Keith M. Rich

Randomized Phase II Study of Cilengitide, an Integrin-Targeting Arginine-Glycine-Aspartic Acid Peptide, in Recurrent Glioblastoma Multiforme

PURPOSE Cilengitide, an inhibitor of alphavbeta3 and alphavbeta5 integrin receptors, demonstrated minimal toxicity and durable activity across a wide range of doses administered to adults with recurrent glioblastoma multiforme (GBM) in a prior phase I study. The current multicenter phase II study was conducted to evaluate the activity and safety of cilengitide in GBM patients at first recurrence. PATIENTS AND METHODS Eligible patients were randomly assigned to receive either 500 or 2,000 mg of cilengitide twice weekly on a continuous basis. Patients were assessed every 4 weeks. The primary end point was 6-month progression-free survival (PFS) rate. Secondary end points included PFS, overall survival (OS), and radiographic response, as well as quality-of-life and pharmacokinetic assessments. RESULTS Eighty-one patients were enrolled, including 41 on the 500-mg arm and 40 on the 2,000-mg arm. The safety profile of cilengitide was excellent, with no significant reproducible toxicities observed on either arm. Antitumor activity was observed in both treatment cohorts but trended more favorably among patients treated with 2,000 mg, including a 6-month PFS of 15% and a median OS of 9.9 months. CONCLUSION Cilengitide monotherapy is well tolerated and exhibits modest antitumor activity among recurrent GBM patients. Additional studies integrating cilengitide into combinatorial regimens for GBM are warranted.

Nerve growth factor protects adult sensory neurons from cell death and atrophy caused by nerve injury

SummaryThe reaction of dorsal root ganglia (DRG) neurons to axotomy and its alteration by locally supplied nerve growth factor (NGF) were examined in adult rats. Surgically implanted silicone chambers attached to the severed tip of the sciatic nerve acted as reservoirs capable of providing prolonged access of NGF to the site of injury. The time course of NGF activity within the chambers was determined by using the standard NGF chick DRG bioassay. The fluid from chambers filled with the NGF-saline solution maintained NGF activity for periods up to 6 weeks after implantation. By 9 weeks, however, the fluid from most chambers failed to show any NGF activity in the bioassay.Experiments were designed to compare the response in adult rats to injury of DRG neurons receiving chambers filled with either NGF-saline or with only saline. The total neuronal counts in the lumbar fourth and fifth DRG at 3 weeks and 6 weeks after sciatic nerve section showed 22% and 16% cell death, respectively, in those injured neurons receiving saline-filled chamber implants. The animals that received chamber implants which contained an NGF-saline solution showed no cell death in the ipsilateral DRG at either 3 or 6 weeks after injury. Morphometric analysis of injured DRG neurons showed evidence of atrophy in the injured neurons which did not receive NGF. The degree of atrophy among all cell sizes was significantly decreased in those injured neurons receiving NGF. At 3 weeks after section the mean volume of injured neurons not treated with NGF was decreased by 28% as compared with only a 13% decrease in neurons treated with NGF. Similar findings were noted in the 6-week studies. NGF treatment did not alter the incidence of classic changes of chromatolysis in the groups of injured neurons receiving either NGF-saline-filled chambers or only saline-filled chambers.

Clinical Features and Outcome in North American Adults With Moyamoya Phenomenon

Background and Purpose— To describe baseline clinical features and outcomes of adults with moyamoya phenomenon treated at a single North American institution. Methods— We identified 34 adults with moyamoya phenomenon by review of angiographic records. Clinical presentation and baseline stroke risk factors were obtained by chart review. Follow-up was obtained prospectively. A 5-year Kaplan-Meier stroke risk was calculated. Results— The median age was 42 (range 20 to 79) years. Twenty-five were women. The initial symptom was ischemia, hemorrhage, or asymptomatic in 24, 7, and 3 patients, respectively. Twenty-two had bilateral involvement and 12 had unilateral moyamoya vessels. Baseline stroke risk factors were similar between groups. The median follow-up in 31 living patients was 5.1 (range 0.2 to 19.6) years. Fourteen patients were treated with surgical revascularization (20 total hemispheres). In medically treated symptomatic hemispheres, the 5-year risk of recurrent ipsilateral stroke was 65% after the initial symptom and 27% after angiographic diagnosis. Patients with bilateral involvement presenting with ischemic symptoms were at the highest risk of subsequent stroke (n=17, 5-year risk of stroke with medical treatment after first symptom of 82%). In surgically treated hemispheres, the 5-year risk of perioperative or subsequent ipsilateral stroke or death was 17%. This was significantly different compared with medical treatment after first symptom (P=0.02) but not after angiographic diagnosis. Conclusion— Moyamoya phenomenon in North American adults is associated with a high risk of recurrent stroke, particularly those with bilateral involvement and ischemic symptoms. These data suggest a potential benefit with surgery if diagnosis could be made earlier.

The role of NGF in sensory neurons in vivo

Abstract Somatic sensory neurons have two target areas, one in the peripheral end organ and the other within the central nervous system. For many decades, it was thought that only the peripheral target was important for the survival of developing and mature sensory neurons. Nerve growth factor (NGF), which is required for the survival of embryonic sensory neurons in vitro , was thought to provide peripherally derived trophic support only during development and that mature sensory neurons were insensitive to NGF. In this article we review recent evidence which demonstrates a broader role for NGF and for the central target in the maintenance of sensory neurons. We review the biology of NGF in relationship to the life history of sensory neurons, the potential use of NGF as a pharmacological agent to ameliorate the effects of injury, and new data establishing the central target tissue as a source of neurotrophic support.

Nerve growth factor enhances regeneration through silicone chambers.

The effect of exogenous NGF on axonal growth across a gap between sectioned ends of a sciatic nerve within silicone chambers was examined in Sprague-Dawley rats. After nerve section and surgical implantation, silicone chambers were filled with either a 1 mg/ml nerve growth factor (NGF)/saline solution (experimental) or a normal saline solution (control). Four weeks after surgery, the regenerated nerves from within the silicone chambers were dissected and fixed for histological studies at both light microscopic and ultrastructural levels. Morphological analysis of the nerves showed no difference between the NGF-treated and control groups in the size of the regenerated nerves within the chambers or in the diameters of myelinated axons. Total myelinated axonal counts were determined from within the distal chamber. NGF significantly increased the number of myelinated axons that grew into the distal end of the chamber (2126 +/- 437 NGF/saline; 1064 +/- 268 saline; P less than 0.05 Students t test). Counts of the unmyelinated axons from the distal nerve segment from the two groups were not different. Myelin sheath thickness was 58% greater in the NGF-treated group compared with that in the saline group. There was no difference between the two groups in the size-frequency spectra of the diameters of the myelinated axons in the distal segment. The NGF/saline group showed a more mature-appearing regenerated nerve based on the percentage of myelinated axons, thickness of the myelin sheaths, and development of internal organization (e.g., amount of endoneurial collagen fibers, ensheathment of unmyelinated axons by Schwann cells, and interfascicular patterns).(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of fibronectin and laminin during Schwann cell migration and peripheral nerve regeneration through silicon chambers

SummaryThe ability of extracellular proteins to influence the regenerative process was examined in Sprague-Dawley rats. Silicon chambers, filled with sterile saline solutions of cytochrome-c, fibronectin, laminin, a combination of fibronectin and laminin, or nerve growth factor were surgically implanted between the severed ends of sciatic nerves to form gaps of 18 mm. Four months later, the various groups were examined to determine the success of regeneration. The incidence of cable formation that bridged the gap was similar in all groups. The group of animals that had implants containing the combination of fibronectin/laminin had increased numbers of myelinated axons in the regenerated segment within the chamber and in the distal sciatic tributary nerves. Horseradish peroxidase labelling demonstrated that increased numbers of sensory and motor neurons in the fibronectin/laminin group had regenerated axons across the gap into the distal tributaries of the sciatic nerve.The effect of the various agents on non-neuronal cells was measured by immunohistochemical staining with S-100 antibodies to determine the effects on Schwann cell migration. Silicon chambers, filled with sterile saline solutions of fibronectin, laminin, fibronectin/laminin, nerve growth factor, or cytochrome-c, were surgically implanted to form 5 mm gaps between severed sciatic nerve ends. Ten days later, Schwann cell migration into the bridging cables was examined in each group. Analysis revealed a greater influx of Schwann cells migrating into the regenerating segments in the fibronectin, the laminin, and the combination fibronectin/laminin groups compared to the control group (cytochrome-c).

Transglutaminase 2 inhibitor, KCC009, disrupts fibronectin assembly in the extracellular matrix and sensitizes orthotopic glioblastomas to chemotherapy

Transglutaminase 2 (TG2, a.k.a. tissue transglutaminase) belongs to a family of transglutaminase enzymes that stabilize proteins by affecting covalent crosslinking via formation of amide bonds. Cell surface TG2 is directly involved as an adhesive receptor in cell–extracellular matrix (ECM) interactions. Here, we show that TG2 activity is elevated in glioblastomas compared with non-neoplastic brain. Immunofluorescent studies showed increased staining of fibronectin colocalized with TG2 in the ECM in glioblastomas. In addition, small clusters of invading human glioblastoma cells present in non-neoplastic brain parenchyma secrete high levels of TG2 and fibronectin that distinguish them from normal brain stroma. Downregulation of TG2 in U87MG glioblastoma cells with RNAi demonstrated decreased assembly of fibronectin in the ECM. Treatment with KCC009 blocked the remodeling of fibronectin in the ECM in glioblastomas in both in vitro and in vivo studies. KCC009 treatment in mice harboring orthotopic glioblastomas (DBT-FG) sensitized the tumors to N,N′-bis(2-chloroethyl)-N-nitrosourea chemotherapy, as measured by reduced bioluminescence, increased apoptosis and prolonged survival. The ability of KCC009 to interfere with the permissive remodeling of fibronectin in the ECM in glioblastomas suggests a novel target to enhance sensitivity to chemotherapy directed not only at the tumor mass, but also invading glioblastoma cells.

Diffusion-weighted MR imaging in the preoperative assessment of brain abscesses.

BACKGROUND Diffusion-weighted MR imaging (DWI) has recently shown promise in differentiating ring-enhancing lesions such as brain abscess and malignant neoplasm. The ability of DWI to strongly suggest brain abscess enables a neurosurgeon to alter stereotactic planning to optimize diagnosis. We report our experience with DWI in 5 patients with lesions on MR imaging and review the literature to assess the usefulness of this technique in the preoperative evaluation of cerebral abscess. METHODS The MR images of 5 patients presenting with ring-enhancing lesions that ultimately proved to be brain abscesses were retrospectively reviewed. In addition to standard MR sequences, trace DWI and apparent diffusion coefficient (ADC) calculations were performed on all patients. Additionally, 15 recently published articles or references in press concerning DWI in cerebral abscesses were reviewed. RESULTS All lesions were markedly hyperintense on DWI and had diminished ADC. Thirty-eight of 39 previously reported abscesses were hyperintense on DWI with reduced ADC. Of 165 nonpyogenic lesions with DWI findings, 87 were hypointense or isointense, 78 lesions had variable hyperintensities, and few manifested the degree of hyperintensity observed with abscesses. Most of these included chordomas and epidermoids, which are not likely to be confused with abscesses. CONCLUSIONS Restricted water diffusion, as indicated by hyperintensity on DWI and low ADC, in ring-enhancing lesions assists in differentiating brain abscess from necrotic tumor. This information facilitates stereotactic surgical planning: abscesses should be preferentially centrally aspirated, whereas necrotic brain tumors should have diagnostic tissue biopsied from cavity walls. Although not definitive for brain abscess, restricted water diffusion is an important MR imaging sign and is useful in neurosurgical treatment strategies for ring-enhancing lesions.

Posterior Segmental Spinal Instrumentation (pssi) with Posterolateral Decompression and Debulking for Metastatic Thoracic and Lumbar Spine Disease: Limitations of the Technique

Twenty-five patients with metastatic thoracic and lumbar spine disease were initially treated by the authors with posterolateral debridement and decompression, along with posterior segmental spinal instrumentation. Ten patients had marked paresis, nine had signs of spinal cord or cauda equina compression without paresis, and all patients had pain severe enough to prevent sitting/standing/walking. The posterior approach was used in these patients instead of an anterior one because of translocation (4), three-column disease (16), three or more vertebral bodies involved (13), disease at two separate locations (2), and inability to tolerate an anterior approach (3). All patients had maintenance of spinal alignment for the length of follow-up or until their ultimate demise. Good pain relief was achieved in 19 of 25 patients. Six of ten patients with significant paresis recovered. Four patients developed recurrent spinal cord compression within 12 months postoperative from regrowth of tumor that was not controlled by radiotherapy or chemotherapy. Six of the 25 patients were not significantly palliated by the technique.

SCIATIC NERVE REGENERATION ACROSS GAPS WITHIN SILICONE CHAMBERS: LONG-TERM EFFECTS OF NGF AND CONSIDERATION OF AXONAL BRANCHING

We examined whether the short-term beneficial effects of nerve growth factor (NGF) upon regeneration are sustained over a prolonged period of time across 8-mm gaps within silicone chambers. Rat sciatic nerve regeneration both with and without NGF was examined after 10 weeks. Myelinated counts from the regenerated sciatic and distal tributary nerves were correlated to the numbers of motor and sensory neurons retrogradely labeled with horseradish peroxidase (HRP) applied distal to the regenerated segment. Regenerated sciatic and sural nerves were examined ultrastructurally for morphological analysis. Both regenerated groups by 10 weeks achieved essentially complete counts of myelinated axons in the distal tributary nerves and the regenerated segment of the sciatic nerve compared to the uninjured controls. There were similar numbers of retrogradely labeled sensory and motor neurons in the dorsal root ganglia (DRG) and lumbar spinal cord of both groups and, surprisingly, of the uninjured normal control group. Ultrastructural analysis demonstrated no difference in the distribution of axonal diameters or myelin thickness between the regenerated groups. In evaluating regeneration in experimental silicone chamber models, it is important to determine such parameters as the percentage of neurons that grow across the gap and the incidence of axonal sprouting. One can then make accurate assessments of experimental perturbations and predict whether they improve the naturally occurring regeneration through chambers. These results must ultimately be compared with equivalent determinations in the uninjured nerve. At 10 weeks there was essentially complete regeneration of both the NGF and control regenerative groups.(ABSTRACT TRUNCATED AT 250 WORDS)