxiceffectsofchemotherapy
-1993teamatHarvardidentifiedcomponentofscorpianvenomthatblockschloridechannels-1994NicoleUllrichandHaraldSontheimerusedCholorotoxintoblockmovementofGliomacellsandfoundcompoundonlybindsmalignantcells-TransmolecularPhase1andPhase2trials-JimOlsonandBlazeBiosciencewithtumorpainttovisualizetumorinsurgery-Makesurgeonsabletoremovemoretumorwithouthdisturbingnormaltissue-Attachchemotherapeuticdrugstoabindingagentthatonlyattachestotumorcells
Page 39
¡ Matchingtherightpatient,totherightmedicine,attherighttime.
¡ Mosttumorsdon’thaveasinglegenemutationorsingleabnormalpathway
¡ Mostbraintumorsareheterogenousandconstantlyevolving
Needtogainadeeperunderstandingofmolecularcharacteristicsthataredrivingtumorgrowthand
matchingtreatmenttothosespecificabnormalities
Page 40
¡ Pediatricgliomasareassociatedwithuniquemutations
¡ Pediatricgliomasoftenresemble“normal”developmentalprograms(e.g.EGLprogenitorsinmedulloblastoma)
¡ PediatricdiseasemorefrequentlypresentsaslowgradewhileadultpresentsasGBM
¡ Notablypediatricdiseasepresentsuniquechallengesduetocoincidentbraindevelopment
Page 41
¡ Next-gensequencinghasleadtorapiddeterminationofthesomaticmutationsinlowandhighgradegliomas
¡ PediatricGlioma§ Schwartzentruberetal.2012,
Nature§ Zhangetal.2013,NatureGenetics
¡ AdultGlioma§ Brennanetal.2013,Cell§ WilliamsParsonset.al.2008,
Science§ Frattiniet.al.2013,NatureGenetics§ TCGA2008,Nature§ Verhaaketal.2010,CancerCell
Page 42
¡ Identifytarget¡ Findspecificdrugsorcombinationsofdrugsthatattackthosetargets
¡ Identifybiomarkersthatcanpredictwhichcombinationofdrugswillbeeffectiveforsubgroupofpatient(s)
Page 43
¡ Thereareanaverageof15somaticmutationsinpediatricglioma—relevanceofeachmutationnotclear
¡ Foradultthisnumberrisesto36somaticmutations
¡ Manymutationsdonothavegeneticallyengineeredmousemodels
Schwartzentrubereta.2012;Nature
Page 44
¡ EngineeredMouseModels§ Costly§ Takemonths/yearstodesign§ Moretimetocross§ EvenwithatransgenicpromotersuchasNestin,a“non-
physiological”amountofcellsexpressthemutationthroughoutdevelopment
¡ ViralModels§ Safetyconcerns(pantropic)§ Needskillinachievinghightiters§ BreedingneededforRcas-Tvamodels(ecotropic)
¡ TransplantModels§ Immuneinteractionsanissue§ Notautochthonicandlikelydoesnotrecapitulatetumorigenic
process
Page 45
Developmentofanovelmethodologyforrapidandefficientgenerationofbraintumormodels
Page 46
¡ ElectroporationistheapplicationofcurrentacrosstheheadtodriveplasmidDNAintothenucleiofdividingcells
¡ Postnatalelectroporationisasimple,“non-invasive”proceduretakinglessthan1hourperlittertocreatesomatictransgenics
Page 50
¡ Veryfewplasmidsstablyintegrate
Page 51
¡ Employs“pBase”transposasetostablyintegratethe“geneofinterest”intothegenomeinatargetedfashion
¡ AdaptedbyLoturcoetal.foruseintheembryonicCNS
Page 52
¡ Postnatalelectroporationallowsfortemporalandspatialcontrolofsomatictransgenesis
¡ PiggyBactranspositionprovidesforpermanenttransgeneintegration
Page 53
CRISPR/Cas9systemcanbeusedforgeneediting• Genesilencing• Replacingnormalgenewithmutantgene
https://www.neb.com/tools-and-resources/feature-articles/crispr-cas9-and-targeted-genome-editing-a-new-era-in-molecular-biology
Page 54
¡ Stable,somatictransgenicmutation¡ Labelandmutatesimultaneously(i.etumorcellsare
fluorescentagainstawildtype,unlabeledbackground)
¡ Flexible-Multiplegenes/shRNAscanbedeliveredsimultaneously(i.e.patientmutationsignatures)
¡ Autochthonic–fromendogenouscells,allowingnaturalprogressionoftumors
¡ Non-viral–nosafety/immuneconcerns¡ Rapid–requiresonlyPiggyBac-baseddonorplasmids¡ Definedinitialmagnitudeofsomatictransgenesisas
wellasthespatialandtemporalgenesisofthetumor
Page 56
¡ TheMAPKpathwayishighlyimplicatedingliomagenesis
¡ Rasmutationsareseenin20-25%ofcancers
¡ Erbb2(HER2/Neu)formsaheterodimerwithotherErbb2familymembersandmutationsarefoundinglioma
http://www.biooncology.com/images/therapeutic-targets/
Page 57
RachelleLevyShawnWagner
Page 60
¡ Thecriticalpathologicalhallmarksarenoted
SergueiBannykh,M.D.
Page 61
RoelVerhaak,Ph.D.
Page 63
• miR-Etechnologyisanevolutionofmir30microRNAtechnology• CanbeusedwithPolIIpromoters(CAG,TRE-Bi,tissuespecificpromoters,etc.)• Nf1functionstoinhibitRasactivationandisafrequentmutationinpediatricglioma
Page 65
Schwartzentruberetal.2012,Nature
Page 72
¡ InhibitionofFattyAcidSynthaseDecreasesExpressionofStemnessMarkersinGliomaStemCells.Yasumotoetal.PloSOne2016Jan25;11(1)
¡ TERTpromotermutationsingliomas,geneticassociationsandclinico-pathologicalcorrelations.LabussièreM1etal,BrJCancer.2014Nov11;111(10):2024-32.doi:10.1038/bjc.2014.538.Epub2014Oct14.
Page 73
¡ Smallmolecules§ Fasn
¡ Geneticproofofprinciple§ Etsfamily
¡ Immunotherapy§ Tgr1-3
Page 74
ADDRESSINGTUMORRECURRANCE
74
Page 77
¡ Cedars-Sinai§ Moise
Danielpour,M.D.§ JoshuaBreunig,
Ph.D.§ RachelleLevy§ C.Danielle
Antonuk§ JessicaMolina-
Arevena§ GibumKim§ AslamAkhtar§ MarinaDutra-
Clarke§ HannahPark
§ SergueiBannykh,
M.D.§ CliveSvendsen,
Ph.D.§ JavierRodriguez§ DavidGate§ PaskoRakicM.D.,
Ph.D.§ Svendsenlab§ ShawnWagner,Ph.D.§ Townlab
¡ Plasmids§ JoeLoturcoPh.D.§ NenadSestanPh.D.
¡ Addgene
¡ Funding
§ SOCCICancerCenterForumAward
§ VeraandPaulGuerinFamilyFoundation
§ SmidtFamilyFoundation
§ RMIandBiomedicalSciences