Bob S. Carter

Glioblastoma microvesicles transport RNA and proteins that promote tumour growth and provide diagnostic biomarkers

Glioblastoma tumour cells release microvesicles (exosomes) containing mRNA, miRNA and angiogenic proteins. These microvesicles are taken up by normal host cells, such as brain microvascular endothelial cells. By incorporating an mRNA for a reporter protein into these microvesicles, we demonstrate that messages delivered by microvesicles are translated by recipient cells. These microvesicles are also enriched in angiogenic proteins and stimulate tubule formation by endothelial cells. Tumour-derived microvesicles therefore serve as a means of delivering genetic information and proteins to recipient cells in the tumour environment. Glioblastoma microvesicles also stimulated proliferation of a human glioma cell line, indicating a self-promoting aspect. Messenger RNA mutant/variants and miRNAs characteristic of gliomas could be detected in serum microvesicles of glioblastoma patients. The tumour-specific EGFRvIII was detected in serum microvesicles from 7 out of 25 glioblastoma patients. Thus, tumour-derived microvesicles may provide diagnostic information and aid in therapeutic decisions for cancer patients through a blood test.

Sexual Function following Radical Prostatectomy: Influence of Preservation of Neurovascular Bundles

The influence of preservation or excision of the neurovascular bundles on return of sexual function is analyzed. Between 1982 and 1988, 600 men 34 to 72 years old underwent radical retropubic prostatectomy for prostate cancer. Of the 503 patients who were potent preoperatively and followed for a minimum of 18 months 342 (68%) are potent postoperatively. Three factors were identified that correlated with the return of sexual function: 1) age, 2) clinical and pathological stage, and 3) surgical technique (preservation or excision of the neurovascular bundle). In men less than 50 years old potency was similar in patients who had both neurovascular bundles preserved (90%) and patients who had 1 neurovascular bundle widely excised (91%). With advancing age of more than 50 years sexual function was better in patients in whom both neurovascular bundles were preserved than in patients in whom 1 neurovascular bundle was excised (p less than 0.05). When the relative risk of postoperative impotence was adjusted for age the risk of postoperative impotence was 2-fold greater if there was capsular penetration or seminal vesicle invasion, or if 1 neurovascular bundle was excised (p less than 0.05). These data indicate that the return of sexual function postoperatively in men more than 50 years old is quantitatively related to preservation of autonomic innervation. In these men when it is necessary to excise the neurovascular bundle on 1 side, consideration in the future should be given to approaches that may restore autonomic function through nerve regeneration, for example partial excision of the bundle or cavernous nerve grafts.

Biogenesis of extracellular vesicles (EV): exosomes, microvesicles, retrovirus-like vesicles, and apoptotic bodies

Recent studies suggest both normal and cancerous cells secrete vesicles into the extracellular space. These extracellular vesicles (EVs) contain materials that mirror the genetic and proteomic content of the secreting cell. The identification of cancer-specific material in EVs isolated from the biofluids (e.g., serum, cerebrospinal fluid, urine) of cancer patients suggests EVs as an attractive platform for biomarker development. It is important to recognize that the EVs derived from clinical samples are likely highly heterogeneous in make-up and arose from diverse sets of biologic processes. This article aims to review the biologic processes that give rise to various types of EVs, including exosomes, microvesicles, retrovirus like particles, and apoptotic bodies. Clinical pertinence of these EVs to neuro-oncology will also be discussed.

Protein typing of circulating microvesicles allows real-time monitoring of glioblastoma therapy

Glioblastomas shed large quantities of small, membrane-bound microvesicles into the circulation. Although these hold promise as potential biomarkers of therapeutic response, their identification and quantification remain challenging. Here, we describe a highly sensitive and rapid analytical technique for profiling circulating microvesicles directly from blood samples of patients with glioblastoma. Microvesicles, introduced onto a dedicated microfluidic chip, are labeled with target-specific magnetic nanoparticles and detected by a miniaturized nuclear magnetic resonance system. Compared with current methods, this integrated system has a much higher detection sensitivity and can differentiate glioblastoma multiforme (GBM) microvesicles from nontumor host cell–derived microvesicles. We also show that circulating GBM microvesicles can be used to analyze primary tumor mutations and as a predictive metric of treatment-induced changes. This platform could provide both an early indicator of drug efficacy and a potential molecular stratifier for human clinical trials.

One-year outcome after decompressive surgery for massive nondominant hemispheric infarction.

OBJECTIVE Massive cerebral infarction is often accompanied by early death secondary to transtentorial herniation. We have tested the hypothesis that decompressive hemicraniectomy for massive nondominant cerebral infarction is lifesaving in a series of 14 patients presenting with right hemispheric infarction and clinical signs of uncal herniation and impending death. We have further analyzed, in prospective follow-up examinations, the levels of physical, psychiatric, and social disabilities in these patients. METHODS The methods used included retrospective analysis to determine rates of immediate mortality and morbidity after surgical intervention. Prospective follow-up data were obtained to determine the level of recovery in surviving patients after 1 year. Standardized measures of outcome to assess physical, psychiatric, and social recovery included the Barthel Index, Zung Depression Scale, and Reintegration to Normal Living Index. RESULTS With decompressive hemicraniectomy, we were able to prevent death secondary to transtentorial herniation in all cases; 11 patients experienced long-term survival after the procedure, and three deaths were related to non-neurological causes. We observed that 8 of the 11 surviving patients were at home, were functioning with minimal to moderate assistance, and had Barthel scores greater than 60. The remaining three patients were severely disabled. Seven of the 11 survivors were able to walk at 1 year after undergoing the procedure. Depression and failure to reintegrate socially were experienced by most patients. CONCLUSION This series confirms the lifesaving nature of hemicraniectomy in patients deteriorating because of cerebral edema after infarction. In patients younger than 50 years, recovery to a state of near-independence is possible.

Microfluidic isolation and transcriptome analysis of serum microvesicles

Microvesicles (exosomes) shed from both normal and cancerous cells may serve as means of intercellular communication. These microvesicles carry proteins, lipids and nucleic acids derived from the host cell. Their isolation and analysis from blood samples have the potential to provide information about state and progression of malignancy and should prove of great clinical importance as biomarkers for a variety of disease states. However, current protocols for isolation of microvesicles from blood require high-speed centrifugation and filtration, which are cumbersome and time consuming. In order to take full advantage of the potential of microvesicles as biomarkers for clinical applications, faster and simpler methods of isolation will be needed. In this paper, we present an easy and rapid microfluidic immunoaffinity method to isolate microvesicles from small volumes of both serum from blood samples and conditioned medium from cells in culture. RNA of high quality can be extracted from these microvesicles providing a source of information about the genetic status of tumors to serve as biomarkers for diagnosis and prognosis of cancer.

Long-term recurrence rates of atypical meningiomas after gross total resection with or without postoperative adjuvant radiation.

OBJECTIVEAtypical meningioma (AM) patients often undergo gross total resection (GTR) at the time of presentation, but subsequent prognosis and optimal management remain unclear. We sought to define the long-term recurrence rate of AMs after GTR, along with factors predicting recurrence, including postoperative radiation. METHODSWe performed a retrospective review of 108 AMs after GTR at our institution from 1993 to 2004. Recurrence risk factors were analyzed using multivariate Cox regression. RESULTSThere were 600 patient-years of imaging follow-up on 48 men and 60 women. Of 108 tumors, 30 (28%) recurred 3 to 144 months after GTR (mean, 36 months). Actuarial tumor recurrence rates were 7% (1 year), 41% (5 years), and 48% (10 years). Of 108 patients, 8 received postoperative radiation without recurrence (P = 0.1). Multivariate analysis including age, sex, postoperative radiation, tumor location, MIB-1 labeling index, and 6 atypical-defining histological features identified recurrence-predicting factors: older age (hazard ratio, 1.6/decade; P = 0.01), sheeting (hazard ratio, 2.2; P = 0.025), and prominent nucleoli (hazard ratio, 2.1; P = 0.034). Recursive partitioning identified a subset, men with mitoses and prominent nucleoli, with 70% recurrence (n = 14). All patients with recurrences received radiation, and 22 of 30 patients underwent craniotomies (average, 2.7 craniotomies per patient with recurrence; range, 1–7 craniotomies). Only 1 of 22 re-resected meningiomas underwent malignant transformation. Of 30 patients with recurrence, 10 experienced tumor-induced mortality an average of 7 years after recurrence (range, 1–14 years). CONCLUSIONAfter GTR without postoperative radiation, AMs have a high recurrence rate. Most recurrences occurred within 5 years after resection. Recurrences caused numerous reoperations per patient and shortened survival. Our finding suggesting lower recurrence rates in patients undergoing immediate postoperative radiation should be investigated in larger, prospective series.

MICROVASCULAR DECOMPRESSION SURGERY IN THE UNITED STATES, 1996 TO 2000: MORTALITY RATES, MORBIDITY RATES, AND THE EFFECTS OF HOSPITAL AND SURGEON VOLUMES

OBJECTIVEMicrovascular decompression (MVD) is associated with low mortality and morbidity rates at specialized centers, but many MVD procedures are performed outside such centers. We studied short-term end points after MVD in a national hospital discharge database sample. METHODSA retrospective cohort study was performed by using the Nationwide Inpatient Sample, 1996 to 2000. RESULTSThe sample included 1326 MVD procedures for treatment of trigeminal neuralgia, 237 for treatment of hemifacial spasm, and 27 for treatment of glossopharyngeal neuralgia, performed at 305 hospitals by 277 identified surgeons. The mortality rate was 0.3%, and the rate of discharge other than to home was 3.8%. Neurological complications were coded in 1.7% of cases, hematomas in 0.5%, and facial palsies in 0.6%, with 0.4% of patients requiring ventriculostomies and 0.7% postoperative ventilation. Trigeminal nerve section was also coded for 3.4% of patients with trigeminal neuralgia, more commonly among older patients (P = 0.08), among female patients (P = 0.03), and at teaching hospitals (P = 0.02). The median annual caseloads were 5 cases per hospital (range, 1–195 cases) and 3 cases per surgeon (range, 1–107 cases). With adjustment for age, sex, race, primary insurance, diagnosis (trigeminal neuralgia versus hemifacial spasm versus glossopharyngeal neuralgia), geographic region, admission type and source, and medical comorbidities, outcomes at discharge were superior at higher-volume hospitals (P = 0.006) and with higher-volume surgeons (P = 0.02). Complications were less frequent after surgery performed at high-volume hospitals (P = 0.04) or by high-volume surgeons (P = 0.01). The rate of discharge other than to home was 5.1% for the lowest-volume-quartile hospitals, compared with 1.6% for the highest-volume-quartile hospitals. Volume and mortality rate were not significantly related, but three of the four deaths in the series followed procedures performed by surgeons who had performed only one MVD procedure that year. Length of stay (median, 3 d) and hospital volume were not significantly related. Hospital charges were slightly higher at higher-volume hospitals (P = 0.007). CONCLUSIONAlthough most MVD procedures in the United States are performed at low-volume centers, mortality rates remain low. Morbidity rates are significantly lower at high-volume hospitals and with high-volume surgeons.

Results of a prospective protocol of computed tomographic angiography in place of catheter angiography as the only diagnostic and pretreatment planning study for cerebral aneurysms by a combined neurovascular team.

OBJECTIVE:At many centers, patients undergo both computed tomographic angiography (CTA) and digital subtraction angiography (DSA). This practice negates most of the advantages of CTA, and it renders the risks and disadvantages of the two techniques additive. Previous reports in the literature have assessed the sensitivity and specificity of CTA compared with DSA; however, these investigations have not analyzed the clinical implications of a protocol that replaces DSA with CTA as the only diagnostic and pretreatment planning study for patients with cerebral aneurysms. METHODS:Since late 2001/early 2002, the combined neurovascular unit of the Massachusetts General Hospital has adopted a prospective protocol of CTA in place of DSA as the only diagnostic and pretreatment planning study for patients with cerebral aneurysms (ruptured and unruptured). We report the results obtained during the 12-month period from January 2002 to January 2003. RESULTS:During the study period, 223 patients with cerebral aneurysms underwent initial diagnostic evaluation for cerebral aneurysm by the combined neurovascular team of Massachusetts General Hospital. Of the 223 patients, 109 patients had confirmed subarachnoid hemorrhage (Group A) and 114 patients did not have SAH (Group B). All of these patients were included in the prospective CTA protocol. Cerebral aneurysm treatment was initiated on the basis of CTA alone in 93 Group A patients (86%), in 89 Group B patients (78%), and in 182 patients (82%) overall. Treatment consisted of surgical clipping in 152 patients (68%), endovascular coiling in 56 patients (25%), endovascular parent artery balloon occlusion in 4 patients (2%), and external carotid artery to internal carotid artery bypass and carotid artery surgical occlusion in 2 patients (1%). Nine patients (4%) did not undergo treatment. The cerebral aneurysm detection rate by CTA was 100% for the presenting aneurysm (ruptured aneurysm in Group A or symptomatic/presenting aneurysm in Group B) in both groups. The detection rate by CTA for total cerebral aneurysms, including incidental multiple aneurysms, was 95.3% in Group A, 98.3% in Group B, and 97% overall. The overall morbidity associated with DSA (pretreatment or as intraoperative or postoperative clip evaluation) was one patient (1.3%) with a minor nonneurological complication, one patient (1.3%) with a minor neurological complication, and no patients (0%) with a major neurological complication. CONCLUSION:We have demonstrated promising results with a prospective protocol of CTA in place of DSA as the only diagnostic and pretreatment planning study for patients with ruptured and unruptured cerebral aneurysms. It seems safe and effective to make decisions regarding treatment on the basis of CTA, without performing DSA, in the majority of patients with ruptured and unruptured cerebral aneurysms.

Adult-Born and Preexisting Olfactory Granule Neurons Undergo Distinct Experience-Dependent Modifications of their Olfactory Responses In Vivo

Neurogenesis continues throughout adulthood in the mammalian olfactory bulb and hippocampal dentate gyrus, suggesting the hypothesis that recently generated, adult-born neurons contribute to neural plasticity and learning. To explore this hypothesis, we examined whether olfactory experience modifies the responses of adult-born neurons to odorants, using immediate early genes (IEGs) to assay the response of olfactory granule neurons. We find that, shortly after they differentiate and synaptically integrate, the population of adult-born olfactory granule neurons has a greater population IEG response to novel odors than mature, preexisting neurons. Familiarizing mice with test odors increases the response of the recently incorporated adult-born neuron population to the test odors, and this increased responsiveness is long lasting, demonstrating that the response of the adult-born neuron population is altered by experience. In contrast, familiarizing mice with test odors decreases the IEG response of developmentally generated neurons, suggesting that recently generated adult-born neurons play a distinct role in olfactory processing. The increased IEG response is stimulus specific; familiarizing mice with a set of different, “distractor” odors does not increase the adult-born neuron population response to the test odors. Odor familiarization does not influence the survival of adult-born neurons, indicating that the changes in the population response of adult-born neurons are not attributable to increased survival of odor-stimulated neurons. These results demonstrate that recently generated adult-born olfactory granule neurons and older, preexisting granule neurons undergo contrasting experience-dependent modifications in vivo and support the hypothesis that adult-born neurons are involved in olfactory learning.