1
|
Dean JA, Tanguturi SK, Cagney D, Shin KY, Youssef G, Aizer A, Rahman R, Hammoudeh L, Reardon D, Lee E, Dietrich J, Tamura K, Aoyagi M, Wickersham L, Wen PY, Catalano P, Haas-Kogan D, Alexander BM, Michor F. Phase I study of a novel glioblastoma radiation therapy schedule exploiting cell-state plasticity. Neuro Oncol 2023; 25:1100-1112. [PMID: 36402744 PMCID: PMC10237407 DOI: 10.1093/neuonc/noac253] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2024] Open
Abstract
BACKGROUND Glioblastomas comprise heterogeneous cell populations with dynamic, bidirectional plasticity between treatment-resistant stem-like and treatment-sensitive differentiated states, with treatment influencing this process. However, current treatment protocols do not account for this plasticity. Previously, we generated a mathematical model based on preclinical experiments to describe this process and optimize a radiation therapy fractionation schedule that substantially increased survival relative to standard fractionation in a murine glioblastoma model. METHODS We developed statistical models to predict the survival benefit of interventions to glioblastoma patients based on the corresponding survival benefit in the mouse model used in our preclinical study. We applied our mathematical model of glioblastoma radiation response to optimize a radiation therapy fractionation schedule for patients undergoing re-irradiation for glioblastoma and developed a first-in-human trial (NCT03557372) to assess the feasibility and safety of administering our schedule. RESULTS Our statistical modeling predicted that the hazard ratio when comparing our novel radiation schedule with a standard schedule would be 0.74. Our mathematical modeling suggested that a practical, near-optimal schedule for re-irradiation of recurrent glioblastoma patients was 3.96 Gy × 7 (1 fraction/day) followed by 1.0 Gy × 9 (3 fractions/day). Our optimized schedule was successfully administered to 14/14 (100%) patients. CONCLUSIONS A novel radiation therapy schedule based on mathematical modeling of cell-state plasticity is feasible and safe to administer to glioblastoma patients.
Collapse
Affiliation(s)
- Jamie A Dean
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, Massachusetts, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
- UCL Cancer Institute, University College London, London, UK
| | - Shyam K Tanguturi
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Cagney
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Kee-Young Shin
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Gilbert Youssef
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Center for Neuro-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ayal Aizer
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Rifaquat Rahman
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Lubna Hammoudeh
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - David Reardon
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Eudocia Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Jorg Dietrich
- Center for Neuro-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kaoru Tamura
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masaru Aoyagi
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Lacey Wickersham
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul Catalano
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Daphne Haas-Kogan
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian M Alexander
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Franziska Michor
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, Massachusetts, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- The Center for Cancer Evolution, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- The Ludwig Center at Harvard, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Acquisition of meiotic DNA repair regulators maintain genome stability in glioblastoma. Cell Death Dis 2015; 6:e1732. [PMID: 25906155 PMCID: PMC4650544 DOI: 10.1038/cddis.2015.75] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 02/13/2015] [Accepted: 02/18/2015] [Indexed: 02/02/2023]
Abstract
Glioblastoma (GBM), the most prevalent type of primary intrinsic brain cancer in adults, remains universally fatal despite maximal therapy, including radiotherapy and chemotherapy. Cytotoxic therapy generates double-stranded DNA breaks (DSBs), most commonly repaired by homologous recombination (HR). We hypothesized that cancer cells coopt meiotic repair machinery as DSBs are generated during meiosis and repaired by molecular complexes distinct from genotoxic responses in somatic tissues. Indeed, we found that gliomas express meiotic repair genes and their expression informed poor prognosis. We interrogated the function of disrupted meiotic cDNA1 (DMC1), a homolog of RAD51, the primary recombinase used in mitotic cells to search and recombine with the homologous DNA template. DMC1, whose only known function is as an HR recombinase, was expressed by GBM cells and induced by radiation. Although targeting DMC1 in non-neoplastic cells minimally altered cell growth, DMC1 depletion in GBM cells decreased proliferation, induced activation of CHK1 and expression of p21CIP1/WAF1, and increased RPA foci, suggesting increased replication stress. Combining loss of DMC1 with ionizing radiation inhibited activation of DNA damage responses and increased radiosensitivity. Furthermore, loss of DMC1 reduced tumor growth and prolonged survival in vivo. Our results suggest that cancers coopt meiotic genes to augment survival under genotoxic stress, offering molecular targets with high therapeutic indices.
Collapse
|
4
|
Mathematical modeling of PDGF-driven glioblastoma reveals optimized radiation dosing schedules. Cell 2014; 156:603-616. [PMID: 24485463 DOI: 10.1016/j.cell.2013.12.029] [Citation(s) in RCA: 182] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 09/18/2013] [Accepted: 12/24/2013] [Indexed: 12/19/2022]
Abstract
Glioblastomas (GBMs) are the most common and malignant primary brain tumors and are aggressively treated with surgery, chemotherapy, and radiotherapy. Despite this treatment, recurrence is inevitable and survival has improved minimally over the last 50 years. Recent studies have suggested that GBMs exhibit both heterogeneity and instability of differentiation states and varying sensitivities of these states to radiation. Here, we employed an iterative combined theoretical and experimental strategy that takes into account tumor cellular heterogeneity and dynamically acquired radioresistance to predict the effectiveness of different radiation schedules. Using this model, we identified two delivery schedules predicted to significantly improve efficacy by taking advantage of the dynamic instability of radioresistance. These schedules led to superior survival in mice. Our interdisciplinary approach may also be applicable to other human cancer types treated with radiotherapy and, hence, may lay the foundation for significantly increasing the effectiveness of a mainstay of oncologic therapy. PAPERCLIP:
Collapse
|
5
|
Ciammella P, Galeandro M, D'Abbiero N, Podgornii A, Pisanello A, Botti A, Cagni E, Iori M, Iotti C. Hypo-fractionated IMRT for patients with newly diagnosed glioblastoma multiforme: a 6 year single institutional experience. Clin Neurol Neurosurg 2013; 115:1609-14. [PMID: 23453151 DOI: 10.1016/j.clineuro.2013.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 02/01/2013] [Accepted: 02/03/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Glioblastoma (GBM) is the most common malignant primary brain tumour in adults. Surgery and radiotherapy constitute the cornerstones for the therapeutic management of GBM. The standard treatment today is maximal surgical resection followed by concomitant chemo-radiation therapy followed by adjuvant TMZ according to Stupp protocol. Despite the progress in neurosurgery, radiotherapy and oncology, the prognosis still results poor. In order to reduce the long time of standard treatment, maintaining or improving the clinical results, in our institute we have investigated the effects of hypo-fractionated radiation therapy for patients with GBM. PATIENTS AND METHODS Sixty-seven patients affected by GBM who had previously undergone surgical resection (total, subtotal or biopsy) were enrolled between October 2005 and December 2011 in a single institutional study of hypo-fractionated intensity modulated radiation therapy (IMRT) followed or not by adjuvant chemotherapy with TMZ (6-12 cycles). The most important eligibility criteria were: biopsy-proven GBM, KPS ≥ 60, age ≥ 18 years, no previous brain irradiation, informed consensus. Hypo-fractionated IMRT was delivered to a total dose of 25 Gy in 5 fractions prescribed to 70% isodose. Response to treatment, OS, PFS, toxicity and patterns of recurrence were evaluated, and sex, age, type of surgery, Karnofsky performance status, Recursive Partitioning Analysis (RPA) classification, time between surgery and initiation of radiotherapy were evaluated as potential prognostic factors for survival. RESULTS All patients have completed the treatment protocol. Median age was 64.5 years (range 41-82 years) with 31 females (46%) and 36 males (54%). Median KPS at time of treatment was 80. The surgery was gross total in 38 patients and subtotal in 14 patients; 15 patients underwent only biopsy. No grade 3-4 acute or late neurotoxicity was observed. With median follow-up of 14.9 months, the median OS and PFS were 13.4 and 7.9 months, respectively. CONCLUSIONS The hypo-fractionated radiation therapy can be used for patients with GBM, resulting in favourable overall survival, low rates of toxicity and satisfying QoL. Future investigations are needed to determine the optimal fractionation for GBM.
Collapse
Affiliation(s)
- Patrizia Ciammella
- Radiation Therapy Unit, Department of Oncology and Advanced Technology, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Laigle-Donadey F, Navarro S, Delattre JY. [Gliomas in the elderly]. Rev Neurol (Paris) 2008; 164:542-6. [PMID: 18565352 DOI: 10.1016/j.neurol.2008.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Accepted: 03/20/2008] [Indexed: 10/22/2022]
Abstract
The incidence of malignant gliomas is growing in the elderly population. Unfortunately, increasing age is one of the most important negative prognostic factors in gliomas and the optimal management of this population remains largely unsettled because older patients are often excluded from clinical trials. However, the classic nihilistic approach is progressively changing towards more active strategies. Particularly, prospective randomized studies have recently established the benefit of radiation therapy and the validity of an accelerated course of radiation in older patients suffering from malignant gliomas. The interest of chemotherapy, alone or concomitant with radiation therapy is still under evaluation in this population. Initial performance status, quality of life and concomitant pathologies are important factors to consider before treatment onset. In the future, it will be necessary to develop specific schedules of treatment in this population.
Collapse
Affiliation(s)
- F Laigle-Donadey
- Service de neurologie Mazarin, hôpital de la Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France.
| | | | | |
Collapse
|
8
|
Abstract
PURPOSE OF REVIEW This review updates available data on the management of gliomas in the elderly. RECENT FINDINGS Prospective randomized studies have recently established the benefit of radiotherapy and the validity of an accelerated course of irradiation in older patients with malignant gliomas. SUMMARY The incidence of gliomas is increasing in the elderly population. Unfortunately, increasing age is one of the most consistent negative prognostic factors in gliomas and the optimal management of this population remains unsettled since patients aged 65 years or more are usually excluded from clinical trials. The previous nihilistic approach is progressively changing towards more active strategies with recent evidence that older patients (70-80 years) may benefit from surgery, radiotherapy, or chemotherapy. Initial performance status, quality of life, and concomitant pathologies are important factors to consider before treatment onset. In the future, it will be necessary to design specific schedules of treatment in this population.
Collapse
Affiliation(s)
- Florence Laigle-Donadey
- Service de Neurologie Mazarin, Hôpital de la Pitié-Salpêtrière - Assistance Publique-Hôpitaux de Paris, Paris, France.
| | | |
Collapse
|
9
|
Abstract
BACKGROUND Gliomas are the most common type of primary brain tumor. Nearly two-thirds of gliomas are highly malignant lesions that account for a disproportionate share of brain tumor-related morbidity and mortality. Despite recent advances, two-year survival for glioblastoma with optimal therapy is less than 30%. Even among patients with low-grade gliomas that confer a relatively good prognosis, treatment is almost never curative. REVIEW SUMMARY Surgery and radiation have been the mainstays of therapy for most glioma patients, but temozolomide chemotherapy has recently been proven to prolong overall survival in patients with glioblastoma. Intriguing data suggests that activity of O6-methylguanine-DNA methyltransferase (MGMT), in tumor cells may predict responsiveness to temozolomide and other alkylating agents. Novel treatment approaches, especially targeted molecular therapies against critical components of glioma signaling pathways, appear promising in preliminary studies. Optimal treatment for patients with low-grade gliomas has yet to be determined. Advances in oligodendroglioma biology have identified loss of chromosomes 1p and 19q as powerful indicators of a favorable prognosis. These same changes may predict response to chemotherapy. CONCLUSIONS Though the prognosis for many patients with gliomas is poor, the last decade produced a number of important advances, some of which have translated directly into survival benefits. Rapid progress in the field of glioma molecular biology continues to identify therapeutic targets and provide hope for the future of this challenging disease.
Collapse
Affiliation(s)
- Andrew D Norden
- Division of Cancer Neurology, Department of Neurology, Brigham and Women's Hospital and Center For Neuro-Oncology, Dana Farber Brigham and Women's Cancer Center, Boston, Massachusetts 02115, USA
| | | |
Collapse
|