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Wang L, Zhou X, Chen X, Liu Y, Huang Y, Cheng Y, Ren P, Zhao J, Zhou GG. Enhanced therapeutic efficacy for glioblastoma immunotherapy with an oncolytic herpes simplex virus armed with anti-PD-1 antibody and IL-12. Mol Ther Oncol 2024; 32:200799. [PMID: 38681801 PMCID: PMC11053222 DOI: 10.1016/j.omton.2024.200799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 10/18/2023] [Accepted: 04/03/2024] [Indexed: 05/01/2024]
Abstract
Glioblastoma is the most common and aggressive malignant brain tumor and has limited treatment options. Hence, innovative approaches are urgently needed. Oncolytic virus therapy is emerging as a promising modality for cancer treatment due to its tumor-specific targeting and immune-stimulatory properties. In this study, we developed a new generation of oncolytic herpes simplex virus C5252 by deletion of a 15-kb internal repeat region and both copies of γ34.5 genes. Additionally, C5252 was armed with anti-programmed cell death protein 1 antibody and interleukin-12 to enhance its therapeutic efficacy for glioblastoma immune-virotherapy. In vitro and in vivo experiments demonstrate that C5252 has a remarkable safety profile and potent anti-tumor activity against glioblastoma. Mechanistic studies demonstrated that C5252 specifically induces cell apoptosis by caspase-3/7 activation via downregulating ciliary neurotrophic factor receptor α. Furthermore, the enhanced anti-tumor therapeutic efficacy of C5252 in a subcutaneous glioblastoma model and an orthotopic glioblastoma model was confirmed. Moreover, syngeneic mouse models showed that the murine surrogate of C5252 has superior anti-tumor activity compared to the unarmed backbone virus, with enhanced immune activation. Taken together, our findings support C5252 as a promising therapeutic option for glioblastoma treatment, positioning it as a highly promising candidate for clinical translation.
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Affiliation(s)
- Lei Wang
- Research Center for Reproduction and Health Development, Institute of Biomedicine and Biotechnology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, 1068 Xueyuan Avenue, Shenzhen University Town, Shenzhen 518055, China
- Shenzhen International Institute for Biomedical Research, 1301 Guan-Guang Road, Building 1-B, Silver Star Hi-tech Industrial Park, Longhua District, Shenzhen 518110, China
| | - Xusha Zhou
- ImmVira Co., Ltd., Shenzhen 518110, China
| | | | | | - Yue Huang
- ImmVira Co., Ltd., Shenzhen 518110, China
| | - Yuan Cheng
- Department of Medical Oncology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China
| | - Peigen Ren
- Research Center for Reproduction and Health Development, Institute of Biomedicine and Biotechnology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, 1068 Xueyuan Avenue, Shenzhen University Town, Shenzhen 518055, China
| | - Jing Zhao
- Shenzhen International Institute for Biomedical Research, 1301 Guan-Guang Road, Building 1-B, Silver Star Hi-tech Industrial Park, Longhua District, Shenzhen 518110, China
| | - Grace Guoying Zhou
- Shenzhen International Institute for Biomedical Research, 1301 Guan-Guang Road, Building 1-B, Silver Star Hi-tech Industrial Park, Longhua District, Shenzhen 518110, China
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Suzuki T, Uchida H. Induction of necroptosis in multinucleated giant cells induced by conditionally replicating syncytial oHSV in co-cultures of cancer cells and non-cancerous cells. Mol Ther Oncol 2024; 32:200803. [PMID: 38706990 PMCID: PMC11067338 DOI: 10.1016/j.omton.2024.200803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 04/11/2024] [Indexed: 05/07/2024]
Abstract
Viral modifications enabling syncytium formation in infected cells can augment lysis by oncolytic herpes simplex viruses (oHSVs) which selectively kill cancer cells. In the case of receptor-retargeted oHSVs (RR-oHSVs) that exclusively enter and spread to cancer cells, anti-tumor effects can be enhanced in a magnitude of >100,000-fold by modifying the virus to a syncytial type (RRsyn-oHSV). However, when syncytia containing non-cancerous cells are induced by conditionally replicating syncytial oHSV (CRsyn-oHSV), syncytial death occurs at an early stage. This results in limited anti-tumor effects of the CRsyn-oHSV. Here, we investigated whether necroptosis is involved in death of the syncytia formed by the fusion of cancer cells and non-cancerous cells. Mixed-lineage kinase domain-like (MLKL), a molecule executing necroptosis, was expressed in all murine cancer cell lines examined, while receptor-interacting protein kinase 3 (RIPK3), which phosphorylates MLKL, was absent from most cell lines. In contrast, RIPK3 was expressed in non-cancerous murine fibroblast cell lines. When a CRsyn-oHSV-infected RIPK3-deficient cancer cell line was co-cultured with the fibroblast cell line, but not with the cancer cells themselves, MLKL was phosphorylated and syncytial death was induced. These results indicate that early necroptosis is induced in multinucleated giant cells formed by CRsyn-oHSV when they also contain non-cancerous cells.
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Affiliation(s)
- Takuma Suzuki
- Tokyo University of Pharmacy and Life Sciences, Tokyo 192-0392, Japan
- Project Division of Cancer Biomolecular Therapy, The Institute of Medical Science, The University of Tokyo, Tokyo 108-8639, Japan
| | - Hiroaki Uchida
- Tokyo University of Pharmacy and Life Sciences, Tokyo 192-0392, Japan
- Project Division of Cancer Biomolecular Therapy, The Institute of Medical Science, The University of Tokyo, Tokyo 108-8639, Japan
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3
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Kardani K, Sanchez Gil J, Rabkin SD. Oncolytic herpes simplex viruses for the treatment of glioma and targeting glioblastoma stem-like cells. Front Cell Infect Microbiol 2023; 13:1206111. [PMID: 37325516 PMCID: PMC10264819 DOI: 10.3389/fcimb.2023.1206111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
Glioblastoma (GBM) is one of the most lethal cancers, having a poor prognosis and a median survival of only about 15 months with standard treatment (surgery, radiation, and chemotherapy), which has not been significantly extended in decades. GBM demonstrates remarkable cellular heterogeneity, with glioblastoma stem-like cells (GSCs) at the apex. GSCs are a subpopulation of GBM cells that possess the ability to self-renew, differentiate, initiate tumor formation, and manipulate the tumor microenvironment (TME). GSCs are no longer considered a static population of cells with specific markers but are quite flexible phenotypically and in driving tumor heterogeneity and therapeutic resistance. In light of these features, they are a critical target for successful GBM therapy. Oncolytic viruses, in particular oncolytic herpes simplex viruses (oHSVs), have many attributes for therapy and are promising agents to target GSCs. oHSVs are genetically-engineered to selectively replicate in and kill cancer cells, including GSCs, but not normal cells. Moreover, oHSV can induce anti-tumor immune responses and synergize with other therapies, such as chemotherapy, DNA repair inhibitors, and immune checkpoint inhibitors, to potentiate treatment effects and reduce GSC populations that are partly responsible for chemo- and radio-resistance. Herein, we present an overview of GSCs, activity of different oHSVs, clinical trial results, and combination strategies to enhance efficacy, including therapeutic arming of oHSV. Throughout, the therapeutic focus will be on GSCs and studies specifically targeting these cells. Recent clinical trials and approval of oHSV G47Δ in Japan for patients with recurrent glioma demonstrate the efficacy and promise of oHSV therapy.
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Affiliation(s)
| | | | - Samuel D. Rabkin
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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Swanner J, Shim JS, Rivera-Caraballo KA, Vázquez-Arreguín K, Hong B, Bueso-Perez AJ, Lee TJ, Banasavadi-Siddegowda YK, Kaur B, Yoo JY. esRAGE-expressing oHSV enhances anti-tumor efficacy by inhibition of endothelial cell activation. Mol Ther Oncolytics 2023; 28:171-181. [PMID: 36789106 PMCID: PMC9918391 DOI: 10.1016/j.omto.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 01/12/2023] [Indexed: 01/17/2023] Open
Abstract
High-mobility group box 1 (HMGB1) is a damage-associated molecular pattern (DAMP) molecule that plays an important role in inflammation and tumorigenesis. Receptor for advanced glycation end products (RAGE) is one of the major receptors to which extracellular HMGB1 binds to mediate its activity. RAGE is highly expressed on the endothelial cells (ECs) and regulates endothelial permeability during inflammation. Here, we introduced the endogenous secretory form of RAGE (esRAGE) as a decoy receptor for RAGE ligands into an oncolytic herpes simplex virus 1 (oHSV) (OVesRAGE), which, upon release, can function to block RAGE signaling. OVesRAGE significantly decreased phosphorylation of MEK1/2 and Erk and increased cleaved PARP in glioblastoma (GBM) cells in vitro and in vivo. oHSV-infected GBM cells co-cultured with ECs were used to test OVesRAGE effect on EC activation, vessel leakiness, virus replication, and tumor cell killing. OVesRAGE could effectively secrete esRAGE and rescue virus-induced EC migration and activation. Reduced EC activation facilitated virus replication in tumor cells when co-cultured with ECs. Finally, OVesRAGE significantly enhanced therapeutic efficacy in GBM-bearing mice. Collectively, our data demonstrate that HMGB1-RAGE signaling could be a promising target and that its inhibition is a feasible approach to improve the efficacy of oHSV therapy.
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Affiliation(s)
- Jessica Swanner
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St., MSE R117A, Houston, TX 77030, USA
| | - Ji Seon Shim
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St., MSE R117A, Houston, TX 77030, USA
| | - Kimberly A. Rivera-Caraballo
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St., MSE R117A, Houston, TX 77030, USA
- Georgia Cancer Center and the Department of Pathology, Augusta University, 1410 Laney Walker Blvd, CN-3311, Augusta, GA 30912, USA
| | - Karina Vázquez-Arreguín
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St., MSE R117A, Houston, TX 77030, USA
- Georgia Cancer Center and the Department of Pathology, Augusta University, 1410 Laney Walker Blvd, CN-3311, Augusta, GA 30912, USA
| | - Bangxing Hong
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St., MSE R117A, Houston, TX 77030, USA
- Georgia Cancer Center and the Department of Pathology, Augusta University, 1410 Laney Walker Blvd, CN-3311, Augusta, GA 30912, USA
| | - Alberto J. Bueso-Perez
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St., MSE R117A, Houston, TX 77030, USA
| | - Tae Jin Lee
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St., MSE R117A, Houston, TX 77030, USA
| | | | - Balveen Kaur
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St., MSE R117A, Houston, TX 77030, USA
- Georgia Cancer Center and the Department of Pathology, Augusta University, 1410 Laney Walker Blvd, CN-3311, Augusta, GA 30912, USA
| | - Ji Young Yoo
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St., MSE R117A, Houston, TX 77030, USA
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Wu Y, Chen X, Wang L, Zhou X, Liu Y, Ji D, Ren P, Zhou GG, Zhao J. Histone Deacetylase Inhibitor Panobinostat Benefits the Therapeutic Efficacy of Oncolytic Herpes Simplex Virus Combined with PD-1/PD-L1 Blocking in Glioma and Squamous Cell Carcinoma Models. Viruses 2022; 14:v14122796. [PMID: 36560800 PMCID: PMC9781547 DOI: 10.3390/v14122796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 11/22/2022] [Accepted: 11/26/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Combination therapy has been widely explored for oncolytic virus (OV), as it can be met with tumor resistance. The HDAC inhibitor (HDACi) panobinostat is a potent pan-deacetylase inhibitor which blocks multiple cancer-related pathways and reverses epigenetic events in cancer progression. METHODS In this study, oncolytic activity in vitro and antitumor therapeutic efficacy in vivo when combined with oHSV and panobinostat were investigated. RESULTS (1) Treatment with panobinostat enhanced oHSV propagation and cytotoxicity in human glioma A172 and squamous cell carcinoma SCC9 cells. (2) Combined treatment with oHSV and panobinostat enhanced virus replication mediated by the transcriptional downregulation of IFN-β- and IFN-responsive antiviral genes in human glioma A172 and squamous cell carcinoma SCC9 cells. (3) Panobinostat treatment induced upregulation of PD-L1 expression in both glioma and squamous cell carcinoma cells. (4) A significantly enhanced therapeutic efficacy was shown in vivo for the murine glioma CT-2A and squamous cell carcinoma SCC7 models when treated with a combination of oHSV, including PD-1/PD-L1 blockade and HDAC inhibition. CONCLUSIONS Consequently, these data provide some new clues for the clinical development of combination therapy with OVs, epigenetic modifiers, and checkpoint blockades for glioma and squamous cell carcinoma.
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Affiliation(s)
- Yinglin Wu
- Department of Immunology, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou 511436, China
| | - Xiaoqing Chen
- Shenzhen International Institute for Biomedical Research, Shenzhen 518110, China
| | - Lei Wang
- Shenzhen International Institute for Biomedical Research, Shenzhen 518110, China
- Research Center for Reproduction and Health Development, Institute of Biomedicine and Biotechnology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Xusha Zhou
- Shenzhen International Institute for Biomedical Research, Shenzhen 518110, China
| | - Yonghong Liu
- Shenzhen International Institute for Biomedical Research, Shenzhen 518110, China
| | - Dongmei Ji
- Department of Medical Oncology, Shanghai Cancer Center and Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Peigen Ren
- Research Center for Reproduction and Health Development, Institute of Biomedicine and Biotechnology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Grace Guoying Zhou
- Shenzhen International Institute for Biomedical Research, Shenzhen 518110, China
- Correspondence: (G.G.Z.); (J.Z.)
| | - Jing Zhao
- Shenzhen International Institute for Biomedical Research, Shenzhen 518110, China
- Correspondence: (G.G.Z.); (J.Z.)
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Liu Y, Zheng Y, Deng T, Huang Y, Liu Z, Zhan B, Zhou X, Yan R, Ren J, Xing Y, Wu G, Zheng B, Hu G, Wang W, Liu Y, Zhao J, Chen X, Zhou GG. Oncolytic herpes simplex virus delivery of dual CAR targets of CD19 and BCMA as well as immunomodulators to enhance therapeutic efficacy in solid tumors combined with CAR T cell therapy. Front Oncol 2022; 12:1037934. [PMID: 36353540 PMCID: PMC9638445 DOI: 10.3389/fonc.2022.1037934] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/06/2022] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND The CAR T-cell therapy is a promising approach to treating hematologic malignancies. However, the application in solid tumors still has many tough challenges, including heterogenicity in antigen expressions and immunosuppressive tumor microenvironment (TME). As a new cancer treatment modality, oncolytic virotherapy can be engineered to circumvent these obstacles for CAR T cell therapy in solid tumors. METHODS In this study, an oHSV T7011 is engineered to drive ectopic expression of dual-antigens, extracellular domains of CD19 and BCMA, on the solid tumor cell surface to be targeted by approved CAR T cells. In addition, multiple immunomodulators, CCL5, IL-12, and anti-PD-1 antibody are also included to modulate the TME. The antitumor activities of T7011 in combination with CD19 or BCMA CAR T-cell were evaluated in vitro and in vivo. RESULTS The expression of CD19 or BMCA on the tumor cell surface could be detected after T7011 infection. The level of CCL5 in TME was also increased. Efficacy studies demonstrated that combination with T7011 and CAR-TCD19 or CAR-TBCMA cells showed significant synergistic anti-tumor responses in several solid tumor models. CONCLUSION These studies indicated that the new generation of oHSV T7011 can be a promising combinational therapy with CD19 or BCMA-specific CAR T cells for the treatment of a broad range of solid tumors.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jiangtao Ren
- Nanjing Bioheng Biotech Co., Ltd., Nanjing, China
| | - Yun Xing
- Nanjing Bioheng Biotech Co., Ltd., Nanjing, China
| | - Guixing Wu
- Nanjing Bioheng Biotech Co., Ltd., Nanjing, China
| | - Biao Zheng
- IASO Biotherapeutics Co., Ltd., Shanghai, China
| | - Guang Hu
- IASO Biotherapeutics Co., Ltd., Shanghai, China
| | - Wen Wang
- IASO Biotherapeutics Co., Ltd., Shanghai, China
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Kalke K, Orpana J, Lasanen T, Esparta O, Lund LM, Frejborg F, Vuorinen T, Paavilainen H, Hukkanen V. The In Vitro Replication, Spread, and Oncolytic Potential of Finnish Circulating Strains of Herpes Simplex Virus Type 1. Viruses 2022; 14:1290. [PMID: 35746761 DOI: 10.3390/v14061290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/06/2022] [Accepted: 06/09/2022] [Indexed: 12/17/2022] Open
Abstract
Herpes simplex virus type 1 (HSV-1) is the only FDA- and EMA- approved oncolytic virus, and accordingly, many potential oncolytic HSVs (oHSV) are in clinical development. The utilized oHSV parental strains are, however, mostly based on laboratory reference strains, which may possess a compromised cytolytic capacity in contrast to circulating strains of HSV-1. Here, we assess the phenotype of thirty-six circulating HSV-1 strains from Finland to uncover their potential as oHSV backbones. First, we determined their capacity for cell-to-cell versus extracellular spread, to find strains with replication profiles favorable for each application. Second, to unfold the differences, we studied the genetic diversity of two relevant viral glycoproteins (gB/UL27, gI/US7). Third, we examined the oncolytic potential of the strains in cells representing glioma, lymphoma, and colorectal adenocarcinoma. Our results suggest that the phenotype of a circulating isolate, including the oncolytic potential, is highly related to the host cell type. Nevertheless, we identified isolates with increased oncolytic potential in comparison with the reference viruses across many or all of the studied cancer cell types. Our research emphasizes the need for careful selection of the backbone virus in early vector design, and it highlights the potential of clinical isolates as backbones in oHSV development.
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Rivera-Caraballo KA, Nair M, Lee TJ, Kaur B, Yoo JY. The complex relationship between integrins and oncolytic herpes Simplex Virus 1 in high-grade glioma therapeutics. Mol Ther Oncolytics 2022; 26:63-75. [PMID: 35795093 PMCID: PMC9233184 DOI: 10.1016/j.omto.2022.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
High-grade gliomas (HGGs) are lethal central nervous system tumors that spread quickly through the brain, making treatment challenging. Integrins are transmembrane receptors that mediate cell-extracellular matrix (ECM) interactions, cellular adhesion, migration, growth, and survival. Their upregulation and inverse correlation in HGG malignancy make targeting integrins a viable therapeutic option. Integrins also play a role in herpes simplex virus 1 (HSV-1) entry. Oncolytic HSV-1 (oHSV) is the most clinically advanced oncolytic virotherapy, showing a superior safety and efficacy profile over standard cancer treatment of solid cancers, including HGG. With the FDA-approval of oHSV for melanoma and the recent conditional approval of oHSV for malignant glioma in Japan, usage of oHSV for HGG has become of great interest. In this review, we provide a systematic overview of the role of integrins in relation to oHSV, with a special focus on its therapeutic potential against HGG. We discuss the pros and cons of targeting integrins during oHSV therapy: while integrins play a pro-therapeutic role by acting as a gateway for oHSV entry, they also mediate the innate antiviral immune responses that hinder oHSV therapeutic efficacy. We further discuss alternative strategies to regulate the dual functionality of integrins in the context of oHSV therapy.
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Affiliation(s)
- Kimberly Ann Rivera-Caraballo
- Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Mitra Nair
- Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Tae Jin Lee
- Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Balveen Kaur
- Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA,Corresponding author Balveen Kaur, The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St., MSE R164, Houston, TX 77030, USA.
| | - Ji Young Yoo
- Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA,Corresponding author Dr. Ji Young Yoo, The Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, 6431 Fannin St., MSE R117A, Houston, TX 77030, USA.
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Zhou X, Zhao J, Zhang JV, Wu Y, Wang L, Chen X, Ji D, Zhou GG. Enhancing Therapeutic Efficacy of Oncolytic Herpes Simplex Virus with MEK Inhibitor Trametinib in Some BRAF or KRAS-Mutated Colorectal or Lung Carcinoma Models. Viruses 2021; 13:v13091758. [PMID: 34578339 PMCID: PMC8473197 DOI: 10.3390/v13091758] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/03/2021] [Accepted: 08/31/2021] [Indexed: 12/22/2022] Open
Abstract
Oncolytic virus (OV) as a promising therapeutic agent can selectively infect and kill tumor cells with naturally inherited or engineered properties. Considering the limitations of OVs monotherapy, combination therapy has been widely explored. MEK inhibitor (MEKi) Trametinib is an FDA-approved kinase inhibitor indicated for the treatment of tumors with BRAF V600E or V600K mutations. In this study, the oncolytic activity in vitro and anti-tumor therapeutic efficacy in vivo when combined with oHSV and MEKi Trametinib were investigated. We found: (1) Treatment with MEKi Trametinib augmented oHSV oncolytic activity in BRAF V600E-mutated tumor cells. (2) Combination treatment with oHSV and MEKi Trametinib enhanced virus replication mediated by down-regulation of STAT1 and PKR expression or phosphorylation in BRAF V600E-mutated tumor cells as well as BRAF wt/KRAS-mutated tumor cells. (3) A remarkably synergistic therapeutic efficacy was shown in vivo for BRAF wt/KRAS-mutated tumor models, when a combination of oHSV including PD-1 blockade and MEK inhibition. Collectively, these data provide some new insights for clinical development of combination therapy with oncolytic virus, MEK inhibition, and checkpoint blockade for BRAF or KRAS-mutated tumors.
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Affiliation(s)
- XuSha Zhou
- Shenzhen International Institute for Biomedical Research, Shenzhen 518110, China; (X.Z.); (J.Z.); (X.C.)
| | - Jing Zhao
- Shenzhen International Institute for Biomedical Research, Shenzhen 518110, China; (X.Z.); (J.Z.); (X.C.)
| | - Jian V. Zhang
- Center for Energy Metabolism and Reproduction, Institute of Biomedicine and Biotechnology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
- Correspondence: (J.V.Z.); (G.G.Z.)
| | - Yinglin Wu
- Department of Immunology, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou 511436, China; (Y.W.); (L.W.)
| | - Lei Wang
- Department of Immunology, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou 511436, China; (Y.W.); (L.W.)
| | - Xiaoqing Chen
- Shenzhen International Institute for Biomedical Research, Shenzhen 518110, China; (X.Z.); (J.Z.); (X.C.)
| | - Dongmei Ji
- Department of Medical Oncology, Shanghai Cancer Center and Shanghai Medical College, Fudan University, Shanghai 200032, China;
| | - Grace Guoying Zhou
- Shenzhen International Institute for Biomedical Research, Shenzhen 518110, China; (X.Z.); (J.Z.); (X.C.)
- Correspondence: (J.V.Z.); (G.G.Z.)
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10
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Zhou X, Zhao J, Wu Y, Wang L, Ji D, Chen X, Ren P, Zhou GG. Identification of Rab27a as a host factor for oncolytic herpes virus susceptibility to tumor cells. Virus Res 2021; 299:198425. [PMID: 33905773 DOI: 10.1016/j.virusres.2021.198425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 11/19/2022]
Abstract
Oncolytic viruses are emerging as therapeutic agents in oncology. However, resistance of tumor cells to HSV oncolysis pose significant barriers to antitumor response. Thus, study on the mechanisms of therapeutic resistance to oHSV and finding strategies for overcoming these mechanisms are needed. In this study, Rab27a, a small GTPase involved in exosome biogenesis, was noticed to highly correlate with the susceptibility of tumor cells to oHSV. We found that i) lower abundance of Rab27a in oHSV resistant mouse tumor cells was shown when compared to that of sensitive tumor cells through deep-sequencing; ii) the resistance of human tumor cells to oHSV infection is associated with a downregulation of Rab27a expression and overexpression of Rab27a can promote the replication capacity of oHSV; iii) Interestingly, a stabilizer protein of Rab27a, KIBRA, highly accumulated in oHSV resistant tumor cells, which is in contrast with the expression pattern of Rab27a. Furthermore, knockdown of KIBRA expression reduced oHSV replication in oHSV resistant tumor cells. Consequently, Rab27a was found to be relevant with oHSV replication without cell type specificity, and low abundance of Rab27a contributes to oHSV resistance in both mouse and human tumor cells, which will give new insights in the identification of potential targets or biomarkers for oHSV cancer therapy.
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Affiliation(s)
- XuSha Zhou
- Shenzhen International Institute for Biomedical Research, Shenzhen, 518110, Guangdong, China
| | - Jing Zhao
- Shenzhen International Institute for Biomedical Research, Shenzhen, 518110, Guangdong, China
| | - Yinglin Wu
- School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou, 511436, China
| | - Lei Wang
- School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou, 511436, China
| | - Dongmei Ji
- Shanghai Cancer Center and Shanghai Medical College, Fudan University, China
| | - Xiaoqing Chen
- Shenzhen International Institute for Biomedical Research, Shenzhen, 518110, Guangdong, China
| | - Peigen Ren
- Research Center for Reproduction and Health Development, Institute of Biomedicine and Biotechnology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China.
| | - Grace Guoying Zhou
- Shenzhen International Institute for Biomedical Research, Shenzhen, 518110, Guangdong, China.
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Samy RN, Earl BR, Lipschitz N, Schweinzger I, Currier M, Cripe T. Engineered oncolytic virus for the treatment of cholesteatoma: A pilot in vivo study. Laryngoscope Investig Otolaryngol 2019; 4:532-542. [PMID: 31637298 PMCID: PMC6793611 DOI: 10.1002/lio2.307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/21/2019] [Accepted: 08/20/2019] [Indexed: 01/04/2023] Open
Abstract
Objective Determine if oncolytic herpes simplex virus (oHSV) can eradicate cholesteatoma (CHST) in a gerbil model. Methods An in vivo model of CHST was developed in Mongolian gerbils by combining Pseudomonas aeruginosa inoculation with double ligation of the external auditory canal (EAC). CHST size and bone thickness were measured using morphometric and volumetric quantification techniques via micro‐computed tomography (micro‐CT). The CHST induction and quantification techniques were then used in an additional group of 10 gerbils (n = 20 ears) to determine the within‐group treatment efficacy of oHSV against CHST in vivo. Treated animals received either one, two, or three intrabullar injections of oHSV between 2 and 6 weeks postinduction of CHST. Results The P. aeruginosa inoculation plus double EAC ligation technique successfully induced a range of CHST growth in 100% of the ears in the model‐development group. Osteolytic effects of CHST were observed in 6% of ears whereas osteoblastic effects were observed in 31% of ears. CHST volume decreased by 50% or more in 12 of the 20 ears in the oHSV‐treatment groups. An apparent reversal of osteoblastic effects was also observed in three out of four ears 6 weeks following the third oHSV injection. Conclusions P. aeruginosa inoculation plus double EAC ligation reliably induces CHST formation in gerbil. CT‐based volumetric measures are significantly more accurate than single‐slice morphometric area measures for quantification of CHST size. Treatment with oHSV appears to be efficacious for reducing CHST volume by as much as 77% with as few as one treatment. Level of Evidence NA
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Affiliation(s)
- Ravi N Samy
- Department of Otolaryngology-Head and Neck Surgery University of Cincinnati College of Medicine Cincinnati Ohio U.S.A.,Neurosensory Disorders Center at University of Cincinnati Gardner Neuroscience Institute Cincinnati Ohio U.S.A.,Cincinnati Children's Hospital Medical Center Cincinnati Ohio U.S.A
| | - Brian R Earl
- Department of Otolaryngology-Head and Neck Surgery University of Cincinnati College of Medicine Cincinnati Ohio U.S.A.,Department of Communication Sciences and Disorders University of Cincinnati College of Allied Health Sciences Cincinnati Ohio U.S.A
| | - Noga Lipschitz
- Department of Otolaryngology-Head and Neck Surgery University of Cincinnati College of Medicine Cincinnati Ohio U.S.A
| | - Ivy Schweinzger
- Department of Communication Sciences and Disorders University of Cincinnati College of Allied Health Sciences Cincinnati Ohio U.S.A
| | - Mark Currier
- Center for Childhood Cancer and Blood Diseases The Research Institute at Nationwide Children's Hospital Columbus Ohio U.S.A
| | - Timothy Cripe
- Center for Childhood Cancer and Blood Diseases The Research Institute at Nationwide Children's Hospital Columbus Ohio U.S.A.,Division of Hematology, Oncology, Blood and Marrow Transplant, Department of Pediatrics Nationwide Children's Hospital Columbus Ohio U.S.A
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Lee JM, Ghonime MG, Cassady KA. STING Restricts oHSV Replication and Spread in Resistant MPNSTs but Is Dispensable for Basal IFN-Stimulated Gene Upregulation. Mol Ther Oncolytics 2019; 15:91-100. [PMID: 31650029 PMCID: PMC6804519 DOI: 10.1016/j.omto.2019.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/09/2019] [Indexed: 01/11/2023]
Abstract
Malignant peripheral nerve sheath tumors (MPNSTs) are an aggressive soft-tissue sarcoma amenable only to surgical resection. Oncolytic herpes simplex viruses (oHSVs) are a promising experimental therapy. We previously showed that basal interferon (IFN) and nuclear factor κB (NFκB) signaling upregulate IFN-stimulated gene (ISG) expression and restrict efficient viral infection and cell-to-cell spread in ∼50% of tested MPNSTs. Stimulator of Interferon Genes (STING) integrates DNA sensor activity and mediates downstream IFN signaling in infected cells. We sought to identify STING’s role in oHSV resistance and contribution to basal ISG upregulation in MPNSTs. We show that the level of STING activity in human MPNST cell lines is predictive of oHSV sensitivity and that resistant cell lines have intact mechanisms for detection of cytosolic double-stranded DNA (dsDNA). Furthermore, we show that STING downregulation renders MPNSTs more permissive to oHSV infection and cell-to-cell spread. While next-generation viruses can exploit this loss of STING activity, first-generation viruses remain restricted. Finally, STING is not integral to the previously-observed basal ISG upregulation, indicating that other pathways contribute to basal IFN signaling in resistant MPNSTs. These data broaden our understanding of the intrinsic pathways in MPNSTs and their role in oHSV resistance and offer potential targets to potentiate oncolytic virus activity.
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Affiliation(s)
- Joel M Lee
- The Ohio State University College of Medicine, Biomedical Sciences Graduate Program, Columbus, OH 43210, USA
| | - Mohammed G Ghonime
- Abigail Wexner Research Institute at Nationwide Children's Hospital Center for Childhood Cancer and Blood Disorders, Columbus, OH 43205, USA.,The Ohio State University, Columbus, OH 43210, USA
| | - Kevin A Cassady
- Abigail Wexner Research Institute at Nationwide Children's Hospital Center for Childhood Cancer and Blood Disorders, Columbus, OH 43205, USA.,The Ohio State University, Columbus, OH 43210, USA.,Department of Pediatrics, Division of Pediatric Infectious Diseases, Nationwide Children's Hospital, Columbus, OH 43205, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH 43210, USA
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Currier MA, Sprague L, Rizvi TA, Nartker B, Chen CY, Wang PY, Hutzen BJ, Franczek MR, Patel AV, Chaney KE, Streby KA, Ecsedy JA, Conner J, Ratner N, Cripe TP. Aurora A kinase inhibition enhances oncolytic herpes virotherapy through cytotoxic synergy and innate cellular immune modulation. Oncotarget 2017; 8:17412-17427. [PMID: 28147331 PMCID: PMC5392259 DOI: 10.18632/oncotarget.14885] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 01/17/2017] [Indexed: 12/31/2022] Open
Abstract
Malignant peripheral nerve sheath tumor (MPNST) and neuroblastoma models respond to the investigational small molecule Aurora A kinase inhibitor, alisertib. We previously reported that MPNST and neuroblastomas are also susceptible to oncolytic herpes virus (oHSV) therapy. Herein, we show that combination of alisertib and HSV1716, a virus derived from HSV-1 and attenuated by deletion of RL1, exhibits significantly increased antitumor efficacy compared to either monotherapy. Alisertib and HSV1716 reduced tumor growth and increased survival in two xenograft models of MPNST and neuroblastoma. We found the enhanced antitumor effect was due to multiple mechanisms that likely each contribute to the combination effect. First, oncolytic herpes virus increased the sensitivity of uninfected cells to alisertib cytotoxicity, a process we term virus-induced therapeutic adjuvant (VITA). Second, alisertib increased peak virus production and slowed virus clearance from tumors, both likely a consequence of it preventing virus-mediated increase of intratumoral NK cells. We also found that alisertib inhibited virus-induced accumulation of intratumoral myeloid derived suppressor cells, which normally are protumorigenic. Our data suggest that clinical trials of the combination of oHSV and alisertib are warranted in patients with neuroblastoma or MPNST.
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Affiliation(s)
- Mark A Currier
- Center for Childhood Cancer and Blood Diseases, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Les Sprague
- Center for Childhood Cancer and Blood Diseases, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Tilat A Rizvi
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center; Cincinnati, Ohio, USA
| | - Brooke Nartker
- Center for Childhood Cancer and Blood Diseases, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Chun-Yu Chen
- Center for Childhood Cancer and Blood Diseases, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Pin-Yi Wang
- Center for Childhood Cancer and Blood Diseases, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Brian J Hutzen
- Center for Childhood Cancer and Blood Diseases, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Meghan R Franczek
- Center for Childhood Cancer and Blood Diseases, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Ami V Patel
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center; Cincinnati, Ohio, USA
| | - Katherine E Chaney
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center; Cincinnati, Ohio, USA
| | - Keri A Streby
- Center for Childhood Cancer and Blood Diseases, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA.,Division of Hematology/Oncology/Blood and Marrow Transplantation, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | | | - Joe Conner
- Virttu Biologics, Ltd, Biocity, Scotland, Newhouse, United Kingdom
| | - Nancy Ratner
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center; Cincinnati, Ohio, USA
| | - Timothy P Cripe
- Center for Childhood Cancer and Blood Diseases, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA.,Division of Hematology/Oncology/Blood and Marrow Transplantation, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
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Nigim F, Esaki SI, Hood M, Lelic N, James MF, Ramesh V, Stemmer-Rachamimov A, Cahill DP, Brastianos PK, Rabkin SD, Martuza RL, Wakimoto H. A new patient-derived orthotopic malignant meningioma model treated with oncolytic herpes simplex virus. Neuro Oncol 2016; 18:1278-87. [PMID: 26951380 DOI: 10.1093/neuonc/now031] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/06/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Higher-grade meningiomas (HGMs; World Health Organization grades II and III) pose a clinical problem due to high recurrence rates and the absence of effective therapy. Preclinical development of novel therapeutics requires a disease model that recapitulates the genotype and phenotype of patient HGM. Oncolytic herpes simplex virus (oHSV) has shown efficacy and safety in cancers in preclinical and clinical studies, but its utility for HGM has not been well characterized. METHODS Tumorsphere cultures and serial orthotopic xenografting in immunodeficient mice were used to establish a patient-derived HGM model. The model was pathologically and molecularly characterized by immunohistochemistry, western blot, and genomic DNA sequencing and compared with the patient tumor. Anti-HGM effects of oHSV G47Δ were assessed using cell viability and virus replication assays in vitro and animal survival analysis following intralesional injections of G47Δ. RESULTS We established a serially transplantable orthotopic malignant meningioma model, MN3, which was lethal within 3 months after tumorsphere implantation. MN3 xenografts exhibited the pathological hallmarks of malignant meningioma such as high Ki67 and vimentin expression. Both the patient tumor and xenografts were negative for neurofibromin 2 (merlin) and had the identical NF2 mutation. Oncolytic HSV G47Δ efficiently spread and killed MN3 cells, as well as other patient-derived HGM lines in vitro. Treatment with G47Δ significantly extended the survival of mice bearing subdural MN3 tumors. CONCLUSIONS We established a new patient-derived meningioma model that will enable the study of targeted therapeutic approaches for HGM. Based on these studies, it is reasonable to consider a clinical trial of G47Δ for HGM.
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Affiliation(s)
- Fares Nigim
- Department of Neurosurgery (F.N., S.-i.E., M.H., N.L., D.P.C., S.D.R., R.L.M., H.W.), Center for Human Genetic Research (M.F.J., V.R.), Department of Neuropathology (A.S.-R.), Division of Neuro-Oncology (P.K.B.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shin-Ichi Esaki
- Department of Neurosurgery (F.N., S.-i.E., M.H., N.L., D.P.C., S.D.R., R.L.M., H.W.), Center for Human Genetic Research (M.F.J., V.R.), Department of Neuropathology (A.S.-R.), Division of Neuro-Oncology (P.K.B.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael Hood
- Department of Neurosurgery (F.N., S.-i.E., M.H., N.L., D.P.C., S.D.R., R.L.M., H.W.), Center for Human Genetic Research (M.F.J., V.R.), Department of Neuropathology (A.S.-R.), Division of Neuro-Oncology (P.K.B.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nina Lelic
- Department of Neurosurgery (F.N., S.-i.E., M.H., N.L., D.P.C., S.D.R., R.L.M., H.W.), Center for Human Genetic Research (M.F.J., V.R.), Department of Neuropathology (A.S.-R.), Division of Neuro-Oncology (P.K.B.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marianne F James
- Department of Neurosurgery (F.N., S.-i.E., M.H., N.L., D.P.C., S.D.R., R.L.M., H.W.), Center for Human Genetic Research (M.F.J., V.R.), Department of Neuropathology (A.S.-R.), Division of Neuro-Oncology (P.K.B.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vijaya Ramesh
- Department of Neurosurgery (F.N., S.-i.E., M.H., N.L., D.P.C., S.D.R., R.L.M., H.W.), Center for Human Genetic Research (M.F.J., V.R.), Department of Neuropathology (A.S.-R.), Division of Neuro-Oncology (P.K.B.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anat Stemmer-Rachamimov
- Department of Neurosurgery (F.N., S.-i.E., M.H., N.L., D.P.C., S.D.R., R.L.M., H.W.), Center for Human Genetic Research (M.F.J., V.R.), Department of Neuropathology (A.S.-R.), Division of Neuro-Oncology (P.K.B.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel P Cahill
- Department of Neurosurgery (F.N., S.-i.E., M.H., N.L., D.P.C., S.D.R., R.L.M., H.W.), Center for Human Genetic Research (M.F.J., V.R.), Department of Neuropathology (A.S.-R.), Division of Neuro-Oncology (P.K.B.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Priscilla K Brastianos
- Department of Neurosurgery (F.N., S.-i.E., M.H., N.L., D.P.C., S.D.R., R.L.M., H.W.), Center for Human Genetic Research (M.F.J., V.R.), Department of Neuropathology (A.S.-R.), Division of Neuro-Oncology (P.K.B.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel D Rabkin
- Department of Neurosurgery (F.N., S.-i.E., M.H., N.L., D.P.C., S.D.R., R.L.M., H.W.), Center for Human Genetic Research (M.F.J., V.R.), Department of Neuropathology (A.S.-R.), Division of Neuro-Oncology (P.K.B.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert L Martuza
- Department of Neurosurgery (F.N., S.-i.E., M.H., N.L., D.P.C., S.D.R., R.L.M., H.W.), Center for Human Genetic Research (M.F.J., V.R.), Department of Neuropathology (A.S.-R.), Division of Neuro-Oncology (P.K.B.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hiroaki Wakimoto
- Department of Neurosurgery (F.N., S.-i.E., M.H., N.L., D.P.C., S.D.R., R.L.M., H.W.), Center for Human Genetic Research (M.F.J., V.R.), Department of Neuropathology (A.S.-R.), Division of Neuro-Oncology (P.K.B.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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