Radiotherapy For Glioblastoma Multiforme Research Articles

Feasibility Study on the nIORT® Adjuvant Treatment of Glioblastoma Multiforme through the Irradiation Field of Fast Neutrons Produced by a Compact Generator

The glioblastoma multiforme (GBM) is the most malignant glial brain tumour with average survival time of 6÷18 months. Emerging evidence suggests that GBM cells appears to reprogram their tumour microenvironment, which is a highly heterogeneous and complex system, so that an efficient GBM radiotherapy (RT) should cover both the cells of the GBM and those of its microenvironment. Relying on a 5-year collaborative research study on the intra-operative radiotherapy (IORT) with fast neutrons - the so-called neutron-IORT (nIORT®) technique - the authors think that this objective could be achieved by using an ionizing radiation field of fast neutrons that behave in the biological tissues as a “foam field” hitting both the GBM cancer cells and the neighbouring microenvironment. The nIORT® research activities - conducted by TheranostiCentre Srl, Berkion Technology LLC and ENEA - led to the fabrication of the first prototype of a compact neutron generator (CNG) that, through the deuterium-deuterium fusion reaction, produces neutrons of 2.45 MeV energy having: i) high linear energy transfer; ii) very high relative biological effectiveness (RBE), about 16 times higher than X-rays (and electrons) used in standard RT and IORT treatments; iii) reduced oxygen enhancement ratio, and hence resulting be very effective in cancer cells necrosis and apoptosis. The CNG is self-shielded, limited in size and weight (~120 kg) and manageable remotely by a robotic arm. A new prototype equipped by a cylindrical applicator to be inserted in the surgical cavities is currently under construction, with some technical advancements making possible its installation in an operating room dedicated to nIORT® treatments without posing any safety and environmental concern. In this article the nIORT® potentiality was investigated in the view of the GBM treatment, but the study is however generalisable for the neutron irradiation of other brain cancer pathologies. Accurate Monte Carlo simulations, modelling the CNG equipped with a couple of cylindrical applicators of 4 and 6 cm in diameter inserted in the brain surgical cavity after craniotomy, demonstrated that the nIORT® device operated at 100 kV-10 mA DC supplies a neutron flux ~108 cm-2 s-1 and can deliver equivalent dose rates ~5 Gy (RBE)/min in the centre of the tumour bed. Thus, it could administer the clinical endpoints foreseen by the standard IORT protocols (~10-20 Gy (RBE)) in treatment times of few minutes, by providing a sort of “switching on and off neutron brachytherapy tool” without using needles of radioisotopes (e.g., 252Cf). The near isotropic neutron emission allows to irradiate the tumour bed margins, normally filled by potential quiescent cancer cells, with lower (but still significant) dose levels. This should improve the local control of the tumour through the reduction of local recurrences and metastasis in the tumour microenvironment, and at the same time to avoid adverse effects of the administered neutron radiation field on the surrounding brain central nervous system. Also, the rapid decrease in tissue depth of the dose gradient (within few centimetres) should avoid any adverse effect on normal brain tissues and the neighbouring organs.

Anticancer effects of ABTL0812, a clinical stage drug inducer of autophagy-mediated cancer cell death, in glioblastoma models.

Glioblastoma multiforme (GBM) is the most malignant adult brain tumor. Current standard of care treatments have very limited efficacy, being the patients´ overall survival 14 months and the 2-year survival rate less than 10%. Therefore, the treatment of GBM is an urgent unmet clinical need. The aim of this study was to investigate in vitro and in vivo the potential of ABTL0812, an oral anticancer compound currently in phase II clinical stage, as a novel therapy for GBM. We showed that ABTL0812 inhibits cell proliferation in a wide panel of GBM cell lines and patient-derived glioblastoma stem cells (GSCs) with half maximal inhibitory concentrations (IC50s) ranging from 15.2 µM to 46.9 µM. Additionally, ABTL0812 decreased GSCs neurosphere formation. GBM cells aggressiveness is associated with a trans-differentiation process towards a less differentiated phenotype known as proneural to mesenchymal transition (PMT). ABTL0812 was shown to revert PMT and induce cell differentiation to a less malignant phenotype in GBM cell lines and GSCs, and consequently reduced cell invasion. As previously shown in other cancer types, we demonstrated that the molecular mechanism of action of ABTL0812 in glioblastoma involves the inhibition of Akt/mTORC1 axis by overexpression of TRIB3, and the activation of endoplasmic reticulum (ER) stress/unfolded protein response (UPR). Both actions converge to induce autophagy-mediated cell death. ABTL0812 anticancer efficacy was studied in vivo using subcutaneous and orthotopic intra-brain xenograft tumor models. We demonstrated that ABTL0812 impairs tumor growth and increases disease-free survival and overall survival of mice. Furthermore, the histological analysis of tumors indicated that ABTL0812 decreases angiogenesis. Finally, we investigated the combination of ABTL0812 with the standard of care treatments for GBM radiotherapy and temozolomide in an orthotopic model, detecting that ABTL0812 potentiates the efficacy of both treatments and that the strongest effect is obtained with the triple combination of ABTL0812+radiotherapy+temozolomide. Overall, the present study demonstrated the anticancer efficacy of ABTL0812 as single agent and in combination with the GBM standard of care treatments in models of glioblastoma and supports the clinical investigation of ABTL0812 as a potential novel therapy for this aggressive brain tumor type.

Determining the optimum tumor control probability model in radiotherapy of glioblastoma multiforme using magnetic resonance imaging data pre- and post- radiation therapy

Background:Glioblastoma multiforme (GBM) is the most common and malignant brain tumor. The current standard of care is surgery followed by radiation therapy (RT). Radiotherapy treatment plan evaluation relies on radiobiological models for accurate estimation of tumor control probability (TCP). This study aimed to assess the impact of obtained magnetic resonance imaging (MRI) data before and 12 weeks after RT to achieve the optimum TCP model to improve dose prescriptions in radiation therapy of GBM.Materials and Methods::In this quasi-experimental study, MR images and its relevant data from 30 patients consisting of 9 females and 21 males (mean age of 46.3 ± 15.8 years) diagnosed with GBM, whose referred for radiotherapy were selected. The data of age, gender, tumor size, volume, and signal intensity using analysis of MRI data pre- and postradiotherapy were used for calculating TCP. TCP was calculated from three common radiobiological models including Poisson, linear quadratic, and equivalent uniform dose. The impact of some radiobiological parameters on final TCP in all patients planned with three-dimensional conformal radiation therapy was obtained.Results:A statistically significant difference was found among TCP in Poisson model compared to the other two models (P < 0.001). Changes in tumor volume and size after treatment were statistically significant (P < 0.05). Different combinations of radiobiological parameters (α/β and SF2 in all models) observed were meaningful (P < 0.05).Conclusion:The results showed that among TCP radiobiological models, the optimum is the Poisson. The results also identified the importance of TCP radiobiological models in order to improve radiotherapy dose prescriptions.

Cranberry Extract Is a Potent Radiosensitizer for Glioblastoma.

Glioblastoma, also known as glioblastoma multiforme (GBM), is the most aggressive type of primary brain tumor and a cornerstone in its treatment is radiotherapy (RT). However, RT for GBM is largely ineffective at clinically safe doses, thus, the study of radiosensitizers is of great significance. With accumulating evidence for the anticancer effect of compounds from cranberry, this study was designed to investigate if cranberry extract (CE) sensitizes GBM to RT in the widely used human glioblastoma cell line U87. We utilized clonogenic survival assays, cell proliferation assays, and caspase-3 activity kits. Potential proliferative and apoptotic molecular mechanisms were evaluated by reverse transcription-polymerase chain reaction. We found that CE alone had little effect on the survival of U87 cells. However, RT supplemented by CE significantly inhibited proliferation and promoted apoptosis of U87 cells when compared with RT alone. The proliferation-inhibitory effect of RT/CE might be attributable to the up-regulation of p21, along with the down-regulation of cyclin B and cyclin-dependent kinase 4. This pro-apoptotic effect might additionally be attributable to the down-regulation of survivin. These results warrant further study of the potential radiosensitizing capacity of CE in glioblastoma and other cancer types.

A New Survival Score for Patients Receiving Radiotherapy for Newly Diagnosed Glioblastoma Multiforme.

In a previous study investigating radiotherapy for newly diagnosed glioblastoma multiforme (GBM), significant or almost significant associations with survival were found for performance status, upfront resection, O6-methylguanine-DNA methyl-transferase (MGMT) promoter methylation and unifocal GBM. This study aimed to create a survival score based on these factors. Most of the 81 patients included received resection of GBM followed by radiochemotherapy (59.4 Gy/33 or 60 Gy/30 fractions). The previously identified predictors of survival were re-evaluated. Factors significantly associated with survival were used for the score. All factors were significantly associated with survival. For each factor, 0 points (less favorable survival) or 1 point (more favorable survival) were assigned and added for each patient. Three groups were designed, 0-1 (n=10), 2 (n=21) and 3-4 points (n=50); 12-month survival rates were 0%, 38% and 78% (p<0.001). A new survival score was created for patients requiring radiotherapy for GBM that can improve treatment personalization.

Dosimetric and clinical results with volumetric modulated radiotherapy for glioblastoma multiforme: Our experience

Dosimetric and clinical results with volumetric modulated radiotherapy for glioblastoma multiforme: Our experience

Angiopep-2 Modified Cationic Lipid-Poly-Lactic-Co-Glycolic Acid Delivery Temozolomide and DNA Repair Inhibitor Dbait to Achieve Synergetic Chemo-Radiotherapy Against Glioma.

The therapeutic treatment of glioblastoma multiforme (GBM) remains a major challenge. Synergistic chemotherapy and radiotherapy (RT) have been considered the standard clinical therapy for malignant glioma, but there are some outstanding problems. First, gliomas are deemed exceedingly radio-resistant tumors, owing to efficient DNA double-strand break repair. In addition, the first-line chemotherapeutic agent (temozolomide, TMZ) for glioma shows extensive side effects and low accumulation in brain tumors. Therefore, we designed and constructed an Angiopep-2 modified cationic lipid-Poly-lactic-co-glycolic acid (PLGA), Angiopep-2 (A2)/DSPE-PEG2000/DOTAP/PLGA (APDP), to transport TMZ and a DNA repair inhibitor (Dbait) into glioblastoma cells, achieving concomitant chemo-radiotherapy treatment of glioma. At the cellular level, the APDP+TMZ/Dbait can be well endocytosed and enhance accumulation of the agent in brain tumors. Furthermore, the nanoparticle combined with Dbait improves the efficiency of radiotherapy in GBM. Our experimental data demonstrate that APDP+TMZ/Dbait has great potential as a multipurpose nanomedicine for the synergistic chemo-radiotherapy and radio-sensitization of malignant glioma in precise medical applications.

Outcomes in palliative radiotherapy for Glioblastoma Multiforme: A single centre experience

Outcomes in palliative radiotherapy for Glioblastoma Multiforme: A single centre experience

Changing trends in radiotherapy for glioblastoma multiforme and effects on normal tissue doses

Changing trends in radiotherapy for glioblastoma multiforme and effects on normal tissue doses

Changing Trends in Radiotherapy for Glioblastoma Multiforme and Effects on Normal Tissue Doses

Changing Trends in Radiotherapy for Glioblastoma Multiforme and Effects on Normal Tissue Doses

Changing Trends in Radiotherapy for Glioblastoma Multiforme and Effects on Normal Tissue Doses

Changing Trends in Radiotherapy for Glioblastoma Multiforme and Effects on Normal Tissue Doses

Orally Bioavailable and Blood-Brain Barrier-Penetrating ATM Inhibitor (AZ32) Radiosensitizes Intracranial Gliomas in Mice.

Inhibition of ataxia-telangiectasia mutated (ATM) during radiotherapy of glioblastoma multiforme (GBM) may improve tumor control by short-circuiting the response to radiation-induced DNA damage. A major impediment for clinical implementation is that current inhibitors have limited central nervous system (CNS) bioavailability; thus, the goal was to identify ATM inhibitors (ATMi) with improved CNS penetration. Drug screens and refinement of lead compounds identified AZ31 and AZ32. The compounds were then tested in vivo for efficacy and impact on tumor and healthy brain. Both AZ31 and AZ32 blocked the DNA damage response and radiosensitized GBM cells in vitro AZ32, with enhanced blood-brain barrier (BBB) penetration, was highly efficient in vivo as radiosensitizer in syngeneic and human, orthotopic mouse glioma model compared with AZ31. Furthermore, human glioma cell lines expressing mutant p53 or having checkpoint-defective mutations were particularly sensitive to ATMi radiosensitization. The mechanism for this p53 effect involves a propensity to undergo mitotic catastrophe relative to cells with wild-type p53. In vivo, apoptosis was >6-fold higher in tumor relative to healthy brain after exposure to AZ32 and low-dose radiation. AZ32 is the first ATMi with oral bioavailability shown to radiosensitize glioma and improve survival in orthotopic mouse models. These findings support the development of a clinical-grade, BBB-penetrating ATMi for the treatment of GBM. Importantly, because many GBMs have defective p53 signaling, the use of an ATMi concurrent with standard radiotherapy is expected to be cancer-specific, increase the therapeutic ratio, and maintain full therapeutic effect at lower radiation doses. Mol Cancer Ther; 17(8); 1637-47. ©2018 AACR.

Relationship between Glioblastoma Dose Volume Parameters Measured by Dual Time Point Fluoroethylthyrosine-PET and Clinical Outcomes.

Glioblastoma multiforme (GBM) is highly invasive. Despite irradiation with wide margins, GBM usually recurs in-field. Recent in vitro data have suggested that progression might be promoted by sublethal irradiation. Fluoroethylthyrosine-PET (FET-PET) can be used to detect glioblastoma invasion not apparent on MRI. We therefore performed a retrospective analysis of a prospective clinical study to examine whether glioblastoma outcomes depend on dose volume parameters measured by MRI and FET-PET. Twenty-three patients were prospectively recruited to a study examining the role of dual time point FET-PET in the treatment planning of GBM radiotherapy. The dose delivered to the site of recurrence was subdivided into suboptimal-dose (SOD) and high-dose (HD) areas. Types of progression were defined for correlation with dosimetric parameters including V100% of gross tumor volume (GTV)PET, GTVPETMRI, and GTVMRI. The HD area did not cover the entire GTVPETMRI in any case. Recurrences were significantly more frequent in the SubD area (chi-squared test, p = 0.004). There was no relationship between increasing dose volume and progression. The V100% for GTVPET and progression-free survival (PFS) was positively correlated (Spearman’s rho 0.417; p = 0.038). Progression is more common in areas with suboptimal dosing. Dose heterogeneity within GTVPET may be responsible for shorter PFS.

Migration pattern, actin cytoskeleton organization and response to PI3K-, mTOR-, and Hsp90-inhibition of glioblastoma cells with different invasive capacities.

High invasiveness and resistance to chemo- and radiotherapy of glioblastoma multiforme (GBM) make it the most lethal brain tumor. Therefore, new treatment strategies for preventing migration and invasion of GBM cells are needed. Using two different migration assays, Western blotting, conventional and super-resolution (dSTORM) fluorescence microscopy we examine the effects of the dual PI3K/mTOR-inhibitor PI-103 alone and in combination with the Hsp90 inhibitor NVP-AUY922 and/or irradiation on the migration, expression of marker proteins, focal adhesions and F-actin cytoskeleton in two GBM cell lines (DK-MG and SNB19) markedly differing in their invasive capacity. Both lines were found to be strikingly different in morphology and migration behavior. The less invasive DK-MG cells maintained a polarized morphology and migrated in a directionally persistent manner, whereas the highly invasive SNB19 cells showed a multipolar morphology and migrated randomly. Interestingly, a single dose of 2 Gy accelerated wound closure in both cell lines without affecting their migration measured by single-cell tracking. PI-103 inhibited migration of DK-MG (p53 wt, PTEN wt) but not of SNB19 (p53 mut, PTEN mut) cells probably due to aberrant reactivation of the PI3K pathway in SNB19 cells treated with PI-103. In contrast, NVP-AUY922 exerted strong anti-migratory effects in both cell lines. Inhibition of cell migration was associated with massive morphological changes and reorganization of the actin cytoskeleton. Our results showed a cell line-specific response to PI3K/mTOR inhibition in terms of GBM cell motility. We conclude that anti-migratory agents warrant further preclinical investigation as potential therapeutics for treatment of GBM.

PO-0646: Temozolomide during radiotherapy of glioblastoma multiforme: daily administration improves survival

PO-0646: Temozolomide during radiotherapy of glioblastoma multiforme: daily administration improves survival

Changes in functional MRI signals after 3D based radiotherapy of glioblastoma multiforme

The purpose of our study was to examine the potential effects of conventional 3D based radiotherapy on functional MRI activation areas following the treatment of glioblastoma multiforme. Seventeen patients with a histologically proven glioblastoma multiforme were enrolled in this study. A functional MRI examination was performed alongside the planning CT and conventional MRI prior to the delivery of conventional 3D based radiotherapy. All patients received 3D based postoperative radiotherapy (up to 60 Gy) combined with temozolomide. Follow-up fMRI examinations were performed after completion of the treatment in the 6th week and in 3 months time. Changes of the task related activation areas were registered and analyzed. The difference in changes of high dose and low dose areas of the brain were also registered and analyzed. The comparison of the pretreatment and 6th week control fMRI activation areas revealed significant changes in motor activation and listening tasks in the case of brain areas which received a high dose (over 40 Gy). Based on the population level statistical parametric images (motor activation tasks) acquired at the 6th week control examination, a significant increase of signal was registered in the precuneus region and in the globus pallidus region. When comparing the 6th week and 3rd month activation signals, no significant changes were registered. Our results demonstrate the influence of radiotherapy on functional MRI signals within the human brain. Based on our findings, functional activation transfers from high dose areas to low dose areas. In case of the motor activation tasks, activations of the secondary motor area were observed following radiotherapy.

A potential role of PI3K inhibition in radiotherapy of glioblastoma multiforme

s of the 51st Workshop for Pediatric Research 51st Workshop for Pediatric Research Gottingen, Germany 16-17 April 2015 This supplement has not been sponsored. Meeting abstracts Meeting abstract Glioblastoma multiforme (GBM) is the most common tumour of the central nervous system in adults and while it is not frequently considered a paediatric malignancies, it is in terms of 'years of life lost' among the most devastating cancers in children and adolescences. The current standard of care consists of tumour resection followed by radiotherapy and a course of Temozolomide. However, despite intense efforts, the mean patient survival of 12-15 months has not significantly improved over the last two decades. While the PI3K/Akt/mTOR 'survival' pathway is aberrantly activated in almost 90% of GBMs and despite promising pre-clinical results, pharmacological inhibitors of this signalling cascade have so far not fulfilled their clinical potential. In this study we use different cell populations cultured directly from primary-derived patient material (so-called cancer stem cells, as well as freshly differentiated cells) to investigate the combination of a pharmacological inhibitor of PI3K, GDC-0941, and clinically relevant doses of radiation. While the induction of apoptosis and the retardation of proliferation is enhanced by the combination treatment in a statistically significant manner, the overall effect is lacklustre. However, importantly, the enhanced motility induced in differentiated GBM cells after radiation can be blocked by PI3K inhibition, while neither radiation, nor GDC-0941 had an effect on the motility of the highly motile cancer stem cells. These data suggest that the role of Pi3K-mediated signalling and the primary mode of movement difference in genetically identical, but epigenetically different GBM cells. We therefore propose that the key role of PI3K inhibitors in combination therapy might lie not in their ability to enhance apoptosis induction, but in preventing tumour invasion in a subpopulation of tumour cells.

Abstract B71: Inhibiting the CSF-1 receptor on tumor-infiltrating monocytes may enhance the efficacy of radiotherapy for glioblastoma multiforme

Abstract Glioblastoma (GBM) is the most common brain tumor and is one of the most deadly forms of cancer with median survival only 15 months after diagnosis. Ionizing radiation (IR) is the most effective treatment for GBM, but the prognosis remains poor because the tumors invariably recur. We have previously shown that bone marrow-derived monocytes promote GBM recurrence after radiotherapy by homing to the irradiation site and stimulating the growth of new tumor blood vessels in a process referred to as vasculogenesis. We found that this infiltration of monocytes can be prevented and tumor recurrences delayed by inhibition of the SDF-1/CXCR4 chemokine axis. Here we present data that suggest Colony Stimulating Factor-1 (CSF-1) may also play an important role in this phenomenon. CSF-1 is a potent chemokine secreted by several different types of solid tumors and is also the main growth factor regulating the differentiation of monocytes into macrophages. RT-PCR analysis of U251 GBM tumors growing in mice revealed a more than 12.5-fold increase in expression of CSF-1 after treatment with a single dose of 12 Gy IR. Increased CSF-1 expression in these tumors correlated with increased recruitment of CD11b+ monocytes. Immunohistochemistry (IHC) and fluorescence activated cell sorting (FACS) showed that the number of CD11b+ monocytes in GBM tumors had approximately doubled within 2 weeks of IR treatment. F4/80 staining indicated that the majority of the CD11b+ cells were mature macrophages. Treatment with 40 mg/kg/day PLX3397, which inhibits the receptor for CSF-1 (CSF-1R), effectively blocked the recruitment of monocytes/macrophages to the irradiated tumors and inhibited tumor blood vessel formation. Moreover, bioluminescence imaging (BLI) of intracranial U251-luciferase tumors growing in mice showed that combined treatment with IR and PLX3397 was more effective at inhibiting tumor growth than IR alone. Eighty percent of mice treated with IR and PLX3397 were alive at 50 days post-irradiation whereas there were no survivors among groups receiving monotherapy. These results suggest inhibition of CSF-1R may prevent post-irradiation recurrence of GBM by blocking the recruitment of tumor-infiltrating monocytes/macrophages. Citation Format: Jason H. Stafford, Sophia Chernikova, Brian L. West, J. Martin Brown. Inhibiting the CSF-1 receptor on tumor-infiltrating monocytes may enhance the efficacy of radiotherapy for glioblastoma multiforme. [abstract]. In: Abstracts: AACR Special Conference on Cellular Heterogeneity in the Tumor Microenvironment; 2014 Feb 26-Mar 1; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2015;75(1 Suppl):Abstract nr B71. doi:10.1158/1538-7445.CHTME14-B71

Feasibility of extreme dose escalation for glioblastoma multiforme using 4π radiotherapy.

BackgroundGlioblastoma multiforme (GBM) frequently recurs at the same location after radiotherapy. Further dose escalation using conventional methods is limited by normal tissue tolerance. 4π non-coplanar radiotherapy has recently emerged as a new potential method to deliver highly conformal radiation dose using the C-arm linacs. We aim to study the feasibility of very substantial GBM dose escalation while maintaining normal tissue tolerance using 4π.Methods11 GBM patients previously treated with volumetric modulated arc therapy (VMAT/RapidArc) on the NovalisTx™ platform to a prescription dose of either 59.4 Gy or 60 Gy were included. All patients were replanned with 30 non-coplanar beams using a 4π radiotherapy platform, which inverse optimizes both beam angles and fluence maps. Four different prescriptions were used including original prescription dose and PTV (4πPTVPD), 100 Gy to the PTV and GTV (4πPTV100Gy), 100 Gy to the GTV only while maintaining prescription dose to the rest of the PTV (4πGTV100Gy), and a 5 mm margin expansion plan (4πPTVPD+5mm). OARs included in the study are the normal brain (brain – PTV), brainstem, chiasm, spinal cord, eyes, lenses, optical nerves, and cochleae.ResultsThe 4π plans resulted in superior dose gradient indices, as indicated by >20% reduction in the R50, compared to the clinical plans. Among all of the 4π cases, when compared to the clinical plans, the maximum and mean doses were significantly reduced (p < 0.05) by a range of 47.01-98.82% and 51.87-99.47%, respectively, or unchanged (p > 0.05) for all of the non-brain OARs. Both the 4πPTVPD and 4π GTV100GYplans reduced the mean normal brain mean doses.Conclusions4π non-coplanar radiotherapy substantially increases the dose gradient outside of the PTV and better spares critical organs. Dose escalation to 100 Gy to the GTV or additional margin expansion while meeting clinical critical organ dose constraints is feasible. 100 Gy to the PTV result in higher normal brain doses but may be tolerated when delivered in proportionally increased treatment fractions. Therefore, 4π non-coplanar radiotherapy on C-arm gantry may provide an accessible tool to improve the outcome of GBM radiotherapy through extreme dose escalation.

Effects of single or combined treatments with radiation and chemotherapy on survival and danger signals expression in glioblastoma cell lines.

The success of chemo- and radiotherapy in glioblastoma multiforme, the most common and lethal primary brain tumour, could rely on the induction of immunogenic tumour cell death and on the induction of anticancer immune response. In this study we investigated cell survival to single treatments or combination of X-rays and temozolomide in glioblastoma cell lines (T98G and U251MG) and we attempted to identify danger signals (HMGB1 and HSP70) released by dying cells in the microenvironment that could activate antitumour immunity contributing to the therapeutic efficacy of conventional treatments. Our data suggest that HSP70 translocates from cytoplasm to extracellular environment after an increase in radiation dose and HMGB1 translocates from the nucleus to the cytoplasm and subsequently is released into the extracellular space, confirming a role of these proteins as signals released after radiation-induced damage in glioblastoma cells. We also could state that TMZ had limited effectiveness in activating HMGB1 and HSP70 signalling and, instead, an adjuvant effect was observed in some combined treatments, depending on schedule, cell line, and timing. A big challenge in tumour therapy is, therefore, to identify the most beneficial combination and chronology of multiple treatment options to contribute to the improvement of the therapeutic outcome.