PURPOSE:Neurofibromatosis type 2 (NF2) is a tumor predisposition syndrome characterized by bilateral vestibular schwannomas (VSs) resulting in deafness and brainstem compression. This study evaluated efficacy and biomarkers of bevacizumab activity for NF2-associated progressive and symptomatic VSs.PATIENTS AND METHODS:Bevacizumab 7.5 mg/kg was administered every 3 weeks for 46 weeks, followed by 24 weeks of surveillance after treatment with the drug. The primary end point was hearing response defined by word recognition score (WRS). Secondary end points included toxicity, tolerability, imaging response using volumetric magnetic resonance imaging analysis, durability of response, and imaging and blood biomarkers.RESULTS:Fourteen patients (estimated to yield > 90% power to detect an alternative response rate of 50% at alpha level of 0.05) with NF2, with a median age of 30 years (range, 14 to 79 years) and progressive hearing loss in the target ear (median baseline WRS, 60%; range 13% to 82%), were enrolled. The primary end point, confirmed hearing response (improvement maintained ≥ 3 months), occurred in five (36%) of 14 patients (95% CI, 13% to 65%; P < .001). Eight (57%) of 14 patients had transient hearing improvement above the 95% CI for WRS. No patients experienced hearing decline. Radiographic response was seen in six (43%) of 14 target VSs. Three grade 3 adverse events, hypertension (n = 2) and immune-mediated thrombocytopenic purpura (n = 1), were possibly related to bevacizumab. Bevacizumab treatment was associated with decreased free vascular endothelial growth factor (not bound to bevacizumab) and increased placental growth factor in plasma. Hearing responses were inversely associated with baseline plasma hepatocyte growth factor (P = .019). Imaging responses were associated with high baseline tumor vessel permeability and elevated blood levels of vascular endothelial growth factor D and stromal cell-derived factor 1α (P = .037 and .025, respectively).CONCLUSION:Bevacizumab treatment resulted in durable hearing response in 36% of patients with NF2 and confirmed progressive VS-associated hearing loss. Imaging and plasma biomarkers showed promising associations with response that should be validated in larger studies.

Individuals with NF2-related schwannomatosis (NF2-SWN) experience a complex constellation of physical, emotional, and social symptoms that substantially impact quality of life (QoL). Although disease-specific patient-reported outcome measures are increasingly important for evaluating treatment benefit in clinical trials, existing NF2-SWN QoL measures have limitations in content coverage and sensitivity to change. This study describes the development and initial validation a new disease-specific QoL assessment - the Quality of Life Evaluation in NF2-related Schwannomatosis Trials (QUEST). Using a three-phase, mixed-methods approach, items were generated through concept elicitation interviews with individuals with NF2-SWN and clinicians, prioritized via patient survey data, and refined through iterative cognitive debriefing procedures. The resulting 21-item QUEST assesses the extent to which NF2-SWN has negatively impacted a person's daily life over the past seven days. Initial psychometric evaluation was conducted in an international sample of 174 individuals with NF2-SWN aged 15 years and older (117 women (67%), 158 White individuals (89%)). Exploratory factor analysis supported a four-factor structure, and the total score demonstrated excellent internal consistency and strong test-retest reliability. Evidence of construct validity was demonstrated through hypothesized associations with disease-specific, generic, and domain-specific QoL measures, as well as known-groups validity based on self-reported disease severity and number of prior surgeries. Incremental validity analyses indicated that QUEST explained unique variance beyond existing measures. Together, findings support the QUEST as a reliable and valid disease-specific QoL measure with strong content validity and feasibility for use as a clinical trial endpoint in NF2-SWN.

Objective: To evaluate the reliability and validity of a modified Mini Balance Evaluation Systems Test (MiniBESTest) in patients with NF2- related schwannomatosis (NF2-SWN). Design: Repeated-measures design. Setting: Neuro-oncology outpatient clinic. Participants: Individuals with NF2-SWN and clinician-confirmed balance impairment were recruited during outpatient clinic visits. All participants were ambulatory and cognitively capable of providing informed consent. Main outcome measures: Reliability was assessed using intraclass correlation coefficients (ICC) for inter-rater and intra-rater performance across two administrations of the Mini-BESTest (scored 0 - 28, higher scores indicating better balance). Concurrent validity was evaluated using the patient-reported Activity-specific Balance Confidence scale (ABC-scale) score collected at first visit (rated 0 - 100%, scores categorized: low <50%, moderate 50 - 80%, and high >80% confidence maintaining balance during daily activities). Results: Twenty individuals with NF2-SWN (mean age, 48.1 years, 65% male, 60% deafened or hard of hearing) were enrolled. The Mini-BESTest demonstrated excellent inter-rater reliability (ICC = 0.99, CI = 0.97 - 0.995) and intra-rater reliability (ICC = 0.95 and 0.96, CI=0.796 - 0.988 and 0.655 - 0.983 for raters 1 and 2 respectively). Mean Mini-BESTest scores at the first visit were 19.4 and 19.3 across raters (range 6 - 27). The mean ABC score was 74.1% (range, 6.9% - 98.8%). Concurrent validity of the Mini-BESTest with the ABC scale was strong (Spearman p = 0.79 and 0.8 for raters 1 and 2, p < .0001). Conclusions: The Mini-BESTest shows strong reliability and concurrent validity in NF2-SWN. Its successful administration in deafened or hard of hearing individuals supports its clinical applicability in this population.

NF2-related schwannomatosis (NF2-SWN) is an inherited autosomal dominant disorder resulting from loss-of-function mutations in the NF2 gene, for which no effective treatment is currently available. Furthermore, truncating variants in NF2 are associated with the severest phenotype compared to in-frame or missense variants. Previously, a shorter NF2 isoform with exon 11 skipped (merlin_e-11), induced through antisense phosphorodiamidate morpholino oligomers (PMOs), was able to partially rescue the deleterious effect of nonsense variants located at that exon in patients’ primary fibroblasts. To test the potential of this approach in Schwann cells, the NF2-SWN tumorigenic cells, we developed an induced pluripotent stem cell (iPSC)-based model carrying heterozygous and homozygous truncating variants in NF2 exon 11 and differentiated them into Schwann cell-forming spheroids. After 3 days of treatment, merlin_e-11 expression was induced in NF2-deficient cell lines. Furthermore, key pathways associated with NF2-deficiency in schwannomas, such as PI3K/Akt/mTORC and YAP levels, were recovered without signs of toxicity. These results confirm that the PMO treatment induces effective skipping of exon 11 in Schwann cell spheroids, generating a hypomorphic merlin_e-11 that has the capacity to partially rescue merlin-deficiency in an NF2-SWN spheroid cell model and that it is a potential treatment of patients who harbor truncating variants located in exon 11.

Abstract Introduction BEACONS-NBS (Building Evidence and Collaboration for GenOmics in Nationwide Newborn Screening) is the first research study to integrate whole genome sequencing into newborn screening (NBS) across multiple U.S. states and territorial public health laboratory programs (PHLPs). We developed a list of conditions for screening. Methods We designed inclusion criteria and assembled an initial condition list from published resources. The list was revised by clinical experts, molecular geneticists, genetic counselors, PHLPs, rare disease advocacy organizations, the BEACONS-NBS Community Advisory Board, and project leadership from the National Institutes of Health. For each condition, we provided a rationale for early detection, diagnostic signs or biomarkers, and treatments or surveillance strategies. Results The BEACONS-NBS condition list includes 777 conditions associated with 743 genes, one copy number variant, and two aneuploidies and is larger than those used in other genomic NBS research studies in the U.S. and United Kingdom. Most conditions are inborn errors of immunity (37.2%), inherited metabolic disorders (18.7%), or endocrine conditions (18.1%). Nearly all conditions (93.3%) can be confirmed using a non-genetic test. Discussion BEACONS-NBS has established a condition list for implementation across multiple state and territorial PHLPs, enabling the prospective evaluation of feasibility of population-wide genomic NBS.

Non-NF2 Schwannomatosis (SWN) is a genetic disorder characterized by multiple non-malignant schwannomas growing on the spine and peripheral nerves. Patients with SWN overwhelmingly present with intractable chronic pain. There are no FDA-approved drugs to halt tumor growth or alleviate pain. Research on SWN is hindered by the lack of clinically relevant models. We established patient-derived SWN cell lines from patients with varying pain levels and developed orthotopic patient-derived xenograft models that reproduce patients' pain responses. We further developed a novel dorsal root ganglia (DRG) imaging model for longitudinal intravital imaging of macrophage infiltration into the DRG and sensory neuron pain response. Leveraging these novel models, we found that Schwannomas grown distantly in the peripheral nerve caused an influx of macrophages into the DRG. These macrophages in the DRG caused pain via overproducing IL-6. Treatment with anti-IL-6 antibody reduced pain but had modest efficacy in tumor control. We identified epidermal growth factor receptor (EGFR) signaling as a key driver of schwannoma growth and an escape mechanism from anti-IL6 treatment. Finally, we found that combining IL-6 and EGFR blockade effectively controlled pain and tumor growth simultaneously in SWN models. In summary, we elucidated the cellular and molecular crosstalk between schwannoma (HMGB1), neuron (CCL2), and macrophage (IL-6) in driving pain, and identified the EGF signaling pathway as a driver of SWN tumor progression, thereby uncovering novel therapeutic targets that may improve clinical management of SWN.

Background: In decentralized clinical trials, some or all activities occur outside of traditional sites, which may reduce time away from school/work and decrease participation burden for patients and their parents/caregivers. This methodology may improve recruitment and retention in studies, which is important for rare diseases like neurofibromatosis type 1 (NF1) and schwannomatosis (SWN). Published guidance exists for the general conduct of decentralized trials, but specific considerations for clinical trial design and endpoints in NF1/SWN have not yet been explored. Methods: The Response Evaluation in Neurofibromatosis and Schwannomatosis (REiNS) International Collaboration is a group of researchers, clinicians, and people affected by NF1 and SWN whose shared goal is to advance clinical trial methodology for NF1/SWN. In December 2023, REiNS members met to discuss the opportunities and challenges of conducting NF1/SWN decentralized trials. Results: Endpoints that are promising for use in NF1/SWN decentralized trials include visual acuity (as tested by the computerized amblyopia treatment study HOTV testing algorithm); electronic versions of REiNS-recommended patient reported outcome measures; digital health technologies for functional outcomes; radiography and computed tomography scans for imaging outcomes; remote photography to assess cutaneous neurofibromas; “e-centralized” evaluations of neurocognitive functioning; and remote biomarkers collected with analyte stabilizing tubes and self-collection devices. Conclusions: Further research is necessary to validate endpoints for decentralized trials for NF1/SWN and evaluate their feasibility. However, trial designs that incorporate decentralized elements hold considerable promise for rare diseases like NF1/SWN where patients encounter significant barriers to traditional clinical trial participation.

To analyze factors associated with hearing preservation in patients undergoing surgery with NF2-related schwannomatosis (NF2-SWN) vestibular schwannomas (VS), and to evaluate artificial intelligence/machine learning (AI/ML) predictors of hearing preservation. Retrospective analysis of NF2-SWN patients with a preoperative word recognition score (WRS) of greater than 50

ABSTRACT:Tumor inflammation-associated neurotoxicity (TIAN) was recently proposed as a unique complication of immunotherapy in patients with brain tumor. Here, we report a first comprehensive characterization of TIAN in patients with central nervous system (CNS) lymphoma (CNSL) treated with CD19-directed chimeric antigen receptor (CD19-CAR) T cells. TIAN occurred in 10 of 56 (17.9%) patients with CNSL, with clinical onset at a median 3.5 days (range, 1-9) after CD19-CAR T-cell infusion. It was less frequently associated with cytokine release syndrome (60% vs 100%; P = .009) than immune effector cell-associated neurotoxicity syndrome (ICANS). Although symptoms were usually transient and fully reversible, TIAN was associated with a fatal outcome in 1 patient. Larger CNS tumor volume at baseline allowed the identification of patients at risk for TIAN (area under the curve, 0.847; P = .002). Maximizing Youden J statistics, a discriminatory tumor volume threshold of >3.4 cm3 was determined, which carried 87.5% sensitivity and 80.5% specificity. TIAN correlated with higher overall response rates to CD19-CAR T cells (90% vs 52%; P = .036) and improved progression-free survival (hazard ratio, 0.22; 95% confidence interval, 0.07-0.61; P = .006) on multivariate Cox proportional hazard regression. Postmortem histopathological evaluation of a TIAN lesion revealed a dense macrophage population with central necrosis and peripheral reactive gliosis, accompanied by loss of white matter and intracytoplasmic myelin in foamy macrophages. Collectively, our work supports TIAN as a localized on-tumor, on-target neurotoxicity syndrome, closely related to preexisting CNSL lesions and distinct from ICANS. CNS tumor volume at baseline may allow to identify patients at risk and may guide management.

Schwannomas are nerve sheath tumors arising at cranial and peripheral nerves, either sporadically or in patients with a schwannomatosis-predisposition syndrome. There is limited understanding of the transcriptional heterogeneity of schwannomas across genetic backgrounds and anatomic locations. Here, we prospectively profile by single-cell full-length transcriptomics tumors from 22 patients with NF2-related schwannomatosis, non-NF2-related schwannomatosis, and sporadic schwannomas, resected from cranial and peripheral nerves. We profiled 11,373 cells (after QC), including neoplastic cells, fibroblasts, T cells, endothelial cells, myeloid cells, and pericytes. We characterize the intra-tumoral genetic and transcriptional heterogeneity of schwannoma, identifying six distinct transcriptional metaprograms, with gene signatures related to stress, myelin production, antigen presentation, interferon signaling, glycolysis, and extracellular matrix. We demonstrate the robustness of our findings with analysis of an independent cohort. Overall, our atlas describes the spectrum of gene expression across schwannoma entities at the single-cell level and will serve as an important resource for the community.

To determine long-term outcomes for patients with NF2-SWN treated with bevacizumab. We retrospectively reviewed the records of NF2-SWN patient at Massachusetts General Hospital who received bevacizumab for ≥2 years. Bevacizumab dose was categorized as low (<2.5 mg/kg/week), standard (2.5 mg/kg/week), and high (>2.5 mg/kg/week) and as continuous or intermittent. Tumor volumes were determined from clinically indicated MRI scans. Radiographic response (RR)/progression were defined as ≥20% decrease/increase in volume from baseline MRI, and hearing improvement/decline were defined as word recognition score above/below the 95% critical threshold. Adverse events resulting in treatment holds or discontinuation were recorded. Fifty-three patients were included in this review; 35 were excluded primarily due to treatment <2 years. Median age at treatment initiation was 27.1 years (range, 12.0-73.4). During treatment, 98% of patients received standard-dose bevacizumab, 81% received low-dose treatment after standard dose, and 15% received high-dose treatment for dose intensification. Median duration of observation was 9.7 years (range, 2.3-16.7) with median duration of treatment 6.1 years (range, 1.5-16.0). Eighty-one VS and 67 ears were evaluable for response. Fifty-three percent of VS had RR during treatment with 26% in RR at last follow-up; the median time to progression was 4.0 years (95% CI, 2.7-6.5). Sixty-seven percent of VS had hearing improvement during treatment, and 8% had hearing improvement at last follow-up; the median time to hearing decline was 3.7 years (95% CI, 2.5-6.3). Treatment holds and discontinuation due to adverse events occurred in 45% and 11% of patients, respectively. The most common adverse events included proteinuria (70%), treatment-emergent hypertension (55%), epistaxis (30%) impaired wound-healing, arthralgias, and GI upset (all 21%). Long-term treatment with bevacizumab using flexible dosing that included low, standard, and high doses was well-tolerated and resulted in durable hearing and radiographic responses with a tolerable safety profile in this patient population.

Somatic LZTR1 variants were initially identified in glioblastomas (GBM). Schwannomatosis (SWN) is a rare neurogenetic tumor suppressor syndrome in which affected individuals have a predisposition to multiple schwannomas and chronic pain. The condition arises from pathogenic variants in genes located on a small region on chromosome 22 including NF2, LZTR1, and SMARCB1. It is not clear if germline variants in LZTR1 predispose SWN patients to glioblastomas. Here, we present two patients with LZTR1-SWN and pathologically confirmed gliomas. Patient 1 presented in his 20s with a lump on his left thigh; pathology revealed schwannoma. Over the next 20 years, he underwent multiple resections of peripheral and spinal schwannomas. He did not undergo germline genetic testing due to cost. At age 60, he developed new headaches, visual changes, and cognitive dysfunction and was found to have a large heterogeneously enhancing right temporal lobe mass, which was subtotally resected. Pathology confirmed IDH-wildtype glioblastoma with an unmethylated MGMT promoter and a likely pathogenic variant in LZTR1 (c.1786-1G>A). Subsequent analysis confirmed the pathogenic variant in blood. He underwent concurrent radiation and temozolomide chemotherapy along with tumor-treating fields. Treatment is ongoing. Patient 2 presented with multiple peripheral schwannomas that were resected in his 40s. Germline genetic testing revealed a LZTR1 pathogenic variant (c.2083dupA). At age 46, he was diagnosed with thyroid cancer. At age 48, he was found to have a left temporal T2/FLAIR hyperintense lesion with punctate enhancement. Biopsy revealed low grade diffuse glioma, NOS. Surveillance is ongoing. Additional studies are needed to determine if there is a heightened risk for gliomas in LZTR1-SWN. Future work to map genetic variants with clinical outcomes will guide surveillance and treatment choices for individuals with SWN.

NF2-related schwannomatosis (NF2-SWN) predisposes affected individuals to vestibular schwannomas (VS), non-vestibular schwannomas (NVS), meningiomas, and ependymomas. Previous trials of erbB1/EGFR and erbB2/HER2 inhibitors have shown some efficacy against VS. Neratinib is a potent irreversible pan-erbB inhibitor. We report the results of the interim analysis of the neratinib treatment arm of INTUITT-NF2. We conducted a multicenter, phase II, open-label basket trial of neratinib for subjects (≥12 years old) with NF2-SWN and progressive tumors (baskets: VS, NVS, meningioma, or ependymoma). Twenty participants were accrued (≥2 participants per basket). Tumor response was evaluated by MRI every 3 months in year 1 and every 6 months thereafter. Radiographic response was defined as ≥20% decrease in tumor volume below baseline. Primary outcome was the radiographic response rate (RR). Pre- and post-treatment growth rates were determined using pre-baseline and study MRI scans. Twenty subjects (median age=27 years; range, 12-45 years) were treated with neratinib. Target tumors included 10 VS, 3 NVS, 5 meningiomas, and 2 ependymomas; non-target tumors included 20 VS, 14 NVS, 13 meningiomas, and 2 ependymomas. Radiographic RR for target and all tumors was 10% and 13%, respectively. By tumor basket, radiographic RR for all tumors was 0% for VS, 35% for non-VS, 17% for meningioma, and 0% for ependymomas. Average annualized tumor growth rates decreased for VS, NVS, meningioma, and ependymoma during neratinib treatment. There were no serious adverse events and five grade 3 treatment-related adverse events (all diarrhea). Three patients held or delayed dose due to grade 2/3 toxicity (diarrhea, rash, malaise), and two discontinued treatment during cycle 1 (diarrhea, malaise). Neratinib treatment showed modest efficacy in treatment of tumors associated with NF2-SWN. Based on this interim analysis, the team will explore whether an additional 20 participants will be enrolled in the two most promising tumor baskets.