Evidence-based adjuvant therapy for gliomas: current concepts and newer developments.

The incidence of gliomas is increasing worldwide, including India. Of the 18,820 new cases of primary central nervous system (CNS) tumors diagnosed annually in the United States, gliomas account for over 60% with 30-40% of them being glioblastoma multiforme (GBM), 10% being anaplastic astrocytoma (AA), and 10% being low grade gliomas (LGGs). This is in contrast to one study from West Bengal, India, in which only 7.9% of the brain tumors were GBMs, while 46.8% were astrocytomas. Of all adult primary CNS tumors, GBM is the most common and the most malignant with about 7,000 to 8,000 new cases annually in the United States. Given poor outcomes, a number of treatment approaches have been investigated. Common to these approaches is the use of adjuvant radiation therapy, even as surgery alone, with or without chemotherapy, may be the mainstay for some lower grade and low-risk gliomas. Today, treatment typically involves external beam radiation, with concurrent and adjuvant chemotherapy for more aggressive histologies. Although gliomas are relatively uncommon, active research is ongoing. Results of landmark trials along with some of the recently published trials are presented. These trials and management strategies as well as evolving concepts are found by reviewing over 200 articles in the National Library Medical (NLM) database, PubMed, more than 60 of which are refrenced. Specifically, the database is searched using the following keywords, with various combinations: glioma, low-grade, anaplastic, astrocytoma, oligodendroglioma, oligoastrocytoma, glioblastoma multiforme, chemotherapy, radiation, new concepts, phase III, MGMT, CDX-110 (Celldex), temozolomide, 1p/19q deletion, and bevacizumab.

Extracellular matrix synthesis by articular chondrocytes and synovial fibroblasts in long-term monolayer culture.

Synthesis of collagen and proteoglycan by rabbit articular chondrocytes and synovial fibroblasts has been studied over a 12-week period in primary monolayer culture. Chondrocytes, but not fibroblasts, accumulate large quantities of proteoglycan over the culture period studied. Radiolabeling studies with [35S]sulfate have shown that the major proteoglycan synthesized by cultured chondrocytes is similar to the proteoglycan of cartilage matrix. Chondrocytes also synthesize a smaller dermatan sulfate proteoglycan, which is apparently the only proteoglycan species produced by synovial fibroblasts. Collagen synthesis was studied by radiolabeling with [3H]proline. Cultured chondrocytes produce mainly Type II collagen, with lesser amounts of Type I, whereas synovial fibroblasts produce Type I collagen and some low molecular weight collagenous species. Therefore, long-term monolayer culture permits the production of extensive chondroid matrix by chondrocytes, but not fibroblasts.

Mechanical Forces Exacerbate Periodontal Defects in Bsp-null Mice.

Bone sialoprotein (BSP) is an acidic phosphoprotein with collagen-binding, cell attachment, and hydroxyapatite-nucleating properties. BSP expression in mineralized tissues is upregulated at onset of mineralization. Bsp-null (Bsp(-/-)) mice exhibit reductions in bone mineral density, bone turnover, osteoclast activation, and impaired bone healing. Furthermore, Bsp(-/-) mice have marked periodontal tissue breakdown, with a lack of acellular cementum leading to periodontal ligament detachment, extensive alveolar bone and tooth root resorption, and incisor malocclusion. We hypothesized that altered mechanical stress from mastication contributes to periodontal destruction observed in Bsp(-/-) mice. This hypothesis was tested by comparing Bsp(-/-) and wild-type mice fed with standard hard pellet diet or soft powder diet. Dentoalveolar tissues were analyzed using histology and micro-computed tomography. By 8 wk of age, Bsp(-/-) mice exhibited molar and incisor malocclusion regardless of diet. Bsp(-/-) mice with hard pellet diet exhibited high incidence (30%) of severe incisor malocclusion, 10% lower body weight, 3% reduced femur length, and 30% elevated serum alkaline phosphatase activity compared to wild type. Soft powder diet reduced severe incisor malocclusion incidence to 3% in Bsp(-/-) mice, supporting the hypothesis that occlusal loading contributed to the malocclusion phenotype. Furthermore, Bsp(-/-) mice in the soft powder diet group featured normal body weight, long bone length, and serum alkaline phosphatase activity, suggesting that tooth dysfunction and malnutrition contribute to growth and skeletal defects reported in Bsp(-/-) mice. Bsp(-/-) incisors also erupt at a slower rate, which likely leads to the observed thickened dentin and enhanced mineralization of dentin and enamel toward the apical end. We propose that the decrease in eruption rate is due to a lack of acellular cementum and associated defective periodontal attachment. These data demonstrate the importance of BSP in maintaining proper periodontal function and alveolar bone remodeling and point to dental dysfunction as causative factor of skeletal defects observed in Bsp(-/-) mice.

Bone mineral and glycosaminoglycans in newborn and mature rabbits.

The relation between bone mineralization and glycosaminoglycans (GAG) was investigated in newborn and mature rabbit diaphyseal bone. Using the density fractionation technique, the bone was separated into fractions of increasing density from 1.4 to 2.3 grams/ml. Each fraction was analyzed by X-ray diffraction to determine the average crystal size. The GAG content of each fraction and of the unfractionated bone was determined by direct extraction and on a few fractions by sequential extraction in guanidine hydrochloride and guanidine/EDTA. There was a decrease in the GAG content with animal age and with increasing fraction density in the newborn rabbit. In one overlapping fraction (2.0-2.1 grams/ml), the GAG content was twice as high in the newborn as in the mature animal. Finally, the crystal size substantially increased from newborn to mature rabbits. Therefore, calcification and maturation of bone is associated with a decrease in the proteoglycan content of the organic matrix.

Functional analysis of bone sialoprotein: identification of the hydroxyapatite-nucleating and cell-binding domains by recombinant peptide expression and site-directed mutagenesis.

Mammalian bone sialoprotein (BSP) is a mineralized tissue-specific protein containing an RGD (arginine-glycine-aspartic acid) cell-attachment sequence and two distinct glutamic acid (glu)-rich regions, with each containing one contiguous glu sequence. These regions have been proposed to contribute to the attachment of bone cells to the extracellular matrix and to the nucleation of hydroxyapatite (HA), respectively. To further delineate the domains responsible for these activities, porcine BSP cDNA was used to construct expression vectors coding for two partial-length recombinant BSP peptides: P2S (residues 42-87), containing the first glutamic acid-rich domain; and P1L (residues 69-300), containing the second glutamic acid-rich region and the RGD sequence. These peptides were expressed in Escherichia coli as his-tag fusion proteins and purified by nickel affinity columns and FPLC chromatography. Digestion with trypsin released the his-tag fusion peptide, which generated P2S-TY (residues 42-87) and P1L-TY (residues 132-239). Using a steady-state agarose gel system, P2S-TY promoted HA nucleation, whereas P2S, P1L, and P1L-TY did not. This implies that the minimum requirement for nucleation of HA resides within the amino acid sequence of the first glutamic acid-rich domain, whereas the second glutamic acid-rich domain may require posttranslational modifications for activity. P1L, but not P2S, promoted RGD-mediated attachment of human gingival fibroblasts in a manner similar to that of native BSP. Deletion of the RGD domain or conversion of it to RGE (arginine-glycine-glutamic acid) abolished the cell-attachment activity of P1L. This suggests that, at least for human gingival fibroblasts, the major cell-attachment activity in the recombinant BSP peptides studied (residues 42-87 and 69-300) requires the RGD sequence located at the C-terminal domain.

Deficiency in acellular cementum and periodontal attachment in bsp null mice.

Bone sialoprotein (BSP) is an extracellular matrix protein found in mineralized tissues of the skeleton and dentition. BSP is multifunctional, affecting cell attachment and signaling through an RGD integrin-binding region, and acting as a positive regulator for mineral precipitation by nucleating hydroxyapatite crystals. BSP is present in cementum, the hard tissue covering the tooth root that anchors periodontal ligament (PDL) attachment. To test our hypothesis that BSP plays an important role in cementogenesis, we analyzed tooth development in a Bsp null ((-/-)) mouse model. Developmental analysis by histology, histochemistry, and SEM revealed a significant reduction in acellular cementum formation on Bsp (-/-) mouse molar and incisor roots, and the cementum deposited appeared hypomineralized. Structural defects in cementum-PDL interfaces in Bsp (-/-) mice caused PDL detachment, likely contributing to the high incidence of incisor malocclusion. Loss of BSP caused progressively disorganized PDL and significantly increased epithelial down-growth with aging. Bsp (-/-) mice displayed extensive root and alveolar bone resorption, mediated by increased RANKL and the presence of osteoclasts. Results collected here suggest that BSP plays a non-redundant role in acellular cementum formation, likely involved in initiating mineralization on the root surface. Through its importance to cementum integrity, BSP is essential for periodontal function.

An ion-exchange mechanism of cartilage calcification.

The provisional calcification of epiphyseal cartilage involves deposition of hydroxyapatite (calcium phosphate) crystals in an extracellular matrix consisting principally of Type II collagen and cartilage proteoglycan. A mechanism is now proposed to explain how epiphyseal cartilage calcification is initiated. Calcium exists at high concentration in cartilage, but is mainly bound to the anionic groups of proteoglycans, and thus is unavailable for precipitation. A local increase in phosphate concentration displaces calcium ions from proteoglycan by an ion-exchange effect, raising the Ca X PO4 product above the threshold for precipitation of hydroxyapatite. Evidence for this hypothesis has been derived from studies of the effect of phosphate on the binding of calcium to cartilage proteoglycan, and on hydroxyapatite formation in the presence of chondroitin sulfate.

Chondroitin sulfate-derivatized agarose beads: a new system for studying cation binding to glycosaminoglycans.

Chondroitin sulfate (CS) has been covalently attached to aminoethyl-agarose beads in a carbodiimide-catalyzed reaction. In this process, an amide bond is formed between carboxylate groups on the glycosaminoglycan (GAG) and the primary amine groups of the beads. Under optimal conditions, up to 160 micrograms of CS is attached per milligram of beads. CS-agarose beads have been used to study Ca binding to GAGs. The beads are mixed with a solution containing CaCl2 and 45Ca and allowed to sediment under unit gravity. An aliquot of supernatant is then removed and 45Ca activity is determined to quantitate remaining (free) Ca. Using this system, it was shown that CS binds approximately 0.7 Ca/disaccharide unit at saturation. Under the conditions used, the apparent association constant (KA) is approximately 14 mM. In principle, this derivatization protocol may be used to attach any proteoglycan or GAG (except keratan sulfate) to an insoluble support. CS-agarose beads provide a rapid, simple, and relatively artifact-free system for studying cation-GAG interactions.

Role of proteoglycan in the provisional calcification of cartilage. A review and reinterpretation.

Study of the calcification of cartilage in endochondral ossification has yielded two apparently contradictory views of the role of proteoglycan in this process. The ability of proteoglycan to act as a calcium-concentrating agent (Kalksalzfänger) in cartilage is consistent with the view that proteoglycans are promoters of calcification. However, study of their effect on hydroxyapatite formation in vitro suggests that proteoglycans are inhibitors of cartilage calcification. A resolution of this paradox is now proposed. Proteoglycans inhibit hydroxyapatite formation under in vitro conditions of limited calcium availability (in part) by binding calcium ions. However, under in vivo conditions of essentially infinite calcium availability, proteoglycans may promote hydroxyapatite formation, since binding of calcium to proteoglycan will not decrease the free calcium concentration, and the bound calcium may easily be displaced. Therefore, it is proposed that the role of proteoglycans in the calcification of cartilage is to function as a cation-exchanging calcium reservoir.

A mathematical modelling study of epiphyseal cartilage calcification.

Recent studies in this laboratory have suggested that proteoglycan may function as a Ca ion-exchanger in the calcification of epiphyseal growth plate cartilage. Specifically, it has been proposed that phosphate liberated from hypertrophic chondrocytes may displace calcium ions bound to the anionic groups of proteoglycans, thereby raising the Ca x PO4 activity product above the threshold for precipitation of hydroxyapatite. In order to determine whether this mechanism is quantitatively feasible, a mathematical model of the interaction between Ca, Na, proteoglycan and phosphate has now been developed. This model is based on a general binding theory, and utilizes previously-determined values for the binding constants of the Ca-proteoglycan interaction, inhibition constants for the effect of Na and phosphate on this interaction, and literature values for the concentrations of proteoglycan, Na and Ca in epiphyseal cartilage. Using this approach, it was predicted that the free Ca concentration in epiphyseal cartilage in the absence of phosphate will be 1.55 mM. At 0.7 mM phosphate, the approximate concentration in non-calcified cartilage matrix, the free Ca concentration will be 2.40 mM, corresponding to a Ca x PO4 product of 1.68 (mM)2. In order to achieve a Ca x PO4 product sufficient for spontaneous precipitation of hydroxyapatite [approximately 4.3 (mM)2], a phosphate concentration of approximately 1.40 mM is required. Therefore, calcification of epiphyseal cartilage matrix by the mechanism described above will require an approximate doubling of the phosphate concentration in the pre-calcifying zones, indicating that the release of a fraction of the intracellular phosphate could trigger the calcification process.

Inhibition of proteoglycan biosynthesis decreases the calcification of chondrocyte cultures.

In order to determine the role of proteoglycan in the calcification of cartilage, the effects on calcifying chondrocyte cultures of treatments that disrupt proteoglycan biosynthesis have been studied. Treatment of secondary cultures of embryonic chick chondrocytes with non-toxic concentrations of the beta-xyloside p-nitrophenyl beta-D-xylopyranoside (PNPX) resulted in dose-dependent inhibition of both proteoglycan and mineral deposition. Based on the expression of Type X collagen, however, PNPX is also a potent inhibitor of chondrocyte differentiation. Under-sulfation of proteoglycans was effected by growth of chondrocyte cultures in sulfate-depleted medium. Growth in low-sulfate medium did not significantly affect the growth or differentiation of these cultures, but caused an approximate two-fold decrease in mineral content compared to cultures grown in normal medium. These findings indicate that disruption of proteoglycan biosynthesis in chondrocyte cultures results in decreased levels of calcification. Therefore, proteoglycans appear to function as promoters of chondrocyte calcification.

Non-selective junctional communication between some different mammalian cell types in primary culture.

Intercellular transfer of tritium-labelled uridine nucleotides has been used to detect junctional communication between various cell types in primary culture. Epidermal keratinocytes, melanocytes and dermal fibroblasts from new-born-mouse skin, and epithelial cells from baby mouse kidney form communicating junctions in all possible homologous and heterologous combinations. This lack of detectable communication specificity between cells in primary culture contrasts with the specificity shown by some established cell lines.

Chondroitin sulfate inhibits calcification of bone formed in vitro.

Chondroitin sulfate is known to inhibit formation of hydroxyapatite in solution. It is not known whether chondroitin sulfate will prevent mineralization in a cellularly controlled environment. In order to evaluate this possibility, chondroitin sulfate was added to the medium of periosteal bone-forming cultures. These cultures normally form mineralized bone in the presence of 10 mM beta-glycerophosphate. Chondroitin sulfate prevented calcium accumulation and thus mineralization in these cultures. However, chondroitin sulfate did not prevent phosphate accumulation in cultures, thus suggesting that calcium and phosphate accumulation in bone may be dependent on two different mechanisms.

Nucleation of hydroxyapatite by bone sialoprotein.

Bone sialoprotein (BSP) and osteopontin, the major phosphorylated proteins of mammalian bone, have been proposed to function in the initiation of mineralization. To test this hypothesis, the effects of BSP and osteopontin on hydroxyapatite crystal formation were determined by using a steady-state agarose gel system. At low calcium phosphate concentrations, no accumulation of calcium and phosphate occurred in control gels or gels containing osteopontin. Gels containing BSP at 1-5 micrograms/ml, however, exhibited a visible precipitation band and significantly elevated Ca + PO4 contents. By powder x-ray diffraction, the precipitate formed in the presence of BSP was shown to be hydroxyapatite. These findings suggest that bone sialoprotein may be involved in the nucleation of hydroxyapatite at the mineralization front of bone.

Effects of proteoglycan on hydroxyapatite formation under non-steady-state and pseudo-steady-state conditions.

Addition of chondroitin sulfate (CS) or cartilage proteoglycan to metastable calcium phosphate solutions inhibits the formation of hydroxyapatite (HA). However, pre-equilibration of CS or proteoglycan with calcium prior to the addition of phosphate results in higher levels of HA precipitation compared to control solutions of identical calcium and phosphate activity. These findings indicate that the inhibition of HA formation by proteoglycans and CS is largely due to calcium binding. Further, its ability to bind calcium ions reversibly suggests that proteoglycan may act as a promoter, not an inhibitor, of calcification in cartilage.

Modulation of crystal formation by bone phosphoproteins: role of glutamic acid-rich sequences in the nucleation of hydroxyapatite by bone sialoprotein.

Bone sialoprotein (BSP) is a bone-specific glycoprotein containing phosphoserine and sulphotyrosine residues and regions of contiguous glutamic acid residues. Recent studies in this laboratory have shown that BSP is capable of nucleating the bone mineral hydroxyapatite in a steady-state agarose gel system. We show here that chemical modification of carboxylate groups abolishes the nucleation activity of BSP, but enzymic dephosphorylation has no effect. Formation of hydroxyapatite is also induced by poly(L-glutamic acid) and poly(D-glutamic acid), but not by poly(L-aspartic acid) or poly(L-lysine). Calreticulin, a muscle protein with short sequences of contiguous glutamic acid residues, also lacks nucleation activity. These findings suggest that the nucleation of hydroxyapatite by BSP involves one or both of the glutamic acid-rich sequences. Based on these findings and others, we propose that polycarboxylate sequences represent a general site for growth-modulating interactions between proteins and biological crystals.

Binding of calcium to glycosaminoglycans: an equilibrium dialysis study.

Binding of calcium to the glycosaminoglycans (GAGs) heparin, chondroitin sulfate (CS), keratan sulfate (KS), and hyaluronic acid (HA) has been studied by equilibrium dialysis using exclusion of sulfate to correct for Gibbs-Donnan effects. Calcium binding occurs to all of these GAG species, suggesting that both sulfate and carboxylate groups are involved in cation binding. For all GAGs, the binding stoichiometry is consistent with a calcium-binding "site" consisting of two anionic groups. The order of calcium binding affinities is heparin greater than CS greater than KS greater than HA, and is critically dependent upon charge density; heparin binds calcium with 10-fold higher affinity than CS. The mode of calcium binding to GAGs is consistent with a recently proposed mechanism of growth plate calcification which states that cartilage proteoglycan functions as a reservoir of calcium for calcification of epiphyseal cartilage.

Proteoglycan synthesis and deposition in fetal rat bone.

A pulse-labeling approach has been used to study proteoglycan metabolism in fetal rat bone. Pregnant rats were injected with [35S]sulfate and sacrificed 6, 24, or 48 h later. Fetal calvaria were dissected and extracted sequentially with 4 M guanidine hydrochloride and 4 M guanidine hydrochloride/0.5 M ( ethylenedinitrilo )tetraacetic acid (EDTA). With time after injection, the proportion of total incorporated radioactivity decreased in the guanidine pool (corresponding to nonmineralized bone and associated soft tissues) and increased in the guanidine/EDTA pool (mineralized bone). Chromatographic analysis of the proteoglycan species present in these pools after different labeling times indicated that three species of proteoglycan are synthesized in fetal rat calvaria. A large chondroitin sulfate (CS) proteoglycan and a smaller dermatan sulfate (DS) proteoglycan are located in the nonmineralized compartment. A CS proteoglycan similar in size to the DS proteoglycan is initially present in the nonmineralized bone but subsequently is located in the mineralized matrix. A fraction of the small CS proteoglycan is strongly associated with collagen.