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Hajare S, Rambhia K, Mukhi J, Singh R. The mystery of brown shawl over back: a rare case of giant plexiform neurofibroma underlying a giant café-au-lait macule. PIGMENT INTERNATIONAL 2022. [DOI: 10.4103/pigmentinternational.pigmentinternational_38_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Acar S, Armstrong AE, Hirbe AC. Plexiform neurofibroma: shedding light on the investigational agents in clinical trials. Expert Opin Investig Drugs 2021; 31:31-40. [PMID: 34932916 DOI: 10.1080/13543784.2022.2022120] [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: 10/19/2022]
Abstract
INTRODUCTION Neurofibromatosis Type 1 (NF1) is an autosomal dominant genetic condition, which predisposes individuals to the development of plexiform neurofibromas (PN), benign nerve sheath tumors seen in 30-50% of patients with NF1. These tumors may cause significant pain and disfigurement or may compromise organ function. Given the morbidity associated with these tumors, therapeutic options for patients with NF1-related PN are necessary. AREAS COVERED We searched the www.clinicaltrials.gov database for 'plexiform neurofibroma.' This article summarizes completed and ongoing trials involving systemic therapies for PN. EXPERT OPINION Surgery is the mainstay treatment; however, complete resection is not possible in many cases. Numerous systemic therapies have been evaluated in patients with NF1, with MEK inhibitors (MEKi) showing the greatest efficacy for volumetric reduction and improvement in functional and patient-reported outcomes. The MEKi selumetinib is now FDA approved for the treatment of inoperable, symptomatic PN in pediatric NF1 patients. Questions remain regarding the use of this drug class in terms of when to initiate therapy, overall duration, reduced dosing schedules, and side effect management. Future studies are needed to fully understand the clinical application of MEKi and to evaluate other potential therapies through appropriate trial designs for this potentially devastating, manifestation in NF1.
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Affiliation(s)
- Simge Acar
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.,School of Medicine, Koç University, Istanbul, Turkey
| | - Amy E Armstrong
- Division of Hematology and Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Mo, USA.,Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Angela C Hirbe
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.,Division of Hematology and Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Mo, USA.,Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
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Rabab’h O, Gharaibeh A, Al-Ramadan A, Ismail M, Shah J. Pharmacological Approaches in Neurofibromatosis Type 1-Associated Nervous System Tumors. Cancers (Basel) 2021; 13:cancers13153880. [PMID: 34359780 PMCID: PMC8345673 DOI: 10.3390/cancers13153880] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 12/11/2022] Open
Abstract
Simple Summary Neurofibromatosis type 1 (NF1) is a common cancer predisposition genetic disease that is associated with significant morbidity and mortality. In this literature review, we discuss the major pathways in the nervous system that are affected by NF1, tumors that are associated with NF1, drugs that target these pathways, and genetic models of NF1. We also summarize the latest updates from clinical trials that are evaluating pharmacological agents to treat these tumors and discuss the efforts that are being made to cure the disease in the future Abstract Neurofibromatosis type 1 is an autosomal dominant genetic disease and a common tumor predisposition syndrome that affects 1 in 3000 to 4000 patients in the USA. Although studies have been conducted to better understand and manage this disease, the underlying pathogenesis of neurofibromatosis type 1 has not been completely elucidated, and this disease is still associated with significant morbidity and mortality. Treatment options are limited to surgery with chemotherapy for tumors in cases of malignant transformation. In this review, we summarize the advances in the development of targeted pharmacological interventions for neurofibromatosis type 1 and related conditions.
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Affiliation(s)
- Omar Rabab’h
- Insight Research Institute, Flint, MI 48507, USA; (O.R.); (A.G.); (A.A.-R.); (M.I.)
- Center for Cognition and Neuroethics, University of Michigan-Flint, Flint, MI 48502, USA
| | - Abeer Gharaibeh
- Insight Research Institute, Flint, MI 48507, USA; (O.R.); (A.G.); (A.A.-R.); (M.I.)
- Center for Cognition and Neuroethics, University of Michigan-Flint, Flint, MI 48502, USA
- Insight Institute of Neurosurgery & Neuroscience, Flint, MI 48507, USA
- Insight Surgical Hospital, Warren, MI 48091, USA
| | - Ali Al-Ramadan
- Insight Research Institute, Flint, MI 48507, USA; (O.R.); (A.G.); (A.A.-R.); (M.I.)
- Center for Cognition and Neuroethics, University of Michigan-Flint, Flint, MI 48502, USA
| | - Manar Ismail
- Insight Research Institute, Flint, MI 48507, USA; (O.R.); (A.G.); (A.A.-R.); (M.I.)
| | - Jawad Shah
- Insight Research Institute, Flint, MI 48507, USA; (O.R.); (A.G.); (A.A.-R.); (M.I.)
- Center for Cognition and Neuroethics, University of Michigan-Flint, Flint, MI 48502, USA
- Insight Institute of Neurosurgery & Neuroscience, Flint, MI 48507, USA
- Insight Surgical Hospital, Warren, MI 48091, USA
- Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI 48824, USA
- Correspondence:
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Feroze K, Kaliyadan F. Targeted genetic and molecular therapies in neurofibromatosis - A review of present therapeutic options and a glimpse into the future. Indian J Dermatol Venereol Leprol 2021; 88:1-10. [PMID: 34379966 DOI: 10.25259/ijdvl_6_2020] [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: 01/01/2020] [Accepted: 05/01/2021] [Indexed: 11/04/2022]
Abstract
Neurofibromatosis type 1, the most common phakomatoses, can present with a host of signs and symptoms, usually involving the skin and the peripheral nervous system. It is characterized by a mutation in the neurofibromatosis type 1 gene on chromosome 17q11.2 that codes for the protein neurofibromin. Neurofibromin acts as a tumor suppressor gene by inhibiting rat sarcoma (Ras) activity and its deficiency leads to increased Ras activity, cellular proliferation and tumor formation. This review was conducted to analyze the various targeted therapies at the genetic and molecular level employed to manage the tumors and other clinical presentations associated with neurofibromatosis type 1. Twenty-eight studies of treatment modalities for the conditions associated with neurofibromatosis and which involved either targeted gene therapy or molecular level therapies, including the latest advances, were included in this review. Mitogen-activated protein kinase kinase inhibition, mammalian target of Rapamycin inhibition and Tyrosine kinase inhibition, represent some of the newer treatment options in this category. Although there are a number of trials for providing therapeutic options at the genetic and molecular level for the various physical and psychological morbidities associated with neurofibromatosis type 1, most of them are in the preclinical stage. Increased clinical trials of the molecules and gene therapies could significantly help in managing the various chronic and sometimes, life-threatening conditions associated with neurofibromatosis 1 and these will probably represent the preferred treatment direction of the future.
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Affiliation(s)
- Kaberi Feroze
- Department of Ophthalmology, Al Azhar Medical College, Thodupuzha, Kerala, India
| | - Feroze Kaliyadan
- Department of Dermatology, College of Medicine, King Faisal University, Hofuf, Saudi Arabia.,Department of Dermatology, Sree Narayana Institute of Medical Sciences, Chalakka, Kerala, India
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Neurofibromatosis type 1: New developments in genetics and treatment. J Am Acad Dermatol 2020; 84:1667-1676. [PMID: 32771543 DOI: 10.1016/j.jaad.2020.07.105] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 07/26/2020] [Accepted: 07/28/2020] [Indexed: 12/12/2022]
Abstract
Neurofibromatosis type 1 is the most common neurocutaneous syndrome, with a frequency of 1 in 2500 persons. Diagnosis is paramount in the pretumor stage to provide proper anticipatory guidance for a number of neoplasms, both benign and malignant. Loss-of-function mutations in the NF1 gene result in truncated and nonfunctional production of neurofibromin, a tumor suppressor protein involved in downregulating the RAS signaling pathway. New therapeutic and preventive options include tyrosine kinase inhibitors, mTOR inhibitors, interferons, and radiofrequency therapy. This review summarizes recent updates in genetics, mutation analysis assays, and treatment options targeting aberrant genetic pathways. We also propose modified diagnostic criteria and provide an algorithm for surveillance of patients with neurofibromatosis type 1.
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Combined Targeting of AKT and mTOR Inhibits Proliferation of Human NF1-Associated Malignant Peripheral Nerve Sheath Tumour Cells In Vitro but not in a Xenograft Mouse Model In Vivo. Int J Mol Sci 2020; 21:ijms21041548. [PMID: 32102484 PMCID: PMC7073166 DOI: 10.3390/ijms21041548] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 02/19/2020] [Accepted: 02/19/2020] [Indexed: 11/17/2022] Open
Abstract
Persistent signalling via the PI3K/AKT/mTOR pathway is a major driver of malignancy in NF1-associated malignant peripheral nerve sheath tumours (MPNST). Nevertheless, single targeting of this pathway is not sufficient to inhibit MPNST growth. In this report, we demonstrate that combined treatment with the allosteric pan-AKT inhibitor MK-2206 and the mTORC1/mTORC2 inhibitor AZD8055 has synergistic effects on the viability of MPNST cell lines in comparison to the treatment with each compound alone. However, when treating animals bearing experimental MPNST with the combined AKT/mTOR regime, no influence on tumour growth was observed. Further analysis of the MPNST xenograft tumours resistant to AKT/mTOR treatment revealed a reactivation of both AKT and mTOR in several tumour samples. Additional targeting of the RAS/RAF/MEK/MAPK pathway with the allosteric MEK1/2 inhibitor AZD6244 showed synergistic effects on the viability of MPNST cell lines in vitro in comparison to the dual AKT/mTOR inhibition. In summary, these data indicate that combined treatment with AKT and mTOR inhibitors is effective on MPNST cells in vitro but tumour resistance can occur rapidly in vivo by restoration of AKT/mTOR signalling. Our data further suggest that a triple treatment with inhibitors against AKT, mTORC1/2 and MEK1/2 may be a promising treatment option that should be further analysed in an experimental MPNST mouse model in vivo.
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Ferguson MJ, Rhodes SD, Jiang L, Li X, Yuan J, Yang X, Zhang S, Vakili ST, Territo P, Hutchins G, Yang FC, Ingram DA, Clapp DW, Chen S. Preclinical Evidence for the Use of Sunitinib Malate in the Treatment of Plexiform Neurofibromas. Pediatr Blood Cancer 2016; 63:206-13. [PMID: 26375012 PMCID: PMC4862309 DOI: 10.1002/pbc.25763] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 08/31/2015] [Indexed: 01/16/2023]
Abstract
PURPOSE Plexiform neurofibromas (pNF) are pathognomonic nerve and soft tissue tumors of neurofibromatosis type I (NF1), which are highly resistant to conventional chemotherapy and associated with significant morbidity/mortality. Disruption of aberrant SCF/c-Kit signaling emanating from the pNF microenvironment induced the first ever objective therapeutic responses in a recent phase 2 trial. Sunitinib malate is a potent, highly selective RTK inhibitor with activity against c-Kit, PDGFR, and VEGFR, which have also been implicated in the pathogenesis of these lesions. Here, we evaluate the efficacy of sunitinib malate in a preclinical Krox20;Nf1(flox/-) pNF murine model. EXPERIMENTAL DESIGN Proliferation, β-hexosaminidase release (degranulation), and Erk1/2 phosphorylation were assessed in sunitinib treated Nf1(+/-) mast cells and fibroblasts, respectively. Krox20;Nf1(flox/-) mice with established pNF were treated sunitinib or PBS-vehicle control for a duration of 12 weeks. pNF metabolic activity was monitored by serial [(18)F]DG-PET/CT imaging. RESULTS Sunitinib suppressed multiple in vitro gain-in-functions of Nf1(+/-) mast cells and fibroblasts and attenuated Erk1/2 phosphorylation. Sunitinib treated Krox20;Nf1(flox/-) mice exhibited significant reductions in pNF size, tumor number, and FDG uptake compared to control mice. Histopathology revealed reduced tumor cellularity and infiltrating mast cells, markedly diminished collagen deposition, and increased cellular apoptosis in sunitinib treated pNF. CONCLUSIONS Collectively, these results demonstrate the efficacy of sunitinib in reducing tumor burden in Krox20;Nf1(flox/-) mice. These preclinical findings demonstrate the utility of inhibiting multiple RTKs in pNF and provide insights into the design of future clinical trials.
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Affiliation(s)
- Michael J. Ferguson
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202,Correspondence should be addressed to: Michael J. Ferguson, M.D., M.S., Assistant Professor, Indiana University School of Medicine, Children’s Clinical Research Center, 705 Riley Hospital Drive, RI 2630, Indianapolis, IN 46202, Phone: (317) 278-3153, Fax: (317) 948-0616,
| | - Steven D. Rhodes
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202,Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Li Jiang
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202,Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Xiaohong Li
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202,Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Jin Yuan
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202,Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Xianlin Yang
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202,Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Shaobo Zhang
- Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Saeed T. Vakili
- Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Paul Territo
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Gary Hutchins
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Feng-Chun Yang
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202,Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN 46202,Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, IN 46202
| | - David A. Ingram
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202,Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN 46202
| | - D. Wade Clapp
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202,Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN 46202,Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Shi Chen
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202,Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN 46202
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Happle R. The categories of cutaneous mosaicism: A proposed classification. Am J Med Genet A 2015; 170A:452-459. [PMID: 26494396 DOI: 10.1002/ajmg.a.37439] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 10/05/2015] [Indexed: 11/08/2022]
Abstract
Mosaic disorders can most easily be studied in the skin. This article presents a comprehensive overview of the different forms of cutaneous mosaicism. Major categories are genomic versus epigenetic mosaicism and nonsegmental versus segmental mosaicism. The class of nonsegmental mosaics includes single point mosaicism as exemplified by solitary benign or malignant skin tumors; disseminated mosaicism as noted in autosomal dominant tumor syndromes such as neurofibromatosis 1; and patchy mosaicism without midline separation as found in giant melanocytic nevus. The class of segmental mosaics includes segmental manifestation of lethal genes surviving by mosaicism as noted in Proteus syndrome; type 1 segmental mosaicism of autosomal dominant skin disorders reflecting heterozygosity for a postzygotic new mutation; type 2 segmental mosaicism of autosomal dominant skin disorders reflecting loss of heterozygosity that occurred at an early developmental stage in a heterozygous embryo; and isolated or superimposed segmental mosaicism of common polygenic skin disorders such as psoriasis or atopic dermatitis. A particular form of genomic mosaicism is didymosis (twin spotting). Revertant mosaicism is recognizable as one or more areas of healthy skin in patients with epidermolysis bullosa or other serious genodermatoses. The category of epigenetic mosaicism includes several X-linked, male lethal disorders such as incontinentia pigmenti, and the patterns of lyonization as noted in X-linked non-lethal disorders such as hypohidrotic ectodermal dysplasia of the Christ-Siemens-Touraine type. An interesting field of future research will be the concept of epigenetic autosomal mosaicism that may explain some unusual cases of autosomal transmission of linear hypo- or hypermelanosis.
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Affiliation(s)
- Rudolf Happle
- Department of Dermatology, Freiburg University Medical Center, Freiburg, Germany
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Yuan SM, Cui L, Guo Y, Wang J, Hu XB, Jiang HQ, Hong ZJ. Surgical management of giant neurofibroma in soft tissue: a single-center retrospective analysis. Int J Clin Exp Med 2015; 8:5245-5253. [PMID: 26131098 PMCID: PMC4483935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 03/17/2015] [Indexed: 06/04/2023]
Abstract
Neurofibroma, a common benign tumor in soft tissue, continues to grow, and often appears to be giant. In this study, we retrospectively analyzed the surgical treatment of 26 patients with giant neurofibromas in our clinic in the past 10 years from Jan. 2004 to Dec. 2013. The tumors were located in the head (n = 10), trunk (n = 9), limbs (n = 5), and multi-sites (n = 2). According to the location and extent of the lesion, as well as the adjacent anatomy, surgical management was performed to partially (n = 15) or almost completely (n = 11) resect the tumor. The wounds were repaired by skin flap or skin graft. Among them, one child with a giant tumor in the scalp underwent three times of skin expander treatment, and acquired complete removal of the tumor finally without baldness. Eleven cases underwent the interventional embolization of tumor's nutrient arteries, which successfully reduced the bleeding in operation. Most of the skin flap and skin graft survived well. After operation, the appearance of the patients and the function of the limbs were improved largely. In conclusion, for the giant neurofibroma, surgical treatment effectively reduces the tumor burden, rehabilitates the appearance and function, and so improves the quality of life. Skin expandor and interventional embolization of nutrient artery can be used when appropriate.
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Affiliation(s)
- Si-Ming Yuan
- Department of Plastic Surgery, Jinling Hospital, School of Medicine, Nanjing University Nanjing 210002, Jiangsu, China
| | - Lei Cui
- Department of Plastic Surgery, Jinling Hospital, School of Medicine, Nanjing University Nanjing 210002, Jiangsu, China
| | - Yao Guo
- Department of Plastic Surgery, Jinling Hospital, School of Medicine, Nanjing University Nanjing 210002, Jiangsu, China
| | - Jun Wang
- Department of Plastic Surgery, Jinling Hospital, School of Medicine, Nanjing University Nanjing 210002, Jiangsu, China
| | - Xin-Bao Hu
- Department of Plastic Surgery, Jinling Hospital, School of Medicine, Nanjing University Nanjing 210002, Jiangsu, China
| | - Hui-Qing Jiang
- Department of Plastic Surgery, Jinling Hospital, School of Medicine, Nanjing University Nanjing 210002, Jiangsu, China
| | - Zhi-Jian Hong
- Department of Plastic Surgery, Jinling Hospital, School of Medicine, Nanjing University Nanjing 210002, Jiangsu, China
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Jiang W, Mautner VF, Friedrich RE, Kluwe L. Preclinical assessment of the anticancer drug response of plexiform neurofibroma tissue using primary cultures. J Clin Neurol 2015; 11:172-7. [PMID: 25851896 PMCID: PMC4387483 DOI: 10.3988/jcn.2015.11.2.172] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 12/01/2014] [Accepted: 12/04/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Individualized drug testing for tumors using a strategy analogous to antibiotic tests for infectious diseases would be highly desirable for personalized and individualized cancer care. METHODS Primary cultures containing tumor and nontumor stromal cells were utilized in a novel strategy to test drug responses with respect to both efficacy and specificity. The strategy tested in this pilot study was implemented using four primary cultures derived from plexiform neurofibromas. Responses to two cytotoxic drugs (nilotinib and imatinib) were measured by following dose-dependent changes in the proportions of tumor and nontumor cells, determined by staining them with cell-type-specific antibodies. The viability of the cultured cells and the cytotoxic effect of the drugs were also measured using proliferation and cytotoxicity assays. RESULTS The total number of cells decreased after the drug treatment, in accordance with the observed reduction in proliferation and increased cytotoxic effect upon incubation with the two anticancer drugs. The proportions of Schwann cells and fibroblasts changed dose-dependently, although the patterns of change varied between the tumor samples (from different sources) and between the two drugs. The highly variable in vitro drug responses probably reflect the large variations in the responses of tumors to therapies between individual patients in vivo. CONCLUSIONS These preliminary results suggest that the concept of assessing in vitro drug responses using primary cultures is feasible, but demands the extensive further development of an application for preclinical drug selection and drug discovery.
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Affiliation(s)
- Wei Jiang
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Victor F Mautner
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Reinhard E Friedrich
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lan Kluwe
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.; Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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