Stem cells and the origin and propagation of brain tumors

Novel approaches for glioblastoma treatment: Focus on tumor heterogeneity, treatment resistance, and computational tools

BACKGROUND

Glioblastoma (GBM) is a highly aggressive primary brain tumor. Currently, the suggested line of action is the surgical resection followed by radiotherapy and treatment with the adjuvant temozolomide, a DNA alkylating agent. However, the ability of tumor cells to deeply infiltrate the surrounding tissue makes complete resection quite impossible, and, in consequence, the probability of tumor recurrence is high, and the prognosis is not positive. GBM is highly heterogeneous and adapts to treatment in most individuals. Nevertheless, these mechanisms of adaption are unknown.

RECENT FINDINGS

In this review, we will discuss the recent discoveries in molecular and cellular heterogeneity, mechanisms of therapeutic resistance, and new technological approaches to identify new treatments for GBM. The combination of biology and computer resources allow the use of algorithms to apply artificial intelligence and machine learning approaches to identify potential therapeutic pathways and to identify new drug candidates.

CONCLUSION

These new approaches will generate a better understanding of GBM pathogenesis and will result in novel treatments to reduce or block the devastating consequences of brain cancers.

Nilotinib, an approved leukemia drug, inhibits smoothened signaling in Hedgehog-dependent medulloblastoma

Dysregulation of the seven-transmembrane (7TM) receptor Smoothened (SMO) and other components of the Hedgehog (Hh) signaling pathway contributes to the development of cancers including basal cell carcinoma (BCC) and medulloblastoma (MB). However, SMO-specific antagonists produced mixed results in clinical trials, marked by limited efficacy and high rate of acquired resistance in tumors. Here we discovered that Nilotinib, an approved inhibitor of several kinases, possesses an anti-Hh activity, at clinically achievable concentrations, due to direct binding to SMO and inhibition of SMO signaling. Nilotinib was more efficacious than the SMO-specific antagonist Vismodegib in inhibiting growth of two Hh-dependent MB cell lines. It also reduced tumor growth in subcutaneous MB mouse xenograft model. These results indicate that in addition to its known activity against several tyrosine-kinase-mediated proliferative pathways, Nilotinib is a direct inhibitor of the Hh pathway. The newly discovered extension of Nilotinib's target profile holds promise for the treatment of Hh-dependent cancers.

Hedgehog pathway and smoothened inhibitors in cancer therapies

The hedgehog (Hh) pathway plays an important role in cancer development and maintenance, as ~25% of all cancers have aberrant Hh pathway activation. Targeted therapy for inhibition of the Hh pathway was thought to be promising for achieving clinical response in the Hh-dependent cancers. However, the results of new clinical trials with smoothened (SMO) antagonists do not show much success in cancers other than basal cell carcinoma. The studies suggest that the Hh pathway involves multiple mechanisms of activation or inhibition in primary cilia and interactions between several related pathways in different types of cells, which makes this pathway extremely complex. The SMO-specific antagonists may not stop all relevant pathways that may lead to escape or development of resistance. Therefore, in the Hh-dependent cancers, the inhibition of two or more oncogenic pathways (including the Hh pathway) with use of a single agent of a suitable multitarget profile or a combination of drugs seems promising for achieving clinical response in patients and decrease in resistance development with prolonged use of the specific SMO antagonists. Furthermore, for studying the effect of new treatments, the inclusion criteria should be more specific for selection of patients with aberrant Hh pathway activity confirmed by tests. These considerations will be very helpful for choosing the right patients and the right drugs for the best therapeutic outcome.

Mir-21-Sox2 Axis Delineates Glioblastoma Subtypes with Prognostic Impact

Glioblastoma (GBM) is the most aggressive human brain tumor. Although several molecular subtypes of GBM are recognized, a robust molecular prognostic marker has yet to be identified. Here, we report that the stemness regulator Sox2 is a new, clinically important target of microRNA-21 (miR-21) in GBM, with implications for prognosis. Using the MiR-21-Sox2 regulatory axis, approximately half of all GBM tumors present in the Cancer Genome Atlas (TCGA) and in-house patient databases can be mathematically classified into high miR-21/low Sox2 (Class A) or low miR-21/high Sox2 (Class B) subtypes. This classification reflects phenotypically and molecularly distinct characteristics and is not captured by existing classifications. Supporting the distinct nature of the subtypes, gene set enrichment analysis of the TCGA dataset predicted that Class A and Class B tumors were significantly involved in immune/inflammatory response and in chromosome organization and nervous system development, respectively. Patients with Class B tumors had longer overall survival than those with Class A tumors. Analysis of both databases indicated that the Class A/Class B classification is a better predictor of patient survival than currently used parameters. Further, manipulation of MiR-21-Sox2 levels in orthotopic mouse models supported the longer survival of the Class B subtype. The MiR-21-Sox2 association was also found in mouse neural stem cells and in the mouse brain at different developmental stages, suggesting a role in normal development. Therefore, this mechanism-based classification suggests the presence of two distinct populations of GBM patients with distinguishable phenotypic characteristics and clinical outcomes.

SIGNIFICANCE STATEMENT

Molecular profiling-based classification of glioblastoma (GBM) into four subtypes has substantially increased our understanding of the biology of the disease and has pointed to the heterogeneous nature of GBM. However, this classification is not mechanism based and its prognostic value is limited. Here, we identify a new mechanism in GBM (the miR-21-Sox2 axis) that can classify ∼50% of patients into two subtypes with distinct molecular, radiological, and pathological characteristics. Importantly, this classification can predict patient survival better than the currently used parameters. Further, analysis of the miR-21-Sox2 relationship in mouse neural stem cells and in the mouse brain at different developmental stages indicates that miR-21 and Sox2 are predominantly expressed in mutually exclusive patterns, suggesting a role in normal neural development.

Isolation and characterization of stem cells from human central nervous system malignancies

Central Nervous System (CNS) tumors include some of the most invasive and lethal tumors in humans. The poor prognosis in patients with CNS tumors is ascribed to their invasive nature. After the description of a stem cell-like cohort in hematopoietic cancers, tumor stem cells (TSCs) have been isolated from a variety of solid tumors, including brain tumors. Further research has uncovered the crucial role these cells play in the initiation and propagation of brain tumors. More importantly, TSCs have also been shown to be relatively resistant to conventional cytotoxic therapeutics, which may also account for the alarmingly high rate of CNS tumor recurrence. In order to elucidate prospective therapeutic targets it is imperative to study these cells in detail and to accomplish this, we need to be able to reliably isolate and characterize these cells. This chapter will therefore, provide an overview of the methods used to isolate and characterize stem cells from human CNS malignancies.

On the Genesis of Neuroblastoma and Glioma

As the emergence of cancer is most frequent in proliferating tissues, replication errors are considered to be at the base of this disease. This review concentrates mainly on two neural cancers, neuroblastoma and glioma, with completely different backgrounds that are well documented with respect to their ontogeny. Although clinical data on other cancers of the nervous system are available, usually little can be said about their origins. Neuroblastoma is initiated in the embryo at a moment when the nervous system (NS) is in full expansion and occasionally genomic damage can lead to neoplasia. Glioma, to the contrary, occurs in the adult brain supposed to be mostly in a postmitotic state. According to current consensus, neural stem cells located in the subventricular zone (SVZ) in the adult are thought to accumulate enough genomic mutations to diverge on a carcinogenic course leading to diverse forms of glioma. After weighing the pros and cons of this current hypothesis in this review, it will be argued that this may be improbable, yielding to the original old concept of glial origin of glioma.

Drosophila melanogaster as a model system for human brain cancers

Glioblastomas (GBM), the most common primary brain tumors, infiltrate the brain, grow rapidly, and are refractory to current therapies. Signature genetic lesions in glioblastomas include mutation of the epidermal growth factor receptor tyrosine kinase (EGFR) receptor tyrosine kinase and activating mutations in components of the PI-3 kinase (PI3K) pathway. Despite years of study, how these pathways specifically regulate glial pathogenesis is unclear. To address the genetic and cellular origins of this disease, a novel Drosophila GBM model has been developed in which glial progenitor cells give rise to proliferative and invasive neoplastic cells that create transplantable tumors in response to constitutive co-activation of the EGFR-Ras and PI3K pathways. Standing with a rich literature demonstrating the direct relevance of Drosophila to studies on human cancer, neurological disease, and neurodevelopment, this model represents a robust cell-type specific Drosophila neurological disease model in which malignant cells are created by mutations in genetic pathways thought to be driving forces in a homologous human disease. Using lineage analysis and cell-type specific markers, neoplastic glial cells were found to originate from committed glial progenitor cells, rather than from multipotent neuroblasts. Genetic analyses demonstrated that EGFR-Ras and PI3K induce fly glial neoplasia through activation of a combinatorial genetic network composed, in part, of other genetic pathways also commonly mutated in human glioblastomas. In the future, large-scale forward genetic screens with this model may reveal new insights into the origins and treatments of human glioblastoma.

A study on the biochemical and cytogenetic status in the blood of glioma patients

Malignant gliomas, the most common subtype of primary brain tumors, are aggressive, highly invasive and neurologically destructive tumors, considered being the deadliest of human cancers. As an attempt to understand the biology of glial tumor, a study on macromolecules like proteins, matrix metalloproteinases, lipids antioxidants and Deoxyribonucleic acid, in the blood of glioma patients was made. Biochemical assessment of significant pathophysiological enzymes, antioxidants and marker enzymes was performed. MMP expression was determined using gelatin zymography. Karyotyping analysis was done to determine chromosomal aberrations. A marked rise was observed in the proteins and lipids of glioma patients as compared to the normal cases. The antioxidant status of the patients was found to be lowered. Karyotypic analysis of the peripheral blood chromosomes presented various chromosomal aberrations in glioma patients. The biochemical parameters were significantly increased in the patient population (p<0.01, p<0.001) when compared to those of normal. Zymographic analysis showed the presence of MMP-2 and MMP-9 in the patient sample. Karyotypic investigation showed alterations in the chromosomal pattern of the glioma patients. The study provides baseline information on the biochemical alterations in the blood of glioma patients which can be further exploited for detailed investigations.

Childhood medulloblastoma: novel approaches to the classification of a heterogeneous disease

Increasing recognition of pediatric medulloblastoma as a heterogeneous disease, with histopathological and molecular variants that have distinct biological behaviors, will impact how the disease is classified and treated. A combination of clinicopathological evaluation and assays based on molecular subgroups of disease will allow stratification of patients into risk groups and a more tailored approach to therapy. Patients with low-risk disease could be treated with de-escalated adjuvant therapy to maximize cure while reducing long-term adverse effects, and novel therapies could be sought for patients with high-risk disease. My review encompasses a brief overview of the clinical landscape, the current World Health Organization (WHO) classification of medulloblastoma, the status of molecular subgroups, and how potential stratification schemes might impact pathologists and their practice.

Learning from Jekyll to control Hyde: Hedgehog signaling in development and cancer

The Hedgehog (Hh) cascade controls cell proliferation, differentiation and patterning of tissues during embryogenesis but is largely suppressed in the adult. The Hh pathway can become reactivated in cancer. Here, we assimilate data from recent studies to understand how and when the Hh pathway is turned on to aid the neoplastic process. Hh signaling is now known to have a role in established tumors, enabling categorization of tumors based on the role Hh signaling plays in their growth. This categorization has relevance for prognosis and targeted therapeutics. In the first category, abnormal Hh signaling initiates the tumor. In the second category, Hh signaling helps maintain the tumor. In the third category, Hh signaling is implicated but its role is not yet defined.

Brain cancer propagating cells: biology, genetics and targeted therapies

Cancer propagating cells (CPCs) within primary central nervous system (CNS) tumors (glioblastoma multiforme (GBM), medulloblastoma (MB) and ependymoma) might be integral to tumor development and perpetuation. These cells, also known as brain cancer propagating cells (BCPCs), have the ability to self-renew and proliferate. BCPCs can initiate new tumors in mice with high efficiency and these exhibit many features that are characteristic of patient's brain tumors. Accumulating evidence suggests that BCPCs might originate from the transformation of neural stem cells (NSCs) and their progenitors. Furthermore, recent studies have shown that NSC surface markers also define BCPCs. Ultimately, treatments that include specific targeting of BCPCs might potentially be more effective at treating the entire tumor mass, translating to improved patient survival and quality of life.