PMC5481307_01
Individual therapy schedule and clinical response of the reported patient with glioblastoma. The time line depicts treatment (left side) and clinical response (right side) including pathological abnormalities and tumor progression. All numbers stated are in weeks with zero simultaneously being the starting point of radiochemotherapy and the evaluation of the immune status (indicated by red blood drops). The colors represent treatments or therapy outcomes according to the color code presented in the top right corner. This color code was also used for data presentation in Figure 3. The magnetic resonance imaging scans directly refer to the according image in Figures 2C-G.
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Temodal (TMZ); therapy scheme presented in Figure 1). Then, therapy was continued as adjuvant CT with TMZ (255 mg/day) until the fifth course (week 26) without any neurological or pathological complications [magnetic resonance imaging (MRI) presented in Figure 2C]. Besides, we observed a strong increase in the leukocyte count after discovery of the second relapse (red bars, week 45 and week 50), which especially was caused by neutrophils (Figure S1A in Supplementary Material). The investigation of T cells revealed a strong temporary decrease following RT from 1,664 to 753 cells/mul (second RT: 1,488 to 737 cells/mul), but they recovered fast and then varied without distinct patterns during the remaining therapy (Figure S1B in Supplementary Material). During that time point likewise neutrophils (Figure S1A in Supplementary Material) and B cells (Figure 3C) were conspicuously elevated. Material) and neutrophils (Figure S1A in Supplementary Material) was observed. Moreover, the CD4:CD8 ratio was extremely reversed in direction of CD4+
Tumor progression identified by consecutive magnetic resonance imaging (MRI) scans reveals transient therapy success and two relapses. MRI scans showing T1- (upper panel) and T2-weighted images (lower panel) of a glioblastoma multiforme in the right temporal lobe, from primary diagnosis through the different stages of tumor progression. After primary diagnosis (A) and subsequent complete resection (B), standard concomitant radiochemotherapy (RCT) followed by adjuvant chemotherapy with Temodal (TMZ) according to Stupp et al. was performed. The first follow-up MRI (3 months after RCT) showed no signs of tumor recurrence (C). Two months later, an MRI was performed due to TMZ cytotoxicity. There were hints of tumor relapse (D), which was histologically confirmed after the lesion had been completely removed by surgery. Yet only 2 (E) and 3 months (F) after this second resection, tumor progression was first suspected and then confirmed. Thus, a conversion of therapy was decided, the therapy of choice being secondary radiotherapy combined with Avastin. This led to tumor regression as observed during the 3-month follow-up during aftercare with Avastin and irinotecan (G).
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The first patient included in the IMMO-GLIO-01 study was a 53-year-old woman suffering from right temporal GBM grade IV (Figure 2A). She was recruited into the study directly after complete resection of the primary tumor (Figure 2B) and then received standard RCT according to Stupp et al. (6 weeks, 60 Gy in 2 Gy fractions, daily 130 mg Temodal (TMZ); therapy scheme presented in Figure 1). Then, therapy was continued as adjuvant CT with TMZ (255 mg/day) until the fifth course (week 26) without any neurological or pathological complications [magnetic resonance imaging (MRI) presented in Figure 2C]. Consequently, MRI was performed (week 29) depicting signs of a relapse (Figure 2D), which was later confirmed by histological examination. The next routine MRI was conducted in week 45 (3 months after surgery) and week 49 and revealed a new relapse (Figures 2E,F), but again this was paired without any neurological findings. The success of this therapy conversion became visible in the next routine MRI (week 66) that showed a regression of the tumor relapse (Figure 2G).
Multimodal therapy of glioblastoma has high impact on immune cells of the peripheral blood. The graphs of (A) and (C-F) display the absolute cell counts of immune cells or immune cell subsets in the peripheral blood, and in (B), the ratio from CD4+ helper T cells to CD8+ cytotoxic T cells is displayed. All immune cells were determined by a multicolor flow cytometry-based assay and directly detected in whole blood samples. The blood was always drawn prior to administering the drug or radiotherapy on the respective day. The color code represents the last applied therapy or pathological finding (red) and was applied according to Figure 1. The green background marks normal values and the red one deviation from it.
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The leukocyte count varied during the whole therapy, but never strikingly dropped below the normal range (Figure 3A). In contrast, we found a connection between therapy and T cell subsets, which is presented as ratio of CD4+ T helper versus CD8+ cytotoxic T cells (Figure 3B). Avastin therapy improved the B cell count (Figure 3C: green bars), which was very low during the complete observation period (<40 cells/mul) and did not rise before Avastin administration. As observed for T cells, the B cell count dropped following initial RCT (from 41 to 13 cells/mul), but recovered later on, even this required more time. The initial RT, likewise, had a very strong effect on NK cells which dropped from 365 to 140 cells/mul and remained fairly low during the complete period of adjuvant TMZ administration (Figure 3D: week 0-29). Furthermore, we found a surprising enhancement of eosinophils by RT, which was observed following both applications (Figure 3F: yellow bars). During that time point likewise neutrophils (Figure S1A in Supplementary Material) and B cells (Figure 3C) were conspicuously elevated. T helper cells in both relapse situations (Figure 3B). This suggests a connection of these immune parameters to clinical response as they correlate with tumor progression monitored by MRI.