Modeling the efficacy of the extent of surgical resection in the setting of radiation therapy for glioblastoma

Intraoperative rapid molecular diagnosis aids glioma subtyping and guides precise surgical resection

OBJECTIVE

The molecular era of glioma diagnosis and treatment has arrived, and a single rapid histopathology is no longer sufficient for surgery. This study sought to present an automatic integrated gene detection system (AIGS), which enables rapid intraoperative detection of IDH/TERTp mutations.

METHODS

A total of 78 patients with gliomas were included in this study. IDH/TERTp mutations were detected intraoperatively using AIGS in 41 of these patients, and they were guided to surgical resection (AIGS detection group). The remaining 37 underwent histopathology-guided conventional surgical resection (non-AIGS detection group). The clinical utility of this technique was evaluated by comparing the accuracy of glioma subtype diagnosis before and after TERTp mutation results were obtained by pathologists and the extent of resection (EOR) and patient prognosis for molecular pathology-guided glioma surgery.

RESULTS

With NGS/Sanger sequencing and chromosome detection as the gold standard, the accuracy of AIGS results was 100%. And the timing was well matched to the intraoperative rapid pathology report. After obtaining the TERTp mutation detection results, the accuracy of the glioma subtype diagnosis made by the pathologists increased by 19.51%. Molecular pathology-guided surgical resection of gliomas significantly increased EOR (99.06% vs. 93.73%, p < 0.0001) and also improved median OS (26.77 vs. 13.47 months, p = 0.0289) and median PFS (15.90 vs. 10.57 months, p = 0.0181) in patients with glioblastoma.

INTERPRETATION

Using AIGS intraoperatively to detect IDH/TERTp mutations to accurately diagnose glioma subtypes can help achieve maximum safe resection of gliomas, which in turn improves the survival prognosis of patients.

TERT expression increases with tumor grade in a cohort of IDH-mutant gliomas

The molecular mechanisms underlying progression from astrocytoma to secondary glioblastoma are poorly understood. Telomerase reverse transcriptase (TERT), a gene encoding for the catalytic subunit of telomerase, is upregulated in various cancers. Upregulation of TERT is a likely mechanism by which malignant cells delay senescence and evade cell death. TERT activity is also the primary mechanism by which malignant cells replenish telomeres, with the other means of telomere replacement being the alternative lengthening of the telomeres (ALT) system. The ALT system is known to be upregulated in tumors harboring loss of function mutations in ATRX. This study analyzed aggregate data on TERT and ATRX expression in astrocytoma, anaplastic astrocytoma, and secondary glioblastoma and then supplemented the data with our findings. In data obtained from Oncomine, significantly higher TERT expression is seen in astrocytomas and secondary glioblastomas compared to normal brain tissue. Additionally, The Cancer Genome Atlas data shows that TERT expression is a significant predictor of overall survival in low-grade gliomas. However, studies comparing the expression of TERT across all grades of astrocytomas had not been performed to date. Using immunohistochemical staining, we showed that controlling for ATRX and IDH mutational status, TERT expression increased with tumor grade in a cohort of patient-derived astrocytoma, anaplastic astrocytoma, and secondary glioblastoma samples. These findings indicate that TERT expression increases as astrocytomas become more aggressive tumors, and probably plays a role in their progression.

Salinomycin-loaded injectable thermosensitive hydrogels for glioblastoma therapy

Local drug delivery approaches for treating brain tumors not only diminish the toxicity of systemic chemotherapy, but also circumvent the blood-brain barrier (BBB) which restricts the passage of most chemotherapeutics to the brain. Recently, salinomycin has attracted much attention as a potential chemotherapeutic agent in a variety of cancers. In this study, poly (ethylene oxide)/poly (propylene oxide)/poly (ethylene oxide) (PEO-PPO-PEO, Pluronic F127) and poly (dl-lactide-co-glycolide-b-ethylene glycol-b-dl-lactide-co-glycolide) (PLGA-PEG-PLGA), the two most common thermosensitive copolymers, were utilized as local delivery systems for salinomycin in the treatment of glioblastoma. The Pluronic and PLGA-PEG-PLGA hydrogels released 100% and 36% of the encapsulated salinomycin over a one-week period, respectively. While both hydrogels were found to be effective at inhibiting glioblastoma cell proliferation, inducing apoptosis and generating intracellular reactive oxygen species, the Pluronic formulation showed better biocompatibility, a superior drug release profile and an ability to further enhance the cytotoxicity of salinomycin, compared to the PLGA-PEG-PLGA hydrogel formulation. Animal studies in subcutaneous U251 xenograftednudemice also revealed that Pluronic + salinomycin hydrogel reduced tumor growth compared to free salinomycin- and PBS-treated mice by 4-fold and 6-fold, respectively within 12 days. Therefore, it is envisaged that salinomycin-loaded Pluronic can be utilized as an injectable thermosensitive hydrogel platform for local treatment of glioblastoma, providing a sustained release of salinomycin at the tumor site and potentially bypassing the BBB for drug delivery to the brain.

Timing of glioblastoma surgery and patient outcomes: a multicenter cohort study

BACKGROUND

The impact of time-to-surgery on clinical outcome for patients with glioblastoma has not been determined. Any delay in treatment is perceived as detrimental, but guidelines do not specify acceptable timings. In this study, we relate the time to glioblastoma surgery with the extent of resection and residual tumor volume, performance change, and survival, and we explore the identification of patients for urgent surgery.

METHODS

Adults with first-time surgery in 2012-2013 treated by 12 neuro-oncological teams were included in this study. We defined time-to-surgery as the number of days between the diagnostic MR scan and surgery. The relation between time-to-surgery and patient and tumor characteristics was explored in time-to-event analysis and proportional hazard models. Outcome according to time-to-surgery was analyzed by volumetric measurements, changes in performance status, and survival analysis with patient and tumor characteristics as modifiers.

RESULTS

Included were 1033 patients of whom 729 had a resection and 304 a biopsy. The overall median time-to-surgery was 13 days. Surgery was within 3 days for 235 (23%) patients, and within a month for 889 (86%). The median volumetric doubling time was 22 days. Lower performance status (hazard ratio [HR] 0.942, 95% confidence interval [CI] 0.893-0.994) and larger tumor volume (HR 1.012, 95% CI 1.010-1.014) were independently associated with a shorter time-to-surgery. Extent of resection, residual tumor volume, postoperative performance change, and overall survival were not associated with time-to-surgery.

CONCLUSIONS

With current decision-making for urgent surgery in selected patients with glioblastoma and surgery typically within 1 month, we found equal extent of resection, residual tumor volume, performance status, and survival after longer times-to-surgery.

Mathematical formulation and parametric analysis of in vitro cell models in microfluidic devices: application to different stages of glioblastoma evolution

In silico models and computer simulation are invaluable tools to better understand complex biological processes such as cancer evolution. However, the complexity of the biological environment, with many cell mechanisms in response to changing physical and chemical external stimuli, makes the associated mathematical models highly non-linear and multiparametric. One of the main problems of these models is the determination of the parameters' values, which are usually fitted for specific conditions, making the conclusions drawn difficult to generalise. We analyse here an important biological problem: the evolution of hypoxia-driven migratory structures in Glioblastoma Multiforme (GBM), the most aggressive and lethal primary brain tumour. We establish a mathematical model considering the interaction of the tumour cells with oxygen concentration in what is called the go or grow paradigm. We reproduce in this work three different experiments, showing the main GBM structures (pseudopalisade and necrotic core formation), only changing the initial and boundary conditions. We prove that it is possible to obtain versatile mathematical tools which, together with a sound parametric analysis, allow to explain complex biological phenomena. We show the utility of this hybrid "biomimetic in vitro-in silico" platform to help to elucidate the mechanisms involved in cancer processes, to better understand the role of the different phenomena, to test new scientific hypotheses and to design new data-driven experiments.

Combined Therapeutic Effects of 131I-Labeled and 5Fu-Loaded Multifunctional Nanoparticles in Colorectal Cancer

Background

Owing to its combined effects, the co-delivery of different therapeutics is a promising option for the treatment of cancer. In the present study, tumor-targeting poly(ethylene glycol)-poly(lactic acid) (PEG-PLA) nanoparticles were developed for the transportation of two molecules, namely chemotherapeutic drug 5-fluorouracil (5Fu) and radionuclide iodine-131 (¹³¹I), in a single platform.

Methods

The obtained nanoparticles (Cetuximab [Cet]-PEG-PLA-5Fu-¹³¹I) were spherical (diameter approximately 110 nm) and pH-sensitive. The targeting effect of nanoparticles via Cet was confirmed in colorectal cancer cells using a fluorescent assay. The combined effects of Cet-PEG-PLA-5Fu-¹³¹I on cell viability and apoptosis were evaluated in colorectal cancer cells by Cell Counting Kit-8 and flow cytometry assays.

Results

Blank nanoparticles (Cet-PEG-PLA) showed good biocompatibility, and Cet-PEG-PLA-5Fu-¹³¹I nanoparticles were the most effective in terms of inhibition of cell viability and induction of apoptosis compared with monotherapy using Cet-PEG-PLA-5Fu or Cet-PEG-PLA-¹³¹I. In the xenograft mouse model, compared with using Cet-PEG-PLA-5Fu or Cet-PEG-PLA-¹³¹I alone, Cet-PEG-PLA-5Fu-¹³¹I nanoparticles exhibited prolonged circulation in the blood and accumulation in the tumor, thus resulting in enhanced antitumor efficacy. Additionally, combined radio-chemotherapy with Cet-PEG-PLA-5Fu-¹³¹I nanoparticles was associated with smaller tumor sizes than monotherapy, revealing the superior antitumor effects of Cet-PEG-PLA-5Fu-¹³¹I nanoparticles. These effects were further evidenced by histological and immunohistochemical analyses.

Conclusion

The multifunctional Cet-PEG-PLA-5Fu-¹³¹I nanoparticles are promising candidates for the co-delivery of 5Fu-mediated chemotherapy and ¹³¹I-mediated radiotherapy.

Gold Nanoparticles in Glioma Theranostics

Despite many endeavors to treat malignant gliomas in the last decades, the median survival of patients has not significantly improved. The infiltrative nature of high-grade gliomas and the impermeability of the blood-brain barrier to the most therapeutic agents remain major hurdles, impeding an efficacious treatment. Theranostic platforms bridging diagnosis and therapeutic modalities aim to surmount the current limitations in diagnosis and therapy of glioma. Gold nanoparticles (AuNPs) due to their biocompatibility and tunable optical properties have widely been utilized for an assortment of theranostic purposes. In this Review, applications of AuNPs as imaging probes, drug/gene delivery systems, radiosensitizers, photothermal transducers, and multimodal theranostic agents in malignant gliomas are discussed. This Review also aims to provide a perspective on cancer theranostic applications of AuNPs in future clinical trials.

Salinomycin-Loaded Iron Oxide Nanoparticles for Glioblastoma Therapy

Salinomycin is an antibiotic introduced recently as a new and effective anticancer drug. In this study, magnetic iron oxide nanoparticles (IONPs) were utilized as a drug carrier for salinomycin for potential use in glioblastoma (GBM) chemotherapy. The biocompatible polyethylenimine (PEI)-polyethylene glycol (PEG)-IONPs (PEI-PEG-IONPs) exhibited an efficient uptake in both mouse brain-derived microvessel endothelial (bEnd.3) and human U251 GBM cell lines. The salinomycin (Sali)-loaded PEI-PEG-IONPs (Sali-PEI-PEG-IONPs) released salinomycin over 4 days, with an initial release of 44% ± 3% that increased to 66% ± 5% in acidic pH. The Sali-IONPs inhibited U251 cell proliferation and decreased their viability (by approximately 70% within 48 h), and the nanoparticles were found to be effective in reactive oxygen species-mediated GBM cell death. Gene studies revealed significant activation of caspases in U251 cells upon treatment with Sali-IONPs. Furthermore, the upregulation of tumor suppressors (i.e., p53, Rbl2, Gas5) was observed, while TopII, Ku70, CyclinD1, and Wnt1 were concomitantly downregulated. When examined in an in vitro blood–brain barrier (BBB)-GBM co-culture model, Sali-IONPs had limited penetration (1.0% ± 0.08%) through the bEnd.3 monolayer and resulted in 60% viability of U251 cells. However, hyperosmotic disruption coupled with an applied external magnetic field significantly enhanced the permeability of Sali-IONPs across bEnd.3 monolayers (3.2% ± 0.1%) and reduced the viability of U251 cells to 38%. These findings suggest that Sali-IONPs combined with penetration enhancers, such as hyperosmotic mannitol and external magnetic fields, can potentially provide effective and site-specific magnetic targeting for GBM chemotherapy.

A Markov decision process approach to optimizing cancer therapy using multiple modalities

There are several different modalities, e.g. surgery, chemotherapy and radiotherapy, that are currently used to treat cancer. It is common practice to use a combination of these modalities to maximize clinical outcomes, which are often measured by a balance between maximizing tumor damage and minimizing normal tissue side effects due to treatment. However, multi-modality treatment policies are mostly empirical in current practice and are therefore subject to individual clinicians' experiences and intuition. We present a novel formulation of optimal multi-modality cancer management using a finite-horizon Markov decision process approach. Specifically, at each decision epoch, the clinician chooses an optimal treatment modality based on the patient's observed state, which we define as a combination of tumor progression and normal tissue side effect. Treatment modalities are categorized as (1) type 1, which has a high risk and high reward, but is restricted in the frequency of administration during a treatment course; (2) type 2, which has a lower risk and lower reward than type 1, but may be repeated without restriction; and (3) type 3, no treatment (surveillance), which has the possibility of reducing normal tissue side effect at the risk of worsening tumor progression. Numerical simulations using various intuitive, concave reward functions show the structural insights of optimal policies and demonstrate the potential applications of using a rigorous approach to optimizing multi-modality cancer management.

A Review of Mathematical Models for Tumor Dynamics and Treatment Resistance Evolution of Solid Tumors

Increasing knowledge of intertumor heterogeneity, intratumor heterogeneity, and cancer evolution has improved the understanding of anticancer treatment resistance. A better characterization of cancer evolution and subsequent use of this knowledge for personalized treatment would increase the chance to overcome cancer treatment resistance. Model‐based approaches may help achieve this goal. In this review, we comprehensively summarized mathematical models of tumor dynamics for solid tumors and of drug resistance evolution. Models displayed by ordinary differential equations, algebraic equations, and partial differential equations for characterizing tumor burden dynamics are introduced and discussed. As for tumor resistance evolution, stochastic and deterministic models are introduced and discussed. The results may facilitate a novel model‐based analysis on anticancer treatment response and the occurrence of resistance, which incorporates both tumor dynamics and resistance evolution. The opportunities of a model‐based approach as discussed in this review can be of great benefit for future optimizing and personalizing anticancer treatment.

131I-labeled and DOX-loaded multifunctional nanoliposomes for radiotherapy and chemotherapy in brain gliomas

The codelivery of different therapeutics is a promising option because of its synergetic effects of drugs. In this study, a new combination therapy that used the doxorubicin-loaded and ¹³¹I-labeled nanoliposomes (¹³¹I-DOX-NL) was proposed to delay tumor growth of gliomas, which are characterized by significant mortality and morbidity. ¹³¹I-DOX-NL was constructed based on bovine serum albumin (BSA)-tailor made hydrophobic maleimide-functionalized poly(ε-caprolactone) (PCL) (Fig. 1) and was evaluated by cellular viability in vitro and by U87 xenograft models in vivo. Compared with using ¹³¹I-NL or DOX-NL alone, our experimental results show that ¹³¹I-DOX-NL exhibits similar high cellular uptake but enhanced efficacy to cure gliomas because of its codelivery of ¹³¹I and DOX. In the U87 mouse tumor models, the combination therapy resulted in higher survival rates of mice and smaller tumor sizes than monotherapy did alone. In conclusion, multifunctional nanoliposome ¹³¹I-DOX-NL is a good candidate for the codelivery of ¹³¹I-mediated radiotherapy and DOX-mediated chemotherapy due to its ability to inhibit U87 cell proliferation and tumor growth. ¹³¹I-DOX-NL can be used as a promising effective therapy for malignant gliomas and deserves further investigation.

Modeling the efficacy of the extent of surgical resection in the setting of radiation therapy for glioblastoma

Standard therapy for glioblastoma (GBM) includes maximal surgical resection and radiation therapy. While it is established that radiation therapy provides the greatest survival benefit of standard treatment modalities, the impact of the extent of surgical resection (EOR) on patient outcome remains highly controversial. While some studies describe no correlation between EOR and patient survival even up to total resection, others propose either qualitative (partial versus subtotal versus complete resection) or quantitative EOR thresholds, below which there is no correlation with survival. This work uses a mathematical model in the form of a reaction–diffusion partial differential equation to simulate tumor growth and treatment with radiation therapy and surgical resection based on tumor‐specific rates of diffusion and proliferation. Simulation of 36 tumors across a wide spectrum of diffusion and proliferation rates suggests that while partial or subtotal resections generally do not provide a survival advantage, complete resection significantly improves patient outcomes. Furthermore, our model predicts a tumor‐specific quantitative threshold below which EOR has no effect on patient survival and demonstrates that this threshold increases with tumor aggressiveness, particularly with the rate of proliferation. Thus, this model may serve as an aid for determining both when surgical resection is indicated as well as the surgical margins necessary to provide clinically significant improvements in patient survival. In addition, by assigning relative benefits to radiation and surgical resection based on tumor invasiveness and proliferation, this model confirms that (with the exception of the least aggressive tumors) the survival benefit of radiation therapy exceeds that of surgical resection.