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Gershon R, Polevikov A, Karepov Y, Shenkar A, Ben-Horin I, Alter Regev T, Dror-Levinsky M, Lipczyc K, Gasri-Plotnitsky L, Diamant G, Shapira N, Bensimhon B, Hagai A, Shahar T, Grossman R, Ram Z, Volovitz I. Frequencies of 4 tumor-infiltrating lymphocytes potently predict survival in glioblastoma, an immune desert. Neuro Oncol 2024; 26:473-487. [PMID: 37870293 PMCID: PMC10912003 DOI: 10.1093/neuonc/noad204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND GBM is an aggressive grade 4 primary brain tumor (BT), with a 5%-13% 5-year survival. Most human GBMs manifest as immunologically "cold" tumors or "immune deserts," yet the promoting or suppressive roles of specific lymphocytes within the GBM tumor microenvironment (TME) is of considerable debate. METHODS We used meticulous multiparametric flow cytometry (FC) to determine the lymphocytic frequencies in 102 GBMs, lower-grade gliomas, brain metastases, and nontumorous brain specimen. FC-attained frequencies were compared with frequencies estimated by "digital cytometry." The FC-derived data were combined with the patients' demographic, clinical, molecular, histopathological, radiological, and survival data. RESULTS Comparison of FC-derived data to CIBERSORT-estimated data revealed the poor capacity of digital cytometry to estimate cell frequencies below 0.2%, the frequency range of most immune cells in BTs. Isocitrate dehydrogenase (IDH) mutation status was found to affect TME composition more than the gliomas' pathological grade. Combining FC and survival data disclosed that unlike other cancer types, the frequency of helper T cells (Th) and cytotoxic T lymphocytes (CTL) correlated negatively with glioma survival. In contrast, the frequencies of γδ-T cells and CD56bright natural killer cells correlated positively with survival. A composite parameter combining the frequencies of these 4 tumoral lymphocytes separated the survival curves of GBM patients with a median difference of 10 months (FC-derived data; P < .0001, discovery cohort), or 4.1 months (CIBERSORT-estimated data; P = .01, validation cohort). CONCLUSIONS The frequencies of 4 TME lymphocytes strongly correlate with the survival of patients with GBM, a tumor considered an immune desert.
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Affiliation(s)
- Rotem Gershon
- The Cancer Immunotherapy Laboratory, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Antonina Polevikov
- The Cancer Immunotherapy Laboratory, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Yevgeny Karepov
- Neurosurgery Department, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Anatoly Shenkar
- The Cancer Immunotherapy Laboratory, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Idan Ben-Horin
- The Cancer Immunotherapy Laboratory, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Oncology Department, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Tal Alter Regev
- The Cancer Immunotherapy Laboratory, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Meytal Dror-Levinsky
- The Cancer Immunotherapy Laboratory, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Kelly Lipczyc
- The Cancer Immunotherapy Laboratory, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Lital Gasri-Plotnitsky
- The Cancer Immunotherapy Laboratory, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Gil Diamant
- The Cancer Immunotherapy Laboratory, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Neurosurgery Department, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Nati Shapira
- The Cancer Immunotherapy Laboratory, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Neurosurgery Department, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Barak Bensimhon
- The Cancer Immunotherapy Laboratory, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Aharon Hagai
- The Cancer Immunotherapy Laboratory, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Tal Shahar
- Neurosurgery Department, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Rachel Grossman
- Neurosurgery Department, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Zvi Ram
- Neurosurgery Department, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Ilan Volovitz
- The Cancer Immunotherapy Laboratory, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Neurosurgery Department, The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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2
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Bos EM, Binda E, Verploegh ISC, Wembacher E, Hoefnagel D, Balvers RK, Korporaal AL, Conidi A, Warnert EAH, Trivieri N, Visioli A, Zaccarini P, Caiola L, van Wijck R, van der Spek P, Huylebroeck D, Leenstra S, Lamfers MLM, Ram Z, Westphal M, Noske D, Legnani F, DiMeco F, Vescovi AL, Dirven CMF. Local delivery of hrBMP4 as an anticancer therapy in patients with recurrent glioblastoma: a first-in-human phase 1 dose escalation trial. Mol Cancer 2023; 22:129. [PMID: 37563568 PMCID: PMC10413694 DOI: 10.1186/s12943-023-01835-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/31/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND This Phase 1 study evaluates the intra- and peritumoral administration by convection enhanced delivery (CED) of human recombinant Bone Morphogenetic Protein 4 (hrBMP4) - an inhibitory regulator of cancer stem cells (CSCs) - in recurrent glioblastoma. METHODS In a 3 + 3 dose escalation design, over four to six days, fifteen recurrent glioblastoma patients received, by CED, one of five doses of hrBMP4 ranging from 0·5 to 18 mg. Patients were followed by periodic physical, neurological, blood testing, magnetic resonance imaging (MRI) and quality of life evaluations. The primary objective of this first-in-human study was to determine the safety, dose-limiting toxicities (DLT) and maximum tolerated dose (MTD) of hrBMP4. Secondary objectives were to assess potential efficacy and systemic exposure to hrBMP4 upon intracerebral infusion. RESULTS Intra- and peritumoral infusion of hrBMP4 was safe and well-tolerated. We observed no serious adverse events related to this drug. Neither MTD nor DLT were reached. Three patients had increased hrBMP4 serum levels at the end of infusion, which normalized within 4 weeks, without sign of toxicity. One patient showed partial response and two patients a complete (local) tumor response, which was maintained until the most recent follow-up, 57 and 30 months post-hrBMP4. Tumor growth was inhibited in areas permeated by hrBMP4. CONCLUSION Local delivery of hrBMP4 in and around recurring glioblastoma is safe and well-tolerated. Three patients responded to the treatment. A complete response and long-term survival occurred in two of them. This warrants further clinical studies on this novel treatment targeting glioblastoma CSCs. TRIAL REGISTRATION ClinicaTrials.gov identifier: NCT02869243.
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Affiliation(s)
- Eelke M Bos
- Department of Neurosurgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Elena Binda
- Unit of Cancer Stem Cells, ISBReMIT, IRCCS CasaSollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - Iris S C Verploegh
- Department of Neurosurgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Cell Biology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Daphna Hoefnagel
- Department of Neurosurgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rutger K Balvers
- Department of Neurosurgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anne L Korporaal
- Department of Cell Biology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Andrea Conidi
- Department of Cell Biology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Esther A H Warnert
- Department of Radiology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nadia Trivieri
- Unit of Cancer Stem Cells, ISBReMIT, IRCCS CasaSollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | | | | | - Laura Caiola
- StemGen SpA, Milan, Italy
- HyperStem SA, Lugano, Switzerland
| | - Rogier van Wijck
- Department of Clinical Bioinformatics, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Peter van der Spek
- Department of Clinical Bioinformatics, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Danny Huylebroeck
- Department of Cell Biology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sieger Leenstra
- Department of Neurosurgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Martine L M Lamfers
- Department of Neurosurgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Manfred Westphal
- Department of Neurosurgery, University Clinic Hamburg-Eppendorf, Hamburg, Germany
| | - David Noske
- Department of Neurosurgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Federico Legnani
- Department of Neurosurgery, National Neurologic Institute IRCCS C. Besta, Milan, Italy
| | - Francesco DiMeco
- Department of Neurosurgery, National Neurologic Institute IRCCS C. Besta, Milan, Italy
| | - Angelo Luigi Vescovi
- Unit of Cancer Stem Cells, ISBReMIT, IRCCS CasaSollievo della Sofferenza, San Giovanni Rotondo (FG), Italy.
- Department of Biotechnology and Biosciences, University of Milano-Bicocca, Milan, Italy.
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
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Paradossi G, Grossman R, Riccitelli F, Todaro F, Ram Z, Schioppa S, Domenici F. Toward a theranostic device for gliomas. Biochem Biophys Res Commun 2023; 671:124-131. [PMID: 37300942 DOI: 10.1016/j.bbrc.2023.05.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND In the surgical management of glioblastoma, a highly aggressive and incurable type of brain cancer, identification and treatment of residual tissue is the most common site of disease recurrence. Monitoring and localized treatment are achieved with engineered microbubbles (MBs) by combining ultrasound and fluorescence imaging with actively targeted temozolomide (TMZ) delivery. METHODS The MBs were conjugated with a near-infrared fluorescence probe CF790, cyclic pentapeptide bearing the RGD sequence and a carboxyl-temozolomide, TMZA. The efficiency of adhesion to HUVEC cells was assessed in vitro in realistic physiological conditions of shear rate and vascular dimensions. Cytotoxicity of TMZA-loaded MBs on U87 MG cells and IC50 were assessed by MTT tests. RESULTS We report on the design of injectable poly(vinyl alcohol) echogenic MBs designed as a platform with active targeting ability to tumor tissues, by tethering on the surface a ligand having the tripeptide sequence, RGD. The biorecognition of RGD-MBs onto HUVEC cells is quantitatively proved. Efficient NIR emission from the CF790-decorated MBs was successfully detected. The conjugation on the MBs surface of a specific drug as TMZ is achieved. The pharmacological activity of the coupled-to-surface drug is preserved by controlling the reaction conditions. CONCLUSIONS We present an improved formulation of PVA-MBs to achieve a multifunctional device with adhesion ability, cytotoxicity on glioblastoma cells and supporting imaging.
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Affiliation(s)
- Gaio Paradossi
- Department of Chemical Sciences and Technologies, University of Rome "Tor Vergata", 00133, Rome, Italy.
| | - Rachel Grossman
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Francesco Riccitelli
- Department of Chemical Sciences and Technologies, University of Rome "Tor Vergata", 00133, Rome, Italy
| | - Federica Todaro
- Department of Chemical Sciences and Technologies, University of Rome "Tor Vergata", 00133, Rome, Italy
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Sara Schioppa
- Department of Chemical Sciences and Technologies, University of Rome "Tor Vergata", 00133, Rome, Italy
| | - Fabio Domenici
- Department of Chemical Sciences and Technologies, University of Rome "Tor Vergata", 00133, Rome, Italy
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Ofek P, Yeini E, Arad G, Danilevsky A, Pozzi S, Luna CB, Dangoor SI, Grossman R, Ram Z, Shomron N, Brem H, Hyde TM, Geiger T, Satchi-Fainaro R. Deoxyhypusine hydroxylase: A novel therapeutic target differentially expressed in short-term vs long-term survivors of glioblastoma. Int J Cancer 2023. [PMID: 37141410 DOI: 10.1002/ijc.34545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 02/13/2023] [Accepted: 03/10/2023] [Indexed: 05/06/2023]
Abstract
Glioblastoma (GB) is the most aggressive neoplasm of the brain. Poor prognosis is mainly attributed to tumor heterogeneity, invasiveness and drug resistance. Only a small fraction of GB patients survives longer than 24 months from the time of diagnosis (ie, long-term survivors [LTS]). In our study, we aimed to identify molecular markers associated with favorable GB prognosis as a basis to develop therapeutic applications to improve patients' outcome. We have recently assembled a proteogenomic dataset of 87 GB clinical samples of varying survival rates. Following RNA-seq and mass spectrometry (MS)-based proteomics analysis, we identified several differentially expressed genes and proteins, including some known cancer-related pathways and some less established that showed higher expression in short-term (<6 months) survivors (STS) compared to LTS. One such target found was deoxyhypusine hydroxylase (DOHH), which is known to be involved in the biosynthesis of hypusine, an unusual amino acid essential for the function of the eukaryotic translation initiation factor 5A (eIF5A), which promotes tumor growth. We consequently validated DOHH overexpression in STS samples by quantitative polymerase chain reaction (qPCR) and immunohistochemistry. We further showed robust inhibition of proliferation, migration and invasion of GB cells following silencing of DOHH with short hairpin RNA (shRNA) or inhibition of its activity with small molecules, ciclopirox and deferiprone. Moreover, DOHH silencing led to significant inhibition of tumor progression and prolonged survival in GB mouse models. Searching for a potential mechanism by which DOHH promotes tumor aggressiveness, we found that it supports the transition of GB cells to a more invasive phenotype via epithelial-mesenchymal transition (EMT)-related pathways.
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Affiliation(s)
- Paula Ofek
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eilam Yeini
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gali Arad
- Department of Molecular Genetics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Artem Danilevsky
- Department of Cell and Developmental Biology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Edmond J Safra Center for Bioinformatics, Tel Aviv University, Tel Aviv, Israel
| | - Sabina Pozzi
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Christian Burgos Luna
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sahar Israeli Dangoor
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rachel Grossman
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Noam Shomron
- Department of Cell and Developmental Biology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Edmond J Safra Center for Bioinformatics, Tel Aviv University, Tel Aviv, Israel
- Sagol School of Neurosciences, Tel Aviv University, Tel Aviv, Israel
| | - Henry Brem
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas M Hyde
- Lieber Institute for Brain Development, Johns Hopkins Medical Campus, Baltimore, Maryland, USA
- Department of Psychiatry & Behavioral Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tamar Geiger
- Department of Molecular Genetics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Satchi-Fainaro
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sagol School of Neurosciences, Tel Aviv University, Tel Aviv, Israel
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Haim O, Agur A, Efrat OT, Valdes P, Ram Z, Grossman R. The clinical significance of radiological changes associated with gliadel implantation in patients with recurrent high grade glioma. Sci Rep 2023; 13:11. [PMID: 36593342 PMCID: PMC9807577 DOI: 10.1038/s41598-022-27128-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 12/26/2022] [Indexed: 01/04/2023] Open
Abstract
Gliadel occasionally induces edema following its implantation. We aimed to correlate such post-surgical radiological changes to its efficacy and subsequent survival. Fifty-six patients with recurrent high grade glioma were treated between 2005 and 2016 with Gliadel implantation. Volumetric measurements of MRI features, including FLAIR abnormalities, tumor bulk (volume of gadolinium enhancement on T1) and resection cavity volumes over time were conducted. To assess dynamics over time, linear regression trendlines for each of these were calculated and examined to correlate with survival. Median follow-up after resection was 21.5 months. Median survival post-Gliadel implantation and overall survival since diagnosis were 12 months and 22 months, respectively. A subgroup of patients (n = 6) with a transient increase in FLAIR changes volume over time survived significantly longer post-Gliadel compared to those who did not demonstrate such change (36 vs 12 months, p = .03). Positive trends, representing overall growth in volume over time, of tumor bulk and resection cavity predicted survival in multivariate analyses (hazard ratios 7.9 and 84, p = .003 and .002, respectively). Increase in tumor bulk and resection cavity over time were associated with decreased survival, while transient FLAIR increase was a favorable prognostic factor. This may represent a transient inflammatory process in the tumor, possibly stemming from a presumed immune-mediated anti-tumor response.
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Affiliation(s)
- Oz Haim
- grid.12136.370000 0004 1937 0546Department of Neurosurgery, Tel-Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, 6423906 Tel-Aviv, Israel
| | - Ariel Agur
- grid.12136.370000 0004 1937 0546Department of Neurosurgery, Tel-Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, 6423906 Tel-Aviv, Israel
| | - Or-Tal Efrat
- grid.12136.370000 0004 1937 0546Department of Neurosurgery, Tel-Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, 6423906 Tel-Aviv, Israel
| | - Pablo Valdes
- grid.12136.370000 0004 1937 0546Department of Neurosurgery, Tel-Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, 6423906 Tel-Aviv, Israel
| | - Zvi Ram
- grid.12136.370000 0004 1937 0546Department of Neurosurgery, Tel-Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, 6423906 Tel-Aviv, Israel
| | - Rachel Grossman
- grid.12136.370000 0004 1937 0546Department of Neurosurgery, Tel-Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, 6423906 Tel-Aviv, Israel
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Zhu JJ, Goldlust SA, Kleinberg LR, Honnorat J, Oberheim Bush NA, Ram Z. Tumor Treating Fields (TTFields) therapy vs physicians' choice standard-of-care treatment in patients with recurrent glioblastoma: a post-approval registry study (EF-19). Discov Oncol 2022; 13:105. [PMID: 36239858 PMCID: PMC9568629 DOI: 10.1007/s12672-022-00555-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/08/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Tumor Treating Fields (TTFields) therapy, a noninvasive, anti-mitotic treatment modality, is approved for recurrent glioblastoma (rGBM) and newly diagnosed GBM based on phase III, EF-11 (NCT00379470) and EF-14 (NCT00916409) studies, respectively. The EF-19 study aimed to evaluate efficacy and safety of TTFields monotherapy (200 kHz) vs physicians' choice standard of care (PC-SOC; EF-11 historical control group) in rGBM. METHODS A prospective, post-marketing registry study of adults with supratentorial rGBM treated with TTFields therapy was conducted. Primary endpoint was overall survival (OS; intent-to-treat [ITT] population) and secondary endpoint was OS per-protocol (PP). Subgroup and toxicity analyses were conducted. RESULTS Median OS (ITT population) was comparable with TTFields monotherapy vs PC-SOC (7.4 vs 6.4 months, log-rank test P = 0.053; Cox test hazard ratio [HR] [95% CI], 0.66 [0.47-0.92], P = 0.016). The upper-bound HR (95% CI) was lower than pre-defined noninferiority (1.375 threshold). In the PP population, median OS was significantly longer for TTFields monotherapy vs PC-SOC (8.1 vs 6.4 months; log-rank test P = 0.017; Cox test HR [95% CI], 0.60 [0.42-0.85], P = 0.004). TTFields therapy showed increased benefit with extended use (≥ 18 h/day [averaged over 28 days]). TTFields therapy-related adverse events (AEs) by body system were lower vs PC-SOC: mainly mild-to-moderate skin AEs. CONCLUSION In the real-world setting, TTFields monotherapy showed comparable (ITT population) and superior (PP population) OS vs PC-SOC in rGBM. In line with previous results, TTFields therapy showed a favorable safety profile vs chemotherapy, without new safety signals/systemic effects. TRIAL REGISTRATION NCT01756729, registered December 20, 2012.
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Affiliation(s)
- Jay-Jiguang Zhu
- University of Texas Health Science Center in Houston (UTHealth)/Memorial Hermann Hospital at Texas Medical Center, 6400 Fannin St., Suite 2800, Houston, TX, 77030, USA.
| | | | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jérôme Honnorat
- Department of Neuro-Oncology, Hôpital Neurologique, Hospices Civils de Lyon, SynatAc Team, MELIS Institute, INSERM U1314/CNRS UMR5284, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- Department of Neuro-Oncology, East Group Hospital, Hospices Civils de Lyon, Lyon Cedex, France
| | - Nancy Ann Oberheim Bush
- Department of Neurological Surgery and Neurology, University of California, San Francisco, CA, USA
| | - Zvi Ram
- Tel Aviv Medical Center, Tel Aviv University School of Medicine, Tel Aviv, Israel
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7
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Berger A, Tzarfati GG, Serafimova M, Valdes P, Meller A, Korn A, Levy NK, Aviram D, Ram Z, Grossman R. Clinical and prognostic implications of rim restriction following glioma surgery. Sci Rep 2022; 12:12874. [PMID: 35896589 PMCID: PMC9329326 DOI: 10.1038/s41598-022-16717-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/14/2022] [Indexed: 11/17/2022] Open
Abstract
Rim restriction surrounding the resection cavity of glioma is often seen on immediate post-op diffusion-weighted imaging (DWI). The etiology and clinical impact of rim restriction are unknown. We evaluated the incidence, risk factors and clinical consequences of this finding. We evaluated patients that underwent surgery for low-grade glioma (LGG) and glioblastoma (GBM) without stroke on post-operative imaging. Analyses encompassed pre- and postoperative clinical, radiological, intraoperative monitoring, survival, functional and neurocognitive outcomes. Between 2013 and 2017, 63 LGG and 209 GBM patients (272 in total) underwent surgical resection and were included in our cohort. Post-op rim restriction was demonstrated in 68 patients, 32% (n = 20) of LGG and 23% (n = 48) of GBM patients. Risk factors for restriction included temporal tumors in GBM (p = 0.025) and insular tumors in LGG (p = 0.09), including longer surgery duration in LGG (p = 0.008). After a 1-year follow-up, LGG patients operated on their dominant with post-op restriction had a higher rate of speech deficits (46 vs 9%, p = 0.004). Rim restriction on postoperative imaging is associated with longer duration of glioma surgery and potentially linked to brain retraction. It apparently has no direct clinical consequences, but is linked to higher rates of speech deficits in LGG dominant-side surgeries.
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Affiliation(s)
- Assaf Berger
- Department of Neurosurgery, Tel Aviv Medical Center, 6 Weizmann St., Tel Aviv, 6423906, Israel. .,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel. .,Center for Advanced Radiosurgery, NYU Langone Medical Center, New York University, 530 First Avenue, New York, NY, 10016, USA.
| | | | - Marga Serafimova
- Department of Neurosurgery, Tel Aviv Medical Center, 6 Weizmann St., Tel Aviv, 6423906, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Pablo Valdes
- Department of Neurosurgery, Tel Aviv Medical Center, 6 Weizmann St., Tel Aviv, 6423906, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Aaron Meller
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Akiva Korn
- Department of Neurosurgery, Tel Aviv Medical Center, 6 Weizmann St., Tel Aviv, 6423906, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Naomi Kahana Levy
- Department of Neurosurgery, Tel Aviv Medical Center, 6 Weizmann St., Tel Aviv, 6423906, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Daniel Aviram
- Division of Anesthesiology, Tel-Aviv University, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center, 6 Weizmann St., Tel Aviv, 6423906, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Rachel Grossman
- Department of Neurosurgery, Tel Aviv Medical Center, 6 Weizmann St., Tel Aviv, 6423906, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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8
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Carmel Neiderman NN, Wengier A, Dominsky O, Ringel B, Warshavsky A, Horowitz G, Baran TZ, Ram Z, Grossman R, Fliss DM, Avraham A. A Prospective Evaluation of Quality of Life in Patients Undergoing Extended Endoscopic Endonasal Surgery for Benign Pituitary Gland Lesion. Skull Base Surg 2022; 83:e386-e394. [DOI: 10.1055/s-0041-1730322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
Abstract
Introduction Endoscopic endonasal surgery (EES) has become the preferred approach for pituitary tumor resection. Nevertheless, research on quality of life related to pituitary adenoma surgery is scarce.
Objective The aim of the study is to evaluate short-term quality of life in patients after endoscopic endonasal resection of pituitary tumors and to find predictors for poor quality of life (QOL) outcome.
Materials and Methods A prospective cohort study was conducted, including all patients who underwent EES for pituitary tumors in a tertiary medical referral center. Recruited patients completed the Anterior Skull Base Disease-Specific QOL (ASBS-Q) questionnaire and the Sinonasal Outcome Test 22 (SNOT-22) questionnaire before surgery, 2 and 4 to 6 months after surgery. Demographic and clinical data was collected.
Results Our study included 49 patients. The overall ASBS-Q scores significantly improved 4 to 6 months after surgery (4.46 vs. 4.2, p < 0.05). We found a significant improvement in QOL related to emotional state 2 months post surgery (4.41 vs. 3.87, p < 0.05), which became borderline significant 4 to 6 months post surgery. There was a significant improvement in pain (4.5 vs. 4.08, p < 0.05) and vitality (4.43 vs. 4.16, p < 0.05) domains 4 to 6 months post surgery. SNOT-22 scores did not change significantly postoperatively. Factors such as secreting and non-secreting tumors, tumor size, intraoperative cerebrospinal fluid leak, gross tumor resection, endocrine remission, and the use of nasoseptal flap reconstruction did not have a significant effect on QOL.
Conclusion We found that patients after EES reported improved QOL 4 to 6 months post surgery. Specific improvement was noted in the QOL related to pain and vitality.
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Affiliation(s)
- Narin Nard Carmel Neiderman
- Department of Otolaryngology, Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Anat Wengier
- Department of Otolaryngology, Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Omri Dominsky
- Department of Otolaryngology, Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Barak Ringel
- Department of Otolaryngology, Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Anton Warshavsky
- Department of Otolaryngology, Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Gilad Horowitz
- Department of Otolaryngology, Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Tomer Ziv Baran
- Department of Epidemiology, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Rachel Grossman
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Dan Marian Fliss
- Department of Otolaryngology, Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Abergel Avraham
- Department of Otolaryngology, Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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9
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Ram Z, Kim CY, Hottinger AF, Idbaih A, Nicholas G, Zhu JJ. Corrigendum: Efficacy and Safety of Tumor Treating Fields (TTFields) in Elderly Patients With Newly Diagnosed Glioblastoma: Subgroup Analysis of the Phase 3 EF-14 Clinical Trial. Front Oncol 2022; 12:902929. [PMID: 35494031 PMCID: PMC9040518 DOI: 10.3389/fonc.2022.902929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 03/25/2022] [Indexed: 12/02/2022] Open
Affiliation(s)
- Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center and Tel Aviv University School of Medicine, Tel Aviv, Israel
- *Correspondence: Zvi Ram,
| | - Chae-Yong Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Andreas F. Hottinger
- Department of Clinical Neuroscience, CHUV Lausanne University Hospital & University of Lausanne, Lausanne, Switzerland
| | - Ahmed Idbaih
- Service de Neurologie 2-Mazarin, Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau, ICM, AP-HP, Hôpitaux Universitaires La Pitié Salpêtrière—Charles Foix, Service de Neurologie 2-Mazarin, Paris, France
| | - Garth Nicholas
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jay-Jiguang Zhu
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, United States
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10
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Glas M, Ballo MT, Bomzon Z, Urman N, Levi S, Lavy-Shahaf G, Jeyapalan S, Sio TT, DeRose PM, Misch M, Taillibert S, Ram Z, Hottinger AF, Easaw J, Kim CY, Mohan S, Stupp R. The Impact of Tumor Treating Fields on Glioblastoma Progression Patterns. Int J Radiat Oncol Biol Phys 2021; 112:1269-1278. [PMID: 34963556 DOI: 10.1016/j.ijrobp.2021.12.152] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 12/06/2021] [Accepted: 12/15/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Tumor-treating fields (TTFields) is an antimitotic treatment modality that interferes with glioblastoma cell division and organelle assembly by delivering low-intensity alternating electric fields to the tumor. A previous analysis from the pivotal EF-14 trial demonstrated a clear correlation between TTFields dose-density at the tumor bed and survival in patients treated with TTFields. This study tests the hypothesis that the antimitotic effects of TTFields result in measurable changes in the location and patterns of progression of newly diagnosed glioblastoma (nGBM) patients. METHODS MRI images of 428 nGBM patients that participated in the pivotal EF-14 trial were reviewed and the rates at which distant progression occurred in the TTFields treatment and control arm were compared. Realistic head models of 252 TTFields treated patients were created and TTFields intensity distributions were calculated using a Finite Elements Method. TTFields dose was calculated within regions of the tumor bed and normal brain and its relationship with progression determined. RESULTS Distant progression was frequently observed in the TTFields-treated arm, and distant lesions in the TTFields-treated arm appeared at larger distances from the primary lesion than in the control arm. Distant progression correlated with improved clinical outcome in the TTFields patients, with no such correlation observed in the controls. Areas of normal brain that remained normal were exposed to higher TTFields doses compared to normal brain that subsequently exhibited neoplastic progression. Additionally, the average dose to areas of enhancing tumor that returned to normal was significantly higher than in the areas of normal brain that progressed to enhancing tumor. CONCLUSIONS There was a direct correlation between TTFields dose distribution and tumor response, confirming the therapeutic activity of TTFields and the rationale for optimizing array placement to maximize TTFields dose in areas at highest risk of progression, as well as array layout adaptation after progression.
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Affiliation(s)
- Martin Glas
- Division of Clinical Neurooncology, Dept. of Neurology and German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Matthew T Ballo
- Department of Radiation Oncology, West Cancer Center & Research Institute, Memphis, TN.
| | | | | | | | | | | | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - Paul M DeRose
- Department of Radiation Oncology, Methodist Dallas Medical Center, Dallas, TX
| | - Martin Misch
- Department of Neurosurgery, University Hospital Charité, Berlin, Germany
| | - Sophie Taillibert
- Department of Neurology, Hôpital Pitié-Salpêtrière, APHP, University Pierre et Marie Curie Paris VI, Paris, France
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel and Tel Aviv University School of Medicine
| | - Andreas F Hottinger
- Departments of Clinical Neurosciences and Oncology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | - Chae-Yong Kim
- Seoul National University Bundang Hospital, Seoul National University College of Medicine, Korea
| | - Suyash Mohan
- Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Roger Stupp
- Lou and Jean Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Departments of Neurological Surgery, Neurology and Medicine (Hem/Onc), Northwestern Medicine, Chicago, IL
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11
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Ram Z, Kim CY, Hottinger AF, Idbaih A, Nicholas G, Zhu JJ. Efficacy and Safety of Tumor Treating Fields (TTFields) in Elderly Patients with Newly Diagnosed Glioblastoma: Subgroup Analysis of the Phase 3 EF-14 Clinical Trial. Front Oncol 2021; 11:671972. [PMID: 34692470 PMCID: PMC8526342 DOI: 10.3389/fonc.2021.671972] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 08/31/2021] [Indexed: 01/05/2023] Open
Abstract
Background Understudied elderly patients comprise a large segment of high-risk patients with glioblastoma (GBM) that are challenging to treat. Tumor Treating Fields (TTFields) is a locoregional, noninvasive, antimitotic therapy delivering low-intensity, intermediate-frequency alternating electric fields to the tumor. In the phase 3 EF-14 clinical trial, TTFields (200 kHz) improved median progression-free survival (PFS) and median overall survival (OS) in patients with newly diagnosed GBM (ndGBM) when added concomitantly to maintenance temozolomide (TMZ). This EF-14 subgroup analysis evaluated the safety and efficacy of TTFields in elderly patients. Methods All 134 patients who are ≥65 years of age were included (TTFields/TMZ combination, n=89; TMZ monotherapy, n=45; 2:1 ratio of randomization). PFS and OS were analyzed using Kaplan-Meier methodology (α=0.05). Health-related quality-of-life (HRQoL) was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) quality-of-life questionnaire QLQ-C30 supplemented with the brain tumor module (QLQ-BN20). Adverse events (AEs) were evaluated using Common Terminology Criteria for AEs (CTCAE) v4.0. Results The PFS was 6.5 months in patients randomized to the treatment group with TTFields/TMZ combination versus 3.9 months in patients treated with TMZ monotherapy (HR, 0.47; 95% CI, 0.30-0.74; P=0.0236). The OS was 17.4 months in patients treated with TTFields/TMZ combination versus 13.7 months in patients treated with TMZ monotherapy (HR, 0.51; 95% CI, 0.33-0.77; P=0.0204). Annual survival rates with TTFields/TMZ versus TMZ monotherapy were 39% (95% CI, 29-50%) versus 27% (95% CI, 15-41%; P=0.072) at 2 years, 19% (95% CI, 11-29%) versus 11% (95% CI, 4-23%; P=0.135) at 3 years, and 15% (95% CI, 7-25%) versus 0% at 5 years, respectively. There were no significant differences between groups in the preselected items of HRQoL assessment. Grade ≥3 systemic AEs were 46% in the TTFields/TMZ group versus 40% in the TMZ monotherapy group, without statistically significant difference between the two groups. The only TTFields-related AEs were reversible scalp skin reactions, with grades 1-2 and grade 3 skin reactions reported by 51% and 2% of patients, respectively. Conclusions Combining TTFields with maintenance TMZ significantly improved PFS and OS in elderly patients with ndGBM in the phase 3 EF-14 clinical trial, without significant increases in systemic toxicity or negatively affecting patient HRQoL. TTFields-related skin AEs were low-grade and manageable. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT00916409, identifier: NCT00916409.
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Affiliation(s)
- Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center and Tel Aviv University School of Medicine, Tel Aviv, Israel
| | - Chae-Yong Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Andreas F Hottinger
- Department of Clinical Neuroscience, CHUV Lausanne University Hospital & University of Lausanne, Lausanne, Switzerland
| | - Ahmed Idbaih
- Service de Neurologie 2-Mazarin, Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau, ICM, AP-HP, Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, Service de Neurologie 2-Mazarin, Paris, France
| | - Garth Nicholas
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jay-Jiguang Zhu
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, United States
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12
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Neufeld L, Yeini E, Reisman N, Shtilerman Y, Ben-Shushan D, Pozzi S, Madi A, Tiram G, Eldar-Boock A, Ferber S, Grossman R, Ram Z, Satchi-Fainaro R. Microengineered perfusable 3D-bioprinted glioblastoma model for in vivo mimicry of tumor microenvironment. Sci Adv 2021; 7:eabi9119. [PMID: 34407932 PMCID: PMC8373143 DOI: 10.1126/sciadv.abi9119] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/28/2021] [Indexed: 05/04/2023]
Abstract
Many drugs show promising results in laboratory research but eventually fail clinical trials. We hypothesize that one main reason for this translational gap is that current cancer models are inadequate. Most models lack the tumor-stroma interactions, which are essential for proper representation of cancer complexed biology. Therefore, we recapitulated the tumor heterogenic microenvironment by creating fibrin glioblastoma bioink consisting of patient-derived glioblastoma cells, astrocytes, and microglia. In addition, perfusable blood vessels were created using a sacrificial bioink coated with brain pericytes and endothelial cells. We observed similar growth curves, drug response, and genetic signature of glioblastoma cells grown in our 3D-bioink platform and in orthotopic cancer mouse models as opposed to 2D culture on rigid plastic plates. Our 3D-bioprinted model could be the basis for potentially replacing cell cultures and animal models as a powerful platform for rapid, reproducible, and robust target discovery; personalized therapy screening; and drug development.
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Affiliation(s)
- Lena Neufeld
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Eilam Yeini
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Noa Reisman
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Yael Shtilerman
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Dikla Ben-Shushan
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Sabina Pozzi
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Asaf Madi
- Department of Pathology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Galia Tiram
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Anat Eldar-Boock
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Shiran Ferber
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Rachel Grossman
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ronit Satchi-Fainaro
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel.
- Sagol School of Neurosciences, Tel Aviv University, Tel Aviv 69978, Israel
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13
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Diamant G, Simchony Goldman H, Gasri Plotnitsky L, Roitman M, Shiloach T, Globerson-Levin A, Eshhar Z, Haim O, Pencovich N, Grossman R, Ram Z, Volovitz I. T Cells Retain Pivotal Antitumoral Functions under Tumor-Treating Electric Fields. J Immunol 2021; 207:709-719. [PMID: 34215656 DOI: 10.4049/jimmunol.2100100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/28/2021] [Indexed: 11/19/2022]
Abstract
Tumor-treating fields (TTFields) are a localized, antitumoral therapy using alternating electric fields, which impair cell proliferation. Combining TTFields with tumor immunotherapy constitutes a rational approach; however, it is currently unknown whether TTFields' locoregional effects are compatible with T cell functionality. Healthy donor PBMCs and viably dissociated human glioblastoma samples were cultured under either standard or TTFields conditions. Select pivotal T cell functions were measured by multiparametric flow cytometry. Cytotoxicity was evaluated using a chimeric Ag receptor (CAR)-T-based assay. Glioblastoma patient samples were acquired before and after standard chemoradiation or standard chemoradiation + TTFields treatment and examined by immunohistochemistry and by RNA sequencing. TTFields reduced the viability of proliferating T cells, but had little or no effect on the viability of nonproliferating T cells. The functionality of T cells cultured under TTFields was retained: they exhibited similar IFN-γ secretion, cytotoxic degranulation, and PD1 upregulation as controls with similar polyfunctional patterns. Glioblastoma Ag-specific T cells exhibited unaltered viability and functionality under TTFields. CAR-T cells cultured under TTFields exhibited similar cytotoxicity as controls toward their CAR target. Transcriptomic analysis of patients' glioblastoma samples revealed a significant shift in the TTFields-treated versus the standard-treated samples, from a protumoral to an antitumoral immune signature. Immunohistochemistry of samples before and after TTFields treatment showed no reduction in T cell infiltration. T cells were found to retain key antitumoral functions under TTFields settings. Our data provide a mechanistic insight and a rationale for ongoing and future clinical trials that combine TTFields with immunotherapy.
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Affiliation(s)
- Gil Diamant
- The Cancer Immunotherapy Laboratory, Neurosurgery Department, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Israel.,Neurosurgery Department, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; and
| | - Hadar Simchony Goldman
- The Cancer Immunotherapy Laboratory, Neurosurgery Department, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Israel
| | - Lital Gasri Plotnitsky
- The Cancer Immunotherapy Laboratory, Neurosurgery Department, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Israel
| | - Marina Roitman
- The Cancer Immunotherapy Laboratory, Neurosurgery Department, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Israel
| | - Tamar Shiloach
- Laboratory for Cancer Research and Immunotherapy, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anat Globerson-Levin
- Laboratory for Cancer Research and Immunotherapy, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zelig Eshhar
- Laboratory for Cancer Research and Immunotherapy, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Oz Haim
- Neurosurgery Department, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; and
| | - Niv Pencovich
- Neurosurgery Department, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; and
| | - Rachel Grossman
- Neurosurgery Department, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; and
| | - Zvi Ram
- Neurosurgery Department, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; and
| | - Ilan Volovitz
- The Cancer Immunotherapy Laboratory, Neurosurgery Department, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Israel; .,Neurosurgery Department, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; and
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14
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Yeini E, Ofek P, Pozzi S, Albeck N, Ben-Shushan D, Tiram G, Golan S, Kleiner R, Sheinin R, Reich-Zeliger S, Grossman R, Ram Z, Brem H, Hyde T, Magod P, Friedmann-Morvinski D, Madi A, Satchi-Fainaro R. Abstract 2716: P-selectin axis plays a key role in microglia immunophenotype and glioblastoma progression. Cancer Res 2021. [DOI: 10.1158/1538-7445.am2021-2716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Glioblastoma (GB) is an aggressive type of brain cancer with high mortality rate. It is a highly angiogenic tumor exhibiting an extremely invasive nature. As such, its brain microenvironment plays a crucial role in its progression. Microglia are the brain resident immune cells which have been shown to facilitate GB cell invasion and immune suppression. The mechanism by which GB cells alter microglia behavior is yet to be fully understood. One proposed mechanism involves adhesion molecules such as the Selectins family of proteins which are expressed on the surface of endothelial and immune cells and are involved in immune modulation and cancer immunity. We have previously shown that P-Selectin (SELP) is expressed by GB cells. Here, we investigated the factional role of SELP in GB-microglia interactions. First, we found that microglia cells facilitate the expression and secretion of SELP by GB cells, and that GB cells facilitate the expression of P-Selectin ligand by microglia. We then showed that SELP mediates microglia-enhanced GB invasion and proliferation in 2D and 3D in vitro models and has a role in microglia activation state. These findings were validated in vivo, showing that inhibition or downregulation of SELP leads to reduced tumor growth, increased overall survival and improved immune response. Single-Cells RNA-seq analysis of the tumors revealed an increase in pro-inflammatory microglia signature, reduction in cancer cell tumorigenesis potential and improved T cell activation. Our results indicated that SELP has an important role in GB progression and microenvironment activation. This work can improve our understanding of tumor-associated microglia function and the mechanisms by which GB cells suppress the immune system and invade the brain tissue.
Citation Format: Eilam Yeini, Paula Ofek, Sabina Pozzi, Nitzan Albeck, Dikla Ben-Shushan, Galia Tiram, Sapir Golan, Ron Kleiner, Ron Sheinin, Shlomit Reich-Zeliger, Rachel Grossman, Zvi Ram, Henry Brem, Thomas Hyde, Prerna Magod, Dinorah Friedmann-Morvinski, Asaf Madi, Ronit Satchi-Fainaro. P-selectin axis plays a key role in microglia immunophenotype and glioblastoma progression [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2716.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Zvi Ram
- 3Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Henry Brem
- 4Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Thomas Hyde
- 4Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Asaf Madi
- 1Tel-Aviv University, Tel Aviv, Israel
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15
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Yeini E, Ofek P, Pozzi S, Albeck N, Ben-Shushan D, Tiram G, Golan S, Kleiner R, Sheinin R, Israeli Dangoor S, Reich-Zeliger S, Grossman R, Ram Z, Brem H, Hyde TM, Magod P, Friedmann-Morvinski D, Madi A, Satchi-Fainaro R. P-selectin axis plays a key role in microglia immunophenotype and glioblastoma progression. Nat Commun 2021; 12:1912. [PMID: 33771989 PMCID: PMC7997963 DOI: 10.1038/s41467-021-22186-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 03/01/2021] [Indexed: 02/06/2023] Open
Abstract
Glioblastoma (GB) is a highly invasive type of brain cancer exhibiting poor prognosis. As such, its microenvironment plays a crucial role in its progression. Among the brain stromal cells, the microglia were shown to facilitate GB invasion and immunosuppression. However, the reciprocal mechanisms by which GB cells alter microglia/macrophages behavior are not fully understood. We propose that these mechanisms involve adhesion molecules such as the Selectins family. These proteins are involved in immune modulation and cancer immunity. We show that P-selectin mediates microglia-enhanced GB proliferation and invasion by altering microglia/macrophages activation state. We demonstrate these findings by pharmacological and molecular inhibition of P-selectin which leads to reduced tumor growth and increased survival in GB mouse models. Our work sheds light on tumor-associated microglia/macrophage function and the mechanisms by which GB cells suppress the immune system and invade the brain, paving the way to exploit P-selectin as a target for GB therapy.
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Affiliation(s)
- Eilam Yeini
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Paula Ofek
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sabina Pozzi
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nitzan Albeck
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sagol School of Neurosciences, Tel Aviv University, Tel Aviv, Israel
| | - Dikla Ben-Shushan
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Galia Tiram
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sapir Golan
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Kleiner
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Sheinin
- Department of Pathology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sahar Israeli Dangoor
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Rachel Grossman
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Henry Brem
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thomas M Hyde
- Lieber Institute for Brain Development, Johns Hopkins Medical Campus, Baltimore, MD, USA
- Department of Psychiatry & Behavioral Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Prerna Magod
- Department of Biochemistry and Molecular Biology, George S. Wise Faculty of Life Sciences, Sherman Building, Tel Aviv University, Tel Aviv, Israel
| | - Dinorah Friedmann-Morvinski
- Sagol School of Neurosciences, Tel Aviv University, Tel Aviv, Israel
- Department of Biochemistry and Molecular Biology, George S. Wise Faculty of Life Sciences, Sherman Building, Tel Aviv University, Tel Aviv, Israel
| | - Asaf Madi
- Department of Pathology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Satchi-Fainaro
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Sagol School of Neurosciences, Tel Aviv University, Tel Aviv, Israel.
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16
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Schellekes N, Barbotti A, Abramov Y, Sitt R, Di Meco F, Ram Z, Grossman R. Resection of primary central nervous system lymphoma: impact of patient selection on overall survival. J Neurosurg 2021; 135:1016-1025. [PMID: 33636699 DOI: 10.3171/2020.9.jns201980] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 09/01/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Primary central nervous system lymphoma (PCNSL) is a rare CNS tumor with a poor prognosis. It is usually diagnosed by needle biopsy and treated mainly with high-dose chemotherapy. Resection is currently not considered a standard treatment option. A possible prolonged survival after resection of PCNSL lesions in selected patients has been suggested, but selection criteria for surgery, especially for solitary lesions, have never been established. METHODS The authors retrospectively searched their patient database for records of adult patients (≥ 18 years) who were diagnosed and treated for a solitary PCNSL between 2005 and 2019. Patients were divided into groups according to whether they underwent resection or needle biopsy. Statistical analyses were performed in an attempt to identify variables affecting outcome and possible survival advantage and to characterize subgroups of patients who would benefit from resection of their tumor compared with undergoing biopsy only. RESULTS A total of 113 patients with a solitary lesion of PCNSL were identified; 36 patients underwent resection, and 77 had a diagnostic stereotactic biopsy only. The statically significant preoperative risk factors included age ≥ 70 years (adjusted HR 9.61, 95% CI 2.42-38.11; p = 0.001), deep-seated lesions (adjusted HR 3.33, 95% CI 1.13-9.84; p = 0.030), and occipital location (adjusted HR 4.26, 95% CI 1.08-16.78; p = 0.039). Having a postoperative Karnofsky Performance Scale (KPS) score < 80 (adjusted HR 3.21, 95% CI 1.05-9.77; p = 0.040) and surgical site infection (adjusted HR 4.27, 95% CI 1.18-15.47; p = 0.027) were significant postoperative risk factors after the adjustment and selection by means of other possible risk factors. In a subgroup analysis, patients younger than 70 years who underwent resection had a nonsignificant trend toward longer survival than those who underwent needle biopsy (median survival 35.0 months vs 15.2 months, p = 0.149). However, patients with a superficial tumor who underwent resection had significantly longer survival times than those who underwent needle biopsy (median survival 34.3 months vs 8.9 months, p = 0.014). Patients younger than 70 years who had a superficial tumor and underwent resection had significantly prolonged survival, with a median survival of 35.0 months compared with 8.9 months in patients from the same group who underwent needle biopsy (p = 0.007). CONCLUSIONS Specific subgroups of patients with a solitary PCNSL lesion might gain a survival benefit from resection compared with undergoing only a diagnostic biopsy.
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Affiliation(s)
- Nadav Schellekes
- 1Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; and
| | - Arianna Barbotti
- 2Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Yael Abramov
- 1Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; and
| | - Razi Sitt
- 1Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; and
| | - Francesco Di Meco
- 2Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Zvi Ram
- 1Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; and
| | - Rachel Grossman
- 1Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; and
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Shimony N, Popovits N, Shofty B, Abergel A, Ram Z, Grossman R. Endoscopic transsphenoidal surgery reduces the need for re-operation compared to the microscopic approach in pituitary macroadenomas. Eur J Surg Oncol 2021; 47:1352-1356. [PMID: 33637372 DOI: 10.1016/j.ejso.2021.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/16/2021] [Accepted: 02/03/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Pituitary surgery has shifted in recent years from microscopic surgery(MS) to endoscopic endonasal surgery (EES). However, the comparative long-term outcome of these surgical approaches, including the need for subsequent re-operation has never been reported. We present our experience in a high-volume referral center experienced in both endoscopic and microscopic approaches to compare the need for re-operation after initial resection of non-functioning pituitary macroadenomas using these surgical approaches. METHODS 684 patients (398 with NF adenomas) underwent trans-sphenoidal pituitary surgery in our institution between 2006 and 2017. Complete follow-up (mean 72 months, minimum two years) was available in 87 newly diagnosed patients with non-functioning pituitary macroadenomas (NFPMA; 48-microscopic and 39-endoscopic). The EES approach has been used almost exclusively since 2012. The need for repeat operation for tumor resection during the follow-up period was assessed as the primary end-point of the study. Extracted data included various demographic and clinical parameters, radiographic findings as well as the extent of resection (EOR). RESULTS The EOR was similar for both groups, with a trend towards better EOR in the EES group. The rate of surgical complications was also similar for both groups. There was a strong trend towards lower need for re-operation in the EES group compared to the MS group (12.8% vs. 29.2%, p = 0.056). In a multivariate analysis, only EOR and Knosp grade were independently associated with the need for re-operation surgery. CONCLUSION Our data indicate that EES in NFPMA tends to be associated with a lower need for re-operation compared to the MS approach, with a similar rate of EOR and complications.
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Affiliation(s)
- Nir Shimony
- Institute of Neuroscience, Geisinger Commonwealth School of Medicine, Danville, PA, USA; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nataly Popovits
- Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ben Shofty
- Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Avraham Abergel
- Department of Otolaryngology-Head and Neck Surgery, Tel-Aviv Medical Center, Tel-Aviv, Israel, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Rachel Grossman
- Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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Ram Z, Kim CY, Zhu JJ. CTNI-68. EFFICACY OF TTFIELDS IN ELDERLY PATIENTS WITH NEWLY DIAGNOSED GLIOBLASTOMA (GBM) – SUB-GROUP ANALYSIS OF THE EF-14 TRIAL. Neuro Oncol 2020. [DOI: 10.1093/neuonc/noaa215.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Tumor Treating Fields (TTFields) are an anti-mitotic, regional treatment that utilizes low intensity alternating electric fields delivered non-invasively to the tumor using a portable medical device. In the EF-14 phase 3 study leading to FDA approval, TTFields significantly extended survival in newly diagnosed GBM when added to maintenance temozolomide (TMZ). Elderly GBM patients usually have worse prognosis and often receive only partial treatment for the disease. This sub-group analysis examined the effects of TTFields in the elderly population (≥65 years of age) enrolled in the EF-14 study.
METHODS
All 134 elderly patients (≥65 years of age) from the EF-14’s intent-to-treat population were included in the analysis, Overall survival (OS) and progression-free survival (PFS), as well as adverse event frequency and severity were compared between the TMZ/TTFields arm and the TMZ alone arm.
RESULTS
The median age was 69 (range: 65–83), median KPS was 90%, and 69% were male. Median PFS from randomization was 6.5 months versus 3.9 months in the TMZ/TTFields versus TMZ alone arms, respectively (hazard ratio [HR], 0.47 [95%CI 0.30, 0.74] P< 0.0236). Median OS was 17.4 months versus 13.7 months in the TMZ/TTFields versus TMZ alone arm, respectively (HR 0.51 [CI 0.33, 0.77] P< 0.020). Serious adverse events (SAEs) were reported in 39% of patients treated with TMZ/TTFields and in 33% of patients treated with TMZ alone. None of the SAEs were considered related to TTFields but attributed to TMZ or to the underlying disease. Grades 1–2 skin AEs related to TTFields were observed in 51% of patients.
CONCLUSION
Consistent with the overall outcome of the EF-14 study, elderly patients treated with TMZ/TTFields showed significantly better OS compared to patients on TMZ alone, and without increase in grade III or IV toxicity.
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Affiliation(s)
- Zvi Ram
- Tel Aviv Medical Center, Tel Aviv, Israel
| | - Chae-Yong Kim
- Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jay-Jiguang Zhu
- McGovern Medical School, The University of Texas Health Science Ctr at Houston, Houston, TX, USA
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Zhu JJ, O’Donnell RT, Goldlust S, Ram Z. CTNI-77. EF-19, A POST-APPROVAL REGISTRY STUDY OF TUMOR TREATING FIELDS (TTFIELDS) IN RECURRENT GLIOBLASTOMA (rGBM). Neuro Oncol 2020. [DOI: 10.1093/neuonc/noaa215.243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Tumor Treating Fields (TTFields) are an anti-mitotic therapy of alternating electric fields delivered non-invasively to the tumor. In phase 3 studies leading to FDA-approvals, TTFields plus temozolomide (TMZ) significantly extended survival in newly diagnosed GBM, and achieved comparable survival to best standard of care (BSC) as monotherapy in recurrent GBM (rGBM). The EF-19 study evaluated efficacy of TTFields vs BSC in rGBM in post-approval real-life setting.
METHODS
This registry trial (192 rGBM patients, >21 yrs, KPS > 70) were treated with TTFields (200 kHz, >18h/day). Primary endpoint was overall survival (OS); secondary endpoints were OS in the per protocol (PP) population, time to treatment failure and adverse events (AEs). The registry data were compared to OS of all 117 patients in EF-11 BSC group (Stupp EJC 2012). The sample size (N=192) was based on non-inferiority log-rank test with two-sided alpha (0.05), 80% power, HR of 1.0 comparing TTFields to control with an upper one-sided 95% CI of HR < 1.375.
RESULTS
Median OS with TTFields versus EF-11 BSC was 7.4 versus 6.4 months, p=0.053; HR = 0.64 (95%CI 0.46–0.91, Cox-test P=0.012). Median OS (PP) with TTFields versus EF-11 BSC was 8.1 months versus 6.5 months; p=0.045; HR 0.65. OS was significantly higher TTFields as the 95% CI upper limit of HR was lower than the pre-defined threshold of 1.375. The overall incidence of AEs was lower with TTFields than EF-11 BSC (67% vs. 95%). The median time to treatment failure was longer in the TTFields arm (3.3 months (95% CI 2.6, 3.9) versus BSC arm (1.6 months; 95% CI 1.1, 1.9); HR=0.53 (95% CI 0.41, 0.68, p< 0.0001). Skin AE was the most common AE in the TTFields arm.
CONCLUSION
The results of the EF-19 registry study confirm the effectiveness and safety of TTFields monotherapy in rGBM.
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Affiliation(s)
- Jay-Jiguang Zhu
- McGovern Medical School, The University of Texas Health Science Ctr at Houston, Houston, TX, USA
| | | | | | - Zvi Ram
- Tel Aviv Medical Center, Tel Aviv, Israel
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Grossman R, Limon D, Bokstein F, Harosh CB, Blumenthal D, Ram Z. RTID-12. PHASE 2 TRIAL OF TUMOR TREATING FIELDS (TTFIELDS) PLUS RADIATION THERAPY (RT) PLUS TEMOZOLAMIDE (TMZ) COMPARED TO RT PLUS TEMOZOLOMIDE IN NEWLY DIAGNOSED GLIOBLASTOMA (ndGBM). Neuro Oncol 2020. [DOI: 10.1093/neuonc/noaa215.817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVE
In the EF-14 phase 3 trial, TTFields 9200 kHz) added to maintenance TMZ increased median OS to 20.9 months versus 16.0 months with maintenance TMZ (p< 0.001) in ndGBM. Preclinical investigations showed that TTFields/RT have a synergistic effect. A pilot study (N=10) in ndGBM demonstrated the feasibility and safety of TTFields combined with RT/TMZ (Grossman Front Onc 2020). The only TTFields-related adverse event was array-associated skin toxicity. Median PFS was 8.9 months. Based on these encouraging results, this prospective, randomized phase 2 study [NCT03869242] in 60 patients further investigates if the addition of TTFields TMZ/RT treatment in ndGBM patients improves treatment efficacy and delays disease progression.
METHODS
Following debulking surgery or biopsy, 60 patients (≥18 years) with histologically confirmed GBM, KPS≥70 and life expectancy >3 months will be randomized 1:1 to: i) RT with concomitant TMZ/TTFields (200 kHz) for 6 weeks followed by up to 6 months of maintenance TMZ combined with TTFields (experimental arm) up to 24 months; or ii) RT with concomitant TMZ alone followed by maintenance TMZ combined with TTFields (control arm). Patients with early progressive disease, significant comorbidities precluding maintenance RT or TMZ or with implanted electronic devices will be excluded. The primary endpoint is the rate of progression free survival at 12 months (PFS12). Treatment with TTF will be continued until second progression or 24 months (the earlier of the two). All patients will be followed for survival. All adverse events will graded per CTCAE V5.0. The sample size of 60 patients provides 80% power with two-sided alpha level of 0.05 to detect a PFS12 of 46.5% with RT/TMZ/TTFields compared to 29.4% with RT/TMZ followed, respectively, by maintenance TMZ/TTFields (calculated from the RT/TMZ followed by maintenance TMZ/TTFields arm of the EF-14 trial). Follow-up will continue for >12 months from recruitment of the last patient.
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Affiliation(s)
| | - Dror Limon
- Tel Aviv Medical Center, Tel Aviv, Israel
| | | | | | | | - Zvi Ram
- Tel Aviv Medical Center, Tel Aviv, Israel
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Zhu J, O'Donnell R, Ram Z. EF-19: A Post-Approval Registry Study Of Tumor Treating Fields (TTFields) In Recurrent Glioblastoma (rGBM). Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ram Z, Zhu J. Efficacy Of Tumor Treating Fields (TTFields) In Elderly Patients With Newly Diagnosed Glioblastoma (GBM): Sub-Group Analysis Of The Phase 3 EF-14 Trial. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Zhu JJ, O'Donnell RT, Ram Z. Abstract CT211: EF-19 - A post-approval registry study of TTFields for the treatment of recurrent glioblastoma (GBM). Cancer Res 2020. [DOI: 10.1158/1538-7445.am2020-ct211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Tumor Treating Fields (TTFields) are an anti-mitotic, regional treatment modality, utilizing low intensity alternating electric fields delivered non-invasively to the tumor using a portable medical device. In phase 3 studies leading to FDA approvals, TTFields significantly extended survival in newly diagnosed GBM when added to maintenance temozolomide, and achieved comparable survival outcome to best standard of care (BSC) when used as monotherapy in recurrent GBM. The aim of the EF-19 study was to confirm the efficacy of TTFields versus BSC for recurrent GBM in the post-approval real-life setting.
Method: This non-inferiority, prospective, non-randomized, post approval registry trial enrolled 192 recurrent GBM patients (>21 years, KPS > 70). All patients were treated with TTFields (200 kHz, >18h/day). Eligibility criteria included histological diagnosis of GBM, past treatment with the Stupp protocol for the primary disease and radiological evidence of progression in the supratentorial region. The primary endpoint was overall survival (OS); secondary endpoints included OS in the per protocol (PP) population (>1 course of TTFields or BSC in each respective arm), time to treatment failure and incidence of adverse events. The TTFields patient registry data were compared to OS of all 117 recurrent GBM patients in the BSC group of the EF-11 pivotal trial (Stupp R., et al., EJC 2012). The sample size of 192 patients (10% loss to follow up) was determined based on non-inferiority log-rank test with a two-sided alpha level of 0.05 and a power of 80%, comparing time to event (i.e., death) between patients treated with TTFields and BSC. The analysis was based on true hazard ratio (HR) of 1.0 comparing TTFields to control with an upper one-sided 95% confidence bound of HR is not exceeding 1.375. Result: Median OS in patients treated with TTFields versus EF-11 BSC was 7.4 vs. 6.4 months, p=0.053; HR = 0.64 (95%CI 0.46-0.91, Cox-test P=0.012). In the PP population, the median OS with TTFields versus EF-11 BSC was 8.1 months vs. 6.5 months, respectively; p=0.045; HR 0.65. The results show a significant superiority HR of overall survival between the ITT groups, as superiority 95% confident interval upper limit of the HR was lower than the pre-defined threshold for non-inferiority for interval bound of 1.375. The overall incidence of adverse event was lower in the TTFields arm (67% vs. 95%) vs. EF-11 BSC arm. The median time to treatment failure was longer in the TTFields arm (3.3 months (95% CI 2.6, 3.9)) compared to the BSC arm (1.6 months; 95% CI 1.1, 1.9); HR=0.53 (95% CI 0.41, 0.68, p<0.0001). Skin AE was the most frequently reported AEs in TTFields-treated patients; No unexpected adverse events were reported with TTFields. Conclusion: The EF-19 confirmed the effectiveness and safety of TTFields as monotherapy in recurrent GBM.
Citation Format: Jay-Jiguang Zhu, Robert T. O'Donnell, Zvi Ram. EF-19 - A post-approval registry study of TTFields for the treatment of recurrent glioblastoma (GBM) [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT211.
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Affiliation(s)
| | | | - Zvi Ram
- 3Tel Aviv Medical Center, Tel Aviv, Israel
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Bokstein F, Blumenthal D, Limon D, Harosh CB, Ram Z, Grossman R. Abstract CT206: Concurrent Tumor Treating Fields (TTFields) and radiation therapy for newly diagnosed glioblastoma: A safety and feasibility study. Cancer Res 2020. [DOI: 10.1158/1538-7445.am2020-ct206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Tumor Treating Fields (TTFields) are a non-invasive, loco-regional, anti-mitotic treatment comprising low-intensity alternating electric fields. In the phase III EF-14 study in newly diagnosed glioblastoma (ndGBM), TTFields in combination with temozolomide (TMZ) significantly improved survival compared with TMZ alone. In preclinical studies TTFields had a radiosensitizing effect and increased the efficacy of radiation therapy (RT). This pilot study [NCT03780569] evaluated the feasibility and safety of TTFields administered concurrently with RT and TMZ in ndGBM patients.
Methods: Patients with histologically confirmed ndGBM were treated with TTFields/RT/TMZ followed by adjuvant TMZ/TTFields. TTFields (200 kHz) were delivered for ≥18 hours/day with transducer arrays removed during RT delivery. RT was administered to the tumor bed in 30 fractions (total dose 60 Gy) in combination with daily TMZ (75 mg/m2). In the adjuvant phase, patients received monthly TMZ (150-200 mg/m2 for 5 days) plus TTFields. The primary outcome was safety of the combined therapies; secondary outcomes included progression-free survival (PFS) and overall survival (OS). Adverse events (AEs) were graded per CTCAE v4.0.
Results: Ten patients were enrolled at a single center between April and December 2017. Median age was 60.2 years, median Karnofsky Performance Score was 90.0, and eight (80%) patients were male. Five (50%) patients had undergone tumor resection while the remainder had biopsy only. Eight patients experienced ≥1 RT treatment delay; delays were unrelated to TTFields treatment. All patients experienced ≥1 AE. Three patients suffered from serious AEs (urinary tract infection, confusional state, and decubitus ulcer) that were considered unrelated to TTFields. The most common AE was skin toxicity, reported in eight (80%) patients; all were of low severity (CTCAE grade 1-2) and were reported as related to TTFields treatment. Median PFS from enrollment was 8.9 months; median OS was not reached at the time of study closure.
Conclusions: Eighty percent of patients experienced grade 1-2 TTFields-related skin toxicity. No other TTFields-related toxicities were observed and there was no increase in RT- or TMZ-related toxicities as a result of combining TTFields with these therapies. Based on the safety and preliminary efficacy results of this pilot study, a phase 2 randomized trial (N=60; NCT03869242) and the Phase 3 TRIDENT trial have been initiated to further investigate the efficacy of concomitant RT/TMZ/TTFields in ndGBM.
Citation Format: Felix Bokstein, Deborah Blumenthal, Dror Limon, Carmit Ben Harosh, Zvi Ram, Rachel Grossman. Concurrent Tumor Treating Fields (TTFields) and radiation therapy for newly diagnosed glioblastoma: A safety and feasibility study [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT206.
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Affiliation(s)
| | | | - Dror Limon
- Tel Aviv Medical Center, Tel Aviv, Israel
| | | | - Zvi Ram
- Tel Aviv Medical Center, Tel Aviv, Israel
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Ram Z, Zhu JJ. Abstract CT219: Efficacy of TTFields in elderly patients with newly diagnosed glioblastoma (GBM): Sub-group analysis of the EF-14 trial. Cancer Res 2020. [DOI: 10.1158/1538-7445.am2020-ct219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Tumor Treating Fields (TTFields) are an anti-mitotic, regional treatment modality, utilizing low intensity alternating electric fields delivered non-invasively to the tumor using a portable medical device. In the EF-14 phase 3 study leading to FDA approval, TTFields significantly extended survival in newly diagnosed GBM when added to maintenance temozolomide (TMZ). Elderly GBM patients usually have worse prognosis and often receive only partial treatment for the disease. The aim of the following post-hoc analysis was to examine the effects of TTFields in the elderly population (≥65 years of age) enrolled in the EF-14 study. Method: All 134 elderly patients (≥65 years of age) from the EF-14's intent-to-treat population were included in the analysis, Overall survival (OS) and progression-free survival (PFS), as well as adverse event frequency and severity were compared between the TMZ + TTFields arm and the TMZ alone arm. Result: The median age was 69 (range: 65-83), 69% were male. Median PFS from randomization was 6.5 months versus 3.9 months in the TTFields + TMZ Vs. TMZ alone arms, respectively (hazard ratio [HR], 0.47 [95%CI 0.30, 0.74] P<0.0236). Median OS was 17.4 months versus 13.7 months in the TTFields + TMZ versus TMZ alone arm, respectively (HR 0.51 [CI 0.33, 0.77] P<0.020). Serious adverse events (SAEs) were reported in 39% of patients treated with TTFields + TMZ and in 33% of patients treated with TMZ alone. None of the SAEs were considered related to TTFields. SAEs were considered related to TMZ or to the underlying disease. Grades 1-2 skin AEs were observed in 51% of patients. Conclusion: Consistent with the overall outcome of the EF-14 study, elderly patients treated with TMZ + TTFields showed significantly better OS compared to patients on TMZ alone, and without increase in grade 3-4 toxicity.
Citation Format: Zvi Ram, Jay-Jiguang Zhu. Efficacy of TTFields in elderly patients with newly diagnosed glioblastoma (GBM): Sub-group analysis of the EF-14 trial [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT219.
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Affiliation(s)
- Zvi Ram
- 1Tel Aviv Medical Center, Tel Aviv, Israel
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Abstract
e14536 Background: Tumor Treating Fields (TTFields) are an anti-mitotic non-invasive therapy of low intensity alternating electric fields delivered to the tumor via a portable medical device. In phase 3 studies that led to FDA approvals, TTFields plus maintenance temozolomide significantly extended survival in newly diagnosed GBM, and achieved comparable survival outcome to best standard of care (BSC) as monotherapy in recurrent GBM (rGBM). The EF-19 study aimed to confirm efficacy of TTFields vs BSC in rGBM in post-approval real-life setting. Methods: This non-inferiority, prospective, non-randomized, post approval registry trial enrolled 192 rGBM patients (>21 yrs, KPS > 70). Patients were treated with TTFields (200 kHz, > 18h/day). Eligibility criteria: histologic GBM, past treatment per Stupp protocol for primary disease and radiological evidence of progression in the supratentorial region. Primary endpoint was overall survival (OS); secondary endpoints were OS in the per protocol (PP) population ( > 1 course of TTFields or BSC in each respective arm), time to treatment failure and adverse events. The TTFields patient registry data were compared to OS of all 117 rGBM patients in the BSC group of the EF-11 trial (Stupp R, EJC 2012). The sample size of 192 patients (10% loss to follow up) was based on non-inferiority log-rank test with a two-sided alpha level of 0.05 and a power of 80%, comparing time to event (i.e., death) between patients treated with TTFields and BSC. The analysis was based on true hazard ratio (HR) of 1.0 comparing TTFields to control with an upper one-sided 95% confidence bound of HR not exceeding 1.375. Results: Median OS with TTFields versus EF-11 BSC was 7.4 vs. 6.4 months, p = 0.053; HR = 0.64 (95%CI 0.46-0.91, Cox-test P = 0.012). Median OS (PP population) with TTFields versus EF-11 BSC was 8.1 months vs. 6.5 months; p = 0.045; HR 0.65. The results showed a significant superiority in HR of OS between the 2 groups, as the 95% confident interval upper limit of the HR was lower than the pre-defined threshold for non-inferiority for interval bound of 1.375. The overall incidence of adverse event was lower with TTFields than EF-11 BSC (67% vs. 95%). The median time to treatment failure was longer in the TTFields arm (3.3 months (95% CI 2.6, 3.9) versus BSC arm (1.6 months; 95% CI 1.1, 1.9); HR = 0.53 (95% CI 0.41, 0.68, p < 0.0001). Skin AE was the most frequently reported AEs in TTFields arm; no unexpected adverse events were reported with TTFields. Conclusions: The results of the EF-19 registry study confirm the effectiveness and safety of TTFields monotherapy in rGBM.
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Affiliation(s)
- Jay-Jiguang Zhu
- The University of Texas Medical School at Houston, Houston, TX
| | | | - Zvi Ram
- Tel Aviv Medical Center, Tel Aviv, Israel
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Grossman R, Bokstein F, Blumenthal DT, Limon D, Ben Harush C, Ram Z. Updated safety/feasibility study of concurrent tumor treating fields (TTFields) and radiation therapy for newly diagnosed glioblastoma. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e14535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e14535 Background: Tumor Treating Fields (TTFields), a non-invasive, loco-regional, anti-mitotic treatment comprises low-intensity alternating electric fields. In the phase III EF-14 study in newly diagnosed glioblastoma (ndGBM), TTFields in combination with temozolomide (TMZ) significantly improved survival compared to TMZ alone. In preclinical studies TTFields had a radiosensitizing effect and increased the efficacy of radiation therapy (RT). This pilot study [NCT03780569] evaluated the feasibility and safety of TTFields administered concurrently with RT and TMZ in ndGBM patients. Methods: Patients with histologically confirmed ndGBM were treated with TTFields/RT/TMZ followed by adjuvant TMZ/TTFields. TTFields (200 kHz) were delivered for ≥18 hours/day with transducer arrays removed during RT delivery. RT was administered to the tumor bed in 30 fractions (total dose 60 Gy) in combination with daily TMZ (75 mg/m2). In the adjuvant phase, patients received monthly TMZ (150–200 mg/m2 for 5 days) plus TTFields. The primary outcome was safety of the combined therapies; secondary outcomes included progression-free survival (PFS) and overall survival (OS). Adverse events (AEs) were graded per CTCAE v4.0. Results: Ten patients were enrolled at a single center between April and December 2017. Median age was 60.2 years, median Karnofsky Performance Score was 90.0, and eight (80%) patients were male. Five (50%) patients had undergone tumor resection while the remainder had biopsy only. Eight patients experienced ≥1 RT treatment delay; delays were unrelated to TTFields treatment. All patients experienced ≥1 AE. Three patients suffered from serious AEs (urinary tract infection, confusional state, and decubitus ulcer) that were considered unrelated to TTFields. The most common AE was skin toxicity, reported in eight (80%) patients; all were of low severity (CTCAE grade 1–2) and were reported as related to TTFields treatment. Median PFS from enrollment was 8.9 months; median OS was not reached at the time of study closure. Conclusions: Eighty percent of patients experienced grade 1–2 TTFields-related skin toxicity. No other TTFields-related toxicities were observed and there was no increase in RT- or TMZ-related toxicities as a result of combining TTFields with these therapies. Based on the safety and preliminary efficacy results of this pilot study, a phase 2 randomized trial (N = 60; NCT03869242) and the Phase 3 TRIDENT trial have been initiated to further investigate the efficacy of concomitant RT/TMZ/TTFields in ndGBM. Clinical trial information: NCT03780569.
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Affiliation(s)
| | | | | | - Dror Limon
- Tel Aviv Medical Center, Tel-Aviv, Israel
| | | | - Zvi Ram
- Tel Aviv Medical Center, Tel Aviv, Israel
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Ram Z, Kim CY, Zhu JJ. Efficacy of tumor treating fields (TTFields) in elderly patients with newly diagnosed glioblastoma (GBM): Sub-group analysis of the phase III EF-14 trial. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e24019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e24019 Background: Tumor Treating Fields (TTFields) are an anti-mitotic, regional treatment modality, utilizing low intensity alternating electric fields delivered non-invasively to the tumor using a portable medical device. TTFields are FDA-approved for glioblastoma and malignant pleural mesothelioma. In the EF-14 [NCT00916409] phase 3 GBM study, TTFields significantly extended survival in newly diagnosed GBM when added to maintenance temozolomide (TMZ). Elderly GBM patients usually have worse prognosis and often receive only partial treatment for the disease. The aim of the following post-hoc analysis was to examine the effects of TTFields in the elderly population (≥65 years of age) enrolled in the EF-14 study. Methods: All 134 elderly patients (≥65 years of age) from the EF-14’s intent-to-treat population were included in the analysis, Overall survival (OS) and progression-free survival (PFS), as well as adverse events were compared between the TMZ + TTFields arm and the TMZ alone arm. Results: The median age was 69 (range: 65-83), 69% were male. Median PFS from randomization was 6.5 months versus 3.9 months in the TTFields + TMZ versus TMZ alone arms, respectively (hazard ratio [HR], 0.47 [95%CI 0.30, 0.74] P < 0.0236). Median OS was 17.4 months versus 13.7 months in the TTFields + TMZ versus TMZ alone arm, respectively (HR 0.51 [CI 0.33, 0.77] P < 0.020). Serious adverse events (SAEs) were reported in 39% of patients treated with TTFields + TMZ and in 33% of patients treated with TMZ alone. None of the SAEs were considered related to TTFields. SAEs were considered related to TMZ or to the underlying disease. Grades 1-2 skin AEs were observed in 51% of patients. Conclusions: Consistent with the overall outcome of the EF-14 study, elderly patients treated with TMZ + TTFields showed significantly better OS compared to patients on TMZ alone, and without increase in grade 3-4 toxicity. Clinical trial information: NCT00916409 .
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Affiliation(s)
- Zvi Ram
- Tel Aviv Medical Center, Tel Aviv, Israel
| | | | - Jay-Jiguang Zhu
- The University of Texas Medical School at Houston, Houston, TX
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Bokstein F, Blumenthal D, Limon D, Harosh CB, Ram Z, Grossman R. Concurrent Tumor Treating Fields (TTFields) and Radiation Therapy for Newly Diagnosed Glioblastoma: A Prospective Safety and Feasibility Study. Front Oncol 2020; 10:411. [PMID: 32373508 PMCID: PMC7186440 DOI: 10.3389/fonc.2020.00411] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 03/09/2020] [Indexed: 11/13/2022] Open
Abstract
Background: TTFields are a loco-regional, anti-mitotic treatment comprising low-intensity alternating electric fields. In the EF-14 study of newly diagnosed glioblastoma (ndGBM), TTFields in combination with temozolomide (TMZ) significantly improved survival vs. TMZ alone. In preclinical studies TTFields had a radiosensitizing effect and increased the efficacy of radiation therapy (RT). This study prospectively evaluated the feasibility and safety of TTFields administered concurrently with RT and TMZ in ndGBM patients. Methods: Patients with histologically confirmed ndGBM were treated with TTFields/RT/TMZ followed by adjuvant TMZ/TTFields. TTFields (200 kHz) were delivered for ≥18 hours/day with transducer arrays removed during RT delivery. RT was administered to the tumor bed in 30 fractions (total dose 60 Gy) combined with daily TMZ (75 mg/m2). In the adjuvant phase, patients received monthly TMZ (150-200 mg/m2 for 5 days) plus TTFields. Patients were followed for 24 months or until second disease progression. The primary outcome was safety of the combined therapies; secondary outcomes included progression-free survival (PFS) and overall survival (OS). Adverse events (AEs) were graded per CTCAE v4.0. Results: Ten patients were enrolled at a single center between April and December 2017. Median age was 60.2 years, median Karnofsky Performance Score was 90.0, and 80% patients were male. Five (50%) patients had undergone tumor resection while the remainder had biopsy only. Eight patients experienced ≥1 RT treatment delay; delays were unrelated to TTFields treatment. All patients experienced ≥1 AE. Three patients suffered from serious AEs (urinary tract infection, confusional state, and decubitus ulcer) that were considered unrelated to TTFields. The most common AE was skin toxicity, reported in eight (80%) patients; all were of low severity (CTCAE grade 1-2) and were reported as related to TTFields treatment. Median PFS from enrollment was 8.9 months; median OS was not reached at the time of study closure. Conclusions: Eighty percent of patients experienced grade 1-2 TTFields-related skin toxicity. No other TTFields-related toxicities were observed without an increase in RT- or TMZ-related toxicities as a result of combining TTFields with these therapies. Preliminary efficacy results are promising and warrant further investigation of concurrent TTFields/RT/TMZ treatment in ndGBM patients.
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Affiliation(s)
- Felix Bokstein
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.,Neuro-Oncology Service, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Deborah Blumenthal
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.,Neuro-Oncology Service, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Dror Limon
- Institute of Radiotherapy, Tel Aviv Medical Center, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Carmit Ben Harosh
- Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Zvi Ram
- Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Rachel Grossman
- Institute of Radiotherapy, Tel Aviv Medical Center, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
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Shofty B, Artzi M, Shtrozberg S, Fanizzi C, DiMeco F, Haim O, Peleg Hason S, Ram Z, Bashat DB, Grossman R. Virtual biopsy using MRI radiomics for prediction of BRAF status in melanoma brain metastasis. Sci Rep 2020; 10:6623. [PMID: 32313236 PMCID: PMC7170839 DOI: 10.1038/s41598-020-63821-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/06/2020] [Indexed: 12/27/2022] Open
Abstract
Brain metastases are common in patients with advanced melanoma and constitute a major cause of morbidity and mortality. Between 40% and 60% of melanomas harbor BRAF mutations. Selective BRAF inhibitor therapy has yielded improvement in clinical outcome; however, genetic discordance between the primary lesion and the metastatic tumor has been shown to occur. Currently, the only way to characterize the genetic landscape of a brain metastasis is by tissue sampling, which carries risks and potential complications. The aim of this study was to investigate the use of radiomics analysis for non-invasive identification of BRAF mutation in patients with melanoma brain metastases, based on conventional magnetic resonance imaging (MRI) data. We applied a machine-learning method, based on MRI radiomics features for noninvasive characterization of the BRAF status of brain metastases from melanoma (BMM) and applied it to BMM patients from two tertiary neuro-oncological centers. All patients underwent surgical resection for BMM, and their BRAF mutation status was determined as part of their oncological work-up. Their routine preoperative MRI study was used for radiomics-based analysis in which 195 features were extracted and classified according to their BRAF status via a support vector machine. The BRAF status of 53 study patients, with 54 brain metastases (25 positive, 29 negative for BRAF mutation) was predicted with mean accuracy = 0.79 ± 0.13, mean precision = 0.77 ± 0.14, mean sensitivity = 0.72 ± 0.20, mean specificity = 0.83 ± 0.11 and with a 0.78 area under the receiver operating characteristic curve for positive BRAF mutation prediction. Radiomics-based noninvasive genetic characterization is feasible and should be further verified using large prospective cohorts.
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Affiliation(s)
- Ben Shofty
- Department of Neurosurgery, Tel Aviv Medical Center, and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Moran Artzi
- Sagol Brain Institute, Tel Aviv Medical Center, and the Sackler Faculty of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel-Aviv, Israel
| | - Shai Shtrozberg
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Claudia Fanizzi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Francesco DiMeco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Oz Haim
- Department of Neurosurgery, Tel Aviv Medical Center, and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shira Peleg Hason
- Division of Oncology, Tel Aviv Medical Center, Tel Aviv, Israel and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center, and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dafna Ben Bashat
- Sagol Brain Institute, Tel Aviv Medical Center, and the Sackler Faculty of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel-Aviv, Israel
| | - Rachel Grossman
- Department of Neurosurgery, Tel Aviv Medical Center, and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Zelitzki R, Korn A, Arial E, Ben-Harosh C, Ram Z, Grossman R. Comparison of Motor Outcome in Patients Undergoing Awake vs General Anesthesia Surgery for Brain Tumors Located Within or Adjacent to the Motor Pathways. Neurosurgery 2020; 85:E470-E476. [PMID: 30783667 DOI: 10.1093/neuros/nyz007] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 02/07/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Surgical removal of intra-axial brain tumors aims at maximal tumor resection while preserving function. The potential benefit of awake craniotomy over craniotomy under general anesthesia (GA) for motor preservation is yet unknown. OBJECTIVE To compare the clinical outcomes of patients who underwent surgery for perirolandic tumors while either awake or under GA. METHODS Between 2004 and 2015, 1126 patients underwent surgical resection of newly diagnosed intra-axial tumors in a single institution. Data from 85 patients (44 awake, 41 GA) with full dataset who underwent resections for perirolandic tumors were retrospectively analyzed. RESULTS Identification of the motor cortex required significantly higher stimulation thresholds in anesthetized patients (9.1 ± 4 vs 6.2 ± 2.7 mA for awake patients, P = .0008). There was no group difference in the subcortical threshold for motor response used to assess the proximity of the lesion to the corticospinal (pyramidal) tract. High-grade gliomas were the most commonly treated pathology. The extent of resection and residual tumor volume were not different between groups. Postoperative motor deficits were more common in the anesthetized patients at 1 wk (P = .046), but no difference between the groups was detected at 3 mo. Patients in the GA group had a longer mean length of hospitalization (10.3 vs 6.7 d for the awake group, P = .003). CONCLUSION Awake craniotomy results in a better early postoperative motor outcome and shorter hospitalization compared with patients who underwent the same surgery under GA. The finding of higher cortical thresholds for the identification of the motor cortex in anesthetized patients may suggest an inhibitory effect of anesthetic agents on motor function.
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Affiliation(s)
- Roni Zelitzki
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Akiva Korn
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eti Arial
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Carmit Ben-Harosh
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Rachel Grossman
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Berger A, Tzarfati G, Costa M, Serafimova M, Korn A, Vendrov I, Alfasi T, Krill D, Aviram D, Ben Moshe S, Kashanian A, Ram Z, Grossman R. Incidence and impact of stroke following surgery for low-grade gliomas. J Neurosurg 2019:1-9. [PMID: 31881532 DOI: 10.3171/2019.10.jns192301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ischemic complications are a common cause of neurological deficits following low-grade glioma (LGG) surgeries. In this study, the authors evaluated the incidence, risk factors, and long-term implications of intraoperative ischemic events. METHODS The authors retrospectively evaluated patients who had undergone resection of an LGG between 2013 and 2017. Analysis included pre- and postoperative demographic, clinical, radiological, and anesthetic data, as well as intraoperative neurophysiology data, overall survival, and functional and neurocognitive outcomes. RESULTS Among the 82 patients included in the study, postoperative diffusion-weighted imaging showed evidence of acute ischemic strokes in 19 patients (23%), 13 of whom (68%) developed new neurological deficits. Infarcts were more common in recurrent and insular surgeries (p < 0.05). Survival was similar between the patients with and without infarcts. Immediately after surgery, 27% of the patients without infarcts and 58% of those with infarcts experienced motor deficits (p = 0.024), decreasing to 16% (p = 0.082) and 37% (p = 0.024), respectively, at 1 year. Neurocognitive functions before and 3 months after surgery were generally stable for the two groups, with the exception of a decline in verbal rhyming ability among patients with infarcts. Confusion during awake craniotomy was a strong predictor of the occurrence of an ischemic stroke. Mean arterial pressure at the beginning of surgery was significantly lower in the infarct group. CONCLUSIONS Recurrent surgeries and insular tumor locations are risk factors for intraoperative strokes. Although they do not affect survival, these strokes negatively affect patient activity and performance status, mainly during the first 3 postoperative months, with gradual functional improvement over 1 year. Several intraoperative parameters may suggest the impending development of an infarct.
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Berger A, Tzarfati G, Costa M, Serafimova M, Korn A, Alfassi T, Aviram D, Kashinian A, Ram Z, Grossman R. NCMP-05. THE INCIDENCE AND IMPACT OF POST-OPERATIVE STROKE IN SURGERY FOR LGG. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Postoperative neurological deficits may outweigh the benefit conferred by maximal resection of gliomas. We evaluated the incidence of ischemic events in patients undergoing surgery for low-grade gliomas (LGG) and the long-term neurological and cognitive sequelae.
METHODS
Between 2013–2017, 168 patients underwent surgical resection or biopsy for LGG at our center. A full dataset, including pre- and postoperative magnetic resonance imaging (MRI) and long-term clinical evaluation findings, was available for 82 patients (study group). Ischemic complications, overall and progression-free survival, and functional and neurocognitive outcomes were evaluated.
RESULTS
The immediate postoperative MRI revealed an acute ischemic stroke adjacent to the tumor resection cavity in 19 patients (23%), 13 of whom developed new neurological deficits due to the ischemic event. Infarcts were more common in patients with recurrent tumors, especially those involving the Sylvian fissure (p< 0.05). Surgery for insular gliomas had the strongest association with postoperative infarcts. Survival of patients w/wo a postoperative infarct was the same. The median Karnofsky-Performance Status was lower for the infarct group vs. the non-infarct group at 3 months post-surgery (p=0.016), with a gradual significant improvement for the former over one year (p=0.04). Immediately after surgery, 27% of the patients without infarcts and 58% of those with infarcts experienced a new motor deficit (p=0.037), decreasing to 16% (p=0.028) and 37% (p=0.001), respectively, at one year. Neurocognitive analysis findings before and 3 months after surgery were unchanged, but patients with an infarct had a significant decrease in naming (p=0.04). Confusion during awake craniotomy was a strong predictor of an ischemic stroke.
CONCLUSIONS
Intraoperative strokes are more prevalent among patients who undergo recurrent surgeries, especially in the insula. Although they do not affect survival, these strokes negatively impact the patients’ activity and performance status, especially during the first 3 postoperative months, with gradual functional improvement over one year.
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Affiliation(s)
| | | | | | | | - Akiva Korn
- Tel-Aviv Medical Center, Tel-Aviv, Israel
| | | | | | | | - Zvi Ram
- Tel-Aviv Medical Center, Tel-Aviv, Israel
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Grossman R, Limon D, Bokstein F, Blumenthal D, Ben Harush C, Ram Z. ACTR-46. TUMOR TREATING FIELDS COMBINED WITH RADIOTHERAPY AND TEMOZOLOMIDE FOR THE TREATMENT OF NEWLY DIAGNOSED GLIOBLASTOMA: FINAL RESULTS FROM A PILOT STUDY. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Tumor Treating Fields (TTFields) are a non-invasive, loco-regional, anti-mitotic treatment comprising low intensity alternating electric fields approved for GBM. Preclinical data show that TTFields have a radio-sensitizing effect. This pilot study evaluated the safety and feasibility of TTFields/RT/TMZ in ndGBM patients.
METHODS
Patients with histologically confirmed ndGBM were treated with TTFields/RT/TMZ followed by maintenance TTFields and TMZ for up to 24 months. TTFields (200kHz) were delivered for >18 hours/day with removal of the transducer arrays during RT delivery. TMZ was administered at 75 mg/m2/daily for 6 weeks and RT at a total dose of 60 Gy. The primary endpoint was safety of the combined TTFields/RT/TMZ; secondary endpoints included progression-free survival (PFS), overall survival (OS) and toxicity. Adverse events (AEs) were graded per CTCAE V4.0.
RESULTS
Ten patients were enrolled at a single center in Israel between April and December 2017. All patients had recovered from maximal debulking surgery or biopsy. Five patients (50%) had undergone gross total resection; rest had biopsy only. Median age was 59 and median KPS was 80. Median dose of RT was 60 Gy. Six patients (60%) reported at least one AE. The most common AE was TTFields-related skin toxicity reported in 4 patients (40%), of Grade 1–2 in severity. Two patients reported serious AEs (seizures and general deterioration) considered unrelated to TTFields. Median PFS with RT/TMZ/TTFields was 10.5 months. Median OS has not been reached.
CONCLUSIONS
The proportion of patients with TTFields-related skin toxicity was similar to that reported in EF-14 phase 3 study (52%). No other TTFields-related toxicities were reported. There was no increase in RT- or TMZ-related toxicities with TTFields/RT/TMZ combination. A phase 2 randomized study has been initiated to investigate the efficacy of concomitant RT/TMZ/TTFields in 60 ndGBM patients.
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Affiliation(s)
| | - Dror Limon
- Tel Aviv Medical Center, Tel Aviv, Israel
| | | | | | | | - Zvi Ram
- Tel Aviv Medical Center, Tel Aviv, Israel
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Taphoorn MJB, Dirven L, Kanner AA, Lavy-Shahaf G, Weinberg U, Taillibert S, Toms SA, Honnorat J, Chen TC, Sroubek J, David C, Idbaih A, Easaw JC, Kim CY, Bruna J, Hottinger AF, Kew Y, Roth P, Desai R, Villano JL, Kirson ED, Ram Z, Stupp R. Influence of Treatment With Tumor-Treating Fields on Health-Related Quality of Life of Patients With Newly Diagnosed Glioblastoma: A Secondary Analysis of a Randomized Clinical Trial. JAMA Oncol 2019; 4:495-504. [PMID: 29392280 DOI: 10.1001/jamaoncol.2017.5082] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Importance Tumor-treating fields (TTFields) therapy improves both progression-free and overall survival in patients with glioblastoma. There is a need to assess the influence of TTFields on patients' health-related quality of life (HRQoL). Objective To examine the association of TTFields therapy with progression-free survival and HRQoL among patients with glioblastoma. Design, Setting, and Participants This secondary analysis of EF-14, a phase 3 randomized clinical trial, compares TTFields and temozolomide or temozolomide alone in 695 patients with glioblastoma after completion of radiochemotherapy. Patients with glioblastoma were randomized 2:1 to combined treatment with TTFields and temozolomide or temozolomide alone. The study was conducted from July 2009 until November 2014, and patients were followed up through December 2016. Interventions Temozolomide, 150 to 200 mg/m2/d, was given for 5 days during each 28-day cycle. TTFields were delivered continuously via 4 transducer arrays placed on the shaved scalp of patients and were connected to a portable medical device. Main Outcomes and Measures Primary study end point was progression-free survival; HRQoL was a predefined secondary end point, measured with questionnaires at baseline and every 3 months thereafter. Mean changes from baseline scores were evaluated, as well as scores over time. Deterioration-free survival and time to deterioration were assessed for each of 9 preselected scales and items. Results Of the 695 patients in the study, 639 (91.9%) completed the baseline HRQoL questionnaire. Of these patients, 437 (68.4%) were men; mean (SD) age, 54.8 (11.5) years. Health-related quality of life did not differ significantly between treatment arms except for itchy skin. Deterioration-free survival was significantly longer with TTFields for global health (4.8 vs 3.3 months; P < .01); physical (5.1 vs 3.7 months; P < .01) and emotional functioning (5.3 vs 3.9 months; P < .01); pain (5.6 vs 3.6 months; P < .01); and leg weakness (5.6 vs 3.9 months; P < .01), likely related to improved progression-free survival. Time to deterioration, reflecting the influence of treatment, did not differ significantly except for itchy skin (TTFields worse; 8.2 vs 14.4 months; P < .001) and pain (TTFields improved; 13.4 vs 12.1 months; P < .01). Role, social, and physical functioning were not affected by TTFields. Conclusions and Relevance The addition of TTFields to standard treatment with temozolomide for patients with glioblastoma results in improved survival without a negative influence on HRQoL except for more itchy skin, an expected consequence from the transducer arrays. Trial Registration clinicaltrials.gov Identifier: NCT00916409.
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Affiliation(s)
- Martin J B Taphoorn
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Linda Dirven
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrew A Kanner
- Department of Neurosurgery, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Uri Weinberg
- Research and Development, Novocure, Haifa, Switzerland
| | - Sophie Taillibert
- Department of Neurology 2, Salpêtrière University Hospital, Assistance Public Hôpitaux de Paris, L'Université Pierre et Marie Curie University, Paris VI University, Paris, France
| | - Steven A Toms
- Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Jerome Honnorat
- Department of Neuro-oncology, Hospices Civils de Lyon, University Claude Bernard Lyon, Lyon, France
| | - Thomas C Chen
- Department of Neurosurgery, University of Southern California, Los Angeles
| | - Jan Sroubek
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Carlos David
- Department of Neurosurgery, Lahey Clinic, Burlington, Massachusetts
| | - Ahmed Idbaih
- Department of Neurology 2, Salpêtrière University Hospital, Assistance Public Hôpitaux de Paris, L'Université Pierre et Marie Curie University, Paris VI University, Paris, France
| | - Jacob C Easaw
- Department of Medical Oncology, Cross Cancer Institute, Edmonton, California
| | - Chae-Yong Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Bundang, Korea
| | - Jordi Bruna
- Department of Neurology, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Andreas F Hottinger
- Department of Medical Oncology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Yvonne Kew
- Clinical Neuro-Oncology Research Program, Department of Internal Medicine, Methodist Hospital, Houston, Texas
| | - Patrick Roth
- Department of Neurology, University of Zurich, Zurich, Switzerland
| | - Rajiv Desai
- Neurosurgery and Spine Association, Maine Medical Center, Scarborough, Maine
| | - John L Villano
- Clinical Neuro-Oncology Research Program, Department of Internal Medicine, University of Kentucky Medical Center, Lexington
| | | | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Roger Stupp
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Northwestern Brain Tumor Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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berger A, Tzarfati G, Costa M, Serafimova M, Korn A, Alfasi T, Kashinian A, Ram Z, Grossman R. P04.06 The incidence and impact of post-operative stroke in surgery for LGG. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz126.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND: INTRODUCTION
Postoperative neurological deficits may outweigh the benefit conferred by maximal resection of gliomas. Ischemic complications are a common cause of such deficits. In this study, we evaluated the incidence of ischemic events in patients undergoing surgery for low-grade gliomas (LGG) and the long-term neurological and cognitive implications of those events.
METHODS
Between 2013–2017, 168 patients underwent surgical resection or biopsy for LGG at our center. A full dataset, including pre- and postoperative magnetic resonance imaging (MRI) and long-term clinical evaluation findings, was available in 82 patients that underwent resection, and they comprised our study cohort. We retrospectively analyzed pre- and postoperative demographic, clinical, radiological, anesthetic, and intraoperative neurophysiology data to characterize associated ischemic complications. Overall and progression-free survival, as well as functional and neurocognitive outcomes were evaluated as well.
RESULTS
The immediate postoperative MRI showed evidence of an acute ischemic stroke adjacent to the tumor resection cavity in 19 patients (23%), 13 of whom developed new neurological deficits as a result of the ischemic event. Infarcts were more common in patients undergoing surgery for a recurrent tumor, especially those involving the Sylvian fissure (p<0.05). Surgery for insular gliomas had the strongest association with postoperative infarcts (multivariate analysis: odds ratio =12.4, 95% confidence interval 2.21–69.8). There was no difference in survival between patients with or without a postoperative infarct. The median Karnofsky Performance Status was lower for the infarct group compared to the non-infarct group at 3 months after surgery (p=0.016), with a gradual significant improvement for the former over one year of follow-up (p=0.04). Immediately after surgery, 27% of the patients without infarcts and 58% of those with infarcts experienced a new motor deficit (p=0.037), decreasing to 16% (p=0.028) and 37% (p=0.001), respectively, at one year. Neurocognitive analysis findings before and 3 months after surgery were unchanged, but there was a significant decrease in naming in patients who experienced an infarct (NeuroTrax computerized battery score of 100±9 and 83±19, p=0.04 respectively). Confusion during awake craniotomy was a strong predictor of the occurrence of an ischemic stroke.
CONCLUSIONS
Intraoperative strokes are more prevalent among patients who undergo recurrent surgeries, especially procedures in the insula. Although they do not affect survival, these strokes negatively affect the patients’ activity and performance status, especially during the first 3 postoperative months, with gradual functional improvement over one year.
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Affiliation(s)
- A berger
- Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - G Tzarfati
- Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - M Costa
- Tel-Aviv Medical Center, Tel-Aviv, Israel
| | | | - A Korn
- Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - T Alfasi
- Tel-Aviv Medical Center, Tel-Aviv, Israel
| | | | - Z Ram
- Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - R Grossman
- Tel-Aviv Medical Center, Tel-Aviv, Israel
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Diamant G, Simchony H, Shiloach T, Globerson-Levin A, Gasri Plotnitsky L, Eshhar Z, Pencovich N, Grossman R, Ram Z, Volovitz I. P12.05 Evaluating the compatibility of tumor treating electric fields with key antitumoral immune functions. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz126.216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
TTFields has the ability to induce immunogenic cell death (ICD). As immunotherapy and TTFields have different mechanisms of action (MOA), combining these therapies is a rational approach. Contrarily, TTFields may interfere with immune functions critical for effective T cell function.
MATERIAL AND METHODS
We cultured T cells from healthy donors’ peripheral blood or from viably dissociated glioblastoma samples under normal or TTFields conditions, with or without superantigen-stimulation. In order to assess T cell responses we used eight-color flow cytometry by monitoring select pivotal antitumoral functions: proliferation (CFSE), IFNγ secretion, cytotoxic degranulation (CD107a), activation/exhaustion (PD1) and viability. Evaluation of direct cytotoxicity was done by using chimeric antigen receptor (CAR) T cells.
RESULTS
TTFields did not change T cell activation rates for all evaluated functions with the exception of reduced proliferation - in line with TTFields’ MOA. TTFields substantially reduced the viability of activated proliferating T cells, moderately affected activated nonproliferating T cells and had almost no effect on the viability of non-activated cells. Polyfunctionality analysis of T-cells, associated with effective antitumoral responses, demonstrated that under TTFields, the activated non-proliferating T cells retained polyfunctional capabilities. PD1-expressing TILs, a subset containing most of the tumor antigen-specific TILs, exhibited unaltered viability and functionality under TTFields. CAR T-cells, which utilize the same killing machinery as unmodified T cells, exhibited unaltered cytotoxic capability under TTFields. Immunohistochemical evaluation of GBM samples before TTFields treatment and after recurrence showed that some patients had accommodated large increases in their CD8 and CD4 counts. RNA-Seq performed on GBM samples from 6 standardly-treated and 6 TTFields-treated patients before treatment and after recurrence. The data shows differential increases in TTFields-treated patients to controls, in the expression of immune genes associated with favorable prognosis (e.g. t-bet, NKG2D, ICOS-L, CD70) and concurrent decreases in genes associated with poor prognosis (e.g. IL4, TSLP, various complement genes).
CONCLUSION
The preclinical data showed that all antitumoral T cell functions examined, but proliferation, were unhindered by TTFields. The clinical data showed that TTFields may shift treated tumors to a state more conducive of antitumoral immune responses. Our findings support the further preclinical and clinical investigation into combining TTFields with immunotherapy.
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Affiliation(s)
- G Diamant
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - H Simchony
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - T Shiloach
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | | | - Z Eshhar
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - N Pencovich
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - R Grossman
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Z Ram
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - I Volovitz
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Limon D, Bokstein F, Blumenthal D, Ben Harush C, Ram Z, Grossman R. P14.79 Randomized phase II trial of Tumor Treating Fields plus radiation therapy plus temozolomide compared to radiation therapy plus temozolomide in patients with newly diagnosed glioblastoma. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz126.314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
In last decade, there were numerous attempts to improve the outcome of patients with glioblastoma (GBM), but even after maximal surgical resection, radiation therapy (RT) and temozolomide (TMZ), followed by maintenance TMZ for 6 months the median OS is 14.6 months. In the EF-14 Phase III trial, the addition of Tumor Treating Fields (TTFields) at 200 kHz to maintenance TMZ increased the median OS to 20.9 months, compared with 16.0 months with maintenance TMZ alone (HR, 0.63; 95% CI, 0.53–0.76; p<0.001). Based on these results, the currently accepted standard of care for newly diagnosed GBM (ndGBM) is surgical resection if safely feasible, followed by RT with concomitant TMZ, and then followed by maintenance TMZ in combination with TTFields. Preclinical investigations have shown a radio-sensitizing effect of TTFields on glioma cells, suggesting synergistic effects between TTFields and radiotherapy. In a pilot study of 10 patients with ndGBM, we demonstrated that there was no increased treatment-related toxicity when TTFields were given in combination with RT/TMZ. The only TTFields-related adverse event was skin toxicity below the arrays. Preliminary progression free survival (PFS) data was encouraging. Based on the results of the pilot study, we designed this prospective, randomized Phase II study to further investigate if the addition of TTFields TMZ/RT treatment in ndGBM patients improves treatment efficacy and delays disease progression.
MATERIAL AND METHODS
Following debulking surgery or biopsy, 60 adult patients (≥18 years) with histologically confirmed GBM, KPS≥70 and life expectancy of at least 3 months will be randomized 1:1 to either a) RT with concomitant TMZ and TTFields (200 kHz) for 6 weeks followed by up to 6 months of maintenance TMZ in combination with TTFields (experimental arm) up to 24 months; or b) RT with concomitant TMZ alone followed by maintenance TMZ in combination with TTFields (control arm). Exclusion criteria: patients with early progressive disease, significant comorbidities precluding maintenance RT or TMZ or patients with an implanted electronic device. The primary endpoint is progression free survival at 12 months (PFS12). Treatment with TTFields will be continued until second progression or 24 months (the earlier of the two). All patients will be followed for survival. Grading and severity of all adverse events will be recorded using CTCAE V5.0. The sample size of 60 patients provides 80% power with a two-sided alpha level of 0.05 to detect a PFS12 of 46.5% with RT/TMZ/TTFields compared to 29.4% with RT/TMZ followed, respectively, by maintenance TMZ/TTFields (calculated from the RT/TMZ followed by maintenance TMZ/TTFields arm of the EF-14 trial). It is forecasted to take 24 months to fully recruit. Follow-up will continue for >12 months from recruitment of the last patient.
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Affiliation(s)
- D Limon
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - F Bokstein
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - D Blumenthal
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - C Ben Harush
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Z Ram
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - R Grossman
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Grossman R, Bokstein F, Blumenthal D, Ben Harush C, Limon D, Ram Z. P14.71 Tumor Treating Fields combined with radiotherapy and temozolomide for newly diagnosed glioblastoma: final safety and efficacy results from a pilot study. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz126.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Tumor Treating Fields (TTFields) are a non-invasive, loco-regional, anti-mitotic treatment consisting of low intensity alternating electric fields. The combination of TTFields with maintenance temozolomide significantly improved survival versus temozolomide alone in the phase 3 EF-14 study in newly diagnosed glioblastoma (ndGBM). In preclinical studies, TTFields increased the number of glioma cells undergoing cellular death following radiotherapy (RT) by inhibiting DNA damage repair, suggesting a radio-sensitizing effect of TTFields. This pilot study is the first to evaluate the safety and feasibility of administering TTFields concomitant to RT and TMZ in ndGBM patients.
MATERIAL AND METHODS
Patients diagnosed with ndGBM were treated with TTFields/RT/TMZ followed by maintenance TMZ and TTFields for up to 24 months. TTFields (200kHz) were delivered for >18 hours/day while the transducer arrays were removed during delivery of RT. TMZ was administered at a dose of 75 mg/m2/daily for 6 weeks and RT at a total dose of 60 Gy. The primary endpoint was safety of the combined TTFields/RT/TMZ; secondary endpoints included progression-free survival (PFS), overall survival (OS) and toxicity. Adverse events (AEs) were graded according to CTCAE V4.0.
RESULTS
10 ndGBM patients that recovered from maximal debulking surgery or biopsy were enrolled at a single center in Israel between April and December 2017. Five patients (50%) had undergone gross total resection while the rest had biopsy only. Eight of the patients were male, median age was 59, median KPS was 80 and median dose of RT was 60 Gy. Six patients (60%) reported at least one AE. The most common AE was TTFields-related skin toxicity, reported in four patients (40%), all of which were grade 1–2 in severity. Two patients reported serious AEs (seizures and general deterioration) that were considered unrelated to TTFields. Median PFS with RT/TMZ/TTFields was 10.5 months. Median OS has not yet been reached.
CONCLUSION
The proportion of patients with TTFields-related skin toxicity was similar to that reported in ndGBM patients in the randomized Phase III study (52%), where patients started TTFields at least 4 weeks after RT. No other TTFields-related toxicities were reported and there were no increase in RT- or TMZ-related toxicities as a result of combining TTFields with RT in addition to TMZ. Based on the safety and preliminary efficacy results of this pilot study, a phase II randomized study has been initiated to investigate the efficacy of concomitant RT/TMZ/TTFields in 60 ndGBM patients.
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Affiliation(s)
- R Grossman
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - F Bokstein
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - D Blumenthal
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - C Ben Harush
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - D Limon
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Z Ram
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Oddo L, Paradossi G, Cerroni B, Ben-Harush C, Ariel E, Di Meco F, Ram Z, Grossman R. In Vivo Biodistribution of Engineered Lipid Microbubbles in Rodents. ACS Omega 2019; 4:13371-13381. [PMID: 31460465 PMCID: PMC6704434 DOI: 10.1021/acsomega.9b01544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 06/25/2019] [Indexed: 05/08/2023]
Abstract
Maximal resection of intrinsic brain tumors is a major prognostic factor for survival. Real-time intraoperative imaging tools, including ultrasound (US), are crucial for maximal resection of such tumors. Microbubbles (MBs) are clinically used in daily practice as a contrast agent for ultrasound and can be further developed to serve combined therapeutic and diagnostic purposes. To achieve this goal, we have developed novel MBs conjugated to specific ligands to receptors which are overexpressed in brain tumors. These MBs are designed to target a tumor tissue, visualize it, and deliver therapeutic molecules into it. The objective of this study was to assess the biodistribution of the test items: We used MBs labeled with indocyanine green (MB-ICG) for visualization and MBs conjugated to a cyclic molecule containing the tripeptide Arg-Gly-Asp (RGD) labeled with ICG (MB-RGD-ICG) to target brain tumor integrins as the therapeutic tools. Male Sprague Dawley rats received a single dose of each MB preparation. The identification of the MB in various organs was monitored by fluorescence microscopy in anesthetized animals as well as real-time US for brain imaging. Equally sized control groups under identical conditions were used in this study. One control group was used to establish fluorescence background conditions (ICG), and two control groups were used to test autofluorescence from the test items (MBs and MB-RGD). ICG with or without MBs (naked or RGD-modified) was detected in the brain vasculature and also in other organs. The pattern, duration, and intensity of the fluorescence signal could not be differentiated between animals treated with ICG alone and animals treated with microbubbles MBs-ICG or MBs-RGD-ICG. Following MB injection, either naked or combined with RGD, there was a sharp rise in the Doppler signal within seconds of injection in the brain. The signal was mainly located at the choroid plexus, septum pellucidum, and the meninges of the brain. The signal subsided within a few minutes. Injection of saline or ICG alone to respective animals did not result in a similar raised signal. Following a single intravenous administration of MB-ICG and MB-RGD-ICG to rats, the MBs were found to be effectively present in the brain.
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Affiliation(s)
- Letizia Oddo
- Dipartimento di Scienze e Tecnologie Chimiche, Universitá degli Studi di Roma Tor Vergata, 00133 Roma, Italy
| | - Gaio Paradossi
- Dipartimento di Scienze e Tecnologie Chimiche, Universitá degli Studi di Roma Tor Vergata, 00133 Roma, Italy
| | - Barbara Cerroni
- Dipartimento di Scienze e Tecnologie Chimiche, Universitá degli Studi di Roma Tor Vergata, 00133 Roma, Italy
| | - Carmit Ben-Harush
- Department of Neurosurgery,
Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6997801 Tel-Aviv, Israel
| | - Eti Ariel
- Department of Neurosurgery,
Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6997801 Tel-Aviv, Israel
| | - Francesco Di Meco
- Neuro-Oncology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Zvi Ram
- Department of Neurosurgery,
Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6997801 Tel-Aviv, Israel
| | - Rachel Grossman
- Department of Neurosurgery,
Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6997801 Tel-Aviv, Israel
- E-mail: . Phone: +972-3-6974273. Fax: +972-3-6974860
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Paramasivam N, Hübschmann D, Toprak UH, Ishaque N, Neidert M, Schrimpf D, Stichel D, Reuss D, Sievers P, Reinhardt A, Wefers AK, Jones DTW, Gu Z, Werner J, Uhrig S, Wirsching HG, Schick M, Bewerunge-Hudler M, Beck K, Brehmer S, Urbschat S, Seiz-Rosenhagen M, Hänggi D, Herold-Mende C, Ketter R, Eils R, Ram Z, Pfister SM, Wick W, Weller M, Grossmann R, von Deimling A, Schlesner M, Sahm F. Mutational patterns and regulatory networks in epigenetic subgroups of meningioma. Acta Neuropathol 2019; 138:295-308. [PMID: 31069492 DOI: 10.1007/s00401-019-02008-w] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 04/01/2019] [Accepted: 04/03/2019] [Indexed: 01/05/2023]
Abstract
DNA methylation patterns delineate clinically relevant subgroups of meningioma. We previously established the six meningioma methylation classes (MC) benign 1-3, intermediate A and B, and malignant. Here, we set out to identify subgroup-specific mutational patterns and gene regulation. Whole genome sequencing was performed on 62 samples across all MCs and WHO grades from 62 patients with matched blood control, including 40 sporadic meningiomas and 22 meningiomas arising after radiation (Mrad). RNA sequencing was added for 18 of these cases and chromatin-immunoprecipitation for histone H3 lysine 27 acetylation (H3K27ac) followed by sequencing (ChIP-seq) for 16 samples. Besides the known mutations in meningioma, structural variants were found as the mechanism of NF2 inactivation in a small subset (5%) of sporadic meningiomas, similar to previous reports for Mrad. Aberrations of DMD were found to be enriched in MCs with NF2 mutations, and DMD was among the most differentially upregulated genes in NF2 mutant compared to NF2 wild-type cases. The mutational signature AC3, which has been associated with defects in homologous recombination repair (HRR), was detected in both sporadic meningioma and Mrad, but widely distributed across the genome in sporadic cases and enriched near genomic breakpoints in Mrad. Compared to the other MCs, the number of single nucleotide variants matching the AC3 pattern was significantly higher in the malignant MC, which also exhibited higher genomic instability, determined by the numbers of both large segments affected by copy number alterations and breakpoints between large segments. ChIP-seq analysis for H3K27ac revealed a specific activation of genes regulated by the transcription factor FOXM1 in the malignant MC. This analysis also revealed a super enhancer near the HOXD gene cluster in this MC, which, together with general upregulation of HOX genes in the malignant MC, indicates a role of HOX genes in meningioma aggressiveness. This data elucidates the biological mechanisms rendering different epigenetic subgroups of meningiomas, and suggests leveraging HRR as a novel therapeutic target.
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Affiliation(s)
- Nagarajan Paramasivam
- Division of Theoretical Bioinformatics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Heidelberg Center for Personalized Oncology (DKFZ-HIPO), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Daniel Hübschmann
- Division of Theoretical Bioinformatics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Division of Stem Cells and Cancer, DKFZ, Heidelberg, Germany
- Heidelberg Institute for Stem Cell Technology and Experimental Medicine (HI-STEM gGmbH), Heidelberg, Germany
- Department of Pediatric Oncology, Hematology and Immunology, University Hospital, Heidelberg, Germany
| | - Umut H Toprak
- Division Neuroblastoma Genomics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Hopp-Children's Cancer Center at the NCT Heidelberg (KiTZ), Heidelberg, Germany
| | - Naveed Ishaque
- Division of Theoretical Bioinformatics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Heidelberg Center for Personalized Oncology (DKFZ-HIPO), German Cancer Research Center (DKFZ), Heidelberg, Germany
- Center for Digital Health, Berlin Institute of Health and Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Marian Neidert
- Department of Neurosurgery, University Hospital of Zürich, Zurich, Switzerland
| | - Daniel Schrimpf
- Department of Neuropathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Damian Stichel
- Department of Neuropathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - David Reuss
- Department of Neuropathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Philipp Sievers
- Department of Neuropathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Annekathrin Reinhardt
- Department of Neuropathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Annika K Wefers
- Department of Neuropathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - David T W Jones
- Hopp-Children's Cancer Center at the NCT Heidelberg (KiTZ), Heidelberg, Germany
- Pediatric Glioma Research Group, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Zuguang Gu
- Division of Theoretical Bioinformatics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Heidelberg Center for Personalized Oncology (DKFZ-HIPO), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Johannes Werner
- Division of Theoretical Bioinformatics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Biological Oceanography, Leibniz Institute of Baltic Sea Research, Rostock, Germany
| | - Sebastian Uhrig
- Division of Applied Bioinformatics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hans-Georg Wirsching
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Matthias Schick
- Genomics and Proteomics Core Facility, Microarray Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Melanie Bewerunge-Hudler
- Genomics and Proteomics Core Facility, Microarray Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Katja Beck
- Heidelberg Center for Personalized Oncology (DKFZ-HIPO), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stephanie Brehmer
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Steffi Urbschat
- Department of Neurosurgery, University Hospital Homburg Saar, Homburg, Germany
| | - Marcel Seiz-Rosenhagen
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christel Herold-Mende
- Division of Experimental Neurosurgery, Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ralf Ketter
- Department of Neurosurgery, University Hospital Homburg Saar, Homburg, Germany
| | - Roland Eils
- Division of Theoretical Bioinformatics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Center for Digital Health, Berlin Institute of Health and Charité Universitätsmedizin Berlin, Berlin, Germany
- Health Data Science Unit, Bioquant, Medical Faculty, University of Heidelberg, Heidelberg, Germany
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Stefan M Pfister
- Department of Pediatric Oncology, Hematology and Immunology, University Hospital, Heidelberg, Germany
- Hopp-Children's Cancer Center at the NCT Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Wolfgang Wick
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Rachel Grossmann
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Andreas von Deimling
- Department of Neuropathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Matthias Schlesner
- Bioinformatics and Omics Data Analytics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Felix Sahm
- Hopp-Children's Cancer Center at the NCT Heidelberg (KiTZ), Heidelberg, Germany.
- Department of Neuropathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany.
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Wengier A, Ram Z, Warshavsky A, Margalit N, Fliss DM, Abergel A. Endoscopic skull base reconstruction with the nasoseptal flap: complications and risk factors. Eur Arch Otorhinolaryngol 2019; 276:2491-2498. [DOI: 10.1007/s00405-019-05531-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 06/22/2019] [Indexed: 11/24/2022]
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43
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Diamant G, Simchony H, Shiloach T, Globerson-levin A, Plotnitsky LG, Eshhar Z, Pencovich N, Grossman R, Ram Z, Volovitz I. Abstract 3954: Evaluating the compatibility of tumor treating electric fields with key anti-tumoral immune functions. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-3954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Combining Tumor Treating electrical Fields (TTFields) with immunotherapy is a rational approach due to their different mechanisms of action (MOA) and to TTFields’ ability to induce immunogenic cell death (ICD). Conversely, TTFields may interfere with immune functions critical for effective T cell responses.
Methods: T cells from healthy donors’ peripheral blood or from viably dissociated glioblastoma samples were cultured under normal or TTFields conditions, with or without superantigen-stimulation. Eight-color flow cytometry was used to assess T cell responses by monitoring select pivotal antitumoral functions: proliferation (CFSE), IFNγ secretion, cytotoxic degranulation (CD107a), activation/exhaustion (PD1) and viability. Direct cytotoxicity was evaluated using chimeric antigen receptor (CAR) T cells.
Results: The viability of stimulated T cells that attempted to proliferate decreased under TTFields, in line with TTFields’ MOA. Small or no reductions in viability were found in activated T cells that did not attempt to proliferate and in unstimulated T cells.
The functionality of stimulated peripheral-blood T cells and tumor-infiltrating T cells (TILs) under TTFields was unhindered: T cells exhibited comparable PD1 upregulation, IFNγ secretion and CD107a expression as controls. T cell polyfunctionality, associated with effective antitumoral responses, was retained under TTFields conditions. PD1-expressing TILs, a subset containing most of the tumor antigen-specific TILs, exhibited unaltered viability and functionality under TTFields. CAR T-cells, which utilize the same killing machinery as unmodified T cells, exhibited unaltered cytotoxic capability under TTFields.
Immunohistochemical evaluation of GBM samples before TTFields treatment and after recurrence showed that some patients had accommodated large increases in their CD8 and CD4 counts. RNA-Seq performed on GBM samples from 6 standardly-treated and 6 TTFields-treated patients before treatment and after recurrence. The data shows differential increases in TTFields-treated patients to controls, in the expression of immune genes associated with favorable prognosis (e.g. t-bet, NKG2D, ICOS-L, CD70) and concurrent decreases in genes associated with poor prognosis (e.g. IL4, TSLP, various complement genes).
Conclusions: The preclinical data showed that all antitumoral T cell functions examined, but proliferation, were unhindered by TTFields. The clinical data showed that TTFields may shift treated tumors to a state more conducive of anti-tumoral immune responses. Our findings support the further preclinical and clinical investigation into combining TTFields with immunotherapy.
Citation Format: Gil Diamant, Hadar Simchony, Tamar Shiloach, Anat Globerson-levin, Lital Gasri Plotnitsky, Zelig Eshhar, Niv Pencovich, Rachel Grossman, Zvi Ram, Ilan Volovitz. Evaluating the compatibility of tumor treating electric fields with key anti-tumoral immune functions [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3954.
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Affiliation(s)
- Gil Diamant
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | | | | | | | - Zelig Eshhar
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | | | - Zvi Ram
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Simchony H, Diamant D, Ram Z, Volovitz I. Evaluation of the Compatibility of Electric Tumor Treating Fields with Key Anti-tumoral T-Cell Functions. Isr Med Assoc J 2019; 21:503. [PMID: 31507132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Tumor treating fields (TTFields) are low-intensity, intermediate frequency electric fields that affect proliferating cells. TTFields are FDA approved for treatment of newly diagnosed and recurrent glioblastoma. Combining TTFields with immunotherapy is a rational approach due to their different mechanisms of action (MOA) and to the ability of TTFields to induce immunogenic cell death. Conversely, TTFields may interfere with immune functions critical for effective T-cell responses. OBJECTIVES To evaluate the effects of TTFields on pivotal antitumoral T-cell functions. METHODS T-cells from healthy donor peripheral blood (PB) or from viably dissociated human glioblastoma samples were cultured under normal or TTFields conditions, with or without superantigen stimulation. Multiparametric flow cytometry (8-color) was used to assess T-cell responses by monitoring select pivotal functions: proliferation (CFSE), IFNγ secretion, cytotoxic degranulation (CD107a), and activation/exhaustion (PD-1). Cellular viability was assessed in a dedicated assay. A chimeric antigen receptor (CAR) T-cell-based assay directly evaluated cellular cytotoxicity. RESULTS Activated PB T-cells and tumor-infiltrating T-cells (TILs) preserved all monitored anti- tumoral functions under TTFields, apart from proliferation. This finding also applied specifically to PD-1 + TILs, comprised predominantly of tumor antigen-specific cells. Activated T-cells that attempted to proliferate under TTFields demonstrated decreased viability, in line with TTField MOA. Small or no reduction in viability was found in T-cells that did not attempt to proliferate, whether activated or resting. CONCLUSIONS All monitored anti-tumoral T cell functions, except for proliferation, were unhindered by TTFields. Our results support further investigation into combinations of TTFields with T-cell based immunotherapeutic approaches.
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Affiliation(s)
- Hadar Simchony
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Diamant Diamant
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Volovitz
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Grossman R, Limon D, Bokstein F, Ram Z. Abstract CT008: Tumor Treating Fields combined with radiotherapy and temzolomide for newly diagnosed glioblastoma: Final results from a pilot study. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-ct008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Tumor Treating Fields (TTFields) are a non-invasive, loco-regional, anti-mitotic treatment comprising low intensity alternating electric fields. In the Phase III EF-14 study in newly diagnosed glioblastoma (ndGBM), TTFields significantly improved survival compared to temozolomide (TMZ). Preclinical data have demonstrated that TTFields increased glioma cell death following radiation therapy (RT), suggesting a radio-sensitizing effect of TTFields. We therefore initiated a pilot study to evaluate the safety and feasibility of administering TTFields concomitant to RT and TMZ in ndGBM patients.
Methods: Patients with histologically confirmed ndGBM were treated with TTFields/RT/TMZ followed by maintenance TTFields and TMZ for up to 24 months. TTFields (200kHz) were delivered for >18 hours/day with removal of the transducer arrays during delivery of RT. TMZ was administered at a dose of 75 mg/m2/daily for 6 weeks and RT at a total dose of 60 Gy. The primary endpoint was safety of the combined TTFields/RT/TMZ; secondary endpoints included progression-free survival (PFS), overall survival (OS) and toxicity. Adverse events (AEs) were graded according to CTCAE V4.0.
Results: Ten patients were enrolled at a single center in Israel between April and December 2017. All patients had recovered from maximal debulking surgery or biopsy. Five patients (50%) had undergone gross total resection while the rest had biopsy only. Median age was 59 and median KPS was 80. Median dose of RT was 60 Gy. Six patients (60%) reported at least one AE. The most common AE was TTFields-related skin toxicity, reported in 4 patients (40%), all of which were Grade 1-2 in severity. Two patients reported serious AEs (seizures and general deterioration) that were considered unrelated to TTFields. Median PFS with RT/TMZ/TTFields was 10.5 months. Median OS has not yet been reached.
Conclusions: The proportion of patients with TTFields-related skin toxicity was similar to that reported in ndGBM patients in the randomized Phase III study (52%). No other TTFields-related toxicities were reported, nor was there an increase in RT- or TMZ-related toxicities as a result of combining TTFields with RT in addition to TMZ. Based on the safety and preliminary efficacy results of this pilot study, a Phase II randomized study has been initiated to investigate the efficacy of concomitant RT/TMZ/TTFields in 60 ndGBM patients.
Citation Format: Rachel Grossman, Dror Limon, Felix Bokstein, Zvi Ram. Tumor Treating Fields combined with radiotherapy and temzolomide for newly diagnosed glioblastoma: Final results from a pilot study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT008.
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Affiliation(s)
| | - Dror Limon
- Tel Aviv Medical Center, Tel Aviv, Israel
| | | | - Zvi Ram
- Tel Aviv Medical Center, Tel Aviv, Israel
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Grossman R, Limon D, Bokstein F, Harosh CB, Ram Z. Abstract CT203: Randomized Phase II trial of Tumor Treating Fields plus radiation therapy plus temozolamide compared to radiation therapy plus temozolomide in patients with newly diagnosed glioblastoma. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-ct203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Despite attempts to improve the outcome of patients with glioblastoma (GBM), the 3-year survival of patients treated with maximal surgical resection, radiation therapy (RT) and temozolomide (TMZ), followed by maintenance TMZ for 6 months is only 6% with a median OS of 14.6 months. In the EF-14 Phase III trial, the addition of Tumor treating fields (TTFields) at 200 kHz to maintenance TMZ increased the median OS to 20.9 months, compared with 16.0 months with maintenance TMZ alone (HR, 0.63; 95% CI, 0.53-0.76; p< 0.001). Based on these results, the currently accepted standard of care for newly diagnosed GBM (ndGBM) is surgical resection if safely feasible, followed by RT with concomitant TMZ, and then followed by maintenance TMZ in combination with TTFields. Preclinical investigations have confirmed a radio-sensitizing effect of TTFields on glioma cells, suggesting that TTFields given in combination with RT may have a synergistic effect. In a pilot study of 10 patients with ndGBM, we demonstrated that there was no increased treatment-related toxicity when TTFields were given in combination with RT/TMZ. The only TTFields-related adverse event was skin toxicity below the arrays. Preliminary progression free survival (PFS) data was encouraging. Based on the results of the pilot study, we designed this prospective, randomized Phase II study to further investigate if the addition of TTFields TMZ/RT treatment in ndGBM patients improves treatment efficacy and delays disease progression.
Methods: Following debulking surgery or biopsy, 60 adult patients (≥18 years) with histologically confirmed GBM, KPS≥70 and life expectancy of at least 3 months will be randomized 1:1 to either i) RT with concomitant TMZ and TTFields (200 kHz) for 6 weeks followed by up to 6 months of maintenance TMZ in combination with TTFields (experimental arm) up to 24 months; or ii) RT with concomitant TMZ alone followed by maintenance TMZ in combination with TTFields (control arm). Patients with early progressive disease, significant comorbidities precluding maintenance RT or TMZ or patients with an implanted electronic device will be excluded. The primary endpoint is the rate of progression free survival at 12 months (PFS12). Treatment with TTF will be continued until second progression or 24 months (the earlier of the two). All patients will be followed for survival. Grading and severity of all adverse events will be recorded using CTCAE V5.0. The sample size of 60 patients provides 80% power with a two-sided alpha level of 0.05 to detect a PFS12 of 46.5% with RT/TMZ/TTFields compared to 29.4% with RT/TMZ followed, respectively, by maintenance TMZ/TTFields (calculated from the RT/TMZ followed by maintenance TMZ/TTFields arm of the EF-14 trial). It is forecasted to take 24 months to fully recruit. Follow-up will continue for >12 months from recruitment of the last patient.
Citation Format: Rachel Grossman, Dror Limon, Felix Bokstein, Carmit Ben Harosh, Zvi Ram. Randomized Phase II trial of Tumor Treating Fields plus radiation therapy plus temozolamide compared to radiation therapy plus temozolomide in patients with newly diagnosed glioblastoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT203.
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Affiliation(s)
| | - Dror Limon
- Tel Aviv Medical Center, Tel Aviv, Israel
| | | | | | - Zvi Ram
- Tel Aviv Medical Center, Tel Aviv, Israel
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Paradossi G, Oddo L, Cerroni B, Ben-Harush C, Ariel E, Di Meco F, Ram Z, Grossman R. In Vivo Toxicity Study of Engineered Lipid Microbubbles in Rodents. ACS Omega 2019; 4:5526-5533. [PMID: 31497678 PMCID: PMC6715268 DOI: 10.1021/acsomega.8b03161] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/16/2019] [Indexed: 05/08/2023]
Abstract
Real-time intraoperative imaging for brain tumor surgery is crucial for achieving complete resection. We are developing novel lipid-based microbubbles (MBs), engineered with specific ligands, which are able to interact with the integrins overexpressed in the endothelium of the brain tumor vasculature. These MBs are designed to visualize the tumor and to carry therapeutic molecules into the tumor tissue, preserving the ultrasound acoustic properties of the starting plain lipid MBs. The potential toxicity of this novel technology was assessed in rats by intravenous injections of two doses of plain MBs and MBs engineered for targeting and near-infrared fluorescence visualization at two time-points, 10 min and 7 days, for potential acute and chronic responses in rats [(1) MB, (2) MB-ICG, (3) MB-RGD, and (4) MB-ICG-RGD]. No mortality occurred during the 7-day study period in any of the dosing groups. All animals demonstrated a body weight gain during the study period. Minor, mostly reversible changes in hematological and biochemical analysis were observed in some of the treated animals. All changes were reversible by the 7-day time-point. Histopathology examination in the high-dose animals showed development of foreign body granulomatous inflammation. We concluded that the low-dose tested items appear to be safe. The results allow for proceeding to clinical testing of the product.
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Affiliation(s)
- Gaio Paradossi
- Dipartimento di Scienze e Tecnologie Chimiche, Università degli Studi di Roma Tor Vergata, 00133 Roma, Italy
| | - Letizia Oddo
- Dipartimento di Scienze e Tecnologie Chimiche, Università degli Studi di Roma Tor Vergata, 00133 Roma, Italy
| | - Barbara Cerroni
- Dipartimento di Scienze e Tecnologie Chimiche, Università degli Studi di Roma Tor Vergata, 00133 Roma, Italy
| | - Carmit Ben-Harush
- Department of Neurosurgery,
Tel Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6997801 Tel-Aviv, Israel
| | - Eti Ariel
- Department of Neurosurgery,
Tel Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6997801 Tel-Aviv, Israel
| | - Francesco Di Meco
- Neuro-Oncology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Zvi Ram
- Department of Neurosurgery,
Tel Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6997801 Tel-Aviv, Israel
| | - Rachel Grossman
- Department of Neurosurgery,
Tel Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6997801 Tel-Aviv, Israel
- E-mail: . Phone: +972-3-6974273. Fax: +972-3-6974860
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Tordjman KM, Greenman Y, Ram Z, Hershkovitz D, Aizenstein O, Ariel O, Asa SL. Plurihormonal Pituitary Tumor of Pit-1 and SF-1 Lineages, with Synchronous Collision Corticotroph Tumor: a Possible Stem Cell Phenomenon. Endocr Pathol 2019; 30:74-80. [PMID: 30610567 DOI: 10.1007/s12022-018-9562-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Thyrotropin (TSH)-secreting pituitary tumors are the rarest functioning pituitary tumors. Nonetheless, they are not infrequently plurihormonal, as they may express/secrete hormones made by other pituitary cells derived from the Pit-1 lineage such as growth hormone (GH), prolactin (PRL), and α-subunit (αSU). However, adrenocorticotropin (ACTH) or gonadotropin secretion by such a tumor is exceptional. Although double pituitary tumors are rare, they often combine ACTH and GH secretion. A 41-year-old presented almost 2 years after delivering her 10th child; she had thyrotoxicosis (goiter and palpitations) masquerading as autoimmune postpartum thyroiditis. She was still breastfeeding and amenorrheic. She proved to have TSH, GH, PRL, and ACTH hypersecretion. Imaging revealed an invasive pituitary macrotumor. She had stigmata neither of Cushing's disease nor of acromegaly. Prior to surgery, hormonal control was achieved for close to 1 year by combined octreotide and cabergoline treatment with significant shrinking of the tumor. Following surgery, pathology revealed a collision tumor; the dominant lesion was positive for GH, βTSH, βFSH, and αSU and expressed both Pit-1 and SF-1.The smaller lesion was a corticotroph tumor. We report an unusual plurihormonal tumor co-expressing Pit-1 and SF-1 along with hormones made by cells of both lineages. Its simultaneous occurrence adjacent to a corticotroph tumor raises questions regarding the pathogenesis of these tumors. We propose the possibility of a stem cell tumor with multiple lineage differentiation. We hypothesize that pregnancy might have played a permissive role in tumorigenesis.
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Affiliation(s)
- Karen M Tordjman
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 64239, Tel Aviv, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yona Greenman
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 64239, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zvi Ram
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Dov Hershkovitz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Pathology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Orna Aizenstein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ofra Ariel
- Maccabi Health Services, Tel Aviv, Israel
| | - Sylvia L Asa
- Department of Pathology, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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Toms SA, Kim CY, Nicholas G, Ram Z. Increased compliance with tumor treating fields therapy is prognostic for improved survival in the treatment of glioblastoma: a subgroup analysis of the EF-14 phase III trial. J Neurooncol 2019; 141:467-473. [PMID: 30506499 PMCID: PMC6342854 DOI: 10.1007/s11060-018-03057-z] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/21/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Tumor treating fields (TTFields) is a non-invasive, antimitotic therapy. In the EF-14 phase 3 trial in newly diagnosed glioblastoma, TTFields plus temozolomide (TTFields/TMZ) improved progression free (PFS) and overall survival (OS) versus TMZ alone. Previous data indicate a ≥ 75% daily compliance improves outcomes. We analyzed compliance data from TTFields/TMZ patients in the EF-14 study to correlate TTFields compliance with PFS and OS and identify potential lower boundary for compliance with improved clinical outcomes. METHODS Compliance was assessed by usage data from the NovoTTF-100A device and calculated as percentage per month of TTFields delivery. TTFields/TMZ patients were segregated into subgroups by percent monthly compliance. A Cox proportional hazard model controlled for sex, extent of resection, MGMT methylation status, age, region, and performance status was used to investigate the effect of compliance on PFS and OS. RESULTS A threshold value of 50% compliance with TTFields/TMZ improved PFS (HR 0.70, 95% CI 0.47-1.05) and OS (HR 0.67, 95% CI 0.45-0.99) versus TMZ alone with improved outcome as compliance increased. At compliance > 90%, median survival was 24.9 months (28.7 months from diagnosis) and 5-year survival rate was 29.3%. Compliance was independent of gender, extent of resection, MGMT methylation status, age, region and performance status (HR 0.78; p = 0.031; OS at compliance ≥ 75% vs. < 75%). CONCLUSION A compliance threshold of 50% with TTFields/TMZ correlated with significantly improved OS and PFS versus TMZ alone. Patients with compliance > 90% showed extended median and 5-year survival rates. Increased compliance with TTFields therapy is independently prognostic for improved survival in glioblastoma.
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Affiliation(s)
- S A Toms
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - C Y Kim
- Seoul National University, Bundang, South Korea
| | - G Nicholas
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Z Ram
- Tel Aviv Medical Center, Tel Aviv, Israel
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Berger A, Constantini S, Ram Z, Roth J. Acute subdural hematomas in shunted normal-pressure hydrocephalus patients - Management options and literature review: A case-based series. Surg Neurol Int 2019; 9:238. [PMID: 30595959 PMCID: PMC6287333 DOI: 10.4103/sni.sni_338_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/25/2018] [Indexed: 11/29/2022] Open
Abstract
Background: Ventriculoperitoneal shunting (VPS) is considered a risk factor for developing subdural hematomas (SDH). Treating cases of acute SDH (aSDH) in shunted normal-pressure hydrocephalus (NPH) patients can be challenging, and data in this field are scarce. We report our experience treating shunted NPH patients presenting with aSDH. Methods: Eight patients, aged 73 ± 6 years, with a history of VPS for NPH, hospitalized because of aSDH were included in this study. We retrospectively analyzed data regarding patients’ clinical and radiological presentation, hospitalization course, the use of antithrombotics, and response to different treatment regimens. Results: Four patients had pure aSDH, three had acute on chronic SDH, and one had subacute SDH. Patients presented with GCS 13–15 and various neurological signs, mainly confusion and unsteady gate. Two cases improved following resetting of their programmable shunt valve to its maximal pressure setting. Six cases improved after evacuation of the hematomas, five of them were operated a few days after initially resetting of the valve pressure. Three patients were discharged home, whereas five were referred to rehabilitation. Extended Glasgow Outcome Scale scores at discharge and during long-term follow-up were 5 and 7, respectively. Conclusions: Treatment of patients with VPS for NPH, presenting with aSDH, may differ according to the neurological status, imaging, and clinical course. Treatment options include restricting shunt function, hematoma evacuation, or both.
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Affiliation(s)
- Assaf Berger
- Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Shlomi Constantini
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Tel-Aviv University, Tel-Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Tel-Aviv University, Tel-Aviv, Israel
| | - Jonathan Roth
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Tel-Aviv University, Tel-Aviv, Israel
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