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Mrugala MM, Shi W, Iwomoto F, Lukas RV, Palmer JD, Suh JH, Glas M. Global post‑marketing safety surveillance of Tumor Treating Fields (TTFields) therapy in over 25,000 patients with CNS malignancies treated between 2011-2022. J Neurooncol 2024; 169:25-38. [PMID: 38949692 PMCID: PMC11269345 DOI: 10.1007/s11060-024-04682-7] [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: 02/06/2024] [Accepted: 04/15/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Tumor Treating Fields (TTFields) are alternating electric fields that disrupt cancer cell processes. TTFields therapy is approved for recurrent glioblastoma (rGBM), and newly-diagnosed (nd) GBM (with concomitant temozolomide for ndGBM; US), and for grade IV glioma (EU). We present an updated global, post-marketing surveillance safety analysis of patients with CNS malignancies treated with TTFields therapy. METHODS Safety data were collected from routine post-marketing activities for patients in North America, Europe, Israel, and Japan (October 2011-October 2022). Adverse events (AEs) were stratified by age, sex, and diagnosis. RESULTS Overall, 25,898 patients were included (diagnoses: ndGBM [68%], rGBM [26%], anaplastic astrocytoma/oligodendroglioma [4%], other CNS malignancies [2%]). Median (range) age was 59 (3-103) years; 66% patients were male. Most (69%) patients were 18-65 years; 0.4% were < 18 years; 30% were > 65 years. All-cause and TTFields-related AEs occurred in 18,798 (73%) and 14,599 (56%) patients, respectively. Most common treatment-related AEs were beneath-array skin reactions (43%), electric sensation (tingling; 14%), and heat sensation (warmth; 12%). Treatment-related skin reactions were comparable in pediatric (39%), adult (42%), and elderly (45%) groups, and in males (41%) and females (46%); and similar across diagnostic subgroups (ndGBM, 46%; rGBM, 34%; anaplastic astrocytoma/oligodendroglioma, 42%; other, 40%). No TTFields-related systemic AEs were reported. CONCLUSIONS This long-term, real-world analysis of > 25,000 patients demonstrated good tolerability of TTFields in patients with CNS malignancies. Most therapy-related AEs were manageable localized, non-serious skin events. The TTFields therapy safety profile remained consistent across subgroups (age, sex, and diagnosis), indicative of its broad applicability.
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Affiliation(s)
- Maciej M Mrugala
- Mayo Clinic College of Medicine and Science, Mayo Clinic, Phoenix/Scottsdale, Arizona, USA.
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Fabio Iwomoto
- Division of Neuro-Oncology, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Rimas V Lukas
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Joshua D Palmer
- The Department of Radiation Oncology, The James Cancer Hospital, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Martin Glas
- Division of Clinical Neurooncology, Department of Neurology, University Hospital Essen, University Duisburg-Essen, West German Cancer Center (WTZ) and German Cancer Consortium, Partner Site, Essen, Germany
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Cao Q, Hajosch A, Kast RE, Loehmann C, Hlavac M, Fischer-Posovszky P, Strobel H, Westhoff MA, Siegelin MD, Wirtz CR, Halatsch ME, Karpel-Massler G. Tumor Treating Fields (TTFields) combined with the drug repurposing approach CUSP9v3 induce metabolic reprogramming and synergistic anti-glioblastoma activity in vitro. Br J Cancer 2024; 130:1365-1376. [PMID: 38396172 PMCID: PMC11015043 DOI: 10.1038/s41416-024-02608-8] [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: 06/18/2023] [Revised: 01/27/2024] [Accepted: 01/30/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Glioblastoma represents a brain tumor with a notoriously poor prognosis. First-line therapy may include adjunctive Tumor Treating Fields (TTFields) which are electric fields that are continuously delivered to the brain through non-invasive arrays. On a different note, CUSP9v3 represents a drug repurposing strategy that includes 9 repurposed drugs plus metronomic temozolomide. Here, we examined whether TTFields enhance the antineoplastic activity of CUSP9v3 against this disease. METHODS We performed preclinical testing of a multimodal approach of TTFields and CUSP9v3 in different glioblastoma models. RESULTS TTFields had predominantly synergistic inhibitory effects on the cell viability of glioblastoma cells and non-directed movement was significantly impaired when combined with CUSP9v3. TTFields plus CUSP9v3 significantly enhanced apoptosis, which was associated with a decreased mitochondrial outer membrane potential (MOMP), enhanced cleavage of effector caspase 3 and reduced expression of Bcl-2 and Mcl-1. Moreover, oxidative phosphorylation and expression of respiratory chain complexes I, III and IV was markedly reduced. CONCLUSION TTFields strongly enhance the CUSP9v3-mediated anti-glioblastoma activity. TTFields are currently widely used for the treatment of glioblastoma patients and CUSP9v3 was shown to have a favorable safety profile in a phase Ib/IIa trial (NCT02770378) which facilitates transition of this multimodal approach to the clinical setting.
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Affiliation(s)
- Qiyu Cao
- Department of Neurosurgery, Ulm University Medical Center, Ulm, Germany
| | - Annika Hajosch
- Department of Neurosurgery, Ulm University Medical Center, Ulm, Germany
| | | | | | - Michal Hlavac
- Department of Neurosurgery, Ulm University Medical Center, Ulm, Germany
| | | | - Hannah Strobel
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm, Germany
| | - Mike-Andrew Westhoff
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm, Germany
| | - Markus D Siegelin
- Department of Pathology, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Marc-Eric Halatsch
- Department of Neurosurgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
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秦 丽, 谢 旭, 王 敏, 马 明, 潘 赟, 陈 光, 张 韶. [Simulation model of tumor-treating fields]. SHENG WU YI XUE GONG CHENG XUE ZA ZHI = JOURNAL OF BIOMEDICAL ENGINEERING = SHENGWU YIXUE GONGCHENGXUE ZAZHI 2024; 41:360-367. [PMID: 38686418 PMCID: PMC11058494 DOI: 10.7507/1001-5515.202306074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 01/04/2024] [Indexed: 05/02/2024]
Abstract
Tumor-treating fields (TTFields) is a novel treatment modality for malignant solid tumors, often employing electric field simulations to analyze the distribution of electric fields on the tumor under different parameters of TTFields. Due to the present difficulties and high costs associated with reproducing or implementing the simulation model construction techniques, this study used readily available open-source software tools to construct a highly accurate, easily implementable finite element simulation model for TTFields. The accuracy of the model is at a level of 1 mm 3. Using this simulation model, the study carried out analyses of different factors, such as tissue electrical parameters and electrode configurations. The results show that factors influncing the distribution of the internal electric field of the tumor include changes in scalp and skull conductivity (with a maximum variation of 21.0% in the treatment field of the tumor), changes in tumor conductivity (with a maximum variation of 157.8% in the treatment field of the tumor), and different electrode positions and combinations (with a maximum variation of 74.2% in the treatment field of the tumor). In summary, the results of this study validate the feasibility and effectiveness of the proposed modeling method, which can provide an important reference for future simulation analyses of TTFields and clinical applications.
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Affiliation(s)
- 丽平 秦
- 浙江省医疗器械检验研究院(杭州 310018)Zhejiang Institute of Medical Device Testing, Hangzhou 310018, P. R. China
| | - 旭 谢
- 浙江省医疗器械检验研究院(杭州 310018)Zhejiang Institute of Medical Device Testing, Hangzhou 310018, P. R. China
- 浙江大学 求是高等研究院 浙江大学生物医学工程教育部重点实验室(杭州 310027)Qiushi Academy for Advanced Studies, Key Laboratory for Biomedical Engineering of Ministry of Education, Zhejiang University, Hangzhou 310027, P. R. China
| | - 敏敏 王
- 浙江省医疗器械检验研究院(杭州 310018)Zhejiang Institute of Medical Device Testing, Hangzhou 310018, P. R. China
| | - 明伟 马
- 浙江省医疗器械检验研究院(杭州 310018)Zhejiang Institute of Medical Device Testing, Hangzhou 310018, P. R. China
| | - 赟 潘
- 浙江省医疗器械检验研究院(杭州 310018)Zhejiang Institute of Medical Device Testing, Hangzhou 310018, P. R. China
| | - 光弟 陈
- 浙江省医疗器械检验研究院(杭州 310018)Zhejiang Institute of Medical Device Testing, Hangzhou 310018, P. R. China
| | - 韶岷 张
- 浙江省医疗器械检验研究院(杭州 310018)Zhejiang Institute of Medical Device Testing, Hangzhou 310018, P. R. China
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Chen X, Cui Y, Zou L. Treatment advances in high-grade gliomas. Front Oncol 2024; 14:1287725. [PMID: 38660136 PMCID: PMC11039916 DOI: 10.3389/fonc.2024.1287725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
High-grade gliomas (HGG) pose significant challenges in modern tumour therapy due to the distinct biological properties and limitations of the blood-brain barrier. This review discusses recent advancements in HGG treatment, particularly in the context of immunotherapy and cellular therapy. Initially, treatment strategies focus on targeting tumour cells guided by the molecular characteristics of various gliomas, encompassing chemotherapy, radiotherapy and targeted therapy for enhanced precision. Additionally, technological enhancements are augmenting traditional treatment modalities. Furthermore, immunotherapy, emphasising comprehensive tumour management, has gained widespread attention. Immune checkpoint inhibitors, vaccines and CAR-T cells exhibit promising efficacy against recurrent HGG. Moreover, emerging therapies such as tumour treating fields (TTFields) offer additional treatment avenues for patients with HGG. The combination of diverse treatments holds promise for improving the prognosis of HGG, particularly in cases of recurrence.
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Affiliation(s)
- Xi Chen
- Department of Radiotherapy, Cancer Center, West China Hospital of Sichuan University, Chengdu, China
| | - Yi Cui
- State Key Laboratory of Biotherapy, Sichuan University, Chengdu, China
| | - Liqun Zou
- Department of Medical Oncology, Cancer Center, West China Hospital of Sichuan University, Chengdu, China
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Iv M, Naya L, Sanan S, Van Buskirk SL, Nagpal S, Thomas RP, Recht LD, Patel CB. Tumor treating fields increases blood-brain barrier permeability and relative cerebral blood volume in patients with glioblastoma. Neuroradiol J 2024; 37:107-118. [PMID: 37931176 PMCID: PMC10863570 DOI: 10.1177/19714009231207083] [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] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVE 200 kHz tumor treating fields (TTFields) is clinically approved for newly-diagnosed glioblastoma (nGBM). Because its effects on conventional surveillance MRI brain scans are equivocal, we investigated its effects on perfusion MRI (pMRI) brain scans. METHODS Each patient underwent institutional standard pMRI: dynamic contrast-enhanced (DCE) and dynamic susceptibility contrast (DSC) pMRI at three time points: baseline, 2-, and 6-months on-adjuvant therapy. At each timepoint, the difference between T1 pre- versus post-contrast tumor volume (ΔT1) and these pMRI metrics were evaluated: normalized and standardized relative cerebral blood volume (nRCBV, sRCBV); fractional plasma volume (Vp), volume of extravascular extracellular space (EES) per volume of tissue (Ve), blood-brain barrier (BBB) permeability (Ktrans), and time constant for gadolinium reflux from EES back into the vascular system (Kep). Between-group comparisons were performed using rank-sum analysis, and bootstrapping evaluated likely reproducibility of the results. RESULTS Among 13 pMRI datasets (11 nGBM, 2 recurrent GBM), therapies included temozolomide-only (n = 9) and temozolomide + TTFields (n = 4). No significant differences were found in patient or tumor characteristics. Compared to temozolomide-only, temozolomide + TTFields did not significantly affect the percent-change in pMRI metrics from baseline to 2 months. But during the 2- to 6-month period, temozolomide + TTFields significantly increased the percent-change in nRCBV (+26.9% [interquartile range 55.1%] vs -39.1% [37.0%], p = 0.049), sRCBV (+9.5% [39.7%] vs -30.5% [39.4%], p = 0.049), Ktrans (+54.6% [1768.4%] vs -26.9% [61.2%], p = 0.024), Ve (+111.0% [518.1%] vs -13.0% [22.5%], p = 0.048), and Vp (+98.8% [2172.4%] vs -24.6% [53.3%], p = 0.024) compared to temozolomide-only. CONCLUSION Using pMRI, we provide initial in-human validation of pre-clinical studies regarding the effects of TTFields on tumor blood volume and BBB permeability in GBM.
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Affiliation(s)
- Michael Iv
- Division of Neuroradiology, Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Lewis Naya
- Stanford Cancer Institute, Stanford, CA, USA
| | - Sajal Sanan
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Samuel L Van Buskirk
- Department of Psychology, University of Texas at San Antonio, San Antonio, TX, USA
| | - Seema Nagpal
- Division of Neuro-Oncology, Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Reena P Thomas
- Division of Neuro-Oncology, Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Lawrence D Recht
- Division of Neuro-Oncology, Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Chirag B Patel
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Cancer Biology Program, The University of Texas MD Anderson Cancer Center, University of Texas at Houston Graduate School of Biomedical Sciences (GSBS), Houston, TX, USA
- Neuroscience Graduate Program, The University of Texas MD Anderson Cancer Center-University of Texas at Houston Graduate School of Biomedical Sciences (GSBS), USA
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Li X, Wang J, Yuan G, Pan Y. Efficacy of TTFields in high-grade gliomas: a protocol for systematic review and meta-analysis. BMJ Open 2023; 13:e073753. [PMID: 37730390 PMCID: PMC10514625 DOI: 10.1136/bmjopen-2023-073753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/15/2023] [Indexed: 09/22/2023] Open
Abstract
INTRODUCTION Despite their recent FDA(Food and Drug Administration) approval, tumour treatment fields (TTFields) have not seen acceptance as part of standard of care (SOC) for the treatment of high-grade gliomas (HGGs). Few studies have reported the clinical effect of simultaneous or sequential use of TTFields with the current SOC. However, whether TTFields are beneficial over the standard treatment remains to be established with a meta-analysis. Therefore, we here performed a systematic review and meta-analysis to understand the benefit of TTFields for patients with HGGs. METHODS AND ANALYSIS We registered this systematic review with the PROSPERO network (registration number: CRD42023398972) and aimed to follow the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines in the study. All articles related to TTFields in glioma will be systematically searched for in the following databases since their inception until November 2023: the China National Knowledge Infrastructure, Embase, Cochrane Library, Wanfang Database, China Science Journal Database, China Biomedical Documentation Database, VIP database, Web of Science and PubMed. Article screening and data extraction will be done independently by the authors and cross-checked by two of the authors on completion. The Cochrane risk of bias assessment tool will be used for quality assessment of the included studies. Review Manager V.5.3 (Cochrane Collaboration) will be used to perform the meta-analysis. ETHICS AND DISSEMINATION Ethical approval is not required because the data used will be obtained from published studies, and there will be no concerns about privacy. The results of this study will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42023398972.
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Affiliation(s)
- Xinlong Li
- Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou, China
- Laboratory of Neurology of Gansu Province, Lanzhou University Second Hospital, Lanzhou, China
| | - Juncheng Wang
- Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou, China
- Laboratory of Neurology of Gansu Province, Lanzhou University Second Hospital, Lanzhou, China
| | - Guoqiang Yuan
- Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou, China
- Laboratory of Neurology of Gansu Province, Lanzhou University Second Hospital, Lanzhou, China
| | - Yawen Pan
- Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou, China
- Laboratory of Neurology of Gansu Province, Lanzhou University Second Hospital, Lanzhou, China
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Leal T, Kotecha R, Ramlau R, Zhang L, Milanowski J, Cobo M, Roubec J, Petruzelka L, Havel L, Kalmadi S, Ward J, Andric Z, Berghmans T, Gerber DE, Kloecker G, Panikkar R, Aerts J, Delmonte A, Pless M, Greil R, Rolfo C, Akerley W, Eaton M, Iqbal M, Langer C. Tumor Treating Fields therapy with standard systemic therapy versus standard systemic therapy alone in metastatic non-small-cell lung cancer following progression on or after platinum-based therapy (LUNAR): a randomised, open-label, pivotal phase 3 study. Lancet Oncol 2023; 24:1002-1017. [PMID: 37657460 DOI: 10.1016/s1470-2045(23)00344-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Tumor Treating Fields (TTFields) are electric fields that disrupt processes critical for cancer cell survival, leading to immunogenic cell death and enhanced antitumour immune response. In preclinical models of non-small-cell lung cancer, TTFields amplified the effects of chemotherapy and immune checkpoint inhibitors. We report primary results from a pivotal study of TTFields therapy in metastatic non-small-cell lung cancer. METHODS This randomised, open-label, pivotal phase 3 study recruited patients at 130 sites in 19 countries. Participants were aged 22 years or older with metastatic non-small-cell lung cancer progressing on or after platinum-based therapy, with squamous or non-squamous histology and ECOG performance status of 2 or less. Previous platinum-based therapy was required, but no restriction was placed on the number or type of previous lines of systemic therapy. Participants were randomly assigned (1:1) to TTFields therapy and standard systemic therapy (investigator's choice of immune checkpoint inhibitor [nivolumab, pembrolizumab, or atezolizumab] or docetaxel) or standard therapy alone. Randomisation was performed centrally using variable blocked randomisation and an interactive voice-web response system, and was stratified by tumour histology, treatment, and region. Systemic therapies were dosed according to local practice guidelines. TTFields therapy (150 kHz) was delivered continuously to the thoracic region with the recommendation to achieve an average of at least 18 h/day device usage. The primary endpoint was overall survival in the intention-to-treat population. The safety population included all patients who received any study therapy and were analysed according to the actual treatment received. The study is registered with ClinicalTrials.gov, NCT02973789. FINDINGS Between Feb 13, 2017, and Nov 19, 2021, 276 patients were enrolled and randomly assigned to receive TTFields therapy with standard therapy (n=137) or standard therapy alone (n=139). The median age was 64 years (IQR 59-70), 178 (64%) were male and 98 (36%) were female, 156 (57%) had non-squamous non-small-cell lung cancer, and 87 (32%) had received a previous immune checkpoint inhibitor. Median follow-up was 10·6 months (IQR 6·1-33·7) for patients receiving TTFields therapy with standard therapy, and 9·5 months (0·1-32·1) for patients receiving standard therapy. Overall survival was significantly longer with TTFields therapy and standard therapy than with standard therapy alone (median 13·2 months [95% CI 10·3-15·5] vs 9·9 months [8·1-11·5]; hazard ratio [HR] 0·74 [95% CI 0·56-0·98]; p=0·035). In the safety population (n=267), serious adverse events of any cause were reported in 70 (53%) of 133 patients receiving TTFields therapy plus standard therapy and 51 (38%) of 134 patients receiving standard therapy alone. The most frequent grade 3-4 adverse events were leukopenia (37 [14%] of 267), pneumonia (28 [10%]), and anaemia (21 [8%]). TTFields therapy-related adverse events were reported in 95 (71%) of 133 patients; these were mostly (81 [85%]) grade 1-2 skin and subcutaneous tissue disorders. There were three deaths related to standard therapy (two due to infections and one due to pulmonary haemorrhage) and no deaths related to TTFields therapy. INTERPRETATION TTFields therapy added to standard therapy significantly improved overall survival compared with standard therapy alone in metastatic non-small-cell lung cancer after progression on platinum-based therapy without exacerbating systemic toxicities. These data suggest that TTFields therapy is efficacious in metastatic non-small-cell lung cancer and should be considered as a treatment option to manage the disease in this setting. FUNDING Novocure.
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Affiliation(s)
- Ticiana Leal
- Winship Cancer Institute at Emory University, Atlanta, GA, USA.
| | - Rupesh Kotecha
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Rodryg Ramlau
- Poznan University of Medical Sciences, Poznan, Poland
| | - Li Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center (SYSUCC), Guangzhou, China
| | | | - Manuel Cobo
- Medical Oncology Intercenter Unit, Regional and Virgen de la Victoria University Hospitals, IBIMA, Málaga, Spain
| | - Jaromir Roubec
- Nemocnice AGEL Ostrava-Vítkovice, Ostrava, Czech Republic
| | | | | | | | - Jeffrey Ward
- Washington University School of Medicine, St Louis, MO, USA
| | - Zoran Andric
- University Clinical Hospital Centre Bezanijska Kosa, Belgrade, Serbia
| | - Thierry Berghmans
- Jules Bordet Institute, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - David E Gerber
- Harold C Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Joachim Aerts
- Department of Pulmonary Medicine, The Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Angelo Delmonte
- IRCCS Istituto Romagnolo per lo Studio dei Tumori Dino Amadori (IRST), Meldola, Italy
| | - Miklos Pless
- Kantonsspital Winterthur, Winterthur, Switzerland
| | - Richard Greil
- Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials (SCRI-CCCIT), Salzburg, Austria; Paracelsus Medical University Salzburg, Salzburg, Austria; Cancer Cluster, Salzburg, Austria
| | - Christian Rolfo
- Center for Thoracic Oncology, Tisch Cancer Institute at Icahn School of Medicine, Mount Sinai, New York, NY, USA
| | - Wallace Akerley
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | | | - Mussawar Iqbal
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Corey Langer
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Ballo MT, Conlon P, Lavy-Shahaf G, Kinzel A, Vymazal J, Rulseh AM. Association of Tumor Treating Fields (TTFields) therapy with survival in newly diagnosed glioblastoma: a systematic review and meta-analysis. J Neurooncol 2023; 164:1-9. [PMID: 37493865 PMCID: PMC10462574 DOI: 10.1007/s11060-023-04348-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/16/2023] [Indexed: 07/27/2023]
Abstract
PURPOSE Tumor Treating Fields (TTFields) therapy, an electric field-based cancer treatment, became FDA-approved for patients with newly diagnosed glioblastoma (GBM) in 2015 based on the randomized controlled EF-14 study. Subsequent approvals worldwide and increased adoption over time have raised the question of whether a consistent survival benefit has been observed in the real-world setting, and whether device usage has played a role. METHODS We conducted a literature search to identify clinical studies evaluating overall survival (OS) in TTFields-treated patients. Comparative and single-cohort studies were analyzed. Survival curves were pooled using a distribution-free random-effects method. RESULTS Among nine studies, seven (N = 1430 patients) compared the addition of TTFields therapy to standard of care (SOC) chemoradiotherapy versus SOC alone and were included in a pooled analysis for OS. Meta-analysis of comparative studies indicated a significant improvement in OS for patients receiving TTFields and SOC versus SOC alone (HR: 0.63; 95% CI 0.53-0.75; p < 0.001). Among real-world post-approval studies, the pooled median OS was 22.6 months (95% CI 17.6-41.2) for TTFields-treated patients, and 17.4 months (95% CI 14.4-21.6) for those not receiving TTFields. Rates of gross total resection were generally higher in the real-world setting, irrespective of TTFields use. Furthermore, for patients included in studies reporting data on device usage (N = 1015), an average usage rate of ≥ 75% was consistently associated with prolonged survival (p < 0.001). CONCLUSIONS Meta-analysis of comparative TTFields studies suggests survival may be improved with the addition of TTFields to SOC for patients with newly diagnosed GBM.
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Affiliation(s)
- Matthew T Ballo
- Department of Radiation Oncology, West Cancer Center, Germantown, TN, USA
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9
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Current status of the preclinical evaluation of alternating electric fields as a form of cancer therapy. Bioelectrochemistry 2023; 149:108287. [DOI: 10.1016/j.bioelechem.2022.108287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/28/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
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Tumor Treating Fields (TTFields) Therapy Concomitant with Taxanes for Cancer Treatment. Cancers (Basel) 2023; 15:cancers15030636. [PMID: 36765594 PMCID: PMC9913762 DOI: 10.3390/cancers15030636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023] Open
Abstract
Non-small cell lung cancer, ovarian cancer, and pancreatic cancer all present with high morbidity and mortality. Systemic chemotherapies have historically been the cornerstone of standard of care (SOC) regimens for many cancers, but are associated with systemic toxicity. Multimodal treatment combinations can help improve patient outcomes; however, implementation is limited by additive toxicities and potential drug-drug interactions. As such, there is a high unmet need to develop additional therapies to enhance the efficacy of SOC treatments without increasing toxicity. Tumor Treating Fields (TTFields) are electric fields that exert physical forces to disrupt cellular processes critical for cancer cell viability and tumor progression. The therapy is locoregional and is delivered noninvasively to the tumor site via a portable medical device that consists of field generator and arrays that are placed on the patient's skin. As a noninvasive treatment modality, TTFields therapy-related adverse events mainly consist of localized skin reactions, which are manageable with effective acute and prophylactic treatments. TTFields selectively target cancer cells through a multi-mechanistic approach without affecting healthy cells and tissues. Therefore, the application of TTFields therapy concomitant with other cancer treatments may lead to enhanced efficacy, with low risk of further systemic toxicity. In this review, we explore TTFields therapy concomitant with taxanes in both preclinical and clinical settings. The summarized data suggest that TTFields therapy concomitant with taxanes may be beneficial in the treatment of certain cancers.
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Nishikawa R, Yamasaki F, Arakawa Y, Muragaki Y, Narita Y, Tanaka S, Yamaguchi S, Mukasa A, Kanamori M. Safety and efficacy of tumour-treating fields (TTFields) therapy for newly diagnosed glioblastoma in Japanese patients using the Novo-TTF System: a prospective post-approval study. Jpn J Clin Oncol 2023; 53:371-377. [PMID: 36647599 PMCID: PMC10150168 DOI: 10.1093/jjco/hyad001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Tumour-treating fields therapy is a locoregional, anti-cancer treatment. Efficacy and safety of tumour-treating fields therapy in adults with newly diagnosed glioblastoma were demonstrated in the pivotal phase 3 EF-14 study (NCT00916409). Here, we report post-approval data of tumour-treating fields therapy in Japanese patients with newly diagnosed glioblastoma. METHODS Unsolicited post-marketing surveillance data from Japanese patients with newly diagnosed glioblastoma treated with tumour-treating fields therapy (December 2016-June 2020) were retrospectively analysed. The primary endpoints were skin, neurological and psychiatric adverse events. The secondary endpoints were 1- and 2-year overall survival rates, and the 6-month progression-free survival. adverse events were analysed using MedDRA v24.0. The overall survival and progression-free survival were assessed using the Kaplan-Meier survival analysis (log-rank testing). The Cox proportional hazard regression analyses were also performed. RESULTS Forty patients with newly diagnosed glioblastoma were enrolled (62.5% male; median age 59 years; median baseline Karnofsky Performance Scale score 90). The most common tumour-treating-fields-therapy-related adverse event was beneath-array local skin reaction (60% of patients). The adverse events were mostly mild to moderate in severity. Neurological disorders were observed in 2.5% patients (one patient reported dysesthesia). No psychiatric disorders were reported. The 1- and 2-year overall survival rates were 77.9% (95% CI 60.6-88.3) and 53.6% (35.5-68.7%), respectively. The 6-month progression-free survival was 77.5% (61.2-87.6%). These survival rates compare favourably with those in the EF-14 trial (1- and 2-year overall survival rates: 73% [69-77%] and 43% [39-48%], respectively; 6-month progression-free survival rate: 56% (51-61%). CONCLUSION This post-approval, real-world evidence study revealed no new safety signals and suggests the safety and efficacy of tumour-treating fields therapy in Japanese patients with newly diagnosed glioblastoma.
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Affiliation(s)
- Ryo Nishikawa
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Fumiyuki Yamasaki
- Department of Neurosurgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Yoshiki Arakawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshihiro Muragaki
- Department of Neurosurgery, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Yoshitaka Narita
- Department of Neurosurgery and Neuro-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Shota Tanaka
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Shigeru Yamaguchi
- Department of Neurosurgery, Hokkaido University Hospital, Sapporo, Japan
| | - Akitake Mukasa
- Department of Neurosurgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Masayuki Kanamori
- Department of Neurosurgery, Tohoku University Hospital, Sendai, Japan
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Anadkat MJ, Lacouture M, Friedman A, Horne ZD, Jung J, Kaffenberger B, Kalmadi S, Ovington L, Kotecha R, Abdullah HI, Grosso F. Expert guidance on prophylaxis and treatment of dermatologic adverse events with Tumor Treating Fields (TTFields) therapy in the thoracic region. Front Oncol 2023; 12:975473. [PMID: 36703794 PMCID: PMC9873416 DOI: 10.3389/fonc.2022.975473] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/23/2022] [Indexed: 01/06/2023] Open
Abstract
Tumor Treating Fields (TTFields) are electric fields, delivered via wearable arrays placed on or near the tumor site, that exert physical forces to disrupt cellular processes critical for cancer cell viability and tumor progression. As a first-in-class treatment, TTFields therapy is approved for use in newly diagnosed glioblastoma, recurrent glioblastoma, and pleural mesothelioma. Additionally, TTFields therapy is being investigated in non-small cell lung cancer (NSCLC), brain metastases from NSCLC, pancreatic cancer, ovarian cancer, hepatocellular carcinoma, and gastric adenocarcinoma. Because TTFields therapy is well tolerated and delivery is locoregional, there is low risk of additive systemic adverse events (AEs) when used with other cancer treatment modalities. The most common AE associated with TTFields therapy is mild-to-moderate skin events, which can be treated with topical agents and may be managed without significant treatment interruptions. Currently, there are no guidelines for oncologists regarding the management of TTFields therapy-related skin AEs in the thoracic region, applicable for patients with pleural mesothelioma or NSCLC. This publication aims to provide guidance on preventing, minimizing, and managing dermatologic AEs in the thoracic region to help improve patient quality of life and reduce treatment interruptions that may impact outcomes with TTFields therapy.
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Affiliation(s)
- Milan J. Anadkat
- Division of Dermatology, Department of Medicine, Washington University, St. Louis, MO, United States,*Correspondence: Milan J. Anadkat,
| | - Mario Lacouture
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Adam Friedman
- Division of Dermatology, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Zachary D. Horne
- Department of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, United States
| | - Jae Jung
- Department of Dermatology, Norton Healthcare, Louisville, KY, United States
| | | | - Sujith Kalmadi
- Oncology and Haematology Department, Ironwood Cancer & Research Center, Chandler, AZ, United States
| | - Liza Ovington
- Ovington & Associates, Walnutport, PA, United States
| | - Rupesh Kotecha
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
| | | | - Federica Grosso
- Mesothelioma Unit, SS Antonio e Biagio General Hospital, Alessandria, Italy
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Bottlenecks and opportunities in immunotherapy for glioma: a narrative review. JOURNAL OF BIO-X RESEARCH 2022. [DOI: 10.1097/jbr.0000000000000135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Du X, Chen C, Xiao Y, Cui Y, Yang L, Li X, Liu X, Wang R, Tan B. Research on application of tumor treating fields in glioblastoma: A bibliometric and visual analysis. Front Oncol 2022; 12:1055366. [DOI: 10.3389/fonc.2022.1055366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022] Open
Abstract
BackgroundGlioblastoma, one of the common tumors of the central nervous system (CNS), is prone to recurrence even after standard treatment protocols. As an innovative physiotherapy method emerging in recent years, the tumor treating fields (TTFields) technique has been approved for the treatment of glioblastoma due to its non-invasive and portable features. The purpose of this study is to visualize and analyze the scientific results and research trends in TTFields therapy for glioblastoma.MethodsPublications related to TTFields therapy for glioblastoma were searched in the Web of Science Core Collection (WoSCC) database in September 2022. A bibliometric and visual analysis of publications in this field was performed mainly using CiteSpace and R software for country/region, author, journal, reference and keyword.ResultsA total of 618 publications in this field were retrieved, and 248 were finally obtained according to the search criteria, including 159 articles (64.11%) and 89 reviews (37.89%). The cumulative number of publications increased year by year, with an average growth rate (AGR) of 28.50%. The test results of Pearson correlation coefficient showed a high positive correlation between publications and citations (r=0.937, p<0.001). The USA had the largest number of publications (123, 49.60%), followed by Germany (32, 12.90%) and China (30, 12.10%). As for the country/region collaborations, the USA cooperated most closely with other countries/regions, followed by Germany and China. The degree of collaboration (DC) between countries/regions was 25.81%. The institutions with the largest number of publications were Tel Aviv Univ (10), Harvard Med Sch (10) and Novocure Ltd (10). Moreover, Wong E (18) possessed the greatest number of publications, followed by Weinberg U (11) and Kirson E (10). The DC between authors was 97.58%. STUPP R (236) was the most cited author followed by KIRSON ED (164) and GILADI M (104). JOURNAL OF NEURO-ONCOLOGY (22) was the journal with the largest number of published publications (75), followed by FRONTIERS IN ONCOLOGY (15) and CANCERS (13). The top 10 keywords that occurred frequently included glioblastoma (156), tumor treating field (152), temozolomide (134), randomized phase III (48), brain (46), survivor (46), cancer (44), trial (42), alternating electric field (42) and radiotherapy (36). Furthermore, cluster analysis was performed on the basis of keyword co-occurrence, and finally 15 clusters were formed to determine the current research status and future development trend of TTFields therapy for glioblastoma.ConclusionTTFields has been increasingly known as the fourth novel physical anti-tumor therapy in addition to surgery, radiotherapy and anti-tumor drugs. Cooperation and communication between countries/regions need to be enhanced in future research. Several studies have demonstrated the therapeutic potential of TTFields in glioma, and its application alone or in combination with other treatments has become a current research hotspot.
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Foo CY, Munir N, Kumaria A, Akhtar Q, Bullock CJ, Narayanan A, Fu RZ. Medical Device Advances in the Treatment of Glioblastoma. Cancers (Basel) 2022; 14:5341. [PMID: 36358762 PMCID: PMC9656148 DOI: 10.3390/cancers14215341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/19/2022] [Accepted: 10/26/2022] [Indexed: 07/30/2023] Open
Abstract
Despite decades of research and the growing emergence of new treatment modalities, Glioblastoma (GBM) frustratingly remains an incurable brain cancer with largely stagnant 5-year survival outcomes of around 5%. Historically, a significant challenge has been the effective delivery of anti-cancer treatment. This review aims to summarize key innovations in the field of medical devices, developed either to improve the delivery of existing treatments, for example that of chemo-radiotherapy, or provide novel treatments using devices, such as sonodynamic therapy, thermotherapy and electric field therapy. It will highlight current as well as emerging device technologies, non-invasive versus invasive approaches, and by doing so provide a detailed summary of evidence from clinical studies and trials undertaken to date. Potential limitations and current challenges are discussed whilst also highlighting the exciting potential of this developing field. It is hoped that this review will serve as a useful primer for clinicians, scientists, and engineers in the field, united by a shared goal to translate medical device innovations to help improve treatment outcomes for patients with this devastating disease.
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Affiliation(s)
- Cher Ying Foo
- Imperial College School of Medicine, Imperial College London, Fulham Palace Rd., London W6 8RF, UK
| | - Nimrah Munir
- QV Bioelectronics Ltd., 1F70 Mereside, Alderley Park, Nether Alderley, Cheshire SK10 4TG, UK
| | - Ashwin Kumaria
- Department of Neurosurgery, Queen’s Medical Centre, Nottingham University Hospitals, Nottingham NG7 2UH, UK
| | - Qasim Akhtar
- QV Bioelectronics Ltd., 1F70 Mereside, Alderley Park, Nether Alderley, Cheshire SK10 4TG, UK
| | - Christopher J. Bullock
- QV Bioelectronics Ltd., 1F70 Mereside, Alderley Park, Nether Alderley, Cheshire SK10 4TG, UK
| | - Ashwin Narayanan
- QV Bioelectronics Ltd., 1F70 Mereside, Alderley Park, Nether Alderley, Cheshire SK10 4TG, UK
| | - Richard Z. Fu
- QV Bioelectronics Ltd., 1F70 Mereside, Alderley Park, Nether Alderley, Cheshire SK10 4TG, UK
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Michael, Smith Building, Dover St., Manchester M13 9PT, UK
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Salford Royal, Stott Lane, Salford M6 8HD, UK
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Zhu JJ, Goldlust SA, Kleinberg LR, Honnorat J, Oberheim Bush NA, Ram Z. Tumor Treating Fields (TTFields) therapy vs physicians' choice standard-of-care treatment in patients with recurrent glioblastoma: a post-approval registry study (EF-19). Discov Oncol 2022; 13:105. [PMID: 36239858 PMCID: PMC9568629 DOI: 10.1007/s12672-022-00555-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/08/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Tumor Treating Fields (TTFields) therapy, a noninvasive, anti-mitotic treatment modality, is approved for recurrent glioblastoma (rGBM) and newly diagnosed GBM based on phase III, EF-11 (NCT00379470) and EF-14 (NCT00916409) studies, respectively. The EF-19 study aimed to evaluate efficacy and safety of TTFields monotherapy (200 kHz) vs physicians' choice standard of care (PC-SOC; EF-11 historical control group) in rGBM. METHODS A prospective, post-marketing registry study of adults with supratentorial rGBM treated with TTFields therapy was conducted. Primary endpoint was overall survival (OS; intent-to-treat [ITT] population) and secondary endpoint was OS per-protocol (PP). Subgroup and toxicity analyses were conducted. RESULTS Median OS (ITT population) was comparable with TTFields monotherapy vs PC-SOC (7.4 vs 6.4 months, log-rank test P = 0.053; Cox test hazard ratio [HR] [95% CI], 0.66 [0.47-0.92], P = 0.016). The upper-bound HR (95% CI) was lower than pre-defined noninferiority (1.375 threshold). In the PP population, median OS was significantly longer for TTFields monotherapy vs PC-SOC (8.1 vs 6.4 months; log-rank test P = 0.017; Cox test HR [95% CI], 0.60 [0.42-0.85], P = 0.004). TTFields therapy showed increased benefit with extended use (≥ 18 h/day [averaged over 28 days]). TTFields therapy-related adverse events (AEs) by body system were lower vs PC-SOC: mainly mild-to-moderate skin AEs. CONCLUSION In the real-world setting, TTFields monotherapy showed comparable (ITT population) and superior (PP population) OS vs PC-SOC in rGBM. In line with previous results, TTFields therapy showed a favorable safety profile vs chemotherapy, without new safety signals/systemic effects. TRIAL REGISTRATION NCT01756729, registered December 20, 2012.
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Affiliation(s)
- Jay-Jiguang Zhu
- University of Texas Health Science Center in Houston (UTHealth)/Memorial Hermann Hospital at Texas Medical Center, 6400 Fannin St., Suite 2800, Houston, TX, 77030, USA.
| | | | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jérôme Honnorat
- Department of Neuro-Oncology, Hôpital Neurologique, Hospices Civils de Lyon, SynatAc Team, MELIS Institute, INSERM U1314/CNRS UMR5284, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- Department of Neuro-Oncology, East Group Hospital, Hospices Civils de Lyon, Lyon Cedex, France
| | - Nancy Ann Oberheim Bush
- Department of Neurological Surgery and Neurology, University of California, San Francisco, CA, USA
| | - Zvi Ram
- Tel Aviv Medical Center, Tel Aviv University School of Medicine, Tel Aviv, Israel
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Salvador E, Kessler AF, Domröse D, Hörmann J, Schaeffer C, Giniunaite A, Burek M, Tempel-Brami C, Voloshin T, Volodin A, Zeidan A, Giladi M, Ernestus RI, Löhr M, Förster CY, Hagemann C. Tumor Treating Fields (TTFields) Reversibly Permeabilize the Blood-Brain Barrier In Vitro and In Vivo. Biomolecules 2022; 12:1348. [PMID: 36291557 PMCID: PMC9599321 DOI: 10.3390/biom12101348] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 10/02/2023] Open
Abstract
Despite the availability of numerous therapeutic substances that could potentially target CNS disorders, an inability of these agents to cross the restrictive blood-brain barrier (BBB) limits their clinical utility. Novel strategies to overcome the BBB are therefore needed to improve drug delivery. We report, for the first time, how Tumor Treating Fields (TTFields), approved for glioblastoma (GBM), affect the BBB's integrity and permeability. Here, we treated murine microvascular cerebellar endothelial cells (cerebEND) with 100-300 kHz TTFields for up to 72 h and analyzed the expression of barrier proteins by immunofluorescence staining and Western blot. In vivo, compounds normally unable to cross the BBB were traced in healthy rat brain following TTFields administration at 100 kHz. The effects were analyzed via MRI and immunohistochemical staining of tight-junction proteins. Furthermore, GBM tumor-bearing rats were treated with paclitaxel (PTX), a chemotherapeutic normally restricted by the BBB combined with TTFields at 100 kHz. The tumor volume was reduced with TTFields plus PTX, relative to either treatment alone. In vitro, we demonstrate that TTFields transiently disrupted BBB function at 100 kHz through a Rho kinase-mediated tight junction claudin-5 phosphorylation pathway. Altogether, if translated into clinical use, TTFields could represent a novel CNS drug delivery strategy.
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Affiliation(s)
- Ellaine Salvador
- Department of Neurosurgery, Section Experimental Neurosurgery, University of Würzburg, D-97080 Würzburg, Germany
| | - Almuth F. Kessler
- Department of Neurosurgery, Section Experimental Neurosurgery, University of Würzburg, D-97080 Würzburg, Germany
| | - Dominik Domröse
- Department of Neurosurgery, Section Experimental Neurosurgery, University of Würzburg, D-97080 Würzburg, Germany
| | - Julia Hörmann
- Department of Neurosurgery, Section Experimental Neurosurgery, University of Würzburg, D-97080 Würzburg, Germany
| | - Clara Schaeffer
- Department of Neurosurgery, Section Experimental Neurosurgery, University of Würzburg, D-97080 Würzburg, Germany
| | - Aiste Giniunaite
- Department of Neurosurgery, Section Experimental Neurosurgery, University of Würzburg, D-97080 Würzburg, Germany
| | - Malgorzata Burek
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University of Würzburg, D-97080 Würzburg, Germany
| | | | | | | | | | | | - Ralf-Ingo Ernestus
- Department of Neurosurgery, Section Experimental Neurosurgery, University of Würzburg, D-97080 Würzburg, Germany
| | - Mario Löhr
- Department of Neurosurgery, Section Experimental Neurosurgery, University of Würzburg, D-97080 Würzburg, Germany
| | - Carola Y. Förster
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University of Würzburg, D-97080 Würzburg, Germany
| | - Carsten Hagemann
- Department of Neurosurgery, Section Experimental Neurosurgery, University of Würzburg, D-97080 Würzburg, Germany
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Shams S, Patel CB. Anti-cancer mechanisms of action of therapeutic alternating electric fields (tumor treating fields [TTFields]). J Mol Cell Biol 2022; 14:6668799. [PMID: 35973687 PMCID: PMC9912101 DOI: 10.1093/jmcb/mjac047] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 06/11/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
Despite improved survival outcomes across many cancer types, the prognosis remains grim for certain solid organ cancers including glioblastoma and pancreatic cancer. Invariably in these cancers, the control achieved by time-limited interventions such as traditional surgical resection, radiation therapy, and chemotherapy is short-lived. A new form of anti-cancer therapy called therapeutic alternating electric fields (AEFs) or tumor treating fields (TTFields) has been shown, either by itself or in combination with chemotherapy, to have anti-cancer effects that translate to improved survival outcomes in patients. Although the pre-clinical and clinical data are promising, the mechanisms of TTFields are not fully elucidated. Many investigations are underway to better understand how and why TTFields is able to selectively kill cancer cells and impede their proliferation. The purpose of this review is to summarize and discuss the reported mechanisms of action of TTFields from pre-clinical studies (both in vitro and in vivo). An improved understanding of how TTFields works will guide strategies focused on the timing and combination of TTFields with other therapies, to further improve survival outcomes in patients with solid organ cancers.
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Affiliation(s)
- Shadi Shams
- Rowan University School of Osteopathic Medicine, Stratford, NJ 08028, USA
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Goldman S, Margol A, Hwang EI, Tanaka K, Suchorska B, Crawford JR, Kesari S. Safety tumor treating fields (TTFields) therapy in pediatric patients with malignant brain tumors: Post-marketing surveillance data. Front Oncol 2022; 12:958637. [PMID: 36072789 PMCID: PMC9443515 DOI: 10.3389/fonc.2022.958637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/28/2022] [Indexed: 11/30/2022] Open
Abstract
There is an unmet need to develop effective and tolerable treatments for pediatric patients with malignant central nervous system tumors. This is especially essential for pediatric patients with aggressive brain tumors such as high-grade gliomas, which have a typical survival rate of under 2 years. Tumor Treating Fields (TTFields) are locoregional, noninvasive electric fields that produce an antimitotic effect on cancerous cells when applied to the skin via arrays. TTFields therapy (200 kHz) is currently approved in adult patients with newly diagnosed glioblastoma (GBM), with temozolomide, and recurrent GBM as monotherapy. Positive preclinical and clinical data have encouraged off-label use of TTFields therapy in pediatric patients with brain tumors, and this study aims to explore the safety of TTFields therapy in pediatric patients (0–18 years of age) based on data from an unsolicited post-marketing surveillance safety database. The real-world data reported here demonstrate that TTFields therapy has a favorable safety profile for pediatric patients with brain tumors, with no new safety signals observed. Findings from this study warrant further research into the efficacy of TTFields therapy, as well as its potential impact on the quality of life in pediatric patients.
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Affiliation(s)
- Stewart Goldman
- Phoenix Children’s Hospital, University of Arizona College of Medicine, Phoenix, AZ, United States
- *Correspondence: Stewart Goldman,
| | - Ashley Margol
- Children’s Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Eugene I. Hwang
- Department of Oncology, Children’s National Hospital, Washington, DC, United States
| | | | - Bogdana Suchorska
- Department of Neurosurgery, Sana Kliniken Duisburg, Duisburg, Germany
| | - John R. Crawford
- Department of Neurology, Children’s Health of Orange County, Orange County, CA, United States
| | - Santosh Kesari
- Providence Southern California Research Clinical Institute, Saint John’s Cancer Institute, Pacific Neuroscience Institute, Los Angeles, CA, United States
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Krigers A, Pinggera D, Demetz M, Kornberger LM, Kerschbaumer J, Thomé C, Freyschlag CF. The Routine Application of Tumor-Treating Fields in the Treatment of Glioblastoma WHO° IV. Front Neurol 2022; 13:900377. [PMID: 35785334 PMCID: PMC9243748 DOI: 10.3389/fneur.2022.900377] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction:Tumor-treating fields (TTFs) are a specific local oncological treatment modality in glioblastoma multiforme WHO° IV (GBM). Their mechanism of action is based on the effect of electrical fields interfering with the mitotic activity of malignant cells. Prospective studies have demonstrated efficacy, but TTF benefits are still controversially discussed. This treatment was implemented in our center as the standard of care in January 2016. We thus discuss the current state of the art and our long-term experience in the routine application of TTF.MethodsThe data of 48 patients suffering from GBM and treated with TTF were assessed and compared with previously published studies. Up-to-date information from open sources was evaluated.ResultsA total of 31 males and 17 females harboring a GBM were treated with TTF, between January 2016 and August 2021, in our center. In 98% of cases, TTFs were started within 6 weeks after concomitant radiochemotherapy (Stupp protocol). Mean overall survival was 22.6 months (95% CI: 17.3–27.9). Current indications, benefits, and restrictions were evaluated. Future TTF opportunities and ongoing studies were reviewed.ConclusionTTFs are a feasible and routinely applicable specific oncological treatment option for glioblastoma multiforme WHO° IV. Further research is ongoing to extend the indications and the efficacy of TTF.
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Chen X, Zhang Y, Zhao Q, Xiaoqun Chen LB, Zhou Z. Management of dermatologic adverse events associated with tumour treating fields in patients with glioblastoma multiforme: A 27-case series. Asia Pac J Oncol Nurs 2022; 9:100095. [PMID: 36060271 PMCID: PMC9428807 DOI: 10.1016/j.apjon.2022.100095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/26/2022] [Indexed: 11/25/2022] Open
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Oberheim-Bush NA, Shi W, McDermott MW, Grote A, Stindl J, Lustgarten L. The safety profile of Tumor Treating Fields (TTFields) therapy in glioblastoma patients with ventriculoperitoneal shunts. J Neurooncol 2022; 158:453-461. [PMID: 35639236 PMCID: PMC9256561 DOI: 10.1007/s11060-022-04033-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/07/2022] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Tumor Treating Fields (TTFields, 200 kHz) therapy is a noninvasive, locoregional cancer treatment approved for use in newly diagnosed glioblastoma (GBM), recurrent GBM, and malignant pleural mesothelioma. GBM patients with hydrocephalus may require implantation of a ventriculoperitoneal (VP) shunt, however, the current TTFields therapy label does not include the use of VP shunts in GBM patients due to insufficient safety data. This analysis evaluates the safety of TTFields therapy use in this population. METHODS Unsolicited post-marketing global surveillance data from patients with GBM and a VP shunt (programmable/non-programmable) who received TTFields therapy between November 2012-April 2021 were retrospectively analyzed. Adverse events (AEs) were assessed using the Medical Dictionary for Regulatory Activities version 24.0. RESULTS Overall, 156 patients with VP shunts were identified and included in this analysis. In total, 77% reported ≥ 1 AE; the most common TTFields therapy-related AEs were non-serious and localized, beneath-array skin AEs (43%). The incidence and categories of AEs were comparable between patients with or without VP shunts. Six patients with VP shunts experienced seven serious TTFields therapy-related AEs: skin erosion at the shunt site (n = 3); wound dehiscence at the shunt site (n = 2) and at the resection scar (n = 2). No shunt malfunctions were deemed related to TTFields therapy. CONCLUSIONS In the real-world setting, TTFields therapy in GBM patients with VP shunts demonstrated good tolerability and a favorable safety profile. There was no evidence that TTFields therapy disrupted VP shunt effectiveness. These results suggest TTFields therapy may be safely used in patients with VP shunts.
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Affiliation(s)
- Nancy Ann Oberheim-Bush
- Division of Neuro-Oncology, UCSF Brain Tumor Center, University of California, 400 Parnassus Ave, A808, San Francisco, CA, 94143, USA.
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael W McDermott
- Division of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Alexander Grote
- Department of Neurosurgery, University Hospital of Marburg, Marburg, Germany
| | | | - Leonardo Lustgarten
- Director of Neurooncology Global Medical Affairs , Novocure Inc, New York, NY, USA
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First Report of Tumor Treating Fields (TTFields) Therapy for Glioblastoma in Comorbidity with Multiple Sclerosis. Brain Sci 2022; 12:brainsci12040499. [PMID: 35448029 PMCID: PMC9032427 DOI: 10.3390/brainsci12040499] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/09/2022] [Accepted: 04/10/2022] [Indexed: 11/30/2022] Open
Abstract
Tumor Treating Fields (TTFields) therapy is FDA approved and has the CE mark for treatment of newly diagnosed and recurrent glioblastoma. To our knowledge, to date TTFields therapy remains unstudied in glioblastoma patients with multiple sclerosis (MS) as a comorbidity. Here, we present a patient who was diagnosed with MS at the age of 34. Treatment included several corticoid pulse treatments and therapies with interferon beta-1a and sphingosine-1-phosphate receptor modulator fingolimod. At the age of 52 the patient was diagnosed with glioblastoma, after experiencing worsening headaches which could not be attributed to the MS condition. After subtotal resection and concomitant radiochemotherapy, the patient received temozolomide in combination with TTFields therapy. For two years, the tumor condition remained stable while the patient showed high adherence to TTFields therapy with low-grade skin reactions being the only therapy-related adverse events. After two years, the tumor recurred. The patient underwent re-resection and radiotherapy and restarted TTFields therapy together with chemotherapy and is currently still on this therapy regime. Although having not been studied systematically, the case presented here demonstrates that TTFields therapy may be considered for newly diagnosed and recurrent glioblastoma patients with previously diagnosed multiple sclerosis.
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Efficacy and safety of tumor-treating fields in recurrent glioblastoma: a systematic review and meta-analysis. Acta Neurochir (Wien) 2022; 164:1985-1993. [PMID: 35397674 DOI: 10.1007/s00701-022-05192-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 03/23/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Tumor-treating fields (TTF) is a novel cancer treatment that uses alternating electric fields to interfere with tumor cell mitosis. It has been approved by the U.S. food and drug administration for the treatment of recurrent glioblastoma (rGBM). We designed this meta-analysis to evaluate the efficacy and safety of TTF in the treatment of rGBM. METHODS The study was based on the PRISMA guideline. Systematic retrieval was performed in PubMed, Cochrane Library, and Embase databases. The outcomes were overall survival (OS) hazard ratio (HR), 1-year survival rate, and cutaneous toxicity. RESULTS These studies included a total of 1048 rGBM patients who received TTF treatment. The overall survival time between the TTF group and the control group was HR 0.75 ([95%CI 0.63 to 0.89]; P = 0.001). Pooled 1-year overall survival rate and incidence of cutaneous toxicity were 0.47 and 0.48, respectively. Data were insufficient to evaluate the effect of MGMT methylation status and tumor recurrence times on heterogeneity. CONCLUSIONS TTF therapy is effective for recurrent glioblastoma. However, most relevant trials should assess rGBM patient baseline characteristics such as age, KPS, MGMT methylation status, and number of tumor recurrence,. In addition, the risk of rashes caused by long-term wearing of devices should also be considered.
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25
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Gkika E, Grosu AL, Macarulla Mercade T, Cubillo Gracián A, Brunner TB, Schultheiß M, Pazgan-Simon M, Seufferlein T, Touchefeu Y. Tumor Treating Fields Concomitant with Sorafenib in Advanced Hepatocellular Cancer: Results of the HEPANOVA Phase II Study. Cancers (Basel) 2022; 14:cancers14061568. [PMID: 35326718 PMCID: PMC8946145 DOI: 10.3390/cancers14061568] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/07/2022] [Accepted: 03/12/2022] [Indexed: 11/24/2022] Open
Abstract
Advanced hepatocellular carcinoma (HCC) is an aggressive disease associated with poor prognosis. Tumor Treating Fields (TTFields) therapy is a non-invasive, loco-regional treatment approved for glioblastoma and malignant pleural mesothelioma. HCC preclinical and abdominal simulation data, together with clinical results in other solid tumors, provide a rationale for investigating TTFields with sorafenib in this patient population. HEPANOVA was a phase II, single arm, historical control study in adults with advanced HCC (NCT03606590). Patients received TTFields (150 kHz) for ≥18 h/day concomitant with sorafenib (400 mg BID). Imaging assessments occurred every 12 weeks until disease progression. The primary endpoint was the overall response rate (ORR). Safety was also evaluated. Patients (n = 27 enrolled; n = 21 evaluable) had a poor prognosis; >50% were Child−Turcotte−Pugh class B and >20% had a baseline Eastern Clinical Oncology Group performance status (ECOG PS) of 2. The ORR was higher, but not statistically significant, for TTFields/sorafenib vs. historical controls: 9.5% vs. 4.5% (p = 0.24), respectively; all responses were partial. Among patients (n = 11) with ≥12 weeks of TTFields/sorafenib, ORR was 18%. Common adverse events (AEs) were diarrhea (n = 15/27, 56%) and asthenia (n = 11/27, 40%). Overall, 19/27 (70%) patients had TTFields-related skin AEs; none were serious. TTFields/sorafenib improved response rates vs. historical controls in patients with advanced HCC, with no new safety concerns or related systemic toxicity.
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Affiliation(s)
- Eleni Gkika
- Department for Radiation Oncology, University Medical Centre Freiburg, Robert-Koch-Straße 3, 79106 Freiburg, Germany;
- Correspondence: ; Tel.: +49-(0)-761-270-95200
| | - Anca-Ligia Grosu
- Department for Radiation Oncology, University Medical Centre Freiburg, Robert-Koch-Straße 3, 79106 Freiburg, Germany;
| | - Teresa Macarulla Mercade
- Department of Medical Oncology, Vall d’Hebrón University Hospital and Vall d’Hebrón Institute of Oncology, 08035 Barcelona, Spain;
| | - Antonio Cubillo Gracián
- Department of Medical Oncology, Centro Integral Oncológico Clara Campal HM CIOCC, Hospital Universitario HM Sanchinarro, 28050 Madrid, Spain;
| | - Thomas B. Brunner
- Department of Radiotherapy, University Hospital Magdeburg, 39120 Magdeburg, Germany;
| | - Michael Schultheiß
- Department of Medicine II, University Hospital Freiburg, 79106 Freiberg, Germany;
| | - Monika Pazgan-Simon
- Department of Infectious Diseases and Hepatology, Wroclaw Medical University, 50-367 Wrocław, Poland;
| | - Thomas Seufferlein
- Department of Internal Medicine, University Hospital Ulm, 89081 Ulm, Germany;
| | - Yann Touchefeu
- Nantes Université, CHU Nantes, Institut des Maladies de l’Appareil Digestif (IMAD), Hépato-Gastroentérologie, Inserm CIC 1413, F-44000 Nantes, France;
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Abstract
Purpose of Review Elderly patients with newly diagnosed glioblastoma (eGBM) carry a worse prognosis compared with their younger counterparts. eGBM garners special attention due to the unique challenges, including increased treatment-associated toxicity, less relative benefit from aggressive therapy, medical comorbidities, and immunosuppression. The pivotal GBM trials excluded patients > 70 years old and the optimal treatment approach remains unsettled for eGBM. In this review, we analyze the historical evidence-based data for treating eGBM and discuss the future direction for managing this vulnerable population. Recent Findings Treatment for eGBM continues to evolve. Therapy choice is guided by performance status and presence of O6-methylguanine-DNA-methyltransferase (MGMT) promoter methylation. For eGBM with good performance status, combinatorial hypofractionated radiation therapy (hRT) and temozolomide should be recommended. For those with poor performance status, further stratification based on MGMT promoter methylation test result is recommended. Single-agent temozolomide is a viable treatment option for MGMT methylated tumors (mMGMT); in particular, those classified with receptor tyrosine kinase II methylation. hRT alone can be considered in MGMT unmethylated (uMGMT) eGBM patients. As precision oncology continues to advance, effective targeted and immunotherapy may emerge as new treatment options for eGBM. Summary Management of elderly patients with newly diagnosed GBM carries a unique set of challenges. Progress has been made in defining the optimal therapeutic approach for these patients, but many questions remain to be answered.
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Affiliation(s)
- Carlen A. Yuen
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, 710 W 168th St, 9th Floor, New York, NY 10032 USA
| | - Marissa Barbaro
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, 710 W 168th St, 9th Floor, New York, NY 10032 USA
- Present Address: Perlmutter Cancer Center at NYU Langone Hematology Oncology Associates – Mineola, NYU Long Island School of Medicine, NYU Langone Health, Mineola, NY USA
| | - Aya Haggiagi
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, 710 W 168th St, 9th Floor, New York, NY 10032 USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY USA
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Liu J, Li C, Wang Y, Ji P, Guo S, Zhai Y, Wang N, Lou M, Xu M, Chao M, Jiao Y, Zhao W, Feng F, Qu Y, Ge S, Wang L. Prognostic and Predictive Factors in Elderly Patients With Glioblastoma: A Single-Center Retrospective Study. Front Aging Neurosci 2022; 13:777962. [PMID: 35173600 PMCID: PMC8841486 DOI: 10.3389/fnagi.2021.777962] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/28/2021] [Indexed: 11/13/2022] Open
Abstract
Glioblastoma (GBM) is the most common primary malignant intracranial tumor and the median age at diagnosis is 65 years. However, elderly patients are usually excluded from clinical studies and age is considered as an independent negative prognostic factor for patients with GBM. Therefore, the best treatment method for GBM in elderly patients has remained controversial. Elderly GBM patients (≥ 60 years old) treated between January 2015 and December 2019 were enrolled in this study. Medical records were reviewed retrospectively, and clinicopathological characteristics, treatments, and outcomes were analyzed. A total of 68 patients were included, with a median age of 65.5 years (range: 60–79). The median preoperative Karnofsky performance scale (KPS) score was 90 (range 40–100) and median postoperative KPS score was 80 (range 0–90). Univariate analysis results showed that age, gender, comorbidities, preoperative KPS < 90 and MGMT promoter methylation were not significantly associated with PFS and OS. On the other hand, total resection, postoperative KPS ≥ 80, Ki67 > 25%, and Stupp-protocol treatment were significantly associated with prolonged PFS and OS. Moreover, multivariate analysis found that postoperative KPS ≥ 80, total resection, and Stupp-protocol treatment were prognostic factors for PFS and OS. The findings of this study have suggested that, on the premise of protecting function as much as possible, the more aggressive treatment regimens may prolong survival for elderly patients with GBM. However, further studies, particularly prospective randomized clinical trials, should be conducted to provide more definitive data on the appropriate management of elderly patients, especially for patients with MGMT promoter methylation.
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Affiliation(s)
- Jinghui Liu
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Chen Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Yuan Wang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Peigang Ji
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Shaochun Guo
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Yulong Zhai
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Na Wang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Miao Lou
- Department of Otolaryngology Head and Neck Surgery, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Meng Xu
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Min Chao
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Yang Jiao
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Wenjian Zhao
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Fuqiang Feng
- Department of Neurosurgery, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Shunnan Ge
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
- *Correspondence: Shunnan Ge,
| | - Liang Wang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
- Liang Wang,
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Ye E, Lee JE, Lim YS, Yang SH, Park SM. Effect of duty cycles of tumor‑treating fields on glioblastoma cells and normal brain organoids. Int J Oncol 2022; 60:8. [PMID: 34970698 PMCID: PMC8727135 DOI: 10.3892/ijo.2021.5298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/09/2021] [Indexed: 11/06/2022] Open
Abstract
Tumor‑treating fields (TTFields) are emerging cancer therapies based on alternating low‑intensity electric fields that interfere with dividing cells and induce cancer cell apoptosis. However, to date, there is limited knowledge of their effects on normal cells, as well as the effects of different duty cycles on outcomes. The present study evaluated the effects of TTFields with different duty cycles on glioma spheroid cells and normal brain organoids. A customized TTFields system was developed to perform in vitro experiments with varying duty cycles. Three duty cycles were applied to three types of glioma spheroid cells and brain organoids. The efficacy and safety of the TTFields were evaluated by analyzing the cell cycle of glioma cells, and markers of neural stem cells (NSCs) and astrocytes in brain organoids. The application of the TTFields at the 75 and 100% duty cycle markedly inhibited the proliferation of the U87 and U373 compared with the control. FACS analysis revealed that the higher the duty cycle of the applied fields, the greater the increase in apoptosis detected. Exposure to a higher duty cycle resulted in a greater decrease in NSC markers and a greater increase in glial fibrillary acidic protein expression in normal brain organoids. These results suggest that TTFields at the 75 and 100% duty cycle induced cancer cell death, and that the neurotoxicity of the TTFields at 75% was less prominent than that at 100%. Although clinical studies with endpoints related to safety and efficacy need to be performed before this strategy may be adopted clinically, the findings of the present study provide meaningful evidence for the further advancement of TTFields in the treatment of various types of cancer.
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Affiliation(s)
- Eunbi Ye
- Department of Convergence IT Engineering, Pohang University of Science and Technology, Pohang-si, Gyeongsangbuk-do 37673, Republic of Korea
| | - Jung Eun Lee
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon-si, Gyeonggi-do 16247, Republic of Korea
| | - Young-Soo Lim
- Department of Convergence IT Engineering, Pohang University of Science and Technology, Pohang-si, Gyeongsangbuk-do 37673, Republic of Korea
| | - Seung Ho Yang
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon-si, Gyeonggi-do 16247, Republic of Korea
| | - Sung-Min Park
- Department of Convergence IT Engineering, Pohang University of Science and Technology, Pohang-si, Gyeongsangbuk-do 37673, Republic of Korea
- Department of Electrical Engineering, Pohang University of Science and Technology, Pohang-si, Gyeongsangbuk-do 37673, Republic of Korea
- Department of Mechanical Engineering, Pohang University of Science and Technology, Pohang-si, Gyeongsangbuk-do 37673, Republic of Korea
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Liang C, Gong J, Zhang B, Meng Z, Li M, Guo Y. Multiple subtentorial metastasis in diffuse midline glioma receiving tumor treating fields: a case report and literature review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1604. [PMID: 34790810 PMCID: PMC8576728 DOI: 10.21037/atm-21-4395] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/16/2021] [Indexed: 01/09/2023]
Abstract
Diffuse midline glioma (DMG) is one of fatal glioblastoma multiforme (GBM) with no proven medical therapies. Tumor treating fields (TTFields) is a new revolutionary therapy for GBM which prolongs the overall survival time obviously. However, we can observe more tumor growth phenomena (such as distant multiple metastases) than before. This report describes an adult patient who presented headache and dizziness, accompanied by left limb weakness, nausea, and vomiting following car accident trauma, following imaging examinations suggested thalamus GBM. He was treated with subtotal excision. Final pathology was diagnosed as DMG with H3F3A mutation, isocitrate dehydrogenase (IDH) wild type. Following concurrent chemoradiation therapy (CCRT) and adjuvant temozolomide (TMZ) chemotherapy + TTFields therapy were carried out. Supratentorial tumor has been exhibited a partial radiological response for nine months until TTFields was used irregularly or even discontinued in the later stage. Especially, subtentorial and spinal multiple metastasis occurred during this time. Both supratentorial and subtentorial tumors were treated with surgery, radiotherapy, chemotherapy, even targeted drugs, with the only difference being TTFields, but we could see different consequences for tumor growth. One conclusion might be drawn that TTFields can provide a longer survival time (14 vs. 8 months reported before) for DMG patients and improve survival benefits. However, we can observe that patients maybe die from subtentorial metastasis because TTFields could not cover the subtentorial tumors, which is the focal challenge at present. So further research on subtentorial tumors with TTFields is urgently needed.
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Affiliation(s)
- Chaofeng Liang
- Department of Neurosurgery, 3rd Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, China
| | - Jin Gong
- Department of Neurosurgery, 3rd Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, China
| | - Baoyu Zhang
- Department of Neurosurgery, 3rd Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, China
| | - Zhan'ao Meng
- Department of Radiology, 3rd Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, China
| | - Manting Li
- Department of Neurosurgery, 3rd Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, China
| | - Ying Guo
- Department of Neurosurgery, 3rd Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, China
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Ram Z, Kim CY, Hottinger AF, Idbaih A, Nicholas G, Zhu JJ. Efficacy and Safety of Tumor Treating Fields (TTFields) in Elderly Patients with Newly Diagnosed Glioblastoma: Subgroup Analysis of the Phase 3 EF-14 Clinical Trial. Front Oncol 2021; 11:671972. [PMID: 34692470 PMCID: PMC8526342 DOI: 10.3389/fonc.2021.671972] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 08/31/2021] [Indexed: 01/05/2023] Open
Abstract
Background Understudied elderly patients comprise a large segment of high-risk patients with glioblastoma (GBM) that are challenging to treat. Tumor Treating Fields (TTFields) is a locoregional, noninvasive, antimitotic therapy delivering low-intensity, intermediate-frequency alternating electric fields to the tumor. In the phase 3 EF-14 clinical trial, TTFields (200 kHz) improved median progression-free survival (PFS) and median overall survival (OS) in patients with newly diagnosed GBM (ndGBM) when added concomitantly to maintenance temozolomide (TMZ). This EF-14 subgroup analysis evaluated the safety and efficacy of TTFields in elderly patients. Methods All 134 patients who are ≥65 years of age were included (TTFields/TMZ combination, n=89; TMZ monotherapy, n=45; 2:1 ratio of randomization). PFS and OS were analyzed using Kaplan-Meier methodology (α=0.05). Health-related quality-of-life (HRQoL) was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) quality-of-life questionnaire QLQ-C30 supplemented with the brain tumor module (QLQ-BN20). Adverse events (AEs) were evaluated using Common Terminology Criteria for AEs (CTCAE) v4.0. Results The PFS was 6.5 months in patients randomized to the treatment group with TTFields/TMZ combination versus 3.9 months in patients treated with TMZ monotherapy (HR, 0.47; 95% CI, 0.30-0.74; P=0.0236). The OS was 17.4 months in patients treated with TTFields/TMZ combination versus 13.7 months in patients treated with TMZ monotherapy (HR, 0.51; 95% CI, 0.33-0.77; P=0.0204). Annual survival rates with TTFields/TMZ versus TMZ monotherapy were 39% (95% CI, 29-50%) versus 27% (95% CI, 15-41%; P=0.072) at 2 years, 19% (95% CI, 11-29%) versus 11% (95% CI, 4-23%; P=0.135) at 3 years, and 15% (95% CI, 7-25%) versus 0% at 5 years, respectively. There were no significant differences between groups in the preselected items of HRQoL assessment. Grade ≥3 systemic AEs were 46% in the TTFields/TMZ group versus 40% in the TMZ monotherapy group, without statistically significant difference between the two groups. The only TTFields-related AEs were reversible scalp skin reactions, with grades 1-2 and grade 3 skin reactions reported by 51% and 2% of patients, respectively. Conclusions Combining TTFields with maintenance TMZ significantly improved PFS and OS in elderly patients with ndGBM in the phase 3 EF-14 clinical trial, without significant increases in systemic toxicity or negatively affecting patient HRQoL. TTFields-related skin AEs were low-grade and manageable. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT00916409, identifier: NCT00916409.
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Affiliation(s)
- Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center and Tel Aviv University School of Medicine, Tel Aviv, Israel
| | - Chae-Yong Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Andreas F Hottinger
- Department of Clinical Neuroscience, CHUV Lausanne University Hospital & University of Lausanne, Lausanne, Switzerland
| | - Ahmed Idbaih
- Service de Neurologie 2-Mazarin, Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau, ICM, AP-HP, Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, Service de Neurologie 2-Mazarin, Paris, France
| | - Garth Nicholas
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jay-Jiguang Zhu
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, United States
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Biswas S, Kapitanova I, Divekar S, Grimm J, Butterwick IJ, Garren D, Kleinberg LR, Redmond KJ, Lacroix M, Mahadevan A, Forster KM. Targeting Accuracy Considerations for Simultaneous Tumor Treating Fields Antimitotic Therapy During Robotic Hypofractionated Radiation Therapy. Technol Cancer Res Treat 2021; 20:15330338211039135. [PMID: 34632866 PMCID: PMC8504228 DOI: 10.1177/15330338211039135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose: Tumor treating fields (TTFields) is a novel antimitotic treatment that was first proven effective for glioblastoma multiforme, now with trials for several extracranial indications underway. Several studies focused on concurrent TTFields therapy with radiation in the same time period, but were not given simultaneously. This study evaluates the targeting accuracy of simultaneous radiation therapy while TTFields arrays are in place and powered on, ensuring that radiation does not interfere with TTFields and TTFields does not interfere with radiation. This is one of several options to enable TTFields to begin several weeks sooner, and opens potential for synergistic effects of combined therapy. Methods: TTFields arrays were attached to a warm saline water bath and salt was added until the TTFields generator reached the maximal 2000 mA peak-to-peak current. A ball cube phantom containing 2 orthogonal films surrounded by fiducials was placed in the water phantom, CT scanned, and a radiation treatment plan with 58 isocentric beams was created using a 3 cm circular collimator. Fiducial tracking was used to deliver radiation, the films were scanned, and end-to-end targeting error was measured with vendor-supplied software. In addition, radiation effects on electric fields generated by the TTFields system were assessed by examining logfiles generated from the field generator. Results: With TTFields arrays in place and powered on, the robotic radiosurgery system achieved a final targeting result of 0.47 mm, which was well within the submillimeter specification. No discernible effects on TTFields current output beyond 0.3% were observed in the logfiles when the radiation beam pulsed on and off. Conclusion: A robotic radiosurgery system was used to verify that radiation targeting was not adversely affected when the TTFields arrays were in place and the TTFields delivery device was powered on. In addition, this study verified that radiation delivered simultaneously with TTFields did not interfere with the generation of the electric fields.
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Affiliation(s)
| | | | - Sabrina Divekar
- Sackler School of Medicine, 58408Tel Aviv University, New York, NY, USA
| | - Jimm Grimm
- 2780Geisinger Cancer Institute, Danville, PA, USA.,Thomas Jefferson University, Philadelphia, PA, USA
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Regev O, Merkin V, Blumenthal DT, Melamed I, Kaisman-Elbaz T. Tumor-Treating Fields for the treatment of glioblastoma: a systematic review and meta-analysis. Neurooncol Pract 2021; 8:426-440. [PMID: 34277021 PMCID: PMC8278345 DOI: 10.1093/nop/npab026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Tumor-Treating Fields (TTFields) is an emerging treatment modality for glioblastoma (GBM). Studies have shown a good safety profile alongside improved efficacy in newly diagnosed GBM (ndGBM), while a less clear effect was shown for recurrent GBM (rGBM). Despite regulatory support, sectors of the neuro-oncology community have been reluctant to accept it as part of the standard treatment protocol. To establish an objective understanding of TTFields' mechanism of action, safety, efficacy, and economical implications, we conducted a systematic literature review and meta-analysis. METHODS A systematic search was conducted in PubMed, Scopus, and Cochrane databases. Twenty studies met the pre-defined inclusion criteria, incorporating 1636 patients (542 ndGBM and 1094 rGBM), and 11 558 patients (6403 ndGBM and 5155 rGBM) analyzed for the clinical outcomes and safety endpoints, respectively. RESULTS This study demonstrated improved clinical efficacy and a good safety profile of TTFields. For ndGBM, pooled median overall survival (OS) and progression-free survival (PFS) were 21.7 (95%CI = 19.6-23.8) and 7.2 (95%CI = 6.1-8.2) months, respectively. For rGBM, pooled median OS and PFS were 10.3 (95%CI = 8.3-12.8) and 5.7 (95%CI = 2.8-10) months, respectively. Compliance of ≥75% was associated with an improved OS and the predominant adverse events were dermatologic, with a pooled prevalence of 38.4% (95%CI = 32.3-44.9). Preclinical studies demonstrated TTFields' diverse molecular mechanism of action, its potential synergistic efficacy, and suggest possible benefits for certain populations. CONCLUSIONS This study supports the use of TTFields for GBM, alongside the standard-of-care treatment protocol, and provides a practical summary, discussing the current clinical and preclinical aspects of the treatment and their implication on the disease course.
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Affiliation(s)
- Ohad Regev
- Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Be’er-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er-Sheva, Israel
| | - Vladimir Merkin
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er-Sheva, Israel
- Department of Neurosurgery, Soroka University Medical Center, Be’er-Sheva, Israel
| | - Deborah T Blumenthal
- Neuro-Oncology Service, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Israel Melamed
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er-Sheva, Israel
- Department of Neurosurgery, Soroka University Medical Center, Be’er-Sheva, Israel
| | - Tehila Kaisman-Elbaz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er-Sheva, Israel
- Department of Neurosurgery, Soroka University Medical Center, Be’er-Sheva, Israel
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Blatt R, Davidi S, Munster M, Shteingauz A, Cahal S, Zeidan A, Marciano T, Bomzon Z, Haber A, Giladi M, Weinberg U, Kinzel A, Palti Y. In Vivo Safety of Tumor Treating Fields (TTFields) Applied to the Torso. Front Oncol 2021; 11:670809. [PMID: 34249709 PMCID: PMC8264759 DOI: 10.3389/fonc.2021.670809] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 06/09/2021] [Indexed: 12/24/2022] Open
Abstract
Background Tumor Treating Fields (TTFields) therapy is a non-invasive, loco-regional, anti-mitotic treatment modality that targets rapidly dividing cancerous cells, utilizing low intensity, alternating electric fields at cancer-cell-type specific frequencies. TTFields therapy is approved for the treatment of newly diagnosed and recurrent glioblastoma (GBM) in the US, Europe, Israel, Japan, and China. The favorable safety profile of TTFields in patients with GBM is partially attributed to the low rate of mitotic events in normal, quiescent brain cells. However, specific safety evaluations are warranted at locations with known high rates of cellular proliferation, such as the torso, which is a primary site of several of the most aggressive malignant tumors. Methods The safety of delivering TTFields to the torso of healthy rats at 150 or 200 kHz, which were previously identified as optimal frequencies for treating multiple torso cancers, was investigated. Throughout 2 weeks of TTFields application, animals underwent daily clinical examinations, and at treatment cessation blood samples and internal organs were examined. Computer simulations were performed to verify that the targeted internal organs of the torso were receiving TTFields at therapeutic intensities (≥ 1 V/cm root mean square, RMS). Results No treatment-related mortality was observed. Furthermore, no significant differences were observed between the TTFields-treated and control animals for all examined safety parameters: activity level, food and water intake, stools, motor neurological status, respiration, weight, complete blood count, blood biochemistry, and pathological findings of internal organs. TTFields intensities of 1 to 2.5 V/cm RMS were confirmed for internal organs within the target region. Conclusions This research demonstrates the safety of therapeutic level TTFields at frequencies of 150 and 200 kHz when applied as monotherapy to the torso of healthy rats.
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Gatson NTN, Barnholtz-Sloan J, Drappatz J, Henriksson R, Hottinger AF, Hinoul P, Kruchko C, Puduvalli VK, Tran DD, Wong ET, Glas M. Tumor Treating Fields for Glioblastoma Therapy During the COVID-19 Pandemic. Front Oncol 2021; 11:679702. [PMID: 34026655 PMCID: PMC8139188 DOI: 10.3389/fonc.2021.679702] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/12/2021] [Indexed: 12/22/2022] Open
Abstract
Background The COVID-19 pandemic has placed excessive strain on health care systems and is especially evident in treatment decision-making for cancer patients. Glioblastoma (GBM) patients are among the most vulnerable due to increased incidence in the elderly and the short survival time. A virtual meeting was convened on May 9, 2020 with a panel of neuro-oncology experts with experience using Tumor Treating Fields (TTFields). The objective was to assess the risk-to-benefit ratio and provide guidance for using TTFields in GBM during the COVID-19 pandemic. Panel Discussion Topics discussed included support and delivery of TTFields during the COVID-19 pandemic, concomitant use of TTFields with chemotherapy, and any potential impact of TTFields on the immune system in an intrinsically immunosuppressed GBM population. Special consideration was given to TTFields' use in elderly patients and in combination with radiotherapy regimens. Finally, the panel discussed the need to better capture data on COVID-19positive brain tumor patients to analyze longitudinal outcomes and changes in treatment decision-making during the pandemic. Expert Opinion TTFields is a portable home-use device which can be managed via telemedicine and safely used in GBM patients during the COVID-19 pandemic. TTFields has no known immunosuppressive effects which is important during a crisis where other treatment methods might be limited, especially for elderly patients with multiple co-morbidities. It is too early to estimate the full impact of COVID-19 on the global healthcare system and on patient outcomes and the panel strongly recommended collaboration with existing cancer COVID-19 registries to follow CNS tumor patients.
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Affiliation(s)
- Na Tosha N Gatson
- Division of Neuro-Oncology, Department of Neurology, Geisinger Health, Neuroscience & Cancer Institutes, Danville, PA & Geisinger Commonwealth School of Medicine, Scranton, PA, United States.,Neuro-Oncology, Banner MD Anderson Cancer Center, Phoenix, AZ, United States
| | - Jill Barnholtz-Sloan
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine & Research and Education, University Hospitals of Cleveland, Cleveland, OH, United States
| | - Jan Drappatz
- Hillman Cancer Center, Department of Medicine and Neurology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Roger Henriksson
- Department of Radiation Sciences & Oncology at the University of Ume, Ume, Sweden
| | - Andreas F Hottinger
- Departments of Clinical Neurosciences & Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Piet Hinoul
- Global Medical Affairs, Novocure Inc., New York, NY, United States
| | - Carol Kruchko
- Central Brain Tumor Registry of the United States (CBTRUS), Hinsdale, IL, United States
| | - Vinay K Puduvalli
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - David D Tran
- Lillian S. Wells Department of Neurosurgery and Preston A. Wells, Jr. Brain Tumor Center at the McKnight Brain Institute of the University of Florida College of Medicine, Gainesville, FL, United States
| | - Eric T Wong
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Martin Glas
- Division of Clinical Neurooncology, Department of Neurology and German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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Makimoto A, Nishikawa R, Terashima K, Kurihara J, Fujisaki H, Ihara S, Morikawa Y, Yuza Y. Tumor-Treating Fields Therapy for Pediatric Brain Tumors. Neurol Int 2021; 13:151-165. [PMID: 33917660 PMCID: PMC8167650 DOI: 10.3390/neurolint13020015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/10/2021] [Accepted: 03/15/2021] [Indexed: 12/03/2022] Open
Abstract
Tumor-treating fields (TTFields) are alternating electric fields applied continuously to the brain by attaching two-pair arrays on the scalp. Although TTFields therapy has demonstrated efficacy against supratentorial glioblastoma (GBM) in adults, its safety and efficacy in children have not been confirmed. Despite differences in the genetic etiology of the adult and pediatric forms of GBM, both have certain clinical behaviors in common, allowing us to test TTFields therapy in pediatric GBM. Recently, several, pediatric case-series using TTFields therapy have been published, and a few, prospective, pediatric studies are ongoing. Because GBMs are extremely rare in pediatric patients, where they comprise a wide variety of genetic subtypes, these pediatric studies are feasibility studies targeting various types of malignant brain tumor. Although they are important for confirming the safety and feasibility of TTFields therapy in the pediatric population, confirming its efficacy against each type of pediatric brain tumor, including the GBM, is difficult. Our clinical research team, therefore, planned an investigator-initiated clinical trial targeting pediatric supratentorial GBMs (as in adults) with the aim of expanding regulatory approval of TTFields therapy for pediatric GBM treatment based on safety and exploratory efficacy data in combination with the accumulated evidence on adult GBMs.
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Affiliation(s)
- Atsushi Makimoto
- Department of Hematology/Oncology, Tokyo Metropolitan Children’s Medical Center, 2-8-29, Musashidai, Fuchu, Tokyo 183-8561, Japan;
- Clinical Research Support Center, Tokyo Metropolitan Children’s Medical Center, 2-8-29, Musashidai, Fuchu, Tokyo 183-8561, Japan;
- Correspondence: ; Tel.: +81-42-300-5111 (ext. 5177)
| | - Ryo Nishikawa
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama 350-1298, Japan;
| | - Keita Terashima
- Department of Neuro-Oncology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo 157-8535, Japan;
| | - Jun Kurihara
- Department of Neurosurgery, Saitama Children’s Medical Center, 1-2, Shin-toshin, Chuo-ku, Saitama 330-8777, Japan;
| | - Hiroyuki Fujisaki
- Department of Pediatric Hematology/Oncology, Osaka City General Hospital, 2-13-22, Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan;
| | - Satoshi Ihara
- Department of Neurosurgery, Tokyo Metropolitan Children’s Medical Center, 2-8-29, Musashidai, Fuchu, Tokyo 183-8561, Japan;
| | - Yoshihiko Morikawa
- Clinical Research Support Center, Tokyo Metropolitan Children’s Medical Center, 2-8-29, Musashidai, Fuchu, Tokyo 183-8561, Japan;
| | - Yuki Yuza
- Department of Hematology/Oncology, Tokyo Metropolitan Children’s Medical Center, 2-8-29, Musashidai, Fuchu, Tokyo 183-8561, Japan;
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Tumor Treating Fields (TTFields) Hinder Cancer Cell Motility through Regulation of Microtubule and Acting Dynamics. Cancers (Basel) 2020; 12:cancers12103016. [PMID: 33080774 PMCID: PMC7603026 DOI: 10.3390/cancers12103016] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/11/2020] [Accepted: 10/14/2020] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Tumor Treating Fields (TTFields), encompassing alternating electric fields within the intermediate frequency range, is an anticancer treatment delivered to the tumor region through transducer arrays placed non-invasively on the skin. Although established as an anti-mitotic treatment modality, the anti-metastatic potential of TTFields and their effect on rapid cytoskeletal dynamics during cellular motility warrant further investigation. In this study, we report that TTFields application induces changes in microtubule organization leading to interference with the directionality and robustness of cancer cell migration. We show that these changes in microtubule organization result in activation of GEF-H1/RhoA/ROCK signaling pathway, and the consequent formation of focal adhesions and changes in actin cytoskeleton architecture. Together, these results propose a novel mechanism by which TTFields induce changes in microtubule and actin organization and dynamics, thereby disrupting processes important for polarity generation and motility in cancer cells. Abstract Tumor Treating Fields (TTFields) are noninvasive, alternating electric fields within the intermediate frequency range (100–300 kHz) that are utilized as an antimitotic cancer treatment. TTFields are loco-regionally delivered to the tumor region through 2 pairs of transducer arrays placed on the skin. This novel treatment modality has been FDA-approved for use in patients with glioblastoma and malignant pleural mesothelioma based on clinical trial data demonstrating efficacy and safety; and is currently under investigation in other types of solid tumors. TTFields were shown to induce an anti-mitotic effect by exerting bi-directional forces on highly polar intracellular elements, such as tubulin and septin molecules, eliciting abnormal microtubule polymerization during spindle formation as well as aberrant cleavage furrow formation. Previous studies have demonstrated that TTFields inhibit metastatic properties in cancer cells. However, the consequences of TTFields application on cytoskeleton dynamics remain undetermined. In this study, methods utilized in combination to study the effects of TTFields on cancer cell motility through regulation of microtubule and actin dynamics included confocal microscopy, computational tools, and biochemical analyses. Mechanisms by which TTFields treatment disrupted cellular polarity were (1) interference with microtubule assembly and directionality; (2) altered regulation of Guanine nucleotide exchange factor-H1 (GEF-H1), Ras homolog family member A (RhoA), and Rho-associated coiled-coil kinase (ROCK) activity; and (3) induced formation of radial protrusions of peripheral actin filaments and focal adhesions. Overall, these data identified discrete effects of TTFields that disrupt processes crucial for cancer cell motility.
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Lacouture ME, Anadkat MJ, Ballo MT, Iwamoto F, Jeyapalan SA, La Rocca RV, Schwartz M, Serventi JN, Glas M. Prevention and Management of Dermatologic Adverse Events Associated With Tumor Treating Fields in Patients With Glioblastoma. Front Oncol 2020; 10:1045. [PMID: 32850308 PMCID: PMC7399624 DOI: 10.3389/fonc.2020.01045] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/27/2020] [Indexed: 12/24/2022] Open
Abstract
Importance: Tumor Treating Fields (TTFields) are an anti-mitotic treatment approved for treating newly diagnosed and recurrent glioblastoma, and mesothelioma. TTFields in glioblastoma comprise alternating electric fields (200 kHz) delivered continuously, ideally for ≥18 h/day, to the tumor bed via transducer arrays placed on the shaved scalp. When applied locoregionally to the tumor bed and combined with systemic temozolomide chemotherapy, TTFields improved overall survival vs. temozolomide alone in patients with newly diagnosed glioblastoma. Improved efficacy outcomes with TTFields were demonstrated, while maintaining a well-tolerated and manageable safety profile. The most commonly-reported TTFields–associated adverse events (AEs) are beneath-array dermatologic events. Since survival benefit from TTFields increases with duration-of-use, prevention and management of skin AEs are critical to maximize adherence. This paper describes TTFields-associated dermatological AEs and recommends prevention and management strategies based on clinical trial evidence and real-world clinical experience. Observations: TTFields–associated skin reactions include contact dermatitis (irritant/allergic), hyperhidrosis, xerosis or pruritus, and more rarely, skin erosions/ulcers and infections. Skin AEs may be prevented through skin-care and shifting (~2 cm) of array position during changes. TTFields–related skin AE management should be based on clinical phenotype and severity. Depending on diagnosis, recommended treatments include antibiotics, skin barrier films, moisturizers, topical corticosteroids, and antiperspirants. Water-based lotions, soaps, foams, and solutions with minimal impact on electrical impedance are preferred with TTFields use over petroleum-based ointments, which increase impedance. Conclusions: Early identification, prophylactic measures, and symptomatic skin AE management help patients maximize TTFields usage, while maintaining quality-of-life and optimizing therapeutic benefit. Implications for practice: TTFields confer a survival benefit in patients with glioblastoma that correlates positively with duration of daily use. Skin events (rash) are the primary treatment-related AE that can limit duration of use. The recommendations described here will help healthcare professionals to recognize, prevent, and manage dermatologic AEs associated with TTFields treatment. These recommendations may improve cutaneous health and support adherence to therapy, both of which would maximize treatment outcomes.
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Affiliation(s)
| | - Milan J Anadkat
- Division of Dermatology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Matthew T Ballo
- Department of Radiation Oncology, West Cancer Center, Memphis, TN, United States
| | - Fabio Iwamoto
- New York-Presbyterian/Columbia University Medical Center, New York, NY, United States
| | - Suriya A Jeyapalan
- Department of Neurology, Tufts Medical Center, Boston, MA, United States.,Department of Hematology-Oncology, Tufts Medical Center, Boston, MA, United States
| | - Renato V La Rocca
- Norton Cancer Institute, Norton Healthcare, Louisville, KY, United States
| | | | - Jennifer N Serventi
- University of Rochester Medical Center, Rochester, New York, NY, United States
| | - Martin Glas
- Division of Clinical Neurooncology, Department of Neurology and West German Cancer Center, German Cancer Consortium, Partner Site Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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