Tumors of the Central Nervous System, Volume 2: Gliomas: Glioblastoma (Part 2)

Tumors of the Central Nervous System Tumors of the Central Nervous System Volume 2 For other titles published in thi...

Author: M.A. Hayat

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Tumors of the Central Nervous System

Tumors of the Central Nervous System Volume 2

For other titles published in this series, go to www.springer.com/series/8812

Tumors of the Central Nervous System Volume 2

Tumors of the Central Nervous System Gliomas: Glioblastoma (Part 2) Edited by

M.A. Hayat Distinguished Professor Department of Biological Sciences, Kean University, Union, NJ, USA

123

Editor M.A. Hayat Department of Biological Sciences Kean University Union, NJ, USA [email protected]

ISBN 978-94-007-0617-0 e-ISBN 978-94-007-0618-7 DOI 10.1007/978-94-007-0618-7 Springer Dordrecht Heidelberg London New York Library of Congress Control Number: 2011923069 © Springer Science+Business Media B.V. 2011 No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission from the Publisher, with the exception of any material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

“Although touched by technology, surgical pathology always has been, and remains, an art. Surgical pathologists, like all artists, depict in their artwork (surgical pathology reports) their interactions with nature: emotions, observations, and knowledge are all integrated. The resulting artwork is a poor record of complex phenomena.” Richard J. Reed MD

Preface

The primary objective of this series, Tumors of the Central Nervous System, is to present the readers with the most up-to-date information on the initiation, progression, recurrence, metastasis, and treatment of the CNS tumors. As in volume 1, volume 2 has discussed in detail biomarkers and diagnosis of gliomas, especially glioblastoma. The role of a large number of biomarkers in the diagnosis of glioblastoma is included. Advantages and limitations of the use of biomarkers for diagnosis are presented. The role of TP53 gene mutation in the initiation and progression of glioblastoma is presented as well as germline mutations of this gene. Role of oncogenes and tumor suppressor genes is also discussed. Also, is discussed the role of specific genes in the resistance to drug therapy. The importance of the use of imaging modalities (e.g., PET, CT, MRI, and SPECT) in clinical diagnosis, treatment assessment, and recurrence determination is pointed out. It is well established that early diagnosis is the key to cancer “cure”. Prognosis is highly dependent on the stage of the disease. Thus, a simple and reliable screening method would be of tremendous advantage. Imaging techniques in clinical practice are used for the staging of tumors, detection of tumor recurrence, monitoring of efficacy of therapy, and differentiation between malignant and benign tissues. In this volume, use of PET in diagnosing glioma and in assessment of biological target volume in high-grade glioma patients is explained. Also is discussed the use of MRI in glioma surgery. Present and future therapeutic drugs for malignant gliomas are described. The efficacy of several drugs, such as cyclosporine, interferon, heparin, and cannabinoids in treating glioblastoma is explained. Effectiveness of therapies, such as resection, radiation, chemotherapy, and immunotherapy, against high-grade gliomas is detailed. Therapy for recurrent high-grade glioma with bevacizumab and irinotecan is presented. Use of dendritic cell therapy and adenoviral vectors for glioblastoma is discussed. Brainstem gliomas are also described, so is tumor-associated epilepsy. This work consists of 37 chapters that were contributed by 101 authors representing 16 countries. The high quality of each manuscript made my work as the editor an easy one. Strictly uniform style of manuscript writing has been accomplished. The results are presented in the form of both black-and-white and color images and diagrams. I am indebted to the contributors for their promptness in accepting my suggestions, and appreciate their dedication and hard work in sharing their knowledge and expertise with the readers. Each chapter provides unique individual, practical knowledge based on the expertise of a large number of researches and physicians. A vast medical vii

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Preface

field such as tumors of the CNS can be discussed adequately only by a large number of experts. It is my hope that this volume will be published expediously. I am thankful to Dr. Dawood Farahi, Dr. Kristie Reilly, and Mr. Philip Connelly for recognizing the importance of scholarship in an institution of higher education, and providing resources for completing this project. Union, New Jersey September 2010

M.A. Hayat

Contents

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M.A. Hayat Part I

1

Biomarkers and Diagnosis . . . . . . . . . . . . . . . . . . . .

9

2 Gliomagenesis: Advantages and Limitations of Biomarkers . . . . . Michel Wager, Lucie Karayan-Tapon, and Christian-Jacques Larsen

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3 Molecular Subtypes of Gliomas . . . . . . . . . . . . . . . . . . . . . Lonneke A.M. Gravendeel and Pim J. French

25

4 Glioblastoma: Germline Mutation of TP53 . . . . . . . . . . . . . . . Haruhiko Sugimura, Hidetaka Yamada, Shinji Kageyama, Yasuhiro Yamamura, Naoki Yokota, Hiroki Mori, Moriya Iwaizumi, Kazuya Shinmura, Kiyotaka Kurachi, Toshio Nakamura, Masaru Tsuboi, Masato Maekawa, and Tomoaki Kahyo

31

5 Familial Gliomas: Role of TP53 Gene . . . . . . . . . . . . . . . . . . Soufiane El Hallani and Ilham Ratbi

39

6 The Role of IDH1 and IDH2 Mutations in Malignant Gliomas . . . . Yukihiko Sonoda, Ichiyo Shibahara, Ryuta Saito, Toshihiro Kumabe, and Teiji Tominaga

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7 Malignant Glioma: Isocitrate Dehydrogenases 1 and 2 Mutations . . Zachary J. Reitman and Hai Yan

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8 Metabolic Differences in Different Regions of Glioma Samples . . . . Francisca M. Santandreu, Jordi Oliver, and Pilar Roca

63

9

73

Glioblastoma Patients: Role of Methylated MGMT . . . . . . . . . . Giulio Metro and Alessandra Fabi

10 Brain Tumor Angiogenesis and Glioma Grading: Role of Tumor Blood Volume and Permeability Estimates Using Perfusion CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rajan Jain

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Contents

11

Vasculogenic Mimicry in Glioma . . . . . . . . . . . . . . . . . . . . Zhong-Ping Chen and Yin-Sheng Chen

12

Newly Diagnosed Glioma: Diagnosis Using Positron Emission Tomography with Methionine and Fluorothymidine . . . . Nobuyuki Kawai, Yoshihiro Nishiyama, and Takashi Tamiya

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Role of Diffusion Tensor Imaging in Differentiation of Glioblastomas from Solitary Brain Metastases . . . . . . . . . . . Sumei Wang, Harish Poptani, Elias R. Melhem, and Sungheon Kim

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13

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14

131 I-TM-601

SPECT imaging of Human Glioma . . . . . . . . . . . . Adam N. Mamelak and David Hockaday

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15

Assessment of Biological Target Volume Using Positron Emission Tomography in High-Grade Glioma Patients . . . . . . . . Habib Zaidi and Srinivasan Senthamizhchelvan

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16

Skin Metastases of Glioblastoma . . . . . . . . . . . . . . . . . . . . Rebecca Senetta and Paola Cassoni

Part II 17

18

19

20

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Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

151

Diffuse Low-Grade Gliomas: What Does “Complete Resection” Mean? . . . . . . . . . . . . . . . . . . . . . . . . . . . . Johan Pallud

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Quantitative Approach of the Natural Course of Diffuse Low-Grade Gliomas . . . . . . . . . . . . . . . . . . . . . . . . . . . Johan Pallud and Emmanuel Mandonnet

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Impact of Extent of Resection on Outcomes in Patients with High-Grade Gliomas . . . . . . . . . . . . . . . . . . . . . . . . Debraj Mukherjee and Alfredo Quinones-Hinojosa

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Glioma Surgery: Intraoperative Low Field Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . Christian Senft

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21

Low-Grade Gliomas: Intraoperative Electrical Stimulations . . . . . Hugues Duffau

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22

Malignant Gliomas: Present and Future Therapeutic Drugs . . . . . Linda Coate and Warren Mason

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23

Recurrent Malignant Glioma Patients: Treatment with Conformal Radiotherapy and Systemic Therapy . . . . . . . . . Abhirami Hallock and Lauren VanderSpek

24

Glioblastoma: Boron Neutron Capture Therapy . . . . . . . . . . . . Tetsuya Yamamoto, Kei Nakai, and Hiroaki Kumada

25

Glioblastoma: Anti-tumor Action of Cyclosporin A and Functionally Related Drugs . . . . . . . . . . . . . . . . . . . . . Bozena Kaminska, Magdalena Tyburczy, Konrad Gabrusiewicz, and Malgorzata Sielska

215 229

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26 Glioblastoma Patients: Chemotherapy with Cisplatin, Temozolomide and Thalidomide . . . . . . . . . . . . . . . . . . . . . Fable Zustovich and Giuseppe Lombardi

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27 Glioblastoma: Role of Galectin-1 in Chemoresistance . . . . . . . . . Florence Lefranc and Robert Kiss

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28 Glioma-Initiating Cells: Interferon Treatment . . . . . . . . . . . . . Atsushi Natsume, Masasuke Ohno, Kanako Yuki, Kazuya Motomura, and Toshihiko Wakabayashi

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29 Glioblastoma: Anti-tumor Action of Natural and Synthetic Cannabinoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aleksandra Ellert-Miklaszewska, Iwona Ciechomska, and Bozena Kaminska

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30 Patients with Recurrent High-Grade Glioma: Therapy with Combination of Bevacizumab and Irinotecan . . . . . . . . . . Benedikte Hasselbalch, Ulrik Lassen, and Hans Skovgaard Poulsen

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31 Monitoring Gliomas In Vivo Using Diffusion-Weighted MRI During Gene Therapy-Induced Apoptosis . . . . . . . . . . . . Timo Liimatainen, Olli Gröhn, and Kimmo Lehtimäki

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32 High-Grade Gliomas: Dendritic Cell Therapy . . . . . . . . . . . . . Hilko Ardon, Steven De Vleeschouwer, Frank Van Calenbergh, and Stefaan W. Van Gool

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33 Glioblastoma Multiforme: Use of Adenoviral Vectors . . . . . . . . . Thomas Wirth, Haritha Samaranayake, and Seppo Ylä-Herttuala

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34 Fischer/F98 Glioma Model: Methodology . . . . . . . . . . . . . . . David Fortin

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35 Cellular and Molecular Characterization of Anti-VEGF and IL-6 Therapy in Experimental Glioma . . . . . . . . . . . . . . Sophie Javerzat and Martin Hagedorn 36 Adult Brainstem Gliomas: Diagnosis and Treatment . . . . . . . . . Florence Laigle-Donadey and Jean-Yves Delattre

361 371

37 The Use of Low Molecular Weight Heparin in the Treatment and Prevention of Thromboembolic Disease in Glioma Patients . . . Bo H. Chao and H. Ian Robins

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Part III

Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

385

38 Brainstem Gliomas: An Overview . . . . . . . . . . . . . . . . . . . . Marco Antonio Lima

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39 Tumor-Associated Epilepsy in Patients with Glioma . . . . . . . . . Anja Smits and Anette Storstein

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40 Brain Tumors Arising in the Setting of Chronic Epilepsy . . . . . . . Richard A. Prayson

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41

42

Contents

Low-Grade Gliomas: Role of Relative Cerebral Blood Volume in Malignant Transformation . . . . . . . . . . . . . . . . . . Neil Upadhyay and Adam D. Waldman

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Angiocentric Glioma-Induced Seizures: Lesionectomy . . . . . . . . Dave F. Clarke and Timothy M. George

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Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Contents of Volume 1

1 Introduction 2 Molecular Classification of Gliomas 3 Glioblastoma: Endosialin Marker for Pericytes 4 Glioma Grading Using Cerebral Blood Volume Heterogeneity 5 The Role of Ectonucleotidases in Glioma Cell Proliferation 6 Gliomas: Role of Monoamine Oxidase B in Diagnosis 7 Glioma: Role of Integrin in Pathogenesis and Therapy 8 Proton Magnetic Resonance Spectroscopy in Intracranial Gliomas 9 Infiltration Zone in Glioma: Proton Magnetic Resonance Spectroscopic Imaging 10 Malignant Gliomas: Role of E2F1 Transcription Factor 11 The Role of Glucose Transporter-1 (GLUT-1) in Malignant Gliomas 12 Malignant Gliomas: Role of Platelet-Derived Growth Factor Receptor A (PDGFRA) 13 Molecular Methods for Detection of Tumor Markers in Glioblastomas 14 Role of MGMT in Glioblastomas 15 Glioblastomas: Role of CXCL12 Chemokine 16 Cell Death Signaling in Glioblastoma Multiforme: Role of the Bcl2L12 Oncoprotein 17 Glioblastoma Multiforme: Role of Polycomb Group Proteins 18 Glioblastoma Multiforme: Role of Cell Cycle-Related Kinase Protein (Method) 19 Markers of Stem Cells in Gliomas 20 Efficient Derivation and Propagation of Glioblastoma Stem-Like Cells Under Serum-Free Conditions Using the Cambridge Protocol

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21

Glioma Cell Lines: Role of Cancer Stem Cells

22

Glioblastoma Cancer Stem Cells: Response to Epidermal Growth Factor Receptor Kinase Inhibitors

23

Low- and High-Grade Gliomas: Extensive Surgical Resection

24

Brainstem Gangliogliomas: Total Resection and Close Follow-Up

25

Glioblastoma: Temozolomide-Based Chemotherapy

26

Drug-Resistant Glioma: Treatment with Imatinib Mesylate and Chlorimipramine

27

Glioblastoma Multiforme: Molecular Basis of Resistance to Erlotinib

28

Enhanced Glioma Chemosensitivity

29

Malignant Glioma Patients: Anti-Vascular Endothelial Growth Factor Monoclonal Antibody, Bevacizumab

30

Aggravating Endoplasmic Reticulum Stress by Combined Application of Bortezomib and Celecoxib as a Novel Therapeutic Strategy for Glioblastoma

31

Targeted Therapy for Malignant Gliomas

32

Glioblastomas: HER1/EGFR-Targeted Therapeutics

33

Epidermal Growth Factor Receptor Inhibition as a Therapeutic Strategy for Glioblastoma Multiforme

34

Role of Acyl-CoA Synthetases in Glioma Cell Survival and Its Therapeutic Implication

35

Malignant Glioma Patients: Combined Treatment with Radiation and Fotemustine

36

Malignant Glioma Immunotherapy: A Peptide Vaccine from Bench to Bedside

37

Malignant Glioma: Chemovirotherapy

38

Intracranial Glioma: Delivery of an Oncolytic Adenovirus

39

Use of Magnetic Resonance Spectroscopy Imaging (MRSI) in the Treatment Planning of Gliomas

40

Malignant Glioma Cells: Role of Trail-Induced Apoptosis

41

Long-Term Survivors of Glioblastoma

42

Glioblastoma Patients: p15 Methylation as a Prognostic Factor

Contributors

Hilko Ardon Department of Neurosurgery, Laboratory of Experimental Immunology, Catholic University Leuven, Leuven, Belgium, [email protected] Paola Cassoni Department of Biomedical Sciences and Human Oncology, University of Turin, Turin, Italy, [email protected] Bo H. Chao Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA, [email protected] Yin-Sheng Chen Department of Neurosurgery, Cancer Center, Sun Yat-sen University, Guangzhou, China, [email protected] Zhong-Ping Chen Department of Neurosurgery, Cancer Center, Sun Yat-sen University, Guangzhou, China, [email protected] Iwona Ciechomska Department of Cell Biology, Nencki Institute of Experimental Biology, Warsaw, Poland, [email protected] Dave F. Clarke Division of Neurology, Department of Pediatrics, Dell Children’s Medical Center, Austin, TX, USA, [email protected] Linda Coate Department of Medical Oncology, Princess Margaret Hospital, Toronto, ON, Canada, [email protected] Steven De Vleeschouwer Department of Neurosurgery, Laboratory of Experimental Immunology, Catholic University Leuven, Leuven, Belgium, [email protected] Jean-Yves Delattre Service de Neurologie Mazarin, Hôpital de la Pitié-Salpêtrière – APHP, 75651 Paris Cedex 13, France, [email protected] Hugues Duffau Department of Neurosurgery and INSERM U1051, Institute for Neurosciences of Montpellier, Montpellier University Medical Center, Hôpital Gui de Chauliac, CHU Montpellier 34295, Montpellier Cedex 5, France, [email protected] Soufiane El Hallani Cancer Imaging Unit, Integrative Oncology Department, British Columbia Cancer Research Centre, Vancouver, BC, Canada V5Z 1L3, [email protected]

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Aleksandra Ellert-Miklaszewska Department of Cell Biology, Nencki Institute of Experimental Biology, Warsaw, Poland, [email protected] Alessandra Fabi Division of Medical Oncology, Regina Elena National Cancer Center Institute, Rome, Italy, [email protected] David Fortin Division of Neurosurgery, Department of Surgery, Sherbrooke University, Sherbrooke, QC, Canada, [email protected] Pim J. French Department of Neurology, Josephine Nefkens Institute, Erasmus Medical Centre, Rotterdam, The Netherlands, [email protected] Konrad Gabrusiewicz Laboratory of Transcription Regulation, Department of Cell Biology, Nencki Institute of Experimental Biology, Warsaw, Poland, [email protected] Timothy M. George Division of Neurosurgery, Department of Pediatrics, Dell Children’s Medical Center, Austin, TX, USA, [email protected] Lonneke A.M. Gravendeel Department of Neurology, Josephine Nefkens Institute, Erasmus Medical Centre, Rotterdam, The Netherlands, [email protected] Olli Gröhn Department of Neurobiology, University of Eastern Finland, Kuopio, Finland, [email protected] Martin Hagedorn INSERM U1029, Université Bordeaux 1, Talence, Cedex, France, [email protected] Abhirami Hallock Department of Radiation Oncology, London Regional Cancer Program, University of Western Ontario, E. London, ON, Canada, [email protected] Benedikte Hasselbalch Department of Radiation Biology, The Finsen Center, Sec 6321, Copenhagen University Hospital, Copenhagen, Denmark, [email protected] M.A. Hayat Department of Biological Sciences, Kean University, Union, NJ, USA, [email protected] David Hockaday Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA Moriya Iwaizumi Department of Investigative Pathology I, Hamamatsu University School of Medicine, Higashi-ward, Hamamatsu, Japan, [email protected] Rajan Jain Division of Neuroradiology, Department of Radiology and Department of Neurosurgery, Henry Ford Health System, Detroit, MI, USA, [email protected] Sophie Javerzat INSERM U1029, Université Bordeaux 1, Talence, Cedex, France, [email protected] Shinji Kageyama Department of Investigative Pathology I, Hamamatsu University School of Medicine, Higashi-ward, Hamamatsu, Japan, [email protected]

Contributors

Contributors

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Tomoaki Kahyo Department of Investigative Pathology I, Hamamatsu University School of Medicine, Higashi-ward, Hamamatsu, Japan, [email protected] Bozena Kaminska Laboratory of Transcription Regulation, Department of Cell Biology, Nencki Institute of Experimental Biology, Warsaw, Poland, [email protected] Lucie Karayan-Tapon Department of Molecular Biology, Poitiers University Hospital, University of Poitiers Medical School, Poitiers, France, [email protected] Nobuyuki Kawai Department of Neurological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan, [email protected] Sungheon Kim Department of Radiology, Center for Biomedical Imaging, New York University School of Medicine, New York, NY, USA, [email protected] Robert Kiss Laboratoire de Toxicologie, Faculté de Pharmacie, Université Libre de Bruxelles (ULB), Brussels, Belgium, [email protected] Toshihiro Kumabe Department of Neurosurgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai-shi, Miyagi, Japan, [email protected] Hiroaki Kumada Proton Medical Research Center, University of Tsukuba, Tsukuba City, Ibaraki, Japan, [email protected] Kiyotaka Kurachi Department of Investigative Pathology I, Hamamatsu University School of Medicine, Higashi-ward, Hamamatsu, Japan, [email protected] Florence Laigle-Donadey Service de Neurologie Mazarin, Hôpital de la Pitié-Salpêtrière – APHP, Paris Cedex 13, France, [email protected] Christian-Jacques Larsen Poitiers University Hospital, University of Poitiers Medical School, Poitiers, France, [email protected] Ulrik Lassen Department of Radiation Biology, The Finsen Center, Sec 6321, Copenhagen University Hospital, Copenhagen, Denmark, [email protected] Florence Lefranc Laboratoire de Toxicologie, Faculté de Pharmacie, Université Libre de Bruxelles (ULB), Brussels, Belgium, [email protected] Kimmo Lehtimäki Department of Biotechnology and Molecular Medicine, University of Eastern Finland, Kuopio, Finland, [email protected] Timo Liimatainen Department of Biotechnology and Molecular Medicine, University of Eastern Finland, Kuopio, Finland, [email protected] Marco Antonio Lima Department of Neurosurgery, Instituto Nacional de Câncer-INCa, Centro, Rio de Janeiro, Brazil, [email protected] Giuseppe Lombardi Oncologia Medica 1, I.O.V. – IRCCS, Ospedale Busonera, Padova, Italy, [email protected]

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Masato Maekawa Department of Investigative Pathology I, Hamamatsu University School of Medicine, Higashi-ward, Hamamatsu, Japan, [email protected] Adam N. Mamelak Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA, [email protected] Emmanuel Mandonnet Laboratoire Kastler Brossel de l’ens, Paris Cedex 5, France, [email protected] Warren Mason Department of Medical Oncology, Princess Margaret Hospital, Toronto, ON, Canada, [email protected] Elias R. Melhem Division of Neuroradiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA, [email protected] Giulio Metro Division of Medical Oncology, Regina Elena National Cancer Center Institute, Rome, Italy, [email protected] Hiroki Mori Department of Investigative Pathology I, Hamamatsu University School of Medicine, Higashi-ward, Hamamatsu, Japan, [email protected] Kazuya Motomura Department of Neurosurgery, Nagoya University School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan, [email protected] Debraj Mukherjee Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Medical Center, Los Angeles, California 90048, [email protected] Kei Nakai Department of Neurosurgery, Institute of Clinical Medicine, University of Tsukuba, Tsukuba City, Ibaraki, Japan, [email protected] Toshio Nakamura Department of Investigative Pathology I, Hamamatsu University School of Medicine, Higashi-ward, Hamamatsu, Japan, [email protected] Atsushi Natsume Department of Neurosurgery, Nagoya University School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan, [email protected] Yoshihiro Nishiyama Department of Radiology, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan, [email protected] Masasuke Ohno Department of Neurosurgery, Nagoya University School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan, [email protected] Jordi Oliver Universitat de les Illes Balears, Palma de Mallorca, Spain, [email protected] Johan Pallud Service de Neurochirurgie, Hôpital Sainte-Anne, Paris Cedex 14, France, [email protected] Harish Poptani Division of Neuroradiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA, [email protected]

Contributors

Contributors

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Hans Skovgaard Poulsen Department of Radiation Biology, The Finsen Center, Sec 6321, Copenhagen University Hospital, Copenhagen, Denmark, [email protected] Richard A. Prayson Section of Neuropathology, Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH, USA, [email protected] Alfredo Quinones-Hinojosa Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA, [email protected] Ilham Ratbi Department of Medical Genetics, Human Genomic Center, Faculty of Medicine and Pharmacy, University Mohamed V Souissi, National Institute of Health, Rabat, Marocco, [email protected] Zachary J. Reitman The Pediatric Brain Tumor Foundation Institute, The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA; The Department of Pathology, Duke University Medical Center, Durham, NC, USA, [email protected] H. Ian Robins Department of Medicine, Human Oncology, and Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA, [email protected] Pilar Roca Department de Biologia Fonamental i Ciències de la Salut. Ed. Guillem Colom, Universitat de les Illes Balears, Carretera Valldemossa Km 7.5, Palma de Mallorca, 07122, Balearic Islands, Spain, [email protected] Ryuta Saito Department of Neurosurgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai-shi, Miyagi, Japan, [email protected] Haritha Samaranayake Department of Biotechnology and Molecular Medicine, A. I. Virtanen Institute, University of Kuopio, Kuopio, Finland, [email protected] Francisca M. Santandreu Universitat de les Illes Balears, Palma de Mallorca, Spain, [email protected] Rebecca Senetta Department of Biomedical Sciences and Human Oncology, University of Turin, Turin, Italy, [email protected] Christian Senft Department of Neurosurgery, Johann Wolfgang Goethe-University, Frankfurt, Germany, [email protected] Srinivasan Senthamizhchelvan Division of Nuclear Medicine, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA, [email protected] Ichiyo Shibahara Department of Neurosurgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai-shi, Miyagi, Japan, [email protected] Kazuya Shinmura Department of Investigative Pathology I, Hamamatsu University School of Medicine, Higashi-ward, Hamamatsu, Japan, [email protected] Malgorzata Sielska Laboratory of Transcription Regulation, Department of Cell Biology, Nencki Institute of Experimental Biology, Warsaw, Poland, [email protected]

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Anja Smits Department of Neuroscience, Neurology, University Hospital Uppsala, Uppsala, Sweden, [email protected] Yukihiko Sonoda Department of Neurosurgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai-shi, Miyagi, Japan, [email protected] Anette Storstein Department of Neuroscience, Haukeland University Hospital, N5021 Bergen, Norway, [email protected] Haruhiko Sugimura Department of Investigative Pathology I, Hamamatsu University School of Medicine, Higashi-ward, Hamamatsu, Japan, [email protected] Takashi Tamiya Department of Neurological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan, [email protected] Teiji Tominaga Department of Neurosurgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai-shi, Miyagi, Japan, [email protected] Masaru Tsuboi Department of Investigative Pathology I, Hamamatsu University School of Medicine, Higashi-ward, Hamamatsu, Japan, [email protected] Magdalena Tyburczy Laboratory of Transcription Regulation, Department of Cell Biology, Nencki Institute of Experimental Biology, Warsaw, Poland, [email protected] Neil Upadhyay Institute of Clinical Science, Imperial College London, Charing Cross Hospital, W68RF, London, UK, [email protected] Frank Van Calenbergh Department of Neurosurgery, Catholic University Leuven, Leuven, Belgium, [email protected] Lauren VanderSpek Department of Radiation Oncology, London Regional Cancer Program, University of Western Ontario, E. London, ON, Canada, [email protected] Stefaan W. Van Gool Department of Pediatrics and Laboratory of Experimental Immunology, Catholic University Leuven, Leuven, Belgium, [email protected] Michel Wager Poitiers University Hospital, University of Poitiers Medical School, Poitiers, France, [email protected] Toshihiko Wakabayashi Department of Neurosurgery, Nagoya University School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan, [email protected] Adam D. Waldman Institute of Clinical Science, Imperial College London, Charing Cross Hospital, W68RF, London, UK, [email protected] Sumei Wang Division of Neuroradiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA, [email protected] Thomas Wirth Department of Biotechnology and Molecular Medicine, A. I. Virtanen Institute, University of Kuopio, Kuopio, Finland, [email protected]

Contributors

Contributors

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Hidetaka Yamada Department of Investigative Pathology I, Hamamatsu University School of Medicine, Higashi-ward, Hamamatsu, Japan, [email protected] Tetsuya Yamamoto Department of Neurosurgery and Radiation Oncology, Institute of Clinical Medicine, University of Tsukuba, Tsukuba City, Ibaraki, Japan, [email protected] Yasuhiro Yamamura Department of Investigative Pathology I, Hamamatsu University School of Medicine, Higashi-ward, Hamamatsu, Japan, [email protected] Hai Yan The Pediatric Brain Tumor Foundation Institute, The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA; The Department of Pathology, Duke University Medical Center, Durham, NC, USA, [email protected] Seppo Ylä-Herttuala Department of Biotechnology and Molecular Medicine, A. I. Virtanen Institute, University of Kuopio, Kuopio, Finland, [email protected] Naoki Yokota Department of Investigative Pathology I, Hamamatsu University School of Medicine, Higashi-ward, Hamamatsu, Japan, [email protected] Kanako Yuki Department of Neurosurgery, Nagoya University School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan, [email protected] Habib Zaidi Division of Nuclear Medicine, Geneva University Hospital, Geneva 4, Switzerland, [email protected] Fable Zustovich Oncologia Medica 1, I.O.V. – IRCCS, Ospedale Busonera, Padova, Italy, [email protected]

Chapter 1

Introduction M.A. Hayat

In developed countries cancer is the second leading cause of death exceeded only by cardiovascular diseases. There are more than 100 types of cancers that can inflict any part of the body. In 2005, 7.6 million people died of cancer, which constitutes 13% of the 58 million deaths worldwide. In the global population exceeding 6 billion in the year 2002, there were approximately 10.9 million new cancer cases, 6.7 million cancer deaths, and 22.4 million surviving from cancer diagnosed in the previous 5 years. In 2020, it is expected that the world’s population will increase to 7.5 billion, with 15 million new cancer cases and 12 million cancer deaths. Approximately, 1.4 million new cases of cancer and 550,000 cancer deaths were reported in the United States in 2008 (Am. Cancer Soc.), These data amount to ∼1500 deaths caused by cancer every day in the United States. In 2006 an estimated 19,000 new cases of brain tumors and 13,000 deaths were reported in the United States. This figure accounts for ∼1.4% of all cancer cases and 2.3% of all cancer cases that cause death. More than 10,000 Americans die annually from glioblastoma. Survival for this disease has not changed much in three decades. Since 1970, the number of cancer survivors has increased four-fold, with cancer survivors representing ∼3.5% of the United States population and 5-years survival rates increasing into the 60% range. These raises invite issues related to long-term and late effects of cancer treatment and the realization that cancer survivors represent ∼16% of all new primary cancers.

M.A. Hayat () Department of Biological Sciences, Kean University, Union, NJ 07083, USA e-mail: [email protected]

Glioblastoma Gliomas can arise either spontaneously (primary glioma) or can progress from a lower-grade to a highergrade (glioblastoma) of tumor. Malignant glioma is the most common tumor of the CNS, and glioblastoma is the most malignant form. Glioblastoma is characterized by rapid, highly invasive growth, extensive neovascularisation, and high mortality. The key reason for the lack of successful therapy is the infiltration of single tumor cells into the surrounding brain parenchyma cells, preventing complete glioblastoma resection. This process is facilitated by two related processes: (1) angiogenesis, the sprouting of new blood vessels from preexisting vasculature in response to external chemical stimulation, and (2) vasculogenesis, the reorganization of randomly distributed cells into a blood vessel network. Tumor cells can also acquire blood supply through other ways to escape conventional antiangiogenesis. In other words, blood vessels are formed by tumor cells instead of endothelial cells. This novel concept in tumor vascularization is termed as vasculogenic mimicry, which is the ability of aggressive tumor cells to express endotheliumassociated genes and form extracellular matrix-rich vasculogenic-like networks in three-dimensional culture. Such networks recapitulate embryonic vasculogenesis, and have been observed in human aggressive tumors such as glioblastoma (El Hallani et al., 2010, and Chapter 11, in this volume). Glioblastoma can be divided into two subtypes based on amplication and mutation of different genes, and characterization of molecular pathways has opened new venues to targeted therapies based on the individual genetic signature of the tumor (Ohgaki and

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_1, © Springer Science+Business Media B.V. 2011

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Kleihues, 2007). Two main subtypes on the basis of genetic differences are: (1) Primary glioblastomas typically occur in patients alder than 50 years of age, and are characterized by epidermal growth factor receptor (EGFR) amplification and mutations, loss of heterozygosity of chromosome log, deletion of the phosphatase and tension homologue on chromosome 10 (PTEN), and p16 deletion. (2) Secondary glioblastomas occur in younger patients as low-grade or anaplastic astrocytomas that are transformed over a period of several years into glioblastoma multiforme. Secondary glioblastomas are much less common than primary glioblastoma, and are characterized by mutations in the TP53 tumor suppressor gene, overexpression of the platelet-derived growth factor receptor (PDGFR), abnormalities in the p16 and retinoblastoma (Rb) pathways, and loss of heterozygosity of chromosome loq. Although glioblastoma is the most common and aggressive type of glioma and has the poorest survival, a small percentage of patients survive longer than the established median. Identification of genetic variants that influence long term survival of such patients may provide insight into tumor biology and treatment. A recent study by Liu et al. (2010) indicates that polymorphisms in the LIG4, BTBD2, HMGA2, and RTEL1 genes are associated with the survival of glioblastoma patients. LIG4 and BTBD2 are predictors of short-term survival, while CCDC26, HMGA2, and RTEL1 are predictors of long-term survival. In general, older patients (>50 years) have the worst survival (1.2 years), while younger patients may show a median survival-term of 7.8 years. These genes are known to be involved in the double strand break repair pathway. It is known that glioblastoma responds poorly to conventional therapies. Glioblastoma cells thrive despite an irregular blood supply and a frequently hypoxic microenvironment. Compensatory mechanisms, including glucose uptake and glycolytic activity, are enhanced in these tumors. In other words, glioblastoma cells, posses sufficient glycolytic capacity (more than that in normal brain tissue), supporting their migration even without mitochondrial involvement (Beckner et al., 1990) A recent study has identified ATP citrate lyase (ACLY) as a positive regulator of glycolysis in glioblastomas (Beckner et al., 2010). ACLY can be targeted to suppress hypoxic cell migration and invasion, and restore glycolytic inhibition. This inhibition of hypotoxic tumor cells potentially

M.A. Hayat

complement antiangiogenesis therapies that compromise the blood supply to tumor cells.

Treatment The three most common treatments are resection, radiation, and chemotherapy, or a combination of these methods. According to Sandmair et al. (2000), when radiation is utilized following surgical resectioning of the tumor, the median survival time may increase from 14 to 40 weeks. Maximal resection of brain glioma is usually the first or second treatment choice. Radiation is the alternative treatment. The goal is to maximize the effectiveness of resection, while minimize the operative risk. To accomplish this goal is not easy. Active migration of glioblastoma cells through the narrow extracellular spaces in the brain makes them elusive targets for surgical management. Glioma cells are “self-propelled”, and are able to adjust their shape and volume rapidly as they invade the brain parenchyma. The infiltrative nature of malignant gliomas results in poor demarcation of malignant boundaries. Another reason is the frequent location of supratentorial gliomas near or within eloquent areas. Consequently, the advantage of maximal resection in all cases is controversial. Image-guided surgery utilizing fluorescence with 5-aminolevulinic acid, neuronavigation, and intraoperative MRI has enabled more complete resectioning of contrast-enhancing tumors (Stummer et al., 2006; Nimsky et al., 2006) Chemotherapy in conjunction with surgery and radiation can increase the estimated survival of patients by 10.1% at 1 year and 8.6% at 2 years, but these rates apply to lower-grade glioma tumors. The current recommended chemotherapeutic agent is alkylating drug temozolomide. The 2-year survival rate of patients with newly diagnosed glioblastoma treated with radiotherapy and temozolomide is 26.5%, compared with 10.4% for radiotherapy alone (Stupp et al., 2005). Telozolomide also exerts antitumor affects by impairing angiogenic process. In vitro and in vivo studies have shown antiangiogenic activity by this drug even when it is used alone (Mathieu et al., 2008). The efficacy can be further enhanced by combining this treatment with bevacizumab; the later also has an antiangiogenic effect, although with a different mechanism of action. Antiangiogenic compounds

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Introduction

also increase the therapeutic benefits of radiotherapy (Nieder et al., 2006). A phase 2 pilot study of bevacizumab in combination with telozolomide and regional radiotherapy for the treatment of patients with newly diagnosed glioblastoma recently reported that toxicities were acceptable to continue enrollment and a preliminary analysis of efficacy showed encouraging mean progression-free survival (Lai et al., 2008). It is concluded that a range of side-effects, including post-therapeutic neurological deterioration, can commonly or uncommonly are experienced by patients undergoing chemotherapy. To overcome some of the limitations mentioned above, intraoperative eletrostimulation can be used (Duffau, 2007, also, see Chapter 22, in this volume). The purpose is to understand the interindividual anatomical-functional variability in the case of glioma patients. In order to tailor the resection for each patient, it is mandatory to study the cortical functional organization, the affective connectivity, and the potentiality for brain plasticity. Another limitation is the innate inter individual prognostic variability encountered among malignant glioma patients. This limitation can be overcome by carrying out analysis of prognostic factors, which can predict the outcome of a therapy among diagnosed malignant glioma patients. Such an information can affect the design and conduct of clinical trials in the case of patients with recurrent glioma. Phase II trials play a critical role in the assessment of novel therapeutic approaches. Factors associated with an increased risk of death are old age (50 years or older), lower karnofsky performance score (<80), initial and on study histological data of glioblastoma multiforme, corticosteroid use, shorter time from original diagnosis to recurrence, and tumor outside frontal lobe (Carson et al., 2007). However, patients differ with respect to their characteristics, including age, performance status, histological data, time from initial diagnosis to recurrence, exact location of tumor, whether the tumor is resectable, number and type of prior therapies, and use of concomitant medication (e.g., anticonvulsants). Thus, patients with recurrent gliomas have significantly different prognoses depending on their characteristics including those mentioned above. The importance of the role of immune-signaling in the regulation and function of resident neural stem cells in the CNS is beginning to be understood

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(Carpentier and Palmer, 2009). The complexity of the immune signaling becomes apparent considering that some aspects of this signaling are beneficial by promoting intrinsic plasticity and replacement of injured cells, while others inhibit the regenerative response that might restore or replace neural networks lost in disease. The broad implication is that tissue environment may influence the activity and fate of endogenous or transplanted neural stem cells. Immunotherapy alone or in combination with other treatments has also been tried with some success. For example, bevacizumab has shown some promise for recurrent glioblastoma, although recurrence is common following treatment with this antibody. Thus, this treatment is transient. Another approach is to develop novel drugs that target glioblastoma cells. Role of Na+ /K+ -ATPAse (the sodium pump, a membrane protein) in the migration of glioblastoma cells is interesting. It has been shown that the α1 subunit of the ubiquitous sodium pump is over-expressed in glioblastoma (Lefranc et al., 2008). This study demonstrates that UNBS1450 drug, a cardionolide compound that inhibits sodium pump, impairs glioblastoma cell migration through disorganization of the actin cytoskeleton and has potent proautophagic effects on glioblastoma cell lines. Thus, sodium pump may prove to be another useful target for drug development against this disease. The importance of prior laboratory prediction of individual drug response cannot be overemphasized. Drug sensitivity is determined by multiple genes and accessibility to the target tumor. The complexity of mechanisms involved in drug sensitivity becomes apparent, considering that gene expression profile in response to drug exposure vary considerably among individuals even for the same drug or regimen and tumor type. It is known that gliomas, in their proliferative stage, are highly vascularized tumors, and their persistence and growth depend on the pathological formation of new capillary blood vessels. Thus, angiogenesis inhibition is an efficient therapeutic strategy for treating malignant gliomas. However, the benefit of current anti-angiogenic agents has been at best modest. Reasons for limited effectiveness of such agents include their short circulating half-life, doselimiting toxicity, and the noninvasive methods to monitor anti-angiogenic therapies in vivo (van Eekelen et al., 2010). Recently, these authors have engineered and characterized a secretable form of antiangiogenic

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thrombospondin-1 (TSP-1) that targets the vascular component of gliomas and reduces tumor blood vessel density, resulting in the inhibition of tumor progression and increased survival of mice bearing highly malignant human gliomas. A large number of standard and novel treatments against malignant gliomas are discussed by other authors in this and volume 1 of this series. Glioblastoma tumors containing CD133-positive cells display strong capability of resistance to chemotherapy (temozolomide, carboplatin, VP16, and Taxol) (Liu et al., 2006). Brain cancer stem cells (CSCs) with such resistance also show a higher expression of drug resistance genes (e.g., BCRPI) and DNA mismatch repair genes (e.g., MGMT) as well as antiapoptotic proteins (e.g., Bcl-2). Growing evidence also indicates that CD133-posiotive CSCs show higher expression of mRNA levels of inhibitors of apoptotic proteins such as IAPs (Liu et al., 2006). Based on this and other evidence it can be concluded that apoptotic pathways contribute to resistance of CD133-posiotive to chemotherapy and medical radiation. Thus, CD133positive cells can be considered as a marker for glioblastoma CSCs that can be targeted either biochemically or immunologically without harming normal brain tissue stem cells. One approach to treat glioblastoma is to induce differentiation of CD133 brain tumor cells, critically weakening their tumor-forming ability. Piccirillo et al. (2006) have shown that bone morphogenetic proteins (BMPs) prompt the differentiation of such cells. This study demonstrated that the BMP-treated tumor cells engrafted into mice were more mature and less invasive, and CD133 cells could not be recovered from these small tumors. The implication is that a differentiation-promoting agent (BMP) is a potential treatment for brain tumors. This experimental approach is ripe for further testing. As stated earlier, CD133 (prominin-1) has been proposed as a marker for brain tumor-initiating cells. However, a recent study shows that tumorigenic potential also exists among CD133– cells to form tumors (Prestegarden et al., 2010). Nestin glial fibrillary acidic protein and neuron-specific enolase markers were expressed in CD133– cells. It seems that the ability to form tumors maybe a general trait associated with different glioma cell phenotypes, rather than a property limited to an exclusive subpopulation of glioma stem cells.

M.A. Hayat

Nevertheless, targeting CSCs pathways will ultimately prove to be an effective therapeutic strategy against malignant gliomas. In order to accomplish this goal, it is necessary to understand and link cellular, molecular, genetic, and epigenetic mechanisms to compare the similarities and differences between normal neural stem cells and glioblastoma-initiating stem cells. The relevant question is whether chemoresistance of glioblastoma stem cells is due to reduced drug uptake or due to drug efflux. An in vivo study indicates that neither of these two alternatives is fully applicable to answer this question (Eramo et al., 2006). According to this study, drug resistance by glioblastoma stem cells depends on the abnormalities of the cell death pathways such as overexpression of antiapoptotic factor or silencing of key death effectors. In other words, the altered expression of apoptosis related proteins renders normal neural stem cells strongly resistant to death receptor ligands and inflammatory cytokines. More extensive studies are required to fully understand the mechanisms of chemoresistance by glioblastoma stem cells. As indicated earlier, cerebral glioma shows the highest incidence rate among malignant intracranial tumors, and the therapeutic efficacy of surgery, radiotherapy, and chemotherapy for the former are not satisfactory, and these tumors show a tendency to recur after the treatments. Many drugs exert their anticancer actions only after entering the cells, but some drug-resistant tumor cells can prevent the drugs from penetrating and thus avoid being destroyed. Ultrasound can increase the intracellular bioaccumulation of drugs by increasing the membrane permeability in tumor cells and thus reducing the thereshold values of cell death (Deckers et al., 2008). Currently, inducing tumor cell death is considered the endpoint in most nonsurgical therapies, but there is increasing evidence that different death modes of tumor cells have different effects on the functions of immune cells, especially macrophages. Macrophages play important roles in the occurrence and development of tumors. Recently, Xu et al. (2009) studied the effects of ultrasound on the cell death induced by arsenic trioxide, and the secondary activation of macrophages; this study was carried out using rat glioma cell line C6. Arsenic trioxide has been approved by the FDA for the treatment of refractory leukemia. Kim et al. (2008) have also used arsenic

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Introduction

trioxide for sensitizing human glioma cells. It seems that ultrasound synergisticulary enhances the cell death effect by promoting arsenic trioxide entry into the cell line C6, and macrophages are activated by the killed C6 cells (Xu et al., 2009). This study provides a theoretical basis for the clinical use of this drug and ultrasound in glioma treatment. Because conventional treatments are not very effective against glioblastoma, there is an urgent need to develop novel, effective therapeutic strategies against this disease. One such therapy involves the role played by brain tumor-derived stem cells (BTSC) and neural stem cells (NSC) in cancer initiation and progression (Germano et al., 2010). BTSC are a small subpopulation of cancer cells having similarities, such as selfrenewal, multipotency, and relative quiescence. BTSC originate from a population of endogenous NSC. It is thought that BTSC play a crucial role in the recurrence of primary brain tumors and treatment resistance. Therapies targeting BTSC might be more effective in treating this disease. One of the new treatments to improve patient survival is targeting cancer stem cells that contain higher NOTCH activity. The NOTCH signaling pathway regulates stem cells in the brain. It has been shown that the NOTCH pathway blockade depletes stem-like cells in the glioblastoma, suggesting the usefulness of using NOTCH inhibitors (e.g., γ-secretase) as chemotherapeutic reagents to target cancer stem cells (Fan et al., 2010). Another critical role of NOTCH signaling is that it promotes radio resistance of glioma stem cells (Wang et al., 2009). Thus, inhibition of this signaling holds promise to improve the efficiency of current radiotherapy in glioma therapy.

Glioblastoma Multiforme Glioblastoma multiforme is the most common primary intrinsic brain tumor of adulthood, and the most malignant glioma subtype. Although significant advances have taken place during the last 25 years in the basic understanding of tumor pathogenesis, the median survival of patients has increased only 3.3 months (from 11.3 to 14.6 months). This poor prognosis is due to the near inevitability of the recurrence of the tumor in spite of the initial use of maximal safe surgical resection, radiotherapy, and chemotherapy. Under the

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circumstances, additional systemic and local therapies, as well as repeat surgery, are considered; these therapies have potential benefits and risks, especially resulting from surgery. Surgery does provide benefits, such as immediate decrease in tumor burden and improvement of tumorrelated neurologic symptoms and deficits. A potential risk is the exacerbation or new onset of the same, as well as a temporary or permanent exclusion from other therapies. In addition, potential injury to the M1 and M2 segments of the middle cerebral artery can result in damage to the eloquent brain regions they supply (Park et al., 2010). In the light of risks and uncertainity involved in the outcome of the reoperation, these patients deserve to know their treatment options. In the past, studies have been carried out assessing the outcome of reoperation of patients with recurrent glioblastoma multiforme (Ammirati et al., 1987). However, such studies did not establish guidelines for providing preoperative advice to patients considering reoperation. Recently, Park et al. (2010) have devised a preoperative scale that predicts survival after resurgery for recurrent glioblastoma multiforme. This scale identifies patients likely to have poor, intermediate, or good relative outcomes after surgical resection of the recurrent tumor. On the basis of this scale, survival benefit and the attendant risk can be evaluated, on case-by-case basis, from surgery. Because surgery is not curative, it is important to identify potentially effective treatments with minimal risk.

Medical Imaging A large of imaging modalities, including computed tomography (CT), position emission tomography (PET), magnetic resonance imaging (MRI), functional magnetic resonance imaging (fMRI), and single photon emission computed tomography (SPECT), are being routinely used for diagnosis, treatment, and assessment of treatments (Hayat, 2008). Combined PET/CT is a well-established approach that has been extensively validated in routine clinical practice; CT provides anatomical information, while PET contributes functional information. The introduction of PET/CT was a revolutionary milestone in clinical imaging. However, because the effective radiation

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dose is the sum of the doses from PET and CT, this combined examination (particularly diagnostic one requiring high resolution CT) results in increased patient exposure and a higher theoretical radiationinduced cancer risk than that with PET or CT alone. Understandably, but unfortunately, the acceptance of a treatment by patients is much higher when the information primarily addresses the benefits than the risk. A more recently emerging therapeutic modality for glioblastoma consists of boron neutron capture protocol (Yamamoto et al., 2008). This technique theoretically allows tumor-selective destruction, while sparing normal tissue, even when the cells have microscopically spread to the surrounding normal brain. The tumor cell selective irradiation depends on the nuclear reaction between the stable isotope of boron (10 B) and thermal neutrons, which release α and 7 Li particles within a limited path length through the boron neutron capture reaction, 10 B (n,α) 7 Li. The selectivity depends on the dose from the boron neutron capture reaction, i.e., the accumulation of boron-10 in tumor cells. Prospective randomized clinical trials are needed to confirm the efficacy of this modality.

Risk of Medical Radiation At the outset it is pointed out that although radiation therapy has been the standard treatment of glioblastoma for four decades, it is only transiently effective, and offers no lasting cure. Medical radiation fails in the long run because it cannot kill the subpopulation of CD133 tumor-initiating cells. Although many nuclear medicine and radiological procedures are safe, there is still the need to justify these procedures on the basis of a favorable risk: benefit ratio. Hazards associated with medical radiation exposure do exist. Radiation, for example, may induce necrosis at doses of 60 Gy and above. The recent dramatic increase in the number of diagnostic medical procedures and nuclear medicine procedures has resulted in a very significant increase in cumulative exposure to radiation and related risk of carcinogenesis. In the United States in 2006, ∼377 million diagnostic and interventional radiological examinations and 18.6 million nuclear medicine examinations were performed (Mettler et al., 2009). Among the diagnostic nuclear medicine procedures, cardiac studies followed by bone scanning

M.A. Hayat

are the most frequent nuclear medicine procedures. Approximately, 12% of all radiological procedures and 50% of nuclear medicine procedures carried out worldwide are performed in the United States (Salvatori and Lucignani, 2010). These startling findings underline the pressing need to optimize and justify all exposures of patients to medical ionizing radiation. Starting from last decade, there has been a substantial increase in the use of PET/CT in children. In all patients, especially in children, it is crucial to keep radiation doses as low as is clinically feasible. It is known that some children who undergo medical radiation, are prone to develop cancer or heart disease later in life. Medical radiation protection has implication for a range of persons: patients, medical, technical, and nursing staff, friends, relatives, caregivers, and members of the public.

References Ammirati M, Galicich JH, Arbit E, Liao Y (1987) Reoperation in the treatment of recurrent intracranial malignant gliomas. Neurosurgery 21:607–614 Beckner ME, Fellows-Mayle W, Zhang Z, Agostino NR, Kant JA, Day BW, Pollack IF (2010) Identification of ATP citrate lyase as a positive regulator of glycolytic function in glioblastomas. Nat J Cancer 126:2282–2295 Beckner ME, Stracke ML, Liotta LA, Schiffmann E (1990) Glycolysis as primary energy source in tumor cell chemotaxis. J Nat Cancer Inst 82:1836–1840 Carpentier PA, Palmer TD (2009) Immune influence on adult neural stem cell regulation and function. Neuron 64:79–92 Carson KA, Grossman SA, Fisher JD, Shaw EG (2007) Prognostic factors for survival in adult patients with recurrent glioma enrolled onto the new approaches to brain tumor therapy CNS consortium phases I and II clinical trials. J Clin Oncol 25:2601–2606 Deckers R, Rome C, Moonen CT (2008) The role of ultrasound and magnetic resonance in local drug delivery. J Magn Reson Imag 27:400–409 Duffau H (2007) Contributation of cortical and subcortical electrostimulation in brain glioma surgery: methodological and functional considerations. Clin Neurophysiol 37:373–382 El Hallani S, Boisselier B, Peglion F, Rousseau A, Colin C, Idbaih A, Marie Y, Mokhtari K, Thomas JL, Eichmann A, Delattre JY, Maniotis AJ, Sanson M (2010) A new alternative mechanism in glioblastoma vascularization: tubular vasculogenic mimicry. Brain 133:973–982 Eramo A, Ricci-Vitiani L, Zeuner A, Pallini R, Lotti F, Sette G, Pilozzi E, Larocca LM, Peschle C, De Maria R (2006) Chemotherapy resistance of glioblastoma stem cells. Cell Death Diff 13:1238–1241 Fan X, Khaki L, Zhu TS, Soules ME, Talsma CE, Gul N, Koh C, Li JY-M, Maciaczyk J, Nikkhah G, DiMeco F, Piccirillo S,

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Vescpvi AL, Eberhart C (2010) NOTCH pathway blockade depletes CD133-positive glioblastoma cells and inhibits growth of tumor neurospheres and xenografts. Stem Cells 28:5–16 Germano I, Swiss V, Casaccia P (2010) Primary brain tumors, neural stem cell, and brain tumor cancer cell: where is the link?. Neuropharmacology 58:903–910 Hayat MA (ed) (2008) Cancer imaging, volumes 1 and 2. Elsevier, San Diego, CA Kim EH, Yoon MJ, Kim SU, Kwon TK, Sohn S, Choi KS (2008) Arsenic trioxide sensitizes human glioma cells, but not normal astrocytes, to TRAIL-induced apoptosis via CCAT/enhancer-binding protein homologous proteindependent DR5 upregulation. Cancer Res 68:266–275 Lai A, Filka E, McGibbon B, Leia P et al (2008) Phase II pilot study of bevacizumab in combination with temozolomide and regional radiation therapy for up-front treatment of patients with newly diagnosed glioblastoma multiforme: interim analysis of safety and tolerability. Int J Radiat Oncol Biol Phys 71:1372–1380 Lefranc F, Mijatovic T, Kondo Y, Sauvage S et al (2008) Targeting the α1 subunit of the sodium pump to combat glioblastoma cells. Neurosurgery 62:211–222 Liu Y, Shete S, Erzel CJ, Scheurer M, Alexiou G, Armstrong G, Tsavachidis S, Liang F-W, Gilbert M, Aldape K, Armstrong T, Houlson R, Hosking F, Robertson L, Xiao Y, Wiencke J, Wrensch M, Andersson U, Melin BS, Bondy M (2010) Polymorphisms of LIG4, BTBD2, HMGA2, and RTEL1 genes involved in the double-strand break repair pathway predict glioblastoma survival. J Clin Oncol 28:2467–2474 Liu G, Yuan X, Zeng Z, Tunici P, Ng H, Abdulkadir IR, Lu L, Irvin D, Black KL, Yu JS (2006) Analysis of gene expression and chemoresistance of CD133 cancer stem cells in glioblastoma. Mol Cancer 5:67–68 Mathieu V, De Neve N, Le Mercier M, Dewelle J, Gaussin J-F, Dehoux M, Kiss R, Lefranc F (2008) Combining bevacizumab with temozolomide increases the antitumor efficacy of temozolomide in a human glioblastoma orthotopic xenograft model. Neoplasia 10:1383–1392 Mettler Jr,FA, Bhargavan M, Faulkner K, Gilley DB, Gray JE, Ibbott GS et al (2009) Radiologic and nuclear medicine studies in the United States and worldwide: frequency, radiation dose, and vomparison with other radiation sources-1950– 2007. Radiology 253:520–531 Nieder C, Wiedenmann N, Andratschke N, Molls M (2006) Current status of angiogenesis inhibitors combined with radiation therapy. Cancer Treat Rev 32:348–364 Nimsky C, Ganslandt O, von Keller B, Fahlbusch R (2006) Intraoperative visulization for resection of gliomas: the role

7 of functional neuronavigation and intraoperaive 1.57 MRI. Neurol Res 28:482–487 Ohgaki H, Kleihues P (2007) Genetic pathways to primary and secondary glioblastomas. Am J Pathol 170:1445–1453 Park JK, Hodges T, Arko L, Shen M et al (2010) Scale to predict survival after surgery for recurrent glioblastoma multiforme. J Clin Oncol 28:3838–3843 Piccirillo SGM, Reynolds BA, Zanetti N, Lamorte G, Binda E, Broggi G, Brem H, Olivi A, Dimeco F, Vescovi AL (2006) Bone morphogenetic proteins inhibit the tumorigenic potential of human brain tumour-initiating cells. Nature 444:761–765 Prestegarden L, Svendsen A, Wang J, Sleire L, Skaftnesmo KO, Bjerkvig R, Yan T, Askland L, Persson A, Sakariassen PQ, Enger PQ (2010) Glioma cell populations grouped by different cell type markers drive brain tumor growth. Cancer Res 70:4274–4279 Salvatori M, Lucignani G (2010) Radiation exposure, protection, and risk from nuclear medicine procedures. Eur J Nucl Med Mol Imaging 37:1225–12231 Sandmair AM, Vapalahti M, Yla-Herttuala S (2000) Adenovirus-mediated herpes simplex thymidine kinase gene therapy for brain tumors. Adv Exp Med Biol 465:163–170 Stummer W, Pichlmeier U, Meinel T, Wiestler OD, Zanella F, Reulen H-J (2006) Fluorescence-guided surgery with 5aminolevulinic acid forresection of malignant glioma: a randomised controlled multicentre phase III trial. Lancet Oncol 7:392–401 Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJB, Belanger K, Brandes AA, Marosi C, Bogdahn U, Curschmann J, Janzer RC, Ludwin SK, Gorlia T, Allgeier A, Locombe D, Cairncross G, Eisenhauer E, Mirimanoff RO (2005) Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. New Engl J Med 352:987–996 Van Eekelen M, Sasportas LS, Kasmieh R, Yip S, Figueiredo JL, Louis DN, Weissleder R, Shah K (2010) Human stem cells expressing novel TSP-1 variant have anti-angiogenic effect on brain tumors. Oncogene 29:3185–3195 Wang J, Wakeman TP, Lathia JD, Hjelmeland AB, Wang X-F, White RR, Rich N, Sullenger BA (2009) Notch promotes radioresistance of glioma stem cells. Stem Cells 28:17–28 Xu Y, Zhang Y, Liu X, Wang Z, Ma J, Wang J, Yue W (2009) The effects of ultrasound and arsenic trioxide on neurogliocytoma cells and secondary activation of macrophages. Tumori 95:780–788 Yamamoto T, Nakai K, Matsumura A (2008) Boron neutron capture therapy for glioblastoma. Cancer Lett 262:143–152

Part I

Biomarkers and Diagnosis

Chapter 2

Gliomagenesis: Advantages and Limitations of Biomarkers Michel Wager, Lucie Karayan-Tapon, and Christian-Jacques Larsen

Abstract During the last years, spectacular progress in the field of molecular biology raised the hope that it might replace or at least improve significantly the World Health Organization classification of tumors of the central nervous system. Although up to now, this has not been the case, a few biomarkers have found their place as prognostic factors for certain tumor types on the one hand, and as predictive factors of response to treatments on the other hand. The present chapter will deal with the following tumor types: astrocytic tumors (including Diffuse astrocytoma, Anaplastic astrocytoma, Glioblastoma, and Pilocytic astrocytoma), Oligodendroglial tumours (including Oligodendroglioma and Anaplastic oligodendroglioma), and mixed gliomas (including Oligoastrocytoma and Anaplastic oligodendroglioma). The current biomarkers are not decision-making parameters on a case by case basis, but they have progressively emerged as cornerstone indicators as far as stratification in clinical studies is concerned. As a consequence, during therapeutic trials, it can be considered that groups of patients whose biomarkers anticipate a poor response to standard treatment might be offered the opportunity of innovative therapies. In this context, the most recent developments of molecular biology culminating in integrated molecular analysis of tumors and the possibilities offered by neurosphere cultures established from glioblastoma multiforme that recapitulate the tumor allow to

M. Wager () Poitiers University Hospital, University of Poitiers Medical School, EA 3805 Poitiers, France e-mail: [email protected]

anticipate a growing importance of a series of new biomarker in the years to come. Keywords Biomarkers · Gliomagenesis · Gliomas · Genomic analysis · Kinase · Tumor grade

Introduction This chapter will focus on adult gliomas only. The authors think that gliomas in children and adults are quiet different entities that should be considered separately. This conviction relies on clinical reasons on the one hand, because, as compared to adult gliomas, tumors in children are of lower prevalence, more often low grade at diagnosis, and tumor progression to higher grades arise later in the course of the disease. Furthermore, their anatomical distribution is different from that in the adult. Available biologic data also tend to distinguish these two periods of life: three of the main ways of gliomagenesis in adults – PI3-kinase/Akt/PTEN, p53/MDM2/p14 ARF, Rb/CyclinD1/CD4/p16 CyclinD1 Rb/CyclinD1/ CD4/p16INK4A CD4 seem only rarely involved in children gliomas, quite as EGFr’s amplification (Tamber et al., 2006). Grade I glioma, i.e. pilocytic astrocytomas, is a truly benign lesion that can be cured by total surgical removal. This tumor will be only quickly evoked in this chapter. Indeed, every aspect of this tumor – clinical presentation and imaging features, principles of treatment and outcome – distinguish it from adult diffuse gliomas, and its place in the World Health Organization (WHO) classification can be considered a historic inheritance.

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_2, © Springer Science+Business Media B.V. 2011

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The WHO classification (Louis et al., 2007) describes, according to malignity criteria, different grades among the diffuse infiltrating gliomas, from low grade gliomas (LGG, grade II) to high grade gliomas (grade III or anaplastic gliomas, and grade IV or glioblastoma multiforme – GBM). The second criterion for classification is morphology, according to the cellular type considered as predominant, leading to astrocytic, oligodendroglial or mixed (i.e.oligoastrocytic) tumors. The course of the disease, therapeutic strategy and outcome are so profoundly different according to these criteria that it is necessary to treat the question of biomarkers separately for each of them. Indeed, even among the biomarkers that have gained clinical attention, no one covers neither the full spectrum of the different grades, nor the spectrum of response to all treatments, regarding an overall survival prognosis. And the perspective of a classification relying on exclusive biologic criteria appears very far from us. So, it is necessary to consider each biomarker in its limited, relevant context. For each grade (II, II or IV) of each morphotype, the usefulness of biomarkers can be considered on two different points of view: diagnostic and outcome prognosis on the one hand, prediction of the response to treatments on the other hand. It will be seen through this chapter that each biomarker finds an original place according to both criterions.

Who and Sainte Anne Hospital Classifications It is not conceivable today to study gliomas biomarkers without referring at least at some point to pathology. Considering that some instances of clear relationship between a tumor type and a biomarker – oligodendroglial phenotype and loss of heterozygosity (LOH) 1p/19q is far the better known example – have been recognized, one understands that the internal logic of a pathology classification is pivotal. There are today two classifications for adult gliomas: the WHO classification, and the Sainte-Anne Hospital (SAH) classification. It is noteworthy that until today, the pathology of these tumors remains so debated that it has been possible to describe them from at least two profoundly different points of view, reflected in these two classifications. This remark underlines

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the need for biomarkers. Furthermore, classifications sometimes lack reproductibility (Mittler et al., 1996) and some samples are misinterpreted. This situation also stresses the need for relevant biomarkers. The WHO classification is the most universally admitted and is the standard in literature. It classifies gliomas according to their predominant cellular type. So, it carries the drawback not to distinguish tumor cells from elements of the infiltrated parenchyma, and particularly tumor astrocytes, from reactive astrocytes. Furthermore, in the WHO classification, the word “glioblastoma” is applied both to a histological type and to a concept – i.e. tumors gathered due to the fact that they are highly malignant, but the origin of which can be astrocytic or oligendendrocytic. This point can be confusing and very pejorative when these groups are approached under the angle of biomarkers. The so-called Sainte Anne hospital classification is a completely original approach of these tumors (Daumas-Duport et al., 2000; Varlet et al., 2005). Contrasting with the WHO classification based on the predominant cell type, the Sainte Anne hospital classification is based on the distinction of two patterns of tumor growth, solid tumour tissue versus isolated tumor cells. It defines glioblastoma multiforme as tumors of certain and exclusive astrocytic differentiation, defined by variable intensity of glial fibrillary acidic protein (GFAP ) staining, the observation of necrosis being mandatory. In the Sainte Anne hospital classification, the other tumors are oligodendrogliomas, of low (type A oligodendrogliomas) or high (type B oligodendrogliomas) grade. In those tumors, encountered astrocytes are considered reactive. The Sainte Anne hospital classification also relies on clinical and imaging features that are part of a diagnosis considered as a synthesis combining these different parameters. Besides, Sainte Anne hospital classification also defines among the high grade gliomas a subgroup named glioneuronal tumors. These tumors exhibit non neuronal cells expressing neurofilamentary protein immunostaining (Varlet et al., 2004).

Interest of Biological Fluids Biomarkers A literature review shows that until now biomarkers have been looked for mostly on gliomas themselves,

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and very rarely in the body fluids (serum or cerebrospinal fluid) of these patients. While the examples of solid tumors are numerous, for which one observes how valuable body fluids biomarkers can be, this interest might be less obvious at first sight as far as gliomas are concerned. Indeed, the sensitivity of magnetic resonance imaging (MRI) is so good that is allows positive diagnosis of brain tumor in almost every patient harbouring a glioma. And when brain MRI discloses a brain tumor, as a rule diagnosis requires either a biopsy, or a surgical removal. Hence in both situations samples are available for biomarkers study. That is probably one of the reasons why body fluid biomarkers received so little attention up until now. All the biomarkers presented below were studied on tumors. There are nevertheless clinical situations in which the availability of body fluids biomarkers would be of great value, and particularly: first for the patients in whom surgery is impossible. Second if biomarkers could help detecting progression of low grade gliomas to anaplasia, and the degree of anaplasia. Indeed, one of the greatest difficulties in gliomas diagnosis is tumor heterogeneity, raising the question of samples representativeness, with the risk of underestimating the tumor grade, in cases where the sample(s) do not come from a region reflecting the highest degree of anaplasia of the tumor. This question remains if biomarkers are looked for on tumor samples. Body fluids biomarker solving this difficulty would constitute a progress. Thirdly if they allowed the tumour growth rate assessment, as it seems that this can be case (Hormigo et al., 2006). Last but not least, some patients benefit long survival, and for them access to body fluids biomarkers would mean possible and even comfortable repeated workups. Figure 2.1 presents the potential interest of different biomarkers including body fluids markers. It is possible today to distinguish two types of biomarker: those which are now considered relevant in the clinical field, and those which are until now interesting perspectives raised by the recent new findings in cancer biology, but that have not – not yet? – gained – clinical interest. Both groups are presented below. As already mentioned, genotypic and phenotypic features of low grade gliomas (LGG) and high grade gliomas, as well as their natural history, response to treatments and prognosis appear to be so profoundly different

that it is necessary to deal with their biomarkers distinctly.

Biomarkers in the Clinical Field Importance of Biomarkers in Low Grade Gliomas Management Low grade gliomas have long been considered benign tumors. It is now a well recognized fact that they are truly pre malignant tumors carrying a poor mid term prognosis. These tumors progress to anaplasia over a few years, until their eventual transformation into glioblastoma multiforme carrying gloomy prognosis. In this context, after long controversies it is now widely admitted that low grade gliomas surgical total or subtotal removal is the cornerstone of their treatment (Sanai and Berger, 2008). Surgery can nevertheless be insufficient to prevent tumor progression and change of grade in two scenarios. In the first place when sufficient tumor resection as first treatment is impossible due to the alliance of volume and location of the tumor. Secondly if in spite of initial surgery a residual tumor volume superior to 8–10 cc remains inaccessible to surgical removal in spite of possibilities offered by awake surgery for eloquent brain areas (Berger, 1995). In this context two parameters are useful to determine, that biomarkers could contribute to assess. The first one is the tumor volume and even more importantly the tumor growth rate, parameters influencing directly the therapeutic strategy and particularly on a surgical point of view. Presently this volume is calculated on serial repeated follow-up MRIs. One should insist on this pivotal well documented fact that not only the volume itself, but also the growth rate carries prognostic value (Pallud et al., 2006).

Spontaneous Course of the Disease Until today relatively few biomarkers have received attention in this context. Regarding low grade gliomas prognosis, it has been demonstrated that the Delta Ex2-3 isoform of the p73 gene predicts survival (Wager et al., 2006). But the major achievement of molecular biology in the characterization of low

14 Fig. 2.1 Anticipated usefulness of biomarkers for diagnosis and follow-up of adult gliomas, in relation with tumor grade. (∗ ) +/–: moderate; (∗∗ ) + important; (∗∗∗ ) ++ very important. Grades II, III and IV according to the WHO classification

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Grade III

Grade IV

++ (***)

+ (**)

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In case of total or

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++

response to

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treatments

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In case of non sufficient resection : ++ Body fluid

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biomarkers 1- because follow up

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+ / – because as a

rule, tumor samples

rule, tumor samples

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are available

often on long periods of time. 2 – because no tumor sample is available as long as there is no surgery (neither biopsy nor resection) 3 – If they resolve the difficulty of surgical samples representativeness

grade gliomas up until now has been the demonstration that codeletion of the chromosome arms 1p and 19q is generally associated to the oligodendroglial phenotype, while tumours not presenting this codeletion are generally astrocytomas or mixed oligoastrocytic tumours (Reifenberger et al., 1994). Molecular studies have shown that loss of chromosomal material arises through an unbalanced translocation of 19p to 1q t(1;19)(q10;p10) (Jenkins et al., 2006). The molecular significance of these deletions relies on the characterization of genes located in the deleted areas. Several candidate genes have been located in the 1p36 region but currently, no functional data are available that

could provide interest for clinicians. This finding is all the more so important that this codeletion is found in approximately two thirds of “oligo” tumors (“pure” oligodendroglial and anaplastic oligodendroglial, and “mixted” oligoastrocytic and anaplastic oligoastrocytic) considered altogether (Reifenberger et al., 1994). It appears that low grade tumors presenting this codeletion both carry a better prognosis, and are better responders to alkylating chemotherapy (Ricard et al., 2007). Other data in literature support the combination of these two aspects, and the 1p/19q codeletion is now recognized as a clinically relevant biomarker of these tumors.

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Prediction of Response to Treatments For patients harbouring a tumor not amenable to surgical treatment, and demonstrating clinical and/or volumetric tumor progression, the two available therapeutic modalities are radiation therapy and chemotherapy. Historically, radiation therapy has been, and remains today a pivotal treatment for low grade gliomas inaccessible to sufficient surgical resection. There is today no predictive biomarker of low grade gliomas response to radiation therapy. A fairly recent strategy proposes neo adjuvant chemotherapy for low grade gliomas which are deemed inaccessible to sufficient surgical removal as initial treatment. This chemotherapy relies on alkylating agents, and some responding patients can benefit surgery as a second step, depending on the tumor response to chemotherapy in terms of volume shrinkage. Regarding the predictive value of response to chemotherapy, low grade gliomas now benefit the recent progress of molecular biology initially reported for higher grade oligendendroglioma which treatment have included chemotherapy for long (Ricard et al., 2007). The methylation status of the MGMT (O6-methyl-guanyl-methyl transferase) gene promoter might also be predictive of low grade gliomas chemosensitivity to alkylating agents, but this remains to be demonstrated. Concerning astrocytic tumors, other biomarkers are under investigation, which are presented below, but although promising they have not reached the clinician yet. However, whatever the loss of portions of chromosomes 1p36 and 19q13.3 and the therapeutic strategy, all the patients that are not in remission after initial – and even repeated when functionally possible – sufficient surgical removal of their low grade tumor eventually develop a progression to a higher grade tumor.

Importance of Biomarkers in High Grade Gliomas Management

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are homogenous enough as far as overall survival is concerned. However, observed survival is, for some patients, different and sometime quiet different from the anticipated outcome. As previously mentioned, part of the explanation might be the lack of reproductibility of grading. Another part of explanation might be the particular behaviour of some subsets of gliomas (i.e. glioneuronal tumors as described in the Sainte Anne hospital classification), that might benefit very long survival after complete surgical removal. In this context, while numerous biomarkers are identified as prognostic factors, many of them have no impact on decision-making due to fact that their value is less relevant than that of already known indicators (e.g., grade, age, impact of treatment on survival) (Wager et al., 2008). Focusing on anaplastic (Grade III) “oligos”, either “pure” oligodendroglial, or mixed tumors, it has been shown that 1p/19q codeletion is an independent favourable prognostic factor (for a review, see Idbaih et al., 2007). Methylation status of the MGMT promoter gene is also prognostic, and of potential interest, its relevance can exceed the predictiveness of the response to alkylating agents (nitrosoureas and temozolomide) for these tumors. Indeed, a high correlation was reported between MGMT methylation and 1p/19q codeletions which are associated to a better prognosis in anaplastic astrocytomas. Glioblastoma (grade IV) patients present the shorter overall survival of all gliomas. While one of the first successes of molecular biology have been to distinguish primary and secondary glioblastoma, their clinical outcome and response to treatment are so identical that this distinction had no clinical consequence. During the last years, the biological breakthrough concerned biomarkers predicting response of these tumors to chemotherapy (see following paragraph). But several purely prognostic biomarkers are now emerging, which are on the verge of penetrating the clinical field. They will be presented further in this chapter (see Biomarkers outside of the clinical field: perspectives emerging of recent new findings in cancer biology).

Spontaneous Course of the Disease Prediction of Response to Treatments High grade gliomas are today among the most difficult tumors to treat and carry a gloomy prognosis. The WHO classification defines according to tumor grade (III and IV) groups of patients that

Focusing on grade III tumors, a wide corpus of retrospective studies suggests that 1p/19q codeletion predicts better response to alkylating agents

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(Cairncross et al., 1998, for a review, see Idbaih et al., 2007). As far as methylation of the MGMT promoter gene status is concerned, noticeably its status in anaplastic astrocytomas is only prognostic but not predictive of response to alkylating agent chemotherapy as it is in glioblastoma. Regarding glioblastoma, in 2005 a benefit on overall survival was demonstrated, real although modest, for a subpopulation of glioblastoma patients receiving the concomitant administration of radiation therapy and chemotherapy by alkylating agents (Stupp et al., 2005). It appeared that this benefit depends on the methylation status of the MGMT gene promoter (Hegi et al., 2005). MGMT is a DNA repair enzyme that catalyses the elimination of alkyl groups on DNA. This observation has been at the origin of an important renewal of interest in the medical community in the biologic aspect of the problem, and methylation status of this promoter gene has become a biomarker predicting response to a protocol which rapidly became the first line standard of treatment for newly diagnosed glioblastoma multiforme. Because response to this alkylating agent (temozolomide) is strongly correlated with the methylation status of the MGMT promoter gene, systematic analysis of the MGMT promoter is today considered to be the strongest predictor of response to alkylating chemotherapy in newly diagnosed glioblastoma multiforme. Several methods for this analysis are available, and this constitutes another aspect of this problem (Karayan-Tapon et al., 2010) – see below. As a conclusion, a review of literature shows that several relevant biomarkers have recently emerged in the clinical field. But it is remarkable that there is often a persisting ambiguity in data, as impact on survival of genuine response to treatment is not always clearly distinguished from natural course of these diseases. In the end, the question is whether clinicians should consider these biomarkers for decision making? The core of the problem is that those biomarkers are reliable as far as groups are concerned, but are very disputable as far as patients are considered on a case by case basis. This is why the answer to this question is different today for groups of patients, and for patients considered individually. Stratifications of patients in clinical studies now widely rely on biomarkers, and one cannot ignore them anymore when drawing conclusions from clinical trials data. It is also a very common idea today that these biomarkers can help

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to decide which groups of patients should be considered for innovative treatments in clinical trials – i.e. groups whose biomarker(s) anticipate a poor response to standard treatments. But one has to keep in mind the persisting uncertainty – ambiguity between natural course and genuine response to treatments – in numerous situations. Otherwise the price to pay would be important bias in these trials. As far as individuals are concerned, it is not considered relevant today to use those biomarkers for therapeutic decision making – regarding administration of alkylating agents – on a individual, case by case basis. It is also noteworthy that many technical and standardization difficulties remain, which should be resolved before a personalized medicine can be envisioned (Karayan-Tapon et al., 2010; Weller et al., 2010).

Biomarkers Outside of the Current Clinical Field: Perspectives Emerging of Recent New Findings in Cancer Biology In terms of cancer physiopathology of brain tumors, the beginning of the twentyfirst century has seen remarkable progress in the understanding of biology and molecular mechanisms. One of the most significant concepts is the notion that, similarly to other cancers, glioblastomas possess a population of cells with stem cell properties. In addition to their tumorigenic potential, these tumors stem cells (TSC) or tumor initiating cells (TIC) share two main properties of the stem cells, namely self-renewal and toti/pluripotency, that is to say a capacity to differentiate into the different cell lineages that constitute the nervous tissue. Because of these properties and their resistance to a variety of stresses (chemotherapy, radiations), these TSC are capable of escaping to the conventional therapies and maintaining the recurring capability of the tumors. Furthermore, a few cells inside this pool of TSC is prone to additional genetic events that favor their dissemination and increase their resistance. A second exciting approach is the development of the so-called “omics” fields that are currently applied to achieve a very precise knowledge of the genome and the abnormalities present in tumors (genomics), as well as to the acquisition of gene expression patterns (transcriptome) resulting in the possibility of

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classification of different glioblastoma subtypes, and the detection in the tumors and in different fluids of the patients of a number of proteins which could be of real interest to improve the tumor classification, help to the choice of treatments and improve followup of the tumor itself. Although these findings open the way to new approaches in the comprehensive biology of the tumors, they have not still given us keys to major therapeutic breakthroughs. With regards to this problem, this presentation is subdivided into three parts: description of the current alterations that are found in glioblastomas (primary as well as secondary) and might constitute in the near future biomarkers participating in decision making. The tumor stem cell concept and its utilization for a better understanding of the biology of glioblastomas. The use of new molecular features recently discovered to develop future molecularly targeted diagnosis approaches and therapies.

promoter have already been detailed in the previous paragraph, as they have received the most important clinical interest. Several other important biomarkers have recently emerged. They are presented now.

Present Status of Genetic Alterations That Drive Gliomagenesis and Progression Analysis of various cohorts of tumors, the most informative being that of the Cancer Genome Atlas Research Network, have got insight into the principal ways that are deregulated in glioblastomas, the most informative being that of the Cancer Genome Atlas Research Network: (a) the TP53 pathway (>60% of tumors) with abnormalities of TP53 gene itself or one member of the pathway (MDM2, MDM4, p14ARF); (b) the pRB1 pathway (68% of tumors) that includes RB1, CD4, CDKN2A (p16INK4A); 3) the PI3 K-PTEN pathway that involves PIK3CA, PIK3R1, PTEN, and IRS1. As a rule one abnormality of one of the genes belonging to a given pathway excludes aberrations of other genes belonging to this pathway. Even if this huge number of data has largely contributed to a better understanding of the mechanisms underlying the biology of gliomas, none of them presents a real practical interest on a therapeutic point of view. In contrast, a few abnormalities not implicated in the above-mentioned pathways and more or less specific to gliomas are currently used in the clinical field. Loss of portions of chromosomes 1p36 and 19q13.3, and methylation status of the MGMT gene

– Amplification of the BRAF gene on chromosome band 7q34 in pilocytic astrocytpomas. A tandem duplication of BRAF activates the gene by generating a fusion gene between the kinase domain of BRAF and the adjacent locus KIAA1549 (Jones et al., 2009). This rearrangement is present in 60–80% of pylocytic astrocytomas and infrequent in diffuse low grade astrocytomas thus providing clues for differential diagnosis. Constitutive activation of BRAF activates the MEK/ERK pathway leading to increased proliferation of tumor cells. In view of these data, inhibition of the BRAF/MEK/ERK cascade might constitute a therapeutic target for the treatment of low grade pediatric astrocytomas. However, a serious caveat has occurred with a new report showing that the use of some BRAF inhibitors in the control of tumor growth actually resulted in stimulatory effects on proliferation rather than stopping it. According to this work, BRAF-specific inhibitors (for instance 885-A) facilitate the association to its partner CRAF that is linked to Ras and induce an over activation of the MEK/ERK pathway. In contrast, pan-RAF inhibitors (sorafenib) while they do not block the association of BRAF to CRAF, inhibit the two partners and abolish the stimulation of the MAP kinase pathway (Heidorn et al., 2010). – Mutations of IDH1 and IDH2 gene (chromosome band 2q33) as a differential diagnosis tool. The Isocitrate dehydrogenase (IDH) gene encodes a metabolic enzyme that converts isocitrate to α-ketoglutarate with the concurrent reduction of NAD(P)+ into NAD(P)H. The two IDH1 and IDH2 isoforms are cytosolic and mitochondrial respectively. Whereas IDH3, as a part of the tricarboxylic acide (TCA) cycle, generates NADH for energy production, IDH1 and 2 participate to shuttling of electrons between mitochondria and cytosol. In 2008, it was found that mutations in IDH1 all located on the R132 residue and less frequent mutations on R172 in IDH2 were present in 12% of gliomas analysed in the series. The IDH1 mutated tumors were most common to young

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patients and secondary glioblastomas and associated to longer survival (Parsons et al., 2008). A subsequent study (Balss et al., 2008) explored the presence of IDH1 mutations on a series of 685 tumors comprised of most if not all major glioma subtypes. The mutations were nearly absent in primary glioblastoma and present in 88% of secondary glioblastomas. The high frequency of IDH1 R132 mutations in oligodendrogiomas (69%) and mixed oligoastrocytic tumors (78%) were consistent with an arising of secondary glioblasoma from lower grade tumors. No mutation was found in pilocytic astrocytomas making possible a molecular discrimination between this tumor type and infiltrating low-grade gliomas. Analysis of another series (Watanabe et al., 2009) provided arguments suggesting that IDH mutations are early events in gliomagenesis. The biochemical consequences of the IDH1 mutation most likely rely on the substitution of R132/R172 in IDH1/IDH2 because the two arginine residues contract hydrophilic interactions that allow the binding of isocitrate to the enzymes. Because of the large range of substituting residues, it is probable that R replacement supports tumorigenesis by impairing isocitrate binding. This leads to a loss of function and qualifies IDH1 and 2 as tumor suppressor genes (Zhao et al., 2009). In fact new recent data have been reported indicating that R132 mutant IDH1 not only does not catalyze the conversion of isocitrate to α-ketoglutarate but instead reduces α-ketoglutarate to the D-2 enantiomer form of 2-hydroxyglutarate (Dang et al., 2009). Consistent with this gain of function by the mutant enzyme, human gliomas with the R132 mutation in IDH1 contain 100-fold more 2-hydroxyglutarate than in tumors with WT IDH1. One possible explanation for an oncogenic function of mutant IDH1 could result from its inhibitory capacity of the oxygen-sensing enzymes hypoxia-inducible prolylhydroxylases (PHDs). Indeed, PHDs are inhibited in cells carrying mutant IDH1. PHD inhibition leads to the activation of the HIF transcription factor but currently, this does not give a clue as to know the real function of the mutant IDH1 in an oncogenic process. Pathological increase in the D2-hydroxyglutarate levels are found is associated with encephalopathy and cardiomyopathy but not with tumor risk, whereas the L-2-hydroxyglutarate

enantiomer also associated with progressive neural defects is linked to increased risk of glioma (Aghili et al., 2009). – A new mechanism relevant to the occurrence of resistance to alkylating agents has emerged from data showing an increased frequency of inactivating mutations in the MSH6 mismatch repair gene in patients who had recurrence following temozolomide treatment. This suggested that MSH6 deficiency may contribute to the emergence of resistance. Thus, MSH6 mutations are likely to be selected during temozolomide therapy. Most recently, studies on significant cohorts of annotated tumors have resulted in the detection of new genetic abnormalities: the NF1 gene was found mutated in 14% of glioblastomas; mutations of PIK3 R1 and ERBB2 genes were also detected respectively in 10 and 8% of analysed glioblastomas. However, the practical interest has not yet been proven and further studies will be necessary before concluding on their utility for clinicians.

Brain Tumours and Stem Cells A profusion of data in the literature feeds the notion that, as for other tumor types, brain tumors and particularly glioblastoma multiforme contain a fraction of tumor cells that share a number of features characteristic of neural stem cells and immature precursors (progenitors) more or less engaged in a differentiated lineage. Briefly, these cells are defined by two main properties: ability to perpetuate themselves (self-renewal capacity for true stem cells) and capacity to give rise to populations of postmitotic cells of the cerebral tissues through differentiation. While the existence of SC has been strongly established in hematopoietic tissue since the nineties, the presence of NSC in brain has been delayed until the demonstration of neural stem cells in subventricular zones of the adult human brain was reported (Sanai et al., 2004). This immediately reinforces the hypothesis that recurrence of GBM is likely to occur through cancer-initiating precursors with stem-cell properties, involving principally self-renewal in vitro and in vivo. For different reasons, this model postulates that only this small subset of cells is able to proliferate extensively and has

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a true tumorigenic potential whereas most if not all of the cells composing the bulk of the tumor have lost this potential (for a review see Vescovi et al., 2006). The model immediately raises one obvious question about the status of NSC as targets for transforming events. There are at least two reasons that this may be the case: first, fewer events are required to impair the phenotype of cells that have self-activating mechanisms already operating. In addition, the persistence for long periods of time of self-renewing SC implies that the opportunity for mutations to accumulate in individual stem cells is higher than in non proliferating dying cells. This is of particular interest to explain the resistance to radiotherapy and chemotherapy acquired by TSC (Eramo et al., 2006; Liu et al., 2006; Bao et al., 2006). Two important consequences emerge from the tumor stem cell paradigm: first, distinct signaling pathways are activated in self-renewing stem cells and progenitors more advanced in differentiation. This opens the way to the definition of new targets. Second, the impact of therapeutics on a tiny subset of tumorigenic stem cells could reduce the useful targets for efficient treatment of tumors. In addition, the new data provided by integrated genomic analysis (see next section) could be useful for defining with accuracy molecular signatures for each category of TSC or progenitors.

and pathways involved in gliomas physiopathology. Second they should provide the clinician with new tools for improving diagnosis of tumors that are not easily classified by conventional histopathological analysis. In this respect, the definition of gene signatures specific of tumors types and grades is likely to introduce new classification schemes that will go further than those resulting from histopathological and imaging analysis alone. Such large studies require the establishment of publicly available banks of annotated tumors. By definition, these banks should contain sufficient numbers of each tumor subtype as to allow robust statistical analysis. Furthermore, use of efficient algorithms for achieving successfully specific signatures predictive of a given cellular phenotype. These conditions have been fulfilled by the creation of large networks, the Cancer Genome Atlas Research Network (TCGA, URL:http://cancer genome.nih.gov) being the most representative. These approaches confirmed some of the molecular pathways that had been previously involved in gliomagenesis and, most interestingly, identified new subtypes of GBM. Among the series of recent publications on the subject, a few deserve particular attention as they open the way to real progress in terms of diagnosis, prognosis and treatment. The work published by the Cancer Genome Atlas Network in 2008 is the first integrated genomic analysis implicating several parameters: DNA copy number, gene expression (trancriptome) and DNA methylation profiling in 206 human glioblastomas (an almost simultaneously published study led to the same general conclusions). This study univocally showed that most of the GBM carry abnormalities in TP53, RB1 and tyrosine kinase receptor pathways. One major conclusion was that these abnormalities implicating significant signalization pathways were a “core requirement for GBM pathogenesis”. The most recent data published by the TCGA start from the idea that different tumor subtypes may originate from different causes or different cells of origin, or both (Verhaak et al., 2010). By combining gene expression classification data, discarding several possible bias and by demonstrating their reproducibility on an independent validation set, the authors defined a molecular classification into four primary GBM subtypes, namely Proneural, Neural, Classical and Mesenchymal subtypes. For each of them, the 210 genes (per subtype) signature that was established was integrated with genomic aberrations. Principal characteristics for each

Perspectives Resulting from Integrated Genomic Analysis to Define a Framework for a Molecular Classification of Tumours and for Investigation of Targeted Therapies The New Tools of Genomic Analysis Molecular biology of cancer is more and more dominated by the development of large scale-array-based profiling methods at the DNA, RNA and protein levels. New technologies that are now commonly used involve array-based comparative genomic hybridization (array-CGH), SNP (single nucleotide polymorphism) arrays, transcriptomic arrays for gene expression, new sequencing techniques. The interest of such approaches is double: first from a fundamental point of view, the findings resulting from these technologies should culminate in an overview of unregulated genes

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CLASSICAL SUBTYPE: Chromosome 7 amplification and chromosome 10 loss Four-fold increase EGFR amplification (97%) EGFR point mutation or vII EGFR mutation (12/22 tumors) Relative absence of TP53 mutations Frequent deletion of chromosome band 9p21.3 (p16INK4A and p14ARF) accompanying EGFR alterations (94%). Mutual exclusion with alterations of the RB pathway indicating the implication of this way by the only CDKN2A deletions. Overexpression of components of stem cell marker NES, NOTCH (NOTCH3, JAG1, LFNG), Sonic Hedgehog (SMO, GAS1, GLI2) signaling pathways.

MESENCHYMAL SUBTYPE:

Focal hemizygous deletions of a 17q11.2 chromosome region containing NF1 (53%°

lower

NF1 expression levels. No methylation in the NF1 locus Frequency of NF1 mutations (14/20 tumors classified as Mesenchymal) Expression of Mesenchymal markers: CHI3L1/YKL40, MET High expression of members of the tumor necrosis factor superfamily pathway and NF-kb pathway: TRADD, RELB, TNFRS1A

PRONEURAL:

Focal amplification at 4q12 GBM than other subtypes)

alterations of PDGFRA most frequently found in this subtype of PDGFRA overexpression almost excusively found in this subtype

Point mutations (R132) in IDH1 (11/12 tumor) Frequent TP53 mutations and loss of heterozygosity (LOH) High expression of oligodendrocyitic development genes: PDGFRA, NKX2-2, OLIG2 Mutations of PI3KCA/PI3KR1 (10/16 tumors) Expression of several neural development genes: DCX, DLL3, ASCL1, TCF4

NEURAL:

Expression of neuron markers: NEFL, GABRA1, SYT1, SLC12A5. Two normal brain tissues were classified as Neural

Fig. 2.2 Properties of the four glioblastoma subtypes as reported by Verhaak et al. (2010)

subtype are presented in Fig. 2.2. Characteristically, the four subtypes exhibited molecular expression features reminiscent of distinct cell type gene sets associated with neurons, oligodendrocytes, astrocytes and cultured astroglial cells. For instance, the Proneural subtype was associated to an oligodendrocytic signature but not the astrocytic signature.

A clinical correlation could also be established with each subtype. The most consistent one was age, with younger patients overrepresented in the Proneural subtype. This association survived the multicentric origin of the patients. Furthermore, a comparison of intensive treatments (concurrent chemotherapy and radiotherapy or more than three subsequent cycles

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of chemotherapy) on survival was done. It showed a significant reduction in mortality in Classical and Mesenchymal subtypes but not in Proneural subtype. Finally, the methylation status of MGMT promoter gene, previously associated to response to therapy, was not found associated to subtype.

is that the identification of the small number of MR generating and maintaining a specific tumor signature is synonymous of efficient tools for diagnostic and pharmacological interventions. Integrative genome analysis has also been performed to the rapidly progressing microRNA (miRs) field. The importance of the miRs in the oncogenic process and more precisely the metastatic progression has been particularly explored in various tumor pathologies. In gliomasa number of papers have confirmed the stimulatory role of certain miRs such as miR-21 in the progression of metastasis. Down-regulation of miR-21 inhibits the EGFR pathway thus confirming the stimulating activity of this miR on oncongenic genes as shown previously in other tumors (Zhou et al., 2010). More recently, Johnson’s group in Harvard reported the characterization of miR-26a as a cooperating component of an amplicon the presence of which in human glioblastomas is associated with a markedly decreased survival (Kim et al., 2010). This amplicon contains CDK4 and CENTG1, two oncogenes, regulating the RB1 and PI3K/AKT pathways respectively. miR-26a alone induces in vivo decrease of PTEN, RB1 and MAP3K2/MEKK2 pathways, thereby promoting AKT activation, proliferation and decreasing c-Jun terminal kinase-dependent apoptosis. As a whole, these data define a functional oncomiR/oncogene DNA cluster that promotes aggressiveness of glioblastomas by targeting the RB1, PI3K/AKT and JNK pathways. While these data should be completed by functional studies that will definitely characterize the pathways targeted by the different miRs, these results open the way to a molecular follow-up of the tumors by use of miR microarrays. The next approach would consist of designing inhibitors of miRs in order to block some of the steps in which their tumor stimulatory function is involved.

Perspectives for Transfer to Patients Care As a whole, this amazing set of data is going to provide the clinician with a frame of relevant informations that might be exploited for diagnosis and treatment. However, it is clear that at the present level, only clinical departments with an access to specialized laboratories will acquire the capacity to treat their patients in function of the recent data. Simplification of analysis is therefore needed in terms of tests and cost. A recent publication suggests that this could be achieved (Carro et al., 2010). The authors postulated that specific transcriptional signatures of tumors are placed under the regulatory effects of master gene regulators (MR). In other words, the model of gene expression profile-based cancer analysis which is currently studied in most cancer pathologies could be advantageously replaced by a cellular network analysis of the MR controlling the signatures and the corresponding phenotypes (subtypes). Such an approach was applied to the search of a transcriptional module of MRs regulating the molecular signature of the mesenchymal subtype. This analysis identified two transcriptional genes, C/EBPβ and STAT3, whose simultaneous over-expression oriented cell neural stem cells toward mesenchymal transformation. Most significantly, co-expression of the two factors was necessary and sufficient to reprogram the neural lineage along the malignant mesenchymal lineage. In contrast, their simultaneous elimination led to reduction of the mesenchymal signature and diminution of tumor aggressiveness. These results were corroborated by data showing a direct relationship between the expression levels of STAT3 and C/EBPβ in human GBM and poor clinical outcome. The biological significance of these results is presently unknown as STAT3 induces astrocytic differentiation and counteracts neuronal differentiation while C/EBPβ induces neurogenesis and inhibits gliomagenesis. The principal conclusion regarding the clinical utility of these results

Neurosphere Cultures: Biomarkers Themselves, or a Tool for Analysing Molecular Biomarkers? On the border of the biomarkers field, we have to mention the ability for some gliomas to generate neurospheres. It has been shown not only that only a subset of gliomas can generate neurospheres, but also that this ability is predictive of overall survival of patients

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(Laks et al., 2009). On a clinical point of view, several factors preclude clinical use of neurosphere. A number of papers have shown that glioblastoma contain cells that can generate neurospheres when placed under stem cell culture conditions. Because these cells derived from tumors exhibit representative markers of stemness (usually CD133) and because of their tumorigenic potential in vivo, it is generally admitted that neurospheres might reflect the tumor cell origin. In this respect, molecular analysis of individual neurospheres could be of obvious interest to establish the tumor phenotype of each tumor and predict tumor response to treatment and outcome. However, several points must be clarified before achieving this goal. One of the most recent papers on the subject (Chen et al., 2010) reports a hierarchy of self-renewing tumor-initiating cell types in glioblastoma. It has shown that individual glioblastoma multiforme carry a CD133+ /CD133– heterogeneous population of self-renewing cells with tumor initiation capacity. These points are important as they raise the crucial question of the representativity of cultures of neurospheres. Furthermore, while the growth of neurospheres has already been shown to be limited to a subset of glioblastoma, the new data establish that PTEN deficiency of the tumor cells is a necessary requirement for successful neurospheres propagation. In other words, on the basis of these two parameters – cell heterogeneity and PTEN insufficiency – the possibility exist that cell types initially present in the tumor are not conserved in the cultures. For these reasons and in spite of the obvious interest for a better understanding of the biology of glioblastoma, other studies will have to be performed before neurospheres acquire a biomarker status. In conclusion, recent advances in molecular biology have permitted a better understanding of the complex mechanisms underlying gliomagenesis, and numerous biomarkers appeared. Some of them – LOH 1p/19q, methylation status of the MGMT promoter gene – have proven such an association to overall survival as far as groups of patients are concerned that stratifying analysis of clinical trials on these parameters has become a standard. But uncertainties remain regarding what pertains to natural history of gliomas, and what pertains to response to treatments, as assessed by biomarkers. It is also the reason why their importance in the choice between standard treatment and innovative therapies during clinical trials on this basis should remain cautious. Due to these uncertainties, and other technical

M. Wager et al.

and standardization reasons, time has not come – yet?for biomarkers based personalized medicine. Many other biomarkers are currently under study, and some of them – IDH1 and IDH2 – seem to be on the verge of reaching the clinical field. Recent data of integrated genomic analysis show that we are in the edge of new approaches which will improve tools given to clinicians for the diagnosis, decision making, and follow-up of adult gliomas. The molecular characterization of glioblastoma main subcategories will probably allow innovations in their classification. It should benefit from data to come on micro-RNAs (MiRs), as several preliminary results showed that their status of expression could contribute to tumor signatures. One can conceive a personalized approach to each tumor generating neurospheres, beginning with culture. Neurospheres might be valuable for their capacity at maintaining the original tumor, assessment of response and study of resistance to treatments.

References Aghili M, Zahedi F, Rafiee E (2009) Hydroxyglutaric aciduria and malignant brain tumor: a case report and literature review. J Neurooncol 91:233–236 Balss J, Meyer J, Mueller W, Korshunov A, Hartmann C, Von Deimling A (2008) Analysis of the IDH1 codon 132 mutation in brain tumors. Acta Neuropathol 116:597–602 Bao S, Wu Q, McLendon RE, Hao Y, Shi Q, Hjelmeland AB, Dewhirst MW, Bigner DD, Rich JN (2006) Glioma stem cells promote radioresistance by preferential activation of the DNA damage response. Nature 444:756–760 Berger MS (1995) Role of surgery n diagnosis and management of low grade gliomas. In: Appuzzo MLJ (eds) Benign cerebral glioma, vol II, Chapter 15. Neurosurgical topics. AANS Publications, Park Ridge, IL, pp 293–307 Cairncross JG, Ueki K, Zlatescu MC, Lisle DK, Finkelstein DM, Hammond RR, Silver JS, Stark PC, Macdonald DR, Ino Y, Ramsay DA, Louis DN (1998) Specific predictors of chemotherapeutic response and survival in patients with anaplastic oligodendroglioma. J Natl Cancer Inst 90: 1473–1479 Carro MS, Lim WK, Alvarez MJ, Bollo RJ, Zhao X, Snyder EY, Sulman EP, Anne SL, Doetsch F, Colman H, Lasorella A, Aldape K, Califano A, Iavarone A (2010) The transcriptional network for mesenchymal transformation of brain tumours. Nature 463:318–325 Chen R, Nishimura MC, Bumbaca SM, Kharbanda S, Forrest WF, Kasman IM, Greve JM, Soriano RH, Gilmour LL, Rivers CS, Modrusan Z, Nacu S, Guerrero S, Edgar KA, Wallin JJ, Lamszus K, Westphal M, Heim S, James CD, VandenBerg SR, Costello JF, Moorefield S, Cowdrey CJ, Prados M, Phillips HS (2010) A hierarchy of self-renewing

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tumor-initiating cell types in glioblastoma. Cancer Cell 17:362–375 Dang L, White DW, Gross S, Bennett BD, Bittinger MA, Driggers EM, Fantin VR, Jang HG, Jin S, Keenan MC, Marks KM, Prins RM, Ward PS, En KE, Liau LM, Rabinowitz JD, Cantley LC, Thompson CB, Vander Heiden MG, Su SM (2009) Cancer- associated IDH1 mutations produce 2-hydroxyglutarate. Nature 462:739–744 Daumas-Duport C, Beuvon F, Varlet P, Fallet-Bianco C (2000) Gliomas: WHO and Sainte-Anne hospital classifications. Ann Pathol 5:413–428 Eramo A, Ricci-Vitiani L, Zeuner A, Pallini R, Lotti F, Sette G, Pilozzi E, Larocca LM, Peschle C, De Maria R (2006) Chemotherapy resistance of glioblastoma stem cells. Cell Death Diff 17:1238–1241 Hegi ME, Diserens AC, Gorlia T, Hamou MF, DeTribolet N, Weller M, Kros JMJM, Hainfellner JA, Mason W, Mariani L, Bromberg JEC, Hau P, Mirimanoff RO, Cairncross JG, Janzer RC, Stupp R (2005) MGMT gene silencing and benefit from temozolomide in glioblastoma. N Engl J Med 352:997–1003 Heidorn SJ, Milagre C, Whittaker S, Nourry A, NiculescuDuvas I, Dhomen N, Hussain J, Reis-Filho JS, Springer CJ, Pritchard C, Marais R (2010) Kinase-dead BRAF and oncogenic RAS cooperate to drive tumor progression through CRAF. Cell 140:209–221 Hormigo A, Gu B, Karimi S, Riedel E, Panageas KS, Edgar MA, Tanwar MK, Rao JS, Fleisher M, DeAngelis LM, Holland EC (2006) YKL-40 and matrix metalloproteinase-9 as potential serum biomarkers for patients with high grade gliomas. Clin Cancer Res 12:5698–5704 Idbaih A, Omurao A, Ducray F, Hoang-Xuan K (2007) Molecular genetic markers as predictors of response to chemotherapy in gliomas. Curr Opin Oncol 19:606–611 Jenkins RB, Blair H, Ballman KV, Giannini C, Arusell RM, Law M, Flynn H, Passé S, Felten S, Brown PD, Shaw EG, Buckner JC (2006) A t(1;19)(p10;q10) mediates the combined deletions of 1 p and 19q and predicts a better prognosis of patients with oligodendroglioma. Cancer Res 66:9852–9861 Jones DT, Kocialkowski S, Liu L, Pearson DM, Ichimura K, Collins VP (2009) Oncogenic RAF1 rearrangement and a novel BRAF mutation as alternatives to KIAA1549:BRAF fusionin activating the MAPK pathway in pilocytic astrocytoma. Oncogene 28:2119–2123 Karayan-Tapon L, Quillien V, Guilhot J, Wager M, Fromont G, Saikali S, Etchevery A, Hamlat A, Loussouarn D, Campion L, Campone M, Vallette FM, Gratas-Rabbia-Ré C (2010) Prognostic value of O6-methylguanine-DNA methyltransferase status in glioblastoma patients, assessed by five different methods. J Neurooncol 97:311–322 Kim H, Huang W, Jiang X, Pennicooke B, Par PJ, Johnson MD (2010) Integrative genome analysis reveals an oncomir/oncogene cluster regulating glioblastoma survivorship. Proc Natl Acad Sci USA 107:2183–2188 Laks DR, Masterman-Smiyh M, Visnyel K, Angenieux B, Orozco N, Foran I, Young WH, Vinters HV, Liau LM, Lazareff JA, Mischel PS, Cloughesy TF, Horvath S, Kornblum HL (2009) Neurosphere formation is an independent predictor of clinical outcome in malignant glioma. Stem Cells 27:980–987

Liu G, Yuan X, Zeng Z, Tunici P, Ng H, Abdulkadir IR, Lu L, Irvin D, Black KL, Yu JS (2006) Analysis of gene expression and chemoresistance of CD133+ cancer stem cells in glioblastoma. Mol Cancer 5:67 Louis DN, Ohgaki H, Wiestler OD, Cavenee WK (eds) (2007) WHO Classification of tumours of the central nervous system, 3rd ed. IARC Press, Lyon Mittler MA, Walters BC, Stopa EG (1996) Observer reliability in histological grading of astrocytoma stereotactic biopsies. J Neurosurg 85:1091–1094 Pallud J, Mandonnet E, Duffau H, Kujas M, Guillevin R, Galanaud D, Taillandier L, Capelle L (2006) Prognostic value of initial magnetic resonance imaging growth rates for world health organization grade II gliomas. Ann Neurol 60:380–383 Parsons DW, Jones S, Zhang X, Lin JC, Leary RJ, Angenendt P, Mankoo P, Carter H, Siu IM, Gallia GL, Olivi A, McLendon R, Rasheed BA, Keir S, Nikolskaya T, Nikolsky Y, Busam DA, Tekleab H, Diaz LA Jr, Hartigan J, Smith DR, Strausberg RL, Marie SK, Shinjo SM, Yan H, Riggins GJ, Bigner DD, Karchin R, Papadopoulos N, Parmigiani G, Vogelstein B, Velculescu VE, Kinzler KW (2008) An integrated genomic analysis of human glioblastoma multiforme. Science 321:1807–1812 Reifenberger J, Reifenberger G, Liu L, James CD, Wechsler W, Collins VP (1994) Molecular genetic analysis of oligodendroglial tumors shows preferential allelic deletions on 19q and 1p. Am J Pathol 145:1175–1190 Ricard D, Kaloshi G, Amiel-Benouaich A, Lejeune J, Marie Y, Mandonnet E, Kujas M, Mokhtari K, Taillibert S, LaigleDonadey F, Carpentier AF, Omuro A, Capelle L, Duffau H, Cornu P, Guillevin R, Canson M, Hoang-Xuan K, Delattre JY (2007) Dynamic history of low-grade gliomas before and after temozolomide treatment. Ann Neurol 61:484–490 Sanai N, Berger MS (2008) Glioma extend of resection and its impact on patient outcome. Neurosurg 62(4):753–4766 Sanai N, Tramontin AD, Quinones-Hinojosa A, Barbaro NM, Gupta N, Kunwar S, Lawton MT, McDermott MW, Parsa AT, Manuel-Garcia Verdugo J, Berger MS, Alvarez-Buylla A (2004) Unique astrocyte ribbon in adult human brain contains neural stem cells but lacks chain migration. Nature 427:740–744 Stupp R, Mason WP, Van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, Belanger K, Brandes AA, Marosi C, Bogdahn U, Curschmann J, Janzer RC, Ludwin SK, Gorlia T, Allgeier A, Lacombe D, Cairncross JG, Eisenhauer E, Mirimanoff ROand the European Organisation for Research and Treatment of Cancer Brain Tumor and Radiotherapy Groups; National Cancer Institute of Canada Clinial Trials Group (2005) Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352:987–996 Tamber MS, Bansal K, Liang M-L, Mainprize TG, Salhia B, Northcott P, Taylor M, Rutka JT (2006) Current concepts in the molecular genetics of pediatric brain tumors: implication for emerging therapies. Child Nerv Syst 22:1379–1394 Varlet P, Jouvet A, Miquel C, Saint-Pierre G, Beuvon F, DaumasDuport C (2005) Criteria of diagnosis and grading of oligodendrogliomas or oligoastrocytomas according to the WHO and Sainte-Anne classifications. Neurochirurgie 51:239–246 Varlet P, Soni D, Miquel C, Roux FX, Meder JF, Chneiweiss H, Daumas- Duport C (2004) New variants of malignant

24 glioneuronal tumors: a clinicopathological study of 40 cases. Neurosurg 55:1377–1391 Verhaak RGW, Hoadley KA, Purdom E, Wang V, Qi Y, Wilkerson MD, Miller CR, Ding L, Golub T, Mesirov JP, Alexe G, Lawrence M, O’Kelly M, Tamayo P, Weir BA, Gabriel S, Winckler W, Gupta S, Jakkula L, Feiler HS, Hogson JG, James CD, Sarkaria JN, Brennan C, Kahn A, Spellman PT, Wilson RK, Speed TP, Gray JW, Meyerson M, Getz G, Perou CM, Hayes DN, and Cancer Genome Atlas Research Network (2010) Integrated genomic analysis identifies clinically relevant subtypes of glioblastoma characterized by abnormalities in PDGFRA, IDH1, EGFR, and NF1. Cancer Cell 17:98–110 Vescovi AL, Galli R, Reynolds BA (2006) Brain tumour stem cells. Nat Rev Cancer 6:425–436 Wager M, Guilhot J, Blanc JL, Ferrand S, Milin S, Bataille B, Lapierre F, Denis S, Chantereau T, Larsen CJ, KarayanTapon L (2006) Prognostic value of increase in transcript levels of Tp73 DeltaEx2-3isoforms in low-grade glioma patients. Br J Cancer 95:1062–1069 Wager M, Menei P, Guilhot J, Levillain P, Michalak S, Bataille B, Blanc JL, Lapierre F, Rigoard P, Milin S, Duthe F,

M. Wager et al. Bonneau D, Larsen CJ, Karayan-Tapon L (2008) Prognostic molecular markers with no impact on decision-making: the paradox of glioma based on a prospective study. Br J Cancer 98:1830–1838 Watanabe T, Nobusawa S, Kleihues P, Ohgaki H (2009) IDH1 mutations are early events in the development of astrocytomas and oligodendrogliomas. Am J Pathol 174: 1149–1153 Weller M, Stupp R, Reifenberger G, Brandes AA, Van Den Bent MJ, Wick W, Hegi ME (2010) MGMT promoter methylation in malignant gliomas: ready for personalized medicine? Nat Rev Neurol 6:39–51 Zhao S, Lin Y, Xu W, Jiang W, Zha Z, Wang P, Yu W, Li Z, Gong L, Peng Y, Ding J, Lei Q, Guan KL, Xiong Y (2009) Glioma-derived mutations in IDH1 dominantly inhibit IDH1 activity and induce HIF-1α. Science 32: 261–265 Zhou X, Ren Y, Moore L, Mei M, You Y, Xu P, Wang G, Jia Z, Pu P, Zhang W, Kang C (2010) Downregulation of miR-21 inhibits EGFR pathway and suppresses the growth of human glioblastoma cells independent of PTEN status. Lab Invest 90:144–155

Chapter 3

Molecular Subtypes of Gliomas Lonneke A.M. Gravendeel and Pim J. French

Abstract Gliomas are the most common primary brain tumors with heterogeneous morphology and variable prognosis. However, differences between histological subclasses and grades are subtle, and classifying gliomas is subject to a large inter-observer variability. This variability can result in misdiagnosis of gliomas. As treatment decisions in patients rely mainly on histological classification and clinical parameters, there is an urgent need of developing a more accurate and objective classification model. The identification of specific molecular markers (LOH of 1p19q, IDH1 mutation, MGMT methylation status), as well as molecular clusters based on gene expression have been studied extensively. These specific molecular features within gliomas can help diagnosis, can give a more accurate prognosis, and may also be used to develop personalized targeted therapy in the future. Keywords Gliomas · Molecular markers · Molecular cluster · LOH 1p19q · IDH1 · MGMT

Introduction Gliomas are the most common type of primary brain tumors in adults with an incidence rate of 5.27 per 100,000 patients every year (Ohgaki et al., 2004; Louis et al., 2007). In 1926, Bailey and Cushing suggested a classification model based on distinct

P.J. French () Department of Neurology, Josephine Nefkens Institute, Erasmus Medical Centre, 3000 DR Rotterdam, The Netherlands e-mail: [email protected]

histological morphologies (Bailey and Cushing, 1926), which forms the basis of the currently used WHO classification (Louis et al., 2007). Two major subtypes are recognized: Astrocytic (A) and oligodendrocytic (OD) tumors, the latter including pure OD tumors and mixed oligoastrocytic (MOA) tumors. Astrocytic tumors are further separated into grades I (pilocytic astrocytomas [PA]), II (low grade), III (anaplastic), and IV (glioblastoma [GBM]). Oligodendrocytic tumors are further separated into grades II (low grade) and III (anaplastic). Patient survival, time to tumor progression, and response to therapy are all associated with subtype and grade of the tumor (Louis et al., 2007). This classification model, combined with the patients’ prognostic features (e.g. age and Karnofsky Performance Score [KPS]), guides treatment decisions. Differences between histological subtypes are very subtle, and classifying gliomas is subject to a large interobserver variability (Scott et al., 1995; Murphy et al., 2002; Kros et al., 2007; Hildebrand et al., 2008). Clearly, this variability can result in misdiagnosis of gliomas, for example by assigning a prognostically favorable lower-grade glioma into a poor prognostic glioma (e.g. “false-positive GBM”), and in assigning a prognostically less favorable higher-grade glioma into a good prognostic glioma (e.g. “false-negative GBM”). Since treatment protocols often depend on the diagnosed histological subtype, accuracy in diagnosis is very important for patients in order to get optimal treatment (Murphy et al., 2002). Therefore, more accurate methods to diagnose gliomas are urgently required. The molecular characteristics of gliomas have been studied extensively over the last years, in order to provide more objective and accurate methods of identifying distinct molecular tumor subgroups, and to identify specific molecular tumor markers that can help

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_3, © Springer Science+Business Media B.V. 2011

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diagnosis. In the future, these molecular features may also be used to develop personalized targeted therapy.

Single Molecular Markers in Gliomas LOH 1p19q Loss of heterozygosity (LOH) of 1p19q is a chromosomal aberration that is strongly associated with classical ODs (Griffin et al., 2006; Jenkins et al., 2006; Cairncross and Jenkins, 2008). Determination of the 1p19 status in gliomas is clinically relevant because of two important features. First, gliomas with LOH of 1p19q generally grow more slowly than most other gliomas and therefore have a better prognosis. Second, the presence of this mutation is predictive for response to treatment with alkylating agents such as PCV (procarbazine, lomustine, and vincristine) (Cairncross et al., 1998; Kouwenhoven et al., 2006). However, many glial tumors benefit from alkylating agents at some level. Nevertheless, 1p19q status is a strong prognostic factor, and the presence or absence of 1p and 19q is currently tested for in patients with a tumor containing oligodendroglial features.

IDH1 Recently, somatic mutations in the gene encoding isocitrate dehydrogenase 1 (IDH1) have been identified in gliomas (Parsons et al., 2008). IDH1 mutations occur mainly in lower grade gliomas and in secondary GBMs and are therefore thought to be early events in glioma genesis (Hartmann et al., 2009). Interestingly, glioma-specific mutations in IDH1 always affect the amino acid arginine in position 132 of the amino acid sequence, which belongs to an evolutionary highly conserved region located at the binding site for isocitrate (Parsons et al., 2008; Bleeker et al., 2009). The most frequent mutation occurring in this region is the R132H mutation (>90%), but other variants also have been found (R132S, R132C, R132G, and R132L) (Bleeker et al., 2009; Gravendeel et al., 2010). Interestingly, non-R132H mutations segregate in distinct histological and molecular subtypes of glioma (Hartmann et al., 2009; Gravendeel et al., 2010).

L.A.M. Gravendeel and P.J. French

Histologically, non-R132H mutations occur sporadically in classic oligodendrogliomas and at significantly higher frequency in other grade II and III gliomas. Genetically, non-p.R132H mutations occur in tumors with TP53 mutation, are virtually absent in tumors with LOH on 1p and 19q and accumulate in distinct (gene-expression profiling based) intrinsic molecular subtypes (Gravendeel et al., 2009; 2010). Importantly, IDH1 mutations are associated with improved prognosis (Parsons et al., 2008; Kloosterhof et al., 2010). Therefore IDH1 mutation status is likely to be used as a prognostic molecular marker in the near future. Additionally, two studies have examined whether IDH1 mutation status can predict response to treatment in gliomas. In a group of patients with dedifferentiated low-grade astrocytomas progressive after radiotherapy response to TMZ did not differ between IDH1 mutant and wild-type tumors (Dubbink et al., 2009). In patients with anaplastic oligodendroglial tumors treated with radiotherapy alone or radiotherapy with adjuvant PCV, IDH1 mutations reported had no predictive value for response (van den Bent et al., 2010).

MGMT The O6 -methylguanine-DNA methyltransferase (MGMT) gene encodes for the nuclear repair enzyme alkyltransferase, which removes alkylating adducts from the O6 position of thymine. By doing this, the enzyme is involved in maintaining the integrity of the DNA. More specifically, the product of the MGMT gene protects the cells from being damaged by alkylating and methylating agents (e.g. BCNU [N,N[prime]-bis(2-chloroethyl)-N-nitrosourea], procarbazine and TMZ). In gliomas, the CpG islands located in the promotor of the MGMT gene are frequently methylated, causing “epigenetic” silencing of this gene. Theoretically, this methylation would result in a greater susceptibility for alkylating and methylating agents. In daily practice, the meaning and implications of the MGMT status are more difficult to interpret. Several studies showed that the epigenetic silencing of the MGMT gene is of clinical importance, because its association with increased survival and better response to combined chemoirradiation in GBMs (Gerson, 2004;

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Molecular Subtypes of Gliomas

Hegi et al., 2005). It was shown that the effect of the MGMT silencing was especially present when TMZ was used as chemotherapy (Hegi et al., 2005). Other studies showed that the time of administering the TMZ seemed to be crucial. One study showed that a positive effect of the methylated MGMT gene on survival was only seen if TMZ was administered at the time of radiation, while other studies showed positive effects when administering TMZ before or after irradiation (Chakravarti et al., 2006; Everhard et al., 2006; Criniere et al., 2007). Interestingly, a recent study showed that MGMT promotor methylation in GBMs was a predictor for better response to radiotherapy, and a prognostic marker even in patients not receiving adjuvant alkylating chemotherapy (Rivera et al., 2010). This study suggests that MGMT might be a general favorable prognostic factor in GBMs, instead of being a predictive marker for response to alkylating chemotherapy. Another issue that makes it difficult to interpret the role of MGMT, is that there are several different approaches in the assays for measuring the MGMT promoter methylation status. These different approaches cause variable results, which may be difficult to compare. MGMT activity can be measured using immunohistochemistry, but also using Q-pcr, or promotor methylation assays. Also, differences in outcome arise using assays on frozen tissue as well as on paraffin samples, as well as by possible interobservervariability. Nevertheless, MGMT status is thought to be an important biomarker in gliomas.

Genome Wide Molecular Markers in Gliomas Several techniques have been developed to perform genome wide analysis of the tumors’ epigenome, genome or transcriptome. Whilst markers for glioma have been identified on all levels (TCGARN, 2008), this review will discuss the molecular markers identified by the tumor’s transcriptome, that are currently used (or show promise to aid) in clinical decision making. Gene expression profiling involves the measurement of the activity (the expression) of thousands of genes at once. In general, gene expression profiling is performed using microarrays; chips that contain the complementary sequence to thousands of target mRNA

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sequences. mRNA isolated from tumor samples is processed and labeled and subsequently hybridized to the microarray. The signal extracted from the microarray is a measure of gene expression levels, which is visualized using fluorescence. Expression profiling can be used to identify molecular subtypes of tumors roughly by two methods: Supervised and unsupervised. Supervised clustering uses external information to separate tumors into predefined subgroups (e.g. responders vs. non-responders; long vs. short-survivors), and then specifically screens for genes that are differentially expressed between these groups. In contrast, unsupervised clustering does not use external information and thus classifies tumors based on homologies in gene expression profiles. One of the first large studies that used supervised clustering (on survival) has identified three large subtypes of glioma with distinct prognosis. Subtypes were named according to the signature of the genes they predominantly expressed: Proneural, Mesenchymal and Proliferative subtypes (Phillips et al., 2006). These subtypes have also been identified in GBM using unsupervised methods (Verhaak et al., 2010). A different supervised study identified genes associated with response to treatment (French et al., 2005). Most often however, supervised clustering has been used to define gene expression signatures based on histological subtypes (Nutt et al., 2003). Thus far, only three groups have performed unsupervised analysis to define “intrinsic” molecular subgroups of gliomas (Gravendeel et al., 2009; Li et al., 2009; Verhaak et al., 2010). In all cases, the unsupervised clusters identified more subtypes of gliomas than histology. The molecular clusters correlate better with survival than histology (Nutt et al., 2003; Gravendeel et al., 2009; Li et al., 2009). Therefore, molecular clustering provides an objective and more accurate method to classify gliomas, and may even be used to predict patients’ prognosis. The molecular clusters all contained a wide variety of histological subtypes. The fact that different histological subtypes were assigned to the same molecular cluster means that these phenotypically different tumors have a similar genetic composition. Indeed, two independent studies have demonstrated that genetic changes segregate into distinct molecular subtypes indicating that causal genetic change drives a distinct pattern of gene expression (Gravendeel et al., 2009; 2010; Verhaak et al., 2010).

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For example, gliomas of different histological subtypes with LOH of 1p19q are accumulating within one distinct molecular profile, regardless of their histological appearance, showing significant longer survival times than other molecular subgroups (Gravendeel et al., 2009). These findings imply that 1p19q status should be determined in all histological subtypes of gliomas, instead of testing this mutation in oligodendroglial-like tumors only. In the future, the specific genetic features of molecular glioma subgroups can be used to improve diagnosis, to give a more accurate prognosis, as well as to develop personalized therapies. It is likely that each molecular glioma subgroup will benefit from its own specific treatment based on the specific underlying molecular pathways and markers. Novel randomized controlled trials should take these molecular clusters into account when comparing different therapy regimens in gliomas.

References Bailey P, Cushing HW (1926) A Classification of the tumors of the glioma group on a histogenetic basis with a correlated study of prognosis. J. B. Lippincott, Philadelphia, PA Bleeker FE, Lamba S, Leenstra S, Troost D, Hulsebos T, Vandertop WP, Frattini M, Molinari F, Knowles M, Cerrato A, Rodolfo M, Scarpa A, Felicioni L, Buttitta F, Malatesta S, Marchetti A, Bardelli A (2009) IDH1 mutations at residue p.R132 (IDH1(R132)) occur frequently in high-grade gliomas but not in other solid tumors. Hum Mutat 301:7–11 Cairncross JG, Ueki K, Zlatescu MC, Lisle DK, Finkelstein DM, Hammond RR, Silver JS, Stark PC, Macdonald DR, Ino Y, Ramsay DA, Louis DN (1998) Specific genetic predictors of chemotherapeutic response and survival in patients with anaplastic oligodendrogliomas. J Natl Cancer Inst 90(19):1473–1479 Cairncross G, Jenkins R (2008) Gliomas with 1p/19q codeletion: a.k.a. oligodendroglioma. Cancer J 14(6):352–357 Chakravarti A, Erkkinen MG, Nestler U, Stupp R, Mehta M, Aldape K, Gilbert MR, Black PM, Loeffler JS (2006) Temozolomide-mediated radiation enhancement in glioblastoma: a report on underlying mechanisms. Clin Cancer Res 12(15):4738–4746 Criniere E, Kaloshi G, Laigle-Donadey F, Lejeune J, Auger N, Benouaich-Amiel A, Everhard S, Mokhtari K, Polivka M, Delattre JY, Hoang-Xuan K, Thillet J, Sanson M (2007) MGMT prognostic impact on glioblastoma is dependent on therapeutic modalities. J Neuro-Oncol 83(2): 173–179 Dubbink HJ, Taal W, van Marion R, Kros JM, van Heuvel I, Bromberg JE, Zonnenberg BA, Zonnenberg CB, Postma TJ, Gijtenbeek JM, Boogerd W, Groenendijk FH, Smitt PA, Dinjens WN, van den Bent MJ (2009) IDH1 mutations in

L.A.M. Gravendeel and P.J. French low-grade astrocytomas predict survival but not response to temozolomide. Neurology 73(21):1792–1795 Everhard S, Kaloshi G, Criniere E, Benouaich-Amiel A, Lejeune J, Marie Y, Sanson M, Kujas M, Mokhtari K, Hoang-Xuan K, Delattre JY, Thillet J (2006) MGMT methylation: a marker of response to temozolomide in low-grade gliomas. Ann Neurol 60(6):740–743 French PJ, Swagemakers SM, Nagel JH, Kouwenhoven MC, Brouwer E, van der Spek P, Luider TM, Kros JM, van den Bent MJ, Sillevis Smitt PA (2005) Gene expression profiles associated with treatment response in oligodendrogliomas. Cancer Res 65(24):11335–11344 Gerson SL (2004) MGMT: its role in cancer aetiology and cancer therapeutics. Nat Rev Cancer 4(4):296–307 Gravendeel LA, Kouwenhoven MC, Gevaert O, de Rooi JJ, Stubbs AP, Duijm JE, Daemen A, Bleeker FE, Bralten LB, Kloosterhof NK, De Moor B, Eilers PH, van der Spek PJ, Kros JM, Sillevis Smitt PA, van den Bent MJ, French PJ (2009) Intrinsic gene expression profiles of gliomas are a better predictor of survival than histology. Cancer Res 69(23):9065–9072 Gravendeel LA, Kloosterhof NK, Bralten LB, van Marion R, Dubbink HJ, Dinjens W, Bleeker FE, Hoogenraad CC, Michiels E, Kros JM, van den Bent M, Smitt PA, French PJ (2010) Segregation of non-p.R132H mutations in IDH1 in distinct molecular subtypes of glioma. Hum Mutat 31(3):E1186–E1199 Griffin CA, Burger P, Morsberger L, Yonescu R, Swierczynski S, Weingart JD, Murphy KM (2006) Identification of der(1;19)(q10;p10) in five oligodendrogliomas suggests mechanism of concurrent 1p and 19q loss. J Neuropathol Exp Neurol 65(10):988–994 Hartmann C, Meyer J, Balss J, Capper D, Mueller W, Christians A, Felsberg J, Wolter M, Mawrin C, Wick W, Weller M, Herold-Mende C, Unterberg A, Jeuken JW, Wesseling P, Reifenberger G, von Deimling A (2009) Type and frequency of IDH1 and IDH2 mutations are related to astrocytic and oligodendroglial differentiation and age: a study of 1,010 diffuse gliomas. Acta Neuropathol 118(4):469–474 Hegi ME, Diserens AC, Gorlia T, Hamou MF, de Tribolet N, Weller M, Kros JM, Hainfellner JA, Mason W, Mariani L, Bromberg JE, Hau P, Mirimanoff RO, Cairncross JG, Janzer RC, Stupp R (2005) MGMT gene silencing and benefit from temozolomide in glioblastoma. N Engl J Med 352(10): 997–1003 Hildebrand J, Gorlia T, Kros JM, Afra D, Frenay M, Omuro A, Stupp R, Lacombe D, Allgeier A, van den Bent MJ, Investigators, E. B. T. G (2008) Adjuvant dibromodulcitol and BCNU chemotherapy in anaplastic astrocytoma: results of a randomised European organisation for research and treatment of cancer phase III study (EORTC study 26882). Eur J Cancer 44(9):1210–1216 Jenkins RB, Blair H, Ballman KV, Giannini C, Arusell RM, Law M, Flynn H, Passe S, Felten S, Brown PD, Shaw EG, Buckner JC (2006) A t(1;19)(q10;p10) mediates the combined deletions of 1p and 19q and predicts a better prognosis of patients with oligodendroglioma. Cancer Res 66(20):9852–9861 Kloosterhof NK, Bralten LB, Dubbink HJ, French PJ, van den Bent MJ (2010) Isocitrate dehydrogenase-1 mutations: a fundamentally new understanding of diffuse glioma? Lancet Oncol. Epub ahead of print

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Kouwenhoven MC, Kros JM, French PJ, Biemond-ter Stege EM, Graveland WJ, Taphoorn MJ, Brandes AA, van den Bent MJ (2006) 1p/19q loss within oligodendroglioma is predictive for response to first line temozolomide but not to salvage treatment. Eur J Cancer 42(15):2499–2503 Kros JM, Gorlia T, Kouwenhoven MC, Zheng PP, Collins VP, Figarella-Branger D, Giangaspero F, Giannini C, Mokhtari K, Mork SJ, Paetau A, Reifenberger G, van den Bent MJ (2007) Panel review of anaplastic oligodendroglioma from European Organization For Research and Treatment of Cancer Trial 26951: assessment of consensus in diagnosis, influence of 1p/19q loss, and correlations with outcome. J Neuropathol Exp Neurol 66(6):545–551 Li A, Walling J, Ahn S, Kotliarov Y, Su Q, Quezado M, Oberholtzer JC, Park J, Zenklusen JC, Fine HA 2009 Unsupervised analysis of transcriptomic profiles reveals six glioma subtypes. Cancer Res 69(5):2091–2099 Louis DN, Ohgaki H, Wiestler OD, Cavenee WK (eds) (2007) WHO Classification of tumours of the central nervous system, Lyon Murphy M, Loosemore A, Ferrer I, Wesseling P, Wilkins PR, Bell BA (2002) Neuropathological diagnostic accuracy. Br J Neurosurg 16(5):461–464 Nutt CL, Mani DR, Betensky RA, Tamayo P, Cairncross JG, Ladd C, Pohl U, Hartmann C, McLaughlin ME, Batchelor TT, Black PM, von Deimling A, Pomeroy SL, Golub TR, Louis DN (2003) Gene expression-based classification of malignant gliomas correlates better with survival than histological classification. Cancer Res 63(7):1602–1607 Ohgaki H, Dessen P, Jourde B, Horstmann S, Nishikawa T, Di Patre PL, Burkhard C, Schuler D, Probst-Hensch NM, Maiorka PC, Baeza N, Pisani P, Yonekawa Y, Yasargil MG, Lutolf UM, Kleihues P (2004) Genetic pathways to glioblastoma: a population-based study. Cancer Res 64(19): 6892–6899 Parsons DW, Jones S, Zhang X, Lin JC, Leary RJ, Angenendt P, Mankoo P, Carter H, Siu IM, Gallia GL, Olivi A, McLendon R, Rasheed BA, Keir S, Nikolskaya T, Nikolsky Y, Busam DA, Tekleab H, Diaz LA Jr., Hartigan J, Smith DR, Strausberg RL, Marie SK, Shinjo SM, Yan H, Riggins GJ, Bigner DD, Karchin R, Papadopoulos N, Parmigiani G,

29 Vogelstein B, Velculescu VE, Kinzler KW (2008) An integrated genomic analysis of human glioblastoma multiforme. Science 321(5897):1807–1812 Phillips HS, Kharbanda S, Chen R, Forrest WF, Soriano RH, Wu TD, Misra A, Nigro JM, Colman H, Soroceanu L, Williams PM, Modrusan Z, Feuerstein BG, Aldape K (2006) Molecular subclasses of high-grade glioma predict prognosis, delineate a pattern of disease progression, and resemble stages in neurogenesis. Cancer Cell 9(3):157–173 Rivera AL, Pelloski CE, Gilbert MR, Colman H, De La Cruz C, Sulman EP, Bekele BN, Aldape KD (2010) MGMT promoter methylation is predictive of response to radiotherapy and prognostic in the absence of adjuvant alkylating chemotherapy for glioblastoma. Neurooncology 12(2):116–121 Scott CB, Nelson JS, Farnan NC, Curran WJ Jr., Murray KJ, Fischbach AJ, Gaspar LE, Nelson DF (1995) Central pathology review in clinical trials for patients with malignant glioma. A Report of Radiation Therapy Oncology Group 83-02. Cancer 76(2):307–313 TCGARN (2008) Comprehensive genomic characterization defines human glioblastoma genes and core pathways. Nature 455(7216):1061–1068 van den Bent MJ, Dubbink HJ, Marie Y, Brandes AA, Taphoorn MJ, Wesseling P, Frenay M, Tijssen CC, Lacombe D, Idbaih A, van Marion R, Kros JM, Dinjens WN, Gorlia T, Sanson M (2010) IDH1 and IDH2 mutations are prognostic but not predictive for outcome in anaplastic oligodendroglial tumors: a report of the European Organization for Research and Treatment of Cancer Brain Tumor Group. Clin Cancer Res 16(5):1597–1604 Verhaak RG, Hoadley KA, Purdom E, Wang V, Qi Y, Wilkerson MD, Miller CR, Ding L, Golub T, Mesirov JP, Alexe G, Lawrence M, O’Kelly M, Tamayo P, Weir BA, Gabriel S, Winckler W, Gupta S, Jakkula L, Feiler HS, Hodgson JG, James CD, Sarkaria JN, Brennan C, Kahn A, Spellman PT, Wilson RK, Speed TP, Gray JW, Meyerson M, Getz G, Perou CM, Hayes DN Cancer Genome Atlas Research, N (2010) Integrated genomic analysis identifies clinically relevant subtypes of glioblastoma characterized by abnormalities in PDGFRA, IDH1, EGFR, and NF1. Cancer Cell 17(1):98–110

Chapter 4

Glioblastoma: Germline Mutation of TP53 Haruhiko Sugimura, Hidetaka Yamada, Shinji Kageyama, Yasuhiro Yamamura, Naoki Yokota, Hiroki Mori, Moriya Iwaizumi, Kazuya Shinmura, Kiyotaka Kurachi, Toshio Nakamura, Masaru Tsuboi, Masato Maekawa, and Tomoaki Kahyo

Abstract Various brain tumors are components of familial cancer syndromes, and Li-Fraumeni syndrome and Li-Fraumeni-like syndromes are the most famous entities. A rare, sporadic occurrence of brain tumor in peculiarly young subjects, however, sometimes provides a clue to understanding of carcinogenesis due to germline mutations. In this section, two cases of glial tumors in subjects having germline mutation of TP53 are presented, and genetic etiology of brain tumor is discussed. The first case is a 41 year-old father of a fatal adrenocortical carcinoma case of a 4-years-old daughter, 16 years prior to the occurrence of astrocytoma of himself. The search for family history and previous clinical records in the four different community hospitals for the last three decades and the followups of his family members disclosed cancer of urinary bladder, cancer of pancreas, hepatoblastoma, and thymoma in the relatives. Germline mutation E286A of TP53 was identified in the affected members. Another case is a 21-year-old male, without any family history of cancer, who suffered from brain tumor and colorectal cancer. An attending physician was sticky to find an etiology in this unusual occurrence of cancer. After several attempts in vain, an I195T germline mutation was identified and functional analysis was performed. These anecdotes highlight importance of genetic analysis in case of glial tumors in relatively young adult or in adolescence whether or not they have family history of cancer. The problems and strategies to find

H. Sugimura () Department of Investigative Pathology I, Hamamatsu University School of Medicine, Higashi-ward, Hamamatsu 431-3192, Japan e-mail: [email protected]

TP53 mutation carriers and to prevent or to delay the occurrence of the tumors in them are discussed. Keywords Glioblastoma · Germline mutation · TP53 · Mismatch deficiencies · Inhibitors · Tumors

Introduction Traditional epidemiological studies have identified few environmental risk factors for malignant brain tumors (Osborne et al., 2001), but genetic components of the etiology of brain tumors, although rare, have been relatively well-defined for glial tumors (Schwartzbaum et al., 2006). Brain tumors are often accompanied by a genetic cancer syndrome such as Li-Fraumeni syndrome (LFS1, OMIM accession 151623), CHEK2related syndrome (LFS2, OMIM accession 609265), Li-Fraumeni-like syndrome (LFLS), Maffuci syndrome (OMIM accession 166000), Olier syndrome (OMIM accession 166000), tuberous sclerosis (OMIM accession 191100), or von Hippel-Lindau syndrome (OMIM accession 193300). The last two of these syndromes are usually related to tumors having specific histopathology, subependymal giant astrocytoma and hemangioblastoma, respectively, but the other syndromes accompany a variety of glial tumors and choroid plexus tumors. TP53 is undoubtedly the most influential genetic factor related to the occurrence of human brain tumors. In this review, we report two cases in which a glial tumors was caused by a germline mutation of TP53. The first case one was diagnosed in a family in which several members had suffered from various malignancies for decades and consulted different community hospitals in the county where they lived, which had a population of 700,000.

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_4, © Springer Science+Business Media B.V. 2011

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A definitive diagnosis of Li-Fraumeni syndrome was finally made by identifying the germline mutation of TP53 (Sameshima et al., 1992), 20 years after the first cancer occurred in the family. The second case was a sporadic case of synchronous colon cancer and glioblastoma multiforme. TP53 sequencing is not routine in such cases, and subsequent identification of the mutation was a very unexpected positive finding. In this chapter we review the TP53 germline mutations identified in glial tumor cases that have been reported in the literature, and we discuss the importance of functional assessment of the variants. We also address the issue of genetic testing for TP53 mutations in patients with glial tumors in situations that would arouse suspicion in most experienced clinicians, such as their occurrence in particularly young persons or clustered in a family, especially in routine clinical practice, and we offer perspectives in regard to the management of TP53 mutant carriers, that may seem bold at the moment.

Case Reports Case 1 A 41-year-old male was diagnosed with a gemistocytic astrocytoma (Fig. 4.1a), and a retrospective and follow-up study of his family over a 40-year period revealed cases of hepatoblastoma, adrenocortical carcinoma, thymoma, pancreatic cancer, and stomach cancer (Fig. 4.1b). A germline TP53 E286A mutation was identified (Sameshima et al., 1992), and there was marked TP53 overexpression in the astrocytoma (Fig. 4.1c). The functional significance of the E286A mutation is not definitively recapitulated in vitro, but the DNA-damage-associated dysregulation of the cell cycle has been investigated in cells derived from carriers (Goi et al., 1997). The spectrum of cancers in this family is typical of Li-Fraumeni syndrome.

Case 2 A 21-year-old male with no family history of cancer simultaneously developed symptoms of colorectal cancer and a brain tumor at the same time. The brain tumor was diagnosed as a glioblastoma multiforme

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(Fig. 4.1d, e), and marked TP53 overexpression was detected in the glioblastoma cells. The histological diagnosis of the colon cancer was well-differentiated adenocarcinoma (Fig. 4.1f), and TP53 was detected in the tumor cells (Fig. 4.1g). The curiosity of the attending physician was aroused by the clinical phenotype of this patient, and the physician suspected one of the genetic syndromes. A tentative diagnosis of Turcot syndrome was made, but the colon cancer did not exhibit microsatellite instability. The patient and his family were very cooperative in regard to further attempts to determine the etiology of his disease. A genetic counselor explained several possible etiologies of the patient’s clinical phenotype and the importance of conducting a genetic analysis. DNA from the blood cells of the patient and his healthy parents was used to sequence the entire germline TP53, including all of the exons, and an I195T mutation, which has been known as a hot spot for somatic mutations, was found as de novo germline mutation in the patient’s gene but not in his parents’. This missense variant TP53 is a wellknown somatic mutation but has never been recorded in Li-Fraumeni syndrome. The locus at the codon 195 has been found to alter transcriptional activity in a yeast system (Petitjean et al., 2007), and deficient transactivation capacity has been demonstrated in a mammalian cell system in vitro by co-transfection with p53 target molecules (Fig. 4.1h) (Yamada et al., 2009).

TP53 and Glial Tumors Glial tumors of varying biological grades are often encountered in both Li-Fraumeni syndrome and Li-Fraumeni-like syndrome (Pearson et al., 1982; Santibanez-Koref et al., 1991). Li’s early collection included 14 brain tumors, 9 of which were gliomas. All of the patients were under age 45 years old, and the mode was 15–29 years old (Li et al., 1988). Germline mutations of TP53 have been one of the best-known genetic etiologies of human cancers, including brain tumors. Cases of human cancer consistent with and not consistent with Li-Fraumeni syndrome have been investigated for germline mutations of TP53. The latest database of TP53 germline mutations (IARC TP53 database, an R14 release, November, 2009) indicates that 138 of the 1053 recorded germline mutations of TP53 have occurred

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Relative luciferase activity

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d Fig. 4.1 (a) Astrocytoma, grade 2, gemistocytic, of Case 1. Hematoxylin-eosin stain; (b) A family pedigree of the Case 1. An arrow indicates a case of astrocytoma. 1, pancreas cancer at age 36. 2, bladder cancer at age 20. 3, astrocytoma at 41. 4, hepatoblastoma at 2. 5, hepatoblastoma at 2. 6, thymoma at 17. Members 3, 5 and 6 were revealed to be carriers of the TP53 mutation (Sameshima et al., 1992). Closed circles and rectangles are carriers identified. The other members were not tested for TP53 mutation; (c) TP53 immunostaining of astrocytoma of the Case 1. Nuclear staining is prominent; (d) Glioblasoma multiforme of the Case 2. Hematoxylin eosin stain; (e) Glioblastoma multiforme, anti-glial fibrillary acidic protein

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0.0 p21

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(GFAP) (f) Adenocarcinoma of the colon in the Case 2; (g) TP53 immunostaining of colon cancer in the Case 2; (h) Transcription repression by mutant TP53 in the Case 2. Evaluation of the transcriptional activation function of p53 by luciferase assay. p21-, BAX-, and MDM2-luciferase activities were measured in p53-null H1299 cells transiently transfected with a p53 expression vector, the firefly luciferase reporter vector pGL4.10, and the transfection control vector pGL4.74. Values for luciferase activity are means ± standard deviation of three independent experiments. For each p53-responsive gene, the luciferase activity of cells transfected with wild-type (wt) p53 was set at 1.0

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in patients with a brain tumor. Even in the absence of characteristic tumors, such as breast cancer, soft tissue sarcoma, and adrenocortical cancers, which are the characteristic tumors of Li-Fraumeni syndrome, there are the cases of familial aggregation, particularly of brain tumors alone (Kyritsis et al., 1994) surveyed immortalized lymphocytes derived from the gliomas of 51 patients and found TP53 mutations in 6 of them. They proposed that multiplicity (in the brain and other organs) and a familial history implies the presence of a TP53 germline mutation, and they pointed out that 6 subjects in 9 pedigrees were in their 30’s when their glial tumors were diagnosed. These reports are instructive when we encounter brain tumor cases in adolescents and young adults in our practice. More than 20 different germline missense mutations have been reported in the germline of patients with glial tumors of various biological grades, ranging from oligodendroglioma to astrocytoma and to glioblastoma multiforme.

Is Any Specific Mutation Spectrum Associated with Brain Tumors? Examination of the updated IARC database, suggests two questions in regard to the relation between germline TP53 mutations and brain tumors. The first question concerns whether there are germline TP53 mutations that specify the occurrence of a tumor in a particular organ. Lubbe et al. reported a familial brain tumor syndrome associated with codon 236 (Lubbe et al., 1995), and Vital et al. (1998) reported two families with a cluster of astrocytomas and choroid plexus tumors caused by codon 248 mutations. The specific significance of this mutation in these families seems to have drawn a great deal of attention since then, but these mutations have never been particularly questioned as brain tumor-causing germline mutations (Kleihues et al., 1997) reviewed 91 families with germline mutations and brain tumors and found an earlier age of onset of their brain tumors than in families with brain tumors but no germline mutations, but they were not able to identify any particular spectrum of germline mutations that tended to be more common in patients with brain tumors than in patients with tumors at other sites. The spectrum of somatic TP53 mutations has been extensively investigated and widely accepted

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as carcinogen fingerprints of the tumors (Hussain et al., 2000), but there has been little assessment of the spectrum of germline TP53 mutations in terms of a possible relationship to the specific phenotype of the proband and the proband’s descendants. Varley summarized the germline mutations in Li-Fraumeni syndrome and other syndromes, and claimed to have detected a mutation specificity preferentially associated with adrenocortical carcinoma (Varley, 2003). That claim requires validation by thorough testing of family members, but the concept of specific germline mutations deserves further corroboration. In any event, no spectrum of germline mutations has ever been identified in brain tumors patients. The second question concerns whether the brain tumors that develop in persons with a germline TP53 mutation have any specific characteristics in common. Bogler (Bogler et al., 1995) reviewed the spectrum of TP53 mutations in brain tumors and found that loss of a remaining wild-type allele was the most important second hit in tumorigenesis and loss of the remaining wild-type allele was detected in our case 2. His review focused on the nature of somatic genetic changes in brain tumors. Glioblastoma multiforme is one of the targets of The Atlas of Cancer Genome, prepared in the United States (Ledford, 2010). Watanabe (Watanabe et al., 2009) recently reported identifying an R132C mutation of the IDH1 gene in an astrocytoma in a patient with the Li-Fraumeni syndrome. The recent “next” generation sequencing has generated tremendous information on genetic changes in glioblastoma (Verhaak et al., 2010). IDH gene mutations are one of the most remarkable discoveries of high-throughput sequencing projects in regard to glioblastoma in general (Yan et al., 2009), and since 12% of glioblastomas have been found to harbor a IDH1 mutation (Parsons et al., 2008), the IDH1 mutations discovered by Watanabe are not specific for glioblastoma multiforme associated with Li-Fraumeni syndrome. The TP53 mutations often coincide found in germline cells are often the same as those found in somatic cells. With few exceptions, the genotype-phenotype relationship in genetic cancer diseases has not been extensively studied. The landscape of somatic genetic changes, including mutations and copy number amplifications, in tumors that occur in persons with a particular genetic background will soon become available, and it will be necessary to wait until enough cases accumulate to draw conclusions as

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to whether any correlation exists between the spectrum of germline mutations and spectrum of phenotypic (somatic) mutations in patients with the tumors.

When and How Should Requests Be Made to Perform Genetic Testing and How and When Should Testing Be Performed? It is not easy to obtain genomic information, especially for practicing physicians, when there is no or little family history of cancer or when the patient’s relatives are not very familiar with recent genetic knowledge, including the significance of DNA. Even after overcoming the hurdles of the difficulty of obtaining DNA and conducting a genomic analysis, the odds of obtaining a result that can completely explain the patient’s condition are seldom high. Several studies, including the study by Paunu et al. (Paunu et al., 2001), did not reveal any germline TP53 mutations in familial glial tumors. Portwine also reported negative findings in a search for germline TP53 mutations in children with sporadic brain tumors (Portwine et al., 2001). The prevalence of germline TP53 mutations that have biological significance in asymptomatic populations appears to be extremely low, perhaps only 0.3% (Palmero et al., 2008), and it is difficult to persuade the healthy relatives to undergo genetic testing. We consider the likelihood of detection of a germline TP53 mutation in the adolescent cancer patient in Case 2 to have been very small. Most brain tumors are not thought of as genetic or hereditary diseases, and brain tumors are still basically classified according to their morphology and somatic genetic information (Burger and Scheithauer, 2007). Despite anecdotal reports of brain tumors as genetic manifestations, the overall attempt to identify constitutional genetic changes in brain tumor patients has been tedious until recently. Li et al. (1995) investigated TP53 germline mutations in 80 unselected glioma patients and found a TP53 germline mutation in only 1 of the 65 cases, that did not have a peculiar family history, as opposed in 3 of the 15 cases with a familial or “unusual” personal history. As stated in the introduction, taking a complete family history is often difficult, and cases in family members who would have developed cancer but died at an early age of some other cause would be missed. When the parents have few siblings, it is very difficult to conclude

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that the occurrence of a disease in a particular case is sporadic. Then, how about “unusual” cases? In many of the cases in which we persuaded young patients and family members to undergo DNA testing and obtained their consent the results were negative, and the reason the patient suffered this particular disease, which was unusual for his or her age remained a mystery to the parents or relatives. There are still no valid scientific criteria for performing or recommending genetic tests in clinical settings. The criteria are often subjective and depend on the feeling of the attending physician or his or her enthusiasm regarding how far to pursue the investigation of the cause of the disease in cases that arouse suspicion in attending clinicians. Unusual clusterings of malignant tumors in a family attract general practitioners attention, but the absence of a family history of cancer or difficulty in obtaining it often impede further investigation by genetic analysis. The recent worldwide trend toward small families further reduces the possibility of identifying a peculiar pedigree to analyze for genetic disease. Then, can luck alone be expected to result in the identification of significant mutations? In compensation the era of small family sizes and the rigorous procedures required to obtain patient consent, a wide variety of genetic test, technologies are now available and are easier and friendlier than ever before. A genome-wide, personal whole genome sequence strategy is now available, and it will become less costly in the near future. The introduction of cytogenetic arrays in recent years has facilitated the discovery of unexpected changes in copy numbers, small deletion/insertion polymorphisms, amplifications, and rather rare (0.1–5%) single nucleotide polymorphisms (SNPs) when we attempt to determine the etiology of a common disease in an unusual situation (Rieber et al., 2009; Schwarzbraun et al., 2009). The era of personal sequencing is coming, and we, as one of the part of medical systems these days, i.e., as a patient, a family member of the patient, counselor, physician, insurer, or scientist, may have to prepare for the time when germline tests will be routinely performed in every patient with an “unusual” brain tumor.

Syndromes Expanding? Mismatch deficiencies are one of the well known genetic causes of brain tumors. Paraf proposed the

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existence of two types of brain tumor-polyposis (BTP) syndrome (Paraf et al., 1997). The BTP syndrome type 1 is characterized by non-polypotic (thus, the name is paradoxical) colorectal tumors and microsatellite instability, the same as found in hereditary non-polypotic colorectal cancer (HNPCC). BTP1 syndrome corresponds to Turcot syndrome (MIM accession 270630) and/or Muir-Torre syndrome (MIM accession 158320), which can also have glioblastoma multiforme as a component of the syndrome (Park et al., 2009). BTP syndrome type 2 is characterized by brain tumors associated with adenomatous polyposis coli. We are not sure whether our Case 2 is a case of BTP syndrome type 1, because of the absence of microsatellite instability in the colorectal cancer in Case 2. It would be inappropriate to call cases like Case 2 “brain tumor-polyposis syndrome”. In conclusion, we are compelled to expand the concept of brain tumor-colorectal tumor syndrome to include what we refer to here as “TP53 disorders”.

Problems in Screenings and Preventions The unusual occurrence of common cancers in subjects harboring a germline mutation of TP53 prompted us to consider the feasibility of detecting or mass screening for such carriers in the general population. An R337H mutation of TP53 was found in two of 750 healthy subjects in a study conducted in southern Brazil (Palmero et al., 2008). A thorough characterization of this germline mutation (variant) in terms of its penetrance and the cancer spectrum of the subjects’ families is under way, and justification of neonatal mass screening for this variant has been debated (Achatz et al., 2009). To justify this kind of attempts of neonatal mass screening, we must be ready and feasible for detection of the early occurrence of tumors in carriers, and we also have to have the tools to treat the tumors or to reduce the hazard caused by tumors in the carriers. Endoscopic surveillance of the gastrointestinal (GI) tract for cancer and surveillance for breast cancer by mammography would be an acceptable choice for many subjects instead of more invasive measures. Some GI tumors can be treated endoscopically, and some breast tumors can be cured by minimally invasive surgery. The situation in regard to brain tumors is different. CT, MRI, and positron emission

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tomography (PET) are powerful diagnostic imaging methods for detecting small tumors, but is it acceptable for the carriers of germline TP53 mutations to undergo craniotomy or stereotactic radioneurosurgery? Since carriers of germline TP53 mutations are thought to be more sensitive to radiation it is not certain that the gamma knife is the best choice of treatment. Many investigators are attempting to find agents that will reduce the risk associated with a germline heterogeneous TP53 mutation. One bold, promising strategy would be to use p53-activating drugs to treat patients with germline heterozygosity of p53. Deacetylase inhibitors are promising candidates for such drugs that would reduce the risk associated with germline heterogeneous TP53 mutation, because acetylation of the C-terminal region of TP53 protein up-regulates its transcriptional and transactivational activity. Treatment with a deacetylase inhibitor is expected to compensate for the depleted function of mutant p53 in the p53-heterozygous cells by increasing the acetylation level of wild-type p53. One of the deacetylase inhibitors, the sirtuin (histone deacetylase type [HDAC] III) -targeting inhibitor, is particularly noteworthy, because the sirtuin (HDAC III) is catalytically different from the other histone deacetylases. The members of the sirtuin deacetylase family require NAD to exert their deacetylase activity, and these characteristics may lead to novel efficacy against cancer cells and cancer-predisposing cells. There is a mouse model with haploinsufficiency of p53 that is prone to develop various tumors (Jacks et al., 1994), and tailless, a nuclear receptor gene has recently been shown to contribute to brain tumor initiation in the p53 haploinsufficient mouse (Liu et al., 2010). Such models will provide monitoring systems to test the preventive efficacy of drugs against tumorigenesis in persons with greater genetic susceptibility to cancers. Various sirtuin inhibitors, both natural and synthetic, have been evaluated in vitro (Kahyo et al., 2008), and application of these drugs to an animal model and then clinically must be assessed in the near future.

References Achatz MI, Hainaut P, Ashton-Prolla P (2009) Highly prevalent TP53 mutation predisposing to many cancers in the Brazilian population: a case for newborn screening? Lancet Oncol 10:920–925

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Bogler O, Huang HJ, Kleihues P, Cavenee WK (1995) The p53 gene and its role in human brain tumors. Gila 15:308–327 Burger PC, Scheithauer BW (2007) Tumor of the central nervous system, vol 7. American Registry of Pathology and Armed Forces Institute of Pathology, Washington, DC Goi K, Takagi M, Iwata S, Delia D, Asada M, Donghi R, Tsunematsu Y, Nakazawa S, Yamamoto H, Yokota J, Tamura K, Saeki Y, Utsunomiya J, Takahashi T, Ueda R, Ishioka C, Eguchi M, Kamata N, Mizutani S (1997) DNA damageassociated dysregulation of the cell cycle and apoptosis control in cells with germ-line p53 mutation. Cancer Res 57:1895–1902 Hussain SP, Hollstein MH, Harris CC (2000) p53 tumor suppressor gene: at the crossroads of molecular carcinogenesis, molecular epidemiology, and human risk assessment. Ann NY Acad Sci 919:79–85 Jacks T, Remington L, Williams BO, Schmitt EM, Halachmi S, Bronson RT, Weinberg RA (1994) Tumor spectrum analysis in p53-mutant mice. Curr Biol 4:1–7 Jeannot E, Mellottee L, Bioulac-Sage P, Balabaud C, Scoazec JY, Van Nhieu JT, Bacq Y, Michalak S, Buob D, Genthep (Inserm network), Laurent-Puig P, Rusyn I, Zucman-Rossi J (2010) Spectrum of HNF1A somatic mutations in hepatocellular adenoma differs from that in MODY3 patients and suggests genotoxic damage. Diabetes. 59:1836–1844 Kahyo T, Ichikawa S, Hatanaka T, Yamada MK, Setou M (2008) A novel chalcone polyphenol inhibits the deacetylase activity of SIRT1 and cell growth in HEK293T cells. J Pharmacol Sci 108:364–371 Kleihues P, Schauble B, zur Hausen A, Esteve J, Ohgaki H (1997) Tumors associated with p53 germline mutations: a synopsis of 91 families. Am J Pathol 150:1–13 Kyritsis AP, Bondy ML, Xiao M, Berman EL, Cunningham JE, Lee PS, Levin VA, Saya H (1994) Germline p53 gene mutations in subsets of glioma patients. J Natl Cancer Inst 86:344–349 Ledford H (2010) Big science: the cancer genome challenge. Nature 464:972–974 Li FP, Fraumeni JF Jr, Mulvihill JJ, Blattner WA, Dreyfus MG, Tucker MA, Miller RA (1988) A cancer family syndrome in twenty-four kindreds. Cancer Res 48:5358–5362 Li YJ, Sanson M, Hoang-Xuan K, Delattre JY, Poisson M, Thomas G, Hamellin R (1995) Incidence of germ-line p53 mutations in patients with gliomas. Int J Cancer 64:383–387 Liu HK, Wang Y, Belz T, Bock D, Takacs A, Radlwimmer B, Barbus S, Reifenberger G, Lichter P, Schütz G (2010) The nuclear receptor tailless induces long-term neural stem cell expansion and brain tumor initiation. Genes Dev 24:683–695 Lubbe J, von Ammon K, Watanabe K, Hegi ME, Kleihues P (1995) Familial brain tumour syndrome associated with a p53 germline deletion of codon 236. Brain Pathol 5:15–23 Osborne RH, Houben MP, Tijssen CC, Coebergh JW, van Duijn CM (2001) The genetic epidemiology of glioma. Neurol 57:1751–1755 Palmero EI, Schuler-Faccini L, Caleffi M, Achatz MI, Olivier M, Martel-Planche G, Marcel V, Aguiar E, Giacomazzi J, Ewald IP, Giugliani R, Hainaut P, Ashton-Prolla P (2008) Detection of R337H, a germline TP53 mutation predisposing to multiple cancers, in asymptomatic women participating in a breast cancer screening program in Southern Brazil. Cancer Lett 261:21–25

37 Paraf F, Jothy S, Van Meir EG (1997) Brain tumor-polyposis syndrome: two genetic diseases? J Clin Oncol 15:2744–2758 Park DM, Yeaney GA, Hamilton RL, Mabold J, Urban N, Appleman L, Flickinger J, Lieberman F, Mintz A (2009) Identifying Muir-Torre syndrome in a patient with glioblastoma multiforme. Neuro Oncol 11:452–455 Parsons DW, Jones S, Zhang X, Lin JC, Leary RJ, Angenendt P, Mankoo P, Carter H, Kamiyama H, Jimeno A, Hong SM, Fu B, Lin MT, Calhoun ES, Kamiyama M, Walter K, Nikolskaya T, Nikolsky Y, Hartigan J, Smith DR, Hidalgo M, Leach SD, Klein AP, Jaffee EM, Goggins M, Maitra A, Iacobuzio-Donahue C, Eshleman JR, Kern SE, Hruban RH, Karchin R, Papadopoulos N, Parmigiani G, Vogelstein B, Velculescu VE, Kinzler KW (2008) An integrated genomic analysis of human glioblastoma multiforme. Science 321: 1807–1812 Paunu N, Syrjakoski K, Sankila R, Simola KO, Helen P, Niemela M, Matikainen M, Isola J, Haapasalo H (2001) Analysis of p53 tumor suppressor gene in families with multiple glioma patients. J Neurooncol 55:159–165 Pearson AD, Craft AW, Ratcliffe JM, Birch JM, Morris-Jones P, Roberts DF (1982) Two families with the Li-Fraumeni cancer family syndrome. J Med Genet 19:362–365 Petitjean A, Mathe E, Kato S, Ishioka C, Tavtigian SV, Hainaut P, Olivier M (2007) Impact of mutant p53 functional properties on TP53 mutation patterns and tumor phenotype: lessons from recent developments in the IARC TP53 database. Hum Mutat 28:622–629 Portwine C, Chilton-MacNeill S, Brown C, Sexsmith E, McLaughlin J, Malkin D (2001) Absence of germline and somatic p53 alterations in children with sporadic brain tumors. J Neurooncol 52:227–235 Rieber J, Remke M, Hartmann C, Korshunov A, Burkhardt B, Sturm D, Mechtersheimer G, Wittmann A, Greil J, Blattmann C, Witt O, Behnisch W, Halatsch ME, Orakcioglu B, von Deimling A, Lichter P, Kulozik A, Pfister S (2009) Novel oncogene amplifications in tumors from a family with Li-Fraumeni syndrome. Genes Chromosomes Cancer 48: 558–568 Sameshima Y, Tsunematsu Y, Watanabe S, Tsukamoto T, Kawaha K, Hirata Y, Mizoguchi H, Sugimura T, Terada M, Yokota J (1992) Detection of novel germ-line p53 mutations in diverse-cancer-prone families identified by selecting patients with childhood adrenocortical carcinoma. J Natl Cancer Inst 84:703–707 Santibanez-Koref MF, Birch JM, Hartley AL, Jones PH, Craft AW, Eden T, Crowther D, Kelsey AM, Harris M (1991) p53 germline mutations in Li-Fraumeni syndrome. Lancet 338:1490–1491 Schwartzbaum JA, Fisher JL, Aldape KD, Wrensch M (2006) Epidemiology and molecular pathology of glioma. Nat Clin Pract Neurol 2:494–503, quiz 491 p following 516 Schwarzbraun T, Obenauf AC, Langmann A, Gruber-Sedlmayr U, Wagner K, Speicher MR, Kroisel PM (2009) Predictive diagnosis of the cancer prone Li-Fraumeni syndrome by accident: new challenges through whole genome array testing. J Med Genet 46:341–344 Varley JM (2003) Germline TP53 mutations and Li-Fraumeni syndrome. Hum Mutat 21:313–320 Verhaak RG, Hoadley KA, Purdom E, Wang V, Qi Y, Wilkerson MD, Miller CR, Ding L, Golub T, Mesirov JP, Alexe G,

38 Lawrence M, O’Kelly M, Tamayo P, Weir BA, Gabriel S, Winckler W, Gupta S, Jakkula L, Feiler HS, Hodgson JG, James CD, Sarkaria JN, Brennan C, Kahn A, Spellman PT, Wilson RK, Speed TP, Gray JW, Meyerson M, Getz G, Perou CM, Hayes DN, and Cancer Genome Atlas Research Network (2010) Integrated genomic analysis identifies clinically relevant subtypes of glioblastoma characterized by abnormalities in PDGFRA, IDH1, EGFR, and NF1. Cancer Cell 17:98–110 Vital A, Bringuier PP, Huang H, San Galli F, Rivel J, Ansoborlo S, Cazauran JM, Taillandier L, Kleihues P, Ohgaki H (1998) Astrocytomas and choroid plexus tumors in two families with identical p53 germline mutations. J Neuropathol Exp Neurol 57:1061–1069

H. Sugimura et al. Watanabe T, Vital A, Nobusawa S, Kleihues P, Ohgaki H (2009) Selective acquisition of IDH1 R132C mutations in astrocytomas associated with Li-Fraumeni syndrome. Acta Neuropathol 117:653–656 Yamada H, Shinmura K, Yamamura Y, Kurachi K, Nakamura T, Tsuneyoshi T, Yokota N, Maekawa M, Sugimura H (2009) Identification and characterization of a novel germline p53 mutation in a patient with glioblastoma and colon cancer. Int J Cancer 125:973–976 Yan H, Parsons DW, Jin G, McLendon R, Rasheed BA, Yuan W, Kos I, Batinic-Haberle I, Jones S, Riggins GJ, Friedman H, Friedman A, Reardon D, Herndon J, Kinzler KW, Velculescu VE, Vogelstein B, Bigner DD (2009) IDH1 and IDH2 mutations in gliomas. N Engl J Med 360:765–773

Chapter 5

Familial Gliomas: Role of TP53 Gene Soufiane El Hallani and Ilham Ratbi

Abstract The presence of a personnel or familial history of cancer in a patient with primary brain tumor should prompt the search for genetic predisposition. Familial aggregation of brain tumors and especially gliomas has been reported in 5–7% of the cases. Rarely, familial gliomas can be attributed to hereditary multisystem syndromes. In majority of the cases, a hereditary syndrome cannot be identified and genetic alterations predisposing to familial gliomas are not clearly identified. Studies investigating candidate loci in glioma families have frequently examined TP53 gene which encodes p53, a checkpoint protein that plays a crucial role in DNA damage repair and apoptosis. Although occasional germline TP53 mutations were reported in glioma families, the frequency remained low (2.5–6.7%). However, germline TP53 mutations are more incriminated in glioma patients with multifocality or secondary malignancy, particularly if these factors are combined. Moreover, a functional single nucleotide polymorphism at codon 72 of TP53 gene was found to be associated with earlier onset of sporadic glioblastomas, opening new insights into the role of low-risk variants as genetic susceptibility to develop brain tumors. This chapter reviews the genetic predisposition in brain tumors and highlights the role of TP53 gene in familial gliomas, and in other forms of genetic predisposition or susceptibility to gliomas.

S. El Hallani () Cancer Imaging Unit, Integrative Oncology Department, British Columbia Cancer Research Centre, Vancouver, BC, Canada V5Z 1L3 e-mail: [email protected]

Keywords Familial gliomas · TP53 · Candidate loci · p53 · Apoptosis · Codon

Introduction Primary brain tumors are a mixture of different histopathologies which include both benign and malignant forms. Gliomas are the major subtype accounting for 90% of primary brain tumors. Astrocytomas, oligodendrogliomas, ependymomas, and tumors of the choroid plexus all arise from the glial origin of the central nervous system. In most cases, glioma etiology is not well understood. Ionizing radiation is one of the few well-recognized exogen factors associated with gliomas and meningiomas. Other environmental agents have been suggested (electromagnetic field, cellular phone, professional exposures) but epidemiologic studies have not been conclusive. Familial aggregation of gliomas is reported in 5–7% of the cases, suggesting a genetic etiology or common familial exposure to environmental agents. A small number of familial gliomas can be attributed to hereditary multisystem syndromes such as Neurofibromatose 1 and 2, Tuberous Sclerosis, Turcot syndrome and Li-Fraumeni syndrome. However, in many other cases, a hereditary syndrome cannot be identified and genetic alterations predisposing to familial gliomas are not yet clarified. The study of inherited predisposition to cancer has been one of the most attractive research areas in the past two decades. Indeed, the identification of susceptibility genes provides a better understanding of molecular oncogenesis, offering potential targets for therapeutic interventions. Furthermore, the ability to identify those at increased risk is of immediate clinical relevance in terms of primary and secondary interventions.

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_5, © Springer Science+Business Media B.V. 2011

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Genetic linkage analysis has led to locate highly penetrant genes for several common cancers, including breast and ovarian cancers (BRCA1 and BRCA2), colon cancer with adenomatous polyposis coli (APC), hereditary non-polyposis colon cancer (MSH2 and MLH1), melanoma (CDNK2A) and testicular cancer (TCG1). However, reports on familial gliomas remained few. Segregation analysis ruled out a single gene explanation and strongly incriminated a multifactorial inheritance model with a gene-gene or gene-environmental interactions. The difficulty to obtain a sufficient number of constitutional DNA from affected members of informative glioma families limited the approach of genetic linkage analysis. Studies investigating candidate loci in glioma families have frequently examined TP53 gene which encodes p53, a checkpoint protein that plays a crucial role in DNA damage repair and apoptosis. Germline TP53 mutations are found in 71–77% of classic Li-Fraumeni syndrome that predisposes individuals to a wide spectrum of cancers including brain tumors. Interestingly, previous studies identified germline TP53 mutations in several families with multiple glioma patients but without ascertained Li-Fraumeni syndrome. This chapter reviews the genetic predisposition in brain tumors and highlights the role of TP53 gene in familial gliomas, and in other forms of genetic predisposition or susceptibility to gliomas.

Genetic Predisposition to Familial Cancer Cancers arise by accumulating structural or functional alteration in DNA. Majority of the DNA alterations involve mutations of proto-oncogenes, tumor suppressor genes and DNA repair genes. Cancers may be sporadic or as a part of hereditary predisposition syndrome. Sporadic cancers are generally characterized by late onset, unilateral and isolated tumor. Mendelian cancer syndromes account for 5% of the common cancer cases. They are characterized by early onset, multifocality and secondary malignancy. They occur in multiple generations and their inheritance fits an autosomal dominant or recessive model. Different strategies have been used to identify predisposing genes in familial cancers including gliomas. Linkage analysis consists to identify an eventual locus of predisposition in one or more informative families.

S. El Hallani and I. Ratbi

Based on polymorphic DNA probes, linkage studies are to locate the predisposing gene by analyzing the cosegregation of polymorphic markers with the disease. Two linkage analysis studies have been conducted in familial gliomas and were able to identify an autosomal dominant locus at 15q23-q26 (Paunu et al., 2002), and an autosomal recessive locus at 1q21-q25 (Malmer et al., 2005). The limitation of this approach lies in the difficulty of obtaining a sufficient number of informative families for such rare cancer syndromes. A second strategy is to identify a possible locus of predisposition using fine genetic mapping of the tumors. By comparing tumor DNA with constitutional DNA of familial glioma patients, molecular techniques known as allelic loss (or loss of heterozygosity) have led to define frequent deletions of several chromosomal regions: 1p, 6q, 9p, 10q, 11p, 13q, 17p, 19q and 22q. Recurrent deletions of these chromosomal segments may reflect the existence within them of one (or more) tumor suppressor gene, whose one copy could be inactivated by this mechanism, and the other one by a germline mutation. More recently, analysis of familial glioma by CGH-array allowed to bring new fields of exploration of locus predisposition (on 6q, 12p, 16p, 22q) (Paunu et al., 2000). Testing known candidate genes is alternative when only the blood sample from the proband is available. Several candidate genes have been explored in familial gliomas. Germline TP53 tumor suppressor gene mutations were reported in some cases, whereas no mutations were identified in the PTEN, P16, CDK4 and CHEK2 genes (Tachibana et al., 2000; El Hallani et al., 2009a).

Brain Tumors in Predisposition Syndromes Hereditary tumor syndromes of the nervous system are varied and their recognition is critical to provide optimal clinical care and genetic counselling. In the last decade, many of the genes responsible for these typically autosomal dominant familial tumor syndromes have been identified.

Neurofibromatosis Type 1 The phenotype of the disease varies widely. Whereas some patients remain asymptomatic, others develop

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Familial Gliomas: Role of TP53 Gene

multiple tumors of the nervous system (neurofibroma, optic glioma, plexiform neurofibroma, neurofibrosarcoma, astrocytoma, and meningioma), tumors of other organs (pheochromocytoma, hypothalamic tumor, rhabdomyosarcoma, duodenal carcinoid), cafe-au-lait spots, axillary or inguinal freckling, hamartomas of the iris, vascular diseases, cognitive impairment, and behavioral problems. It is caused by mutations in the NF1 tumor suppressor gene located on chromosome 17 at q11.2.

Neurofibromatosis Type 2 Bilateral vestibular schwannomas are pathognomonic of the disorder. Patients often develop schwannomas of other cranial, spinal, and peripheral nerves, as well as intracranial and intraspinal meningiomas. Less frequently, they may develop low grade gliomas and ependymomas. Other features associated with neurofibromatosis type 2 are ocular abnormalities, specifically juvenile posterior subcapsular lenticular opacities (60% to 80% of patients), retinal hamartomas, hearing loss, and occassional cafe-au-lait spots. It is caused by mutations in the NF2 tumor suppressor gene located on chromosome 22q12.

Tuberous Sclerosis Complex (TSC) This condition predisposes to hamartomas and benign tumors in the brain, heart, and kidney. Nervous system lesions of TSC include tubers in the cerebral cortex, subependymal nodules, and subependymal giant cell astrocytomas. Two tumor suppressor genes have been identified: TSC1 at 9q34 (coding for hamartin) and TSC2 at 16p13 (coding for tubulin).

Von Hippel-Lindau Syndrome (VHL) Individuals are predisposed to develop a variety of malignant and benign neoplasms, most frequently retinal, cerebellar, and spinal hemangioblastomas, renal cell carcinomas, pheochromocytomas, and pancreatic tumors. The finding of multiple hemangioblastomas at young age is highly suggestive of VHL. It is caused

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by mutations in the VHL gatekeeper tumor suppressor gene on chromosome 3p25.

Gorlin Syndrome Also called nevoid basal cell carcinoma syndrome, it is characterized by the association of developmental abnormalities and an increased incidence of malignancy. Neoplastic manifestations are mainly basal cell carcinomas, medulloblastoma, and, occasionally, meningiomas. Gorlin syndrome is caused by abnormalities in the patched homolog 1 gene (PTCH1) on chromosome 9q31 in about 85% of cases.

Turcot Syndrome (TS) Occurrence of primary brain tumor and multiple colorectal adenomas and/or colorectal adenocarcinoma are the hallmarks of this syndrome. The most frequent brain tumors are astrocytomas, glioblastomas, medulloblastomas, ependymoma, spongioblastoma, gliosarcoma, and oligodendroglioma. TS type 1 includes patients with glioblastoma, often associated with hereditary nonpolyposis colorectal carcinoma and corresponding germline mutations in the DNA mismatch repair genes (MMR): postmeiotic segregation increased 2 (PMS2), MutL homolog 1 (MLH1), and MutS homolog 2 (MSH2). TS type 2 includes patients with medulloblastoma and familial adenomatous polyposis that result from mutations in the adenomatous polyposis of the colon gene (APC).

Cowden Syndrome and Lhermitte-Duclos Disease Cowden syndrome is a rare autosomal dominant disorder, associated with thyroid, breast, and uterine cancer as well as tricholemmomas, hamartomas, skin tumors, and meningiomas. Germline mutations in the phosphatase and tensin homolog (PTEN) gene located on chromosome 10q22-23 were described. LhermitteDuclos disease, also known as dysplastic cerebellar gangliocytoma, is strongly associated with Cowden syndrome.

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Melanoma-Astrocytoma Syndrome People with this rare syndrome have an increased risk of developing malignant cutaneous melanoma and nervous system tumors such as astrocytoma, neurofibroma, schwannoma, and meningioma. To date all published families documented with melanomaastrocytoma syndrome are linked to the CDKN2 locus on 9p21.

Li-Fraumeni Syndrome Li-Fraumeni syndrome (LFS) is a rare but highly penetrant autosomal cancer predisposition syndrome that is characterized by a familial clustering of early onset tumors including sarcomas, breast cancers, brain tumors and adrenocortical carcinomas (Li et al., 1988; Malkin et al., 1990). Initially considered as a rare syndrome, LFS and its variants are increasingly recognized as one of the most frequent and diverse forms of predisposition to cancer. To fulfill the classical LFS definition, the family history must include a proband with sarcoma before 45 years of age; a first degree relative of the proband with any cancer below 45 years and another first or second degree relative in the same lineage with any cancer before 45 years or sarcoma at any age. The most common childhood and adolescent cancers are soft-tissue sarcomas and osteosarcomas. Leukemia and brain tumors, including choroid plexus tumors, are almost exclusively confined to infants and early childhood, whereas adrenocortical carcinomas occur from infancy through late. In young adults, breast cancer is by far the most common malignancy. Other cancers including early onset melanoma, lung, gastric, pancreatic, prostate and colorectal cancer were also described in excess in some families. Germline TP53 gene mutations are the underlying cause of LFS in 71–77% of the cases (Evans et al., 2002). The TP53 tumor suppressor gene located on chromosome 17p13 encodes a protein involved in many overlapping cellular pathways that control cell proliferation and homeostasis, such as cell cycle, apoptosis, and DNA repair. The p53 protein is a transcription factor constitutively expressed in most cell types and activated in response to various stress signals. Loss of p53 function is thought to suppress a mechanism of protection against accumulation of genetic alterations.

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Somatic TP53 genetic alterations are frequent in a variety of human sporadic cancers, with frequencies varying from 10 to 60%, depending on the tumor type or population group. Germline TP53 mutations may contribute up to 17% of all familial cancer cases. Both somatic and germline mutations are compiled in a worldwide database at the International Agency for Research on Cancer (www-p53.iarc.fr). Most mutations result in missense substitutions that are scattered throughout the gene but are particularly dense in exons 5–8, encoding the DNA binding domain. Analysis of tumor patterns in carriers of a TP53 germline mutation has demonstrated some genotype/phenotype correlations. Brain tumors were more likely associated with missense mutations within the DNA-binding surface of the p53 protein that makes contact with the minor groove of DNA (Petitjean et al., 2007). The majority of them were found at codons 175, 245 and 248. These mutant proteins exhibit loss of transactivation function and dominant-negative effects. To date, no other gene has been significantly associated with LFS. Reports that germline mutations in the CHEK2 gene may predispose to LFS have not been substantiated (Vahteristo et al., 2001).

Familial Gliomas: Role of TP53 Gene Brain tumors are the third most common tumors arising from germline TP53 mutations. It is also estimated that not more than a half of families with germline TP53 mutations fulfill the definition of classic LFS. Therefore, the possibility that germline TP53 mutations could play an important role in familial aggregation of gliomas was suggested. Various case reports were first supportive of this hypothesis. Lübbe et al. (1995) described clinical, neuropathological and molecular genetic findings in a Swiss family with four brain tumors in only two generations. The neoplasms observed covered a wide range from a slowly growing lesion already apparent at birth, to anaplastic astrocytoma in a young adult and glioblastomas at the age of less than 10 years. A germline deletion of codon 236 of the TP53 gene was identified as an underlying cause and detected in all affected family members. Vital et al. (1998) reported 2 French families with an identical germline TP53 mutation in codon 248 and a clustering of brain tumors. The youngest patient

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in each family developed a malignant choroid plexus tumor while several young adults of both kindred succumbed to low-grade astrocytoma, anaplastic astrocytoma or glioblastoma. To determine whether TP53 gene plays an important role in familial glioma, the frequency of germline mutations was then investigated. For this purpose, van Meyel et al. (1994) went on to screen 26 members of 16 glioma families for germline TP53 mutations of exons 5 through 9 using a polymerase chain reaction-single-strand conformation polymorphism method. However, no germline mutations were found. Tachibana et al. (2000) investigated 15 familial gliomas by screening exons 5 through 8 and found one GBM patient exhibiting germline TP53 mutation. Careful examination of the corresponding family history showed multiple first degree relatives with GBM and a variety of other cancers (lung, colon, uterine and ovarian), many of them occurring before the age of 45, but not all the criteria for classical LFS were fulfilled; especially no family members developed a sarcoma. Paunu et al. (2001) identified 18 families with two or more gliomas through questionnaires sent to 369 consecutive glioma patients operated at Tampere University Hospital during 1983–1994. Again, sequencing analysis of exons 4 through 10 of the TP53 gene revealed no germline mutations in any of the 18 families. To date, the largest cohort of glioma families was gathered by the Salpetriere group. El Hallani et al. (2009a) examined 79 blood DNA of glioma patients who had at least one family member affected by glioma. Germline TP53 mutation screening was performed on exons 5 through 8. Five patients with variant sequences were identified. Two of them had a known polymorphism at codon 213 and the three other patients had missense TP53 mutations at codon 141, 251, and 273. Only one out of the mutated patient met the criteria for classic LFS. Taken together, only 2.5% (2/78) of familial glioma patients without ascertained LFS carried a mutated TP53 gene. In most studies, it was considered adequate to analyze the highly conserved regions of the TP53 gene, which are exons 5–8. Earlier analyses covering all exons, splice junctions and the promoter region of the TP53 gene suggested that 10% of germline mutations lie outside exons 4–10. Thus, previous reports have only provided a fairly thorough approximation of mutations within the TP53 gene. The fact that the occurrence of germline TP53 mutations among glioma families was a rare event speaks against the claim that

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such mutations would play a significant role in the genesis of familial gliomas. The relatively rare germline TP53 mutation in glioma families should promptly alert one to an incomplete form of LFS rather than a distinct glioma predisposition. An immunohistochemical case-control analysis of the tumor samples was performed to compare the rate of TP53 mutations and consequent aberrant p53 expression in familial and sporadic gliomas (Paunu et al., 2001). This analysis indicated that overexpressing p53 protein is as common in familial as in sporadic gliomas. In the absence of germline mutations, p53 accumulation probably arises from somatic mutations. Thus, somatic mutations of the p53 gene seem to be similarly involved in the pathogenesis of familial and sporadic gliomas. Together with the germline mutation analysis, this suggests that the role of the TP53 tumor suppressor gene is similar in the tumorigenesis of most familial and sporadic gliomas.

TP53 in Other Forms of Genetic Predisposition to Gliomas In addition to familial aggregation of gliomas, clinicians should be aware of other overlapping situations in which genetic etiology should be suspected: patients with multifocal glioma, glioma as another primary malignancy, and glioma associated with a family history of cancer without ascertained Li-Fraumeni syndrome. Gliomas usually present as a single lesion and rarely metastasize. However, multifocal gliomas, which exhibit more than one independent focus of involvement, were found to occur with a frequency of 9–11%. Moreover, multifocal gliomas are frequently associated with other primary malignancies. Kyritsis et al. (1994) investigated whether germline TP53 gene mutations may account for this phenomenon. Overall, nine out of 39 patients (23%) with multifocal glioma, secondary malignancies, or a family history of cancer exhibited heterozygous germline TP53 mutations. All these mutations would have resulted in amino acid changes in the p53 protein. They were detected in six out of 19 patients with multifocal glioma (including two with family history of cancer, one with another primary malignancy, and two with all three risk factors); one out of 4 patients with unifocal glioma, another primary malignancy and

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a family history of cancer; and two out of 15 patients with unifocal glioma and a family history of cancer but no second malignancies. No mutations were detected in the patient with unifocal glioma and another malignancy or in the 12 control patients with unifocal glioma and no second malignancies or family history of cancer. Patients having mutations were younger than other patients in the same group. Combinations of these risk factors increased the percentage of germline TP53 gene mutations to approximately 43% if two factors were present, or 67% in the presence of all three factors. Therefore, screening germline TP53 mutations is recommended if theses factors are combined in order to identify high risk relatives for genetic counseling, early cancer detection, and possible enrollment in chemoprevention trials.

TP53 Polymorphism in Sporadic Gliomas Inherited cancer syndromes are associated with rare and highly penetrant monogenic mutations, but genetic factors also play a role in sporadic cancers. Single Nucleotide Polymorphisms (SNP) can affect protein function, promoter activity, messenger RNA stability, and splice variants and therefore can result in a change in the cellular ability to cope with DNA damage, which contributes to cancer susceptibility. Most of the association studies that aimed at identifying low-penetrance variants for susceptibility to gliomas have been based on a candidate gene approach. One of the critical molecular steps of gliomagenesis involves the p53 pathway. A functional SNP at codon 72 of TP53 gene results in the presence of either proline (Pro) or arginine (Arg) in the amino acid sequence of TP53. This change involves DNA-binding motifs of p53 and the Pro72 variant results in weaker induction of apoptosis than the Arg72 variant (Pim and Banks, 2004). Then this polymorphism has been linked to glioma susceptibility but results from different studies are controversial. The Pro72 variant was also suspected of altering the tumor sensitivity to irradiation and chemotherapy. However, conducted glioma studies suggest that the Pro72 variant does not have any prognostic impact on the survival of GBM patients, neither on less aggressive histologic subgroups of glial tumors. Interestingly, El Hallani et al. (2009b) reported

S. El Hallani and I. Ratbi

that the Pro/Pro genotype is associated with earlier onset in GBM population (49.1 years) compared to Arg/Arg (56.6 years) and Arg/Pro (55.9 years). The Pro/Pro genotype was significantly more represented in young patients (less than 45 years old) than in elderly. The accelerating effect of functional p53 insufficiency on tumorigenesis was previously demonstrated. In a model of mice lacking the xeroderma pigmentosum group A gene (XPA–/– mice) and highly predisposed to tongue tumors when exposed to 4-nitroquinoline 1-oxide, the p53 haploinsufficiency (TP53–/+) and complete inactivation (TP53–/–) did not increase the incidence of cancer but accelerated dramatically tumor development (Ide et al., 2003). Genomic alterations and molecular pathways involved in GBM differ between young and older patients. TP53 inactivation is a prominent mechanism in the GBM of child and young adult compared to the GBM of older patient. As a consequence, young patients might be more sensitive to the functional variation of TP53 codon 72, explaining that Pro/Pro genotype constitutes a potent risk factor in this population. In conclusion, clinicians should inquire about any family history of brain tumors and be familiar with the most important hereditary syndromes with neoplastic manifestations in the nervous system, so that these diagnoses are not missed. Genetic alterations predisposing to familial aggregation of gliomas without ascertained hereditary syndrome are yet to be clarified. Although occasional glioma families carrying germline TP53 mutations have been identified, current data do not support routine screening of TP53 gene, except for atypical combination of multifocality and secondary malignancy. As suggested by segregation analysis, a model of familial glioma predisposition based solely on high-risk mutations seems unlikely, and much of the inherited risk is likely to be a consequence of the coinheritance of multiple low-risk variants. However, our knowledge of predisposition to glioma is developing. The advent of genome-wide association study will enable researchers to identify variants that influence an individual’s susceptibility to develop glioma. Such studies are at the vanguard of the new technologies and started to identify risk loci in gliomas. Identifying the sequence changes responsible for causal associations should thus provide insight into the biological mechanisms of glioma, and this may lead to the development of etiological hypotheses regarding non genetic risk factors.

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Familial Gliomas: Role of TP53 Gene

References El Hallani S, Boisselier B, Marie Y, Paris S, Idbaih A, Carpentier C, Hoang-Xuan K, Delattre JY, Sanson M (2009a) TP53 mutations but no CHEK2 ∗ 1100DelC variant in familial gliomas. Cancer Genet Cytogenet 188:126–128 El Hallani S, Ducray F, Idbaih A, Marie Y, Boisselier B, Colin C, Laigle-Donadey F, Rodéro M, Chinot O, Thillet J, Hoang-Xuan K, Delattre JY, Sanson M (2009b) TP53 codon 72 polymorphism is associated with age at onset of glioblastoma. Neurology 72:332–336 Evans DG, Birch JM, Thorneycroft M, McGown G, Lalloo F, Varley JM (2002) Low rate of TP53 germline mutations in breast cancer/sarcoma families not fulfilling classical criteria for Li-Fraumeni syndrome. J Med Genet 39:941–944 Ide F, Kitada M, Sakashita H, Kusama K, Tanaka K, Ishikawa T (2003) p53haploinsufficiency profoundly accelerates the onset of tongue tumors in mice lacking the xeroderma pigmentosum group A gene. Am J Pathol 163:1729–1733 Kyritsis AP, Bondy ML, Xiao M, Berman EL, Cunningham JE, Lee PS, Levin VA, Saya H (1994) Germline p53 gene mutations in subsets of glioma patients. J Natl Cancer Inst 86:344–349 Li FP, Fraumeni JF, Mulvihill JJ, Blattner WA, Dreyfus MG, Tucker MA, Miller RW (1988) A cancer family syndrome in twenty-four kindreds. Cancer Res 48:5358–5362 Lübbe J, von Ammon K, Watanabe K, Hegi ME, Kleihues P (1995) Familial brain tumour syndrome associated with a p53 germline deletion of codon 236. Brain Pathol 5:15–23 Malkin D, Li FP, Strong LC, Fraumeni JF, Nelson CE, Kim DH, Kassel J, Gryka MA, Bischoff FZ, Tainsky MA (1990) Germ line p53 mutations in a familial syndrome of breast cancer, sarcomas, and other neoplasms. Science 250:1233–1238 Malmer B, Haraldsson S, Einarsdottir E, Lindgren P, Holmberg D (2005) Homozygosity mapping of familial glioma in Northern Sweden. Acta Oncol 44:114–119 Paunu N, Lahermo P, Onkamo P, Ollikainen V, Rantala I, Helén P, Simola KO, Kere J, Haapasalo H (2002) A novel low-

45 penetrance locus for familial glioma at 15q23-q26.3. Cancer Res 62:3798–3802 Paunu N, Sallinen SL, Karhu R, Miettinen H, Sallinen P, Kononen J, Laippala P, Simola KO, Helén P, Haapasalo H (2000) Chromosome imbalances in familial gliomas detected by comparative genomic hybridization. Genes Chromosomes Cancer 29:339–346 Paunu N, Syrjäkoski K, Sankila R, Simola KO, Helén P, Niemelä M, Matikainen M, Isola J, Haapasalo H (2001) Analysis of p53 tumor suppressor gene in families with multiple glioma patients. J Neurooncol 55:159–165 Petitjean A, Mathe E, Kato S, Ishioka C, Tavtigian SV, Hainaut P, Olivier M (2007) Impact of mutant p53 functional properties on TP53 mutation patterns and tumor phenotype: lessons from recent developments in the IARC TP53 database. Hum Mutat 28:622–629 Pim D, Banks L (2004) p53 polymorphic variants at codon 72 exert different effects on cell cycle progression. Int J Cancer 108:196–199 Tachibana I, Smith JS, Sato K, Hosek SM, Kimmel DW, Jenkins RB (2000) Investigation of germline PTEN, p53, p16(INK4A)/p14(ARF), and CDK4 alterations in familial glioma. Am J Med Genet 92:136–141 Vahteristo P, Tamminen A, Karvinen P, Eerola H, Eklund C, Aaltonen LA, Blomqvist C, Aittomäki K, Nevanlinna H (2001) p53, CHK2, and CHK1 genes in Finnish families with Li-Fraumeni syndrome: further evidence of CHK2 in inherited cancer predisposition. Cancer Res 61:5718–5722 van Meyel DJ, Ramsay DA, Chambers AF, Macdonald DR, Cairncross JG (1994) Absence of hereditary mutations in exons 5 through 9 of the p53 gene and exon 24 of the neurofibromin gene in families with glioma. Ann Neuro. 35:120–122 Vital A, Bringuier PP, Huang H, San Galli F, Rivel J, Ansoborlo S, Cazauran JM, Taillandier L, Kleihues P, Ohgaki H (1998) Astrocytomas and choroid plexus tumors in two families with identical p53 germline mutations. J Neuropathol Exp Neurol 57:1061–1069

Chapter 6

The Role of IDH1 and IDH2 Mutations in Malignant Gliomas Yukihiko Sonoda, Ichiyo Shibahara, Ryuta Saito, Toshihiro Kumabe, and Teiji Tominaga

Abstract A recent study identified mutations in the active sites of isocitrate dehydrogenase 1 and 2 (IDH1and IDH2) genes in several types of glioma. All mutations affected a single amino acid located in the binding site of isocitrate (R132 of IDH1 and R172 of IDH2). We analyzed the genomic region spanning wild-type R132 of IDH1 and R172 of IDH2 by direct sequencing in 125 glial tumors. A total of 39 IDH1 mutations and one IDH2 mutation were observed. IDH1 and IDH2 mutations were frequently present in astrocytic and oligodendroglial tumors. However, primary glioblastomas were characterized by a low frequency of mutations (5%) at amino acid position 132 of IDH1. Mutations of IDH1 and IDH2 genes were significantly associated with improved outcome in patients with anaplastic astrocytomas. IDH1 and IDH2 mutations seem to play an important role in early tumor progression of specific types of glioma and might arise from a common glial precursor. The infrequency of IDH1 mutation in primary glioblastomas revealed that these subtypes are entities that are genetically distinct from other glial tumors. Analyses of IDH1 and IDH2 status have significant utility for diagnosis and treatment of patients with gliomas. Keywords IDH1 and IDH2 · Mutations · Gliomas · Glioblastomas · Grades of glioma · Arginine

Introduction Gliomas are the most common type of primary brain tumor and are grouped into four grades according Y. Sonoda () Department of Neurosurgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai-shi, Miyagi 980-8577, Japan e-mail: [email protected]

to the World Health Organization (WHO) criteria (Louis et al., 2007). Gliomas include several specific histological subtypes; the most common are astrocytomas, oligodendrogliomas, and ependymomas. Glioblastomas (GBMs) (WHO grade IV), the most malignant type of glioma, may develop very rapidly de novo (primary glioblastoma) in elderly patients, or develop more slowly from low-grade diffuse (DA) (WHO grade II) or anaplastic astrocytoma (AA) (WHO grade III) (secondary glioblastoma) in younger patients (Ohgaki and Kleihues, 2009). Malignant gliomas are believed to develop as the result of stepwise accumulations of genetic lesions. Several genes, including TP53, PTEN, CDKN2A/CDKN2B, and EGFR, are altered in gliomas (Ohgaki and Kleihues, 2009). These alterations tend to occur in a defined order during the progression to a high-grade tumor. TP53 mutation appears to be a relatively early event during the development of an astrocytoma, whereas the loss or mutation of PTEN and amplification of EGFR are characteristic of higher-grade tumors (Furnari et al., 2007). Oligodendrogliomas (O) (WHO grade II) and anaplastic oligodendrogliomas (AO) (WHO grade III) typically show 1p/19q codeletion (Reifenberger et al., 1994). Recent genome-wide mutational analysis has revealed somatic mutations of the cytosolic nicotinamide adenine dinucleotide phosphate (NADP+ )dependent isocitrate dehydrogenase (IDH1) gene at 2q33 in approximately 12% of GBMs (Parsons et al., 2008). Isocitrate dehydrogenase catalyzes the oxidative decarboxylation of isocitrate to alphaketoglutarate thereby enabling NADPH production. Mutations were found that affect the amino acid arginine in position 132 of the amino acid sequence, which is evolutionarily highly conserved, and is located in

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_6, © Springer Science+Business Media B.V. 2011

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the binding site of isocitrate (Xu et al., 2004). In the vast majority of these cases, wild-type arginine in position 132 was replaced by histidine (R132H) (Balss et al., 2008; Parsons et al., 2008; Ichimura et al., 2009; Sonoda et al., 2009; Watanabe et al., 2009; Yan et al., 2009b). The IDH2 gene is homologous to IDH1, which uses NADP+ as an electron receptor. Gliomas without IDH1 mutations were often found to have mutations at the analogous amino acid (R172) of the IDH2 gene (Yan et al., 2009b). Both IDH1and IDH2 mutations reduced enzymatic activity of the encoded protein.

Methodology We obtained 125 samples of tumor tissue from surgical patients diagnosed and treated at Tohoku University Hospital. Resected specimens were quick-frozen in liquid nitrogen and kept at –80◦ C until nucleic acid extraction (Sonoda et al., 2009). The series included 2 DA, 21 AA, 58 primary glioblastomas (prGBM), 3 secondary glioblastomas (secGBM), 8 O, 14 AO, 4 anaplastic oligoastrocytomas of WHO grade III (AOA), 8 gangliogliomas of WHO grade II (GG), and 5 anaplastic gangliogliomas (AG) of WHO grade III. Exon 4 of the IDH1 gene including codon 132 was amplified using 100 ng each of sense primer 5 -CGGTCTTCAGAGAAGCCATT and antisense primer 5 -GCAAAATCACATTATTGCCAAC. A fragment of 219 bp in length spanning the catalytic domain of IDH2 including codon 172 was amplified using 100 ng each of sense primer 5 CAAGCTGAAGAAGATGTGGAA-3 and antisense primer 5 -CAGAGACAA GAGGATGGCTA-3 . PCR was performed using standard buffer conditions, namely, 100 ng of DNA and Ex-Taq HS DNA Polymerase (Takara Bio Inc., Shiga, Japan) employed for 30 cycles with denaturing at 95◦ C for 30 s, annealing at 56◦ C for 30 s, and extension at 72◦ C for 40 s in a total volume of 50 ul. The PCR products were purified using a highly pure PCR product purification kit (Roche, Basel, Switzerland). All sequence reactions were performed using the GenomeLabTM DTCS quick-start kit (Beckman Coulter, Inc., Fullerton, CA). The reactions were carried out in an automated DNA analyzer (CEQ 8000; Beckman Coulter).

Y. Sonoda et al.

Results IDH Mutations in Gliomas We detected 39 mutations in the IDH1 gene in 125 tumors. All mutations were heterozygous with one wild-type allele being present. Only codon 132 of IDH1 was affected by mutations and all mutations were of the R132H type. In addition, the mutation of IDH2 at codon 172 was detected in one AA without IDH1 mutation. The type of mutation was R172S (AGG to AGT). Mutations of IDH1 or IDH2 were frequently observed in AA (62%), secGBM (67%), O (67%), AO (50%), AOA (75%), GG (38%), and AG (60%). Only a few mutations occurred in prGBM (5%). Despite no mutations in DA, we could not draw any reliable conclusions because of the fact that there were only two cases.

Patient Survival and IDH Mutation Patients with GBM carrying an IDH1 mutation (n = 5) had a median survival of 66 months, which was longer than the 17-month survival in patients with wild-type IDH1 (n = 57). However, there was no significant difference because there were too few tumors of GBM with IDH1 mutation (P = 0.1; log-rank test). Mutations of the IDH1 and IDH2 genes were associated with prolonged overall survival in AA patients; the median overall survival was 50 months for patients with mutation (n = 13) and 22 months for those without mutation (n = 8) (P < 0.001; log-rank test).

Discussion Detection of IDH1 and IDH2 Mutations The current routine procedure for assessing IDH gene status is DNA sequencing. All mutations of the IDH1 gene were somatic and missense mutations at codon 132 (arginine). Of these, almost all mutations were of the R132H type; however, 5 other mutations leading to R132C, R132S, R132G, R132L, and R132V were found. Similarly, all IDH2 mutations were found in codon 172; these mutations resulted in amino acid exchanges from arginine to guanine, methionine,

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The Role of IDH1 and IDH2 Mutations in Malignant Gliomas

serine, and lysine (Balss et al., 2008; Hartmann et al., 2009; Sonoda et al., 2009; Yan et al., 2009b). DNA extraction and sequencing are not available at every institute; however, recently mutation-specific IDH1 antibodies for the most frequent mutation of the R132H type have shown useful properties of high sensitivity and selectivity (Kato et al., 2009; CameloPiragua et al., 2010; Capper et al., 2010).

IDH1 and IDH2 Mutations are Frequently Found in Various Grades of Glioma According to previous reports, no pilocytic astrocytoma with an IDH1 mutation has been found, with the exception of a single case (Balss et al., 2008; Korshunov et al., 2009). High frequencies of IDH1 mutations were found in DA, AO, O, and AO (Watanabe et al., 2009; Yan et al., 2009b). Similarly, IDH1 mutations were more frequent in secGBM than prGBM (Yan et al., 2009b). Among other CNS tumors, IDH1 mutation has been reported in pleomorphic xanthoastrocytoma, primitive neuroectodermal tumor, and GG (Balss et al., 2008; Sonoda et al., 2009; Yan et al., 2009b). On the other hand, no IDH1 mutation was found in ependymal tumors, medulloblastomas, meningeal tumors, and schwannoma (Balss et al., 2008; Ichimura et al., 2009; Yan et al., 2009b). Although the frequency of IDH1 mutation in younger

Fig. 6.1 A model of glioblastoma development. Abbreviations: IDH1/2, isocitrate dehydrogenase 1/2; mut, mutation; 1p19q codel., 1p 19q codeletion; CDKN2A, B, cyclin-dependent kinase inhibitor 2A, B; HD, homozygous deletion; PTEN, phosphatase tensin homolog; EGFR, epidermal growth factor receptor; amp,

49

patients is higher than that in older patients, this mutation has rarely been found in pediatric tumors (Balss et al., 2008). Among non-CNS tumors, IDH1 mutation was found in two prostate cancers and one B-ALL (Bleeker et al., 2009; Kang et al., 2009). In addition, IDH1 mutation has been identified in a subset of acute myeloid leukemia cases (Mardis et al., 2009). IDH2 mutations were only found in WHO grade II or III gliomas, usually without IDH1 mutation. According to previous reports, only one grade III glioma showed both IDH1 and IDH2 mutations (Wick et al., 2009).

IDH1 and IDH2 Mutations Are Early Events in Gliomagenesis IDH1 and IDH2 mutations are commonly found in both astrocytomas and oligodendrogliomas, but the pattern of other genetic alterations is different. Usually, TP53 mutations and 1p/19q codeletion were exclusive, with the exception of only a few cases (Ichimura et al., 2009; Watanabe et al., 2009). The majority of lowgrade diffuse astrocytomas have both TP53 and IDH1 mutations, whereas most oligodendrogliomas show both IDH1 mutations and 1p/19q codeletion (Ichimura et al., 2009; Watanabe et al., 2009). Therefore, IDH1 and IDH2 mutations are very early events in gliomagenesis and may affect common glial precursors (Fig. 6.1).

amplification; DA, diffuse astrocytoma; AA, anaplastic astrocytoma; O, oligodendroglioma; AO, anaplastic astrocytoma; prGBM, primary glioblastoma; secGBM, secondary glioblastoma

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The pattern of other genetic alterations in gliomas with IDH mutations is entirely different from that in gliomas without IDH mutations. Alterations of PTEN, EGFR, or CDKN2A/CDKN2B are frequently found in GBMs with wild-type IDH1 and IDH2, but in only 5% of cases of AA and GBM with IDH mutation (Yan et al., 2009a; b). Similarly, 1p/19q codeletion was rarely found in oligodendroglial tumors without IDH mutation (Watanabe et al., 2009). TP53 mutations were frequently found in AA with IDH1 mutation; however, these were often found in prGBMs without IDH1 mutations (Ohgaki and Kleihues, 2009; Yan et al., 2009a).

IDH Mutation as a Favorable Prognostic Factor in Glioma Patients Clinically, IDH1 mutation is strongly correlated with good prognosis in patients with several grades of glioma (Sanson et al., 2009; Sonoda et al., 2009; Wick et al., 2009; Yan et al., 2009b). Multivariate analysis has confirmed that IDH1 mutation is an independent favorable prognostic marker in anaplastic gliomas and glioblastomas after adjustment for other factors (age, histology, MGMT promoter methylation status, and genomic profile) and treatment modality (extent of resection) (Sanson et al., 2009; Wick et al., 2009).

Fig. 6.2 The roles of IDH1 and IDH2 in cellular metabolism. Abbreviations: IDH1/2, isocitrate dehydrogenase 1/2; α-KG, α-ketoglutarate; 2-HG, 2-hydroxyglutarate; 2HGD, PHD,

Y. Sonoda et al.

2-Hydroxyglutarate (2-HG) Levels Are Elevated in Gliomas with IDH1 Mutations Although the biological function of IDH mutation is not fully understood, IDH mutations are always monoallelic and do not result in simple loss of function. IDH1 mutation impairs the enzyme’s affinity for its substrate and dominantly inhibits wild-type IDH1 activity through the formation of catalytically inactive heterodimers (Zhao et al., 2009). Consequently, R132H mutation disrupts the function of IDH1 to convert isocitrate to α-ketoglutarate. More recently, IDH1 mutations were found to result in a new ability of the enzyme to catalyze the NADPH-dependent reduction of α-ketoglutarate to R(-)-2-HG (2-HG) (Fig. 6.2) (Dang et al., 2009). 2-HG levels were remarkably elevated in human malignant gliomas with IDH1 mutations (Dang et al., 2009). Structural studies demonstrated that the replacement of arginine 132 by histidine results in a shift of the residues in the active site to produce structural changes consistent with reduced oxidative decarboxylation of isocitrate and acquisition of the ability to convert α-ketoglutarate to 2-HG. The accumulation of 2-HG is found in patients with inherited metabolic disorder 2-hydroxyglutaric aciduria. This disease is caused by a deficiency in the enzyme 2-HG dehydrogenase, which converts 2-HG to α-ketoglutarate (Struys et al., 2005). Patients with 2-HG dehydrogenase deficiency have

2-hydroxyglutarate dehydrogenase prolyl hydroxylase; HIF-1, hypoxia-inducible factor 1; HIF-1-OH, hydroxylated HIF-1

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The Role of IDH1 and IDH2 Mutations in Malignant Gliomas

an increased risk of developing brain tumors (Aghili et al., 2009). The effect of IDH1 mutation on cellular metabolism requires more investigation, but reduction of α-ketoglutarate by 2-HG or mutant IDH1 results in a lower level of prolyl hydroxylases and promotes the accumulation of hypoxia-inducible factor 1 (HIF-1) (Fig. 6.2). Alterations in HIF-1 may result from mutant IDH1 protein expression. In addition to IDH mutations in gliomas, mutations of other metabolic enzymes such as fumarate hydratase and succinate dehydrogenase occur in paraganglioma and leiomyoma, respectively (King et al., 2006). Energy is produced predominantly by aerobic glycolysis in the cytoplasm of most cancer cells, rather than by mitochondrial oxidative phosphorylation as in normal differentiated cells, a phenomenon termed the “Warburg effect.” Aerobic glycolysis may provide cancer cells with a growth advantage by supplying required metabolites for incorporation into the biomass to produce new cells. Aerobic glycolysis may also be important for glioma progression. Both PI3K and tyrosine kinase signaling are involved in growth control and glycolysis. PI3K activation by PTEN mutation and/or tyrosine kinase activation by EGFR alteration are frequently found in prGBMs. However, PTEN mutation and EGFR alterations are rarely found in AA and GBM patients with IDH mutation, suggesting that the mechanism of cellular metabolism in glioma might depend on IDH status.

Conclusions IDH mutations seem to play an important role in the formation of astrocytic and oligodendroglial tumors. Detection of IDH mutations is easier to perform and interrupt than the determination of 1p/19q codeletion and MGMT promoter methylation. Such information could be useful to improve the diagnostic and therapeutic strategies for gliomas. Furthermore, measurement of 2-HG production will enable identification of patients with IDH1 mutant brain tumors. Of course, further analysis of IDH1 and IDH2 in glioma model systems will be necessary to clarify the genetic mechanisms involved in the initiation and malignant progression of this disease. In addition, extensive genetic profiling of gliomas may allow the molecular classification of gliomas to replace the current histological classification in the near future. Patients with

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IDH1 mutation may benefit from treatment modalities designed to inhibit the mutant IDH1 expression. Inhibition of 2-HG production might also have therapeutic potential in the treatment of gliomas.

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52 King A, Selak MA, Gottlieb E (2006) Succinate dehydrogenase and fumarate hydratase: linking mitochondrial dysfunction and cancer. Oncogene 25:4675–4682 Korshunov A, Meyer J, Capper D, Christians A, Remke M, Witt H, Pfister S, Von Deimling A, Hartmann C (2009) Combined molecular analysis of BRAF and IDH1 distinguishes pilocytic astrocytoma from diffuse astrocytoma. Acta Neuropathol 118:401–405 Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, Burger PC, Jouvet A, Scheithauer BW, Kleihues P (2007) The 2007 WHO classification of tumours of the central nervous system. Acta Neuropathol 114:97–109 Mardis ER, Ding L, Dooling DJ, Larson DE, Mclellan MD, Chen K, Koboldt DC, Fulton RS, Delehaunty KD, Mcgrath SD, Fulton LA, Locke DP, Magrini VJ, Abbott RM, Vickery TL, Reed JS, Robinson JS, Wylie T, Smith SM, Carmichael L, Eldred JM, Harris CC, Walker J, Peck JB, Du F, Dukes AF, Sanderson GE, Brummett AM, Clark E, Mcmichael JF, Meyer RJ, Schindler JK, Pohl CS, Wallis JW, Shi X, Lin L, Schmidt H, Tang Y, Haipek C, Wiechert ME, Ivy JV, Kalicki J, Elliott G, Ries RE, Payton JE, Westervelt P, Tomasson MH, Watson MA, Baty J, Heath S, Shannon WD, Nagarajan R, Link DC, Walter MJ, Graubert TA, Dipersio JF, Wilson RK, Ley TJ (2009) Recurring mutations found by sequencing an acute myeloid leukemia genome. N Engl J Med 361:1058–1066 Ohgaki H, Kleihues P (2009) Genetic alterations and signaling pathways in the evolution of gliomas. Cancer Sci 15: 6002–6007 Parsons DW, Jones S, Zhang X, Lin JC, Leary RJ, Angenendt P, Mankoo P, Carter H, Siu IM, Gallia GL, Olivi A, Mclendon R, Rasheed BA, Keir S, Nikolskaya T, Nikolsky Y, Busam DA, Tekleab H, Diaz LA Jr., Hartigan J, Smith DR, Strausberg RL, Marie SK, Shinjo SM, Yan H, Riggins GJ, Bigner DD, Karchin R, Papadopoulos N, Parmigiani G, Vogelstein B, Velculescu VE, Kinzler KW (2008) An integrated genomic analysis of human glioblastoma multiforme. Science 321:1807–1812 Reifenberger J, Reifenberger G, Liu L, James CD, Wechsler W, Collins VP (1994) Molecular genetic analysis of oligodendroglial tumors shows preferential allelic deletions on 19q and 1p. Am J Pathol 145:1175–1190

Y. Sonoda et al. Sanson M, Marie Y, Paris S, Idbaih A, Laffaire J, Ducray F, El Hallani S, Boisselier B, Mokhtari K, Hoang-Xuan K, Delattre JY (2009) Isocitrate dehydrogenase 1 codon 132 mutation is an important prognostic biomarker in gliomas. J Clin Oncol 27:4150–4154 Sonoda Y, Kumabe T, Nakamura T, Saito R, Kanamori M, Yamashita Y, Suzuki H, Tominaga T (2009) Analysis of IDH1 and IDH2 mutations in Japanese glioma patients. Cancer Sci 100:1996–1998 Struys EA, Salomons GS, Achouri Y, Van Schaftingen E, Grosso S, Craigen WJ, Verhoeven NM, Jakobs C (2005) Mutations in the D-2-hydroxyglutarate dehydrogenase gene cause D-2hydroxyglutaric aciduria. Am J Hum Genet 76:358–360 Watanabe T, Nobusawa S, Kleihues P, Ohgaki H (2009) IDH1 mutations are early events in the development of astrocytomas and oligodendrogliomas. Am J Pathol 174: 1149–1153 Wick W, Hartmann C, Engel C, Stoffels M, Felsberg J, Stockhammer F, Sabel MC, Koeppen S, Ketter R, Meyermann R, Rapp M, Meisner C, Kortmann RD, Pietsch T, Wiestler OD, Ernemann U, Bamberg M, Reifenberger G, Von Deimling A, Weller M (2009) NOA-04 randomized phase III trial of sequential radiochemotherapy of anaplastic glioma with procarbazine, lomustine, and vincristine or temozolomide. J Clin Oncol 27:5874–5880 Xu X, Zhao J, Xu Z, Peng B, Huang Q, Arnold E, Ding J (2004) Structures of human cytosolic NADP-dependent isocitrate dehydrogenase reveal a novel self-regulatory mechanism of activity. J Biol Chem 279:33946–33957 Yan H, Bigner DD, Velculescu V, Parsons DW (2009a) Mutant metabolic enzymes are at the origin of gliomas. Cancer Res 69:9157–9159 Yan H, Parsons DW, Jin G, Mclendon R, Rasheed BA, Yuan W, Kos I, Batinic-Haberle I, Jones S, Riggins GJ, Friedman H, Friedman A, Reardon D, Herndon J, Kinzler KW, Velculescu VE, Vogelstein B, Bigner DD (2009b) IDH1 and IDH2 mutations in gliomas. N Engl J Med 360:765–773 Zhao S, Lin Y, Xu W, Jiang W, Zha Z, Wang P, Yu W, Li Z, Gong L, Peng Y, Ding J, Lei Q, Guan KL, Xiong Y (2009) Glioma-derived mutations in IDH1 dominantly inhibit IDH1 catalytic activity and induce HIF-1alpha. Science 324: 261–265

Chapter 7

Malignant Glioma: Isocitrate Dehydrogenases 1 and 2 Mutations Zachary J. Reitman and Hai Yan

Abstract Mutations in the cytoplasmic NADP+ dependent isocitrate dehydrogenase, IDH1, frequently occur in gliomas. The mutations are somatic, almost always heterozygous, and occur at R132, an active site residue of IDH1 that is important for its catalytic function. IDH1 mutations occur in >70% of WHO grades II and III astrocytomas and oligodendrogliomas, as well as WHO grade IV secondary glioblastomas, and more rarely in other glioma subtypes. IDH2 is the mitochondrial homolog of IDH1, and mutations in IDH2 R172, the analogous residue to IDH1 R132, also occur in these subtypes of gliomas, albeit at a much lower frequency. R132H and R172K are the most common IDH1 and IDH2 mutations observed in gliomas, respectively, though alterations to other amino acids at these hotspots have also been observed. IDH1 mutations frequently co-occur with loss of chromosomes 1p and 19q or point mutations of TP53, and they appear to occur before other genetic alterations during glioma pathogenesis. Furthermore, IDH1 mutations are associated with a younger age at diagnosis and a better prognosis for many glioma subtypes. The frequency of IDH1 and IDH2 mutations in specific glioma subtypes suggests that testing for these mutations may help to guide clinical decision-making for glioma patients, and PCR- and antibody-based tests have been developed to determine tumor mutation

H. Yan () The Pediatric Brain Tumor Foundation Institute, The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC 27710, USA; The Department of Pathology, Duke University Medical Center, Durham, NC 27710, USA e-mail: [email protected]

status. The IDH1 and IDH2 mutations abolish the normal function of the encoded enzymes to oxidize isocitrate to α-ketoglutarate and confer a neomorphic gain of enzymatic activity to reduce α-ketoglutarate to 2-hydroxyglutarate. This gain of function suggests that IDH1 and IDH2 mutations are oncogenic, but the mechanism by which this promotes glioma pathogenesis remains unknown. Keywords Malignant glioma · IDH1 · Mutation · R132 · Enzyme · Dehydrogenase

Introduction The study of genetic alterations that arise in tumors of the central nervous system represents a decades-old field. Recent whole-genome analyses have advanced this field by integrating years of careful observations and by revealing genetic changes that were not obvious in previous studies. Foremost among discoveries of novel genetic changes are frequent mutations of IDH1 and IDH2 in gliomas. These mutations stand apart from other genetic alterations in cancer due in part to the fact that they occur with striking frequency in certain glioma subtypes. Also, while the vast majority of genetic alterations in cancer affect genes involved in cellular signaling and growth control, the IDH1 and IDH2 mutations affect cellular metabolic enzymes without known signaling or growth regulating properties. Furthermore, rather than simply activate or inactivate the normal function of the genes as is typically the result for alterations in cancer, the IDH1 and IDH2 mutations bestow a novel neomorphic activity on the encoded enzymes. Study of these unique mutations may further our understanding of the pathology of

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_7, © Springer Science+Business Media B.V. 2011

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tumors of the central nervous system and possibly provide avenues to better manage these diseases. Mutations in IDH1 were discovered in a wholegenome sequencing analysis of coding exons in glioblastoma samples (Parsons et al., 2008). IDH1 is the cytoplasmic nicotinamide adenine dinucleotide phosphate (NADP+ )-dependent isocitrate dehydrogenase. IDH1 mutations observed in glioma specifically alter codon 132, which encodes an arginine (R132) in the enzyme’s substrate binding site. The mutations are somatic and almost always heterozygous. Additionally, mutations in the analogous R172 codon of IDH2, which encodes the mitochondrial NADP+ -dependent isocitrate dehydrogenase which is the only homolog of IDH1, also occur in many of the same subtypes of glioma at a much lower frequency (Yan et al., 2009). The most frequent IDH1 alteration observed in gliomas is R132H, with other alterations at this codon more rarely observed (Balss et al., 2008). This chapter considers the epidemiology and clinical characteristics of central nervous system tumors with IDH mutations, and briefly discusses the biochemical function of the mutated enzymes.

Tumor Type Distribution IDH mutations occur frequently in specific glioma subtypes. Gliomas are primary tumors of the central nervous system that histologically resemble glia, the supporting cells of the brain. Like other CNS tumors, gliomas are classified by the World Health Organization from grades I to IV, with grades III–IV tumors considered malignant gliomas. The IDH mutations occur in gliomas classified as astrocytomas and oligodendrogliomas, which histologically resemble astrocytes and oligodendrocytes, respectively. Grade I pilocytic astrocytomas predominantly occur in children and seldom progress to higher-grade tumors. Grade II gliomas comprise diffuse astrocytomas, welldifferentiated oligodendrogliomas, and mixed oligoastrocytomas. These can progress to grade III gliomas of the same histology, with grade II diffuse astrocytomas progressing to grade III anaplastic astrocytomas, grade II well-differentiated oligodendrogliomas progressing to grade III anaplastic oligodendrogliomas, and grade II oligoastrocytomas progressing to grade III anaplastic oligoastrocytomas. Glioblastomas are

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grade IV astrocytomas that have a particularly varied and dysplastic histology and carry a grim prognosis. Secondary glioblastomas, by definition, arise from grade II and III astrocytomas. In contrast to this, the majority of glioblastomas are primary glioblastomas which arise de novo, rather than from a previous lowergrade tumor (Louis et al., 2007). Figure 7.1 depicts the glioma subtypes and pathways of tumor progression discussed above. IDH1 mutations are common (>70%) in grades II and III astrocytomas and oligodendrogliomas, and in secondary glioblastomas (Balss et al., 2008). They occur more rarely in primary glioblastomas (3–16%) (Balss et al., 2008; Parsons et al., 2008; Bleeker et al., 2009; Yan et al., 2009), and are seldom found in grade I pilocytic astrocytomas (0–2%) (Balss et al., 2008; Ichimura et al., 2009; Korshunov et al., 2009; Yan et al., 2009). IDH2 mutations share a similar tumor type distribution with IDH1 mutations (Yan et al., 2009). They are generally found in tumors that do not contain IDH1 mutations, and occur much less frequently than IDH1 mutations (Hartmann et al., 2009; Yan et al., 2009). As an example, in a group of 1,010 grades II and III gliomas, 71% contained IDH1 mutations while only 3% contained IDH2 mutations (Hartmann et al., 2009). The percentage of astrocytic and oligodendroglial tumors containing IDH1 or IDH2 mutations based on two large studies is shown in Fig. 7.1. Gangliogliomas seldom (17% or less) contain IDH1 mutations (Sonoda et al., 2009), and extensive analysis of other CNS tumors such as medulloblastomas, meningiomas, and ependymomas has not revealed IDH mutations. IDH1 and IDH2 mutations are found in tumors but not in normal tissues from the same patient, and are almost always heterozygous with a wild-type allele (Yan et al., 2009). IDH1 and IDH2 mutations in gliomas may be specific for humans, as analogous mutations were not found in grades II–IV canine gliomas which are histopathologically indistinguishable from human gliomas (Reitman et al., 2009). However, IDH1 and IDH2 mutations also occur in up to 23% of human acute myelogenous leukemias (Mardis et al., 2009; Ward et al., 2010), and rare cases of IDH1 R132 mutations in colorectal cancer (Sjoblom et al., 2006), prostate cancer (Kang et al., 2009), and acute lymphoblastic leukemia, B-type (Kang et al., 2009) have been reported.

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Fig. 7.1 Schematic of pathogenesis and progression of astrocytic and oligodendroglial tumors, frequency of tumors carrying IDH1 R132 and/or IDH2 R172 mutations for each tumor type, and other common genetic alterations that occur in the pathogenesis or progression of each tumor type. Tumor grade is indicated to the left. Arrows indicate de novo pathogenesis from a normal cell, which has been speculated to be a normal stem cell, normal glial progenitor, or other normal cell, or progression from the indicated lower-grade tumor type. Grade I tumors: PA, pilocytic astrocytoma. Grade II tumors: O, welldifferentiated oligodendroglioma; OA, oligoastrocytomas; A,

diffuse astrocytoma. Grade III tumors: AO, anaplastic oligodendroglioma; AOA, anaplastic oligoastrocytoma; AA, anaplastic astrocytomas. Grade IV tumors: pGBM, primary glioblastoma; sGBM, secondary glioblastoma; sGBMO, secondary glioblastomas with oligodendroglial component. HD, homozygous deletion. N.S., not studied. Percentages were reported by Yan et al. (2009), except for OA and AOA which were reported by Hartmann et al. (2009) since relatively few OA and AOA tumors were analyzed in Yan et al. Figure reproduced from Reitman and Yan (2010) with permission and adapted to include percentages

Association with Other Genetic Alterations

group of a variety of glioma subtypes, 92% of tumors with IDH1 R132 mutations also contained either TP53 mutations or 1p/19q loss, while IDH1 wildtype tumors rarely contained these changes (Ichimura et al., 2009). Groups of grade II diffuse astrocytomas, grade III anaplastic astrocytomas, primary glioblastomas, and secondary glioblastomas analyzed for both IDH1 and TP53 in the same tumors often have a higher prevalence of TP53 mutations among the IDH1-mutated group than the IDH1–wild type group (Parsons et al., 2008; Ichimura et al., 2009; Watanabe et al., 2009a; Yan et al., 2009). IDH1 R132 mutation is significantly associated with the presence of any alteration in the TP53 pathway, including alterations in MDM2, MDM4, and p14ARF, in the combined group of grades II and III astrocytomas (Ichimura et al., 2009). Interestingly, 5 astrocytoma patients with Li-Fraumeni syndrome, which is defined by germline TP53 mutation and predisposes to astrocytomas and other cancers, had somatic IDH1 mutations (Watanabe et al., 2009b). Together, these findings illustrate that IDH mutations generally co-occur with TP53 mutations in the astrocytic tumors, and suggest that both

In gliomas, IDH mutations strongly associate with TP53 mutation or codeletion of chromosomes 1p and 19q, but are inversely associated with other genetic changes common in glioma, such as EGFR amplification. TP53 mutations are commonly present in grades II and III astrocytomas and oligoastrocytomas as well as secondary glioblastomas, but only about 30% of primary glioblastomas contain TP53 mutations; they are rare in pure oligodendroglial tumors. Pure oligodendroglial tumors frequently possess total 1p/19q loss and rarely contain TP53 mutations. 1p/19q loss is rare, however, in the astrocytic tumors. In grades II and III oligoastrocytomas, either TP53 mutation or 1p/19q loss are often present, and these changes are inversely associated. Thus, TP53 mutation and 1p/19q loss are generally mutually exclusive and distributed among the grade II and III astrocytic and oligodendroglial tumors, respectively. IDH1 and IDH2 mutations frequently co-occur with either TP53 mutations or 1p/19q loss. In one large

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are crucial steps in transformation of normal cells into astrocytoma cells. Oligodendroglial tumors frequently contain 1p/19q codeletions. IDH mutations often co-occur with 1p/ 19q loss in oligodendrogliomas, with one study finding 1p/19q loss in 85% of IDH1 or IDH2-mutated oligodendrocytic tumors, but not in oligodendrocytic tumors with wild-type IDH genes (Yan et al., 2009). In another study, all oligodendroglial tumors with 1p/19q loss harbored mutations in either IDH1 or IDH2, while not all tumors with IDH mutations harbored 1p/19q loss in this group (Ichimura et al., 2009). Overall, IDH mutations seem to be a common feature of astrocytomas and oligodendrogliomas, with oligodendrogliomas defined by 1p/19q loss and astrocytomas defined by TP53 mutations. IDH mutations are inversely associated with many of the hallmark changes of primary glioblastomas, including EGFR amplification, CDKN2A or CDKN2B deletion, and PTEN mutations. These changes are uncommon in secondary glioblastomas and lowergrade tumors. IDH mutations and EGFR amplification are inversely correlated among grades II–IV gliomas (Sanson et al., 2009), grades II–IV astrocytic tumors (Ichimura et al., 2009), grade III–IV astrocytic tumors (Yan et al., 2009), or glioblastomas (Parsons et al., 2008; Nobusawa et al., 2009). Similarly, changes in PTEN and CDKN2A/CDKN2B are common among IDH wild-type, but not IDH-mutated, grade III astrocytomas and glioblastomas (Yan et al., 2009). IDH1 mutations have been shown to be negatively associated with PTEN mutations as well (Ichimura et al., 2009). Secondary glioblastomas with wild-type IDH1 have genetic features, such as frequent EGFR amplification, that are characteristic for primary glioblastomas. This suggests that the IDH1 wild-type secondary glioblastomas are actually primary glioblastomas for which the glioblastoma was initially mistaken for a lowergrade lesion (Nobusawa et al., 2009). On the other hand, primary glioblastomas with mutated IDH1 more frequently have alterations, such as TP53 mutation, that are more common in secondary glioblastoma, suggesting that these tumors may have progressed from a lower-grade astrocytoma that was not clinically evident (Nobusawa et al., 2009). IDH1 mutations also associate with characteristic transcriptional and epigenetic profiles. Gliomas with IDH1 R132 mutations frequently display a pattern of hypermethylation throughout the genome compared to

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gliomas without IDH1 mutations (Noushmehr et al., 2010). Additionally, gene expression analysis has revealed that gliomas typically cluster into proneural, neural, classical, or mesenchymal gene expression signatures (Phillips et al., 2006), and that IDH1mutated gliomas associate with the proneural signature (Verhaak et al., 2010). The proneural signature resembles the gene expression signature of normal oligodendrocytes, and has previously been found to associate with grade II and III gliomas, and with younger age at diagnosis and better prognosis compared to gliomas with the other signatures (Phillips et al., 2006). Because IDH1-mutated gliomas have genetic, epigenetic, and gene expression alterations that are distinct from gliomas without IDH1 mutations, it stands to reason that pathogenesis and biology of IDH1-mutated gliomas may be fundamentally different from other gliomas. Since IDH2 mutations are rarer in gliomas than IDH1 mutations, it is not clear whether IDH2 mutated tumors have similar genetic, epigenetic, and gene expression profiles to the IDH1-mutated tumors.

Timing of Mutations IDH1 and IDH2 mutations appear to be early events in glioma formation. The proportion of IDH1 and IDH2 mutated tumors does not increase with grade (Balss et al., 2008), suggesting that the mutations arise during tumor formation, rather than during progression to a higher grade. The mutations are frequent in grade II gliomas, indicating that they are important for early steps in tumor formation. In a group of 51 grade II glioma patients with two or more biopsies, 42 (82%) had an IDH1 mutation at the first biopsy, and had an identical mutation at later biopsies. Two of the remaining nine patients initially did not have an IDH1 mutation, but developed an IDH1 mutation by a later biopsy (Watanabe et al., 2009a). This indicates that IDH1 mutation is an early event in glioma pathogenesis that persists throughout tumor progression. IDH mutations also occur before other common genetic alterations in glioma. Of 51 patients with multiple biopsies, four grade II glioma patients with IDH1 mutations at their first biopsy had TP53 mutations as well at their last biopsy. Another three of these patients

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Malignant Glioma: Isocitrate Dehydrogenases 1 and 2 Mutations

had IDH1 mutation alone at their first biopsy and 1p/19q loss by the time of their last biopsy (Watanabe et al., 2009a). However, no cases of IDH1 or IDH2 mutation occurring after acquisition of a somatic TP53 mutation or 1p/19q loss have been reported. The fact that IDH mutations occur frequently in astrocytomas containing TP53 mutations and in oligodendrogliomas with 1p/19q loss, and that IDH mutations occur before the other genetic alterations, has led to speculation that the mutations occur in a precursor cell that can give rise to both the astrocytic and oligodendroglial tumor types. Other genetic pathways to tumorigenesis that do not involve frequent IDH mutations likely lead to gliomas such as grade I pilocytic astrocytomas and grade IV primary glioblastomas by separate pathways, as evidenced by a different constellation of genetic changes observed for those tumor types. The common genetic changes found in grades I-IV gliomas, and the suggestion that IDH1 and IDH2 mutations arise in cell that can give rise to both astrocytic and oligodendroglial grade II gliomas, have been incorporated in Fig. 7.1.

Patient Age IDH mutations occur rarely in pediatric glioma patients, and occur in the younger of adult glioma patients. Pediatric patients that do have IDH1 or IDH2 mutations are generally older teenagers with grades II–III tumors rather than young children (De Carli et al., 2009). In studies of adult patients with grades II or III astrocytomas, primary glioblastomas, grade III anaplastic oligoastrocytomas, any grade II glioma, any grade III glioma, or any glioblastoma, patients with IDH1 mutations had a younger median age at diagnosis than those with the same tumor type who did not have IDH1 mutations (Balss et al., 2008; Parsons et al., 2008; Ichimura et al., 2009; Yan et al., 2009). For example, Watanabe et al. found that grade II diffuse astrocytoma patients with IDH1 mutations had a median age of 34 compared to 52 for IDH1 wildtype patients (Watanabe et al., 2009a), and Yan et al. found that grade III anaplastic astrocytoma patients with IDH1 or IDH2 mutations had a median age of 34 compared to 53 for the IDH wild-type patients (Balss et al., 2008). However, a significantly younger age for IDH1-mutated patients has not been observed

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for patients with pure oligodendroglial tumors. The older median age for grade II and III astrocytoma patients without IDH mutations has been speculated to be caused by misclassification of some primary glioblastomas as lower-grade tumors (Balss et al., 2008). Misclassification of primary glioblastomas as grade III anaplastic astrocytomas could also contribute to the lower frequency of IDH1 mutations in grade III anaplastic astrocytomas compared to grade II diffuse astrocytomas that has been observed in multiple studies (Balss et al., 2008; Ichimura et al., 2009; Yan et al., 2009).

Patient Survival Glioma patients with IDH mutations survive longer than patients with wild-type IDH1 and IDH2. In one study, glioblastoma patients with IDH1 mutations survived 3.7 years compared to 1.1 years for IDH1 wildtype glioblastoma patients (Parsons et al., 2008). Other studies have found that patients with IDH-mutated grade III anaplastic astrocytomas and groups of grade II, III, or IV gliomas survive longer than patients with IDH wild-type tumors of the same type (Dubbink et al., 2009; Ichimura et al., 2009; Sanson et al., 2009; Yan et al., 2009). Since IDH-mutated patients are younger than non-mutated patients, and since younger age is associated with longer survival, these univariate analyses do not show whether IDH mutation predicts better survival independently from age. Thus, some of the large differences in survival reported for these tumors may be reflect the fact that IDH mutations are markers for young age, and therefore better prognosis. Despite the association with survival, no association was found between IDH1 status and response to temozolomide in grade II diffuse astocytomas (Dubbink et al., 2009). Multivariate analyses that take into account age and other factors shed the most light on IDH mutations as independent predictors of survival. Results of such analyses have been mixed. In one study, a Cox regression multivariate analysis including age, tumor type, grade, TP53 mutation status, and 1p/19q codeletion status failed to identify IDH1 status as an independent prognostic factor (Ichimura et al., 2009). Other studies, however, have found IDH1 status to be a predictor of good outcome. A Cox multivariate analysis that did not use age as a covariate was

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performed on a randomized clinical trial of grade III glioma patients found IDH1 status to be more strongly associated with longer progression-free survival than other prognostic factors, such as 1p/19q status and MGMT promoter methylation (Wick et al., 2009). In another large group of patients, multivariate analysis adjusting for grade, age above or below 48, MGMT status, genomic profile, and treatment, confirmed that IDH1 mutation as an independent favorable prognostic marker (Sanson et al., 2009). A multivariate analysis of glioblastoma patients that adjusted for age found a significant association of IDH1 mutation with longer survival (Nobusawa et al., 2009).

Clinical Testing The specificity of IDH mutations for certain tumor types and their association with outcome makes testing for IDH mutation status potentially useful for the diagnosis and prognosis of gliomas. The high frequency of IDH mutations in grades II–III gliomas and secondary glioblastomas makes them highly sensitive and specific for these tumors compared to other CNS tumors. This has been exploited to show that IDH1 status can help distinguish between grade II diffuse astrocytomas and grade I pilocytic astrocytomas, which may be helpful in cases for which scant material is available for histopathological analysis (Korshunov et al., 2009). In another study, the sensitivity and specificity of IDH1 mutations were 73.3% and 96.3%, respectively, for secondary glioblastomas compared to primary glioblastomas (Nobusawa et al., 2009). Given the potential diagnostic utility for determining IDH mutation status, several methods have been developed to determine whether IDH1 or IDH2 are mutated in tumor samples. Polymerase chain reaction (PCR)-based assays have been developed to accurately detect IDH1 and IDH2 mutation in the DNA of tumor cells (Meyer et al., 2009), and these methods can determine IDH status in formalin-fixed, paraffinembedded tissues even in histologically normal tissue that contains little tumor material (Horbinski et al., 2009). Additionally, monoclonal antibodies have been developed to specifically stain tumors containing the IDH1 R132H protein (Capper et al., 2009; Kato et al.,

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2009), which could be put to use in typical diagnostic pathology laboratories.

Properties of Mutated Enzymes The frequency, specificity, and early timing of IDH mutations provide strong evidence for their importance in glioma tumorigenesis, and functional studies have begun to reveal the properties of the mutated enzymes. The IDH1 and IDH2 mutations observed in cancer diminish the normal isocitrate dehydrogenase activity of the enzymes, shown on the left side of Fig. 7.2, as demonstrated by in vitro assays of either recombinant mutant enzymes (Zhao et al., 2009) or lysates of cells overexpressing the mutant enzymes (Yan et al., 2009). Additionally, recombinant IDH1 R132H can bind to wild-type IDH1, and the resulting heterodimers have diminished isocitrate dehydrogenase activity (Zhao et al., 2009). Since most IDH mutations are heterozygous with a wild-type allele, this has led to speculation that the IDH1 mutants function in cancer to dominant negatively inactivate wild-type IDH1. However, the formation of wild-type:mutant heterodimers has not been demonstrated in vivo, and overexpression of IDH1 R132 and IDH2 R172 mutants has not been shown to lower cellular isocitrate dehydrogenase activity in glioma cell lines, as would be expected for a dominant negative enzyme. Additionally, Park and colleagues have demonstrated that IDH1 and IDH2 protect of the cell from noxious insults (Kim et al., 2007; Park et al., 2008). It seems reasonable that one wild-type allele of either gene could continue to provide protective benefits to the cell when the other allele is mutated in cancer, but it seems unlikely that the major function for IDH mutations cancer would be to inactivate these protective enzymes. The specificity of the IDH mutations for “hotspot” codons is reminiscent of oncogenes such as KRAS and PIK3CA, which are also activated by specific point mutations. This resemblance suggests that IDH mutations also confer a gain of function. Consistent with this, IDH1 R132 and IDH2 R172 mutants gain the neomorphic activity to reduce α-ketoglutarate to (R)-2-hydroxyglutarate as shown on the right side of Fig. 7.2 (Dang et al., 2009;

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Fig. 7.2 Wild-type IDH1 and IDH2 catalyze the oxidative decarboxylation of isocitrate to form α-ketoglutarate, but IDH1 R132 and IDH2 R172 mutants catalyze the reduction of α-ketoglutarate to (R)-2-hydroxyglutarate. Wild-type IDH1 and IDH2 normally catalyze a two step reaction, starting with isocitrate on the upper left and resulting in α-ketoglutarate on the bottom center. First, they catalyze the NADP+ -dependent oxidation of the α-hydroxyl of isocitrate (blue) to produce an intermediate, oxalosuccinate. Then, they catalyze the decarboxylation of the β-carboxyl (green) of this intermediate to produce α-ketoglutarate and CO2 . This reaction is reversible: under appropriate conditions, the enzymes can catalyze the addition of CO2 to α-ketoglutarate to form oxalosuccinate. Then, they catalyze the NADPH-dependent reduction of the α-ketone to a hydroxyl to form isocitrate. R132 of IDH1 is analogous to R172

of IDH2. In each enzyme, this arginine residue forms hydrogen bonds with the β-carboxyl of isocitrate. This presumably coordinates removal of the β-carboxyl to release CO2 in the forward reaction. Conversely, the arginine coordinates the addition of CO2 to form the β-carboxyl in the reverse reaction. As expected for enzymes with mutations in a residue that aids in substrate binding and catalysis, IDH1 R132 and IDH2 R172 mutants are impaired in their normal ability to bind isocitrate or convert it to α-ketoglutarate. However, the mutated enzymes still bind α-ketoglutarate. Nevertheless, the enzymes do not coordinate the addition of CO2 to α-ketoglutarate followed by reduction of the α-ketone as normally occurs in the reverse reaction. Instead, only reduction of the α-ketone occurs. This results in conversion of α-ketoglutarate and NADPH to (R)-2-hydroxyglutarate and NADP+ as shown on the right

Gross et al., 2010; Ward et al., 2010). IDH1mutated gliomas contain a 100-fold elevated concentration of (R)-2-hydroxyglutarate (also known as R(-)-2-hydroxyglutarate or D-2-hydroxyglutarate) compared to IDH1-wild-type gliomas (Dang et al., 2009). This neomorphic activity apparently leads to the accumulation of (R)-2-hydroxyglutarate observed in the tumors, and also may alter the cellular NADPH/NADP+ ratio and cause flux away from αketoglutarate. One or more of these metabolic changes could confer a selective advantage to glioma cells and promote glioma formation through a yet-unknown mechanism. If the presence of mutated IDH1 or IDH2 is essential for the malignant properties of glioma cells,

it may be possible to design molecular therapies that target these tumor-specific mutants. Further research will be needed to determine the downstream effects of the gain of function of the IDH mutations.

Mutation Types A spectrum of different mutated codons has been observed at IDH1 R132 and IDH2 R172 in glioma. IDH1 R132H is by far the most common IDH mutation in gliomas, accounting for 88.2–92.8% of IDH1-mutated tumors, followed by R132C (3.4–4.6%), R132S (0.8–2.5%), R132G (0.6–3.9%),

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R132L (0–4.5%), and R132V (one case) (Balss et al., 2008; Hartmann et al., 2009; Ichimura et al., 2009; Watanabe et al., 2009a; Yan et al., 2009). Only a handful of the rarer IDH2 mutations have been reported, with a total of 24 R172K, 9 R172M, 5 R172W, and 2 R172G cases found in two large studies (Hartmann et al., 2009; Yan et al., 2009). All of the observed mutations result from a single base pair change in the R132 or R172 codon, except for the single observed case of IDH1 R132V, which results from alteration of two base pairs (Balss et al., 2008). Different mutations have a range of impact on enzyme function. For instance, IDH1 R132H has a greater loss of isocitrate dehydrogenase activity and more rapidly reduces α-ketoglutarate than IDH1 R132C, R132L, or R132S (Dang et al., 2009). If these changes in activity provide a selective advantage to a glioma or pre-glioma cell, then perhaps the greater potency for the R132H mutation explains its higher observed frequency in gliomas compared to the other mutations. Interestingly, IDH1 R132C is observed more frequently than IDH1 R132H in non-glioma cancers, including acute myelogenous leukemia and case reports of prostate cancer, colorectal cancer, and acute lymphoblastic leukemia, B-type (Sjoblom et al., 2006; Kang et al., 2009; Mardis et al., 2009). Additionally, all five cases of IDH1 mutations reported in glioma patients with Li-Fraumeni syndrome were R132C mutations (Watanabe et al., 2009b). Also, patients with IDH1 R132C and R132S mutations were significantly younger than those with R132H mutations in one large study (Hartmann et al., 2009). Differences have also been noted between patients with IDH1- and IDH2-mutated tumors. One large study noted a trend for IDH2 mutations to occur more frequently in grade III tumors compared to grade II tumors, and that IDH2 mutations were significantly more frequent in oligodendroglial tumors compared to astrocytic tumors (Hartmann et al., 2009). Though IDH1 and IDH2 mutations are inversely associated, several cases of grade III gliomas contained both alterations (Hartmann et al., 2009). Interestingly, acute myeloid leukemias exhibit a strikingly different distribution of IDH1 and IDH2 mutations than gliomas. Acute myeloid leukemias contain IDH2 mutations slightly more frequently than IDH1 mutations (Ward et al., 2010). Furthermore, almost half of IDH1 and IDH2 the mutations in acute myeloid leukemias occur at IDH2 R140 which also apparently

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confers (R)-2-hydroxyglutarate production to the enzyme (Ward et al., 2010). Of note, this site that has never been found to be mutated in gliomas (Yan et al., 2009). The biological explanation for the distribution of the different IDH mutations in different cancers remains to be elucidated.

Conclusion IDH1 and IDH2 mutations occur frequently in grades II and III gliomas and secondary glioblastomas. These changes associate with other genetic alterations such as TP53 mutation and 1p/19q loss, as well as a younger patient age and longer patient survival among most tumor types. PCR and immunohistochemical techniques can determine mutation status in surgical tumor samples and hold promise as powerful diagnostic and prognostic tests to aid in the clinical management of this difficult set of diseases. The mutations likely occur early in tumorigenesis and their genetic profile suggests that they act as oncogenes. The mutated enzymes have greatly reduced normal enzymatic activity but gains the novel, possibly oncogenic, ability to produce (R)-2-hydroxyglutarate. The frequency and specificity of the IDH1 and IDH2 mutations in glioma suggests that these alterations are central to glioma formation and/or maintenance, but further study is needed to understand the mechanism by which they interact with glioma biology.

References Balss J, Meyer J, Mueller W, Korshunov A, Hartmann C, von Deimling A (2008) Analysis of the IDH1 codon 132 mutation in brain tumors. Acta Neuropathol 116:597–602 Bleeker FE, Lamba S, Leenstra S, Troost D, Hulsebos T, Vandertop WP, Frattini M, Molinari F, Knowles M, Cerrato A, Rodolfo M, Scarpa A, Felicioni L, Buttitta F, Malatesta S, Marchetti A, Bardelli A (2009) IDH1 mutations at residue p.R132 (IDH1(R132)) occur frequently in high-grade gliomas but not in other solid tumors. Hum Mutat 30:7–11 Capper D, Zentgraf H, Balss J, Hartmann C, von Deimling A (2009) Monoclonal antibody specific for IDH1 R132H mutation. Acta Neuropathol 118:599–601 Dang L, White DW, Gross S, Bennett BD, Bittinger MA, Driggers EM, Fantin VR, Jang HG, Jin S, Keenan MC, Marks KM, Prins RM, Ward PS, Yen KE, Liau LM, Rabinowitz JD, Cantley LC, Thompson CB, Vander Heiden

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MG, Su SM (2009) Cancer-associated IDH1 mutations produce 2-hydroxyglutarate. Nature 462:739–744 De Carli E, Wang X, Puget S (2009) IDH1 and IDH2 mutations in gliomas. N Engl J Med 360:2248 author reply 2249 Dubbink HJ, Taal W, van Marion R, Kros JM, van Heuvel I, Bromberg JE, Zonnenberg BA, Zonnenberg CB, Postma TJ, Gijtenbeek JM, Boogerd W, Groenendijk FH, Smitt PA, Dinjens WN, van den Bent MJ (2009) IDH1 mutations in low-grade astrocytomas predict survival but not response to temozolomide. Neurology 73:1792–1795 Gross S, Cairns RA, Minden MD, Driggers EM, Bittinger MA, Jang HG, Sasaki M, Jin S, Schenkein DP, Su SM, Dang L, Fantin VR, Mak TW (2010) Cancer-associated metabolite 2-hydroxyglutarate accumulates in acute myelogenous leukemia with isocitrate dehydrogenase 1 and 2 mutations. J Exp Med 207:339–344 Hartmann C, Meyer J, Balss J, Capper D, Mueller W, Christians A, Felsberg J, Wolter M, Mawrin C, Wick W, Weller M, Herold-Mende C, Unterberg A, Jeuken JW, Wesseling P, Reifenberger G, von Deimling A (2009) Type and frequency of IDH1 and IDH2 mutations are related to astrocytic and oligodendroglial differentiation and age: a study of 1,010 diffuse gliomas. Acta Neuropathol 118:469–474 Horbinski C, Kofler J, Kelly LM, Murdoch GH, Nikiforova MN (2009) Diagnostic use of IDH1/2 mutation analysis in routine clinical testing of formalin-fixed, paraffin-embedded glioma tissues. J Neuropathol Exp Neurol 68:1319–1325 Ichimura K, Pearson DM, Kocialkowski S, Backlund LM, Chan R, Jones DT, Collins VP (2009) IDH1 mutations are present in the majority of common adult gliomas but are rare in primary glioblastomas. Neuro Oncol 11:341–347 Kang MR, Kim MS, Oh JE, Kim YR, Song SY, Seo SI, Lee JY, Yoo NJ, Lee SH (2009) Mutational analysis of IDH1 codon 132 in glioblastomas and other common cancers. Int J Cancer 125:353–355 Kato Y, Jin G, Kuan CT, McLendon RE, Yan H, Bigner DD (2009) A monoclonal antibody IMab-1 specifically recognizes IDH1R132H, the most common glioma-derived mutation. Biochem Biophys Res Commun 390:547–551 Kim SY, Lee SM, Tak JK, Choi KS, Kwon TK, Park JW (2007) Regulation of singlet oxygen-induced apoptosis by cytosolic NADP+-dependent isocitrate dehydrogenase. Mol Cell Biochem 302:27–34 Korshunov A, Meyer J, Capper D, Christians A, Remke M, Witt H, Pfister S, von Deimling A, Hartmann C (2009) Combined molecular analysis of BRAF and IDH1 distinguishes pilocytic astrocytoma from diffuse astrocytoma. Acta Neuropathol 118:401–405 Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, Burger PC, Jouvet A, Scheithauer BW, Kleihues P (2007) The 2007 WHO classification of tumours of the central nervous system. Acta Neuropathol 114:97–109 Mardis ER, Ding L, Dooling DJ, Larson DE, McLellan MD, Chen K, Koboldt DC, Fulton RS, Delehaunty KD, McGrath SD et al. (2009) Recurring mutations found by sequencing an acute myeloid leukemia genome. N Engl J Med 361:1058–1066 Meyer J, Pusch S, Balss J, Capper D, Mueller W, Christians A, Hartmann C, von Deimling A (2010) PCR- and Restriction Endonuclease-Based Detection of IDH1 Mutations. Brain Pathol 20:298–300

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Nobusawa S, Watanabe T, Kleihues P, Ohgaki H (2009) IDH1 mutations as molecular signature and predictive factor of secondary glioblastomas. Clin Cancer Res 15:6002–6007 Noushmehr H, Weisenberger DJ, Diefes K, Phillips HS, Pujara K, Berman BP, Pan F, Pelloski CE, Sulman EP, Bhat KP, Verhaak RG, Hoadley KA, Hayes DN, Perou CM, Schmidt HK, Ding L, Wilson RK, Van Den Berg D, Shen H, Bengtsson H, Neuvial P, Cope LM, Buckley J, Herman JG, Baylin SB, Laird PW, Aldape K (2010) Identification of a CpG island methylator phenotype that defines a distinct subgroup of glioma. Cancer Cell 17:510–522 Park SY, Lee SM, Shin SW, Park JW (2008) Inactivation of mitochondrial NADP+-dependent isocitrate dehydrogenase by hypochlorous acid. Free Radic Res 42:467–473 Parsons DW, Jones S, Zhang X, Lin JC, Leary RJ, Angenendt P, Mankoo P, Carter H, Siu IM, Gallia GL et al. (2008) An integrated genomic analysis of human glioblastoma multiforme. Science 321:1807–1812 Phillips HS, Kharbanda S, Chen R, Forrest WF, Soriano RH, Wu TD, Misra A, Nigro JM, Colman H, Soroceanu L, Williams PM, Modrusan Z, Feuerstein BG, Aldape K (2006) Molecular subclasses of high-grade glioma predict prognosis, delineate a pattern of disease progression, and resemble stages in neurogenesis. Cancer Cell 9:157–173 Reitman ZJ, Olby NJ, Mariani CL, Thomas R, Breen M, Bigner DD, McLendon RE, Yan H (2010) IDH1 and IDH2 hotspot mutations are not found in canine glioma. Int J Cancer 127(1):245–246 Reitman ZJ, Yan H (2010) Isocitrate dehydrogenase 1 and 2 mutations in cancer: alterations at a crossroads of cellular metabolism. J Natl Cancer Inst 102:932–941 Sanson M, Marie Y, Paris S, Idbaih A, Laffaire J, Ducray F, El Hallani S, Boisselier B, Mokhtari K, Hoang-Xuan K, Delattre JY (2009) Isocitrate dehydrogenase 1 codon 132 mutation is an important prognostic biomarker in gliomas. J Clin Oncol 27:4150–4154 Sjoblom T, Jones S, Wood LD, Parsons DW, Lin J, Barber TD, Mandelker D, Leary RJ, Ptak J, Silliman N, Szabo S, Buckhaults P, Farrell C, Meeh P, Markowitz SD, Willis J, Dawson D, Willson JK, Gazdar AF, Hartigan J, Wu L, Liu C, Parmigiani G, Park BH, Bachman KE, Papadopoulos N, Vogelstein B, Kinzler KW, Velculescu VE (2006) The consensus coding sequences of human breast and colorectal cancers. Science 314:268–274 Sonoda Y, Kumabe T, Nakamura T, Saito R, Kanamori M, Yamashita Y, Suzuki H, Tominaga T (2009) Analysis of IDH1 and IDH2 mutations in Japanese glioma patients. Cancer Sci 100:1996–1998 Verhaak RG, Hoadley KA, Purdom E, Wang V, Qi Y, Wilkerson MD, Miller CR, Ding L, Golub T, Mesirov JP et al (2010) Integrated genomic analysis identifies clinically relevant subtypes of glioblastoma characterized by abnormalities in PDGFRA, IDH1, EGFR, and NF1. Cancer Cell 17: 98–110 Ward PS, Patel J, Wise DR, Abdel-Wahab O, Bennett BD, Coller HA, Cross JR, Fantin VR, Hedvat CV, Perl AE, Rabinowitz JD, Carroll M, Su SM, Sharp KA, Levine RL, Thompson CB (2010) The common feature of leukemia-associated IDH1 and IDH2 mutations is a neomorphic enzyme activity converting alpha-ketoglutarate to 2-hydroxyglutarate. Cancer Cell 17:225–234

62 Watanabe T, Nobusawa S, Kleihues P, Ohgaki H (2009a) IDH1 mutations are early events in the development of astrocytomas and oligodendrogliomas. Am J Pathol 174:1149–1153 Watanabe T, Vital A, Nobusawa S, Kleihues P, Ohgaki H (2009b) Selective acquisition of IDH1 R132C mutations in astrocytomas associated with Li-Fraumeni syndrome. Acta Neuropathol 117:653–656 Wick W, Hartmann C, Engel C, Stoffels M, Felsberg J, Stockhammer F, Sabel MC, Koeppen S, Ketter R, Meyermann R, Rapp M, Meisner C, Kortmann RD, Pietsch T, Wiestler OD, Ernemann U, Bamberg M, Reifenberger G, von Deimling A, Weller M (2009) NOA-04 randomized

Z.J. Reitman and H. Yan Phase III trial of sequential radiochemotherapy of anaplastic glioma with procarbazine, lomustine, and vincristine or temozolomide. J Clin Oncol 27:5874–5880 Yan H, Parsons DW, Jin G, McLendon R, Rasheed BA, Yuan W, Kos I, Batinic-Haberle I, Jones S, Riggins GJ, Friedman H, Friedman A, Reardon D, Herndon J, Kinzler KW, Velculescu VE, Vogelstein B, Bigner DD (2009) IDH1 and IDH2 mutations in gliomas. N Engl J Med 360:765–773 Zhao S, Lin Y, Xu W, Jiang W, Zha Z, Wang P, Yu W, Li Z, Gong L, Peng Y, Ding J, Lei Q, Guan KL, Xiong Y (2009) Gliomaderived mutations in IDH1 dominantly inhibit IDH1 catalytic activity and induce HIF-1alpha. Science 324:261–265

Chapter 8

Metabolic Differences in Different Regions of Glioma Samples Francisca M. Santandreu, Jordi Oliver, and Pilar Roca

Abstract Gliomas are a heterogeneous disease both under a clinical and a pathological point of view. The differential expression of genotypic and metabolic alterations presents a regional distribution within the tumor mass. Even the coexistence of different subpopulations of cancer cells, differing in their sensitivity to apoptosis, autophagy and chemotherapy, has been proved in gliomas. Metabolic alterations are important since they confer adaptive, proliferative, and survival advantages on glioma cells. Thereby, metabolic reprogramming provides substrates for biosynthetic pathway, induces apoptosis resistance. The heterogeneous distribution of oxygen within the tumor determines metabolic differences between regions. Glioma cells located at the periphery of the tumor have higher proliferative capacity, which is accompanied by a greater respiration and mitochondrial oxidative capacity compared to cells located at the center of the tumor; such differences could be related to differential degree of hypoxia or oxidative stress between regions of the tumor. Regional differences within glioma have diagnostic and therapeutic implications, and hinder the prediction of the tumor’s biologic aggressiveness and the patient’s response to standard treatment. Keywords Metabolism · Cancer · Glioma Antioxidant system · Oncogenes · Hypoxia

P. Roca () Department de Biologia Fonamental i Ciències de la Salut. Ed. Guillem Colom, Universitat de les Illes Balears, Carretera Valldemossa Km 7.5, Palma de Mallorca, 07122, Balearic Islands, Spain e-mail: [email protected]

·

Introduction Gliomas are primary tumors of the central nervous system. There are several classifications for gliomas according to cellular type, grade, and location. The World Health Organization subdivides astrocytomas in four grades (I–IV), according to the increasing malignancy determined by pathological evaluation of the tumor. Low-grade gliomas are localized tumors, welldifferentiated and portend a better prognosis for the patient. High-grade gliomas are anaplastic, and have a high growth and invasive capacity; grade IV astrocytomas or glioblastomas constitute the most common and agressive forms. Glioblastoma patients have a median survival expectancy of only 14 months on the current standard treatment of surgical resection to the extent feasible, followed by adjuvant radiotherapy plus temozolomide, given concomitantly with and after radiotherapy. Histological grade, tumor type, age, Karnofsky performance status, tumor location and the magnitude of surgical resection are prognostic factors for gliomas (Hentschel and Sawaya, 2003; Lamborn et al., 2004). Treatment for brain gliomas depends on the location, the cellular type and the grade of malignancy, and often, is a combined approach, using surgery, radiation therapy, and chemotherapy. Highgrade gliomas almost always grow back even after complete surgical excision due to their high tendency to infiltrate (Laerum et al., 1984; Kaba and Kyritsis, 1997). The recurrence of tumor growth, which is the major cause of mortality for patients with gliomas, has been recently associated to the existence of a heterogeneous population of cancer cells within the tumor. From a clinical point of view, gliomas are heterogeneous tumors. The heterogeneity also exists inside

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_8, © Springer Science+Business Media B.V. 2011

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the tumor mass since gliomas express metabolic and histological differences between individual regions. Metabolic alterations in gliomas have a great importance because they promote tumor’s biologic aggressiveness, stimulating cellular proliferation and invasion. In this sense, a better knowledge of the heterogeneous nature of gliomas and their metabolism will facilitate the development of new diagnostic and therapeutic strategies to fight against the disease, overcoming the important limitations of standard therapy. This chapter will describe the heterogeneous nature of glioma, pointing out the presence of regional differences. For their implications on tumor growth and maintenance, we will emphasize the main features of metabolic reprogramming in tumor cells and, in particular, we will describe some metabolic differences between individual regions within glioma tissue.

Human Gliomas: Tumors of Heterogeneous Nature Gliomas are a heterogeneous disease both under a clinical and a pathological point of view. Intratumoral heterogeneity could be defined as a genotypic and/or phenotypic variability within glioma, and it has been recognized in karyotypic and histological analyses, by a variable expression of proliferative markers, growth factors and their receptors, and intrinsic resistance to chemotherapy and radiation therapy (Coons and Johnson, 1993). The differential expression of these cellular features can be diffuse or present a regional distribution. Regional heterogeneity implies that individual cells tend to be similar to their immediate neighbors, whereas more distant cells exhibit different features. Histological analyses indicate that malignant gliomas contain tumor cells with different degrees of dedifferentiation, endothelial cells with variable morphology and blood vessels that contain leukocytes and erythrocytes. Regional differences in proliferative activity, histological features and genotypic alterations have been identified in human gliomas. However, intratumoral heterogeneity in ploidy is not arbitrary, Coons and Johnson described the clustering of regions with similar percentages of aneuploid cells, hypothesizing that glioma progression might be the result of local mutations and subsequent clonal

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expansion. Additionally, the degree of heterogeneity in proliferative markers as well as genotypic heterogeneity increases with the tumor histological grade; most importantly, the higher the intratumoral heterogeneity in these markers of malignancy, the higher the adverse impact in the usefulness of their analysis to predict survival of glioma patients (Coons and Johnson, 1993). Other studies using cell colonies and human paraffin-embedded sections suggest a heterogeneous spatial distribution of cancer cells inside the tumor mass, where the most proliferative cells are located at the periphery of the tumor (Bru et al., 2003). Similarly, magnetic resonance imaging studies evidence a structural heterogeneity within the tumor, where different areas can be distingished from the periphery, which is the most proliferative area of the tumor, to the center. This structural heterogeneity is also correlated with heterogeneity in vascularization (Le Duc et al., 1999). At an additional level of complexity, we must consider that different subpopulations of cancer cells coexist within the tumor mass. The presence of more than one subclone in the primary tumor has been related with tumor recurrence and intratumoral genotypic heterogeneity in gliomas. In relation to this, Ito and colleagues analyzed one case of glioblastoma with oligodendroglial components and determined using a primary cell culture the possible relationship between genetic modifications and chemosensitivity (Ito et al., 2007). While the primary tumor exhibited 1p/19q/10q losses, the recurrent glioblastoma only showed a loss of heterozygosity (LOH) on chromosome 10q. In that study, the chemosensitivity was related to cells with 1p/19q LOH, whereas cells exhibiting 10q LOH were more resistant to chemotherapeutic agents. Shapiro and Shapiro suggested that the karyotypic alterations are associated to cancer cell phenotype. Specifically that hyperdiploid cells, which are unstable in culture, tend to have short doubling times and are usually sensitive to anticancer drugs such as 1,3-bis(2-chloroethyl)1-nitrosourea (BCNU); whereas, cancer cells that are nearly diploid have a normal appearance, are stable in culture, grow more slowly and are more likely to be resistant to nitrosoureas; therefore, it was suggested that the latter population could include stem tumor cells which could be involved in the repopulation of tumor mass (Shapiro and Shapiro, 1985). More recently, the existence of a small fraction of cells, exhibiting features of primitive neural progenitor

8 Metabolic Differences in Different Regions of Glioma Samples

cells, with capacity to induce tumor formation, has been proved in gliomas. These quiescent cells with self-renewal capacity are known as cancer stem cells, which constitute a reservoir of self-sustaining cells with the ability to self-renew and to cause the heterogeneous lineages of cancer cells that comprise the tumor. In 2004, Singh and colleagues succesfully isolated cancer stem cells from different types of brain tumors. Stem cell population was found exclusively in the fraction of tumor cells expressing CD133. The injection of only one hundred CD133+ cells into the NOD-SCID mouse brain led to the growth of a tumor with identical histological features as those displayed by the parenteral tumor. Conversely, the fraction of CD133– tumor cells failed to form tumors, even when 1000-fold more CD133– cells were injected into the brains of the mice. It is important to consider that the existence of tumor cell subpopulations could provide an explanation to the high rate of refractory malignant glioma. In addition, conventional therapeutic approaches targeting the overall population of glioma cells may select the more resistant tumor cells owing to their idiosyncratic properties. In this sense, several studies have found that CD133+ population has an increased resistance to apoptosis (type I programmed cell death), and autophagy (type II programmed cell death) induced by the treatment with chemotherapeutic agents such as temozolomide (Fu et al., 2009). Additionally, gene expression studies in gliomas reveal that CD133+ tumor cells have an elevated expression of multi-drug resistance gene BCRP1, DNA repair genes such as O6-methylguanine-DNA methyltransferase (MGMT) and genes that inhibit apoptosis (Liu et al., 2006; Kang and Kang, 2007).

Interrelationship Between Energy Metabolism and Hallmarks of Cancer Tumors follow the same basic metabolic pathways as normal tissue, but changes in the tumor’s microenvironment and the tumor cells themselves can have important effects on their metabolism. There are two interrelated factors that crucially influence tumor metabolism: oxygen concentration and altered metabolic pathways/enzymes. Hypoxia, a common condition in tumors, determines the way in which cellular energy is produced since the metabolism of

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most energy substrates such as fatty acids, ketone bodies, amino acids (especially glutamine) and lactate is oxygen dependent (Bouzier et al., 1998). However, glucose can be used for energy production under both normoxic and hypoxic conditions in tumor cells. The presence of oxygen in gliomas, unlike in normal brain tissue, does not inhibit glycolysis (Warburg effect). Additionally, in the presence of oxygen, glioma cells preferentially metabolize the excess of glucose by glycolysis, which provokes a decrease in tumor respiration (Crabtree effect). In tumor cells, the metabolic alterations such as enhanced glycolysis, inhibited tricarboxylic acid (TCA) cycle and enhanced lactate production would result in a net loss of carbon that could have been used for anabolic reactions; however, cancer cells can avoid this by means of a much higher net consumption of glucose than normal cells.

Which Advantages Confer Metabolic Alterations to Tumor Cells? Metabolic alterations promote tumor growth for several reasons (Hsu and Sabatini, 2008; Kroemer and Pouyssegur, 2008). Firstly, conditions of fluctuating oxygen tension, due to inconstant hemodynamics of distant blood vessels, would be lethal for cells that rely on oxidative phosphorylation (OXPHOS) to generate ATP. Secondly, lactate produced as end product of aerobic glycolysis causes acidification of the extracellular milieu, supporting tumor invasion and the suppression of anticancer immune effectors. Thirdly, a major advantage to the cancer cell is that intermediates from the glycolytic pathway can be redirected toward anabolic reactions linked to cellular growth and proliferation. Figure 8.1 summarizes how glycolytic intermadiates are used for the synthesis of macromolecules in the cancer cell. For example, cancer cells enhance their biosynthetic capabilities by expressing a tumor-specific form of pyruvate kinase, M2-PK, which is less active in the conversion of phosphoenolpyruvate (PEP) to pyruvate and thus less efficient at ATP production but facilitates the incorporation of glucose carbons into lipids, amino acids and nucleic acids. In this sense, glucose 6-phosphate becomes available for the synthesis of glycogen and ribose 5-phosphate and dihydroxyacetone phosphate for the synthesis of triacylglycerides and phospholipids. Fourthly, tumor

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Fig. 8.1 Metabolic reprogramming constitutes a major advantage to cancer cells since intermediates from the glycolytic pathway can be redirected toward anabolic reactions linked to cellular growth and proliferation. NADPH, nicotinamide adenine dinucleotide phosphate; DHAP, dihydroxyacetone phosphate; PEP, phosphoenolpyruvate; OXPHOS, oxidative phosphorylation

cells can metabolize glucose through pentose phosphate pathway to generate nicotinamide adenine dinucleotide phosphate (NADPH), which ensures the antioxidant systems of cancer cells and facilitates their resistance to chemotherapeutic agents. In summary, actively dividing cells not only need great amounts of ATP but also macromolecules such as nucleotides, lipids and proteins, synthesis of which is facilitated by metabolic reprogramming. Additionally, recent studies have shown that several steps in lipid synthesis are required for and may even actively promote tumorigenesis. The molecular mechanisms that underlie metabolic reprogramming of cancer cells are complex. Tumor microenvironment favors a specific metabolic profile. Oxygen levels within a tumor fluctuate both temporally and spatially, and almost always are insufficient to satisfy tumor cell growth, leading to hypoxia and the stabilization of the hypoxia inducible factor 1 (HIF-1), which initiates a transcriptional program that provides multiple solutions to low oxygen availability by decreasing the dependence on aerobic respiration. In parallel, HIF-1 stimulates angiogenesis by upregulating several factors among which vascular endothelial growth factor (VEGF) is included. When hypoxic

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stress is detected by HIF-1 protein, cell metabolism is shifted toward glycolysis by the increased expression of inhibitors of mitochondrial metabolism, glucose transporters and glycolytic enzymes such as lactate dehydrogenase A (LDH-A). Lactate dehydrogenase is the enzyme that catalyzes the last step of glycolysis. This tetrameric protein is formed by subunits A and B, encoded by two different genes, which are differentially regulated. The inhibition of LDH-A prevents the Warburg effect and forces cancer cells to use oxidative phosphorylation to oxidize NADH and produce ATP (Fantin et al., 2006). In this way, LDH-A overexpression facilitates anaerobic metabolism of glucose and conversion of pyruvate to lactate. During tumorigenesis, a shift from A/B isoenzyme pattern to the LDH-A pattern has been suggested. Besides it has been described that tumor growth is attenuated while cells depend on respiration to obtain energy, suggesting that aerobic glycolysis might be essential for cancer progression. Metabolic alterations in the tumor are also promoted by the activation of oncogenes and the loss of tumor suppressors. The major oncogenic events (such as constitutive activation of growth factor pathways, constitutive activation of HIF-1, and inactivation of p53) could constitute the common cause of metabolic reprogramming and hallmarks of cancer such as autonomous growth, resistance against apoptosis, limitless replication, and angiogenesis (Kroemer and Pouyssegur, 2008). A diagram of the intimate relationship between tumor metabolism and the main events of cellular transformation is shown in Fig. 8.2. The activation of oncogenes such as Myc and Akt is involved in the “Warburg effect”, which inhibits oxidative phosphorylation, stimulates glycolysis and increases lactate production. On the other hand, the loss of the tumor suppressor protein p53 prevents SCO2 (synthesis of cytochrome c oxidase 2) gene expression, which is required for assembling cytochrome c oxidase, and thus, interferes in the mitochondrial respiratory chain’s function; it also prevents the activation of one of its cellular effectors, TIGAR (TP53-induced glycolysis and apoptosis regulator), which inhibits glycolysis by decreasing the levels of fructose-2,6-bis-phosphate. Regardless of whether the tumor microenvironment or oncogene activation plays a more important role in driving the development of a distinct cancer metabolism, it is likely that the resulting alterations confer adaptive, proliferative, and survival advantages

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Fig. 8.2 Tumor altered metabolism is caused by hypoxic stress but also by oncogene activation and tumor suppressor loss. In turn, metabolic reprogramming in cancer cells stimulates

tumor growth, apoptosis resistance, angiogenesis, avoidance of immunosurveillance, tissue invasion and metastasis. OXPHOS, oxidative phosphorylation; HIF-1, hypoxia inducible factor 1

on the cancer cell. Metabolic alterations provide substrates for biosynthetic pathways, induce apoptosis resistance, and stimulate signaling pathways involved in the pro-oncogenic process. Cancer cells are characterized for their ability to support metabolic alterations, chronic hypoxia as well as oxidative stress (Dang and Semenza, 1999). The mitochondrion of tumor cell constitutes an important point of control of cellular processes such as proliferation/apoptosis, oxidative metabolism and production of reactive oxygen species (ROS). The mitochondria of glioma cells exhibit important functional and ultrastructural alterations (Oudard et al., 1997), which could be related with the high dependence of glucose that glioma cells show. Mitochondrial DNA mutations can appear as a result of tumor progression, in turn, some of them could actively contribute to tumor progression due to concomitant stimulation of ROS production, tumor growth and aerobic glycolysis (Zhou et al., 2007). Primary mitochondrial dysfunctions have direct effects on tumor proliferation and metabolism; mutations of the mitochondrial matrix protein fumarate hydratase and the inner mitochondrial membrane protein succinate dehydrogenase could have causal implications in tumor development (Rustin, 2002). Besides, these mutations induce HIF-1 due to the accumulation of TCA cycle intermediates (fumarate or succinate), which competitively inhibit the alphaketoglutarate-dependent HIF-1α prolyl hydroxylase,

the enzyme that usally targets HIF-1α for oxygendependent destruction. Thus, total o partial defects in OXPHOS can lead to increased glycolysis and inherent resistance to apoptosis. Mitochondria are the main cellular source of ROS in tumor cells. Reactive oxygen species are released as a consequence of incomplete reduction of oxygen during respiration, and it is a price that a cell working in the presence of oxygen has to pay in favor of more efficient bioenergetics. Endogenous production of ROS contributes to intracellular signaling transduction (Benhar et al., 2002). It appears that signals linked to proliferation and survival need ROS for efficient transmission to the nucleus. In this way, ROS act as second messengers stimulating cellular proliferation through the activation of redox-sensitive signal transduction pathways; changes in redox state cause structural modifications and, in consequence, modulate the function of cytosolic enzymes and transcription factors that control, among others, the gene expression of proteins that participate in the protection against oxidative stress. Among the proteins and signaling pathways sensitive to redox changes, some signaling cascades play a crucial role in the regulation of gene expression and prevention of apoptosis such as Ras/Raf/MEK/ERK and PTEN/PI3K/Akt/mTOR/NF-kappaB, components of which are mutated or aberrantly expressed in glioblastomas. Oncogenes such as PI3K (phosphatidylinositol 3-kinase) and Akt have direct effects on cellular

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metabolic deregulation (Kroemer and Pouyssegur, 2008). Protein kinase B or Akt is a downstream effector of insulin signaling that stimulates the uptake and consumption of glucose through the glycolytic pathway. The activation of PI3K causes the transcriptional downregulation of carnitine palmitoyltransferase 1A (CPT1A), an enzyme located in the outer mitochondrial membrane that esterifies long-chain fatty acids to carnitine, thereby initiating the mitochondrial import of fatty acids and channeling them to betaoxidation. Therefore, PI3K activation inhibits betaoxidation and contributes to the increased dependency of cancer cells on glucose.

Metabolic Differences Between Regions of Human Glioma Malignant cells in a solid tumor are known to be exposed to a heterogeneous environment, with tumor regions characterized by a variable gradient of essential metabolites, nutrients, oxygen and growth factors. Hypoxia in tumors results from an imbalance between oxygen delivery and oxygen demand, and it is heterogeneous within the tumor mass. Oxygen consumption within tumors varies and depends largely on the number of proliferative cells, since these cells consume the most oxygen. A heterogeneous distribution of oxygen within the tumor can be determined by multiple factors including: variations in vascular density/orientation; altered erythrocyte flux and function; longitudinal oxygen gradients along vessels and radial perivascular oxygen gradients. Depending on the oxygenation status, different areas are established within a solid tumor. This oxygen gradient can influence the different metabolic behavior between regions. Essentially, lactate concentrations are higher in hypoxic areas in relation to the more oxygenated ones, thus supporting a switch from aerobic to anaerobic metabolism concomitant with hypoxia. Lactate tumor concentrations are important since this metabolite is a prognostic factor for several human cancers: high lactate levels increase the likelihood of metastases and have a negative impact on disease free survival and overall survival (Walenta et al., 2000). Hypoxia is specially relevant in human gliomas since it influences the tumor’s clinical behavior, increasing its biologic aggressiveness and decreasing its response to therapy (Evans et al., 2004).

F.M. Santandreu et al.

Hypoxic cells tend to be quiescent and chemotherapy agents are more effective in actively dividing cells. Hypoxia also decreases the response of tumors to radiotherapy. Concerning the intratumoral metabolic differences, it has been postulated that depending on the oxygenation status inside the tumor, a symbiotic relationship between two cancer cell populations could exist. In 2008, Sonveaux and colleagues described a “metabolic symbiosis” between hypoxic and aerobic cancer cells: cancer cells under hypoxic conditions convert glucose to lactate and extrude it, whereas aerobic cells take up lactate and utilize it for oxidative phosphorylation. In the case of limited glucose availability for the tumor, this symbiosis would facilitate a more efficient use of glucose. At the molecular level, it has been described that a key component of this symbiotic relationship could be the monocarboxylate transporter 1 (MCT1), this isoform is repressed by hypoxia and transports lactate into, rather than out of, cancer cells. Oxygen-dependent expression of MCT1 allow aerobic cancer cells to efficiently take up and, in concert with the oxygen-dependent expression of lactate dehydrogenase B (LDH-B), utilize lactate as an energy substrate, thereby freeing these cells from the need to take up large quantities of glucose. Interestingly, a similar hypothesis was proposed three years before by Griguer and colleagues (2005), on the basis of their observations of glycolytic metabolism in cultured glioma cells, suggesting that lactate produced by anaerobic glycolisis within the hypoxic region of glioma could also be used as an oxidative substrate in another region where oxygen supply was higher. These authors proved that glioma cells from different established cell lines showed a heterogeneous glucose metabolism. In this sense, there are highly glycolytic glioma cells whereas others preferentially use OXPHOS to obtain energy. The use of OXPHOS to obtain energy enhances cellular survival in the presence of low glucose concentrations, and this metabolic phenotype is related to the expression of lactate dehydrogenase A and B isoenzymes. In glioma cells, the ratio of LDH reductive/oxidative activity is about 7 for the A form and 1 for the B form, suggesting that lactate oxidation is more favorable for cells that express LDH-B. Whereas the expression of LDH-B isoform is independent of extracellular glucose concentration in glioma cells, the expression of LDH-A isoform is highly glucose-dependent. Thereby, LDH-A

8 Metabolic Differences in Different Regions of Glioma Samples

expression is lost in the presence of low glucose concentrations. Taking the aforementioned considerations into account, we characterized the possible differences in energy metabolism and ROS metabolism between the central and peripheral regions of human glioma (Santandreu et al., 2008). In our study, “central region” refers to the tumor core, where biopsy sampling is usually performed, whereas “peripheral region” refers to a region closer to surgical resection margins. Histological analyses showed that each region contained similar cellularity and number of tumor cells and, additionally, that the presence of residual nontumoral tissue was minimal and equal in both regions. Mitochondrial abundance between regions was similar, and the biochemical composition of isolated mitochondria was equal in terms of protein content and mitochondrial DNA copy number. Immunohistochemical analysis using Ki-67 proliferation marker revealed that the highest number of proliferative cells was located at the periphery of the glioma mass. In contrast with the apparent mitochondrial structural homogeneity between glioma regions, mitochondria from the periphery of the tumor showed a significantly higher resting respiration (nonphosphorylating conditions) than mitochondria from the center of the tumor. Both the drop in oxygen consumption and cytochrome c oxidase activity reflected a lower mitochondrial oxidative capacity in the center as opposed to the periphery of the tumor. It is important to mention that the decline in mitochondrial oxidative capacity in the center of the tumor was not caused by variations in mitochondrial abundance, in mitochondrial DNA copy number or in mitochondrial DNA lesions between regions. Therefore, metabolic differences between the center and the periphery of the tumor could be better explained by intratumoral variations in the degree of oxidative stress or hypoxia. In our study an important trend toward a greater lipid oxidation was identified in the center of the tumor, which was accompanied by a significant adaptive increase in mitochondrial enzymatic antioxidant systems (manganese superoxide dismutase or MnSOD) and tissular non-enzymatic antioxidant systems (an increase in the levels of reduced glutathione and increased relationship between reduced vs oxidized glutathione). During resting respiration the maximum hydrogen peroxide (H2 O2 ) production capacity tends to be higher in isolated mitochondria from the periphery of

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the tumor in relation to those isolated from the center of the tumor, and it is consistent with the notion of an increased mitochondrial functionality in the peripheral region of glioma. The capacity to produce ROS does not reflect the intracellular levels of ROS to which cells are exposed. In contrast, the observations of a trend toward a higher oxidative damage, greater respiratory dysfunction and the adaptive increase in antioxidant systems in the center of the tumor, appear to indicate a greater degree of chronic oxidative stress in this region. Considering that cancer cells located at the periphery of the tumor have higher proliferative activity, there is a higher energy demand in this region. In this situation, it is assumed that oxidative stress is low because cells display a “respiratory control” in which respiration is activated by ADP, and this stimulation stops after the conversion of ADP to ATP. In summary, recent studies support the concept of metabolic heterogeneity within glioma. This metabolic heterogeneity appears not to be random but to be ascribed to defined regions in the spatial structure of the tumor. In this sense, differences in mitochondrial oxidative capacity exist between the central and peripheral region of glioma, and are associated with a differential proliferative capacity; such metabolic differences might be caused by a heterogeneous distribution of oxygen within the tumor. Figure 8.3 represents a hypothetic diagram of metabolic differences between individual regions of glioma and the possible factors involved.

Possible Therapeutic and Diagnostic Implications In this chapter, we have tried to illustrate, in a simplified form, the relevance of cancer cell metabolism, not only for anabolic pathways associated with tumor growth but also for the existence of intimate links between the main oncogenes and metabolic reprogramming in tumors. It should be noted that the knowledge of the high glycolytic rate in tumor cells has led to the development of highly sensitive and specific diagnostic tests for cancer using the glucose analog 2-deoxy-2-[18 F]fluoro-D-glucose by positron emission tomography (FDG-PET). The diagnosis of gliomas using this imaging technique is based on the

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F.M. Santandreu et al.

Fig. 8.3 Possible metabolic differences between the central and peripheral region of human glioma. Mitochondria from the center of the tumor show a decline in respiration compared to those from the periphery of the tumor which it is probably caused by a higher degree of oxidative and hypoxic stress. Cancer cells located at the periphery of the tumor have higher proliferative

activity, which is coupled to a better mitochondrial oxidative capacity and better maintenance of redox homeostasis, compared with cancer cells located at the center of the tumor. In the graphic, the width of the arrow indicates the intensity of the process. OXPHOS, oxidative phosphorylation; ROS, reactive oxygen species; HIF-1, hypoxia inducible factor 1

preferential incorporation and storage of fludeoxyglucose F18 in tumor tissue compared to healthy tissue. Several studies performed with gliomas point out that differences in energy metabolism between normal cells and cancer cells, could be used as a biochemical basis to develop new therapeutic strategies selectively targeted against cancer cells (Seyfried and Mukherjee, 2005; Nebeling et al., 1995). The inhibition of enzymes and pathways that participate in metabolic reprogramming could have a stong effect on tumor growth, not only limiting bioenergetic flux and anabolic reactions in cancer cells but also reverting the neoplastic phenotype by inducing apoptosis or by blocking invasion and angiogenesis. In other words, interventions such as the inhibition of the PI3K/Akt/mTOR pathway (that would inhibit tumor growth), reestablishment of p53 function (that would restore apoptosis and senescence) or inhibition of transcription factor HIF-1 (that would inhibit angiogenesis), would also normalize metabolic functions in gliomas. Preclinical and clinical evaluation of metabolic inhibitors is still in its early stages, with the exception of mTOR antagonists. The mammalian target of rapamycin (mTOR) is a serine/threonine kinase that enhances cellular growth while inhibiting catabolic reactions mediated by autophagy (Faivre et al., 2006). Although the lack of enzymatic inhibitors with an acceptable degree of specificity is one of the main obstacles at this time, the discovery of selective metabolic inhibitors for anabolic and bioenergetic pathways in gliomas will provide, alone or in combination therapy, a completely new arsenal with which to combat central nervous system tumors.

Intratumoral heterogeneity in gliomas is also important because of its relevance in several clinical aspects, notably, histological grading, patient’s therapeutic response and refractory disease. Since variability in specific histological features (cellular density, necrosis, cytologic and nuclear pleomorfism, mitotic activity and microvascular proliferation) produces different histological grades between individual regions within glioma (Coons and Johnson, 1993), it is likely that errors in histological classification induced by regional heterogeneity could be minimized avoiding limited biopsies (localized sample site(s) and small sample size). Recent studies support the idea that malignant gliomas might be considered as “microecosystems” where tumor cells, microenvironment, vasculature and cancer stem cells are all interrelated. Thus, the most malignant cells could be selected under adverse conditions such as the pressure from the immune system, radiotherapy or chemotherapy. The increase in antioxidant defense systems in glioma cells has been associated with a higher resistance to radiotherapy and chemotherapy (Lee et al., 2004). If one accepts that metabolic differences and differences in antioxidant capacity do exist between individual regions of glioma, then it may follow that standard therapy could retard tumor growth in the short term but might facilitate recurrence in the long term by means of a selective pressure in vivo, which would promote the survival of the more resistant cellular population. In most clinical trials, in which monoclonal antibodies or low molecular-weight kinase inhibitors have been used to control the dysregulation in glioma growth,

8 Metabolic Differences in Different Regions of Glioma Samples

monotherapies have failed to show a survival benefit for patients. If we accept the coexistence of more than one subtype of cancer cells within glioma, it is likely that combination therapy might be the more efficient strategy to eliminate the distinct subpopulations contained in the tumor mass. Additionally, functional imaging techniques for diagnosis such as FDG-PET could help to assess in vivo metabolic heterogeneity in human gliomas (Goldman et al., 1997). In all likelyhood, a better understanding of some aspects of tumor cellular biology such as metabolic heterogeneity could clarify the problem of why glioma patients diagnosed with the same histological grade have different evolutions and respond differentially to standard treatment. Acknowledgements We gratefully acknowledge the support from the Conselleria d’Economia, Hisenda i Innovació del Govern de les Illes Balears and the Fondo de Investigaciones Sanitarias del Ministerio de Sanidad y Consumo del Gobierno Español (PI060266).

References Benhar M, Engelberg D, Levitzki A (2002) ROS, stress-activated kinases and stress signaling in cancer. EMBO Rep 3: 420–425 Bouzier AK, Voisin P, Goodwin R, Canioni P, Merle M (1998) Glucose and lactate metabolism in C6 glioma cells: evidence for the preferential utilization of lactate for cell oxidative metabolism. Dev Neurosci 20:331–338 Bru A, Albertos S, Luis Subiza J, Garcia-Asenjo JL, Bru I (2003) The universal dynamics of tumor growth. Biophys J 85:2948–2961 Coons SW, Johnson PC (1993) Regional heterogeneity in the DNA content of human gliomas. Cancer 72:3052–3060 Dang CV, Semenza GL (1999) Oncogenic alterations of metabolism. Trends Biochem Sci 24:68–72 Evans SM, Judy KD, Dunphy I, Jenkins WT, Hwang WT, Nelson PT, Lustig RA, Jenkins K, Magarelli DP, Hahn SM, Collins RA, Grady MS, Koch CJ (2004) Hypoxia is important in the biology and aggression of human glial brain tumors. Clin Cancer Res 10:8177–8184 Faivre S, Kroemer G, Raymond E (2006) Current development of mTOR inhibitors as anticancer agents. Nat Rev Drug Discov 5:671–688 Fantin VR, St-Pierre J, Leder P (2006) Attenuation of LDH-A expression uncovers a link between glycolysis, mitochondrial physiology, and tumor maintenance. Cancer Cell 9:425–434 Fu J, Liu ZG, Liu XM, Chen FR, Shi HL, Pangjesse CS, Ng HK, Chen ZP (2009) Glioblastoma stem cells resistant to temozolomide-induced autophagy. Chin Med J 122: 1255–1259

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Goldman S, Levivier M, Pirotte B, Brucher JM, Wikler D, Damhaut P, Dethy S, Brotchi J, Hildebrand J (1997) Regional methionine and glucose uptake in high-grade gliomas: a comparative study on PET-guided stereotactic biopsy. J Nucl Med 38:1459–1462 Griguer CE, Oliva CR, Gillespie GY (2005) Glucose metabolism heterogeneity in human and mouse malignant glioma cell lines. J Neurooncol 74:123–133 Hentschel SJ, Sawaya R (2003) Optimizing outcomes with maximal surgical resection of malignant gliomas. Cancer Control 10(2):109–114 Hsu PP, Sabatini DM (2008) Cancer cell metabolism: warburg and beyond. Cell 134:703–707 Ito M, Wakabayashi T, Natsume A, Hatano H, Fujii M, Yoshida J (2007) Genetically heterogeneous glioblastoma recurring with disappearance of 1p/19q losses: case report. Neurosurgery 61:E168–E169 Kaba SE, Kyritsis AP (1997) Recognition and management of gliomas. Drugs 53:235–244 Kang MK, Kang SK (2007) Tumorigenesis of chemotherapeutic drug-resistant cancer stem-like cells in brain glioma. Stem Cells Dev 16:837–847 Kroemer G, Pouyssegur J (2008) Tumor cell metabolism: cancer’s Achilles’ heel. Cancer Cell 13:472–482 Laerum OD, Bjerkvig R, Steinsvag SK, de Ridder L (1984) Invasiveness of primary brain tumors. Cancer Metastasis Rev 3:223–236 Lamborn KR, Chang SM, Prados MD (2004) Prognostic factors for survival of patients with glioblastoma: recursive partitioning analysis. Neuro Oncol 6:227–235 Le Duc G, Peoc’h M, Remy C, Charpy O, Muller RN, Le Bas JF, Decorps M (1999) Use of T(2)-weighted susceptibility contrast MRI for mapping the blood volume in the gliomabearing rat brain. Magn Reson Med 42:754–761 Lee HC, Kim DW, Jung KY, Park IC, Park MJ, Kim MS, Woo SH, Rhee CH, Yoo H, Lee SH, Hong SI (2004) Increased expression of antioxidant enzymes in radioresistant variant from U251 human glioblastoma cell line. Int J Mol Med 13:883–887 Liu G, Yuan X, Zeng Z, Tunici P, Ng H, Abdulkadir IR, Lu L, Irvin D, Black KL, Yu JS (2006) Analysis of gene expression and chemoresistance of CD133+ cancer stem cells in glioblastoma. Mol Cancer 5:67 Nebeling LC, Miraldi F, Shurin SB, Lerner E (1995) Effects of a ketogenic diet on tumor metabolism and nutritional status in pediatric oncology patients: two case reports. J Am Coll Nutr 14:202–208 Oudard S, Boitier E, Miccoli L, Rousset S, Dutrillaux B, Poupon MF (1997) Gliomas are driven by glycolysis: putative roles of hexokinase, oxidative phosphorylation and mitochondrial ultrastructure. Anticancer Res 17:1903–1911 Rustin P (2002) Mitochondria, from cell death to proliferation. Nat Genet 30:352–353 Santandreu FM, Brell M, Gene AH, Guevara R, Oliver J, Couce ME, Roca P (2008) Differences in mitochondrial function and antioxidant systems between regions of human glioma. Cell Physiol Biochem 22:757–768 Seyfried TN, Mukherjee P (2005) Targeting energy metabolism in brain cancer: review and hypothesis. Nutr Metab 2:30 Shapiro JR, Shapiro WR (1985) The subpopulations and isolated cell types of freshly resected high grade human

72 gliomas: their influence on the tumor’s evolution in vivo and behavior and therapy in vitro. Cancer Metastasis Rev 4:107–124 Singh SK, Hawkins C, Clarke ID, Squire JA, Bayani J, Hide T, Henkelman RM, Cusimano MD, Dirks PB (2004) Identification of human brain tumour initiating cells. Nature 432:396–401 Sonveaux P, Vegran F, Schroeder T, Wergin MC, Verrax J, Rabbani ZN, De Saedeleer CJ, Kennedy KM, Diepart C, Jordan BF, Kelley MJ, Gallez B, Wahl ML, Feron O, Dewhirst MW (2008) Targeting lactate-fueled respiration selectively kills hypoxic tumor cells in mice. J Clin Invest 118:3930–3942

F.M. Santandreu et al. Walenta S, Wetterling M, Lehrke M, Schwickert G, Sundfor K, Rofstad EK, Mueller-Klieser W (2000) High lactate levels predict likelihood of metastases, tumor recurrence, and restricted patient survival in human cervical cancers. Cancer Res 60:916–921 Zhou S, Kachhap S, Sun W, Wu G, Chuang A, Poeta L, Grumbine L, Mithani SK, Chatterjee A, Koch W, Westra WH, Maitra A, Glazer C, Carducci M, Sidransky D, McFate T, Verma A, Califano JA (2007) Frequency and phenotypic implications of mitochondrial DNA mutations in human squamous cell cancers of the head and neck. Proc Natl Acad Sci USA 104:7540–7545

Chapter 9

Glioblastoma Patients: Role of Methylated MGMT Giulio Metro and Alessandra Fabi

Abstract The O6 -methylguanine-DNA methyltransferase (MGMT) protein is a DNA repair enzyme that antagonizes the anti-tumor effects of alkylating agents, particularly temozolomide. Consistent with this mechanism of action, MGMT silencing by gene promoter methylation has been shown to be both predictive and prognostic in clinical trials of newly diagnosed glioblastoma patients treated with temozolomide in combination with radiotherapy and as adjuvant treatment. However, assessment of methylation of the MGMT gene promoter still requires standardization and prospective validation in clinical trials in order to best define the role of this biomarker for individualization of treatment. Nevertheless, even patients with temozolomide-sensitive glioblastoma cannot avoid eventual recurrence. Moreover, the optimal treatment strategy for patients with tumors lacking methylation of the MGMT gene promoter has yet to be determined. Here, we discuss the predictive and prognostic value of MGMT silencing, focusing on the importance of standardizing MGMT assessment as a crucial prerequisite for achieving personalization of treatment according to MGMT status in the next future. Keywords Glioblastoma · MGMT · Methylation · Alkylating agents · Silencing · Pseudoprogression

Introduction The O6 -methylguanine-DNA methyltransferase (MGMT) protein is a DNA repair enzyme which is A. Fabi () Division of Medical Oncology, Regina Elena National Cancer Center Institute, 00144 Rome, Italy e-mail: [email protected]

ubiquitously expressed in normal tissues (Gerson, 2004). Its high conservation throughout evolution suggests that MGMT plays a crucial role in maintaining cell physiology and genome integrity (Gerson, 2004). Although the levels of MGMT expression may vary considerably among different organs, tumors usually exhibit higher levels of expression compared with their tissue of origin (Gerson, 2004). Importantly, MGMT has been implicated in resistance to anticancer therapy with alkylating agents, particularly temozolomide. In fact, MGMT acts by antagonizing temozolomide-induced DNA methylation at the O6 position of guanine by transferring the methyl group to the active site of the enzyme itself. If left unrepaired, O6 -methylguanine undergoes incorrect pairing with thymine instead of cytosine during DNA replication, eventually leading to cell death (Gerson, 2004). Consistent with this mechanism of action, low levels/loss of function of MGMT have been shown to be associated with increased sensitivity to temozolomide treatment in malignant gliomas (Chinot et al., 2007; Friedman et al., 1998; Hegi et al., 2004, 2005). Importantly, loss of function of MGMT in glioblastoma multiforme (GBM) can be attributed almost exclusively to hypermethylation of the MGMT gene promoter, a phenomenon known to determine epigenetic silencing of the MGMT corresponding protein (Weller et al., 2010). Although the enzyme activity of MGMT appears to be the most important mechanism underlying resistance to temozolomide and alkylating agents in general, other mechanisms may exist such as disturbances of the mismatch repair system and increased expression of the chromatinassociated gene poly(ADP-ribose) polymerase-1 (PARP-1), which is involved in nucleotide excision repair system (Curtin et al., 2004; Yip et al., 2009).

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_9, © Springer Science+Business Media B.V. 2011

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Assessing the Status of MGMT in Tumor Tissue

MGMT Methylation in Newly Diagnosed Glioblastoma: Predictive Role

The potential clinical utility of MGMT as a biomarker in malignant gliomas has led to an ongoing debate on how MGMT status should be assessed and which specific procedure is best suited for routine clinical applications. A test aimed at assessing MGMT status needs to be standardized and reproducible in different laboratories, and must have a clinically relevant cut-off point. This, in order to allow patient selection and individualize therapy. Immunohistochemistry (IHC) detects the levels of the MGMT protein in tumor tissue, while the enzymatic activity of MGMT can be measured by high-performance liquid chromatography (HPLC) (Weller et al., 2010). By contrast, epigenetic silencing of the MGMT gene by promoter methylation can be assessed using methylation-specific PCR (MSP) (Weller et al., 2010). The MSP assay can be performed on DNA extracted from paraffin-embedded tissue samples despite the fact that fixation may cause deterioration of the DNA so that the best results are usually obtained on frozen tissue. Currently, the gelbased MSP assay represents the most widely used technology and is the only test that has been shown to be both predictive and prognostic in clinical trials of GBM patients treated with temozolomide (Hegi et al., 2004, 2005; Stupp et al., 2009). Recently, a real-time PCR MSP assay has been developed for quantitative assessment of the MGMT methylation status (qMSP), proving more amenable to definition of technical cut-off and quality control compared with the qualitative gel-based MSP assay (Vlassenbroeck et al., 2008). Real-time PCR MSP assay is being prospectively validated in the phase III randomized CENTRIC trial (Clinicaltrials.gov NTC00689221) which investigates cilengitide, a new integrin inhibitor, in addition to temozolomide plus radiotherapy for patients with newly diagnosed GBM with methylation of the MGMT gene promoter (Stupp et al., 2010). Given the large variability of MGMT methylation (30–60%) reported in the literature for GBM (Weller et al., 2010), prospective validation of cut-offs for optimal MGMT assessment is crucial for future individualization of treatment according to MGMT methylation status.

The first observation on a potential predictive role of MGMT in malignant glioma patients was made more than 10 years ago (Belanich et al., 1996). Patients with low protein levels of MGMT as assessed by immunofluorescence microscopy showed greater benefit from carmustine (BCNU) compared with patients with high MGMT levels (Belanich et al., 1996). Similarly, low protein levels of MGMT as detected by IHC were found to be predictive of prolonged progression-free survival in GBM patients treated with first-line temozolomide (Friedman et al., 1998) as well as of increased survival in inoperable newly diagnosed GBM treated with neoadjuvant temozolomide (Chinot et al., 2007). Importantly, a correlation with survival was also demonstrated when malignant glioma patients harbouring methylation of the MGMT gene promoter were treated with nitrosoureas (Esteller et al., 2000) or temozolomide plus radiotherapy (Hegi et al., 2004), strongly suggesting that MGMT gene silencing through methylation of the MGMT gene promoter as assessed by gel-based MSP assay could provide both a predictive and prognostic biomarker for increased sensitivity to alkylating agent chemotherapy with or without radiotherapy. This was subsequently confirmed in the randomized European Organization for Research and Treatment of Cancer (EORTC) 26981-22981 – National Cancer Institute of Canada (NCIC) trial, where surgically treated patients for newly diagnosed GBM were randomized to radiotherapy or radiotherapy plus concomitant and adjuvant temozolomide (Stupp et al., 2005). In this trial, consistent with the idea that methylation could predict the benefits of alkylating agent chemotherapy, methylation of the MGMT gene promoter was found to be associated with a strikingly longer progressionfree survival in patients treated with temozolomide plus radiotherapy compared with methylated patients treated with radiotherapy alone (10.3 months versus 5.9 months, respectively, P = 0.001) (Hegi et al., 2005). By contrast, in unmethylated patients only a slight trend was observed towards longer progressionfree survival with temozolomide plus radiotherapy versus radiotherapy alone (5.3 months versus 4.4 months,

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Glioblastoma Patients: Role of Methylated MGMT

respectively, P = 0.02), suggesting little or no benefit from the addition of temozolomide to radiotherapy in the unmethylated group (Hegi et al., 2005). The modest effect of temozolomide in patients lacking methylation of the MGMT gene promoter has raised an ongoing discussion as to whether assessment of the MGMT status should be made mandatory, and whether temozolomide should be avoided in patients with tumors lacking methylation of the MGMT gene promoter. To this regard, it is important to note that the qualitative gel-based MSP assay used in the EORTC-NCIC trial divided patients into methylated and unmethylated (45% versus 55%, respectively) (Stupp et al., 2005). On the other hand, quantitative assays (e.g. qMSP) suggest the presence of a subgroup of patients with intermediate methylation who may still benefit from temozolomide, thus representing the “gray zone” in the test results. For this reason, at the present time MGMT testing should be considered more “informative” rather than “decision-making” in routine clinical practice, and all patients with newly diagnosed GBM should be treated with standard temozolomide plus radiotherapy followed by adjuvant temozolomide irrespective of the methylation status of the MGMT gene promoter.

MGMT Methylation in Newly Diagnosed Glioblastoma: Prognostic Role Besides being predictive of sensitivity to alkylating agent chemotherapy in newly diagnosed GBM, the methylation status of the MGMT gene promoter appears to be also a strong prognostic factor for outcome (Hegi et al., 2004, 2005; Stupp et al., 2009). In the EORTC-NCIC trial methylation of the MGMT gene promoter was found to be significantly associated with longer survival irrespective of treatment compared with absence of methylation (18.2 months versus 12.2 months, respectively, P = 0.001), which corresponds to a risk reduction of 55% (hazard ratio for death = 0.45; 95% confidence interval, 0.32–0.61). In an updated analysis, the 2 and 5 year survival rates in patients with methylated MGMT were 49 and 14%, respectively, while the corresponding figures for

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methylated patients treated initially with radiotherapy alone were 24 and 5%. On the other hand, patients with an unmethylated MGMT promoter treated with temozolomide plus radiotherapy had a 2 and 5 year survival of 15 and 8%, respectively, compared with 2 and 0% of the unmethylated patients who received radiotherapy alone (Stupp et al., 2009). The small improvement in survival observed in unmethylated with the addition of temozolomide to radiotherapy could be attributed to the somewhat arbritary separation of patients into methylated and unmethylated (the so-called “gray zone”) as well as to other situations such as differences in post-progression therapy and individual variability due to other unknown prognostic factors. Recently, the prognostic relevance of methylation of the MGMT gene promoter has been confirmed in elderly GBM patients treated with concomitant and adjuvant temozolomide (Brandes et al., 2009). In addition, the observation that 74% of patients with GBM who survive longer than 5 years have MGMT promoter methylation, as opposed to less than 50% in an unselected population of GBM patients, underlines again the prognostic value of MGMT methylation (Krex et al., 2007). Nevertheless, long-term survival can be observed even in the absence of methylation of the MGMT gene promoter, indicating that MGMT is only one aspect of a more complex biological system (Krex et al., 2007).

The Informative Role of MGMT Methylation in Newly Diagnosed Glioblastoma Recent evidence suggests that the importance of knowing the methylation status of the MGMT gene promoter may go beyond its predictive and prognostic role. In fact, MGMT status could help predict the occurrence of a phenomenon known as “pseudoprogression” (Brandes et al., 2008). Pseudoprogression occurs in up to 30% of GBM patients treated with radiotherapy or concomitant temozolomide and radiotherapy, and consists of a radiologically-detected increase in lesion (with or without worsening of

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neurological symptoms) which subsequently subsides or even decreases in size without further treatment (Brandes et al., 2008; Taal et al., 2008). That is because pseudoprogression likely reflects a treatment-related local tissue reaction with inflammation, oedema and increased abnormal vessel permeability rather than true tumor progression. In a series of 103 glioblastoma patients treated with concomitant temozolomide and radiotherapy, lesion enlargement at MRI occurred in 48.5% of patients, of whom 64% were later on considered as having pseudoprogression (31% of the total) (Brandes et al., 2008). Importantly, in this study MGMT methylated tumors were found to be significantly associated with pseudoprogression, as within the group showing tumor enlargement 91% of the methylated patients had pseudoprogression compared with only 41% of the unmethylated GBMs (P = 0.0002) (Brandes et al., 2008). Considering the diagnosis of pseudoprogression and knowing that it occurs more often in MGMT methylated patients is crucial for planning optimal treatment strategies and designing clinical trials with novel agents.

MGMT Methylation for Predicting Clinical Outcome of Recurrent Glioblastoma In contrast to newly diagnosed GBM, the predictive value of MGMT methylation has been questioned in recurrent glioblastomas. Changes in MGMT methylations at recurrence occur in approximately 40% of patients and appear to be more frequent in patients with methylated tumors at first surgery (Brandes et al., 2010). Importantly, the absence of a strong predictive effect in recurrent GBM with the use of various schedules of administration of temozolomide (Brandes et al., 2006; Wick et al., 2007) might suggest the predominance of MGMT-independent mechanisms of resistance in the setting of recurrent disease. Escape from MGMT methylation-mediated sensitivity to the alkylating drug by selection for mismatch repair deficiency might be involved in this “loss” of prediction (Yip et al., 2009). Few studies investigated the relationship between MGMT methylation and sensitivity to drugs other than temozolomide in recurrent glioblastoma. In 19 patients with recurrent malignant gliomas a study showed that single-agent treatment with a nitrosurea drug,

G. Metro and A. Fabi

namely fotemustine, was associated with a considerable rate of disease control in patients with methylated MGMT (66.5%) compared with those with unmethylated MGMT (0%) (Fabi et al., 2009). Despite the low number of patients analyzed and the heterogeneity of patients histotypes included in this study, these data suggest that the presence of MGMT promoter methylation could predict response to fotemustine. However, assessment of MGMT status was performed at the time of initial surgery and no re-assessment of MGMT was conducted at the time of tumor recurrence. This might be important, since changes in the status of MGMT promoter methylation may occur after primary treatment for newly diagnosed glioblastoma (Brandes et al., 2010).

MGMT Methylation in Grade III Anaplastic Gliomas: Only Prognostic? The possible predictive value of methylation of the MGMT gene promoter in GBM patients has recently been challenged in grade III anaplastic gliomas. In fact, in the NOA-04 trial a significantly longer progressionfree survival and overall survival were shown for anaplastic glioma with MGMT methylation irrespective of initial treatment with radiotherapy or alkylatingbased chemotherapy with temozolomide or PCV (procarbazine, lomustine and vincristine) (Wick et al., 2009). Similarly, in the EORTC trial 26951 testing radiotherapy alone versus radiotherapy followed by adjuvant PCV, progression-free and overall survival were found to be significantly longer in patients whose tumors showed methylation of the MGMT gene promoter irrespective of the administration of chemotherapy (van den Bent et al., 2009). These findings suggest that methylation of the MGMT gene promoter is only prognostic but not predictive for chemotherapy in anaplastic gliomas, thus hypothesizing that other markers might be involved in sensitivity to chemotherapy in anaplastic gliomas. Also, these observation underline the importance of studying grade III and IV gliomas as two distinct entities.

MGMT-Depleting Strategies Alternative, more protracted dosing regimens of temozolomide might have a role in increasing sensitivity to

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Glioblastoma Patients: Role of Methylated MGMT

treatment through optimal depletion of MGMT activity (Weller et al., 2010). Indirect comparisons of treatment efficacy in recurrent disease suggest that the use doseintense schedules of temozolomide might be superior to conventional temozolomide 150–200 mg/m2 administered 5 days every 4 weeks (Brandes et al., 2006; Perry et al., 2010; Wick et al., 2007; Yung et al., 1999). However, whether this presumed superiority is to be attributed to enhanced MGMT depletion is not known. Unfortunately, in a recent trial randomizing chemonaïve patients with recurrent anaplastic astrocytoma or GBM to conventional temozolomide or continuous temozolomide 100 mg/m2 for 21 days every 4 weeks, an inferior outcome was observed for the continuous dose-intense schedule (Brada et al. 2010). At the present time, studies are underway to test dose-intense temozolomide as upfront adjuvant treatment for newly diagnosed GBM following concomitant temozolomide plus radiotherapy. Several MGMT inhibitors are under active investigation with the goal of modulating resistance to alkylating agent chemotherapy. O6-benzylguanine (O6BG) is a potent MGMT-depleting agent that when used in combination with temozolomide has the potential of restoring temozolomide sensitivity in recurrent malignant gliomas (Quinn et al., 2009). However, O6-BG depletes MGMT nonselectively, thus lowering MGMT levels in normal cells as well, therefore resulting in substantial toxicity, particularly myelosuppression. Similarly to O6-BG, Lomeguatrib, O4-benzylfolates and 2-amino-O4-benzylpteridine are other MGMTdepleting agents that are being investigated in combination with temozolomide or BCNU in recurrent disease progressive to alkylating agent chemotherapy.

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a prospective manner, and it is presently not recommended to use the MGMT promoter methylation assay to determine who should receive temozolomide and who should not. On the other hand, the knowledge so far gained about MGMT status should be exploited to design thoughtful clinical studies aimed at improving the overall outcome of glioblastoma patients, eventually leading to individualization of treatment. For instance, an interesting approach would be that of trying to overcome resistance to alkylating agent chemotherapy in patients with unmethylated MGMT gene promoter. On this basis, a recent trial has closed accrual after enrolling 1153 patients with the aim of showing whether temozolomide dose-intensification (temozolomide for 21 days every 4 weeks) after chemo-radiotherapy would improve outcome of patients with newly diagnosed glioblastoma (Clinicaltrials.gov NCT00304031). In this study, assessment of MGMT status by qMSP assay has been made mandatory for trial inclusion and used as a stratification factor for assigning patients to the control and experimental arms. Alternative strategies may also be useful in unmethylated patients for enhancing the antitumor effect of radiotherapy during the concomitant phase of treatment (Metro et al., 2010). To this regard, given the synergistic activity shown by enzastaurin, a protein kinase C-beta inhibitor, in conjunction with radiotherapy (Tabatai et al., 2007), a phase II trial is evaluating enzastaurin given with radiotherapy and as adjuvant treatment in newly diagnosed glioblastoma patients without methylation of the MGMT gene promoter (Clinicaltrials.gov NCT00509821).

References Conclusions and Future Directions In patients with malignant gliomas several molecular markers other than MGMT may have clinical relevance, including overexpression of the epidermal growth factor receptor, presence of the epidermal growth factor receptor vIII mutation, loss or mutation of PTEN gene. However, MGMT methylation status seems to be the most valuable marker for prediction of outcome and prognosis of patients treated with alkylating agent chemotherapy. Nevertheless, to date no biomarker has been definitively validated in

Belanich M, Pastor M, Randall T, Guerra D, Kibitel J, Alas L, Li B, Citron M, Wasserman P, White A, Eyre H, Jaeckle K, Schulman S, Rector D, Prados M, Coons S, Shapiro W, Yarosh D (1996) Retrospective study of the correlation between the DNA repair protein alkyltransferase and survival of brain tumor patients treated with carmustine. Cancer Res 56:783–788 Brada M, Stenning S, Gabe R, Thompson LC, Levy D, Rampling R, Erridge S, Saran F, Gattamaneni R, Hopkins K, Beall S, Collins VP, Lee SM (2010) Temozolomide versus procarbazine, lomustine, and vincristine in recurrent high-grade glioma. J Clin Oncol 28:4601–4608 Brandes AA, Franceschi E, Tosoni A, Bartolini S, Bacci A, Agati R, Ghimenton C, Turazzi S, Talacchi A, Skrap M, Marucci G, Volpin L, Morandi L, Pizzolitto S, Gardiman M, Andreoli

78 A, Calbucci F, Ermani M (2010) O(6)-methylguanine DNAmethyltransferase methylation status can change between first surgery for newly diagnosed glioblastoma and second surgery for recurrence: clinical implications. Neuro Oncol 12:283–288 Brandes AA, Franceschi E, Tosoni A, Benevento F, Scopece L, Mazzocchi V, Bacci A, Agati R, Calbucci F, Ermani M (2009) Temozolomide concomitant and adjuvant to radiotherapy in elderly patients with glioblastoma: correlation with MGMT promoter methylation status. Cancer 115:3512– 3518 Brandes AA, Franceschi E, Tosoni A, Blatt V, Pession A, Tallini G, Bertorelle R, Bartolini S, Calbucci F, Andreoli A, Frezza G, Leonardi M, Spagnolli F, Ermani M (2008) MGMT promoter methylation status can predict the incidence and outcome of pseudoprogression after concomitant radiochemotherapy in newly diagnosed glioblastoma patients. J Clin Oncol 26:2192–2197 Brandes AA, Tosoni A, Cavallo G, Bertorelle R, Gioia V, Franceschi E, Biscuola M, Blatt V, Crinò L, Ermani M (2006) Temozolomide 3 weeks on and 1 week off as firstline therapy for recurrent glioblastoma: phase II study from gruppo italiano cooperativo di neuro-oncologia (GICNO). Br J Cancer 95:1155–1160 Chinot OL, Barrié M, Fuentes S, Eudes N, Lancelot S, Metellus P, Muracciole X, Braguer D, Ouafik L, Martin PM, Dufour H, Figarella-Branger D (2007) Correlation between O6 -methylguanine-DNA methyltransferase and survival in inoperable newly diagnosed glioblastoma patients treated with neoadjuvant temozolomide. J Clin Oncol 25:1470– 1475 Curtin NJ, Wang LZ, Yiakouvaki A, Kyle S, Arris CA, CananKoch S, Webber SE, Durkacz BW, Calvert HA, Hostomsky Z, Newell DR (2004) Novel poly(ADP-ribose) polymerase-1 inhibitor, AG14361, restores sensitivity to temozolomide in mismatch repair-deficient cells. Clin Cancer Res 10:881–889 Esteller M, Garcia-Foncillas J, Andion E, Goodman SN, Hidalgo OF, Vanaclocha V, Baylin SB, Herman JG (2000) Inactivation of the DNA-repair gene MGMT and the clinical response of gliomas to alkylating agents. N Engl J Med 343:1350–1354 Fabi A, Metro G, Russillo M, Vidiri A, Carapella CM, Maschio M, Cognetti F, Jandolo B, Mirri MA, Sperduti I, Telera S, Carosi M, Pace A (2009) Treatment of recurrent malignant gliomas with fotemustine monotherapy: impact of dose and correlation with MGMT promoter methylation. BMC Cancer 9:101 Friedman HS, McLendon RE, Kerby T, Dugan M, Bigner SH, Henry AJ, Ashley DM, Krischer J, Lovell S, Rasheed K, Marchev F, Seman AJ, Cokgor I, Rich J, Stewart E, Colvin OM, Provenzale JM, Bigner DD, Haglund MM, Friedman AH, Modrich PL (1998) DNA mismatch repair and O6alkylguanine-DNA alkyltransferase analysis and response to temodal in newly diagnosed malignant glioma. J Clin Oncol 16:3851–3857 Gerson SL (2004) MGMT: its role in cancer aetiology and cancer therapeutics. Nat Rev Cancer 4:296–307 Hegi ME, Diserens AC, Godard S, Dietrich PY, Regli L, Ostermann S, Otten P, Van Melle G, de Tribolet N, Stupp R (2004) Clinical trial substantiates the predictive value of O-6-methylguanine-DNA methyltransferase

G. Metro and A. Fabi promoter methylation in glioblastoma patients treated with temozolomide. Clin Cancer Res 10:1871–1874 Hegi ME, Diserens AC, Gorlia T, Hamou MF, de Tribolet N, Weller M, Kros JM, Hainfellner JA, Mason W, Mariani L, Bromberg JE, Hau P, Mirimanoff RO, Cairncross JG, Janzer RC, Stupp R (2005) MGMT gene silencing and benefit from temozolomide in glioblastoma. N Engl J Med 352:997–1003 Krex D, Klink B, Hartmann C, von Deimling A, Pietsch T, Simon M, Sabel M, Steinbach JP, Heese O, Reifenberger G, Weller M, Schackert G (2007) German glioma network. Long-term survival with glioblastoma multiforme. Brain 130:2596–2606 Lee SM, Brada M, Stenning S, Thompson L, Gabe R (2008). for BR12 Collaborators; NCRI Brain Tumour Clinical Studies Group/GB. A randomised trial of procarbazine, CCNU and vincristine (PCV) vs temozolomide (5-day or 21-day schedule) for recurrent high grade glioma (MRC BR12, ISRCTN83176944). 33rd meeting of the European Society for Medical Oncology, Stockholm, Sweden, 12–16 September Metro G, Fabi A, Mirri MA, Vidiri A, Pace A, Carosi M, Russillo M, Maschio M, Giannarelli D, Pellegrini D, Pompili A, Cognetti F, Carapella CM (2010) Phase II study of fixed dose rate gemcitabine as radiosensitizer for newly diagnosed glioblastoma multiforme. Cancer Chemother Pharmacol 65:391–397 Perry JR, Bélanger K, Mason WP, Fulton D, Kavan P, Easaw J, Shields C, Kirby S, Macdonald DR, Eisenstat DD, Thiessen B, Forsyth P, Pouliot JF (2010) Phase II trial of continuous dose-intense temozolomide in recurrent malignant glioma: RESCUE study. J Clin Oncol 28:2051–2057 Quinn JA, Jiang SX, Reardon DA, Desjardins A, Vredenburgh JJ, Rich JN, Gururangan S, Friedman AH, Bigner DD, Sampson JH, McLendon RE, Herndon JE 2nd, Walker A, Friedman HS (2009) Phase II trial of temozolomide plus O6-benzylguanine in adults with recurrent, temozolomideresistant malignant glioma. J Clin Oncol 27:1262–1267 Stupp R, Hegi ME, Mason WP, van den Bent MJ, Taphoorn MJ, Janzer RC, Ludwin SK, Allgeier A, Fisher B, Belanger K, Hau P, Brandes AA, Gijtenbeek J, Marosi C, Vecht CJ, Mokhtari K, Wesseling P, Villa S, Eisenhauer E, Gorlia T, Weller M, Lacombe D, Cairncross JG, Mirimanoff RO (2009) European Organisation for Research and Treatment of Cancer Brain Tumour and Radiation Oncology Groups; National Cancer Institute of Canada Clinical Trials Group. Lancet Oncol 10:459–466 Stupp R, Hegi ME, Neyns B, Goldbrunner R, Schlegel U, Clement PM, Grabenbauer GG, Ochsenbein AF, Simon M, Dietrich PY, Pietsch T, Hicking C, Tonn JC, Diserens AC, Pica A, Hermisson M, Krueger S, Picard M, Weller M (2010) Phase I/IIa study of cilengitide and temozolomide with concomitant radiotherapy followed by cilengitide and temozolomide maintenance therapy in patients with newly diagnosed glioblastoma. J Clin Oncol 27:5881–5886 Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, Belanger K, Brandes AA, Marosi C, Bogdahn U, Curschmann J, Janzer RC, Ludwin SK, Gorlia T, Allgeier A, Lacombe D, Cairncross JG, Eisenhauer E, Mirimanoff RO (2005) European Organisation for Research and Treatment of Cancer Brain Tumor and Radiotherapy Groups; National Cancer Institute of Canada Clinical Trials

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Group. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352:987–996 Taal W, Brandsma D, de Bruin HG, Bromberg JE, SwaakKragten AT, Smitt PA, van Es CA, van den Bent MJ (2008) Incidence of early pseudo-progression in a cohort of malignant glioma patients treated with chemoirradiation with temozolomide. Cancer 113:405–410 Tabatabai G, Frank B, Wick A, Lemke D, von Kürthy G, Obermüller U, Heckl S, Christ G, Weller M, Wick W (2007) Synergistic antiglioma activity of radiotherapy and enzastaurin. Ann Neurol 61:153–161 van den Bent MJ, Dubbink HJ, Sanson M, van der Lee-Haarloo CR, Hegi M, Jeuken JW, Ibdaih A, Brandes AA, Taphoorn MJ, Frenay M, Lacombe D, Gorlia T, Dinjens WN, Kros JM (2009) MGMT promoter methylation is prognostic but not predictive for outcome to adjuvant PCV chemotherapy in anaplastic oligodendroglial tumors: a report from EORTC Brain Tumor Group Study 26951. J Clin Oncol 27:5881–5886 Vlassenbroeck I, Califice S, Diserens AC, Migliavacca E, Straub J, Di Stefano I, Moreau F, Hamou MF, Renard I, Delorenzi M, Flamion B, DiGuiseppi J, Bierau K, Hegi ME (2008) Validation of real-time methylation-specific PCR to determine O6 -methylguanine-DNA methyltransferase gene promoter methylation in glioma. J Mol Diagn 10:332–337 Weller M, Stupp R, Reifenberger G, Brandes AA, van den Bent MJ, Wick W, Hegi ME (2010) MGMT promoter methylation

79 in malignant gliomas: ready for personalized medicine? Nat Rev Neurol 6:39–51 Wick A, Felsberg J, Steinbach JP, Herrlinger U, Platten M, Blaschke B, Meyermann R, Reifenberger G, Weller M, Wick W (2007) Efficacy and tolerability of temozolomide in an alternating weekly regimen in patients with recurrent glioma. J Clin Oncol 25:3357–3361 Wick W, Hartmann C, Engel C, Stoffels M, Felsberg J, Stockhammer F, Sabel MC, Koeppen S, Ketter R, Meyermann R, Rapp M, Meisner C, Kortmann RD, Pietsch T, Wiestler OD, Ernemann U, Bamberg M, Reifenberger G, von Deimling A, Weller M (2009) NOA-04 randomized phase III trial of sequential radiochemotherapy of anaplastic glioma with procarbazine, lomustine, and vincristine or temozolomide. J Clin Oncol 27:5874–5880 Yip S, Miao J, Cahill DP, Iafrate AJ, Aldape K, Nutt CL, Louis DN (2009) MSH6 mutations arise in glioblastomas during temozolomide therapy and mediate temozolomide resistance. Clin Cancer Res 15:4622–4629 Yung WK, Prados MD, Yaya-Tur R, Rosenfeld SS, Brada M, Friedman HS, Albright R, Olson J, Chang SM, O’Neill AM, Friedman AH, Bruner J, Yue N, Dugan M, Zaknoen S, Levin VA (1999) Multicenter phase II trial of temozolomide in patients with anaplastic astrocytoma or anaplastic oligoastrocytoma at first relapse. Temodal Brain Tumor Group. J Clin Oncol 17:2762–2771

Chapter 10

Brain Tumor Angiogenesis and Glioma Grading: Role of Tumor Blood Volume and Permeability Estimates Using Perfusion CT Rajan Jain

Abstract Perfusion imaging of brain tumors has been done using various tracer and non-tracer modalities and can provide additional physiologic and hemodynamic information, which is not available with routine morphologic imaging. Tumor vascular perfusion parameters obtained using CT or MR perfusion have been used for tumor grading, prognosis and treatment response in addition to differentiating treatment/radiation effects from recurrent neoplasms. This chapter is an overview of utility of perfusion CT for assessment of brain tumors, description of the technique, its advantages and limitations. Keywords Perfusion CT · Glioma grading · Angiogenesis · Tumor blood volume · Permeability

Introduction Gliomas, the most common primary brain neoplasms in adults are very heterogeneous tumors. High-grade gliomas can be highly invasive and extremely vascular tumors. Two of the most important factors in determining malignancy of gliomas are their ability to infiltrate the brain parenchyma and to recruit or synthesize vascular networks for further growth i.e., neoangiogenesis (Folkman, 1992; Jain et al., 2002).

R. Jain () Division of Neuroradiology, Department of Radiology and Department of Neurosurgery, Henry Ford Health System, Detroit, MI 48202, USA e-mail: [email protected]

Malignant brain tumors are characterized by neovascularity and increased angiogenic activity with a higher proportion of immature and highly permeable vessels. Glioma grading is currently based on the histological assessment of the tumor, which is achieved by either brain biopsy or cytoreductive surgery; however, there are inherent limitations with these techniques and their interpretation (Law et al., 2008). In vivo perfusion imaging techniques provide additional information regarding tumor physiology and hemodynamics, which may help in better characterizing glioma and may also overcome some of the limitations of histopathologic grading and conventional morphologic imaging. Perfusion imaging has been used to assess tumor grade, prognosis, and recently to assess treatment response, which has caught more attention due to advent of newer therapeutic options including antiangiogenic agents. Traditionally, perfusion imaging of brain tumors has been done with magnetic resonance imaging (MRI), using various perfusion imaging techniques and estimating tumor blood volume, blood flow, and permeability (Roberts et al., 2000; Law et al., 2004, 2008). However, perfusion CT (PCT), which has also been used recently for glioma grading (Ellika et al., 2007; Jain et al., 2008), provides a linear relationship between tissue signal and tissue concentration of a contrast agent unlike perfusion MR and, hence, probably provides a more robust and less biased estimation of physiologic and hemodynamic parameters. In view of the wider availability, faster scan times, and low cost combined with its ease of quantification of various perfusion parameters as compared to MR perfusion, PCT is potentially well suited to study brain tumors and monitoring tumor response to antiangiogenic agents (Ellika et al., 2007; Jain et al., 2008).

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_10, © Springer Science+Business Media B.V. 2011

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In Vivo Perfusion Imaging Versus Histopathology The current standard for tumor grading is histopathologic assessment of tissue, which has inherent limitations such as sampling error, interobserver variation and wide variety of classification systems that are available, the most commonly of which used is the WHO grading system (Law et al., 2008). Most of the gliomas, especially high grade gliomas, show a high degree of regional heterogeneity within the tumor based on tumor cellularity, edema, and necrosis. Many of these factors are inherently dependent on the blood supply. Histopathological evaluation of tumor angiogenesis using various markers such as microvascular density (MVD), microvascular cellular proliferation (MVCP), and total vascular area (TVA) is also limited by this regional heterogeneity, and its confounding effect is worsened by its small size and a limited number of samples obtained with surgical biopsy. This can frequently result in inaccurate classification and grading of gliomas due to sampling errors. Hence, there is a need for noninvasive in vivo clinical imaging tools which can study perfusion in the entire tumor, can be used to assess much larger volumes than small biopsy samples, and probably guide biopsy and excision sites for better results. Brain tumor angiogenesis is a continuously evolving process which can also be affected by various treatment modalities. Hence, in vivo perfusion imaging that can be repeated, unlike invasive procedures such as surgical excision or biopsy, can help assess continued evolution of these tumors as well as treatment response. Another important limitation of histopathological grading system is that gliomas having similar grades respond differently to similar treatment regimens as has been noted with different molecular and genetic markers (Cairncross et al., 1998), suggesting that there is a role for other biomarkers such as perfusion parameters in predicting progression or survival apart from histopathological grading (Law et al., 2008).

Perfusion Parameters and Their Importance Dynamic contrast-enhanced imaging techniques using MRI or CT have been used to obtain measures of

R. Jain

tumor vascular physiology and hemodynamics. After the rapid administration of a contrast agent and the acquisition of serial images at short intervals (seconds), an analysis that uses a pharmacokinetic model of the time dependence of contrast can produce imaging biomarkers such as tumor blood volume, blood flow, vascular permeability, and size of extravascular extracellular space. Many of these parameters have been correlated with tumor grade, aggressiveness, and prognosis (Law et al., 2004, 2006, 2008; Jain et al., 2008).

Tumor Blood Volume Regional tumor blood volume measurements reflect an assessment of tumor vasculature and perfusion, and have been correlated with glioma grading as well as prognosis. Measurement of tumor blood volume is a good surrogate marker for MVD, a measure of angiogenesis and an important prognostic indicator (Leon et al., 1996; Li et al., 1994; Weidner, 1995) in many human cancers. The association between MVD and tumor aggressiveness can be explained by the following: (1) solid tumors are composed of two interdependent components which are the malignant cells and the stroma that they induce, and MVD could be a measure of the success that a tumor has in forming this stromal component; (2) endothelial cells in this stromal component stimulate the growth of tumor cells; thus, the more intratumoral vessels there are, the more endothelial cells and paracrine growth stimulation; (3) intratumoral MVD is a direct measure of the vascular window through which tumor cells pass to spread to distant sites (Weidner, 1995). Tumoral MVD, however, does not distinguish new blood vessels from the native ones, does not mark actively proliferating endothelial cells, and does not correlate with the degree of endothelial cell proliferation. However, these limitations do not seem to diminish the clinical value of this measure. Cha et al. (2003) showed a strong correlation of CBV (cerebral blood volume) measurements in mouse gliomas with MVD and suggested that rCBV (regional CBV) may be elevated due to increase in vessel size or total number of vessels or both. Aronen et al. (2000) also showed a strong correlation of CBV and tumor energy metabolism with MVD using MR perfusion and FDG-PET imaging, respectively.

10 Brain Tumor Angiogenesis and Glioma Grading

Tumor Vascular Permeability It is a fact that tumor blood vessels have defective and leaky endothelium. Hypoxia or hypoglycemia that occurs in rapidly growing tumors increases the expression of vascular endothelial growth factor (VEGF) which is not only a potent angiogenic factor, but also a potent permeability factor (Plate et al., 1992; Shweiki et al., 1992). VEGF leads to the development of neoangiogenic vessels which are immature, tortuous (Jain et al., 2002) and also have increased permeability to macromolecules due to large endothelial cell gaps, incomplete basement membrane, and absence of smooth muscles. These abnormal tumor vessels can be used as potential markers to assess the tumor grade. Thus, in vivo measurement of tumor vessel permeability is important for various reasons: (1) it can be used for grading of tumors because increased permeability is associated with immature blood vessels, which is seen with neoangiogenesis; (2) it can be used to study the response of tumors to various therapies especially antiangiogenic therapy (Bhujwalla et al., 2003; Raatschen et al., 2008). (3) understanding the concept of permeability can help in understanding the mechanism of entry of therapeutic agents into the central nervous system and; (4) development of methods to selectively alter the blood brain barrier (BBB) to enhance drug delivery (Provenzale et al., 2005).

In Vivo Blood Volume and Permeability Quantification: Imaging Techniques, Limitations and Controversies MR (Roberts et al., 2000; Cha et al., 2003; Law et al., 2004, 2008) and CT perfusion (Cenic et al., 2000; Purdie et al., 2001; Ellika et al., 2007; Jain et al., 2008) have been used for in vivo characterization of tumor angiogenesis in various animal and human studies. One of the major limitations of clinically used imaging techniques is low spatial resolution which limits assessment of the complex and heterogenous vascular microenvironment in detail (McDonald and Choyke, 2003; Vajkoczy and Menger, 2000). Another limitation is the current use of low molecular weight contrast agents for human subjects. Because permeability measurements depend on the leakage of particles from the

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blood to the interstitial space, it is hypothesized that low molecular weight contrast agents leak relatively easily from the blood into the interstitium. This might also lead to overestimation of the permeability which will be influenced by and will approximate tumor blood flow (de Lussanet et al., 2005). High molecular weight contrast agents leak from the vessels and move through the interstitium with relative difficulty and are flow independent. Thus, macromolecular permeability and vascular volumes may be best measured by high molecular weight contrast agents (de Lussanet et al., 2005). However, currently used CT or MRI contrast agents are of low molecular weight (∼0.5–0.9 kDa) which might limit the accurate differentiation of vascular permeability and blood volume (Choyke, 2005). Even though CT and MR contrast agents do not differ much in their molecular weight, different charges of nonionic CT contrast as compared to ionic MR contrast may also be responsible for the differences in permeability measured with these two modalities. Another controversial aspect of measuring permeability with various perfusion imaging techniques is the scanning time. Delayed permeability due to slow leakage of contrast from a leaky blood vessel may not be accurately measured with first pass of the contrast agent using a 45 or 60 s scanning time (Goh et al., 2005), and can be only measured with longer acquisition times; however, there is no real consensus regarding the optimal acquisition time. Jain et al. (2008) used PCT for tumor vascular permeability quantification and reported slightly higher permeability values than those reported in literature using other techniques, and this could be explained by the mathematical model. Longer acquisition time of 170 s could also explain the higher values that they obtained because the scanning sequence was optimized to include delayed permeability also as described above. Gliomas, particularly high-grade gliomas, can have extremely variable and heterogeneous blood flow due to the complex tumor vasculature which can influence permeability (McDonald and Choyke, 2003; Vajkoczy and Menger, 2000). Other factors which can also influence permeability include luminal surface area, interstitial, hydrostatic, and osmotic pressure across the endothelium. Slow blood flow or low osmotic gradients which can occur in the high-grade tumor with considerable vasogenic edema and also in the central parts of large tumors can lead to a larger component of delayed permeability, requiring longer acquisition times.

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Quantification of vessel permeability with various perfusion techniques requires two or more compartment pharmacokinetic models with an arterial input function, making these studies more complex than CBV estimation (Tofts et al., 1999), and is dependent on the imaging technique employed and the mathematical model that is used. Post gadolinium T1 weighted MRI gives a rough estimate of the disruption of BBB, and has been used in the past for quantitative estimation of permeability but dynamic imaging acquisition provides a better estimate of vascular permeability (Tofts et al., 1999). Dual echo gradient echo perfusion weighted imaging (Uematsu and Maeda, 2006) is based on a simple two compartment kinetic model (Boxerman et al., 2006), and has more recently been used to measure vascular permeability and to correctly estimate blood volume in brain tumors with deficient or absent BBB. There are several studies which have found a correlation between increased vascular permeability and higher tumor grade (Law et al., 2004; Johnson et al., 2004; Jain et al., 2008; Roberts et al., 2001). However, MR perfusion techniques have certain limitations because of the nonlinear relationship of the signal intensity with the contrast, both for dynamic contrast enhanced imaging with T1-weighting (Yankeelov et al., 2005), and for dynamic susceptibility contrast imaging with T2or T2∗ -weighting. In the latter case, when the contrast agent remains intravascular, the method is widely accepted as a relative estimate of CBF (cerebral blood flow) and CBV, although there is a possibility for artifacts because of difficulties in assessing the shape and timing of the arterial input function (Conturo et al., 2005). In the event that substantial leakage of a contrast agent from intra- to extra-vascular space takes place, a strong and competing T1 contrast effect is often noticed in the areas of pathology because of the necessity of short (∼1 s) repetition times needed to estimate CBF. As a first-order tactic to minimize the competing T1 contrast, preloading with contrast agent has been proposed with some success (Boxerman et al., 2006). However, this approach does not allow an estimate of Ktrans . An alternative has also been proposed (Johnson et al., 2004). To decrease the T1 effect, this approach used a slower repetition time, lengthening the repetition time of the experiment, and undermining the estimation of CBF; thus, yielding estimates of only CBV and Ktrans . A further refinement, allowing the estimate

R. Jain

of blood volume and producing an index of transfer constant, has been suggested (Boxerman et al., 2006), and a dual-echo gradient echo sequence (Uematsu and Maeda, 2006) also shows some potential for an index of blood volume and transfer constant. Despite the partial success of these rapid imaging studies, in contrast to CT perfusion, there does not appear to be an MRI technique that will reliably quantify CBF, CBV, and Ktrans in one experiment. PCT also has the advantage of providing absolute measures of these perfusion parameters whereas MR estimates are mostly relative to the normal brain parenchyma. Another major disadvantage of MR perfusion is susceptibility artifacts due to hemorrhage and various mineral depositions, which can be a major issue in posttreatment tumor patients. Despite these facts, MR perfusion has been more often utilized because MRI is the standard of care for brain tumor patients; whereas, PCT requires a separate examination with iodinated contrast agent and moderate exposure to ionizing radiation.

Perfusion CT Tracer Kinetics Theory The model proposed by Johnson and Wilson (1966) is a convenient model for tumor application and is based on the assumption that the distribution volume of CT contrast medium in tissue consists of the extra-cellular space in capillaries and interstitial space. Central Volume Principle relates tissue (tumor) blood flow (TBF), tissue (tumor) blood volume (TBV) and mean transit time (MTT) in the following equation: TBF = TBV/MTT (24). Perfusion studies are obtained by monitoring the passage of an iodinated contrast bolus through the cerebral vasculature. There is a linear relationship between contrast agent concentration and attenuation, with the contrast agent causing a transient rise in attenuation proportional to the amount of contrast in a given region. Contrast agent timeconcentration curves are generated in an arterial region of interest (ROI), a venous ROI as well as in each pixel. Deconvolution of arterial and tissue enhancement curves, according to the adiabatic approximation of the Johnson and Wilson model (St. Lawrence and Lee, 1998), gives the blood flow scaled impulse residue function (IRF), from which TBF, TBV, and MTT can be determined as prescribed in the reference (Lee et al., 2003). Specifically, blood flow is equal to the height of the blood flow scaled IRF. CBV is calculated as an

10 Brain Tumor Angiogenesis and Glioma Grading

area under the initial plateau (intravascular phase) of the blood flow scaled IRF. Permeability surface-area product characterizes the diffusion of some of the contrast agent from the blood vessels into the interstitial space due to deficient or leaky BBB. Permeability is related to the diffusion coefficient of contrast agent in the assumed water filled pores of the capillary endothelium. The diffusion flux of contrast agent across the capillary endothelium is dependent on both the diffusion coefficient and the total surface area of the pores. PS is computed from the IRF. Contrast agent diffusion appears in the IRF as a residual enhancement that occurs after the initial impulse response and which decreases exponentially with time. The IRF is used to estimate the first-pass fraction of contrast agent that remains in the tissue, the extraction fraction, E (Purdie et al., 2001). The extraction fraction is related to the rate at which contrast leaks out of the vasculature via the following relationship: PS

E =1−eF , where PS is the permeability surface-area product and F is flow. The PS product has the same dimensions as flow, and thus the ratio PS F is dimensionless. In physiological terms, PS is the rate at which contrast agent flows into the extravascular tissues; it is related to another commonly stated parameter of vascular leakage, the transfer constant by the following: K trans = EF, Ktrans

is the transfer constant with, again, the where same dimensions as flow. It is easily demonstrated trans ≈ PS. In normal cerethat, if PS F << 1, then K bral vasculature, PS is negligible for all contrast agents presently in use.

Perfusion CT Technique Perfusion studies can be performed using multidetector row CT scanners. Currently available 16-slice CT scanners can cover 2 cm of the brain which is increased to 4 cm using a 64-slice CT scanner. A low radiation dose non-contrast CT head study is usually performed to localize the ROI before obtaining a perfusion scan. For the perfusion scan, 50 ml of nonionic contrast is injected at a rate of 4–5 ml/s through an IV line using an automatic power injector.

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At 5 s into the injection, a cine (continuous) scan is initiated with the following technique: 80 kVp, 100– 120 mA, and 1 s per rotation for duration of 50 s. After the initial 50 s cine scan, eight more axial images can be acquired, one image every 15 s for an additional 2 min, thus giving a total acquisition time of 170 s to assess for delayed permeability (Jain et al., 2008). Four 5 mm thick axial slices are acquired with the 16-slice CT scanner, whereas for 64-slice CT scanner, eight 5 mm thick axial slices are acquired resulting in a total coverage area of 4 cm instead of 2 cm with the 16-slice scanner. Perfusion maps of perfusion parameters can be obtained using many of the commercially available software. We use an Advantage Windows workstation using CT perfusion 3.0 software (General Electric Medical Systems, Milwaukee, WI) and two compartment model to generate CBV, CBF, MTT, and PS maps in our patients. Superior sagittal sinus is generally used as the venous output function and the artery with the greatest peak and slope on time-attenuation curves as the arterial input function (AIF). An ROI is drawn within the confines of a large vessel and the automatic function of the software picks the pixels with greatest peak and slope on the time-attenuation curve for analysis.

Relationship Between Glioma Grade and Perfusion CT Parameters Most of the literature regarding utility of perfusion imaging for glioma grading is based on various MR perfusion techniques. Recently, perfusion CT has also been used to grade gliomas based on perfusion parameters (Ellika et al., 2007; Jain et al., 2008). Ellika et al. (2007) were able to differentiate low and high grade gliomas with a high sensitivity (85.7%) and specificity (100%) using PCT and nCBV (CBV normalized relative to normal appearing contra-lateral white matter) threshold of 1.92. This relationship between CBV and histological grade is intuitive, as pathology studies show higher MVD in higher grade tumors. Jain et al. (2008) apart from differentiating low and high grade gliomas (Figs. 10.1 and 10.2) could also differentiate high grade tumor group into grade III and grade IV based on PS measurements which showed a stronger predictability as compared to CBV and especially could differentiate enhancing grade III from grade IV based on the differences in PS (Fig. 10.3).

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a

Fig. 10.1 (a) PS and (b) CBV perfusion CT maps in a 32year-old woman with WHO grade II astrocytoma showing low permeability (PS = 0.7 ml/100 g/min) and low blood volume (CBV = 1.01 ml/100 g) within the tumor. Inset: Post-contrast

a

Fig. 10.2 Perfusion CT maps in a 55-year-old man with glioblastoma multiforme: (a) PS maps showing very high permeability (PS = 5.14 ml/100 g/min) along the enhancing nodular margins of the tumor and (b) CBV maps showing high blood volume (CBV = 3.49 ml/100 g) within the periphery of the tumor.

b

T1-weighted image showing a non-enhancing right frontal tumor with no surrounding perilesional edema. (Printed with permission from Jain et al., 2008)

b

Inset: Postcontrast T1-weighted image showing heterogenously enhancing mass with irregular central necrosis in the right peritrigonal region. (Printed with permission from Jain et al., 2008)

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as the enhancing grade III tumors show higher PS, CBV and CBF, which may be more aggressive tumors with higher recurrence rate and shorter survival periods as compared to the nonenhancing grade III, which remains to be determined. Previous studies using MR perfusion have described various rCBV threshold values for glioma grading. Lev et al. (2004) described a threshold of 1.5 in discriminating between patients with low and high grade glioma with a sensitivity and specificity of 100 and 69%, respectively. Law et al. (2003) showed a sensitivity and specificity of 95 and 57.5%, respectively, by using 1.75 as the threshold value for rCBV.

Heterogeneity of Glioma Angiogenesis and Perfusion Imaging Fig. 10.3 Perfusion CT PS map in a 46-year-old man with enhancing grade III glioma involving the right frontal lobe with extension across the genu of the corpus callosum showing high permeability (PS = 2.04 ml/100 g/min)., however, significantly less as compared to a grade IV (Fig. 10.1b). Inset: Postcontrast T1-weighted showing an enhancing lesion involving the right frontal lobe with extension across the genu of the corpus callosum. (Printed with permission from Jain et al., 2008)

This is in keeping with the current WHO guidelines of including MVCP as a diagnostic criterion of grade IV, but not for grade III astrocytic tumors, suggesting that PS measurements could show better correlation with MVCP, and hence an imaging biomarker of more immature and leaky blood vessels. Increased angiogenesis in grade IV tumors is characterized not only by an increased number of vessels as compared to grade III astrocytic tumors, but by association also with disproportionate lengthening, increased pliability, endothelial cell proliferation, and irregular shape, which can explain the difference in perfusion parameters for grade IV as compared to grade III tumors. Non-enhancing grade III tumors have also been shown to have lower mean PS, CBV, and CBF as compared to the enhancing grade III group (Jain et al., 2008). This difference is probably due to higher MVD seen in enhancing tumors as compared to the nonenhancing group. This could have prognostic implications

Angiogenesis involves a multitude of controlled signaling cascades and structural changes that occur in a defined order and continue until a new vasculature has been formed. Tumor cellular growth usually outgrows its blood supply leading to hypoxia which leads to the formation of angiogenic mediators such as VEGF. VEGF initially leads to the formation of immature and leaky blood vessels, which results in increased permeability, leading to extravasation of plasma, plasma proteins, and deposition of proangiogenic matrix proteins. Later, as these pericyte-poor new vessels called mother vessels enlarge and give rise to daughter vessels through a complex series of endothelial rearrangements, MVD and TVA increase with continued increase in permeability. Finally, with vessel maturation, the total number and area of blood vessels continue to increase more than the vessel leakiness; hence, evolving into a very heterogeneous tumor with various regions probably showing different mixtures of vessel characteristics and angiogenesis, which can be seen as regions with high CBV but not very high PS and vice versa on perfusion imaging (Fig. 10.4). Correlation of various tumor perfusion estimates with histological angiogenesis markers could thus be very useful as far as in vivo identification of these different regions of angiogenesis is concerned, and using various perfusion parameters as imaging biomarkers.

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b

Fig. 10.4 Perfusion CT maps in a 39-year-old woman with heterogeneously enhancing grade III glioma involving the left temporal lobe. (a) CBV and (b) PS maps showing enhancing region laterally ROI #7 demonstrating the highest PS (PS = 8.52 ml/100 g/min), however, not showing the highest CBV(CBV = 4.73 ml/100 g) within the tumor; whereas ROI #8 shows relatively lower PS (PS = 1.14 ml/100 g/min);

however, shows the highest CBV within the tumor (CBV = 11.65 ml/100 g), suggesting there is marked heterogeneity with in high grade gliomas which could be due to the heterogeneity of tumor angiogenesis. Inset: Post-contrast T1-weighted axial image showing a heterogeneously enhancing left temporal lobe tumor

Role of Perfusion CT in Differentiating Recurrent Tumor from Radiation Necrosis

MR imaging features and MR spectroscopic imaging have been used to differentiate radiation necrosis from recurrent tumors with mixed success (Kumar et al., 2000; Cheronov et al., 2005). Various forms of metabolic imaging techniques have been utilized in the past with limited results. FDG-PET (Langleben and Segall, 2000), which is based on tumor glucose metabolism, has shown variable sensitivity and specificity in differentiating recurrent tumors from radiation necrosis and also has limited spatial resolution. Posttreatment recurrent enhancing lesions have also been evaluated with MR perfusion imaging, showing increased CBV in recurrent tumors as compared to non-neoplastic lesions (Covarrubias et al., 2004). Jain et al. (2007) used perfusion CT to differentiate the two entities and recurrent tumors showed higher CBV, CBF, and lower MTT (Fig. 10.5a) as compared to radiation necrosis (Fig. 10.5b). MR perfusion techniques also have been successfully used; however, PCT could have slight edge as most of these patients after having undergone multiple various combination therapies have some components of hemorrhage and mineralization, which could produce susceptibility artifacts complicating the perfusion analysis especially if using

Recent advances in brain tumor treatment have led to aggressive management strategies with combinations of surgery, chemotherapy, and radiation therapy based on the location and histologic type of the tumor. In particular, various forms of radiation therapy, including stereotactic radiosurgery, high-dose external beam radiation, and brachytherapy, have become important therapeutic adjuncts. Patient survival and quality of life are correlated with response to therapy, tumor recurrence and also adverse effects of radiation therapy such as radiation necrosis. Differentiating recurrent tumors from radiation necrosis on imaging studies has always been an important clinical imperative because the management of these two entities is different. Time interval from radiation therapy to the development of both of these entities after treatment does not help in differentiating one from the other. In addition, the problem is confounded by the fact that there is often a mixture of tumor with necrosis. Conventional

10 Brain Tumor Angiogenesis and Glioma Grading

a

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b

Fig. 10.5 (a) Perfusion CT CBV map in a 21-year-old male who was previously treated for a left posterior temporal lobe astrocytoma, showing a recurrent enhancing lesion in the left peritrigonal region which showed high CBV, suggesting recurrent tumor (b) as compared to radiation necrosis in a 49-year-old

male who underwent treatment for a left frontal lobe anaplastic astrocytoma showing low CBV in a recurrent enhancing lesion in left frontoparietal region. Inset: Corresponding post-contrast T1-weighted images. (Printed with permission from Jain et al., 2007)

dynamic susceptibility weighted imaging (Jain et al., 2007). In conclusion, clinically available perfusion imaging tools whether using MRI or CT can provide additional information regarding brain tumor vascular estimates which could be useful imaging biomarkers for preoperative glioma grading and angiogenesis assessment and could also be useful for treatment planning and response assessment. PCT has the advantage of providing two of the most important tumor vascular estimates i.e., blood volume and permeability in one single experiment as well as a linear relationship of tissue signal with tissue contrast agent unlike most of the available MR perfusion techniques and hence, has the potential to be a useful tool for brain tumor assessment.

macromolecular contrast magnetic resonance imaging after treatment with antiangiogenic agent TNP-470. Clin Cancer Res 9:355–362 Boxerman JL, Schmainda KM, Weisskoff RM (2006) Relative cerebral blood volume maps corrected for contrast agent extravasation significantly correlate with glioma tumor grade, whereas uncorrected maps do not. AJNR Am J Neuroradiol 27:859–867 Cairncross JG, Ueki K, Zlatescu MC, Lisle DK, Finkelstein DM, Hammond RR, Silver JS, Stark PC, Macdonald DR, Ino Y, Ramsay DA, Louis DN (1998) Specific genetic predictors of chemotherapeutic response and survival in patients with anaplastic oligodendrogliomas. J Natl Cancer Inst 90: 1473–1479 Cenic A, Nabavi DG, Craen RA, Gelb AW, Lee TY (2000) A CT method to measure hemodynamics in brain tumors: validation and application of cerebral blood flow maps. AJNR Am J Neuroradiol 21:462–470 Cha S, Johnson G, Wadghiri YZ, Jin O, Babb J, Zagzag D, Turnbull DH (2003) Dynamic, contrast-enhanced perfusion MRI in mouse gliomas: correlation with histopathology. Magn Reson Med 49:848–855 Chernov M, Hayashi M, Izawa M, Ochiai T, Usukura M, Abe K, Ono Y, Muragaki Y, Kubo O, Hori T, Takakura K (2005) Differentiation of the radiation-induced necrosis and tumor recurrence after gamma knife radiosurgery for brain metastases: importance of multivoxel proton MRS. Minim Invasive Neurosurg 48:228–234 Choyke PL (2005) Contrast agents for imaging tumor angiogenesis: is bigger better?. Radiology 235:1–2 Conturo TE, Akbudak E, Kotys MS, Chen ML, Chun SJ, Hsu RM, Sweeney CC, Markham J (2005) Arterial input

References Aronen HJ, Pardo FS, Kennedy DN, Belliveau JW, Packard SD, Hsu DW, Hochberg FH, Fischman AJ, Rosen BR (2000) High microvascular blood volume is associated with high glucose uptake and tumor angiogenesis in human gliomas. Clin Cancer Res 6:2189–2200 Bhujwalla ZM, Artemov D, Natarajan K, Solaiyappan M, Kollars P, Kristjansen PE (2003) Reduction of vascular and permeable regions in solid tumors detected by

90 functions for dynamic susceptibility contrast MRI: requirements and signal options. J Magn Reson Imaging 22: 697–703 Covarrubias DJ, Rosen BR, Lev MH (2004) Dynamic magnetic resonance perfusion imaging of brain tumors. Oncologist 9:528–537 De Lussanet QG, Langere S, Beets-Tan RG, van Genderen MH, Griffioen AW, van Engelshoven JM, Backes WH (2005) Dynamic contrast-enhanced MR imaging kinetic parameters and molecular weight of dendritic contrast agents in tumor angiogenesis in mice. Radiology 235:65–72 Ellika SK, Jain R, Patel SC, Scarpace L, Schultz LR, Rock JP, Mikkelsen T (2007) Role of perfusion CT in glioma grading and comparison with conventional MR imaging features. AJNR Am J Neuroradiol 28:1981–1987 Folkman J (1992) The role of angiogenesis in tumor growth. Semin Cancer Biol 3:65–71 Goh V, Halligan S, Hugill JA, Gartner L, Bartram CI (2005) Quantitative colorectal cancer perfusion measurement using dynamic contrast-enhanced multidetector-row computed tomography: effect of acquisition time and implications for protocols. J Comput Assist Tomogr 29:59–63 Jain R, Ellika SK, Scarpace L, Schultz LR, Rock JP, Gutierrez J, Patel SC, Ewing J, Meikkelsen T (2008) Quantitative estimation of permeability surface-area product in astroglial brain tumors using perfusion CT and correlation with histopathological grade. AJNR Am J Neuroradiol 29:694–700 Jain RK, Munn LL, Fukumura D (2002) Dissecting tumor pathophysiology using intravital microscopy. Nat Rev Cancer 2:266–276 Jain R, Scarpace L, Ellika S, Schultz LR, Rock JP, Rosenblum ML, Patel SC, Lee TY, Mikkelsen T (2007) First-pass perfusion computed tomography: initial experience in differentiating recurrent brain tumors from radiation effects and radiation necrosis. Neurosurgery 61:778–786 Johnson G, Wetzel SG, Cha S, Babb J, Tofts PS (2004) Measuring blood volume and vascular transfer constant from dynamic, T(2)∗ -weighted contrast-enhanced MRI. Magn Reson Med 51:961–968 Johnson JA, Wilson TA (1966) A model for capillary exchange. Am J Physiol 210:1299–1303 Kumar AJ, Leeds NE, Fuller GN, Van Tassel P, Maor MH, Sawaya RE, Levin VA (2000) Malignant Gliomas: MR imaging spectrum of radiation therapy-and chemotherapyinduced necrosis of the brain after treatment. Radiology 217:377–384 Langleben DD, Segall GM (2000) PET in differentiation of recurrent brain tumor from radiation injury. J Nucl Med 41:1861–1867 Law M, Oh S, Johnson G, Babb JS, Zagzag D, Golfinos J, Kelly PJ (2006) Perfusion magnetic resonance imaging predicts patient outcome as an adjunct to histopathology: a second reference standard in the surgical and nonsurgical treatment of low-grade gliomas. Neurosurgery 58:1099–1107 Law M, Yang S, Babb JS, Knopp EA, Golfinos JG, Zagzag D, Janohnson G (2004) Comparison of cerebral blood volume and vascular permeability from dynamic susceptibility contrast- enhanced perfusion MR imaging with glioma grade. AJNR Am J Neuroradiol 25:746–755 Law M, Yang S, Wang H, Babb JS, Johnson G, Cha S, Knopp EA, Zagzag D (2003) Glioma grading: sensitivity, specificity,

R. Jain and predictive values of perfusion MR imaging and proton MR spectroscopic imaging compared with conventional MR imaging. AJNR Am J Neuroradiol 24:1989–1998 Law M, Young RJ, Babb JS, Peccerelli N, Chheang S, Gruber ML, Miller DC, Golfinos JG, Zagzag D, Johnson G (2008) Gliomas: predicting time to progression or survival with cerebral blood volume measurements at dynamic susceptibility-weighted contrast-enhanced perfusion MR imaging. Radiology 247:490–498 Lee TY, Purdie TG, Stewart E (2003) CT imaging of angiogenesis. Q J Nucl Med 47:171–187 Leon SP, Folkerth RD, Black PM (1996) Microvessel density is a prognostic indicator for patients with astroglial brain tumors. Cancer 77:362–372 Lev MH, Ozsunar Y, Henson JW, Rasheed AA, Barest GD, Harsh GR 4th, Fitzek MM, Chiocca EA, Rabinov JD, Csavoy AN, Rosen BR, Hochberg FH, Schaefer PW, Gonzalez RG (2004) Glial tumor grading and outcome prediction using dynamic spin-echo MR susceptibility mapping compared with conventional contrast-enhanced MR: confounding effect of elevated rCBV of oligodendrogliomas. AJNR Am J Neuroradiol 25:214–221 Li VW, Folkerth RD, Watanabe H, Yu C, Rupnick M, Barnes P, Scott RM, Black PM, Sallan SE, Folkman J (1994) Microvessel count and cerebrospinal fluid basic fibroblast growth factor in children with brain tumours. Lancet 344:82–86 McDonald DM, Choyke PL (2003) Imaging of angiogenesis: from microscope to clinic. Nat Med 9:713–725 Plate KH, Breier G, Weich HA, Risau W (1992) Vascular endothelial growth factor is a potential tumour angiogenesis factor in human gliomas in vivo. Nature 359:845–848 Provenzale JM, Mukundan S, Dewhirst M (2005) The role of blood-brain barrier permeability in brain tumor imaging and therapeutics. AJR Am J Roentgenol 185:763–767 Purdie TG, Henderson E, Lee TY (2001) Functional CT imaging of angiogenesis in rabbit VX2 soft-tissue tumour. Phys Med Biol 46:3161–3175 Raatschen HJ, Simon GH, Fu Y, Sennino B, Shames DM, Wendland MF, McDonald DM, Brasch RC (2008) Vascular permeability during antiangiogenesis treatment: MR imaging assay results as biomarker for subsequent tumor growth in rats. Radiology 247:391–399 Roberts HC, Roberts TP, Bollen AW, Ley S, Brasch RC, Dillon WP (2001) Correlation of microvascular permeability derived from dynamic contrast enhanced MR imaging with histologic grade and tumor labeling index: a study in human brain tumors. Acad Radiol 8:384–391 Roberts HC, Roberts TP, Brasch RC, Dillon WP (2000) Quantitative measurement of microvascular permeability in human brain tumors achieved using dynamic contrastenhanced MR imaging: correlation with histologic grade. AJNR Am J Neuroradiol 21:891–899 Shweiki D, Itin A, Soffer D, Keshet E (1992) Vascular endothelial growth factor induced by hypoxia may mediate hypoxiainitiated angiogenesis. Nature 359:843–845 St Lawrence KS, Lee TY (1998) An adiabatic approximation to the tissue homogeneity model for water exchange in the brain: I. Theoretical derivation. J Cereb Blood Flow Metab 18:1365–1377

10 Brain Tumor Angiogenesis and Glioma Grading Tofts PS, Brix G, Buckley DL, Evelhoch JL, Henderson E, Knopp MV, Larsson HB, Lee TY, Mayr NA, Parker GJ, Port RE, Taylor J, Weisskoff RM (1999) Estimating kinetic parameters from dynamic contrast-enhanced T(1)-weighted MRI of a diffusible tracer: standardized quantities and symbols. J Magn Reson Imaging 10:223–232 Uematsu H, Maeda M (2006) Double-echo perfusion-weighted MR imaging: basic concepts and application in brain tumors for the assessment of tumor blood volume and vascular permeability. Eur Radiol 16:180–186

91 Vajkoczy P, Menger MD (2000) Vascular microenvironment in gliomas. J Neurooncol 50:99–108 Weidner N (1995) Intratumor microvessel density as a prognostic factor in cancer. Am J Pathol 147:9–19 Yankeelov TE, Rooney WD, Huang W, Dyke JP, Li X, Tudorica A, Lee JH, Koutcher JA, Springer CS Jr (2005) Evidence for shutter-speed variation in CR bolus-tracking studies of human pathology. NMR Biomed 18:173–185

Chapter 11

Vasculogenic Mimicry in Glioma Zhong-Ping Chen and Yin-Sheng Chen

Abstract For years, sprouting angiogenesis has been considered an exclusive mechanism of tumor vascularization. However, over the last years, several other mechanisms have been identified, including vesselcooption, intussusception, recruitment of endothelial precursor cells (EPCs) and even mechanisms that do not involve endothelial cells, a process called vasculogenic mimicry (VM). The latter describes a mechanism by which highly aggressive tumor cells can form vessel-like structures themselves, by virtue of their high plasticity. Vasculogenic mimicry is known as nonendothelial tumor cell-lined microvascular channels in aggressive tumors, which may function as blood supply networks. There is also evidence of a physiological connection between the endothelial-lined vasculature and VM. Micro-vascular density (MVD) was comparably less in VM positive tumors than in VM negative tumors in high-grade gliomas. Thus, the existence of VM may provide a complementation to ensure tumor blood supply, especially in regions of the gliomas with less MVD. The presence of VM has been associated with more aggressive tumor biology and increased tumor-related mortality. Patients with VM positive gliomas survived a shorter period of time than those without VM. Though the detailed molecular mechanisms for VM are not fully understood, glioma stem cells (GSC) might play a key role since GSC have been shown to be involved in tumor tissue remodeling. In the future, successful management of gliomas and other aggressive cancers could involve the targeting of both vasculogenic mimicry and angiogenesis. Z.-P. Chen () Department of Neurosurgery, Cancer Center, Sun Yat-sen University, Guangzhou 510060, China e-mail: [email protected]

Keywords Vasculogenic mimicry · Angiogenesis · Tumor vascularization · Endothelial cells · MVD · GSC

Introduction Solid tumors require an adequate blood supply for survival, growth, and metastasis. Conventionally, blood vessels are assembled by two processes: (1) vasculogenesis, the reorganization of randomly distributed cells into a blood vessel network, and (2) angiogenesis, the sprouting of new vessels from preexisting vasculature in response to external chemical stimulation. Gliomas are the most frequent and malignant primary brain tumors in adults and have a poor prognosis despite surgery and conventional radiochemotherapy. Histologically, gliomas are highly angiogenic and characterized by microvascular proliferations (Fig. 11.1b) (Louis et al., 2007). However, although anti-vascular endothelial growth factor therapy has had significant efficacy in gliomas with nearly 50% of responders, the clinical benefit remains unsatisfactory (Vredenburgh et al., 2007; Kreisl et al., 2009). Can tumors acquire blood supply through other ways to escape conventional antiangiogenisis therapy? Maniotis et al. (1999) reported that blood vessels of highly aggressive uveal melanomas are formed by tumor cells instead of endothelial cells. He termed this novel concept in tumor vascularization as vasculogenic mimicry (VM). Vasculogenic mimicry describes the ability of aggressive tumor cells to express endothelium-associated genes and form extracellular matrix (ECM)-rich vasculogeniclike networks in three-dimensional culture. These networks recapitulate embryonic vasculogenesis, and

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Fig. 11.1 Vasculogenic mimicry in glioma. Endothelial cells are detected with anti-CD34 immunohistochemistry staining (dark brown) and vascular basement membrane with PAS staining (purple magenta) in tubular blood vessel (a). (b) microvascular proliferation of gliomas. Seven morphological patterns

of PAS-positive channels can been seen in (c) and (e). Large cross section (d) and longitudinally section (f) vessels containing red blood cells stained positively with PAS but negatively with CD34 (VM). (CD34 and PAS dual staining a, b, d and f, ×400; c, ×100; e, ×200)

they have been observed in human aggressive tumors. Vasculogenic mimicry has been seen in several malignant tumor types such as breast cancer, liver cancer, ovarian cancer, melanoma, prostate cancer, and bidirectional differentiated malignant tumors. Vasculogenic mimicry of the patterned matrix type was

previously also reported in human glioblastoma tissues (Yue and Chen, 2005; EI Hallani et al., 2010) and human glioma cell-line xenografts (Niclou et al., 2008). Subsequent studies have suggested that VM channels may function as blood supply networks, and thus could be another target for anti-cancer therapy.

11 Vasculogenic Mimicry in Glioma

However, the relations between VM and vasculogenesis or angiogenesis are not fully understood yet, and the molecular mechanisms of these processes remain a puzzle. Thus, a better understanding of tumor vascularization is needed to optimize antivascular therapy.

The Concept and Characteristic of VM Vasculogenic mimicry is known as non-endothelial tumor cell-lined microvascular channels in aggressive tumors (Fig. 11.1d, f). Under appropriate matrix microenvironment conditions, highly aggressive and metastatic tumor cells can form highly patterned vascular like channels (Fig. 11.1c, e). The generation of such microvascular channels by genetically deregulated, aggressive tumor cells is termed VM to emphasize its de novo generation that is independent of angiogenesis. The channel formed by VM is composed of a basement membrane and lined by tumor cells, and no endothelial cells are found on its inner wall. Blood plasma and red blood cells (RBCs) can flow through the channel (Folberg and Maniotis, 2004; Yue and Chen, 2005). Tumor cells are aligned with the external superficies of the channel. No inflammatory cells or necrosis are found around the channel. The endothelial-lined vasculature is closely apposed to the tumor cell-formed fluid conducting meshwork, and hypothetically, it is presumed that as the tumor remodels, the vasculature becomes leaky, resulting in the extravascular conduction of plasma. Several observations reported that tumour cells are located in the walls of tumor blood vessels and form a part of the vessel surface while the remaining part is covered by endothelium. This is known as “mosaic vessels” where tumor cells undergo intravasation into the lumen and stay temporally in the vessel wall (Chang et al., 2000). The tumor cell-lined vessels could be the result of a complete invasion of the vessel wall by tumor cells, perhaps the endpoint of mosaicism. Since there has been evidence strongly suggesting that glioma stem cell (GSC) are capable of forming blood vessels as well as “tubular vasculogenic mimicry” de novo. There is also evidence of a physiological connection between the endothelial-lined vasculature and the VM channel (Fig. 11.2a). In other words, VM is defined by the unique ability of aggressive tumor cells to express an endothelial cell (EC) phenotype and to form vessel-like networks in three-dimensional culture

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(Fig. 11.3a), “mimicking” the pattern of embryonic vascular networks and recapitulating the patterned networks seen in patients’ aggressive tumors correlating with a poor prognosis (Maniotis et al., 1999). There are two distinctive VM types that have been reported in tumors. (1) The patterned matrix type VM: the channels are composed of a basement membrane, lined by tumor cells in their external superficies and no endothelial cells are found on their inner wall despite blood plasma and red blood cells flowing through the channels (Maniotis et al., 1999). (2) The tubular type VM: Non-endothelial cell-lined channels and only tumor cells as the lining cells of their luminal surface (Tímár and Tóth, 2000; Shirakawa et al., 2002a; Folberg and Maniotis, 2004; Van der Schaft et al., 2005). Morphologically, because VM is PASpositive channel without endothelial cells, CD34 (or other blood vessel endothelial molecular markers such as CD31, CD105 etc.) and periodic acid-Schiff (PAS) dual staining can be used as histological identification of VM. Vasculogenic mimicry has been observed in several human tumors: breast, prostate, ovarian, chorio-, and lung carcinomas; synovial-, rhabdomyo-, and Ewing sarcomas; and phaeochromocytoma (Hendrix et al., 2003). We previously (Yue and Chen, 2005) and subsequently EI Hallani et al. (2010) reported the presence of VM in high grade gliomas. We used CD34 staining to identify the endothelium in glioblastoma tissue sections and PAS staining to determine the basement membrane of tumor blood vessels. Real tumor vessels showed positive reaction for CD34 on their luminal surface and PAS-positive reaction in their walls. However, in a subset of gliomas, PAS-positive tubular structures containing red blood cells but lined by CD34– cells in the luminal surface, i.e. VM, could be clearly found (Fig. 11.1d, f). Meanwhile, VM was also found in human glioma cell-line xenografts (Niclou et al., 2008). As described by Folberg et al. (1993), seven morphological patterns of PAS-positive channels were identified in uveal melanoma: straight channels, arrangements of parallel straight channels, straight channels that cross-link, arcs (incompletely closed loops), arcs with branching, closed loops, and networks (networks were defined arbitrarily as at least three back-to-back closed PAS-positive loops). All these VM paterns have been observed in gliomas (Fig. 11.1c, e).

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Fig. 11.2 Connection between the endothelial-lined vasculature and the VM. (a), Longitudinally sectioned blood vessel presents distinctive CD34+ and CD34– portions. (Cite from EI Hallani et al., 2010). (b), Injected via the jugular vein, absorbite particles could be seen at the hGSC/hGPC-derived intracranial

Z.-P. Chen and Y.-S. Chen

tumor vessels of various sizes. The inner lumens of these tumor vessels, composed of transdifferentiated hGSPCs, were irregular and discontinuous, and absorbite particles aggregated with red blood cells. (Cite from Dong et al., 2010). (A, CD34 and PAS dual staining ×400; B, H & E staining ×400)

Fig. 11.3 Vessel-like networks in three-dimensional culture. (a) Highly aggressive glioma cell line SKMG-4 forms tubular structures in 3D culture on Matrigel while another glioma cell line SHG44 does not (b). (a and b, ×100)

Biological and Clinical Significance of VM (1999) demonstrated that the patterned channels genVasculogenic mimicry is a special biological feature of tumor cells to form a PAS-positive pattern. Morphological analysis showed that PAS-positive patterned networks, which were found in aggressive tumors, seemed to converge with blood vessels. It was thus proposed that some types of anastomosis occur between the tumor-cell-lined networks and the endothelium-lined vasculature, which contributes to the accumulation of erythrocytes in the network infrastructure (Fig. 11.2). Maniotis et al.

erated by aggressive uveal melanoma cells in vitro were capable of conducting dye over a short distance. He suggested that VM PAS-positive pattern in uveal melanoma was indeed a form of tumor microcirculation. Using a mouse xenograft glioma model, Dong et al. (2010) did functional assays to see if these VM channels connecting with real blood vessels. They found that vessels from transdifferentiated human glioma stem cells (hGSCs) in intracranial tumors can conduct absorbite particles which were injected through the peripheral vein (Fig. 11.2b). These observations strongly suggested that hGSCs might

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generate vascular channels that facilitate tumor perfusion independent from tumor angiogenesis. Yue et al. (2000) did blood–brain barrier (BBB) ultrastructure observation of 18 gliomas and two brain-metastases originating from lung cancer under transmission electron microscopy. They found the perfect tight conjunction between endothelial cells: complete basement membrane. Endothelial fenestrae, intercellular gaps, and vesiculovacuolar organelles could not be found in 18 gliomas; however, quite a few endothelial fenestrae and vesiculovacuolar organelles could be easily found in the two brain metastases. The BBB ultra-structure observation of these astrocytomas does not suggest the extravasation of erythrocytes through the abnormal endothelial cell and the secondary PAS- positive pattern formation after intra-tumor micro-hemorrhage formation. In our previous study (Yue and Chen, 2005), erythrocyte shadows could be easily found in the PAS-positive CD34-negative channels of gliomas, supporting that the PAS-positive pattern in gliomas was microcirculation. Studies involving a combination of intravenous tracers, together with confocal and immuno-electron microscopy, have shown that fluid can be conducted by the endothelium-lined vasculature, as well as extravascularly along the channel-like spaces created by the PAS-positive patterned loops and networks that encase clusters of tumor cells (Potgens et al., 1996; Clarijs et al., 2002; Maniotis et al., 2002). Laser-captured micro-dissection was performed in regions that exhibited VM without endothelial cells, central necrosis, or fibrosis. The results revealed that there is a connection between VM and angiogenesis. There are several possible explanations for the functional relevance of VM. The fluid-conducting meshwork might provide a site for nutritional exchange for aggressive tumors, and might therefore prevent necrosis of the tumor. Alternatively, it might be analogous to an oedematous inflammatory response, in which increased blood pressure leads to the escape of fluid along connective-tissue pathways in intratissue spaces. The complex geometry of the laminincontaining extracellular matrix (ECM) covering that encases the spheroidal clusters of tumor cells could also form a suppressive shield against immune surveillance. Vasculogenic mimicry is associated with poor clinical prognosis in tumor patients. The unique structure of VM channels facilitates the metastasis of glioma cells.

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Glioma cells, which line the inner surface of VM channels, are directly exposed to blood flow. Glioma cells that leak out can migrate through the blood stream and metastasize to other regions. Furthermore, glioma cells that line the VM channel are highly malignant, poorly differentiated, and have high plasticity. These cells can degrade adjacent connective tissue and penetrate the basement membrane of blood vessels by secreting proteins that mediate tumor invasion and metastasis. This phenomenon has been confirmed in liver cancer, breast cancer, hepatocellular carcinoma and gastrointestinal stromal tumors (Shirakawa et al., 2002b; Folberg and Maniotis, 2004; Guzman et al., 2007; Sun et al., 2006, 2008). We performed a retrospective analysis on 101 glioma patients. The tumor samples were dual stained for CD34 as well as PAS, and immunohistochemical staining (IHC) for Ki-67, COX-2 and MMP-9. The association between VM and clinical characteristics was analyzed. The VM were revealed in 13 of 101 samples. The higher grade gliomas had a higher incidence of VM than that of lower grade gliomas. VM channels were associated with the expression of COX-2 and MMP-9. There was no association between the existence of VM and the sex, age and preoperative epilepsy of the patients or expression of Ki-67. However, the patients with VM positive tumors survived a shorter period of time than those without it (Fig. 11.4). Interestingly, Our results showed that the micro-vascular density (MVD) was comparably less in VM positive tumors than in VM negative tumors in high-grade gliomas. Thus, the existence of VM may provide a complementation to ensure tumor blood supply without involvement of endothelial cells, and may serve as another mechanism for obtaining nutrients to survive, especially in regions of the gliomas with less MVD. A follow-up blinded study that involved tissue analysis of ovarian carcinoma by two independent pathologists has also shown a strong clinical correlation between the presence of VM, advanced-stage disease and poor outcome. There is a consensus that the microcirculation of aggressive tumors is complex, and depending on the time of observation, could consist of mosaic vessels (which consist of both tumor cells and endothelial cells) (Chang et al., 2000), co-opted vessels (Döme et al., 2002) and/or angiogenic vessels (Kerbel, 2000). There is also strong evidence for the existence of

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Fig. 11.4 Patients whose tumor had vasculogenic mimicry survived shorter than those without it (P = 0.027) by Kaplan-Meier survival analysis

an intratumoral, tumor-cell-lined, ECM-rich, patterned network that can provide an extra-vascular fluid pathway, now known as VM (Maniotis et al., 2002; Clarijs et al., 2002). The entire microcirculation in aggressive tumors seems to be made up of a combination of these elements, and it is the result of destructive tumor growth and remodeling at the same time associated with high tumor grade and poorer prognosis. Zhang et al. (2006) proposed a three-stage phenomenon among vasculogenic mimicry channels, mosaic blood vessels, and endothelium-dependent blood vessels, wherein all three patterns participate in tumor blood supply.

Molecular Mechanisms Underlying VM There are three factors governing VM channel formation: plasticity of highly malignant tumor cells, remodeling of the ECM, and the connection of VM and host microcirculation. Many studies have found that VM can mainly be observed in highly malignant tumors. A cDNA microarray study of 6000 genes from over

30 human cutaneous melanoma cell lines revealed that there was a differential expression in 92 genes (≥2.5fold), including some genes associated with the phenotypes of endothelial and hematopoietic stem cells (Seftor et al., 2002). A representative example of the confirmation of selected differentially expressed genes (in highly aggressive cutaneous melanoma C8161 cells versus poorly aggressive C81-61 cells isolated from the same patient) from the microarray analysis was also determined by semiquantitative RT-PCR measurement. Hendrix et al. (2000) proposed that tumor cells with an embryonic phenotype have high plasticity. Extracellular matrix remodeling provides the space needed for VM and is associated with the MMP secretion by tumor cells. In the absence of blood supply from endothelium-dependent vessels, tumor cells form VM channels to acquire enough blood supply for their sustenance. Vasculogenic mimicry in aggressive tumors involves several signaling molecules that are also involved in embryonic vasculogenesis, including vascular endothelial (VE)-cadherin, erythropoietinproducing hepatocellular carcinoma-A2 (EPHA2), phosphatidylinositol 3-kinase, focal adhesion kinase,

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matrix metaloproteinases and laminin 5γ2-chain. Studies (Hess et al., 2001, 2006) have indicated that the main signalling cascade of VM is initiated by transcriptional up-regulation of VE-cadherin through HIF-2α. VE-cadherin induces a re-localization of EphA2 to the cell membrane where both proteins then co-localize resulting in the phosphorylation of EphA2. Activated EphA2 can phosphorylate FAK, which results in activation of ERK1/2 and subsequently PI3K. However, PI3K can also be activated by VE-cadherin/EphA2 signaling independent of FAK. Active PI3K regulates the transition of pro-MT1-MMP to active MT-MMP, which subsequently activates proMMP2. Both MT1-MMP and MMP-2 promote the cleavage of laminin 5γ2 to the pro-migratory fragments 5γ2 and 5γ2x. The release of these fragments in the extracellular microenvironment may eventually result in the formation of VM networks. Galectin-3 (Gal-3) positively influences this process by repression of the EGR-1 transcription factor, which causes transcriptional repression of VE-cadherin and IL-8. The latter stimulates the expression of MMP-2. Cyclic AMP can also influence VM network formation in multiple ways. By stimulation of Epac/Rap1, cAMP inhibits tube formation. Additionally, it inhibits ERK1/2, thereby manipulating the main signaling cascade. However, the stimulatory effect of cAMP on (Notch-1 and) Notch-4 may cause increased expression of Nodal, which subsequently positively regulates VE-cadherin expression. By this latter effect cAMP may also have a positive effect on VM network formation (Paulis et al., 2010). However, the detailed molecular mechanisms for VM are not yet fully understood.

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inducing cell death. A great deal of intellectual capital has been devoted to targeting angiogenesis and lymph-angiogenesis in patients with cancer. The heterogeneity of the tumor vasculature presents an opportunity, as well as a clinical challenge, aside from issues of drug resistance. Recent in vitro studies have shown that endostatin inhibits endothelial-cell driven angiogenesis, but not the formation of melanoma-cell vascular networks. Scientists are now focusing on VM. Many investigators involved in basic research on VM are trying to find an anti-VM therapy. Therapies targeting VM have been performed in vitro. Suppressing tyrosine kinase activity and knocking out EphA2 gene, downregulating VE-cadherin, using antibodies against human MMPs and the laminin 5γ2 chain, and using anti-PI3K therapy are strategies used to inhibit VM. Chemically modified tetracycline COL-3 can suppress expression of VM-related genes and reduce VM channel formation. Pharmacological studies have shown that COL-3 may depress MMP activity. Hwu (2000) used thalidomide as an antitumor agent and found that it has antiangiogenesis and other biological effects. In clinical phase I and phase II trials, thalidomide in combination with temozolomide has a remarkable antimelanoma effect, especially in cases of metastatic melanoma in the brain. However clinical benefit from anti-VM therapy has not yet been determined. Successful management of gliomas and other aggressive cancers could involve the targeting of one or more stages in the vasculogenic mimicry signaling cascade and/or targets from both vasculogenic mimicry and angiogenesis.

Advances and Challenges Clinical Therapeutic Value of VM Folkman (1971) reported that tumors require a blood supply for survival, growth, and metastasis, he first argued that anti-angiogenic therapy would have significant efficacy in tumors. Over the last few years, antiangiogenesis therapy has been emerging as a promising strategy in the treatment of cancer. Treatment modalities are aimed at inhibiting endothelial proliferation and/or migration of endothelial cells to hypoxic tumor regions, thereby hampering the supply of oxygen and nutrition to tumor cells and

Vasculogenic mimicry (VM), a newly discovered way of blood supply to tumors, has attracted the attention of many researchers, but studies on VM are just at an early stage, many phenomena unique to VM channel formation remain to be elucidated. As a functional tumor microcirculation, VM channels need to be studied with regard to their connection with endothelium dependent vessels, their relationship with lymphatic tubes, and their dual function as vessels and lymphatic tubes. Cells capable of VM display a high degree of plasticity, causing them to resemble dedifferentiated

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cell types. The most well known dedifferentiated cell is the stem cell, as it holds the capacity to generate various novel cell types. Cancer stem cells have been identified in brain tumors, including glioblastomas (Singh et al., 2003; Galli et al., 2004; Yuan et al., 2004). Like physiological stem cells, glioblastoma stem cells are capable of self-renewal and differentiation, and indefinite proliferation, the latter being critical for tumor growth. Dong et al. (2010) reported that GSCs were involved in tumor tissue remodeling in a xenograft model. However, the relationship of glioblastoma stem cells and vasculogenic mimicry in glioblastomas is still unclear and the vasculogenic capacity of glioblastoma tumor stem cells has yet to been proven.

References Chang YS, di Tomaso E, McDonald DM, Jones R, Jain RK, Munn LL (2000) Mosaic blood vessels in tumors: frequency of cancer cells in contact with flowing blood. Proc Natl Acad Sci USA 97:14608–14613 Clarijs R, Otte-Holler I, Ruiter DJ, de Waal RMW (2002) Presence of a fluid-conducting meshwork in xenografted cutaneous and primary human uveal melanoma. Invest Ophthalmol Vis Sci 43:912–918 Döme B, Paku S, Somlai B, Tímár J (2002) Vascularization of cutaneous melanoma involves vessel co-option and has clinical significance. J Pathol 197:355–362 Dong J, Zhang QB, Huang Q, Chen H, Shen YT, Fei XF, Zhang TY, Diao Y, Wu ZC, Qin ZH, Lan Q, Gu XS (2010) Glioma stem cells involved in tumor tissue remodeling in a xenograft model. J Neurosurg 113:249–260 EI Hallani S, Boisselier B, Peglion F, Rousseau A, Colin C, Idbaih A, Marie Y, Mokhtari K, Thomas JL, Eichmann A, Delattre JY, Maniotis AJ, Sanson M (2010) A new alternative mechanism in glioblastoma vascularization: tubular vasculogenic mimicry. Brain 133:973–982 Folberg R, Maniotis AJ (2004) Vasculogenic mimicry. APMIS 112:508–525 Folberg R, Rummelt V, Parys-Van Ginderdeuren R, Hwang T, Woolson RF, Pe’er J, Gruman LM (1993) The prognostic value of tumor blood vessel morphology in primary uveal melanoma. Ophthalmology 100:1389–1398 Folkman J (1971) Tumor angiogenesis: therapeutic implications. N Engl J Med 285:1182–1186 Galli R, Binda E, Orfanelli U, Cipelletti B, Gritti A, De Vitis S, Fiocco R, Foroni C, Dimeco F, Vescovi A (2004) Isolation and characterization of tumorigenic, stem-like neural precursors from human glioblastoma. Cancer Res 64:7011–7021 Guzman G, Cotler SJ, Lin AY, Maniotis AJ, Folberg R (2007) A pilot study of vasculogenic mimicry immunohistochemical expression in hepatocellular carcinoma. Arch Pathol Lab Med 131:1776–1781 Hendrix MJSE, Kirschmann DA, Seftor RE (2000) Molecular biology of breast cancer metastasis. Molecular expression of

Z.-P. Chen and Y.-S. Chen vascular markers by aggressive breast cancer cells. Breast Cancer Res 2:417–422 Hendrix MJC, Seftor EA, Hess AR, Seftor REB (2003) Vasculogenic mimicry and tumor-cell plasticity: lessons from melanoma. Nat Rev Cancer 3:411–421 Hess AR, Seftor EA, Gardner LM, Carles-Kinch K, Schneider GB, Seftor RE, Kinch MS, Hendrix MJ (2001) Molecular regulation of tumor cell vasculogenic mimicry by tyrosine phosphorylation: role of epithelial cell kinase (Eck/EphA2). Cancer Res 61:3250–3255 Hess AR, Seftor EA, Gruman LM, Kinch MS, Seftor RE, Hendrix MJ (2006) VE-cadherin regulates EphA2 in aggressive melanoma cells through a novel signaling pathway: implications for vasculogenic mimicry. Cancer Biol Ther 5:228–233 Hwu WJ (2000) New approaches in the treatment of metastatic melanoma: thalidomide and temozolomide. Oncology (Williston Park) 14(12 Suppl 13):25–28 Kerbel RS (2000) Tumor angiogenesis: past, present and the near future. Carcinogenesis 21:505–515 Kreisl TN, Kim L, Moore K, Duic P, Royce C, Stroud I, Garren N, Mackey M, Butman JA, Camphausen K, Park J, Albert PS, Fine HA (2009) Phase II trial of single-agent bevacizumab followed by bevacizumab plus irinotecan at tumor progression in recurrent glioblastoma. J Clin Oncol 27:740–745 Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, Burger PC, Jouvet A, Scheithauer BW, Kleihues P (2007) 2007 WHO classification of tumours of the central nervous system. Acta Neuropathol 114:97–109 Maniotis AJ, Chen X, Garcia C, DeChristopher PJ, Wu D, Pe’er J, Folberg R (2002) Control of melanoma morphogenesis, endothelial survival, and perfusion by extracellular matrix. Lab Invest 82:1031–1043 Maniotis AJ, Folberg R, Hess A, Seftor EA, Gardner LM, Pe’er J, Trent JM, Meltzer PS, Hendrix MJ (1999) Vascular channel formation by human melanoma cells in vivo and in vitro: vasculogenic mimicry. Am J Pathol 155:739–752 Niclou SP, Danzeisen C, Eikesdal HP, Wiig H, Brons NH, Poli AM, Svendsen A, Torsvik A, Enger PØ, Terzis JA, Bjerkvig R (2008) A novel eGFP-expressing immunodeficient mouse model to study tumorhost interactions. FASEB J 22: 3120–3128 Paulis YW, Soetekouw PM, Verheul HM, Tjan-Heijnen VC, Griffioen AW (2010) Signalling pathways in vasculogenic mimicry. Biochim Biophys Acta 1806:18–28 Potgens AJG, van Altena MC, Lubsen NH, Ruiter DJ, de Waal RMW (1996) Analysis of the tumor vasculature and metastatic behavior of xenografts of human melanoma cell lines transfected with vascular permeability factor. Am J Pathol 148:1203–1217 Seftor EAMP, Schatteman GC, Gruman LM, Hess AR, Kirschmann DA, Seftor RE, Hendrix MJ (2002) Expression of multiple molecular phenotypes by aggressive melanoma tumor cells: role in vasculogenic mimicry. Crit Rev Oncol Hematol 44:17–27 Shirakawa K, Kobayashi H, Heike Y, Kawamoto S, Brechbiel MW, Kasumi F, Iwanaga T, Konishi F, Terada M, Wakasugi H (2002a) Hemodynamics in vasculogenic mimicry and angiogenesis of inflammatory breast cancer xenograft. Cancer Res 62:560–566

11 Vasculogenic Mimicry in Glioma Shirakawa K, Wakasugi H, Heike Y, Watanabe I, Yamada S, Saito K, Konishi F (2002b) Vasculogenic mimicry and pseudo-comedo formation in breast cancer. Int J Cancer 99:821–828 Singh SK, Clarke ID, Terasaki M, Bonn VE, Hawkins C, Squire J, Dirks PB (2003) Identification of a cancer stem cell in human brain tumors. Cancer Res 63:5821–5828 Sun B, Qie S, Zhang S, Sun T, Zhao X, Gao S, Ni C, Wang X, Liu Y, Zhang L (2008) Role and mechanism of vasculogenic mimicry in gastrointestinal stromal tumors. Hum Pathol 39:444–451 Sun B, Zhang S, Zhang D, Du J, Guo H, Zhao X, Zhang W, Hao X (2006) Vasculogenic mimicry is associated with high tumor grade, invasion and metastasis, and short survival in patients with hepatocellular carcinoma. Oncol Rep 16: 693–698 Tímár J, Tóth J (2000) Tumor sinuses-vascular channels. Pathol Oncol Res 6:83–86 van der Schaft DW, Hillen F, Pauwels P, Kirschmann DA, Castermans K, Egbrink MG, Tran MG, Sciot R, Hauben E, Hogendoorn PC, Delattre O, Maxwell PH, Hendrix MJ,

101 Griffioen AW (2005) Tumor cell plasticity in Ewing sarcoma, an alternative circulatory system stimulated by hypoxia. Cancer Res 65:11520–11528 Vredenburgh JJ, Desjardins A, Herndon JE 2nd, Dowell JM, Reardon DA, Quinn JA, Rich JN, Sathornsumetee S, Gururangan S, Wagner M, Bigner DD, Friedman AH, Friedman HS (2007) Phase II trial of bevacizumab and irinotecan in recurrent malignant glioma. Clin Cancer Res 13:1253–1259 Yuan X, Curtin J, Xiong Y, Liu G, Waschsmann-Hogiu S, Farkas DL, Black KL, Yu JS (2004) Isolation of cancer stem cells from adult glioblastoma multiforme. Oncogene 23:9392–9400 Yue WY, Chen ZP (2005) Does vasculogenic mimicry exist in astrocytoma? J Histochem Cytochem 53:997–1002 Yue WY, Zhong ST, Liang HZ (2000) The BBB morphology features of brain tumor. Pract J Cancer (Chinese) 15: 273–275 Zhang S, Guo H, Zhang D, Zhang W, Zhao X, Ren Z, Sun B (2006) Microcirculation patterns in different stages of melanoma growth. Oncol Rep 15:15–20

Chapter 12

Newly Diagnosed Glioma: Diagnosis Using Positron Emission Tomography with Methionine and Fluorothymidine Nobuyuki Kawai, Yoshihiro Nishiyama, and Takashi Tamiya

Abstract The purpose of this prospective study was to clarify the individual and combined role of METPET and FLT-PET in tumor detection, noninvasive grading, and assessment of the cellular proliferation rate in newly diagnosed histologically verified gliomas of different grades. Sixty-two patients with newly diagnosed gliomas were investigated with MET-PET before surgery. Thirty-six patients were also examined with FLT-PET. MET and FLT uptakes were assessed by the standardized uptake value of the tumor showing the maximum uptake (SUVmax), and the ratio to uptake in the normal brain parenchyma (T/N ratio). All tumors were graded by the WHO grading system using surgical specimens and the proliferation activity of the tumors was determined by measuring the Ki-67 index obtained by immunohistochemical staining. On visual analysis, MET exhibited a slightly higher sensitivity (88.7%) in tumor detection than FLT (86.1%) and both tracers were 100% sensitive for malignant gliomas. Low-grade gliomas that were false negative on MET-PET were also false negative on FLT-PET. Although the difference in the MET SUVmax and T/N ratio between grade II and grade III gliomas was statistically significant (P < 0.05), there was a significant overlap of MET uptake in the tumors. The difference in the MET SUVmax and T/N ratio between grade III and grade IV gliomas was not statistically significant. Low-grade gliomas with oligodendroglial components had relatively high MET uptake compared to grade II astrocytoma. The difference in the FLT

N. Kawai () Department of Neurological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa 761-0793, Japan e-mail: [email protected]

SUVmax and T/N ratio between grade III and grade IV gliomas was statistically significant (P < 0.001). However, the difference in the FLT SUVmax and T/N ratio between grade II and grade III gliomas was not statistically significant. Grade III gliomas with noncontrast enhancement on MR images had very low FLT uptake. In 36 patients who underwent PET examination with both tracers, a significant but relatively weak correlation was observed between the individual SUV max of MET and FLT (r = 0.52, P < 0.05) and T/N ratio of MET and FLT (r = 0.49, P < 0.05). FLT SUVmax in the tumor had a higher correlation (r = 0.81, P < 0.001) with the Ki-67 proliferation index than MET SUVmax (r = 0.40, P < 0.05). PET studies using MET and FLT are useful for tumor detection in newly diagnosed gliomas. However, there is no complimentary information in tumor detection with simultaneous measurements of MET- and FLT-PET in low grade gliomas. FLT-PET seems to be superior to MET-PET in noninvasive tumor grading and assessment of proliferation activity in gliomas of different grade. Keywords Glioma · Positron Emission Tomography · Methionine · Fluorothymidine · MET · FLT

Introduction Morphological imaging using magnetic resonance imaging (MRI) with gadolinium (Gd) contrast enhancement is the most widely used method for diagnosis of gliomas. This technique has the drawback, however, of frequent false negatives in tumor regions without blood-brain barrier (BBB) breakdown.

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_12, © Springer Science+Business Media B.V. 2011

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The contrast enhancement only reflects regions of BBB breakdown, whereas glioma cells usually infiltrate the brain structure without significant BBB breakdown. Positron emission tomography (PET) with an appropriate metabolic tracer plays an important role in characterizing and delineating gliomas. Among several metabolic tracers, the glucose analogue FDG (2-deoxy-2-[18 F]fluoro-D-glucose) is most commonly used to measure glucose metabolism, and most malignant tumors show high FDG uptake due to increased FDG uptake and accelerated phosphorylation of FDG by hexokinase in malignant cells. One problem with the use of FDG for the diagnosis of gliomas is the high background uptake of FDG in glucose-dependent brain tissue. Thus, accurate evaluation of gliomas with FDG-PET is difficult especially in low grade gliomas. The rate of protein synthesis is increased in proliferating brain tumors and increased uptake of labeled amino acid has been demonstrated in gliomas. The PET examination with L-methyl-11 C-methionine (MET) has been reported to delineate gliomas more accurately than CT or MRI (Herholz et al., 1998), and is generally considered to provide the most reliable images for grading glioma (Ceyssens et al., 2006; Hatakeyama et al., 2008; Kaschten et al., 1998). MET readily crosses the intact BBB via the neutral amino acid transporter system and is incorporated into the active tumor cells. MET-PET is also a well-established imaging tool for prediction of prognosis (Kaschten et al., 1998; Ribom et al., 2001; Van Laere et al., 2005), evaluation of response to treatment (Galldiks et al., 2006; Nariai et al., 2005; Nuutinen et al., 2000; Ribom et al., 2002), malignant progression (Ullrich et al., 2009), and differentiation between tumor recurrence and radiation necrosis in patients with gliomas (Tsuyuguchi et al., 2004). However, increased MET uptake in non-neoplastic brain lesions including inflammation, infarction, or hemorrhage may cause false-positive. Also, the short half-life of 11 C (20 min) and rapid in vivo degradation make MET-PET less useful for routine clinical use. 3 -deoxy-3 -[18 F]fluorothymidine (FLT), a fluorinated thymidine analog, has emerged as a promising PET tracer for evaluating tumor proliferating activity in various malignant brain tumors (Chen et al., 2005; Choi et al., 2005; Hatakeyama et al., 2008; Saga et al., 2006). FLT is phosphorylated by thymidine kinase-1 (TK1), a principle enzyme in the salvage pathway of DNA synthesis, which is trapped inside the cells. Phosphorylated FLT appears resistant to

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degradation and is suitable for imaging with PET. The application of FLT phosphorylation as a marker of cell proliferation is based on the assumption that cellular FLT trapping is a representation of thymidine incorporation into DNA (Been et al., 2004; Shiels et al., 1998). As FLT uptake in the normal brain tissue is very low, FLT-PET provides a low-background brain image, and thus is considered to be an ideal PET tracer for the imaging of brain tumors. FLT-PET has been found useful for noninvasive grading of gliomas (Chen et al., 2005; Choi et al., 2005; Hatakeyama et al., 2008; Jacobs et al., 2005; Saga et al., 2006). In addition, FLTPET has been utilized in the prognostic assessment (Chen et al., 2005, 2007) and evaluation of treatment response (Chen et al., 2007) in malignant gliomas. Jacobs et al. (2005) compared MET-PET and FLTPET findings and contrast enhanced MRI to determine DNA metabolism and amino acid uptake as well as the integrity of the blood-brain barrier (BBB) in 23 patients with gliomas. They conclude that FLTPET provides information on the extent and activity of a glioma additional to that provided by MET-PET and MRI (Jacobs et al., 2005). However, the patients used in the study were quite heterogeneous and 15 of 23 patients were previously treated cases. Treatment with radiotherapy damages the integrity of the cerebral endothelial cells (Cao et al., 2005). Endothelial cell damage may increase the passive influx of the radioisotope through the disrupted BBB and mislead the interpretation of PET findings. Therefore, the purpose of this prospective study was to clarify the individual and combined role of MET-PET and FLT-PET in tumor detection, noninvasive grading and assessment of the cellular proliferation rate in 62 newly diagnosed histologically verified gliomas of different grades.

Materials and Methods Patients Sixty-two patients with newly diagnosed gliomas (33 men and 29 women; mean age, 49.8 ± 18.3 year; range, 2–89 year) were enrolled in this study. MET has been available from the beginning of this prospective study; however, FLT became available later. Therefore, MET-PET was performed in all 62 patients and FLT-PET was performed in only 36 of the patients. No patients had previous treatment except steroid therapy

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before PET. Histopathology was performed on tissue specimens obtained by biopsy or resection. All tumors were graded by the World Health Organization (WHO) grading system (malignancy scale) for CNS tumors. Tumor types and grades were distributed as follows: WHO grade II astrocytoma (n = 13), WHO grade II oligoastrocytoma (n = 3), WHO grade II oligodendroglioma (n = 1), WHO grade II ependymoma (n = 1), WHO grade III astrocytoma (n = 16), WHO grade III anaplastic oligodendroglioma (n = 2), WHO grade III gliomatosis cerebri (n = 1), WHO grade III anaplastic ependymoma (n = 1), WHO grade IV glioblastoma (n = 23), WHO grade IV gliosarcoma (n = 1). The cellular proliferation activity of the tumor was determined by measuring the Ki-67 labeling index obtained by immunohistochemical staining with antiKi-67/MIB-1. Immunostained slides were examined at a high-power magnification (×400). The percentage of tumor cells that stained positively for Ki-67 antigen was measured in the area containing the largest number of positive tumor cells and was regarded as representative of the tumor proliferation activity. All patients underwent contrast-enhanced MRI with gadoliniumdiethylenetriaminepentaacetic acid (Gd-DTPA) within 1 week of PET examination.

PET Examinations and Data Analysis PET examinations were performed using an ECAT EXACT HR+ scanner (Siemens/CTI, Knoxville, TN, USA) in the three-dimensional acquisition mode. The image system enabled the simultaneous acquisition of 51 transverse per field of view (FOV), with intersection spacing of 3 mm, for a total axial FOV of 15 cm. The in-plane reconstructed resolution was 4.7 mm full-width at half maximum in the brain FOV. In most patients, PET examinations were performed several days before the surgery. When both tracers were examined in one patient (n = 36), studies were not performed on the same day and the time interval between the two examinations was usually 24–72 h. No special dietary instructions were given to the patients before PET examination. Images were acquired with patients in the supine position, resting, with their eyes closed. Using 68 Ge rod sources rotating around the head, transmission images of the brain were obtained for 3 min for MET-PET and for 5 min for FLT-PET. A dose of 113–389 MBq (mean, 218 ± 59 MBq) of 11 C-MET

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or 116–336 MBq (mean, 187 ± 54 MBq) of 18 F-FLT was injected intravenously. Regional emission images of the brain were obtained for 5 min, beginning 10 min after the 11 C-MET injection and for 10 min, beginning 40 min after the 18 F-FLT injection. MET and FLT uptakes in the brain lesion were semiquantitatively assessed by evaluating the standardized uptake value (SUV, activity concentration/injected dose/body weight). A region of interest (ROI) was set manually by an observer around the hottest area of each lesion or its center located by MRI, if increased MET and FLT uptake was absent. The maximum value of SUV (SUVmax) was regarded as the representative value of each tumor. To calculate the tumor-to-normal tissue count density (T/N) ratios, ROI was set on the normal brain parenchyma (usually contralateral normal cerebral tissue excluding ventricles) and the mean value of SUV (SUVmean) was calculated. The T/N ratio was determined by dividing the SUVmax of the tumor with the SUVmean of the normal brain tissue. A lesion was considered to be non-visualized if the T/N ratio was < 1.2. This study was divided into three parts. In the first part, the measured SUVmax and T/N ratios of MET and FLT were compared with the histological diagnoses obtained by biopsy or resection. In the second part, the relationship between MET and FLT uptake in the tumor was evaluated in 18 patients who underwent PET examination with both tracers. Finally, the relationship between the tumor proliferation activity determined by Ki-67 labeling index and tracer uptake was examined.

Statistical Analysis All parametric data were expressed as mean ± SD. Statistical analyses were performed to compare the tumor grade and SUVmax and T/N ratios of each tracer by using analysis of variance and post hoc comparisons with Bonferroni correction. Linear regression analysis, including Spearman rank correlation coefficient test, was used to determine whether MET or FLT SUVmax was related to the proliferative Ki-67 labeling index. Linear regression analysis was also performed to evaluate the relationship between MET and FLT uptake in the tumor. Sensitivity and specificity were calculated based on the PET data compared with the subsequent pathology. Two-tailed probability values of < 0.05 were considered statistically significant.

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Results Tumor Detection of High- and Low-Grade Gliomas with MET and FLT MET-PET detected all 44 high grade (III and IV) gliomas by visual analysis (T/N ratios > 1.2). Seven of 18 low grade (II) gliomas (38.9%) that did not show contrast enhancement on MRI with Gd-DTPA were not detected in MET-PET. Thus, of all the 62 gliomas studied, 55 (88.7%) were imaged by MET-PET. On the other hand, FLT-PET detected all 27 high grade gliomas. Five of 9 low grade gliomas (55.6%) were not visually detected in FLT-PET. Thus, of all the 36 gliomas studied, 31 (86.1%) were imaged by FLTPET. Tumors that were false-negative on MET-PET were also false-negative on FLT-PET. No tumors were detected by FLT-PET only. By using both tracers, the sensitivity rate in tumor detection was 88.9% (32 of 36 cases) in our series, because one false negative low grade glioma with FLT had a positive finding in MET-PET.

a

• MET-PET and FLT-PET can detect all high-grade gliomas (100% sensitivity). • MET-PET cannot detect about 40% of grade II gliomas and FLT-PET cannot detect about 56% of grade II gliomas. • MET-PET exhibits a slightly higher sensitivity in tumor detection than FLT-PET.

Tracer Uptake and Tumor Grade Normal brain parenchyma had low MET uptake with the SUVmean of 1.46 ± 0.33 (range, 0.93–2.62). The average MET SUVmax in WHO grade II (n = 18), III (n = 20) and IV (n = 24) gliomas was 2.80 ± 1.37, 3.94 ± 1.36 and 4.54 ± 1.31, respectively, and the average MET T/N ratio in grade II, III and IV gliomas was 1.83 ± 0.84, 2.81 ± 0.98 and 3.31 ± 0.94, respectively (Fig. 12.1a). There was a highly significant correlation between individual MET SUVmax and T/N ratio (r = 0.89, P < 0.001). The difference in the MET SUVmax and T/N ratio between grade II and grade IV gliomas was statistically significant

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(P < 0.001). Again, the difference in the MET SUVmax and T/N ratio between grade II and grade III gliomas was statistically significant (∗ : P < 0.05). The difference in the MET SUVmax and T/N ratio between grade III and grade IV gliomas was not statistically significant. A scatterplot figure demonstrated that there was a significant overlap of MET uptake in the tumors despite the significant difference between grade II and grade III gliomas (Fig. 12.1a). This is due to relatively high MET uptake in grade II oligodendroglioma and oligoastrocytoma (arrows in Fig. 12.1a) compared to that in grade II astrocytoma. Normal brain parenchyma had very weak FLT uptake with the SUVmean of 0.19 ± 0.04 (range, 0.11– 0.28). The average FLT SUVmax in WHO grade II (n = 9), III (n = 9) and IV (n = 18) gliomas was 0.27 ± 0.08, 0.69 ± 0.42 and 1.98 ± 0.80, respectively, and the average FLT T/N ratio in grade II, III and IV gliomas was 1.48 ± 0.61, 3.87 ± 2.11 and 10.22 ± 3.79, respectively (Fig. 12.1b). There was a highly significant correlation between individual FLT SUVmax and T/N ratio (r = 0.93, P < 0.001). The differences in the FLT SUVmax and T/N ratio between grade III and grade IV gliomas were statistically significant (#: P < 0.001). However, the differences in the FLT SUVmax and T/N ratio between grade II and grade III gliomas were not statistically significant probably due to relatively high variation of FLT uptake in grade III gliomas. Four patients with grade III

anaplastic astrocytoma (Ki-67 index, 5–10%) had no contrast enhancement on MR images with Gd-DTPA. FLT uptake in these patients was similar to the low levels observed in grade II gliomas (SUVmax, 0.28–0.37) (arrows in scatterplot, Fig. 12.1b). • MET and FLT uptakes in gliomas increase with tumor grade. • Average MET uptake in grade III gliomas is significantly higher than that in grade II gliomas (P < 0.05). • MET uptake in grade II oligodendroglioma and oligoastrocytoma is relatively high compared to that in grade II astrocytoma. • Average FLT uptake in grade IV gliomas is significantly higher than that in grade III gliomas (P < 0.001). • FLT uptake in non-contrast enhanced grade III gliomas is relatively low compared to that in contrast enhanced grade III gliomas.

MET and FLT Uptake in Individual Tumors In 36 patients who underwent PET examination with both tracers, a significant but relatively weak correlation was observed between the individual SUVmax of MET and FLT (r = 0.52, P < 0.05) (Fig. 12.2a)

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and T/N ratio of MET and FLT (r = 0.49, P < 0.05) (Fig. 12.2b). The most distant three points (arrows in the figures) from the 95% confidence interval line, which exhibited high FLT uptake with moderate MET uptake, were glioblastoma cases with the highest Ki-67 indices (50–65%) in this series. • A significant but weak correlation is observed between the individual uptake of MET and FLT, and it seems to be difficult to precisely predict one result from the other.

Tracer Uptake and Tumor Proliferation Activity Histopathology was obtained from all 62 patients by surgery after the PET study. In all tumors examined, linear regression analysis showed a significant correlation between tracer uptake and tumor proliferation activity determined by Ki-67 labeling index. The analysis indicated a more significant correlation of the Ki-67 index with FLT SUVmax (r = 0.81, P < 0.001) and T/N ratio (r = 0.91, P < 0.001) (Fig. 12.3b) than with MET SUVmax (r = 0.40, P < 0.05) and T/N ratio (r = 0.48, P < 0.001) (Fig. 12.3a). • A significant correlation is observed between tracer uptake and tumor proliferation activity determined by Ki-67 labeling index. • Ki-67 labeling index is more significantly correlated with FLT uptake than that with MET uptake.

Discussion Positron emission tomography (PET) with 2-deoxy2-[18 F]fluoro-D-glucose (FDG) is a well established method in the diagnosis and management of patients suffering from brain tumors. FDG uptake is generally associated with histological tumor grade in gliomas. FDG uptake in low-grade gliomas (which are mostly grade II in adults) is usually similar to that of the normal white matter, whereas most grade III anaplastic gliomas have an FDG uptake exceeding that of the normal white matter or similar to that of the normal gray matter. Untreated glioblastomas show high FDG

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uptake, which might be higher than that of the normal gray matter. One problem with the use of FDG for the diagnosis of gliomas is the high background uptake of FDG in glucose-dependent brain tissue. Thus, accurate evaluation of gliomas with FDG-PET is difficult especially in low grade gliomas. MET-PET possesses high specificity in tumor detection (Herholz et al., 1998), tumor delineation (Borbély et al., 2006), and differentiation of benign from malignant lesions (Ogawa et al., 1995). Various studies have found a correlation between tumor grade and MET uptake in gliomas (Ceyssens et al., 2006; Hatakeyama et al., 2008; Kaschten et al., 1998). Amino acids, including MET readily cross the intact BBB through neutral amino acid transporters (large amino acid transporter 1: LAT-1) and are incorporated into the area with active tumor. Our recent study has demonstrated that the grade of LAT1 immunostaining increases with glioma grade and the expression of LAT1 is significantly correlated with MET uptake in newly diagnosed gliomas (Okubo et al., 2010). MET uptake in gliomas significantly correlates with cell proliferation, in vitro Ki-67 labeling index (Hatakeyama et al., 2008; Kim et al., 2005), and proliferating cell nuclear antigen expression (Sato et al., 1999). Increased MET uptake seems to be caused by increased carrier-mediated and passive transport rather than elevated protein synthesis and is highly correlated with microvessel density (angiogenesis) in gliomas (Kracht et al., 2003; Nojiri et al., 2009). Many previous studies enrolled patients with newly diagnosed and previously treated recurrent cases in their materials. Radiation therapy used as an adjuvant therapy of gliomas can cause loosening of the endothelial tight junction, vascular leakage, or endothelial cell death and increase vascular permeability (Cao et al., 2005). Radiation could act to increase vascular permeability not only in the BBB but also in the blood-tumor barrier (BTB) (Cao et al., 2005), and thus, potentially increasing passive, non carriermediated transport of MET through the endothelial cells to tumor cells. In an earlier study on suspected gliomas recurrence, there was no significant relationship between the primary tumor histopathology (grade) and MET uptake ratio (Van Laere et al., 2005), in contrast to the findings of this study performed in a pre-therapeutic setting. Also, no significant differences were found in the SUVmax and T/N ratio of MET between recurrent malignant glioma and radionecrosis following stereotactic radiosurgery (Tsuyuguchi

12 Newly Diagnosed Glioma

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et al., 2003). As for the mechanism of tracer uptake, disruption of the BBB and BTB might be responsible for increased availability and transport, and such rupture might also be present in low grade glioma and radionecrosis without active tumor cells and mislead the interpretation of PET findings. In this study, therefore, we only enrolled patients with newly diagnosed glioma to reconfirm the usefulness of MET- and FLT-PET in tumor detection, noninvasive grading and assessment of the proliferation rate. Our study revealed a significant difference in the MET SUVmax and T/N ratio between grade II and grade III gliomas. Several studies have demonstrated the impossibility of differentiation between grade II and grade III gliomas with MET-PET only (Ceyssens et al., 2006; Hatakeyama et al., 2008; Kaschten et al., 1998). We found that 4 patients with grade II oligodendroglioma and oligoastrocytoma had a higher MET uptake (SUVmax, 3.45–6.8) (Fig. 12.1a, arrows in scatterplot) than did grade II astrocytoma (average

SUVmax, 2.21 ± 0.76, n = 13). Higher MET uptake in grade II oligodendroglioma compared with grade II astrocytoma has also been reported in a recent study (Nojiri et al., 2009). This difference might reflect specific metabolic properties of oligodendroglial cells (such as myelin synthesis) and different cellular densities and rates of cell turnover of oligodendroglioma. A recent study has also shown that an increase in the microvessel area in oligodendroglioma may contribute to the higher MET uptake among low-proliferative grade II gliomas (Nojiri et al., 2009). Increased MET uptake was observed not only in pure oligodendroglioma but also in mixed oligoastrocytoma (n = 3) in our study. This finding is contrary to the finding of a previous MET-PET study on increased MET uptake in mixed oligoastrocytoma. This could be explained by the relatively high oligodendroglial tumor components in our cases. Our results indicate that there was a significant overlap of MET uptake in the tumors despite a significant difference between grade II and grade III

110

gliomas. Therefore, MET-PET is not an ideal tool to precisely predict tumor malignancy and a surrogate for pathologic grading. Also, caution must be paid to evaluate the tumors with oligodendroglial components in MET-PET. Some studies have concluded that MET-PET has more clinical usefulness in assessing the tumor invasion (Kim et al., 2005; Ogawa et al., 1995) but not the tumor grade. Although we have not compared the MET-PET and MRI findings, a previous study reported that the gadolinium-enhanced area on MR images covered, on average, only 60% of the MET accumulation area in malignant gliomas (Miwa et al., 2004). In this study we did not include the case with pilocytic astrocytoma. Recently, Galldiks et al. (2009) showed that pilocytic astrocytomas demonstrated relatively high MET uptake when comparison was made with WHO grade II astrocytomas. The histopathological features of pilocytic astrocytoma include microvascular proliferation and infiltration, but are not signs of malignancy in this tumor entity. MET transport may be increased by an increased number of microvessels combined with a higher density of transporters (LAT-1) in the endothelial cells in pilocytic astrocytomas (Okubo et al., 2010). Again, caution must be paid to evaluate the tumors with pilocytic astrocytoma in MET-PET. FLT is a newly developed PET tracer, which allows for noninvasive assessment of tumor proliferation (Chen et al., 2005; Choi et al., 2005; Hatakeyama et al., 2008; Saga et al., 2006). In contrast to MET, which provides only an indirect measure of the proliferation status as amino acid uptake in the tumor, FLT allows the direct measurement of cellular TK1 activity, which has been reported to be proportional to the proliferation activity of the tumor. In fact, our linear regression analysis indicated a much more significant correlation of the Ki-67 labeling index with FLT uptake than with MET uptake in gliomas. As uptake of FLT is low in intact brain tissue, FLT-PET provides a lowbackground cerebral image, and is thus considered to be an ideal and attractive PET tracer for the imaging of gliomas. However, the sensitivity for the detection of tumors with FLT-PET has been reported to be lower compared with MET-PET, especially for low-grade gliomas. This is the case in our small series, absolute uptake of FLT in all tumors examined is lower than that of MET (SUVmax, 1.23 ± 0.98 vs. 3.84 ± 1.50), and the FLT uptake ratio to normal brain tissue

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is higher than that of MET (T/N ratio, 6.45 ± 4.84 vs. 2.72 ± 1.10) because of extremely low uptake of FLT in normal brain tissue. Although sensitivity for tumor detection is lower for FLT-PET (86.1%) than for MET-PET (88.7%) in our series, the difference was not statistically significant. By using both tracers, the sensitivity rate in tumor detection was 88.9% (32 of 36 cases) in our series, because one falsenegative low grade glioma with FLT had a positive finding in MET-PET. Some studies have investigated several parameters simultaneously and concluded that different tracers, such as FDG and MET, can provide different and complimentary information in individual cases (Van Laere et al., 2005). However, low grade gliomas that were false negative on MET-PET were also false-negative on FLT-PET and no tumors were detected by FLT-PET only in our series. Therefore, there is no complimentary information in tumor detection with simultaneous measurements of FLT and MET uptake in cases where the tumor metabolism is only slightly increased (low grade gliomas) from that of the normal brain tissue. When comparison was made between individual MET and FLT uptake in the tumor, there was a significant but relatively weak correlation between the uptake of MET and FLT. The most distant three points from the 95% confidence interval area, which exhibited high FLT uptake with moderate MET uptake, were glioblastoma cases with a highly proliferative nature. This could be explained by the relatively high rate of metabolic trapping of FLT by TK1 compared to the influx effect across the BBB in these patients. Kinetic analysis of FLT uptake could clarify whether the transport effect or metabolic trapping largely contributes to the increased accumulation of FLT in the tumor (Jacobs et al., 2005). The FLT-PET study revealed that the differences in the SUVmax and T/N ratio between grade III and grade IV gliomas were statistically significant, but the differences between grade II and grade III gliomas were not statistically significant in our cases. This may have been due to the relatively small number of grade III gliomas and the relatively wide range of FLT uptake in these tumors (T/N ratio, 1.52–7.10). Four patients with grade III anaplastic astrocytoma (Ki-67 index, 5–10%) had no contrast enhancement on MR images with Gd-DTPA. FLT uptake was similar to the low levels observed in normal brain tissue in these patients (T/N ratio, 1.52–2.18, arrows in scatterplot, Fig. 12.1b).

12 Newly Diagnosed Glioma

These patients exhibited moderately increased MET uptake in the tumor (T/N ratio, 2.83–3.27). This discrepancy might be due to the selectivity of TK1 as a target of FLT for the salvage pathway of DNA synthesis. FLT accumulation is a reliable measure of the salvage pathway of DNA synthesis (Schwartz et al., 2003). In gliomas in which de novo DNA pathways are predominantly used in pyrimidine biosynthesis, the proliferation activity might be underestimated by this tracer (Schwartz et al., 2003). Muzi et al. (2006) reported a similar case in an FLT-PET study and concluded that FLT may be less useful in assessing proliferation in noncontrast-enhancing tumors regardless of histopathology grading. Low tracer access to the tumor tissue may limit the metabolic trapping of FLT by TK1 even in proliferative tumors. In conclusion, we have shown here that PET studies using MET and FLT are useful for tumor detection in 62 newly diagnosed histologically verified gliomas. MET has a slightly higher sensitivity in tumor detection than FLT (but not statistically significant) in newly diagnosed gliomas; and both tracers are 100% sensitive for malignant gliomas. However, there is no complimentary information with simultaneous measurements of MET and FLT in tumor detection of low grade gliomas. Our results reveal that MET-PET and FLT-PET appear to be a valuable tool for noninvasive tumor grading in newly diagnosed gliomas, however, caution must be paid to evaluate the tumors with oligodendroglial components for MET-PET and with noncontrast-enhancement for FLT-PET. FLT-PET seems to be superior to MET-PET in assessment of cellular proliferation activity in gliomas of different grade. This study could be adequately powered to make clear-cut distinctions for glioma grading in newly diagnosed gliomas when the sample size of FLTPET is appropriately increased. Further studies might identify the individual role of MET and FLT in gliomas of different types and grades.

References Been LB, Suumeijer AJH, Cobben DCP, Jager PL, Hoekstra HJ, Elsinga PH (2004) [18 F]FLT-PET in oncology: current status and opportunities. Eur J Nucl Med Mol Imaging 31: 1659–1672 Borbély K, Nyáry I, Tóth M, Ericson K, Gulyás B (2006) Optimization of semi-quantification in metabolic PET studies with 18 F-fluorodeoxyglucose and 11 C-methionine in

111 the determination of malignancy of gliomas. J Neurol Sci 246:85–94 Cao Y, Tsien CI, Shen Z, Tatro DS, Ten Haken R, Kessier ML, Chenevert TL, Lawrence TS (2005) Use of magnetic resonance imaging to assess blood-brain/blood-gliomas barrier opening during conformal radiotherapy. J Clin Oncol 23:4127–4136 Ceyssens S, Van Laere K, de Groot T, Goffin J, Bormans G, Mortelmans L (2006) [11 C]methionine PET, histopathology, and survival in primary brain tumors and recurrence. AJNR Am J Neuroradiol 27:1432–1437 Chen W, Cloughesy T, Kamdar N, Satyamurthy N, Bergsneider M, Liau L, Mischel P, Czernin J, Phelps ME, Silverman DHS (2005) Imaging proliferation in brain tumors with 18 F-FLT PET: comparison with 18 F-FDG. J Nucl Med 46:945–952 Chen W, Delaloye S, Silverman DHS, Geist C, Czernin J, Sayre J, Satyamurthy N, Pope W, Lai A, Phelps ME, Cloughesy T (2007) Predicting treatment response of malignant gliomas to bevacizumab and irinotecan by imaging proliferation with [18 F] fluorothymidine positron emission tomography: a pilot study. J Clin Oncol 25:4714–4721 Choi SJ, Kim JS, Kim JH, Oh SJ, Lee JG, Kim CJ, Ra YS, Yeo JS, Ryu JS, Moon DH (2005) [18 F]3 -deoxy-3 fluorothymidine PET for the diagnosis and grading of brain tumors. Eur J Nucl Med Mol Imaging 32:653–659 Galldiks N, Kracht LW, Berthold F, Miletic H, Klein JC, Herholz K, Jacobs AH, Heiss WD (2009) [11 C]-L-methionine positron emission tomography in the management of children and young adults with brain tumors. J Neurooncol 96:231–239 Galldiks N, Kracht LW, Burghaus L, Thomas A, Jacobs AH, Heiss WD, Herholz K (2006) Use of 11 C-methionine PET to monitor the effects of temozolomide chemotherapy in malignant gliomas. Eur J Nucl Med Mol Imaging 33:516–524 Hatakeyama T, Kawai N, Nishiyama Y, Yamamoto Y, Sasakawa Y, Ichikawa T, Tamiya T (2008) 11 C-methionine (MET) and 18 F-fluorothymidine (FLT) PET in patients with newly diagnosed glioma. Eur J Nucl Med Mol Imaging 35:2009–2017 Herholz K, Hölzer T, Bauer B, Schröder R, Voges J, Ernestus RI, Mendoza G, Weber-Luxenburger G, Löttgen J, Thiel A, Wienhard K, Heiss WD (1998) 11 C-methionine PET for differential diagnosis of low-grade gliomas. Neurology 50:1316–1322 Jacobs AH, Thomas A, Kracht LW, Li H, Dittmar C, Garlip G, Galldiks N, Klein JC, Sobesky J, Hilker R, Vollmar S, Herholz K, Wienhard K, Heiss WD (2005) 18 Ffluoro-L-thymidine and 11 C-methylmethionine as markers of increased transport and proliferation in brain tumors. J Nucl Med 46:1948–1958 Kaschten B, Stevenaert A, Sadzot B, Deprez M, Degueldre C, Fiore GD, Luxen A, Reznik M (1998) Preoperative evaluation of 54 gliomas by PET with fluorine-18fluorodeoxyglucose and/or carbon-11-methionine. J Nucl Med 39:778–785 Kim S, Chung JK, Im SH, Jeong JM, Lee DS, Kim DG, Jung HW, Lee MC (2005) 11 C-methionine PET as a prognostic marker in patients with glioma: comparison with 18 F-FDG PET. Eur J Nucl Med Mol Imaging 32:52–59 Kracht LW, Friese M, Herholz K, Schroeder R, Bauer B, Jacobs A, Heiss WD (2003) Methyl-[11 C]-L-methionine uptake as measured by positron emission tomography correlates to

112 microvessel density in patients with glioma. Eur J Nucl Med Mol Imaging 30:868–873 Miwa K, Shinoda J, Yano H, Okumura A, Iwama T, Nakahashi T, Sakai N (2004) Discrepancy between lesion distributions on methionine PET and MR images in patients with glioblastoma multiforme: insight from a PET and MR fusion image study. J Neurol Neurosurg Psychiatry 75:1457–1462 Muzi M, Spence AM, O’Sullivan F, Mankoff DA, Wells JM, Grierson JR, Link JM, Krohn KA (2006) Kinetic analysis of 3 -deoxy-3 -18 F-fluorothymidine in patients with gliomas. J Nucl Med 47:1612–1621 Nariai T, Tanaka Y, Wakimoto H, Aoyagi M, Tamaki M, Ishikawa K, Senda M, Ishii K, Hirakawa K, Ohno K (2005) Usefulness of L-[methyl-11 C] methionine-positron emission tomography as a biological monitoring tool in the treatment of glioma. J Neurosurg 103:498–507 Nojiri T, Nariai T, Aoyagi M, Senda M, Ishii K, Ishiwata K, Ohno K (2009) Contributions of biological tumor parameters to the incorporation rate of L-[methyl-11 C] methionine into astrocytomas and oligodendrogliomas. J Neurooncol 93:233–241 Nuutinen J, Sonninen P, Lehikoinen P, Sutinen E, Valavaara R, Eronen E, Norrgård S, Kulmala J, Teräs M, Minn H (2000) Radiotherapy treatment planning and long-term follow-up with [11 C]methionine PET in patients with low-grade astrocytoma. Int J Radiat Oncol Biol Phys 48:43–52 Ogawa T, Hatazawa J, Inugami A, Murakami M, Fujita H, Shimosegawa E, Noguchi K, Okudera T, Kanno I, Uemura K, Hadeishi H, Sasajima T (1995) Carbon-11-methionone PET evaluation of intracerebral hematoma: distinguishing neoplastic from non-neoplastic hematoma. J Nucl Med 36: 2175–2179 Okubo S, Zhen HN, Kawai N, Nishiyama Y, Haba R, Tamiya T (2010) Correlation of L-methyl-11 C-methionine (MET) uptake with L-type amino acid transporter 1 in human gliomas. J Neurooncol 99:217–225 Ribom D, Engler H, Blomquist E, Smits A (2002) Potential significance of 11 C- methionine PET as a marker for the radiosensitivity of low grade gliomas. Eur J Nucl Med 29:632–640 Ribom D, Eriksson A, Hartman M, Engler H, Nilsson A, Långström B, Bolander H, Bergström M, Smits A (2001) Positron emission tomography 11 C-methionine and

N. Kawai et al. survival in patients with low-grade gliomas. Cancer 92: 2541–2549 Saga T, Kawashima H, Araki N, Takahashi JA, Nakashima Y, Higashi T, Oya N, Murai T, Hojo M, Hashimoto N, Manabe T, Hiraoka M, Togashi K (2006) Evaluation of primary brain tumors with FLT-PET: usefulness and limitations. Clin Nucl Med 31:774–780 Sato N, Suzuki M, Kuwata N, Kuroda K, Wada T, Beppu T, Sera K, Sasaki T, Ogawa A (1999) Evaluation of the malignancy of glioma using 11 C-methionine positron emission tomography and proliferating cell nuclear antigen staining. Neurosurg Rev 22:210–214 Schwartz JL, Tamura Y, Jordan R, Grierson JR, Hrohn KA (2003) Monitoring tumor cell proliferation by targeting DNA synthetic processes with thymidine and thymidine analogs. J Nucl Med 44:2027–2032 Shiels AF, Grierson JR, Dohmen BM, Machulla HJ, Stayanoff JC, Lawhorn-Crews JM, Obradovich JE, Muzik O, Mangner TJ (1998) Imaging proliferation in vivo with [F-18]FLT and positron emission tomography. Nat Med 4:1334–1336 Tsuyuguchi N, Sunada I, Iwai Y, Yamanaka K, Tanaka K, Takami T, Otsuka Y, Sakamoto S, Ohata K, Goto T, Hara M (2003) Methionine positron emission tomography of recurrent metastatic brain tumor and radiation necrosis after stereotactic radiosurgery: is a differential diagnosis possible?. J Neurosurg 98:1056–1064 Tsuyuguchi N, Takami T, Sunada I, Iwai Y, Yamanaka K, Tanaka K, Nishikawa M, Ohata K, Torii K, Morino M, Nishio A, Hara M (2004) Methionine positron emission tomography for differentiation of recurrent brain tumor and radiation necrosis after stereotactic radiosurgery -in malignant glioma. Ann Nucl Med 18:291–296 Ullrich RT, Kracht L, Brunn A, Herholz K, Frommolt P, Miletic H, Deckert M, Heiss WD, Jacobs AH (2009) Methyl-L11 C-methionine PET as a diagnostic marker for malignant progression in patients with glioma. J Nucl Med 50: 1962–1968 Van Laere K, Ceyssens S, Van Calenbergh F, de Groot T, Menten J, Falmen P, Bormans G, Mortelmans L (2005) Direct comparison of 18 F-FDG and 11 C-methionine PET in suspected recurrence of glioma: sensitivity, inter-observer variability and prognostic value. Eur J Nucl Med Mol Imaging 32:39–51

Chapter 13

Role of Diffusion Tensor Imaging in Differentiation of Glioblastomas from Solitary Brain Metastases Sumei Wang, Harish Poptani, Elias R. Melhem, and Sungheon Kim

Abstract Differentiation between glioblastomas and solitary brain metastases is an important clinical problem as the treatment strategy can significantly differ depending on the tumor type. However, due to their similar appearance on conventional magnetic resonance imaging, accurate distinction between glioblastomas and brain metastases remains challenging and often necessitates an invasive surgical biopsy for a definitive diagnosis. Recently, diffusion tensor magnetic resonance imaging (DTI) has been applied in solving this problem and has demonstrated potential as a noninvasive imaging biomarker to differentiate glioblastomas from solitary brain metastases. This chapter provides a brief review on the fundamental concepts of DTI and how this new imaging method can be applied in differentiation between glioblastomas and solitary brain metastases. It also includes discussions on some practical issue to further improve the reliability of the method and potential metrics sensitive to tumor that can be derived from DTI data. Keywords Glioblastomas · DTI · Metastases · Neoplasms · MRI · ADC and FA

Introduction Glioblastomas and brain metastases are the two most common brain neoplasms in adults. The management of these two neoplasms is vastly different and can

S. Kim () Department of Radiology, Center for Biomedical Imaging, New York University School of Medicine, New York, NY 10016, USA e-mail: [email protected]

potentially affect the clinical outcome (Giese and Westphal, 2001; Soffietti et al., 2002). For example, patients with glioblastomas almost always undergo surgical resection (Giese and Westphal, 2001), while patients with suspected brain metastases without clinical history of systemic cancer undergo a complicated systemic staging to determine the site of primary carcinoma and evaluation for distant metastases before any surgical intervention or medical therapy (Soffietti et al., 2002). In some cases, clinical history and presence of multiple peripheral enhancing lesions in the brain makes the diagnosis of brain metastases relatively straightforward. However, appearance of the solitary brain metastases on magnetic resonance imaging (MRI) can be nonspecific. Similarly, glioblastomas can also occasionally present as multiple peripheral enhancing lesions. Although glioblastomas typically present as a solitary mass, a solitary brain metastasis may be the first manifestation of disease in about 30% of patients with systemic cancer. Hence, accurate distinction between glioblastomas and brain metastases remains challenging, which often necessitates an invasive surgical biopsy for a definitive diagnosis. Conventional MRI is limited in making an accurate distinction between glioblastomas and brain metastases due to their similar appearance. Both neoplasms may exhibit ring-enhancement and extensive edema. Over the past few years, diffusion tensor imaging (DTI) has been increasingly used to study pathologic changes in brain tumors (Murakami et al., 2009; Yamasaki et al., 2005). DTI has also been investigated in differentiating glioblastomas from metastases (Lu et al., 2004; Tsuchiya et al., 2005; Wang et al., 2009). In this chapter, we will briefly explain the DTI technique and its application in differentiating glioblastomas from solitary brain metastases.

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_13, © Springer Science+Business Media B.V. 2011

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Pathophysiology of Brain Tumors Glioblastoma is the most common and most malignant primary brain tumor. According to the World Health Organization (WHO) classification, it is also listed as Grade IV astrocytoma. Pathologically, it is composed of highly cellular anaplastic cells with marked nuclear atypia and mitotic activity, accompanied by marked regional heterogeneity and cellular polymorphism as well as microvascular proliferation and necrosis. Glioblastoma is associated with a high proliferation rate (Ki-67 labeling about 15–20%). As glioblastomas are biologically aggressive tumors, they tend to grow in an infiltrative manner, invading the surrounding tissues, especially the white matter tracts (Rees et al., 1996). Brain metastases are tumors originating from other organs of the body which spread into the brain via hematogenous routes. Neoplastic cells from the primary site can break away and enter the body’s circulatory blood stream. These neoplastic cells circulate, travel and take up residence in the brain. The malignant cells multiply in the endothelial cell layer and grow into the brain parenchyma in a non-infiltrating

Fig. 13.1 (a) Geometric interpretation of the tensor using the diffusion ellipsoid. The re-parameterized tensor obtained from a set of diffusion-weighted measurements has principal, intermediate, and minor eigenvalues (λ1 , λ2 , λ3 ) and corresponding eigenvectors (e1 , e2 , e3 ). These values define the relative magnitude and direction of diffusion along three spatial dimensions within each voxel respectively. Depending on the underlying probability of intravoxel diffusion, the tensor may take on one of three cardinal shapes – prolate (CL), spherical (CS), or oblate

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advancing pattern. The most common brain metastases are from lung, breast and melanoma. Histological appearance and cellularity of the brain metastases are identical to those of the primary tumor (Zhang and Olsson, 1997), and they may vary markedly among the primary tumor types.

Methodology-Diffusion Tensor Imaging Diffusion imaging probes the self-diffusional movement of water molecules, which can be detected by the attenuation of MRI signal using a diffusion weighted sequence. When unimpeded, water molecules move in a random manner (isotropic diffusion). However, the presence of obstacles, such as axonal membranes and myelin sheaths in white matter fiber tracts, restricts and/or hinders this molecular motion in a particular direction resulting in anisotropic diffusion. Apparent diffusivity of water is generally higher in directions parallel to fiber tracts than in the perpendicular direction (Beaulieu, 2002). Three dimensional probability distribution of diffusivity can be described by a diffusion tensor ellipsoid with three eigenvectors and the corresponding eigenvalues (λ1 and λ2 λ3 , Fig. 13.1a).

(CP). Reprinted with permission from Hess CP et al. (2007). (b) Bivariate normal distribution of the tissue shape measurement in 3P space. The distribution is highly overlapping in three groups of tissues: (1) corpus callosum (CC) and internal capsule (IC), (2) arcuate fasciculus (AF) and subcortical white matter (SCW), and (3) gray matter (GM), lentiform nucleus (LEN) and thalamus (TH). Reprinted with permission from Alexander et al. (2000)

13 Role of Diffusion Tensor Imaging in Differentiation of Glioblastomas

The eigenvector associated with the largest eigenvalue denotes the predominant orientation of fibers in a given imaging voxel. If a particular voxel has a high degree of anisotropy, one of the eigenvalues will be much higher than the other two. Most commonly used indices for diffusion tensor are apparent diffusion coefficient (ADC) and fractional anisotropy (FA) (Basser and Pierpaoli, 1996), which can be calculated according to Eqs. (13.1) and (13.2), respectively ADC = (λ1 + λ2 + λ3 )/3

(13.1)

3 (λ1 − λ)2 + (λ2 − λ)2 + (λ3 − λ)2 FA = 2 λ21 + λ22 + λ23 (13.2) where λ denotes mean of the three eigenvalues. ADC is a measure of the directionally averaged magnitude of diffusion and is related to cell density, size and parenchyma permeability. FA represents the degree of diffusion anisotropy, and reflects the degree of alignment of cellular structure (Basser and Pierpaoli, 1996). Although FA is a good indicator of diffusion anisotropy, it does not provide information on the shape of the diffusion ellipsoid. For example, it cannot distinguish a flat ellipsoid from an oblong one. Westin et al. (2002) have modeled diffusion anisotropy using a set of three basic metrics that depend on the shape of the diffusion tensor: linear anisotropy coefficient (CL) where diffusion is mainly along the direction corresponding to the largest eigenvalue; planar anisotropy coefficient (CP) where diffusion is mainly restricted to the plane spanned by the two eigenvectors corresponding to the two largest eigenvalues; and spherical anisotropy coefficient (CS), which indicates isotropic diffusion (Hess and Mukherjee, 2007) (Fig. 13.1a). The CL, CP and CS values can be calculated using the following equations: CL = (λ1 − λ2 )/(λ1 + λ2 + λ3 )

(13.3)

CP = 2(λ2 − λ3 )/(λ1 + λ2 + λ3 )

(13.4)

CS = 3λ3 /(λ1 + λ2 + λ3 ).

(13.5)

The CL, CP and CS values lie in the range from 0 to 1 and the sum of these three metrics is equal to 1 for a given voxel: CL + CP + CS = 1.

(13.6)

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Information on the geometric nature of diffusion tensor can aid in quantitative characterization of the local structure in tissue and provide further tensor shape differentiation in comparison to FA (Alexander et al., 2000; Westin et al., 2002; Zhang et al., 2004). The DTI features of white matter are quite different for each of the anisotropy measures. These differences arise from the relative contribution of the linear, planar and spherical shape components of the diffusion tensor. Figure 13.1b shows the distribution of tensor shape measurements from the gray matter, deep nuclei and white matter regions in three phase (3P) tensor shape diagram. The commissural and deep projection (internal capsule and corticospinal) tracts are dominated by linear shape, whereas arcuate fasciculus and peripheral radiation fibers have a significant planar feature. The gray matter appears isotropic with high CS and mainly clustered near the top of the plot. Deep nuclei (thalamus and lentiform) regions contain some axon connections and are slightly more anisotropic than the gray matter (Westin et al., 2002; Zhang et al., 2004). These studies suggest that tensor shape measurements allow one to explore the tissue microstructural difference.

Diffusion Tensor Imaging in Tumor Classification The diffusion properties of water molecules are directly related to the microstructure of the medium in which they reside, which determines the DWI and DTI contrast for diagnostic purposes. As such, diffusion MR imaging has been used extensively in clinical practice because of its exquisite sensitivity to cellular status, cytotoxic edema, cellular density, and directional organization of the tissue (Chenevert et al., 2006). In brain tumors, DTI provides a promising tool for detecting microscopic difference in tissue properties. Diagnostic brain tumor imaging involves not only the characterization of the tumor, but also detection of reactive and infiltrative changes surrounding the tumor. The neoplastic mass can be generally subdivided into two regions; the contrast-enhancing region representing the solid part of the tumor and the central area with no or slight enhancement representing the necrotic or cystic part of the tumor. Similarly, the peritumoral edematous region can be separated into two regions; proximal region surrounding the enhancing part of

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the tumor potentially including infiltrative tumor cells, and more distal region mainly comprised of vasogenic edema. These four sub-regions of a tumor lesion can be substantially different from each other in terms of their DTI indices. Hence, when comparing the observations of different studies, it is often important to note where the measurements were made. In addition, systematic analysis of DTI parameters from these different areas may provide a robust way for characterization of brain neoplasms.

Correlation of ADC with Tumor Cellularity ADC reflects the rate of diffusional motion of the water molecules. Of all the histologic features used in tumor classification, cellularity has been the main target of assessment with DTI. The higher the tumor cellularity (and hence the higher volume of intracellular space), the lower the ADC value due to decreased water diffusivity caused by a relative reduction in extracellular space for the water molecules to move about (Beaulieu, 2002; Chenevert et al., 2006). This inverse correlation between ADC and cellularity has been reported in both glial (Yamasaki et al., 2005) and nonglial tumors (Guo et al., 2002) (Fig. 13.2).

Fig. 13.2 (a) Scatterplot of FA versus ADC measured in solid enhancing tumors and contralateral NAWM. Measurements from lymphomas tend to cluster in the area corresponding with FA and ADC decreases, whereas measurements from GBMs tend to cluster in area corresponding with FA and ADC increases. Reprinted with permission from Toh et al. (2008). (b) Scatterplot of FA versus MD measured in solid tumors. FA plotted as a function of MD. FA and MD showed an inverse

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ADC values have also been used in differentiating glioblastomas from metastases, however, with mixed results (Calli et al., 2006; Lu et al., 2004; Morita et al., 2005; Oh et al., 2005; Tsuchiya et al., 2005; Yamasaki et al., 2005). Some reports have suggested that ADC (Lu et al., 2004; Morita et al., 2005) is helpful for the differentiation, while others indicated the limited use of ADC in the differentiation of neoplasms (Calli et al., 2006; Oh et al., 2005; Yamasaki et al., 2005). In our previous study (Wang S et al., 2009), we did not observe a significant difference in the ADC values from the enhancing areas between glioblastomas and metastases, indicating limited sensitivity and specificity of this parameter in tumor differentiation (Fig. 13.3b). Besides cellularity, other factors such as extracellular matrix, viscosity and mucins may also affect the measurement of ADC (Zamecnik, 2005).

Role of FA from the Enhancing Region of the Tumor FA reflects the orientation of tissue microstructure, and as such its use may not be limited to the white matter tracts alone (Beaulieu, 2002). Regions of relatively high anisotropy have been reported in brain abscesses (Kumar et al., 2007), glioblastomas (Beppu et al.,

correlation (R = 0.70). Measurements from lymphomas tend to cluster in the area corresponding with FA increases and MD decreases, whereas measurements from high grade tumors tend to cluster in area corresponding with FA decreases and MD increases. G2; grade 2 glioma, G3 and G4; grade 3 and grade 4 glioma, ML; malignant lymphoma. Reprinted with permission from Kinoshita et al. (2008)

13 Role of Diffusion Tensor Imaging in Differentiation of Glioblastomas

Fig. 13.3 (a) A 68 year old female with a glioblastoma in the left frontal lobe. No hemorrhage was noted based on T1 and T2-weighted images (not shown). Transverse contrast-enhanced T1-weighted (1760/3.1) (A) and FLAIR (9420/141) (B) images show ring-enhancement and extensive edema. ADC map (C) shows restricted diffusion of the enhancing part. FA (D), CL (E) and CP (F) from the enhancing part are lower than normal appearing white matter. (b) Box plot of imaging characteristics in glioblastomas (white box) and brain metastases (gray box). Boxes represent the median, the 25th and the 75th percentiles, bars indicate the range of data distribution. Circles

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represent outliers (values more than 1.5 box length from the 75th/25th percentile). ∗ indicates significant differences (p < 0.05) between glioblastomas and brain metastases. CR: central region. ER: enhancing region. IPR: immediate peritumoral region. DPR: distant peritumoral region. (c) Receiver operative characteristic (ROC) curves for FA, CL, CP, ADC and logistic regression model (LRM) from the enhancing region of the tumor. ADC+FA+CP is the best predictor for differentiation of glioblastomas from brain metastases with area under the curve (AUC) 0.98. Reprinted with permission from Wang S et al. (2009)

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2003) and areas of hemorrhage (Kumar et al., 2007), indicating that FA is also related to structural orientation of the tissue/cells other than the white matter. In contrast to ADC, the relationship between FA and tumor cellularity is unclear, as both positive (Beppu et al., 2003; Kinoshita et al., 2008) and negative (Toh et al., 2008) correlation has been reported (Fig. 13.2). While Wang W et al. (2009) and Reiche et al. (2010) reported lower FA from the enhancing regions of glioblastomas compared with brain metastases, we observed higher FA in the enhancing regions of glioblastomas than in those of metastases (Wang S et al., 2009) (Fig. 13.3a). One likely reason for these contradictory results is the lack of standardized methods, both for acquisition as well as postprocessing and selection of region of interest (ROI). Our recent work (Wang et al., 2010) demonstrated high FA in glioblastomas compared with both brain metastases and primary cerebral lymphomas. Among these three tumor types, lymphomas have the highest cellularity, followed by glioblastomas and brain metastases (Koeller et al., 1997; Rees et al., 1996; Zhang and Olsson, 1997). These findings indicate that diffusion anisotropy may not directly correlate with tumor cellularity. It has been reported that FA of tumor can be affected by several factors including extracellular to intracellular space ratio, extracellular matrix, tortuosity and vascularity (Zamecnik, 2005).

Shape Based Diffusion Tensor Metrics in Differentiation of Brain Tumors FA is a scalar metric, which indicates the degree of anisotropy, regardless of the shape of the diffusion ellipsoid. Diffusion tensor can represent tubular, planar, or spherical shape of diffusion pattern, measured by CL, CP and CS, respectively (Alexander et al., 2000; Westin et al., 2002; Zhang et al., 2004). Both CL and CP values contribute to FA observed in tissue and their relative values indicate the shape of diffusion ellipsoid (Alexander et al., 2000). Tensor shape measurements provide further differentiation of tumors in comparison to that based on FA and/or ADC (Westin et al., 2002; Zhang et al., 2004). Zhang et al. (2004) reported lower CL in brain metastases than contralateral normal brain. Higher CP values in fibroblastic meningiomas were reported in

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comparison with other subtypes, such as endothelial meningiomas (Tropine et al., 2007). Kumar et al. (2007) reported high CP and low CL in the abscess cavity compared with normal white matter thus distinguishing true from pseudo white matter tracts. It has also been reported that epidermoid cysts have high CP (Santhosh et al., 2009) and tuberculomas showed lower CL, CP and higher CS (Gupta et al., 2008) compared with normal white matter. We have earlier demonstrated higher FA, CL and CP from the enhancing part of glioblastomas in comparison to brain metastases (Wang S et al., 2009) (Fig. 13.3b). These results suggest that tensor shape measurements provide additional information about tissue characteristics, which may further aid in tumor classification. A ring with high CP has been reported in glioblastomas, brain metastases and meningiomas. While the potential reason for the observation of this ring remains speculative, its presence may reflect compression of surrounding tissue by the tumor (Tropine et al., 2007; Zhang et al., 2004).

DTI in Assessing Tumor Infiltration Generally speaking, peritumoral region is defined as the area of abnormality surrounding the enhancing part of the tumor. In metastatic brain tumors, peritumoral edema is widely regarded as vasogenic edema. In this region, increased extracellular water is present due to leakage of plasma from altered tumor capillaries. Also this region does not include any tumor cells. In glioblastomas, on the other hand, the peritumoral region includes both vasogenic edema and infiltrating tumor cells. Discrimination of tumor-infiltrated edema from pure vasogenic edema may be beneficial for accurate preoperative diagnosis of glioblastomas and metastases. Most DTI studies on this subject have focused on the peritumoral regions of the tumor (Lu et al., 2004; Morita et al., 2005; Tsuchiya et al., 2005; Zhang and Olsson, 1997). In particular, Lu et al. (2004) reported a significant difference between tumor-infiltrated edema and pure vasogenic edema using a parameter called “tumor infiltration index”, which measures departure from a linear relationship between ADC and FA. These authors also reported higher ADC in metastasis compared to glioblastomas. However, another study

13 Role of Diffusion Tensor Imaging in Differentiation of Glioblastomas

demonstrated lower ADC in the peritumoral region of metastases compared to that of glioblastomas (Morita et al., 2005). In contrast, van Westen et al. (2006) reported no difference in ADC and FA values in the peritumoral region of glioblastomas, metastases and meningiomas. Recently, Kinoshita et al. (2010) claimed that “tumor infiltration index” could not differentiate vasogenic edema from tumor infiltrated edema. The difference in defining the ROIs for the peritumoral region in these studies may in part be responsible for the discrepancy. A number of studies have focused on the area close to the enhancing region (peritumoral region) by either manually placing a number of small ROIs around the tumor (Morita et al., 2005) or by using a band of arbitrarily chosen thickness around the tumor (Law et al., 2002; Oh et al., 2005). In our previous study (Wang S et al., 2009), the peritumoral areas were further subdivided into immediate peritumoral region and distant peritumoral region with the hypothesis that the immediate peritumoral region may have a higher degree of tumor infiltration in glioblastomas. We observed a significant difference in FA, CL, and CP between glioblastomas and metastases in the immediate peritumoral region. In the distant peritumoral region, only FA and CP measurements reached significant difference between the two tumor types (Wang S et al., 2009). While statistical significance was observed, the overall sensitivity, specificity and accuracy for all the DTI metrics in the peritumoral areas were lower than in the enhancing part of the tumor (Fig. 13.3c). Since the edematous region contains areas of increased extracellular water, tumor infiltration and varying fractional composition of normal white/gray matter, it is difficult to determine which factor dominates the DTI metrics. These confounding factors may further explain the conflicting reports of DTI characteristics in the peritumoral regions.

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limited role in tumor classification. We have previously reported that the single best predictor for differentiation between glioblastomas and brain metastases is FA, with a sensitivity 89%, specificity 80% and AUC of 0.90 (Wang S et al., 2009). Accurate characterization of complicated tissue, such as a tumor, may require two or more imaging parameters. To date, only a limited number of studies have investigated the role of DTI parameters in combination for tumor classification. In a recent publication, it was suggested that a combination of minimum ADCs and difference of ADC facilitates more accurate grading of astrocytomas than either parameter measured individually (Murakami et al., 2009). We have previously reported that a multivariate logistic regression analysis can determine an optimal combination of DTI parameters to differentiate glioblastomas from brain metastases (Wang S et al., 2009). From a study with sixty three patients, we reported that a combination of ADC, FA and CP from the enhancing part of the tumor provides most accurate tumor classification, with a sensitivity of 92%, specificity of 100% and AUC 0.98 (Fig. 13.3c).

Conclusion In this chapter, we have discussed how glioblastomas and metastases can be characterized by DTI metrics, such as ADC, FA, CL, CP and CS. These DTI metrics can be used individually or in combination, to differentiate glioblastomas from metastases. Further investigations on a larger patient population and histological validation will be necessary to determine the robustness of these parameters in differentiating tumor types. Combined with rapidly growing MRI technology for faster imaging and higher resolution, DTI holds a great promise to elucidate morphological and functional characteristics of brain tumors noninvasively.

Combined DTI Metrics for Classification References As mentioned previously in the introduction, in vivo DTI data provides a number of parameters that provide information about the shape, magnitude and degree of diffusion anisotropy, which may in turn be used to differentiate different tumor types. However, these parameters, by themselves individually, have a

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120 Beaulieu C (2002) The basis of anisotropic water diffusion in the nervous system – a technical review. NMR Biomed 15:435–455 Beppu T, Inoue T, Shibata Y, Kurose A, Arai H, Ogasawara K, Ogawa A, Nakamura S, Kabasawa H (2003) Measurement of fractional anisotropy using diffusion tensor MRI in supratentorial astrocytic tumors. J Neurooncol 63:109–116 Calli C, Kitis O, Yunten N, Yurtseven T, Islekel S, Akalin T (2006) Perfusion and diffusion MR imaging in enhancing malignant cerebral tumors. Eur J Radiol 58:394–403 Chenevert TL, Sundgren PC, Ross BD (2006) Diffusion imaging: insight to cell status and cytoarchitecture. Neuroimaging Clin N Am 16:619–632 Giese A, Westphal M (2001) Treatment of malignant glioma: a problem beyond the margins of resection. J Cancer Res Clin Oncol 127:217–225 Guo AC, Cummings TJ, Dash RC, Provenzale JM (2002) Lymphomas and high-grade astrocytomas: comparison of water diffusibility and histologic characteristics. Radiology 224:177–183 Gupta RK, Haris M, Husain N, Saksena S, Husain M, Rathore RK (2008) DTI derived indices correlate with immunohistochemistry obtained matrix metalloproteinase (MMP-9) expression in cellular fraction of brain tuberculoma. J Neurol Sci 275:78–85 Hess CP, Mukherjee P (2007) Visualizing white matter pathways in the living human brain: diffusion tensor imaging and beyond. Neuroimaging Clin N Am 17:407–426 Kinoshita M, Goto T, Okita Y, Kagawa N, Kishima H, Hashimoto N, Yoshimine T (2010) Diffusion tensor-based tumor infiltration index cannot discriminate vasogenic edema from tumor-infiltrated edema. J Neurooncol 96:409–415 Kinoshita M, Hashimoto N, Goto T, Kagawa N, Kishima H, Izumoto S, Tanaka H, Fujita N, Yoshimine T (2008) Fractional anisotropy and tumor cell density of the tumor core show positive correlation in diffusion tensor magnetic resonance imaging of malignant brain tumors. NeuroImage 43:29–35 Koeller KK, Smirniotopoulos JG, Jones RV (1997) Primary central nervous system lymphoma: radiologic-pathologic correlation. Radiographics 17:1497–1526 Kumar M, Gupta RK, Nath K, Rathore RK, Bayu G, Trivedi R, Husain M, Prasad KN, Tripathi RP, Narayana PA (2007) Can we differentiate true white matter fibers from pseudofibers inside a brain abscess cavity using geometrical diffusion tensor imaging metrics?. NMR Biomed 21:581–588 Law M, Cha S, Knopp EA, Johnson G, Arnett J, Litt AW (2002) High-grade gliomas and solitary metastases: differentiation by using perfusion and proton spectroscopic MR imaging. Radiology 222:715–721 Lu S, Ahn D, Johnson G, Law M, Zagzag D, Grossman RI (2004) Diffusion-tensor MR imaging of intracranial neoplasia and associated peritumoral edema: introduction of the tumor infiltration index. Radiology 232:221–228 Morita K, Matsuzawa H, Fujii Y, Tanaka R, Kwee IL, Nakada T (2005) Diffusion tensor analysis of peritumoral edema using lambda chart analysis indicative of the heterogeneity of the microstructure within edema. J Neurosurg 102: 336–341 Murakami R, Hirai T, Sugahara T, Fukuoka H, Toya R, Nishimura S, Kitajima M, Okuda T, Nakamura H, Oya N,

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Chapter 14 131 I-TM-601 SPECT imaging of Human Glioma Adam N. Mamelak and David Hockaday

Abstract Primary malignant brain tumors (gliomas) typically infiltrate deeply into surrounding normal brain tissue. Currently available methods to determine the true extent of glioma infiltration are limited. For example, T1 weighted MRI tends to underestimate the extent of infiltration, while T2 weighted imaging tends to overestimate it. Most radio-labeled ligands are not tumor specific. Accurate determination of extent of infiltration is important to guide treatment and to measure response to therapy. TM-601 (chlorotoxin), a 36-amino-acid peptide first identified in the venom of a scorpion, selectively binds to glioma cells but not normal brain parenchyma. A phase I/II clinical trial of intracavitary 131 I-TM601 in adult patients with recurrent high grade glioma was performed to determine the bio-distribution and toxicity of this potential therapy. We evaluated the SPECT imaging and bio-distribution data from this trial to determine if 131 I-TM601 might also be useful in determining tumor extent. Adult patients with recurrent high-grade gliomas underwent tumor resection, implantation of an intra-cavitary reservoir, and a single-dose injection of 370 MBq (10 mCi) 131 I-TM601 (0.25–1.0 mg of 131 I-TM601) 2–4 weeks after surgery. Total-body planar scans and whole-brain SPECT scans were obtained on days 0, 1, 2, 3, and 6–8 after injection. Post-resection MRI images were co-registered to the SPECT scans using image analysis software. Analysis of the rate of radioactive decay and biologic elimination from the body and at the cavity site

A.N. Mamelak () Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA e-mail: [email protected]

was performed. T1-weighted with gadolinium contrast (T1-Wc), T2-weighted (T2), and SPECT volumes were estimated by stereological Cavalieri sections and compared for overlap. Nonbound 131 I-TM601 was eliminated by 48 h after injection with the remaining radio-labeled peptide bound to tumor for at least 6– 8 day. Biologic decay rates from 24 to 168 h after injection were only slightly shorter than the physical decay of 131 I(6.3 vs. 8.0 day), indicating steady state binding. A comparison of tumor volume estimates using all three imaging parameters indicated that 131 I-TM601–determined tumor volumes more closely paralleled T2 volumes than T1-Wc volumes. Overlap between co-registered MRI and SPECT scans corroborated the presence of radio-labeled peptide in the vicinity of infiltrating tumor up to 168 h after injection. 131 I-TM601 provides a reliable estimate for primary tumor extent. The poor spatial resolution of 131 Iodine remains a major limitation to this tool. Further modification of this radio-peptide with better imaging isotopes such as 123 I (SPECT) or 124 I (PET), may provide clinicians with an important tool for determining tumor extent and differentiating regions of viable tumor from necrosis. Keywords Gliomas · 131 I-TM601 · Ligand Chlorotoxin · Decay rates · SPECT imaging

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Introduction Accurate imaging of human malignancies in vivo requires methods that define the full extent of tumor, exclude normal tissues, and are spatially resolved enough to permit accurate delineation of tumor size and location. This ideal objective is very rarely

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achieved by most currently available imaging methods, and represents a particular challenge for imaging of gliomas in the human brain. Gliomas are the most common primary brain tumors diagnosed annually, comprising approximately 16,500 cases and accounting for nearly 13,000 deaths (Central Brain Tumor Registry of the United States (CBTRUS), 1992–1997; American Brain Tumor Association, Primer of Brain Tumors (ABTA), 2001). The most lethal gliomas are the high-grade gliomas (HGGs): grade III anaplastic astrocytoma, anaplastic oligoendroglioma, and grade IV gliomablastoma multiforme (GBM). The ability to adequately image tumor volume extent is critical for treatment because more than 85% of HGG patients have recurrences near the original tumor site, and extent of tumor resection is one of the most important predictors of long-term survival (Brady et al., 1992; Natali et al., 1991; Debinski et al., 1995). Magnetic Resonance Imaging (MRI) is the primary method for imaging gliomas in vivo. Magnetic Resonance Imaging carries a very high spatial resolution that can be easily achieved, and is relatively inexpensive. Unfortunately T1 and T2 weighted MRI pulse sequences do not reliably differentiate infiltrating tumor from cytotoxic edema or radiation necrosis. The addition of gadolinium-based contrast agents can aide in defining regions of increased capillary permeability vascularity, but these are indirect measures of tumor and often underestimate the true extent of glioma invasion. Magnetic Resonance Spectroscopy (MRS) can detect biochemical abnormalities that are predictive of tumor, but this approach lacks the spatial resolution needed to reliably determine tumor extent, and is inherently limited by magnetic field inhomogeneities. Radio-isotope based imaging methods such as positron emission tomography (PET) and single photon emission computed tomography (SPECT) rely on cell surface receptor mediated binding or cellular uptake of a ligand, with subsequent imaging of the radio-isotope bound to the ligand. The most prominent example is the widespread use of 18 Flouro deoxyglucose (18 FDG). See other chapters in this volume for a more detailed description of the role of 18 FDG for imaging gliomas. 18 FDG is taken up by metabolically active cells utilizing glucose for energy production. Because cancer cells are generally more metabolically active than normal tissues, they preferentially take up the 18 FDG, providing an indirect measure of tumor.

A.N. Mamelak and D. Hockaday

While 18 FDG has been quite useful for staging of metastatic disease in several systemic cancers, it has been less useful for gliomas because glucose is the sole source of metabolic energy in the brain, and often the metabolic activity of normal brain exceeds that of low grade or intermediate grade glioma. 18 FDG PET is only 80% accurate in differentiating glioma from radiation necrosis (Barker et al., 1997; Thompson et al., 1999). 11 C-Methionine is a similar PET agent, although it may be slightly more accurate than 18 FDG in differentiating tumor from necrosis (Bigner et al., 1998). A comparison of these methods is addressed in another chapter in this volume. Spectroscopy has much less intrinsic spatial resolution than PET, and so in general has been even less useful as an imaging platform. Distinguishing viable tumor from vasogenic edema or necrosis, however, remains difficult, even with the use of metabolic imaging agents due to the significant amount of angiogenesis present in high-grade gliomas and the breaches of the blood-brain barrier (BBB) at the edema site. An imaging agent with the ability to bind to only tumor cells would provide a novel platform for determination of tumor extent. An ideal compound would be rapidly diffusible, tumor-specific, and has high resolution. Most of the currently available radioligands do not meet both of these criteria; either they are too large to negotiate the BBB and the interstices of the extracellular matrix (ECM) or they are not specific in their binding to glioma. Monoclonal antibodies (mAbs) such as 81C6, for instance, are too large to pass the BBB and diffuse from the surgically created resection cavity into the parenchyma, where residual tumor may thrive (Mamelak et al., 2006). Moreover, many mAbs lack glioma specificity and have a high degree of catabolism of the radiolabel. Chlorotoxin (CTX), a scorpion-derived 36 amino acid peptide, has been shown to specifically bind to a phosphatidyl inositide, a phosphorylated lipid on lamellipodia of tumor cells. Several immunohistochemical in vitro and in vivo experiments indicate that CTX does not bind to normal brain parenchyma or endothelial cells but specifically binds to tumescent glial cells. TM-601, a synthetic version of CTX, has been shown to selectively label human gliomas in vivo and in vitro (Soroceanu et al., 1998). Unlike many other radioligands, TM-601 is relatively small at 4 kDa: it passes the BBB and diffuses readily

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through the brain parenchyma and may spread across the volume of the whole tumor. These properties make TM-601 potentially useful for imaging, as well as targeting local therapy. Several immunohistochemistry and cell-binding assays demonstrated a positive correlation between peptide-glioma binding and increasing tumor malignancy (Soroceanu et al., 1998). Intracranial injections in animals reliably showed long-term tumor-specific uptake. These findings and supporting in vivo efficacy and toxicology data in animals justified a Phase I clinical trial of TM-601 conjugated to 131 I in patients with recurrent high-grade glioma (Rajapakse et al., 2000). The primary goals of this study were to determine the safety profile and biodistribution of 131 I-TM-601. To preliminary evaluate the imaging potential of TM-601, the radiographic studies from subset of patients in this trial were analyzed in detail. Of note, 131 I-TM-601 was initially developed as a potential therapeutic agent, and that is why 131 I was chosen as the radioligand. As such the extremely poor spatial resolution of 131 I was a known shortcoming for imaging purposes, but more spatially resolved imaging agents could not provide any potential therapy, rendering their use unfeasible in this initial trial.

Methods Nine adult patients with recurrent high-grade gliomas underwent tumor resection implantation of an intracavitary reservoir and a single dose injection of 10 (±1) mCi 131 I-TM-601 (0.25–1.0 mg) 2–4 weeks after surgery. Protocol, eligibility criteria, and details of the clinical trial are presented elsewhere (Mamelak et al., 2006).

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Prior to delivery of 131 I-TM-601 to the patient, a 1 cc volume of 0.1–1 mCi 111 In-DTPA was injected into the reservoir to assure catheter potency. At the time of 111 In-DTPA administration, a 256 × 256 matrix image was taken with a gamma camera equipped with a high resolution, low-energy (247 keV, 15% window) collimator to monitor delivery of the 111 In-DTPA via catheter and observe any leakage. Upon completion, dynamic planar images of the head were continuously acquired for 15 min. A 57 Co transmission scan was performed with and without the patient on the scanner bench to connect subsequent imaging data acquired for total body planar images. Prior to injection, the 57 Co source was placed 3 cm below the scanner table with the anterior camera 3 cm above the patient. A high-energy collimator centered at 122 keV with a 20% window was used and images were acquired with a gantry speed of 10 cm/min and 256 × 1024 matrix size.

Injection of Radiolabeled Peptide One to two hours after labeling, patients received 131 ITM-601 intracranially via a 25 gauge butterfly needle and a shielded 5 cc syringe with a volume of 2–5 cc. Initially, 25% of the total radiolabeled peptide dose was given. After 5 min. the remaining dose was administered, followed by a 1–2 cc saline flush. Blood and urine samples were collected for assessment of serum radioactivity. Urine samples were also collected over the period of days 1–2, 2–3, 3–4, and 4–6 or 8, while blood samples were collected 1, 2, and 4 h after the completion of the infusion, and days 2, 3, 4, and the time of imaging on day 6 or 8.

Planar Images Preparation of 131 I-TM-601 and Preliminary Scans Presealed, sterilized vials containing lyophilized TM601 were radiolabeled with 10 mCi I131 via the Iodogen bead method. Extent of labeling was determined via immediate thin layer chromatography (ITLC) with >92% efficiency required to justify human use.

After intracranial injection of 131 I-TM-601, anterior and posterior whole-body planar images of matrix size 1024 × 256 were acquired on a dual-detector gamma camera equipped with high-energy collimator set at 364 keV (15% window). Image acquisition included a 20 mL, 200 μCi calibrated 131 I source, which had been placed 10 cm from the feet of the patient. Subsequent images were acquired days 2, 3, 4, and either day 6 or 8 post injection.

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Spectroscopy A 180◦ whole brain spectroscopy scan was performed on a dual headed gamma camera (Toshiba 7200 GCA), with fiducial markers containing10 μCi 131 I-TM-601 placed on each zygoma and on the nasion to orient SPECT scans with regard to subsequent MR images. A 1 mCi 131 I-TM-601 standard was also placed 10 cm above the patient head. Data was acquired at 3 degrees per step at 30 s per step. For these images, a 128 × 128 matrix was employed, the high-energy collimator was kept centered at 364 keV with a 15% window, and a ramp filter was applied for 3D reconstruction. Data were acquired in a proprietary format and converted to Interfile 3.0 for data analysis. Subsequent SPECT scans were performed with the total body planar images on days 2, 3, 4, and 6 or 8 after injection.

Magnetic Resonance Imaging Postoperative MRI scans were also acquired for each patient prior to 131 I-TM-601 injections. For each patient, 20 transverse slices were acquired on a 16 bits per pixel scale with matrix size of 256 × 256. Sequences included coronal, axial, and sagittal T1weighted images (with and without gadolinium contrast), T2 axial, FLAIR, and 3D-SPGR images. All MRI scans were stored as DICOM files for future image processing and analysis.

Spectroscopy Image Processing All image analysis was performed with Analyze 5.0 (AnalyzeDirect, Lenexa, KS). For each patient, the SPECT scan, comprised of 128 × 128 × 68 voxels of 79.5-mm3 , for each day (1–8) was loaded on Analyze 5.0, with the slices containing the standard excluded. For each SPECT scan, the intensity range on a 32 bit per pixel scale was calculated and recorded with the expectation that the magnitude (the range of intensity values) of the brightest voxel should correspond roughly to the decay and/or the dispersion of radioisotope. Each value was normalized for the duration of the scans, and the normalized intensities for each patient were then averaged for all patients on each day of scanning. To check the accuracy of this method,

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the magnitude of the brightest voxel of the standard was recorded for five patients and measured against the physical decay of I131 , accomplished by defining a volume of interest (VOI) which only included the standard (the slices removed from the cranial VOI) and measuring the calculated intensities within this VOI. Once normalized and averaged, the intensities were fitted exponentially.

Formation of Magnetic Resonance Imaging Volumes For each patient, T1 weighted with gadolinium contrast (T1-Wc) and T2 volumes were formed from 2-D images, on the Analyze 5.0 platform. Resolution of the coronal and sagittal images was considerably lower than the axial resolution: voxel height was 7 mm; length and width, 0.83 mm. Therefore, the Force Cubic option (under Load As) was used to load the volumes as linearly interpolated, isotropic voxels of 0.83 mm × 0.83 mm × 0.83 mm or 0.57 mm3 . The volumes were primarily analyzed in the axial (transverse) plane.

Image Analysis: Stereological Estimation of Volume Tumor volumes for each patient were determined from the T1-Wc, T2, and SPECT scans. Given the arbitrary nature of gray-scale threshold methods and the substantial differences that result in volumes of extracted objects (Roberts et al., 2000) stereological Cavalieri sections were used in Analyze 5.0 (Shen et al., 2005). One of every three slices was sampled for each scan, and the highlighted or tumor associated region demarcated. A reasonable minimum volume was determined via the exclusion of ambiguous sample points; a reasonable maximum volume was determined via those sample points inclusion. The mean was then calculated for each volume with the accompanying error equal to half the spread between the recorded minimum and maximum. In addition, for SPECT scans (where limited resolution of 131 I rounds-off tumor extent) a full width at half-maximum (FWHM) was intermittently calculated across the cross-sectional diameter (transverse plane) using the Line Profile option, with the

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assumption that intensity falloff would more or less follow a normal (Gaussian) curve. The diameter of the stereological volume was then checked by the sampled FWHM for accuracy. For MR images, two volumes were determined for each patient: T1-Wc and T2. For SPECT, the tumor volumes for the second day post injection and the final day were catalogued for each patient.

Co-registration After separate image processing, the isotropic MR volumes were co-registered to the SPECT scan-volumes using Analyze 5.0. Under the 3-D Registration program, SPECT scans were matched manually and fused to MR images for each patient, using the alignment of fiducial markers on each SPECT volume to anatomical structures of the nasion and zygoma on the MR image. Gray-scale intensities were converted to a 24bit red, green, blue (RGB) “Hot-Metal” colormap for visual affect.

Results Bioelimination Total body planar-scans had been previously used by Shen et al. (2005) to estimate effective half-lives in various organs; in the present nine patient subset, these half-lives were recalculated as 47±5 h for bodily elimination, 45±5 h for elimination from the brain, and 39±6 h for elimination from the cavity. Qualitatively, these results are seen in the total-body planar scans on day 2 and day 6–8 (Fig. 14.1). For all nine patients, retention of radiolabeled peptide was observed in the tumor cavity region for the duration of scans. All SPECT scans also showed clear evidence of 131 I-TM-601 remaining at the tumor site on Day 8 (168 h post injection) at an activity comparable to that of the 1 mCi standard. For the standard, the decay rate of the value of the brightest voxel roughly followed the theoretical (physical) rate of decay. The calculated exponential of the standard yielded a half-life of 6.3±1 days, comparable to the known half-life for 131 I of 8.04 days.

Fig. 14.1 Total body planar scans of a single patient on days 1 and 8. Note the intense uptake and long-term retention of radioisotope in the right frontal lobe injection site, and minimal uptake anywhere else in the body. The 100 μCi standard is evident at the patient’s foot

Tumor Volume Stereological estimation of tumor volumes in the nine patients showed 131 I-TM-601 estimated volumes were intermediate between the T1-Wc estimated volumes on the low end and T2 determined volumes on the high end. Over the course of scanning, the estimated volume 24 h post-injection was significantly larger and above or equal to T2 estimates for most patients; by 168 h post-injection most peptide determined volumes are smaller, better centered between T1-Wc and T2 volumes, and considerably less uncertain. Overall, SPECT determined volumes on Day 2 and Day 8 were always larger than the T1-Wc determined volumes, and most were smaller than the T2 determined volumes by Day 8. Moreover, FWHM measures across the span of the SPECT volume corresponded to the smaller volumes of Day 8 stereological estimates.

Fusion of Images The fusion of SPECT volumes to MR images via the use of fiducial markers yielded high-overlap and wellcentered regions of tumor extent 168 h post-injection (Fig. 14.2). As the SPECT-estimated volumes were rounded, they tended to approximate the area around the edema (highlighted region in T1-Wc) and necrotic

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Fig. 14.2 Co-registration of MRI and SPECT images demonstrate excellent overlap and permit better definition of region of tracer uptake. Day 8 imaging has better resolution and closer approximates the true tumor extent than day 2 estimates

region (dark center region in T1-Wc) and resection area (also dark) and extend to regions in the T2determined volume. Generally, the SPECT-determined volume was centered in this region and agreed with the highlighted T1-Wc and T2 areas. Spectroscopy images performed on Day 1 exhibited overwhelming scatter and thus were not useful for image analysis. By Day 2, fused images showed considerable isolation of the highlighted SPECT region to that of the tumor region on the MR image. Further differentiation was evident on Day 3, with SPECTdetermined volume better centered and shifted from the site of injection and the cavity towards the necrotic core. By Day 8, residual glow from the cavity and injection site had vanished and remaining radiolabeled isotope had an intensity level comparable to the standard.

Discussions Tumor Volumes For the present study, 131 I was chosen for its potential therapeutic benefit compared with less energetic but better imaging radioisotopes such as 123 I or 124 I. With the limited resolution of the current isotope, considerable difficulty arises in defining exact tumor extent. Stereological methods offer better statistical estimates and more reproducible results than traditional threshold methods when the exact extent of the region of interest is unknown (Roberts et al., 2000; Shen et al.,

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2005; Gadeberg et al., 1999). As a practical measure, stereology also allows the sampling of a smaller number of slices with the same or better accuracy than ROI drawing. Therefore, as far as 131 I is concerned, volume of distribution of TM-601 is best estimated from stereology. Of course, higher resolution radioisotopes may allow more precise methods to be used in the foreseeable future. As it stands, spectroscopy-estimated volumes of distribution must be approached with several factors in mind. Spectroscopy-estimated volumes appear rounded-off due to the limited resolution of the radioisotope. Smaller, more peripheral features are lost among the scatter. Their shape is primarily spherical or ellipsoidal, despite their more irregular appearance in T1-Wc or T2 MRI, and the uncertainty of the estimate is generally large. Similar qualifications exist for MRI-determined volumes, where the tumor per se is not measured but rather the associated enhanced regions of increased capillary permeability associated with tumor but also possibly postoperative or radiation-induced effects, or inflammatory clogs. Generally for T1-Wc, gliomatumor volume is underestimated as invasive fringe tumor cells lack the increased angiogenesis necessary to register in this modality. In contrast, T2 signal hypersensitivity may represent tumor or radiationinduced, vasogenic edema, infiltrating tumor, and/or cytotoxic effects, and as such, T2 estimates tend to exaggerate the true extent of tumor. In the present study, SPECT determined volumes using 131 I-TM-601 appear to provide better estimates than T1-Wc or T2 determined estimates. The larger volume and uncertainties in Day 2 stereological estimates corresponded with the presence of more diffusely highlighted voxels than in Day 8, where steep falloff allowed the highlighted SPECT volume to be readily discernible. Scattering effects diminished resolution beyond practicality for the initial day, and no distinguishable trends could be registered within the interval of a day, i.e., the volumes of consecutive days were effectively the same. By Day 8, this uncertainty had diminished substantially and the volumes were more easily estimated, because a sample marker could be readily identified as belonging to the set of volume points. Therefore, lower energy imaging isotopes of higher spatial resolution may provide substantially better tumor definition.

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On the whole, estimated SPECT volumes were smaller on Day 8 suggesting that the non-bound radiolabeled peptide is rapidly eliminated from the brain, while bound peptide persists. The biodistribution data also support this contention. The volumes are hedged between the stereologically estimated T1-Wc and the T2 volumes. Most SPECT volumes were in fact closer to the T2 estimate than the T1-Wc by Day 8, suggesting that 131 I-TM-601 diffuses and binds to the full extent of primary tumor, while the limited resolution may explain overestimation. Total body planar images and SPECT scans frequently showed some “hot spots” of increased tracer uptake removed from the primary tumor volume. These hot spots may indicate diffusion of the peptide to sites distal from the main tumor mass. This finding, while speculative and preliminary, would be very valuable for determining true tumor extent and predicting sites of recurrence or treatment failure.

Overlap of Fusion Volumes The detailed anatomical clarity of MRI coregistered to SPECT scans allows more accurate differentiation of actual tumor and imaging artifacts then seen in the SPECT scans alone. The increased utility of image fusion is well documented and likely to be important in determining the utility of this peptide for longterm use. Other imaging technologies such as “Digital Subtraction” may also prove useful in increasing the imaging sensitivity with TM-601.

Indications of Decay Rate Qualitative evidence in the SPECT scans supports the elimination calculated by biodistribution in the planar scans. Although calibration was performed for planarscans, quantitative results were unavailable for the SPECT scans. No calibration between count-rate and intensity was available for the particular SPECT scanner used, and the attenuation and scatter corrections remain unknown. Even if these factors were evident, defining the VOI (the exact extent of enhanced region) with the limited resolution of 131 I would be practically ineffective in the clinical setting.

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Nevertheless, the maximum and minimum intensities for each scan had been calculated, the difference of which yielded the intensity value of the brightest voxel. An ad-hoc approach was taken to compare the intensity of the injected radioisotope to that of the standard, though with admittedly limited statistics. These values show substantial slowing of decay 24– 48 h post-injection to rates towards that expected of purely physical decay, in agreement with the calculated elimination by biodistribution in the planar images, 39±6 h for elimination from the cavity. Rates continue mild slowing through 168 h post-injection as they approach physical decay rates. If the above methods are indeed reliable, these rates may represent a shift from radioisotope dispersion to physical decay 24–48 h post-injection.

Future Directions TM-601 appears to represent a very attractive ligand for radioisotope-based imaging of gliomas, and potentially many other malignancies. It meets the ideal criteria of being tumor-specific, non-toxic and rapidly diffusible in solid organs. It appears to exhibit longterm binding to tumor at low doses. Several steps are required to determine the ultimate utility of this approach. First and foremost, less energetic and more spatially selective imaging isotopes must be tested in both animal models and humans. 123 I is an obvious first choice due to the relative ease of labeling. However, it is likely that PET sensitive isotopes such as 124 I or 64 Cu may be even more appealing. Methods to maximize peptide-isotope binding conditions still need to be worked out. In conclusion, the specificity and stability of 131 ITM-601 allow adequate imaging of high-localization and limited resolution in the clinical setting, which is promising for the development of higher resolution radioligands of TM-601 such as 124 I or 64 Cu for PET imaging. Although SPECT determined volumes using 131 I-TM-601 appear to provide better estimates than T1-Wc or T2 determined estimates the overlap of fusion images suggests 131 I-TM-601 fully estimates the extent of primary brain tumor. Imaging studies following intravenous injection will also be important in determining the ultimate utility of this novel peptide in the clinical setting.

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References American Brain Tumor Association, Primer of Brain Tumors (2001) Chapter 3: facts and statistics, 7th edn. ABTA, DesPlaines, IL Barker FGII, Chang SM, Valk PE, Pounds TR, Prados MD (1997) 18-Flourodeoxyglucose uptake and survival of patients with suspected recurrent malignant glioma. Cancer 79(1):115–126 Bigner DD, Brown MT, Friedman AH, Coleman RE, Akabani G, Friedman HS, Thorstad WL, McLendon RE, Bigner SH, Zhao X-G, Pegram CN, Wikstrand CJ, Herndon JEII, Vick NA, Paleologos N, Cokgor I, Provenzale JM, Zalutsky MR (1998) Iodine-131-labeled antitenascin monoclonal antibody 81C6 treatment of patients with recurrent malignant gliomas: phase I trial results. J Clin Oncol 16:2202–2212 Brady LW, Miyamoto C, Woo DV, Rackover M, Emrich J, Bender H, Dadparvar S, Steplewski Z, Koprowski H, Black P, Lazzaro B, Nair S, McCormack T, Nieves J, Morabito M, Eshleman J (1992) Malignant astrocytomas treated with iodine-125 labeled monoclonal antibody 425 against epidermal growth factor receptor: a phase II trial. Int J Radiat Oncol Biol Phys 22(1):225–230 Central Brain Tumor Registry of the United States (CBTRUS), 1992–1997 data. From www.cbtrus.org. 3 Debinski W, Obiri NI, Powers SK, Pastan I, Puri RK (1995) Human glioma cells overexpress receptors for interleukin 13 and are extremely sensitive to a novel chimeric protein composed of interleukin 13 and pseudomonas exotoxin. Clin Cancer Res 1(11):1253–1258

A.N. Mamelak and D. Hockaday Gadeberg P, Gundersen HJG, Tågehøj F (1999) How Accurate are Measurements on MRI? A Study on Multiple Sclerosis Using Reliable 3D Stereological Methods. J MRI 10:72–79 Mamelak AN, Rosenfeld S, Bucholz R, Raubitschek A, Nabors LB, Fiveash JB, Shen S, Khazaeli MB, Colcher D, Liu A, Osman MH, Guthrie B, Schade-Bijur S, Hablitz DM, Alvarez VL, Gonda MA (2006) Phase I single-dose study of intracavitary administered 131 I-TM-601 in adults with recurrent high-grade glioma. J Clin Oncol 24(22): 3644–3649 Natali PG, Nicotra MR, Bigotti A, Botti C, Castellani P, Risso AM, Zardi L (1991) Comparative analysis of the expression of the extracellular matrix protein tenascin in normal human fetal, adult and tumor tissues. Int J Cancer 47(6): 811–816 Rajapakse JC (2000) Random-grid stereologic volumetry of MR head scans. J MRI 12:833–841 Roberts N, Puddephat MJ, McNulty V (2000) The benefit of stereology for quantitative radiology. Br J Radiol 73: 679–697 Shen S, Khaaeli MB, Gillespie G, Alvarez VL (2005) Radiation dosimetry of 131 I-chlorotoxin for targeted radiotherapy in glioma-bearing mice. J Neurooncol 71:113–119 Soroceanu L, Gillespie Y, Khazaeli MB, Sontheimer H (1998) Use of chlorotoxin for targeting of primary brain tumors. Cancer Res 58(12):4871–4879 Thompson TP, Lunsford LD, Kondziolka D (1999) Distinguishing recurrent tumor and radiation necrosis with positron emission tomography versus stereotactic biopsy. Stereot Funct Neurosurg 73(1–4):9–14

Chapter 15

Assessment of Biological Target Volume Using Positron Emission Tomography in High-Grade Glioma Patients Habib Zaidi and Srinivasan Senthamizhchelvan

Abstract High-grade gliomas (HGG) are the most challenging brain tumors to treat. Even though various sophisticated options exist to treat patients with gliomas, the disease invariably leads to death over months or years. The major obstacles encountered in treating gliomas are in determining the exact location, extent, and metabolic activity of the tumor. Molecular imaging of energy metabolism, amino acid transport, cell proliferation and cell death have been found helpful in identifying the biologically active tumor tissues for therapy. It allows a better understanding of pathology at the molecular level. This ability is especially useful in brain tumors where tissue sampling in vivo is associated with significant risks. Positron emission tomography (PET) is one of the most prominent molecular imaging modalities utilized for imaging pathophysiology of tumors at an early stage. In this chapter, the applicability of PET in assessing the biologically active tumor volumes in high-grade glioma patients for radiation therapy treatment planning and therapy monitoring will be reviewed. We will focus on the concept of biological target volume (BTV) and associated methods of image segmentation available for delineating tumor volumes in connection with their applicability in high-grade gliomas. Keywords High-grade gliomas · PET · Molecular imaging · BTV · Necrosis · Dose painting

H. Zaidi () Division of Nuclear Medicine, Geneva University Hospital, CH-1211 Geneva 4, Switzerland e-mail: [email protected]

Introduction The success of cancer treatment depends on multiple factors. One of the most important factors is the accuracy of the information about tumor location, extent and magnitude of disease. Traditionally this information is obtained, through anatomical imaging methods such as x-ray computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US). However, it has become clear now, that the acquisition of molecular and physiological information by noninvasive molecular imaging modalities such as positron emission tomography (PET) could vastly enhance our ability to fight cancer at an early stage (Weissleder, 2006). Molecular imaging has the potential to detect physiological alterations that signal the existence of cancer when it is still at a curable stage. Advances in genomics and proteomics technologies have shown the potential to transform the way in which cancer is clinically managed today. Molecular imaging is poised to play a key role in this transformation, since it will allow the integration of molecular and physiological information specific to each individual case with anatomical information obtained through conventional imaging methods. As a noninvasive molecular imaging method PET exploits the unique decay characteristics of positron-emitting isotopes. The isotopes of fluorine, oxygen, carbon, and others have been routinely used in the development of diagnostically useful biological tracers that are available for PET imaging of functional and/ or metabolic assessment of normal tissues or disease state. Conventional stand-alone PET has now been replaced by PET/CT for improved patient throughput and most importantly for the availability of

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complementary information of molecular PET images and anatomical CT images in one imaging session. There has been a tremendous expansion of clinical applications of PET in oncology for the diagnosis, staging and restaging of cancer patients. More than half of all patients with cancer receive radiation therapy (RT) at some stage during the course of their disease management. Applications of PET in RT have been reported in lung, head and neck, breast, lymphoma, prostate and many other cancers (Zaidi et al., 2009). Studies have also found that PET has advantages over CT in the standardization of tumor volume delineation in the reduction of the risk for geometrical misses, in the minimization of radiation dose to the normal organs, and in the assessment of tumor burden, blood flow, tissue inflammation, and hypoxia. Integration of functional PET data with anatomical CT data has become a standard in RT particularly in treatment planning of various cancers. Imaging plays a key role in the state-of-the-art high-precision RT techniques like three-dimensional conformal radiation therapy (3DCRT), intensity modulated radiation therapy (IMRT), image guided radiation therapy (IGRT), tomotherapy, and stereotactic radiation therapy/surgery (SRT/SRS). These high-precision radiation delivery methods allow better dose distributions within the targeted tumor volume while sparing a larger portion of adjacent normal tissues. Success of these RT techniques requires accurate tumor volume delineation, tumor characterization, and response assessment during and after treatment. Conventionally these tasks are achieved through anatomical imaging (CT, MRI, and US). Of late PET has been increasingly used in high-precision RT for tumor volume delineation and characterization, because PET brings in the crucial functional and molecular information which enable the direct evaluation of tumor metabolism, cell proliferation, apoptosis, hypoxia and angiogenesis. This is a significant advance in cancer imaging with great potential for optimizing RT treatment planning and to the management of cancer patients. The availability of PET and CT in a single imaging system (PET/CT) to obtain a fused anatomical and functional dataset has made the applicability of PET in radiation oncology clinics much easier (Yap et al., 2004). The most recent introduction of PET-MR instrumentation dedicated for concurrent high resolution brain imaging is now revolutionizing the use of multimodality imaging in tumor brain imaging (Boss et al., 2010). Numerous reports are available in the

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literature in support of the routine use of PET for RT target volume delineation in non-small cell lung cancer (NSCLC), head and neck cancers, lymphoma and in esophageal cancers, with promising preliminary data in many other cancers (Gregoire et al., 2007; Nestle et al., 2009; Zaidi et al., 2009). The focus of this chapter is to update the readers on the potential use of PET imaging in the management of high-grade gliomas (HGG), with particular emphasis being given to the role of PET in the assessment of biological target volumes (BTVs) for RT.

PET-Guided Biological Target Volume (BTV) Delineation Over the past two decades radiation oncology community has seen a paradigm shift from 2D treatment planning to 3D conformal treatment planning for RT. One of the major advantages of 3D treatment planning and associated treatment delivery techniques is the leverage offered for the dose escalation to tumor volumes while preserving tolerance doses for normal structures. The state-of-the-art 3D-CRT techniques (IMRT, IGRT, tomotherapy, volumetric arc therapy and SRS/SRT etc.) developed to deliver highly conformal radiation beams directed towards targets warrant equally precise imaging modalities for accurate delineation of the tumor extent. Customizing dose delivery to various parts of the treatment volumes (“dose painting” and/or “dose sculpting”) based on their dose requirements are possible by 3D-CRT techniques today (Ling et al., 2000). However it is important to know what needs to be “painted”, and how much “paint” is required to take complete advantage of these highly conformal radiation delivery techniques (Rickhey et al., 2010). The principal objective of all form of radiation delivery techniques is to achieve highest possible tumor dose without exceeding the dose level of surrounding normal tissue toxicity. This is achieved in RT today by selective dose escalation also known as “dose painting” with sharp dose gradient along the tumor boundary. The rationale for dose painting is that, treating a selective tumor region to high dose should result in higher tumor control probability and lower normal tissue complication probability. The expected outcome of 3D-CRT is minimal complications and side

15 Assessment of Biological Target Volume Using PET in HGG Patients

effects, while achieving maximum possible dose to tumor tissues. Accurate delineation of the tumor volumes and assessment of the tumor response to the ongoing treatment regimens are necessary for successful implementation of modern RT techniques. In order to achieve the above said goals it is highly desirable to precisely locate and visualize metabolic tumor extensions and delineate boundaries. Volumetric patient imaging forms the basis for 3D-CRT treatment planning and also helps in the design of radiation fields and dose distributions. Since 3D imaging is used to delineate target volumes and normal structures, the quality of the imaging and information obtained from the images have a direct impact on the patient treatment and potentially on the outcomes and complications. Traditionally, anatomical imaging like CT and MRI are used for radiotherapy treatment planning, monitoring and follow-up evaluation. The major advantage of anatomical imaging is their high resolution, which enables clear visualization of morphological changes. However, the precise delineation of tumor regions with anatomical imaging has some significant limitations. The CT and MRI measure the differential density and magnetic properties of the tissues respectively, both of which may not necessarily be tumor specific characteristics. The morphological changes similar to malignancy can occur due to other confounding factors like infection, treatment (radiotherapy, chemotherapy and surgery etc.) induced inflammation, which makes the distinction between tumor biology from other pathological conditions difficult. Moreover biological changes manifest first and the time frame for the development of detectable morphological changes is too long, during which the disease might have progressed to an advanced stage. The applicability of anatomical imaging for precise delineation of tumor extension is hampered, when tumor harboring sites have unchanged morphology, density and magnetic properties similar to normal tissue. Successful treatment planning requires information about tumor biological characteristics such as proliferation and hypoxia and the ability to distinguish treatment related scar, edema and necrosis from malignant cells (Sun et al., 2011). Anatomical imaging modalities lack the aforementioned qualities which make them insufficient for the delineation of target volume in most of the clinical presentations and as well treatment response evaluation. Even though PET has

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lower spatial resolution in comparison to its anatomical imaging counterparts the sensitivity of PET for detecting tumor biology is high with required activity concentration of nmol to pmol range to detect biological signals (Nestle et al., 2009). A typical example where PET plays an important role in defining biologically active tumor volume over anatomical imaging is shown in Fig. 15.1. The term “biological imaging” was coined by (Ling et al., 2000) and has become popular in radiation oncology practice. Biological imaging for cancer detection, staging, therapy monitoring and follow up has gained vast interest as the evidence of treatment success with this modality is keep accumulating. The diagnostic utility of PET as the most prominent biological imaging system is evident from the increased interest and utility of PET imaging for cancer imaging and therapy planning for the last few years. The term “biological target volume” (BTV) was also first proposed by (Ling et al., 2000). It is a new method of defining tumor volumes based on metabolism, physiology and molecular biology of tissues. The definition of BTV, apart from the standard definitions of tumor volumes as gross tumor volume (GTV), clinical target volume (CTV) and planning target volume (PTV), is aimed at providing information on the location and extent of tumor margins based on tumor biology. The BTV should also be helpful in assessing the biological response of tumor to therapy. In radiotherapy planning, biological imaging will also guide the radiation oncology community in defining biologically interesting sub-volumes (field in field) of the tumor like a target within the GTV, which could be irradiated with a higher dose through conformal RT (Nestle et al., 2009). Figure 15.2 shows clinical examples comparing biologically defined tumor volumes with anatomically defined tumor volumes. Till date, many PET tracers have been evaluated diagnostically in different cancers. New PET tracers are being developed for staging, RT planning, treatment monitoring and response evaluation during and after completion of RT has gaining more attention in biological imaging.

Techniques for PET-Guided Biological Target Volume (BTV) Delineation Traditionally CT and MRI have been used as primary imaging modalities for radiation therapy treatment

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Fig. 15.1 Example of a patient with a glioblastoma (WHO IV) in the left temporal and frontal areas. The images shown on the top row (temporal area) correspond to gadolinium enhanced T2-weighted MRI (A), coregistered 18 F-FET (B) and fused PET/MR (C) of the first study. The same is shown in the bottom

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row for the same study in the frontal area (D, E and F). The 18 FFET PET study revealed an additional lesion missed on MRI. In addition, the T2-weighted MRI and the 18 F-FET PET show substantially different gross tumor volume extension for radiation therapy treatment planning

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BTVPET GTVMR Fig. 15.2 Biological (BTV, blue) and morphological gross tumour (GTV, red) volume defining the clinical target volume in patients with high-grade glioma. Note the common volume between the tumour volumes (yellow chicken wire). Good

BTV-GTV matching is shown (left) in 1 patient, while substantial BTV-GTV mismatch is also detailed (center and right) in 2 other patients. Adapted from Weber et al. (2008)

15 Assessment of Biological Target Volume Using PET in HGG Patients

planning. X-ray computed tomography and MRI offer excellent spatial resolution, and soft tissue contrast, but both imaging modalities fail to provide functional properties of the imaged tissues. In cases where the true extent of the disease may extend beyond anatomically defined volumes, despite its inferior resolution compared with CT and MRI, PET has been shown valuable for defining the extent of target volumes. Some of the key contributions of PET in addition to or in combination with other imaging modalities are delineation of tumor volumes, biological characterization of tumor, and assessment of treatment response. With the widespread adoption of hybrid PET/CT scanners, in radiotherapy clinics, PET-based delineation of target volumes appears to be an attractive option in RT treatment planning. One of the most difficult issues facing PET-based RT treatment planning is the accurate delineation of target regions from typical noisy functional images. The major problems encountered in functional volume quantification are image segmentation and imperfect system response function. Image segmentation is defined as the process of classifying the voxels of an image into a set of distinct classes. The difficulty in image segmentation is compounded by the low spatial resolution and high-noise characteristics of PET images. Medical image segmentation has been identified as the key problem of medical image analysis and remains a popular and challenging area of research. Despite the difficulties and known limitations, several image segmentation approaches have been proposed and used in clinical setting including thresholding, region growing, classifiers, clustering, edge detection, Markov random field models, artificial neural networks, deformable models, atlas-guided, and many other approaches (Zaidi and El Naqa, 2010). Medical image segmentation remains an unsolved problem that has captured the imagination of image analysis scientists over the past three decades. Manual segmentation methods available on most commercial software packages to identify lesion boundaries and to quantify GTVs in terms of standardized uptake value are very laborious and tedious. They discourage physicians from taking advantage of the inherently quantitative data and compel them to use qualitative means in their diagnosis, therapy planning, and assessment of patient response to therapy. Semi- or fully automated segmentation methods enable physicians to easily extract maximum and mean standardized uptake value estimates from a lesion volume. This also allows

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the physician to track changes in lesion size and uptake after radio/chemotherapy. At present, various methods are used in practice to delineate PET-based target volumes. Manual delineation of target volumes using different window level settings and look up tables is the most common and widely used technique in the clinic. However, the method is highly operatordependent and is subject to high variability between operators. Rather large intra-observer variability was reported for many localizations including HGG as shown in Fig. 15.3 (Weber et al., 2008). In this respect, semi- or fully-automated delineation techniques might offer several advantages over manual techniques by reducing operator error/subjectivity, thereby improving reproducibility.

Assessment of PET-Guided Biological Target Volumes in High-Grade Gliomas (HGG) Accurate determination of the tumor boundary at the microscopic level, assessment of the tumor sensitivity, and/or prognosis to the therapy is essential for successful treatment planning. Glioma cells are one of the most treatment resistant cells and their inherent heterogeneous cell populations, diffuse infiltration into normal brain tissues are the biggest challenge in the tumor localization and precise delineation of tumor extent. Prognosis of cerebral gliomas has continued to remain poor for several decades, albeit significant advances in multimodality diagnostic and therapeutic procedures. Therefore, development of a highly specific and sensitive non-invasive imaging modality is required. The ability to closely correlate diagnosis with pathology, distinguish inflammation and necrosis from tumors, differentiate tumor grades, accurately delineate tumor volume, monitor treatment responses, and identify residual tumor/recurrence are the desirable goals for imaging brain tumors to improve their clinical management. The specificity of anatomical imaging modalities in distinguishing neoplastic disease from vascular or inflammatory processes can be problematic in highgrade gliomas. Treatment effects including surgical trauma, corticosteroid-induced reduction of edema and contrast enhancement, and radionecrosis cannot

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always reliably be distinguished from tumor recurrence or response to therapy. Molecular imaging allows a better understanding of pathology at molecular level. This ability is especially useful in the brain tumors where tissue sampling in vivo is associated with significant risks. Availability of a suitable imaging modality or a multimodality combination to obtain the information of interest noninvasively is also vital for the basic research and development of novel and effective experimental therapeutics required to improve prognosis. Accurate quantitative information on the metabolic state of glioma tumor cells can be achieved through biological imaging using PET. Depending on the radiotracer used, various molecular processes can be visualized through PET imaging, most of them relating to an increased cell proliferation, metabolic rates, and DNA synthesis as well as abnormal microvessel density and thereby define tumor extent better than morphologic imaging in malignant gliomas (Tsien et al., 2009). PET radiotracers are especially helpful (1) in the localization, grading and finding the extent of glioma cells; (2) in the identification of metabolically active residual tumor after therapy; (3) monitoring of tumor progression; and (4) most importantly in the differentiation between recurrent tumor and radiation

necrosis. Various metabolism and biochemical pathways are exploited by PET tracers for glioma imaging. Energy metabolism of cells is imaged by [F-18]-2fluoro-2-deoxyglucose (FDG). Amino acid transport and incorporation of tumor cells are tracked by L -methyl-[C-11]methionine (MET), L -[C-11]tyrosine, L -[F-18]fluorotyrosine. DNA synthesis is imaged by 2-[C-11]thymidine, methyl-[C-11]thymidine, [F-18]-3 deoxy-3 -fluorothymidine (FLT). Cell membrane/lipid biosynthesis is tracked by 1-[C-11]acetate, [C-11]choline, [F-18]fluorocholine. Hypoxia is an important aspect to consider for assessing the aggressiveness of tumor and predicting the outcome of therapy (Sun et al., 2011). Tumor hypoxia is imaged by [F-18]fluoromisonidazole (FMISO) and many other tracers. The preferential uptake of malignant glioma cells in comparison to normal cells are exploited by tracers like 18 F-FDG, 11 C-MET, 18 F-FET and 18 F-FLT, depending on the tumor grade as a reflection of increased activity of membrane transporters for amino acids (11 CMET and 18 F-FET) and nucleosides (18 F-FLT) as well as increased expression of cellular hexokinase (18 FFDG) and thymidine kinase (18 F-FLT) genes, which phosphorylate 18 F-FDG and 18 F-FLT, respectively.

15 Assessment of Biological Target Volume Using PET in HGG Patients

Many hypoxia tracers (18 F-FMISO, 18 F-FAZA, 64 CuATSM and 18 F-EF5) have already shown their importance in target volume delineation or patient management in RT (Grosu et al., 2005a). The most commonly available PET tracer 18 F-FDG has the potential to detect abnormal metabolic rate, through increased cellular glucose metabolism in brain tumors. However, its use in target definition is complicated by the high level of intrinsic glucose uptake in the brain. FDG imaging is useful in distinguishing low-grade gliomas (LGG) from HGG based on tumorto-cortex (T/C) uptake ratio and tumor-to-white matter (T/WM) uptake ratio. Selecting the optimum site for tumor biopsy can be done based on the maximum uptake of FDG for sampling of the most malignant areas of tumors. For assessing response by pre- to posttreatment comparisons, FDG appears to be limited in clinical usefulness. The ability of 18 F-FDG PET to differentiate recurrent tumor from radiation necrosis is also limited. The false-positive and false-negative FDG-PET could result in unacceptably low sensitivity, specificity, and negative predictive values. The goal of PET imaging with radio-labeled amino acids is to assess the protein synthetic process of tumor growth. Amino acid uptake in normal brain tissues is low relative to FDG uptake so that the tumor to normal tissue contrast is better with amino acid imaging than with FDG. Radiolabeled amino acids can also penetrate the blood–brain barrier independently of its disturbance. A variety of 11 C- and 18 F-labeled amino acids such as 11 C-methionine (11 C-MET) and 18 F-fluoro-ethyl-tyrosine (18 F-FET) have been studied for potential use in oncologic PET. Most brain tumors show an increased uptake of amino acids compared with normal brain tissue. In particular, the uptake of 18 F-FET by brain tumors especially by high-grade glioma cells is intense relative to the low uptake in normal cerebral tissue and has shown the potential in the detection of primary and recurrent brain tumors with high sensitivity and specificity. Compared with 11 C-MET, 18 F-FET PET findings in brain tumors are similar. One of the advantages of 18 F-FET over 11 C-MET is that the half life, which makes it possible to be used in clinics not having on-site cyclotron. 11 C- methionine PET and 18 F-fluorothymidine (FLT), provide better differentiation of the tumor from brain background signals than 18 F-FDG PET. The 11 C-methionine PET scan reflects metabolic activity through increased transport of amino acid carriers

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at the level of the blood-brain barrier that is highly expressed in malignant tumors compared with low uptake in the normal brain. On the other hand FLT, is a thymidine analog that is incorporated exclusively into DNA. It measures the activity of cellular thymidine kinase, which increases several-fold as cells enter the S-phase and begin DNA synthesis. Increased FLT uptake and therefore thymidine kinase levels provide a direct measure of the cellular proliferation rate. Tumor hypoxia remains the most challenging condition for treatment. Though oxygen metabolism in gliomas differs from that of normal brain tissue, the lack of oxygen appears to be an important factor in determining glioma aggressiveness and response to therapy. It has been documented in several types of cancers that low levels of oxygen tension are associated with persistent tumor following RT and with the subsequent development of local recurrences. In gliomas, spontaneous necrosis suggests the presence of hypoxic regions that are radioresistant. 18 F-FMISO imaging of hypoxic glioma cells shows significant promise, however larger patient population studies are required to ascertain its clinical impact. Identifying the regional distribution of hypoxia may improve planning of resections and allow targeting higher doses of radiotherapy more precisely to the hypoxic areas. Glioma cell membrane biosynthesis is imaged using 11 C-acetate and 11 C-choline. The rationale for imaging membrane and lipid biosynthesis is that tumor growth requires both of these processes in parallel with DNA and protein synthesis. These will likely show retention in tumor tissue but not by gray matter, an important advantage over FDG. A very few studies have been done so far on this front to show the potential advantages of this approach.

PET Imaging for Differentiating Recurrent Brain Tumor from Radiation Necrosis Radiation damage to vascular endothelial cells and oligodendrocytes causes necrosis. Differentiating tumor growth from post-treatment radiation effect (PTRE) remains a common challenge in high-grade glioma tumors. On MRI, appearances of radiation necrosis and of recurrent tumor are quite similar, as both causes’ areas of increased signal intensity. Conventional MRI/MRSI are currently used for the

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detection of early treatment-bed changes, though accurate diagnosis is challenging because tumor growth, PTRE, and admixed lesions can all have identical MR imaging appearances. Microscopic tissue analysis distinguishes these entities and can document intra-lesion heterogeneity by resolving distinct subregions of tumor from pure PTRE within different locations of the same lesion. Early work on utilizing PET in differentiating radiation induced necrosis from recurrent brain tumor was conducted by Patronas and coworkers using FDG (Patronas et al., 1982). The rationale for using FDG is that radiation necrosis is expected to show decreased uptake in comparison with recurrent tumors. However, in many cases, distinguishing recurrent tumor from radiation necrosis is found to be difficult based on FDG-PET alone (Hustinx et al., 2005). Radiolabeled amino acid analogues like 11 C-MET, 18 F-FET and proliferation marker 18 F-FLT are suggested to perform better in PTRE evaluation, than FDG in detecting residual and recurrent tumors after fractionated irradiation (Hustinx et al., 2005; Reinhardt et al., 1997). Though the exact incidence of true radiation necrosis is largely unknown, differentiating it from recurrent tumor has a larger clinical implication in the clinical management of patients and PET tracers seem to play a major role in it.

Current Practice of Target Volume Delineation in HGG Conventional target volume definitions in high grade gliomas (HGG) have not incorporated PET. The gross tumor volume (GTV) is mostly defined on postoperative MRI and includes the contrast-enhancing lesion as well as the surgical cavity (Fueger et al., 2010). Clinical target volumes (CTVs) include an MRI defined volume with an addition of uniform margin (about 2 cm) within the brain, which includes areas of microscopic extension and peritumoral edema. When therapy is planned for a second CTV (boost volume) a margin of typically 1.5 cm around the GTV is added to account for areas of microscopic disease. These CTVs are then further expanded by a uniform margin of 0.3–0.5 cm to create a PTV to account for treatment setup uncertainties. Initial imaging for HGG is usually done with CT or MRI, which provides accurate information about lesion anatomy

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and location. However, follow-up assessment of primary HGG tumors after radiation therapy, chemotherapy and surgery, is often difficult, since the anatomical imaging modalities are usually not able to differentiate recurrent tumor from radiation necrosis, surgical scar or inflammation. Identifying radiation necrosis and differentiating them from tumor recurrence pose a potential diagnostic challenge because the accurate diagnosis has important implications for the patient management.

PET-Guided Biological Target Volumes in HGG Grosu and co-workers have investigated the use of amino-acid PET and single-photon emission computed tomography (SPECT) in gross tumor volume definition for radiotherapy treatment planning of gliomas (Grosu et al., 2005a, c). They have shown that 11 CMET-PET offers significant additional information about tumor extent in HGG, compared to CT and MRI alone. This study suggested that integration of amino-acid PET in target volume definition might contribute to an improved outcome in HGG patients treatment. It was also showed that abnormal MET PET activity was detected beyond the area of the contrast-enhancing lesion on MRI. In a retrospective study on newly diagnosed glioblastoma multiforme (GBM) who underwent MET PET before radiation, the area of MET uptake was found to be larger than the contrast-enhancing gadolinium volume in 29 (74%) of 39 patients (Grosu et al., 2005c). In the same study it was showed that patients who underwent treatment planning based on 11 C-MET PET/SPECT imaging had improved survival compared with treatment planning based on CT/MRI in recurrent gliomas, with a median survival of 9 months versus 5 months, respectively. Other investigators have also suggested that 11 C-MET PET has the potential to improve target volume definition in the radiation treatment planning of high-grade gliomas by identifying residual tumor after resection and also in recurrent gliomas. Yamane et al. (2010) have recently showed that 11 C-MET PET can provide useful information in initial diagnosis and differentiating tumor recurrence from radiation necrosis. They have also claimed that use of 11 C-MET PET has changed the intended clinical management in half of the patients.

15 Assessment of Biological Target Volume Using PET in HGG Patients

Our group (Vees et al., 2009) has studied the contribution of 18 F-FET PET in the delineation of GTV in HGG patients compared with MRI alone. In this study PET based tumor volumes were delineated in 18 patients using seven image segmentation techniques. The PET image segmentation techniques included manual delineation of contours (GTV(man) ), a 2.5 standardized uptake value (SUV) cutoff (GTV(2.5) ), a fixed threshold of 40 and 50% of the maximum signal intensity (GTV(40%) and GTV(50%) ), signal-to-background ratio (SBR)-based adaptive thresholding (GTV(SBR) ), gradient find (GTV(GF) ), and region growing (GTV(RG) ). Figure 15.4 shows an example of image segmentation using these techniques. Overlap analysis was also conducted to assess geographic mismatch between the GTVs delineated using the different techniques. Contours defined using GTV(2.5) failed to provide successful delineation technically in three patients (18% of cases) as SUV(max) <2.5 and clinically in 14 patients (78% of cases). Overall, the majority of GTVs defined on PET-based techniques were usually found to be smaller than GTV(MRI) (67% of cases). Yet, PET

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detected frequently tumors that are not visible on MRI and added substantial tumor extension outside the GTV(MRI) in six patients (33% of cases). The study showed that the selection of the most appropriate 18 F-FET PET-based segmentation algorithm is crucial, as it impacts both the volume and shape of the resulting GTV. The SBR-based PET technique shown to be useful and suggested that it may add considerably important information on tumor extent to conventional MRI-guided GTV delineation. In a recent study by (Pichler et al., 2010), it has been shown that 18 F-FET-PET is highly sensitive for detecting high-grade glioma in patients with neurological symptoms. It was also suggested that, in the evaluation of new brain lesions of unknown significance via 18 F-FET-PET a negative image can encourage a wait and see strategy-of course in accordance with the clinical picture and morphological imaging. There are a few good reviews on the use of functional PET and MRI imaging for tumor volume definition in high-grade gliomas (Benard et al., 2003; Grosu et al., 2005a; Guha et al., 2008; Jacobs et al., 2002; Lecchi et al., 2008; Pirzkall et al., 2001; Tsien

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Fig. 15.4 (A) Gadolinium enhanced T1-weighted MRI, (B) corresponding 18 F-FET PET, and fused PET/MR (C) transaxial slices of a clinical study with a glioblastoma showing differences in target-volume definition. Indicated are (D) the gross tumour volume (GTV) delineated on MRI (GTVMRI ), and (E) enhanced details of PET-based GTVs obtained by manual delineation of contours (GTVman ; magenta), an isocontour of a standardized uptake value (SUV) of 2.5 (GTV2.5 ; purple), a fixed threshold

of 40% (GTV40% ; green) and 50% (GTV50% ; cyan) of the maximum signal intensity, signal-to-background ratio (SBR)-based adaptive thresholding (GTVSBR ; yellow), gradient find (GTVGF ; blue), and region growing (GTVRG ; red) segmentation algorithms. Note that GTVMRI overestimates the tumour extension relative to GTVman . Reprinted with permission from Vees et al. (2009)

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et al., 2009). The key conclusions are that the PET images could help in detecting metabolic and functional abnormalities beyond the tumor volume seen on conventional MRI, assess early response to treatment, and delineate the regions of high risks for failure in high-grade gliomas.

Concluding Remarks and Future Perspectives PET imaging provides the opportunity to image noninvasively many biological processes in brain tumors. Regional biological information and pathophysiology of gliomas can be obtained by studying energy metabolism, amino acid transport, hypoxia, proliferation and cell death. None of these has been thoroughly studied and utilized to allow judgment of their potential benefit to the management of gliomas. Future large clinical trials will shed some light on the potential benefits of imaging these specific biological processes. The issue of gross tumor volume delineation using biological imaging modalities for high-grade gliomas is not clearly resolved at present for all clinical situations. A multimodality approach of biological imaging (PET, SPECT, CT, MRI and MRSI) might prove to be an effective way as all the imaging modalities complement each other for better target volume delineation. Despite the limited number of published reports, the use of amino-acid PET, SPECT and MRSI, along with anatomical imaging are shown superior to either CT or MRI alone in visualizing the tumor extent in gliomas. There have been studies comparing SPECT and PET with MRI or MRSI to see the combined effect of anato-molecular approach to identify what volume needs to be treated with high conformity (Grosu et al., 2005b). A number of studies showed the existence of significant differences in the target volumes delineations that result from the use of either PET or MRI/MRSI imaging and it is still too early to recommend the use of biologic imaging as the sole determinant of target volumes. However, the incorporation of biological imaging into a treatment planning process that currently depends entirely on anatomic imaging seems advantages in most of the clinical presentations. In essence PET guided biological target volumes helps treatment planning in radiotherapy, in terms of identifying biological processes. However,

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the real outcome of biological imaging is yet to be analyzed in a larger clinical setup. At present limited clinical data is available to prove the superior outcomes in HGG patients with PET defined GTV for RT planning. Retrospective analysis of the outcome of controlled dose-escalation trials that used biological imaging alongside MRI/MRSI for target volume segmentation could provide useful insights for better design of prospective clinical trial for accurate tumor delineation (Grosu et al., 2005a). New studies focusing on the wide applicability of biological imaging in HGG is ongoing, and it remains to be seen how the high precision in gross volume segmentation translates into fruitful results with conformal radiation delivery techniques such as IMRT, IGRT etc, in a large clinical trial settings. In order to take maximum advantages of advances in high precision dose deliver techniques (“dose sculpting” and “dose painting”) most accurate available assessment of tumor extent by biological imaging modalities should be used for high-grade gliomas. Future developments of new tracers for biological imaging and robust automated image segmentation techniques will bridge the existing knowledge gap in the high-grade gliomas tumor volume delineation.

References Benard F, Romsa J, Hustinx R (2003) Imaging gliomas with positron emission tomography and single-photon emission computed tomography. Semin Nucl Med 33:148–162 Boss A, Bisdas S, Kolb A, Hofmann M, Ernemann U, Claussen CD, Pfannenberg C, Pichler BJ, Reimold M, Stegger L (2010) Hybrid PET/MRI of intracranial masses: initial experiences and comparison to PET/CT. J Nucl Med 51:1198– 1205 Fueger BJ, Czernin J, Cloughesy T, Silverman DH, Geist CL, Walter MA, Schiepers C, Nghiemphu P, Lai A, Phelps ME, Chen W (2010) Correlation of 6-18F-Fluoro-L-Dopa PET uptake with proliferation and tumor grade in newly diagnosed and recurrent gliomas. J Nucl Med 51:1532–1538 Gregoire V, Haustermans K, Geets X, Roels S, Lonneux M (2007) PET-based treatment planning in radiotherapy: a new standard?. J Nucl Med 48(Suppl 1):68S–77S Grosu AL, Piert M, Weber WA, Jeremic B, Picchio M, Schratzenstaller U, Zimmermann FB, Schwaiger M, Molls M (2005a) Positron emission tomography for radiation treatment planning. Strahlenther Onkol 181:483–499 Grosu AL, Weber WA, Franz M, Stark S, Piert M, Thamm R, Gumprecht H, Schwaiger M, Molls M, Nieder C (2005b) Reirradiation of recurrent high-grade gliomas using amino acid PET (SPECT)/CT/MRI image fusion to determine gross

15 Assessment of Biological Target Volume Using PET in HGG Patients tumor volume for stereotactic fractionated radiotherapy. Int J Radiat Oncol Biol Phys 63:511–519 Grosu AL, Weber WA, Riedel E, Jeremic B, Nieder C, Franz M, Gumprecht H, Jaeger R, Schwaiger M, Molls M (2005c) L-(methyl-11C) methionine positron emission tomography for target delineation in resected high-grade gliomas before radiotherapy. Int J Radiat Oncol Biol Phys 63:64–74 Guha C, Alfieri A, Blaufox MD, Kalnicki S (2008) Tumor biology-guided radiotherapy treatment planning: gross tumor volume versus functional tumor volume. Semin Nucl Med 38:105–113 Hustinx R, Pourdehnad M, Kaschten B, Alavi A (2005) PET imaging for differentiating recurrent brain tumor from radiation necrosis. Radiol Clin N Am 43:35–47 Jacobs AH, Dittmar C, Winkeler A, Garlip G, Heiss WD (2002) Molecular imaging of gliomas. Mol Imaging 1:309–335 Lecchi M, Fossati P, Elisei F, Orecchia R, Lucignani G (2008) Current concepts on imaging in radiotherapy. Eur J Nucl Med Mol Imaging 35:821–837 Ling CC, Humm J, Larson S, Amols H, Fuks Z, Leibel S, Koutcher JA (2000) Towards multidimensional radiotherapy (MD-CRT): biological imaging and biological conformality. Int J Radiat Oncol Biol Phys 47:551–560 Nestle U, Weber W, Hentschel M, Grosu A-L (2009) Biological imaging in radiation therapy: role of positron emission tomography. Phys Med Biol 54:R1–R25 Patronas NJ, Di Chiro G, Brooks RA, DeLaPaz RL, Kornblith PL, Smith BH, Rizzoli HV, Kessler RM, Manning RG, Channing M, Wolf AP, O’Connor CM (1982) Work in progress: [18F] fluorodeoxyglucose and positron emission tomography in the evaluation of radiation necrosis of the brain. Radiology 144:885–889 Pichler R, Dunzinger A, Wurm G, Pichler J, Weis S, Nussbaumer K, Topakian R, Aigner RM (2010) Is there a place for FET PET in the initial evaluation of brain lesions with unknown significance?. Eur J Nucl Med Mol Imaging 37: 1521–1528 Pirzkall A, McKnight TR, Graves EE, Carol MP, Sneed PK, Wara WW, Nelson SJ, Verhey LJ, Larson DA (2001)

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MR-spectroscopy guided target delineation for high-grade gliomas. Int J Radiat Oncol Biol Phys 50:915–928 Reinhardt MJ, Kubota K, Yamada S, Iwata R, Yaegashi H (1997) Assessment of cancer recurrence in residual tumors after fractionated radiotherapy: a comparison of fluorodeoxyglucose, L-methionine and thymidine. J Nucl Med 38:280–287 Rickhey M, Moravek Z, Eilles C, Koelbl O, Bogner L (2010) 18 F-FET-PET-based dose painting by numbers with protons. Strahlenther Onkol 186:320–326 Sun X, Niu G, Chan N, Shen B, Chen X (2011) Tumor hypoxia imaging. Mol Imaging Biol 2010 Sep 14. [Epub ahead of print] DOI: 10.1007/s11307-010-0420-z Tsien CI, Cao Y, Lawrence TS (2009) Functional and metabolic magnetic resonance imaging and positron emission tomography for tumor volume definition in high-grade gliomas. Semin Radiat Oncol 19:155–162 Vees H, Senthamizhchelvan S, Miralbell R, Weber DC, Ratib O, Zaidi H (2009) Assessment of various strategies for 18 FFET PET-guided delineation of target volumes in high-grade glioma patients. Eur J Nucl Med Mol Imaging 36:182–193 Weber DC, Zilli T, Buchegger F, Casanova N, Haller G, Rouzaud M, Nouet P, Dipasquale G, Ratib O, Zaidi H, Vees H, Miralbell R (2008) [(18)F]Fluoroethyltyrosine- positron emission tomography-guided radiotherapy for high-grade glioma. Radiat Oncol 3:44 Weissleder R (2006) Molecular imaging in cancer. Science 312:1168–1171 Yamane T, Sakamoto S, Senda M (2010) Clinical impact of (11)C-methionine PET on expected management of patients with brain neoplasm. Eur J Nucl Med Mol Imaging 37:685– 690 Yap JT, Carney JP, Hall NC, Townsend DW (2004) Imageguided cancer therapy using PET/CT. Cancer J 10:221–233 Zaidi H, El Naqa I (2010) PET-guided delineation of radiation therapy treatment volumes: a survey of image segmentation techniques. Eur J Nucl Med Mol Imaging 37:2165–2187 Zaidi H, Vees H, Wissmeyer M (2009) Molecular PET/CT imaging-guided radiation therapy treatment planning. Acad Radiol 16:1108–1133

Chapter 16

Skin Metastases of Glioblastoma Rebecca Senetta and Paola Cassoni

Abstract Extra-cranial metastases of glioblastoma (GBM) are rare events, and the mechanisms involved in their development are still controversial and need further elucidations. Although because of their low frequency GBM metastases do not represent a routinely therapeutic challenge in patients with GBM, such modality of tumour progression could be of crucial interest for the comprehension of the biology of GBM. More specifically, metastases of GBM to the skin have been reported in literature in very few and heterogeneous cases. We here review the state of the art of GBM skin metastases, focusing on the hypothesized mechanisms involved, as well as on the suggested diagnostic and therapeutic approaches to these patients, and on the possible relevance of a “glial to mesenchymal transition” as a facilitating event involved in the extra-neural spreading of GBM. Keywords Metastases · GBM · Scalp · Skin · Mesenchymal · FNAc

and diffuse infiltration into surrounding brain matter so that patients survival is very short. In spite of its rapid and aggressive growth, extra-cranial metastases from cerebral GBM are surprisingly rare, occurring only in 0.2–2% of cases (Cervio et al., 2001; Hsu et al., 1998; Mentrikoski et al., 2008) and usually develop at the same time of intracranial tumour progression. However, in the last years an increasing number of extra-neural metastases has been reported, possibly due to longer patient survivals, related to therapeutic advances and improved diagnostic modalities. Lung and pleura are the most frequent sites of GBM metastases (in about 60% of cases) (Houston et al., 2000; Laraqui et al., 2001), followed by cervical lymph nodes (51%) (Campora et al., 1993; Wallace et al., 1996), bone marrow and bones (30%) (Houston et al., 2000; Rajagopalan et al., 2005), liver (22%) (Astner et al., 2006) and skull; metastases in other organs (as pancreas, small bowel and spleen) are extremely rare (Mujic et al., 2006; Yasuhara et al., 2003).

Introduction

Extra-Axial Tumor Spread: Why So Rare?

Glioblastoma multiforme (GBM) represents the most common and malignant astrocytic-derived intracranial primitive brain tumour in adult patients and accounts for 19–25% of all primary CNS tumours (Bauchet et al., 2010). GBM usually grows by a quick, direct

Extra-neural dissemination of intracranial GBM can arise from a local seeding after invasive surgical procedures (Bouillot-Eimer et al., 2005; Figueroa et al., 2002; Mentrikoski et al., 2008) or after ventricular shunting (Newton et al., 1992). Haematogenous spread into extra-cranial tissue and tumour transdural extension is extremely rare in absence of previous surgery; however, spontaneous (Wallace et al., 1996) GBM dissemination has been reported in literature. The rarity of metastases as well as their causes have been diffusely debated in literature by several authors,

P. Cassoni () Department of Biomedical Sciences and Human Oncology, University of Turin, 10100 Turin, Italy e-mail: [email protected]

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but the mechanism of GBM cell spread outside the SNC is not fully understood yet. Certainly, different factors play a concurrent relevant role in preventing GBM metastatic spread (Bernstein et al., 1995; Datta et al., 1998; Figueroa et al., 2002; Mourad et al., 2005; Sadik et al., 1984; Wallace et al., 1996), such as: (1) the short patient survival; (2) the absence of a brain lymphatic system; (3) the presence of a dense and impassable structure represented by the dura, contrasting tumor invasion; (4) the presence the blood-brain barrier, as a “physical” entity, constituted by a dense extracellular matrix and a tough basement membrane surrounding blood vessels; (5) an early collapse of the thin-walled cerebral veins due to the increased intracranial pressure consequent to tumour growth, which prevents any penetration/diffusion of tumour cells; (6) the immune response against malignant glial cells, which would fail to survive in distant organs because of their foreign antigenic specificity which would trigger an exaggerated immunological response, preventing tumour metastatic growth. In addition, some authors highlighted the necessity of neoplastic glial cells to have a specific intracranial supporting micro-environment to survive (Figueroa et al., 2002). Altogether, the previously listed assumptions may explain the rarity of extra-SNC metastases, mainly in absence of surgery.

Skin GBM Metastases: Facts and Hypotheses To date, only eighteen cases of intracranial GBM metastases to skin have been reported overall (see Table 16.1). In one case, the cutaneous spreading occurred in a child (13 years old boy) (Saad et al., 2007) whereas the other seventeen cases developed in adult patients aged 19–74 years (mean age 48,5 years) without any sex prevalence. The most common site of skin metastases was the scalp, though Miliaras

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et co-workers (2009) described a left scapular subcutaneous GBM spreading. In general, the reported cutaneous lesions macroscopically appeared as fixed, ulcerated, soft, rubbery masses or nodules, rarely bleeding, measuring from 1 to 5 centimetres in size, generally localised close to the surgical scar or the craniotomy site. A hypothetical tumour dissemination during and/or after surgery might explain the proximity to surgical suture, as a consequence of a neoplastic cells subcutaneous implantation or a cell escape along the tract of excision through the dura toward skin. The involvement of the scalp occurs more commonly after craniotomy (Allan, 2004; Figueroa et al., 2002; Hata et al., 2001; Jain et al., 2005; Matsuyama et al., 1989; Santos et al., 2003; Schultz et al., 2005; Wallace et al., 1996) and less frequently after a stereotactic biopsy (Bouillot-Eimer et al., 2005; Houston et al., 2000), further underlining the crucial role of the loss of brain anatomical integrity in the pathogenesis of extra-neural involvement. In addition, in the time frame close to surgery, the post-operative neo-vascularization might play a key role in promoting the dissemination of neoplastic cells (Jain et al., 2005). Skin metastases can either be isolated as single site of extra-neural involvement (Allan, 2004; Jain et al., 2005; Mentrikoski et al., 2008; Santos et al., 2003; Schultz et al., 2005) or coexist with other visceral and/or lymph node tumour localisation (BouillotEimer et al., 2005; Figueroa et al., 2002; Hata et al., 2001; Houston et al., 2000; Matsuyama et al., 1989; Saad et al., 2007; Wallace et al., 1996). In general, cutaneous dissemination develops concurrently and synchronous with progression of intracranial disease; only three cases of GBM skin metastases in absence of a synchronous brain or extracranial progression have been reported (Louis et al., 2007; Santos et al., 2003; Senetta et al., 2009). In fact, in our report we described two cases of cutaneous spreading after a 14 and 11month latency from the primary diagnosis and surgery: unexpectedly, in both cases, at the time of skin involvement the intracranial disease was absent or responsive to therapy, suggesting a divergent response to treatment between intracranial (responsive) and skin (resistant) GBM. In both patients, surgery was followed by a conformational radiotherapy (total dose 59.4 and 60 Gy respectively) and adjuvant Temozolomide: in one patient the cutaneous swelling developed after 12 cycles of chemotherapy without any recurrence of the intracranial disease, whereas in the other patient a scalp

42, F 49, F

19, M

Santos et al. (2003) Jain et al. (2005)

L, parietal

32, M

Houston et al. (2000)

34, F

L, temporal

NM

Hata et al. (2001)

Figueroa et al. (2002)

R, frontal

41, M

Supra-tentorial R, temporoparietal

L, temporal

NM

R, temporal

68, M

Matsuyama et al. (1989) Wallace et al. (1996)

Tumor location

Age Sex

Author, year

Stereotactic biopsy; 3 months later craniotomy with partial resection, RT (60 Gy), CT (2 cycles of BCNU), 125 I Craniotomy for subtotal excision, 125 I brachytherapy, RT (59.4 Gy), CT (2 cycles of BCNU) Craniotomy with partial resection + Ommaya, RT (64.8 Gy) Craniotomy Craniotomy, RT

Craniotomy, RT, CT

Craniotomy with total resection, RT, CT Craniotomy with a total resection, RT (60 Gy), CT (2 cycles with carmustine)

Therapy

Table 16.1 Reported cases of intracranial GBM metastases to skin

36 months 10 months

8 months

10 months

6 months

NM

3 months

NM

Timing to cutaneous progression

3 months later the cutaneous spread No Yes

Not mentioned

2 months later the cutaneous spread

NM

No

NM

Intracranial progression

No No

No

LN and mediastinum

Liver, spleen, spinal cord Cervical LN, extraocular muscles, limbus of the right eye Lung, LN and heart Skull, lung, liver

Additional metastatic organs

Unknown Excision

Excision

Biopsy, RT (30 Gy), CT

Excision

NM

Local RT to scalp and neck (45 Gy) and CT

Unknown

Diagnosis/ therapy of cutaneous lesions

>36 months 12 months

13 months

17 months

13 months

NM

8 months

5 months

Survival

16 Skin Metastases of Glioblastoma 145

L, fronto-parietal L, frontal

13, M

58, F 41, M

48, F

53, F

Mentrikoski et al. (2008)

Senetta et al. (2009)

L, frontotemporal

L, frontal NM

Therapy

Craniotomy

Craniotomy, RT, CT

Craniotomy, RT, CT (TMZ) Craniotomy, RT and intratumoral seed implants Craniotomy, RT, CT

Craniotomy, RT, Local CT with DTI-015 Stereotactic biopsy, RT, CT (2 cycles of BCNU) Craniotomy, RT, CT (TMZ)

Craniotomy, RT Craniotomy, RT (55.8 Gy)

7 months

14 months

14 months

16 months 2 months

NM

11 months

12 months

12 months 48 months

Timing to cutaneous progression

Yes

No

No

Yes NM

Yes

Yes

Yes

Yes Yes

Intracranial progression

Parotid gland, LN, bone (L4) No

No

Leptomeninges, lung, liver No No

Axial skeleton

No LN, leptomeniges No

Additional metastatic organs

FNAc

Total removal and focal RT Biopsy and focal RT

Biopsy NM

FNAc/partial excision CT

Excision

No treatment CT

10 months

25 months

26 months

NM NM

10 months

12 months

13 months

14 months 52 months

Diagnosis/therapy of cutaneous lesions Survival

NM not mentioned, F female, M male, L left, R right, RT radiotherapy, CT chemotherapy, TMZ temozolomide, FTM fotemustine, PC procarbazine and CCNU, LN limph nodes, FNAc fine-needle aspiration cytology

63, M

L, frontal

60, F

Bouillot-Eimer et al. (2005) Saad et al. (2007)

Miliaras et al. (2009)

L, parietal

74, F

Schultz et al. (2005)

Supra-tentorial L, Temporooccipital L, temporal

Allan (2004) Moon et al. (2004)

Tumor location

Age Sex

60, M 35, F

Author, year

Table 16.1 (continued)

146 R. Senetta and P. Cassoni

16 Skin Metastases of Glioblastoma

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Fig. 16.1 Histopathology and immunophenotype shift in one case skin metastatic GBM. The intracranial GBM showed (at haematoxylin and eosin) a marked hypercellularity with an area of classical pseudo-palisade necrosis and prominent glomeruloid vascular proliferation (a). At immunohistochemistry, a diffuse

and intense GFAP reactivity was present (b). The skin metastatic tumour was composed of small neoplastic cells with a scant cytoplasm and hyper-chromatic nuclei (c) with only few neoplastic elements positive to GFAP (d) and an intense vimentin immunoreactivity (e)

mass appeared after 6 cycles of chemotherapy, in presence of a partial response of the intracranial tumour (reduction of about 90% of the enhancing area). This observation induced us to verify in these two cases if primary and metastatic lesions still shared a main phenotypical consistency or if the skin localization acquired a prevalent divergent phenotype (Fig. 16.1). In fact, the immunophenotypical profile of cutaneous tumours revealed a strongly reduced GFAP and EGFR expression, paralleled by an increased vimentin and YKL-40 (which is a marker of radio-resistance in GBM) (Pelloski et al., 2005) staining at IHC (Senetta et al., 2009). Other authors similarly observed an intense vimentin-immunoreactivity in the cutaneous GBM sites associated either to a focal (as in our cases) or a robust GFAP expression (Jain et al., 2005; Mentrikoski et al., 2008; Schultz et al., 2005; Senetta et al., 2009). As previously discussed in our paper (Senetta et al., 2009), these changes altogether may suggest a “glial-to-mesenchymal transition” of the cutaneous metastases: the newly acquired immunophenotype could account for the therapy resistance of the skin lesions in contrast to the synchronous responsiveness of the intracranial GBM. This hypothesis is in agreement with previous evidence of the overexpression of mesenchymal and angiogenesis related genes in GBMs with more aggressive behaviour (Phillips et al., 2006) and could then be extended to their metastatic spread: still, it should be understood if such shift towards a mesenchymal de-differentiation in skin lesions can be a spontaneous event in the pathway of tumour progression or if

radiotherapy could favour the sarcomatous transformation and/or the selection of resistant “mesenchymal” cell clones (Burger et al., 1979; Schiffer et al., 1990).

Diagnostic and Therapeutic Approaches to Skin Metastases of GBM As summarized in Table 16.1, the diagnosis of a cutaneous dissemination of GBM is mainly performed on a biopsy, a partial resection or a total excision of the skin lesion. In two cases a fine-needle aspiration cytology (FNAc) approach was used, and the diagnosis was then re-confirmed on the tumour excision histology (Schultz et al., 2005; Miliaras et al., 2009). Some authors highlighted the importance of patient neoplastic history (whether intracranial or extra-neural) for an accurate diagnosis (Schultz et al., 2005; Mentrikoski et al., 2008): without a knowledge of intracranial tumour story, the differential diagnosis must include, above all, a melanoma, followed by a sarcomatoid squamous cell carcinoma and atypical fibroxanthoma (Mentrikoski et al., 2008). In fact, a cutaneous lesions with atypical morphological appearance at histology (spindle-shape cells, nuclear pleomorphism, irregular nuclear membranes, prominent nucleoli and mitoses) associated to immunohistochemical positivity for S-100 protein (as frequently described in GBMs) (Bouillot-Eimer et al., 2005; Figueroa et al., 2002; Mentrikoski et al., 2008) should first be considered as a possible melanoma localization, even in presence of

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a known history of GBM. Schultz and colleagues listed the cytological features of malignant neoplasm that can arise in the scalp and that must be distinguished from a metastatic GBM, when an anamnesis of glioma is present (Schultz et al., 2005). The treatment of GBM scalp metastases can consist in surgery alone (with a partial or total lesion excision with surrounding subcutaneous and bone tissue), or in surgery in combination to chemotherapy or radiotherapy, or in chemotherapy and radiotherapy alone. In the two cases of GBM skin metastases that we reported, total surgery+local radiotherapy (total dose: 40 Gy) proved to be more effective in preventing further cutaneous relapses compared to biopsy+local radiotherapy (total dose: 55 Gy)+6 cycles of Temozolomide. Therefore, in our experience, a radical surgical treatment seems to allow the best local tumour control (Senetta et al., 2009). In conclusion, GBM metastases are rare events, and therefore do not represent an ordinary clinicaloncologic concern: however, comprehension of the mechanisms involved in promoting their development could bear relevance in elucidating GBM biology overall, and considered as a unique model to focus on the crucial steps necessary to GBM progression.

References Allan RS (2004) Scalp metastasis from glioblastoma. J Neurol Neurosurg Psychiatry 75:559 Astner ST, Pihusch R, Nieder C, Rachinger W, Lohnerm H, Tonn JC, Molls M, Grosu AL (2006) Extensive local and systemic therapy in extraneural metastasized glioblastoma multiforme. Anticancer Res 26:4917–4920 Bauchet L, Mathieu-Daudé H, Fabbro-Peray P, Rigau V, Fabbro M, Chinot O, Pallusseau L, Carnin C, Lainé K, Schlama A, Thiebaut A, Patru MC, Bauchet F, Lionnet M, Wager M, Faillot T, Taillandier L, Figarella-Branger D, Capelle L, Loiseau H, Frappaz D, Campello C, Kerr C, Duffau H, Reme-Saumon M, Trétarre B, Daures JP, Henin D, Labrousse F, Menei P, Honnorat J; with the participation of Société Française de Neurochirurgie (SFNC) and the Club de NeuroOncologie of the Société Française de Neurochirurgie (CNOSFNC) and Société Française de Neuropathologie (2010) Oncological patterns of care and outcome for 952 patients with newly diagnosed glioblastoma in 2004. Neurooncol. 12:725–735 Bernstein JJ, Woodard CA (1995) Glioblastoma cells do not intravasate into blood vessels. Neurosurgery 36:124–132 Bouillot-Eimer S, Loiseau H, Vital A (2005) Subcutaneous tumoral seeding from a glioblastoma following stereotactic biopsy: case report and review of the literature. Clin Neuropathol 24:247–251

R. Senetta and P. Cassoni Burger PC, Mahley MS Jr, Dudka L, Vogel FS (1979) The morphologic effects of radiation administered therapeutically for intracranial gliomas. A post-mortem study of 25 cases. Cancer 44:1256–1272 Campora RG, Salaverri CO, Ramirez FV, Villadiego MS, Davidson HG (1993) Metastatic glioblastoma multiforme in cervical lymph nodes: report of a case with diagnosis by fine needle aspiration. Acta Cytol 37:938–942 Cervio A, Piedimonte F, Salaberry J, Alcorta SC, Salvat J, Diez B, Sevlever G (2001) Bone metastases from secondary glioblastoma multiforme: a case report. J Neurooncol 52:141–148 Datta CK, Weinstein JD, Bland JE, Brager PM, Stewart MA (1998) A case of cervical lymph node metastasis resulting from glioblastoma multiforme. W V Med J 94:276–278 Figueroa P, Lupton JR, Remington T, Olding M, Jones RV, Sekhar LN, Sulica VI (2002) Cutaneous metastasis from an intracranial glioblastoma multiforme. J Am Acad Dermatol 46:297–300 Hata N, Katsuta T, Inoue T, Arikawa K, Yano T, Takeshita M, Iwaki T (2001) Extracranial metastasis of glioblastoma to the lung and the heart with a histological resemblance to small cell carcinoma of the lung: an autopsy case. No Shinkei Geka 29:433–438 Houston SC, Crocker IR, Brat DJ, Olson JJ (2000) Extraneural metastatic glioblastoma after interstitial brachytherapy. Int J Radiat Oncol Biol Phys 48:831–836 Hsu E, Keene D, Ventureyra E, Matzinger MA, Jimenez C, Wang HS, Grimard L (1998) Bone marrow metastasis in astrocytic gliomata. J Neurooncol 37:285–293 Jain N, Mirakhur M, Flynn P, Choudhari A (2005) Cutaneous metastasis from glioblastoma. Br J Neurosurg 19:65–68 Laraqui L, Amarti A, Zouiadia F, Maher M, Kettani F, Saidi A (2001) Pulmonary metastasis from glioblastoma: a case report. Rev Pneumol Clin 5713:225–228 Louis DN, Ogaki H, Wiestler OD, Cavanee WK (2007) WHO classification of tumours of the central nervous system, 4th edn. IARC Lyon Press, Lyon Matsuyama J, Mori T, Hori S, Nakano T, Yamada A (1989) Gliosarcoma with multiple extracranial metastases. Case report. Neurol Med Chir 29:938–943 Mentrikoski M, Johnson MD, Korones DN, Scott GA (2008) Glioblastoma multiforme in skin: a report of 2 cases and review of the literature. Am J Dermatopathol 30: 381–384 Miliaras G, Tsitsopoulos PP, Markoula S, Kyritsis A, Polyzoidis KS, Malamou-Mitsi V (2009) Multifocal glioblastoma with remote cutaneous metastasis: a case report and review of the literature. Cen Eur Neurosurg 70:39–42 Moon KS, Jung S, Lee MC, Kim IY, Kim HW, LEE JK, Kim TS (2004) Metastatic glioblastoma in cervical lymph node after repeated craniotomies: report of a case with diagnosis by fine needle aspiration. J Korean Med Sci 19:911–914 Mourad PD, Farrell L, Stamps LD, Chicoine MR, Silbergeld DL (2005) Why are systemic glioblastoma metastases rare? Systemic and cerebral growth of mouse glioblastoma. Surg Neurol 63:511–519 Mujic A, Hunn A, Taylor AB, Lowenthal RM (2006) Extracranial metastases of a glioblastoma multiforme to the pleura, small bowel and pancreas. J Clinic Neurosci 13:677–681

16 Skin Metastases of Glioblastoma Newton HB, Rosenblum MK, Walker RW (1992) Extraneural metastases of infratentorial glioblastoma multiforme to the peritoneal cavity. Cancer 69:2149–2153 Pelloski CE, Mahajan A, Maor M, Chang EL, Woo S, Gilbert M, Colman H, Yang H, Ledoux A, Blair H, Passe S, Jenkins RB, Aldape KD (2005) YKL-40 expression is associated with poorer response to radiation and shorter overall survival in glioblastoma. Clin Cancer Res 11: 3326–3334 Phillips HS, Kharbanda S, Chen R, Forrest WF, Soriano RH, Wu TD, Misra A, Nigro JM, Colman H, Soroceanu L, Williams PM, Modrusan Z, Feuerstein BG, Aldape K (2006) Molecular subclasses of high-grade glioma predict prognosis, delineate a pattern of disease progression, and resemble stages in neurogenesis. Cancer Cell 9:157–173 Rajagopalan V, El Kamar FG, Thayaparan R, Grossbard ML (2005) Bone marrow metastases from glioblastoma multiforme: a case report and review of the literature. J Neurooncol 72:157–161 Saad AG, Sachs J, Turner CD, Proctor M, Marcus KJ, Wang L, Lidov H, Ullrich NJ (2007) Extracranial metastases of glioblastoma in a child: case report and review of the literature. J Pediatr Hematol Oncol 29:190–194

149 Sadik AR, Port R, Garfinkel B, Bravo J (1984) Extracranial metastasis of cerebral glioblastoma multiforme: case report. Neurosurgery 15:549–551 Santos AV, Saraiva PF, Santiago B (2003) Extracranial metastasis of glioblastoma multiforme. Acta Med Port 16:209–211 Schiffer D, Chiò A, Giordana MT, Mauro A, Migheli A, Soffietti R, Vigliani MC (1990) Vascular response to irradiation in malignant gliomas. J Neurooncol 8:73–84 Schultz S, Pinsky GS, Wu NC, Chamberlain MC, Rodrigo AS, Martin SE (2005) Fine needle aspiration diagnosis of extracranial glioblastoma multiforme: case report and review of the literature. CytoJournal 2:19 Senetta R, Trevisan E, Rudà R, Benech F, Soffietti R, Cassoni P (2009) Skin metastases of glioblastoma in the absence of intracranial progression are associated with a shift towards a mesenchymal immunophenotype: report of two cases. Acta Neuropathol 118:313–316 Wallace CJ, Forsyth PA, Edwards DR (1996) Lymph node metastases from glioblastoma multiforme. Am J Neuroradiol 17:1929–1931 Yasuhara T, Tamiya T, Meguro T, Ichikawa T, Sato Y, Date I, Nakashima H, Ohmoto T (2003) Glioblastoma with metastasis to the spleen–case report. Neurol Med Chir (Tokyo) 43:452–456

Part II

Therapy

Chapter 17

Diffuse Low-Grade Gliomas: What Does “Complete Resection” Mean? Johan Pallud

Abstract Supratentorial hemispheric diffuse low-grade gliomas (LGG), i.e., World Health Organization grade II gliomas, are generally revealed by seizures in young adults with no or only mild neurological deficits. These progressive tumors are characterized by a continuous growth, by tumor recurrences and by a progression into a higher grade of malignancy. Maximal safe resection preserving eloquent brain areas, when possible, is currently considered as the optimal primary treatment modality of LGG. Imaging determinations of the spatial extent of LGG are of paramount importance in evaluating the risk-to-benefit ratio of surgical resection. However, it is not yet clear how accurately MRI can delineate LGG. Indeed, LGG may recur postoperatively even after a MRI-based complete resection and recurrences generally occurred in the resection margins. The value of conventional MRI in determining the spatial extent of LGG is thus questionable. As demonstrated by multi-scale correlative approaches with histological and imaging data, conventional MRI underestimates the actual spatial extent of LGG, even when they are well delineated on T2-weigthed and FLAIR sequences. Cycling isolated tumor cells are present beyond MRI-defined abnormalities and permeate surrounding “normal” parenchyma at sites up to at least 15 mm outside MRI-defined tumor limits. Clear tumor boundaries do not actually exist as LGG are diffusely infiltrative tumors with a decrease of tumor cell density as a function of distance from MRI-defined

J. Pallud () Service de Neurochirurgie, Hôpital Sainte-Anne, Paris Cedex 14, France e-mail: [email protected]

abnormalities. This implies that a MRI-based complete resection of a LGG leaves isolated tumor cells beyond the surgical field. These results should be considered when planning a surgical resection of a LGG: (1) a maximal safe resection preserving eloquent brain area is recommended because of the infiltrative nature of LGG and the frequent juxtaposition close to and/or within critically eloquent brain areas; (2) surgical resection should be tailored according to cortico-subcortical functional boundaries rather than MRI-based limits; (3) an extended resection of a margin beyond MRI-defined abnormalities, whenever feasible in non-eloquent brain areas, might increase the survival of patients harboring a LGG; (4) an early surgical treatment while the LGG is smaller might delay tumor progression by decreasing the number of residual isolated tumor cells. Keywords LGG · Complete resection · WHO · Grade II gliomas · Risk-to-benefit ratio · MRI

Introduction Supratentorial hemispheric diffuse low-grade gliomas (LGG), i.e., World Health Organization (WHO) grade II gliomas are generally revealed by seizures in young adults with a normal life and no or only mild neurological deficits (Duffau, 2005). However, these progressive tumors are characterized by a continuous growth (Mandonnet et al., 2003; Pallud et al., 2006), by tumor recurrences and by a progression into a higher grade of malignancy that is the major cause of mortality (Duffau, 2005; Pallud et al., 2006).

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As a consequence, the better knowledge of the natural history of LGG resulted in an active therapeutic management and maximal safe resection preserving eloquent brain areas, when possible, is currently considered as the optimal primary treatment modality (Berger et al., 1994; Duffau, 2005, 2009; Sanai and Berger, 2008; Soffietti et al., 2010). Indeed, despite the lack of Class I evidence, there is growing evidence that the extent of resection is a significant prognostic factor for progression free and overall survivals (Sanai and Berger, 2008; Soffietti et al., 2010). The goal of surgery is thus to optimize the extent of resection while preserving the quality of life. Therefore, individual determinations of the spatial extent of LGG and of the cortical and subcortical functional organization are of paramount importance in evaluating the risk-to-benefit ratio of surgery (Duffau, 2009). The spatial extent of LGG is defined preoperatively on conventional MRI although it is not clear how accurately MRI can delineate LGG. Indeed, they may recur after a MRI-based complete resection and recurrences generally occurred at the site of the initial tumor, in the resection margins (Kelly, 1992, 2004). The value of MRI in determining the actual spatial extent of LGG is questionable. There is thus a need in assessing how MRI reflects their actual tumor limits. Such data are best provided by pathological analysis of spatially oriented surgical samples obtained from sites outside MRI-defined abnormalities. Studies are lacking for LGG as such samples performed are rarely available in a current neurosurgical practice. Therefore, the aim of the present chapter is to clarify the value of conventional MRI in delineating LGG and determining their actual spatial extent. The absence of a clear tumor boundary will be stressed at the light of histologic-imaging correlative studies focused on LGG.

Multiscale Approach of the Spatial Configuration of Cerebral Gliomas Microscopic Scale The understanding of the spatial configuration and growth pattern of a particular glioma is important for planning the best therapeutic strategy. The first

J. Pallud

data were acquired on postmortem analyses before the modern imaging era (Daumas-Duport and Szikla, 1981). They showed that cerebral diffuse gliomas: • Lack of a definite “tumor capsule” and spread diffusely throughout the brain in many cases. • May present without formation of a definite mass and without pronounced destruction of the preexisting tissue. • Present a microscopic tumor extension greater than that observed grossly with a tumor cell infiltration beyond the gross demarcation of the tumor. The brain invasion of diffuse gliomas was found to follow particular anatomical structures, such as myelinated fiber tracts, basement membranes of blood vessels or other basement membrane–like structures, subependyma and the perivascular spaces (Giese et al., 2003). The study of spatially oriented pathological samples obtained from image-based serial stereotactic biopsies of all components of the imaging abnormalities allowed the assessment of in vivo growth pattern of diffuse gliomas (Daumas-Duport et al., 1983, 1987; Daumas-Duport and Szikla, 1981; Kelly et al., 1987). Daumas-Duport et al. studied the histopathological tridimentionnal architectural pattern of diffuse gliomas and identified two distinct tumor components: • The “solid tumor tissue” component where the tumor cells are in contact with each other, containing microvascular proliferation and only residual brain parenchyma or none. • The “isolated tumor cells” component associated with edema but no microvascular proliferation, permeating functional brain parenchyma. This allowed proposing a spatial classification scheme with three tridimentionnal architectural subtypes for diffuse gliomas (Fig. 17.1) (Daumas-Duport et al., 1983, 1987; Daumas-Duport and Szikla, 1981; Kelly et al., 1987): • Type I: solid tumor tissue only without any peripheral isolated tumor cells. • Type II: solid tumor tissue and peripheral parenchyma infiltrated by isolated tumor cells. • Type III: brain parenchyma infiltrated by isolated tumor cells only without solid tumor tissue.

17 Diffuse Low-Grade Gliomas: What Does “Complete Resection” Mean?

Fig. 17.1 (a, b) Histopathological tridimentionnal architectural pattern of diffuse gliomas. The three different architectural subtypes comprise a “solid tumor tissue” component where the tumor cells are in contact with each other, containing microvascular proliferation and only residual brain parenchyma or none and an “isolated tumor cells” component associated with edema but no microvascular proliferation, permeating functional brain parenchyma. (Architectural subtype I: solid tumor tissue only without any peripheral isolated tumor cells; Subtype II: solid tumor tissue and peripheral parenchyma infiltrated by isolated tumor cells; Subtype III: brain parenchyma infiltrated by isolated tumor cells only without solid tumor tissue). (c, d, e, f) The WHO grade IV gliomas are architectural type II tumors.

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A solid tumor tissue component is observed peroperatively (c). They comprised generally a contrast-enhanced mass on axial T1-weighted sequences after gadopentetate dimeglumine (d) surrounded by peripheral hypointensity on T1-weighted sequences (f) and by hyperintensity on FLAIR sequences (e). (g, h, i, j) The WHO grade II gliomas are architectural type III tumors. Isolated tumors cells infiltrate the brain parenchyma and expand the involved gyri, as observed peroperatively (h). They comprise generally an hypointensity on axial T1-weighted sequences (i) and an hyperintensity on axial FLAIR sequences (j) without definite contrast-enhancement on axial T1-weighted sequences after gadopentetate dimeglumine (g)

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The identification of different architectural subtypes for diffuse gliomas has provided a guide for surgical decision-making. Indeed, the spatial architectural subtype III of LGG, implying a possible tumor invasion of functional brain areas, argues for the use of functional preoperative and peroperative mapping methods to optimize the benefit-to-risk ratio of surgical resection. In addition, this spatial classification scheme is generally correlated with WHO tumor grades: • Pilocytic astrocytomas are primarily type I tumors. • Grade II gliomas (LGG) are frequently type III tumors comprised only of a volume of brain parenchyma infiltrated by isolated tumor cells. However, there are some LGG that are type II because patches of tumor tissue exist within areas of infiltrated parenchyma. • The majority of higher-grade diffuse gliomas (WHO grade III and IV) are type II tumors; they have a central area of solid tumor tissue surrounded by a zone of peripheral infiltration.

Macroscopic Scale The MRI findings are correlated with the architectural subtypes of the spatial classification scheme described previously (Fig. 17.1): • Type I corresponds to a contrast-enhancing mass with no peripheral hypointensity on T1-weighted and no hyperintensity on T2-weighted or FLAIR sequences. • Type II corresponds to a contrast-enhanced mass surrounded by peripheral hypointensity on T1weighted and by hyperintensity on T2-weighted or FLAIR sequences. • Type III corresponds to an hypointense on T1weighted and hyperintense on T2-weighted or FLAIR sequences area without definite contrastenhancement. The architectural subtype of LGG explains the typical absence of contrast enhancement and why its occurrence is associated with a worsened prognosis (Pallud et al., 2009). Indeed, contrast enhancement should be considered as a key event in the malignant progression of LGG as it reflects macroscopically the microscopic neoangiogenesis.

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The tumor extension along myelinated white matter fiber tracts is easily demonstrated on MRI. Several reports have illustrated that glioma cells migrate along intra-hemispheric tracts, inter-hemispheric tracts and descending pathways and use them as preferential ways of invasion (Mandonnet et al., 2006; Pallud et al., 2005).

Dynamic Scale Mandonnet et al. first showed quantitatively the spontaneous radiological growth of LGG on successive MRIs in a subset of 27 patients that were followed before oncological treatment (Mandonnet et al., 2003). The study suggested a linear evolution of the mean tumor diameter over time (velocity of diametric expansion) quantified at a 4 mm/year average rate. These results were confirmed on a larger series of 143 LGG that ranged individual velocities of diametric expansion from 1 to 36 mm/year and demonstrated the strong prognostic significance of individual tumor growth rates on overall survival (Pallud et al., 2006). As other teams reported similar observations (Hlaihel et al., 2010; Peyre et al., 2010; Ricard et al., 2007), it is now accepted that LGG present a spontaneous and continuous radiological growth before any transformation into a higher grade of malignancy.

MRI-Based Estimation of the Spatial Extent of LGG Static Approach Conventional MRI is widely used in practice to study the anatomical extent of diffuse gliomas (Laster et al., 1984; Price, 2009). LGG appear as a hypointense area on T1-weighted sequence and hyperintense area on T2-weighted or FLAIR sequences. The margins of LGG is usually indistinct on T1-weighted sequence and is better demonstrated on T2-weighted and FLAIR sequences that show maximal visible imaging abnormalities (Bynevelt et al., 2001; Connor et al., 2004; Price, 2009). The hyperintense area is either with well-circumscribed margins or with indistinct borders,

17 Diffuse Low-Grade Gliomas: What Does “Complete Resection” Mean?

particularly on oligodendrogliomas with a loss of heterozygothy at chromosome 1p19q (Daumas-Duport et al., 1997; Jenkinson et al., 2006). It is suggested that Proton Magnetic Resonance Spectroscopic Imaging (H1 -MRSI) may be more valuable than conventional MRI to assess the spatial extent of diffuse gliomas, as abnormal metabolic areas may exceed areas of MRI-defined abnormalities (Croteau et al., 2001; Ganslandt et al., 2005). One previous report studied histological data of peripheral areas of gliomas that appeared normal on MRI and abnormal on H1 -MRSI and identified tumor infiltration, using proliferation markers, in four studied LGG (Ganslandt et al., 2005). However, this study could not provide reliable data regarding the true spatial extent of LGG from H1 -MRSI since it included gliomas of different histopathological subtypes and grades without imaging data, the biopsy samples were performed with a frameless stereotactic system within one centimeter from MRI-defined abnormalities. In addition, the MRSI techniques are currently limited by the poor resolution (Price et al., 2006). Studies have shown that diffusion tensor imaging reveals peritumoral abnormalities in diffuse gliomas that are not apparent on conventional MRI and that diffusion tensor imaging may delineate tumor margins better than conventional MRI (Price et al., 2006).

Dynamic Approach As LGG present a continuous growth, studying their radiological changes over time by the mean of repeated MRI is a simple way to follow the changes in the spatial extent of LGG (Mandonnet et al., 2008). Imaging changes are correlated with changes in the natural history of LGG and have been shown to be associated with a worsened prognosis, as they reflect the progression into a higher grade of malignancy:

• An elevated tumor growth rate with a velocity of diametric expansion at 8 mm/year or more (Pallud et al., 2006). • The change over time of a contrast enhancement pattern or the occurrence of a new contrast enhancement (Pallud et al., 2009).

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Does MRI Reflect the Actual Spatial Extent of LGG? The actual spatial extent of LGG and their histological margins of tumor infiltration are difficult to determine. Previous studies have demonstrated that conventional MRI underestimate the spatial extent of malignant gliomas and that isolated tumor cells are observed well beyond MRI-defined abnormalities on T2-weighted sequence (Daumas-Duport et al., 1983, 1987; DaumasDuport and Szikla, 1981; Earnest et al., 1988; Kelly, 1992; Kelly et al., 1987). The accurate correlation of MRI with histopathological findings remains the only means of characterizing imaging abnormalities and of establishing tumor margins. However, such data are scarse for LGG as samples performed beyond MRI-defined abnormalities are rarely available. Iwama et al. reported a correlation study between MRI and postmortem histopathological examination in cerebral gliomas (Iwama et al., 1991). In one studied LGG, scattered isolated tumor cells were identified beyond MRI-defined abnormalities on T2weighted sequence. These findings might possibly be explained by tumor growth, since a 19-week interval elapsed between MRI and post-mortem studies. An ideal correlative study would imply correlating MRI and histopathological specimens taken simultaneously. Watanabe et al. identified isolated tumor cells in spatially oriented surgical samples obtained from sites outside MRI-defined abnormalities on T2weighted sequence, from five of the eight studied LGG (Watanabe et al., 1992). These results also question the accuracy of histological and imaging correlation procedures as the location of specimens was performed intraoperatively, based on the depth below the anatomically identified cortex. Accurate real-time correlative studies between MRI and spatially oriented specimens could be allowed by image-based serial stereotactic biopsies. Stereotactic spatially oriented histological specimens from LGG peripheral areas that appeared normal on MRI have already been presented. Using T1weighted MRI-based stereotactic biopsies, Jenkinson et al. (2006) showed an insidious change in cellularity at the radiological margin on T1-weighted sequence in most of 43 LGG. The spatially limited sampling 2–3 mm beyond the MRI-defined tumor border did not allow a precise definition of the spatial extent

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of LGG. Earnest et al. showed the tumor to be confined to the lesion margins as demonstrated by MRI on T1-weighted and T2-weighted in one case of LGG (Earnest et al., 1988). In contrast, Kelly et al. (1987) reported a study of serial stereotactic biopsies obtained from 10 untreated LGG and identified isolated tumor cells in three of the five biopsy specimens obtained beyond MRI-defined abnormalities on T2-weighted sequence. However, these studies included a small number of LGG, were based on histological morphological criteria alone, and did not specify the MRI tumor delineation of the studied LGG.

MRI Underestimates the Spatial Extent of LGG In a recent study, Pallud et al. (2010) retrospectively analyzed all MRI-based serial stereotactic biopsies that were performed according to the Talairach stereotactic method in their institution for the diagnosis of diffuse cerebral gliomas. Such stereotactic biopsies were performed until 2002 to sample all components of the imaging abnormalities for an accurate pathological diagnosis, for classification into histological subtypes and grading and to establish the real tumor extent in a surgical context (Daumas-Duport et al., 1983; Daumas-Duport and Szikla, 1981). They selected, from a series of 109 procedures performed for the diagnosis of a WHO grade II glioma from January 1992 to December 2001, 16 untreated adult patients harboring a well-delineated and non contrast-enhanced supratentorial LGG for whom MRI-based serial stereotactic biopsies were performed, in part, beyond MRI-defined abnormalities before any oncological treatment. In addition to classical morphological histological criteria, the identification of isolated tumor cells was ascertained using multiple immunostainings and cell cycle marker (MIB-1 immunostaining). Moreover, the inaccuracy in the histological and imaging correlation procedure has been limited by several features of this study: • The short interval between preoperative MRI and histological diagnosis should restrict tumor growth between imaging and biopsy. • Biopsy samples were performed in a single operation before any treatment, so that artificially induced

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ultrastructural changes of the tumor should be limited and the use of a Sedan-Vallicioni biopsy cannula should act to reduce brain movements during biopsy procedures. • The superimposition of reformatted preoperative MRI and intraoperative teleradiographic X-rays taken after each biopsy samples allowed each biopsy site to be directly displayed on MRI on the same reference plane. The superimposition accuracy was controlled with postoperative MRI or CT-scan demonstrating the biopsy tract. • Only isolated tumor cells detected in biopsy samples that were at least 10 mm distant from MRIdefined abnormalities were considered. A total of 101 biopsy samples (median 6, range 3–9 per patient) were performed in the 16 patients. A total of 37 biopsy samples (median 2.2, range 1–5 per patient) were performed beyond MRI-defined abnormalities on T2-weighted and FLAIR sequences. The maximal distance of the biopsy samples sites from MRI-defined abnormalities on T2-weighted sequence ranged from 10 to 26 mm. • In all biopsy samples performed beyond MRIdefined abnormalities, the cortex and the white matter had a normal appearance on routine staining. There was no increased cell density, no edema and no gliosis. • MIB-1 immunostaining revealed MIB-1 positive cells (i.e., cycling cells), in all but two of the 37 samples where MIB-1 positive cells were indifferently distributed within the cortex and the white matter and their number was often variable from one BS to one another in a same patient. • None of the MIB-1 positive cells coexpressed glial fibrillary acidic protein and that all MIB-1 positive cells coexpressed OLIG2, thus excluding the possibility that MIB-1 positive cells correspond to reactive astrocytes or activated microglia. MIB-1 positive cells identified beyond MRI-defined abnormalities on T2-weighted and FLAIR sequences were cycling isolated tumor cells, since (Fig. 17.2): • Their morphological characteristics reflected those of tumor cells. • Their number was significantly higher than that of non-tumor controls.

17 Diffuse Low-Grade Gliomas: What Does “Complete Resection” Mean?

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Of note, in this study MIB-1 immunostaining was used to detect cycling tumor cells in brain parenchyma surrounding MRI-defined LGG. MIB-1 immunostaining only labels the fraction of the tumor cells, which at a given time are cycling cells. However, the proliferation rates are low for LGG. Therefore, only a

low percentage of tumor cells (i.e. the cycling tumor cells) could be identified using MIB-1 immunostaining. Moreover, glioma cells under migration present a decreased proliferation rate (Giese et al., 2003). As isolated tumor cells may represent invasive gliomas cells, it is then probable that the brain parenchyma around MRI-defined abnormalities on T2-weighted and FLAIR sequences contains a higher proportion of tumor cells than those demonstrated with MIB-1 immunostaining. This study demonstrated the inability of conventional MRI on T2-weighted and FLAIR sequences in determining the actual spatial extent of LGG.

Fig. 17.2 (a) Preoperative MRI of a patient on axial T2weighted sequences demonstrating the location of serial stereotactic biopsy samples performed in a right fronto-insular WHO grade II glioma. Each biopsy samples are defined as inside (black) or outside (white) areas of hypersignal. (b) A significant decreasing gradient of the number of MIB-1 positive cells with the distance from the MRI-defined abnormalities is observed. The number of cycling cells is expressed as MIB-1 positive cells/cm2 and the distance from MRI-defined abnormalities is expressed in mm. (c, d, e, f) Comparative histological features of biopsy samples performed within (c) and outside (d, e, f) MRIdefined abnormalities. Conventional Hemalun-Phloxin stainings

showed that samples performed within the MRI-defined tumor limits (c) are constituted, in the white matter, of infiltrative tumor cells associated by interstitial edema and gliosis (×400). In samples performed outside MRI-defined abnormalities (d), the white matter cell density appeared normal without any edema or gliosis (×400). Double immunostainings revealing that cycling cells do not shared astrocytic marker but correspond to Olig2 positive cells. Double immunufluorescent labelling (e) showed that all MIB-1 positive cells (green) co-expressed the oligodendrocyte cell marker olig2 (red). Double chromogenic immunostaining (f) revealed that MIB-1 positive cells (red) do not share Glial Fibrillary Acidic Protein astrocytic marker (brown) (×600)

• Their number per square centimeter significantly decreased with distance from the MRI-defined tumor borders. • Their number was significantly correlated with the tumor growth fraction.

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Practical Conclusions As demonstrated by Pallud et al. (2010) using a multi-scale correlative approach with histological and imaging data, conventional MRI underestimates the actual spatial extent of LGG, even when they are well delineated on T2-weigthed and FLAIR sequences: • Cycling isolated tumor cells are present beyond MRI-defined abnormalities in all LGG studied and permeate surrounding “normal” parenchyma. • Isolated tumor cells can be detected at sites up to at least 15 mm beyond MRI-defined abnormalities. It is clearly difficult for present imaging techniques to distinguish between intact brain parenchyma and that infiltrated by scattered isolated tumor cells. As already explicited by Kelly (2004), tumor cells could be found far from any MRI-defined abnormality, even in LGG. Thus, clear tumor boundaries do not actually exists and LGG are diffusely infiltrative tumors with a decrease of tumor cell density as a function of distance from the tumor component associated with abnormalities on conventional MRI. This implies that a gross total removal of a LGG either macroscopically or on postoperative imaging leaves isolated tumor cells beyond the surgical field. This observation may explain clinical events hampering the natural history of LGG: • The observation of tumor recurrences in the margin of the resection (Kelly, 1992, 2004) were isolated tumor cells are the more numerous. • The prognostic value of the extent of resection for progression free survival (Sanai and Berger, 2008) as extensive resection decreases the number of remaining isolated tumor cells. • The prognostic value of the extent of resection for overall survival (Berger et al., 1994; Sanai and Berger, 2008) as extensive resection theoretically decreases the cumulative odds of malignant progression of residual tumor cells. • The prognostic value of the tumor volume (Berger et al., 1994) as larger LGG probably have more surrounding isolated tumor cells and more residual tumor cells after surgical resection. As a practical consequence, the knowledge of the inability of MRI in determining the spatial extent of

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LGG is of paramount importance in evaluating the risk-to-benefit ratio of surgery, which goal is optimizing the extent of resection while preserving the quality of life. These results should be considered when planning a surgical resection of a LGG and several points have to be highlighted: • A maximal safe resection preserving eloquent brain area is recommended because of the infiltrative nature of LGG and the frequent juxtaposition close to and/or within critically eloquent brain areas. • Surgical resection should be tailored according to cortico-subcortical functional boundaries rather than MRI-based limits. • An extended resection of a margin beyond MRIdefined abnormalities, whenever feasible in noneloquent brain areas, might increase the survival of patients harboring a LGG. • An early surgical treatment while the LGG is smaller might delay tumor progression by decreasing the number of residual isolated tumor cells that escape the gross total removal. Acknowledgments Johan Pallud wants to thank FrançoisXavier Roux, Edouard Dezamis and Bertrand Devaux of the department of Neurosurgery, Catherine Daumas-Duport and Pascale Varlet of the department of Neuropathology, JeanFrançois Meder and Catherine Oppenheim of the department of Neuroradiology of the Sainte-Anne Hospital Center in Paris, France. Johan Pallud wants to thanks all the members of the French Glioma Network (REG, Réseau d’Etude des Gliomes) and particularly Emmanuel Mandonnet, Laurent Capelle, Luc Taillandier and Hugues Duffau.

References Berger MS, Deliganis AV, Dobbins J, Keles GE (1994) The effect of extent of resection on recurrence in patients with low grade cerebral hemisphere gliomas. Cancer 74: 1784–1791 Bynevelt M, Britton J, Seymour H, MacSweeney E, Thomas N, Sandhu K (2001) FLAIR imaging in the follow-up of low-grade gliomas: time to dispense with the dual-echo? Neuroradiology 43:129–133 Connor SE, Gunny R, Hampton T, O’Gorman R (2004) Magnetic resonance image registration and subtraction in the assessment of minor changes in low grade glioma volume. Eur Radiol 14:2061–2066 Croteau D, Scarpace L, Hearshen D, Gutierrez J, Fisher JL, Rock JP, Mikkelsen T (2001) Correlation between magnetic resonance spectroscopy imaging and image-guided biopsies: semiquantitative and qualitative histopathological analyses of patients with untreated glioma. Neurosurgery 49:823–829

17 Diffuse Low-Grade Gliomas: What Does “Complete Resection” Mean? Daumas-Duport C, Meder JF, Monsaingeon V, Missir O, Aubin ML, Szikla G (1983) Cerebral gliomas: malignancy, limits and spatial configuration. Comparative data from serial stereotaxic biopsies and computed tomography (a preliminary study based on 50 cases). J Neuroradiol 10:51–80 Daumas-Duport C, Monsaigneon V, Blond S, Munari C, Musolino A, Chodkiewicz JP, Missir O (1987) Serial stereotactic biopsies and CT scan in gliomas: correlative study in 100 astrocytomas, oligo-astrocytomas and oligodendrocytomas. J Neurooncol 4:317–328 Daumas-Duport C, Szikla G (1981) Definition of limits and 3D configuration of cerebral gliomas. Histological data, therapeutic incidences (author’s transl). Neurochirurgie 27: 273–284 Daumas-Duport C, Varlet P, Tucker ML, Beuvon F, Cervera P, Chodkiewicz JP (1997) Oligodendrogliomas. Part I: Patterns of growth, histological diagnosis, clinical and imaging correlations: a study of 153 cases. J Neurooncol 34:37–59 Duffau H (2005) Lessons from brain mapping in surgery for lowgrade glioma: insights into associations between tumor and brain plasticity. Lancet Neurol 4:476–486 Duffau H (2009) Surgery of low-grade gliomas: towards a ‘functional neurooncology’. Curr Opin Oncol 21:543–549 Earnest Ft, Kelly PJ, Scheithauer BW, Kall BA, Cascino TL, Ehman RL, Forbes GS, Axley PL (1988) Cerebral astrocytomas: histopathologic correlation of MR and CT contrast enhancement with stereotactic biopsy. Radiology 166: 823–827 Ganslandt O, Stadlbauer A, Fahlbusch R, Kamada K, Buslei R, Blumcke I, Moser E, Nimsky C (2005) Proton magnetic resonance spectroscopic imaging integrated into image-guided surgery: correlation to standard magnetic resonance imaging and tumor cell density. Neurosurgery 56:291–298 Giese A, Bjerkvig R, Berens ME, Westphal M (2003) Cost of migration: invasion of malignant gliomas and implications for treatment. J Clin Oncol 21:1624–1636 Hlaihel C„ Guilloton L, Guyotat J, Streichenberger N, Honnorat J, Cotton F (2010) Predictive value of multimodality MRI using conventional, perfusion, and spectroscopy MR in anaplastic transformation of low-grade oligodendrogliomas. J Neurooncol 97:73–80 Iwama T, Yamada H, Sakai N, Andoh T, Nakashima T, Hirata T, Funakoshi T (1991) Correlation between magnetic resonance imaging and histopathology of intracranial glioma. Neurol Res 13:48–54 Jenkinson MD, du Plessis DG, Smith TS, Joyce KA, Warnke PC, Walker C (2006) Histological growth patterns and genotype in oligodendroglial tumors: correlation with MRI features. Brain 129:1884–1891 Kelly PJ (1992) Stereotactic resection and its limitations in glial neoplasms. Stereotact Funct Neurosurg 59:84–91 Kelly PJ (2004) Technology in the resection of gliomas and the definition of madness. J Neurosurg 101:284–286 Kelly PJ, Daumas-Duport C, Kispert DB, Kall BA, Scheithauer BW, Illig JJ (1987) Imaging-based stereotaxic serial biopsies in untreated intracranial glial neoplasms. J Neurosurg 66:865–874 Laster DW, Ball MR, Moody DM, Witcofski RL, Kelly DL Jr (1984) Results of nuclear magnetic resonance with cerebral glioma. Comparison with computed tomography. Surg Neurol 22:113–122

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Mandonnet E, Capelle L, Duffau H (2006) Extension of paralimbic low grade gliomas: toward an anatomical classification based on white matter invasion patterns. J Neurooncol 78:179–185 Mandonnet E, Delattre JY, Tanguy ML, Swanson KR, Carpentier AF, Duffau H, Cornu P, Van Effenterre R, Alvord EC Jr, Capelle L (2003) Continuous growth of mean tumor diameter in a subset of grade II gliomas. Ann Neurol 53:524–528 Mandonnet E, Pallud J, Clatz O, Taillandier L, Konukoglu E, Duffau H, Capelle L (2008) Computational modeling of the WHO grade II glioma dynamics: principles and applications to management paradigm. Neurosurg Rev 31:263–269 Pallud J, Capelle L, Taillandier L, Fontaine D, Mandonnet E, Guillevin R, Bauchet L, Peruzzi P, Laigle-Donadey F, Kujas M, Guyotat J, Baron MH, Mokhtari K, Duffau H (2009) Prognostic significance of imaging contrast enhancement for WHO grade II gliomas. Neurooncology 11:176–182 Pallud J, Devaux B, Daumas-Duport C, Oppenheim C, Roux FX (2005) Glioma dissemination along the corticospinal tract. J Neurooncol 73:239–240 Pallud J, Mandonnet E, Duffau H, Kujas M, Guillevin R, Galanaud D, Taillandier L, Capelle L (2006) Prognostic value of initial magnetic resonance imaging growth rates for World Health Organization grade II gliomas. Ann Neurol 60:380–383 Pallud J, Varlet P, Devaux B, Geha S, Badoual M, Deroulers C, Page P, Dezamis E, Daumas-Duport C, Roux FX (2010) Diffuse low-grade oligodendrogliomas extend beyond MRIdefined abnormalities. Neurology 74:1724–1731 Peyre M, Cartalat-Carel S, Meyronet D, Ricard D, Jouvet A, Pallud J, Mokhtari K, Guyotat J, Jouanneau E, Sunyach MP, Frappaz D, Honnorat J, Ducray F (2010) Prolonged response without prolonged chemotherapy: a lesson from PCV chemotherapy in low-grade gliomas. Neurooncology 20:1078–1082 Price SJ (2009) Advances in imaging low grade gliomas. Adv Tech Stand Neurosurg 35:1–34 Price SJ, Jena R, Burnet NG, Hutchinson PJ, Dean AF, Peña A, Pickard JD, Carpenter TA, Gillard JH (2006) Improved delineation of glioma margins and regions of infiltration with the use of diffusion tensor imaging: an image-guided biopsy study. AJNR Am J Neuroradiol 27:1969–1974 Ricard D, Kaloshi G, Amiel-Benouaich A, Lejeune J, Marie Y, Mandonnet E, Kujas M, Mokhtari K, Taillibert S, LaigleDonadey F, Carpentier AF, Omuro A, Capelle L, Duffau H, Cornu P, Guillevin R, Sanson M, Hoang-Xuan K, Delattre JY (2007) Dynamic history of low-grade gliomas before and after temozolomide treatment. Ann Neurol 61: 484–490 Sanai N, Berger MS (2008) Glioma extent of resection and its impact on patient outcome. Neurosurgery 62:753–764 Soffietti R, Baumert BG, Bello L, von Deimling A, Duffau H, Frenay M, Grisold W, Grant R, Graus F, Hoang-Xuan K, Klein M, Melin B, Rees J, Siegal T, Smits A, Stupp R, Wick W (2010) Guidelines on management of low-grade gliomas: report of an EFNS-EANO Task Force. Eur J Neurol 17:1124–1133 Watanabe M, Tanaka R, Takeda N (1992) Magnetic resonance imaging and histopathology of cerebral gliomas. Neuroradiology 34:463–469

Chapter 18

Quantitative Approach of the Natural Course of Diffuse Low-Grade Gliomas Johan Pallud and Emmanuel Mandonnet

Abstract Supratentorial hemispheric diffuse lowgrade gliomas (LGG), i.e., World Health Organization grade II gliomas, are a heterogeneous group of tumors with distinct clinical, histological and molecular characteristics. The prognosis of LGG varies between series and reflects their heterogeneity with different subgroups harboring specific intrinsic properties. The natural course of LGG, as observed in clinical practice can be summarized as a three-step process although there is an actual continuum from “low-grade” to “high-grade” of malignancy. The two first steps correspond to the histological “low-grade” of malignancy with an initial silent period before clinical revelation followed by a symptomatic period. The third step corresponds to the progression to a higher grade of malignancy leading to neurological disability and ultimately to death. It has been well demonstrated that LGG are progressive tumors that present a systematic, spontaneous and continuous radiological growth all along their natural course, even during the initial silent period and during the symptomatic period before any transformation into a higher grade of malignancy. The Velocity of Diametric Expansion (VDE), estimated from the evolution of the mean tumor diameter over time, can easily quantify the radiological tumor growth. The median VDE is at about 4 mm/year for LGG albeit with a great heterogeneity. Several intrinsic factors may influence spontaneous VDE (1p19q codeletion and p53 overexpression) or not (histological subtype) and extrinsic factors may modify VDE

J. Pallud () Service de Neurochirurgie, Hôpital Sainte-Anne, 14 Paris Cedex, France e-mail: [email protected]

(hormonal changes during pregnancy). The spontaneous VDE has a strong prognostic significance on overall and progression free survivals. As a consequence, the analysis of the spontaneous VDE, a dynamic macroscopic parameter easily available in clinical practice, may be a useful tool to overcome biological diversity of LGG and could be integrated along with the other “static” parameters (histological and molecular analyses) in a multi-scale approach to understand better the individual natural course of LGG. The VDE remains unchanged after surgical resection, whereas it decreases markedly during and after chemotherapy with temozolomide or PCV. Thus, a precise assessment of the VDE obtained before and after treatment would help guiding and analyzing the effects of different oncological treatment modalities on an individual basis. Keywords LGG · VDE · Heterogeneity · MTD · codeletion · overexpression

Introduction Supratentorial hemispheric diffuse low-grade gliomas (LGG), i.e., World Health Organization grade II gliomas, are a heterogeneous group of tumors with distinct clinical, histological and molecular characteristics (Soffietti et al., 2010). The prognosis of LGG varies between series and reflects their heterogeneity with different subgroups harboring specific intrinsic properties. Indeed, the 5-year overall and progression-free survival rates in randomized studies range from 58 to 72% and 37 to 55%, respectively (Soffietti et al., 2010). In addition, the natural history of LGG is complex and poorly understood. During their natural course,

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LGG grow continuously and tend to progress to a higher grade of malignancy, leading to neurological disability and ultimately to death. Hence, reference to these lesions as benign gliomas has been abandoned (Lang and Gilbert, 2006). However, a “wait and see” policy has been proposed in the past years in the initial management of LGG before their progression towards a higher grade of malignancy. Thus, long clinical and radiological follow-ups with repeated MRI of untreated LGG are available (Wessels et al., 2003). They allow correlating the quantitative radiological growth rates over time with clinical and histological features. Therefore, the aim of the present chapter is to review quantitative data regarding the natural history of LGG. A 3-step natural history scheme will be proposed. We will show that LGG present systematically a spontaneous and continuous radiological tumor growth before oncological treatment and before progression into a higher grade of malignancy. The practical implications will be detailed, mainly the prognostic significance of spontaneous growth rates of LGG regarding overall survival and progression-free survival, and the effects of oncological treatments on radiological growth rates.

The Three-Step Natural History of LGG A Step-By-Step Approach of a Continuum The natural course of LGG, as observed in clinical practice can be summarized as a three-step process. The two first steps correspond to the histological “lowgrade” of malignancy with an initial silent period before clinical revelation followed by a symptomatic period. The third step corresponds to the progression to a higher grade of malignancy. Beyond this artificial clustering of the LGG natural course, inspired by WHO histological classifications, one should keep in mind the actual continuum from “low-grade” to “high-grade” of malignancy as the tumor acquires progressively genotypic and phenotypic characteristics leading to malignancy.

The Initial Silent Period The natural course of LGG during the initial silent period and their “date of birth” are unknown and

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only analyses of incidental LGG could help the understanding. However, the natural course of an incidental LGG has been very scarcely reported. In a recent report, Pallud et al. (2010a) reviewed 1296 cases of histologically confirmed supratentorial hemispheric LGG in adults and identified 47 incidental tumors, defined as a previously undetected and incidental LGG at the time of radiological diagnosis that was unexpectedly discovered and unrelated to the purpose of the MRI examination in asymptomatic patients. They showed that incidental LGG are similarly proliferative tumours continuously growing on sequential MRI at the same rates than the symptomatic LGG: • The radiological tumour growth and the proliferation rates of incidental LGG were within reported ranges of symptomatic LGG. • When not treated, incidental LGG became symptomatic with time, at a median interval of 48 months since radiological discovery. • Incidental LGG present tumor recurrence and progression to higher grade of malignancy and led to death in several cases despite oncological treatment. In addition, the data suggested that incidental LGG represent an earlier step than symptomatic LGG in the tumor natural course as: • Age at radiological discovery was lower. • Incidental LGG presented with significantly smaller tumour volumes. Accordingly, tumours were limited to one lobe in most of cases, corpus callosum involvement was rare and no midline crossing was observed. • Only rare cases of contrast enhancement were observed, whereas contrast enhancement has been reported in ~16% of cases for all LGG (Pallud et al., 2009a). As the “date of birth” of a LGG is not known, the tumor genesis is still a mater of debate. They probably occur during the young adult period as suggested by rare reports of a normal MRI examination several years before the LGG discovery. This finding is in agreement with literature, which showed that LGG are distinct entities in pediatric and adult populations with different natural courses and prognoses (Bristol, 2009).

18 Quantitative Approach of the Natural Course of Diffuse Low-Grade Gliomas

The Symptomatic Period of Low-Grade of Malignancy Histologically, LGG comprise generally only a volume of isolated tumor without solid tumor tissue associated with edema but no microvascular proliferation permeating brain parenchyma preferentially along particular anatomical structures (Daumas-Duport et al., 1997; Giese et al., 2003). They correspond to a spatial architectural subtype III, as described by Daumas-Duport et al. (1983, 1987) and Daumas-Duport and Szikla (1981). However, there are some LGG that are type II because patches of solid tumor tissue exist within areas of infiltrated parenchyma by isolated tumor cells. In addition, the proliferation rates of LGG are very low (Soffietti et al., 2010). These spatial architectural findings are correlated with the MRI findings: • Repeated MRI examinations demonstrate a spontaneous and slow growth pattern of LGG (Chen et al., 2010; Mandonnet et al., 2003). • Isolated tumor cells present with an area of hypointensity on T1-weighted sequence and hyperintensity on T2-weighted and FLAIR sequences. MRI abnormalities are either with well-circumscribed margins or with indistinct borders, involve the cortex from the surface to its deeper part, extend more or less in the adjacent white matter and occasionally expand the involved gyrus (Daumas-Duport et al., 1997). • Definite contrast enhancement is typically absent in accordance with the architectural subtype III of LGG. Indeed, contrast enhancement reflects macroscopically the microvascular proliferation thus explaining why its occurrence is associated with a worsened prognosis (Pallud et al., 2009a). • The preferential brain invasion along myelinated white matter fiber tracts is easily demonstrated on MRI. Several reports have illustrated that glioma cells migrate along intra-hemispheric tracts, inter-hemispheric tracts and descending pathways (Mandonnet et al., 2006; Pallud et al., 2005). Of note, it has to be underlined that conventional MRI underestimates the actual spatial extent of LGG, even when they are well delineated on T2weigthed and FLAIR sequences since cycling isolated tumor cells can be detected at sites up to at least

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15 mm beyond MRI-defined abnormalities (Pallud et al., 2010c). Taken together, histological and imaging abnormalities explain the silent initial period and the long symptomatic period with no or mild neurological disorders: • The invasive behavior of LGG explains why functional areas may persist within brain parenchyma permeated by isolated tumor cells (Daumas-Duport et al., 1997). • The slow tumor growth allows functional compensation by brain plasticity mechanisms to be efficiently implemented, explaining the lack of neurological deficits despite frequent involvement of eloquent areas (Duffau, 2005, 2009). • The superficial tumor location and the frequent cortical involvment explains why seizures are the commonest presenting symptom and occur in ~90% of LGG (Soffietti et al., 2010). • The lack of solid tumor tissue component explains the rare occurrence of focal neurological deficit and of increased intracranial pressure, despite clear radiological mass effects (Soffietti et al., 2010). Of note, LGG may remain asymptomatic until progression to a higher grade of malignancy.

The Malignant Progression The time to progression to a higher grade of malignancy is variable from one patient to one another since: • LGG are a heterogeneous group of tumors with distinct clinical, histological and molecular characteristics. • LGG are diagnosed at various steps along the continuum of their natural course. Histologically, a solid tumor tissue component where the tumor cells are in contact with each other, containing microvascular proliferation and only residual brain parenchyma or none, occurs within the isolated tumor cells component. The tumor now corresponds to a spatial architectural subtype II, as described by Daumas-Duport et al. (1983, 1987) and Daumas-Duport and Szikla (1981). The malignant transformation is spatially heterogeneous and areas of

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high-grade and low-grade of malignancy may coexist. It is sometimes difficult to perform an accurate histological grading due to the limitations of histological sampling. In addition, proliferation rates increase. These spatial architectural findings are correlated with the MRI findings: • A change of the radiological growth pattern with growth rates at ranges over those of LGG (Pallud et al., 2006). • The occurrence of nodular-like and ring-like contrast enhancement patterns reflecting macroscopically the microvascular proliferation within the architectural subtype II. They are known to be associated with a worsened prognosis (Pallud et al., 2009a). • The occurrence of necrosis within the contrast enhanced areas. Taken together, histological and imaging abnormalities explain functional deficits that are associated with malignant transformation. Neurological disability occurs as: • Brain plasticity mechanisms are overtaken by the fast growing tumor. • The increased mass effect and intracranial pressure injure the peripheral brain areas that were initially recruited by brain plasticity mechanisms. • The solid tumor tissue component destroys the remaining functional infiltrated brain parenchyma. This malignant transformation leads ultimately to death (Soffietti et al., 2010).

Image-Based Monitoring of the Natural Course of LGG Evolution Over Time of the Radiological Growth Pattern of LGG Only rare papers have analyzed qualitatively the evolution of the radiological growth pattern over time of

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LGG. Chen et al. reported that tumors originating from the grey matter will remain bulky while continously growing, whereas tumors originating at the junction of gray and white matters will grow predominantly along the adjacent white matter fiber tracts (Chen et al., 2010). Mandonnet et al., demonstrated the dynamic invasion of major white matter fiber tracts surrounding the insular lobe for paralimbic LGG (Mandonnet et al., 2006).

Quantitative Radiological Growth Rates of LGG All quantitative longitudinal studies of radiological growth patterns demonstrated a spontaneous and continuous growth of LGG (Fig. 18.1a). Mandonnet et al. first quantified the spontaneous radiological growth of LGG on successive MRIs in 27 histologically proven LGG followed before oncological treatment (Fig. 18.1b) (Mandonnet et al., 2003). These initial results were confirmed on a larger series of 143 histologically proven LGG that ranged individual velocities of diametric expansion from 1 to 36 mm/year (Fig. 18.1c) (Pallud et al., 2006). Several independent groups have since reported the same results (Hlaihel et al., 2010; Pallud et al., 2010c; Peyre et al., 2010; Ricard et al., 2007). The quantitative analyses demonstrated a linear evolution of the spontaneous Mean Tumor Diameter (MTD) over time and quantified the Velocity of Diametric Expansion (VDE) at about 4 mm/year average rate (Fig. 18.1b) (Mandonnet et al., 2003). Further studies, performed by distinct groups, have confirmed this range value (Hlaihel et al., 2010; Pallud et al., 2010c; 2006; Peyre et al., 2010; Ricard et al., 2007). Of note, these quantitative studies never reported indolent untreated LGG or LGG alternating indolent and growing periods. In addition, Pallud et al., recently demonstrated that incidental LGG present a similar radiological growth during the silent period preceding their clinical revelation with VDE in the known ranges for symptomatic LGG (Pallud et al., 2010a). As different independent groups have reported similar observations, it has to be accepted that LGG are progressive tumors that present a spontaneous and

18 Quantitative Approach of the Natural Course of Diffuse Low-Grade Gliomas

Fig. 18.1 (a) Example of the natural course of a diffuse lowgrade glioma through the evolution of its Velocity of Diametric Expansion (VDE) over time. A right fronto-temporo-insular glioma was discovered incidentally in a 29-year-old righthanded woman. The tumor was initially followed and consecutive MRI showed a spontaneous growth with a VDE at 5.3 mm/year (e). About 3 years after radiological discovery, partial seizures occurred. A subtotal surgical resection (general anaesthesia) was performed as the first oncological treatment and confirmed a WHO grade II oligodendroglioma on pathological analysis. After surgery, the residual tumor progressed with a VDE at 2.3 mm/year. Three years after histological diagnosis, the patient refused further clinical and radiological follow-up. One year later, epilepsy reccured and the patient presented in emergency with a left hemiparesis. Images

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demonstrated a radiological progression toward a higher grade of malignancy with a VDE increase at 28.4 mm/year and the occurrence of a nodular-like area of contrast enhancement (e). A second subtotal surgical resection (general anaesthesia) was performed and an external conformational radiotherapy plus concomitant and adjuvant chemotherapy with temozolomide was started. b. The evolution of the Mean Tumor Diameter (MTD) is comparable among patients with a median VDE at about 4 mm/year (Adapted from Mandonnet et al., 2003). c. Distribution of patients by individual radiological growth rates. The VDE vary considerably among patients but their distribution results in two groups. About 85% presented a VDE less than 8 mm/year (blue bars) and about 15% presented a VDE at 8 mm/year or more (purple bars) (adapted from Pallud et al., 2006)

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continuous radiological growth all along their natural course (i.e., during the initial silent period and during the symptomatic period before any transformation into a higher grade of malignancy).

Radiological Growth Rates Reflect Different Natural Courses for LGG

Effects of Intrinsic and Extrinsic Factors on Spontaneous Tumor Growth Rates of LGG

Pallud et al. first studied the prognostic value of spontaneous MRI growth rates on overall survival in a retrospective series of 143 histologically proven LGG with measurements of the evolution of the MTD over time (Pallud et al., 2006). The low growth rates subgroup (VDE lower than 8 mm/year) exhibited a significantly longer overall survival than the high growth rates subgroup (VDE at 8 mm/year or more) (Fig. 18.2c). In multivariate analysis, tumor growth rates and initial tumor volume were two independent prognostic factors significantly associated with overall survival. The prognostic significance of spontaneous MRI growth rates on predicting progression into a higher grade of malignancy was addressed by Hlailel et al. (2010). They showed that an elevated VDE higher than 3 mm/year was correlated with a greater risk of progression into a higher grade of malignancy with an average VDE at 7.87 mm/year in transformers group versus an average VDE at 2.14 mm/year in non transformers group. Brasil Caseiras et al. (2009) proved that tumor growth within 6 months was better than baseline volumes, rCBV, or ADC in predicting time to malignant transformation in untreated LGG using the evolution of the tumor volume over time.

Although the different LGG histological subtypes (oligodendroglioma, astrocytoma, mixed glioma) are associated with different prognoses (Pignatti et al., 2002; Soffietti et al., 2010), they do not exhibit significant differences regarding the radiological tumor growth rates (Mandonnet et al., 2009; Pallud et al., 2006; Ricard et al., 2007). As an example, Mandonnet et al. quantified the median VDE at 3.35 mm/year in the astrocytoma subgroup, at 4.2 mm/year in the oligodendroglioma subgroup, and at 3.53 mm/year in the mixed glioma subgroup, without any statistical differences between these subgroups (Fig. 18.2a) (Mandonnet et al., 2009). Ricard et al. (2007) investigated the link between LGG radiological growth rates and genetic alterations. They showed that LGG with 1p-19q codeletion grew significantly slower than LGG without 1p-19q codeletion and that LGG with overexpression of p53 grew significantly faster than LGG without overexpression of p53 (Fig. 18.2a). There is little documentation of the effects of extrinsic factors on glioma growth properties. It has been suggested that pregnancy can have a negative impact on the natural course of glioma, by the mean of hormonal changes (Pallud et al., 2009b). Only one study investigated quantitatively the impact of pregnancy on the radiological growth rates of LGG in 12 pregnancies in 11 adult women harbouring a LGG prior to pregnancy (Pallud et al., 2010b). Pallud et al. (2010b) showed that LGG accelerated their radiological growth rates during pregnancy (Fig. 18.2a). Indeed, VDE significantly increased during pregnancy above levels detected either before pregnancy or after delivery in 75% of cases, changes in tumour growth were associated with an increase in seizure frequency in 40% of cases and radiological and clinical changes during pregancy motivated further oncological treatment after delivery in 25% of cases.

Prognostic Significance of the Spontaneous Growth Rates

Radiological Growth Rates as a New Prognostic Factor for LGG? The prognosis of LGG varies between series and reflects the heterogeneity of the observed natural histories. The 5-year overall (OS) and progression-free survival (PFS) rates in randomized studies range from 58 to 72% and 37 to 55%, respectively (Soffietti et al., 2010). Regarding clinical findings, age over 40 years and presence of pre-operative neurological deficits are adverse prognostic factors (Pignatti et al., 2002; Soffietti et al., 2010). Regarding radiological findings,

18 Quantitative Approach of the Natural Course of Diffuse Low-Grade Gliomas

Fig. 18.2 (a) Factors influencing the spontaneous Velocity of Diametric Expansion (VDE) of WHO grade II gliomas. The different histological subtypes do not exhibit significant differences of VDE (black bars, adapted from Mandonnet et al., 2009). The 1p-19q codeletion molecular status is associated with a significantly slower VDE (dark grey bars, adapted from Ricard et al., 2007). The p53 overexpression molecular status is associated with a significantly faster VDE (light grey bars, adapted from Ricard et al., 2007). Pregnancy increases significantly VDE as compared to pre-pregnancy and post-delivery rates (white bars, adapted from Pallud et al., 2010b). (b) Effects of oncological treatments on the Velocity of Diametric Expansion (VDE). VDE

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are expressed before and after surgery (black bars, adapted from Mandonnet et al.), before and during Temozolomide (TMZ) chemotherapy (dark grey bars, adapted from Ricard et al., 2007), before and during PCV chemotherapy (light grey bars, adapted from Peyre et al., 2010). (c) Kaplan-Meier estimates of overall survival by individual Velocity of Diametric Expansion (VDE). The subgroup with a VDE less than 8 mm/year (blue line) presents a significant longer overall survival (median survival more than 15 years) than the subgroup with a VDE at 8 mm/year or more (purple line) where the overall survival is closer to that of more malignant gliomas (median survival at 5.16 years) (adapted from Pallud et al., 2006)

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larger tumors and tumors crossing the midline correlate with a short OS and PFS (Pignatti et al., 2002; Soffietti et al., 2010) and growth rates are inversely correlated with OS (Pallud et al., 2006). There are conflicting reports as to whether contrast enhancement is associated with a worsened prognosis (Soffietti et al., 2010). However, Pallud et al. recently showed that the presence of contrast enhancement alone, regardless of its pattern, had no prognostic value and that only the presence of a nodular-like pattern or of progressive contrast enhancement over time were associated with a worsened prognosis (Pallud et al., 2009a). A low Cerebral Blood Volume and a low uptake of 11C-methionine correlate with longer PFS and OS (Soffietti et al., 2010). Regarding pathological and molecular findings, the astrocytoma histological subtype is associated with a worsened prognosis (Pignatti et al., 2002; Soffietti et al., 2010). 1p loss (with or without 19q loss) is a favorable prognostic factor (Soffietti et al., 2010). IDH1 codon 132 mutation has been recently suggested as an independent favorable prognostic factor (Soffietti et al., 2010). When risk factors are cumulated, the survival of LGG is dramatically decreased with survival times closer to those of higher grade gliomas. The limitation of the histological diagnosis explains, in part, this prognostic heterogeneity. Analyses on microscopic and macroscopic, static and dynamic, scales are required to refine the prognostic evaluation. A multi-scale approach is a way to circumvent the diagnostic limitations of the histological examination. Thus, analysis of VDE, a dynamic macroscopic parameter easily available in clinical practice by the mean of repeated measurements of MTD over time, may be a useful tool to overcome biological diversity of LGG (Mandonnet et al., 2008; Pallud et al., 2006). As a practical consequence, VDE could be integrated along with the other “static” parameters (histological and molecular analyses) in a multi-scale approach to understand better the individual natural course of LGG.

as promising tool in the follow-up of LGG and in the monitoring of the different oncological treatments. Mandonnet et al. have recently shown that VDE remain unchanged after surgical resection in a retrospective study of 54 resected LGG (Fig. 18.2b) (Mandonnet et al., 2009). This suggests that the survival benefit of surgery is mediated by a cytoreductive effect. Of note, 2 patients exhibited a decrease of their tumor growth rates greater than 3 mm/year whereas in 2 other patients, surgery failed to stop an ongoing malignant transformation, resulting in an increase of 3 mm/year on the post-operative tumor growth rates. Thus, the precise quantitative assessment of the VDE obtained pre and post-operatively would help analyzing the effects of surgical resection on an individual basis and guiding the postoperative oncological treatment. Similarly, the tumor response to chemotherapy can be quantified by the VDE evolution over time. Ricard et al. first quantified the tumor response after temozolomide and almost all LGG exhibited an initial decrease of the VDE after temozolomide onset (Fig. 18.2b) (Ricard et al., 2007). They evidenced different patterns of response, depending on the 1p-19q codeletion status as tumor relapse occured more frequently and earlier in tumors without 1p-19q codeletion. Peyre at al. first quantified the tumor response after PCV chemotherapy and all LGG presented an initial VDE decrease after PCV onset (Fig. 18.2b) (Peyre et al., 2010). They demonstrated that the median VDE decrease after PCV onset was very close to the tumor growth decrease after temozolomide onset found by Ricard et al. (2007). In addition, they showed an ongoing VDE decrease after PCV continuation that was prolonged more than 2 years in 60% of the LGG under study. These results raise the issue of a chemotherapy monitoring based on the quantitative changes of the tumor VDE. Of note, at that time, no study has quantified the radiological response, using VDE evolution over time, after radiation therapy.

Quantitative Assessment of Treatment Efficacy

Conclusions

Along with clinical response, the quantitative assessment of the individual VDE changes by the mean of the MTD evolution over time on consecutive MRI, appears

Quantitative analyses on MRI have demonstrated that LGG are progressive tumors that present a spontaneous and continuous radiological growth all along their natural course during the initial silent period and

18 Quantitative Approach of the Natural Course of Diffuse Low-Grade Gliomas

during the symptomatic period before any transformation into a higher grade of malignancy. LGG are a heterogeneous group of tumors with distinct prognoses and a multi-scale approach may help overpassing the diagnostic limitations of the sole histological examination. Thus, analysis of VDE, a dynamic macroscopic parameter easily available in clinical practice by the mean of repeated measurements of MTD over time (for technical details, see (Mandonnet et al., 2008)), may be a useful tool to understand the biological diversity of LGG. At the light of its strong prognostic significance, VDE could be integrated along with the other “static” parameters (histological and molecular analyses) in a multi-scale approach to understand better the individual natural course of LGG. In addition, the precise quantitative assessment of the VDE obtained before and after treatment would help guiding and analyzing the effects of different oncological treatment modalities on an individual basis. Acknowledgments Johan Pallud and Emmanuel Mandonnet want to thanks all the members of the French Glioma Network (REG, Réseau d’Etude des Gliomes) and particularly Laurent Capelle, Luc Taillandier and Hugues Duffau. Johan Pallud wants to thank François-Xavier Roux, Edouard Dezamis and Bertrand Devaux of the department of Neurosurgery, Catherine DaumasDuport and Pascale Varlet of the department of Neuropathology, Catherine Oppenheim and Jean-François Meder of the department of Neuroradiology of the Sainte-Anne Hospital Center in Paris, France.

References Brasil Caseiras G, Ciccarelli O, Altmann DR, Benton CE, Tozer DJ, Tofts PS, Yousry TA, Rees J, Waldman AD, Jager HR (2009) Low-grade gliomas: six-month tumor growth predicts patient outcome better than admission tumor volume, relative cerebral blood volume, and apparent diffusion coefficient. Radiology 253:505–512 Bristol RE (2009) Low-grade glial tumors: are they all the same? Semin Pediatr Neurol 16:23–26 Chen X, Dai J, Jiang T (2010) Supratentorial WHO grade II glioma invasion: a morphologic study using sequential conventional MRI. Br J Neurosurg 24:196–201 Daumas-Duport C, Meder JF, Monsaingeon V, Missir O, Aubin ML, Szikla G (1983) Cerebral gliomas: malignancy, limits and spatial configuration. Comparative data from serial stereotaxic biopsies and computed tomography (a preliminary study based on 50 cases). J Neuroradiol 10:51–80 Daumas-Duport C, Monsaigneon V, Blond S, Munari C, Musolino A, Chodkiewicz JP, Missir O (1987) Serial stereotactic biopsies and CT scan in gliomas: correlative study

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in 100 astrocytomas, oligo-astrocytomas and oligodendrocytomas. J Neurooncol 4:317–328 Daumas-Duport C, Szikla G (1981) Definition of limits and 3D configuration of cerebral gliomas. Histological data, therapeutic incidences (author’s transl). Neurochirurgie 27:273– 284 Daumas-Duport C, Varlet P, Tucker ML, Beuvon F, Cervera P, Chodkiewicz JP (1997) Oligodendrogliomas. Part I: patterns of growth, histological diagnosis, clinical and imaging correlations: a study of 153 cases. J Neurooncol 34:37–59 Duffau H (2005) Lessons from brain mapping in surgery for lowgrade glioma: insights into associations between tumor and brain plasticity. Lancet Neurol 4:476–486 Duffau H (2009) Surgery of low-grade gliomas: towards a ‘functional neurooncology’. Curr Opin Oncol 21:543–549 Giese A, Bjerkvig R, Berens ME, Westphal M (2003) Cost of migration: invasion of malignant gliomas and implications for treatment. J Clin Oncol 21:1624–1636 Hlaihel C, Guilloton L, Guyotat J, Streichenberger N, Honnorat J, Cotton F (2010) Predictive value of multimodality MRI using conventional, perfusion, and spectroscopy MR in anaplastic transformation of low-grade oligodendrogliomas. J Neurooncol 97:73–80 Lang FF, Gilbert MR (2006) Diffusely infiltrative low-grade gliomas in adults. J Clin Oncol 24:1236–1245 Mandonnet E, Capelle L, Duffau H (2006) Extension of paralimbic low grade gliomas: toward an anatomical classification based on white matter invasion patterns. J Neurooncol 78:179–185 Mandonnet E, Delattre JY, Tanguy ML, Swanson KR, Carpentier AF, Duffau H, Cornu P, Van Effenterre R, Alvord EC Jr, Capelle L (2003) Continuous growth of mean tumor diameter in a subset of grade II gliomas. Ann Neurol 53: 524–528 Mandonnet E, Pallud J, Clatz O, Taillandier L, Konukoglu E, Duffau H, Capelle L (2008) Computational modeling of the WHO grade II glioma dynamics: principles and applications to management paradigm. Neurosurg Rev 31:263–269 Mandonnet E, Pallud J, Fontaine D, Taillandier L, Bauchet L, Peruzzi P, Guyotat J, Bernier V, Baron MH, Duffau H, Capelle L (2009) Inter- and intrapatients comparison of WHO grade II glioma kinetics before and after surgical resection. Neurosurg Rev 33:91–96 Pallud J, Capelle L, Taillandier L, Fontaine D, Mandonnet E, Guillevin R, Bauchet L, Peruzzi P, Laigle-Donadey F, Kujas M, Guyotat J, Baron MH, Mokhtari K, Duffau H (2009a) Prognostic significance of imaging contrast enhancement for WHO grade II gliomas. Neuro-Oncology 11:176–182 Pallud J, Devaux B, Daumas-Duport C, Oppenheim C, Roux FX (2005) Glioma dissemination along the corticospinal tract. J Neurooncol 73:239–240 Pallud J, Duffau H, Razak RA, Barbarino-Monnier P, Capelle L, Fontaine D, Frenay M, Guillet-May F, Mandonnet E, Taillandier L (2009b) Influence of pregnancy in the behavior of diffuse gliomas: clinical cases of a French glioma study group. J Neurol 256:2014–2020 Pallud J, Fontaine D, Duffau H, Mandonnet E, Sanai N, Taillandier L, Peruzzi P, Guillevin R, Bauchet L, Bernier V, Baron MH, Guyotat J, Capelle L (2010a) Natural history of incidental world health organization grade II gliomas. Ann Neurol 68:727–733

172 Pallud J, Mandonnet E, Deroulers C, Fontaine D, Badoual M, Capelle L, Guillet-May F, Page P, Peruzzi P, Jouanneau E, Frenay M, Cartalat-Carel S, Duffau H, Taillandier L Club de Neuro-Oncologie de la Société Française de Neurochirurgie (SFNC), Association des Neuro-Oncologues d’Expression Française (ANOCEF) (2010b) Pregnancy increases the growth rates of World Health Organization grade II gliomas. Ann Neurol 67:398–404 Pallud J, Mandonnet E, Duffau H, Kujas M, Guillevin R, Galanaud D, Taillandier L, Capelle L (2006) Prognostic value of initial magnetic resonance imaging growth rates for World Health Organization grade II gliomas. Ann Neurol 60:380–383 Pallud J, Varlet P, Devaux B, Geha S, Badoual M, Deroulers C, Page P, Dezamis E, Daumas-Duport C, Roux FX (2010c) Diffuse low-grade oligodendrogliomas extend beyond MRIdefined abnormalities. Neurology 74:1724–1731 Peyre M, Cartalat-Carel S, Meyronet D, Ricard D, Jouvet A, Pallud J, Mokhtari K, Guyotat J, Jouanneau E, Sunyach MP, Frappaz D, Honnorat J, Ducray F (2010) Prolonged response without prolonged chemotherapy: a lesson from PCV chemotherapy in low-grade gliomas. Neuro-Oncology 10:1078–1082 Pignatti F, van den Bent M, Curran D, Debruyne C, Sylvester R, Therasse P, Afra D, Cornu P, Bolla M, Vecht C, Karim

J. Pallud and E. Mandonnet AB European organization for research and treatment of cancer brain tumor cooperative group, European organization for research and treatment of cancer radiotherapy cooperative group (2002) Prognostic factors for survival in adult patients with cerebral low-grade glioma. J Clin Oncol 20: 2076–2084 Ricard D, Kaloshi G, Amiel-Benouaich A, Lejeune J, Marie Y, Mandonnet E, Kujas M, Mokhtari K, Taillibert S, LaigleDonadey F, Carpentier AF, Omuro A, Capelle L, Duffau H, Cornu P, Guillevin R, Sanson M, Hoang-Xuan K, Delattre JY (2007) Dynamic history of low-grade gliomas before and after temozolomide treatment. Ann Neurol 61: 484–490 Soffietti R, Baumert BG, Bello L, Von Deimling A, Duffau H, Frénay M, Grisold W, Grant R, Graus F, Hoang-Xuan K, Klein M, Melin B, Rees J, Siegal T, Smits A, Stupp R, Wick W (2010) Guidelines on management of low-grade gliomas: report of an EFNS-EANO∗ Task Force. Eur J Neurol 17:1124–1133 Wessels PH, Weber WE, Raven G, Ramaekers FC, Hopman AH, Twijnstra A (2003) Supratentorial grade II astrocytoma: biological features and clinical course. Lancet Neurol 2:395–403

Chapter 19

Impact of Extent of Resection on Outcomes in Patients with High-Grade Gliomas Debraj Mukherjee and Alfredo Quinones-Hinojosa

Abstract Throughout the course of human history, surgical therapy has remained a viable option for the treatment of certain, well-defined lesions. However, particularly given the technological advancements over the last half-century, the fields of neurosurgery and neurooncology have been able to embrace multimodal forms of therapy, including maximal safe surgical resection, radiotherapy, and both local and systemic chemotherapy, in an effort to improve survival and decrease the odds of developing new post-operative deficits in patients with highly malignant gliomas. Some studies do appear to indicate that extent of resection plays a favorable role in survival of patients with high grade gliomas, although the exact relationship between extent of resection and survival or poor outcomes is not completely defined. Future prospective, randomized trials may need to be developed to assess the effect of multimodal forms of imaging, motor mapping, and combination forms of therapy upon shortand long-term patient outcomes. Keywords High-grade astrocytomas · Mapping · Central nervous system · Temozolomide · Chemotherapy · Radiotherapy

Introduction High-grade astrocytomas are the most common malignant primary central nervous system tumors in adults,

D. Mukherjee () Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Medical Center, Los Angeles, California 90048 e-mail: [email protected]

encompassing both anaplastastic astrocytomas (also known as WHO Grade III tumors) and glioblastoma multiforme (also known as WHO Grade IV tumors). Despite advances in medical and surgical therapy, the median survival remains less than 2 years. While mean survival for patients with high-grade gliomas have remained relatively short, individual patient survival is heterogeneous. Thus, there has been an emphasis on studying intraoperative factors that hold prognostic significance in predicting survival in patients with malignant astrocytomas. For many solid organ malignant tumors, gross total resection with clear margins has been associated with significantly extended survival in well-designed studies. However, the effects of such extensive resection on prolonging survival in patients with malignant astrocytomas is less clear as no prospectively, randomized trials have been conducted in this areas of study. Extensive resection of highgrade gliomas is made increasingly difficult because these tumors are frequently invasive, widely infiltrative, and often involve eloquent areas. Improvements in surgical adjuncts including functional MR imaging, cortical mapping, and intraoperative MR imaging have made it possible to achieve extensive resection of many gliomas. It has remained incompletely understood whether more extensive resection of malignant astrocytomas is associated with significantly prolonged survival in well-designed studies.

Historical Considerations Dating back to the early attempts by Neolithic man, surgery of the brain, meninges, or skull have slowly evolved over 12,000 years. Through most of this history, interventions were technically crude by

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modern measures and aimed almost exclusively toward the removal of extracranial, overtly visualized lesions of the skull. Within the modern era, this work progressed toward surgical intervention of the coverings of the brain by Zanobi Pecchioli, who resected a fungus of the dura mater in a patient presenting with a large extracranial mass in 1835. Yet, there continued to be no widely reported surgical interventions to remove primary intraparenchymal lesions of the brain through the late nineteenth century, as only a limited amount was known of localized areas of cortical functioning until the work of Paul Broca and Hughlings Jackson in the 1860s. With modest improvements in neurosurgical techniques and in the collective understanding of cortical functioning, the first widely recognized resection of a primary brain tumor was performed by Rickman J. Godlee in 1884 on a 25-year old who presented with a nearly 3 year history of intractable seizures. Although removal of this seemingly low-grade glioma was deemed an operative success, the patient died of complications from meningitis 3-weeks after surgical intervention. Yet, at autopsy, the patient was noted to have no residual tumor, likely alluding, in part, to the implicit importance Godlee may have placed in achieving a gross total resection. Attempts at intracranial surgery continued to some degree through the early part of the twentieth century and reached a milestone with Walter Dandy’s 1928 case series of patients undergoing hemispherectomy for removal of invasive high-grade gliomas. This series included one patient surviving three and a half years following surgical resection. Nevertheless, most patients died within 3 months of surgery, often of infectious complications, including meningitis and pneumonia. Over the following decades, advancements in surgical science, including the appropriate use of antibiotics and sterile technique, decreased immediate postoperative morbidity and mortality. Furthermore, the advent of cerebral angiograms in the 1930s, computerized topography (CT) scans in the 1970s, and magnetic resonance imaging (MRI) technology in the 1980s further facilitated in operative planning for these complex operations. With the last two decades, advancements in microsurgery have further increased the possibility of achieving operative gross total resection in patients with both low and high grade gliomas. However, the lack of well-designed, prospective studies have made the role of extensive resection of

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high-grade astrocytomas incompletely defined, despite the great advances made in developing adjuvant radiotherapy and chemotherapy protocols that significant improve survival among these patients (Stupp et al., 2005). For instance, many past studies used varying cut-offs for defining extent of resection thresholds for defining gross total, near total, or subtotal resection, including varying methods of assessing degree of resection (particularly among the non-volumetric studies). Additionally, a majority of these studies did not use standard WHO tumor grading criteria, thus making it difficult to fully generalize the findings of these studies to the general neuro-oncological literature. Furthermore, although most studies has comparable levels of adjuvant radiotherapy or chemotherapy between patients of varying degrees of extent of resection, all studies did not adjust likely predictors of overall survival, including patient comorbidities, location of tumor (for instance near eloquent cortical areas), or known predictors of survival, including 1p19q status among oligodendrogliomas and MGMT status among patient with glioblastoma multiforme. Furthermore, the use of particular pre-operative imaging modalities possibly helpful for operative planning, including DTI or fMRI for patients with lesions involving motor tracts or eloquent cortical areas, respectively, were not accounted for in most studies.

The Impact of Extent of Resection: Lessons Learned from Low-Grade Gliomas Over approximately 20 years, at least eleven studies have independently and retrospectively reviewed the impact of extent of resection on outcomes in patients with low-grade astrocytomas, as reviewed by Sanai and Berger (2008a). Of these, most have used non-volumetric means, including for instance intraoperative surgeon report or gross radiographic evidence of residual disease, to categorize extent of resection. A majority also presented evidence either in univariate or multivariate analysis of supporting greater 5-year progression-free survival or overall survival with greater extent of resection. Only the Johannesen et al. (2003) report from Norway studied 5-year overall survival and found no statistically significant difference in survival between biopsy, subtotal

19 Impact of Extent of Resection on Outcomes in Patients with High-Grade Gliomas

resection, or gross total resection, although there was a trend toward greater survival in those with greater extent of resection. Additionally, a few studies have retrospectively reviewed this association using more precise radiographic volumetrics, as opposed to selfreport or two-dimensional impressions of extent or resection from post-operative radiographic imaging, to assess degree of resection. All retrospective studies demonstrated significantly improved 5-year in those with greater extent of resection, although the threshold for definitely greatest degree of resection ranged from 75 to 100% in these studies. Taken in total, all major retrospective studies analyzing the association between extent of resection and 5-year survival have demonstrated at least a trend toward better outcomes in those with greater resection. These findings have been supported in two reviews and one meta-analyses on this area of study (Pouratian et al., 2007; Sanai and Berger, 2008a; Smith et al., 2008). However, findings in those with low-grade gliomas may not necessarily translate directly to patient with more infiltrative highgrade gliomas with often inherent much worse overall prognoses.

The Impact of Extent of Resection on Survival in Patients with High-Grade Gliomas: A Review of the Literature In the modern era, at least 29 studies have assessed the impact of extent of resection on progression-free or overall survival in patients with high-grade astrocytomas, as reviewed by Sawaya (1999) as well as Sanai and Berger (2008a). Of these, a majority used non-volumetric means of assessing extent or resection while just four studies used the more precise measure of volumetrics (Keles et al., 1999, 2006; Lacroix et al., 2001; Pope et al., 2005). Among the non-volumetric studies, an equal number demonstrated a statistically significant improvement in overall survival in multivariate analysis as those that showed no significant association. Among all studies of high-grade glioma patients, only three have assessed progression-free survival as an outcome (Jeremic et al., 1994; SandbergWollheim et al., 1991; Ushio et al., 2005). Within these studies, two reports demonstrated a statistically significant association between greater extent of resection and longer progression-free survival in multivariate

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analysis (Jeremic et al., 1994; Ushio et al., 2005), while one reports showed no significant association in multivariate analysis (Sandberg-Wollheim et al., 1991). Four volumetric studies have thus far been widely published on the topic (Keles et al., 1999, 2006; Lacroix et al., 2001; Pope et al., 2005). Among these studies, two reports demonstrated significantly improved overall survival in multivariate analysis in those with greater extent of resection (Keles et al., 1999; Lacroix et al., 2001), while the remaining two studies showed no statistically significant relationship in multivariate analysis (Keles et al., 2006; Pope et al., 2005). Only two volumetric studies have thus far assessed the impact of degree of resection on progression-free survival, with one study showing significant association (Keles et al., 1999) and the other demonstrating no significance (Keles et al., 2006), both in multivariate analyses.

The Importance of Multimodal Therapy in Improving Survival Although some progress has been made in understanding the impact of extensive resection on survival, the treatment of high-grade astrocytomas remains multimodal in approach, combining surgical resection with both adjuvant chemotherapy and radiation. The efficacy of combination local chemotherapy following extensive tumor resection was found to improve survival in patient with recurrent malignant gliomas from 23 to 31 weeks after revision resection (Brem et al., 1995). Amongst all high-grade glioma patients, a major advance in the treatment of highgrade gliomas occurred when Valtonen et al. (1997) found that median time from surgery to death in primary, high-grade glioma patients was 58.1 weeks for patients who received carmustine-loaded biodegradable polymers delivering localized chemotherapy in surgically resection tumor beds versus 39.9 weeks for those who only underwent surgical resection. More specifically patients with glioblastoma multiforme, the most deadly form of high-grade gliomas, survived 53.3 weeks compared to 39.9 weeks in those given carmustine-loaded wafer with resection, as compared to those undergoing resection alone. Truly multimodal therapy, incorporating extensive surgical resection along with both adjuvant

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temozolamide chemotherapy and adjuvant radiotherapy demonstrated a further significant improvement in glioblastoma survival through the Stupp et al. (2005) report, which has now become standard of care for all patients with glioblastoma multiforme. Additionally, recent retrospective work has demonstrated that combination surgical resection and both local and systemic chemotherapy may significantly improvement outcomes among these patients as well (McGirt et al., 2009b). In a recent analysis, glioblastoma multiforme patients receiving extensive surgical resection along with both local carmustineimpregnated wafer chemotherapy and systemic temozolamide chemotherapy had 9 months of greater survival relative to counterparts only receiving surgical resection and localized wafer chemotherapy; the two groups did not have significantly different rates of complication (Fig. 19.1). Thus, surgical resection coupled with carmustine-impregnanted, biodegradable wafers, systemic temozolamide, and radiation therapy are currently considered the most effective treatment modalities available for treating high-grade gliomas. Additionally approaches to modifying multimodal therapy, such as using temozolomide in a dose-dense relationship in patient with MGMT silencing, or using temozolomide in combination with MGMT inhibitors (such as O6 -benzylguanine), are currently under further investigation (Quinn et al., 2009).

The Impact of New Post-operative Deficits on Survival

Fig. 19.1 Kaplan-Meier plot of survival after primary resection of glioblastoma multiforme and radiotherapy in patients ≤ 70 years old. Patient receiving concomitant temozolamide according to the Stupp protocol in addition to Gliadel wafer

implantation demonstrated improved survival relative to those receiving Gliadel wafters and radiotherapy alone (n = 78). Mean survival was 21.3 versus 12.4 months, respectively (p = 0.005). Source: McGirt (2009b)

While studies have suggested an association between greater degree of resection among malignant astrocytomas and improved survival, the negative effects that new post-operative deficits, potentially induced by greater extensive resection, may have upon survival is less clear. A single retrospective analysis of 306 patients undergoing primary resection for glioblastoma multiforme was conducted at a single, high-volume institution to assess the relationship between new post-operative motor or language deficits on survival (McGirt et al., 2009a). Even after adjusting for patient age, preoperative KPS score, adjuvant therapy, and extent of resection, those patients with newly acquired motor and language deficits had reductions in median survival of 3.9- and 3.3-months, respectively, relative to their deficit-free counterparts (Fig. 19.2). Those patients who only demonstrated transient deficits in the immediately post-operative period had a smaller decrease in median survival relatively to those who developed permanent deficits. Whether this association was one of causation or simple statistical association currently remains unknown given the retrospective nature of the study (McGirt et al., 2009a). Although a definitive mechanism to explain the observed association is not yet known, past work

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Fig. 19.2 Kaplan-Meier plot demonstrating survival after resection of glioblastoma multiforme in patients without a new post-operative neurological deficit (mean survival 12.8 months), with a surgically acquired language deficit (mean survival 9.6 months), or with surgically acquired motor deficits (mean

survival 9.0 months). Those with new deficits experienced significantly worse survival (p<0.05 for both types of new deficits) relative to their non-deficit counterparts. Source: McGirt (2009a)

has alluded to poor quality of life possibly serving as a conduit between new post-operative deficits and worse survival. Prospective analyses of patients with high-grade gliomas have demonstrated that those with worse baseline quality of life scores, including measures of verbal communication, have worse survival compared to those with normal quality of life scores (Brown et al., 2006; Mauer et al., 2007). Additionally, retrospective studies have shown significant associations between post-operative depression in glioma patients and worse long-term survival (Gathinji et al., 2009; Litofsky et al., 2004). Furthermore, in the study by Mauer et al. (2007), baseline deficits in motor or speech among glioma patients was associated a significant prognostic factor affecting survival. Additionally, in theory, decreased performance status and functionality may contribute to the accelerated development of terminal comorbidities such as pneumonia or cardiovascular deconditioning in post-operative patients. This is consistent with the well-known fact that the KPS score carries prognostic significance. Thus, while the full importance of extensive surgical resection in high-grade glioma patients remains incompletely described, further studies should also likely study the negative effects that extensive resection with new deficits may play balancing possible long-term survival benefits.

The Importance of Neuro-Imaging and Cortical Mapping Over the past 20 years, technological advances have developed with the aim of optimizing the balance between maximizing extent of surgical resection while minimizing poor neurological outcomes. Such advances have included preoperative magnetic source imaging, positron emission tomographic imaging, functional MRI, intraoperative MRI, diffuse tensor imaging, electrical stimulation mapping, and negative language mapping (Sanai et al., 2008b). The use of multimodal forms of imaging has been used in more recent years in an attempt to further optimize this balance. Although reports have demonstrated the validity of these multimodal approaches, few studies have clarified the impact true impact of such approaches upon survival or minimizing the odds of post-operative neurological sequela (Jack et al., 1994; Quiñones-Hinojosa et al., 2003; Simos et al., 1999). New forms of mapping have also been used with greater frequency in recent years to achieve similar goals. For instance, the work of Ojemann et al. (1989) demonstrated the usefulness of electrical stimulation mapping to identify cortical language areas, as patients studied demonstrated significant

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inter-personal variability in the localization of common language areas. Schiffbauer et al. demonstrated that preoperative magnetic source (MS) imaging correlated well with intraoperative electrophysiological stimulation mapping, thus making it possible to neurosurgeons to more appropriately plan neurosurgical intervention for tumors near eloquent areas (2002). Furthermore, Signorelli et al. (2007) demonstrated through a retrospective study that the use of such techniques significantly reduced the proportion of patients who developed new post-operative deficits. Similarly, a recent prospective, randomized study involving diffuse tensor imaging in glioma patients found that those patients who underwent pre-operative imaging were significantly less likely to develop post-operative motor deficits (Wu et al., 2007).

References Brem H, Piantadosi S, Burger PC, Walker M, Selker R, Vick NA, Black K, Sisti M, Brem S, Mohr G, Muller P, Morawetz R, Schold SC (1995) Placebo-controlled trial of safety and efficacy of intraoperative controlled delivery by biodegradable polymers of chemotherapy for recurrent gliomas. The Polymer-brain Tumor Treatment Group. Lancet 345: 1008–1012 Brown PD, Ballman KV, Rummans TA, Maurer MJ, Sloan JA, Boeve BF, Gupta L, Tang-Wai DF, Arusell RM, Clark MM, Buckner JC (2006) Prospective study of quality of life in adults with newly diagnosed high-grade gliomas. J Neurooncol 76:283–291 Gathinji M, McGirt MJ, Attenello FJ, Chaichana KL, Than K, Olivi A, Weingart JD, Brem H, Quinones-Hinojosa A (2009) Association of preoperative depression and survival after resection of malignant brain astrocytoma. Surg Neurol 71:299–303 Jack CR, Thompson RM, Butts RK, Sharbrough FW, Kelly PJ, Hanson DP, Riederer SJ, Ehman RL, Hangiandreou NJ, Cascino GD (1994) Sensory motor cortex: correlation of presurgical mapping with functional MR imaging and invasive cortical mapping. Radiology 190:85–92 Jeremic B, Grujicic D, Antunovic V, Djuric L, Stojanovic M, Shibamoto Y (1994) Influence of extent of surgery and tumor location on treatment outcome of patients with glioblastoma multiforme treated with combined modality approach. J Neurooncol 21:177–185 Johannesen TB, Langmark F, Lote K (2003) Progress in longterm survival in adult patients with supratentorial low-grade gliomas: a population-based study of 993 patients in whom tumors were diagnosed between 1970 and 1993. J Neurosurg 99:854–862 Keles GE, Anderson B, Berger MS (1999) The effect of extent of resection on time to tumor progression and survival in patients with glioblastoma multiforme of the cerebral hemisphere. Surg Neurol 52:371–379

D. Mukherjee and A. Quinones-Hinojosa Keles GE, Chang EF, Lamborn KR, Tihan T, Chang CJ, Chang SM, Berger MS (2006) Volumetric extent of resection and residual contrast enhancement on initial surgery as predictors of outcome in adult patients with hemispheric anaplastic astrocytoma. J Neurosurg 105:34–40 Lacroix M, Abi-Said D, Fourney DR, Gokaslan ZL, Shi W, DeMonte F, Lang FF, McCutcheon IE, Hassenbusch SJ, Holland E, Hess K, Michael C, Miller D, Sawaya R (2001) A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. J Neurosurg 95:190–198 Litofsky NS, Farace E, Anderson F, Meyers CA, Huang W, Laws ER, Glioma Outcomes Project Investigators (2004) Depression in patients with high-grade glioma: results of the glioma outcomes project. Neurosurgery 54: 358–366 Mauer M, Stupp R, Taphoorn MJ, Coens C, Osoba D, Marosi C, Wong R, de Witte O, Cairncross JG, Efficace F, Mirimanoff RO, Forsyth P, van den Bent MJ, Weller M, Bottomley A (2007) The prognostic value of health-related quality-of-life data in predicting survival in glioblastoma cancer patients: results from an international randomised phase III EORTC Brain tumour and Radiation Oncology Groups, and NCIC Clinical Trials Group study. Br J Cancer 97:302–307 McGirt MJ, Mukherjee D, Chaichana KL, Than KD, Weingart JD, Quinones-Hinojosa A (2009a) Association of surgically acquired motor and language deficits on overall survival after resection of glioblastoma multiforme. Neurosurgery 65: 463–469 McGirt MJ, Than KD, Weingart JD, Chaichana KL, Attenello FJ, Olivi A, Laterra J, Kleinberg LR, Grossman SA, Brem H, Quiñones-Hinojosa A (2009b) Gliadel (BCNU) wafer plus concomitant temozolomide therapy after primary resection of glioblastoma multiforme. J Neurosurg 110:583–588 Ojemann G, Ojemann J, Lettich E, Berger M (1989) Cortical language localization in left, dominant hemisphere. An electrical stimulation mapping investigation in 117 patients. J Neurosurg 71:316–326 Pope WB, Sayre J, Perlina A, Villablanca JP, Mischel PS, Cloughesy TF (2005) MR imaging correlates of survival in patients with high-grade gliomas. AJNR Am J Neuroradiol 26:2466–2474 Pouratian N, Asthagiri A, Jagannathan J, Shaffrey ME, Schiff D (2007) Surgery Insight: the role of surgery in the management of low-grade gliomas. Nat Clin Pract Neurol 11: 628–639 Quinn JA, Jiang SX, Reardon DA, Desjardins A, Vredenburgh JJ, Gururangan S, Sampson JH, McLendon RE, Herndon JE, Friedman HS (2009) Phase 1 trial of temozolomide plus irinotecan plus O6-benzylguanine in adults with recurrent malignant glioma. Cancer 115:2964–2970 Quiñones-Hinojosa A, Ojemann SG, Sanai N, Dillon WP, Berger MS (2003) Preoperative correlation of intraoperative cortical mapping with magnetic resonance imaging landmarks to predict localization of the Broca area. J Neurosurg 99: 311–318 Sanai N, Berger MS (2008a) Glioma extent of resection and its impact on patient outcome. Neurosurgery 4:753–764 Sanai N, Mirzadeh Z, Berger MS (2008b) Functional outcome after language mapping for glioma resection. N Engl J Med 358:18–27

19 Impact of Extent of Resection on Outcomes in Patients with High-Grade Gliomas Sandberg-Wollheim M, Malmström P, Strömblad LG, Anderson H, Borgström S, Brun A, Cronqvist S, Hougaard K, Salford LG (1991) A randomized study of chemotherapy with procarbazine, vincristine, and lomustine with and without radiation therapy for astrocytoma grades 3 and/or 4. Cancer 68:22–29 Sawaya R (1999) Extent of resection in malignant gliomas: a critical summary. J Neurooncol 3:303–305 Schiffbauer H, Berger MS, Ferrari P, Freudenstein D, Rowley HA, Roberts TP (2002) Preoperative magnetic source imaging for brain tumor surgery. A quantitative comparison with intraoperative sensory and motor mapping. J Neurosurg 97:1333–1342 Signorelli F, Ruggeri F, Iofrida G, Isnard J, Chirchiglia D, Lavano A, Volpentesta G, Signorelli CD, Guyotat J (2007) Indications and limits of intraoperative cortico-subcortical mapping in brain tumor surgery: an analysis of 101 consecutive cases. J Neurosurg Sci 51:113–127 Simos PG, Papanicolaou AC, Breier JI, Wheless JW, Constantinou JE, Gormley WB, Maggio WW (1999) Localization of language-specific cortex by using magnetic source imaging and electrical stimulation mapping. J Neurosurg 91:787–796 Smith JS, Chang EF, Lamborn KR, Chang SM, Prados M, Cha S, Tihan T, VandenBerg S, McDermott MW, Berger MS (2008) Role of extent of resection in the long-term

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outcome of low-grade hemispheric gliomas. J Clin Oncol 26:1338–1345 Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, Belanger K, Brandes AA, Marosi C, Bogdahn U, Curschmann J, Janzer RC, Ludwin SK, Gorlia T, Allgeier A, Lacombe D, Cairncross JG, Eisenhauer E, Mirimanoff RO, European Organisation for Research and Treatment of Cancer Brain Tumor and Radiotherapy Groups, and National Cancer Institute of Canada Clinical Trials Group (2005) Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352:987–996 Ushio Y, Kochi M, Hamada J, Kai Y, Nakamura H (2005) Effect of surgical removal on survival and quality of life in patients with supratentorial glioblastoma. Neurol Med Chir (Tokyo) 45:454–461 Valtonen S, Timonen U, Toivanen P, Kalimo H, Kivipelto. L, Heiskanen O, Unsgaard G, Kuurne T (1997) Interstitial chemotherapy with carmustine-loaded polymers for high-grade gliomas: a randomized double-blind study. Neurosurgery 41:44–48 Wu JS, Zhou LF, Tang WJ, Mao Y, Hu J, Song YY, Hong XN, Du GH (2007) Clinical evaluation and follow-up outcome of diffusion tensor imaging-based functional neuronavigation: a prospective, controlled study in patients with gliomas involving pyramidal tracts. Neurosurgery 61:935–948

Chapter 20

Glioma Surgery: Intraoperative Low Field Magnetic Resonance Imaging Christian Senft

Abstract For decades, surgical resection has been marking the first step in the treatment of gliomas. The benefit of radical yet safe tumor resection persists even after the introduction of multimodal treatment concepts. While the development of imaging techniques has enhanced the visualization of brain tumors, the intraoperative discrimination between tumor tissue and healthy parenchyma remains problematic. The incorporation of computed tomography and magnetic resonance imaging scans into neurosurgical navigation systems has helped to improve the intraoperative delineation of tumor boundaries. However, navigation systems do not account for intraoperative alterations of the anatomy. To that end, intraoperative imaging technologies such as ultrasound or magnetic resonance imaging have been introduced into modern neurosurgery. Low field units were the first intraoperative magnetic resonance imaging devices that entered neurosurgical operating rooms. They were specifically developed to facilitate brain tumor surgery. Although an increasing number of high field units are being installed today, low field units still represent the most frequently used ones today. This chapter deals with the development and setup of intraoperative low field magnetic resonance imaging as well as the implications and consequences of its use in modern glioma surgery. Keywords Gliomas · iMRI · Surgery · Karnofsky score · Neuronavigation · Brain-shift

Introduction Rationale of Glioma Surgery Ever since the first brain tumor surgery was performed in the late nineteenth century by Rickham John Godlee (Bennett and Godlee, 1884), radical surgical resection has been the first step in the treatment of gliomas. Aside from obtaining tissue samples for histopathology, resection of brain tumors may relieve mass effect and reduce symptoms caused by the compression of neural structures. There has long been a scientific debate regarding the value of cytoreductive surgery in gliomas after the introduction of radiation therapy and chemotherapy (Curran et al., 1992; Tortosa et al., 2003), but there has been increasing evidence recently that the extent of tumor resection is an independent prognostic factor in both high- and low-grade gliomas (Sanai and Berger, 2008; McGirt et al., 2009). Yet, due to the infiltrative nature of these tumors, glioma patients cannot be cured by surgery, whatever its extensiveness may be. The clinical patient status as determined by the Karnofsky performance scale has often been shown to be a strong prognostic factor in glioma patients (Laws et al., 2003; Tortosa et al., 2003). Therefore, tumor resections must not be undertaken at the cost of neurological deterioration.

Neuronavigation and Neurophysiological Monitoring C. Senft () Department of Neurosurgery, Johann Wolfgang Goethe-University, 60528 Frankfurt, Germany e-mail: [email protected]

To avoid surgically induced neurological deficits and clinical deterioration, eloquent structures, especially the motor cortex and the corticospinal tract, need to be

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identified and spared during tumor resection. Eloquent structures may be identified either anatomically or with the help of intraoperative neurophysiological monitoring techniques (Berger et al., 1990). The introduction of neuronavigation systems in the 1990s has dramatically influenced brain tumor surgery. Being a technology similar to GPS-systems, these systems allow neurosurgeons to transfer preoperative neuroimaging data, e.g. anatomical as well as functional MRI, into a computer workstation in the operating room. After matching points on the patient’s head with corresponding points on the images, a navigational tool is depicted on a screen in its corresponding anatomic location along with the preoperative data. As a result, neuronavigation assists in cranial neurosurgery to confirm the exact localization of anatomic structures or lesions in an online fashion. Neuronavigation has become a standard part of modern neurosurgical operating rooms, helping to plan skin incisions, tailor craniotomies, and make approaches to intraparenchymal lesions less invasive (Wirtz et al., 2000). The usefulness of neuronavigation, however, is limited during the dissection of brain tissue due to anatomical alterations caused by leakage of cerebrospinal fluid, brain edema, or removal of tissue itself. These alterations, called brain-shift, cause significant inaccuracy of the neuronavigation because it relies on preoperative images (Roberts et al., 1998).

Rationale of Intraoperative Imaging Low-grade gliomas in particular, but to lesser extent also high-grade gliomas, are often difficult to distinguish from healthy brain parenchyma, which needs to be spared during surgery. This renders tumor resections guided by (even microscopic) vision incomplete in many cases, even if the surgeon believes to have achieved a complete resection (Albert et al., 1994). Further, the phenomenon of brain-shift mentioned above necessitates an intraoperative update of the imaging data used for neuronavigation. Thus, intraoperative imaging was developed in order to overcome the limitations of neuronavigation based on pre-operative images and to visualize tumor remnants that might leave otherwise unrecognized by the neurosurgeon (Nimsky et al., 2003; Ram and Hadani, 2003).

C. Senft

Magnetic resonance imaging represents the best means of imaging the brain, and obviously it would also represent the best means of intraoperative imaging. Consequently, MRI devices were developed for intraoperative neurosurgical use. The first intraoperative MRI (iMRI) unit was installed in 1994 at the Brigham and Women’s Hospital in Boston (Black et al., 1997). For technical reasons, it was designed as a low magnetic field strength device with 0.5 T (Signa SP, General Electric Medical Systems, Milwaukee, WI). Later, several iMRI systems have been set up at different neurosurgical centers. These systems vary by field strength of the magnet and require different adjustments of OR infrastructure, e.g. ferromagnetic shielding or the need for special instruments. Also, the costs for the installation of an iMRI vary significantly between the currently available systems, ranging from $ 1.5 million to well above $ 5 million, especially for high field (1.5 or 3.0 T) devices. Today, low field iMRI units are the ones predominantly used.

Low Field iMRI: Setup Intraoperative magnetic resonance imaging can be performed with a scanner installed in a room adjacent to the OR (two-room concept) (Tronnier et al., 1997), or with a scanner installed in the OR itself (one-room concept) (Black et al., 1997; Hadani et al., 2001). The two-room concept may be advantageous from a reimbursement perspective, since the scanner can be used for outpatients while it is not needed for intraoperative imaging.

Example of iMRI Setup With more than 50 installations worldwide, one of the most frequently employed iMRI devices today is R the PoleStar iMRI navigation suite (Medtronic Inc., Louisville, CO). It was specifically designed for cranial neurosurgical procedures and follows the one-room concept of intraoperative imaging and offers an integrated neuronavigation system (Hadani et al., 2001; R Schulder et al., 2006). The PoleStar N20 consists of two permanent magnets employing a field strength of only 0.15 T. In contrast to the Signa SP, its design

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Fig. 20.1 Schematic drawing R of the PoleStar intraoperative OR Setup (with permission from Medtronic Navigation, Inc.)

and lower field strength obviate the need for special surgical instruments. Also, continuous neurophysiological monitoring in this setting is feasible (Szelenyi et al., 2008). The two magnets are placed perpendicular to each other with an aperture of 27 cm, in which the patient’s head is positioned during scanning. The scanner depicts an ellipsoid field of view measuring approximately 20 cm by 15 cm. Figure 20.1 gives an example of the OR-setup. Solely the neurosurgeon and OR personnel, without the need of a radiologist or MR technician, operate the scanner. The R use of the PoleStar system in glioma surgery has been described in detail (Hadani et al., 2001; Schulder et al., 2006; Ntoukas et al., 2008; Senft et al., 2008).

Example of Surgical Workflow In a typical case, a glioma patient is brought into the OR in general anesthesia. Using a non-ferromagnetic head-holder system, the patient is positioned supine, prone, or lateral as needed, and the head is fixated to the head holder using sterile titanium skull pins. Additionally, a patient reference frame is attached to the head holder to allow for neuronavigation. The scanner is then wheeled to its position beneath the patient’s head, and it is elevated for the pre-surgical navigation scan (Fig. 20.2a). After image acquisition, the magnet is again lowered to its parking position beneath the patient’s head. The acquired images are automatically transferred to the neuronavigation system, and the skin incision and craniotomy are planned. Figure 20.2b, shows the setup after disinfection and sterile draping.

Surgery commences with neuronavigation-guidance and is performed using regular microsurgical instruments (Fig. 20.2c). When the surgeon believes to have resected the tumor, the scanner is brought upwards to its scan position (Fig. 20.2d). Intraoperative imaging is performed, and the neuronavigation data are updated. Pre-surgical and intraoperative images can be compared directly to identify any residual tumor and, if present, to exactly localize it and to determine its extension. Figure 20.3 gives an example of image quality and continued resection after intraoperative scanning. In comparison with conventional microsurgical resection of a brain tumor, patient positioning is a little more cumbersome in the iMRI-setting, and image acqisition is also time consuming, demanding approximately 10–20 min per scan session depending on the imaging sequences. These time demands sum up to roughly 1 h on average.

Safety Concerns in iMRI Aside from any potential benefits of applying iMRI technology in neurosurgery, there are also safety concerns associated with its use. First, intraoperative image acquisition prolongs surgical time with the skull opened, raising the question of an increased risk of infection. This is even more the case in the two-room concept of iMRI, as the patient needs to be transferred out of the OR into an adjacent room for image acquisition. There are, however, no reports of increased rates of infections (Tronnier

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R Fig. 20.2 Example of glioma surgery with the PoleStar iMRI

Fig. 20.3 Example images of a patient with a left temporal glioblastoma. (a) preoperative T1-weighted scan obtained at 1.5 T; (b/c) postoperative T1-weighted scans obtained at 3 T with (b) and without (c) contrast agent confirming complete resection of contrast enhancing tumor tissue; (d–f) intraoperative images

obtained at 0.15 T before (d) and during (e, f), tumor resection. Note that in residual contrast enhancement along the resection cavity is visible in (e), leading to further tumor resection. Finally, a complete tumor resection is documented (f)

20 Glioma Surgery: Intraoperative Low Field Magnetic Resonance Imaging

et al., 1997; Nimsky et al., 2002), even if patients are taken out of the OR to perform scanning (Ramina et al., 2010). In an own unpublished series of more than 200 patients, we only observed one case of a wound infection, occurring about half a year after surgery followed by combined radio-/chemotherapy. On the contrary, iMRI has been described as helpful in the surgical treatment of brain infections (Bernays et al., 2002; Senft et al., 2009). Second, the magnetic field exerted by the scanner might attract surgical instruments, causing patient harm. In some iMRI setups, such as the Signa SP, special non-ferromagnetic instruments are therefore essential – in the PoleStar-setup, regular instruments can be used. So far, intraoperative magnetic resonance imaging has been shown safe with respect to effects of magnetic force (Seifert et al., 1999; Hall et al., 2000). Finally, there are arguments that the intraoperative detection of tumor tissue might lead to more aggressive and extensive resections, leading to higher rates of neurological complications. Yet, especially when used in combination with neurophysiological monitoring, complication rates in iMRI-guided brain tumor surgery are comparable to those in conventional microsurgery (Hall et al., 2000; Bohinski et al., 2001; Senft et al., 2008). In another report, continued resection after intraoperative scanning was not associated with the occurrence of new neurological deficits (Senft et al., 2010a).

Results of iMRI-Guided Glioma Surgery Influence on the Course of Surgery Low field iMRI has been used to facilitate the surgical resection of both low- and high-grade gliomas. Unanimously, reports on the use of (low field) iMRI devices have been positive (Schulder and Carmel, 2003), regardless of the system used (Tronnier et al., 1997; Seifert et al., 1999; Muragaki et al., 2006; Schulder, 2009). The ability to detect residual tumor by intraoperative imaging has led to continued resections in many cases, ranging from 10% (Nimsky et al., 2002) to up to 71% (Schneider et al., 2005), but mostly in approximately 30–40% of the cases (Nimsky et al., 2003; Senft et al., 2010a). Not surprisingly, the use of iMRI was reported to be superior than the use of sole neuronavigation in terms of the extent

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of tumor resection (Bergsneider et al., 2005). Using iMRI-guidance has improved resection rates in both low- and high-grade gliomas alike, although tumor remnants resulting in continued are encountered more often in low-grade than in high-grade gliomas (Senft et al., 2008; Senft et al., 2010b).

Influence on Survival Intraoperative MRI and, consequently, enhanced rates of complete tumor resection have also benefitted patients. Several groups have reported improved survival for glioma patients undergoing complete vs. subtotal resections in iMRI-guided surgery. In a large series of 156 low-grade glioma patients undergoing iMRI-guided surgery using the Signa SP, a trend towards prolonged survival after total resection was observed (Claus et al., 2005). When analyzing patients with glioblastoma, two groups independently reported significantly improved survival in patients undergoing complete resections. In a series of 31 patients undergoing image-guided surgery using the Signa SP, median survival was 1.5 years for patients with complete and only 0.6 years for patients with incomplete resection in a univariate analysis (Schneider et al., 2005). This large difference in may be in part explained by differences in patient age and preoperative Karnofsky score, which both are known prognostic factors. In an own R series of 58 patients using the PoleStar , respective median survival was 1.1 and 0.7 years, respectively (Senft et al., 2010a). In summary, theses reports add to the increasing evidence that extensive surgical resection translates into better outcome (Stummer et al., 2008). From an evidence-based medicine perspective, however, the value of iMRI, regardless of the field strength of the system, has not been proven, as all studies mentioned above have been retrospective series without a control group. There is only one matched-group analysis in a series of 32 patients, which failed to show a statistically significant benefit of iMRI (Hirschberg et al., 2005).

Discussion Neurosurgery has long been using and relying on the most advanced technologies, more than any other subspecialty in medicine. The transportation of technology into the neurosurgical treatment of brain tumors

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has benefitted patients starting with diagnostic imaging of the nervous system using CT or MRI. It continued with the introduction of microsurgical concepts, and did not stop with the invention of image guided surgery or neuronavigation. Surgeries have become safer, and patients today recuperate from brain surgery faster than just a few decades ago. The development of iMRI represents a major technological challenge and also advance in brain tumor surgery. Intraoperative MRI systems bear a tremendous advantage over frameless neuronavigational systems in that they allow for the correction of intraoperative brain shift, which can lead to incomplete tumor resections. In the past 15 years, iMRI systems have come from unique application to every-day routine. Simplicity of operation, minimal interference with the neurosurgical workflow, as well as improvements in surgical results have been critical issues in their introduction. Neurosurgeons and hospital administrators are under pressure to justify the enormous costs associated with the installation of an iMRI unit, regardless of manufacturer or specific design. Currently, arguments in favor of iMRI-guidance primarily rely on so-called “expert-opinion”, and the possibility of performing iMRI-guided brain tumor surgery is limited to a few dedicated centers. There are many advocates of intraoperative imaging in brain tumor surgery, claiming that residual tumor, which would otherwise remain unnoticed, can be detected and resected due to intraoperative image acquisition. Critics of intraoperative imaging argue that imaging is only performed because the technology is at hand, so that the intraoperative detection of residual tumor may only be a self-fulfilling prophecy. Certainly, extremely high rates of continued resection must be doubted, but a large multi-center study reported unintentional residual tumor in more than 60% of the cases after conventional microsurgical resection of glioblastoma (Stummer et al., 2006), indicating that there is a need for the ability to visualize tumor tissue intraoperatively by other means than mere microscopic vision. Still, a scientifically sound proof of the usefulness of intraoperative image guidance in terms of improved rates of tumor resection or improved clinical outcome is missing. Glioma patients succumb to their disease despite neurosurgeons utilizing state-of-the-art techniques. Today, iMRI is a helpful tool in glioma

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surgery, but randomized trials governing its use have not been conducted. The true value of iMRI as part of a skilled neurosurgeon’s armamentarium is yet to be determined.

References Albert FK, Forsting M, Sartor K, Adams HP, Kunze S (1994) Early postoperative magnetic resonance imaging after resection of malignant glioma: objective evaluation of residual tumor and its influence on regrowth and prognosis. Neurosurgery 34:45–60, discussion 60–61 Bennett A, Godlee R (1884) Excision of a tumour from the brain. Lancet 124:1090–1091 Berger MS, Ojemann GA, Lettich E (1990) Neurophysiological monitoring during astrocytoma surgery. Neurosurg Clin N Am 1:65–80 Bergsneider M, Sehati N, Villablanca P, McArthur DL, Becker DP, Liau LM (2005) Mahaley clinical research award: extent of glioma resection using low-field (0.2 T) versus highfield (1.5 T) intraoperative MRI and image-guided frameless neuronavigation. Clin Neurosurg 52:389–399 Bernays RL, Kollias SS, Yonekawa Y (2002) Dynamic changes during evacuation of a left temporal abscess in open MRI: technical case report. Neuroradiology 44:438–442 Black PM, Moriarty T, Alexander E 3rd, Stieg P, Woodard EJ, Gleason PL, Martin CH, Kikinis R, Schwartz RB, Jolesz FA (1997) Development and implementation of intraoperative magnetic resonance imaging and its neurosurgical applications. Neurosurgery 41:831–842, discussion 842–845 Bohinski RJ, Kokkino AK, Warnick RE, Gaskill-Shipley MF, Kormos DW, Lukin RR, Tew JM Jr (2001) Glioma resection in a shared-resource magnetic resonance operating room after optimal image-guided frameless stereotactic resection. Neurosurgery 48:731–742, discussion 742–744 Claus EB, Horlacher A, Hsu L, Schwartz RB, Dello-Iacono D, Talos F, Jolesz FA, Black PM (2005) Survival rates in patients with low-grade glioma after intraoperative magnetic resonance image guidance. Cancer 103:1227–1233 Curran WJ Jr, Scott CB, Horton J, Nelson JS, Weinstein AS, Nelson DF, Fischbach AJ, Chang CH, Rotman M, Asbell SO et al. (1992) Does extent of surgery influence outcome for astrocytoma with atypical or anaplastic foci (AAF)? A report from three Radiation Therapy Oncology Group (RTOG) trials. J Neurooncol 12:219–227 Hadani M, Spiegelman R, Feldman Z, Berkenstadt H, Ram Z (2001) Novel, compact, intraoperative magnetic resonance imaging-guided system for conventional neurosurgical operating rooms. Neurosurgery 48:799–807, discussion 807–809 Hall WA, Liu H, Martin AJ, Pozza CH, Maxwell RE, Truwit CL (2000) Safety, efficacy, and functionality of high-field strength interventional magnetic resonance imaging for neurosurgery. Neurosurgery 46:632–641, discussion 641–642 Hirschberg H, Samset E, Hol PK, Tillung T, Lote K (2005) Impact of intraoperative MRI on the surgical results for high-grade gliomas. Minim Invasive Neurosurg 48:77–84 Laws ER, Parney IF, Huang W, Anderson F, Morris AM, Asher A, Lillehei KO, Bernstein M, Brem H, Sloan A, Berger MS,

20 Glioma Surgery: Intraoperative Low Field Magnetic Resonance Imaging Chang S (2003) Survival following surgery and prognostic factors for recently diagnosed malignant glioma: data from the glioma outcomes project. J Neurosurg 99:467–473 McGirt MJ, Chaichana KL, Gathinji M, Attenello FJ, Than K, Olivi A, Weingart JD, Brem H, Quinones-Hinojosa A (2009) Independent association of extent of resection with survival in patients with malignant brain astrocytoma. J Neurosurg 110:156–162 Muragaki Y, Iseki H, Maruyama T, Kawamata T, Yamane F, Nakamura R, Kubo O, Takakura K, Hori T (2006) Usefulness of intraoperative magnetic resonance imaging for glioma surgery. Acta Neurochir Suppl 98:67–75 Nimsky C, Ganslandt O, Buchfelder M, Fahlbusch R (2003) Glioma surgery evaluated by intraoperative low-field magnetic resonance imaging. Acta Neurochir Suppl 85:55–63 Nimsky C, Ganslandt O, Tomandl B, Buchfelder M, Fahlbusch R (2002) Low-field magnetic resonance imaging for intraoperative use in neurosurgery: a 5-year experience. Eur Radiol 12:2690–2703 Ntoukas V, Krishnan R, Seifert V (2008) The new generation polestar n20 for conventional neurosurgical operating rooms: a preliminary report. Neurosurgery 62:82–89, discussion 89–90 Ram Z, Hadani M (2003) Intraoperative imaging–MRI. Acta Neurochir Suppl 88:1–4 Ramina R, Coelho Neto M, Giacomelli A, Barros E Jr, Vosgerau R, Nascimento A, Coelho G (2010) Optimizing costs of intraoperative magnetic resonance imaging. A series of 29 glioma cases. Acta Neurochir (Wien) 152:27–33 Roberts DW, Hartov A, Kennedy FE, Miga MI, Paulsen KD (1998) Intraoperative brain shift and deformation: a quantitative analysis of cortical displacement in 28 cases. Neurosurgery 43:749–758, discussion 758–760 Sanai N, Berger MS (2008) Glioma extent of resection and its impact on patient outcome. Neurosurgery 62:753–764, discussion 764–766 Schneider JP, Trantakis C, Rubach M, Schulz T, Dietrich J, Winkler D, Renner C, Schober R, Geiger K, Brosteanu O, Zimmer C, Kahn T (2005) Intraoperative MRI to guide the resection of primary supratentorial glioblastoma multiforme–a quantitative radiological analysis. Neuroradiology 47:489–500 Schulder M (2009) Intracranial surgery with a compact, lowfield-strength magnetic resonance imager. Top Magn Reson Imaging 19:179–189 Schulder M, Carmel PW (2003) Intraoperative magnetic resonance imaging: impact on brain tumor surgery. Cancer Control 10:115–124 Schulder M, Salas S, Brimacombe M, Fine P, Catrambone J, Maniker AH, Carmel PW (2006) Cranial surgery with

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an expanded compact intraoperative magnetic resonance imager. Technical note. J Neurosurg 104:611–617 Seifert V, Zimmermann M, Trantakis C, Vitzthum HE, Kuhnel K, Raabe A, Bootz F, Schneider JP, Schmidt F, Dietrich J (1999) Open MRI-guided neurosurgery. Acta Neurochir (Wien) 141:455–464 Senft C, Franz K, Ulrich CT, Bink A, Szelenyi A, Gasser T, Seifert V (2010a) Low field intraoperative MRI-guided surgery of gliomas: a single center experience. Clin Neurol Neurosurg 112:237–243 Senft C, Seifert V, Hermann E, Franz K, Gasser T (2008) Usefulness of intraoperative ultralow-field magnetic resonance imaging in glioma surgery. Neurosurgery 63:257–266, discussion 266–267 Senft C, Seifert V, Hermann E, Gasser T (2009) Surgical treatment of cerebral abscess with the use of a mobile ultralow-field MRI. Neurosurg Rev 32:77–85 Senft C, Ulrich CT, Seifert V, Gasser T (2010b) Intraoperative magnetic resonance imaging in the surgical treatment of cerebral metastases. J Surg Oncol 101:436–441 Stummer W, Pichlmeier U, Meinel T, Wiestler OD, Zanella F, Reulen HJ (2006) Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled multicentre phase III trial. Lancet Oncol 7:392–401 Stummer W, Reulen HJ, Meinel T, Pichlmeier U, Schumacher W, Tonn JC, Rohde V, Oppel F, Turowski B, Woiciechowsky C, Franz K, Pietsch T (2008) Extent of resection and survival in glioblastoma multiforme:identification of and adjustment for bias. Neurosurgery 62:564–576, discussion 564–576 Szelenyi A, Gasser T, Seifert V (2008) Intraoperative neurophysiological monitoring in an open low-field magnetic resonance imaging system:clinical experience and technical considerations. Neurosurgery 63:268–275, discussion 275–276 Tortosa A, Vinolas N, Villa S, Verger E, Gil JM, Brell M, Caral L, Pujol T, Acebes JJ, Ribalta T, Ferrer I, Graus F (2003) Prognostic implication of clinical, radiologic, and pathologic features in patients with anaplastic gliomas. Cancer 97: 1063–1071 Tronnier VM, Wirtz CR, Knauth M, Lenz G, Pastyr O, Bonsanto MM, Albert FK, Kuth R, Staubert A, Schlegel W, Sartor K, Kunze S (1997) Intraoperative diagnostic and interventional magnetic resonance imaging in neurosurgery. Neurosurgery 40:891–900, discussion 900–902 Wirtz CR, Albert FK, Schwaderer M, Heuer C, Staubert A, Tronnier VM, Knauth M, Kunze S (2000) The benefit of neuronavigation for neurosurgery analyzed by its impact on glioblastoma surgery. Neurol Res 22:354–360

Chapter 21

Low-Grade Gliomas: Intraoperative Electrical Stimulations Hugues Duffau

Abstract The goal of low-grade gliomas (LGG) surgery is to optimize the extent of resection, while minimizing the risk of permanent neurological deficit. Because LGG often invade “eloquent areas” and because of major interindividual anatomofunctional variability, the cortical functional organization, the subcortical connectivity and the brain plastic potential should be studied at the individual scale. Indeed, cortical and subcortical structures essential for brain functions must be detected and preserved. Presurgical functional neuroimaging and tractography can show the relationships between eloquent regions and the tumor, but they have several methodological limitations. Consequently, intraoperative electro-stimulation mapping (IES) is more and more used by neurosurgeons, to tailor the resection according to individual functional boundaries. IES can be performed under general anesthesia for motor mapping, or on awake patient for somatosensory (and even motor), visuospatial, language and cognitive mapping. This is an easy, accurate, reliable and safe technique of detection of cortical areas, white matter pathways and deep gray nuclei crucial for the function. Thus, IES enables: (i) to study the individual cortical functional organization before any resection; (ii) to understand the pathophysiology of cerebral “eloquent” areas; (iii) to map the subcortical structures throughout the resection, allowing a study of the anatomo-functional

H. Duffau () Department of Neurosurgery and INSERM U1051, Institute for Neurosciences of Montpellier, Montpellier University Medical Center, Hôpital Gui de Chauliac, CHU Montpellier 34295 Montpellier Cedex 5, France e-mail: [email protected]

connectivity; (iv) to analyze the mechanisms of on-line short-term plasticity, using repeated IES; (v) to tailor the resection according to individual cortico-subcortical functional boundaries. Moreover, IES can be combined with repeated pre-and postoperative functional neuroimaging, before and after surgery, both to validate these non-invasive techniques and to study the reorganization of the functional maps over time at the individual scale. Such plastic potential can open the door to multiple surgeries spaced by several months or years, with the goal to optimize the benefit/risk ratio of surgery for LGG, i.e. to increase the extent of resection while preserving and even improving the quality of life. IES also represents a unique tool to improve our knowledge of brain processing and to revisit the classical model of cognitive neurosciences, by switching from a localisationnist to a “hodotopic” view of cerebral organization. Keywords LGG · Neuroimaging · Tractography · IES · EOR · Mapping

Introduction Hemispheric WHO grade II gliomas, that is, diffuse low-grade gliomas (LGG) are usually revealed by seizures in young adults with no or only mild neurological deficit. However, these precancerous tumors will inescapably continue to grow (Pallud et al., 2006), to migrate along white matter pathways (Mandonnet et al., 2006) and to evolve into anaplasia. As a consequence, in the past decade, this better knowledge of the natural history of LGG resulted in a switch from a classical “wait and see” attitude to an early therapeutic strategy.

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In this context, the dilemma of surgery for LGG is to optimize the extent of resection (EOR) while preserving the quality of life. Indeed, although matter of debate for a long time, maximal resection of glioma, when possible, represents currently the first therapeutic option (Duffau, 2009a; Smith et al., 2008). In the recent series measuring objectively the extent of resection (EOR) on repeated postoperative MRI, all of them supported EOR as a statistically significant predictor of overall survival (OS). When no signal abnormality was visible on control MRI, especially on FLAIRweighted imaging (i.e. the so-called “complete resection”), patients had a significantly longer OS compared with patients having any residual abnormality (Claus et al., 2005; Duffau et al., 2005a; McGirt et al., 2008; Smith et al., 2008; Rezvan et al., 2009). Interestingly, even in cases of incomplete tumor removal, patients with a greater percentage of resection had a significantly longer OS. In addition to the percentage of resection, the postoperative tumor volume is also a predictor of survival, with a significantly longer OS when the residue is less than 10 ml (“subtotal resection”) compared with more than 10 ml (“partial resection”) (Duffau et al., 2005a). On the other hand, due to the frequent location of LGG near or within the so-called “eloquent” areas (Duffau and Capelle, 2004), and due to their infiltrative feature (poorly delineated), it was for a long time considered that the chances to perform an extensive glioma removal were low, whereas the risk to induce postoperative sequelae was high. Indeed, many surgical series have reported a rate of permanent and severe deficit between 13 and 27.5% following LGG removal (for a review, see Duffau et al., 2005a). Therefore, to optimize the benefit-to-risk ratio of surgery, an increase number of authors proposed the use of functional mapping methods. Indeed, considerable interindividual anatomofunctional variability was demonstrated in healthy volunteers (Vigneau et al., 2006). Moreover, this variability is increased in LGG, due to brain plasticity, explaining why many patients have no or only slight symptoms except epilepsy (Duffau, 2005). It is thus mandatory to study for each patient (1) the cortical functional organization, (2) the effective connectivity and (3) the cerebral plastic potential, in order to tailor the resection according to both oncological as well as cortico-subcortical functional boundaries. The goal of this article is to review how, in addition to functional neuroimaging, the technique of

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intraoperative cortical and subcortical electrical stimulations mapping has contributed to improve the results in LGG surgery, both concerning the impact on the natural course of the glioma as well as regarding the preservation of the quality of life. The fundamental applications of IES will also be detailed, particularly in the field of cognitive neurosciences.

Presurgical Neurocognitive Evaluation In spite of a neurological examination often normal, recent extensive neuropsychological assessments showed that most of patients with LGG had cognitive disturbances, especially concerning working memory and executive functions (Teixidor et al., 2007). Therefore, a systematic presurgical neurocognitive assessment is highly recommended (Mauer et al., 2008), with four goals: (i) to search the possible neurocognitive deficit not detected by a standard neurological examination (ii) to adapt the surgical methodology (for instance to select an awake procedure) to the results of this assessment (iii) to obtain a presurgical baseline enabling a comparison with the postsurgical evaluation (iv) and to plan an adapted functional rehabilitation. Interestingly, although LGG regularly involves eloquent areas, neurological deficits are unfrequent or mild, at least in the first period of the clinical history. This is due to brain reshaping, which allows functional compensation in slow-growing lesions. Indeed, cerebral remapping is possible, thanks to recruitment of perilesional or remote areas within the ipsilesional hemisphere and/or recruitment of contralesional homologous areas. The recent integration of these concepts into the therapeutic strategy has resulted in dramatic changes in the surgical management of LGG patients, with an increase of surgical indications within eloquent regions classically considered as “inoperable” (Duffau, 2005).

Presurgical Functional Neuroimaging Advances in functional neuroimaging, especially functional MRI (fMRI), now make possible to perform a non-invasive cortical mapping of the whole brain. fMRI provides data about the location of the eloquent

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regions (namely, the areas involved in sensorimotor, language, visual and even higher-cognitive function) in relation to LGG, and helps to determine the hemispheric language lateralization. Therefore, this method is currently a standard before resection of LGG, since it participates in the selection of the surgical indications, partly depending on the location of the tumor and its relationships with eloquent areas detected by fMRI (allowing an estimation of the tumor resectability). Neurofunctional imaging is also useful for the surgical planning, i.e. the selection of the surgical approach and the delineation of the limits of resection. Finally, fMRI may contribute to the selection of the surgical technique, notably to the decision to perform an awake craniotomy if the LGG is closed to language or cognitive regions. Nonetheless, fMRI is not yet enough reliable at the individual scale, mainly because the results depend on the bio-mathematical models used for the reconstruction. A recent review based on correlations with intraoperative electrophysiology showed that the sensitivity of fMRI was currently only around 71% for movement, and from 59 to 100% for language (specificity from 0 to 97%) (Giussiani et al., 2010). Such discrepancies can be due to a neurovascular decoupling in LGG, by inadequate tasks (not adapted to the location of the glioma or to the neurological status), or to methodological problems such as the selection of the threshold. Thus, there is a risk of false negative and then to operate a patient without intraoperative mapping although the glioma is actually located in crucial areas (even if not detected by presurgical fMRI). Moreover, an erroneous interpretation of brain plasticity (“pseudo-reorganization”) can be made. Finally, these methods are not able to differentiate the structures essential for the function, which should be surgically preserved, from those which can be functionally compensated and so potentially resected without permanent deficit. In summary, fMRI can lead not to select a patient for surgery while the tumor was operable or to stop prematurely the resection. Recent advances in diffusion tensor imaging (DTI) also enable the detection of the main white matter pathways and their relationships to the LGG. Yet, this new techniques needs to be validated before it can be used routinely for surgical planning, particularly because results of DTI, as fMRI, strongly depend on the bio-mathematical models used for the tractography. Indeed, comparison between distinct fiber tracking software tools found different results. Moreover,

correlations between DTI and intrasurgical subcortical stimulation showed that, despite a good correspondence, DTI is not yet optimal to map language tracts. Negative tractography does not rule out the persistence of a fiber tract, especially when invaded by a LGG (Leclercq et al., in press). Furthermore, DTI studies only the anatomy of the subcortical pathways, but not their function. To overcome these pitfalls, one can currently consider to perform longitudinal studies based on pre-, intra- and post-surgical mapping rather than to content itself with static information based on a unique preoperative functional neuroimaging analysis. Consequently, the additional use of invasive electrophysiological investigations remains highly recommended for LGG surgery in eloquent structures.

Principles of Intraoperative Functional Mapping Intrasurgical, the incorporation of multimodal imaging into frameless stereotactic surgery was extensively used and referred to as “functional neuronavigation”. Nonetheless, a randomized trial failed to demonstrate the significant impact of navigation on postoperative results (Willems et al., 2006). This is due to the limitations of the preoperative fMRI and DTI previously detailed, as well as to the high risk of intraoperative brain shift – explained by surgical retraction, mass effect, gravity, EOR and cerebrospinal fluid leakage. Despite methodological improvements to reduce the effects of the shift (e.g. combination with intraoperative ultrasound, producing real-time imaging; use of mathematical models based on data from ultrasonography or digital images that track cortical displacement; intraoperative MRI), their reliability has to be improved. Therefore, invasive electrophysiological investigations remain the “gold-standard” when removing LGG in eloquent brain structures. To this end, intrasurgical somatosensory and motor evoked potentials were proposed to detect the central region. However, its reliability to identify the rolandic sulcus is not optimal, since accurate localization of the central sulcus was reported only between 91 and 94%. Estimation of the overall sensitivity and negative predictive value of this method is 79 and 96%, respectively. Moreover, phase

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reversal recording identifies the central sulcus itself, but offers no direct information on the particular distribution of motor function on the adjacent exposed cerebral structures. In addition, when recording compound muscle action potentials, only the monitored muscles can be controlled, that is, there is an unability to detect motor deficits in nonmonitored muscles. Above all, monitoring of muscle action potentials does not mean monitoring of complex movements and action adapted to the environment, which is the ultimate goal for the patient. Finally, intraoperative evoked potentials cannot map language, memory or other higher functions crucial for the quality of life (for a review, see Duffau et al., 2003). The use of extraoperative electrophysiological recordings and stimulations via the implantation of subdural grids was also suggested (Kral et al., 2007). The patient is in optimal conditions, in his room, to perform the tasks – a point very important for children. Furthermore, advances in the interpretation of the electrophysiological signal, such as electrocorticographic spectral analysis evaluating the event-related synchronization in specific bands of frequency, now enable a better understanding of the organization of the functional cortex, and a study of the connectivity – notably via the recording of “cortico-cortical evoked potential”. Extraoperative electrophysiological mapping nonetheless usually used grids with 1 cmspaced electrodes, thus with a limited accuracy. Two surgical procedures are also necessary, one to implant grids and a second to remove the lesion. In addition, there is a risk of infectious complications due to the presence of subdural grids during several days. Above all, this technique can map only the cortex, but not the subcortical structures, i.e. it provides no information about the axonal connectivity.

The Method of Intraoperative Electrical Stimulations Due to the limitations of these different mapping techniques, intraoperative electrical stimulations (IES) were increasingly used in the past decade, under general or local anesthesia, during LGG surgery in eloquent areas (Duffau et al., 2008; Sanai et al., 2008). Indeed, except for gliomas involving the motor structures, the mapping is performed in awake patients.

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Nonetheless, as mentioned, since movements and action are more complex than single muscle contractions, it is now proposed to map the motor function under local anesthesia with an active collaboration of the patient (Duffau, in press). The principle is to use IES as a focal and transitory virtual lesion, to obtain an individual functional mapping both at cortical and subcortical levels, and to test if a structure involved by a LGG is still essential for the function – what is observed in 15–20% of the cases. Stimulation of a crucial area elicites a transitory disruption of the task performed by the patient, and this region must be preserved. An individual cortical mapping is thus obtained before the resection, which will be tailored according to functional limits (Fig. 21.1). In practice, a bipolar electrode tips spaced 5 mm apart and delivering a biphasic current (pulse frequency 60 Hz, single-pulse phase duration 1 msec) is applied to the brain. The current intensity adapted to each patient is determined by progressively increasing the amplitude in 1 mA increments from a baseline of 2 mA until a functional response is elicited, with 6 mA as the upper limit under local anesthesia, and with 16 mA as the upper limit under general anesthesia – in order to avoid seizures. The patient is never informed when the brain is stimulated. At least 1 picture presentation without stimulation should separate each stimulation, and no site is stimulated twice in succession. Each cortical site (size 5 × 5 mm, due to the spatial resolution of the probe) of the entire cortex exposed by the bone flap is tested 3 times. Indeed, it is currently admitted that 3 trials are sufficient to assure the eloquence of an area, by generating disorders during its 3 stimulations, and with normalization of the function as soon as the stimulation is stopped. This limitation of trials and tasks is required by the timing of the surgical procedure, because the patient is awake and has a risk to be tired at the end of the resection. Interestingly, recent data demonstrated that the surgical procedure could be simplified, by avoiding the use of intraoperative electrocorticography despite an equivalent reliability of IES, and without increasing the rate of seizures (Duffau et al., 2008). Nonetheless, in cases of stimulation-induced seizures, irrigation cold Ringer’s lactate is able to abrogate the seizure activity. In addition, some authors emphasized the value of “negative mapping” (no identification of eloquent sites) in the setting of a tailored cortical exposure (Sanai et al., 2008). Although such recommendation

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Fig. 21.1 (a) Axial T2-weighted MRI in a right-handed young pharmacist with inaugural seizures. No oncological treatment was administrated (b) Axial FLAIR-weighted MRI 4 years later. The patient met several neurosurgeons, who said that the tumor was stable, and that it was impossible to operate due to the invasion of Broca’s area. In fact, volumetric measurement showed that the tumor doubled, with now involvement of the corpus callosum. An awake surgery was thus proposed in our institution (b) Intraoperative views before (left) and after (right) glioma resection, delineated by letter tags. IES shows a reshaping of the eloquent maps, with a recruitment of perilesional language sites located behind the glioma, within the precentral

gyrus (1, 2, 3). There was no crucial site within the left inferior frontal gyrus. Thus, an extensive resection of “Broca’s area” was possible, by preserving the subcortical connectivity in the depth of the cavity (49 and 50, corresponding to language pathways). (c) Postoperative axial FLAIR- and coronal T2-weighted MRI, demonstrating a near-complete resection of the glioma, with removal of the corpus collosum, in a patient with neither neurological nor neurocognitive deficit, leading a normal socioprofessional life. It is worth-noting that a FLAIR-hyperintensity is visible in the deep of the cavity, i.e. within the deep gray nuclei and white matter tracts, still functional

is acceptable for high-grade gliomas, since the surgical goal is mainly to remove the enhanced part of the tumor, a negative mapping can be dangerous in surgery of diffuse LGG, especially in non expert hands. Indeed, because LGG is poorly demarcated, the boundaries

of the resection will be essentially guided according to functional criteria. Since negative mapping can be due to false negative for methodological reasons, it does not guarantee the absence of eloquent sites. In the experience reported by Sanai et al., all 4 of the

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patients with permanent postoperative deficits had no positive sites detected prior to their resections (Sanai et al., 2008). Consequently, other authors continue to prone a wider boneflap, to obtain a systematic positive mapping before to perform the resection (Duffau et al., 2003, 2008). Moreover, a positive mapping also allow to increase the EOR (de Benedictis et al., in press), since the resection can be pursued until eloquent areas are encountered, i.e. with no margin around the functional structures (Gil Robles and Duffau, in press). A recent study demonstrated that, in a consecutive and homogeneous series of 115 LGG in the left dominant hemisphere, the rate of permanent deficit remained lower than 2% despite the absence of margin around the language sites (Duffau et al., 2008). IES allow the mapping of motor function (possibly under general anesthesia, by inducing unvoluntary motor response, but also in awake patient by eliciting a disturbance of the movement), somatosensory function (by eliciting dysesthesias described by the patient himself intraoperatively), visual function (by eliciting phosphenes and/or visual field deficit described by the patient), auditivo-vestibular function (by inducing vertigo), language (spontaneous speech, counting, object naming, comprehension, writing, reading, bilingualism, language switching from one language to another . . .), and also the mapping of higher-order functions such as calculation, memory, spatial cognition, crossmodal judgement or even emotional processing – by generating transient disturbances if the electrical stimulation is applied at the level of a functional “epicenter” (Duffau, in press). A speech therapist or neuropsychologist or neurologist must be present in the operative theater, to interpret accurately the kind of disorders induced by IES, for instance speech arrest, anarthria, speech apraxia, phonological disturbances, semantic paraphasia, perseveration, anomia, dyscalculia, and so on. Thus, IES allow the on-line detection of the cortical sites essential for the function before the beginning of the resection, thus the selection of the best surgical approach as well as the definition of the cortical boundaries of the glioma removal. In addition to the cortical mapping, another major issue is the use of subcortical IES throughout the resection (Duffau et al., 2003, 2008). Brain lesion studies showed that lesion of the white matter pathways induced more severe deficit than cortical damage. Thus, the subcortical tracts sub-serving motor, somatosensory, visual, auditivo-vestibular, language and cognitive functions should be identified during

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the glioma removal. The goal is to preserve cerebral connectivity while optimizing the EOR, namely, to pursue the resection until eloquent pathways are detected. Interestingly, according to the same principle as that described at the cortical level, IES can also identify eloquent subcortical structures. IES enable the study of the anatomo-functional connectivity by directly and regularly stimulating the white matter tracts and deep gray nuclei throughout the resection, and by eliciting functional response when in contact with deep crucial areas (Fig. 21.1). Moreover, IES allow a better understanding of the brain connectivity, showing that dynamic cerebral processing is underlain by parallel distributed and interactive networks, the socalled “hodology” (Duffau, 2008a). This connectionist view also opens the door to the concept of cerebral plasticity, crucial in LGG surgery. One of the major advantages of IES for brain mapping in adult patients is that they intrinsically do not cause any false negatives – if nonetheless the methodology is rigorously applied, as detailed above. Indeed, IES are highly sensitive for detecting the cortical and axonal eloquent structures, and, as mentioned, they also provide a unique opportunity to study brain connectivity, since each area responsive to stimulation is in fact an input gate into large-scale network – rather than an isolated discrete functional site. IES, however, have a limitation: the specificity is suboptimal. Indeed, IES may lead to interpretation that a structure is crucial, due to the induction of a transient functional response when stimulated, whereas (i) this effect is caused by the backward spreading of the stimulation along the network to an essential area, and (ii) the stimulated region can be functionally compensated thanks to longterm brain plasticity mechanisms. Thus, although IES are still the gold standard for brain mapping, due to the risk of “false positives”, their combination with new methods such as fMRI and biomathematical modeling is now mandatory, to clearly differentiate those networks that are actually essential to function from those that can be compensated (Mandonnet et al., in press).

IES: A New Door to Cerebral Functional Anatomy In addition to fMRI, IES participate in a better understand the pathophysiology of functional areas, with

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the goal to improve the surgical planning in eloquent regions.

was not basically involved in speech production, but in high-level language processing, namely: its posterior part (pars opercularis) more involved in phonological processing, its superior part (pars triangularis) implied in syntatic processing, while its anterior part (pars orbitaris) is more involved in a large semantic network underlied by the inferior fronto-occipital fasciculus (see below) (Duffau et al., 2005b). Interestingly, these data provided by IES are in agreement with those obtained using fMRI, as shown in a recent meta-analysis of the literature (Vigneau et al., 2006). – Premotor cortex and language: In addition to its implication in motor function, IES showed that stimulation of the dominant dorsal premotor area (i.e. the structure lateral to the SMA, in front of the primary motor area of the hand), induced anomia when stimulated. Furthermore, stimulation of the dominant ventral premotor cortex regularly elicited anarthria (Duffau et al., 2008). Therefore, IES support the involvement (i) of the dorsal premotor cortex in the naming network, in accordance with fMRI studies which showed its involvement to lexical retrieval and to conceptual category; (ii) of the ventral premotor cortex in the planification of articulation, explaining why lesion studies reported that damage of the “lower motor cortex” induced speech apraxia (i.e. aphemia). – Functional organization of Wernicke’s area: For LGG located in the dominant temporal posterior areas, comprehension tasks have been developed. For instance, a triad of pictures is shown, and the patient is asked to pair them by naming two pictures with conceptual links. Interestingly, during IES, several sites within the posterior part of the superior temporal gyrus specifically elicited an anomia without comprehension disorders, although other sites within the same gyrus elicited only comprehension disorders with preservation of the ability to name, and other areas generated only phonological disturbances. These results support the complexity of the functional organization of Wernicke’s area (in accordance with fMRI results), with its participation to, but also with possible dissociation, between comprehension, naming and phonological processing (Vigneau et al., 2006). – Left angular gyrus and calculation: The supramarginal and angular gyri, in the dominant hemisphere, participate to complex cognitive functions, such as calculation. In patients with a left posterior

– Supplementary Motor Area (SMA) syndrome: The SMA, i.e. the frontomesial area in front of the primary motor cortex, involved in the planning of the movement, is often invaded by LGG. Its resection induces the classical “SMA syndrome”, with a complete akinesia and even mutism (if damage of the left dominant SMA), which occurs approximately 30 min after its resection. Then, this syndrome suddenly and spontaneously resolves around the tenth day following surgery, even if some rehabilitation is often needed during 1–3 months. Preoperative fMRI showed that the occurrence of this syndrome was not related to the volume of the frontal resection, but directly to the removal of a specific structure called the “SMA-proper”. Thus, fMRI enables to predict, before surgery, if a SMA syndrome will occur or not postoperatively, and to inform the patient and his family (Krainik et al., 2004). Moreover, by combining preoperative fMRI, the pattern of clinical deficit after surgery, and the extent of resection on the postoperative MRI, the existence of a somatotopy within the SMA-proper has been demonstrated – with, from anterior to posterior: the representation of language (at least in the dominant hemisphere), of the face, then the upper limb, then the lower limb. This is important for the planning of a specific rehabilitation. – Involvement of the insular lobe in language and swallowing: Although the insula is also frequently involved by LGG, this structure was poorly studied during a long time. Recent fMRI studies showed the role of this multimodal lobe in many functions, in particular in language. These results were confirmed by IES, which induced language disorders, and more specifically articulatory disturbances when applied on the insular cortex, supporting the role of this structure in the complex planning of speech (Duffau, 2009b). It means that in left dominant (fronto-temporo)-insular LGG, resection carries a high risk to be incomplete. Furthermore, after resection of right insulo-opercular LGG, a transient Foix-Chavany-Marie syndrome, i.e. a bilateral facio-linguo-pharyngo-laryngal palsy, may be elicited, with a reversible unability for the patient to speak and swallow. – Functional organization of the left inferior frontal gyrus: IES showed that the classical “Broca’s area”

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parietal LGG, both multiplication and subtraction can be tested using IES. Interestingly, functional epicenters more involved in arithmetic facts such as rote multiplication, with tables learned by heart, were found to be located immediately above the posterior end of the sylvian fissure, thus very close to the language sites. On the other hand, actual calculation such as subtraction recruited functional sites located in the superior part of the angular gyrus, immediately below the intraparietal sulcus, namely close to the areas involved in working memory. These results support the existence of a “calculotopy” within the angular gyrus. Despite a transient dyscalculia following surgery, the patients recovered. – Involvement of frontal eye field and cingulate eye field in oculomotor behavior: The functional anatomy of the frontal eye field was studied by preoperative fMRI and IES. This region, located laterally and in front of the primary motor area of the face, is implied in the regulation of the voluntary and unvoluntary ocular saccades. IES over this area evoked contraversive smooth eye movements recorded electro-oculographically. In addition, stimulation of an anterior sub-region of this electrically determined frontal eye field disclosed both smooth eye movement and interfered with oculomotor behavior, supressing self-paced saccades in awake patient. The posterior part of the anterior cingulum, namely the “cingulate eye field”, also plays a role in suppression of unwanted saccades (antisaccades), thus in attentional processing. – Role of the right supramarginal gyrus and posterior temporal areas in spatial awareness: The use of a line bisection task during awake surgery in patients with a LGG in the right parieto-temporal junction enables the mapping the areas involved in the spatial awareness. A significant rightward deviation is usually observed during the stimulation of the antero-inferior part of the supra-marginal gyrus and the caudal part of the superior temporal gyrus. A transient and reproducible left neglect is thus induced by electrical inactivation of cortical sites essential for the visuo-spatial integration, in the right parieto-temporal junction. If these eloquent areas are preserved, the patients show no signs of neglect a few days after surgery. These findings demonstrate that the supramarginal gyrus and the caudal part of the superior temporal gyrus, at

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least in the right hemisphere, are critical to the symmetrical processing of the visual scene in humans (Thiebaut et al., 2005). – Involvement of the left dorsolateral cortex in judgment: For LGG in the left dominant prefrontal cortex, task of cross-modal (visual-verbal) congruent and incongruent judgment can be performed in awake patient. Visual and auditory stimuli were presently simultaneously, both referring to the same item (congruence condition), or not (semantic or phonemic incongruent condition). Brain areas not involved in naming processing elicited reproducible deficit of incongruent judgment when stimulated, especially at the level of the left dorso-lateral prefrontal region – even if an interindividual variability was observed, as for other functions (Plaza et al., 2008). Preservation of such executive functions is essential for the daily life, in particular regarding the decision-making and planning of complex strategy. Interestingly, other anatomo-functional correlations can also be made using IES in patients operated on for LGG, in particular with regard to writing, reading, bilingualism and language switching, memory, emotional processing or even control of micturition. Therefore, the neurosurgeon must adapt his strategy, particularly the surgical technique (e.g. the selection of the functional tasks to optimize the reliability of the intrasurgical mapping) to the better knowledge of the functional anatomy applied to each patient.

IES: New Insights into the Subcortical Connectivity As mentioned, the study of individual anatomofunctional connectivity underlying the eloquent networks is highly recommended in LGG surgery, to avoid postoperative permanent neurological deficit. – Subcortical motor tracts: In precentral LGG, after detection and preservation of the primary motor cortical areas using IES, it is also important to detect the corresponding descending motor pathways using subcortical stimulation, and their somatotopy – i.e. the different fibers of the corona radiata, with the pyramidal bundles of the lower

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limb medially, of the upper limb and of the face more laterally. These subcortical motor fibers constitute the posterior and deep functional limits of the resection, until the opening of the ventricle. The pyramidal pathways may also be identified within the posterior limb of the internal capsule, particularly in (fronto-temporo-)insular LGG, in which the deep boundaries of the resection are given when subcortical stimulation induce motor responses in the inferior part of the corona radiata up to the superior part of the mesencephalic peduncles (Duffau et al., 2003). – Subcortical somatosensory pathways: In the same way, the thalamo-cortical somatosensory pathways and their somatotopy can be identified by IES, which induce dysesthesias in awake patients, in cases of retrocentral LGG (Duffau et al., 2003). – Subcortical visual pathways: Optic radiations can be mapped in patients who undergo awake surgery for temporo-occipito-parietal LGG, with induction of a transient “shadow” or phosphenes in the controlateral visual field during stimulation of the posterosuperior and deep part of the surgical cavity, sometimes with also metamorphopsia (i.e. visual illusion). Thus, if resection is stopped at this level, patients are left with only a residual quadrantanopsia without consequence on the quality of life, especially for the driving. – Subcortical language pathways: In left dominant precentral LGG, after identification of the motor and language cortical sites within the pre-rolandic and inferior frontal gyri, IES also enable the detection of the language pathways (Duffau et al., 2008). Medially, IES can identify the fasciculus subcallosal medialis (running from the SMA and cingulate gyrus to the head of the caudate nucleus) which elicites transient transcortical motor aphasia during its stimulation: this tract is involved in the initiation of language. Posteriorly, the fibers coming from the premotor ventral cortex must be detected, inducing anarthria when stimulated: this pathway is crucial for speech production. More laterally, the operculoinsular connections should also to be detected, by generating a complete speech arrest during stimulation: these connections are involved in speech planning.

pathways, with first of all, the deep part of the superior longitudinal fasciculus – namely the arcuate fasciculus (AF). In patients with a LGG involving the left insula or left inferior frontal gyrus, IES can identify the anterior part of AF, located within the anterior floor of the external capsule (under the superior part of the insula) and also under the posterior part of the so-called “Broca’s area” (namely the pars opercularis and pars triangularis of the inferior frontal gyrus). Stimulation induces transient symptoms observed in conduction aphasia, i.e. phonemic paraphasia and repetition disorders. AF must also be detected at the level of its postero-superior loop, located under the supramarginal gyrus, in patients operated on for a left parietal LGG. The same symptoms associating phonemic paraphasias and repetition disorders are induced during stimulation. Again, AF is detected in posterior temporal LGG, its posterior part corresponding to the anterior functional limit of the resection. Finally, the anterior part of the lower AF must also been used as the posterior functional boundary of left dominant anterior and mid-temporal lobectomy (Duffau et al., 2008). AF seems also to subserve a wide network involved in language schwitching (from a native language to another language or vive versa): IES can disrupt such function, crucial to preserve in bilingual patients. In addition to the AF, there is a lateral part of the superior longitudinal fasciculus. In patients harboring a left retrocentral supra-sylvian LGG, IES detect not only the language cortical sites at the level both of the ventral premotor cortex in front of the tumor and of the supramarginal gyrus and/or angular gyrus behind it, but also a fronto-parietal subcortical network inducing speech apraxia when stimulated. This operculoopercular loop might underly the anatomo-functional connectivity of the working memory circuit. Indeed, this loop corresponds to the anterior segment of an indirect pathway of the classical superior longitudinal fasciculus, which runs parallel and lateral to the AF, by connecting “Broca’s territory” with the inferior parietal lobe – as recently showed by DTI. This tract might be involved in the vocalization of semantic content. Therefore, this example illustrates well that IES and DTI can be combined in order to better understand the anatomo-functional connectivity of the brain (Duffau, 2008a). In addition to this “dorsal phonological root”, IES supported the likely role of the inferior fronto-occipital fasciculus (IFOF) in the semantic system – the “ventral

In addition to these loco-regional language pathways, IES also detect the long-distance association

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semantic root”. In patients with a frontal LGG in front and above the “Broca’s” area – i.e. the pars orbitaris of the left inferior frontal gyrus and the dorsolateral prefrontal area – the anterior part of the IFOF has been identified under these regions, by eliciting semantic paraphasias during subcortical stimulation. IFOF was also detected in surgery for left insular LGG, by inducing the same symptoms (semantic paraphasias) when stimulated, in its intermediate part located in the anterior floor of the internal capsule (in front and inferiorly to the AF, and behind and superiorly to the uncinate fasciculus). Again, IFOF was detected in left temporal LGG, by eliciting semantic disorders when stimulated: it constituted the deep limit of the resection (above the roof of the temporal horn of the ventricle) (Duffau et al., 2005b). Interestingly, stimulation of the anterior part of the inferior longitudinal fasciculus, in front of the visual word form area (i.e. the basal part of the temporooccipital junction, involved in high-level visual processing such as reading), and stimulation of the uncinate fasciculus, never generated language disturbances. Thus, these fasciculi can be removed without aphasia. This indirect pathway from the temporooccipital areas to the prefrontal region, with a relay in the temporal pole (temporo-occipital area, inferior longitudinal fasciculus, temporal pole, uncinate fasciculus, orbito-frontal and prefrontal areas) might be compensated by the direct pathway constituted by the IFOF (Duffau et al., 2008). IES also allow the mapping of the deep gray nuclei, sometimes invaded by LGG. Indeed, stimulation of the head of the dominant caudate in patients with a frontomesial LGG coming in contact of the striatum in the depth, generally generates perseverations, namely the repetition of the previous item while the next item is presented to the patient. These results support an inhibitor role of the caudate in the control of cognition. Equally, it is important to map the lateral part of the dominant lentiform nucleus, at the end of the resection of insular LGG. Lentiform stimulation induces anarthria, supporting the likely role of this structure in the planning of articulation, in association with the insula and ventral premotor cortex (Duffau et al., 2008). Finally, it is also important to use IES for language mapping, both at cortical and subcortical levels, for LGG involving the right hemisphere in right-handed or even ambidextrous patients, due to the bilateral distribution of language. In all

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cases, these language bundles should constitute the subcortical functional limits of the resection. – Subcortical pathway involved in spatial awareness: Using the task of line bisection previously described during awake surgery in patients with a right parieto-temporal LGG, IES can also detect the white matter tracts implied in spatial processing, to avoid postoperative left neglect. During the stimulation of the lateral part of the superior longitudinal fasciculus, a significant rightward deviation is regularly observed (Thiebaut et al., 2005). This parieto-frontal pathway seems to subserve spatial awareness, and a lesion at its level may generate a permanent left neglect. Stimulation of the right superior longitudinal fasciculus may also induce vertigo, by disrupting a large network between the parieto-insular vestibular cortex, the visual and the sensory-motor areas. These results suggest that damage to restricted regions of white matter can cause the dysfunction of large-scale cognitive networks. Also, they show that it is possible to adapt the intraoperative testing to each patient with the goal to map the subcortical pathway underlying other cognitive functions than language. Interestingly, although IES of the inter-hemispheric white matter pathways has been performed, no functional responses were elicited by the stimulation of the corpus callosum. Thus, it is possible to remove LGG within this structure without consequence on the quality of life, whatever the location of the “callosectomy”. In summary, the vision of the neural basis of cognition begins to shift from a localisationist then an associationist view towards a “hodological” organization (i.e. dynamic parallel large-scale networks able to compensate themselves). Indeed, from Lichtheim to Geschwind, cognitive functions such as language were conceived in associationist terms of centers and pathways, the general assumption being that visual and auditory linguistic information were processed in localized cortical regions with the serial passage of information between regions through white matter tracts. Currently, an alternative hodological account is proposed, in which language is conceived as resulting from parallel distributed processing performed by distributed groups of connected neurons rather that individual centers (Duffau, 2008a). Consequently, it is crucial for the neurosurgeon to improve his knowledge

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of the anatomo-functional connectivity, thus to integrate more easily and more systematically the concept of subcortical mapping in his surgical strategy. First because the gliomas, in essence, involve both cortical and subcortical structures, and thus they may alter the connectivity. Second, because lesions of the white matter may elicite more severe permanent deficits than cortical damages. In addition, such hodological view may explain why some epicentres considered as essential for language in a localisationist model, for instance Broca’s area, can be in certain conditions involved by a LGG (or even surgically removed) with no aphasia – due to a functional compensation within a large distributed network, i.e. the so-called brain plasticity (Desmurget et al., 2007).

the use of IES allows a better study of the dynamic reorganization of the eloquent maps induced by LGG at the individual scale, and thus opens new surgical indications in classically “not operable” areas.

IES: A Study of Cerebral Plastic Potential Brain plasticity can be defined as the continuous processings allowing short, middle and long-term remodelling of the neurono-synaptic organization, in order to optimize the functioning of the networks of the brain – during phylogenesis, ontogeny, physiological learning and following lesions involving the peripheral as well as the central nervous system. Several hypotheses about the pathophysiological mechanisms underlying plasticity have been considered. At a microscopic scale, these mechanisms seem to be represented by: synaptic efficacy modulations, unmasking of latent connections, phenotypic modifications, synchrony changes and neurogenesis. At a macroscopic scale, diaschisis, functional redundancies, cross-modal plasticity with sensory substitution and morphological changes are suggested to be involved. The behavioral consequences of such cerebral phenomena have been analyzed in humans in the last decade, both in physiology – ontogeny and learning – and in pathology. In particular, the ability to recover after a lesion of the nervous system, and the patterns of functional reorganization within eloquent area and/or within distributed networks, allowing such compensation, have been extensively studied (Duffau, 2008a). Interestingly, the field of slow-growing brain tumors such as LGG, has demonstrated that large amounts of cerebral tissue could be removed, inside or outside the so-called eloquent areas, with impressive recovery allowing no permanent detectable functional consequences (Duffau, 2005). Such knowledge combined to

– Preoperative plasticity: As mentioned, it could seem surprising that patients with a LGG have usually only mild functional deficit, despite the frequent invasion of eloquent structures. These slow-growing lesions have induced progressive functional brain reshaping, as suggested by preoperative fMRI. Interestingly, the patterns of reorganization may differ between patients, a very important notion to know by the neurosurgeon with the goal to optimize both surgical indications and planning (Duffau, 2005). Indeed, fMRI showed that three kinds of preoperative functional redistribution are possible. In the first one, due to the infiltrative feature of LGG, function still persists within the tumor, thus with a very limited chance to perform a fair resection without inducing postoperative sequelae. In the second one, eloquent areas are redistributed around the tumor, thus with a reasonable chance to perform at least a near-total resection despite an immediate transient deficit – but with secondary recovery within some weeks. In the third one, there is already a preoperative compensation by remote areas within the lesional hemisphere and/or by the controlateral homologuous: consequently, the chances to perform a real total resection of this kind of gliomas are very high, with only a slight and very transient deficit. Therefore, in cases of LGG involving eloquent areas, plasticity mechanisms seem to be based on an hierarchically organized model, i.e.: first with intrinsic reorganization within injured areas (indice of favorable outcome); second, when this reshaping is not sufficient, other regions implicated in the functional network are recruited, in the ipsilateral hemisphere (close and even remote to the damaged area) then in the controlateral hemisphere if necessary (Duffau, 2008b). – Intraoperative plasticity: IES before any resection has allowed the confirmation of the existence of a functional reshaping induced by LGG, notably with a possible remapping of the sensorimotor homonculus and also a reorganization of the language sites. Moreover, acute reorganization of functional maps was observed throughout the resection, likely due to the surgical act itself which can generate a

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loco-regional hyper-excitability – as in head injury (Duffau, 2005). For instance, in several patients with a frontal LGG, although stimulation of the precentral gyrus induced motor responses only at the level of a limited number of cortical sites before resection, an acute unmasking of redundant motor sites located within the same precentral gyrus and eliciting the same movements than the previous adjacent sites when stimulated, was observed immediately following lesion removal. Acute unmasking of redundant somatosensory sites was also regularly observed within the retrocentral gyrus in patients operated on for a parietal glioma. Furthermore, a redistribution within a more larger network involving the whole rolandic region was detected, i.e. with unmasking of functional homologuous located in the precentral gyrus for the first cortical representation and in the retrocentral gyrus for its redundancy (or vice versa). Finally, intraoperative mapping has also a prognostic value concerning the postoperative recovery: a positive response means that the patient will recover. – Postoperative plasticity: The mechanisms of such a plasticity induced by surgical resection within eloquent areas were also studied, by performing postoperative fMRI once the patient has recovered his preoperative functional status. For instance, several patients were examined following the resection of LGG involving the SMA, which elicited a transient postsurgical SMA syndrome. fMRI showed, in comparison to the preoperative fMRI, the occurrence of activations of the SMA and premotor cortex contralateral to the lesion: the contrahemispheric homologuous thus participated to the postsurgical functional compensation (Krainik et al., 2004).

IES: Applications to LGG Surgery It was recently proposed to incorporate such a better understanding of the individual plastic potential in the surgical strategy in LGG, with the aims (i) to extent the indications of resection in eloquent structures so far considered as “inoperable” (ii) to maximize the EOR, by performing the resection according to (not fixed) functional boundaries (iii) while minimizing the risk of postoperative permanent deficit or even while

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improving the quality of life (Duffau, 2005, 2008b). Consequently, several surgical series showed that it was possible to remove LGG invading the following “eloquent” brain structures (Fig. 21.2): – SMA resection: it induces the occurrence of an SMA syndrome. As mentioned, all the patients recover, and postoperative fMRI supported functional compensation by the controlateral SMA and premotor cortex as well as by the ipsilesional primary motor cortex; – Insular resection: despite a transient hemiparesis after right insula removal, likely because this region is a non-primary motor area, and transient speech disturbances following left dominant insula resection, all patients recover – except in rare cases of deep stroke (Duffau, 2009b). Moreover, it was possible in right non-dominant fronto-temporoinsular LGG involving the deep grey nuclei, to remove the clautrum without any cognitive disorders (despite its role suggested in consciousness), and to remove the invaded striatum without inducing neither motor deficit nor movement disorders. This compensation can be explained by a recruitment of parallel subcortical circuits such as pallido-luyso-pallidal, strio-nigro-striate, corticostrio-nigro-thalamo-cortical and cortico-luysal networks. – Resection of the primary somatosensory area: the first results using pre- and post-operative magnetoencephalography suggested the possible recruitment of “redundant” eloquent sites around the cavity, within the postcentral gyrus. It is in accordance with the IES data, showing unmasking of redundant somatosensory sites during resection, likely explained by the decrease of the corticocortical inhibition. The recruitment of the second somatosensory area or posterior parietal cortex, primary motor area (due to strong anatomo-functional connections between the pre- and retro-central gyri), and controlateral primary somatosensory area are also possible to explain the recovery; – The resection of the (dominant) parietal posterior lobe can be performed without permanent deficit, and even with a possible improvement in comparison to the preoperative status, especially using pointing task (Desmurget et al., 2007); – Resection of non-dominant sensorimotor area of the face: the recovery of the usual transient central

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Fig. 21.2 Examples of extensive glioma resection performed within “eloquent” areas using IES, with preservation the quality of life thanks to brain plasticity: (a) left SMA (b) entire left frontal lobe including Broca’s area (c) right primary sensorimotor area of the face (d) left primary sensorimotor area of the face (e) primary motor area of the hand (f) left primary somatosensory area and parietal lobe (g) right paralimbic system (h) left insula (i) left dominant temporal lobe

facial palsy, with a potential Foix-Chavany-Marie syndrome when the insula is also involved, is likely explained by the disinhibition of the controlateral homologous sites, via the transcallosal pathways (Duffau, 2005); – Resection of the knob of the hand: on the basis of the existence of multiple cortical motor representations showed in humans using fMRI and IES, the compensation of the motor function could be explained by the recruitment of parallel networks within the primary motor region – allowing the superior limb area removal, eventually using two consecutive surgeries in order to induce durable remapping following the first one (see below); – Broca’s area resection: the language compensation may be underlain by the recruitment of adjacent regions, in particular the pars orbitaris of the

inferior frontal gyrus, the dorsolateral prefrontal cortex and the insula (Duffau, 2008b); – Temporal language area resection: language compensation following a left dominant temporal resection could be explained by the fact that this function seems to be organized with multiple parallel networks (Vigneau et al., 2006). Consequently, beyond the recruitment of areas adjacent to the surgical cavity, the long term reshaping could be related to progressive involvement of (i) remote regions within the left dominant hemisphere – such as the posterior part of the superior temporal gyrus, the pars orbitaris of inferior frontal gyrus or other left frontolateral regions – (ii) the controlateral right non-dominant hemisphere due to a transcallosal disinhibition phenomenon (Desmurget et al., 2007).

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IES: Functional and Oncological Results in LGG Surgery A dramatic improvement of the surgical results was provided by advances in IES. First, the use of IES has allowed to significantly increase the surgical indications in eloquent areas which were classically considered as “not operable” (see above) (Duffau et al., 2005a). In addition, despite a frequent transitory neurological worsening in the immediate postoperative period (due to the attempt to perform a maximal glioma removal according to cortico-subcortical functional limits using IES), leading to a specific functional rehabilitation, more than 98% of patients recovered the same status than before surgery after LGG resection within eloquent areas guided by functional mapping, and returned to a normal socio-professional life (Duffau et al., 2008; Sanai et al., 2008). Even more, 15–20% of patients can improve in comparison to their preoperative neurological and neuropsychological assessment, and 80% of patients with presurgical intractable epilepsy can benefit from a relief of their seizures (Duffau, 2009b). Therefore, LGG surgery is currently not only able to preserve brain functions but may also improve the quality of life of patients, as demonstrated by extensive neurocognitive assessment performed after surgical resection (Teixidor et al., 2007). These data support the existence of additional brain plasticity mechanisms occurring after the operation, likely facilitated by a systematic and adapted rehabilitation (Ghering et al., 2009). Interestingly, this rate of less than 2% of sequelae is very reproducible among the teams using IEM worldwide. In comparison, in series which did not use IEMS, the rate of sequelae ranged from 13 to 27.5%, with a mean around 19% (for a review, see Duffau et al., 2005a). Finally, comparative studies between LGG resection performed without or with IES showed that the EOR was significantly increased thanks to IES, despite better functional results following resection within eloquent areas (Duffau et al., 2005a; de Benedictis et al., in press). Indeed, since IES allows identification of the cortical and subcortical eloquent structures individually, it seems logical to perform a resection according to functional boundaries. The resection is continued until the functional structures are detected by IES, and not before, to optimize the EOR – without increasing the risk of permanent deficit. Moreover, as mentioned

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in the introduction, a more extensive resection is now demonstrated as inducing an increased impact on the natural course of LGG.

Towards a Multiple-Stages Surgical Approach in LGG The price to pay to obtain such favorable functional results is sometimes to perform incomplete LGG resection, when the tumor invades sites still crucial for the function. A new concept recently proposed is to use postoperative fMRI, since it can be easily repeated due to its non-invasive feature, when the patient has totally recovered, in order to compare the new maps to those obtained before surgery. Indeed, even if this method has some limitations detailed above, subtraction between a pre- and post-surgical acquisition may nonetheless shows a possible additional functional reshaping, due to (i) the resection itself (ii) the rehabilitation (iii) the re-growth of the residual tumor (as before surgery). Interestingly, recent series demonstrated that such remapping was not a theoretical concept, but a concrete reality. Postoperative fMRI performed some months or years following the surgery clearly showed a new recruitment of perilesional areas and/or remote regions within the ipsilesional hemisphere and/or a recruitment of controlateral structures (Krainik et al., 2004). Based on these data, a second surgery was proposed in patients who continued to lead a normal life, before the occurrence of new symptoms (except possible seizures), only because of an increase of the volume of LGG. The second surgery was also conducted using intraoperative cortical and subcortical mapping, in order to validate the mechanisms of brain reshaping supposed but not proven by preoperative fMRI, before to perform the additional resection (Gil Robles et al., 2008). The preliminary results have supported the efficacy and the safety of such re-operation for LGG not totally removed during a first surgery, due to their location within eloquent areas. Indeed, in this recent experience, 74% resections were complete or subtotal (less than 10 ml of residue) following the second operation, despite no additional serious neurological deficit – at the contrary, with an improvement of the neurological status in 16% of cases. Again, the seizures were reduced or disappeared in 82% of

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patients with epilepsy before the second operation. The median time between the two operations was 4.1 years, and all patients were still alive with a median follow-up of 6.6 years despite an initial incomplete resection. Therefore, these original data demonstrated that, thanks to mechanisms of cerebral plasticity, it is possible to re-operate patients with a LGG involving eloquent areas with a minimal morbidity and an increase of the EOR. However, 58% of tumors had already progressed to high grade glioma during the second surgery, raising the problem of the timing of reoperation. It was thus suggested to “over indicate” an early re-intervention, in order to anticipate the second surgery before the anaplastic transformation (Martino et al., 2009). Interestingly, one can currently consider to perform postoperative fMRI after rehabilitation and recovery following a second surgery, in order to open the door to a possible third or even fourth resection several years after the previous operations. The goal is both to allow the patient to enjoy a normal life as well as to increase the OS. It is also possible to integrate surgeries within a dynamic therapeutic strategy including chemotherapy and radiotherapy, especially when a wide removal is not possible for functional reasons (Duffau, 2009a). To this end, neoadjuvant chemotherapy was recently advocated in LGG, with the goal to induce a shrink of the tumor before an operation or a re-operation (Duffau et al., 2006).

(accurately analyzed by a speech therapist along the surgical procedure). Combination of these intraoperative anatomo-functional data with those provided by DTI (subcortical anatomical informations), magnetoencephalography (temporal data), and fMRI (perioperative functional data) could enable one to elaborate individual and predictive models of the functioning of neurono-synaptic circuits, i.e. to open a new door to hodology (Duffau, 2008b). Such correlations with IES, which remains the gold-standard for functional brain mapping, can also enable to validate the non-invasive method of neuroimaging, especially the new technique of DTI (Leclercq et al., 2010). Anatomic dissections of the brain, in particular the white matter pathways, are now to be revisited in the lights of functional mapping (Martino et al., in press). Moreover, such connectionist models may lead to a better knowledge of the dynamic potential of spatiotemporal reorganization of the parallel and interactive networks, namely the mechanisms of brain plasticity, thought to play a major role of functional compensation in slow-growing tumors and in their surgical resection. In this way, individual plastic potential could be better understood using repeated intraoperative mappings combined to post-surgical fMRI, then possibly guiding specific post-operative rehabilitation program in order to optimize the quality of functional recovery (Duffau, 2005, 2009b; Gil Robles et al., 2008). In addition to its fundamental implications, IES also allow to perform tumor resection according to functional boundaries, therefore, leading to the optimization of the benefit-to-risk ratio of surgical removal in cerebral glioma. Indeed, these new techniques (serial brain mappings) and concepts (hodology and plasticity) have allowed (i) to significantly extend the indications of resection in eloquent areas classically considered as “inoperable”, e.g. Broca’s area, the insula – even in the left dominant hemisphere, the central area or the left posterior temporal regions (ii) to significantly decrease the rate of permanent deficit at less than 2%, instead of 13–27% (mean 19%) without mapping (iii) and even to improve the quality of life, thanks to seizures control (in around 80% of cases, especially in insular and/or temporal LGG) and thanks to cognitive rehabilitation (iv) and to significantly increase the EOR compared with the series without brain mapping, thus with an increased impact on the median survival. In practice, in order to evolve towards a multistage surgical approach (i.e. second or third surgery

Conclusions and Perspectives LGG surgery now benefits from important technical developments in the field of functional mapping, using complementary non-invasive methods of fMRI and invasive IES. Such recent advances have enabled to better understand the organization of the eloquent brain for each patient, in order to integrate the concept of inter-individual anatomo-functional variability in the surgical strategy. Furthermore, intraoperative real-time subcortical stimulation, in association with cortical mapping, gives an unique opportunity to study the so-called “effective connectivity”, since it allows on-line correlations between discrete and transient “virtual” lesions which can be performed at each place of a distributed network (each cortical and subcortical sites being perfectly identified anatomically using 3D MRI) and their functional consequences

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more extensive than the first one in cases of initial incomplete resection within crucial areas), a dynamic strategy has to be envisaged for functional neuroimaging (Gil Robles et al., 2008; Martino et al., 2009). The goal is to switch from a “static” use of a unique preoperative fMRI assessment (limited technique with lack of reliability), to longitudinal studies based on the repetition of the fMRI before and after surgical resection(s), with the goal to analyze a possible brain reshaping at the individual scale, and to select the candidates to re-operation(s). The next step is now to use bio-mathematical models able to examine brain functional interaction through effective connectivity, in order to attempt to predict before surgery the patterns of postsurgical remapping at the individual scale on the basis of the data provided by the preoperative fMRI.

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H. Duffau Duffau H, Gatignol P, Mandonnet E, Capelle L, Taillandier L (2008) Contribution of intraoperative subcortical stimulation mapping of language pathways: a consecutive series of 115 patients operated on for a WHO grade II glioma in the left dominant hemisphere. J Neurosurg 109:461–471 Duffau H, Gatignol P, Mandonnet E, Peruzzi P, TzourioMazoyer N, Capelle L (2005b) New insights into the anatomo-functional connectivity of the semantic system: a study using cortico-subcortical electrostimulations. Brain 128:797–810 Duffau H, Lopes M, Arthuis F, Bitar A, Sichez JP, Van Effenterre R, Capelle L (2005a) Contribution of intraoperative electrical stimulations in surgery of low grade gliomas: a comparative study between two series without (1985–1996) and with (1996–2003) functional mapping in the same institution. J Neurol Neurosurg Psychiatry 76:845–851 Duffau H, Taillandier L, Capelle L (2006) Radical surgery after chemotherapy: a new therapeutic strategy to envision in grade II glioma. J Neurooncol 80:171–176 Ghering K, Sitskoorn MM, Gundy CM, Sikkes SA, Klein M, Postma TJ, van den Bent MJ, Beute GN, Enting RH, Kappelle AC, Boogerd W, Veninga T, Twijnstra A, Boerman DH, Taphoorn MJ, Aaronson NK (2009) Cognitive rehabilitation in patients with gliomas: a randomized, controlled trial. J Clin Oncol 27:3712–3722 Gil Robles S, Duffau H (2010) Surgical management of WHO grade II gliomas in eloquent areas: is the preservation of a margin necessary around functional structures? Neurosurg Focus 28(2):Intro Gil Robles S, Gatignol P, Lehéricy S, Duffau H (2008) Long-term brain plasticity allowing multiple-stages surgical approach for WHO grade II gliomas in eloquent areas: a combined study using longitudinal functional MRI and intraoperative electrical stimulation. J Neurosurg 109: 615–624 Giussani C, Roux FE, Ojemman J, Sganzerla EP, Pirillo D, Papagno C (2010) Is preoperative functional magnetic resonance imaging reliable for language areas mapping in brain tumor surgery? Review of language functional magnetic resonance imaging and direct cortical stimulation correlation studies. Neurosurgery 66:113–120 Krainik A, Duffau H, Capelle L, Cornu P, Boch AL, Mangin JF, Le Bihan D, Marsault C, Chiras J, Lehéricy S (2004) Role of the healthy hemisphere in recovery after resection of the supplementary motor area. Neurology 62:1323–1332 Kral T, Kurthen M, Schramm J, Urbach H, Meyer B (2007) Stimulation mapping via implanted grid electrodes prior to surgery for gliomas in highly eloquent cortex. Neurosurgery 61:319–325 Leclercq D, Duffau H, Delmaire C, Capelle L, Gatignol P, Ducros M, Chiras J, Lehéricy S (2010) Comparison of diffusion tensor imaging tractography of language tracts and intraoperative subcortical stimulations. J Neurosurg 112:503–511 Mandonnet E, Capelle L, Duffau H (2006) Extension of paralimbic low grade gliomas: toward an anatomical classification based on white matter invasion patterns. J Neurooncol 78:179–185 Mandonnet E, Winkler PA, Duffau H (2010) Direct electrical stimulation as an input gate into brain functional networks: principles, advantages and limitations. Acta Neurochir (Wien) 152:185–193

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Martino J, Brogna C, Gil Robles S, Vergani F, Duffau H (2010) Anatomic dissection of the inferior fronto-occipital fasciculus revisited in the lights of brain stimulation data. Cortex 46:691–699 Martino J, Taillandier L, Moritz-Gasser S, Gatignol P, Duffau H (2009) Re-operation is a safe and effective therapeutic strategy in recurrent WHO grade II gliomas within eloquent areas. Acta Neurochir (Wien) 151:427–436 Mauer ME, Bottomley A, Taphoorn MJ (2008) Evaluating health-related quality of life and symptom burden in brain tumour patients: instruments for use in experimental trials and clinical practice. Curr Opin Neurol 21:745–753 McGirt MJ, Chaichana KL, Attenello FJ, Weingart JD, Than K, Burger PC, Olivi A, Brem H, Quinones-Hinojosa A (2008) Extent of resection is independently associated with survival in patients with hemispheric infiltrating low-grade gliomas. Neurosurgery 63:700–708 Pallud J, Mandonnet E, Duffau H, Kujas M, Guillevin R, Galanaud D, Taillandier L, Capelle L (2006) Prognostic value of initial magnetic resonance imaging growth rates for World Health Organization grade II gliomas. Ann Neurol 60:380–383 Plaza M, Gatignol P, Cohen H, Berger B, Duffau H (2008) A discrete area within the left dorsolateral prefrontal cortex involved in visual-verbal incongruence judgment. Cereb Cortex 18:1253–1259 Rezvan A, Christine D, Christian H, Olga Z, Lutz E, Marius H, Stephanie C, Christal HM, Rainer WC, Andreas U (2009) Long-term outcome and survival of surgically treated supra-

tentorial low-grade glioma in adult patients. Acta Neurochir (Wien) 151:1359–1365 Sanai N, Mirzadeh Z, Berger MS (2008) Functional outcome after language mapping for glioma resection. N Engl J Med 358:18–27 Smith JS, Chang EF, Lamborn KR, Chang SM, Prados MD, Cha S, Tihan T, Vandenberg S, McDermott MW, Berger MS (2008) Role of extent of resection in the long-term outcome of low-grade hemispheric gliomas. J Clin Oncol 26:1338–1345 Teixidor P, Gatignol P, Leroy M, Masuet-Aumatell C, Capelle L, Duffau H (2007) Assessment of verbal working memory before and after surgery for low-grade glioma. J Neurooncol 81:305–313 Thiebaut de Schotten M, Urbanski M, Duffau H, Volle E, Lévy R, Dubois B, Bartolomeo P (2005) Direct evidence for a parietal-frontal pathway subserving spatial awareness in humans. Science 309:2226–2228 Vigneau M, Beaucousin V, Herve PY, Duffau H, Crivello F, Houdé O, Mazoyer B, Tzourio-Mazoyer N (2006) Meta-analyzing left hemisphere language areas: phonology, semantics, and sentence processing. NeuroImage 30: 1414–1432 Willems PW, Taphoorn MJ, Burger H, Berkelbach van der Sprenkel JW, Tullekan CA (2006) Effectiveness of neuronavigation in resecting solitary intracerebral contrast-enhancing tumors: a randomized controlled trial. J Neurosurg 104: 360–368

Chapter 22

Malignant Gliomas: Present and Future Therapeutic Drugs Linda Coate and Warren Mason

Abstract Malignant gliomas are the most common primary brain tumors in adults. Surgery, radiation therapy and chemotherapy are the principal components of therapy for this heterogenous group of tumors. Concurrent and adjuvant chemotherapy with temozolomide in addition to radiotherapy is now a standard of care for the treatment of glioblastoma multiforme (GBM). The role of adjuvant chemotherapy for other types of malignant glioma is less clear. Temozolomide has become the most commonly used agent for GBM and even when used adjuvantly, rechallenge with this agent is also effective at the time of relapse as salvage therapy. Molecular classification of gliomas is of increasing importance and several prognostic and predictive biomarkers are currently under investigation. Anti-angiogenic drugs, such as bevacizumab have shown efficacy in relapsed GBM and this agent has recently been approved by several regulatory agencies for recurrent tumors. Other targeted therapies, such as those directed against the epidermal growth factor receptor (EGFR), have been less successful. Multiple trials are underway investigating new agents and attempting to validate prospective biomarkers that have shown promise in retrospective series. Keywords Temozolomide · Astrocytoma · Oligodendroglioma · Glioblastoma multiforme · Molecular biomarkers · PCV

L. Coate () Department of Medical Oncology, Princess Margaret Hospital, Toronto, ON, Canada M5G 2M9 e-mail: [email protected]

Introduction Malignant gliomas are the most frequently occurring primary brain tumors in adults. They are rapidly progressive brain tumors further classified as anaplastic astrocytoma (AA) and oligodendroglioma (AO), and glioblastoma multiforme (GBM). The classification of primary brain tumors is based on histopathological features, although molecular identification is gaining increasing importance in the evaluation of these malignancies. The most commonly occurring glioma is GBM, accounting for more than half of all gliomas. GBM tends to be a cancer of older individuals, with peak incidence occurring at the age of 65. Unfortunately, the prognosis for GBM is dire, with a median survival of 12–18 months with aggressive multimodal therapy. The survival for patients with less aggressive gliomas is estimated at 2–5 years for patients with AA, and 5–15 years for patients with oligodendroglial tumors. Conventional treatment of malignant brain tumors with existing agents and drug development of experimental agents presents unique challenges. Many patients who present with these tumors are prescribed drugs (such as anti-epileptic medications and corticosteroids) that may potentially interfere with the bioavailability of anticancer agents by induction of the cytochrome p450 system. Many targeted agents are metabolized by the cyp2A4 enzyme, creating unique challenges for the evaluation of novel therapies in neurooncology. In addition, drug delivery may present a challenge as a result of the blood-brain barrier. These challenges may in part explain the generally negative results of clinical trials of targeted therapies and the relative lack of active agents available to combat these tumors.

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_22, © Springer Science+Business Media B.V. 2011

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Currently, the drug temozolomide forms the cornerstone of medical treatment for malignant gliomas (Athanassiou et al., 2005; Stupp et al., 2005, 2009). It is the gold standard of chemotherapy for gliomas, having demonstrable efficacy in the adjuvant setting and at relapse (Perry et al., 2010). However, for most patients with progressive malignant gliomas, participation in a clinical trial is the ideal approach, particularly if the patient has been treated aggressively with a temozolomide containing regimen at first presentation. For patients who have been treated with temozolomide and are not candidates for a clinical study, bevacizumab, either alone or in combination with a cytotoxic chemotherapy agent, has emerged as an effective treatment option. More conventional options include cytotoxic chemotherapies such as lomustine, procarbazine, etoposide and platinum analogues. Recent advances in the understanding of the molecular changes that underpin the genesis of malignant gliomas have led to some progress in the treatment of these tumors and have identified novel molecular targets against which to evaluate emerging therapies. However, despite intensive research and extensive clinical research endeavors, there remains a paucity of active drugs for the treatment of malignant gliomas. In this chapter we review currently utilized treatment paradigms and discuss current drug development and future directions for systemic treatment of this challenging group of malignant tumors.

Current Treatment Paradigms for Malignant Gliomas-Initial Therapy For patients with newly diagnosed malignant gliomas, maximal feasible surgical excision is the preferred initial treatment strategy. This approach provides adequate tissue for accurate pathological diagnosis, effectively reduces tumor burden and potentially improves tumor-related symptoms and signs. Following surgery, most patients with malignant gliomas will receive radiation therapy, a treatment that has been a standard of care for over 30 years (Walker et al., 1980). Cranial irradiation is usually delivered to the tumor with a 2–3 cm margin to a total dose of 58–60 Gy in 1.8– 2.0 Gy fractions. For low grade gliomas, radiotherapy delivered at lower doses provides local control, but increasingly radiotherapy is deferred for patients with

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these tumors because survival is independent of the time at which radiation therapy is delivered. While the role of chemotherapy in the management of low grade gliomas remains one of the most controversial issues in neurooncology, early chemotherapy in the treatment of GBM is now the standard of care for most patients with this disease.

Glioblastoma Multiforme Temozolomide is an oral alkylating agent and is the treatment of choice for adjuvant therapy of malignant glioma. A pivotal phase III trial conducted by the European Organization for the Research and Treatment of Cancer and National Cancer Institute of Canada Clinical Trials Group (EORTC/NCIC CTG) established the role of temozolamide for GBM (Stupp et al., 2005). A 5 year follow-up of this study was recently published, providing convincing evidence that longterm survival is now possible for patients with this disease (Stupp et al., 2009). This study randomized 573 patients with glioblastoma multiforme to postoperative involved-field radiation therapy (30 fractions of radiation to a total dose of 60 Gy) to either adjuvant radiation alone or radiation in combination with concurrent temozolomide followed by six further cycles of temozolomide. This demonstrated an absolute overall survival benefit of 8% (10% versus 2%) with a hazard ratio for death of 0.63 (0.53–0.75) (Stupp et al., 2005) (Fig. 22.1). In a follow-up publication, the overall survival advantage remained at long-term follow up (Stupp et al., 2009). A retrospective study of patients from the EORTC/NCIC CTG trial demonstrated that hypermethylation of the promoter for methyl guanine methyl transferase (MGMT) was a major prognostic factor for improved survival and was predictive of significant benefit from chemotherapy. Remarkably, for patients receiving radiotherapy and concurrent and adjuvant temozolomide chemotherapy, the 5-year survival rates were 15% for those with hypermethylated tumors, versus 2% for those patients without (Hegi et al., 2005). This seminal study showed no adverse impact on health-related quality of life related to the addition of temozolomide, and benefit from temozolomide was seen across all subsets of patients, including

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Fig. 22.1 Overall survival (reproduced from Stupp et al., 2005)

those patients with poor baseline prognostic features. Important questions regarding the application of temozolomide for newly-diagnosed GBM remain unanswered, particularly its role in treatment of the elderly, and for those with poor performance status who were excluded from the EORTC/NCIC CTG trial. Although temozolomide is the only approved drug for GBM in the adjuvant setting, a number of promising agents including the antiangiogenic agent bevacizumab are being evaluated in the adjuvant setting. A phase II study of 70 patients treated with bevacizumab in addition to standard chemoradiation demonstrated a nonsignificant improvement in overall survival compared to a matched group treated with radiotherapy and temozolomide alone (25 versus 21 months). The role of bevacizumab in newly diagnosed GBM is currently being addressed by two large phase III trials. Additionally, the CENTRIC trial is a molecularly directed study of adjuvant administration of cilengitide, an integrin inhibitor that has demonstrated promising activity in newly diagnosed and recurrent GBM, with temozolomide and radiation therapy for newly diagnosed GBM patients whose tumors have methylated promoter of MGMT (http://clinicaltrials.gov/ct2/show/NCT00689221).

Anaplastic Astrocytoma Patients with AA frequently receive chemotherapy in the adjuvant setting. Historically the combination of procarbazine, lomustine and vincristine chemotherapy (PCV) was administered to these patients following surgery and radiotherapy for a maximal duration of 12 months, although this regimen has recently been replaced by the more tolerable agent temozolomide. However, there is no class I evidence to support the administration of any adjuvant chemotherapy for patients with AA, as several large phase III trials have consistently failed to show significant improvement in survival when chemotherapy was used immediately following surgery and radiation therapy. However, the practice of adjuvant chemotherapy for AA is widespread because several meta-analyses have shown that there may be as much as a 15% reduction in the risk of death when patients with AA are treated with adjuvant chemotherapy (Stenning et al., 1987; Fine et al., 1993; Stewart, 2002). While temozolomide appears to have activity in patients with this AA, analysis of retrospective data from two trials do not provide convincing evidence for the use of this drug in the adjuvant setting for

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this disease. In this analysis (Brandes et al., 2006), 109 patients with AA were identified, 60 of which were treated with temozolomide. No differences were observed in the 2-year or median survivals between the two cohorts. Moreover, adjuvant chemotherapy has been compared with adjuvant radiotherapy in a trial that allowed patients with anaplastic astrocytoma to participate (Wick et al., 2009). The chemotherapy in this study was either PCV or temozolomide. Patients were randomly assigned to either treatment and patients were crossed over to the alternative regimen upon progression. There was no difference in overall time to treatment failure depending upon the treatment sequence. There were also no differences in outcome seen between patients treated with PCV or temozolomide. Therefore data to support the role of early chemotherapy in AA is not convincing, and the optimal chemotherapy regimen and its timing for patients with AA remain areas of urgent study.

Low Grade and Anaplastic Astrocytoma and Oligodendroglioma Radiotherapy is indicated for some patients with low-grade astrocytic tumors, however, early postoperative radiation does not improve overall survival, rather it only impacts time to tumor progression. Chemotherapy has no firm role in the initial management of patients with low-grade astrocytic neoplasms. Enhanced efficacy is observed in patients with oligodendroglial neoplasms with 1p19q co-deletion, and so patients with this deletion may benefit from early chemotherapy, but this has yet to be prospectively validated. The prognosis for low grade oligodendroglial tumors is more favourable than that for low grade astrocytomas. Adjuvant chemoradiation in the postoperative management of patients with anaplastic oligodendroglial tumors has been addressed in two large phase III trials that compared two strategies for postoperative adjuvant chemotherapy plus radiotherapy with radiotherapy alone. Although oligodendroglial tumors are more sensitive to chemotherapy than other glial tumors, these trials did not provide evidence of a survival advantage

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when adjuvant PCV chemotherapy was added to radiotherapy, rather than delayed until there was evidence of disease progression. Patients treated with radiotherapy and PCV chemotherapy had increased progressionfree survival (PFS), but overall survival in both arms were similar because PCV chemotherapy was effective as salvage therapy at the time of radiotherapy failure for patients initially treated with radiotherapy alone.

Management of Recurrence – Current Paradigms Although for patients with GBM there is a definite survival advantage from treatment with upfront temozolomide chemotherapy, the majority of patients with this disease will experience tumor progression and death. Prior to temozolomide becoming the standard of care in the adjuvant setting for GBM, this agent had been in widespread use for progressive disease, having been shown in randomized phase II trials to extend progression-free survival at 6 months. Because most patients with GBM receive temozolomide in the first-line setting as part of an adjuvant chemoradiation, at recurrence patients with adequate performance status should be considered for entry into clinical trials whenever possible. If a trial is not available, use of the antiangiogenic agent bevacizumab either alone or with cytotoxic chemotherapy has become an increasingly popular option. This recent change in practice is a consequence of promising results of a randomized, noncomparative phase II trial that allocated patients with recurrent or progressive GBM to treatment with bevacizumab alone or bevacizumab (Friedman et al., 2009) in conjunction with irinotecan. This study demonstrated remarkable radiographic response rates and progression-free survivals at 6 months in both arms, and similar results have been observed in another albeit smaller study (Kreisl et al., 2009). Bevacizumab, however, is not a drug devoid of risk, as its use in this patient population has been associated with hypertension, arteriovenous thrombosis, and low incidence of intracranial hemorrhage and craniotomy dehiscence (Nghiemphu et al., 2008). In patients initially treated with temozolomide who are not candidates for clinical study or bevacizumab, nitrosurea-based chemotherapy might be considered either as single agent therapy

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(lomustine or carmustine) or in recognised combinations (PCV). (Brandes et al., 2004; Schmidt et al., 2006; Fabrini et al., 2009). An interesting approach to the management of progressive GBM involves temozolomide rechallenge using alternate extended dosing schedules (Perry et al., 2010). The principal rationale for this strategy was the notion that continuous exposure of tumor cells to temozolomide potentially depletes tumor MGMT thereby overcoming resistance to this agent. Additionally, extended temozolomide schedules result in dose intensification and potentially represent a form of metronomic chemotherapy that may have antiangiogenic effects (Tuettenberg et al., 2005). The continuous dose temozolomide regimen explored by Perry et al. (2010) was very well-tolerated and produced an overall progression-free survival (PFS) at 6 months of 23.9% for patients with GBM and 35.7% for patients with AA. Among patients with GBM, those who recurred early had a PFS of 27.3% at 6 months, while those who experienced disease progression after completion of adjuvant therapy, and never truly experienced treatment failure with temozolomide, had a PFS6 of 35.7%, suggesting that the regimen may be most beneficial in these two subgroups.

Future Therapeutic Drugs New cytotoxic agents to treat malignant gliomas are generally evaluated initially in patients with recurrent or progressive disease. Procarbazine, etoposide, tamoxifen and pegylated liposomal doxorubicin, carboplatin, cyclophosphamide, paclitaxel, and irinotecan and topotecan have all been investigated and have shown some limited activity (Warnick et al., 1994; Fulton et al., 1996; Chamberlain and Kormanik, 1999a, b; Cloughesy et al., 2003; Macdonald, 2003; Hau et al., 2004). An increased understanding in the molecular aberrations underpinning the development and progression of central nervous tumors has revealed putative targets for therapy, particularly relevant are inhibitors targeting receptor tyrosine kinases such as epidermal growth factor receptor (EGFR),the platelet derived growth factor receptor (PDGFR) and the vascular endothelial growth factor receptors (VEGFR) and related

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targets, as well as on signal-transduction inhibitors targeting mammalian target of rapacycin (mTOR), farnesyltransferase and phosphatidyl inositol 3 kinase PI3K (Wen and Kesari, 2008). However, despite the valiant efforts of researchers, many targeted agents tested in malignant gliomas to date have been tested as monotherapy at the time of recurrence and have demonstrated only modest activity. As malignant gliomas are highly vascular tumors, key molecular targets include those involved in angiogenesis, namely the vascular endothelial growth factor (VEGF) and its receptor. A humanized monoclonal antibody against VEGF, bevacizumab has shown efficacy in recurrent GBM and is currently under investigation in the adjuvant setting. A novel pan VEGFR tyrosine kinase inhibitor (cedirinib) has shown efficacy as documented by functional imaging in patients with recurrent GBM (Batchelor et al., 2007, 2010). The epidermal growth factor receptor (EGFR) has been extensively studied in malignant glioma as its pathway is dysregulated in the majority of patients with malignant glioma. Studies involving agents that inhibit this pathway have uniformly revealed disappointing results. The tyrosine kinase inhibitor erlotinib has been investigated both as a single agent (van den Bent et al., 2009) and in combination with chemotherapy (Brown et al., 2008) and has failed to demonstrate an improvement in survival in either context. Monoclonal antibodies directed against the EGFR such as panitumumab are currently under investigation in GBM. Vorinostat, a histone deacetylase inhibitor is currently under investigation for patients with recurrent GBM. This follows a phase II study which met the predetermined criteria to further evaluate vorinostat in this setting (Galanis et al., 2009). Drugs targeting other pathways such as mTOR and PI3K are also under investigation. In addition other novel approaches such as oncolytic viral therapy are currently being trialled.

Molecular Biomarkers The impact of unravelling the molecular underpinning of gliomagenesis is perhaps more evident in terms of the predictive and prognostic markers which have been identified, have the potential to change the face of current management of glioma and have shaped

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ongoing and future trials. Perhaps most importantly MGMT promotor hypermethylation has been found to be a positive molecular genetic prognostic feature in patients with GBM. It is also possibly predictive of a favourable response to temozolomide-containing therapy, a key question that is addressed in a large phase III trialrecently completed by the Radiation Therapy Oncology Group (RTOG 0525). Until the results of this trial are available, the clinical utility of this biomarker remains limited, as MGMT promotor hypermethylation status should not be used to guide therapeutic decisions. In anaplastic oligodendroglioma the identification of 1p19q co-deletion has uncovered a subpopulation of tumors that grow slowly and are more exquisitely sensitive to both chemotherapy and radiation than those tumors not sharing this molecular characteristic (Walker et al., 2006). Increasingly anaplastic gliomas are being classified by the presence or absence of this molecular signature, and 1p19q codeletion is being used to assist in the histologic diagnosis of these tumors. Studies are underway to establish therapies based on 1p19q classification of malignant gliomas. Mutations of p53 and overexpression, mutation and amplification of EGFR are common molecular aberrations observed in astrocytic tumors. Unravelling their prognostic and predictive impact has not been achieved however and their potential clinical utility remains unclear (Mason and Cairncross, 2008). Novel, emerging biomarkers may include mutations in IDH1 and IDH2 which seem to be early molecular events in the gliomagenesis of particular tumors, and seem to be associated with a more favourable prognosis, but this finding requires prospective evaluation (Yan et al., 2009).

Conclusion The last decade has revealed dramatic changes in the treatment of malignant gliomas. Temozolomide is now the agent of choice in the adjuvant setting and may also yield favourable results upon rechallenge for most patients with GBM. Bevacizumab is under investigation in the adjuvant setting for GBM and may be useful in the patient with relapsed disease. Targeting the VEGF pathway appears to be a particularly promising strategy, as preliminary trials using the pan-VEGF

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receptor tyrosine kinase inhibitor cedirinib have also demonstrated signs of efficacy in patients with progressive GBM. As our understanding of the molecular biology of malignant glioma advances, and as biomarkers such as MGMT promotor hypermethylation and 1p/19q codeletion undergo prospective validation in large phase III trials, the possibility of tailoring therapy for patients with malignant glioma based on molecular genetic factors approaches reality. Clearly neurooncology has emerged as an area of intense clinical research for the evaluation of novel molecularly targeted therapies, and it is hoped that these efforts will result in improved therapies and better outcomes for patients afflicted with these intractable and devastating malignancies.

References Athanassiou H, Synodinou M, Maragoudakis E, Paraskevaidis M, Verigos C, Misailidou D, Antonadou D, Saris G, Beroukas K, Karageorgis P (2005) Randomized phase II study of temozolomide and radiotherapy compared with radiotherapy alone in newly diagnosed glioblastoma multiforme. J Clin Oncol 23:2372–2377 Batchelor TT, Duda DG, di Tomaso E, Ancukiewicz M, Plotkin SR, Gerstner E, Eichler AF, Drappatz J, Hochberg FH, Benner T, Louis DN, Cohen KS, Chea H, Exarhopoulos A, Loeffler JS, Moses MA, Ivy P, Sorensen AG, Wen PY, Jain RK (2010) Phase II study of cediranib, an oral panvascular endothelial growth factor receptor tyrosine kinase inhibitor, in patients with recurrent glioblastoma. J Clin Oncol 28:2817–2823 Batchelor T, Sorensen AG, Ancukiewicz M, Duda DG, Louis DN, Plotkin SR, Ivy P, Wen PY, Loeffler JS, Jain R (2007) A phase II trial of AZD2171 (cediranib), an oral pan-VEGF receptor tyrosine kinase inhibitor, in patients with recurrent glioblastoma. J Clin Oncol (Meeting Abstracts) 25:2001 Brandes AA, Tosoni A, Amista P, Nicolardi L, Grosso D, Berti F, Ermani M (2004) How effective is BCNU in recurrent glioblastoma in the modern era? A phase II trial. Neurology 63:1281–1284 Brandes AA, Tosoni A, Cavallo G, Bertorelle R, Gioia V, Franceschi E, Biscuola M, Blatt V, Crino L, Ermani M (2006) Temozolomide 3 weeks on and 1 week off as firstline therapy for recurrent glioblastoma: phase II study from gruppo italiano cooperativo di neuro-oncologia (GICNO). Br J Cancer 95:1155–1160 Brown PD, Krishnan S, Sarkaria JN, Wu W, Jaeckle KA, Uhm JH, Geoffroy FJ, Arusell R, Kitange G, Jenkins RB, Kugler JW, Morton RF, Rowland KM Jr, Mischel P, Yong WH, Scheithauer BW, Schiff D, Giannini C, Buckner JC (2008) Phase I/II trial of erlotinib and temozolomide with radiation therapy in the treatment of newly diagnosed glioblastoma multiforme: North Central Cancer Treatment Group Study N0177. J Clin Oncol 26:5603–5609

22 Malignant Gliomas: Present and Future Therapeutic Drugs Chamberlain MC, Kormanik P (1999a) Salvage chemotherapy with taxol for recurrent anaplastic astrocytomas. J Neurooncol 43:71–78 Chamberlain MC, Kormanik PA (1999b) Salvage chemotherapy with tamoxifen for recurrent anaplastic astrocytomas. Arch Neurol 56:703–708 Cloughesy TF, Filka E, Kuhn J, Nelson G, Kabbinavar F, Friedman H, Miller LL, Elfring GL (2003) Two studies evaluating irinotecan treatment for recurrent malignant glioma using an every-3-week regimen. Cancer 97:2381–2386 Fabrini MG, Silvano G, Lolli I, Perrone F, Marsella A, Scotti V, Cionini L (2009) A multi-institutional phase II study on second-line Fotemustine chemotherapy in recurrent glioblastoma. J Neurooncol 92:79–86 Fine HA, Dear KB, Loeffler JS, Black PM, Canellos GP (1993) Meta-analysis of radiation therapy with and without adjuvant chemotherapy for malignant gliomas in adults. Cancer 71:2585–2597 Friedman HS, Prados MD, Wen PY, Mikkelsen T, Schiff D, Abrey LE, Yung WK, Paleologos N, Nicholas MK, Jensen R, Vredenburgh J, Huang J, Zheng M, Cloughesy T (2009) Bevacizumab alone and in combination with irinotecan in recurrent glioblastoma. J Clin Oncol 27:4733–4740 Fulton D, Urtasun R, Forsyth P (1996) Phase II study of prolonged oral therapy with etoposide (VP16) for patients with recurrent malignant glioma. J Neurooncol 27:149–155 Galanis E, Jaeckle KA, Maurer MJ, Reid JM, Ames MM, Hardwick JS, Reilly JF, Loboda A, Nebozhyn M, Fantin VR, Richon VM, Scheithauer B, Giannini C, Flynn PJ, Moore DF Jr, Zwiebel J, Buckner JC (2009) Phase II trial of vorinostat in recurrent glioblastoma multiforme: a north central cancer treatment group study. J Clin Oncol 27:2052–2058 Hau P, Fabel K, Baumgart U, Rummele P, Grauer O, Bock A, Dietmaier C, Dietmaier W, Dietrich J, Dudel C, Hubner F, Jauch T, Drechsel E, Kleiter I, Wismeth C, Zellner A, Brawanski A, Steinbrecher A, Marienhagen J, Bogdahn U (2004) Pegylated liposomal doxorubicin-efficacy in patients with recurrent high-grade glioma. Cancer 100:1199–1207 Hegi ME, Diserens AC, Gorlia T, Hamou MF, de Tribolet N, Weller M, Kros JM, Hainfellner JA, Mason W, Mariani L, Bromberg JE, Hau P, Mirimanoff RO, Cairncross JG, Janzer RC, Stupp R (2005) MGMT gene silencing and benefit from temozolomide in glioblastoma. N Engl J Med 352:997–1003. http://clinicaltrials.gov/ct2/show/NCT00689221 Kreisl TN, Kim L, Moore K, Duic P, Royce C, Stroud I, Garren N, Mackey M, Butman JA, Camphausen K, Park J, Albert PS, Fine HA (2009) Phase II trial of single-agent bevacizumab followed by bevacizumab plus irinotecan at tumor progression in recurrent glioblastoma. J Clin Oncol 27:740–745 Macdonald DR (2003) New frontiers in the treatment of malignant glioma. Semin Oncol 30:72–76 Mason WP, Cairncross JG (2008) Invited article: the expanding impact of molecular biology on the diagnosis and treatment of gliomas. Neurology 71:365–373 Nghiemphu PL, Green RM, Pope WB, Lai A, Cloughesy TF (2008) Safety of anticoagulation use and bevacizumab in patients with glioma. Neuro Oncol 10:355–360 Perry JR, Belanger K, Mason WP, Fulton D, Kavan P, Easaw J, Shields C, Kirby S, Macdonald DR, Eisenstat DD, Thiessen B, Forsyth P, Pouliot JF (2010) Phase II trial of continuous

213 dose-intense temozolomide in recurrent malignant glioma: RESCUE study. J Clin Oncol 28:2051–2057 Schmidt F, Fischer J, Herrlinger U, Dietz K, Dichgans J, Weller M (2006) PCV chemotherapy for recurrent glioblastoma. Neurology 66:587–589 Stenning SP, Freedman LS, Bleehen NM (1987) An overview of published results from randomized studies of nitrosoureas in primary high grade malignant glioma. Br J Cancer 56: 89–90 Stewart LA (2002) Chemotherapy in adult high-grade glioma: a systematic review and meta-analysis of individual patient data from 12 randomised trials. Lancet 359: 1011–1018 Stupp R, Hegi ME, Mason WP, van den Bent MJ, Taphoorn MJ, Janzer RC, Ludwin SK, Allgeier A, Fisher B, Belanger K, Hau P, Brandes AA, Gijtenbeek J, Marosi C, Vecht CJ, Mokhtari K, Wesseling P, Villa S, Eisenhauer E, Gorlia T, Weller M, Lacombe D, Cairncross JG, Mirimanoff RO (2009) Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomised phase III study: 5-year analysis of the EORTC-NCIC trial. Lancet Oncol 10:459–466 Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, Belanger K, Brandes AA, Marosi C, Bogdahn U, Curschmann J, Janzer RC, Ludwin SK, Gorlia T, Allgeier A, Lacombe D, Cairncross JG, Eisenhauer E, Mirimanoff RO (2005) Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352: 987–996 Tuettenberg J, Grobholz R, Korn T, Wenz F, Erber R, Vajkoczy P (2005) Continuous low-dose chemotherapy plus inhibition of cyclooxygenase-2 as an antiangiogenic therapy of glioblastoma multiforme. J Cancer Res Clin Oncol 131:31–40 van den Bent MJ, Brandes AA, Rampling R, Kouwenhoven MC, Kros JM, Carpentier AF, Clement PM, Frenay M, Campone M, Baurain JF, Armand JP, Taphoorn MJ, Tosoni A, Kletzl H, Klughammer B, Lacombe D, Gorlia T (2009) Randomized phase II trial of erlotinib versus temozolomide or carmustine in recurrent glioblastoma: EORTC brain tumor group study 26034. J Clin Oncol 27:1268–1274 Walker MD, Green SB, Byar DP, Alexander E Jr, Batzdorf U, Brooks WH, Hunt WE, MacCarty CS, Mahaley MS Jr, Mealey J Jr, Owens G, Ransohoff J 2nd, Robertson JT, Shapiro WR, Smith KR Jr, Wilson CB, Strike TA (1980) Randomized comparisons of radiotherapy and nitrosoureas for the treatment of malignant glioma after surgery. N Engl J Med 303:1323–1329 Walker C, Haylock B, Husband D, Joyce KA, Fildes D, Jenkinson MD, Smith T, Broome J, Kopitzki K, du Plessis DG, Prosser J, Vinjamuri S, Warnke PC (2006) Genetic and metabolic predictors of chemosensitivity in oligodendroglial neoplasms. Br J Cancer 95:1424–1431 Warnick RE, Prados MD, Mack EE, Chandler KL, Doz F, Rabbitt JE, Malec MK (1994) A phase II study of intravenous carboplatin for the treatment of recurrent gliomas. J Neurooncol 19:69–74 Wen PY, Kesari S (2008) Malignant gliomas in adults. N Engl J Med 359:492–507 Wick W, Hartmann C, Engel C, Stoffels M, Felsberg J, Stockhammer F, Sabel MC, Koeppen S, Ketter R, Meyermann R, Rapp M, Meisner C, Kortmann RD, Pietsch

214 T, Wiestler OD, Ernemann U, Bamberg M, Reifenberger G, von Deimling A, Weller M (2009) NOA-04 randomized phase III trial of sequential radiochemotherapy of anaplastic glioma with procarbazine, lomustine, and vincristine or temozolomide. J Clin Oncol 27:5874–5880

L. Coate and W. Mason Yan H, Parsons DW, Jin G, McLendon R, Rasheed BA, Yuan W, Kos I, Batinic-Haberle I, Jones S, Riggins GJ, Friedman H, Friedman A, Reardon D, Herndon J, Kinzler KW, Velculescu VE, Vogelstein B, Bigner DD (2009) IDH1 and IDH2 mutations in gliomas. N Engl J Med 360:765–773

Chapter 23

Recurrent Malignant Glioma Patients: Treatment with Conformal Radiotherapy and Systemic Therapy Abhirami Hallock and Lauren VanderSpek

Abstract Malignant gliomas have a propensity to recur despite initial radical treatment. The diagnosis, therapy, and prognosis of recurrent malignant glioma will be discussed with an emphasis on fractionated stereotactic radiotherapy (FSRT) for the reirradiation of recurrent malignant glioma alone or in combination with systemic therapy. The challenges of re-irradiation with a focus on central nervous system radiation tolerances and late effects will be addressed. Studies conducted between 2000 and 2010 for reirradiation with fractionated stereotactic radiotherapy (FSRT) +/– systemic therapy are provided in table format as well as a diagrammatic flowchart to help decision making in patients with recurrent malignant gliomas. Keywords Malignant gliomas · Fractionated stereotactic radiotherapy · Systemic therapy · Conformal radiotherapy · Reirradiation · CTV

Introduction Malignant gliomas are a therapeutic challenge due to their infiltrative growth and biologic behavior with a propensity to recur close to their original location. Therapeutic interventions at the time of relapse include surgery, systemic therapy, reirradiation, supportive care, or a combination of interventions, the choice of which should involve multidisciplinary

A. Hallock () Department of Radiation Oncology, London Regional Cancer Program, University of Western Ontario, E. London, ON, Canada e-mail: [email protected]

discussion taking into account the clinical status of the patient and his or her goals of therapy. Previous treatments and response must also be taken into account in deciding on management at relapse so as to provide patients with a therapy where potential benefits outweigh potential toxicity. Surgery may be considered for malignant glioma at the time of relapse; however the infiltrative nature of gliomas, proximity to eloquent areas of the brain, and the risk for surgery-associated side effects should be weighed against the benefit of surgical intervention (Combs et al., 2007). Systemic therapies have shown modest benefit when used as a single agent or in combination; however, the use of systemic therapies alone at relapse may be limited by prior exposure to chemotherapy during primary treatment or due to decreased bone marrow reserve (Combs et al., 2007). In regard to targeted agents, there are some promising results from Friedman et al. (2009) in their study of 167 patients with recurrent glioblastoma randomized to either Avastin alone or in combination with Irinotecan. In the Avastin alone and the Avastin plus Irinotecan groups, the 6-month progression-free survival rates were 42.6 and 50.3%, respectively. The median overall survival times were 9.2 and 8.7 months, respectively. The use of radiotherapy at relapse has advanced from whole brain techniques, to 3D conformal techniques and subsequently to the use of stereotactic localization either in single fraction or fractionated regimens with the goal of improving target coverage while sparing surrounding normal structures. The use of reirradiation in combination with systemic agents seeks to improve the therapeutic ratio (through either additive or synergistic effects, i.e. radiosensitization) using chemotherapy or targeted agents.

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_23, © Springer Science+Business Media B.V. 2011

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Patterns of Failure Initial radiation volumes for GBM are variable depending on the amount of peritumoral edema covered. The Radiation Therapy Oncology Group (RTOG) has historically included peritumoral edema within the clinical target volume (CTV) (Chang et al., 2007). Arguing in favor of including areas of peritumoral edema are histopathologic correlative studies demonstrating infiltrating tumor cells within this region (Halperin et al., 1989). However, studies suggest most recurrences are confined to the immediate contrast enhancing area on imaging. For instance, using whole brain radiotherapy, Hochberg and Pruitt (1980) demonstrated that 80% of GBM recurrences occur within 2 cm of the margin of the primary tumor bed. Oppitz et al. (1999) studied 79 patients with GBM, with the macroscopic preoperative tumor radiated with a 2 cm safety margin, and showed that in 33 out of 34 patients for which the CT-study showing tumor-recurrence was available, the recurrence was completely situated within the original 90%-isodose. Based on these findings, Chang et al. (2007) and Oppitz et al. (1999) advocate that proximity to the gross tumor volume (GTV) rather than the presence of peritumoral edema is the more important factor in predicting the potential site of recurrence. Chang et al. (2007) recommend an initial CTV defined as the GTV + 2 cm (with no attempt to include all of the edema volume) and a planning target volume (PTV) as CTV + 0.5 cm. They demonstrated in a study of 48 patients treated in this fashion that all relapses where contained within this more limited volume and that irradiated volumes were smaller than comparison plans where edematous regions were deliberately included. Patterns of tumor failure localized to regions close to the original have driven clinical investigations of radiation dose escalation in an attempt to improve local control. Dose escalation attempts to doses up to 90 Gy have not improved local control and this remains the predominant failure pattern (Chan et al., 2002). External beam conformal radiotherapy plus an implant has not resulted in improvements in local control or survival compared to external beam therapy alone (Laperriere et al., 1998). GBM is therefore known to display an aggressive local recurrence pattern, but current imaging modalities are insufficient to determine where a recurrence is most likely to occur within

A. Hallock and L. VanderSpek

the local region (Chang et al., 2007). The contrast enhancing volume on CT or MRI has been used as the target for radiation dose escalation and there is emerging evidence that this may not represent the whole biologically important tumor target. Improved visualization of the microscopic extension of malignant glioma cells is the goal of new imaging techniques; biologic imaging may provide complementary information to that of conventional data from CT and MRI and thus improve the efficacy of treatment while minimizing toxicity by better distinguishing the target from uninvolved brain (Dhermain et al., 2005). Biologic imaging that has been evaluated in previous studies for planning radiation treatment includes functional magnetic resonance imaging (fMRI), positron emission tomography (PET), 11Cmethionine-PET (MET-PET), magnetic resonance spectroscopy (MRSI), and single photon computed emission tomography (SPECT) combined with CT/MRI. Preliminary studies have demonstrated discordance between anatomically defined (T1 contrast enhanced or T2 MRI) and biologically defined (MRSI or PET/SPECT) volumes, however, it is not clear that patterns of failure correlate between with biologic versus anatomically defined targets. For this reason, currently the use of biologic imaging for radiation planning in malignant glioma is investigational, but highlights the need for more accurate determination of the target to enable more efficacious treatment design. For example, in the setting of recurrent malignant glioma, Grosu et al. (2005) demonstrated a statistically significant longer survival time in the univariate analysis for patients reirradiated using (11)C-methionine positron emission tomography (MET-PET) or (123)Ialpha-methyl-tyrosine (IMT)-SPECT/CT/MRI image fusion in the treatment planning compared to patients treated based on MRI/CT alone. The study was small, including 44 patients (1 patient anaplastic oligodendroglioma (AO), 8 with AA, 33 with GBM, and 2 with gliosarcoma) after previous surgery and post-operative conventional radiotherapy with or without chemotherapy. Median survival times were 11 months for patients who received fractionated stereotactic radiotherapy (SFRT) and temozolomide compared to 6 months for patients treated with SFRT without biologic imaging, without temozolomide, or without both (p = 0.008) (Grosu et al., 2005). Imaging advances are also important is in the diagnosis of recurrent malignant glioma as MRI interpretation can be challenging in distinguishing

23 Recurrent Malignant Glioma Patients

between recurrent tumor and treatment effects, both of which may appear as new or worsened areas of contrast enhancement (Chang et al., 2006). Magnetic resonance spectroscopy determines the biology of regions of abnormality on MRI images by measuring the ratio of tissue metabolites such as N-acetylaspartate, creatine, choline, and lactate (Chang et al., 2006). An increase of the choline peak and decrease of N-acetylaspartate indicates tumor recurrence, however, there have been some reports of transient increased choline and decreased N-acetylaspartate after radiotherapy especially in areas exposed to lower doses (Peca et al., 2009). Cerebral perfusion imaging can demonstrate increased cerebral blood volume in recurrent tumor to distinguish it from normal brain tissue (Chang et al., 2006). Diffusion-weighted MR imaging may also be helpful in distinguishing treatment effects from recurrent tumors by measuring differences in apparent diffusion coefficient (Chang et al., 2006). Similarly, PET and SPECT imaging may provide complementary information to help distinguish necrosis from active tumor (Gòmez-Rio et al., 2008). If the diagnosis of recurrent malignant glioma remains uncertain then surgical biopsy (or serial imaging) may be required prior to treatment (Chang et al., 2006).

Radiation Response of the Brain to Initial Radiation The brain is a slowly proliferating and late reacting tissue. The α/βratio is thought to be approximately 2–2.9 Gy suggesting a low repair capacity (Mayer and Sminia, 2009; Yaacov et al., 2010). Concerns of late effects like radiation necrosis, diffuse white matter injury and/or leukoencephalopathy have been the limiting factor for radiation treatments. The significant reluctance to undertake reirradiation stems from the potential for cumulative late toxicity and lack of clinical data to base estimates of recovery of tolerance after initial treatment. Much of our understanding of late radiation effects on the brain come from limited retrospective clinical studies and extrapolated data from animal studies of radiation myelopathy. Such data often reflects older radiation techniques (larger treatment volumes such as whole brain radiotherapy, lack of conformal radiotherapy techniques, non-conventional treatment schedules such as treating one field per day, larger dose per

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fraction, etc). Both clinical and laboratory studies have shown that the CNS toxicity is a function of total dose delivered, dose per fractionation, volume treated and interval between fractions. The pathophysiology of CNS radiation late injury is poorly understood. There is consensus that it is likely secondary to both neuro-glial damage and secondary vascular changes. The abnormal production and release of cytokines by astrocytes or microglia as normal responses to injury, contribute to CNS damage.

Late Effects Focal radiation necrosis is often limited to the white matter, with a latency period of 6 months to 2 years, its presentation mimicking tumor recurrence, and symptoms dependant on the neuro-anatomic location. Histopathological analyses of these areas show focal coagulative necrosis and demyelination likely secondary to fibrinoid necrosis of small arterial vessels (Schultheiss et al., 1995). Imaging changes associated with treatment necrosis make it difficult to distinguish it from tumor recurrence, or tumor necrosis. After radiation, irregular enhancement with diffuse edema and low density white matter changes is seen within the high dose volume regions of treated brain on CT scans, and greater extent of similar white matter changes and edema can be seen on MRI. MR spectroscopy and PET imaging may be useful in deciphering the changes seen on conventional CT and MRI imaging. There is evidence that there is little or no radiation necrosis below 60 Gy delivered in 2 Gy per fractions. For fraction sizes larger than 2.2–2.5 Gy or doses >60 Gy the risk of radiation related necrosis increases (Schultheiss et al., 1995). Yaacov et al. (2010) found a 5% risk of necrosis for at BED of 120 Gy (100–140 Gy) and a 10% risk at BED of 150 Gy (140–170 Gy) for fraction sizes < 2.5 Gy (equivalent to 72 and 89 Gy in 2 Gy per day fractions respectively, α/β= 3). This risk rises significantly for twice daily fractionation and becomes unpredictable for fractionation >2.5 Gy. Based on their analysis, they conclude dose, fraction size, and treatment volume are major players in the risk of necrosis, while location, use of chemotherapy, and, diabetes mellitus are less well established risk factors. They estimate a median time of 1–2 years between initial radiation and development of radiation necrosis.

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The development of diffuse white matter injury is also a potential part of the late effect syndrome and has been documented after both whole brain radiation and focal radiotherapy. For the latter, the changes can extend beyond the peripheral of the high dose volume. They found resulting neurological sequelae ranging from mild lethargy to progressive memory loss leading to dementia. Histopathologically the damaged white matter shows reactive astrocytosis and white matter pallor. White matter injury resulting in cognitive changes seems to be related to volume, dose and fraction size. Leukoencephalopathy describes diffuse white matter injury in the setting of chemotherapy with or without radiation. It is noted in adults beyond 12–18 months and has a spectrum of symptoms with lethargy, dysarthia to progressive severe CNS damage resulting in ataxia, memory loss, and dementia. Imaging changes are similar to those described above and differ with late development of calcifications mostly limited to the basal ganglia and grey-white matter interface. Histopathology analysis show diffuse gliosis and multiple non-inflammatory foci of necrosis (Schultheiss et al., 1995). Late cerebrovascular effect causing stroke like deficits as a result of obliteration of vessels is of less concern in patients with malignant gliomas as these side effects are experienced by those who experience long survivorship, more commonly documented in children and for those receiving treatments for base of skull tumors.

Recovery of Occult Injury and Re-irradiation The recovery of occult radiation injury is important in understanding the safety of retreatments and determination of re-irradiation dose. Rodent studies have shown that the spinal cord is able to recover significant and that the extent of repair is dependant on the initial dose received and time interval to retreatment (Bauman et al., 1996). Studies on monkeys suggest that most of the occult injury induced by an initial treatment is recovered within 2 years; however, there is variability in the rate of recovery (Schultheiss et al., 1995). In this study, the time to late toxicity was similar in both the retreatment and single treatment group.

A. Hallock and L. VanderSpek

However, a retrospective clinical experience of 300 cases of radiation myelopathy from 76 papers showed that latency period for development of toxicity was reduced for the lumbar spine and with increasing doses of radiation. For the brain, given the lack of similar studies, an estimate of 40–50% of the previous radiation dose after 1–2 years maybe accounted for in retreatments (Bauman et al., 1996). It is important to recognize the inadequate understanding of impact of high dose per fractions in setting of retreatments on the brain. Both a recent literature review by Mayer et al. (2009) and Yaacov et al. (2010) highlight the limitations of the present evidence evaluating the sequelae of reirradiation. Most clinical data is derived from single institution studies that often lack details in target volumes, spatial factors or time between radiation treatments. Reporting toxicity as only a crude rate (ratios to number of patients treated) instead of an actuarial risk (ratios to number of survivors at risk) can result in underestimation of true risks (Yaacov et al., 2010). These limitations acknowledged, Mayer et al. (2009) evaluated 21 studies using techniques of radiosurgery and FSRT and conventionally fractionated radiotherapy. They concluded that radiation can be given safely using different techniques with necrosis becoming evident at (normalized total doses) NTDcumulative >100 Gy. The NTDcumulative is the total dose delivered in 2 Gy per fraction using the linear quadratic formulation (accounting for differences in fraction size and total dose) to sum radiation courses. In their review, the major factor contributing to risk of necrosis was total dose and the time interval to retreatment (minimum interval of 3 months) did not significantly correlate to risk of necrosis. Previous published reports on salvage therapies including those for radiosurgery and brachytherapy estimate a necrosis of 10–20% (Bauman et al., 1996) and ranging from 4 to 40% for SRT or 3DCRT (Butowki et al., 2006). The timelines of progression to these symptoms in the setting of reirradiation is not well established particularly for those patients retreated for malignant glioma where competing risk of tumor progression may underestimate the potential for long term toxicity. As systemic therapies combined with focal therapies become a more common component of salvage regimes; it is important to gain an understanding of the impact of both cytotoxic chemotherapy and targeted agents on both acute and late toxicities in the setting of retreatments.

23 Recurrent Malignant Glioma Patients

Re-irradiation of Malignant Glioma There is no consensus on the general management of recurrent malignant gliomas or re-irradiation for recurrence. No comparative studies of the salvage options of surgery, radiation, or systemic therapies are available in the literature. Feasibility of salvage option (i.e. resectability and operability when considering reoperation), expected therapeutic response, and potential for cumulative toxicity should be guiding principles in the management of patients with recurrent malignant gliomas. Figure 23.1 provides a suggested approach. Conventional, fractionated stereotactic radiotherapy, brachytherapy, radiosurgery (Linac based, GammaKnife, and Cyberknife) have been utilized in the salvage setting; the highly focal techniques allow the possibility of maximizing therapeutic efficacy, tolerance, and convenience. Radiosurgery for progressive malignant glioma is the subject of another chapter.

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For this section of the chapter, a literature search for re-irradiation studies in recurrent malignant gliomas between 2000 and 2010 was conducted. Studies with less than ten patients, involving brachytherapy, radiosurgery, or inadequate information about treatment regimes were excluded. Tables 23.2, 23.3 and 23.4 lists these retrospective, prospective and phase I trials and are provided as a guide to the doses, time intervals and regimes used and for an appreciation of tolerances of normal brain. It is important to reemphasize the challenges in making comparison and caution against making overarching general conclusions based on these studies. These studies span eras that have seen significant advancements in technology such as improved neuro-imaging and neurosurgical techniques, have inherent issues of selection biases, and differing institution treatment practices. Also, there is no gold standard for imaging changes to diagnose true normal tissue necrosis; many of the studies did not grade their necrosis or report on re-operation rates or confirm suspected necrosis with biopsy.

Fig. 23.1 A suggested approach to the management of recurrent malignant glioma

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Figure 23.2 shows these studies in a temporal relationship, with median overall survival from time of retreatment.

calculation for specific patient scenarios, the following formulas have been provided (Table 23.1): NTDcumulative = BEDcumulative /2;

3D Conformal/Stereotactic Radiotherapy As stated earlier in this chapter, the customization of salvage radiation treatment regime including radiation technique, total dose, and dose per fraction for individual patients should account for initial dose with first treatment, time interval to retreatment, new treatment volume, and when appropriate consider placement in a clinical trial. As suggested by Mayer and Sminia (2009), attention should be paid to the NTDcumulative . They found that both NTDcumulative and total retreatment dose can be increased when using conformal techniques or radiosurgery, without added risk of necrosis. Based on their review, the range of NTDcumulative for the conventional technique re-irradiation was 81.6– 101.9 Gy; for FSRT was 90–133.9 Gy. To aid in

and BEDcumulative = BEDinitial + BEDreirradiation BED = nd(1 + d/[α/β]) D = dose/fraction (Gy); n = number of fractions; α/β = repair capacity of tissue. Table 23.2 includes studies that have evaluated treatments of recurrence with different radiation techniques and suggest that re-irradiation can be delivered safely by various techniques. There is significant heterogeneity in treatments that patients received within institutions in terms of prior chemotherapy regimes, resections, etc. The increased exploration of FSRT started after some early radiosurgery studies suggested high rates of reoperation for necrosis. FSRT allows for

22

Fig. 23.2 Scatter plot of re-irradiation studies in recurrent malignant gliomas. Median survival is from time of retreatment. XRT (conventional radiation), FSRT (fractionated stereotactic radiotherapy), CTX (chemotherapy), TG (targeted therapy)

Median Overall Survival

20 18 XRT XRT+CTX FSRT FSRT+CTX FSRT+TG

16 14 12 10 8 6 2000

Table 23.1 BED for examples of common radiation regimes Dose/fraction BEDα/β=10 BEDα/β=2 Dose (Gy) Fractions (Gy) (Gy) (Gy)

2005 Year of Study

NTD (Gy)

2010

Comments

60 30 2 72 120 60 Standard initial treatment 35 7 5 53 122.5 61 Hypofractionated Re-XRT 20 1 20 60 220 110 Radiosurgerya a The linear quadratic model was derived for fractionated radiotherapy. Its reliability for small number of fractions or single fractions is uncertain. There are models suggested for radiosurgery but these do not account for all possible variables, and are not well validated.

45–61 Gy/1.8–2 Gy daily OR 45 Gy/3 Gy daily OR 54.8 Gy/1.8 Gy bid+CT (94%) 60 Gy/2 Gy per day/5 days per week +CT (16 patients) 59.4 Gy/2 Gy per day/5 days per week +CT (16 patients) 45–60 Gy/Dose/fx: NA

50–60 Gy/2 Gy per day/5 days per week

30 Gy/5 Gy per day/5 days per week

46 Gy/2 Gy per day/5 days per week

19

33

11

15

NA

12

7.9 15.4 (AA)

6.9

8

Acute edema (1)/necrosis (2): clinical necr + cognitive decline (1) at 62 months/all late toxicity at BED> 204 Gy. Dose >40 Gy major risk factor. Necrosis(2) Mixed (tumor +radiation) necrosis (1)

GBM(51) 36 Gy/2 Gy per day/5 10 49 8 Necrosis(0) GS(1) days per week GCG(1) Combs et al. (2005a) AA(22) 36 Gy/2 Gy per day/5 34 56.2 16 Necrosis (0) AO(10) days per week AOA(8) Ernst-Stecken et al. GBM(11) 35 Gy/5 Gy per day/5 10 22.4 12 Necrosis (0) (2007) AA(4) days per week AA (anaplastic astrocytoma), AO (anaplastic oligodendroglioma), AOA (Anaplastic oligoastrocytoma), AE (Anaplastic Ependymoma), GBM (glioblastoma multiforme), GS (gliosarcoma), GCG (giant cell glioblastoma), LG (low grade), DE (Dose escalation), NA (not available), CT (chemotherapy), fx (fraction). a Median interval is from the time from the first radiation treatment. b Median survival is from the time of retreatment.

Vordermark et al. (2005)

Combs et al. (2005b)

GBM(14) AA(5)

Veninga et al. (2001)

20-36 Gy/4–6 Gy per day/5 days per week

Necrosis(0)

60 Gy/2 Gy per day/5 days per week

Selch et al. (2000)

GBM(15) AOA(3) LG(3) Unk(1) AA(29)

Graded toxicity(n)/necrosis (n)/comments

Table 23.2 Re-irradiation with conventional radiotherapy, fractionated stereotactic radiotherapy, or LINAC based stereotactic radiosurgery First treatment radiation Median Median Median (median or range)/dose/ Median re-radiation/ volume intervala survivalb Author Histology (n) (months) (months) schedule dose/schedule treated (cc)

23 Recurrent Malignant Glioma Patients 221

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delivery for high dose per fraction treatment while taking radiobiological advantage for normal tissue repair and maintaining short overall treatment times. Cho et al. (1999) compared FSRT to SRS and found lower complication rates with FSRT without impact on survival rates. Other studies of FSRT given alone or in conjunction with systemic therapies (Table 23.3) support the results of Cho et al. (1999). Given high progression post retreatments, newer trials are exploring the role of dose escalation and enhancing radiosensitization.

Stereotactic Radiotherapy with Systemic Therapies Brain tumors provide unique challenges to treatment with systemic therapies alone with issues of diffuse infiltrative disease, blood brain barrier, and rapid evolution of resistance. There is only modest benefit to conventional chemotherapy in treatment for recurrent malignant gliomas, with greater benefit observed in patients with grade three gliomas. Chemotherapeutic agents used for recurrent gliomas include temozolomide, nitrosourea, carboplatin, procarbazine, irinotecan, etoposide and carmustine wafers (Wen and Kesari, 2008). Concurrent chemoradiation is becoming increasing common as evidenced by its use in radical treatments of gynecologic, gastrointestinal, head & neck, and thoracic malignancies. The addition of chemotherapy to repeat radiation treatment of recurrent malignant glioma is another treatment strategy and has been described in the literature for several chemotherapeutic agents (Table 23.3). Chemotherapy may interact with radiation through several mechanisms: spatial cooperation, additive or synergistic cell killing or non-overlapping toxicity. In the retreatment of glioma, chemotherapy may potentially address microscopic tumor outside the radiated volume. Improved tumor cell kill within the treated volume may result from the additive effects of chemotherapy and radiation and allow for treatment intensification without the increased risk of necrosis seen when higher dose re-irradiation is used as a single modality due to non-overlapping toxicity. Synergistic effects can include alteration of cell cycle

A. Hallock and L. VanderSpek

by chemotherapy resulting in greater number of cells within the radiosensitive G2/M phase, inhibition of radiation repair and conversion of sub-lethal single strand radiation injury to lethal double strand breaks. The role of Cisplatin (CDDP), Paclitaxel, Lomustine, Topotecan, Temozolomide and hyperbaric oxygen with radiation in recurrent gliomas have been reported (Table 23.3). Cisplatin (CDDP) is used as a radiosensitizer in several tumor types (anal, cervical, head and neck, bladder), but has shown only limited benefit in the setting of re-irradiation for malignant glioma (VanderSpek et al., 2008; Glass et al., 1997). Topotecan has been shown to be efficacious in combination with radiation, both because of its synergistic effect and substantial CNS penetration. Temozolomide is an oral alkylating agent that readily crosses the blood brain barrier that has had the greatest impact on treatment of GBM (Stupp et al., 2005), and its efficacy was first found in recurrent gliomas. Continuous administration of this temozolomide appears to "deplete" the DNA repair enzyme MGMT (O6 methylguanine-DNA methyltransferase), which is increased during radiotherapy (Stupp et al., 2005). Despite these biologic correlations, clinical studies of combined modality treatment for recurrent glioma suggest limited benefit. While the morbidity experienced with combined use of systemic therapy and re-irradiation seems acceptable there do not appear to be any apparent gains in disease control or outcomes compared to re-irradiation alone (Table 23.3, Fig. 23.2). Given the limited benefit of conventional systemic therapies, there is great interest in the role of targeted molecular agents and antiangiogenic agents as our understanding of the molecular pathogenesis of gliomas increases. For malignant gliomas, agents that target Endothelial Growth Factor Receptor (EGFR), Platelet Growth Factor Receptor (PDGFR), Vascular Growth Factor Receptor (VEGFR), mammalian target of rapamycin (mTOR), farnesyltransferase, and P13k are of interest (Wen and Kesari, 2008). Malignant gliomas are known to be highly vascular tumors, expressing VEGF as an important angiogenesis factor and have some response to older, likely less potent antiangiogenic agents like Thalidomide. It is hypothesized that the normalization of abnormal blood vessels with anti-angiogenic therapy targeting

GBM (5) AA (7) AO(2)

HG (25)

60 Gy/1.8–3 Gy 30 Gy/5 Gy per per day/5 days day/5 days per per week + week chemo (20 pts)

NA

20-30 Gy (2 × 1.2 Gy per day) 60 Gy/2 Gy per 30 Gy/2 Gy per day/5 days per day/5 days per week week

Median radiation/ dose/schedule

TMZ (66%)

TMZ

TMZ

Chemotherapy

16

14

NA

Median intervala (months)

11 (received functional imaging)

163 (PTV)

NA

Median volume treated (cc)

20

7.5

9.3

Median survivalb (months)

No G 3 or 4 toxicities/necrosis(0) Grade 3 hematologic (1) Cephalgia(1) Mental degradation (1,query tumor progression) Late toxicity: NA No acute >grade 3 neuro toxicity; hematological toxicity:NA Mixed necrosis (3) Improved survival with PET (SPECT /CT/ MRI compared to CT/ MRI alone; 9 vs. 5 months) 84% previous chemotherapy for recurrence

Graded toxicity/ necrosis/comments

60 Gy/2 Gy per 25–30 Gy/5–6 Gy Topotecan NA 14.5 16.5 day/5 days per per day week OR 54.4 Gy/1.6 Gy twice daily/3.5 weeks Combs et al. GBM(8) 60 Gy/2 Gy per 36 Gy/2 Gy per TMZ 36 50 8 No severe toxicities (2008) HG(10) day/5 days per day/5 days per (PTV) Necrosis(0) week week GBM (glioblastoma multiforme), AA (anaplastic astrocytoma), AO (anaplastic oligodendroglioma), AA (anaplastic astrocytoma), AO (anaplastic oligodendroglioma), AOA (Anaplastic oligoastrocytoma), GS(gliosarcoma), GCG (giant cell glioblastoma), HG (high grade), LG (low grade), TMZ (Temozolomide), NA (not available) a Median Interval is from time from the first radiation treatment. b Median Survival is from the time of retreatment.

Wurm et al. (2006) GBM(18) GCG(2) AA(3) AOA(2)

Grosu et al. (2005) GBM(33) GS(2) AA(8) AO(1)

Schonekaes et al. (2002) Schafer et al. (2004)

Table 23.3 Reirradiation and chemotherapy First treatment r radiation (median or range)/Dose/ Author Histology (n) schedule

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either VEGF or VEGFR will increase the therapeutic benefit of radiation and chemotherapies. While it is thought that glioma stem cells produce VEGF, use of these single agent VEGF inhibiters have shown have limited benefit (Wen and Kesari, 2008). This has prompted evaluation of these agents in combination with chemotherapy. Work from Friedman et al. (2009) has resulted in the approval of bevacizumab in combination with irinotecan for use in recurrent GBM. Given these findings, potential role of targeted therapies with radiation is exciting especially for brain tumors, but we are still in the preliminary stages of our understanding. There is a suggestion that promotion of angiogenesis may occur during radiation, implying the potential benefit of combining anti-angiogenic agents during radiotherapy. In vivo and vitro studies show that exposure to radiation induces VEGF expression in several tumor cell lines and that an anti-VEGF treatment potentiates radiation induced tumor kill (Gorski et al., 1999). Blocking of VEGF-receptor 2 potentiates radiation induced tumor control in vivo human tumor xenograft of glioblastoma multiforme (U87) (Gutin et al., 2009). Gutin et al. (2009) studied the benefits of combination of 7 cycles of bevacizumab with FSRT in recurrent gliomas and reported a 6 months PFS of 65%, with 50% overall response rate. However, three out of 25 patients discontinued treatments due to grade 3 toxicities of intratumoral hemorrhage, wound dehiscence and bowel perforation (but there was no noted necrosis). Evaluation of responses of anti-angiogenic therapies may be complicated by the decreased enhancement on imaging seen with these drugs, independent of their anti-tumor effect. Thus trials evaluating these agents should include survival endpoints (such as 6 month survival) as a complement to radiographic endpoints. Another interesting advantage of combining anti-angiogenic agents is the potential reduction in necrosis suggesting that a potential protective role for this agent in combination with re-irradiation, perhaps sequentially administered given the toxicity seen with concurrent administration in the series by Gutin et al. (2009). Endothelial Growth Factor Receptors (EGFR) are involved in pathways known to cell differentiation, angiogenesis, metastatic spread, resistance to apoptotic death and thought to be expressed highly in cells resistant to radiation and chemotherapy. The majority

A. Hallock and L. VanderSpek

of glioblastomas show a deregulation as a result of mutations, overexpressions and gene amplifications in the molecular pathway involving EGFR. Small molecule inhibitors targeted against the EGFR tyrosine kinase pathways or the EGFR receptor has been evaluated in glioblastoma. For example, the epidermal growth factor receptor tyrosine kinase inhibitor (EGFR TKI), Gefitinib (ZD1839 or Iressa), has demonstrated a median survival for patients with recurrent GBM or 39.4 weeks when used as a single agent after first relapse (Schwer et al., 2008). Combination of the EGFR TKI with radiation can have potentiating effects through greater number of cells in the radiosensitive phase of the cell cycle; greater radiation induced apoptosis and decreased DNA repair mechanisms within the cancer cells. The addition of molecular targeted therapies with re-irradiation provides an exciting new therapeutic option for patients with recurrent malignant gliomas. There are too few studies to make any meaningful conclusions and even these studies report outcomes comparable other studies for salvage therapies (Table 23.4). At present, there is no clear evidence for the standard use of targeted therapies with re-irradiation. This suggests the need for further exploration into their use and identifying patients who may benefit such therapies. For example, EGFR TKI agents are small molecules and should have a theoretical benefit in terms of intracranial delivery, however, only 10-20% of GBM respond to these targeted agents. Mellinghoff et al. (2005) showed that the sensitivity of GBMs to these EFGR inhibitors was based on co-expression of EGFRvIII and PTEN, implying that therapeutic benefit may not be for all patients. There are currently phase 2 trials evaluating multi tyrosine kinase inhibitors underway to determine if therapeutic outcomes can be improved by targeting multiple molecular abnormalities. Consideration of enrolment of patients in trials evaluating molecular targeted therapies with radiation is recommended to help establish clear benefits.

Fractionated Stereotactic Reirradiation Techniques The radiation planning volumes for FSRT used in reirradiation of malignant glioma need to take into account the proximity of the lesion to eloquent areas

GBM(11) AA(4)

60 Gy/1.8–2 Gy per day/5 days per week + TMZ 18–36 Gy/6–12 Gy per day/ consecutive days

Median radiation/dose/ schedule Gefitinib (Iressa)

Target therapy 12

Median intervala (months)

41 (PTV)

Median volume treated (cc)

GBM(20) 59.4 Gy 30 Gy/6 Gy per Bevacizumab 15 34 AA(4) Fractionation: NA day/5 days per (Avastin) AO(1) week GBM (glioblastoma multiforme), AA (anaplastic astrocytoma), AO (anaplastic oligodendroglioma), AO (anaplastic oligodendroglioma) a Median Interval is from the time of first radiation treatment. b Median Survival is from the time of retreatment.

Gutin et al. (2009)

Schwer et al. (2008)

Table 23.4 Re-irradiation with molecular targeted agents First treatment radiation (median or range)/dose/ Author Histology (n) schedule

12.5

10

Median survivalb (months)

Necrosis (2): Grade 1; BCNU wafers given postoperative at recurrence for 5 patients Grade 3 CNS toxicity Necrosis(0)

Graded toxicity/ radiation(n)/comments

23 Recurrent Malignant Glioma Patients 225

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of the brain and location of the recurrence in relation to the previously radiated volume, as well as the method of immobilization, treatment planning system, and delivery techniques available at each institution which influence the accuracy of treatment delivery (Bauman et al., 2006). The typical planning process involves fabrication of any immobilization devices followed by acquisition of a volumetric computed tomotherapy (CT) scan with the patient in the immobilization device for radiation treatment planning purposes (called CT simulation). CT simulation scans are typically acquired using 3 mm slices thickness and with intravenous contrast administration for optimal delineation of the target. Typically a stereotactic image fusion is performed between the planning CT and diagnostic imaging (MRI or PET/SPECT). Most commonly the diagnostic highresolution T1-weighted MRI with Gadolinium contrast is used to assist in target volume delineation. The tumor visible on imaging is defined as the Gross Tumor Volume (GTV) and serves as the target for radiation treatment planning. For reirradiation, delineation of a region of risk (clinical target volume, CTV) surrounding the GTV (as usually performed for initial treatment to cover regions of microscopic infiltration) is omitted in order to minimize the retreated volume. The planning target volume (PTV) is intended to account for geometric errors in setup and is dependent on the immobilization system used. For example for traditional radiosurgery systems, invasive stereotactic frame systems with submillimeter localization accuracy are used, justifying the omission of a PTV margin. For relocatable frame systems, selection of a PTV margin is dependent on the system used and institutional practice. For instance, Hudes et al. (1999) defined the target volume as the contrast-enhanced tumor edge (GTV) without a PTV margin for patients immobilized in the GTC (Gill-Thomas-Cosman) frame. Others utilize a margin around the GTV, such as Schwer et al. (2008) where the PTV was defined as the GTV + 2 mm as they used a technique with patients immobilized using a custom-molded removable head frame and had documented reproducibility within 2 mm. Overall the choice of a PTV margin depends on the measured accuracy of the overall radiation delivery at each institution as well as the proximity to organs at risk and clinical judgment (Bauman et al., 2006). Acknowledgements The authors would like to thank Dr. Glenn Bauman, London Regional Cancer Program, University of

A. Hallock and L. VanderSpek Western Ontario, for his constructive feedback during the development of the chapter.

References Bauman GS, Sneed PK, Wara WM, Staplers LJA, Chang SM, McDermott MW, Gutin PH, Larson DA (1996) Reirradiation of primary CNS tumors. Int J Radiat Oncol Biol Phys 36:433–441 Bauman G, Wong E, McDermott MW (2006) Fractionated radiotherapy techniques. Neurosurg Clin N Am 17:99–110, v, 20 Butowski NA, Sneed PK, Chang SM (2006) Diagnosis and treatment of recurrent high-grade astrocytoma. J Clin Oncol 24: 1273–1280 Chan JL, Lee SW, Fraass BA, Normolle DP, Greenberg HS, Junck LR, Gebarski SS, Sandler HM (2002) Survival and failure patterns of high-grade gliomas after threedimensional conformal radiotherapy. J Clin Oncol 20: 1635–1642 Chang EL, Akyurek S, Avalos T, Rebueno N, Spicer C, Garcia J, Famiglietti R, Allen PK, Chao C, Mahajan A, Woo SY, Maor MH (2007) Evaluation of peritumoral edema in the delineation of radiotherapy clinical target volumes for glioblastoma. Int J Radiat Oncol Biol Phys 68:144–250 Chang SM, Butowski NA, Sneed PK, Garner IV (2006) Standard treatment and experimental targeted drug therapy for recurrent glioblastoma multiforme. Neurosurg Focus 20:E4 Cho KH, Hall WA, Gerbi BJ, Higgins PD, McGuire WA, Clark HB (1999) Single dose versus fractionated stereotactic radiotherapy for recurrent high-grade gliomas. Int J Radiat Oncol Biol Phys 45:1133–1141 Combs SE, Bischof M, Welzel T, Oertel S, Debus J, SchulzErtner D (2008) Radiochemotherapy with temozolomide as re-irradiation using high precision fractionated stereotactic radiotherapy (FSRT) in patients with recurrent gliomas. J Neurooncol 89:205–210 Combs SE, Debus J, Schulz-Ertner D (2007) Radiotherapeutic alternatives for previously irradiated recurrent gliomas. BMC Cancer 7:167–177 Combs SE, Gutwein S, Thilmann C, Debus J, Schulz-Ertner D (2005a) Reirradiation of recurrent WHO grade III astrocytomas using fractionated stereotactic radiotherapy (FSRT). Strahlenther Onkol 181:768–773 Combs SE, Gutwein S, Thilmann C, Huber P, Debus J, Schulz-Ertner D (2005b) Stereotactically guided fractionated re-irradiation in recurrent glioblastoma multiforme. J Neurooncol 74:167–171 Dhermain F, Ducreux D, Bidault F, Bruna A, Parker F, Roujeau T, Beaudre A, Armand JP, Haie-Meder C (2005) Use of functional imaging modalities in radiation therapy treatment planning in patients with glioblastoma. Bull Cancer 92:333–342 Ernst-Stecken A, Ganslandt O, Lambrecht U, Sauer R, Grabenbauer G (2007) Survival and quality of life after hypofractionated stereotactic radiotherapy for recurrent malignant glioma. J Neurooncol 81:287–294 Friedman HS, Prados MD, Wen PY, Mikkelsen T, Schiff D, Abrey LE, Yung WK, Paleologos N, Nicholas MK,

23 Recurrent Malignant Glioma Patients Jensen R, Vredenburgh J, Huang J, Zheng M, Cloughesy T (2009) Bevacizumab alone and in combination with irinotecan in recurrent glioblastoma. J Clin Oncol 27: 4733–4740 Glass J, Silverman C, Axelrod R, Corn B, Andrews D (1997) Fractionated stereotactic radiotherapy with cis-platinum radiosensitization in the treatment of recurrent, progressive, or persistent malignant astrocytoma. Am J Clin Oncol 20:226–229 Gòmez-Rio M, Rodriguez-Fernàez A, Ramos-Font C, LòpezRamirez E, Llamas-Elvira JM (2008) Diagnostic accuracy of 201 Thallium-SPECT and 18 F-FDG-PET in the clinical assessment of glioma recurrence. Eur J Nucl Med Mol Imaging 35:966–975 Gorski DH, Beckett MA, Jaskowiak. NT, Calvin DP, Mauceri HJ, Salloum RM, Seetharam S, Koons A, Hari DM, Kufe DW et al (1999) Blockage of the vascular endothelial growth factor stress response increases the antitumor effects of ionizing radiation. Cancer Res 59:3374–3378 Grosu AL, Weber WA, Franz M, Stark S, Piert M, Thamm R, Gumprecht H, Schwaiger M, Molls M, Nieder C (2005) Reirradiation of recurrent high-grade gliomas using amino acid PET (SPECT)/CT/MRI image fusion to determine gross tumor volume for stereotactic fractionated radiotherapy. Int J Radiat Oncol Biol Phys 63:511–519 Gutin PH, Iwamoto FM, Beal K, Mohile NA, Karimi S, Hou BL, Lymberis S, Yamada Y, Chang J, Abrey LE (2009) Safety and efficacy of bevacizumab with hypofractionated stereotactic irradiation for recurrent malignant gliomas. Int J Radiat Oncol Biol Phys 75:156–163 Halperin EC, Bentel G, Heinz ER, Burger PC (1989) Radiation therapy treatment planning in supratentorial glioblastoma multiforme: an analysis based on post mortem topographic anatomy with CT correlations. Int J Radiat Oncol Biol Phys 17:1347–1350 Hochberg FH, Pruitt A (1980) Assumptions in the radiotherapy of glioblastoma. Neurology 30:907–911 Hudes RS, Corn BW, Werner-Wasik M, Andrews D, Rosenstock J, Thoron L, Downes B, Curran WJ Jr (1999) A phase I dose escalation study of hypofractionated stereotactic radiotherapy as salvage therapy for persistent or recurrent malignant glioma. Int J Radiat Oncol Biol Phys 43:293–298 Laperriere NJ, Leung PMK, McKenzie S (1998) Randomized study of brachytherapy in the initial management of patients with malignant astrocytoma. Int J Radiat Oncol Biol Phys 41:1005–1011 Mayer R, Sminia P (2009) Reirradiation tolerance of the human brain. Int J Radiat Oncol Biol Phys 70:1350-1360 Mellinghoff IK, Wang MY, Vivanco I, Haas-Kogan DA, Zhu S, Dia EQ, Lu KV, Yoshimoto K, Huang JH, Chute DJ, Riggs BL, Horvath S, Liau LM, Cavenee WK, Rao PN, Beroukhim R, Peck TC, Lee JC, Sellers WR, Stokoe D, Prados M, Cloughesy TF, Sawyers CL, Mischel PS (2005) Molecular determinants of the response of glioblastoma to EGFR kinase inhibitors. N Engl J Med 353: 2012–2024

227 Oppitz U, Maessen D, Zunterer H, Richter S, Flentje M (1999) 3D-recurrence-patterns of glioblastomas after CT-planned postoperative irradiation. Radiother Oncol 53:53–57 Peca C, Pacelli R, Elefante A, Del Basso De Caro ML, Vergara P, Mariniello G, Giamundo A, Maiuri F (2009) Early clinical and neuroradiological worsening after radiotherapy and concomitant temozolomide in patients with glioblastoma; tumor progression or radionecrosis? Clin Neurol Neurosurg 111:331–334 Schafer U, Micke O, Schuller P, Schuck A, Willich N (2004) The effect of sequential radiochemotherapy in preirradiated malignant gliomas in a phase II study. J Neurooncol 67:233– 239 Schonekaes K, Mucke R, Panke J, Rama B, Wagner W (2002) Combined radiotherapy and temozolomide in patients with recurrent high grade glioma. Tumori 88:28–31 Schultheiss TE, Kun LE, Ang KK, Stephens LC (1995) Radiation response of the central nervous system. Int J Radiat Oncol Biol Phys 10:1109–1115 Schwer AL, Damek DM, Kavanagh BD, Gaspar LE, Lillehei K, Stuhr K, Chen C (2008) A phase I dose-escalation study of fractionated stereotactic radiosurgery in combination with gefitinib in patients with recurrent malignant gliomas. Int J Radiat Oncol Biol Phys 70:993–1001 Selch MD, DeSalles AA, Solberg TD, Wallace RE, Do TM, Ford J, Cabatan-Wong C, Withers HR (2000) Hypofractionated stereotactic radiotherapy for recurrent malignant gliomas. J Radiosurgery 3:3–12 Stupp R, Mason WP, Van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, Belanger K, Brandes AA, Marosi C, Bogdahn U, Curschmann J, Janzer RC, Ludwin SK, Gorlia T, Allgeier A, Lacombe D, Cairncross JG, Eisenhauer E, Mirimanoff RO (2005) Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352:987–996 VanderSpek L, Fisher B, Bauman G, Macdonald D (2008) 3D conformal radiotherapy and cisplatin for recurrent malignant glioma. Can J Neurol Sci 35:57–64 Veninga T, Langendijk HA, Slotman BJ, Rutten EH, van der Kogel AJ, Prick MJ, Keyser A, van der Maazen RW (2001) Reirradiation of primary brain tumours: survival, clinical response and prognostic factors. Radiother Oncol 59:127– 137 Vordermark D, Kolbl O, Ruprecht K, Vince GH, Bratengeier K, Flentje M (2005) Hypofractionated stereotactic reirradiation: treatment option in recurrent malignant glioma. BMC Cancer 5:55–59 Wen PY, Kesari S (2008) Malignant gliomas in adults. N Engl J Med 359:492–507 Wurm RE, Kuczer DA, Schlenger L, Matnjani G, Scheffle D, Cosgrove VP, Ahswede J, Woiciechowsky C, Budach V (2006) Hypofractionated stereotactic radiotherapy combined with topotecan in recurrent malignant glioma. Int J Radiat Oncol Biol Phys 66:S26–S32 Yaacov RL, Li AX, Naqa IE, Hahn C, Marks LB, Merchant TE, Dicker AP (2010) Radiation dose-volume effects in the brain. Int J Radiat Oncol Biol Phys 76:S20–S27

Chapter 24

Glioblastoma: Boron Neutron Capture Therapy Tetsuya Yamamoto, Kei Nakai, and Hiroaki Kumada

Abstract Boron neutron capture therapy (BNCT) is a unique method that can deliver tumor-cell-selective high-linear energy transfer (LET) particle radiotherapy to an extended target area encompassing a microscopic invasion while avoiding radiation damage to the surrounding normal brain tissue. The process of BNCT is based on the nuclear interaction of 10 B with thermal neutrons with the release of high LET α and 7 Li particles through the boron neutron capture reaction, 10 B(n, α) 7 Li. The very short path length (<9 μm) of α-particles and 7 Li enables high-LET irradiation of tumor cells without undesirable damage to 10 B-unloaded normal cells. Eight non-randomized prospective external beam BNCT trials for glioblastoma (GBM) have been performed over 15 years using the two currently available boron drugs and a neutron beam at a nuclear reactor. Four of the 8 studies suggested that the external beam BNCT may improve survival in newly diagnosed GBM. In addition, 4 of the 8 studies were primary phase I trials that demonstrated only modest toxicity. The median time to progression and the median survival time (MST) were 6–12 months and 12–27 months, respectively. The optimization of dosage and boron delivery agents, the combined use of different boron agents, the combination of BNCT with other therapeutic modalities and the development of a hospital-based neutron source have been studied for the improvement of BNCT. The need for more evidence-based data, either through randomized trials

T. Yamamoto () Department of Neurosurgery and Radiation Oncology, Institute of Clinical Medicine, University of Tsukuba, Tsukuba City, Ibaraki 305-8575, Japan e-mail: [email protected]

or using a prospective case control methodology, is clear from a review of the clinical reports. Keywords Glioblastoma · BNCT · Boron · MST · Radiation

Introduction Despite recent improvements in multimodal therapies, GBM, a radio-chemo-resistant malignant brain tumor, recurs within several months and progresses with a median overall survival time (MST) of less than 1–1.5 years after the initial treatment. Survival prolongation by the conventional fractionated photon radiotherapy has been demonstrated in several randomized trials; these trials used total doses of 45–60 Gy and achieved MSTs of 5.8–15.5 months (Buatti et al., 2008). Recently, the clinical trial EORTC 26981/22981-NCIC CE3 showed that postoperative conventional radiotherapy alone at a dose of 60 Gy in 30 fractions resulted in an MST of 12.1 months. Another arm, the concomitant and adjuvant use of temozolomide with conventional radiotherapy, demonstrated a significant survival advantage (MST=14.6 months) compared to conventional radiotherapy alone, and approximately 25% of the patients survived longer than 24 months (Stupp et al., 2005). The dose of radiation required to control GBM completely has not been clearly determined. In dose escalation studies using an additional stereotactic radiosurgery, fractionated proton beam radiation or other conformal radiotherapies, the MST varied from 9.5 to 26 months. Some of those studies appeared to be

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encouraging; however, they were designed as case series of small numbers of selected patients (Buatti et al., 2008). These dose-escalating studies and their failure analyses imply that at least 90 Gy must be delivered to achieve local control of GBM (Fitzek et al., 1990; Tanaka et al., 2005). Such high-dose radiation exceeds the accepted tolerance dose for conventional radiotherapy of normal brain tissue. Thus, high-dose radiation should be delivered more selectively for the main tumor mass as well as for wide-spreading microscopic invasion, avoiding radiation damage to the surrounding normal brain. This requirement would seem to be beyond the abilities of current 3-D conformal radiation methods, such as stereotactic radiation therapy (SRT), intensity modulated radiation therapy (IMRT) and image-guided radiation therapy (IMGT), because tumor-cell-selectivity at the microscopic level is needed.

Boron Neutron Capture Therapy (BNCT) Boron neutron capture therapy (BNCT) is a unique method that can deliver tumor-cell-selective highlinear energy transfer (LET) particle radiotherapy to an extended target area encompassing the microscopic invasion while avoiding radiation damage to the surrounding normal brain tissue. Theoretically, BNCT allows the preferable destruction of boron-10 (10 B)loaded tumor cells while sparing normal tissue without 10 B. The process is based on the nuclear reaction between 10 B and thermal neutrons, which releases high LET α and 7 Li particles through the boron neutron capture reaction, 10 B(n, α) 7 Li (Fig. 24.1). The very short path length (<9 μm) of α-particles and 7 Li enables high-LET irradiation of tumor cells without undesirable damage to 10 B-unloaded normal cells. Although thermal neutrons can be captured more efficiently by 10 B nuclei, epithermal (high-energy) neutrons are essential for the external beam BNCT, because thermal neutrons have limited penetrability in tissue. Epithermal neutrons are moderated in the scalp and cranial tissues and become thermal neutrons, losing their energy. To deliver 10 B, two boron drugs, p-dihydroxyboryl-phenylalanine (BPA) and sulfohydryl borane Na2 B12 H11 SH (BSH), are currently available for BNCT clinical studies (Fig. 24.1).

T. Yamamoto et al.

Fig. 24.1 Neutron capture reaction of 10 B (upper) and currently available boron delivery agents: boronophenylalanine p-dihydroxyboryl-phenylalanine (BPA, lower left) and borocaptate sodium sulofhydryl borane Na2 B12 H11 SH (BSH, lower right). BNCT is based on the nuclear reaction between 10 B and thermal neutrons, which releases high linear energy transfer (LET) α and 7 Li particles through the boron neutron capture reaction, 10 B(n, α) 7 Li. The effectiveness of BNCT is highly dependent on selective 10 B accumulation in tumor cells, as well as sufficient thermal neutrons even at depth

To determine the eligibility of a patient for BNCT, the 10 B concentration in the tumor and normal brain tissue has to be estimated. 18 F-labeled positron emission tomography (PET) can be used to calculate the lesion-to-normal (L/N) ratio of BPA to estimate the dose necessary for the tumor. The uptake in 11 C-Methionine-PET is shown to have a linear correlation with that of 18 F-BPA-PET (Fig. 24.2), indicating the potential application of 11 C-methionine-PET for the dose planning and candidate selection for BNCT (Nariai et al., 2009). Boron delivery agents such as BSH and/or BPA are administered intravenously before neutron irradiation. Blood samples are drawn serially after intravenous injection of boron agent to measure the blood boron level by inductively coupled plasma-atomic emission spectroscopy (ICP-AES) or by prompt gamma ray analysis (PGA). In the typical BNCT, epithermal neutron beam irradiation is performed at a research reactor, normally in a single fraction, following the boron drug administration (Fig. 24.3).

24 Glioblastoma: Boron Neutron Capture Therapy Fig. 24.2 11 C-Methionine-PET (left) and 18 F-BPA-PET (right) of the left frontal GBM. Similar uptake is shown at the posteromedial wall of the surgical cavity

Fig. 24.3 Neutron irradiation room and head positioning at JRR-4. The patient’s head position is fixed under a laser-guided positioning device in the neutron irradiation room. The figure also shows the relation between the beam direction and the patient’s head

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Clinical Studies of BNCT The previous clinical data suggest that BNCT is effective as a post-operative adjuvant treatment for GBM. The clinical trials of BNCT for newly diagnosed GBM, which consisted of several small, non-randomized series, revealed that the median time to progression varies from 6 to 12 months and the MST varies from 12 to 27 months (Yamamoto et al., 2009). The most favorable survival data of the external beam BNCT appear to be comparable with the best results of the recent studies of high-dose radiotherapy, which show an MST of 19–26 months (Buatti et al., 2008). The results of 4 of the 8 prospective studies, even within subgroups of the patient population, suggest that BNCT may improve survival in newly diagnosed GBM. The other 4 primary phase I trials demonstrate only modest toxicity, but failed to demonstrate survival prolongation (Table 24.1). The need for more clinical data, either through randomized trials or using a prospective case control methodology, is obvious after reviewing these clinical reports. Because of the limited penetrability of neutron beams, the early clinical trials of BNCT were performed intraoperatively under craniotomy. External beam BNCT using epithermal neutrons with greater penetrability was initiated in 1994. In this clinical trial, 53 GBMs were irradiated using 1, 2 or 3 irradiation fields to evaluate the safety and effectiveness of external beam BNCT at the Brookhaven National Laboratory (BNL) (Chanana et al., 1999; Diaz, 2003). The best MST of 14.8 months was found in the onefield BNCT cohort. The MST of 13 months for all 53 subjects was unfavorable, but this initial applications of a single-fraction, BPA-mediated BNCT were well tolerated by patients with GBM. Two-hour intravenous injection of BPA-F at a dose of 250–330 mg/kg caused no major adverse events; however, BPA precipitates in the urine were found in patients receiving 330 mg/kg. One of the 17 subjects treated using 2 fields and 4 of the 10 subjects treated using 3 fields had grade 3 radiation toxicity, such as somnolence with or without motor weakness, expressive aphasia, or ototoxicity (Diaz, 2003; Coddere et al., 2004). A similar BPA-mediated BNCT clinical trial for GBM was carried out at the Harvard/Massachusetts Institute of Technology (MIT) between 1996 and 1999 using

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1 fraction or 2 fractions on consecutive days and 1–3 fields depending on the size and location of the tumor (Busse et al., 2003). No adverse event was found in relation to the intravenous injection of 250 mg/kg over 1 h, 300 mg/kg over 1.5 h, or 350 mg/kg over 1.5 h. The tumors with volumes >60 cm3 and <60 cm3 were associated with a 67 and 19% incidence of developing grade 3 or higher toxicity, respectively. The MST in that clinical trial was 12 months. The Finnish phase I/II trial conducted by Helsinki University Central Hospital and the VTT (Technical Research Centre of Finland) showed that a BPA dose level of 450 mg/kg was optimal for further BNCT studies of newly diagnosed GBM (Joensuu et al., 2003; Kankaanranta et al., 2007, 2008). BPA of 290 mg/kg was infused over 2 h in the first 12 patients suffering from GBM using 2 fields, and the BPA dose to subsequent patients was escalated from 330 mg/kg (n = 1) to 360 mg/kg (n = 3), 400 mg/kg (n = 3), 450 mg/kg (n = 3), or 500 mg/kg (n = 8). The maximum tolerated dose was reached at a BPA dose level of 500 mg/kg, where grade 3 (n = 2) and grade 4 (n = 1) CNS toxicity was found. The median OS values for the dose groups of 290, 330/360, 400, 450, and 500 mg BPA/kg were 13.4, 11.0, 16.9, 21.9 and 14.7 months, respectively. A BSH-mediated BNCT clinical trial was performed at the Petten Irradiation Facility, Netherlands (EORTC trial 11961). The BSH was applied 4 times using a dose suitable for reaching 30 ppm 10 B in blood over the total irradiation time, and the epithermal neutron beam was delivered in 4 fractions on 4 consecutive days. On the first day all patients received 100 mg BSH/kg bodyweight. No dose-related side effects were observed and the limiting radiation dose was not reached in that dose-escalation study. The mean survival for the dose groups varied from 10.4 to 13.2 months (Wittig et al., 2002). The study showed the feasibility and safety of a fractionated BNCT application using BSH at a dose of 100 mg/kg infused at a dose rate of 1 mg/kg/min. BSH-mediated BNCT was also studied at the NRI in Rez with an infusion of 100 mg BSH/kg and was well tolerated with only modest toxicity (Burian et al. 2002). Preclinical data suggest that a longer infusion time may improve the homogeneity of boron accumulation in tumors in BPA-mediated BNCT. This method was applied to the phase II clinical trial

26 (1997–2002), 58 years

30 (1999–2005), 55.5 years for 18 pts 29 (2001–2003), 53 years 5 (2001–),

10 (Protocol 1: 2002–2004), 59 years 11 (Protocol 2: 2004–2006), 47.5 years

EORTC 11961, Phase I

University of Helsinki and VTT, Phase I/II Studsvik, Phase II

Osaka Medical College, Phase II

7.0–15.5/3.3– 6.1 Gy 14.2 >/2 Gy

8.6–11.4 Gya (physical boron dose)/ND 8.1–13.5/3–6 Gy

8.7–16.4/2.7–7.4

8.4–14.8/1.8–8.5

BPA:250 mg/kg, 1 h Prescribed peak BSH:100 mg/kg, dose 13 Gy> 1h BPA:700 mg/kg, 6 h Prescribed peak BSH:100 mg/kg,1 h dose 15 Gy >

BSH:100 mg/kg, 1 h

BPA: 290–500 mg/kg, 2h BPA: 900 mg/kg, 6 h

BPA: 250–330 mg/kg, 2h BPA: 250–350 mg/kg, 1–2 h BSHc : 100 mg/kg/min

14.1

23.5

26.9–65.4

ND

21.9 for 450 mg/kg cohort 14.2e

13.2 for 10.4 Gy cohortd

13 (1 field: 14.8, 2 fields: 12.1, 3 fields: 11.9) 12

16.3–63.0

ND

15.5–54.3

ND

ND

18–55 (data from 38 of 53 subjects) 7.3–24.8

Studsvik AB Sweden LVR-15, NRI Rez, Czech Republic KUR, KURRI and JRR-4, JAEA, Japan

Single fraction (No) Single fraction (No) Single fraction (No) Single fraction (20–30 Gy/10– 20 fraction) Single fraction (30 Gy/15 fr or 30.6 Gy/17 fraction)

Fir1, Helsinki, Finland

HFR, Petten, the Netherlands

MITR-II, M-67, MIT, USA

BMRR, BNL, USA

Reactor, institute, country

Single fraction (No)

4 fractions (No)

1 or 2 fractions (No)

Single fraction (No)

Neutron irradiation, (photon radiation)

University of 8 (1998–2007), 65 BPA:250 mg/kg,1 h 8.4–14.1/2.5–3.4 15.5–42.5 27.1/11.9 JRR-4, JAEA, Tsukuba and years BSH:5 g/body,1 h Japan JAEA, Phase I/II a Weighted dose D w b Includes 2 melanomas. Patients underwent BNCT at MITR-II c Four fractions on consecutive days, 100 mg/kg was administered the first day, and this dose was sufficient to keep the average blood concentration at 30 μg/g during treatment days 2–4 d Mean survival time for the 3rd dose group e Survival time calculated from the BNCT treatment

NRI Rez, Phase I

Harvard/MIT, Phase I

53 (1994–1999), (56.5 years for 1 field) 20 (1997–1999)b , 56 years

BNL, Phase I/II

Table 24.1 Summary of currently underway or recently completed external beam BNCT clinical trials for newly diagnosed GBM Number of evaluated Minimum tumor patients (year), Normal brain Median survival dose in GTVa median age of Boron drug: dose, dosea peak/ave. Trial (reference) (Gy) (months) (Gy) patients infusion time

24 Glioblastoma: Boron Neutron Capture Therapy 233

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at the Studsvik BNCT facility for 29 patients suffering from GBM, who received 900 mg/kg BPA-F in a 6-h infusion. The minimum dose to the tumor volume and to the target volume (defined as tumor plus edema plus a 2 cm margin) ranged from 15.4 to 54.3 Gy and 8.8 to 30.5 Gy, respectively. Four patients developed grade 3–4 toxic events including epileptic seizures, hematuria, thrombosis and erythema. The median time from BNCT treatment to tumor progression was 5.8 months, and the MST after BNCT was 14.2 months, suggesting the survival benefit of long-time infusion compared to conventional 2-h infusion in BPA administration (Henriksson et al., 2008; Sköld et al., 2009). The combined use of BPA and BSH was based on experimental data that showed different uptake characteristics of the cell-cycle dependency of tumor cells (Yoshida et al., 2002). Other experimental data have also suggested that the combination of BNCT and photon radiation leads to significant gains in survival (Barth et al., 2005). In the trial conducted by Osaka Medical College, the first 10 patients suffering from GBM were administered 100 mg/kg of BSH and 250 mg/kg of BPA in a 1-h infusion (protocol 1), and the latter 11 patients were administered 100 mg/kg of BSH and 700 mg/kg of BPA in a 6-h infusion (protocol 2). X-ray irradiation was added in protocol 2 for a total dose of 20–30 Gy. The MSTs for all patients and for protocol 2 patients were 15.6 and 23.5 months, respectively (Kawabata et al., 2008). In the trial at the University of Tsukuba and Tokushima University at Japan Research Reactor No.4 (JRR-4) of the Japan Atomic Energy Agency (JAEA), a low dose (250 mg/kg) of BPA was administered over 1 h, and 5 g BSH/kg bodyweight was infused over 1 h in 8 patients with a single irradiation field. These patients received additional photon radiation to the volume which was defined as a peritumoral high intensity in the T2-weighted MRI after completion of BNCT. The median OS and the time to progression were 27.1 and 11.9 months, respectively. The 1-year and 2-year survival rates were 87.5 and 62.5%, respectively. The small group of patients showed good tolerance to the treatment and there were no severe acute or subacute adverse events. Although it is not certain whether additional photon irradiation could play a role in the clinical response to BNCT, the survival of this small cohort seems to be favorable evidence (Yamamoto et al., 2009).

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Boron Compounds for Clinical BNCT Successful BNCT is dependent on the selective accumulation and absolute level of 10 B atoms in tumor cells. There are two boron delivery agents available for clinical BNCT trials for high-grade glioma, BPA and BSH (Fig. 24.1). Boron is an essential plant nutrient, and necessary for the optimal health of mammals as a rare element, that may be beneficial for bone growth and maintenance, central nervous system function, and the inflammatory response, though its physiological role in mammals is not yet fully understood. Natural boron consists of 80% 11 B and 20% 10 B, and the latter 10 B isotope has high efficiency in capturing thermal neutrons to generate the boron neutron capture reaction,10 B(n, α) 7 Li (Nielsen, 2009). BPA, the amino acid analogue, is remarkably nontoxic. Large doses have been administered to experimental animals without perturbing hematopoietic, hepatic or renal function (FDA-IND #43,317). BPA has structural characteristics similar to those of a melanin precursor, and promising clinical results were shown in the pilot study of BNCT for skin melanoma (Coderre et al., 2003). BPA is usually administrated intravenously as a soluble fructose complex, BPA-F, at doses ranging from 250 mg BPA/kg to 900 mg BPA/kg. BPA can penetrate across the blood-brain barrier into the normal brain, and is actively transported through the tumor cell membrane due to the elevated rate of amino acid transport in proliferating cells. The average macroscopic concentration of boron in tumor is 2–4 times higher than that in blood. However, non-proliferating cells escape the radiation damage following BNCT. The primary mode of BSH distribution is passive diffusion from blood to tumor tissue via the disrupted blood brain barrier. The boron concentration in the normal brain with an intact blood brain barrier remains minimal, while the tumor 10 B concentration is related to both the tumor vessel density and blood 10 B level. A tumor-to-blood boron concentration ratio ranging from 0.5 to 1.0 has been reported in human patients treated with BSH-mediated BNCT. The recent clinical trials have used a combination of BPA and BSH with the intention that these different compounds would accumulate in different subpopulations of tumor cells (Yamamoto et al., 2008).

24 Glioblastoma: Boron Neutron Capture Therapy

New Boron Compound and Delivery System Previous studies showed that a boron concentration of approximately 20–40 μg10 B/g tissue, or 109 10 B atoms/cell, could control the tumor progression. The coefficient rate of BSH is low, thus only 2% or less of the total amount administered participated in the neutron capture reaction in the irradiation field. Roughly translated, these results mean that these agents must be as safe as H2 O or glucose, because the required intracellular boron level could be achieved by drug administration on the order of grams. This is one of the reasons why the development of new boron compounds is difficult. The required characteristics for BNCT agents are as follows: (a) non-toxic at the clinically effective dose; (b) the achievement of at least 10–30 μg10 B/g of tumor; (c) high tumor/brain and tumor/blood concentration ratios; (d) rapid clearance from blood circulation and normal tissues but persistence in tumor; (e) water solubility; and (f) chemical stability (Coderre et al., 2004; Barth et al., 2005). To date, a variety of boron delivery agents have been investigated, including porphyrins, amino acids, polyhedral borane, carbohydrates, polyamines, biochemical precursors, DNA-binding agents, antisense agents, peptides, liposomes and monoclonal antibodies. Low molecular weight boron agents are peptides, porphyrins, amino acids such as BPA or carborane derivatives such as BSH. The high molecular weight group contains boronated antibodies and proteins. Liposomes are categorized independently of boron delivery systems. BOPP, a boronated porphyrin, and GB-10, polyhedral borane Na2 B10 H10 , have been evaluated for their pharmacokinetics in humans. A phase I trial for potential application of BOPP to photodynamic therapy was interrupted because of its general toxicity. Recently, improvement of the synthesis pathway and novel agents such as porphyrin-cobaltacarborane conjugates or 10 B-enriched carboranyl-containing phthalocyanine have been under examination. GB-10 has been proposed as a boron neutron capture agent for an additional dose in fast neutron therapy. In a trial in which GB-10 was used in 15 lung cancer patients, no major toxicity was recorded. Using the principle of antibody-antigen reaction for active tumor targeting, numerous molecular target

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drugs were developed and are clinically used at present. Nevertheless, with respect to boron delivery, this method does not achieve a high cellular concentration of boron, even with the high selectivity and specificity. Most drug delivery systems (DDS) applied to BNCT are liposomal delivery systems. Such liposoms may include a solution containing a high concentration of boron, or boron-containing lipids. Active targeting is achieved by modifying the surface molecules. The current marketing of several liposomal anticancer agents and photodynamic therapy agents for macular degeneration shows the steady growth of the technical improvements in this field. Direct intratumoral injection and convectionenhanced delivery require the use of a pump to achieve a pressure gradient and establish the bulk flow of boron-containing agents during the interstitial infusion. Blood brain barrier disruption with hyperosmotic mannitol or receptor-mediated permeabilizer-7 (CMP7), have helped to achieve high tumor boron concentrations in experimental animals (Yang et al., 2009). Recent reports have revealed that preloading with LDOPA increases the uptake of BPA, that buthionine sulfoximine may similarly enhance the uptake of BSH, and that tumor growth is delayed following administration of either agents and neutron irradiation (Capuani et al., 2008; Yoshida et al., 2008).

Neutron Beam Facilities for BNCT The first clinical trials of BNCT for malignant brain tumors were performed at the Brookhaven Medical Research Reactor (BMRR) of BNL from 1959 to 1961. Another group of patients with malignant gliomas was treated using the reactor at MIT over the same period. Several research reactors, such as the Hitachi Training Reactor, Musashi Institute of Technology Research Reactor (MuITR), Kyoto University Research Reactor (KUR) and Japan Research Reactor No. 2 (JRR-2) in JAEA, have been applied to clinical studies in Japan. In these early BNCT trials, a low energy thermal neutron beam was used for the irradiation. To deliver thermal neutrons to deeper regions of the brain, the BNCT procedure included craniotomy, such as skin flap reopening and bone removal. Since 1994, external beam BNCT using epithermal neutron beams was initiated using the BMRR and the High Flux

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T. Yamamoto et al.

Fig. 24.4 Cross-section of the neutron irradiation facility of Japan Research Reactor No. 4 (JRR-4) (upper) and process flow of the BNCT dose planning system JCDS and the setting simulation (lower)

Reactor (HFR) in Petten, the Netherlands. By using epithermal neutron beams the therapeutic range was expanded more deeply into the brain, compared to that of the thermal neutron beam irradiation, and with the application of the epithermal neutron beam it became possible to perform non-operative irradiation (Yamamoto et al., 2008). At present, neutron beams exclusively for use in BNCT are available at JRR-4 (JAEA, Japan), KUR (Kyoto University, Japan), LVR-15 (NRI Rez, Czech Republic), Studsvik AB (Sweden), Fir1 (Finland), HFR (Petten, the Netherlands), MITR-II and M-67 (MIT, USA), and the TRIGA reactor (Palva, Italy).

JRR-4 in JAEA can generate a thermal neutron beam as well as an epithermal neutron beam (Fig. 24.4). Neutron beam facilities consist of several neutron spectrum control devices, such as a heavy water tank, cadmium shutter, bismuth filter or collimator. The heavy water tank has four separated heavy water layers. The heavy water thickness in the tank can be changed by filling the corresponding layers with heavy water. And the cadmium shutter can be put in or out at the beam line. When the cadmium shutter is put at the beam line, the beam facility generates an epithermal neutron beam. The bismuth filter is installed at the beam line to reduce gamma-rays from the reactor

24 Glioblastoma: Boron Neutron Capture Therapy

core. The utilization of the heavy water tank and the cadmium shutter enables the generation of neutron beams appropriate for the patient’s disease condition. The BNCT clinical trial for malignant brain tumors using the facility of JRR-4 was initiated in 1999 using a thermal neutron beam, including craniotomy, and beginning in 2003 this treatment was switched to external beam BNCT with an epithermal neutron beam (Yamamoto et al., 2009). The epithermal neutron beam allowed the performance of clinical trials for other cancers, including head-and-neck and pulmonary tumors (Kankaanranta et al., 2007; Haginomori et al., 2008). Now the thermal neutron beam is used only for shallow-seated tumors such as skin melanomas.

Treatment Planning System The treatment planning for BNCT differs markedly from the planning for photon or electron irradiation in conventional radiotherapy and, in some ways, is significantly more complex. The boron neutron capture reaction provides a tumor-selective boron dose, 10 B(n, α) 7 Li, while other non-selective dose components are present and consist of proton recoils due to fast neutrons, 1 H(n, n )p, 0.54 MeV protons from the nitrogen capture reaction, 14 N(n, p)14 C, γ-rays arising from the contamination in the primary beam and 2.2 MeV prompt γ-rays from the hydrogen capture. Treatment planning for BNCT involves computation and analysis of these different components of radiation doses and their distribution in a patient to determine the neutron beam orientation and radiation fluence enabling the delivery of an optimized radiation dose and distribution. The optimized combination will comply with the dose prescription, optimize the dose to the target volume, and respect the dose limits to normal tissues and organs at risk. The therapeutic advantage in BNCT is obtained principally through the tumor-selectivity of a neutron capture agent (e.g., 10 B) rather than through precise geometric targeting of multiple well-collimated radiation fields onto the target volume. In conventional photon radiotherapy, only a single low-LET dose component must be computed, the dose from primary photons or electrons, both of which are ultimately delivered by electrons. In contrast, in BNCT the radiation field is a complex mixture of high- and low-LET dose components with varying biological

237

effectiveness that depends on both the tissue and the chemical form of the neutron capture agent. The spatial distribution of each dose component is different and depends on the tissue composition, as well as the neutron and photon fluence spectra. Three BNCT treatment planning systems (TPSs) have been reported and are being applied to clinical trials NCTPlan, SERA and JCDS (Nigg, 2003; Kumada et al., 2007). All three TPSs are noncommercial and have been developed by small research teams, usually with expertise in nuclear engineering. The NCTPlan was developed at MIT and is being applied for the treatment planning of BNCT at MITR and the RA-6 reactor in Argentina. SERA was developed by the Idaho National Engineering and Environmental Laboratory (INEEL) and Montana State University (MSU) in the USA. The system has been used for the planning of BNCT studies that are being performed at the FiR-1 reactor in Finland and KUR in Japan. JCDS was developed by JAEA to perform BNCT at JRR-4, and the system is still being developed in order to improve the dose calculation accuracy (Kumada et al., 2007; 2009). The treatment planning procedure using BNCT TPSs is almost the same as that of the conventional TPSs for photon radiotherapy, and the user interface of TPSs is also similar to that of photon radiotherapy. The algorithms generally used for dose calculations in clinical photon radiotherapy are computationally efficient, simple, and empirical. On the other hand, BNCT TPSs exclusively rely on a Monte Carlo simulation for dose calculations because of the complex, scatterdominated nature of the radiation transport processes involved. Figure 24.4 shows the outline of the procedure for BNCT treatment planning with JCDS. In the process of computational dosimetry, a patient’s CT and MRI images are first used to create a 3-dimensional model. The CT images are used to automatically differentiate compositions of the human body into bone, soft tissues and air according to their CT values. On the other hand, the MRI data are used to define several regions of interest (ROIs), such as the tumor region and organs at risk. By superimposing the MRI images onto the CT images, a detailed 3D model incorporating the information on body composition and ROIs is created. The latest version of JCDS can deal with PET images in addition to CT and MRI images to pick out tumor regions in accordance with the T/N ratio on PET images. To compute the distributions of several dose

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components and neutron fluxes in the body effectively, the detailed 3D model is converted into a voxel calculation model. The initial version of the JCDS made the voxel calculation model by dividing the space into 10 × 10 × 10 mm3 voxel cells that contain the proper material data in each. JCDS has been improved continuously to perform more accurate dosimetry, and the current version of JCDS can produce a voxel calculation model of 2 × 2 × 2 mm3 voxel cells. The distributions of the dose components and fluxes in the voxel model are determined by Mote Carlo transport calculation. JCDS evaluates the detailed distributions of the dose components based on the calculation results, and outputs a two-dimensional distribution superimposed on CT or MRI. Finally, physicians decide the irradiation conditions for the patient based on the JCDS results. In conclusion, BNCT is the most complicated radiotherapy; however, it may one day be a valuable alternative treatment in cases of GBM that invades the surrounding healthy normal brain. BNCT seems to be preferable to currently existing high-dose radiotherapies, since in theory it allows tumor-cell-selective high-dose particle radiation while sparing normal cells. It remains uncertain whether BNCT can control GBM sufficiently and lead to distinct survival benefits because of the limitations of the present clinical trials, which include the lack of a contemporary control arm. Randomized trials of comparably selected patients are required to demonstrate the efficiency of this emerging modality more conclusively. To improve the effectiveness of BNCT, several critical issues must be addressed. Single or combined use of currently available boron agents must be optimized, and more tumor-selective boron agents and/or delivery or targeting systems are needed. The combined use of photon irradiation, chemotherapy, immunotherapy, and/or molecular targeting therapy with BNCT should also be evaluated. Finally, the development of an accelerator-based neutron source could lead to an in-hospital BNCT, which would greatly enhance both basic and clinical research on BNCT. Acknowledgments This study was supported in part by a Grant-in-Aid for Society Collaboration from the Ministry of Education, Science and Culture of Japan (20390379). We thank Professor Akira Matsumura, Dr. Tadashi Nariai and Dr. Alexander Zaboronok for their kind support in the manuscript preparation.

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24 Glioblastoma: Boron Neutron Capture Therapy (2008) Boron neutron capture therapy (BNCT) for glioblastoma multiforme: A phase II study evaluating a prolonged high-dose of boronophenylalanine (BPA). Radiother Oncol 88:183–191 Joensuu H, Kankaanranta L, Seppälä T, Auterinen I, Kallio M, Kulvik M, Laakso J, Vähätalo J, Kortesniemi M, Kotiluoto P, Seren T, Karila J, Brander A, Järviluoma E, Ryynänen P, Paetau A, Ruokonen I, Minn H, Tenhunen M, Jääskeläinen J, Färkkilä M, Savolainen S (2003) Boron neutron capture therapy of brain tumors: clinical trials at the Finnish facility using boronophenylalanine. J Neurooncol 62:123–134 Kankaanranta L, Koivunoro H, Kortesniemi M, Välimäki P, Seppälä T, Kotiluoto P, Auterinen I, Kouri M, Savolainen S, Joensuu H (2008) BPA-based BNCT in the treatment of glioblastoma multiforme In: Zonta A, Altieri S, Roveda L, Barth R (eds) A dose escaration study. Proceedings of the 13th international congress of neutron capture therapy. ENEA, p 30 Kankaanranta L, Seppälä T, Koivunoro H, Saarilahti K, Atula T, Collan J, Salli E, Kortesniemi M, Uusi-Simola J, Mäkitie A, Seppänen M, Minn H, Kotiluoto P, Auterinen I, Savolainen S, Kouri M, Joensuu H (2007) Boron neutron capture therapy in the treatment of locally recurred head and neck cancer. Int J Radiat Oncol Biol Phys 69:475–482 Kawabata S, Miyatake S, Kuroiwa T, Yokoyama K, Doi A, Iida K, Miyata S, Nonoguchi N, Michiue H, Takahashi M, Inomata T, Imahori Y, Kirihata M, Sakurai Y, Maruhashi A, Kumada H, Ono K (2008) Boron neutron capture therapy for newly diagnosed glioblastoma. J Radiat Res (Tokyo) 50:51–60 Kumada H, Nakamura T, Komeda M, Matsumura A (2009) Development of a new multimodal Monte-Carlo radiotherapy planning system. Appl Radiat Isot 67:118–121 Kumada H, Yamamoto K, Matsumura A, Yamamoto T, Nakagawa Y (2007) Development of JCDS, a computational dosimetry system at JAEA for boron neutron capture therapy. J Phy Conf Ser 74:1–7 Nariai T, Ishiwata K, Kimura Y, Inaji M, Momose T, Yamamoto T, Matsumura A, Ishii K, Ohno K (2009) PET pharmacokinetic analysis to estimate boron concentration in tumor and brain as a guide to plan BNCT for malignant cerebral glioma. Appl Radiat Isot 67:S348–S350 Nielsen FH (2009) Micronutrients in parenteral nutrition: boron, silicon, and fluoride. Gastroenterology 137:S55–S60 Nigg DW (2003) Computational dosimetry and treatment planning considerations for neutron capture therapy. J Neurooncol 62:75–86

239 Sköld K-H, Stenstam B, Diaz AZ, Giusti V, Pellettieri L, Hopewell JW (2009) Boron neutron capture therapy for glioblastoma multiforme: advantage of prolonged infusion of BPA-f. Acta Neurol Scand. [Epub ahead of print] Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJB, Belanger K, Brandes AA, Marosi C, Bogdahn U, Curschmann J, Janzer RC, Ludwin SK, Gorlia T, Allgeier A, Lacombe D, Cairncross JG, Eisenhauer E, Mirimanoff RO (2005) Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352:987–996 Tanaka M, Ino Y, Nakagawa K, Tago M, Todo T (2005) High-dose conformal radiotherapy for supratentorial malignant glioma: a historical comparison. Lancet Oncol 6: 953–960 Wittig A, Hideghety K, Paquis P, Heimans J, Vos M, Goetz C, Haselsberger K, Grochulla F, Moss R, Morrissey J, BourhisMartin E, Rassow J, Stecher-Rasmussen F, Turowski B, Westler M, deVris MJ, Fankhauser H, Gabel D, Sauerwein W (2002) Current clinical results of the EORTC-study 11961. In: Surewein W, Moss R, Wittig A (eds) Research and development in neutron capture therapy. Monduzzi Editore, Bologna, pp 1117–1122 Yamamoto T, Nakai K, Kageji T, Kumada H, Endo K, Matsuda M, Shibata Y, Matsumura A (2009) Boron neutron capture therapy for newly diagnosed glioblastoma. Radiother Oncol 91:80–84 Yamamoto T, Nakai K, Matsumura A (2008) Boron neutron capture therapy for glioblastoma. Cancer Lett 262: 143–152 Yang W, Barth RF, Wu G, Huo T, Tjarks W, Ciesielski M, Fenstermaker RA, Ross BD, Wikstrand CJ, Riley KJ, Binns PJ (2009) Convection enhanced delivery of boronated EGF as a molecular targeting agent for neutron capture therapy of brain tumors. J Neurooncol 95:355–365 Yoshida F, Matsumura A, Shibata Y, Yamamoto T, Nakauchi H, Okumura M, Nose T (2002) Cell cycle dependence of boron uptake from two boron compounds used for clinical neutron capture therapy. Cancer Lett 187:135–141 Yoshida F, Yamamoto T, Nakai K, Kumada H, Shibata Y, Tsuruta W, Endo K, Tsurubuchi T, Matsumura A (2008) Combined use of sodium borocaptate and buthionine sulfoximine in boron neutron capture therapy enhanced tissue boron uptake and delayed tumor growth in a rat subcutaneous tumor model. Cancer Lett 263: 253–258

Chapter 25

Glioblastoma: Anti-tumor Action of Cyclosporin A and Functionally Related Drugs Bozena Kaminska, Magdalena Tyburczy, Konrad Gabrusiewicz, and Malgorzata Sielska

Abstract Human malignant gliomas are highly resistant to current therapeutic approaches. Major signaling pathways that have been identified as playing important roles in glioblastomas are: the PTEN/PI3K/Akt/mTOR and the Ras/Raf/MEK/ERK signaling cascades, which support cell invasion, survival and prevent apoptosis. In the face of tumor resistance to apoptosis, novel agents which can overcome resistance or/and affect cell survival by nonapoptotic mechanisms such as necrosis, senescence, autophagy and mitotic catastrophe, are highly desirable. The present chapter focuses on anti-tumor action of cyclosporin A (CsA) and rapamycin that besides their well known immunosuppressive abilities appear to be multitarget kinase inhibitors and moderately effective anti-tumor agents in glioblastomas in vitro, in vivo and in clinical trials. A compelling evidence shows that cyclosporin A induces growth arrest and programmed cell death in cultured rat and human glioblastoma cells. The molecular mechanism involves accumulation of a cell cycle inhibitor – p21Cip1/Waf1, even in the absence of functional p53 tumor suppressor. In C6 glioma cells with functional TP53 and PTEN tumor suppressors CsA treatment up-regulates fasL expression, activates p53 and intrinsic mitochondrial death pathway, while in human glioblastoma cells with defects in either TP53 or PTEN, none

of those effects were observed. Molecular analysis revealed that CsA, trough yet unknown mechanisms, down-regulates PI3K/Akt and mTOR signaling pathways in glioblastoma cells, and interferes with proinvasive activity of tumor-infiltrating microglia. A systemically applied CsA significantly reduced growth of intracranial gliomas, tumor invasion and angiogenesis. Pharmacological inhibitors of the mTOR pathway: rapamycin, temsirolimus, everolimus and AP23573 were tested as potential targeted drugs in human glioblastoma cultures and in animal models. However, rapamycin and derivatives show moderate efficacy in patients with recurrent glioblastoma multiforme, they deserve further clinical studies, particularly in combination with PI-3K pathway inhibitors. Defects of innate and adaptive immunity are common in glioblastoma patients contributing to a lack of effective anti-tumor responses. Thus, immunosuppressants such as CsA, rapamycin and its derivatives may be an effective novel strategy to treat drug-resistant gliomas or complement apoptosis based-therapies. Keywords Glioblastomas · Anti-tumor drugs · Immunosuppressants · Apoptosis · Rapamycin · Inhibitors

Introduction B. Kaminska () Laboratory of Transcription Regulation, Department of Cell Biology, Nencki Institute of Experimental Biology, 02-093 Warsaw, Poland e-mail: [email protected]

Glioblastomas are the most frequent and devastating primary malignant brain tumor in adults. Glioblastomas are highly resistant to current therapeutic approaches, in which surgery is followed

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by radiotherapy with concomitant and adjuvant chemotherapy. The prognosis remains poor with a median survival in the range of 12–15 months (Clarke et al., 2010). Common genetic abnormalities in glioblastoma are associated with multiple molecular mechanisms involved in drug resistance, including drug detoxification, aberrant activation or suppression of cellular signal transduction pathways, deficiencies in tumor suppressors, apoptosis mediators and death ligand/receptor signaling. Significantly high frequency of alterations in cell cycle regulators such as the TP53 tumor suppressor and the p16INK4A cyclin dependent kinase inhibitor results in reduced sensitivity to a majority of anti-cancer drugs (Ohgaki and Kleihues, 2009). Major signaling pathways that have been identified as playing important roles in glioblastomas are: the PTEN/PI3K/Akt/mTOR and the Ras/Raf/MEK/ERK signaling cascades, which support cell proliferation, survival, invasion, and prevent apoptosis (McCubrey et al., 2006). Components of these pathways are frequently mutated, aberrantly expressed or constitutively activated in glioblastomas. Monoclonal antibodies or small molecular-weight kinase inhibitors targeting specific pathways are the most common classes of agents in cancer treatment. However, highly selective or specific blocking of only one of the kinases has been associated with limited or sporadic responses. Therefore, multitargeted kinase inhibitors and combinations of single-target kinase inhibitors should be more effective to overcome therapeutic resistance. Some agents could be used together with radiation, chemotherapy, or immunotherapy to enhance treatment efficacy. Furthermore, in the face of tumor resistance to apoptosis, novel agents which can overcome resistance or/and induce cell death by non-apoptotic mechanisms such as necrosis, senescence, autophagy (type II programmed cell death) and mitotic catastrophe, are highly desirable. The present chapter focuses on anti-tumor action of drugs such as cyclosporin A and rapamycin that besides their well known immunosuppressive abilities appear to be kinase inhibitors and potential anti-tumor agents in glioblastomas. The present chapter summarizes a rationale and results of preclinical/clinical studies of these agents in therapy of glioblastomas.

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Mechanisms of Cyclosporin A Induced Cell Death in Rat C6 Glioma Cells Mode of Immunosuppressant Action Cyclosporin A (CsA), FK506 (tacrolimus, Prograf) and rapamycin (sirolimus) are short polypeptides which have revolutionized transplantology due to ability to block the activation of lymphocytes and other immune system cells. CsA, FK506 and rapamycin bind to specific intracellular proteins called immunophilins: CsA binds to cyclophilin, FK506 and rapamycin bind to FKBP (FK506-binding protein). Drugimmunophilin complexes bind to a regulatory subunit of calcineurin and inhibit its activity. Calcineurin is a calcium- and calmodulin-dependent threonine/serine phosphatase. CsA and FK506 exert immunosuppressive effects by inhibiting of calcineurin-mediated dephosphorylation of NFAT (nuclear factor of activated T cells), thus preventing transcriptional induction of several cytokines and their receptors genes (Fig. 25.1). NFAT family proteins are transcription factors that regulate the expression of a variety of target genes and are implicated in many functions, including cell growth, survival, invasion and angiogenesis (Mancini and Toker, 2009). Several members of NFAT family were detected in C6 glioma cells pointing to a new mechanism of transcription regulation in glioma cells. A transient receptor potential 6 (TRPC6) which is required for the development of the aggressive glioblastoma phenotype and causes a sustained elevation of intracellular calcium, is coupled to activation of the calcineurin-NFAT pathway. Pharmacologic inhibition of this pathway reduced the development of the aggressive glioblastoma phenotype under hypoxia.

Molecular Mechanisms of Pro-apoptotic Action of Cyclosporin A in C6 Glioma Cells It was reported by Mosieniak et al. (1997) that cyclosporin A at concentrations at the range of 30– 60 μM inhibits proliferation of rat C6 glioma cells and induces cell death. CsA-induced cell death was an

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Fig. 25.1 Mechanism of immunosuppressant action (a) Immunosuppressants bind to immunophilines: CsA to cyclophilin (cyc) and FK506 to FKBP (FK506-binding protein); subsequently complexes bind to the calcineurin and inhibit its activity. Calcineurin is a calcium- and calmodulin-dependent phosphatase which dephosphorylates NFAT transcription factors allowing them to translocate to the nucleus, where NFAT proteins in cooperation with other transcription factors (f.e. AP-1) regulate the expression of genes coding for chemokines, cytokines and their receptors. The immunosuppressantimmunophilin complex may interfere with MAPK signaling

pathways. (b) Summary of pro-apoptotic mechanisms induced by CsA in C6 glioma cells. CsA induces activation of JNK (c-Jun amino-terminal kinase) and MKK3 (MAP kinaseactivated protein kinase)-p38 MAPK signaling pathways. It leads to activation of AP-1 and transcriptional up-regulation of FasL (ligand Fas) which binds receptor Fas expressed on glioma cells and induces cell death. Activation of p38 MAPK signaling leads to accumulation of p53 and induction of p53-dependent expression of pro-apoptotic genes involved in mitochondrial death pathway

active process requiring expression of new genes and proteins, with typical features of apoptosis: oligonucleosomal DNA fragmentation and caspase 3 activation (Mosieniak et al., 1997; Pyrzynska et al., 2000). Two major mechanisms responsible for induction of

apoptotic death by CsA were identified. Apoptotic cell death induced by CsA was associated with a persistent activation of mitogen activated protein kinases (MAPK), in particular c–Jun N-terminal kinase (JNK) and p38 MAPK. Prolonged activation of JNK led

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to accumulation of phosphorylated c-Jun and ATF2 (main substrates of JNK) and formation of the AP-1 transcription factor followed by transcriptional activation of the Fas Ligand expression (Pyrzynska et al., 2000). Further studies with promoter constructs depleted of DNA binding sites for particular transcription factors revealed that activation of the FasL gene promoter was only partially AP-1-dependent and collaborative action of other transcription factors was required for promoter activation. It was demonstrated that CsA down-regulates Akt signaling to facilitate activation of Forkhead family members resulting in transcriptional activation of the FasL expression (Ciechomska et al., 2003). Down-regulation of Akt signaling was necessary to permit Forkhead transcription factor translocation to the nucleus and pre-requisite to transcriptional activation of the FasL expression. Treatment of glioma cells with lower doses of CsA (1–10 μM) was sufficient to reduce Akt phosphorylation and sensitized cells to doxorubicin, and UVC treatments (unpublished). Another event resulting from prolonged activation of MAP kinases, in particular p38 MAPK, was accumulation of the tumor suppressor p53 in glioma cells. The p53-family of transcription factors consists of three genes – p53, p63, and p73 sharing significant structural and functional similarities. p53 is a potent inducer of apoptosis and tumor suppression. Many anti-cancer agents, from traditional chemo- and radiation therapies to more recently developed small molecules, exert their effects by enhancing the antiproliferative effects of p53 and transactivating p63/p73 proteins. In normal cells the p53 is expressed at low, constitutive level and localized predominantly in cytoplasm. The latent form of p53 is stabilized and activated by posttranslational modifications. The activation of p53 occurs in response to DNA damage or stress such as hypoxia, nutrients or nucleotide deprivation. p53-mediated cell cycle arrest is largely brought about by induction of p21Waf1, an inhibitor of cyclindependent kinases. Activation of p53 may also result in apoptosis via transcriptional activation of a number of pro-apoptotic proteins including Bax, Fas, p85, IGF-BP3, and PIG3 and apoptotic protease activating factor-1 (apaf-1). It was reported by Pyrzynska et al. (2002) that CsA treatment results in up-regulation of p53 protein level and its accumulation in cell nuclei. Concomitantly, the levels of p21Waf1 and Bax proteins increased,

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and Bcl-xL decreased in CsA-treated glioma cells. Bax protein translocated to mitochondria, as revealed by immunofluorescence and double staining with a mitochondrial marker, and likely induced mitochondrial apoptotic pathway. Contribution of p53 to CsAinduced cell death was further confirmed in experiments, in which glioma cells stably transfected with a mutant p53 (p53Val135) failed to increase p21 and Bax protein levels and were less sensitive to CsA-induced apoptosis. Also primary fibroblasts from p53-/knockout mice were significantly more resistant to CsA-induced apoptosis compared to their corresponding counterparts containing functional p53 (Pyrzynska et al., 2002). Accumulation and activity of p53 can be regulated by phosphorylation that occurs at several Ser and Thr residues, and a number of cellular kinases have been proposed to directly phosphorylate p53, including casein kinase I, casein kinase II, double-strandedRNA-dependent protein kinase, ATM, CDK7, DNAactivated protein kinase, Jun-NH2 kinase and p38 MAP kinase. The induction of cell death by CsA was associated with a persistent activation of MKK3-p38 MAP kinase signaling pathway. Overexpression of a dominant negative form of MKK3, an upstream activator of p38, abrogated phosphorylation of p38 MAPK and p53 accumulation (Pyrzynska et al., unpublished). Together, the compelling evidence demonstrate that the apoptotic program activated by CsA can be mediated by multiple pathways: via activation of p53 transcription factor and p53-mediated apoptosis, and through up-regulation of FasL expression by JNK-AP-1 and Forkhead (Fig. 25.1).

Cyclosporin A Induces Cell Death or Growth Arrest and Senescence of Human Glioblastoma Cells In rat C6 glioma cells apoptotic cell death induced by CsA was associated with induction of intrinsic death pathway: p53- and mitochondria-dependent, as well as extrinsic, death ligand-dependent pathway. However, the experiments performed on glioma cells lacking a functional p53, namely the cell line stably expressing the temperature-sensitive p53 mutant, indicated that up to 20% of cells died even in the absence of functional

25 Glioblastoma: Anti-tumor Action of Cyclosporin A and Functionally Related Drugs

p53, suggesting also a p53-independent mode of CsA action. Therefore, we tested efficacy of CsA towards three human glioblastoma cell lines that are radioand chemotherapy resistant, in part due to mutations in the tumor suppressor PTEN or/and TP53 genes: T98G (mutated PTEN and TP53), U373-MG (mutated TP53 and PTEN) and U87-MG cells (wild type TP53/mutated PTEN). Cultured cells were exposed to increasing concentrations of CsA (Fig. 25.2) and 30 μg/ml CsA affected growth of all studied glioma cells, produced dramatic changes in cell number and morphology in 24 h. The inhibitory effect of CsA on cell growth and survival was dose-dependent, and progressed with the time of exposure. CsA at the concentration range of 5–20 μg/ml had no visible cytotoxic effects (Zupanska et al., 2005). Morphological alterations induced by 30 μg/ml CsA were characterized by shrinkage of the cells, rounding up of the cell body and detachment from the bottom of the plate at 24– 48 h after the treatment (Fig. 25.2). Cell death induced by CsA was blocked by cycloheximide (a protein synthesis inhibitor) and showed no signs of necrosis, such as swelling or disruption of cells. The appearance of numerous large vacuoles was observed in CsAtreated T98G cells and to less extent in U373-MG cells (Zupanska et al., 2005). Features of CsA-triggered cell death in human glioblastoma cells do not fulfill all criteria of apoptosis. For example, biochemical hallmarks of apoptosis such as phosphatidylserine exposure in the external leaflet of the plasma membrane bilayer, the “ladder-like” oligonucleosomal DNA fragmentation or appearance of the subG1 population were not detected, although condensation of chromatin, deformation of nuclei and sparse TUNEL labeling were observed. Cells in CsA-treated cultures showed “bean” shaped nuclei with condensed chromatin or nuclei with irregular clumps of dense chromatin. Such nuclear alterations as “bean” shaped nuclei with condensed chromatin usually preceded oligonucleosomal DNA fragmentation in CsA-treated rat glioma cells (Mosieniak et al., 1997). In T98G glioblastoma cells nuclear alterations were completely abolished by cycloheximide (CHX) treatment, indicating dependency of cell death on de novo protein synthesis. Measurement of changes in the mitochondrial membrane potential in response to CsA treatment with the fluorescent probe JC-1 did not show alterations in mitochondrial potential, which excludes

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a possibility of initiation of mitochondrial pathway along with apoptosome formation (Zupanska et al., 2005). Western blot analysis using specific antibodies recognizing intact and cleaved caspases 7, 3 and PARP (poly (ADP-ribose) polymerase-1) was employed to further characterize cell death induced by CsA. The treatment of human glioblastoma cells with 30 μM CsA resulted in activation of the caspase cascade (as evidenced by the appearance of cleaved caspase 7, 3 and cleaved PARP) in T98G cells, and to lesser extent in U373-MG cells. No caspase activation was detected in U87 glioma cells (Fig. 25.2). Growth arrest may lead to replicative senescence or differentiation. Senescent cells in contrast to presenescent, proliferating or quiescent cells express a beta-galactosidase activity detectable at pH 6.0. Since flatten morphology of CsA-treated U87 cells and reduction of the number of proliferating cells suggested the induction of differentiation process, a senescence-associated β-galactosidase (SA-beta-Gal) staining was performed (Fig. 25.2). Untreated U87MG and T98G cells demonstrated very rare cells positive for the SA-beta-Gal staining. After 24 h of CsA treatment the percentage of cells positive for SA-beta-Gal was doubled in U87-MG cells compared to control, while only few T98G cells were positively stained. SA-beta-Gal positive U87-MG cells increased in size and flattened out, thereby attaining morphology of senescent-like cells (Zupanska et al., 2005). Cell proliferation is controlled by cell cycle regulatory factors which include cyclins and cyclindependent kinases. p21WAF1/Cip1 protein is an universal inhibitor of cyclin kinases and plays an important role in inhibiting cell proliferation. The levels of p21WAF1/Cip1 protein were increased after exposure to 30 μM CsA in all examined glioblastoma cell lines. The highest up-regulation of p21WAF1/Cip1 protein was observed in T98G cells and the moderate accumulation was detected in U373-MG and U87MG cells. Further studies revealed transcriptional activation of p21WAF1/Cip1 expression preceded in time by a long-term activation of ERK1/2 signaling, subsequent c-Jun phosphorylation and accumulation of AP-1 complex in CsA-treated glioblastoma cells. Pre-treatment with ERK pathway inhibitors or overexpression of dominant negative mutants MKK1, ERK2 and c-Jun reduced the p21WAF1/Cip1

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Fig. 25.2 CsA induces programmed cell death or growth arrest/senescence of malignant glioblastoma cells. (a) Morphological alterations induced by CsA treatment in human glioma cells. T98G cells cultured in DMEM with 10% fetal bovine serum, were exposed to 30 μM CsA alone or with 1 μg/ml cycloheximide (CHX). Upper panel shows that a majority of cells lost processes and became round in CsA-treated cultures. Lower panel shows Hoechst 33258 staining revealing deformations of cell nuclei and condensation of chromatin. CHX inhibits morphological alterations in CsA-treated T98G cells. (b) Caspase cascade activation in CsA-triggered cell death.

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A representative immunoblot shows caspase activation in total protein extracts of human glioma cells treated with 30 μM CsA. Specific antibodies recognizing intact and cleaved caspases 7, 3 and cleaved PARP (Cell Signaling, USA) were employed. (c) Detection of the Senescence-Associated beta-galactosidase (SA-beta-Gal) staining in CsA-treated U87-MG glioma cells. The substantial increase in cellular volume and the blue staining reflecting SA-beta-Gal activity was observed in U87-MG cells treated with CsA. Original magnification for larger photos is ×10; for insets ×20

25 Glioblastoma: Anti-tumor Action of Cyclosporin A and Functionally Related Drugs

expression, confirming involvement of this pathway. Transcriptional activation of p21WAF1/Cip1 expression by CsA was independent of p53 and preceded CsA-induced growth arrest in glioblastoma cells (Zupanska et al., 2007). In conclusion, the findings above presented demonstrate an ability of CsA to induce growth arrest or programmed, but non-apoptotic cell death in human glioblastoma cells at the concentration of 30 μM or higher. Many forms of programmed cell death different from “classical” apoptosis have been described by the criteria of morphology, biochemistry, and response to apoptosis inhibitors, particularly in transformed cells which contain endogenous inhibitors preventing a particular pathway.

Anti-tumor Effects of CsA in Glioma Models Good cytostatic and cytotoxic efficacy of CsA in rat and human glioblastoma cultures encouraged studies in more complex models: in organotypic brain slice cultures and in murine glioma model. Organotypic brain slice cultures injected with glioblastoma cells recapitulate many features of glioblastoma and are very useful for investigating the cellular and molecular mechanisms of glioma invasion under conditions most analogous to those of normal brains in vivo. It was reported by Markovic et al. (2005) that microglial cells contribute significantly to invasion of glioma cells in cultured brain slices. Microglia are the intrinsic immune cells of the brain, serving principally to control the innate and the adaptive immune responses in the central nervous system, to initiate host-defense and tissue repair mechanisms. Microglial cells are attracted towards glioma (glioma tissue consists of up to 30% of microglial cells) and microglia density in gliomas positively correlates with malignancy, invasiveness and grading of the tumors (Watters et al., 2005). When glioma cells were injected into brain slices depleted of endogenous microglia (by incubation with clodronate-filled liposomes for 96 h), the invasiveness of the tumors was significantly decreased. Inoculation of exogenous microglia together with glioma cells into cultured brain slices increased the infiltrative behavior of glioma cells. Experiments with

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co-culture of microglia with glioma cells revealed that soluble factors released from glioma cells strongly stimulate metalloprotease-2 (MMP-2) activity increasing breakdown of extracellular matrix and thereby promoting tumor invasiveness (Markovic et al., 2005). Further studies showed that membrane type 1 metalloproteinase (MT1-MMP) is up-regulated in gliomaassociated microglia. Microglial MT1-MMP in turn activates glioma-derived pro-MMP-2 and promotes glioma expansion. Tumor growth and invasion in ex vivo model using MT1-MMP deficient brain tissue and in microglia-depleted animals were strongly reduced (Markovic et al., 2009). It was reported by Sliwa et al. (2007) that migration/invasion of fluorescently labeled GL261 glioma cells in murine brain slices significantly decreased upon treatment with CsA, even at low concentrations: 1, 10 and 30 μM. Anti-invasive effects of lower, non-cytotoxic doses of CsA suggested an existence of the additional mechanism of CsA action on tumor invasion. When glioma cells were injected into slices devoid of endogenous microglia, the inhibitory effect of 1 μM CsA on glioma invasiveness mostly vanished. It indicated that CsA abolishes microglia-promoting effects on glioma malignancy. The inhibitory action of CsA on microglia function has been directly demonstrated in microglia-glioma co-cultures. Glioma-derived factors in co-cultures or glioma conditioned medium induce morphological transformation of microglial cells into amoeboid phagocytes, activate MAPK signaling pathways and production of some cytokines. CsA at low doses of 0.1. and 1 μM blocked transformation of microglial cells stimulated by glioma-conditioned medium and abolished pro-invasive effects of microglia (Sliwa et al., 2007). A recent study points to a crucial role of microglia-derived transforming growth factor beta 1 (TGF-β1) in regulation of glioma invasion (Wesolowska et al., 2008). Blockade of TGF-β1 signaling by silencing of TGF-β1 type II receptor with shRNA or neutralizing anti-TGF-β1 antibody abolished the promoting effect of microglia on glioma invasion. In vivo tumor models developed by intracranial or subcutaneous implantation of glioma cell lines in rodents are used to test novel therapies. The advantages of these glioma models are their highly efficient gliomagenesis, reproducible growth rates, and knowledge of tumor location. However, these

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models have been criticized for not recapitulating all pathological features of human glioblastoma multiforme (GBM), they allow to target different features of GBM, including location in the brain, invasion of brain parenchyma, angiogenesis, and secretion of immune suppressive molecules. In studies by Sliwa et al. (2007) fluorescently labeled GL261 glioma cells were implanted into the striatum of DBA/2 J mice and developed gliomas of considerable size in 14 days. CsA (Sandimmun, Novartis) was administrated intraperitoneally (i.p.) every second days at doses of 2 or 10 mg/kg of body weight starting from the second day after cell inoculation. Systemically applied 2 or 10 mg/kg CsA significantly decreased tumor volumes (by 70%) with similar efficacy. Further studies in syngenic murine models, such as GL261 mouse glioma cells implanted to C57BL6 mice, have confirmed anti-tumor action of CsA administrated intraperitoneally every second day at doses of 2 and 10 mg/kg. Immunofluorescence studies with Iba1 antibody demonstrated that CsA blocks accumulation and activation of glioma-associated microglia confirming the in vitro data (unpublished). It was reported that macrophage–colony stimulating factor (M-CSF) and other cytokines secreted by high-grade glioma cells stimulate differentiation of tumor-infiltrating microglia/macrophages into cells acquiring the anti-inflammatory (M2) phenotype. M-CSF was significantly correlated with histological malignancy and with the proportion of M2 microglia/macrophages in vivo. Such M2 cells instead of initiating immune responses support tumor growth and invasion. CsA with its strong effect on pro-tumorigenic activity of microglia could be effective drug in modulation of anti-inflammatory M2 phenotype of microglia/macrophages in glioma therapy. CsA has been used to block the immune reaction towards human glioblastoma cells transplanted to rodent brains. It was reported by Mathiesen et al. (1989) that human glioblastoma cells implanted to cerebrum of rat hosts survive longer in immunosuppressed animals but aggressive growth of glioblastoma cells and tumor proliferation was not observed. Human glioblastoma cells implanted into the brain of Wistar rats immunosuppressed with CsA applied at 12 mg/kg/daily survived under such conditions but formed dense and poorly diffused tumors (Strojnik

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et al., 2006). Up to now CsA has not been tested as anti-invasive/cytotoxic agent in clinical trials.

Anti-tumor Action of Rapamycin and Derivatives Mechanism of Action of Rapamycin Rapamycin (Sirolimus) is a macrolide discovered ∼1970 as a product of the bacterium Streptomyces hygroscopicus in a soil sample from the Easter Island (Rapa Nui). Rapamycin was originally developed as an antifungal agent, but turned out to be a potent immunosuppressive drug and since 1997 has been used to prevent host-rejection in kidney transplantation. An immunosuppressive effect of rapamycin is due to the inhibition of interleukin 2 (IL-2)-mediated T-cell proliferation and activation. The mode of action of rapamycin is to bind the cytosolic immunophilin FK-binding protein 12 (FKBP12). This complex inhibits the mammalian target of rapamycin (mTOR) pathway by directly binding the mTOR Complex 1 (mTORC1). mTOR is a kinase playing a key role in the regulation of cell growth and proliferation by regulating ribosomal biogenesis and protein translation. Among others, mTOR can be activated by growth factors and hormones, which is mediated by the induction of PI-3-kinase (PI-3K). Active PI-3K generates phosphatidylinositol (3,4,5)trisphosphate [PtdIns(3,4,5)P3 ] which activates kinase Akt phosphorylating and inactivating the tuberous sclerosis complex 2 (TSC2). TSC2 acts as a GTPaseactivating protein for the small GTPase RHEB (Ras homolog enriched in brain). Inhibition of TSC2 activity leads to elevated RHEB-GTP levels and activation of mTORC1 which by its downstream effectors, such as ribosomal protein S6 kinases (S6K) and 4E-binding protein (4E-BP1), further up-regulates ribosome biogenesis and protein translation (Fig. 25.3). This results in an increase in cell size and mass, and enhanced proliferation. On the other hand, inhibition of mTOR promotes autophagy in some cell types. Autophagy is a process of degradation of organelles and macromolecules to supply cells with nutrients and can function as a cytoprotective mechanism or alternative cell death process.

25 Glioblastoma: Anti-tumor Action of Cyclosporin A and Functionally Related Drugs

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Fig. 25.3 Rapamycin inhibits proliferation or induces cell death of malignant glioblastoma cells. (a) mTOR signaling network. mTORC1 stimulates cell growth upon activation by growth factors or insulin (for details see the text). (b) Rapamycin inhibits the kinase activity of mTOR measured by reduction of S6K phosphorylation in T98G cells. Western blot analysis of the phospho-S6K (T389) level in T98G glioma cells after treatment with 10 nM rapamycin for 24 h. S6K served as a protein loading control. (c) Rapamycin affects proliferation of T98G cells. Cell proliferation was determined 24 h after exposure to 1, 10, 30

or 60 μM rapamycin using BrdU test. Bars represent the ratio of proliferating cells treated with the inhibitor related to control cells (means ± SEM of three independent experiments, each in triplicate). Statistical analysis was done by one-way ANOVA followed by Newman-Keuls test, ∗∗∗ p < 0.001. (d) Rapamycin induces morphological alterations in T98G cells. Phase-contrast images of T98G glioma cells performed 24 h after treatment with 10, 30 or 60 μM rapamycin. Cell death was observed after using the highest drug concentration. Original magnification is ×10

Rapamycin and Its Analogs in Pre-clinical and Clinical Trials in Glioblastomas

mTOR is a crucial downstream component of the PTEN/Akt signaling, pre-clinical studies with pharmacological inhibitors of the mTOR pathway were initiated in glioblastomas. Apart from rapamycin, its analogs with improved pharmacokinetic properties were synthesized. CCI779 (temsirolimus; Wyeth), RAD001 (everolimus; Novartis) and AP23573 (Ariad) are currently being tested as potential targeted drugs in glioblastomas. Pharmacological inactivation of mTOR decreased tumor cells proliferation and tumor size in PTEN-deficient mice (Rajasekhar et al., 2003). Moreover, xenografts generated from PTEN null U87 glioma cells in mice had inhibited growth and reduced proliferation rate after rapamycin treatment.

Enhanced or constitutive activation of the PI3K/Akt/mTOR pathway is an important factor in gliomagenesis (Guertin and Sabatini, 2007). In human glioblastomas Akt is activated in approximately 70% of tumors due to loss of PTEN (phosphatase and tensin homolog deleted on Chromosome 10), the tumor suppressor and negative regulator of PI-3 K/Akt signaling, and/or up-regulation of epidermal growth factor receptor (EGFR) and platelet-derived growth factor receptor (PDGFR) tyrosine kinases. PTEN mutations are present in 20–40% of GBM. Since

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Conversely, rapamycin did not decrease size of PTEN wild-type LN229 tumors (Wei et al., 2008). These findings provided grounds to initiate clinical trials of mTOR inhibitors in glioblastomas. The results of six studies using sirolimus or CCI-779 (a dihydroxymethyl propionic acid ester of sirolimus) as a single agent, or sirolimus and RAD001 in combination with inhibitors of EGFR in patients with recurrent glioblastoma multiforme (GBM) are shown in Table 25.1. Treatment with CCI-779 or sirolimus alone had only a limited activity in recurrent GBM, particularly in unselected patients. In the phase II study by Chang et al. (2005) CCI-779 was administered weekly to forty-three patients with recurrent GBM (14 patients were on enzyme-inducing antiepileptic drug). Initially CCI-779 was administered at a dose of 250 mg intravenously but the dose was reduced to 170 mg because of side effects. CCI-779 was well tolerated; however, failed to demonstrate any efficacy as a single agent in patients with recurrent GBM. Despite initial disease stabilization in approximately 50% of patients, the durability of response was short. In another phase II study CCI-779 was administered in a 250-mg intravenous dose weekly to sixty-five recurrent GBM patients with ≥1 chemotherapy regimen (Galanis et al., 2005). The study reported that 20 of 65 patients with recurrent GBM (36%) had radiographic improvement. Progression-free survival at 6 months was 7.8% and median overall survival was 4.4 months. Median time to progression for all patients was 2.3 months and was significantly longer for responders

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(5.4 months) versus non-responders (1.9 months). The authors assessed activation of the PI3K pathway by examining tumor specimens for total/phosphorylated Akt and p70s6 kinase, and found p70s6 kinase staining indices being significantly more frequent in responders versus non-responders (Galanis et al., 2005). It was reported by Cloughesy et al. (2008) that rapamycin treatment leads to substantial inhibition of tumor cell proliferation in seven of 14 patients, as demonstrated by reduction of Ki-67 staining in a subset of patients with PTEN loss. Inhibition of mTOR signaling was observed in tumor tissue. However, rapamycin led to the activation of Akt in some patients, which correlated with faster tumor progression the authors concluded that rapamycin has anti-cancer activity in PTEN-deficient glioblastoma and deserves further clinical study alone or in combination with PI3K pathway inhibitors. More recently, based on evidence of the synergism between inhibitors of mTOR and EGFR (Rao et al., 2005), several studies investigated such a combination. In two trials a partial radiological response (≥50% decrease in the product of perpendicular diameters of contrast enhancing mass without new lesions) was seen. Doherty et al. (2006) reported a trial on 22 GBMs and six anaplastic gliomas patients treated with either gefitinib 500 mg or erlotinib 150 mg orally/daily in combination with sirolimus administered at a dose of 6 mg orally the first day followed by 4 mg orally once daily thereafter. Both medications were given daily in 28-day cycles. Out of this cohort, 19% of patients

Table 25.1 Results of targeted therapy trials of mTOR inhibitors used alone or in combination with inhibitors of EGFR in recurrent glioblastomas Radiological Median PFS 6-month Median OS Study Treatment Patients (n) response (%) (months) PFS (%) (months) Chang et al. (2005)

CCI-779, 170–250 mg 43 5 weekly Galanis et al. (2005) CCI-779, 250 mg weekly 65 0 Cloughesy et al. Sirolimus, 2, 5, or 10 mg 15 14 (2008) daily Doherty et al. Sirolimus, 4 mg daily; 22 18 (2006) gefitinib, 500 mg, or erlotinib, 150 mg daily Kreisl et al. (2009) RAD001, 70 mg weekly; 22 14 gefitinib, 250 mg daily Reardon et al. Sirolimus, 5–10 mg daily; 32 0 (2010) erlotinib, 150–450 mg daily PFS, progression-free survival; OS, overall survival; NA, not available

2.3

3

NA

2.3 NA

8 NA

4.4 NA

3

25

NA

2.6

5

5.8

1.8

3

8.5

25 Glioblastoma: Anti-tumor Action of Cyclosporin A and Functionally Related Drugs

experienced a partial response and 50% had stable disease; 6-month progression-free survival (6 M-PFS) was 25%. In a second study on 22 patients (all had received prior radiation and chemotherapy) receiving gefitinib (250 mg daily) and everolimus (70 mg weekly), 14% of patients had a partial response and 36% of patients stable disease; median overall survival was 5.8 months (Kreisl et al., 2009). Overall response rate was 19% and a 6 M-PFS of 25% in GBM patients. No molecular markers of response were described. A retrospective review of eight consecutive negative phase II trials in recurrent malignant gliomas from the M.D. Anderson Cancer Center found a 6 MPFS for GBM of 15%. For comparison, among GBM patients treated with temozolomide at 200 mg/m2 /day orally for the first 5 days of a 28-day cycle, PFS at 6 months was 18%; median progression-free survival and median overall survival were 2.1 and 5.4 months, respectively. The 6-month survival rate was 46% (Brada et al., 2001). Although the trials demonstrate moderate clinical benefits from the combination of two drugs, ongoing phase I/II studies are investigating the efficacy of using mTOR inhibitors with other targeted agents and chemoradiation, namely: sirolimus plus vandetanib, CCI-779 or RAD001 plus temozolomide, CCI-779 plus radiation or sorafenib or bevacizumab or perifosine, RAD001 plus AEE788, and RAD001 plus Gleevec and hydroxyurea (http://clinicaltrials.gov).

General Considerations A use of CsA may raise reservations due to employment of drug blocking the immune system in tumor patients, poor drug accessibility due to blood-brain barrier or general toxicity. However, a growing evidence shows both innate and adaptive immunity impaired in glioblastomas (Yang et al., 2010). Glioblastomas are poorly immunogenic and do not express specific tumor antigens (Watters et al., 2005). Microglia infiltrating glioblastomas are converted into tumor supportive cells and contribute to tumor growth (Markovic et al., 2005, 2009; Sliwa et al., 2007). Microglial cells operate as the first line innate and adaptive immunity of the central nervous system (CNS). In the normal CNS, microglia express low levels of major histocompatibility complex (MHC)

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class I and class II molecules and co-stimulatory molecules such as CD86 and CD40. Upon activation, microglia convert to an active phenotype, upregulate MHC class I and class II and co-stimulatory molecules and take part in CD4-and CD8-specific T cell responses. Furthermore, malignant glioblastoma cells secrete chemoattractants and growth factors, including monocyte chemoattractant protein 1 (MCP-1), colony stimulating factor 1 (CSF-1), granulocyte-macrophage colony stimulating factor (GM-CSF), hepatocyte growth factor (HGF) and recruit microglia. Even though glioblastoma accumulate many microglia, macrophages and a small population of lymphocytes, the defense mechanisms are down-regulated. It was reported by Hussain et al. (2006) that glioblastoma-infiltrating microglia isolated from human tumor tissue samples do not produce inflammatory cytokines: interleukin 1β (IL-1β), interleukin 6 and tumor necrosis factor α (TNF-α), cytokines critical for developing effective innate immune responses. On the contrary, glioma-associated microglia/ macrophages might promote tumor growth by inducing immunosuppression in the tumor microenvironment. Glioblastoma cells and accumulating microglia release several cytokines, such as interleukin 10 (IL10) and TGF-β which may inhibit T-cell activation and contribute to the local glioma immunosuppressive milieu (Watters et al., 2005). An effective antitumor T-cell response is decreased in glioblastomas, because expression of MHC class II and co-stimulatory B7 molecules is reduced and microglia appear deficient in proper antigen presentation. Thus, potential immunossuppressive effects of CsA can be neglected because the immune system in glioblastoma patients is already paralyzed and anti-tumor responses are nonfunctioning. Although, tumors incidence in transplant recipients is a recognized consequence, a recent examination of reported cases of tumor in the transplant population of the Israel Penn International Transplant Tumor Registry shows that primary brain tumors, including gliomas, do not appear to be overrepresented in the Registry, indicating that they may not arise with increased frequency in transplant recipients (Schiff, 2004). As it has been shown in animal glioma model by Sliwa et al. (2007), CsA has a systemic effect, can affect cell interactions in tumor microenvironment and block pro-tumorigenic activity of tumor infiltrating

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microglia/macrophages. A recent study demonstrates that mTOR signaling controls microglial activation in response to cytokines and appears to play a crucial role in regulating of microglial viability (Dello Russo et al., 2009). Thus anti-tumor action of rapamycin in vivo may be partly due to interference with cell interactions in tumor microenvironment. The blood-brain barrier (BBB) possesses a significant impediment for the delivery of therapeutic drugs into the brain. In the normal adult brain, the BBB mainly consists of vascular endothelial cells, astrocytes and pericytes. In malignant glioblastomas, the blood vessel network is broken down. Increased permeability of tumor blood vessels is induced by angiogenic factors released by malignant glioma cells, such as vascular endothelial growth factor (VEGF) that is associated with intravascular migration of glioma cells into blood vessels and their transfer to distant areas in the brain via blood flow. The mechanism of vascular permeability is used by glioma cells to facilitate migration and invasiveness, but can be also employed to facilitate delivery of anti-tumor medicines into the brain (Tate and Aghi, 2009). Previous studies demonstrated that a systemic injection of 100 mg/kg/i.p. CsA results in a blood concentration of 10 μM maintained for at least 18 h (Ciechomska et al., 2005). Thus, concentrations of CsA (2 and 10 mg/kg) tested in animal glioma model correspond to blood concentrations of 0.2 or 1 μM, respectively. A permeable blood-brain barrier in brain tumors may result in similar CsA concentrations in the brain as detected in the blood. In contrast to widely accepted notion that CsA does not cross or poorly cross the blood-brain barrier, studies on immunosuppressed patients demonstrated the presence of CsA in cerebrospinal fluids suggesting that the drug is able to cross the blood-brain barrier. Furthermore, CsA may impair the brain endothelial barrier function by accelerating NO production in the brain endothelial and astroglial cells. Notably, CsA at lower micromolar concentrations does not affect survival of non-transformed cells. Neurons from mixed neuronal-glial cultures developed from hippocampal dentate gyrus are affected by CsA at the concentrations higher than 8–10 μM (Kaminska et al., 2001). Astrocytes are more resistant and CsA at concentration of 40 μM or higher affects the survival of astrocytes from neonatal brain cultures. Altogether, these results suggest that CsA, particularly

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at lower concentrations affecting pro-invasive activity of microglia, could be effective anti-tumor drug without inducing neurotoxicity. CsA induces cell death via multiple mechanisms and some of them are able to prevail alterations of growth regulatory and apoptotic pathways, caused by common mutations in human glioblastomas. Rapamycin and its derivatives, besides the well described inhibition of mTOR pathway in glioblastoma cells, may additionally affect proinvasive activity of glioblastoma infiltrating microglia. The unique mechanism of action of CsA and pharmacological inhibitors of the mTOR pathway justifies further research on their anti-tumoral properties either alone or in combined therapies. Acknowledgements This work was supported by grant P-N/024/2006.

References Brada M, Hoang-Xuan K, Rampling R, Dietrich PY, Dirix LY, Macdonald D, Heimans JJ, Zonnenberg BA, Bravo-Marques JM, Henriksson R, Stupp R, Yue N, Bruner J, Dugan M, Rao S, Zaknoen S (2001) Multicenter phase II trial of temozolomide in patients with glioblastoma multiforme at first relapse. Ann Oncol 12:259–266 Chang SM, Wen P, Cloughesy T, Greenberg H, Schiff D, Conrad C, Fink K, Robins HI, De Angelis L, Raizer J, Hess K, Aldape K, Lamborn KR, Kuhn J, Dancey J, Prados MD (2005) Phase II study of CCI-779 in patients with recurrent glioblastoma multiforme. Invest New Drugs 23: 357–361 Ciechomska I, Legat M, Golab J, Wesolowska A, Kurzaj Z, Mackiewicz A, Kaminska B (2005) Cyclosporine A and its non-immunosuppressive derivative NIM811 induce apoptosis of malignant melanoma cells- in vitro and in vivo studies. Int J Cancer 117:59–67 Ciechomska I, Pyrzynska B, Kazmierczak P, Kaminska B (2003) Inhibition of Akt kinase signalling and activation of Forkhead are indispensable for up-regulation of FasL expression in apoptosis of glioma cells. Oncogene 22: 7617–7627 Clarke J, Butowski N, Chang S (2010) Recent advances in therapy for glioblastoma. Arch Neurol 67:279–283 Cloughesy TF, Yoshimoto K, Nghiemphu P, Brown K, Dang J, Zhu S, Hsueh T, Chen Y, Wang W, Youngkin D, Liau L, Martin N, Becker D, Bergsneider M, Lai A, Green R, Oglesby T, Koleto M, Trent J, Horvath S, Mischel PS, Mellinghoff IK, Sawyers CL (2008) Antitumor activity of rapamycin in a phase I trial for patients with recurrent PTEN-deficient glioblastoma. PLoS Med 5:e8 Dello Russo C, Lisi L, Tringali G, Navarra P (2009) Involvement of mTOR kinase in cytokine-dependent microglial activation and cell proliferation. Biochem Pharmacol 78:1242–1251

25 Glioblastoma: Anti-tumor Action of Cyclosporin A and Functionally Related Drugs Doherty L, Gigas DC, Kesari S, Drappatz J, Kim R, Zimmerman J, Ostrowsky L, Wen PY (2006) Pilot study of the combination of EGFR and mTOR inhibitors in recurrent malignant gliomas. Neurology 67:156–158 Galanis E, Buckner JC, Maurer MJ, Kreisberg JI, Ballman K, Boni J, Peralba JM, Jenkins RB, Dakhil SR, Morton RF, Jaeckle KA, Scheithauer BW, Dancey J, Hidalgo M, Walsh DJ (2005) Phase II trial of temsirolimus (CCI-779) in recurrent glioblastoma multiforme: a North Central Cancer Treatment Group study. J Clin Oncol 23:5294–5304 Guertin DA, Sabatini DM (2007) Defining the role of mTOR in cancer. Cancer Cell 12:9–22 Hussain SF, Yang D, Suki D, Grimm E, Heimberger AB (2006) Innate immune functions of microglia isolated from human glioma patients. J Transl Med 30:15–24 Kaminska B, Figiel I, Pyrzynska B, Czajkowski R, Mosieniak G (2001) Treatment of hippocampal neurons with cyclosporin a results in calcium overload and apoptosis which are independent on NMDA receptor activation. Br J Pharmacol 133:997–1004 Kreisl TN, Lassman AB, Mischel PS, Rosen N, Scher HI, Teruya-Feldstein J, Shaffer D, Lis E, Abrey LE (2009) A pilot study of everolimus and gefitinib in the treatment of recurrent glioblastoma (GBM). J Neurooncol 92:99–105 Mancini M, Toker A (2009) NFAT proteins: emerging roles in cancer progression. Nat Rev Cancer 9:810–820 Markovic DS, Glass R, Synowitz M, Rooijen N, Kettenmann H (2005) Microglia stimulate the invasiveness of glioma cells by increasing the activity of metalloprotease-2. J Neuropathol Exp Neurol 64:754–762 Markovic DS, Vinnakota K, Chirasani S, Synowitz M, Raguet H, Stock K, Sliwa M, Lehmann S, Kälin R, van Rooijen N, Holmbeck K, Heppner FL, Kiwit J, Matyash V, Lehnardt S, Kaminska B, Glass R, Kettenmann H (2009) Gliomas induce and exploit microglial MT1-MMP expression for tumor expansion. Proc Natl Acad Sci USA 106:12530–12535 Mathiesen T, Collins VP, Olson L, Granholm L (1989) Prolonged survival and vascularization of xenografted human glioblastoma cells in the central nervous system of cyclosporine a treated rats. Cancer Lett 44:151–156 McCubrey JA, Steelman LS, Abrams SL, Lee JT, Chang F, Bertrand FE, Navolanic PM, Terrian DM, Franklin RA, D’Assoro AB, Salisbury JL, Mazzarino MC, Stivala F, Libra M (2006) Roles of the RAF/MEK/ERK and PI3K/PTEN/AKT pathways in malignant transformation and drug resistance. Adv Enzyme Regul 46:249–279 Mosieniak G, Figiel I, Kaminska B (1997) Cyclosporin A, an immunosuppressive drug, induces programmed cell death in rat C6 glioma cells by a mechanism that involves the AP-1 transcription factor. J Neurochem 68:1142–1149 Ohgaki H, Kleihues P (2009) Genetic alterations and signaling pathways in the evolution of gliomas. Cancer Sci 100: 2235–2241 Pyrzynska B, Mosieniak G, Kaminska B (2000) Changes of the trans-activating potential of AP-1 transcription factor during cyclosporin a-induced apoptosis of glioma cells are mediated by phosphorylation and alterations of AP-1 composition. J Neurochem 74:42–51

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Pyrzynska B, Serrano M, Martinez-A C, Kaminska B (2002) Tumor suppressor p53 mediates apoptotic cell death triggered by cyclosporine A. J Biol Chem 277: 14102–14108 Rajasekhar VK, Viale A, Socci ND, Wiedmann M, Hu X, Holland EC (2003) Oncogenic Ras and Akt signaling contribute to glioblastoma formation by differential recruitment of existing mRNAs to polysomes. Mol Cell 12: 889–901 Rao RD, Mladek AC, Lamont JD, Goble JM, Erlichman C, James CD, Sarkaria JN (2005) Disruption of parallel and converging signaling pathways contributes to the synergistic antitumor effects of simultaneous mTOR and EGFR inhibition in GBM cells. Neoplasia 7:921–929 Reardon DA, Desjardins A, Vredenburgh JJ, Gururangan S, Friedman AH, Herndon JE 2nd, Marcello J, Norfleet JA, McLendon RE, Sampson JH, Friedman HS (2010) Phase 2 trial of erlotinib plus sirolimus in adults with recurrent glioblastoma. J Neurooncol 96:219–230 Schiff D (2004) Gliomas following organ transplantation: analysis of the contents of a tumor registry. J Neurosurg 101: 932–934 Sliwa M, Markovic D, Gabrusiewicz K, Synowitz M, Glass R, Zawadzka M, Wesolowska A, Kettenmann H, Kaminska B (2007) The invasion promoting effect of microglia on glioblastoma cells is inhibited by cyclosporin A. Brain 130:476–489 Strojnik T, Kavalar R, Lah TT (2006) Experimental model and immunohistochemical analyses of U87 human glioblastoma cell xenografts in immunosuppressed rat brains. Anticancer Res 26:2887–2900 Tate MC, Aghi MK (2009) Biology of angiogenesis and invasion in glioma. Neurotherapeutics 6:447–457 Watters JJ, Schartner JM, Badie B (2005) Microglia function in brain tumors. J Neurosci Res 81:447–455 Wei LH, Su H, Hildebrandt IJ, Phelps ME, Czernin J, Weber WA (2008) Changes in Tumor Metabolism as Readout for Mammalian Target of Rapamycin Kinase Inhibition by Rapamycin in Glioblastoma. Clin Cancer Res 14: 3416–3426 Wesolowska A, Kwiatkowska A, Slomnicki L, Dembinski M, Master A, Sliwa M, Franciszkiewicz K, Chouaib S, Kaminska B (2008) Microglia-derived TGF-beta as an important regulator of glioblastoma invasion-an inhibition of TGF-beta-dependent effects by shRNA against human TGF-beta type II receptor. Oncogene 27:918–930 Yang I, Han SJ, Kaur G, Crane C, Parsa AT (2010) The role of microglia in central nervous system immunity and glioma immunology. J Clin Neurosc 17:6–10 Zupanska A, Adach A, Dziembowska M, Kaminska B (2007) Alternative pathway of transcriptional induction of p21WAF1/Cip1 by cyclosporine A in p53deficient human glioblastoma cells. Cell Signal 19: 1268–1278 Zupanska A, Dziembowska M, Ellert-Miklaszewska A, Gaweda-Walerych K, Kaminska B (2005) Cyclosporine A induces growth arrest or programmed cell death of human glioma cells. Neurochem Int 47:430–441

Chapter 26

Glioblastoma Patients: Chemotherapy with Cisplatin, Temozolomide and Thalidomide Fable Zustovich and Giuseppe Lombardi

Abstract When relapse occurs the treatment of glioblastoma patients remains a challenge for oncologists, the prognosis is poor and no therapy has proven benefit on survival. There are preclinical evidences of a synergism between cisplatin and temozolomide and between cisplatin and thalidomide. In the contest of a phase I and a subsequent phase II study we treated 17 patients with relapsed high-grade malignant glioma with cisplatin plus temozolomide and then with the same combination plus thalidomide. Toxicity was generally manageable but an incidence of 36.4% of vascular thrombo-embolic events was observed in patients treated with thalidomide. Sixteen patients were evaluable for response: 1 patient had a partial response, 8 patients had stable disease and 5 patients had progression. The median time to progression was 4 months (range 0.9–14.9), the progression-free survival at 6 month was 28% and the median overall survival was 7.8+ months (range 2.6–24.2+). Due to the high incidence of thalidomide-associated thrombo-embolic events we continued the phase II study treating patients only with cisplatin and temozolomide. The availability of new antiangiogenetic agents as bevacizumab could in the future improve the efficacy and tolerability of such combinations. Keywords Cisplatin · Temozolomide · Thalidomide · Toxicity · AGAT · Glioblastoma

F. Zustovich () Oncologia Medica 1, I.O.V. – IRCCS, Ospedale Busonera, 35128 Padova, Italy e-mail: [email protected]

Introduction Malignant gliomas are relatively rare diseases. Although prognosis is poor, recent improvement in the multi-disciplinary approach, such as earlier diagnosis, better and repeated surgery plus local chemotherapy, improved radiotherapy and more effective systemic chemotherapy, has prolonged the survival. Long-term survivors are more frequent in the clinical practice, the median overall survival of patients with glioblastoma has reached the 15 months in phase III studies and ~20 months for selected patients in phase II studies. In a phase III study, temozolomide at a daily dose of 75 mg/m2 when associated with standard radiotherapy, and then administered at a dose of 200 mg/m2 day for 5 days every 28 days for at least 6 cycles, has proven to provide a statistically significant advantage in overall 2-year survival (26.5 vs. 10.4%) in comparison to standard radiotherapy alone in patients with glioblastoma after surgical resection (Stupp et al., 2005). The further analysis of the O6 -methylguanine-DNA methyltransferase (MGMT) methylation status in the tumour cells gave more details on survival results and in particular how patients with methylated-MGMT (45% of the total) had a median survival of 18.2 months compared to 12.2 months of the non-methylated counterpart (Hegi et al., 2005). There are no phase III trials investigating second line therapy for patients progressing during or after temozolomide treatment. Surgery or further chemotherapy is always considered whenever possible. Some data are available using more temozolomide treatment with modified schedules, the combination of procarbazine, carmustine and vincristine (PCV regimen), irinotecan and carmustine, fotemustine and

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_26, © Springer Science+Business Media B.V. 2011

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carmustine, among the other drugs. Unfortunately, all these attempts of treatment are characterized by low response rates and the lack of durability when responses occur. In contrast, the use of inhibitors of the angiogenetic pathways appeared very promising. In a phase II study bevacizumab, a monoclonal antibody, targeted against the vascular endothelial growth factor (VEGF), in combination with irinotecan, gave an overall response rate (ORR) of 57% in 35 patients with progressive refractory glioblastoma, the 6-month progression-free survival (PFS-6) was 46% and the 6-month overall survival was 77% (Goli et al., 2007).

Rationale Temozolomide is an alkylating agent which belongs to the family of imidazotetrazine. It can be orally used, and permeates through the brain-blood barrier. Temozolomide has an excellent tolerability profile at the usual dose of 200 mg/m2 a day for five consecutive days every 4 weeks. The dose limiting toxicity is thrombocytopenia. Initial phase II studies in patients with relapsed glioblastomas showed that temozolomide given in monotherapy was able to obtain an ORR of 19% and a PFS-6 of 24% (Brandes et al., 2000). Temozolamide acts through methylation of the O6 position of guanylic acid in DNA with intrachain links. Consequent mismatch-repair system activation leads to apoptotic cell death. Resistance to temozolomide is due to high intracellular levels of O6 -alkyl-guaninealkyltransferase (AGAT) which is involved in DNArepair mechanisms, transferring an alkyl group from DNA to another cysteine residue. Therefore, cells with increased concentrations of AGAT or with a deficiency in mismatch repair before drug administration, may be resistant to temozolomide (D’Incalci et al., 1988). Cisplatin is able to reduce in vitro intracellular AGAT levels in proportion to the drug concentration and the duration of cell exposure to the drug with an AGAT nadir after 24–48 h (D’Atri et al., 2000). The promoting region of AGAT gene is rich in guanine and cytosine (GC) sequences that have a high affinity for cisplatin. The presence of cisplatin reduces the activity of the gene encoding for AGAT and then impair one of the potential mechanisms of resistance to temozolomide.

F. Zustovich and G. Lombardi

This is the basis for a synergistic effect between temozolomide and cisplatin. Furthermore, platinum compounds have their own cytotoxic activity against malignant gliomas (Yung et al., 1991; Bertolone et al., 1989). A combination of cisplatin and temozolomide in chemo-naïve patients with glioblastoma was investigated in a first-line phase II study. Cisplatin was administered at 75 mg/m2 every 28 days followed by oral temozolomide at a dose of 130 mg/m2 bolus followed by nine doses of 70 mg/m2 every 12 h escalated to 1000 mg/m2 in 5 days if no toxicity occurred. The ORR was 20.4% with a PFS-6 of 34% (Brandes et al., 2004). Thalidomide has a well known anti-angiogenic activity in vivo (D’Amato et al., 1994). Malignant gliomas are rich in blood vessels and vascularization is proportional to the grade of malignancy (Takahashi et al., 1992). Many authors evaluated the feasibility and effectiveness of thalidomide in phase I–II studies. Fine et al. (2000) administered daily doses of thalidomide from 800 to 1200 mg in 39 patients with relapsed high grade malignant gliomas, obtaining two partial responses (PR), two minor responses (MR), and 12 instances of stable disease (SD). Among 18 patients with relapsed high grade malignant gliomas treated with daily 100 mg of thalidomide, Short et al. (2001) obtained 1 PR and 2 SD. Marx et al. (2001) treated 38 patients with relapsed glioblastoma with a daily escalating dose of thalidomide from 100 to 500 mg, obtaining 2 PR and 16 SD. Morabito et al. (2004) administered daily 400 mg of thalidomide to 18 patients with relapsed glioblastoma obtaining 1 MR response and 8 SD. A synergism between thalidomide and cisplatin was documented in vitro. Thalidomide seems to enhance the vascular permeability and to improve the tumour vascularization enhancing intratumoral cisplatin concentration (Murphy et al., 2007). Unfortunately, so far, there are no published clinical data evaluating the combination of thalidomide and cisplatin other than a phase I study published by Zustovich et al. (2007). In conclusion, the combination of temozolomide, cisplatin and thalidomide is based on two different in vitro demonstrated synergies, one between temozolomide and cisplatin and the other between cisplatin and thalidomide.

26 Glioblastoma Patients: Chemotherapy with Cisplatin, Temozolomide and Thalidomide

Clinical Experience The clinical experience using temozolomide, cisplatin, and thalidomide in patients with high grade malignant gliomas is based on a published dose-finding phase I study (Zustovich et al., 2007) and the following attempt to perform a phase II trial. Unfortunately, this study concluded prematurely due to the high incidence of vascular thrombo-embolic events (VTE). Nevertheless, the data analysis led to interesting conclusions that overcome the mere dose-finding investigation and revealed some interesting concerns regarding myelotoxicity and vascular venous complications, as described in the following paragraphs. Patients with relapsed malignant primitive brain tumors (not eligible for further local treatment) were enrolled. Patients that had received prior chemotherapy were admitted, including those treated with temozolomide if not combined with other alkylating agents. Treatment was started with cisplatin at 75 mg/m2 day 1 in combination with daily temozolomide 100 mg/m2 for 5 days every 3 weeks. Progressively increasing dose levels were established to verify, firstly, the tolerance to the 3-week schedule of cisplatin and temozolomide with the usual cisplatin dosage of 75 mg/m2 and temozolomide at the same dose-intensity of the standard 4-week schedule; thus, 150 mg/m2 , for 5 days, instead of 200 mg/m2 . Thalidomide was then added in 50 mg step escalating doses starting from 100 mg total dose per day. From April 2002 to March 2005, we enrolled 17 consecutive eligible patients. Of

Fig. 26.1 Left inferior limb arteriography of the patients with artery occlusion probably induced by thalidomide administration

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the 14 patients with glioblastoma, 11 had previously undergone cytoreductive surgery and 13 had received radiotherapy. All 17 patients were evaluable for toxicity, which was generally mild. The most frequent grade 1–2 toxicities were anemia, nausea, and vomiting. Four patients had grade 1–2 cutaneous/allergic toxicity, one of them also complained of dyspnoea. Grade 3–4 toxicity was febrile neutropenia in one patient, asymptomatic neutropenia in 6 patients, grade 4 thrombocytopenia in 1 patient, deep venous thrombosis (DVT) in 3 patients and pulmonary embolism (PE) in one patient, with an overall VTE incidence of ~23.5% and of 36.4% in the sub-group receiving thalidomide. In these patients, thalidomide was discontinued and not readministered, even after the onset of an anti-coagulant therapy. Sixteen patients were evaluable for response and all for time to progression (TTP) and overall survival (OS). Among the 14 patients with glioblastoma, 1 patient had a PR, 8 patients had SD, and 5 patients had progressive disease. Median TTP was 4 months (range 0.9–14.9 months), PFS-6 was 28% and median OS was 7.8+ months (range 2.6–24.2+ months). As stated before, we planned to continue with a phase II study but an early case of artery thrombotic occlusion occurred (see Fig. 26.1). As a consequence, and in consideration of the high rate VTE in the dose-finding trial, we decided to continue with the sole administration of temozolomide and cisplatin, without thalidomide (see the paragraph “Future perspectives”).

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Mielotoxicity The dose-finding escalation of thalidomide in combination with cisplatin and temozolomide (75 mg/m2 day 1 and 150 mg/m2 days 1–5, respectively, every 3 weeks) was concluded at the level of 200 mg daily total dose. Dose limiting toxicity (DLT) was hemathological with grade 4 thrombocytopenia in one patient and grade 4 febrile neutropenia in another patient. Moreover, 6 out of the 7 patients who developed grade 3–4 neutropenia belonged to the group treated with thalidomide. Thus, we can infer that thalidomide impairs the bone-marrow function in proportion to the dose administered. In a series of 44 patients with multiple myeoloma treated with thalidomide there were 10 cases of grade 3–4 neutropenia and 5 patients had a bone-marrow hypoplasia without any increase of myeloma cell count (Hattori et al., 2004). The dynamic contrast enhanced magnetic resonance (dMRI) in patients with multiple myeloma evidenced as thalidomide is able to reduce the microcirculation in the bone marrow (Scherer et al., 2002). This reduction is greater when thalidomide is administered in combination with chemotherapy (Wasser et al., 2004). A reduction of bone marrow micro vessels density in patients with multiple myeloma tretaed with thalidomide is also been demonstrated (Kumar et al., 2004).

Vascular Complications At first, we did not consider vascular venous grade 3–4 toxicity as a dose limiting toxicity in consideration of the high incidence of VTE in patients with high-grade glioma. In a series of 68 patients with highgrade gliomas, the rate of VTE was 19% and authors reported as risk factors chemotherapy administration (p = 0.027) and the presence of paresis (p = 0.031) (Dhami et al., 1993). The overall rate of VTE in our series of patients treated with the combination of temozolomide, cisplatin and thalidomide was 36.4% and we supposed that thalidomide might have been a VTE risk factor in high grade glioma patients. There are previous reports regarding thalidomideinduced vascular venous grade 3–4 toxicity in cancer patients. Data from FDA’s MedWatch showed an incidence of VTE of 4.6% in patients treated with

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thalidomide alone, of 15.0% in patients receiving concomitant dexamethasone and of 30.9% in patients receiving concomitant chemotherapy (Bennet et al., 2001). In multiple myeloma patients there was a higher incidence of VTE when thalidomide was associated to chemotherapy regimen containing dexamethasone, vincristine, doxorubicin, cyclophosphamide, etoposide and cisplatin (28% vs. 4%; p = 0.002) (Zangari et al., 2001). A low incidence of VTE occurred when thalidomide was administered in combination with a non-doxorubicin containing chemotherapy regimen (dexamethasone, cyclo-phosphamide, and etoposide) (Moehler et al., 2002). A comparison between 2 chemotherapy regimens differing only for the presence or not of doxorubicin revealed as doxorubicin was a VTE risk factor (16.0% vs 2.5%; p = 0.02) (Zangari et al., 2002). A phase II study of temozolomide and thalidomide in patients with brain metastases of melanoma was prematurely interrupted after the enrolment of 16 patients for a high incidence of VTE. Authors reported 3 cases of PE and 1 case of DVT with an overall VTE rate of 25% (Krown et al., 2006). That was not far from 19% reported in high-grade glioma patients series (Dhami et al., 1993). Unfortunately, besides ours, no published data regarding the combination of cisplatin and thalidomide are available. We suppose that the concomitant administration of cisplatin and thalidomide, like doxorubicin in multiple myeloma patients, might be a VTE risk factor in patients with malignant high-grade gliomas.

Future Perspectives The new generation of drugs classified as “Target therapy” have been tested in malignant gliomas. The inhibitors of the EGFR pathways gave poor result but antiangiogenetic drugs, such as bevacizumab, seemed to be very promising. Bevacizumab is a monoclonal antibody targeted against VEGF. In a phase II study, 35 patients with progressive refractory glioblastoma received bevacizumab in combination with irinotecan. Overall response rate was 57%, PFS-6 was 46% and the 6-month OS was 77% (Goli et al., 2007). In a recent phase II study bevacizumab alone gave an ORR of 35% in heavily pre-treated patients with a PFS-6 of

26 Glioblastoma Patients: Chemotherapy with Cisplatin, Temozolomide and Thalidomide

29% while the addition of irinotecan did not seem to improve the outcome (Kreisl et al., 2008). I believe that the combination of temozolomide, cisplatin, and bevacizumab could be safe and even more effective. Bevacizumab has been combined to temozolomide in high-grade glioma patients and to cisplatin in non-small cell lung cancer patients without the evidence of unexpected or increased vascular and haematological toxicity. Our still unpublished data treating temozolomide refractory glioblastoma patients with the combination of temozolomide and cisplatin are promising with a PR rate of 36% with 2 long lasting PFS of 16.9 and 13.2+ months after 14 enrolled patients. A phase I–II study evaluating the combination of temozolomide, cisplatin, and bevacizumab in glioblastoma patients has been designed, but until sufficient clinical data are gathered, it will remain an appropriate suggestion.

References Bennet CL, Schumok GT, Kwaan HC, Raisch DW (2001) High incidence of Thalidomide-associated deep vein thrombosis and pulmonary emboli when chemotherapy is also administered. Blood 98:863a (Abstract) Bertolone SJ, Baum ES, Krivit W, Hammond GD (1989) A phase II study of cisplatin therapy in recurrent childhood brain tumors. A report from the childrens cancer study group. J Neurooncol 1:5–11 Brandes AA, Basso U, Reni M, Vastola F, Tosoni A, Cavallo G, Scopece L, Ferreri AJ, Panucci MG, Monfardini S, Ermani M (2004) First-line chemotherapy with cisplatin plus fractionated temozolomide in recurrent glioblastoma multiforme: a phase II study of the Gruppo Italiano Cooperativo di Neuro-Oncologia. J Clin Oncol 9:1598–1604 Brandes AA, Pasetto LM, Vastola F, Monfardini S (2000) Temozolomide in patients with high grade gliomas. Oncology 3:181–186 D’Amato RJ, Laughnan MS, Flynn E, Folkman J (1994) Thalidomide is an inhibitor of angiogenesis. Proc Natl Acad Sci USA 9:4082–4085 D’Atri S, Graziani G, Lacal PM, Nistico V, Gilberti S, Faraoni I, Watson AJ, Bonmassar E, Margison GP (2000) Attenuation of O(6)-methylguanine-DNA methyltransferase activity and mRNA levels by cisplatin and temozolomide in jurkat cells. J Pharmacol Exp Ther 2:664–671 Dhami MS, Bona RD, Calogero JA, Helman RM (1993) Venous thromboembolism and high grade gliomas. Thromb Haemost 3:393–396 D’Incalci M, Citti L, Taverna P, Catapano CV (1988) Importance of the DNA repair enzyme O6 -alkyl guanine alkyltransferase (AT) in cancer chemotherapy. Cancer Treat Rev 4: 279–292

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Fine HA, Figg WD, Jaeckle K, Wen PY, Kyritsis AP, Loeffler JS, Levin VA, Black PM, Kaplan R, Pluda JM, Yung WK (2000) Phase II trial of the antiangiogenic agent thalidomide in patients with recurrent high-grade gliomas. J Clin Oncol 4:708–715 Goli KJ, Desjardins JE, Herndon JE, Rich JN, Reardon DA, Quinn JA, Sathornsumetee S, Bota DA, Friedman HS, Vredenburgh JJ (2007) Phase II trial of bevacizumab and irinotecan in the treatment of malignant gliomas. Proc ASCO 2007:2003 J Clin Oncol 25(18s) (abstract) Hattori Y, Kakimoto T, Okamoto S, Sato N, Ikeda Y (2004) Thalidomide-induced severe neutropenia during treatment of multiple myeloma. Int J Hematol 3:283–288 Hegi ME, Diserens AC, Gorlia T, Hamou MF, de Tribolet N, Weller M, Kros JM, Hainfellner JA, Mason W, Mariani L, Bromberg JE, Cairncross JG, Janzer RC, Stupp R (2005) MGMT gene silencing and benefit from temozolomide in glioblastoma. N Engl J Med 10:997–1003 Kreisl TN, Kim L, Moore K, Duic P, Royce C, Stroud I, Garren N, Mackey M, Butman JA, Camphausen K, Park J, Albert SA, Fine HA (2008) Phase II trial of single-agent bevacizumab followed by bevacizumab plus irinotecan at tumor progression in recurrent glioblastoma. J Clin Oncol 15(10):3617–3623 (Published on line ahead of print Dec 29 2008) Krown SE, Niedzwiecki D, Hwu WJ, Hodgson L, Houghton AN, Haluska FG et al (2006) Phase II study of temozolomide and thalidomide in patients with metastatic melanoma in the brain. Cancer 107(8):1883–1890 Kumar S, Witzig TE, Dispenzieri A, Lacy MQ, Wellik LE, Fonseca R, Lust JA, Gertz MA, Kyle RA, Greipp PR, Rejkumar SV (2004) Effect of thalidomide therapy on bone marrow angiogenesis in multiple myeloma. Leukemia 3:624–627 Marx GM, Pavlakis N, McCowatt S, Boyle FM, Levi JA, Bell DR, Cook R, Biggs M, Little N, Wheeler HR (2001) Phase II study of thalidomide in the treatment of recurrent glioblastoma multiforme. J Neurooncol 1:31–38 Moehler TM, Dchlenzka J, Kaspar B, Neben K, Egerer G, Ho AD, Goldschmidt H (2002) Low incidence of deep venous thrombosis in poor prognosis multiple myeloma patients treated with thalidomide and CED chemotherapy. Blood 100:5136a (abstract) Morabito A, Fanelli M, Carillio G, Gattuso D, Sarmiento R, Gasparini G (2004) Thalidomide prolongs disease stabilization after conventional therapy in patients with recurrent glioblastoma. Oncol Rep 1:93–95 Murphy S, Davey RA, Gu XQ, Haywood MC, McCann LA, Mather LE, Boyle FM (2007) Enhancement of cisplatin efficacy by thalidomide in a 9L rat gliosarcoma model. J Neurooncol 85:181–189 Scherer A, Strupp C, Wittsack HJ, Engelbrecht V, Willers R, Germing U, Gattermann N, Haas R, Modder U (2002) Dynamic contrast-enhanced MRI for evaluating bone marrow microcirculation in malignant haematological diseases before and after thalidomide therapy. Radiologie 3:222–230 Short SC, Traish D, Dowe A, Hines F, Gore M, Brada M (2001) Thalidomide as an anti-angiogenic agent in relapsed gliomas. J Neurooncol 1:41–45 Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, Belanger K, Brandes AA, Marosi C, Bogdahn

260 U, Curschmann J, Janzer RC, Ludwin SK, Gorlia T, Allgeir A, Lacombe D, Cairncross JG, Eisenhauer E, Mirimanoff RO (2005) European organisation for research and treatment of cancer brain tumor and radiotherapy groups; National Cancer Institute of Canada clinical trials group. 2005. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 10:987–996 Takahashi JA, Fukumoto M, Igarashi K, Oda Y, Kikuchi H, Hatanaka M (1992) Correlation of basic fibroblast growth factor expression levels with the degree of malignancy and vascularity in human gliomas. J Neurosurg 5: 792–798 Wasser K, Moehler T, Neben K, Nosas S, Heiss J, Goldschmidt H, Hillengass J, Duber C, Kauczor HU, Delorme S (2004) Dynamic MRI of the bone marrow for monitoring multiple myeloma during treatment with thalidomide as monotherapy or in combination with CED chemotherapy. Rofo 9: 1285–1295

F. Zustovich and G. Lombardi Yung WK, Mechtler L, Gleason MJ (1991) Intravenous carboplatin for recurrent malignant glioma: a phase II study. J Clin Oncol 5:860–864 Zangari M, Anaissie E, Barlogie B, Badros A, Desikan R, Gopal AV, Morris C, Toor A, Siegel E, Fink L, Tricot G (2001) Increased risk of deep-vein thrombosis in patients with multiple myeloma receiving thalidomide and chemotherapy. Blood 5:1614–1615 Zangari M, Siegel E, Barlogie B, Anaissie E, Saghafifar F, Fassas A, Morris C, Fink L, Tricot G (2002) Thrombogenic activity of doxorubicin in myeloma patients receiving thalidomide: implications for therapy. Blood 4: 1168–1171 Zustovich F, Cartei G, Ceravolo R, Zovato S, Della Puppa A, Pastorelli D, Mattiazzi M, Bertorelle R, Gardiman MP (2007) A phase I study of cisplatin, temozolomide and thalidomide in patients with malignant brain tumors. Anticancer Res 27(2):1019–1024

Chapter 27

Glioblastoma: Role of Galectin-1 in Chemoresistance Florence Lefranc and Robert Kiss

Abstract Malignant gliomas, especially glioblastomas, are associated with a poor prognosis. This prognosis can be at least partly explained by the fact that glioma cells diffusely infiltrate the brain parenchyma and exhibit decreased levels of apoptosis and are thus resistant to cytotoxic drugs. Galectin-1, the expression of which is stimulated by hypoxia, is a potent modulator of glioblastoma cell migration and a pro-angiogenic molecule. Galectin-1 participates in the resistance of cancer cells, including glioma cells, to chemotherapy and to radiotherapy and is involved in the activation of the Ras oncogenic pathway. Our recent data reveal that temozolomide, the standard treatment for glioma patients, increases Galectin-1 expression in various glioblastoma models both in vitro and in vivo. Consequently, reducing Galectin-1 expression in these models increases the anti-tumor effects of various chemotherapeutic agents, in particular temozolomide. Reducing Galectin-1 expression in glioblastoma cells does not induce apoptotic or autophagic features, but rather modulates p53 transcriptional activity and decreases p53-targeted gene expression. The decrease in Galectin-1 expression also impairs the expression levels of several genes implicated in chemoresistance: ORP150, HERP, GRP78/Bip, TRA1, BNIP3L, GADD45B and CYR61. The involvement of Galectin1 in different steps of glioma malignant progression, such as migration, angiogenesis or chemoresistance, makes it a potential target for the development of new drugs to combat these malignant tumors.

F. Lefranc () Laboratoire de Toxicologie, Faculté de Pharmacie, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium e-mail: [email protected]

Keywords GBM · Apoptosis · Galectin-1 · Cell death · Chemoresistance · Ras

Introduction Malignant gliomas, especially glioblastomas (GBM), are characterized by the diffuse invasion of distant brain tissue by a myriad of single migrating cells with reduced levels of apoptosis (type I programmed cell death [PCD]) and consequent resistance to the cytotoxic insults of pro-apoptotic drugs (Lefranc et al., 2005). In contrast, GBM cells are less resistant to autophagy-related cell death (type II PCD) than to apoptosis (Lefranc et al., 2005, 2006). Current recommendations are that patients with GBM should undergo maximum surgical resection followed by concurrent radiation and chemotherapy with temozolomide (Lefranc et al., 2006; Stupp et al., 2009). Galectin-1 (Gal1), a lectin with specificity for β-galactosides (Liu and Rabinovich, 2005; Camby et al., 2006; (LeMercier et al., 2009), markedly influences glioma cell migration both in vitro and in vivo (Camby et al., 2001, 2002, 2005). High-grade glioma patients whose gliomas markedly express Gal1 have a significantly shorter survival period than individuals whose gliomas express less Gal1 (Camby et al., 2002). Decreasing Gal1-expression in human orthotopic GBM xenografts significantly increases the survival of GBM tumorbearing mice (Camby et al., 2002; LeMercier et al., 2008b). Gal1-expression is increased under hypoxic conditions; hypoxia also confers cellular resistance to conventional chemotherapy and accelerates malignant progression (Le et al., 2005). Gal1 is negatively regulated by p53 (Puchades et al., 2007),

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and Gal1 reciprocally has been shown to modify p53 biological functions (Camby et al., 2006). The reciprocal control exerted by Gal1 or p53 on the other could be implicated in GBM chemoresistance, as could also be the case in the partnership between Ras and Gal1. Ras is implicated in gliomagenesis and modulates glioma aggressiveness (Goldberg and Kloog, 2006). Ras signaling and oncogenesis depend on the dynamic interplay of Ras with distinctive plasma membrane micro-domains and various intracellular compartments. Such interactions are dictated by individual elements in the carboxy-terminal domain of the Ras proteins, one of which is recognized by Gal1, galectin3 and cGMP phosphodiesterase delta (Ashery et al., 2006). Gal1 thereby promotes H-Ras signaling to Raf at the expense of phosphoinositide 3-kinase (PI3K) and Ral guanine nucleotide exchange factor (RalGEF) (Ashery et al., 2006). Gal1 could therefore be involved in these Ras-related pathways implicated in GBM resistance to apoptosis (Lefranc et al., 2005; LeMercier et al., 2009).

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when on the current standard treatment (surgical resection to the extent feasible, followed by adjuvant radiotherapy plus temozolomide chemotherapy, given concomitantly with and after radiotherapy) (Lefranc et al., 2005, 2006; Stupp et al., 2009). Malignant gliomas are associated with such dismal prognoses because glioma cells can actively migrate through the narrow extracellular spaces in the brain, often traveling relatively long distances, making them elusive targets for effective surgical management (Lefranc et al., 2005, 2006). Additionally, after surgical resection and adjuvant treatment of malignant gliomas, the residual cancer cells peripheral to the excised lesion give rise to a recurrent tumor that in more than 90% of cases develops immediately adjacent to the resection margin (Lefranc et al., 2005). Clinical and experimental data have also demonstrated that invasive malignant glioma cells show a decrease in proliferation rate and a relative resistance to apoptosis as compared with the highly dense cellular center of the tumor. This may contribute to their resistance to conventional pro-apoptotic chemotherapy and radiotherapy (Lefranc et al., 2005, 2006).

Gliomas: An Overview Galectins: An Overview Gliomas account for more than 50% of all primary brain tumors and are by far the most common primary brain tumor in adults (Lefranc et al., 2005, 2006). Gliomas include tumors that are composed predominantly of astrocytes (astrocytomas), oligodendrocytes (oligodendrogliomas), ependymal cells (ependymomas) or a mixture of various glial cells (e.g., oligoastrocytomas) (Louis et al., 2007). The World Health Organization grading system classifies gliomas as grade I to IV based on the degree of malignancy, as determined by histopathological criteria. Grade I gliomas are generally well-circumscribed and behave in a benign fashion, whereas grade II through IV gliomas are malignant and diffusely infiltrate the brain (Louis et al., 2007). Among gliomas, astrocytomas are the most common and are comprised of pilocytic astrocytomas (grade I), diffuse astrocytomas (grade II), anaplastic astrocytomas (grade III) and GBM (grade IV) (Louis et al., 2007). Glioblastomas are characterized by a very dismal prognosis (Lefranc et al., 2005, 2006; Stupp et al., 2009). GBM patients have a median survival expectancy of only 14 months

Galectins are a structurally-related family of animal lectins defined by two properties: (i) an affinity for β-galactoside sugars; and (ii) sequence homology (Barondes et al., 1994; Liu and Rabinovich, 2005; Camby et al., 2006; Le Mercier et al., 2009, 2010). This consensus sequence corresponds to the carbohydrate-recognition domain (CRD), which is a beta sandwich of about 135 amino acids long and is responsible for β-galactoside binding (Barondes et al., 1994; Liu and Rabinovich, 2005; Camby et al., 2006; Le Mercier et al., 2009). To date, 15 galectins have been characterized; they are numbered according to the chronology of their discovery (galectin-1 to galectin-15) (Barondes et al., 1994; Liu and Rabinovich, 2005; Camby et al., 2006; Le Mercier et al., 2009, 2010). The galectins known so far have either one or two CRDs within a single polypeptide chain, and neither CRD is associated with other types of well-defined protein domains. The mono-CRD galectins can be biologically active as monomers (galectin-5, -7, -10)

27 Glioblastoma: Role of Galectin-1 in Chemoresistance

or as homodimers (galectin-1, -2, -11, -13, -14, -15); the bi-CRD galectins (galectin-4, -6, -8, -9, 12) are active as monomers and might also associate into oligomers (Leffler et al., 2004). Galectin-3, a monoCRD galectin, is unique in that it contains a short proline, glycine and tyrosine rich N-terminal domain fused onto the CRD that therefore allows the formation of oligomers (Leffler et al., 2004). Galectins can segregate into multiple cell compartments. Although these proteins lack the signal sequence that would be required for secretion through the classical secretory pathway, some galectins show extracellular localization, suggesting that they are secreted through a non-classical pathway (Camby et al., 2006). Galectins are present both inside and outside cells. They function extracellularly by interacting with cell surface and extracellular matrix (ECM) glycoproteins and intracellularly by interacting, in a carbohydrate-independent manner, with cytoplasmic and nuclear proteins (Elola et al., 2007). They play a role in a wide range of processes, including cell adhesion, regulation of cell growth, apoptosis, embryonic development and immune processes-like inflammation (Perillo et al., 1998; Moiseeva et al., 1999; Liu and Rabinovich, 2005; Camby et al., 2006). A large amount of experimental evidence has been reported to support the important roles of galectins in cancer biology (Liu and Rabinovich, 2005; Rabinovich, 2005; Lahm et al., 2001; Stillman et al., 2005), including tumor angiogenesis (Moiseeva et al., 1999; Thijssen et al., 2006; Le Mercier et al., 2008b), tumor immune escape (Liu and Rabinovich, 2005) and cancer cell migration (Camby et al., 2001, 2002, 2005; Elola et al., 2007; Jung et al., 2008). In the following section, we focus our attention on the biological roles exerted by Gal1 in gliomas.

Galectin-1 in Glioma Biology The role of Gal1 in glioma biology was first suggested by Yamaoka et al. (2000) and Gunnersen et al. (2000). These groups analyzed the mRNA expression of Gal1 by northern blot in glioma specimens and glioma cell lines. Increased expression of Gal1 mRNA was shown to correlate with increased malignancy in human astrocytic tumors ranging from low-grade astrocytomas to malignant gliomas (Yamaoka et al., 2000). However,

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no statistical analysis was made (Yamaoka et al., 2000). Two studies from our own group using clinical samples have shown that Gal1 is expressed in all glioma types and that the level of Gal1 expression makes a distinction between non-invasive (WHO grade I) and invasive (WHO grade II-IV) gliomas of the astrocytic tumor (Rorive et al., 2001; Camby et al., 2001). Specifically, we quantitatively determined (by computer-assisted microscopy) the immunohistochemical expression of Gal1 in 220 gliomas, including 151 astrocytic, 38 oligodendroglial and 31 ependymal tumors (Rorive et al., 2001). Our data revealed the expression of Gal1 in all human glioma types with no striking variation in levels among astrocytic, oligodendroglial and ependymal tumors; the level of galectin-1 expression within astrocytic tumors, however, significantly correlated with tumor grade (Rorive et al., 2001). Furthermore, expression levels of Gal1 in highgrade astrocytic tumors from patients with short-term survival periods were significantly higher than those in tumors from patients with long-term survivals (Rorive et al., 2001). The expression of Gal1 was shown to be higher in the invasive parts of xenografted GBM than in the less invasive parts, suggesting their involvement in tumor astrocyte invasion of the brain parenchyma (Camby et al., 2001). Our group has focused on the role of Gal1 in glioma cell migration. We xenografted three human glioblastoma cell lines (H4, U87 and U373) into the brains of nude mice in order to characterize the in vivo galectin-1 expression pattern in relation to the tumor invasion of the normal brain parenchyma. Immunohistochemical analysis of galectin-1 expression in human U87 and U373 glioblastoma xenografts revealed a higher level of galectin-1 expression in invasive areas as compared to the non-invasive areas of the xenografts (Camby et al., 2001; Rorive et al., 2001). Moreover, nude mice intracranially grafted with U87 or U373 cells that were constitutively expressing low levels of galectin-1 (by stable transfection with an expression vector containing the antisense galectin-1 mRNA) had longer survival periods than those grafted with U87 or U373 cells unchanged in expression levels of galectin-1 (Camby et al., 2002). Complementary in vitro studies have shown that adding purified galectin-1 to U87 human GBM cells enhanced tumor cell motility in a lactose-inhibited manner (Camby et al., 2005). This effect appeared to be related to an increase

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in polymerized filamentous actin and the expression of the small guanosine triphosphatase RhoA (Camby et al., 2002). Finally, using cDNA microarray analysis and confirmation at protein levels, we observed that the U87 GBM cells that were galectin-1 deficient by means of an antisense galectin-1-stable transfection displayed increased protein levels for p21waf/cip1, cullin-2, p53, ADAM-15 and MAP-2 (Camby et al., 2005). Major differences in ADAM-15 expression and the actin stress fiber organization were also observed (Camby et al., 2005). The ADAM family of membraneanchorage glycoproteins encompasses a catalytically active MMP domain and a disintegrin domain and may thus be involved both in the proteolytic cleavage of cell-surface proteins and in integrin-mediated cell adhesion (including alpha9beta1 integrin/ADAM-15 interactions) via the RGD-dependent and -independent binding. Collectively, these data indicate that galectin-1 enhances the migratory capabilities of tumor astrocytes and, therefore, their biological aggressiveness. These features have been recently confirmed by Strik et al. (2007) and by Jung et al. (2008). Progression-associated genetic alterations are common to different glioma types and target growthpromoting and cell-cycle control pathways resulting in focal hypoxia, necrosis and angiogenesis (Louis et al., 2007). GBM is distinguished pathologically from

lower grade tumors by necrosis and microvascular hyperplasia (Louis et al., 2007). Necrotic foci are typically surrounded by “pseudopalisading” cells – a configuration that is relatively unique to malignant gliomas and has long been recognized as an ominous prognostic feature (Louis et al., 2007). Recent investigations have demonstrated that pseudopalisades are severely hypoxic, overexpress hypoxia-inducible factor 1 (HIF-1), and secrete proangiogenic factors such as vascular endothelial growth factor (VEGF) and IL-8 (Louis et al., 2007). HIF-1 is a potent activator of angiogenesis and invasion by upregulating target genes critical for these functions; activation of the HIF-1 pathway is a common feature of gliomas and may explain the intense vascular hyperplasia often seen in GBM. Galectin-1 is also a hypoxia-regulated protein (Le et al., 2005) that has been shown recently to display major roles in angiogenesis (Thijssen et al., 2006) in both gliomas (Le Mercier et al., 2008b) and melanomas (Mathieu et al., 2007) (Fig. 27.1). Galectin-1 involvement in tumor angiogenesis was first suggested after the discovery that both vascular smooth muscle and endothelial cells express the protein (Moiseeva et al., 1999). Clausse et al. (1999) have previously shown that galectin-1 was upregulated in capillaries associated with carcinoma cells. In addition, they found that galectin-1 could mediate interactions between tumors and endothelial cells in

Fig. 27.1 In stress conditions (black squares) such as hypoxia, radiotherapy and/or chemotherapy, increase of galectin-1 expression in GBM cells may activate migration, radio/chemoresistance, immune escape and angiogenesis.

Intracellular galectin-1 could be targeted by siRNA strategies. Alternatively, extracellular galectin-1 could be the target of small inhibitors

27 Glioblastoma: Role of Galectin-1 in Chemoresistance

vitro, suggesting a potential role for galectin-1 in modulating angiogenesis. Finally, Thijssen et al. (2006) have shown that treatment with either galectin1-specific antisense oligodeoxynucleotides or with polyclonal anti-galectin-1 antibodies resulted in inhibition of endothelial cell proliferation and migration, demonstrating an essential role for galectin-1 during angiogenesis. The role of galectin-1 in tumor angiogenesis is further highlighted in galectin-1-null mice, in which tumor growth is markedly impaired because of insufficient tumor angiogenesis (Thijssen et al., 2006). We ourselves have also put forward evidence for the role of galectin-1 in the process of angiogenesis using human glioma cells. To determine how galectin-1 exerts its pro-angiogenic effects, we investigated galectin-1 signaling in the human Hs683 glioma cell line. We observed that galectin-1 signals through the endoplasmic reticulum transmembrane kinase/ribonuclease inositol-requiring 1alpha (IRE1alpha) that regulates the expression of oxygenregulated protein 150 (ORP150), which in turn controls VEGF maturation. Galectin-1 also modulates the expression of six other hypoxia-related genes (CTGF, ATF3, PPP1R15A, HSPA5, TRA1 and CYR61) that are implicated in angiogenesis. Moreover, we have recently reported that downregulating galectin-1 expression in Hs683 human glioma cells through targeted small interfering RNAs provokes a marked decrease in the expression of the brain expressed Xlinked gene (BEX2), a feature which confers increased survival in Hs683 orthotopic xenograft-bearing mice. This decrease in BEX2 expression impairs vasculogenic mimicry channel formation in vitro and angiogenesis in vivo, and modulates glioma cell adhesion, motility and invasive features (Le Mercier et al., 2009).

Galectin-1 in Glioblastoma Chemo/Radioresistance Resistance of human tumors to anticancer drugs is most often ascribed to gene mutations, gene amplification or epigenetic changes that influence the uptake, metabolism or export of drugs from single cells (Trédan et al., 2007). Another important, yet littleappreciated, cause of anticancer drug resistance is the limited ability of drugs to penetrate tumor tissue and

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to reach all of the tumor cells at a potentially lethal concentration (Trédan et al., 2007). Although now recognized as a major contributor to malignant cancer progression and to treatment failure, the precise role of hypoxia signaling in cancer and in prognosis still needs to be further defined (Koumenis, 2006). As emphasized earlier, intra-tumoral hypoxia causes genetic changes in malignant gliomas that produce a microenvironment that selects for cells of a more aggressive phenotype. Hypoxia can initiate cell demise by apoptosis/necrosis but also prevent cell death by provoking adaptive responses that, in turn, facilitate cell proliferation or angiogenesis, thus contributing to tumor malignant progression (Zhou et al., 2006). Zhou et al. (2006) emphasize that considering that activation of HIF-1 provokes pro-survival as well as pro-death decisions under hypoxia, it will be crucial to understand decision making processes in regulating cell death, adaptation and chemoresistance. Hypoxia is also known to modulate the unfolded protein response, a coordinated program that promotes cell survival under conditions of endoplasmic reticulum (ER) stress (Koumenis, 2006), and which is known to contribute to tumor malignant progression and drug resistance of solid tumors. As mentioned earlier, hypoxia is known to activate galectin-1 expression (Le et al., 2005), and galectin-1 was found to be negatively regulated by transfection with TP53 in glioma cells (Puchades et al., 2007). We recently reported that temozolomide, the standard treatment for glioma patients (Lefranc et al., 2006; Stupp et al., 2009), increases galectin-1 expression in Hs683 glioma cells both in vitro and in vivo. In addition, galectin-1 expression was shown to be upregulated by ionizing irradiation of glioma cell lines in vitro (Strick et al., 2007). Reducing galectin-1 expression in these cells by siRNA increases the antitumor effects of various chemotherapeutic agents, in particular temozolomide both in vitro and in vivo in an orthotopic xenograft mouse model (Le Mercier et al., 2008a). We also observed that decreasing galectin-1 expression by means of an anti-galectin-1 siRNA in the mouse B16F10 metastatic melanoma model (a syngenic model whereby B16F10 melanoma cells are injected in the tail vein) also increases the therapeutic benefits contributed by temozolomide in vivo (Mathieu et al., 2007). This decrease of galectin1 expression in the B16F10 mouse melanoma cells does not modify their sensitivity to apoptosis nor

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autophagy. However, it does induce heat shock protein 70-mediated lysosomal membrane permeabilization (LMP), a process associated with cathepsin B release into the cytosol, which in turn is believed to sensitize the cells to the proautophagic effects of temozolomide when grafted in vivo (Mathieu et al., 2007). In Hs683 glioma cells a decrease in galectin-1 expression does not induce apoptotic or autophagic features and does not induce LMP, but is found to modulate p53 transcriptional activity and decrease p53-targeted gene expression including DDIT3/GADD153/CHOP, DUSP5, ATF3 and GADD45A (Le Mercier et al., 2008a). In addition, the decrease in galectin-1 expression impairs the ER stress response, which is believed to play a role in drug resistance, and also impairs the expression levels of seven other genes implicated in chemoresistance: ORP150; HERP; GRP78/Bip; TRA1; BNIP3; GADD45B; and CYR61, some of which are also known to be modified by hypoxia (Le Mercier et al., 2008a).

Conclusions Galectins are known to play an important role in malignant cancer progression and especially malignant gliomas (Camby et al., 2006; Le Mercier et al., 2009; Le Mercier et al., 2010). Galectin-1 is involved in many different steps of glioma biology, such as migration, angiogenesis and resistance to chemotherapy and radiotherapy. We have already shown that decreasing galectin-1 expression in human GBM orthotopic xenografts in mouse brains by siRNA administration enhances the therapeutic benefits of temozolomide (Le Mercier et al., 2008b). Thus, galectins, especially galectin-1, could be important targets for the development of new anticancer drugs not only for gliomas but for other types of cancer as well (Ingrassia et al., 2006). The novel aspects of Gal1-related function in the ERS response highlighted in the present study and pertinent to the chemoresistance of glioma cells may be amenable to therapeutic manipulation. This manipulation might be achieved either through in vivo delivery of anti-Gal1 siRNA as demonstrated in one of our preliminary studies (Le Mercier et al., 2008b) or through compounds that suppress Gal1 biological activity (Ingrassia et al., 2006; Camby et al., 2008). The in vivo delivery of anti-Gal1 siRNA directly into

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the brain could be achieved in GBM patients by means of Ommaya reservoirs, thus minimizing/avoiding systemic exposure and potential hepatotoxicity. Acknowledgments F. Lefranc is a clinical research fellow and R. Kiss a director of research with the Belgian National FNRS (Belgium). The present chapter was supported by grants awarded by the Fonds de la Recherche Scientifique Médicale (FRSM, Belgium) and by the Fonds Yvonne Boël (Brussels, Belgium).

References Ashery U, Yizhar O, Rotblat B, Elad-Sfadia G, Barkan B, Haklai R, Kloog Y (2006) Spatiotemporal organization of ras signaling: rasosomes and the galectin switch. Cell Mol Neurobiol 26:471–495 Barondes SH, Castronovo V, Cooper DN, Cummings RD, Drickamer K, Feizi T, Gitt MA, Hirabayashi J, Hughes C, Kasai K, Leffler H, Liu FT, Lotan R, Mercurio AM, Monsigny M, Pillai S, Poirer F, Raz A, Rigby PWJ, Rini JM, Wang JL (1994) Galectins: a family of animal betagalactoside-binding lectins. Cell 76:597–598 Camby I, Belot N, Lefranc F, Sadeghi N, de Launoit Y, Kaltner H, Musette S, Darro F, Danguy A, Salmon I, Gabius HJ, Kiss R (2002) Galectin-1 modulates human glioblastoma cell migration into the brain through modifications to the actin cytoskeleton and levels of expression of small GTPases. J Neuropathol Exp Neurol 61:585–596 Camby I, Belot N, Rorive S, Lefranc F, Maurage CA, Lahm H, Kaltner H, Hadari Y, Ruchoux MM, Brotchi J, Zick Y, Salmon I, Gabius HJ, Kiss R (2001) Galectins are differentially expressed in supratentorial pilocytic astrocytomas, astrocytomas, anaplastic astrocytomas and glioblastomas, and significantly modulate tumor astrocyte migration. Brain Pathol 11:12–26 Camby I, Decaestecker C, Lefranc F, Kaltner H, Gabius HJ, Kiss R (2005) Galectin-1 knocking down in human U87 glioblastoma cells alters their gene expression pattern. Biochem Biophys Res Commun 335:27–35 Camby I, Le Mercier M, Lefranc F, Kiss R (2006) Galectin1: a small protein with major functions. Glycobiology 16: 137R–157R Camby I, Le Mercier M, Mathieu V, Ingrassia L, Lefranc F, Kiss R (2008) Galectin-1 as a potential therapeutic target for cancer progression. Drug Fut 33:12 Clausse N, van den Brûle F, Waltregny D, Garnier F, Castronovo V (1999) Galectin-1 expression in prostate tumor-associated capillary endothelial cells is increased by prostate carcinoma cells and modulates heterotypic cell-cell adhesion. Angiogenesis 3:317–325 Elola MT, Wolfenstein-Todel C, Troncoso MF, Vasta GR, Rabinovich GA (2007) Galectins: matricellular glycanbinding proteins linking cell adhesion, migration, and survival. Cell Mol Life Sci 64:1679–1700 Goldberg L, Kloog Y (2006) A Ras inhibitor tilts the balance between Rac and Rho and blocks phosphatidylinositol 3-kinase-dependent glioblastoma cell migration. Cancer Res 66:11709–11717

27 Glioblastoma: Role of Galectin-1 in Chemoresistance Gunnersen JM, Spirkoska V, Smith PE, Danks RA, Tan SS (2000) Growth and migration markers of rat C6 glioma cells identified by serial analysis of gene expression. Glia 32:146–154 Ingrassia L, Camby I, Lefranc F, Mathieu V, Nshimyumukiza P, Darro F, Kiss R (2006) Anti-galectin compounds as potential anti-cancer drugs. Curr Med Chem 13:3513–3527 Jung TY, Jung S, Ryu HH, Jeong YI, Jin YH, Jin SG, Kim IY, Kang SS, Kim HS (2008) Role of galectin-1 in migration and invasion of human glioblastoma multiforme cell lines. J Neurosurg 109:273–284 Koumenis C (2006) ER stress, hypoxia tolerance and tumor progression. Curr Mol Med 6:55–69 Lahm H, Andre S, Hoeflich A, Fischer JR, Sordat B, Kaltner H, Wolf E, Gabius HJ (2001) Comprehensive galectin fingerprinting in a panel of 61 human tumor cell lines by RT-PCR and its implications for diagnostic and therapeutic procedures. J Cancer Res Clin Oncol 127:375–386 Le QT, Shi G, Cao H, Nelson DW, Wang Y, Chen EY, Zhao S, Kong C, Richardson D, O’Byrne KJ, Giaccia AJ, Koong AC (2005) Galectin-1: a link between tumor hypoxia and tumor immune privilege. J Clin Oncol 23:8932–8941 Leffler H, Carlsson S, Hedlund M, Qian Y, Poirier F (2004) Introduction to galectins. Glycoconj J 19:433–440 Lefranc F, Brotchi J, Kiss R (2005) Possible future issues in the treatment of glioblastomas: special emphasis on cell migration and the resistance of migrating glioblastoma cells to apoptosis. J Clin Oncol 23:2411–2422 Lefranc F, Sadeghi N, Camby I, Metens T, Dewitte O, Kiss R (2006) Present and potential future issues in glioblastoma treatment. Expert Rev Anticancer Ther 6:719–732 Le Mercier M, Fortin S, Mathieu V, Kiss R, Lefranc F (2010) Galectins and gliomas. Brain Pathol 20:17–27 Le Mercier M, Fortin S, Mathieu V, Roland I, Spiegl-Kreinecker S, Haibe-Kains B (2009) Galectin-1 pro-angiogenic and promigratory effects in the Hs683 oligodendroglioma model are partly mediated through the control of BEX2 expression. Neoplasia 11:485–496 Le Mercier M, Lefranc F, Mijatovic T, Debeir O, Haibe-Kains B, Bontempi G, Decaestecker C, Kiss R, Mathieu V (2008a) Evidence of galectin-1 involvement in glioma chemoresistance. Toxicol Appl Pharmacol 229:172–183 Le Mercier M, Mathieu V, Haibe-Kains B, Bontempi G, Mijatovic T, Decaestecker C, Kiss R, Lefranc F (2008b) Knocking down galectin 1 in human hs683 glioblastoma cells impairs both angiogenesis and endoplasmic reticulum stress responses. J Neuropathol Exp Neurol 67:456–469 Liu FT, Rabinovich GA (2005) Galectins as modulators of tumour progression. Nat Rev Cancer 5:29–41 Louis DN, Ohgaki H, Wiestler OD, Cavenee WK (2007) WHO classification of tumours of the central nervous system. International Agency for Research on Cancer (IARC), Lyon Mathieu V, Le Mercier M, De Neve N, Sauvage S, Gras T, Roland I, Lefranc F, Kiss R (2007) Galectin-1 knock-

267 down increases sensitivity to temozolomide in a B16F10 mouse metastatic melanoma model. J Invest Dermatol 127: 2399–2410 Moiseeva EP, Spring EL, Baron JH, de Bono DP (1999) Galectin 1 modulates attachment, spreading and migration of cultured vascular smooth muscle cells via interactions with cellular receptors and components of extracellular matrix. J Vasc Res 36:47–58 Perillo NL, Marcus ME, Baum LG (1998) Galectins: versatile modulators of cell adhesion, cell proliferation, and cell death. J Mol Med 76:402–412 Puchades M, Nilsson CL, Emmett MR, Aldape KD, Ji Y, Lang FF, Liu TJ, Conrad CA (2007) Proteomic investigation of glioblastoma cell lines treated with wild-type p53 and cytotoxic chemotherapy demonstrates an association between galectin-1 and p53 expression. J Proteome Res 6:869–875 Rabinovich GA (2005) Galectin-1 as a potential cancer target. Br J Cancer 92:1188–1192 Rorive S, Belot N, Decaestecker C, Lefranc F, Gordower L, Micik S, Maurage CA, Kaltner H, Ruchoux MM, Danguy A, Gabius HJ, Salmon I, Kiss R, Camby I (2001) Galectin-1 is highly expressed in human gliomas with relevance for modulation of invasion of tumor astrocytes into the brain parenchyma. Glia 33:241–255 Stillman BN, Mischel PS, Baum LG (2005) New roles for galectins in brain tumors–from prognostic markers to therapeutic targets. Brain Pathol 15:124–132 Strik HM, Schmidt K, Lingor P, Tonges L, Kugler W, Nitsche M, Rabinovich GA, Bähr M (2007) Galectin-1 expression in human glioma cells: modulation by ionizing radiation and effects on tumor cell proliferation and migration. Oncol Rep 18:483–488 Stupp R, Mayer M, Kann R, Weder W, Zouhair A, Betticher DC, Roth AD, Stahel RA, Majno SB, Peters S, Jost L, Furrer M, Thierstein S, Schmid RA, Hsu-Schmitz SF, Mirimanoff RO, Ris HB, Pless M (2009) Neoadjuvant chemotherapy and radiotherapy followed by surgery in selected patients with stage IIIB non-small-cell lung cancer: a multicentre phase II trial. Lancet Oncol 10:785–793 Thijssen VL, Postel R, Brandwijk RJ, Dings RP, Nesmelova I, Satijn S, Verhofstad N, Nakabeppu Y, Baum LG, Bakkers J, Mayo KH, Poirier F, Griffioen AW (2006) Galectin-1 is essential in tumor angiogenesis and is a target for antiangiogenesis therapy. Proc Natl Acad Sci USA 103:15975–15980 Trédan O, Galmarini CM, Patel K, Tannock IF (2007) Drug resistance and the solid tumor microenvironment. J Natl Cancer Inst 99:1441–1454 Yamaoka K, Mishima K, Nagashima Y, Asai A, Sanai Y, Kirino T (2000) Expression of galectin-1 mRNA correlates with the malignant potential of human gliomas and expression of antisense galectin-1 inhibits the growth of 9 glioma cells. J Neurosci Res 59:722–730 Zhou J, Schmid T, Schnitzer S, Brune B (2006) Tumor hypoxia and cancer progression. Cancer Lett 237:10–21

Chapter 28

Glioma-Initiating Cells: Interferon Treatment Atsushi Natsume, Masasuke Ohno, Kanako Yuki, Kazuya Motomura, and Toshihiko Wakabayashi

Abstract Type I interferons (IFNs) are cytokines that exhibit immunomodulatory, cell differentiative, antiangiogenic, and antiproliferative effects against various neoplasms, particularly glial tumors, by classically activating the Janus Kinase (JAK)/Signal Transducers and Activators of Transcription (STAT) pathways. In contrast to other chemotherapeutic agents, responses to IFN are slow and gradual, often requiring years to develop. However, such responses can be durable. Emerging evidence suggests that the activity of IFNs is directed principally at small populations of cancer stem cells. Glioma stem cells are reported to be resistant to a wide variety of chemotherapeutic agents and possess the remarkable ability to recover from cytotoxic therapy. Interestingly, IFN-β elicits significant antiproliferative effects on glioma stem cells although such effects are not elicited by temozolomide. This cytokine induces terminal differentiation of glioma stem cells to the oligodendroglial cell lineage and downregulates an anti-apoptotic microRNA, miR-21, which is overexpressed in glioma stem cells. IFN-mediated STAT3 phosphorylation may play a crucial role in these events. Previous studies have indicated that chemokines such as bone morphogenetic protein (BMP) and leukemia inhibitory factor/ciliary neurotrophic factor (LIF/CTNF) induce STAT3-mediated differentiation of glioma stem cells. The results of

A. Natsume () Department of Neurosurgery, Nagoya University School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan e-mail: [email protected]

these studies provide a new strategy for therapeutic approaches that can induce glioma stem cells to undergo terminal differentiation. Keywords INFs · Cytokine · STAT pathways · Glioma stem cells · microRNA · Phosphorylation

Introduction Type I interferons (IFNs), including IFN-α and IFN-β, are cytokines that exhibit immunomodulatory, cell differentiative, antiangiogenic, and antiproliferative effects against various neoplasms, particularly glial tumors, by classically activating the Janus Kinase (JAK)/Signal Transducers and Activators of Transcription (STAT) pathways (Borden et al., 2007). One of the type I IFNs, IFN-β has multifaceted functions related to antitumor activity, such as cytostatic effects, participation in the differentiation of cytotoxic T lymphocytes and potentiation of their antitumor immunological responses, and ability to act as a drug sensitizer to enhance toxicity against various malignant neoplasms. Combination therapy with IFN-β and nitrosourea has been particularly useful in the treatment of malignant gliomas. We previously reported that IFN-β markedly enhances chemosensitivity to temozolomide, an alkylating agent (Natsume et al., 2005). This revealed that a major mechanism by which IFN-β enhances chemosensitivity is via the downregulation of O6-methylguanine-DNA methyl-transferase (MGMT) transcription through augmentation with TP53. This effect was also confirmed in an experimental animal model (Natsume et al., 2008). In this

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_28, © Springer Science+Business Media B.V. 2011

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chapter, we show that IFN-β elicits a remarkable antiproliferative effect on glioma stem cells (GSCs) and induces terminal differentiation of GSCs to the oligodendroglial cell lineage by the activation of STAT3. Further, we focus on microRNA regulation by type I IFNs in GSCs.

Cancer Stem Cells and Type I IFNs Cancers harbor small cell populations that have the potential to sustain growth and initiate tumorigenesis. These cells, which are known as cancer stem cells (CSCs) or cancer initiating cells, have been identified in leukemia, multiple myeloma, breast cancer, and glioma. In solid tumors, CSCs share many properties with normal stem cells, including self-renewal and multi-potency, and furthermore are known to initiate the growth of tumors. A long-recognized paradox of response and survival in cancer therapies is that although most cancer patients respond to therapy, few are completely cured. The objective clinical response to treatment may not predict substantial improvements in overall survival. Huff et al. (2006) coined the term “dandelion phenomenon” to describe this paradox in cancer. The pattern of the clinical responses displayed by patients with chronic myeloid leukemia (CML) toward imatinib and IFN are quite different. The rapid responses induced by imatinib are probably a consequence of its impressive activity against differentiated CML cells that make up the bulk of the leukemia. However these early effective responses often do not last. The evidence could be explained by the development of CML stem cell resistance to imatinib. Conversely, responses to IFN are slow and gradual, often requiring years to develop, but can be durable; this is consistent with the data suggesting that IFN’s activity is directed principally at small populations of CML stem cells. The pattern of imatinib activity may be analogous to cutting a dandelion off at ground level and leaving the unseen root behind, while IFN mimics specific attack of the root of the dandelion. This response–survival paradox also applies to other malignancies. In ovarian cancer, Moserle et al. (2008) demonstrated that IFN exerts marked antiproliferative effects on side population cells with higher proliferation rates. However, the mechanism of action underlying this effect remains undefined.

A. Natsume et al.

Establishment of Glioma Stem Cells Glioblastoma multiforme (GBM) is the most lethal primary glioma. Patients diagnosed with this type of glioma typically have a median survival of less than 12 months, despite various therapies, including surgical resection, radiotherapy, and chemotherapy. For many years, gliomas such as GBM have been considered to represent the bulk of heterogeneous tumors that consist of differentiated cells and undifferentiated cells with the capability of self-renewal and partial differentiation (Lee et al., 2006). Therefore, failure to eradicate glioma cells may be responsible for the small fraction of undifferentiated tumor cells that re-grow. Nestin is an intermediate filament cytoskeletal protein found in neuroepithelial stem cells and progenitor cells (Reynolds and Weiss, 1992). It has been shown that glial-derived neoplasms also express nestin, and the level of expression is higher in high-grade gliomas compared to low-grade gliomas (Dahlstrand et al., 1992). Using the neurosphere assay, Ignatova et al. (2002) were able to isolate nestin-expressing cells capable of forming clones that exhibit intraclonal heterogeneity in the expression of neural lineage-specific proteins. Subsequently, when Singh et al. (2003) successfully cultured glioma cells in serum-free medium containing stem cell growth factors bFGF and EGF, it was observed that a small percentage of all glioma cells ranging from 0.3 to 25.1%, depending on the aggressiveness of the tumor, were capable of self-replication and formed non-adherent neurospheres and maintained tumor culture over time via multiple passages. These self-renewing and tumor culture-maintaining cells not only stained positive for the undifferentiated neural stem cell marker nestin, they also stained positive for CD133, a hematopoietic stem cell marker also present on normal human neural stem cells. However, these cells were found to lack the expression of β tubulin III and glial fibrillary acidic protein (GFAP), which can be used as markers for differentiated neuronal lineage. In stark contrast to this small group of CD133+ cells, the majority of glioma cells were found to be CD133- and incapable of forming self-sustaining neurospheres. As a general observation, the fraction of CD133+ GSCs from aggressive tumors exhibited an increased rate of self renewal relative to less aggressive tumors. Under culture conditions that promote differentiation, GSCs lose the expression of primitive markers like

28 Glioma-Initiating Cells: Interferon Treatment

CD133 and nestin and instead express differentiated markers for the cell of origin. When serially transplanted into the brain of a NOD-SCID (non-obese diabetic, severe combined immunodeficient) mouse, these GSCs were able to produce exact phenocopies of the original tumor with all the histopathological features and cell surface markers of the original tumor. Immunohistological staining of these GBM xenografts that showed differential staining for CD133 and GFAP underlines the fact that GSCs can differentiate into mature progeny. Even though the presence of GSC can clearly account for the inherent heterogeneous nature of gliomas, cellular and genetic analysis of GSCs showed that these cells were genetically transformed with enhanced self-renewal properties and possessed an abnormal karyotype, which is not only limited to CD133+ cells, but also present in both CD133+ and CD133- cells. This suggests that all cancer cells were clonally derived. Even though consensus has not yet been reached on the exact mechanism of gliomagenesis, our new found understanding of the presence of functional hierarchy in glioma indicates that it will be important to investigate the slow growing mutated GSCs in order to gain an understanding of the mechanisms of treatment failure. GSCs are reported to be resistant to a wide variety of chemotherapeutic agents and possess the remarkable ability to recover from cytotoxic therapy (Eramo et al., 2006). Kang et al. (2007) reported that a small population of multipotent CD 133+ cancer cells can survive and proliferate upon exposure of GBM cells to a lethal dose of carmustine (BCNU). When transplanted into a SCID mouse brain, the original tumor was reproduced. A significantly higher level of CD133+ cells was reported to be present in previously treated GBM when compared with newly diagnosed GBM (Liu et al., 2006). The gene profile of CD133+ cells exhibits a high level of expression of anti-apoptotic genes and chemotherapy resistance genes such as BCRP1, and MGMT (Liu et al., 2006), rendering these cells resistant to many commonly used chemotherapeutic agents, including temozolomide, carboplatin, paclitaxel (Taxol), and etoposide (VP16). In the same tumor, examples of genes such as multi drug resistance-associated proteins 1 and 3 were found to be markedly elevated in GSCs when compared to non-GSCs (Salmaggi et al., 2006). This emphasizes their role in chemoresistance.

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GSCs not only play a crucial role in chemoresistance, but are vital with respect to the failure of radiation therapy since tumors surviving radiotherapy are found to be enriched in CSCs. In a study conducted by Bao et al. (2006), irradiation of an in vivo glioma xenograft led to a 3–5-fold increase in the CD133+ cell population relative to untreated xenografts. This suggests that irradiation leads to the enrichment of CD133+ cells in the tumor and subsequent formation of more aggressive tumors with decreased latency after serial transplantation. Given the pattern of treatment failure observed with current standard therapy, an alternative strategy involving selectively targeting this functionally distinct chemo- and radiation-resistant small group of GSCs instead of the bulk of the tumor might provide better success in treating this deadly disease.

Terminal Differentiation of GSC by IFN STAT3 activation is crucial for stem cell function, differentiation, and survival. Recent studies demonstrated that bone morphogenetic protein (BMP) and leukemia inhibitory factor/ciliary neurotrophic factor (LIF/CTNF) induced STAT3-mediated differentiation of neural and GSCs (Lee et al., 2008). These studies indicate the potential for therapeutic approaches that can induce GSCs to undergo terminal differentiation. Our previous study showed that STAT3 expression is strongly upregulated in GSCs, and that IFN-β phosphorylates a tyrosine residue of STAT3. IFN-β treatment elicits a remarkable antiproliferative effect and enhances the expression of oligodendroglial markers, including oligodendrocyte-specific protein (OSP), galactosylceraminidase (GalC), and myelin basic protein (MBP), on GSCs. However, the expression of these markers was inhibited by a peptide that specifically inhibits STAT3 (Fig. 28.1). Furthermore, IFNβ treatment did not induce the expression of OSP, GalC, and MBP in human neural stem cells. In contrast, while the expression of other neural lineage markers (i.e., GFAP and neuron-specific class III βtubulin) was unaffected, the expression of nestin and CD133 was reduced in the GSCs after IFN-β treatment. IFN-β-treated GSCs were unable to form tumors in NOD/SCID mice (Yuki et al., 2009). Therefore, IFN may represent a potential therapeutic agent for inducing terminal differentiation of GSCs.

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Fig. 28.1 IFN-β phosphorylates a tyrosine residue of STAT3. IFN-β treatment elicits a remarkable antiproliferative effect. IFN-β induces glioma stem cells to undergo terminal differentiation to mature oligodendrocytes that

express oligodendrocyte-specific protein (OSP), galactosylceraminidase (GalC), and myelin basic protein (MBP), and inhibits gliomagenesis

Regulation of MicroRNAs by IFN in GSCs

its translation (Esquela-Kerscher and Slack, 2006). Emerging evidence suggests that miRNAs are involved in crucial biological processes, including development, differentiation, apoptosis, and proliferation of mammalian cells. In humans, miRNAs have been proposed to contribute to oncogenesis because they possess multifaceted functions either as tumor suppressors or as oncogenes (Schickel et al., 2008). RNA interference induces a multitude of responses in addition to the knockdown of a gene. This is best understood in the context of an antiviral immune response. In particular, double-stranded RNA, a nucleic acid associated with viral replication, is involved in numerous interactions contributing to the induction, activation, and regulation of antiviral mechanisms. One particularly intriguing function of double-stranded RNA is to stimulate important protective responses such as the activation of Dicer-related antiviral pathways, induction of type I IFN (IFN-α/β), and stimulation of double-stranded RNA-activated protein kinase and oligoadenylate synthase (Karpala et al., 2005).

MicroRNAs (miRNAs) are small noncoding RNAs consisting of 20–22 nucleotides that participate in the posttranslational regulation of gene expression by means of RNA interference (RNAi). The miRNA genes are transcribed by RNA polymerase II in the nucleus to form large pri-miRNA transcripts. These pri-miRNA transcripts are processed by the Drosha enzyme to release the pre-miRNA precursor product, which is less than 70 nucleotides in length. After the pre-miRNA is transported into the cytoplasm, another enzyme known as Dicer processes the intermediate to generate a mature 22nucleotide miRNA. This mature miRNA is integrated into the RNA-induced silencing complex and forms double-stranded RNA with complementary mRNAs. Depending on the degree of homology between the miRNA and the mRNA, the RNA-induced silencing complex could inhibit mRNA function by either promoting its cleavage or by inhibiting

28 Glioma-Initiating Cells: Interferon Treatment

IFN-α/β regulates the levels of crucial mediators of the antiviral response, such as protein kinase R, the 2 –5 oligoadenylate synthase/RNase L system, adenosine deaminase ADR1, and Mx GTPase (Katze et al., 2002). Thus, RNA interference might be involved in the IFN-mediated antiviral response. It was recently reported that the levels of liver-specific miRNA, miR-122, and several other miRNAs are regulated by IFN-β in human hepatoma cells, and that IFN-β rapidly modulates the expression of miRNAs that target the hepatitis C virus genomic RNA, thereby inhibiting viral replication (Pedersen et al., 2007). In addition to its ability to interfere with viral replication, IFN-β is also known for its antiproliferative effects in a variety of neoplasms such as hepatocellular carcinoma, chronic myeloblastic leukemia, melanoma, renal cancer, and glioma (Borden et al., 2007). Therefore, the possibility is recognized that IFN-β might induce or downregulate cellular miRNAs in human neoplasms and thereby use the RNA interference system in its action against tumor progression. We tested whether IFN-β can alter the expression of cellular miRNAs in human glioma cells by using the data obtained from a genome-wide microarray (Ohno et al., 2009). On the basis of the initial screening, we found that the expression levels of several miRNAs were increased (miR-187 and miR-194) or attenuated (miR-100, miR-21, and let-7 family miRNAs) in response to IFN-β treatment. Of the miRNAs regulated by IFN-β, we focused on miR-21 because it is one of the best known miRNAs associated with tumorigenesis and progression in gliomas. miR-21 also modulates tumorigenesis through the regulation of genes such as bcl-2, PTEN, tropomyosin-1, and PDCD4 (Chen et al., 2008; Meng et al., 2007; Zhu et al., 2007). Previously, miR-21 was suggested to be aberrantly expressed and was recognized as one of the major anti-apoptotic factors in malignant gliomas (Chan et al., 2005). We demonstrated that the overexpression of miR-21 occurs in a surgical specimen of glioblastoma by performing an in situ hybridization (Fig. 28.2a–c). We also compared the miR-21 expression levels in glioma cell lines, GSCs, and normal brain tissue. The miR-21 was found to be overexpressed in glioma cells relative to normal brain cells. Notably, the expression level of miR-21 was found to be greater in GSCs than in the glioma cell lines (Fig. 28.2d). This finding may indicate that miR-21 plays a crucial role in the initiation and progression of glioma.

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Investigations using quantitative real timepolymerase chain reaction (qRT-PCR) revealed that IFN-β downregulates miR-21 in cultured glioma cell lines and GSCs, and that the systemic delivery of IFN-β reduces the level of miR-21 in intracranial GSC xenografts in mice. In the time course experiments, the IFN-β treatment showed a relatively fast response in reducing miR-21 levels, suggesting that the negative regulation of miR-21 might be mediated directly by IFN-β, for example, through the phosphorylation of JAK/STAT. Our finding that IFN-β also suppresses the expression of pri-miR-21 and pre-miR-21 suggests that it regulates miR-21 transcription. The putative regulatory region of the miR-21 gene is located within an intron of the overlapping transmembrane protein 49 gene (TMEM49). This regulatory region contains 2 consensus STAT3-binding sites located approximately 800 bp upstream from the transcription start site. We used a luciferase reporter gene system with a fused full-length pri-miR-21 promoter, including the STAT3 binding site, to demonstrate that IFN-β inactivates STAT3-mediated miR-21 promoter activity and that the transcription activity could be recovered by using a STAT3 inhibitor. These data suggest that miR-21 expression is negatively regulated by STAT3 activation induced by IFN-β. In conclusion, the downregulation of miR-21 in response to IFN-β treatment contributes to the antitumor effects of this cytokine in GSCs. Furthermore, miR-21 expression is negatively regulated by STAT3 activation (Fig. 28.3). These results highlight the importance of understanding the transcriptional regulation of miRNAs, which would be involved in oncogenesis of gliomas.

Discussion Here, we show that STAT3 activation is crucial for oligodendrogenesis and miR-21 downregulation in GSCs. However, the role of STAT3 activation is debatable because its overactivation has been reported to be oncogenic in other neoplasms (Frank, 2007). Loffler et al. (2007) demonstrated that IL-6dependent STAT3 activates the transcription of miR-21 in multiple myeloma cells. While IL-6 induces proliferation of myeloma cells, IFN-β reduces the growth of glioma cells or induces apoptosis in these cells.

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Fig. 28.2 (a) miR-21 overexpression in glioma-initiating cells (GICs). miR-21–specific probe was hybridized in situ with glioblastoma tissue obtained from a surgical specimen. The miR-21–specific probe clearly stains the glioblastoma tissue but doesnot stain the normal cortextissue. (b) Tumor cells express significant amounts of miR-21, as observed under high

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magnification, (c) whereas nontumorous tissue does not express miR-21. (d) qRT-PCR shows that miR-21 is overexpressed to a great extent in glioma cells than in normal brain cells. Notably, the amount of miR-21 is greater in GICs than in the glioma cell lines. Columns, mean; bars, SD (normal brain expressed as 1)

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Fig. 28.3 IFN-β inactivates STAT3-mediated miR-21 promoter activity. The miRNA genes are transcribed by RNA polymerase II in the nucleus to form large pri-miRNA transcripts. These pri-miRNA transcripts are processed by the Drosha enzyme to release the pre-miRNA precursor product, which is less than 70 nucleotides in length. After the pre-miRNA is transported into

the cytoplasm, another enzyme known as Dicer processes the intermediate to generate a mature 22-nucleotide miRNA. This mature miRNA is integrated into the RNA-induced silencing complex and forms double-stranded RNA with complementary mRNAs of genes such as bcl-2, PTEN, tropomyosin-1, and PDCD4

A possible explanation for this seemingly paradoxical role of STAT3 activation is that the STAT pathway is context-dependent and that various intracellular and/or environmental cues play a pivotal role in determining the outcome of the activation of the pathway. This discrepancy may arise from differences in cytokine stimulus and cell type (Loffler et al., 2007). An unresolved question pertains to the identity of the regulators of oligodendrogenesis of GSCs. Oligodendroglial lineage arises from undifferentiated progenitor cells, which are predominately found in the subventricular zone. These progenitor cells mature into myelinating oligodendrocytes as a result of interactions between BMP, sonic hedgehog, and proteins of the Notch signaling pathways (Nicolay et al., 2007). IFN may activate the BMP/Smad pathway and Notch signaling. There is a strong evidence suggesting that thyroid hormones (THs) directly regulate the differentiation and maturation of oligodendroglial cells. Triiodothyronine (T3) is an active hormone that

regulates gene expression by binding to specific intracellular TH receptors. Our group previously showed that 95% of glioma cells express a member of the thyroid/steroid hormone receptor superfamily – peroxisome proliferative-activated receptor gamma (PPARγ), which activates the transcription of target genes after forming heterodimers with retinoid X receptors (RXR). PPARs are known to be responsible for deciding the fate of specific neural stem cells. It has been reported that PPARs regulate the proliferation, migration, and differentiation of neural stem cells via STAT3 activation. Although further confirmative studies are warranted in this regard, we were able to show that treatment of GSCs with IFN-β causes the release of T3 and that this is inhibited by the STAT3 inhibitor. Treatment with exogenous T3 results in the formation of MBP-positive mature oligodendrocytes displaying a multibranched morphology. This suggests that GSCs may possess neuroendocrinal properties and differentiate into mature oligodendrocytes.

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A. Natsume et al. Loffler D, Brocke-Heidrich K, Pfeifer G, Stocsits C, Hackermuller J, Kretzschmar AK, Burger R, Gramatzki M, Blumert C, Bauer K, Cvijic H, Ullmann AK, Stadler PF, Horn F (2007) Interleukin-6 dependent survival of multiple myeloma cells involves the Stat3-mediated induction of microRNA-21 through a highly conserved enhancer. Blood 110:1330–1333 Meng F, Henson R, Wehbe-Janek H, Ghoshal K, Jacob ST, Patel T (2007) MicroRNA-21 regulates expression of the PTEN tumor suppressor gene in human hepatocellular cancer. Gastroenterology 133:647–658 Moserle L, Indraccolo S, Ghisi M, Frasson C, Fortunato E, Canevari S, Miotti S, Tosello V, Zamarchi R, Corradin A, Minuzzo S, Rossi E, Basso G, Amadori A (2008) The side population of ovarian cancer cells is a primary target of IFN-alpha antitumor effects. Cancer Res 68:5658–5668 Natsume A, Ishii D, Wakabayashi T, Tsuno T, Hatano H, Mizuno M, Yoshida J (2005) IFN-beta down-regulates the expression of DNA repair gene MGMT and sensitizes resistant glioma cells to temozolomide. Cancer Res 65:7573–7579 Natsume A, Wakabayashi T, Ishii D, Maruta H, Fujii M, Shimato S, Ito M, Yoshida J (2008) A combination of IFN-beta and temozolomide in human glioma xenograft models: implication of p53-mediated MGMT downregulation. Cancer Chemother Pharmacol 61:653–659 Nicolay DJ, Doucette JR, Nazarali AJ (2007) Transcriptional control of oligodendrogenesis. Glia 55:1287–1299 Ohno M, Natsume A, Kondo Y, Iwamizu H, Motomura K, Toda H, Ito M, Kato T, Wakabayashi T (2009) The modulation of microRNAs by type I IFN through the activation of signal transducers and activators of transcription 3 in human glioma. Mol Cancer Res 7:2022–2030 Pedersen IM, Cheng G, Wieland S, Volinia S, Croce CM, Chisari FV, David M (2007) Interferon modulation of cellular microRNAs as an antiviral mechanism. Nature 449: 919–922 Reynolds BA, Weiss S (1992) Generation of neurons and astrocytes from isolated cells of the adult mammalian central nervous system. Science 255:1707–1710 Salmaggi A, Boiardi A, Gelati M, Russo A, Calatozzolo C, Ciusani E, Sciacca FL, Ottolina A, Parati EA, La Porta C, Alessandri G, Marras C, Croci D, De Rossi M (2006) Glioblastoma-derived tumorospheres identify a population of tumor stem-like cells with angiogenic potential and enhanced multidrug resistance phenotype. Glia 54:850–860 Schickel R, Boyerinas B, Park SM, Peter ME (2008) MicroRNAs: key players in the immune system, differentiation, tumorigenesis and cell death. Oncogene 27: 5959–5974 Singh SK, Clarke ID, Terasaki M, Bonn VE, Hawkins C, Squire J, Dirks PB (2003) Identification of a cancer stem cell in human brain tumors. Cancer Res 63:5821–5828 Yuki K, Natsume A, Yokoyama H, Kondo Y, Ohno M, Kato T, Chansakul P, Ito M, Kim SU, Wakabayashi T (2009) Induction of oligodendrogenesis in glioblastoma-initiating cells by IFN-mediated activation of STAT3 signaling. Cancer Lett 284:71–79 Zhu S, Si ML, Wu H, Mo YY (2007) MicroRNA-21 targets the tumor suppressor gene tropomyosin 1 (TPM1). J Biol Chem 282:14328–14336

Chapter 29

Glioblastoma: Anti-tumor Action of Natural and Synthetic Cannabinoids Aleksandra Ellert-Miklaszewska, Iwona Ciechomska, and Bozena Kaminska

Abstract The past few decades have seen renewed interest in medicinal cannabis or rather cannabinoids – active compounds derived from the Cannabis plant, as well as their endogenous counterparts and a still growing set of synthetic derivatives. One of the most extensively studied and promising applications of cannabinoids is their potential use as anti-cancer agents in malignant tumors, such as glioblastomas. The anti-tumor action of cannabinoids is mediated via the CB1 and CB2 cannabinoid receptors. Growing array of data suggest that significant alterations of a balance in the cannabinoid system between the levels of endogenous ligands and their receptors occur along with the malignant transformation in various types of cancer. Increased CB2 receptor expression has been observed in glioblastoma cells, invading microglia/macrophages and endothelial cells of the tumor blood vessels as compared to non-tumor brain samples. Thus, among various approaches to avoid CB1-receptor-mediated psychodysleptic side effects of some cannabinoids, special attention is paid to substances, which selectively stimulate the CB2 receptors, putatively overexpressed in target tumor cells. Induction of cell death by cannabinoid treatment relies on the generation of a pro-apoptotic sphingolipid ceramide and disruption of signaling pathways crucial for regulation of cellular proliferation, differentiation or apoptosis. Increased ceramide levels lead also to ER-stress and autophagy in drug treated glioblastoma

B. Kaminska () Laboratory of Transcription Regulation, Department of Cell Biology, Nencki Institute of Experimental Biology, 02-093 Warsaw, Poland e-mail: [email protected]

cells. Cannabinoids have displayed a great potency in reducing glioma tumor growth in experimental animal models without producing the generalized toxic effects unavoidable with most conventional chemotherapeutic drugs. Apparently their effectiveness in vivo has been attributed to several mechanisms of action. Cannabinoids have recently emerged as compounds that beyond inhibition of tumor cell proliferation and survival impair tumor angiogenesis, invasiveness and even gliomagenesis. The good safety profile observed in a pilot clinical trial, together with remarkable antitumor effects reported in preclinical studies may set the basis for further research aimed at better evaluation of the potential anti-cancer activity of cannabinoids. A unique mechanism of cannabinoid action among standard oncology remedies justifies further research on their anti-tumoral properties either alone or in combined therapies. Keywords Glioblastoma · Cannabinoids · Anti-cancer agents · Receptors · Ligands · Autophagy

Introduction Preparations from Cannabis sativa, the hemp plant, have been used for centuries for both medicinal and recreational purposes (Howlett et al., 2002; Mackie, 2006). Isolation of the active components of the plant, called cannabinoids, in 1960s, as much as subsequent cloning of cannabinoid receptors, discovery of their endogenous ligands and development of synthetic cannabinoids contributed to an intensive burst of cannabinoid research. Along with our expanding comprehension of mechanisms of cannabinoids action,

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targeting cannabinoid signaling for therapeutic purposes has inevitably emerged as an interesting area of scientific and clinical investigations. One of the most extensively studied applications of cannabinoids is their potential use as anti-cancer agents. Anti-proliferative effects of cannabinoids have been reported in various cultured cancer cells, including neural, breast, prostate, skin, thyroid cancer cells and leukemia cells. Several studies demonstrated anti-tumor activity of cannabinoids in animal models (Guzman, 2003). Since the first publication by Sanchez and co-workers in 1998 providing evidence that cannabinoids can be an effective tool against glioma cells, growing interest of several groups including ours has been focused on therapeutic potential of cannabinoids in glial tumors. Current scientific data relevant to the use of cannabinoids in treatments of glioblastomas are reviewed here including both in vitro and in vivo results, proposed mechanisms of action, reports from limited human studies and prospects for patients therapy in clinics.

Cannabinoid System in Health and Brain Tumors Cannabinoids are a group of structurally heterogenous but pharmacologically related compounds classified into three subtypes. Plant-derived cannabinoids (phytocannabinoids) are uniquely found in the cannabis plant. (–)-trans-9 -tetrahydrocannabinol (9 -THC) is the most potent and abundant out of approximately 70 identified phytocannabinoids. Endogenous cannabinoids (also known as endocannabinoids) such anandamide and 2-arachidonoylglycerol are produced by mammals as rapidly inactivated lipid mediators, which levels are strictly controlled by a transporter system and hydrolyzing enzymes. Various modifications of the chemical structure of natural cannabinoids based on structure-activity relationship studies have led to generation of a still growing set of synthetic cannabinoids (Fig. 29.1). Cannabinoids elicit a wide range of central and peripheral effects, which are mediated mostly through cannabinoid receptors (Howlett et al., 2002). There are two types of specific Gi/o -protein-coupled receptors cloned so far, called CB1 and CB2, although an existence of additional cannabinoid-binding receptors

A. Ellert-Miklaszewska et al.

has been suggested (Howlett et al., 2002; Stella, 2004). CB1 and CB2 differ in their predicted amino acid sequence, tissue distribution, physiological role and signaling mechanisms. CB1 is abundantly expressed in the central nervous system and peripheral nerve terminals, where it mediates inhibition of neurotransmitter release, but it is also present in some extra-neural sites, such as testis, uterus, vascular endothelium, eye, spleen, and tonsils (Howlett et al., 2002). By contrast, the CB2 receptor is predominantly expressed in cells and organs of the immune system (Howlett et al., 2002). The role of peripheral CB2 receptor activation under baseline physiologic conditions is still not well defined. It is suggested to be involved in B-cell differentiation and modulation of immune response. Increased levels of CB2 are reported in tissues during development, inflammation, injury and cancer, revealing a critical role for the CB2 receptor in regulating these processes (Howlett et al., 2002). The CB2 receptor was believed to be absent from healthy brain, however, its expression has been detected recently in microglia – brain macrophages (Stella, 2004; Gong et al., 2006), as well as in a small subpopulation of neurons (Van Sickle et al., 2005; Gong et al., 2006). The function of CB2 receptor in the brain is completely unknown. Nevertheless, experiments performed in animals show that CB2-selective agonists appear to be free from widespread psychoactive effects attributed to activation of the CB1 receptor (Guzman, 2003; Valenzano et al., 2005). Growing array of data suggest that significant alterations of a balance in the cannabinoid system between the levels of endogenous ligands and their receptors occur along with the malignant transformation in various types of cancer. While non-transformed astrocytes were shown to express only the CB1 cannabinoid receptor, both types of functional cannabinoid receptors have been found in several established human glioblastoma cell lines, as well as in primary cultures derived from the most malignant brain tumor, glioblastoma multiforme (GBM) (Galve-Roperh et al., 2000; Sanchez et al., 2001; Howlett et al., 2002) (and our unpublished data). Immunohistochemical analysis of human low and high grade glioma surgical specimens revealed increased CB2 receptor expression in tumor cells, invading microglia/macrophages and endothelial cells of the tumor blood vessels as compared to non-tumor brain samples (Sanchez et al., 2001; EllertMiklaszewska et al., 2007; Schley et al., 2009). We

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Fig. 29.1 Chemical structures of plant-derived 9 -THC ((-)-trans-9 -tetrahydrocannabinol), endocannabinoid anandamide (N-arachidonoylethanolamine) and synthetic cannabinoids JWH133, selective for non-psychoactive CB2 receptor ((6aR,10aR)-3-(1,1-Dimethylbutyl)-6a,7,10,10a-tetrahydro-6,6,

9-trimethyl-6H-dibenzo[b,d]pyran), and WIN55,212-2, a CB1/ CB2 receptor agonist ((R)-(+)-[2,3-Dihydro-5-methyl-3-(4morpholinylmethyl)pyrrolo[1,2,3-de]-1,4-benzoxazin-6-yl]-1naphthalenylmethanone)

detected the presence of CB2 receptors in all analyzed biopsies of astrocytomas and glioblastomas. The proportion of malignant tumors expressing high levels of CB2 (10 out of 16, 62.5%) was over 2-fold higher than that seen in the tumors of lower grade (7 out of 29, 24%) (Ellert-Miklaszewska et al., 2007). Thus, the extent of CB2 expression correlated with tumor malignancy. Moreover, as observed by Sanchez et al. (2001) CB2 receptor immunoreactivity markedly prevailed over detected CB1 receptor levels in grade IV astrocytomas (Sanchez et al., 2001). The levels of CB1 receptor expression in tumor and tumor-associated endothelial cells were not significantly different from the control tissue and showed no dependence on tumor grade (Sanchez et al., 2001; Schley et al., 2009). As brain tumors constitute the second most common malignancy in children and the prevalence of histological types of brain tumors vary significantly between the adult and pediatric populations, we compared the expression of the CB2 receptor in paraffin-embedded sections from primary brain tumors of adult and pediatric patients (Ellert-Miklaszewska et al., 2007). Most glioblastomas obtained from children expressed very high levels of CB2 receptors. Interestingly,

some benign pediatric astrocytic tumors, such as subependymal giant cell astrocytoma (SEGA), which may occasionally cause mortality owing to progressive growth in some patients, also displayed high CB2imunoreactivity. The high levels of CB2 expression would predestine astrocytic tumors to be vulnerable to cannabinoid treatment. Significant CB2 immunostaining was also found in limited cases of other histological types of brain tumors, primarily in high grade ependymomas and meningiomas (Ellert-Miklaszewska et al., 2007). However, we observed that the CB2 staining intensity was much higher in astrocytomas than in oligodendrogliomas, ependymomas or meningiomas of the same grade. It is worth to mention that all examined cases of embryonal tumors (medulloblastoma and S-PNET), the most frequently diagnosed malignant brain tumors in childhood, showed no or trace CB2 immunoreactivity. Our results suggest that the level of CB2 receptor expression correlates primarily with the histopathological origin of the brain tumor cells and their differentiation state, reflected in the tumor grade. A link between CB2 expression and malignancy grade of the tumor has been reported also in prostate,

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breast and pancreatic cancer, and the level of CB2 expression in transformed cells was higher than in the respective normal tissue (Sarfaraz et al., 2005; Caffarel et al., 2006; Carracedo et al., 2006a). In examined tumors, CB2 receptors were usually located in the areas of intense tissue proliferation and invading cells. The enhancement of cannabinoid receptor expression in malignant versus healthy tissues, might suggest a possible role of the endocannabinoid system in the tonic suppression of cell divisions and cancer growth. This hypothesis is partly supported by the finding of increased levels of anandamide and decreased levels of one of endocannabinoid metabolizing enzymes in human glioblastoma compared to human non-tumor brain tissue (Petersen et al., 2005).

Anti-tumoral Action of Cannabinoids in Glioma Cells and In Vivo Tumor Models The pioneer study to show that cannabinoids had antitumor effect and prolonged the life of mice bearing Lewis lung adenocarcinoma was reported by Munson et al. in 1975 (Munson et al., 1975). Further research in this area was not performed until late 1990s, when an interest in the role of cannabinoids in cancer therapy was renewed. Since then, plant-derived, synthetic and endogenous cannabinoids have been successfully used to block proliferation and invasive potential of various cancer types (glioma, lymphoma, lung, thyroid, skin, pancreas, breast and prostate carcinoma) in both in vitro and in vivo models (Guzman, 2003). The research on therapeutic potential of cannabinoids in cancer treatment is the most advanced in gliomas. Programmed cell death of glioma cells after cannabinoid treatment was first described by Manuel Guzman and his co-workers (Sanchez et al., 1998). They showed that 9 -THC is able to inhibit growth of rat C6 glioma cells in vitro and induce cell death with features typical for apoptosis (Sanchez et al., 1998). We reported an apoptotic death triggered by a mixed CB1/CB2 synthetic agonist WIN 55,212-2 in rat glioma cells (Ellert-Miklaszewska et al., 2005). Recent studies (Gomez del Pulgar et al., 2002; Salazar et al., 2009) and our own observations show effectiveness of 9 -THC, WIN55,212-2 and a CB2-selective synthetic cannabinoid to induce apoptosis of cultured human glioblastoma cells and tumor-derived primary cultures.

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The anti-tumor action of cannabinoids, mediated via the CB1 or CB2 cannabinoid receptors, has been also proved in vivo revealing a significant regression of malignant gliomas in cannabinoid-treated animals (Galve-Roperh et al., 2000; Sanchez et al., 2001; Massi et al., 2004; Duntsch et al., 2006). Local administration of 9 -THC or WIN55,212-2 reduced the size of tumors generated by intracranial inoculation of C6 glioma cells in rats, leading to complete eradication of gliomas and increased survival in one third of the treated rats (Galve-Roperh et al., 2000). There has been no recurrence in any of the surviving rats as monitored periodically by MRI scan. Studies performed in mouse xenograft models with intratumoral and intraperitoneal drug administration demonstrated that non-psychoactive phytocannabinoid cannabidiol (Massi et al., 2004), a CB2selective agonist JWH133 (Sanchez et al., 2001) or a novel cannabinoid KM-233 (Duntsch et al., 2006) blocked the proliferation of human astrocytoma cells implanted subcutaneously in the flank of immune-deficient mice. Our preliminary data suggest that systemic cannabinoid administration can effectively hamper intracranial tumor growth in rats (unpublished).

Mechanism of Cannabinoids Pro-apoptotic Action – Inhibition of Pro-survival Pathways Several events and signal transduction pathways triggered mostly by stimulation of the CB1 and CB2 receptors have already been described to participate in the cannabinoid-induced apoptosis, a programmed cell death process (Guzman et al., 2001; Guzman, 2003). They include inhibition of PKA, superoxide generation, and strong increase in intracellular calcium concentration (Howlett et al., 2002). However, the best characterized mechanism of cannabinoidinduced cell death involves sustained accumulation of pro-apoptotic sphingolipid ceramide, which modulates signaling pathways crucial in the control of tumour cell growth and survival (Galve-Roperh et al., 2000; Sanchez et al., 2001). Cannabinoid receptor activation triggers two peaks of ceramide generation in glioma cells (Galve-Roperh et al., 2000; Sanchez et al., 2001; Gomez del Pulgar

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et al., 2002). Treatment with 9 -THC or another CB1/CB2 receptor agonist produces a rapid release of ceramide via enzymatic hydrolysis of sphingomyelin from the cell membrane. The second ceramide peak is generated within hours or days after receptor activation and depends on increase of ceramide synthesis de novo via induction of serine palimitoyltransferase, a regulatory enzyme of sphingolipid biosynthesis (Gomez del Pulgar et al., 2002). Selective CB2 receptor agonists, such as JWH133, are supposed to stimulate only the ceramide synthesis process, which is sufficient for turning on the cell death program (Sanchez et al., 2001; Gomez del Pulgar et al., 2002). Thus, enhanced production of ceramide de novo is considered as an important event in cannabinoids-induced apoptosis. Galve-Roperh and co-workers (2000) postulated that the increased ceramide levels reported upon cannabinoid challenge led to prolonged activation of Raf-1/MEK/Erk signaling cascade and thus mediated glioma cell cycle arrest and cell death. The same authors showed also that pharmacological inhibition of ceramide synthesis de novo prevented the inhibition of protein kinase B (also known as Akt) triggered by cannabinoids (Gomez del Pulgar et al., 2002). Our studies revealed that rather down-regulation of Erk activity, together with inhibition of PI3K/Akt pathway, contributed to C6 glioma cell death induced by WIN55,212-2 (Ellert-Miklaszewska et al., 2005). The serine/threonine protein kinase Akt, activated downstream of phosphoinositide 3-kinase (PI3K), as well as the Ras-activated Raf1/MEK/Erk pathway are widely recognized as key mediators of growth factor-promoted cell survival in gliomas (Kapoor and O’Rourke, 2003). Both survival pathways converge on a small pro-apoptotic member of a Bcl-2 family of proteins, Bad. Phosphorylation of Bad by Akt and Erk retains the protein in the cytosol, where it is recognized by certain regulatory proteins and sequestered (Zha et al., 1996). Otherwise, Bad translocates to mitochondria, and formation of heterodimers between nonphosphorylated Bad and anti-apoptotic proteins, such as Bcl-XL or Bcl-2, may result in a loss of integrity of the outer mitochondrial membrane (Zha et al., 1996). The release of apoptogenic proteins, including cytochrome c, triggers the executive phase of programmed cell death. We proposed a mechanism, in which the decrease of mitogenic/prosurvival signaling evoked by the synthetic cannabinoid

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WIN55,212-2 promoted the pro-apoptotic function of Bad (Fig. 29.2). Accordingly, we demonstrated changes in Bad phosphorylation level followed by collapse of the mitochondrial membrane potential in C6 glioma cells treated with WIN55,212-2. These events preceded activation of caspase 9 by factors released from disrupted mitochondria, subsequent processing of effector caspases, cysteine proteases, which play essential roles in apoptosis, and finally oligonucleosomal DNA fragmentation. Our further studies, as well as some published data suggest that human glioma cells treated with cannabinoids enter the suicide cell death using the same mitochondria-dependent (intrinsic) pathway (Carracedo et al., 2006b). This mechanism contributes to the induction of apoptosis by cannabinoids also in other types of tumor cells (Velasco et al., 2007). However, an involvement of an alternative, death receptor–dependent (extrinsic) pathway in the apoptotic process triggered by these compounds cannot be ruled out.

The Role of ER Stress and Autophagy in Cannabinoid-Induced Cell Death Different experimental approaches shown that the pro-apoptotic and tumor growth-inhibiting activity of cannabinoids relies on the accumulation of de novosynthesized ceramide, an event that occurs in the ER (endoplasmic reticulum) and eventually leads to execution of cell death via mitochondrial intrinsic pathway. A recent study by Carracedo et al. 2006b) suggested a new link between the two events, alternative to inhibition of pro-survival pathways. They showed that 9 THC treatment of glioma cells leads to up-regulation of the stress-regulated protein p8 and ER stress-related downstream targets: ATF-4 (activating transcription factor 4), CHOP (the C/EBP-homologous protein) and TRB3 (tribbles homologue 3). Selective knockdown of ATF-4 and TRB3 blocked cannabinoid-induced apoptosis in glioma cells. Inhibition of ceramide synthesis de novo prevented 9 -THC-induced p8, ATF-4, CHOP and TRB3 up-regulation as well as ER dilation, indicating that ceramide accumulation is an early event in the cannabinoid-triggered ER stress and apoptosis in glioma cells (Carracedo et al., 2006b). Furthermore, ER-stress–evoked stimulation of

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Fig. 29.2 Mechanisms of multimode anti-tumoral action of cannabinoids. Natural and synthetic cannabinoids induce tumor cell death, block angiogenesis and invasiveness crucial for tumor progression. Increased ceramide synthesis de novo via induction of serine palimitoyltransferase (SPT) cell death. Inhibition of pro-survival pathways (Akt and Erk signaling) stimulates translocation of Bad to the outer mitochondrial membrane and its pro-apoptotic function. Interaction between Bad and Bcl-2 triggers a decrease of the mitochondrial membrane potential () and release of pro-apoptotic factors (such as cytochrome c)

to the cytosol, where apoptosis is executed by caspase cascade. Alternatively, induction of apoptosis by cannabinoids can be mediated by ER (endoplasmic reticulum)-stress and autophagy. Up-regulation of the stress-regulated protein p8 and ER-stress-related downstream targets: ATF-4 (activating transcription factor 4), CHOP (the C/EBP-homologous protein) and TRB3 (tribbles homologue 3) leads to inhibition of Akt, an upstream activator of mTOR. Decreased activity of Akt/mTOR pathway contributes to initiation of autophagy, that precedes apoptosis of glioma cell

the p8/TRB3 pathway preceded the inhibition of the Akt/mTOR (mammalial target of rapamycin) axis, considered a key step in the early triggering of autophagy (Salazar et al., 2009). Irradiation and chemotherapeutic drugs kill cancer cells typically through induction of apoptosis. However most cancers (including gliomas) are resistant to therapies that induce apoptosis (type I programmed cell death). Macroautophagy, hereafter called autophagy, is an evolutionarily conserved catabolic process, where a cell self-digests its cytoplasmic contents. Autophagy is accompanied by the progressive development of vesicle structures from autophagosomes to autolysosomes. Autophagy is activated in response to multiple stresses during cancer progression, such as nutrient starvation, the unfolded protein response (ER stress) and hypoxia.

Indeed, a detailed analysis of human astrocytoma cell lines and a primary culture of human glioma cells indicated that 9 -THC treatment led to formation of autophagosomes in tumor cells (Salazar et al., 2009). The authors also observed that ER stress occurred earlier than autophagy and it preceded apoptosis in cannabinoid-induced human and mouse cancer cell death. Administration of 9 -THC to mice bearing tumors derived from human astrocytoma cells produced increased TRB3 expression, inhibition of mTOR signaling pathway, occurrence of autophagy markers and caspase-3 activation. These findings indicate that cannabinoid promotes the autophagy-mediated cell death through stimulation of ER stress in human glioma cells. Classically autophagy has been proposed to promote cell survival but paradoxically autophagy has

29 Glioblastoma: Anti-tumor Action of Natural Synthetic Cannabinoids

been reported to contribute to cell death (type II programmed cell death). Recently it was also demonstrated that autophagy, not apoptosis, is induced in glioblastoma cell by radiation and several chemotherapeutic agents (Aoki et al., 2008). The most striking evidence for pro-autophagic chemotherapy to overcome apoptosis resistance in cancer cells comes from the use of temozolomide (Aoki et al., 2008), a cytotoxic drug, which has demonstrated therapeutic benefits in glioblastoma patients. However, the role of autophagy in causing cell death, rather than occurring along with cell death, is still not clear. As reported by Salazar et al. (2009) pharmacological or genetic inhibition of autophagy at different levels prevented 9 -THC-induced cell death, suggesting that autophagy contributes to cannabinoid anti-tumoral action.

Other Targets of Cannabinoid Action Cannabinoids have displayed a great potency in reducing glioma tumor growth in experimental animal models. Apparently their effectiveness in vivo has been attributed to several mechanisms of action. Cannabinoids have recently emerged as compounds that beyond inhibition of tumor cell proliferation and survival impair tumor angiogenesis, invasiveness and even gliomagenesis (Blazquez et al., 2003; Aguado et al., 2007). Increased demand for oxygen and nutrients supply to proliferating cancer cells makes angiogenesis a critical factor for the progression of solid tumors and a popular target for oncologic therapies. Local administration of the CB2 selective cannabinoid JWH133 in a mouse flank inoculation model of glioma turned the vascular hyperplasia characteristic of actively growing tumors to a pattern of blood vessels characterized by small, differentiated and impermeable capillaries, thus proving antiangiogenic potential of the cannabinoid (Blazquez et al., 2003). This was associated with a reduced expression of pro-angiogenic factors, such as vascular endothelial growth factor (VEGF) and angiopoietin-2 in cannabinoid treated tumors and could be partly related to a direct influence of the cannabinoid on endothelial cells migration and survival as well as on VEGF signaling in tumor cells. This and subsequent studies of the same authors (Blazquez

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et al., 2003, 2008) showed that 9 -THC or JWH133 administration to glioma-bearing mice decreased the activity and expression of matrix metalloproteinase-2 (MMP-2). MMP-2 is a proteolytic enzyme that allows tissue breakdown and remodeling during angiogenesis and metastasis and its up-regulation is associated with high progression and poor prognosis of gliomas. 9 THC inhibited MMP-2 expression and cell invasion in cultured glioma cells (Blazquez et al., 2008). Blocking the release of pro-angiogenic factors or the extracellular matrix degrading enzyme by in vivo administered cannabinoids correlated with decreased tumor volumes (Blazquez et al., 2003, 2008). Although the identification of the cell of origin of gliomas is still a matter of debate, recent findings support the existence of brain cancer stem cells generated by transformation of the normal neural stem cell. Aguado and coworkers (2007) showed that activation of CB1 and CB2 receptors with HU-210 and JWH133 promoted differentiation of glioma stem-like cells derived from GBM biopsies and from glioma cell lines. Moreover, cannabinoid challenge decreased neurosphere formation and cell proliferation in secondary xenografts, which correlated with the decreased efficiency of cannabinoid-treated glioma stem-like cells to initiate glioma formation in vivo (Aguado et al., 2007). Multimode action of cannabinoids, including inhibition of gliomagenesis may have important implications for development of cannabinoid-based therapeutic strategies.

Perspectives for the Clinical Use of Cannabinoids in Glioma Patients The past few decades have seen renewed interest in medicinal cannabis. Capsules of THC and its synthetic analogue nabilone are approved in several countries as a prescription-only medicine for nausea and vomiting caused by cytotoxic chemotherapy, unresponsive to other anti-emetics. Other potential palliative effects of cannabinoids in oncology – supported by phase III clinical trials – include apetite stimulation and pain inhibition (Guzman, 2003). However, discussions on controlled medical use of cannabis and cannabinoids are now beyond its application for symptomatic relief. There is quite a large number of emerging evidence that cannabinoids can in fact modify the progression

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of certain diseases. The efficacy of intra-tumorally or systemically administered cannabinoids against high-grade glioma in rat and mouse models (GalveRoperh et al., 2000; Sanchez et al., 2001; Massi et al., 2004; Duntsch et al., 2006), raised promises of using cannabinoid-based therapies against malignant gliomas.

Safety Profile of Therapeutic Cannabinoids Standard chemotherapeutics are a double edged sword, they eliminate cancer cells but affect severely healthy cells in the body. Based on evidence from in vitro and in vivo studies cannabinoids appear to have a favorable safety profile and do not produce the generalized toxic effects as most conventional chemotherapeutic drugs. Several mechanisms could be responsible for cannabinoid targeting only the cancer cells. In contrast to pro-apoptotic action of CB1/CB2-activating cannabinoids, such as 9 -THC and WIN55,212-2, on transformed cells, treatment of primary cultured astrocytes with these compounds did not trigger ceramide accumulation or induction of ER stress-related genes. Furthermore, cannabinoids promote survival of glial cells and neurons in different models of injury, suggesting that the anti-proliferative effect of cannabinoids is selective for brain tumor cells, viability of normal brain cells remains unaffected or even favored by cannabinoid challenge (Guzman, 2003). In our studies astrocytes and glioma cells were vulnerable to WIN55,212-2 which was in line with data on human primary mixed glial cultures and glioblastoma cells treated with the synthetic cannabinoid (McAllister et al., 2005). Administration of JWH133 although effective toward tumor cells, did not affect survival or morphology of normal astrocytes (unpublished). Apparently negligible expression of CB2 receptor in the brain and its abundance in high grade gliomas seems to confer a relative safety of CB2-selective agonists for targeted glioma therapy. Concomitantly, a novel cannabinoid chemotherapeutic exhibiting over 10-times higher affinity for the CB2 vs. CB1 receptor produced a minimal toxicity to healthy cultured brain slices at micromolar concentrations required to eradicate U87 glioma cells (Duntsch et al., 2006).

A. Ellert-Miklaszewska et al.

As reported by the same authors, clinical monitoring of mice with U87-derived subcutaneous tumors proved that treatment with the cannabinoid was effective in reducing tumor volume and produced no general toxic effects under intratumoral or systemic administration. More importantly, some animal studies show also a good safety profile of CB1-activating agents. In the studies by Galve-Roperh et al. (2000) 9 THC and WIN55,212-2 were delivered intratumorally via an osmotic pump for 7 days leading to partial remission or complete eradication of the tumors generated intracranially by inoculation of C6 glioma cells The same effective doses of cannabinoids were evaluated in tumor-free animals for potential adverse effects in the brain. MRI analysis showed no signs of damage related to necrosis, edema, infection or trauma. Cannabinoid administration to tumor-bearing and control rats induced no substantial modification in behavioral parameters, in food and water intake or in body weight. No abnormalities in biochemical and hematological parameters nor markers of tissue damage have been revealed during 7-day delivery period and for at least 2 months after cannabinoid treatment (Galve-Roperh et al., 2000). The strategy to use CB2 selective compounds in glioma treatment has at least one more advantage over the non-selective cannabinoids. The medical use of cannabinoids is limited mainly by their undesirable side-effects attributed to marijuana abuse. Due to the well known psychotropic activity of 9 -THC and related compounds mimicking its action on the CB1 receptors, potential application of these agents to patients raises a number of clinical and ethical considerations. Among various approaches to avoid CB1receptor-mediated psychodysleptic side effects, special attention is paid to substances, which selectively stimulate the CB2 receptors, putatively overexpressed in target tumor cells (Guzman et al., 2001; Duntsch et al., 2006).

Results from a Pilot Clinical Study On the basis of successful preclinical findings Guzman and his collaborators conducted a pilot phase I clinical trial, in which nine patients with actively growing recurrent glioblastoma multiforme were administered THC intratumorally via an infusion catheter placed

29 Glioblastoma: Anti-tumor Action of Natural Synthetic Cannabinoids

into the resection cavity (Guzman et al., 2006). The enrolled patients had previously failed standard therapy (surgery and radiotherapy) and had clear evidence of tumor progression. The primary endpoint of the study was to determine the safety of intracranial 9 THC administration in a dose escalation regime. The initial dose of 9 -THC delivered to the patients was 20–40 μg at day 1, increasing progressively for 2–5 days up to 80–180 μg/day. Over the median treatment duration of 15 days patients underwent continuous physical, neurological, biochemical and hematological examinations as well as frequent magnetic resonance and computed tomography scans of the brain. The cannabinoid treatment did not result in any marked alterations of clinical and laboratory tests. There was no evidence of hemorrhage, oedema or injury. The good safety profile observed in this pilot clinical trial, together with remarkable anti-tumor effects reported in preclinical studies may set the basis for further research aimed at better evaluation of the potential anti-cancer activity of cannabinoids.

Risks, Constrains and Benefits The controlled clinical use of natural or synthetic cannabinoids should not be perceived equally as the use of smoked cannabis, which is a declared addictive drug. Noteworthy, central and peripheral effects of cannabinoids pronounced in marihuana smokers are not apparent in a controlled clinical setting (Guzman, 2003). Moreover, tolerance to these unwanted effects of cannabinoids develops rapidly in humans and laboratory animals. The possibility that tolerance also develops after therapeutic application as well as psychotic and addictive potential of cannabinoids have not been thoroughly examined. Although the general consensus indicates that cannabinoids have anti-tumor effects there are a few studies that have shown contradictory results or duality of cannabinoids effects on tumor cell fate depending of the dose range used (Guzman, 2003). Some authors questioned whether cannabinoid receptors do constitute relevant molecular targets to treat glioblastoma in humans, as the high concentrations of the currently available cannabinoids required to trigger apoptosis in glioma cells in culture are not pharmacologically relevant (Held-Feindt et al., 2006). This

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emphasizes the need for comprehensive dose-response studies in the future correlated with analysis of the cannabinoid receptor expression. In general, existing data encourage to survey of new synthetic compounds in order to replace 9 -THC or related cannabinoids with more potent and selective mimetics. Another possibility would be to prolong the effectiveness of endocannabinoids by development of the inhibitors of their breakdown. Due to genetic and epigenetic alterations malignant glioblastomas are highly resistant to radiation and chemotherapy. Mainstream therapeutic strategies for the management of all primary brain tumors are still mostly palliative, known to leave survivors with devastating neurological deficits and frequently with a high risk of the disease recurrence. The potency of synthetic cannabinoids to induce apoptosis in glioblastoma cells has been tested by us and others on several cell lines and primary cell cultures derived from biopsies of human tumors, which to some extent may reflect the heterogeneity of glioma molecular characteristics (Galve-Roperh et al., 2000; Sanchez et al., 2001; Guzman, 2003; Massi et al., 2004; Duntsch et al., 2006; Ellert-Miklaszewska et al., 2005; McAllister et al., 2005). Thus, cannabinoids were able to override alterations of growth regulatory and apoptotic pathways, caused by common mutations reported in primary and secondary glioblastomas. Cannabinoid apoptotic action relies on the generation of ceramide and disruption of signaling pathways crucial for regulation of cellular proliferation, differentiation or apoptosis (Galve-Roperh et al., 2000; Gomez del Pulgar et al., 2002; Ellert-Miklaszewska et al., 2005; Salazar et al., 2009). Their unique mechanism of action among standard oncology remedies justifies further research on their anti-tumoral properties either alone or in combined therapies.

References Aguado T, Carracedo A, Julien B Velasco G, Milman G, Mechoulam R, Alvarez L, Guzman M, Galve-Roperh I (2007) Cannabinoids induce glioma stem-like cell differentiation and inhibit gliomagenesis. J Biol Chem 282:6854–6862 Aoki H, Kondo Y, Aldape K, Yamamoto A, Iwado E, Yokoyama T, Hollingsworth EF, Kobayashi R, Hess K, Shinojima N, Shingu T, Tamada Y, Zhang L, Conrad C, Bogler O, Mills G, Sawaya R, Kondo S (2008) Monitoring autophagy in

286 glioblastoma with antibody against isoform B of human microtubule-associated protein 1 light chain 3. Autophagy 4:467–475 Blazquez C, Casanova ML, Planas A, Del Pulgar TG, Villanueva C, Fernandez-Acenero MJ, Aragones J, Huffman JW, Jorcano J L, Guzman M (2003) Inhibition of tumor angiogenesis by cannabinoids. FASEB J 2:2 Blazquez C, Salazar M, Carracedo A, Lorente M, Egia A, Gonzalez-Feria L, Haro A, Velasco G, Guzman M (2008) Cannabinoids inhibit glioma cell invasion by downregulating matrix metalloproteinase-2 expression. Cancer Res 68:1945–1952 Caffarel MM, Sarrio D, Palacios J, Guzman M, Sanchez C (2006) Delta9-tetrahydrocannabinol inhibits cell cycle progression in human breast cancer cells through Cdc2 regulation. Cancer Res 66:6615–6621 Carracedo A, Gironella M, Lorente M, Garcia S, Guzman M, Velasco G, Iovanna JL (2006a) Cannabinoids induce apoptosis of pancreatic tumor cells via endoplasmic reticulum stress-related genes. Cancer Res 66:6748–6755 Carracedo A, Lorente M, Egia A, Blazquez C, Garcia S, Giroux V, Malicet C, Villuendas R, Gironella M, Gonzalez-Feria L, Piris MA, Iovanna J L, Guzman M, Velasco G (2006b) The stress-regulated protein p8 mediates cannabinoid-induced apoptosis of tumor cells. Cancer Cell 9:301–312 Duntsch C, Divi MK, Jones T, Zhou Q, Krishnamurthy M, Boehm P, Wood G, Sills A, Ii BM (2006) Safety and efficacy of a novel cannabinoid chemotherapeutic, KM-233, for the treatment of high-grade glioma. J Neurooncol 77(2):143–152 Ellert-Miklaszewska A, Grajkowska W, Gabrusiewicz K, Kaminska B, Konarska L (2007) Distinctive pattern of cannabinoid receptor type II (CB2) expression in adult and pediatric brain tumors. Brain Res 1137:161–169 Ellert-Miklaszewska A, Kaminska B, Konarska L (2005) Cannabinoids down-regulate PI3K/Akt and Erk signalling pathways and activate proapoptotic function of bad protein. Cell Signal 17:25–37 Galve-Roperh I, Sanchez C, Cortes ML, del Pulgar TG, Izquierdo M, Guzman M (2000) Anti-tumoral action of cannabinoids: involvement of sustained ceramide accumulation and extracellular signal-regulated kinase activation. Nat Med 6:313–319 Gomez del Pulgar T, Velasco G, Sanchez C, Haro A, Guzman M (2002) De novo-synthesized ceramide is involved in cannabinoid-induced apoptosis. Biochem J 363:183–188 Gong JP, Onaivi ES, Ishiguro H, Liu QR, Tagliaferro PA, Brusco A, Uhl GR (2006) Cannabinoid CB2 receptors: immunohistochemical localization in rat brain. Brain Res 1071:10–23 Guzman M (2003) Cannabinoids: potential anti-cancer agents. Nat Rev Cancer 3:745–755 Guzman M, Duarte MJ, Blazquez C, Ravina J, Rosa MC, GalveRoperh I, Sanchez C, Velasco G, Gonzalez-Feria L (2006) A pilot clinical study of Delta9-tetrahydrocannabinol in patients with recurrent glioblastoma multiforme. Br J Cancer 95:197–203 Guzman M, Sanchez C, Galve-Roperh I (2001) Control of the cell survival/death decision by cannabinoids. J Mol Med 78:613–625 Held-Feindt J, Dorner L, Sahan G, Mehdorn HM, Mentlein R (2006) Cannabinoid receptors in human astroglial tumors. J Neurochem 98:886–893

A. Ellert-Miklaszewska et al. Howlett AC, Barth F, Bonner TI, Cabral G, Casellas P, Devane WA, Felder CC, Herkenham M, Mackie K, Martin BR, Mechoulam R, Pertwee RG (2002) International union of pharmacology. XXVII. Classification of cannabinoid receptors. Pharmacol Rev 54:161–202 Kapoor GS, O’Rourke DM (2003) Receptor tyrosine kinase signaling in gliomagenesis: pathobiology and therapeutic approaches. Cancer Biol Ther 2:330–342 Mackie K (2006) Cannabinoid receptors as therapeutic targets. Annu Rev Pharmacol Toxicol 46:101–122 Massi P, Vaccani A, Ceruti S, Colombo A, Abbracchio MP, Parolaro D (2004) Anti-tumor effects of cannabidiol, a nonpsychoactive cannabinoid, on human glioma cell lines. J Pharmacol Exp Ther 308:838–845 McAllister SD, Chan C, Taft RJ, Luu T, Abood ME, Moore DH, Aldape K, Yount G (2005) Cannabinoids selectively inhibit proliferation and induce death of cultured human glioblastoma multiforme cells. J Neurooncol 74:31–40 Munson AE, Harris LS, Friedman MA, Dewey WL, Carchman RA (1975) Antineoplastic activity of cannabinoids. J Natl Cancer Inst 55:597–602 Petersen G, Moesgaard B, Schmid PC, Schmid HH, Broholm H, Kosteljanetz M, Hansen HS (2005) Endocannabinoid metabolism in human glioblastomas and meningiomas compared to human non-tumour brain tissue. J Neurochem 93:299–309 Salazar M, Carracedo A, Salanueva IJ, Hernandez-Tiedra S, Lorente M, Egia A, Vazquez P, Blazquez C, Torres S, Garcia S, Nowak J, Fimia GM, Piacentini M, Cecconi F, Pandolfi PP, Gonzalez-Feria L, Iovanna JL, Guzman M, Boya P Velasco G (2009) Cannabinoid action induces autophagy-mediated cell death through stimulation of ER stress in human glioma cells. J Clin Invest 119:1359–1372 Sanchez C, de Ceballos ML, del Pulgar TG, Rueda D, Corbacho C, Velasco G, Galve-Roperh I, Huffman JW, Ramon y Cajal S, Guzman M (2001) Inhibition of glioma growth in vivo by selective activation of the CB(2) cannabinoid receptor. Cancer Res 61:5784–5789 Sanchez C, Galve-Roperh I, Canova C, Brachet P, Guzman M (1998) Delta9-tetrahydrocannabinol induces apoptosis in C6 glioma cells. FEBS Lett 436:6–10 Sarfaraz S, Afaq F, Adhami VM, Mukhtar H (2005) Cannabinoid receptor as a novel target for the treatment of prostate cancer. Cancer Res 65:1635–1641 Schley M, Stander S, Kerner J, Vajkoczy P, Schupfer G, Dusch M, Schmelz M, Konrad C (2009) Predominant CB2 receptor expression in endothelial cells of glioblastoma in humans. Brain Res Bull 79:333–337 Stella N (2004) Cannabinoid signaling in glial cells. Glia 48:267–277 Valenzano KJ, Tafesse L, Lee G, Harrison JE, Boulet JM, Gottshall SL, Mark L, Pearson MS, Miller W, Shan S, Rabadi L, Rotshteyn Y, Chaffer SM, Turchin PI, Elsemore DA, Toth M, Koetzner L, Whiteside GT (2005). Pharmacological and pharmacokinetic characterization of the cannabinoid receptor 2 agonist, GW405833, utilizing rodent models of acute and chronic pain, anxiety, ataxia and catalepsy. Neuropharmacology 48:658–672 Van Sickle MD, Duncan M, Kingsley PJ, Mouihate A, Urbani P, Mackie K, Stella N, Makriyannis A, Piomelli D, Davison JS, Marnett LJ, Di Marzo V, Pittman QJ, Patel KD, Sharkey

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Chapter 30

Patients with Recurrent High-Grade Glioma: Therapy with Combination of Bevacizumab and Irinotecan Benedikte Hasselbalch, Ulrik Lassen, and Hans Skovgaard Poulsen

Abstract Despite surgery, radiotherapy, and chemotherapy, most patients with recurrent high-grade glioma have a poor prognosis. High-grade gliomas are known to be vascular tumors that produce the vascular endothelial growth factor (VEGF), one of the mediators necessary for angiogenesis which facilitates for tumor growth. Treatment of recurrent high-grade gliomas with the VEGF neutralizing antibody, bevacizumab in combination with the topoisomerase inhibitor irinotecan has demonstrated promising response rates and enhanced progression free survival when compared to historical controls. However, it still needs to be confirmed, that bevacizumab and irinotecan improves overall survival. Moreover, as not all patients benefit from this treatment, there is an ongoing search for one or more predictive biomarkers. Keywords HGG · Bevacizumab · Irinotecan · VEGF · Topoisomerase I · Hypoxia

Introduction Malignant primary brain tumors represents 1–2% of all newly diagnosed tumors and account for about 2% of all cancer-related deaths. Overall, malignant gliomas account for 78% of malignant brain tumors. Primary brain tumors (PBT) are of neuroepithelial origin and according to WHO classification there are three main

H.S. Poulsen () Department of Radiation Biology, The Finsen Center, Sec 6321, Copenhagen University Hospital, DK-2100 Copenhagen, Denmark e-mail: [email protected]

types which usually can be distinguished by their histological features; oligodendrogliomas, mixed oligoastrocytomas and astrocytomas (or gliomas) (Louis et al., 2007). Through analyzing the most malignant region of the tumors, PBT are graded as low-grade tumors (WHO grades I and II), or as high-grade tumors (WHO grades III and IV) dependent on four main features: nuclear atypia, mitoses, microvascular proliferation, and necrosis. By the degree of increasing anaplasia, the types of astrocytomas usually include pilocytic astrocytoma (grade I), diffuse astrocytoma (grade II), anaplastic astrocytoma (grade III) and the most malignant form, glioblastoma multiforme (grade IV/GBM). In addition, grade III malignant tumors include anaplastic oligodendroglioma, anaplastic oligoastrocytoma and mixed glioma. Areas of vascular proliferation and/or necrosis are mandatory for GBM whereas occasional proliferation of tumor vessels can occur in grade III astrocytomas (Louis et al., 2007). The pronounced vascularization arises because of increased angiogenesis. The dense vascularity does not prevent the HGG tumor from being hypoxic, partly because of the dysfunctional nature of the tumor vessels. Standard treatment for HGG is debulking surgery if possible. For GBM, this is followed by concomitant R temozolomide (Temodal ); an oral alkylating agent, plus radiotherapy and adjuvant temozolomide (Stupp et al., 2005). The introduction of temozolomide has improved the survival of GBM significantly, increasing the 2-year survival from 10 to 27% and 5-year survival from 1.9 to 9.8%, compared to previous treatment regimens (Stupp et al., 2009). However, nearly all patients with GBM will eventually relapse. The prognosis for recurrent GBM is even worse with a median survival of

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_30, © Springer Science+Business Media B.V. 2011

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3–9 months when using traditional chemotherapeutic agents. The survival benefit of temozolomide as part of a primary setting for grade III astrocytomas still needs to be determined. Accordingly, the primary treatment of grade III astrocytoma varies between the continents, e.g. most patients in north America receives the same treatment regimen as GBM, whereas most places in Europe use surgery and radiotherapy as primary treatment, giving temozolomide at recurrence, -if possible, after tumor-reductive surgery. The median survival is longer for this group of patients (2–4 years), although most typically recur and may progress to GBM. The primary treatment of anaplastic oligodendroglioma includes debulking surgery followed by radiotherapy, whereas the timing and survival benefit from the addition of chemotherapy still remains to be established. Two large randomized control trials failed to show that the addition of chemotherapy with procarbazine, lomustin and vincristin (PCV) either adjuvant or neoadjuvant to radiotherapy significantly prolonged disease free survival (Cairncross et al., 2006; van den Bent et al., 2006). However, as most patients randomly assigned to RT alone received chemotherapy at progression, interpretation of the survival data from these studies are difficult. HGG are still considered incurable and accordingly there is a pivotal need for improved treatment strategies for this malignancy. The aim of therapy for patients with relapsed HGG is to offer a better quality of life in terms of improvement in neurological function, neuro-cognitive function and steroid requirements, ideally coupled with a prolongation of survival. Despite numerous studies using temozolomide, PCV, carboplatin, lomustin (CCNU), carmustine (BCNU), or imatinib with or without the combination of hydroxyurea, no regimen has emerged as a standard for relapsed HGG after radiation and temozolomide. Recently, the use of bevacizumab and irinotecan has shown promising results in recurrent HGG, improving progression free survival (PFS) and quality of life compared with historical results (Friedman et al., 2009; Wong et al., 1999). However, it still needs to be established if a regimen including bevacizumab for recurrent HGG, improve overall survival (OS) compared to other treatment regimens used at recurrence. Furthermore, there is an ongoing search for one or more biomarkers that can predict which patients will benefit from treatment with bevacizumab.

B. Hasselbalch et al.

Hypoxia Hypoxia plays a prominent role in tumor growth, invasion, angiogenesis, resistance to chemo- and radiotherapy and decreased patient survival in various cancer types, including HGG. The characteristic necrotic regions of GBM are assumed to be regions of hypoxia, although this involvement is not conclusively determined. When available blood flow cannot fulfill the requirements for maintaining oxygen homeostasis, the partial oxygen pressure of these tumor areas become low, i.e. hypoxic, or close to zero, anoxic. The diffusion limit for oxygen is approximately 100 μm and oxygen transport over further distances requires red blood cells. Tumor hypoxia evolves as a consequence of insufficient oxygen delivery and is a feature of most solid tumors. Tumor growth results in increased distance to existing blood vessels, which in combination with insufficient neo-vascularization, contributes to a tumor microenvironment with low oxygen tension. Moreover, tumor vessels are leaky, leading to tumor edema and increased intratumoral pressure, which further increases hypoxia. Cancer cells undergo numerous changes that enable them to adapt to and survive hypoxia, contributing to a more aggressive behavior of the tumor. The hypoxia inducible factors (HIF), HIF-1α and HIF-2α, are critical for this adaptive response. The characteristic necrotic regions of GBM are surrounded by a cluster of cells known as pseudopalisading that are suspected to be regions of hypoxia, although this has not been conclusively proven. These necrotic areas do not seem to be related to tumor size, as they have been found in both small and large tumors. Furthermore, it has been demonstrated in animal glioma models that tumors <1 mm in diameter are more hypoxic and poorly perfused with sparse vasculature as compared to larger tumors (1–4 mm in diameter) (Jensen, 2009). This suggests that necrosis might not be simply due to inadequate vascular supply, but instead a result of intrinsic molecular or genetic changes within the tumor. Hypoxia also seems to induce HGG cell migration and invasion (Jensen, 2009). However, the extent of hypoxia in HGG has still to be elucidated. HIF-1α overexpression and angiogenesis have been shown to correlate in brain tumors (Jensen, 2009), and there is a significant association between HIF-1α overexpression and tumor grade (Semenza, 2003).

30 Patients with Recurrent High-Grade Glioma

Cellular Response to Hypoxia The HIF-1 transcription factor mediates adaptive responses to changes in tissue oxygenation by regulating numerous genes involved in e.g. angiogenesis, cell proliferation, vascular reactivity and remodeling, and survival. HIF-1 is a member of the basic helixloop-helix-PAS (bHLH-PAS) family, which includes the hypoxia regulated HIF-1α, 2α, 3α and the constitutively expressed HIF-1β (also known as ARNT) (Semenza, 2001). HIF-2α and, especially HIF-1α have been most intensively studied, and the two factors display some differences, which will be mentioned below when relevant (otherwise described as HIF-α). HIF-1α is expressed in an apparently ubiquitous fashion, whereas HIF-2α expression is restricted to particular cell types, including brain and vascular endothelial cells. HIF-1α and HIF-2α are both implicated in tumor growth and are frequently coexpressed in human tumors. The HIF-α proteins form a transcriptional active heterodimer with HIF-1β during hypoxia, which initiates transcription by binding to hypoxia response elements (HREs) in promoters or enhancers of target genes (Semenza, 2001). The HIF-α expression is determined by the rate of protein synthesis regulated via O2 -independent mechanisms whereas protein degradation and activity is regulated via O2 -dependent mechanisms. HIF-1α synthesis is regulated by activation of receptor tyrosine kinases (RTKs), non-receptor tyrosine kinases og G-protein-coupled receptors through the phosphatidylinositol 3-kinase (PI3K) and the Ras/mitogen activated protein kinase (MAPK) pathways (Semenza, 2003). Furthermore, HIF-1α is known to induce the expression of the epidermal growth factor receptor (EGFR) ligand, transforming growth factor α (TGF-α) thus providing an autocrine loop regulating the hypoxic response. During normoxia, the HIF-α proteins are degraded through the proteasomal machinery. HIF-α is also regulated at the level of transcriptional activity, as hypoxia (1–2% O2 ) results in stabilization of the HIF-α proteins allowing HIF-α to form a complex together with HIF-1β which initiate transcription among others of vascular endothelial growth factor (VEGF) (Semenza, 2003). Exclusive target genes for HIF-2α has yet to be identified, however, it has been shown that HIF-2α can regulate cancer stem cell function and/or differentiation through the

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octamer-binding transcription factor (Oct-4) which in turn contributes to HIF-2α activity.

Angiogenesis High micro vessel density (MVD) is a hallmark for GBM and pronounced tumor vascularity is significantly correlated with poor survival (Jain et al., 2007). Angiogenesis is development of new vessels from preexisting ones by sprouting or by intussusception from their vessels of origin. Many molecules are implicated in the positive regulation of angiogenesis, e.g. acidic fibroblast growth factor (aFGF), basic FGF (bFGF), epidermal growth factor (EGF), transforming growth factor β (TGF-β), TGF-α, angiogenin, interleukin 8 (IL-8), angiopoitins and VEGF (Fig. 30.1) (Bergers and Benjamin, 2003). In tumor development, angiogenesis is essential for tumor growth and being one of the most vasculized tumors, angiogenesis seems fundamental for HGG. Tumor vasculature is characterized as immature and malformed with abnormal branching resulting in a chaotic structure. Moreover, the leaky nature of tumor vessels induce edema, which further promotes the hypoxic tumor milieu and induction of pro-angiogenic factors like VEGF thus creating a positive paracrine loop, maintaining angiogenesis and conditions necessary for sustained tumor growth. Besides activating tissue endothelial cells, angiogenic factors also activates circulating endothelial cells (CECs) and endothelial progenitor cells (EPCs) from the bone marrow, that enter the circulation and generates new blood vessels in tumor tissue.

VEGF/VEGFR Signaling Pathway in Pathological Conditions VEGF is the major endothelial mitogen in central nervous system neoplasms. Of endogenous angiogenic factors identified, the VEGF family and the angiopoietins are the endothelium-specific angiogenic factors. The VEGF family consists of at least five ligands (VEGF-A, -B, -C, -D, and placenta-like growth factor (PlGF)) and three tyrosine kinase receptors (VEGFR-1, -2, -3). VEGF-A (also known as VEGF) is a 34–45 kDa dimeric glycosylated protein. Alternative

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Fig. 30.1 Tumor induced VEGF release gives rise to angiogenesis and increased vessel permeability. Modified from Tabernero (2007)

exon splicing of the VEGF gene results in at least five isoforms of VEGF (VEGF121 , VEGF145 , VEGF165 , VEGF189 and VEGF206 ), with VEGF165 being the predominant form in general and the most common form found in HGG (Ferrara et al., 2003). VEGF is a survival factor for endothelial cells of newly formed but not established vessels within the tumor. Moreover, VEGF is a major permeability factor partly responsible for the loss of blood-brain barrier (BBB) during tumor growth. The elevated expression of VEGF in human cancer is likely induced by numerous mechanisms, of which hypoxia via HIF-1α plays a key role as described above. Tumor cells are the main source of VEGF in HGG, whereas VEGF receptors are predominantly expressed by endothelial cells. Furthermore, several major growth factors, including EGF, TGF-α and TGF-β, insulin-like growth factor-1 (IGF-1), bFGF, IL-8 and PDGF up regulate VEGF mRNA expression in a paracrine or autocrine manner, in cooperation with hypoxia (Fig. 30.1). In addition to VEGF, glioma cells are known to produce a variety of pro-angiogenic factors, including bFGF, PDGF, IL-8, HIF-1α and hepatocyte growth factor (HGF) (Fig. 30.1). Although tumor cells represent the major source of

VEGF, tumor-associated stroma is also an important site of VEGF production. The expression of VEGF is especially prominent in tumor cells around necrotic areas in GBM, and increased concentrations of VEGF have been found to correlate with malignancy grade (Steiner et al., 2004) and in one study (Sathornsumetee et al., 2008) with radiological response to bevacizumab in HGG. VEGF binds to two related RTKs, VEGFR-1 (Flt-1) and VEGFR-2 (KDR or Flk-1) which are both expressed on endothelial cell surface and are found to have increased expression in GBM, when compared to normal brain (Steiner et al., 2004). VEGFR3 is not a receptor for VEGF, but instead binds VEGF-C and VEGF-D and its expression is largely restricted to lymphatic endothelial cells. Despite being the first VEGF receptor to be identified, the precise role of VEGFR-1 in angiogenesis is to be fully elucidated. VEGFR-2 is expressed both on endothelial cells and tumor cells. VEGFR-2 undergoes dimerization and ligand-dependent tyrosine phosphorylation inducing phosphorylation of among others; protein kinase C-γ (PKC-γ), phosphatidylinositol 3-kinase (PI3K), Ras and the Src kinase familiy. VEGFR-2 is the major

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receptor involved in angiogenesis and VEGF activation leads to endothelial cell survival, proliferation, endothelial cell migration, and vascular permability. VEGF also interacts with the co-receptors neurophilin1 and neurophilin-2.

Anti-angiogenic Drugs R Bevacizumab (Avastin ) is a humanized immunoglobulin (Ig) G1 that binds to and inhibits the biologic activity of all active isoforms of the human VEGF ligand (VEGF-A) (Fig. 30.2). It is administrated intravenously and the terminal half-life of bevacizumab in humans is 17–21 days. Bevacizumab was the first inhibitor of angiogenesis to be approved by FDA, based on the survival benefit observed in a randomized phase III trial, for patients with metastatic colorectal cancer in combination with conventional chemotherapy. Bevacizumab has also been FDA approved as first line treatment of advanced non-small-cell lung cancer in combination with standard chemotherapy. In addition it has been approved for metastatic HER2 negative breast cancer in combination with paclitaxel, and for metastatic renal cancer in combination with interferon alpha. Bevacizumab is well tolerated and lacks the major toxicities typically associated

Fig. 30.2 Examples of different targeted therapies investigated in HGG. The different types of therapeutic compounds are for simplification assembled in the yellow boxes according to their respective targets. Tumor angiogenesis can be inhibited by monoclonal antibodies against the pro-angiogenic factor VEGF or by TKI targeting VEGFR. See text for further details

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with cytotoxic chemotherapies. Common toxicities related to anti-angiogenic drugs are hypertension, proteinuria, fatigue, tromboembolic events, hemorrhage and wound-healing complications. Hypertension is normally manageable with ordinary anti-hypertensive treatment, whereas treatment delay can be necessary at impaired wound heeling. In addition to bevacizumab, another anti-VEGF therapy in clinical trials is aflibercept (also known as VEGF Trap), a soluble decoy VEGFR that binds VEGF, VEGF-B and placenta-like growth factor (PlGF) (Fig. 30.2). Another strategy for anti-angiogenic treatment is inhibition of the VEGFR. Several inhibitors of VEGFR are either underway for approval in clinical trials or already approved for cancer therapy. One such drug is cediranib, a multi-targeted TKI which blocks VEGFR-1, VEGFR-2, and VEGFR-3 signaling and shows a response rate of 56% as singleagent therapy in recurrent GBM (Batchelor et al., R R 2007). Sorafenib (Nexavar ) and sunitinib (Sutent ) are FDA approved small molecule TKIs targeting multiple receptor tyrosine kinases, including VEGFR and PDGFR (Norden et al., 2009). An overview of VEGF/VEGFR inhibitors are presented in Fig. 30.2. Finally, thalidomide and the analog lenalidomide are also under investigation as anti-angiogenic therapy

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for HGG either as monotherapy or in combination with e.g. temozolomide or BCNU. However, the preliminary results so far are not superior to the abovementioned treatment.

Irinotecan R R Irinotecan (Camptosar , Campto ) is a topoisomerase I inhibitor, used as first-line treatment in for metastatic colorectal cancer and which has demonstrated high activity against solid tumors of the gastrointestinal tract. Irinotecan is administrated intravenously and is able to cross the BBB but demonstrates only limited effect against HGG when used as singleagent therapy, with response rates between 0 and 15% (Vredenburgh et al., 2008). Topoisomerase I play a crucial role in the replication of DNA. In the chromosome, the DNA helix is supercoiled and tightly packed into chromatin. Topoisomerase I transiently remove the negative supercoils, facilitating transcription and replication of the parent DNA. Topoisomerase I and II activities are significantly enhanced in malignant gliomas following DNA damage. Irinotecan undergo carboxylesterase-mediated breakdown to the active metabolite, SN-38 that is 10– 1,000 times more potent than irinotecan. Glioma cells can convert irinotecan to SN-38 directly (Vredenburgh et al., 2008). SN-38 is eliminated primarily by the lever to the inactive metabolite SN-38 glucuronide. The terminal half-lives for both irinotecan and SN-38 are 7.9–14.2 h and 13.0–13.8 h respectively. In addition to biotransformation of to SN-38, irinotecan is oxidated by cytochrome P450 enzymes (especially CY3A4/5) forming a number of relative inactive metabolites. The use of anticonvulsant in CNS tumor patients are frequent and several antiepileptic medications have been shown to induce cytochrome P450 enzyme activity and thereby also increase systemic clearance of irinotecan, reducing systemic exposure to irinotecan and SN-38 considerably. Accordingly, a higher dose of irinotecan is necessary for patients receiving enzymeinducing antiepileptic drugs (EIAEDs) (Vredenburgh et al., 2008). The main toxicities observed with irinotecan are myelosuppression that can affect all the bloodforming elements of the bone marrow. Leukopenia,

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neutropenia, anemia, and thrombocytopenia have all been reported following irinotecan administration with neutropenia being the most clinically significant consequence of myelosuppression. Moreover, nausea, vomiting, and diarrhea are common adverse events following treatment with irinotecan. Especially diarrhea can be severe and a dose-limiting toxicity of irinotecan.

Bevacizumab in HGG It is generally accepted that tumor growth is dependent of angiogenesis in most solid tumors, and being one of the most vasculized tumors, angiogenesis appears to be of importance in malignant glioma growth. VEGF secreted by the glioma cells acts by paracrine mechanisms upon endothelial cells resulting in endothelial cell proliferation, survival and migration. VEGF might also have an impact on VEGFR expressing glioma cells, although the effect has not been clarified. The efficacy of bevacizumab in recurrent HGG, was first described by Stark-Vance (2005), which combined bevacizumab and irinotecan. Subsequently, several studies have shown the efficacy of bevacizumab in recurrent HGG (Norden et al., 2009) and in May 2009, the American food and drug administration (FDA) approved the use of bevacizumab as a single agent for patients with recurrent GBM based on two phase II studies showing durable objective response rates (Friedman et al., 2009; Kreisl et al., 2008). The promising results obtained with bevacizumab are -however, shown to be temporary, as recurrence is inevitable and despite prolonged PFS, overall survival remains largely unchanged when compared to the historic controls often used as reference for phase II trials using bevacizumab (Wong et al., 1999). Jain et al. found that VEGF inhibition transiently “normalizes” the disorganized and dysfunctional tumor vasculature in some experimental models, potentially improving delivery of oxygen and cytotoxic drugs to tumor cells (Jain, 2005). Given the transient nature of this phenomenon, it remains unknown whether the proposed “vasculare normalization” model has relevance in the long-term therapeutic effects of bevacizumab-chemotherapy. Nevertheless, as described below, this effect is of importance when evaluating treatment response radiographically on computed tomography (CT) or magnetic resonance imaging (MRI).

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The clinical and radiological benefit of bevacizumab and other anti-angiogenic therapies is indisputable. However, only 20–30% of HGG patients experience this effect and there is a compelling need to select and stratify patients most likely to benefit from the treatment. Consequently, there is an ongoing search for one or more valid biomarkers, which could prove to be predictive for response to treatment.

Treatment with Bevacizumab and Irinotecan The combination of irinotecan and bevacizumab was shown to be feasible and demonstrating a significant survival benefit when used phase III trial of patients with metastatic colorectal cancer comparing bevacizumab plus irinotecan/5-fluoruracil/leucovorin versus irinotecan/5-fluoruracil/leucovorin alone. In one of the first reported studies, 29 patients with recurrent malignant glioma were treated with bevacizumab and irinotecan, of which three patients had complete responses (CR), 16 partial responses (PR) and seven stable diseases (SD) according to the MacDonald criteria (Macdonald et al., 1990; Vredenburgh et al., 2007). These promising results have subsequently been confirmed by several other groups (Poulsen et al., 2009; Vredenburgh et al., 2007). The proposed dose of bevacizumab for patients with relapsed HGG is 10 mg/kg every other week (q2w) or 15 mg/kg every third week (q3w), with 10 mg/kg q2w being the most common regimen used. No direct comparison of the efficacy of bevacizumab administrated q2w or q3w has been performed in patients with relapsed HGG. Irinotecan is administrated in combination with bevacizumab using 340 mg/m2 for patients receiving EIAEDs and 125 mg/m2 for patients not receiving EIAEDs. To date, the importance of irinotecan in the regime of BI still needs to be elucidated. The FDA approval of bevacizumab as monotherapy in recurrent GBM was based on two phase II studies performed by Kreisl et al. (2008) and Friedman et al. (2009). The first study demonstrated that the effect of bevacizumab as monotherapy in recurrent GBM was feasible and responses were comparable with previous reports using BI in recurrent GBM (Kreisl et al., 2008). In

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the second study, patients with recurrent GBM were randomized in a noncomparative phase II trial to bevacizumab alone or in combination with irinotecan (Friedman et al., 2009). The primary objective of this trial was evaluation of safety and efficacy, and there was no intension of comparing the outcome of the two treatment groups, although it was observed that data did not indicate a treatment benefit of the addition of irinotecan. Subsequently, bevacizumab was FDA approved as monotherapy in recurrent GBM. However, a randomized phase III study (randomizing between bevacizumab versus bevacizumab and irinotecan) is still necessary to determine the effect of irinotecan. Even better would be a randomized trial between bevacizumab and one or more of the previously used regimens like PVC, BCNU or CCNU since a phase III trial showing a survival benefit of bevacizumab in recurrent GBM still remains to be performed. For this reason, European Medicines Agency (EMEA) recently did not approve bevacizumab for this indication in 2009 (http://www.emea.europa.eu), in contrast to the FDA approval. However, due to the promising effect of bevacizumab at recurrent disease, there are expectations that bevacizumab would be beneficial at the primary setting. Thus there are two ongoing phase III trials, randomizing between the standard regime (temozolomide and radiotherapy (Stupp et al., 2005)) or standard regime plus bevacizumab as first line treatment for GBM (http://www.clinicaltrials.gov).

The Clinical Effect of Bevacizumab Bevacizumab, with or without concomitant irinotecan, has indisputably shown activity in recurrent HGG in terms of clinical response. Corticosteroid use, neurocognetive function and performance status are likely to affect quality of life and accordingly it is reasonable to use these as surrogate markers. An improvement in or maintenance of steroid dose, performance status or clinical status is almost invariable in patients with clinical response (CR + PR) and frequently found in patients with SD whereas it is uncommon in patients with PD (Friedman et al., 2009; Poulsen et al., 2009). This indicates a benefit in terms of the patients health related quality of life although this has not been profoundly investigated so far.

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Whether bevacizumab is truly superior to other available therapies is unknown due to the lack of directly comparative trials. As the patient characteristics are not identical in the historical controls compared to patients in uncontrolled phase II studies with bevacizumab, it is not possible to determine if bevacizumab would be more efficient than previous treatments in terms OS.

The Difficulty in Evaluating Clinical Response When Using Anti-angiogenic Therapy The effects of bevacizumab on tumor vasculature have given rise to challenges in response evaluation. Disruption of the BBB by the tumor results in increased accumulation of fluid and plasma proteins in the surrounding brain. Because of the lack of lymphatic vasculature in the brain, and the fact that it is located in a confined space, the fluid leakage leads to increased interstitial pressure within the tumor and accumulation of fluid outside the tumor, resulting in vasogenic brain edema. Corticosteroids have been used for decades as temporary control of vasogenic brain edema, with moderate efficacy but also numerous side effects. The vascular normalization induced by anti-angiogenic agents like bevacizumab has shown to alleviate brain edema (Vredenburgh et al., 2007). This “steroid effect” might also improve drug delivery. However, the steroid effect from anti-angiogenic therapy gives rise to additional challenges when evaluating tumor load and response by CT or MRI scans. The MacDonald criteria is still used for evaluation of response to treatment (Macdonald et al., 1990). These criteria are based on the WHO criteria using the contrast-enhanced largest cross-sectional area of tumor on CT or MRI scans in combination with corticosteroid use and changes in neurological function. However, enhancement is nonspecific and primarily reflects a disrupted BBB. Besides bevacizumab, enhancement can be influenced by changes in corticosteroid dose and radiologic technique. Thus, when treating HGG with anti-angiogenic therapy like bevacizumab, the response to treatment observed may result at least partially from the bevacizumab induced normalization of abnormally permeable blood vessels and not from anti-tumor activity. Furthermore, anti-angiogenic

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treatment might control the contrast enhancing tumor more effectively than non-enhancing tumor, causing problems in interpretation of CT or MRI scans (LucioEterovic et al., 2009). This is also reflected in the overall survival data from patients treated with antiangiogenic therapy, which fail to show prolonged OS in recurrent HGG despite a promising response rate and PFS (Norden et al., 2008a). Accordingly, other response measurements are needed in evaluation of tumor response in HGG taking into account both enhancing and non-enhancing tumor, the latter being best visualized on T2 weighted and fluid-attenuated inversion recovery (FLAIR) MRI sequences. In order to improve endpoints in clinical trials and response criteria, an international working party [Response Assessment in Neuro-Oncology[(RANO)] has been established and recommendations are still to come.

Biomarkers as Surrogate Markers for Clinical Response As a consequence of the development and use of targeted therapies, the identification of biomarkers correlating with disease activity and the efficacy of treatment is rapidly evolving. However, so far none have been shown to predict a group of patients must likely to benefit from bevacizumab treatment, nor predict treatment response. Because of heterogeneity and insufficiency of tumor vasculature in HGG tumors, hypoxia within the tumor can be chronic or acute (fluctuating) although the importance of this is not known with respect to survival and/or response to anti-angiogenic treatment in HGG. This could also influence the potential information obtained from tissue related hypoxic biomarkers, as their precise role in HGG when treated with antiangiogenic compounds, needs to be revealed before they can be used as predictive biomarkers. When using an anti-angiogenic agent for the treatment of a highly vascularized tumor as GBM, it is intriguing to assume that MVD would be of importance for response and hence could be used as a predictive biomarker. However, as emphasized in the review by Hlatky et al. (2002) MVD is not equivalent to the degree of tumor angiogenic activity and measurement of MVD is not predictive of tumor response under anti-angiogenic treatment. Consequently the level of MVD in the tumor

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should not be used to decide which patients would benefit from anti-angiogenic treatment. Immunohistochemical methods have been the most used approach in the search for predictive and/or prognostic biomarkers. VEGF and carbon anhydrase 9 (CA9) have been found to be associated with radiologic response and survival outcome in 27 HGG patients treated with BI in one previous study (Sathornsumetee et al., 2008). However, these observations have not been confirmed in a larger study. This could be caused by heterogeneity of HGG tumors where the small tumor sample investigated might not be representative for the gross mass. Moreover, small differences in techniques and tissue handling could influence antigen preservation and thereby staining (Hasselbalch et al., 2010). In the search of biomarkers that predict response and resistance to anti-angiogenic therapy, additional modalities are under investigation. This include systemic, circulating, tissue and imaging biomarkers (reviewed in Jain et al. (2009)). However, as described above, the use of anti-angiogenic treatment has given rise to difficulty in establishing adequate criteria of response. Accordingly, this issue must be solved before any information regarding response can be used in combination with potential predictive biomarkers. Moreover, the biomarkers investigated might not be representative for the underlying biological mechanisms inducing response (or no response) to antiangiogenic therapy in HGG. This area still remains to be thoroughly investigated. In addition, it must be emphasized that most new drugs including bevacizumab are often tested in recurrent disease, from which tissue is not available. Recurrent tumor may be different from the primary tumor in terms of genetic expression and relevance of specific targets. Thus correlative studies based in tumor tissue and expression of tissue biomarkers may not capture meaningful associations of response and/or survival data.

Resistance to VEGF Pathway Inhibitors Is Inevitable VEGF pathway inhibitors induce only temporary tumor stasis or shrinkage but fail to produce enduring clinical responses in HGG. Despite the frequent benefit of bevacizumab and other anti-angiogenic drugs

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used for treatment of HGG, tumor progression is inevitable. The traditional concept of drug resistance involves mutational alterations of the target gene or alteration in the drug uptake and/or efflux resulting in treatment failure. This appears to be different when using angiogenic inhibitors, as the tumor functionally evade the therapeutic blockade of angiogenesis even though the specific therapeutic target remains inhibited. Instead, alternative pathways are activated resulting in angiogenesis and sustained tumor growth. In order to improve the effect of anti-angiogenic treatment and achieve improved OS, we need to understand this mechanism of resistance. In a recent study by Lucio-Eterovic et al. (2009) it was demonstrated in vitro that bevacizumab was able to sequester the majority of secreted VEGF in glioblastomas (LucioEterovic et al., 2009). In addition, it was observed that bevacizumab induced upregulation of several proangiogenic molecules in vivo (bFGF) and in vitro (i.e. bFGF, IL-1α, angiogenin and TGFα), which supports the idea that one of the reasons for lack of sustained effect from anti-angiogenic treatment is caused by up-regulation of additional pro-angiogenic molecules. Another concern is that inhibition of angiogenesis leads to an infiltrative tumor growth pattern with co-option of existing cerebral blood vessels thereby achieving vascular sufficiency (Lucio-Eterovic et al., 2009). Although not pathologically confirmed, this observation is supported in several clinical studies, which suggest an increased invasive growth on MRI scans from bevacizumab treated HGG patients (Norden et al., 2008b). In addition, it has been demonstrated in an in vitro model, that addition of bevacizumab induced an increased migration/invasion of glioma cells in a concentration-dependent manner (Lucio-Eterovic et al., 2009). As glioma cells releases VEGF, this is suggesting that autocrine VEGF signaling blockade plays an important role in glioma cell invasion. This could also be of importance in the resistance pattern observed upon anti-angiogenic therapy, thus reduced levels of VEGF gives rice to increased invasion. In addition, these findings also indicate that VEGF can influence glioma cells directly which are known to express both VEGFR-1 and VEGFR-2 and that the effects are not restricted to the influence on endothelial cells. Moreover, Lucio-Eterovic et al. (2009) demonstrated both in vitro and in vivo, that bevacizumab treatment induced up-regulation

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of invasion-related proteins (e.g. matrix metalloproteinase (MMP) -2, -9 and -12 and tissue inhibitor of metalloproteinases 1 (TIMP1) which further supports the idea that GBM cells can escape from antiangiogenic treatment by up-regulating molecules that allow them to invade into surrounding brain areas. The mechanism of resistance to anti-angiogenic therapy has been profoundly reviewed by Bergers and Hanahan (2008) who suggest four adaptive mechanisms that induce resistance to anti-angiogenic therapy. The first two overrule the necessity of VEGF by (1) activation and/or upregulation of alternative pro-angiogenic pathways as mentioned above or (2) recruitment of bone marrow-derived pro-angiogenic cells. Next, (3) the increased pericyte coverage of the tumor vasculature, which is known to occur, is serving to support its integrity, attenuating the necessity for VEGF-mediated survival signaling. Finally, and discussed above (4) they also state that inhibition of angiogenesis leads to an infiltrative tumor growth. This could originate from the activation and increased invasion of tumor cells into normal tissue, by co-option of normal blood vessels thereby achieving vascular sufficiency, and could explain the frequently observed decrease in neurological status, despite the relative stability of contrast-enhancing tumor on MRI scans. Furthermore, tumor recurrence could also originate from brain cancer stem cell (bCSC) that are not known to be influenced by anti-angiogenic treatment. The self-renewing, multipotent and tumorigenic capacities of bCSC are yet another option for inducing tumor recurrence. In addition, bCSC are able to migrate throughout the brain parenchyma, which along with the above mentioned infiltrative growth induced by anti-angiogenic treatment might explain the diffuse recurrence pattern observed by MRI scan. Thus, the absence of response to anti-angiogenic therapy could be due to intrinsic (pre-existing) resistance or reflect a rapid adaptation to the above-mentioned evasive resistance mechanisms.

Conclusion Several studies have demonstrated notable anti-tumor activity of bevacizumab in combination with irinotecan in recurrent HGG with promising response rates and prolongation of PFS when compared to historical

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controls. However, overall survival has not improved significantly, when compared to previous regimens. In addition, enhanced quality of life, measured by improvement in neurocognetive status, performance status and decrease in corticosteroid dose, are almost always observed in patients with clinical response (CR + PR). The regimen is well tolerated, with hypertension, tromboembolic events, diarrhea and neutropenia being to must common side effects. Thus, the effect of irinotecan in this regimen still needs to be determined. The MacDonald criteria used for evaluation might be misleading since normalization of tumor vessels and BBB reduce the contrast-enhancing tumor volume. This could lead to an apparent response, which is not due to decrease in number of clonogenic cells. Moreover, as only one third of the patients experience a benefit from the treatment, the ongoing search for predictive biomarkers is important.

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30 Patients with Recurrent High-Grade Glioma Jain RK (2005) Normalization of tumor vasculature: an emerging concept in antiangiogenic therapy. Science 307:58–62 Jain RK, Duda DG, Willett CG, Sahani DV, Zhu AX, Loeffler JS, Batchelor TT, Sorensen AG (2009) Biomarkers of response and resistance to antiangiogenic therapy. Nat Rev Clin Oncol 6:327–338 Jain RK, di Tomaso E, Duda DG, Loeffler JS, Sorensen AG, Batchelor TT (2007) Angiogenesis in brain tumours. Nat Rev Neurosci 8:610–622 Jensen RL (2009) Brain tumor hypoxia: tumorigenesis, angiogenesis, imaging, pseudoprogression, and as a therapeutic target. J Neurooncol 92:317–335 Kreisl TN, Kim L, Moore K, Duic P, Royce C, Stroud I, Garren N, Mackey M, Butman JA, Camphausen K, Park J, Albert PS, Fine HA (2008) Phase II trial of single-agent bevacizumab followed by bevacizumab plus irinotecan at tumor progression in recurrent glioblastoma. J Clin Oncol 5:740–745 Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, Burger PC, Jouvet A, Scheithauer BW, Kleihues P (2007) The 2007 WHO classification of tumours of the central nervous system. Acta Neuropathol 114:97–109 Lucio-Eterovic AK, Piao Y, de Groot JF (2009) Mediators of glioblastoma resistance and invasion during antivascular endothelial growth factor therapy. Clin Cancer Res 15: 4589–4599 Macdonald DR, Cascino TL, Schold SC Jr, Cairncross JG (1990) Response criteria for phase II studies of supratentorial malignant glioma. J Clin Oncol 8:1277–1280 Norden AD, Drappatz J, Muzikansky A, David K, Gerard M, McNamara MB, Phan P, Ross A, Kesari S, Wen PY (2008a) An exploratory survival analysis of anti-angiogenic therapy for recurrent malignant glioma. J Neurooncol 2:149–155 Norden AD, Drappatz J, Wen PY (2009) Antiangiogenic therapies for high-grade glioma. Nat Rev Neurol 5:610–620 Norden AD, Young GS, Setayesh K, Muzikansky A, Klufas R, Ross GL, Ciampa AS, Ebbeling LG, Levy B, Drappatz J, Kesari S, Wen PY (2008b) Bevacizumab for recurrent malignant gliomas: efficacy, toxicity, and patterns of recurrence. Neurology 70:779–787 Poulsen HS, Grunnet K, Sorensen M, Olsen P, Hasselbalch B, Nelausen K, Kosteljanetz M, Lassen U (2009) Bevacizumab plus irinotecan in the treatment patients with progressive recurrent malignant brain tumours. Acta Oncol 48:52–58 Sathornsumetee S, Cao Y, Marcello JE, Herndon JE, McLendon RE, Desjardins A, Friedman HS, Dewhirst MW, Vredenburgh JJ, Rich JN (2008) Tumor angiogenic and hypoxic profiles predict radiographic response and survival in malignant astrocytoma patients treated with bevacizumab and irinotecan. J Clin Oncol 26:271–278 Semenza GL (2001) Hypoxia-inducible factor 1: oxygen homeostasis and disease pathophysiology. Trends Mol Med 7: 345–350

299 Semenza GL (2003) Targeting HIF-1 for cancer therapy. Nat Rev Cancer 3:721–732 Stark-Vance V (2005) Bevacizumab and CPT-11 in the treatment of relapsed malignant glioma. Neuro Oncol 7:279–402 (Abstract 342) Steiner HH, Karcher S, Mueller MM, Nalbantis E, Kunze S, Herold-Mende C (2004) Autocrine pathways of the vascular endothelial growth factor (VEGF) in glioblastoma multiforme: clinical relevance of radiation-induced increase of VEGF levels. J Neurooncol 66:129–138 Stupp R, Hegi ME, Mason WP, van den Bent MJ, Taphoorn MJ, Janzer RC, Ludwin SK, Allgeier A, Fisher B, Belanger K, Hau P, Brandes AA, Gijtenbeek J, Marosi C, Vecht CJ, Mokhtari K, Wesseling P, Villa S, Eisenhauer E, Gorlia T, Weller M, Lacombe D, Cairncross JG, Mirimanoff RO (2009) Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomised phase III study: 5-year analysis of the EORTC-NCIC trial. Lancet Oncol 10:459–466 Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, Belanger K, Brandes AA, Marosi C, Bogdahn U, Curschmann J, Janzer RC, Ludwin SK, Gorlia T, Allgeier A, Lacombe D, Cairncross JG, Eisenhauer E, Mirimanoff RO (2005) Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352: 987–996 Tabernero J (2007) The role of VEGF and EGFR inhibition: implications for combining anti-VEGF and anti-EGFR agents. Mol Cancer Res 5:203–220 Vredenburgh JJ, Desjardins A, Herndon JE, Dowell JM, Reardon DA, Quinn JA, Rich JN, Sathornsumetee S, Gururangan S, Wagner M, Bigner DD, Friedman AH, Friedman HS (2007) Phase II trial of bevacizumab and irinotecan in recurrent malignant glioma. Clin Cancer Res 13:1253–1259 Vredenburgh JJ, Desjardins A, Reardon DA, Friedman HS (2008) Experience with irinotecan for the treatment of malignant glioma. Neuro Oncol 1:80–91 Wong ET, Hess KR, Gleason MJ, Jaeckle KA, Kyritsis AP, Prados MD, Levin VA, Yung WK (1999) Outcomes and prognostic factors in recurrent glioma patients enrolled onto phase II clinical trials. J Clin Oncol 17: 2572–2578 van den Bent MJ, Carpentier AF, Brandes AA, Sanson M, Taphoorn MJ, Bernsen HJ, Frenay M, Tijssen CC, Grisold W, Sipos L, Haaxma-Reiche H, Kros JM, van Kouwenhoven MC, Vecht CJ, Allgeier A, Lacombe D, Gorlia T (2006) Adjuvant procarbazine, lomustine, and vincristine improves progression-free survival but not overall survival in newly diagnosed anaplastic oligodendrogliomas and oligoastrocytomas: a randomized European Organisation for Research and Treatment of Cancer phase III trial. J Clin Oncol 24:2715–2722

Chapter 31

Monitoring Gliomas In Vivo Using Diffusion-Weighted MRI During Gene Therapy-Induced Apoptosis Timo Liimatainen, Olli Gröhn, and Kimmo Lehtimäki

Abstract Diffusion as detected by magnetic resonance imaging is typically self diffusion of water in biological samples or in vivo. Diffusion MRI has been widely studied and applied in clinical settings including detection of therapy responses in cancers. Malignant brain tumors especially gliomas are significant cause of cancer related deaths even though they are a reasonably rare type of cancer. Different kinds of therapies comprising of surgery, radiation-, chemotherapy or combined therapies have been applied routinely for treatment of these malignancies. Despite the developed therapy methods, the prognosis for the patients with malignant gliomas remains poor. Recently, gene therapy methods have also been developed for the treatment of the malignant glioma. When gene therapy becomes more widely available, the value of the imaging methods to detect treatment response will increase. Changes in the diffusion of water and metabolites, as measured with MRI and MRS, have been shown to serve as marker for positive treatment response in experimental settings. The main but simplified results from these studies in cell suspensions and in vivo are: water diffusion increases as a result of excessive cell loss and increase in extracellular water, and the diffusion of intracellular metabolites (total choline) decreases most likely due to cell shrinkage. The clinical studies are limited to chemotherapy and radiation therapy responses, which show similar responses as gene therapy in experimental models. As a conclusion, amongst

T. Liimatainen () Department of Biotechnology and Molecular Medicine, University of Eastern Finland, Kuopio, Finland e-mail: [email protected]

the magnetic resonance markers water diffusion is one of the most extensively studied and it has been found to be sensitive to treatment response in several tumor treatment protocols, including gene therapy approaches. Keywords Diffusion MRI · Gene therapy Apoptosis · Water diffusion · Cell death · ADC

·

Introduction The diffusion of molecules as measured by magnetic resonance imaging (MRI) or spectroscopy is most often defined as self diffusion i.e. the displacement of molecules by random thermal, Brownian motion without a concentration gradient. Diffusion of water molecules is most often assessed since water is the most abundant molecule in the human body and it contains magnetic resonance (MR) detectable spinhalf (1 H) atoms. For the free non-restricted diffusion, Stokes-Einstein’s well known relation claims that the diffusion constant D of molecules is proportional to temperature, inversely proportional to the viscosity of a solution and inversely proportional to the hydrodynamic radius of a molecule. Stokes-Einstein’s relation holds well in solutions, however diffusion in tissue is far more complex due to permeable or semi permeable cell membranes, cell organelles, active transport of molecules, flow, charge, variation in protein content, viscosity, and so on. The method for measuring diffusion using MR was introduced by Stejskall and Tanner in the early sixties (Stejskal and Tanner, 1965). They suggested a pulsed field gradient method for diffusion detection, which is still widely in use. Since those

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_31, © Springer Science+Business Media B.V. 2011

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times MR techniques and devices have been developed to provide a number of routine clinical applications. One of the most lethal cancers are malignant brain tumors, which include high-grade gliomas (Germano and Binello, 2009). Surgery, radiation therapy, chemotherapy or combined therapies have been applied routinely for the treatment of these malignancies. Despite the ongoing effort to develop therapy methods, the prognosis for patients with malignant gliomas remains poor (Germano and Binello, 2009). Gene therapy is a rapidly developing method to treat malignant tumors when location or other reasons prevent the use of surgical therapy and/or the close proximity of tissues sensitive to ionizing radiation prevents the use of radiation therapy. Also, the inefficiency or side effects of chemotherapy for certain types of malignancies may hamper its use. No matter which therapy method is applied, the aim of the anticancer therapy is to remove malignant tissue or kill malignant cells. The response to therapy is likely to vary between individuals and therefore a non-invasive method for visualizing and optimizing the treatment protocols is required. Medical imaging is typically used to follow up the treatment response during such therapies. Tumor volume, derived from anatomical MRI or CT images has often been used as a surrogate marker for treatment response. Tumor volume measurements show whether or not a treatment was effective in stabilizing or reversing tumor growth. However, far before volume response, several cellular level events take place. This cascade of physicochemical processes includes numerous components indicating the physicochemical state of the tumor tissue and providing a basis for imaging markers for therapy response. Among the markers, diffusion MRI is one of the most extensively studied and it has been found to be sensitive to treatment response in several tumor treatment protocols, including gene therapy approaches (Kettunen and Gröhn 2005).

insult such as toxicity, hypoxia, ischemia or physical injury. The insult leads to failure in cell energy metabolism in the early phase, resulting in swelling of mithochondria and ruptured nuclei, organelles, and plasma membranes. Widespread necrosis leads to the release of lysosome contents into the extracellular space causing inflammation and damage of neighboring cells. In contrast, apoptosis is an active and well controlled cell death mechanism that requires adenosine triphosphate to maintain cell integrity and cell removal in a controlled manner (Savill and Fadok, 2000 and references therein). Apoptosis can be divided into two main stages. First, apoptotic bodies are formed through a cascade of molecular events and second, the degradation and phagocytosis of the formed apoptotic bodies takes place. Apoptosis is present in several processes that modify and remodel tissue architecture (Kerr et al., 1972). Several pathological changes occur during apoptotic cell death, such as cell shrinkage, DNA fragmentation, nuclear condensation, and the formation of membrane-encapsulated apoptotic bodies (Kerr et al., 1972), in which the content of the demised cells are recycled by macrophages and/or neighboring cells to serve the needs of the other cells (Savill and Fadok, 2000). Interplay between external stimuli such as hormones, growth factors, cytokines and cell internal sensing mechanisms are needed for a cell to undergo apoptosis (Hale et al., 1996). Due to its role in life and death, apoptosis can be thought of as the default cell death pathway (Kinloch et al., 1999). For instance, in many cancers apoptosis is “turned off”, leading to uncontrolled cell proliferation (Kinloch et al., 1999). In terms of non-surgical anti-cancer therapy strategies, in many cases, apoptosis is a desired way to cells die, since harmful intracellular metabolites and electrolyte fluxes, which could elicit inflammatory reactions and necrosis, remain within the apoptotic bodies. This means that apoptosis is relatively non-toxic for neighboring cells.

Cell Death and Gene Therapy

Gene Therapy

Cell Death Mechanisms Cell death may take place through two distinguishable mechanisms, namely apoptosis or necrosis. Typically necrosis occurs when the cell is exposed to an acute

Gene therapy is a promising new way to treat patients with cancer and some other serious diseases. The goal of the gene therapy is an insertion or modification of genes in the individual’s cell for the purpose of treatment (Germano and Binello, 2009). The definition

31 Monitoring Gliomas In Vivo Using Diffusion-Weighted MRI

of the gene therapy can be phrased as the transfer of nucleic acids to the somatic cells of a patient with a therapeutic intent (Wirth et al., 2009). Gene therapy can be used alone or together with surgical removal of the cancerous tissue, which is the most common target for gene therapy. Gene delivery is performed using viral vectors, stem cells, and synthetic vectors like nanoparticles or liposomes. The most often used approach exploits so-called suicide genes, which cause wide-spread apoptosis in the malignant tissue leading to structural changes in tissue that can be detected by diffusion based MRI. The first gene therapy clinical protocol was approved by the FDA in 1989. In 2009 there were more than 1400 ongoing gene therapy trials worldwide. Most of them were cancer gene therapies, but only few for the treatment of brain cancers. Five of them were gene therapies targeted to brain cancer in phase III (Wirth et al., 2009).

Magnetic Resonance Methods for Detection of Diffusion The first pulsed gradient diffusion measurement using magnetic resonance (MR) consisted of a spin echo pulse sequence with diffusion field gradients inserted both sides of a 180 degree refocusing pulse (Stejskall and Tanner, 1965). The diffusion weighting factor b of the pulse sequence depends on the gyromagnetic ratio of the nucleus (γ ) and user-controllable field gradient parameters; amplitude of the gradients (G), their duration δ and time interval () between them b=γ G δ 2

2 2

δ . − 3

In this equation, the diffusion time is tdiff = (−δ/3). By varying b value in the pulse sequence, the observed signal intensity in the diffusion experiment can be altered according to equation S = e−bD , S0 where D is the diffusion coefficient of the molecule. Usually the compound under investigation is a water molecule, since its abundance in the many tissues is high. The idea in diffusion weighting is to attenuate the MR signal in the measurement due to

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Brownian motion of the imaged molecules (Fig. 31.1). In addition to this weighting, a readout sequence, for instance a spin echo sequence, causes an additional weighting to the MR signal. Therefore, contrast in the diffusion weighted images is mixed. A common way to eliminate readout weighting is to measure the MR signal (S) with several diffusion weightings followed by plotting of natural logarithm of S as a function of the b value and the diffusion coefficient (D) is determined by the slope of the curve. In many cases with the diffusion times used in MRI the diffusion appears restricted. If the compartment diameter is far larger than the average diffusion distance during tdiff , diffusion can be approximated as free diffusion and average diffusion distance can be calculated by the relation x0 =

2Dtdiff .

In the cases where the average diffusion distance is in order of compartment size, diffusion is restricted, which leads to decreased D. When the measured diffusion coefficient is affected by restriction, active transfer, etc., which is usually the case in tissue, it is often called apparent diffusion coefficient (ADC). Compartment size and/or other aspects affecting the measured D might not be homogeneous in all directions, causing difference between D’s measured in different directions (i.e. using pulsed field gradients in different physical orientations x, y, z). Several measurements (at least six) with diffusion gradients in different orientations are needed to define a full diffusion tensor matrix, which includes more descriptive information of the directional dependency of the diffusion. From the diffusion tensor, trace, fractional anisotropy, and diffusivity along main axis can be calculated and information can be used to resolve, for instance, fiber tracts in the brain tissue. It is worth noting that although the most common parameter to study molecular diffusion in the tumor tissue still remains to be the average diffusion of water in single or all physical axes (x, y, z; the trace of the diffusion tensor), there is body of evidence that at least in experimental intracranial gliomas that there are distinct patterns of cellularity (spherical, radial) that are specific for different tumors (Zhang et al., 2007). These characteristics may be detected using diffusion tensor MRI but it remains to be shown whether the possible changes in the cellular patterns

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Fig. 31.1 The schematic interpretation of the MR diffusion measurement. Let’s consider the ensemble of stationary molecules; during the first field gradient pulse the magnetization dephases an amount depending on molecule(s) location (here i, ii or iii) in both stationary and moving molecules; during the second field gradient the magnetization fully rephases in the stationary molecule ensemble. Despite that moving molecules

experience similar dephasing, the movement of the molecules between the field gradients changes the magnetic field and therefore angular velocity of rephasing experienced by the molecules, causing only partial rephasing in this population. Partial rephasing leads to signal loss compared with stationary molecules and this signal loss forms the base of diffusion contrast and measurements in MRI

in tumors can be exploited to evaluate the treatment responses.

Multi-compartmental Diffusion in the Tissue

Water Diffusion in the Tissue

The slope of the natural logarithm of signal intensity log(S) remains close to linear up to 1000 s/mm2 , but if we apply higher b values the decay will begin to bend. This is due to multi-exponentiality of the water diffusion in the tissue environment. In a simplified tissue model the slow diffusing water component originates mostly from intracellular space and the fast decaying component originates mostly from extracellular space. The most obvious way to analyze such data is a two compartment bi-exponential decay model

Water in the Brain Tissue Water can be located in several compartments with varying physical and chemical environments with characteristic ADCs. The volume ratio of the intravascular space is 3–4% in healthy brain tissue. Intra and extracellular spaces occupy the remainder by 80 and 20% (Norris, 2001). Intracellular space comprises mostly of cytoplasm, which is a mixture of 70% of water, 20% of proteins, 10% of lipids and inorganic compounds (Alberts et al., 1994).

S = AI exp( − bDI ) + AE exp( − bDE ),

31 Monitoring Gliomas In Vivo Using Diffusion-Weighted MRI

where AI + AE = S0 , DI and DE refer to intraand extracellular diffusion coefficients, respectively. Over the years debate has continued about the illconditioned nature of the multi-exponential decay equation, thus several other models to analyze multicompartmental diffusion data has been suggested with experimental verifications (reviewed by Mulkern et al., 2009). Diffusion in compartments is affected by tortuosity, especially extracellular space, volume fractions of the compartments, cell membrane permeability and exchange times between compartments, all these having an impact on the measured ADC. Therefore, water ADC in extra- and intracellular spaces is not trivial to determine experimentally. Using the cell cultures, the intracellular ADCs can be determined, first demonstrated by van Zijl et al. (van Zijl et al., 1991). The idea is to use high b values to spoil out the signal from the rapidly diffusing cell medium. Work was extended to cover different cell types, and dataanalysis was performed taking permeable cell membranes into account. Water analogs can also be used to determine intra- and extracellular ADCs separately. The first approach was to use 133 Cs as a water diffusion analog in the tissue. The 133 Cs is a potassium analog accumulating into intracellular space and shedding the light to intracellular water diffusion. The ADC of 0.91×10−3 mm/s2 was measured in normal rat brain tissue (Neil et al., 1996). The use of analogs was continued by administration of 2FDG6P in the rats intravenously. 2FDG-6P metabolizes when it is taken up by the cells and fluoride is kept in the intracellular space allowing diffusion measurements. The same compound administered directly into the ventricle allows the measurement of extracellular ADC. Despite a massive amount of effort to figure out mechanisms behind the water diffusion in the healthy brain using MRI and other methods, the relationship between tissue microstructure, water dynamics and ADC is not yet fully understood (Norris, 2001). This fact does not prevent us from exploiting diffusion MRI to study several different diseases. In acute stroke, a dramatic acute drop in ADC is detected – a phenomenon that is associated with a shift in tissue water from extracellular space to intracellular space due to cytotoxic edema – while the degradation of the cellular structures in a mature stroke lesion or in many neurodegenerative diseases leads to increased diffusion.

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Assessing Response to Gene Therapy Through Water Diffusion Biological Aspects in Tumor and Gene Therapy Detection Several differences can be itemized between normal tissue and tumor or neoplastic tissue. One of the most characteristic features is excessive proliferation, which typically leads to high cell density in the tumor tissue. Also increased metabolic activity, angiogenesis, dysregulation of cellular homeostasis and formation of distant colonies from the primary site are typical for fast proliferating tissue. Expression of specific cell surface receptors may occur as well. All of these features of tumor can be detected using imaging applications with several physical approaches, such as magnetic resonance, x-rays, and radioactive isotopelabeled compounds (Rudin, 2007). Cell death and changes in vasculature are early markers of successful therapy response. Both of these alter the water environment in the tissue, indicating the potential of water ADC as an effective surrogate marker for the therapy outcome both for agents that disrupt vasculature and therapies that induce apoptosis (Padhani et al., 2009). Changes in cell density alter the ratio between extra and intracellular spaces and therefore also the ADC of water in the tissue. Therefore it is not surprising that a correlation between cell density and ADC has been found during tumor treatment. Cell density often decreases in the tumor before any shrinkage of the tumor can be detected and therefore diffusion measurements can provide an early marker for the treatment response.

Early Research for the Detection of Tumor Treatment Response by Diffusion MRI In the very first studies of water ADC on tumor treatment, Zhao et al. (1996) found that a dosage of 300 mg/kg of cycliphosphamine in breast tumor xenografts resulted in the doubling of water ADC in 4 days, suggesting water ADC as an early marker for chemotherapy outcome. The increase in water diffusion, as measured using spectroscopic method, preceded the decrease in tumor volume. In the 9L tumor

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model treated with a single injection of 13.3 mg/kg of 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU or carmustine), the water ADC was found to increase by roughly 50% more than the baseline. For confirmation there were no significant changes in ADC in normal tissue during the treatment or in non-treated tumors (Chenevert et al., 1997). The recurrence of the tumor took place 8 days after a single shot of BCNU; at the same time as water ADC began to decline towards its initial pretreatment value, which was confirmed with histological analysis (Chenevert et al., 1997). In this study, increased water ADC was explained by increased mobility of the water due to increased extracellular space as a result of ongoing apoptosis and the formation of apoptotic bodies. The first report of water diffusion changes during gene therapy is by Poptani et al. (Poptani et al., 1998). In the study, BT4C thymidine kinase transfected tumor cells were inoculated into the BDIX rat brain and 3–4 weeks after inoculation, animals were treated with ganciclovir to induce apoptosis. Gene therapy in these tumors results in elevation in water ADC in an early phase of treatment (Fig. 31.2) and later the tumor volume response to gene therapy, as defined from T2 weighted images. Similar results were

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reported also in a refined cytosine deaminase (CD)/5fluorocytosine (5FC) chemosensitization gene therapy paradigm in orthotopic 9L gliomas stably expressing the cloned S. cerevisiae CD gene (Stegman et al., 2000).

Association Between Water Diffusion and Cell Density In many experimental studies and clinical settings water ADC has been found to increase with decreasing cell density in tumor tissue (Kettunen and Gröhn 2005). The increase in water ADC is often explained by the increased extracellular space i.e. decreased number of the cells in the tissue (Chenevert et al., 1997) and/or decreased size of the cells (Galons et al., 1999). Increase in water diffusion was also confirmed for the extracellular water component by Valonen and colleagues (Valonen et al., 2004). In vitro data measured in macrophages undergoing apoptosis by Hortelano and colleagues show that the apoptotic cell shrinkage was most likely the reason for decreased ADC after apoptotic caspase activation (Hortelano et al., 2001).

Water ADC Initial Decrease in Therapies

Fig. 31.2 The first published MRI diffusion study of gene therapy response is shown. The experiment introduces water T2 and ADC changes during gene therapy in the rat BT4C tumor model using HSV tk+ transfected cells (a–c and e–f) and wildtype cells with intratumoral injection of PA317/3.OD5 cells to mimic clinical gene therapy (d and h). Both groups were treated with ganciclovir and both T2 (a–c) and water ADC (e–g) increased during therapy in HSV tk+ transfected tumors, whereas no significant change was detected in wild type tumors. The increase in ADC and T2 corresponded to the later detected decrease in tumor volume. Adapted by permission from Macmillan Publishers Ltd: Cancer Gene Therapy 5(2):101–109, 1998, copyright (1998)

Decreased water ADC values before treatment are detected in nearly all malignant tumors (Padhani et al., 2009). This is most likely due to higher cell density and decreased extracellular space in the tumor tissue when compared with normal tissue. A decrease in ADC soon after the initiation of therapy has also been detected, which seems to be due to cellular swelling, reduction in blood flow, or reduction in extracellular space (Padhani et al., 2009). The extent and duration of such ADC reductions depend most likely on the tumor type and timing of imaging with respect to the used treatment (Padhani et al., 2009). Cellular swelling might occur in the early phase of apoptosis in the response to treatment; for instance, water ADC values are reduced by fibrosis, dehydration in rectal cancer and brain glioma therapies (Padhani et al., 2009). These findings indicate the complex interplay between physicochemical events reflected by changes in ADC maps.

31 Monitoring Gliomas In Vivo Using Diffusion-Weighted MRI

Inhomogeneous ADC Response within the Tumor Tissue During Therapy It should be noted here, that typically changes in ADC are not uniform across the tumors (Moffat et al., 2006). The imaging postprocessing technique to image nonuniform therapy response is introduced for diffusion by Moffat and colleagues (Moffat et al., 2006). They found that by increasing the dosage of BCNU in 9L tumor bearing rats, and calculating the change of water ADC between initial and treated stages of the same tumors pixel wise, the tumor response to therapy can be evaluated. The percentage of increased water diffusion was demonstrated to predict histology derived cell loss and overall survival of the animals. The method is called functional diffusion mapping and it has been extended into other anticancer treatments and clinical studies (Hamstra et al., 2005 and references therein).

Metabolite Diffusion in the Tissue Magnetic resonance spectroscopy (MRS) can be used instead of imaging to detect metabolites in the tissue based on the difference in chemical shift. A spectroscopic experiment can be sensitized to molecular diffusion in a similar manner to imaging. For in vivo use, the signal needs to be localized to originate from the tissue of interest (the tumor). In the case of 1 H spectroscopy, metabolite levels are in the range of 10−3 of the water signal in the normal brain tissue therefore also effective water suppression has to be used to enhance dynamic range of metabolite detection. MRS signal for choline containing compounds (Cho) at 3.2 ppm consists of signals originating predominantly from glycerophosphocholine, phosphocholine and to a lesser extent from free choline. These compounds are important constituents in plasma membrane build-up and/or catabolism and increased Cho signal is typically detected in tumor as a consequence of active cell membrane metabolism. The resonance for choline containing compounds in the 1 H NMR spectrum of brain tissue includes also resonances from taurine, myo-inositol and phosphoethanolamine (Remy et al., 1994). The diffusion of tCho may be interesting in terms of the response to therapy, since apoptosis alters the physical size of the cell while maintaining the integrity of the cell membrane at the

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same time. The single voxel spectroscopic study in BT4C gliomas undergoing apoptosis in vivo showed that the diffusion of tCho decreases as a response to the therapy and in the opposite direction to water diffusion (Hakumäki et al., 1998). In the same study, the reduction of the smaller pool of water, most likely from within intracellular space, has been detected together with a decrease in tCho indicating the tCho signal origin from intact cells. Unpublished diffusion weighted spectroscopic imaging data from the same tumor-therapy model shows that tCho ADC decreases during the treatment and this response is the most dramatic in the center of the tumor (Fig. 31.3). Reduction most likely reflects a reduction in the percentage of intracellular volume and cell diameter, which were measured using histological methods. The result may indicate that the intracellular compartment where tCho resides decreases in volume, or that the intracellular hindrance/viscosity changes during the treatment. The analysis of cell diameter and detected cell shrinkage using histological methods confirms the first option, although it is expected that also the latter has its own contribution to the effect. The signals from fatty acids at 0.9 and 1.3 ppm originate mostly from mobile lipids located in lipid vesicles (Hakumäki et al., 1999), and contain significant contribution from cholesterol (Liimatainen et al., 2006). The diffusion of the fatty acids is relatively slow and detection of restricted diffusion of these compounds needs long diffusion times, which make the experiment prone to movement artifacts in vivo. No significant changes in ADC’s of mobile lipids were found in the BT4C glioma model during apoptotic cell death (Hakumäki et al., 1998). In the same model, an increase in visible triglycerides has been reported using single voxel and spectroscopic imaging techniques (Hakumäki et al., 1999; Liimatainen et al., 2006). In summary, these findings support the idea of an increase in the number of lipid vesicles without a change in size during therapy. However, most likely the restriction was not reached for these resonances and the result reflects the constant viscosity in the vesicles during the treatment. The recent study (Liimatainen et al., 2009) showed that in the early phase of the HSV tk+ gene therapy, water diffusion correlates especially with polyunsaturated lipid resonances. The loss of relationship between unsaturated lipid signals and water diffusion in the late phase was explained by a low number of cells in the remaining tissue (dead tissue).

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Fig. 31.3 Diffusion weighted spectroscopic imaging data measured from rat BT4C HSV tk+ tumors during ganciclovir induced apoptosis and histological parameters: (a) representative diffusion weighted spectra from an intra tumoral voxel at baseline (day 0) showing well resolvable choline containing moieties (CCM) signal at 3.2 ppm and signal attenuation due to diffusion

at different b values; (b) ADC map of CCM at day 0; (c) ADC map of CCM at day 8; (d) ADC of CCM resolved for border, center and whole tumor area; and (e) histologically derived intracellular volume (bars) and cell diameter (dotted lines). Figure by Kimmo Lehtimäki, Timo Liimatainen and Juhana Hakumäki

Other MR Contrast Methods for Treatment Response Detection

parameters, such as average exchange time of bulk water and macromolecule pools (Sierra et al., 2008). Even though the measurements allow extraction of fundamental parameters, the mechanisms behind these findings are still partly unknown. Nevertheless, these methods may track changes in water-protein interactions, cell microarchitecture, protein/lipid content and composition as well as changes in pH levels. These approaches are less sensitive to motion than diffusion MRI, after all clinical exploitation has been delayed because of potential tissue heating effects (high specific absorption rate, SAR).

Despite the wide use of diffusion for detection of therapy response, several other MRI methods can be applied for the same purpose. For instance, water T1 and T2 increase during apoptosis in the tumor tissue, as shown in a rodent tumor gene therapy model (Hakumäki et al., 2002; Poptani et al., 1998). However, these changes are typically delayed compared with diffusion changes. Also water T1 in a rotating frame of reference (T1ρ ) increases significantly even in the earlier phase of the gene therapy before diffusion (Hakumäki et al., 2002; Kettunen et al., 2007). With certain assumptions, the several measurements using rotating frame contrasts (T1ρ and T2ρ with varying RF amplitude and phase modulation functions) can be used to calculate fundamental characteristic tissue

Clinical Aspects The clinical use of gene therapy for brain tumors is still limited to clinical trials. However, the first gene therapy products are waiting for the permission of

31 Monitoring Gliomas In Vivo Using Diffusion-Weighted MRI

authorities to be released for commercial use. As the efficacy of gene therapy, like other anticancer treatments, needs to be controlled in every patient, there is evidently an urge for non-invasive imaging of treatment response. Water diffusion MRI is one potential candidate for that purpose. While there is currently only a few clinical gene therapy trials ongoing in brain cancers and none of these utilize diffusion MRI to our knowledge, the use of water ADC has been evaluated in many other treatment protocols. The following paragraph is based on the review article by Hamstra et al. (2007) and references therein. Increased water ADC values have been measured after chemotherapy in patients, indicating the possible importance of diffusion weighted MRI as a biomarker for therapy response in clinical settings. The increased ADC has been shown to predict positive treatment outcomes in oncotherapy, irrespective of whether the cell death occurs by apoptosis or necrosis. In two patients, ADC was found to increase several weeks before actual tumor response. It should be noted that during the time when tumors were responding with conventional markers, the water ADC had already begun to decrease. In another study, the tumors were treated with convection-enhanced chemotherapy administered intratumorally for several days. Diffusion changes were observed as early as after 24 h from the beginning of chemotherapy administration. Significant increase in water diffusion was also measured after 3 days of radiotherapy in six patients with primary or metastatic tumors. A preliminary study in three children with medulloblastoma supports the clinical value of diffusion MRI for the detection chemotherapy response. The water diffusion was increased also after stereotactic radiation therapy. In a study using fractionated radiation therapy, the initial water ADC was found to predict treatment response; low ADC was associated with high viability, high cell density and probable response to therapy whereas high ADC indicated necrosis and non-successful therapy outcome, which is called functional diffusion mapping. Functional diffusion mapping has been used in a prospective trial in patients with primary brain tumors. Patients underwent diffusion imaging 1 week before chemo and/or radiation therapy and a second time was set approximately 3 weeks from the start of therapy when half of the fractionated radiation therapy was delivered. The weak correlation between water diffusion and later radiographic response was found. Responsive,

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stable and progressive tumor growth patients were able to discriminate using functional diffusion mapping. The other study from the same research group indicated that functional diffusion mapping correlated with radiographic response, progression free and overall survival times. The patients divided into responders and non-responders based on functional diffusion mapping showed overall survival of 18.2 and 8.2 months (p < 0.01; log rank test).

Future Aspects In addition to a standardized ADC measurement protocol to follow up treatment response, more advanced methods that measure and analyze the diffusion data are needed. For instance, routine clinical use of functional diffusion mapping to follow up the treatment response may be feasible with little effort. Diffusion MRI has been evaluated as a part of study protocol to predict gene therapy outcome in a rat glioma model with 1 H MRS of lipid compounds. The study showed that diffusion, together with other MRI/imaging parameters, may provide an even more complete picture of tissue response to treatment. One interesting and arising diffusion measurement strategy is to separate different motion regimes by repeating measurement with several frequencies of oscillating field gradients, allowing application of short diffusion times while simultaneously keeping a reasonable gradient amplitude (Colvin et al., 2008). The authors demonstrated their method in an experimental glioma model and suggested its use also for monitoring treatment response. All of these methods may provide complementary information on water/metabolite biophysical status during the treatment and add to the clinical value of diffusion measurements. In conclusion, diffusion MRI has been evaluated widely for the detection of the gene therapy response in preclinical settings. For imaging the gene therapy response, clinical applications are promising, even though the current results are only from chemo and/or radiation therapies. In general, evaluation of diffusion MRI data from clinical settings is hampered by the variety of diffusion measurement protocols (b values, imaging readout, etc.) and also variation in analytical methods (absolute ADC, mean ADC,

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normalized ADC, threshold changes in ADC and functional diffusion maps). The true value of diffusion MRI for the assessment of gene therapy response will be seen when gene therapy is more widely available and tested in multi-institutional trials incorporating diffusion MRI with uniform protocols.

References Alberts B, Bray D, Lewis J, Ralf M, Roberts K, Watson JD (1994) Molecular biology of the cell. Garland Publishing, New York, NY Chenevert TL, McKeever PE, Ross BD (1997) Monitoring early response of experimental brain tumors to therapy using diffusion magnetic resonance imaging. Clin Cancer Res 3:1457–1466 Colvin DC, Yankeelov TE, Does MD, Yue Z, Quarles C, Gore JC (2008) New insights into tumor microstructure using temporal diffusion spectroscopy. Cancer Res 68:5941–5947 Galons J-P, Altbach M-I, Paine-Murrieta GD, Taylor CW, Gillies RJ (1999) Early increases in breast tumor xenograft water mobility in response to paclitaxel therapy detected by noninvasive diffusion magnetic resonance imaging. Neoplasia 1:113–117 Germano IM, Binello E (2009) Gene therapy as an adjuvant treatment for malignant gliomas: from bench to bedside. J Neurooncol 93:79–87 Hakumäki JM, Gröhn OHJ, Tyynelä, Valonen P, Ylä-Herttuala S, Kauppinen RA (2002) Early gene therapy-induced apoptotic response in BT4C gliomas by magnetic resonance relaxation contrast T1 in the rotating frame. Cancer Gene Ther 9: 338–345 Hakumäki JM, Poptani H, Puumalainen AM, Loimas S, Paljärvi LA, Ylä-Herttuala S, Kauppinen RA (1998) Quantitative 1 H nuclear magnetic resonance diffusion spectroscopy of BT4C rat glioma during thymidine kinase-mediated gene therapy in vivo: identification of apoptotic response. Cancer Res 58:3791–3799 Hakumäki JM, Poptani H, Sandmair AM, Ylä-Herttuala S, Kauppinen RA (1999) 1 H MRS detects polyunsaturated fatty acid accumulation during gene therapy of glioma: implications for the in vivo detection of apoptosis. Nat Med 5:1323–1327 Hale AJ, Smith CA, Sutherland LC, Stoneman VE, Longthorne VL, Culhane AC, Williams GT (1996) Apoptosis: molecular regulation of cell death. Eur J Biochem 236:1–26 Hamstra DA, Chenevert TL, Moffat BA, Johnson TD, Meyer CR, Mukherji SK, Quint DJ, Gebarski SS, Fan X, Tsien CI, Lawrence TS, Junck L, Rehemtulla A, Ross BD (2005) Evaluation of the functional diffusion map as an early biomarker of time-to-progression and overall survival in high-grade glioma. Proc Natl Acad Sci USA 102: 16759–16764 Hamstra DA, Rehemtulla A, Ross BD (2007) Diffusion magnetic resonance imaging: a biomarker for treatment response in oncology. J Clin Oncol 25:4104–4109

T. Liimatainen et al. Hortelano S, Garcia-Martin ML, Cerdan S, Castrillo A, Alvarez AM, Bosca L (2001) Intracellular water motion decreases in apoptotic macrophages after caspase activation. Cell Death Diff 8:1022–1028 Kerr JFR, Wyllie AH, Currie AR (1972) Apoptosis: a basic biological phenomenon with wide-rangingimplications in tissue kinetics. Br J Cancer 26:239–257 Kettunen MI, Gröhn OHJ (2005) Tumour gene therapy monitoring using magnetic resonance imaging and spectroscopy. Curr Gene Ther 5:685–696 Kettunen MI, Sierra A, Närväinen MJ, Valonen PK, YläHerttuala S, Kauppinen RA, Gröhn OHJ (2007) Low spinlock field T1 relaxation in the rotating frame as a sensitive MR imaging marker for gene therapy treatment response in rat glioma. Radiology 243:796–803 Kinloch RA, Treherne JM, Furness LM, Hajimohamadreza I (1999) The pharmacology of apoptosis. Trends Pharmacol Sci 20:35–42 Liimatainen T, Hakumäki JM, Kauppinen RA„ Ala-Korpela M (2009) Monitoring of gliomas in vivo by diffusion MRI and 1 H MRS during gene therapy-induced apoptosis: interrelationships between water diffusion and mobile lipids. NMR Biomed 22:272–279 Liimatainen T, Lehtimäki K, Ala-Korpela M, Hakumäki JM (2006) Identification of mobile cholesterol compounds in experimental gliomas by 1 H MRS in vivo: effects of ganciclovir-induced apoptosis on lipids. FEBS Lett 580: 4746–4750 Moffat BA, Chenevert TL, Meyer CR, McKeever PE, Hall DE, Hoff BA, Johnson TD, Rehemtulla A, Ross BD (2006) The functional diffusion map: an imaging biomarker for the early prediction of cancer treatment outcome. Neoplasia 8:259–267 Mulkern RW, Haker SJ, Maier SE (2009) On high b diffusion imaging in the human brain: ruminations and experimental insights. Magn Reson Med 27:1151–1162 Neil JJ, Duong TQ, Ackerman JJH (1996) Evaluation of intracellular diffusion in normal and globally-ischemic rat brain via 133 Cs NMR. Magn Reson Med 35:329–335 Norris DG (2001) The effects of microscopic tissue parameters on the diffusion weighted magnetic resonance experiment. NMR Biomed 14:77–93 Padhani AR, Liu G, Mu-Koh D, Chenevert TL, Thoeny HC, Takahara T, Dzik-Jurasz A, Ross BD, Van Cauteren M, Collins D, Hammoud DA, Rustin GJS, Taouli B, Choyke PL (2009) Diffusion-weighted magnetic resonance imaging as a cancer biomarker: Consensus and recommendations. Neoplasia 11:102–125 Poptani H, Puumalainen AM, Gröhn OHJ, Loimas S, Kainulainen R, Ylä-Herttuala S, Kauppinen RA (1998) Monitoring thymidine kinase and ganciclovir-induced changes in rat malignant glioma in vivo by nuclear magnetic resonance imaging. Cancer Gene Ther 5:101–109 Remy C, Arus C, Ziegler A, Lai ES, Moreno A, Le Fur Y, Decorps M (1994) In vivo, ex vivo, and in vitro one- and twodimensional nuclear magnetic resonance spectroscopy of an intracerebral glioma in rat brain: assignment of resonances. J Neurochem 62:166–179 Rudin M (2007) Imaging readouts as biomarkers or surrogate parameters for the assessment of therapeutic interventions. Eur Radiol 17:2441–2457

31 Monitoring Gliomas In Vivo Using Diffusion-Weighted MRI Savill J, Fadok V (2000) Corpse clearance defines the meaning of cell death. Nature 407:784–788 Sierra A, Michaeli S, Niskanen JP, Valonen PK, Gröhn HI, Ylä-Herttuala S, Garwood M, Gröhn OHJ (2008) Water spin dynamics during apoptotic cell death in glioma gene therapy probed by T1ρ and T2ρ . Magn Reson Med 59: 1311–1319 Stegman LD, Rehemtulla A, Hamstra DA, Rice DJ, Jonas SJ, Stout KL, Chenevert TL, Ross BD (2000) Diffusion MRI detects early events in the response of a glioma model to the yeast cytosine deaminase gene therapy strategy. Gene Ther 7:1005–1010 Stejskal EO, Tanner JE (1965) Spin diffusion measurements: Spin echoes in the presence of a time-dependent field gradient. J Chem Phys 42:288–292 Valonen PK, Lehtimäki KK, Väisänen TH, Kettunen MI, GröhnOHJ, Ylä-Herttuala S, Kauppinen RA (2004) Water diffusion in a rat glioma during ganciclovir-thymidine kinase

311 gene therapy-induced programmed cell death in vivo: correlation with cell density. J Magn Reson Imaging 19:389–396 Van Zijl PC, Moonen CT, Faustino P, Pekar J, Kaplan O, Cohen JS (1991) Complete separation of intracellular and extracellular information in NMR spectra of perfused cells by diffusion-weighted spectroscopy. Proc Natl Acad Sci USA 15:3228–3232 Wirth T, Samaranayake H, Pikkarainen J, Määttä A-M, YläHerttuala S (2009) Clinical trials for gliblastoma multiforme using adenoviral vectors. Curr Opin Mol Ther 11:485–492 Zhang J, van Zijl PCM, Laterra J, Salhotra A, Lal B, Mori S, Zhou J (2007) Unique patterns of diffusion directionality in rat brain tumors revealed by high-resolution diffusion tensor MRI. Magn Reson Med 58:454–462 Zhao M, Pipe JG, Bonnett J, Evelhoch JL (1996) Early detection of treatment response by diffusion-weighted 1 H-NMR spectroscopy in a murine tumour in vivo. Br J Cancer 73:61–64

Chapter 32

High-Grade Gliomas: Dendritic Cell Therapy Hilko Ardon, Steven De Vleeschouwer, Frank Van Calenbergh, and Stefaan W. Van Gool

Abstract The relationship between the development of a tumor and the immune system is depicted by the fundamental model of “cancer immunoediting”: a tumor will only grow if the immune system is not capable of eliminating immune-resistant tumor cells (“tumor immune escape”). Both the adaptive and innate immunity play a key-role in this process. Multiple tumor-associated antigens have been described in gliomas and the expression of these antigens is very heterogeneous with important interand intra-individual differences. This is in contrast with other tumors, such as malignant melanoma, where tumor-associated antigens are almost universally expressed in all tumor cells. Several studies have shown that antigens can drain from the central nervous system to the cervical lymph nodes, where antigenspecific T cells can be activated by antigen-presenting cells. These activated T cells can subsequently migrate into the brain parenchyma to the sites of antigen challenge. This points to possible, naturally occurring immune responses eventually also against tumors, and indicates that the central nervous system is not an “immune-silent” environment. Therefore, it seems that the immune system can provide us with some interesting tools to treat gliomas. Several types of immunotherapy have been used and the most promising strategy for the induction of durable immune responses seems to be active, specific immunotherapy, or the so-called tumor vaccination. Further research

S. De Vleeschouwer () Department of Neurosurgery, Laboratory of Experimental Immunology, Catholic University Leuven, B-3000 Leuven, Belgium e-mail: [email protected]

has to be done, however, to establish the value of this form of immunotherapy in the treatment of gliomas. Keywords Immunity · Cancer immunoediting · Dendritic cells · Antigens · Blood-brain barrier · Lymphatic vessels

Introduction The concept that the immune system can recognize and eliminate primary developing tumors in the absence of external therapeutic intervention has existed for nearly 100 years. Although tumor-genetics and cancer cell biology have claimed the greatest interest in cancer research the last decades, tumor-immunology has recently gained renewed attention. Initially the question of specificity was raised, i.e. the capacity of the immune system to distinguish normal cells from tumor cells. In recent years though, many tumor-associated antigens (TAA) have been described and these antigens can be recognized by innate and adaptive components of the immune system (Dunn et al., 2007). Furthermore, innate immune cells can recognize specific molecular structures in tumor cells. The specificity of the immune system has therefore been widely accepted. However, new questions have arisen, most importantly on how a tumor can escape the immune system (“tumor immune escape”), and whether and how the immune system can be (re-)activated against the tumor. The first immunotherapeutical approach against cancer was adapted by Wiliam Coley at the end of the nineteenth century (Copier et al., 2009). He

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_32, © Springer Science+Business Media B.V. 2011

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used bacterial toxins (“Coley’s toxins”) to activate the immune system against tumors. The current immunotherapeutical approaches are mainly aimed at inducing a tumor-specific immune response. Several types of cancer (including glioma, melanoma, prostate carcinoma, renal cell carcinoma and non-small cell lung cancer) have been treated with immunotherapy and the largest experience has been gained in malignant melanoma (Engell-Noerregaard et al., 2009). So far, overall results seem promising and intriguing, although efficacy of immunotherapy cannot be measured by classical response criteria. Until recently, the central nervous system (CNS) has always been looked upon as an immune-privileged organ in which the immune system could not play a role of importance due to the blood-brain barrier (BBB) and the absence of lymphatic vessels and immune cells. However, recent data do point to immune responses in the CNS and it would therefore be better to define the CNS as an “immune-distinct” environment. In this chapter we will discuss cancer immunoediting in a broader sense, with the main focus on glioma immunity and immunotherapy.

“Cancer Immunoediting” The growth of tumor cells is on the one hand regulated and prevented by intrinsic nonimmune surveillance systems, such as DNA-repair and intracellular control mechanisms (e.g. p53 pathway). On the other hand, both innate and adaptive immunological control mechanisms exist which form the so-called “immunosurveillance” (Dunn et al., 2002, 2004a, b; Zitvogel et al., 2006). The interactions between a tumor and the immune system can be divided into three different phases of “cancer immunoediting” (Fig. 32.1). This process is responsible for both eliminating tumors and sculpting the immunogenic phenotypes of tumors that eventually form in immune competent hosts (Dunn et al., 2002, 2004a, b; Zitvogel et al., 2006). In a first phase of elimination, equivalent to immune surveillance, nascent transformed cells are eradicated by the immune system. The innate immune system is activated by inflammatory cytokines released by the tumor, macrophages and stromal cells surrounding tumor cells. This results in the activation of natural

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killer (NK) cells, natural killer T (NKT) cells and γδT cells. These cells produce other pro-inflammatory cytokines (such as interleukin (IL)-12 and interferon (IFN)-γ) that enhance the immune response. Tumor cell death by NK cells results in release of TAA that can lead to activation of the adaptive immune system. Uptake of TAA by dendritic cells (DC) will lead to tumor-specific antigen-presentation resulting in a clonal expansion of tumor-specific CD8+ cytotoxic T cells. In a second phase, there is a balance between the elimination of immune-sensitive tumor cells and the outgrowth of newly-formed immune-resistant tumor cells: “equilibrium”. Due to continuous, genetic adaptations of the tumor cells (“mutation-drift”), tumor cell clones with a non-immunogenic phenotype will arise (“immune resistance”). The immune selection pressure will favor the growth of these tumor cell variants resulting in ongoing tumor formation. Eventually, the balance will tip in favor of the immune-resistant tumor cells and then the final phase will set in: “immune escape”. Most of the tumor cells will now evade the immune system as they are insensitive to immunological detection and subsequent elimination. Hence, this will result in clinically detectable malignant lesions. Three forms of “tumor immune escape” can be recognized: 1. loss of TAA-recognition by the immune system; 2. diminished susceptibility of tumor cells to cell death; 3. induction of immune dysfunction (Malmberg, 2004). Tumor cells can release “tumor-derived soluble factors” that can suppress the immune response (e.g. transforming growth factor β (TGF-β), prostaglandin E2 (PGE2 ) and IL-10). The extracellular matrix can bind TAA in competition with DC leading to decreased antigen-presentation by DC and subsequently less activated T cells. Also, regulatory T cells (Treg) can be induced by the tumor resulting in a suppression of the immune system. Moreover, the functional phenotype of intratumoral macrophages can be switched to M2type macrophages which can promote tumor growth and angiogenesis. Finally, myeloid-derived suppressor cells (MDSC) can further disturb the immune response. Based on these strong interactions between tumor cells and the immune system, one could speculate about a remarkable hypothesis; tumors that are very potent in suppressing the immune system might mainly rely on this immune suppression for their immune escape. The need for “editing” the tumor cells to evade the immune system might therefore be less in

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Fig. 32.1 Cancer immunoediting and relevance to tumor vaccination against malignant glioma (a).General principle of cancer immunoediting: 1. In the first phase of elimination, the immune system is capable of eliciting an effective immune response (illustrated as a black box) against an immunogenic tumor (illustrated as a white ellipse), and tumor growth is prevented. 2. In the second phase, there is an equilibrium between tumor growth and elimination of tumor cells by the immune system (illustrated by a gray ellipse and gray box). Due to immunoediting and sculpting of the tumor cells, some tumor cells become non-immunogenic and evade the immune response. Tumor-induced immune suppression counteracts the immune response as well. 3. In the third and final phase, the tumor is fully “immunoedited” and has become non-immunogenic (illustrated as a black ellipse). This leads, in combination with the ongoing tumor-induced immune suppression, to tumor immune escape and outgrowth of the tumor. The immune system and response have become ineffective (illustrated by a white box). (b). Tumor vaccination (general): At the time of immune escape, the “immunoedited” tumor is diagnosed and surgery is performed leading to a state

of minimal residual disease (1). The “immunoedited”, nonimmunogenic tumor cells are used to generate a tumor vaccine (2), but tumor vaccination does not lead to re-activation of the immune system (3), since stimulation of the immune system is done with non-immunogenic cells. Thus, there is no effective immune response to eliminate the tumor (4), resulting in renewed tumor immune escape (5). (c) Glioma immunoediting: From the start of gliomagenesis tumor-induced immune suppression is very potent, leading to an ineffective immune response. Consequently, the tumor can grow and evade the immune system, without the need for editing/sculpting of the tumor cells. (d).Tumor vaccination (glioma): At the time of diagnosis, the tumor consists of a “non-immunoedited”, still immunogenic phenotype. Surgery is performed leading to a state of minimal residual disease (1). The “non-immunoedited”, immunogenic tumor cells are used to generate a tumor vaccine (2), which is able to activate the immune system (3), in combination with inhibition of the tumor-induced immune suppression (4). Activation of the immune system leads to an effective immune response and the tumor is eliminated (4)

these immune suppressive tumors. Since the tumor cells will not be attacked by the suppressed immune system, the immune selection pressure will be less and fewer genetic adaptations of the tumor cells will occur. This will result in less tumor cell clones with a non-immunogenic phenotype and more cell clones

with an immunogenic phenotype. Following this line of thought, an active immunotherapeutical approach to such a tumor at time of minimal residual disease (e.g. after total resection of the tumor), in combination with a strategy to block the tumor-mediated immune suppression, might be of more benefit. This could be in

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contrast to a tumor with an “immunoedited” phenotype, since the former tumor might still be immune sensitive (Fig. 32.1). In other words, tumors that do not lead to spontaneous immune reactions because of strong immune suppressive characteristics, might be best suited for immunotherapy at time of minimal residual disease.

Central Nervous System and Immunity In contrast to antigen-specific immune responses in peripheral tissues, the details are less clear for immune responses to antigens in the CNS. The biology of immune responses within the CNS would appear to be distinct due to the lack of secondary lymphoid tissues within the brain parenchyma, as well as to the possible obstacles presented by the BBB. In general, TAA have to be acquired and presented by antigen-presenting cells (APC), leading to the activation of tumor-specific lymphocytes that will have to infiltrate the brain tumor. Research in this area is ongoing and much is still to be learned.

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microglia, perivascular macrophages, choroid plexus epithelial cells, neurons, and DC – have been put forward as potential APC. Recent publications point especially to DC as most important APC in the CNS (McMahon et al., 2006), although their presence in the CNS is limited. DC capture TAA from dying tumor cells in the CNS and migrate to draining lymph nodes in the cervical region. There, antigens are presented to different subtypes of T cells in a “major histocompatibility complex” (MHC)-I and MHC-II context. Antigen-presentation in a MHC-I molecule (cross-presentation, a typical feature of DC) leads to activation of CD8+ T cells, presentation in a MHC-II molecule to activation of CD4+ T cells. Antitumoral CD4+ T cells support a strong and prolonged CD8+ T cell reaction, promote the maturation of DC and stimulate B cells to produce antitumoral antibodies (De Vleeschouwer et al., 2006; Heath and Carbone, 2001; Maldonado-Lopez and Moser, 2001). In several animal studies it has been shown that antigen-specific T cells are primed by immigrant, antigen-loaded DC in the cervical lymph nodes, after which the activated T cells traffic to sites of antigen challenge in the brain (Dunn et al., 2007). However, further research in brain tumor models is necessary to validate this principle.

Cervical Lymphatic Drainage of the Brain Blood-Brain Barrier Although lymphatic vessels cannot be identified in the brain parenchyma, several animal studies have shown that antigens can be drained to the cervical lymph nodes (Bradbury et al., 1981; Cserr and Knopf, 1992). Possibly, the antigens run through the subarachnoid space along cranial nerves and cross the cribiform plate to the nasal mucosa where they access lymphatic drainage basins. The potential of antigens to drain to cervical lymph nodes points to possible interactions between the CNS and peripheral lymphoid tissue, highlighting a theoretical starting point for the initiation of brain tumor-specific immune responses.

Antigen-Presenting Cells in the Central Nervous System Several cell types in the CNS – including vascular endothelial cells, smooth muscle cells, astrocytes,

Activated, antigen-specific T cells have to traffic from the cervical lymph nodes into the brain parenchyma to infiltrate the brain tumor. Three pathways by which immune cells can access the CNS have been proposed: 1. from blood to the cerebrospinal fluid (CSF) via the choroid plexus; 2. from blood to the subarachnoid space; 3. from blood to brain parenchyma (Ransohoff et al., 2003). The most important obstacle is formed by the BBB that prevents passive transit of molecules between the CNS parenchyma and the systemic circulation. The barrier is formed by tight junctions of the capillary endothelial cells, creating a tight seal which limits the paracellular transport of molecules. Moreover, more than 90% of the capillary endothelium is covered by astrocyte foot processes that form the “glia limitans”. The capillaries of the circumventricular organs of the brain represent areas in which there is no BBB, and these are thus sites that more freely permit transport of molecules across vascular endothelial

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cells. Additionally, the “blood-CSF barrier” restricts free movement of cells and molecules between the CSF and the capillaries of the choroid plexus (Dunn et al., 2007). Within the glioma microenvironment, the vasculature is substantially altered and structures such as the BBB are significantly compromised. Therefore, the BBB in gliomas is more porous than the intact BBB in healthy subjects. This increased permeability might lead to increased immune cell infiltration. However, efficient lymphocyte trafficking into the tumor may be significantly reduced due the fact that tumor tissue is severely dysregulated and may contain poor target substrates to attract T cells.

Lymphocyte-Trafficking to Glioma Although it has been shown that T cells can traffic to the CNS in autoimmune diseases, it is less clear how lymphocytes traffic to developing CNS neoplasms. One possible model is the “multi-step” model of migration, characterized by the “rolling, sticking and migrating” paradigm (Balkwill, 2004). T cells homing to the brain parenchyma slow down in a first step by gradually tethering to capillary endothelium in a “rolling” fashion mediated by interactions between several selectins and their ligands. Subsequently, lymphocytes adhere to the vascular endothelium in the “sticking” step mediated by integrins that become “activated” by chemokines. Lymphocytes ultimately transmigrate to the brain parenchyma in the “diapedesis” (migrating) step, which may occur via transor para-cellular endothelial transport. Several immune cells have been shown to infiltrate gliomas, including tumor-infiltrating lymphocytes (TIL), MDSC and M2-macrophages. Among the TIL, CD4+ T cells, CD8+ CTL and immune suppressive Treg have been documented (Abou-Ghazal et al., 2008; Dunn et al., 2007; Heimberger et al., 2008).

Gliomas and Immunity Several TAA have been identified in human gliomas: Aim-2, Trp-1, Trp-2, Sart-1, Sart-2, Sart-3, Her2/neu, GP100, Mage-1, Galt-1, Galt-3, Sox2, Sox6, Survivin,

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EGFRvIII, Gage-1, WT1 (Dunn et al., 2007). These antigens can be recognized by T cells and form the basis for potential spontaneous immune responses against CNS tumors. Two subgroups of gliomaspecific antigens have been described: 1. antigens that are solely expressed by tumor tissue; 2. antigens that are expressed both by normal and tumor tissue. Only the antigens from the first subgroup are of immunotherapeutical interest, since antigens that are expressed by normal tissue could lead to possible autoimmune phenomena. The ideal antigens for immunotherapy are antigens that are immunogenic and tumor-specific, i.e. not expressed by normal tissue. Moreover, these antigens should ideally be present on all tumor cells or at least at the tumor cells that are responsible for recurrence of the tumor. There are no universal glioma-specific antigens that are expressed by all gliomas, and inter-individual differences are the rule. Therefore, it seems important to give every patient an individual and gliomaspecific treatment using TAA that are expressed by the tumor of the patient. Besides, even within the tumor of one patient expression of antigens is very heterogeneous and there are no known TAA that are universally expressed by all tumor cells. Moreover, due to the plasticity of the tumor cells with genetic alterations and loss of expression of antigens, the immunotherapeutical use of one glioma-specific antigen would lead to a selection of tumor cells that do not express that antigen (any longer) and that are not targeted by the immunotherapy (antigen-loss variants) (De Vleeschouwer et al., 2005; Gilboa et al., 1998). Furthermore, it is important to know which tumor cells are responsible for recurrence of the tumor. In other words, do all tumor cells have the same tumorigenic potential or does a subgroup of glioma stem cells exist? Several studies have shown that neurosphereforming, CD133+ glioma cells are chemo- and radioresistant and might be seen as so-called brain tumor initiating cells (Bao et al., 2006; Eramo et al., 2006; Hemmati et al., 2003; Liu et al., 2006; Singh et al., 2003, 2004). If this truly is the case, then immunotherapeutical approaches should focus on the TAA of these tumor initiating cells. Finally, high-grade gliomas (HGG) can actively suppress the immune system through different immune escape mechanisms: production of immune

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suppressive cytokines, negative regulatory pathways in lymphocytes, lack of glioma-specific antigen recognition by immune cells (loss of MHC-I expression on tumor cells), and induction of Treg (Grauer et al., 2009; Yamanaka, 2009). This glioma-induced immune suppression is not only evident within the tumor, but systemically as well (Dix et al., 1999; Elliott et al., 1987; Fecci et al., 2006; Roszman et al., 1991).

Immunotherapy Restorative, Passive and Adoptive Immunotherapy Immunotherapy for cancer covers a broad field of diverse approaches, all using different aspects of the immune system repertoire. The common goal is to destroy remaining cancer cells and prevent tumor (re)growth (De Vleeschouwer et al., 2005). Restorative immunotherapy consists of systemic or local (intratumoral) administration of cytokines (including IL-2, tumor necrosis factor α (TNF-α) and IFN-γ) to enhance non-specific immunity. As for other tumors, this type of treatment showed considerable, treatment-limiting, systemic toxicity and neurotoxicity for gliomas. No conclusive evidence of efficacy was shown and treatments had to be stopped (De Vleeschouwer et al., 2005; Grauer et al., 2009; McDermott, 2009). In case of passive immunotherapy targetspecific antitumoral monoclonal antibodies (mAb) are used with or without a conjugated ligand. Antibody-dependent cellular cytotoxicity, complement-dependent cytotoxicity and induction/blockade of intracellular signals have been described as working mechanisms of tumor cell killing. Several mAb have been shown to be active, often in combination with chemotherapy: rituximab (non-Hodgkin lymphoma and chronic lymphocytic leukemia), trastuzumab (metastasized breast carcinoma), cetuximab (colorectal carcinoma, head/neck carcinoma and non-small cell lung carcinoma) and bevacizumab (colorectal carcinoma, breast carcinoma and lung carcinoma) (Borghaei et al., 2009). Although some studies have shown moderate results with this

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type of immunotherapy for glioma, especially in patients with minimal disease burden, it is unclear whether the mAb can infiltrate sufficiently into the tumor to induce an optimal antitumoral effect (De Vleeschouwer et al., 2005; Grauer et al., 2009). Recently, several studies have focused on the treatment of gliomas with bevacizumab, which is an angiogenesis inhibitor targeting VEGF. Although results show that symptoms are tempered, it seems that furtive invasion of the disease might continue, unrecognized or underestimated by standard imaging modalities. Moreover, while treatment of other tumor types is improved by combining chemotherapy with anti-angiogenic drugs, inhibiting angiogenesis in glioblastoma multiforme (GBM) may antagonize the efficacy of chemotherapeutic drugs by restoring the BBB. Several studies suggest an antitumoral effect based on improved response rates and prolonged progression-free survival (PFS). However, these data are derived from non-randomized trials with PFS as primary endpoint and the true antitumoral effect is not yet clear. Available data on overall survival (OS) are less robust (phase II) and sometimes even conflicting. Furthermore, serious side-effects of angiogenesis inhibitors (e.g. venous and arterial thrombo-embolism, arterial hypertension and hemorrhage) have been demonstrated in phase II studies (Norden et al., 2009; Verhoeff et al., 2009). Adoptive immunotherapy is the infusion of ex vivo (antigen-specific or non-specific) stimulated lymphocytes or NK cells. This can be done locally in the brain or systemically. An important advantage of this strategy is that autoimmune reactions can be avoided. Possible drawbacks, however, are the risk of contamination with Treg and the short survival of ex vivo stimulated cells. Studies have shown that adoptive transfer of autologous T cells held little or no value for leukemia, but was moderately effective for malignant melanoma. On the other hand, adoptive transfer of allogeneic NK cells could play a role in selected cases of acute myeloid leukemia (Borghaei et al., 2009). For gliomas local (intracerebral) administration of different effector immune cells (including NK cells, CTL and activated “killer” cells) has been widely studied. This strategy was well-tolerated but did not yield clinical responses. Additional local administration of IL-2 as “immuno-adjuvant” resulted in significant toxicity (De Vleeschouwer et al., 2005; Grauer et al., 2009).

32 High-Grade Gliomas: Dendritic Cell Therapy

Active Specific Immunotherapy Finally, active specific immunotherapy, or the so-called tumor vaccination, comprises the in vivo induction of tumor-specific CTL (and/or humoral responses) and this approach has gained considerable interest the last decade (De Vleeschouwer et al., 2006). Four types of tumor vaccination can be distinguished (Table 32.1). 1. Autologous or allogeneic tumor cell vaccines are based on the assumption that the TAA that are expressed by the tumor can induce a cytotoxic T cell response. The vaccine consists of nonproliferating tumor cells in combination with an “immuno-adjuvant” to enhance the immune response (Bradbury and Shepherd, 2008; Grange et al., 2009; Van Poppel et al., 2009). 2. In case of genetically modified tumor cell vaccines, autologous or allogeneic tumor cell vaccines have been genetically engineered; genes encoding immunostimulatory cytokines or positive co-stimulatory molecules have been integrated into the tumor cells by transfection. This strategy is based on evidence that local cytokine secretion can activate T cells and NK cells as well as induce inflammatory responses against tumors (Bradbury and Shepherd, 2008; Terando et al., 2007; Van Poppel et al., 2009). 3. Peptide-based vaccines make use of one or more immunogenic TAA that are universally expressed by the tumor cells (Bradbury and Shepherd, 2008; Terando et al., 2007; Van Poppel et al., 2009). 4. DC-based tumor vaccines use DC as APC to activate CD4+ and CD8+ T cells. Moreover, DC can activate NK and NKT cells as well (Dhodapkar et al., 2004). DC are generated ex vivo and subsequently loaded with a source of TAA, that will be presented by the DC. Several cellular products can be used to load the DC: purified defined peptides, undefined acideluted peptides from autologous tumor, tumor cell lysate, viral vector containing genes, apoptotic bodies, tumor homogenate, mRNA, and necrotic tumor cells (Bradbury and Shepherd, 2008; Grange et al., 2009; Mu et al., 2003; Sorg et al., 2003; Terando et al., 2007; Thurner et al., 1999; Tuyaerts et al., 2002; Van Poppel et al., 2009). From a theoretical point of view, the use of total tumor-derived material (lysate/homogenate) as a source of tumor antigens may be preferable because of the emergence of antigen-loss variants if the immunization is only targeted at one TAA, which might not be expressed by a subpopulation of tumor cells that

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will be positively selected (De Vleeschouwer et al., 2005; Gilboa et al., 1998). For glioma immunotherapy, the best responses have been reported with tumor vaccination as adjuvant postoperative therapy (Choi et al., 2009; Grauer et al., 2009; Van Gool et al., 2009). Autologous tumor cell vaccines in combination with cytokinesecreting fibroblasts and genetically modified autologous tumor cell vaccines have been used to treat gliomas, but especially the results of peptide- and DCbased immunotherapeutical approaches seem promising. Peptide-based vaccines use epidermal growth factor receptor class III variant (EGFRvIII) to induce an immune response. EGFRvIII is expressed by many, but not all malignant gliomas and can induce specific cellular and humoral immunity. Preclinical and clinical studies have shown that the use of EGFRvIII vaccines is safe and feasible. Results of an ongoing phase III study are eagerly anticipated (Choi et al., 2009). Furthermore, much preclinical and clinical research has been done on the role of DC-based tumor vaccination in the treatment of malignant gliomas. So far, seventeen clinical phase I/II studies and case reports have been published in the literature with emphasis on feasibility and toxicity of the treatment approach (Table 32.2). No autoimmune phenomena were observed and the treatment was welltolerated. As for the EGFRvIII-based vaccines, results are promising.

Experimental Glioma Models for Dendritic Cell Therapy Over the last decades, numerous reports on heterotopic and orthotopic rat and mouse GBM models have been published, and it is important to know that there are some fundamental differences between those models. For example, models exploiting spontaneous tumor formation in genetically engineered mice differ from engrafted tumor models that are established by implantation of primary tumor cells or tumor cell lines. Spontaneous tumor models mimic gliomagenesis much better than engrafted models, but the main disadvantages are the poor reproducibility, low tumor penetrance, prolonged and unpredictable latency for tumor formation, and the need for advanced in vivo

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Table 32.1 Active specific immunotherapy Vaccine type

Advantages

Disadvantages

Tumor typea

Autologous tumor cell vaccine

Patient specific

Not widely applicable

MM

Potential to generate immunity to any TAA

Time-consuming and technically challenging preparation

RCC

Humoral and cellular antitumoral immunity

Requires adequate tumor tissue for manufacture

NSCLC

HGG

Allogeneic tumor cell vaccine

Widely applicable

Not patient specific

MM

Patient’s tumor tissue need not be available

Moderately complex/demanding preparation Response dictated by similarity between TAA of vaccine and TAA of patient’s tumor Requires additional exvivo manipulation with issues of altered cell viability and/or functionality

RCC

Humoral and cellular antitumoral immunity

Gene modified cellular vaccine

May enhance efficacy of non-gene modified approaches

NSCLC

Limited clinical response (Grange et al., 2009; Terando et al., 2007) Immunological and clinical response in selected patients–Phase III study (Reniale) with significant improved PFS and OS (Van Poppel et al., 2009) Limited data available – ongoing studies (Bradbury and Shepherd, 2008; Kakimi et al., 2009) Limited data available (De Vleeschouwer et al., 2005, Grauer et al., 2009) Limited clinical response (Grange et al., 2009; Terando et al., 2007) Only used after gene modification (Van Poppel et al., 2009) Only used after gene modification (Bradbury and Shepherd, 2008; Kakimi et al., 2009)

MM

Limited immunological and clinical response (Grange et al., 2009; Terando et al., 2007)

RCC

Possible limited response (Van Poppel et al., 2009) Belagenpumatucel-L. clinical response GVAX (“granulocyte macrophage-colony stimulating factor” secreting tumor cells): no response (Bradbury and Shepherd, 2008; Kakimi et al., 2009) Limited data available (De Vleeschouwer et al., 2005; Grauer et al., 2009) Extensively studied measurable T cell response rarely clinical response (Grange et al., 2009; Terando et al., 2007) Limited number of studies – phase III study (Vitespen) showed no better PFS (Van Poppel et al., 2009)

NSCLC

HGG

Peptide vaccine

Resultsb

Acellular technique

TAA have to be immunogenic and tumorigenic

MM

Widely applicable

Tumor cells not expressing TAA evade immune system (“tumor immune escape”)

RCC

32 High-Grade Gliomas: Dendritic Cell Therapy

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Table 32.1 (continued) Vaccine type

Advantages

Disadvantages

Tumor typea

Use of known epitopes simplifies immune monitoring

HLA restriction

NSCLC

Resultsb

Mucin-1 vaccine promising results – ongoing phase III study (Bradbury and Shepherd, 2008; Kakimi et al., 2009) HGG EGFRvIII: immunological and clinical (better PFS and OS) response – ongoing phase III study (De Vleeschouwer et al., 2005; Choi et al., 2009) DC vaccine Utilizes most potent Leukapheresis MM Clinical response; 7% (other antigen-presenting necessary active specific cells immunotherapy 3–4%) (Engell-Noerregaard et al., 2009; Terando et al., 2007) Can be loaded with Time-consuming and Phase III study with positive TAA through a technically results (Editorial note Future variety of techniques challenging Oncol, 2009) and phase III preparation study with negative results (Schadendorf et al., 2006) Yield can be variable RCC Immunological and clinical and patient response (Van Poppel et al., dependent 2009) NSCLC Immunological response – no clinical Response (Bradbury and Shepherd, 2008; Kakimi et al., 2009) HGG Immunological and clinical response (no clear correlation) (Ardon et al., 2010a; Ardon et al., 2010b; De Vleeschouwer et al., 2008; Van Gool et al., 2009; De Vleeschouwer et al., 2006; De Vleeschouwer et al., 2005; Grauer et al., 2009) DC. dendritic cells. EGFRvIII. epidermal growth factor receptor class III variant. HGG. high-grade ghoma. HLA. human leukocyte antigen. MM. malignant melanoma. NSCLC. non-small cell lung carcinoma. PFS. progression-free survival. OS. overall survival. RCC. renal cell carcinoma. TAA. tumor-associated antigen a not exhaustive b phase III studies and case reports. unless otherwise stated

imaging techniques. Engrafted models on the other hand lack the stepwise genetic changes occurring during tumor progression, resulting in tumors that are well circumscribed and less invasive, lack the human counterpart of microvascular proliferation and rarely recapitulate the tumor-of-origin phenotype. Nevertheless, based on greater reproducibility, engrafted models are better suited for evaluating preclinical therapies such as DC-based immunotherapy, as long as the models are studied in immune competent animals.

The GL261 glioma model has been widely studied and Ni et al. (2001) underscored the immunogenicity of GL261 tumor cells by treating mice with intracranial glioma with tumor extract-pulsed cloned DC. Cured animals showed increased delayed-type hypersensitivity (DTH) responses to GL261 cells, with long-term tumor protection. Aoki et al. (2001) showed that pulsing DC with a complex of tumor extract and cationic liposomes induces an antitumoral immune response against intracranial glioma in which CD8+

Neurosurgical Focus 9: e8 (2000)

Cancer Res 61:842–847 (2001)

Cancer Immunol. Immunother. 50: 337–344 (2001)

Br J Cancer 89:1172–1179 (2003)

J Immunol 171:4927– 4933 (2003)

Liau et al.

Yu et al.

Kikuchi et al.

Yamanaka et al.

Wheeler et al.

17 (phase II)

17 (phase I)

10 (phase I-II)

8 (phase I)

9 (phase I)

1 (case report)

Table 32.2 Overview of reported clinical trials No. of patients Author Publication (type of trial)

Autologous tumor freeze-thaw lysate

Autologous tumor lysate

DC fusion with autologous glioma cells

Tumor-specific MHC-I associated peptides

Allogeneic MHC class I-matched GBM peptides

Cell product

Not reported

Not reported

Intradermal and/or intratumoral (Ommaya)

Intradermal

Subcutaneous

Intradermal

Administration

3 vaccinations at 2-week intervals with fourth vaccination 6 week after the third (n=10)

3 vaccinations at 2-week intervals

1–10 vaccinations at 3-week intervals

3–7 vaccinations at 3-week intervals

3 vaccinations at 2-week intervals

3 biweekly vaccinations

Treatment schedule

Increase in NK cells in peripheral blood (n=5); positive DTH reaction to tumor lysate (n=3); increased T-cell mediated antitumoral activity (n=2); Elispot IFNγ Not reported (study on CD8+ RTE)

T-cell proliferation response to allogeneic acid-eluted tumor peptides Systemic CTL cytotoxicty against tumor (n=4) (JAM assay) Increase in NK cells in peripheral blood (n=4); increased IFNγ in supernatant (n=6)

Immune response

Clinical response

Not reported

Mixed response (n=1); steroids during vaccination (n=5); 2 minor responses Minor response (n=2)

Prolonged survival compared to control group

None

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Publication

Cancer Res 64:4973–4979 (2004)

J. Neurosurg. (Pediatrics) 100: 492–497 (2004)

Br J. Cancer 91:1656–1662 (2004)

J Immunother 27:452–459 (2004)

Clin Cancer Res 11:5515–5525 (2005)

Author

Yu et al.

De Vleeschouwer et al.

Rutkowski et al.

Kikuchi et al.

Liau et al.

Table 32.2 (continued)

12 (multicohort dose-escalation study – phase I)

15 (phase I-II)

12 (phase I)

1 (case report)

14 (phase I-II)

No. of patients (type of trial)

Acid-eluted tumor associated peptides (autologous)

DC fusion with autologous glioma cells

Autologous tumor lysate

Autologous tumor lysate

Autologous tumor lysate

Cell product

Intradermal

Intradermal

Intradermal

Intradermal

Subcutaneous

Administration

≤3 vaccinations

Vaccination + rhIL-12

Weeks 1, 3, and further with 4-week interval (6 total) Weeks 1, 3, and further with 4-week interval (2–7 vaccinations)

3 vaccinations at 2-week intervals

Treatment schedule Immune response

Positive DTH reaction to tumor lysate (n=15); increased cytotoxic activity (n=2); increased intracellular IFNγ in CD8+ T cells (n=1) CTL response (n=6)

Positive DTH reaction to tumor lysate (n=6)

IFNγ release in PBMC (n=6); expansion of CD8+ antigen specific T cell clones (n=4); systemic T cell cytotoxicity against tumor (n=1) Positive DTH reaction to tumor lysate

Clinical response

Median TTP 19.9 mo; OS 18 to >58 mo; median OS 35.8 mo

Long-lasting tumor-free survival (> 5 year after vaccination) Partial response (n=1); tumor-free survival (n=2; 5 year after vaccination) Partial response (n=4); mixed response (n=1)

Significant increase in median survival

32 High-Grade Gliomas: Dendritic Cell Therapy 323

Publication

Clin Cancer Res 11:4160–4167 (2005)

J Transl Med 5:67 (2007)

Cancer Res 68:5955–5964 (2008)

J Clin Neurosci 15:114–121 (2008)

Author

Yamanaka et al.

Okada et al.

Wheeler et al.

Walker et al.

Table 32.2 (continued)

13 (phase I)

34 (phase II)

2 (A)/5 (B)

24 (phase I-II)

No. of patients (type of trial)

Single-cell suspension of autologous tumor cells

IL-4 transfected fibroblasts + apoptotic glioma cells (A)/autologous tumor lysate (B) Autologous tumor lysate

Autologous tumor lysate

Cell product

Intradermal

Subcutaneous

Intradermal

Intradermal or intradermal + intratumoral (Ommaya)

Administration

Priming phase consisting of 6 vaccinations at 2-week intervals; further vaccinations at 6-week intervals

3 vaccinations at 2-week intervals with fourth vaccination 6 week after the third

2 vaccinations with 2-week interval

1–10 vaccinations at 3-week intervals

Treatment schedule

Post-vaccine antigen-directed IFNγ response in PBMC (qPCR-based assay) (n=17); DTH-test resulted in cutaneous GBM in 1 pat (DTH was subsequently discontinued) Increased T cell infiltration in post-vaccination tumor specimens compared to pre-vaccination specimens (n=3)

A: increased T cell reactivity; B: no response

Positive DTH reaction to tumor lysate (n=8); positive IFNγ Elispot (n=7)

Immune response

9-month survival (9/13); 12-month survival (6/13); 18 months or longer survival (3/13)

Significant positive correlation between post-vaccine response magnitude on one hand and TTS and TTP spanning chemotherapy on the other hand

Partial response (n=1); minor response (n=3); significant increase in median survival A: clinical and radiological response in both patients; B: no response

Clinical response

324 H. Ardon et al.

Clin Cancer Res 14:3098–3104 (2008)

Pediatr Blood Cancer 54:519–525 (2010a)

J Neurooncol 99:261–272 (2010b)

De Vleeschouwer et al.

Ardon et al.

Ardon et al.

8 (pilot study)

45 children (phase I-II) (33 HGG)

56 (phase I-II)

No. of patients (type of trial)

Autologous tumor lysate

Autologous tumor lysate

Autologous tumor lysate

Cell product

Intradermal

Intradermal

Intradermal

Administration

Cohort comparison

Cohort comparison

Treatment schedule

Not reported

Positive DTH reaction to tumor lysate (9/21 at time of diagnosis and 9/17 after two vaccinations)

Immune response

PFS 3 months; OS 9.6 months; 2-year OS 14.8%; total resection is predictor for better PFS; younger age and total resection are predictors for better OS in univariable analysis; tendency towards improved PFS when faster DC vaccination schedule with tumor lysate boosting was applied PFS HGG 4.4 months – GBM 4.3 months; OS HGG 13.5 months – GBM 12.2 months; 2-year OS 18% 6-month PFS 75%; PFS 18 months; OS 24 months

Clinical response

Incorporated in Positive DTH RChT – 4 reaction to tumor induction lysate (3/7); vaccinations positive IFNγ at 1-week Elispot (5/8); interval; then increase CTL 3 boost (6/7) vaccinations with 1-month interval, followed by 3-monthly boostvaccinations CTL, cytotoxic T lymphocyte; DC, dendritic cell; DTH, delayed-type hypersensitivity; GBM, glioblastoma multiforme; IFNγ, interferon-γ; IL-4, interleukin-4; JAM, just another method; MHC, major histocompatibility complex; mo, month; NK, natural killer; no., number; OS, overall survival; pat, patient; PBMC, peripheral blood mononuclear cell; PFS, progression-free survival; qPCR, quantitative polymerase chain reaction; rhIL-12, recombinant human interleukin-12; RTE, naive recent thymic emigrant T cell; TTP, time to progression; TTS, time to survival; w, week

Publication

Author

Table 32.2 (continued)

32 High-Grade Gliomas: Dendritic Cell Therapy 325

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T cells are involved. Protective immunity against intracranial glioma growth obtained through immunization with either lysate- or RNA-loaded DC was reported by Insug et al. (2002), while adding recombinant IL-12 to the vaccine regimen further improved its efficacy. Vaccination with lysate-pulsed DC combined with IFN-β gene therapy resulted in a survival benefit, as was demonstrated by Saito et al. (2004). Similarly, the group of Okada et al. (2007) revealed that the sequential intratumoral delivery of an IFN-α encoding adenoviral vector and DC induced longterm survival and specific CTL activity. Furthermore, the same group showed that intratumoral administration of DC, genetically engineered to secrete IFNα, enhanced the efficacy of peripheral vaccines with cytokine gene-transduced tumor cells. Using vaccines created through electrofusion of DC and irradiated tumor cells, Kjaergaard et al. (2005) observed complete tumor regression of established intracranial tumors with infiltration of both CD4+ and CD8+ T cells. Ciesielski et al. (2006) have focused on survivin, a member of the apoptosis inhibition family of proteins, as GL261 TAA. In particular, the authors exploited the xenogeneic differences between human and murine survivin sequences to develop a more immunogenic tumor vaccine. The efficacy of systemic immunotherapy with DC loaded with GL261 antigens was confirmed by Pellegatta et al. (2006a). Additionally, these authors introduced the concept of cancer stem cells in this model and reported that DC targeting of such stem cells within the GL261 tumor cell pool provides a higher level of protection against GL261 glioma (Pellegatta et al., 2006b). Recently, Grauer et al. (2007 and 2008) illustrated the pronounced impact of FoxP3+ Treg in the GL261 model and suggested that Treg elimination is a prerequisite for successful eradication of established glioma using tumor lysate pulsed DC. Maes et al. (2009) showed that DC loaded with tumor antigens in the form of RNA molecules are capable of inducing a T cellmediated antitumoral immune response. Furthermore, the impact of Treg in this model was evident and elimination of Treg resulted in long-term surviving mice. Strikingly, upon rechallenge of long-term surviving mice after Treg depletion and/or DC vaccination, only those mice that were treated with DC vaccination depicted a prolonged antitumoral protective immune response.

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Dendritic Cell Therapy for Human Gliomas Seventeen clinical phase I/II studies and case reports have been published in the literature since 2000 (Table 32.2). The median patient number in these reports was only 12, ranging from 1 to 56. The inclusion criteria, immunotherapeutic designs and interpretations varied significantly among and even within the reports, being based entirely on single-center approaches and hypotheses. Hence, no firm conclusions can be drawn regarding the optimal immunotherapeutic strategy, nor would it make sense to perform a meta-analysis on these data. The importance of a minimal residual disease setting for adjuvant postoperative DC vaccination in HGG patients was already stressed in the first reports. In the series published by De Vleeschouwer et al. (2008), the importance of a gross total resection prior to DC vaccination for GBM patients was confirmed in a multivariate analysis. General awareness and agreement on this important issue is mounting and even culminating in the assumption that therapeutic tumor vaccinations should be used for early disease states. Most of the reports describe patients treated with immunotherapy at a stage of minimal residual disease, after gross total or near-total resection. Interestingly, patients have been under maintenance corticosteroid treatment just prior and/or during immunotherapy in some trials, which one would expect to have a negative effect on the generation of an effective immune response. In order to avoid this confounding variable, other trials have been restricted to patients who could obtain a total or near-total resection and be rapidly weaned from corticosteroids. There are multiple arguments supporting the need for these restrictions. First, because there are major immune-suppressive mechanisms at play within the tumor microenvironment and even systemically, only a gross total resection results in a clinically effective recovery of normal immune system function. Second, it might be difficult to produce good-quality DC out of monocytes isolated at the time of corticosteroid treatment. Third, an overwhelming peritumoral inflammatory reaction was seen in one patient with bulky residual tumor (Rutkowski et al., 2004). In this patient, the vaccine-induced inflammatory immune reaction occurred with a progressively

32 High-Grade Gliomas: Dendritic Cell Therapy

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increasing delay after the vaccine injection. This is in line with the hypothesis that the growing tumor and, maybe as such, the increasingly induced immune suppression counteract the vaccine-induced immune response. This observation points to a tumor-specific reaction induced by the vaccine, but maybe also to a gradually shifting balance in favor of tumor-induced immune suppression.

monitoring tools directed toward the affected organ, that is, the brain, will have to take into account that the presence of tumor-infiltrating lymphocytes and other immune effector cells does not unequivocally correlate with a good or a bad outcome. Proof of efficacy of immunotherapy asks for impact on OS in patients with HGG, of whom the different prognostic risk factors are clearly categorized.

Selection of Outcome Measures

Nature of Dendritic Cells

Immunological responses, assessed by a wide variety of immune monitoring tools, have been demonstrated in 50% of reported cases, ranging from 20 to 100%. Only recently, Wheeler et al. (2008) found stronger evidence between immunological responses and survival in vaccinated glioma patients. However, the use of peripheral immune monitoring tools might prove inadequate in case the peripheral immune system does not mirror in any way local immune events in the brain tumor microenvironment. Although immunological responses are mandatory to map the way and to provide proof of the principle for this therapeutic strategy, “proof of efficacy” can only be established in large well-designed comparative clinical trials, ideally in controlled randomized trials. Especially in HGG, an old paradigm states that pre-treatment prognostic variables might have more impact on outcome than any (new) potentially active therapy or treatment strategy. To that end, recursive partitioning analysis (RPA) as originally described and validated for newly diagnosed malignant gliomas by the Radiation Therapy Oncology Group (RTOG) in 1993, provides us with an excellent model of prognostic classes of pre-treatment and treatment-related patients’ variables. Using this RPA classification, the impact of new treatments on OS in HGG can be examined in clinically similar patient groups and compared with large databases of conventionally treated patients. To date, there is consensus that clinical responses, as defined by the Macdonald criteria (Macdonald et al., 1990), do not apply for biological treatment modalities such as tumor vaccination. The paradigm of a therapeutic vaccine leading to (detectable) immunological responses and hence to (detectable) clinical responses with increased OS is at least incomplete. Even immune

All clinical reports have used monocyte-derived DC for their trials. The methodology for DC preparation is now fairly well established, and gives a sufficient yield of mature DC (DCm) for injections into patients. Most of the older trials have used immature DC, while others have used maturation stimuli like TNFα, penicillin-killed Streptococcus pyogenes (OK-432), monocyte-conditioned medium, IFN-γ and TNF-α in combination with IL-4-secreting fibroblasts (Van Gool et al., 2009). Only one phase I study focused on the dose of DC and could not find any dose-limiting toxicity (Liau et al., 2005). At the time of the design of most published clinical trials, it was not known if and which lymph nodes would be the optimal destination of injected DC. Later on, however, data became available that priming of T cells by DC within the cervical lymph nodes induced an integrin homing pattern toward intracerebral locations. Other preclinical in vivo brain tumor models clearly showed an enrichment of tumor-specific Treg in the blood and cervical lymph nodes. As pointed out by Tuyaerts et al. (2007), the question whether DC should be injected intradermally, intravenously or in the lymph nodes is not yet resolved. This becomes particularly important as only a small amount of the intradermally injected DC ultimately reaches the T cell area of lymph nodes. However, taking into account the documented failure rate of even experienced radiologists injecting DC in lymph nodes under ultrasound guidance, and the desire to spread DC vaccination technology to more centers in order to perform largescale clinical trials, most researchers in the field favor the intradermal route for DC injection. A very interesting issue is the potential role that local injection of DC directly into the tumor region

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might play in immunotherapeutical approaches. In their study, Yamanaka et al. (2005) showed some benefit from intratumoral plus intradermal injections of DC as compared with only intradermal injections, although one should note that this observation was not derived from a prospective randomized approach. Nevertheless, a local change from an immune suppressive into a more immune stimulatory microenvironment might be induced by intratumoral administration of DC.

Monitoring Immune responses following vaccination have been monitored in most trials. These analyses have included positive DTH skin reaction, T cell reactivity and NK cell enrichment in peripheral blood, as well as measuring T cell infiltration in tumoral tissue taken after vaccination. The reported immune monitoring remains very global in these clinical trials, mainly due to the lack of specific antigens to be targeted. Although data are still preliminary, advanced magnetic resonance imaging (MRI) eventually combined with positron emission tomography (PET) may soon provide better tools to monitor the effects of immunotherapy of HGG.

Results of Clinical Studies Because all clinical trials reported thus far comprise case reports, phase I, phase I/II or phase II trials, the questions answered in these trials relate to feasibility, toxicity and early efficacy, both immunologically and/or oncologically (Table 32.2). In all trials, it seemed to be feasible to administer DCbased vaccines. Moreover, all reports conclude that the toxicity is minimal except for the case reported by Rutkowski et al. (2004) where an overwhelming inflammatory reaction around a residual tumor was observed. Of major importance, none of the reports describes autoimmune phenomena induced by DC vaccination. Besides feasibility, toxicity and clinical outcome, all published studies on DC-based immunotherapy have aimed to assess immune responses. Several immune assays have been developed for this purpose,

H. Ardon et al.

but so far, results have been difficult to interpret. Moreover, immunological responses are not detected in all patients. A correlation between immunologically measurable effects and clinical outcome was reported in several papers. In the study by Wheeler et al. (2008), a significant progressive (logarithmic) association was found between time to survival after inclusion and post-vaccine IFN-γ enhancement. This allowed them to propose that single-vaccine response metrics can quantitatively reflect inhibition of tumor progression by T cells in GBM patients. Only a limited number of research groups are actively performing clinical trials world-wide. All these trials are small, and include heterogeneous groups of patients with regard to histology and/or time of vaccination. Some studies included patients with all subtypes of HGG, while others focused solely on patients with GBM. Some studied patients with relapsed HGG, while others included patients with a first diagnosis of HGG, either exclusively or combined with patients treated at recurrence. Only one group reported on children with relapsed HGG. Moreover, as pointed out before, the vaccination protocol varied enormously among research groups. Due to this heterogeneity in study design and execution, sound comparative analyses on clinical outcome are difficult. Nevertheless, in most trials, some clinical effect is observed and some important clues for future clinical studies are provided, especially from trials where there are comparisons with historical controls or between internal subgroups. For example, Yu et al. (2001) reported that seven patients with newly diagnosed GBM who received three biweekly intradermal vaccinations with peptide-pulsed DC had median survival times of 455 days as compared to 257 for 42 nonvaccinated but otherwise comparably treated patients in the same institute. Although compared with historical control patients and although no statistics are provided, the prolongation of the median survival is an interesting observation in this phase I clinical trial. The same group reported on vaccinations at the time of relapse in eight GBM patients, and made a similar comparison to 26 historical control patients (Yu et al., 2004). Both patient groups underwent second craniotomy for relapsed GBM. Whereas the median survival was 30 weeks in the control group, subsequent vaccination after new resection resulted in a significant change of median survival to 133 weeks, with some patients surviving for more than 250 weeks.

32 High-Grade Gliomas: Dendritic Cell Therapy

In a recent paper, the same group demonstrated that vaccine responders exhibited more favorable clinical outcomes relative to non-responders. Moreover, the vaccine-induced responses elicited therapeutic benefits primarily by sensitizing tumors to subsequent chemotherapy (Wheeler et al., 2008). In the phase I study reported by Liau et al. (2005), clinical outcome in the patients with stable tumors or no residual disease at time of DC vaccination compared favorably, even when compared with historical/concurrent data for the best prognostic subgroup of GBM patients treated during the same time period at their institute. In contrast, Okada et al. (2007) did not show any benefit in PFS in patients treated with DC loaded with autologous tumor lysate in combination with IL-4 producing fibroblasts. In the study on recurrent HGG patients reported by Yamanaka et al. (2003), radiological responses were observed in the group of five patients who received intratumoral plus intradermal vaccinations, while no response was detected in the five patients who were only injected intradermally. De Vleeschouwer et al. (2008) report on a large group of patients with relapsed GBM treated with DC loaded with tumor lysate in a stepwise process using a cohort-comparison study concept (HGG-IMMUNO2003), comprising of four cohorts (A-D). Following this strategy, the authors have been able to compare each cohort within the trial with the other cohorts. Thus far, three major issues in the complexity of DC immunotherapy have been addressed: the vaccination schedule, the boosting and the maturation cocktail. In this large group of patients, a complete resection improved the median PFS and OS as compared to an incomplete resection. Interestingly, a stepwise improvement in PFS curves could be seen by shortening the interval between the induction DC vaccines, with further improvements noted by adapting the boosting intervals and technology, and finally by changing the maturation cocktail. Reported 2-year survival was 16.7% in cohort C and 27.8% in cohort D. In the report by Ardon et al. (2010b), DC-based immunotherapy was integrated into the primary treatment regimen for eight pilot patients with newly diagnosed GBM. After radiochemotherapy, 4 weekly DC-based vaccines were injected, and further boosting was done with lysate vaccines during the maintenance temozolomide phase. Median PFS in these eight patients was 17.8 months and median OS was 24.3 months. PFS at 6 months was seen in six of the eight

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patients (75%). The report on the results of a large phase I/II trial HGG-2006 with 77 patients included, is in preparation.

Optimization of Immunotherapy Although several studies have reported promising results, and activation of the immune system against gliomas seems possible, immunotherapeutical approaches are counteracted by rapid tumor progression and glioma-induced immune suppression. There is a clear need for improvement of the immunotherapeutical strategies and several options exist to enhance the immune response. It has been shown in murine models that co-stimulation of T cells can be enhanced by using agonistic antibodies to costimulatory molecules, resulting in a better activation of T cells. The use of antagonistic antibodies to coinhibitory molecules (such as “cytotoxic lymphocyteassociated antigen-4” (CTLA-4) and “programmeddeath-1 receptor”) can also lead to a stronger T cell activation (Grauer et al., 2009; McDermott, 2009). It is also important to target Treg that suppress the antitumoral immune response. As already mentioned, it has been shown in mouse models that elimination of Treg, either in combination with anti-CTLA-4 antibodies or not, results in increased immunity against glioma and a stronger response to DC-based immunotherapy (Grauer et al., 2008; Maes et al., 2009). In humans, studies have been carried out using daclizumab (anti-CD25 antibody), ONTAK (“denileukin diftitox”) and CD25-specific immunotoxins (LMB-2) (Grauer et al., 2009; Rech and Vonderheide, 2009). Clinical responses, however, have been limited. Low-dose metronomic temozolomide diminished Treg in a rodent glioma model and in melanoma patients, and therefore seems a promising tool to use in glioma patients. Unfortunately, this tool cannot be combined with DCbased immunotherapy since metronomic temozolomide administration would counteract the induction of an immune response (Banissi et al., 2009; Su et al., 2004). On the other hand, low-dose metronomic oral cyclophosphamide has been propagated as an effective Treg-depleting regimen that does not counteract immunotherapy (Ghiringhelli et al., 2004, 2007). The local immune suppression by the glioma itself can be targeted via suppressive cytokines, such as

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TGF-β2, that are produced by the tumor. TGF-β is capable of inhibiting T cell and B cell activation and proliferation, it suppresses the activity of NK cells, reduces the production of cytokines like IL-2, IL-6, IL-10, IFN-γ, and suppresses the expression of MHCII molecules on glioma cells. In preclinical studies it has been shown that the expression of TGF-β2 by GBM cells can be diminished by exposing them to antisense oligonucleotides (AON) against mRNA of TGF-β2 The most advanced AON for the therapy of high-grade gliomas is a phosphorothioate-modified AON, AP 12009 (trabedersen), which targets mRNA encoding TGF-β2. AP 12009 is administered intratumorally using convection-enhanced delivery. A series of Phase I and II clinical trials have evaluated the toxicity profile and optimal dose of the substance, and a randomized, controlled Phase III study is ongoing in patients with recurrent or refractory anaplastic astrocytoma after standard radio- and chemotherapy (Hau et al., 2007, 2009; Schneider et al., 2008). Finally, production of DC can be optimized; for example, maturation of DC can be improved by using “Toll-like receptor” agonists (De Vleeschouwer et al., 2008; Grauer et al., 2009; Van Gool et al., 2009).

Conclusion In recent years insights into tumor immunology have been refined and it is now clear that both the adaptive and innate immune system play an important role. Moreover, it has been shown that immunological processes take place within the CNS and the brain should be looked upon as an immune-distinct environment. Many glioma-specific antigens have been described and interactions between gliomas and the immune system are being elucidated: gliomas will grow and evade the antitumoral immune responses if the balance between tumor cell proliferation and elimination tips in favor of immune-resistant cells (“immune escape”). Immunotherapy for patients with HGG is a novel therapeutic approach that opens new opportunities for enhanced survival without major toxicity. This is of particular importance, taking into account that HGG cause a relatively high community burden, not only with many years of life lost due to cancer,

H. Ardon et al.

but also because of the morbidity from the tumor and subsequent treatments. In the assessment of immunotherapeutical results for patients with HGG, the improvement of PFS and, particularly, the significant increase of OS with satisfactory quality of life are, of course, by far the most important variables, much more than immunologic surrogate markers for response. The studies in preclinical animal models for human gliomas, especially the murine models, are interesting in order to obtain more insight into the basic biology underlying disease evolution and immunotherapeutic mechanisms. Still, timely translation of new concepts into clinical practice should be the primary objective. With several groups entering into clinical practice in this field, new data are now being generated. However, it is of paramount importance to study this promising approach based on data from well designed trials with appropriate end points. Thus far, the observations with regard to both immunological responses and clinical responses are promising and beneficial effects are reproducible. Of particular interest is the fact that no induction of autoimmunity or other major toxicities have been observed to date. However, larger and more homogeneous patient groups with more refined inclusion criteria should be studied for more rapid progress in this field. Moreover, confirmatory studies with an appropriate randomization versus a control patient group, preferably even stratified for prognostic markers, including molecular tumor signature, should be implemented in the near future. For this, collaborative efforts between wellorganized and experienced vaccination centers should be established.

Acknowledgements This translational research program has been supported by the Olivia Hendrickx Research Fund (http://www.olivia.be). Support was also obtained from Electrabel Netmanagement Vlaanderen, CAF Belgium, Baxter, the Herman Memorial Research Fund (http://www.hmrf.be), the James E. Kearney Memorial Fund and gifts from private families and service clubs. Additionally, grants were obtained from “Stichting tegen Kanker,” IWT (TBM project), the Stem Cell Institute Leuven, the Emmanuel van der Schueren Fund, the International Union against Cancer, the Klinisch Onderzoeksfonds UZ Leuven, and the Fund for Scientific Research – Flanders (FWO-V). We are very grateful for the technical assistance from KatjaVandenbrande, Goedele Stegen, Vallentina Schaiko, Elke Nackers and Anaïs Van Hoylandt. We thank the neurooncology team in the hospital for fruitful patient discussion, and the staff of the Laboratory of Experimental Immunology for basic scientific discussions.

32 High-Grade Gliomas: Dendritic Cell Therapy

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Chapter 33

Glioblastoma Multiforme: Use of Adenoviral Vectors Thomas Wirth, Haritha Samaranayake, and Seppo Ylä-Herttuala

Abstract Glioblastoma multiforme is a tumour of the brain with extremely poor prognosis. It constitutes approximately 60–70% of all primary brain tumours with a mean survival of 14.6 months after diagnosis. Current standard therapy includes surgical resection followed by adjuvant radiotherapy and/or chemotherapy. With the introduction of gene therapy a new therapeutic area has been opened and numerous approaches are currently been studied in pre-clinical as well as in clinical settings for the treatment of brain tumours. These include pro-drug activation/suicide gene therapy, anti-angiogenic gene therapy, oncolytic virotherapy, immune modulation and many other strategies, which will be discussed in this review. The use of suicide gene therapy has been probably one of the most studied therapeutic approaches and will be also discussed in this review in more detail. Keywords Glioblastoma multiforme · Adenoviral vector · Pro-drug activation · Proliferation · Invasion · Suicide gene therapy

Introduction One of the most lethal malignancies are gliomas, which constitute approximately 60–70% of all primary brain tumours with an overall global incidence

T. Wirth () Department of Biotechnology and Molecular Medicine, A. I. Virtanen Institute, University of Kuopio, FI-70211 Kuopio, Finland e-mail: [email protected]

of 4–6 new cases per 100,000 population per year. Current standard therapy includes surgical resection followed by adjuvant radiotherapy and/or chemotherapy. The overall prognosis of patients diagnosed with glioblastoma multiforme (GBM) and treated with current therapies has remained poor for the last few decades, with a mean survival of 14.6 months after diagnosis and a 5-year survival of <3% for these patients. The diffusely infiltrating property of GBM makes total surgical resection often virtually impossible, leading invariable to tumour recurrence at some point of time. The maximum radiation dose that can be given to the brain is limited to 60 Gy, which is usually not sufficient to completely eradicate the tumour. This has provided impetus to test novel therapy modalities to achieve better responses to improve the quality of life and to increase the survival time of GBM patients. With the introduction of gene therapy a new therapeutic area has been started, and so far, several gene therapy approaches have been studied against glioma. By September 2008 there were a total of 91 gene therapy clinical trials registered world wide, targeting brain cancer: 62 of them in phase I, 17 in phase I/II, 7 in phase II, 1 in phase II/III and 4 in phase III, of which one was a study using adenoviruses as the gene transfer vector. In that study the suicide gene Herpes simplex virus thymidine kinase is used to target dividing cells within the brain (i.e. tumour cells). Since this is so far the most advanced gene therapy study for GBM, where adenoviral vector is used, it will be discussed in more detail. In addition to the suicide gene therapy approach, other gene therapy approaches where adenoviral vectors are used will be highlighted.

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_33, © Springer Science+Business Media B.V. 2011

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Brain Tumours The brain is an important site in oncology. Many malignancies originating from organs such as lung, breast, colon, skin, kidney and thyroid can metastasize to the brain resulting in secondary brain tumours. At the same time many different cell types in the brain can ascertain a malignant phenotype giving rise to primary brain tumours. Primary brain tumours are classified based on histological appearance, resemblance of the tumour cells to embryonic, foetal or differentiated mature cells, growth pattern, radiological features and surgical appearance. In the majority of brain tumours the cell of origin is unknown due to unavailability of identifiable pre-malignant lesions and cellular atypia preventing the comparison with any normal cells. Primary brain tumours can be classified into three groups: (1) neuroepithelial tumours which include astrocytic, oligodendroglial, ependymal, choroid plexus, neuronal and pineal parenchymal tumours, (2) non-neuroepithelial tumours such as meningeomas, nerve sheath tumours, malignant lymphoma, pituitary adenoma and germ cell tumours, and (3) other tumours including tumours of unknown origin. Approximately 60–70% of all primary intracranial tumours are of neuroepithelial origin. About 30% are derived from brain coverings (meningiomas) and 7.5% are located in cranial or spinal nerves, whereas lymphomas and germ cell tumours account for 4 and 1% respectively. The most common primary brain tumours in adults are gliomas, which account for 60–70% of primary tumors.

Glioblastoma Multiforme In the WHO tumour grading system gliomas are graded into four grades of malignancy from grade I to IV based on morphological characteristics, such as nuclear atypia, mitotic figures, microvascular proliferation and focal pseudopalisading necrosis, with increasing biological aggressiveness with increasing tumour grade. Tumours with malignant grade I and II are termed low grade whereas those with grade III and IV are termed high grade tumours. Tumours of astrocytic origin are graded in order of increasing anaplasia into pilocytic astrocytoma (WHO grade I), low grade diffuse astrocytoma (WHO grade II), anaplastic astrocytoma (AA) (WHO grade

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III) and the most frequent and most malignant subtype glioblastoma multiforme (GBM) (WHO grade IV), which accounts for 60–70% of all gliomas (Ohgaki and Kleihues, 2005). Oligodendrogliomas and mixed oligodendroastrocytomas are classifies into two grades; low grade (grade II) and high grade (grade III). Diffuse astrocytic tumours including low grade diffuse astrocytomas, AA and GBM, oligodendrogliomas and meningiomas in adults and pilocytic astrocytomas, ependymomas and medulloblastomas in children, are in general the most frequent primary brain tumours.

Current Therapy Current standard therapy of GBM includes surgical resection followed by adjuvant radiotherapy and chemotherapy (i.e. temozolomide). In the latest study presented by Stupp and his colleagues the overall mean survival with this therapy was shown to be 14.6 months after diagnosis with a 5-year survival of 9.8% (Stupp et al., 2009). More recently, in May 2009 the FDA approved Avastin (bevacizumab) for GBM under an accelerated approval process. The approval was based on the results of 2 phase II clinical trials that showed Avastin reduced tumour size in some GBM patients. In addition, another recently published phase II trial of single-agent bevacizumab followed by bevacizumab plus irinotecan showed significant therapeutic activity in patients with recurrent glioblastoma. In general, the challenge in the treatment of malignant gliomas lies in the nature of how they grow. Gliomas are characterized by an extensive, diffuse infiltration of the tumour cells into the surrounding brain parenchyma. Partly because of their growth pattern, complete surgical resection is generally not possible. The consequence is an inevitable tumour recurrence at some point. In addition, some tumours due to their anatomical location are either surgically inaccessible or have limited likelihood of near-total surgical resection. The maximum radiation dose that can be given to the brain is limited to 60 Gy, which is often not sufficient, as brain tumours are generally resistant to radiotherapy. Studies have shown that doses above 60 Gy would not give any additional therapeutic benefit, because of the increase in adverse effects, such as radiation induced necrosis of normal brain.

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Treatment of gliomas with systemic chemotherapy is challenging, since the blood brain barrier (BBB) impairs the delivery of adequate concentrations of most chemotherapeutic compounds. The reasons for not achieving adequate concentrations is because the BBB lacks intercellular fenestrations, has high electrical resistance and is not permeable to ionic compounds rendering it relatively impermeable to most water soluble compounds.

History of Gene Therapy Scientific understanding of the molecular basis of life increased dramatically after Oswald T. Avery’s discovery in 1944 that deoxyribonucleic acid (DNA) was the “transforming principle” – the secret code of life. Then Francis Crick and James Watson described the “double helix” structure of DNA in 1953. The process, however, by which DNA replicates itself during cellular reproduction, or how DNA expresses its genetic information, was still a mystery in the late 1950s. A little less than 20 years after Oswald T. Avery’s discovery Marshall Nirenberg and his colleagues in 1962 deciphered UUU (one three-unit batch of uracil, which was a “code word” for identifying phenylalanine) as the first word in the chemical dictionary of life and thereby set a pillar for gene therapy. Gene therapy is generally defined as the transfer of nucleic acids to somatic cells of a patient with a therapeutic intent. According to the EMA, gene therapy medicinal product means “a biological medicinal product that contains an active substance, which contains or consists of a recombinant nucleic acid used in or administered to human beings with a view regulating, replacing, adding or deleting a genetic sequence, as well as if its therapeutic, prophylactic or diagnostic effect relates to the recombinant nucleic acid sequence it contains, or to the products of genetic expression of this sequence”. As compared to traditional medicine, gene therapy offers unique possibilities to treat genetic causes of diseases, as an example can be mentioned diseases like fatal enzyme deficiencies. In the US, the FDA approved the first gene therapy clinical protocol, which was initiated in 1989. In the protocol, tumour-infiltrating lymphocytes were collected from patients with advanced melanoma, and transduced ex vivo with a marker gene, expanded in vitro and then re-infused into the patients. A year

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later, the first gene therapy with a therapeutic intent was conducted on the 4-year old Ashanti de Silva, on September 14, 1990, at the NIH Clinical Centre. The patient had adenosine deaminase (ADA) deficiency, a genetic disease making her defenseless against infections. Unfortunately, the efficacy of Ashanti’s gene therapy was not clearly demonstrated due to simultaneous enzyme replacement therapy with polyethylene glycol adenine deaminase (PEG-ADA), which she had to take as a back up. In 2009 Kohn and Candotti compared the transplantation of hematopoietic stem cells with gene therapy, concluding that gene therapy has been at least as successful, if not better, than the transplantation of hematopoietic stem cells (Kohn and Candotti, 2009). However, before that, in 1999 a tragic incident happened, and it was ultimately after the death of Jesse Gelsinger – a patient who was treated for a disorder called partial ornithine transcarbamylase (OTC) deficiency by adenoviral gene therapy and in whom death could be directly linked to the viral vector – concerns of the safety of gene therapy were raised. Another incident also raised doubts about the safety of gene therapy. Eleven young children suffering from the fatal X-linked SCID-XI syndrome were treated with gene therapy. However, after the initial success 3 out of 11 treated patients had developed a leukaemia-like disease as a result of the use of the murine leukaemia virus (MLV) vector. Today, there are more than 1400 ongoing gene therapy clinical trials worldwide, most of which are targeted against cancer, and currently two approved gene therapy-based medicines are approved in China, Gendicine and H-101 (Oncorine), both indicated for head and neck cancer. Gendicine, approved in 2003 by the Chinese State FDA, is a p53 adenovirus (Ad) for the treatment of head and neck squamous cell cancer in combination with radiotherapy. H-101 (which is similar to Onyx-015) is a conditionally replicative Ad that gained marketing approval in China in 2006. Along with this progress, gene therapy has evolved as a new therapeutic option for the treatment of GBM. Ideally, a gene therapy vector would target a specific tissue with high transduction efficiency and sustain a stable, regulated gene expression without any side effects or immunogenic responses. Currently, none of the most commonly used gene delivery vectors fulfil all these criteria. Nevertheless, the majority of gene therapy clinical trials have been performed using viral vectors, reflecting their superiority over non-viral systems.

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Adenoviral Vector Adenoviral vectors (Ads) have been widely utilized for gene therapy studies, both, in preclinical and clinical settings. To date, 52 serotypes of human Ads have been found and they have been classified into seven species (human adenovirus A to G). Ads are non-enveloped, icosahedral viruses of 60–90 nm in diameter. They have a linear double stranded DNA genome of 30–40 kb and as gene transfer vectors they can carry relatively large fragments of foreign DNA. The main components of Ads are the capsid and the core. The main component of the capsid is hexon. The homotrimeric hexon capsomers form the 20 triangular faces of the icosahedron. In each of the 12 vertices, there is a penton capsomere composed of penton base and fiber proteins. The latter forms a spike-shaped protrusion with a terminal globular domain or “knob” that is responsible for the attachement of the virus to its primary receptor. In addition to hexon and penton capsomers, there are several hexonassociated proteins that have capsid-stabilizing functions. The double stranded DNA genome is located in the virion core with DNA associated proteins and terminal proteins that serves as a primer for DNA replication. Human Ads are known to cause a variety of clinical symptoms, depending on the serotype in question. These include upper and lower respiratory tract infections, gastroenteritis, keratoconjunctivitis, acute hemorrhagic cystitis, meningoencephalitis and hepatitis. The coxsackie- and adenovirus receptor (CAR) is the primary receptor for human Ads. The knob domain of the homotrimeric fiber binds to CAR, mediating virus attachment to the cell. Subsequently, an RGDmotif located in the penton base interacts with a cell surface integrin molecule that plays a role as a secondary or internalization receptor and triggers the virus entry via clathrin-dependent receptor mediated endocytosis. In addition to the CAR receptor other receptors, such as class I major histocompatibility complex (MHC), heparan sulphate glycosaminoglycans and vascular cell adhesion molecule-1 have been shown to play a role in cell entry. Ads transduce both dividing and quiescent cells and they provide an efficient, but transient, transgene expression. They exist

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extrachromosomally within the cell, although the DNA migrates into the nucleus. Because of their broad host and cell range adenoviral vectors have been extensively used in experimental models, as well as in clinical protocols. Even though there is not much data about the long-term aspects regarding the safety of adenoviral vectors in humans, at least one meta-analysis showed that adenoviruses have demonstrated adequate safety as gene transfer vectors in humans (Wirth et al., 2006). Most adenoviral vectors used in gene therapy are based on serotype 2 and 5, since these serotypes are associated only with mild or asymptomatic infections. In the first generation of adenoviral vectors, the region encoding for early viral protein E1 is replaced by the transgene making the vectors replication defective. By deleting the E1 gene, a transgene capacity of 4.7–4.9 kb was achieved, which was then further increased to 8.3 kb by deleting the non-essential region E3. To circumvent the problem of the host cellular immune response against the viral proteins produced by other early viral genes, a second generation vector was described, where the E4 region was deleted. This second generation of adenoviral vectors was shown to be safer in terms of not causing as much apoptosis and inducing to a lesser extent an immune response in vivo. The third generation adenovirual vectors were constructed by deleting other adenovirus genes, resulting in a so called high-capacity, gutless or helper-dependent Ads vectors.

Gene Therapy of Brain Tumours Brain tumours are in most cases single, localized lesions of rapidly dividing cells in a background of non-dividing cells. They rarely metastasize outside CNS and recurrences occur typically in the close vicinity of the original lesion, making them highly amenable for gene therapy. In gene therapy, the vectors can generally be classified into viral and nonviral vectors, where the viral vectors are considered to be currently the most effective ones. Commonly used viral vectors for brain tumour gene therapy include retroviruses, herpes simplex viruses, Ads and adeno-associated viruses (AAV). Apart from these Baculoviruses, New Castles’ Disease viruses (NDV), polio viruses, Semliki Forest viruses, measles viruses, lentiviruses, reoviruses, and vaccinia viruses have been

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used. In most of these vectors the viral genome is genetically modified to make them replication defective and non-pathogenic. However, in the oncolytic viruses the genome is modified to give them the ability to specifically replicate only in tumour cells, thereby lysing these cells. Some of the new viral vectors have the ability to replicate only once in the target cells, without the ability to disseminate, so that the transgene copy number and expression within the transduced cells increases. For gene therapy of brain tumours, several approaches have been studied. These include pro-drug activation/suicide gene therapy, anti-angiogenic gene therapy, oncolytic virotherapy, immune modulation, correction of gene defects, inhibition of tumour invasion, apoptosis induction, gene therapy to enhance chemo- and radiotherapy, myeloprotective gene therapy, antisense and RNA interference (RNAi) based strategies. Although most of these methods have demonstrated promising success in in vitro and preclinical studies, only a few of these approaches have progressed up to phase III clinical trials. The very first clinical gene therapy trials against brain tumours have been registered in 1992. In that trial autologous tumour cells were modified ex vivo with retrovirus to express interleukin-2 gene in neuroblastoma. In the following year brain tumour patients were treated with herpes simplex virus thymidine kinase (HSV-tk) suicide gene therapy using retrovirus vectors producing cells (VPCs) and concomitant administration of ganciclovir (GCV). By September 2008 there were a total of 91, gene therapy clinical trials registered world wide, targeting brain tumours: 62 of them in phase I, 17 in phase I/II, 7 in phase II, 1 in phase II/III and 4 in phase III. In 14 out of 62 trials adenoviral vectors were used and only one of them, so far, has reached and completed phase III. That study was a randomized multicentre phase III trial using HSV-tk adenoviral vectors for the treatment of GBM.

Adenoviruses as a Gene Transfer Vector in Malignant Glioma Gene Therapy Ads vectors are next to retroviral vectors as the most commonly used gene transfer vectors for the delivery of therapeutic genes into GBM. They have been used in a variety of different gene therapy strategies,

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including suicide gene therapy, anti-angiogenic gene therapy, oncoviral therapy, gene therapy based on immune modulation, gene therapy targeting oncogenes or tumour suppressor genes and gene therapy targeting tumour invasion and apoptosis. Also, gene delivery of antisense or siRNAs targeted to growth factors, to increase the sensitivity of glioma cells to chemotherapeutics or to inhibit migration and invasion of glioma cells, are more recent approaches that have been developed.

Anti-angiogenic Therapy Angiogenesis is an integral part in tumour development. As the tumour growth continues, new blood vessels need to be developed to meet with the new metabolic demands, and to sustain the growth. Angiogenesis was initially described by Judah Folkman as a complex process, tightly regulated by coordinated expression of a variety of stimulating and inhibiting molecules, which involves rapid proliferation of endothelial cells, resulting in new blood vessel formation. In tumours VEGF is secreted by tumour cells and stromal cells. GBM is a highly vascular tumour with profound neovascularisation, with angiogenesis playing a key role in its development and progression. Therefore, gene therapy approaches inhibiting angiogenesis has naturally become a logical and widely experimented area also for the treatment of malignant gliomas. Both, VEGFR-1 (Flt-1) and VGFR-2 are shown to be overexpressed in high grade gliomas, of which VEFGR-2 seems to play a significant role in promoting angiogenesis (Stratmann et al., 1997). However, the significance of VEGFR-1 (Flt-1) is yet to be elucidated. Apart from VEGF, other angiogenic factors such as PDGF, hepatocyte growth/scatter factor, FGF, uPAR, and cathepsin B are frequently over expressed in GBM. An artificial transcription factor based on Cys2His2 zinc-finger proteins (ZFPs) targeting the VEGF promoter has been used by Kang et al. as a strategy for modulating VEGF levels in gliomas, eliciting a pronounced antitumour effect in a human glioblastoma xenograft model (Kang et al., 2008). He showed also that in vivo inoculation with adenoviral vectors encoding for brain-specific angiogenesis inhibitor 1 (BAI1) resulted in antiangiogenic and antitumour

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effects of established subcutaneous or intracerebral tumours, and that it promoted increased survival in mice (Kang et al., 2006). Adenoviral vector containing the cDNA of wild-type p16 and antisense RNA of uPAR were used to transduce the U251 glioblastoma and a glioblastoma xenograft cell line, resulting in a significant inhibition of human mammary epithelial cell capillary formation and VEGF expression (Nalabothula et al., 2007). Also, retargeting of Ads carrying the gene for HSV/tk to endothelial cells of the tumour vasculature by using the fibroblast growth factor ligand was used as an antiangiogenesis strategy (Gupta et al., 2006). Insertion of tissue inhibitor of metalloproteinase-3 (TIMP-3) cDNA in the oncolytic adenovirus-Delta-24-RGD by Lamfers and colleagues has not shown to improve the therapeutic outcome over the parent oncolytic virus without the transgene (Lamfers et al., 2005). Another group demonstrated that inhibition of matrix metalloproteinase-9 by using Ads resulted in reduced in vitro invasion and angiogenesis of human microvascular endothelial cells (Jadhav et al., 2004). The same was shown also by two other groups, where ribozymes targeted to the mRNA of VEGF were used (Ciafre et al., 2004). The multifunctional growth factor scatter factor/hepatocyte growth factor (SF/HGF) and its receptor c-met have been implicated in the tumorigenesis, malignant progression, and chemo/radioresistance of multiple human malignancies, including gliomas. Adenovirus expressing anti-SF/HGF and anti-c-met U1snRNA/ribozymes substantially inhibited tumour growth and promoted animal survival in an orthotopic glioma model, as well as in a subcutaneous mouse model using the glioma cell line U87MG (Kargiotis et al., 2008). Also, adenoviral vector mediated gene transfer of the tumour necrosis factor-α (TNF-α) was shown to improve the antiglioma efficacy with concomitant radiation and temozolomide therapy (Yamini et al., 2007).

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viral proteins. Since the function of the E1b in the wild type virus is to prevent p53 induced apoptosis of viral infected cells, it was thought that E1b mutated viruses would replicate only in p53 deficient tumour cells, eventually leading to tumour cell death. After some promising pre-clinical studies a phase I clinical trial was conducted, showing that it was well tolerated without serious adverse effects (Chiocca et al., 2004). However, no definitive anti-tumour efficacy was observed in that trial. Later, several other genetically modfied oncolytic viruses have been studied. Adenovirus-Delta-24-RGD oncolytic adenovirus has a 24 base pair deletion within the E1A early viral protein gene that renders the virus replication ability only in cells with defective retinoblastoma pathway, which is commonly altered in malignant gliomas, independent of the host cell p53 status. This oncolytic adenovirus selectively replicates in malignant cells with a defective p16/Rb/E2F signalling circuitry. One phase I clinical trial has been registered so far using adenovirus-delta-24-RGD for glioma gene therapy. A variant of this vector, adenovirus-delta-24-hyCD was designed to express a humanised form of the Saccharomyces cerevisiae cytosine deaminase gene (hyCD). It has shown better efficacy in glioma models than the adenovirus-Delta-24-RGD, when combined with 5-FC. Also, due to their tumour tropic properties, human mesenchymal stem cells were used as intravascular delivery vehicles of Delta24-RGD to human gliomas. Other mutant adenoviral vectors, with mutations in both E1A and E1B genes, demonstrated a potent anti-tumour effect in a glioma xenograft model. Additionally, a number of CRADs, based on tumour selective expression of genes required for viral replication under the control of a tumour or tissue specific promoter, have been constructed. Also, CRADs carrying an additional transgene, such as p53 or HSV-tk, have been developed in order to potentiate the therapeutic effect of these vectors.

Oncolytic Viruses Immune Modulation A very interesting therapeutic approach that has been edexploited is the natural capacity of adenoviral vectors to induce cell lysis, often termed as oncolytic viruses or conditionally replicative adenoviruses (CRADs). The first genetically modified oncolytic adenovirus was ONYX-015, which carries a mutation in the E1b region that encodes for early

Like most other malignancies, gliomas are known to suppress the host immune system. The secretion of immunosuppressive substances by the tumour, such as transforming growth factor-β (TGF-β) and interleukin-10 (IL-10), that decreases the expression of MHC molecules and FasL are some of the

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tumour factors contributing to immunosuppression and impaired anti-tumour immune response by the host. With the aim of enhancing cell mediated immunity, both, adoptive and active (vaccines) immunotherapy strategies have been attempted in GBM with varying degrees of success. Ads expressing fms-like tyrosine kinase-3 ligand (Flt3L), heat shock protein 72 and the activating immunoreceptor NKG2D have been used to induce an immune response against the tumour and to stimulate the infiltration of immune cells into the tumour microenvironment. Ads Flt3L have been used in combination with adenovirus HSV-tk gene therapy by several groups demonstrating an induction of cellular and humoral immune responses, as well as an immunological memory against glioblastoma (King et al., 2008; Ghulam Muhammad et al., 2009). Also, Ads gene transfer encoding for the wild type p53, the granulocyte monocyte-colony stimulating factor (GMCSF) and the co-stimulatory signal B7 have been used, resulting in inhibition of cell growth and the induction of apoptosis, as well as in a significant proliferation of autologous peripheral blood lymphocytes and specific cytotoxicity against primary glioma cells (Pan et al., 2009). In addition, adenovirally transduced bone marrow stromal cells transduced with interleukin-12 were used in one study, resulting in an increase in natural killer cell infiltration in brain tissue. Significant (Hong et al., 2009) Ads gene transfer of a secreted trimeric form of the TNF-related apoptosis-inducing ligand (TRAIL) has shown efficacy when injected intra-tumourally in a xenograft model of a human glioma cell line U-87MG, and when injected into intracranial human glioma tumours established in nude mice (Kim et al., 2006; Jeong et al., 2009).

Targeting Tumour Proliferation and Invasion Tumourigenesis/carcinogenesis is a multi-step process with mutations in many genes, including protooncogenes, tumour suppressor genes and genes that promote cell cycle progression, growth factor independence, angiogenesis, enhanced motility, decreased cell-to-cell cohesion, decreased levels of apoptosis, and reduced chemosensitivity. The development of gliomas is commonly associated with mutations in four genetic pathways: the p53/ARF/human MDM2

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pathway, the p16/cyclin D/CDK4 pathway, the receptor tyrosine kinase (RTK)/Ras pathway, and the PI3K/PTEN/Akt pathway. Correction of these genetic defects by delivery of the wild type gene through a vector seems to be a logical approach for cancer gene therapy. The tumour suppressor gene p53 has been one of the most common targets in cancer gene therapy. p53 is mutated or deleted in more than 50% of human cancers, including gliomas, and has been for that reason also a target in glioma gene therapy. p53 maintains the genetic integrity after DNA damage and functions as a gatekeeper of cellular growth, apoptosis and senescence. p53 normally exists in cells in very low amounts and is relatively inactive, but the amount is increased and protein is activated during cellular stress. Depending on the cellular environment, activation of the protein leads to either cell cycle arrest or apoptosis. A variety of different p53 gene correction therapies have been attempted showing promising results in preclinical studies, such as reduced tumour proliferation in nude mice, reduction in tumour volume in rats, increased survival, chemo and radio-sensitisation, inhibition of angiogenesis and induction of apoptosis. As a result, the first gene therapy product was approved for clinical use in China in 2003 (GendicineTM ). GendicineTM is based on an adenovirus encoding for p53 and indicated for the treatment of head- and neck squamous cell cancer. However, after the approval by the Chinese SFDA, there has been discussion about the efficacy of GendicineTM treatment, since the FDA refused to accept an approval application for a similar product: AdvexinTM (INGN 201; Introgen; Austin, TX, USA) for the treatment of head and neck cancer. Another gene of interest has been the tumour suppressor gene retinoblastoma (Rb). In normal cells the retinoblastoma (Rb) gene is in a hyperphosphorylated form, and bound to the transcription factor E2F1, which prevents transcription of genes important for mitosis and progression of cell cycle through the G1/S phase restriction point. P16/Rb/cyclinD/CDK4 is the most commonly mutated pathway in gliomas, and is associated with the progression from low-grade to intermediate-grade gliomas. Enforced expression of MDA-7/IL-24, by use of a recombinant adenovirus, was shown by (Hamed et al., 2010) to have a potent cancer cell–specific apoptosis-inducing ability and tumour growth–suppressing properties in an orthotopic rat glioma model.

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In addition to uncontrolled cell proliferation of tumour cells, another target and challenge in glioma therapy is the extensive invasion of the surrounding normal brain parenchyma by the glioma cells. Modification of the extracellular matrix by proteases and protease inhibitors, cytoskeletal reorganization, growth factors, cytokines and intracellular signalling molecules are the key players involved in this process. A study showed that gene transfer of tissue inhibitors of matrix metalloproteinases (TIMP’s) concomitant with PTEN inhibited the invasion of glioma cells, mainly by inhibiting the secretion of matrix metalloproteinase 2 (MMP-2) (Lu et al., 2004). Another way to block invasion by using adenoviral vectors was shown in a study by Furakawa and his colleagues, showing that PTEN was able to suppress invasion in an organotypic brain slice model, co-culture of glioma spheroids and rat brain slices, where adenoviral vector transduced cells failed to invade surrounding normal brain tissues (Furukawa et al., 2006). Urokinase-type plasminogen activator (uPA) and its receptor (uPAR) have been shown to play an important role in the invasiveness of gliomas and other infiltrative tumours. Downregulation of uPAR, uPA or MMP-9 by antisense oligonucleotides has been shown to inhibit the invasiveness and tumourigenicity of glioma cells in an orthotopic animal model, as well as caused regression of glioma in a subcutaneous glioma model using the human glioma cell line U87MG (Lakka et al., 2003; Gondi et al., 2003).

Suicide Gene Therapy Suicide gene therapies can generally be divided into two steps. In the first step, a gene of a foreign enzyme is delivered (e.g. by the use of a viral vector) to the tumour where it is to be expressed. In the second step, a non-active pro-drug is administered, after which it is selectively metabolized to the active form by the foreign enzyme expressed in the tumour (Fig. 33.1). Ideally, the gene for the enzyme should be expressed exclusively in the tumour cells and should reach a concentration sufficient to activate the pro-drug for a clinical benefit. Several suicide genes have been studied with varying results. HSV-tk, Cytosine deaminase (CD)/5-fluorocytosine (5-FC), cytochrome P450/cyclophosphamide (CPA), E.coli purine nucleoside phosphorylase (PNP)/

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6-methyl-purine-2 -deoxynucleoside, and carboxypeptidase G2 (CPG2)/methotrexate-α-phenylalanine are some of the pro-drug activation systems that have been attempted on brain tumour treatment. Because the expression of the foreign enzyme will not occur in all cells of the targeted tumour in vivo, a “bystander effect” is required, whereby the pro-drug is cleaved to an active drug that kills not only the tumour cells in which it is formed, but also neighboring tumour cells that do not express the transgene. Of all suicide gene therapy apporaches, the HSV-tk suicide gene therapy has been the most widely studied suicide gene therapy approach for the treatment of brain tumours. It is currently also the only adenoviral based gene therapy strategy for the treatment of glioblastomas having finished a phase III clinical trial.

HSV-TK/Ganciclovir Therapy HSV-tk/GCV therapy is based on the pro-drug activating enzyme HSV-tk that converts the nucleotide analogue GCV to its toxic metabolite. Apart from malignant glioma, HSV-tk/GCV has been studied also in many other cancer types, both in pre-clinical models as well as in clinical trials. Originally, the HSV-tk gene was cloned byMcKnight in 1980 (McKnight. 1980). Their property to kill tumour cells, when given GCV, was soon realized and led to the idea of using this as a therapeutic strategy to treat solid tumours. The first proof-of-concept of the therapeutic efficacy of HSV-tk/GCV therapy was established ten years later by Moolten and Wells, when they used retroviral vectors expressing the HSV-tk gene to transduce murine sarcoma and lymphoma cells in vivo. In the initial studies murine fibroblasts producing HSV-tk retroviral vectors were inoculated intratumourally, followed by GCV treatment.

Ganciclovir Mechanism of Action Ganciclovir is a synthetic acyclic analogue of 2 -deoxy-guanosine, chemically designated as 9[[2-hydroxy-1-(hydroxymethyl)ethoxy]methyl]guanine. Originally, GCV is known as being the first antiviral drug to be effective in the treatment of cytomegalovirus

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Fig. 33.1 A schematic representation of suicide gene therapy. In the first step, the gene for an exogenous enzyme is delivered and expressed in the target cells. Subsequently, a pro-drug

is administered that is converted to the active drug by the foreign enzyme in the target cells. The active drug will then cause the therapeutic effect in the malignant cells

(CMV) diseases in humans. GCV has antiviral activity against all members of the human herpes virus family. It is more toxic than its congener, acyclovir, but has a 8–20 fold higher antiviral activity against human CMV than acyclovir, which is generally ineffective against diseases caused by CMV. GCV is converted to GCV-monophosphate by the HSV-tk, which has a 1000 fold higher affinity for GCV than the mammalian form of the enzyme. Cell kinases continue the phosphorylation further and convert the GCV-monophosphate into a GCV diphosphate and finally to a toxic GCV triphosphate. Cytotoxic GCV-triphosphate results in the inhibition of the DNA polymerase, thus preventing DNA replication. HSVtk/GCV therapy is cell cycle dependent, where only dividing cells will be affected. This property is considered to be an advantage in cancer therapy where dividing tumour cells are surrounded by non-dividing, healthy cells. An additional mechanism of action that has been connected to HSV-tk gene therapy is the expression of the non-human enzyme HSV-tk and the presence of tumour antigens that become available after the death of the transduced cells. These antigens are able to induce an antitumoural immune response against the tumour cells. It is believed that both local and systemic immune responses contribute to the overall therapeutic effect of HSV-tk/GCV by stimulating the tumour infiltration of CD4+ and CD8+ T cells, natural killer

(NK) cells and macrophages into the tumour. Work by different groups suggests that GCV induced cell killing occurs due to apoptosis induced by the activation of mitochondrial damage pathways, chromosomal aberrations, and sister chromatin exchange that leads to target cell death due to cell cycle arrest.

The Bystander Effect As current gene therapy vectors cannot achieve 100% gene transfer efficacy, the bystander effect is essential for an effective anti-tumour therapy. Because of that, a very important advantage of HSV-tk/GCV gene therapy is its bystander effect, where neighbouring non-transduced cells are also exposed to the toxic GCV-triphosphate form. Interestingly, it was noticed that also HSV-tk-negative cells were killed after exposure to GCV. Moreover, it was found that even with low concentration of HSV-tk-positive tumour cells, tumour growth could be prevented. Several experiments in murine models suggest that 10% of the tumour cells have to be transduced with HSV-tk gene in order to achieve a significant tumour regression. However, this “bystander effect” seems to be dependent on the cell type. The exact mechanism of the “bystander effect” is not completely understood, but several mechanisms have been postulated. For example, it has been observed by that the number of gap junctions plays a

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vital role in this effect. Additionally, it was demonstrated that the number of gap junctions seems to correlate with the efficiency of killing neighbouring cells. There is experimental evidence that the release of toxic GCV-triphosphate into culture medium by dying cells results in apoptosis of non-transduced cells. This was shown to be dependent on GCV-triphosphate accumulation in the surrounding cells and the concentration of GCV in the medium, suggesting that cell-to cell contacts are not essential. Other possible mechanisms that could be responsible for the bystander effect include stimulation of the immune system, endothelial cell transduction leading to disruption of tumour vasculature and phagocytosis of apoptotic vesicles by neighbouring non-transduced cells.

Clinical Efficacy So far, the only adenoviral vector that has finished a R phase III clinical trial (Cerepro , by Ark Therapeutics Group plc) is based on the suicide gene therapy HSVtk. In that trial Ads vector encoding for HSV-tk was injected into the walls of the tumour cavity of glioma patients after the resection of the tumour (Fig. 33.2). R The clinical efficacy of Cerepro was evaluated first in two separate phase II clinical trials; a phase IIa trial, and a phase IIb trial (Sandmair et al., 2000) (Immonen et al., 2004). In the phase IIa study Sandmair compared the efficacy of retrovirus-packaging cells (VPC’s) and R Cerepro . In that study efficacy was shown already 3 months after the resection and gene transfer, when R R Cerepro was used. Cerepro showed a mean survival advantage of 15 months, which was significantly (p < 0.001) longer than with the control group (8.3 months) or the VPC-group (7.4 months). This was the first controlled trial to show a significant survival advantage using HSV-tk gene therapy. Although the VPC approaches have been found safe, no efficacy has been observed in GBM patients (Rainov, 2000). The low gene transfer efficacy with retrovirus and lack of the treatment response in a study by Sandmair et al. indicated that retroviral HSV-tk gene therapy may not be efficient enough in human clinical settings. This was also further confirmed by two independent clinical trials who reported results from the first randomized, open-label, parallel group phase III trial of 248 patients, where HSV-tk produced

T. Wirth et al.

retroviral producing cells did not result in an improvement of survival. However, the randomized and controlled phase IIb trial published by Immonen, carried out in 36 patients, seventeen patients with operable or recurrent malignant gliomas receiving HSV-tk R adenoviral vector (Cerepro ), implicated a survival advantage over control patients, who did not receive R Cerepro . The mean survival of the patients in R the Cerepro -group (70.6 weeks) was significantly (p < 0.0095) longer when compared to the standard care group (39.0 weeks) or a historical control group (P < 0.0017). This study was also historically the first randomized, controlled study done with an adenoviral vector using HSV-tk, where increased survival of the patients was shown when compared to standard therapy. The results from the study were very encouraging R and it was concluded that Cerepro could provide an effective adjuvant treatment for patients with operable primary or recurrent malignant glioma and therefore a multicentre, standard care controlled, randomized clinical phase III trial was commenced. However, the results coming out of that trial were not as significant as those from the previous IIb trial. As a result, suggestions by the European Medicines Agency were given, after which Ark Therapeutics withdrew their market application to enrol additional patients to the trial.

Safety of Adenoviral Vectors The safety data of adenoviral mediated gene therapy collected from different human trials have uniformly been satisfactory. A report shows that the tolerability towards adenoviral vectors is acceptable and that side effects have mostly been mild without any serious adverse events related to gene therapy (Wirth et al., 2006). Generally, the main concerns in cancer gene therapy of GBM are the safety issues when using viruses to deliver the therapeutic genes into the brain. Especially in the case of adenoviruses the inflammatory reactions that might arise in the brain are of concern. In other clinical HSV-tk studies with retroviruses and adenoviruses there have been evidence of increased brain edema, epileptic seizures and haemorrhages. However, these complications have not been related directly to viral mediated gene therapy, but more likely to the advanced disease and the surgical procedures.

33 Glioblastoma Multiforme: Use of Adenoviral Vectors

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Fig. 33.2 The adenoviral vector based suicide gene therapy R by Ark Therapeutics is injected into the wall of Cerepro the tumour cavity of glioma patients, after the resection of the tumour. Mainly healthy cells will be transduced producing

the HSV-tk and converting the pro-drug Ganciclovir into Ganciclovir monophosphate. The actual cytotoxic metabolite Ganciclovir triphosphate is killing possible residual proliferating tumour cells

The first study evaluating the safety and efficacy R of Cerepro was also the first completed recombinant adenovirus mediated HSV-tk gene therapy trial against MG in humans. In that study serological assessment, i.e. routine blood and urine analysis, was done as well as tests for the detection of anti-adenoviral antibodies were performed in order to evaluate the safety of HSV-tk therapy. The study showed that the therapy was well tolerated and no major alterations in routine laboratory tests were detected. No systemic escape of the virus was detected from urine or plasma samples with PCR. Anti-adenovirus antibodies were measured before and 2 weeks after the gene transfer. Some increases (4 fold) in four patients were detected, two of the patients having also a short-term transient fever reaction. No severe adverse events related to viral mediated gene therapy were detected in either of the treatment groups. The most serious adverse events were some elevation in the frequency of epileptic seizures (2 patients), hemiparesis and aphasia (1 patient). Nevertheless, it could not be excluded that these adverse events were related to the tumour resection itself and the mechanical irritation of the operation procedure. R The phase IIb study of Cerepro showed also a good safety profile with no signs of significant safety concerns. Three patients had transient reversible elevation of liver enzymes; two out of 17 patients in the R Cerepro group developed localized post-opertaive intracerebral oedema. Adenovirus was detected by

PCR in the plasma of two patients 3 days after gene therapy, but not thereafter. A similar good safety profile was seen also in the phase III trial. It has now been almost a decade since the first successful gene therapy trial using an adenoviral vector for gene therapy of GBM. Altogether 344 patients of whom 194 have received adenoviral vector have been participants in the AdHSV-tk/GCV clinical trials, no treatment related deaths have occurred and only a few serious adverse effects related to the gene therapy has been observed. On the basis of these findings the therapy is very safe and well tolerated.

Conclusion Currently, most of the gene therapy strategies used are limited to the local administration of the gene delivery vector, or to ex vivo gene transfer approach. For that, GBM represent an attractive target for gene therapy because of its restricted anatomical location and absence of metastases outside the CNS. However, as far as it comes to local gene therapy, the greatest shortcoming in this approach appears to be the low transduction efficiency of the gene transfer vector and its minimal distribution from the injection site. To some extent the low transduction efficiency can be regarded as a methodological problem, but still, if one wants to improve the potential scope of gene therapy, focus needs to be directed towards vector development.

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This seems necessary, since apart from a limited number of studies little success has been made with gene therapy of GBM today. Nevertheless, a lot of effort and innovation can be seen and it is probably only a question of time, when gene therapy will be reckoned as a therapy for the treatment of GBM.

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T. Wirth et al. intravenous ganciclovir improves survival in human malignant glioma: a randomised, controlled study. Mol Ther 10: 967–972 Jadhav U, Chigurupati S, Lakka SS, Mohanam S (2004) Inhibition of matrix metalloproteinase-9 reduces in vitro invasion and angiogenesis in human microvascular endothelial cells. Int J Oncol 25:1407–1414 Jeong M, Kwon YS, Park SH, Kim CY, Jeun SS, Song KW, Ko Y, Robbins PD, Billiar TR, Kim BM, Seol DW (2009) Possible novel therapy for malignant gliomas with secretable trimeric TRAIL. PLoS One 4:e4545 Kang YA, Shin HC, Yoo JY, Kim JH, Kim JS, Yun CO (2008) Novel cancer antiangiotherapy using the VEGF promotertargeted artificial zinc-finger protein and oncolytic adenovirus. Mol Ther 16:1033–1040 Kang X, Xiao X, Harata M, Bai Y, Nakazaki Y, Soda Y, Kurita R, Tanaka T, Komine F, Izawa K, Kunisaki R, Setoyama M, Nishimori H, Natsume A, Sunamura M, Lozonshi L, Saitoh I, Tokino T, Asano S, Nakamura Y, Tani K (2006) Antiangiogenic activity of BAI1 in vivo: implications for gene therapy of human glioblastomas. Cancer Gene Ther 13:385–392 Kargiotis O, Chetty C, Gondi CS, Tsung AJ, Dinh DH, Gujrati M, Lakka SS, Kyritsis AP, Rao JS (2008) Adenovirusmediated transfer of siRNA against MMP-2 mRNA results in impaired invasion and tumor-induced angiogenesis, induces apoptosis in vitro and inhibits tumor growth in vivo in glioblastoma. Oncogene 27:4830–4840 Kim CY, Jeong M, Mushiake H, Kim BM, Kim WB, Ko JP, Kim MH, Kim M, Kim TH, Robbins PD, Billiar TR, Seol DW (2006) Cancer gene therapy using a novel secretable trimeric TRAIL. Gene Ther 13:330–338 King GD, Muhammad AK, Curtin JF, Barcia C, Puntel M, Liu C, Honig SB, Candolfi M, Mondkar S, Lowenstein PR, Castro MG (2008) Flt3L and TK gene therapy eradicate multifocal glioma in a syngeneic glioblastoma model. Neuro Oncol 10:19–31 Kohn DB, Candotti F (2009) Gene therapy fulfilling its promise. N Engl J Med 360:518–521 Lakka SS, Gondi CS, Yanamandra N, Dinh DH, Olivero WC, Gujrati M, Rao JS (2003) Synergistic down-regulation of urokinase plasminogen activator receptor and matrix metalloproteinase-9 in SNB19 glioblastoma cells efficiently inhibits glioma cell invasion, angiogenesis, and tumor growth. Cancer Res 63:2454–2461 Lamfers ML, Gianni D, Tung CH, Idema S, Schagen FH, Carette JE, Quax PH, Van Beusechem VW, Vandertop WP, Dirven CM, Chiocca EA, Gerritsen WR (2005) Tissue inhibitor of metalloproteinase-3 expression from an oncolytic adenovirus inhibits matrix metalloproteinase activity in vivo without affecting antitumor efficacy in malignant glioma. Cancer Res 65:9398–9405 Lu W, Zhou X, Hong B, Liu J, Yue Z (2004) Suppression of invasion in human U87 glioma cells by adenovirusmediated co-transfer of TIMP-2 and PTEN gene. Cancer Lett 214:205–213 McKnight SL (1980) The nucleotide sequence and transcript map of the herpes simplex virus thymidine kinase gene. Nucleic Acids Res 8:5949–5964 Nalabothula N, Lakka SS, Dinh DH, Gujrati M, Olivero WC, Rao JS (2007) Sense p16 and antisense uPAR bicistronic

33 Glioblastoma Multiforme: Use of Adenoviral Vectors construct inhibits angiogenesis and induces glioma cell death. Int J Oncol 30:669–678 Ohgaki H, Kleihues P (2005) Population-based studies on incidence, survival rates, and genetic alterations in astrocytic and oligodendroglial gliomas. J Neuropathol Exp Neurol 64:479–489 Pan D, Wei X, Liu M, Feng S, Tian X, Feng X, Zhang X 2009. Adenovirus mediated transfer of p53, GM-CSF and B7-1 suppresses growth and enhances immunogenicity of glioma cells. Neurol Res 32(5):502–509 Rainov NG (2000) A phase III clinical evaluation of herpes simplex virus type 1 thymidine kinase and ganciclovir gene therapy as an adjuvant to surgical resection and radiation in adults with previously untreated glioblastoma multiforme. Hum Gene Ther 11:2389–2401 Sandmair AM, Loimas S, Puranen P, Immonen A, Kossila M, Puranen M, Hurskainen H, Tyynela K, Turunen M, Vanninen R, Lehtolainen P, Paljarvi L, Johansson R, Vapalahti M, YlaHerttuala S (2000) Thymidine kinase gene therapy for human malignant glioma, using replication-deficient retroviruses or adenoviruses. Hum Gene Ther 11:2197–2205 Stratmann A, Machein MR, Plate KH (1997) Anti-angiogenic gene therapy of malignant glioma. Acta Neurochir Suppl 68:105–110

347 Stupp R, Hegi ME, Mason WP, van den Bent MJ, Taphoorn MJ, Janzer RC, Ludwin SK, Allgeier A, Fisher B, Belanger K, Hau P, Brandes AA, Gijtenbeek J, Marosi C, Vecht CJ, Mokhtari K, Wesseling P, Villa S, Eisenhauer E, Gorlia T, Weller M, Lacombe D, Cairncross JG, Mirimanoff RO (2009) European Organisation for Research and Treatment of Cancer Brain Tumour and Radiation Oncology Groups and National Cancer Institute of Canada Clinical Trials Group. Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomised phase III study: 5-year analysis of the EORTC-NCIC trial. Lancet Oncol 10: 459–466 Wirth T, Hedman M, Makinen K, Manninen H, Immonen A, Vapalahti M, Yla-Herttuala S (2006) Safety profile of plasmid/liposomes and virus vectors in clinical gene therapy. Curr Drug Saf 1:253–257 Yamini B, Yu X, Pytel P, Galanopoulos N, Rawlani V, Veerapong J, Bickenbach K, Weichselbaum RR (2007) Adenovirally delivered tumor necrosis factor-alpha improves the antiglioma efficacy of concomitant radiation and temozolomide therapy. Clin Cancer Res 13: 6217–6223

Chapter 34

Fischer/F98 Glioma Model: Methodology David Fortin

Abstract Adequate animal glioma models are mandatory for the pursuit of preclinical research in neuro-oncology. Many implantation models have been described, but none perfectly emulate human malignant gliomas. This chapter reports our experience in standardizing, optimizing and characterizing the Fischer/F98 glioma model on the clinical, pathological, radiological and metabolic aspects. We specifically analyzed H&E staining and immunohistochemistry for GFAP, vimentin, albumin, TGF-b1, TGF-b2, CD3 and CD45. We also used MR imaging at 5, 10, 15 and 20 days to correlate with the clinical and pathological evolution. 18 F-FDG and 11 C-acetate PET studies for metabolic characterization of the tumors were also assessed. The standardized model described in this study behaves in a predictable and reproducible fashion, and could be considered for future pre-clinical studies by research investigators. It adequately mimics the behavior of human malignant astrocytomas. Keywords Animal model · Neuro-oncology · Fischer/F98 glioma model · Cell line · Host · Implantation

Introduction Malignant glial tumors remain a therapeutic challenge, despite many advances in the field. Most of these advances have had a minor impact on the survival of

D. Fortin () Division of Neurosurgery, Department of Surgery, Sherbrooke University, Sherbrooke, QC, Canada J1H5N4 e-mail: [email protected]

patients. Considering the aggressive nature of malignant gliomas, as well as the limited progress realized in patients outcome over the last decades, it is obvious that research endeavors shall continue unabated. In vivo preclinical studies require adequate representative models to this end. The use of animal glioma models thus remain mandatory in our pursuit of better treatment strategies, as well as a practical tool to improve our knowledge of the disease process. Many models have been developed for this purpose using different approaches. Although from a theoretical point of view, transgenic models might better emulate human tumors and present several advantages (Lampson, 2001; Peterson et al., 1994), in practice most researchers still use implantation models. This is largely attributable to their simplicity of use and relatively inexpensive cost compared to transgenic models, which require substantial resources to develop and handle (Lampson, 2001; Peterson et al., 1994). More so, to produce a representative glioma model using transgenic strategies, one would require a detailed knowledge of the different genes and genetic pathways involved in the genesis of these tumors. Although diverse genetic anomalies have been described in malignant glial tumors, these anomalies are multiple, complex and highly variables from tumor to tumor, thus rendering the use of such an approach empiric. These transgenic models are best used to study specific genotypic alterations, and their consequent role in the tumor genesis and development. To study the potency of newly designed treatment strategies, implantation models remain actual and useful. Implantation models, derived from cultured cell lines that are implanted in the brain of the target animal, are widely used (Barth, 1998; Ko et al., 1980). However, a great number of these models tend to

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neglect some essential characteristics that can limit the way they emulate the behavior of their human counterparts. The goal of any such model should be to reproduce as best as possible the clinical situation, so that conclusions derived from experiments using a given animal model is likely to be transposable to the clinic. In essence, this is the quintessential of translational research. In order to optimize glioma implantation models, some determinants should be carefully sought (Barth, 1998; Peterson et al., 1994). A close attention to details in the design of the model and in the implantation technique are paramount, and flaws should be aggressively pursued and resolved. The first point that needs to be addressed in the design of an adequate glioma implantation model is the choice of the studied cell line and the host animal.

The Choice of a Cell Line and of the Host The selection of the appropriate cell line and host animal obviously represents the first step in the design of an implantation model. As most brain tumors develop in relatively immunocompetent people, and given the fact that immune modulation is a potential therapeutic approach in the treatment of brain tumors, the neoplastic cells should be implanted in immunocompetent hosts rather than nude animals. Thus, in order to avoid any undesired immune reaction producing inherent tumor rejection, an essential quality of any implantation model is syngeneicity between the tumor cell line and the host (Barth, 1998). Nude animals will find application when working in xenogenic conditions, with human glioma cells extracted from fresh tumor samples. Another important characteristic of the selected glioma model is the presence of a relative resistance to the available treatment strategies, as are human malignant gliomas. A large number of rodent malignant glial cell lines are commercially available, and models have been described using each of them. The C6 and 9L lines are the most widely used, although both have obvious shortcomings when it comes to preclinical evaluation of therapeutic strategies. The C6 cell line is the most commonly reported model in the literature. Interestingly, it is also probably one of the most flawed model, being an infiltrative glioma which has no known syngeneic host and is usually implanted in the Wistar rat (Barth 1998; Peterson et al., 1994; Parsa et al., 2000). Immune responses

D. Fortin

potentially leading to tumor rejection and complete spontaneous tumor regression have been reported with this model (Parsa et al., 2000; Grobben et al., 2002) as it has been shown to generate important humoral and cellular immune responses after tumor implantation. Spectacular in vivo experimental results using the C6 model have not translated so far in any real therapeutic breakthrough for malignant glioma patients. Thus, the use of this model should be discouraged, as any conclusions obtained with it is subject to bias and thus hardly transferable to the clinic. The 9L cell line gives rise to sarcomatous tumors that often behave like metastatic lesions, with poor infiltration of surrounding brain parenchyma (Stojiljkovic et al., 2003). As the infiltrative behavior and the migrational potential of malignant astrocytic cells represent one of the most disconcerting phenotypical characteristics of this cancer, infiltration of adjacent brain parenchyma is expected and should be present in any model attempting to reproduce a malignant astrocytic tumor. We chose to work with the F98 cell line for several reasons. The F98 cell line is an anaplastic glioma with a minor sarcomatous component that was originally produced by a single N-ethyl-N-nitrosourea (ENU) injection to a 20-week pregnant Fischer rat (barth, 1998). The offspring developed brain tumors that were harvested and maintained in culture. Its syngeneic host is well known to be the Fischer rat (Barth, 1998). A very weak immunogenicity characterizes this line, with reports of successful short-term implantations in cat brains (Wechsler et al., 1989). It is extremely stable in culture, with no morphological changes observed in over a hundred cell passages in our laboratory. Finally, and of the outmost importance, this cell line is extremely resistant to treatment. Few treatment strategies have produced significant tumor regression when tested on this cell line after intracranial implantation in its syngeneic host, and only a few investigators have reported survival improvement using this model in preclinical therapeutic trials (Adam et al., 2003; Barth et al., 2003; Fournier et al., 2003; Mathieu et al., 2005). This aggressive behavior adequately parallels the clinical situation. The F98 cell line is an anaplastic glioma with a minor sarcomatous component depicting low immunogenicity when implanted in its syngeneic host. Consequently to their implantation, animals develop infiltrative tumors that are very resistant to conventional treatment.

34 Fischer/F98 Glioma Model: Methodology

The Implantation Technique The selected cell line should obviously be implanted in the brain of the syngeneic host. As the rat brain can only accommodate tumor of a very small caliber, some authors still use subcutaneous flank tumor implantation models. Needless to say that these models are totally incompetent to investigate glioma therapeutic strategies, as the brain microenvironment plays a fundamental role in tumor infiltration, angiogenesis and tumor growth via complex molecular interactions (Saini et al., 1999). Besides, the delivery issue cannot be addressed with flank tumor implantation. The different technical aspects leading to tumor cell implantation are all essential steps in the success of a reproducible and valid tumor model. These steps are too frequently occulted from discussion and dismissed as unimportant, with the consequence that the lack of standardization plague a great number of implantation models. As a result, different implantation coordinates are used without validation, tumor takes are highly variable, and so are tumor volumes within a given study group (Fournier et al., 2003; Peterson et al., 1994; Raila et al., 1999; Thorsen et al., 2003). Reports of free-hand implantation, as well as uncontrolled tumor cell suspension infusion are legion in the literature. Given all these variations, it can be difficult to draw reliable conclusions from therapeutic studies investigating tumor growth and/or tumor volumes. It is thus paramount to standardize all the steps involved in the elaboration of a glioma implantation model to minimize these procedural-related factors that can bias the model. The mandatory use of a stereotactic frame for the procedure cannot be overemphasized (Fig. 34.1). A freehand injection has already been reported to be inaccurate and to give rise to inconsistent tumors (Maggio, 1996), but some investigators still use this approach for their models, as illustrated by recently published work (Stojiljkovic et al., 2003). In designing the implantation procedure, the goals sought are the constant and reproducible production of tumors growing in a predictable pattern, low morbidity and no mortality for the host, and a tumor take rate of or close to 100%. The implantation technique should be relatively non traumatic, with minimal brain parenchymal damage set as a goal to reduce the associated local inflammatory reaction inherent to the implantation process. To facilitate in vivo imaging

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with noninvasive modalities such as magnetic resonance (MR) and positron emission tomography (PET), the implantation should be suitably located to avoid adjacent structures that could interfere with the tumor model imaging (e.g. Harderian glands in the rat). Very few of the current animal models described in the literature meet all these criteria. Many authors using a given rat strain use different implantation coordinates and techniques (Parsa et al., 2000). Reported tumor take is highly variable from study to study, ranging from 50 to 100% (Fournier et al., 2003; Raila et al., 1999). A considerable variation in tumor volumes can also be observed within a group of implanted animals using the same technique. A recently published study reported tumor volume after a constant observation period ranging from less than 10 mm3 to more than 80 mm3 , despite standardization in the implantation technique (Thorsen et al., 2003).

The Choice of Implantation Coordinates The choice of implantation coordinates has an obvious impact on the model, and influences all the clinical parameters of the animal. Obviously, the set of coordinates can be adjusted to suit specific objectives pursued. Usually, as the coordinates are adjusted in the rostro-caudal plane, the more caudal (or posterior) implantation will tend to produce shorter survival and precocious clinical manifestations. Typically, in brain tumor survival studies, the set of coordinates targets the area of the caudate nucleus. Although an excellent location that allows a sizeable tumor growth prior to clinical manifestations, two pitfalls should be avoided when implanting in the frontal lobe: ventricular implantation and implantation at proximity of the Harderian glands. Ventricular implantation will lead to intraventricular dissemination, and significantly shorten the lifespan of the test animal. The Harderian glands are exocrine glands located in the medial aspect of the orbit that depict a highly metabolic activity. Uptake of the [18 F]fluorodeoxyglucose used in pet scanning of the animals by the glands could potentially obscure tumor uptake thus abrogating all possibility at metabolic characterization with this tracer. When designing the initial phase of our F98-Fischer implantation model, we used a simple method to identify the ideal implantation coordinates based on Evans

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D. Fortin

Fig. 34.1 Final setup for the implantation. (a) The microinfusion pump is mounted on the stereotactic frame to allow a continuous and slow infusion rate. (b) Once again care is used in the placement of the animal’s head in the frame as even a slight sagittal mis-angulation will significantly affect the implantation

coordinates. (c) The burr hole was accomplished using a 16 gauge needle after coordinates localisation using the stereotactic frame. A 27 gauge needle is used to deliver the implantation solution

blue staining (Fig. 34.2a). This step should ideally be performed to verify the validity of selected implantation coordinates, when designing, modifying or starting to work with a new model. Using the bregma as a reference landmark, anterior (0–3 mm) and lateral (1–4 mm) coordinates were tested by intracerebral infusion of an Evans blue solution using a stereotactic frame as the targeting device. Depth of implantation was also assessed, varying from a 5 to 7 mm depth to the external table of the skull. Once the Evans blue solution had been infused, the animals were euthanized, brain specimens were harvested, cut in the coronal plane and assessed for Evans blue localization (Fig. 34.2b). The optimal implantation coordinates identified by this approach were as follow: 1 mm anterior and 3 mm lateral to the right of the bregma, with implantation solution infusion at a depth of 6 mm from the outer table of the skull. When animals are

mounted on the stereotactic frame, special care should be used in placing the head in the frame to avoid sagittal angulation, so that the head remains parallel to the frame stand. This will prevent implanting the tumor cell suspension away from the planned coordinates.

Tumor Cell Implantation Suspension Finally, the volume of implantation solution, as well as the number of cells suspended should be standardized. Serial experiments were performed in our laboratory to assess the cellular suspension characteristics that would lead to a valid and reproducible model with an optimal time-frame from implantation to death. The smallest infusion volume and the smallest number of cells were pursued, the rationale being that this would decrease the trauma associated

34 Fischer/F98 Glioma Model: Methodology

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Fig. 34.2 Localization of implantation coordinates and histopathological characerization. (a) Brain specimen harvested after implantation coordinates testing using Evans blue as a marker. The entry points are noticeable. For standardization, the stereotactic frame was used in all procedures, and great care was used to place the head of the animal in the frame in an horizontal fashion, minimizing any sagittal angulation, so that implantation coordinates would be reproducible. (b) Coronal cut of the brain showing the depth of the projected implantation coordinates and the implantation tracts. A depth of 6 mm was used on the left side, whereas a 4 mm depth was used on the right side. (c) Coronal H&E slide of a representative specimen obtained and sacrificed at 25 days post-implantation, when the animal presented a lethargic condition. Notice the large right hemispheric

tumor distorting the brain parenchyma and producing a significant midline shift. This tumor also depicts central necrosis, and peripheral brain infiltration. (d) H&E slide (40×) of a representative specimen, focusing the field of view at the periphery of the tumor nodule. Infiltration of the adjacent brain parenchyma by neoplastic cells is obvious, as is a pattern of perivascular clustering. (e) GFAP immunohistochemistry (40×) of a representative specimen. Widespread cytoplasmic staining for GFAP is obvious in numerous cells. The field of view is focused in the center of the tumor nodule. (f) Albumin immunohistochemistry (20×) of a representative specimen sacrificed at 26 days post implantation. The field of view is centered at the periphery of the main tumor nodule to emphasize the albumin staining in the region of the brain around tumor depicting BBB breakdown

to the implantation procedure, and thus the consequent inflammatory reaction. Moreover, we hypothesized that by delivering smaller volumes, we would

increase the infiltrative behavior of the tumor cells by decreasing the artifactual cavity created by the implantation. For the same reason, the use of a micro-infusion

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pump to infuse the suspension solution was introduced. Initially, manual injection of the solution was accomplished. In an effort to standardize infusion time, ensure a constant rate, and decrease the implantation traumatism, a micro-infusion pump (UltraMicroPump, World Precision Instruments Inc.) was acquired and was used to deliver the implantation solution. By allowing the slowest delivery time, we intended to decrease the risks of reflux of the solution along the implantation tract, an artifactual problem common with glioma implantation models. The following parameters were tested: volumes of 10 μL containing 5 × 105 and 2 × 105 tumor cells; volumes of 5 μL with 1 × 105 or 1 × 104 cells, and 1 μL containing 1 × 103 cells.

Final Implantation Parameters Based on the survival interval obtained after implantation and on the pathological examination of the specimens, we elected to work with a final solution concentration of 1 × 104 cells diluted in a volume of 5 μL, and delivered at a rate of 1 μL/min.

The Standardized Fisher-F98 Model Cell Line Preparation The F98 cell line was obtained from ATCC, and was grown in monolayer using a solution of Dulbecco’s modified Eagle medium (DMEM) supplemented with 10% fetal bovine serum (FBS) and a mix of penicillinstreptomycin. Cells are incubated at 37◦ C in a humidified environment with 5% CO2 and propagated upon confluence, every 3 days. The implantation solution is prepared by trypsinization of the cell culture followed by re-suspension in a DMEM solution free of FBS. Briefly, after washing twice with PBS, the adherent cell lines are detached from the Petri dishes by the addition of 1 ml of 0.05% trypsin-0.02% EDTA. The trypsin is then inactivated using 9 ml of DMEM without FBS. 1 × 104 cells are resuspended in a final volume of 5 μL of DMEM solution free of FBS. A trypan blue exclusion test is performed to assess cell viability before implantation. Typically, tumor cell viability decreases sharply 120 min. after suspension in solution.

D. Fortin

Implantation Technique Adult male Fischer rats weighting 225–250 g are used for the model. Anesthesia is induced by inhalation of a mixture of oxygen with 5% halothane, followed by an intra-peritoneal injection of ketamine (87 mg/kg) and xylazine (13 mg/kg) for maintenance. Animals are then mounted on a stereotactic frame. As mentioned previously, special care is used in the placement of the head in the frame to avoid sagittal angulation, so that the head is parallel to the frame stand (Fig. 34.1). This will prevent inadequate posterior implantation, as the head has a tendency to be tilted backward. A midline scalp incision is performed, followed by identification and exposure of the bregma. Using a 16-gauge needle, a burr hole is placed on the right frontal bone, using these coordinates: 1 mm anterior and 3 mm lateral to the right of the bregma, with implantation solution infusion at a depth of 6 mm from the outer table of the skull. A 25-μL SGF syringe with a 27-gauge needle secured to the frame is used to infuse the cellular solution over a period of 5 min. The solution is delivered at a constant rate of 1 μL per minute, using a micro-infusion pump, after which the needle is slowly withdrawn over 1 min, to minimize backflow of the suspension solution. Bone wax is applied to close the burr hole and the scalp is closed with a continuous one-layer resorbable suture.

Clinical Evolution Animals are allowed to recover from the procedure, and are given food and water ad libitum afterward. They are assessed clinically bi-daily for the apparition of signs of raised intracranial pressure (lethargy, vomiting, and cachexia) or focal neurological signs (hemiparesis, ataxia). Symptoms typically consist of progressive lethargy with variable degree of hemiplegia contralateral to the implantation side. In the later phases, ataxic irregular pattern of breathing is observed. A significant majority of test subjects lose weight over the course of their evolution, with a mean of 5.2% body weight loss. The median survival is 26 days. The implantation technique described herein depicted very low morbidity in our hands with no peri-procedural death in 58 implantations, as described

34 Fischer/F98 Glioma Model: Methodology

in our original study (Mathieu et al., 2007). Since then, more than 400 implantations have been performed in our laboratory with less than 10 procedural-related death events.

Histopathological Characterization Results presented here refer to a group of 68 animals comprised in our original study (Mathieu et al., 2007).

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Pathologic Analysis Slides were scanned at low-power magnification to identify the tumors, which were then examined at higher magnification. Tumor morphology and characteristics were assessed on H&E. The number of mitotic figures per high-power field (HPF, 40× magnification) was noted for proliferation assessment. Immunohistochemistry labeling was assessed qualitatively for GFAP, vimentin, albumin, and TGF-b, and quantitatively for CD3 and CD45 (number of labeling cells per HPF).

Immunocytochemistry Pathological Analysis Results Upon retrieval, brain specimens are fixed in a formalin solution for 48 h, cut in the coronal plane in 1 mm-width slices using a dedicated brain matrix and embedded in paraffin. The blocks are sectioned at 3 μm intervals and the resulting slides are stained with hematoxylin and eosin (H&E). After deparaffinization and dehydration, a microwave antigen retrieval process is performed. Slides are placed in 0.1 mmol/l citrate buffer in a microwaveable pressure cooker and boiled in a 700-W microwave oven for 30 min. Sections are incubated with the primary antibodies selected for study. Biotinylated species-specific secondary antibodies are applied followed by an avidin-biotin amplification and peroxides development. For this histopathological characterization, monoclonal antibody labeling was obtained for GFAP (BD bioscience, San Jose, California, dilution 1/10), vimentin (BD bioscience, San Jose, California dilution 1/100), TGF-b1 (Santa Cruz biotechnology, Santa Cruz, California, dilution 1/100), TGF-b2 (Santa Cruz biotechnology, Santa Cruz, California, dilution 1/80), albumin, CD3 (BD bioscience, San Jose, California dilution 1/175) and CD45 (BD bioscience, San Jose, California dilution 1/800). Many publications have reported the overexpression of TGF-b in malignant gliomas, with a possible role in neoplastic tumor growth, and migration (Jachimczak et al., 1996). Since the suppression of this protein is considered paramount in the research efforts of our laboratory, the characterization of its expression in this model was accomplished. CD3 and CD45 were labelled to study the presence and extent of an associated inflammatory reaction.

The specimen examination revealed the presence of a significant tumor in 68 of a total of 68 eligible animals, thus producing a tumor take of 100%. Histopathological characteristics of tumors grown from F98 cells implanted in the brain of Fischer rats have previously been described (Reifenberger et al., 1989; Seitz et al., 1988). These tumors grow by diffusely infiltrating the surrounding brain. They demonstrate extensive areas of necrosis and vascular proliferation. The findings reported in this work are entirely congruent with these descriptions. The tumors obtained with this model were large, with a central necrotic core and numerous mitotic figures, with a mean of 8 mitoses per HPF. The very high mitotic count translates the aggressiveness of this lineage. Obvious distortion in the cerebral architecture was accompanied by important brain shift and mass effect (Fig. 34.2c). Vascular proliferative changes could be observed in most specimens. Perivascular neoplastic infiltration was obvious, as was the adjacent brain parenchymal infiltration by individual tumor cells at the edge of the lesion, in all samples (Fig. 34.2d). Extention of the tumor along the implantation tract all the way to the surface of the brain, with leptomeningeal spread was rarely seen in this model, whereas it was common place when we tested solution volumes greater than 5 μL without the micro-infusion pump. GFAP immunohistochemistry confirmed that a significant proportion of the neoplastic cells were of astrocytic lineage (Fig. 34.2e). In addition, dense GFAP labeling was observed in the adjacent parenchyma surrounding the tumors in reactive astrocytes. Vimentin

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expression was diffuse in the tumor, being present in almost every tumor cells. As was previously postulated by Whittle et al., this observation probably suggests that the majority of tumor cells are neoplastic astrocytes in a dedifferentiated state, as vimentin expression is an early event in normal glial differentiation, while GFAP appears in later stages (Whittle et al., 1998). Profuse albumin immunostaining was observed in the extracellular space at the periphery of the tumors, an illustration of the pathologically increase in the bloodbrain barrier permeability (Fig. 34.2f). This reflects the fact that the blood-brain barrier is locally disrupted by the growth of the tumor, as albumin normally is only minimally present in the interstitial space of the brain, due to its large molecular weight. Indeed, albumin immunohistochemistry has been reported to be a reliable marker of blood-brain barrier integrity (Poduslo et al., 2001). When positive, labeling for CD3 cells was seen at the periphery of the tumor and around adjacent capillaries. A mean of 2.8 staining cells per HPF was observed. CD45 staining was extremely low, with only an occasional staining cell. This observation confirms the weakly immunogenic properties of the F98 cells after their implantation into the brain of the Fischer rat, and the fact that the implantation procedure did not generate a significant inflammatory reaction. This is in sharp contrast to an earlier study we led, testing the implantation of F98 cells in syngeneic (fischer) vs allogenic (Long-Evans) setting. In allogenic setting, a significant inflammatory reaction was detected (mean of 29.1 CD3 staining cell per HPF); this ultimately was associated with a tumor graft rejection, and a decrease tumor take (50% in Long-Evans, compared to 100% in Fischer) (Mathieu et al., 2005). The risk that immunologic graft rejection will produce biases when evaluating therapeutic strategies with this animal model in syngeneic setting is minimal. The importance of working in a syngeneic context cannot be over-emphasized. TGF-b1 depicted perivascular staining in the tumor nodules, especially at the periphery. Occasional individual neoplastic cells depicted cytoplasmic staining. We have also documented that F98 cells produce TGF-b1 in active isoform by rt-PCR, ELISA and western blotting. TGF-b2 has been reported as an important local immunosuppressive factor produced by malignant astrocytic cells (Maxwel et al., 1992). However, TGF-b2 staining was insignificant in this model.

D. Fortin

MRI Evaluation Using a Clinical MRI Unit The original study reporting our full characterization of the present model was accomplished prior to the acquisition of an animal high field magnet MRI unit (Blanchard et al., 2006). Thus, in vivo tumor growth was originally characterized using a clinical 1.5 T unit (Siemens 1.5T magnetom Sonata with Syngo 2002B software). To determine the optimal imaging parameters, a series of preliminary images were performed on a non implanted test animal subject. Twelve implanted rats were then randomly assigned to one of four groups, who were to be imaged at 5, 10, 15 and 20 days following tumor implantation. Procedures were performed under ketamin/xylazine anesthesia. Animals were positioned prone in the magnet, with the antenna (Siemens small loop flex coil antenna) placed directly on the head. Coronal T2-weighted images and contrast-enhanced T1-weighted images were obtained. Following the imaging procedure, the animals were immediately sacrificed. Brains were harvested and processed for H&E. To validate the MRI images, contrast-enhanced T1 images were compared with the corresponding H&E slides (Fig. 34.3). The volume and largest cross-sectional area on contrast imaging were assessed using the image-processing software Sigma Scan Pro 5 (Hallogram Publishing, Aurora, USA). Gadolinium-enhanced T1-weighted images depicted a clear brain-tumor interface in all the study specimens. Tumor progression was obvious and measurable over the study period. The average volume calculated for each time group was as follows: 6.15 mm3 ± 2.74 at 5 days, 15.9 mm3 ± 7.0 at 10 days, 59.8 mm3 ± 18.8 at 15 days and 77.0 mm3 ± 29.0 at 20 days. Comparisons of the largest radiological and pathological cross-sectional area demonstrated a parallel increase over time, although the MRI studies consistently overestimated tumor volumes. The reasons for this discrepancy are multiple: a shrinking factor produced by tissue fixation at pathology and the enhancement on MR at the brain around tumor area, related to the presence of neovascularization are the major mechanisms at play (Wree et al., 1995). Moreover, and in a distinctive behaviour observed with the pathology specimens, the growth pattern reached a treshold between day 15 and day 20. Interestingly, when results were plotted on a logarithmic scaled graphic, tumor volumes at day 5, 10

34 Fischer/F98 Glioma Model: Methodology

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Fig. 34.3 Composite picture displaying tumor progression in four animals, at 5, 10, 15 and 20 days after implantation. Top row depict coronal gadolinium-enhanced T1 MRI at 5, 10, 15 and 20 days in four different animals, whereas bottom row match the

corresponding pathology samples. The MRI adequately translates the general morphology of the tumors and progression over the observation period

and 15 depicted a near-perfect exponential relationship with a doubling time of 3.05 days. Using this function, the extrapolated initial implantation volume was estimated at 1.85 mm3 . A threshold was observed after 15 days, thus implying that tumor growth gradually decreases after day 15 post-implantation. This effect is likely related to the increase interstitial pressure in and around the tumor, and the incompetence of the vascular supply past a certain volume to accommodate tumor growth. T2-weighted images demonstrated significant peritumoral edema, with blurred tumor margins. The use of an image analysis software allowed a precise and quantitative characterization of tumor volumes, suggesting that it could be a useful adjunct method for the evaluation of the impact of a therapeutic strategy by allowing volumetric comparisons of the tumors between treatment groups in living animals.

underwent this imaging modality 14 days after the implantation. Scans were carried with the animals under general anesthesia. The animals were placed supine on the bed of the camera and kept warm with a heating pad. Prior to imaging, the camera was calibrated with a phantom filled with water containing 0.98 MBq (700 uCi) of 18 F-FDG in a volume of 22 ml. Dynamic imaging was initiated 1 min prior to injection of the isotopes, and continued for 1830 s, followed by 3 (1289 s) volumetric acquisitions. The images were reconstructed using 25 iterations of the maximum likelihood expectation maximization (ML-EM) algorithm implementing position-dependent detector response (Selivanoc et al., 2000). Isotope uptake was analyzed on the reconstructed images using the Sherbrooke LabTEP software (Benard F, Rousseau E, Sherbrooke LABTEP software, v. 1.25 release 3, November 2003). A region of interest (ROI) was drawn over the tumor and from an equivalent size ROI traced over an area of healthy brain tissue. Results were expressed as the tumor to healthy brain tissue uptake ratio. PET scanning studies demonstrated strong 18 FFDG uptake by the tumors as compared to the adjacent brain parenchyma. Harderian glands also demonstrated a significant uptake of the radiotracer, showing the importance of tumor implantation at a distance from those glands. Fortunately, harderian glands uptake did not obscure neoplastic uptake in such a way as to hinder adequate delineation of the tumors, as we took

Metabolic Evaluation Metabolic evaluation of the model was carried out by 18F-FDG and 11 C-acetate positron emission tomography (PET) scanning. The Sherbrooke small animal PET scanner (based on avalanche photodiode detectors) was used to acquire the images over the whole brain (Lecomte et al., 1994). With proper sampling motion, this scanner achieves 2.1 mm FWHM transaxial and 14 μL volumetric resolution. Two animals

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great care in the establishment of our implantation coordinates to implant at a significant distance from these glands. These results are consistent with the extremely malignant behavior of the model, as FDGPET has been demonstrated to be a reliable prognostic tool for pathology and survival in human low and high grade astrocytomas (Padma et al., 2003). Tumor-tobrain uptake ratio increased over time after the isotope injection, which reflects the normal clearance of the isotope from the brain, and selective sequestration in tumor cells. For 11 C-acetate, no difference in uptake between tumor and surrounding brain was observed. Radiotracer uptake ratio was 1.12 for 11 C-acetate, and 1.71 and 1.97 for 18 F-FDG at 30 and 50 min postinjection, respectively. Therefore, 11 C-acetate was not considered suitable for metabolic evaluation of the F98-Fischer model.

Conclusion Animal models are necessary for the preclinical evaluation of antitumoral therapeutic strategies. The syngeneic Fischer/F98 rat glioma model described in this work adequately mimics the clinical and pathological behaviour of human high-grade astrocytic tumors. Careful and systematic implantation techniques, and the use of a stereotactic apparatus and micro-infusion pump, contribute to produce a predictive and constant growth pattern that allows an accurate assessment of treatment. The use of the micro-infusion pump allows delivery of the implantation solution at a constant flow, thus minimizing local tissue trauma at the time of infusion. We believe that a meticulous attention to all the steps involved in the implantation is important, as the accuracy and reproducibility of the model is at stake. Ultimately, results of therapeutic experiments will be biased if the model is inadequate. Using the parameters evoked in this chapter, a median survival of 26 days is obtained, with a gradual, constant and predictable growth in tumors as documented pathologically and radiologically. This survival length is ideal for therapeutic trials as it allows a sufficient time-window to treat the animals, and the effect of treatment can be recognized soon enough by using prolongation of survival as a surrogate. Moreover, magnetic resonance imaging and PET imaging studies can easily be accomplished to complement the clinical and pathological

D. Fortin

data and generate a thorough evaluation and understanding in the tumor growth of the model, whether it is for the purpose of a therapeutic trial or for detailed characterization.

References Adam JF, Elleaume H, Joubert A, Biston MC, Charvet AM, Balosso J (2003) Synchrotron radiation therapy of malignant brain glioma loaded with an Iodinated contrast agent: first trial on rats bearing F98 gliomas. Int J Radiat Oncol Biol Phys 57:1413–1426 Barth RF (1998) Rat brain tumor models in experimental neurooncology. The 9L, C6, T9, F98, RG2(D74), RT-2 and CNS-1 gliomas. J Neurooncol 36:91–102 Barth RF, Yang W, Coderre JA (2003) Rat brain tumor models to assess the efficacy of boron neutron capture therapy: a critical evaluation. J Neurooncol 62:61–74 Blanchard J, Mathieu D, Patenaude Y, Fortin D (2006) MRpathological comparison in F98-Fischer glioma model using a human gantry. Can J Neurol Sci 33:86–91 Fournier E, Passirani C, Montero-Menei C, Colin N, Breton P, Sagodira S, Menei P, Benoit JP (2003) Therapeutic effectiveness of novel 5-fluorouracil-loaded poly (methylidene malonate 2.1.2)-based microspheres on F98 glioma-bearing rats. Cancer 97:2822–2829 Grobben B, De Deyn PP, Slegers H (2002) Rat C6 glioma as experimental model system for the study of glioblastoma growth and invasion. Cell Tissue Res 310:257–270 Jachimczak P, Hessdorfer B, Fabel-Schulte K, Wismeth C, Brysch W, Schlingensiepen KH (1996) Transforming growth factor-beta-mediated autocrine growth regulation of gliomas as detected with phosphorothioate antisense oligonucleotides. Int J Cancer 65:332–337 Ko L, Koestner A, Wechsler W (1980) Morphological characterization of nitrosourea-induced glioma cell lines and clones. Acta Neuropathol 51:23–31 Lampson LA (2001) New animal models to probe brain tumor biology, therapy, and immunotherapy: advantages and remaining concerns. J Neurooncol 53:275–287 Lecomte R, Cadorette J, Richard P, Rodrigue S, Rouleau D (1994) Design and engineering aspects of a high resolution positron tomograph for small animal imaging. IEEE Trans Nucl Sci 41:1446–1452 Maggio WW (1996) Rodent glioma models. Methods Neurosci 30:81–96 Mathieu D, Lamarche J, Fortin D (2005) The importance of a syngeneic glioma implantation model: comparison of the F98 cell line in Fischer and Long-Evans rats. J Appl Res 5:17–25 Mathieu D, Lecomte R, Tsanaclis AM, Larouche A, Fortin D (2007) Standardization and detailed characterization of the syngeneic fischer/F98 glioma model. CJNS 34:296–306 Maxwell M, Galanopoulos T, Neville-Golden J, Antoniades HN (1992) Effect of the expression of transforming growth factor-beta 2 in primary human glioblastomas on immunosuppression and loss of immune surveillance. J Neurosurg 76:799–804

34 Fischer/F98 Glioma Model: Methodology Padma MV, Said S, Jacobs M, Hwang DR, Dunigan K, Satter M, Christian B, Ruppert J, Bernstein T, Kraus G, Mantil JC (2003) Prediction of pathology and survival by FDG PET in gliomas. J Neurooncol 64:227–237 Parsa AT, Chakrabarti I, Hurley PT, Chi JH, Hall JS, Kaiser MG, Bruce JN (2000) Limitations of the C6/Wistar rat Intracerebral glioma model: implications for evaluating immunotherapy. Neurosurgery 47:993–1000 Peterson DL, Sheridan PJ, Brown E W Jr (1994) Animal models for brain tumors: historical perspectives and future directions. J Neurosurg 80:865–876 Poduslo JF, Curran GL, Wengenack TM, Malester B, Duff K (2001) Permeability of proteins at the blood-brain barrier in the normal adult mouse and double transgenic mouse model of Alzheimer’s disease. Neurobiol Dis 8:555–567 Raila FA, Bowles AP, Perkins E, Terrell A (1999) Sequential imaging and volumetric analysis of an intracerebral C6 glioma by means of a clinical MRI system. J Neurooncol 43:11–17 Reifenberger G, Bilzer T, Seitz RJ„ Wechsler W (1989) Expression of vimentin and glial fibrillary acidic protein in ethylnitrosourea-induced rat gliomas and glioma cell lines. Acta Neuropathol 78:270–282 Saini M, Bellinzona M, Meyer F, Cali’ G, Samii M (1999) Morphometrical characterization of two glioma models in the brain of immunocompetent and immunodeficient rats. J Neurooncol 42:59–67

359 Seitz RJ, Deckert M, Wechsler W (1988) Vascularization of syngenic intracerebral RG2 and F98 rat transplantation tumors. A histochemical and morphometric study by use of ricinus communis agglutinin I. Acta Neuropathol 76: 599–605 Selivanoc V, Picard Y, Cadorette J, Rodrigue S, Lecomte R (2000) Detector response models for statistical iterative image reconstruction in high resolution PET. IEEE Trans Nucl Sci 47:1168–1175 Stojiljkovic M, Piperski V, Dacevic M, Rakic L, Ruzdijic S, Kanazir S (2003) Characterization of 9L glioma model of the Wistar rat. J Neurooncol 63:1–7 Thorsen F, Ersland L, Nordli H, Enger PO, Huszthy PC, Lundervold A, Standnes T, Bjerkvig R, Lund-Johansen M (2003) Imaging of experimental rat gliomas using a clinical MR scanner. J Neurooncol 63:225–231 Wechsler W, Szymas J, Bilzer T, Hossmann KA (1989) Experimental transplantation gliomas in the adult cat brain. 1.Experimental model and neuropathology. Acta Neurochir 98:77–89 Whittle IR, Macarthur DC, Malcolm GP, Li M, Washington K, Ironside JK (1998) Can experimental models of rodent implantation glioma be improved? A study of pure and mixed glioma cell line tumours. J Neurooncol 36:231–242 Wree A, Goller HJ, Beck T (1995) Local cerebral glucose utilization in perfusion-fixed rat brains. J Neurosci Methods 58:143–149

Chapter 35

Cellular and Molecular Characterization of Anti-VEGF and IL-6 Therapy in Experimental Glioma Sophie Javerzat and Martin Hagedorn

Abstract Vascular endothelial growth factor (VEGF) and interleukin 6 (IL6) play central roles in various angiogenesis-dependent diseases, including malignant brain tumors. VEGF-blocking agents are increasingly used against glioblastoma, but the potential of IL6 pathway inhibition is little explored in this pathology. Here we resume recent work performed in our recently developed experimental glioma model grown on the chick chorio-allantoic membrane (CAM) showing that (1) VEGF-inhibition leads to avascular tumors which up-regulate genes associated with poor survival in glioblastoma patients, (2) single inhibition of VEGF or IL6 is equally effective in regard to angiogenesis inhibition, activates different molecular responses in tumor cells but increases invasion and (3) combined inhibition of IL6 and VEGF prevents tumor development without inducing invasion. Different treatment and transcriptomic profiling strategies are discussed with emphasis to alternative tumor models such as the chicken CAM experimental glioma. Keywords VEGF · Interleukin 6 · Gene profiling · Chick embryo · CAM · Anti-angiogenic therapies

Introduction The capability of a growing cancer to attract new blood vessels from the host (angiogenesis) is one of

M. Hagedorn () INSERM U1029, Université Bordeaux 1, F-33405, Talence, Cedex, France e-mail: [email protected]

the essential features of human tumor progression (Hanahan and Weinberg, 2000). Blocking angiogenesis has now become a validated treatment paradigm to increase efficacy of standard chemotherapy. Vascular endothelial growth factor (VEGF) and its receptors KDR (kinase insert domain receptor; also called VEGFR-1), FLT1 and FLT4 (fms-related tyrosine kinase 1 and 4; VEGFR-2 and -3) are central modulators of blood vessel growth and key targets of current anti-angiogenic drugs. VEGF blockage is sufficient to delay or inhibit tumor growth as well as formation of metastasis in various animal models (Cheng et al., 1996; Inoue et al., 2002). Inhibition of VEGF also leads to tumor regression of established tumors in mice (Huang et al., 2003) and to reduction of angiogenesis in human rectal carcinoma (Willett et al., 2004). However, targeting only one angiogenic factor might not be sufficient to cure. There is evidence that impairing two or more anti-angiogenic pathways in a combinational therapy setting is more efficient than monotherapy (Jendreyko et al., 2005; Saidi et al., 2009; Strieth et al., 2006). Indeed, tumors may switch on alternative pro-angiogenic pathways such as fibroblast growth factor (FGF) and bypass the need for VEGF signaling (Casanovas et al., 2005), for review see (Ferrara, 2010). Severe hypoxia caused by angiogenesis inhibitors may increase malignant potential of cancer cells leading to tumor persistence or increased vessel co-option and invasion (Kunkel et al., 2001; Niola et al., 2006). It is therefore of importance to comprehend how tumor cells react to different anti-angiogenic therapies on a molecular level. Such information should be useful to design novel inhibitors of individual molecules, which are involved in anti-angiogenesis resistance. Here, we describe an experimental system, which

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_35, © Springer Science+Business Media B.V. 2011

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allows to selectively study gene regulation in glioma cells in response to anti-angiogenic mono (VEGF or IL6) and combo (VEGF+IL6) therapy.

The Experimental Glioma Model in the Chick Embryo: A Tool for Gene Profiling Studies Most existing in vivo GBM models are based on inoculation of glioma cells into rodent brains (Dai and Holland, 2001) or the use of transgenic mice with modified expression of tumor suppressors or oncogenes in glial cell lineages (Holland et al., 2000; Reilly et al., 2000). However, rodent models require stereo-tactical equipment, specific surgical techniques, costly animal housing and raise ethical concerns. We have developed an alternative experimental glioma model based on grafting of the U87 glioma cell line on the chick chorio-allantoic membrane (CAM). The chorionic epithelium of the CAM constitutes a natural barrier, which generally is difficult to penetrate for tumor cells. However, a high number of tumor cells (3–5 million/CAM) and gentle laceration of the CAM surface allow reproducible tumor development (Hagedorn et al., 2005). Furthermore, tumor cells are placed in a plastic ring, which restricts displacement of the cell suspension during movements of the embryo. The implantation of tumor cells is generally done on day 10 of embryonic development, when the CAM has reached a sufficient size, making displacement of the plastic ring a rare occurrence. Developing tumors can be examined on a daily basis and are well vascularized 4 days after implantation (see Fig. 35.1a). Experimental tumors reproducibly form in a VEGFdependent manner, and recapitulate key morphological features of glioblastoma in patients such as hemorrhage, necrosis and angiogenesis. On a molecular level, newly formed chick blood vessels inside the tumor become positive for VEGFR-2 from the second day on, as evidenced by in situ hybridization using a probe for the avian VEGFR-2 homolog Quek2 (Hagedorn et al., 2005). A typical experimental glioma 4 days after implantation is shown in Fig. 35.1b (left panel). The rapid development of experimental glioma on the CAM and the close resemblance to important histopathological events observed in patients suggest that growth may be accompanied by pertinent changes

S. Javerzat and M. Hagedorn

in gene expression pattern. An advantage of the model is a perfect visual control of the tumor material used for gene expression studies. The tumor is excised in vivo under a bio-microscope using sterile scissors and immediately placed in liquid nitrogen. This eliminates contamination with adjacent, non-relevant tissue, which is a major point if tumor material needs to be analyzed by sensitive molecular biology methods such as semi-quantitative real-time PCR or microarrays. Experimental gliomas are hybrid tissues, composed of human tumor cells and chicken host cells, including, but not limited to endothelial cells, pericytes and immune cells. Using species-specific GeneChips, it is therefore possible to selectively study gene regulation of one or the other compartment (host vs. tumor cells). This approach maximizes the chance to identify genes, which are specifically regulated in tumor cells in response to anti-angiogenic treatments. On the other hand, if one is interested in the molecular reaction of the stroma during tumor progression, the use of the chicken GeneChips helps to focus on these genes (Dumartin et al., 2010). To illustrate the discrimination level of species-specific microarrays, we mixed human mRNA isolated from U87 cells with increasing amounts of chicken mRNA isolated from the CAM. These mixtures (ratios indicated as percent in the figure legend) were then hybridized in parallel on human and chicken Affymetrix GeneChips (Fig. 35.1c). Chicken CAM mRNA on a human chip hybridizes to less than 5% of the probes representing human genes. The same result was obtained when U87 mRNA was incubated with the chicken GeneChip. We estimate the amount of chick tissue (mainly blood vessels) accounts for about 10% of the tumor mass in the experimental glioma. We therefore also tested different ratios of human and chick mRNA on the two chips, keeping the amount of total mRNA constant. When chick and human mRNA mixes were hybridized on the human chip, the percentage of significantly detected transcripts decreases in a dose-dependent manner. The more chick mRNA was present in the mix, the less positive detection on the human chip occurred. This shows that chick mRNA does not hybridize to the human chip in a non-specific manner. As expected, increasing quantity of human mRNA in the mixture decreases detection if hybridized on the chicken chips. These results demonstrate that species-specific gene expression changes can be detected in this system. The experimental glioma model on the CAM thus allows

35 Cellular and Molecular Characterization of Anti-VEGF and IL-6 Therapy

A

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Timeline of a typical experiment Tumor angiogenesis Transfection/ transduction of tumor cells

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Fig. 35.1 (a) Typical set-up of an experimental glioma experiment on the CAM. On embryonic day 10, cells are implanted on the CAM. The cell suspension reforms a tumor, which starts to acquire blood vessels approximately 24–48 h after implantation. Tumors can be treated from the second day on and photographed in vivo. At day 4, tumors can be isolated for histology or gene profiling studies. Alternatively, the tumor can be let grown until day 7, when the experiments needs to be ended due to the near hatching of the chick embryo. (b) Typical results after 4 days of growth. Control tumors show strong angiogenic response, already visible by slight magnification, whereas

anti-VEGF tumors are small and appear white, due to the near absence of blood vessels. (c) Advantage of the chick glioma model for gene profiling studies. The experimental glioma is a hybrid tissue, containing both mRNAs regulated in the human cells as well as angiogenic blood vessels from the chick. Chick and human mRNAs isolated were mixed at indicated ratios and hybridized in parallel on both chip types. Note low significant detection of chick mRNA on the human chip (arrow) and vice versa. Hybridization occurs in a dose-dependent manner, in a similar manner on both chips (C=chick mRNA, H=human mRNA)

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fast and precise analysis on the cellular and molecular level of major steps of human GBM progression and response to different treatment with new anti-cancer drugs.

Interfering with Angiogenic Regulators in the Experimental Glioma: The Example of VEGF To simulate a defined anti-angiogenic setting in our model, we transfected U87 glioma cells with shortinterfering RNAs (siRNAs) targeting all isoforms of VEGFA. Efficacy of siRNAs has been evaluated in vitro using semi-quantitative real-time PCR and commercially available ELISAs. siRNA-mediated blocking of VEGF has initially been chosen to circumvent problems related to drug delivery and control of doses in the chick system. However, more recent results in our laboratory have shown that Avastin at daily topical administration of 100 μg per CAM results in strong reduction of tumor growth and vascularization, comparable to siRNA-mediated effects (Fig. 35.1b). Intriguingly, small tumors still formed albeit of a whitish appearance as evidenced by biomicroscopy (Fig. 35.1b). Histological analysis revealed that VEGF knock down leads to almost complete absence of functional blood vessels inside experimental glioma. However, although siRNA-mediated knock down of VEGF is extremely efficient and varies few within one experiment, some heterogeneity in the degree of response may occur. Over the years, we observed slight differences in the phenotypes depending on the time, ranging from series of tumors with no blood vessels at all to tumors with some residual vessels. These differences are most likely due to the variable genetic background of chick embryos.

Gene Profiling of Anti-Angiogenic Therapy: A Glimpse of Resistance The fact that glioma cells are still able to survive on the CAM after VEGF withdrawal and form little

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avascular tumors, suggests that angiogenesisindependent tumor growth has taken place. Tumor cells growing in such conditions are often exposed to metabolic stress such as hypoxia, lack of serum and other nutrients. Hypoxia will drive cancer cells to adapt to this unfavorable environment and eventually become more aggressive. On a molecular level, this means over expression of genes, which render tumor cells resistant to apoptosis and resistant to radiotherapy (Jensen, 2009; Knisely and Rockwell, 2002). To get more insight into the genes over expressed in these “resistant” tumors, we undertook a simple gene profiling experiment where a pool of typical avascular glioma under VEGF knockdown (VEGF-KD) was compared to a pool of control tumors (Saidi et al., 2008). We then investigated whether genes induced in VEGF-KD tumors could be related to disease aggressiveness. Several results support this hypothesis. IL1B, CHI3L2 and PI3 (encoding for interleukin 1 beta, chitinase 3-like 2 and elafin, respectively) were significantly co-regulated with CHI3L1 encoding YKL-40, a known marker for disease progression (Pelloski et al., 2005) in a cohort of patient glioblastoma, suggesting functional linkage of these factors. More, CHI3L1, CHI3L2, IL1B and PI3 were significantly over expressed in high-grade glioma (grade IV, glioblastoma) compared to grade II astrocytoma (Fig. 35.2a). Most important, high PI3 mRNA levels were significantly associated with shorter survival in our patient cohort (Fig. 35.2b). Immunhistochemical detection of elafin protein could be found in hypoxic areas in gliobastoma sections from patients (Fig. 35.2c, d), but was not present in low-grade glioma (Fig. 35.2e). The linkage between metabolic stress and PI3 gene expression could also be evidenced in vitro: both, hypoxia and low-serum induced PI3 mRNA in U87 cells, up to 30-fold. Very recently, a link between elafin expression and poor prognosis has also been validated in ovarian cancer (Clauss et al., 2010). This simple experiment gives a snapshot of molecular adaptation of glioma cells exposed to anti-VEGF. Genes induced in this condition are potentially mediators of disease progression, as they are associated with higher tumor grade and worse prognosis.

35 Cellular and Molecular Characterization of Anti-VEGF and IL-6 Therapy

Fig. 35.2 (a) mRNA levels of selected genes in GBM (n=42, except for PI3, n=38) and low-grade (LG) glioma (n=10, except for CHI3L1 n=9 and PI3, n=8) were compared using the MannWhitney U-test. Medians of mRNA levels for CHI3L1, CHI3L2, IL1B and PI3 differed significantly between GBMs and LG glioma. (b) High levels of PI3 (encoding elafin) are significantly associated with poor survival as determined by analysis of Kaplan and Meier survival curves. Three censored subjects are

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indicated by symbols. (c–e) Immunohistochemistry with antielafin antibody in GBMs. Elafin-positive tumor cells are mainly seen around necrotic areas (N), no staining is observed in lowgrade gliomas (original magnification: A and B ×100, C–E ×400). (f) Malignant glioma cells in vitro strongly expressed PI3/elafin 24 and 48 h after serum deprivation or exposure to hypoxia (Mean ± SD)

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Pre-clinical Evaluation of New Candidates and Combined Therapies in the Experimental Glioma As discussed above, RNA interference directed against VEGF models anti-angiogenesis in the experimental glioma and allows evaluating tumor response both at the morphological and molecular level. If a particular gene needs to be studied more in detail, it may be preferable to create stably transduced cells with lentiviral vectors carrying siRNA precursors. It is however advisable to first test transiently transfected cells and evaluate phenotypes. In our hands, both methods show comparable knock down efficacies in regard to transcript reduction. Vectorization may be an advantage for cost purposes when many different assays with the same interfering RNA are required. RNA interference in the experimental glioma model is ideal for investigating alternative tumor-specific targets. Another group has successfully demonstrated inhibition of tumor growth and angiogenesis using siRNAs against OPN (osteopontin) or HDAC4 (Lamour V et al., 2010, Mottet et al., 2009). We chose interleukin-6 as a potential candidate to be evaluated in the model. Inhibition of the IL-6 pathway is already broadly explored in chronic inflammatory diseases such as rheumatoid arthritis. Several lines of evidence suggest that interfering with IL-6 may be a promising rationale for anti-glioma therapy. Mice expressing GFAP-v-src fail to develop glioma on an IL6–/– background (Weissenberger et al., 2004). Patient glioma produce large amounts of interleukin6 in culture and in vivo (Van Meir et al., 1990), its expression is significantly higher in patients with poor prognosis and amplification of the IL6 locus is associated with shorter survival (Chang et al., 2005; Tchirkov et al., 2001). At some point the IL-6 and VEGF axis converge in glioma cells, as interleukin-6 stimulates VEGF production in vitro and in vivo via the signal transducer and activator of transcription 3 (STAT3) pathway (Loeffler et al., 2005). The experimental glioma on the CAM is particularly suited to challenge IL6 dependent pathways, as U87 cells positively regulate the transcription of the IL6 gene when the tumor switches to the angiogenic phenotype (Hagedorn et al., 2005). Because VEGF and IL6 cross-regulate each other while functioning independently, inhibiting one pathway at a time

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or both together can give valuable information on a possible synergistic antitumoral effect. We showed that knock down of each of the gene reduces corresponding transcripts in the experimental tumor with >95% efficiency and also observed cross-inhibiton at around 50%. Combined knock down resulted in tumors with hardly detectable amounts of VEGF and IL6. On a morphological level, combined inhibition of IL6 and VEGF is significantly more efficient than single inhibition as evidenced by reduced size, proliferation and neovascularization of the tumors. This comparative analysis can be easily led on significant numbers of tumors (n>20 per group) providing robust quantitative data. On the left panel of Fig. 35.3, we show an example of vascular changes to different treatments. In anti-IL6 or anti-VEGF conditions alone a similar reduction in tumor angiogenesis can be observed, compared to control tumors. Combinatory treatment completely inhibits vascularization of the tumors. Interestingly, the experimental glioma allows investigating invasive properties that may be enhanced under anti-angiogenic treatment, a feature that neurooncologists are particularly sensitized to when treating glioma patients with Avastin (de Groot et al., 2010). In control glioma, tumor cells are rarely detected at distance from the primary implantation site in the supporting CAM. Under metabolic/hypoxic stress induced by IL6 or VEGF knockdown, tumor cells invade the CAM tissue (Fig. 35.3 right panels), with a 3–4 fold increase in the number of tumor cells detected in the CAM. Different modes of invasion can be observed. In the anti-VEGF condition, cells invade in a collective manner, whereas IL6 knock down mostly induces single-cell spreading. In combined treated tumors, the invasive phenotype was significantly reduced, to a similar degree as seen in controls. These results have been confirmed in an orthotopic mouse glioma model. The experimental glioma is a fast, cost-effective alternative to screen different combination of inhibitors, including siRNAs for their effect on standard tumor parameters such as angiogenesis, but also recapitulates biological phenomena observed in mammalian brains such as induction of infiltration after treatment with single angiogenesis inhibitors.

35 Cellular and Molecular Characterization of Anti-VEGF and IL-6 Therapy

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Fig. 35.3 Left panel: representative illustrations of angiogenic and invasive phenotypes revealed by triple immunofluorescence staining (blue: DAPI; red: anti-vimentin; green: SNA-lectin; scale bar left panels = 50 μm; right panels = 100 μm). Note that control tumors are characterized by the presence of a dense immature vascular network. Knockdown of IL6 and/or VEGF strongly decreases tumor vascularization and combined knockdown is even more efficient at reducing vascular density. Right

panel: invasive behavior of tumor cells in the CAM. Sections of tumor and surrounding CAM tissue 7 days after implantation were stained with DAPI (blue) and anti-vimentin (red). A representative field of the margin between tumor (asterisk) and the CAM (dashed line) is shown. Both, anti-IL6 and antiVEGF cause increased invasion in the CAM stroma, whereas IL6/VEGF combined knockdown cells barely invade the CAM

Exploring Molecular Pathways Associated with Inhibition

tissue than murine models and cross hybridization between chicken and human sequences is negligible (see Fig. 35.1c). Tumors with or without treatment (single or double knock down) harbored a specific gene signature. As the phenotypes of anti-VEGF and antiIL6 treated tumors are very similar, with an equivalent reduction in tumor volume and vascularization, and

As detailed previously, the CAM experimental glioma is well suited to perform comparative gene profiling as it allows more precise isolation of tumor

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the two induced pathways are partially overlapping, highlighting differences at the level of the molecular responses may be predictive for a better therapeutic outcome. For instance there were twice as many genes down regulated in anti-IL6 tumors compared to antiVEGF tumors. In addition and as anticipated from the small volumes of the tumors, we found out that the cell cycle machinery is severely affected when both VEGF and IL6 pathways are inhibited. Around 25 positive regulators of mitosis and 10 major components of chromatin assembly (mainly histone subunits) are significantly down regulated in the combined treatment. Interestingly, many genes involved in invasion were over expressed in tumors after single inhibition, but were strongly inhibited when VEGF and IL6 were inhibited. Amongst those factors, CXCL12/SDF1 (Tu et al., 2009) and PDPLN (Wicki and Christofori, 2007) merit further investigation as potential markers of poor prognosis and inducers of invasive behavior glioma cells. We showed that the experimental glioma on the CAM allows to predict the efficiency (reduction of tumor growth) and adverse effect (induction of invasiveness) of anti-VEGF and anti-IL6 pathways inhibitors. Humanized antibodies specifically raised against Interleukin-6 receptor are available and used in the clinic for rheumatoid arthritis (Tocilizumab, Actemra, Roche) but no trials have yet been engaged to estimate anti-glioma effects of this new drug. We are currently investigating effects on tumor progression and infiltration of a combination of Avastin and Tocilizumab in mouse glioma models.

Future Directions The experimental glioma model is a useful tool to predict treatment efficacy of new anti-angiogenic drugs and to validate new targets. An advantage of the model is fast development of tumors and the possibility to visually evaluate treatment efficacy. There are a growing number of humanized antibodies, aptamers and small molecules inhibitors of pro-angiogenic key factors. It will therefore be of interest to test different combinations of these drugs to find a treatment paradigm that efficiently blocks tumor vascularization and invasion at the lowest dose possible. This combination is likely to give similar results in other

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pre-clinical models and ultimately may be of benefit for glioblastoma patients. The experimental glioma model on the CAM might considerably speed up the search for efficient anti-glioma treatments. Acknowledgements This work was supported La Ligue Contre le Cancer, Comitée de la Dordogne (to SJ) and l’Agence Nationale de la Recherche, ANR (“Glioma Model”, JC05_0060, to MH).

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35 Cellular and Molecular Characterization of Anti-VEGF and IL-6 Therapy J, Yancopoulos GD, Yamashiro DJ, Kandel JJ (2003) Regression of established tumors and metastases by potent vascular endothelial growth factor blockade. Proc Natl Acad Sci USA 100:7785–7790 Inoue M, Hager JH, Ferrara N, Gerber HP, Hanahan D (2002) VEGF-A has a critical, nonredundant role in angiogenic switching and pancreatic beta cell carcinogenesis. Cancer Cell 1:193–202 Jendreyko N, Popkov M, Rader C, Barbas CF 3rd (2005) Phenotypic knockout of VEGF-R2 and Tie-2 with an intradiabody reduces tumor growth and angiogenesis in vivo. Proc Natl Acad Sci USA 102:8293–8298 Jensen RL (2009) Brain tumor hypoxia: tumorigenesis, angiogenesis, imaging, pseudoprogression, and as a therapeutic target. J Neurooncol 92:317–335 Knisely JP, Rockwell S (2002) Importance of hypoxia in the biology and treatment of brain tumors. Neuroimaging Clin N Am 12:525–536 Kunkel P, Ulbricht U, Bohlen P, Brockmann MA, Fillbrandt R, Stavrou D, Westphal M, Lamszus K (2001) Inhibition of glioma angiogenesis and growth in vivo by systemic treatment with a monoclonal antibody against vascular endothelial growth factor receptor-2. Cancer Res 61: 6624–6628 Lamour V, Le Mercier M, Lefranc F, Hagedorn M, Javerzat S, Bikfalvi A, Kiss R, Castronovo V, Bellahcene A (2010) Selective osteopontin knockdown exerts anti-tumoral activity in a human glioblastoma model. Int J Cancer 126: 1797–1805 Loeffler S, Fayard B, Weis J, Weissenberger J (2005) Interleukin-6 induces transcriptional activation of vascular endothelial growth factor (VEGF) in astrocytes in vivo and regulates VEGF promoter activity in glioblastoma cells via direct interaction between STAT3 and Sp1. Int J Cancer 115:202–213 Mottet D, Pirotte S, Lamour V, Hagedorn M, Javerzat S, Bikfalvi A, Bellahcene A, Verdin E, Castronovo V (2009) HDAC4 represses p21(WAF1/Cip1) expression in human cancer cells through a Sp1-dependent, p53-independent mechanism. Oncogene 28:243–256 Niola F, Evangelisti C, Campagnolo L, Massalini S, Bue MC, Mangiola A, Masotti A, Maira G, Farace MG, Ciafre SA (2006) A plasmid-encoded VEGF siRNA reduces glioblastoma angiogenesis and its combination with interleukin-4 blocks tumor growth in a xenograft mouse model. Cancer Biol Ther 5:174–179

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Pelloski CE, Mahajan A, Maor M, Chang EL, Woo S, Gilbert M, Colman H, Yang H, Ledoux A, Blair H, Passe S, Jenkins RB, Aldape KD (2005) YKL-40 expression is associated with poorer response to radiation and shorter overall survival in glioblastoma. Clin Cancer Res 11:3326–3334 Reilly KM, Loisel DA, Bronson RT, McLaughlin ME, Jacks T (2000) Nf1; Trp53 mutant mice develop glioblastoma with evidence of strain-specific effects. Nat Genet 26:109–113 Saidi A, Hagedorn M, Allain N, Verpelli C, Sala C, Bello L, Bikfalvi A, Javerzat S (2009) Combined targeting of interleukin-6 and vascular endothelial growth factor potently inhibits glioma growth and invasiveness. Int J Cancer 125:1054–1064 Saidi A, Javerzat S, Bellahcene A, De Vos J, Bello L, Castronovo V, Deprez M, Loiseau H, Bikfalvi A, Hagedorn M (2008) Experimental anti-angiogenesis causes upregulation of genes associated with poor survival in glioblastoma. Int J Cancer 122:2187–2198 Strieth S, Eichhorn ME, Sutter A, Jonczyk A, Berghaus A, Dellian M (2006) Antiangiogenic combination tumor therapy blocking alpha(v)-integrins and VEGF-receptor-2 increases therapeutic effects in vivo. Int J Cancer 119:423–431 Tchirkov A, Rolhion C, Bertrand S, Dore JF, Dubost JJ, Verrelle P (2001) IL-6 gene amplification and expression in human glioblastomas. Br J Cancer 85:518–522 Tu H, Zhou Z, Liang Q, Li Z, Li D, Qing J, Wang H, Zhang L (2009) CXCR4 and SDF-1 production are stimulated by hepatocyte growth factor and promote glioma cell invasion. Onkologie 32:331–336 Van Meir E, Sawamura Y, Diserens AC, Hamou MF, de Tribolet N (1990) Human glioblastoma cells release interleukin 6 in vivo and in vitro. Cancer Res 50:6683–6688 Weissenberger J, Loeffler S, Kappeler A, Kopf M, Lukes A, Afanasieva TA, Aguzzi A, Weis J (2004) IL-6 is required for glioma development in a mouse model. Oncogene 23: 3308–3316 Wicki A, Christofori G (2007) The potential role of podoplanin in tumour invasion. Br J Cancer 96:1–5 Willett CG, Boucher Y, di Tomaso E, Duda DG, Munn LL, Tong RT, Chung DC, Sahani DV, Kalva SP, Kozin SV, Mino M, Cohen KS, Scadden DT, Hartford AC, Fischman AJ, Clark JW, Ryan DP, Zhu AX, Blaszkowsky LS, Chen HX, Shellito PC, Lauwers GY, Jain RK (2004) Direct evidence that the VEGF-specific antibody bevacizumab has antivascular effects in human rectal cancer. Nat Med 10:145–147

Chapter 36

Adult Brainstem Gliomas: Diagnosis and Treatment Florence Laigle-Donadey and Jean-Yves Delattre

Abstract Adult brainstem gliomas constitute a heterogeneous group of tumors. A better radiological analysis of these tumors will improve their classification and help to better distinguish prognosis subgroups. New MRI techniques may also contribute to differential diagnosis and help neurosurgeons in removing resectable brainstem tumors. However, biopsy remains indicated in many contrast enhancing brainstem masses in adults because of the great variety of differential diagnosis. Conventional radiotherapy is the standard of care of brainstem glioma and chemotherapy has been disappointing to date. Given the lack of efficacy of conventional drugs, a better understanding of the biology of this tumor is the key to develop targeted therapy. In the future, advances in diagnostic and treatment modalities will probably result in improvement in the pattern of care of brainstem gliomas which remain now associated with a poor prognosis. Keywords Brainstem gliomas · MRI techniques · Differential diagnosis · Exophytic gliomas · Drugs · Radiotherapy

F. Laigle-Donadey () Service de Neurologie Mazarin, Hôpital de la Pitié-Salpêtrière – APHP, 75651 Paris Cedex 13, France e-mail: [email protected]

Introduction Brainstem tumors occur in a region located between the mesencephalon and the medulla. This definition excludes patients with tumors originating in the thalamus and hypothalamus, or lesions originating from the cerebellum, cerebellar peduncles, upper cervical spinal cord, as well as tumors arising from ventricles. “Brainstem glioma” is the most frequent tumor of the region but it constitutes a heterogeneous group of tumors with variable prognoses. A bimodal age distribution has been noted, allowing a clear distinction between BS gliomas in children and adults that differ in their clinical and radiological presentation, histology, biological behaviour, and clinical course. This chapter will focus on adult BS gliomas which is a rare disease. Indeed, in contrast with in children, where brainstem tumors are frequent, accounting for approximately 10–20% of all pediatric CNS tumors, brainstem gliomas are much less frequent in adults, accounting for 2–2.5% of all intracranial tumors in adults (White, 1963). As for children, tissue confirmation is frequently not feasible unless an exophytic component exists, because of the risks associated with direct histologic examination (Packer et al., 1985) and their classification relies mainly on clinical presentation and MRI characteristics (Guillamo et al., 2001a). A striking difference between adults and children is the better prognosis of the “diffuse intrinsic form” in adults (Landolfi et al., 1998; Selvapandian et al., 1999; Guillamo et al., 2001a).

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_36, © Springer Science+Business Media B.V. 2011

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“Diffuse Intrinsic” or “Diffusely Infiltrative Low Grade” Brainstem Gliomas Epidemiology Diffuse intrinsic brainstem gliomas represent the most frequent type of brainstem glioma in adults, accounting for 45–50% of cases (Guillamo et al., 2001a; Salmaggi et al., 2008). These tumors usually occur in young patients, between the age of 20 and 30 years.

Pathology Biopsy is rarely performed in typical intrinsic diffuse low-grade glioma in adults. When a biopsy is performed, a benign histology (grade II glioma) is found in up to 82% of cases in adults, in contrast with children (Guillamo et al., 2001a, b) which is a likely explanation for the better survival of the diffuse intrinsic form in adults (Guillamo et al., 2001a; Salmaggi et al., 2008). For this reason, Guillamo et al. suggest that this subgroup of tumor should be named “diffuse intrinsic low-grade brainstem gliomas” in adults. However, adult patients can rarely present a rapidly growing tumor similar to diffuse intrinsic BSG of children (Guillamo et al., 2001a).

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pseudomyasthenic presentation (Dirr et al., 1989), as well as orthostatic hypotension (Hsu et al., 1984).

Radiological Presentation MRI reveals a pattern similar to the pattern observed in children with a diffuse enlargement of the brainstem, with high signal on T2-weighted images and low signal on T1-weighted images, located in the pons (70%) or in the medulla (30%). The lesion does not enhance after contrast infusion (Freeman and Farmer, 1998; Guillamo et al., 2001b). MRS showed an elevation of the Cho/NAA ratio at diagnosis in all nine patients from a cohort that was investigated with MRS (Fig. 36.1) (Salmaggi et al., 2008).

Treatment Neurosurgery Biopsy is rarely performed in typical intrinsic diffuse low-grade glioma in adults (Guillamo et al., 2001b). However, this remains a matter of debate. Some authors consider that guided stereotactic biopsy

Clinical Presentation Despite this histological difference, there are no major differences in clinical presentation between adults and children (Selvapandian et al., 1999), except for a longer duration of symptoms and signs in adults, (Landolfi et al., 1998; Selvapandian et al., 1999). Patients typically present with a long-lasting history of facial palsy. Facial myokymia (Selvapandian et al., 1999), as well as hemifacial spasm (Elgamal and Coakham, 2005) may occur. Other symptoms rarely described include snoring associated with Ondine’s curse in the case of medulla oblongata glioma (Marin-Sanabria et al., 2006), central neurogenic hyperventilation (Gaviani et al., 2005), tongue tremor (Saka et al., 2006), visual auras and migraine (Lim et al., 2005),

Fig. 36.1 Axial flair MR in a 35 year-old patient presenting with diplopia. Note diffuse swelling and increased signal intensity due to intrinsic pontine glioma

36 Adult Brainstem Gliomas: Diagnosis and Treatment

is relatively “safe” and believe that an accurate diagnosis should be obtained in all cases and not only when atypical clinical or imaging features suggesting a non-neoplastic lesion (Thomas et al., 1988). Resection of intrinsic diffuse brainstem tumors remains impossible despite technical advances (Tanaka et al., 2005; Mursch et al., 2005). A stereotaxic approach can be a rapid and safe method for evacuation of the contents of cysts (Thomas et al., 1988; Rajshekhar and Chandy, 1995), providing neurological benefit in most cases. A stereotactic placement of an Ommaya reservoir after reaccumulation of the cyst can also be performed. Patients with hydrocephalus may require ventriculostomy or ventriculoperitoneal shunting for symptomatic relief. Radiotherapy Focal radiotherapy is the standard treatment for adult brainstem gliomas and can improve or stabilize patients for years. The conventional dose of radiotherapy ranges from 54 to 60 Gy. Diffuse intrinsic brainstem glioma seems to be more responsive to radiotherapy in adults than in children. However there is an important discrepancy between the clinical and the radiological response. In one series, a majority of patients (62%) clinically improved for a “long” period (over 6 months) after radiotherapy while radiological response was noted in only 19% of cases (Guillamo et al., 2001a). The optimal date of treatment remains unknown. Indeed, some patients may have mild symptoms during extended periods without any treatment, suggesting that radiotherapy may sometimes be deferred until clear evidence of symptomatic tumor progression (Guillamo et al., 2001a).

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radiological result in one case report of progressive diffuse BS glioma treated with bevacizumab and irinotecan (Torcuator et al., 2009). Symptomatic Treatment Patients with difficulties in swallowing may need gastrostomy, such as percutaneous esophagogastrostomy. Steroids are frequently administered to brainstem tumor patients. However, they should be used sparingly, at the lowest necessary dosage, because of their numerous side effects.

Follow-up The frequently indolent growth pattern of the intrinsic form in adults contrasts with the natural history of this disease in children and is likely related to a lower grade of the tumors. Median survival of diffuse intrinsic lowgrade gliomas in adults is 7.3 years, as compared to less than 1 year in children. Two recent retrospective studies have evaluated the characteristics from adult BSGs. In an American cohort including 101 adult patients, the overall survival at 5 and 10 years was 58 and 41%, respectively, with a median survival of 85 months (range 1–228) (Kesari et al., 2008). In an Italian cohort of 34 adult patients, the median overall survival was 59 months (Salmaggi et al., 2008). However, it is worth noting that rarely some adult patients can present with a rapidly growing tumor similar to children with diffuse intrinsic brainstem glioma (Guillamo et al., 2001a).

Malignant Brainstem Gliomas Epidemiology

Chemotherapy Efficacy of chemotherapy in adult brainstem gliomas remains unproven and adjuvant chemotherapy cannot be currently recommended. Moreover, the effectiveness of chemotherapy on relapse is uncertain, although it may benefit some patients, sometimes with a frank clinical improvement contrasting with a lack of radiological response. The role of new therapies such as anti-angiogenic drugs need to be defined in this case. Torcuator et al. reported an interesting clinical and

Malignant brainstem glioma accounts for 31–39% of adults with BSG (Guillamo et al., 2001a; Salmaggi et al., 2008) and appear in older patients, usually after the age of 40.

Pathology Histological examination shows high-grade (III, IV) gliomas in all cases.

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Clinical Presentation The clinical history is subacute, consisting of cranial palsies and long tract signs, rapidly leading to an altered performance status.

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Careful systemic and neurologic work up usually leads to the correct diagnosis. However, a biopsy should be considered in many contrast enhancing brainstem masses when this work up is not conclusive (Abernathey et al., 1989; Rajshekhar and Chandy, 1995).

Radiological Presentation Treatment Contrast enhancement was found in 100% of cases upon initial MRI in Guillamo’s series, and often exhibited a ring-like pattern (Guillamo et al., 2001a), suggesting central necrosis. However, the radiological picture of malignant BS glioma is non specific and justifies histological confirmation in most cases. In previous studies, preoperative radiological diagnoses were found to be incorrect in 10–25% of cases in patients over 20 years of age who presented with a contrast enhancing lesion in the brainstem (Fig. 36.2) (Rajshekhar and Chandy, 1995; Boviatsis et al., 2003).

Differential Diagnoses The differential diagnosis of malignant brainstem gliomas is often difficult and includes many various diseases (Table 36.1).

Fig. 36.2 Axial T1-weighted MR after gadolinium infusion in an adult patient with an exophytic brainstem glioma showing post gadolinium enhancement

Surgery In order to avoid the complications of an empiric and inappropriate therapy, biopsy is indicated in many contrast enhancing brainstem masses because the histological variety is much more important in adults than in childhood (see paragraph above) (Abernathey et al., 1989; Kratimenos and Thomas, 1993; GoncalvesFerreira et al., 2003; Shad et al., 2005). Moreover, a benign, non-neoplastic pathology was diagnosed in 13–17% of adults with a suspected malignant brainstem mass (Rajshekhar and Chandy, 1995). Although it is difficult to estimate, the risk of severe complications of a stereotactic biopsy for a suspected malignant brainstem glioma is considered to be low (probably between 1 and 5.6%) (Rajshekhar and Chandy, 1995; Boviatsis et al., 2003). Usually, the lower the lesion is located in the brainstem, the greater the risks involved. Operative mortality is exceedingly rare (Thomas et al., 1988; Kratimenos and Thomas, 1993; Boviatsis et al., 2003). Morbidity is usually minimal and temporary, consisting of transient neurological deterioration (Kratimenos and Thomas, 1993; Goncalves-Ferreira et al., 2003), or obstructive hydrocephalus. Permanent neurological deficit was estimated to occur in about 1.4% in Rajshekhar’s series (Rajshekhar and Chandy, 1995) and some patients required early re-aspiration of a haematoma (Kratimenos and Thomas, 1993). The optimal method and routes of biopsy are controversial (Abernathey et al., 1989; Kratimenos and Thomas, 1993; Goncalves-Ferreira et al., 2003). CT-or MRI-guided stereotactic surgery of the brainstem appears safe and reliable (Rajshekhar and Chandy, 1995; Massager et al., 2000; Boviatsis et al., 2003). PET-scan may be helpful (Massager et al., 2000). Biopsy provides a high yield of positive histological diagnosis, estimated in the literature around

36 Adult Brainstem Gliomas: Diagnosis and Treatment

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Table 36.1 Main differential diagnoses of malignant brainstem gliomas Other tumors

Infections

Vascular processes

• Metastasis (Friedman et al., 1989) • Lymphoma (Friedman et al., 1989; Goncalves-Ferreira et al., 2003) • Germinoma and other intracranial germ cell tumors (Friedman et al., 1989) • Ganglioglioma (Goncalves-Ferreira et al., 2003) • Ependymoma (Abernathey et al., 1989) • Dysembryoplastic neuroepithelial tumor (Fujimoto et al., 2000) • Chordoma (Friedman et al., 1989) • Neurocytoma (Swinson et al., 2006) • Dermoid and epidermoid cysts (Rajshekhar and Chandy, 1995) • Cystic trochlear nerve neurinoma (Shenoy and Raja, 2004) • Acoustic neuroma (Yousry et al., 2004)

• Tuberculomas (Rajshekhar and Chandy, 1995) • Toxoplasmosis (Goncalves-Ferreira et al., 2003) • Pyogenic abscess (Rajshekhar and Chandy, 1995) • Aspergillus abscess (Goncalves-Ferreira et al., 2003) • Cryptococcal abscess (Abernathey et al., 1989)

• Haematomas, vasculitis (Goncalves-Ferreira et al., 2003) • Arteriovenous malformations (Abernathey et al., 1989), especially intracranial dural arteriovenous fistula (Crum and Link, 2004) and cavernous angiomas • Hypertensive encephalopathy (Jurcic et al., 2004) • Infarctions (Abernathey et al., 1989) • Radionecrosis (Abernathey et al., 1989)

95% (Thomas et al., 1988; Abernathey et al., 1989; Kratimenos and Thomas, 1993; Massager et al., 2000).

Inflammations and systemic diseases • Neuro behçet (Ben Taarit et al., 2002), • Sarcoidosis (Goncalves-Ferreira et al., 2003), • Progressive multifocal leukencephalopathy (Friedman et al., 1989; Goncalves-Ferreira et al., 2003), • Demyelinating disease (Abernathey et al., 1989; Goncalves-Ferreira et al., 2003)

overlap between adults and children. They include focal tectal gliomas (8%), cystic pilocytic astrocytoma and exophytic posterior glioma.

Radiotherapy These malignant tumors are highly resistant to treatment by radiotherapy. Indeed, after radiotherapy, only 13% of patients showed clinical and radiological improvement (Guillamo et al., 2001a). Gamma Knife radiosurgery has been recently used in some cases of brainstem gliomas, sometimes with satisfying functional outcome (Fuchs et al., 2002), although it seems to be ineffective in other cases. Chemotherapy Chemotherapy has been occasionally used in this subgroup of tumors but data are too scant to draw any recommendation on this issue. Follow-up The overall prognosis remains very poor despite radiotherapy and chemotherapy, with a median survival about 11.2 months (Guillamo et al., 2001a) and 25 months (Salmaggi et al., 2008). The other types of BS tumors identified in the adult do not seem to differ from pediatric types, suggesting

Focal Tectal Brainstem Gliomas Epidemiology Focal tectal gliomas constitute a small subgroup in adults (8% of cases).

Pathology Histopathology, in the few cases where it could be obtained, most often reveals a grade II oligoastrocytoma (Guillamo et al., 2001a). However, some cases of pilocytic astrocytomas have been described. A few cases of glioblastoma have also been reported in this location with an aggressive course.

Clinical and Radiological Presentation Focal tectal glioma usually presents with obstructive hydrocephalus, as in children. They may rarely present with intracranial hemorrhage, which should be removed.

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Treatment and Follow-up These lesions are associated with long survival (sometimes exceeding 10 years) following ventriculoperitoneal shunting and usually focal radiotherapy (Chamberlain, 1999). Since simple observation after shunting may be an appropriate option in children, the decision to treat adult patients with radiotherapy is also questionable to some authors (Guillamo et al., 2001a), who propose a similar approach in adults.

F. Laigle-Donadey and J.-Y. Delattre

progress has been made. In this group, advances in treatment will require a better knowledge of the biology of these tumors, and innovative approaches, possibly based on the analysis of the molecular profile of the tumor. Experimental animal models of BSG and preclinical human studies to investigate intratumoral drug treatment as well as promising new agents, such as signal transduction inhibitors, are actively being studied in children (Fouladi et al., 2007; Pollack et al., 2007) and could secondly benefit to adult patients. Finally, the criteria to evaluate tumor response during therapy of BSG remain unclear and require novel approaches.

Posterior Exophytic Gliomas Exophytic contrast-enhancing glioma, which is well known in children (up to 10% of cases) and is associated with a good prognosis, is extremely rare in adults, maybe because most exophytic gliomas are pilocytic astrocytomas, a rare tumor type in adults (Guillamo et al., 2001a). A case report of exophytic pontine glioma simulating acoustic neurinoma has been reported in an adult patient (Swaroop and Whittle, 1997). Surgical resection is reserved for such patients with specific tumoral locations as dorsal exophytic tumors protruding into the fourth ventricle. Improvement in neurosurgical techniques (particularly the use of intraoperative ultrasound, intraoperative neurophysiological mapping and computer reconstruction techniques) has facilitated partial resection of tumors previously considered as inoperable (Tanaka et al., 2005), or even gross total removal in some cases, without affecting the functional prognosis.

Brainstem Gliomas Associated with Neurofibromatosis Type 1 Data regarding brainstem glioma associated with NF1 in adult patients are too scarce to draw conclusions, but these tumors may be more aggressive in adults than in children (Guillamo et al., 2001a).

Conclusion In conclusion, despite improvements in the understanding and classification of BSGs, the primary challenge remains diffuse BSG of adults where little

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36 Adult Brainstem Gliomas: Diagnosis and Treatment Gaviani P, Gonzalez RG, Zhu JJ, Batchelor TT, Henson JW (2005) Central neurogenic hyperventilation and lactate production in brainstem glioma. Neurology 64:166–167 Goncalves-Ferreira AJ, Herculano-Carvalho M, Pimentel J (2003) Stereotactic biopsies of focal brainstem lesions. Surg Neurol 60:311–320 Guillamo JS, Doz F, Delattre JY (2001b) Brain stem gliomas. Curr Opin Neurol 14:711–715 Guillamo JS, Monjour A, Taillandier L, Devaux B, Varlet P, Haie-Meder C, Defer GL, Maison P, Mazeron JJ, Cornu P, Delattre JY, Association des Neuro-Oncologues d’Expression Francaise (ANOCEF) (2001a) Brainstem gliomas in adults: prognostic factors and classification. Brain 124:2528–2539 Hsu CY, Hogan EL, Wingfield W Jr, Webb JG, Perot PL Jr, Privitera PJ, Talbert OR, Balentine JD (1984) Orthostatic hypotension with brainstem tumors. Neurology 34:1137–1143 Jurcic V, Ferluga D, Jeruc J, Pogacnik T, Popovic M (2004) Hypertensive encephalopathy mimicking brainstem tumour in psychiatric patient. Folia Neuropathol 42:37–41 Kesari S, Kim RS, Markos V, Drappatz J, Wen PY, Pruitt AA (2008) Prognostic factors in adult brainstem gliomas: a multicenter, retrospective analysis of 101 cases. J Neurooncol 88:175–183 Kratimenos GP, Thomas DG (1993) The role of image-directed biopsy in the diagnosis and management of brainstem lesions. Br J Neurosurg 7:155–164 Landolfi JC, Thaler HT, DeAngelis LM (1998) Adult brainstem gliomas. Neurology 51:1136–1139 Lim EC, Wilder-Smith EP, Chong JL, Wong MC (2005) Seeing the light: brainstem glioma causing visual auras and migraine. Cephalalgia 25:154–156 Marin-Sanabria EA, Kobayashi N, Miyake S, Kohmura E (2006) Snoring associated with Ondine’s curse in a patient with brainstem glioma. J Clin Neurosci 13:370–373 Massager N, David P, Goldman S, Pirotte B, Wikler D, Salmon I, Nagy N, Brotchi J, Levivier M (2000) Combined magnetic resonance imaging- and positron emission tomographyguided stereotactic biopsy in brainstem mass lesions: diagnostic yield in a series of 30 patients. J Neurosurg 93:951–957 Mursch K, Halatsch ME, Markakis E, Behnke-Mursch J (2005) Intrinsic brainstem tumours in adults: results of microneurosurgical treatment of 16 consecutive patients. Br J Neurosurg 19:128–136 Packer RJ, Zimmerman RA, Luerssen TG, Sutton LN, Bilaniuk LT, Bruce DA, Schut L (1985) Brainstem gliomas of childhood: magnetic resonance imaging. Neurology 35:397–401 Pollack IF, Jakacki RI, Blaney SM, Hancock ML, Kieran MW, Phillips P, Kun LE, Friedman H, Packer R, Banerjee A,

377 Geyer JR, Goldman S, Poussaint TY, Krasin MJ, Wang Y, Hayes M, Murgo A, Weiner S, Boyett JM (2007) Phase I trial of imatinib in children with newly diagnosed brainstem and recurrent malignant gliomas: a Pediatric Brain Tumor Consortium report. Neuro Oncol 9:145–160 Rajshekhar V, Chandy MJ (1995) Computerized tomographyguided stereotactic surgery for brainstem masses: a riskbenefit analysis in 71 patients. J Neurosurg 82:976–981 Saka E, Ozkaynak S, Tuncer R (2006) Tongue tremor in brainstem pilocytic astrocytoma. J Clin Neurosci 13:503–506 Salmaggi A, Fariselli L, Milanesi I, Lamperti E, Silvani A, Bizzi A, Maccagnano E, Trevisan E, Laguzzi E, Rudà R, Boiardi A, Soffietti R., Associazione Italiana di Neurooncologia (2008) Natural history and management of brainstem gliomas in adults. A retrospective Italian study. J Neurol 255:171–177 Selvapandian S, Rajshekhar V, Chandy MJ (1999) Brainstem glioma: comparative study of clinico-radiological presentation, pathology and outcome in children and adults. Acta Neurochir (Wien) 141:721–727 Shad A, Green A, Bojanic S, Aziz T (2005) Awake stereotactic biopsy of brain stem lesions: technique and results. Acta Neurochir (Wien) 147:47–49 Shenoy SN, Raja A (2004) Cystic trochlear nerve neurinoma mimicking intrinsic brainstem tumour. Br J Neurosurg 18:183–186 Swaroop GR, Whittle IR (1997) Exophytic pontine glioblastoma mimicking acoustic neuroma. J Neurosurg Sci 41: 409–411 Swinson BM, Friedman WA, Yachnis AT (2006) Pontine atypical neurocytoma: case report. Neurosurgery 58:E990 Tanaka S, Kobayashi I, Utsuki S, Iwamoto K, Takanashi J (2005) Biopsy of brain stem glioma using motor-evoked potential mapping by direct peduncular stimulation and individual adjuvant therapy. Case report. Neurol Med Chir (Tokyo) 45:49–55 Thomas DG, Bradford R, Gill S, Davis CH (1988) Computerdirected stereotactic biopsy of intrinsic brain stem lesions. Br J Neurosurg 2:235–240 Torcuator R, Zuniga R, Loutfi R, Mikkelsen T (2009) Bevacizumab and irinotecan treatment for progressive diffuse brainstem glioma: case report. J Neurooncol 93: 409–412 White HH (1963) Brain stem tumors occurring in adults. Neurology 13:292–300 Yousry I, Muacevic A, Olteanu-Nerbe V, Naidich TP, Yousry TA (2004) Exophytic pilocytic astrocytoma of the brain stem in an adult with encasement of the caudal cranial nerve complex (IX–XII): presurgical anatomical neuroimaging using MRI. Eur Radiol 14:1169–1173

Chapter 37

The Use of Low Molecular Weight Heparin in the Treatment and Prevention of Thromboembolic Disease in Glioma Patients Bo H. Chao and H. Ian Robins

Abstract The neuro-oncologist routinely deals with an extraordinarily high risk patient population relative to thromboembolic disease. With the advent of easily accessible diagnostic studies, e.g., ultrasound and/or spiral CT scans, timely diagnosis of venous thromboembolic events (VTE) is readily accomplished. The introduction of low molecular weight heparin (LMWH) about 20 years ago (in contrast to unfractionated heparin and vitamin K antagonists) has provided a class of agents with a favorable therapeutic index. In the review to follow, the literature regarding the use of LMWH in neuro-oncology patient populations is summarized. Topics addressed include prophylaxis, treatment, as well as consideration of the potential anti-neoplastic properties of these drugs. Keywords Low molecular Thromboembolic disease · Prophylaxis · Antagonist

weight Glioma

heparin · VTE

· ·

Introduction It is well recognized that cancer patients in general (Shlebak and Smith, 1997), and in particular glioma patients are highly predisposed to thromboembolic phenomena (Sawaya and Highsmith, 1988; Marras et al., 2000). Brisman and Mendell (1973) demonstrated an 8.4% incidence of pulmonary emboli in glioma patients; this represents a three fold increase H.I. Robins () Department of Medicine, Human Oncology, and Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA e-mail: [email protected]

in the incidence seen in non-malignant neurosurgical patients. Similarly, the incidence of deep vein thromboembolism (DVT) in such patients is 27.5% compared to 17% in a control neurosurgical group (Kayser-Gatchalian and Kayser, 1975). Ruff and Posner (1983) noted a 31% incidence of confirmed DVT in 264 glioma patients. Quevedo et al. (1994) noted an incidence of 28% of thromboembolism in a series of 64 high grade glioma patients. Sawaya et al. (1992), using I-fibrinogen scanning, demonstrated DVTs in 60% of glioblastoma multiforme (GBM) patients; the presence of venous thromboembolic events (VTE) did not correlate with ambulatory status, time of surgery, length of operation, or occurrence in a paretic limb. Sawaya and Highsmith (1992) have suggested that malignant brain tumors release a factor responsible for this predisposition to coagulopathy. Previous work suggesting increased platelet adhesiveness in malignant brain tumors is consistent with this supposition (Nathanson and Savitsky, 1952; Millac, 1967). More recent work by Iberti et al. (1994) and Hamilton et al. (1994) supports the concept of an increased coagulable state of brain tumor patients. Coupled to this significant morbidity is the potential risk for the central nervous system hemorrhage when anti-coagulants are used as a therapeutic intervention and/or prophylaxis. In the text to follow we will discuss the existing data for the treatment and prophylaxis of thromboembolic disease in glioma patients. The review will focus on the use of low molecular weight heparin (LMWH), as the published literature and experience center on this class of anti-coagulants relative to both safety and efficacy. Encompassed in this discussion will be a review of the data suggesting the potential for anti-neoplastic effects with the application of LMWH.

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_37, © Springer Science+Business Media B.V. 2011

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Low Molecular Weight Heparin as Treatment for Thromboembolic Disease Based on randomized clinical studies, LMWH is the agent of choice for the initial and long term treatment of VTE in patients with neoplastic disease (Lee, 2009; Lyman et al., 2007). The cumulative risk of symptomatic and recurrent VTE during 6 months of anticoagulation was 17% for patients treated with a vitamin K antagonist, such as warfarin or acenocoumarol, compared with 9% for patients treated with dalteparin, a LMWH (Lee et al., 2003). The relative risk reduction of 52% was statistically significant (hazard ratio = 0.48; P = 0.002). One episode of recurrent VTE is prevented for every 13 patients treated with dalteparin. Regarding side effects, no difference in major or minor bleeding was detected between the groups, with 6% of dalteparin-treated patients and 4% of control patients having major bleeding episodes (Lee et al., 2003). There were no confirmed cases of heparin-induced thrombocytopenia, and patient compliance with selfinjection in these studies was good (Deitcher et al., 2006; Meyer et al., 2002; Lee et al., 2003; Hull et al., 2006). Comparing to unfractionated heparin, LMWH reduces the risk of recurrent thrombosis by 32%, major bleeding by 43%, and death by 24%, according to a Cochrane systemic review summarizing 22 clinical trials (van Dongen et al., 2004). LMWH is the preferred agent for treatment of cancer-associated thrombosis because of its efficacy, safety, and convenience. In the aforementioned studies in a general population of cancer patients with VTE, dalteparin was given at full therapeutic dose of 200 U/kg once daily for a month, followed by dose reduction down to 75% of the full dose for the remainder of the 6-month period (Lee et al., 2003). It should be noted that the concept of a 25% dose reduction after initial therapy was an arbitrary choice, and not evaluated in comparison to other possibilities. Other studies used full therapeutic dose of enoxaparin for 3 months (Deitcher et al., 2006; Meyer et al., 2002). However, in patients with GBM, because of a higher risk of bleeding, we typically treat VTE in GBM patients with full dose LMWH until resolutions of symptoms from their thrombosis, usually within 2 weeks of onset of VTE, followed by 50% dose reduction in the following month, and followed by another 25% dose reduction after 2–3 months. We recommend dividing the total daily dose during the acute phase

B.H. Chao and H.I. Robins

of treatment into twice-a-day dosing to reduce bleeding risk. If the GBM patient develops recurrent VTE during dose reduction of LMWH, we would check the antifactor Xa levels 4 h after an injection and adjust the dose accordingly. There has not been a trial to evaluate this treatment algorithm; it has been used at our center since the introduction of LMWH with an estimated incidence of recurrent VTE less than 5%. This use of a lower dose of LMWH post acute treatment is consistent with the efficacy of LMWH in the prophylaxis setting and had evolved as a conceptual extrapolation. It has been our practice to continue LMWH indefinitely in high grade glioma patients based on the experience in a Eastern Cooperative Oncology Group (ECOG)/Radiation Therapy Oncology Group (RTOG) trial, described in detail in section “Anti-neoplastic Effects of Low Molecular Weight Heparin” below (Robins et al., 2008). Patients who are on LMWH for protracted periods of time are at risk for osteoporosis, (and often have another risk factor for bone demineralization, i.e., steroids). We suggest monitoring such patients with bone mineral density studies, and considering interventions such as bisphosphonates as appropriate. It should be noted that fondaparinux, a synthetic selective inhibitor of activated factor X (with no activity against thrombin), is approved for the initial therapy of VTE (Buller et al., 2004). In terms of administration, convenience, and cost, it is comparable to LMWH. Similar to LMWH, it is contraindicated in patients with significant renal insufficiency. However, it has not been studied in cancer patients. Hence its use in cancer patients is generally limited in those who have allergies to heparin or a history of heparin-induced thrombocytopenia (Lee, 2009). The role of vena cava filters in the treatment of VTE in cancer patients remains undefined as previously reviewed (Lee, 2009). Filters do not treat the underlying hypercoagulable state in cancer patients. The use of filters in patients receiving anticoagulation led to a reduction in symptomatic pulmonary embolism, but more recurrent DVTs and no difference in overall survival (Investigators, 2005). It is our view that the use of filters should be reserved for situations in which anticoagulant therapy is contraindicated, e.g., active bleeding, severe thrombocytopenia, or in preparation for a significant neurosurgical intervention.

37 LMWH in the Treatment and Prevention of Thromboembolic Disease in Glioma Patients

Low Molecular Weight Heparin as Prophylaxis for Thromboembolic Disease As discussed in section “Introduction”, glioma patients are highly predisposed to thromboembolic phenomena with an incidence approaching ~30%. In a phase II study in patients with newly diagnosed glioblastoma multiforme (GBM), patients were given dalteparin 5000 units during and post radiation, as described in detail in section “Anti-neoplastic Effects of LMWH” below (Robins et al., 2008). The primary endpoint was survival, and the secondary end point was the incidence of VTE. This study closed prematurely with only 42 patients accrued due to a change in standard of care for GBM. As the study was conceived it was estimated that over the course of the study, 30% of the enrolled patients would develop a VTE over the entire time course of their disease. With a planned cohort of 72 patients, there was 81% power to detect a decrease from 30 to 15% in VTE using a two-sided 0.05 exact test for a single proportion. In the end the study observed no VTE in patients actively receiving dalteparin. Time on dalteparin ranged from 1.2 to 25.4 months, with a median time of 6.3 months. There were no reports of grade 3/4 bleeding or thrombocytopenia related to dalteparin pre or post progression. There were local site reactions to dalteparin in up to 71% of patients; two patients experienced grade 3 toxicities ascribed to radiation. Two patients developed DVT after stopping dalteparin when they developed progressive GBM. A seemingly contradictory result in the context of a phase III Canadian study was later reported at American Society of Clinical Oncology annual meeting in 2007 (Perry et al., 2007b), and was updated later in the year at another meeting (Perry et al., 2007a). This trial was planned to enroll 512 patients; it closed prematurely, secondary to lack of drug availability, with 186 malignant glioma patients randomized to dalteparin 5000 units daily versus placebo. The primary endpoint was the development of VTE. Although there was a trend for LMWH to decrease VTE, it was not statistically significant (HR = 0.65, 95% CI: 0.27–1.54, p = 0.33). However, the hazard ratio was impressive at 0.65 in favor of the LMWH arm. It remains speculative whether this hazard ratio would have achieved statistical significance if the study had met its accrual

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objective. There was also a trend for increased bleeding in the LMWH arm 5.1% (n = 5) versus 1.2% (n = 1). These authors in commenting on the “trend toward increased intracranial bleeding” noted “the clinical significance of this is unclear since intratumoral hemorrhage is sometimes part of the natural history of this disease” (Perry et al., 2007a). Potential noteworthy differences in these studies may relate to patient populations. The RTOG study was restricted to a GBM cohort (as opposed to all malignant glioma), as well as a requirement for an unusually good performance status, i.e., 95% ECOG performance status of 0 or 1. To date a final published report regarding the Canadian study has not become available. At present, we agree with the authors of both of these individual studies: The results of these studies taken collectively leave the role of anticoagulant in thromboembolic prophylaxis as unclear for this group of patients. Definitive conclusions regarding the application of VTE prophylaxis strategies will require further investigation. There have, however, been studies of VTE prophylaxis after elective neurosurgery in patients with brain tumors, including but not exclusive to glioma. Two multi-center, randomized, double-blind trials studied the use of LMWH (nadroparin 7500 units subcutaneously once daily, or enoxaparin 40 mg subcutaneously once daily, respectively) versus placebo in conjunction with the use of compression stockings in the prevention of VTE after elective neurosurgery (Nurmohamed et al., 1996; Agnelli et al., 1998). The majority of the accrued patients had brain tumors, up to 30% of whom were diagnosed with glioma (Agnelli et al., 1998). LMWH or placebo was given within 24 h after surgery and continued for up to 10 days or until hospital discharge. Both studies showed that LMWH combined with compression stockings is more effective than compression stockings alone for the prevention of VTE after elective neurosurgery, without inducing any significant increase of major bleeding. The absolute risk reduction of VTE in patients receiving LMWH was 8 and 14%, whereas the absolute risk reduction of proximal VTE or pulmonary embolism in patients receiving LMWH was 4 and 8%, respectively (Nurmohamed et al., 1996; Agnelli et al., 1998). However, it should be noted that LMWH in these studies was given within 24 h after surgery. Another randomized study conducted at the University of Michigan, where LMWH (enoxaparin

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30 mg subcutaneously every 12 h) was initiated before the induction of anesthesia and was continued throughout the hospital stay, showed that enoxaparin therapy initiated at the time of anesthesia induction significantly increased postoperative intracranial hemorrhage (Dickinson et al., 1998). This study was terminated early because of the increased incidence of adverse events in the enoxaparin treatment group. In conclusion, LMWH given within 24 h after neurosurgery, but not prior to neurosurgery, in combination with compression stockings, is effective for the prevention of VTE in glioma patients. However, the role of VTE prophylaxis beyond the postoperative period after hospital discharge is yet to be determined and still requires further studies.

Anti-neoplastic Effects of Low Molecular Weight Heparin The genesis of a clinical study to test the antineoplastic proprieties of LMWH in GBM patients occurred when investigators anecdotally noted usually good outcome in high grade glioma patients who were receiving LMWH for DVT. In reviewing the literature, a meta-analysis was identified that suggested a reduced mortality in cancer patients receiving LMWH compared with patients receiving standard heparin; further, this benefit was not consequent to a reduced thromboembolism rate (Siragusa, 1996). Additionally, a potential mechanistic basis for this was identified: (i) anti-angiogenesis (Folkman et al., 1983; Norrby 1993), (ii) effects on cellular matrix (Bitan et al., 1995; Collen et al., 2000), and (iii) reduced cell proliferation (Castellot et al., 1986). In this regard, it is of interest to note that based on preclinical studies, anti-angiogenesis agents can putatively serve as radiosensitizers (Teicher et al., 1995; Wachsberger et al., 2003). Also, a preclinical study linked up-regulated tissue factor expression by epidermal growth factor receptor (EGFR) and EGFRvIII and the prothrombotic events that occur in the progression of GBM (Rong et al., 2006). As GBM is among the most vascular of all neoplasms, abundantly expressing vascular endothelial growth factor and platelet-derived growth factor (Dunn et al., 2004), the use of LMWH as a therapeutic adjunct to radiotherapy was viewed as worthy of clinical testing.

B.H. Chao and H.I. Robins

Taking aforementioned considerations into account, the ECOG in cooperation with the RTOG initiated a phase II study of the effect of dalteparin during and post radiation in newly diagnosed patients with GBM (Robins et al., 2008): Dalteparin of 5000 units daily was given subcutaneously with and after conventional radiotherapy to newly diagnosed GBM patients. Forty-five patients were accrued. The study was designed such that at time of progression, patients could continue dalteparin in addition to standard regimens. Pretreatment characteristics included: Median age 61 (range 26–78); ECOG Performance status: 0 = 38%, 1 = 57%, 2 = 5%; gross total resection 45%. There were no grade 3/4 bleeding or thrombocytopenic events, and no VTE occurred while patients were on dalteparin. Median time on dalteparin was 6.3 months, median time to progression was 3.9 months; median survival was 11.9 months. There was no significant improvement in survival when compared to the RTOG GBM database (with various radiation/drug doublets including BCNU) using recursive partitioning analysis (RPA) (Curran et al., 1993). The results were, however, inferior to the use of temozolomide, which became the new standard of care just at the time this study was concluded (Stupp et al., 2004). As noted above, investigators were provided the option of continuing dalteparin after disease progression. The rationale for this included its potential use as an anti-angiogenesis agent, i.e., to slow disease progression, as well as use for DVT prophylaxis. In this study, 22 of 38 patients continued dalteparin post first progression. Median survival for those who stopped dalteparin at first progression versus continued use was 3.2 and 7.8 months, respectively. This analysis is confounded by several factors and should be interpreted with caution. Patients could receive other treatments at progression, as outlined in the protocol, with or without the continuation of dalteparin. The patients who stopped dalteparin at first progression may have been too sick to receive other treatments. For those patients who continued dalteparin at first progression, their survival could be confounded by the varying lengths that they continued dalteparin and/or by any of the other treatments they received. As discussed in section “Low Molecular Weight Heparin as Prophylaxis for Thromboembolic Disease” of this chapter above, historically the incidence of VTE in GBM patients is ~30%, and in this study, no VTE was observed in GBM patients actively receiving

37 LMWH in the Treatment and Prevention of Thromboembolic Disease in Glioma Patients

dalteparin. Because dalteparin might reduce the incidence of VTE, having no significant overlapping toxicities with most other drugs, its testing in a combined modality approach with other medications active in the treatment of GBM might be warranted in future trials.

Summary Comments As outlined above, the neuro-oncologist routinely deals with an extraordinarily high risk patient population relative to VTE. Indeed, it is recommended that new patients be trained in the signs and symptoms of DVT and pulmonary embolism. With the advent of easily accessible diagnostic studies, e.g., ultrasound and/or spiral CT scans, timely diagnosis of VTE is less problematic than in past years. Outpatient therapy is becoming standard practice at most centers for clinically well compensated patients. For more than 5 decades, unfractionated heparin and vitamin K antagonists have been used for the treatment and prevention of VTE. The introduction of LMWH about 20 years ago, however, has provided a class of agents with a unique therapeutic index that is favorable in glioma patients. It is anticipated that more convenient drugs (e.g., oral, or perhaps not requiring monitoring) currently in development, targeting activated factor X (i.e., factor Xa) or thrombin (factor IIa), will become available. As the optimal treatment for VTE is prevention, it is hoped and anticipated that such drug development of oral IIa and Xa inhibitors will provide a new set of efficacious and safe agents for this high risk patient population.

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Brisman R, Mendell J (1973) Thromboembolism and brain tumor. J Neurosurg 38:337–338 Buller HR, Davidson BL, Decousus H, Gallus A, Gent M, Piovella F, Prins MH, Raskob G, Segers AE, Cariou R, Leeuwenkamp O, Lensing AW (2004) Fondaparinux or enoxaparin for the initial treatment of symptomatic deep venous thrombosis: a randomized trial. Ann Intern Med 140:867–873 Castellot JJ, Jr, Choay J, Lormeau J, Petitou M, Sache E, Kamovsky MJ (1986) Structural determinants of the capacity of heparin to inhibit the proliferation of vascular smooth muscle cells. II. Evidence for a pentasaccharide sequence that contains a 3-0-sulfate group. J Cell Biol 102:1979–1984 Collen A, Smorenburg SM, Peters E, Lupu F, Koolwijk P, van Noordan C, van Hinsbergh VWM (2000) Unfractionated and low molecular weight heparin affect fibrin structure and angiogenisis in vitro. Cancer Res 60:6196–6200 Curran WJ Jr, Scott CB, Horton J, Nelson JS, Weinstein AS, Fischbach AJ, Chang CH, Rotman M, Asbell SO, Krisch RE (1993) Recursive partitioning analysis of prognostic factors in three Radiation Therapy Oncology Group malignant glioma trials. J Natl Cancer Inst 85:704–710 Deitcher SR, Kessler CM, Merli G, Rigas JR, Lyons RM, Fareed J (2006) Secondary prevention of venous thromboembolic events in patients with active cancer: enoxaparin alone versus initial enoxaparin followed by warfarin for a 180-day period. Clin Appl Thromb Hemost 12:389–396 Dickinson LD, Miller LD, Patel CP, Gupta SK (1998) Enoxaparin increases the incidence of postoperative intracranial hemorrhage when initiated preoperatively for deep venous thrombosis prophylaxis in patients with brain tumors. Neurosurgery 43:1074–1081 Dunn IF, Hesse O, Black PM (2004) Growth factors in glioma angiogenesis: FGFs, PDGF, EGF, and TGFs. J Neurooncol 50:121–137 Folkman J, Langer R, Linhardt RJ, Haudenschild C, Taylor S (1983) Angiogenesis inhibition and tumor regression caused by heparin or a heparin fragment in the presence of cortisone. Science 221:719–725 Hamilton MG, Hull RD, Pineo GF (1994) Venous thromboembolism in neurosurgery and neurology patients: A review. Neurosurgery 34:280–296 Hull RD, Pineo GF, Brant RF, Mah AF, Burke N, Dear R, Wong T, Cook R, Solymoss S, Poon MC, Raskob G (2006) Long-term low-molecular-weight heparin versus usual care in proximal-vein thrombosis patients with cancer. Am J Med 119:1062–1072 Iberti TJ, Miller M, Abalos A, Fischer EP, Post KD, Benjamin E, Oropello JM, Wiltshire-Clement M, Rand JH (1994) Abnormal coagulation profile in brain tumor patients during surgery. Neurosurgery 34:389–395 Investigators, P.d.R.d.E.P.p.I.C (2005) Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d’Embolie Pulmonaire par Interruption Cave) randomized study. Circulation 112:416–422 Kayser-Gatchalian MC, Kayser K (1975) Thrombosis and intracranial tumors. J Neurol 209:217–224 Lee AY (2009) Anticoagulation in the treatment of established venous thromboembolism in patients with cancer. J Clin Oncol 27:4895–4901

384 Lee AY, Levine MN, Baker RI, Bowden C, Kakkar AK, Prins M, Rickles FR, Julian JA, Haley S, Kovacs MJ, Gent M (2003) Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 349:146–153 Lyman GH, Khorana AA, Falanga A, Clarke-Pearson D, Flowers C, Jahanzeb M, Kakkar A, Kuderer NM, Levine MN, Liebman H, Mendelson D, Raskob G, Somerfield MR, Thodiyil P, Trent D, Francis CW (2007) American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol 25:5490–5505 Marras LC, Geerts WH, Perry JR (2000) The risk of venous thromboembolism is increased throughout the course of malignant glioma: an evidence-based review. Cancer 89:640–646 Meyer G, Marjanovic Z, Valcke J, Lorcerie B, Gruel Y, SolalCeligny P, Le Maignan C, Extra JM, Cottu P, Farge D (2002) Comparison of low-molecular-weight heparin and warfarin for the secondary prevention of venous thromboembolism in patients with cancer: a randomized controlled study. Arch Intern Med 162:1729–1735 Millac P (1967) Platelet stickiness in patients with intracranial tumors. BMJ 4:25–26 Nathanson M, Savitsky JP (1952) Platelet adhesive index studies in multiple sclerosis and other neurological disorders. Bull NY Acad Med 28:462–468 Norrby K (1993) Heparin and angiogenesis: a low-molecularweight fraction inhibits and a highmolecular-weight fraction stimulates angiogenesis systemically. Haemostasis 23(Suppl 1):141–149 Nurmohamed MT, van Riel AM, Henkens CM, Koopman MM, Que GT, d’Azemar P, Buller HR, ten Cate JW, Hoek JA, van der Meer J, van der Heul C, Turpie AG, Haley S, Sicurella A, Gent M (1996) Low molecular weight heparin and compression stockings in the prevention of venous thromboembolism in neurosurgery. Thromb Haemost 75: 233–238 Perry JR, Rogers L, Laperrier N, Julian J, Geerts W, Agnelli G, Malkin M, Sawaya R, Baker R, Levine M (2007a) A phase III randomized placebo-controlled trial of thromboprophylaxis using dalteparin low molecular weight heparin (LMWH) in patients with newly diagonsed malignant glioma updated results. Thromb Res 120:ABS PO–40 Perry JR, Rogers L, Laperriere N, Julian J, Geerts W, Agnelli G, Malkin M, Sawaya R, Baker R, Levine M (2007b) PRODIGE: a Phase III randomized placebo-controlled trial of thromboprophylaxis using dalteparin low molecular weight heparin (LMWH) in patients with newly diagnosed malignant glioma. J Clin Oncol 25:77s (Abstr 2011)

B.H. Chao and H.I. Robins Quevedo JF, Buckner JC, Schmidt JL, Dinapoli RP, O’Fallon JR (1994) Thromboembolism in patients with high-grade glioma. Mayo Clin Proc 69:329–332 Robins HI, O’Neill A, Gilbert M, Olsen M, Sapiente R, Berkey B, Mehta M (2008) Effect of dalteparin and radiation on survival and thromboembolic events in glioblastoma multiforme: a phase II ECOG trial. Cancer Chemother Pharmacol 62:227–233 Rong Y, Durden DL, Van Meir EG, Brat DG (2006) Differential regulation of tissue factor expression by EGFR and EGFRvIII in GBM. Neuro-Oncology 8:401 (ABS CB–27) Ruff RL, Posner JB (1983) Incidence and treatment of peripheral venous thrombosis in patients with glioma. Ann Neurol 13:334–336 Sawaya R, Highsmith RF (1988) Brain tumors and the fibrinolytic enzyme system. In: Kornblith PL, Walker MD (eds) Advances in neuro-oncology. Futura, Mount Kisco, NY, pp 103–157 Sawaya R, Highsmith RF (1992) Postoperative venous thromboembolism and brain tumors: Part III. Biochemical profile. J Neuro-Oncol 14:113–118 Sawaya R, Zuccarrello M, Elkalliny M, Nishiyama H (1992) Postoperative venous thromboembolism and brain tumors: Part I. Clinical Profile. J Neurooncol 14:119–125 Shlebak AA, Smith DB (1997) Incidence of objectively diagnosed thromboembolic disease in cancer patients undergoing cytotoxic chemotherapy and/or hormonal therapy. Cancer Chemother Pharmacol 39:462–466 Siragusa SCB, Piovella F, Hirsh J, Ginsberg S (1996) Lowmolecular-weight heparins and unfractionated heparin in the treatment of patients with acute venous thromboembolism: Results of a meta-analysis. J Am Med 100:269–277 Stupp R, Mason WP, Van Den Bent MJ, Weller M, Fisher B, Taphoorn M, Brandes AA, Cairncross G, Lacombe D, Mirimanoff RO (2004) Conclusive results of a randomized phase III trial by the EROTC Brain and RT groups and NICIC Clinical Trails Group. Concomitant and adjuvant temozolomide and radiotherapy for newly diagnosed glioblastoma multiforme. Proc Am Soc Clin Oncol 23:1 (Abstract 2) Teicher BA, Holden SA, Ara G, Dupuis NP, Liu F, Yuan J, Ikebe M, Kakeji Y (1995) Influence of an antiangiogenic treatment on 9L gliosarcoma: oxygenation and response to cytotoxic therapy. Int J Cancer 61:732–737 van Dongen CJ, van den Belt AG, Prins MH, Lensing AW (2004) Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism. Cochrane Database Syst Rev CD001100:1–92 Wachsberger P, Burd R, Dicker AP (2003) Tumor response to ionizing radiation combined with antiangiogenesis or vascular targeting agents. Clin Cancer Res 9:1957–1971

Part III

Prognosis

Chapter 38

Brainstem Gliomas: An Overview Marco Antonio Lima

Abstract Brainstem gliomas are a heterogeneous group of tumors that affect all ages, although they are predominant in children. There are several grading systems but they are often divided in four subgroups: tectal, diffuse pontine, cervicomedullary and dorsal exophytic. While diffuse pontine gliomas usually are high-grade tumors, the other three subtypes are low- grade lesions (pilocytic astrocytoma or grade II gliomas). The clinical presentation is diverse, but involvement of cranial nerves and long tracts are frequently present. Imaging is crucial for diagnosis and surgical planning and, in the case of diffuse pontine gliomas, MRI has replaced biopsy as gold standard. Treatment includes general measures (control of pain, seizures, physical and speech therapy) that are best addressed by a multidisciplinary team and surgical resection or palliation depending on the extension, grade and location. Since hydrocephalus is common, ventricular derivation followed by observation is the most frequent approach for tectal gliomas. Surgery and/or radiation therapy are reserved for clinical or radiological progression. Diffuse pontine gliomas are inoperable and radiation therapy is the mainstay of treatment leading to transient control of the symptoms. Most cervicomedullary and dorsally exophytic tumors are treated with partial or complete resection when feasible, followed by radiation therapy at time of recurrence or progression. Prognosis is dismal for pontine gliomas, and most patients do not survive 2 years from diagnosis. Outcome is better for tectal,

M.A. Lima () Department of Neurosurgery, Instituto Nacional de Câncer-INCa, Centro, Rio de Janeiro RJ-22230-130, Brazil e-mail: [email protected]

cervicomedullary and dorsally exophytic tumors and many patients achieve a long-term survival, although neurological sequelae are common. Keywords Brainstem gliomas · Tectal gliomas · Diffuse pontine gliomas · Cervicomedullary gliomas · Dorsal exophytic gliomas · CNS

Introduction Brainstem gliomas are a group of heterogeneous tumors that may affect either children or adults, but are more prevalent in the first years of life. In the pre-imaging era, they were considered a single entity and inoperable, but newer imaging techniques allowed the classification of subgroups with distinct behaviors. Nowadays, the knowledge of course of the disease as well the outcome of these different subtypes permits a better determination of which patients would benefit from surgery. In addition, despite the involvement of a crucial area of the central nervous system, modern neurosurgical procedures currently permit safer resections with minimal additional morbidity.

Epidemiology Brainstem gliomas are more frequent in children and represent 10% of pediatric central nervous system tumors (Walker et al., 1999). In a recent review of 6212 pediatric patients with gliomas, 19.8% were located in

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_38, © Springer Science+Business Media B.V. 2011

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the brainstem (Qaddoumi et al., 2009). There is no gender predilection and the mean age at onset in children is 7–9 years (Jallo et al., 2004). According to Smith et al. in the 1990–1994 period, the age-adjusted incidence of brainstem high-grade gliomas was 0.14 per 105 person-years, while the low-grade gliomas was 0.18 per 105 person-years (Smith et al., 1998). There are few studies of brainstem gliomas in adults since they are a rare entity, representing less than 2% of gliomas in this population (Guillamo et al., 2001). Although they can occur at any age, the peak incidence in adult patients is between the third and fourth decades (Selvapandian et al., 1999). In a recent study of brainstem gliomas in adults, the median age at diagnosis was 36 years (Kesari et al., 2008). Neurofibromatosis 1 (NF1) predisposes to central nervous system tumors, especially pilocytic astrocytomas. Although the optic pathways are the preferred site, other common locations are the brainstem and cerebellum (Ferner, 2007). In a retrospective study of 104 NF1 patients, 17% had brainstem gliomas (Guillamo et al., 2003), but lesions were more indolent in this group.

Classification Several grading systems for classification and staging of brainstem gliomas have been described over the years based on their location, focality, pattern of tumor growth and the presence of necrosis and hydrocephalus (Barkovich et al., 1990; Epstein, 1985). A simple classification would divide brainstem gliomas in four major categories: diffuse intrinsic gliomas, focal tectal, cervicomedullary and dorsal exophytic tumors (LaigleDonadey et al., 2008). • Focal tectal gliomas: these are rare tumors, representing less than 5% of brainstem gliomas in children (Laigle-Donadey et al., 2008). However, in a recent study with 101 adult brainstem glioma patients revealed that 20% of the lesions were tectal (Kesari et al., 2008). Indeed, Guillamo et al. have shown focal tectal gliomas in 8/48 adult patients (16.7%) suggesting that this subtype might be more frequent in adults than previously thought (Guillamo et al., 2001). The lesions are well

M.A. Lima

circumscribed and most are low-grade gliomas (WHO I and II). • Diffuse intrinsic gliomas: these are the most prevalent and aggressive brainstem gliomas, being responsible for 80% of the cases. Although they can occur anywhere in the brainstem, they are usually located at the pons, extending into the midbrain or medulla over the course of the disease. Most diffuse gliomas are malignant fibrillary astrocytomas (grade III or IV), but biopsy is not performed in all cases, since diagnosis is frequently based solely on clinical and radiological presentation. • Cervicomedullary gliomas: lesions in the cervicomedulary region are present in 5–10% with brainstem gliomas and occur predominantely in the pediatric population. Most tumors are low-grade astrocytomas and are similar to intramedullary spinal cord gliomas. According to Epstein et al. their growth is limited rostrally by the decussating fibers and pial elements (Epstein and Farmer, 1993). The lesion is well circumscribed and may be associated with syringomyelia caudally. • Dorsal exophytic gliomas: this subgroup represents between 14 and 24% of the brainstem gliomas. The epicenter is usually within the fourth ventricle and the age at presentation is younger than in other subtypes. The biopsy or surgical resection often reveals a low-grade glioma. Although, total resection is not feasible in many cases, partial resection can improve outcome.

Clinical Manifestations Tectal lesions grow insidiously and usually produce symptoms due to compression of cerebral aqueduct leading to a non-communicating hydrocephalus. The time from onset of symptoms until diagnosis is variable ranging from days to several years (Stark et al., 2005). Headache, vomiting and ataxia are frequently present at time of diagnosis (Daglioglu et al., 2003). Papilledema is observed in close to 50% of the patients. Parinaud syndrome, strabismus and long tract signs are found in a minority of patients (Ternier et al., 2006). Unusual presentations are tremor, irritability, parkinsonism, seizures, vertigo and decline in school performance. After ventricular drainage and treatment

38 Brainstem Gliomas: An Overview

of hydrocephalus, signs and symptoms can remain stable for years. Patients with diffuse pontine gliomas present with rapidly progressive neurological deficits, usually in weeks or few months, but it may be sudden, suggesting a stroke initially (Guillamo et al., 2001). A shorter duration of symptoms is associated with a worse outcome (Ueoka et al., 2009). The clinical triad includes ataxia, long tract signs and multiple cranial nerve palsies, particularly the sixth and seventh nerves. Clinical course is more protracted in adults when compared to children (Guillamo et al., 2001). Headache is common and can be indistinguishable from migraine including the presence of visual aura (Lim et al., 2005). The single involvement of the facial nerve may initially suggest Bell’s palsy (Walker et al., 1999). Very rarely, spontaneous remission can occur (Lenard et al., 1998). Duration of symptoms in patients with cervicomedullary gliomas range from months to years and it is shorter in fibrilary astrocytomas than in pilocytic astrocytomas and gangliogliomas (Di Maio et al., 2009). Due to preponderance of low-grade tumors, the clinical course is protracted and delay in diagnosis is frequent. Clinical manifestations are related to the primary site of the lesion, medulla or spinal cord, but in most patients, symptoms are overlapping. Involvement of medulla leads to lower cranial nerve dysfunction. Nasal speech, swallowing problems, head tilt, palate deviation and facial nerve palsies dominate the clinical picture. Nausea and vomiting are particularly common and related to bulbar compression and not to increased intracranial pressure. Children may present with failure to thrive. Predominant spinal cord lesions produce weakness, muscle wasting, sphincteric disturbances and may lead to respiratory failure. Patients with dorsally exophytic tumors present with headache, vomiting, failure to thrive, torticollis and ataxia. Signs of long tract dysfunction are not common at presentation, but may appear over the course of the disease.

Differential Diagnosis Infectious, autoimmune, vascular, metabolic and tumoral disorders may have a similar clinical or radiological presentation of a brainstem glioma

389 Table 38.1 Differential diagnosis of brainstem gliomas Infectious Tuberculosis Listeria monocytogenes infection Toxoplasmosis Pyogenic abscess Viral rhombencephalitis Progressive multifocal leukoencephalopathy Autoimmune Sarcoidosis NeuroBehçet Multiple sclerosis Neuromyelitis optica Systemic eritematous lupus Vascular Haematomas Vascular malformations Vasculitis Infarction Posterior reversible leukoencephalopathy Metabolic/inherited Alexander disease Neurofibromatosis type 1 Tumoral Lymphoma Metastasis Germinoma Acoustic neuroma

(Table 38.1) (Laigle-Donadey et al., 2008; Park et al., 2007). Many infectious agents can penetrate de CNS and provoke lesions in the brainstem. Usually, the process is acute or subacute and clinical picture evolves over days. Conversely, brainstem tumors grow more insidiously and years may elapse until diagnosis. Fever and systemic signs are clues for an infectious process as well as the presence of immune system dysfunction. Tuberculosis, toxoplasmosis and Listeria monocytogenes infection predominantly occur in immunossupressed individuals. Cerebrospinal fluid analysis can be helpful in order to determine the specific agent. Inflammatory lesions secondary to autoimmune process may present with mass effect and/or contrast enhancement, mimicking brainstem tumors. When the neurological lesion is the first manifestation of the disease, diagnosis is particularly challenging and may be obtained only after brain biopsy. A relapsing remitting course, the predilection for young women, and involvement of other sites of the neuraxis suggests multiple

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sclerosis. Neuromyelits optica affects mainly the optic nerves and spinal cord, but is not restricted to these sites. Anti-acquaporine 4 antibody is present in more than half of the cases. Sole involvement of CNS in sarcoidosis is rare and other organs such as lung and lymph nodes are affected first. Patients with Behçet disease can present with a pseudotumoral brainstem lesion, which can be hard to differentiate from a tumor. History of eye lesions, arthritis and genital and oral ulcers should be inquired and are crucial for diagnosis. Hemorrhagic or ischemic strokes produce sudden symptoms and signs in most patients and only rarely can be mistaken for a brainstem glioma. However, a progressive or relapsing course can be seen in brainstem vasculitis and vascular malformations, casting doubt in diagnosis. In these cases, imaging (MR angiography, CT angiography and digital subtraction angiography) is particularly helpful. NF1 patients may develop T2-weighted hyperintense lesions on MRI named unidentified bright objects in the brainstem. These lesions spontaneously disappear during childhood but can be confused with a tumoral lesion. Alexander disease is a rare degenerative leukodystrophy secondary to a mutation in the glial fibrillary acidic protein (GFAP) gene. In juvenile and adult types, a predominant bulbar involvement can occur. Diagnosis is made through MRI and genetic testing. Brainstem can be affected by other tumors including primary CNS neoplasms and metastasis. The clinical and radiological aspects of these lesions are reviewed elsewhere in this book.

Diagnosis Imaging is fundamental to determine the location and extension of brainstem gliomas. CT imaging can show cysts, calcification or the presence of hydrocephalus, but its sensitivity for posterior fossa lesions is low and definition is poor. MRI is the preferred method since it can differentiate tumors from inflammatory and vascular lesions and special techniques such as spectroscopy and perfusion/diffusion sequences can help to determine tumor grade before surgery. Tectal gliomas are iso or hypointense in T1-weighted and hyperintense in T2-weighted and FLAIR sequences (Fig. 38.1). Lesions are located

M.A. Lima

Fig. 38.1 A fluid attenuation inversion recovery (FLAIR) MR image showing a hyperintense lesion in tectum. Biopsy revealed a pilocytic astrocytoma

in the tectal plate, well circumscribed and show contrast enhancement in less than 20% of the cases. Extension into the tegmentum or thalamus may occur and ventricular dilatation is frequently present (Squires et al., 1994). MRI is particularly important for diagnosis of diffuse pontine gliomas in children, since it has replaced biopsy as gold standard for treatment decisions. Schumacher et al. conducted a multicentric study with 142 patients with brainstem disease, including 78 patients with brainstem gliomas (Schumacher et al., 2007). When clinical, immunological, MRI and CSF data were considered, it was possible to differentiate tumoral form non-tumoral lesions in more than 95% of the cases, obviating the need of histological confirmation. On the other hand, it is believed that pontine gliomas are uniformly high-grade, but in a recent study with 24 patients that underwent biopsy for pontine gliomas, two had low-grade tumors (grade II glioma and pilocytic astrocytoma) (Roujeau et al., 2007). In the same study, the procedure was considered safe with minimal morbidity. Nowadays,

38 Brainstem Gliomas: An Overview

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Fig. 38.2 (a) A hypointense sagital T1-weighted and (b) a hyperintense FLAIR lesion with ill defined margins typical of a pontine glioma

Fig. 38.4 A dorsally exophytic tumor with heterogeneous contrast enhancement is seen in T1-weighted MR sequence

Fig. 38.3 T2-weighted sagital MR sequence showing an extensive cervicomedullary tumor from the medulla to C6

most specialized centers indicate biopsy only in atypical cases. Characteristically, there is a diffuse enlargement of pons and tumor limits are ill defined due to

its infiltrative nature (Fig. 38.2). The lesion is hyperintense in T2-weighted and mostly hypointense in T1-weighted sequences. Contrast enhancement is not usually observed and its presence is of no prognostic significance. Engulfment of the basilar artery can occur (Jallo et al., 2004). MR spectroscopy may be a useful adjuvant in the diagnosis and follow-up of the pontine gliomas. Elevated choline/creatine (Cho/Cr)

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and Cho/N-acetylaspartate (NAA) ratios are usually observed (Thakur et al., 2006). Upon MRI, cervicomedullary gliomas are homogeneous T1-weighted iso or hypointense and T2-weighted hyperintense lesions (Fig. 38.3). Di Maio et al. reported that tumors in 8/9 patients showed contrast enhancement (Di Maio et al., 2009). Their growth is limited rostrally by the decussating fibers of the corticospinal tract and tumor expands caudally into the spinal cord. Dorsally exophytic tumors are well-demarcated lesions located in the floor of the fouth ventricle and expand dorsolaterally (Fig. 38.4). Similar to other brainstem tumor, they show T1-weighted hypointensity and T2-weighted hyperintensitiy. Most often, gadolinium enhancement is homogeneous.

Treatment General measures in the treatment of brainstem gliomas include analgesia, management of bulbar symptoms and motor impairment, relief of hydrocephalus and emotional support. Palliation is the main component of care in patients with diffuse pontine gliomas. These issues are best addressed by a multidisciplinary team that should include oncologists, neurologists, neurosurgeons, speech and physical therapists in a brain tumor center. Tectal gliomas are indolent lesions that usually present with signs of raised intracranial pressure. The initial approach is aimed to relieve hydrocephalus either with ventricular shunt placement or third ventriculostomy. While shunt placement has been used traditionally, many patients need revision due to infection or malfunction. More recently, third ventriculostomy has become the preferred method by many neurosurgeons. It is safe and efficacious in the short and long term. Li et al. attempted third ventriculostomy in 18 tectal glioma patients and was successful in all. At follow-up, 89% of the individuals remained shunt-free (Li et al., 2005). The procedure can be repeated if the ventriculostomy has closed. Surgical resection soon after diagnosis is controversial. While some groups favor early resection if complete removal of the mass seems feasible, others sustain a conservative approach and reserve surgery for clinical or radiological (contrast enhancement, enlargement

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or cystic changes) progression. Another approach is stereotactic biopsy followed by radiation therapy as described below. In all cases, intraoperative neurophysiological monitoring should be performed in order to avoid excessive damage. Radiation therapy can be used as an initial approach soon after stereotactic biopsy in patients with high grade lesions or, late in the course of the disease, after clinical progression of low grade tumors. Either conformal radiation therapy or stereotactic radiosurgery (SR) have been used depending on the size, presence of distinct tumor margins and experience at the center. Doses are in the 9–12 Gy range to the tumor margins when SR is employed. In order to avoid radiation induced damage, peripheral doses higher than 14 Gy should not be used (Kihlstrom et al., 1994). Chemotherapy has a limited role in the management of tectal gliomas, being used mostly after clinical progression. Surgery has no role for diffuse pontine gliomas, except in cases of CSF diversion for hydrocephalus. The diffuse and infiltrative nature of these tumors does not produce any well-defined margins. As described above, it is consensus that biopsy is not necessary for most patients, and it should be performed only in atypical cases. The mainstay of treatment for diffuse pontine gliomas is focal conventional radiation therapy. Doses from 50 to 60 Gy divided in daily fraction of 1.5–2 Gy over 6 weeks are used (Laigle-Donadey et al., 2008). This approach leads to clinical improvement in over 75% of the patients initially but does not improve survival (Hargrave et al., 2006). The median onset of disease progression after radiation therapy is < 6 months. The radiological response occurs only in half of the cases. In the last two decades, several studies have investigated alternative radiation protocols such as hyperfractionation and dose escalation. In a large phase III trial, 130 patients were randomly assigned to receive local field radiation at doses of 1.8 Gy daily to a total dose of 54 Gy or a twice a day regimen of 1.17 Gy per fraction to a total dose of 70.2 Gy over 6 weeks (Mandell et al., 1999). The results were disappointing: in the conventional radiation group the median time to death was 8.5 months and in the hyperfractionation group was 8 months. In another study, 66 children underwent treatment with 1 Gy twice daily to a total dose of 78 Gy (Packer et al., 1994). This regimen resulted in a prolonged dependency of steroids

38 Brainstem Gliomas: An Overview

and 9/66 patients showed radiological evidence of radiation induced necrosis. There was no improvement in survival when compared to the standard regimen. Various single or multiple drug regimens have been tested in several trials for management of diffuse pontine gliomas either alone or in combination with radiation therapy. Regimens that used chemotherapy prior to radiation therapy usually failed due to early disease progression. Temozolomide, a drug that has extensively used in supratentorial high grade gliomas improving survival, had no impact in diffuse pontine gliomas either with concurrent radiation therapy or at clinical progression (De Sio et al., 2006). Bevacizumab, an antiangiogenic agent that has been used in recurrent high grade supratentorial gliomas also had no impact in the outcome (Torcuator et al., 2009), but may be useful for radiation induced necrosis in pontine glioma patients (Liu et al., 2009). Radiosensitizing drugs also had disappointing results. Overall, chemotherapy has not brought any substantial impact in the prognosis of these patients. Newer approaches such as local delivery of chemotherapeutic agents in order to bypass the blood brain barrier, immunotherapy and gene therapy are currently being evaluated. Due to the poor response to the conventional therapies, trials with experimental treatments should be offered to these patients. Surgical resection is recommended initially for cervicomedullary gliomas, but morbidity of a radical excision may be important. In most series, biopsy or subtotal excision of the tumor can be performed safely. Di Maio et al. achieved subtotal resection in 6/7 patients (Di Maio et al., 2009), while 9/11 patients underwent subtotal resection in Poussaint series (Young Poussaint et al., 1999). Neurological deficits can be transient or permanent, especially bulbar cranial nerve dysfunction and respiratory function. In cases of extensive spinal cord manipulation, intubation for 48–72 h after surgery is advised (Jallo et al., 2004). Early tracheostomy and feeding gastrostomy may be necessary in the presence of swallowing impairment. Cervical kyphosis is a late complication in patients with cervical laminectomies at the time of surgery due to spinal cord extension of the tumor. Since most tumors in the cervicomedullary region are low grade and grow slowly, radiation therapy is deferred until recurrence or clinical progression with the aim of prevents its deleterious effects in the CNS

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(Laigle-Donadey et al., 2008). In patients with high grade gliomas, radiation therapy can be performed soon after biopsy or resection of the lesion. Chemotherapy role is yet to be defined in cervicomedullary gliomas. It is usually reserved for recurrence, but a recent study showed that chemotherapy soon after subtotal resection may improve tumor/brainstem interface, opening the possibility for a more extensive resection (Di Maio et al., 2009). Surgical resection is indicated for dorsally exophytic tumors. Advances in neurosurgical and imaging techniques allow extensive resection, although total removal of the lesion is not possible in most cases (Jallo et al., 2004). The goal is the removal of the extrinsic component following by debulking of the intrinsic component in order to prevent neurological morbidity (ataxia, long tract dysfunction and nystagmus). Due to the benign nature of these tumors, radiation therapy and chemotherapy are used in cases of recurrence or progression.

Outcome The outcome of brainstem gliomas is related to the location and histological grade of the tumors. Tectal lesions portray a good prognosis and tumors may remain stable for years. Stark et al. followed 12 children for a median time of 9.5 years (Stark et al., 2005). Radiological progression was observed in three patients, but no clinical deterioration occurred. All children had a good neurological performance at the end of follow-up. In Poussaint series, 20/32 children were stable after a mean follow up of 5 years (Poussaint et al., 1998). For the 12 remaining patients who showed clinical or radiological progression, eight showed decreased tumor size and three showed stable residual lesion after surgery and/or radiation therapy. The prognosis of diffuse pontine gliomas remains dismal despite many experimental protocols of radiation and chemotherapy. The mean survival is less than 1 year in most series and the 2-year survival is only 10% (Broniscer and Gajjar, 2004). Age at onset of disease is prognostic since survival is longer in adults then children (Guillamo et al., 2001; Kesari et al., 2008). Tumor control can be achieved in most patients with cervicomedullary gliomas. In a study with 39 patients, the 5-year progression-free and total survivals

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were 60 and 89% respectively. In another study, 6/11 patients were stable after surgery at a mean follow-up of 5.2 years (Young Poussaint et al., 1999). Dorsally exophytic tumors have a good outcome after surgical resection. Among 18 patients who underwent surgery, only four showed evidence of radiological progression after a median follow-up of 113 months (Pollack et al., 1993).

References Barkovich AJ, Krischer J, Kun LE, Packer R, Zimmerman RA, Freeman CR, Wara WM, Albright L, Allen JC, Hoffman HJ (1990) Brain stem gliomas: a classification system based on magnetic resonance imaging. Pediatr Neurosurg 16(2):73–83 Broniscer A, Gajjar A (2004) Supratentorial high-grade astrocytoma and diffuse brainstem glioma: two challenges for the pediatric oncologist. Oncologist 9(2):197–206 Daglioglu E, Cataltepe O, Akalan N (2003) Tectal gliomas in children: the implications for natural history and management strategy. Pediatr Neurosurg 38(5):223–231 De Sio L, Milano GM, Castellano A, Jenkner A, Fidani P, Dominici C, Donfrancesco A (2006) Temozolomide in resistant or relapsed pediatric solid tumors. Pediatr Blood Cancer 47(1):30–36 Di Maio S, Gul SM, Cochrane DD, Hendson G, Sargent MA, Steinbok P (2009) Clinical, radiologic and pathologic features and outcome following surgery for cervicomedullary gliomas in children. Childs Nerv Syst 25(11):1401–1410 Epstein F (1985) A staging system for brain stem gliomas. Cancer 56(7 Suppl):1804–1806 Epstein FJ, Farmer JP (1993) Brain-stem glioma growth patterns. J Neurosurg 78(3):408–412 Ferner RE (2007) Neurofibromatosis 1 and neurofibromatosis 2: a twenty first century perspective. Lancet Neurol 6(4): 340–351 Guillamo JS, Creange A, Kalifa C, Grill J, Rodriguez D, Doz F, Barbarot S, Zerah M, Sanson M, Bastuji-Garin S, Wolkenstein P (2003) Prognostic factors of CNS tumours in Neurofibromatosis 1 (NF1): a retrospective study of 104 patients. Brain 126(Pt 1):152–160 Guillamo JS, Monjour A, Taillandier L, Devaux B, Varlet P, Haie-Meder C, Defer GL, Maison P, Mazeron JJ, Cornu P, Delattre JY (2001) Brainstem gliomas in adults: prognostic factors and classification. Brain 124(Pt 12):2528–2539 Hargrave D, Bartels U, Bouffet E (2006) Diffuse brainstem glioma in children: critical review of clinical trials. Lancet Oncol 7(3):241–248 Jallo GI, Biser-Rohrbaugh A, Freed D (2004) Brainstem gliomas. Childs Nerv Syst 20(3):143–153 Kesari S, Kim RS, Markos V, Drappatz J, Wen PY, Pruitt AA (2008) Prognostic factors in adult brainstem gliomas: a multicenter, retrospective analysis of 101 cases. J Neurooncol 88(2):175–183 Kihlstrom L, Lindquist C, Lindquist M, Karlsson B (1994) Stereotactic radiosurgery for tectal low-grade gliomas. Acta Neurochir Suppl 62:55–57

M.A. Lima Laigle-Donadey F, Doz F, Delattre JY (2008) Brainstem gliomas in children and adults. Curr Opin Oncol 20(6):662–667 Lenard HG, Engelbrecht V, Janssen G, Wechsler W, Tautz C (1998) Complete remission of a diffuse pontine glioma. Neuropediatrics 29(6):328–330 Li KW, Roonprapunt C, Lawson HC, Abbott IR, Wisoff J, Epstein F, Jallo GI (2005) Endoscopic third ventriculostomy for hydrocephalus associated with tectal gliomas. Neurosurg Focus 18(6A):E2 Lim EC, Wilder-Smith EP, Chong JL, Wong MC (2005) Seeing the light: brainstem glioma causing visual auras and migraine. Cephalalgia 25(2):154–156 Liu AK, Macy ME, Foreman NK (2009) Bevacizumab as therapy for radiation necrosis in four children with pontine gliomas. Int J Radiat Oncol Biol Phys 75(4):1148–1154 Mandell LR, Kadota R, Freeman C, Douglass EC, Fontanesi J, Cohen ME, Kovnar E, Burger P, Sanford RA, Kepner J, Friedman H, Kun LE (1999) There is no role for hyperfractionated radiotherapy in the management of children with newly diagnosed diffuse intrinsic brainstem tumors: results of a Pediatric Oncology Group phase III trial comparing conventional vs. hyperfractionated radiotherapy. Int J Radiat Oncol Biol Phys 43(5):959–964 Packer RJ, Boyett JM, Zimmerman RA, Albright AL, Kaplan AM, Rorke LB, Selch MT, Cherlow JM, Finlay JL, Wara WM (1994) Outcome of children with brain stem gliomas after treatment with 7800 cGy of hyperfractionated radiotherapy. A Childrens Cancer Group Phase I/II Trial. Cancer 74(6):1827–1834 Park KY, Ahn JY, Cho JH, Choi YC, Lee KS (2007) Neuromyelitis optica with brainstem lesion mistaken for brainstem glioma. Case report. J Neurosurg 107(3 Suppl):251–254 Pollack IF, Hoffman HJ, Humphreys RP, Becker L (1993) The long-term outcome after surgical treatment of dorsally exophytic brain-stem gliomas. J Neurosurg 78(6):859–863 Poussaint TY, Kowal JR, Barnes PD, Zurakowski D, Anthony DC, Goumnerova L, Tarbell NJ (1998) Tectal tumors of childhood: clinical and imaging follow-up. AJNR Am J Neuroradiol 19(5):977–983 Qaddoumi I, Sultan I, Gajjar A (2009) Outcome and prognostic features in pediatric gliomas: a review of 6212 cases from the surveillance, epidemiology, and end results database. Cancer 115(24):5761–5770 Roujeau T, Machado G, Garnett MR, Miquel C, Puget S, Geoerger B, Grill J, Boddaert N, Di Rocco F, Zerah M, Sainte-Rose C (2007) Stereotactic biopsy of diffuse pontine lesions in children. J Neurosurg 107(1 Suppl):1–4 Schumacher M, Schulte-Monting J, Stoeter P, Warmuth-Metz M, Solymosi L (2007) Magnetic resonance imaging compared with biopsy in the diagnosis of brainstem diseases of childhood: a multicenter review. J Neurosurg 106(2 Suppl): 111–119 Selvapandian S, Rajshekhar V, Chandy MJ (1999) Brainstem glioma: comparative study of clinico-radiological presentation, pathology and outcome in children and adults. Acta Neurochir (Wien) 141(7):721–726; discussion 726–727 Smith MA, Freidlin B, Ries LA, Simon R (1998) Trends in reported incidence of primary malignant brain tumors in children in the United States. J Natl Cancer Inst 90(17): 1269–1277

38 Brainstem Gliomas: An Overview Squires LA, Allen JC, Abbott R, Epstein FJ (1994) Focal tectal tumors: management and prognosis. Neurology 44(5): 953–956 Stark AM, Fritsch MJ, Claviez A, Dorner L, Mehdorn HM (2005) Management of tectal glioma in childhood. Pediatr Neurol 33(1):33–38 Ternier J, Wray A, Puget S, Bodaert N, Zerah M, SainteRose C (2006) Tectal plate lesions in children. J Neurosurg 104(6 Suppl):369–376 Thakur SB, Karimi S, Dunkel IJ, Koutcher JA, Huang W (2006) Longitudinal MR spectroscopic imaging of pediatric diffuse pontine tumors to assess tumor aggression and progression. AJNR Am J Neuroradiol 27(4):806–809

395 Torcuator R, Zuniga R, Loutfi R, Mikkelsen T (2009) Bevacizumab and irinotecan treatment for progressive diffuse brainstem glioma: case report. J Neurooncol 93(3): 409–412 Ueoka DI, Nogueira J, Campos JC, Maranhao Filho P, Ferman S, Lima MA (2009) Brainstem gliomas–retrospective analysis of 86 patients. J Neurol Sci 281(1–2):20–23 Walker DA, Punt JA, Sokal M (1999) Clinical management of brain stem glioma. Arch Dis Child 80(6):558–564 Young Poussaint T, Yousuf N, Barnes PD, Anthony DC, Zurakowski D, Scott RM, Tarbell NJ (1999) Cervicomedullary astrocytomas of childhood: clinical and imaging follow-up. Pediatr Radiol 29(9):662–668

Chapter 39

Tumor-Associated Epilepsy in Patients with Glioma Anja Smits and Anette Storstein

Abstract Epileptic seizures are common symptoms in patients with glioma, occurring at disease presentation as well as during later disease. The frequency of tumor-related seizures is strongly related to the growth rate of the tumor. In low-grade gliomas, seizures as initial symptom leading to the brain tumor diagnosis occur in 70–90% of all patients. About 50% of these patients continue to have seizures before operation in spite of optimal antiepileptic drug treatment. In high-grade gliomas, seizures at disease presentation are less frequent and occur in only 30–50% of all patients but may be more difficult to control. Apart from the tumor growth rate, the specific location of the tumor in the brain and its proximity to the cortex affect seizure risk and seizure control in glioma. For many patients with tumor-related seizures, optimal seizure control is not achieved by antiepileptic drugs only but requires additional therapy such as surgical resection and/or radio- and chemotherapy. In this review, we discuss different aspects of the clinical presentation of the disease in patients with tumor-related seizures. We also discuss the possible therapeutic strategies for patients with medically refractory seizures, illustrating the importance of a qualified specialized team of neuro-oncologists, neurologists and neurosurgeons for the optimal management of this patient group.

A. Smits () Department of Neuroscience, Neurology, University Hospital Uppsala, S-751 85 Uppsala, Sweden e-mail: [email protected]

Keywords Epilepsy · Glioma · Antiepileptic drugs · Epileptogenesis · Differential diagnoses · Ischemic infarction

Introduction Epileptic seizures are common in patients with gliomas, affecting the majority of patients with lowgrade tumors and a substantial proportion of patients with high-grade glioma. Seizures occur as initial symptoms at disease onset and are frequent symptoms of chronic tumor disease as well. With tumor treatments for patients with glioma becoming more effective resulting in longer patient survival, the burden of chronic epilepsy will add substantial morbidity to this patient group. Several studies have shown that persistent seizures in patients with brain tumors have sustained negative effects on daily functioning and quality of life (Klein et al., 2003). Optimal seizure control is therefore an important part of the clinical management in patients with brain tumors. Cognitive dysfunction, another main symptom in patients with glioma, is often closely related to both refractory seizures and antiepileptic therapy. The clinical management of cognitive dysfunction in patients with brain tumors is discussed elsewhere. The incidence of seizures in patients with glioma is highly variable and is affected by several factors. The location of the tumor in the brain, the proximity to adjacent cortex and the growth rate of the tumor are important parameters determining seizure risk. The majority of patients with slowly growing low-grade gliomas presents with epileptic seizures at disease onset or within the first year from tumor diagnosis,

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often as the only symptom. In patients with high-grade gliomas, epileptic seizures occur less frequently both at disease onset as well as during later course of disease. In addition to symptomatic seizures, these tumors cause neurological deficits as a result of the destructive growth in the brain. Apart from the evident variability in seizure risk at disease onset, the seizure control that can be obtained in patients with gliomas is highly variable. Tumor-related seizures in high-grade gliomas are less frequent, but the epileptic symptoms of these patients may be difficult to control. Many patients with slowly growing gliomas suffer from chronic epilepsy during the entire course of disease, whereas others become seizure-free after their first initial seizure when antiepileptic treatment is started. Add-on treatment with new antiepileptic drugs may increase the proportion of seizure-free patients in the glioma population, but further studies need to assess the efficiency of these drugs in glioma-related seizures as well as the side effects induced by polypharmacy. Other treatment options should be considered when antiepileptic drug treatment fails. Surgical resection including resection of the epileptic foci is known to have beneficial effects on seizure control, especially in low-grade gliomas. Recent reports have shown positive effects with seizure reduction obtained by radiotherapy and chemotherapy as well in this patient group. In general, however, current therapy of tumor-related seizures is far from perfect (van Breemen et al., 2007). A deeper understanding of the underlying mechanisms of brain-tumor epilepsy is a prerequisite for improving seizure control and optimizing the clinical management of gliomarelated seizures.

Epidemiology In general, slowly growing tumors are significantly more epileptogenic than fast growing tumors. Epileptic seizures as initial symptoms leading to the brain tumor diagnosis occur in 70–90% of low-grade gliomas and in 30–50% of high-grade gliomas. Some specific histological tumor subtypes characterized by a typically indolent course of disease, such as dysembryoblastic neuroepithelial tumors (DNET) and gangliogliomas, are associated with a seizure frequency of almost 100%. In contrast, the incidence of seizures as first

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symptoms in metastatic brain disease is as low as 20–30% (van Breemen et al., 2007). Around 4–5% of all adult-onset seizures are caused by brain tumors (Olafsson et al., 2005). However, seizures may go unnoticed for long time periods. The difficulty in defining initial seizures in adults as first symptoms at the time point of disease onset is illustrated in a study by King et al. (1998) who investigated 300 consecutive adults and children presenting with an unexplained seizure. A clinical diagnosis of generalized or focal epilepsy could be made in 141 (47%) of these patients, and imaging of the brain by CT or MRI identified 38 epileptogenic lesions (17 of these were tumors). It was demonstrated that 17% of the patients who presented with their first tonic-clonic seizure reported similar events in the past and 28% had earlier experienced focal epileptic symptoms, such as temporal lobe auras due to non-convulsive seizures. This study confirms the common experience by many doctors that patients may not be aware of or not appreciate the importance of minor epileptic symptoms, and fail to mention these in an initial interview. As a consequence, the brain tumor diagnosis may be delayed for months or, in case of slowly growing tumors, up to several years.

Epileptogenesis in Gliomas The mechanisms behind the development of tumorrelated seizures are likely to involve tumor-related as well as individual patient-related factors but are incompletely understood. The seizure risk and the individual response to antiepileptic drug treatment are variable within subgroups of patients with similar tumor localization and histology. Thus, apart from tumor location and tumor growth rate, other factors that are related to the genetic susceptibility of the individual patient and the intrinsic properties of the host brain may contribute to the development of glioma-related seizures. A putative mechanism of acquiring intrinsic epileptic properties is by altered expression of signaling molecules involved in neuronal circuitries. According to the modern theory of neuronal networks, synchronization of neurons in complex networks is the prerequisite for normal neurological functioning. Due to modifications in such existing circuitries by for example tumor growth, active processes of axonal sprouting,

39 Tumor-Associated Epilepsy in Patients with Glioma

synaptogenesis and neurogenesis will take place in the peritumoral region (Brogna et al., 2008). Such excessive and random synchronization of neurons may persist during critical periods of time, typically in slowly growing tumors, and cause epilepsy. This theory provides new insights also in the underlying mechanisms of cognitive disturbances, the other main symptom of disease in low-grade gliomas. Thus, disarrangement of the same neuronal cerebral networks may lead to cognitive disturbances, as a result of destruction, and epileptic seizures, as a result of pathological excess of functional network structures (Brogna et al., 2008).

Pathophysiology The pathophysiology of seizure development in patients with glioma is thought to occur through different mechanisms in high-grade and low-grade tumors. In fast growing high-grade gliomas, focal ischemia and deafferentiation of cortical areas due to mass effect are likely to be important causative factors (Fig. 39.1), whereas gliosis and chronic inflammatory changes in peritumoral regions of slowly growing gliomas are considered to predispose for epileptic seizures (Fig. 39.2). Increased levels of Fe3+ ions deposits in intra- or peritumoral areas, due to small bleedings from pathological blood vessels, typically occur in high-grade gliomas and may further contribute to the development of tumor-associated seizures (Fig. 39.1) (Beaumont and Whittle, 2000; Schaller and Rüegg, 2003). The almost 100% association of epileptic seizures in patients with specific histological types of neuroglial tumors, such as DNET and gangliogliomas, has raised the question whether these tumors contain intrinsic epileptogenic properties. It has been speculated that the specific neurochemical profiles of these lesions predispose for generating epileptic activity (Beaumont and Whittle, 2000).

Tumor Characteristics The inverse relationship between tumor growth rate and seizure risk is true also for patients with tumors of similar histological malignancy grade. Thus, within the group of grade II gliomas, the slowly growing oligodendrogliomas are more epileptogenic than the

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diffuse astrocytomas. Other important factors underlying the development of epilepsy are the localization of the tumor in the brain and the proximity with the cortical gray matter (Schaller and Ruegg, 2003). Tumors with location in the vicinity of the primary motor cortex and with limbic and perilimbic cortical localization are highly epileptogenic, whereas occipital tumors are less likely to manifest with seizures. Low-grade gliomas are more frequently than de novo glioblastomas situated in eloquent cortico-subcortical regions, such as the supplementary motor area (SMA) and the insular and peri-insular area. These locations are highly epileptogenic areas and strongly associated with medically refractory seizures (Duffau and Capelle, 2004).

Peritumoral Brain In tumor-associated epilepsy, the tumor somehow acts as a generator to produce an epileptic focus in the brain. In many cases, however, the epileptic focus, i.e. the location corresponding with the start of the seizure, is not contiguous with the tumor. The interplay between the tumor histology and the surrounding tissue is of importance for seizure development, especially in chronic epilepsy of patients with slowly growing gliomas. Alterations in the ultrastructure of the peritumoral brain regions have been demonstrated in patients with tumor-associated seizures, as well as changes in metabolic activity and in pH (Beaumont and Whittle, 2000). The presence of necrotic tissue and the hypoxia of fast growing high-grade gliomas due to pathological vascularization may induce changes in the adjacent regions with the potential to increase neuronal excitability (Fig. 39.1). Some patients with chronic tumor-related seizures may develop secondary epileptic foci that do not correspond to the tumor or peritumoral area, although this phenomenon is still far more controversial in human epilepsy compared to animal models (Cibula and Gilmore, 1997). It is clear though that epileptic activity in regions distant to the tumor is more frequently found in patients with a long seizure history and with temporal lobe tumors. Consistent with the existence of separate epileptic foci, these patients tend to have two different types of focal seizures (Cibula and Gilmore, 1997). Unless complete resection of

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a c

b d

e

Fig. 39.1 Micrographs of histopathological sections of a glioblastoma (kindly provided by Dr Aronica, Department of Neuropathology, University of Amsterdam, the Netherlands). (a) Hematoxylin-eosin staining shows characteristic tumor morphology with necrotic areas; (b) Immunostaining with

a

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anti-GFAP-antibody shows invasion of the tumor in the cortex; (c) Hematoxylin-eosin staining at higher magnification shows polymorphic tumor cells and (d) proliferating blood vessels; (e) Immunostaining with anti-Ki6 antibody shows a large amount of proliferating tumor cells

b

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Fig. 39.2 Micrographs of histopathological sections of an astrocytoma grade II (kindly provided by Dr Aronica, Department of Neuropathology, University of Amsterdam, the Netherlands). (a) Hematoxylin-eosin staining shows a well-differentiated tumor at low, respectively; (b) high magnification; (c) and the infiltration of the tumor in the cortex;

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f (d) Immunostaining with anti-GFAP antibody shows immunoreactive astrocytic tumor cells; (e) whereas the tumor cells lack immunoreactivity for neuronal nuclear protein; (f) Immunostaining with anti-Ki6 antibody shows few (<4%) proliferating tumor cells

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the epileptogenic zones is performed in addition to tumor resection, identified by preoperative foci mapping, these patients will continue to have postoperative seizures.

Genetic Factors It is likely that genetic factors play a causative role in the large variability of epileptic symptoms in patients with glioma. No candidate genes have been identified yet that can be associated with susceptibility for tumorassociated epilepsy in glioma (Berntsson et al., 2009). A number of monogenetic diseases are known with an increased risk for developing epilepsy. Of particular interest for glioma-related seizures are mutations in the tumor-suppressor gene LGl1. This gene, located at the 10q24 region, codes for the leucine-rich glioma inactivated protein 1 (LGI1) or epitempin. LGI1 plays a role in glioma progression, probably by regulation of cell migration and invasion, and mutations of this gene cause the syndrome autosomal dominant partial epilepsy with auditory features, a rare form of lateral temporal lobe epilepsy (Kalachikov et al., 2002). The exact mechanism of how LGII contributes to the epileptogenesis of glioma is not known.

Clinical Manifestations Clinical manifestations of tumor-related seizures include all types of partial seizures with or without secondary generalization. Sometimes the duration of the focal seizure component is extremely short and these clinical seizure manifestations may erroneously be classified as primary generalized tonic-clonic seizures. Secondary generalization is more common in early seizures, i.e. seizures that occur at disease presentation and before antiepileptic treatment is started. Once antiepileptic drug therapy has been initiated, the seizures tend to become focal only (Hildebrand et al., 2005).

Seizure Types Complex focal seizures are more common in patients with slowly growing gliomas and chronic epilepsy,

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whereas simple focal seizures occur more frequently in high-grade gliomas. There is often a good correlation between tumor location and seizure type, although it may be extremely difficult to differentiate on clinical grounds only, for example between temporal lobe and frontal lobe seizures (Manford et al., 1996). In general, manifestations of behavioral automatisms and experiential symptoms are strongly associated with temporal lobe lesions. Tonic movements and head turning are, if appearing at seizure start, strongly associated with frontal tumor location. Adversive seizures due to frontal lobe lesions are characterized by turning of the neck, head and eyes to one side. Another typical manifestation of frontal lobe epilepsy is motor agitation, characteristically occurring at night or upon awakening in early morning, occurring in patients with deep frontal lobe tumors. Focal Jacksonian motor or somatosensory seizures occur with tumor location in perirolandic areas. Patients with temporal lobe tumors may report characteristic focal complex seizures with auditory hallucinations, language or memory disturbances, déjà vu phenomena, epigastric or gustatory or olfactory auras. They can also experience isolated auras without other signs of epileptic manifestations. In general, complex automatisms are strongly associated with temporal lobe lesions. Seizures in patients with occipital lobe tumor location typically consist of positive visual symptoms as hallucinations (flickering or blinking lights) and other visual disturbances but may also include visual field defects or blurred vision. Thus, a differential diagnosis of migraine is sometimes difficult to exclude even in patients with known lesions of the occipital lobe.

Status Epilepticus Considering the frequency of epilepsy in the glioma population, studies on status epilepticus in this patient group are surprisingly sparse. In line with the general pattern of tumor-related seizures, status epilepticus seems to occur most often at disease onset or at the time of tumor recurrence. Data from the literature suggest that status epilepticus is more common in patients with low-grade gliomas with an oligodendroglial tumor component (Cavaliere et al., 2006).

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Seizures and Tumor Progression Recurrent seizures after an initial seizure-free period or late-onset seizures should raise the suspicion of increased growth rate of the tumor in patients with a history of glioma, although the exact correlation with tumor progression is not known. As mentioned, the onset of epileptic seizures in glioma patients is usually an early symptom of disease. However, in 10–15% of all patients with glioma-related epilepsy, seizures manifest at a later stage of disease. Half of all patients with late-onset seizures are diagnosed with a tumor recurrence or progressive tumor growth (Hildebrand et al., 2005). In case neuroimaging does not reveal progressive tumor growth, seizure breakthrough due to insufficient therapeutic serum levels of antiepileptic drugs should always be ruled out. Likewise, interactions of antiepileptic drugs with other ongoing medication have to be considered. However, frequent breakthrough seizures may antedate radiological evidence of tumor recurrence. Therefore, radiological investigations should be repeated over time or other imaging modalities should be considered in patients with deterioration of seizure control.

Differential Diagnoses The wide availability of MRI-technology has greatly improved the efficiency of glioma diagnosis in patients presenting with epileptic seizures. The two main causes for delaying tumor diagnosis are clinical misinterpretation of symptoms as non-epileptogenic and misinterpretation of radiological findings. As a rule, a brain tumor diagnosis should be excluded by neuroimaging in all adults presenting with a first unprovoked epileptic seizure. Symptomatic focal seizures are typical for tumor-related epilepsy, but when the focal onset is of short duration and rapidly followed by secondary generalization the seizures are often interpreted as primary generalized. In clinical practice, a tumor should therefore always be considered as a differential diagnosis in adult-onset epilepsy, regardless of seizure semiology. Another important clinical issue is that focal epileptic seizures are quite commonly not recognized as such and misdiagnosed by both patients and health

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care professionals. The presence of focal seizures, with or without secondary generalization, can easily be confused with other diagnoses, resulting in delayed tumor diagnosis. Some of the differential diagnoses, together with their typical symptoms and signs, are described here.

Transient Ischemic Attack (TIA) or Ischemic Infarction Vascular disease etiology is the main differential diagnosis in elderly individuals presenting with intermittent or persistent neurological symptoms. In vascular disease, there is typically an abrupt loss of neurological function that, in contrast to simple focal motor or somatosensory seizures, does not show the characteristic spread (“March”) to adjacent parts of the body. The duration of symptoms induced by transient ischemic attacks (TIA) is usually minutes – hours, whereas focal seizures are typically shorter (seconds – minutes).

Syncope In case of syncope, there is a transient self-limiting loss of consciousness, usually preceded by symptoms and signs of light-headedness, nausea and pallor and followed by rapid recovery without prolonged confusion or drowsiness. Provoking factors like orthostatic hypotension and emotional distress are often present.

Migraine Aura A migraine aura has a typical gradual onset of neurological symptoms and lasts approximately 5–30 min, often migrating from one part of the body to another. Migraine auras may involve several neurological functions (visual, sensory, speech) and several vascular domains. The aura is usually, but not always, followed by headache and by symptoms such as nausea and photophobia.

Drop Attacks Drop attacks are characterized by abrupt loss of tonus causing sudden falls, without any precipitating factors and without affecting consciousness. Such attacks

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Disturbances in cardiac conduction may clinically resemble epileptic seizures, especially when not typically provoked by physical exercise. This underlines the importance of a thorough clinical history and physical examination together with ambulatory electrocardiographic (ECG) and electroencephalographic (EEG) recording in these patients.

activities of daily life (Taphoorn and Klein, 2004). In particular elderly patients or patients with prior cognitive impairment are prone to disabling sedative and cognitive side effects of antiepileptic drugs. Finally, elderly patients with aggressive high-grade gliomas may experience a prolonged post-ictal loss of neurological function following generalized seizures and are at risk of not or very slowly regaining their pre-ictal level of functioning. It is important to realize that in many cases optimal seizure control is not achieved by antiepileptic drugs only but requires additional surgical resection and/or radiotherapy and chemotherapy. Thus, a multidisciplinary team of dedicated neurologists, neurooncologists and neurosurgeons is required for optimal clinical management of glioma-related seizures.

Psychogenic Symptoms

Antiepileptic Drug Treatment

Non-convulsive temporal lobe seizures or frontal seizures without generalization may be misdiagnosed as panic or anxiety attacks, hyperventilation spells or other emotional and behavioral disorders, especially in patients with psychiatric co-morbidity.

The choice of which antiepileptic drug to prescribe to a patient with glioma should be made based upon drug efficacy, pharmacodynamic profiles and side effects of the individual substances. Antiepileptic drugs that induce components of the hepatic cytochrome P450 enzyme system include carbamazepine, phenytoin, phenobarbital, and to a lesser degree lamotrigine and topiramate. Enzymatic induction may result in an increased metabolism of chemotherapeutic agents as well as of other antiepileptic drugs and dexamethasone, which is frequently used in patients with highgrade gliomas. Although carbamazepine is one of the most effective and well-studied antiepileptic drugs for focal epilepsy, its use in patients with tumor-associated epilepsy is therefore hampered. The other drawback of carbamazepine in patients with glioma receiving chemotherapy is the potential risk of bone marrow depression. However, carbamazepine is still one of the drugs of choice for patients who are not to receive chemotherapy within the nearest future. Phenytoin, in spite of its potent antiepileptic effect, is not used that often any more because of its serious side effects on cognitive function and its complex pharmacokinetics with a high risk of toxicity. The prodrug phosphenytoin, on the other hand, is a useful drug when administered intravenously in the emergency situation for treating status epilepticus.

can be of purely benign nature, typically occurring in middle-aged women. However, drop attacks may also be caused by insufficient brain perfusion during episodes of increased intracranial pressure, due to space occupying lesions.

Cardiac Arrythmia

Treatment Although epileptic seizures are common and distressing symptoms of disease in patients with glioma, the clinical management of seizures by antiepileptic treatment is not always optimal. A possible explanation for this is that tumor treatment often has higher priority, consuming most of the time and resources of health care professionals, especially in the case of high-grade gliomas. However, optimal seizure control during the entire course of disease is of great importance for all patients with glioma. It has been confirmed by several studies that persistent seizures have a profound negative impact on the quality of life for these patients (Klein et al., 2003). Furthermore, poor seizure control often leads to multiple antiepileptic drug strategies, at the price of serious side effects such as drowsiness and disturbances of memory and attention. Impairment of cognitive function induced by polypharmacy may further deteriorate the capability to maintain social and professional

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Valproate is effective in treating focal as well as primary generalized seizures. Furthermore, the putative inherent antitumor properties of the drug, through its inhibition of histone deacetylase, are of interest in treating patients with glioma-related seizures. Valproate has relatively mild side effects, apart from rare but potentially fatal liver damage. However, valproate is an enzyme-inhibiting drug. Thus, decreased hepatic metabolism can cause increased risk of toxicity by concomitantly administered drugs such as chemotherapeutics. Furthermore, valproate may prolong bleeding time and is therefore avoided by some neurosurgeons. Several of the more modern antiepileptic drugs that are used for focal epilepsies have established an evident role in the treatment of gliomas-associated seizures, either in monotherapy or as add-on drug (van Breemen et al., 2007). Commonly used and well-tolerated antiepileptic drugs are levetiracetam, gabapentin and lamotrigin. These drugs do not have the strong enzyme-influencing effects of some of the older antiepileptic drugs, and the risk of interactions with other drugs is therefore probably smaller. On the other hand, psychotropic side effects of these antiepileptic drugs have been reported in some patients, which should be remembered in the clinical follow-up. Status epilepticus in glioma patients should be treated according to standard guidelines. Small patient series suggest that this subgroup responds well to conventional therapy with benzodiazepines or phosphenytoin (Lowenstein and Alldredge, 1993; Cavaliere et al., 2006). In spite of the frequent occurrence of epilepsy in patients with glioma, routine prophylactic use of antiepileptic drugs for patients who have not experienced seizures is not recommended (Glantz et al., 2000).

Refractory Seizures Refractory seizures are defined as seizures so frequent or sincere that they limit daily life, despite the use of antiepileptic drugs in adequate serum concentrations (Devinsky, 1999). According to this definition, around 35% of the overall patient population with focal epilepsy suffer from refractory seizures. The state of refractory seizures is commonly associated with a structural lesion in the brain, including brain tumors.

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Whereas approximately half of all adults with lowgrade gliomas presenting with seizures at disease onset become seizure-free on antiepileptic treatment, the other half of this population continues to have seizures in spite of optimal antiepileptic drug treatment (Chang et al., 2008). Some specific tumor locations in the brain are highly epileptogenic and thus frequently associated with refractory seizures, such as the insular and peri-insular region and the mesiotemporal lobe. These areas constitute common localizations for low-grade gliomas, in contrast to high-grade gliomas. Epileptic seizures in high-grade gliomas are less frequent but may be more difficult to control (Chaichana et al., 2009). The frequent lack of efficacy of antiepileptic drugs in glioma-associated epilepsy suggests that the pharmacological mechanisms of the anticonvulsant drug do not interfere with the critical epileptogenic pathways of these lesions. There are a number of alternative causes behind drug failure of glioma-related seizures, such as insufficient concentrations of the active drug metabolite in the tumor or blood due to active defense mechanisms by multi-drug resistance proteins. This hypothesis is supported by studies showing the expression of multi-drug resistance proteins in tumor types associated with refractory seizures (Aronica et al., 2003). Other possible mechanisms of drug failure include restricted penetration of lipophilic substances into the brain and loss of receptor sensitivity for antiepileptic drugs in tumor cells. In addition, interactions with other drugs may result in increased metabolism of the antiepileptic drug with insufficient serum levels of active drug metabolite (van Breemen et al., 2007).

Antitumor Treatment Alternative treatment modalities should be considered for patients who continue to have ongoing seizures in spite of optimal treatment with antiepileptic drugs. The effectiveness of surgery on seizure control has been shown in a number of studies, in particular for patients with low-grade gliomas (Brogna et al., 2008). Maximal tumor resection is a valuable strategy for improving seizure control in these patients but resection of epileptic foci needs to be included for optimal effect. Longterm video-electroencephalographic (EEG) monitoring is recommended for complicated cases where

39 Tumor-Associated Epilepsy in Patients with Glioma

seizure start and clinical seizure manifestations need to be explored. Also, the use of intraoperative electrocorticography monitoring has improved seizure control through identifying separate seizure foci surrounding the tumor (Brogna et al., 2008). By intraoperative electrostimulation mapping, the extent of the surgical resection can be increased while preserving the eloquent areas. This method has increased the indication for surgery of brain tumors that previously have been considered as “inoperable”, such as tumors located in the insular lobe and the rolandic area (Duffau and Capelle, 2004). Valuable lessons can be learned from the specialized medical staff taking care of patients admitted for epilepsy surgery. In fact, slowly growing gliomas such as gangliogliomas are frequently represented in this patient group and there is a considerable overlap between the two diagnostic patient groups (Duffau, 2009; Lombardi et al., 1997). In addition, radiotherapy, as single therapy or in combination with surgery, has shown beneficial effects in terms of seizure reduction. Studies have been performed mostly on patients with low-grade gliomas. In the randomized EORTC (European Organization for Research and Treatment of Cancer) 22845 trial, designed to compare survival in adult low-grade gliomas treated by early versus delayed radiotherapy, seizure outcome by radiotherapy was included as secondary endpoint in patients still progressionfree 2 years from randomization (van den Bent et al., 2005). Twenty-five percent of the irradiated patients had seizures compared to 41% of those not irradiated. Since there was no difference in seizure control at baseline between the two groups, it was concluded that seizures were better controlled in the group receiving radiotherapy. Consistent findings have been found in small retrospective reviews, showing a significant seizure reduction in irradiated patients. Small clinical studies are available on the role of chemotherapy in glioma-related seizures. Chemotherapy with temozolomide has shown to be effective in improving seizure control in patients with progressive low-grade gliomas (Brada et al., 2003). Interestingly, a significantly better seizure control by temozolomide was found in non-enhancing tumors compared to enhancing tumors in a study on progressive low-grade gliomas (Pace et al., 2003). Other chemotherapeutic agents may also have positive effects on seizure control, as shown in a study on paralimbic low-grade gliomas treated by surgery,

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chemotherapy or by a combination of these two (Taillandier and Duffau, 2009).

Summary and Discussion The clinical management of seizures is an important and challenging issue for all patients with gliomarelated seizure, irrespective of tumor histology. The specific aspects that need to be considered in optimizing seizure control for individual patients are related to the delicate balance between the efficacy, pharmacological profiles and side effects (in particular on cognitive function) of antiepileptic drugs, the impact of refractory seizures on cognition and the social and professional consequences of refractory seizures. In choosing antiepileptic drugs, other ongoing or planned medication needs to be taken into account and possible interactions between these drugs and the antiepileptic drug must be anticipated. When antiepileptic drug treatment fails, other treatment modalities for optimizing seizure control may be realistic options, such as surgery, radiotherapy and chemotherapy. For achieving optimal effect of surgery on seizure control, resection of the epileptic foci needs to be included in addition to tumor resection. Modern tools to identify separate epileptic foci such as preoperative video-EEG monitoring and intraoperative electrocorticography monitoring have largely improved the chances of favorable postoperative seizure control. The use of intraoperative electrostimulation mapping has increased the indication for epilepsy surgery, including patients with tumors previously considered to be inoperable. For optimal management of patients with gliomarelated seizures, a close collaboration is recommended between neuro-oncologists and a qualified team of neurosurgeons, neurophysiologists and neurologists involved in epilepsy surgery.

References Aronica E, Gorter JA, van Vliet EA, Spliet WG, van Veelen CW, van Rijen PC, Leenstra S, Ramkema MD, Scheffer GL, Scheper RJ, Sisodiya SM, Troost D (2003) Overexpression of the human major vault protein in gangliogliomas. Epilepsia 44:1166–1174

406 Beaumont A, Whittle IR (2000) The pathogenesis of tumour associated epilepsy. Acta Neurochir (Wien) 142:1–15 Berntsson SG, Malmer B, Bondy ML, Qu MQ, Smits A (2009) Tumor-associated epilepsy and glioma; Are there common genetic pathways? Acta Oncol 48:328–342 Brada M, Viviers L, Abson C, Hines F, Britton J, Ashley S, Sardell S, Traish D, Gonsalves A, Wilkins P, Westbury C (2003) Phase II study of primary temozolomide chemotherapy in patients with WHO grade II gliomas. Ann Oncol 14:1715–1721 Brogna C, Gil Robles S, Duffau H (2008) Brain tumors and epilepsy. Exper Rev Neurother 8:941–955 Cavaliere R, Farace E, Schiff D (2006) Clinical implications of status epilepticus in patients with neoplasms. Arch Neurol 63:1746–1749 Chaichana KL, Parker SL, Olivi A, Quiñones-Hinojosa A (2009) Long-term seizure outcomes in adult patients undergoing primary resection of malignant brain astrocytomas. J Neurosurg 111:282–292 Chang EF, Potts MB, Keles GE, Lamborn KR, Chang SM, Barbaro NM, Berger MS (2008) Seizure characteristics and control following resection in 332 patients with low-grade gliomas. J Neurosurg 108:227–235 Cibula JE, Gilmore RL (1997) Secondary epileptogenesis in humans. J Clin Neurophys 14:111–127 Devinsky O (1999) Patients with refractory seizures. N Eng J Med 340:1565–1570 Duffau H (2009) Surgery of low-grade gliomas: towards a ‘functional neurooncology’. Curr Opin Oncol 21:543–549 Duffau H, Capelle L (2004) Preferential brain locations of lowgrade gliomas. Cancer 100:2622–2626 Glantz MJ, Cole BF, Forsyth PA, Recht LD, Wen PY, Chamberlain MC, Grossman SA, Cairncross JG (2000) Practice parameter: anticonvulsant prophylaxis in patients with newly diagnosed brain tumors. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 54:1886–1893 Hildebrand J, Lecaille C, Perennes J, Delattre JY (2005) Epileptic seizures during follow-up of patients treated for primary brain tumors. Neurology 65:212–215 Kalachikov S, Evgrafov O, Ross B, Winawer M, BarkerCummings C, Martinelli Boneschi F, Choi C, Morozov P, Das K, Teplitskaya E, Yu A, Cayanis E, Penchaszadeh G, Kottmann AH, Pedley TA, Hauser WA, Ottman R, Gilliam TC (2002) Mutations in LGI1 cause autosomal-dominant partial epilepsy with auditory features. Nat Genet 30: 335–341

A. Smits and A. Storstein King MA, Newton MR, Jackson GD, Fitt GJ, Mitchell LA, Silvapulle MJ, Berkovic SF (1998) Epileptology of the firstseizure presentation: a clinical, electroencephalographic, and magnetic resonance imaging study of 300 consecutive patients. Lancet 352:1007–1011 Klein M, Engelberts NH, van der Ploeg HM, KasteleijnNolst Trenité DG, Aaronson NK, Taphoorn MJ, Baaijen H, Vandertop WP, Muller M, Postma TJ, Heimans JJ (2003) Epilepsy in low-grade gliomas: the impact on cognitive function and quality of life. Ann Neurol 54:514–520 Lombardi D, Marsh R, de Tribolet N (1997) Low grade glioma in intractable epilepsy: lesionectomy versus epilepsy surgery. Acta Neurochir 68(Suppl):70–74 Lowenstein DH, Alldredge BK (1993) Status epilepticus at an urban public hospital in the 19802. Neurology 3:483–488 Manford M, Fish DR, Shorvon SD (1996) An analysis of clinical seizure patterns and their localizing value in frontal and temporal lobe epilepsies. Brain 119:17–40 Olafsson E, Ludvigsson P, Gudmundsson G, Hesdorffer D, Kjartansson O, Hauser WA (2005) Incidence of unprovoked seizures and epilepsy in Iceland and assessment of the epilepsy syndrome classification: a prospective study. Lancet Neurol 4:627–634 Pace A, Vidiri A, Galiè E, Carosi M, Telera S, Cianciulli AM, Canalini P, Giannarelli D, Jandolo B, Carapella CM (2003) Temozolomide chemotherapy for progressive lowgrade glioma: clinical benefits and radiological response. Ann Oncol 14:1722–1726 Schaller B, Rüegg SJ (2003) Brain tumor and seizures: pathophysiology and its implications for treatment revisited. Epilepsia 44:1223–1232 Taillandier L, Duffau H (2009) Epilepsy and insular Grade II gliomas: an interdisciplinary point of view from a retrospective monocentric series of 46 cases. Neurosurg Focus 27:E8 Taphoorn MJ, Klein M (2004) Cognitive deficits in adult patients with brain tumours. Lancet Neurol 3:159–168 van Breemen MS, Wilms EB, Vecht CJ (2007) Epilepsy in patients with brain tumours: epidemiology, mechanisms, and management. Lancet Neurol 6:421–430 van den Bent MJ, Afra D, de Witte O, Ben Hassel M, Schraub S, Hoang-Xuan K, Malmström PO, Collette L, Piérart M, Mirimanoff R, Karim AB, EORTC Radiotherapy and Brain Tumor Groups and the UK Medical Research Council (2005) Long-term efficacy of early versus delayed radiotherapy for low-grade astrocytoma and oligodendroglioma in adults: the EORTC 22845 randomised trial. Lancet 366:985–990

Chapter 40

Brain Tumors Arising in the Setting of Chronic Epilepsy Richard A. Prayson

Abstract Brain tumors, along with malformations of cortical development (cortical dysplasia), hippocampal sclerosis, and remote ischemic damage, are among the more common identifiable causes of pharmacoresistent chronic epilepsy. The majority of tumors arising in this setting present in the first two decades of life and fortunately most tumors tend to be low grade neoplasms, with at least half of the tumors representing glioneuronal neoplasms. The spectrum of tumor types which have been identified in this clinical setting of chronic epilepsy continues to expand with the recent addition of the angiocentric glioma to The WHO Classification of Tumours of the Central Nervous System. This chapter will review some of the more commonly encountered tumors that arise in the setting of medically intractable epilepsy. Keywords Brain tumor · Malformation · Chronic epilepsy · Ganglioglioma · DNET · Astrocytic neoplasms

Introduction Tumors are a well recognized cause of medically intractable, chronic epilepsy. In cases where pathology is identifiable, neoplasms account for the primary pathology in anywhere from 10 to 30% of patients going undergoing surgical treatment for

R.A. Prayson () Section of Neuropathology, Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH 44195, USA e-mail: [email protected]

chronic epilepsy (Britton et al., 1994). Collectively, these tumors typically present in the first two decades of life and are generally low grade neoplasms (WHO grade I or II). In the larger series that have been reported in the literature, gangliogliomas, dysembryoplastic neuroepithelial tumors (DNET) and low grade astrocytomas (pilocytic or fibrillary) are the most commonly encountered neoplasms (Bourgeois et al., 1999; Pasquier et al., 1996; Zentner et al., 1997). In a recently published large series of pediatric patients with tumors in chronic epilepsy, the majority of tumors presented in the temporal lobe (59.7%) and were WHO grade I tumors (56.6%) (Prayson, 2010). The most common tumor types encountered in this series of 129 patients in descending order included ganglioglioma (37.2%), DNET (13.2%), low grade astrocytoma (11.6%), low grade mixed glioma (6.2%), and low grade oligodendroglioma (3.9%). A coexistent malformation of cortical development or cortical dysplasia was observed in 29.8% of evaluable cases, suggesting that many of these glioneuronal tumors may have a maldevelopmental basis to their origin. Some of the differences that have been reported in terms of incidences of various tumors in surgical series may be explained by a number of factors. Differences in terms of how one interprets definitions of these various entities clearly exist. This is particularly problematic at times because a number of these tumors can resemble one another. A microcytic oligodendroglioma, on a limited pathology specimen, can resemble areas of a DNET. If one is not careful to closely follow the diagnostic criteria for DNET, one can very easily interpret the oligodendroglioma as representing a DNET, which has prognostic and potential treatment implications. The typical DNET is a multinodular, cortical based glioneuronal

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neoplasm with associated cortical dysplasia in contrast to the typical uninodular, white matter based oligodendroglioma, which is not known to be associated with cortical dysplasia. Definitions of what constitutes a mixed glioma (oligoastrocytoma) also varies and can result in different interpretations of the pathology. The exact percentage of a minor component in a mixed glioma that needs to be present in order to make that diagnosis has not been well established. Mixed gliomas, which contain areas in which both the astrocytoma and oligodendroglioma component are mixed, are also problematic. The extent of tissue sampling at the time of dissection of the pathology specimen can also impact the diagnosis. Gangliogliomas are tumors that comprised of areas resembling low grade glioma, typically astrocytoma, accompanied by areas which contain atypical neuronal or ganglionic cells. Unfortunately, both components of the tumor are not evenly mixed throughout the neoplasm. A limited sampling may not demonstrate the atypical ganglion cell component of the tumor and may result in an erroneous diagnosis of a low grade astrocytoma. Extensive sampling of the neoplasm is therefore warranted to ensure that diagnostic features of the tumor are sampled. There are a variety of tumors which are less frequently encountered in this setting and are relatively uncommon neoplasms in general. Unfamiliarity with such entities as protoplasmic astrocytoma, angiocentric glioma, and meningioangiomatosis may present additional challenges to the pathologist who may not have had much experience with diagnosing these lesions. Also, there are entities which are more complex and do not clearly fit into the current classification systems for brain tumors. Composite tumors consisting of mixtures of DNET and ganglioglioma or ganglioglioma and pleomorphic xanthoastrocytoma have been also described.

Ganglioglioma (WHO Grade I) The most common tumor encountered in the setting of chronic epilepsy is ganglioglioma (Miller et al., 1993; Prayson et al., 1995; Wolf et al., 1994). The majority of these tumors arise in the first three decades of life. The tumor has been described to arise throughout the central nervous system, although the majority of tumors are localized to the temporal lobe. On imaging,

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the tumor appears as a circumscribed solid or cystic mass. Calcifications are frequently present. Contrast enhancement is common but may be absent in some neoplasms. Histologically, the tumor is marked by a glioma component that generally resembles a low grade fibrillary astrocytoma, pilocytic astrocytoma, or less commonly an oligodendroglioma (Fig. 40.1a). Intermixed with this component is a population of atypical neuronal or ganglionic cells marked by a cytologic alterations including an abnormal distribution of Nissl substance, binucleation, and occasional neurofibrillary tangles (Fig. 40.1b). Vascular proliferative changes may be focally evident but do not carry the same poor prognosis that they do when seen in the setting of a fibrillary astrocytoma or oligodendroglioma. Focal leptomeningeal extension of the tumor may be evident but does not appear to carry with it a poor prognosis (Fig. 40.1c). Other common features include the presence of perivascular chronic inflammation consisting of benign appearing lymphocytes, microcalcifications, and eosinophilic granular bodies. Necrosis and prominent mitotic activity are generally not features of the typical ganglioglioma, and if present in any appreciable amount, may be indicative of a higher grade lesion, so called anaplastic ganglioglioma (WHO grade III). Not surprisingly, markers of cell proliferation, such as Ki-67, generally show low rates of cell proliferation; Ki-67 labeling indices are ∼1%. Immunohistochemistry may be useful in confirming that the ganglionic-like cells are neuronal in the derivation. Tumors with large or giant astrocytic cells (such as gemistocytic astrocytoma) may mimic a ganglioglioma, if the large cells are interpreted as being neuronal in derivation rather than astrocytic (Fig. 40.1d). Care should be used when interpreting immunohistochemical staining for neuronal markers. Normal entrapped resident neurons will also stain with neuronal antibodies and should not be misinterpreted as being part of the tumor. Care should be taken in using cell proliferation labeling indices to assist in differential diagnosis. Although a higher labeling index in excess of 5% would be quite unusual in a ganglioglioma and may be indicative of a grade II or III neoplasm, a low labeling index does not necessarily make a diagnosis of ganglioglioma; some grade II gliomas will focally demonstrate similarly low labeling indices. As briefly mentioned in the introduction, these tumors need to be extensively sampled, since

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Fig. 40.1 (a) The components of ganglioglioma are often not evenly distributed throughout the neoplasm. This area shows the glioma component of the tumor resembling a low grade diffuse astrocytoma with moderate hypercellularity and atypia (original magnification ×200); (b) This area of a ganglioglioma is marked by atypical neuronal cells with cytoplasmic neurofibrillary tangles. Microcalcification is observed in the lower right corner (original magnification ×400); (c) Focal leptomeningeal extension can be observed in some gangliogliomas and does not appear to adversely influence outcome (original magnification ×100); (d) The large cells seen in this tumor turned out

to be GFAP positive and synaptophysin negative and represent a component of a gemistocytic astrocytoma. Immunostaining can be useful in delineating the lineage of cellular components in ganglioglioma (original magnification ×200); (e) Low magnification appearance of a DNET highlighting the intracortical location and multinodular architecture (original magnification ×50); (f) DNET marked by a proliferation of generally rounded cells with scant cytoplasm arranged against a microcystic background. Occasional normal appearing neuronal cells are observed floating in the cystic spaces (original magnification ×200)

the neuronal or ganglionic component of the tumor may be only focally evident. A failure to sample the neuronal component may potentially result in the erroneous diagnosis of a grade II low grade glioma, which has the potential of recurring and progressing to a higher grade lesion in a shorter interval of time. The prognosis of a ganglioglioma is excellent. These tumors are presumably cured with gross total resection. A significant relief of epilepsy has been documented in many of these tumors following resection. Interestingly, the tumors themselves are frequently electrically silent and the seizures appear to originate

from the surrounding tissue. Studies have documented that the majority of these tumors are accompanied by adjacent malformations of cortical development or cortical dysplasia. The malformations of cortical development represent a group of abnormalities of cortical architectural disorganization thought to be related to some abnormality that occurs during the development of the brain. The patients, who have recurrent or persistent seizures following excision of their ganglioglioma, are thought to have residual cortical dysplasia.

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Dysembryoplastic Neuroepithelial Tumor (DNET) (WHO Grade I) DNETs are another glioneuronal tumor that have a particularly good prognosis (Daumas-Duport et al., 1988; Daumas-Duport, 1993; Prayson et al., 2002). Like gangliogliomas, these tumors are most commonly encountered in younger age patients, with the temporal lobe being the most common, albeit not the only, location for these neoplasms. On imaging, the tumor is predominately cortical-based and may appear hyperintense on T2-weighted MRI images or hypointense or isointense on T1-weighted images. The lesion often has a pseudopolycystic appearance and may show evidence of calcification. Histologically, the classic lesion is marked by a cortical location and a multinodular architecture (Fig. 40.1e). The predominate tumor cell resembles an oligodendroglial-like cell with generally rounded nucleus and scant cytoplasm (Fig. 40.1f). These cells are often arranged against a microcystic background. Floating in the microcystic pools are normal appearing neuronal cells. There is minimal cytologic atypia in either component of this glioneuronal neoplasm. Prominent mitotic activity and necrosis are unusual; occasional tumors may show vascular proliferative changes. Calcification may be evident. Like gangliogliomas, careful inspection of the adjacent parenchyma shows architectural disorganization consistent with a malformative or developmental origin for the neoplasm (Fig. 40.2a). Proliferation markers show low levels of staining, on par with ganglioglioma. Like gangliogliomas, excision of the lesion results in good seizure outcome. The tumor is generally considered benign. Occasional case reports of more aggressive or “malignant” behavior in these tumors have been reported; these cases are often based on criteria which deviate from the WHO definition and raise questions regarding the proper classification of these unusual cases. From a practical differential diagnostic standpoint, differentiation of this lesion from a low grade oligodendroglioma or mixed glioma can be problematic, particularly in a less intact surgical specimen. A small sampling of an infiltrative low grade oligodendroglioma with a microcystic background and entrapped cortical neurons can closely resemble areas of a DNET and the two entities may be

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indistinguishable. Characteristic features or clues to resolve the differential may not always be evident i.e. things such as predominate cortical location, multinodularity, and adjacent cortical dysplasia, all of which favor a DNET versus subpial aggregation of cells, predominate white matter location, uninodularity, and the presence of minigemistocytes which favor oligodendroglioma. In cases where these distinguishing features are not evident, one can employ molecular studies looking for evidence of large deletions on chromosomes 1p and 19q, features with have been associated with oligodendroglioma. In the presence of large deletions, a diagnosis of oligodendroglioma or mixed glioma would be favored. In cases where the deletions are not evident, the diagnostic dilemma remains; deletions have not been reported in DNETs and are not present in approximately 20–40% of oligodendrogliomas.

Astrocytic Neoplasms A variety of astrocytic neoplasms have been associated with chronic epilepsy. Low grade diffuse or fibrillary astrocytomas (WHO grade II) may occasionally present with chronic seizures and may arise anywhere throughout neuroaxis (Louis et al., 2007). These neoplasms are characterized by mild hypercellularity and a proliferation of atypical appearing fibrillary-type astrocytes marked by nuclear enlargement, irregularities of the nuclear contour, and nuclear hyperchromasia (Fig. 40.2b). A rare mitotic figure may also be observed. Focally, calcifications or microcystic changes may be evident. Vascular proliferative changes and necrosis are absent. In contrast to the gangliogliomas and DNETs, these tumors tend to be more infiltrative in nature and are not as amenable to surgical resection. With time, these tumors will progress to a higher grade lesion and may require adjuvant radiation therapy or chemotherapy. Cell proliferation indices are generally low and may overlap with indices observed in grade I glioneuronal tumors. Although astrocytomas may present in the first two decades of life, they are typically more commonly encountered in a slightly older population of patients, with a peak incidence in young adults between the ages of 30–40 years. Imaging studies show an illdefined, homogeneous lesion of low signal intensity.

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Fig. 40.2 (a) The area adjacent to a DNET showing an abnormal cortical architecture marked by an absence of cortical layer 2 consistent with a malformation of cortical development or cortical dysplasia (original magnification ×200); (b) This low grade diffuse or fibrillary astrocytoma is characterized by mild hypercellularity due to a proliferation of atypical cells with enlarged nuclei and irregular nuclear contours (original magnification ×400); (c) The looser area of a pilocytic astrocytoma characterized by multiple eosinophilic granular bodies (original magnification ×400); (d) A microcystic area of a pilocytic

astrocytoma showing focal vascular proliferative changes; this finding does not carry with it the same poor prognosis as it does when encountered in the setting of a diffuse astrocytoma (original magnification ×200); (e) This protoplasmic astrocytoma is comprised of generally rounded cells with scant cytoplasm arranged against a microcystic background (original magnification ×200); (f) Pleomorphic xanthoastrocytomas are typically marked hypercellular and are comprised of very pleomorphic cells. Lipidized astrocytes, as seen here, are present in only a subset of cases (original magnification ×200)

Occasional tumors may show appreciable numbers of large gemistocytes. These gemistocytes are marked by abundant eosinophilic cytoplasm and laterally displaced nuclei, which are slightly enlarged and may have a slightly irregular nuclear contour. Care should be taken in not confusing gemistocytes with a neuronal or ganglion cells proliferation, resulting in an erroneous diagnosis or ganglioglioma. If one is uncertain about the linage of these cells, they are readily highlighted with a GFAP (glial fibrillary acidic protein) immunostain in contrast to neuronal or ganglionic cells which will stain with markers of neural differentiation such as synaptophysin.

Pilocytic astrocytomas (WHO grade I) represent a special variant of astrocytoma that have a particularly good prognosis (Louis et al., 2007). They comprise approximately 5–6% of all gliomas and arise most commonly in children. Most tumors originate in the cerebellum, brain stem, thalamic/basal ganglia, and optic chiasm regions. Occasional tumors arise in the region of the third ventricle and may present with epilepsy. The classic imaging appearance of the lesion is that of a cystic tumor with enhancing mural nodule or nodules. Histologically, the classic pilocystic astrocytoma has a biphasic appearance. Areas of the tumor are

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marked by cells that are elongated and arranged against a fibrillary background. Eosinophilic Rosenthal fibers are usually identifiable in these regions if present (about 75% of cases). These fibrillary zones alternate with areas in which the cells are more rounded and arranged against a microcystic background. The eosinophilic granular bodies, if present, are usually more readily observable in the looser regions (Fig. 40.2c). Pleomorphic nuclei are not uncommon in these tumors. Vascular proliferative changes and vascular sclerosis may be also evident (Fig. 40.2d); the vascular proliferation does not carry the same ominous prognosis it does when observed with a fibrillary astrocytoma. Infiltration of the leptomeninges may on occasion be noted. Areas of the tumor may consist of more rounded cells and resemble a low grade oligodendroglioma, creating the overall impression of a mixed glioma. Cell proliferation indices are generally low, typically on the order of approximately 1%; however, occasional cases may show labeling indices as high as 3–4%. The challenge from a diagnostic standpoint is usually in cases where the sampling is limited and the characteristic features of the tumor are not evident. This can result in an erroneous diagnosis of a fibrillary astrocytoma or low grade mixed glioma. The glioma component of a ganglioglioma can also resemble a pilocytic astrocytoma and a failure to identify the atypical ganglion cell component may result in an incorrect diagnosis of pilocytic astrocytoma. The pilocytic tumors are generally amenable to surgical resection and have an excellent prognosis. The rare protoplasmic astrocytoma (WHO grade II) has also been associated with chronic epilepsy (Prayson and Estes 1995, 1996). Protoplasmic astrocytomas show a preference for temporal and frontal lobes and seem to be predominately cortical based. Microscopically, they are marked by a proliferation of astrocytic cells with generally round or slightly oval nuclear contours and a scant amount of eosinophilic cytoplasm (Fig. 40.2e). The tumor cells are generally arranged against a microcystic background. The histologic appearance warrants a differential diagnosis with microcystic oligodendroglioma and DNET. In contrast to the DNET, the protoplasmic astrocytoma does not show evidence of adjacent cortical dysplasia and is not a multinodular neoplasm. Chromosomal studies have shown no evidence of the signature 1p deletions that are associated with oligodendroglioma

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in the protoplasmic astrocytoma. The number of cases that have been reported to date are rather small and the literature suggests that a subset of tumors may progress or degenerate into a higher grade lesion over time. The pleomorphic xanthoastrocytoma (WHO grade II) is a rare variant of astrocytoma which typically presents in children and young adults, often with a long history of seizures (Giannini et al., 1999; Kepes et al., 1979). The vast majority of tumors arise in the temporal or parietal lobes. Like DNETs, they are often cortical based. They may have a cystic component with a mural nodule. Histologically, they are markedly hypercellular and as its name suggests marked by prominent nuclear pleomorphism (Fig. 40.2f). Prior to its recognition as a distinct entity, many of them were mislabeled as representing glioblastoma. In contrast to glioblastoma, these tumors show little in the way of mitotic activity and lack necrosis. Vacular proliferative changes may be evident. The xanthoastrocytes (lipidized astrocytes) are a variable feature of this tumor but are helpful when present. Perivascular lymphocytes, eosinophilic granular bodies, focal extension into the leptomeninges, and microcalcifications may all be present. Reticulin staining highlights the presence of increased staining surrounding individual cells or small groups of cells; this is in contrast to the typical glioblastoma lesion where reticulin staining is usually observed only in association with vascular proliferative changes. Most of the tumor’s cells stain positively with antibodies to GFAP and S-100 protein. Interestingly, a subset of cells in the tumor has been reported to variably stain with markers of neuronal differentiation, such as synaptophysin, neurofilament and class III beta-tubulin. This finding raises interesting questions regarding the lineage of this tumor and suggests the possibility of a glioneuronal neoplasm. A report of adjacent malformation of cortical development (cortical dysplasia) has been published. Cell proliferation labeling indices may be variable and range from low to intermediate levels. Rare cases of anaplastic pleomorphic xanthoastrocytoma (WHO grade III) have been described and are typically marked by increased mitotic activity (5 or more mitoses per 10 high power fields), necrosis and high cell proliferation labeling indices. Progression of low grade tumors to this higher grade lesion has also been described. The prognosis is generally favorable with a 70% 10 year survival

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(much better than its histologic appearance would suggest).

Low Grade Oligodendroglioma and Mixed Glioma (Oligoastrocytoma) (WHO Grade II) Low grade oligodendrogliomas are a relatively infrequent case of chronic epilepsy in young patients (Louis et al., 2007). Overall, oligodendrogliomas are much less common than their fibrillary astrocytoma counterparts. The peak incidence is in the 5th decade of life. Tumors arise in the white matter with the frontal and temporal lobes being the most common sites of origin. On imaging studies, calcifications and evidence of hemorrhage are fairly common. Microscopically, the tumor is marked by a fairly monomorphic proliferation of cells with generally rounded nuclear contours and scant cytoplasm (Fig. 40.3a). Pericellular haloes (fried egg appearance) represent an artifact of delayed formalin fixation; therefore, the haloes will not be evident on a frozen section slides or smear cytologic preparations. An arcuate or chicken wire vascular pattern is evident due to accentuation of small vessels resulting from a paucity of cell processes. Microcystic changes may be evident and may result in an appearance resembling the DNET. Some tumors contain cells which resemble small gemistocytes (minigemistocytes) (Fig. 40.3b). Cells comprising the tumor have a propensity to satellite around preexisting structures, such as neurons or blood vessels. Subpial aggregation of infiltrating tumor cells may also be evident. Similar to fibrillary astrocytoma, higher grade lesions (anaplastic oligodendrogliomas- WHO grade III) have been described and are generally characterized by increased cellularity and nuclear pleomorphism, increased mitotic activity (typically 5 or more mitoses per 10 high power fields), and necrosis. These higher grade tumors usually are too rapidly growing to result in a presentation of chronic epilepsy. Markers of cell proliferation show higher indices in the higher grade tumors. Oligodendrogliomas are infiltrative tumors and not always amenable to complete resection. A majority of oligodendrogliomas are chemoresponsive and grade for grade, they have a better prognosis than

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fibrillary astrocytomas. With time, many of the low grade tumors will progress to higher grade neoplasms. Of particular note is the association of chemoresponsiveness in oligodendrogliomas with large deletions on chromosomes 1p and 19q. The large deletions afford tumors (especially the higher grade lesions) a better prognosis because of the association with chemoresponsiveness. These molecular findings can also be useful in terms of sorting out differential diagnoses; oligodendroglioma lookalike tumors like DNET and protoplasmic astrocytomas do not demonstrate the large chromosomal deletions. The mixed gliomas (oligoastrocytomas) represent a group of tumors which are marked by geographically distinct areas resembling a fibrillary astrocytoma and an oligodendroglioma. The diagnosis is not terribly reproducible, since the criteria are a bit nebulous and identification of patterns is not always agreed upon. Guidelines suggest that somewhere between 20 and 35% of a minor component (depending on who you read) should be recognized in order to make the diagnosis. It is not unusual in many of these tumors for the two phenotypes to be intermixed in a more diffuse pattern. The diagnosis ends up being reflective of the biases of the pathologist; some pathologists may use the diagnosis fairly regularly; whereas, others may use it sparingly. Consequently, interpretation of the literature on the subject is difficult. Many studies simply lump mixed gliomas together with pure oligodendrogliomas for purpose of analysis, further confusing the matter. Like fibrillary astrocytomas and low grade oligodendrogliomas, mixed gliomas generally arise in the white matter and are infiltrative neoplasms. The same parameters that are used for grading astrocytomas and oligodendrogliomas are also used to evaluate and grade these tumors as well. Anaplastic mixed gliomas are generally more cellular, more pleomorphic, marked by increased mitotic activity and may demonstrate vascular proliferative changes. The presence of necrosis now warrants classification of the tumor as a glioblastoma with an oligodendroglioma component. Chromosome 1p and 19q analysis shows a deletion prevalence intermediate between pure astrocytoma and oligodendroglioma. Prognosis is thought to be intermediate between the low grade astrocytoma and low grade oligodendroglioma, although 1p/19q deleted mixed gliomas tend to behave more like oligodendrogliomas.

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R.A. Prayson

Fig. 40.3 (a) The classic appearance of a low grade oligodendroglioma is marked by a monomorphic proliferation of rounded cells; the pericellular clearing is an artifact of delayed formalin fixation (original magnification ×400); (b) Occasional oligodendrogliomas may contain a subpopulation of cells with increased eosinophilic cytoplasm and eccentrically placed nucleus, socalled minigemistocytes (original magnification ×400); (c) Meningioangiomatosis is characterized by a proliferation of blood vessels surrounded by collars of spindled meningothelial

cells (original magnification ×200); (d) Sometimes, prominent sclerosis of blood vessels in meningioangiomatosis can result in an appearance suggestive of a vascular malformation original magnification ×400); (e) Perivascular pseudorosettes are a characteristic feature of the angiocentric glioma (original magnification ×200); (f) The interface between the angiocentric glioma and adjacent brain shows an infiltrative border (original magnification ×400)

Meningioangiomatosis (No WHO Grade)

of a vascular malformation. Microscopically, the lesion is marked by a proliferation of blood vessels surrounded by collars of spindled meningothelial cells (Fig. 40.3c). Calcifications are frequently seen in the intervening parenchyma. Neurons in the cortex may show dysmorphic changes including neurofibrillary tangles and granulovacuolar degeneration. In some cases, prominent sclerotic vessel changes are observed and recognition of the meningothelial collars may be difficult (Fig. 40.3d). Excision of the lesion usually results in dramatic seizure improvement.

Meningioangiomatosis is a rare developmental or hamartomatous abnormality which may present like a neoplasm (Halper et al., 1986; Perry et al., 2005; Prayson, 1995). There is a known association with neurofibromatosis type 2. The lesion appears as a somewhat discrete, plaque-like cortical mass (although microscopically, the lesion extends to involve the white matter). Overlying meningioma may be present in some cases. Large blood vessels may be situated on the surface of the lesion, giving the gross impression

40 Brain Tumors Arising in the Setting of Chronic Epilepsy

Angiocentric Glioma (WHO Grade I) Angiocentric glioma is a fairly recently recognized entity which presents primarily in children or young adults (Lellouch-Tubiana et al., 2005; Preusser et al., 2007; Wang et al., 2005). The tumor appears fairly well circumscribed and solid on imaging studies, although it is typically infiltrative microscopically. Histologically, the neoplasm is marked by a proliferation of spindled cells focally arranged around blood vessels (predominantly in the cortex) forming perivascular pseudorosette structures (Fig. 40.3e). Subpial aggregation of tumor cells is also evident in some cases. The tumor has an infiltrative pattern at the perimeter (Fig. 40.3f). Prominent mitotic activity, vascular proliferative changes and necrosis are not seen. The prominence of the pseudorosette pattern raises a differential diagnosis with ependymoma and astroblastoma. Interestingly, a subset of these tumors demonstrate dot-like EMA (epithelial membrane antigen) positivity on immunostaining as well as microvilli, cilia and desmosomes, all features typically associated with ependymal differentiation. The current hypothesis regarding origin is that the tumor arises from bipolar radial glia that have the capability to differentiate along ependymal lines. Cell proliferation indices are generally very low. The tumor has a generally excellent prognosis and is thought to be cured with total surgical resection.

Composite Tumors There are still occasional tumors that one encounters in the setting of chronic epilepsy that do not neatly fit into the current WHO classification. Rare examples of socalled composite tumors have been described, tumors with combined features of pleomorphic xanthoastrocytoma/ganglioglioma or tumors with features of ganglioglioma/DNET (Hirose and Scheithauer, 1998; Napekoski and Prayson, 2010; Perry et al., 1997; Vajtai et al., 1997). One recent small series of the later group found them to be more common in children or young adults and most commonly arising in the temporal lobe. The tumors were all multinodular with some nodules showing typical features of either ganglioglioma or DNET, with some nodules showing

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intermixed features of both tumors intermixed. Cell proliferation indices were low in the tumors evaluated and adjacent malformations of cortical development were observed in a subset of cases.

References Bourgeosis M, Sainte-Rose C, Lellouch-Tubiana A, Malucci C, Brunelle F, Maixner W, Cinalli G, Pierre-Kahn A, Renier D, Zerah M, Hirsch J-F, Goutieres F, Aicardi J (1999) Surgery of epilepsy associated with focal lesions in childhood. J Neurosurg 90:833–842 Britton JW, Cascino GD, Sharbrough FW, Kelly PH (1994) Low-grade glial neoplasms and intractable partial epilepsy: efficacy of surgical treatment. Epilepsia 35:1130–1135 Daumas-Duport C (1993) Dysembryoplastic neuroepithelial tumors. Brain Pathol 3:283–295 Daumas-Duport C, Scheithauer BW, Chodkiewicz JP, Laws ER, Vedrenne C (1988) Dysembryoplastic neuroepithelial tumor: a surgically curable tumour of young patients with intractable partial seizures. Neurosurgery 23:545–556 Giannini C, Scheithauer BW, Burger PC, Brat DJ, Wollan PC, Lach B, O’Neill BP (1999) Pleomorphic xanthoastrocytoma. What do we really know about it? Cancer 85:2033–2045 Halper J, Scheithauer BW, Okasaki H, Laws ER (1986) Meningoangiomatosis: a report of six cases with special reference to the occurrence of neurofibrillary tangles. J Neuropathol Exp Neurol 45:426–446 Hirose T, Scheithauer BW (1998) Mixed dysembryoplastic neuroepithelial tumor and ganglioglioma. Acta Neuropathol 95:649–654 Kepes JJ, Rubinstein LJ, Eng LF (1979) Pleomorphic xanthoastrocytoma: a distinctive meningocerebral glioma of young subjects with relatively favorable prognosis. A study of 12 cases. Cancer 44:1839–1852 Lellouch-Tubiana A, Boddaert N, Bourgeois M, Fohlen M, Jouvet A, Delalande O, Seidenwurm D, Brunelle F, SainteRose C (2005) Angiocentric neuroepithelial tumor (ANET): a new epilepsy-related clinicopathological entity with distinctive MRI. Brain Pathol 15:281–286 Louis DN, Ohgaki H, Wiestler OD, Cavenee WK (eds) (2007) WHO classification of tumours of the central nervous system. IARC Press, Lyon, France Miller DC, Lang FF, Epstein FJ (1993) Central nervous system gangliogliomas. Part 1. pathology. J Neurosurg 75:859–866 Napekoski KM, Prayson RA (2010) Composite ganglioglioma/dysembryoplastic neuroepithelial tumor: a clinicopathologic study of 6 cases. Mod Pathol 23(Suppl 1): 378–379A Pasquier B, Bost F, Peoc’h M, Barnoud R, Pasquier D (1996) Neuropathologic data in drug-resistant partial epilepsy. Report of a series of 195 cases. Ann Pathol (Paris) 16: 174–181 Perry A, Giannini C, Scheithauer BW, Rojiani AM, Yachnes AT, Seo IS, Johnson PC, Kho J, Shapiro S (1997) Composite pleomorphic xanthoastrocytoma and ganglioglioma report of four cases and review of the literature. Am J Surg Pathol 21:763–771

416 Perry A, Kurtkaya-Yapicier O, Scheithauer BW, Robinson S, Prayson RA, Kleinschmidt-DeMasters BK, StemmerRachaminov AO, Gutmann DH (2005) Insights into meningioangiomatosis with and without meningioma: a clinicopathologic and genetic series of 24 cases with review of the literature. Brain Pathol 15:55–65 Prayson RA (1995) Meningioangiomatosis: a clinicopathologic study including MIB-1 immunoreactivity. Arch Pathol Lab Med 119:1061–1064 Prayson RA, Castilla EA, Hartke M, Pettay J, Tubbs RR, Barnett GH (2002) Chromosome 1p allelic loss by fluorescence in situ hybridization (FISH) not observed in dysembryoplastic neuroepithelial tumors. Am J Clin Pathol 118: 512–517 Prayson RA (2010) Tumors arising in the setting of pediatric chronic epilepsy. Pathology 42:426–431 Prayson RA, Estes ML (1995) Protoplasmic astrocytoma. A clinicopathologic study of 16 tumors. Am J Clin Pathol 10:705–709 Prayson RA, Estes ML (1996) MIB-1 and p53 immunoreactivity in protoplasmic astrocytomas. Pathol Int 46: 862–866

R.A. Prayson Prayson RA, Khajavi K, Comair YG (1995) Cortical architectural abnormalities and MIB-1 Immunoreactivity in gangliogliomas: a study of 60 patients with intracranial tumors. J Neuropathol Exp Neurol 1995 54:513–520 Preusser M, Hoischen AM, Novak K (2007) Angiocentric glioma: report of clinico-pathologic and genetic findings in 8 cases. Am J Surg Pathol 31:1709–1718 Vajtai I, Varga Z, Aguzzi A (1997) Pleomorphic xanthoastrocytoma with gangliogliomatous component. Pathol Res Pract 193:617–621 Wang M, Tihan T, Rojiani AM (2005) Monomorphous angiocentric glioma: a distinctive epileptogenic neoplasm with features of infiltrating astrocytoma and ependymoma. J Neuropathol Exp Neurol 64:875–881 Wolf HK, Müller MB, Spänle M, Zentner J, Schramm J, Wiestler OD (1994) Ganglioglioma: a detailed histopathological and immunohistochemical analysis of 61 cases. Acta Neuropathol 88:166–173 Zentner J, Hufnagel A, Wolf HK, Ostertan B, Behrens E, Campos MG, Elger CE, Wiestler OD, Schramm J (1997) Surgical treatment of neoplasms associated with medically intractable epilepsy. Neurosurgery 41:378–387

Chapter 41

Low-Grade Gliomas: Role of Relative Cerebral Blood Volume in Malignant Transformation Neil Upadhyay and Adam D. Waldman

Abstract Accurate characterisation of gliomas is important for appropriate risk stratification, which will inform decisions on potentially invasive investigation and treatment that have an associated risk of morbidity and mortality. In many institutions aggressive therapy is only commenced when low grade gliomas (LGGs) show signs of malignant transformation. Limitations with conventional contrast enhanced CT and MRI for glioma evaluation are well-recognised. Relative Cerebral Blood Volume (rCBV) measurements offer a non-invasive method of characterising and monitoring LGGs which has been validated by histopathological correlations and clinical endpoints. The widespread use of rCBV in clinical practice will require consensus on evidence-based rCBV values which discriminate aggressive gliomas from more indolent tumors. The future role of rCBV is likely to be within the framework of a multimodality approach to glioma evaluation. Keywords Gliomas · LGG · rCBV · WHO · Astrocytomas · Oligodendrogliomas

Introduction The management of low grade diffuse gliomas (WHO grade II, LGGs) is one of the most controversial areas N. Upadhyay () Institute of Clinical Science, Imperial College London, Charing Cross Hospital, W68RF, London, UK e-mail: [email protected] A.D. Waldman () Institute of Clinical Science, Imperial College London, Charing Cross Hospital, W68RF, London, UK e-mail: [email protected]

of neuro-oncology. These tumors frequently present with readily-controlled seizures in patients who are often young, and have no fixed neurological deficit. They behave indolently for an unpredictable period, which may be many years, before undergoing malignant transformation into high grade lesions which are rapidly fatal. Prospective evidence for survival advantage from early intervention is weak, and although total or subtotal resection may confer benefit, this is frequently not possible due to eloquent anatomical location and the infiltrative nature of the tumor. The potential benefit of early aggressive treatment must therefore be balanced against the morbidity associated with investigation and treatment in patients who are frequently clinically well, and may not develop significant problems for several years. In many institutions, patients with LGG are therefore monitored on a “watch and wait” policy until there are signs of malignant transformation, at which point radiotherapy and/or surgery is commenced. Conventional techniques for assessing gliomas include contrast enhanced MRI and histopathological assessment based on stereotactic biopsy or bulk resection, although limitations with these methods are well recognised in the literature (Knopp et al., 1999; Coons et al., 1997). The development of more reliable methods for characterisation and risk stratification of LGG is important, to aid clinical decision making. Perfusion Magnetic Resonance (MR) imaging techniques allow calculation of cerebral blood volume (CBV), which is a measure of localised cerebral blood volume within tissue. Changes in the CBV of gliomas can be explained by tumor pathophysiology; neoangiogenesis is associated with an increase in vessel density, tortuosity and permeability, and are a hallmark of aggressive elements in histopathological analysis of

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7_41, © Springer Science+Business Media B.V. 2011

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gliomas. CBV therefore provides a non-invasive quantitative imaging biomarker that reflects angiogenesis in gliomas, and hence can aid characterisation of gliomas. In particular, it may be helpful in grading gliomas and identifying malignant transformation at an earlier stage.

Acquisition of rCBV Dynamic susceptibility contrast enhanced MRI (DSCMRI) is the most common perfusion method used in clinical practice, and the technique on which most published relative cerebral blood volume (rCBV) data in gliomas has been based. The method involves acquiring time-resolved images during the transit of an exogenous gadolinium chelate (Gd) contrast agent through the brain. Local magnetic field inhomogeneities caused by the Gd leads to a transient reduction in the transverse relaxation time of water protons in adjacent tissues, and a consequent reduction in tissue signal intensity (T2∗ effect). The concentration of agent is proportional to the change in relaxation rate, and analysis of the kinetics of signal intensity change allows perfusion parameters to be derived. In order to sample the signal profile from the first pass of contrast agent, the compound is injected intravenously as a rapid bolus, and rapid echo planar imaging (EPI) based spin echo or gradient echo sequences allow the whole brain to be imaged with sufficient time-resolution. CBV is proportional to the area under the deconvolved time intensity curve, assuming there has been no recirculation or contrast leakage. Because the blood-brain barrier of contrast-enhancing tumors is leaky, contrast leakage needs to be accounted for when CBV values are calculated. A significant correlation between glioma grade and CBV values corrected for contrast extravasation has been previously demonstrated, but no correlation for uncorrected values was found (Boxerman et al., 2006). CBV is the proportion of the volume of interest which is comprised of vessels. It is measured as millilitres of blood per grams of tissue. Because of difficulties in reproducible absolute quantification of CBV, relative CBV is usually expressed as a ratio of CBV within the tissue of interest against normal contralateral white matter; this facilitates stable longitudinal perfusion measurement and inter-subject comparisons. Comparison of quantitative data across institutions and different MRI manufacturer platforms, however, remain a challenge.

N. Upadhyay and A.D. Waldman

Perfusion parameters can also be derived from the first pass phase of dynamic contrast enhanced MRI, which is based on T1-dependent signal abnormality, and also yields permeability data. These methods have been used to study gliomas, but are less widely validated. Arterial Spin Labelling is an alternative perfusion technique which uses “magneticallylabelled” water as an endogenous tracer. Water is labelled by inversion or saturation pulses and imaging is performed downstream from the site of labelled water to allow flow to the region of interest. The technique offers the advantage of being completely non-invasive and allows absolute quantification of blood flow, but its clinical application has been limited by long acquisition times and requirements for complex off-line processing. Technical advances with the current generation of commercial 3T MRI systems and more user-friendly processing software are likely to allow wider clinical application of ASL in future.

Comparison of rCBV and Conventional MRI for Glioma Evaluation Several studies have demonstrated that rCBV can give useful information about tumor grade and patient prognosis (Table 41.1). Accurate characterisation of gliomas is important to allow appropriate risk stratification, which will inform difficult decisions on potentially invasive investigation and treatment. Conventional assessment of gliomas includes evaluation with contrast enhanced MRI sequences and histopathological evaluation following biopsy or tumor resection. Limitations of conventional methods of assessment are well recognised in the literature (Knopp et al., 1999; Coons et al., 1997). Relative CBV gives supplementary information on tumor physiology which complements that from conventional contrast enhanced MRI and can potentially detect signs of transformation earlier than conventional methods (Figs. 41.1, 41.2, and 41.3). Relative CBV is related to perfusion, and is felt to reflect angiogenesis, which is an important marker of tumor aggressiveness in the pathological grading of gliomas. Relative CBV can therefore differentiate biologically aggressive tumors from more indolent tumors and guide the most appropriate management. Contrast enhancement is often used as an indicator of progression on conventional

41 Low-Grade Gliomas: Role of Relative Cerebral Blood Volume in Malignant Transformation

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Table 41.1 rCBV values suggested by different authors for characterising gliomas Study

Tumor type

Low grade

High grade

Aronen et al. (1994) Arvinda et al. (2009) Bisdas et al. (2009) Danchaivijitr et al. (2008)

Gliomas Gliomas Astrocytomasb Gliomas

Hakyemez et al. (2005) Law et al. (2006) Law et al. (2008)

Gliomas Gliomas Gliomas

1.11 3.64 1.21 3.29 / / 1.31c 1.93c No statistically significant difference 1.69 3.32 2.14 5.18 / /

Lev et al. (2004) Jackson et al. (2002)

Gliomase Astrocytomas Astrocytomas

Jenkinson et al. (2006)

Oligodendrogliomas

Optimal discrimination

Reference

/ 2.91a 3.8 /

Grade Grade 1 yr survival Time to progressiond

2.00 1.75a 1.75

Grade Grade Time to progressiond Grade and survival Grade

1.5 2.9 1.5 1.3 3.1 Specific values not published. rCBV increased significantly with grade rCBV did not increase with 1.59f identifies grade deletion of 1p/19q 1.44 5.07 / 1.30 3.87 / 2.00 4.91 2.93 1.74 6.10 / 2.01 2.47 1.6

Grade 1p/19q deletion Grade Grade Grade Grade Grade

Knopp et al. (1999) Astrocytomas Rollin et al. (2006) Gliomasg Shin et al. (2002) Gliomas Yang et al. (2002) Gliomas Zonari et al. (2007) Gliomas P < 0.05 unless otherwise stated a Minimising C2 error, which is the fraction of misclassified tumors b Subgroup analysis on astrocytomas; when oligodendrogliomas and oligoastrocytomas were included, results were not statistically significant c Longitudinal study following LGG; rCBV of patients with no transformation was 1.31 at baseline whilst rCBV of patients with transformation was 1.93 at baseline. There was no statistically significant difference at baseline. The group mean rCBV was 5.36 at transformation d Progression was defined by clinical and conventional MRI parameters e Study on gliomas; subgroup analysis performed on astrocytomas and oligodendrogliomas f Study on oligodendrogliomas; threshold value discriminates between oligodendrogliomas which have 1p/19q deletion and those which do not have 1p/19q deletion g Study on intra-axial tumors; subgroup analysis performed on gliomas

Fig. 41.1 Grade 2 astrocytoma. Left: T1-weighted contrast-enhanced (T1CE) study demonstrates minimal contrast enhancement. Right: The rCBV map demonstrates low rCBV values

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Fig. 41.2 Glioblastoma multiforme. Left: T1CE study demonstrates marked contrast enhancement around the tumour. Right: The rCBV map demonstrates elevated rCBV values

Fig. 41.3 Glioblastoma multiforme. The rCBV map (right) shows elevated rCBV values before any significant contrast enhancement is demonstrated on the T1CE study (left)

MRI studies, but this can lead to an inaccurate assessment of the tumor (Knopp et al., 1999). Enhancement represents loss of the local blood-brain barrier but does not necessarily give a good indication of vascularity. Lack of enhancement does not always equate to a low grade tumor (Fig. 41.3) and variability in enhancement patterns between subgroups of low grade and high grade gliomas is well recognised (White et al., 2005; Ginsberg et al., 1998). Other characteristics on conventional MRI such as mass effect, oedema, necrosis and haemorrhage also lack accuracy in differentiating gliomas by grade (Aronen et al., 1994; Law et al., 2003; Rollin et al., 2006).

Differentiating Gliomas Using rCBV Many groups have attempted to determine rCBV measurements that will discriminate LGGs from high grade gliomas (HGGs). Table 41.1 summarises the results from 15 studies which analysed tumors using

rCBV. The range of mean maximal rCBV values for LGGs is 1.11–2.14. The range of mean maximal rCBV values for HGGs is 2.47–6.10. A wide range of threshold values were suggested to discriminate between low grade and high grade (1.5–3.8).

Challenges of Glioma Evaluation with rCBV For use in routine clinical practice, consensus on a precise rCBV value is required to distinguish between low grade and high grade gliomas. However, Table 41.1 demonstrates a range of values have been suggested in the literature, which can be attributed to a number of factors. Technical differences in acquisition and analytical methods make comparison and synthesis of data from these studies difficult. A study found CBV values were higher using Gradient Echo – Echo Planar imaging (GE EPI) compared with Spin Echo – Echo Planar

41 Low-Grade Gliomas: Role of Relative Cerebral Blood Volume in Malignant Transformation

imaging (SE EPI) (Sugahara et al., 2001). GE EPI has been preferred to SE EPI by some groups because it is more sensitive to the contribution of vessels of a range of sizes whilst SE derived imaging has been reported as being more sensitive for capillary sized vessels (Boxerman et al., 2006; Sugahara et al., 2001). High grade tumors contain larger calibre vessels and studies have suggested GE rCBV values show significant correlation with tumor grade whilst SE rCBV values do not (Boxerman et al., 2006). The technique for selecting regions of interest (ROIs) may also affect values (Lev et al., 2004). A relatively small “hot spot” surrounded by lower rCBVs will be perceived as a lower value if a larger ROI is used than a smaller ROI. Inclusion or exclusion of visible intratumoural vessels also affects the magnitude of calculated rCBV and hence thresholds for discriminating between tumor groups (Caseiras et al., 2008). Variability in the subgroups of gliomas that were studied may also contribute to the differences. A difference in tumor architecture between astrocytomas and oligodendrogliomas is likely to cause an intrinsic difference in the rCBV of tumors of comparable grade. Maximum rCBV of low grade oligodendrogliomas have demonstrated higher values than low grade astrocytomas, which is thought to be because the former have a higher density of capillaries than the latter (Lev et al., 2004; Cha et al., 2005); moreover, deletion of chromosome 1p has also been associated with elevated rCBV values (Jenkinson et al., 2006). Relative CBV is a sensitive discriminant for 1p 19q deletion status, the genetic hallmark of oligodendroglioma features, in LGGs. This is, in effect, a confounder of reliable tumor grading in a lesion of unknown subtype; it may not be possible to distinguish between aggressive elements within a low grade astrocytoma and a stable low grade oligodendroglioma. Pilocytic astrocytomas have been excluded from some studies because they can demonstrate high rCBV despite their classification as grade 1 gliomas (Arvinda et al., 2009); fortunately they are frequently morphologically distinctive on structural imaging, although may occasionally mimic high grade diffuse gliomas. Differences in the management of patient cohorts between studies will also affect rCBV. Treatment with steroids can decrease tumor permeability and blood volume measurements. Changes in permeability have been described at one hour after steroid administration,

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with a 15% decrease in the rCBV of peritumoral tissue (Ostergaard et al., 1999). The level at which to set a threshold value will depend on what is felt to be the optimum balance between acceptable false positives and false negative rates. A high false positive rate will lead to potentially unnecessary investigation and treatment with associated risks. A high false negative rate will lead to inappropriate management of patients at high risk. The judgement of the most appropriate balance is likely to vary between authors. The choice of reference point used to determine threshold values also varies between studies. Arguments have been made for the use of hard clinical endpoints rather than histology to determine threshold values (Bisdas et al., 2009). A clinical endpoint may not necessarily correlate well with grade and there are concerns over the validity of the use of histology as a “gold standard”. Histological grading of gliomas can be difficult, particularly when a tumor demonstrates an atypical pattern; suboptimal reproducibility and interobserver variation are recognised challenges (Coons et al., 1997). There is also the risk of sampling a misrepresentative area of tumor, which will result in misleading histopathological analysis in heterogeneous lesions; this typically results in an underestimate of grade or aggressiveness. As with other methods, characterising tumor heterogeneity with perfusion presents challenges. A commonly used technique is to analyse the brightest discrete region, although such an area may not always be apparent, and the decision on the most appropriate region of interest for analysis may vary between observers. Some groups have overcome this by analysing the whole tumor, although these methods are more labor-intensive and time consuming.

The Role of rCBV Within a Multimodalilty Approach to Glioma Evaluation Opinions on the performance of rCBV compared to other advanced imaging techniques for the evaluation of LGGs vary, but there is general consensus that the future role of rCBV is likely to be within the framework of a multimodal approach which incorporates both conventional MRI and other advanced MRI techniques. Such an approach is advantageous because it

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allows interrogation of different aspects of tumor biology, growth rate and tumor metabolism, in addition to angiogenesis. Amalgamation of this information is likely to give a more accurate estimation of risk of transformation than the individual techniques, which have their own intrinsic weaknesses. Some comparisons between rCBV measurements, diffusion imaging, MR Spectroscopy (MRS) and conventional MR imaging have found rCBV to be the best performing parameter to distinguish low grade from high grade gliomas (Law et al., 2003; Zonari et al., 2007), and for distinguishing gliomas for other brain tumors (Weber et al., 2006). MRS was found to be better than rCBV for regions near the cortex because the rCBV of grey matter is less distinct from tumor values than white matter (Henry et al., 2000), although coregistration of rCBV maps with structural images can help to distinguish tumor signal from that of adjacent cortex. The evidence for rCBV as a marker of tumor behaviour and grade is best established in diffuse gliomas of astrocytic lineage. A borderline significant elevation in choline/creatine ratio on MRS was demonstrated 12 months before rCBV changes (p = 0.06) in oligodendrogliomas (Hlaihel et al., 2010); other techniques may be of particular use in characterising this tumor subtype, in which rCBV is known to correlate less reliably with malignancy. A study of a heterogeneous group of paediatric tumors has also reported changes in choline adjacent to enhancing tumor bed without corresponding changes in rCBV (Tzika et al., 2002). A comparison of tumor volume growth over a 6 month interval with a number of other parameters, including rCBV but not MRS measurements, found tumor growth at 6 months was the best overall predictor for time to transformation in LGGs (Caseiras et al., 2009), although comparative risk stratification over short and long time periods was not investigated. Some groups have attempted to overcome the limitations of individual advanced MR techniques by developing algorithms which use a multimodality approach. Groups have analysed sensitivity, specificity and predictive value of tumor grading following addition of rCBV and MRS findings to conventional MRI, and concluded that accuracy increases (Zonari et al., 2007; Law et al., 2003; Arvinda et al., 2009). A multimodal algorithm has been suggested, which uses different techniques in a systematic manner to narrow the differential for an unknown intra-axial lesion (Al-Okaili et al., 2006).

N. Upadhyay and A.D. Waldman

Conclusion Relative CBV measurements offer a validated, noninvasive method of characterising and monitoring LGGs. Standardisation of techniques for acquisition of rCBV, consensus on the optimal threshold value to discriminate gliomas and appreciation of the variability in rCBV between subgroups of gliomas will facilitate its use in routine clinical practice. Current evidence suggests variable performance, with rCBV demonstrating strengths in some areas but weaknesses in others when comparison is made with other advanced MRI techniques. The future role of rCBV is likely to be as part of a multimodal approach to glioma characterisation and monitoring.

References Al-Okaili RN, Krejza J, Wang S, Woo JH, Melhem ER (2006) Advanced MR imaging techniques in the diagnosis of intraaxial brain tumors in adults. Radiographics 26: S173–S189 Aronen HJ, Gazit IE, Louis DN, Buchbinder BR, Pardo FS, Weisskoff RM, Harsh GR, Cosgrove GR, Halpern EF, Hochberg FH (1994) Cerebral blood volume maps of gliomas: comparison with tumor grade and histologic findings. Radiology 191:41–51 Arvinda H, Kesavadas C, Sarma P, Thomas B, Radhakrishnan V, Gupta A, Kapilamoorthy T, Nair S (2009) Glioma grading: sensitivity, specificity, positive and negative predictive values of diffusion and perfusion imaging. J Neurooncol 94: 87–96 Bisdas S, Kirkpatrick M, Giglio P, Welsh C, Spampinato MV, Rumboldt Z (2009) Cerebral blood volume measurements by perfusion-weighted MR imaging in gliomas: ready for prime time in predicting short-term outcome and recurrent disease? AJNR Am J Neuroradiol 30:681–688 Boxerman JL, Schmainda KM, Weisskoff RM (2006) Relative cerebral blood volume maps corrected for contrast agent extravasation significantly correlate with glioma tumor grade, whereas uncorrected maps do not. AJNR Am J Neuroradiol 27:859–867 Caseiras G, Ciccarelli O, Altmann DR, Benton CE, Tozer DJ, Tofts PS, Yousry TA, Rees J, Waldman AD, Jäger HR (2009) Low-grade gliomas: six-month tumor growth predicts patient outcome better than admission tumor volume, relative cerebral blood volume, and apparent diffusion coefficient. Radiology 253:505–512 Caseiras GB, Thornton JS, Yousry T, Benton C, Rees J, Waldman AD, Jäger HR (2008) Inclusion or exclusion of intratumoral vessels in relative cerebral blood volume characterization in low-grade gliomas: does it make a difference? AJNR Am J Neuroradiol 29:1140–1141

41 Low-Grade Gliomas: Role of Relative Cerebral Blood Volume in Malignant Transformation Cha S, Tihan T, Crawford F, Fischbein NJ, Chang S, Bollen A, Nelson SJ, Prados M, Berger MS, Dillon WP (2005) Differentiation of low-grade oligodendrogliomas from lowgrade astrocytomas by using quantitative blood-volume measurements derived from dynamic susceptibility contrastenhanced MR imaging.. AJNR Am J Neuroradiol 26: 266–273 Coons SW, Johnson PC, Scheithauer BW, Yates AJ, Pearl DK (1997) Improving diagnostic accuracy and interobserver concordance in the classification and grading of primary gliomas. Cancer 79:1381–1393 Danchaivijitr N, Waldman AD, Tozer DJ, Benton CE, Caseiras GB, Tofts PS, Rees JH, Jäger HR (2008) Low-grade gliomas: do changes in rCBV measurements at longitudinal perfusionweighted MR imaging predict malignant transformation? Radiology 247:170–178 Ginsberg LE, Fuller GN, Hashmi M, Leeds NE, Schomer DF (1998) The significance of lack of MR contrast enhancement of supratentorial brain tumors in adults: histopathological evaluation of a series. Surg Neurol 49:436–440 Hakyemez B, Erdogan C, Ercan I, Ergin N, Uysal S, Atahan S (2005) High-grade and low-grade gliomas: differentiation by using perfusion MR imaging. Clin Radiol 60:493–502 Henry RG, Vigneron DB, Fischbein NJ, Grant PE, Day MR, Noworolski SM, Star-Lack JM, Wald LL, Dillon WP, Chang SM, Nelson SJ (2000) Comparison of relative cerebral blood volume and proton spectroscopy in patients with treated gliomas.. AJNR Am J Neuroradiol 21:357–366 Hlaihel C, Guilloton L, Guyotat J, Streichenberger N, Honnorat J, Cotton F (2010) Predictive value of multimodality MRI using conventional, perfusion, and spectroscopy MR in anaplastic transformation of low-grade oligodendrogliomas. J Neurooncol 97:73–80 Jackson A, Kassner A, Annesley-Williams D, Reid H, Zhu XP, Li KL (2002) Abnormalities in the recirculation phase of contrast agent bolus passage in cerebral gliomas: comparison with relative blood volume and tumor grade. AJNR Am J Neuroradiol 23:7–14 Jenkinson MD, Smith TS, Joyce KA, Fildes D, Broome J, Du Plessis DG, Haylock B, Husband DJ, Warnke PC, Walker C (2006) Cerebral blood volume, genotype and chemosensitivity in oligodendroglial tumors. Neuroradiology 48: 703–713 Knopp EA, Cha S, Johnson G, Mazumdar A, Golfinos JG, Zagzag D, Miller DC, Kelly PJ, Kricheff II (1999) Glial neoplasms: dynamic contrast-enhanced T2∗ -weighted MR imaging. Radiology 211:791–798 Law M, Oh S, Babb JS, Wang E, Inglese M, Zagzag D, Knopp EA, Johnson G (2006) Low-grade gliomas: dynamic susceptibility-weighted contrast-enhanced perfusion MR imaging – prediction of patient clinical response. Radiology 238:658–667 Law M, Yang S, Wang H, Babb JS, Johnson G, Cha S, Knopp EA, Zagzag D (2003) Glioma grading: sensitivity, specificity, and predictive values of perfusion MR imaging and proton MR spectroscopic imaging compared with conventional MR imaging. AJNR Am J Neuroradiol 24:1989–1998

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Law M, Young RJ, Babb JS, Peccerelli N, Chheang S, Gruber ML, Miller DC, Golfinos JG, Zagzag D, Johnson G (2008) Gliomas: predicting time to progression or survival with cerebral blood volume measurements at dynamic susceptibility-weighted contrast-enhanced perfusion MR imaging. Radiology 247:490–498 Lev MH, Ozsunar Y, Henson JW, Rasheed AA, Barest GD, Harsh GRIV, Fitzek MM, Chiocca EA, Rabinov JD, Csavoy AN, Rosen BR, Hochberg FH, Schaefer PW, Gonzalez RG (2004) Glial tumor grading and outcome prediction using dynamic spin-echo MR susceptibility mapping compared with conventional contrast-enhanced MR: confounding effect of elevated rCBV of oligodendrogliomas. AJNR Am J Neuroradiol 25:214–221 Ostergaard L, Hochberg FH, Rabinov JD, Sorensen AG, Lev M, Kim L, Weisskoff RM, Gonzalez RG, Gyldensted C, Rosen BR (1999) Early changes measured by magnetic resonance imaging in cerebral blood flow, blood volume, and blood-brain barrier permeability following dexamethasone treatment in patients with brain tumors. J Neurosurgery 90:300–305 Rollin N, Guyotat J, Streichenberger N, Honnorat J, Tran Minh VA, Cotton F (2006) Clinical relevance of diffusion and perfusion magnetic resonance imaging in assessing intra-axial brain tumors. Neuroradiology 48:150–159 Shin JH, Lee HK, Kwun BD, Kim JS, Kang W, Choi CG, Suh DC (2002) Using relative cerebral blood flow and volume to evaluate the histopathologic grade of cerebral gliomas: preliminary results. Am J Roentgenol 179:783–789 Sugahara T, Korogi Y, Kochi M, Ushio Y, Takahashi M (2001) Perfusion-sensitive MR imaging of gliomas: comparison between gradient-echo and spin-echo echo-planar imaging techniques. AJNR Am J Neuroradiol 22:1306–1315 Tzika AA, Zarifi MK, Goumnerova L, Astrakas LG, Zurakowski D, Young-Poussaint T, Anthony DC, Scott RM, Black PM (2002) Neuroimaging in Pediatric Brain Tumors: GdDTPA-enhanced, hemodynamic, and diffusion MR imaging compared with MR spectroscopic imaging. AJNR Am J Neuroradiol 23:322–333 Weber MA, Zoubaa S, Schlieter M, Juttler E, Huttner HB, Geletneky K, Ittrich C, Lichy MP, Kroll A, Debus J, Giesel FL, Hartmann M, Essig M (2006) Diagnostic performance of spectroscopic and perfusion MRI for distinction of brain tumors. Neurology 66:1899–1906 White ML, Zhang Y, Kirby P, Ryken TC (2005) Can tumor contrast enhancement be used as a criterion for differentiating tumor grades of oligodendrogliomas? AJNR Am J Neuroradiol 26:784–790 Yang D, Korogi Y, Sugahara T, Kitajima M, Shigematsu Y, Liang L, Ushio Y, Takahashi M (2002) Cerebral gliomas: prospective comparison of multivoxel 2D chemical-shift imaging proton MR spectroscopy, echoplanar perfusion and diffusion-weighted MRI. Neuroradiology 44:656–666 Zonari P, Baraldi P, Crisi G (2007) Multimodal MRI in the characterization of glial neoplasms: the combined role of singlevoxel MR spectroscopy, diffusion imaging and echo-planar perfusion imaging. Neuroradiology 49:795–803

Chapter 42

Angiocentric Glioma-Induced Seizures: Lesionectomy Dave F. Clarke and Timothy M. George

Abstract Glioneuronal tumors, such as dysembryoplastic neuroepithelial tumors and gangliomas, are known to induce intractable partial onset epilepsy. A recently described tumor type, angiocentric glioma, has been found to be extremely epileptogenic with seizures affecting all diagnosed patients. Individuals with complete tumor removal achieve freedom from seizure, and those with partial removal have a significant reduction in seizures. This chapter will review the complications of intractable symptomatic epilepsy, discuss medical management, and make the case proceed directly to lesionectomy, however others require further investigation prior to surgery. Identifying eloquent cortex is essential in surgical planning and minimizing post-surgical morbidity. Non-invasive and invasive techniques required to define the epiletogenic zone and identify areas of critical cortical function will be described. Keywords Lesionectomy · Angiocentric glioma · Intractable epilepsy · Antiepileptic medication · Epilepsy surgery · Seizure semiology

Introduction Thirty to forty percent of patients with epilepsy become pharmacoresistant after taking 2–3 medications (Kwan and Brodie, 2000). Many of these

D.F. Clarke () Division of Neurology, Department of Pediatrics, Dell Children’s Medical Center, Austin, TX 78723, USA e-mail: [email protected]

patients are suitable candidates for epilepsy surgery which may potentially cause seizure cessation or significant reduction in seizures (Spencer and Huh, 2008). The potential for seizure freedom increases if a lesion is found and completely removed (Lote et al., 1998). Sir Victor Horsley, in his initial description of epilepsy surgery in 1886, described performing a lesionectomy on a tubeculoma, specifically for treating intractable epilepsy (Feindel, 2003). Horsley used the clinical description of the seizure to localize the area for resection. The field of epilepsy surgery has since seen significant investigative advances with continuous evolving neuroimaging, electrophysiological techniques to identify seizure foci, as well as invasive and non-invasive means of identifying function. Identifying exactly where the lesions are located in three dimensions and determining the spatial distribution of primary functional (eloquent) cortex allows for better resection and minimizes postsurgical motor, language and memory impairments. Abnormalities of cortical development are the most frequently described lesions causing seizures, however, tumors and or destructive lesions may also be causative (Lellouch-Tubiana et al., 2005; Beaumont and Whittle, 2000; Britton et al., 1994). Seizure prevalence is dependent on the pathological features of the tumor (van Breemen et al., 2007). Dysembryoblastic neuroepithelial tumors (DNETS) (100%) or gangliogliomas (90%), are described as having the highest seizure frequency, followed by other low-grade gliomas (60–85%) (Lellouch-Tubiana et al., 2005; (Beaumont and Whittle, 2000; van Breemen et al., 2007; Tandon et al., 2001). A recently described tumor type, angiocentric glioma, likely approximates the epileptogenicity found in DNET’s. All patients

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described in the literature with this tumor type thus far, manifested seizures and most had pharmacoresistant epilepsy (Lellouch-Tubiana et al., 2005; Wang et al., 2005; Preusser et al., 2007; Shakur et al., 2009; Fulton et al., 2009). Most patients became seizure free or had a significant reduction in seizures after the removal of their angiocentric glioma (Shakur et al., 2009). Unfortunately, in some individuals there was a prolonged period between seizure onset and epilepsy surgery potentially increasing risk of seizure related morbidity (Lellouch-Tubiana et al., 2005; Wang et al., 2005; Preusser et al., 2007). There is an increase in mortality in patients with epilepsy (Mohanraj et al., 2006). Patients who respond to treatment have a much lower mortality risk when compared to those with intractable seizures (Hitiris et al., 2007; Lhatoo et al., 2001). Sudden unexpected death in epilepsy (SUPED) increases with increasing seizure frequency and may be as high as 3.6/1000 in high risk populations (Ryvlin et al., 2006). Significant psychosocial and neurocognitive pathology is also found in patients with chronic epilepsy (Elliot et al., 2005). The potential for significant morbidity and mortality associated with intractable epilepsy suggests that patients with a lesion, especially those who fit characteristics described in benign gliomas or angiocentric gliomas, epilepsy surgery, which includes lesionectomy, should be expedited. The concurrence of epileptogenic gliomas with an approximating or surrounding region of epileptogenic cortical dysplasia further supports the stance for expedited surgical resection (Duffau, 2005). Though this concurrent phenomenon has not been confirmed in angiocentric gliomas, it is important that the epiletogenic zone be adequately delineated as it may extend beyond the area visualized on imaging studies (Awad et al., 1991). Clearly, a multidisciplinary approach is required to identify suitable surgery candidates. An ideal team is comprised of an epiletologist, epilepsy surgeon, neuropsychologist, psychiatrist, neuroradiologist, electroencephalographer, specialized epilepsy nurse, a social worker and, in the case of neoplasia, a neuro-oncologist. These individuals are vitally important in identifying the epileptogenic zone, minimizing post surgical impairment and addressing any cognitive, developmental or psychosocial needs of the patient (Clarke and Boop, 2009).

D.F. Clarke and T.M. George

Patients Demographics Angiocentric glioma-induced seizures were initially described by Wang et al. (2005). Patients were presented as early as 3 years of age, and most presented with seizures starting in childhood. Even earlier onset of seizures has been described (Fulton et al., 2009). Time from seizure onset to surgery in Wang’s cohort ranged from several months to as long as 25 years. Two other studies, of 10 and 8 patients experienced maximal diagnosis to surgery intervals over 15 and 57 years, respectively (Lellouch-Tubiana et al., 2005; Preusser et al., 2007). More recent studies, show shorter delays (Fulton et al., 2009; Shakur et al., 2009). Although angiocentric glioma is a relatively rare tumor, no gender predilection has been described.

Complications of Intractable Epilepsy The somewhat subjective definition of intractability may have a role in the prolonged period from the time of seizure onset to epilepsy surgery. It is known however, that two to three antiepileptic drug failures, either as monotherapy or in combination, predict a low probability of seizure freedom with another drug Kwan and Brodie found that 47% of individuals became seizure free with the first anti-epileptic medication tried. A second drug worked in an additional 13%, while only another 4% gained seizure freedom with a third (1% with monotherapy, and 3% in combination) (Kwan and Brodie 2000). With a structural lesion, patients are even less likely to become seizure free unless the lesion is removed (Koepp and Woermann, 2005). As stated earlier, seizures starting in childhood, the period when most patients with angiocentic gliomas present, may have the longest and most severe impact on neurocognitive and psychosocial development (Elliot et al., 2005). Mortality in patients with intractable epilepsy may be up to 4–7 time higher than in the general population. Sudden unexplained death in epilepsy (SUPED) is the most common epilepsyrelated death in adolescents and adults, occurring 24 times more frequently than death in the general population (Sperling, 2004). Both seizure frequency and the number of AEDs used have been shown to be risk factors (Ryvlin et al., 2006). Gliomas may also be causative of the neurocognitive and behavioral

42 Angiocentric Glioma-Induced Seizures: Lesionectomy

dysfunction seen in patients with symptomatic epilepsy. Epilepsy surgery leading to effective seizure control has been shown to potentially improve quality of life through neurocognitive and IQ score improvements (Freitag and Tuxhorn, 2005). Such changes are likely due to multiple factors, including better seizure control, lower dosing antiepileptic medication, which decreases side effects, and the psychosocial improvements associated with seizure freedom.

Distribution and Semiology of Angiocentric Glioma Induced Seizures Studies suggest that most angiocentric gliomas occur in the frontal lobe or temporal lobe. They are seen less frequently in the parietal lobe and only rarely in the occipital region (Lellouch-Tubiana et al., 2005; Wang et al., 2005; Preusser et al., 2007; Shakur et al., 2009; Fulton et al., 2009). Clinical presentation depends on the neuroanatomical location of the lesion. Seizures arising from the frontal lobe occur predominantly at night, are brief, frequent, and cause little or no postictal changes (Losey and Ng, 2009). Due to their atypical symptom, they may be mistaken for psychogenic non-epileptic spells. With a lesion involving the primary motor area, seizures present with contralateral clonic or tonic motor activity. They begin as simple partial seizures but cortical spread of the epileptic activity leads to more complex symptoms, including altered consciousness and generalization. In addition to spreading throughout the frontal lobe or crossing to the contralateral hemisphere, the seizure may march somatatopically along the homunculus to involve the neuroanatomical area representing the upper extremity, face and tongue. The term Jacksonian march was coined by Hughlings Jackson to describe this phenomenon (Holms, 1927). Seizures involving the supplementary motor area are also brief and nocturnal. They may be preceded by a poorly defined aura, which is followed by atypical, but stereotyped movements involving one or both sides. Consciousness may be preserved but vocalization and speech arrest is common, dependant on the hemisphere involved. Posturing is an inconsistent phenomenon. Both lateral and fronto-polar seizures present with versive head and eye deviation, as well as tonic/clonic

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activity contralateral to the side of seizure onset. Speech arrest is common with left hemisphere involvement. Automatisms, witnessed often, affect the side ipsilateral to seizure onset, and may be accompanied by paucity of movement on the contralateral side. Both orbito-frontal and cingulated gyrus epileptic discharges may cause seizures simulating those arising from the temporal lobe because both areas are involved in limbic circuitry. Autonomic features maybe prominent in both. Olfactory hallucination and urinary incontinence, laughing or atypical smiling, and sexual automatism maybe experienced. Sensation of hunger or thirst has been described. Pelvic thrusting, often seen in non-epileptic spells may also be noted primarily in orbito-frontal seizures. Staring and diminished responsiveness are also common. The rare opercular lesion may cause excessive chewing and swallowing, increase salivation, speech arrest, and autonomic features. Seizure spread and an invasive angiocentric glioma involving multiple lobes may trump the involvement of only one area; producing combinations of the symptoms described above. Seizures are however often stereotyped at onset in each individual. Seizures arising from the temporal lobe, another area frequently affected by angiocentric gliomas, have been described by Weiser as exhibiting five typical symptom constellations (Wiser, 1983). The temporobasal limbic pattern stemming from hippocampal and perhaps amygdale involvement causes alteration of consciousness, symptoms of nausea and a “cephalic” aura. Pupillary change, altered temperature sensation, pallor or flushing (visceromotor symptoms), changes in emotion (often fear), and focal motor activity are also prominent. The temperopolar pattern involves similar visceromotor symptoms and alteration of consciousness, but oroalimentary automatisms, behavioral change, and psychic phenomenon may also occur. The fronto-basal-cingulate type involves gesticularexploratory complex automatisms, bilateral lower limb and trunk automatisms, and change in behavior and facial expressions. Ictal warning with retained consciousness, psychic and auditory hallucinations and aphasia is described in seizures of the opercular type. Lastly, the posterior neocortical pattern is associated with aphasia, staring and changes in facial expression, vestibular and visual hallucinations, and unilateral gestural-exploratory automatisms of the upper limb. Younger children may not be able to describe their symptoms. Instead they run towards a parent or other

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adult as a sign that they are experiencing something unusual. Parents and physicians therefore should be more vigilant in evaluating this age group. Angiocentric gliomas seldom affect the parietal lobe, but those that do may present with atypical sensations such as numbness or other parathesias. Once again, the younger patient may be incapable of elaborating and may even suggest pain or grab the area during the seizure (Fulton et al., 2009). Due to the rapid spread to the frontal and or temporal lobe, parietial seizures are the most difficult to localize. Occipital angiocentric gliomas are also rare, but present with unusual visual disturbance. Either non-specific visual hallucinations, such as white or colored light, or the negative phenomenon, of itcal blindness may be seen. Since headaches are a feature of migraines and brain tumors, one must discern visual features associated with migraine headaches from those caused by seizures. Children may have idiopathic partial or focal generalized seizures independent of their tumor, therefore one has to always determine a causal relationship between tumor and seizure.

Medical Management Most researchers agree that treatment should be initiated with antiepileptic medication after a second unprovoked seizure. At least two antiepileptic agents should be tried before surgery is entertained (Kwan and Brodie, 2000). Since evidence suggests that surgery is potentially curative in this patient population, an aggressive approach of simultaneously considering surgery, while employing medication trials is warranted. When choosing an antiepileptic medication for patients with an intracranial mass, one has to take into account not only the seizure type, but potential co-morbidities such as headaches, memory loss and other neurocognitive and neuropsychological deficits. The tumor type is often unclear prior to removal; therefore one must also consider the potential need for chemotherapeutic agents. Expert consensus suggests that, in both children and adults, carbamazepine and oxcarbazepine are drugs of first choice for partial focal seizures (Wheless et al., 2005). With either agent one has to be aware of the potential for worsening

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frontal lobe seizures. One must also consider potential liver induction by both medications, which may alter the distribution of both chemotherapeutic agents. If comorbid headaches are experienced, valproic acid or topiramate may be agents of choice; however, as with carbamazepine, hepatic function may be altered (Glauser et al., 2006). Both medications may affect weight, with valproic acid stimulating hunger and topiramate having the opposite effect. Fosphenytoin may be used for seizures in an acute setting, but long term use is suboptimal due to induction, significant protein binding, chronic gum hyperplasia, hirsutism, and bone loss, to name a few potential pitfalls. Many of these agents may also suppress the bone marrow, which is less than ideal in this patient population. Gabapentin and levatiracetam have little or no effect on both chemotherapeutic agents. Levatiracetam occasionally causes significant behavior changers, potentially compounding psychiatrics issues caused by lesions affecting the frontal lobe. Gabapentin is often less effective than other antiepileptic agents and may cause weight gain. There are pros and cons of using newer agents such as locosamide and rufinamide. The metabolism, volume, distribution and available preparation of all antiepileptic drugs have to be taken into account. This far from comprehensive list of antiepileptic drug side effects offer another motive for considering surgery sooner rather than later.

Investigative Studies It has been recommended by both the International League Against Epilepsy (ILAE) and the American Epilepsy Society (AES) that an electroencephalogram (EEG) be completed after the first unprovoked seizure (Hirtz, 2000). Though the EEG yield is less than 50%, a finding of focal slowing or discharges may help to identify a seizure focus. An EEG capturing wakefulness and sleep using a, internationally recognized, 10–20 electrode placement system increased yield. Time locked Video EEG, is useful in distinguishing nonepileptic from epileptic events. Brain magnetic resonance imaging (MRI) is also suggested after the first unprovoked seizure (Fig. 42.1). T1 and T2 weighted images are essential (Koepp and Woermann, 2005; Hirtz, 2000). T1 weighted images define neuroanatomy and T2 is highly sensitive in

42 Angiocentric Glioma-Induced Seizures: Lesionectomy

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Fig. 42.1 Evaluation of tumor induced intractable epilepsy

detecting and defining pathological brain processes. T1 gradient echo, T2 fast spin echo, fluid attenuation iversion recover (FLAIR) and proton density sequences are other techniques used in identifying dysplastic cortex or tumors. Contrast material should always be given in cases where tumors are suspected. The combination of tumor and mesial temporal sclerosis is not unusual in patients with intractable epilepsy. In such cases spoiled gradient echo sequence with slices perpendicular to the long access of the temporal lobe are sensitive in detecting hippocampal atrophy. Specific to angicentric gliomas, Lellouch-Tubiana et al., described isointense cortical gyri with an intrinsic rim-like hyperintensity on T1 weighted images. On T2 weighted image or FLAIR sequences the lesions appeared hyperintense. The authors also described a stalk-like extension of the lesion to the ventricle. In other cases, however, there was neither lesional extension to the ventricular wall, nor ring-like enhancement (Fulton et al., 2009; Preusser et al., 2007) Contrast enhancement and calcification is seldom seen with these lesions. They are described as most often seen in the frontal and temporal regions. Several parasagittal lesions were described, yet others involved the highly epiletogenic mesial temporal structures. Several authors described streaks of grey matter from the surrounding normal cortex dispersed within the tumor tissue (Fig. 42.2a, b). It is unclear whether these entrapped neurons or the tumor cells are the epileptogenic culprits. Positron emission tomography (PET) and single photon emission computed tomography (SPECT) imaging studies enable identification of potential

epileptogentic zones (PET), which usually employs the ligand, depicts metabolic differences in the brain. PET performed done in the inter-ictal (between seizures) period reveals hypometabolism of the epileptogenic zone (zone of seizure origin) (Knowlton, 2005; Koepp and Woermann, 2005). It may delineate either hypometabolism or, rarely hypermetabolism in the region occupied by the lesion in question. SPECT measures cerebral blood flow utilizing an injected radionucleotide. Interictal SPECT detects abnormal shows hypoprofusion similar in distribution to that seen in PET, while an ictal (during seizure) SPECT performed by injecting the radionucleotide at the onset of the seizure can yield increased signal of the seizure focus. A subtraction technique in which the ictal data is removed from the interictal data significantly improves specificity. Interictal PET and SPECT alone offer less specificity in that the area of hypometabolism is often larger in diameter then the actual epiletigenic zone. The Magnetoencephalogram (MEG) is a tool used to detect magnetic fields produced by cortical neurons (Knowlton, 2005). The maximal magnetic field is then superimposed on a three dimensional magnetic resonance imaging through the technique called magnetic source imaging (MSI). This technique is superior to surface electrodes placed on the scalp at identifying the site of seizure onset. Because a special magnetically shielded room is necessary to identify only eliminate extraneous magnetic fields, the study is usually obtained interictally. It may however better delineate whether the seizure is coming from within or around the tumor in question. MEG/MSI is less able

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Fig. 42.2 (a) T1 Axial showing an isointense parasagital lesion with imbedded depth electrodes and interhemisperic electrodes; (b) T2 MRI with a hyperintense parasagital lesion and subdural electrodes visualized. Entrapped cortical gray matter with finger like projections are observed with depth electrodes placed by stealth to sample these areas; (c) Resected gross pathological specimen of angiocentric gliomas shown in Fig. 42.2a, b; (d) Histology reveals the malignant cells concentrically placed around blood vessels of varying sizes. There is diffuse immunoreactivity of GFAP and focal epithelial membrane antigen staining

to evaluate very deep structures. Furthermore its sensitivity and specificity have been questioned in detecting discharges in mesial temporal structures. As is true with other seizure types, angiocentric gliomas cannot always be removed due to proximity to or involvement of the eloquent cortex. Unfortunately, many prior studies fail to identify the method of functional analysis employed. A lesion merely displacing eloquent cortex may allow for a complete resection; therefore neuroanatomical estimation of primary functional areas is insufficient (Duffau, 2005). Identifying the eloquent cortex prior to surgery is therefore essential (Fig. 42.3). If deficits are not preventable they may be minimized and identifying function preoperatively may enable, better preoperative counseling of patient and relatives. The best means of identifying cortical function is direct cortical stimulation using electrodes placed on the brain. This involves significant surgical and procedural risk, however, meaning that extra-operative functional studies might be more advisable. fMRI and MEG are non-invasive techniques now frequently used to identify essential areas of primary function in the

pre-operative period and are therefore instrumental in preoperative planning (Knowlton, 2005). WADA may be used in cooperative patients with temporal lobe involvement to lateralize memory and language function (Clarke and Boop, 2009). MEG functional studies identify somatosensory evoked potentials, visual evoked potentials, auditory evoked potentials, expressive and receptive language, and primary motor cortex. This is accomplished by using, magnetic field dipole localization, the same technique described above for characterizing epileptiform activity. Frequent epileptiform discharges may be difficult to discern from the discharges generated by the magnetic field created by evoked potentials. Functional magnetic resonance imaging (fMRI) will also identify identical areas i.e., language, motor, sensory, auditory and visual cortices. fMRI samples blood flow to produces still or moving images of the subject’s brain activity. Because of its dependence on blood flow, sensitivity and specificity may suffer in vascular lesions and tumors which distort blood flow. Motor and language mapping require patient cooperation, which limits the use of MEG and fMRI in

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Fig. 42.3 Graphic depiction of subdural grid and strips placed over the frontal and temporal lobes. Eloquent motor and language cortex is labeled and is displaced by the tumor shown on the T2 axial MRI image in the lower right of the figure

younger patients, due to their lesser ability to cooperate during testing. This disadvantage has however, been overcome in more recent studies by the utilization of passive movement to identify the sensory and motor (Ogg et al., 2009) regions. Recent literature has suggested that sedated receptive language testing may also be carried out successfully during light sleep (Perkins et al., 2008). Both fMRI and MEG identify activity on the cortical surface, but are unable to determine the trajectory of cortical pathways through white matter, which may be grossly distorted by lesions. Magnetic resonance tractography is a newer technique growing in popularity and use. It delineates cerebral white matter tracts with diffusion tensor imaging, which examines in water molecule diffusion in tissue. The functional area can then be identified on the cortical surface by MEG and fMRI and the cortical tracts followed. Although the sensitivity, specificity, and therefore accuracy of the technique are continually improving, it presently finds use in limited centers to assist in the Neurosurgical approach to avoid functional pathways. The most established extra-operative technique for lateralizing expressive and receptive language and memory has been the sodium amobarbital test (WADA). In this procedure sodium amobarbital is injected into the carotid artery to temporarily anesthetize one hemisphere, while neuropshycological testing of language and memory is carried out. Once the

patient recovers, testing is repeated by injecting the cortralateral carotid artery. The technique described above, however have substituted its use for language in many centers and memory paradigms are being attempted for both fMRI and MEG.

Cortical Mapping and Lesionectomy Direct cortical stimulation is the most sensitive and specific technique available for defining cortical function, in cases of close tumor proximity to somatosensory, motor, or expressive and receptive language cortices. Language mapping is dependent on patient response during current application while the patient is actively speaking or a question is being asked. Micro-currents are applied directly to subdural electrodes placed over the cortex just below after-discharge (a rhythmic discharge caused by electrically activating cortical neurons which, if it persists, may spread to other neurons and cause a clinical seizure). After-discharge threshold is higher in young children and patients with tumors; therefore more current is required for an adequate response (Chitoku et al., 2003). Stimulation over the motor area may cause tonic or clonic movement while that over the sensory area may cause a change in sensation. Testing can be done in awake older individuals with an open craniotomy,

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intraoperatively, or extraoperatively post intracranial electrodes placement at the bedside. In younger children, motor mapping can be done with anesthesia in the operating room, but language mapping efforts usually prove futile. Therefore mapping in young children is best done extra-operatively. Potential discordance between the seizure focus or epileptogenic zone and the tumor, necessitates invasive monitoring. Studies suggest that subdural electrodes often identify the ictal onset zone or seizure onset zone in the region immediately surrounding tumors (Tandon et al., 2001; Awad et al., 1991). A more recent case study questions whether placement of depth electrodes in the body of certain tumors may reveal seizures originating from within some tumor types (Fulton et al., 2009). Although further studies are required to test this hypothesis, depth electrodes may assist subdural electrodes may be helpful in obtaining more detailed sampling of the areas around and within a tumor (Fulton et al., 2009). This may then prevent unnecessary removal of normal functioning brain tissue.

Practical Surgical Application A lesionectomy should always be performed if the tumor does not approximate eloquent cortex and electrophysiological data supports the seizure coming solely from the tumor. This is concordant with studies that support complete tumor resection as being the best predictor of good seizure outcome (Awad et al., 1991). As stated earlier, a two-staged procedure using intracranial recording electrodes is performed to define seizure onset or cortical function in uncertain situations. In the first surgical procedure the tumor site and surrounding tissue is exposed. Pre-made grids or strips with embedded subdural electrodes are placed over the area in question, while depth electrodes can be placed directly in the tumor. A digital picture may be taken of the electrode array to document placement, identify neuroanatomical landmarks, and allow later labeling of seizure focus and functional mapping (Fig. 42.3). The patient then returns to the video-EEG monitoring room, with or without overnight ICU stay, and antiepileptic medications are withdrawn to capture typical seizures. Imaging studies are carried out to define three dimensional electrode placements. The necessary cortical mapping is then done at the bedside before the

D.F. Clarke and T.M. George

patient returns for the second surgery. A hand drawn or digital depiction of the region of seizure onset and functional cortex is presented to the epilepsy team, which then develops appropriate surgical plan (Rutka et al., 1999). Removal of the abnormal area is then carried out during the second surgical stage.

Pathology Angiocentric gliomas are usually intra-cortical and comprised of monomorphous, gliofibrillary acid protein positive (GFAP), usually slender cells often with focal epithelial membrane antigen (EMA) immunoreactivity (Fig. 42.2c, d). Features of both astocytic and ependymal differentiation are present (Fulton et al., 2009; Lum et al., 2008). The tendency for tumor cells to accumulate around blood vessels (Wang et al., 2005) in an angiocentric manner lends the tumor its name. Tumors cells are aligned in a radial or circumstantial longitudinal manner along small to medium size vessels. This pattern suggests a developmental nature of the tumor. Most lesions infiltrate the cortex and surrounding subdural white matter and gradations of minimally invasive or compact tumors displacing surrounding tissues has been described (Lellouch). White matter infiltration is accompanied by demyelination in some tumors (Lellouch). Preusser et al. described finding single neurons interdispersed within the tumor tissue itself, while Wang described trapping of cortical ganglion cells (Wang et al., 2005; Preusser et al., 2007). Rosenthal fibers, eosinophil granular bodies, and components of dysembryoplastic neuroepithelial tumor are absent. Vascular proliferations, necrosis, mitosis and other features associated with more aggressive tumor types are also seldom described (Wang et al., 2005).

Seizure Outcome Post-resection Only one reported death appears in the literature, that of a 26 year old male with recurrence of a left frontal lobe tumor (Wang et al., 2005). Seizure outcome in most cases is classified according to the Engle proposed seizure classification (class 1-free of disabling seizure; class 2-rare disabling seizures; class

42 Angiocentric Glioma-Induced Seizures: Lesionectomy

3-worthwhile improvement and class 4-no worthwhile improvement) (Engle et al., 1993). All patients with complete tumor resection were stated to be seizure free or free from disabling seizures. The only patients identified as having rare disabling seizures were those in whom total resection was not possible and the single reported fatality. This agrees with a study by Awad et al., which found postoperative control of partial epilepsy to be up to 94% effective with a complete lesioncetomy, 83% with incomplete lesionectomy but complete seizure focus removal and 52% effective with incomplete lesionectomy and incomplete resection of seizure focus (Awad et al., 1991). Other studies failed to reveal similar success rates. One revealed only 66% seizure freedom and 88% significant reduction in seizure frequency in patients with low-grade neoplasm induced seizures (Britton et al., 1994). The literature was unclear if patients remained on antiepileptic agents after angiocentric glioma removal. However Preusser et al. described two seizure-free patients who were not on any anti-epileptic agents, both of whom had a total lesionectomy. While a more recent study have shown that, post-tumor resection, individuals may be taken off anti-epileptic agents successfully within 3–6 months, most physicians continue patients on antiepileptic agents for 1–2 years prior to entertaining weaning.

Conclusion Angiocentric glioma is a recently described, novel tumor type with distinct pathological features. It is highly epiltogenic with most affected patients presenting with seizures. As in other more indolent tumor types, the true prevalence is unclear. Apart from a single case report, angiocentic glioma has a clinical pathological characteristic of a low-grade lesion. Prolonged period of sympotomatic epilepsy of up to 57 years in individuals affected is in concordance with these lesions being biologically benign. Nevertheless, there are severe psychosocial and neurocognitive ramifications of poorly controlled epilepsy over so many years. Antiepileptic agents may cause additional problems. As in other low grade lesions the angiocentric glioma, though not aggressive, is not necessarily benign. Factors described above suggest that surgical resection should be expedited if possible. It is

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imperative however, that electrophysiological and neuroimaging techniques be utilized appropriately to identify the region of seizure onset and functional areas, therefore minimizing post-operative mobidity. Total lesion resection provides best seizure outcome. It is unclear, however, how many patents could be successfully taken off anti-epileptic medication after tumor removal. Acknowledgements We would like to thank Dr. Jeffrey Kerr for his editorial expertise and Santa LeSure for the graphic labeling and design. Radiographic images were completed at Le Bonheur Children’s Medical Center and used with permission.

References Awad IA, Rosenfeld J, Ahl J, Hahn JF, Luders H (1991) Intractable epilepsy and structural lesions of the brain: mapping, resection strategies, and seizure outcome. Epilepsia 32:179–186 Beaumont A, Whittle IR (2000) The pathogenesis of tumor associated epilepsy. Acta Neurochir (Wien) 142:1–15 Britton JW, Cascino GD, Sharbrough FW, Kelly PJ (1994) Low-grade glial neoplasms and intractable partial epilepsy: efficacy of surgical treatment. Epilepsia 35:1130–1135 Chitoku S, Otsubo H, Harada Y, Jay V, Rutka JT, Weiss SK, Elliott I, Ochi A, Kitayama M, Snead OC (2003) Characteristics of prolonged after discharges in children with malformations of cortical development. Child Neurol 18:247–253 Clarke DF, Boop F (2009) Epilepsy surgery. In: Wheless J, Willmore L, Brumback R (eds) Advanced therapy in epilepsy, vol 52. People’s Medical Publishing House, Shelton, CT, pp 402–414 Duffau H (2005) Lessons from brain mapping in surgery for low grade glioma: insights into associations between tumor and brain plasticity. Lancet Neurol 4:476–86 Elliot IM, Lach L, Smith ML (2005) I just want to be normal: a qualitative study exploring how children and adolescents view the impact of intractable epilepsy on their quality of life. Epilepsy Behav 74:664–678 Engle J Jr, Van Ness PC, Rasmussen TB, Ojemann LM (1993) Outcome with respect to epileptic seizures. In: Engel J Jr (ed) Surgical treatment of the epilepsies, 2nd edn. Raven, New York, NY, pp 609–621 Feindel WJ (2003) Osler and the ‘medico-chirurgical neurologist’: horsley, cushing, and penfield. J Neurosurg 99(1): 188–199 Freitag H, Tuxhorn I (2005) Cognitive function in preschool children after epilepsy surgery: rationale for early intervention. Epilepsia 46:561–567 Fulton SP, Clarke DF, Wheless JW, Ellison DW, Ogg R, Boop FA (2009) Angiocentric glioma-induced seizures in a two-year old child. J Child Neurol 24(7):852–856 Glauser T, Ben-Menachem E, Bourgeois B, Cnaan A, Chadwick D, Guerreiro C, Kalviainen R, Mattson R, Perucca E,

434 Tomson T (2006) ILAE treatment guidelines: evidence-based analysis of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes. Epilepsia 47(7):1094–1120 Hirtz D (2000) Practice parameter: evaluating a first nonfebrile seizure in children. Neurology 55:616–623 Hitiris N, Mohanraj R, Norrie J, Brodie MJ (2007) Mortality in epilepsy. Epilepsy Behav 10(3):363–376 Holms G (1927) On local epilepsy. Lancet 1:957–962 Knowlton RC (2005) The role of FDG-positron emission tomography, itcal single photon emission computed tomography, and magentoencephalography in the epilepsy surgery evaluation. Epilepsy Behav 8:91–101 Koepp MJ, Woermann FG (2005) Imaging structure and function in refractory focal epilepsy. Lancet Neurol 4:42–53 Kwan P, Brodie MJ (2000) Early identification of refractory epilepsy. N Engl J Med 342(5):314–319 Lellouch-Tubiana A, Boddaert N, Bourgeois M, Fohlen M, Anne Jouvet A, Delalande O, Seidenwurm D, Brunelle F, Sainte-Rose C (2005) Angiocentric neuroepithelial tumor (ANET): a new epilepsy-related clinicopathological entity with distinctive MRI. Brain Pathol 15:281–286 Lhatoo SD, Johnson AL, Goodridge DM, MacDonald BK, Sander JW, Shorvon SD (2001) Mortality in epilepsy in the first 11 to 14 years after diagnosis: multivariate analysis of a long-term, prospective, population-based cohort. Ann Neurol 49(3):336–344 Losey TE, Ng Y-t (2009) Partial-onset seizures and localizationrelated epilepsy syndromes. In: Wheless J, Willmore L, Brumback R (eds) Advance therapy in epilepsy, vol 23. People’s Medical Publishing House. Shelton, CT, pp 165–178 Lote K, Stenwig AE, Skullerud K, Hirschberg H (1998) Prevalence and prognostic significance of epilepsy in patients with gliomas. Eur J Cancer 34:98–102 Lum DJ, Halliday W, Watson M, Smith A (2008) Law, A. Cortical ependymoma or monomorphous angiocentric glioma? Neuropathy 28:81–86 Mohanraj R, Norrie J, Stephen L, Kelly K, Hitiris N, Brodie MJ (2006) Mortality in adults with newly diagnosed and chronic epilepsy: a retrospective comparative study. Lancet Neurol 5(6):484–487

D.F. Clarke and T.M. George Ogg RJ, Laningham FH, Clarke DF, Einhaus S, Zou P, Tobias ME, Boop FA (2009) Passive range of motion functional magnetic resonance imaging localizing sensorimotor cortex in sedated children. J Neurosurg Pediatr 4:317–322 Perkins F, Clarke D, Richie S, Brewer V, Wheless J, McGregor A, Ogg R, McManis M (2008) Passive language mapping using magnetoencephalograpy. Epilepsia (Abst. 2.056) Preusser M, Hoischen A, Novak K (2007) Angiocentric glioma: report of clinico-pathologic and genetic findings in 8 cases. Am J Surg Pathol 31:1709–1718 Rutka JT, Otsubo H, Kitano S, Sakamoto H, Shirasawa A, Ochi A, Snead OC (1999) Utility of digital camera derived intraoperative images in the planning of epilepsy surgery for children. Neurosurgery 45:1186–1191 Ryvlin P, Montavont A, Kahane P (2006) Sudden unexpected death in epilepsy: from mechanisms to prevention. Curr Opin Neurol 19:194–199 Shakur SF, McGrit MJ, Johnson MW, Burger PC, Ahn E, Carson G, Jallo GI (2009) Angiocentric glioma: a case series. J Neurosurg Pediatr 3(3):197–202 Spencer SS, Huh L (2008) Outcome of epilepsy surgery in adults and children. Lancet Neurol 7:525–537 Sperling MR (2004) The consequences of uncontrolled epilepsy. CNS Spectr 9:98–101, 106–109. Tandon PN, Mahapatra AK, Khosla A (2001) Epileptic seizures in supratentorial gliomas. Neurol India 49:55–59 van Breemen MSM, Wilms EB, Vecht CJ (2007) Epilepsy in patients with brain tumors: epidemiology, mechanisms, and management. Lancet Neurol 6:421–430 Wang M, Tihan T, Rojiani AM, Bodhireddy SR, Prayson RA, Iacuone JJ, Alles AJ, Donahue DJ, Hessler RB, Kim JH, Haas M, Rosenblum MK, Burger PC (2005) Monomorphous angiocentric glioma: a distinctive epileptogenic neoplasm with features of infiltrating astrocytoma and ependymoma. J Neuropathol Exp Neurol 64:875–881 Wheless JW, Clarke DF, Carpenter D (2005) Treatment of pediatrics epilepsy: expert opinion. J Child Neurol 20:51–56 Wiser HG (1983) Part 3. Electroclinical features of the psychomotor seizure. Butterworths, London, pp 177–235

Index

A Abernathey, C.D., 374–375 Abou-Ghazal, M., 317 Achatz, M.I., 36 Acute myeloid leukemias, 60 Adam, J.F., 350 Adeno-associated viruses (AAV), 338 Adenoviral vectors (Ads), 344 CAR, 338 HSV-tk gene therapy, 345 MHC, 338 suicide gene therapy, 345 Adjuvant chemotherapy, 210 Adult brainstem gliomas “diffuse intrinsic”/“diffusely infiltrative low grade” clinical presentation, 372 diplopia, axial flair MR, 372 epidemiology, 372 follow-up, 373 pathology, 372 radiological presentation, 372 treatment, 372–373 focal tectal brainstem gliomas clinical and radiological presentation, 375 epidemiology, 375 pathology, 375 treatment and follow-up, 376 malignant brainstem gliomas clinical presentation, 374 differential diagnoses, 374–375 epidemiology, 373 follow-up, 375 gadolinium infusion, axial T1-weighted MR, 374 pathology, 373 radiological presentation, 374 treatment, 374–375 neurofibromatosis type 1, 376 posterior exophytic gliomas, 376 Adult gliomas, see Gliomagenesis Aghili, M., 18, 51 Aghi, M.K., 252 Agnelli, G., 381 Aguado, T., 283 Albert, F.K., 182

Alberts, B., 304 Alexander, A.L., 114–115, 118 Allan, R.S., 144, 146 Alldredge, B.K., 404 Al-Okaili, R.N., 422 Ammirati, M., 5 Anaplastic astrocytoma (AA), 207, 336 adjuvant chemotherapy, 210 lomustine chemotherapy, 209 procarbazine chemotherapy, 209 temozolomide, 209–210 vincristine chemotherapy, 209 Anaplastic gliomas, 12 Anaplastic oligodendrogliomas (AO) (WHO grade III), 47, 212 Angiocentric glioma, see Lesionectomy Angiogenesis, 291 Animal glioma models cell line and host C6 cell line, 349 9L cell line, 349 selection of, 349 implantation technique animal’s head, 352 burr hole, 352 choice of coordinates, 351–352 localization, 353 microinfusion pump, 352 MR and PET, 351 parameters, 354 tumor cell suspension, 352–353 standardized model cell line preparation, 354 Antiepileptic drug treatment in glioma carbamazepine, 403 enzymatic induction, 403 hepatic cytochrome P450, 403 phenytoin, 403 valproate, 404 Anti-glial fibrillary acidic protein (GFAP), 33 Antisense oligonucleotides (AON), 330 Antitumor treatment in glioma chemotherapy, 405 intraoperative electrostimulation mapping, 405 radiotherapy, 405

M.A. Hayat (ed.), Tumors of the Central Nervous System, Volume 2, DOI 10.1007/978-94-007-0618-7, © Springer Science+Business Media B.V. 2011

435

436 Anti-vascular endothelial growth factor in glioma angiogenic regulators siRNAs, 364 anti-angiogenic therapy GBM, 364–365 hypoxia, 364 immunhistochemical detection, 364–365 malignant glioma cells, 365 PI3 levels, 365 gene profiling studies, model in chick embryo CAM, 362–363 GeneChips, 362–363 tumour, 362–364 U87 cells, 362–363 molecular pathways inhibition CAM, 367–368 pre-clinical evaluation angiogenic and invasive phenotypes, 367 knockdown of IL6 and/or VEGF, 366–367 siRNA, 366–367 tumor cells in CAM, 366–367 Aoki, H., 283, 321 AON, see Antisense oligonucleotides (AON) Ardon, H., 313–330 Aronen, H.J., 82, 419–420 Aronica, E., 404 Arsenic trioxide, 4–5 Arvinda, H., 419, 421–422 Ashery, U., 262 Astner, S.T., 143 Astrocytic tumors, 15, 25 pathogenesis and progression, 55 Astrocytoma, 419 Athanassiou, H., 208 ATP citrate lyase (ACLY), 2 R , see Bevacizumab Avastin Awad, I.A., 426, 432–433 B Bailey, P., 25 Balkwill, F., 317 Balss, J., 18, 48–49, 54, 56–57, 60 Banissi, C., 329 Banks, L., 44 Bao, S., 19, 271, 317 Barker, F.G.I.I., 124 Barkovich, A.J., 388 Barondes, S.H., 262 Barth, R.F., 234–235, 349–350 Basser, P.J., 115 Batchelor, T.T., 211, 293 Bauchet, L., 143 Bauman, G.S., 218, 226 Beaulieu, C., 114, 116 Beaumont, A., 399, 425 Beckner, M.E., 2 Been, L.B., 104 Belanich, M., 74 Benard, F., 139 Benhar, M., 67

Index Benjamin, L.E., 291 Bennet, C.L., 258 Bennett, A., 181 Ben Taarit, C., 375 Beppu, T., 116, 118 Berger, M.S., 174–175, 181–182 Bergers, G., 291, 298 Bergsneider, M., 185 Bernays, R.L., 185 Bernstein, J.J., 144 Berntsson, S.G., 401 Bertolone, S.J., 256 Bevacizumab, 2, 209, 289 clinical and radiological benefit, 295 clinical effect corticosteroid use, 295 neurocognetive function and performance status, 295–296 clinical response evaluation steroid effect, 296 HGG and efficacy, 294 phase 2 pilot study, 3 recurrent glioblastoma, 3 treatment with irinotecan, 295 VEGF inhibition, 294 Bhujwalla, Z.M., 83 Bi-exponential decay model, 304 Bigner, D.D., 124 Bigner, S.H., 124 Binello, E., 302 Biological fluids biomarkers, 12 cerebrospinal fluid, 13 diagnosis and tumor heterogeneity, 13 LGG, 13 magnetic resonance imaging (MRI), 13 Biomarkers cancer biology, new findings in genomics, 16 glioblastomas and, 17 TIC and TSC, 16 transcriptome, 16–17 neurosphere cultures glioblastoma multiforme, 22 gliomas and, 21–22 IDH1 and IDH2, 22 LOH 1p/19q, 22 PTEN deficiency, 22 usefulness of, 14 Biomarkers and HGG management course anaplastic oligos, 15 glioneuronal tumors, 15 WHO classification, 15 response to treatments chemotherapy, 16 grade III tumors and, 15–16 radiation therapy, 16 stratifications, 16 temozolomide, 16 Biomarkers and LGG management benign tumors, 13

Index response to treatments chemotherapy, 15 methylation status, MGMT, 15 oligendendroglioma, 15 radiation therapy, 15 spontaneous course alkylating chemotherapy, 14 anaplastic oligodendroglial, 14 anticipated usefulness of, 14 chromosomal material, loss of, 14 Delta Ex2-3 isoform of p73 gene, 13–14 tumor growth rate and volume, 13 1,3-Bis(2-chloroethyl)- 1-nitrosourea (BCNU), 64 Bisdas, S., 419, 421 Bitan, M., 382 Black, P.M., 182 Blanchard, J., 356 Blazquez, C., 283 Bleeker, F.E., 26, 49 Blood–brain barrier (BBB), 97, 108, 314, 316 BNL, see Brookhaven National Laboratory (BNL) Bogler, O., 34 Bohinski, R.J., 185 Bone morphogenetic proteins (BMPs), 4 Boop, F., 426, 430 Boop, F.A., 426, 430 Borbély, K., 108 Borden, E.C., 269, 273 Borghaei, H., 318 Boron neutron capture protocol, 6 Boron neutron capture therapy (BNCT) beam facilities bismuth filter, 236–237 clinical trials, 235 cross-section of, 236 research reactors, 235–236 spectrum control devices, 236 clinical studies beams penetrability, 232 BNL, 232 BSH distribution, 233 BSH-mediated, 232 external beam, 233 C-methionine-PET, 231 delivery system and antibody-antigen reaction, 235 characteristics, 235 DDS, 235 direct intratumoral injection, 235 irradiation room and head positioning, 231 LET and PET, 230 reaction of, 230 treatment planning system INEEL, 237 radiotherapy, 238 ROI, 237 therapeutic advantage in, 237 Boss, A., 132 Bouillot-Eimer, S., 143–144, 146–147 Bourgeois, M., 407 Bouzier, A.K., 65

437 Boviatsis, E.J., 374 Boxerman, J.L., 84, 418, 421 Brada, M., 77, 251, 405 Bradbury, M.W., 316 Bradbury, P.A., 319–321 Brady, L.W., 124 Brain metastases, 113 Brainstem gliomas classification cervicomedullary, 388 diffuse intrinsic, 388 dorsal exophytic, 388 focal tectal, 388 clinical manifestations, 388 symptoms duration, 389 diagnosis exophytic tumor, 391–392 hyperintense FLAIR, 391 hypointense sagital T1, 391 Listeria monocytogenes, 389 MRI, 390 T2-weighted sagital MR sequence, 391 differential diagnosis, 389 fluid attenuation inversion recovery (FLAIR), 390 hemorrhagic or ischemic strokes, 390 infectious agents, 389 inflammatory lesions, 389–390 epidemiology, 387 neurofibromatosis 1 (NF1), 388 treatment chemotherapy, 393 mainstay of, 392–393 radiation therapy, 392 single or multiple drug regimens, 393 surgical resection, 393 Brain tumor angiogenesis, 81 blood volume and permeability quantification aspect of, 83 contrast agent leakage, 84 dual echo gradient echo perfusion weighted imaging, 84 imaging techniques, 83 perfusion techniques, 83–84 heterogeneity and perfusion imaging, 87 PCT CBV map, 89 glioma grade and, 85, 86– 87 kinetics theory, 84–85 parameters, 85, 87 recurrent tumor from radiation necrosis, 88–89 technique, 85 perfusion imaging and histopathology WHO grading system, 82 perfusion parameters and importance, 82 tumor blood volume endothelial cells, 82 intratumoral MVD, 82 measurement of, 82 solid tumors, 82 tumor vascular permeability, 83 Brain tumor-derived stem cells (BTSC), 5

438 Brain tumor-polyposis (BTP), 35 syndrome type 1 and 2, 36 Brain tumors, 31, 302 case study, 32 classification of, 336 Cowden syndrome and Lhermitte-Duclos disease, 41 DTI use in classification apparent diffusion coefficient (ADC), 116 combined metrics, 119 FA role, enhancing region, 116, 118 measurements from, 116 shape based diffusion tensor metrics, 118 tumor infiltration assessing, 118–119 gene therapy AAV, 338 NDV, 338 pro-drug activation and suicide, 339 VPCs, 339 Gorlign syndrome, 41 groups, 336 Li-Fraumeni syndrome, 42 melanoma-astrocytoma syndrome, 42 methodology-diffusion tensor imaging, 114 apparent diffusion coefficient (ADC), 115 fractional anisotropy (FA), 115 geometric nature, 115 isotropic diffusion, 115 mismatch deficiencies, 35–36 mutation spectrum associated with, 34–35 neurofibromatosis type 1, 40–41 neurofibromatosis type 2, 42 pathophysiology brain metastases, 114 geometric interpretation of, 114 WHO classification, 114 and stem cells, 18 distinct signaling pathways, 18 integrated genomic analysis, 18 NSC, presence of, 18 progenitors, 18 therapeutics, impact of, 18 tuberous sclerosis complex (TSC), 41 Turcot syndrome (TS), 41 von Hippel-Lindau (VHL) syndrome, 41 Brandes, A.A., 75–76, 210–211, 256 Brasil Caseiras, G., 168 Brem, H., 175 Brem, S., 175 Brisman, R., 379 Bristol, R.E., 164 Britton, J.W., 407, 425, 433 Brodie, M.J., 425–426, 428 Brogna, C., 399, 404–405 Broniscer, A., 393 Brookhaven National Laboratory (BNL), 232 Brown, K., 211 Brown, P.D., 177 Bru, A., 64 Bru, I., 64 BTP, see Brain tumor-polyposis (BTP) BTSC, see Brain tumor-derived stem cells (BTSC)

Index Buatti, J., 229–230, 232 Buller, H.R., 380 Burger, P.C., 35, 147 Burian, J., 232 Busse, P.M., 232 Bynevelt, M., 156 C Cairncross, G., 290 Cairncross, J.G., 16, 26, 82, 212 Calli, C., 116 Camby, I., 261–264, 266 Camelo-Piragua, S., 49 Campora, R.G., 143 R , see Irinotecan Campto R , see Irinotecan Camptosar Cancer, 301 stem cells, type I IFNs, 270 tissue, 303 types and world’s population, 1 Candotti, F., 337 Cannabinoids (anti-cancer agents) in glioblastoma, 277 anti-tumoral action, 280 demand for oxygen and nutrients supply, 283 inhibition of pro-survival pathways, 280–281 pro-angiogenic factors, 283 role of ER stress and autophagy in, 281–283 applications, 278 clinical use of pilot study, 284–285 risks, constrains and benefits, 285 safety profile, 284 THC capsules, 283–284 health and brain tumors CB1 and CB2 receptors, 278 CB2 immunostaining, 279 central and peripheral effects, 278 endogenous, 278 immunohistochemical analysis, 278–279 malignancy grade and CB2 expression, 279–280 plant-derived 9–THX, chemical structures, 279 Cao, Y., 104, 108 Capelle, L., 190, 399, 405 Capper, D., 49, 58 Capuani, S., 235 CAR, see Coxsackie- and adenovirus receptor (CAR) Carbamazepine, 403, 428 Carbone, F.R., 316 Carmel, P.W., 185 Carpentier, P.A., 3 Carracedo, A., 280–281 Carro, M.S., 31 Carson, K.A., 3 Casanovas, O., 361 Caseiras, G., 168 Caseiras, G.B., 421, 422 Cassoni, P., 143–148 Castellot, J.J.Jr., 382 Cavaliere, R., 401, 404 CBTRUS, see Central brain tumor registry of united states (CBTRUS)

Index CD133-positive cells in glioblastoma, 4 Cell death mechanisms, 302 Cenic, A., 83 Cental nervous system (CNS) tumors, 143 Central brain tumor registry of united states (CBTRUS), 124 Cerebral gliomas, 4 dynamic scale, 156 macroscopic scale, 156 microscopic scale histopathological tridimentionnal architectural, 155 isolated tumor cells, 154 microscopic tumor, 154 pilocytic astrocytomas, 156 solid tumor tissue, 154 tumor capsule, 154 WHO tumor grades, 156 Cervicomedullary gliomas, 388 Cervio, A., 143 Ceyssens, S., 104, 108–109 CGH, see Comparative genomic hybridization (CGH) Chaichana, K.L., 404 Chakravarti, A., 27 Chamberlain, M.C., 211, 376 Chanana, A.D., 232 Chandy, M.J., 373–375 Chang, C.Y., 366 Chang, E.F., 404 Chang, E.L., 216 Chang, S., 250 Chang, S.M., 217 Chang, Y.S., 95, 97 Chan, J.A., 273 Chan, J.L., 216 Cha, S., 82–83, 421 Chemotherapy for GB, 222, 393 left inferior limb arteriography, 257 temozolomide, cisplatin, thalidomide clinical experience, 257 combination of cisplatin and, 256 mielotoxicity, 258 rationale, 256 resistance to, 256 vascular complications, 258 Chenevert, T.L., 115–116, 306 Cheng, S.Y., 361 Chen, R., 22 Chen, W., 104, 110 Chen, X., 165–166 Chen, Y., 273 Chen, Y.S., 93–100 Chen, Z.P., 93–100 Chinot, O.L., 73–74 Chiocca, E.A., 340 Chitoku, S., 431 Choi, B.D., 319, 321 Choi, S.J., 104, 110 Cho, K.H., 222 Chorio-allantoic membrane (CAM), 361–364, 366–368 Choyke, P.L., 83 Christofori, G., 368 Ciafre, S.A., 340

439 Cibula, J.E., 399 Ciechomska, I., 244, 252, 277–285 Ciesielski, M.J., 326 Cisplatin clinical experience phase II study, 257 left inferior limb arteriography, 257 malignant gliomas, 256 mielotoxicity dose limiting toxicity (DLT), 258 dynamic contrast enhanced magnetic resonance (dMRI), 258 phase III study, 255–256 thalidomide and temozolomide, 256 vascular complications phase II study, 258 venous grade 3-4 toxicity, 258 Clarijs, R., 97–98 Clarke, D.F., 425–433 Clarke, J., 242 Claus, E.B., 185, 190 Clauss, A., 364 Clausse, N., 264 Clinical target volume (CTV), 133, 216 Cloughesy, T.F., 211, 250 Coakham, H.B., 372 Coate, L., 207–212 Coderre, J.A., 234–235 Collen, A., 382 Colon cancer, 32 Colvin, D.C., 309 Combs, S.E., 215, 221, 223 Comparative genomic hybridization (CGH), 19 Conditionally replicative adenoviruses (CRADs), 340 Conformal radiotherapy, 215 Connor, S.E., 156 Conturo, T.E., 84 Coons, S.W., 64, 70, 417–418, 421 Copier, J., 313 Covarrubias, D.J., 88 Cowden syndrome and Lhermitte-Duclos disease, 41 Coxsackie- and adenovirus receptor (CAR), 338 CRADs, see Conditionally replicative adenoviruses (CRADs) Criniere, E., 27 Croteau, D., 157 Crum, B.A., 375 Cserr, H.F., 316 CTV, see Clinical target volume (CTV) Curran, W.J.Jr., 181, 382 Current therapy adjuvant radiotherapy and chemotherapy, 337 maximum radiation dose, 336 Curtin, N.J., 73 Cushing, H.W., 25 D Daglioglu, E., 388 Dahlstrand, J., 270 Dai, C., 362 D’Amato, R.J., 256 Danchaivijitr, N., 419

440 Dang, C.V., 67 Dang, L., 18, 50, 58–60 D’Atri, S., 256 Datta, C.K., 144 Daumas-Duport, C., 12, 154, 157–158, 160, 165, 410 3D Conformal/stereotactic radiotherapy BED, 220 conventional radiotherapy with, 221 fractionated stereotactic radiotherapy with, 221 LINAC based stereotactic radiosurgery with, 221 re-irradiation studies, 220 DDS, see Drug delivery systems (DDS) Deacetylase inhibitors, 36 Death effectors, 4 De Benedictis, A., 194, 202 Debinski, W., 124 De Carli, E., 57 Deckers, R., 4 Deep vein thromboembolism (DVT), 379, 381–383 De Groot, J.F., 366 Deitcher, S.R., 380 Delattre, J.Y., 371–376 Delayed-type hypersensitivity (DTH), 321 Dello Russo, C., 252 Del Pulgar, T.G., 280–281, 285 De Lussanet, Q.G., 83 Deoxyribonucleic acid (DNA), 337 De Sio, L., 393 Desmurget, M., 199–201 Devinsky, O., 404 De Vleeschouwer, S., 316–321, 323, 325–326, 329–330 Dhami, M.S., 258 Dhermain, F., 216 Dhodapkar, K.M., 319 Diaz, A.Z., 232 Dickinson, L.D., 382 Diffuse intrinsic gliomas, 388 Diffuse low-grade gliomas (LGG), 163 history of, 154 image-based monitoring of MTD, 166 natural course, 167 quantitative radiological growth rates, 166–168 radiological growth pattern, 166 spontaneous tumor growth rates, 168 VDE, 166 MRI-based estimation of dynamic approach, 157 FLAIR sequences, 156 malignancy grade, 157 static approach, 156–157 tumor growth rate, 157 MRI reflect, actual spatial extent of, 157 isolated tumor cells, 158 MRI underestimates, spatial extent of biopsy samples, 158 features, 158 isolated tumor cells, cycling, 158–159 MIB-1 positive cells, 158 preoperative MRI, 159

Index prognostic value, 160 surgical resection of, 160 radiological growth rates apparent diffusion coefficient (ADC), 168 limitation of, 170 prognostic factor, 168–170 spontaneous VDE, 169 static parameters, 170 surgery benefits, 170 treatment efficacy, 170 spatial configuration of cerebral gliomas dynamic scale, 156 macroscopic scale, 156 microscopic scale, 154–156 surgical resection of, 153 three-step natural history of initial silent period, 164 malignant progression, 165–166 step-by-step approach, 164 symptomatic period of, 165 WHO grading, 153 Di Maio, S., 389, 392–393 D’Incalci, M., 256 Dirr, L.Y., 372 Dix, A.R., 318 DNA, see Deoxyribonucleic acid (DNA) DNET, see Dysembryoblastic neuroepithelial tumors (DNET) Doherty, L., 250 Döme, B., 97 Donghi, R., 37 Dong, J., 96, 100 Dorsal exophytic gliomas, 388 Double strand break repair pathway, 2 Drug delivery systems (DDS), 235 Drug resistance genes, 4 DTH, see Delayed-type hypersensitivity (DTH) Dubbink, H.J., 26, 57 Duffau, H., 3, 153–154, 165, 189–204, 399, 405, 426, 430 Dulbecco’s modified Eagle medium (DMEM), 354 Dumartin, L., 362 Dunn, G.P., 313–314, 316–317, 382 Duntsch, C., 280, 284–285 DVT, see Deep vein thromboembolism (DVT) Dysembryoblastic neuroepithelial tumors (DNET), 398–399 E Earnest, Ft, 157–158 EI Hallani, S., 94–96 Elgamal, E.A., 372 El Hallani, S., 1, 39–44, 94–96 Ellert-Miklaszewska, A., 277–285 Ellika, S.K., 81, 83, 85 Elliot, I.M., 426 Elliott, L., 318 El Naqa, I., 135 Elola, M.T., 263 Elowitz, E.H., 283 EMA, see Epithelial membrane antigen (EMA) Endothelial-lined vasculature, 95 Engell-Noerregaard, L., 314, 321

Index Engle, J.Jr., 432–433 EOR, see Extent of resection (EOR) Epidermal growth factor receptor (EGFR), 211 Epileptic seizures in glioma clinical manifestations status epilepticus, 401 TIA, 401 tumor progression, 402 types, 401 differential diagnoses cardiac arrythmia, 403 drop attacks, 402–403 migraine aura, 402 psychogenic symptoms, 403 syncope, 402 TIA/ischemic infarction, 402 epidemiology epileptogenic lesions, 398 epileptogenesis in astrocytoma grade II, 400 glioblastoma histopathological sections, 400 pathophysiology, 399 peritumoral brain, 399, 401 SMA, 399 genetic factors, 401 tumor characteristics, 399 treatment antiepileptic drug, 403–404 antitumor, 405 hepatic cytochrome P450 enzyme system, 403 refractory seizures, 404 Epithelial membrane antigen (EMA), 430, 432 Epstein, F., 388 Eramo, A., 4, 19, 271, 317 Ernst-Stecken, A., 221 Esquela-Kerscher, A., 272 Esteller, M., 74 Estes, M.L., 412 European Organization for Research and Treatment of Cancer (EORTC), 74 Evans, D.G., 42 Evans, S.M., 68 Everhard, S., 27 Extent of resection (EOR), 190 F Fabi, A., 73–77 Fabrini, M.G., 211 Fadok, V., 302 Faivre, S., 70 False-negative and false-positive glioblastoma, 25 Familial gliomas Cowden syndrome and Lhermitte-Duclos disease, 41 genetic forms, 43–44 genetic linkage analysis, 40 genetic predisposition, 40 Gorlign syndrome, 41 Li-Fraumeni syndrome, 42 melanoma-astrocytoma, 42 neurofibromatosis type 1 and type 2, 40–41

441 segregation analysis, 40 TP53 gene, role in polymorphism in sporadic, 44 role of, 42–43 tuberous sclerosis complex (TSC), 41 Turcot syndrome (TS), 41 Fantin, V.R., 66 Fan, X., 5 Farmer, J.P., 372, 388 Fecci, P.E., 318 Feindel, W.J., 425 Ferner, R.E., 388 Ferrara, N., 292, 361 Figueroa, P., 143–145, 147 Fine, H.A., 256 Fine-needle aspiration cytology (FNAc), 147 Fisher-F98 Model cell line preparation ATCC, 354 DMEM, 354 trypsinization of, 354 clinical evolution, 354–355 histopathological characterization immunocytochemistry, 355 pathologic analysis, 355 results of, 355–356 implantation technique bone wax, 354 Fitzek, M.M., 230 FNAc, see Fine-needle aspiration cytology (FNAc) Focal tectal gliomas, 388 Folberg, R., 95 Folkman, J., 81, 99, 382 Fortin, D., 349–358 Fosphenytoin, 428 Fouladi, M., 376 Fournier, E., 350–351 Francis, C.W., 337 Frank, D.A., 273 Freeman, C.R., 372 Freitag, H., 427 French, P.J., 25–28 Friedman, H., 210 Friedman, H.S., 73–74, 215, 224, 290, 294–295, 375 Fuchs, I., 375 Fueger, B.J., 138 Fu, J., 65 Fujimoto, K., 375 Fulton, D., 211 Fulton, S.P., 426–429, 432 Functional neuronavigation, 191 Furnari, F.B., 47 Furukawa, K., 342 G Gabapentin, 428 Gabrusiewicz, K., 241–252 Gadeberg, P., 128 Gajjar, A., 393 Galanis, E., 211, 250

442 Galectin-1 (Gal 1) glioblastoma chemo/radioresistance anticancer drug, 265 hypoxia, 265 temozolomide, 265–266 in glioma biology angiogenesis, 265 cDNA microarray, 264 immunohistochemical analysis, 263 progression-associated genetic alterations, 264 stress conditions, 264 in vitro studies, 263–264 Galectins family angiogenesis, 265 carbohydrate-recognition domain (CRD), 262 cDNA microarray, 264 extracellular matrix, 263 immunohistochemical analysis, 263 progression-associated genetic alterations, 264 properties, 262 stress conditions, 264 in vitro studies, 263–264 Galldiks, N., 104, 110 Galli, R., 100 Galons, J.-P., 306 Galve-Roperh, I., 278, 280–281, 284–285 Ganslandt, O., 157 Gathinji, M., 177 Gaviani, P., 372 GBM, see Glioblastoma multiforme (GBM) Gemistocytic astrocytoma case study, 32 Gene therapy DNA, 337 MLV, 337 NIH Clinical Centre, 337 OTC, 337 transforming principle, 337 Gene therapy-induced apoptosis, 301 assessing response, water diffusion, 305–307 BDIX rat brain, 306 biological aspects, 305 cell density, 306 inhomogeneous ADC response with, 307 tumor treatment response, diffusion MRI, 305–306 water ADC initial decrease, 306 brain tumors, 302 Brownian motion, 301 cancer, 301 cancerous tissue, 303 cell death mechanisms DNA fragmentation, 302 membrane-encapsulated apoptotic bodies, 302 nuclear condensation, 302 shrinkage of cell, 302 clinical aspects, 308 apparent diffusion coefficient (ADC), 309 definition of, 302 FDA, 303 magnetic resonance imaging (MRI), 301 magnetic resonance methods

Index apparent diffusion coefficient (ADC), 303 diffusion and, 303 diffusion measurement of, 304 gradient parameters, 303 tissue, metabolite diffusion, 309 cell diameter and, 307 diffusion weighted spectroscopic imaging data, 308 MRS, 307 treatment response detection, MR contrast methods, 308 water diffusion apparent diffusion coefficient (ADC), 305 bi-exponential decay model, 304 brain tissue, 304 multi-compartmental diffusion, tissue, 304–305 Gene transfer vector, adenoviruses as anti-angiogenic therapy, 339–340 scatter factor (SF), 339–340 TIMP-3, 340 tumour development, 339 ZFPs, 339 immune modulation GMCSF, 341 TGF-β, 340 oncolytic viruses CRADs, 340 Saccharomyces cerevisiae, 340 suicide gene therapy, 342 targeting tumour proliferation and orthotopic rat glioma model, 341 retinoblastoma (Rb), 341 TIMP’s, 342 Genome wide molecular markers, gliomas gene expression profiling, 27 mesenchymal, 27 1p19q status and, 28 proliferative, 27 proneural, 27 George, T.M., 425 Germano, I., 5 Germano, I.M., 302 Germline mutation TP53 in glioblastoma brain tumors and mutation spectrum as carcinogen fingerprints, 34 IARC database, 34 IDH gene mutations, 34 R132C, 34 somatic genetic changes, 34–35 wild-type allele and, 34 case 1 report, 32 astrocytoma, grade 2, 33 family pedigree, 33 TP53 immunostaining, 33 case 2 report, 32 adenocarcinoma of colon, 33 anti-glial fibrillary acidic protein (GFAP), 33 colon cancer, TP53 immunostaining of, 33 multiforme, 33 transcription repression, 33 CHEK2- related syndrome (LFS2), 31 genetic testing and brain tumors, 35

Index criteria for, 35 DNA, 35 germline TP53 mutations, 35 malignant tumors, 35 single nucleotide polymorphisms (SNPs), 35 Li-Fraumeni-like syndrome (LFLS), 31 Li-Fraumeni syndrome (LFS1), 31 Maffuci syndrome, 31 screening problems and preventions deacetylase inhibitor, 36 gastrointestinal (GI) tract, 36 histone deacetylase type (HDAC) III, 36 neonatal mass screening, 36 p53-activating drugs and, 36 positron emission tomography (PET), 36 R337H mutation of TP53, 36 syndromes and brain tumor-polyposis (BTP), 35–36 hereditary non-polypotic colorectal cancer (HNPCC), 36 mismatch deficiencies, 35–36 Muir-Torre syndrome, 36 TP53 disorders, 36 TP53 and glial tumors adrenocortical cancers and, 32, 34 germline mutations of, 32, 34 Li-Fraumeni-like syndrome, 32 Li-Fraumeni syndrome, 32 TP53, germline mutation of, 31–32 tuberous sclerosis, 31 von Hippel-Lindau syndrome, 31 Gerson, S.L., 26, 28, 73 Geschwind, D.H., 198 Ghering, K., 202 Ghiringhelli, F., 329 Ghulam Muhammad, A.K., 346 Giannini, C., 412 Giese, A., 113, 154, 159, 165 Gilbert, M.R., 164 Gilmore, R.L., 399 Gil Robles, S., 194, 202 Ginsberg, L.E., 420 Glantz, M.J., 404 Glass, J., 222 Glauser, T., 428 Glial fibrillary acidic protein (GFAP), 12 Glial tumors, 32 Glioblastoma multiforme (GBM), 12, 73, 124, 138, 207, 318, 335, 379–383 anaplastic astrocytoma (AA), 336 immunohistochemistry with antielafin antibody, 365 MGMT, 208 mRNA levels of selected genes, 365 prognosis, 5 risks and uncertainity, 5 surgery, 5 survival, 209 temozolomide, 208 Glioblastomas, 113, 229–230 angiogenesis and vasculogenesis, 1 boron neutron capture protocol, 6

443 medical imaging, 5 radiation risk, 6 model of, 49 subtypes, 1–2 treatments active migration, 2 CD133 brain tumor cells differentiation, 4 chemoresistance of, 4 chemotherapy, 2 NOTCH signaling, 5 radiation, 2 Gliofibrillary acid protein positive (GFAP), 430, 432 Gliomagenesis in adults, 11 biological fluids biomarkers, 12 cerebrospinal fluid, 13 diagnosis and tumor heterogeneity, 13 low grade gliomas (LGG), 13 magnetic resonance imaging (MRI), 13 biomarkers, 12 GBM, 12 genetic alterations BRAF gene, amplification of, 17 Cancer Genome Atlas Research Network, 17 IDH1 and IDH2, mutations of, 17–18 MSH6 mismatch, 18 pan-RAF inhibitors, 17 pilocytic astrocytomas, 18 prolylhydroxylases (PHDs), 18 low grade gliomas (LGG, grade II), 12 morphology, 12 oligodendroglial tumors, 12 Sainte Anne Hospital classifications astrocytic, 12 glial fibrillary acidic protein (GFAP), 12 glioneuronal tumors, 12 LOH 1p/19q, 12 oligodendroglial phenotype, 12 predominant cellular type, 12 WHO classification, 11 astrocytic, 12 glial fibrillary acidic protein (GFAP), 12 glioneuronal tumors, 12 LOH 1p/19q, 12 oligodendroglial phenotype, 12 predominant cellular type, 12 Glioma-initiating cells, 269 Glioma models, anti-tumor effects microglia density, 247 Glioma stem cells (GSC), 95 regulation of microRNAs α/β, 273 biological processes, 272 interference, 272–273 quantitative real time polymerase chain reaction (qRT-PCR), 273 terminal differentiation STAT3 activation, 271 tyrosine residue of STAT3, 272

444 Glioma stem cells (GSC) (cont.) type 1 IFNs CD133+ cells and, 270–271 chemotherapy resistance genes, 271 GBM, 270 GSC, 271 nestin, 270 tumor culture-maintaining cells, 270 Glycolysis in glioblastomas, 2 GMCSF, see Granulocyte monocyte-colony stimulating factor (GMCSF) Godlee, R., 181 Goh, V., 83 Goi, K., 32 Goldberg, L., 262 Goldman, S., 71 Goli, K.J., 256, 258 Gomez del Pulgar, T., 280–281, 285 Gòmez-Rio, M., 217 Goncalves-Ferreira, A.J., 374–375 Gondi, C.S., 342 Gong, J.P., 278 Gorlign syndrome, 41 Gorski, D.H., 224 Grade I glioma, 11 Grade III gliomas, 12 Grange, J.M., 319–320 Granulocyte monocyte-colony stimulating factor (GMCSF), 341 Grauer, O.M., 318–321, 326, 329–330 Gravendeel, L.A., 25–28 Gregoire, V., 132 Griffin, C.A., 26 Griguer, C.E., 68 Grobben, B., 350 Gröhn, O., 301–310 Gröhn, O.H.J., 306 Gross, S., 59 Gross tumor volume (GTV), 133 Grosu, A.L., 137–140, 216, 223 GSC, see Glioma stem cells (GSC) GTV, see Gross tumor volume (GTV) Guertin, D.A., 249 Guha, C., 139 Guillamo, J.S., 371–376, 388–389, 393 Gunnersen, J.M., 263 Guo, A.C., 116 Gupta, R.K., 118 Gupta, V., 340 Gutin, P.H., 224–225 Guzman, G., 97 Guzman, M., 278, 280, 283–285 H Hadani, M., 182–183 Hagedorn, M., 361–368 Haginomori, S., 237 Hakumäki, J.M., 307–308 Hakyemez, B., 419 Hale, A.J., 302

Index Hallock, A., 215–226 Hall, W.A., 185 Halperin, E.C., 216 Halper, J., 414 Hamilton, M.G., 379 Hamstra, D.A., 307, 309 Hanahan, D., 298, 361 Hargrave, D., 392 Hartmann, C., 26, 49, 54–55, 60 Hasselbalch, B., 289–298 Hatakeyama, T., 104, 108–110 Hata, N., 144–145 Hattori, Y., 258 Hau, P., 211, 330 Hayat, M.A., 1–6 Heath, W.R., 316 Hegi, M.E., 16, 27, 73–75, 208 Heidorn, S.J., 17 Heimberger, A.B., 317 Held-Feindt, J., 285 Hemmati, H.D., 317 Hendrix, M.J.C., 95 Hendrix, M.J.S.E., 98 Henriksson, R., 234 Hentschel, S.J., 63 Hereditary non-polypotic colorectal cancer (HNPCC), 36 Herholz, K., 104, 108 Hess, A.R., 99, 114–115 High-grade astrocytoma, 173 cortical mapping impact, 177–178 HGG resection, impact of, 175 historical considerations, 173–174 LGG resection, impact of, 174–175 multimodal therapy importance of, 175–176 neuro-imaging impact, 177–178 new post-operative deficits Kaplan-Meier plot, 176–177 WHO grade classification, 173 High-grade gliomas (HGG), 124, 313 “biological imaging,” 133 blood-brain barrier (BBB), 314 cancer immunoediting dendritic cells (DC), 314 immunoedited phenotype, 316 MDSC, 314 natural killer (NK) cells, 314 tumor cells growth, 314 tumor vaccination, 315 cancer, types of, 314 central nervous system (CNS) antigen-presenting cells (APC), 316 blood-brain barrier (BBB), 316 cerebrospinal fluid (CSF), 316 cervical lymphatic drainage of brain, 316 gliomas and immunity, 317 lymphocyte-trafficking, 317 clinical studies results, 329 PFS and OS, 328 post-vaccine IFN-γ, 328

Index 3D-CRT techniques, 132 experimental glioma models for, 319, 326 delayed-type hypersensitivity (DTH), 321 gliomas and immunity human gliomas DC, 326 dendritic cells nature, 327–328 monitoring, 328 MRI and PET, 328 outcome measures, selection of, 327 RPA and RTOG, 327 immunotherapy active specific, 319, 320–321 adoptive, 318 optimization of, 329–330 passive, 318 restorative, 318 TAA, 313 T cells, 313 MRI and PET, 131 NSCLC, 132 PET-guided BTV, 135 amino acid transport, 136 assessment of, 135–137 biological tumor volume measurements, 136 CTV, 133 delineation, practice of, 138 18 F-FET PET, 139 18 F-FMISO, 137 gadolinium enhanced T1-weighted MRI, 139 glioblastoma, 138 GTV, 133, 139 hypoxia tracers, 137 LGG, 137 practice of target volume delineation, 138 PTV, 133 radiation delivery techniques, 132 radiation necrosis, 137–138 radiotracers, 136 SPECT, 138 SUV, 139 tracer 18 F-FDG, 137 transaxial slices, 139 tumor hypoxia, 137 volumetric patient imaging, 133 radiation delivery techniques, 132–133 resection, impact of, 175 stereotactic radiation therapy/surgery (SRT/SRS), 132 targeted therapies, 293 tomotherapy, 132 volumetric patient imaging, 133 X-ray CT, 131 High-grade gliomas (HGG) management biomarkers course, 15 response to treatments, 15–16 in cancer biology, 16–17 response to treatments prediction, 15–16 spontaneous course, 15 Highsmith, R.F., 379 Hildebrand, J., 25, 401–402

445 Hirose, T., 415 Hirschberg, H., 185 Hirtz, D., 428 Hitiris, N., 426 Hlaihel, C., 156, 166, 422 Hlatky, L., 296 HNPCC, see Hereditary non-polypotic colorectal cancer (HNPCC) Hochberg, F.H., 216 Hockaday, D., 123–129 Holland, E., 362 Holland, E.C., 362 Holms, G., 427 Hong, X., 341 Horbinski, C., 58 Hormigo, A., 13 Hortelano, S., 306 Houston, S.C., 143–145 Howlett, A.C., 277–278, 280 Hsu, C.Y., 372 Hsu, E., 143 Hsu, P.P., 65 HSV-tk and ganciclovir therapy, 342 bystander effect, 342, 344 current gene therapy, 343 clinical efficacy, 344 mechanism of action, 342 cytomegalovirus, 343 suicide gene therapy, 343 Huang, Y.L., 361 Hudes, R.S., 226 Huff, C.A., 270 Huh, L., 425 Human glioma I-TM-601 SPECT imaging in, 123 bioelimination, 127 CBTRUS, 124 chlorotoxin (CTX), 124–125 co-registration, 127–128 decay rate indications, 129 extracellular matrix (ECM), 124 flouro deoxyglucose (FDG), 124 fusion of images, 127 fusion volumes, 129 glioblastoma, 124 HGGs, 124 image analysis, 126–127 magnetic resonance, 124 MRI and PET, 124, 128 MRS volumes, formation of, 124 planar images, 125 preparation and preliminary scans, 125 radiolabeled peptide injection, 125 spectroscopy, 126, 128 stereological estimation, 126–127 TM-601 use, 125 tumor volumes, 127–129 metabolic differences between regions, 68–69 tumor nature, 64–65 Hussain, S.F., 251 Hussain, S.P., 34

446 Hustinx, R., 138 Hwu, W.J., 99 2-Hydroxyglutarate (2-HG) levels in gliomas, 50–51 Hypothetical tumour, 144 Hypoxia cellular response HIF-α proteins, 291 HIF-1 transcription factor, 291 HIF-1α overexpression and angiogenesis, 290 necrotic regions of glioblastoma, 290 Hypoxia inducible factors (HIF), 66, 290 I Iberti, T.J., 379 Idaho national engineering and environmental laboratory (INEEL), 237 Idbaih, A., 15–16 Ide, F., 44 IES, see Intraoperative electro-stimulation mapping (IES) Ignatova, T.N., 270 Image guided radiation therapy (IGRT), 132 Immonen, A., 344 Immunotherapy active specific immuno-adjuvant, 319 reported clinical trials, 322–325 T cells and, 319 tumor vaccination, 319 adoptive, 319 passive glioblastoma, 319 PFC, 319 restorative, 318 IMRT, see Intensity modulated radiation therapy (IMRT) INEEL, see Idaho national engineering and environmental laboratory (INEEL) Ingrassia, L., 266 Innate inter individual prognostic variability, 3 Inoue, M., 361 Insug, O., 326 Integrated genomic analysis, molecular classification of tumors new tools cellular phenotype, 19 comparative genomic hybridization (CGH), 19 DNA copy number, 19 DNA methylation profiling, 19 gene expression (trancriptome), 19 glioblastoma pathogenesis, 19 glioblastoma subtypes, 20 mesenchymal subtypes, 21 molecular biology, 19 proneural subtype, 20 patients care, transfer to C/EBPâ and STAT3, 21 master gene regulators (MR), 21 microRNA (miRs) field, 21 Intensity modulated radiation therapy (IMRT), 132 Interleukin 6 (IL6) therapy in experimental glioma angiogenic regulators siRNAs precursors, 364

Index anti-angiogenic therapy glioblastoma, 364–365 hypoxia, 364 immunhistochemical detection, 364–365 malignant glioma cells, 365 PI3 levels, 365 gene profiling studies, model in chick embryo CAM, 362–363 GeneChips, 362–363 tumor, 362–364 U87 cells, 362–363 molecular pathways inhibition CAM, 367–368 pre-clinical evaluation angiogenic and invasive phenotypes, 367 knockdown of IL6 and/or VEGF, 366–367 siRNA, 366–367 tumor cells in CAM, 366–367 Intracranial disease, 144 Intraoperative electro-stimulation mapping (IES) cerebral functional anatomy, 194 functional organization, 195 functional organization of Wernicke’s area, 195 insular lobe, 195 left angular gyrus and calculation, 195–196 left dorsolateral cortex, 196 oculomotor behavior, 196 premotor cortex and language, 195 SMA syndrome, 195 spatial awareness, 196 cerebral plastic potential brain plasticity, 199 intraoperative plasticity, 199–200 postoperative plasticity, 200 preoperative plasticity, 199 LGG surgery Broca’s area resection, 201 extensive glioma resection, 201 functional and oncological results in, 202 insular resection, 200 knob of hand resection, 201 non-dominant sensorimotor area resection, 200–201 parietal posterior resection, 200 primary somatosensory area resection, 200 SMA resection, 200 temporal language area resection, 201 multiple-stages surgical approach in LGG effective connectivity, 203 functional reshaping, 202 median time, 203 techniques and concepts, 203–204 subcortical connectivity dorsal phonological root, 197 language pathways, 197 motor tracts, 196–197 somatosensory pathways, 197 spatial awareness, 198 ventral semantic root, 198 visual pathways, 197 Intraoperative eletrostimulation, 3 Intratumoral heterogeneity, 64

Index Irinotecan, 289 carboxylesterase-mediated breakdown, 294 topoisomerase I, 294 toxicitiy, 294 Isocitrate dehydrogenase 1 and 2 (IDH1and IDH2), 47 cellular metabolism, role in, 50 genome-wide mutational analysis, 47 single molecular markers, gliomas, 26 Isocitrate dehydrogenases 1 and 2 (IDHI and IDH2) mutations detection, 48–49 as favorable prognostic factor, 50 genetic alterations with changes, 56 gene expression analysis, 56 oligodendroglial tumors, 56 R132, 55 TP53, 55 transcriptional and epigenetic profiles, 56 gliomagenesis, 49–50 in gliomas, 48 grades of, 49 2-HG levels, 50–51 patient survival and, 48 properties early timing, 58 frequency, 58 neomorphic activity, 59 specificity, 58–59 wild-type formation, 58–59 timing, genetic alterations, 56–57 types acute myeloid leukemias, 60 codons spectrum, 59–60 function, impact on, 60 patients, differences between, 60 Isolated tumor cells, 154 Iwaizumi, M., 31–36 Iwama, T., 157 J Jachimczak, P., 355 Jack, C.R., 177 Jackson, A., 419 Jacks, T., 36 Jacobs, A., 104, 110, 139 Jadhav, U., 340 Jain, N., 144–145 Jain, R., 81–89 Jain, R.K., 291, 294, 297 Jallo, G.I., 388, 391, 393 Javerzat, S., 361–368 Jendreyko, N., 361 Jenkinson, M.D., 157, 419, 421 Jenkins, R., 28 Jenkins, R.B., 14, 26 Jensen, R.L., 290, 364 Jeong, M., 341 Jeremic, B., 175 Joensuu, H., 232 Johannesen, T.B., 174

447 Johnson, P.C., 64, 70 Jones, D.T., 17 Jung, T.Y., 263–264 Jurcic, V., 375 K Kaba, S.E., 63 Kageyama, S., 31–36 Kakimi, K., 320–321 Kalachikov, S., 401 Kaminska, B., 241–252, 277–285 Kang, M.K., 65, 271 Kang, M.R., 49, 54, 60 Kang, S.K., 65 Kang, X., 340 Kang, Y.A., 339 Kankaanranta, L., 232, 237 Kapoor, G.S., 281 Karayan-Tapon, L., 11–22 Kargiotis, O., 340 Karnofsky performance score (KPS), 3, 25 Karpala, A.J., 272 Kaschten, B., 104, 108–109 Kato, Y., 49, 58 Katze, M.G., 273 Kawabata, S., 234 Kawai, N., 103–111 Kayser-Gatchalian, M.C., 379 Kayser, K., 379 Keles, G.E., 175 Kelly, P.J., 154, 157–158, 160 Kepes, J.J., 412 Kerbel, R.S., 97 Kerr, J.F.R., 302 Kesari, S., 211, 222, 224, 373, 388, 393 Kettunen, M.I., 302, 306, 308 Kihlstrom, L., 392 Kikuchi, T., 322–323 Kim, B.M., 341 Kim, C.J., 108, 110 Kim, C.Y., 341 Kim, D.G., 108, 110 Kim, E.H., 4 Kim, H., 21 Kim, J.H., 108, 110 Kim, J.S., 108, 110 Kim, M., 341 Kim, M.H., 341 Kim, M.S., 58 Kim, S., 108, 110 Kim, T.H., 341 Kim, W.B., 341 King, A., 51 King, G.D., 341 King, M.A., 398 Kinloch, R.A., 302 Kinoshita, M., 116, 118–119 Kiss, R., 261–266 Kjaergaard, J., 326 Kleihues, P., 2, 34, 47, 50, 242, 336

448 Klein, M., 397, 403 Kloog, Y., 262 Kloosterhof, N.K., 26 Knisely, J.P., 364 Knopf, P.M., 316 Knopp, E.A., 417–420 Knowlton, R.C., 429–430 Koeller, K.K., 118 Koepp, M.J., 426, 428–429 Kohn, D.B., 337 Ko, L., 349 Kormanik, P., 211 Kormanik, P.A., 211 Korshunov, A., 49 Koumenis, C., 265 Kouwenhoven, M.C., 26 Kracht, L.W., 108 Krainik, A., 195, 200, 202 Kral, T., 192 Kratimenos, G.P., 374–375 Kreisl, T.N., 93, 210, 250–251, 259, 294–295 Krex, D., 75 Kroemer, G., 65–66, 68 Kros, J.M., 25 Krown, S.E., 258 Kumabe, T., 47–51 Kumada, H., 229–238 Kumar, A.J., 88 Kumar, S., 258 Kunkel, P., 361 Kurachi, K., 31–36 Kwan, P., 425–426, 428 Kyritsis, A.P., 34, 43, 63 L Lacroix, M., 175 Lactate dehydrogenase A (LDH-A), 66 Laerum, O.D., 63 Lahm, H., 263 Lai, A., 3 Laigle-Donadey, F., 371–376 Lakka, S.S., 342 Laks, D.R., 22 Lamborn, K.R., 63 Lamfers, M.L., 346 Lamour, V., 366 Lampson, L.A., 349 Landolfi, J.C., 371–372 Lang, F.F., 164 Langleben, D.D., 88 Laperriere, N.J., 216 Laraqui, L., 143 Larsen, C.J., 11 Lassen, U., 289–298 Laster, D.W., 156 Law, M., 81–84, 87, 119, 419–420, 422 Laws, E.R., 181 Lecchi, M., 139 Leclercq, D., 191, 203 Lecomte, R., 357

Index Ledford, H., 34 Le Duc, G., 64 Lee, H.C., 70 Lee, J., 270–271 Lee, T.Y., 84 Lee, A.Y., 380 Leffler, H., 263 Lefranc, F., 3, 261–266 Lehtimäki, K., 301–310 Lellouch-Tubiana, A., 415, 425–427, 429 Le Mercier, M., 262–266 Lenard, H.G., 389 Leon, S.P., 82 Le, Q.T., 261, 264–265 Lesionectomy angiocentric glioma, distribution and semiology, 427–428 cortical mapping, 431–432 and cortical mapping, 431–432 demographics, patients angiocentric glioma, 426 distribution and semiology angiocentric glioma, 427–428 seizures arising, 427–428 intractable epilepsy, complications, 426–427 anti-epileptic medication, 426–427 SUPED, 426 investigative studies eloquent cortex, tumour, 430–431 fluid attenuation iversion recover (FLAIR), 429 functional magnetic resonance imaging (fMRI), 429–431 magnetic resonance tractography, 431 MEG, 429–431 parasagital lesion, 429–430 PET and SPECT, 429 tumor induced intractable epilepsy, 429 medical management, 428 antiepileptic medication, 428 carbamazepine, 428 fosphenytoin, 428 gabapentin, 428 levatiracetam, 428 oxcarbazepine, 428 pathology, 432 EMA, 430, 432 GFAP, 430, 432 post-resection, seizure outcome, 432–433 patients demographics, 432–433 seizure outcome, 432–433 post-resection, 432–433 studies, 428–431 surgical application, 432 Leukoencephalopathy, 218 Levatiracetam, 428 Lev, M.H., 87, 419, 421 Lewis, J., 280 LGG management, see Low grade gliomas (LGG) management Lhatoo, S.D., 426 Li, A., 27 Liau, L.M., 322–323, 327, 329 Li-Fraumeni syndrome, 55 case study, 32

Index characteristic tumors of, 34 diagnosis of, 32 glial tumors, 32, 34 missense variant TP53, 32 Liimatainen, T., 301–310 Li, K.W., 392 Lima, M.A., 387–394 Lim, E.C., 372, 389 Ling, C.C., 132–133 Link, M., 375 Li, F.P., 32, 42 Litofsky, N.S., 177 Liu, G., 4, 19, 65, 271, 317 Liu, H.K., 36 Liu, A.K., 393 Liu, F.T., 261–263 Liu, Y., 2 Li, V.W., 82 Li, Y.J., 35 LMWH, see Low Molecular Weight Heparin (LMWH) Loeffler, S., 366 Loffler, D., 273, 275 Lombardi, D., 405 Lombardi, G., 255–259 Lomustine chemotherapy, 209 Losey, T.E., 427 Loss of heterozygosity (LOH) of 1p19q, 64 single molecular markers, gliomas, 26 Lote, K., 425 Louis, D.N., 12, 25, 47, 54, 93, 144, 262, 264, 289, 410–411, 413 Lowenstein, D.H., 404 Low grade and anaplastic astrocytoma adjuvant chemoradiation, 210 oligodendroglial tumors, 210 radiotherapy, 210 Low-grade gliomas (LGG), 137, 417, 419–422 intraoperative electrical stimulations, 189 benefit-to-risk ratio, 190 complete resection, 190 EOR, 190 functional mapping, principles of, 191–192 intraoperative electrical stimulations method, 192–194 partial resection, 190 presurgical functional neuroimaging, 190–191 presurgical neurocognitive evaluation, 190 subtotal resection, 190 rCBV role in malignant transformation acquisition of, 418 conventional MRI, comparison of, 418, 420 differentiating gliomas, 420 evaluation, challenges of, 420–421 multimodalilty approach, 421–422 resection, impact of, 174–175 Low grade gliomas (LGG) management, 13 biomarkers benign tumors, 13 response to treatments, 15 spontaneous course, 13–14 tumor growth rate, 13 tumor volume, 13

449 Low Molecular Weight Heparin (LMWH), 379–381, 383 Lubbe, J., 34, 42 Lucignani, G., 6 Lucio-Eterovic, A.K., 296–297 Lum, D.J., 432 Lu, S., 113, 116, 118 Lu, W., 342 Lyman, G.H., 380 M MacDonald, B.K., 295–296 Macdonald, D.R., 211, 295–296, 327 Mackie, K., 277 Maeda, M., 84 Maekawa, M., 31–36 Maes, W., 326, 329 Maggio, W.W., 351 Magnetic resonance methods apparent diffusion coefficient (ADC), 303 diffusion and, 303 diffusion measurement of, 304 gradient parameters, 303 Major histocompatibility complex (MHC), 338 Maldonado-Lopez, R., 316 Malignant brainstem gliomas clinical presentation, 374 differential diagnoses, 374–375 epidemiology, 373 follow-up, 375 gadolinium infusion, axial T1-weighted MR, 374 pathology, 373 radiological presentation, 374 treatment, 374–375 Malignant gliomas, 47, 261 clinical and experimental data, 262 clinical testing diagnostic utility, 58 monoclonal antibodies, 58 PCR-based assays, 58 specificity of, 58 Gal1-expression, 261–262 Gal1 thereby, 262 glioblastoma, 207 IDH1 and IDH2 mutations, see Isocitrate dehydrogenases 1 and 2 (IDHI and IDH2) mutations molecular biomarkers, 211 anaplastic oligodendroglioma, 212 p53 mutations, 212 mutation types acute myeloid leukemias, 60 codons spectrum, 59–60 function, impact on, 60 patients, differences between, 60 patient age adult studies, 57 older median, 57 pediatric, 57 primary glioblastomas, misclassification of, 57 patient survival Cox regression multivariate analysis, 57–58

450 Malignant gliomas (cont.) multivariate analyses, 57 study on, 57 Ras signaling and oncogenesis, 262 recurrence management, 210 PFS, 211 therapeutic drugs bevacizumab, 209 EGFR, 211 initial therapy, 208 PDGFR, 211 temozolomide, 208 timing, genetic alterations, 56–57 tumor failure, patterns of CTV, 216 magnetic resonance spectroscopy, 217 radiation treatment, 216 RTOG, 216 SFRT, 216 surgery, 215 tumor type distribution WHO classification, 54 VEGFR, 211 WHO grading system classification, 262 whole-genome analyses, 53 Malkin, D., 42 Malmberg, K.J., 314 Malmer, B., 40 Mamelak, A.N., 123–129 Mancini, M., 242 Mandell, L.R., 392 Mandonnet, E., 153, 156–157, 163–171, 189, 194 Manford, M., 401 Maniotis, A.J., 93, 95–98 Mardis, E.R., 49, 54, 60 Marin-Sanabria, E.A., 372 Markovic, D.S., 247, 251 Marras, L.C., 379 Martino, J., 203–204 Marx, G.M., 256 Mason, W., 207–212 Massager, N., 374–375 Massi, P., 280, 284–285 Mathiesen, T., 248 Mathieu, D., 350, 355–356 Mathieu, V., 2, 264–266 Matsuyama, J., 144–145 Mauer, M.E., 177, 190 Mayer, R., 217–218, 220 McAllister, S.D., 284–285 McCubrey, J.A., 242 McDermott, D.F., 318, 329 McDonald, D.M., 83 McGirt, M.J., 176–177, 181, 190 McKnight, S.L., 342 McMahon, E.J., 316 MDSC, see Myeloid-derived suppressor cells (MDSC) Mean Tumor Diameter (MTD), 166 Melanoma-astrocytoma syndrome, 42 Melhem, E.R., 113–119 Mellinghoff, I.K., 224

Index Mendell, J., 379 Meng, F., 273 Menger, M.D., 83 Mentrikoski, M., 143–144, 146–147 Metabolic differences in gliomas brain gliomas, treatment for, 63 energy metabolism and hallmarks and Akt, 67 cancer cells, 67 glucose 6-phosphate, avaibility, 65 glycolytic pathway, 65 HIF-1, 66 LDH-A, 66 molecular mechanisms, 66 NADPH, 66 PEP, conversion of, 65 phosphatidylinositol 3-kinase (PI3K), 67 ROS, 67 tricarboxylic acid (TCA) cycle, 65 tumor microenvironment/oncogene activation, 66–67 heterogeneous nature, tumors of BCNU, 64 cancer stem cells, 65 histological analyses, 64 intratumoral heterogeneity, 64 LOH, 64 magnetic resonance imaging studies, 64 MGMT, 65 regional heterogeneity, 64 stem cell population, 65 metabolic alterations in, 64–66 metabolic reprogramming, 66 tumor altered metabolism, 67 Metabolic evaluation, 358 positron emission tomography (PET), 357 Sherbrooke LabTEP software, 357 Metro, G., 73–77 Mettler, F.A.Jr., 6 Meyer, G., 380 Meyer, J., 58 MHC, see Major histocompatibility complex (MHC) Microscopic tumor, 154 Micro-vascular density (MVD), 97 Miliaras, G., 144, 146–147 Millac, P., 379 Miller, D.C., 408 Mismatch repair genes, 4 Mittler, M.A., 12 Miwa, K., 110 Mixed oligoastrocytic (MOA), 25 MLV, see Murine leukaemia virus (MLV) vector Moehler, T.M., 258 Moffat, B.A., 307 Mohanraj, R., 426 Moi, seeva, E.P., 263–264 Molecular biomarkers, 211 anaplastic oligodendroglioma, 212 p53 mutations, 212 Molecular subtypes of gliomas astrocytic, 25 false-negative GBM, 25

Index false-positive GBM, 25 genome wide markers gene expression profiling, 27 mesenchymal, 27 1p19q status and, 28 proliferative, 27 proneural, 27 glioblastoma, 25 incidence rate, 25 KPS, 25 MOA, 25 oligodendrocytic, 25 single markers IDH1, 26 LOH 1p19q, 26 MGMT, 26–27 WHO classification, 25 Moon, K.S., 146 Morabito, A., 256 Mori, H., 31–36 Morita, K., 116, 118–119 Moserle, L., 270 Moser, M., 316 Mosieniak, G., 242–243, 245 Motomura, K., 269–275 Mottet, D., 366 Mourad, P.D., 144 MTD, see Mean Tumor Diameter (MTD) Muir-Torre syndrome, 36 Mujic, A., 143 Mukherjee, D., 173–178 Mukherjee, P., 70, 115 Mu, L.J., 319 Mulkern, R.W., 305 Munson, A.E., 280 Muragaki, Y., 185 Murakami, R., 113, 119 Murine leukaemia virus (MLV) vector, 337 Murphy, M., 25 Murphy, S., 256 Mursch, K., 373 Muzi, M., 111 Myeloid-derived suppressor cells (MDSC), 314 N Nakai, K., 229–238 Nakamura, T., 31–36 Nalabothula, N., 340 Napekoski, K.M., 415 Nariai, T., 104, 230 Natali, P.G., 124 Nathanson, M., 379 National Cancer Institute of Canada (NCIC) trial, 74 Natsume, A., 269–275 Natural killer T (NKT) cells, 314 Nebeling, L.C., 70 Neil, J.J., 305 Nestin glial fibrillary acidic protein, 4 Nestle, U., 132–133 Neuron-specific enolase markers, 4

451 New Castles’ Disease viruses (NDV), 338 Newly diagnosed glioma BTB, 108 contrast enhancement, 104 endothelial cell damage, 104 FLT-PET study, 110–111 fluorothymidine (FLT), 104 L-methyl C-methionine (MET), 104 materials and methods patients, 104–105 PET examinations and data analysis, 105 statistical analysis, 105 WHO grading system, 105 MRI, 103 PET, 104, 108 pilocytic astrocytoma., 110 protein synthesis, 104 radiation, 108 stereotactic radiosurgery, 108–109 tracer uptake and tumor grade, 106 brain parenchyma, 107 MET and FLT uptake, 107 proliferation activity, 108 tumor detection of HGG and LLG MET-PET, 106 PET tracer uptake, 106 Newton, H.B., 143 R , see Sorafenib Nexavar Nghiemphu, P.L., 210 Ng, Y-t, 427 Niclou, S.P., 94–95 Nicolay, D.J., 275 Nieder, C., 3 Nielsen, F.H., 234 Nigg, D.W., 237 Ni, H.T., 321 Nimsky, C., 2, 182, 185 Niola, F., 361 Nishiyama, Y., 103–111 Nobusawa, S., 56, 58 Nojiri, T., 108–109 Non-polypotic colorectal cancer (HNPCC), 36 Non-small cell lung cancer (NSCLC), 132 Norden, A.D., 293–294, 296–297, 318 Norrby, K., 382 Norris, D.G., 304–305 NOTCH signaling pathway, 5 Noushmehr, H., 56 NSCLC, see Non-small cell lung cancer (NSCLC) Ntoukas, V., 183 Nurmohamed, M.T., 381 Nutt, C.L., 27 Nuutinen, J., 104 O Ogawa, T., 108, 110 Ogg, R., 431 Ohgaki, H., 1–2, 25, 47, 50, 242, 336 Oh, J., 116, 119 Ohno, M., 269–275

452 Ojemann, G., 177 Ojemann, J., 177 Okada, H., 324, 326, 329 Okubo, S., 108, 110 Olafsson, E., 398 Oligodendrogliomas (O) (WHO grade II), 47, 56, 207, 210, 420 pathogenesis and progression, 55 Oliver, J., 63–71 Olsson, Y., 114, 118 O6 -methyl-guanyl-methyl transferase gene promoter (MGMT), 15, 65 glioblastoma anaplastic gliomas, prognostic, 76 clinical outcome, 76 depleting strategies, 76–77 in grade III anaplastic gliomas, 76 informative role, 75–76 inhibitors, 77 methylation, role in, 74–75 optimal depletion of, 77 prognostic role, 75–76 quantitative assays, 75 recurrent, clinical outcome of, 75–76 role of mgmtmethylation, 75–76 status assessing, 74 in tumor tissue, 74 single molecular markers, gliomas, 26–27 Oppitz, U., 216 Ornithine transcarbamylase (OTC), 337 Osborne, R.H., 31 Ostergaard, L., 421 Oudard, S., 67 Oxcarbazepine, 428 P Pace, A., 405 Packer, R.J., 371, 392 Padhani, A.R., 305–306 Padma, M.V., 358 Pallud, J., 13, 153–160, 163–171, 189 Palmero, E.I., 35–36 Palmer, T.D., 3 Pan, D., 341 Paraf, F., 35–36 Park, D.M., 36 Park, J.K., 5 Park, J.W., 58 Park, K.Y., 389 Park, S.Y., 58 Parsa, A.T., 350–351 Parsons, D.W., 18, 26, 34, 47–48, 54–57 Pasquier, B., 407 Patronas, N.J., 138 Paulis, Y.W., 99 Paunu, N., 35, 40, 43 PDGFR, see Platelet-derived growth factor receptor (PDGFR) Pearson, A.D., 32 Peca, C., 217 Pedersen, I.M., 273 Pellegatta, S., 326 Pelloski, C.E., 147, 364

Index PEP, see Phosphoenolpyruvate (PEP) Perillo, N.L., 263 Perkins, F., 431 Perry, A., 414–415 Perry, J.R., 77, 208, 211, 381 Petersen, G., 280 Peterson, D.L., 349–351 Petitjean, A., 32, 42 Peyre, M., 156, 166, 169–170 PFS, see Progression-free survival (PFS) PHD, see Prolylhydroxylase (PHD) Phenytoin, 403 Phillips, H.S., 27, 56, 147 Phosphoenolpyruvate (PEP), 65 Piccirillo, S., 4 Pichler, B.J., 139 Pichler, J., 139 Pichler, R., 139 Pierpaoli, C., 115 Pignatti, F., 168, 170 Pilocytic astrocytomas, 11, 110 Pim, D., 44 Pirzkall, A., 139 Placenta-like growth factor (PlGF), 291 Planning target volume (PTV), 133, 226 Platelet-derived growth factor receptor (PDGFR), 2, 211 Plate, K.H., 83 Plaza, M., 196 Poduslo, J.F., 356 Pollack, I.F., 376, 394 R intraoperative OR Setup, 183 PoleStar Polymerase chain reaction (PCR), 58 Pope, W.B., 175 Poptani, H., 113–119, 306, 308 Portwine, C., 35 Posner, J.B., 379 Post-treatment radiation effect (PTRE), 137 Potgens, A.J.G., 97 Poulsen, H.S., 289–298 Pouratian, N., 175 Poussaint, T.Y., 393 Pouyssegur, J., 65–66, 68 Prayson, R.A., 407–415 Prestegarden, L., 4 Presurgical neurocognitive evaluation, 190 Preusser, M., 415, 426–427, 429, 432–433 Price, S.J., 156–157 Primary brain tumors, 39 Primary glioblastomas, 2 glioblastoma multiforme, 5 Procarbazine chemotherapy, 209 Progression-free survival (PFS), 211, 318 Prolylhydroxylase (PHD), 18 Prominin-1, marker for brain tumor-initiating cells, 4 Provenzale, J.M., 83 Pruitt, A., 216 PTRE, see Post-treatment radiation effect (PTRE) PTV, see Planning target volume (PTV) Puchades, M., 261, 265 Purdie, T.G., 83, 85 Pyrzynska, B., 243–244

Index Q Qaddoumi, I., 388 Quevedo, J.F., 379 Quinn, J.A., 77, 176 Quinones-Hinojosa, A., 173–178 R Raatschen, H.J., 83 Rabinovich, G.A., 261–263 Radiation therapy, 392 brain response, 217 late effects cerebrovascular, 218 histopathological analyses, 217 leukoencephalopathy, 218 white matter injury, 218 Radiation Therapy Oncology Group (RTOG), 216, 327 Radiation therapy (RT), 132 Radiotherapy, 210, 238 Raila, F.A., 351 Rainov, N.G., 344 Raja, A., 375 Rajagopalan, V., 143 Rajapakse, J.C., 125 Rajasekhar, V.K., 249 Rajshekhar, V., 373–375 Ramina, R., 185 Ram, Z., 182 Ransohoff, R.M., 316 Rao, R.D., 250 Ratbi, I., 39–44 Reactive oxygen species (ROS), 67 Reardon, D.A., 250 Rech, A.J., 329 Recurrent HGG, 289 angiogenesis high micro vessel density (MVD), 291 tumor vasculature, 291 anti-angiogenic drugs anti-angiogenic treatment, 293 bevacizumab, 293, 294–295 irinotecan, 294 thalidomide and analog lenalidomide, 293–294 biomarkers anti-angiogenic therapy, 297 heterogeneity and insufficiency of tumor vasculature, 296–297 immunohistochemical methods, 297 hypoxia cellular response, 291 HIF-1α overexpression and angiogenesis, 290 necrotic regions of glioblastoma, 290 targeted therapies, 293 temozolomide, 290 treatment for, 289 VEGF pathway inhibitors, resistance to anti-angiogenic therapy, 298 anti-angiogenic treatment, 297 glioma cells, 297–298 traditional concept, 297 VEGF/VEGFR signaling pathway, 291

453 endothelial and tumor cells, 292–293 increased vessel permeability, 291 tumor cells, 292 WHO grades, 289 Recursive partitioning analysis (RPA), 327, 382 Rees, J.H., 114, 118 Reiche, W., 118 Reifenberger, G., 14, 47, 355 Reifenberger, J., 14, 47 Reilly, K.M., 362 Reinhardt, M.J., 138 Reirradiation and chemotherapy, 223 malignant glioma management approach, 219 salvage option, 219 with molecular targeted agents, 225 occult radiation injury recovery, 218 Reitman, Z.J., 53–60 Relative cerebral blood volume (rCBV), 417–422 acquisition of EPI, 418 gadolinium chelate, 418 challenges evaluation GE EPI technique, 420–421 SE EPI technique, 420–421 conventional MRI, comparison astrocytoma, 419 glioblastoma multiforme, 420 oligodendrogliomas, 420 tumor grade, 418–419 differentiating gliomas HGGs, 420 multimodalilty approach, 421 paediatric tumors, study, 422 Remy, C., 307 Reynolds, B.A., 270 Rezvan, A., 190 Ribom, D., 104 Ricard, D., 14–15, 156, 166, 168–170 Rickhey, M., 132 Rieber, J., 35 Rivera, A.L., 27 Roberts, D.W., 182 Roberts, H.C., 81, 83–84 Roberts, N., 126, 128 Roberts, T.P., 81, 83–84 Robins, H.I., 379–383 Roca, P., 63–71 Rockwell, S., 364 Rollin, N., 419–420 Rong, Y., 382 Rorive, S., 263 Roszman, T., 318 Roujeau, T., 390 RPA, see Recursive partitioning analysis (RPA) RTOG, see Radiation Therapy Oncology Group (RTOG) Rudin, M., 305 Rüegg, S.J., 399 Ruff, R.L., 379 Rustin, P., 67

454 Rutka, J.T., 432 Rutkowski, S., 323, 326, 328 Ryvlin, P., 426 S Saad, A.G., 144, 146 Sabatini, D.M., 65, 249 Sadik, A.R., 144 Saga, T., 104, 110 Saidi, A., 361, 364 Saini, M., 351 Sainte Anne Hospital classifications and gliomagenesis astrocytic, 12 glial fibrillary acidic protein (GFAP), 12 glioneuronal tumors, 12 LOH 1p/19q, 12 oligodendroglial phenotype, 12 predominant cellular type, 12 Saito, R., 47–51, 326 Saka, E., 372 Salazar, M., 280, 282–283, 285 Salmaggi, A., 271, 372–373, 375 Salvatori, M., 6 Samaranayake, H., 335–346 Sameshima, Y., 32–33 Sanai, N., 13, 18, 154, 160, 174–175, 177, 181, 192–194, 202 Sanchez, C., 278–281, 284–285 Sandberg-Wollheim, M., 175 Sandmair, A.M., 2, 344 Sanson, M., 50, 56–58 Santandreu, F.M., 63–71 Santhosh, K., 118 Santibanez-Koref, M.F., 32 Santos, A.V., 144–145 Sarfaraz, S., 280 Sathornsumetee, S., 292, 297 Sato, N., 108 Savill, J., 302 Savitsky, J.P., 379 Sawaya, R., 63, 175, 379 Schadendorf, D., 321 Schafer, U., 223 Schaller, B., 399 Scheithauer, B.W., 35, 415 Scherer, A., 258 Schickel, R., 272 Schiffbauer, H., 178 Schiff, D., 251 Schley, M., 278–279 Schmidt, F., 211 Schneider, J.P., 185 Schneider, T., 330 Schonekaes, K., 223 Schulder, M., 182–183, 185 Schultheiss, T.E., 217–218 Schultz, S., 144, 146–148 Schumacher, M., 390 Schwartzbaum, J.A., 31 Schwartz, J.L., 111 Schwarzbraun, T., 35

Index Schwer, A.L., 224–226 Scott, C.B., 25 Secondary glioblastomas, 2 Seftor, E.A.M.P., 98 Seftor, R.E., 98 Segall, G.M., 88 Seifert, V., 185 Seitz, R.J., 355 Selch, M.T., 221 Selivanoc, V., 357 Selvapandian, S., 371–372, 388 Semenza, G.L., 67, 290–291 Senetta, R., 143–148 Senft, C., 181–186 Senthamizhchelvan, S., 131–140 Seyfried, T.N., 70 Shad, A., 374 Shakur, S.F., 426–427 Shapiro, J.R., 64 Shapiro, W.R., 64 Shenoy, S.N., 375 Shen, S., 126–128 Shepherd, F.A., 319–321 Shibahara, I., 47–51 Shiels, A.F., 104 Shin, J.H., 419 Shinmura, K., 31–36 Shirakawa, K., 95, 97 Shlebak, A.A., 379 Short, S.C., 256 Shweiki, D., 83 Sielska, M., 241–252 Sierra, A., 308 Signorelli, F., 178 Signorelli, C.D., 178 Simos, P.G., 177 Singh, S.K., 65, 100, 270, 317 Single molecular markers in gliomas IDH1, 26 LOH 1p19q, 26 MGMT, 26–27 Siragusa, S.C.B., 382 Sjoblom, T., 54, 60 Skin metastases CNS tumours, 143 diagnostic and therapeutic approaches FNAc, 147 patient neoplastic history, 147–148 treatment of, 148 extra-axial tumor spread, 143 factors, 144 facts and hypotheses GFAP and EGFR, 147 histopathology and immunophenotype, 147 hypothetical tumour, 144 IHC, 147 intracranial cases, 145–146 intracranial disease, 144 mesenchymal and angiogenesis, 147 mesenchymal cell clones, 147 temozolomide, 144, 147

Index GBM, 143 lung and pleura, 143 Sköld, K.-H., 234 Slack, F.J., 272 Sliwa, M., 247–248, 251 SMA, see Supplementary motor area (SMA) Sminia, P., 217, 220 Smith, D.B., 379 Smith, J.S., 175, 190 Smith, M.A., 388 Smits, A., 397–405 Soffietti, R., 113, 154, 163, 165–166, 168, 170 Solid tumors, 82, 93 Solid tumor tissue, 154 Sonoda, Y., 47–51, 54 Sonveaux, P., 68 Sorafenib, 293 Sorg, R.V., 319 Soroceanu, L., 124–125 Spencer, S.S., 425 Sperling, M.R., 426 Squires, L.A., 390 SRT/SRS, see Stereotactic radiation therapy/surgery (SRT/SRS) Standardized uptake value (SUV), 139 Stark, A.M., 388, 393 Stark-Vance, V., 294 Stegman, L.D., 306 Stejskal, E.O., 301 Stella, N., 278 Stenning, S.P., 209 Stereotactic radiation therapy/surgery (SRT/SRS), 132 Stereotactic radiosurgery, 108–109 Stereotactic radiotherapy with systemic therapies chemotherapy, 222 cisplatin (CDDP), 222 concurrent chemoradiation, 222 EGFR, 224 malignant gliomas, 222, 224 molecular targeted, 224 planning process, 226 PTV, 226 temozolomide, 222 VEGF-receptor blocking, 224 Stewart, L.A., 209 Stillman, B.N., 263 St. Lawrence, K.S., 84 Stojiljkovic, M., 350–351 Storstein, A., 397–405 Stratmann, A., 339 Strieth, S., 361 Strik, H.M., 264 Strojnik, T., 248 Struys, E.A., 50 Stummer, W., 2, 185–186 Stupp, R., 2, 16, 74–75, 174, 176, 208–209, 222, 229, 255, 261–262, 265, 289, 295, 336, 382 Sudden unexplained death in epilepsy (SUPED), 426 Sugahara, T., 420–421 Sugimura, H., 31–36 Sun, B., 97 Sunitinib, 293

455 Sun, T., 97 Sun, X., 133, 136 Supplementary motor area (SMA), 195 Surgery for glioma intraoperative magnetic resonance imaging (iMRI), 182–183 development, 186 influence on, 185 safety concerns in, 183, 185 left temporal glioblast, 184 low field magnetic resonance imaging (iMRI) example of, 182–183 neuronavigation and neurophysiological monitoring, 181–182 R intraoperative, 183–184 PoleStar rationale of, 181 surgical workflow, 183 R , see Sunitinib Sutent SUV, see Standardized uptake value (SUV) Su, Y.B., 329 Swaroop, G.R., 376 Swinson, B.M., 375 Szelenyi, A., 183 Szikla, G., 154, 157–158, 165 T TAA, see Tumor-associated antigens (TAA) Taal, W., 76 Tabernero, J., 292 Tachibana, I., 40, 43 Taillandier, L., 405 Takahashi, J.A., 256 Tamber, M.S., 11 Tamiya, T., 103–111 Tanaka, M., 230 Tanaka, S., 373, 376 Tandon, P.N., 425, 432 Tanner, J.E., 301, 303 Taphoorn, M.J., 403 Tate, M.C., 252 Tchirkov, A., 366 Teicher, B.A., 382 Teixidor, P., 190, 202 Telozolomide, 2 R , see Temozolomide Temodal Temozolomide, 209–210, 265–266, 290 clinical experience phase II study, 257 left inferior limb arteriography, 257 malignant gliomas, 256 mielotoxicity dose limiting toxicity (DLT), 258 dynamic contrast enhanced magnetic resonance (dMRI), 258 phase III study, 255–256 thalidomide and cisplatin, 255–256 vascular complications phase II study, 258 venous grade 3-4 toxicity, 258 Terando, A.M., 319–321 Ternier, J., 388 Thakur, S.B., 392

456 Thalidomide cisplatin and temozolomide, 256 clinical experience phase II study, 257 left inferior limb arteriography, 257 malignant gliomas, 256 mielotoxicity dose limiting toxicity (DLT), 258 dynamic contrast enhanced magnetic resonance (dMRI), 258 vascular complications phase II study, 258 venous grade 3–4 toxicity, 258 Thiebaut de Schotten, M., 196, 198 Thijssen, V.L., 263–265 Thomas, D.G., 373–375 Thompson, T.P., 124 Thorsen, F., 351 Three-dimensional conformal radiation therapy (3D-CRT), 132 Three-step natural history of LGG initial silent period radiological tumour growth, 164 tumor natural course, 164 malignant progression brain plasticity mechanisms, 166 heterogeneous group, 165 radiological growth pattern, 166 solid tumor tissue, 165 step-by-step approach, 164 symptomatic period of isolated tumor cells, 165–166 mild neurological disorders, 165 MRI, 165 solid tumor tissue, 165 Thromboembolic disease in glioma patients LMWH anti-neoplastic effects dalteparin, 380–382 DVT, 379–383 EGFR and RPA, 382 enoxaparin, 380–382 glioblastoma, 379–383 heparin-induced thrombocytopenia, 380 RTOG/ECOG, role, 380 vitamin K antagonist, 380 VTE, 379–383 prophylaxis for nadroparin, 381 Thrombospondin-1 (TSP-1), 3–4 Thurner, B., 319 TIA, see Transient ischemic attack (TIA) TIC, see Tumor initiating cells (TIC) Tímár, J., 95 Tissue inhibitor of metalloproteinase-3 (TIMP-3), 340, 342 Tofts, P.S., 84 Toh, C.H., 116, 118 Toker, A., 242 Tominaga, T., 47–51 Torcuator, R., 373, 393 Tortosa, A., 181 Tóth, J., 95 TP53 tumor suppressor gene, mutations in, 2 Transforming growth factor-β (TGF-β), 340

Index Transient ischemic attack (TIA), 401–402 Treatment for“diffuse intrinsic”/“diffusely infiltrative low grade” chemotherapy, 373 neurosurgery, 372–373 radiotherapy, 373 steroids and gastrostomy, 373 for malignant brainstem gliomas chemotherapy, 375 radiotherapy, 375 surgery, 374–375 Trédan, O., 265 Tronnier, V.M., 182–185 Tropine, A., 118 TSC, see Tumors stem cells (TSC) Tsien, C.I., 136, 139–140 Tsuboi, M., 31–36 Tsuchiya, K., 113, 116, 118 Tsuyuguchi, N., 104, 108–109 Tuettenberg, J., 211 Tu, H., 368 Tumor-associated antigens (TAA), 313 Tumor initiating cells (TIC), 16 Tumors altered metabolism, 67 classification and diffusion tensor imaging (DTI), 113, 115 apparent diffusion coefficient (ADC) correlation with, 116 FA, role of, 116–118 metrics for, 119 shape based, 118 tumor infiltration assessing in, 118–119 infiltration index, 118–119 macrophages, role in, 4–5 type distribution gliomas, 54 IDH mutations, 54 secondary glioblastomas, 54 WHO grades classification, 54 vascularization, 1 vasculature, 291 Tumors stem cells (TSC), 16 Turcot syndrome (TS), 32, 36, 41 Tuxhorn, I., 427 Tuyaerts, S., 319, 327 Tyburczy, M., 241–252 Type I interferons (IFNs), 269 cancer stem cells, 270 GSC CD133+ cells and, 270–271 chemotherapy resistance genes, 271 glioblastoma multiforme (GBM), 270 nestin, 270 tumor culture-maintaining cells, 270 miR-21 overexpression in glioma-initiating cells, 274 regulation of microRNAs in GSCs α/β, 273 biological processes, 272 interference, 272–273 quantitative real timepolymerase chain reaction (qRT-PCR), 273

Index STAT3 and miR-21, 275 terminal differentiation of GSC STAT3 activation, 271 tyrosine residue of STAT3, 272 thyroid hormones (THs), 275 Tzika, A.A., 422 U Uematsu, H., 84 Ueoka, D.I., 389 Ullrich, R.T., 104 UNBS1450 drug, 3 Upadhyay, N., 417–422 Ushio, Y., 175 V Vahteristo, P., 42 Vajkoczy, P., 83 Vajtai, I., 415 Valenzano, K.J., 278 Valonen, P.K., 307 Valproate, 404 Valtonen, S., 175 Van Breemen, M.S., 398, 404 Van Breemen, M.S.M., 425 Van Calenbergh, F., 313–330 Van den Bent, M., 26 Van den Bent, M.J., 76, 211, 290, 405 VanderSpek, L., 215–226 Van Dongen, C.J., 380 Van Eekelen, M., 3 Van Gool, S.W., 313–330 Van Laere, K., 104, 108, 110 Van Meir, E., 366 Van Meyel, D.J., 43 Van Poppel, H., 319–321 Van Sickle, M.D., 278 Van Westen, D., 119 Van Zijl, P.C., 305 Varlet, P., 12 Varley, J.M., 34 Vascular endothelial growth factor receptors (VEGFR), 211 Vascular endothelial growth factor (VEGF), 291, 361–368 elevated expression of, 292 pathway inhibitors, resistance to HGG anti-angiogenic therapy, 298 anti-angiogenic treatment, 297 glioma cells, 297–298 traditional concept, 297 VEGF/VEGFR signaling pathway, 291 tumor cells, 292 tumor induced release, 292 VEGF gene, 292 VEGF/VEGFR signaling pathway endothelial and tumor cells, 292–293 increased vessel permeability, 291 Vasculogenesis, 95 Vasculogenic mimicry (VM) in glioma, 94 advances and challenges, 99 cancer stem cells, 100

457 biological and clinical significance BBB ultra-structure observation, 97 clinical prognosis, 97 extra cellular matrix, 97 Kaplan-Meier survival analysis, 98 microcirculation of, 97–98 mouse xenograft glioma model, 96 PAS-positive patterned networks, 96–97 retrospective analysis, 97 clinical therapeutic value COL-3, 99 EphA2 gene, 99 Folkman report, 99 treatment modalities, 99 tyrosine kinase activity, 99 concept and characteristic CD34 staining, 95 endothelial cell (EC) phenotype, 95 endothelial-lined vasculature and, 95–96 GSC, 95 mimicking, 95 mosaic vessels, 95 PAS-positive channels, 95 RBCs, 95 vessel-like networks, 96 extracellular matrix (ECM)-rich, 93 human glioblastoma tissues, 94 molecular mechanisms C81-61 cells, 98 galectin-3 (Gal-3), role in, 99 signaling molecules, 98 studies, 99 VE-cadherin, 99 solid tumors, 93 vasculogenesis, 95 VDE, see Velocity of Diametric Expansion (VDE) Vectors producing cells (VPCs), 339 Vees, H., 139 VEGFR, see Vascular endothelial growth factor receptors (VEGFR) Velasco, G., 281 Velocity of Diametric Expansion (VDE), 163 Veninga, T., 221 Venous thromboembolic events (VTE), 379–383 Verhaak, R.G.W., 19–20, 27, 34, 56 Verhoeff, J.J., 318 Vescovi, A.L., 19 Vigneau, M., 190, 195, 201 Vincristine chemotherapy, 209 Vital, A., 34, 42 Vlassenbroeck, I., 74 Vonderheide, R.H., 329 Vordermark, D., 221 von Hippel-Lindau (VHL) syndrome, 41 VPCs, see Vectors producing cells (VPCs) Vredenburgh, J.J., 93, 294–296 W Wachsberger, P., 382 Wager, M., 11–22 Wakabayashi, T., 269–275

458 Waldman, A.D., 417–422 Walenta, S., 68 Walker, C., 212 Walker, D.A., 387, 389 Walker, D.G., 324 Walker, M.D., 208 Wallace, C.J., 143–145 Wang, J., 5 Wang, M., 415, 426–427, 432 Wang, S., 113–119 Wang, W., 118 “Warburg effect,” 51 Ward, P.S., 54, 59–60 Warnick, R.E., 211 Wasser, K., 258 Watanabe, M., 157 Watanabe, T., 18, 34, 48–50, 55–57, 59–60 Watters, J.J., 247, 251 Weber, D.C., 134–135 Weber, M.A., 422 Wechsler, W., 350 Weidner, N., 82 Wei, L.H., 249–250 Weinberg, R.A., 361 Weissenberger, J., 366 Weissleder, R., 131 Weiss, S., 270 Weller, M., 16, 73–74, 76–77 Wen, P.Y., 211, 222, 224 Wesolowska, A., 247 Wessels, P.H., 164 Westin, C.F., 115, 118 Westphal, M., 113 Wheeler, C.J., 322, 324, 327–329 Wheless, J.W., 428 White, H.H., 371 White, M.L., 420 Whittle, I.R., 356, 376, 399, 425 Wick, A., 76–77 Wicki, A., 368 Wick, W., 49–50, 58, 76, 77, 210 Willems, P.W., 191 Willett, C.G., 361 Wilson, T.A., 84 Wirth, T., 303, 335–346 Wirtz, C.R., 182 Wiser, H.G., 427 Wittig, A., 232 Woermann, F.G., 426, 428–429 Wolf, H.K., 408 Wong, E.T., 290, 294 World Health Organization (WHO) classification of gliomagenesis, 11 astrocytic, 12 glial fibrillary acidic protein (GFAP), 12 glioneuronal tumors, 12 LOH 1p/19q, 12 oligodendroglial phenotype, 12 predominant cellular type, 12 grading system, 105 Wree, A., 356

Index Wu, J.S., 178 Wurm, R.E., 223 X Xu, X., 47–48 Xu, Y., 4–5 Xu, Z., 47–48 Y Yaacov, R.L., 217–218 Yamada, H., 31–36 Yamamoto, T., 6, 229–238 Yamamura, Y., 31–36 Yamanaka, R., 317–318, 322, 324, 327–329 Yamane, T., 138 Yamaoka, K., 263 Yamasaki, F., 113, 116 Yamini, B., 340 Yang, D., 419 Yang, I., 251 Yang, W., 235 Yan, H., 34, 47–50, 53–60, 212 Yankeelov, T.E., 84 Yap, J.T., 132 Yasuhara, T., 143 Yip, S., 73, 76 Ylä-Herttuala, S., 335–346 Yokota, N., 31–36 Yoshida, F., 234–235 Young Poussaint, T., 393–394 Yousry, I., 375 Yousry, T.A., 375 Yuan, X., 100 Yue, W.Y., 94–95, 97 Yu, J.S., 322–323, 328 Yuki, K., 269–275 Yung, W.K., 77, 256 Z Zaidi, H., 131–140 Zamecnik, J., 116, 118 Zangari, M., 258 Zentner, J., 407 Zha, J., 281 Zhang, D., 98 Zhang, J., 303 Zhang, M., 114, 118 Zhang, S., 98, 115, 118 Zhang, W., 98 Zhao, M., 305 Zhao, S., 18, 50, 58 Zhou, J., 265 Zhou, S., 67 Zhou, X., 21 Zhu, S., 273 Zinc-finger proteins (ZFPs), 339 Zitvogel, L., 314 Zonari, P., 419, 422 Zupanska, A., 245–247 Zustovich, F., 255–259