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Khagi S, Kotecha R, Gatson NTN, Jeyapalan S, Abdullah HI, Avgeropoulos NG, Batzianouli ET, Giladi M, Lustgarten L, Goldlust SA. Recent advances in Tumor Treating Fields (TTFields) therapy for glioblastoma. Oncologist 2024:oyae227. [PMID: 39401002 DOI: 10.1093/oncolo/oyae227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 07/23/2024] [Indexed: 10/15/2024] Open
Abstract
Tumor Treating Fields (TTFields) therapy is a locoregional, anticancer treatment consisting of a noninvasive, portable device that delivers alternating electric fields to tumors through arrays placed on the skin. Based on efficacy and safety data from global pivotal (randomized phase III) clinical studies, TTFields therapy (Optune Gio) is US Food and Drug Administration-approved for newly diagnosed (nd) and recurrent glioblastoma (GBM) and Conformité Européenne-marked for grade 4 glioma. Here we review data on the multimodal TTFields mechanism of action that includes disruption of cancer cell mitosis, inhibition of DNA replication and damage response, interference with cell motility, and enhancement of systemic antitumor immunity (adaptive immunity). We describe new data showing that TTFields therapy has efficacy in a broad range of patients, with a tolerable safety profile extending to high-risk subpopulations. New analyses of clinical study data also confirmed that overall and progression-free survival positively correlated with increased usage of the device and dose of TTFields at the tumor site. Additionally, pilot/early phase clinical studies evaluating TTFields therapy in ndGBM concomitant with immunotherapy as well as radiotherapy have shown promise, and new pivotal studies will explore TTFields therapy in these settings. Finally, we review recent and ongoing studies in patients in pediatric care, other central nervous system tumors and brain metastases, as well as other advanced-stage solid tumors (ie, lung, ovarian, pancreatic, gastric, and hepatic cancers), that highlight the broad potential of TTFields therapy as an adjuvant treatment in oncology.
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Affiliation(s)
- Simon Khagi
- Hoag Family Cancer Institute, Newport Beach, CA, United States
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
| | - Na Tosha N Gatson
- Neuro-Oncology Center of Excellence, Indiana University School of Medicine, Indianapolis, IN, United States
- IU Health Neuroscience & Simon Cancer Institutes, Indianapolis, IN, United States
- Geisinger Commonwealth School of Medicine, Scranton, PA, United States
| | | | | | | | | | | | | | - Samuel A Goldlust
- Department of Neuro-Oncology, Saint Luke's Cancer Institute, Kansas City, MO, United States
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Wang L, Chen C, Xiao Y, Gong R, Shen J, Lu M. Personalized optimization strategy for electrode array layout in TTFields of glioblastoma. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2024; 40:e3859. [PMID: 39154656 DOI: 10.1002/cnm.3859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 07/16/2024] [Accepted: 08/05/2024] [Indexed: 08/20/2024]
Abstract
Tumor treating fields (TTFields) is a novel therapeutic approach for the treatment of glioblastoma. The electric field intensity is a critical factor in the therapeutic efficacy of TTFields, as stronger electric field can more effectively impede the proliferation and survival of tumor cells. In this study, we aimed to improve the therapeutic effectiveness of TTFields by optimizing the position of electrode arrays, resulting in an increased electric field intensity at the tumor. Three representative head models of real glioblastoma patients were used as the research subjects in this study. The improved subtraction-average-based optimization (ISABO) algorithm based on circle chaos mapping, opposition-based learning and golden sine strategy, was employed to optimize the positions of the four sets of electrode arrays on the scalp. The electrode positions are dynamically adjusted through iterative search to maximize the electric field intensity at the tumor. The experimental results indicate that, in comparison to the conventional layout, the positions of the electrode arrays obtained by the ISABO algorithm can achieve average electric field intensity of 1.7887, 2.0058, and 1.3497 V/cm at the tumor of three glioblastoma patients, which are 23.6%, 29.4%, and 8.5% higher than the conventional layout, respectively. This study demonstrates that optimizing the location of the TTFields electrode array using the ISABO algorithm can effectively enhance the electric field intensity and treatment coverage in the tumor area, offering a more effective approach for personalized TTFields treatment.
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Affiliation(s)
- Liang Wang
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Nanjing, China
| | - Chunxiao Chen
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Nanjing, China
| | - Yueyue Xiao
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Nanjing, China
| | - Rongfang Gong
- Department of Mathematics, Nanjing University of Aeronautics and Astronautics, Nanjing, China
| | - Jun Shen
- Department of Mathematics, Nanjing University of Aeronautics and Astronautics, Nanjing, China
| | - Ming Lu
- Department of Radiology, GuiQian International General Hospital, Guiyang, China
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Zheng J, Xu G, Guo W, Wang Y, Wu J, Zong D, Ding B, Sun L, He X. Preliminary study of feasibility of surface-guided radiotherapy with concurrent tumor treating fields for glioblastoma: region of interest. Radiat Oncol 2024; 19:129. [PMID: 39334165 PMCID: PMC11430246 DOI: 10.1186/s13014-024-02525-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 09/18/2024] [Indexed: 09/30/2024] Open
Abstract
OBJECTIVE To evaluate the impact of the residual setup errors from differently shaped region of interest (ROI) and investigate if surface-guided setup can be used in radiotherapy with concurrent tumor treating fields (TTFields) for glioblastoma. METHODS Fifteen patients undergone glioblastoma radiotherapy with concurrent TTFields were involved. Firstly, four shapes of region of interest (ROI) (strip-shaped, T-shaped, ⊥ -shaped and cross-shaped) with medium size relative to the whole face were defined dedicate for patients wearing TTFields transducer arrays. Then, ROI-shape-dependent residual setup errors in six degrees were evaluated using an anthropomorphic head and neck phantom taking CBCT data as reference. Finally, the four types of residual setup errors were converted into corresponding dosimetry deviations (including the target coverage and the organ at risk sparing) of the fifteen radiotherapy plans using a feasible and robust geometric-transform-based method. RESULTS The algebraic sum of the average residual setup errors in six degrees (mm in translational directions and ° in rotational directions) of the four types were 6.9, 1.1, 4.1 and 3.5 respectively. In terms of the ROI-shape-dependent dosimetry deviations, the D98% of PTV dropped off by (3.4 ± 2.0)% (p < 0.05), (0.3 ± 0.5)% (p < 0.05), (0.9 ± 0.9)% (p < 0.05) and (1.1 ± 0.8)% (p < 0.05). The D98% of CTV dropped off by (0.5 ± 0.6)% (p < 0.05) for the strip-shaped ROI while remained unchanged for others. CONCLUSION Surface-guided setup is feasible in radiotherapy with concurrent TTFields and a medium-sized T-shaped ROI is appropriate for the surface-based guidance.
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Affiliation(s)
- Jiajun Zheng
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing, 210009, China.
- School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing, 210024, China.
| | - Geng Xu
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing, 210009, China
| | - Wenjie Guo
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing, 210009, China
| | - Yuanyuan Wang
- Department of Clinical Physics and Technique, Ion Medical Center of the First Affiliated Hospital of University of Science and Technology of China (Hefei Ion Medical Center), Hefei, 230088, China
| | - Jianfeng Wu
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing, 210009, China
| | - Dan Zong
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing, 210009, China
| | - Boyang Ding
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing, 210009, China
| | - Li Sun
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing, 210009, China.
| | - Xia He
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing, 210009, China.
- Department of Environmental Genomics, Jiangsu Key Laboratory of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, 210024, China.
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Mrugala MM, Shi W, Iwomoto F, Lukas RV, Palmer JD, Suh JH, Glas M. Global post‑marketing safety surveillance of Tumor Treating Fields (TTFields) therapy in over 25,000 patients with CNS malignancies treated between 2011-2022. J Neurooncol 2024; 169:25-38. [PMID: 38949692 PMCID: PMC11269345 DOI: 10.1007/s11060-024-04682-7] [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: 02/06/2024] [Accepted: 04/15/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Tumor Treating Fields (TTFields) are alternating electric fields that disrupt cancer cell processes. TTFields therapy is approved for recurrent glioblastoma (rGBM), and newly-diagnosed (nd) GBM (with concomitant temozolomide for ndGBM; US), and for grade IV glioma (EU). We present an updated global, post-marketing surveillance safety analysis of patients with CNS malignancies treated with TTFields therapy. METHODS Safety data were collected from routine post-marketing activities for patients in North America, Europe, Israel, and Japan (October 2011-October 2022). Adverse events (AEs) were stratified by age, sex, and diagnosis. RESULTS Overall, 25,898 patients were included (diagnoses: ndGBM [68%], rGBM [26%], anaplastic astrocytoma/oligodendroglioma [4%], other CNS malignancies [2%]). Median (range) age was 59 (3-103) years; 66% patients were male. Most (69%) patients were 18-65 years; 0.4% were < 18 years; 30% were > 65 years. All-cause and TTFields-related AEs occurred in 18,798 (73%) and 14,599 (56%) patients, respectively. Most common treatment-related AEs were beneath-array skin reactions (43%), electric sensation (tingling; 14%), and heat sensation (warmth; 12%). Treatment-related skin reactions were comparable in pediatric (39%), adult (42%), and elderly (45%) groups, and in males (41%) and females (46%); and similar across diagnostic subgroups (ndGBM, 46%; rGBM, 34%; anaplastic astrocytoma/oligodendroglioma, 42%; other, 40%). No TTFields-related systemic AEs were reported. CONCLUSIONS This long-term, real-world analysis of > 25,000 patients demonstrated good tolerability of TTFields in patients with CNS malignancies. Most therapy-related AEs were manageable localized, non-serious skin events. The TTFields therapy safety profile remained consistent across subgroups (age, sex, and diagnosis), indicative of its broad applicability.
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Affiliation(s)
- Maciej M Mrugala
- Mayo Clinic College of Medicine and Science, Mayo Clinic, Phoenix/Scottsdale, Arizona, USA.
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Fabio Iwomoto
- Division of Neuro-Oncology, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Rimas V Lukas
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Joshua D Palmer
- The Department of Radiation Oncology, The James Cancer Hospital, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Martin Glas
- Division of Clinical Neurooncology, Department of Neurology, University Hospital Essen, University Duisburg-Essen, West German Cancer Center (WTZ) and German Cancer Consortium, Partner Site, Essen, Germany
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Berckmans Y, Ene HM, Ben-Meir K, Martinez-Conde A, Wouters R, Van den Ende B, Van Mechelen S, Monin R, Frechtel-Gerzi R, Gabay H, Dor-On E, Haber A, Weinberg U, Vergote I, Giladi M, Coosemans A, Palti Y. Tumor Treating Fields (TTFields) induce homologous recombination deficiency in ovarian cancer cells, thus mitigating drug resistance. Front Oncol 2024; 14:1402851. [PMID: 38993641 PMCID: PMC11238040 DOI: 10.3389/fonc.2024.1402851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/10/2024] [Indexed: 07/13/2024] Open
Abstract
Background Ovarian cancer is the leading cause of mortality among gynecological malignancies. Carboplatin and poly (ADP-ribose) polymerase inhibitors (PARPi) are often implemented in the treatment of ovarian cancer. Homologous recombination deficient (HRD) tumors demonstrate increased sensitivity to these treatments; however, many ovarian cancer patients are homologous recombination proficient (HRP). TTFields are non-invasive electric fields that induce an HRD-like phenotype in various cancer types. The current study aimed to investigate the impact of TTFields applied together with carboplatin or PARPi (olaparib or niraparib) in preclinical ovarian cancer models. Methods A2780 (HRP), OVCAR3 (HRD), and A2780cis (platinum-resistant) human ovarian cancer cells were treated in vitro with TTFields (1 V/cm RMS, 200 kHz, 72 h), alone or with various drug concentrations. Treated cells were measured for cell count, colony formation, apoptosis, DNA damage, expression of DNA repair proteins, and cell cycle. In vivo, ID8-fLuc (HRP) ovarian cancer cells were inoculated intraperitoneally to C57BL/6 mice, which were then treated with either sham, TTFields (200 kHz), olaparib (50 mg/kg), or TTFields plus olaparib; over a period of four weeks. Tumor growth was analyzed using bioluminescent imaging at treatment cessation; and survival analysis was performed. Results The nature of TTFields-drug interaction was dependent on the drug's underlying mechanism of action and on the genetic background of the cells, with synergistic interactions between TTFields and carboplatin or PARPi seen in HRP and resistant cells. Treated cells demonstrated elevated levels of DNA damage, accompanied by G2/M arrest, and induction of an HRD-like phenotype. In the tumor-bearing mice, TTFields and olaparib co-treatment resulted in reduced tumor volume and a survival benefit relative to olaparib monotherapy and to control. Conclusion By inducing an HRD-like phenotype, TTFields sensitize HRP and resistant ovarian cancer cells to treatment with carboplatin or PARPi, potentially mitigating a-priori and de novo drug resistance, a major limitation in ovarian cancer treatment.
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Affiliation(s)
- Yani Berckmans
- Laboratory of Tumor Immunology and Immunotherapy, Department of Oncology, Leuven Cancer Institute, KU Leuven, Leuven, Belgium
| | | | | | | | - Roxanne Wouters
- Laboratory of Tumor Immunology and Immunotherapy, Department of Oncology, Leuven Cancer Institute, KU Leuven, Leuven, Belgium
- Oncoinvent AS, Oslo, Norway
| | - Bieke Van den Ende
- Laboratory of Tumor Immunology and Immunotherapy, Department of Oncology, Leuven Cancer Institute, KU Leuven, Leuven, Belgium
| | - Sara Van Mechelen
- Laboratory of Tumor Immunology and Immunotherapy, Department of Oncology, Leuven Cancer Institute, KU Leuven, Leuven, Belgium
| | | | | | | | | | | | | | - Ignace Vergote
- Department of Gynecology and Obstetrics, Gynecologic Oncology, Leuven Cancer Institute, KU Leuven, Leuven, Belgium
| | | | - An Coosemans
- Laboratory of Tumor Immunology and Immunotherapy, Department of Oncology, Leuven Cancer Institute, KU Leuven, Leuven, Belgium
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Lan J, Liu Y, Chen J, Liu H, Feng Y, Liu J, Chen L. Advanced tumor electric fields therapy: A review of innovative research and development and prospect of application in glioblastoma. CNS Neurosci Ther 2024; 30:e14720. [PMID: 38715344 PMCID: PMC11077002 DOI: 10.1111/cns.14720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 03/16/2024] [Accepted: 03/21/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Glioblastoma multiforme (GBM) is an aggressive malignant tumor with a high mortality rate and is the most prevalent primary intracranial tumor that remains incurable. The current standard treatment, which involves surgery along with concurrent radiotherapy and chemotherapy, only yields a survival time of 14-16 months. However, the introduction of tumor electric fields therapy (TEFT) has provided a glimmer of hope for patients with newly diagnosed and recurrent GBM, as it has been shown to extend the median survival time to 20 months. The combination of TEFT and other advanced therapies is a promising trend in the field of GBM, facilitated by advancements in medical technology. AIMS In this review, we provide a concise overview of the mechanism and efficacy of TEFT. In addition, we mainly discussed the innovation of TEFT and our proposed blueprint for TEFT implementation. CONCLUSION Tumor electric fields therapy is an effective and highly promising treatment modality for GBM. The full therapeutic potential of TEFT can be exploited by combined with other innovative technologies and treatments.
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Affiliation(s)
- Jinxin Lan
- Department of NeurosurgeryChinese PLA General HospitalBeijingChina
- School of MedicineNankai UniversityTianjinChina
- Medical School of Chinese PLABeijingChina
| | - Yuyang Liu
- Medical School of Chinese PLABeijingChina
- Department of Neurosurgery920th Hospital of Joint Logistics Support ForceKunmingChina
| | - Junyi Chen
- Department of NeurosurgeryChinese PLA General HospitalBeijingChina
- Medical School of Chinese PLABeijingChina
| | - Hongyu Liu
- Medical School of Chinese PLABeijingChina
- Department of NeurosurgeryHainan Hospital of Chinese PLA General HospitalHainanChina
| | - Yaping Feng
- Department of Neurosurgery920th Hospital of Joint Logistics Support ForceKunmingChina
| | - Jialin Liu
- Department of NeurosurgeryChinese PLA General HospitalBeijingChina
- Medical School of Chinese PLABeijingChina
| | - Ling Chen
- Department of NeurosurgeryChinese PLA General HospitalBeijingChina
- School of MedicineNankai UniversityTianjinChina
- Medical School of Chinese PLABeijingChina
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Yu A, Zeng J, Yu J, Cao S, Li A. Theory and application of TTFields in newly diagnosed glioblastoma. CNS Neurosci Ther 2024; 30:e14563. [PMID: 38481068 PMCID: PMC10938032 DOI: 10.1111/cns.14563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 11/07/2023] [Accepted: 11/29/2023] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Glioblastoma is the most common primary malignant brain tumor in adults. TTFields is a therapy that use intermediate-frequency and low-intensity alternating electric fields to treat tumors. For patients with ndGBM, the addition of TTFields after the concurrent chemoradiotherapy phase of the Stupp regimen can improve prognosis. However, TTFields still has the potential to further prolong the survival of ndGBM patients. AIM By summarizing the mechanism and application status of TTFields in the treatment of ndGBM, the application prospect of TTFields in ndbm treatment is prospected. METHODS We review the recent literature and included 76 articles to summarize the mechanism of TTfields in the treatment of ndGBM. The current clinical application status and potential health benefits of TTFields in the treatment of ndGBM are also discussed. RESULTS TTFields can interfere with tumor cell mitosis, lead to tumor cell apoptosis and increased autophagy, hinder DNA damage repair, induce ICD, activate tumor immune microenvironment, reduce cancer cell metastasis and invasion, and increase BBB permeability. TTFields combines with chemoradiotherapy has made progress, its optimal application time is being explored and the problems that need to be considered when retaining the electrode patches for radiotherapy are further discussed. TTFields shows potential in combination with immunotherapy, antimitotic agents, and PARP inhibitors, as well as in patients with subtentorial gliomas. CONCLUSION This review summarizes mechanisms of TTFields in the treatment of ndGBM, and describes the current clinical application of TTFields in ndGBM. Through the understanding of its principle and application status, we believe that TTFields still has the potential to further prolong the survival of ndGBM patients. Thus,research is still needed to explore new ways to combine TTFields with other therapies and optimize the use of TTFields to realize its full potential in ndGBM patients.
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Affiliation(s)
- Ao Yu
- Department of Radiotherapy, Liaoning Cancer Hospital & Institute, Cancer Hospital of China Medical UniversityCancer Hospital of Dalian University of TechnologyShenyangChina
- School of GraduateChina Medical UniversityShenyangChina
| | - Juan Zeng
- Department of OncologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Jinhui Yu
- Department of Radiotherapy, Liaoning Cancer Hospital & Institute, Cancer Hospital of China Medical UniversityCancer Hospital of Dalian University of TechnologyShenyangChina
- School of GraduateChina Medical UniversityShenyangChina
| | - Shuo Cao
- Department of OncologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Ailin Li
- Department of Radiotherapy, Liaoning Cancer Hospital & Institute, Cancer Hospital of China Medical UniversityCancer Hospital of Dalian University of TechnologyShenyangChina
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Obrador E, Moreno-Murciano P, Oriol-Caballo M, López-Blanch R, Pineda B, Gutiérrez-Arroyo JL, Loras A, Gonzalez-Bonet LG, Martinez-Cadenas C, Estrela JM, Marqués-Torrejón MÁ. Glioblastoma Therapy: Past, Present and Future. Int J Mol Sci 2024; 25:2529. [PMID: 38473776 DOI: 10.3390/ijms25052529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/10/2024] [Accepted: 02/16/2024] [Indexed: 03/14/2024] Open
Abstract
Glioblastoma (GB) stands out as the most prevalent and lethal form of brain cancer. Although great efforts have been made by clinicians and researchers, no significant improvement in survival has been achieved since the Stupp protocol became the standard of care (SOC) in 2005. Despite multimodality treatments, recurrence is almost universal with survival rates under 2 years after diagnosis. Here, we discuss the recent progress in our understanding of GB pathophysiology, in particular, the importance of glioma stem cells (GSCs), the tumor microenvironment conditions, and epigenetic mechanisms involved in GB growth, aggressiveness and recurrence. The discussion on therapeutic strategies first covers the SOC treatment and targeted therapies that have been shown to interfere with different signaling pathways (pRB/CDK4/RB1/P16ink4, TP53/MDM2/P14arf, PI3k/Akt-PTEN, RAS/RAF/MEK, PARP) involved in GB tumorigenesis, pathophysiology, and treatment resistance acquisition. Below, we analyze several immunotherapeutic approaches (i.e., checkpoint inhibitors, vaccines, CAR-modified NK or T cells, oncolytic virotherapy) that have been used in an attempt to enhance the immune response against GB, and thereby avoid recidivism or increase survival of GB patients. Finally, we present treatment attempts made using nanotherapies (nanometric structures having active anti-GB agents such as antibodies, chemotherapeutic/anti-angiogenic drugs or sensitizers, radionuclides, and molecules that target GB cellular receptors or open the blood-brain barrier) and non-ionizing energies (laser interstitial thermal therapy, high/low intensity focused ultrasounds, photodynamic/sonodynamic therapies and electroporation). The aim of this review is to discuss the advances and limitations of the current therapies and to present novel approaches that are under development or following clinical trials.
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Affiliation(s)
- Elena Obrador
- Scientia BioTech S.L., 46002 Valencia, Spain
- Department of Physiology, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
| | | | - María Oriol-Caballo
- Scientia BioTech S.L., 46002 Valencia, Spain
- Department of Physiology, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
| | - Rafael López-Blanch
- Scientia BioTech S.L., 46002 Valencia, Spain
- Department of Physiology, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
| | - Begoña Pineda
- Department of Physiology, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
| | | | - Alba Loras
- Department of Medicine, Jaume I University of Castellon, 12071 Castellon, Spain
| | - Luis G Gonzalez-Bonet
- Department of Neurosurgery, Castellon General University Hospital, 12004 Castellon, Spain
| | | | - José M Estrela
- Scientia BioTech S.L., 46002 Valencia, Spain
- Department of Physiology, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
- Department of Physiology, Faculty of Pharmacy, University of Valencia, 46100 Burjassot, Spain
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Goldlust SA, Singer S, Cappello LA, AlMekkawi AK, Lee KD, Ingenito AC, Lewis BE, Nyirenda T, Azmi H, Kaptain GJ. Phase 1 study of concomitant tumor treating fields and temozolomide chemoradiation for newly diagnosed glioblastoma. Neurooncol Adv 2024; 6:vdae129. [PMID: 39211521 PMCID: PMC11358815 DOI: 10.1093/noajnl/vdae129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
Background Glioblastoma (GBM) is the most common and aggressive primary brain tumor and has limited effective therapies. Tumor treating fields (TTF; Optune Gio®) is an FDA-approved device with data supporting a significant survival benefit and minimal toxicity when added to maintenance chemotherapy. Uptake in clinical practice is not universal and might improve if a shorter duration of treatment is feasible. This phase 1 trial was designed to determine the safety and preliminary efficacy of TTF concomitant to chemoradiation. Methods Patients with newly diagnosed, histologically confirmed GBM were eligible. Following surgery, patients were treated with TTF concomitant to standard chemoradiation. The device continued through 2 monthly cycles of maintenance temozolomide with imaging and clinical assessments at regular intervals to assess toxicity and response. The primary endpoint was the safety and tolerability of combined modality treatment based upon the incidence and severity of adverse events. Secondary endpoints were overall survival (OS) and progression-free survival (PFS). Results Thirteen patients were enrolled. Dermatologic adverse events were frequent but limited to grade 1/2. There was only 1 serious adverse event possibly related to TTF and no patients were unable to complete the prescribed course of multimodality treatment due to TTF-associated toxicity. Twelve patients were evaluable for median and 6-month progression-free survival which were 8.5 months (mo) and 66.7%, respectively. Median and 12 mo overall survival were 16.0 mo and 83.3%, respectively. Conclusions TTF can be safely delivered in conjunction with chemoradiation. The potential for a finite TTF course merits further evaluation.
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Affiliation(s)
- Samuel A Goldlust
- Department of Oncology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Samuel Singer
- Department of Oncology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Lori A Cappello
- Department of Oncology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Ahmad K AlMekkawi
- Department of Neurosurgery, Saint Luke’s Hospital of Kansas City, Kansas City, Missouri, USA
| | - Kangmin D Lee
- Department of Neurosurgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Anthony C Ingenito
- Department of Radiation Oncology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Brett E Lewis
- Department of Radiation Oncology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Themba Nyirenda
- Office of Research Administration, Hackensack Meridian Health, Edison, New Jersey, USA
| | - Hooman Azmi
- Department of Neurosurgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - George J Kaptain
- Department of Neurosurgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
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Slavkov D, Hadzhiyanev A, Slavkova S. Tumor treating fields: a new treatment for glioblastoma. BIOTECHNOL BIOTEC EQ 2023. [DOI: 10.1080/13102818.2022.2155567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Dimitar Slavkov
- Clinic for Neurosurgery, Spine Surgery and Neuromodulation, HELIOS Vogtland-Klinikum Plauen GmbH, Plauen, Germany
| | - Asen Hadzhiyanev
- Department of Neurosurgery, University Hospital ‘St. Ivan Rilsky’, Medical University of Sofia, Sofia, Bulgaria
| | - Svetoslava Slavkova
- Clinic for Dermatology, HELIOS Vogtland-Klinikum Plauen GmbH, Plauen, Germany
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Pan M, Xiao Y, Zhu L, Dong S, Liang L, Sun L, Shi W, Wang Y. Evaluation of Interfraction Setup Uncertainty of Patients With Glioblastoma Wearing TTFields (Tumor Treating Fields) During Radiation Therapy. Pract Radiat Oncol 2023; 13:522-530. [PMID: 37437806 DOI: 10.1016/j.prro.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE Tumor treating fields (TTFields) with concurrent radiation therapy (RT) might improve the outcome of patients with newly diagnosed glioblastoma. Several trials, including that conducted in our center, have allowed patients to wear TTFields during RT. We aimed to evaluate the setup uncertainty introduced by TTFields and calculate the planning target volume (PTV) margin for clinical reference. METHODS AND MATERIALS We collected and analyzed 201 cone beam computed tomography images of 22 patients in our center. Patients with or without TTFields were divided into the control and TTFields groups. We evaluated the setup errors in 6 degrees of freedom and 3 degrees of freedom and the magnitudes in the 3-dimensional vectors. An estimated PTV margin for patients requiring nonimaging-guided RT was recommended. RESULTS A significant difference was observed in the longitudinal axis between the TTFields and control groups (P < .05). These results were consistent with that of the intragroup comparison of the TTFields group. The position error of the longitudinal axis (from head to feet) was -0.51 ± 2.05 mm in the TTFields group. CONCLUSIONS Wearing TTFields during RT increased the uncertainty, especially in the longitudinal axis, with a system error of 1.40 mm and a random error of 1.28 mm. Daily image guided RT for TTFields patients seems necessary. However, the recommended expansion margin of the PTV is 5 mm for patients requiring nonimage-guided RT to enhance the safety and efficacy of treatment.
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Affiliation(s)
- Mingyuan Pan
- Radiation Oncology Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Yixuan Xiao
- Radiation Oncology Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Liying Zhu
- Radiation Oncology Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Shengnan Dong
- Radiation Oncology Center, Huashan Hospital, Fudan University, Shanghai, China; Henan Province Hospital of TCM, Henan, China
| | - Liping Liang
- Radiation Oncology Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Lei Sun
- Cyberknife Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Yang Wang
- Radiation Oncology Center, Huashan Hospital, Fudan University, Shanghai, China.
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12
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Szklener K, Bilski M, Nieoczym K, Mańdziuk D, Mańdziuk S. Enhancing glioblastoma treatment through the integration of tumor-treating fields. Front Oncol 2023; 13:1274587. [PMID: 37916157 PMCID: PMC10616854 DOI: 10.3389/fonc.2023.1274587] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/28/2023] [Indexed: 11/03/2023] Open
Abstract
Glioblastoma (GBM) represents a significant therapeutic challenge due to its aggressive nature. Tumor Treating Fields (TTFields) present a promising approach to GBM therapy. The primary mechanism of TTFields, an antimitotic effect, alongside numerous indirect effects including increased cell membrane permeability, signifies their potential in combination with other treatment modalities. Current combinations often include chemotherapy, particularly with temozolomide (TMZ), however, emerging data suggests potential synergy with targeted therapies, radiotherapy, and immunotherapy as well. TTFields display minimal side effects, predominantly skin-related, posing no significant barrier to combined therapies. The effectiveness of TTFields in GBM treatment has been demonstrated through several post-registration studies, advocating for continued research to optimize overall survival (OS) and progression-free survival (PFS) in patients, as opposed to focusing solely on quality of life.
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Affiliation(s)
- Katarzyna Szklener
- Department of Clinical Oncology and Chemotherapy, Medical University of Lublin, Lublin, Poland
| | - Mateusz Bilski
- Department of Radiotherapy, Medical University of Lublin, Lublin, Poland
| | - Karolina Nieoczym
- Student Scientific Association at the Department of Clinical Oncology and Chemotherapy, Medical University of Lublin, Lublin, Poland
| | - Dominika Mańdziuk
- Student Scientific Association at the Department of Clinical Oncology and Chemotherapy, Medical University of Lublin, Lublin, Poland
| | - Sławomir Mańdziuk
- Department of Clinical Oncology and Chemotherapy, Medical University of Lublin, Lublin, Poland
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13
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Liu X, Zhao Z, Dai W, Liao K, Sun Q, Chen D, Pan X, Feng L, Ding Y, Wei S. The Development of Immunotherapy for the Treatment of Recurrent Glioblastoma. Cancers (Basel) 2023; 15:4308. [PMID: 37686584 PMCID: PMC10486426 DOI: 10.3390/cancers15174308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/04/2023] [Accepted: 08/04/2023] [Indexed: 09/10/2023] Open
Abstract
Recurrent glioblastoma (rGBM) is a highly aggressive form of brain cancer that poses a significant challenge for treatment in neuro-oncology, and the survival status of patients after relapse usually means rapid deterioration, thus becoming the leading cause of death among patients. In recent years, immunotherapy has emerged as a promising strategy for the treatment of recurrent glioblastoma by stimulating the body's immune system to recognize and attack cancer cells, which could be used in combination with other treatments such as surgery, radiation, and chemotherapy to improve outcomes for patients with recurrent glioblastoma. This therapy combines several key methods such as the use of monoclonal antibodies, chimeric antigen receptor T cell (CAR-T) therapy, checkpoint inhibitors, oncolytic viral therapy cancer vaccines, and combination strategies. In this review, we mainly document the latest immunotherapies for the treatment of glioblastoma and especially focus on rGBM.
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Affiliation(s)
- Xudong Liu
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China; (X.L.); (Y.D.)
| | - Zihui Zhao
- School of Medicine, Shanghai Jiao Tong University, Shanghai 200011, China;
| | - Wufei Dai
- Department of Plastic and Reconstructive Surgery, Shanghai Key Laboratory of Tissue Engineering Research, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200011, China;
| | - Kuo Liao
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou 510006, China;
| | - Qi Sun
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; (Q.S.); (L.F.)
| | - Dongjiang Chen
- Division of Neuro-Oncology, USC Keck Brain Tumor Center, University of Southern California Keck School of Medicine, Los Angeles, CA 90089, USA;
| | - Xingxin Pan
- Department of Oncology, Livestrong Cancer Institutes, Dell Medical School, The University of Texas at Austin, Austin, TX 78712, USA;
| | - Lishuang Feng
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; (Q.S.); (L.F.)
| | - Ying Ding
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China; (X.L.); (Y.D.)
| | - Shiyou Wei
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
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14
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Yang C, Zhang Q, Ma C, Huang Y, Ding HX, Lu JW, Wang J, Li X, Zhong YH, Li ZQ. Characteristics and management of tumor treating fields-related dermatological complications in patients with glioblastoma. Medicine (Baltimore) 2023; 102:e33830. [PMID: 37335714 PMCID: PMC10194479 DOI: 10.1097/md.0000000000033830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/26/2023] [Indexed: 06/21/2023] Open
Abstract
Tumor treating fields (TTFields) is a novel approved modality for the treatment of glioblastoma (GBM) exhibiting a satisfactory effect. Although TTFields has shown considerable safety for the normal brain, dermatological adverse events (DAEs) often occur during therapy. However, studies focused on the identification and management of DAEs are rare. The clinical data and photos of skin lesions from 9 patients with GBM were retrospectively analyzed, and the types and grades of individual scalp dermatitis were evaluated based on the Common Terminology Criteria for Adverse Events version 5.0 (CTCAE v 5.0). Adherence and safety were also evaluated on the basis of the device monitoring data. Eight patients (88.9%) exhibited grade 1 or grade 2 CTCAE DAEs, all of whom were cured after interventions. The adherence was >90%, with no relevant safety events reported. Finally, a guideline for preventing DAEs in patients with GBM was proposed. The identification and management of TTFields-related DAEs is necessary and urgent in patients with GBM. Timely interventions of DAEs will help to improve the adherence and quality of life of patients, which ultimately improves prognosis. The proposed guideline for preventing DAEs in patients with GBM assists in the management of healthcare providers and may avoid dermatologic complications.
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Affiliation(s)
- Chao Yang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Qing Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Chao Ma
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yong Huang
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Hai-Xia Ding
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jun-Wei Lu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jie Wang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiang Li
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ya-Hua Zhong
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhi-Qiang Li
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
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15
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Zhou Y, Xing X, Zhou J, Jiang H, Cen P, Jin C, Zhong Y, Zhou R, Wang J, Tian M, Zhang H. Therapeutic potential of tumor treating fields for malignant brain tumors. Cancer Rep (Hoboken) 2023; 6:e1813. [PMID: 36987739 PMCID: PMC10172187 DOI: 10.1002/cnr2.1813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/02/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Malignant brain tumors are among the most threatening diseases of the central nervous system, and despite increasingly updated treatments, the prognosis has not been improved. Tumor treating fields (TTFields) are an emerging approach in cancer treatment using intermediate-frequency and low-intensity electric field and can lead to the development of novel therapeutic options. RECENT FINDINGS A series of biological processes induced by TTFields to exert anti-cancer effects have been identified. Recent studies have shown that TTFields can alter the bioelectrical state of macromolecules and organelles involved in cancer biology. Massive alterations in cancer cell proteomics and transcriptomics caused by TTFields were related to cell biological processes as well as multiple organelle structures and activities. This review addresses the mechanisms of TTFields and recent advances in the application of TTFields therapy in malignant brain tumors, especially in glioblastoma (GBM). CONCLUSIONS As a novel therapeutic strategy, TTFields have shown promising results in many clinical trials, especially in GBM, and continue to evolve. A growing number of patients with malignant brain tumors are being enrolled in ongoing clinical studies demonstrating that TTFields-based combination therapies can improve treatment outcomes.
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Affiliation(s)
- Youyou Zhou
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Xiaoqing Xing
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Jinyun Zhou
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Han Jiang
- Faculty of Science and Technology, Department of Electrical and Computer Engineering, Biomedical Imaging Laboratory (BIG), University of Macau, Taipa, Macau SAR, China
| | - Peili Cen
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Chentao Jin
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Yan Zhong
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Rui Zhou
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Jing Wang
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Mei Tian
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, Zhejiang, China
- Human Phenome Institute, Fudan University, Shanghai, China
| | - Hong Zhang
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, Zhejiang, China
- College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory for Biomedical Engineering of Ministry of Education, Zhejiang University, Hangzhou, Zhejiang, China
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16
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Szasz AM, Arrojo Alvarez EE, Fiorentini G, Herold M, Herold Z, Sarti D, Dank M. Meta-Analysis of Modulated Electro-Hyperthermia and Tumor Treating Fields in the Treatment of Glioblastomas. Cancers (Basel) 2023; 15:cancers15030880. [PMID: 36765840 PMCID: PMC9913117 DOI: 10.3390/cancers15030880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Glioblastoma is one of the most difficult to treat and most aggressive brain tumors, having a poor survival rate. The use of non-invasive modulated electro-hyperthermia (mEHT) and Tumor Treating Fields (TTF) devices has been introduced in the last few decades, both of which having proven anti-tumor effects. METHODS A meta-analysis of randomized and observational studies about mEHT and TTF was conducted. RESULTS A total of seven and fourteen studies about mEHT and TTF were included, with a total number of 450 and 1309 cases, respectively. A 42% [95% confidence interval (95% CI): 25-59%] 1-year survival rate was found for mEHT, which was raised to 61% (95% CI: 32-89%) if only the studies conducted after 2008 were investigated. In the case of TTF, 1-year survival was 67% (95% CI: 53-81%). Subgroup analyses revealed that newly diagnosed patients might get extra benefits from the early introduction of the devices (mEHT all studies: 73% vs. 37%, p = 0.0021; mEHT studies after 2008: 73% vs. 54%, p = 0.4214; TTF studies: 83% vs. 52%, p = 0.0083), compared with recurrent glioblastoma. CONCLUSIONS Our meta-analysis showed that both mEHT and TTF can improve glioblastoma survival, and the most benefit may be achieved in newly diagnosed cases.
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Affiliation(s)
- Attila Marcell Szasz
- Division of Oncology, Department of Internal Medicine and Oncology, Semmelweis University, 1083 Budapest, Hungary
- Correspondence: ; Tel.: +36-1-459-1500
| | - Elisabeth Estefanía Arrojo Alvarez
- Oncología Radioterápica, Servicios y Unidades Asistenciales, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain
- Medical Institute of Advanced Oncology, 28037 Madrid, Spain
| | - Giammaria Fiorentini
- Department of Oncology, Azienda Ospedaliera “Ospedali Riuniti Marche Nord”, 61121 Pesaro, Italy
- IHF Integrative Oncology Outpatient Clinic, 40121 Bologna, Italy
| | - Magdolna Herold
- Division of Oncology, Department of Internal Medicine and Oncology, Semmelweis University, 1083 Budapest, Hungary
- Department of Internal Medicine and Hematology, Semmelweis University, 1088 Budapest, Hungary
| | - Zoltan Herold
- Division of Oncology, Department of Internal Medicine and Oncology, Semmelweis University, 1083 Budapest, Hungary
| | - Donatella Sarti
- Department of Oncology, Azienda Ospedaliera “Ospedali Riuniti Marche Nord”, 61121 Pesaro, Italy
| | - Magdolna Dank
- Division of Oncology, Department of Internal Medicine and Oncology, Semmelweis University, 1083 Budapest, Hungary
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17
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Anadkat MJ, Lacouture M, Friedman A, Horne ZD, Jung J, Kaffenberger B, Kalmadi S, Ovington L, Kotecha R, Abdullah HI, Grosso F. Expert guidance on prophylaxis and treatment of dermatologic adverse events with Tumor Treating Fields (TTFields) therapy in the thoracic region. Front Oncol 2023; 12:975473. [PMID: 36703794 PMCID: PMC9873416 DOI: 10.3389/fonc.2022.975473] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/23/2022] [Indexed: 01/06/2023] Open
Abstract
Tumor Treating Fields (TTFields) are electric fields, delivered via wearable arrays placed on or near the tumor site, that exert physical forces to disrupt cellular processes critical for cancer cell viability and tumor progression. As a first-in-class treatment, TTFields therapy is approved for use in newly diagnosed glioblastoma, recurrent glioblastoma, and pleural mesothelioma. Additionally, TTFields therapy is being investigated in non-small cell lung cancer (NSCLC), brain metastases from NSCLC, pancreatic cancer, ovarian cancer, hepatocellular carcinoma, and gastric adenocarcinoma. Because TTFields therapy is well tolerated and delivery is locoregional, there is low risk of additive systemic adverse events (AEs) when used with other cancer treatment modalities. The most common AE associated with TTFields therapy is mild-to-moderate skin events, which can be treated with topical agents and may be managed without significant treatment interruptions. Currently, there are no guidelines for oncologists regarding the management of TTFields therapy-related skin AEs in the thoracic region, applicable for patients with pleural mesothelioma or NSCLC. This publication aims to provide guidance on preventing, minimizing, and managing dermatologic AEs in the thoracic region to help improve patient quality of life and reduce treatment interruptions that may impact outcomes with TTFields therapy.
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Affiliation(s)
- Milan J. Anadkat
- Division of Dermatology, Department of Medicine, Washington University, St. Louis, MO, United States,*Correspondence: Milan J. Anadkat,
| | - Mario Lacouture
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Adam Friedman
- Division of Dermatology, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Zachary D. Horne
- Department of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, United States
| | - Jae Jung
- Department of Dermatology, Norton Healthcare, Louisville, KY, United States
| | | | - Sujith Kalmadi
- Oncology and Haematology Department, Ironwood Cancer & Research Center, Chandler, AZ, United States
| | - Liza Ovington
- Ovington & Associates, Walnutport, PA, United States
| | - Rupesh Kotecha
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
| | | | - Federica Grosso
- Mesothelioma Unit, SS Antonio e Biagio General Hospital, Alessandria, Italy
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18
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Shams S, Patel CB. Anti-cancer mechanisms of action of therapeutic alternating electric fields (tumor treating fields [TTFields]). J Mol Cell Biol 2022; 14:mjac047. [PMID: 35973687 PMCID: PMC9912101 DOI: 10.1093/jmcb/mjac047] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 06/11/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
Despite improved survival outcomes across many cancer types, the prognosis remains grim for certain solid organ cancers including glioblastoma and pancreatic cancer. Invariably in these cancers, the control achieved by time-limited interventions such as traditional surgical resection, radiation therapy, and chemotherapy is short-lived. A new form of anti-cancer therapy called therapeutic alternating electric fields (AEFs) or tumor treating fields (TTFields) has been shown, either by itself or in combination with chemotherapy, to have anti-cancer effects that translate to improved survival outcomes in patients. Although the pre-clinical and clinical data are promising, the mechanisms of TTFields are not fully elucidated. Many investigations are underway to better understand how and why TTFields is able to selectively kill cancer cells and impede their proliferation. The purpose of this review is to summarize and discuss the reported mechanisms of action of TTFields from pre-clinical studies (both in vitro and in vivo). An improved understanding of how TTFields works will guide strategies focused on the timing and combination of TTFields with other therapies, to further improve survival outcomes in patients with solid organ cancers.
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Affiliation(s)
- Shadi Shams
- Rowan University School of Osteopathic Medicine, Stratford, NJ 08028, USA
| | - Chirag B Patel
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Neuroscience Graduate Program, The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX 77030, USA
- Cancer Biology Program, The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX 77030, USA
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19
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Concurrent chemoradiation and Tumor Treating Fields (TTFields, 200 kHz) for patients with newly diagnosed glioblastoma: patterns of progression in a single institution pilot study. J Neurooncol 2022; 160:345-350. [PMID: 36355259 DOI: 10.1007/s11060-022-04146-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/23/2022] [Indexed: 11/12/2022]
Abstract
Current standard of care for glioblastoma (GBM) includes concurrent chemoradiation and maintenance temozolomide (TMZ) with Tumor Treating Fields (TTFields). Preclinical studies suggest TTFields and radiation treatment have synergistic effects. We conducted a pilot clinical trial of concurrent chemoradiation with TTFields and report pattern of progression. MATERIALS AND METHODS This is a single arm pilot study (clinicaltrials.gov Identifier: NCT03477110). Adult patients (age ≥ 18 years) with KPS ≥ 60 with newly diagnosed GBM were eligible. All patients received concurrent scalp-sparing radiation (60 Gy in 30 fractions), standard concurrent TMZ and TTFields. Maintenance therapy included standard TMZ and continuation of TTFields. Radiation treatment was delivered through TTFields arrays. Incidence and location of progression was documented. Distant recurrence was defined as recurrence more than 2 cm from the primary enhancing lesion. RESULTS Thirty patients were enrolled on the trial. Twenty were male with median age 58 years (19-77 years). Median KPS was 90 (70-100). Median follow-up was 15.2 months (1.7-23.6 months). Ten (33.3%) patients had a methylated promoter status. Twenty-seven patients (90%) had progression, with median PFS of 9.3 months (range 8.5 to 11.6 months). Six patients presented with distant recurrence, with median distance from primary lesion of 5.05 cm (2.26-6.95 cm). One infratentorial progression was noted. CONCLUSIONS We observed improved local control using concurrent chemoradiation with TTFields for patients with newly diagnosed when compared to historical controls. Further data are needed to validate this finding. TRIAL REGISTRATION Clinicaltrials.gov Identifier NCT03477110.
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20
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Foo CY, Munir N, Kumaria A, Akhtar Q, Bullock CJ, Narayanan A, Fu RZ. Medical Device Advances in the Treatment of Glioblastoma. Cancers (Basel) 2022; 14:5341. [PMID: 36358762 PMCID: PMC9656148 DOI: 10.3390/cancers14215341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/19/2022] [Accepted: 10/26/2022] [Indexed: 07/30/2023] Open
Abstract
Despite decades of research and the growing emergence of new treatment modalities, Glioblastoma (GBM) frustratingly remains an incurable brain cancer with largely stagnant 5-year survival outcomes of around 5%. Historically, a significant challenge has been the effective delivery of anti-cancer treatment. This review aims to summarize key innovations in the field of medical devices, developed either to improve the delivery of existing treatments, for example that of chemo-radiotherapy, or provide novel treatments using devices, such as sonodynamic therapy, thermotherapy and electric field therapy. It will highlight current as well as emerging device technologies, non-invasive versus invasive approaches, and by doing so provide a detailed summary of evidence from clinical studies and trials undertaken to date. Potential limitations and current challenges are discussed whilst also highlighting the exciting potential of this developing field. It is hoped that this review will serve as a useful primer for clinicians, scientists, and engineers in the field, united by a shared goal to translate medical device innovations to help improve treatment outcomes for patients with this devastating disease.
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Affiliation(s)
- Cher Ying Foo
- Imperial College School of Medicine, Imperial College London, Fulham Palace Rd., London W6 8RF, UK
| | - Nimrah Munir
- QV Bioelectronics Ltd., 1F70 Mereside, Alderley Park, Nether Alderley, Cheshire SK10 4TG, UK
| | - Ashwin Kumaria
- Department of Neurosurgery, Queen’s Medical Centre, Nottingham University Hospitals, Nottingham NG7 2UH, UK
| | - Qasim Akhtar
- QV Bioelectronics Ltd., 1F70 Mereside, Alderley Park, Nether Alderley, Cheshire SK10 4TG, UK
| | - Christopher J. Bullock
- QV Bioelectronics Ltd., 1F70 Mereside, Alderley Park, Nether Alderley, Cheshire SK10 4TG, UK
| | - Ashwin Narayanan
- QV Bioelectronics Ltd., 1F70 Mereside, Alderley Park, Nether Alderley, Cheshire SK10 4TG, UK
| | - Richard Z. Fu
- QV Bioelectronics Ltd., 1F70 Mereside, Alderley Park, Nether Alderley, Cheshire SK10 4TG, UK
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Michael, Smith Building, Dover St., Manchester M13 9PT, UK
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Salford Royal, Stott Lane, Salford M6 8HD, UK
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Marcel EI, Ramdas GV, Chaurasia B. Letter to the Editor Regarding “Awake Craniotomy with Functional Mapping for Glioma Resection in a Limited-Resource-Setting: Preliminary Experience from a Lower-Middle Income Country”. World Neurosurg 2022; 164:463-464. [DOI: 10.1016/j.wneu.2022.04.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 11/28/2022]
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Tumor-Treating Fields in Glioblastomas: Past, Present, and Future. Cancers (Basel) 2022; 14:cancers14153669. [PMID: 35954334 PMCID: PMC9367615 DOI: 10.3390/cancers14153669] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 07/21/2022] [Accepted: 07/25/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Glioblastoma (GBM) is the most common malignant primary brain tumor. Although the standard of care, including maximal resection, concurrent radiotherapy with temozolomide (TMZ), and adjuvant TMZ, has largely improved the prognosis of these patients, the 5-year survival rate is still < 10%. Tumor-treating fields (TTFields), a noninvasive anticancer therapeutic modality, has been rising as a fourth treatment option for GBMs, as confirmed by recent milestone large-scale phase 3 randomized trials and subsequent real-world data, elongating patient overall survival from 16 months to 21 months. However, the mechanisms of antitumor efficacy, its clinical safety, and potential benefits when combined with other treatment modalities are far from completely elucidated. As an increasing number of studies have recently been published on this topic, we conducted this updated, comprehensive review to establish an objective understanding of the mechanism of action, efficacy, safety, clinical concerns, and future perspectives of TTFields. Abstract Tumor-treating fields (TTFields), a noninvasive and innovative therapeutic approach, has emerged as the fourth most effective treatment option for the management of glioblastomas (GBMs), the most deadly primary brain cancer. According to on recent milestone randomized trials and subsequent observational data, TTFields therapy leads to substantially prolonged patient survival and acceptable adverse events. Clinical trials are ongoing to further evaluate the safety and efficacy of TTFields in treating GBMs and its biological and radiological correlations. TTFields is administered by delivering low-intensity, intermediate-frequency, alternating electric fields to human GBM function through different mechanisms of action, including by disturbing cell mitosis, delaying DNA repair, enhancing autophagy, inhibiting cell metabolism and angiogenesis, and limiting cancer cell migration. The abilities of TTFields to strengthen intratumoral antitumor immunity, increase the permeability of the cell membrane and the blood–brain barrier, and disrupt DNA-damage-repair processes make it a promising therapy when combined with conventional treatment modalities. However, the overall acceptance of TTFields in real-world clinical practice is still low. Given that increasing studies on this promising topic have been published recently, we conducted this updated review on the past, present, and future of TTFields in GBMs.
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Krigers A, Pinggera D, Demetz M, Kornberger LM, Kerschbaumer J, Thomé C, Freyschlag CF. The Routine Application of Tumor-Treating Fields in the Treatment of Glioblastoma WHO° IV. Front Neurol 2022; 13:900377. [PMID: 35785334 PMCID: PMC9243748 DOI: 10.3389/fneur.2022.900377] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction:Tumor-treating fields (TTFs) are a specific local oncological treatment modality in glioblastoma multiforme WHO° IV (GBM). Their mechanism of action is based on the effect of electrical fields interfering with the mitotic activity of malignant cells. Prospective studies have demonstrated efficacy, but TTF benefits are still controversially discussed. This treatment was implemented in our center as the standard of care in January 2016. We thus discuss the current state of the art and our long-term experience in the routine application of TTF.MethodsThe data of 48 patients suffering from GBM and treated with TTF were assessed and compared with previously published studies. Up-to-date information from open sources was evaluated.ResultsA total of 31 males and 17 females harboring a GBM were treated with TTF, between January 2016 and August 2021, in our center. In 98% of cases, TTFs were started within 6 weeks after concomitant radiochemotherapy (Stupp protocol). Mean overall survival was 22.6 months (95% CI: 17.3–27.9). Current indications, benefits, and restrictions were evaluated. Future TTF opportunities and ongoing studies were reviewed.ConclusionTTFs are a feasible and routinely applicable specific oncological treatment option for glioblastoma multiforme WHO° IV. Further research is ongoing to extend the indications and the efficacy of TTF.
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Miller R, Song A, Ali A, Niazi M, Bar-Ad V, Martinez N, Glass J, Alnahhas I, Andrews D, Judy K, Evans J, Farrell C, Werner-Wasik M, Chervoneva I, Ly M, Palmer J, Liu H, Shi W. Scalp-Sparing Radiation With Concurrent Temozolomide and Tumor Treating Fields (SPARE) for Patients With Newly Diagnosed Glioblastoma. Front Oncol 2022; 12:896246. [PMID: 35574391 PMCID: PMC9106370 DOI: 10.3389/fonc.2022.896246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/06/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Standard-of-care treatment for patients with newly diagnosed glioblastoma (GBM) after surgery or biopsy includes concurrent chemoradiation followed by maintenance temozolomide (TMZ) with tumor treating fields (TTFields). Preclinical studies suggest TTFields and radiotherapy work synergistically. We report the results of our trial evaluating the safety of TTFields used concurrently with chemoradiation. Methods This is a single-arm pilot study (clinicaltrials.gov Identifier: NCT03477110). Adult patients (age ≥ 18 years) with newly diagnosed glioblastoma and a Karnofsky performance score (KPS) of ≥ 60 were eligible. All patients received concurrent scalp-sparing radiation (60 Gy in 30 fractions) with TMZ (75 mg/m2 daily) and TTFields (200 kHz). Maintenance therapy included TMZ and continuation of TTFields. Scalp-sparing radiation treatment was used to reduce radiation dermatitis. Radiation treatment was delivered through the TTFields arrays. The primary endpoint was safety and toxicity of tri-modality treatment within 30 days of completion of chemoradiation treatment. Results There were 30 patients enrolled, including 20 (66.7%) men and 10 (33.3%) women, with a median age of 58 years (range 19 to 77 years). Median KPS was 90 (range 70 to 100). A total of 12 (40%) patients received a gross total resection and 18 (60%) patients had a subtotal resection. A total of 12 (40%) patients had multifocal disease at presentation. There were 20 (66.7%) patients who had unmethylated O(6)-methylguanine-DNA-methyltransferase (MGMT) promotor status and 10 (33.3%) patients who had methylated MGMT promoter status. Median follow-up was 15.2 months (range 1.7 to 23.6 months). Skin adverse events were noted in 83.3% of patients, however, these were limited to Grade 1 or 2 events, which resolved spontaneously or with topical medications. The primary end point was met; no TTFields discontinuation occurred during the evaluation period due to high grade scalp toxicity. A total of 27 (90%) patients had progression, with a median progression-free survival (PFS) of 9.3 months (95% confidence interval (CI): 8.5-11.6 months). The 1-year progression-free survival was 23% (95% CI: 12%-45%). The median overall survival (OS) was 15.8 months (95% CI: 12.5 months-infinity). The 1-year overall survival was 66% (95% CI: 51%-86%). Conclusions Concurrent TTFields with scalp-sparing chemoradiation is a feasible and well-tolerated treatment option with limited toxicity. A phase 3, randomized clinical trial (EF-32, clinicaltrials.gov Identifier: NCT04471844) investigating the clinical benefit of concurrent TTFields with chemoradiation treatment is currently enrolling. Clinical Trial Registration Clinicaltrials.gov, identifier NCT03477110.
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Affiliation(s)
- Ryan Miller
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Andrew Song
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Ayesha Ali
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Muneeb Niazi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Voichita Bar-Ad
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Nina Martinez
- Department of Neuro-Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Jon Glass
- Department of Neuro-Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Iyad Alnahhas
- Department of Neuro-Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - David Andrews
- Department of Neuro-Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Kevin Judy
- Department of Neuro-Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - James Evans
- Department of Neuro-Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Christopher Farrell
- Department of Neuro-Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Maria Werner-Wasik
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Inna Chervoneva
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, United States
| | - Michele Ly
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Joshua Palmer
- Department of Radiation Oncology, The Ohio State University, Columbus, OH, United States
| | - Haisong Liu
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, United States
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Li R, Wang H, Liang Q, Chen L, Ren J. Radiotherapy for glioblastoma: clinical issues and nanotechnology strategies. Biomater Sci 2022; 10:892-908. [PMID: 34989724 DOI: 10.1039/d1bm01401c] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Glioblastoma multiforme (GBM) is the most common primary brain cancer in adults with poor prognosis. Despite the current state of knowledge on its genetic characteristics, relatively little progress has been made in improving the treatment of patients with this fatal disease. Radiotherapy (RT) has been identified as a crucial treatment for GBM following surgical resection to improve both local control and survival. Unfortunately, radiotherapy resistance is frequently observed in GBM patients, which is the major reason for the high mortality rate of cancer patients. Radioresistance of GBM is often multifactorial and heterogeneous, and associated with the recurrence of GBM after surgery. Nanotechnology has gained increasing attention and has already been investigated for optimization of radiosensitization due to the unique properties of nanobiomaterials, such as photoelectric decay characteristics or potential as carriers for drug delivery to the central nervous system. A large body of preclinical data has accumulated over the past several years, in which nanotechnology-based strategies exhibit promising potential to enhance the radiosensitivity of GBM, both in cellular and animal models. In this review, we summarize the mechanisms of GBM radioresistance, including tumor cell-intrinsic factors as well as tumor microenvironment (TME). We further discuss current nano-biotechnology-based radiosensitizer in the treatment of GBM, summarize the latest findings, highlight challenges, and put forward prospects for the future of nano-radiosensitizers. These data suggest that nanotechnology has the potential to address many of the clinical challenges and nanobiomaterials would become promising next-generation radiotherapy sensitizers for GBM treatment.
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Affiliation(s)
- Ruiqi Li
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan 430022, P. R. China.
| | - Haihong Wang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan 430022, P. R. China.
| | - Qing Liang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan 430022, P. R. China.
| | - Lian Chen
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan 430022, P. R. China.
| | - Jinghua Ren
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan 430022, P. R. China.
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Radiotherapy in Current Neuro-Oncology: There Is Still Much to Reveal. Life (Basel) 2021; 11:life11121412. [PMID: 34947942 PMCID: PMC8706956 DOI: 10.3390/life11121412] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/11/2021] [Accepted: 12/16/2021] [Indexed: 01/07/2023] Open
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Liang C, Gong J, Zhang B, Meng Z, Li M, Guo Y. Multiple subtentorial metastasis in diffuse midline glioma receiving tumor treating fields: a case report and literature review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1604. [PMID: 34790810 PMCID: PMC8576728 DOI: 10.21037/atm-21-4395] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/16/2021] [Indexed: 01/09/2023]
Abstract
Diffuse midline glioma (DMG) is one of fatal glioblastoma multiforme (GBM) with no proven medical therapies. Tumor treating fields (TTFields) is a new revolutionary therapy for GBM which prolongs the overall survival time obviously. However, we can observe more tumor growth phenomena (such as distant multiple metastases) than before. This report describes an adult patient who presented headache and dizziness, accompanied by left limb weakness, nausea, and vomiting following car accident trauma, following imaging examinations suggested thalamus GBM. He was treated with subtotal excision. Final pathology was diagnosed as DMG with H3F3A mutation, isocitrate dehydrogenase (IDH) wild type. Following concurrent chemoradiation therapy (CCRT) and adjuvant temozolomide (TMZ) chemotherapy + TTFields therapy were carried out. Supratentorial tumor has been exhibited a partial radiological response for nine months until TTFields was used irregularly or even discontinued in the later stage. Especially, subtentorial and spinal multiple metastasis occurred during this time. Both supratentorial and subtentorial tumors were treated with surgery, radiotherapy, chemotherapy, even targeted drugs, with the only difference being TTFields, but we could see different consequences for tumor growth. One conclusion might be drawn that TTFields can provide a longer survival time (14 vs. 8 months reported before) for DMG patients and improve survival benefits. However, we can observe that patients maybe die from subtentorial metastasis because TTFields could not cover the subtentorial tumors, which is the focal challenge at present. So further research on subtentorial tumors with TTFields is urgently needed.
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Affiliation(s)
- Chaofeng Liang
- Department of Neurosurgery, 3rd Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, China
| | - Jin Gong
- Department of Neurosurgery, 3rd Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, China
| | - Baoyu Zhang
- Department of Neurosurgery, 3rd Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, China
| | - Zhan'ao Meng
- Department of Radiology, 3rd Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, China
| | - Manting Li
- Department of Neurosurgery, 3rd Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, China
| | - Ying Guo
- Department of Neurosurgery, 3rd Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, China
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Biswas S, Kapitanova I, Divekar S, Grimm J, Butterwick IJ, Garren D, Kleinberg LR, Redmond KJ, Lacroix M, Mahadevan A, Forster KM. Targeting Accuracy Considerations for Simultaneous Tumor Treating Fields Antimitotic Therapy During Robotic Hypofractionated Radiation Therapy. Technol Cancer Res Treat 2021; 20:15330338211039135. [PMID: 34632866 PMCID: PMC8504228 DOI: 10.1177/15330338211039135] [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: 11/15/2022] Open
Abstract
Purpose: Tumor treating fields (TTFields) is a novel antimitotic treatment that was first proven effective for glioblastoma multiforme, now with trials for several extracranial indications underway. Several studies focused on concurrent TTFields therapy with radiation in the same time period, but were not given simultaneously. This study evaluates the targeting accuracy of simultaneous radiation therapy while TTFields arrays are in place and powered on, ensuring that radiation does not interfere with TTFields and TTFields does not interfere with radiation. This is one of several options to enable TTFields to begin several weeks sooner, and opens potential for synergistic effects of combined therapy. Methods: TTFields arrays were attached to a warm saline water bath and salt was added until the TTFields generator reached the maximal 2000 mA peak-to-peak current. A ball cube phantom containing 2 orthogonal films surrounded by fiducials was placed in the water phantom, CT scanned, and a radiation treatment plan with 58 isocentric beams was created using a 3 cm circular collimator. Fiducial tracking was used to deliver radiation, the films were scanned, and end-to-end targeting error was measured with vendor-supplied software. In addition, radiation effects on electric fields generated by the TTFields system were assessed by examining logfiles generated from the field generator. Results: With TTFields arrays in place and powered on, the robotic radiosurgery system achieved a final targeting result of 0.47 mm, which was well within the submillimeter specification. No discernible effects on TTFields current output beyond 0.3% were observed in the logfiles when the radiation beam pulsed on and off. Conclusion: A robotic radiosurgery system was used to verify that radiation targeting was not adversely affected when the TTFields arrays were in place and the TTFields delivery device was powered on. In addition, this study verified that radiation delivered simultaneously with TTFields did not interfere with the generation of the electric fields.
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Affiliation(s)
| | | | - Sabrina Divekar
- Sackler School of Medicine, 58408Tel Aviv University, New York, NY, USA
| | - Jimm Grimm
- 2780Geisinger Cancer Institute, Danville, PA, USA.,Thomas Jefferson University, Philadelphia, PA, USA
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Wang Z, Ren Y, Du F, Sun Y, Jiang W. Tumor treating fields combined with a poly (adenosine diphosphate-ribose) polymerase inhibitor during radiotherapy for rapidly progressing IDH-wildtype diffuse astrocytoma: a case report. J Int Med Res 2021; 49:3000605211036847. [PMID: 34407687 PMCID: PMC8381428 DOI: 10.1177/03000605211036847] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
A 57-year-old woman was diagnosed with IDH-wildtype (IDHwt) astrocytoma (World Health
Organization grade II) with the molecular characteristics of glioblastoma. She underwent
concurrent radiotherapy and chemotherapy according to the Stupp protocol in combination
with a multi-target antiangiogenic drug and additional intrathecal chemotherapy using
methotrexate. During treatment, the patient’s tumor showed rapid progression. The
chemotherapy with temozolomide was stopped and replaced with radiotherapy combined with
tumor treating fields (TTF), the poly (adenosine diphosphate-ribose) polymerase (PARP)
inhibitor niraparib, and anlotinib. After the radiotherapy was completed, the symptoms of
increased intracranial pressure and epilepsy were well controlled. Considering the
patient’s tolerance to the treatment, the combined therapy of TTF and anlotinib was
continued, and osimertinib, a third-generation epidermal growth factor receptor–tyrosine
kinase inhibitor with good permeability of the blood–brain barrier, was added. The patient
was regularly followed up and had no obvious adverse drug reactions. Head magnetic
resonance imaging (plain scan + enhanced scan) suggested that the lesions were stable. For
rapidly progressing glioblastomas or histological grade II/III IDHwt astrocytomas, the
combination of TTF and a PARP inhibitor during radiotherapy may have a synergistic effect
on tumor control and is well tolerated by patients.
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Affiliation(s)
- Zheng Wang
- Department of Oncology Radiotherapy, 117918Tianjin Huanhu Hospital, Tianjin Huanhu Hospital, Tianjin, China
| | - Yi Ren
- Department of Oncology Radiotherapy, 117918Tianjin Huanhu Hospital, Tianjin Huanhu Hospital, Tianjin, China
| | - Fangfang Du
- Department of Oncology Radiotherapy, 117918Tianjin Huanhu Hospital, Tianjin Huanhu Hospital, Tianjin, China
| | - Yafang Sun
- Department of Oncology Radiotherapy, 117918Tianjin Huanhu Hospital, Tianjin Huanhu Hospital, Tianjin, China
| | - Wei Jiang
- Department of Oncology Radiotherapy, 117918Tianjin Huanhu Hospital, Tianjin Huanhu Hospital, Tianjin, China
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Regev O, Merkin V, Blumenthal DT, Melamed I, Kaisman-Elbaz T. Tumor-Treating Fields for the treatment of glioblastoma: a systematic review and meta-analysis. Neurooncol Pract 2021; 8:426-440. [PMID: 34277021 PMCID: PMC8278345 DOI: 10.1093/nop/npab026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Tumor-Treating Fields (TTFields) is an emerging treatment modality for glioblastoma (GBM). Studies have shown a good safety profile alongside improved efficacy in newly diagnosed GBM (ndGBM), while a less clear effect was shown for recurrent GBM (rGBM). Despite regulatory support, sectors of the neuro-oncology community have been reluctant to accept it as part of the standard treatment protocol. To establish an objective understanding of TTFields' mechanism of action, safety, efficacy, and economical implications, we conducted a systematic literature review and meta-analysis. METHODS A systematic search was conducted in PubMed, Scopus, and Cochrane databases. Twenty studies met the pre-defined inclusion criteria, incorporating 1636 patients (542 ndGBM and 1094 rGBM), and 11 558 patients (6403 ndGBM and 5155 rGBM) analyzed for the clinical outcomes and safety endpoints, respectively. RESULTS This study demonstrated improved clinical efficacy and a good safety profile of TTFields. For ndGBM, pooled median overall survival (OS) and progression-free survival (PFS) were 21.7 (95%CI = 19.6-23.8) and 7.2 (95%CI = 6.1-8.2) months, respectively. For rGBM, pooled median OS and PFS were 10.3 (95%CI = 8.3-12.8) and 5.7 (95%CI = 2.8-10) months, respectively. Compliance of ≥75% was associated with an improved OS and the predominant adverse events were dermatologic, with a pooled prevalence of 38.4% (95%CI = 32.3-44.9). Preclinical studies demonstrated TTFields' diverse molecular mechanism of action, its potential synergistic efficacy, and suggest possible benefits for certain populations. CONCLUSIONS This study supports the use of TTFields for GBM, alongside the standard-of-care treatment protocol, and provides a practical summary, discussing the current clinical and preclinical aspects of the treatment and their implication on the disease course.
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Affiliation(s)
- Ohad Regev
- Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Be’er-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er-Sheva, Israel
| | - Vladimir Merkin
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er-Sheva, Israel
- Department of Neurosurgery, Soroka University Medical Center, Be’er-Sheva, Israel
| | - Deborah T Blumenthal
- Neuro-Oncology Service, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Israel Melamed
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er-Sheva, Israel
- Department of Neurosurgery, Soroka University Medical Center, Be’er-Sheva, Israel
| | - Tehila Kaisman-Elbaz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er-Sheva, Israel
- Department of Neurosurgery, Soroka University Medical Center, Be’er-Sheva, Israel
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Liu S, Shi W, Zhao Q, Zheng Z, Liu Z, Meng L, Dong L, Jiang X. Progress and prospect in tumor treating fields treatment of glioblastoma. Biomed Pharmacother 2021; 141:111810. [PMID: 34214730 DOI: 10.1016/j.biopha.2021.111810] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/28/2021] [Accepted: 06/07/2021] [Indexed: 12/19/2022] Open
Abstract
Glioblastoma (GBM) is a challenging cancer with poor prognosis. The classical standard for treatment is safe resection, followed by concurrent chemoradiotherapy with subsequent adjuvant temozolomide (TMZ). Despite several attempts at different treatments, the 5-year survival rate remains poor. In recent years, with the continuous progress of treatment technology, tumor treating fields (TTFields) were preferable. The device could generate an intermediate frequency alternating electric field and induce apoptosis of some specific types of cancer cells with few toxic and side effects. TTFields induced apoptosis through multiple activations of the pathway. TTFields have been Food and Drug Administration (FDA)-approved for diagnosis and recurrent GBM as additional clinical trial results are revealed. This study reviewed the current status, mechanisms, correlations with immune pathways, the prospects of applying TTFields for GBM, and the adverse events.
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Affiliation(s)
- Shiyu Liu
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
| | - Weiyan Shi
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
| | - Qin Zhao
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
| | - Zhuangzhuang Zheng
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
| | - Zijing Liu
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
| | - Lingbin Meng
- Department of Hematology and Medical Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Lihua Dong
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China.
| | - Xin Jiang
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China.
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Gatson NTN, Barnholtz-Sloan J, Drappatz J, Henriksson R, Hottinger AF, Hinoul P, Kruchko C, Puduvalli VK, Tran DD, Wong ET, Glas M. Tumor Treating Fields for Glioblastoma Therapy During the COVID-19 Pandemic. Front Oncol 2021; 11:679702. [PMID: 34026655 PMCID: PMC8139188 DOI: 10.3389/fonc.2021.679702] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/12/2021] [Indexed: 12/22/2022] Open
Abstract
Background The COVID-19 pandemic has placed excessive strain on health care systems and is especially evident in treatment decision-making for cancer patients. Glioblastoma (GBM) patients are among the most vulnerable due to increased incidence in the elderly and the short survival time. A virtual meeting was convened on May 9, 2020 with a panel of neuro-oncology experts with experience using Tumor Treating Fields (TTFields). The objective was to assess the risk-to-benefit ratio and provide guidance for using TTFields in GBM during the COVID-19 pandemic. Panel Discussion Topics discussed included support and delivery of TTFields during the COVID-19 pandemic, concomitant use of TTFields with chemotherapy, and any potential impact of TTFields on the immune system in an intrinsically immunosuppressed GBM population. Special consideration was given to TTFields' use in elderly patients and in combination with radiotherapy regimens. Finally, the panel discussed the need to better capture data on COVID-19positive brain tumor patients to analyze longitudinal outcomes and changes in treatment decision-making during the pandemic. Expert Opinion TTFields is a portable home-use device which can be managed via telemedicine and safely used in GBM patients during the COVID-19 pandemic. TTFields has no known immunosuppressive effects which is important during a crisis where other treatment methods might be limited, especially for elderly patients with multiple co-morbidities. It is too early to estimate the full impact of COVID-19 on the global healthcare system and on patient outcomes and the panel strongly recommended collaboration with existing cancer COVID-19 registries to follow CNS tumor patients.
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Affiliation(s)
- Na Tosha N Gatson
- Division of Neuro-Oncology, Department of Neurology, Geisinger Health, Neuroscience & Cancer Institutes, Danville, PA & Geisinger Commonwealth School of Medicine, Scranton, PA, United States.,Neuro-Oncology, Banner MD Anderson Cancer Center, Phoenix, AZ, United States
| | - Jill Barnholtz-Sloan
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine & Research and Education, University Hospitals of Cleveland, Cleveland, OH, United States
| | - Jan Drappatz
- Hillman Cancer Center, Department of Medicine and Neurology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Roger Henriksson
- Department of Radiation Sciences & Oncology at the University of Ume, Ume, Sweden
| | - Andreas F Hottinger
- Departments of Clinical Neurosciences & Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Piet Hinoul
- Global Medical Affairs, Novocure Inc., New York, NY, United States
| | - Carol Kruchko
- Central Brain Tumor Registry of the United States (CBTRUS), Hinsdale, IL, United States
| | - Vinay K Puduvalli
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - David D Tran
- Lillian S. Wells Department of Neurosurgery and Preston A. Wells, Jr. Brain Tumor Center at the McKnight Brain Institute of the University of Florida College of Medicine, Gainesville, FL, United States
| | - Eric T Wong
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Martin Glas
- Division of Clinical Neurooncology, Department of Neurology and German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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Wang M, Zhang C, Wang X, Yu H, Zhang H, Xu J, Zhao J, Jiang X. Tumor-treating fields (TTFields)-based cocktail therapy: a novel blueprint for glioblastoma treatment. Am J Cancer Res 2021; 11:1069-1086. [PMID: 33948346 PMCID: PMC8085847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 02/22/2021] [Indexed: 06/12/2023] Open
Abstract
Glioblastoma is one of the most common malignant tumors in the central nervous system. Due to the high plasticity, heterogeneity and complexity of the tumor microenvironment, these tumors are resistant to almost all therapeutic strategies when they reach an advanced stage. Along with being a unique and effective way to kill cancer cells, tumor-treating fields (TTFields) has emerged as a breakthrough among glioblastoma therapies since the advent of temozolomide (TMZ), and the combination of these treatments has gradually been promoted and applied in the clinic. The combination of TTFields with other therapies is particularly suitable for this type of "cold" tumors and has attracted a large amount of attention from clinicians and researchers in the era of cancer cocktail therapy. Here, we introduced the current treatment regimen for glioblastoma, highlighting the unique advantages of TTFields in the treatment of glioblastoma. Then, we summarized current glioblastoma clinical trials that combine TTFields and other therapies. In addition, the main and potential mechanisms of TTFields were introduced to further understand the rationale for each combination therapy. Finally, we focused on the most advanced technologies applied in glioblastoma research and treatment and the prospect of their combination with TTFields. This review provides a unique overview of glioblastoma treatment.
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Affiliation(s)
- Minjie Wang
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan 430022, China
| | - Chaocai Zhang
- Department of Neurosurgery, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical UniversityHaikou 570311, China
| | - Xuan Wang
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan 430022, China
| | - Hao Yu
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan 430022, China
| | - Hemei Zhang
- Department of Neurosurgery, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical UniversityHaikou 570311, China
| | - Junnv Xu
- Department of Medical Oncology, The Second Affiliated Hospital of Hainan Medical UniversityHaikou 570311, China
| | - Jiannong Zhao
- Department of Neurosurgery, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical UniversityHaikou 570311, China
| | - Xiaobing Jiang
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan 430022, China
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Nguyen HM, Guz-Montgomery K, Lowe DB, Saha D. Pathogenetic Features and Current Management of Glioblastoma. Cancers (Basel) 2021; 13:cancers13040856. [PMID: 33670551 PMCID: PMC7922739 DOI: 10.3390/cancers13040856] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/09/2021] [Accepted: 02/16/2021] [Indexed: 02/06/2023] Open
Abstract
Glioblastoma (GBM) is the most common form of primary malignant brain tumor with a devastatingly poor prognosis. The disease does not discriminate, affecting adults and children of both sexes, and has an average overall survival of 12-15 months, despite advances in diagnosis and rigorous treatment with chemotherapy, radiation therapy, and surgical resection. In addition, most survivors will eventually experience tumor recurrence that only imparts survival of a few months. GBM is highly heterogenous, invasive, vascularized, and almost always inaccessible for treatment. Based on all these outstanding obstacles, there have been tremendous efforts to develop alternative treatment options that allow for more efficient targeting of the tumor including small molecule drugs and immunotherapies. A number of other strategies in development include therapies based on nanoparticles, light, extracellular vesicles, and micro-RNA, and vessel co-option. Advances in these potential approaches shed a promising outlook on the future of GBM treatment. In this review, we briefly discuss the current understanding of adult GBM's pathogenetic features that promote treatment resistance. We also outline novel and promising targeted agents currently under development for GBM patients during the last few years with their current clinical status.
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Alamsyah F, Pratiwi R, Firdausi N, Irene Mesak Pello J, Evi Dwi Nugraheni S, Ghitha Fadhlurrahman A, Nurhidayat L, Purwo Taruno W. Cytotoxic T cells response with decreased CD4/CD8 ratio during mammary tumors inhibition in rats induced by non-contact electric fields. F1000Res 2021; 10:35. [PMID: 34164110 PMCID: PMC8142601 DOI: 10.12688/f1000research.27952.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/24/2020] [Indexed: 04/03/2024] Open
Abstract
Background: Breast cancer is the most common cancer in women worldwide and is the leading cause of death in women with cancer. One novel therapy used for breast cancer treatment is non-contact electric fields called electro-capacitive cancer therapy (ECCT) with intermediate frequency (100 kHz) and low intensity (18 Vpp). The objective of this study was to examine the effect of ECCT on mammary tumors growth in rats and observing the immune responses that play a role in fighting the tumor. Methods: Female SD rats were used and divided into four groups, namely control (NINT), placebo (NIT), non- therapy (INT), and therapy (IT) groups with 6 biological replicates in each group. Rats in INT and IT groups were treated with 7,12-dimethylbenz[a]anthracene for mammary tumor induction. Only rats in NIT and IT groups were exposed to ECCT individually for 10 hours per day for 21 days. The size of all tumors was measured with a digital caliper. The distributions of PCNA, ErbB2, caspase-3, CD68, CD4 and CD8-positive cells were observed with immunohistochemistry and scoring with ImageJ. Results: The growth rate of mammary tumors in IT group was significantly lower (p<0.05) than that in the INT group. The number of mitotic figures and the percentage of PCNA, caspase-3, and CD68- positive cells in IT group were significantly lower (p<0.05) than those in INT group. Conversely, the percentage of CD8-positive T cells in IT group was significantly higher (p<0.05) than that in INT group. Moreover, the CD4/CD8 ratio in IT group was decreased. Some tumor tissues were blackened and detached from the surrounding tissue, resulting in an open wound which then healed up upon exposure. Conclusions: Non-contact electric fields exposure showed inhibition on mammary tumor growth in rats while inducing CD8+ T cells that lead to tumor cells death and potentially helps wound healing.
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Affiliation(s)
- Firman Alamsyah
- Center for Medical Physics and Cancer Research, Ctech Labs Edwar Technology, Tangerang, Banten, 15143, Indonesia
| | - Rarastoeti Pratiwi
- Faculty of Biology, Universitas Gadjah Mada, Sleman, DI Yogyakarta, 55281, Indonesia
| | - Nisrina Firdausi
- Faculty of Biology, Universitas Gadjah Mada, Sleman, DI Yogyakarta, 55281, Indonesia
| | | | | | | | - Luthfi Nurhidayat
- Faculty of Biology, Universitas Gadjah Mada, Sleman, DI Yogyakarta, 55281, Indonesia
| | - Warsito Purwo Taruno
- Center for Medical Physics and Cancer Research, Ctech Labs Edwar Technology, Tangerang, Banten, 15143, Indonesia
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36
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Alamsyah F, Pratiwi R, Firdausi N, Irene Mesak Pello J, Evi Dwi Nugraheni S, Ghitha Fadhlurrahman A, Nurhidayat L, Purwo Taruno W. Cytotoxic T cells response with decreased CD4/CD8 ratio during mammary tumors inhibition in rats induced by non-contact electric fields. F1000Res 2021; 10:35. [PMID: 34164110 PMCID: PMC8142601 DOI: 10.12688/f1000research.27952.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Breast cancer is the most common cancer in women worldwide and is the leading cause of death amongst women with cancer. One novel therapy used for breast cancer treatment constitutes non-contact electric fields and is called electro-capacitive cancer therapy (ECCT) with intermediate frequency and low intensity. The objective of this study was to examine the effect of ECCT on mammary tumors growth in rats and observing the immune responses that play a role in fighting the tumor. Methods: Female SD rats were used and divided into four groups, namely control (NINT), placebo (NIT), non- therapy (INT), and therapy (IT) groups with 6 biological replicates in each group. Rats in INT and IT groups were treated with 7,12-dimethylbenz[a]anthracene for mammary tumor induction. Only rats in NIT and IT groups were exposed to ECCT individually for 10 hours per day for 21 days. The size of all tumors was measured with a digital caliper. The distributions of PCNA, ErbB2, caspase-3, CD68, CD4, and CD8-positive cells were observed with immunohistochemistry and scoring with ImageJ. Results: The growth rate of mammary tumors in IT group was significantly lower (p<0.05) than that in INT group. The number of mitotic figures and the percentage of PCNA, caspase-3, and CD68-positive cells in IT group were significantly lower (p<0.05) than those in INT group. Conversely, the percentage of CD8-positive T cells in IT group was significantly higher (p<0.05) than that in INT group. Moreover, the CD4/CD8 ratio in IT group was found to have decreased. Some tumor tissues were blackened and detached from the surrounding tissue, resulting in an open wound which then healed upon exposure. Conclusions: Non-contact electric fields exposure showed inhibition on mammary tumor growth in rats while inducing CD8+ T cells, leading to tumor cell death and potentially helping wounds heal.
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Affiliation(s)
- Firman Alamsyah
- Center for Medical Physics and Cancer Research, Ctech Labs Edwar Technology, Tangerang, Banten, 15143, Indonesia
| | - Rarastoeti Pratiwi
- Faculty of Biology, Universitas Gadjah Mada, Sleman, DI Yogyakarta, 55281, Indonesia
| | - Nisrina Firdausi
- Faculty of Biology, Universitas Gadjah Mada, Sleman, DI Yogyakarta, 55281, Indonesia
| | | | | | | | - Luthfi Nurhidayat
- Faculty of Biology, Universitas Gadjah Mada, Sleman, DI Yogyakarta, 55281, Indonesia
| | - Warsito Purwo Taruno
- Center for Medical Physics and Cancer Research, Ctech Labs Edwar Technology, Tangerang, Banten, 15143, Indonesia
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Nour Y, Pöttgen C, Kebir S, Lazaridis L, Lüdemann L, Guberina M, Gauler T, Scheffler B, Jabbarli R, Pierscianek D, Sure U, Schmidt T, Oster C, Hau P, Glas M, Lübcke W, Stuschke M, Guberina N. Dosimetric impact of the positioning variation of tumor treating field electrodes in the PriCoTTF-phase I/II trial. J Appl Clin Med Phys 2021; 22:242-250. [PMID: 33389825 PMCID: PMC7856507 DOI: 10.1002/acm2.13144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/06/2020] [Accepted: 12/04/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose The aim of the present study based on the PriCoTTF‐phase I/II trial is the quantification of skin‐normal tissue complication probabilities of patients with newly diagnosed glioblastoma multiforme treated with Tumor Treating Field (TTField) electrodes, concurrent radiotherapy, and temozolomide. Furthermore, the skin‐sparing effect by the clinically applied strategy of repetitive transducer array fixation around their center position shall be examined. Material and Methods Low‐dose cone‐beam computed tomography (CBCT) scans of all fractions of the first seven patients of the PriCoTTF‐phase I/II trial, used for image guidance, were applied for the dosimetric analysis, for precise TTField transducer array positioning and contour delineation. Within this trial, array positioning was varied from fixation‐to‐fixation period with a standard deviation of 1.1 cm in the direction of the largest variation of positioning and 0.7 cm in the perpendicular direction. Physical TTField electrode composition was examined and a respective Hounsfield Unit attributed to the TTField electrodes. Dose distributions in the planning CT with TTField electrodes in place, as derived from prefraction CBCTs, were calculated and accumulated with the algorithm Acuros XB. Dose‐volume histograms were obtained for the first and second 2 mm scalp layer with and without migrating electrodes and compared with those with fixed electrodes in an average position. Skin toxicity was quantified according to Lyman's model. Minimum doses in hot‐spots of 0.05 cm2 and 25 cm2 (ΔD0.05cm2, ΔD25cm2) size in the superficial skin layers were analyzed. Results Normal tissue complication probabilities (NTCPs) for skin necrosis ranged from 0.005% to 1.474% (median 0.111%) for the different patients without electrodes. NTCP logarithms were significantly dependent on patient (P < 0.0001) and scenario (P < 0.0001) as classification variables. Fixed positioning of TTField arrays increased skin‐NTCP by a factor of 5.50 (95%, CI: 3.66–8.27). The variation of array positioning increased skin‐NTCP by a factor of only 3.54 (95%, CI: 2.36–5.32) (P < 0.0001, comparison to irradiation without electrodes; P = 0.036, comparison to irradiation with fixed electrodes). NTCP showed a significant rank correlation with D25cm2 over all patients and scenarios (rs = 0.76; P < 0.0001). Conclusion Skin‐NTCP calculation uncovers significant interpatient heterogeneity and may be used to stratify patients into high‐ and low‐risk groups of skin toxicity. Array position variation may mitigate about one‐third of the increase in surface dose and skin‐NTCP by the TTField electrodes.
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Affiliation(s)
- Youness Nour
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Christoph Pöttgen
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Sied Kebir
- Division of Clinical Neurooncology, Department of Neurology and West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Lazaros Lazaridis
- Division of Clinical Neurooncology, Department of Neurology and West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Lutz Lüdemann
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Maja Guberina
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Thomas Gauler
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Björn Scheffler
- DKFZ-Division Translational Neurooncology at the West German Cancer Centre (WTZ), German Cancer Consortium (DKTK), Partner Site University Hospital Essen, University of Duisburg, Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Ulrich Sure
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Germany.,Department of Neurosurgery, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Teresa Schmidt
- Division of Clinical Neurooncology, Department of Neurology and West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Christoph Oster
- Division of Clinical Neurooncology, Department of Neurology and West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Peter Hau
- Department of Neurology and Wilhelm Sander-NeuroOncology Unit, Regensburg University Hospital, Germany
| | - Martin Glas
- Division of Clinical Neurooncology, Department of Neurology and West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Germany
| | - Wolfgang Lübcke
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Martin Stuschke
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Germany
| | - Nika Guberina
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg, Essen, Germany
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