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Cao Q, Hajosch A, Kast RE, Loehmann C, Hlavac M, Fischer-Posovszky P, Strobel H, Westhoff MA, Siegelin MD, Wirtz CR, Halatsch ME, Karpel-Massler G. Tumor Treating Fields (TTFields) combined with the drug repurposing approach CUSP9v3 induce metabolic reprogramming and synergistic anti-glioblastoma activity in vitro. Br J Cancer 2024; 130:1365-1376. [PMID: 38396172 PMCID: PMC11015043 DOI: 10.1038/s41416-024-02608-8] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 01/27/2024] [Accepted: 01/30/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Glioblastoma represents a brain tumor with a notoriously poor prognosis. First-line therapy may include adjunctive Tumor Treating Fields (TTFields) which are electric fields that are continuously delivered to the brain through non-invasive arrays. On a different note, CUSP9v3 represents a drug repurposing strategy that includes 9 repurposed drugs plus metronomic temozolomide. Here, we examined whether TTFields enhance the antineoplastic activity of CUSP9v3 against this disease. METHODS We performed preclinical testing of a multimodal approach of TTFields and CUSP9v3 in different glioblastoma models. RESULTS TTFields had predominantly synergistic inhibitory effects on the cell viability of glioblastoma cells and non-directed movement was significantly impaired when combined with CUSP9v3. TTFields plus CUSP9v3 significantly enhanced apoptosis, which was associated with a decreased mitochondrial outer membrane potential (MOMP), enhanced cleavage of effector caspase 3 and reduced expression of Bcl-2 and Mcl-1. Moreover, oxidative phosphorylation and expression of respiratory chain complexes I, III and IV was markedly reduced. CONCLUSION TTFields strongly enhance the CUSP9v3-mediated anti-glioblastoma activity. TTFields are currently widely used for the treatment of glioblastoma patients and CUSP9v3 was shown to have a favorable safety profile in a phase Ib/IIa trial (NCT02770378) which facilitates transition of this multimodal approach to the clinical setting.
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Affiliation(s)
- Qiyu Cao
- Department of Neurosurgery, Ulm University Medical Center, Ulm, Germany
| | - Annika Hajosch
- Department of Neurosurgery, Ulm University Medical Center, Ulm, Germany
| | | | | | - Michal Hlavac
- Department of Neurosurgery, Ulm University Medical Center, Ulm, Germany
| | | | - Hannah Strobel
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm, Germany
| | - Mike-Andrew Westhoff
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm, Germany
| | - Markus D Siegelin
- Department of Pathology, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Marc-Eric Halatsch
- Department of Neurosurgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
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Grübel N, Antoniadis G, AK U, Mayer B, König R, Wirtz CR, Pala A, Dengler NF, Pedro MT. Health-related quality of life in patients with peripheral nerve tumors: results from the German multicentric Peripheral Nerve Tumor Registry. Front Oncol 2024; 14:1398252. [PMID: 38711847 PMCID: PMC11070577 DOI: 10.3389/fonc.2024.1398252] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 03/25/2024] [Indexed: 05/08/2024] Open
Abstract
Objective Peripheral nerve tumors (PNTs) are rare diseases. So far, no multicenter data on diagnostics, the efficacy of treatment, long-term outcomes, and health-related quality of life (HRQoL) exist. The establishment of the Peripheral Nerve Tumor Registry (PNTR) in 2015 allows for the systematic analysis of patients with tumors associated with peripheral nerves. The present study aims to investigate the impact of PNT on an individual's HRQoL and the effect of surgery. Methods HRQoL was pre- and postoperatively assessed by the Euro-Qol-5D-5L (EQ-5D-5L) and Euro-Qol visual analog scale (EQ-VAS) survey in the retrospective and prospective study arm in three active participating study centers. An index was calculated based on the EQ-5D-5L for the quantification of health state (0: worst possible state of health, 1: best possible state of health). The EQ-VAS ranges from 0% (worst imaginable health status) to 100% (best possible health status). Patient characteristics (age, sex), as well as disease (histopathological entity) and treatment (pre- and postoperative symptoms, type of treatment)-specific data, were analyzed. Results Data from 171 patients from three high-volume centers were included, with schwannoma (70.8%, n = 121) and neurofibroma (15.8%, n = 27) being the most prevalent histopathological diagnoses. Both the median health index value (preoperative: 0.887, n = 167; postoperative: 0.910, n = 166) and the median EQ-VAS (preoperative: 75%, n = 167; postoperative: 85%, n = 166) of the entire cohort regarding all histopathological diagnosis improved significantly after surgical therapy (p < 0.001). Preoperatively, 12.3% (n = 21) reached the highest index score of 1.0 in EQ-5D-5L and 100% in the EQ-VAS score in 5.3% (n = 9) of all patients. Postoperatively, the highest index score of 1.0 and 100% in the EQ-VAS score increased significantly and were achieved in 33.3% (n = 57) and 11.1% (n = 19) of the patients, respectively (p < 0.001). Conclusion For the first time, our study presents multicenter data on life quality and the effect of surgery in primarily benign peripheral nerve tumors. Early surgery at a specialized center could improve neurological outcomes and, in conclusion, better QoL. In summary, surgical therapy significantly improved the entire cohort's QoL, VAS, and analgesia.
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Affiliation(s)
- Nadja Grübel
- Peripheral Nerve Unit, Department of Neurosurgery, University Medicine of Ulm, Günzburg, Germany
| | - Gregor Antoniadis
- Peripheral Nerve Unit, Department of Neurosurgery, University Medicine of Ulm, Günzburg, Germany
| | - Uerschels AK
- Department of Neurosurgery, University Medicine Essen, Essen, Germany
| | - Benjamin Mayer
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Ralph König
- Peripheral Nerve Unit, Department of Neurosurgery, University Medicine of Ulm, Günzburg, Germany
| | - Christian Rainer Wirtz
- Peripheral Nerve Unit, Department of Neurosurgery, University Medicine of Ulm, Günzburg, Germany
| | - Andrej Pala
- Peripheral Nerve Unit, Department of Neurosurgery, University Medicine of Ulm, Günzburg, Germany
| | - Nora F. Dengler
- Department of Neurosurgery, University Medicine Charité Berlin, Berlin, Germany
| | - Maria Teresa Pedro
- Peripheral Nerve Unit, Department of Neurosurgery, University Medicine of Ulm, Günzburg, Germany
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Durner G, Ulrich I, Gerst A, Becker R, Wirtz CR, Antoniadis G, Pedro MT, Pala A. Mapping Motor Neuroplasticity after Successful Surgical Brachial Plexus Reconstruction Using Navigated Transcranial Magnetic Stimulation (nTMS). Neurol Int 2024; 16:239-252. [PMID: 38392957 PMCID: PMC10891637 DOI: 10.3390/neurolint16010016] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/12/2024] [Accepted: 01/23/2024] [Indexed: 02/25/2024] Open
Abstract
Brachial plexus reconstruction (BPR) consists of the complex surgical restoration of nerve structures. To further understand the underlying motor cortex changes and evaluate neuroplasticity after a successful surgery, we performed a navigated transcranial magnetic stimulation (nTMS) study mapping the postoperative motor representation of the formerly plegic arm. We conducted a prospective nTMS study mapping the musculocutaneous nerve as a representative, prominent target of BPR including a patient (n = 8) and a control group (n = 10). Measurements like resting motor threshold (RMT), cortical motor area location, and size were taken. Mathematical analysis was performed using MATLAB 2022, statistical analysis was performed using SPSS 26, and nTMS mapping was performed using the Nexstim NBS 5.1 system. Mapping was feasible in seven out of eight patients. Median RMT on the affected hemisphere was 41% compared to 50% on the unaffected hemisphere and they were 37% and 36% on the left and right hemispheres of the control group. The motor area location showed a relocation of bicep brachii representation at the middle precentral gyrus of the corresponding contralateral hemisphere. Motor area size was increased compared to the control group and the patient's unaffected, ipsilateral hemisphere. Understanding cortical reorganization is important for potential future treatments like therapeutic nTMS. The issue of motor neuroplasticity in patients with brachial plexus lesions is worth exploring in further studies.
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Affiliation(s)
- Gregor Durner
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany (G.A.)
| | - Ina Ulrich
- Department of Neurosurgery, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany (C.R.W.)
| | - Alexandra Gerst
- Department of Neurosurgery, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany (C.R.W.)
| | - Ralf Becker
- Department of Neuroradiology, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany;
| | - Christian Rainer Wirtz
- Department of Neurosurgery, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany (C.R.W.)
| | - Gregor Antoniadis
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany (G.A.)
| | - Maria Teresa Pedro
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany (G.A.)
| | - Andrej Pala
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany (G.A.)
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Pfnür A, Antoniadis G, Wirtz CR, Pedro MT. [Long-Term Outcomes after Surgery of the Neurogenic Thoracic-Outlet Syndrome in Adolescents]. HANDCHIR MIKROCHIR P 2024; 56:32-39. [PMID: 38316411 DOI: 10.1055/a-2234-5066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Neurogenic Thoracic Outlet Syndrome (nTOS) describes a complex of symptoms caused by the compression of neural structures at the upper thoracic outlet. Typical symptoms include pain, numbness and motor weakness of the affected extremity. The incidence of nTOS is 2-3 per 100,000 and is highest between the ages of 25 and 40. There are only a few studies evaluating the surgical outcomes of nTOS in adolescent patients. In particular, there is a lack of long-term data. MATERIALS AND METHODS In a retrospective study of nTOS cases receiving surgical treatment in our clinic between 2002 and 2021, eight patients between 15 and 18 years of age were included. Demographic data, risk factors, clinical symptoms, clinical functional tests, neurophysiological, radiological and intraoperative findings were evaluated. Postoperative data were recorded using a standardised questionnaire. Decompression of the inferior truncus and the C8 and Th1 nerve roots was performed via a supraclavicular approach. RESULTS The average duration of symptoms before surgery was two years. Of the eight patients who underwent surgery, six answered the written questionnaire and could be analysed for the study. The average follow-up was nine years (1-18 years). After surgery, all patients experienced pain reduction; three were pain-free in the long run and five no longer required pain medication. Strength improved in all patients, but two patients still had mild motor deficits. Sensory disturbances were reduced in all patients, but residual hypoesthesia persisted in five. With regard to overhead work, half of the patients had no impairment after surgery. All patients were able to work at the time of the survey. Half of the patients pursued their sports activities without impairment, while mild impairment was reported by the other half. CONCLUSION nTOS in adolescents is a rare compression syndrome. Decompression of the lower parts of the brachial plexus using a supraclavicular approach without resection of the first rib is an adequate treatment. This retrospective study showed that a reduction in pain was achieved in all patients. In some patients, slight sensory and motor disturbances as well as a certain restriction in overhead work persisted. Patients were able to return to sports.
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Affiliation(s)
- Andreas Pfnür
- Neurochirurgie, Bezirkskrankenhaus Günzburg, Günzburg, Germany
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Tosin D, Antoniadis G, Wirtz CR, Pedro MT. [Rare Compression Syndrome of the Median Nerve due to a Supracondylar Humeral Process and a Ligament of Struthers]. HANDCHIR MIKROCHIR P 2024; 56:101-105. [PMID: 38359863 DOI: 10.1055/a-2234-4636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION A supracondylar process is a bony spur on the distal anteromedial surface of the humerus, and it is considered an anatomical variant with a prevalence of 0.4-2.7% according to anatomical studies. In almost all cases, it is associated with a fibrous, sometimes ossified ligament, which extends from the supracondylar process to the medial epicondyle. This ligament is known in the literature as the ligament of Struthers, named after the Scottish anatomist who first described it in detail in 1854. In rare cases, the supracondylar process can be a clinically relevant finding as a cause of nerve compression syndrome. The median and ulnar nerve can be trapped by the ring-shaped structure formed by the ligament of Struthers and the supracondylar process. CASE REPORT A 59-year-old patient with symptoms of a cubital tunnel syndrome and additional ipsilateral sensory deficits in his thumb was referred to our clinic. Electroneurography showed no signs of an additional carpal tunnel syndrome. Preoperative x-ray and CT scans of the upper arm revealed a supracondylar process, which led us to suspect an associated entrapment of the median nerve. An MRI scan of the upper arm showed a ligament of Struthers and signs of a related median nerve compression as we initially assumed. We performed a surgical decompression of the median nerve in the distal upper arm and of the ulnar nerve in the cubital tunnel. Intraoperatively, there was evidence of compression of the median nerve due to the supracondylar process and the ligament of Struthers. The latter was cleaved and then resected along with the supracondylar process. Three months after surgery, the patient had no motor or sensory deficits. SUMMARY The ring-shaped structure formed by the supracondylar process and ligament of Struthers represents a rare cause of compression syndrome of the median and ulnar nerve. Its incidence remains unknown so far. This anatomical variant should be considered a differential diagnosis in case of possibly related nerve entrapment symptoms after ruling out other, more frequent nerve compression causes. Moreover, the supracondylar process should be completely resected including the periosteum during surgery to minimise the risk of recurrence.
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Affiliation(s)
- Davide Tosin
- Neurochirurgie, Bezirkskrankenhaus Günzburg, Günzburg, Germany
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Minzenmay L, Antoniadis G, Paľa A, Bäzner UM, Knoll A, Petkov M, Wirtz CR, Pedro MT. The impact of SARS-Covid-19 pandemic on peripheral nerve surgery - A single centre report. Clin Neurol Neurosurg 2024; 237:108124. [PMID: 38266330 DOI: 10.1016/j.clineuro.2024.108124] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 01/26/2024]
Abstract
OBJECTIVE SARS-Cov-19 pandemic totally changed daily routine work in German hospitals. As hospital capacity was reduced, many surgeries were postponed or even cancelled. On March 25th 2020 the German Society of Neurosurgery (DGNC) published a statement in which urgent non-elective surgeries were defined for each neurosurgical domain, whereas elective interventions were deferred. The present work examines the impact of these Covid strategies focusing on patients with peripheral lesions who were conducted to our department during this period of time. METHODS All patients who underwent any peripheral nerve surgery at our department from January 2018 until December 2022, were included. The complete range of surgeries including peripheral nerve lesions was examined encompassing compression syndromes, traumatic lesions of brachial plexus, traumatic lesions and tumors of single peripheral nerves. The numbers of surgical procedures were compared before, during and after pandemic. Pearson correlation coefficient was analysed. RESULTS From 2018 to 2022 the total number of surgical procedures involving peripheral nerves included 2422 procedures. Compression syndromes made up the largest proportion (1433 operations, 59%), followed by peripheral nerve lesions (445 operations, 18%), peripheral nerve tumors (344 operations, 14%) and lesions of the brachial plexus (142 operations, 6%). The average was 40,5 interventions per month, the range was 7-63. Two declines in the number of peripheral nerve surgeries were noted during this period. The first was in April and May 2020 with an average drop of 65% and 41% respectively. In these months the average number of operations was 37. The second decrease was from October 2021 until January 2022, where number of surgeries was reduced by 16%, 36%, 83% and 18% with an average number of 50 operations. Both declines showed a significant and strong correlation with the lower number of compression syndrome treatments (r = 0.952, p < 0.001 and r = 0.968, p < 0.001), while no drop and no significant correlation was found in the treatment of traumatic peripheral nerve injuries (p = 0.769, r = 0.095 and p = 0.243, r = 0.366) and traumatic brachial plexus injuries (p = 0.787, r = 0.088 and p = 0.780, r = 0.09). A weak significant correlation was seen in the treatment numbers of peripheral nerve tumors (p = 0.017, r = 0.672 and p = 0.015, r = 0.67). CONCLUSION Covid-19 pandemic lead to a significant decrease in the number of nerve decompressions, since, according to the German Society of Neurosurgery, those were considered as elective surgeries.
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Affiliation(s)
- Lena Minzenmay
- University of Ulm, Department of Neurosurgery, Lindenallee 2, 89312 Günzburg, Germany.
| | - Gregor Antoniadis
- University of Ulm, Department of Neurosurgery, Lindenallee 2, 89312 Günzburg, Germany
| | - Andrej Paľa
- University of Ulm, Department of Neurosurgery, Lindenallee 2, 89312 Günzburg, Germany
| | - Ute Marlies Bäzner
- University of Ulm, Department of Neurosurgery, Lindenallee 2, 89312 Günzburg, Germany
| | - Andreas Knoll
- University of Ulm, Department of Neurosurgery, Lindenallee 2, 89312 Günzburg, Germany
| | - Martin Petkov
- University of Ulm, Department of Neurosurgery, Lindenallee 2, 89312 Günzburg, Germany
| | | | - Maria Teresa Pedro
- University of Ulm, Department of Neurosurgery, Lindenallee 2, 89312 Günzburg, Germany
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Pfnür A, Tosin D, Petkov M, Sharon O, Mayer B, Wirtz CR, Knoll A, Pala A. Exploring complications following cranioplasty after decompressive hemicraniectomy: A retrospective bicenter assessment of autologous, PMMA and CAD implants. Neurosurg Rev 2024; 47:72. [PMID: 38285230 PMCID: PMC10824806 DOI: 10.1007/s10143-024-02309-z] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/12/2024] [Accepted: 01/20/2024] [Indexed: 01/30/2024]
Abstract
Cranioplasty (CP) after decompressive hemicraniectomy (DHC) is a common neurosurgical procedure with a high complication rate. The best material for the repair of large cranial defects is unclear. The aim of this study was to evaluate different implant materials regarding surgery related complications after CP. Type of materials include the autologous bone flap (ABF), polymethylmethacrylate (PMMA), calcium phosphate reinforced with titanium mesh (CaP-Ti), polyetheretherketone (PEEK) and hydroxyapatite (HA). A retrospective, descriptive, observational bicenter study was performed, medical data of all patients who underwent CP after DHC between January 1st, 2016 and December 31st, 2022 were analyzed. Follow-up was until December 31st, 2023. 139 consecutive patients with a median age of 54 years who received either PMMA (56/139; 40.3%), PEEK (35/139; 25.2%), CaP-Ti (21/139; 15.1%), ABF (25/139; 18.0%) or HA (2/139; 1.4%) cranial implant after DHC were included in the study. Median time from DHC to CP was 117 days and median follow-up period was 43 months. Surgical site infection was the most frequent surgery-related complication (13.7%; 19/139). PEEK implants were mostly affected (28.6%; 10/35), followed by ABF (20%; 5/25), CaP-Ti implants (9.5%; 2/21) and PMMA implants (1.7%, 1/56). Explantation was necessary for 9 PEEK implants (25.7%; 9/35), 6 ABFs (24.0%; 6/25), 3 CaP-Ti implants (14.3%; 3/21) and 4 PMMA implants (7.1%; 4/56). Besides infection, a postoperative hematoma was the most common cause. Median surgical time was 106 min, neither longer surgical time nor use of anticoagulation were significantly related to higher infection rates (p = 0.547; p = 0.152 respectively). Ventriculoperitoneal shunt implantation prior to CP was noted in 33.8% (47/139) and not significantly associated with surgical related complications. Perioperative lumbar drainage, due to bulging brain, inserted in 38 patients (27.3%; 38/139) before surgery was protective when it comes to explantation of the implant (p = 0.035). Based on our results, CP is still related to a relatively high number of infections and further complications. Implant material seems to have a high effect on postoperative infections, since surgical time, anticoagulation therapy and hydrocephalus did not show a statistically significant effect on postoperative complications in this study. PEEK implants and ABFs seem to possess higher risk of postoperative infection. More biocompatible implants such as CaP-Ti might be beneficial. Further, prospective studies are necessary to answer this question.
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Affiliation(s)
- A Pfnür
- Department of Neurosurgery, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
| | - D Tosin
- Department of Neurosurgery, University of Ulm, Lindenallee 2, 89312, Günzburg, Germany
| | - M Petkov
- Department of Neurosurgery, University of Ulm, Lindenallee 2, 89312, Günzburg, Germany
| | - O Sharon
- Department of Neurosurgery, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - B Mayer
- Institute of Epidemiology and Medical Biometry, University of Ulm, Schwabstraße 13, 89075, Ulm, Germany
| | - C R Wirtz
- Department of Neurosurgery, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
- Department of Neurosurgery, University of Ulm, Lindenallee 2, 89312, Günzburg, Germany
| | - A Knoll
- Department of Neurosurgery, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - A Pala
- Department of Neurosurgery, University of Ulm, Lindenallee 2, 89312, Günzburg, Germany
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Roder C, Stummer W, Coburger J, Scherer M, Haas P, von der Brelie C, Kamp MA, Löhr M, Hamisch CA, Skardelly M, Scholz T, Schipmann S, Rathert J, Brand CM, Pala A, Ernemann U, Stockhammer F, Gerlach R, Kremer P, Goldbrunner R, Ernestus RI, Sabel M, Rohde V, Tabatabai G, Martus P, Bisdas S, Ganslandt O, Unterberg A, Wirtz CR, Tatagiba M. Intraoperative MRI-Guided Resection Is Not Superior to 5-Aminolevulinic Acid Guidance in Newly Diagnosed Glioblastoma: A Prospective Controlled Multicenter Clinical Trial. J Clin Oncol 2023; 41:5512-5523. [PMID: 37335962 PMCID: PMC10730068 DOI: 10.1200/jco.22.01862] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 03/07/2023] [Accepted: 05/10/2023] [Indexed: 06/21/2023] Open
Abstract
PURPOSE Prospective data suggested a superiority of intraoperative MRI (iMRI) over 5-aminolevulinic acid (5-ALA) for achieving complete resections of contrast enhancement in glioblastoma surgery. We investigated this hypothesis in a prospective clinical trial and correlated residual disease volumes with clinical outcome in newly diagnosed glioblastoma. METHODS This is a prospective controlled multicenter parallel-group trial with two center-specific treatment arms (5-ALA and iMRI) and blinded evaluation. The primary end point was complete resection of contrast enhancement on early postoperative MRI. We assessed resectability and extent of resection by an independent blinded centralized review of preoperative and postoperative MRI with 1-mm slices. Secondary end points included progression-free survival (PFS) and overall survival (OS), patient-reported quality of life, and clinical parameters. RESULTS We recruited 314 patients with newly diagnosed glioblastomas at 11 German centers. A total of 127 patients in the 5-ALA and 150 in the iMRI arm were analyzed in the as-treated analysis. Complete resections, defined as a residual tumor ≤0.175 cm³, were achieved in 90 patients (78%) in the 5-ALA and 115 (81%) in the iMRI arm (P = .79). Incision-suture times (P < .001) were significantly longer in the iMRI arm (316 v 215 [5-ALA] minutes). Median PFS and OS were comparable in both arms. The lack of any residual contrast enhancing tumor (0 cm³) was a significant favorable prognostic factor for PFS (P < .001) and OS (P = .048), especially in methylguanine-DNA-methyltransferase unmethylated tumors (P = .006). CONCLUSION We could not confirm superiority of iMRI over 5-ALA for achieving complete resections. Neurosurgical interventions in newly diagnosed glioblastoma shall aim for safe complete resections with 0 cm³ contrast-enhancing residual disease, as any other residual tumor volume is a negative predictor for PFS and OS.
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Affiliation(s)
- Constantin Roder
- Department of Neurosurgery, University Hospital Tübingen, Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, Eberhard-Karls-University, Tübingen, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Westphalian-Wilhelms-University, Münster, Germany
| | - Jan Coburger
- Department of Neurosurgery, University Hospital Ulm/Günzburg, University of Ulm, Günzburg, Germany
| | - Moritz Scherer
- Department of Neurosurgery, University Hospital Heidelberg, Rupprecht-Karls-University, Heidelberg, Germany
| | - Patrick Haas
- Department of Neurosurgery, University Hospital Tübingen, Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, Eberhard-Karls-University, Tübingen, Germany
| | - Christian von der Brelie
- Department of Neurosurgery, University Hospital Göttingen, Georg-August-University, Göttingen, Germany
- Department of Neurosurgery, Johanniter Hospital Bonn, Bonn, Germany
| | - Marcel Alexander Kamp
- Department of Neurosurgery, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
- Department of Neurosurgery, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Mario Löhr
- Department of Neurosurgery, University Hospital Würzburg, Julius-Maximilians-University, Würzburg, Germany
| | - Christina A. Hamisch
- Department of Neurosurgery, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Marco Skardelly
- Department of Neurosurgery, University Hospital Tübingen, Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, Eberhard-Karls-University, Tübingen, Germany
- Department of Neurosurgery, Municipal Hospital Reutlingen, Reutlingen, Germany
| | - Torben Scholz
- Department of Neurosurgery, Asklepios Klinik Nord—Heidberg, Hamburg, Germany
| | - Stephanie Schipmann
- Department of Neurosurgery, University Hospital Münster, Westphalian-Wilhelms-University, Münster, Germany
- Department of Neurosurgery, Haukeland University Hospital Bergen, Bergen, Norway
| | - Julian Rathert
- Department of Neurosurgery, Helios Hospital Erfurt, Erfurt, Germany
| | | | - Andrej Pala
- Department of Neurosurgery, University Hospital Ulm/Günzburg, University of Ulm, Günzburg, Germany
| | - Ulrike Ernemann
- Department of Neuroradiology, University Hospital Tübingen, Eberhards-Karls-University, Tübingen, Germany
| | | | - Rüdiger Gerlach
- Department of Neurosurgery, Helios Hospital Erfurt, Erfurt, Germany
| | - Paul Kremer
- Department of Neurosurgery, Asklepios Klinik Nord—Heidberg, Hamburg, Germany
| | - Roland Goldbrunner
- Department of Neurosurgery, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ralf-Ingo Ernestus
- Department of Neurosurgery, University Hospital Würzburg, Julius-Maximilians-University, Würzburg, Germany
| | - Michael Sabel
- Department of Neurosurgery, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Hospital Göttingen, Georg-August-University, Göttingen, Germany
| | - Ghazaleh Tabatabai
- Department of Neurology and Interdisciplinary Neuro-Oncology, University Hospital Tübingen, Hertie Institute for Clinical Brain Research, Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, German Cancer Consortium (DKTK), Partner Site Tübingen, Eberhard-Karls-University, Tübingen, Germany
| | - Peter Martus
- Department of Clinical Epidemiology and Applied Biostatistics, Eberhard-Karls-University, Tübingen, Germany
| | - Sotirios Bisdas
- Lysholm Department of Neuroradiology, The National Hospital for Neurology & Neurosurgery, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Oliver Ganslandt
- Department of Neurosurgery, Municipal Hospital Stuttgart, Stuttgart, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University Hospital Heidelberg, Rupprecht-Karls-University, Heidelberg, Germany
| | - Christian Rainer Wirtz
- Department of Neurosurgery, University Hospital Ulm/Günzburg, University of Ulm, Günzburg, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University Hospital Tübingen, Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, Eberhard-Karls-University, Tübingen, Germany
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9
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Schneider M, Kunz C, Wirtz CR, Mathis-Ullrich F, Pala A, Hlavac M. Augmented Reality-Assisted versus Freehand Ventriculostomy in a Head Model. J Neurol Surg A Cent Eur Neurosurg 2023; 84:562-569. [PMID: 37402395 DOI: 10.1055/s-0042-1759827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
BACKGROUND Ventriculostomy (VST) is a frequent neurosurgical procedure. Freehand catheter placement represents the standard current practice. However, multiple attempts are often required. We present augmented reality (AR) headset guided VST with in-house developed head models. We conducted a proof of concept study in which we tested AR-guided as well as freehand VST. Repeated AR punctures were conducted to investigate if a learning curve can be derived. METHODS Five custom-made 3D-printed head models, each holding an anatomically different ventricular system, were filled with agarose gel. Eleven surgeons placed two AR-guided as well as two freehand ventricular drains per head. A subgroup of four surgeons did a total of three series of AR-guided punctures each to test for a learning curve. A Microsoft HoloLens served as the hardware platform. The marker-based tracking did not require rigid head fixation. Catheter tip position was evaluated in computed tomography scans. RESULTS Marker-tracking, image segmentation, and holographic display worked satisfactorily. In freehand VST, a success rate of 72.7% was achieved, which was higher than under AR guidance (68.2%, difference not statistically significant). Repeated AR-guided punctures increased the success rate from 65 to 95%. We assume a steep learning curve as repeated AR-guided punctures led to an increase in successful attempts. Overall user experience showed positive feedback. CONCLUSIONS We achieved promising results that encourage the continued development and technical improvement. However, several more developmental steps have to be taken before an application in humans can be considered. In the future, AR headset-based holograms have the potential to serve as a compact navigational help inside and outside the operating room.
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Affiliation(s)
- Max Schneider
- Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
| | - Christian Kunz
- Institute for Anthropomatics and Robotics - Health Robotics and Automation (HERA), KIT, Karlsruhe, Germany
| | | | - Franziska Mathis-Ullrich
- Institute for Anthropomatics and Robotics - Health Robotics and Automation (HERA), KIT, Karlsruhe, Germany
| | - Andrej Pala
- Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
| | - Michal Hlavac
- Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
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10
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Knoll A, Durner G, Braun M, Schmitz B, Wirtz CR, König R, Pala A. Combined stent retriever angioplasty and continuous intra-arterial nimodipine infusion as salvage therapy for cerebral vasospasm and delayed cerebral ischemia after subarachnoid hemorrhage: illustrative case. J Neurosurg Case Lessons 2023; 6:CASE23339. [PMID: 37782962 PMCID: PMC10555600 DOI: 10.3171/case23339] [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] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/01/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) and cerebral vasospasm (CV) are severe complications of spontaneous subarachnoid hemorrhage (SAH) contributing to an inferior outcome. Rescue therapies include intra-arterial balloon angioplasty and repetitive and finally continuous intra-arterial nimodipine infusion. OBSERVATIONS In the presented case, a young female patient with fulminant refractory DCI and CV, despite induced hypertension and nimodipine application, was treated with three-vessel continuous intra-arterial infusion and additional repetitive angioplasty of the basilar and middle cerebral arteries using a stent retriever, leading to a good clinical outcome. Additional stent retriever dilatation to continuous intra-arterial nimodipine application in three vessel territories may represent a further escalation step in the rescue therapy for severe CV and DCI after SAH. Montreal Cognitive Assessment and SF-36 testing showed satisfactory results 3 months after initial treatment with intra-arterial nimodipine catheters in three vessel territory circulations and additional stent retriever vasodilation of severe CV. LESSONS We report a unique rescue strategy involving implantation of an additional intra-arterial catheter into the vertebral artery and repetitive stent retriever dilatations of the middle cerebral and basilar arteries as an extra therapy for continuous intra-arterial nimodipine vaspospasmolytic therapy in three vessel territories, resulting in a very good clinical outcome.
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Affiliation(s)
| | | | - Michael Braun
- Neuroradiology, University of Ulm, Günzburg, Germany
| | - Bernd Schmitz
- Neuroradiology, University of Ulm, Günzburg, Germany
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11
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Becker R, Hlavac M, Etzrodt-Walter G, Sommer F, Wirtz CR, Schmitz B, Pala A. Pituitary Stalk Morphology as a Predictor of New-Onset Adrenocortical Insufficiency and Arginine Vasopressin Deficiency after Transsphenoidal Resections of Pituitary Macroadenomas: A Retrospective Single-Center Study with a Focus on iMRI. Cancers (Basel) 2023; 15:3929. [PMID: 37568744 PMCID: PMC10417128 DOI: 10.3390/cancers15153929] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND A new-onset adrenocortical insufficiency (NAI) is the most critical postoperative endocrinological complication after transsphenoidal surgery for macroadenomas. Because of increased mortality risk, arginine vasopressin deficiency (AVP-D) is also a relevant postoperative complication. This study aimed to identify easy-to-acquire magnet resonance imaging (MRI) aspects of the pituitary stalk to predict these insufficiencies after transsphenoidal surgery. METHODS Pituitary stalk morphology was reviewed intraoperatively and three months postoperatively in the MRIs of 48 transsphenoidal surgeries for macroadenomas. NAI was validated in endocrinological follow-up controls 10-14 months post-surgery. RESULTS Intraoperative pituitary stalk diameters were 0.5 mm larger in patients who developed NAI and AVP-D. The odds ratio was 29 for NAI and 6 for AVP-D in binary regression analysis. A value of 2.9 mm was identified as the optimal cut-off for the minimal pituitary stalk diameter regarding NAI, with a high specificity of 89%. There was no difference in pituitary stalk diameter regarding these insufficiencies three months post-surgery. CONCLUSIONS We identified an increased pituitary stalk diameter in intraoperative MRIs as a predictive factor of NAI and AVP-D after transsphenoidal surgery. These findings might improve the early detection of NAI and, thus, optimal management. However, validating these retrospective findings in prospective studies is obligatory.
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Affiliation(s)
- Ralf Becker
- Department of Neuroradiology, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany;
| | - Michal Hlavac
- Department of Neurosurgery, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany
| | | | - Fabian Sommer
- Department of Otorhinolaryngology, University of Ulm, Frauensteige 12, 89075 Ulm, Germany
| | | | - Bernd Schmitz
- Department of Neuroradiology, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany;
| | - Andrej Pala
- Department of Neurosurgery, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany
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12
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Durner G, Gerst A, Ulrich I, Mayer B, Wirtz CR, König R, Antoniadis G, Pedro M, Pala A. Restoring musculocutaneous nerve function in 146 brachial plexus operations – a retrospective analysis. Clin Neurol Neurosurg 2023; 228:107677. [PMID: 37028253 DOI: 10.1016/j.clineuro.2023.107677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/09/2023] [Accepted: 03/12/2023] [Indexed: 03/17/2023]
Abstract
INTRODUCTION A brachial plexus lesion is a devastating injury often affecting young, male adults after traffic accidents. Therefore, surgical restoration of elbow flexion is critical for establishing antigravity movement of the upper extremity. We analyzed different methods for musculocutaneous reconstruction regarding outcome. METHODS We conducted a retrospective analysis of 146 brachial plexus surgeries with musculocutaneous reconstruction performed at our department from 2013 to 2017. Demographic data, surgical method, donor and graft nerve characteristics, body mass index (BMI) as well as functional outcome of biceps muscle based on medical research council (MRC) strength grades before and after surgery were analyzed. Multivariate analysis was performed using SPSS. RESULTS Oberlin reconstruction was the procedure performed most often (34.2%, n = 50). Nerve transfer and autologous repair showed no significant differences regarding outcome (p = 0.599, OR 0.644 CI95% 0.126-3.307). In case of nerve transfers, we found no significant difference whether reconstruction was performed with or without a nerve graft (e.g. sural nerve) (p = 0.277, OR 0.619 CI95% 0.261-1.469). Multivariate analysis identifies patient age as a strong predictor for outcome, univariate analysis indicates that nerve graft length > 15 cm and BMI of > 25 could lead to inferior outcome. When patients with early recovery (n = 19) are included into final evaluation after 24 months, the general success rate of reconstructions is 62,7% (52/83). CONCLUSION Reconstruction of musculocutaneous nerve after brachial plexus injury results in a high rate of clinical improvement. Nerve transfer and autologous reconstruction both show similar results. Young age was confirmed as an independent predictor for better clinical outcome. Prospective multicenter studies are needed to further clarify.
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13
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Dengler NF, Scholz C, Beck J, Uerschels AK, Sure U, Scheller C, Strauss C, Martin D, Schackert G, Heinen C, Woitzik J, McLean AL, Rosahl SK, Kolbenschlag J, Heinzel J, Schuhmann M, Tatagiba MS, Guerra WKW, Schroeder HWS, Vetrano IG, Ahmadi R, Unterberg A, Reinsch J, Zdunczyk A, Unteroberdoerster M, Vajkoczy P, Wehner S, Becker M, Matthies C, Pérez-Tejón J, Dubuisson A, Barrone DG, Trivedi R, Capone C, Ferraresi S, Kraschl J, Kretschmer T, Dombert T, Staub F, Ronellenfitsch M, Marquardt G, Prinz V, Czabanka M, Carolus A, Braun V, König R, Antoniadis G, Wirtz CR, Rasulic L, Pedro MT. Rationale and design of the peripheral nerve tumor registry: an observational cohort study. Neurol Res 2023; 45:81-85. [PMID: 36208460 DOI: 10.1080/01616412.2022.2129762] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIM Peripheral nerve tumors (PNT) are rare lesions. To date, no systematic multicenter studies on epidemiology, clinical symptoms, treatment strategies and outcomes, genetic and histopathologic features, as well as imaging characteristics of PNT were published. The main goal of our PNT Registry is the systematic multicenter investigation to improve our understanding of PNT and to assist future interventional studies in establishing hypotheses, determining potential endpoints, and assessing treatment efficacy. METHODS Aims of the PNT registry were set at the 2015 Meeting of the Section of Peripheral Nerve Surgery of the German Society of Neurosurgery. A study protocol was developed by specialists in PNT care. A minimal data set on clinical status, treatment types and outcomes is reported by each participating center at initial contact with the patient and after 1 year, 2 years, and 5 years. Since the study is coordinated by the Charité Berlin, the PNR Registry was approved by the Charité ethics committee (EA4/058/17) and registered with the German Trials Registry (www.drks.de). On a national level, patient inclusion began in June 2016. The registry was rolled out across Europe at the 2019 meeting of the European Association of Neurosurgery in Dublin. RESULTS Patient recruitment has been initiated at 10 centers throughout Europe and 14 additional centers are currently applying for local ethics approval. CONCLUSION To date, the PNT registry has grown into an international study group with regular scientific and clinical exchange awaiting the first results of the retrospective study arm.
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Affiliation(s)
- Nora F Dengler
- Department of Neurosurgery, Charité - Universitaetsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Christoph Scholz
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg i.B, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg i.B, Germany
| | - Anne-Kathrin Uerschels
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Ullrich Sure
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Christian Scheller
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06120 Halle, Germany
| | - Christian Strauss
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06120 Halle, Germany
| | - Daniel Martin
- Department of Neurosurgery, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Gabriele Schackert
- Department of Neurosurgery, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Christian Heinen
- Department of Neurosurgery, Evangelisches Krankenhaus, Carl von Ossietzky University Oldenburg, Marienstr. 11, 26121 Oldenburg, Germany.,Department of Neurosurgery, PeripheralNerveUnit Nord, Christliches Krankenhaus Quakenbrück GmbH, Quakenbrück, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Evangelisches Krankenhaus, Carl von Ossietzky University Oldenburg, Marienstr. 11, 26121 Oldenburg, Germany
| | - Anna Lawson McLean
- Department of Neurosurgery, HELIOS Klinikum Erfurt, Nordhäuser Str. 74, 99089 Erfurt, Germany
| | - Steffen K Rosahl
- Department of Neurosurgery, HELIOS Klinikum Erfurt, Nordhäuser Str. 74, 99089 Erfurt, Germany
| | - Jonas Kolbenschlag
- Department of Hand-, Plastic, Reconstructive, and Burn Surgery, BG Klinik Tübingen, Schnarrenbergstraße 95, 72076 Tübingen Germany
| | - Johannes Heinzel
- Department of Hand-, Plastic, Reconstructive, and Burn Surgery, BG Klinik Tübingen, Schnarrenbergstraße 95, 72076 Tübingen Germany
| | - Martin Schuhmann
- Department of Neurosurgery, Universitätsklinikum Tübingen, Hippe-Seyler-Straße 3, 72076 Tübingen Germany
| | - Marco Soares Tatagiba
- Department of Neurosurgery, Universitätsklinikum Tübingen, Hippe-Seyler-Straße 3, 72076 Tübingen Germany
| | | | - Henry W S Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Sauerbruchstr. 1, 17475 Greifswald, Germany
| | - Ignazio Gaspare Vetrano
- Department of Neurosurgery, Fondazione I.R.C.C.S Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133 Milano, Italy
| | - Rezvan Ahmadi
- Department of Neurosurgery, Heidelberg University Hospital, Berlin, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Berlin, Germany
| | - Jennifer Reinsch
- Department of Neurosurgery, Charité - Universitaetsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Anna Zdunczyk
- Department of Neurosurgery, Charité - Universitaetsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Meike Unteroberdoerster
- Department of Neurosurgery, Charité - Universitaetsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitaetsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Sarah Wehner
- Department of Plastic, Reconstructive, and Hand Surgery, Burn Center, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Becker
- Department of Plastic, Reconstructive, and Hand Surgery, Burn Center, University Hospital RWTH Aachen, Aachen, Germany
| | - Cordula Matthies
- Department of Neurosurgery, Würzburg University Hospital, Würzburg, Germany
| | - Jose Pérez-Tejón
- Department of Neurosurgery, Würzburg University Hospital, Würzburg, Germany
| | - Annie Dubuisson
- Department of Neurosurgery, CHU Liège, Avenue de L'Hôpital 1, Liège, Belgium
| | - Damiano G Barrone
- Department of Clinical Neurosciences, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Rikin Trivedi
- Department of Clinical Neurosciences, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Crescenzo Capone
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, School of Medicine and Surgery, University Napoli "Frederico II", Naples, Italy
| | - Stefano Ferraresi
- Department of Neurosurgery, Ospedale Santa Maria della Misericordia, Rovigo, Italy
| | - Jakob Kraschl
- Department of Neurosurgery and Neurorestoration, Klinikum Klagenfurt Am Wörthersee, Klagenfurt, Austria
| | - Thomas Kretschmer
- Department of Neurosurgery and Neurorestoration, Klinikum Klagenfurt Am Wörthersee, Klagenfurt, Austria
| | | | - Frank Staub
- Center for Peripheral Neurosurgery, Dossenheim, Germany
| | - Michael Ronellenfitsch
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Schleusenweg, Frankfurt am Main, Germany
| | - Gerhard Marquardt
- Department of Neurosurgery, University Hospital Frankfurt, Goethe University, Siegen, Germany
| | - Vincent Prinz
- Department of Neurosurgery, University Hospital Frankfurt, Goethe University, Siegen, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, University Hospital Frankfurt, Goethe University, Siegen, Germany
| | - Anne Carolus
- Department of Neurosurgery, Diakonie Klinikum Jung-Stilling-Krankenhaus Neurochriurgische Klinik, Siegen, Germany
| | - Veit Braun
- Department of Neurosurgery, Diakonie Klinikum Jung-Stilling-Krankenhaus Neurochriurgische Klinik, Siegen, Germany
| | - Ralph König
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, Ulm University, District Hospital, Günzburg, Germany
| | - Gregor Antoniadis
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, Ulm University, District Hospital, Günzburg, Germany
| | - Christian Rainer Wirtz
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, Ulm University, District Hospital, Günzburg, Germany
| | - Lukas Rasulic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Neurosurgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Maria Teresa Pedro
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, Ulm University, District Hospital, Günzburg, Germany
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14
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Spilz A, Hajosch A, Seyfried F, Peraud A, Prabhu VV, Allen JE, Westhoff MA, Siegelin M, Wirtz CR, Karpel-Massler G. EXTH-86. BH3 PROFILING IDENTIFIES ONC201/TIC10 AS A PROMISING PARTNER OF ABT-263 IN MEDULLOBLASTOMA IN VITRO. Neuro Oncol 2022. [DOI: 10.1093/neuonc/noac209.884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
OBJECTIVE
Medulloblastoma represents one of the most common brain tumors in children. In this study, we identified by BH3 profiling that ONC201/TIC10 sensitizes for Bcl-xL/Bcl-2 inhibition in medulloblastoma and performed a preclinical testing of a combined treatment with ONC201/TIC10 and the Bcl-xL/Bcl-2 inhibitor ABT-263.
METHODS
BH3 profiling was performed to examine ONC201/TIC10-mediated dependencies on anti-apoptotic Bcl-2 family proteins. The combination treatment with ONC201/TIC10 and ABT-263 was tested in different medulloblastoma cells using MTT assays. Isobolograms were calculated to characterize the drug-drug interaction. Tumor spheroid and chorioallantoic membrane assays were used to examine the effects of the combination therapy in a 3D setting. Annexin V/PI staining and flowcytometry were used to detect pro-apoptotic effects. Western blot analyses and knockdown experiments with siRNA were performed for molecular analysis. Extracellular flux analyses served at examining effects on the tumor cell metabolism.
RESULTS
BH3 profiling showed that ONC201/TIC10 sensitizes medulloblastoma cells to Bcl-xL/Bcl-2 inhibition. In line with this finding, combined treatment with ONC201/TIC10 and ABT-263 led to a predominantly synergistic inhibitory effect on the cell viability of established (D425, D458, DAOY, HD-MB03), primary cultured (PC322) and stem-like (SC322) medulloblastoma cells in 2D and 3D models. The response towards the combination therapy was independent of baseline c-myc expression. On the molecular level, treatment with ONC201/TIC10 led to a dose-dependent decrease of Mcl-1. Moreover, the combination caused enhanced cleavage of caspases 9 and 3. On the metabolic level, the combination therapy led to a reduction in both, oxidative phosphorylation and the glycolytic rate and a reduced expression of respiratory chain proteins.
CONCLUSION
Combined treatment with ONC201/TIC10 and ABT-263 had a predominantly synergistic inhibitory effect on the cell viability of medulloblastoma cells. This effect was associated with downregulation of Mcl-1. Moreover, the combination treatment resulted in a metabolic reprogramming which likely creates a state of energy deprivation.
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15
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Tosin D, Schlotter D, Hajosch A, Hlavac M, Westhoff MA, Siegelin M, Wirtz CR, Karpel-Massler G. EXTH-48. INHIBITION OF SREBP-1 IS SYNTHETICALLY LETHAL WITH BCL-XL/BCL-2 INHIBITION IN GLIOBLASTOMA IN VITRO. Neuro Oncol 2022. [PMCID: PMC9660787 DOI: 10.1093/neuonc/noac209.846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
OBJECTIVE
A cellular homeostasis that is shifted away from apoptosis and a reprogramming of the lipid metabolism are both, features that are frequently encountered in glioblastoma. This study aimed at investigating whether interference with the lipid metabolism is synthetically lethal with inhibition of anti-apoptotic Bcl-2 family proteins in glioblastoma in vitro.
METHODS
Established (U251) and primary-cultured glioblastoma cells (PC38, PC40 and PC128) as well as glioblastoma stem-like cells (SC38 and SC40) were treated with the Bcl-xL/Bcl-2 inhibitor ABT-263 (navitoclax) and/or the SREBP-1 inhibitor Fatostatin. MTT-assays were performed to assess effects of the combination therapy on the cell viability. Isobolograms were calculated to characterize the drug-drug interaction. Spheroids were used to determine anti-proliferative effects in a 3-dimensional setting. Staining with annexin V/propidium iodide and flowcytometric analysis were performed to assess pro-apoptotic effects. For molecular analyses, Western blots and specific knock-down experiments with siRNA were performed.
RESULTS
Combined targeting of SREBP-1 and Bcl-xL/Bcl-2 led to a synergistic inhibitory effect on the cellular viability of established, primary-cultured and glioblastoma stem-like cells as well as spheroids. This effect was shown to be at least in part mediated by enhanced apoptosis and to occur in a caspase-dependent manner. On the molecular level, treatment with increasing concentrations of Fatostatin led to a downregulation of Mcl-1.
CONCLUSION
Our study indicates that combined inhibition of Bcl-xL/Bcl-2 and interference with the lipid metabolism targeting SREBP-1 synergistically induces caspase-dependent apoptosis in glioblastoma cells. This effect can also be observed in more complex 3-dimensional glioblastoma cell formations. Further studies will focus on deciphering the drug-induced alterations of the metabolic pathways that are responsible for the synergistic effect of this therapeutic strategy.
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16
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Cao Q, Hajosch A, Kast R, Hlavac M, Westhoff MA, Siegelin M, Wirtz CR, Halatsch ME, Karpel-Massler G. EXTH-72. TTFIELDS ENHANCE THE ANTINEOPLASTIC ACTIVITY OF THE DRUG-REPURPOSING APPROACH CUSP9V3 IN GLIOBLASTOMA IN VITRO. Neuro Oncol 2022. [DOI: 10.1093/neuonc/noac209.870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
OBJECTIVE
Drug repurposing represents a promising strategy to safely accelerate the clinical use of therapeutics with antineoplastic activity. In this study, we examined whether Tumor Treating Fields (TTFields) enhance the biological effects of CUSP9v3, a treatment strategy including nine repurposed drugs, in an in vitro setting of glioblastoma.
METHODS
We performed MTT-assays to examine effects of the combination treatment on the viability of different glioblastoma cells. Tumor spheroids were used as a model to examine effects of the combination treatment in a 3-dimensional setting. Staining with annexin V/propidium iodide or MitoTrackerTM followed by flow cytometry was done to assess pro-apoptotic effects. Specific protein expression of caspases and members of the Bcl-2 family of proteins was determined by Western blot analyses.
RESULTS
TTFields had at least additive inhibitory effects on the cell viability of established (U251), primary cultured (PC38, PC40, PC128) and stem-like (SC38, SC40) glioblastoma cells when combined with CUSP9v3. In addition, flow cytometric analyses revealed that a simultaneous treatment with TTFields and CUSP9v3 significantly increased the fraction of annexin V-positive (apoptotic) glioblastoma cells. Moreover, the fraction of cells with a reduced mitochondrial outer membrane potential was significantly higher following a simultaneous treatment with TTFields and CUSP9v3. On the molecular level, these observations were associated with enhanced cleavage of effector caspase 3 and a reduced expression of the anti-apoptotic Bcl-2 family proteins Bcl-2 and Mcl-1.
CONCLUSION
These data suggest that TTFields enhance the susceptibility of glioblastoma cells towards CUSP9v3, potentially allowing significant dose reduction and decreased toxicity. This observation seems to rely at least in part on a caspase-dependent cell death mechanism. TTFields are widely used for the treatment of glioblastoma patients and CUSP9v3 was recently shown to have a favorable safety profile in a phase Ib/IIa trial (NCT02770378) which facilitates transition of a combined approach to the clinical setting.
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Affiliation(s)
- Qiyu Cao
- Ulm University Medical Center , Ulm , Germany
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Fröhlich E, Sassenrath C, Nadji-Ohl M, Unteroberdörster M, Rückriegel S, von der Brelie C, Roder C, Forster MT, Schommer S, Löhr M, Pala A, Goebel S, Mielke D, Gerlach R, Renovanz M, Wirtz CR, Onken J, Czabanka M, Tatagiba MS, Rohde V, Ernestus RI, Vajkoczy P, Gansland O, Coburger J. Resilience in Lower Grade Glioma Patients. Cancers (Basel) 2022; 14:cancers14215410. [PMID: 36358828 PMCID: PMC9656661 DOI: 10.3390/cancers14215410] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022] Open
Abstract
Current data show that resilience is an important factor in cancer patients’ well-being. We aim to explore the resilience of patients with lower grade glioma (LGG) and the potentially influencing factors. We performed a cross-sectional assessment of adult patients with LGG who were enrolled in the LoG-Glio registry. By phone interview, we administered the following measures: Resilience Scale (RS-13), distress thermometer, Montreal Cognitive Assessment Test for visually impaired patients (MoCA-Blind), internalized stigmatization by brain tumor (ISBI), Eastern Cooperative Oncological Group performance status (ECOG), patients’ perspective questionnaire (PPQ) and typical clinical parameters. We calculated correlations and multivariate regression models. Of 74 patients who were assessed, 38% of those showed a low level of resilience. Our results revealed significant correlations of resilience with distress (p < 0.001, −0.49), MOCA (p = 0.003, 0.342), ECOG (p < 0.001, −0.602), stigmatization (p < 0.001, −0.558), pain (p < 0.001, −0.524), and occupation (p = 0.007, 0.329). In multivariate analyses, resilience was negatively associated with elevated ECOG (p = 0.020, β = −0.383) and stigmatization levels (p = 0.008, β = −0.350). Occupation showed a tendency towards a significant association with resilience (p = 0.088, β = −0.254). Overall, low resilience affected more than one third of our cohort. Low functional status is a specific risk factor for low resilience. The relevant influence of stigmatization on resilience is a novel finding for patients suffering from a glioma and should be routinely identified and targeted in clinical routine.
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Affiliation(s)
- Ellen Fröhlich
- Department of Neurosurgery, University of Ulm, 89312 Günzburg, Germany
| | - Claudia Sassenrath
- Department of Social Psychology, Institute of Psychology and Education, Faculty of Engering, Informatics and Psychology, University of Ulm, 89312 Günzburg, Germany
| | - Minou Nadji-Ohl
- Department of Neurosurgery, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | | | - Stefan Rückriegel
- Department of Neurosurgery, University of Würzburg, 97080 Würzburg, Germany
| | | | - Constantin Roder
- Department of Neurosurgery, University of Tübingen, 72076 Tübingen, Germany
| | - Marie-Therese Forster
- Department of Neurosurgery, University of Frankfurt, 60528 Frankfurt am Main, Germany
| | - Stephan Schommer
- Department of Social Psychology, Institute of Psychology and Education, Faculty of Engering, Informatics and Psychology, University of Ulm, 89312 Günzburg, Germany
| | - Mario Löhr
- Department of Neurosurgery, Charité—Universitätsmedizin Berlin, 12200 Berlin, Germany
| | - Andrej Pala
- Department of Neurosurgery, University of Ulm, 89312 Günzburg, Germany
- Correspondence:
| | - Simone Goebel
- Department of Psychology, University of Kiel, 24118 Kiel, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University of Göttingen, 37075 Göttingen, Germany
| | - Rüdiger Gerlach
- Department of Neurosurgery, Helioskliniken Erfurt, 99089 Erfurt, Germany
| | - Mirjam Renovanz
- Department of Neurosurgery, University of Tübingen, 72076 Tübingen, Germany
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Otfried-Müller-Straße 27, 72076 Tübingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital of Tuebingen, Eberhard Karls University of Tübingen, 72076 Tübingen, Germany
- Department of Neurosurgery, University Hospital Tübingen, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | | | - Julia Onken
- Department of Neurosurgery, Charité—Universitätsmedizin Berlin, 12200 Berlin, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, University of Frankfurt, 60528 Frankfurt am Main, Germany
| | | | - Veit Rohde
- Department of Neurosurgery, Helioskliniken Erfurt, 99089 Erfurt, Germany
| | - Ralf-Ingo Ernestus
- Department of Neurosurgery, University of Würzburg, 97080 Würzburg, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité—Universitätsmedizin Berlin, 12200 Berlin, Germany
| | - Oliver Gansland
- Department of Neurosurgery, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Jan Coburger
- Department of Neurosurgery, University of Ulm, 89312 Günzburg, Germany
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Coburger J, Onken J, Rueckriegel S, von der Brelie C, Nadji-Ohl M, Forster MT, Gerlach R, Unteroberdörster M, Roder C, Kniese K, Schommer S, Rothenbacher D, Nagel G, Wirtz CR, Ernestus RI, Nabavi A, Tatagiba M, Czabanka M, Ganslandt O, Rohde V, Löhr M, Vajkoczy P, Pala A. Eloquent Lower Grade Gliomas, a Highly Vulnerable Cohort: Assessment of Patients' Functional Outcome After Surgery Based on the LoG-Glio Registry. Front Oncol 2022; 12:845992. [PMID: 35311092 PMCID: PMC8927728 DOI: 10.3389/fonc.2022.845992] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/31/2022] [Indexed: 11/28/2022] Open
Abstract
Majority of lower grade glioma (LGG) are located eloquently rendering surgical resection challenging. Aim of our study was to assess rate of permanent deficits and its predisposing risk factors. We retrieved 83 patients harboring an eloquently located LGGs from the prospective LoG-Glio Database. Patients without surgery or incomplete postoperative data were excluded. Sign rank test, explorative correlations by Spearman ρ and multivariable regression for new postoperative deficits were calculated. Eloquent region involved predominantly motor (45%) and language (40%). At first follow up after 3 months permanent neuro-logical deficits (NDs) were noted in 39%. Mild deficits remained in 29% and severe deficits in 10%. Complete tumor removal (CTR) was successfully in 62% of intended cases. Postoperative and 3-month follow up National Institute of Health Stroke Score (NIHSS) showed significantly lower values than preoperatively (p<0.001). 38% cases showed a decreased NIHSS at 3-month, while occurrence was only 14% at 9-12-month follow up. 6/7 patients with mild aphasia recovered after 9-12 months, while motor deficits present at 3-month follow up were persistent in majority of patients. Eastern oncology group functional status (ECOG) significantly decreased by surgery (p < 0.001) in 31% of cases. Between 3-month and 9-12-months follow up no significant improvement was seen. In the multivariable model CTR (p=0.019, OR 31.9), and ECOG>0 (p=0.021, OR 8.5) were independent predictors for permanent postoperative deficit according to NIHSS at 3-month according to multivariable regression model. Patients harboring eloquently located LGG are highly vulnerable for permanent deficits. Almost one third of patients have a permanent reduction of their functional status based on ECOG. Risk of an extended resection has to be balanced with the respective oncological benefit. Especially, patients with impaired pre-operative status are at risk for new permanent deficits. There is a relevant improvement of neurological symptoms in the first year after surgery, especially for patients with slight aphasia.
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Affiliation(s)
- Jan Coburger
- Department of Neurosurgery, University of Ulm, Günzburg, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité - University of Berlin, Berlin, Germany
| | | | | | - Minou Nadji-Ohl
- Department of Neurosurgery, Katharinenhospital Stuttgart, Stuttgart, Germany
| | | | - Rüdiger Gerlach
- Department of Neurosurgery, Helios Hospital Erfurt, Erfurt, Germany
| | | | - Constantin Roder
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Katja Kniese
- Department of Neurosurgery, KRH Klinikum Region Hannover, Hannover, Germany
| | - Stefan Schommer
- Department of Neurosurgery, Katharinenhospital Stuttgart, Stuttgart, Germany
| | | | - Gabriele Nagel
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | | | | | - Arya Nabavi
- Department of Neurosurgery, KRH Klinikum Region Hannover, Hannover, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, University of Frankfurt, Frankfurt am Main, Germany
| | - Oliver Ganslandt
- Department of Neurosurgery, Katharinenhospital Stuttgart, Stuttgart, Germany
| | - Veit Rohde
- Department of Neurosurgery, University of Göttingen, Göttingen, Germany
| | - Mario Löhr
- Department of Neurosurgery, University of Würzburg, Würzburg, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - University of Berlin, Berlin, Germany
| | - Andrej Pala
- Department of Neurosurgery, University of Ulm, Günzburg, Germany
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Xu P, Westhoff MA, Hadzalic A, Debatin KM, Winiarski L, Oleksyszyn J, Wirtz CR, Knippschild U, Burster T. Diisothiocyanate-Derived Mercapturic Acids Are a Promising Partner for Combination Therapies in Glioblastoma. ACS Omega 2022; 7:5929-5936. [PMID: 35224353 PMCID: PMC8867792 DOI: 10.1021/acsomega.1c06169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/24/2021] [Indexed: 06/14/2023]
Abstract
Glioblastoma represents the most aggressive tumor of the central nervous system. Due to invasion of glioblastoma stem cells into the healthy tissue, chemoresistance, and recurrence of the tumor, it is difficult to successfully treat glioblastoma patients, which is demonstrated by the low life expectancy of patients after standard therapy treatment. Recently, we found that diisothiocyanate-derived mercapturic acids, which are isothiocyanate derivatives from plants of the Cruciferae family, provoked a decrease in glioblastoma cell viability. These findings were extended by combining diisothiocyanate-derived mercapturic acids with dinaciclib (a small-molecule inhibitor of cyclin-dependent kinases with anti-proliferative capacity) or temozolomide (TMZ, standard chemotherapeutic agent) to test whether the components have a cytotoxic effect on glioblastoma cells when the dosage is low. Here, we demonstrate that the combination of diisothiocyanate-derived mercapturic acids with dinaciclib or TMZ had an additive or even synergistic effect in the restriction of cell growth dependent on the combination of the components and the glioblastoma cell source. This strategy could be applied to inhibit glioblastoma cell growth as a therapeutic interference of glioblastoma.
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Affiliation(s)
- Pengfei Xu
- Department
of General and Visceral Surgery, Surgery Center, Ulm University Medical Center, 89081 Ulm, Germany
| | - Mike-Andrew Westhoff
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, 89081 Ulm, Germany
| | - Amina Hadzalic
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, 89081 Ulm, Germany
| | - Klaus-Michael Debatin
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, 89081 Ulm, Germany
| | - Lukasz Winiarski
- Faculty
of Chemistry, Division of Medicinal Chemistry and Microbiology, Wroclaw University of Science and Technology, Wybrzeże Wyspiańskiego
27, 50-370 Wrocław, Poland
| | - Jozef Oleksyszyn
- Faculty
of Chemistry, Division of Medicinal Chemistry and Microbiology, Wroclaw University of Science and Technology, Wybrzeże Wyspiańskiego
27, 50-370 Wrocław, Poland
| | - Christian Rainer Wirtz
- Department
of Neurosurgery, Ulm University Medical
Center, Albert-Einstein-Allee
7, 89081 Ulm, Germany
| | - Uwe Knippschild
- Department
of General and Visceral Surgery, Surgery Center, Ulm University Medical Center, 89081 Ulm, Germany
| | - Timo Burster
- Department
of Biology, School of Sciences and Humanities, Nazarbayev University, Kabanbay Batyr Ave. 53, 010000 Nur-Sultan, Kazakhstan Republic
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20
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Kapapa T, König R, Mayer B, Braun M, Schmitz B, Müller S, Schick J, Wirtz CR, Pala A. Adverse Events and Complications in Continuous Intra-arterial Nimodipine Infusion Therapy After Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2022; 12:812898. [PMID: 35250795 PMCID: PMC8895039 DOI: 10.3389/fneur.2021.812898] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo determine the frequency and severity of complications associated with the continuous intra-arterial infusion of nimodipine (CIANI) as a new treatment of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH).MethodsPatients from two centers (n = 718) treated for SAH between 2008 and 2016 were included. Demographic and SAH-related parameters were evaluated, and also the frequency of adverse events (AEs) and complications including their severity (mild, moderate, and severe). Clinical outcome was analyzed using Glasgow Outcome Scale (GOS). The unfavorable outcome was defined as GOS 1 to 3, and favorable outcome as GOS 4 to 5. The Short-Form 36 (SF-36) health-related quality-of-life (QoL) questionnaire served as a QoL measurement.ResultsOf 718 patients, 65 (9%) were treated by CIANI and had a higher clinical or imaging grade of bleeding severity. Clinical deterioration while on treatment happened more often in patients who were treated with CIANI than in others. In patients with CIANI, 67% had AEs and/or complications during the treatment. Nimodipine-associated hypotension was seen in 8% (mild). Catheter-associated thrombus occurred in 9% (moderate). New intracerebral hemorrhage was found in 14% (moderate). A total of 6% treated by CIANI died during the treatment period (severe). More than one-third (39%) of patients of CIANI reached at least moderate disability, and 23% showed good recovery. Patients who received CIANI showed reduced QoL, but differences in mental and general health, and also pain were minimal.ConclusionPatients who received CIANI had higher rates of AEs and complications. However, this does not exclude the possibility that the use of CIANI might be helpful in patients with severe and therapy-refractory CV and DCI. Controlled and randomized studies would be helpful to clarify this question but they are methodologically and ethically challenging.
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Affiliation(s)
- Thomas Kapapa
- Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
| | - Ralph König
- Department of Neurosurgery, University of Ulm, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Benjamin Mayer
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Michael Braun
- Section Neuroradiology, University Hospital Ulm, Günzburg, Germany
| | - Bernd Schmitz
- Section Neuroradiology, University Hospital Ulm, Günzburg, Germany
| | - Silwia Müller
- Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
| | - Julia Schick
- Section Interdisciplinary Operative Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Christian Rainer Wirtz
- Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
- Department of Neurosurgery, University of Ulm, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Andrej Pala
- Department of Neurosurgery, University of Ulm, Bezirkskrankenhaus Günzburg, Günzburg, Germany
- *Correspondence: Andrej Pala
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Westhoff MA, Schuler-Ortoli M, Zerrinius D, Hadzalic A, Schuster A, Strobel H, Scheuerle A, Wong T, Wirtz CR, Debatin KM, Peraud A. Bcl-XL but Not Bcl-2 Is a Potential Target in Medulloblastoma Therapy. Pharmaceuticals (Basel) 2022; 15:ph15010091. [PMID: 35056150 PMCID: PMC8779796 DOI: 10.3390/ph15010091] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 01/26/2023] Open
Abstract
Medulloblastoma (MB) is the most common solid tumour in children and, despite current treatment with a rather aggressive combination therapy, accounts for 10% of all deaths associated with paediatric cancer. Breaking the tumour cells’ intrinsic resistance to therapy-induced cell death should lead to less aggressive and more effective treatment options. In other tumour entities, this has been achieved by modulating the balance between the various pro- and anti-apoptotic members of the Bcl-2 family with small molecule inhibitors. To evaluate the therapeutic benefits of ABT-199 (Venetoclax), a Bcl-2 inhibitor, and ABT-263 (Navitoclax), a dual Bcl-XL/Bcl-2 inhibitor, increasingly more relevant model systems were investigated. Starting from established MB cell lines, progressing to primary patient-derived material and finally an experimental tumour system imbedded in an organic environment were chosen. Assessment of the metabolic activity (a surrogate readout for population viability), the induction of DNA fragmentation (apoptosis) and changes in cell number (the combined effect of alterations in proliferation and cell death induction) revealed that ABT-263, but not ABT-199, is a promising candidate for combination therapy, synergizing with cell death-inducing stimuli. Interestingly, in the experimental tumour setting, the sensitizing effect of ABT-263 seems to be predominantly mediated via an anti-proliferative and not a pro-apoptotic effect, opening a future line of investigation. Our data show that modulation of specific members of the Bcl-2 family might be a promising therapeutic addition for the treatment of MB.
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Affiliation(s)
- Mike-Andrew Westhoff
- Department of Pediatrics and Adolescent Medicine, Ulm University Hospital, 89075 Ulm, Germany; (A.S.); (H.S.); (T.W.); (K.-M.D.)
- Correspondence: (M.-A.W.); (A.P.); Tel.: +49-731-500-57495 (M.-A.W.); +49-731-500-55001 (A.P.)
| | - Marie Schuler-Ortoli
- Section Pediatric Neurosurgery, Department of Neurosurgery, Ulm University Hospital, 89081 Ulm, Germany; (M.S.-O.); (D.Z.); (A.H.)
| | - Daniela Zerrinius
- Section Pediatric Neurosurgery, Department of Neurosurgery, Ulm University Hospital, 89081 Ulm, Germany; (M.S.-O.); (D.Z.); (A.H.)
| | - Amina Hadzalic
- Section Pediatric Neurosurgery, Department of Neurosurgery, Ulm University Hospital, 89081 Ulm, Germany; (M.S.-O.); (D.Z.); (A.H.)
| | - Andrea Schuster
- Department of Pediatrics and Adolescent Medicine, Ulm University Hospital, 89075 Ulm, Germany; (A.S.); (H.S.); (T.W.); (K.-M.D.)
| | - Hannah Strobel
- Department of Pediatrics and Adolescent Medicine, Ulm University Hospital, 89075 Ulm, Germany; (A.S.); (H.S.); (T.W.); (K.-M.D.)
| | | | - Tiana Wong
- Department of Pediatrics and Adolescent Medicine, Ulm University Hospital, 89075 Ulm, Germany; (A.S.); (H.S.); (T.W.); (K.-M.D.)
- Section Pediatric Neurosurgery, Department of Neurosurgery, Ulm University Hospital, 89081 Ulm, Germany; (M.S.-O.); (D.Z.); (A.H.)
| | | | - Klaus-Michael Debatin
- Department of Pediatrics and Adolescent Medicine, Ulm University Hospital, 89075 Ulm, Germany; (A.S.); (H.S.); (T.W.); (K.-M.D.)
| | - Aurelia Peraud
- Section Pediatric Neurosurgery, Department of Neurosurgery, Ulm University Hospital, 89081 Ulm, Germany; (M.S.-O.); (D.Z.); (A.H.)
- Correspondence: (M.-A.W.); (A.P.); Tel.: +49-731-500-57495 (M.-A.W.); +49-731-500-55001 (A.P.)
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22
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Dwucet A, Pruss M, Cao Q, Tanriover M, Prabhu VV, Allen JE, Peraud A, Westhoff MA, Siegelin MD, Wirtz CR, Karpel-Massler G. ONC201/TIC10 Is Empowered by 2-Deoxyglucose and Causes Metabolic Reprogramming in Medulloblastoma Cells in Vitro Independent of C-Myc Expression. Front Cell Dev Biol 2021; 9:734699. [PMID: 34900991 PMCID: PMC8661473 DOI: 10.3389/fcell.2021.734699] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/21/2021] [Indexed: 11/13/2022] Open
Abstract
The purpose of this study was to examine whether the imipridone ONC201/TIC10 affects the metabolic and proliferative activity of medulloblastoma cells in vitro. Preclinical drug testing including extracellular flux analyses (agilent seahorse), MTT assays and Western blot analyses were performed in high and low c-myc-expressing medulloblastoma cells. Our data show that treatment with the imipridone ONC201/TIC10 leads to a significant inihibitory effect on the cellular viability of different medulloblastoma cells independent of c-myc expression. This effect is enhanced by glucose starvation. While ONC201/TIC10 decreases the oxidative consumption rates in D458 (c-myc high) and DAOY (c-myc low) cells extracellular acidification rates experienced an increase in D458 and a decrease in DAOY cells. Combined treatment with ONC201/TIC10 and the glycolysis inhibitor 2-Deoxyglucose led to a synergistic inhibitory effect on the cellular viability of medulloblastoma cells including spheroid models. In conclusion, our data suggest that ONC201/TIC10 has a profound anti-proliferative activity against medulloblastoma cells independent of c-myc expression. Metabolic targeting of medulloblastoma cells by ONC201/TIC10 can be significantly enhanced by an additional treatment with the glycolysis inhibitor 2-Deoxyglucose. Further investigations are warranted.
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Affiliation(s)
- Annika Dwucet
- Department of Neurosurgery, Ulm University Medical Center, Ulm, Germany
| | - Maximilian Pruss
- Department of Neurosurgery, Ulm University Medical Center, Ulm, Germany
| | - Qiyu Cao
- Department of Neurosurgery, Ulm University Medical Center, Ulm, Germany
| | - Mine Tanriover
- Department of Neurosurgery, Ulm University Medical Center, Ulm, Germany
| | | | | | - Aurelia Peraud
- Department of Neurosurgery, Ulm University Medical Center, Ulm, Germany
| | - Mike-Andrew Westhoff
- Department of Pediatric and Adolescent Medicine, Ulm University Medical Center, Ulm, Germany
| | - Markus D Siegelin
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, United States
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Rush J, Paľa A, Kapapa T, Wirtz CR, Mayer B, Micah-Bonongwe A, Gladstone M, Kamalo P. Assessing neurodevelopmental outcome in children with hydrocephalus in Malawi. A pilot study. Clin Neurol Neurosurg 2021; 212:107091. [PMID: 34922292 DOI: 10.1016/j.clineuro.2021.107091] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/06/2021] [Accepted: 12/10/2021] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Congenital and infantile hydrocephalus are assumed to be major contributors to pediatric morbidity, mortality and functional disability in low-income countries. Despite this, epidemiologic data and the overview of neurodevelopmental outcomes in these regions is very limited. We aimed to pilot the use of a wide range of more locally suitable tools to assess neurodevelopment to understand whether they were feasible for use and could provide estimates of developmental delay and poor functioning in a population of children with hydrocephalus in Malawi. METHODS We conducted a prospective observational cohort study, at the tertiary neurosurgery clinic in Blantyre, Malawi in 2018, recruiting consecutive children with congenital and infantile hydrocephalus who were previously treated with ventriculoperitoneal shunts and endoscopic third ventriculostomy (ETV) in the neurosurgery unit of the hospital. We assessed demographic details, and gained information on children's functioning using the Liverpool Outcome Score (LOS), and the Eating and Drinking Ability Classification System as well as full anthropometric assessment and child development with the Malawi Developmental Assessment Tool (MDAT). RESULTS All tools were feasible for use, easy to train on, could be used for assessing children with hydrocephalus and were suitable to adapt for our environment. We evaluated 41 children, aged 2-60 months with a mean age of 22.6 months (interquartile range [IQR] = 8.3 months -36.5 months). Functional assessment using the Liverpool Outcome Score showed the majority of children 92.7% (CI 80.1-98.5, n = 38) had severe sequelae from the hydrocephalus and were dependent on their parents or caregivers. Only 27 children (65.9%, CI 49.4, 80.0) had full or expected control of their bowel and bladder and 6 children (14.6%, CI 5.6, 29.2), had a recent history of seizures. About two thirds (63.4% CI 45.0-77.9, n = 26/41) of children were able to eat and to drink safely and efficiently. Over two thirds of the children (70.7%, CI 56.8, 84.6, n = 29) were stunted and almost half of the cohort underweight (43.9%,(CI 28.5, 60.3, n = 18). Almost half 48.8% (CI 32.9, 64.9, n = 20/41) had developmental delay on MDAT with 41.5% (CI 26.4, 56.6, n = 17/41) graded as severely delayed (-<2sd on developmental age z score). We found significant associations between dependence identified by the LOS and developmental delay according to the MDAT (p = 0.014, Pearson's chi-squared test). CONCLUSION This pilot study demonstrates that the assessment tools we used identified a high proportion of children with hydrocephalus as having functional difficulties, stunted growth and developmental delay, in Malawi. Use of these tools can now be scaled up and will be helpful to support research in understanding what factors contribute to poor functioning, growth and development in these cohorts and help us to investigate what strategies may prevent and support children with hydrocephalus in African settings.
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Affiliation(s)
- James Rush
- Liverpool School of Tropical Medicine, University of Liverpool, Pembroke Pl, Liverpool L3 5QA, UK
| | - Andrej Paľa
- University Hospital Ulm, Department of Neurosurgery, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
| | - Thomas Kapapa
- University Hospital Ulm, Department of Neurosurgery, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Christian Rainer Wirtz
- University Hospital Ulm, Department of Neurosurgery, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Benjamin Mayer
- Liverpool School of Tropical Medicine, University of Liverpool, Pembroke Pl, Liverpool L3 5QA, UK; University Hospital Ulm, Department of Neurosurgery, Albert-Einstein-Allee 23, 89081 Ulm, Germany; Blantyre Institute of Neurological Surgery, Queen Elizabeth Central Hospital, Department of Neurosurgery, Chipatala Road, Blantyre, Malawi; Institute of Translational Medicine, University of Liverpool, Department of Women's and Children's Health University Department, First Floor, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK
| | - Annie Micah-Bonongwe
- Blantyre Institute of Neurological Surgery, Queen Elizabeth Central Hospital, Department of Neurosurgery, Chipatala Road, Blantyre, Malawi
| | - Melissa Gladstone
- Institute of Translational Medicine, University of Liverpool, Department of Women's and Children's Health University Department, First Floor, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK
| | - Patrick Kamalo
- Blantyre Institute of Neurological Surgery, Queen Elizabeth Central Hospital, Department of Neurosurgery, Chipatala Road, Blantyre, Malawi
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Dwucet A, Cao Q, Pruss M, Westhoff MA, Wirtz CR, Siegelin MD, Karpel-Massler G. EXTH-68. DUAL METABOLIC REPROGRAMMING BY ONC201/TIC10 AND 2-DEOXYGLUCOSE HAS A STRONG ANTIPROLIFERATIVE EFFECT ON MEDULLOBLASTOMA CELLS. Neuro Oncol 2021. [DOI: 10.1093/neuonc/noab196.707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Medulloblastoma represents one of the most common brain tumors in children. While the understanding of the molecular characteristics of this disease has very much advanced, more efficient and less toxic therapeutics are still in high demand. In this study we examined whether the imipridone ONC201/TIC10 affects the metabolic and proliferative activity of medulloblastoma cells alone and in combination with 2-Deoxyglucose in vitro.
METHODS
Extracellular flux (agilent seahorse) and Western blot analyses were performed to assess effects on tumor cell metabolism and the expression of proteins of the respiratory chain in established medulloblastoma cells. MTT assays and spheroid assays were performed to examine anti-proliferative effects in a 2-D and 3-D setting.
RESULTS
Treatment with ONC201/TIC10 has a strong inihibitory effect on the cellular viability of different medulloblastoma cells independent of c-Myc expression. While ONC201/TIC10 decreases the oxidative consumption rates in D458 (c-Myc high) and DAOY (c-Myc low) cells, extracellular acidification rates experienced an increase in D458 and a decrease in DAOY cells. Treatment with ONC201/TIC10 in combination with the glycolysis inhibitor 2-Deoxyglucose synergistically inhibited the cellular viability of medulloblastoma cells and impaired the growth of spheroids.
CONCLUSION
Overall, ONC201/TIC10 profoundly inhibits the proliferative activity of medulloblastoma cells in a c-Myc-independent manner. Additional treatment with the glycolysis inhibitor 2-Deoxyglucose synergistically enhances the anti-medulloblastoma activity of ONC201/TIC10. This promising approach warrants further investigations.
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Affiliation(s)
| | - Qiyu Cao
- Ulm University Medical Center, Ulm, Germany
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Pala A, Durner G, Braun M, Schmitz B, Wirtz CR, Coburger J. The Impact of an Ultra-Early Postoperative MRI on Treatment of Lower Grade Glioma. Cancers (Basel) 2021; 13:cancers13122914. [PMID: 34200923 PMCID: PMC8230433 DOI: 10.3390/cancers13122914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 04/28/2021] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 11/16/2022] Open
Abstract
The timing of MRI imaging after surgical resection may have an important role in assessing the extent of resection (EoR) and in determining further treatment. The aim of our study was to evaluate the time dependency of T2 and FLAIR changes after surgery for LGG. The Log-Glio database of patients treated at our hospital from 2016 to 2021 was searched for patients >18a and non-enhancing intra-axial lesion with complete MR-imaging protocol. A total of 16 patients matched the inclusion criteria and were thus selected for volumetric analysis. All patients received an intraoperative scan (iMRI) after complete tumor removal, an ultra-early postoperative scan after skin closure, an early MRI within 48 h and a late follow up MRI after 3-4 mo. Detailed volumetric analysis of FLAIR and T2 abnormalities was conducted. Demographic data and basic characteristics were also analyzed. An ultra-early postoperative MRI was performed within a median time of 30 min after skin closure and showed significantly lower FLAIR (p = 0.003) and T2 (p = 0.003) abnormalities when compared to early postoperative MRI (median 23.5 h), though no significant difference was found between ultra-early and late postoperative FLAIR (p = 0.422) and T2 (p = 0.575) images. A significant difference was calculated between early and late postoperative FLAIR (p = 0.005) and T2 (p = 0.019) MRI scans. Additionally, we found no significant difference between intraoperative and ultra-early FLAIR/T2 (p = 0.919 and 0.499), but we found a significant difference between iMRI and early MRI FLAIR/T2 (p = 0.027 and p = 0.035). Therefore, a postoperative MRI performed 24 h or 48 h might lead to false positive findings. An MRI scan in the first hour after surgery (ultra-early) correlated best with residual tumor at 3 months follow up. An iMRI with open skull, at the end of resection, was similar to an ultra-early MRI with regard to residual tumor.
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Affiliation(s)
- Andrej Pala
- Department of Neurosurgery, University of Ulm, 89312 Günzburg, Germany; (G.D.); (C.R.W.); (J.C.)
- Correspondence: ; Tel.: +49-82-219-628-866
| | - Gregor Durner
- Department of Neurosurgery, University of Ulm, 89312 Günzburg, Germany; (G.D.); (C.R.W.); (J.C.)
| | - Michael Braun
- Department of Neuroradiology, University of Ulm, 89312 Günzburg, Germany; (M.B.); (B.S.)
| | - Bernd Schmitz
- Department of Neuroradiology, University of Ulm, 89312 Günzburg, Germany; (M.B.); (B.S.)
| | - Christian Rainer Wirtz
- Department of Neurosurgery, University of Ulm, 89312 Günzburg, Germany; (G.D.); (C.R.W.); (J.C.)
| | - Jan Coburger
- Department of Neurosurgery, University of Ulm, 89312 Günzburg, Germany; (G.D.); (C.R.W.); (J.C.)
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Durner G, Wahler H, Braun M, Kapapa T, Wirtz CR, König R, Pala A. The value of intraoperative angiography in the time of indocyanine green videoangiography in the treatment of cerebrovascular lesions: Efficacy, workflow, risk-benefit and cost analysis A prospective study. Clin Neurol Neurosurg 2021; 205:106628. [PMID: 33895619 DOI: 10.1016/j.clineuro.2021.106628] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/28/2021] [Accepted: 03/28/2021] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Intraoperative digital subtraction angiography (ioDSA) allows early treatment evaluation after neurovascular procedures. However, the value and efficiency of this procedure has been discussed controversially. We have evaluated the additional value of hybrid operating room equipped with an Artis Zeego robotic c-arm regarding cost, efficiency and workflow. Furthermore, we have performed a risk-benefit analysis and compared it with indocyanine green (ICG) angiography. METHODS For 3 consecutive years, we examined all neurovascular patients, treated in the hybrid operating theater in a risk-benefit analysis. After using microdoppler and ICG angiography for best operative result, every patient received an additional ioDSA to look for remnants or unfavorable clip placement which might lead to a change of operating strategy or results. Furthermore, a workflow-analysis reviewing operating steps, staff positioning, costs, technical errors or complications were conducted on randomly selected cases. RESULTS 54 patients were enrolled in the risk-benefit analysis, 22 in the workflow analysis. The average duration of a cerebrovascular operation was 4 h 58 min 2 min 35 s accounted for ICG angiography, 46 min 4 s for ioDSA. Adverse events occurred during one ioDSA. In risk-benefit analysis, ioDSA was able to detect a perfusion rest in 2 out of 43 cases (4,7%) of aneurysm surgery, which could not have been visualized by ICG angiography before. In arterio-venous-malformation (AVM) surgery, one of 11 examined patients (7,7%) showed a remnant in ioDSA and resulted in additional resection. The average cost of an ioDSA in Ulm University can be estimated with 1928,00€. CONCLUSION According to our results ioDSA associated complications are low. Relevant findings in ioDSA can potentially avoid additional intervention, however, due to the high costs and lower availability, the main advantage might lie in the treatment of selected patients with complexes neurovascular pathologies since ICG angiography is equally safe but associated with lower costs and better availability.
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Affiliation(s)
- Gregor Durner
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany.
| | - Hellen Wahler
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
| | - Michael Braun
- University of Ulm, Department of Neuroradiology, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
| | - Thomas Kapapa
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
| | - Christian Rainer Wirtz
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
| | - Ralph König
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
| | - Andrej Pala
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
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Pedro MT, Grübel N, Durner G, Pala A, Wirtz CR, Koenig RW. Intraoperative Sodium-Fluorescence Imaging in Peripheral Nerve Sheath Tumors (PNST)-A New Additional Promising Diagnostic Tool. Front Oncol 2021; 11:655392. [PMID: 33768010 PMCID: PMC7985443 DOI: 10.3389/fonc.2021.655392] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 01/18/2021] [Accepted: 02/12/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Through the development and implementation of specific fluorophore filters to microscopes in 2012, sodium fluorescein (SF) is currently experiencing a remarkable renaissance in neurosurgery. The present study examines its intraoperative application during surgical removal of peripheral nerve sheath tumors (PNST) and metastases. Methods: This single-center study includes 10 cases of benign and malignant tumors as well as metastases of peripheral nerves (in total 11 PNST). Their surgical resections were all performed under microscope-based fluorescence with SF, which was administered intravenously (0.5–1.0 mg/kg body weight) during anesthesia induction. Microsurgical tumor removals were filmed and the collected data were retrospectively analyzed via ImageJ. Results: Microsurgical tumor preparation was possible under the usage of fluorophore filter. In seven histological confirmed schwannoma (n = 6 patients) tissue differentiation between tumor mass and not involved fascicles was statistically significant for the colors green and red. Schwannoma maximum mean for green reached 254.7 pixel and 179.4 pixel for red, whereas passing healthy fascicles revealed a maximum mean for green 94.91 and for red 120.76 pixel. One case of neurofibroma achieved lower amount of pixel. Similar to schwannoma, the two MPNST cases showed a strong homogeneous fluorescence (max. mean green 215 pixel and red 124.51) involving the whole nerve segment. Subcutaneous tumor remnants were visualized and therefore resected. Via fascicular nerve biopsy a B-cell lymphoma of the tibial nerve could be detected. SF led to variable stain intensities in single fascicles. The resected fascicle revealed a max mean green of 100.54 pixel, whereas surrounding fascicles came up with max. mean green of 63.0 pixel. Conclusions: Intraoperative SF visualization for PNST is feasible and of low risk. During resection of benign PNST, enhanced tissue differentiation between affected and not affected nerve segments is very useful. Tumor remnants can be detected safely and effectively. Its application during resection of malignant PNST is limited. Due to the infiltrative nature of those tumors, intraneural tissue differentiation is not possible. “Fluorescence-guided” biopsy can be regarded as an additional advantage in PNST surgery. Due to the encouraging experience in our institution SF was established as standard visualization tool in PNST surgery.
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Affiliation(s)
- Maria Teresa Pedro
- Klinik für Neurochirurgie, Medizinische Fakultät, Universität Ulm, Ulm, Germany
| | - Nadja Grübel
- Klinik für Neurochirurgie, Medizinische Fakultät, Universität Ulm, Ulm, Germany
| | - Gregor Durner
- Klinik für Neurochirurgie, Medizinische Fakultät, Universität Ulm, Ulm, Germany
| | - Andrej Pala
- Klinik für Neurochirurgie, Medizinische Fakultät, Universität Ulm, Ulm, Germany
| | | | - Ralph Werner Koenig
- Klinik für Neurochirurgie, Medizinische Fakultät, Universität Ulm, Ulm, Germany
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Schneider M, Kunz C, Pal'a A, Wirtz CR, Mathis-Ullrich F, Hlaváč M. Augmented reality-assisted ventriculostomy. Neurosurg Focus 2021; 50:E16. [PMID: 33386016 DOI: 10.3171/2020.10.focus20779] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [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: 08/31/2020] [Accepted: 10/22/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Placement of a ventricular drain is one of the most common neurosurgical procedures. However, a higher rate of successful placements with this freehand procedure is desirable. The authors' objective was to develop a compact navigational augmented reality (AR)-based tool that does not require rigid patient head fixation, to support the surgeon during the operation. METHODS Segmentation and tracking algorithms were developed. A commercially available Microsoft HoloLens AR headset in conjunction with Vuforia marker-based tracking was used to provide guidance for ventriculostomy in a custom-made 3D-printed head model. Eleven surgeons conducted a series of tests to place a total of 110 external ventricular drains under holographic guidance. The HoloLens was the sole active component; no rigid head fixation was necessary. CT was used to obtain puncture results and quantify success rates as well as precision of the suggested setup. RESULTS In the proposed setup, the system worked reliably and performed well. The reported application showed an overall ventriculostomy success rate of 68.2%. The offset from the reference trajectory as displayed in the hologram was 5.2 ± 2.6 mm (mean ± standard deviation). A subgroup conducted a second series of punctures in which results and precision improved significantly. For most participants it was their first encounter with AR headset technology and the overall feedback was positive. CONCLUSIONS To the authors' knowledge, this is the first report on marker-based, AR-guided ventriculostomy. The results from this first application are encouraging. The authors would expect good acceptance of this compact navigation device in a supposed clinical implementation and assume a steep learning curve in the application of this technique. To achieve this translation, further development of the marker system and implementation of the new hardware generation are planned. Further testing to address visuospatial issues is needed prior to application in humans.
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Affiliation(s)
- Max Schneider
- 1Department of Neurosurgery, University of Ulm, Günzburg; and
| | - Christian Kunz
- 2Health Robotics and Automation Lab, Institute for Anthropomatics and Robotics, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Andrej Pal'a
- 1Department of Neurosurgery, University of Ulm, Günzburg; and
| | | | - Franziska Mathis-Ullrich
- 2Health Robotics and Automation Lab, Institute for Anthropomatics and Robotics, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Michal Hlaváč
- 1Department of Neurosurgery, University of Ulm, Günzburg; and
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Renovanz M, Hickmann AK, Nadji-Ohl M, Keric N, Weimann E, Wirtz CR, Singer S, Ringel F, Coburger J. Health-related quality of life and distress in elderly vs. younger patients with high-grade glioma-results of a multicenter study. Support Care Cancer 2020; 28:5165-5175. [PMID: 32060706 PMCID: PMC7546979 DOI: 10.1007/s00520-020-05354-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/06/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Half of all newly diagnosed patients with glioblastoma are > 65 years still with a poor prognosis. Preserving quality of life is of high importance. However, patient reported outcome (PRO) data in this patient group is rare. The aim was to compare health-related quality of life (HRQoL) and distress between elderly and younger patients with high-grade glioma (HGG). METHODS We used baseline data of a prospective study where HGG patients were enrolled from 4 hospitals. Distress was measured using the distress thermometer (DT), HRQoL using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30) plus brain module (BN20). We compared distress and HRQoL by age (≥ 65 vs. < 65 years), gender, performance score, and time since diagnosis using multivariate linear and logistic regressions. RESULTS A total of n = 93 (30%) out of n = 309 patients were ≥ 65 years (mean 70 years, range 65-86 years). Mean DT score of elderly patients (5.2, SD 2.6) was comparable with younger patients (4.9, SD 2.6). Elderly patients reported significantly lower global health (GHS, mean elderly vs. younger; 50.8 vs. 60.5, p = 0.003), worse physical (56.8 vs. 73.3, p < 0.001) and lower cognitive functioning (51.1 vs. 63.2, p = 0.002), worse fatigue (52.5 vs. 43.5, p = 0.042), and worse motor dysfunction (34.9 vs. 23.6, p = 0.030). KPS and not age was consistently associated with HRQoL. CONCLUSION Physical functioning was significantly reduced in the elderly compared with younger HGG patients, and at the same time, emotional functioning and DT scores were comparable. KPS shows a greater association with HRQoL than with calendric age in HGG patients reflecting the particular importance for adequate assessment of HRQoL and general condition in elderly patients.
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Affiliation(s)
- Mirjam Renovanz
- Department of Neurosurgery, University Medical Center, Mainz, Germany.
- Division of Neuro-Oncology, University Medical Center Tubingen, Tübingen, Germany.
| | | | - Minou Nadji-Ohl
- Department of Neurosurgery, Klinikum Stuttgart, Stuttgart, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Medical Center, Mainz, Germany
| | - Elke Weimann
- Department of Neurology, RKH Kliniken Ludwigsburg, Ludwigsburg, Germany
| | | | - Susanne Singer
- Division of Epidemiology and Health Services Research, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center, Mainz, Germany
| | - Jan Coburger
- Department of Neurosurgery, University Medical Center Ulm, Ulm, Germany
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Scherer M, Ahmeti H, Roder C, Gessler F, Jungk C, Pala A, Mayer B, Senft C, Tatagiba M, Synowitz M, Wirtz CR, Unterberg AW, Coburger J. Surgery for Diffuse WHO Grade II Gliomas: Volumetric Analysis of a Multicenter Retrospective Cohort From the German Study Group for Intraoperative Magnetic Resonance Imaging. Neurosurgery 2020; 86:E64-E74. [PMID: 31574147 DOI: 10.1093/neuros/nyz397] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [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: 12/24/2018] [Accepted: 07/18/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In diffuse WHO grade II gliomas (LGG), the extent of resection (EOR) required to achieve significant survival benefits remains elusive. OBJECTIVE To evaluate the association of residual volume (RV) and EOR with progression-free survival (PFS) or overall survival (OS) in LGG in a retrospective, multicenter series by the German study group of intraoperative MRI (GeSGIM). METHODS Consecutive cases were retrospectively assessed from 5 centers. Tumors were volumetrically quantified before and after surgery, and clinical data were analyzed, including IDH mutations and neurologic deficits. Kaplan-Meier estimates, accelerated failure time models (AFT), and multivariate Cox regression models were calculated to identify determinants of survival. RESULTS A total of 140 cases were analyzed. Gross total resection (GTR) was associated with significantly longer PFS compared to any incomplete resection (P = .009). A significant survival disadvantage was evident even for small (>0-5 ml) residuals and increased for moderate (>5-20 ml) and large remnants (>20 ml) P = .001). Accordingly, PFS increased continuously for 20% incremental steps of EOR (P < .001). AFT models supported the notion of a continuous association of RV and EOR with PFS. Multivariate Cox regression models confirmed RV (P = .01) and EOR (P = .005) as continuous prognosticators of PFS. Univariate analysis showed significant associations of RV and EOR with OS. CONCLUSION Our data support the hypothesis of a continuous relationship of RV and EOR with survival for LGG with superiority seen for GTR. Hence, GTR should be achieved whenever safely feasible, and resections should be maximized whenever tumor has to be left behind to spare function.
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Affiliation(s)
- Moritz Scherer
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Hajrulla Ahmeti
- Department of Neurosurgery, University of Schleswig-Holstein, Kiel, Germany
| | - Constantin Roder
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Florian Gessler
- Department of Neurosurgery, University of Frankfurt, Frankfurt, Germany
| | - Christine Jungk
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Andrej Pala
- Department of Neurosurgery, University of Ulm, Günzburg, Germany
| | - Benjamin Mayer
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Christian Senft
- Department of Neurosurgery, University of Frankfurt, Frankfurt, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Michael Synowitz
- Department of Neurosurgery, University of Schleswig-Holstein, Kiel, Germany
| | | | | | - Jan Coburger
- Department of Neurosurgery, University of Ulm, Günzburg, Germany
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Hlaváč M, Knoll A, Mayer B, Braun M, Karpel-Massler G, Etzrodt-Walter G, Coburger J, Wirtz CR, Paľa A. Ten years’ experience with intraoperative MRI-assisted transsphenoidal pituitary surgery. Neurosurg Focus 2020; 48:E14. [DOI: 10.3171/2020.3.focus2072] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEMany innovations have been introduced into pituitary surgery in the quest to maximize the extent of tumor resection. Because of the deep and narrow surgical corridor as well as the heterogeneity of confronted pathologies, anatomical orientation and identification of the target tissue can become difficult. Intraoperative MRI (iMRI) may have the potential to increase extent of resection (EOR) in transsphenoidal pituitary surgery. Furthermore, it may simplify anatomical orientation and risk assessment in difficult cases. Here, the authors evaluated the additional value of iMRI for the resection of pituitary adenomas performed in the past 10 years in their department.METHODSThey performed a retrospective single-center analysis of patients treated for pituitary adenoma in their department after the introduction of iMRI between 2008 and 2018. Of 495 transsphenoidal approaches, 300 consecutive MRI-assisted surgeries for pituitary adenomas encompassing 294 patients were selected for further analysis. Microscopic, endoscopic, or endoscope-assisted microscopic transsphenoidal approaches were distinguished. EOR as well as additional resection following iMRI was evaluated via detailed volumetric analysis. Patients were stratified according to the Knosp adenoma classification. Furthermore, demographic data, clinical symptoms, endocrine outcome, and complications were evaluated. Univariable and multivariable Cox regression analyses of progression-free survival (PFS) were performed.RESULTSPituitary adenomas classified as Knosp grades 0–2 were found in 60.3% of cases (n = 181). The most common tumors were nonfunctioning adenomas (75%). Continued resection following iMRI significantly increased EOR (7.5%, p < 0.001) and the proportion of gross-total resections (GTRs) in transsphenoidal pituitary surgery (54% vs 68.3%, p < 0.001). Additional resection after iMRI was performed in 37% of cases. Only in the subgroup of patients with Knosp grades 0–2 adenomas treated with the microsurgical technique was additional resection significantly more common than in the endoscopic group (p = 0.039). Residual tumor volume, Knosp grade, and age were confirmed as independent predictors of PFS (p < 0.001, p = 0.021, and p = 0.029, respectively) in a multivariable Cox regression analysis. Improvement of visual field deficits was documented in 78.6% of patients whose optic apparatus had been affected preoperatively. Revision surgery was done in 7.3% of cases; in 5.6% of cases, it was performed for cerebrospinal fluid fistula.CONCLUSIONSIn this series, iMRI led to the detection of a resectable tumor remnant in a high proportion of patients, resulting in a greater EOR and higher proportion of GTRs after continued resection in microsurgical and endoscopic transsphenoidal resection of pituitary adenomas. The volume of residual tumor was the most important predictor of PFS. Given the study data, the authors postulated that every bit of removed tumor serves the patient and increases their chances of a favorable outcome.
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Affiliation(s)
- Michal Hlaváč
- 1Department of Neurosurgery, University of Ulm, Günzburg
| | - Andreas Knoll
- 1Department of Neurosurgery, University of Ulm, Günzburg
| | - Benjamin Mayer
- 3Institute of Epidemiology and Medical Biometry, University of Ulm
| | - Michael Braun
- 4Department of Neuroradiology, University of Ulm, Günzburg, Germany
| | | | | | - Jan Coburger
- 1Department of Neurosurgery, University of Ulm, Günzburg
| | | | - Andrej Paľa
- 1Department of Neurosurgery, University of Ulm, Günzburg
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Pruss M, Dwucet A, Tanriover M, Hlavac M, Kast RE, Debatin KM, Wirtz CR, Halatsch ME, Siegelin MD, Westhoff MA, Karpel-Massler G. Dual metabolic reprogramming by ONC201/TIC10 and 2-Deoxyglucose induces energy depletion and synergistic anti-cancer activity in glioblastoma. Br J Cancer 2020; 122:1146-1157. [PMID: 32115576 PMCID: PMC7156767 DOI: 10.1038/s41416-020-0759-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 01/08/2020] [Accepted: 02/05/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Dysregulation of the metabolome is a hallmark of primary brain malignancies. In this work we examined whether metabolic reprogramming through a multi-targeting approach causes enhanced anti-cancer activity in glioblastoma. METHODS Preclinical testing of a combined treatment with ONC201/TIC10 and 2-Deoxyglucose was performed in established and primary-cultured glioblastoma cells. Extracellular flux analysis was used to determine real-time effects on OXPHOS and glycolysis. Respiratory chain complexes were analysed by western blotting. Biological effects on tumour formation were tested on the chorioallantoic membrane (CAM). RESULTS ONC201/TIC10 impairs mitochondrial respiration accompanied by an increase of glycolysis. When combined with 2-Deoxyglucose, ONC201/TIC10 induces a state of energy depletion as outlined by a significant decrease in ATP levels and a hypo-phosphorylative state. As a result, synergistic anti-proliferative and anti-migratory effects were observed among a broad panel of different glioblastoma cells. In addition, this combinatorial approach significantly impaired tumour formation on the CAM. CONCLUSION Treatment with ONC201/TIC10 and 2-Deoxyglucose results in a dual metabolic reprogramming of glioblastoma cells resulting in a synergistic anti-neoplastic activity. Given, that both agents penetrate the blood-brain barrier and have been used in clinical trials with a good safety profile warrants further clinical evaluation of this therapeutic strategy.
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Affiliation(s)
- Maximilian Pruss
- Department of Neurological Surgery, Ulm University Medical Center, Ulm, Germany
| | - Annika Dwucet
- Department of Neurological Surgery, Ulm University Medical Center, Ulm, Germany
| | - Mine Tanriover
- Department of Neurological Surgery, Ulm University Medical Center, Ulm, Germany
| | - Michal Hlavac
- Department of Neurological Surgery, Ulm University Medical Center, Ulm, Germany
| | | | - Klaus-Michael Debatin
- Department of Pediatric and Adolescent Medicine, Ulm University Medical Center, Ulm, Germany
| | | | - Marc-Eric Halatsch
- Department of Neurological Surgery, Ulm University Medical Center, Ulm, Germany
| | - Markus David Siegelin
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA
| | - Mike-Andrew Westhoff
- Department of Pediatric and Adolescent Medicine, Ulm University Medical Center, Ulm, Germany
| | - Georg Karpel-Massler
- Department of Neurological Surgery, Ulm University Medical Center, Ulm, Germany.
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Pala A, Nadji-Ohl M, Faust K, Rückriegel S, Roder C, von der Brelie C, Forster MT, Löbel F, Schommer S, Löhr M, Grübel N, Rothenbacher D, König R, Engelke J, Schmitz B, Wirtz CR, Senft C, Rohde V, Tatagiba M, Ernestus RI, Vajkoczy P, Ganslandt O, Nagel G, Coburger J, Ringel F, Renovanz M. Erratum: Multicentric Registry Study on Epidemiological and Biological Disease Profile as Well as Clinical Outcome in Patients with Low-Grade Gliomas: The LoG-Glio Project. J Neurol Surg A Cent Eur Neurosurg 2020; 81:e1. [PMID: 32413930 DOI: 10.1055/s-0040-1712923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Andrej Pala
- Department of Neurosurgery, University of Ulm, Ludwig Heilmeyerstr, Günzburg, Germany
| | - Minou Nadji-Ohl
- Department of Neurosurgery, Katharinenhospital Stuttgart, Kriegsbergstr, Stuttgart, Germany
| | - Katharina Faust
- Department of Neurosurgery, Charité - University of Berlin, Charitéplatz, Berlin, Germany
| | - Stefan Rückriegel
- Department of Neurosurgery, University of Würzburg, Josef-Schneider-Strasse, Würzburg, Germany
| | - Constantin Roder
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Strasse, Tuebingen, Germany
| | | | - Marie-Therese Forster
- Department of Neurosurgery, University of Frankfurt, Schleusenweg, Frankfurt am Main, Germany
| | - Franziska Löbel
- Department of Neurosurgery, Charité - University of Berlin, Charitéplatz, Berlin, Germany
| | - Stefan Schommer
- Department of Neurosurgery, Katharinenhospital Stuttgart, Kriegsbergstr, Stuttgart, Germany
| | - Mario Löhr
- Department of Neurosurgery, University of Würzburg, Josef-Schneider-Strasse, Würzburg, Germany
| | - Nadja Grübel
- Department of Neurosurgery, University of Ulm, Ludwig Heilmeyerstr, Günzburg, Germany
| | - Dietrich Rothenbacher
- Institute of Epidemiology and Medical Biometry, University of Ulm, Helmholzstrasse, Ulm, Germany
| | - Ralph König
- Department of Neurosurgery, University of Ulm, Ludwig Heilmeyerstr, Günzburg, Germany
| | - Jens Engelke
- Department of Neurosurgery, University of Ulm, Ludwig Heilmeyerstr, Günzburg, Germany
| | - Bernd Schmitz
- Department of Neuroradiology, University of Ulm, Ludwig Heilmeyerstr, Günzburg, Germany
| | | | - Christian Senft
- Department of Neurosurgery, University of Frankfurt, Schleusenweg, Frankfurt am Main, Germany
| | - Veit Rohde
- Department of Neurosurgery, University of Göttingen, Robert-Koch-Strasse, Göttingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Strasse, Tuebingen, Germany
| | - Ralf Ingo Ernestus
- Department of Neurosurgery, University of Würzburg, Josef-Schneider-Strasse, Würzburg, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - University of Berlin, Charitéplatz, Berlin, Germany
| | - Oliver Ganslandt
- Department of Neurosurgery, Katharinenhospital Stuttgart, Kriegsbergstr, Stuttgart, Germany
| | - Gabriele Nagel
- Institute of Epidemiology and Medical Biometry, University of Ulm, Helmholzstrasse, Ulm, Germany
| | - Jan Coburger
- Department of Neurosurgery, University of Ulm, Ludwig Heilmeyerstr, Günzburg, Germany
| | - Florian Ringel
- Department of Neurosurgery, Universitätsmedizin Mainz, Mainz, Germany
| | - Mirjam Renovanz
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Strasse, Tuebingen, Germany
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Pala A, Awad F, Braun M, Hlavac M, Wunderlich A, Schmitz B, Wirtz CR, Coburger J. Value of whole-body low-dose computed tomography in patients with ventriculoperitoneal shunts: a retrospective study. J Neurosurg 2019; 129:1598-1603. [PMID: 29303439 DOI: 10.3171/2017.7.jns17476] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 07/07/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe gold standard for evaluation of ventriculoperitoneal (VP) shunt position, dislocation, or disconnection is conventional radiography. Yet, assessment with this modality can be challenging because of low image quality and can result in repetitive radiation exposure with high fluctuation in the radiation dose. Recently, CT-based radiation doses have been significantly reduced by using low-dose protocols. Thus, whole-body low-dose CT (LDCT) has become applicable for routine use in VP shunt evaluation. The authors here compared image quality and approximate radiation dose between radiography and LDCT in patients with implanted VP shunt systems.METHODSVentriculoperitoneal shunt systems have been investigated with LDCT scanning at the authors' department since 2015. A consecutive series of 57 patients (70 investigations) treated between 2015 and 2016 was retrospectively assessed. A historical patient cohort that had been evaluated with radiography was compared with the LDCT patients in terms of radiation dose and image quality. Three independent observers evaluated projection of the valve pressure level and correct intraperitoneal position, as well as complete shunt projection, using a Likert-type scale of 1-5, where 1 indicated "not assessable" and 5 meant "assessable with high accuracy." Descriptive statistics and the Mann-Whitney U-test were used for analysis.RESULTSTwenty-seven radiographs (38.6%) and 43 LDCT scans (61.4%) were analyzed. The median dose-length product (DLP) of the LDCT scans was 100 mGy·cm (range 59.9-183 mGy·cm). The median total dose-area product (DAP) of the radiographic images was 3177 mGy·cm2 (range 641-13,833 mGy·cm2). The estimated effective dose (EED) was significantly lower with the LDCT scan (p < 0.001). The median EED was 4.93 and 1.90 mSv for radiographs and LDCT, respectively. Significantly better identification of the abdominal position of the distal shunt catheter was achieved with LDCT (p < 0.001). Simultaneously, significantly improved visualization of the entire shunt system was realized with this technique (p < 0.001). On the contrary, identification of the valve settings was significantly worse with LDCT (p < 0.001).CONCLUSIONSWhole-body LDCT scanning allows good visualization of the distal catheter after VP shunt placement. Despite the fact that only a rough estimation of effective doses is possible in a direct comparison of LDCT and radiography, the data showed that shunt assessment via LDCT does not lead to greater radiation exposure. Thus, especially in difficult anatomical conditions, as in patients who have undergone multiple intraabdominal surgeries, have a high BMI, or are immobile, the use of LDCT shunt evaluation has high clinical value. Further data are needed to determine the value of LDCT for the evaluation of complications or radiation dose in pediatric patients.
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Affiliation(s)
| | | | | | | | - Arthur Wunderlich
- 3Radiology; and.,4Section for Experimental Radiology, University of Ulm, Günzburg, Germany
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Pala A, Nadji-Ohl M, Faust K, Rückriegel S, Roder C, von der Brelie C, Forster MT, Löbel F, Schommer S, Löhr M, Renovanz M, Grübel N, Rothenbacher D, König R, Engelke J, Schmitz B, Wirtz CR, Ringel F, Senft C, Rohde V, Tatagiba M, Ernestus RI, Vajkoczy P, Ganslandt O, Nagel G, Coburger J. Multicentric Registry Study on Epidemiological and Biological Disease Profile as Well as Clinical Outcome in Patients with Low-Grade Gliomas: The LoG-Glio Project. J Neurol Surg A Cent Eur Neurosurg 2019; 81:48-57. [PMID: 31550737 DOI: 10.1055/s-0039-1693650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND World Health Organization (WHO) grade II low-grade gliomas (LGGs) in adults are rare, and patients' mean overall survival (OS) is relatively long. Epidemiological data on factors influencing tumor genesis and progression are scarce, and prospective data on surgical management are still lacking. Because of the molecular heterogeneity of LGG, a comprehensive molecular characterization is required for any clinical and epidemiological research. Further, a detailed radiologic assessment is needed as the only established objective criterion for progressive disease. Both radiologic and molecular assessments have to be standardized to produce comparable data. The aim of the registry is to improve the evidence for surgical management of LGG patients by establishing a multicenter registry with a strong surgical and clinical focus including mandatory biobanking. METHODS The LoG-Glio project is a prospective national observational multicenter registry that began on November 1, 2015. Inclusion criteria encompass all patients > 18 years of age with a radiologic suspicion of LGG. Patients with severe neurologic or psychiatric disorders that may interfere with their informed consent or if there is no possibility for further follow-up are excluded. Diagnosis of glioblastoma WHO grade IV isocitrate dehydrogenase (IDH) wild type leads to a secondary exclusion of patients. In addition to demographic data, results of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, add-on for patients with brain tumors, and National Health Institute Stroke Scale before and after surgery and during regular follow-ups are collected. At each time point a detailed recording of surgical and adjuvant treatment is performed. Radiologic assessment involves three-dimensional (3D) acquisition of T1, fluid-attenuated inversion recovery, and T2 sequences. For the final evaluation, a central detailed neuropathologic and molecular assessment of tumor samples and a radiologic evaluation of imaging sets are part of the study protocol. RESULTS We report the first 100 consecutively registered patients for LoG-Glio. Three patients dropped out due to loss of follow-up. Of the remaining recruited patients, 8 were classified as wait and scan; 89 had surgery. Using the inclusion criteria described previously, 70 patients had an IDH-mutated glioma, 10 had miscellaneous rare LGGs, and 8 patients had an IDH wild-type WHO grade II or III glioma. CONCLUSION The LoG-Glio registry has been successfully implemented. Applied selection criteria result in an appropriately balanced patient cohort. Short-term outcome data on epidemiology as well as the influence of current surgical techniques and adjuvant treatment on patient outcomes are expected. In the long run, the aim of the registry is to validate the new molecular-based WHO classification and the influence of the extent of resection on progression-free survival and OS. The registry provides an open platform for future research projects benefiting patients with LGG. TRIAL REGISTRATION NCT02686229 Clinical trials.
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Affiliation(s)
- Andrej Pala
- Department of Neurosurgery, University of Ulm, Ludwig Heilmeyerstr, Günzburg, Germany
| | - Minou Nadji-Ohl
- Department of Neurosurgery, Katharinenhospital Stuttgart, Kriegsbergstr, Stuttgart, Germany
| | - Katharina Faust
- Department of Neurosurgery, Charité - University of Berlin, Charitéplatz, Berlin, Germany
| | - Stefan Rückriegel
- Department of Neurosurgery, University of Würzburg, Josef-Schneider-Strasse, Würzburg, Germany
| | - Constantin Roder
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Strasse, Tuebingen, Germany
| | | | - Marie-Therese Forster
- Department of Neurosurgery, University of Frankfurt, Schleusenweg, Frankfurt am Main, Germany
| | - Franziska Löbel
- Department of Neurosurgery, Charité - University of Berlin, Charitéplatz, Berlin, Germany
| | - Stefan Schommer
- Department of Neurosurgery, Katharinenhospital Stuttgart, Kriegsbergstr, Stuttgart, Germany
| | - Mario Löhr
- Department of Neurosurgery, University of Würzburg, Josef-Schneider-Strasse, Würzburg, Germany
| | - Mirjam Renovanz
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Strasse, Tuebingen, Germany
| | - Nadja Grübel
- Department of Neurosurgery, University of Ulm, Ludwig Heilmeyerstr, Günzburg, Germany
| | - Dietrich Rothenbacher
- Institute of Epidemiology and Medical Biometry, University of Ulm, Helmholzstrasse, Ulm, Germany
| | - Ralph König
- Department of Neurosurgery, University of Ulm, Ludwig Heilmeyerstr, Günzburg, Germany
| | - Jens Engelke
- Department of Neurosurgery, University of Ulm, Ludwig Heilmeyerstr, Günzburg, Germany
| | - Bernd Schmitz
- Department of Neuroradiology, University of Ulm, Ludwig Heilmeyerstr, Günzburg, Germany
| | | | - Florian Ringel
- Department of Neurosurgery, Universitätsmedizin Mainz, Mainz, Germany
| | - Christian Senft
- Department of Neurosurgery, University of Frankfurt, Schleusenweg, Frankfurt am Main, Germany
| | - Veit Rohde
- Department of Neurosurgery, University of Göttingen, Robert-Koch-Strasse, Göttingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Strasse, Tuebingen, Germany
| | - Ralf Ingo Ernestus
- Department of Neurosurgery, University of Würzburg, Josef-Schneider-Strasse, Würzburg, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - University of Berlin, Charitéplatz, Berlin, Germany
| | - Oliver Ganslandt
- Department of Neurosurgery, Katharinenhospital Stuttgart, Kriegsbergstr, Stuttgart, Germany
| | - Gabriele Nagel
- Institute of Epidemiology and Medical Biometry, University of Ulm, Helmholzstrasse, Ulm, Germany
| | - Jan Coburger
- Department of Neurosurgery, University of Ulm, Ludwig Heilmeyerstr, Günzburg, Germany
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Halatsch M, Kast RE, Dwucet A, Hlavac M, Heiland T, Westhoff M, Debatin K, Wirtz CR, Siegelin MD, Karpel‐Massler G. Bcl-2/Bcl-xL inhibition predominantly synergistically enhances the anti-neoplastic activity of a low-dose CUSP9 repurposed drug regime against glioblastoma. Br J Pharmacol 2019; 176:3681-3694. [PMID: 31222722 PMCID: PMC6715605 DOI: 10.1111/bph.14773] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 04/27/2019] [Accepted: 06/04/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND PURPOSE Drug repurposing represents a promising approach to safely accelerate the clinical application of therapeutics with anti-cancer activity. In this study, we examined whether inhibition of the anti-apoptotic Bcl-2 family proteins Bcl-2 and Bcl-xL enhances the biological effects of the repurposed CUSP9 regimen in an in vitro setting of glioblastoma. EXPERIMENTAL APPROACH We applied 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide assays to assess cellular proliferation. Annexin V/propidium iodide and tetramethylrhodamine, ethyl ester staining were used to examine apoptosis. Western blotting, RT-PCR, and specific knockdown experiments using siRNA were employed to examine molecular mechanisms of action. KEY RESULTS Bcl-2/Bcl-xL inhibition exerted synergistic anti-proliferative effects across established, primary cultured, and stem-like glioblastoma cells when combined with CUSP9 which had been reduced to only one tenth of its proposed original concentration (CUSP9-LD). The combination treatment also led to enhanced apoptosis with loss of mitochondrial membrane potential and activation of caspases. On the molecular level, CUSP9-LD counteracted ABT263-mediated up-regulation of Mcl-1. Silencing of Mcl-1 enhanced ABT263-mediated apoptosis which indicates that down-regulation of Mcl-1 is crucial for the induction of cell death by the combination treatment. CONCLUSION AND IMPLICATIONS These data suggest that Bcl-2/Bcl-xL inhibition enhances the susceptibility of glioblastoma cells towards CUSP9, allowing dramatic dose reduction and potentially decreased toxicity when applied clinically. A clinical trial involving the original CUSP doses (CUSP9v3) is currently ongoing in our institution (NCT02770378). The Bcl-2/Bcl-xL inhibitor ABT263 is in clinical trials and might represent a valuable adjunct to the original CUSP.
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Affiliation(s)
| | | | - Annika Dwucet
- Department of NeurosurgeryUlm University Medical CenterUlmGermany
| | - Michal Hlavac
- Department of NeurosurgeryUlm University Medical CenterUlmGermany
| | - Tim Heiland
- Department of NeurosurgeryUlm University Medical CenterUlmGermany
| | - Mike‐Andrew Westhoff
- Department of Pediatrics and Adolescent MedicineUlm University Medical CenterUlmGermany
| | - Klaus‐Michael Debatin
- Department of Pediatrics and Adolescent MedicineUlm University Medical CenterUlmGermany
| | | | - Markus David Siegelin
- Department of Pathology and Cell BiologyColumbia University Medical CenterNew YorkNYUSA
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Brand C, Pala A, Scheuerle A, Scheglmann K, König R, Kratzer W, Wirtz CR, Antoniadis G, Pedro MT. [Neurolymphomatosis : Two case reports]. Nervenarzt 2019; 89:701-704. [PMID: 29181546 DOI: 10.1007/s00115-017-0460-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- C Brand
- Klinik für Neurochirurgie, Universitätsklinikum Ulm, Ludwig-Heilmeyer-Str. 2, 89312, Günzburg, Deutschland.
| | - A Pala
- Klinik für Neurochirurgie, Universitätsklinikum Ulm, Ludwig-Heilmeyer-Str. 2, 89312, Günzburg, Deutschland
| | - A Scheuerle
- Abteilung Neuropathologie am BKH Günzburg, Universitätsklinikum Ulm, Günzburg, Deutschland
| | | | - R König
- Klinik für Neurochirurgie, Universitätsklinikum Ulm, Ludwig-Heilmeyer-Str. 2, 89312, Günzburg, Deutschland
| | - W Kratzer
- Innere Medizin, Universitätsklinikum Ulm, Ulm, Deutschland
| | - C R Wirtz
- Klinik für Neurochirurgie, Universitätsklinikum Ulm, Ludwig-Heilmeyer-Str. 2, 89312, Günzburg, Deutschland
| | - G Antoniadis
- Klinik für Neurochirurgie, Universitätsklinikum Ulm, Ludwig-Heilmeyer-Str. 2, 89312, Günzburg, Deutschland
| | - M T Pedro
- Klinik für Neurochirurgie, Universitätsklinikum Ulm, Ludwig-Heilmeyer-Str. 2, 89312, Günzburg, Deutschland
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Paľa A, Coburger J, Scherer M, Ahmeti H, Roder C, Gessler F, Jungk C, Scheuerle A, Senft C, Tatagiba M, Synowitz M, Wirtz CR, Schmitz B, Unterberg AW. To treat or not to treat? A retrospective multicenter assessment of survival in patients with IDH-mutant low-grade glioma based on adjuvant treatment. J Neurosurg 2019; 133:273-280. [PMID: 31323633 DOI: 10.3171/2019.4.jns183395] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 12/11/2018] [Accepted: 04/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The level of evidence for adjuvant treatment of diffuse WHO grade II glioma (low-grade glioma, LGG) is low. In so-called "high-risk" patients most centers currently apply an early aggressive adjuvant treatment after surgery. The aim of this assessment was to compare progression-free survival (PFS) and overall survival (OS) in patients receiving radiation therapy (RT) alone, chemotherapy (CT) alone, or a combined/consecutive RT+CT, with patients receiving no primary adjuvant treatment after surgery. METHODS Based on a retrospective multicenter cohort of 288 patients (≥ 18 years old) with diffuse WHO grade II gliomas, a subgroup analysis of patients with a confirmed isocitrate dehydrogenase (IDH) mutation was performed. The influence of primary adjuvant treatment after surgery on PFS and OS was assessed using Kaplan-Meier estimates and multivariate Cox regression models, including age (≥ 40 years), complete tumor resection (CTR), recurrent surgery, and astrocytoma versus oligodendroglioma. RESULTS One hundred forty-four patients matched the inclusion criteria. Forty patients (27.8%) received adjuvant treatment. The median follow-up duration was 6 years (95% confidence interval 4.8-6.3 years). The median overall PFS was 3.9 years and OS 16.1 years. PFS and OS were significantly longer without adjuvant treatment (p = 0.003). A significant difference in favor of no adjuvant therapy was observed even in high-risk patients (age ≥ 40 years or residual tumor, 3.9 vs 3.1 years, p = 0.025). In the multivariate model (controlled for age, CTR, oligodendroglial diagnosis, and recurrent surgery), patients who received no adjuvant therapy showed a significantly positive influence on PFS (p = 0.030) and OS (p = 0.009) compared to any other adjuvant treatment regimen. This effect was most pronounced if RT+CT was applied (p = 0.004, hazard ratio [HR] 2.7 for PFS, and p = 0.001, HR 20.2 for OS). CTR was independently associated with longer PFS (p = 0.019). Age ≥ 40 years, histopathological diagnosis, and recurrence did not achieve statistical significance. CONCLUSIONS In this series of IDH-mutated LGGs, adjuvant treatment with RT, CT with temozolomide (TMZ), or the combination of both showed no significant advantage in terms of PFS and OS. Even in high-risk patients, the authors observed a similar significantly negative impact of adjuvant treatment on PFS and OS. These results underscore the importance of a CTR in LGG. Whether patients ≥ 40 years old should receive adjuvant treatment despite a CTR should be a matter of debate. A potential tumor dedifferentiation by administration of early TMZ, RT, or RT+CT in IDH-mutated LGG should be considered. However, these data are limited by the retrospective study design and the potentially heterogeneous indication for adjuvant treatment.
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Affiliation(s)
| | | | | | - Hajrullah Ahmeti
- 3Department of Neurosurgery, University of Schleswig-Holstein, Kiel
| | | | - Florian Gessler
- 5Department of Neurosurgery, University of Frankfurt, Germany
| | | | | | - Christian Senft
- 5Department of Neurosurgery, University of Frankfurt, Germany
| | | | - Michael Synowitz
- 3Department of Neurosurgery, University of Schleswig-Holstein, Kiel
| | | | - Bernd Schmitz
- 7Department of Radiology, Section of Neuroradiology, University of Ulm, Günzburg
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Knoll A, Pal'a A, Pedro MT, Bäzner U, Schneider M, König RW, Wirtz CR, Friedrich S, Pauly M, Antoniadis G. Clinical outcome after decompression of intraneural peroneal ganglion cyst and its morphologic correlation to postoperative nerve ultrasound. J Neurosurg 2019; 133:233-239. [PMID: 31252391 DOI: 10.3171/2019.3.jns182699] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 03/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intraneural ganglion cysts are rare and benign mucinous lesions that affect peripheral nerves, most frequently the common peroneal nerve (CPN). The precise pathophysiological mechanisms of intraneural ganglion cyst development remain unclear. A well-established theory suggests the spread of mucinous fluid along the articular branch of the peroneal nerve as the underlying mechanism. Clinical outcome following decompression of intraneural ganglion cysts has been demonstrated to be excellent. The aim of this study was to evaluate the correlation between clinical outcome and ultrasound-detected morphological nerve features following decompression of intraneural ganglion cysts of the CPN. METHODS Data were retrospectively analyzed from 20 patients who underwent common peroneal nerve ganglion cyst decompression surgery at the Universität Ulm/Günzburg Neurosurgery Department between October 2003 and October 2017. Postoperative clinical outcome was evaluated by assessment of the muscular strength of the anterior tibial muscle, the extensor hallucis longus muscle, and the peroneus muscle according to the Medical Research Council grading system. Hypesthesia was measured by sensation testing. In all patients, postoperative morphological assessment of the peroneal nerve was conducted between October 2016 and October 2017 using the iU22 Philips Medical ultrasound system at the last routine follow-up appointment. Finally, the correlations between morphological changes in nerve ultrasound and postoperative clinical outcomes were evaluated. RESULTS During the postoperative ultrasound scan an intraneural hypoechogenic ring structure located at the medial side of the peroneal nerve was detected in 15 (75%) of 20 patients, 14 of whom demonstrated an improvement in motor function. A regular intraneural fasicular structure was identified in 3 patients (15%), who also reported recovery. In 1 patient, a recurrent cyst was detected, and 1 patient showed intraneural fibrosis for which recovery did not occur in the year following the procedure. Two patients (10%) developed neuropathic pain that could not be explained by nerve ultrasound findings. CONCLUSIONS The results of this study demonstrate significant recovery from preoperative weakness after decompression of intraneural ganglion cysts of the CPN. A favorable clinical outcome was highly correlated with an intraneural hypoechogenic ring-shaped structure on the medial side of the CPN identified during a follow-up postoperative ultrasound scan. These study results indicate the potential benefit of ultrasound scanning as a prognostic tool following decompression procedures for intraneural ganglion cysts of the CPN.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Gregor Antoniadis
- 3Department of Neurosurgery-Section of Peripheral Nerve Surgery, University of Ulm, Günzburg, Germany
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Brand C, Pala A, Kielhorn W, Wirtz CR, Kapapa T. Do Complication Rates of Ventricular Drain Placement Differ between Twist Drill and Burr Hole in Acute Hydrocephalus? J Neurol Surg A Cent Eur Neurosurg 2019; 80:277-284. [PMID: 31018224 DOI: 10.1055/s-0039-1685195] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of the study was to compare two techniques for external ventricular drainage (EVD) placement with respect to their complication rates. METHODS A retrospective descriptive study was performed to analyze all patients who had undergone EVD implantation for acute hydrocephalus between January 2010 and December 2013 with a focus on surgical technique and rate of complications. The burr hole technique (BHT) was used in one group and the twist-drill technique (TDT) in the other. Particular attention was paid to malposition, hemorrhage, and catheter-associated infection. RESULTS A total of 350 consecutive patients underwent EVD implantation for acute hydrocephalus: BHT was performed in 201 and TDT in 147 of the patients, whereas in two patients the technique used was unknown. The overall infection rate was 6.3% (n = 22). Fourteen patients (4%) in the BHT group developed an infection compared with eight patients (9.5%) in the TDT group (p = 0.154). In 16 (4.5%) of all cases, postoperative computed tomography revealed catheter-induced hemorrhage.In one case (0.3%), surgery was necessary due to acute subdural hematoma. The difference between both techniques was not statistically significant (p = 0.343). In 44 (12.6%) of all cases, the position of the EVD tip was contralateral; in 36 (10.3%) of all cases, the EVD tip was in the brain parenchyma. The rate of malposition was 11.6% (n = 17) in the TDT group and 9.5% (n = 19) in the BHT group (p = 0.078). CONCLUSION Neither technique showed significantly different numbers in terms of infection, malposition, and hemorrhagic complications. EVD implantation using the TDT is an adequate method compared with BHT. The advantages of TDT are clear: the duration of surgery is shorter, the size of the wound is smaller, and the surgeon is not confined to the operating room.
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Affiliation(s)
| | - Andrej Pala
- Department of Neurosurgery, University of Ulm, Ulm, Germany
| | | | | | - Thomas Kapapa
- Department of Neurosurgery, Universitätsklinikum Ulm, Ulm, Germany
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Hlaváč M, Knoll A, Etzrodt-Walter G, Sommer F, Scheithauer M, Coburger J, Wirtz CR, Pala A. Intraoperative MRI in transsphenoidal resection of invasive pituitary macroadenomas. Neurosurg Rev 2019; 42:737-743. [DOI: 10.1007/s10143-019-01102-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 03/04/2019] [Accepted: 03/27/2019] [Indexed: 10/27/2022]
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Pedro MT, Eissler A, Schmidberger J, Kratzer W, Wirtz CR, Antoniadis G, Koenig RW. Sodium Fluorescein–Guided Surgery in Peripheral Nerve Sheath Tumors: First Experience in 10 Cases of Schwannoma. World Neurosurg 2019; 124:e724-e732. [PMID: 30660884 DOI: 10.1016/j.wneu.2019.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/06/2019] [Accepted: 01/08/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The intravenous application of sodium fluorescein (SF) for brain tumor surgery goes back to the late 1940s. The development of specific fluorophore filters significantly reduced the required dosage of SF and therefore diminished possible side effects. This study investigates the application of SF in benign peripheral nerve sheath tumors (PNSTs), concentrating on its feasibility during microsurgical removal. METHODS The single-center study includes 10 consecutive schwannoma cases operated on between September 2016 and March 2017. Inclusion criteria were defined as age ≥18 years, preoperative magnetic resonance imaging with suspicion of schwannoma, and final histopathologic confirmation of schwannoma. Exclusion criteria were a history of intolerance to SF and renal insufficiency. The microsurgical part of each surgery was video recorded, and the collected material was retrospectively analyzed. Red, green, and blue values of various regions of interest set on tumor and normal nerve of each patient were evaluated using ImageJ, an open platform for scientific image analysis. RESULTS Digital video analysis confirmed the intraoperative impression of increased fluorescence of the tumor in contrast with normal nerve tissue. Because the color yellow is predominantly a mixture of red and green, values of these colors were significantly increased in schwannomas compared with normal nerve tissue (P = 0.0003 and P = 0.0023, respectively). CONCLUSIONS SF reveals increased fluorescence in schwannomas compared with normal nerve tissue. Intraoperative differentiation of tumor and normal nerve tissue becomes possible using a low dose of SF (0.5-1 mg/kg). No side effects occurred. Secure microsurgical preparation is feasible during application of the YELLOW 560 nm filter.
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Hlavac M, Dwucet A, Kast RE, Engelke J, Westhoff MA, Siegelin MD, Debatin KM, Wirtz CR, Halatsch ME, Karpel-Massler G. Combined inhibition of RAC1 and Bcl-2/Bcl-xL synergistically induces glioblastoma cell death through down-regulation of the Usp9X/Mcl-1 axis. Cell Oncol (Dordr) 2019; 42:287-301. [PMID: 30859392 DOI: 10.1007/s13402-019-00425-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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] [Accepted: 01/28/2019] [Indexed: 01/10/2023] Open
Abstract
PURPOSE Anti-apoptotic and pro-migratory phenotypes are hallmarks of neoplastic diseases, including primary brain malignancies. In this work, we examined whether reprogramming of the apoptotic and migratory machineries through a multi-targeting approach would induce enhanced cell death and enhanced inhibition of the migratory capacity of glioblastoma cells. METHODS Preclinical testing and molecular analyses of combined inhibition of Bcl-2/Bcl-xL and RAC1 were performed in established, primary cultured and stem-like glioblastoma cell systems. RESULTS We found that the combined inhibition of Bcl-2/Bcl-xL and RAC1 resulted in synergistic pro-apoptotic and anti-migratory effects in a broad range of different glioblastoma cells. At the molecular level, we found that RAC1 inhibition led to a decreased expression of the deubiquitinase Usp9X, followed by a decreased stability of Mcl-1. We also found that the combined inhibition led to a significantly decreased migratory activity and that tumor formation of glioblastoma cells on chorion allantoic membranes of chicken embryos was markedly impaired following the combined inhibition. CONCLUSIONS Our data indicate that concomitant inhibition of RAC1 and Bcl-2/Bcl-xL induces pro-apoptotic and anti-migratory glioblastoma phenotypes as well as synergistic anti-neoplastic activities. The clinical efficacy of this inhibitory therapeutic strategy warrants further evaluation.
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Affiliation(s)
- Michal Hlavac
- Department of Neurological Surgery, Ulm University Medical Center, Albert-Einstein-Allee 23, D-89081, Ulm, Germany
| | - Annika Dwucet
- Department of Neurological Surgery, Ulm University Medical Center, Albert-Einstein-Allee 23, D-89081, Ulm, Germany
| | | | - Jens Engelke
- Department of Neurological Surgery, Ulm University Medical Center, Albert-Einstein-Allee 23, D-89081, Ulm, Germany
| | - Mike-Andrew Westhoff
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm, Germany
| | - Markus D Siegelin
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA
| | - Klaus-Michael Debatin
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm, Germany
| | - Christian Rainer Wirtz
- Department of Neurological Surgery, Ulm University Medical Center, Albert-Einstein-Allee 23, D-89081, Ulm, Germany
| | - Marc-Eric Halatsch
- Department of Neurological Surgery, Ulm University Medical Center, Albert-Einstein-Allee 23, D-89081, Ulm, Germany
| | - Georg Karpel-Massler
- Department of Neurological Surgery, Ulm University Medical Center, Albert-Einstein-Allee 23, D-89081, Ulm, Germany.
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Paľa A, Schick J, Klein M, Mayer B, Schmitz B, Wirtz CR, König R, Kapapa T. The influence of nimodipine and vasopressors on outcome in patients with delayed cerebral ischemia after spontaneous subarachnoid hemorrhage. J Neurosurg 2019; 132:1096-1104. [PMID: 30849754 DOI: 10.3171/2018.11.jns182891] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 10/10/2018] [Accepted: 11/27/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI) is a major factor contributing to the inferior outcome of patients with spontaneous subarachnoid hemorrhage (SAH). Nimodipine and induced hypertension using vasopressors are an integral part of standard therapy. Consequences of the opposite effect of nimodipine and vasopressors on blood pressure on patient outcome remain unclear. The authors report the detailed general characteristics and influence of nimodipine and vasopressors on outcome in patients with SAH. METHODS The authors performed a 2-center, retrospective, clinical database analysis of 732 SAH patients treated between 2008 and 2016. Demographic and clinical data such as age, sex, World Federation of Neurosurgical Societies (WFNS) grade, BMI, Fisher grade, history of arterial hypertension and smoking, aneurysm location, C-reactive protein (CRP) level, and detailed dosage of vasopressors and nimodipine during the treatment period were evaluated. Clinical outcome was analyzed using the modified Rankin Scale (mRS) 6 months after treatment. Univariate and multivariate regression analyses were performed. Additionally, mean arterial pressure (MAP), age, nimodipine, and vasopressor dose cutoff were evaluated with regard to outcome. The level of significance was set at ≤ 0.05. RESULTS Follow-up was assessed for 397 patients, 260 (65.5%) of whom achieved a good outcome (defined as an mRS score of 0-3). Univariate and multivariate analyses confirmed that nimodipine (p = 0.049), age (p = 0.049), and CRP level (p = 0.002) are independent predictors of good outcome. WFNS grade, Fisher score, hypertension, initial hydrocephalus, and total vasopressor dose showed significant influence on outcome in univariate analysis, and patient sex, smoking status, BMI, and MAP showed no significant association with outcome. A subgroup analysis of patients with milder initial SAH (WFNS grades I-III) revealed that initial hydrocephalus (p = 0.003) and CRP levels (p = 0.001) had significant influence on further outcome. When evaluating only patients with WFNS grade IV or V, age, CRP level (p = 0.011), vasopressor dose (p = 0.030), and nimodipine dose (p = 0.049) were independent predictors of patient outcome. Patients with an MAP < 93 mm Hg, a nimodipine cutoff dose of 241.8 mg, and cutoff total vasopressor dose of 523 mg had better outcomes. CONCLUSIONS According to the authors' results, higher doses of vasopressors can safely provide a situation in which the maximum dose of nimodipine could be administered. Cutoff values of the total vasopressor dose were more than 3 times higher in patients with severe SAH (WFNS grade IV or V), while the nimodipine cutoff remained similar in patients with mild and severe SAH. Hence, it seems encouraging that a maximum nimodipine dosage can be achieved despite the need for a higher vasopressor dose in patients with SAH.
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Affiliation(s)
- Andrej Paľa
- 1Department of Neurosurgery, University of Ulm.,2Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
| | | | - Moritz Klein
- 2Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
| | - Benjamin Mayer
- 3Institute of Epidemiology and Medical Biometry, University of Ulm; and
| | - Bernd Schmitz
- 4Section of Neuroradiology, University of Ulm, Günzburg, Germany
| | - Christian Rainer Wirtz
- 1Department of Neurosurgery, University of Ulm.,2Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
| | - Ralph König
- 1Department of Neurosurgery, University of Ulm.,2Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
| | - Thomas Kapapa
- 1Department of Neurosurgery, University of Ulm.,2Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
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Pala A, Pawlikowski A, Brand C, Schmitz B, Wirtz CR, König R, Kapapa T. Quality of Life After Treatment of Unruptured Intracranial Aneurysms. World Neurosurg 2019; 121:e54-e59. [DOI: 10.1016/j.wneu.2018.09.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/30/2018] [Accepted: 09/02/2018] [Indexed: 11/16/2022]
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Coburger J, Wirtz CR. Fluorescence guided surgery by 5-ALA and intraoperative MRI in high grade glioma: a systematic review. J Neurooncol 2018; 141:533-546. [PMID: 30488293 DOI: 10.1007/s11060-018-03052-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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: 05/25/2018] [Accepted: 11/13/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Fluorescence guided surgery by 5-aminolevulinic acid (5-ALA) and intraoperative MRI (iMRI) are currently the most important intraoperative imaging techniques in high grade glioma (HGG) surgery. Few comparative studies exist for these techniques. This review aims to systematically compare 5-ALA and iMRI assisted surgery based on the current literature and discuss the potential impact of a combined use of both techniques. METHODS A systematic literature search based on preferred reporting items for systematic reviews and meta-analysis was performed concerning accuracy of tumor detection; extent of resection; neurological deficits (ND); Quality of life (QoL); usability and combined use of both techniques. Original clinical articles on HGG published until March 31st were screened. RESULTS 169 publications were screened, 81 were eligible and 22 were finally included in the review using. Overall, there is evidence that both imaging techniques improve gross total resection rate in non-eloquent lesions. Imaging results do not correlate at the border zone of a HGG. 5-ALA and contrast-enhanced iMRI seem to have a supplementary effect in tumor detection. Overall, both imaging techniques alone or combined do not seem to increase rate of permanent ND or decrease QoL in HGG surgery when used with intraoperative monitoring/mapping. CONCLUSION Based on the currently available literature no superiority of one technique over the other can be found in the most important outcome parameters. Based on the available information a combined use of 5-ALA and iMRI seems very promising to achieve a resection beyond gadolinium-enhancement. However, only low quality of evidence exists for this approach.
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Affiliation(s)
- Jan Coburger
- Department of Neurosurgery, University of Ulm, Campus Günzburg, Ludwig-Heilmeyerstr. 2, 89321, Günzburg, Germany.
| | - Christian Rainer Wirtz
- Department of Neurosurgery, University of Ulm, Campus Günzburg, Ludwig-Heilmeyerstr. 2, 89321, Günzburg, Germany
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Hlavac M, Dwucet A, Westhoff MA, Kast RE, Engelke J, Siegelin M, Wirtz CR, Halatsch ME, Karpel-Massler G. EXTH-55. CONCOMITANT INHIBITION OF RAC1 AND Bcl-2/Bcl-xL INTERFERES WITH THE Mcl-1/Usp9X AXIS AND YIELDS SYNERGISTIC ANTI-GLIOMA ACTIVITY. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Halatsch ME, Kast RE, Dwucet A, Wirtz CR, Siegelin M, Karpel-Massler G. EXTH-54. Bcl-2/Bcl-xL INHIBITION SYNERGISTICALLY ENHANCES THE ANTI-NEOPLASTIC ACTIVITY OF CUSP9 AGAINST GLIOBLASTOMA CELLS IN VITRO. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Renovanz M, Maurer D, Lahr H, Weimann E, Deininger M, Wirtz CR, Ringel F, Singer S, Coburger J. Supportive Care Needs in Glioma Patients and Their Caregivers in Clinical Practice: Results of a Multicenter Cross-Sectional Study. Front Neurol 2018; 9:763. [PMID: 30254605 PMCID: PMC6141995 DOI: 10.3389/fneur.2018.00763] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 08/22/2018] [Indexed: 12/21/2022] Open
Abstract
Objective: Supportive care needs in glioma patients often remain unrecognized, and optimization in assessment is required. First, we aimed at assessing the support needed using a simple structured questionnaire. Second, we investigated the psychosocial burden and support requested from caregivers. Methods: Patients were assessed at three centers during their outpatient visits. They completed the Distress Thermometer (DT; score ≥ 6 indicated significant burden in brain tumor patients), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ)-C30+BN20, and the Patients' Perspective Questionnaire (PPQ) that assessed psychosocial distress as well as support requested and received by patients for specific domains (e.g., family, doctor, and mobile care). In each subgroup, patients' caregivers were assessed simultaneously by a questionnaire developed for the study. Multivariate backward logistic regressions were performed for investigating predictors of patients' request for support. Results: Assessments were conducted for 232 patients. Most patients (82%) had a high-grade glioma and a mean age of 52 years (range 20-87). The male to female ratio was 1.25:1. According to the PPQ results, 38% (87) of the patients felt depressed; 44% (103), anxious; and 39% (91), tense/nervous. Desired support was highest from doctors (59%) and psychologists (19%). A general request for support was associated with lower global health status (p = 0.03, odds ratio (OR) = 0.96, 95% CI: 0.92-0.99) according to EORTC QLQ-C30. Most of the assessed caregivers (n = 96) were life partners (64%; n = 61) who experienced higher distress than the corresponding patients (caregivers: 6.5 ± 2.5 vs. patients: 5.3 ± 2.4). When patients were on chemotherapy, caregivers indicated DT ≥ 6 significantly more frequently than patients themselves (p = 0.02). Conclusion: Our data showed that glioma patients and their caregivers were both highly burdened. The PPQ allowed us to evaluate the psychosocial support requested and perceived by patients, detect supportive care needs, and provide information at a glance. Patients in poorer clinical condition are at risk of having unmet needs. The caregivers' burden and unmet needs are not congruent with the patients' need for support. In particular, caregivers of patients on chemotherapy were more highly burdened than patients themselves.
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Affiliation(s)
- Mirjam Renovanz
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Dorothea Maurer
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Heike Lahr
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Elke Weimann
- Department of Neurology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Monika Deininger
- Department of Neurosurgery, University Medical Center Ulm, Günzburg, Germany
| | | | - Florian Ringel
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Susanne Singer
- Division of Epidemiology and Health Services Research, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jan Coburger
- Department of Neurosurgery, University Medical Center Ulm, Günzburg, Germany
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Cwiklowska K, Westhoff MA, Freisinger S, Dwucet A, Halatsch ME, Knippschild U, Debatin KM, Schirmbeck R, Winiarski L, Oleksyszyn J, Wirtz CR, Burster T. Viability of glioblastoma stem cells is effectively reduced by diisothiocyanate-derived mercapturic acids. Oncol Lett 2018; 16:6181-6187. [PMID: 30344758 DOI: 10.3892/ol.2018.9347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 10/06/2016] [Accepted: 02/01/2017] [Indexed: 12/19/2022] Open
Abstract
Glioblastoma is the most aggressive tumor of the central nervous system and is manifested by diffuse invasion of glioblastoma stem cells into the healthy tissue, chemoresistance and recurrence. Despite aggressive therapy, consisting of maximal surgical resection, radiotherapy and chemotherapy with temozolomide (Temodal®), life expectancy of patients with glioblastoma is typically less than 15 months. In general, natural isothiocyanates isolated from plants of the Cruciferae family are selectively cytotoxic to tumor cells. It has been demonstrated previously that diisothiocyanate-derived mercapturic acids are highly cytotoxic to colon cancer cells. In the present study, the application of diisothiocyanate-derived mercapturic acids led to a decrease in the viability of an established glioblastoma cell line, primary patient-derived sphere-cultured stem cell-enriched cell populations (SCs), and cells differentiated from SCs. Consequently, targeting glioblastoma cells by diisothiocyanate-derived mercapturic acids is a promising approach to restrict tumor cell growth and may be a novel therapeutic intervention for the treatment of glioblastoma.
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Affiliation(s)
- Kamila Cwiklowska
- Department of Neurosurgery, Surgery Center, Ulm University Medical Center, D-89081 Ulm, Germany
| | - Mike-Andrew Westhoff
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, D-89081 Ulm, Germany
| | - Simon Freisinger
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, D-89081 Ulm, Germany
| | - Annika Dwucet
- Department of Neurosurgery, Surgery Center, Ulm University Medical Center, D-89081 Ulm, Germany
| | - Marc-Eric Halatsch
- Department of Neurosurgery, Surgery Center, Ulm University Medical Center, D-89081 Ulm, Germany
| | - Uwe Knippschild
- Department of General and Visceral Surgery, Surgery Center, Ulm University Medical Center, D-89081 Ulm, Germany
| | - Klaus-Michael Debatin
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, D-89081 Ulm, Germany
| | | | - Lukasz Winiarski
- Faculty of Chemistry, Wroclaw University of Technology, 50-370 Wroclaw, Poland
| | - Jozef Oleksyszyn
- Faculty of Chemistry, Wroclaw University of Technology, 50-370 Wroclaw, Poland
| | - Christian Rainer Wirtz
- Department of Neurosurgery, Surgery Center, Ulm University Medical Center, D-89081 Ulm, Germany
| | - Timo Burster
- Department of Neurosurgery, Surgery Center, Ulm University Medical Center, D-89081 Ulm, Germany
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