Med Pediatr Oncol 2003;41:171–176

PROLOGUEPediatric Neurooncology Reports of the 2002 Meetings

of the German Brain Tumor Group: ExperimentalNeurooncology Held in Gottingen, March 8–9 andClinical Research Held in Regensburg, April 18–21

Johannes Wolff, MD, and Sabine Wagner, MD

The central nervous system is the most frequent loca-tion of solid tumors in children, yet both basic research andtreatment success lag behind, when compared to othersolid tumors and leukemia. Among the reasons for thisdelay are the complicated biology of the developing braineven as a normal organ, the difficult access to samples forbasic research, and the need for large interdisciplinarygroups for clinical studies.With respect to clinical studies,the high incidence of brain tumors in general is signi-ficantly counteracted by the large number of differenttumor entities, each needs to be studied separately. Inparticular the transition from basic science to clinicalapplication has proven difficult in pediatric neuroonco-logy. Phase I studies have difficulty in getting formalapproval by ethic committees, phase III studies arehampered by insufficient numbers. Despite all this, thereis progress. The number of publications in basic neuro-science has increased greatly during the past decade,several pharmaceutical companies have turned to adultmalignant glioma as a model disease for studying newdrugs, and in pediatric oncology, the multi-institutional

groups are strengthening their brain tumor subgroups.Pediatric oncology in the German speaking countries isorganized in the GPOH (‘‘Gesellschaft fur PaddiatrischeOnkologie und Hamatologie’’), the brain tumor groupwhich was formed by Joachim Kuhl starting in 1987 withthe first Phase II study. Most of the clinical studies of thisgroup since then may be recognized by the letters ‘‘HIT’’in their names, which is an abbreviation of the Germanword for brain tumor. At present, the group has two re-peating meetings. That for experimental neurooncology,chaired this year by Dr. Erdlenbruch in Gottingen, aims tofind novel treatment approaches that can be translated intoclinical application. The meeting for clinical studies,chaired this year by Johannes Wolff in Regensburg, in-forms participating centers about the recent data of activestudies, and develops the next clinical trials. The chal-lenges of low survival rates and severe long-term sequelaeof children with brain tumors are internationally under-stood. This report aims to communicate the GPOH de-velopments to the international community. Selectedabstracts are followed by summaries of the results.

——————Accepted 6 November 2002

� 2003 Wiley-Liss, Inc.DOI 10.1002/mpo.10344

SMAC AGONISTS SENSITIZE FOR APO2L/TRAIL- OR ANTICANCER

DRUG-INDUCED APOPTOSIS AND INDUCE REGRESSION

OF MALIGNANT GLIOMA IN VIVO

Simone Fulda, Wolfgang Wick, Michael Weller, and Klaus-Michael Debatin

Despite aggressive therapy, resistance of many tumors including glioblastoma to celldeath induced by current treatment protocols still remains a major concern in cancertherapy. Here, we report that Smac gene transfer or Smac peptides sensitized varioustumor cell lines in vitro and malignant glioma cells in vivo for apoptosis induced bydeath receptor ligation or cytotoxic drugs by antagonizing the apoptosis inhibitorXIAP known to be strongly expressed in many tumors. Ectopic expression of acytosolic active form of Smac or cell permeable Smac peptides bypassed the Bcl-2block, which prevented the release of Smac from mitochondria, and also sensitizedresistant glioblastoma cells lacking caspase-8, melanoma cells lacking Apaf-1 orpatient’s derived primary tumor cells ex vivo. Most importantly, Smac peptidessignificantly enhanced the antitumor activity of Apo2L/TRAIL in an intracranialmalignant glioma xenograft model in vivo resulting in complete eradication ofestablished tumors only upon combined treatment with Smac and Apo2L/TRAILwithout acute or delayed neurotoxicity. Thus, Smac agonists represent novelpromising cancer therapeutics to potentiate the efficacy of cytotoxic therapies even inresistant tumors.

SELECTIVE REPORTER GENE EXPRESSION IN NEUROECTODERMAL

TUMORS: A MODEL FOR GENE THERAPY

S. Steffens,* S. Frank, A. Sandquist, U. Fischer, C.M. Kramm

University Children’s Hospital, Heinrich-Heine-University, Moorenstr. 5,

40225 Duesseldorf, Germany.

In order to develop a selective gene therapy approach for neuronal tumors, weinvestigated the usefulness of the promoters for neuron specific enolase (NSE),dopamine b-hydroxylase (DBH), and tyrosine hydroxylase (TH), for tumor targetingof transgene expression. For this purpose, we studied reporter gene expression undercontrol of these promoters in transient transfection experiments using human andmouse neuroblastoma cell lines as a model for neuroectodermal tumors. Fibroblastsand non-neuroectodermal tumor cell lines served as negative controls. We applied twodifferent assays for our promoter studies: FACS analysis of specific enhanced greenfluorescent protein (EGFP) expression and a dual luciferase assay with thepromoter-dependent firefly luciferase gene (lucþ from photinus pyralis) expressionand the constitutively expressed Renilla luciferase (from Renilla reniformis) as internalcontrol. Both egfp and lucþ reporter gene assays revealed neuroectodermaltumor-specific expression of all promoters investigated. Neuroblastoma-specific geneexpression by the NSE promoter was significantly higher than expression by the DBHor TH promoter. But in non-neuronal cells, transgene expression mediated by theNSE promoter was relatively high as well. In contrast, the TH promoter mediatedlow levels of background activity in non-neuronal cell lines. The DBH promoter wasnot active in all neuroectodermal tumor cell lines investigated. The feasibility of aretrovirus-mediated suicide gene approach under transcriptional control of the THpromoter was confirmed by in vitro studies, although differences in expression levelswere markedly lower than in our reporter gene assays. In summary, the TH promoter isa valuable tool to direct suicide gene expression to neuroblastoma cells and may beother neuroectodermal tumors and, thus, reduce cytotoxicity for non-malignant cells.But therapeutic efficiency is still limited due to the lack of powerful vector systems.

INFLUENCE OF SERUM ON ERUCYLPHOSPHOCHOLINE-INDUCED

CYTOTOXICITY ON A172 ASTROCYTOMA CELL LINE

Michael Damkohler,1 Dagmar Heinemann,2 Wilfried Kugler,1

Bernhard Erdlenbruch,1 Hansjorg Eibl,2 and Max Lakomek1

1Department of Pediatrics, University of Gottingen, Germany2Max Planck Institute for Biophysical Chemistry, Gottingen, GermanyErucylphosphocholine (ErPC) represents the first intravenous injectible derivative ofalkylphosphocholines, a new class of antineoplastic and antiprotozoal drugs, and it hasbeen shown to be selectively cytotoxic to tumor cells in vitro and in vivo. Repeatedintravenous administration of ErPC to rats resulted in tissue concentrations exceeding250 nmol/g without signs of toxicity.We have analyzed the antitumor effect of ErPC on A172 cells (WST-1 test) understandard cell culture conditions using 10% heat-inactivated (568C, 30 min) fetal calfserum (iFCS) in RPMI medium. Alternatively heat-inactivated or active human serum(iHS and aHS) was added instead of iFCS. Treatment with 50 mM ErPC for 24 hrreduced the viability of the cells to 25–35% if the medium contained iFCS. The ErPCeffect was markedly reduced (50–80% viability) with iHS whereas in the presence ofaHS virtually no cytotoxicity was found (80–100% viability). Increasing theconcentration of ErPC allows to overcome the inhibitory effect of aHS. Since wesupposed that complement could be an inhibitory factor of human serum we addedpurified complement from rabbit to the medium together with 10% iFCS. Atconcentrations from 0.85 to 3.4 mg/ml, complement showed a strong inhibitory effecton ErPC (80–100 % viability) which was less pronounced when it was incubated for30 min at 568C before use (60–73% viability). Purified immunoglobulines or humanserum albumin at a similar protein concentration (5 mg/ml) had no influence on thecytotoxicity of ErPC.From our findings we conclude that active complement may specifically interfere withErPC resulting in reduced cytotoxicity. The results strongly indicate that cell culturestudies with alkylphosphocholines should be performed with aHS. The presence ofinactivated serum will cause misleading results.

ENHANCED TUMOR UPTAKE OF SMALL AND HIGH MOLECULAR

WEIGHT MARKERS AND SURVIVAL IN GLIOMA-BEARING RATS BY

INTRACAROTID ADMINISTRATION OF PENTYLGLYCEROL

B. Erdlenbruch,1 M. Alipour,1 W. Kugler,1 W. Schulz-Schaffer,2 H. Eibl,3

and M. Lakomek1

1Department of Pediatrics, University of Gottingen, Gottingen, Germany2Department of Neuropathology, University of Gottingen,

Gottingen, Germany3Max-Planck-Institute for Biophysical Chemistry, Gottingen, Germany

Chemotherapy of malignant brain tumors is characterized by low cure rates resultingfrom ineffective concentrations of anticancer agents within the lesion andcircumventing brain. The intracarotid administration of alkylglycerols has beenreported to be an effective and low toxic strategy to increase the transfer of variouschemotherapeutics to the brain. We have investigated the transfer of small and largefluorescence markers (fluorescein sodium and Lissamine rhodamine B-200-albumin,RB 200) and of methotrexate (MTX) across the blood-brain barrier in C6 gliomabearing rats. Antitumor effects of a single course of intraarterial cisplatin (4 mg/kg) inconjunction with intracarotid pentylglycerol (120 mM) at day 7 after tumorimplantation were examined. Intracarotid bolus infusion of 1-O-pentylglycerol(200 mM) increased the transport of the fluorescence markers to both tumor andsurrounding ipsilateral tumor-free brain as evidenced by marked extravasation ofthe dyes into the brain tissue. MTX concentrations were increased 18-fold in tumor,28-fold in surrounding ipsilateral brain, and 18-fold in contralateral brain, ascompared with intracarotid MTX alone. C6 glioma bearing rats treated withcisplatin and 1-O-pentylglycerol exhibited a significantly higher median survival(P< 0.05, logrank test). Fifty days after tumor implantation, survival rateamounted to 42% (5 of 12 rats) whereas all animals treated with cisplatin alone orcontrols without chemotherapy were dead. Histological examination revealed largeand rapidly growing tumors in untreated rats. Partial tumor regression and earlyrelapses were found in animals receiving cisplatin alone. In pentylglycerol-treatedrats almost complete tumor eradication was observed at the implantation site andtumor recurrence occurred lately and less frequently. In conclusion, intracarotidpentylglycerol resulted in increased delivery of small and large compounds to normalbrain and C6 tumors, and resulted in higher survival in rats with gliomas. There isevidence that intraarterial chemotherapy in conjunction with alkylglycerols representsa promising tool in the treatment of brain tumors.

EMPLOYMENT OF NANOPARTICLES FOR THE DELIVERY OF

ANTICANCER AGENTS TO THE BRAIN

Jorg Kreuter

Institut fur Pharmazeutische Technologie, J.W. Goethe-Universitat,

Frankfurt/Main, Germany

Nanoparticles are polymeric particles in the nanometer size range used as drugcarriers. Poly(butyl cyanoacrylate) nanoparticles coated with polysorbate 80 enabledthe transport of a number of drugs including peptides and cytostatics after i.v. injectionacross the blood–brain barrier and enabled these drugs to exhibit a significantpharmacological effect. The mechanism appears to be adsorption of apolipoprotein Eand/or B from the blood stream to the polysorbate-coated nanoparticles. Thus theseparticles mimic lipoprotein particles and seem to be taken up by the brain endothelialcells via receptor-mediated endocytosis. After binding of doxorubicin to theseparticles and i.v. injection at a dose level of 5 mg/kg, doxorubicin brain concentrationsof 6 mg/g were obtained, whereas the concentrations in all controls, includingdoxorubicin solution with or without polysorbate 80 or uncoated doxorubicin-loadednanoparticles were below the detection level of 0.1 mg/g. The heart concentrationswere drastically decreased with both nanoparticle preparations. Up to 40% of rats withintracranially transplanted glioblastoma 101/8 survived for half a year after injectionof the polysorbate-coated nanoparticles and were then sacrificed and showed totalremission of the tumor. Glioblastoma 101/8 belongs to the most aggressiveexperimental brain tumors. Untreated controls died within 13–18 days. Some of theother preparations increased survival somewhat but were statistically inferior tothe polysorbate-coated doxorubicin nanoparticles. The toxicity of the abovementioned four preparations, doxorubicin solution with or without polysorbate 80or uncoated or polysorbate 80-coated doxorubicin-loaded nanoparticles, was similar.Gastro-intestinal effects even were much less pronounced with the nanoparticles.These results were confirmed by histology. The nanoparticles, therefore, hold promisefor the treatment of brain tumors.

TUMOR VACCINATION FOR GLIOBLASTOMA: LABORATORY DATA

AND REPORT ON PRELIMINARY CLINICAL EXPERIENCE IN LEUVEN

Steven De Vleeschouwer,1 Yuzhi Zheng,1 Frank Van Calenbergh,1

Jan L. Ceuppens,1 Stefan Rutkowski,2 Johannes Wolff,3

and Stefaan W. Van Gool1

1Catholic University of Leuven, Germany2University of Wurzburg, Germany3University of Regensburg, GermanyIn spite of advanced oncological treatments, the prognosis of patients withglioblastoma multiforme (GBM) remains dismal. In this project, stimulation of theimmune system against GBM cells is studied in vitro with human cells and as a phaseI/II clinical trial. T cells from donors or patients were stimulated twice in vitro withisolated autologous dendritic cells (DC), which were loaded with tumor proteins.T cells responded by production of cytokines and proliferation. Moreover, in a newco-culture with GBM cells, reduced viability of GBM cells was observed during MTTassay. In a Cr51 release assay, cytotoxicity of activated T cells was found. Based onour observations that DC loaded with tumor lysates induce T cell responses, and basedon published data in animal models, a ‘‘Heilversuch’’ trial was set up. At time ofwriting, we enrolled four patients, of whom one patient received the 6th vaccination, asecond patient received the 3rd vaccination, and two patients are starting immunetherapy. Clinical data on the first 2 patients are described by Rutkowski et al., and willbe presented at the meeting. The concept of a phase I/II tumor vaccination trialHGG-IMMUNO-2003 will also be discussed.

DENDRITIC CELL-BASED IMMUNOTHERAPY IN PATIENTS WITH

MALIGNANT GLIOMA: RESULTS OF A PILOT-STUDY

S. Rutkowski,1 S. De Vleeschouwer,5 E. Kaempgen,2 P. Keikavoussi,2 K. Otto,2

A. Opitz,3 J.E. Wolff,4 J. Kuehl,1 and S.W. van Gool5

1Department of Pediatrics, University of Wuerzburg, Germany2Department of Dermatology, University of Wuerzburg, Germany3Department of Transfusion Medicine, University of Wuerzburg, Germany4Department of Pediatric Oncology, St. Hedwig, Regensburg, Germany5Department of Pediatric Oncology, Laboratory of Experimental

Immunology, University of Leuven, Belgium

Objectives. Prognosis of patients with malignant glioma remains poor aftermultimodal standard treatment. Animal models and human trials have shown thatdendritic cell-based immunotherapy can elicit antitumoral immune responses. Inthis pilot-study, toxicity and the in vivo generated immune response of dendriticcell-mediated immunotherapy has been investigated in five patients with relapsedmalignant glioma.Methods. In 3 children and 2 adults with relapsed malignant glioma (3 glioblastoma, 1anaplastic astrocytoma, 1 rapidly recurring pleomorphic xanthoastrocytoma), tumorswere at least subtotally resected except of one patient with partial resection. Dendriticcells were generated from PBMC of patients and loaded with inactivated autologoustumor-homogenate ex vivo. Vaccinations were administered intradermally at week 1,3, 7, 11, and continued every 4 weeks, if applicable. Tumor size was assessed by MRI-scan before each vaccination. T cell activation is analyzed in serial PBMC-samples ofthree patients.Resulsts. Vaccinations were well-tolerated except of one patient with partial resection,who suffered intermittently an increased peritumoral edema after vaccinations 2–5.Three patients remain in remission 9, 6, and 3 months after surgery. The patient withpartial resection had stable disease for 2 months before progression. In one patienttumor relapse was observed after 3 months.Immunomonitoring of T cell activation and cytotoxicity assays against gliomacell-lines are under way.Conclusion. This pilot-study indicates the feasibility and safety of dendriticcell-mediated immunotherapy in patients with malignant glioma and represents apotential immunotherapeutic approach. Further recruitment of patients is under way.

INTRAVENTRICULAR THERAPY WITH ETOPOSIDE (VP16)

IN RELAPSED METASTATIC BRAIN TUMORS IN CHILDREN

AND ADOLESCENTS

G. Fleischhack, C. Hasan, A. Simon, M. Zimmermann, and U. Bode

Department of Pediatric Hematology/Oncology,

University of Bonn, Germany

As the systemic administration of VP16 is efficious in relapsed metastatic braintumors in childhood, a pilot trial was designed to study the feasibility ofintraventricularly administered VP16 in these patients.Between February 1998 and April 2002, 35 patients aged 1.9–33.2 years mostlywith relapsed metastatic medulloblastoma/PNET’s (n¼ 28) were treated withintraventricular VP16 simultaneously to oral or intravenous both conventional andhigh dose chemotherapy with trofosfamide or carboplatin and VP16. VP16 wasadministered via an indwelling subcutaneous reservoir daily for 5–10 consecutivedays every 2–5 weeks over a period of 0.5–19 months in doses of 0.25 mg (5 patients,16 courses), of 0.5 mg (28 patients, 120 courses), and of 1.0 mg (8 patients, 46courses). The tumor response was documented clinically, by CSF cytology and MRI.The efficacy of the intrathecal therapy alone could not be assessed because all patientsreceived one kind of systemic chemotherapy concurrently. Clinically nine patientsshowed improvement of neurological symptoms. CSF cytology were evaluable only in16 patients. Six patients being initially positive for tumor cells cleared their CSFfollowing 1–5 courses of intraventricular VP16. Six other patients developed CSFdissemination under the continuation of systemic and intraventricular chemotherapy.Nonhematological side effects were observed in form of mild transient headache andinfectious complications as meningitis in four patients each. In two patients a CSFpleocytosis without any infection was observed. Two other patient with meningeosisshowed a reversible coma following intraventricular VP16 application andsimultaneously administered systemic chemotherapy.These preliminary data suggest that the repeated intraventricular VP16 application iswell tolerated. It seems to have cytotoxic efficacy in metastatic medulloblastoma andshould be tested in phase II trials of these brain tumors and neoplastic meningeosis.

PHASE I/II STUDY OF ORAL TOPOTECAN IN HIGH GRADE GLIOMAS

Sabine Wagner,1 Alfred Langler,2 Uwe Kordes,3 Norbert Jorch,4

Astrid Gnekow,5 and Johannes Wolff1

1Department of Pediatric Oncology, Regensburg, Germany2Department of Pediatric Oncology, Herdecke, Germany3Department of Pediatric Oncology, Hamburg, Germany4Department of Pediatric Oncology, Bielefeld, Germany5Department of Pediatric Oncology, Augsburg, Germany

Background. The aim of this study was to determine the maximal tolerated dose andthe toxicity of oral topotecan. Children with recurrent or progressive high gradegliomas pretreated belong to the HIT-GBM-C protocol were enrolled in this study.Methods. Oral Topotecan was given once a day as a maintenance therapy starting with0.4 mg/m2/day. Individual increase of 0.2 mg/m2/day per week was done up to anindividual maximal dose. Treatment was discontinued in case of tumor progression orafter 1 year.Results. Twelve boys and 15 girls were enrolled in this study (age 3.3–18.6 years,median: 10.15 years). The individual maximal dose was as median 0.97 mg/m2/day(range:0.5–2.0, n¼ 21). Evaluation of toxicity could be done in 14 patients(NCI-CTC); anemia: III8 n¼ 4, IV8 n¼ 1, leucopenia: III8 n¼ 5, IV8 n¼ 1,thrombopenia: III8 n¼ 6, IV8 n¼ 0, infection: III8 n¼ 2, IV8 n¼ 0, nausea andvomiting: III8 n¼ 1, IV8, diarrhea: I8 n¼ 3, II8/III8IV8 n¼ 0. Fever was only observedI8 n¼ 3 and stomatitis I8/II8 n¼ 1. There was no death caused by toxicity.Conclusion. Topotecan given orally was well tolerable in children with a dose of1 mg/m2/day. Diarrhea was not dose limiting in this study. The major toxicity wasmyelosupression.

DIAGNOSTIC DEVELOPMENTS IN PEDIATRIC

INFRATENTORIAL TUMORS

Monika Warmuth-Metz

Department of Neuroradiology, University of Wurzburg, GermanyPreoperative differential diagnosis between pilocytic astrocytomas,medulloblastomas, and ependymomas around the fourth ventricle is possible on thebasis of tumor site, internal structure, contrast and growth behavior, and CT density.In the HIT’91-trial, 86.8% of 83 medulloblastomas arose from the vermis, while only23.1% of 13 ependymomas were originating there. Eighty seven percent ofependymomas were markedly inhomogeneous on T2 while only 18.9% ofmedulloblastomas showed marked and 47.3% were moderate inhomogeneity. Allependymomas enhanced with contrast medium while 5% of medulloblastomas did notenhance at all and 38.5% enhanced in less than 50% of tumor volume. Ependymomas(23.1%) had left the posterior fossa and only 2.4% of medulloblastomas. Seventeenpercent of medulloblastomas had disseminated via the CSF at the time of diagnosiswhile this was the case in not a single ependymoma. Pilocytic astrocytomas have a lowcellularity and, therefore, CT density is mostly hypodens, rarely isodens. Only one outof 44 medulloblastomas and 1 out 5 ependymomas, both nearly completely cystic,were hypodens on CT.If staging MRI of the spinal canal is performed after an operation of the posteriorfossa, one has to be aware of non-specific contrast enhancement in the pachymeningesin the spinal canal. This phenomenon could be mistaken for leptomeningialdissemination. We found an incidence of 15.5% up to 25 days after surgery.Pontine gliomas with diffuse growth are usually malignant gliomas. Results of biopsy donot correlate to prognosis. In nine children, we performed 18 Proton-MR-Spectroscopicexperiments and found a significant correlation of survival time to the ratio ofcholine/creatine (P< 0.05).Chemotherapy may induce leukencephalopathy. Grading of signal changes onT2-weighted MRI in 36 children less than 3-years-old after intense chemo- and/orradiotherapy resulted in no or minimal changes in 56%. Only 30% showed moderateand 14% widespread lesion. The grade of lesions correlated strongly (P< 0.01) to theamount of intraventicular MTX and did not correlate to the results of psychologicaltesting.

INTERIM ANALYSIS OF THE HIT-REZ-97 STUDY: A STUDY FOR

TREATMENT OF RELAPSED PRIMITIVE NEUROECTODERMAL

BRAIN TUMORS IN CHILDHOOD AND ADOLESCENTS

G. Fleischhack,1 M. Zimmermann,1 C. Hasan,1 J. Kuehl,2 and U. Bode1

1Department of Pediatric Hematology/Oncology, University of Bonn,

Bonn, Germany2Department of Pediatric Hematology/Oncology, University of Wurzburg,

Wurzburg, Germany

In 1997, a phase III trial in children and adolescents with relapsed primitiveneuroectodermal brain tumors (PNET’s), the HIT-REZ-97 study, was initiated. In thisprotocol, three treatment arms were designed assuming that not all patients are able toget again an intensive therapy: a curative, a palliative, and a documentation arm. In thecurative arm, the recommendation was to apply high dose chemotherapy (HDCT,thiotepa 600 mg/m2, carboplatin 2,000 mg/m2, VP16 1,000 mg/m2) with autologousstem cell support in CR or PR following a conventional chemotherapy withcontinuous infusion of carboplatin and VP16 (800 and 400 mg/m2 over 96 hr, three tofour courses) and to explore the opportunities of local therapy. In the palliative arm, anoral chemotherapy with VP16 and trofosfamide (daily 25 and 100 mg/m2 for 21 days,every 4 weeks) should be administered until progression. Patients who could not betreated with any chemotherapy according to the first two arms or who got otherpalliative treatment should be documented in the third arm. Since 1997, 123 patientsentered the study (medulloblastomas/PNET’s: 76%, median age: 11.5 years). Seventynine patients (59% of them for their first relapse) were treated according to thecurative arm. Twenty seven of them got in CR/PR HDCT. In one third of patients,local therapy (tumor resection and/or a focussed radiotherapy) was applied. Twentytwo patients were treated orally with VP16/trofosfamide and 56 patients entered thedocumentation arm for their first or further relapse. Following the conventionaltherapy with carboplatin/VP16 54% of patients were in CR/PR. Four to eight weeksfollowing HDCT 92% of patients were in CR/PR. Unfortunately, the long-termfollow-up of these patients is disappointing. Only 22% of patients are free ofprogression at a median follow-up time of 11 months. In the palliative arm, patientsgot a median of seven courses of VP16/trofosfamide and were alive progression-freefor a median of 5 months. The main toxicity of the curative arm was severemyelosuppression associated with febrile episodes in about 50% of courses. Followingthe HDCT main non-hematological toxicities were infections, severe mucositis, andototoxicity. The toxicity of the oral chemotherapy was mild. Considering the shorttime of follow-up these interim results are preliminary. Further recruitment of patientsis necessary to explore the feasibility and efficacy of the different study arms.

MELATONIN SECRETION AND INCREASED DAYTIME SLEEPINESS IN

CHILDHOOD CRANIOPHARYNGIOMA PATIENTS

H.L. Muller,1 G. Handwerker,2 N. Etavard-Gorries,1 U. Gebhardt,1

R. Kolb,1 and N. Sorensen3

1Department of Pediatrics, Klinikum Oldenburg, University Hospital,

Wurzburg, Germany2Kinderklinik Dritter Orden, Passau, University Hospital,

Wurzburg, Germany3Pediatric Neurosurgery, University Hospital, Wurzburg, Germany

Background. Craniopharyngioma is a rare dysontogenetic malformation. Although, itis a benign tumor and resection is often complete, patients frequently suffer fromsequel such as endocrine deficiencies and severe obesity due to pituitary andhypothalamic lesions. Weight reduction by increased physical activity is often limiteddue to daytime sleepiness.Methods. A standardized questionnaire for self-assessment of daytime sleepiness(German version of the Epworth Sleepiness Scale [ESS]) was evaluated in 123patients with childhood craniopharyngioma. Since hypothalamic lesions may explaindaytime sleepiness in craniopharyngioma patients, we examined the salivarymelatonin and cortisol concentrations (0800, 1300, 1800, 0200) in 30 severely obese(BMI> 4 SD) craniopharyngioma patients, 49 non-severely obese (BMI< 4 SD)craniopharyngioma patients, 19 patients with other hypothalamic tumors (pilocyticastrocytoma), 15 normal weight control subjects, and 13 obese control subjects.Results. Thirty-eight of 123 patients with childhood craniopharyngioma had increaseddaytime sleepiness, defined as an ESS score>10. Craniopharyngioma patients with anESS score>10 had lower (P< 0.05) salivary melatonin concentrations in the morningand at night than craniopharyngioma patients with an ESS score � 10. In 30 severelyobese patients with craniopharyngioma nocturnal melatonin secretion was signifi-cantly reduced in comparison to non-severely obese patients and obese controls.Severely obese patients with hypothalamic astrocytoma had melatonin secretionpatterns similar to severely obese craniopharyngioma patients. Differences in salivarycortisol concentrations were not related to impaired melatonin secretion in patientswith childhood craniopharyngioma.Conclusions. We speculate that hypothalamic lesions might be responsible for bothobesity and daytime sleepiness in these patients. Hypersomnia seems to be a commoncondition, which has not been recognized yet in patients with childhoodcraniopharyngioma. Further studies are part of the prospective multicenter study onpatients with childhood craniopharyngioma KRANIOPHARYNGEOM 2000(www.kraniopharyngeom. com)

QUALITY OF LIFE (QOL) IN LONG-TERM SURVIVORS OF

CHILDHOOD CRANIOPHARYNGIOMA—GERMAN MULTICENTER STUDY

ON THE EFFECTS OF THERAPEUTIC STRATEGIES

AND THE DEGREE OF SURGICAL RESECTION ON QOL

H.L. Muller,1 K. Bueb,2 G. Calaminus,3 C. Teske,3 N. Etavard-Gorries,1

U. Gebhardt,1 R. Kolb,1 N. Sorensen4

1Department of Pediatric Hematology and Oncology, Oldenburg, Germany2Department of Pediatric Hematology and Oncology, Wurzburg, Germany3Department of Pediatric Hematology and Oncology, Dusseldorf, Germany

Background. Therapeutic strategies in childhood craniopharyngioma are controver-sial. The intention to achieve a complete resection might be associated with adversesequel and reduced quality of life (QoL) in long-term survivors. Obesity has a majorimpact on QoL in those patients [Muller HL et al.: Klin Paediatr 213:244–249, 2001].Patients and Methods. We retrospectively analyzed 205 children withcraniopharyngioma. The records of 186 patients (91%) could be evaluated for initialtherapeutic strategies and the degree of surgical resection. Quality of life wasmeasured by FMH-score (n¼ 129) and PEDQOL questionnaire (n¼ 64).Results. One hundred twenty eight patients were treated with the intention of radicalsurgery, 58 patients received a biopsy/partial resection followed by irradiation. Therewas no significant correlation between initial therapeutic strategy and FMH-score.Patients who were treated with the intention of radical surgery had a higherself-estimation in the PEDQOL domains for body image. In patients with completelyremoved craniopharyngioma QoL was self-estimated similar as in patients withincomplete resection for the PEDQOL domains physical, emotional function,cognition, and autonomy. Only in terms of social function patients with completeresection had a higher self-estimation of QoL. The development of severe obesity wasnot correlated with a certain therapeutic strategy or the achievement of completeresections. However, the self-estimation of QoL significantly (P< 0.01) correlatedwith the degree of obesity as measured by body mass index.Conclusions. QoL in patients with childhood craniopharyngioma does not seem tocorrelate with the intended or realized degree of surgical resection. Severe obesity isassociated with a lower self-estimation of QoL but not with a certain therapeuticstrategy. To confirm the results of our retrospective cross-sectional study a prospectivemulticenter surveillance study (Kraniopharyngeom, 2000) was initiated(www.kraniopharyngeom.com).

A COMPARATIVE STUDY TO DETERMINE BODY

COMPOSITION BY MEANS OF BIOELECTRICAL

IMPEDANCE (BI) AND ANTHROPOMETRY IN PATIENTS

WITH CRANIOPHARYNGIOMA AND HEALTHY

CHILDREN AND ADOLESCENTS

C. Zinn,1 P. Schneider,2 N. Etavard-Gorries,3 U. Gebhardt,3

R. Kolb,3 and HL. Muller3

1Department of Pediatrics, University of Wurzburg, Germany2Clinic for Nuclear Medicine, University of Wurzburg, Germany3Department of Pediatrics, Klinikum Oldenburg, Germany

Introduction. In follow-up examinations of obese patients, reliable and feasibleprocedures are of great importance to determine body composition. Anthropometryand BI-measurement are suitable methods for this purpose. In this study, patients withcraniopharyngioma as well as healthy children and adolescents were assessedaccordingly.Methods. In 344 healthy children and 26 patients with childhood craniopharyngioma;BI, body mass index (BMI), and skinfold-thickness was measured. The fat free mass(FFM) and body-fat percentage were calculated using standard-regression-equations.Dual-X-Ray-Absorptiometry (DXA) was used as reference method for patients withchildhood craniopharyngioma.Results. For craniopharyngioma patients, resistance index (RI), BMI, and the sumof four skinfolds showed equally high correlations with calculated FFM orbody-fat-content measured by DXA. The closest estimation of fat mass was achievedwith the subscapular skinfold. Published standard equations seemed to be applicableto the cohort of healthy children only. A new, valid equation for the calculation ofFFM using BI, height, weight, and age was established for patients with childhoodcraniopharyngioma. Standard values regarding BI, BMI, and skinfold thickness wereevaluated from the data of 344 healthy children and adolescents.Conclusions. Using a new prediction equation, the BI presents an easy and practicablemethod to assess body composition in patients with childhood craniopharyngioma.The analysis of body composition by BI measurement is part of the prospectivemulticenter study on children and adolescents with craniopharyngioma.

ECHOCARDIOGRAPHIC PARAMETERS AFTER

CHILDHOOD CRANIOPHARYNGIOMA

I. Milsch,1,2,3 N. Etavard-Gorries,1,2,3 U. Gebhardt,1,2,3 R. Kolb,1,2,3

N. Sorensen,1,2,3 and H.L. Muller1,2,3

1Department of Pediatrics, University of Wurzburg, Wurzburg, Germany2Department of Pediatric Neurosugery, University of Wurzburg, Wurzburg, Germany3Department of Pediatric Hematology and Oncology, Zentrum fur Kinder- und

Jugendmedizin, Klinikum Oldenburg, Germany

Introduction. The cardiac function can be influenced by obesity and hypopituitarism.We analyzed echocardiographic parameters in 26 patients with childhoodcraniopharyngioma. The median follow-up time was 7.2 years.Methods. After having measured the blood pressure (Riva-Rocchi) the systolicfunction and the diameters and the mass of the left ventricle were assessed byechocardiography. The parameters obtained were related to body surface area (m2).Results. Patients (n¼14) who developed severe obesity (BMI> 4SD) were comparedwith patients (n¼ 12) without severe obesity (BMI< 4SD). Significant differences interms of the systolic function of the left ventricle and of the mass of the left ventriclewere not detectable between both groups. However, significant differences were seenfor the diameters of the left ventricle. In the group of severely obese patients, theinterventricular septum and the posterior wall of the left ventricle were thickerwhen compared with non-severely obese patients (BMI< 4SD, P< 0.05). Sixcraniopharyngioma patients with severe obesity (BMI> 4SD) showed a pathologicalthickening of the posterior wall of the left ventricle and three patients of the samegroup a pathological thickening of the interventricular septum. Arterial blood pressurewas normal in all patients.Conclusion. Whether these findings indicate that obese patients with childhoodcraniopharyngioma might develop cardiomyopathy will be tested prospectively.Furthermore, the influence of hormonal substitution will be evaluated. A multicenterprospective surveillance study KRANIOPHARYNGEOM 2000 was initiated.(www.kraniopharyngeom.com)

REDUCED BONE MINERAL DENSITY IN LEAN MALE PATIENTS

WITH CHILDHOOD CRANIOPHARYNGIOMA—RESULTS

OF A GERMAN MULTICENTER STUDY

H.L. Muller,1 K. Bueb,2 N. Sorensen,3 N. Etavard-Gorries,1 U. Gebhardt,1

R. Kolb,1 and P. Schneider4

As the overall survival is high in patients with craniopharyngioma, the prognosis andquality of life (QoL) in survivors depend mainly on late effects. Late effects such ashypogonadism, growth hormone deficiency, and obesity have a strong impact on bonemineral density (BMD). We analyzed BMD and possible risk factors for reducedBMD in 61 children and adolescents with craniopharyngioma (29f; 32m) treated atmajor German centers and in 14 weight-, age-, and sex-matched normal controls.BMD was quantified by peripheral quantitative computed tomography (pQCT).Endocrine status, hormonal substitution therapy, and calcium phosphate metabolismwere evaluated. QoL was analyzed using the self-rating questionnaireFertigkeitenskala Munster-Heidelberg (FMH).BMD was in the lower normal range in 61 craniopharyngioma patients (total radialz-scores: median �1.5; range: �3.1 to 1.4; spongiosal z-scores: median �0.4;range:�2.4 to 2.3). Twenty-three severely obese patients (body mass index[BMI] > 4SD) had a higher radial (P< 0.05) and spongiosal (P< 0.05) BMD whencompared with 38 non-severely obese patients and 7 weight-matched normal controls.Although there was no gender difference in terms of obesity, endocrine substitutiontherapy, or calcium phosphate metabolism, male patients had lower radial (P< 0.01)and spongiosal (P< 0.05) BMD. Only in male patients, BMD z-scores showed apositive correlation with BMI SDS (total radial z-score: Spearman r¼ 0.38, P¼ 0.03;spongiosal z-score: Spearman r¼ 0.35, P¼ 0.04). QoL as self-estimated byFMH-questionnaire did not correlate with BMD or gender. However, FMH-centileswere significantly lower (P< 0.001) in severely obese patients with craniopharyngioma.We conclude that obesity has a major impact on BMD and QoL in patients withcraniopharyngioma. Lean male patients are at special risk for a lower BMD, whereasfemale gender and severe obesity seem to have a protective effect regarding BMD.The prospective German multicenter study Kraniopharyngeom 2000 on children andadolescents with craniopharyngioma was initiated (www.kraniopharyngeom.com) toconfirm the results of our cross-sectional study.

EPILOGUE

Johannes Wolff, MD*

Neurooncologymoves on. In the basic sciencemeeting,a reporter gene model and the influence of SMAC onchemosensitivity were presented and discussed. Thesepromising approaches will require further basic workincluding animal data. The meeting was dominated bynovel methods to overcome the blood brain barrier.Nanoparticles have become available to carry drugs acrossthe intact blood brain barrier, and pentylglycerols to openit. Both methods have moved from cell culture to animalexperiments and should soon go on to application inhumans. This step has already been taken for dendritic cellvaccination, work that was presented in both meetings. Inthis approach, crude tumor extracts load dendritic cells,that are subsequently injected intradermally. Basic ex-periments showed preliminary evidence for cross im-munoreactivity. T-cells exposed to one tumor cell linesubsequently were reactive not only to the sensitizing cellbut also to another cell line. Evidence for multiple injec-tionswas presented aswell. In the clinicalmeeting, experi-ence of the first patients was presented. It gave evidencefor immunoreactivity in vivo; however, it is too early tojudge antitumor results. The guest of honor in this meetingwas Dr. David Ashley (Melburne), who also presentedAustralian data on death pathways and on dendritic cell

vaccination. As a consequence of the meeting, theAustralian and the German groups are considering furtherscientific exchange or even common clinical studies. Themedulloblastoma trial lead by Joachim Kuhl explores atpresent the efficacy of hyperfractionated irradiation in arandomized trial. The low-grade glioma group and theGerm cell group will join efforts with other Europeancountries. In low-gradegliomas, ahigh-riskgrouphasbeendefined and will receive more intense front line chemo-therapy. In germinomas, craniospinal irradiation will besubstituted by focal irradiation combinedwith chemother-apy. The high-grade glioma group plans a randomized trialasking if high dose methotrexate prior to simultaneousradiochemotherapy will increase survival. Diagnosticimaging surprised with new emphasis on CT-scanning,which can add information to the MRI about the cellulardensity of tumors. In the future, MRI spectroscopy will bestudied in brain stem glioma. The radiation oncologistshavebuiltanetworkofqualitycontrol formedulloblastomairradiation. Building on this success and improving radio-therapy for other entities will be the next challenge.Posterprizes were given to Rutkowski (Wurzburg) andProsch (Vienna) for their excellent work on dendritic cellvaccination and CNS histocytosis, respectively.

Studienleiter, HIT-GBM-Studienzentrale, Krankenhaus Barmherzige

Bruder, Klinik St. Hedwig Steinmetzstr. 1–3, D-93049 Regensburg,

Germany

*Correspondence to: Dr. Johannes Wolff, Studienkoordinatorin, HIT-

GRB-Studienzentrale, Krankenhaus Barmherzige Bruder, Klinik St.

Hedwig Steinmetzstr. 1–3, D-93049 Regensburg, Germany.

E-mail: KZVAHITGBM@aol.com

Received 6 November 2002Accepted 12 November 2002

� 2003 Wiley-Liss, Inc.DOI 10.1002/mpo.10361