Relapse in medulloblastoma: what can be done after abandoning high-dose chemotherapy? A mono-institutional experience

Purpose

We retrospectively report strategies used for medulloblastoma patients progressing after craniospinal irradiation where we aimed for: symptom control, a satisfactory quality of life, accrual in phase 1–2 trials, when available, and the first two conditions could no longer be satisfied by already experienced second-line strategies.

Methods

Surgery was used in cases of doubtful relapse or when only one site was affected. Radiotherapy was given whenever possible, especially to relieve symptoms. The main chemotherapy regimens were oral temozolomide/etoposide, intravenous (iv.) cisplatin/etoposide, iv. gemcitabine/oxaliplatin, an oral sonic hedgehog pathway inhibitor and oral melphalan.

Results

Between 1998 and 2011, we treated 18 patients relapsed after median 20 months. Nine had relapsed locally, four had dissemination, three single metastases, and two had one synchronous local and metastatic recurrence. Responses to chemotherapy were seen in 32 % of cases. The median hospital stay for treatments/complications was 19 days. The 1- and 3-year progression-free survival (PFS) rates were 28?±?10 % and 0 %, respectively, for OS, they were 44?±?12 % and 22?±?10 % but no patient was cured. The median PFS after a first relapse was 7 months (range 1–29); the median OS was 7 months (range 4–44). No patients died due to treatment toxicity. Late recurrence (more than 1–2 years after diagnosis) and involvement of single sites were favorable prognostic factors.

Conclusions

Without succeeding in patients cure, we ensured them further treatment with short hospital stay thus affording low personal and social costs. The chances of cure may emerge from tailored therapies according to genetic stratification.     

Decreased susceptibility of mice to infection with Listeria monocytogenes in the absence of interleukin-18

The induction of proinflammatory cytokines such as gamma interferon (IFN-gamma) and tumor necrosis factor alpha is crucial for the early control of bacterial infections. Since interleukin-18 (IL-18) acts as a potent inducer of IFN-gamma, it might play an important role in the induction of a protective immune response in listeriosis. We used a murine model of systemic Listeria monocytogenes infection to study the immune response to these intracellular bacteria in the absence of IL-18. For this purpose, IL-18-deficient mice and mice treated with anti-IL-18 neutralizing antibody were infected with L. monocytogenes, and their innate and adaptive immune responses were compared to those of control mice. Unexpectedly, we found that mice deficient in IL-18 were partially resistant to primary infection with L. monocytogenes. At day 3 after infection, the numbers of listeriae in the livers and spleens of control mice were up to 500 times higher than those in IL-18-deficient or anti-IL-18 antibody-treated mice. In addition, the level of proinflammatory cytokines was markedly reduced in IL-18-deficient mice. Enhanced resistance to L. monocytogenes infection in IL-18-deficient mice was accompanied by increased numbers of leukocytes and reduced apoptosis in the spleen 48 to 72 h after infection. In contrast, control and IL-18-deficient mice showed no significant differences in their abilities to mount a protective L. monocytogenes-specific T-cell response.     

Correlation between umbilical arterial pH values and fetal vertebral artery Doppler waveforms at the beginning of the second stage of labor: a pilot prospective study

Objective: The aim of this study was to evaluate the association between umbilical arterial pH and fetal vertebral artery Doppler velocimetry waveforms measured at the beginning of the second stage of labor in physiological term pregnancies.

Methods: This was a prospective cohort study of 250 pregnancies. The resistance index, pulsatility index, and peak systolic velocity were measured. The relationship between the fetal Doppler and the umbilical arterial pH was evaluated. A simple linear regression and a general linear model were used to explore possible correlations of Doppler parameters with fetal and neonatal outcome adjusted for confundents.

Results: Umbilical arterial pH values were directly associated with vertebral artery pulsatility index. Fetuses with lower pulsatility index values were at increased risk of a subsequent diagnosis of pathological fetal heart rate tracing patterns (presence of decelerations or reduced variability according to FIGO criteria during the second stage of labor). We estimated a decrease in pulsatility index of 10% in those fetuses destined to show a pathological fetal heart rate tracing.

Conclusion: Vertebral artery Doppler waveforms correlates with umbilical pH in normal pregnancies and is also a function of fetal heart rate patterns. If this proportional association would be demonstrated also for abnormal pH values, vertebral artery pulsatility index might be useful to evaluate fetal wellbeing in those cases of suspected hypoxia/academia.