Screening glioblastoma brain tumours for two gene variations can reliably predict which tumours will respond to a specific class of drugs, a new study shows. The findings may lead to improved treatment for this devastating disease. The study was funded in part by the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health (NIH).

"Glioblastomas are the most common malignant brain tumours in adults, and they are notoriously difficult to treat successfully. The survival with glioblastoma is usually a year on average, and that hasn't improved in a while, so this is a very serious and challenging disease," said Paul Mischel, David Geffen School of Medicine and Jonsson Comprehensive Cancer Center at the University of California, Los Angeles (UCLA), who led the study.

While drugs are available to help treat glioblastoma, they often have minimal effect, and doctors usually have time to try only one or two treatments before the disease causes severe impairment. Glioblastomas feature many genetic variations that affect their response to different treatments. Researchers are trying to identify these genetic factors and to tease apart how they affect the disease in order to determine which patients are the most likely to benefit from specific drugs, states a NIH release.

In the new study, Dr. Mischel and his colleagues performed genetic analysis on tissue from recurrent malignant glioblastoma patients, 26 of whom responded either very well or very poorly to the drugs erlotinib (Tarceva) and gefitinib (Iressa). These two drugs belong to a class called EGFR (epidermal growth factor receptor) kinase inhibitors, and both are currently approved by the by the US FDA to treat advanced lung cancer that has not responded to other treatments.

Based on results from other studies, the researchers hypothesised that variations in several different genes might play a role in the tumour's response to EGFR inhibitors. They looked for mutations in genes called EGFR and HER2/neu, and they analysed the activity of EGFR, an EGFR variant called EGFRvIII, and a gene called PTEN. Many tumours, not just brain tumours, have mutations or abnormal activity of one or more of these genes, which help to control cell growth and other functions.

Glioblastomas that produced both EGFRvIII and PTEN were 51 times more likely to shrink when treated with EGFR inhibitors than tumours without this combination of proteins, the researchers found. Patients whose tumours expressed these proteins and who received an EGFR inhibitor went almost 5 times longer on average before their tumours progressed (243 days vs. 50 days) than those whose tumours did not express both of the proteins. In contrast, EGFR and HER2/neu activity had no effect on how tumours responded to these drugs. Similar results were found in tissues from another group of 33 glioblastoma patients who had taken part in a clinical trial of erlotinib at the University of California, San Francisco.

The findings suggest that both EGFRvIII and PTEN proteins are important for tumours to be susceptible to EGFR inhibitors, Dr. Mischel says. Their data further suggest that EGFRvIII may act to sensitise glioblastoma cells, while PTEN loss may act as a resistance factor. The researchers tested their results in several different cell models and repeatedly found that expression of these two proteins made the cells sensitive to EGFR inhibitors and that PTEN loss promoted resistance in those models.

The study shows that genetic analysis of glioblastomas can predict the tumour's sensitivity to specific drugs. Adjusting treatment based on each tumour's genetic activity could significantly prolong life for a subset of glioblastoma patients, Dr. Mischel says. It also may prevent patients from undergoing unnecessary and expensive treatments, and it could allow some people to be treated with the most effective therapy immediately, before the tumours can grow and develop new mutations that make them more difficult to treat.

The release further added that kinases are enzymes that play key roles in cell proliferation, metabolism, and other functions, and they are often overactive in cancer cells. Because cancer cells may become dependent on the persistent signals created by altered kinases in a way in which non-cancerous cells do not, kinase inhibitors such as EGFR inhibitors can often target cancer cells without seriously affecting the rest of the body. Therefore they cause fewer side effects than most other cancer drugs. The drug imatinib (Gleevec), which is FDA-approved to treat chronic myeloid leukemia, is one of the early success stories for this kind of treatment.

"The study also reveals important information about how glioblastomas and other tumours develop," said Dr. Mischel. Knowing that EGFRvIII and PTEN play critical roles in tumour response to treatment could lead to new combination therapies that target both proteins. Such therapies might also be beneficial for other types of cancer.

Dr. Mischel further added that screening for these factors also might allow researchers to better determine a treatment's effects in clinical trials Traditional clinical trials that do not take into account each tumour's genetic makeup often fail to show enough of an effect to warrant FDA approval for a drug because only a subset of patients respond well to the treatment.

The researchers are planning prospective clinical trials to determine whether selecting treatment based on each tumour's genetic activity can lead to better patient survival. They also plan to continue looking for other tumour susceptibility factors, to develop new treatments that target those factors, and to try to learn how some patients become resistant to treatment. Researchers also need to develop their genetic screening techniques into a diagnostic test so that it can be available to all people with glioblastoma, Dr. Mischel informed.

The NINDS is a component of the NIH within the Department of Health and Human Services and is the nation's primary supporter of biomedical research on the brain and nervous system.