Local control and overall survival after frameless radiosurgery: A single center experience.

INTRODUCTION: Stereotactic radiosurgery (SRS) has been increasingly advocated for 1-3 small brain metastases. The goal of this study was to evaluate the clinical results in patients with brain metastases treated with LINAC-based SRS using a thermoplastic mask (non-invasive fixation system) and Image-Guided Radiotherapy (IGRT). MATERIAL AND METHODS: In this single-institution study 48 patients with 77 brain metastases were treated between February 2012 and January 2014. The prescribed dose was 20 Gy or 18 Gy as a single fraction. SRS was performed with a True Beam STX Novalis Radiosurgery LINAC (Varian Medical Systems). The verification of positioning was done using the BrainLAB ExacTrac ® X-ray 6D system and cone-beam CT. RESULTS: In 69 of 77 treated brain metastases (90%) the follow-up was documented on MR imaging performed every 3 months. Mean follow-up time was 10.86 months. Estimated 1-year local control was 83%, using the Kaplan-Meier method. In 7/69 brain metastases (10%) local failure (LF) was diagnosed. Median progression free survival (PFS) was 3.73 months, largely due to distant brain relapse. A GTV of ≤2.0 cm3 was significantly associated with a better PFS than a GTV >2.0 cm3. Extracranial stable disease and GTV ≤2.5 cm³ were significant predictors of OS.We observed 2 cases of radiation necrosis diagnosed by histology after surgical resection. No other cases of severe side effects (CTACE ≥ 3) were observed. CONCLUSION: LINAC-based frameless SRS with the BrainLAB Mask using the BrainLAB ExacTrac ® X-ray 6D system for patient positioning is well tolerated, safe and leads to favorable crude local control of 90%. In our experience, local control after frameless (ringless) SRS is as good as ring-based SRS reported in literature. Without invasive head fixation, radiotherapy is more comfortable for patients.

Stereotactic fractionated radiotherapy of the resection cavity in patients with one to three brain metastases.

OBJECTIVES: The goal of this study is to evaluate the role of stereotactic fractionated radiotherapy (SFRT) in patients with one to three brain metastases after surgical resection. METHODS AND MATERIALS: We performed a retrospective single-institutional study in patients undergoing SFRT of surgical cavity after resection of ≤3 brain metastases. 60 patients with newly diagnosed brain metastases treated with SFRT following resection were included. The total irradiation dose was 30 Gy (5 Gy/d, BED 45 Gy) after complete macroscopical resection and 35 Gy (5 Gy/d, BED 52.5 Gy) in patients with macroscopic residual tumour after surgery. Macroscopic residual tumour was defined as contrast enhancement next to the resection cavity on the postoperative T1-MRI. The gross tumour volume (GTV) encompassing the residual tumour was delineated on the T1-MRI, the clinical target volume (CTV) encompassed the surgical cavity plus 1mm and the planning target volume (PTV) the CTV plus 2mm. RESULTS: Eight of 60 patients had no imaging follow-up due to morbidity/mortality. Two of 52 (3.8%) patients experienced local failures only, 25 of 52 (48.1%) patients experienced distant intracranial failures only and 4 (7.7%) patients experienced both local and distant intracranial failures. In summary, there were 6 (11.5%) local failures and 29 (55.8%) distant failures. Age was significant for local control in the Cox regression test (p=0.046). Thirty-seven of 60 (61.7%) patients died during follow-up. Median follow-up was 8 months. Median overall survival was 15 months. Cox regression for survival was significant for KPS score ≤70% and size of PTV. No severe side effects were seen. Patients undergoing whole brain radiation therapy (WBRT) as salvage therapy in case of progression had no severe side effects either. CONCLUSION: In the light of encouraging local control rates, SFRT could be an alternative to WBRT after surgical resection of ≤3 brain metastases. Due to the high rate of distant intracranial failure regular follow-up with MRI is mandatory.

Inhibition of 13-cis retinoic acid-induced gene expression of reactive-resistance genes by thalidomide in glioblastoma tumours in vivo.

The cell differentiation potential of 13-cis retinoic acid (RA) has not succeeded in the clinical treatment of glioblastoma (GBM) so far. However, RA may also induce the expression of resistance genes such as HOXB7 which can be suppressed by Thalidomide (THAL). Therefore, we tested if combined treatment with RA+THAL may inhibit growth of glioblastoma in vivo. Treatment with RA+THAL but not RA or THAL alone significantly inhibited tumour growth. The synergistic effect of RA and THAL was corroborated by the effect on proliferation of glioblastoma cell lines in vitro. HOXB7 was not upregulated but microarray analysis validated by real-time PCR identified four potential resistance genes (IL-8, HILDPA, IGFBPA, and ANGPTL4) whose upregulation by RA was suppressed by THAL. Furthermore, genes coding for small nucleolar RNAs (snoRNA) were identified as a target for RA for the first time, and their upregulation was maintained after combined treatment. Pathway analysis showed upregulation of the Ribosome pathway and downregulation of pathways associated with proliferation and inflammation. In conclusion, combined treatment with RA + THAL delayed growth of GBM xenografts and suppressed putative resistance genes associated with hypoxia and angiogenesis. This encourages further pre-clinical and clinical studies of this drug combination in GBM.

FET-PET-based reirradiation and chloroquine in patients with recurrent glioblastoma: first tolerability and feasibility results.

BACKGROUND: Treatment of recurrent glioblastoma (rGBM) remains an unsolved clinical problem. Reirradiation (re-RT) can be used to treat some patients with rGBM, but as a monotherapy it has only limited efficacy. Chloroquine (CQ) is an anti-malaria and immunomodulatory drug that may inhibit autophagy and increase the radiosensitivity of GBM. PATIENTS AND METHODS: Between January 2012 and August 2013, we treated five patients with histologically confirmed rGBM with re-RT and 250 mg CQ daily. RESULTS: Treatment was very well tolerated; no CQ-related toxicity was observed. At the first follow-up 2 months after finishing re-RT, two patients achieved partial response (PR), one patient stable disease (SD), and one patient progressive disease (PD). One patient with reirradiated surgical cavity did not show any sign of PD. CONCLUSION: In this case series, we observed encouraging responses to CQ and re-RT. We plan to conduct a CQ dose escalation study combined with re-RT.

The influence of retinoic Acid and thalidomide on the radiosensitivity of u343 glioblastoma cells.

BACKGROUND/AIM: 13-cis-retinoic acid (RA) and thalidomide have shown a synergistic anti-proliferative effect on U343 glioblastoma (GBM) cells. In the present study, we test if their combined treatment might enhance the radiosensitivity of these cells. MATERIALS AND METHODS: The radiosensitivity of U343 GBM cells was determined by the colony formation assay. Fibroblast growth factor-2 (FGF2) gene expression was determined by a quantitative polymerase chain reaction (qPCR). RESULTS: RA up-regulated FGF2 gene expression, which was abrogated by thalidomide. No radiosensitisation by RA was observed under standard culture conditions with 10% serum, but enhanced radiosensitivity was observed under 1% serum during irradiation. However, a synergistic effect with thalidomide was not observed. CONCLUSION: Growth factors in the culture medium may mask radiosensitization by RA while autocrine expression of FGF2 did not seem to be protective. Importantly, the anti-proliferative effect of RA in combination with thalidomide would not compromise the radiosensitivity of these GBM cells.

Increased radiosensitivity and radiothermosensitivity of human pancreatic MIA PaCa-2 and U251 glioblastoma cell lines treated with the novel Hsp90 inhibitor NVP-HSP990.

BACKGROUND AND PURPOSE: Heat shock Protein 90 (Hsp90) is a molecular chaperone that folds, stabilizes, and functionally regulates many cellular proteins involved in oncogenic signaling and in the regulation of radiosensitivity. It is upregulated in response to stress such a heat. Hyperthermia is a potent radiosensitizer, but induction of Hsp90 may potentially limit its efficacy. Our aim was to investigate whether the new Hsp90 inhibitor NVP-HSP990 increases radiosensitivity, thermosensitivity and radiothermosensitivity of human tumor cell lines. MATERIAL AND METHODS: U251 glioblastoma and MIA PaCa-2 pancreatic carcinoma cells were used. To determine clonogenic survival, colony forming assays were performed. Cell viability and proliferation were assesed by Trypan blue staining. Cell cycle and apoptosis analyses were performed by flow cytometry. DAPI staining was used to detect mitotic catastrophe. RESULTS: NVP-HSP990 increased the thermosensitivity, radiosensitivity and radio-thermosensitivity of both cell lines in clonogenic assays. 72 hours after irradiation with 4 Gy, a significant reduction in cell number associated with considerable G2/M acumulation and mitotic catastrophe as well as cell death by apoptosis/necrosis was observed. CONCLUSIONS: Treatment with NVP-HSP990 strongly sensitized U251 and MIA PaCa-2 cells to hyperthermia and ionizing radiation or combination thereof through augmentation of G2/M arrest, mitotic catastrophe and associated apoptosis.

The influence of the combined treatment with Vadimezan (ASA404) and taxol on the growth of U251 glioblastoma xenografts.

BACKGROUND: One of the most important biological characteristics of Glioblastoma multiforme (GBM) is high vascular density. Vadimezan (ASA404, DMXAA) belongs to the class of small molecule vascular disrupting agents (VDA) that cause disruption of established tumor vessels and subsequent tumor hemorrhagic necrosis. Its selective antivascular effect is mediated by intratumoral induction of several cytokines including tumor necrosis factor-α (TNF-α), granulocyte-colony-stimulating factor (G-CSF), interleukin 6 (IL-6) and macrophage inflammatory protein 1α (MIP-1α). Preclinical studies have demonstrated that ASA404 acts synergistically with taxanes. In this study, we investigated if treatment of mice bearing U251 human glioblastoma xenografts with ASA404 and taxol may be synergistic. Therapy response was evaluated by measuring changes in tumor size and metabolic activity using 18F-FDG PET (Fluorodeoxyglucose - positron emision tomography) imaging. METHODS: U251 cells were inoculated s.c. in the right hind limb of NMRI-Foxn1nu athymic female nude mice. Animals were randomly assigned into 4 groups (7-9 animals/group) for treatment: control, taxol, ASA404, and ASA404 plus taxol. The animals received either a single dose of taxol (10 mg/kg), ASA404 (27.5 mg/kg), or taxol (10 mg/kg) plus ASA404 (27.5 mg/kg) administered i.p.; ASA404 was administred 24 h after the treatment with taxol. 4 and 24 h after treatment with ASA404 (28 and 48 h hours after treatment with taxol) 18 F-FDG PET scans were performed. RESULTS: The treatment with taxol did not affect the tumor growth in comparison to untreated controls. The treatment of animals with single dose ASA404 alone or in combination with taxol caused a significant delay in tumor growth. The combined treatment did not decrease the growth of the xenografts significantly more than ASA404 alone, but early changes in tumor 18 F-FDG uptake preceded subsequent growth inhibition. The tumor weights, which were determined at the end of treatment, were lower in case of combined treatment. CONCLUSIONS: The treatment with ASA404 alone or in combination with taxol showed antitumoral effects in our glioblastoma model probably through destruction of blood vessels. The implications for the anticancer effect of this compound warrant further preclinical studies. 18F-FDG PET appears to be a promising tool to monitor treatment with ASA404 early in the course of therapy.

Inhibition of 13-cis retinoic acid-induced gene expression of homeobox B7 by thalidomide.

Thalidomide and 13-cis retinoic acid (RA) show anticancer effects as sole agents or in combination with other drugs. However, induction of homeobox (HOX) gene expression by 13-cis RA may contribute to tumor progression thereby potentially limiting its efficacy. The purpose was to test if thalidomide can inhibit 13-cis RA-induced HOXB7 expression and whether thalidomide may enhance the antiproliferative effect of 13-cis RA in U343MG glioblastoma cells. Quantitative real-time PCR showed significant inhibition of 13-cis RA-induced HOXB7 expression by thalidomide with IC(50) approximately 0.1-0.2 microg/ml when given simultaneously with 13-cis RA but not when administered 18 h later (p < 0.0001). 13-cis RA alone inhibited proliferation and colony formation in a concentration-dependent manner whereas growth inhibition by thalidomide alone at 5-100 microg/ml was constant at 80-90% of controls. At 10% serum concentration, growth inhibition by a combination of the 2 drugs was additive but at 1% serum, growth inhibition was synergistic. It is concluded that thalidomide inhibits the RA-induced HOXB7 expression in glioblastoma cells and that 13-cis RA/thalidomide combinations can in principle enhance cytotoxicity. The improved cell kill induced by thalidomide is attributed to downregulation of growth stimulatory factors induced by 13-cis RA. Implications for the modus operandi of thalidomide in embryogenesis are noted.