Overall Survival In Glioblastoma Patients Research Articles

Systematic Review and Pooled Analysis of the Impact of Treatment-Induced Lymphopenia on Survival of Glioblastoma Patients

Lymphopenia is a known toxicity of chemotherapy and radiation therapy (RT), part of the standard treatment for glioblastoma (GBM). Given the immune system's role in cancer control and general health, a number of single-institution studies have examined the association between treatment-related lymphopenia and survival outcomes of GBM patients. We performed a systematic review and pooled analysis to evaluate the association between lymphopenia and overall survival (OS) for GBM patients undergoing chemoRT.Following PRISMA guidelines, a systematic review of the MEDLINE database and abstracts from ASTRO, ASCO, and SNO annual meetings was conducted. Inclusion criteria included: (1) retrospective/prospective studies of human subjects (2) GBM patients (3) treated with chemoRT (4) reported lymphopenia and OS outcomes (5) analyzed lymphopenia and OS association. Analysis was conducted using inverse variance-weighted random effects to generate a pooled estimate of the hazard ratio of association between lymphopenia and OS.104 studies were identified, with 11 studies meeting the inclusion criteria, representing 2,196 unique patients. The threshold of lymphopenia varied between studies (lymphocyte count cutoff value range of 400 - 1200 cells/uL; mode 500 cell/uL). The time of lymphopenia onset was dichotomized into two groups (time-point vs time-range), with 6 studies tabulating the incidence of lymphopenia defined at a fixed time point approximately 2-months after the start of RT, while 5 studies utilized a time-range, tabulating the incidence of lymphopenia defined as any occurrence of lymphopenia from the start of RT to approximately 2-months after the start of RT. The mean overall pooled incidence of lymphopenia for all 11 studies was 32.4%, and was 21.1% vs 41% for time-point studies and time-range studies, respectively. Lymphopenia was associated with increased risk of death, with a pooled HR of 1.78 (95% CI: 1.46 - 2.17, P < 0.00001) for the time-point studies, and a pooled HR of 1.38 (95% CI: 1.24 - 1.55, P < 0.00001) for the time-point studies. There was no significant heterogeneity between studies (P = 0.6 for time-point and P = 0.5 for time-range studies). Available pooled analysis of MVA estimates of HR for the time-range studies were confirmatory, with pooled HR of 1.36 (95% CI: 1.12 - 1.65, P < 0.002), with significant heterogeneity between studies, P = 0.02.These results strengthen observations from previous individual single-institution studies and better defines the magnitude of the association between treatment-related lymphopenia with decreased OS in GBM patients, highlighting lymphopenia as a poor prognostic factor. These results are hypothesis generating, stimulating a better understanding regarding causality and underscores the need for investigations into strategies to mitigate lymphopenia. Such insights may improve outcomes and possibly shed light on the limited efficacy of immunotherapy for the treatment of GBM.A. Saeed: None. S.M. Bentzen: Travel Expenses; University of Copenhagen. M.V. Mishra: Employee; Orthofix. Research Grant; ASTRO, Keep Punching. Advisory Board; Patient Centers Outcomes Research Institute (PCORI. Travel Expenses; Patient Centers Outcomes Research Institute (PCORI.

A Feasibility Study Evaluating the Use of Cell-free DNA Analysis in Laboratory Brain Cancer Investigations

Abstract Aims Circulating tumour DNA (ctDNA), shed from solid cancers in to the plasma, represents an exciting analyte for diagnosis and monitoring of disease in cancer patients. However, its use in glioma brain cancer patients represents a challenge, due to reduced permeability of the blood brain barrier. This pilot study sought to investigate the practical aspects and clinical utility of using cell-free DNA (cfDNA) in glioma tests in a NHS diagnostic laboratory. Firstly, we investigated the potential of ctDNA as a proxy for the brain cancer biopsy; where cfDNA analysis was compared to the paired FFPE brain specimen for relevant glioma genetic biomarkers. Secondly, ctDNA constitutes a portion of the overall cfDNA and there is evidence cfDNA metrics per se may also be of value as prognostic tools and surrogates of tumour burden. Additionally, we investigated a potential role for cfDNA metrics in prognostic impact; linking cfDNA concentrations to clinical outcome measures. Method 10ml peripheral blood was collected in specialist preservative tubes and cfDNA isolated using an extraction kit (Qiagen MinElute ccfDNA kit). cfDNA concentration and purity was assessed using chip-based automated electrophoresis. Where relevant (12/39 cases), cfDNA samples were run though laboratory tests of IDH variant detection, 1p19q co-deletion assessment and MGMT promoter methylation analysis. Results were compared with ‘standard of care’ brain biopsy tests. A potential correlate of cfDNA concentration and clinical outcomes data were assessed in a sub-cohort of glioblastoma patients (n=32). The cohort was divided in to 2 groups – high cfDNA vs. low cfDNA - based on whether a subject’s extracted sample cfDNA concentration fell above or below the mean. Comparison of overall survival in months between subjects was checked for normal distribution using the Shapiro-Wilk t-test. The test of equity of survival distributions for the high cfDNA vs. low cfDNA was then analysed as a Kaplan-Meier curve. Results The protocol delivered cfDNA of high purity, averaging 91%, within the plasma nucleic acid fraction, however the cfDNA concentrations (mean ≈1ng µl-1) fell below the conventional limit of detection of the laboratory tests. In spite of the low concentration, cfDNA samples did generate test PCR amplicon; however results reflected the germline DNA profile rather than the new somatic changes of the tumour. The cfDNA analysis did not pick up the tumour biomarkers seen in the paired tumour biopsy sample. In a second part of the study, cfDNA concentrations for the glioblastoma cohort were assessed in the context of their clinical outcomes data. The data showed a correlate where high cfDNA concentration in the extracted sample was independently associated with inferior outcome in terms of overall survival, with Log Rank significance p=0.014 (Figure 1). Conclusion The cfDNA yields from a 10ml blood sample were consistently too low to meet the limit of detection requirements of the standard laboratory neuropathology genetic tests and glioma tumour profile could not be picked up against the germline background. Thus, in spite of the considerable advantages to glioma plasma molecular testing, using cfDNA as a proxy for a brain biopsy would currently not be possible in our routine diagnostic environment. However, within the limitations of the pilot project testing strategy, the data showed an interesting correlate where high cfDNA concentration was independently associated with inferior outcome in terms of overall survival for glioblastoma patients. Given the simplicity of obtaining this quantifiable metric, there are grounds for further investigations as to its utility; not only with survival outcomes, but also potential correlation with the clinical assessment of tumour burden, blood brain barrier integrity and disease pseudoprogression.

P14.87 Significance of clinical and molecular-genetic factors for prognosis in 574 adult patients with primary glioblastoma

Abstract BACKGROUND Despite advances in the characterization of genomic alterations in glioblastoma patient survival remains poor. The aim of this single center retrospective study was to estimate prognostic factors affecting to survival for optimizing personalized treatment strategy in glioblastoma patients. MATERIAL AND METHODS 574 consecutive patients with primary glioblastoma treated at the Burdenko National Medical Research Center of Neurosurgery from 2014 to 2019 were included in this study (314 male /260 female). Survival data was analyzed using Kaplan-Meier with log-rank tests to assess statistical significance. A linear regression model was built to predict overall survival. RESULTS Older patients (&amp;gt; 45 years) had the worse prognosis than patients ≤ 45 (p = 2.37 * 10^-6). Female patients had advantages in overall survival (p = 0.014). Time interval from surgery to the starting of radiotherapy longer than 4 weeks was associated with worse overall survival (p = 0.062). Patients with positive IDH1/2 and MGMT had better prognosis than patients with wild type and MGMT negative (p = 0.000841, p = 0.000138, respectively). We revealed that there were significant differences in overall survival between patients who had progression on the first (p = 0.000312), second (p = 0.001046) and third (p = 0.00223) follow-up MRI after radiotherapy. Median survival times (from the date of surgery) were 17, 20, 23 months, respectively. The feature importance in the linear regression model was patient’s age, IDH1/2 mutation, MGMT promoter methylation status, progression on the first follow-up MRI and sex. CONCLUSION Older patient’s age, prolonged time between surgery and RT starting, male sex, negative IDH1/2 and MGMT, progression on the first MRI were associated with poor overall survival in glioblastoma patients. Our results suggested additional clinical, radiomics and molecular-genetic data should be added to improve the overall survival prediction. The results have been obtained under the support of the RFBR grant 18-29-01054

Identification of prognostic values defined by copy number variation, mRNA and protein expression of LANCL2 and EGFR in glioblastoma patients

BackgroundEpidermal growth factor receptor (EGFR) and lanthionine synthetase C-like 2 (LanCL2) genes locate in the same amplicon, and co-amplification of EGFR and LANCL2 is frequent in glioblastoma. However, the prognostic value of LANCL2 and EGFR co-amplification, and their mRNA and protein expression in glioblastoma remain unclear yet.MethodsThis study analyzed the prognostic values of the copy number variations (CNVs), mRNA and protein expression of LANCL2 and EGFR in 575 glioblastoma patients in TCGA database and 100 glioblastoma patients in tumor banks of the Shenzhen Second People’s Hospital and the Sun Yat-sen University Cancer Center.ResultsThe amplification of LANCL2 or EGFR, and their co-amplification were frequent in glioblastoma of TCGA database and our tumor banks. A significant correlation was found between the CNVs of LANCL2 and EGFR (p < 0.001). CNVs of LANCL2 or EGFR were significantly correlated with IDH1/2 mutation but not MGMT promoter methylation. Multivariate analysis showed that LANCL2 amplification was significantly correlated with reduced overall survival (OS) in younger (< 60 years) glioblastoma patients of TCGA database (p = 0.043, HR = 1.657) and our tumor banks (p = 0.018, HR = 2.199). However, LANCL2 or EGFR amplification, and their co-amplification had no significant impact on OS in older (≥ 60 years) or IDH1/2-wild-type glioblastoma patients. mRNA and protein overexpression of LANCL2 and EGFR was also frequently found in glioblastoma. The mRNA expression rather than the protein expression of LANCL2 and EGFR was positively correlated (p < 0.001). However, mRNA or protein expression of EGFR and LANCL2 was not significantly correlated with OS of glioblastoma patients. The protein expression level of LANCL2, rather than EGFR, was elevated in relapsing glioblastoma, compared with newly diagnosed glioblastoma. In addition, the intracellular localization of LanCL2, not EGFR, was associated with the grade of gliomas.ConclusionsTaken together, amplification and mRNA overexpression of LANCL2 and EGFR, and their co-amplification and co-expression were frequent in glioblastoma patients. Our findings suggest that amplification of LANCL2 and EGFR were the independent diagnostic biomarkers for glioblastoma patients, and LANCL2 amplification was a significant prognostic factor for OS in younger glioblastoma patients.

BCL7A as a novel prognostic biomarker for glioma patients

BackgroundGlioma is the most common primary brain tumor and represents one of the most aggressive and lethal types of human cancer. BCL7 family has been found in several cancer types and could be involved in tumor progression. While the role of BCL7 family in human glioma has remained to be elucidated.MethodsParaffin-embedded tumor samples were obtained to detect BCL7 expression by performing in glioma. Data (including normalized gene expression and corresponding clinical data) were obtained from Gliovis, CGGA, GEO, cBioportal and Oncomine and were used to investigate BCL7 genes expression in glioma. Survival analyses were calculated by Kaplan–Meier methods and Cox regression analysis in TCGA and CGGA. Gene Set Enrichment Analyses (GSEA) and gene ontology (GO) analysis was employed to perform the biological processes enrichment.ResultsBCL7A expression in glioma tissues was lower compared to non-tumor brain tissues (NBT), and exhibited a negative correlation with glioma grades. Results from immunohistochemical (IHC) staining and public dataset validation demonstrated that BCL7B and BCL7C were highly expressed in glioma tissues compared to NBT. Cox regression analysis identified BCL7A as the only gene in the BCL7 family that was independently associated with the prognosis of lower-grade glioma (LGG) and glioblastoma (GBM). GO and GSEA analyses revealed the potential contribution of BCL7A in adaptive immune response and neutrophil activation in the tumor microenvironment. Moreover, we found that BCL7A had no prognostic effect on the overall survival of GBM patients who received IR only; however, patients who received chemotherapy (TMZ) combined with IR in the high BCL7A group survived longer than patients in the low BCL7A group (HR = 0.346, p < 0.05).ConclusionBCL7A is a new tumor suppressor gene and can be adopted as a biomarker for independent prognosis in glioma and to evaluate response to TMZ.

A novel patient stratification strategy to enhance the therapeutic efficacy of dasatinib in glioblastoma.

Glioblastoma is the most common primary malignancy of the central nervous system with a dismal prognosis. Genomic signatures classify isocitrate dehydrogenase 1 (IDH)-wildtype glioblastoma into three subtypes: proneural, mesenchymal, and classical. Dasatinib, an inhibitor of proto-oncogene kinase Src (SRC), is one of many therapeutics which, despite promising preclinical results, have failed to improve overall survival in glioblastoma patients in clinical trials. We examined whether glioblastoma subtypes differ in their response to dasatinib and could hence be evaluated for patient enrichment strategies in clinical trials. We carried out in silico analyses on glioblastoma gene expression (TCGA) and single-cell RNA-Seq data. In addition, in vitro experiments using glioblastoma stem-like cells (GSCs) derived from primary patient tumors were performed, with complementary gene expression profiling and immunohistochemistry analysis of tumor samples. Patients with the mesenchymal subtype of glioblastoma showed higher SRC pathway activation based on gene expression profiling. Accordingly, mesenchymal GSCs were more sensitive to SRC inhibition by dasatinib compared to proneural and classical GSCs. Notably, SRC phosphorylation status did not predict response to dasatinib treatment. Furthermore, serpin peptidase inhibitor clade H member 1 (SERPINH1), a collagen-related heat-shock protein associated with cancer progression, was shown to correlate with dasatinib response and with the mesenchymal subtype. This work highlights further molecular-based patient selection strategies in clinical trials and suggests the mesenchymal subtype as well as SERPINH1 to be associated with response to dasatinib. Our findings indicate that stratification based on gene expression subtyping should be considered in future dasatinib trials.

Advances in Chemokine Signaling Pathways as Therapeutic Targets in Glioblastoma.

Simple SummaryChemokine signaling is crucial for tumorigenesis, proliferation, angiogenesis, tumor progression and metastasis in glioblastoma. Furthermore, chemokines have an impact on the overall survival of GBM patients that, with a median survival of 15 months, still lack effective treatment. Several chemokine signaling axes, for instance CXCR2/CXCL2/IL-8, CXCR4/CXCL12 and CCR2/CCL2, were investigated in detail and appear to be promising therapeutic targets. The aim was to review novel approaches that target chemokines or chemokine receptors in glioblastoma. Here, preclinical and clinical studies were used to clarify their significance for targeted treatments alone and in combination with other therapeutic applications.With a median patient survival of 15 months, glioblastoma (GBM) is still one of the deadliest malign tumors. Despite immense efforts, therapeutic regimens fail to prolong GBM patient overall survival due to various resistance mechanisms. Chemokine signaling as part of the tumor microenvironment plays a key role in gliomagenesis, proliferation, neovascularization, metastasis and tumor progression. In this review, we aimed to investigate novel therapeutic approaches targeting various chemokine axes, including CXCR2/CXCL2/IL-8, CXCR3/CXCL4/CXCL9/CXCL10, CXCR4/CXCR7/CXCL12, CXCR6/CXCL16, CCR2/CCL2, CCR5/CCL5 and CX3CR1/CX3CL1 in preclinical and clinical studies of GBM. We reviewed targeted therapies as single therapies, in combination with the standard of care, with antiangiogenic treatment as well as immunotherapy. We found that there are many antagonist-, antibody-, cell- and vaccine-based therapeutic approaches in preclinical and clinical studies. Furthermore, targeted therapies exerted their highest efficacy in combination with other established therapeutic applications. The novel chemokine-targeting therapies have mainly been examined in preclinical models. However, clinical applications are auspicious. Thus, it is crucial to broadly investigate the recently developed preclinical approaches. Promising preclinical applications should then be investigated in clinical studies to create new therapeutic regimens and to overcome therapy resistance to GBM treatment.

Expression and Clinical Significance of Long Non-Coding RNA RP4-669H2.1 in Glioblastoma

Neuroglioma is the most common malignant tumor in the central nervous system and still has a poor prognosis. Here, we investigated the prognostic value of long non-coding RNAs(lncRNAs) in glioblastoma. We first analyzed the lncRNA expression profiles of glioblastoma (GBM) in The Cancer Genome Atlas database and selected the most differential survival genes (lncRNA RP4-669H2.1) for further validation. We then performed qRT-PCR using samples of 88 glioblastoma patients treated in our department between January 2011 and December 2017 that were retrospectively selected to validate the prognostic value of RP4-669H2.1expression in glioblastoma. Using a Cox multivariate analysis, we explored the prognostic value of RP4-669H2.1 and analyzed whether it was an independent prognostic factor. This analysis confirmed that the RP4-669H2.1 expression was significantly associated with glioblastoma-associated mortality in this patient cohort (P =1.80E–05) in TCGA database. In fact, the overall survival (OS) of the RP4-669H2.1 high-expression group (78 cases) was lower than that of the low-expression group (49 cases) (P = 4.6E–06) in TCGA database. Moreover, the TNM stage of the RP4-669H2.1 high-expression group was higher than that of the RP4-669H2.1 low-expression group (P = 0.001). A multivariate analysis further showed that a higher TNM stage (OR = 2.167, 95% CI: 1.349–3.479) and a higher RP4-669H2.1 expression (OR = 2.933, 95% CI: 1.122–7.663) were independent risk factors for the OS of glioblastoma patients. Finally, we predicted the target genes of RP4-669H2.1 using a Multi Experiment Matrix and annotated their biological functions. We observed that the target genes of RP4-669H2.1 were mainly enriched in biological functions related to DNA-binding transcription factor activity. Among these, we selected SMAD6 because the expression of RP4-669H2.1 was positively correlated with that of SMAD6 in glioblastoma. Overall, we conclude that the upregulation of RP4-669H2.1 is an independent poor prognosis factor for glioblastoma and that it can regulate the DNA-binding activity of transcription factors.

Dynein Light Chain Protein Tctex1: A Novel Prognostic Marker and Molecular Mediator in Glioblastoma.

Simple SummaryGlioblastoma (GBM) remains one of the deadliest solid cancers, with only a dismal proportion of GBM patients achieving 5-year survival. Thus, it is critical to identify molecular mechanisms that could be targeted by novel therapeutic approaches in this tumor type. Our study identified Tctex1/DYNLT1 as an independent prognostic marker for the overall survival of GBM patients. Importantly, Tctex1 promoted the aggressiveness of GBM cells by enhancing tumor proliferation and invasion. These effects of Tctex1 appeared to be modulated via phosphorylation of retinoblastoma protein (RB) and the release of matrix metalloprotease 2 (MMP2), respectively. As Tctex1 can potentially be inhibited in vivo, our study provides a rationale for novel, individualized therapeutic strategies in GBM patients.The purpose of this study was to determine the role of Tctex1 (DYNLT1, dynein light chain-1) in the pathophysiology of glioblastoma (GBM). To this end, we performed immunohistochemical analyses on tissues from GBM patients (n = 202). Tctex1 was additionally overexpressed in two different GBM cell lines, which were then evaluated in regard to their proliferative and invasive properties. We found that Tctex1 levels were significantly higher in GBM compared to healthy adjacent brain tissues. Furthermore, high Tctex1 expression was significantly associated with the short overall- (p = 0.002, log-rank) and progression-free (p = 0.028, log-rank) survival of GBM patients and was an independent predictor of poor overall survival in multivariate Cox-regression models. In vitro, Tctex1 promoted the metabolic activity, anchorage-independent growth and proliferation of GBM cells. This phenomenon was previously shown to occur via the phosphorylation of retinoblastoma protein (phospho-RB). Here, we found a direct and significant correlation between the levels of Tctex1 and phospho-RB (Ser807/801) in tissues from GBM patients (p = 0.007, Rho = 0.284, Spearman’s rank). Finally, Tctex1 enhanced the invasiveness of GBM cells and the release of pro-invasive matrix metalloprotease 2 (MMP2). These findings indicate that Tctex1 promotes GBM progression and therefore might be a useful therapeutic target in this type of cancer.

The Role of Cytokines and Chemokines in Shaping the Immune Microenvironment of Glioblastoma: Implications for Immunotherapy.

Glioblastoma is the most common form of primary brain tumour in adults. For more than a decade, conventional treatment has produced a relatively modest improvement in the overall survival of glioblastoma patients. The immunosuppressive mechanisms employed by neoplastic and non-neoplastic cells within the tumour can limit treatment efficacy, and this can include the secretion of immunosuppressive cytokines and chemokines. These factors can play a significant role in immune modulation, thus disabling anti-tumour responses and contributing to tumour progression. Here, we review the complex interplay between populations of immune and tumour cells together with defined contributions by key cytokines and chemokines to these intercellular interactions. Understanding how these tumour-derived factors facilitate the crosstalk between cells may identify molecular candidates for potential immunotherapeutic targeting, which may enable better tumour control and improved patient survival.

A Prognostic Model for Glioblastoma Patients Treated With Standard Therapy Based on a Prospective Cohort of Consecutive Non-Selected Patients From a Single Institution.

BackgroundGlioblastoma patients administered standard therapies, comprising maximal surgical resection, radiation therapy with concomitant and adjuvant temozolomide, have a variable prognosis with a median overall survival of 15–16 months and a 2-year overall survival of 30%. The aim of this study was to develop a prognostic nomogram for overall survival for glioblastoma patients treated with standard therapy outside clinical trials.MethodsThe study included 680 consecutive, non-selected glioblastoma patients administered standard therapy as primary treatment between the years 2005 and 2016 at Rigshospitalet, Copenhagen, Denmark. The prognostic model was generated employing multivariate Cox regression analysis modeling overall survival.ResultsThe following poor prognostic factors were included in the final prognostic model for overall survival: Age (10-year increase: HR = 1.18, 95% CI: 1.08–1.28, p < 0.001), ECOG performance status (PS) 1 vs. 0 (HR = 1.30, 95% CI: 1.07–1.57, p = 0.007), PS 2 vs. 0 (HR = 2.99, 95% CI: 1.99–4.50, p < 0.001), corticosteroid use (HR = 1.42, 95% CI: 1.18–1.70, p < 0.001), multifocal disease (HR = 1.63, 95% CI: 1.25–2.13, p < 0.001), biopsy vs. resection (HR = 1.35, 95% CI: 1.04–1.72, p = 0.02), un-methylated promoter of the MGMT (O6-methylguanine-DNA methyltransferase) gene (HR = 1.71, 95% CI: 1.42–2.04, p < 0.001). The model was validated internally and had a concordance index of 0.65.ConclusionA nomogram for overall survival was established. This model can be used for risk stratification and treatment planning, as well as improve enrollment criteria for clinical trials.

Relationship between the overall survival in glioblastomas and the radiomic features of intraoperative ultrasound: a feasibility study.

Predicting the survival of patients diagnosed with glioblastoma (GBM) is essential to guide surgical strategy and subsequent adjuvant therapies. Intraoperative ultrasound (IOUS) can contain biological information that could be correlated with overall survival (OS). We propose a simple extraction method and radiomic feature analysis based on IOUS imaging to estimate OS in GBM patients. A retrospective study of surgically treated glioblastomas between March 2018 and November 2019 was performed. Patients with IOUS B-mode and strain elastography were included. After preprocessing, segmentation and extraction of radiomic features were performed with LIFEx software. An evaluation of semantic segmentation was carried out using the Dice similarity coefficient (DSC). Using univariate correlations, radiomic features associated with OS were selected. Subsequently, survival analysis was conducted using Cox univariate regression and Kaplan-Meier curves. Sixteen patients were available for analysis. The DSC revealed excellent agreement for the segmentation of the tumour region. Of the 52 radiomic features, two texture features from B-mode (conventional mean and the grey-level zone length matrix/short-zone low grey-level emphasis [GLZLM_SZLGE]) and one texture feature from strain elastography (grey-level zone length matrix/long-zone high grey-level emphasis [GLZLM_LZHGE]) were significantly associated with OS. After establishing a cut-off point of the statistically significant radiomic features, we allocated patients in high- and low-risk groups. Kaplan-Meier curves revealed significant differences in OS. IOUS-based quantitative texture analysis in glioblastomas is feasible. Radiomic tumour region characteristics in B-mode and elastography appear to be significantly associated with OS.

Association of XRCC3 rs1799794 polymorphism with survival of glioblastoma multiforme patients treated with combined radio-chemotherapy.

This study reports the results of a monocentric prospective analysis conducted with the aim of evaluating the impact of XRCC1 rs25487, XRCC3 rs861539, XRCC3 rs1799794, RAD51 rs1801320 and GSTP-1 rs1695 single nucleotide polymorphisms (SNP) on patients with high-grade glioma treated with concomitant radio-chemotherapy. From October 2010 to August 2019, a total of 75 patients aged ≥18years, with histological diagnosis of high-grade glioma, isocitrate dehydrogenase (IDH) 1/2 wild type and treated with radio-chemotherapy and sequential chemotherapy with temozolomide (TMZ) were prospectively recruited. The local ethic committee approved this study (Comitato Etico di Area Vasta Nord Ovest [CEAVNO]; protocol 3304/2011). After a median follow up of 25months (range: 7-98months), median progression-free survival (PFS) and overall survival (OS) were 11months (CI95%: 8-14months) and 18months (CI95%: 15-21months), respectively. In univariate and multivariate Cox regression analysis, a statistically significant association with PFS and OS was found with XRCC3 rs1799794 SNP. The study suggests that XRCC3 rs1799794 SNP can be associated with different PFS and OS in glioblastoma patients treated with radio-chemotherapy.

Mucosal thickening of the maxillary sinus is frequently associated with diffuse glioma patients and correlates with poor survival prognosis of GBM patients: comparative analysis to meningioma patients

Glioma patients were frequently associated with mucosal thickening of the maxillary sinus (MTMS), which reflects mucosal inflammation. We suspected that MTMS is associated with impaired mucosal immune response and correlated with dysfunction in the anti-tumor immune response in diffuse glioma patients. Therefore, the aim of this study was to determine whether the occurrence of diffuse glioma is correlated with MTMS compared to meningioma and control groups. Furthermore, we investigated whether MTMS is associated with overall survival (OS) in glioblastoma (GBM) patients. This study included 343 patients with newly diagnosed diffuse gliomas and 218 patients with meningioma treated at our institution between 2015 and 2018. As control, 201 patients with headache who did not have an intracranial organic lesion were included. Using three-axis MR images, we evaluated the incidence of MTMS in all patients. Additionally, we investigated the relationship between MTMS and OS. The incidence of MTMS in patients with diffuse glioma was significantly higher than that in the meningioma (p < .0001) and control groups (p < .0001). In 128 patients with GBM, MTMS status correlated significantly with OS (p = .0064). We revealed that the incidence of MTMS is significantly associated with patients with diffuse glioma. This suggests that MTMS is indirectly involved in the occurrence of diffuse gliomas. Furthermore, the presence of MTMS correlated significantly with shorter OS in GBM patients, indicating that MTMS is involved in suppression of anti-tumor immune response. Preoperative recognition of MTMS might be useful for improving the clinical management of GBM patients.

A novel protein encoded by circular SMO RNA is essential for Hedgehog signaling activation and glioblastoma tumorigenicity

BackgroundAberrant activation of the Hedgehog pathway drives tumorigenesis of many cancers, including glioblastoma. However, the sensitization mechanism of the G protein-coupled-like receptor smoothened (SMO), a key component of Hedgehog signaling, remains largely unknown.ResultsIn this study, we describe a novel protein SMO-193a.a. that is essential for Hedgehog signaling activation in glioblastoma. Encoded by circular SMO (circ-SMO), SMO-193a.a. is required for sonic hedgehog (Shh) induced SMO activation, via interacting with SMO, enhancing SMO cholesterol modification, and releasing SMO from the inhibition of patched transmembrane receptors. Deprivation of SMO-193a.a. in brain cancer stem cells attenuates Hedgehog signaling intensity and suppresses self-renewal, proliferation in vitro, and tumorigenicity in vivo. Moreover, circ-SMO/SMO-193a.a. is positively regulated by FUS, a direct transcriptional target of Gli1. Shh/Gli1/FUS/SMO-193a.a. form a positive feedback loop to sustain Hedgehog signaling activation in glioblastoma. Clinically, SMO-193a.a. is more specifically expressed in glioblastoma than SMO and is relevant to Gli1 expression. Higher expression of SMO-193a.a. predicts worse overall survival of glioblastoma patients, indicating its prognostic value.ConclusionsOur study reveals that SMO-193a.a., a novel protein encoded by circular SMO, is critical for Hedgehog signaling, drives glioblastoma tumorigenesis and is a novel target for glioblastoma treatment.

Prognostic relevance of CSF and peri-tumoral edema volumes in glioblastoma

BackgroundWe conducted a segmental volumetric analysis of pre-operative brain magnetic resonance images (MRIs) of glioblastoma patients to identify brain- and tumor-related features that are prognostic of survival. MethodsUsing a dataset of 210 single-institutional adult glioblastoma patients, total volumes of the following tumor- and brain-related features were quantified on pre-operative MRIs using a fully automated segmentation tool: tumor enhancement, tumor non-enhancement, tumor necrosis, peri-tumoral edema, grey matter, white matter, and cerebrospinal fluid (CSF). Their association with survival using Cox regression models, adjusting for the well-known predictors of glioblastoma survival. The findings were verified in a second dataset consisting of 96 glioblastoma patients from The Cancer Imaging Archive and The Cancer Genome Atlas (TCIA/TCGA). ResultsCSF volume and edema were independently and consistently associated with overall survival of glioblastoma patients in both datasets. Greater edema was associated with increased hazard or decreased survival [adjusted hazard ratio (aHR) with 95% confidence interval (CI): 1.34 [1.08–1.67], p = 0.008 (institutional dataset); and, 1.44 [1.08–1.93], p = 0.013 (TCIA/TCGA dataset)]. Greater CSF volume also correlated with increased hazard or decreased survival [aHR 1.27 [1.02–1.59], p = 0.035 (institutional dataset), and 1.42 [1.03–1.95], p = 0.032 (TCIA/TCGA dataset)]. ConclusionsHigher brain CSF volume and higher edema levels at diagnosis are independently associated with decreased survival in glioblastoma patients. These results highlight the importance of a broader, quantitative brain-wide radiological analyses and invite investigations to understand tumor-related causes of increased edema and possibly increased CSF volume.

RBIO-04. NEW THERAPEUTIC DELIVERY METHODS FOR TUMOR-TREATING FIELDS FOR HIGHER EFFICACY

Abstract Tumor-treating fields (TTFields) are the fourth modality of glioblastoma (GBM) treatment and in conjunction with chemotherapy can increase overall survival of GBM patients up to 60 months. However, in vitro and in animal models TTFields show 100% efficacy on a variety of tumor cell types including GBM cells when field strength is 4 V/cm, versus ~2 V/cm that is the clinical delivery target, TTFields are delivered transcranially. TTFields finite element modeling studies, supported by similar transcranial electric stimulation studies, show that the principal obstacle to delivering 4 V/cm is the electrically resistive skull. Our modeling shows the biophysics is more complicated than these findings. For instance, electrically-conductive cerebrospinal fluid regions surrounding the grey matter and in ventricles shunt electric current from anode to cathode, hindering delivery of the current required to produce 4 V/cm at the tumor/peritumor target. Thus, we consider two new delivery methods for TTFields. First, the transcranial array can be made more focal and directional, following modeling and development of electrode arrays used in spinal cord and deep brain stimulation. Our finite element modeling shows that similarly-designed TTFields electrode arrays can deliver field strength focally to a tumor target approaching 4 V/cm. Second, pre- or post-resection, TTFields can be delivered via electrode arrays surgically placed in the tumor or tumor resection cavity (intra-tumoral delivery), circumventing the resistive skull and CSF shunting effects. Such intra-tumoral arrays can deliver 4 V/cm to the tumor/peritumor region, opening up the potential to replicate clinically the 100% efficacy of TTFields in vitro and in animal models. Thus, new TTFields delivery may lead to unlimited survival of GMB patients via a side-effect free treatment modality.

Machine Learning Based on a Multiparametric and Multiregional Radiomics Signature Predicts Radiotherapeutic Response in Patients with Glioblastoma.

Methods The MRI images, genetic data, and clinical data of 152 patients with GBM were analyzed. 122 patients from the TCIA dataset (training set: n = 82; validation set: n = 40) and 30 patients from local hospitals were used as an independent test dataset. Radiomics features were extracted from multiple regions of multiparameter MRI. Kaplan-Meier survival analysis was used to verify the ability of the imaging signature to predict the response of GBM patients to radiotherapy before an operation. Multivariate Cox regression including radiomics signature and preoperative clinical risk factors was used to further improve the ability to predict the overall survival (OS) of individual GBM patients, which was presented in the form of a nomogram. Results The radiomics signature was built by eight selected features. The C-index of the radiomics signature in the TCIA and independent test cohorts was 0.703 (P < 0.001) and 0.757 (P = 0.001), respectively. Multivariate Cox regression analysis confirmed that the radiomics signature (HR: 0.290, P < 0.001), age (HR: 1.023, P = 0.01), and KPS (HR: 0.968, P < 0.001) were independent risk factors for OS in GBM patients before surgery. When the radiomics signature and preoperative clinical risk factors were combined, the radiomics nomogram further improved the performance of OS prediction in individual patients (C‐index = 0.764 and 0.758 in the TCIA and test cohorts, respectively). Conclusion This study developed a radiomics signature that can predict the response of individual GBM patients to radiotherapy and may be a new supplement for precise GBM radiotherapy.

Systemic Inflammatory Indicators as Prognosticators in Glioblastoma Patients: A Comprehensive Meta-Analysis.

Background: Inflammation plays an important role in tumorigenesis. Previous studies have reported the prognostic value of several peripheral inflammatory markers in glioma patients, including the neutrophil-to-lymphocyte ratio (NLR). However, it still remains unclear whether inflammatory markers can independently predict the prognosis of glioblastoma (GBM) patients. The present study aims to explore the prognostic value of systemic inflammatory markers, including neutrophils, lymphocytes, platelets, the NLR, and the platelet-to-lymphocyte ratio (PLR), in patients with GBM.Methods: A comprehensive systemic search and review was performed using the PubMed, EMBASE, and Cochrane Library databases to identify all the relevant literature (published before June 30, 2020) that evaluated the association between any of these inflammatory markers and survival in GBM.Results: There were 2 (634 patients), 3 (723 patients), 2 (237 patients), 8 (1,225 patients), and 3 (505 patients) studies examining the correlation of survival with neutrophils, lymphocytes, platelets, the NLR, and the PLR, respectively. An elevated NLR and elevated neutrophil and platelet counts were associated with worse overall survival (OS) in GBM patients (NLR: hazard ratio [HR] = 1.63, 95% confidence interval [CI]: 1.23–2.15, p = 0.0007; neutrophil count: HR = 1.46, 95% CI:1.16–1.83, p = 0.001; platelet count: HR = 1.58, 95% CI: 1.42–1.77, p < 0.00001). However, there was no significant association between the PLR or the absolute lymphocyte count and OS in GBM patients.Conclusion: The NLR and the absolute neutrophil and platelet counts may be valuable and convenient peripheral inflammatory markers to evaluate the prognosis of GBM patients. Further prospective studies are needed to verify its reliability.

E2F7\u2212EZH2 axis regulates PTEN/AKT/mTOR signalling and glioblastoma progression

BackgroundE2F transcription factors are considered to be important drivers of tumour growth. E2F7 is an atypical E2F factor, and its role in glioblastoma remains undefined.MethodsE2F7 expression was examined in patients by IHC and qRT-PCR. The overall survival probability was determined by statistical analyses. MTT assay, colony formation, cell-cycle assay, cell metastasis and the in vivo model were employed to determine the functional role of E2F7 in glioblastoma. Chromatin immunoprecipitation, luciferase assay and western blot were used to explore the underlying mechanisms.ResultsE2F7 was found to be up-regulated in glioblastoma patients, and high E2F7 expression was associated with poor overall survival in glioblastoma patients. Functional studies showed that E2F7 promoted cell proliferation, cell-cycle progression, cell metastasis and tumorigenicity abilities in vitro and in vivo. E2F7 promoted the transcription of EZH2 by binding to its promoter and increased H3K27me3 level. EZH2 recruited H3K27me3 to the promoter of PTEN and inhibited PTEN expression, and then activated the AKT/mTOR signalling pathway. In addition, restored expression of EZH2 recovered the abilities of cell proliferation and metastasis in E2F7-silencing cells.ConclusionCollectively, our findings indicate that E2F7 promotes cell proliferation, cell metastasis and tumorigenesis via EZH2-mediated PTEN/AKT/mTOR pathway in glioblastoma.