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Yu A, Zeng J, Yu J, Cao S, Li A. Theory and application of TTFields in newly diagnosed glioblastoma. CNS Neurosci Ther 2024; 30:e14563. [PMID: 38481068 PMCID: PMC10938032 DOI: 10.1111/cns.14563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 11/07/2023] [Accepted: 11/29/2023] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Glioblastoma is the most common primary malignant brain tumor in adults. TTFields is a therapy that use intermediate-frequency and low-intensity alternating electric fields to treat tumors. For patients with ndGBM, the addition of TTFields after the concurrent chemoradiotherapy phase of the Stupp regimen can improve prognosis. However, TTFields still has the potential to further prolong the survival of ndGBM patients. AIM By summarizing the mechanism and application status of TTFields in the treatment of ndGBM, the application prospect of TTFields in ndbm treatment is prospected. METHODS We review the recent literature and included 76 articles to summarize the mechanism of TTfields in the treatment of ndGBM. The current clinical application status and potential health benefits of TTFields in the treatment of ndGBM are also discussed. RESULTS TTFields can interfere with tumor cell mitosis, lead to tumor cell apoptosis and increased autophagy, hinder DNA damage repair, induce ICD, activate tumor immune microenvironment, reduce cancer cell metastasis and invasion, and increase BBB permeability. TTFields combines with chemoradiotherapy has made progress, its optimal application time is being explored and the problems that need to be considered when retaining the electrode patches for radiotherapy are further discussed. TTFields shows potential in combination with immunotherapy, antimitotic agents, and PARP inhibitors, as well as in patients with subtentorial gliomas. CONCLUSION This review summarizes mechanisms of TTFields in the treatment of ndGBM, and describes the current clinical application of TTFields in ndGBM. Through the understanding of its principle and application status, we believe that TTFields still has the potential to further prolong the survival of ndGBM patients. Thus,research is still needed to explore new ways to combine TTFields with other therapies and optimize the use of TTFields to realize its full potential in ndGBM patients.
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Affiliation(s)
- Ao Yu
- Department of Radiotherapy, Liaoning Cancer Hospital & Institute, Cancer Hospital of China Medical UniversityCancer Hospital of Dalian University of TechnologyShenyangChina
- School of GraduateChina Medical UniversityShenyangChina
| | - Juan Zeng
- Department of OncologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Jinhui Yu
- Department of Radiotherapy, Liaoning Cancer Hospital & Institute, Cancer Hospital of China Medical UniversityCancer Hospital of Dalian University of TechnologyShenyangChina
- School of GraduateChina Medical UniversityShenyangChina
| | - Shuo Cao
- Department of OncologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Ailin Li
- Department of Radiotherapy, Liaoning Cancer Hospital & Institute, Cancer Hospital of China Medical UniversityCancer Hospital of Dalian University of TechnologyShenyangChina
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Goldlust SA, Singer S, Cappello LA, AlMekkawi AK, Lee KD, Ingenito AC, Lewis BE, Nyirenda T, Azmi H, Kaptain GJ. Phase 1 study of concomitant tumor treating fields and temozolomide chemoradiation for newly diagnosed glioblastoma. Neurooncol Adv 2024; 6:vdae129. [PMID: 39211521 PMCID: PMC11358815 DOI: 10.1093/noajnl/vdae129] [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] [Indexed: 09/04/2024] Open
Abstract
Background Glioblastoma (GBM) is the most common and aggressive primary brain tumor and has limited effective therapies. Tumor treating fields (TTF; Optune Gio®) is an FDA-approved device with data supporting a significant survival benefit and minimal toxicity when added to maintenance chemotherapy. Uptake in clinical practice is not universal and might improve if a shorter duration of treatment is feasible. This phase 1 trial was designed to determine the safety and preliminary efficacy of TTF concomitant to chemoradiation. Methods Patients with newly diagnosed, histologically confirmed GBM were eligible. Following surgery, patients were treated with TTF concomitant to standard chemoradiation. The device continued through 2 monthly cycles of maintenance temozolomide with imaging and clinical assessments at regular intervals to assess toxicity and response. The primary endpoint was the safety and tolerability of combined modality treatment based upon the incidence and severity of adverse events. Secondary endpoints were overall survival (OS) and progression-free survival (PFS). Results Thirteen patients were enrolled. Dermatologic adverse events were frequent but limited to grade 1/2. There was only 1 serious adverse event possibly related to TTF and no patients were unable to complete the prescribed course of multimodality treatment due to TTF-associated toxicity. Twelve patients were evaluable for median and 6-month progression-free survival which were 8.5 months (mo) and 66.7%, respectively. Median and 12 mo overall survival were 16.0 mo and 83.3%, respectively. Conclusions TTF can be safely delivered in conjunction with chemoradiation. The potential for a finite TTF course merits further evaluation.
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Affiliation(s)
- Samuel A Goldlust
- Department of Oncology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Samuel Singer
- Department of Oncology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Lori A Cappello
- Department of Oncology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Ahmad K AlMekkawi
- Department of Neurosurgery, Saint Luke’s Hospital of Kansas City, Kansas City, Missouri, USA
| | - Kangmin D Lee
- Department of Neurosurgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Anthony C Ingenito
- Department of Radiation Oncology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Brett E Lewis
- Department of Radiation Oncology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Themba Nyirenda
- Office of Research Administration, Hackensack Meridian Health, Edison, New Jersey, USA
| | - Hooman Azmi
- Department of Neurosurgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - George J Kaptain
- Department of Neurosurgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
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Zheng J, Zhu H, Guo W, Gao C, Guo J, Sun L, Xu G, Wang Z, Dai B, Gu N, He X. Investigation of sponge medium for efficient concurrent tumor treating fields and radiotherapy for glioblastomas. NANOSCALE 2023; 15:17839-17849. [PMID: 37882243 DOI: 10.1039/d3nr04228f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
Realizing precise therapy for glioblastomas (GBMs), a kind of high-frequency malignant brain tumor, is of great importance in improving the overall survival (OS) of patients. With relentless efforts made in the past few years, a sponge medium has been introduced into concurrent tumor treating fields (TTFields) and radiotherapy to enhance therapy efficacy for GBMs, and some progresses have been witnessed. However, the specific physical and chemical characteristics of the sponge that can be used for GBMs have not been reported as far as we know. Therefore, this study aims to develop a simple yet robust method to select a candidate sponge medium and verify its safety in advanced concurrent TTFields and radiotherapy for GBMs through interdisciplinary investigation among materials science, medical physics, and clinical radiation oncology. Significantly, latex-free polyurethane (PU) sponges with a Hounsfield unit (HU) value lower than -750, which exhibit almost no negative influence on planning computed tomography (CT) imaging and radiotherapy dosimetry, are demonstrated to be available for concurrent TTFields and radiotherapy for GBMs. Moreover, in clinical research, the achieved clear CT images, negligible scalp toxicity, lower residual positioning errors, and high compliant rate of 82% over the selected representative sponge sample corroborate the availability and safety of PU sponges in practical applications for GBM treatment.
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Affiliation(s)
- Jiajun Zheng
- Jiangsu Cancer Hospital, the Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Institute of Cancer Research, Nanjing 210009, China.
- Key Laboratory for Bio-Electromagnetic Environment and Advanced Medical Theranostics, School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing 211166, China.
| | - Huanfeng Zhu
- Jiangsu Cancer Hospital, the Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Institute of Cancer Research, Nanjing 210009, China.
| | - Wenjie Guo
- Jiangsu Cancer Hospital, the Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Institute of Cancer Research, Nanjing 210009, China.
| | - Chenchen Gao
- State Key Laboratory of Organic Electronics and Information Displays & Institute of Advanced Materials (IAM), Jiangsu Key Laboratory for Biosensors, Jiangsu National Synergetic Innovation Center for Advanced Materials (SICAM), Nanjing University of Posts and Telecommunications, Nanjing 210023, China.
| | - Jiahao Guo
- State Key Laboratory of Organic Electronics and Information Displays & Institute of Advanced Materials (IAM), Jiangsu Key Laboratory for Biosensors, Jiangsu National Synergetic Innovation Center for Advanced Materials (SICAM), Nanjing University of Posts and Telecommunications, Nanjing 210023, China.
| | - Li Sun
- Jiangsu Cancer Hospital, the Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Institute of Cancer Research, Nanjing 210009, China.
| | - Geng Xu
- Jiangsu Cancer Hospital, the Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Institute of Cancer Research, Nanjing 210009, China.
| | - Zhi Wang
- The First Affiliated Hospital of Anhui Medical University, Nanjing 230022, China
| | - Baoying Dai
- State Key Laboratory of Organic Electronics and Information Displays & Institute of Advanced Materials (IAM), Jiangsu Key Laboratory for Biosensors, Jiangsu National Synergetic Innovation Center for Advanced Materials (SICAM), Nanjing University of Posts and Telecommunications, Nanjing 210023, China.
| | - Ning Gu
- Key Laboratory for Bio-Electromagnetic Environment and Advanced Medical Theranostics, School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing 211166, China.
- Medical School, Nanjing University, Nanjing 210093, China
| | - Xia He
- Jiangsu Cancer Hospital, the Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Institute of Cancer Research, Nanjing 210009, China.
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Pan M, Xiao Y, Zhu L, Dong S, Liang L, Sun L, Shi W, Wang Y. Evaluation of Interfraction Setup Uncertainty of Patients With Glioblastoma Wearing TTFields (Tumor Treating Fields) During Radiation Therapy. Pract Radiat Oncol 2023; 13:522-530. [PMID: 37437806 DOI: 10.1016/j.prro.2023.06.006] [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: 04/05/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE Tumor treating fields (TTFields) with concurrent radiation therapy (RT) might improve the outcome of patients with newly diagnosed glioblastoma. Several trials, including that conducted in our center, have allowed patients to wear TTFields during RT. We aimed to evaluate the setup uncertainty introduced by TTFields and calculate the planning target volume (PTV) margin for clinical reference. METHODS AND MATERIALS We collected and analyzed 201 cone beam computed tomography images of 22 patients in our center. Patients with or without TTFields were divided into the control and TTFields groups. We evaluated the setup errors in 6 degrees of freedom and 3 degrees of freedom and the magnitudes in the 3-dimensional vectors. An estimated PTV margin for patients requiring nonimaging-guided RT was recommended. RESULTS A significant difference was observed in the longitudinal axis between the TTFields and control groups (P < .05). These results were consistent with that of the intragroup comparison of the TTFields group. The position error of the longitudinal axis (from head to feet) was -0.51 ± 2.05 mm in the TTFields group. CONCLUSIONS Wearing TTFields during RT increased the uncertainty, especially in the longitudinal axis, with a system error of 1.40 mm and a random error of 1.28 mm. Daily image guided RT for TTFields patients seems necessary. However, the recommended expansion margin of the PTV is 5 mm for patients requiring nonimage-guided RT to enhance the safety and efficacy of treatment.
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Affiliation(s)
- Mingyuan Pan
- Radiation Oncology Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Yixuan Xiao
- Radiation Oncology Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Liying Zhu
- Radiation Oncology Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Shengnan Dong
- Radiation Oncology Center, Huashan Hospital, Fudan University, Shanghai, China; Henan Province Hospital of TCM, Henan, China
| | - Liping Liang
- Radiation Oncology Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Lei Sun
- Cyberknife Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Yang Wang
- Radiation Oncology Center, Huashan Hospital, Fudan University, Shanghai, China.
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Szklener K, Bilski M, Nieoczym K, Mańdziuk D, Mańdziuk S. Enhancing glioblastoma treatment through the integration of tumor-treating fields. Front Oncol 2023; 13:1274587. [PMID: 37916157 PMCID: PMC10616854 DOI: 10.3389/fonc.2023.1274587] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/28/2023] [Indexed: 11/03/2023] Open
Abstract
Glioblastoma (GBM) represents a significant therapeutic challenge due to its aggressive nature. Tumor Treating Fields (TTFields) present a promising approach to GBM therapy. The primary mechanism of TTFields, an antimitotic effect, alongside numerous indirect effects including increased cell membrane permeability, signifies their potential in combination with other treatment modalities. Current combinations often include chemotherapy, particularly with temozolomide (TMZ), however, emerging data suggests potential synergy with targeted therapies, radiotherapy, and immunotherapy as well. TTFields display minimal side effects, predominantly skin-related, posing no significant barrier to combined therapies. The effectiveness of TTFields in GBM treatment has been demonstrated through several post-registration studies, advocating for continued research to optimize overall survival (OS) and progression-free survival (PFS) in patients, as opposed to focusing solely on quality of life.
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Affiliation(s)
- Katarzyna Szklener
- Department of Clinical Oncology and Chemotherapy, Medical University of Lublin, Lublin, Poland
| | - Mateusz Bilski
- Department of Radiotherapy, Medical University of Lublin, Lublin, Poland
| | - Karolina Nieoczym
- Student Scientific Association at the Department of Clinical Oncology and Chemotherapy, Medical University of Lublin, Lublin, Poland
| | - Dominika Mańdziuk
- Student Scientific Association at the Department of Clinical Oncology and Chemotherapy, Medical University of Lublin, Lublin, Poland
| | - Sławomir Mańdziuk
- Department of Clinical Oncology and Chemotherapy, Medical University of Lublin, Lublin, Poland
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She L, Gong X, Su L, Liu C. Effectiveness and safety of tumor-treating fields therapy for glioblastoma: A single-center study in a Chinese cohort. Front Neurol 2023; 13:1042888. [PMID: 36698900 PMCID: PMC9869119 DOI: 10.3389/fneur.2022.1042888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/13/2022] [Indexed: 01/12/2023] Open
Abstract
Objective Tumor-treating fields (TTFields) are a new therapeutic modality for patients with glioblastoma (GBM). However, studies on survival outcomes of TTFields are rarely reported in China. This study aimed to examine the clinical efficacy and safety of TTFields therapy for GBM in China. Methods A total of 93 patients with newly diagnosed GBM (ndGBM) and recurrent GBM (rGBM) were included in our study retrospectively. They were divided into two groups based on whether they used TTFields. Progression-free survival (PFS), overall survival (OS), and toxicities were assessed. Results Among the patients with ndGBM, there were 13 cases with TTFields and 39 cases with no TTFields. The median PFS was 15.3 [95% confidence interval (CI): 6.5-24.1] months and 10.6 (95% CI: 5.4-15.8) months in the two groups, respectively, with P = 0.041. The median OS was 24.8 (95% CI: 6.8-42.8) months and 18.6 (95% CI: 11.4-25.8) months, respectively, with P = 0.368. Patients with subtotal resection (STR) who used TTFields had a better PFS than those who did not (P = 0.003). Among the patients with rGBM, there were 13 cases with TTFields and 28 cases with no TTFields. The median PFS in the two groups was 8.4 (95% CI: 1.7-15.2) months and 8.0 (95% CI: 5.8-10.2) months in the two groups, respectively, with P = 0.265. The median OS was 10.6 (95% CI: 4.8-16.4) months and 13.3 (95% CI: 11.0-15.6) months, respectively, with P = 0.655. A total of 21 patients (21/26, 80.8%) with TTFields developed dermatological adverse events (dAEs). All the dAEs could be resolved or controlled. Conclusion TTFields therapy is a safe and effective treatment for ndGBM, especially in patients with STR. However, it may not improve survival in patients with rGBM.
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Affiliation(s)
- Lei She
- Department of Oncology, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China,Hunan Key Laboratory of Pharmacogenetics, Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xuan Gong
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lin Su
- Department of Oncology, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chao Liu
- Department of Oncology, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China,*Correspondence: Chao Liu ✉
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Li X, Oziel M, Rubinsky B. Evaluating the therapeutic effect of tumor treating fields (TTFields) by monitoring the impedance across TTFields electrode arrays. PeerJ 2022; 10:e12877. [PMID: 35186474 PMCID: PMC8833244 DOI: 10.7717/peerj.12877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 01/12/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Tumor Treating Fields (TTFields), are a novel, non-invasive tissue ablation technology for treatment of cancer. Tissue ablation is achieved through the continuous delivery of a narrow range of electromagnetic fields across a tumor, for a period of months. TTFields are designed to affect only cells that divide and to interfere with the cell division process. The therapy is monitored with MRI imaging, performed every couple of months. Current technology is unable to assess the treatment effectiveness in real time. METHODS We propose that the effect of the treatment can be assessed, in real time, by continuously measuring the change in electrical impedance across the TTFields delivery electrode arrays. An in vitro anatomic skull experimental study, with brain and tumor mimics phantom tissues was conducted to confirm the potential value of the proposed monitoring system. RESULTS Experiments show that measuring the change in the impedance amplitude between opposite TTFields electrode arrays, at a typical TTFields treatment frequency of (200 kHz), can detect changes in the tumor radius with a sensitivity that increases with the radius of the tumor. The study shows that TTFields electrode arrays can be used to assess the effectiveness of TTFields treatment on changes in the tumor dimensions in real time, throughout the treatement. This monitoring system may become a valuable addition to the TTFields cancer treatment technology. It could provide the means to continuously assess the effectiveness of the treatment, and thereby optimize the design of the treatment protocol.
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Affiliation(s)
- Xing Li
- National University of Defense Technology, Electronic Countermeasure Institute, Hefei, Anhui, China
| | - Moshe Oziel
- Department of Physiology and Pharmacology, Tel Aviv University, Tel Aviv, Israel
| | - Boris Rubinsky
- Department of Mechanical Engineering, Department of Bioenegineering, University of California, Berkeley, CA, USA
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Liu S, Shi W, Zhao Q, Zheng Z, Liu Z, Meng L, Dong L, Jiang X. Progress and prospect in tumor treating fields treatment of glioblastoma. Biomed Pharmacother 2021; 141:111810. [PMID: 34214730 DOI: 10.1016/j.biopha.2021.111810] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/28/2021] [Accepted: 06/07/2021] [Indexed: 12/19/2022] Open
Abstract
Glioblastoma (GBM) is a challenging cancer with poor prognosis. The classical standard for treatment is safe resection, followed by concurrent chemoradiotherapy with subsequent adjuvant temozolomide (TMZ). Despite several attempts at different treatments, the 5-year survival rate remains poor. In recent years, with the continuous progress of treatment technology, tumor treating fields (TTFields) were preferable. The device could generate an intermediate frequency alternating electric field and induce apoptosis of some specific types of cancer cells with few toxic and side effects. TTFields induced apoptosis through multiple activations of the pathway. TTFields have been Food and Drug Administration (FDA)-approved for diagnosis and recurrent GBM as additional clinical trial results are revealed. This study reviewed the current status, mechanisms, correlations with immune pathways, the prospects of applying TTFields for GBM, and the adverse events.
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Affiliation(s)
- Shiyu Liu
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
| | - Weiyan Shi
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
| | - Qin Zhao
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
| | - Zhuangzhuang Zheng
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
| | - Zijing Liu
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
| | - Lingbin Meng
- Department of Hematology and Medical Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Lihua Dong
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China.
| | - Xin Jiang
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China.
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Singh N, Miner A, Hennis L, Mittal S. Mechanisms of temozolomide resistance in glioblastoma - a comprehensive review. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2021; 4:17-43. [PMID: 34337348 PMCID: PMC8319838 DOI: 10.20517/cdr.2020.79] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Glioblastoma (GBM) is the most common primary malignant brain tumor in adults and has an exceedingly low median overall survival of only 15 months. Current standard-of-care for GBM consists of gross total surgical resection followed by radiation with concurrent and adjuvant chemotherapy. Temozolomide (TMZ) is the first-choice chemotherapeutic agent in GBM; however, the development of resistance to TMZ often becomes the limiting factor in effective treatment. While O6-methylguanine-DNA methyltransferase repair activity and uniquely resistant populations of glioma stem cells are the most well-known contributors to TMZ resistance, many other molecular mechanisms have come to light in recent years. Key emerging mechanisms include the involvement of other DNA repair systems, aberrant signaling pathways, autophagy, epigenetic modifications, microRNAs, and extracellular vesicle production. This review aims to provide a comprehensive overview of the clinically relevant molecular mechanisms and their extensive interconnections to better inform efforts to combat TMZ resistance.
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Affiliation(s)
- Neha Singh
- Division of Neurosurgery, Virginia Tech Carilion School of Medicine, Roanoke, VA 24014, USA.,Fralin Biomedical Research Institute at VTC, Roanoke, VA 24014, USA
| | - Alexandra Miner
- Division of Neurosurgery, Virginia Tech Carilion School of Medicine, Roanoke, VA 24014, USA.,Fralin Biomedical Research Institute at VTC, Roanoke, VA 24014, USA
| | - Lauren Hennis
- Division of Neurosurgery, Virginia Tech Carilion School of Medicine, Roanoke, VA 24014, USA.,Fralin Biomedical Research Institute at VTC, Roanoke, VA 24014, USA
| | - Sandeep Mittal
- Division of Neurosurgery, Virginia Tech Carilion School of Medicine, Roanoke, VA 24014, USA.,Fralin Biomedical Research Institute at VTC, Roanoke, VA 24014, USA.,Carilion Clinic - Neurosurgery, Roanoke, VA 24014, USA
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Kumaria A. Observations on the anti-glioma potential of electrical fields: is there a role for surgical neuromodulation? Br J Neurosurg 2021; 36:564-568. [PMID: 33583293 DOI: 10.1080/02688697.2021.1886242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Alternating electrical field therapy represents a recent addition to the armamentarium against high grade glioma. Randomised trial evidence suggests a survival benefit from adjunctive scalp delivered Tumour Treating Fields (TTFields) in glioblastoma. Any underlying anti-glioma effect is not fully understood, but interference with cell division and microtubule assembly has been averred. The survival benefit claimed for TTFields is modest and is associated with mild reductions in health-related quality of life indices amid costs that presently preclude routine use. I review possible mechanisms by which alternating electrical fields may confer an anti-glioma effect. As scalp and skull are poor conductors of an electrical field, a case is made here for implantable electrodes, perhaps placed at the time of tumour debulking. Such a system may deliver an electrical field directly to the tumour resection cavity and with greater precision.
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Affiliation(s)
- Ashwin Kumaria
- Department of Neurosurgery, Queen's Medical Centre, Nottingham, UK
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Nour Y, Pöttgen C, Kebir S, Lazaridis L, Lüdemann L, Guberina M, Gauler T, Scheffler B, Jabbarli R, Pierscianek D, Sure U, Schmidt T, Oster C, Hau P, Glas M, Lübcke W, Stuschke M, Guberina N. Dosimetric impact of the positioning variation of tumor treating field electrodes in the PriCoTTF-phase I/II trial. J Appl Clin Med Phys 2021; 22:242-250. [PMID: 33389825 PMCID: PMC7856507 DOI: 10.1002/acm2.13144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/06/2020] [Accepted: 12/04/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose The aim of the present study based on the PriCoTTF‐phase I/II trial is the quantification of skin‐normal tissue complication probabilities of patients with newly diagnosed glioblastoma multiforme treated with Tumor Treating Field (TTField) electrodes, concurrent radiotherapy, and temozolomide. Furthermore, the skin‐sparing effect by the clinically applied strategy of repetitive transducer array fixation around their center position shall be examined. Material and Methods Low‐dose cone‐beam computed tomography (CBCT) scans of all fractions of the first seven patients of the PriCoTTF‐phase I/II trial, used for image guidance, were applied for the dosimetric analysis, for precise TTField transducer array positioning and contour delineation. Within this trial, array positioning was varied from fixation‐to‐fixation period with a standard deviation of 1.1 cm in the direction of the largest variation of positioning and 0.7 cm in the perpendicular direction. Physical TTField electrode composition was examined and a respective Hounsfield Unit attributed to the TTField electrodes. Dose distributions in the planning CT with TTField electrodes in place, as derived from prefraction CBCTs, were calculated and accumulated with the algorithm Acuros XB. Dose‐volume histograms were obtained for the first and second 2 mm scalp layer with and without migrating electrodes and compared with those with fixed electrodes in an average position. Skin toxicity was quantified according to Lyman's model. Minimum doses in hot‐spots of 0.05 cm2 and 25 cm2 (ΔD0.05cm2, ΔD25cm2) size in the superficial skin layers were analyzed. Results Normal tissue complication probabilities (NTCPs) for skin necrosis ranged from 0.005% to 1.474% (median 0.111%) for the different patients without electrodes. NTCP logarithms were significantly dependent on patient (P < 0.0001) and scenario (P < 0.0001) as classification variables. Fixed positioning of TTField arrays increased skin‐NTCP by a factor of 5.50 (95%, CI: 3.66–8.27). The variation of array positioning increased skin‐NTCP by a factor of only 3.54 (95%, CI: 2.36–5.32) (P < 0.0001, comparison to irradiation without electrodes; P = 0.036, comparison to irradiation with fixed electrodes). NTCP showed a significant rank correlation with D25cm2 over all patients and scenarios (rs = 0.76; P < 0.0001). Conclusion Skin‐NTCP calculation uncovers significant interpatient heterogeneity and may be used to stratify patients into high‐ and low‐risk groups of skin toxicity. Array position variation may mitigate about one‐third of the increase in surface dose and skin‐NTCP by the TTField electrodes.
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Affiliation(s)
- Youness Nour
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Christoph Pöttgen
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Sied Kebir
- Division of Clinical Neurooncology, Department of Neurology and West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Lazaros Lazaridis
- Division of Clinical Neurooncology, Department of Neurology and West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Lutz Lüdemann
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Maja Guberina
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Thomas Gauler
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Björn Scheffler
- DKFZ-Division Translational Neurooncology at the West German Cancer Centre (WTZ), German Cancer Consortium (DKTK), Partner Site University Hospital Essen, University of Duisburg, Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Ulrich Sure
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Germany.,Department of Neurosurgery, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Teresa Schmidt
- Division of Clinical Neurooncology, Department of Neurology and West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Christoph Oster
- Division of Clinical Neurooncology, Department of Neurology and West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Peter Hau
- Department of Neurology and Wilhelm Sander-NeuroOncology Unit, Regensburg University Hospital, Germany
| | - Martin Glas
- Division of Clinical Neurooncology, Department of Neurology and West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Germany
| | - Wolfgang Lübcke
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Martin Stuschke
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Germany
| | - Nika Guberina
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
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