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Ma K, Wang S, Ma Y, Zeng L, Xu K, Mu N, Lai Y, Shi Y, Yang C, Chen B, Quan Y, Li L, Lu Y, Yang Y, Liu Y, Hu R, Wang X, Chen Y, Bian X, Feng H, Li F, Chen T. Increased oxygen stimulation promotes chemoresistance and phenotype shifting through PLCB1 in gliomas. Drug Resist Updat 2024; 76:101113. [PMID: 39053384 DOI: 10.1016/j.drup.2024.101113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/24/2024] [Accepted: 06/14/2024] [Indexed: 07/27/2024]
Abstract
Gliomas, the most common CNS (central nerve system) tumors, face poor survival due to severe chemoresistance exacerbated by hypoxia. However, studies on whether altered hypoxic conditions benefit for chemo-sensitivity and how gliomas react to increased oxygen stimulation are limited. In this study, we demonstrated that increased oxygen stimulation promotes glioma growth and chemoresistance. Mechanically, increased oxygen stimulation upregulates miR-1290 levels. miR-1290, in turn, downregulates PLCB1, while PLCB1 facilitates the proteasomal degradation of β-catenin and active-β-catenin by increasing the proportion of ubiquitinated β-catenin in a destruction complex-independent mechanism. This process inhibits PLCB1 expression, leads to the accumulation of active-β-catenin, boosting Wnt signaling through an independent mechanism and ultimately promoting chemoresistance in glioma cells. Pharmacological inhibition of Wnt by WNT974 could partially inhibit glioma volume growth and prolong the shortened survival caused by increased oxygen stimulation in a glioma-bearing mouse model. Moreover, PLCB1, a key molecule regulated by increased oxygen stimulation, shows promising predictive power in survival analysis and has great potential to be a biomarker for grading and prognosis in glioma patients. These results provide preliminary insights into clinical scenarios associated with altered hypoxic conditions in gliomas, and introduce a novel perspective on the role of the hypoxic microenvironment in glioma progression. Furthermore, the outcomes reveal the potential risks of utilizing hyperbaric oxygen treatment (HBOT) in glioma patients, particularly when considering HBOT as a standalone option to ameliorate neuro-dysfunctions or when combining HBOT with a single chemotherapy agent without radiotherapy.
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Affiliation(s)
- Kang Ma
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Shi Wang
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Yingjie Ma
- Medical Data Science Academy, Chongqing Medical University, Chongqing, China
| | - Lan Zeng
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China; Department of Neurology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Kai Xu
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Ning Mu
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Ying Lai
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Yaning Shi
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Chuanyan Yang
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Beike Chen
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Yulian Quan
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Lan Li
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Yongling Lu
- Medical Research Center, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yang Yang
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Yan Liu
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Rong Hu
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Xiaoming Wang
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Yujie Chen
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Xiuwu Bian
- Institute of Pathology and Southwest Cancer Center, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Hua Feng
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Fei Li
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Tunan Chen
- Glioma Medical Research Center and Department of Neurosurgery, The First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
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Kerezoudis P, Kerezoudi EN, Choudhry A, Himes BT, Parney IF. Complementary and Alternative Medicine for Gliomas: Systematic Review and Critical Appraisal of Current Literature. Neurosurgery 2023; 92:464-471. [PMID: 36650046 DOI: 10.1227/neu.0000000000002236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/14/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Many patients with glioma and their caregivers seek complementary and alternative medicine (CAM) methods to comfort themselves, cope with cancer medication side effects, and feel they are taking control of their disease. OBJECTIVE To summarize existing evidence on safety and efficacy of CAM treatments for gliomas. METHODS We performed an exhaustive electronic literature search for in vitro, animal, and clinical studies (English language, all years available) on CAM modalities for gliomas. RESULTS A total of 378 studies (315 unique articles) were analyzed. Distribution was as follows: in vitro-274 (73%), animal-77 (20%), and clinical-26 (7%, 2491 patients). Most studies were conducted in China (n = 135, 43%), followed by the United States (n = 62, 20%) and Spain (n = 17, 5%-6%). Resveratrol was the most commonly investigated CAM therapy in the in vitro (n = 62) and in vivo (n = 17) setting. Safety/toxicity was examined in 21% of in vitro (cytotoxic at same dose in 48%), 39% of in vivo (no evidence of organ toxicity), and 50% of clinical studies (adverse events reported in 6). Cytotoxicity was the most frequent end point among in vitro (60%) and animal studies (56%), followed by synergistic action with chemotherapy and inhibition of invasiveness and migration. Finally, 7 of 26 studies found no clinical effect, whereas 5 reported possible impact on progression-free or overall survival, 3 demonstrated decrease or arrest of tumor progression, and 2 showed positive impact on symptoms and quality of life. CONCLUSION These findings will hopefully educate providers and patients and stimulate further research in the field of CAM therapy for gliomas.
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Affiliation(s)
- Panagiotis Kerezoudis
- Department of Neurologic Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Evangelia N Kerezoudi
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | | | - Benjamin T Himes
- Department of Neurologic Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Ian F Parney
- Department of Neurologic Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
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Hartford AC, Gill GS, Ravi D, Tosteson TD, Li Z, Russo G, Eskey CJ, Jarvis LA, Simmons NE, Evans LT, Williams BB, Gladstone DJ, Roberts DW, Buckey JC. Sensitizing brain metastases to stereotactic radiosurgery using hyperbaric oxygen: A proof-of-principle study. Radiother Oncol 2022; 177:179-184. [PMID: 36404528 PMCID: PMC10827304 DOI: 10.1016/j.radonc.2022.10.024] [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: 07/06/2021] [Revised: 09/30/2022] [Accepted: 10/21/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE Increased oxygen levels may enhance the radiosensitivity of brain metastases treated with stereotactic radiosurgery (SRS). This project administered hyperbaric oxygen (HBO) prior to SRS to assess feasibility, safety, and response. METHODS 38 patients were studied, 19 with 25 brain metastases treated with HBO prior to SRS, and 19 historical controls with 27 metastases, matched for histology, GPA, resection status, and lesion size. Outcomes included time from HBO to SRS, quality-of-life (QOL) measures, local control, distant (brain) metastases, radionecrosis, and overall survival. RESULTS The average time from HBO chamber to SRS beam-on was 8.3 ± 1.7 minutes. Solicited adverse events (AEs) were comparable between HBO and control patients; no grade III or IV serious AEs were observed. Radionecrosis-free survival (RNFS), radionecrosis-free survival before whole-brain radiation therapy (WBRT) (RNBWFS), local recurrence-free survival before WBRT (LRBWFS), distant recurrence-free survival before WBRT (DRBWFS), and overall survival (OS) were not significantly different for HBO patients and controls on Kaplan-Meier analysis, though at 1-year estimated survival rates trended in favor of SRS + HBO: RNFS - 83% vs 60%; RNBWFS - 78% vs 60%; LRBWFS - 95% vs 78%; DRBWFS - 61% vs 57%; and OS - 73% vs 56%. Multivariate Cox models indicated no significant association between HBO treatment and hazards of RN, local or distant recurrence, or mortality; however, these did show statistically significant associations (p < 0.05) for: local recurrence with higher volume, radionecrosis with tumor resection, overall survival with resection, and overall survival with higher GPA. CONCLUSION Addition of HBO to SRS for brain metastases is feasible without evident decrement in radiation necrosis and other clinical outcomes.
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Affiliation(s)
- Alan C Hartford
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA.
| | - Gobind S Gill
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Divya Ravi
- Dartmouth Cancer Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Tor D Tosteson
- Dartmouth Cancer Center, One Medical Center Drive, Lebanon, NH 03756, USA.
| | - Zhongze Li
- Dartmouth Cancer Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Gregory Russo
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Clifford J Eskey
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Lesley A Jarvis
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Nathan E Simmons
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Linton T Evans
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Benjamin B Williams
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - David J Gladstone
- Dartmouth Cancer Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - David W Roberts
- Dartmouth Cancer Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Jay C Buckey
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
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Alpuim Costa D, Sampaio-Alves M, Netto E, Fernandez G, Oliveira E, Teixeira A, Daniel PM, Bernardo GS, Amaro C. Hyperbaric Oxygen Therapy as a Complementary Treatment in Glioblastoma-A Scoping Review. Front Neurol 2022; 13:886603. [PMID: 35847231 PMCID: PMC9283648 DOI: 10.3389/fneur.2022.886603] [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] [Received: 02/28/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
Glioblastoma (GBM) is the most common and aggressive malignant brain tumor in adults. The mainstay of management for GBM is surgical resection, radiation (RT), and chemotherapy (CT). Even with optimized multimodal treatment, GBM has a high recurrence and poor survival rates ranging from 12 to 24 months in most patients. Recently, relevant advances in understanding GBM pathophysiology have opened new avenues for therapies for recurrent and newly diagnosed diseases. GBM's hypoxic microenvironment has been shown to be highly associated with aggressive biology and resistance to RT and CT. Hyperbaric oxygen therapy (HBOT) may increase anticancer therapy sensitivity by increasing oxygen tension within the hypoxic regions of the neoplastic tissue. Previous data have investigated HBOT in combination with cytostatic compounds, with an improvement of neoplastic tissue oxygenation, inhibition of HIF-1α activity, and a significant reduction in the proliferation of GBM cells. The biological effect of ionizing radiation has been reported to be higher when it is delivered under well-oxygenated rather than anoxic conditions. Several hypoxia-targeting strategies reported that HBOT showed the most significant effect that could potentially improve RT outcomes, with higher response rates and survival and no serious adverse events. However, further prospective and randomized studies are necessary to validate HBOT's effectiveness in the 'real world' GBM clinical practice.
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Affiliation(s)
- Diogo Alpuim Costa
- Haematology and Oncology Department, CUF Oncologia, Lisbon, Portugal
- NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Lisbon, Portugal
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Centro de Medicina Subaquática e Hiperbárica, Azinhaga dos Ulmeiros, Lisbon, Portugal
- Centro Hiperbárico de Cascais, Cascais, Portugal
| | - Mafalda Sampaio-Alves
- Faculty of Medicine, University of Porto, Oporto, Portugal
- PTSurg – Portuguese Surgical Research Collaborative, Lisbon, Portugal
| | - Eduardo Netto
- Radioncology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil (IPOLFG), E.P.E., Lisbon, Portugal
| | | | - Edson Oliveira
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Neurosurgery Department, Cluster CUF Descobertas, Lisbon, Portugal
| | - Andreia Teixeira
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Centro de Medicina Subaquática e Hiperbárica, Azinhaga dos Ulmeiros, Lisbon, Portugal
| | - Pedro Modas Daniel
- Centro de Medicina Subaquática e Hiperbárica, Azinhaga dos Ulmeiros, Lisbon, Portugal
| | - Guilherme Silva Bernardo
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Centro de Medicina Subaquática e Hiperbárica, Azinhaga dos Ulmeiros, Lisbon, Portugal
- Urology Department, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Carla Amaro
- Centro de Medicina Subaquática e Hiperbárica, Azinhaga dos Ulmeiros, Lisbon, Portugal
- Otorhinolaryngology Department, CUF Descobertas, Lisbon, Portugal
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The use of radiosensitizing agents in the therapy of glioblastoma multiforme-a comprehensive review. Strahlenther Onkol 2022; 198:507-526. [PMID: 35503461 PMCID: PMC9165247 DOI: 10.1007/s00066-022-01942-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/30/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Glioblastoma is the most common malignant brain tumor in human adults. Despite several improvements in resective as well as adjuvant therapy over the last decades, its overall prognosis remains poor. As a means of improving patient outcome, the possibility of enhancing radiation response by using radiosensitizing agents has been tested in an array of studies. METHODS A comprehensive review of clinical trials involving radiation therapy in combination with radiosensitizing agents on patients diagnosed with glioblastoma was performed in the National Center for Biotechnology Information's PubMed database. RESULTS A total of 96 papers addressing this matter were published between 1976 and 2021, of which 63 matched the subject of this paper. All papers were reviewed, and their findings discussed in the context of their underlining mechanisms of radiosensitization. CONCLUSION In the history of glioblastoma treatment, several approaches of optimizing radiation-effectiveness using radiosensitizers have been made. Even though several different strategies and agents have been explored, clear evidence of improved patient outcome is still missing. Tissue-selectiveness and penetration of the blood-brain barrier seem to be major roadblocks; nevertheless, modern strategies try to circumvent these obstacles, using novel sensitizers based on preclinical data or alternative ways of delivery.
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Abstract
Gliomas are common brain mass with a high mortality rate. Patients with gliomas have a severely bad outcome, with an average survive duration less 15 months because of high recurrent rate and being resistant to radio-therapy and chemistry drugs therapy. Hyperbaric oxygen is extensively taken as an adjuvant treatment for various disease conditions. To know the characteristics of hyperbaric oxygen as a remedy for gliomas, we find that, in general, hyperbaric oxygen shows an obviously positive effect on the treatment of gliomas, and it can also relieve the complications caused by postoperative radiotherapy and chemotherapy of gliomas. Whereas, several researches have shown that hyperbaric oxygen promotes glioma progression.
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Affiliation(s)
- Wen-Jie Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Jia-Sheng Ding
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Qing Sun
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Xiang Xu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Gang Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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Pangal DJ, Baertsch H, Kellman EM, Cardinal T, Brunswick A, Rutkowski M, Strickland B, Chow F, Attenello F, Zada G. Complementary and Alternative Medicine for the Treatment of Gliomas: Scoping Review of Clinical Studies, Patient Outcomes, and Toxicity Profiles. World Neurosurg 2021; 151:e682-e692. [PMID: 33940275 DOI: 10.1016/j.wneu.2021.04.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Complementary and alternative medicine (CAM) are highly used among those diagnosed with glioma. Further research is warranted, however, as it remains important to clearly delineate CAM practices that are unproven, disproven, or promising for future research and implementation. METHODS A systematic review was conducted to identify all articles that investigated the effect of any CAM therapy on survival of patients with newly diagnosed or recurrent glioma. RESULTS Eighteen papers and 4 abstracts pertaining to the effects of ketogenic diet (4), antioxidants (3), hyperbaric oxygen (4), cannabinoids (2), carbogen and nicotinamide (3), mistletoe extract (2), hypocupremia and penicillamine (1), and overall CAM use (3) on overall and progression-free survival in patients with low- and high-grade glioma were identified (Levels of Evidence I-IV). Ketogenic diets, hyperbaric oxygen therapy, and cannabinoids appear to be safe and well tolerated by patients; preliminary studies demonstrate tumor response and increased progression-free survival and overall survival when combined with standard of care therapies. Antioxidant usage exhibit mixed results perhaps associated with glioma grade with greater effect on low-grade gliomas; vitamin D intake was associated with prolonged survival. Conversely, carbogen breathing and hypocupremia were found to have no effect on the survival of patients with glioma, with associated significant toxicity. Most modalities under the CAM umbrella have not been appropriately studied and require further investigation. CONCLUSIONS Despite widespread use, Level I or II evidence for CAM for the treatment of glioma is lacking, representing future research directions to optimally counsel and treat glioma patients.
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Affiliation(s)
- Dhiraj J Pangal
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.
| | - Hans Baertsch
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Eliza M Kellman
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Tyler Cardinal
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Andrew Brunswick
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Martin Rutkowski
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Ben Strickland
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Frances Chow
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Frank Attenello
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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Arpa D, Parisi E, Ghigi G, Cortesi A, Longobardi P, Cenni P, Pieri M, Tontini L, Neri E, Micheletti S, Ghetti F, Monti M, Foca F, Tesei A, Arienti C, Sarnelli A, Martinelli G, Romeo A. Role of Hyperbaric Oxygenation Plus Hypofractionated Stereotactic Radiotherapy in Recurrent High-Grade Glioma. Front Oncol 2021; 11:643469. [PMID: 33859944 PMCID: PMC8042328 DOI: 10.3389/fonc.2021.643469] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/09/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The presence of hypoxic cells in high-grade glioma (HGG) is one of major reasons for failure of local tumour control with radiotherapy (RT). The use of hyperbaric oxygen therapy (HBO) could help to overcome the problem of oxygen deficiency in poorly oxygenated regions of the tumour. We propose an innovative approach to improve the efficacy of hypofractionated stereotactic radiotherapy (HSRT) after HBO (HBO-RT) for the treatment of recurrent HGG (rHGG) and herein report the results of an ad interim analysis. METHODS We enrolled a preliminary cohort of 9 adult patients (aged >18 years) with a diagnosis of rHGG. HSRT was administered in daily 5-Gy fractions for 3-5 consecutive days a week. Each fraction was delivered up to maximum of 60 minutes after HBO. RESULTS Median follow-up from re-irradiation was 11.6 months (range: 3.2-11.6 months). The disease control rate (DCR) 3 months after HBO-RT was 55.5% (5 patients). Median progression-free survival (mPFS) for all patients was 5.2 months (95%CI: 1.34-NE), while 3-month and 6-month PFS was 55.5% (95%CI: 20.4-80.4) and 27.7% (95%CI: 4.4-59.1), respectively. Median overall survival (mOS) of HBO-RT was 10.7 months (95% CI: 7.7-NE). No acute or late neurologic toxicity >grade (G)2 was observed in 88.88% of patients. One patient developed G3 radionecrosis. CONCLUSIONS HSRT delivered after HBO appears to be effective for the treatment of rHGG, it could represent an alternative, with low toxicity, to systemic therapies for patients who cannot or refuse to undergo such treatments. CLINICAL TRIAL REGISTRATION www.ClinicalTrials.gov, identifier NCT03411408.
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Affiliation(s)
- Donatella Arpa
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Elisabetta Parisi
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Giulia Ghigi
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Annalisa Cortesi
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | | | - Patrizia Cenni
- Neuroradiology Unit, “Santa Maria delle Croci” Hospital, Ravenna, Italy
| | - Martina Pieri
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Luca Tontini
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Elisa Neri
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Simona Micheletti
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Francesca Ghetti
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Manuela Monti
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Flavia Foca
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Anna Tesei
- Biosciences Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Chiara Arienti
- Biosciences Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Anna Sarnelli
- Medical Physics Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Giovanni Martinelli
- Scientific Directorate, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Antonio Romeo
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
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Zembrzuska K, Ostrowski RP, Matyja E. Hyperbaric oxygen increases glioma cell sensitivity to antitumor treatment with a novel isothiourea derivative in vitro. Oncol Rep 2019; 41:2703-2716. [PMID: 30896865 PMCID: PMC6448092 DOI: 10.3892/or.2019.7064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 03/04/2019] [Indexed: 12/27/2022] Open
Abstract
Glioblastoma (GBM) is the most common primary brain tumor. Tumor hypoxia is a pivotal factor responsible for the progression of this malignant glioma, and its resistance to radiation and chemotherapy. Thus, improved tumor tissue oxygenation may promote greater sensitivity to anticancer treatment. Protein kinase D1 (PKD1) protects cells from oxidative stress, and its abnormal activity serves an important role in multiple malignancies. The present study examined the effects of various oxygen conditions on the cytotoxic potential of the novel isothiourea derivate N,N′-dimethyl-S-(2,3,4,5,6-pentabromobenzyl)- isothiouronium bromide (ZKK-3) against the T98G GBM cell line. ZKK-3 was applied at concentrations of 10, 25 and 50 µM, and cells were maintained under conditions of normoxia, anoxia, hypoxia, hyperbaric oxygen (HBO), hypoxia/hypoxia and hypoxia/HBO. The proliferation and viability of neoplastic cells, and protein expression levels of hypoxia-inducible factor 1α (HIF-1α), PKD1, phosphorylated (p)PKD1 (Ser 916) and pPKD1 (Ser 744/748) kinases were evaluated. Oxygen deficiency, particularly regarding hypoxia, could diminish the cytotoxic effect of ZKK-3 at 25 and 50 µM and improve T98G cell survival compared with normoxia. HBO significantly reduced cell proliferation and increased T98G cell sensitivity to ZKK-3 when compared with normoxia. HIF-1α expression levels were increased under hypoxia compared with normoxia and decreased under HBO compared with hypoxia/hypoxia at 0, 10 and 50 µM ZKK-3, suggesting that HBO improved oxygenation of the cells. ZKK-3 exhibited inhibitory activity against pPKD1 (Ser 916) kinase; however, the examined oxygen conditions did not appear to significantly influence the expression of this phosphorylated form in cells treated with the tested compound. Regarding pPKD1 (Ser 744/748), a significant difference in expression was observed only for cells treated with 10 µM ZKK-3 and hypoxia/hypoxia compared with normoxia. However, there were significant differences in the expression levels of both phosphorylated forms of PKD1 under different oxygen conditions in the controls. In conclusion, the combination of isothiourea derivatives and hyperbaric oxygenation appears to be a promising therapeutic approach for malignant glioma treatment.
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Affiliation(s)
- Katarzyna Zembrzuska
- Department of Experimental and Clinical Neuropathology, Mossakowski Medical Research Centre, Polish Academy of Sciences, 02‑106 Warsaw, Poland
| | - Robert P Ostrowski
- Department of Experimental and Clinical Neuropathology, Mossakowski Medical Research Centre, Polish Academy of Sciences, 02‑106 Warsaw, Poland
| | - Ewa Matyja
- Department of Experimental and Clinical Neuropathology, Mossakowski Medical Research Centre, Polish Academy of Sciences, 02‑106 Warsaw, Poland
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10
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Seliger C, Luber C, Gerken M, Schaertl J, Proescholdt M, Riemenschneider MJ, Meier CR, Bogdahn U, Leitzmann MF, Klinkhammer-Schalke M, Hau P. Use of metformin and survival of patients with high-grade glioma. Int J Cancer 2018; 144:273-280. [PMID: 30091464 DOI: 10.1002/ijc.31783] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/03/2018] [Accepted: 07/25/2018] [Indexed: 12/12/2022]
Abstract
High-grade glioma (HGG) is associated with poor prognosis. Drug repurposing evolves as new modality to improve standard therapy. The antidiabetic drug metformin has been found to inhibit glioma cell growth in vitro and in vivo. The aim of the present retrospective cohort study was to evaluate the survival of patients with HGG with or without treatment with metformin, based on a large cohort of a cancer registry. The analysis included 1,093 patients with HGG diagnosed between 1998 and 2013 from the population-based clinical cancer registry Regensburg (Germany), which covers 2.1 Mio inhabitants and 98% of all cancer diagnoses. We performed multivariable adjusted Cox-regression analyses. Hazard Ratios (HRs) with 95% Confidence Intervals (CIs) for overall survival (OS) and progression-free survival (PFS) of patients with HGG with or without treatment with metformin were obtained. Use of metformin was associated with a significantly better overall and progression-free survival of patients with WHO grade III glioma (HR for OS = 0.30; 95% CI = 0.11-0.81, HR for PFS = 0.29; 95% CI = 0.11-0.78), while there were no significant relations with OS (HR = 0.83; 95% CI = 0.57-1.20) or PFS (HR = 0.85; 95% CI = 0.59-1.22) in patients with WHO grade IV glioma. In conclusion, use of metformin is associated with better overall and progression-free survival of patients with WHO grade III. Possible underlying mechanisms include the higher prevalence of IDH mutations in WHO grade III glioma, which might sensitize to the metabolic drug metformin.
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Affiliation(s)
- Corinna Seliger
- Department of Neurology and Wilhelm Sander-NeuroOncology Unit, Regensburg University Hospital, Regensburg, Germany
| | - Christian Luber
- Department of Neurology and Wilhelm Sander-NeuroOncology Unit, Regensburg University Hospital, Regensburg, Germany
| | - Michael Gerken
- Institute for Quality Assurance and Health Services Research, University of Regensburg, Regensburg, Germany
| | - Julia Schaertl
- Department of Neurology and Wilhelm Sander-NeuroOncology Unit, Regensburg University Hospital, Regensburg, Germany
| | - Martin Proescholdt
- Department of Neurosurgery, Regensburg University Hospital, Regensburg, Germany
| | | | - Christoph R Meier
- Basel Pharmacoepidemiology Unit, Division of CIinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Switzerland.,Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Boston University, USA.,Department of Pharmaceutical Sciences, Hospital Pharmacy, University Hospital Basel, Switzerland
| | - Ulrich Bogdahn
- Department of Neurology and Wilhelm Sander-NeuroOncology Unit, Regensburg University Hospital, Regensburg, Germany
| | - Michael F Leitzmann
- Department of Epidemiology and Preventive Medicine, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Monika Klinkhammer-Schalke
- Institute for Quality Assurance and Health Services Research, University of Regensburg, Regensburg, Germany
| | - Peter Hau
- Department of Neurology and Wilhelm Sander-NeuroOncology Unit, Regensburg University Hospital, Regensburg, Germany
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11
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Wang YG, Long J, Shao DC, Song H. Hyperbaric oxygen inhibits production of CD3+ T cells in the thymus and facilitates malignant glioma cell growth. J Int Med Res 2018; 46:2780-2791. [PMID: 29785863 PMCID: PMC6124287 DOI: 10.1177/0300060518767796] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Hyperbaric oxygen (HBO) is an emerging complementary alternative medical approach in glioma treatment. However, its mode of action is unknown, so this was investigated in the present study. Methods We constructed an intracranial glioma model of congenic C57BL/6J mice. Glioma growth under HBO stimulation was assessed by bioluminescent imaging and magnetic resonance imaging. Flow cytometry assessed direct effects of HBO on reactive oxygen species (ROS) signaling of transplanted glioma cells and organs, and quantified mature T cells and subgroups in tumors, the brain, and blood. Results HBO promoted the growth of transplanted GL261-Luc glioma in the intracranial glioma mouse model. ROS signaling of glioma cells and brain cells was significantly downregulated under HBO stimulation, but thymus ROS levels were significantly upregulated. CD3+ T cells were significantly downregulated, while both Ti/Th cells (CD3+CD4+) and Ts/Tc cells (CD3+CD8+) were inhibited in tumors of the HBO group. The percentage of regulatory T cells in Ti/Th (CD3+CD4+) cells was elevated in the tumors and thymuses of the HBO group. Conclusion HBO induced ROS signaling in the thymus, inhibited CD3+ T cell generation, and facilitated malignant glioma cell growth in vivo in the intracranial glioma mouse model.
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Affiliation(s)
- Yong-Gang Wang
- 1 Department of Neurosurgery, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan 650032, China
| | - Jiang Long
- 1 Department of Neurosurgery, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan 650032, China
| | - Dong-Chuan Shao
- 2 Department of Neurosurgery, First People's Hospital of Kunming, Kunming, Yunnan 650032, China
| | - Hai Song
- 1 Department of Neurosurgery, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan 650032, China
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12
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Huang L, Boling W, Zhang JH. Hyperbaric oxygen therapy as adjunctive strategy in treatment of glioblastoma multiforme. Med Gas Res 2018; 8:24-28. [PMID: 29770193 PMCID: PMC5937300 DOI: 10.4103/2045-9912.229600] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Glioblastoma multiforme (GBM) is the most common type of malignant intracranial tumor in adults. Tumor tissue hypoxia, high mitotic rate, and rapid tumor spread account for its poor prognosis. Hyperbaric oxygen therapy (HBOT) may improve the sensitivity of radio-chemotherapy by increasing oxygen tension within the hypoxic regions of the neoplastic tissue. This review summarizes the research of HBOT applications within the context of experimental and clinical GBM. Limited clinical trials and preclinical studies suggest that radiotherapy immediately after HBOT enhances the effects of radiotherapy in some aspects. HBOT also is able to strengthen the anti-tumor effect of chemotherapy when applied together. Overall, HBOT is well tolerated in the GBM patients and does not significantly increase toxicity. However, HBOT applied by itself as curative strategy against GBM is controversial in preclinical studies and has not been evaluated rigorously in GBM patients. In addition to HBOT favorably managing the therapeutic resistance of GBM, future research needs to focus on the multimodal or cocktail approaches to treatment, as well as molecular strategies targeting GBM stem cells.
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Affiliation(s)
- Lei Huang
- Department of Neurosurgery, School of Medicine, Loma Linda University, Loma Linda, CA, USA.,Department of Basic Sciences, Division of Physiology, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Warren Boling
- Department of Neurosurgery, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - John H Zhang
- Department of Neurosurgery, School of Medicine, Loma Linda University, Loma Linda, CA, USA.,Department of Basic Sciences, Division of Physiology, School of Medicine, Loma Linda University, Loma Linda, CA, USA.,Department of Anesthesiology, School of Medicine, Loma Linda University, Loma Linda, CA, USA
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Yahara K, Ohguri T, Udono H, Yamamoto J, Tomura K, Onoda T, Imada H, Nishizawa S, Korogi Y. Radiotherapy using IMRT boosts after hyperbaric oxygen therapy with chemotherapy for glioblastoma. JOURNAL OF RADIATION RESEARCH 2017; 58:351-356. [PMID: 27864508 PMCID: PMC5440883 DOI: 10.1093/jrr/rrw105] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 04/07/2016] [Indexed: 05/27/2023]
Abstract
The purpose of this study was to evaluate the feasibility and efficacy of radiotherapy (RT) using intensity-modulated radiotherapy (IMRT) boosts after hyperbaric oxygen (HBO) therapy with chemotherapy in patients with glioblastoma. Twenty-four patients with glioblastoma were treated with the combined therapy, which was RT using IMRT boosts after HBO with chemotherapy, and were retrospectively analyzed. The RT protocol was as follows: first, 3D conformal RT [40 Gy/20 fractions (fr)] was delivered to the gross tumor volume (GTV) and the surrounding edema, including an additional 1.5-2.0 cm. The IMRT boost doses were then continuously delivered to the GTV plus 5 mm (28 Gy/8 fr) and the surrounding edema (16 Gy/8 fr). Each IMRT boost session was performed immediately after HBO to achieve radiosensitization. The planned RT dose was completed in all patients, while HBO therapy was terminated in one patient (4%) due to Grade 2 aural pain. The toxicities were mild, no non-hematological toxicity of Grade 3-5 was observed. The 2-year overall survival (OS) and progression-free survival rates in all patients were 46.5% and 35.4%, respectively. The median OS time was 22.1 months. In conclusion, the combined therapy of RT using IMRT boosts after HBO with chemotherapy was a feasible and promising treatment modality for patients with glioblastoma. The results justify further evaluation to clarify the benefits of this therapy.
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Affiliation(s)
- Katsuya Yahara
- Department of Radiology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan
| | - Takayuki Ohguri
- Department of Radiology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan
| | - Hiroki Udono
- Department of Neurosurgery, Tobata Kyoritsu Hospital, Kitakyushu, Japan, University of Occupational and Environmental Health, 2-5-1 Sawami Tobata-ku, Kitakyushu 804-0093, Japan
| | - Junkoh Yamamoto
- Department of Neurosurgery, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan
| | - Kyosuke Tomura
- Department of Radiology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan
| | - Toshihiro Onoda
- Department of Cancer Therapy Center, Tobata Kyoritsu Hospital, Kitakyushu, Japan, University of Occupational and Environmental Health, 2-5-1 Sawami Tobata-ku, Kitakyushu 804-0093, Japan
| | - Hajime Imada
- Department of Cancer Therapy Center, Tobata Kyoritsu Hospital, Kitakyushu, Japan, University of Occupational and Environmental Health, 2-5-1 Sawami Tobata-ku, Kitakyushu 804-0093, Japan
| | - Shigeru Nishizawa
- Department of Neurosurgery, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan
| | - Yukunori Korogi
- Department of Radiology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan
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14
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Stępień K, Ostrowski RP, Matyja E. Hyperbaric oxygen as an adjunctive therapy in treatment of malignancies, including brain tumours. Med Oncol 2016; 33:101. [PMID: 27485098 PMCID: PMC4971045 DOI: 10.1007/s12032-016-0814-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 07/16/2016] [Indexed: 12/22/2022]
Abstract
Hyperbaric oxygen (HBO) therapy is widely used as an adjunctive treatment for various pathological states, predominantly related to hypoxic and/or ischaemic conditions. It also holds promise as an approach to overcoming the problem of oxygen deficiency in the poorly oxygenated regions of the neoplastic tissue. Occurrence of local hypoxia within the central areas of solid tumours is one of the major issues contributing to ineffective medical treatment. However, in anti-cancer therapy, HBO alone gives a limited curative effect and is typically not applied by itself. More often, HBO is used as an adjuvant treatment along with other therapeutic modalities, such as radio- and chemotherapy. This review outlines the existing data regarding the medical use of HBO in cancer treatment, with a particular focus on the use of HBO in the treatment of brain tumours. We conclude that the administration of HBO can provide many clinical benefits in the treatment of tumours, including management of highly malignant gliomas. Applied immediately before irradiation, it is safe and well tolerated by patients, causing rare and limited side effects. The results obtained with a combination of HBO/radiotherapy protocol proved to be especially favourable compared to radiation treatment alone. HBO can also increase the cytostatic effect of certain drugs, which may render standard chemotherapy more effective. The currently available data support the legitimacy of conducting further research on the use of HBO in the treatment of malignancies.
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Affiliation(s)
- Katarzyna Stępień
- Department of Experimental and Clinical Neuropathology, Mossakowski Medical Research Centre, Polish Academy of Sciences, 5 Pawińskiego Str., 02-106, Warsaw, Poland.
| | - Robert P Ostrowski
- Department of Experimental and Clinical Neuropathology, Mossakowski Medical Research Centre, Polish Academy of Sciences, 5 Pawińskiego Str., 02-106, Warsaw, Poland
| | - Ewa Matyja
- Department of Experimental and Clinical Neuropathology, Mossakowski Medical Research Centre, Polish Academy of Sciences, 5 Pawińskiego Str., 02-106, Warsaw, Poland
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Abstract
OBJECTIVE This review was to evaluate the efficacy and toxicity of radiation therapy (RT) administered immediately after hyperbaric oxygen (HBO) therapy in patients with high grade gliomas. RESEARCH DESIGN AND METHODS PubMed, Embase, ISI Web of Knowledge, and Cochrane databases were searched using combinations of the following search terms: radiotherapy, hyperbaric oxygenation, chemotherapy, glioma, brain tumor. Selection was limited to prospective studies involving patients given HBO followed by RT for high-grade gliomas. Data extracted from studies included the clinical research phase of the study, number of study arms, number of patients, patient age and gender, glioma type and grade, pressure and length of HBO, protocol of radiation therapy, duration of follow-up, and the outcomes. MAIN OUTCOME MEASURES Overall survival, time to progression, response rate, tumor regression, and toxic effects associated with HBO plus RT treatment. RESULTS Literature search/screening yielded eight studies for analysis. Six of the studies were single-arm in design and enrolled a total of 203 patients, of whom 142 had grade IV gliomas and 61 had grade III gliomas. In these six studies, all patients received HBO then RT. Two studies were double-arm in design, with 24 patients treated with HBO followed by RT and 26 patients treated with RT alone. The findings from both the single- and double-arm studies indicated improved outcomes (survival rate, progression free survival, time to progression, response rate) with HBO and RT therapy. Reported toxicity included leucopenia, anemia, thrombocytopenia, fever, loss of appetite, constipation, nausea, vomiting, and liver dysfunction. The addition of HBO had minimal effect on toxicity or side effects; across the eight studies, only one patient with severe middle ear barotrauma had a complication directly related to HBO exposure. CONCLUSION This systematic reviews suggests that the addition of HBO to RT is tolerated and may be beneficial in patients with high-grade gliomas.
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Affiliation(s)
- Jun-rui Chen
- a Department of Neurosurgery , Huashan Hospital, Shanghai Medical College, Fudan University , Shanghai , China
| | - Hong-zhi Xu
- a Department of Neurosurgery , Huashan Hospital, Shanghai Medical College, Fudan University , Shanghai , China
| | - Jian-bo Ding
- a Department of Neurosurgery , Huashan Hospital, Shanghai Medical College, Fudan University , Shanghai , China
| | - Zhi-yong Qin
- a Department of Neurosurgery , Huashan Hospital, Shanghai Medical College, Fudan University , Shanghai , China
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Temporal changes in tumor oxygenation and perfusion upon normo- and hyperbaric inspiratory hyperoxia. Strahlenther Onkol 2015; 192:174-81. [PMID: 26501141 DOI: 10.1007/s00066-015-0916-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 10/07/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Inspiratory hyperoxia under hyperbaric conditions has been shown to effectively reduce tumor hypoxia and to improve radiosensitivity. However, applying irradiation (RT) under hyperbaric conditions is technically difficult in the clinical setting since RT after decompression may be effective only if tumor pO2 remains elevated for a certain period of time. The aim of the present study was to analyze the time course of tumor oxygenation and perfusion during and after hyperbaric hyperoxia. MATERIALS AND METHODS Tumor oxygenation, red blood cell (RBC) flux for perfusion monitoring, and vascular resistance were assessed continuously in experimental rat DS-sarcomas by polarographic catheter electrodes and laser Doppler flowmetry at 1 and 2 atm (bar) of environmental pressure during breathing of pure O2 or carbogen (95 % O2 + 5 % CO2). RESULTS During room air breathing, the tumor pO2 followed very rapidly within a few minutes the change of the ambient pressure during compression or decompression. With O2 breathing under hyperbaric conditions, the tumor pO2 increased more than expected based on the rise of the environmental pressure, although the time course was comparably rapid. Breathing carbogen, the tumor pO2 followed with a slight delay of the pressure change, and within 10 min after decompression the baseline values were reached again. RBC flux increased during carbogen breathing but remained almost constant with pure O2, indicating a vasodilation (decrease in vascular resistance) with carbogen but a vasoconstriction (increase in vascular resistance) with O2 during hyperbaric conditions. CONCLUSION Since the tumor pO2 directly followed the environmental pressure, teletherapy after hyperbaric conditions does not seem to be promising as the pO2 reaches baseline values again within 5-10 min after decompression.
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WANG YONGGANG, ZHAN YIPING, PAN SHUYI, WANG HAIDONG, ZHANG DUNXIAO, GAO KAI, QI XUELING, YU CHUNJIANG. Hyperbaric oxygen promotes malignant glioma cell growth and inhibits cell apoptosis. Oncol Lett 2015; 10:189-195. [PMID: 26170997 PMCID: PMC4487135 DOI: 10.3892/ol.2015.3244] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 04/13/2015] [Indexed: 11/06/2022] Open
Abstract
Glioblastoma multiforme (GBM) is the most frequently diagnosed intracranial malignant tumor in adults. Clinical studies have indicated that hyperbaric oxygen may improve the prognosis and reduce complications in glioma patients; however, the specific mechanism by which this occurs remains unknown. The present study investigated the direct effects of hyperbaric oxygen stimulation on glioma by constructing an intracranial transplanted glioma model in congenic C57BL/6J mice. Bioluminescent imaging (BLI) was used to assess the growth of intracranial transplanted GL261-Luc glioma cells in vivo, while flow cytometric and immunohistochemical assays were used to detect and compare the expression of the biomarkers, Ki-67, CD34 and TUNEL, reflecting the cell cycle, apoptosis and angiogenesis. BLI demonstrated that hyperbaric oxygen promoted the growth of intracranially transplanted GL261-Luc glioma cells in vivo. Flow cytometric analysis indicated that hyperbaric oxygen promoted GL261-Luc glioma cell proliferation and also prevented cell cycle arrest. In addition, hyperbaric oxygen inhibited the apoptosis of the transplanted glioma cells. Immunohistochemical analysis also indicated that hyperbaric oxygen increased positive staining for Ki-67 and CD34, while reducing staining for TUNEL (a marker of apoptosis). The microvessel density was significantly increased in the hyperbaric oxygen treatment group compared with the control group. In conclusion, hyperbaric oxygen treatment promoted the growth of transplanted malignant glioma cells in vivo and also inhibited the apoptosis of these cells.
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Affiliation(s)
- YONG-GANG WANG
- Department of Neurosurgery, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing 100093, P.R. China
| | - YI-PING ZHAN
- Department of Neurosurgery, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing 100093, P.R. China
| | - SHU-YI PAN
- Department of Hyperbaric Oxygen, Navy General Hospital, Beijing 100048, P.R. China
| | - HAI-DONG WANG
- Department of Hyperbaric Oxygen, Navy General Hospital, Beijing 100048, P.R. China
| | - DUN-XIAO ZHANG
- Department of Hyperbaric Oxygen, Navy General Hospital, Beijing 100048, P.R. China
| | - KAI GAO
- Institute of Laboratory Animal Sciences, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100021, P.R. China
| | - XUE-LING QI
- Department of Pathology, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing 100093, P.R. China
| | - CHUN-JIANG YU
- Department of Neurosurgery, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing 100093, P.R. China
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Ogawa K, Kohshi K, Ishiuchi S, Matsushita M, Yoshimi N, Murayama S. Old but new methods in radiation oncology: hyperbaric oxygen therapy. Int J Clin Oncol 2013; 18:364-70. [PMID: 23463521 DOI: 10.1007/s10147-013-0537-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Indexed: 11/25/2022]
Abstract
The presence of hypoxic tumor cells is widely regarded as one of the main reasons behind the failure to control malignant tumors with radiotherapy treatments. Since hyperbaric oxygenation (HBO) improves the oxygen supply to the hypoxic tumor cells, HBO therapy has previously been used in combination with simultaneous radiotherapy to treat malignant tumors. In some clinical trials, significant improvements in local control and survival have been seen in cancers of the head and neck and the uterine cervix. However, the delivery of simultaneous HBO therapy and radiotherapy is both complex and time-consuming, with some trials reporting increased side effects. As a result, the regimen of HBO therapy in combination with simultaneous radiotherapy has yet to be used as a standard treatment for malignant tumors. In recent years, however, radiotherapy immediately after HBO therapy has been emerging as an attractive approach for overcoming hypoxia in cancer treatment. Several studies have reported that radiotherapy immediately after HBO therapy was safe and seemed to be effective in patients with high-grade gliomas. Also, this approach may protect normal tissues from radiation injury. To accurately estimate whether the delivery of radiotherapy immediately after HBO therapy can be beneficial in patients with high-grade gliomas and other cancers, further prospective studies are warranted.
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Affiliation(s)
- Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University, 2-2 D10, Yamadaoka, Suita, Osaka, 565-0871, Japan.
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Microenvironment and radiation therapy. BIOMED RESEARCH INTERNATIONAL 2012; 2013:685308. [PMID: 23509762 PMCID: PMC3591225 DOI: 10.1155/2013/685308] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 07/13/2012] [Indexed: 12/19/2022]
Abstract
Dependency on tumor oxygenation is one of the major features of radiation therapy and this has led many radiation biologists and oncologists to focus on tumor hypoxia. The first approach to overcome tumor hypoxia was to improve tumor oxygenation by increasing oxygen delivery and a subsequent approach was the use of radiosensitizers in combination with radiation therapy. Clinical use of some of these approaches was promising, but they are not widely used due to several limitations. Hypoxia-inducible factor 1 (HIF-1) is a transcription factor that is activated by hypoxia and induces the expression of various genes related to the adaptation of cellular metabolism to hypoxia, invasion and metastasis of cancer cells and angiogenesis, and so forth. HIF-1 is a potent target to enhance the therapeutic effects of radiation therapy. Another approach is antiangiogenic therapy. The combination with radiation therapy is promising, but several factors including surrogate markers, timing and duration, and so forth have to be optimized before introducing it into clinics. In this review, we examined how the tumor microenvironment influences the effects of radiation and how we can enhance the antitumor effects of radiation therapy by modifying the tumor microenvironment.
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[Treatment of brain tumor patients: hyperthermia, hyperbaric oxygenation, electric fields or nanoparticles]. DER NERVENARZT 2012; 83:982-7. [PMID: 22801663 DOI: 10.1007/s00115-012-3569-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Despite considerable advancements in the therapy of malignant glioma in recent years with modern radiation and surgical techniques, alkylating and antiangiogenic chemotherapy, as well as molecular-based treatment decisions, treatment outcomes are mostly unsatisfactory. Understandably, patients often ask for experimental, sometimes unusual therapeutic modalities and this should be integrated into the clinical practice. In addition to experimental therapeutic approaches based on novel drugs, viral agents, immunotherapy and radiation approaches, experimental procedures of interest for patients particularly encompass mechanical approaches with the aim at physically altering the tumor tissue by temperature, oxygenation or magnetization. These mechanical procedures are based on intuitive concepts and promise fewer side effects than other experimental approaches. In addition, the requirements for approval by medical device regulations in terms of proof of efficacy are generally less stringent. As a consequence approaches, such as hyperbaric oxygenation, hyperthermia and electric fields, which are often heavily advertised and in part reimbursed by health insurances, have been used for many years, often by centers not specialized in the treatment of brain tumor patients, although sound data from prospective controlled clinical trials that determine which patients in which situation may benefit, are generally lacking. In this review we review these clinical therapeutic approaches.
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Sun S, Lee D, Lee NP, Pu JKS, Wong STS, Lui WM, Fung CF, Leung GKK. Hyperoxia resensitizes chemoresistant human glioblastoma cells to temozolomide. J Neurooncol 2012; 109:467-75. [PMID: 22763762 PMCID: PMC3434886 DOI: 10.1007/s11060-012-0923-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 06/19/2012] [Indexed: 12/27/2022]
Abstract
Temozolomide (TMZ) is standard chemotherapy for glioblastoma multiforme (GBM). Intratumoral hypoxia is common in GBM and may be associated with the development of TMZ resistance. Oxygen therapy has previously been reported to potentiate the effect of chemotherapy in cancer. In this study, we investigated whether hyperoxia can enhance the TMZ-induced cytotoxicity of human GBM cells, and whether and how it would resensitize TMZ-resistant GBM cells to TMZ. TMZ-sensitive human GBM cells (D54-S and U87-S) were treated with TMZ to develop isogenic subclones of TMZ-resistant cells (D54-R and U87-R). All cell lines were then exposed to different oxygen levels (1, 21, 40, or 80 %), with or without concomitant TMZ treatment, before assessment of cell cytotoxicity and morphology. Cell death and survival pathways elicited by TMZ and/or hyperoxia were elucidated by western blotting. Our results showed that TMZ sensitivity of both chemo-sensitive and resistant cells was enhanced significantly under hyperoxia. At the cell line-specific optimum oxygen concentration (D54-R, 80 %; U87-R, 40 %), resistant cells had the same response to TMZ as the parent chemosensitive cells under normoxia via the caspase-dependent pathway. Both TMZ and hyperoxia were associated with increased phosphorylation of ERK p44/42 MAPK (Erk1/2), but to a lesser extent in D54-R cells, suggesting that Erk1/2 activity may be involved in regulation of hyperoxia and TMZ-mediated cell death. Overall, hyperoxia enhanced TMZ toxicity in GBM cells by induction of apoptosis, possibly via MAPK-related pathways. Induced hyperoxia is a potentially promising approach for treatment of TMZ-resistant GBM.
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Affiliation(s)
- Stella Sun
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, Hong Kong
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Nakajima H, Oka Y, Tsuboi A, Tatsumi N, Yamamoto Y, Fujiki F, Li Z, Murao A, Morimoto S, Hosen N, Shirakata T, Nishida S, Kawase I, Isaka Y, Oji Y, Sugiyama H. Enhanced tumor immunity of WT1 peptide vaccination by interferon-β administration. Vaccine 2011; 30:722-9. [PMID: 22133512 DOI: 10.1016/j.vaccine.2011.11.074] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 11/18/2011] [Accepted: 11/19/2011] [Indexed: 10/14/2022]
Abstract
To induce and activate tumor-associated antigen-specific cytotoxic T lymphocytes (CTLs) for cancer immunity, it is important not only to select potent CTL epitopes but also to combine them with appropriate immunopotentiating agents. Here we investigated whether tumor immunity induced by WT1 peptide vaccination could be enhanced by IFN-β. For the experimental group, C57BL/6 mice were twice pre-treated with WT1 peptide vaccine, implanted with WT1-expressing C1498 cells, and treated four times with WT1 peptide vaccine at one-week intervals. During the vaccination period, IFN-β was injected three times a week. Mice in control groups were treated with WT1 peptide alone, IFN-β alone, or PBS alone. The mice in the experimental group rejected tumor cells and survived significantly longer than mice in the control groups. The overall survival on day 75 was 40% for the mice treated with WT1 peptide+IFN-β, while it was 7, 7, and 0% for those treated with WT1 peptide alone, IFN-β alone or PBS alone, respectively. Induction of WT1-specific CTLs and enhancement of NK activity were detected in splenocytes from mice in the experimental group. Furthermore, administration of IFN-β enhanced expression of MHC class I molecules on the implanted tumor cells. In conclusion, our results showed that co-administration of WT1 peptide+IFN-β enhanced tumor immunity mainly through the induction of WT1-specific CTLs, enhancement of NK activity, and promotion of MHC class I expression on the tumor cells. WT1 peptide vaccination combined with IFN-β administration can thus be expected to enhance the clinical efficacy of WT1 immunotherapy.
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Affiliation(s)
- Hiroko Nakajima
- Department of Cancer Immunology, Osaka University Graduate School of Medicine, Osaka, Japan
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23
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Ogawa K, Ishiuchi S, Inoue O, Yoshii Y, Saito A, Watanabe T, Iraha S, Toita T, Kakinohana Y, Ariga T, Kasuya G, Murayama S. Phase II trial of radiotherapy after hyperbaric oxygenation with multiagent chemotherapy (procarbazine, nimustine, and vincristine) for high-grade gliomas: long-term results. Int J Radiat Oncol Biol Phys 2011; 82:732-8. [PMID: 21420247 DOI: 10.1016/j.ijrobp.2010.12.070] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 12/17/2010] [Accepted: 12/20/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE To analyze the long-term results of a Phase II trial of radiotherapy given immediately after hyperbaric oxygenation (HBO) with multiagent chemotherapy in adults with high-grade gliomas. METHODS AND MATERIALS Patients with histologically confirmed high-grade gliomas were administered radiotherapy in daily 2 Gy fractions for 5 consecutive days per week up to a total dose of 60 Gy. Each fraction was administered immediately after HBO, with the time interval from completion of decompression to start of irradiation being less than 15 minutes. Chemotherapy consisting of procarbazine, nimustine, and vincristine and was administered during and after radiotherapy. RESULTS A total of 57 patients (39 patients with glioblastoma and 18 patients with Grade 3 gliomas) were enrolled from 2000 to 2006, and the median follow-up of 12 surviving patients was 62.0 months (range, 43.2-119.1 months). All 57 patients were able to complete a total radiotherapy dose of 60 Gy immediately after HBO with one course of concurrent chemotherapy. The median overall survival times in all 57 patients, 39 patients with glioblastoma and 18 patients with Grade 3 gliomas, were 20.2 months, 17.2 months, and 113.4 months, respectively. On multivariate analysis, histologic grade alone was a significant prognostic factor for overall survival (p < 0.001). During treatments, no patients had neutropenic fever or intracranial hemorrhage, and no serious nonhematologic or late toxicities were seen in any of the 57 patients. CONCLUSIONS Radiotherapy delivered immediately after HBO with multiagent chemotherapy was safe, with virtually no late toxicities, and seemed to be effective in patients with high-grade gliomas.
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Affiliation(s)
- Kazuhiko Ogawa
- Department of Radiology, University of the Ryukyus, Okinawa, Japan.
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Kashimura H, Inoue T, Ogasawara K, Beppu T, Kanbara Y, Ogawa A. Three-dimensional anisotropy contrast imaging of pontine gliomas: 2 case reports. ACTA ACUST UNITED AC 2007; 67:156-9; discussion 159. [PMID: 17254873 DOI: 10.1016/j.surneu.2006.05.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2005] [Accepted: 05/21/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND Magnetic resonance imaging can provide a preoperative diagnosis of pontine glioma, but the findings sometimes do not correspond with the clinical symptoms. We describe 2 cases of pontine gliomas who did not present with motor and sensory disturbance. CASE REPORT Three-dimensional anisotropy contrast (3DAC) imaging was used to assess the neuronal tracts in 2 patients with pontine gliomas. Conventional MR imaging depicted markedly abnormal findings of abnormally high or heterogeneous signal intensity in the pons in 2 cases. In contrast, 3DAC imaging obviously showed the corticospinal and spinothalamic tracts and cerebellar peduncles without destruction by tumors. CONCLUSION Three-dimensional anisotropy contrast imaging provides more information about damage to the neuronal tracts in cases of pontine gliomas than other MR imaging techniques. This technique may be used for preoperative mapping of the tumor and its relationship to the tracts, thus, providing an accurate road map for tumor resection.
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Affiliation(s)
- Hiroshi Kashimura
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Iwate 020-8505, Japan
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Al-Waili NS, Butler GJ. A combination of radiotherapy, nitric oxide and a hyperoxygenation sensitizing protocol for brain malignant tumor treatment. Med Hypotheses 2007; 68:528-37. [PMID: 17069987 DOI: 10.1016/j.mehy.2005.12.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2005] [Accepted: 12/03/2005] [Indexed: 11/19/2022]
Abstract
Brain malignant tumor such as glioblastoma is a challenging medical and surgical problem. In spite of surgery, radiotherapy and chemotherapy, the prognosis is still very poor. The limitations of currently available treatment modalities to cure or significantly prolong and improve the quality of life should stimulate rigorous research and studies to combat brain malignant tumors. While precision radiotherapy to reduce tumor size and ameliorate symptoms is still the standard of care, tumor sensitivity to radiation is compromised by low oxygen tensions and a necrotic tumor center. We propose to take advantage of the fact that elevated oxygen increases sensitivity of tumor cells to radiation. A specific application of hyperbaric oxygen (HBO(2)), using nitric oxide (NO) donors and inducers (such as L-arginine, dinitrite or tocopheryl succinate) and ascorbic acid to dilate blood vessels, should permit oxygen tensions in the range of 1000 mmHg to diffuse into the cells and thus increase sensitivity to radiation. This should permit doses that are low enough to cause the death of tumors cells yet minimize injury to brain tissue near the tumor and induced neurological sequelae.
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Affiliation(s)
- Noori S Al-Waili
- Life Support Technologies Group, NEWT Technologies, Inc., The Mount Vernon Hospital, Sound Shore Health System, New York, USA.
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Ogawa K, Yoshii Y, Inoue O, Toita T, Saito A, Kakinohana Y, Adachi G, Iraha S, Tamaki W, Sugimoto K, Hyodo A, Murayama S. Phase II trial of radiotherapy after hyperbaric oxygenation with chemotherapy for high-grade gliomas. Br J Cancer 2006; 95:862-8. [PMID: 16953239 PMCID: PMC2360529 DOI: 10.1038/sj.bjc.6603342] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
We conducted a phase II trial to evaluate the efficacy and toxicity of radiotherapy immediately after hyperbaric oxygenation (HBO) with chemotherapy in adults with high-grade gliomas. Patients with histologically confirmed high-grade gliomas were administered radiotherapy in daily 2 Gy fractions for 5 consecutive days per week up to a total dose of 60 Gy. Each fraction was administered immediately after HBO with the period of time from completion of decompression to irradiation being less than 15 min. Chemotherapy consisted of procarbazine, nimustine (ACNU) and vincristine and was administered during and after radiotherapy. A total of 41 patients (31 patients with glioblastoma and 10 patients with grade 3 gliomas) were enrolled. All 41 patients were able to complete a total radiotherapy dose of 60 Gy immediately after HBO with one course of concurrent chemotherapy. Of 30 assessable patients, 17 (57%) had an objective response including four CR and 13 PR. The median time to progression and the median survival time in glioblastoma patients were 12.3 months and 17.3 months, respectively. On univariate analysis, histologic grade (P=0.0001) and Karnofsky performance status (P=0.036) had a significant impact on survival, and on multivariate analysis, histologic grade alone was a significant prognostic factor for survival (P=0.001). Although grade 4 leukopenia and grade 4 thrombocytopenia occurred in 10 and 7% of all patients, respectively, these were transient with no patients developing neutropenic fever or intracranial haemorrhage. No serious nonhaematological or late toxicities were seen. These results indicated that radiotherapy delivered immediately after HBO with chemotherapy was safe with virtually no late toxicity in patients with high-grade gliomas. Further studies are required to strictly evaluate the effectiveness of radiotherapy after HBO for these tumours.
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Affiliation(s)
- K Ogawa
- Department of Radiology, University of the Ryukyus School of Medicine, 207 Uehara, Nishihara-cho, and Department of Radiology, Naha City Hospital, Okinawa 903-0215, Japan.
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