Jos M. A. Kuijlen

Target cell‐restricted and ‐enhanced apoptosis induction by a scFv:sTRAIL fusion protein with specificity for the pancarcinoma‐associated antigen EGP2

The apparent tumor selective apoptosis‐inducing activity of recombinant soluble TNF‐related apoptosis‐inducing ligand (TRAIL) has aroused much interest for use in clinical application. However, to exploit fully its therapeutic potential, the characteristics of both the TRAIL receptor system and soluble TRAIL (sTRAIL) should be taken into account: first, the widespread expression of the various TRAIL receptors throughout the human body; second, the differential binding affinities and crosslinking requirements of the agonistic receptors TRAIL‐R1 and TRAIL‐R2; and third, the solution behavior of particular sTRAIL preparations. Therefore, we constructed a novel TRAIL fusion protein, designated scFvC54:sTRAIL, comprising the human scFv antibody fragment C54 genetically linked to the N‐terminus of human sTRAIL. The scFvC54:sTRAIL fusion protein was designed to induce apoptosis by crosslinking of agonistic TRAIL receptors only after specific binding of scFvC54:sTRAIL to the abundantly expressed carcinoma‐associated cell surface antigen EGP2 (alias EpCAM). Target antigen‐restricted apoptosis induction was demonstrated for various EGP2‐positive tumor cells and could be inhibited by an EGP2 competing antibody. Target antigen binding converted soluble scFvC54:sTRAIL into a membrane‐bound form of TRAIL that was capable of signaling apoptosis not only through TRAIL‐R1 but also through TRAIL‐R2. Size‐exclusion fast protein liquid chromatography (FPLC) indicated that scFvC54:sTRAIL was produced as stable and homogeneous trimers in the absence of detectable TRAIL aggregates. The favorable characteristics of the scFvC54:sTRAIL fusion protein potentially reduce the amount of sTRAIL required for antitumor activity and may be of value for the treatment of various human carcinomas.

TRAIL-receptor expression is an independent prognostic factor for survival in patients with a primary glioblastoma multiforme.

SummaryPurposeIn order to improve the survival of patients with a glioblastoma multiforme tumor (GBM), new therapeutic strategies must be developed. The use of a death inducing ligand such as TRAIL (TNF Related Apoptosis Inducing Ligand) seems a promising innovative therapy. The aim of this study was to quantify the expression of the death regulating receptors TRAIL-R1, TRAIL-R2 and TRAIL on primary GBM specimens and to correlate this expression with survival.Experimental designExpression of TRAIL and TRAIL-receptors was assessed by immunohistochemistry, both quantitatively (% of positive tumor cells) and semi-quantitatively (staining intensity) within both the perinecrotic and intermediate tumor zones of primary GBM specimens. RT-PCR of GBM tissue was performed to show expression of TRAIL receptor mRNA.ResultsImmunohistochemistry showed a slight diffuse intracytoplasmic and a stronger membranous staining for TRAIL and TRAIL receptors in tumor cells. Semi-quantitative expression of TRAIL showed a significantly higher expression of TRAIL in the perinecrotic zone than in the intermediate zone of the tumor (P=0.0001). TRAIL-R2 expression was significantly higher expressed than TRAIL-R1 (P=0.005). The antigenic load of TRAIL-R2 was positively correlated with survival (P=0.02). Multivariate analysis of TRAIL-R1 within the study group (n=62) showed that age, gender, staining intensity, antigenic load, % of TRAIL-R1 expression, were not statistically correlated with survival however radiotherapy was significantly correlated (multivariate analysis: age: P=0.15; gender: P=0.64; staining intensity: P=0.17; antigenic load: P=0.056; % of TRAIL-R1 expression: P=0.058; radiotherapy: P=0.0001). Subgroup analysis of patients who had received radiotherapy (n=47) showed a significant association of % of TRAIL-R1 expression and the antigenic load of TRAIL-R1 with survival (multivariate analysis: P=0.036, respectively, P=0.023).Multivariate analysis of TRAIL-R2 staining intensity and antigenic load, within the study group (P=0.004, respectively, P=0.03) and the subgroup (P=0.002, respectively, P=0.004), showed a significant association with survival. RT-PCR analysis detected a negative relation between the amount of TRAIL-R1 mRNA and the WHO grade of astrocytic tumors (P=0.03).ConclusionsTRAIL-R1 and TRAIL-R2 expression on tumor cells are independent prognostic factors for survival in patients with a glioblastoma multiforme. Both receptors could be targets for TRAIL therapy. As TRAIL-R2 is more expressed, in comparison with TRAIL-R1, on GBM tumor cells, TRAIL-R2 seems to be of more importance as a target for future TRAIL therapy than TRAIL-R1.

Review: On TRAIL for malignant glioma therapy?

J. M. A. Kuijlen, E. Bremer, J. J. A. Mooij, W. F. A. den Dunnen and W. Helfrich (2010) Neuropathology and Applied Neurobiology36, 168–182
On TRAIL for malignant glioma therapy?

The efficacy of alginate encapsulated CHO-K1 single chain-TRAIL producer cells in the treatment of brain tumors

SummaryObjectPatients with astrocytic tumors in the central nervous system (CNS) have low survival rates despite surgery and radiotherapy. Innovative therapies and strategies must be developed to prolong survival of these patients. The alginate microencapsulation method, used to continuously release a certain cytotoxic agent in the vicinity of the tumor, is such a novel therapeutic strategy. The biological functionality of the apoptosis inducing scFv425:sTRAIL protein, which was released through the microencapsulation method, was studied in vitro. Analysis of the intracerebral biocompatibility of alginate capsules was performed by implantation of empty alginate capsules in the brain of mice.MethodChinese Hamster Ovary cells (CHO-K1) were recombinantly engineered to produce the single chain anti-EGFR-sTRAIL protein (scFv425:sTRAIL). The CHO-K1 producer cells were encapsulated in an alginate capsule with a semi-permeable membrane through which the scFv425:sTRAIL protein could be released.ResultsIn vitro studies show maintained biological functionality of the released scFv425:sTRAIL protein. There was no immunological tissue response detectable after intracerebral implantation of the alginate capsules in mice brains.ConclusionBiological functionality of the produced scFv425:sTRAIL protein is maintained and intracerebral biocompatibility of the capsules is warranted. Alginate encapsulation of CHO-K1 - scFv425:sTRAIL - producer cells and subsequently their intracerebral implantation is technically feasible. This study justifies further in vivo experiments.

Bilateral versus unilateral interlaminar approach for bilateral decompression in patients with single-level degenerative lumbar spinal stenosis : a multicenter retrospective study of 175 patients on postoperative pain, functional disability, and patient satisfaction

OBJECT The bilateral and unilateral interlaminar techniques for bilateral decompression both demonstrate good results for the treatment of degenerative lumbar spinal stenosis (DLSS). Although there is some discussion about which approach is more effective, studies that directly compare these two popular techniques are rare. To address this shortcoming, this study compares postoperative functional disability, pain, and patient satisfaction among patients with single-level DLSS who underwent bilateral decompression using either a bilateral or unilateral approach. METHODS This retrospective study included patients who underwent operations between November 1, 2009, and October 1, 2011. These patients underwent single-level bilateral decompressive surgery using either the bilateral or unilateral interlaminar approach at one of 5 participating hospitals. Exclusion criteria included previous lumbar surgery, additional disc surgery, and spondylolisthesis requiring fusion surgery. Primary outcome measures included bodily pain (as reported using the visual analog scale [VAS]), the Roland-Morris Disability Questionnaire (RMDQ), and the Oswestry Disability Index (ODI). In addition, reductions in leg and back symptoms and the patients general evaluation of the procedure were queried. Finally, patient satisfaction and surgical parameters were evaluated. Questionnaires were sent to each patients home, and electronic patient files were used to collect the data. RESULTS One hundred and seventy-five patients returned the questionnaire (74.4% response rate; 68 and 107 patients who underwent the bilateral or unilateral approach, respectively). Mean age at surgery was 68 years (range 34-89 years), and the mean follow-up period was 14.2 months (range 3.3-27.4 years). There were no significant differences in ODI (20.3 vs 22.6 for the bilateral and unilateral approaches, respectively), RMDQ (3.99 vs 4.8, respectively), or pain scores between treatment groups. Back symptoms were reduced in 74.8% (bilateral: 74.6% vs unilateral: 75%; not significant), and leg symptoms in 80.6% of the patients (bilateral: 73.1% vs unilateral: 85.4%; p = 0.048). In total, 72.1% (bilateral) and 80.0% (unilateral) of patients reported good overall treatment results (p = 0.226). Significantly more patients in the unilateral group reported a better overall satisfaction with the procedure (82.1% vs 69.1%; p = 0.047). CONCLUSIONS There were no differences in postoperative functional disability and pain between the surgical techniques. The significant differences in patient satisfaction and reduction in leg symptoms were unrelated to surgical technique. The overall treatment results were satisfactory. Both techniques are safe and effective options for treating patients with single-level DLSS.

Surgery on spinal epidural metastases (SEM) in renal cell carcinoma: a plea for a new paradigm

BACKGROUND CONTEXT Prediction models for outcome of decompressive surgical resection of spinal epidural metastases (SEM) have in common that they have been developed for all types of SEM, irrespective of the type of primary tumor. It is our experience in clinical practice, however, that these models often fail to accurately predict outcome in the individual patient. PURPOSE To investigate whether decision making could be optimized by applying tumor-specific prediction models. For the proof of concept, we analyzed patients with SEM from renal cell carcinoma that we have operated on. STUDY DESIGN/SETTING Retrospective chart analysis 2006 to 2012. PATIENT SAMPLE Twenty-one consecutive patients with symptomatic SEM of renal cell carcinoma. OUTCOME MEASURES Predictive factors for survival. METHODS Next to established predictive factors for survival, we analyzed the predictive value of the Motzer criteria in these patients. The Motzer criteria comprise a specific and validated risk model for survival in patients with renal cell carcinoma. RESULTS After multivariable analysis, only Motzer intermediate (hazard ratio [HR] 17.4, 95% confidence interval [CI] 1.82-166, p=.01) and high risk (HR 39.3, 95% CI 3.10-499, p=.005) turned out to be significantly associated with survival in patients with renal cell carcinoma that we have operated on. CONCLUSIONS In this study, we have demonstrated that decision making could have been optimized by implementing the Motzer criteria next to established prediction models. We, therefore, suggest that in future, in patients with SEM from renal cell carcinoma, the Motzer criteria are also taken into account.

Study protocol for a randomised controlled multicentre study: the Foraminotomy ACDF Cost-Effectiveness Trial (FACET) in patients with cervical radiculopathy

Introduction Cervical radiculopathy due to discogenic or spondylotic stenosis of the neuroforamen can be surgically treated by an anterior discectomy with fusion (ACDF) or a posterior foraminotomy (FOR). Most surgeons prefer ACDF, although there are indications that FOR is as effective as ACDF, has a lower complication rate and is less expensive. A head-to-head comparison of the 2 surgical techniques in a randomised controlled trial has not yet been performed. The study objectives of the Foraminotomy ACDF Cost-Effectiveness Trial (FACET) study are to compare clinical outcomes, complication rates and cost-effectiveness of FOR to ACDF. Methods and analysis The FACET study is a prospective randomised controlled trial conducted in 7 medical centres in the Netherlands. The follow-up period is 2 years. The main inclusion criterion is a radiculopathy of the C4, C5, C6 or C7 nerve root, due to a single-level isolated cervical foraminal stenosis caused by a soft disc and/or osteophytic component, requiring operative decompression. A sample size of 308 patients is required to test the hypothesis of clinical non-inferiority of FOR versus ACDF. Primary outcomes are: ‘operative success’, the measured decrease in radiculopathy assessed by the visual analogue scale and ‘patient success’, assessed by the modified Odoms criteria. Secondary outcomes are: Work Ability Index (single-item WAI), quality of life (EuroQol 5 Dimensions 5 level Survey, EQ-5D-5L), Neck Disability Index (NDI) and complications. An economic evaluation will assess cost-effectiveness. In addition, a budget impact analysis will be performed. Ethics and dissemination Ethical approval was obtained from the Institutional Ethics Committee of the University Medical Center Groningen. Results of this study will be disseminated through national and international papers. The participants and relevant patient support groups will be informed about the results of the study. Trial registration number NTR5536, pre-results.

Minimally invasive surgery versus open surgery in the treatment of lumbar spondylolisthesis: study protocol of a multicentre, randomised controlled trial (MISOS trial)

Introduction Patients with symptomatic spondylolisthesis are frequently treated with nerve root decompression, in addition to pedicle screw fixation and interbody fusion. Minimally invasive approaches are gaining attention in recent years, although there is no clear evidence supporting the proclamation of minimally invasive spine surgery (MISS) being better than open surgery. We present the design of the MISOS (Minimal Invasive Surgery versus Open Surgery) trial on the effectiveness of MISS versus open surgery in patients with degenerative or spondylolytic spondylolisthesis. Methods and analysis All patients (age 18–75 years) with neurogenic claudication or radicular leg pain based on low-grade degenerative or spondylolytic spondylolisthesis with persistent complaints for at least 3 months are eligible. Patients will be randomised into mini-open decompression with bilateral interbody fusion with percutaneous pedicle screw fixation (MISS), or conventional surgery with decompression and instrumented fusion with pedicle screws and bilateral interbody fusion (open). The primary outcome measure is Visual Analogue Scale of self-reported low back pain. Secondary outcome measures include improvement of leg pain, Oswestry Disability Index, patients’ perceived recovery, quality of life, resumption of work, complications, blood loss, length of hospital stay, incidence of reoperations and documentation of fusion. This study is designed as a multicentre, randomised controlled trial in which two surgical techniques are compared in a parallel group design. Based on a 20 mm difference of low back pain score at 6 weeks (power of 90%, assuming 8% loss to follow-up), a total of 184 patients will be needed. All analyses will be performed according to the intention-to-treat principle. Ethics and dissemination The study has been approved by the Medical Ethical Review Board Southwest Holland in August 2014 (registration number NL 49044.098.14) and subsequently approved by the board of all participating hospitals. Dissemination will include peer-reviewed publications and presentations at national and international conferences. Trial registration number NTR 4532, pre-results.

Acute hydrocephalus in a child with a third ventricle arachnoid cyst and coincidental enteroviral meningitis

We present a 2.5-year-old child suffering from acute hydrocephalus. First, the child was diagnosed with aseptic viral meningitis. The PCR of the cerebrospinal fluid (CSF) was positive for enterovirus. Subsequently, MRI revealed that the hydrocephalus was caused by a cyst in the third ventricle. During ventriculoscopy, the cyst had all aspects of an arachnoid cyst. An endoscopic fenestration and partial removal of the cyst was performed, combined with a ventriculocisternostomy. The coincidental finding of viral meningitis and a third ventricle arachnoid cyst in a patient with acute hydrocephalus has, to our knowledge, not been described in literature before. If there is a relation between the enteroviral meningitis, the arachnoid cyst (possibly causing a pre-existing subclinical hydrocephalus) and the rapidly evolving neurological deterioration, remains speculative. Proposed mechanisms, by which the viral meningitis could accelerate the disease process, are slight brain swelling or increased CSF production. This rare combination of diagnoses could also be coincidental.

Successful surgical treatment of an arachnoid cyst inducing a Holmes' tremor

A 25-year-old man presented with a progressively developing tremor of his left arm provoked by stressful events. A Holmes’ tremor of the left arm (2–5 Hz) was diagnosed. MRI demonstrated a suprasellar arachnoid cyst (Fig. 1) compressing the mesencephalon and cerebral peduncle. The cyst was fenestrated by a pterional craniotomy. After the surgical procedure, the tremor had completely resolved. Postoperative imaging revealed a satisfying fenestration with flow voids in the collapsed cyst, indicating the presence of cerebrospinal fluid flow within the lesion (Fig. 2). The imaging also shows a remarkable unfolding of the brainstem.