Effective treatments for gliomas remain elusive despite decades of work investigating the biological basis of these tumors. There have been many recent advances in knowledge that have leveraged the tools of genetics, genomics, epigenetics, and proteomics to allow investigators to more finely subclassify and make more detailed prognostic assessments (1). However, many of the barriers that prevent the implementation of clinically effective therapeutics remain unbroken: intrinsic therapeutic resistance mechanisms, biological heterogeneity within and between the same type of tumor in different patients, and the presence of blood–brain and blood–tumor barriers that prevent most systemic therapeutics from reaching their tumor targets within the CNS at effective concentrations (2). More recently, there has been substantial interest in the development of therapeutics that do not require molecular access to the CNS, for example, antiangiogenic agents (3) and immunotherapeutics (4), which act on intravascular or systemic, non-CNS targets. These novel agents are being developed mostly for the treatment of higher grade gliomas, and glioblastoma (WHO grade IV glioma, GBM) in particular, and have yet to demonstrate survival benefit in randomized trials.
For lower grade gliomas there have been few novel therapeutic options and treatment remains restricted to the conventional modalities of biopsy or surgical resection (to the extent feasible), radiation therapy, and cytotoxic chemotherapy. It is in the low-grade gliomas (WHO grade II, LGG) where an interesting molecular genetic discovery has been made: a tumor-initiating mutation in the IDH1 or IDH2 gene (5). These mutations result in a metabolic change within the Krebs cycle of tumor cells that renders the cells susceptible to depletion of NAD+ (6). While this finding is of considerable excitement to oncologists in general, neurooncologists have recognized that pharmacological depletion of NAD+ with use of systemically administered small-molecule inhibitors targeting nicotinamide phosphoribosyltransferase (NAMPT) is unlikely to produce meaningful …
[↵][1]1Email: vogelbm{at}ccf.org.
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