• David I Sandberg, Bangning Yu, Rajan Patel, John Hagan, Emilie Miesner, Jennifer Sabin, Sarah Smith, Stephen Fletcher, Manish N Shah, Rachael W Sirianni, and Michael D Taylor.
• Division of Pediatric Neurosurgery, Departments of Pediatric Surgery and Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston and Mischer Neuroscience Center, 6431 Fannin St., MSB 5.140, Houston, TX, 77030, USA. David.I.Sandberg@uth.tmc.edu.
• J. Neurooncol. 2019 Jan 1; 141 (2): 449-457.

BackgroundDNA methylation inhibitors are logical therapeutic candidates for ependymomas originating in the posterior fossa of the brain. Our objective was to test the safety of infusing 5-Azacytidine (5-AZA), a DNA methylation inhibitor, directly into cerebrospinal fluid (CSF) spaces of the fourth ventricle or tumor resection cavity in children with recurrent ependymoma originating in the posterior fossa.Materials And MethodsIn patients with recurrent ependymoma whose disease originated in the posterior fossa, a maximal safe subtotal tumor resection was performed. At the conclusion of the tumor resection, a catheter was surgically placed into the fourth ventricle or tumor resection cavity and attached to a ventricular access device. CSF flow from the posterior fossa to the sacrum was confirmed by CINE phase contrast magnetic resonance imaging (MRI) postoperatively. 12 consecutive weekly 10 milligram (mg) infusions of 5-Azacytidine (AZA) were planned. Disease response was monitored with MRI scans and CSF cytology.ResultsSix patients were enrolled. One patient was withdrawn prior to planned 5-AZA infusions due to surgical complications after tumor resection. The remaining five patients received 8, 12, 12, 12, and 12 infusions, respectively. There were no serious adverse events or new neurological deficits attributed to 5-AZA infusions. All five patients with ependymoma who received 5-AZA infusions had progressive disease. Two of the five patients, however, were noted to have decrease in the size of at least one intraventricular lesion.Conclusion5-AZA can be infused into the fourth ventricle or posterior fossa tumor resection cavity without causing neurological toxicity. Future studies with higher doses and/or increased dosing frequency are warranted.

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