Tumor treating fields for high-grade gliomas

High costs, low quality of life, reduced survival, and room for improving treatment: an analysis of burden and unmet needs in glioma

Gliomas are a group of heterogeneous tumors that account for substantial morbidity, mortality, and costs to patients and healthcare systems globally. Survival varies considerably by grade, histology, biomarkers, and genetic alterations such as IDH mutations and MGMT promoter methylation, and treatment, but is poor for some grades and histologies, with many patients with glioblastoma surviving less than a year from diagnosis. The present review provides an introduction to glioma, including its classification, epidemiology, economic and humanistic burden, as well as treatment options. Another focus is on treatment recommendations for IDH-mutant astrocytoma, IDH-mutant oligodendroglioma, and glioblastoma, which were synthesized from recent guidelines. While recommendations are nuanced and reflect the complexity of the disease, maximum safe resection is typically the first step in treatment, followed by radiotherapy and/or chemotherapy using temozolomide or procarbazine, lomustine, and vincristine. Immunotherapies and targeted therapies currently have only a limited role due to disappointing clinical trial results, including in recurrent glioblastoma, for which the nitrosourea lomustine remains the de facto standard of care. The lack of treatment options is compounded by frequently suboptimal clinical practice, in which patients do not receive adequate therapy after resection, including delayed, shortened, or discontinued radiotherapy and chemotherapy courses due to treatment side effects. These unmet needs will require significant efforts to address, including a continued search for novel treatment options, increased awareness of clinical guidelines, improved toxicity management for chemotherapy, and the generation of additional and more robust clinical and health economic evidence.

Efficacy of tumour-treating fields therapy in recurrent glioblastoma: A narrative review of current evidence

Recurrent Glioblastoma presents a formidable challenge in oncology due to its aggressive nature and limited treatment options. Tumour-Treating Fields (TTFields) Therapy, a novel therapeutic modality, has emerged as a promising approach to address this clinical conundrum. This review synthesizes the current evidence surrounding the efficacy of TTFields Therapy in the context of recurrent Glioblastoma. Diverse academic databases were explored to identify relevant studies published within the last decade. Strategic keyword selection facilitated the inclusion of studies focusing on TTFields Therapy's efficacy, treatment outcomes, and patient-specific factors. The review reveals a growing body of evidence suggesting the potential clinical benefits of TTFields Therapy for patients with recurrent Glioblastoma. Studies consistently demonstrate its positive impact on overall survival (OS) and progression-free survival (PFS). The therapy's safety profile remains favorable, with mild to moderate skin reactions being the most commonly reported adverse events. Our analysis highlights the importance of patient selection criteria, with emerging biomarkers such as PTEN mutation status influencing therapy response. Additionally, investigations into combining TTFields Therapy with other treatments, including surgical interventions and novel approaches, offer promising avenues for enhancing therapeutic outcomes. The synthesis of diverse studies underscores the potential of TTFields Therapy as a valuable addition to the armamentarium against recurrent Glioblastoma. The narrative review comprehensively explains the therapy's mechanisms, clinical benefits, adverse events, and future directions. The insights gathered herein serve as a foundation for clinicians and researchers striving to optimize treatment strategies for patients facing the challenging landscape of recurrent Glioblastoma.

Comparative dosimetric study of radiotherapy in high-grade gliomas based on the guidelines of EORTC and NRG-2019 target delineation

Purpose

Radiotherapy is one of the most important treatments for high-grade glioma (HGG), but the best way to delineate the target areas for radiotherapy remains controversial, so our aim was to compare the dosimetric differences in radiation treatment plans generated based on the European Organization for Research and Treatment of Cancer (EORTC) and National Research Group (NRG) consensus to provide evidence for optimal target delineation for HGG.

Methods

We prospectively enrolled 13 patients with a confirmed HGG from our hospital and assessed dosimetric differences in radiotherapy treatment plans generated according to the EORTC and NRG-2019 guidelines. For each patient, two treatment plans were generated. Dosimetric parameters were compared by dose-volume histograms for each plan.

Results

The median volume for planning target volume (PTV) of EORTC plans, PTV1 of NRG-2019 plans, and PTV2 of NRG-2019 plans were 336.6 cm³ (range, 161.1-511.5 cm³), 365.3 cm³ (range, 123.4-535.0 cm³), and 263.2 cm³ (range, 116.8-497.7 cm³), respectively. Both treatment plans were found to have similar efficiency and evaluated as acceptable for patient treatment. Both treatment plans showed well conformal index and homogeneity index and were not statistically significantly different (P = 0.397 and P = 0.427, respectively). There was no significant difference in the volume percent of brain irradiated to 30, 46, and 60 Gy according to different target delineations (P = 0.397, P = 0.590, and P = 0.739, respectively). These two plans also showed no significant differences in the doses to the brain stem, optic chiasm, left and right optic nerves, left and right lens, left and right eyes, pituitary, and left and right temporal lobes (P = 0.858, P = 0.858, P = 0.701 and P = 0.794, P = 0.701 and P = 0.427, P = 0.489 and P = 0.898, P = 0.626, and P = 0.942 and P = 0.161, respectively).

Conclusion

The NRG-2019 project did not increase the dose of organs at risk (OARs) radiation. This is a significant finding that further lays the groundwork for the application of the NRG-2019 consensus in the treatment of patients with HGGs.

Clinical trial registration

The effect of radiotherapy target area and glial fibrillary acidic protein (GFAP) on the prognosis of high-grade glioma and its mechanism, number ChiCTR2100046667. Registered 26 May 2021.

TTFields Prolonged the PFS of Epithelioid Glioblastoma Patient: A Case Report

Epithelioid glioblastoma (EGBM, classified as glioblastoma, IDH wild type, grade 4 according to the fifth edition of the World Health Organization (WHO) Classification of Tumors of the Central Nervous System (CNS) (WHO CNS5)) is a highly aggressive malignancy, with a median progression-free survival (mPFS) of about 6 months in adults. The application of tumor-treating fields (TTFields, possessing anti-cancer capabilities via anti-mitotic effects) in the maintenance of temozolomide (TMZ) chemotherapy showed a benefit for prolonging the mPFS of newly diagnosed glioblastoma (GBM) for patients for up to 6.9 months in the EF-14 clinical trial (NCT00916409). However, studies focusing on the effect of TTFields in EGBM treatment are very limited due to the rarity of EGBM. Here, we have reported a case of a 28-year-old male (recurrent left-sided limb twitching for 1 month and dizziness for 1 week) diagnosed with EGBM. A right frontal lobe occupancy was detected by magnetic resonance imaging (MRI), and a total tumor resection was performed. Meanwhile, a postoperative histopathology test, including immunohistochemistry and molecular characterization, was conducted, and the results revealed a BRAF V600E mutation, no co-deletion of 1p and 19q, and negative O-6-methylguanine DNA methyltransferase (MGMT) promoter methylation. Then, chemoradiotherapy was conducted, and TTFields and TMZ were performed sequentially. Notably, a long-term PFS of 34 months and a Karnofsky Performance Scale (KPS) of 90 were achieved by the patient on TTFields combined with TMZ, whose average daily usage of TTFields was higher than 90%.

Highlighted Advances in Therapies for Difficult-To-Treat Brain Tumours Such as Glioblastoma

Glioblastoma multiforme (GBM) remains a challenging disease, as it is the most common and deadly brain tumour in adults and has no curative solution and an overall short survival time. This incurability and short survival time means that, despite its rarity (average incidence of 3.2 per 100,000 persons), there has been an increased effort to try to treat this disease. Standard of care in newly diagnosed glioblastoma is maximal tumour resection followed by initial concomitant radiotherapy and temozolomide (TMZ) and then further chemotherapy with TMZ. Imaging techniques are key not only to diagnose the extent of the affected tissue but also for surgery planning and even for intraoperative use. Eligible patients may combine TMZ with tumour treating fields (TTF) therapy, which delivers low-intensity and intermediate-frequency electric fields to arrest tumour growth. Nonetheless, the blood–brain barrier (BBB) and systemic side effects are obstacles to successful chemotherapy in GBM; thus, more targeted, custom therapies such as immunotherapy and nanotechnological drug delivery systems have been undergoing research with varying degrees of success. This review proposes an overview of the pathophysiology, possible treatments, and the most (not all) representative examples of the latest advancements.

Mechanism of RIP2 enhancing stemness of glioma cells induces temozolomide resistance

AIMS

We aimed to investigate the role of receptor-interacting protein 2 (RIP2) in regulation of stemness of glioma cells and chemotherapy resistance.

METHODS

Plasmid transfection was used to overexpress RIP2. Chemical inhibitors were used to inhibit RIP2 or NF-κB activity. Cancer stemness of glioma cells was investigated by sphere formation assays, clone formation assays, and xenograft tumor formation assays. The expression of RIP2, p-NF-κB, IκBα, CD133, or SOX-2 was detected by Western blotting and immunofluorescence. Apoptosis was detected by flow cytometry. Immunohistochemical staining was used to detect the expression of RIP2, CD133, and SOX-2 in xenograft tumor tissue. The effect of the RIP2/NF-κB pathway on temozolomide (TMZ) resistance was evaluated by xenograft tumor assay.

RESULTS

Transfection with RIP2 plasmid enhanced the sphere formation capability of U251 cells, clone formation capability, and xenograft tumor formation capability. RIP2 could mediate TMZ resistance by upregulating the expression of CD133 and SOX-2 by activating the NF-κB pathway. Both RIP2 inhibitor GSK583 and the NF-κB inhibitor SC75741 could reverse the resistance of U251 cells to TMZ.

CONCLUSION

RIP2 mediates TMZ resistance by regulating the maintenance of stemness in glioma cells through NF-κB. Interventions targeting the RIP2/NF-κB pathway may be a new strategy for TMZ-resistant gliomas.

Glioma stem cell signature predicts the prognosis and the response to tumor treating fields treatment

INTRODUCTION

Glioma stem cells (GSCs) play an important role in glioma recurrence and chemo-radiotherapy (CRT) resistance. Currently, there is a lack of efficient treatment approaches targeting GSCs. This study aimed to explore the potential personalized treatment of patients with GSC-enriched gliomas.

METHODS

Single-cell RNA sequencing (scRNA-seq) was used to identify the GSC-related genes. Then, machine learning methods were applied for clustering and validation. The least absolute shrinkage and selection operator (LASSO) and COX regression were used to construct the risk scores. Survival analysis was performed. Additionally, the incidence of chemo-radiotherapy resistance, immunotherapy status, and tumor treating field (TTF) therapy response were evaluated in high- and low-risk scores groups.

RESULTS

Two GSC clusters exhibited significantly different stemness indices, immune microenvironments, and genomic alterations. Based on GSC clusters, 11-gene GSC risk scores were constructed, which exhibited a high predictive value for prognosis. In terms of therapy, patients with high GSC risk scores had a higher risk of resistance to chemotherapy. TTF therapy can comprehensively inhibit the malignant biological characteristics of the high GSC-risk-score gliomas.

CONCLUSION

Our study constructed a GSC signature consisting of 11 GSC-specific genes and identified its prognostic value in gliomas. TTF is a promising therapeutic approach for patients with GSC-enriched glioma.

Whole transcriptome and proteome analyses identify potential targets and mechanisms underlying tumor treating fields against glioblastoma

Glioblastoma (GBM) is one of the most malignant types of brain cancer. Tumor treating fields (TTFields) is the up-to-date treatment for GBM. However, its molecular mechanism requires additional investigation. Herein, a novel TTFields system was developed (CL-301A) and its efficiency in suppressing GBM cell proliferation and inducing cell apoptosis was demonstrated. Through the whole proteomic and transcriptomic analyses, a multitude of differentially expressed proteins (1243), mRNAs (4191), miRtNAs (47), lncRNAs (4286), and circRNAs (13,903) were identified. Bioinformatic analysis indicated that TTFields mainly affected nuclear proteins and interrupt cell mitosis-related events. Moreover, the inhibition of autophagy could significantly enhance the anti-GBM activity of TTFields. And CDK2-AS1 might be a target of TTFields to mediate cell cycle arrest via regulating CDK2 mRNA stability. This study provided valuable resources for understanding the mechanism of TTFields, which might further assist the investigation of TTFields in GBM treatment.

Overexpression of NNMT in Glioma Aggravates Tumor Cell Progression: An Emerging Therapeutic Target

Simple Summary

Glioma is one of the most common intracranial malignancies and is incurable due to strong aggressiveness and resistance to radiotherapy and chemotherapy. The lack of effective therapeutic targets is a major problem in current treatment. In the present study, we found that nicotinamide N-methyltransferase (NNMT) is a key factor influencing the occurrence and development of glioma. High NNMT expression in glioma is a predictor of short overall survival and poor patient outcome. NNMT knockdown reduced the volume of mice xenograft glioma and the viability of glioma cells. Additionally, overexpression of NNMT epigenetically silenced GAP43 through DNA methylation, histone methylation, and deacetylation modification processes. GAP43 can inhibit the formation of microtubules in tumor and intertumor cell network connections and induce apoptosis through the SIRT1 signaling pathway. Therefore, NNMT could be a potential candidate for the clinical diagnosis and treatment of glioma.

Abstract

Purpose: Increasing evidence has revealed that nicotinamide N-methyltransferase (NNMT) is a key factor influencing the prognosis of tumors. The present study aimed to investigate the role of NNMT in glioma and to elucidate the associated functional mechanisms. Methods: Clinical samples were analyzed by immunohistochemical staining and Western blotting to evaluate NNMT expression in glioma and normal brain tissues. The correlation between NNMT expression and glioma was analyzed using the Cancer Genome Atlas (TCGA) database. Additionally, NNMT was knocked down in two types of glioma cells, U87 and U251, to evaluate the invasive ability of these cells. Quantitative real-time polymerase chain reaction (qRT-PCR) was used to validate NNMT knockdown in the cells. Furthermore, ELISA was used to determine the balance between nicotinamide adenine dinucleotide and nicotinamide adenine dinucleotide hydrogen (NAD/NADH ratio), which verified the altered methylation patterns in the cells. The glioma xenograft mouse models were used to verify the regulatory role of NNMT, GAP43, and SIRT1. Results: Analysis based on our clinical glioma samples and TCGA database revealed that overexpression of NNMT was associated with poor prognosis of patients. Knockdown of NNMT reduced the invasive ability of glioma cells, and downregulation of its downstream protein GAP43 occurred due to altered cellular methylation caused by NNMT overexpression. Gene Set Enrichment Analysis confirmed that NNMT modulated the NAD-related signaling pathway and showed a negative association between NNMT and SIRT1. Moreover, the regulatory roles of NNMT, GAP43, and SIRT1 were confirmed in glioma xenograft mouse models. Conclusion: Overexpression of NNMT causes abnormal DNA methylation through regulation of the NAD/NADH ratio, which in turn leads to the downregulation of GAP43 and SIRT1, eventually altering the biological behavior of tumor cells.

Expression and Potential Biomarkers of Regulators for M7G RNA Modification in Gliomas

Gliomas are the most frequent primary malignant brain tumors of the central nervous system, causing significant impairment and death. There is mounting evidence that N7 methylguanosine (m7G) RNA dysmethylation plays a significant role in the development and progression of cancer. However, the expression patterns and function of the m7G RNA methylation regulator in gliomas are yet unknown. The goal of this study was to examine the expression patterns of 31 critical regulators linked with m7G RNA methylation and their prognostic significance in gliomas. To begin, we systematically analyzed patient clinical and prognostic data and mRNA gene expression data from The Cancer Genome Atlas (TCGA) and the Gene Expression Omnibus (GEO) databases. We found that 17 key regulators of m7G RNA methylation showed significantly higher expression levels in gliomas. We then divided the sample into two subgroups by consensus clustering. Cluster 2 had a poorer prognosis than cluster 1 and was associated with a higher histological grade. In addition, cluster 2 was significantly enriched for cancer-related pathways. Based on this discovery, we developed a risk model involving three m7G methylation regulators. Patients were divided into high-risk and low-risk groups based on risk scores. Overall survival (OS) was significantly lower in the high-risk group than in the low-risk group. Further analysis showed that the risk score was an independent prognostic factor for gliomas.

The Role of m5C-Related lncRNAs in Predicting Overall Prognosis and Regulating the Lower Grade Glioma Microenvironment

Glioma is the most lethal primary brain tumor with a poor prognosis and high recurrence rate. Enormous efforts have been made to find therapeutic targets for gliomas. In the current study, we identified m5C-related lncRNAs through Pearson correlation analysis by the criteria |R|>0.5 and p<0.001 in TCGA LGG and CGGA325 datasets. We then established an eight-lncRNA m5C-related prognostic signature (m5C LPS) through lasso cox regression analysis and multivariate analysis. The performance of the signature was confirmed in the CGGA325 dataset and evaluated in differential subgroups divided by relevant clinicopathological characteristics. Patients were then divided into high and low risk groups using risk scores calculated with the signature. Next, we performed GO, KEGG and gene set enrichment analysis (GSEA) and identified the m5C LPS to be related with glioma microenvironment, immune response, EMT, cell cycle, and hypoxia. Correlation of the risk groups with immune cell infiltration, somatic mutation, and CNVs was then explored. Responses to immuno- and chemotherapies in different risk groups were evaluated using submap and pRRophetic R packages respectively. The high-risk group was more sensitive to anti-CTLA4 therapy and to compounds including Temozolomide, Bleomycin, Cisplatin, Cyclopamine, A.443654 (Akt inhibitor), AZD6482 (PI3K inhibitor), GDC0941(PI3K inhibitor), and metformin. We present for the first time a m5C-related lncRNA signature for lower grade glioma patient prognosis and therapy response prediction with validated performance, providing a promising target for future research.

Treatment Response and Prognosis Evaluation in High-Grade Glioma: An Imaging Review Based on MRI

In recent years, the development of advanced magnetic resonance imaging (MRI) technology and machine learning (ML) have created new tools for evaluating treatment response and prognosis of patients with high-grade gliomas (HGG); however, patient prognosis has not improved significantly. This is mainly due to the heterogeneity between and within HGG tumors, resulting in standard treatment methods not benefitting all patients. Moreover, the survival of patients with HGG is not only related to tumor cells, but also to noncancer cells in the tumor microenvironment (TME). Therefore, during preoperative diagnosis and follow-up treatment of patients with HGG, noninvasive imaging markers are needed to characterize intratumoral heterogeneity, and then to evaluate treatment response and predict prognosis, timeously adjust treatment strategies, and achieve individualized diagnosis and treatment. In this review, we summarize the research progress of conventional MRI, advanced MRI technology, and ML in evaluation of treatment response and prognosis of patients with HGG. We further discuss the significance of the TME in the prognosis of HGG patients, associate imaging features with the TME, indirectly reflecting the heterogeneity within the tumor, and shifting treatment strategies from tumor cells alone to systemic therapy of the TME, which may be a major development direction in the future. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY STAGE: 4.

The Role of Graphene Oxide Nanocarriers in Treating Gliomas

Gliomas are the most common primary malignant tumors of the central nervous system, and their conventional treatment involves maximal safe surgical resection combined with radiotherapy and temozolomide chemotherapy; however, this treatment does not meet the requirements of patients in terms of survival and quality of life. Graphene oxide (GO) has excellent physical and chemical properties and plays an important role in the treatment of gliomas mainly through four applications, viz. direct killing, drug delivery, immunotherapy, and phototherapy. This article reviews research on GO nanocarriers in the treatment of gliomas in recent years and also highlights new ideas for the treatment of these tumors.

Tumor-Treating Fields: A fourth modality in cancer treatment, new practice updates

Although major innovations in treatment are advancing, cancer persists as one of the leading causes of mortality. With the rising incidence of cancer and as we treat them, patients incur short term and long-term toxicities of current traditional therapies, including chemotherapy. This imposes a significant physical, emotional, and financial burden among patients, which affects their quality of life. Tumor-Treating Fields (TTFields) is a novel innovative new treatment modality that utilizes alternating electric fields at specific intermediate frequencies to diminish tumor growth by inhibiting mitosis and thus proliferation of malignant cells. The distinguishing feature of this new treatment modality is that it is noninvasive and tolerable. In fact, TTFields is currently FDA approved for the treatment of glioblastoma multiforme (GBM) as well as malignant pleural mesothelioma (MPM). Recently, TTFields have also been found to affect immunogenic cell death resulting in stronger anti-neoplastic effects. In this review, we discuss the mechanism of action of TTFields, the plethora of clinical trials being conducted in patients with GBM, pancreatic adenocarcinoma, ovarian cancer, non-small-cell-lung-cancer (NSCLC), brain metastasis from NSCLC, and MPM and toxicity profile.

An insight into the risk factors of brain tumors and their therapeutic interventions

Brain tumors are an abnormal growth of cells in the brain, also known as multifactorial groups of neoplasm. Incidence rates of brain tumors increase rapidly, and it has become a leading cause of tumor related deaths globally. Several factors have potential risks for intracranial neoplasm. To date, the International Agency for Research on Cancer has classified the ionizing radiation and the N-nitroso compounds as established carcinogens and probable carcinogens respectively. Diagnosis of brain tumors is based on histopathology and suitable imaging techniques. Labeled amino acids and fluorodeoxyglucose with or without contrast-enhanced MRI are used for the evaluation of tumor traces. T2-weighted MRI is an advanced diagnostic implementation, used for the detection of low-grade gliomas. Treatment decisions are based on tumor size, location, type, patient's age and health status. Conventional therapeutic approaches for tumor treatment are surgery, radiotherapy and chemotherapy. While the novel strategies may include targeted therapy, electric field treatments and vaccine therapy. Inhibition of cyclin-dependent kinase inhibitors is an attractive tumor mitigation strategy for advanced-stage cancers; in the future, it may prove to be a useful targeted therapy. The blood-brain barrier poses a major hurdle in the transport of therapeutics towards brain tissues. Moreover, nanomedicine has gained a vital role in cancer therapy. Nano drug delivery system such as liposomal drug delivery has been widely used in the cancer treatment. Liposome encapsulated drugs have improved therapeutic efficacy than free drugs. Numerous treatment therapies for brain tumors are in advanced clinical research.

Challenges and Perspectives of Standard Therapy and Drug Development in High-Grade Gliomas

Despite their low incidence rate globally, high-grade gliomas (HGG) remain a fatal primary brain tumor. The recommended therapy often is incapable of resecting the tumor entirely and exclusively targeting the tumor leads to tumor recurrence and dismal prognosis. Additionally, many HGG patients are not well suited for standard therapy and instead, subjected to a palliative approach. HGG tumors are highly infiltrative and the complex tumor microenvironment as well as high tumor heterogeneity often poses the main challenges towards the standard treatment. Therefore, a one-fit-approach may not be suitable for HGG management. Thus, a multimodal approach of standard therapy with immunotherapy, nanomedicine, repurposing of older drugs, use of phytochemicals, and precision medicine may be more advantageous than a single treatment model. This multimodal approach considers the environmental and genetic factors which could affect the patient's response to therapy, thus improving their outcome. This review discusses the current views and advances in potential HGG therapeutic approaches and, aims to bridge the existing knowledge gap that will assist in overcoming challenges in HGG.

New 3β-hydroxysteroid-indolamine conjugates: Design, synthesis and inhibition of C6 glioma cell proliferation

Four novel indole steroids based on dehydroepiandrosterone (IS-1), estrone (IS-2) and pregnenolone (IS-3) were obtained and studied for their ability to inhibit C6 glioma proliferation. A reduction in cell proliferation by 52 ± 13% was observed for IS-1 at 10 μM, whereas IS-3 and abiraterone acetate at 10 μM caused a 36 ± 8% decrease. Surprisingly, the cellular effects reported for abiraterone, namely, cytochrome P450 CYP17A1 inhibition and endoplasmic reticulum stress were not detected for IS-1. However, both abiraterone and IS-1 significantly increased glutathione levels. Docking studies predicted good affinity of IS-1 to liver X receptors and regulatory protein Keap1, which are proposed to be involved in the compounds' antiproliferative activity.