Present and potential future issues in glioblastoma treatment

The treatment of glioblastomas requires a multidisciplinary approach that takes the presently incurable nature of the disease into consideration. Treatments are multimodal and include surgery, radiotherapy and chemotherapy. Current recommendations are that patients with glioblastomas should undergo maximum surgical resection, followed by concurrent radiation and chemotherapy with the novel alkylating drug temozolomide. This is then to be followed by additional adjuvant temozolomide for a period of up to 6 months. Major advances in surgical and imaging technologies used to treat glioblastoma patients are described. These technologies include magnetic resonance imaging and metabolic data that are helpful in the diagnosis and guiding of surgical resection. However, glioblastomas almost invariably recur near their initial sites. Disease progression usually occurs within 6 months and leads rapidly to death. A number of signaling pathways can be activated constitutively in migrating glioma cells, thus rendering these cells resistant to proapoptotic insults, such as conventional chemotherapies. Therefore, the molecular and cellular therapies and local drug delivery that could be used to complement conventional treatments are described, and some of the currently ongoing clinical trials are reviewed, with respect to these new approaches.     

Present and potential future issues in glioblastoma treatment

The treatment of glioblastomas requires a multidisciplinary approach that takes the presently incurable nature of the disease into consideration. Treatments are multimodal and include surgery, radiotherapy and chemotherapy. Current recommendations are that patients with glioblastomas should undergo maximum surgical resection, followed by concurrent radiation and chemotherapy with the novel alkylating drug temozolomide. This is then to be followed by additional adjuvant temozolomide for a period of up to 6 months. Major advances in surgical and imaging technologies used to treat glioblastoma patients are described. These technologies include magnetic resonance imaging and metabolic data that are helpful in the diagnosis and guiding of surgical resection. However, glioblastomas almost invariably recur near their initial sites. Disease progression usually occurs within 6 months and leads rapidly to death. A number of signaling pathways can be activated constitutively in migrating glioma cells, thus rendering these cells resistant to proapoptotic insults, such as conventional chemotherapies. Therefore, the molecular and cellular therapies and local drug delivery that could be used to complement conventional treatments are described, and some of the currently ongoing clinical trials are reviewed, with respect to these new approaches.     

Proautophagic drugs: a novel means to combat apoptosis-resistant cancers, with a special emphasis on glioblastomas

The therapeutic goal of cancer treatment has been to trigger tumor-selective cell death. Although cell death can be achieved not only by apoptosis (type I programmed cell death) but also by necrosis, mitotic catastrophe, and autophagy, drugs inducing apoptosis remain the main chemotherapeutic agents in medical oncology. However, cancer cells in their relentless drive to survive, hijack cell processes, resulting in apoptosis resistance, which underlies not only tumorigenesis but also the inherent resistance of certain cancers to radiotherapy and chemotherapy. Unlike apoptosis, which is a caspase-dependent process characterized by nuclear condensation and fragmentation, autophagic cell death is a caspase-independent process characterized by the accumulation of autophagic vacuoles in the cytoplasm accompanied by extensive degradation of the Golgi apparatus, the polyribosomes, and the endoplasmic reticulum, which precedes the destruction of the nucleus. The most striking evidence for proautophagic chemotherapy to overcome apoptosis resistance in cancer cells comes from the use of temozolomide, a proautophagic cytotoxic drug, which has demonstrated real therapeutic benefits in glioblastoma patients and is in clinical trials for several types of apoptosis-resistant cancers. A number of potential common targets in autophagy and apoptosis resistance pathways, that is, mammalian target of rapamycin (mTOR), phosphatidylinositol 3' kinase (PI3K), and Akt have been identified. Thus, further success in certain devastating cancers might be achieved by the combination of proautophagic drugs such as temozolomide with mTOR, PI3K, or Akt inhibitors, or with endoplasmic reticulum stress inhibitors as adjuvant chemotherapies.     

Survival signalling and apoptosis resistance in glioblastomas: opportunities for targeted therapeutics

Glioblastoma multiforme (GBM) is the most common primary brain tumour in adults and one of the most aggressive cancers in man. Despite technological advances in surgical management, combined regimens of radiotherapy with new generation chemotherapy, the median survival for these patients is 14.6 months. This is largely due to a highly deregulated tumour genome with opportunistic deletion of tumour suppressor genes, amplification and/or mutational hyper-activation of receptor tyrosine kinase receptors. The net result of these genetic changes is augmented survival pathways and systematic defects in the apoptosis signalling machinery. The only randomised, controlled phase II trial conducted targeting the epidermal growth factor receptor (EGFR) signalling with the small molecule inhibitor, erlotinib, has showed no therapeutic benefit. Survival signalling and apoptosis resistance in GBMs can be viewed as two sides of the same coin. Targeting increased survival is unlikely to be efficacious without at the same time targeting apoptosis resistance. We have critically reviewed the literature regarding survival and apoptosis signalling in GBM, and highlighted experimental, preclinical and recent clinical trials attempting to target these pathways. Combined therapies simultaneously targeting apoptosis and survival signalling defects might shift the balance from tumour growth stasis to cytotoxic therapeutic responses that might be associated with greater therapeutic benefits.     

Protein kinase C-eta regulates resistance to UV- and gamma-irradiation-induced apoptosis in glioblastoma cells by preventing caspase-9 activation.

Both increased cell proliferation and apoptosis play important roles in the malignant growth of glioblastomas. We have demonstrated recently that the differential expression of protein kinase C (PKC)-eta increases the proliferative capacity of glioblastoma cells in culture; however, specific functions for this novel PKC isozyme in the regulation of apoptosis in these tumors has not been defined. In the present study of several glioblastoma cell lines, we investigated the role of PKC-eta in preventing UV- and gamma-irradiation-induced apoptosis and in caspase-dependent signaling pathways that mediate cell death. Exposure to UV or gamma irradiation killed 80% to 100% of PKC-eta-deficient nonneoplastic human astrocytes and U-1242 MG cells, but had little effect on the PKC-eta-expressing U-251 MG and U-373 MG cells. PKC-eta appears to mediate resistance to irradiation specifically such that when PKC-eta was stably expressed in U-1242 MG cells, more than 80% of these cells developed resistance to irradiation-induced apoptosis. Reducing PKC-eta expression by transient and stable expression of antisense PKC-eta in wild-type U-251 MG cells results in increased sensitivity to UV irradiation in a fashion similar to U-1242 MG cells and nonneoplastic astrocytes. Irradiation of PKC-eta-deficient glioblastoma cells resulted in the activation of caspase-9 and caspase-3, cleavage of poly (ADP-ribose) polymerase (PARP), and a substantial increase in subdiploid DNA content that did not occur in PKC-eta-expressing tumor cells. A specific inhibitor (Ac-DEVD-CHO) of caspase-3 blocked apoptosis in PKC-eta-deficient U-1242 MG cells. The data demonstrate that resistance to UV and gamma irradiation in glioblastoma cell lines is modified significantly by PKC-eta expression and that PKC-eta appears to block the apoptotic cascade at caspase-9 activation.     

Immunotherapy in glioblastoma treatment: Current state and future prospects

Glioblastoma remains as the most common and aggressive malignant brain tumor, standing with a poor prognosis and treatment prospective. Despite the aggressive standard care, such as surgical resection and chemoradiation, median survival rates are low. In this regard, immunotherapeutic strategies aim to become more attractive for glioblastoma, considering its recent advances and approaches. In this review, we provide an overview of the current status and progress in immunotherapy for glioblastoma, going through the fundamental knowledge on immune targeting to promising strategies, such as Chimeric antigen receptor T-Cell therapy, immune checkpoint inhibitors, cytokine-based treatment, oncolytic virus and vaccine-based techniques. At last, it is discussed innovative methods to overcome diverse challenges, and future perspectives in this area.     

Intratumoral heterogeneity: pathways to treatment resistance and relapse in human glioblastoma

Intratumoral heterogeneity (ITH) has increasingly being described for multiple cancers as the root cause of therapy resistance. Recent studies have started to explore the scope of ITH in glioblastoma (GBM), a highly aggressive and fatal form of brain tumor, to explain its inevitable therapy resistance and disease relapse. In this review, we detail the emerging data that explores the extensive genetic, cellular and functional ITH present in GBM. We discuss current experimental models of human GBM recurrence and suggest harnessing new technologies (CRISPR-Cas9 screening, CyTOF, cellular barcoding, single cell analysis) to delineate GBM ITH and identify treatment-refractory cell populations, thus opening new therapeutic windows. We will also explore why current therapeutics have failed in clinical trials and how ITH can inform us on developing empiric therapies for the treatment of recurrent GBM.     

Overexpression of SSAT by DENSPM treatment induces cell detachment and apoptosis in glioblastoma

N1,N11-diethylnorspermine (DENSPM), a polyamine analog that induces expression of spermidine/spermine N1-acetyltransferase (SSAT) and reduces polyamine levels in eukaryotic cells, has demonstrated anticancer effects in many cancer cell types. Gene expression of SSAT after treatment with DENSPM was measured in both U87 and LN229 cells using real-time PCR. Induction of SSAT mRNA using DENSPM resulted in significantly higher levels in U87 cells than in LN229 cells. Furthermore, DENSPM caused marked cell detachment in U87 cells and to a lesser extent in LN229 cells. We hypothesized that elevated SSAT expression plays a key role in DENSPM-induced cell detachment in glioblastoma cells. To investigate whether forced expression of SSAT would lead to reduced cell adhesion and increased cell detachment, we transfected a PCMV-SSAT plasmid into LN229 cells and observed significant cell detachment. In addition, we treated U87 cells with SSAT siRNA together with DENSPM to blunt the induction of SSAT by DENSPM. This resulted in an inhibition of cell detachment in U87 cells compared with the DENSPM treatment alone. Increased SSAT expression by transfection enhanced the DENSPM cell-kill effect in LN229 cells whereas reduction of SSAT by siRNA attenuated the DENSPM cell-kill effect. The protein levels of AKT, mTOR and integrin?α5β1, which are members of the cell adhesion and anti-apoptotic signal transduction pathways, were decreased in the PCMV-SSAT transfected LN229 cells. Collectively, these results demonstrate that SSAT induction at least partially plays a role in cell detachment and apoptosis of glioblastoma cells by DENSPM treatment.     

MicroRNA-125b-2 confers human glioblastoma stem cells resistance to temozolomide through the mitochondrial pathway of apoptosis

MicroRNAs (miRNAs) are small, non-coding RNA molecules that regulate protein expression by cleaving or repressing the translation of target mRNAs. miR-125b, one of the neuronal miRNAs, was recently found to be necessary for stem cell fission and for making stem cells insensitive to chemotherapy signals. Temozolomide (TMZ) is a promising chemotherapeutic agent for treating glioblastomas. However, resistance develops quickly and with a high frequency. Given the insensitivity of some glioblastomas to TMZ and the hypothesis that glioma stem cells cause resistance to drug therapy, exploring the functions and mechanisms of miR-125b action on TMZ-treated glioblastoma stem cells would be valuable. In this study, we found that miR-125b-2 is overexpressed in glioblastoma multiforme tissues and the corresponding stem cells (GBMSC); downregulation of miR-125b-2 expression in GBMSC could allow TMZ to induce GBMSC apoptosis. Additionally, the expression of the anti-apoptotic protein Bcl-2 was decreased after the TMZ+miR-125b-2 inhibitor treatment, while the expression of the proapoptotic protein Bax was increased. Further research demonstrated that the induction of apoptosis in GBMSC is also associated with increased cytochrome c release from mitochondria, induction of Apaf-1, activation of caspase-3 and poly-ADP-ribose polymerase (PARP). Taken together, these results suggest that miR-125b-2 overexpression might confer glioblastoma stem cells resistance to TMZ.     

HMGB1 as an autocrine stimulus in human T98G glioblastoma cells: role in cell growth and migration

HMGB1 (high mobility group box 1 protein) is a nuclear protein that can also act as an extracellular trigger of inflammation, proliferation and migration, mainly through RAGE (the receptor for advanced glycation end products); HMGB1–RAGE interactions have been found to be important in a number of cancers. We investigated whether HMGB1 is an autocrine factor in human glioma cells. Western blots showed HMGB1 and RAGE expression in human malignant glioma cell lines. HMGB1 induced a dose-dependent increase in cell proliferation, which was found to be RAGE-mediated and involved the MAPK/ERK pathway. Moreover, in a wounding model, it induced a significant increase in cell migration, and RAGE-dependent activation of Rac1 was crucial in giving the tumour cells a motile phenotype. The fact that blocking DNA replication with anti-mitotic agents did not reduce the distance migrated suggests the independence of the proliferative and migratory effects. We also found that glioma cells contain HMGB1 predominantly in the nucleus, and cannot secrete it constitutively or upon stimulation; however, necrotic glioma cells can release HMGB1 after it has translocated from the nucleus to cytosol. These findings provide the first evidence supporting the existence of HMGB1/RAGE signalling pathways in human glioblastoma cells, and suggest that HMGB1 may play an important role in the relationship between necrosis and malignancy in glioma tumours by acting as an autocrine factor that is capable of promoting the growth and migration of tumour cells. Rosaria Bassi and Paola Giussani contributed equally to this study.     

Gastrin induces over-expression of genes involved in human U373 glioblastoma cell migration.

Astrocytic tumors are the most common and the most malignant primary tumors of the central nervous system. We had previously observed that gastrin could significantly modulate both cell proliferation and migration of astrocytoma cells. We have investigated in the present study which genes could be targeted by gastrin in tumor astrocyte migration. Using a subtractive hybridization PCR technique we have cloned genes differentially over-expressed in human astrocytoma U373 cells treated or not with gastrin. We found about 70 genes over-expressed by gastrin. Among the genes overexpressed by gastrin, we paid particular attention to tenascin-C, S100A6 and MLCK genes because their direct involvement in cell migration features. Their gastrin-induced overexpression was quantitatively determined by competitive RT-PCR technique. We also showed by means of a reporter gene system that S100A6 and tenascin-C respective promoters were upregulated after gastrin treatment. These data show that gastrin-mediated effects in glioblastoma cells occur through activation of a number of genes involved in cell migration and suggest that gastrin could be a target in new therapeutic strategies against malignant gliomas.     

Identification of a novel switch in the dominant forms of cell adhesion-mediated drug resistance in glioblastoma cells

The failure of malignant cells to undergo apoptosis is a major obstacle in cancer therapy, and thus identifying the underlining molecules involved therein is imperative for improving patient survival. An important mechanism of drug resistance is cell adhesion-mediated drug resistance (CAM-DR). In this study we identify a novel switch by which glioblastoma multiforme (GBM) cells alter the mode of CAM-DR. In the absence of a microenvironmental cue provided by components of the extracellular matrix (ECM), GBM cells are able to employ an alternative, but equally effective, mode of CAM-DR by forming spheres via cell-cell interactions. Intriguingly, when inhibiting cell-cell interactions in the absence of ECM components, either by low cell density or by inhibition of gap junctions (intercellular connexin tunnels) through chemical inhibition with carbenoxyolone or co-incubation with the connexin-mimicking Gap 27 Cx37,43 peptide, GBM cells were sensitized to tumor necrosis factor-related apoptosis-inducing ligand- and CD95-induced apoptosis. By demonstrating that GBM cells can alternate from one form of CAM-DR (cell-substrate tethering) to another (homocellular cell-cell adhesion) and that inhibition of both forms is necessary for apoptosis sensitization, our findings not only have important implications for novel approaches to restore defective apoptosis programs, but also reveal a novel role of gap junctions in GBM.     

Circulating T regulatory cells migration and phenotype in glioblastoma patients: an in vitro study

Glioblastoma multiforme (GBM) is the most aggressive primary human brain tumor. The relatively high amount of T regulatory lymphocytes present in the tumor, contributes to the establishment of an immunosuppressive microenvironment. Samples of peripheral blood were collected from GBM patients and healthy controls and a purified population of Treg (CD4⁺/CD25^bright) was isolated using flow cytometric cell sorting. Treg migrating capacities toward human glioma cell line conditioned medium were evaluated through an in vitro migration test. Our data show that supernatants collected from GBM cell lines were more attractant to Treg when compared to complete standard medium. The addition of an anti-CCL2 antibody to conditioned medium decreased conditioned medium-depending Treg migration, suggesting that CCL2 (also known as Monocyte Chemoattractant Protein, MCP-1) is implicated in the process. The number of circulating CD4⁺/μL or Treg/μL was similar in GBM patients and controls. Specific Treg markers (FOXP3; CD127; Helios; GITR; CTLA4; CD95; CCR2, CCR4; CCR7) were screened in peripheral blood and no differences could be detected between the two populations. These data confirm that the tumor microenvironment is attractive to Treg, which tend to migrate toward the tumor region changing the immunological response. Though we provide evidence that CCL2 is implicated in Treg migration, other factors are needed as well to provide such effect.     

塞来昔布抑制人神经胶质瘤细胞SHG-44的增殖和迁移

目的:观察选择性环氧化酶2(cyclooxygenase 2, COX-2)抑制剂塞来昔布对人神经胶质瘤细胞株SHG-44的体外抑制增殖和迁移的效应.方法:采用不同浓度塞来昔布(30、50、100和150 μmol/L)处理SHG-44细胞24和48 h,并设不用药组作为对照.观察细胞形态学变化,应用MTT法观察塞来昔布对SHG-44细胞的增殖抑制效应,细胞划痕实验观察塞来昔布对SHG-44细胞迁移能力的影响,ELISA检测细胞培养上清液中基质金属蛋白酶2(matrix metalloproteinase 2, MMP-2)的含量.结果:塞来昔布对SHG-44细胞的增殖抑制作用呈浓度和时间依赖效应.不同浓度塞来昔布组SHG-44细胞的迁移能力均较对照组下降,且随药物浓度的增加,下降幅度更为明显.ELISA检测发现,不同浓度塞来昔布组细胞培养上清液中MMP-2的含量均较对照组明显下降(P＜0.05).结论:塞来昔布对SHG-44细胞的增殖和迁移均有抑制作用,呈浓度和时间依赖效应.塞来昔布可能通过抑制SHG-44细胞分泌MMP-2,继而抑制细胞的迁移能力.     

Verapamil reverts resistance to drug-induced apoptosis in Ki-ras-transformed cells by altering the cell membrane and the mitochondrial transmembrane potentials

We have previously shown that in vivo ras-transformed cell lines display natural doxorubicin resistance compared with the normal cells and that such resistance is accompanied by a plasma membrane depolarization. In this article we first extend the analysis of doxorubicin effect to other ras-transformed cell lines, which are characterized by an increasing degree of malignant phenotype. Rat thyroid ras-transformed cells are markedly resistant to doxorubicin and the degree of drug resistance correlates with the degree of cell malignancy. The lower amount of drug accumulated inside the malignant and resistant cells is a consequence of their constitutive depolarized membrane potential and may account for their lack of drug-induced apoptosis. Verapamil, a known modulator of drug resistance, is able to decrease the resistance of all the malignant cell lines, initially causing a higher incorporation of doxorubicin as a consequence of its ability to hyperpolarize the membrane potential. In resistant cells, verapamil is also able to alter the mitochondrial membrane potential allowing apoptosis. In conclusion, these studies demonstrate that ras transformation induces the natural resistance to doxorubicin of the malignant cells. We suggest that the most malignant and resistant cells, of metastatic origin, could be preferentially destroyed by manipulation of their membrane properties, and we confirm the possibility of overcoming drug resistance by the administration of verapamil also in P-gp170-nonexpressing cells.     

Glioma cell VEGFR-2 confers resistance to chemotherapeutic and antiangiogenic treatments in PTEN-deficient glioblastoma

Loss of the tumor suppressor phosphatase and tensin homolog deleted on chromosome 10 (PTEN) is a prerequisite for tumor cell-specific expression of vascular endothelial growth factor receptor (VEGFR)-2 in glioblastoma defining a subgroup prone to develop evasive resistance towards antiangiogenic treatments. Immunohistochemical analysis of human tumor tissues showed VEGFR-2 expression in glioma cells in 19% of specimens examined, mainly in the infiltration zone. Glioma cell VEGFR-2 positivity was restricted to PTEN-deficient tumor specimens. PTEN overexpression reduced VEGFR-2 expression in vitro, as well as knock-down of raptor or rictor. Genetic interference with VEGFR-2 revealed proproliferative, antiinvasive and chemoprotective functions for VEGFR-2 in glioma cells. VEGFR-2-dependent cellular effects were concomitant with activation of ''kappa-light-chain-enhancer’ of activated B-cells, protein kinase B, and N-myc downstream regulated gene 1. Two-photon in vivo microscopy revealed that expression of VEGFR-2 in glioma cells hampers antiangiogenesis. Bevacizumab induces a proinvasive response in VEGFR-2-positive glioma cells. Patients with PTEN-negative glioblastomas had a shorter survival after initiation of bevacizumab therapy compared with PTEN-positive glioblastomas. Conclusively, expression of VEGFR-2 in glioma cells indicates an aggressive glioblastoma subgroup developing early resistance to temozolomide or bevacizumab. Loss of PTEN may serve as a biomarker identifying those tumors upfront by routine neuropathological methods.     

In vitro pharmacological characterizations of the anti-angiogenic and anti-tumor cell migration properties mediated by microtubule-affecting drugs,with special emphasis on the organization of the actin cytoskeleton

The aim of the present work is to investigate whether microtubule-affecting drugs including vincristine, vinblastine, vindesine and vinorelbine are able to produce an anti-angiogenic effect at non-cytotoxic doses in the same way of taxol. The cytotoxic effects were determined by means of the colorimetric MTT assay, and the anti-angiogenic effects on HUVEC cells growing on Matrigel and forming capillary networks. Sixteen additional drugs (camptothecin, SN38, topothecan, adriamycin, daunomycin, etoposide, bleomycin, melphalan, mitomycin C, TNP-470, cisplatin, carboplatin, 5-fluorouracil, methotrexate, suramin and batimastat) were used as control in order to test the specificity of the microtubule-affecting drug effects. We also investigated by means of videomicroscopy whether microtubule-affecting drugs could produce anti-migratory effects at non-cytotoxic doses on tumor cells. Finally, we used computer-assisted fluorescence microscopy to characterize the influence of microtubule-affecting drugs on the polymerization/depolymerization dynamics of the actin cytoskeleton in tumor cells. Our results show that taxol, vincristine and vindesine behave similarly in their ability to reduce the capillary network formation by HUVEC cells cultured on Matrigel. These anti-angiogenic effects appear at non-cytotoxic concentrations. In contrast, vinblastine and vinorelbine produce apparent anti-angiogenic effects by direct cytotoxicity. Microtubule-affecting agents are also able to significantly reduce the level of migration of tumor cells at non-cytotoxic concentrations, some of these effects may occur via modifications to the actin cytoskeleton organization. Several types of microtubule-affecting agents could be used as anti-angiogenic agents by administering them at non-cytotoxic concentrations, and some microtubule-affecting agents abandoned in pharmacological assays could turn out to be potent anti-migratory drugs acting on tumor cells, though without being too cytotoxic.