Maximilian G. Schliesser

PURPOSE: Preclinical data indicate anti-invasive activity of APG101, a CD95 ligand (CD95L)-binding fusion protein, in glioblastoma. EXPERIMENTAL DESIGN: Patients (N = 91) with glioblastoma at first or second progression were randomized 1:2 between second radiotherapy (rRT; 36 Gy; five times 2 Gy per week) or rRT+APG101 (400 mg weekly i.v.). Patient characteristics [N = 84 (26 patients rRT, 58 patients rRT+APG101)] were balanced. RESULTS: Progression-free survival at 6 months (PFS-6) rates were 3.8% [95% confidence interval (CI), 0.1-19.6] for rRT and 20.7% (95% CI, 11.2-33.4) for rRT+APG101 (P = 0.048). Median PFS was 2.5 (95% CI, 2.3-3.8) months and 4.5 (95% CI, 3.7-5.4) months with a hazard ratio (HR) of 0.49 (95% CI, 0.27-0.88; P = 0.0162) adjusted for tumor size. Cox regression analysis adjusted for tumor size revealed a HR of 0.60 (95% CI, 0.36-1.01; P = 0.0559) for rRT+APG101 for death of any cause. Lower methylation levels at CpG2 in the CD95L promoter in the tumor conferred a stronger risk reduction (HR, 0.19; 95% CI, 0.06-0.58) for treatment with APG101, suggesting a potential biomarker. CONCLUSIONS: CD95 pathway inhibition in combination with rRT is an innovative concept with clinical efficacy. It warrants further clinical development. CD95L promoter methylation in the tumor may be developed as a biomarker.

BACKGROUND: The number of patients age >65 years with malignant gliomas is increasing. Prognosis of these patients is worse compared with younger patients. To determine biological differences among malignant gliomas of different age groups and help to explain the survival heterogeneity seen in the NOA-08 trial, the prevalence and impact of recently established biomarkers for outcome in younger patients were characterized in elderly patients. METHODS: Prevalences of mutations of isocitrate dehydrogenase 1 (IDH1) and histone H3.3 (H3F3A), the glioma cytosine-phosphate-guanine island methylator phenotype (G-CIMP), and methylation of alkylpurine DNA N-glycosylase (APNG) and peroxiredoxin 1 (PRDX1) promoters were determined in a representative biomarker subset (n = 126 patients with anaplastic astrocytoma or glioblastoma) from the NOA-08 trial. RESULTS: IDH1 mutations (R132H) were detected in only 3/126 patients, precluding determination of an association between IDH mutation and outcome. These 3 patients also displayed the G-CIMP phenotype. None of the IDH1 wild-type tumors were G-CIMP positive. Mutations in H3F3A were absent in all 103 patients sequenced for H3F3A. MassARRAY analysis of the APNG promoter revealed generally low methylation levels and failed to confirm any predictive properties for benefit from alkylating chemotherapy. Neither did PRDX1 promoter methylation show differential methylation or association with outcome in this cohort. In a 170-patient cohort from The Cancer Genome Atlas database matched for relevant prognostic factors, age ≥65 years was strongly associated with shorter survival. CONCLUSIONS: Despite an age-independent stable frequency of O(6)-methylguanine-DNA methyltransferase (MGMT) promoter hypermethylation, tumors in this age group largely lack prognostically favorable markers established in younger glioblastoma patients, which likely contributes to the overall worse prognosis of elderly patients. However, the survival differences hint at fundamental further differences among malignant gliomas of different age groups.

// Maximilian Georg Schliesser 1,3 , Rainer Claus 6,24 , Thomas Hielscher 7 , Christiane Grimm 1,3 , Dieter Weichenhan 6 , Jonas Blaes 3 , Benedikt Wiestler 1,3,25 , Peter Hau 10 , Johannes Schramm 11 , Felix Sahm 2,4 , Elisa K. Weiß 1,3 , Markus Weiler 1,3,8 , Constance Baer 6 , Friederike Schmidt-Graf 8,12 , Gabriele Schackert 13 , Manfred Westphal 14 , Anne Hertenstein 1,3 , Patrick Roth 8,15 , Norbert Galldiks 16 , Christian Hartmann 2,4,17 , Torsten Pietsch 19 , Joerg Felsberg 20,22 , Guido Reifenberger 20,22 , Michael Christoph Sabel 21 , Frank Winkler 1,3 , Andreas von Deimling 2,4 , Christoph Meisner 9 , Peter Vajkoczy 23 , Michael Platten 1,5,8 , Michael Weller 8,15 , Christoph Plass 6 and Wolfgang Wick 1,3,8 1 Department of Neurology, Heidelberg University Hospital and German Cancer Consortium, Clinical Cooperation Units, Germany 2 Department of Neuropathology, Heidelberg University Hospital and German Cancer Consortium, Clinical Cooperation Units, Germany 3 Clinical Cooperation Unit of Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany 4 Clinical Cooperation Unit of Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany 5 Clinical Cooperation Unit of Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany 6 Division of Epigenomics and Cancer Risk Factors, German Cancer Research Center (DKFZ), Heidelberg, Germany 7 Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany 8 Department of General Neurology, University Hospital Tübingen, Germany 9 Department of Biostatistics, University Hospital Tübingen, Germany 10 Neurology Clinic, Regensburg University, Regensburg, Germany 11 Neurosurgery Clinic, University of Bonn Medical Center, TU Munich, Munich, Germany 12 Neurology Clinic, TU Munich, Munich, Germany 13 Neurosurgery Clinic, Dresden University Medical Center, Germany 14 Neurosurgery Clinic, University Clinic Hamburg, Eppendorf, Germany 15 Department of Neurology, University Hospital Zurich, Zurich, Switzerland 16 Neurology Clinic, Cologne University, Cologne, Germany 17 Department for Neuropathology, Institute of Pathology, Medical University of Hannover, Hannover, Germany 19 Department of Neuropathology, University of Bonn Medical Center, Bonn, Germany 20 Department of Neuropathology, Heinrich-Heine-University, Germany 21 Department of Neurosurgery, Heinrich-Heine-University, Germany 22 DKTK, Partner Site Essen/Düsseldorf, Düsseldorf, Germany 23 Neurosurgery Clinic, Charité, Berlin, Germany 24 Department Hematology, Oncology and Stem Cell Transplantation, University Hospital Freiburg, Germany 25 Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany Correspondence to: Wolfgang Wick, email: // Keywords : anaplastic glioma, miR-155, IDH, NFκB, NOA-04 Received : May 09, 2016 Accepted : September 13, 2016 Published : November 18, 2016 Abstract The outcome of patients with anaplastic gliomas varies considerably depending on single molecular markers, such as mutations of the isocitrate dehydrogenase ( IDH ) genes, as well as molecular classifications based on epigenetic or genetic profiles. Remarkably, 98% of the RNA within a cell is not translated into proteins. Of those, especially microRNAs (miRNAs) have been shown not only to have a major influence on physiologic processes but also to be deregulated and prognostic in malignancies. To find novel survival markers and treatment options we performed unbiased DNA methylation screens that revealed 12 putative miRNA promoter regions with differential DNA methylation in anaplastic gliomas. Methylation of these candidate regions was validated in different independent patient cohorts revealing a set of miRNA promoter regions with prognostic relevance across data sets. Of those, miR-155 promoter methylation and miR-155 expression were negatively correlated and especially the methylation showed superior correlation with patient survival compared to established biomarkers. Functional examinations in malignant glioma cells further cemented the relevance of miR-155 for tumor cell viability with transient and stable modifications indicating an onco-miRNA activity. MiR-155 also conferred resistance towards alkylating temozolomide and radiotherapy as consequence of nuclear factor (NF)κB activation. Preconditioning glioma cells with an NFκB inhibitor reduced therapy resistance of miR-155 overexpressing cells. These cells resembled tumors with a low methylation of the miR-155 promoter and thus mir-155 or NFκB inhibition may provide treatment options with a special focus on patients with IDH wild type tumors.