Non-cytotoxic therapies for malignant gliomas

Educate, not kill: treating cancer without triggering its defenses

Traditionally, anticancer therapies focus on restraining uncontrolled proliferation. However, these cytotoxic therapies expose cancer cells to direct killing, instigating the process of natural selection favoring survival of resistant cells that become the foundation for tumor progression and therapy failure. Recognizing this phenomenon has prompted the development of alternative therapeutic strategies. Here we propose strategies targeting cancer hallmarks beyond proliferation, aiming at re-educating cancer cells towards a less malignant phenotype. These strategies include controlling cell dormancy, transdifferentiation therapy, normalizing the cancer microenvironment, and using migrastatic therapy. Adaptive resistance to these educative strategies does not confer a direct proliferative advantage to resistant cells, as non-resistant cells are not subject to eradication, thereby delaying or preventing the development of therapy-resistant tumors.

Bromodeoxyuridine inhibits cancer cell proliferation in vitro and in vivo

The thymidine analog bromodeoxyuridine (BrdU) is incorporated into newly synthesized DNA and has been shown to increase the susceptibility of incorporating cells to ionizing radiation. However, in the absence of secondary stressors, BrdU is thought to substitute relatively benignly for thymidine and is commonly used to "birth-date" proliferative cells. We report a novel antiproliferative effect of BrdU on cancer cells, which is independent of its role in radiosensitization. A single, brief in vitro exposure to BrdU induces a profound and sustained reduction in the proliferation rate of all cancer cells examined. Cells do not die but variably up-regulate some senescence-associated proteins as they accumulate in the G1 phase of the cell cycle. Bromodeoxyuridine also impairs the proliferative capacity of primary tumor-initiating human glioma cells and may therefore represent a means of targeting cancer stem cells. Finally, conservative in vivo BrdU regimens--in the absence of any other treatment--significantly suppress the progression of gliomas in the highly aggressive, syngeneic RG2 model. These results suggest that BrdU may have an important role as an adjunctive therapeutic for a wide variety of cancers based on new insights into its effect as a negative regulator of cell cycle progression.

Strain-specific spontaneous and NNK-mediated tumorigenesis in Pten+/- mice

Pten is a negative regulator of the Akt pathway, and its inactivation is believed to be an etiological factor in many tumor types. Pten+/- mice are susceptible to a variety of spontaneous tumor types, depending on strain background. Pten+/- mice, in lung tumor-sensitive and -resistant background strains, were treated with a tobacco carcinogen, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), to determine whether allelic Pten deletion can cooperate with NNK in carcinogenesis in lung or other tissues. In lung tumor-resistant C57BL/6 Pten+/- or +/+ mice, NNK treatment did not lead to any lung tumors and did not increase the incidence or severity of tumors previously reported for this strain. In contrast, in a lung tumor-susceptible pseudo-A/J strain, there was a dose-dependent increase in lung tumor size in Pten+/- compared with +/+ mice, although there was no increase in multiplicity. No other tumor types were observed in pseudo-A/J Pten+/- mice regardless of NNK treatment. Lung tumors from these Pten+/- mice had K-ras mutations, retained Pten expression and had similar Akt pathway activation as lung tumors from +/+ mice. Therefore, deletion of a single copy of Pten does not substantially add to the lung tumor phenotype conferred by mutation of K-ras by NNK, and there is likely no selective advantage for loss of the second Pten allele in lung tumor initiation.

Potentiation of anticancer-drug cytotoxicity by sea anemone pore-forming proteins in human glioblastoma cells

The search for new drugs and treatment approaches is of particular importance for glioblastomas (GBMs), as with other types of malignant gliomas, as they are lethal without the available medical care. Current anticancer cocktails have failed to prolong survival beyond 1 year, in part owing to the natural resistance of GBM cells and to the toxic side effects of the available drugs. In many organisms, cell death can be induced by cytolysins, which are proteins that can form pores in biological membranes. Perhaps by facilitating drugs to enter into the cytosol, cytolysins might be used to increase the efficacy of conventional anticancer agents. Here, the cytotoxicity of two sea anemone pore-forming cytolysins, toxin Bc2, and equinatoxin (EqTx-II) were investigated. Toxin Bc2 and EqTx-II were cytotoxic against human U87 and A172 GBM cell lines either wild type or p53 mutant, a tumor suppressor frequently mutated in malignant gliomas. Moreover, noncytotoxic concentrations of Bc2 or EqTx-II potentiated the cytotoxicity induced by low dose concentrations of all classical chemotherapeutics agents tested: cytosine arabinoside, doxorubicin, and vincristine. In comparison with the cytotoxicity induced by each of these classical anticancer drugs alone, 10-300-fold less of the therapeutic drug was needed when combined with the cytolysins. These results are promising, since lower concentrations of chemotherapeutic drugs could reduce the adverse effects of chemotherapy.

Progesterone effects on cell growth of U373 and D54 human astrocytoma cell lines

Astrocytomas are the most frequent primary brain tumors and constitute a leading cause of cancer-related deaths. We studied the effects of progesterone and its antagonist, RU486, on cell growth of two human astrocytoma cell lines with different evolution grade (U373, grade III; and D54, grade IV). Progesterone receptor expression was determined by Western blot. The effects of different doses of progesterone and RU486 on cell number, cell cycle, and apoptosis were analyzed for five consecutive days. Progesterone (10 nM) significantly increased the number of D54 cells from the second day of culture, and the number of U373 cells on days 3-5. RU486 (10 muM) blocked progesterone effects in both astrocytoma cell lines. Interestingly, RU486 administered without progesterone significantly reduced the number of cells from the second day of culture in both cell lines. Progesterone increased S phase of cell cycle in U373 cells (61%, on day 5). RU486 blocked the effects of progesterone on cell cycle but administered alone did not significantly change cell cycle profile. DNA fragmentation (TUNEL) assay showed that the diminution in the number of astrocytoma cells produced by RU486 was not by apoptosis. Progesterone receptor isoforms were detected in both cell lines. Our data suggest that progesterone induces cell growth of human astrocytoma cell lines through the interaction with its nuclear receptor.

Nonspecific immunotherapy with intratumoral lipopolysaccharide and zymosan A but not GM-CSF leads to an effective anti-tumor response in subcutaneous RG-2 gliomas

PURPOSE

Nonspecific stimulation of cells of the immune system may be useful in generating an anti-tumor response for a variety of cancers and may work synergistically with currently available cytotoxic therapies. In this study we examined the response of syngeneic rat gliomas to treatment with several nonspecific stimulators of dendritic cells and macrophages alone or in combination with radiation therapy.

EXPERIMENTAL DESIGN

RG-2 gliomas were implanted subcutaneously and treated with intratumoral (IT) injections of the toll-like receptor (TLR) ligands lipopolysaccharide (LPS) and zymosan A (ZymA) and the cytokine granulocyte-macrophage colony stimulating factor (GM-CSF). Combination treatment with IT LPS and single-fraction external beam radiotherapy (EBRT) was also evaluated.

RESULTS

Treatment with IT LPS and ZymA delayed tumor growth compared to saline controls. Multiple doses of both substances were superior to single doses, and led to complete tumor regression in 71% (LPS) and 50% (ZymA) of animals. GM-CSF showed no anti-tumor effects in this study. Combinations of IT LPS and EBRT appeared to have a synergistic effect in delaying tumor growth. Rechallenge studies and IT LPS treatment of RG-2 tumors in nude rats suggested the importance of T cells in this treatment paradigm.

CONCLUSIONS

Direct IT treatment with the TLR ligands LPS and ZymA are effective in generating an anti-tumor response. These treatments may synergize with cytotoxic therapies such as EBRT, and appear to require T cells for a successful outcome.

Convection-enhanced delivery of interleukin-13 receptor-directed cytotoxin for malignant glioma therapy

The treatment of patients with malignant brain tumors, in particular glioblastoma multiforme (GBM) is very challenging because of their diffuse infiltrative nature and the cytological heterogeneity. The median survival of patients with newly diagnosed GBM is only 12-15 months, and only 8-12% of them survive for two years. Novel approaches for brain tumor therapy are needed. Recently, targeted therapies have emerged as promising modality for cancer targeting. We have discovered that high affinity plasma membrane receptor for interleukin-13 (IL-13), an immune regulatory cytokine, is over-expressed in 60-80% of malignant brain tumors. To target these IL-13R, we generated a chimeric fusion protein, composed of human IL-13 and mutated Pseudomonas exotoxin (PE), termed IL-13 cytotoxin (IL13-PE), and tested its cytotoxicity to IL-13R-expressing GBM cells. IL-13 cytotoxin was highly potent and selective in killing IL-13R-expressing GBM cells. In contrast, normal cells including brain, immune, and endothelial cells were generally not affected by this cytotoxin due to no or low expression of IL-13R. In vivo pre-clinical studies for safety and toxicity were also performed in mice, rats, and monkeys, and IL-13 cytotoxin was found to be well tolerated by both systemic and intracerebral administrations. IL-13 cytotoxin was found to mediate remarkable efficacy in animal models of human brain tumors. Encouraged by these pre-clinical studies, four Phase 1/2 clinical trials in adult patients with recurrent malignant glioma have been completed. These clinical trials involved convection-enhanced delivery (CED) of IL-13 cytotoxin either intratumoral or intraparenchymal after resection of tumor. CED is a novel loco-regional drug delivery method for intracranial tumors that relies on a continuous pressure gradient to distribute drug into interstitial space. This route of IL-13 cytotoxin administration appears to be very well tolerated and have a good risk-benefit profile. Most recently, a randomized controlled Phase 3 clinical trial (PRECISE) with intraparenchymal IL-13 cytotoxin administration was completed and subjects are being monitored for safety and survival.

Rejection of RG-2 gliomas is mediated by microglia and T lymphocytes

Immunotherapy holds great promise for the treatment of invasive brain tumors, and we are interested specifically in evaluating immune stimulation of microglial cells as one potential strategy. In order to better understand the tumor fighting capabilities of microglial cells, we have compared the responses of syngeneic (Fisher 344) and allogeneic (Wistar) rat strains after intracranial implantation of RG-2 gliomas. Animals were evaluated by clinical examination, magnetic resonance imaging (MRI) and immunohistochemistry for microglial and other immune cell antigens. While lethal RG-2 gliomas developed in all of the Fisher 344 rats, tumors grew variably in the Wistar strain, sometimes reaching considerable sizes, but eventually all of them regressed. Tumor regression was associated with greater numbers of T cells and CD8 positive cells and increases in MHC I and CD4 positive microglia. Our findings suggest that the combined mobilization of peripheral and CNS endogenous immune cells is required for eradicating large intracranial tumors.

The IL-4 and IL-13 pseudomonas exotoxins: new hope for brain tumor therapy

✓ Targeting cell surface receptors with cytotoxins or immunotoxins provides a unique opportunity for brain tumor therapy. The authors have discovered that receptors for two cytokines, interleukin (IL)-4 and IL-13, are overexpressed on tumor biopsy samples and on cell lines derived from a variety of human tumors, including brain tumors. These investigators have demonstrated that the structure of these cytokine receptors on tumor cells is different from that found on normal immune cells. In human solid tumor cells, IL-4 binds to two chains (IL-4Rα and IL-13Rα1), whereas IL-13 binds to three chains in many solid tumor cells, including glioma cells (to IL-4Rα, IL-13Rα1, and IL-13Rα2). To target IL-4Rs and IL-13Rs, the authors generated two recombinant fusion cytotoxins composed of IL-4 or IL-13 and a mutated form of pseudomonas exotoxin (PE), which for simplicity are called IL4-PE and IL13-PE in this paper. These chimeric cytotoxins are highly toxic in vitro to human tumor cell lines and primary cell cultures, including glioma cells, and in vivo to animal models of human tumors, including gliomas. In contrast, normal cells, including immune, endothelial, and brain cells, are spared from their cytotoxic effects. Based on numerous preclinical studies, IL13-PE (also known as IL13-PE38QQR or cintredekin besudotox) has been tested in four Phase I/II clinical trials. The agent IL13-PE was administered intracranially by using convection-enhanced delivery (CED). The drug was delivered through catheters placed either directly into the tumor bed or in the peritumoral region after resection of the lesion. The CED of IL13-PE was fairly well tolerated, with a reasonable benefit/risk profile for treatment of patients with glioma. Based on Phase I/II clinical trials, the Phase III Randomized Evaluation of CED of IL13-PE Compared to Gliadel Wafer with Survival Endpoint Trial (also known as the PRECISE Trial) in patients with initial recurrence of glioblastoma multiforme has recently been completed. Patients are being monitored for safety of the agents, duration of overall survival, and quality of life.

Therapy for recurrent malignant glioma in adults

Malignant gliomas are the most common form of primary brain tumors in adults. Although the prognosis remains poor, there has been recent progress in the treatment of these tumors. Standard therapy for patients with this disease will be reviewed, together with more novel approaches such as targeted molecular therapies, angiogenesis inhibitors, immunotherapies, gene therapies and intratumoral therapies.

Anti-angiogenic Therapy in Pediatric Neuro-oncology

In order to grow, tissues require additional nutrients and oxygen as well as removal of waste products. Tumors achieve this by up-regulating angiogenic cytokines and/or down-regulating natural inhibitory proteins that allow neovascularization to proceed. Brain tumors continue to account for significant morbidity and mortality, in spite of significant advances in neurosurgical and radiation techniques and new chemotherapy combinations. As such, there is a real and immediate need for novel biologic therapies that can target these tumors. A number of new drugs that target different aspects of the angiogenic cascade have been identified and are now in clinical trials in children with primary brain tumors. In many of these pre-clinical and clinical studies, anti-angiogenic therapy has been well tolerated, has lacked many of the traditional toxicities of radiation and chemotherapy, does not require blood-brain barrier penetration, and targets a critical pathway in central nervous system tumor development. This review will discuss what angiogenesis is, how pediatric brain tumors regulate angiogenesis to obtain a vascular supply, what types of inhibitors are available, how different classes of inhibitors work, the types of resistance possible, how rapidly these inhibitors may work, and what surrogate markers of activity are available to follow response.

Quantification of viability in organotypic multicellular spheroids of human malignant glioma using lactate dehydrogenase activity: a rapid and reliable automated assay

Organotypic spheroids from malignant glioma resemble the biological complexity of the original tumor and are therefore appealing to study anticancer drug responses. Accurate and reproducible quantification of response effect has been lacking to determine drug responses in this three-dimensional tumor model. Lactate dehydrogenase (LDH) activity was demonstrated in cryostat sections of spheroids using the tetrazolium salt method. Calibrated digital image acquisition of the stained cryostat sections enables quantification of LDH activity. Fully automated image cytometry reliably demarcates LDH-active and LDH-inactive tissue areas by thresholding at specific absorbance values. The viability index (VI) was calculated as ratio of LDH-active areas and total spheroid tissue areas. Duplicate staining and processing on the same tissue showed good correlation and therefore reproducibility. Sodium azide incubation of spheroids induced reduction in VI to almost zero. We conclude that quantification of viability in cryostat sections of organotypic multicellular spheroids from malignant glioma can be performed reliably and reproducibly with this approach.

Microsurgery for malignant gliomas

Reflections directly involving the ongoing, intense research activities in biology, the neurosciences and in neurosurgery are discussed including the evolving diagnostic and treatment modalities of primary and secondary malignant gliomas of the central nervous system. The etiology of this enigmatic disease remains obscure, and a curative therapy is still not available. Nevertheless, as a result of changing paradigms in neuroanatomy, neuropathology, neurophysiology, neuroradiology and in neurosurgery, and taking into account the broader selection of adjuvant therapies available, well circumscribed malignant gliomas, which are in predilected compartments of the brain, can be efficiently resected. Good life quality and a respectable survival time are achieved in the majority of patients.

Non-cytotoxic drugs as potential treatments for gliomas

PURPOSE OF REVIEW

Despite advances in surgery, radiation therapy, and chemotherapy, malignant gliomas continue to be associated with a poor prognosis. Even the most intensive combinations of radiotherapy and chemotherapy are not curative. In recent years our understanding of how tumor cells overcome cell cycle control, evade programmed cell death, induce blood vessel formation, and escape immune regulation has increased substantially. Significant efforts are directed towards the development of novel experimental therapies to target these molecular and biological mechanisms that lead to the development and growth of brain tumors. This review summarizes the most recent developments in non-cytotoxic therapy for malignant gliomas, such as targeted molecular drugs, inhibitors of angiogenesis and intratumoral therapy.

RECENT FINDINGS

The first generation of studies using these novel therapies is nearing completion. In general, most of these treatments are well tolerated, but single-agent activity is modest. There is significant interest in combining these therapies with each other and with conventional cytotoxic therapies such as radiation therapy and chemotherapy.

SUMMARY

These new therapeutic approaches for malignant gliomas are showing modest activity. As we learn to use these agents more effectively, and as an increasing number of new and potentially promising agents are developed, it is likely that therapies for malignant gliomas will improve over the next few years.

Interleukin-13 receptor-directed cytotoxin for malignant glioma therapy: from bench to bedside

Central nervous system malignant neoplasias, in particular, glioblastoma multiforme (GBM) have defied all current therapeutic modalities. New therapies involving tumor targeting approach are being explored. This approach relies on the identification of unique or over-expressed cell surface receptors or antigens on tumor cells. In that regard, we have identified receptor for an immune regulatory cytokine, interleukin-13 (IL-13), which is over-expressed on human malignant glioma cell lines and primary tumor cell cultures. To target IL-13 receptors (IL-13R) for cancer therapy, we have developed a recombinant fusion protein composed of IL-13 and a mutated form of Pseudomonas exotoxin (IL13-PE38QQR or IL-13 cytotoxin). The IL-13 cytotoxin was found to be highly selective and potent in killing human GBM cells in vitro while normal cells including immune cells, endothelial cells and normal brain cells were generally spared the cytotoxic effect of IL-13 cytotoxin. This is because these cells either expressed none or expressed low levels of IL-13R. Consistent with in vitro cytotoxic activity, IL-13 cytotoxin mediated remarkable anti-tumor activity to human glioma in animal xenograft models. The direct injection of IL-13 cytotoxin into subcutaneous human GBM tumors grown in nude mice produced complete and durable regression of established tumors. Intravenous and intraperitoneal administration of IL-13 cytotoxin also reduced tumor burden significantly with fewer complete responders. All animals tolerated therapy well with minimal toxicity to vital organs. Pre-clinical safety and toxicity studies were performed in mice, rats and monkeys. Systemic administration of IL-13 cytotoxin appeared to be well tolerated at high doses (up to 50 microg/kg). Intrabrain parenchyma administration of IL-13 cytotoxin at doses up to 100 microg/ml was very well tolerated without any evidence of gross or microscopic necrosis, whereas at 500 microg/ml dose, localized necrosis was observed in normal rat brain. Based on these encouraging pre-clinical studies, three Phase I/II clinical trials in adults with malignant glioma have been initiated. The first clinical trial involves convection-enhanced delivery (CED) of IL-13 cytotoxin into recurrent malignant glioma. This route of IL-13 cytotoxin administration appears to be fairly well tolerated with no neurotoxicity. The second clinical trial involves infusion of IL-13 cytotoxin by CED following tumor resection. The initial stage of the second study assessed histologic effect of drug administered prior to resection. In third one, IL-13 cytotoxin is infused by CED followed by tumor resection. All three clinical trials are currently ongoing.

Anti-angiogenic chemotherapy in central nervous system tumors

Primary central nervous system tumors are infrequent lesions observed in both pediatric and adult patients that account for a disproportionate amount of cancer related morbidity and mortality. A significant number of advances in neurosurgical and radiation therapy techniques have occurred over the last few decades and yet only small improvements in long-term outcome have resulted. The major reason for this is the ability of these advances to minimize surgical or radiation morbidity on surrounding normal tissue rather than eradicating the microscopic infiltrating disease that remains after up-front standard therapy. As such, a great deal of effort has gone into adjuvant chemotherapy that might complement the standard surgical and radiation approaches. This paper will review the literature on anti-angiogenic therapies in central nervous system (CNS) tumor models and clinical disease, with a focus on anti-angiogenic chemotherapy (also referred to as metronomic or low-dose chemotherapy) and the utilization of this approach in conjunction with standard radiation and surgery. A number of excellent reviews covering related aspects of this topic are also available (1-13).

Current chemotherapy for glioblastoma

INTRODUCTION

Glioblastoma multiforme continues to be associated with a dismal prognosis, despite aggressive therapy. What limited therapeutic impact that has been made has come via multimodality treatment in which chemotherapy plays an important role. In this manuscript, we review current chemotherapy options for glioblastomas.

METHODS

The current literature concerning glioblastoma multiforme chemotherapy was reviewed. In addition to a review of landmark references, a MEDLINE search of the literature published from January 2000 to November 2002 was performed using the key words "chemotherapy AND malignant glioma" and limiting responses to clinical trials.

RESULTS

Several cytotoxic chemotherapeutic agents that are efficacious in treating glioblastoma are in common clinical use. These can be classified as first-line or second-line agents, depending on their efficacy. In addition, cytostatic chemotherapy agents are beginning to play a role in glioblastoma treatment. Finally, new methods to deliver high chemotherapy doses to brain tumors hold promise for future therapies.

CONCLUSIONS

Despite the overall poor prognosis of patients with glioblastoma multiforme, multimodality treatment and chemotherapy in particular improve outcome, and chemotherapeutic options are beginning to have an increased impact. Strategies currently in clinical trials may improve this impact more in the future.