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Rolfe NW, Dadario NB, Canoll P, Bruce JN. A Review of Therapeutic Agents Given by Convection-Enhanced Delivery for Adult Glioblastoma. Pharmaceuticals (Basel) 2024; 17:973. [PMID: 39204078 PMCID: PMC11357193 DOI: 10.3390/ph17080973] [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: 06/25/2024] [Revised: 07/15/2024] [Accepted: 07/18/2024] [Indexed: 09/03/2024] Open
Abstract
Glioblastoma remains a devastating disease with a bleak prognosis despite continued research and numerous clinical trials. Convection-enhanced delivery offers researchers and clinicians a platform to bypass the blood-brain barrier and administer drugs directly to the brain parenchyma. While not without significant technological challenges, convection-enhanced delivery theoretically allows for a wide range of therapeutic agents to be delivered to the tumoral space while preventing systemic toxicities. This article provides a comprehensive review of the antitumor agents studied in clinical trials of convection-enhanced delivery to treat adult high-grade gliomas. Agents are grouped by classes, and preclinical evidence for these agents is summarized, as is a brief description of their mechanism of action. The strengths and weaknesses of each clinical trial are also outlined. By doing so, the difficulty of untangling the efficacy of a drug from the technological challenges of convection-enhanced delivery is highlighted. Finally, this article provides a focused review of some therapeutics that might stand to benefit from future clinical trials for glioblastoma using convection-enhanced delivery.
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Affiliation(s)
- Nathaniel W. Rolfe
- Department of Neurological Surgery, Columbia University Irving Medical Center/NY-Presbyterian Hospital, New York, NY 10032, USA;
| | - Nicholas B. Dadario
- Department of Neurological Surgery, Columbia University Irving Medical Center/NY-Presbyterian Hospital, New York, NY 10032, USA;
| | - Peter Canoll
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center/NY-Presbyterian Hospital, New York, NY 10032, USA;
| | - Jeffrey N. Bruce
- Department of Neurological Surgery, Columbia University Irving Medical Center/NY-Presbyterian Hospital, New York, NY 10032, USA;
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2
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Shaha S, Rodrigues D, Mitragotri S. Locoregional drug delivery for cancer therapy: Preclinical progress and clinical translation. J Control Release 2024; 367:737-767. [PMID: 38325716 DOI: 10.1016/j.jconrel.2024.01.072] [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: 11/24/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 02/09/2024]
Abstract
Systemic drug delivery is the current clinically preferred route for cancer therapy. However, challenges associated with tumor localization and off-tumor toxic effects limit the clinical effectiveness of this route. Locoregional drug delivery is an emerging viable alternative to systemic therapies. With the improvement in real-time imaging technologies and tools for direct access to tumor lesions, the clinical applicability of locoregional drug delivery is becoming more prominent. Theoretically, locoregional treatments can bypass challenges faced by systemic drug delivery. Preclinically, locoregional delivery of drugs has demonstrated enhanced therapeutic efficacy with limited off-target effects while still yielding an abscopal effect. Clinically, an array of locoregional strategies is under investigation for the delivery of drugs ranging in target and size. Locoregional tumor treatment strategies can be classified into two main categories: 1) direct drug infusion via injection or implanted port and 2) extended drug elution via injected or implanted depot. The number of studies investigating locoregional drug delivery strategies for cancer treatment is rising exponentially, in both preclinical and clinical settings, with some approaches approved for clinical use. Here, we highlight key preclinical advances and the clinical relevance of such locoregional delivery strategies in the treatment of cancer. Furthermore, we critically analyze 949 clinical trials involving locoregional drug delivery and discuss emerging trends.
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Affiliation(s)
- Suyog Shaha
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Allston, MA 02134, USA; Wyss Institute for Biologically Inspired Engineering, Boston, MA 02115, USA
| | - Danika Rodrigues
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Allston, MA 02134, USA; Wyss Institute for Biologically Inspired Engineering, Boston, MA 02115, USA
| | - Samir Mitragotri
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Allston, MA 02134, USA; Wyss Institute for Biologically Inspired Engineering, Boston, MA 02115, USA.
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3
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Fine RL, Mao Y, Dinnen R, Rosal RV, Raffo A, Hochfeld U, Senatus P, Bruce JN, Nichols G, Wang H, Li Y, Brandt-Rauf PW. C-Terminal p53 Palindromic Tetrapeptide Restores Full Apoptotic Function to Mutant p53 Cancer Cells In Vitro and In Vivo. Biomedicines 2023; 11:137. [PMID: 36672645 PMCID: PMC9855826 DOI: 10.3390/biomedicines11010137] [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: 05/08/2022] [Revised: 07/25/2022] [Accepted: 08/15/2022] [Indexed: 01/06/2023] Open
Abstract
We previously demonstrated that a synthetic monomer peptide derived from the C-terminus of p53 (aa 361−382) induced preferential apoptosis in mutant p53 malignant cells, but not normal cells. The major problem with the peptide was its short half-life (half-life < 10 min.) due to a random coil topology found in 3D proton NMR spectroscopy studies. To induce secondary/tertiary structures to produce more stability, we developed a peptide modelled after the tetrameric structure of p53 essential for activation of target genes. Starting with the above monomer peptide (aa 361−382), we added the nuclear localization sequence of p53 (aa 353−360) and the end of the C-terminal sequence (aa 383−393), resulting in a monomer spanning aa 353−393. Four monomers were linked by glycine to maximize flexibility and in a palindromic order that mimics p53 tetramer formation with four orthogonal alpha helices, which is required for p53 transactivation of target genes. This is now known as the 4 repeat-palindromic-p53 peptide or (4R-Pal-p53p). We explored two methods for testing the activity of the palindromic tetrapeptide: (1) exogenous peptide with a truncated antennapedia carrier (Ant) and (2) a doxycycline (Dox) inducer for endogenous expression. The exogenous peptide, 4R-Pal-p53p-Ant, contained a His tag at the N-terminal and a truncated 17aa Ant at the C-terminal. Exposure of human breast cancer MB-468 cells and human skin squamous cell cancer cells (both with mutant p53, 273 Arg->His) with purified peptide at 7 µM and 15 µM produced 52% and 75%, cell death, respectively. Comparatively, the monomeric p53 C-terminal peptide-Ant (aa 361−382, termed p53p-Ant), at 15 µM and 30 µM induced 15% and 24% cell death, respectively. Compared to the p53p-Ant, the exogenous 4R-pal-p53p-Ant was over five-fold more potent for inducing apoptosis at an equimolar concentration (15 µM). Endogenous 4R-Pal-p53p expression (without Ant), induced by Dox, resulted in 43% cell death in an engineered MB468 breast cancer stable cell line, while endogenous p53 C-terminal monomeric peptide expression produced no cell death due to rapid peptide degradation. The mechanism of apoptosis from 4R-Pal-p53p involved the extrinsic and intrinsic pathways (FAS, caspase-8, Bax, PUMA) for apoptosis, as well as increasing reactive oxygen species (ROS). All three death pathways were induced from transcriptional/translational activation of pro-apoptotic genes. Additionally, mRNA of p53 target genes (Bax and Fas) increased 14-fold and 18-fold, respectively, implying that the 4R-Pal-p53p restored full apoptotic potential to mutant p53. Monomeric p53p only increased Fas expression without a transcriptional or translational increase in Fas, and other genes and human marrow stem cell studies revealed no toxicity to normal stem cells for granulocytes, erythrocytes, monocytes, and macrophages (CFU-GEMM). Additionally, the peptide specifically targeted pre-malignant and malignant cells with mutant p53 and was not toxic to normal cells with basal levels of WT p53.
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Affiliation(s)
- Robert L. Fine
- Experimental Therapeutics Program, Division of Medical Oncology, College of Physicians and Surgeons of Columbia University, New York, NY 10314, USA
| | - Yuehua Mao
- Experimental Therapeutics Program, Division of Medical Oncology, College of Physicians and Surgeons of Columbia University, New York, NY 10314, USA
| | - Richard Dinnen
- Experimental Therapeutics Program, Division of Medical Oncology, College of Physicians and Surgeons of Columbia University, New York, NY 10314, USA
| | - Ramon V. Rosal
- Department of Environmental Health Sciences, Mailman School of Public Health of Columbia University, New York, NY 10314, USA
| | - Anthony Raffo
- Experimental Therapeutics Program, Division of Medical Oncology, College of Physicians and Surgeons of Columbia University, New York, NY 10314, USA
| | - Uri Hochfeld
- Experimental Therapeutics Program, Division of Medical Oncology, College of Physicians and Surgeons of Columbia University, New York, NY 10314, USA
| | - Patrick Senatus
- Department of Neurosurgery, Neurologic Institute of New York, Columbia University Medical Center, New York, NY 10032, USA
| | - Jeffrey N. Bruce
- Department of Neurosurgery, Neurologic Institute of New York, Columbia University Medical Center, New York, NY 10032, USA
| | - Gwen Nichols
- Experimental Therapeutics Program, Division of Medical Oncology, College of Physicians and Surgeons of Columbia University, New York, NY 10314, USA
| | - Hsin Wang
- Department of Chemistry, College of Staten Island, 2800 Victory Boulevard, New York, NY 10314, USA
| | - Yongliang Li
- Department of Environmental Health Sciences, Mailman School of Public Health of Columbia University, New York, NY 10314, USA
| | - Paul W. Brandt-Rauf
- Department of Environmental Health Sciences, Mailman School of Public Health of Columbia University, New York, NY 10314, USA
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA 19104, USA
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Mehta JN, Morales BE, Rossmeisl JH, Debinski W, Rylander CG. Solid Fiber Inside of Capillary and Modified Fusion-Spliced Fiber Optic Microneedle Devices for Improved Light Transmission Efficiency. J Med Device 2022; 16:041014. [PMID: 36353365 PMCID: PMC9632479 DOI: 10.1115/1.4055607] [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: 03/30/2022] [Revised: 09/01/2022] [Indexed: 11/08/2022] Open
Abstract
Convection-enhanced delivery (CED) is a drug delivery technique used to deliver therapeutics directly to the brain and is a continually evolving technique to treat glioblastoma. Early versions of CED have proven to result in inadequate drug volume dispersed (Vd), increasing the likelihood of tumor recurrence. Fiber optic microneedle devices (FMDs) with the ability to deliver fluid and thermal energy simultaneously have shown an ability to increase Vd, but FMDs have historically had low light transmission efficiency. In this study, we present a new fabrication method, solid fiber inside capillary (SFIC) FMD, and a modified fusion splicing (FS) method with the goal of increasing light delivery efficiency. The modified FS FMD resulted in an increase in light transmission efficiency between 49% and 173% compared to previous prototypes. However, the FS FMD resulted in significantly lower transmission efficiencies compared to the SFIC FMD (p ≤ 0.04) and FS FMDs perform much worse when light-absorptive materials, like black dye, are placed in the bore. The light absorption of a candidate cytotoxic agent, QUAD-CTX, appear to be similar to water, and light delivery through FS FMDs filled with QUAD-CTX achieves a transmission efficiency of 85.6 ± 5.4%. The fabrication process of the SFIC FMDs results in extremely fragile FMDs. Therefore, the use of a modified FS FMD fabrication process appears to be better suited for balancing the desire to increase light transmission efficiency while retaining a sturdy FMD construction.
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Affiliation(s)
- Jason N. Mehta
- Department of Mechanical Engineering, University of Texas at Austin, 204 E. Dean Keeton Street, Stop C2200, Austin, TX 78712-1591
| | - Brianna E. Morales
- Department of Biomedical Engineering, University of Texas at Austin, 301 E. Dean Keeton Street, C2100, Austin, TX 78712-2100
| | - John H. Rossmeisl
- Department of Small Animal Clinical Sciences, VA-MD College of Veterinary Medicine, Virginia Tech 205 Duckpond Drive, Blacksburg, VA 24061
| | - Waldemar Debinski
- Wake Forest Baptist Medical Center Comprehensive Cancer Center, 1 Medical Center Boulevard, Winston-Salem, NC 27157
| | - Christopher G. Rylander
- Department of Mechanical Engineering, University of Texas at Austin, 204 E. Dean Keeton Street, Stop C2200, Austin, TX 78712-1591
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5
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Chronic convection-enhanced intratumoural delivery of chemotherapy for glioblastoma. Lancet Oncol 2022; 23:1347-1348. [DOI: 10.1016/s1470-2045(22)00626-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/03/2022] [Accepted: 10/04/2022] [Indexed: 11/07/2022]
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Mehta JN, Rausch MK, Rylander CG. Convection-enhanced delivery with controlled catheter movement: A parametric finite element analysis. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2022; 38:e3635. [PMID: 35763587 PMCID: PMC9516958 DOI: 10.1002/cnm.3635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 05/12/2022] [Accepted: 06/26/2022] [Indexed: 06/15/2023]
Abstract
Convection-enhanced delivery (CED) is an investigational method for delivering therapeutics directly to the brain for the treatment of glioblastoma. However, it has not become a common clinical therapy due to an inability of CED treatments to deliver therapeutics in a large enough tissue volume to fully saturate the target region. We have recently shown that the combination of controlled catheter movement and constant pressure infusions can be used to significantly increase volume dispersed (Vd ) in an agarose gel brain tissue phantom. In the present study, we develop a computational model to predict Vd achieved by various retraction rates with both constant pressure and constant flow rate infusions. An increase in Vd is achieved with any movement rate, but increase in Vd between successive movement rates drops off at rates above 0.3-0.35 mm/min. Finally, we found that infusions with retraction result in a more even distribution in concentration level compared to the stationary catheter, suggesting a potential increased ability for moving catheters to have a therapeutic impact regardless of the required therapeutic concentration level.
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Affiliation(s)
- Jason N. Mehta
- Department of Mechanical Engineering, University of Texas at Austin, Austin, Texas, USA
| | - Manuel K. Rausch
- Department of Aerospace Engineering and Engineering Mechanics, University of Texas at Austin, Austin, Texas, USA
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Zhou YS, Wang W, Chen N, Wang LC, Huang JB. Research progress of anti-glioma chemotherapeutic drugs (Review). Oncol Rep 2022; 47:101. [PMID: 35362540 PMCID: PMC8990335 DOI: 10.3892/or.2022.8312] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 03/08/2022] [Indexed: 11/13/2022] Open
Abstract
Glioma is the most common primary intracranial malignancy in the central nervous system. At present, the most important treatment option is surgical resection of the tumor combined with radiotherapy and chemotherapy. The principle of operation is to remove the tumor to the maximal extent on the basis of preserving brain function. However, prominent invasive and infiltrative proliferation of glioma tumor cells into the surrounding normal tissues frequently reduces the efficacy of treatment. This in turn worsens the prognosis, because the tumor cannot be completely removed, which can readily relapse. Chemotherapeutic agents when applied individually have demonstrated limited efficacy for the treatment of glioma. However, multiple different chemotherapeutic agents can be used in combination with other treatment modalities to improve the efficacy while circumventing systemic toxicity and drug resistance. Therefore, it is pivotal to unravel the inhibitory mechanism mediated by the different chemotherapeutic drugs on glioma cells in preclinical studies. The aim of the present review is to provide a summary for understanding the effects of different chemotherapeutic drugs in glioma, in addition to providing a reference for the preclinical research into novel chemotherapeutic agents for future clinical application.
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Affiliation(s)
- Yi-Shu Zhou
- Department of Medical Imaging, Health Science Center, Yangtze University, Jingzhou, Hubei 434000, P.R. China
| | - Wei Wang
- Department of Radiology and Research Institute for Translation Medicine on Molecular Function and Artificial Intelligence Imaging, The First People's Hospital of Foshan, Foshan, Guangdong 528000, P.R. China
| | - Na Chen
- Department of Medical Imaging, Health Science Center, Yangtze University, Jingzhou, Hubei 434000, P.R. China
| | - Li-Cui Wang
- Department of Medical Imaging, Health Science Center, Yangtze University, Jingzhou, Hubei 434000, P.R. China
| | - Jin-Bai Huang
- Department of Medical Imaging, Health Science Center, Yangtze University, Jingzhou, Hubei 434000, P.R. China
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Aquilina K, Chakrapani A, Carr L, Kurian MA, Hargrave D. Convection-Enhanced Delivery in Children: Techniques and Applications. Adv Tech Stand Neurosurg 2022; 45:199-228. [PMID: 35976451 DOI: 10.1007/978-3-030-99166-1_6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Since its first description in 1994, convection-enhanced delivery (CED) has become a reliable method of administering drugs directly into the brain parenchyma. More predictable and effective than simple diffusion, CED bypasses the challenging boundary of the blood brain barrier, which has frustrated many attempts at delivering large molecules or polymers into the brain parenchyma. Although most of the clinical work with CED has been carried out on adults with incurable neoplasms, principally glioblastoma multiforme, an increasing number of studies have recognized its potential for paediatric applications, which now include treatment of currently incurable brain tumours such as diffuse intrinsic pontine glioma (DIPG), as well as metabolic and neurotransmitter diseases. The roadmap for the development of hardware and use of pharmacological agents in CED has been well-established, and some neurosurgical centres throughout the world have successfully undertaken clinical trials, admittedly mostly early phase, on the basis of in vitro, small animal and large animal pre-clinical foundations. However, the clinical efficacy of CED, although theoretically logical, has yet to be unequivocally demonstrated in a clinical trial; this applies particularly to neuro-oncology.This review aims to provide a broad description of the current knowledge of CED as applied to children. It reviews published studies of paediatric CED in the context of its wider history and developments and underlines the challenges related to the development of hardware, the selection of pharmacological agents, and gene therapy. It also reviews the difficulties related to the development of clinical trials involving CED and looks towards its potential disease-modifying opportunities in the future.
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Affiliation(s)
- K Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK.
| | - A Chakrapani
- Department of Metabolic Medicine, Great Ormond Street Hospital, London, UK
| | - L Carr
- Department of Neurology and Neurodisability, Great Ormond Street Hospital, London, UK
| | - M A Kurian
- Department of Neurology and Neurodisability, Great Ormond Street Hospital, London, UK
- Neurogenetics Group, Developmental Neurosciences, Zayed Centre for Research into Rare Disease in Children, UCL-Great Ormond Street Institute of Child Health, London, UK
| | - D Hargrave
- Cancer Group, UCL-Great Ormond Street Institute of Child Health, London, UK
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Convection Enhanced Delivery in the Setting of High-Grade Gliomas. Pharmaceutics 2021; 13:pharmaceutics13040561. [PMID: 33921157 PMCID: PMC8071501 DOI: 10.3390/pharmaceutics13040561] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/04/2021] [Accepted: 04/12/2021] [Indexed: 11/16/2022] Open
Abstract
Development of effective treatments for high-grade glioma (HGG) is hampered by (1) the blood–brain barrier (BBB), (2) an infiltrative growth pattern, (3) rapid development of therapeutic resistance, and, in many cases, (4) dose-limiting toxicity due to systemic exposure. Convection-enhanced delivery (CED) has the potential to significantly limit systemic toxicity and increase therapeutic index by directly delivering homogenous drug concentrations to the site of disease. In this review, we present clinical experiences and preclinical developments of CED in the setting of high-grade gliomas.
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Molotkov A, Carberry P, Dolan MA, Joseph S, Idumonyi S, Oya S, Castrillon J, Konofagou EE, Doubrovin M, Lesser GJ, Zanderigo F, Mintz A. Real-Time Positron Emission Tomography Evaluation of Topotecan Brain Kinetics after Ultrasound-Mediated Blood-Brain Barrier Permeability. Pharmaceutics 2021; 13:405. [PMID: 33803856 PMCID: PMC8003157 DOI: 10.3390/pharmaceutics13030405] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 01/13/2023] Open
Abstract
Glioblastoma (GBM) is the most common primary adult brain malignancy with an extremely poor prognosis and a median survival of fewer than two years. A key reason for this high mortality is that the blood-brain barrier (BBB) significantly restricts systemically delivered therapeutics to brain tumors. High-intensity focused ultrasound (HIFU) with microbubbles is a methodology being used in clinical trials to noninvasively permeabilize the BBB for systemic therapeutic delivery to GBM. Topotecan is a topoisomerase inhibitor used as a chemotherapeutic agent to treat ovarian and small cell lung cancer. Studies have suggested that topotecan can cross the BBB and can be used to treat brain metastases. However, pharmacokinetic data demonstrated that topotecan peak concentration in the brain extracellular fluid after systemic injection was ten times lower than in the blood, suggesting less than optimal BBB penetration by topotecan. We hypothesize that HIFU with microbubbles treatment can open the BBB and significantly increase topotecan concentration in the brain. We radiolabeled topotecan with 11C and acquired static and dynamic positron emission tomography (PET) scans to quantify [11C] topotecan uptake in the brains of normal mice and mice after HIFU treatment. We found that HIFU treatments significantly increased [11C] topotecan brain uptake. Moreover, kinetic analysis of the [11C] topotecan dynamic PET data demonstrated a substantial increase in [11C] topotecan volume of distribution in the brain. Furthermore, we found a decrease in [11C] topotecan brain clearance, confirming the potential of HIFU to aid in the delivery of topotecan through the BBB. This opens the potential clinical application of [11C] topotecan as a tool to predict topotecan loco-regional brain concentration in patients with GBMs undergoing experimental HIFU treatments.
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Affiliation(s)
- Andrei Molotkov
- Department of Radiology, Columbia University Medical Center, 722 West 168th Street, New York, NY 10032, USA; (A.M.); (P.C.); (M.A.D.); (S.J.); (S.I.); (S.O.); (J.C.); (M.D.)
| | - Patrick Carberry
- Department of Radiology, Columbia University Medical Center, 722 West 168th Street, New York, NY 10032, USA; (A.M.); (P.C.); (M.A.D.); (S.J.); (S.I.); (S.O.); (J.C.); (M.D.)
| | - Martin A. Dolan
- Department of Radiology, Columbia University Medical Center, 722 West 168th Street, New York, NY 10032, USA; (A.M.); (P.C.); (M.A.D.); (S.J.); (S.I.); (S.O.); (J.C.); (M.D.)
| | - Simon Joseph
- Department of Radiology, Columbia University Medical Center, 722 West 168th Street, New York, NY 10032, USA; (A.M.); (P.C.); (M.A.D.); (S.J.); (S.I.); (S.O.); (J.C.); (M.D.)
| | - Sidney Idumonyi
- Department of Radiology, Columbia University Medical Center, 722 West 168th Street, New York, NY 10032, USA; (A.M.); (P.C.); (M.A.D.); (S.J.); (S.I.); (S.O.); (J.C.); (M.D.)
| | - Shunichi Oya
- Department of Radiology, Columbia University Medical Center, 722 West 168th Street, New York, NY 10032, USA; (A.M.); (P.C.); (M.A.D.); (S.J.); (S.I.); (S.O.); (J.C.); (M.D.)
| | - John Castrillon
- Department of Radiology, Columbia University Medical Center, 722 West 168th Street, New York, NY 10032, USA; (A.M.); (P.C.); (M.A.D.); (S.J.); (S.I.); (S.O.); (J.C.); (M.D.)
| | - Elisa E. Konofagou
- Department of Biomedical Engineering, Columbia University Medical Center, 722 West 168th Street, New York, NY 10032, USA;
| | - Mikhail Doubrovin
- Department of Radiology, Columbia University Medical Center, 722 West 168th Street, New York, NY 10032, USA; (A.M.); (P.C.); (M.A.D.); (S.J.); (S.I.); (S.O.); (J.C.); (M.D.)
| | - Glenn J. Lesser
- Department of Internal Medicine, Section on Hematology and Oncology, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC 27157, USA;
| | - Francesca Zanderigo
- Department of Psychiatry, Columbia University Medical Center, 722 West 168th Street, New York, NY 10032, USA;
- Molecular Imaging and Neuropathology Area, New York State Psychiatric Institute, New York, NY 10032, USA
| | - Akiva Mintz
- Department of Radiology, Columbia University Medical Center, 722 West 168th Street, New York, NY 10032, USA; (A.M.); (P.C.); (M.A.D.); (S.J.); (S.I.); (S.O.); (J.C.); (M.D.)
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D'Amico RS, Aghi MK, Vogelbaum MA, Bruce JN. Convection-enhanced drug delivery for glioblastoma: a review. J Neurooncol 2021; 151:415-427. [PMID: 33611708 DOI: 10.1007/s11060-020-03408-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/18/2020] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Convection-enhanced delivery (CED) is a method of targeted, local drug delivery to the central nervous system (CNS) that bypasses the blood-brain barrier (BBB) and permits the delivery of high-dose therapeutics to large volumes of interest while limiting associated systemic toxicities. Since its inception, CED has undergone considerable preclinical and clinical study as a safe method for treating glioblastoma (GBM). However, the heterogeneity of both, the surgical procedure and the mechanisms of action of the agents studied-combined with the additional costs of performing a trial evaluating CED-has limited the field's ability to adequately assess the durability of any potential anti-tumor responses. As a result, the long-term efficacy of the agents studied to date remains difficult to assess. MATERIALS AND METHODS We searched PubMed using the phrase "convection-enhanced delivery and glioblastoma". The references of significant systematic reviews were also reviewed for additional sources. Articles focusing on physiological and physical mechanisms of CED were included as well as technological CED advances. RESULTS We review the history and principles of CED, procedural advancements and characteristics, and outcomes from key clinical trials, as well as discuss the potential future of this promising technique for the treatment of GBM. CONCLUSION While the long-term efficacy of the agents studied to date remains difficult to assess, CED remains a promising technique for the treatment of GBM.
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Affiliation(s)
- Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA.
| | - Manish K Aghi
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | - Jeffrey N Bruce
- Department of Neurological Surgery, New York Presbyterian/Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA
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Convection Enhanced Delivery of Topotecan for Gliomas: A Single-Center Experience. Pharmaceutics 2020; 13:pharmaceutics13010039. [PMID: 33396668 PMCID: PMC7823846 DOI: 10.3390/pharmaceutics13010039] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 12/24/2020] [Accepted: 12/24/2020] [Indexed: 12/24/2022] Open
Abstract
A key limitation to glioma treatment involves the blood brain barrier (BBB). Convection enhanced delivery (CED) is a technique that uses a catheter placed directly into the brain parenchyma to infuse treatments using a pressure gradient. In this manuscript, we describe the physical principles behind CED along with the common pitfalls and methods for optimizing convection. Finally, we highlight our institutional experience using topotecan CED for the treatment of malignant glioma.
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D’Amico RS, Neira JA, Yun J, Alexiades NG, Banu M, Englander ZK, Kennedy BC, Ung TH, Rothrock RJ, Romanov A, Guo X, Zhao B, Sonabend AM, Canoll P, Bruce JN. Validation of an effective implantable pump-infusion system for chronic convection-enhanced delivery of intracerebral topotecan in a large animal model. J Neurosurg 2020; 133:614-623. [PMID: 31374547 PMCID: PMC7227320 DOI: 10.3171/2019.3.jns1963] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/04/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intracerebral convection-enhanced delivery (CED) has been limited to short durations due to a reliance on externalized catheters. Preclinical studies investigating topotecan (TPT) CED for glioma have suggested that prolonged infusion improves survival. Internalized pump-catheter systems may facilitate chronic infusion. The authors describe the safety and utility of long-term TPT CED in a porcine model and correlation of drug distribution through coinfusion of gadolinium. METHODS Fully internalized CED pump-catheter systems were implanted in 12 pigs. Infusion algorithms featuring variable infusion schedules, flow rates, and concentrations of a mixture of TPT and gadolinium were characterized over increasing intervals from 4 to 32 days. Therapy distribution was measured using gadolinium signal on MRI as a surrogate. A 9-point neurobehavioral scale (NBS) was used to identify side effects. RESULTS All animals tolerated infusion without serious adverse events. The average NBS score was 8.99. The average maximum volume of distribution (Vdmax) in chronically infused animals was 11.30 mL and represented 32.73% of the ipsilateral cerebral hemispheric volume. Vdmax was achieved early during infusions and remained relatively stable despite a slight decline as the infusion reached steady state. Novel tissue TPT concentrations measured by liquid chromatography mass spectroscopy correlated with gadolinium signal intensity on MRI (p = 0.0078). CONCLUSIONS Prolonged TPT-gadolinium CED via an internalized system is safe and well tolerated and can achieve a large Vdmax, as well as maintain a stable Vd for up to 32 days. Gadolinium provides an identifiable surrogate for measuring drug distribution. Extended CED is potentially a broadly applicable and safe therapeutic option in select patients.
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Affiliation(s)
- Randy S. D’Amico
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Justin A. Neira
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Jonathan Yun
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Nikita G. Alexiades
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Matei Banu
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Zachary K. Englander
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Benjamin C. Kennedy
- Division of Neurosurgery, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy H. Ung
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Robert J. Rothrock
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Alexander Romanov
- Institute of Comparative Medicine, Columbia University Medical Center, New York, New York
| | - Xiaotao Guo
- Department of Radiology, Columbia University Medical Center, New York, New York
| | - Binsheng Zhao
- Department of Radiology, Columbia University Medical Center, New York, New York
| | - Adam M. Sonabend
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Peter Canoll
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Jeffrey N. Bruce
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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Butowski NA, Bringas JR, Bankiewicz KS, Aghi MK. Editorial. Chronic convection-enhanced delivery: the next frontier in regional drug infusion for glioblastoma. J Neurosurg 2020; 133:611-613. [PMID: 31374552 DOI: 10.3171/2019.4.jns19614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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15
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Celastrol-induced degradation of FANCD2 sensitizes pediatric high-grade gliomas to the DNA-crosslinking agent carboplatin. EBioMedicine 2019; 50:81-92. [PMID: 31735550 PMCID: PMC6921187 DOI: 10.1016/j.ebiom.2019.10.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/26/2019] [Accepted: 10/31/2019] [Indexed: 12/25/2022] Open
Abstract
Background Pediatric high-grade gliomas (pHGG) are the leading cause of cancer-related death during childhood. Due to their diffuse growth characteristics, chemoresistance and location behind the blood-brain barrier (BBB), the prognosis of pHGG has barely improved in the past decades. As such, there is a dire need for new therapies that circumvent those difficulties. Since aberrant expression of DNA damage-response associated Fanconi anemia proteins play a central role in the onset and therapy resistance of many cancers, we here investigated if FANCD2 depletion could sensitize pHGG to additional DNA damage. Methods We determined the capacity of celastrol, a BBB-penetrable compound that degrades FANCD2, to sensitize glioma cells to the archetypical DNA-crosslinking agent carboplatin in vitro in seven patient-derived pHGG models. In addition, we tested this drug combination in vivo in a patient-derived orthotopic pHGG xenograft model. Underlying mechanisms to drug response were investigated using mRNA expression profiling, western blotting, immunofluorescence, FANCD2 knockdown and DNA fiber assays. Findings FANCD2 is overexpressed in HGGs and depletion of FANCD2 by celastrol synergises with carboplatin to induce cytotoxicity. Combination therapy prolongs survival of pHGG-bearing mice over monotherapy and control groups in vivo (P<0.05). In addition, our results suggest that celastrol treatment stalls ongoing replication forks, causing sensitivity to DNA-crosslinking in FANCD2-dependent glioma cells. Interpretation Our results show that depletion of FANCD2 acts as a chemo-sensitizing strategy in pHGG. Combination therapy using celastrol and carboplatin might serve as a clinically relevant strategy for the treatment of pHGG. Funding This study was funded by a grant from the Children Cancer-Free Foundation (KIKA, project 210). The disclosed funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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Stine CA, Munson JM. Convection-Enhanced Delivery: Connection to and Impact of Interstitial Fluid Flow. Front Oncol 2019; 9:966. [PMID: 31632905 PMCID: PMC6783516 DOI: 10.3389/fonc.2019.00966] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 09/11/2019] [Indexed: 01/08/2023] Open
Abstract
Convection-enhanced delivery (CED) is a method used to increase transport of therapeutics in and around brain tumors. CED works through locally applying a pressure differential to drive fluid flow throughout the tumor, such that convective forces dominate over diffusive transport. This allows therapies to bypass the blood brain barrier that would otherwise be too large or solely rely on passive diffusion. However, this also drives fluid flow out through the tumor bulk into surrounding brain parenchyma, which results in increased interstitial fluid (IF) flow, or fluid flow within extracellular spaces in the tissue. IF flow has been associated with altered transport of molecules, extracellular matrix rearrangement, and triggering of cellular motility through a number of mechanisms. Thus, the results of a simple method to increase drug delivery may have unintended consequences on tissue morphology. Clinically, prediction of dispersal of agents via CED is important to catheter design, placement, and implementation to optimize contact of tumor cells with therapeutic agent. Prediction software can aid in this problem, yet we wonder if there is a better way to predict therapeutic distribution based simply on IF flow pathways as determined from pre-intervention imaging. Overall, CED based therapy has seen limited success and we posit that integration and appreciation of altered IF flow may enhance outcomes. Thus, in this manuscript we both review the current state of the art in CED and IF flow mechanistic understanding and relate these two elements to each other in a clinical context.
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Affiliation(s)
| | - Jennifer M. Munson
- Department of Biomedical Engineering and Mechanics, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States
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Arnone GD, Bhimani AD, Aguilar T, Mehta AI. Localized targeted antiangiogenic drug delivery for glioblastoma. J Neurooncol 2018; 137:223-231. [DOI: 10.1007/s11060-018-2747-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/05/2018] [Indexed: 12/25/2022]
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18
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Systems engineers’ role in biomedical research. Convection-enhanced drug delivery. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/b978-0-444-63964-6.00009-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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19
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Mehta A, Ghaghada K, Mukundan S. Molecular Imaging of Brain Tumors Using Liposomal Contrast Agents and Nanoparticles. Magn Reson Imaging Clin N Am 2016; 24:751-763. [PMID: 27742115 DOI: 10.1016/j.mric.2016.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The first generation of cross-sectional brain imaging using computed tomography (CT), ultrasonography, and eventually MR imaging focused on determining structural or anatomic changes associated with brain disorders. The current state-of-the-art imaging, functional imaging, uses techniques such as CT and MR perfusion that allow determination of physiologic parameters in vivo. In parallel, tissue-based genomic, transcriptomic, and proteomic profiling of brain tumors has created several novel and exciting possibilities for molecular targeting of brain tumors. The next generation of imaging translates these molecular in vitro techniques to in vivo, noninvasive, targeted reconstruction of tumors and their microenvironments.
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Affiliation(s)
- Arnav Mehta
- Medical Scientist Training Program, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA 90095, USA; Division of Biology and Biological Engineering, California Institute of Technology, 1200 East California Boulevard, Pasadena, CA 91125, USA
| | - Ketan Ghaghada
- Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, 1102 Bates Street, Suite 850, Houston, TX 77030, USA; Department of Radiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Srinivasan Mukundan
- Division of Neuroradiology, Department of Radiology, Brigham and Woman's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Jahangiri A, Chin AT, Flanigan PM, Chen R, Bankiewicz K, Aghi MK. Convection-enhanced delivery in glioblastoma: a review of preclinical and clinical studies. J Neurosurg 2016; 126:191-200. [PMID: 27035164 DOI: 10.3171/2016.1.jns151591] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Glioblastoma is the most common malignant brain tumor, and it carries an extremely poor prognosis. Attempts to develop targeted therapies have been hindered because the blood-brain barrier prevents many drugs from reaching tumors cells. Furthermore, systemic toxicity of drugs often limits their therapeutic potential. A number of alternative methods of delivery have been developed, one of which is convection-enhanced delivery (CED), the focus of this review. The authors describe CED as a therapeutic measure and review preclinical studies and the most prominent clinical trials of CED in the treatment of glioblastoma. The utilization of this technique for the delivery of a variety of agents is covered, and its shortcomings and challenges are discussed in detail.
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Affiliation(s)
- Arman Jahangiri
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
| | - Aaron T Chin
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
| | - Patrick M Flanigan
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
| | - Rebecca Chen
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
| | - Krystof Bankiewicz
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
| | - Manish K Aghi
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
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21
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Ung TH, Malone H, Canoll P, Bruce JN. Convection-enhanced delivery for glioblastoma: targeted delivery of antitumor therapeutics. CNS Oncol 2015; 4:225-34. [PMID: 26103989 DOI: 10.2217/cns.15.12] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Glioblastoma is the most common primary brain tumor in adults and carries a dismal prognosis despite advancements in treatment. Diffuse tumor infiltration precludes curative surgical resection and necessitates advancements in drug delivery mechanisms. Convection-enhanced delivery (CED) enables continuous local drug delivery for a diverse population of antitumor agents. Importantly, CED circumvents therapeutic challenges posed by the blood-brain barrier by facilitating concentrated local therapeutic drug delivery with limited systemic effects. Here, we present a concise review of properties essential for safe and efficient convection-enhanced drug delivery, as well as a focused review of clinical studies evaluating CED in the treatment of glioblastoma.
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Affiliation(s)
- Timothy H Ung
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032, USA
| | - Hani Malone
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032, USA
| | - Peter Canoll
- Department of Pathology & Cellular Biology, Columbia University Medical Center, New York, NY 10032, USA
| | - Jeffrey N Bruce
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032, USA
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22
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Movement of magnetic nanoparticles in brain tissue: mechanisms and impact on normal neuronal function. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2015; 11:1821-9. [PMID: 26115639 DOI: 10.1016/j.nano.2015.06.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 06/01/2015] [Accepted: 06/09/2015] [Indexed: 12/11/2022]
Abstract
UNLABELLED Magnetic nanoparticles (MNPs) have been used as effective vehicles for targeted delivery of theranostic agents in the brain. The advantage of magnetic targeting lies in the ability to control the concentration and distribution of therapy to a desired target region using external driving magnets. In this study, we investigated the behavior and safety of MNP motion in brain tissue. We found that MNPs move and form nanoparticle chains in the presence of a uniform magnetic field, and that this chaining is influenced by the applied magnetic field intensity and the concentration of MNPs in the tissue. Using electrophysiology recordings, immunohistochemistry and fluorescent imaging we assessed the functional health of neurons and neural circuits and found no adverse effects associated with MNP motion through brain tissue. FROM THE CLINICAL EDITOR Much research has been done to test the use of nanocarriers for gaining access across the blood brain barrier (BBB). In this respect, magnetic nanoparticles (MNPs) are one of the most studied candidates. Nonetheless, the behavior and safety of MNP once inside brain tissue remains unknown. In this article, the authors thus studied this very important subject.
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23
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Woodworth GF, Dunn GP, Nance EA, Hanes J, Brem H. Emerging insights into barriers to effective brain tumor therapeutics. Front Oncol 2014; 4:126. [PMID: 25101239 PMCID: PMC4104487 DOI: 10.3389/fonc.2014.00126] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 05/13/2014] [Indexed: 12/27/2022] Open
Abstract
There is great promise that ongoing advances in the delivery of therapeutics to the central nervous system (CNS) combined with rapidly expanding knowledge of brain tumor patho-biology will provide new, more effective therapies. Brain tumors that form from brain cells, as opposed to those that come from other parts of the body, rarely metastasize outside of the CNS. Instead, the tumor cells invade deep into the brain itself, causing disruption in brain circuits, blood vessel and blood flow changes, and tissue swelling. Patients with the most common and deadly form, glioblastoma (GBM) rarely live more than 2 years even with the most aggressive treatments and often with devastating neurological consequences. Current treatments include maximal safe surgical removal or biopsy followed by radiation and chemotherapy to address the residual tumor mass and invading tumor cells. However, delivering effective and sustained treatments to these invading cells without damaging healthy brain tissue is a major challenge and focus of the emerging fields of nanomedicine and viral and cell-based therapies. New treatment strategies, particularly those directed against the invasive component of this devastating CNS disease, are sorely needed. In this review, we (1) discuss the history and evolution of treatments for GBM, (2) define and explore three critical barriers to improving therapeutic delivery to invasive brain tumors, specifically, the neuro-vascular unit as it relates to the blood brain barrier, the extra-cellular space in regard to the brain penetration barrier, and the tumor genetic heterogeneity and instability in association with the treatment efficacy barrier, and (3) identify promising new therapeutic delivery approaches that have the potential to address these barriers and create sustained, meaningful efficacy against GBM.
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Affiliation(s)
- Graeme F Woodworth
- Department of Neurosurgery, University of Maryland School of Medicine , Baltimore, MD , USA ; Department of Anatomy and Neurobiology, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Gavin P Dunn
- Department of Neurosurgery, Pathology and Immunology, Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine , St. Louis, MO , USA
| | - Elizabeth A Nance
- Center for Nanomedicine, Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Justin Hanes
- Center for Nanomedicine, Johns Hopkins University School of Medicine , Baltimore, MD , USA ; Department of Ophthalmology, Johns Hopkins University School of Medicine , Baltimore, MD , USA ; Department of Neurosurgery, Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Henry Brem
- Department of Neurosurgery, Johns Hopkins University School of Medicine , Baltimore, MD , USA
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AndersoN RCE, Kennedy B, Yanes CL, Garvin J, Needle M, Canoll P, Feldstein NA, Bruce JN. Convection-enhanced delivery of topotecan into diffuse intrinsic brainstem tumors in children. J Neurosurg Pediatr 2013; 11:289-95. [PMID: 23240851 PMCID: PMC7227321 DOI: 10.3171/2012.10.peds12142] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Convection-enhanced delivery (CED) for the treatment of malignant gliomas is a technique that can deliver chemotherapeutic agents directly into the tumor and the surrounding interstitium through sustained, low-grade positive-pressure infusion. This allows for high local concentrations of drug within the tumor while minimizing systemic levels that often lead to dose-limiting toxicity. Diffuse intrinsic pontine gliomas (DIPGs) are universally fatal childhood tumors for which there is currently no effective treatment. In this report the authors describe CED of the topoisomerase inhibitor topotecan for the treatment of DIPG in 2 children. As part of a pilot feasibility study, the authors treated 2 pediatric patients with DIPG. Stereotactic biopsy with frozen section confirmation of glial tumor was followed by placement of bilateral catheters for CED of topotecan during the same procedure. The first patient underwent CED 210 days after initial diagnosis, after radiation therapy and at the time of tumor recurrence, with a total dose of 0.403 mg in 6.04 ml over 100 hours. Her Karnofsky Performance Status (KPS) score was 60 before CED and 50 posttreatment. Serial MRI initially demonstrated a modest reduction in tumor size and edema, but the tumor progressed and the patient died 49 days after treatment. The second patient was treated 24 days after the initial diagnosis prior to radiation with a total dose of 0.284 mg in 5.30 ml over 100 hours. Her KPS score was 70 before CED and 50 posttreatment. Serial MRI similarly demonstrated an initial modest reduction in tumor size. The patient subsequently underwent fractionated radiation therapy, but the tumor progressed and she died 120 days after treatment. Topotecan delivered by prolonged CED into the brainstem in children with DIPG is technically feasible. In both patients, high infusion rates (> 0.12 ml/hr) and high infusion volumes (> 2.8 ml) resulted in new neurological deficits and reduction in the KPS score, but lower infusion rates (< 0.04 ml/hr) were well tolerated. While serial MRI showed moderate treatment effect, CED did not prolong survival in these 2 patients. More studies are needed to improve patient selection and determine the optimal flow rates for CED of chemotherapeutic agents into DIPG to maximize safety and efficacy. Clinical trial registration no.: NCT00324844.
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Affiliation(s)
- Richard C. E. AndersoN
- Departments of Neurosurgery, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Benjamin Kennedy
- Departments of Neurosurgery, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Candix L. Yanes
- Departments of Neurosurgery, Columbia University, College of Physicians and Surgeons, New York, New York
| | - James Garvin
- Departments of Oncology, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Michael Needle
- Departments of Oncology, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Peter Canoll
- Departments of Pathology and Cell Biology, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Neil A. Feldstein
- Departments of Neurosurgery, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Jeffrey N. Bruce
- Departments of Neurosurgery, Columbia University, College of Physicians and Surgeons, New York, New York
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Convection-enhanced delivery for targeted delivery of antiglioma agents: the translational experience. JOURNAL OF DRUG DELIVERY 2013; 2013:107573. [PMID: 23476784 PMCID: PMC3586495 DOI: 10.1155/2013/107573] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 12/10/2012] [Indexed: 11/18/2022]
Abstract
Recent improvements in the understanding of glioblastoma (GBM) have allowed for increased ability to develop specific, targeted therapies. In parallel, however, there is a need for effective methods of delivery to circumvent the therapeutic obstacles presented by the blood-brain barrier and systemic side effects. The ideal delivery system should allow for adequate targeting of the tumor while minimizing systemic exposure, applicability across a wide range of potential therapies, and have existing safe and efficacious systems that allow for widespread application. Though many alternatives to systemic delivery have been developed, this paper will focus on our experience with convection-enhanced delivery (CED) and our focus on translating this technology from pre-clinical studies to the treatment of human GBM.
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Vogelbaum MA, Iannotti CA. Convection-enhanced delivery of therapeutic agents into the brain. HANDBOOK OF CLINICAL NEUROLOGY 2012; 104:355-62. [PMID: 22230453 DOI: 10.1016/b978-0-444-52138-5.00023-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
CED of therapeutic agents remains a promising strategy for treating malignant gliomas and non-neoplastic neurological diseases. Although initial clinical trials have failed to show survival benefit for new agents delivered via this approach, multiple earlier stage trials have addressed only a fraction of the myriad of technical and technological issues that surround this novel approach. Development of CED has been limited by the fact that both new technologies and novel therapeutic agents are being developed simultaneously.New trials are being planned to investigate agents that can be coinfused with radiographic tracers, as well as novel catheters that avoid problems with backflow and potentially will provide more reliable drug distribution.
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Martin Bauknight W, Chakrabarty S, Hwang BY, Malone HR, Joshi S, Bruce JN, Sander Connolly E, Winfree CJ, Cunningham MG, Martin JH, Haque R. Convection enhanced drug delivery of BDNF through a microcannula in a rodent model to strengthen connectivity of a peripheral motor nerve bridge model to bypass spinal cord injury. J Clin Neurosci 2012; 19:563-9. [DOI: 10.1016/j.jocn.2011.09.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Accepted: 09/27/2011] [Indexed: 12/16/2022]
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Bruce JN, Fine RL, Canoll P, Yun J, Kennedy BC, Rosenfeld SS, Sands SA, Surapaneni K, Lai R, Yanes CL, Bagiella E, DeLaPaz RL. Regression of recurrent malignant gliomas with convection-enhanced delivery of topotecan. Neurosurgery 2012; 69:1272-9; discussion 1279-80. [PMID: 21562434 DOI: 10.1227/neu.0b013e3182233e24] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Convection-enhanced delivery of chemotherapeutics for the treatment of malignant glioma is a technique that delivers drugs directly into a tumor and the surrounding interstitium through continuous, low-grade positive-pressure infusion. This allows high local concentrations of drug while overcoming the limitations imposed by toxicity and the blood-brain barrier in systemic therapies that prevent the use of many potentially effective drugs. OBJECTIVE To examine the safety profile of a conventional chemotherapeutic agent, topotecan, via convection-enhanced delivery in the treatment of recurrent malignant gliomas and secondarily to assess radiographic response and survival. METHODS We performed a prospective, dose-escalation phase Ib study of the topoisomerase-I inhibitor topotecan given by convection-enhanced delivery in patients with recurrent malignant gliomas. RESULTS Significant antitumor activity as described by radiographic changes and prolonged overall survival with minimal drug-associated toxicity was demonstrated. A maximum tolerated dose was established for future phase II studies. CONCLUSION Topotecan by convection-enhanced delivery has significant antitumor activity at concentrations that are nontoxic to normal brain. The potential for use of this therapy as a generally effective treatment option for malignant gliomas will be tested in subsequent phase II and III trials.
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Affiliation(s)
- Jeffrey N Bruce
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York 10032, USA.
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Monoclonal antibody therapy for malignant glioma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 746:121-41. [PMID: 22639164 DOI: 10.1007/978-1-4614-3146-6_10] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Monoclonal antibody (mAb) therapy is a rapidly evolving treatment immunotherapy modality for malignant gliomas. Many studies have provided evidence that the blood brain barrier-both at baseline and in the context of malignancy-is permissive for mAbs, thus providing a rationale for their use in treating intracranial malignancy. Furthermore, techniques such as convection enhanced delivery (CED) are being implemented to maximize exposure of tumor cells to mAb therapy. The mechanisms and designs of mAbs are widely varying, including unarmed immunoglobulins as well as immunoglobulins conjugated to radioisotopes, biological toxins, boronated dendrimers and immunoliposomes. The very structure of the immunoglobulin molecule has also been manipulated to generate a diverse armamentarium including single-chain Fv, bispecific T-cell engagers and chimeric antigen receptors. The targeted neutralization capacity of mAbs has been employed to modulate the immunologic milieu in hopes of optimizing other immunotherapy platforms. Many clinical trials have evaluated these mAb strategies to treat malignant gliomas, and the implementation of mAb therapy seems imminent and optimistic.
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30
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Affiliation(s)
- Ian F Parney
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA.
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Aljuffali IA, Mock JN, Costyn LJ, Nguyen H, Nagy T, Cummings BS, Arnold RD. Enhanced antitumor activity of low-dose continuous administration schedules of topotecan in prostate cancer. Cancer Biol Ther 2011; 12:407-20. [PMID: 21709443 DOI: 10.4161/cbt.12.5.15950] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
PURPOSE The objective of this study was to determine the antitumor effects of alternate dosing schedules of topotecan in prostate cancer. RESULTS A concentration-dependent increase in cytotoxicity was observed in PC-3 and LNCaP cells after topotecan treatment using conventional and metronomic protocols. A significant increase in potency (2.4-18 fold, after 72 hr) was observed following metronomic dosing compared to conventional dosing administration in both cell lines. Metronomic dosing also increased the percentage of PC-3 cells in the G2/M, compared to control, but did not alter LNCaP cell cycle distribution. Metronomic dosing increased p21 protein expression in LNCaP and PC-3 cells compared to conventional dosing. The observed in vitro activity was confirmed using an in vivo model of human prostate cancer. Metronomic dosing and continuous infusion decreased tumor volume significantly (p < 0.05) compared to control and conventional topotecan treatment, but had no effect on tumor vascular staining. METHODS The cytotoxicity of topotecan after conventional or metronomic dosing was determined by examining cellular morphology, mitochondrial enzymatic activity (MTT), total cellular protein (SRB), annexin V and propidium iodine (PI) staining, cell cycle and western blot analysis in human prostate cancer cell lines (PC-3 and LNCaP) and the effects metronomic or continuous infusion on tumor growth in an in vivo tumor xenograft model. CONCLUSIONS These data support the hypothesis that low-dose continuous administration of topotecan increases potency compared to conventional dosing in prostate cancer. These data also suggest the novel finding that the enhanced antitumor activity of topotecan following low-dose exposure correlates to alterations in cell cycle and increased p21 expression.
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Affiliation(s)
- Ibrahim A Aljuffali
- Department of Pharmaceutical and Biomedical Sciences, University of Georgia, Athens, GA USA
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Sonabend AM, Stuart RM, Yun J, Yanagihara T, Mohajed H, Dashnaw S, Bruce SS, Brown T, Romanov A, Sebastian M, Arias-Mendoza F, Bagiella E, Canoll P, Bruce JN. Prolonged intracerebral convection-enhanced delivery of topotecan with a subcutaneously implantable infusion pump. Neuro Oncol 2011; 13:886-93. [PMID: 21750007 DOI: 10.1093/neuonc/nor051] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Intracerebral convection-enhanced delivery (CED) of chemotherapeutic agents currently requires an externalized catheter and infusion system, which limits its duration because of the need for hospitalization and the risk of infection. To evaluate the feasibility of prolonged topotecan administration by CED in a large animal brain with the use of a subcutaneous implantable pump. Medtronic Synchromed-II pumps were implanted subcutaneously for intracerebral CED in pigs. Gadodiamide (28.7 mg/mL), with or without topotecan (136 μM), was infused at 0.7 mL/24 h for 3 or 10 days. Pigs underwent magnetic resonance imaging before and at 6 times points after surgery. Enhancement and FLAIR+ volumes were calculated in a semi-automated fashion. Magnetic resonance spectroscopy-based topotecan signature was also investigated. Brain histology was analyzed by hematoxylin and eosin staining and with immunoperoxidase for a microglial antigen. CED of topotecan/gadolinium was well tolerated in all cases (n = 6). Maximum enhancement volume was reached at day 3 and remained stable if CED was continued for 10 days, but it decreased if CED was stopped at day 3. Magnetic resonance spectroscopy revealed a decrease in parenchymal metabolites in the presence of topotecan. Similarly, the combination of topotecan and gadolinium infusion led to a FLAIR+ volume that tended to be larger than that seen after the infusion of gadolinium alone. Histological analysis of the brains showed an area of macrophage infiltrate in the ipsilateral white matter upon infusion with topotecan/gadolinium. Intracerebral topotecan CED is well tolerated in a large animal brain for up to 10 days. Intracerebral long-term CED can be achieved with a subcutaneously implanted pump and provides a stable volume of distribution. This work constitutes a proof of principle for the safety and feasibility for prolonged CED, providing a means of continuous local drug delivery that is accessible to the practicing neuro-oncologist.
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Affiliation(s)
- Adam M Sonabend
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
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Nakamura T, Saito R, Sugiyama SI, Sonoda Y, Kumabe T, Tominaga T. Local convection-enhanced delivery of chemotherapeutic agent transiently opens blood-brain barrier and improves efficacy of systemic chemotherapy in intracranial xenograft tumor model. Cancer Lett 2011; 310:77-83. [PMID: 21763069 DOI: 10.1016/j.canlet.2011.06.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 06/02/2011] [Accepted: 06/12/2011] [Indexed: 01/02/2023]
Abstract
Recently, local chemotherapy proved its efficacy against malignant gliomas. Under the hypothesis that local delivery of chemotherapeutic agents into the brain parenchyma induce opening of the blood-brain barrier (BBB), we evaluated the opening of BBB after convection-enhanced delivery of nimustine hydrochloride into the brain parenchyma. Local convection-enhanced delivery of nimustine hydrochloride transiently opened the BBB from about 7-12 days after delivery in normal rodent brain. Systemic chemotherapy during this period of BBB disruption had synergistic effects resulting in prolonged survival of tumor-bearing rats. The present strategy may provide a new approach for glioma chemotherapy.
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Affiliation(s)
- Taigen Nakamura
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Lopez KA, Tannenbaum AM, Assanah MC, Linskey K, Yun J, Kangarlu A, Gil OD, Canoll P, Bruce JN. Convection-enhanced delivery of topotecan into a PDGF-driven model of glioblastoma prolongs survival and ablates both tumor-initiating cells and recruited glial progenitors. Cancer Res 2011; 71:3963-71. [PMID: 21464045 DOI: 10.1158/0008-5472.can-10-0906] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The contribution of microenvironment to tumor growth has important implications for optimizing chemotherapeutic response and understanding the biology of recurrent tumors. In this study, we tested the effects of locally administered topotecan on a rat model of glioblastoma that is induced by intracerebral injection of PDGF (platelet-derived growth factor)-IRES (internal ribosome entry site)-GFP (green fluorescent protein)-expressing retrovirus, treated the tumors by convection-enhanced delivery (CED) of topotecan (136 μmol/L) for 1, 4, or 7 days, and then characterized the effects on both the retrovirus-transformed tumor cells (GFP(+) cells) as well as the uninfected glial progenitor cells (GFP(-) cells) that are recruited to the tumor. Topotecan treatment reduced GFP(+) cells about 10-fold and recruited progenitors by about 80-fold while providing a significant survival advantage that improved with greater treatment duration. Regions of glial progenitor ablation occurred corresponding to the anatomic distribution of topotecan as predicted by MRI of a surrogate tracer. Histopathologic changes in recurrent tumors point to a decrease in recruitment, most likely due to the chemotherapeutic ablation of the recruitable progenitor pool.
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Affiliation(s)
- Kim A Lopez
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA
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35
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Hoover JM, Chang SM, Parney IF. Clinical Trials in Brain Tumor Surgery. Neuroimaging Clin N Am 2010; 20:409-24. [DOI: 10.1016/j.nic.2010.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ghaghada KB, Colen RR, Hawley CR, Patel N, Mukundan S. Liposomal Contrast Agents in Brain Tumor Imaging. Neuroimaging Clin N Am 2010; 20:367-78. [DOI: 10.1016/j.nic.2010.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Haar PJ, Broaddus WC, Chen ZJ, Fatouros PP, Gillies GT, Corwin FD. Quantification of convection-enhanced delivery to the ischemic brain. Physiol Meas 2010; 31:1075-89. [DOI: 10.1088/0967-3334/31/9/001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Luther N, Cheung NK, Souliopoulos EP, Karampelas I, Karempelas I, Bassiri D, Edgar MA, Guo HF, Pastan I, Gutin PH, Souweidane MM. Interstitial infusion of glioma-targeted recombinant immunotoxin 8H9scFv-PE38. Mol Cancer Ther 2010; 9:1039-46. [PMID: 20371725 DOI: 10.1158/1535-7163.mct-09-0996] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Monoclonal antibodies have the potential to target therapy for high-grade gliomas. Monoclonal antibody 8H9 is specific for membrane protein B7H3 and is reactive with most human high-grade gliomas. We tested the 8H9scFv-PE38 recombinant Pseudomonas immunotoxin in a preclinical model of high-grade glioma. The half maximal inhibitory concentration (IC(50)) of 8H9scFv-PE38 in vitro was determined using glioblastoma cell lines U87 and U251. Maximum tolerated infusion dose of 8H9scFv-PE38 following interstitial infusion to the striatum and pons was defined using athymic rats. Maximum tolerated infusion dose of 8H9scFv-PE38 or PBS control were interstitially delivered to athymic rats xenografted with U87 in the striatum or brain stem. Radiographic response and survivals were measured and compared between treatment groups. The in vitro IC(50) of 8H9scFv-PE38 for U87 was 1,265 ng/mL and, for U251, 91 ng/mL. The maximum tolerated infusion doses of interstitially infused 8H9scFv-PE38 to the striatum and brain stem were 0.75 and 1.8 mug, respectively. For rats harboring intracranial U87 xenografts, infusion of 8H9scFv-PE38 increased mean survival (striatum, 43.4 versus 24.6 days; brain stem, 80.6 versus 45.5 days; n = 28 total) and produced three long-term survivors past 120 days. None of the 14 placebo-treated animals survived >54 days. Tumors also showed volumetric response to infusion of 8H9scFv-PE38 by magnetic resonance imaging. Interstitial infusion of 8H9scFv-PE38 shows potential for the treatment of hemispherical and brain stem glioma. Mol Cancer Ther; 9(4); 1039-46. (c)2010 AACR.
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Affiliation(s)
- Neal Luther
- Department of Neurologic Surgery, Weill Medical College of Cornell University, Room A-969, 1300 York Avenue, New York, NY, USA.
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Tange Y, Miyazaki M, Iwata J, Aiko Y, Sakamoto S, Mori K. Novel antitumor effect of carboplatin delivered by intracerebral microinfusion in a rat malignant glioma model. Neurol Med Chir (Tokyo) 2010; 49:572-9. [PMID: 20035131 DOI: 10.2176/nmc.49.572] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Carboplatin loaded osmotic mini-pumps were implanted in 24 9L malignant glioma-bearing rats to investigate the implications of direct intracerebral microinfusion. Carboplatin using 0.1 mg/ml (low dose group) or 1.0 mg/ml (high dose group) with eight rats in each group, or 5% D-glucose (control group) in eight rats were infused at 1 microl/hr for 7 days. The tumor volume was serially measured by magnetic resonance (MR) imaging with gadolinium as the enhanced area, and the survival periods and histological findings were also examined. Separately, to examine the effects of intracerebral carboplatin infusion on vascular permeability, tumor-bearing rats received intravenous administration of 2% Evans blue at 21 days after infusion. The high dose group showed transient increase of enhanced volume at 21 days associated with mass effect, and significantly decreased tumor volume at 28 and 35 days compared with the control and low dose groups. The high dose group showed significant longer survival time than the control and low dose groups. Histological examination of the high dose group at 21 days showed the central tumor necrotic area around the infusion site and Evans blue leakage into the surrounding enhanced rim and the necrotic core. Therefore, leakage of plasma fluid into the necrotic area was considered to be the cause of apparent transient swelling. The present study demonstrated quantitatively using MR imaging that intracerebral carboplatin microinfusion significantly inhibited the rapid growth of experimental rat glioma but that the high dose required carries the risk of transient swelling of the target tumor.
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Affiliation(s)
- Yuichi Tange
- Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Izunokuni, Shizuoka, Japan
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In vivo evaluation of intracellular drug-nanocarriers infused into intracranial tumours by convection-enhanced delivery: distribution and radiosensitisation efficacy. J Neurooncol 2009; 97:195-205. [DOI: 10.1007/s11060-009-0012-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Accepted: 09/14/2009] [Indexed: 10/20/2022]
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Bidros DS, Vogelbaum MA. Novel drug delivery strategies in neuro-oncology. Neurotherapeutics 2009; 6:539-46. [PMID: 19560743 PMCID: PMC5084189 DOI: 10.1016/j.nurt.2009.04.004] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Accepted: 04/08/2009] [Indexed: 12/01/2022] Open
Abstract
Treatment of malignant gliomas represents one of the most formidable challenges in oncology. Despite treatment with surgery, radiation therapy, and chemotherapy, the prognosis remains poor, particularly for glioblastoma, which has a median survival of 12 to 15 months. An important impediment to finding effective treatments for malignant gliomas is the presence of the blood brain barrier, which serves to prevent delivery of potentially active therapeutic compounds. Multiple efforts are focused on developing strategies to effectively deliver active drugs to brain tumor cells. Blood brain barrier disruption and convection-enhanced delivery have emerged as leading investigational delivery techniques for the treatment of malignant brain tumors. Clinical trials using these methods have been completed, with mixed results, and several more are being initiated. In this review, we describe the clinically available methods used to circumvent the blood brain barrier and summarize the results to date of ongoing and completed clinical trials.
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Affiliation(s)
- Dani S. Bidros
- grid.239578.20000000106754725Department of Neurological Surgery, Brain Tumor and NeuroOncology Center, Neurological Institute, Cleveland Clinic, 44195 Cleveland, Ohio
| | - Michael A. Vogelbaum
- grid.239578.20000000106754725Department of Neurological Surgery, Brain Tumor and NeuroOncology Center, Neurological Institute, Cleveland Clinic, 44195 Cleveland, Ohio
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Luther N, Cheung NKV, Dunkel IJ, Fraser JF, Edgar MA, Gutin PH, Souweidane MM. INTRAPARENCHYMAL AND INTRATUMORAL INTERSTITIAL INFUSION OF ANTI-GLIOMA MONOCLONAL ANTIBODY 8H9. Neurosurgery 2008; 63:1166-74; discussion 1174. [DOI: 10.1227/01.neu.0000334052.60634.84] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Neal Luther
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
| | - Nai-Kong V. Cheung
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ira J. Dunkel
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Justin F. Fraser
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
| | - Mark A. Edgar
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Philip H. Gutin
- Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Mark M. Souweidane
- Department of Neurological Surgery, Weill Cornell Medical College, and Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
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Effects, in an in-vivo model system, of 1,2,3,4-tetrahydroisoquinoline on glioma. Anticancer Drugs 2008; 19:859-70. [DOI: 10.1097/cad.0b013e32830d5887] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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44
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Petit S, Garcion E, Benoit JP, Menei P. Chimiothérapie locale dans les gliomes malins : de l’injection à la seringue aux nanotechnologies. Rev Neurol (Paris) 2008; 164:547-53. [DOI: 10.1016/j.neurol.2008.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2007] [Accepted: 03/13/2008] [Indexed: 10/22/2022]
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Ferguson SD, Foster K, Yamini B. Convection-enhanced delivery for treatment of brain tumors. Expert Rev Anticancer Ther 2008; 7:S79-85. [PMID: 18076322 DOI: 10.1586/14737140.7.12s.s79] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Recently, innovative therapies have been developed for the treatment of malignant gliomas. Unfortunately, adequate delivery of these therapies has been a major obstacle to clinical success. Intravenous administration is restricted by the presence of the blood-brain barrier while local delivery, such as with drug-impregnated wafers, results in limited parenchyma penetration. Convection-enhanced delivery is a promising method for the delivery of macromolecules to the CNS. Convection-enhanced delivery involves the infusion of therapeutic agents via surgically implanted catheters and uses a pressure gradient to achieve a greater volume of distribution compared with that seen with diffusion alone. This article will review the development of convection-enhanced delivery and its use in the treatment of malignant gliomas.
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Affiliation(s)
- Sherise D Ferguson
- The University of Chicago Hospitals, Section of Neurosurgery, MC4066, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
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Vogelbaum MA, Sampson JH, Kunwar S, Chang SM, Shaffrey M, Asher AL, Lang FF, Croteau D, Parker K, Grahn AY, Sherman JW, Husain SR, Puri RK. CONVECTION-ENHANCED DELIVERY OF CINTREDEKIN BESUDOTOX (INTERLEUKIN-13-PE38QQR) FOLLOWED BY RADIATION THERAPY WITH AND WITHOUT TEMOZOLOMIDE IN NEWLY DIAGNOSED MALIGNANT GLIOMAS. Neurosurgery 2007; 61:1031-7; discussion 1037-8. [DOI: 10.1227/01.neu.0000303199.77370.9e] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
OBJECTIVE
Cintredekin besudotox (CB), a recombinant cytotoxin consisting of interleukin-13 and truncated Pseudomonas exotoxin, binds selectively to interleukin-13Rα2 receptors overexpressed by malignant gliomas. This study assessed the safety of CB administered by convection-enhanced delivery followed by standard external beam radiation therapy (EBRT) with or without temozolomide (Temodar; Schering-Plough, Kenilworth, NJ) in patients with newly diagnosed malignant gliomas.
METHODS
After gross total resection of the tumor, two to four intraparenchymal catheters were stereotactically placed and CB (0.25 or 0.5 μg/mL) was infused for 96 hours. This was followed, 10 to 14 days later, by EBRT (5940–6100 cGy, 5 d/wk for 6–7 wk) with or without temozolomide (75 mg/m2/d, 7 d/wk during EBRT). Safety was assessed during an 11-week observation period after catheter placement
RESULTS
Twenty-two patients (12 men, 10 women; median age, 55 yr; 21 with glioblastoma multiforme and one with an anaplastic mixed oligoastrocytoma) were enrolled. None of the patients experienced dose-limiting toxicities in the first two cohorts (0.25 μg/mL CB + EBRT [n = 3] and 0.25 μg/mL CB + EBRT + temozolomide [n = 3]). One patient experienced a dose-limiting toxicity (Grade 4 seizure) in the third cohort (0.5 μg/mL CB + EBRT [n = 6]). Six patients in the final cohort (0.5 μg/mL CB + EBRT + temozolomide [n = 10]) completed treatment, and one patient experienced a dose-limiting toxicity (Grade 3 aphasia and confusion). Four patients were not considered evaluable for a dose decision and were replaced. CB related adverse events occurring in more than one patient were fatigue, gait disturbance, nystagmus, and confusion. No Grade 3 to 4 hematological toxicities were observed.
CONCLUSION
CB (0.5 μg/mL) administered via convection-enhanced delivery before standard radiochemotherapy seems to be well tolerated in adults with newly diagnosed malignant gliomas. Further clinical study assessment is warranted.
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Affiliation(s)
- Michael A. Vogelbaum
- Brain Tumor and Neuro-Oncology Center, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - John H. Sampson
- Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Sandeep Kunwar
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Susan M. Chang
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Mark Shaffrey
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Anthony L. Asher
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Frederick F. Lang
- Department of Neurosurgery, MD Anderson Cancer Center, Houston, Texas
| | | | | | | | | | - S. Rafat Husain
- Center for Biologics Evaluation and Research, United States Food and Drug Administration, Bethesda, Maryland
| | - Raj K. Puri
- Center for Biologics Evaluation and Research, United States Food and Drug Administration, Bethesda, Maryland
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Rousseau J, Boudou C, Estève F, Elleaume H. Convection-Enhanced Delivery of an Iodine Tracer Into Rat Brain for Synchrotron Stereotactic Radiotherapy. Int J Radiat Oncol Biol Phys 2007; 68:943-51. [PMID: 17544004 DOI: 10.1016/j.ijrobp.2007.01.065] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Revised: 01/30/2007] [Accepted: 01/31/2007] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate direct intracerebral and intratumoral iodine delivery as means to improve iodine distribution for synchrotron stereotactic radiotherapy (SSR) and to evaluate the corresponding X-ray dose distribution. METHODS AND MATERIALS Healthy rats and F98 glioma-bearing rats received an iodinated contrast agent (iopamidol) intracerebrally either by bolus injection (5 microL over approximately 1 min) or by convection-enhanced delivery (infusion volumes of 5, 10, and 20 microL at a rate of 0.5 microL/min). We used synchrotron computed tomography (CT) to determine the iodine distribution after completion of infusion and a Monte Carlo code to compute the resulting radiation dose in SSR. RESULTS Post-infusion CT imaging revealed high iodine concentrations in the perfused area with both injection methods. The iodine concentration remained elevated, with an exponential decay time constant of approximately 50 min, well suited for SSR treatment. Convection-enhanced delivery was shown to provide more uniform and controlled volumes of distribution than bolus injection and was chosen to evaluate the corresponding X-ray dose distribution. Sharp dose gradients around the target and excellent sparing of the contralateral brain were achievable with low iodine concentrations in the surrounding healthy brain tissues and blood vessels. CONCLUSIONS Convection-enhanced delivery is an effective method to deliver high iodine concentrations and could improve the outcome of iodine-enhanced SSR.
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Kunwar S, Prados MD, Chang SM, Berger MS, Lang FF, Piepmeier JM, Sampson JH, Ram Z, Gutin PH, Gibbons RD, Aldape KD, Croteau DJ, Sherman JW, Puri RK. Direct Intracerebral Delivery of Cintredekin Besudotox (IL13-PE38QQR) in Recurrent Malignant Glioma: A Report by the Cintredekin Besudotox Intraparenchymal Study Group. J Clin Oncol 2007; 25:837-44. [PMID: 17327604 DOI: 10.1200/jco.2006.08.1117] [Citation(s) in RCA: 242] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Glioblastoma multiforme (GBM) is a devastating brain tumor with a median survival of 6 months after recurrence. Cintredekin besudotox (CB) is a recombinant protein consisting of interleukin-13 (IL-13) and a truncated form of Pseudomonas exotoxin (PE38QQR). Convection-enhanced delivery (CED) is a locoregional-administration method leading to high-tissue concentrations with large volume of distributions. We assessed the use of intracerebral CED to deliver CB in patients with recurrent malignant glioma (MG). Patients and Methods Three phase I clinical studies evaluated intracerebral CED of CB along with tumor resection. The main objectives were to assess the tolerability of various concentrations and infusion durations; tissue distribution; and methods for optimizing delivery. All patients underwent tumor resection followed by a single intraparenchymal infusion (in addition to the intraparenchymal one following resection), with a portion of patients who had a preresection intratumoral infusion. Results A total of 51 patients with MG were treated including 46 patients with GBM. The maximum tolerated intraparenchymal concentration was 0.5 μg/mL and tumor necrosis was observed at this concentration. Infusion durations of up to 6 days were well tolerated. Postoperative catheter placement appears to be important for optimal drug distribution. CB- and procedure-related adverse events were primarily limited to the CNS. Overall median survival for GBM patients is 42.7 weeks and 55.6 weeks for patients with optimally positioned catheters with patient follow-up extending beyond 5 years. Conclusion CB appears to have a favorable risk-benefit profile. CED is a complex delivery method requiring catheter placement via a second procedure to achieve accurate catheter positioning, better drug distribution, and better outcome.
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Affiliation(s)
- Sandeep Kunwar
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143-0350, USA.
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de Vries NA, Beijnen JH, Boogerd W, van Tellingen O. Blood-brain barrier and chemotherapeutic treatment of brain tumors. Expert Rev Neurother 2006; 6:1199-209. [PMID: 16893347 DOI: 10.1586/14737175.6.8.1199] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The blood-brain barrier (BBB) is of pivotal importance to maintain homeostasis of the CNS, as it closely regulates the composition of the interstitial fluid in the brain. Unfortunately, malignancies that grow within the CNS may evade chemotherapeutic drugs using the same barrier, making this disease refractory to most chemotherapy regimens. This review will outline the impact of the BBB in brain cancer and discuss the efforts that have been made to enhance the drug exposure of brain tumors. Although this review will focus on the role of the BBB in primary brain cancer (malignant glioma), its impact on brain metastases will also be briefly discussed.
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Affiliation(s)
- Nienke A de Vries
- The Netherlands Cancer Institute, Department of Clinical Chemistry, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
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50
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Convection-enhanced delivery of liposomal doxorubicin in intracranial brain tumor xenografts. Target Oncol 2006. [DOI: 10.1007/s11523-006-0011-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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