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Indira Chandran V, Gopala S, Venkat EH, Kjolby M, Nejsum P. Extracellular vesicles in glioblastoma: a challenge and an opportunity. NPJ Precis Oncol 2024; 8:103. [PMID: 38760427 PMCID: PMC11101656 DOI: 10.1038/s41698-024-00600-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 05/03/2024] [Indexed: 05/19/2024] Open
Abstract
Glioblastoma is a highly heterogeneous tumor whose pathophysiological complexities dictate both the diagnosis of disease severity as well as response to therapy. Conventional diagnostic tools and standard treatment regimens have only managed to achieve limited success in the management of patients suspected of glioblastoma. Extracellular vesicles are an emerging liquid biopsy tool that has shown great promise in resolving the limitations presented by the heterogeneous nature of glioblastoma. Here we discuss the contrasting yet interdependent dual role of extracellular vesicles as communication agents that contribute to the progression of glioblastoma by creating a heterogeneous microenvironment and as a liquid biopsy tool providing an opportunity to accurately identify the disease severity and progression.
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Affiliation(s)
- Vineesh Indira Chandran
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark.
| | - Srinivas Gopala
- Department of Biochemistry, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Easwer Hariharan Venkat
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Mads Kjolby
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Pharmacology and Steno Diabetes Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Nejsum
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
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2
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Roda D, Veiga P, Melo JB, Carreira IM, Ribeiro IP. Principles in the Management of Glioblastoma. Genes (Basel) 2024; 15:501. [PMID: 38674436 PMCID: PMC11050118 DOI: 10.3390/genes15040501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
Glioblastoma, the most aggressive and common malignant primary brain tumour, is characterized by infiltrative growth, abundant vascularization, and aggressive clinical evolution. Patients with glioblastoma often face poor prognoses, with a median survival of approximately 15 months. Technological progress and the subsequent improvement in understanding the pathophysiology of these tumours have not translated into significant achievements in therapies or survival outcomes for patients. Progress in molecular profiling has yielded new omics data for a more refined classification of glioblastoma. Several typical genetic and epigenetic alterations in glioblastoma include mutations in genes regulating receptor tyrosine kinase (RTK)/rat sarcoma (RAS)/phosphoinositide 3-kinase (PI3K), p53, and retinoblastoma protein (RB) signalling, as well as mutation of isocitrate dehydrogenase (IDH), methylation of O6-methylguanine-DNA methyltransferase (MGMT), amplification of epidermal growth factor receptor vIII, and codeletion of 1p/19q. Certain microRNAs, such as miR-10b and miR-21, have also been identified as prognostic biomarkers. Effective treatment options for glioblastoma are limited. Surgery, radiotherapy, and alkylating agent chemotherapy remain the primary pillars of treatment. Only promoter methylation of the gene MGMT predicts the benefit from alkylating chemotherapy with temozolomide and it guides the choice of first-line treatment in elderly patients. Several targeted strategies based on tumour-intrinsic dominant signalling pathways and antigenic tumour profiles are under investigation in clinical trials. This review explores the potential genetic and epigenetic biomarkers that could be deployed as analytical tools in the diagnosis and prognostication of glioblastoma. Recent clinical advancements in treating glioblastoma are also discussed, along with the potential of liquid biopsies to advance personalized medicine in the field of glioblastoma, highlighting the challenges and promises for the future.
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Affiliation(s)
- Domingos Roda
- Algarve Radiation Oncology Unit—Joaquim Chaves Saúde (JCS), 8000-316 Faro, Portugal;
| | - Pedro Veiga
- Institute of Cellular and Molecular Biology, Cytogenetics and Genomics Laboratory, Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal; (P.V.); (J.B.M.)
| | - Joana Barbosa Melo
- Institute of Cellular and Molecular Biology, Cytogenetics and Genomics Laboratory, Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal; (P.V.); (J.B.M.)
- Coimbra Institute for Clinical and Biomedical Research (iCBR) and Center of Investigation on Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology (CIBB) and Clinical Academic Center of Coimbra (CACC), University of Coimbra, 3000-548 Coimbra, Portugal
| | - Isabel Marques Carreira
- Institute of Cellular and Molecular Biology, Cytogenetics and Genomics Laboratory, Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal; (P.V.); (J.B.M.)
- Coimbra Institute for Clinical and Biomedical Research (iCBR) and Center of Investigation on Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology (CIBB) and Clinical Academic Center of Coimbra (CACC), University of Coimbra, 3000-548 Coimbra, Portugal
| | - Ilda Patrícia Ribeiro
- Institute of Cellular and Molecular Biology, Cytogenetics and Genomics Laboratory, Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal; (P.V.); (J.B.M.)
- Coimbra Institute for Clinical and Biomedical Research (iCBR) and Center of Investigation on Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology (CIBB) and Clinical Academic Center of Coimbra (CACC), University of Coimbra, 3000-548 Coimbra, Portugal
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Vatankhahan H, Esteki F, Jabalameli MA, Kiani P, Ehtiati S, Movahedpour A, Vakili O, Khatami SH. Electrochemical biosensors for early diagnosis of glioblastoma. Clin Chim Acta 2024; 557:117878. [PMID: 38493942 DOI: 10.1016/j.cca.2024.117878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 03/19/2024]
Abstract
Glioblastoma (GBM) is a highly aggressive and life-threatening neurological malignancy of predominant astrocyte origin. This type of neoplasm can develop in either the brain or the spine and is also known as glioblastoma multiforme. Although current diagnostic methods such as magnetic resonance imaging (MRI) and positron emission tomography (PET) facilitate tumor location, these approaches are unable to assess disease severity. Furthermore, interpretation of imaging studies requires significant expertise which can have substantial inter-observer variability, thus challenging diagnosis and potentially delaying treatment. In contrast, biosensing systems offer a promising alternative to these traditional approaches. These technologies can continuously monitor specific molecules, providing valuable real-time data on treatment response, and could significantly improve patient outcomes. Among various types of biosensors, electrochemical systems are preferred over other types, as they do not require expensive or complex equipment or procedures and can be made with readily available materials and methods. Moreover, electrochemical biosensors can detect very small amounts of analytes with high accuracy and specificity by using various signal amplification strategies and recognition elements. Considering the advantages of electrochemical biosensors compared to other biosensing methods, we aim to highlight the potential application(s) of these sensors for GBM theranostics. The review's innovative insights are expected to antecede the development of novel biosensors and associated diagnostic platforms, ultimately restructuring GBM detection strategies.
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Affiliation(s)
- Hamid Vatankhahan
- Department of Biochemistry and Clinical Laboratories, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farnaz Esteki
- Department of Medical Laboratory Sciences, School of Paramedicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Mohammad Amin Jabalameli
- Department of Cell and Molecular Biology, School of Biology, College of Science, University of Tehran, Tehran, Iran
| | - Pouria Kiani
- Department of Clinical Biochemistry, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sajad Ehtiati
- Department of Clinical Biochemistry, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Omid Vakili
- Department of Clinical Biochemistry, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran; Autophagy Research Center, Department of Clinical Biochemistry, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Seyyed Hossein Khatami
- Student Research Committee, Department of Clinical Biochemistry, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Hallal SM, Tűzesi Á, Sida LA, Xian E, Madani D, Muralidharan K, Shivalingam B, Buckland ME, Satgunaseelan L, Alexander KL. Glioblastoma biomarkers in urinary extracellular vesicles reveal the potential for a 'liquid gold' biopsy. Br J Cancer 2024; 130:836-851. [PMID: 38212481 PMCID: PMC10912426 DOI: 10.1038/s41416-023-02548-9] [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: 08/14/2023] [Revised: 12/05/2023] [Accepted: 12/08/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Biomarkers that reflect glioblastoma tumour activity and treatment response are urgently needed to help guide clinical management, particularly for recurrent disease. As the urinary system is a major clearance route of circulating extracellular vesicles (EVs; 30-1000 nm nanoparticles) we explored whether sampling urinary-EVs could serve as a simple and non-invasive liquid biopsy approach for measuring glioblastoma-associated biomarkers. METHODS Fifty urine specimens (15-60 ml) were collected from 24 catheterised glioblastoma patients immediately prior to primary (n = 17) and recurrence (n = 7) surgeries, following gross total resection (n = 9), and from age/gender-matched healthy participants (n = 14). EVs isolated by differential ultracentrifugation were characterised and extracted proteomes were analysed by high-resolution data-independent acquisition liquid chromatography tandem mass spectrometry (DIA-LC-MS/MS). RESULTS Overall, 6857 proteins were confidently identified in urinary-EVs (q-value ≤ 0.01), including 94 EV marker proteins. Glioblastoma-specific proteomic signatures were determined, and putative urinary-EV biomarkers corresponding to tumour burden and recurrence were identified (FC ≥ | 2 | , adjust p-val≤0.05, AUC > 0.9). CONCLUSION In-depth DIA-LC-MS/MS characterisation of urinary-EVs substantiates urine as a viable source of glioblastoma biomarkers. The promising 'liquid gold' biomarker panels described here warrant further investigation.
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Affiliation(s)
- Susannah M Hallal
- Brain Cancer Research, Neurosurgery Department, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- School of Medical Sciences, Faculty of Medicine and Health Sciences, The University of Sydney, Camperdown, NSW, Australia
| | - Ágota Tűzesi
- Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- School of Medical Sciences, Faculty of Medicine and Health Sciences, The University of Sydney, Camperdown, NSW, Australia
| | - Liam A Sida
- School of Medical Sciences, Faculty of Medicine and Health Sciences, The University of Sydney, Camperdown, NSW, Australia
| | - Elissa Xian
- Brain Cancer Research, Neurosurgery Department, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Neurosurgery Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Daniel Madani
- Brain Cancer Research, Neurosurgery Department, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Neurosurgery Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Krishna Muralidharan
- Brain Cancer Research, Neurosurgery Department, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Neurosurgery Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Brindha Shivalingam
- Brain Cancer Research, Neurosurgery Department, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Neurosurgery Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Sydney Medical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
| | - Michael E Buckland
- Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- School of Medical Sciences, Faculty of Medicine and Health Sciences, The University of Sydney, Camperdown, NSW, Australia
| | - Laveniya Satgunaseelan
- Brain Cancer Research, Neurosurgery Department, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Sydney Medical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
| | - Kimberley L Alexander
- Brain Cancer Research, Neurosurgery Department, Chris O'Brien Lifehouse, Camperdown, NSW, Australia.
- Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
- School of Medical Sciences, Faculty of Medicine and Health Sciences, The University of Sydney, Camperdown, NSW, Australia.
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5
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Tankov S, Petrovic M, Lecoultre M, Espinoza F, El-Harane N, Bes V, Chliate S, Bedoya DM, Jordan O, Borchard G, Migliorini D, Dutoit V, Walker PR. Hypoxic glioblastoma-cell-derived extracellular vesicles impair cGAS-STING activity in macrophages. Cell Commun Signal 2024; 22:144. [PMID: 38389103 PMCID: PMC10882937 DOI: 10.1186/s12964-024-01523-y] [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: 09/01/2023] [Accepted: 02/10/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Solid tumors such as glioblastoma (GBM) exhibit hypoxic zones that are associated with poor prognosis and immunosuppression through multiple cell intrinsic mechanisms. However, release of extracellular vesicles (EVs) has the potential to transmit molecular cargos between cells. If hypoxic cancer cells use EVs to suppress functions of macrophages under adequate oxygenation, this could be an important underlying mechanism contributing to the immunosuppressive and immunologically cold tumor microenvironment of tumors such as GBM. METHODS EVs were isolated by differential ultracentrifugation from GBM cell culture supernatant. EVs were thoroughly characterized by transmission and cryo-electron microscopy, nanoparticle tracking analysis (NTA), and EV marker expression by Western blot and fluorescent NTA. EV uptake by macrophage cells was observed using confocal microscopy. The transfer of miR-25/93 as an EV cargo to macrophages was confirmed by miRNA real-time qPCR. The impact of miR-25/93 on the polarization of recipient macrophages was shown by transcriptional analysis, cytokine secretion and functional assays using co-cultured T cells. RESULTS We show that indirect effects of hypoxia can have immunosuppressive consequences through an EV and microRNA dependent mechanism active in both murine and human tumor and immune cells. Hypoxia enhanced EV release from GBM cells and upregulated expression of miR-25/93 both in cells and in EV cargos. Hypoxic GBM-derived EVs were taken up by macrophages and the miR-25/93 cargo was transferred, leading to impaired cGAS-STING pathway activation revealed by reduced type I IFN expression and secretion by macrophages. The EV-treated macrophages downregulated expression of M1 polarization-associated genes Cxcl9, Cxcl10 and Il12b, and had reduced capacity to attract activated T cells and to reactivate them to release IFN-γ, key components of an efficacious anti-tumor immune response. CONCLUSIONS Our findings suggest a mechanism by which immunosuppressive consequences of hypoxia mediated via miRNA-25/93 can be exported from hypoxic GBM cells to normoxic macrophages via EVs, thereby contributing to more widespread T-cell mediated immunosuppression in the tumor microenvironment.
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Affiliation(s)
- Stoyan Tankov
- Translational Research Center in Onco-Hematology (CRTOH), Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Swiss Cancer Center Léman, Geneva and Lausanne, Switzerland
| | - Marija Petrovic
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Marc Lecoultre
- Translational Research Center in Onco-Hematology (CRTOH), Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Swiss Cancer Center Léman, Geneva and Lausanne, Switzerland
| | - Felipe Espinoza
- Translational Research Center in Onco-Hematology (CRTOH), Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Swiss Cancer Center Léman, Geneva and Lausanne, Switzerland
| | - Nadia El-Harane
- Translational Research Center in Onco-Hematology (CRTOH), Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Swiss Cancer Center Léman, Geneva and Lausanne, Switzerland
| | - Viviane Bes
- Translational Research Center in Onco-Hematology (CRTOH), Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Swiss Cancer Center Léman, Geneva and Lausanne, Switzerland
| | - Sylvie Chliate
- Translational Research Center in Onco-Hematology (CRTOH), Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Swiss Cancer Center Léman, Geneva and Lausanne, Switzerland
| | - Darel Martinez Bedoya
- Translational Research Center in Onco-Hematology (CRTOH), Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Swiss Cancer Center Léman, Geneva and Lausanne, Switzerland
- Agora Cancer Research Center, Lausanne, Switzerland
| | - Olivier Jordan
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Gerrit Borchard
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Denis Migliorini
- Translational Research Center in Onco-Hematology (CRTOH), Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Swiss Cancer Center Léman, Geneva and Lausanne, Switzerland
- Agora Cancer Research Center, Lausanne, Switzerland
| | - Valérie Dutoit
- Translational Research Center in Onco-Hematology (CRTOH), Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Swiss Cancer Center Léman, Geneva and Lausanne, Switzerland
| | - Paul R Walker
- Translational Research Center in Onco-Hematology (CRTOH), Faculty of Medicine, University of Geneva, Geneva, Switzerland.
- Swiss Cancer Center Léman, Geneva and Lausanne, Switzerland.
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6
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Liguori GL. Challenges and Promise for Glioblastoma Treatment through Extracellular Vesicle Inquiry. Cells 2024; 13:336. [PMID: 38391949 PMCID: PMC10886570 DOI: 10.3390/cells13040336] [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: 12/15/2023] [Revised: 01/31/2024] [Accepted: 02/08/2024] [Indexed: 02/24/2024] Open
Abstract
Glioblastoma (GB) is a rare but extremely aggressive brain tumor that significantly impacts patient outcomes, affecting both duration and quality of life. The protocol established by Stupp and colleagues in 2005, based on radiotherapy and chemotherapy with Temozolomide, following maximum safe surgical resection remains the gold standard for GB treatment; however, it is evident nowadays that the extreme intratumoral and intertumoral heterogeneity, as well as the invasiveness and tendency to recur, of GB are not compatible with a routine and unfortunately ineffective treatment. This review article summarizes the main challenges in the search for new valuable therapies for GB and focuses on the impact that extracellular vesicle (EV) research and exploitation may have in the field. EVs are natural particles delimited by a lipidic bilayer and filled with functional cellular content that are released and uptaken by cells as key means of cell communication. Furthermore, EVs are stable in body fluids and well tolerated by the immune system, and are able to cross physiological, interspecies, and interkingdom barriers and to target specific cells, releasing inherent or externally loaded functionally active molecules. Therefore, EVs have the potential to be ideal allies in the fight against GB and to improve the prognosis for GB patients. The present work describes the main preclinical results obtained so far on the use of EVs for GB treatment, focusing on both the EV sources and molecular cargo used in the various functional studies, primarily in vivo. Finally, a SWOT analysis is performed, highlighting the main advantages and pitfalls of developing EV-based GB therapeutic strategies. The analysis also suggests the main directions to explore to realize the possibility of exploiting EVs for the treatment of GB.
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Affiliation(s)
- Giovanna L Liguori
- Institute of Genetics and Biophysics (IGB) "Adriano Buzzati-Traverso", National Research Council (CNR) of Italy, 80131 Naples, Italy
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Patnam S, Majumder B, Joshi P, Singh AD, Nagalla B, Kumar D, Biswas M, Ranjan A, Majumder PK, Rengan AK, Kamath AV, Ray A, Manda SV. Differential Expression of SRY-Related HMG-Box Transcription Factor 2, Oligodendrocyte Lineage Transcription Factor 2, and Zinc Finger E-Box Binding Homeobox 1 in Serum-Derived Extracellular Vesicles: Implications for Mithramycin Sensitivity and Targeted Therapy in High-Grade Glioma. ACS Pharmacol Transl Sci 2024; 7:137-149. [PMID: 38230292 PMCID: PMC10789128 DOI: 10.1021/acsptsci.3c00198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/27/2023] [Accepted: 12/01/2023] [Indexed: 01/18/2024]
Abstract
Glioblastoma multiforme (GBM) is the most aggressive type of glioma and is often resistant to traditional therapies. Evidence suggests that glioma stem cells (GSCs) contribute to this resistance. Mithramycin (Mit-A) targets GSCs and exhibits antitumor activity in GBM by affecting transcriptional targets such as SRY-related HMG-box transcription factor 2 (SOX2), oligodendrocyte lineage transcription factor 2 (OLIG2), and zinc finger E-box binding homeobox 1 (ZEB1). However, its clinical use has been limited by toxicity. This study explored the diagnostic potential of serum extracellular vesicles (EVs) to identify Mit-A responders. Serum EVs were isolated from 70 glioma patients, and targeted gene expression was analyzed using qRT-PCR. Using chemosensitivity assay, we identified 8 Mit-A responders and 17 nonresponders among 25 glioma patients. The M-score showed a significant correlation (p = 0.045) with isocitrate dehydrogenase 1 mutation but not other clinical variables. The genes SOX2 (p = 0.005), OLIG2 (p = 0.003), and ZEB1 (p = 0.0281) were found to be upregulated in the responder EVs. SOX2 had the highest diagnostic potential (AUC = 0.875), followed by OLIG2 (AUC = 0.772) and ZEB1 (AUC = 0.632).The combined gene panel showed significant diagnostic efficacy (AUC = 0.956) through logistic regression analysis. The gene panel was further validated in the serum EVs of 45 glioma patients. These findings highlight the potential of Mit-A as a targeted therapy for high-grade glioma based on differential gene expression in serum EVs. The gene panel could serve as a diagnostic tool to predict Mit-A sensitivity, offering a promising approach for personalized treatment strategies and emphasizing the role of GSCs in therapeutic resistance.
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Affiliation(s)
- Sreekanth Patnam
- Apollo
Hospitals Educational and Research Foundation (AHERF), Hyderabad, Hyderabad, Telangana 500033, India
- Department
of Biomedical Engineering, Indian Institute
of Technology, Kandi, Hyderabad 502285, India
| | - Biswanath Majumder
- Farcast
Biosciences, Bangalore, Karnataka 560100, India
- Oncology
Division, Bugworks Research India Pvt. Ltd., C-CAMP, Bangalore, Karnataka 560065, India
| | - Parth Joshi
- Department
of Neurosurgery, Apollo Hospitals, Hyderabad, Telangana 500029, India
| | - Anula Divyash Singh
- Apollo
Hospitals Educational and Research Foundation (AHERF), Hyderabad, Hyderabad, Telangana 500033, India
- Department
of Biomedical Engineering, Indian Institute
of Technology, Kandi, Hyderabad 502285, India
| | - Balakrishna Nagalla
- Apollo
Institute of Medical Sciences and Research, Hyderabad, Telangana, Hyderabad 500090, India
| | - Dilli Kumar
- Farcast
Biosciences, Bangalore, Karnataka 560100, India
| | | | - Alok Ranjan
- Department
of Neurosurgery, Apollo Hospitals, Hyderabad, Telangana 500029, India
| | - Pradip K. Majumder
- Department
of Cancer Biology, Praesidia Biotherapeutics, 1167 Massachusetts Avenue, Arlington, Massachusetts 02476, United States
| | - Aravind Kumar Rengan
- Department
of Biomedical Engineering, Indian Institute
of Technology, Kandi, Hyderabad 502285, India
| | | | - Amitava Ray
- Department
of Neurosurgery, Apollo Hospitals, Hyderabad, Telangana 500029, India
- Exsegen
Genomics Research Pvt.Ltd, Hyderabad, Telangana 500033, India
| | - Sasidhar Venkata Manda
- Apollo
Hospitals Educational and Research Foundation (AHERF), Hyderabad, Hyderabad, Telangana 500033, India
- UrvogelBio
Private Ltd, Hyderabad, Telangana 500096, India
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8
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Lunavat TR, Nieland L, Vrijmoet AB, Zargani-Piccardi A, Samaha Y, Breyne K, Breakefield XO. Roles of extracellular vesicles in glioblastoma: foes, friends and informers. Front Oncol 2023; 13:1291177. [PMID: 38074665 PMCID: PMC10704464 DOI: 10.3389/fonc.2023.1291177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/10/2023] [Indexed: 02/12/2024] Open
Abstract
Glioblastoma (GB) tumors are one of the most insidious cancers which take over the brain and defy therapy. Over time and in response to treatment the tumor and the brain cells in the tumor microenvironment (TME) undergo many genetic/epigenetic driven changes in their phenotypes and this is reflected in the cellular contents within the extracellular vesicles (EVs) they produce. With the result that some EVs try to subdue the tumor (friends of the brain), while others participate in the glioblastoma takeover (foes of the brain) in a dynamic and ever changing process. Monitoring the contents of these EVs in biofluids can inform decisions based on GB status to guide therapeutic intervention. This review covers primarily recent research describing the different cell types in the brain, as well as the tumor cells, which participate in this EV deluge. This includes EVs produced by the tumor which manipulate the transcriptome of normal cells in their environment in support of tumor growth (foes), as well as responses of normal cells which try to restrict tumor growth and invasion, including traveling to cervical lymph nodes to present tumor neo-antigens to dendritic cells (DCs). In addition EVs released by tumors into biofluids can report on the status of living tumor cells via their cargo and thus serving as biomarkers. However, EVs released by tumor cells and their influence on normal cells in the tumor microenvironment is a major factor in immune suppression and coercion of normal brain cells to join the GB "band wagon". Efforts are being made to deploy EVs as therapeutic vehicles for drugs and small inhibitory RNAs. Increasing knowledge about EVs in the TME is being utilized to track tumor progression and response to therapy and even to weaponize EVs to fight the tumor.
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Affiliation(s)
- Taral R. Lunavat
- Molecular Neurogenetics Unit, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, United States
- Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Lisa Nieland
- Molecular Neurogenetics Unit, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, United States
- Department of Neurosurgery, Leiden University Medical Center, Leiden, RC, Netherlands
| | - Anne B. Vrijmoet
- Molecular Neurogenetics Unit, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, United States
| | - Ayrton Zargani-Piccardi
- Molecular Neurogenetics Unit, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, United States
| | - Youssef Samaha
- Molecular Neurogenetics Unit, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, United States
| | - Koen Breyne
- Molecular Neurogenetics Unit, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, United States
| | - Xandra O. Breakefield
- Molecular Neurogenetics Unit, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, United States
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9
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Trivedi R, Bhat KP. Liquid biopsy: creating opportunities in brain space. Br J Cancer 2023; 129:1727-1746. [PMID: 37752289 PMCID: PMC10667495 DOI: 10.1038/s41416-023-02446-0] [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: 05/24/2023] [Revised: 09/10/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023] Open
Abstract
In recent years, liquid biopsy has emerged as an alternative method to diagnose and monitor tumors. Compared to classical tissue biopsy procedures, liquid biopsy facilitates the repetitive collection of diverse cellular and acellular analytes from various biofluids in a non/minimally invasive manner. This strategy is of greater significance for high-grade brain malignancies such as glioblastoma as the quantity and accessibility of tumors are limited, and there are collateral risks of compromised life quality coupled with surgical interventions. Currently, blood and cerebrospinal fluid (CSF) are the most common biofluids used to collect circulating cells and biomolecules of tumor origin. These liquid biopsy analytes have created opportunities for real-time investigations of distinct genetic, epigenetic, transcriptomics, proteomics, and metabolomics alterations associated with brain tumors. This review describes different classes of liquid biopsy biomarkers present in the biofluids of brain tumor patients. Moreover, an overview of the liquid biopsy applications, challenges, recent technological advances, and clinical trials in the brain have also been provided.
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Affiliation(s)
- Rakesh Trivedi
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Krishna P Bhat
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX, USA
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10
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Van Gool SW, Van de Vliet P, Kampers LFC, Kosmal J, Sprenger T, Reich E, Schirrmacher V, Stuecker W. Methods behind oncolytic virus-based DC vaccines in cancer: Toward a multiphase combined treatment strategy for Glioblastoma (GBM) patients. Methods Cell Biol 2023; 183:51-113. [PMID: 38548421 DOI: 10.1016/bs.mcb.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Glioblastoma (GBM) remains an orphan cancer disease with poor outcome. Novel treatment strategies are needed. Immunotherapy has several modes of action. The addition of active specific immunotherapy with dendritic cell vaccines resulted in improved overall survival of patients. Integration of DC vaccination within the first-line combined treatment became a challenge, and immunogenic cell death immunotherapy during chemotherapy was introduced. We used a retrospective analysis using real world data to evaluate the complex combined treatment, which included individualized multimodal immunotherapy during and after standard of care, and which required adaptations during treatment, and found a further improvement of overall survival. We also discuss the use of real world data as evidence. Novel strategies to move the field of individualized multimodal immunotherapy forward for GBM patients are reviewed.
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Affiliation(s)
| | | | | | | | | | - Ella Reich
- Immun-onkologisches Zentrum Köln, Cologne, Germany
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11
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Berzero G, Pieri V, Mortini P, Filippi M, Finocchiaro G. The coming of age of liquid biopsy in neuro-oncology. Brain 2023; 146:4015-4024. [PMID: 37289981 PMCID: PMC10545511 DOI: 10.1093/brain/awad195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 04/05/2023] [Accepted: 05/16/2023] [Indexed: 06/10/2023] Open
Abstract
The clinical role of liquid biopsy in oncology is growing significantly. In gliomas and other brain tumours, targeted sequencing of cell-free DNA (cfDNA) from CSF may help differential diagnosis when surgery is not recommended and be more representative of tumour heterogeneity than surgical specimens, unveiling targetable genetic alterations. Given the invasive nature of lumbar puncture to obtain CSF, the quantitative analysis of cfDNA in plasma is a lively option for patient follow-up. Confounding factors may be represented by cfDNA variations due to concomitant pathologies (inflammatory diseases, seizures) or clonal haematopoiesis. Pilot studies suggest that methylome analysis of cfDNA from plasma and temporary opening of the blood-brain barrier by ultrasound have the potential to overcome some of these limitations. Together with this, an increased understanding of mechanisms modulating the shedding of cfDNA by the tumour may help to decrypt the meaning of cfDNA kinetics in blood or CSF.
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Affiliation(s)
- Giulia Berzero
- Neurology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Valentina Pieri
- Neurology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Pietro Mortini
- Vita-Salute San Raffaele University, 20132 Milan, Italy
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Massimo Filippi
- Neurology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Vita-Salute San Raffaele University, 20132 Milan, Italy
- Neurorehabilitation Unit; Neurophysiology Unit; Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
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12
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Young JS, Al-Adli N, Scotford K, Cha S, Berger MS. Pseudoprogression versus true progression in glioblastoma: what neurosurgeons need to know. J Neurosurg 2023; 139:748-759. [PMID: 36790010 PMCID: PMC10412732 DOI: 10.3171/2022.12.jns222173] [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: 09/19/2022] [Accepted: 12/12/2022] [Indexed: 02/16/2023]
Abstract
Management of patients with glioblastoma (GBM) is complex and involves implementing standard therapies including resection, radiation therapy, and chemotherapy, as well as novel immunotherapies and targeted small-molecule inhibitors through clinical trials and precision medicine approaches. As treatments have advanced, the radiological and clinical assessment of patients with GBM has become even more challenging and nuanced. Advances in spatial resolution and both anatomical and physiological information that can be derived from MRI have greatly improved the noninvasive assessment of GBM before, during, and after therapy. Identification of pseudoprogression (PsP), defined as changes concerning for tumor progression that are, in fact, transient and related to treatment response, is critical for successful patient management. These temporary changes can produce new clinical symptoms due to mass effect and edema. Differentiating this entity from true tumor progression is a major decision point in the patient's management and prognosis. Providers may choose to start an alternative therapy, transition to a clinical trial, consider repeat resection, or continue with the current therapy in hopes of resolution. In this review, the authors describe the invasive and noninvasive techniques neurosurgeons need to be aware of to identify PsP and facilitate surgical decision-making.
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Affiliation(s)
- Jacob S. Young
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Nadeem Al-Adli
- Department of Neurological Surgery, University of California, San Francisco, California
- School of Medicine, Texas Christian University, Fort Worth, Texas
| | - Katie Scotford
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Soonmee Cha
- Department of Neurological Surgery, University of California, San Francisco, California
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Mitchel S. Berger
- Department of Neurological Surgery, University of California, San Francisco, California
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13
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Zanganeh S, Abbasgholinejad E, Doroudian M, Esmaelizad N, Farjadian F, Benhabbour SR. The Current Landscape of Glioblastoma Biomarkers in Body Fluids. Cancers (Basel) 2023; 15:3804. [PMID: 37568620 PMCID: PMC10416862 DOI: 10.3390/cancers15153804] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Glioblastoma (GBM) is a highly aggressive and lethal primary brain cancer that necessitates early detection and accurate diagnosis for effective treatment and improved patient outcomes. Traditional diagnostic methods, such as imaging techniques and tissue biopsies, have limitations in providing real-time information and distinguishing treatment-related changes from tumor progression. Liquid biopsies, used to analyze biomarkers in body fluids, offer a non-invasive and dynamic approach to detecting and monitoring GBM. This article provides an overview of GBM biomarkers in body fluids, including circulating tumor cells (CTCs), cell-free DNA (cfDNA), cell-free RNA (cfRNA), microRNA (miRNA), and extracellular vesicles. It explores the clinical utility of these biomarkers for GBM detection, monitoring, and prognosis. Challenges and limitations in implementing liquid biopsy strategies in clinical practice are also discussed. The article highlights the potential of liquid biopsies as valuable tools for personalized GBM management but underscores the need for standardized protocols and further research to optimize their clinical utility.
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Affiliation(s)
- Saba Zanganeh
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
| | - Elham Abbasgholinejad
- Department of Cell and Molecular Sciences, Faculty of Biological Sciences, Kharazmi University, Tehran 15719-14911, Iran; (E.A.); (N.E.)
| | - Mohammad Doroudian
- Department of Cell and Molecular Sciences, Faculty of Biological Sciences, Kharazmi University, Tehran 15719-14911, Iran; (E.A.); (N.E.)
| | - Nazanin Esmaelizad
- Department of Cell and Molecular Sciences, Faculty of Biological Sciences, Kharazmi University, Tehran 15719-14911, Iran; (E.A.); (N.E.)
| | - Fatemeh Farjadian
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz 71348-14336, Iran;
| | - Soumya Rahima Benhabbour
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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14
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Cumba Garcia LM, Bouchal SM, Bauman MMJ, Parney IF. Advancements and Technical Considerations for Extracellular Vesicle Isolation and Biomarker Identification in Glioblastoma. Neurosurgery 2023; 93:33-42. [PMID: 36749103 DOI: 10.1227/neu.0000000000002393] [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: 08/17/2022] [Accepted: 12/06/2022] [Indexed: 02/08/2023] Open
Abstract
Extracellular vesicles (EVs) are membrane-bound particles released by all cells. Previous research has found that these microscopic vesicles contribute to intercellular signaling and communication. EVs carry a variety of cargo, including nucleic acids, proteins, metabolites, and lipids. The composition of EVs varies based on cell of origin. Therefore, EVs can serve as an important biomarker in the diagnosis and treatment of various cancers. EVs derived from glioblastoma (GBM) cells carry biomarkers, which could serve as the basis for a potential diagnostic strategy known as liquid biopsy. Multiple EV isolation techniques exist, including ultrafiltration, size exclusion chromatography, flow field-flow fractionation, sequential filtration, differential ultracentrifugation, and density-gradient ultracentrifugation. Recent and ongoing work aims to identify cellular markers to distinguish GBM-derived EVs from those released by noncancerous cells. Strategies include proteomic analysis of GBM EVs, identification of GBM-specific metabolites, and use of Food and Drug Administration-approved 5-aminolevulinic acid-an oral agent that causes fluorescence of GBM cells-to recognize GBM EVs in a patient's blood. In addition, accurately and precisely monitoring changes in EV cargo concentrations could help differentiate between pseudoprogression and GBM recurrence, thus preventing unnecessary surgical interventions.
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Affiliation(s)
- Luz M Cumba Garcia
- Department of Immunology, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, USA
| | - Samantha M Bouchal
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Megan M J Bauman
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ian F Parney
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
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15
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Beetler DJ, Di Florio DN, Bruno KA, Ikezu T, March KL, Cooper LT, Wolfram J, Fairweather D. Extracellular vesicles as personalized medicine. Mol Aspects Med 2023; 91:101155. [PMID: 36456416 PMCID: PMC10073244 DOI: 10.1016/j.mam.2022.101155] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 10/14/2022] [Accepted: 10/26/2022] [Indexed: 11/29/2022]
Abstract
Extracellular vesicles (EVs) are released from all cells in the body, forming an important intercellular communication network that contributes to health and disease. The contents of EVs are cell source-specific, inducing distinct signaling responses in recipient cells. The specificity of EVs and their accumulation in fluid spaces that are accessible for liquid biopsies make them highly attractive as potential biomarkers and therapies for disease. The duality of EVs as favorable (therapeutic) or unfavorable (pathological) messengers is context dependent and remains to be fully determined in homeostasis and various disease states. This review describes the use of EVs as biomarkers, drug delivery vehicles, and regenerative therapeutics, highlighting examples involving viral infections, cancer, and neurological diseases. There is growing interest to provide personalized therapy based on individual patient and disease characteristics. Increasing evidence suggests that EV biomarkers and therapeutic approaches are ideal for personalized medicine due to the diversity and multifunctionality of EVs.
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Affiliation(s)
- Danielle J Beetler
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, 55902, USA; Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Damian N Di Florio
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, 55902, USA; Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Katelyn A Bruno
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, 32224, USA; Center for Regenerative Medicine, University of Florida, Gainesville, FL, 32611, USA; Division of Cardiology, University of Florida, Gainesville, FL, 32611, USA
| | - Tsuneya Ikezu
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Keith L March
- Center for Regenerative Medicine, University of Florida, Gainesville, FL, 32611, USA; Division of Cardiology, University of Florida, Gainesville, FL, 32611, USA
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Joy Wolfram
- School of Chemical Engineering, The University of Queensland, Brisbane, QLD, 4072, Australia; Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - DeLisa Fairweather
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, 55902, USA; Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, 32224, USA; Department of Environmental Health Sciences and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
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16
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Bauman MM, Bouchal SM, Monie DD, Aibaidula A(Z, Singh R, Parney IF. Strategies, considerations, and recent advancements in the development of liquid biopsy for glioblastoma: a step towards individualized medicine in glioblastoma. Neurosurg Focus 2022; 53:E14. [PMID: 36455271 PMCID: PMC9879623 DOI: 10.3171/2022.9.focus22430] [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: 07/31/2022] [Accepted: 09/19/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Glioblastoma (GBM) is a devasting primary brain tumor with less than a 5% 5-year survival. Treatment response assessment can be challenging because of inflammatory pseudoprogression that mimics true tumor progression clinically and on imaging. Developing additional noninvasive assays is critical. In this article, the authors review various biomarkers that could be used in developing liquid biopsies for GBM, along with strengths, limitations, and future applications. In addition, they present a potential liquid biopsy design based on the use of an extracellular vesicle-based liquid biopsy targeting nonneoplastic extracellular vesicles. METHODS The authors conducted a current literature review of liquid biopsy in GBM by searching the PubMed, Scopus, and Google Scholar databases. Articles were assessed for type of biomarker, isolation methodology, analytical techniques, and clinical relevance. RESULTS Recent work has shown that liquid biopsies of plasma, blood, and/or CSF hold promise as noninvasive clinical tools that can be used to diagnose recurrence, assess treatment response, and predict patient outcomes in GBM. Liquid biopsy in GBM has focused primarily on extracellular vesicles, cell-free tumor nucleic acids, and whole-cell isolates as focal biomarkers. GBM tumor signatures have been generated via analysis of tumor gene mutations, unique RNA expression, and metabolic and proteomic alterations. Liquid biopsies capture tumor heterogeneity, identifying alterations in GBM tumors that may be undetectable via surgical biopsy specimens. Finally, biomarker burden can be used to assess treatment response and recurrence in GBM. CONCLUSIONS Liquid biopsy offers a promising avenue for monitoring treatment response and recurrence in GBM without invasive procedures. Although additional steps must be taken to bring liquid biopsy into the clinic, proof-of-principle studies and isolation methodologies are promising. Ultimately, CSF and/or plasma-based liquid biopsy is likely to be a powerful tool in the neurosurgeon's arsenal in the near future for the treatment and management of GBM patients.
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Affiliation(s)
- Megan M.J. Bauman
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA,Department of Neurological Surgery, Rochester, Minnesota, USA
| | - Samantha M. Bouchal
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA,Department of Neurological Surgery, Rochester, Minnesota, USA
| | - Dileep D. Monie
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA,Department of Neurological Surgery, Rochester, Minnesota, USA
| | - Abudumijiti (Zack) Aibaidula
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Rohin Singh
- Mayo Clinic Alix School of Medicine, Phoenix, Arizona, USA
| | - Ian F. Parney
- Department of Neurological Surgery, Rochester, Minnesota, USA
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17
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Rackles E, Lopez PH, Falcon-Perez JM. Extracellular vesicles as source for the identification of minimally invasive molecular signatures in glioblastoma. Semin Cancer Biol 2022; 87:148-159. [PMID: 36375777 DOI: 10.1016/j.semcancer.2022.11.004] [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: 07/01/2022] [Revised: 10/21/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
The analysis of extracellular vesicles (EVs) as a source of cancer biomarkers is an emerging field since low-invasive biomarkers are highly demanded. EVs constitute a heterogeneous population of small membrane-contained vesicles that are present in most of body fluids. They are released by all cell types, including cancer cells and their cargo consists of nucleic acids, proteins and metabolites and varies depending on the biological-pathological state of the secretory cell. Therefore, EVs are considered as a potential source of reliable biomarkers for cancer. EV biomarkers in liquid biopsy can be a valuable tool to complement current medical technologies for cancer diagnosis, as their sampling is minimally invasive and can be repeated over time to monitor disease progression. In this review, we highlight the advances in EV biomarker research for cancer diagnosis, prognosis, and therapy monitoring. We especially focus on EV derived biomarkers for glioblastoma. The diagnosis and monitoring of glioblastoma still relies on imaging techniques, which are not sufficient to reflect the highly heterogenous and invasive nature of glioblastoma. Therefore, we discuss how the use of EV biomarkers could overcome the challenges faced in diagnosis and monitoring of glioblastoma.
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Affiliation(s)
- Elisabeth Rackles
- Exosomes Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Derio, Spain.
| | - Patricia Hernández Lopez
- Exosomes Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Derio, Spain.
| | - Juan M Falcon-Perez
- Exosomes Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Derio, Spain; Metabolomics Platform, CIC bioGUNE, Bizkaia Technology Park, 48160 Derio, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Madrid, Spain; Ikerbasque, Basque Foundation for Science, Bilbao, Spain.
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18
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Batool SM, Hsia T, Khanna SK, Gamblin AS, Rosenfeld Y, You DG, Carter BS, Balaj L. Decoding vesicle-based precision oncology in gliomas. Neurooncol Adv 2022; 4:ii53-ii60. [PMID: 36380860 PMCID: PMC9650467 DOI: 10.1093/noajnl/vdac035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Extracellular vesicles (EVs) represent a valuable tool in liquid biopsy with tremendous clinical potential in diagnosis, prognosis, and therapeutic monitoring of gliomas. Compared to tissue biopsy, EV-based liquid biopsy is a low-cost, minimally invasive method that can provide information on tumor dynamics before, during, and after treatment. Tumor-derived EVs circulating in biofluids carry a complex cargo of molecular biomarkers, including DNA, RNA, and proteins, which can be indicative of tumor growth and progression. Here, we briefly review current commercial and noncommercial methods for the isolation, quantification, and biochemical characterization of plasma EVs from patients with glioma, touching on whole EV analysis, mutation detection techniques, and genomic and proteomic profiling. We review notable advantages and disadvantages of plasma EV isolation and analytical methods, and we conclude with a discussion on clinical translational opportunities and key challenges associated with the future implementation of EV-based liquid biopsy for glioma treatment.
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Affiliation(s)
| | | | - Sirena K Khanna
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Austin S Gamblin
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yulia Rosenfeld
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dong Gil You
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Leonora Balaj
- Corresponding Author: Leonora Balaj, PhD, Department of Neurosurgery, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA ()
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19
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Rosa P, De Falco E, Pacini L, Piazza A, Ciracì P, Ricciardi L, Fiorentino F, Trungu S, Miscusi M, Raco A, Calogero A. Next-Generation Sequencing Comparative Analysis of DNA Mutations between Blood-Derived Extracellular Vesicles and Matched Cancer Tissue in Patients with Grade 4 Glioblastoma. Biomedicines 2022; 10:biomedicines10102590. [PMID: 36289852 PMCID: PMC9599233 DOI: 10.3390/biomedicines10102590] [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: 07/29/2022] [Revised: 10/05/2022] [Accepted: 10/12/2022] [Indexed: 12/24/2022] Open
Abstract
The biological heterogeneity of glioblastoma, IDH-wildtype (GBM, CNS WHO grade 4), the most aggressive type of brain cancer, is a critical hallmark, caused by changes in the genomic mutational asset and influencing clinical progression over time. The understanding and monitoring of the mutational profile is important not only to reveal novel therapeutic targets in this set of patients, but also to ameliorate the clinical stratification of subjects and the prognostic significance. As neurosurgery represents the primary technique to manage GBM, it is of utmost importance to optimize alternative and less invasive methods to monitor the dynamic mutation profile of these patients. Extracellular vesicles (EVs) are included in the liquid biopsy analysis and have emerged as the biological mirror of escaping and surviving mechanisms by many tumors, including glioblastoma. Very few studies have investigated the technical feasibility to detect and analyze the genomic profile by Next-Generation Sequencing (UMI system) in circulating EVs of patients with grade IV glioblastoma. Here, we attempted to characterize and to compare the corresponding matched tissue samples and potential variants with pathogenic significance of the DNA contained in peripheral-blood-derived EVs. The NGS analysis has revealed that patients with grade IV glioblastoma exhibited lesser DNA content in EVs than controls and that, both in EVs and matched cancer tissues, the NF1 gene was consistently mutated in all patients, with the c.2568C>G as the most common pathogenic variant expressed. This study supports the clinical utility of circulating EVs in glioblastoma as an eligible tool for personalized medicine.
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Affiliation(s)
- Paolo Rosa
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, C.so Della Repubblica 79, 04100 Latina, Italy
- Correspondence: (P.R.); (M.M.)
| | - Elena De Falco
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, C.so Della Repubblica 79, 04100 Latina, Italy
- Mediterranea Cardiocentro, 80122 Naples, Italy
| | - Luca Pacini
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, C.so Della Repubblica 79, 04100 Latina, Italy
| | - Amedeo Piazza
- Operative Unit of Neurosurgery, Department of NESMOS, Sapienza University of Rome, 00185 Rome, Italy
| | - Paolo Ciracì
- Operative Unit of Neurosurgery, Department of NESMOS, Sapienza University of Rome, 00185 Rome, Italy
| | - Luca Ricciardi
- Operative Unit of Neurosurgery, Department of NESMOS, Sapienza University of Rome, 00185 Rome, Italy
| | - Francesco Fiorentino
- Department of Molecular Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Sokol Trungu
- Operative Unit of Neurosurgery, Department of NESMOS, Sapienza University of Rome, 00185 Rome, Italy
- UO di Neurochirurgia, Azienda Ospedaliera Cardinal G. Panico, 73039 Tricase, Italy
| | - Massimo Miscusi
- Operative Unit of Neurosurgery, Department of NESMOS, Sapienza University of Rome, 00185 Rome, Italy
- Correspondence: (P.R.); (M.M.)
| | - Antonino Raco
- Operative Unit of Neurosurgery, Department of NESMOS, Sapienza University of Rome, 00185 Rome, Italy
| | - Antonella Calogero
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, C.so Della Repubblica 79, 04100 Latina, Italy
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20
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Tzaridis T, Weller J, Bachurski D, Shakeri F, Schaub C, Hau P, Buness A, Schlegel U, Steinbach J, Seidel C, Goldbrunner R, Schäfer N, Wechsler‐Reya RJ, Hallek M, Scheffler B, Glas M, Haeberle L, Herrlinger U, Coch C, Reiners KS, Hartmann G. “A novel serum extracellular vesicle protein signature to monitor glioblastoma tumor progression”. Int J Cancer 2022; 152:308-319. [DOI: 10.1002/ijc.34261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/01/2022] [Accepted: 08/10/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Theophilos Tzaridis
- Institute of Clinical Chemistry and Clinical Pharmacology University of Bonn Germany
- Division of Clinical Neurooncology, Department of Neurology, Center of Integrated Oncology Aachen‐Bonn‐Cologne‐Düsseldorf, Partner Site Bonn University of Bonn Germany
- Tumor Initiation & Maintenance Program Sanford Burnham Prebys Medical Discovery Institute La Jolla USA
| | - Johannes Weller
- Division of Clinical Neurooncology, Department of Neurology, Center of Integrated Oncology Aachen‐Bonn‐Cologne‐Düsseldorf, Partner Site Bonn University of Bonn Germany
| | - Daniel Bachurski
- Department I of Internal Medicine, Center for Integrated Oncology Aachen‐Bonn‐Cologne‐Düsseldorf, Partner Site Cologne, Center for Molecular Medicine Cologne University of Cologne Germany
| | - Farhad Shakeri
- Institute for Medical Biometry, Informatics and Epidemiology, Institute for Genomic Statistics and Bioinformatics, Medical Faculty University of Bonn Germany
| | - Christina Schaub
- Division of Clinical Neurooncology, Department of Neurology, Center of Integrated Oncology Aachen‐Bonn‐Cologne‐Düsseldorf, Partner Site Bonn University of Bonn Germany
| | - Peter Hau
- Department of Neurology and Wilhelm Sander NeuroOncology Unit University Hospital Regensburg Germany
| | - Andreas Buness
- Institute for Medical Biometry, Informatics and Epidemiology, Institute for Genomic Statistics and Bioinformatics, Medical Faculty University of Bonn Germany
| | - Uwe Schlegel
- Department of Neurology University Hospital Knappschaftskrankenhaus, Ruhr–University Bochum Germany
| | | | - Clemens Seidel
- Department of Radiation Oncology University of Leipzig Germany
| | | | - Niklas Schäfer
- Division of Clinical Neurooncology, Department of Neurology, Center of Integrated Oncology Aachen‐Bonn‐Cologne‐Düsseldorf, Partner Site Bonn University of Bonn Germany
| | - Robert J. Wechsler‐Reya
- Tumor Initiation & Maintenance Program Sanford Burnham Prebys Medical Discovery Institute La Jolla USA
| | - Michael Hallek
- Department I of Internal Medicine, Center for Integrated Oncology Aachen‐Bonn‐Cologne‐Düsseldorf, Partner Site Cologne, Center for Molecular Medicine Cologne University of Cologne Germany
| | - Björn Scheffler
- DKFZ‐Division Translational Neurooncology at the West German Cancer Center, German Cancer Consortium, DKFZ Heidelberg & Partner Site University Hospital Essen Germany
| | - Martin Glas
- Division of Clinical Neurooncology, Department of Neurology and West German Cancer Center, German Cancer Consortium University Hospital Essen Germany
| | - Lothar Haeberle
- Erlangen University Hospital, Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen‐EMN Friedrich Alexander University of Erlangen– Nuremberg Germany
| | - Ulrich Herrlinger
- Division of Clinical Neurooncology, Department of Neurology, Center of Integrated Oncology Aachen‐Bonn‐Cologne‐Düsseldorf, Partner Site Bonn University of Bonn Germany
| | - Christoph Coch
- Institute of Clinical Chemistry and Clinical Pharmacology University of Bonn Germany
| | - Katrin S. Reiners
- Institute of Clinical Chemistry and Clinical Pharmacology University of Bonn Germany
| | - Gunther Hartmann
- Institute of Clinical Chemistry and Clinical Pharmacology University of Bonn Germany
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DTI Abnormalities Related to Glioblastoma: A Prospective Comparative Study with Metastasis and Healthy Subjects. Curr Oncol 2022; 29:2823-2834. [PMID: 35448204 PMCID: PMC9027882 DOI: 10.3390/curroncol29040230] [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: 03/10/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Glioblastoma multiforme (GBM) shows complex mechanisms of spreading of the tumor cells, up to remote areas, and little is still known of these mechanisms, thus we focused on MRI abnormalities observable in the tumor and the brain adjacent to the lesion, up to the contralateral hemisphere, with a special interest on tensor diffusion imaging informing on white matter architecture; (2) Material and Methods: volumes, macroscopic volume (MV), brain-adjacent-tumor (BAT) volume and abnormal color-coded DTI volume (aCCV), and region-of-interest samples (probe volumes, ipsi, and contra lateral to the lesion), with their MRI characteristics, apparent diffusion coefficient (ADC), fractional anisotropy (FA) values, and number of fibers (DTI fiber tracking) were analyzed in patients suffering GBM (n = 15) and metastasis (n = 9), and healthy subjects (n = 15), using ad hoc statistical methods (type I error = 5%) (3) Results: GBM volumes were larger than metastasis volumes, aCCV being larger in GBM and BAT ADC was higher in metastasis, ADC decreased centripetally in metastasis, FA increased centripetally either in GBM or metastasis, MV and BAT FA values were higher in GBM, ipsi FA values of GBM ROIs were higher than those of metastasis, and the GBM ipsi number of fibers was higher than the GBM contra number of fibers; (4) Conclusions: The MV, BAT and especially the aCCV, as well as their related water diffusion characteristics, could be useful biomarkers in oncology and functional oncology.
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Bonosi L, Ferini G, Giammalva GR, Benigno UE, Porzio M, Giovannini EA, Musso S, Gerardi RM, Brunasso L, Costanzo R, Paolini F, Graziano F, Scalia G, Umana GE, Di Bonaventura R, Sturiale CL, Iacopino DG, Maugeri R. Liquid Biopsy in Diagnosis and Prognosis of High-Grade Gliomas; State-of-the-Art and Literature Review. Life (Basel) 2022; 12:life12030407. [PMID: 35330158 PMCID: PMC8950809 DOI: 10.3390/life12030407] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/05/2022] [Accepted: 03/08/2022] [Indexed: 12/31/2022] Open
Abstract
Gliomas, particularly high-grade gliomas, represent the most common and aggressive tumors of the CNS and are still burdened by high mortality and a very poor prognosis, regardless of the type of therapy. Their diagnosis and monitoring rely on imaging techniques and direct biopsy of the pathological tissue; however, both procedures have inherent limitations. To address these limitations, liquid biopsies have been proposed in this field. They could represent an innovative tool that could help clinicians in the early diagnosis, monitoring, and prognosis of these tumors. Furthermore, the rapid development of next-generation sequencing (NGS) technologies has led to a significant reduction in sequencing cost, with improved accuracy, providing a molecular profile of cancer and leading to better survival results and less disease burden. This paper focuses on the current clinical application of liquid biopsy in the early diagnosis and prognosis of cancer, introduces NGS-related methods, reviews recent progress, and summarizes challenges and future perspectives.
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Affiliation(s)
- Lapo Bonosi
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (U.E.B.); (M.P.); (E.A.G.); (S.M.); (R.M.G.); (L.B.); (R.C.); (F.P.); (D.G.I.); (R.M.)
- Correspondence: ; Tel.: +39-0916554656
| | - Gianluca Ferini
- Department of Radiation Oncology, REM Radioterapia srl, 95125 Catania, Italy;
| | - Giuseppe Roberto Giammalva
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (U.E.B.); (M.P.); (E.A.G.); (S.M.); (R.M.G.); (L.B.); (R.C.); (F.P.); (D.G.I.); (R.M.)
| | - Umberto Emanuele Benigno
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (U.E.B.); (M.P.); (E.A.G.); (S.M.); (R.M.G.); (L.B.); (R.C.); (F.P.); (D.G.I.); (R.M.)
| | - Massimiliano Porzio
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (U.E.B.); (M.P.); (E.A.G.); (S.M.); (R.M.G.); (L.B.); (R.C.); (F.P.); (D.G.I.); (R.M.)
| | - Evier Andrea Giovannini
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (U.E.B.); (M.P.); (E.A.G.); (S.M.); (R.M.G.); (L.B.); (R.C.); (F.P.); (D.G.I.); (R.M.)
| | - Sofia Musso
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (U.E.B.); (M.P.); (E.A.G.); (S.M.); (R.M.G.); (L.B.); (R.C.); (F.P.); (D.G.I.); (R.M.)
| | - Rosa Maria Gerardi
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (U.E.B.); (M.P.); (E.A.G.); (S.M.); (R.M.G.); (L.B.); (R.C.); (F.P.); (D.G.I.); (R.M.)
| | - Lara Brunasso
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (U.E.B.); (M.P.); (E.A.G.); (S.M.); (R.M.G.); (L.B.); (R.C.); (F.P.); (D.G.I.); (R.M.)
| | - Roberta Costanzo
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (U.E.B.); (M.P.); (E.A.G.); (S.M.); (R.M.G.); (L.B.); (R.C.); (F.P.); (D.G.I.); (R.M.)
| | - Federica Paolini
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (U.E.B.); (M.P.); (E.A.G.); (S.M.); (R.M.G.); (L.B.); (R.C.); (F.P.); (D.G.I.); (R.M.)
| | - Francesca Graziano
- Unit of Neurosurgery, Garibaldi Hospital, 95124 Catania, Italy; (F.G.); (G.S.)
| | - Gianluca Scalia
- Unit of Neurosurgery, Garibaldi Hospital, 95124 Catania, Italy; (F.G.); (G.S.)
| | - Giuseppe Emmanuele Umana
- Trauma Center, Gamma Knife Center, Department of Neurosurgery, Cannizzaro Hospital, 95125 Catania, Italy;
| | - Rina Di Bonaventura
- Department of Neurosurgery, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.D.B.); (C.L.S.)
| | - Carmelo Lucio Sturiale
- Department of Neurosurgery, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.D.B.); (C.L.S.)
| | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (U.E.B.); (M.P.); (E.A.G.); (S.M.); (R.M.G.); (L.B.); (R.C.); (F.P.); (D.G.I.); (R.M.)
| | - Rosario Maugeri
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (U.E.B.); (M.P.); (E.A.G.); (S.M.); (R.M.G.); (L.B.); (R.C.); (F.P.); (D.G.I.); (R.M.)
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