Children s Brain Tumour Research translating research into practice

Children’s Brain Tumour Research: translating research into practice of Dr David Walker, Professor Paediatric Oncology, Children’s Brain Tumour Research Centre, Faculty of Medicines and Health Sciences,

Childrens Brain Tumour Research Centre www. cbtrc. org • To highlight the epidemiology clinical challenges of childhood brain tumours – including Proton Beam Therapy • To illustrate two research projects within a CNS drug delivery development programme for childhood brain tumours

Worldwide, ~260, 000 children develop cancer each year Of these, 30, 000 -40, 000 children have CNS tumors

A Developmental Hypothesis for Childhood Cancer Nature Reviews Cancer (2005) 5; 481 -488

Prof David Walker Professor of Pediatric Oncology

Cerebellar Medulloblastoma with Spinal Metastases Survival Rates: No metastases ~ 80% 5 -10 yr + Chemo & Cranio Spinal RT 24 Gy Metastases ~ 60% 5 -10 yr + Chemo & Cranio Spinal RT >36 Gy

IQ modelling after cranial irradiation during childhood

Height SDS for patients treated with: Cranial Irradiation Cranio-Spinal Irradiation

$Improved Exec Functn SIOP PNET 4 Trial comparing Hyperfractionated RT (HFRT) versus Standard RT$

Improved Exec Functn SIOP PNET 4 Trial comparing Hyperfractionated RT (HFRT) versus Standard RT STRT

$SIOP PNET 4 Trial comparing Hyperfractionated RT (HFRT) versus Standard RT STRT Height SDS$

SIOP PNET 4 Trial comparing Hyperfractionated RT (HFRT) versus Standard RT STRT Height SDS Greater loss of height

Conventional craniospinal radiotherapy Tomotherapy Machine Similar principle to 3 D / conformal Radiotherapy

The Therapeutic Challenge of Childhood CNS Tumour Therapies • • Optimization / individualisation of therapies Maximise efficacy against tumour Minimise toxicity for brain and organ systems Incorporate new therapeutics

HATCH, MATCH, DESPATCH and DELIVER A drug delivery programme to optimise medical therapy for brain tumours : A PROPOSAL FOR A COLLABORATIVE NETWORK Match Hatch Tumour Biology Targets Pathways Bioinformatics Drugs Chemotherapeutics Biological agents Existing or new Tumour Biology Drug/ biomodifier Delivery system/route Intra-CSF Interstitial Enhanced systemic Sustained release Enhanced local Despatch Delivery system testing Does it get into the brain? Does it get into the cell? Does it damage the tumour? Does it damage the brain? Enhanced Experimental Models 3 D C—culture Organotypic Blood brain barrier Rotary Cell Culture System In vivo orthotopic resection model Deliver Clinical trials Licensing Commercialisation Clinical practice

Direct CNS drug delivery Provides Needs Cytotoxic concentration to tumour bypassing blood-brain barrier (BBB) Matching of effective drug, biology and optimal delivery system to tumour location

Blood-brain-barrier complicates CSF entrance of systemic administered drugs 3 barrier sites to CNS 1. Blood-brain-barrier 2. Arachnoid membrane (meninges) 3. Choroid plexus epithelium Problem tight junctions 2 1 3 Abbott 2006

Leukaemia: replace RT by intra-CSF Tx: No significant difference in outcome Clarke, 2003

A systematic literature and dataset review • To identify drugs most suitable for further investigation for intrathecal administration to children with brain tumours – based on physicochemical characteristics and current knowledge of use. – Conroy, Walker et al

Effective drug for drug delivery system Clinically • Non-irritant • Low/absent neurotoxicity • Evidence of tumour sensitivity Adapted from Conroy et. al 2010 Physico-chemical and pharmaceutical • Characteristics that suit delivery method • Active, e. g. does not need metabolisation • Stable in drug delivery system • Readily diffusion from drug delivery system

Most promising drugs for IT use? • Carboplatin • Cytarabine - depot formulations • Diaziquone • Etoposide • Floxuridine • • • Mafosfamide Mercaptopurine Nimustine Ranimustine Temozolomide Topotecan

Intra-CSF administration VR: ventricular route Through Ommaya reservoir LR: lumbar route Through Port-A-Cath with lumbar line extension Blue is cerebrospinal fluid space Red is blood space

Mode of administration has impact on clinical outcome Intraventricular Etoposide Reduction in tumour size Prechemo Postchemo Oral Etoposide Tumour growth Nottingham University Hospital Prechemo Postchemo

HATCH, MATCH, DESPATCH and DELIVER A drug delivery programme to optimise medical therapy for brain tumours : A PROPOSAL FOR A COLLABORATIVE NETWORK Match Hatch Tumour Biology Targets Pathways Bioinformatics Drugs Chemotherapeutics Biological agents Existing or new Tumour Biology Drug/ biomodifier Delivery system/route Intra-CSF Interstitial Enhanced systemic Sustained release Enhanced local Despatch Delivery system testing Does it get into the brain? Does it get into the cell? Does it damage the tumour? Does it damage the brain? Enhanced Experimental Models 3 D C—culture Organotypic Blood brain barrier Rotary Cell Culture System In vivo orthotopic resection model Deliver Clinical trials Licensing Commercialisation Clinical practice

HD systemic administration does not yield cytotoxic CSF concentration Intra-CSF at 1/200 th systemic dose does IVC: intraventricular CIV: continuous intravenous infusion VP 16: etoposide cytotoxic concentration 0. 5 mg /day intraventricular etoposide bolus on 5 consecutive days vs. 400 mg/m 2 continuous intravenous etoposide over 96 hours At 1/200 of dose Fleischhack 2001, Henwood 1990

Clinical studies with ventricular route etoposide Fleischhack et al 2001 Slavc et al. 2003 • 59 courses, 14 patients • 0. 5 mg intraventricular, 5 days, every 2 -5 weeks • 2 courses headache, 2 courses bacterial meningitis • 2 CR, 1 SD, 2 MR, 7 PR, 2 PD • 122 courses, 2 patients etoposide, 9 patients etopose/mafosfamide • 0. 5 mg intraventricular, 2 -6 weeks • No short or long term toxicity with etoposide • 3 CR, 3 PR, 5 DOD (1, 12, 23, 30, 42 months)

Etoposide more cytotoxic at longer exposure than higher dose Fleischhack group

HATCH, MATCH, DESPATCH and DELIVER A drug delivery programme to optimise medical therapy for brain tumours : A PROPOSAL FOR A COLLABORATIVE NETWORK Match Hatch Tumour Biology Targets Pathways Bioinformatics Drugs Chemotherapeutics Biological agents Existing or new Tumour Biology Drug/ biomodifier Delivery system/route Intra-CSF Interstitial Enhanced systemic Sustained release Enhanced local Despatch Delivery system testing Does it get into the brain? Does it get into the cell? Does it damage the tumour? Does it damage the brain? Enhanced Experimental Models 3 D C—culture Organotypic Blood brain barrier Rotary Cell Culture System In vivo orthotopic resection model Deliver Clinical trials Licensing Commercialisation Clinical practice

Preparing Infusional Etoposide for Despatch • CRUK New Agent Committee Funding • Selection of Etoposide formulation – ETO Gry, preservative free • Clinical risk assessment for Intra-CSF administration • Etoposide stability over prolonged periods • Surety syringe system and drug interaction requiring syringe re-design. • Neurosurgical survey of device insertion and safety • Patient acceptability reporting – see video • Ethical and R and I approval • Setting trial launch date Dec 2014

Selecting target CSF [Etoposide] • 3 D human culture system • Previously published pharmacokinetic data • Cytotoxicity of sustained Etoposide exposure in human tumour cells • CSF route administration and clearance data in young children with different CSF volumes

HATCH, MATCH, DESPATCH and DELIVER A drug delivery programme to optimise medical therapy for brain tumours : A PROPOSAL FOR A COLLABORATIVE NETWORK Match Hatch Tumour Biology Targets Pathways Bioinformatics Drugs Chemotherapeutics Biological agents Existing or new Tumour Biology Drug/ biomodifier Delivery system/route Intra-CSF Interstitial Enhanced systemic Sustained release Enhanced local Despatch Delivery system testing Does it get into the brain? Does it get into the cell? Does it damage the tumour? Does it damage the brain? Enhanced Experimental Models 3 D C—culture Organotypic Blood brain barrier Rotary Cell Culture System In vivo orthotopic resection model Deliver Clinical trials Licensing Commercialisation Clinical practice

INTREPID protocol scheme Cohort 1 Over three years ≥ 3 yr D: 0. 8 μg/ml 7 days + shunt ≥ 3 yr D: 0. 8 μg/ml 7 days - shunt Under three years <3 yr D: 0. 8 μg/ml 7 days + shunt <3 yr D: 0. 8 μg/ml 7 days - shunt Cohort 2 Cohort 3 Cohort 4 ≥ 3 yr D: 1. 2 μg/ml 7 days +/- shunt ≥ 3 yr D: 1. 2 μg/ml 10 days +/- shunt ≥ 3 yr D: 1. 2 μg/ml 14 days +/- shunt Dose escalation Infusion duration escalation <3 yr D: 1. 2 μg/ml 7 days +/- shunt <3 yr D: 1. 2 μg/ml 10 days +/- shunt <3 yr D: 1. 2 μg/ml 14 days +/- shunt Dose rate (µg/min) = clearance (ml/min) x steady state concentration x 60 (min) DR = 0. 56 x 0. 8 x 60

What have we learnt? Ø It is possible to bring a novel drug to trial for intra-CSF infusional administration in children Ø Infusional intra-CSF delivery offers strong theoretical benefits over systemic administration Ø Clinical risk assessment must be tackled as a specific step in planning the clinical trial Ø Sharing learning through collaboration would offer a route to disseminate expertise Ø Using experience of development of other Drug Delivery Systems in a collaborating network in rare disease is the ethically preferred method for further system development

INTREPID PI: David Walker Co-applicants Lisethe Meijer Gareth Veal Richard Grundy Pamela Kearns Collaborators Neuro-surgery Pharmacy: - Donald Macarthur - Research pharmacist to appoint - Stuart Smith Neuro-radiology - Rob Dineen - Tim Jaspan (central radiology review) - Malcolm Partridge - Nigel Ballentine Statistician - Veronica Moroz Neuro-toxicity study Trial coordinator: - Charlotte Teunissen - Elena Brodgen

Childrens Brain Tumour Research Centre www. cbtrc. org • To highlight the epidemiology clinical challenges of childhood brain tumours – including Proton Beam Therapy • To illustrate two research projects within a CNS drug delivery development programme for childhood brain tumours

Multiplexing Three Methods for Spheroid Viability Determination in High-Throughput Delyan Ivanov

Inception of project Selective uptake of NPs into tumors in 3 D Weina Meng (2007), Ph. D Thesis, University of Nottingham

Safety and efficacy in brain cancer therapy Stem cell neurosphere Tumor spheroid Safety Efficacy Neural stem cells UW 228 Tumor cells: Human fetal brain tissue Human medulloblastoma Proliferating part of brain Invading cancer cells

User-friendly 3 D screens Seed cell suspension Spheroid formation Ultra low attachment plate Spheroid ready for analysis Reproducible diameter from 100 to 900µm with CV 3 -10% Fast form dense spheroids in 72 h Analysis-friendly measure fluorescence and absorbance directly in plates Vinci M, BMC Biology 2012, 10: 29

Stem cells vs Tumors * *

Acknowledgements Martin Garnett Cameron Alexander Weina Meng David Walker Beth Coyle Marianne Ashford Paul Gellert Terry Parker CBTRC FRAME Lab

Aim INTREPID study To achieve target CSF steady state etoposide concentration by continuous infusion in patients with/without shunt < and ≥ three years of age.

Intra-cavity chemotherapy: neurosurgical drug delivery to paediatric brain tumours

Introduction • High grade invasive childhood brain tumours have high recurrence rates despite multimodal therapy, often within 2 cm of resection cavity wall • Intra-cavity application of chemotherapy bypasses the blood brain barrier, targeting micro-deposits of residual neoplastic cells • Has the potential to achieve high levels of drug within the brain parenchyma, whilst minimising systemic exposure • Mode of therapy currently utilised by Gliadel. TM wafers in adult high grade glioma (polifeprosan 20 with carmustine implant) • Shown to be safe with modest but significant survival benefit (Brem et al. Lancet 1995)

Tumour Bed directed Rx However : • Monotherapy, with an agent that may not be best choice for childhood brain tumours • Wafers can dislodge and fall to bottom of cavity • Poor contact with brain parenchyma due to rigid, non -conformable nature of wafer • Release can not be tailored or controlled Development of PLGA / PEG polymer matrix as carrier for locally applied chemotherapy which potentially offers several advantages over Gliadel. TM Gliadel wafers

Poly(lactic-co-glycolic acid)/poly(ethylene glycol (PLGA/PEG) matrix formation STEP 1: PRE-ADMINISTRATION PLGA/PEG particles Aqueous carrier STEP 2: IMMEDIATELY POST-ADMINISTRATION Particles become cohesive at 37°C & adhere to each other (sintering time 15 minutes) STEP 3: POST-ADMINISTRATION Particles re-solidify to form adhesion bridges between other particles (porous structure stabilised) 100 m

PLGA/PEG matrix application ex vivo

PLGA/PEG is distinguishable on MRI and CT scans (E) T 2 weighted MR scan of ex vivo ovine brain with pseudo-resection cavity filled with PLGA/PEG (arrow) (F) CT scan of ex vivo sheep brain demonstrating cavity filled with PLGA/PEG (white arrow) and second cavity lined with PLGA/PEG (black arrow) Rahman et al. PLOSone 2013

PLGA/PEG matrices are non-toxic Human Brain Microvascular Endothelial Cells Rahman et al. PLOSone 2013

Sustained in vitro drug release from PLGA/PEG matrices Trichostatin A Etoposide – 24 day release (total release 77%) Trichostatin A – 18 day release (total release 94%) Methotrexate – 6 day release (total release 51%) Etoposide Methotrexate

% cell viability +72 hrs Released agents retain cytotoxic capabilities 100 80 60 40 20 0 % cell viability +72 hrs 100 PFSK-1 No drug Trichostatin A Etoposide Drug loaded into PLGA/PEG matrix Methotrexate DAOY 80 60 40 20 0 No drug Trichostatin A Etoposide Methotrexate Drug loaded into PLGA/PEG matrix

In vivo efficacy H&E GFAP Group 1: Partial resection 100µM Group 2: Partial resection + PLGA/PEG + etoposide (3 days post-implant) Smith et al. Annals RCSEng 2014

Smith et al. Annals RCSEng 2014

Issues and Concerns • Infection • Chemotherapy release preventing wound healing • Induction of epileptic focus • Limited treatment period – 1 month • Parenchymal diffusion • Neurotoxicity

Future Directions • Adaptation of relevant chemotherapeutic agents to allow sustained and controlled release e. g. temozolomide • In vivo xenograft trial in rodent flank ongoing • Establish effective drug combinations in two and three dimensional tissue models • Development of orthotopic partial resection model • First in human trials

INTREPID PI: David Walker Co-applicants Lisethe Meijer Gareth Veal Richard Grundy Pamela Kearns Collaborating children’s hospitals Newcastle Bristol Leeds GOSH Collaborators Neuro-surgery Pharmacy: - Donald Macarthur - Research pharmacist to appoint - Stuart Smith Neuro-radiology - Rob Dineen - Tim Jaspan (central radiology review) - Malcolm Partridge - Nigel Ballentine Statistician - Veronica Moroz Neuro-toxicity study Trial coordinator: - Charlotte Teunissen - Elena Brodgen

Team / Funding PLGA/PEG Children’s Brain Tumour Research Centre, University of Nottingham Dr. Stuart Smith Prof. Richard Grundy Dr. Ruman Rahman Dr. Jennifer Ward Dr Toby Gould School of Pharmacy, University of Nottingham Prof. Kevin Shakesheff Dr. Cheryl Rahman Dr. Felicity Rose Division of Pre-Clinical Oncology, University of Nottingham Dr. Phil Clarke Dr. Alison Ritchie Department of Neurosurgery, University of Cambridge Mr. Colin Watts Department of Neurosurgery, Queen’s Medical Centre Nottingham Mr. Donald Macarthur, Mr. Paul Byrne Academic Radiology Department, University of Nottingham Dr. Paul Morgan Radiation Physics Unit, City Hospital Nottingham Dr. Keith Langmack

Thank you for your attention