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Howard CM, Valluri J, Alberico A, Julien T, Mazagri R, Marsh R, Alastair H, Cortese A, Griswold M, Wang W, Denning K, Brown L, Claudio PP. Analysis of Chemopredictive Assay for Targeting Cancer Stem Cells in Glioblastoma Patients. Transl Oncol 2017; 10:241-254. [PMID: 28199863 PMCID: PMC5310181 DOI: 10.1016/j.tranon.2017.01.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 01/23/2017] [Accepted: 01/23/2017] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The prognosis of glioblastoma (GBM) treated with standard-of-care maximal surgical resection and concurrent adjuvant temozolomide (TMZ)/radiotherapy remains very poor (less than 15 months). GBMs have been found to contain a small population of cancer stem cells (CSCs) that contribute to tumor propagation, maintenance, and treatment resistance. The highly invasive nature of high-grade gliomas and their inherent resistance to therapy lead to very high rates of recurrence. For these reasons, not all patients with similar diagnoses respond to the same chemotherapy, schedule, or dose. Administration of ineffective anticancer therapy is not only costly but more importantly burdens the patient with unnecessary toxicity and selects for the development of resistant cancer cell clones. We have developed a drug response assay (ChemoID) that identifies the most effective chemotherapy against CSCs and bulk of tumor cells from of a panel of potential treatments, offering great promise for individualized cancer management. Providing the treating physician with drug response information on a panel of approved drugs will aid in personalized therapy selections of the most effective chemotherapy for individual patients, thereby improving outcomes. A prospective study was conducted evaluating the use of the ChemoID drug response assay in GBM patients treated with standard of care. METHODS Forty-one GBM patients (mean age 54 years, 59% male), all eligible for a surgical biopsy, were enrolled in an Institutional Review Board-approved protocol, and fresh tissue samples were collected for drug sensitivity testing. Patients were all treated with standard-of-care TMZ plus radiation with or without maximal surgery, depending on the status of the disease. Patients were prospectively monitored for tumor response, time to recurrence, progression-free survival (PFS), and overall survival (OS). Odds ratio (OR) associations of 12-month recurrence, PFS, and OS outcomes were estimated for CSC, bulk tumor, and combined assay responses for the standard-of-care TMZ treatment; sensitivities/specificities, areas under the curve (AUCs), and risk reclassification components were examined. RESULTS Median follow-up was 8 months (range 3-49 months). For every 5% increase in in vitro CSC cell kill by TMZ, 12-month patient response (nonrecurrence of cancer) increased two-fold, OR=2.2 (P=.016). Similar but somewhat less supported associations with the bulk tumor test were seen, OR=2.75 (P=.07) for each 5% bulk tumor cell kill by TMZ. Combining CSC and bulk tumor assay results in a single model yielded a statistically supported CSC association, OR=2.36 (P=.036), but a much attenuated remaining bulk tumor association, OR=1.46 (P=.472). AUCs and [sensitivity/specificity] at optimal outpoints (>40% CSC cell kill and >55% bulk tumor cell kill) were AUC=0.989 [sensitivity=100/specificity=97], 0.972 [100/89], and 0.989 [100/97] for the CSC only, bulk tumor only, and combined models, respectively. Risk categorization of patients was improved by 11% when using the CSC test in conjunction with the bulk test (risk reclassification nonevent net reclassification improvement [NRI] and overall NRI=0.111, P=.030). Median recurrence time was 20 months for patients with a positive (>40% cell kill) CSC test versus only 3 months for those with a negative CSC test, whereas median recurrence time was 13 months versus 4 months for patients with a positive (>55% cell kill) bulk test versus negative. Similar favorable results for the CSC test were observed for PFS and OS outcomes. Panel results across 14 potential other treatments indicated that 34/41 (83%) potentially more optimal alternative therapies may have been chosen using CSC results, whereas 27/41 (66%) alternative therapies may have been chosen using bulk tumor results. CONCLUSIONS The ChemoID CSC drug response assay has the potential to increase the accuracy of bulk tumor assays to help guide individualized chemotherapy choices. GBM cancer recurrence may occur quickly if the CSC test has a low in vitro cell kill rate even if the bulk tumor test cell kill rate is high.
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Affiliation(s)
- Candace M Howard
- Department of Radiology, University of Mississippi Medical Center, Jackson, MS 39216
| | - Jagan Valluri
- Department of Biological Sciences, Marshall University, Huntington, WV 25755
| | - Anthony Alberico
- Department of Neuroscience, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25705
| | - Terrence Julien
- Department of Neuroscience, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25705
| | - Rida Mazagri
- Department of Neuroscience, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25705
| | - Robert Marsh
- Department of Neuroscience, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25705
| | - Hoyt Alastair
- Department of Neuroscience, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25705
| | - Antonio Cortese
- Department of Medicine and Surgery, University of Salerno, Italy
| | - Michael Griswold
- Department of Data Science, University of Mississippi Medical Center, Jackson, MS 39216
| | - Wanmei Wang
- Department of Data Science, University of Mississippi Medical Center, Jackson, MS 39216
| | - Krista Denning
- Department of Anatomy and Pathology, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25705
| | - Linda Brown
- Department of Anatomy and Pathology, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25705
| | - Pier Paolo Claudio
- Department of BioMolecular Sciences, National Center for Natural Products Research, University of Mississippi, University, MS; Department of Radiation Oncology, University of Mississippi Medical Center Cancer Institute, Jackson, MS 39216.
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Mathis SE, Alberico A, Nande R, Neto W, Lawrence L, McCallister DR, Denvir J, Kimmey GA, Mogul M, Oakley G, Denning KL, Dougherty T, Valluri JV, Claudio PP. Chemo-predictive assay for targeting cancer stem-like cells in patients affected by brain tumors. PLoS One 2014; 9:e105710. [PMID: 25144312 PMCID: PMC4140819 DOI: 10.1371/journal.pone.0105710] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 07/23/2014] [Indexed: 11/18/2022] Open
Abstract
Administration of ineffective anticancer therapy is associated with unnecessary toxicity and development of resistant clones. Cancer stem-like cells (CSLCs) resist chemotherapy, thereby causing relapse of the disease. Thus, development of a test that identifies the most effective chemotherapy management offers great promise for individualized anticancer treatments. We have developed an ex vivo chemotherapy sensitivity assay (ChemoID), which measures the sensitivity of CSLCs as well as the bulk of tumor cells to a variety of chemotherapy agents. Two patients, a 21-year old male (patient 1) and a 5-month female (patient 2), affected by anaplastic WHO grade-III ependymoma were screened using the ChemoID assay. Patient 1 was found sensitive to the combination of irinotecan and bevacizumab, which resulted in a prolonged disease progression free period of 18 months. Following recurrence, the combination of various chemotherapy drugs was tested again with the ChemoID assay. We found that benzyl isothiocyanate (BITC) greatly increased the chemosensitivity of the ependymoma cells to the combination of irinotecan and bevacizumab. After patient 1 was treated for two months with irinotecan, bevacizumab and supplements of cruciferous vegetable extracts containing BITC, we observed over 50% tumoral regression in comparison with pre-ChemoID scan as evidenced by MRI. Patient 2 was found resistant to all treatments tested and following 6 cycles of vincristine, carboplatin, cyclophosphamide, etoposide, and cisplatin in various combinations, the tumor of this patient rapidly progressed and proton beam therapy was recommended. As expected animal studies conducted with patient derived xenografts treated with ChemoID screened drugs recapitulated the clinical observation. This assay demonstrates that patients with the same histological stage and grade of cancer may vary considerably in their clinical response, suggesting that ChemoID testing which measures the sensitivity of CSLCs as well as the bulk of tumor cells to a variety of chemotherapy agents could lead to more effective and personalized anticancer treatments in the future.
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Affiliation(s)
- Sarah E. Mathis
- Department of Biochemistry and Microbiology, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, United States of America
- Translational Genomic Research Institute, Marshall University, Huntington, West Virginia, United States of America
| | - Anthony Alberico
- Department of Neurosurgery, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, United States of America
| | - Rounak Nande
- Department of Biochemistry and Microbiology, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, United States of America
- Translational Genomic Research Institute, Marshall University, Huntington, West Virginia, United States of America
| | - Walter Neto
- Department of Biochemistry and Microbiology, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, United States of America
- Translational Genomic Research Institute, Marshall University, Huntington, West Virginia, United States of America
| | - Logan Lawrence
- Department of Biochemistry and Microbiology, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, United States of America
- Translational Genomic Research Institute, Marshall University, Huntington, West Virginia, United States of America
| | - Danielle R. McCallister
- Department of Biochemistry and Microbiology, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, United States of America
- Translational Genomic Research Institute, Marshall University, Huntington, West Virginia, United States of America
| | - James Denvir
- Department of Biochemistry and Microbiology, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, United States of America
- Translational Genomic Research Institute, Marshall University, Huntington, West Virginia, United States of America
| | - Gerrit A. Kimmey
- Department of Medical Oncology, St. Mary's Hospital, Huntington, West Virginia, United States of America
| | - Mark Mogul
- Department of Pediatrics, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, United States of America
| | - Gerard Oakley
- Department of Pathology, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, United States of America
| | - Krista L. Denning
- Department of Pathology, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, United States of America
| | - Thomas Dougherty
- Department of Pathology, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, United States of America
| | - Jagan V. Valluri
- Department of Biology, Marshall University, Huntington, West Virginia, United States of America
| | - Pier Paolo Claudio
- Department of Biochemistry and Microbiology, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, United States of America
- Translational Genomic Research Institute, Marshall University, Huntington, West Virginia, United States of America
- Department of Surgery, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, United States of America
- * E-mail:
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