Tracy T. Batchelor, MD, MPH, executive director, Pappas Center for Neuro-Oncology, says, “The field of neuro-oncology is rapidly advancing and newer techniques and drugs appear to be increasing the length of time patients live after a GBM diagnosis.”
NPR interview, June 3, 2008

Molecular Guides to Diagnosing Brain Tumors      
Accurate biopsy diagnosis is essential for the management of brain tumors since different types are treated in different ways. Specialized neuropathologists from the Massachusetts General Hospital Pathology Service work at the Cancer Center to interpret biopsies to ensure these tumors are treated with the most effective combination of surgery, radiation and drugs.

“It is exciting that our depth of expertise in traditional biopsy interpretation is now complemented by remarkable strengths in molecular diagnosis,” says David N. Louis, MD, chief of Massachusetts General Hospital’s Department of Pathology and Benjamin Castleman Professor of Pathology at Harvard Medical School. Many novel methods now enable pathologists to look directly at abnormal chromosomes and genes in tumors.

Mass General pathologists were the first to show that brain tumors could be diagnosed through the examination of molecular features called "molecular fingerprinting." They were also the first to demonstrate that molecular differences could guide therapies. 

For example, future delivery of new smart drugs that target a specific molecule will require precise biopsy analysis to determine which drug will have the greatest chance of destroying a tumor.

ve brain tumor
Preliminary results show tumor shrinkage, reduction in edema, normalization of blood vessels

New angiogenesis inhibitor has promise for treating agresssi

Researchers from the Massachusetts General Hospital (MGH) Cancer Center have found that AZD2171, a new angiogenesis inhibitor, can reduce the size of brain tumors called glioblastomas and has the potential of improving the effectiveness of other therapeutic techniques.  The Phase 2 clinical trial also finds that AZD2171 treatment can alleviate brain swelling (edema), a debilitating symptom in many brain cancer patients that currently can be treated only with steroid drugs.  Appeared in the January 2007 issue of Cancer Cell, the study is too preliminary to determine whether this new drug may have an impact on overall patient survival.

“Patients with recurrent glioblastomas desperately need new, effective treatment alternatives,” says Tracy Batchelor, MD, MPH, executive director of Stephen E. and Catherine Pappas Center for Neuro-Oncology, the study’s lead author.  “While these are preliminary results of an initial trial, it’s looking like these agents may play an increasingly important role in the treatment of patients whose tumors have recurred and perhaps in newly diagnosed patients as well.”


Glioblastoma is the most malignant form of brain tumor and has a very poor prognosis.  Standard treatments – including surgery, chemotherapy and radiation therapy – may delay tumor growth, but patients usually survive for little more than a year.  There are currently no effective options for patients whose tumors recur, the vast majority of whom die within 6 months. 

Angiogenesis inhibitors suppress the growth of blood vessels supplying a tumor and have received a lot of attention as potential cancer-fighting agents.  While the earliest clinical trials did not meet expectations that these drugs would ‘starve’ tumors, the agents did improve patient survival when combined with traditional anticancer therapies.  Three anti-angiogenic drugs have received FDA approval for the treatment of certain tumors, and several others are under investigation.  An oral medication, AZD2171 is a potent inhibitor of the three primary receptors for the powerful angiogenesis factor VEGF, known be present on glioblastoma blood vessels.  Manufactured by AstraZeneca, AZD2171 is currently available only to participants in clinical trials. 

The Cancer Center trial, sponsored by the National Cancer Institute, was designed to assess whether AZD2171 could benefit patients with recurrent glioblastomas and also if the drug might normalize tumor vasculature.  Blood vessels that develop around and within tumors are leaky and disorganized, potentially blocking the delivery of chemotherapy drugs or the effectiveness of radiation therapy, which requires an adequate supply of oxygen to the tumor. 

The fact that combining angiogenesis inhibitors with other therapies improved survival for some patients supports a theory developed by Rakesh Jain, PhD, director of the Steele Laboratory in the Department of Radiation Oncology and senior author of the Cancer Cell article, that the agents temporarily ‘normalize’ blood vessels, creating a period during which chemotherapy and radiation treatment can be more effective. 

The paper reports on the first 16 patients to enter the clinical trial, which began in January 2006.  All had glioblastomas that had resumed growing despite prior radiation or chemotherapy.  Participants took a daily oral dose of AZD2171, which started at 45 mg and could be reduced in those experiencing negative side effects, including fatigue, diarrhea and hypertension.  Participants were followed with regular physical, neurological, and MR imaging exams during the 6-month study period. 

Enlarge Image		Enlarge Image
Imaging studies showed that tumors began to shrink in most participants within 28 days of the initial AZD2171 dose.
Enlarge Image

Overall, the tumors shrank by at least 25 percent in three-quarters of the study participants and by 50 percent or more in half of the patients.  Factors indicating a normalization of the tumors’ blood vessels – including reduction in size and a decrease in permeability or ‘leakiness’ – were seen almost immediately in most participants and continued for at least 28 days, with some features persisting up to four months.  These results are the first to define how long the period of vascular normalization might last, which may establish a window of time during which applying additional therapies would be most effective. 

The highly advanced MR imaging techniques used in this report, developed at Massachusetts General Hospital, showed the vascular normalization to be very rapid, beginning after the first dose in some patients. Other MGH-pioneered MRI techniques showed that AZD2171 treatment led to a rapid decrease in brain edema, an effect that continued as long as the medication was taken.  Edema produces many of the symptoms experienced by brain tumor patients and can only be treated with steroids, which have negative side effects of their own.  The alleviation of edema allowed several study participants to reduce or even discontinue steroid treatment.

Analysis of potential biomarkers – molecular and cellular factors that can be measured in the blood – identified several that may indicate when the period of vascular normalization is ending or which patients’ tumors are most likely to become resistant to AZD2171 treatment.  These findings suggest that the imaging and biomarker studies will be important scientific tools for future assessment of therapy with AZD2171 and other drugs.

“This small group of patients needs to be followed for a longer period of time, but we are cautiously optimistic that this trial and future studies will lead to positive long-term outcomes for some patients,” says Jain.  He is the Cook Professor of Radiation Oncology at Harvard Medical School, where Batchelor is an associate professor of Neurology.  The researchers expect that the complete results of this trial, which enrolled a total of 31 patients, will be available later this year.  They also are exploring additional trials to further define the role of AZD2171 in glioblastoma treatment and hope to study the drug in combination with traditional therapies and in newly diagnosed patients.

Contact Information

For Patient Inquiries

The clinical trial reported in the news media for the drug Recentim is currently closed. If you live outside of the Boston area and are seeking treatment for glioblastoma through clinical trials, please contact your physician for more information.

However, for patients with glioblastoma who live within New England, clinical trials for this disease are available the Massachusetts General Hospital Cancer Center through the Stephen E. and Catherine Pappas Center for Neuro-Oncology. To schedule a consult at the Cancer Center, please contact the Cancer Center at 877-726-5130.

For Research Professionals

For information on the Edwin L. Steele Laboratory

For Information on Athinoula A. Martinos Center for Biomedical Imaging: www.nmr.mgh.harvard.edu or www.martinos.org

 

Additional News Sources

National Cancer Institute Bulletin
Bloomberg News
BBC News
Washington Post
Newsday
Health News - Indianapolis Star

CN8 Interview with Dr. Tracey Batchelor and Dr. Rakesh Jain on how "Smart Drugs" are leading the way to new clinical trials in neuro-oncology. (7 minutes)

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Different types of radiation therapy for brain tumors including proton beam therapy.

Depending on the needs of the patient, the radiation oncologist may use intensity-modulated radiation therapy, stereotactic radiotherapy, or proton beam therapy. The mission of all three forms is to maximize the dose to the tumor and minimize the dose to nearby healthy tissue.

In intensity-modulated radiation, the strength of the radiation beam is adjusted to conform to the three-dimensional shape of the tumor. Unlike traditional radiation, this computer-controlled treatment uses hundreds of very narrow beams to selectively treat the tumor.

“It is particularly advantageous for a tumor that requires a high dose of radiation that is near but not touching critical structures,” says Jay Loeffler, MD, Chief of Radiation Oncology who with his colleague Arnab Chakravarti, MD, treats adult patients in the Pappas Center. “For example, it allows us to give a therapeutic dose to a tumor in the lower part of the brain and largely spare the spinal cord.”

Stereotactic radiotherapy uses focused radiation over a series of treatment sessions. Under computer guidance, this therapy targets large tumors or ones located near or within sensitive tissues, such as the optic nerve.

Proton therapy is the newest, and some argue the best, kind of external-beam radiation. Using proton particles instead of x rays, a beam is created to match the shape of the tumor. Also known as “no-exit dose” proton beam therapy, this method directs radiation to the target area, while sparing the normal tissue beyond it. One of only three centers in the nation, the Northeast Proton Therapy Center treats both children and adults with brain tumors.

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New technology allows neurosurgeons to plan and perform brain operations more safely and precisely than ever before.

Depending on the needs of the patient, the radiation oncologist may use intensity-modulated radiation therapy, stereotactic radiotherapy, or proton beam therapy. The mission of all three forms is to maximize the dose to the tumor and minimize the dose to nearby healthy tissue.

In intensity-modulated radiation, the strength of the radiation beam is adjusted to conform to the three-dimensional shape of the tumor. Unlike traditional radiation, this computer-controlled treatment uses hundreds of very narrow beams to selectively treat the tumor.

“It is particularly advantageous for a tumor that requires a high dose of radiation that is near but not touching critical structures,” says Jay Loeffler, MD, Chief of Radiation Oncology who with his colleague Arnab Chakravarti, MD, treats adult patients in the Pappas Center. “For example, it allows us to give a therapeutic dose to a tumor in the lower part of the brain and largely spare the spinal cord.”

Stereotactic radiotherapy uses focused radiation over a series of treatment sessions. Under computer guidance, this therapy targets large tumors or ones located near or within sensitive tissues, such as the optic nerve.

Proton therapy is the newest, and some argue the best, kind of external-beam radiation. Using proton particles instead of x rays, a beam is created to match the shape of the tumor. Also known as “no-exit dose” proton beam therapy, this method directs radiation to the target area, while sparing the normal tissue beyond it. One of only three centers in the nation, the Northeast Proton Therapy Center treats both children and adults with brain tumors.

Researchers in the Pappas Center have pioneered a treatment regimen for CNS lymphoma that uses chemotherapy without radiation.

Scientific and clinical research at the Center helps ensure that patients receive the latest treatments. MGH is a founding member of New Approaches to Brain Tumor Therapy (NABTT), a national consortium sponsored by the National Cancer Institute and dedicated to improving outcomes for adults with brain tumors.

Part of Dana-Farber/Partners CancerCare, Pappas Center scientists conduct cutting-edge clinical research. Last year 64 patients participated in clinical trials for new drugs, radiation therapy, and gene therapy. Twenty-one trials are currently underway at MGH. Some of these trials are a joint effort with Dana-Farber Cancer Institute and Brigham and Women’s Hospital.

In one exciting new study Rakesh Jain, PhD, of the Department of Radiation Oncology, is investigating whether combining radiation with an antibody that blocks vascular endothelial growth factor (VEGF) will inhibit angiogenesis or blood vessel growth. This therapy, which has already yielded dramatic responses with colon cancer, shows promise for the brain, where tumors depends on new vessel growth for their nutrient supply.

Proton Beam Therapy May Improve Rare Tumor
Proton beam radiation therapy may be an effective treatment for advanced adenoid cystic carcinoma that has spread to the cranial base. Read More

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