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Gatto L, Franceschi E, Tosoni A, Di Nunno V, Bartolini S, Brandes AA. Glioblastoma treatment slowly moves toward change: novel druggable targets and translational horizons in 2022. Expert Opin Drug Discov 2023; 18:269-286. [PMID: 36718723 DOI: 10.1080/17460441.2023.2174097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Glioblastoma (GBM) is the most common primary brain tumor in adults. GBM treatment options have been the same for the past 30 years and have only modestly extended survival, despite aggressive multimodal treatments. The progressively better knowledge of GBM biology and a comprehensive analysis of its genomic profile have elucidated GBM heterogeneity, contributing to a more effective molecular classification and to the development of innovative targeted therapeutic approaches. AREAS COVERED This article reports all the noteworthy innovations for immunotherapy and targeted therapy, providing insights into the current advances in trial designs, including combination therapies with immuno-oncology agents and target combinations. EXPERT OPINION GBM molecular heterogeneity and brain anatomical characteristics critically restrain drug effectiveness. Nevertheless, stimulating insights for future research and drug development come from innovative treatment strategies for GBM, such as multi-specific 'off-the-shelf' CAR-T therapy, oncolytic viral therapy and autologous dendritic cell vaccination. Disappointing results from targeted therapies-clinical trials are mainly due to complex interferences between signaling pathways and biological processes leading to drug resistance: hence, it is imperative in the future to develop combinatorial approaches and multimodal therapies.
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Affiliation(s)
- Lidia Gatto
- Department of Oncology, AUSL Bologna, Bologna, Italy
| | - Enrico Franceschi
- Nervous System Medical Oncology Department, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Alicia Tosoni
- Nervous System Medical Oncology Department, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | | | - Stefania Bartolini
- Nervous System Medical Oncology Department, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Alba Ariela Brandes
- Nervous System Medical Oncology Department, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
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Li H, He J, Li M, Li K, Pu X, Guo Y. Immune landscape-based machine-learning-assisted subclassification, prognosis, and immunotherapy prediction for glioblastoma. Front Immunol 2022; 13:1027631. [PMID: 36532035 PMCID: PMC9751405 DOI: 10.3389/fimmu.2022.1027631] [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] [Received: 08/25/2022] [Accepted: 11/15/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction As a malignant brain tumor, glioblastoma (GBM) is characterized by intratumor heterogeneity, a worse prognosis, and highly invasive, lethal, and refractory natures. Immunotherapy has been becoming a promising strategy to treat diverse cancers. It has been known that there are highly heterogeneous immunosuppressive microenvironments among different GBM molecular subtypes that mainly include classical (CL), mesenchymal (MES), and proneural (PN), respectively. Therefore, an in-depth understanding of immune landscapes among them is essential for identifying novel immune markers of GBM. Methods and results In the present study, based on collecting the largest number of 109 immune signatures, we aim to achieve a precise diagnosis, prognosis, and immunotherapy prediction for GBM by performing a comprehensive immunogenomic analysis. Firstly, machine-learning (ML) methods were proposed to evaluate the diagnostic values of these immune signatures, and the optimal classifier was constructed for accurate recognition of three GBM subtypes with robust and promising performance. The prognostic values of these signatures were then confirmed, and a risk score was established to divide all GBM patients into high-, medium-, and low-risk groups with a high predictive accuracy for overall survival (OS). Therefore, complete differential analysis across GBM subtypes was performed in terms of the immune characteristics along with clinicopathological and molecular features, which indicates that MES shows much higher immune heterogeneity compared to CL and PN but has significantly better immunotherapy responses, although MES patients may have an immunosuppressive microenvironment and be more proinflammatory and invasive. Finally, the MES subtype is proved to be more sensitive to 17-AAG, docetaxel, and erlotinib using drug sensitivity analysis and three compounds of AS-703026, PD-0325901, and MEK1-2-inhibitor might be potential therapeutic agents. Conclusion Overall, the findings of this research could help enhance our understanding of the tumor immune microenvironment and provide new insights for improving the prognosis and immunotherapy of GBM patients.
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Wu W, Klockow JL, Zhang M, Lafortune F, Chang E, Jin L, Wu Y, Daldrup-Link HE. Glioblastoma multiforme (GBM): An overview of current therapies and mechanisms of resistance. Pharmacol Res 2021; 171:105780. [PMID: 34302977 PMCID: PMC8384724 DOI: 10.1016/j.phrs.2021.105780] [Citation(s) in RCA: 181] [Impact Index Per Article: 60.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 12/21/2022]
Abstract
Glioblastoma multiforme (GBM) is a WHO grade IV glioma and the most common malignant, primary brain tumor with a 5-year survival of 7.2%. Its highly infiltrative nature, genetic heterogeneity, and protection by the blood brain barrier (BBB) have posed great treatment challenges. The standard treatment for GBMs is surgical resection followed by chemoradiotherapy. The robust DNA repair and self-renewing capabilities of glioblastoma cells and glioma initiating cells (GICs), respectively, promote resistance against all current treatment modalities. Thus, durable GBM management will require the invention of innovative treatment strategies. In this review, we will describe biological and molecular targets for GBM therapy, the current status of pharmacologic therapy, prominent mechanisms of resistance, and new treatment approaches. To date, medical imaging is primarily used to determine the location, size and macroscopic morphology of GBM before, during, and after therapy. In the future, molecular and cellular imaging approaches will more dynamically monitor the expression of molecular targets and/or immune responses in the tumor, thereby enabling more immediate adaptation of tumor-tailored, targeted therapies.
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Affiliation(s)
- Wei Wu
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, CA 94305, USA
| | - Jessica L Klockow
- Department of Radiation Oncology, Stanford University, Stanford, CA 94305, USA
| | - Michael Zhang
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, CA 94305, USA; Department of Neurosurgery, Stanford University, Stanford, CA 94305, USA
| | - Famyrah Lafortune
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, CA 94305, USA
| | - Edwin Chang
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, CA 94305, USA
| | - Linchun Jin
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
| | - Yang Wu
- Department of Neuropathology, Institute of Pathology, Technical University of Munich, Munich, Bayern 81675, Germany
| | - Heike E Daldrup-Link
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, CA 94305, USA.
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Wielgat P, Niemirowicz-Laskowska K, Wilczewska AZ, Car H. Sialic Acid-Modified Nanoparticles-New Approaches in the Glioma Management-Perspective Review. Int J Mol Sci 2021; 22:ijms22147494. [PMID: 34299113 PMCID: PMC8304714 DOI: 10.3390/ijms22147494] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/02/2021] [Accepted: 07/10/2021] [Indexed: 12/23/2022] Open
Abstract
The cell surface is covered by a dense and complex network of glycans attached to the membrane proteins and lipids. In gliomas, the aberrant sialylation, as the final stage of glycosylation, is an important regulatory mechanism of malignant cell behavior and correlates with worse prognosis. Better understanding of the role of sialylation in cellular and molecular processes opens a new way in the development of therapeutic tools for human brain tumors. According to the recent clinical observation, the cellular heterogeneity, activity of brain cancer stem cells (BCSCs), immune evasion, and function of the blood–brain barrier (BBB) are attractive targets for new therapeutic strategies. In this review, we summarize the importance of sialic acid-modified nanoparticles in brain tumor progression.
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Affiliation(s)
- Przemyslaw Wielgat
- Department of Clinical Pharmacology, Medical University of Bialystok, Waszyngtona 15A, 15-274 Bialystok, Poland;
- Correspondence: (P.W.); (K.N.-L.); Tel.: +48-85-7450647 (P.W.); +48-85-7485554 (K.N.-L.)
| | - Katarzyna Niemirowicz-Laskowska
- Department of Experimental Pharmacology, Medical University of Bialystok, Szpitalna 37, 15-265 Bialystok, Poland
- Correspondence: (P.W.); (K.N.-L.); Tel.: +48-85-7450647 (P.W.); +48-85-7485554 (K.N.-L.)
| | | | - Halina Car
- Department of Clinical Pharmacology, Medical University of Bialystok, Waszyngtona 15A, 15-274 Bialystok, Poland;
- Department of Experimental Pharmacology, Medical University of Bialystok, Szpitalna 37, 15-265 Bialystok, Poland
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Paolillo M, Comincini S, Schinelli S. In Vitro Glioblastoma Models: A Journey into the Third Dimension. Cancers (Basel) 2021; 13:cancers13102449. [PMID: 34070023 PMCID: PMC8157833 DOI: 10.3390/cancers13102449] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary In this review, the thorny issue of glioblastoma models is addressed, with a focus on 3D in vitro models. In the first part of the manuscript, glioblastoma features and classification are recapitulated, in order to highlight the major critical aspects that should be taken into account when choosing a glioblastoma 3D model. In the second part of the review, the 3D models described in the literature are critically discussed, considering the advantages, disadvantages, and feasibility for each experimental model, in the light of the potential issues that researchers want to address. Abstract Glioblastoma multiforme (GBM) is the most lethal primary brain tumor in adults, with an average survival time of about one year from initial diagnosis. In the attempt to overcome the complexity and drawbacks associated with in vivo GBM models, together with the need of developing systems dedicated to screen new potential drugs, considerable efforts have been devoted to the implementation of reliable and affordable in vitro GBM models. Recent findings on GBM molecular features, revealing a high heterogeneity between GBM cells and also between other non-tumor cells belonging to the tumoral niche, have stressed the limitations of the classical 2D cell culture systems. Recently, several novel and innovative 3D cell cultures models for GBM have been proposed and implemented. In this review, we first describe the different populations and their functional role of GBM and niche non-tumor cells that could be used in 3D models. An overview of the current available 3D in vitro systems for modeling GBM, together with their major weaknesses and strengths, is presented. Lastly, we discuss the impact of groundbreaking technologies, such as bioprinting and multi-omics single cell analysis, on the future implementation of 3D in vitro GBM models.
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Affiliation(s)
- Mayra Paolillo
- Department of Drug Sciences, University of Pavia, 27100 Pavia, Italy;
- Correspondence:
| | - Sergio Comincini
- Department of Biology and Biotechnology “Lazzaro Spallanzani”, University of Pavia, 27100 Pavia, Italy;
| | - Sergio Schinelli
- Department of Drug Sciences, University of Pavia, 27100 Pavia, Italy;
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OPALS: A New Osimertinib Adjunctive Treatment of Lung Adenocarcinoma or Glioblastoma Using Five Repurposed Drugs. Cells 2021; 10:cells10051148. [PMID: 34068720 PMCID: PMC8151869 DOI: 10.3390/cells10051148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/30/2021] [Accepted: 05/07/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Pharmacological targeting aberrant activation of epidermal growth factor receptor tyrosine kinase signaling is an established approach to treating lung adenocarcinoma. Osimertinib is a tyrosine kinase approved and effective in treating lung adenocarcinomas that have one of several common activating mutations in epidermal growth factor receptor. The emergence of resistance to osimertinib after a year or two is the rule. We developed a five-drug adjuvant regimen designed to increase osimertinib’s growth inhibition and thereby delay the development of resistance. Areas of Uncertainty: Although the assembled preclinical data is strong, preclinical data and the following clinical trial results can be discrepant. The safety of OPALS drugs when used individually is excellent. We have no data from humans on their tolerability when used as an ensemble. That there is no data from the individual drugs to suspect problematic interaction does not exclude the possibility. Data Sources: All relevant PubMed.org articles on the OPALS drugs and corresponding pathophysiology of lung adenocarcinoma and glioblastoma were reviewed. Therapeutic Opinion: The five drugs of OPALS are in wide use in general medicine for non-oncology indications. OPALS uses the anti-protozoal drug pyrimethamine, the antihistamine cyproheptadine, the antibiotic azithromycin, the antihistamine loratadine, and the potassium sparing diuretic spironolactone. We show how these inexpensive and generically available drugs intersect with and inhibit lung adenocarcinoma growth drive. We also review data showing that both OPALS adjuvant drugs and osimertinib have data showing they may be active in suppressing glioblastoma growth.
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Updated Insights on EGFR Signaling Pathways in Glioma. Int J Mol Sci 2021; 22:ijms22020587. [PMID: 33435537 PMCID: PMC7827907 DOI: 10.3390/ijms22020587] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 12/28/2020] [Accepted: 01/05/2021] [Indexed: 02/06/2023] Open
Abstract
Nowadays, due to recent advances in molecular biology, the pathogenesis of glioblastoma is better understood. For the newly diagnosed, the current standard of care is represented by resection followed by radiotherapy and temozolomide administration, but because median overall survival remains poor, new diagnosis and treatment strategies are needed. Due to the quick progression, even with aggressive multimodal treatment, glioblastoma remains almost incurable. It is known that epidermal growth factor receptor (EGFR) amplification is a characteristic of the classical subtype of glioma. However, targeted therapies against this type of receptor have not yet shown a clear clinical benefit. Many factors contribute to resistance, such as ineffective blood-brain barrier penetration, heterogeneity, mutations, as well as compensatory signaling pathways. A better understanding of the EGFR signaling network, and its interrelations with other pathways, are essential to clarify the mechanisms of resistance and create better therapeutic agents.
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Anderson AR, Segura T. Injectable biomaterials for treatment of glioblastoma. ADVANCED MATERIALS INTERFACES 2020; 7:2001055. [PMID: 34660174 PMCID: PMC8513688 DOI: 10.1002/admi.202001055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Indexed: 06/13/2023]
Abstract
Despite ongoing advancements in the field of medicine, glioblastoma multiforme (GBM) is presently incurable, making this advanced brain tumor the deadliest tumor type in the central nervous system. The primary treatment strategies for GBM (i.e. surgical resection, radiation therapy, chemotherapy, and newly incorporated targeted therapies) fail to overcome the challenging characteristics of highly aggressive GBM tumors and are presently given with the goal of increasing the quality of life for patients. With the aim of creating effective treatment solutions, research has shifted toward utilizing injectable biomaterial adjuncts to minimize invasiveness of treatment, provide spatiotemporal control of therapeutic delivery, and engage with cells through material-cell interfaces. This review aims to summarize the limitations of the current standard of care for GBM, discuss how these limitations can be addressed by local employment of injectable biomaterial systems, and highlight developments in the field of biomaterials for these applications.
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Affiliation(s)
- Alexa R. Anderson
- Duke University Department of Biomedical Engineering, 101 Science Drive, Durham, NC 27708, U.S.A
| | - Tatiana Segura
- Duke University Department of Biomedical Engineering, 101 Science Drive, Durham, NC 27708, U.S.A
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Dong Z, Zou J, Li J, Pang Y, Liu Y, Deng C, Chen F, Cui H. MYST1/KAT8 contributes to tumor progression by activating EGFR signaling in glioblastoma cells. Cancer Med 2019; 8:7793-7808. [PMID: 31691527 PMCID: PMC6912028 DOI: 10.1002/cam4.2639] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/30/2019] [Accepted: 10/10/2019] [Indexed: 12/18/2022] Open
Abstract
With short survival time, glioblastoma (GBM) is the most malignant tumor in the central nervous system. Recently, epigenetic enzymes play essential roles in the regulation of tumorigenesis and cancer development of GBM. However, little is known about MYST1/KAT8/MOF, a histone acetylation enzyme, in GBM. The present study shows that MYST1 promotes GBM progression through activating epidermal growth factor receptor (EGFR) signaling. MYST1 expression was increased in GBM and was negatively correlated with prognosis in patients with glioma and GBM. Knockdown of MYST1 reduced cell proliferation and BrdU incorporation in LN229, U87, and A172 GBM cells. Besides, MYST1 downregulation also induced cell cycle arrest at G2M phase, as well as the reduced expression of CDK1, Cyclin A, Cyclin B1, and increased expression of p21CIP1/Waf1. Meanwhile, Self‐renewal capability in vitro and tumorigenecity in vivo were also impaired after MYST1 knockdown. Importantly, MYST1 expression was lowly expressed in mesenchymal subtype of GBM and was positively correlated with EGFR expression in a cohort from The Cancer Genome Atlas. Western blot subsequently confirmed that phosphorylation and activation of p‐Try1068 of EGFR, p‐Ser473 of AKT and p‐Thr202/Tyr204 of Erk1/2 were also decreased by MYST1 knockdown. Consistent with the results above, overexpression of MYST1 promoted GBM growth and activated EGFR signaling in vitro and in vivo. In addition, erlotinib, a US Food and Drug Administration approved cancer drug which targets EGFR, was able to rescue MYST1‐promoted cell proliferation and EGFR signaling pathway. Furthermore, the transcription of EGF, an EFGR ligand, was shown to be positively regulated by MYST1 possibly via H4K16 acetylation. Our findings elucidate MYST1 as a tumor promoter in GBM and an EGFR activator, and may be a potential drug target for GBM treatment.
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Affiliation(s)
- Zhen Dong
- State Key Laboratory of Silkworm Genome Biology, Institute of Sericulture and Systems Biology, Southwest University, Chongqing, China.,Cancer Center, Medical Research Institute, Southwest University, Chongqing, China.,Engineering Research Center for Cancer Biomedical and Translational Medicine, Southwest University, Chongqing, China.,Chongqing Engineering and Technology Research Center for Silk Biomaterials and Regenerative Medicine, Southwest University, Chongqing, China
| | - Jiahua Zou
- State Key Laboratory of Silkworm Genome Biology, Institute of Sericulture and Systems Biology, Southwest University, Chongqing, China
| | - Jifu Li
- College of Biotechnology, Southwest University, Chongqing, China
| | - Yi Pang
- Chongqing Engineering Research Center of Antitumor Natural Drugs, Chongqing Three Gorges Medical College, Chongqing, China
| | - Yudong Liu
- State Key Laboratory of Silkworm Genome Biology, Institute of Sericulture and Systems Biology, Southwest University, Chongqing, China.,Cancer Center, Medical Research Institute, Southwest University, Chongqing, China.,Engineering Research Center for Cancer Biomedical and Translational Medicine, Southwest University, Chongqing, China.,Chongqing Engineering and Technology Research Center for Silk Biomaterials and Regenerative Medicine, Southwest University, Chongqing, China
| | - Chaowei Deng
- State Key Laboratory of Silkworm Genome Biology, Institute of Sericulture and Systems Biology, Southwest University, Chongqing, China.,Cancer Center, Medical Research Institute, Southwest University, Chongqing, China.,Engineering Research Center for Cancer Biomedical and Translational Medicine, Southwest University, Chongqing, China.,Chongqing Engineering and Technology Research Center for Silk Biomaterials and Regenerative Medicine, Southwest University, Chongqing, China
| | - Fei Chen
- Department of Pharmaceutical Sciences, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
| | - Hongjuan Cui
- State Key Laboratory of Silkworm Genome Biology, Institute of Sericulture and Systems Biology, Southwest University, Chongqing, China.,Cancer Center, Medical Research Institute, Southwest University, Chongqing, China.,Engineering Research Center for Cancer Biomedical and Translational Medicine, Southwest University, Chongqing, China.,Chongqing Engineering and Technology Research Center for Silk Biomaterials and Regenerative Medicine, Southwest University, Chongqing, China
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Kast RE, Skuli N, Karpel-Massler G, Frosina G, Ryken T, Halatsch ME. Blocking epithelial-to-mesenchymal transition in glioblastoma with a sextet of repurposed drugs: the EIS regimen. Oncotarget 2017; 8:60727-60749. [PMID: 28977822 PMCID: PMC5617382 DOI: 10.18632/oncotarget.18337] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 05/12/2017] [Indexed: 12/11/2022] Open
Abstract
This paper outlines a treatment protocol to run alongside of standard current treatment of glioblastoma- resection, temozolomide and radiation. The epithelial to mesenchymal transition (EMT) inhibiting sextet, EIS Regimen, uses the ancillary attributes of six older medicines to impede EMT during glioblastoma. EMT is an actively motile, therapy-resisting, low proliferation, transient state that is an integral feature of cancers’ lethality generally and of glioblastoma specifically. It is believed to be during the EMT state that glioblastoma’s centrifugal migration occurs. EMT is also a feature of untreated glioblastoma but is enhanced by chemotherapy, by radiation and by surgical trauma. EIS Regimen uses the antifungal drug itraconazole to block Hedgehog signaling, the antidiabetes drug metformin to block AMP kinase (AMPK), the analgesic drug naproxen to block Rac1, the anti-fibrosis drug pirfenidone to block transforming growth factor-beta (TGF-beta), the psychiatric drug quetiapine to block receptor activator NFkB ligand (RANKL) and the antibiotic rifampin to block Wnt- all by their previously established ancillary attributes. All these systems have been identified as triggers of EMT and worthy targets to inhibit. The EIS Regimen drugs have a good safety profile when used individually. They are not expected to have any new side effects when combined. Further studies of the EIS Regimen are needed.
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Affiliation(s)
| | - Nicolas Skuli
- INSERM, Centre de Recherches en Cancérologie de Toulouse, CRCT, Inserm/Université Toulouse III, Paul Sabatier, Hubert Curien, Toulouse, France
| | - Georg Karpel-Massler
- Department of Neurosurgery, Ulm University Hospital, Albert-Einstein-Allee, Ulm, Germany
| | - Guido Frosina
- Mutagenesis & Cancer Prevention Unit, IRCCS Azienda Ospedaliera Universitaria San Martino, IST Istituto Nazionale per la Ricerca sul Cancro, Largo Rosanna Benzi, Genoa, Italy
| | - Timothy Ryken
- Department of Neurosurgery, University of Kansas, Lawrence, KS, USA
| | - Marc-Eric Halatsch
- Department of Neurosurgery, Ulm University Hospital, Albert-Einstein-Allee, Ulm, Germany
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Simultaneous Interference with HER1/EGFR and RAC1 Signaling Drives Cytostasis and Suppression of Survivin in Human Glioma Cells in Vitro. Neurochem Res 2017; 42:1543-1554. [PMID: 28271323 DOI: 10.1007/s11064-017-2213-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 12/08/2016] [Accepted: 02/20/2017] [Indexed: 12/12/2022]
Abstract
We have previously reported that combined inhibition of the epidermal growth factor receptor by erlotinib and of RAC1 by NSC23766 yielded a synergistic antiproliferative effect on established and primary cultured glioblastoma cells. The current study aimed at identifying the molecular mechanism. Staining for annexin V/PI or carboxyfluorescein succinimidyl ester was performed in order to determine the induction of apoptosis, necrosis or cytostasis in established and primary cultured glioblastoma cells. Moreover, expression of Ki-67 was determined by immunofluorescence, and the expression of cell cycle proteins was analysed by Western blot. Our data show that combined treatment with erlotinib and NSC23766 resulted in a reduced number of cell divisions, a significantly decreased Ki-67 expression, increased apoptosis and autophagy when compared to single agent treatments. On the molecular level, concomitant treatment with both agents resulted in a pronounced downregulation of cyclin D1, cyclin-dependent kinases 2, 4 and 6, as well as of survivin when compared to treatments with either agent alone. In conclusion, we demonstrate that combined treatment of human glioma cell lines in vitro with erlotinib and NSC23766 markedly inhibits cell division, induces apoptosis independent of caspase-3 activation and induces autophagy concomitant with suppression of survivin.
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Zanotto-Filho A, Gonçalves RM, Klafke K, de Souza PO, Dillenburg FC, Carro L, Gelain DP, Moreira JCF. Inflammatory landscape of human brain tumors reveals an NFκB dependent cytokine pathway associated with mesenchymal glioblastoma. Cancer Lett 2016; 390:176-187. [PMID: 28007636 DOI: 10.1016/j.canlet.2016.12.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 12/08/2016] [Accepted: 12/12/2016] [Indexed: 12/14/2022]
Abstract
The tumor microenvironment is being increasingly recognized as a key factor in cancer aggressiveness. In this study, we characterized the inflammatory gene signatures altered in glioma cell lines and tumor specimens of differing histological and molecular subtypes. The results showed that glioblastoma multiforme (GBM) shows upregulation of a subset of inflammatory genes when compared to astrocytomas and oligodendrogliomas. With molecular subtypes of GBM, the expression of inflammatory genes is heterogeneous, being enriched in mesenchymal and downregulated in Proneural/GCIMP. Other inflammation-associated processes such as tumor-associated macrophage (TAM) signatures are upregulated in mesenchymal, and a subset of 33 mesenchymal-enriched inflammatory and TAM markers showed correlation with poor survival. We found that various GBM tumor-upregulated genes such as IL6, IL8 and CCL2 are also actively expressed in glioma cell lines, playing differential and cooperative roles in promoting proliferation, invasion, angiogenesis and macrophage polarization in vitro. These genes can be stimulated by pathways typically altered in GBM, including the EGFR, PDGFR, MEK1/2-ERK1/2, PI3K/Akt and NFκB cascades. Taken together, the results presented herein depict some inflammatory pathways altered in gliomas and highlight potentially relevant targets to therapy improvement.
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Affiliation(s)
- Alfeu Zanotto-Filho
- Departamento de Farmacologia, Centro de Ciências Biológicas (CCB), Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil; Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde (ICBS), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.
| | - Rosângela Mayer Gonçalves
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde (ICBS), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Karina Klafke
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde (ICBS), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Priscila Oliveira de Souza
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde (ICBS), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Fabiane Cristine Dillenburg
- Instituto de Informática, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Luigi Carro
- Instituto de Informática, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Daniel Pens Gelain
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde (ICBS), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - José Cláudio Fonseca Moreira
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde (ICBS), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
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Karpel-Massler G, Shu C, Chau L, Banu M, Halatsch ME, Westhoff MA, Ramirez Y, Ross AH, Bruce JN, Canoll P, Siegelin MD. Combined inhibition of Bcl-2/Bcl-xL and Usp9X/Bag3 overcomes apoptotic resistance in glioblastoma in vitro and in vivo. Oncotarget 2016; 6:14507-21. [PMID: 26008975 PMCID: PMC4546483 DOI: 10.18632/oncotarget.3993] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 04/10/2015] [Indexed: 11/25/2022] Open
Abstract
Despite great efforts taken to advance therapeutic measures for patients with glioblastoma, the clinical prognosis remains grim. The antiapoptotic Bcl-2 family protein Mcl-1 is overexpressed in glioblastoma and represents an important resistance factor to the BH-3 mimetic ABT263. In this study, we show that combined treatment with ABT263 and GX15-070 overcomes apoptotic resistance in established glioblastoma cell lines, glioma stem-like cells and primary cultures. Moreover, this treatment regimen also proves to be advantageous in vivo. On the molecular level, GX15-070 enhanced apoptosis by posttranslational down-regulation of the deubiquitinase, Usp9X, and the chaperone Bag3, leading to a sustained depletion of Mcl-1 protein levels. Moreover, knock-down of Usp9X or Bag3 depleted endogenous Mcl-1 protein levels and in turn enhanced apoptosis induced through Bcl-2/Bcl-xL inhibition. In conclusion, combined treatment with ABT263 and GX15-070 results in a significantly enhanced anti-cancer activity in vitro as well as in vivo in the setting of glioblastoma. Both drugs, ABT263 and GX15-070 have been evaluated in clinical studies which facilitates the translational aspect of taking this combinatorial approach to the clinical setting. Furthermore we present a novel mechanism by which GX15-070 counteracts Mcl-1 expression which may lay a foundation for a novel target in cancer therapy.
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Affiliation(s)
- Georg Karpel-Massler
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, USA
| | - Chang Shu
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, USA
| | - Lily Chau
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, USA
| | - Matei Banu
- Department of Neurosurgery, Columbia University Medical Center, New York, USA
| | | | - Mike-Andrew Westhoff
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm, Germany
| | - Yulian Ramirez
- Department of Biochemistry and Molecular Pharmacology, University of Massachusetts Medical School, Massachusetts, USA
| | - Alonzo H Ross
- Department of Biochemistry and Molecular Pharmacology, University of Massachusetts Medical School, Massachusetts, USA
| | - Jeffrey N Bruce
- Department of Neurosurgery, Columbia University Medical Center, New York, USA
| | - Peter Canoll
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, USA
| | - Markus D Siegelin
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, USA
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14
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Westhoff MA, Karpel-Massler G, Brühl O, Enzenmüller S, La Ferla-Brühl K, Siegelin MD, Nonnenmacher L, Debatin KM. A critical evaluation of PI3K inhibition in Glioblastoma and Neuroblastoma therapy. MOLECULAR AND CELLULAR THERAPIES 2014; 2:32. [PMID: 26056598 PMCID: PMC4452069 DOI: 10.1186/2052-8426-2-32] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 10/16/2014] [Indexed: 12/11/2022]
Abstract
Members of the PI3K/Akt/mTor signaling cascade are among the most frequently altered proteins in cancer, yet the therapeutic application of pharmacological inhibitors of this signaling network, either as monotherapy or in combination therapy (CT) has so far not been particularly successful. In this review we will focus on the role of PI3K/Akt/mTOR in two distinct tumors, Glioblastoma multiforme (GBM), an adult brain tumor which frequently exhibits PTEN inactivation, and Neuroblastoma (NB), a childhood malignancy that affects the central nervous system and does not harbor any classic alterations in PI3K/Akt signaling. We will argue that inhibitors of PI3K/Akt signaling can be components for potentially promising new CTs in both tumor entities, but further understanding of the signal cascade's complexity is essential for successful implementation of these CTs. Importantly, failure to do this might lead to severe adverse effects, such as treatment failure and enhanced therapy resistance.
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Affiliation(s)
- Mike-Andrew Westhoff
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Georg Karpel-Massler
- Department of Neurosurgery, University Medical Center Ulm, Ulm, Germany ; Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY USA
| | - Oliver Brühl
- Laboratorio Analisi Sicilia Catania, Lentini, SR Italy
| | - Stefanie Enzenmüller
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | | | - Markus D Siegelin
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY USA
| | - Lisa Nonnenmacher
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Klaus-Michael Debatin
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
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15
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Westhoff MA, Karpel-Massler G, Brühl O, Enzenmüller S, La Ferla-Brühl K, Siegelin MD, Nonnenmacher L, Debatin KM. A critical evaluation of PI3K inhibition in Glioblastoma and Neuroblastoma therapy. MOLECULAR AND CELLULAR THERAPIES 2014; 2:32. [PMID: 26056598 PMCID: PMC4452069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 10/16/2014] [Indexed: 11/21/2023]
Abstract
Members of the PI3K/Akt/mTor signaling cascade are among the most frequently altered proteins in cancer, yet the therapeutic application of pharmacological inhibitors of this signaling network, either as monotherapy or in combination therapy (CT) has so far not been particularly successful. In this review we will focus on the role of PI3K/Akt/mTOR in two distinct tumors, Glioblastoma multiforme (GBM), an adult brain tumor which frequently exhibits PTEN inactivation, and Neuroblastoma (NB), a childhood malignancy that affects the central nervous system and does not harbor any classic alterations in PI3K/Akt signaling. We will argue that inhibitors of PI3K/Akt signaling can be components for potentially promising new CTs in both tumor entities, but further understanding of the signal cascade's complexity is essential for successful implementation of these CTs. Importantly, failure to do this might lead to severe adverse effects, such as treatment failure and enhanced therapy resistance.
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Affiliation(s)
- Mike-Andrew Westhoff
- />Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Georg Karpel-Massler
- />Department of Neurosurgery, University Medical Center Ulm, Ulm, Germany
- />Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY USA
| | - Oliver Brühl
- />Laboratorio Analisi Sicilia Catania, Lentini, SR Italy
| | - Stefanie Enzenmüller
- />Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | | | - Markus D Siegelin
- />Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY USA
| | - Lisa Nonnenmacher
- />Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Klaus-Michael Debatin
- />Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
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16
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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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17
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Furgason JM, Li W, Milholland B, Cross E, Li Y, McPherson CM, Warnick RE, Rixe O, Stambrook PJ, Vijg J, Bahassi EM. Whole genome sequencing of glioblastoma multiforme identifies multiple structural variations involved in EGFR activation. Mutagenesis 2014; 29:341-50. [PMID: 25103728 DOI: 10.1093/mutage/geu026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Next generation sequencing has become a powerful tool in dissecting and identifying mutations and genomic structural variants that accompany tumourigenesis. Sequence analysis of glioblastoma multiforme (GBM) illustrates the ability to rapidly identify mutations that may affect phenotype. Approximately 50% of human GBMs overexpress epidermal growth factor receptor (EGFR) which renders the EGFR protein a compelling therapeutic target. In brain tumours, attempts to target EGFR as a cancer therapeutic, however, have achieved little or no benefit. The mechanisms that drive therapeutic resistance to EGFR inhibitors in brain tumours are not well defined, and drug resistance contributes to the deadly and aggressive nature of the disease. Whole genome sequencing of four primary GBMs revealed multiple pathways by which EGFR protein abundance becomes deregulated in these tumours and will guide the development of new strategies for treating EGFR overexpressing tumours. Each of the four tumours displayed a different mechanism leading to increased EGFR protein levels. One mechanism is mediated by gene amplification and tandem duplication of the kinase domain. A second involves an intragenic deletion that generates a constitutively active form of the protein. A third combines the loss of a gene which encodes a protein that regulates EGFR abundance as well as an miRNA that modulates EGFR expression. A fourth mechanism entails loss of an ubiquitin ligase docking site in the C-terminal part of the protein whose absence inhibits turnover of the receptor.
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Affiliation(s)
- John M Furgason
- Department of Internal Medicine, Division of Hematology/Oncology, University of Cincinnati College of Medicine, 231, Albert Sabin Way, Cincinnati, OH, USA
| | - Wenge Li
- Albert Einstein Medical Center, 1301 Morris Park Avenue, New York, NY, USA
| | - Brandon Milholland
- Albert Einstein Medical Center, 1301 Morris Park Avenue, New York, NY, USA
| | - Emily Cross
- Department of Molecular Genetics, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, USA
| | - Yaqin Li
- Department of Molecular Genetics, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, USA
| | - Christopher M McPherson
- Department of Neurosurgery and UC Brain Tumor Center, University of Cincinnati, 234 Goodman Street, Cincinnati, OH, USA
| | - Ronald E Warnick
- Department of Neurosurgery and UC Brain Tumor Center, University of Cincinnati, 234 Goodman Street, Cincinnati, OH, USA
| | - Olivier Rixe
- GRU Cancer Center, 1411 Laney Walker Boulevard Augusta, GA, USA
| | - Peter J Stambrook
- Department of Molecular Genetics, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, USA
| | - Jan Vijg
- Albert Einstein Medical Center, 1301 Morris Park Avenue, New York, NY, USA
| | - El Mustapha Bahassi
- Department of Internal Medicine, Division of Hematology/Oncology, University of Cincinnati College of Medicine, 231, Albert Sabin Way, Cincinnati, OH, USA, UC Brain Tumor Center, University of Cincinnati, 234 Goodman Street, Cincinnati, OH, USA,
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18
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A conceptually new treatment approach for relapsed glioblastoma: coordinated undermining of survival paths with nine repurposed drugs (CUSP9) by the International Initiative for Accelerated Improvement of Glioblastoma Care. Oncotarget 2013; 4:502-30. [PMID: 23594434 PMCID: PMC3720600 DOI: 10.18632/oncotarget.969] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
To improve prognosis in recurrent glioblastoma we developed a treatment protocol based on a combination of drugs not traditionally thought of as cytotoxic chemotherapy agents but that have a robust history of being well-tolerated and are already marketed and used for other non-cancer indications. Focus was on adding drugs which met these criteria: a) were pharmacologically well characterized, b) had low likelihood of adding to patient side effect burden, c) had evidence for interfering with a recognized, well-characterized growth promoting element of glioblastoma, and d) were coordinated, as an ensemble had reasonable likelihood of concerted activity against key biological features of glioblastoma growth. We found nine drugs meeting these criteria and propose adding them to continuous low dose temozolomide, a currently accepted treatment for relapsed glioblastoma, in patients with recurrent disease after primary treatment with the Stupp Protocol. The nine adjuvant drug regimen, Coordinated Undermining of Survival Paths, CUSP9, then are aprepitant, artesunate, auranofin, captopril, copper gluconate, disulfiram, ketoconazole, nelfinavir, sertraline, to be added to continuous low dose temozolomide. We discuss each drug in turn and the specific rationale for use- how each drug is expected to retard glioblastoma growth and undermine glioblastoma's compensatory mechanisms engaged during temozolomide treatment. The risks of pharmacological interactions and why we believe this drug mix will increase both quality of life and overall survival are reviewed.
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19
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Karpel-Massler G, Westhoff MA, Zhou S, Nonnenmacher L, Dwucet A, Kast RE, Bachem MG, Wirtz CR, Debatin KM, Halatsch ME. Combined Inhibition of HER1/EGFR and RAC1 Results in a Synergistic Antiproliferative Effect on Established and Primary Cultured Human Glioblastoma Cells. Mol Cancer Ther 2013; 12:1783-95. [DOI: 10.1158/1535-7163.mct-13-0052] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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