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Freire NH, Jaeger MDC, de Farias CB, Nör C, Souza BK, Gregianin L, Brunetto AT, Roesler R. Targeting the epigenome of cancer stem cells in pediatric nervous system tumors. Mol Cell Biochem 2023; 478:2241-2255. [PMID: 36637615 DOI: 10.1007/s11010-022-04655-2] [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: 03/09/2022] [Accepted: 12/30/2022] [Indexed: 01/14/2023]
Abstract
Medulloblastoma, neuroblastoma, and pediatric glioma account for almost 30% of all cases of pediatric cancers. Recent evidence indicates that pediatric nervous system tumors originate from stem or progenitor cells and present a subpopulation of cells with highly tumorigenic and stem cell-like features. These cancer stem cells play a role in initiation, progression, and resistance to treatment of pediatric nervous system tumors. Histone modification, DNA methylation, chromatin remodeling, and microRNA regulation display a range of regulatory activities involved in cancer origin and progression, and cellular identity, especially those associated with stem cell features, such as self-renewal and pluripotent differentiation potential. Here, we review the contribution of different epigenetic mechanisms in pediatric nervous system tumor cancer stem cells. The choice between a differentiated and undifferentiated state can be modulated by alterations in the epigenome through the regulation of stemness genes such as CD133, SOX2, and BMI1 and the activation neuronal of differentiation markers, RBFOX3, GFAP, and S100B. Additionally, we highlighted the stage of development of epigenetic drugs and the clinical benefits and efficacy of epigenetic modulators in pediatric nervous system tumors.
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Affiliation(s)
- Natália Hogetop Freire
- Cancer and Neurobiology Laboratory, Experimental Research Center, Clinical Hospital (CPE-HCPA), Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil.
- Graduate Program in Cellular and Molecular Biology, Center of Biotechnology, Universidade Federal do Rio Grande do Sul (UFRGS), Av. Bento Gonçalves, 9500 (Setor IV - Campus do Vale), Porto Alegre, 91501-970, Brazil.
| | - Mariane da Cunha Jaeger
- Cancer and Neurobiology Laboratory, Experimental Research Center, Clinical Hospital (CPE-HCPA), Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
- Children's Cancer Institute, Porto Alegre, RS, Brazil
| | - Caroline Brunetto de Farias
- Cancer and Neurobiology Laboratory, Experimental Research Center, Clinical Hospital (CPE-HCPA), Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
- Children's Cancer Institute, Porto Alegre, RS, Brazil
| | - Carolina Nör
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Lauro Gregianin
- Cancer and Neurobiology Laboratory, Experimental Research Center, Clinical Hospital (CPE-HCPA), Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
- Department of Pediatrics, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
- Pediatric Oncology Service, Clinical Hospital, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - André Tesainer Brunetto
- Cancer and Neurobiology Laboratory, Experimental Research Center, Clinical Hospital (CPE-HCPA), Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
- Children's Cancer Institute, Porto Alegre, RS, Brazil
| | - Rafael Roesler
- Cancer and Neurobiology Laboratory, Experimental Research Center, Clinical Hospital (CPE-HCPA), Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
- Graduate Program in Cellular and Molecular Biology, Center of Biotechnology, Universidade Federal do Rio Grande do Sul (UFRGS), Av. Bento Gonçalves, 9500 (Setor IV - Campus do Vale), Porto Alegre, 91501-970, Brazil
- Department of Pharmacology, Institute for Basic Health Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
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Emotion Regulation Flexibility and Electronic Patient-Reported Outcomes: A Framework for Understanding Symptoms and Affect Dynamics in Pediatric Psycho-Oncology. Cancers (Basel) 2022; 14:cancers14163874. [PMID: 36010870 PMCID: PMC9405711 DOI: 10.3390/cancers14163874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 11/25/2022] Open
Abstract
Simple Summary The individual’s ability to conceive and regulate the broad spectrum of their human emotions is closely linked to their mental health. The implications of a serious disease such as cancer represent an extraordinary burden to these internal coping mechanisms, especially in the case of young patients. Regarding their well-being and support, it is therefore of particular interest for caregivers to be able to follow the dynamics of the patient’s emotional world and perceptions. Technical progress enables new possibilities for data collection through tools for digital patient self-reports while simultaneously creating new challenges. Within the scope of this article, we provide an overview of the literature on this topic, outlining the current strengths and weaknesses and possible perspectives on digital aids, especially in terms of capturing the flexibility, fluctuations and early detection of symptom changes. Abstract Emotion dysregulation is regarded as a driving mechanism for the development of mental health problems and psychopathology. The role of emotion regulation (ER) in the management of cancer distress and quality of life (QoL) has recently been recognized in psycho-oncology. The latest technological advances afford ways to assess ER, affective experiences and QoL in child, adolescent and young adult (CAYA) cancer patients through electronic patient-reported outcomes (ePRO) in their daily environment in real-time. Such tools facilitate ways to study the dynamics of affect and the flexibility of ER. However, technological advancement is not risk-free. We critically review the literature on ePRO in cancer existing models of ER in pediatric psycho-oncology and analyze strength, weaknesses, opportunities and threats of ePRO with a focus on CAYA cancer research and care. Supported by personal study-based experiences, this narrative review serves as a foundation to propose a novel methodological and metatheoretical framework based on: (a) an extended notion of ER, which includes its dynamic, adaptive and flexible nature and focuses on processes and conditions rather than fixed categorical strategies; (b) ePRO as a means to measure emotion regulation flexibility and affect dynamics; (c) identifying early warning signals for symptom change via ePRO and building forecasting models using dynamical systems theory.
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Drug Repurposing for Glioblastoma and Current Advances in Drug Delivery-A Comprehensive Review of the Literature. Biomolecules 2021; 11:biom11121870. [PMID: 34944514 PMCID: PMC8699739 DOI: 10.3390/biom11121870] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/19/2021] [Accepted: 12/03/2021] [Indexed: 12/22/2022] Open
Abstract
Glioblastoma (GBM) is the most common primary malignant brain tumor in adults with an extremely poor prognosis. There is a dire need to develop effective therapeutics to overcome the intrinsic and acquired resistance of GBM to current therapies. The process of developing novel anti-neoplastic drugs from bench to bedside can incur significant time and cost implications. Drug repurposing may help overcome that obstacle. A wide range of drugs that are already approved for clinical use for the treatment of other diseases have been found to target GBM-associated signaling pathways and are being repurposed for the treatment of GBM. While many of these drugs are undergoing pre-clinical testing, others are in the clinical trial phase. Since GBM stem cells (GSCs) have been found to be a main source of tumor recurrence after surgery, recent studies have also investigated whether repurposed drugs that target these pathways can be used to counteract tumor recurrence. While several repurposed drugs have shown significant efficacy against GBM cell lines, the blood–brain barrier (BBB) can limit the ability of many of these drugs to reach intratumoral therapeutic concentrations. Localized intracranial delivery may help to achieve therapeutic drug concentration at the site of tumor resection while simultaneously minimizing toxicity and side effects. These strategies can be considered while repurposing drugs for GBM.
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Gagliardi F, De Domenico P, Snider S, Pompeo E, Roncelli F, Barzaghi LR, Bailo M, Piloni M, Spina A, Fodor A, Berzero G, Di Muzio N, Filippi M, Finocchiaro G, Mortini P. Gamma Knife radiosurgery as primary treatment of low-grade brainstem gliomas: A systematic review and metanalysis of current evidence and predictive factors. Crit Rev Oncol Hematol 2021; 168:103508. [PMID: 34678323 DOI: 10.1016/j.critrevonc.2021.103508] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 10/05/2021] [Accepted: 10/10/2021] [Indexed: 10/20/2022] Open
Abstract
The current standard of care for surgically inaccessible low-grade brainstem gliomas (BS-LLGs) is external-beam radiotherapy (RT). Developments toward more innovative conformal techniques have focused on decreasing morbidity, by limiting radiation to surrounding tissues. Among these Gamma Knife radiosurgery (SRS-GK) has recently gained an increasingly important role in the treatment of these tumors. Although SRS-GK has not yet been compared with conventional RT in patients harboring focal BS-LGGs, clinical practice has been deeply influenced by trials performed on other tumors. This is the first meta-analysis on the topic, systematically reviewing the most relevant available evidence, comparing RT and SRS-GK as primary treatments of BS-LGGs, focusing on survival, clinical outcome, oncological control, and complications. Predictive factors have been systematically evaluated and analyzed according to statistical significance and clinical relevance.
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Affiliation(s)
- Filippo Gagliardi
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.
| | - Pierfrancesco De Domenico
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Silvia Snider
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Edoardo Pompeo
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Francesca Roncelli
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Lina Raffaella Barzaghi
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Michele Bailo
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Martina Piloni
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Alfio Spina
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Andrei Fodor
- Department of Radiation Oncology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giulia Berzero
- Department of Neurology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Nadia Di Muzio
- Department of Radiation Oncology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Massimo Filippi
- Department of Neurology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Gaetano Finocchiaro
- Department of Neurology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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Pötschke R, Gielen G, Pietsch T, Kramm C, Klusmann JH, Hüttelmaier S, Kühnöl CD. Musashi1 enhances chemotherapy resistance of pediatric glioblastoma cells in vitro. Pediatr Res 2020; 87:669-676. [PMID: 31756732 DOI: 10.1038/s41390-019-0628-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 09/25/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Glioblastoma (GBM) is the most aggressive form of glioma in adults and children and is associated with very poor prognosis. Pediatric tumors are biologically distinct from adult GBM and differ in response to current GBM treatment protocols. Regarding pediatric GBM, new drug combinations and the molecular background of chemotherapy effects need to be investigated, in order to increase patient survival outcome. METHODS The expression of the RNA-binding protein Musashi1 (MSI1) in pediatric glioma samples of different WHO tumor grades was investigated on the protein (immunohistochemistry) and on the RNA level (publicly accessible RNA sequencing dataset). The impact of the chemotherapeutic temozolomide (TMZ) in combination with valproic acid (VPA) was tested in two pediatric glioblastoma-derived cell lines. The supportive effect of MSI1 expression against this treatment was investigated via transient knockdown and protein overexpression. RESULTS MSI1 expression correlates with pediatric high-grade glioma (HGG). The combination of TMZ with VPA significantly increases the impact of drug treatment on cell viability in vitro. MSI1 was found to promote drug resistance to the combined treatment with TMZ and VPA. CONCLUSION MSI1 expression is a potential marker for pediatric HGG and increases chemoresistance. Inhibition of MSI1 might lead to an improved patient outcome and therapy response.
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Affiliation(s)
- Rebecca Pötschke
- Molecular Cell Biology, Institute of Molecular Medicine, Martin-Luther-University, Halle (Saale), Germany.,Department of Pediatric Hematology/Oncology, University Hospital, Halle (Saale), Germany
| | - Gerrit Gielen
- Institute of Neuropathology, University Hospital, Bonn, Germany
| | - Torsten Pietsch
- Institute of Neuropathology, University Hospital, Bonn, Germany
| | - Christof Kramm
- Division of Pediatric Hematology and Oncology, University Medical Center, Göttingen, Germany
| | - Jan-Henning Klusmann
- Department of Pediatric Hematology/Oncology, University Hospital, Halle (Saale), Germany
| | - Stefan Hüttelmaier
- Molecular Cell Biology, Institute of Molecular Medicine, Martin-Luther-University, Halle (Saale), Germany.
| | - Caspar D Kühnöl
- Department of Pediatric Hematology/Oncology, University Hospital, Halle (Saale), Germany.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight advances in the management of seizures in brain metastases from solid tumors. RECENT FINDINGS The highest risk for seizures is in patients with melanoma and lung cancer. There is lack of data on the efficacy of antiepileptic drugs (AEDs), but interactions between enzyme-inducing AEDs and anticancer agents must be avoided. Levetiracetam and valproic acid are the most appropriate drugs. Prophylaxis with AEDs for patients with brain metastases without a history of seizures is not recommended. Total resection of a brain metastasis allows complete seizure control. Seizures may represent an adverse effect of stereotactic radiosurgery or of high-dose chemotherapy. New preclinical and clinical studies should define the risk of brain metastasis in light of the new treatment options in the different tumor types. New clinical trials should be designed in patients with brain metastases in terms of treatment or prophylaxis of seizures.
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Maschio M, Aguglia U, Avanzini G, Banfi P, Buttinelli C, Capovilla G, Casazza MML, Colicchio G, Coppola A, Costa C, Dainese F, Daniele O, De Simone R, Eoli M, Gasparini S, Giallonardo AT, La Neve A, Maialetti A, Mecarelli O, Melis M, Michelucci R, Paladin F, Pauletto G, Piccioli M, Quadri S, Ranzato F, Rossi R, Salmaggi A, Terenzi R, Tisei P, Villani F, Vitali P, Vivalda LC, Zaccara G, Zarabla A, Beghi E. Management of epilepsy in brain tumors. Neurol Sci 2019; 40:2217-2234. [PMID: 31392641 DOI: 10.1007/s10072-019-04025-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/20/2019] [Indexed: 12/15/2022]
Abstract
Epilepsy in brain tumors (BTE) may require medical attention for a variety of unique concerns: epileptic seizures, possible serious adverse effects of antineoplastic and antiepileptic drugs (AEDs), physical disability, and/or neurocognitive disturbances correlated to tumor site. Guidelines for the management of tumor-related epilepsies are lacking. Treatment is not standardized, and overall management might differ according to different specialists. The aim of this document was to provide directives on the procedures to be adopted for a correct diagnostic-therapeutic path of the patient with BTE, evaluating indications, risks, and benefits. A board comprising neurologists, epileptologists, neurophysiologists, neuroradiologists, neurosurgeons, neuro-oncologists, neuropsychologists, and patients' representatives was formed. The board converted diagnostic and therapeutic problems into seventeen questions. A literature search was performed in September-October 2017, and a total of 7827 unique records were retrieved, of which 148 constituted the core literature. There is no evidence that histological type or localization of the brain tumor affects the response to an AED. The board recommended to avoid enzyme-inducing antiepileptic drugs because of their interference with antitumoral drugs and consider as first-choice newer generation drugs (among them, levetiracetam, lamotrigine, and topiramate). Valproic acid should also be considered. Both short-term and long-term prophylaxes are not recommended in primary and metastatic brain tumors. Management of seizures in patients with BTE should be multidisciplinary. The panel evidenced conflicting or lacking data regarding the role of EEG, the choice of therapeutic strategy, and timing to withdraw AEDs and recommended high-quality long-term studies to standardize BTE care.
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Affiliation(s)
- Marta Maschio
- Center for Brain Tumor-Related Epilepsy, UOSD Neuro-Oncology, I.R.C.C.S. Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy.
| | - Umberto Aguglia
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Giuliano Avanzini
- Department of Neurophysiology and Experimental Epileptology, Carlo Besta Neurological Institute, Milan, Italy
| | - Paola Banfi
- Neurology Unit, Department of Emergency, Medicine Epilepsy Center, Circolo Hospital, Varese, Italy
| | - Carla Buttinelli
- Department of Neuroscience, Mental Health and Sensory Organs, University of Rome "La Sapienza", Rome, Italy
| | - Giuseppe Capovilla
- Department of Mental Health, Epilepsy Center, C. Poma Hospital, Mantua, Italy
| | | | - Gabriella Colicchio
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonietta Coppola
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, Epilepsy Centre, University of Naples Federico II, Naples, Italy
| | - Cinzia Costa
- Neurological Clinic, Department of Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Filippo Dainese
- Epilepsy Centre, UOC Neurology, SS. Giovanni e Paolo Hospital, Venice, Italy
| | - Ornella Daniele
- Epilepsy Center-U.O.C. Neurology, Policlinico Paolo Giaccone, Experimental Biomedicine and Clinical Neuroscience Department (BioNeC), University of Palermo, Palermo, Italy
| | - Roberto De Simone
- Neurology and Stroke Unit, Epilepsy and Sleep Disorders Center, St. Eugenio Hospital, Rome, Italy
| | - Marica Eoli
- Molecular Neuro-Oncology Unit, IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Sara Gasparini
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | | | - Angela La Neve
- Department of Neurological and Psychiatric Sciences, Centre for Epilepsy, University of Bari, Bari, Italy
| | - Andrea Maialetti
- Center for Brain Tumor-Related Epilepsy, UOSD Neuro-Oncology, I.R.C.C.S. Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Oriano Mecarelli
- Neurology Unit, Human Neurosciences Department, Sapienza University, Umberto 1 Hospital, Rome, Italy
| | - Marta Melis
- Department of Medical Sciences and Public Health, Institute of Neurology, University of Cagliari, Monserrato, Cagliari, Italy
| | - Roberto Michelucci
- Unit of Neurology, Bellaria Hospital, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesco Paladin
- Epilepsy Center, UOC Neurology, Ospedale Santi Giovanni e Paolo, Venice, Italy
| | - Giada Pauletto
- Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Marta Piccioli
- UOC Neurology, PO San Filippo Neri, ASL Roma 1, Rome, Italy
| | - Stefano Quadri
- USC Neurology, Epilepsy Center, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Federica Ranzato
- Epilepsy Centre, Neuroscience Department, S. Bortolo Hospital, Vicenza, Italy
| | - Rosario Rossi
- Neurology and Stroke Unit, San Francesco Hospital, 08100, Nuoro, Italy
| | | | - Riccardo Terenzi
- Epilepsy Consultation Room, Neurology Unit, S. Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Paolo Tisei
- Neurophysiology Unit, Department of Neurology-University "La Sapienza", S. Andrea Hospital, Rome, Italy
| | - Flavio Villani
- Clinical Epileptology and Experimental Neurophysiology Unit, Fondazione IRCCS, Istituto Neurologico C. Besta, Milan, Italy
| | - Paolo Vitali
- Neuroradiology and Brain MRI 3T Mondino Research Center, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Gaetano Zaccara
- Regional Health Agency of Tuscany, Via P Dazzi 1, 50141, Florence, Italy
| | - Alessia Zarabla
- Center for Brain Tumor-Related Epilepsy, UOSD Neuro-Oncology, I.R.C.C.S. Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Ettore Beghi
- Department of Neurosciences, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
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Hoja S, Schulze M, Rehli M, Proescholdt M, Herold-Mende C, Hau P, Riemenschneider MJ. Molecular dissection of the valproic acid effects on glioma cells. Oncotarget 2018; 7:62989-63002. [PMID: 27556305 PMCID: PMC5325342 DOI: 10.18632/oncotarget.11379] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/12/2016] [Indexed: 11/25/2022] Open
Abstract
Many glioblastoma patients suffer from seizures why they are treated with antiepileptic agents. Valproic acid (VPA) is a histone deacetylase inhibitor that apart from its anticonvulsive effects in some retrospective studies has been suggested to lead to a superior outcome of glioblastoma patients. However, the exact molecular effects of VPA treatment on glioblastoma cells have not yet been deciphered. We treated glioblastoma cells with VPA, recorded the functional effects of this treatment and performed a global and unbiased next generation sequencing study on the chromatin (ChIP) and RNA level. 1) VPA treatment clearly sensitized glioma cells to temozolomide: A protruding VPA-induced molecular feature in this context was the transcriptional upregulation/reexpression of numerous solute carrier (SLC) transporters that was also reflected by euchromatinization on the histone level and a reexpression of SLC transporters in human biopsy samples after VPA treatment. DNA repair genes were adversely reduced. 2) VPA treatment, however, also reduced cell proliferation in temozolomide-naive cells: On the molecular level in this context we observed a transcriptional upregulation/reexpression and euchromatinization of several glioblastoma relevant tumor suppressor genes and a reduction of stemness markers, while transcriptional subtype classification (mesenchymal/proneural) remained unaltered. Taken together, these findings argue for both temozolomide-dependent and -independent effects of VPA. VPA might increase the uptake of temozolomide and simultaneously lead to a less malignant glioblastoma phenotype. From a mere molecular perspective these findings might indicate a surplus value of VPA in glioblastoma therapy and could therefore contribute an additional ratio for clinical decision making.
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Affiliation(s)
- Sabine Hoja
- Department of Neuropathology, Regensburg University Hospital, Regensburg, Germany
| | - Markus Schulze
- Department of Neuropathology, Regensburg University Hospital, Regensburg, Germany
| | - Michael Rehli
- Department of Internal Medicine III, Regensburg University Hospital, Regensburg, Germany.,RCI Regensburg Centre for Interventional Immunology, Regensburg University Hospital, Regensburg, Germany
| | - Martin Proescholdt
- Department of Neurosurgery, Regensburg University Hospital, Regensburg, Germany.,Wilhelm Sander Neuro-Oncology Unit, Regensburg University Hospital, Regensburg, Germany
| | - Christel Herold-Mende
- Experimental Neurosurgery, Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Peter Hau
- Wilhelm Sander Neuro-Oncology Unit, Regensburg University Hospital, Regensburg, Germany.,Department of Neurology, Regensburg University, Regensburg, Germany
| | - Markus J Riemenschneider
- Department of Neuropathology, Regensburg University Hospital, Regensburg, Germany.,Wilhelm Sander Neuro-Oncology Unit, Regensburg University Hospital, Regensburg, Germany
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9
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Tan SK, Jermakowicz A, Mookhtiar AK, Nemeroff CB, Schürer SC, Ayad NG. Drug Repositioning in Glioblastoma: A Pathway Perspective. Front Pharmacol 2018; 9:218. [PMID: 29615902 PMCID: PMC5864870 DOI: 10.3389/fphar.2018.00218] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 02/27/2018] [Indexed: 12/27/2022] Open
Abstract
Glioblastoma multiforme (GBM) is the most malignant primary adult brain tumor. The current standard of care is surgical resection, radiation, and chemotherapy treatment, which extends life in most cases. Unfortunately, tumor recurrence is nearly universal and patients with recurrent glioblastoma typically survive <1 year. Therefore, new therapies and therapeutic combinations need to be developed that can be quickly approved for use in patients. However, in order to gain approval, therapies need to be safe as well as effective. One possible means of attaining rapid approval is repurposing FDA approved compounds for GBM therapy. However, candidate compounds must be able to penetrate the blood-brain barrier (BBB) and therefore a selection process has to be implemented to identify such compounds that can eliminate GBM tumor expansion. We review here psychiatric and non-psychiatric compounds that may be effective in GBM, as well as potential drugs targeting cell death pathways. We also discuss the potential of data-driven computational approaches to identify compounds that induce cell death in GBM cells, enabled by large reference databases such as the Library of Integrated Network Cell Signatures (LINCS). Finally, we argue that identifying pathways dysregulated in GBM in a patient specific manner is essential for effective repurposing in GBM and other gliomas.
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Affiliation(s)
- Sze Kiat Tan
- Department of Psychiatry and Behavioral Sciences, Center for Therapeutic Innovation, Miami Project to Cure Paralysis, Sylvester Comprehensive Cancer Center, University of Miami Brain Tumor Initiative, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Anna Jermakowicz
- Department of Psychiatry and Behavioral Sciences, Center for Therapeutic Innovation, Miami Project to Cure Paralysis, Sylvester Comprehensive Cancer Center, University of Miami Brain Tumor Initiative, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Adnan K Mookhtiar
- Department of Psychiatry and Behavioral Sciences, Center for Therapeutic Innovation, Miami Project to Cure Paralysis, Sylvester Comprehensive Cancer Center, University of Miami Brain Tumor Initiative, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Charles B Nemeroff
- Department of Psychiatry and Behavioral Sciences and Center on Aging, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Stephan C Schürer
- Department of Molecular Pharmacology, Center for Computational Sciences, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Nagi G Ayad
- Department of Psychiatry and Behavioral Sciences, Center for Therapeutic Innovation, Miami Project to Cure Paralysis, Sylvester Comprehensive Cancer Center, University of Miami Brain Tumor Initiative, University of Miami Miller School of Medicine, Miami, FL, United States
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10
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Head RJ, Fay MF, Cosgrove L, Y. C. Fung K, Rundle-Thiele D, Martin JH. Persistence of DNA adducts, hypermutation and acquisition of cellular resistance to alkylating agents in glioblastoma. Cancer Biol Ther 2017; 18:917-926. [PMID: 29020502 PMCID: PMC5718815 DOI: 10.1080/15384047.2017.1385680] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 09/01/2017] [Accepted: 09/24/2017] [Indexed: 01/13/2023] Open
Abstract
Glioblastoma is a lethal form of brain tumour usually treated by surgical resection followed by radiotherapy and an alkylating chemotherapeutic agent. Key to the success of this multimodal approach is maintaining apoptotic sensitivity of tumour cells to the alkylating agent. This initial treatment likely establishes conditions contributing to development of drug resistance as alkylating agents form the O6-methylguanine adduct. This activates the mismatch repair (MMR) process inducing apoptosis and mutagenesis. This review describes key juxtaposed drivers in the balance between alkylation induced mutagenesis and apoptosis. Mutations in MMR genes are the probable drivers for alkylation based drug resistance. Critical to this interaction are the dose-response and temporal interactions between adduct formation and MMR mutations. The precision in dose interval, dose-responses and temporal relationships dictate a role for alkylating agents in either promoting experimental tumour formation or inducing tumour cell death with chemotherapy. Importantly, this resultant loss of chemotherapeutic selective pressure provides opportunity to explore novel therapeutics and appropriate combinations to minimise alkylation based drug resistance and tumour relapse.
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Affiliation(s)
- R. J. Head
- University of South Australia, Adelaide, SA, Australia
| | - M. F. Fay
- University of Newcastle, Newcastle, NSW, Australia
- Genesis Cancer Care, NSW, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - L. Cosgrove
- CSIRO Health & Biosecurity, Adelaide, SA, Australia
| | | | - D. Rundle-Thiele
- School of Medicine, Flinders University, Bedford Park, SA, Australia
| | - J. H. Martin
- University of Newcastle, Newcastle, NSW, Australia
- University of Queensland, Brisbane, QLD, Australia
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11
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Furuta T, Sabit H, Dong Y, Miyashita K, Kinoshita M, Uchiyama N, Hayashi Y, Hayashi Y, Minamoto T, Nakada M. Biological basis and clinical study of glycogen synthase kinase- 3β-targeted therapy by drug repositioning for glioblastoma. Oncotarget 2017; 8:22811-22824. [PMID: 28423558 PMCID: PMC5410264 DOI: 10.18632/oncotarget.15206] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 01/25/2017] [Indexed: 11/25/2022] Open
Abstract
Background Glycogen synthase kinase (GSK)-3β has emerged as an appealing therapeutic target for glioblastoma (GBM). Here, we investigated the therapeutic effect of the current approved drugs against GBM via inhibition of GSK3β activity both, in experimental setting and in a clinical study for recurrent GBM patients by repositioning existent drugs in combination with temozolomide (TMZ). Materials and Methods Progression-free and overall survival rates were compared between patients with low or high expression of active GSK3β in the primary tumor. GBM cells and a mouse model were examined for the effects of GSK3β-inhibitory drugs, cimetidine, lithium, olanzapine, and valproate. The safety and efficacy of the cocktail of these drugs (CLOVA cocktail) in combination with TMZ were tested in the mouse model and in a clinical study for recurrent GBM patients. Results Activation of GSK3β in the tumor inversely correlated with patient survival as an independent prognostic factor. CLOVA cocktail significantly inhibited cell invasion and proliferation. The patients treated with CLOVA cocktail in combination with TMZ showed increased survival compared to the control group treated with TMZ alone. Conclusions Repositioning of the GSK3β-inhibitory drugs improved the prognosis of refractory GBM patients with active GSK3β in tumors. Combination of CLOVA cocktail and TMZ is a promising approach for recurrent GBM.
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Affiliation(s)
- Takuya Furuta
- Department of Neurosurgery, Division of Neuroscience, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Hemragul Sabit
- Department of Neurosurgery, Division of Neuroscience, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Yu Dong
- Department of Neurosurgery, Division of Neuroscience, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Katsuyoshi Miyashita
- Department of Neurosurgery, Division of Neuroscience, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Masashi Kinoshita
- Department of Neurosurgery, Division of Neuroscience, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Naoyuki Uchiyama
- Department of Neurosurgery, Division of Neuroscience, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Yasuhiko Hayashi
- Department of Neurosurgery, Division of Neuroscience, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Yutaka Hayashi
- Department of Neurosurgery, Division of Neuroscience, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Toshinari Minamoto
- Division of Translational and Clinical Oncology, Cancer Research Institute, Kanazawa University, Kanazawa, Japan
| | - Mitsutoshi Nakada
- Department of Neurosurgery, Division of Neuroscience, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
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12
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Killick-Cole CL, Singleton WGB, Bienemann AS, Asby DJ, Wyatt MJ, Boulter LJ, Barua NU, Gill SS. Repurposing the anti-epileptic drug sodium valproate as an adjuvant treatment for diffuse intrinsic pontine glioma. PLoS One 2017; 12:e0176855. [PMID: 28542253 PMCID: PMC5444593 DOI: 10.1371/journal.pone.0176855] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 04/18/2017] [Indexed: 11/18/2022] Open
Abstract
Targeting epigenetic changes in diffuse intrinsic pontine glioma (DIPG) may provide a novel treatment option for patients. This report demonstrates that sodium valproate, a histone deacetylase inhibitor (HDACi), can increase the cytotoxicity of carboplatin in an additive and synergistic manner in DIPG cells in vitro. Sodium valproate causes a dose-dependent decrease in DIPG cell viability in three independent ex vivo cell lines. Furthermore, sodium valproate caused an increase in acetylation of histone H3. Changes in cell viability were consistent with an induction of apoptosis in DIPG cells in vitro, determined by flow cytometric analysis of Annexin V staining and assessment of apoptotic markers by western blotting. Subsequently, immunofluorescent staining of neuronal and glial markers was used to determine toxicity in normal rat hippocampal cells. Pre-treatment of cells with sodium valproate enhanced the cytotoxic effects of carboplatin, in three DIPG cell lines tested. These results demonstrate that sodium valproate causes increased histone H3 acetylation indicative of HDAC inhibition, which is inversely correlated with a reduction in cell viability. Cell viability is reduced through an induction of apoptosis in DIPG cells. Sodium valproate potentiates carboplatin cytotoxicity and prompts further work to define the mechanism responsible for the synergy between these two drugs and determine in vivo efficacy. These findings support the use of sodium valproate as an adjuvant treatment for DIPG.
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Affiliation(s)
- Clare L. Killick-Cole
- Functional Neurosurgery Research Group, School of Clinical Sciences, University of Bristol, Learning & Research Building, Southmead Hospital, Bristol, United Kingdom
- * E-mail: (SG); (CKC)
| | - William G. B. Singleton
- Functional Neurosurgery Research Group, School of Clinical Sciences, University of Bristol, Learning & Research Building, Southmead Hospital, Bristol, United Kingdom
- Department of Neurosurgery, North Bristol NHS Trust, Bristol, United Kingdom
| | - Alison S. Bienemann
- Functional Neurosurgery Research Group, School of Clinical Sciences, University of Bristol, Learning & Research Building, Southmead Hospital, Bristol, United Kingdom
| | - Daniel J. Asby
- Functional Neurosurgery Research Group, School of Clinical Sciences, University of Bristol, Learning & Research Building, Southmead Hospital, Bristol, United Kingdom
| | - Marcella J. Wyatt
- Functional Neurosurgery Research Group, School of Clinical Sciences, University of Bristol, Learning & Research Building, Southmead Hospital, Bristol, United Kingdom
| | - Lisa J. Boulter
- Functional Neurosurgery Research Group, School of Clinical Sciences, University of Bristol, Learning & Research Building, Southmead Hospital, Bristol, United Kingdom
| | - Neil U. Barua
- Functional Neurosurgery Research Group, School of Clinical Sciences, University of Bristol, Learning & Research Building, Southmead Hospital, Bristol, United Kingdom
- Department of Neurosurgery, North Bristol NHS Trust, Bristol, United Kingdom
| | - Steven S. Gill
- Functional Neurosurgery Research Group, School of Clinical Sciences, University of Bristol, Learning & Research Building, Southmead Hospital, Bristol, United Kingdom
- Department of Neurosurgery, North Bristol NHS Trust, Bristol, United Kingdom
- * E-mail: (SG); (CKC)
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13
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Fay MF, Head R, Sminia P, Dowson N, Cosgrove L, Rose SE, Martin JH. Valproate in Adjuvant Glioblastoma Treatment. J Clin Oncol 2016; 34:3105-7. [DOI: 10.1200/jco.2016.67.2162] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Michael F. Fay
- University of Newcastle; Genesis Cancer Care; Calvary Mater Hospital; Newcastle, New South Wales; University of Queensland, Brisbane, Queensland, Australia
| | - Richard Head
- University of South Australia, Adelaide, South Australia, Australia
| | | | | | | | - Stephen E. Rose
- CSIRO; University of Queensland, Brisbane, Queensland, Australia
| | - Jenny H. Martin
- University of Newcastle; Calvary Mater Hospital, Newcastle, New South Wales; University of Queensland, Brisbane, Queensland, Australia
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14
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Highlights from the Literature. Neuro Oncol 2016. [DOI: 10.1093/neuonc/now056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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15
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Mellai M, Cattaneo M, Storaci AM, Annovazzi L, Cassoni P, Melcarne A, De Blasio P, Schiffer D, Biunno I. SEL1L SNP rs12435998, a predictor of glioblastoma survival and response to radio-chemotherapy. Oncotarget 2016; 6:12452-67. [PMID: 25948789 PMCID: PMC4494950 DOI: 10.18632/oncotarget.3611] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 03/14/2015] [Indexed: 12/18/2022] Open
Abstract
The suppressor of Lin-12-like (C. elegans) (SEL1L) is involved in the endoplasmic reticulum (ER)-associated degradation pathway, malignant transformation and stem cells. In 412 formalin-fixed and paraffin-embedded brain tumors and 39 Glioblastoma multiforme (GBM) cell lines, we determined the frequency of five SEL1L single nucleotide genetic variants with regulatory and coding functions by a SNaPShot™ assay. We tested their possible association with brain tumor risk, prognosis and therapy. We studied the in vitro cytotoxicity of valproic acid (VPA), temozolomide (TMZ), doxorubicin (DOX) and paclitaxel (PTX), alone or in combination, on 11 GBM cell lines, with respect to the SNP rs12435998 genotype. The SNP rs12435998 was prevalent in anaplastic and malignant gliomas, and in meningiomas of all histologic grades, but unrelated to brain tumor risks. In GBM patients, the SNP rs12435998 was associated with prolonged overall survival (OS) and better response to TMZ-based radio-chemotherapy. GBM stem cells with this SNP showed lower levels of SEL1L expression and enhanced sensitivity to VPA.
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Affiliation(s)
- Marta Mellai
- Neuro-Bio-Oncology Center/Policlinico di Monza Foundation, Vercelli 13100, Italy
| | - Monica Cattaneo
- Institute for Genetic and Biomedical Research, National Research Council, Milan 20138, Italy
| | | | - Laura Annovazzi
- Neuro-Bio-Oncology Center/Policlinico di Monza Foundation, Vercelli 13100, Italy
| | - Paola Cassoni
- Department of Medical Sciences, University of Turin/Città della Salute e della Scienza, Turin 10126, Italy
| | - Antonio Melcarne
- Department of Neurosurgery, CTO Hospital/Città della Salute e della Scienza, Turin 10126, Italy
| | | | - Davide Schiffer
- Neuro-Bio-Oncology Center/Policlinico di Monza Foundation, Vercelli 13100, Italy
| | - Ida Biunno
- Institute for Genetic and Biomedical Research, National Research Council, Milan 20138, Italy.,IRCCS-Multimedica, Milan 20138, Italy
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16
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Redjal N, Reinshagen C, Le A, Walcott BP, McDonnell E, Dietrich J, Nahed BV. Valproic acid, compared to other antiepileptic drugs, is associated with improved overall and progression-free survival in glioblastoma but worse outcome in grade II/III gliomas treated with temozolomide. J Neurooncol 2016; 127:505-14. [PMID: 26830093 DOI: 10.1007/s11060-016-2054-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 01/03/2016] [Indexed: 10/22/2022]
Abstract
Valproic acid (VPA) is an anti-epileptic drug with properties of a histone deacetylase inhibitor (HDACi). HDACi play a key role in epigenetic regulation of gene expression and have been increasingly used as anticancer agents. Recent studies suggest that VPA is associated with improved survival in high-grade gliomas. However, effects on lower grade gliomas have not been examined. This study investigates whether use of VPA correlates with tumor grade, histological progression, progression-free and overall survival (OS) in grade II, III, and IV glioma patients. Data from 359 glioma patients (WHO II-IV) treated with temozolomide plus an antiepileptic drug (VPA or another antiepileptic drug) between January 1997 and June 2013 at the Massachusetts General Hospital was analyzed retrospectively. After confounder adjustment, VPA was associated with a 28 % decrease in hazard of death (p = 0.031) and a 28 % decrease in the hazard of progression or death (p = 0.015) in glioblastoma. Additionally, VPA dose correlated with reduced hazard of death by 7 % (p = 0.002) and reduced hazard of progression or death by 5 % (p < 0.001) with each 100 g increase in total dose. Conversely, in grade II and III gliomas VPA was associated with a 118 % increased risk of tumor progression or death (p = 0.014), and every additional 100 g of VPA raised the hazard of progression or death by 4 %, although not statistically significant (p = 0.064). Moreover, grade II and III glioma patients taking VPA had 2.17 times the risk of histological progression (p = 0.020), although this effect was no longer significant after confounder adjustment. In conclusion, VPA was associated with improved survival in glioblastoma in a dose-dependent manner. However, in grade II and III gliomas, VPA was linked to histological progression and decrease in progression-free survival. Prospective evaluation of VPA treatment for glioma patients is warranted to confirm these findings.
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Affiliation(s)
- Navid Redjal
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White Building Room, Gray 502, Boston, MA, 02114, USA.
| | - Clemens Reinshagen
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, 02114, Boston, MA, USA
| | - Andrew Le
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White Building Room, Gray 502, Boston, MA, 02114, USA
| | - Brian P Walcott
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White Building Room, Gray 502, Boston, MA, 02114, USA
| | - Erin McDonnell
- MGH Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, 50 Staniford Street, Boston, MA, 02114, USA
| | - Jorg Dietrich
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, 02114, MA, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White Building Room, Gray 502, Boston, MA, 02114, USA
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17
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Happold C, Gorlia T, Chinot O, Gilbert MR, Nabors LB, Wick W, Pugh SL, Hegi M, Cloughesy T, Roth P, Reardon DA, Perry JR, Mehta MP, Stupp R, Weller M. Does Valproic Acid or Levetiracetam Improve Survival in Glioblastoma? A Pooled Analysis of Prospective Clinical Trials in Newly Diagnosed Glioblastoma. J Clin Oncol 2016; 34:731-9. [PMID: 26786929 DOI: 10.1200/jco.2015.63.6563] [Citation(s) in RCA: 129] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Symptomatic epilepsy is a common complication of glioblastoma and requires pharmacotherapy. Several uncontrolled retrospective case series and a post hoc analysis of the registration trial for temozolomide indicated an association between valproic acid (VPA) use and improved survival outcomes in patients with newly diagnosed glioblastoma. PATIENTS AND METHODS To confirm the hypothesis suggested above, a combined analysis of survival association of antiepileptic drug use at the start of chemoradiotherapy with temozolomide was performed in the pooled patient cohort (n = 1,869) of four contemporary randomized clinical trials in newly diagnosed glioblastoma: AVAGlio (Avastin in Glioblastoma; NCT00943826), CENTRIC (Cilengitide, Temozolomide, and Radiation Therapy in Treating Patients With Newly Diagnosed Glioblastoma and Methylated Gene Promoter Status; NCT00689221), CORE (Cilengitide, Temozolomide, and Radiation Therapy in Treating Patients With Newly Diagnosed Glioblastoma and Unmethylated Gene Promoter Status; NCT00813943), and Radiation Therapy Oncology Group 0825 (NCT00884741). Progression-free survival (PFS) and overall survival (OS) were compared between: (1) any VPA use and no VPA use at baseline or (2) VPA use both at start of and still after chemoradiotherapy. Results of Cox regression models stratified by trial and adjusted for baseline prognostic factors were analyzed. The same analyses were performed with levetiracetam (LEV). RESULTS VPA use at start of chemoradiotherapy was not associated with improved PFS or OS compared with all other patients pooled (PFS: hazard ratio [HR], 0.91; 95% CI, 0.77 to 1.07; P = .241; OS: HR, 0.96; 95% CI, 0.80 to 1.15; P = .633). Furthermore, PFS and OS of patients taking VPA both at start of and still after chemoradiotherapy were not different from those without antiepileptic drug use at both time points (PFS: HR, 0.92; 95% CI, 0.74 to 1.15; P = .467; OS: HR, 1.10; 95% CI, 0.86 to 1.40; P = .440). Similarly, no association with improved outcomes was observed for LEV use. CONCLUSION The results of this analysis do not justify the use of VPA or LEV for reasons other than seizure control in patients with newly diagnosed glioblastoma outside clinical trials.
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Affiliation(s)
- Caroline Happold
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Thierry Gorlia
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Olivier Chinot
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Mark R Gilbert
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - L Burt Nabors
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Wolfgang Wick
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Stephanie L Pugh
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Monika Hegi
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Timothy Cloughesy
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Patrick Roth
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - David A Reardon
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - James R Perry
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Minesh P Mehta
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Roger Stupp
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Michael Weller
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD.
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Fay M, Head R, Martin J. Where is the radiobiology and pharmacology research to improve outcomes in glioblastoma? J Neurooncol 2015; 124:1-3. [PMID: 26024652 DOI: 10.1007/s11060-015-1816-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/21/2015] [Indexed: 12/12/2022]
Abstract
Personalized medicine has been helpful for drug development in diseases with single and relatively stable gene mutations. The benefit for complex solid tumours with heterogeneous and changing genetic profiles is less clear. Whether it is efficient to continue diverting resources from combined biological and pharmacological approaches to trial new and existing genetic 'targeted therapies' for brain tumours is unknown but of developing concern in resource constrained environments.
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Affiliation(s)
- Michael Fay
- Department of Radiation Oncology, Calvary Mater Hospital, Waratah, New South Wales, Australia
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19
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Hosein AN, Lim YC, Day B, Stringer B, Rose S, Head R, Cosgrove L, Sminia P, Fay M, Martin JH. The effect of valproic acid in combination with irradiation and temozolomide on primary human glioblastoma cells. J Neurooncol 2015; 122:263-71. [DOI: 10.1007/s11060-014-1713-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 12/28/2014] [Indexed: 12/11/2022]
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Weller M. Are we ready for a randomized trial of valproic acid in newly diagnosed glioblastoma? Neuro Oncol 2014; 15:809-10. [PMID: 23788268 DOI: 10.1093/neuonc/not095] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Felix FHC, de Araujo OL, da Trindade KM, Trompieri NM, Fontenele JB. Retrospective evaluation of the outcomes of children with diffuse intrinsic pontine glioma treated with radiochemotherapy and valproic acid in a single center. J Neurooncol 2013; 116:261-6. [PMID: 24293221 DOI: 10.1007/s11060-013-1280-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 10/14/2013] [Indexed: 12/11/2022]
Abstract
Diffuse intrinsic pontine glioma is a pediatric oncologic disease with dismal prognosis and no effective treatment. Since 2007, our patients have been using valproic acid as prophylactic anticonvulsant. We have undertaken a retrospective study in order to evaluate the influence of valproate in the outcomes of children with this disease in our center. Patients were treated with weekly carboplatin and vincristine and received conformal radiotherapy, either concurrent or sequential. Event-free survival and overall survival of patients not treated with valproic acid were 6.5 and 7.8 months. Accelerated failure time model (a parametric multivariate regression test for time-to-failure data) showed a statistically significant superiority of the median event-free survival of treated patients (6.5 vs. 9.5 months in treated patients; HR 0.54-95 % CI 0.33-0.87; p < 0.05) and also of overall survival (7.8 vs. 13.4 months in treated patients; HR 0.60-95 % CI 0.37-0.98; p = 0.05).
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Affiliation(s)
- Francisco Helder Cavalcante Felix
- Pediatric Hemato-oncology Service, Pediatric Cancer Center, Hospital Infantil Albert Sabin, R Alberto Montezuma, 350 Vila Uniao, Fortaleza, CE, 60410-770, Brazil,
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Abstract
The prognosis for children with diffuse intrinsic pontine gliomas (DIPGs) is dismal. Although DIPGs constitute only 10-15 % of all pediatric brain tumors, they are the main cause of death in this group with a median survival of less than 12 months. Standard therapy involves radiotherapy, which produces transient neurologic improvement. Despite several clinical trials having been conducted, including trials on targeted agents to assess their efficacy, there is no clear improvement in prognosis. However, knowledge of DIPG biology is increasing, mainly as a result of research using biopsy and autopsy samples. In this review, we discuss recent studies in which systemic therapy was administered prior to, concomitantly with, or after radiotherapy. The discussion also includes novel therapeutic options in DIPG. Continuing multimodal and multitargeted therapies might lead to an improvement in the dismal prognosis of the disease.
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Affiliation(s)
- Rejin Kebudi
- Istanbul University Cerrahpasa Medical Faculty Pediatric Hematology-Oncology, P.C: 34090, Millet Street, Capa, Istanbul, Turkey,
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Kerkhof M, Dielemans JCM, van Breemen MS, Zwinkels H, Walchenbach R, Taphoorn MJ, Vecht CJ. Effect of valproic acid on seizure control and on survival in patients with glioblastoma multiforme. Neuro Oncol 2013; 15:961-7. [PMID: 23680820 DOI: 10.1093/neuonc/not057] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To examine the efficacy of valproic acid (VPA) given either with or without levetiracetam (LEV) on seizure control and on survival in patients with glioblastoma multiforme (GBM) treated with chemoradiation. METHODS A retrospective analysis was performed on 291 patients with GBM. The efficacies of VPA and LEV alone and as polytherapy were analyzed in 181 (62%) patients with seizures with a minimum follow-up of 6 months. Cox-regression survival analysis was performed on 165 patients receiving chemoradiation with temozolomide of whom 108 receiving this in combination with VPA for at least 3 months. RESULTS Monotherapy with either VPA or LEV was instituted in 137/143 (95.8%) and in 59/86 (68.6%) on VPA/LEV polytherapy as the next regimen. Initial freedom from seizure was achieved in 41/100 (41%) on VPA, in 16/37 (43.3%) on LEV, and in 89/116 (76.7%) on subsequent VPA/LEV polytherapy. At the end of follow-up, seizure freedom was achieved in 77.8% (28/36) on VPA alone, in 25/36 (69.5%) on LEV alone, and in 38/63 (60.3%) on VPA/LEV polytherapy with ongoing seizures on monotherapy. Patients using VPA in combination with temozolomide showed a longer median survival of 69 weeks (95% confidence interval [CI]: 61.7-67.3) compared with 61 weeks (95% CI: 52.5-69.5) in the group without VPA (hazard ratio, 0.63; 95% CI: 0.43-0.92; P = .016), adjusting for age, extent of resection, and O(6)-DNA methylguanine-methyltransferase promoter methylation status. CONCLUSIONS Polytherapy with VPA and LEV more strongly contributes to seizure control than does either as monotherapy. Use of VPA together with chemoradiation with temozolomide results in a 2-months' longer survival of patients with GBM.
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Affiliation(s)
- Melissa Kerkhof
- Neuro-oncology Unit, Department of Neurology,Medical Center Haaglanden, The Hague, The Netherlands.
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Survival of children with malignant brain tumors receiving valproate: a retrospective study. Childs Nerv Syst 2013; 29:195-7. [PMID: 23233213 DOI: 10.1007/s00381-012-1997-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 11/30/2012] [Indexed: 12/19/2022]
Abstract
PURPOSE The treatment of pediatric patients with malignant brain tumors has evolved considerably in the past decades. However, results are still unsatisfactory for some patients. Valproate has been shown to positively affect the survival of adult glioblastoma patients. We have been giving prophylactic antiepileptic drugs to newly diagnosed children with brain tumors. Since then, we noted a trend towards a better survival from our patients. In order to study this, we performed a retrospective evaluation in our institution. METHODS Standard survival analysis was used, calculating survival until death by all causes or censoring. Comparisons were made by Cox's proportional hazards model regression. RESULTS Between 2000 and 2010, 94 patients were treated (12 with high-grade gliomas, 56 medulloblastomas, and 26 ependymomas); median and mean ages were 7.7 and 7.8 years. Median follow-up was 60 months (35 for treated and 109 for untreated patients). Of these, 47 received valproate 10-15 mg/kg/day every 8-12 h and 47 did not. Patients who received valproate had a median survival of 34 months, whereas the other group had a median survival of 24 months (hazard ratios = 0.99, 0.57-1.75, p = 0.99). CONCLUSIONS These results do not prove that valproate prophylactic treatment in pediatric patients with malignant brain tumors had an influence on their survival. However, our cohort showed an effect of higher size than the recent European Organization for Research and Treatment of Cancer trial analysis, even though not significant. Clinical trials with valproate in pediatric malignant brain tumors should be carefully planned, in order to detect a possible effect of this drug in survival.
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