10.1007/s12015-009-9066-0</TIT= LE> <META http-equiv=3DContent-Type content=3D"text/html; = charset=3DISO-8859-1"><LINK=20 href=3D"http://www.springerlink.com/config/css/A++_common.css" = type=3Dtext/css=20 rel=3DstyleSheet><LINK=20 href=3D"http://www.springerlink.com/config/css/content_A++_SpringerLink.c= ss"=20 type=3Dtext/css rel=3DstyleSheet> <META content=3D"MSHTML 6.00.6000.16890" name=3DGENERATOR></HEAD> <BODY class=3Dfor-print> <TABLE cellPadding=3D2 border=3D1> <TBODY> <TR class=3Dheader> <TD>Stem Cell Reviews and Reports</TD></TR> <TR> <TD>=A9 Springer Science + Business Media 2009</TD></TR> <TR> <TD>10.1007/s12015-009-9066-0</TD></TR></TBODY></TABLE> <H2 class=3Drubric>Hypothesis and Commentary</H2> <DIV class=3DHeading1><A name=3Dtitle></A>Therapeutic Window of Stem = Cell Potential=20 for Targeting Pediatric Malignant Brain Tumors: An Opportunity for Stem = Cell=20 Therapy </DIV> <P class=3DAuthorGroup>Shengwen Calvin Li<SUP>1, 2, 4, 5 <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#ContactOfAuthor1"><IMG=20 alt=3D"Contact Information"=20 src=3D"http://www.springerlink.com/content/75j31p7168n50t21/contact.gif" = border=3D0></A></SUP>, Yuan-Ping Han<SUP>6</SUP>,=20 Brent A. Dethlefs<SUP>1</SUP> and William G=FCnter = Loudon<SUP>1,=20 3</SUP></P> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff1></A>(1) </SPAN></TD> <TD><SPAN class=3DAffiliation>Neuro-Oncology Research Laboratory, = Center for=20 Neuroscience and Stem Cell Research, CHOC Children=92s Research = Institute,=20 455 S. Main Street, Orange, CA 92868-3874,=20 USA</SPAN></TD></TR></TBODY></TABLE> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff2></A>(2) </SPAN></TD> <TD><SPAN class=3DAffiliation>Department of Neurology, University of = California, Irvine, CA 92697, = USA</SPAN></TD></TR></TBODY></TABLE> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff3></A>(3) </SPAN></TD> <TD><SPAN class=3DAffiliation>Department of Neurological Surgery, = University=20 of California, Irvine, CA 92697, = USA</SPAN></TD></TR></TBODY></TABLE> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff4></A>(4) </SPAN></TD> <TD><SPAN class=3DAffiliation>Department of Biological Science, = California=20 State University, Fullerton, CA 92834, = USA</SPAN></TD></TR></TBODY></TABLE> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff5></A>(5) </SPAN></TD> <TD><SPAN class=3DAffiliation>Center for Stem Cell Biology and = Regenerative=20 Medicine, Thomas Jefferson University, Philadelphia, = PA 19107,=20 USA</SPAN></TD></TR></TBODY></TABLE> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff6></A>(6) </SPAN></TD> <TD><SPAN class=3DAffiliation>Department of Surgery, Keck School of=20 Medicine, University of Southern California, Los Angeles,=20 CA 90033-4680, USA</SPAN></TD></TR></TBODY></TABLE> <P><A name=3DContactOfAuthor1></A></P> <TABLE class=3DContact> <TBODY> <TR> <TD vAlign=3Dtop><IMG alt=3D"Contact Information"=20 = src=3D"http://www.springerlink.com/content/75j31p7168n50t21/contact.gif" = border=3D0></TD> <TD><STRONG>Shengwen </STRONG><STRONG>Calvin=20 Li</STRONG><STRONG></STRONG><BR><STRONG>Email: </STRONG><A=20 = href=3D"mailto:sli@choc.org">sli@choc.org</A></TD></TR></TBODY></TABLE> <P class=3DAffiliation><STRONG>Published online: = </STRONG>23 April 2009=20 </P> <DIV class=3DAbstract><A name=3DAbs1></A><SPAN=20 class=3DAbstractHeading>Abstract </SPAN>In children, cancers = are the=20 deadliest of diseases and second only to accidents as the leading cause = of=20 death. The deadliest of the brain cancers are the malignant gliomas.=20 Approximately two-thirds of children can survive less malignant types of = brain=20 cancers, however, in ~ 67% of these survivors recurs under the = current regimes=20 of surgery followed by administration of high doses toxic drugs and = exposure to=20 high doses of radiation. Even more distressing is that fortunate = survivors are=20 generally left with life-long cognitive disabilities. A new medical = approach is=20 desperately needed. Stem cells, with their natural ability to seek out = brain=20 tumors, could be used to accurately deliver therapy directly to the = cancer=20 sparing normal tissues for suppression of tumor growth. Despite exciting = initial=20 reports, clinical potency of stem cell therapy in animal brain tumor = models has=20 to date proven disappointing. Attempts to extrapolate the animal study = results=20 to humans are stymied by the fact that stem cells are heterogeneous, = resulting=20 in differences in their efficacy. Indeed, therapeutic success relies on = an=20 effective strategy to select for a stem cell sub-population within some=20 particular stage of the development at which they are competitive and = capable of=20 targeting brain tumors. To improve this during developmental path, = concept of a=20 =91therapeutic window=92 is proposed. The =93therapeutic window=94 for = stem cells or=20 more specifically a =93biochemical therapeutic window=94 can be = determined from=20 biochemical assays and a =93biological therapeutic window=94 from = biological assays=20 or even a molecular window for genetic description. Taken together, we = can use=20 selective processes to generate more effective stem cells to treat = cancers as is=20 clearly needed today. </DIV> <P class=3DKeyword><SPAN = class=3DKeywordHeading>Keywords </SPAN>Pediatric=20 brain tumors - Stem=20 cells - Therapy - Tumor-targeting </P> <DIV class=3DKeyword><SPAN=20 class=3DKeywordHeading>Abbreviations </SPAN><SPAN=20 class=3DTerm>BTSC </SPAN>brain tumor stem cells - <SPAN=20 class=3DTerm>CNS </SPAN>central nerve system - <SPAN=20 class=3DTerm>CXCR-4 </SPAN>chemokine (C-X-C motif) receptor 4 = a.k.a., SDF-1=20 receptor - <SPAN class=3DTerm>ECM </SPAN>extracellular matrix - = <SPAN=20 class=3DTerm>GAPDH </SPAN>glyceraldehyde-3-phosphate dehydrogenase = - <SPAN=20 class=3DTerm>MMP </SPAN>matrix metalloproteinase - <SPAN=20 class=3DTerm>MSC </SPAN>bone marrow derived mesenchymal stem cells = - <SPAN=20 class=3DTerm>NSC </SPAN>neural stem cells - <SPAN=20 class=3DTerm>3D </SPAN>three dimensional extra-cellular matrix=20 microenvironment - <SPAN class=3DTerm>SDF-1 </SPAN>stromal derived = factor-1=20 (chemokine) a.k.a., CXCL12 </DIV> <DIV class=3DFulltext> <DIV class=3D""><A name=3DSec1></A> <HR> <DIV class=3Dheading2>Malignant Brain Tumor is the Leading Cause of = Cancer-Related=20 Death in Children</DIV> <P class=3D"">As estimated 18,820 new cases of brain and other CNS = cancers will be=20 diagnosed in the United States each year, and more than 12,000 will die = from the=20 diseases (data from the US National Cancer Institute). Brain tumors are = now the=20 leading cause of cancer-related deaths in children under age 15. In = contrast to=20 pediatric hematological malignancies, meaningful improvements in = survival=20 statistics for patients with malignant brain tumors have not been = realized in=20 over 30 years of clinical research [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR1">1</A></CITE>].=20 The median survival after diagnosis of glioblastoma multiforme, the most = aggressive type of brain tumors, remains less than one year, with a = two-year=20 survival rate near zero [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR2">2</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR3">3</A></CITE>].=20 A significant challenge to treating gliomas arises from the fact that = high grade=20 gliomas diffusely migrate and disseminate tumor microsatellites deeply = into=20 distant regions of the normal central nervous system. Surgical removal = combined=20 with adjuvant therapies including chemotherapy and radiation therapy = proves=20 insufficient to eliminate the neoplastic disease. Despite gross total = surgical=20 resection, chemotherapy and radiation therapy, neoplastic cells persist = and=20 subsequently give rise to recurrent tumor. </P> <P class=3D"">As a heterogeneous group of neoplasia with diverse = histological,=20 molecular, and genetic spectra and widely variable clinical prognoses, = brain=20 tumors remain difficult to cure. Early treatment response may be = transient, not=20 necessarily translating into long-term responses or favorable clinical = outcomes.=20 This may reflect a small window of opportunity, i.e., therapeutic = window, during=20 which time tumor cells can be most effectively addressed by therapeutic=20 interventions. </P></DIV> <DIV class=3D""><A name=3DSec2></A> <HR> <DIV class=3Dheading2>=93Time is Life=94 for the Resection of the = Primary Treatment=20 Modalities for Pediatric Malignant Brain Tumors</DIV> <P class=3D"">=93Time is life=94 comes from the idea that neurosurgeons = must treat=20 patients within a time window of severe neurological attack in order to = have a=20 measurable effect. The primary treatment of malignant brain tumors is = resection=20 followed by chemotherapy and radiation therapy, however; these regimes = carry=20 consequences. Evidence accumulated shows that the effects of tumour = removal may=20 activate minimal residual tumor growth, suggesting that therapeutic = approaches=20 are needed to protect patients against the oncologically adverse effects = after=20 the tumor removal [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR4">4</A></CITE>]=20 . As such, certain postoperative periods can offer a window of = opportunity=20 during which the patient may be further protected against the minimal = residual=20 tumor activation by the resection. </P> <P class=3D"">For example, surgical intervention coupled with = postradiation=20 chemotherapeutic regimens within a window of opportunity as defined = clinically=20 is the most effective treatment for pediatric medulloblastoma as=20 pharmacokinetically guided by topotecan dosing for assessment of the = antitumor=20 efficacy [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR5">5</A></CITE>].=20 To maximize delivery of chemotherapy in the treatment of brain tumor = patients,=20 osmotic breaching of the blood-brain barrier (BBB) allows the spatial = and=20 temporal distribution of molecular liposolubility, enabling a window of = BBB=20 permeabilization, promoting therapeutic agents across the BBB and into = the CNS=20 [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR6">6</A></CITE>].=20 </P> <P class=3D"">Rakesh Jain has pointed out that there is a = =93normalization window,=94=20 in which cancer cells may be more vulnerable to traditional cytotoxic = therapies=20 and to novel targeted therapies (such as anti-angiogenic antibody to = VEGF=20 receptor-2) [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR7">7</A></CITE>].=20 The degree of =93normalization=94 is dependent upon the spatial and = temporary=20 regulation of these targeted molecules. This window was reported to be=20 short-lived (about 6 days) and is characterized by an increase in = tumor=20 oxygenation, which enhances radiation therapy by increasing the = concentration of=20 reactive oxygen species created by the radiation. In animals, targeted = toxins=20 for treatment of malignant astrocytoma, have shown prolongation of = survival and=20 complete tumor regression without significant neurological toxicity. = These=20 studies have confirmed the existence of a therapeutic window between = normal=20 brain tissue and malignant cells that can be exploited with targeted = therapy=20 directed against the transferrin receptor [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR8">8</A></CITE>].=20 In children with medulloblastoma, the theoretical possibility of <B>a=20 therapeutic window</B> immediately after surgery has led to neoadjuvant=20 treatments, improving the therapeutic effects of multimodality therapy = [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR9">9</A></CITE>].=20 </P></DIV> <DIV class=3D""><A name=3DSec3></A> <HR> <DIV class=3Dheading2>Current Knowledge and Unanswered Questions about = Emerging=20 Stem Cell Therapy of Brain Tumors</DIV> <P class=3D"">The lack of efficacy for conventional treatments of = malignant brain=20 tumors underscores the need for new strategies which circumvent the = limitations=20 of conventional brain tumor treatments. One such emerging strategy is to = use the=20 tumor-tracking capacity apparently inherent in many stem cell = populations to=20 =93seek out=94 dispersed tumor cells in the brain and deliver = anti-neoplastic agents=20 to these infiltrative cancer satellite foci [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR10">10</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR12">12</A></CITE>].=20 Stem cells possess the capacity of self-renewal and the potential to=20 differentiate into different types of cells. Stem cells transplanted in = the=20 tumor bed may directly modulate the tumor microenvironment via the = therapeutic=20 effects of their regenerative potential, neurotrophic and = neuroprotective=20 properties, and immune regulatory functions (e.g., inhibit the cellular=20 inflammatory process in the tumor) [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR12">12</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR15">15</A></CITE>].=20 Human bone marrow derived mesenchymal stem cells (MSC) transcriptome = analyses=20 reveal that MSC transplanted at sites of nerve injury promote functional = recovery by producing trophic factors that induce survival and = regeneration of=20 host neurons, including BDNF and β-NGF, various neurite-inducing = factors, axon=20 guidance and neural cell adhesion molecules [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR16">16</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR17">17</A></CITE>].=20 </P> <DIV class=3DPara> <DIV class=3D"">However, the clinical potentials for stem cell therapy = have=20 resulted in controversial efficacies [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR10">10</A></CITE>].=20 Many factors influence efficacy including the number of effective stem = cells in=20 a sub-population, the differentiation status, the age of the stem cells, = the=20 occurrence of graft versus host reaction, etc. [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR18">18</A></CITE>].=20 Certain stages of stem cell developmental cycles may be useful for=20 transplantation as stem cells in other stages lose their capacity for = migration=20 and integration into the injured tissues, or may generate tumor = formation=20 (Fig. <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig1">1</A>).=20 Stem cell migratory capacity is quintessential to their successful use = in=20 therapy as stem cells lacking migratory ability may induce new tumor = formation=20 at the injection site [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR19">19</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR20">20</A></CITE>].=20 <DIV class=3DFigure><A name=3DFig1></A><IMG=20 alt=3DMediaObjects/12015_2009_9066_Fig1_HTML.gif=20 src=3D"http://www.springerlink.com/content/75j31p7168n50t21/MediaObjects/= 12015_2009_9066_Fig1_HTML.gif"></DIV> <DIV class=3DCapt><SPAN class=3DCaptNr>Fig. 1 </SPAN>Stem cell = developmental stages. a: Schematic diagram for stem cell migration = toward=20 cytokines produced by the tumor microenvironment (modified from Li and = Loudon,=20 2008). b: Stem cell developmental cycle can be defined into four stages: = quiescent (T0), activation/proliferation (T1), migration (T2), and=20 integration/fate determination (T3). In T1 activated stem cells, = target-related=20 molecules are upregulated, which drive stem cells toward injured = tissues. Upon=20 reaching the injury tissues, stem cells lose expression of the targeting = molecules and integrate into the injured tissue by differentiation (fate = determination) in response to microenvironmental cues in the injured = tissue. T0,=20 T1, T2, and T3 represent different times during the stem cell = development </DIV> <HR> </DIV></DIV> <DIV class=3DPara> <DIV class=3D"">For migratory behavior of stem cells, two properties of = stem cell=20 functional activity are critical: the ability of the stem cell to detect = a=20 target (homing) and the ability of the stem cell to move through the = tissue=20 (migration) to its target (ECM-remodeling). These functions have been = discussed=20 interchangeably but they are distinct and equally important. Homing = appears to=20 be mediated to a large extent by the secretion of chemokines into the = tumor=20 microenvironment and the parallel expression of chemokine receptors on = the stem=20 cells [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR21">21</A></CITE>].=20 ECM remodeling appears to be mediated, by the secretion of matrix=20 metalloproteinases by the stem cell as well as the tumor [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR22">22</A></CITE>].=20 Independent, but coordinated, regulation of these two functional = behaviors=20 (therapeutic activation) must occur for stem cells to be therapeutically = useful.=20 Little is known about how we can effectively activate and program stem = cells for=20 transplantation. For example, quiescent stem cell populations minimally = express=20 chemokine receptors [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR23">23</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR24">24</A></CITE>].=20 <BLOCKQUOTE> <DIV class=3DPara> <DIV class=3D"">Variations in stem cell efficacies may arise from = their=20 activation heterogeneous. A therapeutic state of stem cells must be = clearly=20 defined and utilized in a clinical setting. We postulate to identify = and=20 manipulate the =93therapeutic activation state or therapeutic = window=94 to address=20 a potential window of opportunity when stem cells are most effective = at=20 targeting brain tumors (Fig. <A=20 = href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig2">2</A>).=20 <DIV class=3DFigure><A name=3DFig2></A><IMG=20 alt=3DMediaObjects/12015_2009_9066_Fig2_HTML.gif=20 = src=3D"http://www.springerlink.com/content/75j31p7168n50t21/MediaObjects/= 12015_2009_9066_Fig2_HTML.gif"></DIV> <DIV class=3DCapt><SPAN class=3DCaptNr>Fig. 2 </SPAN>The = =93<B>Therapeutic=20 window</B>=94 of stem cells with cancer-targeting capability can be = defined in=20 the developmental path of stem cells at the molecular level of = expressing=20 cancer-targeting molecules (e.g., CXCR4 and MMP-9) in an in vivo mimic = three-dimensional, extracellular microenvironment model (T1, T2, T3, = and T4=20 represent different times during the stem cell development). Panel = <B>a</B>:=20 The rectangles (in pink color) represent different therapeutic = windows, or by=20 =93<B>biochemical therapeutic windows</B>,=94 expression of different = levels of=20 biomarker and =93<B>biological therapeutic window</B>=94 defined by = temporal=20 biological functions (e.g., migratory behavior). Panel <B>b</B>: The=20 =93biochemical therapeutic windows=94 can be determined by expression = levels of=20 molecules responsible for migration. Left: The time course of MMP9 = expression=20 zymography-Lane 1: 16 h, lane 2: 1 day, lane 3: 3 d, lane 4: 1 week, = lane 5: 2=20 wk, lane 6: 3 wk, lane 7: 4 wk (Lanes were loaded with equivalent = amounts of=20 total lysate); Right: CXCR4 mRNA expression. Panel <B>c</B>: = =93biological=20 therapeutic windows=94 are defined by the capacity of stem cells for = migration,=20 showing that cultivated mesenchymal stem cells of 3-week in = 3D/cytokines=20 increased the migratory capacity compared with that of 1-day culture = and=20 control cells of NIH3T3 </DIV> <HR> </DIV></DIV></BLOCKQUOTE></DIV></DIV></DIV> <DIV class=3D""><A name=3DSec4></A> <HR> <DIV class=3Dheading2>The Hypothesis</DIV> <P class=3D"">Understanding of the functional events during different = stages of=20 the stem cell development is essential for development of effective stem = cell=20 therapy. The therapeutic efficacy of stem cells can be defined by the = percentage=20 of a given number of stem cells competent to target brain tumors. </P> <P class=3D"">The therapeutic window (or pharmaceutical window) is an = estimate of=20 the drug dosage which can effectively treat a disease condition within = the safe=20 range. More specifically, it is formally determined as the range between = the=20 ED50 and the starting point of LD50 curve, i.e. over that which starts = to=20 produce adverse effects. It also indicates a usually short time interval = during=20 which a particular therapy can be given safely and effectively. </P> <P class=3D"">This concept is also highly relevant to stem cell therapy. = Specifically, a =93therapeutic activation state or therapeutic = window=94- a critical=20 stage of stem cell development can be defined as a time when stem cells = acquire=20 ability to migrate, target and integrate when grafted into a targeting = injured=20 tissue for regeneration (Fig. <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig2">2</A>).=20 The defined parameters of a =93therapeutic window=94 can be specifically = determined=20 by using molecular, biochemical and biological studies. </P> <P class=3D"">Optimizing targeting capacity is an essential requirement = of stem=20 cells used in the therapy of brain tumors. Little is known, however, = about the=20 mechanisms by which SC target malignant brain tumors. Growing evidence = shows=20 that chemokine signaling axes (homing) and matrix remodeling = (enhancement of=20 migration) represent major pathways for driving SC trafficking and = migration=20 towards the microenvironment of a brain tumor. Strategies that optimize = the=20 chemokine responsiveness (expressed as chemokine receptors-<B>CR</B>) = and=20 upregulate matrix-remodeling (as matrix metalloproteinase-<B>MMP</B>) = are seen=20 as creating a <B>=93Biochemical Therapeutic Window</B>=94 in stem cells = that enhance=20 the biological behavior (e.g., targeted migration) -hereby defined as a=20 =93<B>biological therapeutic window</B>=94 and subsequently their = therapeutic=20 potential. To determine the migratory behavior of stem cells, (1) the=20 =93biochemical therapeutic window=94 can be modulated through = biochemical events=20 such as matrix remodeling enzymatic activities (e.g., MMPs) and = chemokine=20 receptor expression (e.g., CXCR4) in stem cells <I>in vitro</I>; and (2) = the=20 =93biological therapeutic window=94 can be confirmed by using <I>ex = vivo</I> and=20 <I>in vivo models</I> [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR33">33</A></CITE>].=20 </P> <DIV class=3DPara> <DIV class=3D"">In parallel to the =93therapeutic window=94 state of = normal stem cell=20 development, there may be also a =91therapeutic window=92 for targeting = brain tumor=20 stem cells (BTSC) (Fig. <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig3">3</A>).=20 To establish a =93Therapeutic Window=94 for the optimal treatment of = inherited and=20 acquired malignant brain tumors, we have to identify a period of time in = the=20 life cycle of the BTSC in which intervention (which may include = chemotherapy,=20 radiation therapy, and stem cell therapy) is likely to be most = effective. To=20 understand the life cycle of cancer cells, a great deal of information = has been=20 gained through molecular profiling of cancer cells. However, these = profiles,=20 patterns of gene or protein expression have been identified by analysis = of=20 purified components. Little is known about the context and timing of the = expression of these molecules. Lack of information on spatial and = temporal=20 changes in protein and other molecules in the development of human = cancers=20 requires new methods for real-time visualization of gene expression, = proteins or=20 other molecules in normal and cancer cells to define a therapeutic = window at the=20 molecular level for treatment of human cancers.=20 <DIV class=3DFigure><A name=3DFig3></A><IMG=20 alt=3DMediaObjects/12015_2009_9066_Fig3_HTML.gif=20 src=3D"http://www.springerlink.com/content/75j31p7168n50t21/MediaObjects/= 12015_2009_9066_Fig3_HTML.gif"></DIV> <DIV class=3DCapt><SPAN class=3DCaptNr>Fig. 3 </SPAN>Matching = the=20 =93Therapeutic Window=94 of the normal stem cell (e.g., mesenchymal stem = cells=20 (MSC)) with the =93Therapeutic Window=94 of the brain tumor stem cell = (BTSC) for the=20 target therapy Arrows in red or blue color illustrate that different = matches=20 between MSC and BTSC in their developmental stages can be tried out to = determine=20 a crossing point at which an optimized stem cell state (i.e., the = therapeutic=20 window of stem cells) is acclimatized to a brain tumor in its most = receptive=20 state (i.e., the therapeutic window of brain tumors). T1, T2, T3, and T4 = represent different times (horizontal black arrows) during the stem cell = development. (See text for details) </DIV> <HR> </DIV></DIV></DIV> <DIV class=3D""><A name=3DSec5></A> <HR> <DIV class=3Dheading2>Testing the Hypothesis: Supporting Evidence</DIV> <P class=3D"">Our hypothesis of the =93Therapeutic Window=94 for SC for=20 transplantation is modeled after the clinically established concept of a = =93therapeutic window=94 for embryonic organ transplantation (Dekel et = al., 2003).=20 Previous study by Thomson et al. (1998) suggests that embryonic stem = cells (ESC)=20 can be derived from human blastocysts and maintained in culture = [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR25">25</A></CITE>].=20 Human ESC, after 4=965 months of culture, were injected into = four-week-old=20 severe combined immunodeficient (SCID) mice resulting in teratomas = composed of=20 endoderm, cartilage, bone, smooth muscle and mesoderm. These results led = to a=20 new effort to define the optimal gestational age at which to grow = functional=20 tissues with minimal risk for teratoma formation [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR26">26</A></CITE>].=20 This goal prompted Eventov-Friedman et al. [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR27">27</A></CITE>]=20 to expand the scope of the =93narrow window=94, defined in [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR26">26</A></CITE>],=20 by examining various embryonic pig organ precursors at different = gestational=20 stages. They reported that maximal liver growth and function were = achieved at=20 age (E28), the earliest teratoma-free gestational age. Growth and = functional=20 ability of the pancreas increased toward E42 and E56 and = insulin-secreting=20 capacity declined at E80 and E100. Mature lung tissue development, with=20 essential respiratory system elements, was observed at E56. Determining = the=20 optimal window for pig embryonic pancreas transplantation improves the = chances=20 for the successful treatment of diabetes [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR28">28</A></CITE>].=20 Our preliminary studies indicate that if a distinct =93Therapeutic = Window,=94 for=20 expression of SC targeting-related molecules is determined, the chances = for=20 successful implementation of SC transplantation in the treatment of = human=20 diseases is enhanced. =93Therapeutic Windows=94 in brain tumor work can = be=20 determined by the use of our proprietary platform technology: living = slices=20 derived from rodent brain, which now needs to be translated into = improved=20 clinical treatment for the pediatric gliomas [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR33">33</A></CITE>].=20 </P> <P class=3D"">This novel concept of an optimal window might partially = explain the=20 failures in previous transplantation trials. Examining the relative = amount of=20 committed stem cells and pluripotent cells found in the specific = developing=20 organ might explain why some organs are more prone to formation of = teratoma=20 while others are not. As suggested by Eventov-Friedman <I>et al. = (2005),</I>=20 further studies using phenotypic analysis as well as <I>in vitro</I> = molecular=20 and cellular assays are needed to define the levels of pluripotential as = opposed=20 to committed stem cells in the early embryonic tissue. No further=20 characterization of these =93therapeutic windows=94 are reported. For = example, it=20 has been proposed that there is a limited =93therapeutic window=94 = following=20 myocardial infarction during which stem cells can home in on and = integrate=20 within the heart tissue for myocardial regeneration. In the = =93therapeutic=20 window,=94 =93healing pathways=94 are activated [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR29">29</A></CITE>].=20 Conversely, some initial attempts to use embryonic stem cell therapy in = human=20 diseases have proved dangerous to the subject, e.g., the formation of = teratomas=20 and inflammation responses [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR13">13</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR30">30</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR31">31</A></CITE>].=20 </P> <P class=3D"">Little is known about characterizing the =93therapeutic = window=94 of=20 stem cells at the molecular level. Some of the cellular, molecular and=20 biochemical mechanisms underlying the therapeutic window have now been=20 elucidated. In a range of laboratory assays certain cancers=96malignant = glioma in=20 particular=96are intrinsically sensitive to stem cell therapy. We and = others are=20 characterizing the cellular, molecular and biochemical mechanisms = underlying=20 this therapeutic window. </P> <P class=3D"">The potential complexity associated with generating = adequate=20 populations of SC with targeting capacity requires therapeutic = re-programming=20 (directed activation steps for optimization of: activation, = mobilization,=20 tracking, and targeting) prior to delivery of SC-mediated anti-tumor = treatment.=20 The mechanisms by which SC target glioblastoma maltiforme (GBM) are = slowly being=20 elucidated with growing evidence demonstrating that chemokine signaling = axes=20 (homing) and matrix remodeling (enhancement of migration) providing much = of the=20 driving force in SC trafficking and migration towards GBM = microenvironment.=20 Strategies to optimize the chemokine responsiveness and to upregulate=20 matrix-remodeling should enhance the biological behavior of targeted = migration=20 and improve the potential of cultured SC. </P> <P class=3D"">We have taken the following approaches to proof-of-concept = experiments: 1) an <I>in vitro</I> three dimensional extracellular = milieu model=20 (3D) for controlled expression of chemokine receptors (CRs) and MMPs; 2) = an=20 <I>ex vivo</I> organotypic brain slice model (Li and Loudon, 2008); and = 3) an=20 <I>in vivo</I> intracranial brain tumor model. We should be able to = confirm that=20 the expression levels of chemokine receptors and MMPs of the stem cell = correlate=20 quantitatively with their capacity for migration toward brain tumors. = </P> <P class=3D"">Our data support the fact that a three dimensional (3D) = system can=20 induce up-regulation of chemokine receptors and matrix remodeling = capacity in a=20 time-dependent manner, effectively creating a =93therapeutic window for = stem=20 cells=94 (Fig. <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig2">2</A>a).=20 Stem cells in a 3D system remain quiescent in the absence of chemokine, = as=20 assessed by morphology and expression markers (data not shown). In the = presence=20 of chemokines in a 3D environment, stem cells undergo neurite formation = and=20 produce matrix remodeling enzymes. In addition, these cells home on the=20 chemokine source (publication in preparation). </P> <P class=3D"">The functional gelatinolytic activity of SDF-1-induced = MMP-9 in MSCs=20 grown in a 3D matrix is demonstrated by zymography (Fig. <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig2">2</A>b).=20 As we did not see such induction when the cells were grown in monolayer, = it=20 appears that dual signals from SDF-1 and the 3D matrix are required for=20 induction of MMP-9 (Fig. <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig2">2</A>).=20 We have seen similar results with several types of stem cells, including = human=20 neural stem cells. We have also tested synthetic polymers such as = PLA/PGLA. The=20 polymers can keep the stem cell in a quiescent state without chemokine = or=20 cytokine stimulation. However, the level of MMP-9 production is higher = in 3D=20 collagen I than in synthetic polymers, suggesting that when collagen I = is=20 degraded by induced MMP-9, it acts synergistically with chemokines to = enhance=20 MMP-9 production. </P> <P class=3D"">As whether chemokine receptor expression correlates with = stem cell=20 migration toward chemokines by experiments in microfluidic chambers, it = was=20 found that homing of neural stem cells (NSC) could be enhanced by an=20 intermediate concentration of SDF-1 but while inhibited at a high = concentration,=20 suggesting the SDF-1 signals both the start and stop of stem cell = migration.=20 Interestingly, NSCs also migrate toward fresh tumors [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR33">33</A></CITE>].=20 </P></DIV> <DIV class=3D""><A name=3DSec6></A> <HR> <DIV class=3Dheading2>Implications of the Hypothesis for = Clinicians</DIV> <P class=3D"">Mirroring a therapeutic window in stem cells, is a = therapeutic=20 window for treatment of brain tumors (Fig. <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig3">3</A>).=20 A major challenge in identifying this latter therapeutic window is to = develop=20 imaging technology that will determine the optimal time for treatment = with stem=20 cells. Measurement of tumor growth in situ currently requires tissue = biopsy,=20 which may provide information on brain tumor staging. Stem cell = transplant and=20 tumor imaging have been reviewed by us (in press) and others. Imaging = can=20 provide data about tumor viability, growth and invasion. Imaging = techniques can=20 also provide serial measures of stem cell migration, permeability, and=20 differentiation and can therefore be used to monitor the window of = therapeutic=20 efficacy in patients. PET with 18-fluoromisonidzole and MRI can provide = some=20 indication of tumor oxygenation and might be useful for checking the = efficacy of=20 stem cell therapy [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR32">32</A></CITE>].=20 </P> <P class=3D"">We propose that understanding the unique characteristics = of stem=20 cells will help determine the best therapeutic windows, (i.e., time) in = which=20 cancer-specific targeted therapy ought to be introduced for optimal and = ultimate=20 destruction of cancers. Research results will likely lead to the = identification=20 of novel targets for therapy, better clinical diagnostic and prognostic = tools,=20 and ultimately, to better treatments and cures for CSC-related = malignancies.=20 </P> <P class=3D"">Neuro-oncology argues for a window of opportunity to = attack a brain=20 cancer early phase of cancer development, in which treatments are = usually more=20 successful in inhibiting tumor progression. It is worth considering stem = cell=20 treatment as an effective alternative to conventional therapies that = fail. </P> <P class=3D"">Research from stem cell clinical trials, has shown = inconsistent=20 results possibly due to the heterogeneity of stem cells as well as tumor = cells.=20 The production of cytokines after tumor resection reveals an Achilles = heel,=20 which opens a window of opportunity for combating cancers using stem = cell=20 therapy. To take full advantage of the therapeutic window of = opportunity, we=20 need to develop suitable screening tests that are clinically relevant, = rapid,=20 simple, inexpensive, and impose minimal additional risk to patients = [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR33">33</A></CITE>].=20 </P></DIV> <DIV class=3DAcknowledgments><SPAN=20 class=3DAcknowledgmentsHeading>Acknowledgements </SPAN><SPAN=20 class=3D"">Support is from CHOC Children=92s Hospital Foundation and = Neuroscience=20 Institute as well as from the Austin Ford Tribute Fund and the W. M. = Keck=20 Foundation (to S.C.L.). Many thanks to the Li lab members: Long Vu, Vic=20 Keschrumrus, Michael Ho, Lisa Tachiki, Shi Yu, and Tiffany Dao for their = helpful=20 discussions. We thank Henry J. Klassen, MD-PhD; Philip H. Schwartz, PhD; = Maria=20 Minon, MD; John H. Weiss, MD-PhD; Saul Puszkin, PhD; Michael P Lisanti, = MD-PhD;=20 Richard G Pestell, MD-PhD; Joan S Brugge, PhD; and Robert A Koch, PhD, = for their=20 support and enthusiasm.</SPAN> <DIV class=3DFormalPara> <DIV class=3D""><SPAN style=3D"FONT-STYLE: italic; TEXT-DECORATION: = none">Competing=20 Interests</SPAN> None. </DIV></DIV></DIV> <P></P> <HR> <H2><A name=3DBib1></A>Reference </H2> <TABLE> <TBODY class=3DCitation> <TR vAlign=3Dtop> <TD>1.</TD> <TD><A name=3DCR1></A>Louis, D. N. (2006). 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From: Subject: 10.1007/s12015-009-9066-0 Date: Sat, 1 Aug 2009 18:08:20 +0200 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01CA12D3.0D9C0A90" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01CA12D3.0D9C0A90 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.springerlink.com/content/75j31p7168n50t21/fulltext.html 10.1007/s12015-009-9066-0</TIT= LE> <META http-equiv=3DContent-Type content=3D"text/html; = charset=3DISO-8859-1"><LINK=20 href=3D"http://www.springerlink.com/config/css/A++_common.css" = type=3Dtext/css=20 rel=3DstyleSheet><LINK=20 href=3D"http://www.springerlink.com/config/css/content_A++_SpringerLink.c= ss"=20 type=3Dtext/css rel=3DstyleSheet> <META content=3D"MSHTML 6.00.6000.16890" name=3DGENERATOR></HEAD> <BODY class=3Dfor-print> <TABLE cellPadding=3D2 border=3D1> <TBODY> <TR class=3Dheader> <TD>Stem Cell Reviews and Reports</TD></TR> <TR> <TD>=A9 Springer Science + Business Media 2009</TD></TR> <TR> <TD>10.1007/s12015-009-9066-0</TD></TR></TBODY></TABLE> <H2 class=3Drubric>Hypothesis and Commentary</H2> <DIV class=3DHeading1><A name=3Dtitle></A>Therapeutic Window of Stem = Cell Potential=20 for Targeting Pediatric Malignant Brain Tumors: An Opportunity for Stem = Cell=20 Therapy </DIV> <P class=3DAuthorGroup>Shengwen Calvin Li<SUP>1, 2, 4, 5 <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#ContactOfAuthor1"><IMG=20 alt=3D"Contact Information"=20 src=3D"http://www.springerlink.com/content/75j31p7168n50t21/contact.gif" = border=3D0></A></SUP>, Yuan-Ping Han<SUP>6</SUP>,=20 Brent A. Dethlefs<SUP>1</SUP> and William G=FCnter = Loudon<SUP>1,=20 3</SUP></P> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff1></A>(1) </SPAN></TD> <TD><SPAN class=3DAffiliation>Neuro-Oncology Research Laboratory, = Center for=20 Neuroscience and Stem Cell Research, CHOC Children=92s Research = Institute,=20 455 S. Main Street, Orange, CA 92868-3874,=20 USA</SPAN></TD></TR></TBODY></TABLE> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff2></A>(2) </SPAN></TD> <TD><SPAN class=3DAffiliation>Department of Neurology, University of = California, Irvine, CA 92697, = USA</SPAN></TD></TR></TBODY></TABLE> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff3></A>(3) </SPAN></TD> <TD><SPAN class=3DAffiliation>Department of Neurological Surgery, = University=20 of California, Irvine, CA 92697, = USA</SPAN></TD></TR></TBODY></TABLE> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff4></A>(4) </SPAN></TD> <TD><SPAN class=3DAffiliation>Department of Biological Science, = California=20 State University, Fullerton, CA 92834, = USA</SPAN></TD></TR></TBODY></TABLE> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff5></A>(5) </SPAN></TD> <TD><SPAN class=3DAffiliation>Center for Stem Cell Biology and = Regenerative=20 Medicine, Thomas Jefferson University, Philadelphia, = PA 19107,=20 USA</SPAN></TD></TR></TBODY></TABLE> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff6></A>(6) </SPAN></TD> <TD><SPAN class=3DAffiliation>Department of Surgery, Keck School of=20 Medicine, University of Southern California, Los Angeles,=20 CA 90033-4680, USA</SPAN></TD></TR></TBODY></TABLE> <P><A name=3DContactOfAuthor1></A></P> <TABLE class=3DContact> <TBODY> <TR> <TD vAlign=3Dtop><IMG alt=3D"Contact Information"=20 = src=3D"http://www.springerlink.com/content/75j31p7168n50t21/contact.gif" = border=3D0></TD> <TD><STRONG>Shengwen </STRONG><STRONG>Calvin=20 Li</STRONG><STRONG></STRONG><BR><STRONG>Email: </STRONG><A=20 = href=3D"mailto:sli@choc.org">sli@choc.org</A></TD></TR></TBODY></TABLE> <P class=3DAffiliation><STRONG>Published online: = </STRONG>23 April 2009=20 </P> <DIV class=3DAbstract><A name=3DAbs1></A><SPAN=20 class=3DAbstractHeading>Abstract </SPAN>In children, cancers = are the=20 deadliest of diseases and second only to accidents as the leading cause = of=20 death. The deadliest of the brain cancers are the malignant gliomas.=20 Approximately two-thirds of children can survive less malignant types of = brain=20 cancers, however, in ~ 67% of these survivors recurs under the = current regimes=20 of surgery followed by administration of high doses toxic drugs and = exposure to=20 high doses of radiation. Even more distressing is that fortunate = survivors are=20 generally left with life-long cognitive disabilities. A new medical = approach is=20 desperately needed. Stem cells, with their natural ability to seek out = brain=20 tumors, could be used to accurately deliver therapy directly to the = cancer=20 sparing normal tissues for suppression of tumor growth. Despite exciting = initial=20 reports, clinical potency of stem cell therapy in animal brain tumor = models has=20 to date proven disappointing. Attempts to extrapolate the animal study = results=20 to humans are stymied by the fact that stem cells are heterogeneous, = resulting=20 in differences in their efficacy. Indeed, therapeutic success relies on = an=20 effective strategy to select for a stem cell sub-population within some=20 particular stage of the development at which they are competitive and = capable of=20 targeting brain tumors. To improve this during developmental path, = concept of a=20 =91therapeutic window=92 is proposed. The =93therapeutic window=94 for = stem cells or=20 more specifically a =93biochemical therapeutic window=94 can be = determined from=20 biochemical assays and a =93biological therapeutic window=94 from = biological assays=20 or even a molecular window for genetic description. Taken together, we = can use=20 selective processes to generate more effective stem cells to treat = cancers as is=20 clearly needed today. </DIV> <P class=3DKeyword><SPAN = class=3DKeywordHeading>Keywords </SPAN>Pediatric=20 brain tumors - Stem=20 cells - Therapy - Tumor-targeting </P> <DIV class=3DKeyword><SPAN=20 class=3DKeywordHeading>Abbreviations </SPAN><SPAN=20 class=3DTerm>BTSC </SPAN>brain tumor stem cells - <SPAN=20 class=3DTerm>CNS </SPAN>central nerve system - <SPAN=20 class=3DTerm>CXCR-4 </SPAN>chemokine (C-X-C motif) receptor 4 = a.k.a., SDF-1=20 receptor - <SPAN class=3DTerm>ECM </SPAN>extracellular matrix - = <SPAN=20 class=3DTerm>GAPDH </SPAN>glyceraldehyde-3-phosphate dehydrogenase = - <SPAN=20 class=3DTerm>MMP </SPAN>matrix metalloproteinase - <SPAN=20 class=3DTerm>MSC </SPAN>bone marrow derived mesenchymal stem cells = - <SPAN=20 class=3DTerm>NSC </SPAN>neural stem cells - <SPAN=20 class=3DTerm>3D </SPAN>three dimensional extra-cellular matrix=20 microenvironment - <SPAN class=3DTerm>SDF-1 </SPAN>stromal derived = factor-1=20 (chemokine) a.k.a., CXCL12 </DIV> <DIV class=3DFulltext> <DIV class=3D""><A name=3DSec1></A> <HR> <DIV class=3Dheading2>Malignant Brain Tumor is the Leading Cause of = Cancer-Related=20 Death in Children</DIV> <P class=3D"">As estimated 18,820 new cases of brain and other CNS = cancers will be=20 diagnosed in the United States each year, and more than 12,000 will die = from the=20 diseases (data from the US National Cancer Institute). Brain tumors are = now the=20 leading cause of cancer-related deaths in children under age 15. In = contrast to=20 pediatric hematological malignancies, meaningful improvements in = survival=20 statistics for patients with malignant brain tumors have not been = realized in=20 over 30 years of clinical research [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR1">1</A></CITE>].=20 The median survival after diagnosis of glioblastoma multiforme, the most = aggressive type of brain tumors, remains less than one year, with a = two-year=20 survival rate near zero [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR2">2</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR3">3</A></CITE>].=20 A significant challenge to treating gliomas arises from the fact that = high grade=20 gliomas diffusely migrate and disseminate tumor microsatellites deeply = into=20 distant regions of the normal central nervous system. Surgical removal = combined=20 with adjuvant therapies including chemotherapy and radiation therapy = proves=20 insufficient to eliminate the neoplastic disease. Despite gross total = surgical=20 resection, chemotherapy and radiation therapy, neoplastic cells persist = and=20 subsequently give rise to recurrent tumor. </P> <P class=3D"">As a heterogeneous group of neoplasia with diverse = histological,=20 molecular, and genetic spectra and widely variable clinical prognoses, = brain=20 tumors remain difficult to cure. Early treatment response may be = transient, not=20 necessarily translating into long-term responses or favorable clinical = outcomes.=20 This may reflect a small window of opportunity, i.e., therapeutic = window, during=20 which time tumor cells can be most effectively addressed by therapeutic=20 interventions. </P></DIV> <DIV class=3D""><A name=3DSec2></A> <HR> <DIV class=3Dheading2>=93Time is Life=94 for the Resection of the = Primary Treatment=20 Modalities for Pediatric Malignant Brain Tumors</DIV> <P class=3D"">=93Time is life=94 comes from the idea that neurosurgeons = must treat=20 patients within a time window of severe neurological attack in order to = have a=20 measurable effect. The primary treatment of malignant brain tumors is = resection=20 followed by chemotherapy and radiation therapy, however; these regimes = carry=20 consequences. Evidence accumulated shows that the effects of tumour = removal may=20 activate minimal residual tumor growth, suggesting that therapeutic = approaches=20 are needed to protect patients against the oncologically adverse effects = after=20 the tumor removal [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR4">4</A></CITE>]=20 . As such, certain postoperative periods can offer a window of = opportunity=20 during which the patient may be further protected against the minimal = residual=20 tumor activation by the resection. </P> <P class=3D"">For example, surgical intervention coupled with = postradiation=20 chemotherapeutic regimens within a window of opportunity as defined = clinically=20 is the most effective treatment for pediatric medulloblastoma as=20 pharmacokinetically guided by topotecan dosing for assessment of the = antitumor=20 efficacy [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR5">5</A></CITE>].=20 To maximize delivery of chemotherapy in the treatment of brain tumor = patients,=20 osmotic breaching of the blood-brain barrier (BBB) allows the spatial = and=20 temporal distribution of molecular liposolubility, enabling a window of = BBB=20 permeabilization, promoting therapeutic agents across the BBB and into = the CNS=20 [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR6">6</A></CITE>].=20 </P> <P class=3D"">Rakesh Jain has pointed out that there is a = =93normalization window,=94=20 in which cancer cells may be more vulnerable to traditional cytotoxic = therapies=20 and to novel targeted therapies (such as anti-angiogenic antibody to = VEGF=20 receptor-2) [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR7">7</A></CITE>].=20 The degree of =93normalization=94 is dependent upon the spatial and = temporary=20 regulation of these targeted molecules. This window was reported to be=20 short-lived (about 6 days) and is characterized by an increase in = tumor=20 oxygenation, which enhances radiation therapy by increasing the = concentration of=20 reactive oxygen species created by the radiation. In animals, targeted = toxins=20 for treatment of malignant astrocytoma, have shown prolongation of = survival and=20 complete tumor regression without significant neurological toxicity. = These=20 studies have confirmed the existence of a therapeutic window between = normal=20 brain tissue and malignant cells that can be exploited with targeted = therapy=20 directed against the transferrin receptor [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR8">8</A></CITE>].=20 In children with medulloblastoma, the theoretical possibility of <B>a=20 therapeutic window</B> immediately after surgery has led to neoadjuvant=20 treatments, improving the therapeutic effects of multimodality therapy = [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR9">9</A></CITE>].=20 </P></DIV> <DIV class=3D""><A name=3DSec3></A> <HR> <DIV class=3Dheading2>Current Knowledge and Unanswered Questions about = Emerging=20 Stem Cell Therapy of Brain Tumors</DIV> <P class=3D"">The lack of efficacy for conventional treatments of = malignant brain=20 tumors underscores the need for new strategies which circumvent the = limitations=20 of conventional brain tumor treatments. One such emerging strategy is to = use the=20 tumor-tracking capacity apparently inherent in many stem cell = populations to=20 =93seek out=94 dispersed tumor cells in the brain and deliver = anti-neoplastic agents=20 to these infiltrative cancer satellite foci [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR10">10</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR12">12</A></CITE>].=20 Stem cells possess the capacity of self-renewal and the potential to=20 differentiate into different types of cells. Stem cells transplanted in = the=20 tumor bed may directly modulate the tumor microenvironment via the = therapeutic=20 effects of their regenerative potential, neurotrophic and = neuroprotective=20 properties, and immune regulatory functions (e.g., inhibit the cellular=20 inflammatory process in the tumor) [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR12">12</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR15">15</A></CITE>].=20 Human bone marrow derived mesenchymal stem cells (MSC) transcriptome = analyses=20 reveal that MSC transplanted at sites of nerve injury promote functional = recovery by producing trophic factors that induce survival and = regeneration of=20 host neurons, including BDNF and β-NGF, various neurite-inducing = factors, axon=20 guidance and neural cell adhesion molecules [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR16">16</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR17">17</A></CITE>].=20 </P> <DIV class=3DPara> <DIV class=3D"">However, the clinical potentials for stem cell therapy = have=20 resulted in controversial efficacies [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR10">10</A></CITE>].=20 Many factors influence efficacy including the number of effective stem = cells in=20 a sub-population, the differentiation status, the age of the stem cells, = the=20 occurrence of graft versus host reaction, etc. [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR18">18</A></CITE>].=20 Certain stages of stem cell developmental cycles may be useful for=20 transplantation as stem cells in other stages lose their capacity for = migration=20 and integration into the injured tissues, or may generate tumor = formation=20 (Fig. <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig1">1</A>).=20 Stem cell migratory capacity is quintessential to their successful use = in=20 therapy as stem cells lacking migratory ability may induce new tumor = formation=20 at the injection site [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR19">19</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR20">20</A></CITE>].=20 <DIV class=3DFigure><A name=3DFig1></A><IMG=20 alt=3DMediaObjects/12015_2009_9066_Fig1_HTML.gif=20 src=3D"http://www.springerlink.com/content/75j31p7168n50t21/MediaObjects/= 12015_2009_9066_Fig1_HTML.gif"></DIV> <DIV class=3DCapt><SPAN class=3DCaptNr>Fig. 1 </SPAN>Stem cell = developmental stages. a: Schematic diagram for stem cell migration = toward=20 cytokines produced by the tumor microenvironment (modified from Li and = Loudon,=20 2008). b: Stem cell developmental cycle can be defined into four stages: = quiescent (T0), activation/proliferation (T1), migration (T2), and=20 integration/fate determination (T3). In T1 activated stem cells, = target-related=20 molecules are upregulated, which drive stem cells toward injured = tissues. Upon=20 reaching the injury tissues, stem cells lose expression of the targeting = molecules and integrate into the injured tissue by differentiation (fate = determination) in response to microenvironmental cues in the injured = tissue. T0,=20 T1, T2, and T3 represent different times during the stem cell = development </DIV> <HR> </DIV></DIV> <DIV class=3DPara> <DIV class=3D"">For migratory behavior of stem cells, two properties of = stem cell=20 functional activity are critical: the ability of the stem cell to detect = a=20 target (homing) and the ability of the stem cell to move through the = tissue=20 (migration) to its target (ECM-remodeling). These functions have been = discussed=20 interchangeably but they are distinct and equally important. Homing = appears to=20 be mediated to a large extent by the secretion of chemokines into the = tumor=20 microenvironment and the parallel expression of chemokine receptors on = the stem=20 cells [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR21">21</A></CITE>].=20 ECM remodeling appears to be mediated, by the secretion of matrix=20 metalloproteinases by the stem cell as well as the tumor [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR22">22</A></CITE>].=20 Independent, but coordinated, regulation of these two functional = behaviors=20 (therapeutic activation) must occur for stem cells to be therapeutically = useful.=20 Little is known about how we can effectively activate and program stem = cells for=20 transplantation. For example, quiescent stem cell populations minimally = express=20 chemokine receptors [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR23">23</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR24">24</A></CITE>].=20 <BLOCKQUOTE> <DIV class=3DPara> <DIV class=3D"">Variations in stem cell efficacies may arise from = their=20 activation heterogeneous. A therapeutic state of stem cells must be = clearly=20 defined and utilized in a clinical setting. We postulate to identify = and=20 manipulate the =93therapeutic activation state or therapeutic = window=94 to address=20 a potential window of opportunity when stem cells are most effective = at=20 targeting brain tumors (Fig. <A=20 = href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig2">2</A>).=20 <DIV class=3DFigure><A name=3DFig2></A><IMG=20 alt=3DMediaObjects/12015_2009_9066_Fig2_HTML.gif=20 = src=3D"http://www.springerlink.com/content/75j31p7168n50t21/MediaObjects/= 12015_2009_9066_Fig2_HTML.gif"></DIV> <DIV class=3DCapt><SPAN class=3DCaptNr>Fig. 2 </SPAN>The = =93<B>Therapeutic=20 window</B>=94 of stem cells with cancer-targeting capability can be = defined in=20 the developmental path of stem cells at the molecular level of = expressing=20 cancer-targeting molecules (e.g., CXCR4 and MMP-9) in an in vivo mimic = three-dimensional, extracellular microenvironment model (T1, T2, T3, = and T4=20 represent different times during the stem cell development). Panel = <B>a</B>:=20 The rectangles (in pink color) represent different therapeutic = windows, or by=20 =93<B>biochemical therapeutic windows</B>,=94 expression of different = levels of=20 biomarker and =93<B>biological therapeutic window</B>=94 defined by = temporal=20 biological functions (e.g., migratory behavior). Panel <B>b</B>: The=20 =93biochemical therapeutic windows=94 can be determined by expression = levels of=20 molecules responsible for migration. Left: The time course of MMP9 = expression=20 zymography-Lane 1: 16 h, lane 2: 1 day, lane 3: 3 d, lane 4: 1 week, = lane 5: 2=20 wk, lane 6: 3 wk, lane 7: 4 wk (Lanes were loaded with equivalent = amounts of=20 total lysate); Right: CXCR4 mRNA expression. Panel <B>c</B>: = =93biological=20 therapeutic windows=94 are defined by the capacity of stem cells for = migration,=20 showing that cultivated mesenchymal stem cells of 3-week in = 3D/cytokines=20 increased the migratory capacity compared with that of 1-day culture = and=20 control cells of NIH3T3 </DIV> <HR> </DIV></DIV></BLOCKQUOTE></DIV></DIV></DIV> <DIV class=3D""><A name=3DSec4></A> <HR> <DIV class=3Dheading2>The Hypothesis</DIV> <P class=3D"">Understanding of the functional events during different = stages of=20 the stem cell development is essential for development of effective stem = cell=20 therapy. The therapeutic efficacy of stem cells can be defined by the = percentage=20 of a given number of stem cells competent to target brain tumors. </P> <P class=3D"">The therapeutic window (or pharmaceutical window) is an = estimate of=20 the drug dosage which can effectively treat a disease condition within = the safe=20 range. More specifically, it is formally determined as the range between = the=20 ED50 and the starting point of LD50 curve, i.e. over that which starts = to=20 produce adverse effects. It also indicates a usually short time interval = during=20 which a particular therapy can be given safely and effectively. </P> <P class=3D"">This concept is also highly relevant to stem cell therapy. = Specifically, a =93therapeutic activation state or therapeutic = window=94- a critical=20 stage of stem cell development can be defined as a time when stem cells = acquire=20 ability to migrate, target and integrate when grafted into a targeting = injured=20 tissue for regeneration (Fig. <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig2">2</A>).=20 The defined parameters of a =93therapeutic window=94 can be specifically = determined=20 by using molecular, biochemical and biological studies. </P> <P class=3D"">Optimizing targeting capacity is an essential requirement = of stem=20 cells used in the therapy of brain tumors. Little is known, however, = about the=20 mechanisms by which SC target malignant brain tumors. Growing evidence = shows=20 that chemokine signaling axes (homing) and matrix remodeling = (enhancement of=20 migration) represent major pathways for driving SC trafficking and = migration=20 towards the microenvironment of a brain tumor. Strategies that optimize = the=20 chemokine responsiveness (expressed as chemokine receptors-<B>CR</B>) = and=20 upregulate matrix-remodeling (as matrix metalloproteinase-<B>MMP</B>) = are seen=20 as creating a <B>=93Biochemical Therapeutic Window</B>=94 in stem cells = that enhance=20 the biological behavior (e.g., targeted migration) -hereby defined as a=20 =93<B>biological therapeutic window</B>=94 and subsequently their = therapeutic=20 potential. To determine the migratory behavior of stem cells, (1) the=20 =93biochemical therapeutic window=94 can be modulated through = biochemical events=20 such as matrix remodeling enzymatic activities (e.g., MMPs) and = chemokine=20 receptor expression (e.g., CXCR4) in stem cells <I>in vitro</I>; and (2) = the=20 =93biological therapeutic window=94 can be confirmed by using <I>ex = vivo</I> and=20 <I>in vivo models</I> [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR33">33</A></CITE>].=20 </P> <DIV class=3DPara> <DIV class=3D"">In parallel to the =93therapeutic window=94 state of = normal stem cell=20 development, there may be also a =91therapeutic window=92 for targeting = brain tumor=20 stem cells (BTSC) (Fig. <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig3">3</A>).=20 To establish a =93Therapeutic Window=94 for the optimal treatment of = inherited and=20 acquired malignant brain tumors, we have to identify a period of time in = the=20 life cycle of the BTSC in which intervention (which may include = chemotherapy,=20 radiation therapy, and stem cell therapy) is likely to be most = effective. To=20 understand the life cycle of cancer cells, a great deal of information = has been=20 gained through molecular profiling of cancer cells. However, these = profiles,=20 patterns of gene or protein expression have been identified by analysis = of=20 purified components. Little is known about the context and timing of the = expression of these molecules. Lack of information on spatial and = temporal=20 changes in protein and other molecules in the development of human = cancers=20 requires new methods for real-time visualization of gene expression, = proteins or=20 other molecules in normal and cancer cells to define a therapeutic = window at the=20 molecular level for treatment of human cancers.=20 <DIV class=3DFigure><A name=3DFig3></A><IMG=20 alt=3DMediaObjects/12015_2009_9066_Fig3_HTML.gif=20 src=3D"http://www.springerlink.com/content/75j31p7168n50t21/MediaObjects/= 12015_2009_9066_Fig3_HTML.gif"></DIV> <DIV class=3DCapt><SPAN class=3DCaptNr>Fig. 3 </SPAN>Matching = the=20 =93Therapeutic Window=94 of the normal stem cell (e.g., mesenchymal stem = cells=20 (MSC)) with the =93Therapeutic Window=94 of the brain tumor stem cell = (BTSC) for the=20 target therapy Arrows in red or blue color illustrate that different = matches=20 between MSC and BTSC in their developmental stages can be tried out to = determine=20 a crossing point at which an optimized stem cell state (i.e., the = therapeutic=20 window of stem cells) is acclimatized to a brain tumor in its most = receptive=20 state (i.e., the therapeutic window of brain tumors). T1, T2, T3, and T4 = represent different times (horizontal black arrows) during the stem cell = development. (See text for details) </DIV> <HR> </DIV></DIV></DIV> <DIV class=3D""><A name=3DSec5></A> <HR> <DIV class=3Dheading2>Testing the Hypothesis: Supporting Evidence</DIV> <P class=3D"">Our hypothesis of the =93Therapeutic Window=94 for SC for=20 transplantation is modeled after the clinically established concept of a = =93therapeutic window=94 for embryonic organ transplantation (Dekel et = al., 2003).=20 Previous study by Thomson et al. (1998) suggests that embryonic stem = cells (ESC)=20 can be derived from human blastocysts and maintained in culture = [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR25">25</A></CITE>].=20 Human ESC, after 4=965 months of culture, were injected into = four-week-old=20 severe combined immunodeficient (SCID) mice resulting in teratomas = composed of=20 endoderm, cartilage, bone, smooth muscle and mesoderm. These results led = to a=20 new effort to define the optimal gestational age at which to grow = functional=20 tissues with minimal risk for teratoma formation [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR26">26</A></CITE>].=20 This goal prompted Eventov-Friedman et al. [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR27">27</A></CITE>]=20 to expand the scope of the =93narrow window=94, defined in [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR26">26</A></CITE>],=20 by examining various embryonic pig organ precursors at different = gestational=20 stages. They reported that maximal liver growth and function were = achieved at=20 age (E28), the earliest teratoma-free gestational age. Growth and = functional=20 ability of the pancreas increased toward E42 and E56 and = insulin-secreting=20 capacity declined at E80 and E100. Mature lung tissue development, with=20 essential respiratory system elements, was observed at E56. Determining = the=20 optimal window for pig embryonic pancreas transplantation improves the = chances=20 for the successful treatment of diabetes [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR28">28</A></CITE>].=20 Our preliminary studies indicate that if a distinct =93Therapeutic = Window,=94 for=20 expression of SC targeting-related molecules is determined, the chances = for=20 successful implementation of SC transplantation in the treatment of = human=20 diseases is enhanced. =93Therapeutic Windows=94 in brain tumor work can = be=20 determined by the use of our proprietary platform technology: living = slices=20 derived from rodent brain, which now needs to be translated into = improved=20 clinical treatment for the pediatric gliomas [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR33">33</A></CITE>].=20 </P> <P class=3D"">This novel concept of an optimal window might partially = explain the=20 failures in previous transplantation trials. Examining the relative = amount of=20 committed stem cells and pluripotent cells found in the specific = developing=20 organ might explain why some organs are more prone to formation of = teratoma=20 while others are not. As suggested by Eventov-Friedman <I>et al. = (2005),</I>=20 further studies using phenotypic analysis as well as <I>in vitro</I> = molecular=20 and cellular assays are needed to define the levels of pluripotential as = opposed=20 to committed stem cells in the early embryonic tissue. No further=20 characterization of these =93therapeutic windows=94 are reported. For = example, it=20 has been proposed that there is a limited =93therapeutic window=94 = following=20 myocardial infarction during which stem cells can home in on and = integrate=20 within the heart tissue for myocardial regeneration. In the = =93therapeutic=20 window,=94 =93healing pathways=94 are activated [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR29">29</A></CITE>].=20 Conversely, some initial attempts to use embryonic stem cell therapy in = human=20 diseases have proved dangerous to the subject, e.g., the formation of = teratomas=20 and inflammation responses [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR13">13</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR30">30</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR31">31</A></CITE>].=20 </P> <P class=3D"">Little is known about characterizing the =93therapeutic = window=94 of=20 stem cells at the molecular level. Some of the cellular, molecular and=20 biochemical mechanisms underlying the therapeutic window have now been=20 elucidated. In a range of laboratory assays certain cancers=96malignant = glioma in=20 particular=96are intrinsically sensitive to stem cell therapy. We and = others are=20 characterizing the cellular, molecular and biochemical mechanisms = underlying=20 this therapeutic window. </P> <P class=3D"">The potential complexity associated with generating = adequate=20 populations of SC with targeting capacity requires therapeutic = re-programming=20 (directed activation steps for optimization of: activation, = mobilization,=20 tracking, and targeting) prior to delivery of SC-mediated anti-tumor = treatment.=20 The mechanisms by which SC target glioblastoma maltiforme (GBM) are = slowly being=20 elucidated with growing evidence demonstrating that chemokine signaling = axes=20 (homing) and matrix remodeling (enhancement of migration) providing much = of the=20 driving force in SC trafficking and migration towards GBM = microenvironment.=20 Strategies to optimize the chemokine responsiveness and to upregulate=20 matrix-remodeling should enhance the biological behavior of targeted = migration=20 and improve the potential of cultured SC. </P> <P class=3D"">We have taken the following approaches to proof-of-concept = experiments: 1) an <I>in vitro</I> three dimensional extracellular = milieu model=20 (3D) for controlled expression of chemokine receptors (CRs) and MMPs; 2) = an=20 <I>ex vivo</I> organotypic brain slice model (Li and Loudon, 2008); and = 3) an=20 <I>in vivo</I> intracranial brain tumor model. We should be able to = confirm that=20 the expression levels of chemokine receptors and MMPs of the stem cell = correlate=20 quantitatively with their capacity for migration toward brain tumors. = </P> <P class=3D"">Our data support the fact that a three dimensional (3D) = system can=20 induce up-regulation of chemokine receptors and matrix remodeling = capacity in a=20 time-dependent manner, effectively creating a =93therapeutic window for = stem=20 cells=94 (Fig. <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig2">2</A>a).=20 Stem cells in a 3D system remain quiescent in the absence of chemokine, = as=20 assessed by morphology and expression markers (data not shown). In the = presence=20 of chemokines in a 3D environment, stem cells undergo neurite formation = and=20 produce matrix remodeling enzymes. In addition, these cells home on the=20 chemokine source (publication in preparation). </P> <P class=3D"">The functional gelatinolytic activity of SDF-1-induced = MMP-9 in MSCs=20 grown in a 3D matrix is demonstrated by zymography (Fig. <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig2">2</A>b).=20 As we did not see such induction when the cells were grown in monolayer, = it=20 appears that dual signals from SDF-1 and the 3D matrix are required for=20 induction of MMP-9 (Fig. <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig2">2</A>).=20 We have seen similar results with several types of stem cells, including = human=20 neural stem cells. We have also tested synthetic polymers such as = PLA/PGLA. The=20 polymers can keep the stem cell in a quiescent state without chemokine = or=20 cytokine stimulation. However, the level of MMP-9 production is higher = in 3D=20 collagen I than in synthetic polymers, suggesting that when collagen I = is=20 degraded by induced MMP-9, it acts synergistically with chemokines to = enhance=20 MMP-9 production. </P> <P class=3D"">As whether chemokine receptor expression correlates with = stem cell=20 migration toward chemokines by experiments in microfluidic chambers, it = was=20 found that homing of neural stem cells (NSC) could be enhanced by an=20 intermediate concentration of SDF-1 but while inhibited at a high = concentration,=20 suggesting the SDF-1 signals both the start and stop of stem cell = migration.=20 Interestingly, NSCs also migrate toward fresh tumors [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR33">33</A></CITE>].=20 </P></DIV> <DIV class=3D""><A name=3DSec6></A> <HR> <DIV class=3Dheading2>Implications of the Hypothesis for = Clinicians</DIV> <P class=3D"">Mirroring a therapeutic window in stem cells, is a = therapeutic=20 window for treatment of brain tumors (Fig. <A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#Fig3">3</A>).=20 A major challenge in identifying this latter therapeutic window is to = develop=20 imaging technology that will determine the optimal time for treatment = with stem=20 cells. Measurement of tumor growth in situ currently requires tissue = biopsy,=20 which may provide information on brain tumor staging. Stem cell = transplant and=20 tumor imaging have been reviewed by us (in press) and others. Imaging = can=20 provide data about tumor viability, growth and invasion. Imaging = techniques can=20 also provide serial measures of stem cell migration, permeability, and=20 differentiation and can therefore be used to monitor the window of = therapeutic=20 efficacy in patients. PET with 18-fluoromisonidzole and MRI can provide = some=20 indication of tumor oxygenation and might be useful for checking the = efficacy of=20 stem cell therapy [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR32">32</A></CITE>].=20 </P> <P class=3D"">We propose that understanding the unique characteristics = of stem=20 cells will help determine the best therapeutic windows, (i.e., time) in = which=20 cancer-specific targeted therapy ought to be introduced for optimal and = ultimate=20 destruction of cancers. Research results will likely lead to the = identification=20 of novel targets for therapy, better clinical diagnostic and prognostic = tools,=20 and ultimately, to better treatments and cures for CSC-related = malignancies.=20 </P> <P class=3D"">Neuro-oncology argues for a window of opportunity to = attack a brain=20 cancer early phase of cancer development, in which treatments are = usually more=20 successful in inhibiting tumor progression. It is worth considering stem = cell=20 treatment as an effective alternative to conventional therapies that = fail. </P> <P class=3D"">Research from stem cell clinical trials, has shown = inconsistent=20 results possibly due to the heterogeneity of stem cells as well as tumor = cells.=20 The production of cytokines after tumor resection reveals an Achilles = heel,=20 which opens a window of opportunity for combating cancers using stem = cell=20 therapy. To take full advantage of the therapeutic window of = opportunity, we=20 need to develop suitable screening tests that are clinically relevant, = rapid,=20 simple, inexpensive, and impose minimal additional risk to patients = [<CITE><A=20 href=3D"http://www.springerlink.com/content/75j31p7168n50t21/fulltext.htm= l#CR33">33</A></CITE>].=20 </P></DIV> <DIV class=3DAcknowledgments><SPAN=20 class=3DAcknowledgmentsHeading>Acknowledgements </SPAN><SPAN=20 class=3D"">Support is from CHOC Children=92s Hospital Foundation and = Neuroscience=20 Institute as well as from the Austin Ford Tribute Fund and the W. M. = Keck=20 Foundation (to S.C.L.). Many thanks to the Li lab members: Long Vu, Vic=20 Keschrumrus, Michael Ho, Lisa Tachiki, Shi Yu, and Tiffany Dao for their = helpful=20 discussions. We thank Henry J. Klassen, MD-PhD; Philip H. Schwartz, PhD; = Maria=20 Minon, MD; John H. Weiss, MD-PhD; Saul Puszkin, PhD; Michael P Lisanti, = MD-PhD;=20 Richard G Pestell, MD-PhD; Joan S Brugge, PhD; and Robert A Koch, PhD, = for their=20 support and enthusiasm.</SPAN> <DIV class=3DFormalPara> <DIV class=3D""><SPAN style=3D"FONT-STYLE: italic; TEXT-DECORATION: = none">Competing=20 Interests</SPAN> None. </DIV></DIV></DIV> <P></P> <HR> <H2><A name=3DBib1></A>Reference </H2> <TABLE> <TBODY class=3DCitation> <TR vAlign=3Dtop> <TD>1.</TD> <TD><A name=3DCR1></A>Louis, D. N. (2006). 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