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Avastin-induced tumor calcifications can be elicited in glioblastoma

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gdpawel
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Avastin (bevacizumab)-induced tumor calcifications can be elicited in glioblastoma microspheroid culture and represent massive calcium uptake death (MCAD) of tumor endothelial cells.

Larry Weisenthal, Summer Williamson, Cindy Brunschwiler, and Constance Rueff- Weisenthal

Bähr and colleagues reported that 22 of 36 glioblastoma patients treated with bevacizumab showed tumor calcifications on 8 week post therapy follow up with MRI. Early tumor calcification strongly predicted for response, time to progression, and overall survival (Neuro-Oncology, 13:1020, 2011, doi:10.1093/neuonc/nor099).

The authors didn't understand the mechanism, but speculated that it was vascular in nature.

At the 13th International Anti-Angiogenic Symposium (2011), we presented our discovery of the phenomenon of massive calcium accumulation death, wherein MCAD occurred in endothelial cells (tumor, circulating, and HUVEC), in response to VEGF depletion by bevacizumab and other putative anti-angiogenic agents, but not in response to non-specific cytotoxins.

In subsequent work, we have documented marked MCAD to occur in primary microcluster cultures from 6 fresh human glioblastoma biopsies, following 96 hours of VEGF depletion in vitro by Avastin (bevacizumab). The presence and degree of MCAD is strikingly dependent on the type of serum in the culture medium (RPMI-1640 + 25% serum) -- typically most striking in (very low VEGF) fetal calf serum, but inhibited (often) or enhanced (rarely) by 25% human serum from different patients or normal donors containing variable quantities of VEGF.

There was not a linear relationship between VEGF concentration and MCAD inhibition (or enhancement), suggesting that other pro-angiogenic (or anti-angiogenic) serum factors may play a role.

In epithelial metastatic tumors, circulating peripheral blood endothelial cells may be easily tested, using our methods, and the serum inhibition (or, rarely, enhancement) is faithfully reproduced on circulating endothelial cells, in comparison with the tumor cluster-associated endothelial cells.

We propose MCAD as the mechanism of glioblastoma calcification following Avastin (bevacizumab) and further propose that testing tumor microclusters and/or circulating endothelial cells, in the presence of autologous serum, could be a useful predictive biomarker and research tool.

Weisenthal, Larry. Bevacizumab-induced tumor calcifications can be elicited in glioblastoma microspheroid culture and represent massive calcium accumulation death (MCAD) of tumor endothelial cells. Available from Nature Precedings (2012)

http://precedings.nature.com/documents/7069/version/1

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gdpawel
Posts: 549
Joined: May 2001

Endothelial Massive Calcium Accumulation Death (MCAD): Mechanism, Target, and Predictive Biomarker for Anti-Angiogenic Therapy.

When you culture endothelial cells (either pure cultures of endothelial cells or endothelial cells associated with fresh human tumor microclusters) with Avastin, all of the VEGF gets pulled out of the culture medium and the endothelial cells undergo what is called "massive calcium accumulation death."

Cytotoxic anticancer drugs (topotecan, vinorelbine, melphalan, doxorubicin, cisplatin) antagonize the ability of Avastin to kill endothelial cells through this specific cell death mechanism. The standard, traditional cytotoxic drugs all inhibited Avastin, but the new, "targeted" drugs either don't inhibit it or actually enhance it (e.g. lapatinib, erlotinib).

Clinical trials have shown that the combination of chemotherapy with Avastin generally works better than either alone (that is, in situations where Avastin works at all). But this is because Avastin has a very long half life (weeks) and it has the opportunity to work at times when the drug levels of the standard anticancer drugs go down to undetectable levels (where they won't antagonize the ability of low VEGF to cause death of the tumor endothelial cells).

It would be predictive that continuous chemotherapy with a drug like Taxol would be antagonistic; so that intermittent, lower dose therapy might actually work much better than continuous high dose therapy. This is a theoretical extrapolation from cell culture data.

The mechanism of antagonism is that the "MCAD" (massive calcium accumulation death of endothelial cells) is a bioenergetically active process. I'm sure that there's a specific pathway for it that someone will eventually work out and that non-specific cytotoxins inhibit this active process and, thus, the withdrawal of VEGF can't trigger this active, MCAD form of endothelial cell death.

Bibliography relevant to AngioRx/Microvascular Viability assay (MVVA)

1. Weisenthal, L. M. Patel, N., Rueff-Weisenthal, C. (2008). "Cell culture detection of microvascular cell death in clinical specimens of human neoplasms and peripheral blood." J Intern Med 264(3): 275-287.

2. Weisenthal, L., Lee, DJ, and Patel, N. (2008). Antivascular activity of lapatinib and bevacizumab in primary microcluster cultures of breast cancer and other human neoplasms. ASCO 2008 Breast Cancer Symposium. Washington, D.C.: Abstract # 166. Slide presentation at: http://tinyurl.com/weisenthal-breast-lapatinib

3. Weisenthal, L. M. (2010). Antitumor and anti-microvascular effects of sorafenib in fresh human tumor culture in comparison with other putative tyrosine kinase inhibitors. J Clin Oncol 28, 2010 (suppl; abstr e13617)

4.Weisenthal, L., H. Liu, Rueff-Weisenthal, C. (2010). "Death of human tumor endothelial cells in vitro through a probable calcium-associated mechanism induced by bevacizumab and detected via a novel method." Nature Precedings 28 May 2010. from http://hdl.handle.net/10101/npre.2010.4499.1

5. Weisenthal, Larry. Endothelial Massive Calcium Accumulation Death (MCAD): Mechanism, Target, and Predictive Biomarker for Anti-Angiogenic Therapy. 13th international symposium on anti-angiogenic therapy: recent advances and future directions in basic and clinical cancer research. LaJolla, CA. February 2011
Available from Nature Precedings http://dx.doi.org/10.1038/npre.2011.6647.1> (2011)

6. Weisenthal, L, Williamson, S, Ryan, K, Brunshwiler, C, and Rueff-Weisenthal, C. Massive calcium uptake in human endothelial cells, submitted for publication.

7.Bevacizumab-induced tumor calcifications can be elicited in glioblastoma microspheroid culture and represent massive calcium uptake death (MCAD) of tumor endothelial cells. Larry Weisenthal, Summer Williamson, Cindy Brunschwiler, and Constance Rueff-Weisenthal, 14th International Anti-Angiogenesis Symposium, LaJolla CA, Feb 2012. Available from Nature Precedings http://dx.doi.org/10.1038/npre.2012.7069.1> (2012)

Weisenthal, Larry. Endothelial Massive Calcium Accumulation Death (MCAD): Mechanism, Target, and Predictive Biomarker for Anti-Angiogenic Therapy. Available from Nature Precedings (2011)

http://dx.doi.org/10.1038/npre.2011.6647.1

Poster Presentation

http://precedings.nature.com/documents/6647/version/1/files/npre20116647-1.pdf

gdpawel's picture
gdpawel
Posts: 549
Joined: May 2001

J Intern Med. 2008 Sep;264(3):275-87.

Cell culture detection of microvascular cell death in clinical specimens of human neoplasms and peripheral blood.

Weisenthal LM, Patel N, Rueff-Weisenthal C.

Weisenthal Cancer Group, Huntington Beach, CA 92647, USA. [email]mail@weisenthal.org

Abstract

BACKGROUND:

Angiogenesis studies are limited by the clinical relevance of laboratory model systems. We developed a new method for measuring dead microvascular (MV) cells in clinical tissue, fluid and blood specimens, and applied this system to make several potentially novel observations relating to cancer pharmacology.

METHODS:

Dead MV cells tend to have a hyperchromatic, refractile quality, further enhanced during the process of staining with Fast Green and counterstaining with either haematoxylin-eosin or Wright-Giemsa. We used this system to quantify the relative degree of direct antitumour versus anti-MV effects of cisplatin, erlotinib, imatinib, sorafenib, sunitinib, gefitinib and bevacizumab.

RESULTS:

Bevacizumab had striking anti-MV effects and minimal antitumour effects; cisplatin had striking antitumour effects and minimal anti-MV effects. The ;nib' drugs had mixed antitumour and anti-MV effects. Anti-MV effects of erlotinib and gefitinib were equal to those of sunitinib and sorafenib. There was no detectable VEGF in culture medium without cells; tumour cells secreted copious VEGF, reduced to undetectable levels by bevacizumab, greatly reduced by cytotoxic levels of cisplatin + anguidine, and variably reduced by DMSO and/or ethanol. We observed anti-MV additivity between bevacizumab and other drugs on an individual patient basis. Peripheral blood specimens had numerous MV cells which were strikingly visualized for quantification with public domain image analysis software using bevacizumab essentially as an imaging reagent.

CONCLUSIONS:

This system could be adapted for simple, inexpensive and sensitive/specific detection of tissue and circulating MV cells in a variety of neoplastic and non-neoplastic conditions, and for drug development and individualized cancer treatment.

PMID: 18793333 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/18793333

gdpawel's picture
gdpawel
Posts: 549
Joined: May 2001

It's neither. It gives a much better understanding of what happens when Avastin is used. In pharmacology, the term agonist-antagonist is used to refer to a drug which exhibits some properties of an agonist (a substance that fully activates the neuronal receptor that it attaches to) and some properties of an antagonist (a substance that attaches to a receptor but does not activate it or if it displaces an agonist at that receptor it seemingly deactivates it thereby reversing the effect of the agonist).

When you culture endothelial cells with Avastin, all the VEGF gets pulled out of the culture medium and the endothelial cells undergo what is called "massive calcium accumulation death." Cytotoxic anticancer drugs antagonize the ability of Avastin to kill endothelial cells through this specific cell death mechanism. What is unique is that standard, traditional cytotoxic drugs inhibit Avastin, but the new "targeted" drugs don't inhibit it.

Clinical trials have shown that the combination of conventional chemotherapy with Avastin generally works better than either alone. But this is because Avastin has a very long half life (weeks) and it has the opportunity to work at times when the drug levels of the standard anticancer drugs go down to undetectable levels, where they won't antagonize the ability of low VEGF to cause death of the tumor endothelial cells. In other words, intermittent, "low dose" therapy might actually work much better than continuous "high dose" therapy.

In cell-based functional profiling assays, conducted on human tumor samples utilizing native microspheroids (fresh, live cells, not cell lines) replete with vascular, stromal and inflammatory cells to analyze cellular responses in the context of the tumor microenvironment, this snapshot of cellular response recapitulates patient response to cytotoxic compounds, signal transduction inhibitors and growth factor agonists/antagonists in real time.

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gdpawel
Posts: 549
Joined: May 2001

A new population-based study has found that patients with glioblastoma who died in 2010, after the Food and Drug Administration (FDA) approval of bevacizumab, had lived significantly longer than patients who died of the disease in 2008, prior to the conditional approval of the drug for the treatment of the deadly brain cancer. Bevacizumab is used to treat patients with certain cancers whose cancer has spread. The study appears in the journal Cancer.

"There has been a great deal of debate about the effectiveness of bevacizumab in treating patients with glioblastoma," says lead author Derek Johnson, M.D., a neuro-oncologist at Mayo Clinic Cancer Center. "Our study found that, at the population level, treatment strategies involving bevacizumab prolonged survival in patients with progressive glioblastoma."

Researchers analyzed data on 5,607 adult patients from the National Cancer Institute (NCI) Surveillance, Epidemiology and End Results (SEER) database before and after the conditional approval of bevacizumab for the treatment of glioblastoma in 2009. The SEER database covers 18 geographic areas of the U.S., which collectively represent 28 percent of the U.S. population.

Researchers studied survival in 1,715 patients with glioblastoma who died in 2006, 1,924 who died in 2008 and 1,968 who died in 2010. "The difference in survival between 2008 and 2010 was highly significant and likely unrelated to any advancements in supportive care," Dr. Johnson says. "This study provides the strongest evidence to date that bevacizumab therapy improves survival in patients with glioblastoma."

Glioblastoma, is an aggressive cancer in which tumors grow rapidly and spread rapidly to new sites. It is the most common malignant brain tumor in adults and accounts for about 22 percent of all brain cancers. About 3,000 people develop a glioblastoma each year in the U.S.

References:

Glioblastoma survival in the United States improved after Food and Drug Administration approval of bevacizumab: A population-based analysis

http://onlinelibrary.wiley.com/doi/10.1002/cncr.28259/abstract

Co-authors include Heather Leeper, M.D., and Joon Uhm, M.D. both of Mayo Clinic. Article first published online: 18 JUL 2013; DOI: 10.1002/cncr.28259

Citation: Mayo Clinic. "Glioblastoma survival improved following FDA approval of bevacizumab." Medical News Today. MediLexicon, Intl., 21 Aug. 2013.

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gdpawel
Posts: 549
Joined: May 2001

Advanced imaging techniques may be able to distinguish which patients' tumors will respond to treatment with anti-angiogenic drugs and which will not. In patients newly diagnosed with the dangerous brain tumor glioblastoma, Massachusetts General Hospital (MGH) researchers report, those for whom treatment with the anti-angiogenic drug cediranib rapidly 'normalized' abnormal blood vessels around their tumors and increased blood flow within tumors survived significantly longer than did patients in whom cediranib did not increase blood flow. The report appears in PNAS Early Edition.

"Two recent phase III trials of another anti-angiogenic drug, bevacizumab, showed no improvement in overall survival for glioblastoma patients, but our study suggests that only a subset of such patients will really benefit from these drugs," explains Tracy Batchelor, MD, director of the Pappas Center for Neuro-Oncology at the MGH Cancer Center and co-lead and corresponding author of the current study. "Our results also verify that normalization of tumor vasculature appears to be the way that anti-angiogenic drugs enhance the activity of chemotherapy and radiation treatment."

Anti-angiogenic drugs, which block the action of factors that stimulate the growth of blood vessels, were first introduced for cancer treatment under the theory that they would act by 'starving' tumors of their blood supply. Since that time, however, new evidence has suggested that the drugs' benefits come through their ability to 'normalize' the abnormal, leaky vessels that usually surround and penetrate tumors, improving delivery of both chemotherapy drugs and the oxygen that is required for effective radiation therapy. This hypothesis was first proposed and has subsequently been developed by Rakesh Jain, PhD, senior author of the current study and director of the Steele Laboratory for Tumor Biology in the MGH Department of Radiation Oncology.

A 2007 clinical study led by Batchelor found evidence suggesting that cediranib, which has not yet received FDA approval, could temporarily normalize tumor vasculature in recurrent glioblastoma, but it was not clear what role normalization might have in patients' survival. In the past few years, several research teams with leadership from Batchelor, Jain and other co-authors of the current paper reported evidence that cediranib alone improved blood perfusion within recurrent glioblastoma tumors in a subset of patients and improved their survival. A Nature Medicine study published earlier this year used a technique called vessel architectural imaging (VAI), developed at the Martinos Center for Biomedical Imaging at MGH, to reveal that cediranib on its own improved the delivery of oxygen within tumors of some patients with recurrent glioblastoma.

Patients in the current study were participants in a clinical trial of cediranib plus radiation and chemotherapy for postsurgical treatment of newly diagnosed glioblastoma. Among participants in that trial, 40 also had advanced brain imaging with VAI and other MR imaging techniques. While all but one of the participants in the overall trial showed some evidence of vascular normalization and reduced edema - tissue swelling that can be dangerous within the brain - of the 40 who had imaging studies, only 20 were found to have persistent improvement in vessel perfusion. VAI also revealed improved oxygen delivery only in the patients with improved perfusion. Those patients ended up surviving about 9 months longer - 26 months, compared with 17 months - than did those whose perfusion levels remained stable or worsened. A comparison group of glioblastoma patients treated with radiation and chemotherapy only survived an average of 14 months.

"It's quite likely that the results we've found with cediranib will apply to other anti-angiogenics," Batchelor says. "In fact a presentation at a recent meeting showed that patients with improved perfusion from bevacizumab were also the ones in that study who lived longer. More research is needed, but these findings suggest that MR imaging techniques should play an essential role in future studies of anti-angiogenic drugs in glioblastoma and possibly other types of solid tumors. We've received National Cancer Institute funding to study this approach with bevacizumab treatment, and we will also be investigating tumor delivery of chemotherapy and oxygen status using combined MR/PET techniques at the Martinos Center's MR/PET facility."

Jain adds, "We originally introduced the normalization hypothesis for anti-angiogenic treatment in 2001, but it's taken more than a decade to confirm that vascular normalization actually increases tumor perfusion and that increased perfusion, rather than tumor starvation, is what improves survival. This study provides compelling evidence that normalization-induced increased vessel perfusion is the mechanism of benefit in glioblastoma patients." Jain is the Cook Professor of Radiation Oncology (Tumor Biology), and Batchelor is the Armenise-Harvard Professor of Neurology at Harvard Medical School.

References: Co-lead authors of the PNAS Early Edition report are Elizabeth Gerstner, MD, MGH Neurology; Kyrre Emblem, PhD, Martinos Center; and Dan Duda, PhD, DMD, Steele Laboratory. Additional co-authors include Jay Loeffler, MD, MGH Radiation Oncology; Bruce Rosen, MD, PhD, Martinos Center; Gregory Sorensen, MD, formerly of the Martinos Center and now with Siemens Healthcare; Patrick Wen, MD, Dana-Farber Cancer Institute, and Percy Ivy, MD, National Cancer Institute. Support for the study includes National Institutes of Health grants R01CA129371, K24CA125440A, P01CA080124 and R01CA163815, and a grant from the National Foundation for Cancer Research.

Citation: Hospital, Massachusetts General. "Predicting tumor response to anti-angiogenic drugs." Medical News Today. MediLexicon, Intl., 6 Nov. 2013.

gdpawel's picture
gdpawel
Posts: 549
Joined: May 2001

MCED in glioblastoma patients measures favorable responses to Avastin

MCED explains why glioblastoma (the most common primary brain tumor) patients who have favorable responses to bevacizumab (Avastin) develop early calcifications in the tumor bed while glioblastoma patients with poor responses to bevacizumab do not develop calcifications.”

http://www.vasocell.com/MCED_Home.html

MCED Discovery

http://www.vasocell.com/MCED_Discovery.html

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