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Introduction: Primary pituitary lymphoma (PPL) is a rare disease characterized by lymphoma confined to the sella or parasellar region without systemic involvement. The clinical symptoms of PPL may include headache, hypopituitarism, visual field disturbance and visual impairment. To date, there is no established standard treatment for this condition. Here, we present a case of successful treatment with a Bruton’s tyrosine kinase (BTK) inhibitor. Case report: A 78-years-old man with a history of severe left renal insufficiency caused by retroperitoneal fibrosis, and sequential right nephrostomy, underwent brain magnetic resonance imaging (MRI) due to the altered hormonal status. An enlarged pituitary stalk was noted and led to a diagnosis of lymphocytic hypopituitarism. Six months later, visual field disturbance and visual acuity deterioration developed, and an MRI revealed a neoplastic lesion and further enlargement of the stalk and the pituitary itself, with an obvious optic nerve compression. Expedited transsphenoidal partial resection was performed to relieve the compression. Pathohystology led to the diagnosis of the large B-cell lymphoma of the germinal center origin. Because of the patient’s poor renal function, high-dose methotrexate therapy was not an option; rather, the patient was treated with a BTK inhibitor - tirabrutinib. Symptoms improved within a week, and a follow-up MRI confirmed a marked reduction of the pituitary lesion. Conclusion: BTK inhibitors may be considered as a first-line treatment option for PPL, especially in patients with contraindications for other treatment protocols.

INTELLANCE‐J was a phase 1/2 study of a potent antibody‐drug conjugate targeting epidermal growth factor receptor (EGFR), depatuxizumab mafodotin (Depatux‐M), as a second‐ or first‐line therapy, alone or combined with chemotherapy or chemoradiotherapy in 53 Japanese patients with World Health Organization (WHO) grade III/IV glioma. In second‐line arms, patients with EGFR‐amplified recurrent WHO grade III/IV glioma received Depatux‐M plus chemotherapy (temozolomide) or Depatux‐M alone regardless of EGFR status. In first‐line arms, patients with newly diagnosed WHO grade III/IV glioma received Depatux‐M plus chemoradiotherapy. The study was halted following lack of survival benefit with first‐line Depatux‐M in the global trial INTELLANCE‐1. The primary endpoint was 6‐month progression‐free survival (PFS) in patients with EGFR‐amplified tumors receiving second‐line Depatux‐M plus chemotherapy. Common nonocular treatment‐emergent adverse events (TEAEs) with both second‐line and first‐line Depatux‐M included lymphopenia (42%, 33%, respectively), thrombocytopenia (39%, 47%), alanine aminotransferase increase (29%, 47%), and aspartate aminotransferase increase (24%, 60%); incidence of grade ≥3 TEAEs was 66% and 53%, respectively. Ocular side effects (OSEs) occurred in 93% of patients receiving second‐line Depatux‐M plus chemotherapy and all patients receiving second‐line Depatux‐M alone or first‐line Depatux‐M plus chemoradiotherapy. Most OSEs were manageable with dose modifications and concomitant medications. The 6‐month PFS estimate was 25.6% (95% confidence interval [CI] 11.4‒42.6), and median PFS was 2.1 months (95% CI 1.9‒3.9) with second‐line Depatux‐M plus chemotherapy in the EGFR‐amplified subgroup. This study showed acceptable safety profile of Depatux‐M alone or plus chemotherapy/chemoradiotherapy in Japanese patients with WHO grade III/IV glioma. The study was registered at ClinicalTrials.gov (NCT02590263)., INTELLANCE‐J was a phase 1/2 study of a potent antibody‐drug conjugate targeting epidermal growth factor receptor (EGFR), depatuxizumab mafodotin, as a second‐ or first‐line therapy, alone or combined with chemotherapy or chemoradiotherapy in Japanese patients with World Health Organization grade III/IV glioma. The results of this trial demonstrate an acceptable safety profile of depatuxizumab mafodotin, with ocular side effects being the most common adverse events that were mostly reversible. Second‐line depatuxizumab mafodotin in combination with temozolomide resulted in a 6‐month progression‐free survival estimate of 25.6% (95% confidence interval 11.4‒42.6) in patients with EGFR‐amplified tumors and showed encouraging antitumor activity in this subgroup of patients (NCT02590263).

Background The goal was to determine whether the addition of temozolomide (TMZ) to the standard treatment of high-dose methotrexate (HD-MTX) and whole-brain radiotherapy (WBRT) for primary central nervous system lymphoma (PCNSL) improves survival. Methods An open-label, randomized, phase III trial was conducted in Japan, enrolling immunocompetent patients aged 20–70 years with histologically confirmed, newly diagnosed PCNSL. After administration of HD-MTX, patients were randomly assigned to receive WBRT (30 Gy) ± 10 Gy boost (arm A) or WBRT ± boost with concomitant and maintenance TMZ for 2 years (arm B). The primary endpoint was overall survival (OS). Results Between September 29, 2014 and October 15, 2018, 134 patients were enrolled, of whom 122 were randomly assigned and analyzed. At the planned interim analysis, 2-year OS was 86.8% (95% confidence interval [CI]: 72.5–94.0%) in arm A and 71.4% (56.0–82.2%) in arm B. The hazard ratio was 2.18 (95% CI: 0.95–4.98), with the predicted probability of showing the superiority of arm B at the final analysis estimated to be 1.3%. The study was terminated early due to futility. O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status was measured in 115 tumors, and it was neither prognostic nor predictive of TMZ response. Conclusions This study failed to demonstrate the benefit of concomitant and maintenance TMZ in newly diagnosed PCNSL.

BACKGROUND In the pathological classification of brain tumors, newly revised in 2021, molecular genetic analysis of gliomas has become more important for diagnosis and understanding of the pathogenesis of the disease. Gliomas are prone to recurrence and malignant progression, and collecting tumor tissue during every genetic analysis is highly invasive. Therefore, techniques have been developed to analyze tumor-derived circulating cell-free DNA (ccfDNA) in the cerebrospinal fluid as a substitute for tissue collection. However, the amount of ccfDNA derived from the cerebrospinal fluid is extremely small and the number of cases for whom genetic analysis is possible is currently limited. In this study, we attempted to establish an efficient method for the integrated analysis of glioma-related genes by in vitro amplification of cerebrospinal fluid-derived ccfDNA from glioma patients and a highly sensitive assay. METHODS Tumor-derived ccfDNA was extracted and purified from 1 ml of cerebrospinal fluid obtained by lumbar puncture using the Maxwell RSC instrument in five glioma cases. Hot spots of mutations in IDH1 and H3F3A genes were analyzed by high resolution melting (HRM), TERT mutation by droplet digital PCR, MGMT promoter methylation by methylation-specific HRM, and chromosome 1p/19q loss by multiplex ligation-dependent probe amplification. For samples in which the amount of ccfDNA was too small to analyze, DNA was amplified approximately 500-fold by DNA polymerase using the GenomiPhi kit and analyzed by the same assay method. RESULTS AND CONCLUSIONS Although two of the five cases required amplification with the GenomiPhi kit, it was possible to analyze all cases for glioma-related genes as described above. Although the amount of ccfDNA obtained from low-grade gliomas and gliomas that are not in contact with the ventricles or subarachnoid space is small, this amplification method may increase the possibility of liquid biopsy using cerebrospinal fluid.

BACKGROUND The revised fourth edition of the World Health Organization classification of central nervous system tumors was published in 2016. Based on this classification, one of the infiltrating glioma entities named “oligoastrocytoma/anaplastic oligoastrocytoma” is discouraged. It is proposed that these mixed gliomas should be classified as diffuse astrocytoma/anaplastic astrocytoma or oligodendroglioma/anaplastic oligodendroglioma when analyzing their genetic alteration. OBSERVATIONS A 78-year-old female underwent brain computed tomography (CT) because of a traffic accident. Cranial CT revealed a brain tumor in the left temporoparietal lobe; therefore, she was hospitalized. She underwent awake craniotomy. After the operation, she was treated with only local radiotherapy; the authors could not prescribe temozolomide, because she had had levetiracetam-induced pancytopenia. The remaining tumor neuroradiologically disappeared, and she was alive 40 months after the operation without tumor recurrence. LESSONS Histopathologically, this tumor was diagnosed as an anaplastic oligoastrocytoma with a distinct dual phenotype of astrocytoma and oligodendroglioma components. Genetically, these two components revealed astrocytoma and oligodendroglioma genotypes, respectively. Therefore, the authors considered the integrated diagnosis of the temporal tumor as a true anaplastic oligoastrocytoma with a dual genotype. Interestingly, this case also included an area composed of spindle to oval neoplastic cells that revealed intermediate genetic alterations between astrocytomas and oligodendrogliomas.

BackgroundThe safety, tolerability, efficacy, and pharmacokinetics of tirabrutinib, a second-generation, highly selective oral Bruton’s tyrosine kinase inhibitor, were evaluated for relapsed/refractory primary central nervous system lymphoma (PCNSL).MethodsPatients with relapsed/refractory PCNSL, Karnofsky performance status ≥70, and normal end-organ function received tirabrutinib 320 and 480 mg once daily (q.d.) in phase I to evaluate dose-limiting toxicity (DLT) within 28 days using a 3 + 3 dose escalation design and with 480 mg q.d. under fasted conditions in phase II.ResultsForty-four patients were enrolled; 20, 7, and 17 received tirabrutinib at 320, 480, and 480 mg under fasted conditions, respectively. No DLTs were observed, and the maximum tolerated dose was not reached at 480 mg. Common grade ≥3 adverse events (AEs) were neutropenia (9.1%), lymphopenia, leukopenia, and erythema multiforme (6.8% each). One patient with 480 mg q.d. had grade 5 AEs (pneumocystis jirovecii pneumonia and interstitial lung disease). Independent review committee assessed overall response rate (ORR) at 64%: 60% with 5 complete responses (CR)/unconfirmed complete responses (CRu) at 320 mg, 100% with 4 CR/CRu at 480 mg, and 53% with 6 CR/CRu at 480 mg under fasted conditions. Median progression-free survival was 2.9 months: 2.1, 11.1, and 5.8 months at 320, 480, and 480 mg under fasted conditions, respectively. Median overall survival was not reached. ORR was similar among patients harboring CARD11, MYD88, and CD79B mutations, and corresponding wild types.ConclusionThese data indicate favorable efficacy of tirabrutinib in patients with relapsed/refractory PCNSL.Trial registrationJapicCTI-173646.

Background Glioblastoma (GBM) is an aggressive primary brain tumor with poor prognosis. One strategy for overcoming resistance is developing a new therapy targeting the cancer stem/initiating cells. We have shown that the antidiabetic drug metformin (MF) can induce differentiation of stem-like glioma-initiating cells and suppress tumor formation through AMPK-FOXO3 activation. We conducted a phase I/II study to examine the clinical effect of MF combined with standard maintenance temozolomide (TMZ). Here, we report the result of phase I part and the current status of phase II part. Patients and Methods Patients between 20 and 74 years of age with supratentorial GBM histologically diagnosed according to the World Health Organization 2016 classification were eligible. MF dose-escalation was planned using a 3 + 3 design. Dose-limiting toxicities (DLTs) were assessed during the first 6 weeks after MF initiation. Results Between February 2021 and January 2022, the first three patients were treated with 1,500 mg/day MF and the next four patients were treated with 2,250 mg/day MF, which is the maximum dose approved in Japan. The median age of the patients was 41 years. Three tumors (42.9 %) were IDH1/2 mutants and 4 (57.1 %) were IDH1/2 wild-types. No DLTs were observed. The most common adverse effects were appetite loss, nausea, and diarrhea, which were observed in three patients. All of them were manageable, with grade 1 or 2. Only one grade 3 seizure was reported, which was likely related to the tumor. Two patients experienced tumor progression at 6.0 and 6.1 months, and one died 12.2 months after initial surgery. The other five patients remained stable at the last follow-up. Conclusion MF dose of up to 2,250 mg/day combined with maintenance TMZ appeared to be well tolerated, and we proceeded to phase II study with 2,250 mg/day MF.

Background Many patients with primary CNS lymphoma (PCNSL) relapse despite complete response (CR) after initial therapy. Relapsed PCNSL (rPCNSL) has a poor prognosis, and no adequate standard of treatment has been established. Autologous stem cell transplant (ASCT)-assisted high-dose chemotherapy (HDC) for rPCNSL is a promising treatment option, as is thiotepa (TT), which has been used in malignant lymphoma as a treatment option for PCNSL. In March 2020, TT was approved in Japan as a pre-treatment for ASCT in malignant lymphoma. TBC, TT with busulfan and cyclophosphamide, and BCNU+TT are used in Europe and the US, but treatment-related mortality (TRM) has been reported in about 10% of patients. The regimen approved in Japan is Buslufan-TT(BuTT) therapy in combination with busulfan, which differs from TBC in dosage, and there is little information on efficacy and safety for rPCNSL. In our hospital, we have introduced BuTT therapy for rPCNSL in patients under 65 years of age. In this report, we describe our experience with this treatment. Subjects: Five patients with rPCNSL since May 2021, age Methods After obtaining CR with (R)MPV therapy after relapse, peripheral blood stem cells were harvested after administration of G-CSF and plerixafor, pretreated with BuTT therapy (Bu: 3.2 mg/kg, Day-8, -7, -6, -5: TT: 5 mg/kg, Day-4, -3) and transplanted on Day 0. Results Adverse events of Grade 3 or higher were abdominal pain in 2 cases, diarrhea in 1 case, pharyngitis in 2 cases, sepsis in 1 case, and pleuritis in 1 case, but all recovered, and no TRM was observed. All five patients are currently alive without recurrence. Conclusion HDC/ASCT is expected to be a curative treatment for rPCNSL. Future issues include the establishment of an upper age limit for the indication.

Glioblastoma (GBM) inevitably recurs due to a resistance to current standard therapy. We showed that the antidiabetic drug metformin (MF) can induce the differentiation of stem-like glioma-initiating cells and suppress tumor formation through AMPK-FOXO3 activation. In this study, we design a phase I/II study to examine the clinical effect of MF. We aim to determine a recommended phase II MF dose with maintenance temozolomide (TMZ) in patients with newly diagnosed GBM who completed standard concomitant radiotherapy and TMZ. MF dose-escalation was planned using a 3 + 3 design. Dose-limiting toxicities (DLTs) were assessed during the first six weeks after MF initiation. Three patients were treated with 1500 mg/day MF and four patients were treated with 2250 mg/day MF between February 2021 and January 2022. No DLTs were observed. The most common adverse effects were appetite loss, nausea, and diarrhea, all of which were manageable. Two patients experienced tumor progression at 6.0 and 6.1 months, and one died 12.2 months after initial surgery. The other five patients remained stable at the last follow-up session. The MF dose of up to 2250 mg/day combined with maintenance TMZ appeared to be well tolerated, and we proceeded to a phase II study with 2250 mg/day MF.

Palliative care and advance care planning (ACP) from the first diagnosis of glioblastoma are important. This questionnaire survey was conducted to understand the current status of palliative care for brain tumors in Japan. Representative characteristics of Japan in comparison with Western countries (P

Background: Based on the results of a phase I/II study in Japan (Trial registration: JapicCTI-173646), tirabrutinib (TIR), a second-generation inhibitor of Bruton's tyrosine kinase, was approved in March 2020 for the treatment of relapsed or refractory primary central nervous system lymphoma (r/r PCNSL). We have previously reported overall response rate of 63.6% and manageable safety profile results of this study (Narita et al. Neuro Oncol. 2021;23(1):122-133). Further, one-year follow-up data after the last patient had enrolled showed that the effects of TIR persisted in r/r PCNSL patients (Mishima et al. Poster presented at the Society for Neuro-Oncology virtual conference; November 19-21, 2020). Here, based on this one-year follow-up data, we describe the Quality of Life (QoL) and Karnofsky Performance Status (KPS) in r/r PCNSL patients treated with TIR. Methods: Patients with r/r PCNSL, age ≥20 years, and KPS ≥70 were treated with TIR once daily (QD) at a dose of 320 mg, 480 mg, or 480 mg upon fasting (480 mg fasted QD). TIR was administered in 28-day cycles, and treatment was continued until disease progression or clinically unacceptable toxicity was observed. QoL was assessed using questionnaires issued by the European Organization for Research and Treatment of Cancer (EORTC), namely QLQ-C30 (EORTC QLQ-C30), EORTC QLQ-BN20, and EuroQol 5 dimensions 3-level (EQ-5D-3L). The QoL survey was conducted during the screening period, on Day 28 of Cycle 1, after every 2 cycles (i.e., after Day 1 of Cycle 3), after every 4 cycles (i.e., after Day 1 of Cycle 25), and at the end of treatment. KPS was measured during the screening period, on days 1, 8, 15, and 28 of Cycle 1, on day 1 of every cycle after Cycle 3, and at the end of treatment. Results: Forty-four patients were prospectively enrolled, and 20, 7, and 17 patients were treated with TIR at 320 mg QD, 480 mg QD, and 480 mg fasted QD, respectively. Median patient age was 60 years (range 29-86). Median follow-up period was 14.9 months (range, 1.4-27.7) for the entire cohort but was 19.1 months, 23.5 months, and 12.0 months for the 320 mg QD, 480 mg QD, and 480 mg fasted QD groups, respectively. At the time of data cutoff (February 25, 2020), 11 patients (25%) remained on treatment. Mean (SD) score for the global health status/QoL section of the EORTC QLQ-C30 was 50.9 (23.7) at baseline and remained relatively constant during treatment (Figure 1). This trend was also observed for emotional function, cognitive function, and fatigue sections of the EORTC QLQ-C30, for motor dysfunction, communication deficit, weakness of legs, and bladder control sections of the EORTC QLQ-BN20, and in items pertaining to self-care, usual activities, and anxiety/depression in the EQ-5D-3L. Median KPS was 80.0 (range, 70-100) at baseline, which remained unchanged during TIR treatment (Figure 2). Conclusion: QoL and KPS scores in r/r PCNSL patients were maintained during TIR administration, a new treatment option for r/r PCNSL, which does not lead to the deterioration of QoL and KPS. Figure 1 Figure 1. Disclosures Terui: Ono Pharmaceutical: Speakers Bureau; MSD: Speakers Bureau; Janssen: Speakers Bureau; Esai: Speakers Bureau; Chugai Pharmaceutical: Speakers Bureau; Celgene: Speakers Bureau; AbbVie: Speakers Bureau; Takeda Pharmaceutical: Speakers Bureau. Narita: Ono Pharmaceutical co.: Honoraria, Research Funding; Dainippon-Sumitomo: Membership on an entity's Board of Directors or advisory committees, Research Funding; Eisai: Honoraria, Research Funding; Stella-pharma: Research Funding; Daiichi-Sankyo: Honoraria, Research Funding; Bayer: Research Funding; Ohara: Research Funding; Chugai Pharmaceutical co.: Honoraria; Novocure: Honoraria. Nagane: AbbVie: Membership on an entity's Board of Directors or advisory committees, Research Funding; Chugai: Honoraria, Research Funding; Daiichi-Sankyo: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Eisai: Honoraria, Research Funding; Pfizer: Research Funding; MSD: Research Funding; Astellas: Research Funding; Nippon-Kayaku: Honoraria, Research Funding; Bayer: Honoraria, Research Funding; Shionogi: Research Funding; Otsuka: Research Funding; Ono Pharma: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novocure: Honoraria; Sumitomo Dainippon Pharma: Honoraria; RIEMSER: Membership on an entity's Board of Directors or advisory committees. Mishima: Ono Pharmaceutical Co: Research Funding; Astellas: Research Funding; HOYA Technosurgical Co.: Research Funding; Daiichi-Sankyo: Research Funding; AbbVie: Research Funding; Medical U and A: Research Funding; Teijin Pharma: Research Funding; Eisai: Research Funding; MSD: Research Funding; Chugai: Research Funding. Arakawa: Sanofi: Research Funding; Carl Zeiss: Honoraria, Research Funding; Brainlab: Honoraria, Research Funding; Nihon Medi-Physics: Research Funding; Ono Pharmaceutical: Honoraria, Research Funding; Philips: Research Funding; Siemens: Research Funding; Tanabe Mitsubishi: Research Funding; Chugai: Honoraria, Research Funding; Eisai: Honoraria, Research Funding; Merck: Honoraria, Research Funding; Meiji Seika: Honoraria, Research Funding; Daiichi Sankyo: Honoraria, Research Funding; CSL Behring: Honoraria, Research Funding; Takeda: Research Funding; Pfizer: Research Funding; Stryker: Research Funding; Astellas Pharma: Research Funding; Taiho Pharma: Research Funding; Nippon Kayaku: Honoraria; Novocure: Honoraria; UCB Japan: Honoraria; Integra Japan: Honoraria; Otsuka: Honoraria; Abbvie: Honoraria. Yonezawa: Eisai: Speakers Bureau; Ono Pharmaceutical co.: Speakers Bureau; Chugai Pharmaceutical co.: Speakers Bureau. Fukuhara: Celgene: Honoraria, Research Funding; Chugai Pharmaceutical: Honoraria, Research Funding; Eisai: Honoraria; HUYA Bioscience International: Honoraria; Incyte: Research Funding; Janssen: Honoraria; Kyowa Kirin: Honoraria; Nippon Shinyaku: Honoraria; Novartis: Honoraria; Ono Pharmaceutical: Honoraria, Research Funding; Takeda Pharmaceutical: Honoraria; Zenyaku Kogyo: Honoraria; Bayer: Research Funding; AbbVie: Honoraria. Sugiyama: Daichi Sankyo Inc.: Consultancy; Ono Pharmaceutical Inc: Honoraria. Aoi: Ono Pharma USA, Inc.: Current Employment. Nishikawa: Novocure: Consultancy; Chugai: Honoraria, Research Funding; MSD: Research Funding; Daiichi-Sankyo: Honoraria, Research Funding; Eisai: Honoraria, Research Funding; Ono: Honoraria; Nihon-Kayaku: Honoraria. OffLabel Disclosure: Tirabrutinib. Clinical trial for PCNSL.

We report a case of a 24-year-old woman who presented with an uncomfortable feeling in her right foot with a 6-month history of slight weakness in her right hand. Neuroimaging demonstrated irregular shaped lesions in the left thalamus and basal ganglia in addition to spotty lesions in the contralateral thalamus. The MRI showed high-intensity signals on T2-weighted, fluid-attenuated inversion recovery, and diffusion-weighted images. The lesions demonstrated low-intensity signaling on T1-weighted images and were slightly enhanced with gadolinium. Other examinations including positron emission tomography, MR spectroscopy, and laboratory tests did not reveal any specific information regarding the lesions. The biopsied specimens, from the left basal ganglia, revealed proliferation of dysplastic neuronal cells without any neoplastic glial elements; thus, gangliocytoma (WHO grade I) was the most likely diagnosis. The patient was further observed based on this diagnosis of suspicious gangliocytoma, and the follow-up MRI, performed a year after the biopsy, revealed that the disease was stable. To our knowledge, gangliocytoma in the thalamus and basal ganglia have not been reported. Additionally, the findings of the magnetic resonance imaging (MRI) in this case were unique and different from those previously reported in cases of gangliocytoma. The authors report this unique case and discuss the radiological, pathological, and genetic findings.

Primary central nervous system lymphoma (PCNSL) is known as one of the incurable brain tumors. In March 2020, Tirabrutinib (TIR), a second-generation oral Bruton’s tyrosine kinase inhibitor, was approved for the indication of relapsed or refractory PCNSL (rrPCNSL) based on the results of a phase I/II study in Japan (Trial registration: JapicCTI-173646). In this study, 44 Japanese patients with rrPCNSL were treated with TIR QD at 320 mg, 480 mg, or 480 mg in the fasted condition (480 mg fasted QD). The primary endpoint was overall response rate (ORR) assessed by an independent review committee according to International PCNSL Collaborative Group criteria. We previously reported the results of this study with data cutoff on June 13, 2019 (Nagane et al., the 61st American Society of Hematology Annual Meeting and Exposition in 2019). In the report, 17 of 44 patients were treated with TIR at 480 mg fasted QD which is an approved dose, and had ORR of 52.9%, median progression-free survival of 5.8 months, and median overall survival of not reached (median follow-up: 3.8 months). In 44 patients, ORR was similar among patients harboring either of the oncogenic mutants CARD11, MYD88, CD79B, or wild type. Throughout the whole patients, most common adverse events (AEs) at any grade were rash (32%), neutropenia (23%), leukopenia (18%), and lymphopenia (16%), and grade ≥3 AEs were neutropenia (9.1%), lymphopenia, leukopenia, and erythema multiforme (6.8% each). One patient with 480 mg QD had grade 5 AEs (pneumocystis jirovecii pneumonia and interstitial lung disease). We will present one-year follow-up data of this study at the meeting. As of data cutoff (February 25, 2020), 11 of 44 patients continued to receive TIR, including 6 patients with 480 mg fasted QD. Updated data for OS, duration of response, and time to onset of AEs will also be presented.

BACKGROUND MGMT promoter methylation is an important biomarker related to glioblastoma therapeutic response and prognosis. There are qualitative and quantitative methods as assays for MGMT methylation. Although the qualitative method is common, there is a disadvantage that low or high methylation cannot be distinguished. The quantitative method is an excellent method for evaluating methylation of tumors characterized by intratumoral heterogeneity like malignant glioma, but cutoff value of methylation that defines the prognosis of glioblastoma is unknown. Therefore, we examined the cutoff value of quantitative MGMT methylation assay determining the prognosis in glioblastoma. METHODS 180 newly diagnosed glioblastoma which underwent radiotherapy and temozolomide treatment after tumor removal in our department were included. MGMT methylation was quantitatively analyzed by methylation-specific high resolution melting (MS-HRM) analysis. For each level of methylation, progression-free survival (PFS) and overall survival (OS) were calculated and statistically analyzed. RESULTS In the low MGMT methylation cases in which the proportion of methylation was 25% or less in PFS and 30% or less in OS, no difference was observed in PFS and OS as compared with those of unmethylated cases. The cutoff value of MGMT methylation most contributing to survival was calculated to be 35% by the survival classification and regression tree method. CONCLUSION The prognosis for MGMT hypomethylated group is as poor as unmethylated one. In the quantitative MS-HRM method, we found that the value of MGMT methylation of 35% is useful as a cut off determining the prognosis of glioblastoma.

BACKGROUND Activation of telomerase plays a critical role in tumor development. Somatic alterations in the promoter of the telomerase reverse transcriptase (TERT) gene are a major mechanism of upregulating telomerase. Several mechanisms have been associated with TERT abnormalities, including TERT promoter mutations or methylation. Mutations in the TERT promoter have been observed in a subset of brain tumors, especially in adult gliomas. In pituitary adenomas (PAs), however, TERT abnormalities are not fully understood. The present study aimed to investigate not only mutational but also methylation status changes in the TERT promoter in PAs and to analyze their correlations with clinical variables. MATERIAL AND METHODS We retrospectively studied 70 PAs consisting of 53 primary and 17 recurrent samples. Clinical data, including age at surgery, sex, tumor size, tumor subtype, resection rate, presence or absence of postoperative irradiation, and progression-free survival (PFS), were obtained from medical records. First, we investigated TERT promoter hotspot mutations via Sanger sequencing. Next, we quantified the methylation status of the TERT promoter using methylation-sensitive high-resolution melting analysis (MS-HRM). Finally, we investigated TERT mRNA expression levels using real-time quantitative PCR. Fisher’s exact test was applied to evaluate the statistical significance between TERT promoter methylation status and tumor recurrence. PFS was calculated using Kaplan-Meier estimates and compared between methylated with ummethylated PAs with the log-rank test. The correlation between TERT promoter methylation status and mRNA levels was analyzed with the Mann-Whitney U-test. PFS was analyzed using multivariate analysis with the Cox proportional hazards model and included the following variables: age, sex, tumor size, tumor subtype, resection rate, radiation therapy, and methylation status. RESULTS TERT promoter hotspot mutations were not observed in any PA sample. Nineteen percent of PAs exhibitedTERT promoter methylation, which was significantly predominant in recurrent PA samples. PFS was significantly shorter in the methylated cases than in the unmethylated cases. Higher TERT expression levels were correlated with methylation status. CONCLUSION We found that TERT promoter methylation upregulated TERT expression and was associated with shorter PFS in PAs. Our results suggest thatTERT promoter methylation may be a potential biomarker for predicting tumor recurrence in PAs.

von Hippel-Lindau (VHL) disease is a hereditary tumor disease in which tumors develop in multiple organs, not only as hemangioblastomas (HBs) in the central nervous system, but also as kidney tumors, pheochromocytomas, and so on. Much about the epidemiology of VHL disease remained unknown until fairly recently in Japan, leading to calls for the establishment of a VHL disease epidemiological database in Japanese. To elucidate its epidemiology in Japan, the Japanese Ministry of Health, Labour and Welfare created the VHL Disease Study Group, which was put in charge of carrying out a nationwide epidemiological survey. The survey found close to 400 Japanese VHL disease patients throughout the country. Based on those results, the VHL Disease Study Group created the VHL Disease Treatment Guideline and also a severity classification. It is thought that the prognosis of VHL disease patients can be improved by performing genetic diagnosis and careful follow-up. Accordingly, the University of Tokyo Hospital put in place an in-hospital system for implementing genomic medicine for VHL disease based on genetic diagnosis. For that system, it was especially important to establish (I) accurate genetic diagnostic techniques, (II) genetic counseling capabilities for the patients and their families, and (III) a system of cooperation among multiple departments, including urology departments, and so on. Further elucidation of the epidemiology and the development of genomic medicine are needed to improve the treatment results of VHL disease in Japan.

OBJECTIVE Human chorionic gonadotropin (HCG) can be detected in a certain population of patients with a germinoma, but the frequency of germinoma HCG secretion and the prognostic value of HCG in the CSF are unknown. METHODS The authors measured HCG levels in sera and CSF in patients with a histologically confirmed germinoma by using a highly sensitive assay known as an immune complex transfer enzyme immunoassay (EIA), which is more than 100 times as sensitive as the conventional method, and they analyzed the correlation between HCG levels and the prognoses of patients with a germinoma. RESULTS HCG levels in sera and CSF of 35 patients with a germinoma were examined with the immune complex transfer EIA. The median CSF HCG levels in patients with a germinoma during the pretreatment and posttreatment evaluations were 192.5 pg/ml (range 1.2–13,116.5 pg/ml) and 18.7 pg/ml (1.2–283.9 pg/ml), respectively. Before treatment, the CSF HCG level was greater than the cutoff value in 85.7% of the patients with a germinoma. The authors compared survival rates among the patients by using a CSF HCG cutoff level of 1000 pg/ml, and the difference was statistically significant between the groups (p = 0.029, log-rank test). CONCLUSIONS Results of this study demonstrate that most germinomas secrete HCG. Patients with a germinoma that secretes higher amounts of HCG in their CSF experienced recurrence more frequently than those with lower CSF HCG levels.

In March 2020, Tirabrutinib (TIR), a second-generation oral Bruton’s tyrosine kinase inhibitor, was approved for the indication of relapsed or refractory PCNSL (r/rPCNSL) based on the results of a phase I/II study in Japan. In this study, 44 Japanese patients with r/rPCNSL were treated with TIR QD at 320 mg, 480 mg, or 480 mg in the fasted condition (480 mg fasted QD). The primary endpoint was overall response rate (ORR) assessed by an independent review committee according to International PCNSL Collaborative Group criteria. We previously reported the results of this study with data cutoff in June 2019 (Narita et al. Neuro Oncol. 2020). In the report, 17 of 44 patients were treated with TIR at 480 mg fasted QD which is an approved dose, and had ORR of 52.9%, median progression-free survival of 5.8 months, and median overall survival of not reached (median follow-up: 3.8 months). In 44 patients, ORR was similar among patients harboring either of the oncogenic mutants CARD11, MYD88, CD79B, or wild type. Throughout the whole patients, most common adverse events (AEs) at any grade were rash (31.8%), neutropenia (22.7%), leukopenia (18.2%), and lymphopenia (15.9%), and grade ≥3 AEs were neutropenia (9.1%), lymphopenia, leukopenia, and erythema multiforme (6.8% each). One patient with 480 mg QD had grade 5 AEs (pneumocystis jirovecii pneumonia and interstitial lung disease). We will present one-year follow-up data of this study at the meeting. As of data cutoff (February 2020), 11 of 44 patients continued to receive TIR, including 6 patients with 480 mg fasted QD. Updated data for overall survival, duration of response, and time to onset of AEs will also be presented. TIR is a promising new treatment for r/rPCNSL.

Primary CNS Lymphomas (PCNSLs) is a highly aggressive malignant tumor with poor prognosis and increasing incidence in elderly patients. High-dose methotrexate (HD-MTX) followed by whole-brain radiation therapy (WBRT) improves survival in PCNSLs. Several HD-MTX–based regimens, in combination with alkylating agents and rituximab, have been developed that can achieve high and durable complete response rates in patients with newly diagnosed PCNSL. In Japan, the R-MPV regimen using rituximab, HD-MTX, procarbazine, and vincristine has been recognized as the standard treatment for initial induction for newly diagnosed PCNSL. The optimal consolidative therapy for patients with disease responsive to induction chemotherapy is not yet defined. WBRT at standard dose (30–45 Gy) has a risk of neurotoxicity. To minimize the effects of delayed neurotoxicity, high-dose chemotherapy supported by autologous stem cell transplantation, reduced dose WBRT (23.4Gy), non-myeloablative chemotherapy, and maintenance chemotherapy have been addressed in large randomized trials. Gene expression profiling has provided insights into the pathogenesis of PCNSL. Recent insight into the pathophysiology of PCNSL has led to the investigation of targeted agents in the treatment of recurrent disease. In March 2020, Tirabrutinib (TIR), a second-generation oral Bruton’s tyrosine kinase inhibitor, was approved for relapsed or refractory PCNSL based on the results of the phase I/II study in Japan. Seventeen of 44 patients treated with TIR at 480 mg fasted QD, an approved dose, had overall response rate of 52.9%, median progression-free survival of 5.8 months, and time to response as short as 0.92 months. The most common adverse event at any grade was rash (32%). The skin-related disorders were manageable with appropriate skin treatments. However, greater attention and management is needed the case of more rare adverse events such as severe skin-related disorders and pneumocystis pneumonia. This lecture aims to present the recent development in treatment for PCNSL.

Mutation in the IDH1gene is a genetic defect exclusively found in glioma, and has been established as a prognostic factor for WHO Grade 2–4 glioma. Therefore, detecting this mutation is clinically important. In this study, we report the results of analyzing defects in IDH1 mutation by detecting circulating cell free (ccf) DNA in the CSF derived from the tumor tissue of glioma patients. Moreover, MGMTpromoter methylation, H3F3A and BRAFmutation were evaluated for the CSF samples in a subset of glioma patients. Lumbar puncture was performed to obtain CSF from 7 patients with glioma. ccfDNA was extracted from 1 ml of CSF using the Maxwell rapid sample concentrator system. Subsequently, the presence of point mutation of theIDH1gene was screened by real-time PCR/high-resolution melting (HRM) curve analysis, and the mutation was confirmed on the basis of DNA sequencing results. Status in the IDH1gene was also analyzed using the same assay technique for the DNA extracted from the excised fresh tumor tissue, to compare the results with that of CSF-derived ccfDNA. In addition, ccfDNA was also extracted from the plasma in 3 patients to additionally examine the presence of the IDH1gene mutation. MGMTpromoter methylation, H3F3A and BRAFmutation were also performed using the HRM method. CSF-derived ccfDNA was successfully extracted from all patients and analyzed. IDH1gene mutation was detected in 3 of the 7 glioma patients. The results of the IDH1gene analysis of CSF-derived ccfDNA and that of the DNA extracted from the surgically excised tumor tissue were consisted in all patients. Three MGMTpromoter methylation, two H3F3Amutations, and three BRAFmutations were detected, respectively. Gene analysis of ccfDNA from the CSF enabled the evaluation of IDH1 mutation in glioma patients less invasively, without directly obtaining any tumor tissue. Moreover, this technique can be applied to analyze MGMTgene promotor methylation, H3F3A and BRAFmutation.

According to the 2016 World Health Organization Classification of Tumors of the Central Nervous System (2016 CNS WHO), IDH-mutant astrocytic gliomas comprised WHO grade II diffuse astrocytoma, IDH-mutant (AII(IDHmut)), WHO grade III anaplastic astrocytoma, IDH-mutant (AAIII(IDHmut)), and WHO grade IV glioblastoma, IDH-mutant (GBM(IDHmut)). Notably, IDH gene status has been made the major criterion for classification while the manner of grading has remained unchanged: it is based on histological criteria that arose from studies which antedated knowledge of the importance of IDH status in diffuse astrocytic tumor prognostic assessment. Several studies have now demonstrated that the anticipated differences in survival between the newly defined AII(IDHmut) and AAIII(IDHmut) have lost their significance. In contrast, GBM(IDHmut) still exhibits a significantly worse outcome than its lower grade IDH-mutant counterparts. To address the problem of establishing prognostically significant grading for IDH-mutant astrocytic gliomas in the IDH era, we undertook a comprehensive study that included assessment of histological and genetic approaches to prognosis in these tumors. A discovery cohort of 211 IDH-mutant astrocytic gliomas with an extended observation was subjected to histological review, image analysis, and DNA methylation studies. Tumor group-specific methylation profiles and copy number variation (CNV) profiles were established for all gliomas. Algorithms for automated CNV analysis were developed. All tumors exhibiting 1p/19q codeletion were excluded from the series. We developed algorithms for grading, based on molecular, morphological and clinical data. Performance of these algorithms was compared with that of WHO grading. Three independent cohorts of 108, 154 and 224 IDH-mutant astrocytic gliomas were used to validate this approach. In the discovery cohort several molecular and clinical parameters were of prognostic relevance. Most relevant for overall survival (OS) was CDKN2A/B homozygous deletion. Other parameters with major influence were necrosis and the total number of CNV. Proliferation as assessed by mitotic count, which is a key parameter in 2016 CNS WHO grading, was of only minor influence. Employing the parameters most relevant for OS in our discovery set, we developed two models for grading these tumors. These models performed significantly better than WHO grading in both the discovery and the validation sets. Our novel algorithms for grading IDH-mutant astrocytic gliomas overcome the challenges caused by introduction of IDH status into the WHO classification of diffuse astrocytic tumors. We propose that these revised approaches be used for grading of these tumors and incorporated into future WHO criteria.

OBJECTIVE: Intracranial germ cell tumors (GCTs) are a heterogeneous group of lesions. It is important to obtain the accurate histological diagnosis since the treatment outcomes can depend on histology. Neuroendoscopic biopsy is a minimally invasive procedure and employed widely. But it is not yet clear whether neuroendoscopy can make so accurate diagnosis as craniotomy without increasing the risk of dissemination. We compared the diagnostic rate and recurrence rate of these two procedures. METHODS: Forty patients with intracranial GCTs treated in our institute from 2007 to 2017 were included in this study. More than 6 pieces of tumor tissues were obtained with neuroendoscopy. As highly elevated tumor marker signifies highly malignant tumor, we started treatment without a histological diagnosis. RESULTS: For all patients except those with extremely highly elevated tumor markers, the histological diagnoses were made by neuroendoscopy or craniotomy. Of number cases with germinoma, 3 cases (neuroendoscopy 2, craniotomy 1) relapsed. All three cases were treated with additional chemotherapy and/or radiotherapy to survive. Of number cases with intermediate risk group tumors, 1 case who underwent craniotomy developed recurrence. High-risk tumors were diagnosed by tumor markers in 2 patients, 5 by endoscopy and one by craniotomy. One patient thought to be intermediate risk group by tumor marker, obtained the histological diagnosis of yolk sac tumor. The recurrence rate for neuroendoscopy and craniotomy was 8% and 15% respectively. CONCLUSIONS: Neuroendoscopy is useful for histological diagnosis as well as craniotomy and would not increase recurrence rate.

BACKGROUND Pilocytic astrocytoma is one of the common tumors found during childhood. However, the clinical course of disseminated pilocytic astrocytoma is not clearly known. Here, we present two cases with disseminated pilocytic astrocytoma and discuss the treatment strategy. Patients We treated a 7-year-old female (case 1) and 9-year-old male (case 2) with hypothalamic pilocytic astrocytomas. The results of magnetic resonance imaging showed diffuse spinal dissemination at diagnosis. Chemotherapy with vincristine and carboplatin was administered as the firstline therapy. The tumors showed some shrinkage, and symptoms improved. During chemotherapy, the patients developed allergies to carboplatin. Therefore, we changed the chemotherapy treatment to vincristine. Other adverse events were not observed. In Case 1, we observed an intratumoral hemorrhage and hydrocephalus due to occlusion of the foramen Monro. Endoscopic surgery was performed, and no clinical deficit was observed. Case 2 underwent ventricular peritoneal shunt procedure for communicating hydrocephalus and a reoperation for shunt malfunction because of dense cerebrospinal fluid with elevated protein levels. The patients have not undergone radiotherapy until now. They had no severe clinical symptoms and went to school for 5 and 10 years, respectively, after the diagnoses. CONCLUSION Chemotherapy for disseminated pilocytic astrocytoma is effective and may help in avoiding radiotherapy. Chemotherapy should be administered before radiotherapy, considering long-term complications.

Objective Preoperative embolization of meningioma is commonly performed; however, there is no consensus on the best embolic material to reduce intraoperative blood loss and surgery time. Method We retrospectively assessed the safety and efficacy of 56 cases of preoperative embolization of the middle meningeal artery with N-butyl cyanoacrylate (NBCA) in 105 cases of surgery for meningioma. We also defined a blood loss to tumor volume ratio to compensate for bias caused by tumor volume, and analyzed limited cases (the embolized group n = 52, the non-embolized group n = 21) of the convexity, the parasagittal region, the falx, and the sphenoidal ridge. Result The blood loss to tumor volume ratio was significantly less in the embolized group ( p Conclusion Tumor embolization with NBCA can be safely performed, and the procedure significantly reduces intraoperative blood loss.

Purpose This study explored the superiority of temozolomide (TMZ) + interferonβ (IFNβ) to standard TMZ as treatment for newly diagnosed glioblastoma (GBM) via randomized phase II screening design. Experimental design Eligibility criteria included histologically proven GBM, with 50% of the tumor located in supratentorial areas, without involvement of the optic, olfactory nerves, and pituitary gland and without multiple lesions and dissemination. Patients in the TMZ + radiotherapy (RT) arm received RT (2.0 Gy/fr/day, 30 fr) with TMZ (75 mg/m2, daily) followed by TMZ maintenance (100–200 mg/m2/day, days 1–5, every 4 weeks) for 2 years. Patients in the TMZ + IFNβ + RT arm intravenously received IFNβ (3 MU/body, alternative days during RT and day 1, every 4 weeks during maintenance period) and TMZ + RT. The primary endpoint was overall survival (OS). The planned sample size was 120 (one-sided alpha 0.2; power 0.8). Results Between Apr 2010 and Jan 2012, 122 patients were randomized. The median OS with TMZ + RT and TMZ + IFNβ + RT was 20.3 and 24.0 months (HR 1.00, 95% CI 0.65–1.55; one-sided log rank P = 0.51). The median progression-free survival times were 10.1 and 8.5 months (HR 1.25, 95% CI 0.85–1.84). The incidence of neutropenia with the TMZ + RT and the TMZ + IFNβ + RT (grade 3–4, CTCAE version 3.0) was 12.7 versus 20.7% during concomitant period and was 3.6 versus 9.3% during maintenance period. The incidence of lymphopenia was 54.0 versus 63.8% and 34.5 versus 41.9%. Conclusions TMZ + IFNβ + RT is not considered as a candidate for the following phase III trial, and TMZ + RT remained to be a most promising treatment. This trial was registered with the UMIN Clinical Trials Registry: UMIN000003466.

BACKGROUND The addition of high-dose methotrexate (HD-MTX)-based chemotherapy to whole brain irradiation (WBRT) has improved the prognosis of primary central nervous system lymphoma (PCNSL). However, the high neurotoxicity rates observed, especially in the elderly, raised interest in chemotherapy-only treatments. Withholding radiotherapy substantially decreases the risk of neurotoxicity, however, disease control may be compromised. In the elderly who cannot tolerate WBRT as a consolidation, maintenance treatment may serve as a feasible approach after an initial response. We treated ePCNSL with induction immunochemotherapy, maintenance chemotherapy with HD-MTX and deferred WBRT. Here, we retrospectively investigated the prognosis for ePCNSL that became CR after the induction chemotherapy. MATERIAL AND METHODS Newly diagnosed ePCNSL (median age: 74 years) received biweekly rituximab/HD-MTX for 6 cycles (induction) followed by monthly rituximab/HD-MTX for 2 cycles (consolidation) and then were treated differently according to the radiological response. With CR patients, HD-MTX was continued with every 3 months (maintenance) for 2 years. Patients who did not obtain consent for maintenance therapy were followed up. For PD patients, immunochemotherapy was interrupted and WBRT initiated immediately. Patients with PR and SD were treated with alternative chemotherapy with temozolomide and/or stereotactic radiotherapy or WBRT. RESULTS The median PFS was 24.6 months and median OS was 27 months for the entire cohort. Of the 42 ePCNSL, 26 had CR after induction and consolidation, of which 18 cases were carried out maintenance (M+) and 8 cases were followed up (M-). Median PFS was 73 months in the M+ group and 24.5 months in the M- group. Median OS is 102.2months versus 27.6 months, respectively. Both mPFS (P= 0.0125) and mOS (P =0.0015) were significantly prolonged by maintenance therapy. CONCLUSION It was suggested that maintenance treatment with HD-MTX may improve the prognosis for ePCNSL that reached complete response after induction therapy.

BACKGROUND Brainstem tumours account for 10–15% of brain tumors in childhood. Diffuse intrinsic pontine glioma (DIPG) accounts for 60–80% of them and are diagnosed based on clinical findings and radiologic features. All the rest of tumours excluding DIPG are very rare, heterogeneous group of tumours including low-grade glioma and malignant embryonal tumors. It is often difficult to diagnose and decide treatment strategy for their rarity. METHODS To present our experience with atypical brainstem tumours, a retrospective chart review was conducted to identify eligible cases treated over a ten-year period. All tumors involving brainstem, felt not to be DIPGs for absence of clinical/neuroimaging features were included. Demographic information, pathological findings, neuroimaging characteristics, surgical and nonsurgical management plans, and survival data were collected for analysis. RESULTS Between April 2007 and March 2017, 16 patients (14 initial and 2 recurrent) aged from 3 to 20 years were identified. 14 of them were symptomatic and 4 of them were asymptomatic at reference. Of 10 symptomatic cases, 10 were biopsied and pathological diagnosis was low-grade glioma in 8, glioblastoma in 2 cases. They had treatment depending on the pathological diagnosis. Of 4 asymptomatic cases, one with small focal tumour, with no findings suggesting malignant tumour with 11C-methioninePET or MRS, progressed to show typical clinical and image findings of DIPG in a year. For other three, they remain asymptomatic without progression with no treatment for 25months, 60months, and 65 months respectively. Malignant transformation was observed in one with biopsy-conformed oligoastrocytoma with no K27M-H3 mutations treated with chemotherapy and another with pilocytic astrocytoma treated with chemotherapy and radiotherapy. CONCLUSIONS Though molecular findings such as K27M-H3 mutations can predict clinical outcome in some cases, it still remains difficult to diagnose and find treatment strategy of atypical brainstem tumours. The need and usefulness of nationwide registry study is warranted.

MGMT methylation in glioblastoma is a biomarker for determining treatment responsiveness and predicting prognosis. We analyzed whether there were differences in the prognosis between glioblastoma with MGMT hypermethylation and other glioblastomas after tumor recurrence. We enrolled 184 patients who underwent radiation therapy and temozolomide chemotherapy after tumor resection for newly diagnosed glioblastoma. MGMT methylation was quantitatively analyzed using methylation-specific high resolution melting analysis. The cut-off value for MGMT methylation had a difference of 35% from the previous values. The subjects were split into three groups according to their MGMT methylation levels, 122 in the low (L) methylation group (levels of 0–34%), 40 in the medium (M) methylation group (levels of 35–69%), and 22 in the high (H) methylation group (levels of 70% or more). We mainly focused on and compared the progression after recurrence. The progression-free survival (PFS) rate and overall survival (OS) rate were significantly longer in the M and H groups than in the L group. There was no difference in PFS between group M and group H, but OS was significantly longer in group H. The details of treatment for the 16 of 22 patients who had recurrences in group H are as follows: temozolomide, n = 1; bevacizumab, n = 8; investigational drugs (peptide vaccines and immune checkpoint inhibitors), n = 3; and supportive care, n = 4. The median survival rate for these 16 patients after recurrence was 18 months. Even patients who received only supportive care had a median survival time ranging between 9 and 17 months. Our results indicate that MGMT hypermethylation in glioblastoma is effective to a certain degree with other treatments even after recurrence. Even patients who underwent only supportive care survived for a relatively longer period of time. Biologically, MGMT hypermethylation may be associated with a moderately slow-growing tumor.

Purpose Genomic medicine is in progress, but the median survival of glioblastoma is 14–16 months. It seems to have the same life prognosis as stage 4 like unresectable pancreatic cancer, lung cancer and colon cancer. Palliative care including Advance care planning (ACP) at first diagnosis of glioblastoma is important We conducted a questionnaire survey to understand the current status of Japanese oncologists. Method In July 2018, a questionnaire of 37 items was sent by e-mail to 767 members of Japanese Society of Neuro Oncology, and in August replies were received from 154 persons (20%). The same 22-item questionnaire in 2012–2013 was compared internationally with a report (Walbert T., et al., 2015) by Society of NeuroOncology and the European Association of NeuroOncology. In addition, we compared domestically with a 30-item questionnaire (Narita et al. 2009) in 2007. The Nonparametric Mann-Whitney’s U test was mainly used. Result 1 Characteristics of Japan in comparison with Western countries(p

BACKGROUND The first-generation Bruton's tyrosine kinase (BTK) inhibitor ibrutinib is effective in patients with relapsed/refractory (r/r) primary central nervous system lymphoma (PCNSL). Tirabrutinib is a second-generation oral BTK inhibitor with greater selectivity than ibrutinib. We evaluated the safety, tolerability, efficacy, and pharmacokinetics (PK) of tirabrutinib once daily (QD) as monotherapy in patients with PCNSL to investigate BTK targeting as a novel therapeutic strategy. This multicenter clinical trial was sponsored by Ono Pharmaceutical Co., Ltd. and was conducted in Japan. METHODS Patients with r/r PCNSL, at least 1 parenchymal disease, Karnofsky performance status (KPS) ≥70, and normal end-organ function were treated with tirabrutinib 320 and 480 mg QD in the phase 1 portion to evaluate dose-limiting toxicity (DLT) within 28 days using a 3+3 dose escalation design, and with 480 mg QD in a fasted condition in the phase 2 portion to assess the safety, efficacy, and PK of tirabrutinib. The primary objective of the phase 2 portion was to evaluate overall response rate (ORR) as assessed by an independent review committee (IRC) according to International PCNSL Collaborative Group (IPCG) criteria. RESULTS Forty-four patients were enrolled; 20 received tirabrutinib at 320 mg, 7 at 480 mg, and 17 at 480 mg under fasted conditions as of June 13, 2019. The median patient age and KPS were 60 years (range 29-86) and 80, respectively. The median number of prior therapies was 2 (range 1-14); all patients had received methotrexate; and 28 had isolated parenchymal disease, 14 cerebrospinal fluid (CSF) involvement, and 3 intraocular involvement. No DLTs were observed, and the maximum tolerated dose (MTD) was not reached up to 480 mg. Commonly observed events (AEs) at any grade were rash (32%), neutropenia (23%), leukopenia (18%), and lymphopenia (16%). Commonly observed grade ≥3 AEs were neutropenia (9.1%), lymphopenia, leukopenia, and erythema multiforme (6.8% each). Two grade 5 AEs (pneumocystis jirovecii pneumonia and interstitial lung disease) were observed in a patient 33 days after starting tirabrutinib at 480 mg QD. IRC-assessed ORR was 64% (28/44); 60% (12/20) with 5 complete response (CR)/unconfirmed complete response (CRu) at 320 mg, 100% (7/7) with 4 CR/CRu at 480 mg, and 53% (9/17) with 6 CR/CRu at 480 mg under fasted conditions. Median progression-free survival (PFS) was 2.9 months (95% confidence interval [CI]: 1.8-11.1); 2.1 months (95% CI: 1.8-NA) at 320 mg, 11.1 months (95% CI: 1.4-NA) at 480 mg, and 5.8 months (95% CI: 1.0-5.8) at 480 mg under fasted conditions. Median overall survival was not reached (95% CI: NA-NA). ORR was similar among patients harboring the oncogenic mutants CARD11, MYD88, CD79B, and wild type (Table 1). Mean values of maximum observed plasma concentration of tirabrutinib after multiple administration on Day 28 at 320 mg, 480 mg, and 480 mg under fasting conditions were 1360, 2270, and 2690 ng/mL, respectively. The area under the plasma concentration time curve over a dosing interval was 6370, 11800, and 11800 ng*h/mL, respectively. The exposure of tirabrutinib increased with increasing dose, regardless of fasting status. Mean trough concentration of tirabrutinib in CSF/plasma at 320 mg and 480 mg on Day 28 was 2.19/16.3 ng/mL and 14.0/89.3 ng/mL, respectively. This indicated that CSF concentration increased with increasing plasma concentration at trough, while the trough concentration ratios between CSF and plasma at each dose were comparable with the free fraction of tirabrutinib in plasma. CONCLUSION Tirabrutinib had a tolerable safety profile and MTD was not reached in patients with PCNSL. IRC-assessed ORR was 64%, despite the presence of CARD11 mutation. Median PFS was longer with the increasing dose. Further investigation is warranted. Disclosures Nagane: Tsumura: Research Funding; Takeda: Research Funding; Astellas: Research Funding; Pfizer: Research Funding; Otsuka: Research Funding; Bristol-Myers-Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; Dainippon-Sumitomo: Honoraria; NovoCure: Honoraria; UCB Japan: Honoraria; Daiichi-Sankyo: Honoraria, Research Funding; Nippon-Kayaku: Honoraria, Research Funding; Eisai: Honoraria, Research Funding; MSD: Honoraria, Research Funding; AbbVie: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Ono: Honoraria, Research Funding; Chugai: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Shionogi: Research Funding; Sanofi: Research Funding. Narita:Ono: Honoraria, Research Funding; Chugai: Honoraria, Research Funding; AbbVie: Honoraria, Research Funding; Dainippon-Sumitomo: Honoraria, Research Funding; Daiichi-Sankyo: Honoraria, Research Funding; Eisai: Honoraria, Research Funding; Stella-pharma: Honoraria, Research Funding; Otsuka: Honoraria, Research Funding; Meiji-seika: Honoraria, Research Funding; SBI pharma: Honoraria, Research Funding. Mishima:Ono: Research Funding; Chugai: Research Funding; MSD: Research Funding; Eisai: Research Funding; Teijin Pharma: Research Funding; Medical U and A: Research Funding; AbbVie: Research Funding; Otsuka: Research Funding; Daiichi-Sankyo: Research Funding; Nihon-Medi-Physics: Research Funding. Terui:Bristol-Myers Squibb, Celgene, Janssen, Takeda, MSD, Eisai, Ono, and Chugai-Roche Pharmaceuticals Co.,Ltd.: Honoraria; Bristol-Myers Squibb K.K.: Research Funding. Arakawa:UCB: Honoraria; Otsuka: Honoraria; AbbVie: Honoraria; NovoCure: Honoraria; CSL Behring: Honoraria; Nippon-Kayaku: Honoraria; Pfizer: Research Funding; Takeda: Research Funding; CLS: Research Funding; Daiichi-Sankyo: Honoraria, Research Funding; Meiji Seika: Honoraria, Research Funding; Eisai: Honoraria, Research Funding; Chugai: Honoraria, Research Funding; Merck: Honoraria, Research Funding; TanabeMitsubishi: Research Funding; Zeiss: Research Funding; Brainlab: Honoraria, Research Funding; Nihon Medi-Physics: Research Funding; Sanofi: Research Funding; Philips: Research Funding; Siemens: Research Funding; Ono: Research Funding. Yonezawa:Ono: Research Funding. Asai:Ono: Research Funding. Fukuhara:Mundi: Honoraria; Takeda Pharmaceutical Co., Ltd.: Honoraria, Research Funding; Nippon Shinkyaku: Honoraria; Kyowa-Hakko Kirin: Honoraria; Mochida: Honoraria; Bayer: Research Funding; Gilead: Research Funding; Chugai Pharmaceutical Co., Ltd.: Honoraria; Ono Pharmaceutical Co., Ltd.: Honoraria; Eisai: Honoraria, Research Funding; Celgene Corporation: Honoraria, Research Funding; Janssen Pharma: Honoraria; Zenyaku: Honoraria; AbbVie: Research Funding; Solasia Pharma: Research Funding. Sugiyama:Ono: Research Funding; Taiho: Research Funding; Daiichi-Sankyo: Research Funding; Bristol-Myers-Squibb: Research Funding; Chugai: Research Funding; Meiji Seika: Research Funding; Yakult: Research Funding. Shinojima:Ono: Research Funding. Kitagawa:Ono: Employment. Aoi:Ono: Employment. Nishikawa:Ono: Honoraria, Research Funding; MSD: Research Funding; AbbVie: Honoraria, Research Funding; Eisai: Honoraria, Research Funding; Chugai: Honoraria, Research Funding; NovoCure: Honoraria; Daiichi-Sankyo: Honoraria. OffLabel Disclosure: Tirabrutinib. Clinical trial for PCNSL.

BACKGROUND The addition of high-dose methotrexate (HD-MTX)-based chemotherapy to whole brain irradiation (WBRT) has improved the prognosis of primary central nervous system lymphoma (PCNSL). However, the high neurotoxicity rates observed, especially in the elderly, raised interest in chemotherapy-only treatments. Withholding radiotherapy substantially decreases the risk of neurotoxicity, however, disease control may be compromised. Therefore, developing a novel treatment for the elderly PCNSL patients (ePCNSL) is crucial. In the elderly who cannot tolerate WBRT as a consolidation, maintenance treatment may serve as a feasible approach after an initial response. We treated ePCNSL with induction immunochemotherapy with rituximab (RIT) and HD-MTX, maintenance chemotherapy with HD-MTX and deferred WBRT. Here, we retrospectively investigated the prognosis for ePCNSL that became CR after the induction chemotherapy. MATERIAL AND METHODS Newly diagnosed ePCNSL (median age: 74 years) received biweekly RIT/ HD-MTX (375 mg/m2/dose; 3.5g/m2/dose) for 6 cycles (induction) followed by monthly RIT/MTX for 2 cycles (consolidation) and then were treated differently according to the radiological response. With CR patients, HD-MTX was continued with every 3 months (maintenance) for 2 years. Patients who did not obtain consent for maintenance therapy were followed up. RESULTS Of the 42 ePCNSL (median age 74 years), 26 had CR after induction and consolidation, of which 18 cases were carried out maintenance (M +) and 8 cases were followed up (M-). The median age was 74 and 76, respectively. Median progression-free survival (mPFS) was 73 months in the M+ group and 24.6 months in the M- group. Median overall survival (mOS) is 92.5 months versus 27.6 months, respectively. Both mPFS (P= 0.025) and mOS (P =0.0003) were significantly prolonged by maintenance therapy. In addition, ePCNSL with tumors involvement of deep brain structure had a poor prognosis. CONCLUSION It was suggested that maintenance treatment with HD-MTX may improve the prognosis for ePCNSL that reached complete response after induction therapy.

Carmustine (BCNU) implants (Gliadel® Wafer, Eisai Inc., New Jersey, USA) for the treatment of malignant gliomas (MGs) were shown to enhance overall survival in comparison to placebo in controlled clinical trials in the United States and Europe. A prospective, multicenter phase I/II study involving Japanese patients with MGs was performed to evaluate the efficacy, safety, and pharmacokinetics of BCNU implants. The study enrolled 16 patients with newly diagnosed MGs and 8 patients with recurrent MGs. After the insertion of BCNU implants (8 sheets maximum, 61.6 mg BCNU) into the removal cavity, various chemotherapies (including temozolomide) and radiotherapies were applied. After placement, overall and progression-free survival rates and whole blood BCNU levels were evaluated. In patients with newly diagnosed MGs, the overall survival rates at 12 months and 24 months were 100.0% and 68.8%, and the progression-free survival rate at 12 months was 62.5%. In patients with recurrent MGs, the progression-free survival rate at 6 months was 37.5%. There were no grade 4 or higher adverse events noted due to BCNU implants, and grade 3 events were observed in 5 of 24 patients (20.8%). Whole blood BCNU levels reached a peak of 19.4 ng/mL approximately 3 hours after insertion, which was lower than 1/600 of the peak BCNU level recorded after intravenous injections. These levels decreased to less than the detection limit (2.00 ng/mL) after 24 hours. The results of this study involving Japanese patients are comparable to those of previous studies in the United States and Europe.

We report an 84-year-old woman with rheumatoid meningitis. She developed weakness in her muscles and became cognitively impaired. However, physical examination revealed no evidence of rheumatoid arthritis. Levels of anti-cyclic citrullinated peptide antibodies were elevated. Brain magnetic resonance imaging (MRI) showed hyperintense lesions in the frontotemporoparietal subarachnoid space on fluid attenuated inversion recovery (FLAIR) images. Leptomeningeal enhancement was also evident on gadolinium-enhanced T1-weighted images. We suspected rheumatoid meningitis. A brain biopsy was performed and methylprednisolone pulse therapy was started. Subsequently, her symptoms and MRI findings rapidly improved.

Central nervous system (CNS) hemangioblastoma (HB) is one of the most common manifestations in von Hippel-Lindau disease (VHL), but large-scale studies on clinical features of CNS HB in VHL are scarce. On the basis of the results of a questionnaire, we collected data of VHL patients with CNS HB. The total number of CNS HBs in 111 VHL patients (male 59, female 52) was 264 with the following distributions: cerebellar, 65.4 %; brainstem, 9.9 %; spinal cord, 23.9 %; and pituitary, 1. 1 %. The follow-up period was 0.6 to 39.2 years, with the mean 12.5 years. Patients bearing brainstem or spinal cord HB also had another HB significantly more frequently than those bearing cerebellar HBs (P

Recent gene expression and copy number profilings of glioblastoma multiforme (GBM) by The Cancer Genome Atlas (TCGA) Research Network suggest the existence of distinct subtypes of this tumor. However, these approaches might not be easily applicable in routine clinical practice. In the current study, we aimed to establish a proteomics‐based subclassification of GBM by integrating their genomic and epigenomic profiles. We subclassified 79 newly diagnosed GBM based on expression patterns determined by comprehensive immunohistochemical observation in combination with their DNA copy number and DNA methylation patterns. The clinical relevance of our classification was independently validated in TCGA datasets. Consensus clustering identified the four distinct GBM subtypes: Oligodendrocyte Precursor (OPC) type, Differentiated Oligodendrocyte (DOC) type, Astrocytic Mesenchymal (AsMes) type and Mixed type. The OPC type was characterized by highly positive scores of Olig2, PDGFRA, p16, p53 and synaptophysin. In contrast, the AsMes type was strongly associated with strong expressions of nestin, CD44 and podoplanin, with a high glial fibrillary acidic protein score. The median overall survival of OPC‐type patients was significantly longer than that of the AsMes‐type patients (19.9 vs 12.8 months). This finding was in agreement with the Oncomine analysis of TCGA datasets, which revealed that PDGFRA and Olig2 were favorable prognostic factors and podoplanin and CD44 were associated with a poor clinical outcome. This is the first study to establish a subclassification of GBM on the basis of immunohistochemical analysis. Our study will shed light on personalized therapies that might be feasible in daily neuropathological practice. (Cancer Sci, doi: 10.1111/j.1349‐7006.2012.02377.x, 2012)

BACKGROUND: Central nervous system germ cell tumors (CNS-GCT) are a heterogeneous group of diseases. The management of CNS-GCT remains controversial. Objective: To clarify the relapse pattern and outcome of patients with recurrent CNS-GCT in order to find problems with current initial management. METHODS: Chart review of patients with recurrent CNS-GCTs treated in two institutions from 2007 to 2017. RESULTS: There were 19 germinomas and six non-germinomatous germ cell tumors (NGGCT), referred to us for the first (n=19), second (n=4), third (n=1) and fourth (n=1) relapse. The time from the diagnosis to the first relapse was within three years for 15 patients (range 6- 24 months) and over three years (range 36 -144 months) for 10 patients. The site of recurrence was outside the irradiation field for 13 germinoma cases, and inside for six germinoma and six NGGCT patients. Thirteen patients with first recurrent germinoma survived with chemotherapy and re-irradiation, and one failed with high-dose chemotherapy only. Two patients with second relapse of germinoma were successfully treated with high-dose chemotherapy only. One patient with second relapse of germinoma refractory to chemotherapy and re-irradiation is alive with oral metronomic etoposide for nine years. Only one of six NGGCT patients survived in spite of intensive treatments. CONCLUSIONS: Germinoma patients treated with reduced radiotherapy and chemotherapy can relapse both within and outside irradiation fields, very early and very late in longer follow-up. These results can teach us not only the optimal management of recurrent disease, but also suggest possible novel management of initial disease.

CD9 has been reported to play a role in tumor metastasis suppression. However, it is not fully understood how CD9 affects the hematogenous spread of tumor cells. To clarify a new mechanism (or mechanisms), we generated HT1080 cells that had been transfected with a CD9-expressing plasmid. Ectopic expression of CD9 in HT1080 cells actually reduced their metastatic ability. CD9 expression reduced lung retention and platelet ag-gregation activity of the transfectants. Because HT1080 cells express the metastasis-promoting, platelet aggregation-inducing factor Aggrus/podoplanin on their surface, we examined the relationship between CD9 and Aggrus. We discovered that CD9 formed a complex with Aggrus via transmembrane domains 1 and 2 (TM1 and TM2) of CD9. Investigation of the interaction revealed that each CD9 and Aggrus interacted homophilically, and that they colocalized in low-density membrane fractions. Deleting TM1 and TM2 attenuated the ability of CD9 to interact homophilically or to localize in low-density membrane fractions. The expression of CD9–wild-type (WT), but not CD9 lacking TM1 and TM2, attenuated the platelet aggregation and metastasis induced by forced expression of Aggrus in CHO cells. Therefore, CD9 may act as a metastasis suppressor, at least in part, by neutralizing Aggrus-mediated platelet aggregation.

Purpose: The p16 gene is frequently inactivated in lung adenocarcinoma. In particular, homozygous deletions (HD) have been frequently detected in cell lines; however, their frequency and specificity is not well-established in primary tumors. The purpose of this study was to elucidate the prevalence and the timing for the occurrence of p16 HDs in lung adenocarcinoma progression in vivo. Experimental Design: Multiple ligation-dependent probe amplification was used for the detection of p16 HDs in 28 primary small-sized lung adenocarcinomas and 22 metastatic lung adenocarcinomas to the brain. Cancer cells were isolated from primary adenocarcinoma specimens by laser capture microdissection. HDs were confirmed by quantitative real-time genomic PCR analysis. Results: HDs were detected in 8 of 28 (29%) primary tumors, including 2 of 8 (25%) noninvasive bronchioloalveolar carcinomas, and 5 of 22 (26%) brain metastases, respectively. No significant associations were observed between p16 HDs and gender, age, smoking history, stage, and prognosis. HDs were detected with similar frequencies (17–29%) among adenocarcinomas with epidermal growth factor receptor (EGFR) mutations, with KRAS mutations, and without EGFR/KRAS mutations, and with similar frequencies (22–28%) between adenocarcinomas with and without p53 mutations. Conclusions: p16 HDs occur early in the development of lung adenocarcinomas and with similar frequencies among EGFR type, KRAS type, and non-EGFR/KRAS type lung adenocarcinomas. Tobacco carcinogens would not be a major factor inducing p16 HDs in lung adenocarcinoma progression.

Podoplanin (aggrus), a transmembrane sialoglycoprotein, is involved in tumor cell-induced platelet aggregation, tumor metastasis, and lymphatic vessel formation. However, the mechanism by which podoplanin induces these cellular processes including its receptor has not been elucidated to date. Podoplanin induced platelet aggregation with a long lag phase, which is dependent upon Src and phospholipase Cgamma2 activation. However, it does not bind to glycoprotein VI. This mode of platelet activation was reminiscent of the snake toxin rhodocytin, the receptor of which has been identified by us as a novel platelet activation receptor, C-type lectin-like receptor 2 (CLEC-2) (Suzuki-Inoue, K., Fuller, G. L., Garcia, A., Eble, J. A., Pohlmann, S., Inoue, O., Gartner, T. K., Hughan, S. C., Pearce, A. C., Laing, G. D., Theakston, R. D., Schweighoffer, E., Zitzmann, N., Morita, T., Tybulewicz, V. L., Ozaki, Y., and Watson, S. P. (2006) Blood 107, 542-549). Therefore, we sought to evaluate whether CLEC-2 serves as a physiological counterpart for podoplanin. Association between CLEC-2 and podoplanin was confirmed by flow cytometry. Furthermore, their association was dependent on sialic acid on O-glycans of podoplanin. Recombinant CLEC-2 inhibited platelet aggregation induced by podoplanin-expressing tumor cells or lymphatic endothelial cells, suggesting that CLEC-2 is responsible for platelet aggregation induced by endogenously expressed podoplanin on the cell surfaces. These findings suggest that CLEC-2 is a physiological target protein of podoplanin and imply that it is involved in podoplanin-induced platelet aggregation, tumor metastasis, and other cellular responses related to podoplanin.

Primary central nervous system lymphoma (PCNSL) is a rare malignancy confined to CNS. Despite low tendency of systemic dissemination, its prognosis is poor with median overall survival of 4 years when treated with standard of care high-dose methotrexate-based chemoradiotherapy. Despite majority of PCNSL is diffuse large B-cell lymphoma (DLBCL), its response to therapy and biological behavior differ from the systemic disease, necessitating detailed investigation of its pathogenesis and genetic alterations. Here we performed whole-exome sequencing (WES) on 41 PCNSL and paired normal specimens as well as RNA sequencing. Seven cases were classified as germinal center B-cell-like (GCB) subtype (17%), while 34 cases were non-GCB. Progression-free survival was significantly longer in cases with GCB subtype as in systemic DLBCL (p = 0.027). WES yielded sequencing data with a mean coverage of 158Χ with 98% of the targeted bases covered by ≥20 independent reads. We identified a total of 17,385 somatic mutations, of which 62% were nonsynonymous single nucleotide variations. The predominant nucleotide substitution was a C > T transition (57.8%), especially in the context of the sequence GCG. WES revealed a substantial extent of aberrant somatic hypermutation (aSHM) with a high frequency of nonsynonymous somatic mutations especially in PIM1 (90.2%) and BTG2 (65.9%). Genes mutated other than aSHM include MYD88 (85.4%), most of which being L265P activating mutation. These mutations were not associated with GCB/non-GCB subtypes. Notably, mutations in a number of genes related to the NF-κB signaling pathway were also prominent. Copy number aberration analysis identified gains in chromosomes 1q, 7, 12, and 18q, and a loss of 6q. These results suggest that MYD88 and PIM1 mutations may play an important role in PCNSL development regardless of GCB subtypes, and NF-κB pathway could be the therapeutic targets of this intractable disease.

PURPOSE: Of the genetic mutations seen in gliomas, IDH1/2 mutations, chromosome 1p/19q loss, MGMT promoter methylation, and genetic alterations of TERT promoter, BRAF, and H3F3A, have become increasingly important as biomarkers for the diagnosis, prognostication, and treatment response of gliomas. Here we report on the establishment of a system, within our institution, of the efficient and rapid detection of these genetic mutations. METHODS: Tumor-derived DNA and RNA extracted from either frozen or paraffin-embedded histological sections were used as specimens. For the point mutation assay, the following mutations of: IDH1/2, H3F3A, BRAF codon 600, and the TERT promoter were screened using High Resolution Melting (HRM) method, and identified by DNA sequencing. For the MGMT promoter methylation, a quantitative analysis was performed using the methylation-specific HRM method. Real-time PCR was used for determining the presence or absence of the BRAF-KIAA fusion gene, and FISH was used for detecting chromosome 1p/19q loss. Further, immunostaining was performed to analyze loss of ATRX (alpha-thalassemia/mental-retardation syndrome-X-linked) expression. RESULTS: Screening of each of the genetic mutations by the point mutation assay using the HRM method was completed in one run of approximately 70 minutes. Furthermore, all genetic mutation results were obtained within 5 ∼ 72 hours after nucleic acid extraction using our assay system. CONCLUSION: For clinics that specialize in diagnosis and treatment of brain tumors, the genetic biomarker information mentioned above will become indispensible in the future. Outsourcing this testing has issues relating to cost and time to obtaining results, and thus testing in-house is desirable. Utilizing PCR primer settings that allow the screening of multiple genetic mutations in one run, and simple and sensitive/specific assays such as the HRM method, allows efficient and rapid analysis.

BACKGROUND: Intracranial germ cell tumors (iGCTs) are rare in the Western countries, however they are the second most common brain tumors in patients under 14 in Japan. Unlike other common pediatric brain tumors, the biology of iGCTs is largely unknown. METHODS: We performed a whole exome sequencing in a large series of iGCTs to elucidate their molecular pathogenesis. A total of 198 germ cell tumors (GCTs) including 133 iGCTs (69 pure germinomas, 56 NGGCTs and 8 metastatic tumors) as well as 65 testicular germ cell tumors (tGCTs) (39 seminomas and 26 non-seminoma GCTs) were collected from 13 centers participating in the Intracranial Germ Cell Tumor Consortium in Japan. Somatic mutations in all coding exons were investigated by whole exome sequencing (WES) in 41 tumors and the matched normal DNAs. Based on the WES data, 41 candidate genes were selected according to the frequency and/or significance of the mutations found. All coding exons of these 41 genes spanning over 160kb were PCR-amplified in a further 157 GCTs and sequenced using the IonTorrent system. The results were integrated with the patients' clinical information that was available for 124 iGCT patients. RESULTS: On average, 15.4 non-synonymous somatic mutations were observed in each tumor, ranging from 1 to 140 by WES in 41 iGCTs. The combined WES and IonTorrent screenings showed that KIT was the most frequently mutated gene in both iGCTs (27%) and tGCTs (18%). MTOR was the second most frequently mutated also in both iGCTs (7%) and tGCTs (6%). RAS mutations (KRAS, HRAS, NRAS) were altogether found in 13% of iGCTs and 12% of tGCTs. These mutations were mutually exclusive to each other and also to KIT mutations. Collectively, the genes involved in the MAPK pathway (e.g., KIT, RAS, NF1) and the PI3K/MTOR pathway (e.g., MTOR, PTEN) were mutated in 44% and 13% of all GCTs. Among the iGCTs, these alterations were significantly more common among pure germinomas than NGGCTs. The mutated MTOR protein was shown to have increased kinase activity, which was suppressed by specific MTOR inhibitors. CONCLUSIONS: Our comprehensive mutational genomic analysis of GCTs revealed that alterations of the MAPK and/or PI3K/MTOR pathways play a critical role in the pathogenesis of both iGCTs and tGCTs, although the extent of their involvement depends on the histopathological subtypes. Our findings will hopefully lead to the development of a targeted therapy for treatment-resistant iGCTs. SECONDARY CATEGORY: Tumor Biology.

Glioblastoma multiforme (GBM) is the most aggressive type of glioma and GBMs frequently contain amplifications or mutations of the EGFR gene. The most common mutation results in a truncated receptor tyrosine kinase known as Delta EGFR that signals constitutively and promotes GBM growth. Here, we report that the 45-kDa variant of the protein tyrosine phosphatase TCPTP (TC45) can recognize Delta EGFR as a cellular substrate. TC45 dephosphorylated Delta EGFR in U87MG glioblastoma cells and inhibited mitogen-activated protein kinase ERK2 and phosphatidylinositol 3-kinase signaling. In contrast, the substrate-trapping TC45-D182A mutant, which is capable of forming stable complexes with TC45 substrates, suppressed the activation of ERK2 but not phosphatidylinositol 3-kinase. TC45 inhibited the proliferation and anchorage-independent growth of Delta EGFR cells but TC45-D182A only inhibited cellular proliferation. Notably, neither TC45 nor TC45-D182A inhibited the proliferation of U87MG cells that did not express Delta EGFR. Delta EGFR activity was necessary for the activation of ERK2, and pharmacological inhibition of ERK2 inhibited the proliferation of Delta EGFR-expressing U87MG cells. Expression of either TC45 or TC45-D182A also suppressed the growth of Delta EGFR-expressing U87MG cells in vivo and prolonged the survival of mice implanted intracerebrally with these tumor cells. These results indicate that TC45 can inhibit the Delta EGFR-mediated activation of ERK2 and suppress the tumorigenicity of Delta EGFR-expressing glioblastoma cells in vivo.