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Saltarin F, Wegmüller A, Bejarano L, Ildiz ES, Zwicky P, Vianin A, Spadin F, Soukup K, Wischnewski V, Engelhardt B, Deutsch U, J. Marques I, Frenz M, Joyce JA, Lyck R. Compromised Blood-Brain Barrier Junctions Enhance Melanoma Cell Intercalation and Extravasation. Cancers (Basel) 2023; 15:5071. [PMID: 37894438 PMCID: PMC10605101 DOI: 10.3390/cancers15205071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Melanoma frequently metastasises to the brain, and a detailed understanding of the molecular and cellular mechanisms underlying melanoma cell extravasation across the blood-brain barrier (BBB) is important for preventing brain metastasis formation. Making use of primary mouse brain microvascular endothelial cells (pMBMECs) as an in vitro BBB model, we imaged the interaction of melanoma cells into pMBMEC monolayers. We observed exclusive junctional intercalation of melanoma cells and confirmed that melanoma-induced pMBMEC barrier disruption can be rescued by protease inhibition. Interleukin (IL)-1β stimulated pMBMECs or PECAM-1-knockout (-ko) pMBMECs were employed to model compromised BBB barrier properties in vitro and to determine increased melanoma cell intercalation compared to pMBMECs with intact junctions. The newly generated brain-homing melanoma cell line YUMM1.1-BrM4 was used to reveal increased in vivo extravasation of melanoma cells across the BBB of barrier-compromised PECAM-1-deficient mice compared to controls. Taken together, our data indicate that preserving BBB integrity is an important measure to limit the formation of melanoma-brain metastasis.
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Affiliation(s)
- Federico Saltarin
- Theodor Kocher Institute, University of Bern, 3012 Bern, Switzerland; (F.S.); (P.Z.)
| | - Adrian Wegmüller
- Theodor Kocher Institute, University of Bern, 3012 Bern, Switzerland; (F.S.); (P.Z.)
| | - Leire Bejarano
- Department of Oncology, University of Lausanne, 1011 Lausanne, Switzerland (V.W.)
- Ludwig Institute for Cancer Research, University of Lausanne, 1011 Lausanne, Switzerland
| | - Ece Su Ildiz
- Theodor Kocher Institute, University of Bern, 3012 Bern, Switzerland; (F.S.); (P.Z.)
| | - Pascale Zwicky
- Theodor Kocher Institute, University of Bern, 3012 Bern, Switzerland; (F.S.); (P.Z.)
| | - Andréj Vianin
- Department of Developmental Biology and Regeneration, Institute of Anatomy, University of Bern, 3012 Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, 3010 Bern, Switzerland
| | - Florentin Spadin
- Institute of Applied Physics, University of Bern, 3012 Bern, Switzerland; (F.S.)
| | - Klara Soukup
- Department of Oncology, University of Lausanne, 1011 Lausanne, Switzerland (V.W.)
- Ludwig Institute for Cancer Research, University of Lausanne, 1011 Lausanne, Switzerland
| | - Vladimir Wischnewski
- Department of Oncology, University of Lausanne, 1011 Lausanne, Switzerland (V.W.)
- Ludwig Institute for Cancer Research, University of Lausanne, 1011 Lausanne, Switzerland
| | - Britta Engelhardt
- Theodor Kocher Institute, University of Bern, 3012 Bern, Switzerland; (F.S.); (P.Z.)
| | - Urban Deutsch
- Theodor Kocher Institute, University of Bern, 3012 Bern, Switzerland; (F.S.); (P.Z.)
| | - Ines J. Marques
- Department of Developmental Biology and Regeneration, Institute of Anatomy, University of Bern, 3012 Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, 3010 Bern, Switzerland
| | - Martin Frenz
- Institute of Applied Physics, University of Bern, 3012 Bern, Switzerland; (F.S.)
| | - Johanna A. Joyce
- Department of Oncology, University of Lausanne, 1011 Lausanne, Switzerland (V.W.)
- Ludwig Institute for Cancer Research, University of Lausanne, 1011 Lausanne, Switzerland
| | - Ruth Lyck
- Theodor Kocher Institute, University of Bern, 3012 Bern, Switzerland; (F.S.); (P.Z.)
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2
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Yu Y, Chen H, Tian Z, Zhang Q, Shui Y, Shen L, Hu Q, Huang Z, Zhu S, Jiang H, Wei Q. Improved survival outcome with not-delayed radiotherapy and immediate PD-1/PD-L1 inhibitor for non-small-cell lung cancer patients with brain metastases. J Neurooncol 2023; 165:127-137. [PMID: 37848757 PMCID: PMC10638122 DOI: 10.1007/s11060-023-04459-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/20/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE To investigate the impact of radiotherapy (RT) and immune checkpoint inhibitor (ICI) sequence on the survival outcome in NSCLC patients with brain metastasis, and decide the best time to initiate RT. METHODS Patients were managed with delayed RT (ICI delivered over 2 weeks prior to RT), concurrent RT (ICI delivered within 2 weeks prior to or after RT), or upfront RT (RT delivered over 2 weeks prior to ICI). Overall survival (OS), intracranial local progression-free survival (iLPFS), and intracranial distant progression-free survival (iDPFS) were assessed. A meta-analysis was performed to analyze the association between survival outcome and RT/ICI sequence. RESULTS A total of 73 NSCLC patients were identified with a median follow-up of 13.9 months. Patients who receive delayed RT demonstrated shorter iLPFS (P = 0.0029), iDPFS (P = 0.016), and OS (P < 0.001). A meta-analysis was conducted and a total of 4 studies, 254 patients were included. The HR was 0.44 for iDPFS (P = 0.03), 0.41 for OS (P < 0.01) when compared concurrent with delayed RT, 0.21 for iDPFS (P < 0.01), 0.32 for OS (P < 0.01) when compared upfront with delayed RT, consistent with our conclusion that delayed RT brought with worst iDPFS and OS. More importantly, the best overall response rate (BOR) decreased in cases with longer RT and ICI intervals. Patients who receive intervals of RT and ICI within 7 days achieve the best median BOR of - 53%. CONCLUSIONS Delayed RT brought poor survival outcomes including iLPFS, iDPFS, and OS in NSCLC patients. The shorter interval of RT and ICI is associated with better BOR.
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Affiliation(s)
- Yaner Yu
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Cancer, Cancer Center of Zhejiang University, Hangzhou, China
| | - Haiyan Chen
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Cancer, Cancer Center of Zhejiang University, Hangzhou, China
- Anhui Campus of the Second Affiliated Hospital, Zhejiang University School of Medicine, Bengbu, 233000, China
| | - Zhifeng Tian
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Radiotherapy, Lishui Municipal Central Hospital, Lishui, China
| | - Qun Zhang
- Department of Radiation Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233000, China
| | - Yongjie Shui
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Cancer, Cancer Center of Zhejiang University, Hangzhou, China
| | - Li Shen
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Cancer, Cancer Center of Zhejiang University, Hangzhou, China
| | - Qiongge Hu
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Cancer, Cancer Center of Zhejiang University, Hangzhou, China
| | - Zhifei Huang
- Department of Radiation Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233000, China
| | - Shuangqiu Zhu
- Department of Radiation Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233000, China
| | - Hao Jiang
- Department of Radiation Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233000, China.
| | - Qichun Wei
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
- Zhejiang Provincial Clinical Research Center for Cancer, Cancer Center of Zhejiang University, Hangzhou, China.
- Anhui Campus of the Second Affiliated Hospital, Zhejiang University School of Medicine, Bengbu, 233000, China.
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Wang J, Li Z, Pan M, Fiaz M, Hao Y, Yan Y, Sun L, Yan F. Ultrasound-mediated blood-brain barrier opening: An effective drug delivery system for theranostics of brain diseases. Adv Drug Deliv Rev 2022; 190:114539. [PMID: 36116720 DOI: 10.1016/j.addr.2022.114539] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 09/04/2022] [Accepted: 09/11/2022] [Indexed: 01/24/2023]
Abstract
Blood-brain barrier (BBB) remains a significant obstacle to drug therapy for brain diseases. Focused ultrasound (FUS) combined with microbubbles (MBs) can locally and transiently open the BBB, providing a potential strategy for drug delivery across the BBB into the brain. Nowadays, taking advantage of this technology, many therapeutic agents, such as antibodies, growth factors, and nanomedicine formulations, are intensively investigated across the BBB into specific brain regions for the treatment of various brain diseases. Several preliminary clinical trials also have demonstrated its safety and good tolerance in patients. This review gives an overview of the basic mechanisms, ultrasound contrast agents, evaluation or monitoring methods, and medical applications of FUS-mediated BBB opening in glioblastoma, Alzheimer's disease, and Parkinson's disease.
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Affiliation(s)
- Jieqiong Wang
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai 201206, China
| | - Zhenzhou Li
- Department of Ultrasound, The Second People's Hospital of Shenzhen, The First Affiliated Hospital of Shenzhen University, Shenzhen 518061, China
| | - Min Pan
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen 518034, China
| | - Muhammad Fiaz
- Department of Radiology, Azra Naheed Medical College, Lahore, Pakistan
| | - Yongsheng Hao
- Center for Cell and Gene Circuit Design, CAS Key Laboratory of Quantitative Engineering Biology, Shenzhen Institute of Synthetic Biology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Yiran Yan
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510282, China
| | - Litao Sun
- Cancer Center, Department of Ultrasound Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang 310014, China.
| | - Fei Yan
- Center for Cell and Gene Circuit Design, CAS Key Laboratory of Quantitative Engineering Biology, Shenzhen Institute of Synthetic Biology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China.
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Gutiérrez ML, Carrasco-Moro R, Ruz-Caracuel I, San Millán JSM. Stroke secondary to leptomeningeal carcinomatosis with radiologic signs of arterial invasion. Surg Neurol Int 2022; 13:290. [PMID: 35855115 PMCID: PMC9282822 DOI: 10.25259/sni_336_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/17/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Compared to the general population, cancer patients are more likely to suffer from cerebral ischemia, either caused by the tumor itself or by the treatments applied. Case Description: We hereby present the clinical case of a patient treated for lung adenocarcinoma, who, years later, developed a case of the right frontal-temporal-insular ischemia secondary to leptomeningeal spread of the primary neoplasm, with an invasion of the walls of the right-middle cerebral artery and its branches. Conclusion: This should be considered an extremely rare form of recurrence of a primary solid tumor with clinical and radiological features that can mimic those of vascular inflammatory entities.
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Gao Y, Wang R, Zhao L, Liu A. Natural polymeric nanocarriers in malignant glioma drug delivery and targeting. J Drug Target 2021; 29:960-973. [PMID: 33745392 DOI: 10.1080/1061186x.2021.1904250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Among all central nervous diseases, malignant glioma is a crucial part that deserves more attention since high fatality and disability rate. There are several therapeutic strategies applied to the treatment of malignant glioma, especially certain chemotherapy-related treatments. However, the existence of the blood-brain barrier (BBB) seriously hinders the strategy's progress, so how to escape from the barriers is a fascinating question. Herein, we comprehensively discussed the details of malignant glioma and the BBB's functional morphology and summarized several routes bypassing the BBB. Additionally, since possessing excellent properties for drug delivery, we provided an insight into various promising natural polymeric materials and highlighted their applications in the treatment of malignant glioma.
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Affiliation(s)
- Yuan Gao
- School of Pharmaceutical Sciences, Key Laboratory of Chemical Biology, Ministry of Education, Shandong University, Jinan 250012, China
| | - Rui Wang
- School of Pharmaceutical Sciences, Key Laboratory of Chemical Biology, Ministry of Education, Shandong University, Jinan 250012, China
| | - Lixia Zhao
- Department of Pharmacy, Qilu Hospital of Shandong University, Jinan 250012, China
| | - Anchang Liu
- Department of Pharmacy, Qilu Hospital of Shandong University, Jinan 250012, China
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6
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López Vázquez M, Du W, Kanaya N, Kitamura Y, Shah K. Next-generation immunotherapies for brain metastatic cancers. Trends Cancer 2021; 7:809-822. [PMID: 33722479 DOI: 10.1016/j.trecan.2021.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/29/2020] [Accepted: 02/09/2021] [Indexed: 02/06/2023]
Abstract
Patients with extracranial tumors, like lung, breast, and skin cancers, often develop brain metastases (BM) during the course of their diseases and BM commonly represent the terminal stage of cancer progression. Recent insights in the immune biology of BM and the increasing focus of immunotherapy as a therapeutic option for cancer has prompted testing of promising biological immunotherapies, including immune cell-targeting, virotherapy, vaccines, and different cell-based therapies. Here, we review the pathobiology of BM progression and evaluate the potential of next-generation immunotherapies for BM tumors. We also provide future perspectives on the development and implementation of such therapies for brain metastatic cancer patients.
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Affiliation(s)
- María López Vázquez
- Center for Stem Cell Therapeutics and Imaging (CSTI), Harvard Medical School, Boston, MA 02115, USA; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Wanlu Du
- Center for Stem Cell Therapeutics and Imaging (CSTI), Harvard Medical School, Boston, MA 02115, USA; Department of Molecular, Cellular and Developmental Biology, University of Michigan, Ann Arbor, MI 48109-1085, USA
| | - Nobuhiko Kanaya
- Center for Stem Cell Therapeutics and Imaging (CSTI), Harvard Medical School, Boston, MA 02115, USA; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Yohei Kitamura
- Center for Stem Cell Therapeutics and Imaging (CSTI), Harvard Medical School, Boston, MA 02115, USA; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Khalid Shah
- Center for Stem Cell Therapeutics and Imaging (CSTI), Harvard Medical School, Boston, MA 02115, USA; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA; Harvard Stem Cell Institute, Harvard University, Cambridge, MA 02138, USA.
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7
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Makawita S, Tawbi HA. Nonsurgical Management of Melanoma Brain Metastasis: Current Therapeutics, Challenges, and Strategies for Progress. Am Soc Clin Oncol Educ Book 2021; 41:79-90. [PMID: 34010041 DOI: 10.1200/edbk_321137] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
This review aims to provide an overview of nonsurgical treatment strategies for central nervous system metastases in melanoma as well as discuss treatment challenges and future directions. Recent strategies for melanoma brain metastases have involved proving the intracranial activity of approved therapies as well as identifying novel drug targets. BRAF/MEK combination therapy has intracranial activity in those with BRAF V600 mutations, though disease control is shorter for intracranial than extracranial metastases. Immunotherapy and combination immunotherapies have emerged as providing durable responses in melanoma, and newer studies combining immunotherapy with targeted therapies are emerging. Continued challenges include penetration through the blood-brain barrier and development of resistance mechanisms. Novel therapeutic targets and methods to improve central nervous system penetrance are being identified through the application of deep DNA- and RNA-sequencing analyses. Radiation therapy approaches, especially stereotactic radiosurgery in combination or in sequence with systemic therapies, are also being investigated. Both targeted therapies and immunotherapies have revolutionized the field of melanoma treatment. Multimodality approaches with multidisciplinary teams will pave the way for the future of central nervous system disease treatment in melanoma.
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Affiliation(s)
- Shalini Makawita
- Department of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hussein A Tawbi
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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8
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Barbaro M, Fine HA, Magge RS. Scientific and Clinical Challenges within Neuro-Oncology. World Neurosurg 2021; 151:402-410. [PMID: 33610863 DOI: 10.1016/j.wneu.2021.01.151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/25/2022]
Abstract
Both primary and metastatic brain tumors carry poor prognoses despite modern advances in medical therapy, radiation therapy, and surgical techniques. Gliomas, including glioblastoma (GBM), are particularly difficult to treat, and high-grade gliomas have poor outcomes. Treatment of brain tumors involves a unique set of scientific and clinical challenges, which are often not present in the treatment of systemic malignancies. With respect to scientific challenges, the anatomy and physiology of brain tumors (including the blood-brain barrier, blood-tumor barrier, and blood-cerebrospinal fluid barrier) prevent adequate drug delivery into the central nervous system. The unique nature of the immune system in the central nervous system as well as the immunosuppressive microenvironment of tumors such as GBM also create therapeutic roadblocks in the treatment of brain tumors. Tumor heterogeneity, particularly in GBM, has classically been believed to contribute to multitherapy resistance; however, recent data suggest that this may not be the case. Clinical challenges include neurologic and medical comorbidities of patients with brain tumor, as well as potential toxicity of tumor-directed treatment. Clinical trials investigating new treatment paradigms are needed, but several roadblocks exist to good and promising clinical trial availability.
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Affiliation(s)
- Marissa Barbaro
- Weill Cornell Brain Tumor Center, Department of Neurology, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Howard A Fine
- Weill Cornell Brain Tumor Center, Department of Neurology, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Rajiv S Magge
- Weill Cornell Brain Tumor Center, Department of Neurology, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA.
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Steindl A, Berghoff AS. Brain metastases in metastatic cancer: a review of recent advances in systemic therapies. Expert Rev Anticancer Ther 2020; 21:325-339. [PMID: 33196341 DOI: 10.1080/14737140.2021.1851200] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Brain metastases (BM) are a frequent complication of metastatic cancer. Due to the wider availability and application of screening procedures, an increasing fraction of patients are diagnosed at the asymptomatic stage. The introduction of immune checkpoint inhibitors and targeted therapies has revolutionized treatment in several frequently BM-causing entities like metastatic lung cancer, melanoma and breast cancer. However, registered trials of new targeted and immunotherapy mostly excluded patients with BM resulting in limited knowledge of the intracranial efficacy of new systemic agents.Areas covered: The present review highlights recent advances in systemic therapies for the treatment and prophylaxis of the three leading BM causing tumors: NSCLC, melanoma and breast cancer.Expert opinion: High intracranial efficacy was observed for several next-generation tyrosine kinase inhibitors as well as immune checkpoint inhibitors, especially in patients with asymptomatic disease. Ongoing discussions addressed the need for local therapies in patients with asymptomatic BM and the availability of systemic therapy with high intracranial efficacy. Further BM-specific studies as well as BM-specific endpoints in registered trials are needed to define the role of systemic monotherapies in patients with BM.
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Affiliation(s)
- Ariane Steindl
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Anna S Berghoff
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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10
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Fares J, Kanojia D, Rashidi A, Ulasov I, Lesniak MS. Genes that Mediate Metastasis across the Blood-Brain Barrier. Trends Cancer 2020; 6:660-676. [PMID: 32417182 DOI: 10.1016/j.trecan.2020.04.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 04/15/2020] [Accepted: 04/22/2020] [Indexed: 12/21/2022]
Abstract
Brain metastasis is an important cause of mortality in patients with cancer and represents the majority of all intracranial tumors. A key step during the metastatic journey of the cancer cell to the brain is the invasion through the blood-brain barrier (BBB). Nevertheless, the molecular mechanisms that govern this process remain unknown. The BBB has been blamed for limiting the access of therapeutic drugs to the brain, which provides a safe haven for cancer cells in the brain and confers poor prognosis for the patient. Here, we explore the genes that control the transmigration of metastatic cancer cells across the BBB, offering new targets for the development of gene and cell therapies against brain metastases.
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Affiliation(s)
- Jawad Fares
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Deepak Kanojia
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Aida Rashidi
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Ilya Ulasov
- Group of Experimental Biotherapy and Diagnostic, Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, Moscow 119991, Russia
| | - Maciej S Lesniak
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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11
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Li J, Zhao J, Tan T, Liu M, Zeng Z, Zeng Y, Zhang L, Fu C, Chen D, Xie T. Nanoparticle Drug Delivery System for Glioma and Its Efficacy Improvement Strategies: A Comprehensive Review. Int J Nanomedicine 2020; 15:2563-2582. [PMID: 32368041 PMCID: PMC7173867 DOI: 10.2147/ijn.s243223] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/21/2020] [Indexed: 12/22/2022] Open
Abstract
Gliomas are the most common tumor of the central nervous system. However, the presence of the brain barrier blocks the effective delivery of drugs and leads to the treatment failure of various drugs. The development of a nanoparticle drug delivery system (NDDS) can solve this problem. In this review, we summarized the brain barrier (including blood-brain barrier (BBB), blood-brain tumor barriers (BBTB), brain-cerebrospinal fluid barrier (BCB), and nose-to-brain barrier), NDDS of glioma (such as passive targeting systems, active targeting systems, and environmental responsive targeting systems), and NDDS efficacy improvement strategies and deficiencies. The research prospect of drug-targeted delivery systems for glioma is also discussed.
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Affiliation(s)
- Jie Li
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, People’s Republic of China
- Holistic Integrative Pharmacy Institutes, Hangzhou Normal University, Hangzhou, Zhejiang, People’s Republic of China
- Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
- Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
| | - Jiaqian Zhao
- Holistic Integrative Pharmacy Institutes, Hangzhou Normal University, Hangzhou, Zhejiang, People’s Republic of China
- Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
- Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
- College of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Tiantian Tan
- Holistic Integrative Pharmacy Institutes, Hangzhou Normal University, Hangzhou, Zhejiang, People’s Republic of China
- Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
- Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
| | - Mengmeng Liu
- Holistic Integrative Pharmacy Institutes, Hangzhou Normal University, Hangzhou, Zhejiang, People’s Republic of China
- Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
- Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
| | - Zhaowu Zeng
- Holistic Integrative Pharmacy Institutes, Hangzhou Normal University, Hangzhou, Zhejiang, People’s Republic of China
- Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
- Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
| | - Yiying Zeng
- Holistic Integrative Pharmacy Institutes, Hangzhou Normal University, Hangzhou, Zhejiang, People’s Republic of China
- Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
- Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
| | - Lele Zhang
- School of Medicine, Chengdu University, Chengdu, People’s Republic of China
| | - Chaomei Fu
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, People’s Republic of China
| | - Dajing Chen
- Holistic Integrative Pharmacy Institutes, Hangzhou Normal University, Hangzhou, Zhejiang, People’s Republic of China
- Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
- Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
| | - Tian Xie
- Holistic Integrative Pharmacy Institutes, Hangzhou Normal University, Hangzhou, Zhejiang, People’s Republic of China
- Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
- Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
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Lynagh R, Ishak M, Georges J, Lopez D, Osman H, Kakareka M, Boyer B, Goldman HW, Eschbacher J, Preul MC, Nakaji P, Turtz A, Yocom S, Appelt D. Fluorescence-guided stereotactic biopsy: a proof-of-concept study. J Neurosurg 2020. [DOI: 10.3171/2018.11.jns18629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVEAccurate histopathological diagnoses are often necessary for treating neuro-oncology patients. However, stereotactic biopsy (STB), a common method for obtaining suspicious tissue from deep or eloquent brain regions, fails to yield diagnostic tissue in some cases. Failure to obtain diagnostic tissue can delay initiation of treatment and may result in further invasive procedures for patients. In this study, the authors sought to determine if the coupling of in vivo optical imaging with an STB system is an effective method for identification of diagnostic tissue at the time of biopsy.METHODSA minimally invasive fiber optic imaging system was developed by coupling a 0.65-mm-diameter coherent fiber optic fluorescence microendoscope to an STB system. Human U251 glioma cells were transduced for stable expression of blue fluorescent protein (BFP) to produce U251-BFP cells that were utilized for in vitro and in vivo experiments. In vitro, blue fluorescence was confirmed, and tumor cell delineation by fluorescein sodium (FNa) was quantified with fluorescence microscopy. In vivo, transgenic athymic rats implanted with U251-BFP cells (n = 4) were utilized for experiments. Five weeks postimplantation, the rats received 5–10 mg/kg intravenous FNa and underwent craniotomies overlying the tumor implantation site and contralateral normal brain. A clinical STB needle containing our 0.65-mm imaging fiber was passed through each craniotomy and images were collected. Fluorescence images from regions of interest ipsilateral and contralateral to tumor implantation were obtained and quantified.RESULTSLive-cell fluorescence imaging confirmed blue fluorescence from transduced tumor cells and revealed a strong correlation between tumor cells quantified by blue fluorescence and FNa contrast (R2 = 0.91, p < 0.001). Normalized to background, in vivo FNa-mediated fluorescence intensity was significantly greater from tumor regions, verified by blue fluorescence, compared to contralateral brain in all animals (301.7 ± 34.18 relative fluorescence units, p < 0.001). Fluorescence intensity measured from the tumor margin was not significantly greater than that from normal brain (p = 0.89). Biopsies obtained from regions of strong fluorescein contrast were histologically consistent with tumor.CONCLUSIONSThe authors found that in vivo fluorescence imaging with an STB needle containing a submillimeter-diameter fiber optic fluorescence microendoscope provided direct visualization of neoplastic tissue in an animal brain tumor model prior to biopsy. These results were confirmed in vivo with positive control cells and by post hoc histological assessment. In vivo fluorescence guidance may improve the diagnostic yield of stereotactic biopsies.
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Affiliation(s)
- Robert Lynagh
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Mark Ishak
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Joseph Georges
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Danielle Lopez
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Hany Osman
- Massachusetts General Hospital, Wellman Center for Photomedicine, Boston, Massachusetts
| | - Michael Kakareka
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Brandon Boyer
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - H. Warren Goldman
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
- Department of Neurosurgery, Cooper University Hospital, Camden, New Jersey; and
| | | | - Mark C. Preul
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Alan Turtz
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
- Department of Neurosurgery, Cooper University Hospital, Camden, New Jersey; and
| | - Steven Yocom
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
- Department of Neurosurgery, Cooper University Hospital, Camden, New Jersey; and
| | - Denah Appelt
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
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O'Connell K, Romo CG, Grossman SA. Brain Metastases as a First Site of Recurrence in Patients Receiving Chemotherapy with Controlled Systemic Cancer: a Critical but Under-Recognized Clinical Scenario. Curr Treat Options Neurol 2019; 21:55. [PMID: 31707548 DOI: 10.1007/s11940-019-0598-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW As the treatment of many malignancies has improved, brain metastases (BM) have been observed as a site of the first recurrence in patients with controlled systemic cancers. This suggests that while the administered chemotherapy is effective against systemic cancer, drug concentrations in the central nervous system (CNS) are likely too low to be effective. These findings are in accord with data suggesting that more than 98% of FDA-approved drugs on the market today are unable to cross the blood-brain barrier (BBB). RECENT FINDINGS This retrospective literature review was conducted to estimate the proportion of patients with non-small lung cancer, breast cancer, and melanoma who develop BM as their initial site of recurrence while their systemic cancers are well controlled. Of 267 studies screened, 12 studies fit criteria for inclusion. These 12 studies reported on 923 patients. According to compiled data across these studies, 16% of patients on chemotherapy with stable or responding systemic cancer developed isolated BM as their initial site of relapse. These findings strongly suggest that while chemotherapy controlled systemic cancer, drug concentrations within the CNS were low enough to allow disease progression. Ultimately, reducing the incidence of BM in these patients will require novel therapeutic approaches that facilitate drug entry through an intact BBB early in their treatment.
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Affiliation(s)
- Kaelin O'Connell
- The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Hospital, 401 N. Broadway, Baltimore, MD, 21287, USA. .,Brain Cancer Program, The Johns Hopkins Comprehensive Cancer Center, 201 North Broadway, Room 9178, Baltimore, MD, 21287, USA.
| | - Carlos G Romo
- The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Hospital, 401 N. Broadway, Baltimore, MD, 21287, USA
| | - Stuart A Grossman
- The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Hospital, 401 N. Broadway, Baltimore, MD, 21287, USA.,Brain Cancer Program, The Johns Hopkins Comprehensive Cancer Center, 201 North Broadway, Room 9178, Baltimore, MD, 21287, USA
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Mendes M, Sousa JJ, Pais A, Vitorino C. Targeted Theranostic Nanoparticles for Brain Tumor Treatment. Pharmaceutics 2018; 10:E181. [PMID: 30304861 PMCID: PMC6321593 DOI: 10.3390/pharmaceutics10040181] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/21/2018] [Accepted: 09/27/2018] [Indexed: 12/13/2022] Open
Abstract
The poor prognosis and rapid recurrence of glioblastoma (GB) are associated to its fast-growing process and invasive nature, which make difficult the complete removal of the cancer infiltrated tissues. Additionally, GB heterogeneity within and between patients demands a patient-focused method of treatment. Thus, the implementation of nanotechnology is an attractive approach considering all anatomic issues of GB, since it will potentially improve brain drug distribution, due to the interaction between the blood⁻brain barrier and nanoparticles (NPs). In recent years, theranostic techniques have also been proposed and regarded as promising. NPs are advantageous for this application, due to their respective size, easy surface modification and versatility to integrate multiple functional components in one system. The design of nanoparticles focused on therapeutic and diagnostic applications has increased exponentially for the treatment of cancer. This dual approach helps to understand the location of the tumor tissue, the biodistribution of nanoparticles, the progress and efficacy of the treatment, and is highly useful for personalized medicine-based therapeutic interventions. To improve theranostic approaches, different active strategies can be used to modulate the surface of the nanotheranostic particle, including surface markers, proteins, drugs or genes, and take advantage of the characteristics of the microenvironment using stimuli responsive triggers. This review focuses on the different strategies to improve the GB treatment, describing some cell surface markers and their ligands, and reports some strategies, and their efficacy, used in the current research.
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Affiliation(s)
- Maria Mendes
- Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal.
- Center for Neurosciences and Cell Biology (CNC), University of Coimbra, 3004-504 Coimbra, Portugal.
| | - João José Sousa
- Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal.
- LAQV, REQUIMTE, Group of Pharmaceutical Technology, 3000-548 Coimbra, Portugal.
| | - Alberto Pais
- Coimbra Chemistry Centre, Department of Chemistry, University of Coimbra, 3004-535 Coimbra, Portugal.
| | - Carla Vitorino
- Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal.
- Center for Neurosciences and Cell Biology (CNC), University of Coimbra, 3004-504 Coimbra, Portugal.
- LAQV, REQUIMTE, Group of Pharmaceutical Technology, 3000-548 Coimbra, Portugal.
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Liu Y, Rao L, Zhang H, Cen Y, Cheng K. Conjugation of vitamin E-TPGS and guar gum to carry borneol for enhancing blood–brain barrier permeability. J Biomater Appl 2018; 33:590-598. [PMID: 30208770 DOI: 10.1177/0885328218799551] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Herb borneol is usually used in clinics for the treatment of central nervous system illness, for its ability of blood–brain barrier permeability, although its poor water solubility and poor bioavailability limit its clinical application to some degree. In this study, we developed a novel nanoparticle combining the benefits of vitamin E d-ɑ-tocopheryl poly(ethylene glycol) succinate (E-TPGS) (or TPGS) and guar gum to get TPGS-g-guar gum as a drug delivery system to carry borneol, which could improve the solubility of borneol and increase the drug-loading capacity efficiently. The results showed that TPGS-g-guar gum nanoparticles delivery system was suitable to carry borneol and release the drug effectively, and TPGS-g-guar gum/borneol nanoparticles would be a potential platform for improving the treatment of central nervous system illness and cerebrovascular disease.
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Affiliation(s)
- Yude Liu
- Department of Cardiovascular, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou, China
| | - Lian Rao
- Department of Cardiovascular, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou, China
| | - Hongguan Zhang
- Department of Cardiovascular, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou, China
| | - Yanyou Cen
- Department of Cardiovascular, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou, China
| | - Kaili Cheng
- Department of Cardiovascular, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou, China
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Toccaceli G, Delfini R, Colonnese C, Raco A, Peschillo S. Emerging Strategies and Future Perspective in Neuro-Oncology Using Transcranial Focused Ultrasonography Technology. World Neurosurg 2018; 117:84-91. [DOI: 10.1016/j.wneu.2018.05.239] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 01/08/2023]
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Attili I, Karachaliou N, Conte P, Bonanno L, Rosell R. Therapeutic approaches for T790M mutation positive non-small-cell lung cancer. Expert Rev Anticancer Ther 2018; 18:1021-1030. [PMID: 30079781 DOI: 10.1080/14737140.2018.1508347] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Epidermal growth factor receptor (EGFR) mutation positive non-small cell lung cancer (NSCLC) is a subset of lung cancer with demonstrated response to targeted therapies. However, resistance to the first targeted approach usually occurs within the first year, and it is associated in 50-60% of cases to the T790M resistance mutation. Areas covered: The review provides an overview on the significance of the presence of the T790M mutation, its detection, treatment options and subsequent mechanisms of resistance. Expert commentary: Osimertinib is the current treatment option for T790M mutation positive NSCLC after progression to first or second-generation EGFR TKIs, with activity also on brain metastasis. However, the scenario is in continuous evolution and results from clinical trials are awaited in first-line setting and in combination strategies.
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Affiliation(s)
- Ilaria Attili
- a Department of Surgical, Oncological and Gastroenterological Sciences , University of Padova , Padova , Italy
| | - Niki Karachaliou
- b Instituto Oncológico Dr Rosell (IOR) , University Hospital Sagrat Cor , Barcelona , Spain.,c Coyote Research Group, Pangaea Oncology, Laboratory of Molecular Biology , Quirón-Dexeus University Institute , Barcelona , Spain
| | - PierFranco Conte
- a Department of Surgical, Oncological and Gastroenterological Sciences , University of Padova , Padova , Italy
| | - Laura Bonanno
- d Medical Oncology 2 , Istituto Oncologico Veneto, IRCCS , Padova , Italy
| | - Rafael Rosell
- c Coyote Research Group, Pangaea Oncology, Laboratory of Molecular Biology , Quirón-Dexeus University Institute , Barcelona , Spain.,e Institut d'Investigació en Ciències Germans Trias i Pujol , Badalona , Spain.,f Instituto Oncológico Dr Rosell (IOR) , Quirón-Dexeus University Institute , Barcelona , Spain.,g Institut Català d'Oncologia , Hospital Germans Trias i Pujol , Badalona , Spain
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