Pediatric Brain Tumor
Conditions
Keywords
Aminolevulinic Acid (ALA), Gleolan®, Fluorescence-Guided Resection, Brain Tumor, Pediatric
Brief summary
This clinical trial focuses on pediatric patients aged 2 up to 18 years of age with a new or recurrent pediatric brain tumor, suspected to be either a high-grade or low-grade glioma, and scheduled for surgical removal. 5-aminolevulinic acid (5-ALA) is FDA-approved for improving brain tumor visualization in adults during surgery through fluorescence, enabling more complete removal of the tumor. This study aims to evaluate the feasibility of administering 5-ALA to pediatric brain tumor patients and to assess the quality of tumor fluorescence during surgery in this patient population. For the clinical trial, the patient will orally ingest 5-ALA 6 to 12 hours before brain surgery. All study participants will be provided standard medical care for removal of the brain tumor. All children enrolled in the study will be closely monitored prior to, during, and after surgery to ensure there are no reactions to the study drug. 5-ALA can make the patient more sensitive to sunlight and direct indoor lighting, referred to as photosensitivity, and can cause a sunburn-type reaction. It is for this reason that patients will be kept in subdued light conditions for 48 hours following surgery. Study participation starts once the patient is enrolled in the study until 6-month post-surgery.
Detailed description
The aim of this study is to assess the feasibility of administering 5-ALA pre-operatively and to access if the resulting 5-ALA-induced tumor fluorescence is adequate for fluorescence-guided brain tumor resection in pediatric patients. In this single-arm, multicenter study, the guardians of the pediatric patient with a newly diagnosed or select recurrent brain tumors will provide consent for the administration of 5-ALA. In relevant cases, assent from the pediatric patients will also be obtained. A total of twenty pediatric brain tumor patients will be treated to evaluate the feasibility of using 5-ALA in this population. All enrolled patients will receive an oral solution of 5-ALA at a dose of 20mg/kg body weight 6-12 hours prior to surgery, followed by tumor resection using either the institutional standard of care or the surgeon's preferred technique. Resection of fluorescent and non-fluorescent areas will proceed at the surgeon's discretion and the surgeon will indicate the fluorescence of each section. The fluorescence will be characterized as 'none', 'weak,' 'moderate,' or 'strong'; and described as 'patchy' or 'uniform'. When positive fluorescence is present, fluorescence-guided surgery will be performed under white light visualization with the ability to select for the use of appropriate filters adapted to the surgical microscope to allow specific wavelength of blue light to excite the tumor tissue during the operative procedure. Tissue fluorescence will be recorded by intraoperative photography. Biopsies, routinely performed during surgical tumor resection, will be obtained. An additional three to six research tissue specimens will be collected per patient for histopathologic analysis. If fluorescence is present in the tumor, three fluorescent specimens will be obtained from the tumor-core, tumor-margin, and regions just distant to the tumor margins as well as three non-fluorescent tissue specimens will be obtained adjacent to the resection cavity. If no fluorescence is visualized, this will be documented, and only three samples of non-fluorescent tissue specimens will be obtained from the tumor-core, tumor-margin, and regions just distant to the tumor margins. Histopathologic analysis on all collected fluorescent and non-fluorescent tissue specimens will be performed by a neuropathologist who will not be informed of the fluorescence status of the tissue specimens. The neuropathologist will characterize the biopsies and the additional three to six research tissue specimens by WHO grade, tumor type, and the number of tumor cells present. If institutions perform routine genetic and molecular analysis on resected tissue, this data will also be collected. 5-ALA makes a person more sensitive to sunlight and direct indoor lighting, referred to as photosensitivity, and can cause a sunburn-type reaction. Skin photosensitization lasts from approximately 24 to 48 hours following 5-ALA administration. It is for this reason that patients will be kept in low light conditions for 48 hours following surgery. Patients will undergo standard of care clinical assessments, including physical exams, neurological assessments (Karnofsky Performance Scale and the Lansky Scale), and laboratory evaluations, at several time points: upon entry into the trial (before surgery), within 48 hours after surgery, 2-weeks post-surgery, 6-weeks post-surgery, 3-months post-surgery, and 6-months post-surgery. MRIs will be conducted as part of standard care before surgery, within 48 hours of surgery, and at 3-months post-surgery, and 6-months post-surgery. All patients enrolled on the study will be monitored according to the protocol for 6-months post-surgery.
Interventions
Pediatric patients diagnosed with a new or recurrent brain tumor, suspected to be either a high-grade or low-grade glioma, and scheduled for surgical removal will receive aminolevulinic acid hydrochloride prior to surgery for resection of the brain tumor.
Sponsors
Costas Hadjipanayis
NX Development Corp
Southeastern Brain Tumor Foundation
StacheStrong Foundation
Neuroscience Research Foundation
University of Pittsburgh Medical Center
Advocate Hospital System
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
DIAGNOSTIC
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
2 Years to 17 Years
Healthy volunteers
No
Inclusion criteria
1. Subjects included in this trial must have had an MRI documentation of "a new or recurrent primary pediatric brain tumor" for which resection is indicated and has been planned. 2. The anticipated histology at resection will be "newly diagnosed" or "recurrent": pilocytic astrocytoma, pleomorphic xanthoastrocytoma (PXA), ganglioglioma, diffuse neuroepithelial tumor (DNET), astrocytoma, oligodendroglioma, ependymoma, anaplastic astrocytoma, anaplastic oligodendroglioma, anaplastic ependymoma, anaplastic ganglioglioma, anaplastic PXA, PNET, ATRT, or medulloblastoma. 3. Male or Female Age 2-17 years and 182 days 4. Subjects must have normal organ and marrow function as defined below: Leukocytes \>3,000/mL Platelets \>100,000/mL Total bilirubin Below upper limit of normal (ULN) AST (SGOT)/ALT (SGPT)/ GGT \<2.5 X institutional age-specific ULN Creatinine Below ULN OR Creatinine Clearance \>60 mL/min/1.73 m2 for patients with creatinine levels above institutional age-specific normal as defined per institution. 5. The effects of 5-ALA on the developing human fetus are unknown. A pregnancy test will be performed for all young women of childbearing ability prior to surgery (see
Exclusion criteria
below). Should a young woman become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately. 6. Ability for patient/patient's guardian to understand and the willingness to sign a written informed consent document. In appropriate cases, assent of pediatric patients will be obtained. Translation will be provided as appropriate. 7. Inclusion of Women and Minorities: Both males and females and members of all ethnic groups are eligible for this trial.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Overall frequency/rate of positive fluorescence in all patients that receive 5-ALA | Day of Surgery | Overall frequency/rate of positive fluorescence, which is defined as patients with at least one tissue sample with positive fluorescence (score of at least weak and patchy) after using 5-ALA, in all patients administrated 5-ALA with a suspected primary or recurrent brain tumor that is considered to be a low grade (WHO grade I/II) or high grade (WHO grade III/IV) glioma. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Frequency/rate of positive fluorescence within each tumor type | Day of Surgery | Presence or absence of fluorescence in each tumor type. |
| Fluorescence quality in all patients receiving 5-ALA and within each tumor type | Day of Surgery | Fluorescence will be categorized as 'none,' 'weak,' 'moderate,' or 'strong,' and described as 'patchy' or 'uniform.' If fluorescence is present, surgery will be guided by white light with appropriate filters to excite the tumor tissue. Intraoperative photos will capture tissue fluorescence. Biopsies will be taken, including 3-6 additional research specimens per patient for histopathologic analysis. If fluorescence is present, three fluorescent samples will be collected from the tumor core, margin, and areas near the margin, along with three non-fluorescent samples from the resection cavity. If no fluorescence is seen, only non-fluorescent samples from the tumor core, margin, and surrounding areas will be collected. All samples will undergo histopathological examination by a neuropathologist for WHO grade, tumor type, and cell count. Genetic and molecular analysis data will be collected if available. |
| Accrual rate for each tumor type | Day of Surgery | Histopathology assessment will characterize the standard of care biopsies by WHO grade and tumor type. If institutions perform routine genetic and molecular analysis of resected tissue, this data will also be collected. |
| Determination of the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of tumor fluorescence. | Day of Surgery | Sensitivity of 5-ALA induced fluorescence is calculated as proportion of all tumor (confirmed by histopathology analysis) specimens with positive fluorescence. Specificity is the proportion of all tumor (confirmed by histopathology analysis) specimens without the presence of fluorescence. Positive predictive value (PPV) is defined as proportion of tissues with 5-ALA induced fluorescence that were confirmed tumor on histopathology. Negative predictive value (NPV) is the proportion of tissues without fluorescence that were confirmed tumor by histopathology. In addition PPV will also be calculated with the proportion of tissues with no visible 5-ALA-induced fluorescence but with detectable levels of fluorescence through novel detection system that were confirmed malignant on pathology. |
| Frequency/rate of AE in all patients receiving ALA and for each tumor type | Day of Consent signing, day of surgery; within 48 hours of surgery; 2-weeks post-surgery, 6-weeks post-surgery, 3-months post-surgery, 6-months post-surgery | All adverse events will be collected from the time of drug administration until 6 months following surgery. In addition, serious adverse events (SAE) will be collected beginning from the time the consent/ assent is obtained. The descriptions and grading scales found in the revised NCI CTCAE version 5.0, which will be utilized for adverse event reporting are available online at http://ctep.cancer.gov/reporting/ctc.html. |
| 6-month progression free survival (PFS) | 6-months post-surgery | Standard of care, gadolinium-enhanced brain MRI will be obtained at 3- and 6-months after tumor resection to assess surgical field and progression. |
Countries
United States
Contacts
CONTACTKristy Boggs, PhD
STUDY_DIRECTORConstantinos G. Hadjipanayis, MD, PhD
University of Pittsburgh
PRINCIPAL_INVESTIGATORJohn Ruge, MD, FAANS
Midwest Children's Brain Tumor Center, Advocate Children's Hospital-Park Ridge
Outcome results
None listed