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Bhaskaran D, Savage J, Patel A, Collinson F, Mant R, Boele F, Brazil L, Meade S, Buckle P, Lax S, Billingham L, Short SC. A randomised phase II trial of temozolomide with or without cannabinoids in patients with recurrent glioblastoma (ARISTOCRAT): protocol for a multi-centre, double-blind, placebo-controlled trial. BMC Cancer 2024; 24:83. [PMID: 38225549 PMCID: PMC10790538 DOI: 10.1186/s12885-023-11792-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/22/2023] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Glioblastoma (GBM) is the most common adult malignant brain tumour, with an incidence of 5 per 100,000 per year in England. Patients with tumours showing O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation represent around 40% of newly diagnosed GBM. Relapse/tumour recurrence is inevitable. There is no agreed standard treatment for patients with GBM, therefore, it is aimed at delaying further tumour progression and maintaining health-related quality of life (HRQoL). Limited clinical trial data exist using cannabinoids in combination with temozolomide (TMZ) in this setting, but early phase data demonstrate prolonged overall survival compared to TMZ alone, with few additional side effects. Jazz Pharmaceuticals (previously GW Pharma Ltd.) have developed nabiximols (trade name Sativex®), an oromucosal spray containing a blend of cannabis plant extracts, that we aim to assess for preliminary efficacy in patients with recurrent GBM. METHODS ARISTOCRAT is a phase II, multi-centre, double-blind, placebo-controlled, randomised trial to assess cannabinoids in patients with recurrent MGMT methylated GBM who are suitable for treatment with TMZ. Patients who have relapsed ≥ 3 months after completion of initial first-line treatment will be randomised 2:1 to receive either nabiximols or placebo in combination with TMZ. The primary outcome is overall survival time defined as the time in whole days from the date of randomisation to the date of death from any cause. Secondary outcomes include overall survival at 12 months, progression-free survival time, HRQoL (using patient reported outcomes from QLQ-C30, QLQ-BN20 and EQ-5D-5L questionnaires), and adverse events. DISCUSSION Patients with recurrent MGMT promoter methylated GBM represent a relatively good prognosis sub-group of patients with GBM. However, their median survival remains poor and, therefore, more effective treatments are needed. The phase II design of this trial was chosen, rather than phase III, due to the lack of data currently available on cannabinoid efficacy in this setting. A randomised, double-blind, placebo-controlled trial will ensure an unbiased robust evaluation of the treatment and will allow potential expansion of recruitment into a phase III trial should the emerging phase II results warrant this development. TRIAL REGISTRATION ISRCTN: 11460478. CLINICALTRIALS Gov: NCT05629702.
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Affiliation(s)
- Divyalakshmi Bhaskaran
- School of Medicine, University of Leeds, LS2 9JT, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joshua Savage
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer & Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Amit Patel
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer & Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Fiona Collinson
- School of Medicine, University of Leeds, LS2 9JT, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rhys Mant
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer & Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Florien Boele
- School of Medicine, University of Leeds, LS2 9JT, Leeds, UK
| | - Lucy Brazil
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sara Meade
- University Hospitals Birmingham Foundation Trust, Birmingham, UK
| | | | - Siân Lax
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer & Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Lucinda Billingham
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer & Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Susan C Short
- School of Medicine, University of Leeds, LS2 9JT, Leeds, UK.
- Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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Abstract
Glioblastoma is the most aggressive primary brain tumor with a poor prognosis. The 2021 WHO CNS5 classification has further stressed the importance of molecular signatures in diagnosis although therapeutic breakthroughs are still lacking. In this review article, updates on the current and novel therapies in IDH-wildtype GBM will be discussed.
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Affiliation(s)
- Jawad M Melhem
- Division of Neurology, Department of Medicine, Faculty of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Mary Jane Lim-Fat
- Division of Neurology, Department of Medicine, Faculty of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - James R Perry
- Division of Neurology, Department of Medicine, Faculty of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.
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Lin Q, Bao JH, Xue F, Qin JJ, Chen Z, Chen ZR, Li C, Yan YX, Fu J, Shen ZL, Chen XZ. The Risk of Heart Disease-Related Death Among Anaplastic Astrocytoma Patients After Chemotherapy: A SEER Population-Based Analysis. Front Oncol 2022; 12:870843. [PMID: 35795052 PMCID: PMC9251342 DOI: 10.3389/fonc.2022.870843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background Despite improved overall survival outcomes, chemotherapy has brought concerns for heart disease–related death (HDRD) among cancer patients. The effect of chemotherapy on the risk of HDRD in anaplastic astrocytoma (AA) patients remains unclear. Methods We obtained 7,129 AA patients from the Surveillance, Epidemiology, and End Results (SEER) database from 1975 to 2016. Kaplan–Meier and Cox regression analysis were conducted to evaluate the effect of chemotherapy on the HDRD risk. Based on the competing risk model, we calculated the cumulative incidences of HDRD and non-HDRD and performed univariate and multivariate regression analyses. Then, a 1:1 propensity score matching (PSM) was used to improve the comparability between AA patients with and without chemotherapy. Landmark analysis at 216 and 314 months was employed to minimize immortal time bias. Results AA patients with chemotherapy were at a lower HDRD risk compared to those patients without chemotherapy (adjusted HR=0.782, 95%CI=0.736–0.83, P<0.001). For competing risk regression analysis, the cumulative incidence of HDRD in non-chemotherapy exceeded HDRD in the chemotherapy group (P<0.001) and multivariable analysis showed a lower HDRD risk in AA patients with chemotherapy (adjusted SHR=0.574, 95%CI=0.331–0.991, P=0.046). In the PSM-after cohort, there were no significant association between chemotherapy and the increased HDRD risk (adjusted SHR=0.595, 95%CI=0.316−1.122, P=0.11). Landmark analysis showed that AA patients who received chemotherapy had better heart disease–specific survival than those in the non-chemotherapy group (P=0.007) at the follow-up time points of 216 months. No difference was found when the follow-up time was more than 216 months. Conclusion AA patients with chemotherapy are associated with a lower risk of HDRD compared with those without chemotherapy. Our findings may help clinicians make a decision about the management of AA patients and provide new and important evidence for applying chemotherapy in AA patients as the first-line treatment. However, more research is needed to confirm these findings and investigate the correlation of the risk of HDRD with different chemotherapy drugs and doses.
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Affiliation(s)
- Qi Lin
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jia-Hao Bao
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Fei Xue
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jia-Jun Qin
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhen Chen
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhong-Rong Chen
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chao Li
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yi-Xuan Yan
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Jin Fu
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Xian-Zhen Chen, ; Zhao-Li Shen, ; Jin Fu,
| | - Zhao-Li Shen
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Xian-Zhen Chen, ; Zhao-Li Shen, ; Jin Fu,
| | - Xian-Zhen Chen
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Xian-Zhen Chen, ; Zhao-Li Shen, ; Jin Fu,
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Integration of synthetic and natural derivatives revives the therapeutic potential of temozolomide against glioma- an in vitro and in vivo perspective. Life Sci 2022; 301:120609. [DOI: 10.1016/j.lfs.2022.120609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/02/2022] [Accepted: 04/29/2022] [Indexed: 11/24/2022]
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5
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Weathers SP, Rood-Breithaupt J, de Groot J, Thomas G, Manfrini M, Penas-Prado M, Puduvalli VK, Zwingelstein C, Yung WKA. Results of a phase I trial to assess the safety of macitentan in combination with temozolomide for the treatment of recurrent glioblastoma. Neurooncol Adv 2021; 3:vdab141. [PMID: 34693288 PMCID: PMC8528265 DOI: 10.1093/noajnl/vdab141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background There is an urgent need for additional therapies to treat recurrent glioblastoma (GBM). Preclinical studies suggest that high dose macitentan, an oral dual endothelin receptor antagonist, enhances the cytotoxic effects of temozolomide (TMZ) in GBM, improving survival. This phase I trial investigated the maximum tolerated dose of macitentan combined with TMZ in patients with recurrent GBM and assessed the safety and tolerability of high dose macitentan in these patients (NCT01499251). Methods Adults with recurrent GBM received ascending doses of macitentan from 30 mg once daily concomitantly with TMZ. Safety and tolerability were assessed in addition to exploratory efficacy and pharmacokinetic endpoints. An ancillary study examined biomarker expression following macitentan treatment prior to surgical resection of recurrent GBM. Results Thirty-eight patients with recurrent GBM were administered macitentan doses up to 300 mg once daily; no dose-limiting toxicities were observed, and a maximum tolerated dose was not determined. All patients experienced at least one treatment-emergent adverse event (TEAE), the majority associated with GBM or TMZ treatment. TEAEs related to macitentan and TMZ were reported for 16 (42.1%) and 26 (68.4%) patients, respectively, with no serious macitentan-related TEAEs. Macitentan concentrations increased with dose, with no plateau in exposure. Substantial heterogeneity was observed in the expression of efficacy biomarkers within tumors. The Kaplan-Meier estimate of median overall survival across all dose groups was 9.4 (95% CI 8.5, 13.4) months. Conclusion High-dose macitentan was well tolerated in recurrent GBM patients concomitantly receiving TMZ. TEAEs were consistent with those seen in patients receiving either drug individually.
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Affiliation(s)
| | | | - John de Groot
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gail Thomas
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | | | | | - Vinay K Puduvalli
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | | | - W K Alfred Yung
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Martínez-González A, Cabrera R, Lloret M, Lara PC. Pretreatment inflammatory indices predict Bevacizumab response in recurrent Glioma. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2020; 3:623-635. [PMID: 35582438 PMCID: PMC8992487 DOI: 10.20517/cdr.2020.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/18/2020] [Accepted: 06/07/2020] [Indexed: 12/26/2022]
Abstract
Aim: It remains unclear what the best therapeutic option for recurrent glioma patients after Stupp treatment is. Bevacizumab (BVZ) is commonly administered in progression, but it appears that only some patients benefit. It would be useful to find biomarkers that determine beforehand who these patients are. Methods: The protocol included 31 high-risk progressing glioma patients after Stupp treatment who received BVZ 5-10 mg/kg every 14 days and temozolomide (3-19 cycles, 150-200 mg five days each 28-day cycle) during a mean of eight cycles of BVZ or until tumor progression or unacceptable toxicity. We analyzed the clinical outcome values of inflammatory indices measured before BVZ administration. Results: Lymphocyte level before BVZ administration was the best independent predictor of overall survival (HR = 0.34; 95%CI: 0.145-0.81; P = 0.015). The area under the receiver operating characteristic (ROC) curve was 0.823, with 1.645 being the optimal cut-off value, and 0.80 and 0.85 the sensitivity and specificity values, respectively. Responder and non-responder survival curves were also significantly different, considering the first and second tertiles as cut-off points. The number of BVZ cycles was not related to lymphopenia. Pretreatment neutrophil, platelet levels, platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (NLR) did not have independent predictive value. Inflammatory variables were not correlated with each other. However, patients with high NLR and PLR simultaneously (double positive PLR-NLR) showed a worse clinical outcome than the rest (P = 0.043). Conclusion: Pretreatment lymphocyte levels and double positive PLR-NLR could be used as non-invasive hematological prognostic markers for recurrent gliomas treated with bevacizumab. A close relationship emerged between inflammation and angiogenesis.
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Affiliation(s)
- Alicia Martínez-González
- Department de Matemáticas, Universidad de Castilla-La Mancha, ETSI Industriales, Avda, Ciudad Real 13071, Spain
| | - Raquel Cabrera
- Oncología Radioterápica Hospital Universitario de Gran Canaria Dr Negrin, Barranco de la Ballena s/n, Las Palmas de Gran Canaria, Las Palmas 35010, Spain
| | - Marta Lloret
- Oncología Radioterápica Hospital Universitario de Gran Canaria Dr Negrin, Barranco de la Ballena s/n, Las Palmas de Gran Canaria, Las Palmas 35010, Spain.,Facultad de Ciencias de la Salud, Universidad de Las Palmas de Gran Canaria, Paseo de Blas Cabrera Felipe, s/n, Las Palmas de Gran Canaria, Las Palmas 35016, Spain.,Fundación Canaria del Instituto Canario de Investigación del Cáncer, Avda de la Trinidad 61 Torre Agustín Arevalo 7 planta La Laguna, Santa Cruz de Tenerife 38204, Spain
| | - Pedro C Lara
- Fundación Canaria del Instituto Canario de Investigación del Cáncer, Avda de la Trinidad 61 Torre Agustín Arevalo 7 planta La Laguna, Santa Cruz de Tenerife 38204, Spain.,San Roque University Hospitals, Dolores de la Rocha, 5, Las Palmas de Gran Canaria, Las Palmas 35001, Spain.,Fernando Pessoa Canarias University, Dolores dela Rocha 14, Las Palmas de Gran Canaria, Las Palmas 35016, Spain
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Looking for A Place for Dose-Dense TMZ Regimens in GBM Patients: An Experience with MGMT Exploratory Evaluation. Bioengineering (Basel) 2019; 6:bioengineering6010011. [PMID: 30678211 PMCID: PMC6466220 DOI: 10.3390/bioengineering6010011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/19/2019] [Accepted: 01/21/2019] [Indexed: 12/23/2022] Open
Abstract
Prolonged exposure to temozolomide (TMZ) could improve clinical outcomes in recurrent glioblastoma multiforme (GBM) patients. We previously developed a dose-dense regimen of TMZ in a phase II study (180 mg/m2 from days 1 to 5 every two weeks). A retrospective analysis of patients with macroscopic residual GBM treated with “post-induction” dose-dense TMZ was conducted, adding an explorative subgroup analyses among patients with different O6-methylguanine DNA methyltransferase (MGMT) expressions (negative vs positive, < vs ≥ of 50 % of cells stained, < vs ≥ 70% of cells stained). Thirty-six patients were evaluated; after a median follow-up of 36 weeks, median Progression Free Survival (PFS) and median Overall Survival (OS) were 19 and 34 weeks, respectively. MGMT expression (70% cut-off) and sex were confirmed as independent predictors for disease control rate (DCR) at multivariate analysis. At univariate analysis ECOG-PS, Sex (female), extensive tumor resection was shown to be related to a longer PFS, while MGMT expression (cut-off 70%) to a shorter PFS. Multivariate analysis with Cox hazard regression confirmed only ECOG-PS as an independent predictor for PFS. ECOG-PS showed to be significant related to a longer OS. Our analysis showed that dose-dense TMZ regimens are still an option for patients with recurrent GBM, but should be used for re-challenge treatments. MGMT immunohistochemistry high expression might be used as a “surrogate” negative predictor for DCR for dd-TMZ treatments.
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Llaguno-Munive M, Romero-Piña M, Serrano-Bello J, Medina LA, Uribe-Uribe N, Salazar AM, Rodríguez-Dorantes M, Garcia-Lopez P. Mifepristone Overcomes Tumor Resistance to Temozolomide Associated with DNA Damage Repair and Apoptosis in an Orthotopic Model of Glioblastoma. Cancers (Basel) 2018; 11:cancers11010016. [PMID: 30583528 PMCID: PMC6356343 DOI: 10.3390/cancers11010016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 12/19/2018] [Accepted: 12/20/2018] [Indexed: 12/20/2022] Open
Abstract
The standard treatment for glioblastoma multiforme (GBM) is surgery followed by chemo/radiotherapy. A major limitation on patient improvement is the high resistance of tumors to drug treatment, likely responsible for their subsequent recurrence and rapid progression. Therefore, alternatives to the standard therapy are necessary. The aim of the present study was to evaluate whether mifepristone, an antihormonal agent, has a synergistic effect with temozolomide (used in standard therapy for gliomas). Whereas the mechanism of temozolomide involves damage to tumor DNA leading to apoptosis, tumor resistance is associated with DNA damage repair through the O6-methylguanine-DNA-methyltransferase (MGMT) enzyme. Temozolomide/mifepristone treatment, herein examined in Wistar rats after orthotopically implanting C6 glioma cells, markedly reduced proliferation. This was evidenced by a decreased level of the following parameters: a proliferation marker (Ki-67), a tumor growth marker (18F-fluorothymidine uptake, determined by PET/CT images), and the MGMT enzyme. Increased apoptosis was detected by the relative expression of related proteins, (e.g. Bcl-2 (B-cell lymphoma 2), Bax (bcl-2-like protein 4) and caspase-3). Thus, greater apoptosis of tumor cells caused by their diminished capacity to repair DNA probably contributed significantly to the enhanced activity of temozolomide. The results suggest that mifepristone could possibly act as a chemo-sensitizing agent for temozolomide during chemotherapy for GBM.
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Affiliation(s)
- Monserrat Llaguno-Munive
- Laboratorio de Farmacología, Subdirección de Investigación Básica, Instituto Nacional de Cancerología, Ciudad de México 14080, Mexico.
- Posgrado en Ciencias Biomédicas, Universidad Nacional Autónoma de México (UNAM), Ciudad de México 04510, Mexico.
| | - Mario Romero-Piña
- Laboratorio de Farmacología, Subdirección de Investigación Básica, Instituto Nacional de Cancerología, Ciudad de México 14080, Mexico.
| | - Janeth Serrano-Bello
- Facultad de Odontología, Universidad Nacional Autónoma de México (UNAM), Ciudad de México 04510, Mexico.
| | - Luis A Medina
- Instituto de Física, Universidad Nacional Autónoma de México (UNAM), Unidad de Investigación Biomédica en Cáncer INCan-UNAM, Ciudad de México, 14080, Mexico.
| | - Norma Uribe-Uribe
- Instituto Nacional de Ciencias Médicas y de la Nutrición Salvador Zubirán, Ciudad de México 14080, Mexico.
| | - Ana Maria Salazar
- Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México (UNAM), Ciudad de México 04510, Mexico.
| | | | - Patricia Garcia-Lopez
- Laboratorio de Farmacología, Subdirección de Investigación Básica, Instituto Nacional de Cancerología, Ciudad de México 14080, Mexico.
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Xie CR, You CG, Zhang N, Sheng HS, Zheng XS. Epigallocatechin Gallate Preferentially Inhibits O6-Methylguanine DNA-Methyltransferase Expression in Glioblastoma Cells Rather than in Nontumor Glial Cells. Nutr Cancer 2018; 70:1339-1347. [PMID: 30558449 DOI: 10.1080/01635581.2018.1539189] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Chao-Ran Xie
- Department of Neurosurgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
- Department of Neurosurgery, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Chao-Guo You
- Department of Neurosurgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
- Department of Neurosurgery, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Nu Zhang
- Department of Neurosurgery, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Han-Song Sheng
- Department of Neurosurgery, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Xue-Sheng Zheng
- Department of Neurosurgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
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JIAPAER S, FURUTA T, TANAKA S, KITABAYASHI T, NAKADA M. Potential Strategies Overcoming the Temozolomide Resistance for Glioblastoma. Neurol Med Chir (Tokyo) 2018; 58:405-421. [PMID: 30249919 PMCID: PMC6186761 DOI: 10.2176/nmc.ra.2018-0141] [Citation(s) in RCA: 200] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 07/31/2018] [Indexed: 12/14/2022] Open
Abstract
Glioblastoma (GBM) is a highly malignant type of primary brain tumor with a high mortality rate. Although the current standard therapy consists of surgery followed by radiation and temozolomide (TMZ), chemotherapy can extend patient's post-operative survival but most cases eventually demonstrate resistance to TMZ. O6-methylguanine-DNA methyltransferase (MGMT) repairs the main cytotoxic lesion, as O6-methylguanine, generated by TMZ, can be the main mechanism of the drug resistance. In addition, mismatch repair and BER also contribute to TMZ resistance. TMZ treatment can induce self-protective autophagy, a mechanism by which tumor cells resist TMZ treatment. Emerging evidence also demonstrated that a small population of cells expressing stem cell markers, also identified as GBM stem cells (GSCs), contributes to drug resistance and tumor recurrence owing to their ability for self-renewal and invasion into neighboring tissue. Some molecules maintain stem cell properties. Other molecules or signaling pathways regulate stemness and influence MGMT activity, making these GCSs attractive therapeutic targets. Treatments targeting these molecules and pathways result in suppression of GSCs stemness and, in highly resistant cases, a decrease in MGMT activity. Recently, some novel therapeutic strategies, targeted molecules, immunotherapies, and microRNAs have provided new potential treatments for highly resistant GBM cases. In this review, we summarize the current knowledge of different resistance mechanisms, novel strategies for enhancing the effect of TMZ, and emerging therapeutic approaches to eliminate GSCs, all with the aim to produce a successful GBM treatment and discuss future directions for basic and clinical research to achieve this end.
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Affiliation(s)
| | - Takuya FURUTA
- Department of Pathology, Kurume University, Kurume, Fukuoka, Japan
| | - Shingo TANAKA
- Department of Neurosurgery, Kanazawa University, Kanazawa, Ishikawa, Japan
| | | | - Mitsutoshi NAKADA
- Department of Neurosurgery, Kanazawa University, Kanazawa, Ishikawa, Japan
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Dose-dense temozolomide for recurrent high-grade gliomas: a single-center retrospective study. Med Oncol 2018; 35:136. [PMID: 30155806 DOI: 10.1007/s12032-018-1198-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 08/22/2018] [Indexed: 01/10/2023]
Abstract
There are limited treatment modalities after high-grade gliomas recurrence. MGMT depletion modulated by dose-dense temozolomide (ddTMZ) remains a debated therapy for initial TMZ responders. Patients were selected retrospectively from our practice with diagnosis of high-grade gliomas (WHO grade III or IV), and were followed since the start of ddTMZ until death or change of therapy. Twenty-one patients were reviewed, with a median age of 47 (25-61) years and a median of 5.8 (1.5-38.8) cycles of ddTMZ. The majority were males (71.4%). Sixty-six percent received 21 on/28 off ddTMZ schedule, 28.6% daily, and 1 patient received a 7 days on/7 days off schedule. IDH mutation status was available for 18 (85.7%) patients, with 7 (33.3%) IDH mutant and 11 (52.5%) IDH wild type. MGMT methylation was assessed in 6 (28.6%) of the patients, being MGMT methylated in 3 (14.3%) patients, and non-methylated in 3 (14.3%) patients. The majority of patients (57.1%) were receiving ddTMZ in addition to other forms of therapy, including either bevacizumab (38.1%) or tumor-treating fields (TTFields) (19.1%). Overall ddTMZ was well tolerated, with few adverse events reported. The estimated median overall survival after ddTMZ start was 11 months. Median progression-free survival (PFS) was 6 months. Outcomes did not vary between patients receiving ddTMZ alone or those using TTFields or bevacizumab as concomitant therapy, but there was a trend to longer survival with the use of concomitant TTFields. Our results demonstrate benefit of ddTMZ after previous treatment with standard TMZ dosing with no apparent increase in treatment-related toxicities. In summary, ddTMZ should be considered in TMZ responsive patients and warrants further investigation.
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12
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You CG, Sheng HS, Xie CR, Zhang N, Zheng XS. FM19G11 inhibits O 6 -methylguanine DNA-methyltransferase expression under both hypoxic and normoxic conditions. Cancer Med 2018; 7:3292-3300. [PMID: 29761922 PMCID: PMC6051152 DOI: 10.1002/cam4.1551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/14/2018] [Accepted: 04/19/2018] [Indexed: 12/20/2022] Open
Abstract
FM19G11 is a small molecular agent that inhibits hypoxia-inducible factor-1-alpha (HIF-1α) and other signaling pathways. In this study, we characterized the modulating effects of FM19G11 on O6 -methylguanine DNA-methyltransferase (MGMT), the main regulator of temozolomide (TMZ) resistance in glioblastomas. This study included 2 MGMT-positive cell lines (GBM-XD and T98G). MGMT promoter methylation status, mRNA abundance, and protein levels were determined before and after FM19G11 treatment, and the roles of various signaling pathways were characterized. Under hypoxic conditions, MGMT mRNA and protein levels were significantly downregulated by FM19G11 via the HIF-1α pathway in both GBM-XD and T98G cells. In normoxic culture, T98G cells were strongly positive for MGMT, and MGMT expression was substantially downregulated by FM19G11 via the NF-κB pathway. In addition, TMZ resistance was reversed by treatment with FM19G11. Meanwhile, FM19G11 has no cytotoxicity at its effective dose. FM19G11 could potentially be used to counteract TMZ resistance in MGMT-positive glioblastomas.
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Affiliation(s)
- Chao-Guo You
- Department of Neurosurgery, Xinhua Hospital, Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai, China.,Department of Neurosurgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Han-Song Sheng
- Department of Neurosurgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chao-Ran Xie
- Department of Neurosurgery, Xinhua Hospital, Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai, China.,Department of Neurosurgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Nu Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xue-Sheng Zheng
- Department of Neurosurgery, Xinhua Hospital, Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai, China
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Roussakow SV. Clinical and economic evaluation of modulated electrohyperthermia concurrent to dose-dense temozolomide 21/28 days regimen in the treatment of recurrent glioblastoma: a retrospective analysis of a two-centre German cohort trial with systematic comparison and effect-to-treatment analysis. BMJ Open 2017; 7:e017387. [PMID: 29102988 PMCID: PMC5722101 DOI: 10.1136/bmjopen-2017-017387] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE To assess the efficacy and cost-effectiveness of modulated electrohyperthermia (mEHT) concurrent to dose-dense temozolomide (ddTMZ) 21/28 days regimen versus ddTMZ 21/28 days alone in patients with recurrent glioblastoma (GBM). DESIGN A cohort of 54 patients with recurrent GBM treated with ddTMZ+mEHT in 2000-2005 was systematically retrospectively compared with five pooled ddTMZ 21/28 days cohorts (114 patients) enrolled in 2008-2013. RESULTS The ddTMZ+mEHT cohort had a not significantly improved mean survival time (mST) versus the comparator (p=0.531) after a significantly less mean number of cycles (1.56 vs 3.98, p<0.001). Effect-to-treatment analysis (ETA) suggests that mEHT significantly enhances the efficacy of the ddTMZ 21/28 days regimen (p=0.011), with significantly less toxicity (no grade III-IV toxicity vs 45%-92%, p<0.0001). An estimated maximal attainable median survival time is 10.10 months (9.10-11.10). Cost-effectiveness analysis suggests that, unlike ddTMZ 21/28 days alone, ddTMZ+mEHT is cost-effective versus the applicable cost-effectiveness thresholds €US$25 000-50 000/quality-adjusted life year (QALY). Budget impact analysis suggests a significant saving of €8 577 947/$11 201 761 with 29.1-38.5 QALY gained per 1000 patients per year. Cost-benefit analysis suggests that mEHT is profitable and will generate revenues between €3 124 574 and $6 458 400, with a total economic effect (saving+revenues) of €5 700 034 to $8 237 432 per mEHT device over an 8-year period. CONCLUSIONS Our ETA suggests that mEHT significantly improves survival of patients receiving the ddTMZ 21/28 days regimen. Economic evaluation suggests that ddTMZ+mEHT is cost-effective, budget-saving and profitable. After confirmation of the results, mEHT could be recommended for the treatment of recurrent GBM as a cost-effective enhancer of ddTMZ regimens, and, probably, of the regular 5/28 days regimen. mEHT is applicable also as a single treatment if chemotherapy is impossible, and as a salvage treatment after the failure of chemotherapy.
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