KLF6 depletion promotes NF-κB signaling in glioblastoma.

Dysregulation of the NF-κB transcription factor occurs in many cancer types. Krüppel-like family of transcription factors (KLFs) regulate the expression of genes involved in cell proliferation, differentiation and survival. Here, we report a new mechanism of NF-κB activation in glioblastoma through depletion of the KLF6 tumor suppressor. We show that KLF6 transactivates multiple genes negatively controlling the NF-κB pathway and consequently reduces NF-κB nuclear localization and downregulates NF-κB targets. Reconstitution of KLF6 attenuates their malignant phenotype and induces neural-like differentiation and senescence, consistent with NF-κB pathway inhibition. KLF6 is heterozygously deleted in 74.5% of the analyzed glioblastomas and predicts unfavorable patient prognosis suggesting that haploinsufficiency is a clinically relevant means of evading KLF6-dependent regulation of NF-κB. Together, our study identifies a new mechanism by which KLF6 regulates NF-κB signaling, and how this mechanism is circumvented in glioblastoma through KLF6 loss.

Progression-free and overall survival in patients with recurrent Glioblastoma multiforme treated with last-line bevacizumab versus bevacizumab/lomustine.

Bevacizumab (BEV) is widely used for treatment of patients with recurrent glioblastoma multiforme (GBM). 1-(2-Chlorethyl)-cyclohexyl-nitrosourea (CCNU, lomustine) monotherapy is an approved chemotherapeutical option for recurrent GBM. Recent evidence demonstrated a survival benefit of combined treatment with BEV and CCNU in patients with a first recurrence of GBM. We examined the outcome of recurrent GBM patients with BEV monotherapy versus BEV/CCNU therapy when used as last-line therapy. 35 patients with recurrent GBM treated between 2010 and 2014 were included in this retrospective study. Progression-free and overall survival was determined with reference to the beginning of BEV or BEV/CCNU therapy and initial diagnosis. 17 patients received BEV monotherapy, 18 patients received combined BEV and CCNU therapy. The impact of parameters such as IDH mutation, MGMT promoter methylation, tumor localization, histology and the number of surgeries were included in a multivariate ANOVA analysis. Furthermore, Karnofsky performance score (KPS), neurological function and toxicity were assessed. BEV/CCNU treatment led to an extension of PFS (6.11 months; 95% CL 3.41-12.98 months; log-rank p = 0.00241) and OS (6.59 months; 95% CL 5.51-16.3 months; log-rank p = 0.0238) of 2 months compared to BEV monotherapy. This survival advantage was independent of histology, IDH mutation status or the number of previous surgeries. Neurological function, KPS and toxicity were not significantly different between both treatment groups. Last-line therapy with BEV/CCNU results in a longer PFS and OS compared to BEV monotherapy and is well-tolerated. These findings confirm the role of these agents in the treatment of recurrent GBM and are in line with other studies.

Global tracking in human gliomas: a comparison with established tracking methods.

PURPOSE: Global tracking (GT) is a recently published fibre tractography (FT) method that takes simultaneously all fibres into account during their reconstruction. The purpose of this study was to compare this new method with fibre assignment by continuous tracking (FACT) and probabilistic tractography (PT) for the detection of the corticospinal tract (CST) in patients with gliomas. METHODS: Tractography of the CST was performed in 17 patients with eight low grade and nine anaplastic astrocytomas located in the motor cortex or the corticospinal tract. Diffusions metrics as fractional anisotropy (FA), mean (MD), axial (AD) and radial diffusivity (RD) were obtained. The methods were additionally applied on a physical phantom to assess their accuracy. RESULTS: PT was successful in all (100 %), GT in 16 (94 %) and FACT in 15 patients (88 %). The case where GT and FACT, both, missed the CST showed the highest AD and RD, whereas the one where FACT algorithm, alone, was not successfully showed the lowest AD and RD of the group. FA was reduced on the pathologic side (FApath 0.35 ± 0.16 (mean ± SD) versus FAcontralateral 0.51 ± 0.15, pcorr < 0.03). RD was increased on the pathologic side (RDpath 0.67 ± 0.29 × 10(-3) mm(2)/s versus RDcontralateral 0.46 ± 0.08 × 10(-3) mm(2)/s, pcorr < 0.03). In the phantom measurement, only GT did not detect false positive fibres at fibre crossings. CONCLUSION: PT performed well even in areas of increased diffusivities indicating a severe oedema or disintegration of tissue. FACT was also susceptible to a decrease of diffusivities and to a susceptibility artefact, where GT was robust.

Differential inhibitory effects of drugs acting at the noradrenaline and 5-hydroxytryptamine transporters in rat and human neocortical synaptosomes.

BACKGROUND AND PURPOSE: Although the amino acid sequences of rat and human 5-hydroxytryptamine (5-HT) and noradrenaline (NA) transporters (i.e. SERT and NET) are highly homologous, species differences exist in the inhibitory effects of drugs acting at these transporters. Therefore, comparison of the potencies of drugs acting at SERT and NET in native human and rat neocortex may serve to more accurately predict their clinical profile. EXPERIMENTAL APPROACH: Synaptosomes prepared from fresh human and rat neocortical tissues were used for [(3)H]-5-HT and [(3)H]-NA saturation and competition uptake experiments. The drugs tested included NA reuptake inhibitors (desipramine, atomoxetine and (S,S)-reboxetine), 5-HT reuptake blockers (citalopram, fluoxetine and fluvoxamine) and dual 5-HT/NA reuptake inhibitors (duloxetine and milnacipran). KEY RESULTS: In saturation experiments on synaptosomal [(3)H]-5-HT and [(3)H]-NA uptake, the dissociation constants did not indicate species differences although a smaller density of both SERT and NET was observed in human tissues. In competition experiments with the various drugs, marked species differences in their potencies were observed, especially at SERT. The rank order of selectivity ratios (SERT/NET) in human neocortex was as follows: citalopram >or= duloxetine = fluvoxamine >or= fluoxetine > milnacipran > desipramine = atomoxetine > (S,S)-reboxetine. Significant species differences in these ratios were observed for duloxetine, atomoxetine and desipramine. CONCLUSIONS AND IMPLICATIONS: This study provides the first compilation of drug potency at native human neocortical SERT and NET. The significant species differences (viz., human vs. rat) in drug potency suggest that the general use of rodent data should be limited to predict clinical efficacy or profile.

Aneurysmal and non-aneurysmal SAH--is initial computed tomography predictive?

PURPOSE: Diagnostic workup in patients with angiographically negative subarachnoid hemorrhage (SAH) remains controversial. We discuss the relevance of bleeding patterns on CT as they pertain to the prediction of angiographic results. MATERIALS AND METHODS: We compared bleeding patterns on 112 CTs of patients with non-aneurysmal subarachnoid hemorrhage (non-ASAH) and 104 CTs of patients with aneurysmal SAH (ASAH) taken within 48 hours according to a CT-based grading system (Type 0 - 4). RESULTS: Bleeding patterns differed between ASAH and non-ASAH patients (p < 0.0001). Non-ASAH patients had no or prepontine blood (type 0 + 1) in 40% of cases, extension into the medial (type 2) or lateral (type 3) Sylvian fissure in 60% of cases and no intracerebral hemorrhage (type 4). All type 0 and 1 patients had negative initial and repeat angiographies. CONCLUSION: A CT classification of bleeding patterns helps to predict angiographic results. Digital subtraction angiography (DSA) should remain the gold standard as it allows detection non-aneurysmal bleeding sources at low-risk. Repeat angiography may be omitted in the case of type 0 and 1 bleeding if a complete, high quality DSA was obtained initially.

Effects of gabapentin and pregabalin on K+-evoked 3H-GABA and 3H-glutamate release from human neocortical synaptosomes.

One site of action of the anticonvulsant, analgesic, and anxiolytic drugs gabapentin and pregabalin is the alpha(2)delta-subunit of voltage-sensitive Ca(2+) channels (VSCC). We therefore analyzed the effects of gabapentin and pregabalin on K(+)-evoked release of (3)H-gamma-aminobutyric acid (GABA) and (3)H-glutamate from superfused human neocortical synaptosomes. These neurotransmitters are released by Ca(2+)-dependent exocytosis and by Ca(2+)-independent uptake reversal. When a GABA transport inhibitor was present throughout superfusion to isolate exocytotic conditions, gabapentin and pregabalin (100 microM each) reduced K(+)-evoked (3)H-GABA release by 39% and 47%, respectively. These effects were antagonized by the alpha(2)delta-ligand L: -isoleucine (1 microM) suggesting the alpha(2)delta-subunit of terminal VSCC to mediate the reduction of exocytosis. Both drugs had no effect on exocytotic (3)H-glutamate release and also failed to modulate the release of (3)H-GABA and (3)H-glutamate caused by reversed uptake in the absence of external Ca(2+). Thus, an inhibition of glutamate release by gabapentin and pregabalin as main anticonvulsant principle is not supported by our experiments. An anticonvulsant mode of action of both drugs may be the reduction of a proconvulsant exocytotic GABA release.

Differential modulation of K(+)-evoked (3)H-neurotransmitter release from human neocortex by gabapentin and pregabalin.

Anticonvulsant, analgesic, and anxiolytic effects have been observed both in preclinical and clinical studies with gabapentin (GBP) and pregabalin (PGB). These drugs appear to act by binding to the alpha(2)delta subunit of voltage-sensitive Ca(2+) channels (VSCC), resulting in the inhibition of neurotransmitter release. In this study, we examined the effects of GBP and PGB (mostly 100 microM, corresponding to relatively high preclinical/clinical plasma levels) on the release of neurotransmitters in human neocortical slices. These slices were prelabeled with (3)H-dopamine ((3)H-DA), (3)H-choline (to release (3)H-acetylcholine ((3)H-ACh)), (3)H-noradrenaline ((3)H-NA), and (3)H-serotonin ((3)H-5-HT), and stimulated twice in superfusion experiments by elevation of extracellular K(+) in the presence and absence of GBP and PGB. The alpha(2)delta ligands produced significant inhibitions of K(+)-evoked (3)H-ACh, (3)H-NA, and (3)H-5-HT release between 22% and 56% without affecting (3)H-DA release. Neither drug reduced (3)H-NA release in the presence of L: -isoleucine, a putative alpha(2)delta antagonist. Interestingly, this antagonism did not occur using the enantiomer, D: -isoleucine. These results suggest that GBP and PGB are not general inhibitors of VSCC and neurotransmitter release. Such alpha(2)delta ligands appear to be selective modulators of the release of certain, but not all, neurotransmitters. This differential modulation of neurotransmission presumably contributes to their clinical profile.

Interdisciplinary pain therapy: an innovative therapeutic but pre-DRG Economical Center of Medical Excellence.

OBJECTIVE: After the implementation of the G-DRG system in Germany, doubts arose whether and how interdisciplinary pain therapy centers should be restructured to remain profitable and maintain medical excellence for patients with a long ordeal of malaise. METHODS: To reveal structural deficits, we performed a detailed economic analysis of all patients treated at an interdisciplinary pain therapy center of a German University hospital in 2004. RESULTS: 3,672 patients were treated: 2,163 outpatients, 753 at the daycare clinic, 619 as consults and 132 inpatients. The costs for personnel were euro 736,645, consumables euro 105,061, and infrastructure euro 277,762. We calculated fixed costs of euro 236, and consumables of euro 24 per patient. The costs for surgery were euro 1,595, and for a neuroradiological examination euro 245 per patient. Overall treatment costs were euro 319 per patient. We calculated an overall loss of euro 476,752 or euro 109.19 per patient. Outpatients caused a total loss of euro 456,665.83 or euro 211 per patient, consults a total loss of euro 161 683.16 or euro 261.20 per patient, daycare patients a slight profit of euro 30,370 or euro 40 per patient and inpatients a total profit of euro 111,225 or euro 135 per day. CONCLUSION: Managerial optimization can yield considerable cost reductions in the G-DRG coding system, without any change in treatment strategies, selection of profitable patients or dismissal of personnel. Inversely, additional personnel are needed to accomplish the implementation process. Board certification was unveiled to constitute the key structural implementation that ensures the economic survival of the department and continuing medical excellence for the patients.

Gene transfer technologies for malignant gliomas.

Although early clinical gene therapy trials for recurrent central nervous system neoplasms showed the proof-of-principle, they did not fulfill the high expectations suggested by the preclinical experimental data. Insufficient distribution of vectors in human brain tumors and very low transduction efficiency require that we reevaluate gene transfer concepts for brain tumor treatment. Major steps to improve gene transfer into the central nervous system and the efficacy of gene therapy for malignant brain tumors include: 1) the design of more effective vector systems; 2) the development of new or improved prodrug/suicide systems, gene replacement approaches, or strategies targeting the immune response or tumor angiogenesis; 3) the study of new techniques to enhance delivery of genetic vectors into brain tumors and for monitoring gene delivery into tumors; and 4) assessment of the role of gene therapy as part of a combined treatment approach.

Significant reduction of seizure incidence and increase of benzodiazepine receptor density after interstitial radiosurgery in low-grade gliomas.

Epilepsy is the leading symptom in low grade gliomas. In order to evaluate the effect of interstitial radiosurgery on seizure incidence the authors retrospectively analysed the outcome of 80 patients with temporal grade-II astrocytomas and a history of epilepsy. Patients were treated by 125-iodine temporary implants using 60 Gy as reference dose. The dose rate was 9.6 +/- 1.6 cGy/h. Median follow-up was 4.1 years. In 20 patients benzodiazepine receptor imaging was performed using single photon emission computed tomography and iomazenil. Treatment with carbamazepine alone led to a significant reduction in seizure incidence with 28% of patients being seizure-free (p < 0.05). Interstitial radiosurgery led to a further reduction of seizures rendering 40% of patients seizure-free after 3 months. After 6 months only 21% of patients still had seizures that were refractory to medical treatment (p < 0.01). SPECT imaging revealed that all tumours had a significant reduction of benzodiazepine receptors which also applied to the surrounding brain. After interstitial radiosurgery of tumours, receptor density increased in brain adjacent to the tumour (0.68 to 0.94 ratio ipsi to contralateral brain, p < 0.01) coincident with significant tumour shrinkage. Thus, in epileptogenic temporal low grade gliomas, interstitial radiosurgery not only reduced the tumour burden but also effectively treated the concomitant epilepsy, resulting in 79% of patients being seizure-free after combined treatment by radiosurgery and anticonvulsive medication. These results compare favourably to the outcome after resection in lesional epilepsy raising the issue of radiosurgery as a less invasive alternative to open epilepsy surgery.

Effect of LINAC radiosurgery on regional cerebral blood flow, glucose metabolism and sodium-potassium AtPase in skull base meningiomas and metastasis.

Stereotactic radiosurgery is an elegant alternative to microsurgery in both skull base meningiomas and solitary brain metastasis. Though efficacy for both entities has been established prognostic variables pertaining to individual tumour biology have not yet been identified. Therefore the authors measured regional glucose utilisation, thallium-uptake and blood flow in 20 patients (10 meningiomas, 10 metastasis) before and after LINAC radiosurgery. Measurements were performed using SPECT and stable xenon-CT. The mean tumour dose given was 16.3 and 19.5 Gy in meningiomas and metastasis respectively. Metastatic tumours were hypermetabolic in comparison to contralateral normal brain and responders to radiosurgery showed a lower tumour/brain ratio than non-responders (1.43 vs 0.91 respectively, p < 0.01). Meningiomas did not exhibit hypermetabolism and therapeutic outcome was not related to glucose utilisation. Thallium-uptake, however, was closely related to therapeutic response in meningiomas (1.37 vs 2.2 in responders vs non-responders, p < 0.01). This relationship could not be established in metastatic lesions. Blood flow was widely distributed in both meningiomas and metastasis (26-72.8 and 30.2-70.8 ml/100 g/min). rCBF did not correlate with therapeutic outcome. Using FDG-SPECT and thallium-201-SPECT the authors were able to distinguish between tumours likely to respond to stereotactic radiosurgery and those not prone to respond. Furthermore the methodology can be used to monitor therapeutic response in treated tumours before morphologic changes occur.

Cytokine production during sleep and wakefulness and its relationship to cortisol in healthy humans.

A growing body of evidence indicates that cytokines, especially interleukin-1 beta, are involved in the regulation of sleep and wakefulness. The aim of the present pilot study was to investigate the relationship between interleukin-1 beta (IL-1 beta) and gamma-interferon (gamma-IFN) production and the regulation of sleep and wakefulness. Four healthy male volunteers were investigated. After one adaptation night, beginning at 8 a.m. in the morning, the EEG was recorded by means of a mobile long-term EEG and blood samples were drawn every 45 min for the analysis of IL-1 beta, gamma-IFN and cortisol for 24 h. For the analysis of cytokines whole blood cultures were established. After 48 h of incubation in the presence of endotoxin Salmonella typhimurium, IL-1 beta and gamma-IFN levels were measured in the culture supernatants using specific immunodetection assays. Methods of stochastic time series analysis were adopted to evaluate the biochemical data. Our results show the capability of cultured blood cells to produce cytokines upon endotoxin challenge to be at a maximum around the time of sleep onset and during the first hours of sleep, declining during the night to a minimum level in the morning hours. The opposite was observed for cortisol. The analysis of autocorrelation functions gives evidence of a 24-hour rhythm of cortisol and cytokines. The results indicate that the cytokines IL-1 beta and gamma-IFN may play a role in sleep regulation.