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Innovating Strategies and Tailored Approaches in Neuro-Oncology. Cancers (Basel) 2022; 14:cancers14051124. [PMID: 35267432 PMCID: PMC8909701 DOI: 10.3390/cancers14051124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/11/2022] [Accepted: 02/18/2022] [Indexed: 01/25/2023] Open
Abstract
Diffuse gliomas, the most frequent and aggressive primary central nervous system neoplasms, currently lack effective curative treatments, particularly for cases lacking the favorable prognostic marker IDH mutation. Nonetheless, advances in molecular biology allowed to identify several druggable alterations in a subset of IDH wild-type gliomas, such as NTRK and FGFR-TACC fusions, and BRAF hotspot mutations. Multi-tyrosine kinase inhibitors, such as regorafenib, also showed efficacy in the setting of recurrent glioblastoma. IDH inhibitors are currently in the advanced phase of clinical evaluation for patients with IDH-mutant gliomas. Several immunotherapeutic approaches, such as tumor vaccines or checkpoint inhibitors, failed to improve patients' outcomes. Even so, they may be still beneficial in a subset of them. New methods, such as using pulsed ultrasound to disrupt the blood-brain barrier, gene therapy, and oncolytic virotherapy, are well tolerated and may be included in the therapeutic armamentarium soon.
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Mechanisms of EGFR Resistance in Glioblastoma. Int J Mol Sci 2020; 21:ijms21228471. [PMID: 33187135 PMCID: PMC7696540 DOI: 10.3390/ijms21228471] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 12/13/2022] Open
Abstract
Glioblastoma (GBM) is the most common primary malignant brain tumor in adults. Despite numerous efforts to target epidermal growth factor receptor (EGFR), commonly dysregulated in GBM, approaches directed against EGFR have not achieved the same degree of success as seen in other tumor types, particularly as compared to non-small cell lung cancer (NSCLC). EGFR alterations in glioblastoma lie primarily in the extracellular domain, unlike the kinase domain alterations seen in NSCLC. Small molecule inhibitors are difficult to develop for the extracellular domain. Monoclonal antibodies can be developed to target the extracellular domain but must contend with the blood brain barrier (BBB). We review the role of EGFR in GBM, the history of trialed treatments, and the potential paths forward to target the pathway that may have greater success.
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Raizer JJ, Giglio P, Hu J, Groves M, Merrell R, Conrad C, Phuphanich S, Puduvalli VK, Loghin M, Paleologos N, Yuan Y, Liu D, Rademaker A, Yung WK, Vaillant B, Rudnick J, Chamberlain M, Vick N, Grimm S, Tremont-Lukats IW, De Groot J, Aldape K, Gilbert MR. A phase II study of bevacizumab and erlotinib after radiation and temozolomide in MGMT unmethylated GBM patients. J Neurooncol 2016; 126:185-192. [PMID: 26476729 DOI: 10.1007/s11060-015-1958-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/05/2015] [Indexed: 11/25/2022]
Abstract
Survival for glioblastoma (GBM) patients with an unmethyated MGMT promoter in their tumor is generally worse than methylated MGMT tumors, as temozolomide (TMZ) response is limited. How to better treat patients with unmethylated MGMT is unknown. We performed a trial combining erlotinib and bevacizumab in unmethylated GBM patients after completion of radiation (RT) and TMZ. GBM patients with an unmethylated MGMT promoter were trial eligible. Patient received standard RT (60 Gy) and TMZ (75 mg/m2 × 6 weeks) after surgical resection of their tumor. After completion of RT they started erlotinib 150 mg daily and bevacizumab 10 mg/kg every 2 weeks until progression. Imaging evaluations occurred every 8 weeks. The primary endpoint was overall survival. Of the 48 unmethylated patients enrolled, 46 were evaluable (29 men and 17 women); median age was 55.5 years (29-75) and median KPS was 90 (70-100). All patients completed RT with TMZ. The median number of cycles (1 cycle was 4 weeks) was 8 (2-47). Forty-one patients either progressed or died with a median progression free survival of 9.2 months. At a follow up of 33 months the median overall survival was 13.2 months. There were no unexpected toxicities and most observed toxicities were categorized as CTC grade 1 or 2. The combination of erlotinib and bevacizumab is tolerable but did not meet our primary endpoint of increasing survival. Importantly, more trials are needed to find better therapies for GBM patients with an unmethylated MGMT promoter.
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Affiliation(s)
- J J Raizer
- Department of Neurology, Northwestern University, 710 North Lake Shore Drive, Abbott Hall, Room 1123, Chicago, IL, 60611, USA.
| | - P Giglio
- James Cancer Hospital, Ohio State University, Columbus, OH, USA
| | - J Hu
- Departments of Neurology and Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - M Groves
- Austin Brain Tumor Center, Austin, USA
| | - R Merrell
- Department of Neurology, NorthShore University Health System, Evanston, USA
| | - C Conrad
- Austin Brain Tumor Center, Austin, USA
| | - S Phuphanich
- Departments of Neurology and Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - V K Puduvalli
- James Cancer Hospital, Ohio State University, Columbus, OH, USA
| | - M Loghin
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - N Paleologos
- Department of Neurology, Rush University Medical Center, Chicago, USA
| | - Y Yuan
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, USA
| | - D Liu
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, USA
| | - A Rademaker
- Department of Preventive Medicine, Northwestern University, Chicago, USA
| | - W K Yung
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - B Vaillant
- Dell Medical School, The University of Texas, Austin, USA
| | - J Rudnick
- Departments of Neurology and Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - M Chamberlain
- Department of Neurology, University of Washington, Seattle, USA
| | - N Vick
- Department of Neurology, NorthShore University Health System, Evanston, USA
| | - S Grimm
- Department of Neurology, Northwestern University, 710 North Lake Shore Drive, Abbott Hall, Room 1123, Chicago, IL, 60611, USA
| | - I W Tremont-Lukats
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - J De Groot
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - K Aldape
- Department of Pathology, Princess Margaret Cancer Centre, Toronto, Canada
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Zorzan M, Giordan E, Redaelli M, Caretta A, Mucignat-Caretta C. Molecular targets in glioblastoma. Future Oncol 2016; 11:1407-20. [PMID: 25952786 DOI: 10.2217/fon.15.22] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Glioblastoma is the most lethal brain tumor. The poor prognosis results from lack of defined tumor margins, critical location of the tumor mass and presence of chemo- and radio-resistant tumor stem cells. The current treatment for glioblastoma consists of neurosurgery, followed by radiotherapy and temozolomide chemotherapy. A better understanding of the role of molecular and genetic heterogeneity in glioblastoma pathogenesis allowed the design of novel targeted therapies. New targets include different key-role signaling molecules and specifically altered pathways. The new approaches include interference through small molecules or monoclonal antibodies and RNA-based strategies mediated by siRNA, antisense oligonucleotides and ribozymes. Most of these treatments are still being tested yet they stay as solid promises for a clinically relevant success.
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Affiliation(s)
- Maira Zorzan
- Department of Molecular Medicine, University of Padova, Padova, Italy
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Abstract
Current first-line treatment regimens combine surgical resection and chemoradiation for Glioblastoma that provides a slight increase in overall survival. Age on its own should not be used as an exclusion criterion of glioblastoma multiforme (GBM) treatment, but performance should be factored heavily into the decision-making process for treatment planning. Despite aggressive initial treatment, most patients develop recurrent diseases which can be treated with re-resection, systemic treatment with targeted agents or cytotoxic chemotherapy, reirradiation, or radiosurgery. Research into novel therapies is investigating alternative temozolomide regimens, convection-enhanced delivery, immunotherapy, gene therapy, antiangiogenic agents, poly ADP ribose polymerase inhibitors, or cancer stem cell signaling pathways. Given the aggressive and resilient nature of GBM, continued efforts to better understand GBM pathophysiology are required to discover novel targets for future therapy.
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Affiliation(s)
- Sanjoy Roy
- Department of Radiotherapy, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
| | - Debarshi Lahiri
- Department of Radiotherapy, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
| | - Tapas Maji
- Department of Radiotherapy, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
| | - Jaydip Biswas
- Department of Radiotherapy, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
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Abstract
Glioblastoma is the most common adult malignant primary brain tumor. Despite the advances in therapeutic options, survival of patients with glioblastoma remains dismal at 15-18 months. Current standard of care for newly diagnosed glioblastoma is maximal possible safe resection consistent with the preservation of neurologic function followed by concurrent temozolomide with radiation and adjuvant. Treatment options at recurrence include surgical resection with or without the placement of carmustine wafers, re-irradiation and chemotherapeutics such as nitrosoureas (lomustine, carmustine) or bevacizumab, a monoclonal antibody targeting vascular endothelial growth factor (VEGF).
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Affiliation(s)
- Vyshak Alva Venur
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, S73, Cleveland, OH, 44195, USA
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Yoshida Y, Ozawa T, Yao TW, Shen W, Brown D, Parsa AT, Raizer JJ, Cheng SY, Stegh AH, Mazar AP, Giles FJ, Sarkaria JN, Butowski N, Nicolaides T, James CD. NT113, a pan-ERBB inhibitor with high brain penetrance, inhibits the growth of glioblastoma xenografts with EGFR amplification. Mol Cancer Ther 2014; 13:2919-29. [PMID: 25313012 DOI: 10.1158/1535-7163.mct-14-0306] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This report describes results from our analysis of the activity and biodistribution of a novel pan-ERBB inhibitor, NT113, when used in treating mice with intracranial glioblastoma (GBM) xenografts. Approaches used in this investigation include: bioluminescence imaging (BLI) for monitoring intracranial tumor growth and response to therapy; determination of survival benefit from treatment; analysis of tumor IHC reactivity for indication of treatment effect on proliferation and apoptotic response; Western blot analysis for determination of effects of treatment on ERBB and ERBB signaling mediator activation; and high-performance liquid chromatography for determination of NT113 concentration in tissue extracts from animals receiving oral administration of inhibitor. Our results show that NT113 is active against GBM xenografts in which wild-type EGFR or EGFRvIII is highly expressed. In experiments including lapatinib and/or erlotinib, NT113 treatment was associated with the most substantial improvement in survival, as well as the most substantial tumor growth inhibition, as indicated by BLI and IHC results. Western blot analysis results indicated that NT113 has inhibitory activity, both in vivo and in vitro, on ERBB family member phosphorylation, as well as on the phosphorylation of downstream signaling mediator Akt. Results from the analysis of animal tissues revealed significantly higher NT113 normal brain-to-plasma and intracranial tumor-to-plasma ratios for NT113, relative to erlotinib, indicating superior NT113 partitioning to intracranial tissue compartments. These data provide a strong rationale for the clinical investigation of NT113, a novel ERBB inhibitor, in treating patients with GBM.
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Affiliation(s)
- Yasuyuki Yoshida
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Tomoko Ozawa
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Tsun-Wen Yao
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California. Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Wang Shen
- NewGen Therapeutics, Inc., Menlo Park, California
| | - Dennis Brown
- NewGen Therapeutics, Inc., Menlo Park, California
| | - Andrew T Parsa
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jeffrey J Raizer
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Shi-Yuan Cheng
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Alexander H Stegh
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Andrew P Mazar
- Northwestern Medicine Developmental Therapeutics Institute, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Francis J Giles
- Northwestern Medicine Developmental Therapeutics Institute, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jann N Sarkaria
- Department of Radiation Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Nicholas Butowski
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Theodore Nicolaides
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California. Department of Pediatrics, University of California San Francisco, San Francisco, California.
| | - C David James
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. Northwestern Medicine Developmental Therapeutics Institute, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
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Abstract
Medical therapies are an important part of adjunctive therapy for gliomas. In this chapter we will review the chemotherapeutic and targeted agents that have been evaluated in clinical trials in grade II-IV gliomas in the last decade. A number of randomized phase III trials were completed and reported. There has been a clear success in oligodendroglial tumors and low grade glioma. Although some progress has been made in glioblastoma, considerable work involving the multidisciplinary collaboration of basic science, translational and clinical investigators needs to be done to improve the outcome of patients with anaplastic astrocytoma and glioblastoma. In addition, tailoring treatment based on molecular cytogenetic characteristics is a major focus of research into precision based medicine for glioma.
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Affiliation(s)
- Manmeet S Ahluwalia
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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Abstract
Afatinib, an irreversible inhibitor of the ErbB family of tyrosine kinases, is under development with Boehringer Ingelheim for the once-daily, oral treatment of cancer. Afatinib downregulates ErbB signalling by covalently binding to epidermal growth factor receptor (EGFR), human epidermal growth factor receptor (HER) 2 and HER4, irreversibly inhibiting tyrosine kinase autophosphorylation. It also inhibits transphosphorylation of HER3. Oral afatinib (Gilotrif™) has been approved in the US for the first-line treatment of patients with metastatic non-small-cell lung cancer (NSCLC) who have tumours with EGFR exon 19 deletions or exon 21 (L858R) substitution mutations as detected by a US FDA-approved test. Afatinib has also been approved in Taiwan for the first-line treatment of patients with EGFR mutation-positive NSCLC. In addition, the European Medicines Agency's Committee for Medicinal Products for Human Use has recommended the approval of afatinib (Giotrif®) for the treatment of patients with locally advanced or metastatic NSCLC with activating EGFR mutations who are EGFR tyrosine kinase inhibitor naïve. Afatinib is also under regulatory review in Canada, Japan and other Asian countries. This article summarizes the milestones in the development of afatinib, leading to this first approval in patients with metastatic NSCLC.
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Affiliation(s)
- Rosselle T Dungo
- Adis R & D Insight, 41 Centorian Drive, Private Bag 65901, Mairangi Bay, North Shore, 0754, Auckland, New Zealand,
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