What is the role of the subventricular zone in radiotherapy of glioblastoma patients?

The subventricular zone structure, function and implications for neurological disease

The subventricular zone (SVZ) is a region surrounding the lateral ventricles that contains neural stem cells and neural progenitor cells, which can proliferate and differentiate into various neural and glial cells. SVZ cells play important roles in neurological diseases like neurodegeneration, neural injury, and glioblastoma multiforme. Investigating the anatomy, structure, composition, physiology, disease associations, and related mechanisms of SVZ is significant for neural stem cell therapy and treatment/prevention of neurological disorders. However, challenges remain regarding the mechanisms regulating SVZ cell proliferation, differentiation, and migration, delivering cells to damaged areas, and immune responses. In-depth studies of SVZ functions and related therapeutic developments may provide new insights and approaches for treating brain injuries and degenerative diseases, as well as a scientific basis for neural stem cell therapy. This review summarizes research findings on SVZ and neurological diseases to provide references for relevant therapies.

Therapeutic and prognostic impact of target volume delineation in postoperative radiotherapy for high-grade glioma patients with subventricular zone involvement

OBJECTIVE

This study aimed to analyze the effect of target volumes for radiotherapy and dose on the prognosis of high-grade glioma (HGG) patients when the tumor involves the subventricular zone (SVZ), and to provide a reference for postoperative target volume delineation in HGG patients with SVZ involvement.

METHODS

The clinical and pathological data were collected from 50 HGG patients with SVZ involvement were collected in the Department of Neurosurgery of the First Affiliated Hospital of Soochow University during the period from January 1, 2017 to December 31, 2020. The average dose (Dmean) of the whole ipsilateral and contralateral SVZs as well as the V45Gy and V60Gy of the whole ipsilateral SVZs of the tumor were derived from the dose-volume histograms (DVH). The Kaplan-Meier analysis was applied to compare the survival differences between groups under different factors. The Cox proportional risk regression model was used to analyze the influencing factors of progression-free survival (PFS) and overall survival (OS). The correlation between the size of the ipsilateral SVZ target area range and the progression pattern was tested by chi-square test.

RESULTS

Univariate analysis revealed that the potential predictors of PFS of HGG patients with tumor involvement in SVZ were as follows: multiple lesions, tumor size > 3.5 cm and total resection; the potential predictors of OS were multiple lesions, surgical approaches to the lateral ventricles and the dose of contralateral SVZ > 37.33 Gy. Multibariate analysis showed that tumor size > 3.5 cm and total resection were the independent prognostic factors of PFS; multiple lesions was the independent prognostic factors of OS. The Kaplan-Meier method showed that the median PFS and OS of HGG patients with V60Gy ≥ 50% was higher than that of patients with V60Gy < 50% but the difference was not statistically significant. Subgroup analysis showed that patients with V60Gy ≥ 50% had significantly higher PFS in the age < 60 years subgroup (P = 0.006), WHO IV grade (P = 0.006), and surgical penetration of the lateral ventricle subgroup (P = 0.034) than in the V60Gy < 50%. Patients with V60Gy ≥ 50% had significantly higher OS in the WHO IV grade subgroup (P = 0.035), surgically penetrated lateral ventricle subgroup (P = 0.008), IDH1 wild-type subgroup (P = 0.012), and MGMT unmethylated subgroup (P = 0.047) than in V60Gy < 50%. A volume of ≥ 50% of the ipsilateral SVZ receiving a 60 Gy irradiation dose improves local control and reduces the risk of local recurrence in patients with SVZ involvement in HGG.

CONCLUSIONS

For SVZ-involved HGG patients, the whole ipsilateral SVZ receiving 60 Gy irradiation dose in ≥ 50% of the volume prolonged PFS in those with age < 60 years, WHO IV grade and surgically penetrating lateral ventricles and prolonged OS in those with WHO IV grade, surgically penetrating lateral ventricles, IDH1 wild-type and MGMT unmethylated.

Quantitative assessment of residual tumor is a strong and independent predictor of survival in methylated glioblastoma following radiochemotherapy with lomustine/temozolomide

BACKGROUND

Maximum tumor resection improves overall survival (OS) in patients with glioblastoma. The extent of resection (EOR) is historically dichotomized. The response assessment in neuro-oncology (RANO) resects group recently proposed criteria for volumetry-based EOR assessment in patients that were treated according to Stupp´s protocol. The purpose of this study was (1) to investigate the prognostic value of EOR in patients receiving combined chemotherapy with lomustine (CCNU)/temozolomide (TMZ), and (2) to analyze the prognostic performance of binary EOR assessment compared to volumetric assessment.

METHODS

Seventy-eight patients with newly diagnosed MGMT-methylated GBM undergoing tumor resection followed by radiochemotherapy with CCNU/TMZ were included in this study. Residual contrast-enhancing (CE) tumor volume after the first resection was measured and its influence on OS and progression-free survival was analyzed using uni- and multivariable Cox regression analysis as well as two-sided log-rank test. Patients were divided into residual tumor volume (RTV) ≤1 cm³, >1-≤5 cm³, and >5 cm³ following the proposed criteria of the RANO resect group.

RESULTS

Prolonged OS was associated with age <60 years, low RTV, and gross total resection. RTV had a superior prognostic value compared to binary EOR assessment. Patients with total or near total resection of CE tumor (≤ 1 cm³ RTV) showed prolonged OS (median 54.4 months, 95% CI: 46.94-not reached), with a 5-year survival rate of 49%.

CONCLUSIONS

Low RTV is associated with increased survival in glioblastoma patients undergoing radiochemotherapy with CCNU/TMZ. This study demonstrates the applicability of the recently proposed RANO resect criteria in this subgroup of patients.

Prognostic nomogram model based on quantitative metrics of subregions surrounding residual cavity in glioblastoma patients

BACKGROUND

The hyperintensity area surrounding the residual cavity on postoperative fluid-attenuated inversion recovery (FLAIR) image is a potential site for glioblastoma (GBM) recurrence. This study aimed to develop a nomogram using quantitative metrics from subregions of this area, prior to chemoradiotherapy (CRT), to predict early GBM recurrence.

METHODS

Adult patients with GBM diagnosed between October 2018 and October 2022 were retrospectively analyzed. Quantitative metrics, including the mean, maximum, minimum, median values, and standard deviation of FLAIR signal intensity (SI) (measured using 3D-Slicer software), were extracted from the following subregions surrounding the residual cavity on post-contrast T1-weighted (CE-T1WI)-FLAIR fusion images: the enhancing region (ER), non-enhancing region (NER), and combined ER + NER. Independent prognostic factors were identified using Cox regression and least absolute shrinkage and selection operator (LASSO) analyses and were incorporated into the prediction nomogram model. The model's performance was evaluated using the C-index, calibration curves, and decision curves.

RESULTS

A total of 129 adult GBM patients were enrolled and randomly assigned to a training (n = 90) and a validation cohorts (n = 39) in a 7:3 ratio. Sixty-nine patients experienced postoperative recurrence. Cox regression analysis identified subventricular zone involvement, the median FLAIR intensity in the ER, the rFLAIR (relative FLAIR intensity compared to the contralateral normal region) of ER + NER, and corpus callosum involvement as independent prognostic factors. For predicting recurrence within 1 year after surgery, the nomogram model had a C-index of 0.733 in the training cohort and 0.746 in the validation cohort. Based on the nomogram score, post-operative GBM patients could be stratified into high- and low-risk for recurrence.

CONCLUSIONS

Nomogram models which based on quantitative metrics from FLAIR hyperintensity subregions may serve as potential markers for assessing GBM recurrence risk. This approach could enhance clinical decision-making and provide an alternative method for recurrence estimation in GBM patients.

Combination of MRI-based prediction and CRISPR/Cas12a-based detection for IDH genotyping in glioma

Early identification of IDH mutation status is of great significance in clinical therapeutic decision-making in the treatment of glioma. We demonstrate a technological solution to improve the accuracy and reliability of IDH mutation detection by combining MRI-based prediction and a CRISPR-based automatic integrated gene detection system (AIGS). A model was constructed to predict the IDH mutation status using whole slices in MRI scans with a Transformer neural network, and the predictive model achieved accuracies of 0.93, 0.87, and 0.84 using the internal and two external test sets, respectively. Additionally, CRISPR/Cas12a-based AIGS was constructed, and AIGS achieved 100% diagnostic accuracy in terms of IDH detection using both frozen tissue and FFPE samples in one hour. Moreover, the feature attribution of our predictive model was assessed using GradCAM, and the highest correlations with tumor cell percentages in enhancing and IDH-wildtype gliomas were found to have GradCAM importance (0.65 and 0.5, respectively). This MRI-based predictive model could, therefore, guide biopsy for tumor-enriched, which would ensure the veracity and stability of the rapid detection results. The combination of our predictive model and AIGS improved the early determination of IDH mutation status in glioma patients. This combined system of MRI-based prediction and CRISPR/Cas12a-based detection can be used to guide biopsy, resection, and radiation for glioma patients to improve patient outcomes.

Validation of a methylation-based signature for subventricular zone involvement in glioblastoma

PURPOSE

Glioblastomas (GBM) with subventricular zone (SVZ) contact have previously been associated with a specific epigenetic fingerprint. We aim to validate a reported bulk methylation signature to determine SVZ contact.

METHODS

Methylation array analysis was performed on IDHwt GBM patients treated at our institution. The v11b4 classifier was used to ensure the inclusion of only receptor tyrosine kinase (RTK) I, II, and mesenchymal (MES) subtypes. Methylation-based assignment (SVZM ±) was performed using hierarchical cluster analysis. Magnetic resonance imaging (MRI) (T1ce) was independently reviewed for SVZ contact by three experienced readers.

RESULTS

Sixty-five of 70 samples were classified as RTK I, II, and MES. Full T1ce MRI-based rater consensus was observed in 54 cases, which were retained for further analysis. Epigenetic SVZM classification and SVZ were strongly associated (OR: 15.0, p = 0.003). Thirteen of fourteen differential CpGs were located in the previously described differentially methylated LRBA/MAB21L2 locus. SVZ + tumors were linked to shorter OS (hazard ratio (HR): 3.80, p = 0.02) than SVZM + at earlier time points (time-dependency of SVZM, p < 0.05). Considering the SVZ consensus as the ground truth, SVZM classification yields a sensitivity of 96.6%, specificity of 36.0%, positive predictive value (PPV) of 63.6%, and negative predictive value (NPV) of 90.0%.

CONCLUSION

Herein, we validated the specific epigenetic signature in GBM in the vicinity of the SVZ and highlighted the importance of methylation of a part of the LRBA/MAB21L2 gene locus. Whether SVZM can replace MRI-based SVZ assignment as a prognostic and diagnostic tool will require prospective studies of large, homogeneous cohorts.

Histopathologically confirmed radiation-induced damage of the brain - an in-depth analysis of radiation parameters and spatio-temporal occurrence

BACKGROUND

Radiation-induced damage (RID) after radiotherapy (RT) of primary brain tumors and metastases can be challenging to clinico-radiographically distinguish from tumor progression. RID includes pseudoprogression and radiation necrosis; the latter being irreversible and often associated with severe symptoms. While histopathology constitutes the diagnostic gold standard, biopsy-controlled clinical studies investigating RID remain limited. Whether certain brain areas are potentially more vulnerable to RID remains an area of active investigation. Here, we analyze histopathologically confirmed cases of RID in relation to the temporal and spatial dose distribution.

METHODS

Histopathologically confirmed cases of RID after photon-based RT for primary or secondary central nervous system malignancies were included. Demographic, clinical, and dosimetric data were collected from patient records and treatment planning systems. We calculated the equivalent dose in 2 Gy fractions (EQD22) and the biologically effective dose (BED2) for normal brain tissue (α/β ratio of 2 Gy) and analyzed the spatial and temporal distribution using frequency maps.

RESULTS

Thirty-three patients were identified. High-grade glioma patients (n = 18) mostly received one normofractionated RT series (median cumulative EQD22 60 Gy) to a large planning target volume (PTV) (median 203.9 ccm) before diagnosis of RID. Despite the low EQD22 and BED2, three patients with an accelerated hyperfractionated RT developed RID. In contrast, brain metastases patients (n = 15; 16 RID lesions) were often treated with two or more RT courses and with radiosurgery or fractionated stereotactic RT, resulting in a higher cumulative EQD22 (median 162.4 Gy), to a small PTV (median 6.7 ccm). All (n = 34) RID lesions occurred within the PTV of at least one of the preceding RT courses. RID in the high-grade glioma group showed a frontotemporal distribution pattern, whereas, in metastatic patients, RID was observed throughout the brain with highest density in the parietal lobe. The cumulative EQD22 was significantly lower in RID lesions that involved the subventricular zone (SVZ) than in lesions without SVZ involvement (median 60 Gy vs. 141 Gy, p = 0.01).

CONCLUSIONS

Accelerated hyperfractionated RT can lead to RID despite computationally low EQD22 and BED2 in high-grade glioma patients. The anatomical location of RID corresponded to the general tumor distribution of gliomas and metastases. The SVZ might be a particularly vulnerable area.

Clinicogenetic characteristics and the effect of radiation on the neural stem cell niche in subventricular zone-contacting glioblastoma

BACKGROUND AND PURPOSE

Neural stem cells (NSCs) in the subventricular zone (SVZ) are recognized as the cellular origin of glioblastoma (GBM) and a potential therapeutic target. However, the characteristics of SVZ contacting GBM (SVZ + GBM) and radiotherapeutic strategies for NSCs are still controversial. Here, we investigated the clinicogenetic features of SVZ + GBM and evaluated the dose effect of NSC irradiation depending on SVZ involvement.

MATERIALS AND METHODS

We identified 125 patients with GBM treated with surgery followed by chemoradiotherapy. The genomic profiles were obtained by next-generation sequencing targeting 82 genes. NSCs in the SVZ and hippocampus were contoured using standardized methods, and dosimetric factors were analyzed. SVZ + GBM was defined as GBM with SVZ involvement in a T1 contrast-enhanced image. Progression-free survival (PFS) and overall survival (OS) were used as endpoints.

RESULTS

The number of patients with SVZ + GBM was 95 (76%). SVZ + GBM showed lower PFS than GBM without SVZ involvement (SVZ-GBM) (median 8.6 vs. 11.5 months, p = 0.034). SVZ contact was not associated with any specific genetic profile but was an independent prognostic factor in multivariate analysis. In SVZ + GBM, patients receiving high doses to the ipsilateral NSC region showed significantly better OS (HR = 1.89, p = 0.011) and PFS (HR = 1.77, p = 0.013). However, in SVZ-GBM, high doses to the ipsilateral NSC region were associated with worse OS (HR = 0.27, p = 0.013) and PFS (HR = 0.37, p = 0.035) in both univariate and multivariate analyses.

CONCLUSION

SVZ involvement in GBM was not associated with distinct genetic features. However, irradiation of NSCs was associated with better prognosis in patients with tumors contacting the SVZ.

Targeting the neural stem cells in subventricular zone for the treatment of glioblastoma: an update from preclinical evidence to clinical interventions

BACKGROUND

Glioblastoma is one of the most common and aggressive adult brain tumors. The conventional treatment strategy, surgery combined with chemoradiotherapy, did not change the fact that the recurrence rate was high and the survival rate was low. Over the years, accumulating evidence has shown that the subventricular zone has an important role in the recurrence and treatment resistance of glioblastoma. The human adult subventricular zone contains neural stem cells and glioma stem cells that are probably a part of reason for therapy resistance and recurrence of glioblastoma.

MAIN BODY

Over the years, both bench and bedside evidences strongly support the view that the presence of neural stem cells and glioma stem cells in the subventricular zone may be the crucial factor of recurrence of glioblastoma after conventional therapy. It emphasizes the necessity to explore new therapy strategies with the aim to target subventricular zone to eradicate neural stem cells or glioma stem cells. In this review, we summarize the recent preclinical and clinical advances in targeting neural stem cells in the subventricular zone for glioblastoma treatment, and clarify the prospects and challenges in clinical application.

CONCLUSIONS

Although there remain unresolved issues, current advances provide us with a lot of evidence that targeting the neural stem cells and glioma stem cells in subventricular zone may have the potential to solve the dilemma of glioblastoma recurrence and treatment resistance.

Therapy Resistance of Glioblastoma in Relation to the Subventricular Zone: What Is the Role of Radiotherapy?

Glioblastoma is a highly heterogeneous primary malignant brain tumor with marked inter-/intratumoral diversity and a poor prognosis. It may contain a population of neural stem cells (NSC) and glioblastoma stem cells that have the capacity for migration, self-renewal and differentiation. While both may contribute to resistance to therapy, NSCs may also play a role in brain tissue repair. The subventricular zone (SVZ) is the main reservoir of NSCs. This study investigated the impact of bilateral SVZ radiation doses on patient outcomes. We included 147 patients. SVZs were delineated and the dose administered was extracted from dose–volume histograms. Tumors were classified based on their spatial relationship to the SVZ. The dose and outcome correlations were analyzed using the Kaplan–Meier and Cox proportional hazards regression methods. Median progression-free survival (PFS) was 7 months (range: 4–11 months) and median overall survival (OS) was 14 months (range: 9–23 months). Patients with an ipsilateral SVZ who received ≥50 Gy showed significantly better PFS (8 versus 6 months; p < 0.001) and OS (16 versus 11 months; p < 0.001). Furthermore, lower doses (<32 Gy) to the contralateral SVZ were associated with improved PFS (8 versus 6 months; p = 0.030) and OS (15 versus 11 months; p = 0.001). Targeting the potential tumorigenic cells in the ipsilateral SVZ while sparing contralateral NSCs correlated with an improved outcome. Further studies should address the optimization of dose distribution with modern radiotherapy techniques for the areas surrounding infiltrated and healthy SVZs.

Glioblastoma and Methionine Addiction

Glioblastoma is a fatal brain tumor with a bleak prognosis. The use of chemotherapy, primarily the alkylating agent temozolomide, coupled with radiation and surgical resection, has provided some benefit. Despite this multipronged approach, average patient survival rarely extends beyond 18 months. Challenges to glioblastoma treatment include the identification of functional pharmacologic targets as well as identifying drugs that can cross the blood-brain barrier. To address these challenges, current research efforts are examining metabolic differences between normal and tumor cells that could be targeted. Among the metabolic differences examined to date, the apparent addiction to exogenous methionine by glioblastoma tumors is a critical factor that is not well understood and may serve as an effective therapeutic target. Others have proposed this property could be exploited by methionine dietary restriction or other approaches to reduce methionine availability. However, methionine links the tumor microenvironment with cell metabolism, epigenetic regulation, and even mitosis. Therefore methionine depletion could result in complex and potentially undesirable responses, such as aneuploidy and the aberrant expression of genes that drive tumor progression. If methionine manipulation is to be a therapeutic strategy for glioblastoma patients, it is essential that we enhance our understanding of the role of methionine in the tumor microenvironment.