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Barkley A, Butler E, Park C, Friedman A, Landi D, Ashley DM, Bigner D, Bernstock JD, Friedman GK, Johnston JM, Thompson EM. The safety and accuracy of intratumoral catheter placement to infuse viral immunotherapies in children with malignant brain tumors: a multi-institutional study. J Neurosurg Pediatr 2024; 33:359-366. [PMID: 38215438 PMCID: PMC10810678 DOI: 10.3171/2023.12.peds23404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/06/2023] [Indexed: 01/14/2024]
Abstract
OBJECTIVE Relatively little is known about the safety and accuracy of catheter placement for oncolytic viral therapy in children with malignant brain tumors. Accordingly, this study combines data from two phase I clinical trials that employed viral immunotherapy across two institutions to describe the adverse event profile, safety, and accuracy associated with the stereotactic placement and subsequent removal of intratumoral catheters. METHODS Children with progressive/recurrent supratentorial malignant tumors were enrolled in two clinical trials (NCT03043391 and NCT02457845) and treated with either the recombinant polio:rhinovirus (lerapolturev) or the genetically modified oncolytic herpesvirus (G207). Age, sex, race, tumor diagnosis, and tumor location were analyzed. Events related to the catheter placement or removal were categorized. A catheter that was either pulled back or could not be used was defined as "misplaced." Neuronavigation software was used to analyze the accuracy of catheter placement for NCT03043391. Descriptive statistics were performed. RESULTS Nineteen patients were treated across the two completed trials with a total of 49 catheters. The mean ± SD (range) age was 14.1 ± 3.6 (7-19) years. All tumors were grade 3 or 4 gliomas. Nonlobar catheter tip placement included the corpus callosum, thalamus, insula, and cingulate gyrus. Six of 19 patients (31.6%) had minor hemorrhage noted on CT; however, no patients were symptomatic and/or required intervention related to these findings. One of 19 patients had a delayed CSF leak after catheter removal that required oversewing of the surgical site. No patients developed infection or a neurological deficit. In 7 patients with accuracy data, the mean ± SD distance of the planned trajectory (PT) to the catheter tip was 1.57 ± 1.6 mm, the mean angle of the PT to the catheter was 2.43° ± 2.1°, and the greatest distance of PT to the catheter in the parallel plane was 1.54 ± 1.5 mm. Three of 49 (6.1%) catheters were considered misplaced. CONCLUSIONS Although instances of minor hemorrhage were encountered, they were clinically asymptomatic. One of 49 catheters required intervention for a CSF leak. Congruent with previous studies in the literature, the stereotactic placement of catheters in these pediatric tumor patients was accurate with approximately 95% of catheters having been adequately placed.
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Affiliation(s)
- Ariana Barkley
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico
- Departments of Neurosurgery and
| | | | - Christine Park
- School of Medicine, Duke University, Durham, North Carolina
| | | | - Daniel Landi
- Pediatrics, Duke University, Durham, North Carolina
| | | | | | - Joshua D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregory K. Friedman
- Pediatrics, University of Alabama at Birmingham, Alabama
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | | | - Eric M. Thompson
- Departments of Neurosurgery and
- Department of Neurosurgery, University of Chicago, Illinois
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Thompson EM, Kang KD, Stevenson K, Zhang H, Gromeier M, Ashley D, Brown M, Friedman GK. Elucidating cellular response to treatment with viral immunotherapies in pediatric high-grade glioma and medulloblastoma. Transl Oncol 2024; 40:101875. [PMID: 38183802 PMCID: PMC10809117 DOI: 10.1016/j.tranon.2024.101875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 12/08/2023] [Accepted: 12/27/2023] [Indexed: 01/08/2024] Open
Abstract
HSV G207, a double-stranded, DNA virus, and the polio:rhinovirus chimera, PVSRIPO, a single positive-strand RNA virus, are viral immunotherapies being used to treat pediatric malignant brain tumors in clinical trials. The purpose of this work is to elucidate general response patterns and putative biomarkers of response. Multiple pediatric high-grade glioma and medulloblastoma cell lines were treated with various multiplicities of infection of G207 or PVSRIPO. There was a significant inverse correlation between expression of one HSV cellular receptor, CD111, and the lethal dose of 50% of cells (LD50) of cells treated with G207 (r = -0.985, P<0.001) but no correlation between PVSRIPO cellular receptor expression (CD155) and LD50. RNA sequencing of control cells and cells treated for 8 and 24 h revealed that there were few shared differentially expressed (DE) genes between cells treated with PVSRIPO and G207: GCLM, LANCL2, and RBM3 were enriched whilst ADAMTS1 and VEGFA were depleted. Likewise, there were few shared DE genes enriched between medulloblastoma and high-grade glioma cell lines treated with G207: GPSM2, CHECK2, SEPTIN2, EIF4G2, GCLM, GDAP1, LANCL2, and PWP1. Treatment with G207 and PVSRIPO appear to cause disparate gene enrichment and depletion suggesting disparate molecular mechanisms in malignant pediatric brain tumors.
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Affiliation(s)
- Eric M Thompson
- Department of Neurosurgery, University of Chicago, Chicago, IL, USA; Department of Neurosurgery, Duke University, Durham, NC, USA.
| | - Kyung-Don Kang
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kevin Stevenson
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Hengshan Zhang
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | | | - David Ashley
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Michael Brown
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Gregory K Friedman
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Low JT, Brown MC, Reitman ZJ, Bernstock JD, Markert JM, Friedman GK, Waitkus MS, Bowie ML, Ashley DM. Understanding and therapeutically exploiting cGAS/STING signaling in glioblastoma. J Clin Invest 2024; 134:e163452. [PMID: 38226619 PMCID: PMC10786687 DOI: 10.1172/jci163452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
Since the discovery that cGAS/STING recognizes endogenous DNA released from dying cancer cells and induces type I interferon and antitumor T cell responses, efforts to understand and therapeutically target the STING pathway in cancer have ensued. Relative to other cancer types, the glioma immune microenvironment harbors few infiltrating T cells, but abundant tumor-associated myeloid cells, possibly explaining disappointing responses to immune checkpoint blockade therapies in cohorts of patients with glioblastoma. Notably, unlike most extracranial tumors, STING expression is absent in the malignant compartment of gliomas, likely due to methylation of the STING promoter. Nonetheless, several preclinical studies suggest that inducing cGAS/STING signaling in the glioma immune microenvironment could be therapeutically beneficial, and cGAS/STING signaling has been shown to mediate inflammatory and antitumor effects of other modalities either in use or being developed for glioblastoma therapy, including radiation, tumor-treating fields, and oncolytic virotherapy. In this Review, we discuss cGAS/STING signaling in gliomas, its implications for glioma immunobiology, compartment-specific roles for STING signaling in influencing immune surveillance, and efforts to target STING signaling - either directly or indirectly - for antiglioma therapy.
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Affiliation(s)
| | | | - Zachary J. Reitman
- Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
| | - Joshua D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - James M. Markert
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gregory K. Friedman
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Karandikar PV, Suh L, Gerstl JVE, Blitz SE, Qu QR, Won SY, Gessler FA, Arnaout O, Smith TR, Peruzzi PP, Yang W, Friedman GK, Bernstock JD. Positioning SUMO as an immunological facilitator of oncolytic viruses for high-grade glioma. Front Cell Dev Biol 2023; 11:1271575. [PMID: 37860820 PMCID: PMC10582965 DOI: 10.3389/fcell.2023.1271575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/18/2023] [Indexed: 10/21/2023] Open
Abstract
Oncolytic viral (OV) therapies are promising novel treatment modalities for cancers refractory to conventional treatment, such as glioblastoma, within the central nervous system (CNS). Although OVs have received regulatory approval for use in the CNS, efficacy is hampered by obstacles related to delivery, under-/over-active immune responses, and the "immune-cold" nature of most CNS malignancies. SUMO, the Small Ubiquitin-like Modifier, is a family of proteins that serve as a high-level regulator of a large variety of key physiologic processes including the host immune response. The SUMO pathway has also been implicated in the pathogenesis of both wild-type viruses and CNS malignancies. As such, the intersection of OV biology with the SUMO pathway makes SUMOtherapeutics particularly interesting as adjuvant therapies for the enhancement of OV efficacy alone and in concert with other immunotherapeutic agents. Accordingly, the authors herein provide: 1) an overview of the SUMO pathway and its role in CNS malignancies; 2) describe the current state of CNS-targeted OVs; and 3) describe the interplay between the SUMO pathway and the viral lifecycle and host immune response.
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Affiliation(s)
- Paramesh V. Karandikar
- T. H. Chan School of Medicine, University of Massachusetts, Worcester, MA, United States
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Lyle Suh
- T. H. Chan School of Medicine, University of Massachusetts, Worcester, MA, United States
| | - Jakob V. E. Gerstl
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Sarah E. Blitz
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Qing Rui Qu
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Sae-Yeon Won
- Department of Neurosurgery, University of Rostock, Rostock, Germany
| | | | - Omar Arnaout
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Timothy R. Smith
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Pier Paolo Peruzzi
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Wei Yang
- Department of Anesthesiology, Multidisciplinary Brain Protection Program, Duke University Medical Center, Durham, NC, United States
| | - Gregory K. Friedman
- Department of Neuro-Oncology, Division of Cancer Medicine, MD Anderson Cancer Center, Houston, TX, United States
| | - Joshua D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, United States
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Wang Q, Xin X, Dai Q, Sun M, Chen J, Mostafavi E, Shen Y, Li X. Medulloblastoma targeted therapy: From signaling pathways heterogeneity and current treatment dilemma to the recent advances in development of therapeutic strategies. Pharmacol Ther 2023; 250:108527. [PMID: 37703952 DOI: 10.1016/j.pharmthera.2023.108527] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/27/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023]
Abstract
Medulloblastoma (MB) is a major pediatric malignant brain tumor that arises in the cerebellum. MB tumors exhibit highly heterogeneous driven by diverse genetic alterations and could be divided into four major subgroups based on their different biological drivers and molecular features (Wnt, Sonic hedgehog (Shh), group 3, and group 4 MB). Even though the therapeutic strategies for each MB subtype integrate their pathogenesis and were developed to focus on their specific target sites, the unexpected drug non-selective cytotoxicity, low drug accumulation in the brain, and complexed MB tumor microenvironment still be huge obstacles to achieving satisfied MB therapeutic efficiency. This review discussed the current advances in modern MB therapeutic strategy development. Through the recent advances in knowledge of the origin, molecular pathogenesis of MB subtypes and their current therapeutic barriers, we particularly reviewed the current development in advanced MB therapeutic strategy committed to overcome MB treatment obstacles, focusing on novel signaling pathway targeted therapeutic agents and their combination discovery, advanced drug delivery systems design, and MB immunotherapy strategy development.
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Affiliation(s)
- Qiyue Wang
- School of Pharmaceutical Science, Nanjing Tech University, Nanjing 211816, China
| | - Xiaofei Xin
- Center for Research Development and Evaluation of Pharmaceutical Excipients and Generic Drugs, Department of Pharmaceutics, China Pharmaceutical University, Nanjing 210009, China
| | - Qihao Dai
- School of Pharmaceutical Science, Nanjing Tech University, Nanjing 211816, China
| | - Mengjuan Sun
- Center for Research Development and Evaluation of Pharmaceutical Excipients and Generic Drugs, Department of Pharmaceutics, China Pharmaceutical University, Nanjing 210009, China
| | - Jinhua Chen
- Center for Research Development and Evaluation of Pharmaceutical Excipients and Generic Drugs, Department of Pharmaceutics, China Pharmaceutical University, Nanjing 210009, China
| | - Ebrahim Mostafavi
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Yan Shen
- Center for Research Development and Evaluation of Pharmaceutical Excipients and Generic Drugs, Department of Pharmaceutics, China Pharmaceutical University, Nanjing 210009, China.
| | - Xueming Li
- School of Pharmaceutical Science, Nanjing Tech University, Nanjing 211816, China.
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Hervás-Corpión I, Alonso MM. Oncolytic viruses as treatment for adult and pediatric high-grade gliomas: On the way to clinical success. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2023; 379:169-188. [PMID: 37541723 DOI: 10.1016/bs.ircmb.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
High-grade gliomas (HGGs) are the most common and aggressive primary brain tumors in both adult and pediatric populations. Despite the multimodal treatment modality currently available for HGG, the prognosis is dismal, with a low overall survival rate at two years after diagnosis. In the last decade, oncolytic virotherapy has emerged as a promising and feasible therapeutic tool in management of these tumors due to its oncolytic and immunostimulatory properties. Various oncolytic viruses, such as herpes simplex virus, adenovirus, poliovirus, reovirus, parvovirus and others, have been evaluated in the early stages of the clinical setting with regard to improving the outcome of patients with HGG. In this review, we summarize completed and ongoing clinical trials of oncolytic virotherapy for adult and pediatric malignant gliomas in terms of safety and efficacy, followed by a brief discussion about the current status and future directions of this therapy in the brain tumor field.
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Affiliation(s)
- Irati Hervás-Corpión
- Health Research Institute of Navarra (IdiSNA), Pamplona, Navarra, Spain; Solid Tumor Program, Center for the Applied Medical Research (CIMA), Pamplona, Navarra, Spain; Department of Pediatrics, Clínica Universidad de Navarra (CUN), Pamplona, Navarra, Spain.
| | - Marta M Alonso
- Health Research Institute of Navarra (IdiSNA), Pamplona, Navarra, Spain; Solid Tumor Program, Center for the Applied Medical Research (CIMA), Pamplona, Navarra, Spain; Department of Pediatrics, Clínica Universidad de Navarra (CUN), Pamplona, Navarra, Spain.
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Fudaba H, Wakimoto H. Oncolytic virus therapy for malignant gliomas: entering the new era. Expert Opin Biol Ther 2023; 23:269-282. [PMID: 36809883 DOI: 10.1080/14712598.2023.2184256] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION To overcome the challenge of treating malignant brain tumors, oncolytic viruses (OVs) represent an innovative therapeutic approach, featuring unique mechanisms of action. The recent conditional approval of the oncolytic herpes simplex virus G47Δ as a therapeutic for malignant brain tumors marked a significant milestone in the long history of OV development in neuro-oncology. AREAS COVERED This review summarizes the results of recently completed and active clinical studies that investigate the safety and efficacy of different OV types in patients with malignant gliomas. The changing landscape of the OV trial design includes expansion of subjects to newly diagnosed tumors and pediatric populations. A variety of delivery methods and new routes of administration are vigorously tested to optimize tumor infection and overall efficacy. New therapeutic strategies such as combination with immunotherapies are proposed that take advantage of the characteristics of OV therapy as an immunotherapy. Preclinical studies of OV have been active and aim to translate new OV strategies to the clinic. EXPERT OPINION For the next decade, clinical trials and preclinical and translational research will continue to drive the development of innovative OV treatments for malignant gliomas and benefit patients and define new OV biomarkers.
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Affiliation(s)
- Hirotaka Fudaba
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Department of Neurosurgery, Oita University Faculty of Medicine, Yufu, Japan
| | - Hiroaki Wakimoto
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Fierro Pineda JC, Wedekind MF, Glod JW. Immunotherapy approaches for rare pediatric solid tumors: advances and future directions. Curr Opin Pediatr 2023; 35:63-74. [PMID: 36420774 DOI: 10.1097/mop.0000000000001206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Immunotherapy for pediatric tumors is rapidly evolving. From major successes in pediatric hematologic malignancies, immunotherapy utility increased in the pediatric solid tumor landscape. Numerous pediatric solid tumors are defined as rare with limitations in diagnosis and treatment. This review will describe four major immunotherapies used in pediatrics and discuss results seen in rare pediatric tumors. We will also briefly review the challenges of immunotherapy in solid tumors and opportunities to drive this therapy forward. RECENT FINDINGS Despite rare success employing immunotherapy for pediatric solid tumors, recently there have been several successes in pediatric rare solid tumors. After describing the evolving landscape of rare pediatric tumors, we will demonstrate the successes or disappointments of immunotherapy. We will describe the mechanism of four immunotherapies used in the pediatrics, followed by the published results. Finally, we will discuss the challenges and opportunities for immunotherapies in pediatric rare tumors. SUMMARY Pediatric rare tumors are lacking in treatment options. Despite numerous disappointments utilizing immunotherapies in the more common pediatric solid tumors, there have been several successes within the pediatric rare tumor landscape. Much work is still needed to enhance our understanding and knowledge on utilizing these immunotherapies for pediatric rare solid tumors.
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Affiliation(s)
- Juan C Fierro Pineda
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health
- Division of Pediatric Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mary Frances Wedekind
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health
| | - John W Glod
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health
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Intraventricular immunovirotherapy; a translational step forward. Oncotarget 2023; 14:40-43. [PMID: 36634220 PMCID: PMC9836381 DOI: 10.18632/oncotarget.28343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Oncolytic virotherapy with intratumoral engineered type-1 herpes simplex virus (HSV) has been proven safe with promising efficacy in recent clinical trials for treatment of both pediatric and adult high-grade glioma. However, this approach excludes patients with tumors in surgically inaccessible and/or eloquent brain regions. Current delivery methods are also unable to access/treat those patients with metastatic disease in the spinal cord and/or leptomeningeal disease. A recent preclinical study has paved the way for clinical translation of intraventricular administration of oHSV by identifying and mitigating the toxicity associated with this route for therapeutic benefit in murine models of disseminated medulloblastoma. This work may ultimately allow for targeting of intractable disease and provides a feasible option for the repetitive dosing of clinically relevant immunovirotherapy, G207.
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Raghu ALB, Chen JA, Valdes PA, Essayed WI, Claus E, Arnaout O, Smith TR, Chiocca EA, Peruzzi PP, Bernstock JD. Cerebellar High-Grade Glioma: A Translationally Oriented Review of the Literature. Cancers (Basel) 2022; 15:174. [PMID: 36612169 PMCID: PMC9818238 DOI: 10.3390/cancers15010174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/23/2022] [Accepted: 12/26/2022] [Indexed: 12/29/2022] Open
Abstract
World Health Organization (WHO) grade 4 gliomas of the cerebellum are rare entities whose understanding trails that of their supratentorial counterparts. Like supratentorial high-grade gliomas (sHGG), cerebellar high-grade gliomas (cHGG) preferentially affect males and prognosis is bleak; however, they are more common in a younger population. While current therapy for cerebellar and supratentorial HGG is the same, recent molecular analyses have identified features and subclasses of cerebellar tumors that may merit individualized targeting. One recent series of cHGG included the subclasses of (1) high-grade astrocytoma with piloid features (HGAP, ~31% of tumors); (2) H3K27M diffuse midline glioma (~8%); and (3) isocitrate dehydrogenase (IDH) wildtype glioblastoma (~43%). The latter had an unusually low-frequency of epidermal growth factor receptor (EGFR) and high-frequency of platelet-derived growth factor receptor alpha (PDGFRA) amplification, reflecting a different composition of methylation classes compared to supratentorial IDH-wildtype tumors. These new classifications have begun to reveal insights into the pathogenesis of HGG in the cerebellum and lead toward individualized treatment targeted toward the appropriate subclass of cHGG. Emerging therapeutic strategies include targeting the mitogen-activated protein kinases (MAPK) pathway and PDGFRA, oncolytic virotherapy, and immunotherapy. HGGs of the cerebellum exhibit biological differences compared to sHGG, and improved understanding of their molecular subclasses has the potential to advance treatment.
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Affiliation(s)
- Ashley L. B. Raghu
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Oxford Functional Neurosurgery Group, Nuffield Departments of Surgical Sciences, University of Oxford, Oxford OX3 9DU, UK
| | - Jason A. Chen
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Pablo A. Valdes
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Walid Ibn Essayed
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Elizabeth Claus
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Omar Arnaout
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Timothy R. Smith
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - E. Antonio Chiocca
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Pier Paolo Peruzzi
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Joshua D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
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11
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Kang KD, Bernstock JD, Totsch SK, Gary SE, Rocco A, Nan L, Li R, Etminan T, Han X, Beierle EA, Eisemann T, Wechsler-Reya RJ, Bae S, Whitley R, Yancey Gillespie G, Markert JM, Friedman GK. Safety and Efficacy of Intraventricular Immunovirotherapy with Oncolytic HSV-1 for CNS Cancers. Clin Cancer Res 2022; 28:5419-5430. [PMID: 36239623 PMCID: PMC9771977 DOI: 10.1158/1078-0432.ccr-22-1382] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/12/2022] [Accepted: 10/12/2022] [Indexed: 01/24/2023]
Abstract
PURPOSE Oncolytic virotherapy with herpes simplex virus-1 (HSV) has shown promise for the treatment of pediatric and adult brain tumors; however, completed and ongoing clinical trials have utilized intratumoral/peritumoral oncolytic HSV (oHSV) inoculation due to intraventricular/intrathecal toxicity concerns. Intratumoral delivery requires an invasive neurosurgical procedure, limits repeat injections, and precludes direct targeting of metastatic and leptomeningeal disease. To address these limitations, we determined causes of toxicity from intraventricular oHSV and established methods for mitigating toxicity to treat disseminated brain tumors in mice. EXPERIMENTAL DESIGN HSV-sensitive CBA/J mice received intraventricular vehicle, inactivated oHSV, or treatment doses (1×107 plaque-forming units) of oHSV, and toxicity was assessed by weight loss and IHC. Protective strategies to reduce oHSV toxicity, including intraventricular low-dose oHSV or interferon inducer polyinosinic-polycytidylic acid (poly I:C) prior to oHSV treatment dose, were evaluated and then utilized to assess intraventricular oHSV treatment of multiple models of disseminated CNS disease. RESULTS A standard treatment dose of intraventricular oHSV damaged ependymal cells via virus replication and induction of CD8+ T cells, whereas vehicle or inactivated virus resulted in no toxicity. Subsequent doses of intraventricular oHSV caused little additional toxicity. Interferon induction with phosphorylation of eukaryotic initiation factor-2α (eIF2α) via intraventricular pretreatment with low-dose oHSV or poly I:C mitigated ependyma toxicity. This approach enabled the safe delivery of multiple treatment doses of clinically relevant oHSV G207 and prolonged survival in disseminated brain tumor models. CONCLUSIONS Toxicity from intraventricular oHSV can be mitigated, resulting in therapeutic benefit. These data support the clinical translation of intraventricular G207.
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Affiliation(s)
- Kyung-Don Kang
- Department of Pediatrics, Division of Pediatric Hematology
and Oncology, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Joshua D. Bernstock
- Department of Pediatrics, Division of Pediatric Hematology
and Oncology, University of Alabama at Birmingham; Birmingham, AL, USA,Department of Neurosurgery, Brigham and Women’s
Hospital, Harvard University; Boston, MA, USA,Corresponding authors: Joshua D.
Bernstock MD, PhD, MPH, Department of Neurosurgery
- Harvard Medical School,
Brigham and Women’s Hospital
- Boston Children’s Hospital, Hale
Building
- 60 Fenwood Road
- Boston, MA 02115, USA, P: 914.419.7749
- F:
617.713.3050
- ; Gregory K. Friedman,
MD, Department of Pediatrics, University of Alabama at Birmingham, 1600 7th Ave
S, Lowder 512, Birmingham, AL 35233, USA, P: 205.638.9285
- F: 205.975.1941
| | - Stacie K. Totsch
- Department of Pediatrics, Division of Pediatric Hematology
and Oncology, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Sam E. Gary
- Department of Pediatrics, Division of Pediatric Hematology
and Oncology, University of Alabama at Birmingham; Birmingham, AL, USA,Medical Scientist Training Program, University of Alabama
at Birmingham, Birmingham, AL, USA
| | - Abbey Rocco
- Department of Pediatrics, Division of Pediatric Hematology
and Oncology, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Li Nan
- Department of Pediatrics, Division of Pediatric Hematology
and Oncology, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Rong Li
- Department of Pathology, Children’s of Alabama;
Birmingham, AL, USA
| | - Tina Etminan
- Department of Pediatrics, Division of Pediatric Hematology
and Oncology, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Xiaosi Han
- Department of Neurology, Division of Neuro-Oncology,
University of Alabama at Birmingham; Birmingham, AL, USA
| | | | - Tanja Eisemann
- Sanford Burnham Prebys Medical Discovery Institute; La
Jolla, CA, USA
| | | | - Sejong Bae
- Department of Medicine, Division of Preventative Medicine,
University of Alabama at Birmingham; Birmingham, AL, USA
| | - Richard Whitley
- Department of Pediatrics, Division of Infectious Diseases,
University of Alabama at Birmingham; Birmingham, AL, USA
| | - G. Yancey Gillespie
- Department of Neurosurgery, University of Alabama at
Birmingham; Birmingham, AL, USA
| | - James M. Markert
- Department of Neurosurgery, University of Alabama at
Birmingham; Birmingham, AL, USA
| | - Gregory K. Friedman
- Department of Pediatrics, Division of Pediatric Hematology
and Oncology, University of Alabama at Birmingham; Birmingham, AL, USA,Department of Neurosurgery, University of Alabama at
Birmingham; Birmingham, AL, USA,Corresponding authors: Joshua D.
Bernstock MD, PhD, MPH, Department of Neurosurgery
- Harvard Medical School,
Brigham and Women’s Hospital
- Boston Children’s Hospital, Hale
Building
- 60 Fenwood Road
- Boston, MA 02115, USA, P: 914.419.7749
- F:
617.713.3050
- ; Gregory K. Friedman,
MD, Department of Pediatrics, University of Alabama at Birmingham, 1600 7th Ave
S, Lowder 512, Birmingham, AL 35233, USA, P: 205.638.9285
- F: 205.975.1941
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12
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Wang X, Maeng HM, Lee J, Xie C. Therapeutic Implementation of Oncolytic Viruses for Cancer Immunotherapy: Review of Challenges and Current Clinical Trials. JOURNAL OF BIOMEDICAL SCIENCE AND RESEARCH 2022; 4:164. [PMID: 36381110 PMCID: PMC9647850 DOI: 10.36266/jbsr/164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The development of cancer therapeutics has evolved from general targets with radiation and chemotherapy and shifted toward treatments with a more specific mechanism of action such as small molecule kinase inhibitors, monoclonal antibodies against tumor antigens, or checkpoint inhibitors. Recently, oncolytic viruses (OVs) have come to the forefront as a viable option for cancer immunotherapy, especially for "cold" tumors, which are known to inhabit an immunologically suppressive tumor microenvironment. Desired characteristics of viruses are selected through genetic attenuation of uncontrolled virulence, and some genes are replaced with ones that enhance conditional viral replication within tumor cells. Treatment with OVs must overcome various hurdles such as premature viral suppression by the host's immune system and the dense stromal barrier. Currently, clinical studies investigate the efficacy of OVs in conjunction with various anti-cancer therapeutics, including radiotherapy, chemotherapy, immune checkpoint inhibitors, and monoclonal antibodies. Thus, future research should explore how cancer therapeutics work synergistically with certain OVs in order to create more effective combination therapies and improve patient outcomes.
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Affiliation(s)
- X Wang
- Thoracic and GI Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20814, USA
| | - H M Maeng
- Vaccine Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20814, USA
| | - J Lee
- Thoracic and GI Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20814, USA
| | - C Xie
- Thoracic and GI Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20814, USA
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13
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Bernstock JD, Hoffman SE, Kappel AD, Valdes PA, Essayed WI, Klinger NV, Kang KD, Totsch SK, Olsen HE, Schlappi CW, Filipski K, Gessler FA, Baird L, Filbin MG, Hashizume R, Becher OJ, Friedman GK. Immunotherapy approaches for the treatment of diffuse midline gliomas. Oncoimmunology 2022; 11:2124058. [PMID: 36185807 PMCID: PMC9519005 DOI: 10.1080/2162402x.2022.2124058] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Diffuse midline gliomas (DMG) are a highly aggressive and universally fatal subgroup of pediatric tumors responsible for the majority of childhood brain tumor deaths. Median overall survival is less than 12 months with a 90% mortality rate at 2 years from diagnosis. Research into the underlying tumor biology and numerous clinical trials have done little to change the invariably poor prognosis. Continued development of novel, efficacious therapeutic options for DMGs remains a critically important area of active investigation. Given that DMGs are not amenable to surgical resection, have only limited response to radiation, and are refractory to traditional chemotherapy, immunotherapy has emerged as a promising alternative treatment modality. This review summarizes the various immunotherapy-based treatments for DMG as well as their specific limitations. We explore the use of cell-based therapies, oncolytic virotherapy or immunovirotherapy, immune checkpoint inhibition, and immunomodulatory vaccination strategies, and highlight the recent clinical success of anti-GD2 CAR-T therapy in diffuse intrinsic pontine glioma (DIPG) patients. Finally, we address the challenges faced in translating preclinical and early phase clinical trial data into effective standardized treatment for DMG patients.
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Affiliation(s)
- Joshua D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA,David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA,CONTACT Joshua D. Bernstock Department of Neurosurgery, Harvard Medical School, Brigham and Women’s Hospital, Boston Children’s Hospital, Hale Building, 60 Fenwood Road, Boston, MA02115, USA
| | - Samantha E. Hoffman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Children’s Hospital Cancer Center, Boston, MA, USA
| | - Ari D. Kappel
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Pablo A. Valdes
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Walid Ibn Essayed
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Neil V. Klinger
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Kyung-Don Kang
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stacie K. Totsch
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hannah E. Olsen
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Charles W. Schlappi
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Children’s Hospital Cancer Center, Boston, MA, USA
| | - Katharina Filipski
- Neurological Institute (Edinger Institute), University Hospital, Frankfurt Am Main, Germany,German Cancer Consortium (DKTK), Germany and German Cancer Research Center (DFKZ), Heidelberg, Germany,Frankfurt Cancer Institute (FCI), Frankfurt, Germany,University Cancer Center (UCT), Frankfurt, Germany
| | - Florian A. Gessler
- Department of Neurosurgery, University Medicine Rostock, Rostock, Germany
| | - Lissa Baird
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Mariella G. Filbin
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Children’s Hospital Cancer Center, Boston, MA, USA
| | - Rintaro Hashizume
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Oren J. Becher
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, the Mount Sinai Hospital, NY, NY, USA
| | - Gregory K. Friedman
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA,Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA,Gregory K. Friedman Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham, 1600 7th Avenue South, Lowder 512, Birmingham, AL35233, USA
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14
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Ghajar-Rahimi G, Kang KD, Totsch SK, Gary S, Rocco A, Blitz S, Kachurak K, Chambers MR, Li R, Beierle EA, Bag A, Johnston JM, Markert JM, Bernstock JD, Friedman GK. Clinical advances in oncolytic virotherapy for pediatric brain tumors. Pharmacol Ther 2022; 239:108193. [PMID: 35487285 DOI: 10.1016/j.pharmthera.2022.108193] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/10/2022] [Accepted: 04/21/2022] [Indexed: 10/18/2022]
Abstract
Malignant brain tumors constitute nearly one-third of cancer diagnoses in children and have recently surpassed hematologic malignancies as the most lethal neoplasm in the pediatric population. Outcomes for children with brain tumors are unacceptably poor and current standards of care-surgical resection, chemotherapy, and radiation-are associated with significant long-term morbidity. Oncolytic virotherapy has emerged as a promising immunotherapy for the treatment of brain tumors. While the majority of brain tumor clinical trials utilizing oncolytic virotherapy have been in adults, five viruses are being tested in pediatric brain tumor clinical trials: herpes simplex virus (G207), reovirus (pelareorep/Reolysin), measles virus (MV-NIS), poliovirus (PVSRIPO), and adenovirus (DNX-2401, AloCELYVIR). Herein, we review past and current pediatric immunovirotherapy brain tumor trials including the relevant preclinical and clinical research that contributed to their development. We describe mechanisms by which the viruses may overcome barriers in treating pediatric brain tumors, examine challenges associated with achieving effective, durable responses, highlight unique aspects and successes of the trials, and discuss future directions of immunovirotherapy research for the treatment of pediatric brain tumors.
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Affiliation(s)
- Gelare Ghajar-Rahimi
- Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kyung-Don Kang
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stacie K Totsch
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sam Gary
- Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Abbey Rocco
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Kara Kachurak
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - M R Chambers
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rong Li
- Department of Pathology, University of Alabama at Birmingham, and Children's of Alabama, Birmingham, AL, USA
| | - Elizabeth A Beierle
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Asim Bag
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - James M Johnston
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James M Markert
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital and Boston Children's Hospital, Harvard University, Boston, MA, USA.
| | - Gregory K Friedman
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA.
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15
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Otani Y, Yoo JY, Shimizu T, Kurozumi K, Date I, Kaur B. Implications of immune cells in oncolytic herpes simplex virotherapy for glioma. Brain Tumor Pathol 2022; 39:57-64. [PMID: 35384530 DOI: 10.1007/s10014-022-00431-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/27/2022] [Indexed: 12/13/2022]
Abstract
Despite current progress in treatment, glioblastoma (GBM) remains a lethal primary malignant tumor of the central nervous system. Although immunotherapy has recently achieved remarkable survival effectiveness in multiple malignancies, none of the immune checkpoint inhibitors (ICIs) for GBM have shown anti-tumor efficacy in clinical trials. GBM has a characteristic immunosuppressive tumor microenvironment (TME) that results in the failure of ICIs. Oncolytic herpes simplex virotherapy (oHSV) is the most advanced United States Food and Drug Administration-approved virotherapy for advanced metastatic melanoma patients. Recently, another oHSV, Delytact®, was granted conditional approval in Japan against GBM, highlighting it as a promising treatment. Since oncolytic virotherapy can recruit abundant immune cells and modify the immune TME, oncolytic virotherapy for immunologically cold GBM will be an attractive therapeutic option for GBM. However, as these immune cells have roles in both anti-tumor and anti-viral immunity, fine-tuning of the TME using oncolytic virotherapy will be important to maximize the therapeutic efficacy. In this review, we discuss the current knowledge of oHSV, with a focus on the role of immune cells as friend or foe in oncolytic virotherapy.
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Affiliation(s)
- Yoshihiro Otani
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
| | - Ji Young Yoo
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St., Houston, TX, 77030, USA
| | - Toshihiko Shimizu
- Department of Neurosurgery, Matsuyama Shimin Hospital, 2-6-5 Otemachi, Matsuyama, Ehime, 790-0067, Japan
| | - Kazuhiko Kurozumi
- Department of Neurosurgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Isao Date
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Balveen Kaur
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St., Houston, TX, 77030, USA
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16
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Jahan N, Ghouse SM, Martuza RL, Rabkin SD. In Situ Cancer Vaccination and Immunovirotherapy Using Oncolytic HSV. Viruses 2021; 13:v13091740. [PMID: 34578321 PMCID: PMC8473045 DOI: 10.3390/v13091740] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 12/13/2022] Open
Abstract
Herpes simplex virus (HSV) can be genetically altered to acquire oncolytic properties so that oncolytic HSV (oHSV) preferentially replicates in and kills cancer cells, while sparing normal cells, and inducing anti-tumor immune responses. Over the last three decades, a better understanding of HSV genes and functions, and improved genetic-engineering techniques led to the development of oHSV as a novel immunovirotherapy. The concept of in situ cancer vaccination (ISCV) was first introduced when oHSV was found to induce a specific systemic anti-tumor immune response with an abscopal effect on non-injected tumors, in the process of directly killing tumor cells. Thus, the use of oHSV for tumor vaccination in situ is antigen-agnostic. The research and development of oHSVs have moved rapidly, with the field of oncolytic viruses invigorated by the FDA/EMA approval of oHSV talimogene laherparepvec in 2015 for the treatment of advanced melanoma. Immunovirotherapy can be enhanced by arming oHSV with immunomodulatory transgenes and/or using them in combination with other chemotherapeutic and immunotherapeutic agents. This review offers an overview of the development of oHSV as an agent for ISCV against solid tumors, describing the multitude of different oHSVs and their efficacy in immunocompetent mouse models and in clinical trials.
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Affiliation(s)
- Nusrat Jahan
- Molecular Neurosurgery Laboratory and Brain Tumor Research Center, Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (N.J.); (S.M.G.); (R.L.M.)
| | - Shanawaz M. Ghouse
- Molecular Neurosurgery Laboratory and Brain Tumor Research Center, Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (N.J.); (S.M.G.); (R.L.M.)
| | - Robert L. Martuza
- Molecular Neurosurgery Laboratory and Brain Tumor Research Center, Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (N.J.); (S.M.G.); (R.L.M.)
| | - Samuel D. Rabkin
- Department of Neurosurgery, Massachusetts General Hospital, 185 Cambridge St., CPZN-3800, Boston, MA 02114, USA
- Correspondence:
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17
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The Effect of Herpes Simplex Virus-Type-1 (HSV-1) Oncolytic Immunotherapy on the Tumor Microenvironment. Viruses 2021; 13:v13071200. [PMID: 34206677 PMCID: PMC8310320 DOI: 10.3390/v13071200] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/11/2021] [Accepted: 06/16/2021] [Indexed: 12/19/2022] Open
Abstract
The development of cancer causes disruption of anti-tumor immunity required for surveillance and elimination of tumor cells. Immunotherapeutic strategies aim for the restoration or establishment of these anti-tumor immune responses. Cancer immunotherapies include immune checkpoint inhibitors (ICIs), adoptive cellular therapy (ACT), cancer vaccines, and oncolytic virotherapy (OVT). The clinical success of some of these immunotherapeutic modalities, including herpes simplex virus type-1 derived OVT, resulted in Food and Drug Administration (FDA) approval for use in treatment of human cancers. However, a significant proportion of patients do not respond or benefit equally from these immunotherapies. The creation of an immunosuppressive tumor microenvironment (TME) represents an important barrier preventing success of many immunotherapeutic approaches. Mechanisms of immunosuppression in the TME are a major area of current research. In this review, we discuss how oncolytic HSV affects the tumor microenvironment to promote anti-tumor immune responses. Where possible we focus on oncolytic HSV strains for which clinical data is available, and discuss how these viruses alter the vasculature, extracellular matrix and immune responses in the tumor microenvironment.
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18
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Bernstock JD, Hoffman SE, Chen JA, Gupta S, Kappel AD, Smith TR, Chiocca EA. The Current Landscape of Oncolytic Herpes Simplex Viruses as Novel Therapies for Brain Malignancies. Viruses 2021; 13:v13061158. [PMID: 34204248 PMCID: PMC8234451 DOI: 10.3390/v13061158] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/09/2021] [Accepted: 06/12/2021] [Indexed: 01/02/2023] Open
Abstract
Despite advances in surgical resection and chemoradiation, high-grade brain tumors continue to be associated with significant morbidity/mortality. Novel therapeutic strategies and approaches are, therefore, desperately needed for patients and their families. Given the success experienced in treating multiple other forms of cancer, immunotherapy and, in particular, immunovirotherapy are at the forefront amongst novel therapeutic strategies that are currently under investigation for incurable brain tumors. Accordingly, herein, we provide a focused mini review of pertinent oncolytic herpes viruses (oHSV) that are being investigated in clinical trials.
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Affiliation(s)
- Joshua D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (J.D.B.); (S.E.H.); (J.A.C.); (S.G.); (A.D.K.); (T.R.S.)
| | - Samantha E. Hoffman
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (J.D.B.); (S.E.H.); (J.A.C.); (S.G.); (A.D.K.); (T.R.S.)
- Harvard-MIT MD-PhD Program, Harvard Medical School, Boston, MA 02115, USA
| | - Jason A. Chen
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (J.D.B.); (S.E.H.); (J.A.C.); (S.G.); (A.D.K.); (T.R.S.)
| | - Saksham Gupta
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (J.D.B.); (S.E.H.); (J.A.C.); (S.G.); (A.D.K.); (T.R.S.)
| | - Ari D. Kappel
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (J.D.B.); (S.E.H.); (J.A.C.); (S.G.); (A.D.K.); (T.R.S.)
| | - Timothy R. Smith
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (J.D.B.); (S.E.H.); (J.A.C.); (S.G.); (A.D.K.); (T.R.S.)
- Computational Neuroscience Outcomes Center, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - E. Antonio Chiocca
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (J.D.B.); (S.E.H.); (J.A.C.); (S.G.); (A.D.K.); (T.R.S.)
- Correspondence:
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19
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Quintarelli C, Camera A, Ciccone R, Alessi I, Del Bufalo F, Carai A, Del Baldo G, Mastronuzzi A, De Angelis B. Innovative and Promising Strategies to Enhance Effectiveness of Immunotherapy for CNS Tumors: Where Are We? Front Immunol 2021; 12:634031. [PMID: 34163465 PMCID: PMC8216238 DOI: 10.3389/fimmu.2021.634031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 04/30/2021] [Indexed: 12/12/2022] Open
Abstract
Although there are several immunotherapy approaches for the treatment of Central Nervous System (CNS) tumors under evaluation, currently none of these approaches have received approval from the regulatory agencies. CNS tumors, especially glioblastomas, are tumors characterized by highly immunosuppressive tumor microenvironment, limiting the possibility of effectively eliciting an immune response. Moreover, the peculiar anatomic location of these tumors poses relevant challenges in terms of safety, since uncontrolled hyper inflammation could lead to cerebral edema and cranial hypertension. The most promising strategies of immunotherapy in neuro-oncology consist of the use of autologous T cells redirected against tumor cells through chimeric antigen receptor (CAR) constructs or genetically modified T-cell receptors. Trials based on native or genetically engineered oncolytic viruses and on vaccination with tumor-associated antigen peptides are also under evaluation. Despite some sporadic complete remissions achieved in clinical trials, the outcome of patients with CNS tumors treated with different immunotherapeutic approaches remains poor. Based on the lessons learned from these unsatisfactory experiences, novel immune-therapy approaches aimed at overcoming the profound immunosuppressive microenvironment of these diseases are bringing new hope to reach the cure for CNS tumors.
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Affiliation(s)
- Concetta Quintarelli
- Department Onco-Hematology, Cell and Gene Therapy, IRCCS, Bambino Gesù Children's Hospital, Rome, Italy.,Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Antonio Camera
- Department Onco-Hematology, Cell and Gene Therapy, IRCCS, Bambino Gesù Children's Hospital, Rome, Italy
| | - Roselia Ciccone
- Department Onco-Hematology, Cell and Gene Therapy, IRCCS, Bambino Gesù Children's Hospital, Rome, Italy
| | - Iside Alessi
- Department Onco-Hematology, Cell and Gene Therapy, IRCCS, Bambino Gesù Children's Hospital, Rome, Italy
| | - Francesca Del Bufalo
- Department Onco-Hematology, Cell and Gene Therapy, IRCCS, Bambino Gesù Children's Hospital, Rome, Italy
| | - Andrea Carai
- Neurosurgery Unit, Department of Neurological and Psychiatric Sciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Giada Del Baldo
- Department Onco-Hematology, Cell and Gene Therapy, IRCCS, Bambino Gesù Children's Hospital, Rome, Italy
| | - Angela Mastronuzzi
- Department Onco-Hematology, Cell and Gene Therapy, IRCCS, Bambino Gesù Children's Hospital, Rome, Italy
| | - Biagio De Angelis
- Department Onco-Hematology, Cell and Gene Therapy, IRCCS, Bambino Gesù Children's Hospital, Rome, Italy
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20
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Ross JL, Vega JV, Plant A, MacDonald TJ, Becher OJ, Hambardzumyan D. Tumor immune landscape of paediatric high-grade gliomas. Brain 2021; 144:2594-2609. [PMID: 33856022 DOI: 10.1093/brain/awab155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/11/2021] [Accepted: 04/02/2021] [Indexed: 11/13/2022] Open
Abstract
Over the last decade, remarkable progress has been made towards elucidating the origin and genomic landscape of childhood high-grade brain tumors. It has become evident that pediatric high-grade gliomas (pHGGs) differ from adult HGGs with respect to multiple defining aspects including: DNA copy number, gene expression profiles, tumor locations within the central nervous system, and genetic alterations such as somatic histone mutations. Despite these advances, clinical trials for children with glioma have historically been based on ineffective adult regimens that fail to take into consideration the fundamental biological differences between the two. Additionally, although our knowledge of the intrinsic cellular mechanisms driving tumor progression has considerably expanded, little is known concerning the dynamic tumor immune microenvironment (TIME) in pHGGs. In this review, we explore the genetic and epigenetic landscape of pHGGs and how this drives the creation of specific tumor sub-groups with meaningful survival outcomes. Further, we provide a comprehensive analysis of the pHGG TIME and discuss emerging therapeutic efforts aimed at exploiting the immune functions of these tumors.
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Affiliation(s)
- James L Ross
- Department of Microbiology and Immunology, Emory Vaccine Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jose Velazquez Vega
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ashley Plant
- Division of Hematology, Oncology and Stem Cell Transplant, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Tobey J MacDonald
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Oren J Becher
- Division of Hematology, Oncology and Stem Cell Transplant, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Dolores Hambardzumyan
- Department of Oncological Sciences, The Tisch Cancer Institute, Mount Sinai Icahn School of Medicine, New York, New York, USA.,Department of Neurosurgery, Mount Sinai Icahn School of Medicine, New York, New York, USA
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21
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Nguyen HM, Saha D. The Current State of Oncolytic Herpes Simplex Virus for Glioblastoma Treatment. Oncolytic Virother 2021; 10:1-27. [PMID: 33659221 PMCID: PMC7917312 DOI: 10.2147/ov.s268426] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 01/18/2021] [Indexed: 12/12/2022] Open
Abstract
Glioblastoma (GBM) is a lethal primary malignant brain tumor with no current effective treatments. The recent emergence of immuno-virotherapy and FDA approval of T-VEC have generated a great expectation towards oncolytic herpes simplex viruses (oHSVs) as a promising treatment option for GBM. Since the generation and testing of the first genetically engineered oHSV in glioma in the early 1990s, oHSV-based therapies have shown a long way of great progress in terms of anti-GBM efficacy and safety, both preclinically and clinically. Here, we revisit the literature to understand the recent advancement of oHSV in the treatment of GBM. In addition, we discuss current obstacles to oHSV-based therapies and possible strategies to overcome these pitfalls.
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Affiliation(s)
- Hong-My Nguyen
- Department of Immunotherapeutics and Biotechnology, Texas Tech University Health Sciences Center, School of Pharmacy, Abilene, TX, 79601, USA
| | - Dipongkor Saha
- Department of Immunotherapeutics and Biotechnology, Texas Tech University Health Sciences Center, School of Pharmacy, Abilene, TX, 79601, USA
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22
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Estevez-Ordonez D, Chagoya G, Salehani A, Atchley TJ, Laskay NMB, Parr MS, Elsayed GA, Mahavadi AK, Rahm SP, Friedman GK, Markert JM. Immunovirotherapy for the Treatment of Glioblastoma and Other Malignant Gliomas. Neurosurg Clin N Am 2021; 32:265-281. [PMID: 33781507 DOI: 10.1016/j.nec.2020.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Glioblastoma multiforme (GBM) represents one of the most challenging malignancies due to many factors including invasiveness, heterogeneity, and an immunosuppressive microenvironment. Current treatment modalities have resulted in only modest effect on outcomes. The development of viral vectors for oncolytic immunovirotherapy and targeted drug delivery represents a promising therapeutic prospect for GBM and other brain tumors. A host of genetically engineered viruses, herpes simplex virus, poliovirus, measles, and others, have been described and are at various stages of clinical development. Herein we provide a review of the advances and current state of oncolytic virotherapy for the targeted treatment of GBM and malignant gliomas.
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Affiliation(s)
- Dagoberto Estevez-Ordonez
- Department of Neurosurgery, The University of Alabama at Birmingham, 1060 Faculty Office Tower 510 20th Street South, Birmingham, AL, USA
| | - Gustavo Chagoya
- Department of Neurosurgery, The University of Alabama at Birmingham, 1060 Faculty Office Tower 510 20th Street South, Birmingham, AL, USA
| | - Arsalaan Salehani
- Department of Neurosurgery, The University of Alabama at Birmingham, 1060 Faculty Office Tower 510 20th Street South, Birmingham, AL, USA
| | - Travis J Atchley
- Department of Neurosurgery, The University of Alabama at Birmingham, 1060 Faculty Office Tower 510 20th Street South, Birmingham, AL, USA
| | - Nicholas M B Laskay
- Department of Neurosurgery, The University of Alabama at Birmingham, 1060 Faculty Office Tower 510 20th Street South, Birmingham, AL, USA
| | - Matthew S Parr
- Department of Neurosurgery, The University of Alabama at Birmingham, 1060 Faculty Office Tower 510 20th Street South, Birmingham, AL, USA
| | - Galal A Elsayed
- Department of Neurosurgery, The University of Alabama at Birmingham, 1060 Faculty Office Tower 510 20th Street South, Birmingham, AL, USA
| | - Anil K Mahavadi
- Department of Neurosurgery, The University of Alabama at Birmingham, 1060 Faculty Office Tower 510 20th Street South, Birmingham, AL, USA
| | - Sage P Rahm
- Department of Neurosurgery, The University of Alabama at Birmingham, 1060 Faculty Office Tower 510 20th Street South, Birmingham, AL, USA
| | - Gregory K Friedman
- Department of Neurosurgery, The University of Alabama at Birmingham, 1060 Faculty Office Tower 510 20th Street South, Birmingham, AL, USA; Department of Pediatrics, Division of Pediatric Hematology-Oncology, The University of Alabama at Birmingham
| | - James M Markert
- Department of Neurosurgery, Neurosurgery, Pediatrics, and Cell, Developmental and Integrative Biology, The University of Alabama at Birmingham, 1060 Faculty Office Tower 510 20th Street South, Birmingham, AL, USA.
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23
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Jin KT, Du WL, Liu YY, Lan HR, Si JX, Mou XZ. Oncolytic Virotherapy in Solid Tumors: The Challenges and Achievements. Cancers (Basel) 2021; 13:cancers13040588. [PMID: 33546172 PMCID: PMC7913179 DOI: 10.3390/cancers13040588] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/26/2021] [Accepted: 01/30/2021] [Indexed: 12/14/2022] Open
Abstract
Oncolytic virotherapy (OVT) is a promising approach in cancer immunotherapy. Oncolytic viruses (OVs) could be applied in cancer immunotherapy without in-depth knowledge of tumor antigens. The capability of genetic modification makes OVs exciting therapeutic tools with a high potential for manipulation. Improving efficacy, employing immunostimulatory elements, changing the immunosuppressive tumor microenvironment (TME) to inflammatory TME, optimizing their delivery system, and increasing the safety are the main areas of OVs manipulations. Recently, the reciprocal interaction of OVs and TME has become a hot topic for investigators to enhance the efficacy of OVT with less off-target adverse events. Current investigations suggest that the main application of OVT is to provoke the antitumor immune response in the TME, which synergize the effects of other immunotherapies such as immune-checkpoint blockers and adoptive cell therapy. In this review, we focused on the effects of OVs on the TME and antitumor immune responses. Furthermore, OVT challenges, including its moderate efficiency, safety concerns, and delivery strategies, along with recent achievements to overcome challenges, are thoroughly discussed.
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Affiliation(s)
- Ke-Tao Jin
- Department of Colorectal Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, China; (K.-T.J.); (Y.-Y.L.)
| | - Wen-Lin Du
- Key Laboratory of Gastroenterology of Zhejiang Province, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310014, China;
- Clinical Research Institute, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310014, China
| | - Yu-Yao Liu
- Department of Colorectal Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, China; (K.-T.J.); (Y.-Y.L.)
| | - Huan-Rong Lan
- Department of Breast and Thyroid Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, China;
| | - Jing-Xing Si
- Clinical Research Institute, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310014, China
- Correspondence: (J.-X.S.); (X.-Z.M.); Tel./Fax: +86-571-85893781 (J.-X.S.); +86-571-85893985 (X.-Z.M.)
| | - Xiao-Zhou Mou
- Clinical Research Institute, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310014, China
- Correspondence: (J.-X.S.); (X.-Z.M.); Tel./Fax: +86-571-85893781 (J.-X.S.); +86-571-85893985 (X.-Z.M.)
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24
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Omar NB, Bentley RT, Crossman DK, Foote JB, Koehler JW, Markert JM, Platt SR, Rissi DR, Shores A, Sorjonen D, Yanke AB, Gillespie GY, Chambers MR. Safety and interim survival data after intracranial administration of M032, a genetically engineered oncolytic HSV-1 expressing IL-12, in pet dogs with sporadic gliomas. Neurosurg Focus 2021; 50:E5. [PMID: 33524948 DOI: 10.3171/2020.11.focus20844] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/12/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The diagnosis of glioma remains disheartening in the clinical realm. While a multitude of studies and trials have shown promise, improvements in overall survival have been disappointing. Modeling these tumors in the laboratory setting has become increasingly challenging, given their complex in situ behavior and interactions for therapeutic evasion. Dogs, particularly brachycephalic breeds, are known to spontaneously develop gliomas that resemble human gliomas both clinically and pathophysiologically, making canines with sporadic tumors promising candidates for study. Typically, survival among these dogs is approximately 2 months with palliation alone. METHODS The authors have completed the first stage of a unique phase I dose-escalating canine clinical trial in which the safety and tolerability of M032, a nonneurovirulent oncolytic herpes simplex virus-1 vector genetically engineered to express interleukin-12, are being studied in pet dogs with gliomas undergoing maximum safe tumor resection and inoculation of the cavity with the viral infusate. RESULTS Twenty-five canine patients were enrolled between January 2018 and August 2020. One patient was electively withdrawn from the trial by its owner, and 3 did not receive the virus. For the 21 dogs that remained, 13 had high-grade gliomas, 5 had low-grade gliomas, and 3 were undetermined. According to histopathological analysis, 62% of the tumors were oligodendrogliomas. At the time of this report, the median overall survival from the date of treatment was 151 days (± 78 days). No significant adverse events attributable to M032 or dose-limiting toxicities have been observed to date. CONCLUSIONS In this largest study of oncolytic viral therapy for canine brain tumors to date, treatment with M032 did not cause harm and the combination of surgery and oncolytic viral therapy may have contributed to prolonged survival in pet dogs with spontaneous gliomas. Forthcoming in-depth radiographic, immunohistochemical, and genetic analyses will afford a more advanced understanding of how this treatment impacts these tumors and the immune system. Our goal is to utilize these findings bitranslationally to inform human studies and refine therapies that will improve outcomes in both humans and pet dogs with gliomas.
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Affiliation(s)
| | - R Timothy Bentley
- 4Purdue University College of Veterinary Medicine, West Lafayette, Indiana
| | | | - Jeremy B Foote
- 3Microbiology, The University of Alabama at Birmingham, Alabama
| | | | | | - Simon R Platt
- 5University of Georgia College of Veterinary Medicine, Athens, Georgia
| | - Daniel R Rissi
- 5University of Georgia College of Veterinary Medicine, Athens, Georgia
| | - Andy Shores
- 6Mississippi State University College of Veterinary Medicine, Mississippi State, Mississippi; and
| | - Donald Sorjonen
- 7Auburn University College of Veterinary Medicine, Auburn, Alabama
| | - Amy B Yanke
- 7Auburn University College of Veterinary Medicine, Auburn, Alabama
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