Investigational treatment strategies in glioblastoma: progress made and barriers to success

INTRODUCTION

Glioblastoma, isocitrate dehydrogenase wildtype (IDHwt), remains an incurable disease despite considerable research effort. The current standard of care since 2005 comprises maximal safe resection followed by radiation with concurrent and adjuvant temozolomide; more recently, the addition of tumor treating fields was approved in the newly diagnosed and recurrent disease settings.

AREAS COVERED

Searches of PubMed, Cochrane Library, and ClinicalTrials.gov provided a foundation for this review. We first describe early research including carmustine wafers, brachytherapy, anti-angiogenesis, and immune checkpoint inhibition for glioblastoma. Next, we discuss challenges precluding the translation of preclinical successes. This is followed by a description of promising treatments such as chimeric antigen receptor T-cell therapy as well as the recent qualified successes of cancer vaccinations. Non-immunotherapy trials are also highlighted, and ongoing or pending phase 2 and 3 clinical trials are codified in study tables.

EXPERT OPINION

Unfortunately, hundreds of trials, including of agents effective in systemic malignancy, have not drastically changed management of glioblastoma. This may reflect unique resistance mechanisms and highlights a need for multimodality treatments beyond surgery, radiation, and conventional chemotherapy. Novel techniques, such as those in the emerging field of cancer neuroscience, may help uncover tolerable and effective regimens for this lethal malignancy.

Targeting lung cancer brain metastases: a narrative review of emerging insights for anaplastic lymphoma kinase (ALK)-positive disease

Background and Objective

Lung cancer is commonly associated with brain metastasis formation, and certain subtypes, such as anaplastic lymphoma kinase (ALK) rearranged disease, have an especially high propensity for early and frequent central nervous system (CNS) involvement for which treatment can be challenging. Historical management has centered on surgery and radiation therapy (RT), which persist as mainstays of treatment for large, symptomatic lesions and widespread CNS disease. To date, sustained disease control remains elusive, and the role for effective systemic adjunctive therapies is clear. Here we discuss the epidemiology, genomics, pathophysiology, identification, and management of lung cancer brain metastases with a particular emphasis on systemic treatment of ALK-positive disease according to the best available evidence.

Methods

Review of PubMed and Google Scholar databases as well as ClinicalTrials.gov provided background and seminal trials for the local and systemic management of ALK rearranged lung cancer brain metastases.

Key Content and Findings

The development of effective, CNS-penetrant systemic agents-including alectinib, brigatinib, ceritinib, and lorlatinib-has dramatically changed the management and prevention of ALK rearranged brain metastases. Most notably, there is a burgeoning role for upfront systemic therapy for both symptomatic and incidentally discovered lesions.

Conclusions

Novel targeted therapies offer patients a pathway to delay, obviate, or supplement traditional local therapies while minimizing neurologic sequelae of treatment and may reduce the risk of brain metastasis formation. However, the selection of patients to whom local and targeted treatments is offered is not trivial, and the risks and benefits of both must be weighed carefully. More work is needed to establish treatment regimens that yield durable intra- and extracranial disease control.

Oral Presentation No. 84 Initial clinical experience with 6-hour enoxaparin regimen in opiate-treated patients undergoing primary percutaneous coronary intervention

Background

Opioid treatment delays the onset of oral P2Y12 inhibitors in patients with acute ST-segment elevation myocardial infarction (STEMI), leading to suboptimal antithrombotic therapy during primary percutaneous coronary intervention (PPCI).

Material and methods

We retrospectively compared using a prolonged enoxaparin regimen (0.75 mg/kg bolus followed by 6-hour intravenous infusion) to using unfractionated heparin (UFH) with or without tirofiban in opioid-treated patients with STEMI who underwent PPCI. We compared the proportions of acute stent thrombosis (AST) and bleeding events according to the bleeding academic research consortium (BARC) within 24 hours post-PPCI.

Results

270 opioid-treated patients with a mean age of 63 [SD ± 12] years were enrolled, of which 49 (18%) were with diabetes mellitus (DM). 90 (34%) patients (mean age 61 [SD ± 11] years) received enoxaparin, 110 (41%) (mean age 65 [SD ± 14] years) UFH with tirofiban, and 69 (25%) (mean age 63 [SD ± 12] years) UFH only. Compared to the other strategies, a higher proportion of DM was observed in the enoxaparin-treated group (21%). No AST was associated with enoxaparin compared to 2 (1.8%) events in UFH with tirofiban and 1 (1.4%) in UFH only. The rate of severe bleeding events (BARC 2 and 3) was significantly lower in the enoxaparin-treated patients than in UFH with tirofiban (0 (0%) vs. 8 (7%), P = 0.01). 3 enoxaparin-treated patients needed switching to tirofiban as a bailout strategy due to distal vessel embolisation.

Conclusions

The novel 6-hour enoxaparin regimen is safe during PPCI and was associated with fewer bleeding events than UFH with tirofiban.

Differential effect of clopidogrel and ticagrelor on leukocyte count in relation to patient characteristics, biomarkers and genotype: a PLATO substudy

Inflammation plays a key role in cardiovascular disease by contributing to atherothrombosis. The PLATelet inhibition and patient Outcomes (PLATO) study (NCT00391872) compared ticagrelor to clopidogrel in patients with acute coronary syndromes and demonstrated fewer cardiovascular events with ticagrelor but lower white blood cell counts (WBC) with clopidogrel. In this further analysis of the PLATO biomarker substudy, we assessed associations between WBC and clinical characteristics, biomarker levels, and CYP2C19 polymorphisms.On-treatment mean (SD) WBC in the clopidogrel group was mildly reduced at each stage of follow-up compared with either the ticagrelor group (1 month: 7.27 (2.1) and 7.67 (2.23) x109/L for clopidogrel and ticagrelor, respectively; p < .001) or following cessation of clopidogrel (7.23 (1.97) x109/L, at 6 months vs 7.56 (2.28) x109/L after treatment cessation; P < .001). This occurred independently of baseline biomarkers and CYP2C19 genotype (where known). Adjusting for clinical characteristics and other biomarkers, no significant interaction was detected between clinical risk factors and the observed effect of clopidogrel on WBC.Clopidogrel weakly suppresses WBC, independent of clinical characteristics, baseline inflammatory biomarker levels, and CYP2C19 genotype. Further work is required to determine the mechanism for this effect and whether it contributes to clopidogrel's efficacy as well as therapeutic interaction with anti-inflammatory drugs.

Characterization of persistent atrial fibrillation with non‐contact charge density mapping and relationship to voltage

Background

Despite studies using localized high density contact mapping and lower resolution panoramic approaches, the mechanisms that sustain human persistent atrial fibrillation (AF) remain unresolved. Voltage mapping is commonly employed as a surrogate of atrial substrate to guide ablation procedures.

Objective

To study the distribution and temporal stability of activation during persistent AF using a global non‐contact charge density approach and compare the findings with bipolar contact mapping.

Methods

Patients undergoing either redo or de novo ablation for persistent AF underwent charge density and voltage mapping to guide the ablation procedure. Offline analysis was performed to measure the temporal stability of three specific charge density activation (CDA) patterns, and the degree of spatial overlap between CDA patterns and low voltage regions.

Results

CDA was observed in patient‐specific locations that partially overlapped, comprising local rotational activity (18% of LA), local irregular activity (41% of LA), and focal activity (39% of LA). Local irregular activity had the highest temporal stability. LA voltage was similar in regions with and without CDA.

Conclusion

In persistent AF, CDA patterns appear unrelated to low voltage areas but occur in varying locations with high temporal stability.

Radiofrequency ablation of ventricular tachycardia in Anderson–Fabry disease: a case series

Background

Cardiac involvement in Anderson–Fabry disease (AFD) can lead to arrhythmia, including ventricular tachycardia (VT). The literature on radiofrequency ablation (RFA) for the treatment of VT in AFD disease is limited.

Case summary

We discuss RFA of drug-refractory VT electrical storm in three males with AFD. The first patient (53 years old) had extensive involvement of the inferolateral left ventricle (LV) demonstrated with cardiac magnetic resonance imaging (CMRI), with a left ventricular ejection fraction (LVEF) of 35%. Two VT ablation procedures were performed. At the first procedure, the inferobasal endocardial LV was ablated. Furthermore, VT prompted a second ablation, where epicardial and endocardial sites were ablated. The acute arrhythmia burden was controlled but he died 4 months later despite appropriate implantable cardioverter-defibrillator therapies for VT. The second patient (67 years old) had full-thickness inferolateral involvement demonstrated with CMRI and LVEF of 45%. RFA of several endocardial left ventricular sites was performed. Over a 3-year follow-up, only brief non-sustained VT was identified, but he subsequently died of cardiac failure. Our third patient (69 years old), had an LVEF of 35%. He had RFA of endocardial left ventricular apical disease, but died 3 weeks later of cardiac failure.

Discussion

RFA of drug-refractory VT in AFD is feasible using standard electrophysiological mapping and ablation techniques, although the added clinical benefit is of questionable value. VT storm in the context of AFD may be a marker of end-stage disease.

EcoAnthromes of Alberta: An example of disturbance-informed ecological regionalization using remote sensing

Humans influence ecosystems on magnitudes that often exceed that of natural forces such as climate and geology; however, frameworks rarely include anthropogenic disturbance when delineating unique ecological regions. A critical step toward understanding, managing and monitoring human-altered ecosystems is to incorporate disturbance into ecological regionalizations. Furthermore, quantitative regionalization approaches are desirable to provide cost-effective, repeatable and statistically sound stratification for environmental monitoring. We applied a two-stage multivariate clustering technique to identify 'EcoAnthromes' across a large area - the province of Alberta, Canada - at 30 m spatial resolution, and using primarily remotely sensed inputs. The EcoAnthrome clusters represent regions with unique ecological characteristics based on a combination of natural ecological potential (e.g., climatic and edaphic factors) and disturbance, both natural and anthropogenic. Compared to existing expert-derived Natural Subregions in Alberta, the model-based EcoAnthromes showed greater class separation and explained more variance for an assortment of variables related to land cover, disturbance and species intactness. The EcoAnthromes successfully separated important ecological regions that are defined by complex assemblages of topography, climate and disturbance, such as gravel-bed river valleys, boreal forests, grasslands, post-fire recovery areas and highly disturbed agricultural, industrial and urban landscapes. In addition to presenting a flexible method for EcoAnthrome regionalization, we group and describe the EcoAnthromes created for Alberta and discuss how they can complement expert-derived regionalizations to aid in environmental management efforts, such as species recovery planning and monitoring for threatened species.

Clinical benefits of incorporating doxycycline into a canine heartworm treatment protocol

BACKGROUND

The objective of heartworm treatment is to improve the clinical condition of the patient and to eliminate pre-cardiac, juvenile, and adult worm stages with minimal complications. Pulmonary thromboembolisms are an inevitable consequence of worm death and can result in severe pulmonary reactions and even death of the patient. To minimize these reactions, various treatment protocols involving melarsomine, the only adulticidal drug approved by the US Food and Drug Administrations (FDA), in conjunction with macrocyclic lactone heartworm preventives and glucocorticosteroids have been advocated. The discovery of the bacterial endosymbiont Wolbachia in Dirofilaria immitis has led to several experimental studies examining the effects of administering doxycycline to reduce or eliminate Wolbachia organism. These studies have shown a decrease in gross and microscopic pathology of pulmonary parenchyma in experimental heartworm infections pretreated with doxycycline before melarsomine administration.

METHODS

Electronic medical records from a large veterinary practice in northeast Alabama were searched to identify dogs treated for heartworms with melarsomine from January 2005 through December 2012. The search was refined further to select for dogs that met the following criteria: 1) received two or three doses of ivermectin heartworm preventive prior to melarsomine injections, 2) received one injection of melarsomine followed by two injections 4 to 8 weeks later, and 3) were treated with prednisone following melarsomine injections. The dogs were then divided into those that also were treated with doxycycline 10 mg/kg BID for 4 weeks (Group A, n = 47) and those that did not receive doxycycline (Group B, n = 47). The medical notes of all 94 cases were then reviewed for comments concerning coughing, dyspnea, or hemoptysis in the history, physical exam template, or from telephone conversations with clients the week following each visit. Any dog that died within one year of treatment from either cardiovascular or pulmonary problems was noted.

RESULTS

Dogs from Group A receiving doxycycline had fewer respiratory complications (6.52%) and heartworm disease-related deaths (0%) than Group B (19.14% and 4.25%, respectively).

CONCLUSIONS

Although there are not enough cases to indicate statistical significance, the results strongly suggest that including doxycycline into canine heartworm treatment protocols decreases post-treatment complications and mortality in naturally infected clinical cases.

EVALUATION OF PLASMA SUBSTANCE P AND BETA-ENDORPHIN LEVELS IN CHILDREN WITH PRADER-WILLI SYNDROME

BACKGROUND

Prader-Willi syndrome (PWS) is a rare obesity-related genetic disorder often caused by a deletion of the chromosome 15q11-q13 region inherited from the father or by maternal disomy 15. Growth hormone deficiency with short stature, hypogonadism, cognitive and behavioral problems, analgesia, decreased gastric motility and decreased ability to vomit with hyperphagia are common in PWS leading to severe obesity in early childhood, if not controlled. Substance P (SP) and beta-endorphin (BE) are neuropeptides involved with centrally and peripherally mediated pain perception, emotional regulation, and gastric motility impacting nausea, emesis and feeding patterns.

OBJECTIVE

The goal of this study was to investigate potential mechanisms for PWS symptom development for pain, emotion and gastric motility and plasma levels of substance P and beta-endorphin between PWS and unrelated unaffected children.

METHODOLOGY

Plasma samples were collected from 23 Caucasian children with PWS and 18 unrelated, unaffected siblings with an average age of 8.2 ±2.0 years and age range of 5 to 11 years following an overnight fast and neuropeptide substance p and beta-endorphin levels were assessed using Multiplex sandwich immunoassays using the Luminex magnetic-bead based platform. Linear regression analysis was carried out on log-transformed values adjusted for age, sex, and body mass index (BMI).

RESULTS

The mean plasma SP (57 ± 23 pg/ml) and BE (592 ± 200 pg/ml) levels in PWS were significantly higher than SP (35 ± 20 pg/ml, F=10.5, P<0.01) and BE (402 ± 162 pg/ml, F=10.8, P<0.01) levels found in unrelated, unaffected siblings suggesting a previously uncharacterized neuroendocrine pathophysiology in PWS.

CONCLUSIONS

The increased BE and SP plasma levels relative to unrelated, unaffected siblings may contribute to hyperphagia, abnormal pain sensation and adrenal insufficiency seen in PWS. Increases in SP levels may be modulated by central and/or peripheral actions of BE on opioid, GABA or POMC precursors and may reflect loss of feedback inhibitory control. Further studies are needed to confirm and elucidate the biochemical basis for observed disturbances in neuropeptide levels seen in our study and may impact on the development and persistence of symptoms commonly seen in PWS.

A metabolomic view of how the human gut microbiota impacts the host metabolome using humanized and gnotobiotic mice

Defining the functional status of host-associated microbial ecosystems has proven challenging owing to the vast number of predicted genes within the microbiome and relatively poor understanding of community dynamics and community-host interaction. Metabolomic approaches, in which a large number of small molecule metabolites can be defined in a biological sample, offer a promising avenue to 'fingerprint' microbiota functional status. Here, we examined the effects of the human gut microbiota on the fecal and urinary metabolome of a humanized (HUM) mouse using an optimized ultra performance liquid chromatography-mass spectrometry-based method. Differences between HUM and conventional mouse urine and fecal metabolomic profiles support host-specific aspects of the microbiota's metabolomic contribution, consistent with distinct microbial compositions. Comparison of microbiota composition and metabolome of mice humanized with different human donors revealed that the vast majority of metabolomic features observed in donor samples are produced in the corresponding HUM mice, and individual-specific features suggest 'personalized' aspects of functionality can be reconstituted in mice. Feeding the mice a defined, custom diet resulted in modification of the metabolite signatures, illustrating that host diet provides an avenue for altering gut microbiota functionality, which in turn can be monitored via metabolomics. Using a defined model microbiota consisting of one or two species, we show that simplified communities can drive major changes in the host metabolomic profile. Our results demonstrate that metabolomics constitutes a powerful avenue for functional characterization of the intestinal microbiota and its interaction with the host.

CANINE HEARTWORMS IN COYOTES IN ILLINOIS

Canine heartworm (Dirofilaria immitis) disease affects wild canids and may be a factor impacting the health and population dynamics of coyotes (Canis latrans). Coyotes may serve also as a potential reservoir for transmission of these parasites to domestic dogs. We investigated 920 coyotes harvested by hunters and trappers throughout Illinois (USA) from 1995-1997. The objectives of the study were to: 1) survey the regional prevalence and intensity of heartworms in coyotes in Illinois, 2) determine whether heartworm intensity correlates with physical condition, particularly body weight and winter fat levels, and 3) evaluate the relationship between heartworm infections and the reproductive success of females. Prevalence of heartworms statewide was 16.0%. Prevalence was significantly higher in males (17.7%) than in females (14.1%; P = 0.04) and was higher in the older age-classes (P < 0.0001). The regional prevalence of heartworms increased from northern to southern Illinois. Intensity ranged from 1 to 111 with a mean of 8.7 (SD = 13.2) worms. Intensities did not differ significantly between sexes (P = 0.53) or among age-classes (P = 0.84). Most infected coyotes had low intensity infections, 78.2% carried < 12 heartworms, 11.6% had 12-24 worms, and 10.2% were infected with > 24 worms. Body weights were not correlated with the presence of heartworms, nor were levels of kidney fat and marrow fat. However, reproductive success was lower in infected females. The percent of yearling females that bred was lower among infected females, as was the number of offspring produced by adults > or = 3.5 yr old. Our study demonstrates that heavy infections adversely affect fur quality and reduce fecundity of some females, but these effects are small and few coyotes (4.1%) had enough worms to trigger them. Coyote populations have increased in Illinois during the past 20 yr, but prevalence and intensity of heartworm disease appears to have changed little in that period. We conclude that heartworm disease is only a minor factor influencing coyote population dynamics in Illinois.

Heat Production in the Voodoo Lily (Sauromatum guttatum) as Monitored by Infrared Thermography

The pattern of surface temperatures of the inflorescence of Sauromatum guttatum was investigated by using an infrared camera. The male flowers are weakly thermogenic on the first day of inflorescence opening (D-day) as well as on the next day (D + 1), reaching 0.5 to 1 degrees C above ambient temperature. The appendix (the upper sterile part of the inflorescence) is highly thermogenic on D-day, reaching 32 degrees C, and is faintly thermogenic on D + 1, reaching 1 degrees C above ambient temperature. The lower part of the spadix, close to the female flowers, is also thermogenic on D-day and D + 1, reaching a temperature similar to that of the appendix only on D + 1. Salicylic acid does not induce heat production in the lower part of the spadix, as it does in the appendix. Respiration of tissue slices obtained from the appendix shows that the capacity for cyanide-insensitive respiration is present in young and mature appendices. This alternative respiratory pathway is not, however, utilized in young appendix tissue, but is engaged during the maturation of that tissue.

Infrared thermography ofArum lily inflorescences

The infrared radiation emitted from the surface of inflorescences of 12 aroid species was monitored with an infrared camera, capable of 0.1°C resolution, and the data were converted to temperature values by means of temperature reference standards. Images representing surface temperatures were obtained forAmorphophallus bulbifer Blume,A. campanulatus Blume,A. forbesii Engl. et Gehrm.,A. rivieri Dur.,Philodendron selloum Koch,Monstera deliciosa Liebm.,Dracunculus vulgaris Schott,Arum italicum Mill.,A. dioscoridis Sibth.,A. creticum Boiss et Heldr.,Caladium sp., andRemusatia vivipara Schott. These images were different among species with respect to temperature, duration of detectable heat development, and organ type (male and female flowers, spathe and appendix) found to be thermogenic. All these species, however, exhibited three common characteristics: 1) production of heat by the male flowers; 2) pollen-shedding immediately after heat production had ceased; and 3) when male flowers were some distance away from female flowers along the spadix, heat was not detected in female flowers. Heat emission was associated with the alternative, cyanide-insensitive pathway that was fully operative.

Low blood mononuclear cell magnesium content and hypocalcemia in normomagnesemic patients

Hypomagnesemia can cause hypocalcemia. Because less than 1% of the total body magnesium (Mg) is in extracellular fluids, however, patients may be Mg-deficient despite normal serum Mg concentrations. To determine if hypocalcemia can be seen in patients who have normal serum Mg concentrations but low intracellular Mg, we studied the serum and mononuclear cell Mg contents in 82 alcoholic subjects, 30 of whom had hypocalcemia that could not be explained by other known causes of hypocalcemia. The mononuclear cell Mg content in both hypomagnesemic and normomagnesemic patients with and without hypocalcemia was significantly lower than in normal controls. The serum Mg level did not correlate with the mononuclear cell Mg or serum calcium level, but hypocalcemic patients had a significantly lower mononuclear cell content than normocalcemic patients. Six patients underwent parenteral Mg tolerance testing as an additional measure of Mg deficiency and had increased Mg retention. The serum calcium concentration returned to normal in hypocalcemic patients who were given magnesium intravenously.

Ticks on white-tailed deer fawns from southern Illinois

Seventy-six white-tailed deer (Odocoileus virginianus (Zimmermann] fawns captured on Crab Orchard National Wildlife Refuge in southern Illinois during June-July 1980-1983 were aged and examined for ticks. The prevalence of ticks (Amblyomma americanum (Linnaeus, 1758) and Dermacentor variabilis (Say, 1821] was 80%; intensity of infestation ranged from one to 123 ticks per fawn, averaging 21.6. Tick intensity correlated poorly with age suggesting that there were other, more important determinants of infestation rates. Packed cell volumes in blood of the fawns increased significantly with age, but were not significantly affected by existing tick intensities. Ticks were not directly or indirectly implicated in any of 16 mortalities that occurred among 61 radio-collared fawns monitored for approximately 6 mo post-partum, and were not considered a serious health problem for fawns on the study area.

A comparison of AMA and non-AMA patients on a short-term crisis unit

Nineteen patients who left a short-term psychiatric crisis unit against medical advice were compared with 109 patients who received a regular discharge during a six-month period. Demographic, historic, assessment, and diagnostic variables of both groups were examined. Results indicated that patients diagnosed as having personality or substance use disorders and patients judges abnormal on a mental status examination were more likely to be AMA patients. However, AMA patients indicated fewer social problems as rated on Linn's Social Dysfunction Scale. It was concluded that diagnostic variables best differentiated patients leaving the treatment unit against medical advice from those who completed treatment.