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Ermiş E, Althaus A, Blatti M, Uysal E, Leiser D, Norouzi S, Riggenbach E, Hemmatazad H, Ahmadli U, Wagner F. Therapy Resistance of Glioblastoma in Relation to the Subventricular Zone: What Is the Role of Radiotherapy? Cancers (Basel) 2023; 15:cancers15061677. [PMID: 36980563 PMCID: PMC10046464 DOI: 10.3390/cancers15061677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/02/2023] [Accepted: 03/05/2023] [Indexed: 03/12/2023] Open
Abstract
Glioblastoma is a highly heterogeneous primary malignant brain tumor with marked inter-/intratumoral diversity and a poor prognosis. It may contain a population of neural stem cells (NSC) and glioblastoma stem cells that have the capacity for migration, self-renewal and differentiation. While both may contribute to resistance to therapy, NSCs may also play a role in brain tissue repair. The subventricular zone (SVZ) is the main reservoir of NSCs. This study investigated the impact of bilateral SVZ radiation doses on patient outcomes. We included 147 patients. SVZs were delineated and the dose administered was extracted from dose–volume histograms. Tumors were classified based on their spatial relationship to the SVZ. The dose and outcome correlations were analyzed using the Kaplan–Meier and Cox proportional hazards regression methods. Median progression-free survival (PFS) was 7 months (range: 4–11 months) and median overall survival (OS) was 14 months (range: 9–23 months). Patients with an ipsilateral SVZ who received ≥50 Gy showed significantly better PFS (8 versus 6 months; p < 0.001) and OS (16 versus 11 months; p < 0.001). Furthermore, lower doses (<32 Gy) to the contralateral SVZ were associated with improved PFS (8 versus 6 months; p = 0.030) and OS (15 versus 11 months; p = 0.001). Targeting the potential tumorigenic cells in the ipsilateral SVZ while sparing contralateral NSCs correlated with an improved outcome. Further studies should address the optimization of dose distribution with modern radiotherapy techniques for the areas surrounding infiltrated and healthy SVZs.
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Affiliation(s)
- Ekin Ermiş
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Correspondence:
| | - Alexander Althaus
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Marcela Blatti
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Emre Uysal
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Dominic Leiser
- Center for Proton Therapy, Paul Scherrer Institute, 5232 Villigen, Switzerland
| | - Shokoufe Norouzi
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Elena Riggenbach
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Hossein Hemmatazad
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Uzeyir Ahmadli
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Franca Wagner
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
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Basu Achari R, Chakraborty S, Goyal L, Saha S, Roy P, Zameer L, Mishra D, Parihar M, Das A, Chandra A, Biswas B, Mallick I, Arunsingh MA, Chatterjee S, Bhattacharyya T. Evaluating Quality Indicators of Glioblastoma Care: Audit Results From an Indian Tertiary Care Cancer Center. JCO Glob Oncol 2022; 8:e2100405. [PMID: 35298293 PMCID: PMC8955054 DOI: 10.1200/go.21.00405] [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] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There are limited reports of quality metrics in glioblastoma. We audited our adherence to quality indicators as proposed in the PRIME Quality Improvement study. METHODS This is a retrospective audit of patients treated between 2017 and 2020. After postsurgical integrated diagnosis, patients received radiotherapy (RT) with concurrent and adjuvant temozolomide (TMZ). Multiparametric magnetic resonance imaging at predefined times guided management. Numbers with proportions for indices were calculated. Survival was estimated using the Kaplan-Meier method. RESULTS One hundred six patients were consecutively treated. The median age was 55 years (interquartile range of 47-61 years) with a male preponderance (68%). Ninety-six (90.6%) patients underwent subtotal resection, and 10 (9.4%) biopsy alone. Isocitrate dehydrogenase was wild-type in 96 (91%), and O6-methylguanine-DNA methyltransferase was unmethylated in 70 (66.0%) patients. Telomerase reverse transcriptase promoter was mutated in 64 (60.4%), and TP53 was mutated in 22 (20.8%). Concurrent radiation and TMZ were planned for 104 (98.1%), and radiation alone for 2 (1.9%). The median time to concurrent RT-TMZ was 36 days (interquartile range 30-44 days). All patients planned for RT-TMZ completed treatment, but only 81 (76%) completed adjuvant TMZ. Sixty-three (59%) completed six cycles, 18 (17%) received less than six cycles, and 25 (24%) did not receive adjuvant TMZ. At a median follow-up of 24 months (range 21-31 months), the median (95% CI) progression-free survival and overall survival were 11 (95% CI, 9.4 to 13.0) and 20.0 (95% CI, 15 to 26) months, respectively. CONCLUSION Our patients met quality indices in most domains; outcomes are comparable with global results. Metrics will be periodically evaluated to include new standards and assess continuous service appropriateness.
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Affiliation(s)
- Rimpa Basu Achari
- Department of Radiation Oncology, Tata Medical Center, Kolkata, India
| | | | - Love Goyal
- Department of Radiation Oncology, Tata Medical Center, Kolkata, India
| | - Saheli Saha
- Department of Radiation Oncology, Tata Medical Center, Kolkata, India
| | - Paromita Roy
- Department of Oncopathology, Tata Medical Center, Kolkata, India
| | - Lateef Zameer
- Department of Oncopathology, Tata Medical Center, Kolkata, India
| | - Deepak Mishra
- Department of Laboratory Hematology, Molecular Genetics and Cytogenetics, Tata Medical Center, Kolkata, India
| | - Mayur Parihar
- Department of Laboratory Hematology, Molecular Genetics and Cytogenetics, Tata Medical Center, Kolkata, India
| | - Anirban Das
- Department of Pediatric Oncology, Tata Medical Center, Kolkata, India
| | - Aditi Chandra
- Department of Radiology, Tata Medical Center, Kolkata, India
| | - Bivas Biswas
- Department of Medical Oncology, Tata Medical Center, Kolkata, India
| | - Indranil Mallick
- Department of Radiation Oncology, Tata Medical Center, Kolkata, India
| | - Moses A Arunsingh
- Department of Radiation Oncology, Tata Medical Center, Kolkata, India
| | - Sanjoy Chatterjee
- Department of Radiation Oncology, Tata Medical Center, Kolkata, India
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Bruil DE, David S, Nagtegaal SHJ, de Sonnaville SFAM, Verhoeff JJC. Irradiation of the subventricular zone and subgranular zone in high- and low-grade glioma patients: an atlas-based analysis on overall survival. Neurooncol Adv 2022; 4:vdab193. [PMID: 35128399 PMCID: PMC8809520 DOI: 10.1093/noajnl/vdab193] [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
BACKGROUND Neural stem cells in the subventricular zone (SVZ) and subgranular zone (SGZ) are hypothesized to support growth of glioma. Therefore, irradiation of the SVZ and SGZ might reduce tumor growth and might improve overall survival (OS). However, it may also inhibit the repair capacity of brain tissue. The aim of this retrospective cohort study is to assess the impact of SVZ and SGZ radiotherapy doses on OS of patients with high-grade (HGG) or low-grade (LGG) glioma. METHODS We included 273 glioma patients who received radiotherapy. We created an SVZ atlas, shared openly with this work, while SGZ labels were taken from the CoBrA atlas. Next, SVZ and SGZ regions were automatically delineated on T1 MR images. Dose and OS correlations were investigated with Cox regression and Kaplan-Meier analysis. RESULTS Cox regression analyses showed significant hazard ratios for SVZ dose (univariate: 1.029/Gy, P < .001; multivariate: 1.103/Gy, P = .002) and SGZ dose (univariate: 1.023/Gy, P < .001; multivariate: 1.055/Gy, P < .001) in HGG patients. Kaplan-Meier analysis showed significant correlations between OS and high-/low-dose groups for HGG patients (SVZ: respectively 10.7 months (>30.33 Gy) vs 14.0 months (<30.33 Gy) median OS, P = .011; SGZ: respectively 10.7 months (>29.11 Gy) vs 15.5 months (<29.11 Gy) median OS, P < .001). No correlations between dose and OS were found for LGG patients. CONCLUSION Irradiation doses on neurogenic areas correlate negatively with OS in patients with HGG. Whether sparing of the SVZ and SGZ during radiotherapy improves OS, should be subject of prospective studies.
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Affiliation(s)
- Danique E Bruil
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Szabolcs David
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Steven H J Nagtegaal
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Joost J C Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
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Hallaert G, Pinson H, Van den Broecke C, Sweldens C, Van Roost D, Kalala JP, Boterberg T. Survival impact of incidental subventricular zone irradiation in IDH-wildtype glioblastoma. Acta Oncol 2021; 60:613-619. [PMID: 33689536 DOI: 10.1080/0284186x.2021.1893899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE The subventricular zone (SVZ) is an important niche for neural stem cells but probably also for brain tumor propagating cells, including the glioblastoma stem cell. The SVZ may become a target for radiation therapy in glioblastoma patients. However, reports studying the effect of irradiation of the SVZ on glioblastoma patient survival show conflicting results. We studied the correlation between incidental SVZ radiation dose and survival in a cohort of isocitrate dehydrogenase-wildtype (IDHwt) glioblastoma patients with inclusion of important survival prognosticators. PATIENTS AND METHODS In this retrospective analysis, only adult patients with supratentorial IDHwt glioblastoma were included who were treated with temozolomide-based chemoradiotherapy after surgery. The SVZ was contoured on the radiotherapy planning imaging. Cox proportional regression overall survival (OS) analysis was used to study the correlation between SVZ dose and survival. Age, Karnofsky Performance Score, extent of resection and O6-methylguanine-methyl-DNA-transferase gene promoter (MGMTp) methylation were used as covariates in multivariate analysis. RESULTS In total, 137 patients were included. Median OS was 13.3 months. The MGMTp methylation was present in 40% of cases. Ipsilateral SVZ (iSVZ) mean dose was 44.4 Gy and 27.2 Gy for the contralateral SVZ (cSVZ). Univariate survival analysis showed an inverse relationship between cSVZ mean dose and OS (HR 1.029 (1.003-1.057); p= .032). However, there was no correlation between cSVZ mean dose and OS in multivariate analysis. iSVZ dose did not correlate with survival. CONCLUSION In this cohort of 137 IDHwt glioblastoma patients, iSVZ did not correlate with OS. Higher cSVZ dose was inversely correlated with OS in univariate survival analysis but lost its significance in multivariate analysis, including MGMTp-methylation. Hence, the correlation between SVZ radiation and glioblastoma patient survival remains unclear. Carefully designed prospective studies are needed to provide unequivocal results on this controversial topic.
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Affiliation(s)
- Giorgio Hallaert
- Department of Neurosurgery, Ghent University Hospital, Ghent, Belgium
| | - Harry Pinson
- Department of Neurosurgery, Ghent University Hospital, Ghent, Belgium
| | - Caroline Van den Broecke
- Department of Pathology, AZ St Lucas Gent, Gent, Belgium
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | | | - Dirk Van Roost
- Department of Neurosurgery, Ghent University Hospital, Ghent, Belgium
| | | | - Tom Boterberg
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
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5
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Bender K, Träger M, Wahner H, Onken J, Scheel M, Beck M, Ehret F, Budach V, Kaul D. What is the role of the subventricular zone in radiotherapy of glioblastoma patients? Radiother Oncol 2021; 158:138-145. [PMID: 33636228 DOI: 10.1016/j.radonc.2021.02.017] [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] [Received: 11/01/2020] [Revised: 01/28/2021] [Accepted: 02/13/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND PURPOSE Current glioblastoma (GBM) therapies prolong survival, but overall prognosis is still poor. Irradiation of the subventricular zone (SVZ) has recently been discussed as a promising concept as this tissue harbors stem cells which seem to play a role in the initiation and recurrence of GBM. In this study, we retrospectively examined the relationship of SVZ irradiation dose and survival in a large, homogeneous GBM patient cohort. MATERIALS AND METHODS We included 200 GBM patients who had been treated at our institution with trimodal therapy (surgery, radiotherapy and chemotherapy) between 2009 and 2020. The SVZ was delineated, and dose-volume histograms were calculated and extracted. Tumors were classified according to their contact with the SVZ. The Kaplan-Meier method was used for survival analysis, and univariable and multivariable Cox regression (MVA) were used to determine prognostic effects on progression-free survival (PFS) and overall survival (OS). RESULTS Median PFS of the study group was 7.2 months; median OS was 15.1 months. In MVA (with mean dose to the ipsilateral SVZ as a continuous covariable), PFS was significantly lower for patients with a Karnofsky performance status (KPS) < 70% and without MGMT promoter methylation. Factors prognostic for shorter OS were old age, lower KPS, unmethylated MGMT status, SVZ contact and biopsy instead of subtotal- or gross total resection. There was no significant correlation between survival and SVZ dose. CONCLUSION In this cohort, an increased mean dose to the ipsilateral or contralateral SVZ did not correlate with improved survival in irradiated GBM patients in MVA. Patients whose tumor directly involved the SVZ showed worse OS in MVA.
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Affiliation(s)
- Katja Bender
- Department of Radiation Oncology Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Malte Träger
- Department of Radiation Oncology Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Helena Wahner
- Department of Radiation Oncology Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; German Cancer Consortium (DKTK), partner site Berlin, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Marcus Beck
- Department of Radiation Oncology Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Felix Ehret
- Department of Radiation Oncology Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Volker Budach
- Department of Radiation Oncology Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - David Kaul
- Department of Radiation Oncology Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; German Cancer Consortium (DKTK), partner site Berlin, Germany.
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6
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Muracciole X, El-Amine W, Tabouret E, Boucekine M, Barlier A, Petrirena G, Harivony T, Solignac L, Chinot OL, Macagno N, Figarella-Branger D, Padovani L. Negative Survival Impact of High Radiation Doses to Neural Stem Cells Niches in an IDH-Wild-Type Glioblastoma Population. Front Oncol 2018; 8:426. [PMID: 30338243 PMCID: PMC6180179 DOI: 10.3389/fonc.2018.00426] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 09/12/2018] [Indexed: 12/17/2022] Open
Abstract
Aims: Assess the impact of radiation doses to neural stem cell (NSC) niches in patients with IDH-wild-type glioblastoma. Materials and Methods: Fifty patients were included in the study. NSC niches [SubVentricular Zone (SVZ) and Sub Granular Zone (SGZ)] were contoured by fusing CT scans and pre-therapy MRI, Tumor location defined ipsilateral and contralateral SVZ and SGZ. Prognostic significance of clinical, biological and dosimetric parameters were examined. We generated a Recursive Partitioning Analysis (RPA) model with independent prognostic classes. Results: Median follow-up: 23.8 months. Event free and overall survival (OS): 10 and 19.1 months. Incomplete surgery, PTV (planning target volume), ipsilateral SVZ or NSC niche mean dose > 57.4 Gy, contralateral NSC niche mean dose > 35 Gy and bilateral NSC niche mean dose > 44 Gy were significantly correlated with reduced OS. Only EGFR amplification was an independent prognostic factor (p = 0.019) for OS. RPA generated independent risk groups: 1 (low risk): [ipsilateral NSC mean dose (INMD) < 58.01 Gy and methylated MGMT promoter], 2: (INMD < 58.01 Gy and unmethylated MGMT promoter and contralateral SVZ mean dose < 18.6 Gy; p = 0.43), 3: (INMD < 58.01 Gy and unmethylated MGMT promoter and contralateral SVZ mean dose > 18.6 Gy; p = 0.002) and 4: (very high risk) (INMD > 58.01 Gy; p < 0.001). Conclusion: High radiation doses to ipsilateral NSC and contralateral SVZ could have a negative impact on overall survival in IDH-wild-type glioblastoma population.
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Affiliation(s)
- Xavier Muracciole
- Radiotherapy Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Wassim El-Amine
- Radiotherapy Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Emmeline Tabouret
- Neuro-Oncology Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France.,Angiogenesis and Micro Environnment UMR 911 CRO2, Aix-Marseille University, Marseille, France
| | - Mohamed Boucekine
- Unity of Research EA3279, Aix-Marseille Université, Marseille, France
| | - Anne Barlier
- Molecular Biology and Oncogenetics Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Gregorio Petrirena
- Neuro-Oncology Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Tovo Harivony
- Radiotherapy Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Laetitia Solignac
- Radiotherapy Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Olivier L Chinot
- Neuro-Oncology Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Nicolas Macagno
- Angiogenesis and Micro Environnment UMR 911 CRO2, Aix-Marseille University, Marseille, France.,Neuropathology Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Dominique Figarella-Branger
- Angiogenesis and Micro Environnment UMR 911 CRO2, Aix-Marseille University, Marseille, France.,Neuropathology Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Laetitia Padovani
- Radiotherapy Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France.,CRCM INSERM UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
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Sinnaeve J, Mobley BC, Ihrie RA. Space Invaders: Brain Tumor Exploitation of the Stem Cell Niche. THE AMERICAN JOURNAL OF PATHOLOGY 2017; 188:29-38. [PMID: 29024634 DOI: 10.1016/j.ajpath.2017.08.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 07/22/2017] [Accepted: 08/17/2017] [Indexed: 12/20/2022]
Abstract
Increasing evidence indicates that the adult neurogenic niche of the ventricular-subventricular zone (V-SVZ), beyond serving as a potential site of origin, affects the outcome of malignant brain cancers. Glioma contact with this niche predicts worse prognosis, suggesting a supportive role for the V-SVZ environment in tumor initiation or progression. In this review, we describe unique components of the V-SVZ that may permit or promote tumor growth within the region. Cell-cell interactions, soluble factors, and extracellular matrix composition are discussed, and the role of the niche in future therapies is explored. The purpose of this review is to highlight niche intrinsic factors that may promote or support malignant cell growth and maintenance, and point out how we might leverage these features to improve patient outcome.
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Affiliation(s)
- Justine Sinnaeve
- Departments of Cell and Developmental Biology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Bret C Mobley
- Departments of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rebecca A Ihrie
- Departments of Cell and Developmental Biology, Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
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