Bevacizumab Combined with Intensity-Modulated Radiation Therapy on Cognitive and Coagulation Function in Postoperative Glioma Patients.

To examine the influences of bevacizumab combined with intensity-modulated radiation therapy (IMRT) on postoperative brain glioma, particularly its impact on coagulation function and cognitive function, the complete clinical data of 156 patients undergoing glioma surgery in the neurosurgery department of our hospital between March 2015 and October 2018 were retrospectively analyzed. All patients underwent glioma surgery and were then assigned to the observation group (Obs group, n = 79, received bevacizumab combined with IMRT) or the control group (Con group, n = 77, received IMRT without bevacizumab) for analysis during postoperative treatment. The patients' short-term efficacy was evaluated, and their serum markers and coagulation function were compared, as well as the cognitive function, the occurrence of adverse reactions during treatment, the Karnofsky performance status (KPS) score, and quality of life after treatment. Patients' survival was followed up within 2 years after surgery. The Obs group showed a notably higher clinical remission rate and clinical control rate (DCR) than the Con group after treatment. The Obs group showed notably lower levels of interleukin-2 (IL-2), vascular endothelial growth factor (VEGF), IL-6, and epidermal growth factor (EGF), experienced notably shorter prothrombin time (PT) and activated partial thromboplastin time (APTT), and showed higher fibrinogen (FIB) and D-dimer (D-D) levels than Con group. The Obs group showed notably better cognitive function, KPS score, and quality of life than the Con group, but no notable difference was observed between them in the incidence of adverse reactions (P > 0.0500). The survival rates in the Obs group were higher than in the Con group. For patients with glioma, postoperative bevacizumab combined with IMRT delivers substantially higher clinical efficacy by lowering serum marker levels and improving cognitive function without significantly affecting coagulation function.

Both p53 codon 72 Arg/Arg and pro/Arg genotypes in glioblastoma multiforme are associated with a better prognosis in bevacizumab treatment.

BACKGROUND: It has previously been shown that bevacizumab, when added to chemotherapy, improved overall survival in several cancers. In glioblastoma multiforme (GBM), bevacizumab increased progression-free survival and it is widely used for tumor recurrence, though it has failed to improve overall survival (OS) in controlled trials. However, an effective biomarker for predicting the prognosis of bevacizumab treatment has yet to be identified. This study, therefore, aimed to retrospectively analyze the polymorphisms of p53 codon 72 and the clinical characteristics of GBM specimens from Taiwanese patients. METHODS: The polymorphisms of p53 codon 72 in 99 patients with GBM treated at Taichung Veterans General Hospital in Taiwan from 2007 to 2017 were analyzed using direct DNA sequencing and PCR-RFLP analysis. RESULTS: We found that among these GBM patients, the distribution of codon 72 polymorphisms was 28.3% for proline homozygotes (Pro/Pro), 38.4% for arginine homozygotes (Arg/Arg), and 33.3% for proline/arginine heterozygotes (Pro/Arg). Although the polymorphisms of p53 codon 72 were not directly associated with the overall survival of GBM, both the Arg/Arg and Arg/Pro genotypes were associated with significant benefits in terms of overall survival in patients treated with CCRT plus bevacizumab compared to patients treated with CCRT alone. CONCLUSIONS: This pilot study suggests that both the Arg/Arg and Arg/Pro genotypes of p53 codon 72 polymorphism may have value as independent prognostic or predictive parameters for bevacizumab treatment response and failure. Relatedly, the results of the study further demonstrate the utility of stratifying GBM patients according to bevacizumab sensitivity.

Effectiveness of Surgical Treatments for Basal Ganglia Hemorrhage and Imaging Factors Affecting Hematoma Evacuation Rate by Neuroendoscopic Surgery.

BACKGROUND: Basal ganglia hemorrhage (BGH) is a devastating neurologic disease with high morbidity and mortality, and its management is still controversial. We evaluated the effectiveness of surgical treatments for BGH and investigated computed tomography (CT) imaging features affecting the hematoma evacuation rate (ER) in patients treated with neuroendoscopic surgery. MATERIALS AND METHODS: A total of 104 BGH patients who underwent craniotomy, burr-hole drainage, or neuroendoscopic surgery were analyzed retrospectively. Clinical characteristics, imaging features, and postoperative complications were compared. Univariate and multivariate regression analyses were applied to identify imaging factors associated with ER. RESULTS: A significant difference in ER was observed: 78.4% in patients treated with neuroendoscopic surgery, 33.6% in patients treated with burr-hole drainage, and 82.5% in patients treated with craniotomy (p < 0.001). Similar results were observed for operative time (p < 0.001). Five cases (12.5%) of rebleeding were found in patients treated with burr-hole drainage (p = 0.020). No significant difference was found for pneumonia, intracranial infection, gastrointestinal bleeding, hospital mortality, hospital stay, expenses, 3-day Glasgow Coma Scale (GCS) scores after surgery, or GCS at discharge. The CT imaging feature, the island sign (p = 0.004), was observed as an independent factor correlated with lower ER for neuroendoscopic surgery. CONCLUSIONS: The benefits and drawbacks of surgical treatments confirmed they have their own indications, and neuroendoscopic surgery may be relatively beneficial for BGH treatment. The island sign was an independent factor affecting ER for neuroendoscopic surgery. Therefore, comprehensive assessment of clinical data, especially the island sign, should be performed preoperatively in BGH patients.

High IFIT1 expression predicts improved clinical outcome, and IFIT1 along with MGMT more accurately predicts prognosis in newly diagnosed glioblastoma.

Interferon-induced protein with tetratricopeptide repeat 1 (IFIT1) plays a key role in growth suppression and apoptosis promotion in cancer cells. Interferon was reported to induce the expression of IFIT1 and inhibit the expression of O-6-methylguanine-DNA methyltransferase (MGMT).This study aimed to investigate the expression of IFIT1, the correlation between IFIT1 and MGMT, and their impact on the clinical outcome in newly diagnosed glioblastoma. The expression of IFIT1 and MGMT and their correlation were investigated in the tumor tissues from 70 patients with newly diagnosed glioblastoma. The effects on progression-free survival and overall survival were evaluated. Of 70 cases, 57 (81.4%) tissue samples showed high expression of IFIT1 by immunostaining. The χ(2) test indicated that the expression of IFIT1 and MGMT was negatively correlated (r = -0.288, P = .016). Univariate and multivariate analyses confirmed high IFIT1 expression as a favorable prognostic indicator for progression-free survival (P = .005 and .017) and overall survival (P = .001 and .001), respectively. Patients with 2 favorable factors (high IFIT1 and low MGMT) had an improved prognosis as compared with others. The results demonstrated significantly increased expression of IFIT1 in newly diagnosed glioblastoma tissue. The negative correlation between IFIT1 and MGMT expression may be triggered by interferon. High IFIT1 can be a predictive biomarker of favorable clinical outcome, and IFIT1 along with MGMT more accurately predicts prognosis in newly diagnosed glioblastoma.

The vascular delta-like ligand-4 (DLL4)-Notch4 signaling correlates with angiogenesis in primary glioblastoma: an immunohistochemical study.

Delta-like ligand-4 (DLL4)-Notch signaling is known to play a pivotal role in the regulation of tumor angiogenesis. We had previously found that DLL4 was overexpressed, while Notch1 receptor, which binds to DLL4 during angiogenesis, was absent in the majority of human primary glioblastomas. Thus, DLL4-Notch signaling pathway in the regulation of tumor angiogenesis in primary glioblastoma remains unknown. Tumor tissues from 70 patients with primary glioblastoma were analyzed by immunohistochemistry for expression of components of DLL4-Notch signaling, vascular endothelial growth factor (VEGF), and microvessel density (MVD). Immunohistochemistry results showed that the positive staining of DLL4 and Notch4 was primarily distributed in tumor vascular endothelial cells but rarely detected in tumor cells. However, VEGF, hairy/enhancer of split-1 (HES1; a target gene of Notch signaling), and Notch1-3 expression was seen in both tumor vascular endothelial cells and tumor cells. Univariate analysis showed that the expression levels of VEGF and DLL4, HES1, and Notch4 in tumor endothelial cells were significantly associated with MVD in primary glioblastoma (P < 0.001). Binary logistic regression analysis showed that high expression levels of DLL4, HES1, and Notch4 in tumor endothelial cells were associated with a decrease of MVD in primary glioblastoma, while MVD increased with elevated VEGF expression in contrast. In addition, DLL4, Notch4, and HES1 expression were positively correlated in tumor vascular endothelial cells (P < 0.05). We conclude that the vascular DLL4-Notch4 signaling and VEGF signaling complementing each other plays an important role in the progression of tumor angiogenesis in primary glioblastoma. Graphical abstract A, positive staining of DLL4 in human kidney; B, positive staining of VEGF in human breast cancer; C, positive staining of CD34 in human lung cancer; D, positive staining of HES1 in human breast cancer; E-H, positive staining of Notch1-4: E-F in human lung cancer; G-H in human kidney.

Peritumoral edema shown by MRI predicts poor clinical outcome in glioblastoma.

BACKGROUND: Magnetic resonance imaging (MRI) plays an irreplaceable role in the preoperative diagnosis of glioma, and its imaging features are the base of making treatment decisions in patients with glioma, but it is still controversial whether peritumoral edema shown by MRI from preoperative routine scans are associated with patient survival. The aim of this study was to assess the prognostic value of preoperative MRI features in patients with glioblastoma. METHODS: A retrospective review of 87 patients with newly diagnosed supratentorial glioblastoma was performed using medical records and MRI data from routine scans. The Kaplan-Meier method and COX proportional hazard model were applied to evaluate the prognostic impact on overall survival of pretreatment MRI features (including peritumoral edema, edema shape, necrosis, cyst, enhancement, tumor crosses midline, edema crosses midline, and tumor size). RESULTS: In addition to patient age, Karnofsky performance status (KPS) and postoperative chemoradiotherapy, peritumoral edema extent and necrosis on preoperative MRI were independent prognostic indicator for poor survival. Furthermore, patients with two unfavorable conditions (major edema and necrosis) had a shorter overall survival compared with the remainder. CONCLUSIONS: Our data confirm that peritumoral edema extent and necrosis are helpful for predicting poor clinical outcome in glioblastoma. These features were easy to determine from routine MRI scans postoperatively and therefore could provide a certain instructive significance for clinical activities.

Peritumoral edema on magnetic resonance imaging predicts a poor clinical outcome in malignant glioma.

Peritumoral edema (PTE), one of the main characteristics of malignant glioma, is a significant contributor to the morbidity and mortality from glioma, however, a recent systematic review suggested that controversy remains with regard to its prognostic value. To further determine whether PTE was a potential prognostic factor on routine pre-operative magnetic resonance imaging (MRI) for malignant glioma, the association between survival and PTE was investigated in the present retrospective review of 109 patients with newly diagnosed supratentorial malignant glioma using MRI data from these routine scans. The Kaplan-Meier method was used to calculate overall survival (OS) in univariate analysis, and COX proportional hazards model was applied to evaluate the effect of pre-operative MRI features on OS in multivariate analysis. The PTE extent, edema shape, degree of necrosis, enhancement extent, pathological grade, patient age, Karnofsky performance status (KPS) and post-operative chemoradiotherapy were associated with OS in the patients with malignant glioma on univariate analysis. Multivariate analysis indicated that the extent of PTE and degree of necrosis shown by pre-operative MRI were independent predictors of OS, in addition to pathological grade, patient age, KPS and post-operative chemoradiotherapy. Moreover, patients with two unfavorable factors (major edema and severe necrosis) exhibited a poorer OS compared with the remainder. In summary, PTE and degree of necrosis, which are easily determined from routine MRI, can be useful for predicting a poor clinical outcome in patients with newly diagnosed malignant glioma.

Classification of microvascular patterns via cluster analysis reveals their prognostic significance in glioblastoma.

There are limited researches focusing on microvascular patterns (MVPs) in human glioblastoma and their prognostic impact. We evaluated MVPs of 78 glioblastomas by CD34/periodic acid-Schiff dual staining and by cluster analysis of the percentage of microvascular area for distinct microvascular formations. The distribution of 5 types of basic microvascular formations, that is, microvascular sprouting (MS), vascular cluster (VC), vascular garland (VG), glomeruloid vascular proliferation (GVP), and vasculogenic mimicry (VM), was variable. Accordingly, cluster analysis classified MVPs into 2 types: type I MVP displayed prominent MSs and VCs, whereas type II MVP had numerous VGs, GVPs, and VMs. By analyzing the proportion of microvascular area for each type of formation, we determined that glioblastomas with few MSs and VCs had many GVPs and VMs, and vice versa. VG seemed to be a transitional type of formation. In case of type I MVP, expression of Ki-67 and p53 but not MGMT was significantly higher as compared with those of type II MVP (P < .05). Survival analysis showed that the type of MVPs presented as an independent prognostic factor of progression-free survival (PFS) and overall survival (OS) (both P < .001). Type II MVP had a more negative influence on PFS and OS than did type I MVP. We conclude that the heterogeneous MVPs in glioblastoma can be categorized properly by certain histopathologic and statistical analyses and may influence clinical outcome.

Association of pSTAT3-VEGF signaling pathway with peritumoral edema in newly diagnosed glioblastoma: an immunohistochemical study.

It is well recognized that peritumoral edema is vasogenic cerebral edema in malignant glioma, and vascular endothelial growth factor (VEGF) induced by phosphorylated signal transducer and activator of transcription factor 3 (pSTAT3) strongly contributes to tumor angiogenesis in glioblastoma. However, there is no study with regard to the correlation between pSTAT3 or VEGF and peritumoral edema. Such evidence may contribute to providing new targets for the management of peritumoral cerebral. In this study, newly diagnosed glioblastoma tissues from 84 patients were collected to investigate pSTAT3 and VEGF expression by immunohistochemistry, and peritumoral edema was detected by preoperative magnetic resonance imaging. We found that a significantly positive correlation emerged between VEGF and pSTAT3 expression (P = 0.000) in glioblastoma tissues, but they were not related to patient gender and age (P > 0.05); the expression of pSTAT3 and VEGF were associated with peritumoral edema extent (P = 0.005), but not with edema shape (P > 0.05). Therefore, the pSTAT3-VEGF signaling pathway, which is correlated with peritumoral edema extent, might be a regulatory mechanism in the course of peritumoral edema formation during glioblastoma tumorigenesis and progression, thereby suggesting that STAT3 inhibition might be helpful for alleviation of peritumoral cerebral edema.

STAT3 serine 727 phosphorylation influences clinical outcome in glioblastoma.

Besides STAT3 tyrosine 705 phosphorylation (pTyr705-STAT3), phosphorylation of STAT3 at serine 727 (pSer727-STAT3) is shown to contribute to tumorigenesis and be closely related with resistance to radiotherapy and chemotherapy in glioma, but there is currently no study regarding its relevance to prognosis in glioblastoma (GBM). Here, the expression of phosphorylated STAT3 was detected in tumor specimens from 88 patients with newly diagnosed GBM by immunohistochemistry, the Kaplan-Meier survival curve and COX proportional hazards regression model were applied to estimate its influences on progression-free survival (PFS) and overall survival (OS). Immunohistochemical assay showed elevated expression of pSer727-STAT3 in GBM compared with normal brain tissue. Univariate analysis indicated significant correlations of high percentage of pSer727-STAT3 positive tumor cells with shorter PFS (P = 0.006) and OS (P = 0.002). In multivariate analysis, high pSer727-STAT3 expression was demonstrated as an independent unfavorable prognostic indicator for PFS (HR 1.830, P = 0.022) and OS (HR 1.797, P = 0.040). And patients with high expression of both pTyr705-STAT3 and pSer727-STAT3 had a poorer prognosis compared with the remainder (P < 0.005). In conclusion, the high proportion of pSer727-STAT3 positive neoplastic cells in GBM is an independent unfavorable prognostic factor, and increased expression of both pTyr705-STAT3 and pSer727-STAT3 is predictive of poorer clinical outcome, thereby adding to the growing evidence that STAT3 inhibition may be a potential therapeutic strategy in glioblastoma.

STAT3 Tyr705 phosphorylation affects clinical outcome in patients with newly diagnosed supratentorial glioblastoma.

STAT3 tyrosine705 phosphorylation (p-STAT3, Tyr705), a molecular hub for several signal transduction pathways of glioma, plays a central role in glioblastoma (GBM) carcinogenesis and progression. However, it is still controversial whether p-STAT3 expression is associated with the clinical outcome of patients with glioblastoma. Such evidence would contribute to further illustrate whether STAT3 inhibition is suitable for clinical treatment. Here, we examined the expression of p-STAT3 in the tumor tissues from 90 patients with newly diagnosed supratentorial GBM via immunohistochemical technique and evaluated the influences of its expression on progression-free survival (PFS) and overall survival (OS) using the Kaplan-Meier curve and COX proportional hazards regression model. Immunohistochemical assay indicated increased expression of p-STAT3 in GBM tissue compared to adjacent normal brain tissue without p-STAT3 expression. There were no observed associations between p-STAT3 expression and patients' gender (P = 0.660), age (P = 0.867) or preoperative Karnofsky Performance Status (KPS) (P = 0.121). Univariate survival analysis revealed significant correlations of high p-STAT3 expression with shorter PFS (P = 0.012) and OS (P = 0.009). Multivariate survival analysis confirmed high p-STAT3 expression as a significant prognostic indicator for shorter PFS (HR 2.158, P = 0.019) and OS (HR 2.120, P = 0.031), independent of age, KPS and chemoradiotherapy. In summary, the high percentage of p-STAT3 positive tumor cells is a significant independent prognostic indicator for poor clinical outcome in patients with GBM, in addition to advanced age, poor performance status and nonstandard chemoradiotherapy, suggesting that STAT3 might be as a promising therapeutic target in GBM.