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Susa F, Arpicco S, Pirri CF, Limongi T. An Overview on the Physiopathology of the Blood-Brain Barrier and the Lipid-Based Nanocarriers for Central Nervous System Delivery. Pharmaceutics 2024; 16:849. [PMID: 39065547 DOI: 10.3390/pharmaceutics16070849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 06/12/2024] [Accepted: 06/20/2024] [Indexed: 07/28/2024] Open
Abstract
The state of well-being and health of our body is regulated by the fine osmotic and biochemical balance established between the cells of the different tissues, organs, and systems. Specific districts of the human body are defined, kept in the correct state of functioning, and, therefore, protected from exogenous or endogenous insults of both mechanical, physical, and biological nature by the presence of different barrier systems. In addition to the placental barrier, which even acts as a linker between two different organisms, the mother and the fetus, all human body barriers, including the blood-brain barrier (BBB), blood-retinal barrier, blood-nerve barrier, blood-lymph barrier, and blood-cerebrospinal fluid barrier, operate to maintain the physiological homeostasis within tissues and organs. From a pharmaceutical point of view, the most challenging is undoubtedly the BBB, since its presence notably complicates the treatment of brain disorders. BBB action can impair the delivery of chemical drugs and biopharmaceuticals into the brain, reducing their therapeutic efficacy and/or increasing their unwanted bioaccumulation in the surrounding healthy tissues. Recent nanotechnological innovation provides advanced biomaterials and ad hoc customized engineering and functionalization methods able to assist in brain-targeted drug delivery. In this context, lipid nanocarriers, including both synthetic (liposomes, solid lipid nanoparticles, nanoemulsions, nanostructured lipid carriers, niosomes, proniosomes, and cubosomes) and cell-derived ones (extracellular vesicles and cell membrane-derived nanocarriers), are considered one of the most successful brain delivery systems due to their reasonable biocompatibility and ability to cross the BBB. This review aims to provide a complete and up-to-date point of view on the efficacy of the most varied lipid carriers, whether FDA-approved, involved in clinical trials, or used in in vitro or in vivo studies, for the treatment of inflammatory, cancerous, or infectious brain diseases.
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Affiliation(s)
- Francesca Susa
- Department of Applied Science and Technology, Politecnico di Torino, Corso Duca degli Abruzzi 24, 10129 Turin, Italy
| | - Silvia Arpicco
- Department of Drug Science and Technology, University of Turin, Via Pietro Giuria 9, 10125 Turin, Italy
| | - Candido Fabrizio Pirri
- Department of Applied Science and Technology, Politecnico di Torino, Corso Duca degli Abruzzi 24, 10129 Turin, Italy
| | - Tania Limongi
- Department of Drug Science and Technology, University of Turin, Via Pietro Giuria 9, 10125 Turin, Italy
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Takata S, Kosen K, Matsumoto A, Tanabe M, Itaya T, Asayama Y. Growth speed of large brain metastases between diagnostic and radiosurgical planning MRI and predictors of rapid tumor growth. Jpn J Radiol 2024; 42:546-552. [PMID: 38212514 PMCID: PMC11056330 DOI: 10.1007/s11604-023-01524-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/06/2023] [Indexed: 01/13/2024]
Abstract
PURPOSE We aimed to assess volumetric changes of large brain metastases (≥ 2 cm) between their diagnosis and planning for treatment with fractionated stereotactic radiation surgery (fSRS). Predictors of rapid tumor growth were also analyzed. MATERIALS AND METHODS One hundred nine patients harboring 126 large brain metastases were retrospectively evaluated. Tumor characteristics were evaluated on diagnostic magnetic resonance imaging (dMRI) and MRI performed when planning fSRS (pMRI). Average tumor growth rate and percentage growth rate were calculated. Predictors of rapid growth (percentage growth rate > 5%) were determined using multivariate logistic regression. RESULTS Both tumor diameter and volume were significantly larger on pMRI than on dMRI (P < 0.001). Median tumor percentage growth rate was 2.6% (range, - 10.8-43.3%). Eighty-eight tumors (70%) were slow-growing (percentage growth rate < 5%) and 38 (30%) grew rapidly (percentage growth rate ≥ 5%). Major peritumoral edema and no steroids were predictors of rapid tumor growth. CONCLUSION Large brain metastases can grow considerably between the time of diagnosis and the time of fSRS treatment planning. We recommend the time between dMRI and fSRS treatment initiation be as short as possible.
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Affiliation(s)
- Shoko Takata
- Department of Radiology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan.
- Department of Radiology, Oita Prefectural Hospital, 2-8-1, Bunyo, Oita, 870-8511, Japan.
| | - Kazuhisa Kosen
- Department of Radiology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan
- Keiwakai Oka Hospital, 3-7-11 Nishitsurusaki, Oita, 870-0105, Japan
| | - Akira Matsumoto
- Department of Radiation Therapy, Central Japan International Medical Center, 1-1 Kenkonomachi, Minokamo, Gifu, 505-8510, Japan
| | - Motoko Tanabe
- Department of Radiology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Takayoshi Itaya
- Department of Radiology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Yoshiki Asayama
- Department of Radiology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan
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Zhao FF, Chen Y, Li TP, Wang Y, Lin HJ, Yang JF, Chen L, Tan SY, Liang JJ, Cen LP. Visual outcome of various dose of glucocorticoids treatment in nonarteritic anterior ischemic optic neuropathy- a retrospective analysis. BMC Ophthalmol 2024; 24:100. [PMID: 38438845 PMCID: PMC10913239 DOI: 10.1186/s12886-024-03354-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 02/16/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND AND PURPOSE The objective of this investigation was to assess the therapeutic efficacy of distinct glucocorticoid therapy dosages in the management of acute nonarteritic anterior ischemic optic neuropathy (NAION). MATERIALS AND METHODS This retrospective, unmasked, and non-randomized study included a total of 85 patients. The patients were categorized into four groups: Group 1 (control) consisted of 15 patients who did not receive glucocorticoids, Group 2 included 16 patients administered with oral prednisone at a dosage of 1 mg/kg/d for 14 days, Group 3 comprised 30 patients who received 250 units of methylprednisolone once daily for 3 days, followed by oral prednisone at a dosage of 1 mg/kg/d for 11 days, and Group 4 encompassed 24 patients who received 500 units of methylprednisolone once daily for 3 days, followed by oral prednisone at a dosage of 1 mg/kg/d for 11 days. The best-corrected visual acuity (BCVA) was assessed at baseline and the final follow-up (> 7 days post-treatment). The changes in visual acuity between baseline and the 7-14 day follow-up, as well as between baseline and the concluding appraisal, were employed as metrics for assessing the extent of visual enhancement. RESULTS No significant differences were noted in the final visual outcomes or in the changes between final visual acuity and baseline across the four groups. In Group 1 (control), the best-corrected visual acuity (BCVA) remained unchanged during final follow-ups compared to baseline. Conversely, the intervention groups exhibited statistically significant enhancements in BCVA during final follow-up (p = 0.012, p = 0.03, and p = 0.009 for Group 2, Group 3, and Group 4, respectively) when compared to baseline. During the 7-14 day follow-up, there was a significant difference in the changes between baseline BCVA and follow-up BCVA across the groups (p = 0.035). Go a step further by Bonferroni correction for multiple comparisons, group 4 showed a greater change in vision compared with group1 (p = 0.045). CONCLUSION Our study on acute nonarteritic anterior ischemic optic neuropathy (NAION) showed no significant final visual outcome differences. Nevertheless, Groups 2, 3, and 4 demonstrated improved best-corrected visual acuity (BCVA) during the final follow-up. Notably, a 500-unit dose of methylprednisolone resulted in short-term BCVA enhancement. This suggests potential consideration of 500 units of methylprednisolone for short-term NAION vision improvement, despite its limited long-term impact.
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Affiliation(s)
- Fang-Fang Zhao
- Joint Shantou International Eye Center of Shantou University and The Chinese University of Hong Kong, North Dongxia Road, 515041, Shantou, Guangdong, China
| | - Yun Chen
- Joint Shantou International Eye Center of Shantou University and The Chinese University of Hong Kong, North Dongxia Road, 515041, Shantou, Guangdong, China
- Shantou University Medical College, Shantou, Guangdong, China
- The Fourth Hospital of Wuhan, Wuhan, China
| | - Tai-Ping Li
- Joint Shantou International Eye Center of Shantou University and The Chinese University of Hong Kong, North Dongxia Road, 515041, Shantou, Guangdong, China
| | - Yun Wang
- Joint Shantou International Eye Center of Shantou University and The Chinese University of Hong Kong, North Dongxia Road, 515041, Shantou, Guangdong, China
| | - Hong-Jie Lin
- Joint Shantou International Eye Center of Shantou University and The Chinese University of Hong Kong, North Dongxia Road, 515041, Shantou, Guangdong, China
| | - Jian-Feng Yang
- Joint Shantou International Eye Center of Shantou University and The Chinese University of Hong Kong, North Dongxia Road, 515041, Shantou, Guangdong, China
| | - Lan Chen
- Joint Shantou International Eye Center of Shantou University and The Chinese University of Hong Kong, North Dongxia Road, 515041, Shantou, Guangdong, China
| | - Shao-Ying Tan
- School of Optometry, The Hong Kong Polytechnic University, Kowloon, Hong Kong, China
| | - Jia-Jian Liang
- Joint Shantou International Eye Center of Shantou University and The Chinese University of Hong Kong, North Dongxia Road, 515041, Shantou, Guangdong, China
| | - Ling-Ping Cen
- Joint Shantou International Eye Center of Shantou University and The Chinese University of Hong Kong, North Dongxia Road, 515041, Shantou, Guangdong, China.
- Shantou University Medical College, Shantou, Guangdong, China.
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Yakubov E, Schmid S, Hammer A, Chen D, Dahlmanns JK, Mitrovic I, Zurabashvili L, Savaskan N, Steiner HH, Dahlmanns M. Ferroptosis and PPAR-gamma in the limelight of brain tumors and edema. Front Oncol 2023; 13:1176038. [PMID: 37554158 PMCID: PMC10406130 DOI: 10.3389/fonc.2023.1176038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/04/2023] [Indexed: 08/10/2023] Open
Abstract
Human malignant brain tumors such as gliomas are devastating due to the induction of cerebral edema and neurodegeneration. A major contributor to glioma-induced neurodegeneration has been identified as glutamate. Glutamate promotes cell growth and proliferation in variety of tumor types. Intriguently, glutamate is also an excitatory neurotransmitter and evokes neuronal cell death at high concentrations. Even though glutamate signaling at the receptor and its downstream effectors has been extensively investigated at the molecular level, there has been little insight into how glutamate enters the tumor microenvironment and impacts on metabolic equilibration until recently. Surprisingly, the 12 transmembrane spanning tranporter xCT (SLC7A11) appeared to be a major player in this process, mediating glutamate secretion and ferroptosis. Also, PPARγ is associated with ferroptosis in neurodegeneration, thereby destroying neurons and causing brain swelling. Although these data are intriguing, tumor-associated edema has so far been quoted as of vasogenic origin. Hence, glutamate and PPARγ biology in the process of glioma-induced brain swelling is conceptually challenging. By inhibiting xCT transporter or AMPA receptors in vivo, brain swelling and peritumoral alterations can be mitigated. This review sheds light on the role of glutamate in brain tumors presenting the conceptual challenge that xCT disruption causes ferroptosis activation in malignant brain tumors. Thus, interfering with glutamate takes center stage in forming the basis of a metabolic equilibration approach.
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Affiliation(s)
- Eduard Yakubov
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Germany
| | - Sebastian Schmid
- Department of Trauma, Orthopaedics, Plastic and Hand Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Alexander Hammer
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Germany
- Center for Spine and Scoliosis Therapy, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
| | - Daishi Chen
- Department of Otorhinolaryngology, Shenzhen People's Hospital, Jinan University, Shenzhen, China
| | - Jana Katharina Dahlmanns
- Institute for Physiology and Pathophysiology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Ivana Mitrovic
- Department of Cardiac Surgery, Bogenhausen Hospital, Munich, Germany
| | | | - Nicolai Savaskan
- Department of Neurosurgery, University Medical School Hospital Universitätsklinikum Erlangen (UKER), Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
- Department of Public Health Neukölln, District Office Neukölln of Berlin Neukölln, Berlin, Germany
| | | | - Marc Dahlmanns
- Institute for Physiology and Pathophysiology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
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Ikawa T, Kanayama N, Arita H, Ohira S, Takano K, Hirata T, Morimoto M, Teshima T, Konishi K. Linear accelerator-based stereotactic radiotherapy for brain metastases, including multiple and large lesions, carries a low incidence of acute toxicities: a retrospective analysis. Radiat Oncol 2023; 18:80. [PMID: 37165431 PMCID: PMC10173492 DOI: 10.1186/s13014-023-02262-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/11/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Data on acute toxicities after stereotactic radiotherapy (SRT) for brain metastases, including multiple and large lesions, are lacking. We aimed to evaluate the incidence and nature of toxicities immediately after SRT using a linear accelerator. METHODS This retrospective study reviewed the medical records of 315 patients with brain metastases treated with SRT at our institution between May 2019 and February 2022. In total, 439 SRT sessions were performed for 2161 brain metastases. The outcome of interest was immediate side effects (ISEs), defined as new or worsening symptoms occurring during SRT or within 14 days after the end of SRT. RESULTS Grade ≥ 2 and ≥ 3 ISEs occurred in 16 (3.6%) and 7 (1.6%) cases, respectively. Among 63 treatments for 10 or more lesions (range: 10-40), 1 (1.6%) ISE occurred. Among 22 treatments for lesions with a maximum tumor volume of > 10 cc, 2 (9.1%) ISEs occurred. Grade ≥ 3 ISEs included 1, 4, 1, and 1 cases of grade 3 nausea, grade 3 new-onset partial and generalized seizures, grade 3 obstructive hydrocephalus, and grade 5 intracranial hemorrhage, respectively. ISEs were more common in patients with a larger maximum tumor volume, primary sites other than lung and breast cancer, and pre-treatment neurological symptoms. CONCLUSION SRT using a linear accelerator for brain metastases, including multiple and large lesions, is safe, with a low incidence of ISEs. Serious complications immediately after SRT are rare but possible; therefore, careful follow-up is necessary after treatment initiation.
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Affiliation(s)
- Toshiki Ikawa
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan.
| | - Naoyuki Kanayama
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hideyuki Arita
- Department of Neurosurgery, Osaka International Cancer Institute, Osaka, Japan
| | - Shingo Ohira
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Koji Takano
- Department of Neurosurgery, Osaka International Cancer Institute, Osaka, Japan
| | - Takero Hirata
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masahiro Morimoto
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | | | - Koji Konishi
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
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Fiani B, Jarrah R, Bhandarkar AR, De Stefano F, Amare A, Aljameey UA, Reardon T. Peritumoral edema in meningiomas: pathophysiology, predictors, and principles for treatment. Clin Transl Oncol 2023; 25:866-872. [PMID: 36427121 DOI: 10.1007/s12094-022-03009-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 11/07/2022] [Indexed: 11/27/2022]
Abstract
Meningiomas is a tumor of the meninges and is among the most common intracranial neoplasms in adults, accounting for over a third of all primary brain tumors in the United States. Meningiomas can be associated with peritumoral brain edema (PTBE) which if not managed appropriately can lead to poor clinical outcomes. In this review, we summarize the relevant pathophysiology, predictors, and principles for treatment of PTBE. The results of various case-reports and case-series have found that meningioma-associated PTBE have patterns in age, tumor size, and hormone receptor positivity. Our study describes how increased age, increased tumor size, tumor location in the middle fossa, and positive expression of hormone receptors, VEGF, and MMP-9 can all be predictors for worse clinical outcomes. We also characterize treatment options for PTBE such as glucocorticoids and VEGF inhibitors along with the ongoing clinical trials attempting to alleviate PTBE in meningioma cases. The trends summarized in this review can be used to better predict the behavior of meningioma-associated PTBE and establish prognosis models to identify at risk patients.
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Affiliation(s)
- Brian Fiani
- Department of Neurosurgery, Weill Cornell Medical Center/NewYork Presbyterian Hospital, 525 East 68th Street, New York, NY, 10065, USA.
| | - Ryan Jarrah
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Frank De Stefano
- Department of Neurosurgery, University of Kansas Medical Center, Kansas, MO, USA
| | - Abrham Amare
- Morehouse School of Medicine, Morehouse College, Atlanta, GA, USA
| | - Usama A Aljameey
- Lincoln Memorial DeBusk College of Osteopathic Medicine, Lincoln Memorial University, Knoxville, TN, USA
| | - Taylor Reardon
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, KY, USA
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McKevitt C, Marenco-Hillembrand L, Bamimore M, Chandler R, Otamendi-Lopez A, Almeida JP, Quiñones-Hinojosa A, Chaichana KL. Predictive factors for post operative seizures following meningioma resection in patients without preoperative seizures: a multicenter retrospective analysis. Acta Neurochir (Wien) 2023; 165:1333-1343. [PMID: 36977866 DOI: 10.1007/s00701-023-05571-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/15/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE Meningiomas are the most common primary brain tumor and represent 35% of all intracranial neoplasms. However, in the early post-operative period approximate 3-5% of patients experience an acute symptomatic seizure. Establishing risk factors for postoperative seizures will identify those patients without preoperative seizures at greatest risk of postoperative seizures and may guide antiseizure medications (ASMs) management. METHODS Adult seizure naïve patients who underwent primary resection of a World Health Organization (WHO) Grade 1-3 meningioma at the three Mayo Clinic Campuses between 2012-2022 were retrospectively reviewed. Multivariate regression analyses were used to identify radiological, surgical, and management features with the development of new-onset seizures in patients undergoing meningioma resection. RESULTS Of 113 seizure naïve patients undergoing meningioma resection 11 (9.7%) experienced a new-onset post-operative seizure. Tumor volume ≥ 25 cm3 (Odds Ratio (OR) 5.223, 95% Confidence Interval (CI) 1.546 - 17.650, p = 0.008) and cerebral convexity meningiomas (OR 4.742, 95% CI 1.255 - 14.336, p = 0.016) were most associated with new onset postoperative seizures in multivariate analysis. ASMs and corticosteroid therapies did not display a significant difference among those with and without a new onset postoperative seizure. CONCLUSION In the current study, a larger tumor volume (≥ 25 cm3) and/or convexity meningiomas predicted the development of new onset post-operative seizures. Those who present with these factors should be counseled for their increased risk of new onset post-operative seizures and may benefit from prophylactic ASMs therapy.
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Affiliation(s)
- Chase McKevitt
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Lina Marenco-Hillembrand
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Michael Bamimore
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
- Department of Neurological Surgery, Cooper University Health Care, 1 Cooper Plz, Camden, NJ, 08103, USA
| | - Rosemary Chandler
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Andrea Otamendi-Lopez
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Joao Paulo Almeida
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | | | - Kaisorn L Chaichana
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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Lechpammer M, Rao R, Shah S, Mirheydari M, Bhattacharya D, Koehler A, Toukam DK, Haworth KJ, Pomeranz Krummel D, Sengupta S. Advances in Immunotherapy for the Treatment of Adult Glioblastoma: Overcoming Chemical and Physical Barriers. Cancers (Basel) 2022; 14:cancers14071627. [PMID: 35406398 PMCID: PMC8997081 DOI: 10.3390/cancers14071627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/18/2022] [Accepted: 03/22/2022] [Indexed: 02/07/2023] Open
Abstract
Simple Summary The poor prognosis for glioblastoma (GBM) despite the existence of a standard-of-care treatment of resection, radiotherapy, and adjuvant chemotherapy has necessitated the exploration of other therapeutic avenues. One particularly promising avenue is an immunotherapeutic approach in which the body′s immune system is artificially stimulated to directly identify and attack the tumor cells. A variety of methods including immune checkpoint inhibition, T-cell transfer, vaccination, and a viral approach are being developed for GBM. Barriers such as tumor heterogeneity, the physical blood–brain barrier, the immunosuppressive nature of GBM, and the limited number of identifiable GBM-specific targets have reduced the efficacy of the aforementioned approaches. In the following review, we document the advances in immunotherapy, the barriers to implementation, and the development of a new technology (microbubble-enhanced focused ultrasound) to overcome the physical barriers to immunotherapy. Abstract Glioblastoma, or glioblastoma multiforme (GBM, WHO Grade IV), is a highly aggressive adult glioma. Despite extensive efforts to improve treatment, the current standard-of-care (SOC) regimen, which consists of maximal resection, radiotherapy, and temozolomide (TMZ), achieves only a 12–15 month survival. The clinical improvements achieved through immunotherapy in several extracranial solid tumors, including non-small-cell lung cancer, melanoma, and non-Hodgkin lymphoma, inspired investigations to pursue various immunotherapeutic interventions in adult glioblastoma patients. Despite some encouraging reports from preclinical and early-stage clinical trials, none of the tested agents have been convincing in Phase III clinical trials. One, but not the only, factor that is accountable for the slow progress is the blood–brain barrier, which prevents most antitumor drugs from reaching the target in appreciable amounts. Herein, we review the current state of immunotherapy in glioblastoma and discuss the significant challenges that prevent advancement. We also provide thoughts on steps that may be taken to remediate these challenges, including the application of ultrasound technologies.
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Affiliation(s)
- Mirna Lechpammer
- Foundation Medicine, Inc., Cambridge, MA 02141, USA;
- Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Rohan Rao
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (R.R.); (D.B.); (A.K.); (D.K.T.)
| | - Sanjit Shah
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA;
| | - Mona Mirheydari
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (M.M.); (K.J.H.)
| | - Debanjan Bhattacharya
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (R.R.); (D.B.); (A.K.); (D.K.T.)
| | - Abigail Koehler
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (R.R.); (D.B.); (A.K.); (D.K.T.)
| | - Donatien Kamdem Toukam
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (R.R.); (D.B.); (A.K.); (D.K.T.)
| | - Kevin J. Haworth
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (M.M.); (K.J.H.)
| | - Daniel Pomeranz Krummel
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (R.R.); (D.B.); (A.K.); (D.K.T.)
- Correspondence: (D.P.K.); (S.S.)
| | - Soma Sengupta
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (R.R.); (D.B.); (A.K.); (D.K.T.)
- Correspondence: (D.P.K.); (S.S.)
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Kourouklari E, Charalambous D, Faropoulos K, Fotakopoulos G. Epidural Hematoma: The Outcome of Glucocorticoids’ Complementary Use to Surgical Treatment. Cureus 2022; 14:e22607. [PMID: 35371733 PMCID: PMC8958032 DOI: 10.7759/cureus.22607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 11/05/2022] Open
Abstract
Background: The use of glucocorticoids in trauma patients with parenchymal damage is deemed unnecessary and is not advocated. Notwithstanding, acute epidural hematomas (aEH) are extra-parenchymal lesions, so the patients could benefit from the use of glucocorticoids. Methodology/Results: 97 patients with acute epidural hematoma were separated into two groups, whether they received glucocorticoid treatment or not. Depending on the severity of the deficit and their clinical status, some of the patients were operated on and others not. The patients who received glucocorticoids had better neurological status upon discharge, while their hospitalization was shorter. Conclusions: The surgical management of the acute epidural hematomas in combination with glucocorticoid treatment had the best outcome in our protocol.
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Makwana M, Hussain H, Merola JP, Zaben M, Jesurasa AR, Patel C, Leach P. Pre-operative dosing of dexamethasone for the management of children with posterior fossa tumours: are we getting it right? Br J Neurosurg 2022; 36:609-612. [PMID: 35176921 DOI: 10.1080/02688697.2022.2040948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Posterior fossa (PF) tumours are associated with vasogenic oedema causing symptoms of raised intracranial pressure. Preoperatively this is managed with dexamethasone. To minimise steroid related complications, the lowest effective dose should be administered. No neurosurgical guidelines exist for pre-operative dosing of dexamethasone in PF tumours. METHODS A retrospective review was performed of surgically managed cases for patients under 16 years of age between 2013 and 2018 to ascertain the initial dose of dexamethasone with symptomatic PF tumours. RESULTS Thirty-six patients were identified of which 30 notes were available. Sixteen were male. Median age was 6 years (range 10 months - 15 years). Twenty-two (73%) were referrals from DGH and 8 (27%) presented to our neurosurgical centre. All patients presented with symptomatic PF tumours including headache (97%), vomiting (93%), gait disturbance (43%), and nystagmus (17%). Four (13%) had papilloedema. Average initial stat dexamethasone dose was 9.15 mg; 0.31 mg/kg (range 1-16.7 mg; 0.05 - 1.77 mg/kg). Stratified according to weight, average dose (and range) was 8.8 mg; 0.94 mg/kg (1-16.6 mg; 0.13 - 1.77 mg/kg) in those weighing <10 kg; 9.7 mg; 0.66 mg/kg (4-16.7 mg; 0.21 - 1.35 mg/kg) in 10-20 kg; 12.3 mg;0.52 mg/kg (8-16.7 mg; 0.27 - 0.73mg/kg) in 20-30 kg and 7.8 mg; 0.17mg/kg (2-16.7 mg; 0.0 - 0.39 mg/kg) in >30 kg up to a maximum of 16.6 mg in any 24h period. These results suggest that dosage was higher in those children weighing less. PPI was used in 24 (80%) of cases. All doses were reduced after review by the neurosurgical team and a PPI added. CONCLUSION Pre-operative dexamethasone dosing does not always reflect the severity of clinical symptoms for PF tumours. Guidelines are required to correlate clinical symptoms with a suggested suitable dose of dexamethasone to prevent overdose and complications associated with corticosteroid use. We recommend a weight-based regimen as provided by the Food and Drug Administration. The current advice is for 0.02-0.3mg/kg/day in 3-4 divided doses.
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Affiliation(s)
- Milan Makwana
- Department of Paediatric Neurosurgery, University Hospital of Wales & Noah's Ark Children's Hospital, Cardiff, United Kingdom.,School of Medicine, Neuroscience and Mental Health Research Institute, Institute of Psychological Medicine and Clinical Neurosciences, University Hospital Wales, Cardiff University, Cardiff, United Kingdom
| | - Humaira Hussain
- Department of Paediatric Neurosurgery, University Hospital of Wales & Noah's Ark Children's Hospital, Cardiff, United Kingdom
| | - Joseph P Merola
- Department of Paediatric Neurosurgery, University Hospital of Wales & Noah's Ark Children's Hospital, Cardiff, United Kingdom.,School of Medicine, Neuroscience and Mental Health Research Institute, Institute of Psychological Medicine and Clinical Neurosciences, University Hospital Wales, Cardiff University, Cardiff, United Kingdom
| | - Malik Zaben
- Department of Paediatric Neurosurgery, University Hospital of Wales & Noah's Ark Children's Hospital, Cardiff, United Kingdom.,School of Medicine, Neuroscience and Mental Health Research Institute, Institute of Psychological Medicine and Clinical Neurosciences, University Hospital Wales, Cardiff University, Cardiff, United Kingdom
| | - Anthony R Jesurasa
- Department of Paediatric Neurosurgery, University Hospital of Wales & Noah's Ark Children's Hospital, Cardiff, United Kingdom
| | - Chirag Patel
- Department of Paediatric Neurosurgery, University Hospital of Wales & Noah's Ark Children's Hospital, Cardiff, United Kingdom
| | - Paul Leach
- Department of Paediatric Neurosurgery, University Hospital of Wales & Noah's Ark Children's Hospital, Cardiff, United Kingdom
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11
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Cai X, Tao W, Li L. Glioma cell-derived FGF20 suppresses macrophage function by activating β-catenin. Cell Signal 2021; 89:110181. [PMID: 34757019 DOI: 10.1016/j.cellsig.2021.110181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 10/23/2021] [Accepted: 10/26/2021] [Indexed: 01/19/2023]
Abstract
Macrophages, which are the main regulators of the tumor-associated microenvironment, play a crucial role in the progression of various tumors. The anti-inflammatory role of β-catenin in macrophages has been extensively studied in recent years. However, the association between macrophages and β-catenin with regards to the development of glioma has not yet been investigated, at least to the best of our knowledge. The present study found that fibroblast growth factor 20 (FGF20), as a paracrine cytokine, was secreted by glioma cells and acted on macrophages. FGF20 treated macrophages exhibited a decreased pro-inflammatory phenotype upon LPS and IFN-γ stimulation, characterized by the decreased the level of M1 macrophage markers and the reduced production of pro-inflammatory cytokines. Mechanistic analysis revealed that FGF20 interacted with FGF receptor 1 isoform of macrophages, and subsequently increased the stability of β-catenin via phosphorylating GSK3β, which suppressed macrophage polarization to the M1-phenotype. Finally, it was found that FGF20 of glioma cells expression was upregulated by the glucocorticoids (GCs) treatment, and decreased FGF20 expression of glioma cells markedly blocked the effects of GCs on the polarization of macrophages. On the whole, the present study demonstrates that FGF20, secreted from glioma cells, participates the GCs regulated macrophage function and exerts anti-inflammatory effects during the treatment of glioma by GCs. Moreover, a molecular link was identified between glioma cells and macrophages, demonstrating that FGF20 modulates the GCs-induced dysfunction of macrophages during glioma development.
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Affiliation(s)
- Xue Cai
- Department of Emergency, ShengJing Hospital of China Medical University, Shenyang, Liaoning Province 110004, China.
| | - Weichen Tao
- Department of Emergency, ShengJing Hospital of China Medical University, Shenyang, Liaoning Province 110004, China
| | - Lei Li
- Department of Emergency, ShengJing Hospital of China Medical University, Shenyang, Liaoning Province 110004, China.
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12
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Eltanahy AM, Koluib YA, Gonzales A. Pericytes: Intrinsic Transportation Engineers of the CNS Microcirculation. Front Physiol 2021; 12:719701. [PMID: 34497540 PMCID: PMC8421025 DOI: 10.3389/fphys.2021.719701] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/29/2021] [Indexed: 12/15/2022] Open
Abstract
Pericytes in the brain are candidate regulators of microcirculatory blood flow because they are strategically positioned along the microvasculature, contain contractile proteins, respond rapidly to neuronal activation, and synchronize microvascular dynamics and neurovascular coupling within the capillary network. Analyses of mice with defects in pericyte generation demonstrate that pericytes are necessary for the formation of the blood-brain barrier, development of the glymphatic system, immune homeostasis, and white matter function. The development, identity, specialization, and progeny of different subtypes of pericytes, however, remain unclear. Pericytes perform brain-wide 'transportation engineering' functions in the capillary network, instructing, integrating, and coordinating signals within the cellular communicome in the neurovascular unit to efficiently distribute oxygen and nutrients ('goods and services') throughout the microvasculature ('transportation grid'). In this review, we identify emerging challenges in pericyte biology and shed light on potential pericyte-targeted therapeutic strategies.
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Affiliation(s)
- Ahmed M. Eltanahy
- Department of Physiology and Cell Biology, School of Medicine, University of Nevada, Reno, NV, United States
| | - Yara A. Koluib
- Tanta University Hospitals, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Albert Gonzales
- Department of Physiology and Cell Biology, School of Medicine, University of Nevada, Reno, NV, United States
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Glucocorticoid-Dependent Mechanisms of Brain Tolerance to Hypoxia. Int J Mol Sci 2021; 22:ijms22157982. [PMID: 34360746 PMCID: PMC8348130 DOI: 10.3390/ijms22157982] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 12/16/2022] Open
Abstract
Adaptation of organisms to stressors is coordinated by the hypothalamic-pituitary-adrenal axis (HPA), which involves glucocorticoids (GCs) and glucocorticoid receptors (GRs). Although the effects of GCs are well characterized, their impact on brain adaptation to hypoxia/ischemia is still understudied. The brain is not only the most susceptible to hypoxic injury, but also vulnerable to GC-induced damage, which makes studying the mechanisms of brain hypoxic tolerance and resistance to stress-related elevation of GCs of great importance. Cross-talk between the molecular mechanisms activated in neuronal cells by hypoxia and GCs provides a platform for developing the most effective and safe means for prevention and treatment of hypoxia-induced brain damage, including hypoxic pre- and post-conditioning. Taking into account that hypoxia- and GC-induced reprogramming significantly affects the development of organisms during embryogenesis, studies of the effects of prenatal and neonatal hypoxia on health in later life are of particular interest. This mini review discusses the accumulated data on the dynamics of the HPA activation in injurious and non-injurious hypoxia, the role of the brain GRs in these processes, interaction of GCs and hypoxia-inducible factor HIF-1, as well as cross-talk between GC and hypoxic signaling. It also identifies underdeveloped areas and suggests directions for further prospective studies.
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Silencing long non-coding RNA zinc finger antisense 1 restricts secondary cerebral edema and neuron injuries after traumatic brain injury. Neurosci Lett 2021; 756:135958. [PMID: 34000346 DOI: 10.1016/j.neulet.2021.135958] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 05/07/2021] [Accepted: 05/09/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To investigate the interaction of long non-coding RNA zinc finger antisense 1 (lncRNA ZFAS1) in secondary cerebral edema (CE) and neuron injuries after traumatic brain injury (TBI) in a mouse model. METHODS TBI mouse models was established by free-fall strike. Adeno-associated virus-short hairpin-ZFAS1 was administrated into mice via intracerebral injection to downregulate lncRNA ZFAS1. LncRNA ZFAS1 in mouse brain was examined. Neurological severity score (NSS), cerebral water content (CWC) and lesion volume were measured. The number of TUNEL-positive cells in brain tissue was accessed. Bax and cleaved caspase-3 in brain tissues were measured by western blot analysis, and pro-inflammatory factor levels were detected. RESULTS LncRNA ZFAS1 expression was upregulated in mouse brain tissues 3 days after TBI modelling. After the knockdown of lncRNA ZFAS1, NSS, CWC and lesion volume were decreased, apoptotic gene levels were decreased and pro-inflammatory cytokine levels were reduced, suggesting that lncRNA ZFAS1 knockdown could alleviate TBI-induced brain injuries in mice. CONCLUSION This study demonstrated that silencing lncRNA ZFAS1 inhibited TBI by quenching apoptosis, reducing inflammatory response and improving the recovery of neurological function in TBI mice. LncRNA ZFAS1 might function as a possible curative management in secondary CE and neuron injury in TBI mice.
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Koehler A, Karve A, Desai P, Arbiser J, Plas DR, Qi X, Read RD, Sasaki AT, Gawali VS, Toukam DK, Bhattacharya D, Kallay L, Pomeranz Krummel DA, Sengupta S. Reuse of Molecules for Glioblastoma Therapy. Pharmaceuticals (Basel) 2021; 14:99. [PMID: 33525329 PMCID: PMC7912673 DOI: 10.3390/ph14020099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/25/2021] [Indexed: 12/12/2022] Open
Abstract
Glioblastoma multiforme (GBM) is a highly malignant primary brain tumor. The current standard of care for GBM is the Stupp protocol which includes surgical resection, followed by radiotherapy concomitant with the DNA alkylator temozolomide; however, survival under this treatment regimen is an abysmal 12-18 months. New and emerging treatments include the application of a physical device, non-invasive 'tumor treating fields' (TTFs), including its concomitant use with standard of care; and varied vaccines and immunotherapeutics being trialed. Some of these approaches have extended life by a few months over standard of care, but in some cases are only available for a minority of GBM patients. Extensive activity is also underway to repurpose and reposition therapeutics for GBM, either alone or in combination with the standard of care. In this review, we present select molecules that target different pathways and are at various stages of clinical translation as case studies to illustrate the rationale for their repurposing-repositioning and potential clinical use.
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Affiliation(s)
- Abigail Koehler
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (A.K.); (V.S.G.); (D.K.T.); (D.B.); (L.K.); (D.A.P.K.)
| | - Aniruddha Karve
- Division of Pharmaceutical Sciences, University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH 45229, USA; (A.K.); (P.D.)
| | - Pankaj Desai
- Division of Pharmaceutical Sciences, University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH 45229, USA; (A.K.); (P.D.)
| | - Jack Arbiser
- Department of Dermatology, Emory School of Medicine, Atlanta, GA 30322, USA;
- Atlanta Veterans Administration Medical Center, Decatur, GA 30033, USA
| | - David R. Plas
- Department of Cancer Biology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA;
| | - Xiaoyang Qi
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (X.Q.); (A.T.S.)
| | - Renee D. Read
- Department of Pharmacology and Chemical Biology, Emory School of Medicine, Atlanta, GA 30322, USA;
| | - Atsuo T. Sasaki
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (X.Q.); (A.T.S.)
| | - Vaibhavkumar S. Gawali
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (A.K.); (V.S.G.); (D.K.T.); (D.B.); (L.K.); (D.A.P.K.)
| | - Donatien K. Toukam
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (A.K.); (V.S.G.); (D.K.T.); (D.B.); (L.K.); (D.A.P.K.)
| | - Debanjan Bhattacharya
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (A.K.); (V.S.G.); (D.K.T.); (D.B.); (L.K.); (D.A.P.K.)
| | - Laura Kallay
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (A.K.); (V.S.G.); (D.K.T.); (D.B.); (L.K.); (D.A.P.K.)
| | - Daniel A. Pomeranz Krummel
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (A.K.); (V.S.G.); (D.K.T.); (D.B.); (L.K.); (D.A.P.K.)
| | - Soma Sengupta
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (A.K.); (V.S.G.); (D.K.T.); (D.B.); (L.K.); (D.A.P.K.)
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Trembath DG, Davis ES, Rao S, Bradler E, Saada AF, Midkiff BR, Snavely AC, Ewend MG, Collichio FA, Lee CB, Karachaliou GS, Ayvali F, Ollila DW, Krauze MT, Kirkwood JM, Vincent BG, Nikolaishvilli-Feinberg N, Moschos SJ. Brain Tumor Microenvironment and Angiogenesis in Melanoma Brain Metastases. Front Oncol 2021; 10:604213. [PMID: 33552976 PMCID: PMC7860978 DOI: 10.3389/fonc.2020.604213] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/17/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND High tumor-infiltrating lymphocytes (TILs) and hemorrhage are important prognostic factors in patients who have undergone craniotomy for melanoma brain metastases (MBM) before 2011 at the University of Pittsburgh Medical Center (UPMC). We have investigated the prognostic or predictive role of these histopathologic factors in a more contemporary craniotomy cohort from the University of North Carolina at Chapel Hill (UNC-CH). We have also sought to understand better how various immune cell subsets, angiogenic factors, and blood vessels may be associated with clinical and radiographic features in MBM. METHODS Brain tumors from the UPMC and UNC-CH patient cohorts were (re)analyzed by standard histopathology, tumor tissue imaging, and gene expression profiling. Variables were associated with overall survival (OS) and radiographic features. RESULTS The patient subgroup with high TILs in craniotomy specimens and subsequent treatment with immune checkpoint inhibitors (ICIs, n=7) trended to have longer OS compared to the subgroup with high TILs and no treatment with ICIs (n=11, p=0.059). Bleeding was significantly associated with tumor volume before craniotomy, high melanoma-specific expression of basic fibroblast growth factor (bFGF), and high density of CD31+αSMA- blood vessels. Brain tumors with high versus low peritumoral edema before craniotomy had low (17%) versus high (41%) incidence of brisk TILs. Melanoma-specific expression of the vascular endothelial growth factor (VEGF) was comparable to VEGF expression by TILs and was not associated with any particular prognostic, radiographic, or histopathologic features. A gene signature associated with gamma delta (gd) T cells was significantly higher in intracranial than same-patient extracranial metastases and primary melanoma. However, gdT cell density in MBM was not prognostic. CONCLUSIONS ICIs may provide greater clinical benefit in patients with brisk TILs in MBM. Intratumoral hemorrhage in brain metastases, a significant clinical problem, is not merely associated with tumor volume but also with underlying biology. bFGF may be an essential pathway to target. VEGF, a factor principally associated with peritumoral edema, is not only produced by melanoma cells but also by TILs. Therefore, suppressing low-grade peritumoral edema using corticosteroids may harm TIL function in 41% of cases. Ongoing clinical trials targeting VEGF in MBM may predict a lack of unfavorable impacts on TIL density and/or intratumoral hemorrhage.
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Affiliation(s)
- Dimitri G. Trembath
- Departments of Pathology and Laboratory Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Eric S. Davis
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Shanti Rao
- University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Evan Bradler
- University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Angelica F. Saada
- State University of New York Downstate Medical Center College of Medicine, Brooklyn, NY, United States
| | - Bentley R. Midkiff
- Translational Pathology Laboratory, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Anna C. Snavely
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Matthew G. Ewend
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Neurosurgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Frances A. Collichio
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Carrie B. Lee
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Georgia-Sofia Karachaliou
- Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Fatih Ayvali
- Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - David W. Ollila
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Michal T. Krauze
- Melanoma and Skin Cancer Program, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - John M. Kirkwood
- Melanoma and Skin Cancer Program, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Benjamin G. Vincent
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Nana Nikolaishvilli-Feinberg
- Translational Pathology Laboratory, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Stergios J. Moschos
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Forst DA. Palliative and Supportive Care in Neuro-oncology. ACTA ACUST UNITED AC 2020; 26:1673-1685. [PMID: 33273177 DOI: 10.1212/con.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article reviews the supportive care needs of patients with primary brain tumors and their caregivers, outlines the management of selected common symptoms of patients with brain tumors, and describes challenges and opportunities in providing palliative care for this population. RECENT FINDINGS Patients with primary malignant brain tumors generally have a poor prognosis and experience progressive neurologic decline and significant physical and psychological symptoms. Management of these symptoms, including fatigue, mood disorders, and the manifestations of cerebral edema, can be challenging. Caregivers for these patients have high rates of psychological distress and report significant caregiving burden. Although the benefit of early palliative care for patients with other advanced solid tumors is well established, our understanding of the role of palliative care in neuro-oncology is incomplete, and thus palliative care and hospice services remain underutilized. SUMMARY Patients with brain tumors and their caregivers have significant supportive care needs, which often differ from the needs of patients with cancers outside of the nervous system. Clinicians face challenges associated with managing patients' symptoms and adequately facilitating prognostic understanding and decision making. Palliative care and hospice services may offer important benefits for this population.
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Dalby T, Wohl E, Dinsmore M, Unger Z, Chowdhury T, Venkatraghavan L. Pathophysiology of Cerebral Edema—A Comprehensive Review. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2020. [DOI: 10.1055/s-0040-1721165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
AbstractCerebral edema is a condition where an excess of cerebral water accumulates due to primary neurological or non-neurological causes. Cerebral edema complicates many brain pathologies causing additional injury often in excess of the original neurological insult. Classic descriptions divide cerebral edema into cytotoxic, vasogenic, interstitial, and osmotic subtypes. The interplay of different mechanisms is important in the clinical manifestations. Recent research has advanced our understanding of the molecular pathophysiology of cerebral edema, exposing the central role of aquaporins and specific ion channels. The aim of this review is to provide a comprehensive overview of the molecular pathophysiology of cerebral edema including unique disease specific mechanisms.
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Affiliation(s)
- Tara Dalby
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Elyana Wohl
- Department of Anesthesia, Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Michael Dinsmore
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Zoe Unger
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Tumul Chowdhury
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Lakshmikumar Venkatraghavan
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
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Dono A, Husein N, Ybarra C, Hasbun R, Choi HA, Ballester LY, Esquenazi Y. Real-time intracranial pressure monitoring during high-dose methotrexate treatment for primary central nervous system lymphoma. Cancer Treat Res Commun 2020; 25:100234. [PMID: 33161322 DOI: 10.1016/j.ctarc.2020.100234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Primary central nervous system lymphoma (PCNSL) is an aggressive non-Hodgkin lymphoma with exclusive central nervous system (CNS) and/or ocular involvement. Increased intracranial pressure (ICP) from cerebral edema can commonly presents secondary to the mass effect of PCNSL. Methotrexate-based induction chemotherapy is the gold standard for treatment, however, several neurotoxic complications have been associated with high-dose methotrexate (HD-MTX) treatment. Tumor lysis and other biochemical disruptions following administration of HD-MTX are postulated to increase cerebral edema and ICP in predisposed patients, therefore, in the setting of ring-enhancing lesions with significant mass effect, monitoring of ICP to prevent cerebral herniation may be necessary. PRESENTATION OF CASE We present the case of a patient with diffuse cerebral edema secondary to PCNSL, who was treated with methotrexate-based induction chemotherapy and underwent real-time ICP monitoring to allow for early recognition, and management with aggressive medical therapy to prevent worsening cerebral edema and potential fatal herniation. DISCUSSION AND CONCLUSIONS Treatment of patients with high tumor burden PCNSL can prove to be challenging, particularly at the time of initiation of methotrexate based induction chemotherapy in the setting of impending cerebral herniation, as in the case presented. Close monitoring of the patient's ICP proved advantageous in rapidly recognizing, and successfully treating elevations in ICP that could have worsened mass effect and lead to fatal herniation.
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Affiliation(s)
- Antonio Dono
- Vivian L. Smith Department of Neurosurgery, the University of Texas Health Science Center at Houston - McGovern Medical School, 6431 Fannin St. Houston, TX, 77030, United States
| | - Nuruddin Husein
- Vivian L. Smith Department of Neurosurgery, the University of Texas Health Science Center at Houston - McGovern Medical School, 6431 Fannin St. Houston, TX, 77030, United States; Memorial Hermann Hospital-Texas Medical Center, 6411 Fannin St. Houston, TX, 77030, United States
| | - Cristian Ybarra
- Vivian L. Smith Department of Neurosurgery, the University of Texas Health Science Center at Houston - McGovern Medical School, 6431 Fannin St. Houston, TX, 77030, United States
| | - Rodrigo Hasbun
- Department of Internal Medicine - Division of Infectious Diseases, the University of Texas Health Science Center at Houston - McGovern Medical School, 6431 Fannin St. Houston, TX, 77030, United States
| | - H Alex Choi
- Vivian L. Smith Department of Neurosurgery, the University of Texas Health Science Center at Houston - McGovern Medical School, 6431 Fannin St. Houston, TX, 77030, United States; Memorial Hermann Hospital-Texas Medical Center, 6411 Fannin St. Houston, TX, 77030, United States
| | - Leomar Y Ballester
- Vivian L. Smith Department of Neurosurgery, the University of Texas Health Science Center at Houston - McGovern Medical School, 6431 Fannin St. Houston, TX, 77030, United States; Memorial Hermann Hospital-Texas Medical Center, 6411 Fannin St. Houston, TX, 77030, United States; Department of Pathology and Laboratory Medicine, the University of Texas Health Science Center at Houston - McGovern Medical School, 6431 Fannin St. Houston, TX, 77030, United States.
| | - Yoshua Esquenazi
- Vivian L. Smith Department of Neurosurgery, the University of Texas Health Science Center at Houston - McGovern Medical School, 6431 Fannin St. Houston, TX, 77030, United States; Memorial Hermann Hospital-Texas Medical Center, 6411 Fannin St. Houston, TX, 77030, United States; Center for Precision Health, School of Biomedical Informatics, the University of Texas Health Science Center at Houston - McGovern Medical School, 6431 Fannin St. Houston, TX, 77030, United States.
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Robert SM, Reeves BC, Alper SL, Zhang J, Kahle KT. New drugs on the horizon for cerebral edema: what's in the clinical development pipeline? Expert Opin Investig Drugs 2020; 29:1099-1105. [PMID: 32815401 PMCID: PMC8104020 DOI: 10.1080/13543784.2020.1813715] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Research has advanced our understanding of the molecular and cellular mechanisms of cerebral edema and has propelled the development of novel antiedema therapeutics. Current evidence supports aberrant neuro-glial ion transport as a central mechanism that underlies pathological fluid accumulation after central nervous system injury. AREAS COVERED Novel agents in clinical development show potential in altering the natural history and treatment of cerebral edema. Using the PubMed and Google Scholar databases, we review recent advances in our understanding of cerebral edema and describe agents under active investigation, their mechanism, and their application in recent and ongoing clinical trials. EXPERT OPINION Pharmacotherapies that target molecular mechanisms underlying the compensatory post-injury response of ion channels and transporters that lead to pathological alteration of osmotic gradients are the most promising therapeutic strategies. Repurposing of drugs such as glyburide that inhibit the aberrant upregulation of ion channels such as SUR1-TRPM4, and novel agents, such as ZT-1a, which reestablish physiological regulation of ion channels such as NKCC1/KCC, could be useful adjuvants to prevent and even reverse fluid accumulation in the brain parenchyma.
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Affiliation(s)
- Stephanie M Robert
- Department of Neurosurgery, Yale School of Medicine , New Haven, CT, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale School of Medicine , New Haven, CT, USA
| | - Seth L Alper
- Division of Nephrology and Vascular Biology Research Center, Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School , Boston, MA, USA
| | - Jinwei Zhang
- Institute of Biomedical and Clinical Sciences, Medical School, College of Medicine and Health, University of Exeter, Hatherly Laboratories , Exeter, UK
| | - Kristopher T Kahle
- Departments of Neurosurgery, Pediatrics, and Cellular & Molecular Physiology and Yale-Rockefeller NIH Centers for Mendelian Genomics, Yale School of Medicine , New Haven, CT, USA
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21
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Peripheral Blood Occludin Level as a Biomarker for Perioperative Cerebral Edema in Patients with Brain Tumors. DISEASE MARKERS 2020; 2020:8813535. [PMID: 32884584 PMCID: PMC7455817 DOI: 10.1155/2020/8813535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/02/2020] [Accepted: 07/31/2020] [Indexed: 11/17/2022]
Abstract
Objective Cerebral edema is a common complication of brain tumors in the perioperative period. However, there is currently no reliable and convenient method to evaluate the extent of brain edema. The objective is to explore the effectiveness of serum occludin on predicting the extent of perioperative brain edema and outcome in patients with brain tumors. Methods This prospective study enrolled 55 patients with brain tumors and 24 healthy controls in Sanbo Brain Hospital from June 2019 through November 2019. Serum occludin levels were measured preoperatively and on postoperative day 1. Peritumoral edema was assessed preoperatively using MRI. Pericavity brain edema on postoperative day 1 was evaluated using CT. Results Compared with healthy controls, the serum occludin level was higher in patients with brain tumors both preoperatively and postoperatively (P < 0.001). The serum occludin level correlated positively with the degree of brain edema preoperatively (r = 0.78, P < 0.001) and postoperatively (r = 0.59, P < 0.001). At an optimal cutoff of 3.015 ng/mL, the preoperative serum occludin level discriminated between mild and severe preoperative brain edema with a sensitivity of 90.48% and specificity of 84.62%. At an optimal cutoff value of 3.033 ng/mL, the postoperative serum occludin level distinguished between mild and severe postoperative brain edema with a sensitivity of 97.30% and specificity of 55.56%. Conclusions The serum occludin level is associated with cerebral edema and could potentially be used as a biomarker for perioperative cerebral edema. This trial is registered with ChiCTR1900023742.
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22
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Yao Y, Yao QY, Xue JS, Tian XY, An QM, Cui LX, Xu C, Su H, Yang L, Feng YY, Hao CY, Zhou TY. Dexamethasone inhibits pancreatic tumor growth in preclinical models: Involvement of activating glucocorticoid receptor. Toxicol Appl Pharmacol 2020; 401:115118. [PMID: 32619553 DOI: 10.1016/j.taap.2020.115118] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/21/2020] [Accepted: 06/28/2020] [Indexed: 01/07/2023]
Abstract
Glucocorticoid receptor (GR) modulates extensive biological and pathological processes including tumor progression through diverse mechanisms. The regulatory effects of dexamethasone (DEX), a synthetic glucocorticoid, as well as its interaction with GR have been recognized beyond hematologic cancers. In the present study, we investigated the anti-cancer efficacy of DEX and the correlation with GR in pancreatic cancer, a most aggressive malignancy threatening human health. The differential levels of GR expression were examined in two human pancreatic cancer cell lines, PANC-1 and SW1990, as well as in xenografts and patient tumor tissues. DEX significantly inhibited colony formation, migration, and tumor growth of PANC-1 cells expressing abundant GR. The underlying mechanisms involved suppression of nuclear factor κB (NF-κB) phosphorylation and down-regulation of epithelial-to-mesenchymal transition (EMT), interleukin 6 (IL-6) and vascular endothelial growth factor (VEGF). The anti-cancer effects of DEX were partially reversed by GR silencing or combinational administration of GR antagonist, RU486. The dose-dependent efficacy of DEX in tumor growth inhibition was also demonstrated in a GR-positive patient-derived xenograft model along with safety in mice. DEX was less potent, however, in SW1990 cells with poor GR expression. Our findings suggest that DEX effectively inhibits pancreatic tumor growth partially through GR activation. The potential correlation between GR expression and anti-cancer efficacy of DEX may have some clinical implications.
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Affiliation(s)
- Ye Yao
- Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery System, Department of Pharmaceutics, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Qing-Yu Yao
- Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery System, Department of Pharmaceutics, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Jun-Sheng Xue
- Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery System, Department of Pharmaceutics, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Xiu-Yun Tian
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Qi-Ming An
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Li-Xuan Cui
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Chang Xu
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Hong Su
- Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery System, Department of Pharmaceutics, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Liang Yang
- Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery System, Department of Pharmaceutics, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Yao-Yao Feng
- Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery System, Department of Pharmaceutics, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Chun-Yi Hao
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing 100142, China.
| | - Tian-Yan Zhou
- Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery System, Department of Pharmaceutics, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China.
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23
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Dormagen JB, Verma N, Fink KR. Imaging in Oncologic Emergencies. Semin Roentgenol 2020; 55:95-114. [PMID: 32438984 DOI: 10.1053/j.ro.2019.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Nupur Verma
- Department of Radiology, University of Florida, Gainesville, FL
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24
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Outcomes of Total Hip Arthroplasty in Patients with Osteonecrosis of the Femoral Head Following Surgical Treatment of Brain Tumors. J Clin Med 2019; 8:jcm8101703. [PMID: 31623217 PMCID: PMC6832427 DOI: 10.3390/jcm8101703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/13/2019] [Accepted: 10/14/2019] [Indexed: 12/23/2022] Open
Abstract
Corticosteroids have been widely used in patients with brain tumors to reduce tumor-associated edema and neurological deficits. This study examined the outcomes of total hip arthroplasty (THA) in patients with osteonecrosis of the femoral head (ONFH) following brain tumor surgery. We identified 34 THAs performed in 26 patients with steroid-induced ONFH among 9254 patients undergoing surgical treatment for primary brain tumors. After propensity score matching with demographics, 68 THAs (52 patients) in ONFH unrelated to brain tumors were selected as the control group. At the time of THA, 54% of brain tumor patients had neurological sequelae and 46% had adrenal insufficiency. After THA, patients with brain tumor required longer hospital stay, reported a lower functional score, and showed a higher rate of heterotopic ossification compared to the control group. However, hip pain score improved significantly after THA in the brain tumor group, and did not differ from that of the control group (P-value = 0.168). Major complication rates were similar (2.9% and 1.5% for the brain tumor and control groups, respectively; P-value = 1.000), and implant survivorships were not different at 7 years (100% and 98.1% for the brain tumor and control groups, respectively; P-value = 0.455). Our findings suggest that THA can be safely performed to reduce hip pain in patients with steroid-induced ONFH after surgical treatment of primary brain tumors.
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25
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Halstead MR, Geocadin RG. The Medical Management of Cerebral Edema: Past, Present, and Future Therapies. Neurotherapeutics 2019; 16:1133-1148. [PMID: 31512062 PMCID: PMC6985348 DOI: 10.1007/s13311-019-00779-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Cerebral edema is commonly associated with cerebral pathology, and the clinical manifestation is largely related to the underlying lesioned tissue. Brain edema usually amplifies the dysfunction of the lesioned tissue and the burden of cerebral edema correlates with increased morbidity and mortality across diseases. Our modern-day approach to the medical management of cerebral edema has largely revolved around, an increasingly artificial distinction between cytotoxic and vasogenic cerebral edema. These nontargeted interventions such as hyperosmolar agents and sedation have been the mainstay in clinical practice and offer noneloquent solutions to a dire problem. Our current understanding of the underlying molecular mechanisms driving cerebral edema is becoming much more advanced, with differences being identified across diseases and populations. As our understanding of the underlying molecular mechanisms in neuronal injury continues to expand, so too is the list of targeted therapies in the pipeline. Here we present a brief review of the molecular mechanisms driving cerebral edema and a current overview of our understanding of the molecular targets being investigated.
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Affiliation(s)
- Michael R Halstead
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology-Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287, USA.
| | - Romergryko G Geocadin
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology-Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287, USA
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26
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Song S, Luo L, Sun B, Sun D. Roles of glial ion transporters in brain diseases. Glia 2019; 68:472-494. [PMID: 31418931 DOI: 10.1002/glia.23699] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/22/2019] [Accepted: 07/26/2019] [Indexed: 12/21/2022]
Abstract
Glial ion transporters are important in regulation of ionic homeostasis, cell volume, and cellular signal transduction under physiological conditions of the central nervous system (CNS). In response to acute or chronic brain injuries, these ion transporters can be activated and differentially regulate glial functions, which has subsequent impact on brain injury or tissue repair and functional recovery. In this review, we summarized the current knowledge about major glial ion transporters, including Na+ /H+ exchangers (NHE), Na+ /Ca2+ exchangers (NCX), Na+ -K+ -Cl- cotransporters (NKCC), and Na+ -HCO3 - cotransporters (NBC). In acute neurological diseases, such as ischemic stroke and traumatic brain injury (TBI), these ion transporters are rapidly activated and play significant roles in regulation of the intra- and extracellular pH, Na+ , K+ , and Ca2+ homeostasis, synaptic plasticity, and myelin formation. However, overstimulation of these ion transporters can contribute to glial apoptosis, demyelination, inflammation, and excitotoxicity. In chronic brain diseases, such as glioma, Alzheimer's disease (AD), Parkinson's disease (PD), and multiple sclerosis (MS), glial ion transporters are involved in the glioma Warburg effect, glial activation, neuroinflammation, and neuronal damages. These findings suggest that glial ion transporters are involved in tissue structural and functional restoration, or brain injury and neurological disease development and progression. A better understanding of these ion transporters in acute and chronic neurological diseases will provide insights for their potential as therapeutic targets.
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Affiliation(s)
- Shanshan Song
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Pittsburgh Institute for Neurodegenerative Disorders, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lanxin Luo
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Pittsburgh Institute for Neurodegenerative Disorders, University of Pittsburgh, Pittsburgh, Pennsylvania.,School of Traditional Chinese Materia Medica, Shenyang Pharmaceutical University, Shenyang, China.,School of Functional Food and Wine, Shenyang Pharmaceutical University, Shenyang, China
| | - Baoshan Sun
- School of Functional Food and Wine, Shenyang Pharmaceutical University, Shenyang, China.,Pólo Dois Portos, Instituto National de Investigação Agrária e Veterinária, Dois Portos, Portugal
| | - Dandan Sun
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Pittsburgh Institute for Neurodegenerative Disorders, University of Pittsburgh, Pittsburgh, Pennsylvania.,Veterans Affairs Pittsburgh Health Care System, Geriatric Research, Educational and Clinical Center, Pittsburgh, Pennsylvania
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27
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Schroeder T, Bittrich P, Noebel C, Kuhne JF, Schroeder J, Schoen G, Fiehler J, Kniep HC, Gellißen S. Efficiency of Dexamethasone for Treatment of Vasogenic Edema in Brain Metastasis Patients: A Radiographic Approach. Front Oncol 2019; 9:695. [PMID: 31417871 PMCID: PMC6683846 DOI: 10.3389/fonc.2019.00695] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 07/15/2019] [Indexed: 12/27/2022] Open
Abstract
Background and Purpose: To date, imaging studies quantifying the amount of vasogenic edema reduction (VE) in patients with brain metastases (BM) treated with glucocorticoids (GC) have included a very limited number of patients and showed ambiguous results. Here, we aim to determine the radiological effect of GC on VE in BM patients in a large cohort with multiple primary tumor entities in a cross-sectional approach. Materials and Methods: This monocentric retrospective study includes 299 patients first-ever diagnosed with 2,759 intra-axial BM on the respective MRI. 126/299 patients received GC prior to MRI due to mass effect of edema on cranial CT scan and clinical symptoms (GC-pos) and 173 patients did not (GC-neg). GC dose was documented in 85/126 patients. All BM and their respective VE were semi-automatically segmented on post-contrast T1-weighted images. Results: VE volumes were higher in GC-pos compared to GC-neg (p = 0.009) and did not correlate with GC dose. Multivariate linear regression analysis with interaction terms on the assumption that BM volume and BM number influence the probability of GC administration shows that large and higher numbers of BM under GC treatment generate less VE than without (p < 0.001 and p = 0.038, respectively). The primary tumor type and total BM volume did not influence VE volume. Conclusion: Use of GC is especially effective for treatment of VE formation in patients with larger and multiple BM regardless of primary tumor type and dosage. However, based on the present data a direct causative relationship between GC and VE cannot be proven.
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Affiliation(s)
- Tanja Schroeder
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiology, Schoen Klinik Hamburg Eilbek, Hamburg, Germany
| | - Paul Bittrich
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Clara Noebel
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Felix Kuhne
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Schroeder
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schoen
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge C Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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28
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Tran TT, Mahajan A, Chiang VL, Goldberg SB, Nguyen DX, Jilaveanu LB, Kluger HM. Perilesional edema in brain metastases: potential causes and implications for treatment with immune therapy. J Immunother Cancer 2019; 7:200. [PMID: 31362777 PMCID: PMC6668163 DOI: 10.1186/s40425-019-0684-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/18/2019] [Indexed: 02/07/2023] Open
Abstract
Background Little is known about tumor-associated vasogenic edema in brain metastasis, yet it causes significant morbidity and mortality. Our purpose was to characterize edema in patients treated with anti-PD-1 and to study potential causes of vessel leakage in humans and in pre-clinical models. Methods We analyzed tumor and edema volume in 18 non-small cell lung (NSCLC) and 18 melanoma patients with untreated brain metastases treated with pembrolizumab on a phase II clinical trial. Melanoma brain metastases were stained with anti-CD34 to assess vessel density and its association with edema. We employed an in vitro model of the blood-brain barrier using short-term cultures from melanoma brain and extracranial metastases to determine tight junction resistance as a measure of vessel leakiness. Results Edema volumes are similar in NSCLC and melanoma brain metastases. While larger tumors tended to have more edema, the correlation was weak (R2 = 0.30). Patients responding to pembrolizumab had concurrent shrinkage of edema volume and vice versa (R2 = 0.81). Vessel density was independent of the degree of edema (R2 = 0.037). Melanoma brain metastasis cells in culture caused loss of tight junction resistance in an in vitro blood-brain barrier model system in some cases, whereas extracerebral cell cultures did not. Conclusions Edema itself should not preclude using anti-PD-1 with caution, as sensitive tumors have resultant decreases in edema, and anti-PD-1 itself does not exacerbate edema in sensitive tumors. Additional factors aside from tumor mass effect and vessel density cause perilesional edema. Melanoma cells themselves can cause decline in tight junction resistance in a system void of immune cells, suggesting they secrete factors that cause leakiness, which might be harnessed for pharmacologic targeting in patients with significant perilesional edema. Electronic supplementary material The online version of this article (10.1186/s40425-019-0684-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thuy T Tran
- Yale School of Medicine and Yale Cancer Center, Yale University, New Haven, CT, USA
| | - Amit Mahajan
- Yale School of Medicine and Yale Department of Radiology & Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Veronica L Chiang
- Yale School of Medicine and Yale Cancer Center, Yale University, New Haven, CT, USA.,Yale School of Medicine and Yale Department of Neurosurgery, Yale University, New Haven, CT, USA
| | - Sarah B Goldberg
- Yale School of Medicine and Yale Cancer Center, Yale University, New Haven, CT, USA
| | - Don X Nguyen
- Yale School of Medicine and Yale Department of Pathology, Yale University, New Haven, CT, USA
| | - Lucia B Jilaveanu
- Yale School of Medicine and Yale Cancer Center, Yale University, New Haven, CT, USA
| | - Harriet M Kluger
- Yale School of Medicine and Yale Cancer Center, Yale University, New Haven, CT, USA.
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29
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Ryu JA, Jung W, Jung YJ, Kwon DY, Kang K, Choi H, Kong DS, Seol HJ, Lee JI. Early prediction of neurological outcome after barbiturate coma therapy in patients undergoing brain tumor surgery. PLoS One 2019; 14:e0215280. [PMID: 30995269 PMCID: PMC6469802 DOI: 10.1371/journal.pone.0215280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 03/31/2019] [Indexed: 11/18/2022] Open
Abstract
After a difficult brain tumor surgery, refractory intracranial hypertension (RICH) may occur due to residual tumor or post-operative complications such as hemorrhage, infarction, and aggravated brain edema. We investigated which predictors are associated with prognosis when using barbiturate coma therapy (BCT) as a second-tier therapy to control RICH after brain tumor surgery. The study included adult patients who underwent BCT after brain tumor surgery between January 2010 and December 2016. The primary outcome was neurological status upon hospital discharge, which was assessed using the Glasgow Outcome Scale (GOS). In the study period, 4,296 patients underwent brain tumor surgery in total. Of these patients, BCT was performed in 73 patients (1.7%). Among these 73 patients, 56 (76.7%) survived to discharge and 25 (34.2%) showed favorable neurological outcomes (GOS scores of 4 and 5). Invasive monitoring of intracranial pressure (ICP) was performed in 60 (82.2%) patients, and revealed that the maximal ICP within 6 h after BCT was significantly lower in patients with favorable neurological outcome as well as in survivors (p = 0.008 and p = 0.028, respectively). Uncontrolled RICH (ICP ≥ 22 mm Hg within 6 h of BCT) was an important predictor of mortality after BCT (adjusted hazard ratio 12.91, 95% confidence interval [CI] 2.788–59.749), and in particular, ICP ≥ 15 mm Hg within 6 h of BCT was associated with poor neurological outcome (adjusted odds ratio 9.36, 95% CI 1.664–52.614). Therefore, early-controlled ICP after BCT was associated with clinical prognosis. There were no significant differences in the complications associated with BCT between the two neurological outcome groups. No BCT-induced death was observed. The active and timely control of RICH may be beneficial for clinical outcomes in patients with RICH after brain tumor surgery.
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Affiliation(s)
- Jeong-Am Ryu
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Wonkyung Jung
- Department of Nursing, Neurosurgery Intensive Care Unit, Samsung Medical Center, Seoul, Republic of Korea
| | - Yoo Jin Jung
- Department of Nursing, Neurosurgery Intensive Care Unit, Samsung Medical Center, Seoul, Republic of Korea
| | - Do Yeon Kwon
- Department of Nursing, Neurosurgery Intensive Care Unit, Samsung Medical Center, Seoul, Republic of Korea
| | - Kina Kang
- Department of Nursing, Neurosurgery Intensive Care Unit, Samsung Medical Center, Seoul, Republic of Korea
| | - Hyeok Choi
- Department of Nursing, Neurosurgery Intensive Care Unit, Samsung Medical Center, Seoul, Republic of Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- * E-mail:
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30
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Wijk A, Canning P, Heijningen RP, Vogels IM, Noorden CJ, Klaassen I, Schlingemann RO. Glucocorticoids exert differential effects on the endothelium in an in vitro model of the blood-retinal barrier. Acta Ophthalmol 2019; 97:214-224. [PMID: 30168271 DOI: 10.1111/aos.13909] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 08/03/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Glucocorticoids (GCs) are used as treatment in diabetic macular oedema, a condition caused by blood-retinal barrier (BRB) disruption. The proposed mechanisms by which GCs reduce macular oedema are indirect anti-inflammatory effects and inhibition of VEGF production, but direct effects on the BRB endothelium may be equally important. Here, we investigated direct effects of GCs on the endothelium to understand the specific pathways of GC action, to enable development of novel therapeutics lacking the adverse side-effects of the presently used GCs. METHODS Primary bovine retinal endothelial cells (BRECs) were grown on Transwell inserts and treated with hydrocortisone (HC), dexamethasone (Dex) or triamcinolone acetonide (TA). Molecular barrier integrity of the BRB was determined by mRNA and protein expression, and barrier function was assessed using permeability assays. In addition, we investigated whether TA was able to prevent barrier disruption after stimulation with VEGF or cytokines. RESULTS Treatment of BRECs with GCs resulted in upregulation of tight junction mRNA (claudin-5, occludin, ZO-1) and protein (claudin-5 and ZO-1). In functional assays, only TA strengthened the barrier function by reducing endothelial permeability. Moreover, TA was able to prevent cytokine-induced permeability in human retinal endothelial cells and VEGF-induced expression of plasmalemma vesicle-associated protein (PLVAP), a key player in VEGF-induced retinal vascular leakage. CONCLUSION Glucocorticoids have differential effects in an experimental in vitro BRB model. TA is the most potent in improving barrier function, both at the molecular and functional levels, and TA prevents VEGF-induced expression of PLVAP.
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Affiliation(s)
- Anne‐Eva Wijk
- Departments of Ophthalmology and Medical Biology Amsterdam UMC University of Amsterdam Ocular Angiogenesis Group Amsterdam Cardiovascular Sciences Amsterdam Neuroscience Amsterdam The Netherlands
| | - Paul Canning
- The Wellcome‐Wolfson Institute for Experimental Medicine School of Medicine Dentistry and Biomedical Sciences Queen's University Belfast Belfast UK
| | - Rutger P. Heijningen
- Departments of Ophthalmology and Medical Biology Amsterdam UMC University of Amsterdam Ocular Angiogenesis Group Amsterdam Cardiovascular Sciences Amsterdam Neuroscience Amsterdam The Netherlands
| | - Ilse M.C. Vogels
- Departments of Ophthalmology and Medical Biology Amsterdam UMC University of Amsterdam Ocular Angiogenesis Group Amsterdam Cardiovascular Sciences Amsterdam Neuroscience Amsterdam The Netherlands
| | - Cornelis J.F. Noorden
- Departments of Ophthalmology and Medical Biology Amsterdam UMC University of Amsterdam Ocular Angiogenesis Group Amsterdam Cardiovascular Sciences Amsterdam Neuroscience Amsterdam The Netherlands
- Department of Genetic Toxicology and Cancer Biology National Institute of Biology Ljubljana Slovenia
| | - Ingeborg Klaassen
- Departments of Ophthalmology and Medical Biology Amsterdam UMC University of Amsterdam Ocular Angiogenesis Group Amsterdam Cardiovascular Sciences Amsterdam Neuroscience Amsterdam The Netherlands
| | - Reinier O. Schlingemann
- Departments of Ophthalmology and Medical Biology Amsterdam UMC University of Amsterdam Ocular Angiogenesis Group Amsterdam Cardiovascular Sciences Amsterdam Neuroscience Amsterdam The Netherlands
- Department of Ophthalmology University of Lausanne Jules Gonin Eye Hospital Lausanne Switzerland
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31
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[CARs, CRS and neurotoxicity: severe complications after administration of immunotherapy : Essentials for intensivists]. Med Klin Intensivmed Notfmed 2018; 115:198-204. [PMID: 30547223 DOI: 10.1007/s00063-018-0518-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/14/2018] [Accepted: 11/09/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The development of chimeric antigen receptor (CAR) T‑cells has shown promising results in relapsed/refractory B‑cell acute lymphoblastic leukemia/lymphoma (B-ALL) and diffuse large cell B‑cell lymphoma. Complications, especially cytokine release syndrome (CRS) and CAR T‑cell related encephalopathy syndrome (CRES), can be life threatening. The management of both plays a key role in CAR T‑cell therapy. OBJECTIVES Diagnosis, clinical presentation and development of complications in the treatment with CAR T‑cells. MATERIALS AND METHODS Summary of incidence, mortality and treatment of severe complications after administration of CAR T‑cells referring to current studies and therapy recommendations. RESULTS Complications after administration of CAR T‑cells, especially CRS and CRES, can be life threatening. The timely identification of side effects and their appropriate treatment usually leads to complete recovery. CONCLUSIONS Using a therapy algorithm in the treatment with CAR T‑cells allows safe management of toxicities and can be helpful in recognizing them in time.
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Tsidulko AY, Bezier C, de La Bourdonnaye G, Suhovskih AV, Pankova TM, Kazanskaya GM, Aidagulova SV, Grigorieva EV. Conventional Anti-glioblastoma Chemotherapy Affects Proteoglycan Composition of Brain Extracellular Matrix in Rat Experimental Model in vivo. Front Pharmacol 2018; 9:1104. [PMID: 30333749 PMCID: PMC6176078 DOI: 10.3389/fphar.2018.01104] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 09/10/2018] [Indexed: 12/19/2022] Open
Abstract
Temozolomide (TMZ) is a conventional chemotherapy drug for adjuvant treatment of glioblastoma multiforme (GBM), often accompanied by dexamethasone (DXM) to prevent brain oedema and alleviate clinical side effects. Here, we aimed to investigate an ability of the drugs to affect normal brain tissue in terms of proteoglycan (PG) composition/content in experimental rat model in vivo. Age- and brain zone-specific transcriptional patterns of PGs were demonstrated for 8, 60, and 120 days old rats, and syndecan-1, glypican-1, decorin, biglycan, and lumican were identified as the most expressed PGs. DXM treatment affected both PG core proteins expression (mainly syndecan-1, glypican-1, decorin, biglycan, lumican, versican, brevican, and NG2) and heparan sulphate (HS)/chondroitin sulphate (CS) content in organotypic brain slice culture ex vivo and experimental animals in vivo in a dose-dependent manner. TMZ treatment did not result in the significant changes in PG core proteins expression both in normal rat brain hippocampus and cortex in vivo (although generics did), but demonstrated significant effects onto polysaccharide HS/CS content in the brain tissue. The effects were age- and brain zone-specific and similar with the age-related PGs expression changes in rat brain. Combination of TMZ with DXM resulted in the most profound deterioration in PGs composition and content in the brain tissue both at core protein and glycosaminoglycan levels. Taken together, the obtained results demonstrate that conventional anti-glioblastoma therapy affects proteoglycan structure and composition in normal brain tissue, potentially resulting in deterioration of brain extracellular matrix and formation of the favourable tumorigenic niche for the expansion of the residual glioma cells. During the TMZ chemotherapy, dose and regimen of DXM treatment matter, and repetitive low DXM doses seem to be more sparing treatment compared with high DXM dose(s), which should be avoided where possible, especially in combination with TMZ.
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Affiliation(s)
| | - Cynthia Bezier
- Novosibirsk State University, Novosibirsk, Russia.,UPMC-Sorbonne Universities, Paris, France
| | - Gabin de La Bourdonnaye
- Novosibirsk State University, Novosibirsk, Russia.,Institut National des Sciences Appliquées de Toulouse, Toulouse, France
| | - Anastasia V Suhovskih
- Institute of Molecular Biology and Biophysics, Novosibirsk, Russia.,Novosibirsk State University, Novosibirsk, Russia
| | | | - Galina M Kazanskaya
- Institute of Molecular Biology and Biophysics, Novosibirsk, Russia.,Meshalkin Novosibirsk State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Elvira V Grigorieva
- Institute of Molecular Biology and Biophysics, Novosibirsk, Russia.,Novosibirsk State University, Novosibirsk, Russia
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Nordström CH, Koskinen LO, Olivecrona M. Aspects on the Physiological and Biochemical Foundations of Neurocritical Care. Front Neurol 2017; 8:274. [PMID: 28674514 PMCID: PMC5474476 DOI: 10.3389/fneur.2017.00274] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/29/2017] [Indexed: 12/25/2022] Open
Abstract
Neurocritical care (NCC) is a branch of intensive care medicine characterized by specific physiological and biochemical monitoring techniques necessary for identifying cerebral adverse events and for evaluating specific therapies. Information is primarily obtained from physiological variables related to intracranial pressure (ICP) and cerebral blood flow (CBF) and from physiological and biochemical variables related to cerebral energy metabolism. Non-surgical therapies developed for treating increased ICP are based on knowledge regarding transport of water across the intact and injured blood-brain barrier (BBB) and the regulation of CBF. Brain volume is strictly controlled as the BBB permeability to crystalloids is very low restricting net transport of water across the capillary wall. Cerebral pressure autoregulation prevents changes in intracranial blood volume and intracapillary hydrostatic pressure at variations in arterial blood pressure. Information regarding cerebral oxidative metabolism is obtained from measurements of brain tissue oxygen tension (PbtO2) and biochemical data obtained from intracerebral microdialysis. As interstitial lactate/pyruvate (LP) ratio instantaneously reflects shifts in intracellular cytoplasmatic redox state, it is an important indicator of compromised cerebral oxidative metabolism. The combined information obtained from PbtO2, LP ratio, and the pattern of biochemical variables reveals whether impaired oxidative metabolism is due to insufficient perfusion (ischemia) or mitochondrial dysfunction. Intracerebral microdialysis and PbtO2 give information from a very small volume of tissue. Accordingly, clinical interpretation of the data must be based on information of the probe location in relation to focal brain damage. Attempts to evaluate global cerebral energy state from microdialysis of intraventricular fluid and from the LP ratio of the draining venous blood have recently been presented. To be of clinical relevance, the information from all monitoring techniques should be presented bedside online. Accordingly, in the future, the chemical variables obtained from microdialysis will probably be analyzed by biochemical sensors.
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Affiliation(s)
| | - Lars-Owe Koskinen
- Department of Clinical Neuroscience, Division of Neurosurgery, Umeå University, Umeå, Sweden
| | - Magnus Olivecrona
- Faculty of Health and Medicine, Department of Anesthesia and Intensive Care, Section for Neurosurgery Örebro University Hospital, Örebro University, Örebro, Sweden
- Department for Medical Sciences, Örebro University, Örebro, Sweden
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