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Marcigaglia S, De Plus R, Vandendriessche C, Schiltz E, Cuypers ML, Cools J, Hoffman LD, Vandenbroucke RE, Dewilde M, Haesler S. Microfluidic Interfaces for Chronic Bidirectional Access to the Brain. Adv Healthc Mater 2024; 13:e2400438. [PMID: 38885495 DOI: 10.1002/adhm.202400438] [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: 02/04/2024] [Revised: 06/11/2024] [Indexed: 06/20/2024]
Abstract
Two-photon polymerization (TPP) is an additive manufacturing technique with micron-scale resolution that is rapidly gaining ground for a range of biomedical applications. TPP is particularly attractive for the creation of microscopic three-dimensional structures in biocompatible and noncytotoxic resins. Here, TPP is used to develop microfluidic interfaces which provide chronic fluidic access to the brain of preclinical research models. These microcatheters can be used for either convection-enhanced delivery (CED) or for the repeated collection of liquid biopsies. In a brain phantom, infusions with the micronozzle result in more localized distribution clouds and lower backflow compared to a control catheter. In mice, the delivery interface enables faster, more precise, and physiologically less disruptive fluid injections. A second microcatheter design enables repeated, longitudinal sampling of cerebrospinal fluid (CSF) over time periods as long as 250 days. Moreover, further in vivo studies demonstrate that the blood-CSF barrier is intact after chronic implantation of the sampling interface and that samples are suitable for downstream molecular analysis for the identification of nucleic acid- or peptide-based biomarkers. Ultimately, the versatility of this fabrication technique implies a great translational potential for simultaneous drug delivery and biomarker tracking in a range of human neurological diseases.
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Affiliation(s)
- Simone Marcigaglia
- Neuroelectronics Research Flanders (NERF), Leuven, 3000, Belgium
- Department of Neurosciences, KU Leuven, Leuven, 3000, Belgium
| | - Robin De Plus
- Neuroelectronics Research Flanders (NERF), Leuven, 3000, Belgium
- Department of Neurosciences, KU Leuven, Leuven, 3000, Belgium
| | - Charysse Vandendriessche
- VIB Center for Inflammation Research, VIB, Ghent, 9052, Belgium
- Department of Biomedical Molecular Biology, Ghent University, Ghent, 9052, Belgium
| | - Eleonore Schiltz
- Neuroelectronics Research Flanders (NERF), Leuven, 3000, Belgium
- Department of Neurosciences, KU Leuven, Leuven, 3000, Belgium
| | - Marie-Lynn Cuypers
- Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, 3000, Belgium
| | - Jordi Cools
- Neuroelectronics Research Flanders (NERF), Leuven, 3000, Belgium
- Current affiliation, Thermofisher Scientific (AIG/MSD), Dilbeek, 1702, Belgium
| | - Luis D Hoffman
- Neuroelectronics Research Flanders (NERF), Leuven, 3000, Belgium
- Current affiliation, SWave Photonics, Leuven, 3001, Belgium
| | - Roosmarijn E Vandenbroucke
- VIB Center for Inflammation Research, VIB, Ghent, 9052, Belgium
- Department of Biomedical Molecular Biology, Ghent University, Ghent, 9052, Belgium
| | - Maarten Dewilde
- Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, 3000, Belgium
- PharmAbs-The KU Leuven Antibody Center, KU Leuven, Leuven, 3000, Belgium
| | - Sebastian Haesler
- Neuroelectronics Research Flanders (NERF), Leuven, 3000, Belgium
- Department of Neurosciences, KU Leuven, Leuven, 3000, Belgium
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Schupper AJ, Hadjipanayis CG. Novel approaches to targeting gliomas at the leading/cutting edge. J Neurosurg 2023; 139:760-768. [PMID: 36840741 PMCID: PMC11225597 DOI: 10.3171/2023.1.jns221798] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/17/2023] [Indexed: 02/26/2023]
Abstract
Despite decades of clinical trials and surgical advances, the most common high-grade glioma, glioblastoma (GBM), remains an incurable disease with a dismal prognosis. Because of its infiltrative nature, GBM almost always recurs at the margin, or leading edge, where tumor cells invade the surrounding brain parenchyma. This region of GBMs is unique, or heterogeneous, with its own microenvironment that is different from the tumor bulk or core. The GBM microenvironment at the margin contains immunosuppressive constituents as well as invasive and therapy-resistant tumor cells that are difficult to treat. In addition, the blood-brain barrier remains essentially intact at the infiltrative margin of tumors; further limiting the effectiveness of therapies. The invasive margin creates the greatest challenge for neurosurgeons when managing these tumors. The current paradigm of resection of GBM tumors mainly focuses on resection of the contrast-enhancing component of tumors, while GBMs extend well beyond the contrast enhancement. The infiltrative margin represents a unique challenge and opportunity for solutions that may overcome current limitations in tumor treatments. In this review of the current literature, the authors discuss the current and developing advances focused on the detection and treatment of GBM at the infiltrative margin and how this could impact patient outcomes.
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Affiliation(s)
- Alexander J. Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Vanbilloen WJF, Rechberger JS, Anderson JB, Nonnenbroich LF, Zhang L, Daniels DJ. Nanoparticle Strategies to Improve the Delivery of Anticancer Drugs across the Blood-Brain Barrier to Treat Brain Tumors. Pharmaceutics 2023; 15:1804. [PMID: 37513992 PMCID: PMC10383584 DOI: 10.3390/pharmaceutics15071804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 07/30/2023] Open
Abstract
Primary brain and central nervous system (CNS) tumors are a diverse group of neoplasms that occur within the brain and spinal cord. Although significant advances in our understanding of the intricate biological underpinnings of CNS neoplasm tumorigenesis and progression have been made, the translation of these discoveries into effective therapies has been stymied by the unique challenges presented by these tumors' exquisitely sensitive location and the body's own defense mechanisms (e.g., the brain-CSF barrier and blood-brain barrier), which normally protect the CNS from toxic insult. These barriers effectively prevent the delivery of therapeutics to the site of disease. To overcome these obstacles, new methods for therapeutic delivery are being developed, with one such approach being the utilization of nanoparticles. Here, we will cover the current state of the field with a particular focus on the challenges posed by the BBB, the different nanoparticle classes which are under development for targeted CNS tumor therapeutics delivery, and strategies which have been developed to bypass the BBB and enable effective therapeutics delivery to the site of disease.
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Affiliation(s)
- Wouter J. F. Vanbilloen
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA (J.S.R.)
- Department of Neurology, Elisabeth-Tweesteden Hospital, 5022 GC Tilburg, The Netherlands
| | - Julian S. Rechberger
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA (J.S.R.)
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN 55905, USA
| | - Jacob B. Anderson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA (J.S.R.)
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN 55905, USA
- Medical Scientist Training Program, Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
| | - Leo F. Nonnenbroich
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA (J.S.R.)
- Hopp Children’s Cancer Center Heidelberg (KiTZ), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), 69120 Heidelberg, Germany
| | - Liang Zhang
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA (J.S.R.)
| | - David J. Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA (J.S.R.)
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN 55905, USA
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4
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Rechberger JS, Power BT, Power EA, Nesvick CL, Daniels DJ. H3K27-altered diffuse midline glioma: a paradigm shifting opportunity in direct delivery of targeted therapeutics. Expert Opin Ther Targets 2023; 27:9-17. [PMID: 36744399 PMCID: PMC10165636 DOI: 10.1080/14728222.2023.2177531] [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: 02/07/2023]
Abstract
INTRODUCTION Despite much progress, the prognosis for H3K27-altered diffuse midline glioma (DMG), previously known as diffuse intrinsic pontine glioma when located in the brainstem, remains dark and dismal. AREAS COVERED A wealth of research over the past decade has revolutionized our understanding of the molecular basis of DMG, revealing potential targetable vulnerabilities for treatment of this lethal childhood cancer. However, obstacles to successful clinical implementation of novel therapies remain, including effective delivery across the blood-brain barrier (BBB) to the tumor site. Here, we review relevant literature and clinical trials and discuss direct drug delivery via convection-enhanced delivery (CED) as a promising treatment modality for DMG. We outline a comprehensive molecular, pharmacological, and procedural approach that may offer hope for afflicted patients and their families. EXPERT OPINION Challenges remain in successful drug delivery to DMG. While CED and other techniques offer a chance to bypass the BBB, the variables influencing successful intratumoral targeting are numerous and complex. We discuss these variables and potential solutions that could lead to the successful clinical implementation of preclinically promising therapeutic agents.
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Affiliation(s)
- Julian S Rechberger
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.,Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, USA
| | - Blake T Power
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Erica A Power
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Cody L Nesvick
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - David J Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.,Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, USA
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Pinkiewicz M, Pinkiewicz M, Walecki J, Zawadzki M. A systematic review on intra-arterial cerebral infusions of chemotherapeutics in the treatment of glioblastoma multiforme: The state-of-the-art. Front Oncol 2022; 12:950167. [PMID: 36212394 PMCID: PMC9539841 DOI: 10.3389/fonc.2022.950167] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 09/02/2022] [Indexed: 12/24/2022] Open
Abstract
Objective To provide a comprehensive review of intra-arterial cerebral infusions of chemotherapeutics in glioblastoma multiforme treatment and discuss potential research aims. We describe technical aspects of the intra-arterial delivery, methods of blood-brain barrier disruption, the role of intraoperative imaging and clinical trials involving intra-arterial cerebral infusions of chemotherapeutics in the treatment of glioblastoma multiforme. Method 159 articles in English were reviewed and used as the foundation for this paper. The Medline/Pubmed, Cochrane databases, Google Scholar, Scielo and PEDro databases have been used to select the most relevant and influential papers on the intra-arterial cerebral infusions of chemotherapeutics in the treatment of glioblastoma multiforme. Additionally, we have included some relevant clinical trials involving intra-arterial delivery of chemotherapeutics to other than GBM brain tumours. Conclusion Considering that conventional treatments for glioblastoma multiforme fall short of providing a significant therapeutic benefit, with a majority of patients relapsing, the neuro-oncological community has considered intra-arterial administration of chemotherapeutics as an alternative to oral or intravenous administration. Numerous studies have proven the safety of IA delivery of chemotherapy and its ability to ensure higher drug concentrations in targeted areas, simultaneously limiting systemic toxicity. Nonetheless, the scarcity of phase III trials prevents any declaration of a therapeutic benefit. Given that the likelihood of a single therapeutic agent which will be effective for the treatment of glioblastoma multiforme is extremely low, it is paramount to establish an adequate multimodal therapy which will have a synergistic effect on the diverse pathogenesis of GBM. Precise quantitative and spatial monitoring is necessary to guarantee the accurate delivery of the therapeutic to the tumour. New and comprehensive pharmacokinetic models, a more elaborate understanding of glioblastoma biology and effective methods of diminishing treatment-related neurotoxicity are paramount for intra-arterial cerebral infusion of chemotherapeutics to become a mainstay treatment for glioblastoma multiforme. Additional use of other imaging methods like MRI guidance during the procedure could have an edge over X-ray alone and aid in selecting proper arteries as well as infusion parameters of chemotherapeutics making the procedure safer and more effective.
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Affiliation(s)
- Mateusz Pinkiewicz
- Department of Diagnostic Imaging, Mazowiecki Regional Hospital in Siedlce, Siedlce, Poland
| | - Milosz Pinkiewicz
- English Division, Faculty of Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Jerzy Walecki
- Division of Interventional Neuroradiology of the Central Clinical Hospital of the Ministry of Interior and Administration, Department of Radiology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Michał Zawadzki
- Division of Interventional Neuroradiology of the Central Clinical Hospital of the Ministry of Interior and Administration, Department of Radiology, Centre of Postgraduate Medical Education, Warsaw, Poland
- *Correspondence: Michał Zawadzki,
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Rechberger JS, Daniels DJ. Locoregional infusion of IL13Rα2-specific immunotoxins in children and adults with high-grade glioma. Ther Deliv 2022; 13:385-389. [PMID: 35872639 PMCID: PMC9756106 DOI: 10.4155/tde-2022-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/18/2022] [Indexed: 08/03/2023] Open
Affiliation(s)
- Julian S Rechberger
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
- Department of Molecular Pharmacology & Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN 55905, USA
| | - David J Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
- Department of Molecular Pharmacology & Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN 55905, USA
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Rechberger JS, Porath KA, Zhang L, Nesvick CL, Schrecengost RS, Sarkaria JN, Daniels DJ. IL-13Rα2 Status Predicts GB-13 (IL13.E13K-PE4E) Efficacy in High-Grade Glioma. Pharmaceutics 2022; 14:922. [PMID: 35631512 PMCID: PMC9143740 DOI: 10.3390/pharmaceutics14050922] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/14/2022] [Accepted: 04/22/2022] [Indexed: 02/05/2023] Open
Abstract
High-grade gliomas (HGG) are devastating diseases in children and adults. In the pediatric population, diffuse midline gliomas (DMG) harboring H3K27 alterations are the most aggressive primary malignant brain tumors. With no effective therapies available, children typically succumb to disease within one year of diagnosis. In adults, glioblastoma (GBM) remains largely intractable, with a median survival of approximately 14 months despite standard clinical care of radiation and temozolomide. Therefore, effective therapies for these tumors remain one of the most urgent and unmet needs in modern medicine. Interleukin 13 receptor subunit alpha 2 (IL-13Rα2) is a cell-surface transmembrane protein upregulated in many HGGs, including DMG and adult GBM, posing a potentially promising therapeutic target for these tumors. In this study, we investigated the pharmacological effects of GB-13 (also known as IL13.E13K-PE4E), a novel peptide-toxin conjugate that contains a targeting moiety designed to bind IL-13Rα2 with high specificity and a point-mutant cytotoxic domain derived from Pseudomonas exotoxin A. Glioma cell lines demonstrated a spectrum of IL-13Rα2 expression at both the transcript and protein level. Anti-tumor effects of GB-13 strongly correlated with IL-13Rα2 expression and were reflected in apoptosis induction and decreased cell proliferation in vitro. Direct intratumoral administration of GB-13 via convection-enhanced delivery (CED) significantly decreased tumor burden and resulted in prolonged survival in IL-13Rα2-upregulated orthotopic xenograft models of HGG. In summary, administration of GB-13 demonstrated a promising pharmacological response in HGG models both in vitro and in vivo in a manner strongly associated with IL-13Rα2 expression, underscoring the potential of this IL-13Rα2-targeted therapy in a subset of HGG with increased IL-13Rα2 levels.
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Affiliation(s)
- Julian S. Rechberger
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (J.S.R.); (L.Z.); (C.L.N.)
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN 55905, USA
| | - Kendra A. Porath
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA; (K.A.P.); (J.N.S.)
| | - Liang Zhang
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (J.S.R.); (L.Z.); (C.L.N.)
| | - Cody L. Nesvick
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (J.S.R.); (L.Z.); (C.L.N.)
| | | | - Jann N. Sarkaria
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA; (K.A.P.); (J.N.S.)
| | - David J. Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (J.S.R.); (L.Z.); (C.L.N.)
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN 55905, USA
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8
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Knudson KM, Hwang S, McCann MS, Joshi BH, Husain SR, Puri RK. Recent Advances in IL-13Rα2-Directed Cancer Immunotherapy. Front Immunol 2022; 13:878365. [PMID: 35464460 PMCID: PMC9023787 DOI: 10.3389/fimmu.2022.878365] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/17/2022] [Indexed: 01/14/2023] Open
Abstract
Interleukin-13 receptor subunit alpha-2 (IL-13Rα2, CD213A), a high-affinity membrane receptor of the anti-inflammatory Th2 cytokine IL-13, is overexpressed in a variety of solid tumors and is correlated with poor prognosis in glioblastoma, colorectal cancer, adrenocortical carcinoma, pancreatic cancer, and breast cancer. While initially hypothesized as a decoy receptor for IL-13-mediated signaling, recent evidence demonstrates IL-13 can signal through IL-13Rα2 in human cells. In addition, expression of IL-13Rα2 and IL-13Rα2-mediated signaling has been shown to promote tumor proliferation, cell survival, tumor progression, invasion, and metastasis. Given its differential expression in tumor versus normal tissue, IL-13Rα2 is an attractive immunotherapy target, as both a targetable receptor and an immunogenic antigen. Multiple promising strategies, including immunotoxins, cancer vaccines, and chimeric antigen receptor (CAR) T cells, have been developed to target IL-13Rα2. In this mini-review, we discuss recent developments surrounding IL-13Rα2-targeted therapies in pre-clinical and clinical study, including potential strategies to improve IL-13Rα2-directed cancer treatment efficacy.
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Jamal A, Yuan T, Galvan S, Castellano A, Riva M, Secoli R, Falini A, Bello L, Rodriguez y Baena F, Dini D. Insights into Infusion-Based Targeted Drug Delivery in the Brain: Perspectives, Challenges and Opportunities. Int J Mol Sci 2022; 23:3139. [PMID: 35328558 PMCID: PMC8949870 DOI: 10.3390/ijms23063139] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 01/31/2023] Open
Abstract
Targeted drug delivery in the brain is instrumental in the treatment of lethal brain diseases, such as glioblastoma multiforme, the most aggressive primary central nervous system tumour in adults. Infusion-based drug delivery techniques, which directly administer to the tissue for local treatment, as in convection-enhanced delivery (CED), provide an important opportunity; however, poor understanding of the pressure-driven drug transport mechanisms in the brain has hindered its ultimate success in clinical applications. In this review, we focus on the biomechanical and biochemical aspects of infusion-based targeted drug delivery in the brain and look into the underlying molecular level mechanisms. We discuss recent advances and challenges in the complementary field of medical robotics and its use in targeted drug delivery in the brain. A critical overview of current research in these areas and their clinical implications is provided. This review delivers new ideas and perspectives for further studies of targeted drug delivery in the brain.
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Affiliation(s)
- Asad Jamal
- Department of Mechanical Engineering, Imperial College London, London SW7 2AZ, UK; (T.Y.); (S.G.); (R.S.); (F.R.y.B.)
| | - Tian Yuan
- Department of Mechanical Engineering, Imperial College London, London SW7 2AZ, UK; (T.Y.); (S.G.); (R.S.); (F.R.y.B.)
| | - Stefano Galvan
- Department of Mechanical Engineering, Imperial College London, London SW7 2AZ, UK; (T.Y.); (S.G.); (R.S.); (F.R.y.B.)
| | - Antonella Castellano
- Vita-Salute San Raffaele University, 20132 Milan, Italy; (A.C.); (A.F.)
- Neuroradiology Unit and CERMAC, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Marco Riva
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milan, Italy;
| | - Riccardo Secoli
- Department of Mechanical Engineering, Imperial College London, London SW7 2AZ, UK; (T.Y.); (S.G.); (R.S.); (F.R.y.B.)
| | - Andrea Falini
- Vita-Salute San Raffaele University, 20132 Milan, Italy; (A.C.); (A.F.)
- Neuroradiology Unit and CERMAC, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Lorenzo Bello
- Department of Oncology and Hematology-Oncology, Universitá degli Studi di Milano, 20122 Milan, Italy;
| | - Ferdinando Rodriguez y Baena
- Department of Mechanical Engineering, Imperial College London, London SW7 2AZ, UK; (T.Y.); (S.G.); (R.S.); (F.R.y.B.)
| | - Daniele Dini
- Department of Mechanical Engineering, Imperial College London, London SW7 2AZ, UK; (T.Y.); (S.G.); (R.S.); (F.R.y.B.)
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Aquilina K, Chakrapani A, Carr L, Kurian MA, Hargrave D. Convection-Enhanced Delivery in Children: Techniques and Applications. Adv Tech Stand Neurosurg 2022; 45:199-228. [PMID: 35976451 DOI: 10.1007/978-3-030-99166-1_6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Since its first description in 1994, convection-enhanced delivery (CED) has become a reliable method of administering drugs directly into the brain parenchyma. More predictable and effective than simple diffusion, CED bypasses the challenging boundary of the blood brain barrier, which has frustrated many attempts at delivering large molecules or polymers into the brain parenchyma. Although most of the clinical work with CED has been carried out on adults with incurable neoplasms, principally glioblastoma multiforme, an increasing number of studies have recognized its potential for paediatric applications, which now include treatment of currently incurable brain tumours such as diffuse intrinsic pontine glioma (DIPG), as well as metabolic and neurotransmitter diseases. The roadmap for the development of hardware and use of pharmacological agents in CED has been well-established, and some neurosurgical centres throughout the world have successfully undertaken clinical trials, admittedly mostly early phase, on the basis of in vitro, small animal and large animal pre-clinical foundations. However, the clinical efficacy of CED, although theoretically logical, has yet to be unequivocally demonstrated in a clinical trial; this applies particularly to neuro-oncology.This review aims to provide a broad description of the current knowledge of CED as applied to children. It reviews published studies of paediatric CED in the context of its wider history and developments and underlines the challenges related to the development of hardware, the selection of pharmacological agents, and gene therapy. It also reviews the difficulties related to the development of clinical trials involving CED and looks towards its potential disease-modifying opportunities in the future.
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Affiliation(s)
- K Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK.
| | - A Chakrapani
- Department of Metabolic Medicine, Great Ormond Street Hospital, London, UK
| | - L Carr
- Department of Neurology and Neurodisability, Great Ormond Street Hospital, London, UK
| | - M A Kurian
- Department of Neurology and Neurodisability, Great Ormond Street Hospital, London, UK
- Neurogenetics Group, Developmental Neurosciences, Zayed Centre for Research into Rare Disease in Children, UCL-Great Ormond Street Institute of Child Health, London, UK
| | - D Hargrave
- Cancer Group, UCL-Great Ormond Street Institute of Child Health, London, UK
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Havaei SM, Aucoin MG, Jahanian-Najafabadi A. Pseudomonas Exotoxin-Based Immunotoxins: Over Three Decades of Efforts on Targeting Cancer Cells With the Toxin. Front Oncol 2021; 11:781800. [PMID: 34976821 PMCID: PMC8716853 DOI: 10.3389/fonc.2021.781800] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/16/2021] [Indexed: 12/16/2022] Open
Abstract
Cancer is one of the prominent causes of death worldwide. Despite the existence of various modalities for cancer treatment, many types of cancer remain uncured or develop resistance to therapeutic strategies. Furthermore, almost all chemotherapeutics cause a range of side effects because they affect normal cells in addition to malignant cells. Therefore, the development of novel therapeutic agents that are targeted specifically toward cancer cells is indispensable. Immunotoxins (ITs) are a class of tumor cell-targeted fusion proteins consisting of both a targeting moiety and a toxic moiety. The targeting moiety is usually an antibody/antibody fragment or a ligand of the immune system that can bind an antigen or receptor that is only expressed or overexpressed by cancer cells but not normal cells. The toxic moiety is usually a protein toxin (or derivative) of animal, plant, insect, or bacterial origin. To date, three ITs have gained Food and Drug Administration (FDA) approval for human use, including denileukin diftitox (FDA approval: 1999), tagraxofusp (FDA approval: 2018), and moxetumomab pasudotox (FDA approval: 2018). All of these ITs take advantage of bacterial protein toxins. The toxic moiety of the first two ITs is a truncated form of diphtheria toxin, and the third is a derivative of Pseudomonas exotoxin (PE). There is a growing list of ITs using PE, or its derivatives, being evaluated preclinically or clinically. Here, we will review these ITs to highlight the advances in PE-based anticancer strategies, as well as review the targeting moieties that are used to reduce the non-specific destruction of non-cancerous cells. Although we tried to be as comprehensive as possible, we have limited our review to those ITs that have proceeded to clinical trials and are still under active clinical evaluation.
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Affiliation(s)
- Seyed Mehdi Havaei
- Department of Pharmaceutical Biotechnology, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Marc G. Aucoin
- Department of Chemical Engineering, Faculty of Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Ali Jahanian-Najafabadi
- Department of Pharmaceutical Biotechnology, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
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Antibody-drug conjugates for H3K27M-mutant diffuse midline gliomas: prospects and challenges. Ther Deliv 2021; 12:553-557. [PMID: 34286602 DOI: 10.4155/tde-2021-0045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Convection Enhanced Delivery in the Setting of High-Grade Gliomas. Pharmaceutics 2021; 13:pharmaceutics13040561. [PMID: 33921157 PMCID: PMC8071501 DOI: 10.3390/pharmaceutics13040561] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/04/2021] [Accepted: 04/12/2021] [Indexed: 11/16/2022] Open
Abstract
Development of effective treatments for high-grade glioma (HGG) is hampered by (1) the blood–brain barrier (BBB), (2) an infiltrative growth pattern, (3) rapid development of therapeutic resistance, and, in many cases, (4) dose-limiting toxicity due to systemic exposure. Convection-enhanced delivery (CED) has the potential to significantly limit systemic toxicity and increase therapeutic index by directly delivering homogenous drug concentrations to the site of disease. In this review, we present clinical experiences and preclinical developments of CED in the setting of high-grade gliomas.
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Janjua TI, Rewatkar P, Ahmed-Cox A, Saeed I, Mansfeld FM, Kulshreshtha R, Kumeria T, Ziegler DS, Kavallaris M, Mazzieri R, Popat A. Frontiers in the treatment of glioblastoma: Past, present and emerging. Adv Drug Deliv Rev 2021; 171:108-138. [PMID: 33486006 DOI: 10.1016/j.addr.2021.01.012] [Citation(s) in RCA: 116] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/13/2020] [Accepted: 01/09/2021] [Indexed: 12/13/2022]
Abstract
Glioblastoma (GBM) is one of the most aggressive cancers of the brain. Despite extensive research over the last several decades, the survival rates for GBM have not improved and prognosis remains poor. To date, only a few therapies are approved for the treatment of GBM with the main reasons being: 1) significant tumour heterogeneity which promotes the selection of resistant subpopulations 2) GBM induced immunosuppression and 3) fortified location of the tumour in the brain which hinders the delivery of therapeutics. Existing therapies for GBM such as radiotherapy, surgery and chemotherapy have been unable to reach the clinical efficacy necessary to prolong patient survival more than a few months. This comprehensive review evaluates the current and emerging therapies including those in clinical trials that may potentially improve both targeted delivery of therapeutics directly to the tumour site and the development of agents that may specifically target GBM. Particular focus has also been given to emerging delivery technologies such as focused ultrasound, cellular delivery systems nanomedicines and immunotherapy. Finally, we discuss the importance of developing novel materials for improved delivery efficacy of nanoparticles and therapeutics to reduce the suffering of GBM patients.
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Neurosurgical involvement in clinical trials for CNS tumors. J Neurooncol 2021; 151:367-373. [PMID: 33611704 DOI: 10.1007/s11060-020-03438-3] [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: 01/10/2020] [Accepted: 02/14/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Most clinical trials in neurooncology are led by investigators primarily trained in neurology or medical oncology. While neurosurgeons are trained to be problem-solvers and innovators, research training has historically been focused on laboratory-based discovery approaches and formalized training in prospective clinical trials research is not part of routine graduate training. METHODS We reviewed literature that demonstrates that innovation and problem-solving are integral to the practice of neurosurgery cite multiple examples of advances in technique and technology that may have had an empirical origin but that led to prospective clinical trials resulting in change in practice. RESULTS Neurosurgeons have developed and led both traditional (clinical outcome-oriented) and translational prospective clinical trials that have evaluated the best use of currently available therapeutics or tested the ability of novel therapeutics to alter the biology and/or course of disease. CONCLUSIONS In this review, we focus on a number of the recently developed technologies and therapeutics that were evaluated in clinical trials led or co-led by neurosurgeons. We also highlight some of the barriers that need to be addressed in order to foster neurosurgical participation and leadership in the prospective development of novel therapeutics.
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D'Amico RS, Aghi MK, Vogelbaum MA, Bruce JN. Convection-enhanced drug delivery for glioblastoma: a review. J Neurooncol 2021; 151:415-427. [PMID: 33611708 DOI: 10.1007/s11060-020-03408-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/18/2020] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Convection-enhanced delivery (CED) is a method of targeted, local drug delivery to the central nervous system (CNS) that bypasses the blood-brain barrier (BBB) and permits the delivery of high-dose therapeutics to large volumes of interest while limiting associated systemic toxicities. Since its inception, CED has undergone considerable preclinical and clinical study as a safe method for treating glioblastoma (GBM). However, the heterogeneity of both, the surgical procedure and the mechanisms of action of the agents studied-combined with the additional costs of performing a trial evaluating CED-has limited the field's ability to adequately assess the durability of any potential anti-tumor responses. As a result, the long-term efficacy of the agents studied to date remains difficult to assess. MATERIALS AND METHODS We searched PubMed using the phrase "convection-enhanced delivery and glioblastoma". The references of significant systematic reviews were also reviewed for additional sources. Articles focusing on physiological and physical mechanisms of CED were included as well as technological CED advances. RESULTS We review the history and principles of CED, procedural advancements and characteristics, and outcomes from key clinical trials, as well as discuss the potential future of this promising technique for the treatment of GBM. CONCLUSION While the long-term efficacy of the agents studied to date remains difficult to assess, CED remains a promising technique for the treatment of GBM.
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Affiliation(s)
- Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA.
| | - Manish K Aghi
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | - Jeffrey N Bruce
- Department of Neurological Surgery, New York Presbyterian/Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA
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Abstract
For a chemotherapeutic agent to be effective, it must conquer the presence of blood-brain barrier (BBB), which limits the penetration of drugs into the brain. Tumours in the brain compromise the integrity of BBB and result in a highly heterogeneous vasculature, known as blood-brain tumour barrier (BBTB). In this chapter, we firstly highlight the cellular and molecular characteristics of the BBB and BBTB as well as the challenges aroused by BBB/BBTB for drug delivery. Secondly, we discuss the current strategies overcoming the challenges in invasive and non-invasive manners. Finally, we highlight the emerging strategy using focused ultrasound (FUS) with systemic microbubbles to transiently and reversibly enhance the permeability of these barriers for drug delivery.
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Wu SK, Tsai CL, Huang Y, Hynynen K. Focused Ultrasound and Microbubbles-Mediated Drug Delivery to Brain Tumor. Pharmaceutics 2020; 13:pharmaceutics13010015. [PMID: 33374205 PMCID: PMC7823947 DOI: 10.3390/pharmaceutics13010015] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/14/2022] Open
Abstract
The presence of blood–brain barrier (BBB) and/or blood–brain–tumor barriers (BBTB) is one of the main obstacles to effectively deliver therapeutics to our central nervous system (CNS); hence, the outcomes following treatment of malignant brain tumors remain unsatisfactory. Although some approaches regarding BBB disruption or drug modifications have been explored, none of them reach the criteria of success. Convention-enhanced delivery (CED) directly infuses drugs to the brain tumor and surrounding tumor infiltrating area over a long period of time using special catheters. Focused ultrasound (FUS) now provides a non-invasive method to achieve this goal via combining with systemically circulating microbubbles to locally enhance the vascular permeability. In this review, different approaches of delivering therapeutic agents to the brain tumors will be discussed as well as the characterization of BBB and BBTB. We also highlight the mechanism of FUS-induced BBB modulation and the current progress of this technology in both pre-clinical and clinical studies.
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Affiliation(s)
- Sheng-Kai Wu
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada; (S.-K.W.); (C.-L.T.); (Y.H.)
- Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7, Canada
| | - Chia-Lin Tsai
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada; (S.-K.W.); (C.-L.T.); (Y.H.)
- Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7, Canada
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
| | - Yuexi Huang
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada; (S.-K.W.); (C.-L.T.); (Y.H.)
- Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7, Canada
| | - Kullervo Hynynen
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada; (S.-K.W.); (C.-L.T.); (Y.H.)
- Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7, Canada
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
- Correspondence:
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Abstract
Although surgical resection of the solid tumor component of glioblastoma has been shown to provide a survival advantage, it will never be a curative procedure. Yet, systemically applied adjuvants (radiation therapy and chemotherapy) also are not curative and their options are limited by the inability of most agents to cross the blood-brain barrier. Direct delivery of adjuvant therapies during a surgical procedure potentially provides an approach to bypass the blood-brain barrier and effectively treat residual tumor cells. This article summarizes the approaches and therapeutics that have been evaluated to date, and challenges that remain to be overcome.
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D’Amico RS, Neira JA, Yun J, Alexiades NG, Banu M, Englander ZK, Kennedy BC, Ung TH, Rothrock RJ, Romanov A, Guo X, Zhao B, Sonabend AM, Canoll P, Bruce JN. Validation of an effective implantable pump-infusion system for chronic convection-enhanced delivery of intracerebral topotecan in a large animal model. J Neurosurg 2020; 133:614-623. [PMID: 31374547 PMCID: PMC7227320 DOI: 10.3171/2019.3.jns1963] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/04/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intracerebral convection-enhanced delivery (CED) has been limited to short durations due to a reliance on externalized catheters. Preclinical studies investigating topotecan (TPT) CED for glioma have suggested that prolonged infusion improves survival. Internalized pump-catheter systems may facilitate chronic infusion. The authors describe the safety and utility of long-term TPT CED in a porcine model and correlation of drug distribution through coinfusion of gadolinium. METHODS Fully internalized CED pump-catheter systems were implanted in 12 pigs. Infusion algorithms featuring variable infusion schedules, flow rates, and concentrations of a mixture of TPT and gadolinium were characterized over increasing intervals from 4 to 32 days. Therapy distribution was measured using gadolinium signal on MRI as a surrogate. A 9-point neurobehavioral scale (NBS) was used to identify side effects. RESULTS All animals tolerated infusion without serious adverse events. The average NBS score was 8.99. The average maximum volume of distribution (Vdmax) in chronically infused animals was 11.30 mL and represented 32.73% of the ipsilateral cerebral hemispheric volume. Vdmax was achieved early during infusions and remained relatively stable despite a slight decline as the infusion reached steady state. Novel tissue TPT concentrations measured by liquid chromatography mass spectroscopy correlated with gadolinium signal intensity on MRI (p = 0.0078). CONCLUSIONS Prolonged TPT-gadolinium CED via an internalized system is safe and well tolerated and can achieve a large Vdmax, as well as maintain a stable Vd for up to 32 days. Gadolinium provides an identifiable surrogate for measuring drug distribution. Extended CED is potentially a broadly applicable and safe therapeutic option in select patients.
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Affiliation(s)
- Randy S. D’Amico
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Justin A. Neira
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Jonathan Yun
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Nikita G. Alexiades
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Matei Banu
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Zachary K. Englander
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Benjamin C. Kennedy
- Division of Neurosurgery, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy H. Ung
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Robert J. Rothrock
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Alexander Romanov
- Institute of Comparative Medicine, Columbia University Medical Center, New York, New York
| | - Xiaotao Guo
- Department of Radiology, Columbia University Medical Center, New York, New York
| | - Binsheng Zhao
- Department of Radiology, Columbia University Medical Center, New York, New York
| | - Adam M. Sonabend
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Peter Canoll
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Jeffrey N. Bruce
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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Tosi U, Kommidi H, Adeuyan O, Guo H, Maachani UB, Chen N, Su T, Zhang G, Pisapia DJ, Dahmane N, Ting R, Souweidane MM. PET, image-guided HDAC inhibition of pediatric diffuse midline glioma improves survival in murine models. SCIENCE ADVANCES 2020; 6:eabb4105. [PMID: 32832670 PMCID: PMC7439439 DOI: 10.1126/sciadv.abb4105] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/05/2020] [Indexed: 05/24/2023]
Abstract
Efforts at altering the dismal prognosis of pediatric midline gliomas focus on direct delivery strategies like convection-enhanced delivery (CED), where a cannula is implanted into tumor. Successful CED treatments require confirmation of tumor coverage, dosimetry, and longitudinal in vivo pharmacokinetic monitoring. These properties would be best determined clinically with image-guided dosimetry using theranostic agents. In this study, we combine CED with novel, molecular-grade positron emission tomography (PET) imaging and show how PETobinostat, a novel PET-imageable HDAC inhibitor, is effective against DIPG models. PET data reveal that CED has significant mouse-to-mouse variability; imaging is used to modulate CED infusions to maximize tumor saturation. The use of PET-guided CED results in survival prolongation in mouse models; imaging shows the need of CED to achieve high brain concentrations. This work demonstrates how personalized image-guided drug delivery may be useful in potentiating CED-based treatment algorithms and supports a foundation for clinical translation of PETobinostat.
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Affiliation(s)
- Umberto Tosi
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Harikrishna Kommidi
- Department of Radiology, Molecular Imaging Innovations Institute, Weill Cornell Medicine, New York, NY 10065, USA
| | - Oluwaseyi Adeuyan
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Hua Guo
- Department of Radiology, Molecular Imaging Innovations Institute, Weill Cornell Medicine, New York, NY 10065, USA
| | - Uday Bhanu Maachani
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Nandi Chen
- Department of Radiology, Molecular Imaging Innovations Institute, Weill Cornell Medicine, New York, NY 10065, USA
| | - Taojunfeng Su
- Proteomics and Metabolomics Core Facility, Weill Cornell Medicine, New York, NY 10021, USA
| | - Guoan Zhang
- Proteomics and Metabolomics Core Facility, Weill Cornell Medicine, New York, NY 10021, USA
| | - David J. Pisapia
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY 10021, USA
| | - Nadia Dahmane
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Richard Ting
- Department of Radiology, Molecular Imaging Innovations Institute, Weill Cornell Medicine, New York, NY 10065, USA
| | - Mark M. Souweidane
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY 10065, USA
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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Himes BT, Zhang L, Daniels DJ. Treatment Strategies in Diffuse Midline Gliomas With the H3K27M Mutation: The Role of Convection-Enhanced Delivery in Overcoming Anatomic Challenges. Front Oncol 2019; 9:31. [PMID: 30800634 PMCID: PMC6375835 DOI: 10.3389/fonc.2019.00031] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 01/11/2019] [Indexed: 12/30/2022] Open
Abstract
Diffuse midline gliomas harboring the H3 K27M mutation—including the previously named diffuse intrinsic pontine glioma (DIPG)—are lethal high-grade pediatric brain tumors that are inoperable and without cure. Despite numerous clinical trials, the prognosis remains poor, with a median survival of ~1 year from diagnosis. Systemic administration of chemotherapeutic agents is often hindered by the blood brain barrier (BBB), and even drugs that successfully cross the barrier may suffer from unpredictable distributions. The challenge in treating this deadly disease relies on effective delivery of a therapeutic agent to the bulk tumor as well as infiltrating cells. Therefore, methods that can enhance drug delivery to the brain are of great interest. Convection-enhanced delivery (CED) is a strategy that bypasses the BBB entirely and enhances drug distribution by applying hydraulic pressure to deliver agents directly and evenly into a target region. This technique reliably distributes infusate homogenously through the interstitial space of the target region and achieves high local drug concentrations in the brain. Moreover, recent studies have also shown that continuous delivery of drug over an extended period of time is safe, feasible, and more efficacious than standard single session CED. Therefore, CED represents a promising technique for treating midline tumors with the H3K27M mutation.
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Affiliation(s)
- Benjamin T Himes
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Liang Zhang
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - David J Daniels
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States.,Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, United States
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Vogelbaum MA, Brewer C, Barnett GH, Mohammadi AM, Peereboom DM, Ahluwalia MS, Gao S. First-in-human evaluation of the Cleveland Multiport Catheter for convection-enhanced delivery of topotecan in recurrent high-grade glioma: results of pilot trial 1. J Neurosurg 2019; 130:476-485. [PMID: 29652233 DOI: 10.3171/2017.10.jns171845] [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: 07/27/2017] [Accepted: 10/24/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Progress in management of high-grade gliomas (HGGs) has been hampered by poor access of potential therapeutics to the CNS. The Cleveland Multiport Catheter (CMC), which deploys 4 independent delivery microcatheters, was developed to be a reliable, high-volume delivery device for delivery of therapeutic agents to the brain and other solid organs. The authors undertook this first-in-human clinical trial effort to evaluate the delivery characteristics of the CMC in patients with HGGs. METHODS A series of pilot studies were launched after approval of a sponsor-investigator IND (investigational new drug) application to evaluate the delivery of topotecan and gadolinium-DTPA (Gd-DTPA) via the CMC in patients with recurrent HGG. The first pilot trial evaluated delivery into enhancing tumor and nonenhancing, tumor-infiltrated brain. Two catheters were placed with the use of a conventional frameless stereotactic technique following a biopsy to confirm tumor recurrence, and drug infusion was performed both intraoperatively and postoperatively for a total of 96 hours with the same rate for all microcatheters. Delivery was assessed by intermittent MRI. RESULTS Three patients were enrolled in the first pilot study. MRI demonstrated delivery from all 6 catheters (24 microcatheters). The volume of distribution (Vd) of Gd-DTPA was heavily dependent upon CMC location (enhancing vs nonenhancing) with an approximately 10-fold difference in Vd observed (p = 0.005). There were no hemorrhages related to catheter placement or removal, and all 3 patients completed the protocol-defined treatment. CONCLUSIONS The CMC is capable of providing backflow-resistant drug delivery to the brain and brain tumors. The volume of distribution is heavily dependent upon the integrity of the blood-brain barrier. Assessment of delivery is essential for development of loco-regionally applied therapeutics in the CNS.Clinical trial registration no.: NCT02278510 (clinicaltrials.gov).
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Affiliation(s)
- Michael A Vogelbaum
- 1Brain Tumor and Neuro-Oncology Center and
- Departments of2Neurosurgery and
- 3Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
| | | | - Gene H Barnett
- 1Brain Tumor and Neuro-Oncology Center and
- Departments of2Neurosurgery and
| | | | | | | | - Shenqiang Gao
- 3Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
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Maximising coverage of brain structures using controlled reflux, convection-enhanced delivery and the recessed step catheter. J Neurosci Methods 2018; 308:337-345. [DOI: 10.1016/j.jneumeth.2018.08.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/14/2018] [Accepted: 08/31/2018] [Indexed: 11/18/2022]
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Personalized therapeutic delivery in the neurosurgical operating room. Proc Natl Acad Sci U S A 2018; 115:8846-8848. [PMID: 30127023 DOI: 10.1073/pnas.1812559115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Systems engineers’ role in biomedical research. Convection-enhanced drug delivery. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/b978-0-444-63964-6.00009-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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Lueshen E, Tangen K, Mehta AI, Linninger A. Backflow-free catheters for efficient and safe convection-enhanced delivery of therapeutics. Med Eng Phys 2017; 45:15-24. [DOI: 10.1016/j.medengphy.2017.02.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/15/2017] [Accepted: 02/26/2017] [Indexed: 10/19/2022]
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D’Amico RS, Englander ZK, Canoll P, Bruce JN. Extent of Resection in Glioma–A Review of the Cutting Edge. World Neurosurg 2017; 103:538-549. [DOI: 10.1016/j.wneu.2017.04.041] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/03/2017] [Accepted: 04/06/2017] [Indexed: 11/29/2022]
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Abstract
Convection-enhanced delivery (CED) is a promising technique that generates a pressure gradient at the tip of an infusion catheter to deliver therapeutics directly through the interstitial spaces of the central nervous system. It addresses and offers solutions to many limitations of conventional techniques, allowing for delivery past the blood-brain barrier in a targeted and safe manner that can achieve therapeutic drug concentrations. CED is a broadly applicable technique that can be used to deliver a variety of therapeutic compounds for a diversity of diseases, including malignant gliomas, Parkinson's disease, and Alzheimer's disease. While a number of technological advances have been made since its development in the early 1990s, clinical trials with CED have been largely unsuccessful, and have illuminated a number of parameters that still need to be addressed for successful clinical application. This review addresses the physical principles behind CED, limitations in the technique, as well as means to overcome these limitations, clinical trials that have been performed, and future developments.
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Affiliation(s)
- A M Mehta
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, 10032, USA
| | - A M Sonabend
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, 10032, USA
| | - J N Bruce
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, 10032, USA.
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Saito R, Tominaga T. Convection-enhanced Delivery of Therapeutics for Malignant Gliomas. Neurol Med Chir (Tokyo) 2016; 57:8-16. [PMID: 27980285 PMCID: PMC5243160 DOI: 10.2176/nmc.ra.2016-0071] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Convection-enhanced delivery (CED) circumvents the blood–brain barrier by delivering agents directly into the tumor and surrounding parenchyma. CED can achieve large volumes of distribution by continuous positive-pressure infusion. Although promising as an effective drug delivery method in concept, the administration of therapeutic agents via CED is not without challenges. Limitations of distribution remain a problem in large brains, such as those of humans. Accurate and consistent delivery of an agent is another challenge associated with CED. Similar to the difficulties caused by immunosuppressive environments associated with gliomas, there are several mechanisms that make effective local drug distribution difficult in malignant gliomas. In this review, methods for local drug application targeting gliomas are discussed with special emphasis on CED. Although early clinical trials have failed to demonstrate the efficacy of CED against gliomas, CED potentially can be a platform for translating the molecular understanding of glioblastomas achieved in the laboratory into effective clinical treatments. Several clinical studies using CED of chemotherapeutic agents are ongoing. Successful delivery of effective agents should prove the efficacy of CED in the near future.
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Affiliation(s)
- Ryuta Saito
- Department of Neurosurgery, Tohoku University Graduate School of Medicine
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Application of Convection-Enhanced Drug Delivery in the Treatment of Malignant Gliomas. World Neurosurg 2016; 90:172-178. [DOI: 10.1016/j.wneu.2016.02.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 02/01/2023]
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Han SJ, Bankiewicz K, Butowski NA, Larson PS, Aghi MK. Interventional MRI-guided catheter placement and real time drug delivery to the central nervous system. Expert Rev Neurother 2016; 16:635-9. [PMID: 27054877 DOI: 10.1080/14737175.2016.1175939] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Local delivery of therapeutic agents into the brain has many advantages; however, the inability to predict, visualize and confirm the infusion into the intended target has been a major hurdle in its clinical development. Here, we describe the current workflow and application of the interventional MRI (iMRI) system for catheter placement and real time visualization of infusion. We have applied real time convection-enhanced delivery (CED) of therapeutic agents with iMRI across a number of different clinical trials settings in neuro-oncology and movement disorders. Ongoing developments and accumulating experience with the technique and technology of drug formulations, CED platforms, and iMRI systems will continue to make local therapeutic delivery into the brain more accurate, efficient, effective and safer.
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Affiliation(s)
- Seunggu J Han
- a Department of Neurological Surgery , University of California, San Francisco , San Francisco , CA , USA
| | - Krystof Bankiewicz
- a Department of Neurological Surgery , University of California, San Francisco , San Francisco , CA , USA
| | - Nicholas A Butowski
- a Department of Neurological Surgery , University of California, San Francisco , San Francisco , CA , USA
| | - Paul S Larson
- a Department of Neurological Surgery , University of California, San Francisco , San Francisco , CA , USA
| | - Manish K Aghi
- a Department of Neurological Surgery , University of California, San Francisco , San Francisco , CA , USA
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Jahangiri A, Chin AT, Flanigan PM, Chen R, Bankiewicz K, Aghi MK. Convection-enhanced delivery in glioblastoma: a review of preclinical and clinical studies. J Neurosurg 2016; 126:191-200. [PMID: 27035164 DOI: 10.3171/2016.1.jns151591] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Glioblastoma is the most common malignant brain tumor, and it carries an extremely poor prognosis. Attempts to develop targeted therapies have been hindered because the blood-brain barrier prevents many drugs from reaching tumors cells. Furthermore, systemic toxicity of drugs often limits their therapeutic potential. A number of alternative methods of delivery have been developed, one of which is convection-enhanced delivery (CED), the focus of this review. The authors describe CED as a therapeutic measure and review preclinical studies and the most prominent clinical trials of CED in the treatment of glioblastoma. The utilization of this technique for the delivery of a variety of agents is covered, and its shortcomings and challenges are discussed in detail.
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Affiliation(s)
- Arman Jahangiri
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
| | - Aaron T Chin
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
| | - Patrick M Flanigan
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
| | - Rebecca Chen
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
| | - Krystof Bankiewicz
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
| | - Manish K Aghi
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
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Lewis O, Woolley M, Johnson D, Rosser A, Barua NU, Bienemann AS, Gill SS, Evans S. Chronic, intermittent convection-enhanced delivery devices. J Neurosci Methods 2016; 259:47-56. [DOI: 10.1016/j.jneumeth.2015.11.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 10/28/2015] [Accepted: 11/06/2015] [Indexed: 12/11/2022]
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Suzuki A, Leland P, Joshi BH, Puri RK. Targeting of IL-4 and IL-13 receptors for cancer therapy. Cytokine 2015; 75:79-88. [DOI: 10.1016/j.cyto.2015.05.026] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 05/22/2015] [Accepted: 05/26/2015] [Indexed: 02/03/2023]
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The TWEAK receptor Fn14 is a potential cell surface portal for targeted delivery of glioblastoma therapeutics. Oncogene 2015; 35:2145-55. [PMID: 26300004 DOI: 10.1038/onc.2015.310] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 07/14/2015] [Accepted: 07/14/2015] [Indexed: 12/11/2022]
Abstract
UNLABELLED Fibroblast growth factor-inducible 14 (Fn14; TNFRSF12A) is the cell surface receptor for the tumor necrosis factor (TNF) family member TNF-like weak inducer of apoptosis (TWEAK). The Fn14 gene is normally expressed at low levels in healthy tissues but expression is significantly increased after tissue injury and in many solid tumor types, including glioblastoma (GB; formerly referred to as 'GB multiforme'). GB is the most common and aggressive primary malignant brain tumor and the current standard-of-care therapeutic regimen has a relatively small impact on patient survival, primarily because glioma cells have an inherent propensity to invade into normal brain parenchyma, which invariably leads to tumor recurrence and patient death. Despite major, concerted efforts to find new treatments, a new GB therapeutic that improves survival has not been introduced since 2005. In this review article, we summarize studies indicating that (i) Fn14 gene expression is low in normal brain tissue but is upregulated in advanced brain cancers and, in particular, in GB tumors exhibiting the mesenchymal molecular subtype; (ii) Fn14 expression can be detected in glioma cells residing in both the tumor core and invasive rim regions, with the maximal levels found in the invading glioma cells located within normal brain tissue; and (iii) TWEAK Fn14 engagement as well as Fn14 overexpression can stimulate glioma cell migration, invasion and resistance to chemotherapeutic agents in vitro. We also discuss two new therapeutic platforms that are currently in development that leverage Fn14 overexpression in GB tumors as a way to deliver cytotoxic agents to the glioma cells remaining after surgical resection while sparing normal healthy brain cells.
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van Tellingen O, Yetkin-Arik B, de Gooijer M, Wesseling P, Wurdinger T, de Vries H. Overcoming the blood–brain tumor barrier for effective glioblastoma treatment. Drug Resist Updat 2015; 19:1-12. [DOI: 10.1016/j.drup.2015.02.002] [Citation(s) in RCA: 438] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 02/23/2015] [Accepted: 02/25/2015] [Indexed: 12/23/2022]
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Healy AT, Vogelbaum MA. Convection-enhanced drug delivery for gliomas. Surg Neurol Int 2015; 6:S59-67. [PMID: 25722934 PMCID: PMC4338487 DOI: 10.4103/2152-7806.151337] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 10/15/2014] [Indexed: 11/09/2022] Open
Abstract
In spite of aggressive multi-modality treatments, patients diagnosed with anaplastic astrocytoma and glioblastoma continue to display poor median survival. The success of our current conventional and targeted chemotherapies are largely hindered by systemic- and neurotoxicity, as well as poor central nervous system (CNS) penetration. Interstitial drug administration via convection-enhanced delivery (CED) is an alternative that potentially overcomes systemic toxicities and CNS delivery issues by directly bypassing the blood–brain barrier (BBB). This novel approach not only allows for directed administration, but also allows for newer, tumor-selective agents, which would normally be excluded from the CNS due to molecular size alone. To date, randomized trials of CED therapy have yet to definitely show survival advantage as compared with today's standard of care, however, early studies appear to have been limited by “first generation” delivery techniques. Taking into consideration lessons learned from early trials along with decades of research, newer CED technologies and therapeutic agents are emerging, which are reviewed herein.
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Affiliation(s)
- Andrew T Healy
- Neurosurgical Resident, Department of Neurological Surgery, Director, Center for Translational Therapeutics, Associate Director, Brain Tumor and Neuro-Oncology Center, ND40, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Michael A Vogelbaum
- Department of Neurological Surgery, Director, Center for Translational Therapeutics, Associate Director, Brain Tumor and Neuro-Oncology Center, ND40, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Rhun EL, Taillibert S, Chamberlain MC. The future of high-grade glioma: Where we are and where are we going. Surg Neurol Int 2015; 6:S9-S44. [PMID: 25722939 PMCID: PMC4338495 DOI: 10.4103/2152-7806.151331] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 10/15/2014] [Indexed: 01/12/2023] Open
Abstract
High-grade glioma (HGG) are optimally treated with maximum safe surgery, followed by radiotherapy (RT) and/or systemic chemotherapy (CT). Recently, the treatment of newly diagnosed anaplastic glioma (AG) has changed, particularly in patients with 1p19q codeleted tumors. Results of trials currenlty ongoing are likely to determine the best standard of care for patients with noncodeleted AG tumors. Trials in AG illustrate the importance of molecular characterization, which are germane to both prognosis and treatment. In contrast, efforts to improve the current standard of care of newly diagnosed glioblastoma (GB) with, for example, the addition of bevacizumab (BEV), have been largely disappointing and furthermore molecular characterization has not changed therapy except in elderly patients. Novel approaches, such as vaccine-based immunotherapy, for newly diagnosed GB are currently being pursued in multiple clinical trials. Recurrent disease, an event inevitable in nearly all patients with HGG, continues to be a challenge. Both recurrent GB and AG are managed in similar manner and when feasible re-resection is often suggested notwithstanding limited data to suggest benefit from repeat surgery. Occassional patients may be candidates for re-irradiation but again there is a paucity of data to commend this therapy and only a minority of selected patients are eligible for this approach. Consequently systemic therapy continues to be the most often utilized treatment in recurrent HGG. Choice of therapy, however, varies and revolves around re-challenge with temozolomide (TMZ), use of a nitrosourea (most often lomustine; CCNU) or BEV, the most frequently used angiogenic inhibitor. Nevertheless, no clear standard recommendation regarding the prefered agent or combination of agents is avaliable. Prognosis after progression of a HGG remains poor, with an unmet need to improve therapy.
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Affiliation(s)
- Emilie Le Rhun
- Department of Neuro-oncology, Roger Salengro Hospital, University Hospital, Lille, and Neurology, Department of Medical Oncology, Oscar Lambret Center, Lille, France, Inserm U-1192, Laboratoire de Protéomique, Réponse Inflammatoire, Spectrométrie de Masse (PRISM), Lille 1 University, Villeneuve D’Ascq, France
| | - Sophie Taillibert
- Neurology, Mazarin and Radiation Oncology, Pitié Salpétrière Hospital, University Pierre et Marie Curie, Paris VI, Paris, France
| | - Marc C. Chamberlain
- Department of Neurology and Neurological Surgery, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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D'Amico RS, Kennedy BC, Bruce JN. Neurosurgical oncology: advances in operative technologies and adjuncts. J Neurooncol 2014; 119:451-63. [PMID: 24969924 DOI: 10.1007/s11060-014-1493-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 05/22/2014] [Indexed: 12/31/2022]
Abstract
Modern glioma surgery has evolved around the central tenet of safely maximizing resection. Recent surgical adjuncts have focused on increasing the maximum extent of resection while minimizing risk to functional brain. Technologies such as cortical and subcortical stimulation mapping, intraoperative magnetic resonance imaging, functional neuronavigation, navigable intraoperative ultrasound, neuroendoscopy, and fluorescence-guided resection have been developed to augment the identification of tumor while preserving brain anatomy and function. However, whether these technologies offer additional long-term benefits to glioma patients remains to be determined. Here we review advances over the past decade in operative technologies that have offered the most promising benefits for glioblastoma patients.
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Affiliation(s)
- Randy S D'Amico
- Department of Neurological Surgery, Neurological Institute, Columbia University Medical Center, 4th Floor, 710 West 168th Street, New York, NY, 10032, USA,
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Suzuki A, Leland P, Kobayashi H, Choyke PL, Jagoda EM, Inoue T, Joshi BH, Puri RK. Analysis of biodistribution of intracranially infused radiolabeled interleukin-13 receptor-targeted immunotoxin IL-13PE by SPECT/CT in an orthotopic mouse model of human glioma. J Nucl Med 2014; 55:1323-9. [PMID: 24947060 DOI: 10.2967/jnumed.114.138404] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 05/01/2014] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED Interleukin-13 Pseudomonas exotoxin (IL-13PE), a targeted agent for interleukin-13 receptor α2 (IL-13Rα2)-expressing tumors, has been administered intracranially by convection-enhanced delivery (CED) for glioma therapy in several clinical trials including a randomized phase 3 clinical trial. However, its intracranial distribution was not optimally evaluated. We investigated the intracranial distribution of radiolabeled IL-13PE after CED in a murine model of glioblastoma multiforme. METHODS IL-13PE was radiolabeled with Na(125)I and evaluated for its activity in vitro in receptor-positive U251 or -negative T98G human glioma cell lines. Gliomas were grown in nude mice after intracranial implantation with U251 cells, and (125)I-IL-13PE was stereotactically administered by bolus or CED for 3 d, followed by micro-SPECT/CT imaging. SPECT images were evaluated quantitatively and compared with histology and autoradiography results. RESULTS The radioiodination technique resulted in a specific and biologically active (125)I-IL-13PE, which bound and was cytotoxic to IL-13Rα2-positive but not to IL-13Rα2-negative tumor cells. Both the binding and the cytotoxic activities were blocked by a 100-fold excess of IL-13, which indicated the specificity of binding and cytotoxicity. SPECT/CT imaging revealed retention of (125)I-IL-13PE administered by CED in U251 tumors and showed significantly higher volumes of distribution and maintained detectable drug levels for a longer period of time than the bolus route. These results were confirmed by autoradiography. CONCLUSION IL-13PE can be radioiodinated without the loss of specificity, binding, or cytotoxic activity. Intracranial CED administration produces a higher volume of distribution for a longer period of time than the bolus route. Thus, CED of IL-13PE is superior to bolus injection in delivering the drug to the entire tumor.
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Affiliation(s)
- Akiko Suzuki
- Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland
| | - Pamela Leland
- Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland
| | - Hisataka Kobayashi
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland; and
| | - Peter L Choyke
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland; and
| | - Elaine M Jagoda
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland; and
| | - Tomio Inoue
- Department of Radiology, Yokohama City University, Yokohama, Japan
| | - Bharat H Joshi
- Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland
| | - Raj K Puri
- Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland
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Wilson TA, Karajannis MA, Harter DH. Glioblastoma multiforme: State of the art and future therapeutics. Surg Neurol Int 2014; 5:64. [PMID: 24991467 PMCID: PMC4078454 DOI: 10.4103/2152-7806.132138] [Citation(s) in RCA: 182] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 03/13/2014] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Glioblastoma multiforme (GBM) is the most common and lethal primary malignancy of the central nervous system (CNS). Despite the proven benefit of surgical resection and aggressive treatment with chemo- and radiotherapy, the prognosis remains very poor. Recent advances of our understanding of the biology and pathophysiology of GBM have allowed the development of a wide array of novel therapeutic approaches, which have been developed. These novel approaches include molecularly targeted therapies, immunotherapies, and gene therapy. METHODS We offer a brief review of the current standard of care, and a survey of novel therapeutic approaches for treatment of GBM. RESULTS Despite promising results in preclinical trials, many of these therapies have demonstrated limited therapeutic efficacy in human clinical trials. Thus, although survival of patients with GBM continues to slowly improve, treatment of GBM remains extremely challenging. CONCLUSION Continued research and development of targeted therapies, based on a detailed understanding of molecular pathogenesis can reasonably be expected to yield improved outcomes for patients with GBM.
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Affiliation(s)
- Taylor A Wilson
- Department of Neurosurgery, Division of Oncology, New York University School of Medicine, NY, USA
| | - Matthias A Karajannis
- Department of Pediatrics, Division of Oncology, New York University School of Medicine, NY, USA
| | - David H Harter
- Department of Neurosurgery, Division of Oncology, New York University School of Medicine, NY, USA
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Barua NU, Hopkins K, Woolley M, O'Sullivan S, Harrison R, Edwards RJ, Bienemann AS, Wyatt MJ, Arshad A, Gill SS. A novel implantable catheter system with transcutaneous port for intermittent convection-enhanced delivery of carboplatin for recurrent glioblastoma. Drug Deliv 2014; 23:167-73. [PMID: 24786643 DOI: 10.3109/10717544.2014.908248] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
CONTEXT Inadequate penetration of the blood-brain barrier (BBB) by systemically administered chemotherapies including carboplatin is implicated in their failure to improve prognosis for patients with glioblastoma. Convection-enhanced delivery (CED) of carboplatin has the potential to improve outcomes by facilitating bypass of the BBB. OBJECTIVE We report the first use of an implantable CED system incorporating a novel transcutaneous bone-anchored port (TBAP) for intermittent CED of carboplatin in a patient with recurrent glioblastoma. MATERIALS AND METHODS The CED catheter system was implanted using a robot-assisted surgical method. Catheter targeting accuracy was verified by performing intra-operative O-arm imaging. The TBAP was implanted using a skin-flap dermatome technique modeled on bone-anchored hearing aid surgery. Repeated infusions were performed by attaching a needle administration set to the TBAP. Drug distribution was monitored with serial real-time T2-weighted magnetic resonance imaging (MRI). RESULTS All catheters were implanted to within 1.5 mm of their planned target. Intermittent infusions of carboplatin were performed on three consecutive days and repeated after one month without the need for further surgical intervention. Infused volumes of 27.9 ml per day were well tolerated, with the exception of a single seizure episode. Follow-up MRI at eight weeks demonstrated a significant reduction in the volume of tumor enhancement from 42.6 ml to 24.6 ml, and was associated with stability of the patient's clinical condition. CONCLUSION Reduction in the volume of tumor enhancement indicates that intermittent CED of carboplatin has the potential to improve outcomes in glioblastoma. The novel technology described in this report make intermittent CED infusion regimes an achievable treatment strategy.
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Affiliation(s)
- Neil U Barua
- a Department of Neurosurgery , Frenchay Hospital , Bristol , UK
| | - Kirsten Hopkins
- b Department of Oncology , Bristol Oncology Centre , Bristol , UK
| | - Max Woolley
- c Neurological Applications Division , Renishaw PLC , Gloucs , Wotton-under-Edge , UK , and
| | - Stephen O'Sullivan
- c Neurological Applications Division , Renishaw PLC , Gloucs , Wotton-under-Edge , UK , and
| | - Rob Harrison
- c Neurological Applications Division , Renishaw PLC , Gloucs , Wotton-under-Edge , UK , and
| | | | - Alison S Bienemann
- d Functional Neurosurgery Research Group , University of Bristol , Bristol , UK
| | - Marcella J Wyatt
- d Functional Neurosurgery Research Group , University of Bristol , Bristol , UK
| | - Azeem Arshad
- d Functional Neurosurgery Research Group , University of Bristol , Bristol , UK
| | - Steven S Gill
- a Department of Neurosurgery , Frenchay Hospital , Bristol , UK
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Thaci B, Brown CE, Binello E, Werbaneth K, Sampath P, Sengupta S. Significance of interleukin-13 receptor alpha 2-targeted glioblastoma therapy. Neuro Oncol 2014; 16:1304-12. [PMID: 24723564 DOI: 10.1093/neuonc/nou045] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Glioblastoma multiforme (GBM) remains one of the most lethal primary brain tumors despite surgical and therapeutic advancements. Targeted therapies of neoplastic diseases, including GBM, have received a great deal of interest in recent years. A highly studied target of GBM is interleukin-13 receptor α chain variant 2 (IL13Rα2). Targeted therapies against IL13Rα2 in GBM include fusion chimera proteins of IL-13 and bacterial toxins, nanoparticles, and oncolytic viruses. In addition, immunotherapies have been developed using monoclonal antibodies and cell-based strategies such as IL13Rα2-pulsed dendritic cells and IL13Rα2-targeted chimeric antigen receptor-modified T cells. Advanced therapeutic development has led to the completion of phase I clinical trials for chimeric antigen receptor-modified T cells and phase III clinical trials for IL-13-conjugated bacterial toxin, with promising outcomes. Selective expression of IL13Rα2 on tumor cells, while absent in the surrounding normal brain tissue, has motivated continued study of IL13Rα2 as an important candidate for targeted glioma therapy. Here, we review the preclinical and clinical studies targeting IL13Rα2 in GBM and discuss new advances and promising applications.
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Affiliation(s)
- Bart Thaci
- Brain Tumor Laboratory, Roger Williams Medical Center, Providence, Rhode Island (P.S., S.S.); Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts (B.T., K.W., E.B., P.S., S.S.); Department of Hematology & Hematopoietic Cell Transplantation, City of Hope Hospital, Duarte, California (C.E.B.)
| | - Christine E Brown
- Brain Tumor Laboratory, Roger Williams Medical Center, Providence, Rhode Island (P.S., S.S.); Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts (B.T., K.W., E.B., P.S., S.S.); Department of Hematology & Hematopoietic Cell Transplantation, City of Hope Hospital, Duarte, California (C.E.B.)
| | - Emanuela Binello
- Brain Tumor Laboratory, Roger Williams Medical Center, Providence, Rhode Island (P.S., S.S.); Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts (B.T., K.W., E.B., P.S., S.S.); Department of Hematology & Hematopoietic Cell Transplantation, City of Hope Hospital, Duarte, California (C.E.B.)
| | - Katherine Werbaneth
- Brain Tumor Laboratory, Roger Williams Medical Center, Providence, Rhode Island (P.S., S.S.); Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts (B.T., K.W., E.B., P.S., S.S.); Department of Hematology & Hematopoietic Cell Transplantation, City of Hope Hospital, Duarte, California (C.E.B.)
| | - Prakash Sampath
- Brain Tumor Laboratory, Roger Williams Medical Center, Providence, Rhode Island (P.S., S.S.); Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts (B.T., K.W., E.B., P.S., S.S.); Department of Hematology & Hematopoietic Cell Transplantation, City of Hope Hospital, Duarte, California (C.E.B.)
| | - Sadhak Sengupta
- Brain Tumor Laboratory, Roger Williams Medical Center, Providence, Rhode Island (P.S., S.S.); Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts (B.T., K.W., E.B., P.S., S.S.); Department of Hematology & Hematopoietic Cell Transplantation, City of Hope Hospital, Duarte, California (C.E.B.)
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Luther N, Zhou Z, Zanzonico P, Cheung NK, Humm J, Edgar MA, Souweidane MM. The potential of theragnostic ¹²⁴I-8H9 convection-enhanced delivery in diffuse intrinsic pontine glioma. Neuro Oncol 2014; 16:800-6. [PMID: 24526309 DOI: 10.1093/neuonc/not298] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Reasons for failure in prior human glioma convection-enhanced delivery (CED) clinical trials remain unclear. Concentration-dependent volume of distribution (Vd) measurement of CED-infused agents in the human brain is challenging and highlights a potential technical shortcoming. Activity of iodine isotope 124 ((124)I ) in tissue can be directly measured in vivo with high resolution via PET. With the potential therapeutic utility of radioimmunotherapy, we postulate (124)I conjugated to the antiglioma monoclonal antibody 8H9 may serve as a "theragnostic" agent delivered via CED to diffuse intrinsic pontine glioma. METHODS Fifteen rats underwent CED of 0.1-1.0 mCi of (131)I-8H9 to the pons for toxicity evaluation. Six additional rats underwent CED of 10 µCi of (124)I-8H9 to the pons for dosimetry, with serial microPET performed for 1 week. Two primates underwent CED of gadolinium-albumin and 1.0 mCi of (124)I-8H9 to the pons for safety and dosimetry analysis. Serial postoperative PET, blood, and CSF radioactivity counts were performed. RESULTS One rat (1.0 mCi (131)I-8H9 infusion) suffered toxicity necessitating early sacrifice. PET analysis in rats yielded a pontine absorbed dose of 37 Gy/mCi. In primates, no toxicity was observed, and absorbed pontine dose was 3.8 Gy/mCi. Activity decreased 10-fold with 48 h following CED in both animal models. Mean Vd was 0.14 cc(3) (volume of infusion [Vi] to Vd ratio = 14) in the rat and 6.2 cc(3) (Vd/Vi = 9.5) in primate. CONCLUSION The safety and feasibility of (124)I dosimetry following CED via PET is demonstrated, establishing a preclinical framework for a trial evaluating CED of (124)I-8H9 for diffuse intrinsic pontine glioma.
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Affiliation(s)
- Neal Luther
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York (N.L., Z.Z.); Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York (P.Z., J.H.); Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York (N.-K.C.); Department of Pathology, Emory University, Atlanta, Georgia (M.A.E.); Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York (M.M.S.)
| | - Zhiping Zhou
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York (N.L., Z.Z.); Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York (P.Z., J.H.); Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York (N.-K.C.); Department of Pathology, Emory University, Atlanta, Georgia (M.A.E.); Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York (M.M.S.)
| | - Pat Zanzonico
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York (N.L., Z.Z.); Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York (P.Z., J.H.); Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York (N.-K.C.); Department of Pathology, Emory University, Atlanta, Georgia (M.A.E.); Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York (M.M.S.)
| | - Nai-Kong Cheung
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York (N.L., Z.Z.); Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York (P.Z., J.H.); Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York (N.-K.C.); Department of Pathology, Emory University, Atlanta, Georgia (M.A.E.); Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York (M.M.S.)
| | - John Humm
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York (N.L., Z.Z.); Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York (P.Z., J.H.); Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York (N.-K.C.); Department of Pathology, Emory University, Atlanta, Georgia (M.A.E.); Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York (M.M.S.)
| | - Mark A Edgar
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York (N.L., Z.Z.); Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York (P.Z., J.H.); Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York (N.-K.C.); Department of Pathology, Emory University, Atlanta, Georgia (M.A.E.); Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York (M.M.S.)
| | - Mark M Souweidane
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York (N.L., Z.Z.); Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York (P.Z., J.H.); Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York (N.-K.C.); Department of Pathology, Emory University, Atlanta, Georgia (M.A.E.); Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York (M.M.S.)
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Samis Zella MA, Wallocha M, Slotty PJ, Isik G, Hänggi D, Schroeteler J, Ewelt C, Steiger HJ, Sabel M. Evaluation of post-operative complications associated with repeat resection and BCNU wafer implantation in recurrent glioblastoma. Acta Neurochir (Wien) 2014; 156:313-23. [PMID: 24287680 DOI: 10.1007/s00701-013-1931-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 10/21/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with glioblastoma treated with BCNU wafer implantation for recurrence frequently receive frontline chemoradiotherapy with temozolomide as part of the Stupp protocol. A retrospective investigation was conducted of surgical complications in a cohort of these patients treated at a single institution. METHODS We searched our institutional database for patients treated between January 2006 and October 2012 who had recurrent glioblastoma previously treated with open surgery followed by the Stupp protocol and then underwent repeat resection with or without BCNU wafers for recurrent disease. Rates of select post-operative complications within 3 months of surgery were estimated. RESULTS We identified 95 patients with glioblastoma who underwent resection followed by the Stupp protocol as frontline treatment. At disease recurrence (first and second recurrence), 63 patients underwent repeat resection with BCNU wafer implantation and 32 without implantation. Generally, BCNU wafer use was associated with minor to moderate increases in rates of select complications versus non-implantation-wound healing abnormalities (14.2 vs. 6.2 %), cerebrospinal fluid leak (7.9 vs. 3.1 %), hydrocephalus requiring ventriculoperitoneal shunt (6.3 vs. 9.3 %), chemical meningitis (3.1 vs. 0 %), cerebral infections (3.1 vs. 0 %), cyst formation (3.1 vs. 3.1 %), cerebral edema (4.7 vs. 0 %), and empyema formations (1.5 vs. 0 %). Performance status was well maintained post-operatively in both groups. Median progression-free survival from the time of first recurrence was 6.0 and 5.0 months, respectively. CONCLUSIONS The use of the Stupp protocol as frontline therapy in patients with glioblastoma does not preclude the use of BCNU wafers at the time of progression.
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Affiliation(s)
- Maria Angela Samis Zella
- Department of Neurosurgery, Heinrich Heine University Hospital Düsseldorf, Medical Faculty, Moorenstraße 5, 40225, Düsseldorf, Germany,
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Gmeiner WH, Lema-Tome C, Gibo D, Jennings-Gee J, Milligan C, Debinski W. Selective anti-tumor activity of the novel fluoropyrimidine polymer F10 towards G48a orthotopic GBM tumors. J Neurooncol 2013; 116:447-54. [PMID: 24346635 PMCID: PMC3905194 DOI: 10.1007/s11060-013-1321-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 11/28/2013] [Indexed: 12/29/2022]
Abstract
F10 is a novel anti-tumor agent with minimal systemic toxicity in vivo and which displays strong cytotoxicity towards glioblastoma (GBM) cells in vitro. Here we investigate the cytotoxicity of F10 towards GBM cells and evaluate the anti-tumor activity of locally-administered F10 towards an orthotopic xenograft model of GBM. The effects of F10 on thymidylate synthase (TS) inhibition and Topoisomerase 1 (Top1) cleavage complex formation were evaluated using TS activity assays and in vivo complex of enzyme bioassays. Cytotoxicity of F10 towards normal brain was evaluated using cortices from embryonic (day 18) mice. F10 displays minimal penetrance of the blood–brain barrier and was delivered by intra-cerebral (i.c.) administration and prospective anti-tumor response towards luciferase-expressing G48a human GBM tumors in nude mice was evaluated using IVIS imaging. Histological examination of tumor and normal brain tissue was used to assess the selectivity of anti-tumor activity. F10 is cytotoxic towards G48a, SNB-19, and U-251 MG GBM cells through dual targeting of TS and Top1. F10 is not toxic to murine primary neuronal cultures. F10 is well-tolerated upon i.c. administration and induces significant regression of G48a tumors that is dose-dependent. Histological analysis from F10-treated mice revealed tumors were essentially completely eradicated in F10-treated mice while vehicle-treated mice displayed substantial infiltration into normal tissue. F10 displays strong efficacy for GBM treatment with minimal toxicity upon i.c. administration establishing F10 as a promising drug-candidate for treating GBM in human patients.
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Affiliation(s)
- William H Gmeiner
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA,
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Barua NU, Gill SS, Love S. Convection-enhanced drug delivery to the brain: therapeutic potential and neuropathological considerations. Brain Pathol 2013; 24:117-27. [PMID: 23944716 DOI: 10.1111/bpa.12082] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 08/08/2013] [Indexed: 12/16/2022] Open
Abstract
Convection-enhanced delivery (CED) describes a direct method of drug delivery to the brain through intraparenchymal microcatheters. By establishing a pressure gradient at the tip of the infusion catheter in order to exploit bulk flow through the interstitial spaces of the brain, CED offers a number of advantages over conventional drug delivery methods-bypass of the blood-brain barrier, targeted distribution through large brain volumes and minimization of systemic side effects. Despite showing early promise, CED is yet to fulfill its potential as a mainstream strategy for the treatment of neurological disease. Substantial research effort has been dedicated to optimize the technology for CED and identify the parameters, which govern successful drug distribution. It seems likely that successful clinical translation of CED will depend on suitable catheter technology being used in combination with drugs with optimal physicochemical characteristics, and on neuropathological analysis in appropriate preclinical models. In this review, we consider the factors most likely to influence the success or failure of CED, and review its application to the treatment of high-grade glioma, Parkinson's disease (PD) and Alzheimer's disease (AD).
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Affiliation(s)
- Neil U Barua
- Department of Neurosurgery, Institute of Clinical Neurosciences, School of Clinical Sciences, University of Bristol, Frenchay Hospital, Bristol, UK
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The treatment of glioblastomas: a systematic update on clinical Phase III trials. Crit Rev Oncol Hematol 2013; 87:265-82. [PMID: 23453191 DOI: 10.1016/j.critrevonc.2013.01.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Revised: 12/27/2012] [Accepted: 01/18/2013] [Indexed: 11/21/2022] Open
Abstract
Glioblastomas (GBMs) are invariably associated with unavoidable tumor recurrence and overall poor prognosis. The present study is to summarize the results of clinical Phase III studies on GBMs over the past seven years. A systematic literature search was performed using major electronic databases and by screening meeting abstracts. Totally, 16 studies of patients with newly diagnosed GBMs, recurrent GBMs, and elderly patients with GBMs were selected for this review. Although the outcomes of the experimental therapies were not encouraging, these studies produced a considerable amount of potentially clinically relevant information. Such aspects as surgical outcomes, radiation schedules, temozolomide (TMZ) schedules, methylation status of the O6-methylguanine DNA methyltransferase (MGMT) gene, combination of therapies, novel drug delivery methods and use of targeted agents have come to light and are being addressed here. In addition, we discuss the existing controversies of (1) surgical studies, (2) evaluations of recurrence, (3) salvage treatment bias, and (4) studies on elderly patients.
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Wainwright DA, Nigam P, Thaci B, Dey M, Lesniak MS. Recent developments on immunotherapy for brain cancer. Expert Opin Emerg Drugs 2012; 17:181-202. [PMID: 22533851 DOI: 10.1517/14728214.2012.679929] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Brain tumors are a unique class of cancers since they are anatomically shielded from normal immunosurveillance by the blood-brain barrier, lack a normal lymphatic drainage system and reside in a potently immunosuppressive environment. Of the primary brain cancers, glioblastoma multiforme (GBM) is the most common and aggressive in adults. Although treatment options include surgery, radiation and chemotherapy, the average lifespan of GBM patients remains at only 14.6 months post-diagnosis. AREAS COVERED A review of key cellular and molecular immune system mediators in the context of brain tumors including TGF-β, cytotoxic T cells, Tregs, CTLA-4, PD-1 and IDO is discussed. In addition, prognostic factors, currently utilized immunotherapeutic strategies, ongoing clinical trials and a discussion of new or potential immunotherapies for brain tumor patients are considered. EXPERT OPINION Current drugs that improve the quality of life and overall survival in patients with brain tumors, especially for GBM, are poorly effective. This disease requires a reanalysis of currently accepted treatment strategies, as well as newly designed approaches. Here, we review the fundamental aspects of immunosuppression in brain tumors, new and promising immunotherapeutic drugs as well as combinatorial strategies that focus on the simultaneous inhibition of immunosuppressive hubs, both in immune and brain tumor cells, which is critical to consider for achieving future success for the treatment of this devastating disease.
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