DIPG Dialogue

Dr. Maryam Rahman

June 2009

Introduction:

Dr. Maryam Rahman is a research fellow in Dr. Reynolds’ lab at the University of Florida. Dr. Rahman is also a 4th year neurosurgery resident with a strong interest in neuro-oncology and novel therapy development. She has been responsible for BMP receptor/pathway activation experiments and the application to the NIH and FDA for testing of BMP 4 in human malignant glioma.
Dr. Rahman’s research on BMP4 and cell lines has recently been funded through a collaborative effort within the United Forces Against Brain Tumors. Just One More Day along with Gunner’s Magic Train and the Musella Foundation joined together to support her research. BMP4 has been shown to cause human glioblastoma cancer stem cells to become end cells that have a limited number of cell divisions and are more easily killed. The question is whether this effect can occur with other types of glioma cells.

Questions & Answers:

Where do you get cancer cell lines from?

Cancer lines are created by taking fresh tumor tissue from a surgical specimen. This tissue is dissociated into single cells and then placed in culture with growth factors. These cultures are placed in an incubator at 37 degrees C (like all cultures) and nurtured with media and growth factors until they start proliferating. Once the cells start proliferating, after several days, they outgrow their culture flask and need to be "passed" which means that they are dissociated into single cell suspension. Some of these cells are placed in a new flask with media and growth factors. The other cells can also be placed in culture (to expand the number of cells you produce) or used for experiments. Here at the University of Florida, we obtain our tumor tissue from the Florida Center for Brain Tumor Research. They obtain consent from the patients pre-operatively. Tissue is collected intra-operatively and given to us for cell culture and experimentation.

Would each individual's tumor grow out a different type of cell line?

Absolutely. Every patient's tumor is unique and therefore, having multiple lines of a type of tumor is beneficial for experimentation. Even within a certain type of tumor, there is variation in behavior and response to drugs.

Why does one use a cell line?

Cell lines are useful because it gives you an endless supply of tumor cells to use for experiments. If the cells we obtain from tumor tissue are fixed and used immediately for experimentation (which we do if we have a lot of cells and have some left over after placing them in culture), it could only be used once. The cell lines allow us to experiment with the tumor indefinitely.

Are cell lines stable or do they change over time?

Cell lines do not usually change over time. However, culture conditions do select out certain cells that can grow in media and growth factors. Therefore, cell lines are not always completely representative of the original tumor. This is the biggest argument against cell line work. I think cell line work is an important first step in understanding tumor biology, but it has to be supplemented and followed by animal and finally human work.

If there is a biopsy is there enough tissue to do what is needed therapeutically and perhaps to grow out a cell line?

Unfortunately, there is usually not enough tissue from a biopsy to do anything other than pathologic analysis. We only get tissue that is given to us after the pathologist takes what is necessary for diagnosis.

Dr. Rahman, you are saying that there are no cell lines of diffuse intrinsic pontine gliomas. Since we do not have cell lines but we have had biopsy and autopsy tissue which show most of these tumors to be gliomas , but not all GBMs, then it could follow that it might be important to find an agent that works on a wide variety of gliomas to try to cure DIPGs?

I do think that experimentation using other low grade glioma cell lines may be relevant to the treatment of DIPGs. You are absolutely correct with that question. I think that's why it's important to experiment with BMP in gliomas other than GBM.

References-

Bone morphogenetic proteins inhibit the tumorigenic potential of human brain tumour-initiating cells. Nature. 2006 Dec 7;444(7120):761-5

BMPing off glioma stem cells. Cancer Cell. 2008 Jan;13(1):3-4

DIPG Conference

Memorial “Alicia Pueyo” Workshop

Click here for workshop notes.
Research on Pontine Gliomas

Barcelona, February 26th 2009

Presentation videos:

Diffuse Intrinsic Pontine Glioma a Clinical Introduction by Ofelia Cruz

Pontine Glioma: By Darren Hargrave
Clinical Trials for Children with DIPG, a Critical View
To Biopsy or Not Biopsy: Diagnostic and Therapeutic Challenges
Investigational Avenues in UK

The Origin of Brainstem Tumors by Sebastian Pons
Wrong Cell or Just the Right Cell at Wrong Place

Molecular Gliomagenesis:Gene and Core Pathways by Joan Seoane
The Therapeutic TGF-Beta Approach

Molecular Medicine for Diffuse Intrinsic Pontine Gliomas by Mark W. Kieran

Murine Animal Models of Brainstem Tumors & Delivery Systems of Drugs to the Brainstem
by Ioannis Roussos

New Clinical Trials from St. Jude/PBTC by Alberto Broniscer
The St. Jude Protocol of Autopsies for Children with DIPG

Clinical Trials at Duke - So What is New? by Sri Gururangan

Gene Therapy Strategies by Manuel Ramirez

Development of Novel Therapeutics &Targeted Delivery in Pediatric Brainstem Glioma
by Viola Caretti & Dannis Van Vuurden

Clinical Trials for the Newly Diagnosed

This is meant to assist those looking for clinical trails for the newly diagnosed child with a DIPG. Since trials are continually being updated, added and closed all information should be independently confirmed as it may no longer be accurate. You can find out more information about clinical trials at-http://www.justonemoreday.org/TreatingPontineGliomas/ClinicalTrials.html


Radiologic Study (can be in conjunction with other therapeutic studies)Proton Nuclear Magnatic Resonance Spectroscopic Imaging Compared with Fludeoxyglucose F 18 Positron Emission Tomography Scanning in Determining Biologic or Metabolic Tumor Activity in Young Persons with Brain Tumors
Eligible Age- 1 to 21
Location- Bethesda, MD (NIH)
Study Chair- Katherine Warren, MD
http://clinicaltrials.gov/ct2/show/NCT00070512?term=Newly+Diagnosed+Glioma+Children&recr=Open&rank=26


Open Therapeutic TrialsArsenic Trioxide and Radiation Therapy in Treating Young Patients With Newly Diagnosed Gliomas
Phase 1
Eligible Age- 3 to 21
Location- Johns Hopkins, MD
Study Chair- Kenneth J Cohen, MD
http://clinicaltrials.gov/ct2/show/NCT00095771?term=arsenic+Trioxide+brain+tumor&rank=3


Interferon Alfa After Radiation Therapy in Treating Young Patients With Glioma
Phase 2
Eligible Age- up to 21
Study Chair- Katherine Warren, MD
Location- Bethesda, MD (NIH)
http://clinicaltrials.gov/ct2/show/NCT00041145?term=pontine+glioma&rank=10


Combination Chemotherapy and Radiation Therapy With and Without Methotrexate in Treating Young Patients with Newly Diagnosed Gliomas
Phase 3
Eligible Age- 3 to 18
Study Chair- Christoph Kramm, MD
Location- MD Anderson (sponsor from Germany)http://clinicaltrials.gov/ct2/show/NCT00278278?term=pontine+glioma&rank=8


A Study of Bevacizumab Therapy in Patients With Newly Diagnosed High Grade Gliomas and Diffuse Intrinsic Pontine Gliomas
Phase 1//2
Eligible Age- 3 to 30
Principal Investigator- Maryam Fouladi, MDUS
Location- Cincinnati, Ohio
http://clinicaltrials.gov/ct2/show/NCT00890786?term=pontine+glioma&rank=2


Temozolomide and Radiation Therapy in Treating Young Patients with Pontine Glioma
Phase 3
Eligible Age- 2 to 21
Study Chair- Simon Bailey, MD
Locations- Multiple throughout the UK
http://clinicaltrials.gov/ct2/show/NCT00514397?term=pontine+glioma&rank=5


Vandetanib and Radiation Therapy in Treating Young Patients with Newly Diagnosed Diffuse Brainstem Glioma
Phase 1
Eligible Age- 2 to 20
Study Chair- Alberto Broniscer, MD
Location- St Jude, Memphis, TN
http://clinicaltrials.gov/ct2/show/NCT00472017?term=St+Jude+brainstem&rank=2


Capceitabine and Radiation Therapy in Treating Young Patients with Newly Diagnosed, Nonmetastatic Brain Stem Glioma or High Grade Glioma
Phase 1
Eligible Age- 3 to 21
Study Chair- Susan Blaney, MD
Location – PBTC sites in the US
http://clinicaltrials.gov/ct2/show/NCT00357253?term=St+Jude+brainstem&rank=10


Vaccine Therapy in Treating Young Patients With Newly Diagnosed or Recurrent Glioma
Phase 1
Eligible Age- 3 to 20
Study Chair- Regina Jakacki, MD
Location- Pittsburgh, Pennsylvania
http://clinicaltrials.gov/ct2/show/NCT00862199?term=Newly+Diagnosed+Glioma&recr=Open&rank=7



Trials on Clinicaltrials.gov but Not Yet Opened for the Newly Diagnosed Child with a DIPG (at the time of being placed on the site but could be now)


Valproic Acid and Radiation Followed by Maintenance Valproic Acid and Bevacizumab in Children with High Grade Gliomas
Phase-1
Eligible Age- 3 to 21
Study Chair- Susan Blaney MD
Location- Texas Children’s
http://clinicaltrials.gov/ct2/show/NCT00879437?term=Newly+Diagnosed+Glioma+Children&recr=Open&rank=10

As of May 25, 2009

DIPG Dialogue

Just One More Day is starting a new regular blog feature called DIPG Dialogue which will contain interviews with researchers, physicians and other advocates in the DIPG community.

Introduction:

Dr. Ohlfest is an Assistant Professor and the Director of the gene therapy program in Department of Neurosurgery and a faculty member of the Stem Cell Institute. Dr. Ohlfest studied molecular biology as an undergraduate at Iowa State University and received his Ph.D. in molecular genetics and cell biology at the University of Minnesota. He then did post-doctoral research with Dr. Andrew Freese at the University of Minnesota focusing on gene therapy in the central nervous system. Dr. Ohlfest's research interests are focused on using gene transfer to correct disease and manipulating endogenous progenitor cells by gene transfer. In addition, targeted therapies for the eradication of so called "brain tumor stem cells", the tumor cells capable of self-renewal and the cause of tumor relapse, is an area of ongoing investigation in his lab.


Questions & Answers:

Dr Ohlfest, it seems that you have a super hero, Batman, that just might be making a difference for children with brain tumors. How is that?

Batman was the first dog to undergo an experimental treatment for glioma, an aggressive form of brain cancer. Batman was treated with the combination of surgery, gene therapy, and anti-tumor vaccination in the summer of 2008. Remarkably, Batman is alive and tumor-free nearly one year later. This novel treatment could only be tested in a large animal because mice, the standard preclinical "model" for testing new therapy, are just too small. Specifically, the brains of mice are not amenable to surgery where the gene therapy can be deposited into the resection site to hit the tumor cells left behind. In dogs we can use the same dose of gene therapy and vaccine that would be given to people. Because of this, we not only help the dog, we also get answers about effectiveness and safety that can be extrapolated to human patients.

We feel the treatment of dogs can revolutionize the way clinical trials are done for brain tumor patients. By using the dog data to justify dose, timing, and drug choices, it may become possible to test several experimental agents in a single phase I trial, a scenario that seldom happens in modern neuro-oncology. This is important because history has shown that combination therapy is better than mono therapy, yet for brain tumor patients, most phase I clinical trial are restricted to single experimental drugs.


How does this type of treatment differ from other forms of treatment?

It does not involve chemotherapy or radiation, which those people familiar with DIPG know causes toxicity. Instead, we attempt to get the body to take care of the problem by activating a tumor-specific immune response. The vaccine and gene therapy we are using have been optimized for potency over the last 4 years. They are superior to some of the first generation vaccines and gene therapies that were developed in the 1990s and first part of this decade.


What have the results been so far with the dogs?

We have documented stable disease, and tumor regressions, with minimal side effects. Four dogs have been treated to date, although we are going to enroll dozens more.


It seems that this approach is something that you feel strongly about, why is that?

I have seen first hand what brain cancer and brain cancer therapy does to people. My grandmother died from therapy-induced toxicity after her ovarian cancer spread into her brain. She was participating in a clinical trial where chemotherapy was directly administered into the brain. At that time, I thought “we can do better” and I still believe that today. I think we have pushed radiation and chemotherapy to the upper limit. Fresh ideas are long over due. There is mounting evidence that the immune response controls cancer in many people spontaneously. We just need to learn how to direct the immune response to the right target.


Do you feel that this is something that truly can be translated to children- and specifically children with DIPGs? If so, how long would it take to get such a trial open?

Absolutely. DIPG is an ideal target for vaccine therapy in particular. In many cases, after radiation there is a large reduction in tumor burden, a perfect time to harness the immune response to target those few tumor cells that are left behind. A trial for DIPG using immunotherapy could be open in a year or less. That’s the best case. The rate limiting steps to getting this trial open are time (required to go through the process of FDA approval) and funding (to pay all costs associated with vaccine production and immune monitoring).


What sort of funding are you in need of?

Because DIPG is very rare, it can be difficult to get funding from the usual sources to focus on this particular tumor. We are in need of funding to conduct preclinical research focused on DIPG experimental therapeutics specifically. Additionally, funding is needed to support the first phase I clinical trial.


Besides raising money, is there anything that DIPG parents can do to help with your research?

Yes, spread the word. Learn more about our research by visiting www.braintumorlab.com and tell your friends.

Any dog with a brain tumor is eligible for consideration in one of our canine clinical trials. Most dog owners don’t know we are offering to pay for the entire cost of their dog’s therapy. We are treating these dogs with the intent to cure; this is not research for research’s sake.

In addition, tell your congressman and senators about the lack of funding for brain tumor research, and DIPG in particular. Less than 20% of grants submitted to the National Institutes of Health are funded. The state of Minnesota could develop a brain cancer research bill, similar to California (stem cells) or Texas (cancer research). We can do better, but it will require a change in priorities at the state and federal level.

To see a video clip featuring Batman and Dr. Ohlfest, click here: