1
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Peschillo S, Meling TR. Endovascular neurosurgery in Europe: an International Survey and future perspectives. J Neurosurg Sci 2024; 68:254-259. [PMID: 38635305 DOI: 10.23736/s0390-5616.24.06252-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND Recent advancements in neurosurgery have transformed patient care through minimally invasive procedures and led to a notable surge in endovascular treatments. However, the regulatory landscape governing these procedures across European countries varies, impacting treatment access and collaboration. This paper discusses the results of a survey on European legislation regarding endovascular neurosurgery, exploring current practices and speculating on the field's future. METHODS An e-mail survey was distributed to 41 European countries, targeting European member societies within the EANS. Thirty-seven completed questionnaires were returned, providing insights into neuroendovascular treatment legislation and restrictions. RESULTS Legislation and certification varied across the surveyed countries, with only two countries prohibiting endovascular neurosurgery. Eight countries required specific fellowship programs. Resistance from radiologists was noted in many countries. CONCLUSIONS Despite growing support for neurosurgeons performing endovascular treatments in Europe, challenges persist. Specialized care, improved access, and a broadening spectrum of treatable conditions contribute to the argument for involvement of neurosurgeons.
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Affiliation(s)
- Simone Peschillo
- UniCamillus-Saint Camillus International University of Health Sciences, Rome, Italy -
| | - Torstein R Meling
- Department of Neurosurgery, The National Hospital of Denmark (Rigshospitalet), Copenhagen, Denmark
- Department of Neurological Surgery, C. Besta National Institute of Neurology, Milan, Italy
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2
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Xie Q, Yang Y, Hao W, Luo C. Unleashing the potential: transarterial chemoembolization combined with intra-arterial infusion of bevacizumab for unresectable hepatocellular carcinoma. Clin Transl Oncol 2024:10.1007/s12094-024-03498-1. [PMID: 38801510 DOI: 10.1007/s12094-024-03498-1] [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: 01/20/2024] [Accepted: 04/17/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND The purpose of this study is to compare the efficacy and safety of transarterial chemoembolization (TACE) alone with transarterial chemoembolization combined with the arterial infusion of bevacizumab (TACE + Bev) in patients with unresectable hepatocellular carcinoma (uHCC). METHODS A retrospective analysis was conducted on 446 uHCC patients treated with TACE or TACE + Bev between January 2021 and March 2023. The study evaluated objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), overall survival (OS), and adverse events in both treatment groups. RESULTS Finally, the TACE group comprised 295 patients, and the TACE + Bev group comprised 151 patients. Patients in the TACE + Bev group exhibited significantly prolonged median PFS (7.9 months vs. 10.3 months, P = 0.013) and median OS (16.1 months vs. 21.4 months, P = 0.041), improved ORR (26.8% vs. 37.7%, P = 0.017) and DCR (71.5% vs. 80.8%, P = 0.033) compared to the TACE group. Multifactorial Cox analysis identified alpha-fetoprotein (AFP) > 400 ng/ml as an independent prognostic factor for PFS and OS. Meanwhile, portal vein cancer thrombosis and distant metastasis are poor prognostic factors for OS. The overall incidence of adverse events was similar between the two groups. CONCLUSION In comparison with the TACE group, the TACE + Bev group demonstrated efficacy in improving outcomes for patients with uHCC with a manageable safety profile.
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Affiliation(s)
- Qu Xie
- Department of Hepato-Pancreato-Biliary & Gastric Medical Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, 310022, Zhejiang, China
- Postgraduate Training Base Alliance of Wenzhou Medical University, Zhejiang Cancer Hospital, Hangzhou, 310022, Zhejiang, China
| | - Yanzhen Yang
- Department of Hepato-Pancreato-Biliary & Gastric Medical Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, 310022, Zhejiang, China
- Postgraduate Training Base Alliance of Wenzhou Medical University, Zhejiang Cancer Hospital, Hangzhou, 310022, Zhejiang, China
| | - Weiyuan Hao
- Department of Intervention, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, 310022, Zhejiang, China
| | - Cong Luo
- Department of Hepato-Pancreato-Biliary & Gastric Medical Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, 310022, Zhejiang, China.
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3
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Doron O, Patel AB, Hawryluk GWJ. Neurovascular Interventions for Neurotrauma: From Treatment of Injured Vessels to Treatment of the Injured Brain? Oper Neurosurg (Hagerstown) 2024; 26:247-255. [PMID: 37976141 DOI: 10.1227/ons.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 09/17/2023] [Indexed: 11/19/2023] Open
Abstract
Traumatic brain injury is often associated with a direct or secondary neurovascular pathology. In this review, we present recent advancements in endovascular neurosurgery that enable accurate and effective vessel reconstruction with emphasis on its role in early diagnosis, the expanding use of flow diversion in pseudoaneurysms, and traumatic arteriovenous fistulas. In addition, future directions in which catheter-based interventions could potentially affect traumatic brain injury are described: targeting blood brain barrier integrity using the advantages of intra-arterial drug delivery of blood brain barrier stabilizers to prevent secondary brain edema, exploring the impact of endovascular venous access as a means to modulate venous outflow in an attempt to reduce intracranial pressure and augment brain perfusion, applying selective intra-arterial hypothermia as a neuroprotection method mitigating some of the risks conferred by systemic cooling, trans-vessel wall delivery of regenerative therapy agents, and shifting attention using multimodal neuromonitoring to post-traumatic vasospasm to further characterize the role it plays in secondary brain injury. Thus, we believe that the potential of endovascular tools can be expanded because they enable access to the "highways" governing perfusion and flow and call for further research focused on exploring these routes because it may contribute to novel endovascular approaches currently used for treating injured vessels, harnessing them for treatment of the injured brain.
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Affiliation(s)
- Omer Doron
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston , Massachusetts , USA
- Department of Biomedical Engineering, The Aldar and Iby Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv , Israel
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston , Massachusetts , USA
| | - Gregory W J Hawryluk
- Department of Neurosurgery, Akron General Neuroscience Institute, Cleveland Clinic, Akron , Ohio , USA
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Kan P, Srinivasan VM, Gumin J, Garcia R, Chen SR, Johnson JN, Collins DE, Chen MM, Ledbetter D, Huse J, Evan Luna ZA, Robledo A, Vasandani V, Rao A, Singh SK, Shpall EJ, Fueyo J, Gomez-Manzano C, Lang FF. Development of a rabbit human glioblastoma model for testing of endovascular selective intra-arterial infusion (ESIA) of novel stem cell-based therapeutics. Neuro Oncol 2024; 26:127-136. [PMID: 37603323 PMCID: PMC10768973 DOI: 10.1093/neuonc/noad152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND Endovascular selective intra-arterial (ESIA) infusion of cellular oncotherapeutics is a rapidly evolving strategy for treating glioblastoma. Evaluation of ESIA infusion requires a unique animal model. Our goal was to create a rabbit human GBM model to test IA infusions of cellular therapies and to test its usefulness by employing clinical-grade microcatheters and infusion methods to deliver mesenchymal stem cells loaded with an oncolytic adenovirus, Delta-24-RGD (MSC-D24). METHODS Rabbits were immunosuppressed with mycophenolate mofetil, dexamethasone, and tacrolimus. They underwent stereotactic xenoimplantation of human GBM cell lines (U87, MDA-GSC-17, and MDA-GSC-8-11) into the right frontal lobe. Tumor formation was confirmed on magnetic resonance imaging, histologic, and immunohistochemistry analysis. Selective microcatheter infusion of MSC-D24 was performed via the ipsilateral internal carotid artery to assess model utility and the efficacy and safety of this approach. RESULTS Twenty-five rabbits were implanted (18 with U87, 2 MDA-GSC-17, and 5 MDA-GSC-8-11). Tumors formed in 68% of rabbits (77.8% for U87, 50.0% for MDA-GSC-17, and 40.0% for MDA-GSC-8-11). On MRI, the tumors were hyperintense on T2-weighted image with variable enhancement (evidence of blood brain barrier breakdown). Histologically, tumors showed phenotypic traits of human GBM including varying levels of vascularity. ESIA infusion into the distal internal carotid artery of 2 ml of MSCs-D24 (107 cells) was safe in the model. Examination of post infusion specimens documented that MSCs-D24 homed to the implanted tumor at 24 hours. CONCLUSIONS The intracranial immunosuppressed rabbit human GBM model allows testing of ESIA infusion of novel therapeutics (eg, MSC-D24) in a clinically relevant fashion.
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Affiliation(s)
- Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | | | - Joy Gumin
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Roberto Garcia
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Stephen R Chen
- Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jeremiah N Johnson
- Department of Neurosurgery, The University of California Los Angeles, Los Angeles, California, USA
| | - Dalis E Collins
- Unit for Laboratory Animal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Melissa M Chen
- Department of Diagnostic Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Daniel Ledbetter
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jason Huse
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Zean Aaron Evan Luna
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Ariadna Robledo
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Viren Vasandani
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Abhijit Rao
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Sanjay K Singh
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Juan Fueyo
- Department of Neuro-Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Candelaria Gomez-Manzano
- Department of Neuro-Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Frederick F Lang
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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5
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Pinkiewicz M, Pinkiewicz M, Walecki J, Zaczyński A, Zawadzki M. Breaking Barriers in Neuro-Oncology: A Scoping Literature Review on Invasive and Non-Invasive Techniques for Blood-Brain Barrier Disruption. Cancers (Basel) 2024; 16:236. [PMID: 38201663 PMCID: PMC10778052 DOI: 10.3390/cancers16010236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024] Open
Abstract
The blood-brain barrier (BBB) poses a significant challenge to drug delivery for brain tumors, with most chemotherapeutics having limited permeability into non-malignant brain tissue and only restricted access to primary and metastatic brain cancers. Consequently, due to the drug's inability to effectively penetrate the BBB, outcomes following brain chemotherapy continue to be suboptimal. Several methods to open the BBB and obtain higher drug concentrations in tumors have been proposed, with the selection of the optimal method depending on the size of the targeted tumor volume, the chosen therapeutic agent, and individual patient characteristics. Herein, we aim to comprehensively describe osmotic disruption with intra-arterial drug administration, intrathecal/intraventricular administration, laser interstitial thermal therapy, convection-enhanced delivery, and ultrasound methods, including high-intensity focused and low-intensity ultrasound as well as tumor-treating fields. We explain the scientific concept behind each method, preclinical/clinical research, advantages and disadvantages, indications, and potential avenues for improvement. Given that each method has its limitations, it is unlikely that the future of BBB disruption will rely on a single method but rather on a synergistic effect of a combined approach. Disruption of the BBB with osmotic infusion or high-intensity focused ultrasound, followed by the intra-arterial delivery of drugs, is a promising approach. Real-time monitoring of drug delivery will be necessary for optimal results.
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Affiliation(s)
- Miłosz Pinkiewicz
- Faculty of Medicine, Wroclaw Medical University, 50-367 Wrocław, Poland
| | - Mateusz Pinkiewicz
- Department of Diagnostic Imaging, Mazowiecki Regional Hospital in Siedlce, 08-110 Siedlce, Poland
| | - Jerzy Walecki
- Division of Interventional Neuroradiology, Department of Radiology, The National Medical Institute of the Ministry of the Interior and Administration, 02-507 Warsaw, Poland
| | - Artur Zaczyński
- Department of Neurosurgery, The National Medical Institute of the Ministry of the Interior and Administration, 02-507 Warsaw, Poland
| | - Michał Zawadzki
- Division of Interventional Neuroradiology, Department of Radiology, The National Medical Institute of the Ministry of the Interior and Administration, 02-507 Warsaw, Poland
- Department of Radiology, Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland
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6
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Ruan J, Shi Y, Luo P, Li L, Huang J, Chen J, Yang H. Safety and feasibility of intra-arterial delivery of teniposide to high grade gliomas after blood-brain barrier disruption: a case series. J Neurointerv Surg 2023:jnis-2023-021055. [PMID: 38071559 DOI: 10.1136/jnis-2023-021055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 11/11/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND This case series describes the safety and efficacy of superselective intra-arterial (IA) cerebral infusion of teniposide for the treatment of patients with glioma, to provide new ideas and methods for the treatment of high grade gliomas. METHODS 12 patients with glioma who were previously treated with standard therapy were treated with superselective IA cerebral infusion of teniposide. Patients received at least two cycles of treatment (one cycle: 150 mg/time, used for 1 day, repeated at 28 day intervals) after blood-brain barrier disruption. Patients received individualized treatment on the tumor location. The ophthalmic artery was bypassed during the super-selective arterial infusion. RESULTS No significant differences in biochemical indexes and Karnofsky performance status (KPS) score were observed before and after treatment, and no evident adverse events occurred (P>0.05). In a recent response evaluation (August 2023), two (8%) patients presented with a complete response (16.7%), four had a partial response (33.3%), four had stable disease (33.3%), and two showed progressive disease (16.7%). The overall response rate and disease control rate were 50.0% and 83.3%, respectively. In addition, we described the detailed course of treatment in two patients. Case No 1 (recurrent tumor) and case No 2 (primary tumor) received six and three cycles of teniposide infusion, respectively. After treatment, the tumors of the patients were significantly reduced without evident adverse effects. CONCLUSION This small series suggests that superselective IA cerebral infusion of teniposide may be a safe and effective therapy in the multimodal treatment of malignant glioma and warrants further study in larger prospective investigations.
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Affiliation(s)
- Jian Ruan
- Department of Neuro-Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - You Shi
- Department of Neuro-Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Pengren Luo
- Department of Neuro-Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Lin Li
- Department of Neuro-Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Jiashang Huang
- Department of Neuro-Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Jie Chen
- Department of Neuro-Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Haifeng Yang
- Department of Neuro-Oncology, Chongqing University Cancer Hospital, Chongqing, China
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7
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Gravino G. The pioneering past and cutting-edge future of interventional neuroradiology. Interv Neuroradiol 2022:15910199221130234. [PMID: 36214159 DOI: 10.1177/15910199221130234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Abstract
This review provides a thorough understanding of the developments in the field of interventional neuroradiology (INR). A concise overview of the pioneering past and current state of this field is presented first, followed by a greater emphasis on its future. Five main aspects predicted to undergo significant developments are identified and discussed. These include changes in 'education and training', 'clinical practice and logistics', 'devices and equipment', 'techniques and procedures', and 'relevant diagnostic imaging'. INR is at the crossroads of neuroradiology, neurosurgery, neurology, and the neurosciences. To progress we must value the uniqueness and vitality of this multidisciplinary aspect. While minimal access techniques offer very good anatomical accessibility to treat multiple pathologies of the central nervous system, it is also important to recognise its limitations. Medical, surgical, and radiosurgery modalities retain an important role in the management of some complex neuropathology. This review is certainly not exhaustive of all ongoing and predicted developments, but it is an important update for INR specialists and other interested professionals.
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Affiliation(s)
- Gilbert Gravino
- 195157Neuroradiology Department, The Walton Centre for Neurology and Neurosurgery, Liverpool, L9 7LJ, UK
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Uluc K, Neuwelt EA, Ambady P. Advances in Intraarterial Chemotherapy Delivery Strategies and Blood-Brain Barrier Disruption. Neurosurg Clin N Am 2022; 33:219-223. [PMID: 35346454 DOI: 10.1016/j.nec.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Chemotherapeutics play a significant role in the management of most brain tumors. First pass effect, systemic toxicity, and more importantly, the blood-brain barrier pose significant challenges to the success of chemotherapy. Over the last 80 years, different techniques of intraarterial chemotherapy delivery have been performed in many studies but failed to become standard of care. The purpose of this article is to review the history of intraarterial drug delivery and osmotic blood-brain barrier disruption, identify the challenges for clinical translation, and identify future directions for these approaches.
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Affiliation(s)
- Kutluay Uluc
- Neurosurgery, Northernlight Eastern Maine Medical Center, Bangor, ME, USA
| | - Edward A Neuwelt
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA; Department of Neurosurgery, Oregon Health & Science University, Portland, OR, USA; Portland Veterans Affairs Medical Center, Portland, OR, USA
| | - Prakash Ambady
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA.
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9
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Rechberger JS, Thiele F, Daniels DJ. Status Quo and Trends of Intra-Arterial Therapy for Brain Tumors: A Bibliometric and Clinical Trials Analysis. Pharmaceutics 2021; 13:pharmaceutics13111885. [PMID: 34834300 PMCID: PMC8625566 DOI: 10.3390/pharmaceutics13111885] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 12/13/2022] Open
Abstract
Intra-arterial drug delivery circumvents the first-pass effect and is believed to increase both efficacy and tolerability of primary and metastatic brain tumor therapy. The aim of this update is to report on pertinent articles and clinical trials to better understand the research landscape to date and future directions. Elsevier's Scopus and ClinicalTrials.gov databases were reviewed in August 2021 for all possible articles and clinical trials of intra-arterial drug injection as a treatment strategy for brain tumors. Entries were screened against predefined selection criteria and various parameters were summarized. Twenty clinical trials and 271 articles satisfied all inclusion criteria. In terms of articles, 201 (74%) were primarily clinical and 70 (26%) were basic science, published in a total of 120 different journals. Median values were: publication year, 1986 (range, 1962-2021); citation count, 15 (range, 0-607); number of authors, 5 (range, 1-18). Pertaining to clinical trials, 9 (45%) were phase 1 trials, with median expected start and completion years in 2011 (range, 1998-2019) and 2022 (range, 2008-2025), respectively. Only one (5%) trial has reported results to date. Glioma was the most common tumor indication reported in both articles (68%) and trials (75%). There were 215 (79%) articles investigating chemotherapy, while 13 (65%) trials evaluated targeted therapy. Transient blood-brain barrier disruption was the commonest strategy for articles (27%) and trials (60%) to optimize intra-arterial therapy. Articles and trials predominately originated in the United States (50% and 90%, respectively). In this bibliometric and clinical trials analysis, we discuss the current state and trends of intra-arterial therapy for brain tumors. Most articles were clinical, and traditional anti-cancer agents and drug delivery strategies were commonly studied. This was reflected in clinical trials, of which only a single study had reported outcomes. We anticipate future efforts to involve novel therapeutic and procedural strategies based on recent advances in the field.
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Affiliation(s)
- Julian S. Rechberger
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN 55905, USA
- Correspondence:
| | - Frederic Thiele
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA;
| | - David J. Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN 55905, USA
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10
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Fischell JM, Fishman PS. A Multifaceted Approach to Optimizing AAV Delivery to the Brain for the Treatment of Neurodegenerative Diseases. Front Neurosci 2021; 15:747726. [PMID: 34630029 PMCID: PMC8497810 DOI: 10.3389/fnins.2021.747726] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/31/2021] [Indexed: 12/12/2022] Open
Abstract
Despite major advancements in gene therapy technologies, there are no approved gene therapies for diseases which predominantly effect the brain. Adeno-associated virus (AAV) vectors have emerged as the most effective delivery vector for gene therapy owing to their simplicity, wide spread transduction and low immunogenicity. Unfortunately, the blood-brain barrier (BBB) makes IV delivery of AAVs, to the brain highly inefficient. At IV doses capable of widespread expression in the brain, there is a significant risk of severe immune-mediated toxicity. Direct intracerebral injection of vectors is being attempted. However, this method is invasive, and only provides localized delivery for diseases known to afflict the brain globally. More advanced methods for AAV delivery will likely be required for safe and effective gene therapy to the brain. Each step in AAV delivery, including delivery route, BBB transduction, cellular tropism and transgene expression provide opportunities for innovative solutions to optimize delivery efficiency. Intra-arterial delivery with mannitol, focused ultrasound, optimized AAV capsid evolution with machine learning algorithms, synthetic promotors are all examples of advanced strategies which have been developed in pre-clinical models, yet none are being investigated in clinical trials. This manuscript seeks to review these technological advancements, and others, to improve AAV delivery to the brain, and to propose novel strategies to build upon this research. Ultimately, it is hoped that the optimization of AAV delivery will allow for the human translation of many gene therapies for neurodegenerative and other neurologic diseases.
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Affiliation(s)
- Jonathan M Fischell
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Paul S Fishman
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
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11
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Carnevale JA, Imber BS, Winston GM, Goldberg JL, Ballangrud A, Brennan CW, Beal K, Tabar V, Moss NS. Risk of tract recurrence with stereotactic biopsy of brain metastases: an 18-year cancer center experience. J Neurosurg 2021; 136:1045-1051. [PMID: 34507279 DOI: 10.3171/2021.3.jns204347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic biopsy is increasingly performed on brain metastases (BrMs) as improving cancer outcomes drive aggressive multimodality treatment, including laser interstitial thermal therapy (LITT). However, the tract recurrence (TR) risk is poorly defined in an era defined by focused-irradiation paradigms. As such, the authors aimed to define indications and adjuvant therapies for this procedure and evaluate the BrM-biopsy TR rate. METHODS In a single-center retrospective review, the authors identified stereotactic BrM biopsies performed from 2002 to 2020. Surgical indications, radiographic characteristics, stereotactic planning, dosimetry, pre- and postoperative CNS-directed and systemic treatments, and clinical courses were collected. Recurrence was evaluated using RANO-BM (Response Assessment in Neuro-Oncology Brain Metastases) criteria. RESULTS In total, 499 patients underwent stereotactic intracranial biopsy for any diagnosis, of whom 25 patients (5.0%) underwent biopsy for pathologically confirmed viable BrM, a proportion that increased over the time period studied. Twelve of the 25 BrM patients had ≥ 3 months of radiographic follow-up, of whom 6 patients (50%) developed new metastatic growth along the tract at a median of 5.0 months post-biopsy (range 2.3-17.1 months). All of the TR cases had undergone pre- or early post-biopsy stereotactic radiosurgery (SRS), and 3 had also undergone LITT at the time of initial biopsy. TRs were treated with resection, reirradiation, or observation/systemic therapy. CONCLUSIONS In this study the authors identified a nontrivial, higher than previously described rate of BrM-biopsy tract recurrence, which often required additional surgery or radiation and justified close radiographic surveillance. As BrMs are commonly treated with SRS limited to enhancing tumor margins, consideration should be made, in cases lacking CNS-active systemic treatments, to include biopsy tracts in adjuvant radiation plans where feasible.
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Affiliation(s)
- Joseph A Carnevale
- 1Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center.,2Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical Center; and
| | | | - Graham M Winston
- 1Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center.,2Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical Center; and
| | - Jacob L Goldberg
- 1Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center.,2Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical Center; and
| | - Ase Ballangrud
- 4Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cameron W Brennan
- 1Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center
| | | | - Viviane Tabar
- 1Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center
| | - Nelson S Moss
- 1Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center
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12
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Srinivasan VM, Gumin J, Camstra KM, Collins DE, Chen MM, Shpall EJ, Parker Kerrigan BC, Johnson JN, Chen SR, Fueyo J, Gomez-Manzano C, Lang FF, Kan P. Endovascular Selective Intra-Arterial Infusion of Mesenchymal Stem Cells Loaded With Delta-24 in a Canine Model. Neurosurgery 2021; 88:E102-E113. [PMID: 33231254 DOI: 10.1093/neuros/nyaa470] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/12/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Delta-24-RGD, an oncolytic adenovirus, shows promise against glioblastoma. To enhance virus delivery, we recently demonstrated that human bone marrow-derived mesenchymal stem cells loaded with Delta-24-RGD (hMSC-D24) can eradicate glioblastomas in mouse models. There are no studies examining the safety of endovascular selective intra-arterial (ESIA) infusions of MSC-D24 in large animals simulating human clinical situations. OBJECTIVE To perform canine preclinical studies testing the feasibility and safety of delivering increasing doses of hMSCs-D24 via ESIA infusions. METHODS ESIA infusions of hMSC-D24 were performed in the cerebral circulation of 10 normal canines in the target vessels (internal carotid artery [ICA]/P1) via transfemoral approach using commercially available microcatheters. Increasing concentrations of hMSC-D24 or particles (as a positive control) were injected into 1 hemisphere; saline (negative control) was infused contralaterally. Toxicity (particularly embolic stroke) was assessed on postinfusion angiography, diffusion-weighted magnetic resonance imaging, clinical exam, and necropsy. RESULTS ESIA injections were performed in the ICA (n = 7) or P1 (n = 3). In 2 animals injected with particles (positive control), strokes were detected by all assays. Of 6 canines injected with hMSC-D24 through the anterior circulation, escalating dose from 2 × 106 cells/20 mL to 1 × 108 cells/10 mL resulted in no strokes. Two animals had ischemic and hemorrhagic strokes after posterior cerebral artery catheterization. A survival experiment of 2 subjects resulted in no complications detected for 24-h before euthanization. CONCLUSION This novel study simulating ESIA infusion demonstrates that MSCs-D24 can be infused safely at least up to doses of 1 × 108 cells/10 mL (107 cells/ml) in the canine anterior circulation using commercially available microcatheters. These findings support a clinical trial of ESIA infusion of hMSCs-D24.
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Affiliation(s)
| | - Joy Gumin
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Kevin M Camstra
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Dalis E Collins
- Center for Comparative Medicine, Baylor College of Medicine, Houston, Texas
| | - Melissa M Chen
- Department of Diagnostic Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | | | - Jeremiah N Johnson
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Stephen R Chen
- Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Juan Fueyo
- Department of Neuro-Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Cande Gomez-Manzano
- Department of Neuro-Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Frederick F Lang
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.,Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
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13
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Scullen T, Mathkour M, Nerva JD, Dumont AS. Commentary: Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Multi-Center Experience of 154 Consecutive Embolizations. Neurosurgery 2021; 88:E130-E132. [PMID: 33045740 DOI: 10.1093/neuros/nyaa432] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 07/20/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Mansour Mathkour
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - John D Nerva
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
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14
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Srinivasan VM, Lang FF, Kan P. Intraarterial delivery of virotherapy for glioblastoma. Neurosurg Focus 2021; 50:E7. [PMID: 33524944 DOI: 10.3171/2020.11.focus20845] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/16/2020] [Indexed: 11/06/2022]
Abstract
Oncolytic viruses (OVs) have been used in the treatment of cancer, in a focused manner, since the 1990s. These OVs have become popular in the treatment of several cancers but are only now gaining interest in the treatment of glioblastoma (GBM) in recent clinical trials. In this review, the authors discuss the unique applications of intraarterial (IA) delivery of OVs, starting with concepts of OV, how they apply to IA delivery, and concluding with discussion of the current ongoing trials. Several OVs have been used in the treatment of GBM, including specifically several modified adenoviruses. IA delivery of OVs has been performed in the hepatic circulation and is now being studied in the cerebral circulation to help enhance delivery and specificity. There are some interesting synergies with immunotherapy and IA delivery of OVs. Some of the shortcomings are discussed, specifically the systemic response to OVs and feasibility of treatment. Future studies can be performed in the preclinical setting to identify the ideal candidates for translation into clinical trials, as well as the nuances of this novel delivery method.
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Affiliation(s)
- Visish M Srinivasan
- 1Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Frederick F Lang
- 2Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - Peter Kan
- 3Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas
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15
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Hashimoto Y, Campbell M. Tight junction modulation at the blood-brain barrier: Current and future perspectives. BIOCHIMICA ET BIOPHYSICA ACTA-BIOMEMBRANES 2020; 1862:183298. [PMID: 32353377 DOI: 10.1016/j.bbamem.2020.183298] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 03/09/2020] [Accepted: 03/28/2020] [Indexed: 12/14/2022]
Abstract
The blood-brain barrier (BBB) is the one of the most robust physical barriers in the body, comprised of tight junction (TJ) proteins in brain microvascular endothelial cells. The need for drugs to treat central nervous systems diseases is ever increasing, however the presence of the BBB significantly hampers the uptake of drugs into the brain. To overcome or circumvent the barrier, many kinds of techniques are being developed. Modulating the paracellular route by disruption of the TJ complex has been proposed as a potential drug delivery system to treat brain diseases, however, it has several limitations and is still in a developmental stage. However, recent significant advance in medical equipment /tools such as targeted ultra-sound technologies may resolve these limitations. In this review, we introduce recent advances in site- or molecular size-selective BBB disruption/modulation technologies and we include details on pharmacological inhibitory molecules against intercellular TJ proteins to modulate the BBB.
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Affiliation(s)
- Yosuke Hashimoto
- Trinity College Dublin, Smurfit Institute of Genetics, Dublin 2, Ireland.
| | - Matthew Campbell
- Trinity College Dublin, Smurfit Institute of Genetics, Dublin 2, Ireland.
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