Upfront boost Gamma Knife "leading-edge" radiosurgery to FLAIR MRI-defined tumor migration pathways in 174 patients with glioblastoma multiforme: a 15-year assessment of a novel therapy.

OBJECTIVE Glioblastoma multiforme (GBM) is composed of cells that migrate through the brain along predictable white matter pathways. Targeting white matter pathways adjacent to, and leading away from, the original contrast-enhancing tumor site (termed leading-edge radiosurgery [LERS]) with single-fraction stereotactic radiosurgery as a boost to standard therapy could limit the spread of glioma cells and improve clinical outcomes. METHODS Between December 2000 and May 2016, after an initial diagnosis of GBM and prior to or during standard radiation therapy and carmustine or temozolomide chemotherapy, 174 patients treated with radiosurgery to the leading edge (LE) of tumor cell migration were reviewed. The LE was defined as a region outside the contrast-enhancing tumor nidus, defined by FLAIR MRI. The median age of patients was 59 years (range 22-87 years). Patients underwent LERS a median of 18 days from original diagnosis. The median target volume of 48.5 cm3 (range 2.5-220.0 cm3) of LE tissue was targeted using a median dose of 8 Gy (range 6-14 Gy) at the 50% isodose line. RESULTS The median overall survival was 23 months (mean 43 months) from diagnosis. The 2-, 3-, 5-, 7-, and 10-year actual overall survival rates after LERS were 39%, 26%, 16%, 10%, and 4%, respectively. Nine percent of patients developed treatment-related imaging-documented changes due to LERS. Nineteen percent of patients were hospitalized for management of edema, 22% for resection of a tumor cyst or new tumor bulk, and 2% for shunting to treat hydrocephalus throughout the course of their disease. Of the patients still alive, Karnofsky Performance Scale scores remained stable in 90% of patients and decreased by 1-3 grades in 10% due to symptomatic treatment-related imaging changes. CONCLUSIONS LERS is a safe and effective upfront adjunctive therapy for patients with newly diagnosed GBM. Limitations of this study include a single-center experience and single-institution determination of the LE tumor target. Use of a leading-edge calculation algorithm will be described to achieve a consistent approach to defining the LE target for general use. A multicenter trial will further elucidate its value in the treatment of GBM.

Closed head injury-induced changes in brain pathophysiology assessed with near-infrared structured illumination in a mouse model.

Use of near-infrared (NIR) structured illumination technique has recently received great interest in biomedical research and clinical studies because of its ability to perform wide-field imaging and quantitatively map changes in tissue hemodynamic properties and morphological features in a noncontact and scan-free fashion. We report on the feasibility of using the same to quantitatively monitor and map changes in brain optical properties and physiological parameters pre- and post-closed head injury in a mouse model. Five anesthetized male mice underwent head injury by weight-drop model using a ~50-g cylindrical metal object falling from a height of 90 cm onto the intact scalp. During experiments, NIR structured illumination was projected on the mouse head at two spatial frequencies and six different NIR wavelengths. A CCD camera positioned perpendicular to the head recorded the diffuse-reflected light. Computer analysis performed off-line on the captured data reveals spatiotemporal changes in the distribution of brain tissue absorption and reduced scattering coefficients. Using Beer's law and Mie theory, hemodynamic (hemoglobin, oxygen saturation, and lipids) and morphological (scattering amplitude and power) changes up to 1-h post-trauma were observed in comparison with baseline measurements. Functional maps of different brain properties were also generated. Following injury, we found difference in both brain hemodynamic and morphologic properties with respect to baseline levels, where in some properties, this difference was considered statistically significant. Specifically, a t-test indicates a substantial decrease in oxyhemoglobin (HbO(2)) concentration and tissue oxygen saturation (StO(2)) post-injury (p < 0.01 and p < 0.001, respectively). Overall, our preliminary results demonstrate the potential application of NIR structured illumination technique to track and spatially map changes in intact mouse brain pathophysiological parameters following head injury.

Monitoring hemodynamic and morphologic responses to closed head injury in a mouse model using orthogonal diffuse near-infrared light reflectance spectroscopy.

The authors' aim is to assess and quantitatively measure brain hemodynamic and morphological variations during closed-head injury (CHI) in mice using orthogonal diffuse near-infrared reflectance spectroscopy (o-DRS). CHI is a type of injury to the head that does not penetrate the skull. Usually, it is caused by mechanical blows to the head and frequently occurs in traffic accidents, falls, and assaults. Measurements of brain optical properties, namely absorption and reduced scattering coefficients in the wavelength range from 650 to 1000 nm were carried out by employing different source-detector distance and locations to provide depth sensitivity on an intact scalp over the duration of the whole experiment. Furthermore, alteration in both cortical hemodynamics and morphologic markers, i.e., scattering power and amplitude properties were derived. CHI was induced in anesthetized male mice by a weight-drop model using ∼50 g cylindrical metal falling from a height of 90 cm onto the intact scalp producing an impact of 4500 g cm. With respect to baseline, difference in brain physiological properties was observed following injury up to 1 h post-trauma. Additionally, the reduced scattering spectral shapes followed Mie scattering theory was quantified and clearly shows changes in both scattering amplitude and power from baseline indicating structural variations likely from evolving cerebral edema during CHI. We further demonstrate high correlation between scattering amplitude and scattering power, with more than 20% difference in slope in comparison to preinjury. This result indicates the possibility of using the slope also as a marker for detection of structural changes. Finally, experiments investigating brain function during the first 20 min postinjury were conducted and changes in chromophore concentrations and scattering were observed. Overall, our experiments demonstrate the potential of using the proposed technique as a valuable quantitative noninvasive tool for monitoring brain physiology following CHI injury at the bedside and/or at the field.

Diffuse near-infrared reflectance spectroscopy during heatstroke in a mouse model: pilot study.

Heatstroke, a form of hyperthermia, is a life-threatening condition characterized by an elevated core body temperature that rises above 40°C (104°F) and central nervous system dysfunction that results in delirium, convulsions, or coma. Without emergency treatment, the victim lapses into a coma and death soon follows. The study presented was conducted with a diffuse reflectance spectroscopy (DRS) setup to assess the effects of brain dysfunction that occurred during heatstroke in mice model (n=6). It was hypothesized that DRS can be utilized in small animal studies to monitor change in internal brain tissue temperature during heatstroke injury since it induces a sequence of pathologic changes that change the tissue composition and structure. Heatstroke was induced by exposure of the mice body under general anesthesia, to a high ambient temperature. A type of DRS in which the brain tissue was illuminated through the intact scalp with a broadband light source and diffuse reflected spectra was employed, taking in the spectral region between 650 and 1000 nm and acquired at an angle of 90 deg at a position on the scalp ∼12 mm from the illumination site. The temperature at the onset of the experiment was ∼34°C (rectal temperature) with increasing intervals of 1°C until mouse death. The increase in temperature caused optical scattering signal changes consistent with a structural alteration of brain tissue, ultimately resulting in death. We have found that the peak absorbance intensity and its second derivative at specific wavelengths correlate well with temperature with an exponential dependence. Based on these findings, in order to estimate the influence of temperature on the internal brain tissue a reflectance-temperature index was established and was seen to correlate as well with measured temperature. Overall, results indicate variations in neural tissue properties during heatstroke and the feasibility to monitor and assess internal temperature variations using DRS. Although several approaches have described the rise in temperature and its impact on tissue, to the best of our knowledge no information is available describing the ability to monitor temperature during heatstroke with DRS. The motivation of this study was to successfully describe this ability.

Glioma cell growth inhibition following photochemical internalization enhanced non-viral PTEN gene transfection.

BACKGROUND AND OBJECTIVE: One of many limitations for cancer gene therapy is the inability of the therapeutic gene to transfect a sufficient number of tumor cells. Photochemical internalization (PCI) is a photodynamic therapy-based approach for improving the delivery of macromolecules and genes into the cell cytosol. The utility of PCI for the delivery of the GFP reporter gene on the same plasmid as a tumor suppressor gene (PTEN) was investigated in monolayers of U251 human glioma cells and muticell U87 glioma spheroids. MATERIALS AND METHODS: U251 monolayers or U87 spheroids were incubated in AlPcS(2a) and non-viral vector polyplexes for 18 hours. In all cases, light treatment was performed with a diode laser at a wavelength of 670 nm. The non-viral transfection agents, branched polyethylenimine (bPEI), or protamine sulfate (PS), were used with the plasmid constructs GFP/PTEN or GFP. RESULTS: PS/GFP polyplexes were much less toxic to the glioma cells compared to bPEI/GFP polyplexes but were highly inefficient at gene transfection if used alone. PCI resulted in a 5- to 10-fold increase in GFP protein expression compared to controls. PCI-bPEI/PTEN or PCI-PS/PTEN transfection of either U251 monolayers or U87 spheroids significantly inhibited their growth. but had no effect on MCF-7 cells containing a wild-type PTEN gene. In addition PCI-GFP transfection of gliomas cells had no effect on their growth pattern. CONCLUSIONS: Collectively, the results suggest that AlPcS(2a) -mediated PCI can be used to enhance cell growth inhibition via transfection of tumor suppressor genes in glioma cells containing mutant PTEN genes.

Photochemical internalization-mediated delivery of chemotherapeutic agents in human breast tumor cell lines.

Breast-conservation surgery (BCS) is now utilized in patients with stage I and II invasive breast cancer. However, positive surgical margins are associated with recurrence, and therefore some form of localized postoperative therapy (radiation/chemotherapy) is necessary to eliminate remaining cancer cells. Existing modalities have significant treatment-limiting side effects; therefore, alternative forms of localized therapy need to be explored. We studied the ex vivo effects of photochemical internalization (PCI) using 4 chemotherapeutic agents: cisplatin, cisplatin analog [D prostanoid, DP], doxorubicin, and bleomycin) on 3 breast cancer cell lines: MCF-7, MDA-MB-435, and MDA-MB-231. Illumination was carried out using a 670-nm diode laser at 5 mW/cm2 following incubation in the photosensitizer with aluminum phthalocyanine disulfonate. Toxicity was investigated using colony-forming assays and the mechanism of cell death was determined using Annexin flow-cytometry. We found that toxicity of DP and bleomycin was significantly enhanced by PCI compared with drug alone but was unchanged for cisplatin and doxorubicin. PCI treatment caused a decrease in the percentage of viable cells, predominantly by enhancing apoptosis. The action was synergistic across all 3 cell lines tested for DP and bleomycin. Thus, with appropriate delivery devices and choice of chemotherapeutic agents, PCI holds the promise of enhancing tumor cell toxicity surrounding the cavity of BCS resection sites and thereby decreasing local recurrence.

Photochemical internalization of bleomycin for glioma treatment.

We study the use of photochemical internalization (PCI) for enhancing chemotherapeutic response to malignant glioma cells in vitro. Two models are studied: monolayers consisting of F98 rat glioma cells and human glioma spheroids established from biopsy-derived glioma cells. In both cases, the cytotoxicity of aluminum phthalocyanine disulfonate (AlPcS2a)-based PCI of bleomycin was compared to AlPcS(2a)-photodynamic therapy (PDT) and chemotherapy alone. Monolayers and spheroids were incubated with AlPcS(2a) (PDT effect), bleomycin (chemotherapy effect), or AlPcS(2a)+bleomycin (PCI effect) and were illuminated (670 nm). Toxicity was evaluated using colony formation assays or spheroid growth kinetics. F98 cells in monolayer/spheroids were not particularly sensitive to the effects of low radiant exposure (1.5 J/cm(2) @ 5 mW/cm(2)) AlPcS(2a)-PDT. Bleomycin was moderately toxic to F98 cells in monolayer at relatively low concentrations-incubation of F98 cells in 0.1 µg/ml for 4 h resulted in 80% survival, but less toxic in human glioma spheroids respectively. In both in vitro systems investigated, a significant PCI effect is seen. PCI using 1.5 J/cm(2) together with 0.25 µg/ml bleomycin resulted in approximately 20% and 18% survival of F98 rat glioma cells and human glioma spheroids, respectively. These results show that AlPcS(2a)-mediated PCI can be used to enhance the efficacy of chemotherapeutic agents such as bleomycin in malignant gliomas.

The sacral hiatus approach for drainage of anterior lumbo-sacral epidural abscesses. A case report and technical note.

Lumbosacral epidural abscesses are managed either conservatively with IV antibiotics or with open surgery, particularly in the presence of acute neurological symptoms. Their location makes it difficult for image-guided interventional approaches either for biopsy or evacuation. We report the sacral hiatus and canal as a corridor for image-guided minimally invasive abscess of lumbosacral epidural abscess for aspiration. A 56-year-old man presented to the emergency department complaining of six weeks of worsening low back pain. MRI of the patient's lumbosacral spine showed osteomyelitis involving his L5, S1 vertebrae, L5-S1 discitis, as well as an anterior epidural abscess extending from L4-5 disc space to the S2 vertebral level. Blood cultures grew out gram-positive cocci. For drainage, a 5-French micropuncture kit was utilized to access the hiatus. Under fluoroscopic guidance a microwire was then advanced along the sacral canal. An 18-gauge needle curved to approximate the contours of the sacral canal was then advanced over the guidewire. Once anatomic access was established 2 ml of thick purulent material was aspirated. The patient tolerated the procedure well, and no focal nerve root symptoms were noted following the procedure. Image-guided aspiration of lumbosacral epidural abscesses can thus be carried out in a safe and effective manner using a sacral hiatus approach.

Cerebral edema following photodynamic therapy using endogenous and exogenous photosensitizers in normal brain.

BACKGROUND AND OBJECTIVE: Failure of treatment for high-grade gliomas is usually due to local recurrence at the site of surgical resection indicating that a more aggressive form of local therapy such as photodynamic therapy (PDT) could be of benefit. The increase in brain edema following PDT using endogenous and exogenous photosensitizers was compared in terms of animal survival, MR imaging, and histopathological changes in normal brain. MATERIALS AND METHODS: Fischer rats were exposed to increasing laser light treatment following intraperitoneal injection of either the photosensitizers 5-aminolevulinic acid (ALA) or aluminum phthalocyanine disulfonate (AlPcS2a). Light treatment was applied either via an optical fiber inserted directly into the brain parenchyma or through a fiber applied to the surface of the intact skull. Edema development was followed by T2-weighted MR imaging. RESULTS: ALA and AlPcS2a PDT resulted in a fluence dependent increase in cerebral edema and mortality. AlPcS2a PDT showed significant edema and mortality even at low fluences following interstitial light delivery, which was reduced with surface illumination. The mechanism of edema was determined to be vasogenic by response to steroid therapy and confirmed on histological images. CONCLUSIONS: T2 and contrast enhanced T1 MRI scanning proved to be a highly effective and noninvasive modality in following the development of the edema reaction and the degree and time course of blood-brain barrier dysfunction thus allowing the use of fewer animals. ALA mediated PDT induced a lower edema reaction than that observed with the photosensitizer AlPcS2a.

EFEMP1 suppresses malignant glioma growth and exerts its action within the tumor extracellular compartment.

PURPOSE: There are conflicting reports regarding the function of EFEMP1 in different cancer types. In this study, we sought to evaluate the role of EFEMP1 in malignant glioma biology. EXPERIMENTAL DESIGN: Real-time qRT-PCR was used to quantify EFEMP1 expression in 95 glioblastoma multiforme (GBM). Human high-grade glioma cell lines and primary cultures were engineered to express ectopic EFEMP1, a small hairpin RNA of EFEMP1, or treated with exogenous recombinant EFEMP1 protein. Following treatment, growth was assayed both in vitro and in vivo (subcutaneous (s.c.) and intracranial (i.c.) xenograft model systems). RESULTS: Cox regression revealed that EFEMP1 is a favorable prognostic marker for patients with GBM. Over-expression of EFEMP1 eliminated tumor development and suppressed angiogenesis, cell proliferation, and VEGFA expression, while the converse was true with knock-down of endogenous EFEMP1 expression. The EFEMP1 suppression of tumor onset time was nearly restored by ectopic VEGFA expression; however, overall tumor growth rate remained suppressed. This suggested that inhibition of angiogenesis was only partly responsible for EFEMP1's impact on glioma development. In glioma cells that were treated by exogenous EFEMP1 protein or over-expressed endogenous EFEMP1, the EGFR level was reduced and AKT signaling activity attenuated. Mixing of EFEMP1 protein with cells prior to s.c. and i.c. implantations or injection of the protein around the established s.c. xenografts, both significantly suppressed tumorigenicity. CONCLUSIONS: Overall, our data reveals that EEFEMP1 suppresses glioma growth in vivo, both by modulating the tumor extracellular microenvironment and by altering critical intracellular oncogenic signaling pathways.