Associations between prediagnostic blood glucose levels, diabetes, and glioma

Metabolic Syndrome and Survival in Glioblastoma Patients: Retrospective Cohort Study and Review of the Literature

Background Several studies point to metabolic syndrome as a risk factor for the development and progression of several types of cancer. Its association with glioblastoma has yet to be determined, and only two studies investigate the impact of metabolic syndrome on the survival of glioblastoma patients, indicating a trend toward decreased survival in patients with metabolic syndrome. The aim of this study was to determine whether patients with glioblastoma and metabolic syndrome had a worse clinical outcome. Methods We retrospectively reviewed the clinical records of 180 patients diagnosed with glioblastoma. Metabolic syndrome was defined according to the American Heart Association, as the presence of at least three of the following criteria: diabetes, hypertension, hyperlipidemia, and obesity. We analyzed the overall survival and progression-free survival of patients with and without metabolic syndrome. Results Of 180 patients, 20 (11.1%) met the diagnostic criteria for metabolic syndrome. The overall survival of patients with metabolic syndrome was 19.8 months, and without metabolic syndrome was 17.7 months (p-value=0.085). The progression-free survival of patients with metabolic syndrome was 9.9 months, and without metabolic syndrome was 7.9 months (p-value=0.076). Conclusion Our results showed no prognostic relevance of metabolic syndrome in patients with glioblastoma, although there was a trend towards increased overall survival and progression-free survival in patients with metabolic syndrome.

The Role of Ketone Bodies in Treatment Individualization of Glioblastoma Patients

Glioblastoma is the most common and aggressive primary brain tumor in adults. According to the 2021 WHO CNS, glioblastoma is assigned to the IDH wild-type classification, fulfilling the specific characteristic histopathology. We have conducted a prospective observational study to identify the glucose levels, ketone bodies, and the glucose-ketone index in three groups of subjects: two tumoral groups of patients with histopathological confirmation of glioblastoma (9 male patients, 7 female patients, mean age 55.6 years old) or grade 4 astrocytoma (4 male patients, 2 female patients, mean age 48.1 years old) and a control group (13 male patients, 9 female patients, mean age 53.9 years old) consisting of subjects with no personal pathological history. There were statistically significant differences between the mean values of glycemia (p value = 0.0003), ketones (p value = 0.0061), and glucose-ketone index (p value = 0.008) between the groups of patients. Mortality at 3 months in glioblastoma patients was 0% if the ketone levels were below 0.2 mM and 100% if ketones were over 0.5 mM. Patients with grade 4 astrocytoma and the control subjects all presented with ketone values of less than 0.2 mM and 0.0% mortality. In conclusion, highlighting new biomarkers which are more feasible to determine such as ketones or glucose-ketone index represents an essential step toward personalized medicine and survival prolongation in patients suffering from glioblastoma and grade 4 astrocytoma.

Associations between adiposity, diabetes, lifestyle factors and the risk of gliomas

Background

Despite numerous observational studies linking adiposity, diabetes, and lifestyle factors with gliomas, the causal associations between them remain uncertain.

Methods

This study aimed to use two-sample Mendelian randomization (MR) analysis to investigate whether these associations are causal. Specifically, independent genetic variants in body mass index (BMI), waist circumference (WC), type 2 diabetes (T2D), smoking, alcohol, and coffee consumption were extracted from the published genome-wide association studies (GWASs) with genome-wide significance. The corresponding summary-level data for gliomas were available from a GWAS of 1,856 cases and 4,955 controls of European descent from the GliomaScan consortium. Additionally, glioma pathogenesis-related protein 1 data were used for validation, and Radial MR analysis was conducted to examine the potential outlier single-nucleotide polymorphisms (SNPs).

Results

One standard deviation (SD) increase in BMI had an odds ratio (OR) of 1.392 (95% confidence interval (CI), 0.935-2.071) for gliomas, while one SD increase in WC had an OR of 0.967 (95% CI, 0.547-1.710). For T2D, a one-unit increase in log-transformed OR had an OR of 0.923 (95% CI, 0.754-1.129). The prevalence of smoking initiation had an OR of 1.703 (95% CI, 0.871-3.326) for gliomas, while the prevalence of alcohol intake frequency had an OR of 0.806 (95% CI, 0.361-1.083), and the prevalence of coffee intake had an OR of 0.268 (95% CI, 0.033-2.140) for gliomas.

Conclusion

This study provides evidence that adiposity, T2D, smoking, alcohol drinking, and coffee intake do not play causal roles in the development of gliomas. The findings highlight the importance of reconsidering causal relationships in epidemiological research to better understand the risk factors and prevention strategies for gliomas.

Sitagliptin inhibits the survival, stemness and autophagy of glioma cells, and enhances temozolomide cytotoxicity

The standard regimen treatment has improved GBM outcomes, but the survival rate of patients is still unsatisfactory. Temozolomide (TMZ) resistance is one of main reasons limiting the therapeutic efficacy of GBM. However, there are currently no TMZ-sensitizing drugs available in the clinic. Here we aimed to study whether the antidiabetic drug Sitagliptin can inhibit the survival, stemness and autophagy of GBM cells, and thus enhance TMZ cytotoxicity. We used CCK-8, EdU, colony formation, TUNEL and flow cytometry assays to assess cell proliferation and apoptosis; sphere formation and limiting dilution assays to measure self-renewal and stemness of glioma stem cells (GSCs); Western blot, qRT-PCR or immunohistochemical analysis to measure the expression of proliferation or stem cell markers; Western blot/fluorescent analysis of LC3 and other molecules to evaluate autophagy formation and degradation in glioma cells. We found that Sitagliptin inhibited proliferation and induced apoptosis in GBM cells and suppressed self-renewal and stemness of GSCs. The in vitro findings were further confirmed in glioma intracranial xenograft models. Sitagliptin administration prolonged the survival time of tumor-bearing mice. Sitagliptin could inhibit TMZ-induced protective autophagy and enhance the cytotoxicity of TMZ in glioma cells. In addition, Sitagliptin acted as a dipeptidyl peptidase 4 inhibitor in glioma as well as in diabetes, but it did not affect the blood glucose level and body weight of mice. These findings suggest that Sitagliptin with established pharmacologic and safety profiles could be repurposed as an antiglioma drug to overcome TMZ resistance, providing a new option for GBM therapy.

Pre-diagnostic blood biomarkers for adult glioma

Glioma is one of the most common malignant primary brain tumours in adults, of which, glioblastoma is the most prevalent and malignant entity. Glioma is often diagnosed at a later stage of disease progression, which means it is associated with significant mortality and morbidity. Therefore, there is a need for earlier diagnosis of these tumours, which would require sensitive and specific biomarkers. These biomarkers could better predict glioma onset to improve diagnosis and therapeutic options for patients. While liquid biopsies could provide a cheap and non-invasive test to improve the earlier detection of glioma, there is little known on pre-diagnostic biomarkers which predate disease detection. In this review, we examine the evidence in the literature for pre-diagnostic biomarkers in glioma, including metabolomics and proteomics. We also consider the limitations of these approaches and future research directions of pre-diagnostic biomarkers for glioma.

Impact of abdominal obesity on the risk of glioma development in patients with diabetes: A nationwide population-based cohort study in Korea

BACKGROUND

Abdominal obesity has been suggested as a risk factor for glioma; however, it is unclear whether this association applies to people with diabetes. This study examined the association between abdominal obesity and the risk of developing gliomas in diabetic patients.

METHODS

We conducted a retrospective cohort study using the National Health Insurance System of South Korea from 2009 to 2012. The primary outcome was the incidence of newly diagnosed gliomas according to waist circumference (WC), and subgroup analyses were performed according to demographic characteristics and diabetes status including disease duration, number of oral hypoglycemic agents, and insulin use.

RESULTS

Of a total of 1,893,057 participants, 1,846 (0.10%) cases of gliomas occurred. After adjusting for confounding factors, WC ≥90 cm (men)/85 cm (women) was associated with significantly higher risks of gliomas (adjusted HR [95% CI]; 1.279 [1.053, 1.554], 1.317 [1.048, 1.655], and 1.369 [1.037, 1.807] in the WC <95 cm (men)/90 cm (women) group, WC <100 cm (men)/95 cm (women) group, and WC ≥100 cm (men)/95 cm (women) group, respectively). Subgroup analysis showed that patients with larger WC had a consistently higher incidence of glioma than their lean counterparts, except for insulin users (insulin user vs. nonuser, P for interaction = .03).

CONCLUSIONS

Abdominal obesity was associated with the development of gliomas in diabetic patients in a nationwide population-based database. Further study is needed in diabetic patients to stratify the risk for glioma development according to WC and to establish the underlying mechanism of carcinogenesis.

Metabolic management of microenvironment acidity in glioblastoma

Glioblastoma (GBM), similar to most cancers, is dependent on fermentation metabolism for the synthesis of biomass and energy (ATP) regardless of the cellular or genetic heterogeneity seen within the tumor. The transition from respiration to fermentation arises from the documented defects in the number, the structure, and the function of mitochondria and mitochondrial-associated membranes in GBM tissue. Glucose and glutamine are the major fermentable fuels that drive GBM growth. The major waste products of GBM cell fermentation (lactic acid, glutamic acid, and succinic acid) will acidify the microenvironment and are largely responsible for drug resistance, enhanced invasion, immunosuppression, and metastasis. Besides surgical debulking, therapies used for GBM management (radiation, chemotherapy, and steroids) enhance microenvironment acidification and, although often providing a time-limited disease control, will thus favor tumor recurrence and complications. The simultaneous restriction of glucose and glutamine, while elevating non-fermentable, anti-inflammatory ketone bodies, can help restore the pH balance of the microenvironment while, at the same time, providing a non-toxic therapeutic strategy for killing most of the neoplastic cells.

Insulin-like Growth Factor 2 mRNA-Binding Protein 2-a Potential Link Between Type 2 Diabetes Mellitus and Cancer

CONTEXT

Type 2 diabetes mellitus (T2DM) and cancer share a variety of risk factors and pathophysiological features. It is becoming increasingly accepted that the 2 diseases are related, and that T2DM increases the risk of certain malignancies.

OBJECTIVE

This review summarizes recent advancements in the elucidation of functions of insulin-like growth factor 2 (IGF-2) messenger RNA (mRNA)-binding protein 2 (IGF2BP2) in T2DM and cancer.

METHODS

A PubMed review of the literature was conducted, and search terms included IGF2BP2, IMP2, or p62 in combination with cancer or T2DM. Additional sources were identified through manual searches of reference lists. The increased risk of multiple malignancies and cancer-associated mortality in patients with T2DM is believed to be driven by insulin resistance, hyperinsulinemia, hyperglycemia, chronic inflammation, and dysregulation of adipokines and sex hormones. Furthermore, IGF-2 is oncogenic, and its loss-of-function splice variant is protective against T2DM, which highlights the pivotal role of this growth factor in the pathogenesis of these 2 diseases. IGF-2 mRNA-binding proteins, particularly IGF2BP2, are also involved in T2DM and cancer, and single-nucleotide variations (formerly single-nucleotide polymorphisms) of IGF2BP2 are associated with both diseases. Deletion of the IGF2BP2 gene in mice improves their glucose tolerance and insulin sensitivity, and mice with transgenic p62, a splice variant of IGF2BP2, are prone to diet-induced fatty liver disease and hepatocellular carcinoma, suggesting the biological significance of IGF2BP2 in T2DM and cancer.

CONCLUSION

Accumulating evidence has revealed that IGF2BP2 mediates the pathogenesis of T2DM and cancer by regulating glucose metabolism, insulin sensitivity, and tumorigenesis. This review provides insight into the potential involvement of this RNA binding protein in the link between T2DM and cancer.

Local and Systemic Immune Dysregulation Alters Glioma Growth in Hyperglycemic Mice

PURPOSE

Unlike most cancers, no clear epidemiological correlation between diabetes (Db) and malignant glioma progression exists. Because hyperglycemia activates proinflammatory pathways through the receptor for advanced glycation endproducts (RAGE), we hypothesized that Db can also promote malignant glioma progression.

EXPERIMENTAL DESIGN

We compared the growth of two phenotypically diverse syngeneic glioma models in control and diabetic mice. Tumor growth and antitumor immune responses were evaluated in orthotopic and heterotopic models and correlated to RAGE and RAGE ligand expression.

RESULTS

Irrespective of tumor implantation site, growth of a "classical" glioma model, GL261, increased in hyperglycemic mice and was mediated by upregulation of RAGE and its ligand, HMGB1. However, growth of a "mesenchymal" glioma subtype, K-Luc, depended on tumor implantation site. Whereas heterotopic K-Luc tumors progressed rapidly in Db mice, intracranial K-Luc tumors grew slower. We further showed that hyperglycemia inhibited the innate antitumor inflammatory responses in both models. Although this contributed to the accelerated growth of heterotopic tumors, suppression of tumor inflammatory responses dampened the growth of orthotopic K-Luc gliomas.

CONCLUSIONS

Hyperglycemia may enhance glioma growth through promotion of RAGE expression and suppression of antitumor immune responses. However, abrogation of the proinflammatory milieu in tumors may also dampen the growth of inflammatory glioma subtypes in the brains of diabetic mice. This dichotomy in glioma growth response to hyperglycemia may partly explain why conflicting epidemiological studies show both an increased risk and a protective effect of Db in patients with malignant gliomas.

Autoimmune diseases and immunosuppressive therapy in relation to the risk of glioma

Effectors from the immune system can modulate the course and possibly the early development of gliomas. We, therefore, hypothesized that autoimmune diseases associated with increased immune‐surveillance may also modulate the risk of human glioma. To test this hypothesis, we used data from the well‐validated Clinical Practice Research Datalink (CPRD) GOLD from the UK to analyze the association of immune‐related disorders or use of immunosuppressive drugs and the risk of glioma. We identified 3112 incident glioma cases diagnosed between 1995 and 2017. We randomly selected up to 10 controls, matching them to glioma cases on age, sex, index date, general practice, and number of years of active history in the database prior to the index date. We performed conditional logistic regression analyses to estimate Odds Ratios (ORs) of glioma among those exposed to allergies, autoimmune diseases, and immunosuppressive drugs. Overall, we found no materially altered association between a history of any autoimmune disease (OR 0.98, 95% CI 0.86‐1.11), allergy (OR 0.97, 95% CI 0.89‐1.05), or use of immunosuppressive drugs and the risk of glioma. However, subgroup analyses among younger patients found a statistically significant increased risk of glioma in patients with a history of inflammatory bowel disease (IBD) (OR 2.59, 95% CI 1.31‐5.12). There was also an inverse association between asthma and risk of glioma in patients with longer survival (OR 0.73, 95% CI 0.58‐0.91) and between long‐term duration diabetes and risk of glioma (OR 0.71, 95% CI 0.53‐0.96).

Therapeutic benefit of combining calorie-restricted ketogenic diet and glutamine targeting in late-stage experimental glioblastoma

Glioblastoma (GBM) is an aggressive primary human brain tumour that has resisted effective therapy for decades. Although glucose and glutamine are the major fuels that drive GBM growth and invasion, few studies have targeted these fuels for therapeutic management. The glutamine antagonist, 6-diazo-5-oxo-L-norleucine (DON), was administered together with a calorically restricted ketogenic diet (KD-R) to treat late-stage orthotopic growth in two syngeneic GBM mouse models: VM-M3 and CT-2A. DON targets glutaminolysis, while the KD-R reduces glucose and, simultaneously, elevates neuroprotective and non-fermentable ketone bodies. The diet/drug therapeutic strategy killed tumour cells while reversing disease symptoms, and improving overall mouse survival. The therapeutic strategy also reduces edema, hemorrhage, and inflammation. Moreover, the KD-R diet facilitated DON delivery to the brain and allowed a lower dosage to achieve therapeutic effect. The findings support the importance of glucose and glutamine in driving GBM growth and provide a therapeutic strategy for non-toxic metabolic management.

Provocative Question: Should Ketogenic Metabolic Therapy Become the Standard of Care for Glioblastoma?

No major advances have been made in improving overall survival for glioblastoma (GBM) in almost 100 years. The current standard of care (SOC) for GBM involves immediate surgical resection followed by radiotherapy with concomitant temozolomide chemotherapy. Corticosteroid (dexamethasone) is often prescribed to GBM patients to reduce tumor edema and inflammation. The SOC disrupts the glutamate-glutamine cycle thus increasing availability of glucose and glutamine in the tumor microenvironment. Glucose and glutamine are the prime fermentable fuels that underlie therapy resistance and drive GBM growth through substrate level phosphorylation in the cytoplasm and the mitochondria, respectively. Emerging evidence indicates that ketogenic metabolic therapy (KMT) can reduce glucose availability while elevating ketone bodies that are neuroprotective and non-fermentable. Information is presented from preclinical and case report studies showing how KMT could target tumor cells without causing neurochemical damage thus improving progression free and overall survival for patients with GBM.

Use of Mendelian andomization for dentifying isk actors for rain umors

Gliomas are a group of primary brain tumors, the most common and aggressive subtype of which is glioblastoma. Glioblastoma has a median survival of just 15 months after diagnosis. Only previous exposure to ionizing radiation and particular inherited genetic syndromes are accepted risk factors for glioma; the vast majority of cases are thought to occur spontaneously. Previous observational studies have described associations between several risk factors and glioma, but studies are often conflicting and whether these associations reflect true casual relationships is unclear because observational studies may be susceptible to confounding, measurement error and reverse causation. Mendelian randomization (MR) is a form of instrumental variable analysis that can be used to provide supporting evidence for causal relationships between exposures (e.g., risk factors) and outcomes (e.g., disease onset). MR utilizes genetic variants, such as single nucleotide polymorphisms (SNPs), that are robustly associated with an exposure to determine whether there is a causal effect of the exposure on the outcome. MR is less susceptible to confounding, reverse causation and measurement errors as it is based on the random inheritance during conception of genetic variants that can be relatively accurately measured. In previous studies, MR has implicated a genetically predicted increase in telomere length with an increased risk of glioma, and found little evidence that obesity related factors, vitamin D or atopy are causal in glioma risk. In this review, we describe MR and its potential use to discover and validate novel risk factors, mechanistic factors, and therapeutic targets in glioma.

Influence of obesity-related risk factors in the aetiology of glioma

BACKGROUND

Obesity and related factors have been implicated as possible aetiological factors for the development of glioma in epidemiological observation studies. We used genetic markers in a Mendelian randomisation framework to examine whether obesity-related traits influence glioma risk. This methodology reduces bias from confounding and is not affected by reverse causation.

METHODS

Genetic instruments were identified for 10 key obesity-related risk factors, and their association with glioma risk was evaluated using data from a genome-wide association study of 12,488 glioma patients and 18,169 controls. The estimated odds ratio of glioma associated with each of the genetically defined obesity-related traits was used to infer evidence for a causal relationship.

RESULTS

No convincing association with glioma risk was seen for genetic instruments for body mass index, waist-to-hip ratio, lipids, type-2 diabetes, hyperglycaemia or insulin resistance. Similarly, we found no evidence to support a relationship between obesity-related traits with subtypes of glioma-glioblastoma (GBM) or non-GBM tumours.

CONCLUSIONS

This study provides no evidence to implicate obesity-related factors as causes of glioma.