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Molecular Biology of Human Brain Tumors

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 Molecular Biology of Human Brain
Tumors
Daniel Coluccia, Adrienne Weeks, Javier Fandino,
Christian Schneider, Christian Smith, and James T. Rutka
35.1 Introduction
The Central Brain Tumor Registry of the USA estimates the
annual incidence of primary brain and central nervous system
(CNS) tumors at 7.3/100,000 for malignant and 13.3/100,000
for nonmalignant tumors [1]. A true comparison of incidence
numbers across different time periods and countries is diffi-
cult given the inconsistency of data collection methods and
the diversity in diagnostic criteria. Available diagnosis rates
for malignant gliomas spanning the last three decades do not
allow the determination of an increase or decline of age
adapted incidence [2, 3], despite remarkable changes of
environment and lifestyle in industrial nations.
The etiology of most brain tumors is largely unknown. In
gliomas, familial clustering is found in about 5 % and in 1 %
an autosomal dominant inheritance is assumed [4]. Besides
family history, demographic risk factors listed are age and
gender. Most brain tumors such as gliomas occur in older
adults with a slight predominance in males [1]. However, this
might be different depending on origin and location of the
D. Coluccia, M.D.
Division of Neurosurgery, The Arthur and Sonia Labatt Brain
Tumor Research Centre, The Hospital for Sick Children,
University of Toronto, Toronto, ON, Canada
Department of Neurosurgery, Cantonal Hospital of Aarau,
Aarau, Switzerland
A. Weeks, Ph.D., M.D., F.R.C.S.C.
Division of Neurosurgery, Dalhousie University,
Halifax, NS, Canada
J. Fandino, M.D.
Department of Neurosurgery, Cantonal Hospital of Aarau,
Aarau, Switzerland
C. Schneider, M.D. • C. Smith
J.T. Rutka, M.D., Ph.D., F.R.C.S.C., F.A.C.S., F.A.A.P. (*)
Division of Neurosurgery, The Arthur and Sonia Labatt Brain
Tumor Research Centre, The Hospital for Sick Children,
University of Toronto, Toronto, ON, Canada
e-mail: james.rutka@sickkids.ca
© Springer Science+Business Media New York 2017
W.B. Coleman, G.J. Tsongalis (eds.), The Molecular Basis of Human Cancer, DOI 10.1007/978-1-59745-458-2_35
35
tumor. For example, brainstem gliomas, medulloblastomas or
intracranial ependymomas are usually found in children and
adolescents [1]. Even though children constitute only 7 % of
all CNS tumors, these tumors comprise 25 % of all cancers in
infants and are the most frequent solid tumor and the second
most common neoplasm in their age group after leukemia [1,
5]. The only established environmental risk factor is exposure
to elevated ionizing radiation [2, 3]. Other environmental car-
cinogens possibly related to increased brain tumor formation
have been examined, such as n-nitroso compounds and poly-
cyclic aromatic hydrocarbons, but no correlation was found
[2, 3]. Nonionizing radiation such as cellular phones or smok-
ing have also been extensively evaluated, but no reliable causal
link has been established [2, 3]. Chronic viral infections,
which are recognized as important risk factors for various can-
cers [6], are also implicated as triggering processes in brain
tumors. Studies of persistent immunohistochemical detection
of cytomegalovirus (CMV) in glioblastoma and the benefit of
adding antiviral drugs to the standard treatment protocols are
still premature, but importantly remain part of an ongoing
debate into the etiology of some gliomas [7, 8].
The term brain tumor applies to cancers that arise in
different parenchymal layers and tissues from various cellu-
lar origins within the central nervous system. The 2007
WHO classification identifies seven categories of brain
tumors, depending on the presumed histogenetic origin: (1)
neuroepithelial, (2) cranial and paraspinal nerves, (3) menin-
geal and mesenchymal, (4) lymphomas and hematopoietic
neoplasms, (5) germ cell tumors, (6) sellar region, and (7)
metastases [9].
In this chapter we will focus on neuroepithelial tumors
derived from central neuroglia, which have an annual inci-
dence of 6.6/100,000 and account for the most malignant
forms of primary brain tumors [1]. We review the basic biol-
ogy of human brain tumors with a special focus placed on
the most common primary brain tumors in adults and children
including the astrocytoma and medulloblastoma (Fig. 35.1).
These and other human brain tumors will be discussed insofar
as their relationships to the familial predisposition syndromes,
657
658
Fig. 35.1 MRI sequences of common primary brain tumors. (a) Sagittal
T1-weighted and gadolinium-enhanced MR image showing a medullo-
blastoma in the posterior fossa (arrow) with compression of the pons
and medulla oblongata; (b) Axial T2-weighted MR image showing a
space occupying ependymoma (hyperintense signaling, arrow) in the left
paramedian posterior fossa resulting in displacement of the brain stem;
cytogenetic alterations, dysregulation of the cell cycle
machinery, tumor cell migration and invasion, angiogenesis,
developmental signaling pathways, brain tumor stem cells,
and preclinical animal models.
The management strategies of human brain tumors rely
mostly on histopathological characteristics that are used to
predict the clinical behavior and eventual patient prognosis
of a diagnosed brain tumor. Features including degree of
anaplasia, mitosis, infiltration, necrosis, and neovasculariza-
tion define the corresponding tumor grade, which ranges
from benign, WHO grade I, to the most malignant, WHO
grade IV [9]. The advances in molecular diagnostics over
the last 5 years however have led to rapid genetic profiling
of many brain tumors, which allow us now to recognize
D. Coluccia et al.
(c) Sagital T1-weighted and gadolinium-enhanced MR image depicting
a slightly and inhomogenously enhancing low grade astrocytoma in the
thalamic and mesencephalic region (arrow); (d) Axial T1-weighted and
gadolinium-enhanced MR image showing a centrally located
Glioblastoma (arrow) in the region of basal ganglia resulting in dis-
placement of the pyramidal tracts (brown fringe).
remarkable differences in prognosis for tumors harboring
similar histopathological patterns [10, 11]. Currently, the
utilization of some molecular markers informs individual-
ized treatment decisions for patients with the same histo-
logical tumor [10]. Future revisions of brain tumors
classification systems need to implement molecular profiles
in order to support the differential diagnosis and to be of
value in predicting the efficacy of treatment options.
Despite concerted efforts in the field of neuro-oncology,
brain tumors represent perhaps the most intimidating and
difficult to treat type of cancer. Compared to other neoplasms,
patient with malignant gliomas still face disproportionately
high rates of morbidity and mortality [12] (Table 35.1).
Fortunately, recent advances in molecular biology have
Table 35.1 Clinical characteristics of common primary brain tumors

35
Preferential Annual WHO

Molecular Biology of Human Brain Tumors

Tumor location Age Gender incidence grade Present treatment strategy Prognosis
Medulloblastoma Cerebellar Median: 8 y m: f ~ 1.6:1 0.6/100,000 Grade IV – Maximal safe resection followed Pediatric:
[1, 424–427] 93 % < 15 y (age 1–9) by C (<3 y) and RT (>3 y) – 5-y survival
– High-dose C and autologous • 42 % (infants < 1 y)
stem cell transplantation with or • 72 % (1–9 y, including high- and
without RT to be considered, average-risk (ar))
especially for high-risk group – 10-y survival for ar group:
– Re-resection at progression • 81 %
followed by C with or without Adults:
RT – 5-y survival
• 67 % WNT group correlates with
good prognosis (>90 %
long-term survivals)
Intracranial ependymoma Infratentorial Median: 8 y m: f ~ 1.1:1 0.3/100,000 Grade II – Maximal safe resection followed Pediatric:
[1, 208, 428] (60–70 %), (~50 %) by RT – 5-y survival
supratentorial Grade III – C for Grade III, non-resectable • 66–79 %
(30–40 %) (~50 %) tumors, low EOR and at – 10-y survival
progression • 55–68 %
– Re-resection at progression
followed by RT with or without
C
Pilocytic astrocytoma [1, Cerebellar (in Median: 18 y m: f ~ 1:1 0.9/100,000 (age Grade I – Maximal safe resection Pediatric:
247, 249, 429] children > 50 %), 38 % < 15 y 0–19) (>90 %) – Post-OP: – 10-y survival
optic pathway, 75 % < 20 y • Usually no additional Cerebellar: 100 %
hypothalamus therapy, depending on EOR Overall: 97 %
• RT optional for non- Adults:
resectable tumors and at – 5-y survival
progression Overall: 84 %
• C optional for non-resectable
tumors and at progression
– Re-resection at progression
Diffuse low-grade glioma Frontal (50 %), Median: 45 y m: f ~ 1.3:1 1/100,000 Grade II – Maximal safe resection 5-y survival
(DLGG) temporal (25 %) – A 20–50 % – Post-OP: – >95 % After GTR
– Astrocytoma (A) Insular (10 %) – OD 35 % • C to be considered, – 78 % if Resection < 50 %
– Oligodendroglioma – OA 10–45 % especially for OD, non- 10-y survival
– (OD) resectable DLGG, low EOR – 90 % After GTR
– Oligoastrocytoma and at Progression – 54 % if resection < 50 %
(OA) [107, 430-432] • RT for non-resectable DLGG OD and LOH 1p/19q tend to correlate
and at Progression with better outcome
– Re-resection at progression,
followed by C and/or RT
(continued)

659
Table 35.1 (continued)

660
Preferential Annual WHO
Tumor location Age Gender incidence grade Present treatment strategy Prognosis
High-grade/anaplastic Parietal, frontal, Median: 43 y m: f ~ 1.4:1 0.6/100,000 Grade III – Maximal safe resection followed Median survival
(A) glioma temporal by RT or alkylating C (AA, – 4.6- 6.5 y (AOD, AOA)
– AA AOD and AOA without LOH 5-y survival
– AOD 1p/19q) ~50–65 % (AOD, AOA)
– AOA – Maximum resection followed by ~15–50 % (AA)
[121, 206, 433–435] C with or without RT (AOD and 10-y survival
AOA with LOH 1p/19q) ~20–45 % (AOD, AOA)
– Re-resection and C/RT at ~15–30 % (AA)
progression AOD, IDH1 mutations and LOH
1p/19q correlate with increased
sensitivity to RT/C and better outcome
Glioblastoma [433, 436, Temporal, frontal, Median: 57 y m: f ~ 1.7:1 5/100,000 Grade IV – Maximal safe resection, Median survival
437] parietal followed by RT plus concurrent – 14.6 mt (overall)
TMZ, followed by adjuvant – 23.4 mt with methylated (met)
TMZ (age < 65–70 years) MGMT promoter
– Maximal safe resection, 5-y survival
followed by RT or TMZ with or – 9.8 % (overall)
without RT based on MGMT – 13.8 % with met MGMT
status (age > 65–70 years) IDH1/2 mutations and met MGMT
– Re-resection and C/RT at correlate with better outcome
progression to be considered
y Year(s), mt months, m male, f female, C chemotherapy, RT radiotherapy, EOR extent of resection, GTR gross total resection

D. Coluccia et al.
35 Molecular Biology of Human Brain Tumors
provided a wealth of new information that can now be applied
to improving patient treatment strategies and outcome.
Modern medicine is on the threshold of achieving many tan-
gible gains in overall patient survival based on the progress
that has been made in several areas of experimental
neuro-oncology.
35.2 The Familial Central Nervous System
Tumor Syndromes
Most CNS tumors occur in adults and arise spontaneously
with no previous family history or genealogic pattern of
inheritance. In some cases, especially in younger patients,
they may present as a familial syndrome and transmitted
most frequently in an autosomal dominant (AD) pattern of
inheritance. Advances in the identification and characteriza-
tion of gene mutations have permitted insight into the molec-
ular basis of both familial and sporadic CNS tumors.
Many familial CNS cancer syndromes are associated with
mutations in tumor suppressor genes, which mediate func-
tions such as DNA repair and cell cycle arrest. Affected indi-
viduals typically inherit a germ-line mutation in one copy of
the genetic locus and in the cases of non-AD mutations, are
associated with somatic loss of the wild-type allele in order
to promote the initiation of tumor growth. One important dis-
tinction of the familial syndromes is the predisposition of
patients to develop multiple tumors in the CNS as observed
in neurofibromatosis 1 (NF1), neurofibromatosis 2 (NF2),
von Hippel–Lindau disease, tuberous sclerosis complex,
Gorlin syndrome, Li–Fraumeni syndrome, Turcot syndrome,
and Cowden syndrome.
35.2.1 Neurofibromatosis Type 1
NF1, also known as von Recklinghausen’s disease, is one of
the most common inherited monogenetic syndromes predis-
posing individuals to the formation of CNS tumors, with an
incidence of 1 in 3500 individuals and an equal predomi-
nance in both genders [13] (Fig. 35.2). NF1 is AD, with
marked pleiotropy and variability in clinical expression.
Approximately 50 % of newly diagnosed patients have no
previous family history, suggesting the occurrence of de
novo mutations, with a bias for the paternal germ-line. The
disease is caused by loss-of-function mutations of the NF1
gene. The diagnosis of NF1 is made according to well
defined clinical criteria (NIH criteria) [14], which are usually
diagnostic by the age of 8 years [15]. Detecting mutations in
the NF1 gene is difficult and complex given the large size of
the gene and the lack of established mutation hotspots.
Protocols combining PCR and high-performance liquid
chromatography to detect germ-line mutations have been
661
Fig. 35.2 T1-weighted and gadolinium-enhanced MRI sequence
showing a Pilocytic Astrocytoma of the optic pathway in a patient with
neurofibromatosis type 1.
developed and have reported the identification of more than
95 % of individuals fulfilling clinical NF1 criteria [16].
The disease is characterized by the presence of multiple
neurofibromas, pilocytic astrocytoma within the optic nerve
pathways, malignant peripheral nerve sheath tumors
(MPNST), and susceptibility to other astrocytomas. The
optic pathway astrocytoma (OPA) represents the most com-
mon CNS tumor in NF1, affecting up to 20 % of all patients
and usually arising in children under the age of six [17].
Remarkably, half of the individuals with OPA remain asymp-
tomatic [17].
NF1 is inherited with high penetrance but the phenotypic
expression is variable, suggesting a role for other disease-
modifying genes and heterogeneous mutations of the NF1
gene [18–20]. The timing of NF1 gene inactivation or muta-
tion is also assumed to interfere with disease manifestation
[20]. The NF1 gene is localized to chromosome 17q in 1987
and mapped to the 17q11.2 locus 3 years later [21–23]. The
NF1 gene encodes the protein Neurofibromin and spans at
least 350 kilobases (kb) and includes over 60 exons. More
than 1000 mutations resulting primarily in Neurofibromin
truncations have been identified [24] and complete gene
deletion is associated with a severe phenotype [25].
Neurofibromin functions as a tumor suppressor and is a
cytoplasmic protein of that is highly expressed in neurons,
Schwann cells, oligodendrocytes, astrocytes, leucocytes and
the adrenal medulla, while its expression in other tissues is
minimal [26]. Neurofibromin harbors a Guanosine Activating
Protein (GAP)-related domain, conferring homology to other
guanosine triphosphatase (GTP) activating proteins [27].
Ras is a GTP-binding oncoprotein, which promotes cell
growth and differentiation. By accelerating the conversion of
active GTP to its inactive, guanosine diphosphatase (GDP)-
bound form, Neurofibromin acts as a negative regulator of Ras.
662
Defects in Neurofibromin are thought to increase cell growth
and facilitate tumor formation due to loss of Ras regulation.
In addition, Neurofibromin regulates other proteins includ-
ing adenylate cyclase in astrocytes, and potentially plays a
role in neural stem cell proliferation, survival, and astroglial
differentiation [28, 29].
While most of the neoplasms encountered in NF1 patients
are not considered malignant, adults with NF 1 have a
50–100-fold increased risk of high-grade glioma formation
[30, 31] and a 20 % lifetime risk to develop a malignant
peripheral nerve sheet tumor (MPNST) [32, 33] which are
assumed to arise from preexisting neurofibromas [32]. To
date, only two genetics alterations have been identified as
progression pathways. Mutation in the TP53 loci and genetic
alterations in INK4A have been frequently identified in malig-
nant but not benign forms of neurofibromas [30, 34].
Numerous animal models have been employed to explore
the molecular basis of NF1 pathogenesis. NF1 heterozygous
mice with selective inactivation of NF1 in Schwann cells
develop tumors with histologic and molecular features of
human neurofibromas [35]. The generation of astrocyte-
specific NF1 knockout mouse yielded similar findings, with
low-grade optic astrocytomas developing only when
Neurofibromin expression was ablated in astrocytes of NF1
heterozygous mice [36].
Several therapeutic approaches based on blocking the
dysfunctional neurofibromin pathway have been attempted
in animal studies [37]. However, most clinical studies have
not extended beyond Phase II trials [38]. The mTOR path-
way is regarded as a key mediator of optic pathway glioma
development. Currently, an ongoing Phase II study is inves-
tigating the growth inhibition of NF1 related low-grade glio-
mas using the mTOR-inhibitor everolimus [39].
35.2.2 Neurofibromatosis Type 2
NF2 is approximately tenfold less common than NF1 and
has distinct phenotypic and genetic features. It is an autoso-
mal dominant syndrome that occurs at an incidence of 1 in
25,000–40,000, with a penetrance close to 100 % by the age
of 60 [40]. Half of the individuals inherit a germ-line muta-
tion from a parent or acquire a de novo mutation at the stage
of embryogenesis [41]. Bilateral vestibular schwannomas
are pathognomonic of the disorder, which is also character-
ized by schwannomas of other nerves (cranial, spinal or
peripheral) as well as intracranial and intraspinal meningi-
oma and ependymomas. NF2 is characterized by a variable
age at onset, with a majority of patients developing signs in
the second to third decade of life, and thus, NF2 schwanno-
mas and meningiomas occur at an earlier age compared to
their sporadic counterparts [41]. NF2 is clinically diagnosed
according to the 2005 Manchester criteria [42].
D. Coluccia et al.
The NF2 gene was mapped to chromosome 22 in 1987
and further localized on locus 22q12.2 [43]. The gene
responsible for this disorder was cloned in 1993 by two
groups by positional cloning and was notably also found to
be mutated or deleted in the majority of sporadic meningio-
mas and schwannomas [44, 45]. The gene spans 17 exons
distributed approximately over 110 kb, and it encodes for a
protein of 595 amino acids called merlin (for moesin, ezrin,
radixin-like) due to its homology to three proteins of the
ezrin, radixin, moesin (ERM) family [45]. Merlin, alterna-
tively named Schwannomin, is expressed in many normal
human tissues, including the brain, and functions as a tumor
suppressor [46]. Tumors resulting from dysfunction or loss
of Merlin activity are mostly benign [47].
Several studies have shown that Merlin controls cell pro-
liferation and cell motility by regulating cytoskeletal organi-
zation, but the pathways involved in its mediation of growth
suppression are poorly understood [46, 48]. Merlin interacts
with F-actin and negatively regulates cell motility through
cytoskeletal reorganization. Moreover, it may act with CD44
(a hyaluronic acid receptor), β1 integrin (a transmembrane
glycoprotein) and paxillin (a cytoskeletal adaptor protein) to
regulate cell motility [48]. Merlin deficiency has also been
linked to abnormal activation and overexpression of receptor
tyrosine kinases such as EGFR family receptors [49].
A number of NF2 mouse models have been developed.
Homozygous mutation of NF2 results in embryonic lethality,
indicating that its function is essential at early stages of
mouse development [50]. Heterozygous NF2 mutant mice
develop many neoplasms but do not manifest the classical
tumors linked to NF2. However, as observed in NF1 murine
models, the model of conditioned Schwann cells for knock-
out mice show many similarities with NF2 patients [51].
Merlin dysfunction or loss affects various signaling path-
ways, therefore several therapeutic targets have been pro-
posed. As schwannomas represent the most common
symptomatic and limiting tumor in NF2 patients, clinical tri-
als are primarily directed against schwannoma formation
[52]. A recent Phase II study in NF2 patients with progres-
sive vestibular schwannomas observed some decrease in
tumor volume and improvement in hearing in response to the
EGRF inhibitor Lapatinib [53].
35.2.3 von Hippel–Lindau Syndrome
von Hippel–Lindau (VHL) is a rare inherited disease with an
AD pattern of transmission and was first described in the
early 1900s by Eugen von Hippel and Arvid Lindau [54, 55].
It is characterized by the development of benign
hamartomatous tumors in the CNS and adrenal glands
including hemangioblastoma and retina angioma, pheochro-
mocytoma, pancreatic neuroendocrine tumors and inner ear
35 Molecular Biology of Human Brain Tumors
tumors as well as malignant tumors of the kidney such as
renal cell carcinoma [56]. Its incidence is estimated at 1 in
36,000–45,000 births per year [57, 58]. Up to 20 % of VHL
patients are estimated to derive from de novo mutations [59].
The disease shows variable expressivity with almost 95 %
penetrance at the age of 60 years [60]. A combination of
characteristic clinical features, with or without a positive
family history, permits the establishment of a clinical diag-
nosis. The most frequent lesion observed is hemangioblas-
toma, a mesenchymal solid and cystic tumor mainly localized
in the brain (mostly located in the cerebellum), which occurs
in 60 to 80 % of all VHL patients [61]. Depending on specific
mutation in the gene locus, VHL is classified as type 1 or
type 2, according to the absence or presence of a pheochro-
mocytoma [56].
The gene responsible for this disease is the VHL tumor-
suppressor gene, located on chromosome 3p25-26 [57].
Under normoxic conditions, the gene product targets
hypoxia-inducible factors (HIF) for polyubiquitination and
proteosomal degradation. Under hypoxic conditions, the
accumulation of HIF will induce the transcription of hypoxia-
regulated genes such as vascular endothelial growth factor
(VEGF), platelet derived growth factor (PDGF) and trans-
forming growth factor (TGF) -α. This explains the high vas-
cularization of VHL-related tumors. Loss of the VHL gene
can also result in aberrant expression of genes that control
cell cycle progression and invasion [62, 63]. It has been
shown in renal carcinoma cells that loss of the VHL gene
results in the accumulation of hepatocyte growth factor
(HGF), which interacts with the β-catenin pathway [64].
Loss of VHL protein activity has also been recently corre-
lated to the activation of kinases required for Ras-induced
cell transformation, thus representing a possible target for
molecular )inhibition [65].
Hemangioblastoma is a mesenchymal-derived hamartoma-
tous tumor and patients with VHL-syndrome are not typically
linked with glioma manifestation. However, there is some
evidence that VHL expression interferes also with neuroepi-
thelial tumor formation via suppression of HIF-1α/VEGF,
which is coupled with inhibition of glioma proliferation and
invasion [66].
35.2.4 Tuberous Sclerosis Complex
Tuberous sclerosis complex (TSC) is a multisystem autoso-
mal dominant disorder, affecting 1 in 6000–10,000 individu-
als [67]. It was first described by Bourneville in 1880 and is
characterized by CNS tumors including cortical hamartomas
named tubers, subcortical glioneuronal hamartomas, subep-
endymal glial nodules, and subependymal giant cell astrocy-
tomas. TSC patients often suffer from debilitating neurologic
disorders, including epilepsy, mental retardation, and autism.
663
Essentially, any organ system can be involved and common
features of TSC include dermatologic manifestations such as
cutaneous angiofibromas, subungual fibromas, cardiac rhab-
domyomas, renal angiomyolipomas, intestinal and visceral
cysts, and pulmonary lymphoangiomyomatosis,
The diagnostic criteria consists of a set of major and
minor features which appear at distinct points in develop-
ment, but most patients have manifestations of the disease
before 10 years of age [68]. Neurologic disabilities seem to
be intimately related to the presence of cortical tubers, which
occur in approximately 70 % of patients [69].
The penetrance of the disease is high but the clinical man-
ifestations are considerably variable [70]. There is a high rate
of new mutations, accounting for up to 85 % of cases [71].
TSC results from the mutation of one of two genes, TSC1 on
chromosomes 9q34 and TSC2 located on 16p13.3. Clinical
and pathological features caused by mutations in these two
genes are indistinguishable, but the prognosis seems to be
more severe when the disease is associated with a TSC2
mutation [72]. The TSC1 gene encodes a transcript of 8.6 kb
called Hamartin, containing 23 exons, whereas the TSC2
gene encodes a transcript of 5.5 kb called Tuberin, contain-
ing 41 exons. Mutations in these genes can be identified in
60–80 % of TSC patients, with a wide spectrum of specific
genetic alterations [73]. Hamartin and Tuberin function as a
regulatory complex inhibiting the small GTPase RHEB and
consequently limiting the activity of the mammalian target
of rapamycin complex 1 (mTORC1), which is an intracellu-
lar regulator of cell growth and metabolism [74]. In a recent
Phase I–II open-label study of patients receiving the mTOR-
inhibitor everolimus, a clinically significant reduction in tumor
volume of TSC related subependymal giant-cell astrocytoma
was shown [75, 76].
35.2.5 Gorlin Syndrome
Gorlin syndrome is also known as nevoid basal cell carcinoma
syndrome (NBCCS) or basal cell nevus syndrome (BCNS)
and was first described by Goltz and Gorlin in the 1960s.
It is a rare AD disorder occurring in 1 of 57,000 live births
and characterized by basal cell-carcinoma, skeletal anoma-
lies and a 2–5 % incidence of childhood medulloblastomas
(mostly SHH medulloblastomas) [11, 77]. The penetrance is
very high but the clinical expression is variable, with up to
30 % of patients presenting with de novo mutations [78].
The clinical criteria are based on the association of multiple
basal cell carcinomas and odontogenic keratocysts [79].
Other manifestations include the presence of palm or sole
pits, intracranial calcifications in particular along the falx
and macrocephaly [77].
The disease results from a mutation of the human homo-
logue of the Drosophila melanogaster gene PTCH located
664
on 9q22.3 [80]. It contains 23 exons and encodes for a trans-
membrane protein (Ptch), which is a receptor and negative
regulator for the secreted Hedgehog family proteins such as
Sonic Hedgehog (Shh).
35.2.6 Li–Fraumeni Syndrome and TP53
Germ-Line Mutations
Li–Fraumeni syndrome (LFS) is an AD disorder predispos-
ing patients to an early onset of a wide spectrum of neo-
plasms. The syndrome was defined by Li and Fraumeni after
they noticed a high incidence of cancer among family mem-
bers of children with rhabdomyosarcoma [81]. Often
described as a very rare syndrome with only several hundred
identified individuals, its effective incidence is probably
underestimated [82], in part also due to the existence of dif-
ferent classification schemes [83]. The most frequent tumors
observed are breast cancer, sarcomas, osteosarcomas, brain
tumors, acute leukemia and adrenocortical carcinomas.
The major genetic abnormality underlying this syndrome
is a germ-line mutation of TP53, which has been identified in
70 % of LFS cases and in 22–44 % of families with the LF
variant form [84]. Importantly, 50 % of the families with a
TP53 germ-line mutation meet the diagnostic criteria of
LFS. In the remaining cases of LFS without TP53 mutation, a
germ-line mutation of the hCHK2 gene involved in G2 check-
point control has been identified [84]. TP53 germ-line muta-
tions occur most frequently in exons 5–8, with major hotspots
on codons 245 and 248. In the 143 LFS families reported, the
most frequently identified mutations are point mutations
(85.3 % of cases). Interestingly, low grade and anaplastic
astrocytomas of LFS patients harbor somatic IDH1 mutations
at much higher rates compared to sporadic gliomas [85].
35.2.7 Turcot Syndrome
Turcot syndrome is an AD disorder characterized by the
occurrence of adenomatous colorectal polyps or colon carci-
nomas and malignant brain tumors, mainly anaplastic astro-
cytomas, as well as glioblastomas and medulloblastomas
(95 %) [86]. Turcot described the first cases in 1959, where
two siblings developed malignant CNS tumors and numer-
ous adenomatous colorectal polyps [87].
There are two major subgroups of Turcot syndrome. The
type 1 pattern is characterized by an association of glioblasto-
mas and hereditary non-polyposis colorectal carcinomas
(HNPCC). This subgroup results from a germ-line mutation
in DNA mismatch repair genes such as hPMS1 (ch 2q32),
hPMS2 (ch 7p22), hMSH2 (ch 2p16), or hMLH1 (ch 3p21)
[86]. These deficiencies lead to DNA replication errors and
microsatellite instability, which is rare in brain tumors in the
D. Coluccia et al.
absence of Turcot syndrome [88]. In this subgroup, the mean
age for occurrence of glioblastoma is lower than in the
general population (18 years old versus 40–70 years old).
The type 2 subgroup is characterized by association of WNT
subgroup medulloblastomas with familial adenomatous pol-
yposis (FAP). These patients tend to have a germ-line muta-
tion in the adenomatous polyposis coli (APC) gene that lies on
chromosome 5q21 [86]. In the type 2 Turcot syndrome sub-
group, the median age of occurrence of medulloblastoma is 15
years, compared to 7 years of age in the general population.
35.2.8 Cowden Syndrome and Lhermitte–
Duclos Disease
Cowden syndrome (CS) is a rare AD condition associated
with multiple benign hamartomatous lesions mostly involv-
ing the skin and mucosa, but various organ systems including
the cerebellum may be affected [89]. CS predisposes patients
to malignant tumors, especially of the breast, thyroid, intes-
tine, and endometrium [89]. The penetrance of CS is high and
approaches over 90 % by the age of 20 years [89]. The syn-
drome was first documented in 1963 by Lloyd and Dennis
and named after the first patient [90]. In 1991, more than 70
years after its first description [91], it was recognized that
dysplastic cerebellar gangliocytoma or Lhermitte–Duclos
disease (LDD) is often a manifestation of CS [92]. The preva-
lence of CS is estimated at 1:200,000, but the frequency is
likely underestimated given that many non-symptomatic
mucocutaneous manifestations related to this disease are also
common in the general population and thus may not lead to
extensive diagnosis [89]. Approximately half of the CS cases
are recorded as inherited and half occur spontaneously [93].
The most common germ-line mutation) involves the tumor
suppressor gene PTEN, located at the chromosome 10q23.3
[94, 95]. Early clinical data including nearly 50 CS families
suggest that 85 % of patients with CS harbor a PTEN muta-
tion [96, 97] However this may not be universally adopted
given that application of risk assessment criteria from the
National Comprehensive Cancer Network (NCCN) results in
many patients diagnosed as CS despite the absence of PTEN
mutations [98]. Germ-line mutations downstream of PTEN
signaling were found in the PI3K/AKT pathway in up to 10 %
of CS patients lacking PTEN gene alterations [99]. Not all
patients with LDD show clinical manifestation of CS [100]
and dysfunction or inactivation of PTEN is found in 67–83 %
of LDD lesions [100, 101]. Selective inactivation of PTEN in
neural cells of mice results in impaired migration of granular
cell precursors and formation of cerebellar tumors histopath-
ologically resembling LDD [102, 103]. Inactivation of PTEN
is linked with increased levels of PI3K/AKT, which promotes
cell growth and proliferation [102, 103]. Activated AKT
regulates various pathways involved in protein synthesis and
35 Molecular Biology of Human Brain Tumors
cell growth, including the mTOR pathway, suggesting that
mTOR inhibitors may be effective in reversing cellular hyper-
trophy and tumor growth [101].
35.3 Cytogenetics and Molecular Genetics
of Neuroepithelial Human Brain
Tumors
35.3.1 Glioma (Astrocytoma
and Oligodendroglioma)
Gliomas comprise tumors of astrocytic or oligodendrocytic
histopathological appearance. Whether these tumors have
the same origin of tumor-initiating cells from neural progeni-
tors or arise from dedifferentiated astrodendrocytes/oligo-
dendrocytes is a matter of ongoing debate [104, 105]. The
WHO distinguishes between gliomas with more circum-
scribed growth (WHO Grade I) and gliomas with diffuse
infiltration (WHO Grade II: low grade, WHO Grade III–IV:
high grade) [9]. Diffuse low-grade gliomas are considered a
precancerous disease, as over time they progress to anaplas-
tic, malignant tumors in most instances [106].
Gliomas demonstrate the full spectrum of cytogenetic and
molecular abnormalities: From numerical and structural
chromosomal alterations, to gene amplifications and overex-
pression, deletions and small-scale mutations up to and
including epigenetic deregulations.
35.3.2 Chromosomal Alterations
Chromosomal number alterations occur with increased fre-
quencies in high grade and adult gliomas, and chromosomal
losses are observed more frequently than gains [107]. One of
most common numerical autosomal changes seen in high-
grade astrocytomas includes gain of chromosome 7, and loss
of chromosome 10 [107–109]. Gain of chromosome 7 is
seen in up to 83 % of adult high-grade astrocytomas, whereas
chromosome 10 is reported to be lost in up to 86 % [109,
110]. In some studies, a combined gain of chromosome 7
accompanied by loss of chromosome 10 (7+/10-) occurs in
over 80 % of GBM samples [108, 111].
The occurrence of trisomy 7 and monosomy 10 together
has often been correlated with short-term survival, although
currently available data does not allow a distinct conclusion
[112]. Gains of chromosome 7 are also among the most com-
mon autosomal changes in low-grade gliomas (LGG), seen
in 57 % of cases [110] and loss of chromosome 10 may be
correlated with shorter overall survival [113]. Chromosomal
alterations commonly observed in secondary GBM include
19q loss (see Box 35.1) [114]. An additional numerical chro-
mosomal abnormality is the presence of double minute chro-
665
Box 35.1: Primary Versus Secondary GBM
According to current evidence, there are two different
routes of glioblastoma tumorigenesis, both with differ-
ent genetic alterations but ultimately undistinguishable
histology [114]. GBM mostly occurs as a rapidly grow-
ing de novo tumor from a glial progenitor or dedifferen-
tiated cell and affecting patients with a mean age around
60 years. This Primary GBM constitutes 90 % of the
cases, where no evidence of a less malignant precursor
lesion can be detected. Secondary GBMs (10 %) affect
typically younger patients around a mean age of 45
years. These tumors progress from a preexisting diffuse
low-grade or anaplastic astrocytoma, are more often
located frontally, and the overall survival after diagno-
sis is significantly longer. Histologically, Secondary
GBMs show less necrosis and frequent regions of oli-
godendroglioma-like appearance when compared to
the Primary form. From a molecular basis, the Primary
tumors often show loss of chromosome 10, EGFR
amplification and PTEN mutation, whereas in
Secondary GBM, TP53 mutations, loss of chromosome
19q and PDGFRA alterations are more frequent.
Classification of GBM origin has been significantly
improved by the recent identification of mutations in
the enzyme gene IDH1/2 (isocitrate dehydrogenase,
involved in the citric acid pathway), which are predom-
inantly found in Secondary (80 %) but only rarely
(<5 %) in Primary GBMs [132–134]. Consequently,
IDH1/2 mutations are now commonly accepted as
molecular markers of Secondary GBM.
Over 90 % of secondary GBM diagnosed through
IDH1/2 mutations belong to the proneural subgroup,
which indicates that this tumor subgroup is homoge-
neous compared to the primary form. IDH1/2 mutations
occur early during progression from low-grade to high-
grade glioma given they are detected in over 80 % of
grade II and III astrocytoma and oligodendroglial tumors
[134, 141]. It is possible IDH1/2 mutations precede
1p/19q loss in oligodendrogliomas and TP53 mutation in
low-grade astrocytomas [242]. Finally, there is evidence
that primary and secondary GBMs derive from different
glial progenitor cells. In support of this, CD133 positive
cancer stem cells could only be cultured from Primary
GBMs, whereas samples from secondary GBMs did not
have CD133 positive stem cells within [243].
mosomes, seen in approximately 20 % of GBM specimens,
which can further confer oncogene amplification and drug
resistance [115].
Oligodendroglioma (OD) and oligoastrocytomas (OA)
constitute a subtype of glioma for which the specific loss of
666
portions of 1p and 19q (loss of heterozygosity, LOH 1p/19q)
is associated with important prognostic implications and is
used as a marker to support the histological diagnosis of OD
[116, 117]. Approximately 50–80 % of ODs have allelic loss
of chromosomes 1p and 19q, whereas OA (mixed oligoden-
drogliomas, arrangement of cells presenting astrocytic or
oligodendroglial differentiation) show this co-deletion 40 %
of the time [118–120]. LOH 1p/19q is frequently observed in
WHO grade II oligodendric tumors compared to those of
grade III, though conflicting data exists in this regard [118–
120]. Notably, oligodendric gliomas of the frontal lobe show
higher incidence of 1p/19q co-deletion than those of non-
frontal origin [119]. Low-grade OD (WHO II) treated by sur-
gical resection and nitrosourea-based chemotherapy without
radiotherapy show favorable long-term outcome (10-year
overall survival rates over 90 %) irrespective of LOH 1p/19q
status [121]. Anaplastic pure and mixed oligodendroglio-
mas (WHO III) identified with 1p/19q co-deletion are gen-
erally associated with marked higher overall survival and
chemosensitivity in comparison to non-co-deleted WHO III
oligodendrogliomas, where the addition of chemotherapy to
radiotherapy did not prove beneficial over radiotherapy
alone [120, 122].
35.3.3 Gene Amplification and Overexpression
Gene amplification has been described for several target genes
in astrocytic tumors, and appears to be more common in high-
grade lesions than low-grade astrocytomas [109, 123]. Genes
continuously found to be amplified in high grade gliomas
include EGFR, MET, PDGFRA, MDM4, MDM2, CCND2,
PIK3CA, MYC, CDK4, and CDK6 [124]. Amplification and
overexpression of EGFR occurs frequently and predominantly
in primary GBMs (60 % of the samples), but rarely in the sec-
ondary form [114, 125]. In up to 30 % of the cases this gene has
undergone loss of exon 2–7, resulting in the production of a
constitutively active, truncated EGFR receptor (EGFRvIII)
[109, 126, 127]. At this time, Phase II and III vaccination trials
using rindopepimut to stimulate immune response against the
EGFRvIII peptide in GBM patients are ongoing [128, 129]
35.3.4 Gene Mutations and Deletions
Tumor suppressor gene silencing events in astrocytomas
may be the result of gene deletions, mutations, or promoter
methylation events. Primary GBMs are characterized by
CDKN2A deletion (31-50 %), and PTEN mutation (32 %)
[109, 130, 131]. While CDKN2A deletions occur in primary
GBM, TP53 mutations appear more common in secondary
GBM [109, 114]. In the progression of low-grade tumors to
secondary GBM, TP53 mutations are the most common and
D. Coluccia et al.
early-detected genetic abnormality—seen in about 2/3 of
precursor low-grade astrocytomas and secondary GBMs
derived from them. TP53 mutations occur in primary GBM
but at a lower frequency (35 %) compared to secondary GBM
[108, 109, 130]. Additionally, in secondary GBM, 60 % of the
TP53 mutations are clustered in two hot spot codons (amino
acids 248 and 273), whereas in the primary form, TP53 muta-
tions appear more equally distributed within exon 5–8 [108].
Mutations in the gene encoding for NADPH-dependent
isocitrate dehydrogenase (IDH1) were identified from a large-
scale genomic sequencing analysis of astrocytoma [131].
Since the initial description, multiple studies have shown that
IDH1 mutations are common in low-grade diffuse astrocyto-
mas, anaplastic astrocytomas and tumors of oligodendroglial
origin [132–134]. Notably, there is evidence that IDH1 muta-
tions precede TP53 mutations, suggesting an important role
in tumor initiation [114]. A proportion of low-grade astrocy-
tomas that lack IDH1 mutations (e.g., pilocytic astrocytoma,
and ependymoma) contain mutations of the related IDH2
gene [134]. As IDH1 mutations are very common in second-
ary (>80 %) but markedly rare in primary GBM (<5 %), a
consensus is that IDH1 mutation can serve as a molecular
marker of secondary GBM, as this form is neither clinically
nor histologically distinguishable from the primary form
[114]. IDH1 status is important to clinicians as patients with
tumors harboring IDH1 mutations have a survival benefit
[135–139]. IDH mutations also seem to correlate with both
TP53 mutational status and 1p/19q deletions, both of which
predict survival [137, 140, 141].
35.3.5 Epigenetic Alterations
In addition to aberrant changes in the genome, epigenetic
alterations have emerged as important factors in gliomagen-
esis [142]. Potentially reversible and more amenable to
treatment than numerical or structural changes in chromo-
somes, studies of epigenetic deregulations is a promising
strategy in glioma therapy. GBM cells showing high activity
level of the DNA repair enzyme MGMT (O6-methylguanine-
DNA methyltransferase) are more resistant to therapies
including alkylating agent such as temozolomide (TMZ)
[143]. About 40 % of GBM have a methylated MGMT pro-
moter status resulting in epigenetic silencing of the MGMT
gene and thus higher sensitivity to TMZ and distinctive lon-
ger survival with actual standard therapy [143, 144]. Hence,
MGMT promoter methylation is a strong prognostic and
predictive biomarker.
The increased awareness of the role of metabolic enzymes
in astrocytoma pathogenesis has brought about a resurgence
of interest in the Warburg Effect [145]. The Warburg effect
first described in 1956 by biochemist Otto Warburg promotes
the observation that tumors predominantly use a high rate of
35 Molecular Biology of Human Brain Tumors
aerobic glycolysis to meet metabolic demand [146]. Recently,
isoforms of both pyruvate kinase (PK) M1/M2 and hexoki-
nase (HK1/HK2) have shown differential expression in glio-
blastoma, in which PKM2 and HK2 predominate, promoting
glycolysis [147, 148].
35.3.6 Pediatric Versus Adult Gliomas
The genetic changes that are found in pediatric astrocytomas
are distinct from those in the adult variant of these tumors. No
consistent karyotypic abnormalities have been identified in
pediatric low-grade astrocytomas [149, 150]. Even in high-
grade gliomas, the number of chromosomal aberrations is gen-
erally lower from their adult counterparts with up to 15 %
lacking detectably number irregularities [107]. Relatively fre-
quent compared to adult GBM, some pediatric GBMs have
gain of chromosome 1q (up to 30 %) and loss of 16p (up to
24 %), while numerical aberrations of chromosome 7 and 10
are relatively rare (<30 %) [151, 152]. Cytogenetic changes
recurrently observed in pediatric anaplastic astrocytomas and
GBM include gains of 1q, 5q, and loss of 6q, 9q, 10q, 12q,
13q, and 22q [152, 153]. In contrast to adult tumors, amplifi-
cation of the EGFR gene is not common in pediatric astrocy-
tomas and PDGF-driven signaling is preferentially activated
[151, 154]. Notably, this feature is also prevalent in secondary
GBM [155]. Similarly, pediatric astrocytomas rarely exhibit
loss or mutation of PTEN. Aberrant activation of the BRAF
proto-oncogene (7q34) by copy number alteration or forma-
tion of an abnormal fusion protein is an important marker of
pilocytic astrocytoma but not diffuse infiltrating pediatric
astrocytomas (see Box 35.2) [156–158]. Aberrant BRAF acti-
vation leads to increased signaling through the MAP kinase/
ERK pathways, which results in high levels of mTOR activa-
tion, and ultimately to increased cell growth [159, 160].
35.3.7 Core Signaling Pathways and GBM
Subgroups
The understanding of the molecular basis of astrocytoma has
benefited from large-scale genomic profiling approaches from
networks such as The Cancer Genome Atlas (TCGA) and the
International Cancer Genome Consortium (ICGC) [109, 130,
131, 161] GBM was the first cancer to be systematically ana-
lyzed by TCGA, highlighting the role of oncogenes such as
ERBB2 and PDGFRA and suppressor genes such as NF1 and
TP53 as well as reinforcing core defects in three signaling
pathways involved in the pathogenesis: (1) retinoblastoma
(RB)-signaling (79 %), (2) p53 signaling (90 %), and (3)
PIK(3)K/RAS signaling (88 %) (Fig. 35.3). Large-scale genomic
consortia have allowed the stratification of astrocytomas based
667
Box 35.2: Pilocytic Astrocytoma
Pilocytic Astrocytoma (PA) is a non-infiltrative, slow
growing, and often cystic tumor typically classified as
WHO grade I. It is one of the most common CNS neo-
plasms in childhood accounting for ~20 % of all pediat-
ric brain tumors [1]. Almost three-fourths of the patients
are younger than 20 years [1]. Approximately half of
PAs are located in the cerebellum, but they can occur
throughout the neuraxis such as the optic pathway,
hypothalamus, and spinal cord (mostly in pediatric
patients) as well as in the cerebral hemispheres (mostly
in young adults) [244]. Optic nerve PAs are often asso-
ciated with NF1. Provided that the tumor is accessible
and extensive surgical resection is performed, most
patients show a favorable outcome with a 10-year sur-
vival rate of over 95 % [244–246]. Until recently, the
genetic mechanisms underlying this disease were not
extensively investigated. Early genomic analysis of
tumor samples showed often balanced karyotypes,
whereas whole chromosomal gains occurred in about
30 %, frequently affecting chromosomes 5 and 7 [247].
Activating alterations within the MAPK-signaling
pathway are considered a hallmark aberration in the
pathogenesis of PA, affecting 80–100 % of analyzed
tumor samples [248, 249]. Consequently it is hypothe-
sized that PA represents a single-pathway disease [249].
The most frequent genetic event leading to MAPK acti-
vation is BRAF-KIAAI549 (B-K) fusion, which pro-
duces a fusion protein that lacks the regulatory domain
of BRAF [249, 250]. In addition, various MAPK path-
way-activating fusions )typically involving BRAF are
described [249]. The somatic mutation rate is very low
(<0.1/Mb) and BRAF, FGFR1, K/-NRAS, PIK3CA,
CDKN2A, and NF1 are the main genes found to be
mutated or rearranged [245, 249, 251]. Similar to other
tumor types, the copy number changes and mutation
rates positively correlate with patient age and poten-
tially with an aggressive clinical course [245, 247,
249]. The distribution of oncogenic hits within the
MAPK pathway may vary depending on tumor loca-
tion: NF1 mutations are more often detected in optic
PA, while PAs in other locations are dominated by
BRAF activation [248]. BRAF fusions are more com-
mon in cerebellar PAs and mutations are typically seen
in supratentorial PAs [248]. In adult PAs, BRAF V600E
mutations appear to be very infrequent compared to the
pediatric counterpart [245]. As B-K fusions are particu-
larly rare in diffuse astrocytomas (~2 %), the presence
of this event can be considered an adjuvant diagnostic
tool for PA [245].
668 D. Coluccia et al.

Fig. 35.3 Core defects in

three signaling pathways
involved in the pathogenesis
of Glioblastoma. Overall
alteration rate is summarized
for the TP53 pathway
(eluding apoptosis), PI(3)K/
RAS pathway (increasing
proliferation), and RB1
pathway (avoiding cell cycle
checkpoints).

on genetic profiles giving valuable clinical information. The
first subgrouping analysis on high-grade astrocytomas was
reported by Philips et al. differentiating three distinct GBM
clusters: proneural, proliferative, and mesenchymal, with the
proneural subgroup predicting better survival [162]. A recent
TCGA based study classified GBM into four molecular sub-
groups: classical, proneural, neural, and mesenchymal [155].
Genetic alterations in EGFR, PDGFRA/IDH1 and NF1 char-
acterize the classical, proneural, and mesenchymal subgroups
respectively [155]. Classical GBMs are further delineated by
amplification of chromosome 7 paired with loss of chromo-
some 10, while often lacking TP53 mutations [155]. No dis-
tinctive genetic alteration is known that distinguishes the
Neural from the other subtypes [124]. It still has to be eluci-
dated to what extent the subgroup defining molecular profile
may affect clinical outcome and sensitivity to specific therapeu-
tic agents. DNA methylation profiling of 272 TCGA glioblas-
tomas revealed a subset of tumors with a hypermethylation
phenotype that was assigned to the proneural subgroup, fur-
ther correlated with IDH1 mutations and in extended analysis
also often found in low-grade gliomas [109, 163]. This glioma
phenotype is an expression subtype and termed G-CIMP (CpG
island methylator phenotype). G-CIMP positive gliomas affect
younger patients, are probably more common in secondary
GBM, and are associated with improved outcome [163]. In
anaplastic oligodendroglioma the G-CIMP phenotype also
consistently exhibit IDH1-mutations, MGMT promoter meth-
ylation, and LOH 1p/19q and is used as a predictor for better
survival [164].
35.3.8 Medulloblastoma
Medulloblastomas are considered embryonal tumors arising
from the dorsal brainstem or the cerebellum. Progenitor
cells from the cochlear nucleus, dorsal brainstem, and neu-
ron precursors from the external granular layer of the cere-
bellar germinal zone are the proposed cells of origin [165].
35 Molecular Biology of Human Brain Tumors
Medulloblastomas exhibit a high amount of heterogeneity at
histomorphological and subcellular level resulting in vari-
able clinical behavior. Histological subtypes comprise classi-
cal (70–80 %), nodular desmoplastic/extensive nodular
(16 %) and large cell anaplastic (10 %), while all are classi-
fied as WHO Grade IV [9, 166]. Over the past few years
novel molecular subclassifications have been established that
put histopathologic differentiations into perspective.
35.3.9 Chromosomal Alterations
Almost all medulloblastoma samples show various numerical
gains or losses of chromosomal regions. The most common
specific cytogenetic abnormality seen in this tumor type is iso-
chromosome 17q (iso17q), which occurs in about 50 % of
medulloblastomas [167, 168]. The breakpoint is often in the
proximal p-arm (17p11), producing a dicentromeric isochro-
mosome. Loss of one arm of chromosome 17p (25–35 %) is
often a consequence of isochromosome 17q formation, but
may also occur in isolation [169, 170]. In certain cases, smaller
deletions are seen, with the minimal deleted region occurring at
17p13.3 [171]. The frequent involvement of 17p in medullo-
blastoma has resulted in efforts to identify the targeted putative
tumor suppressor gene (TSG). REN(KCTD11) maps to
17p13.2, and is a candidate TSG for medulloblastoma on chro-
mosome 17p [172]. Aberrations of chromosomal regions have
also been evaluated as prognostic markers, whereas iso17q and
losses of 10q and 17p are correlated with a poor prognosis and
loss of chromosome 6 (monosomy 6) with good outcome
across all subgroups [173]. Loss of chromosome 9q, which
contains the suppressor gene locus PTCH 1, promotes activa-
tion of Sonic Hedgehog (SHH) signaling pathway and is used
as a co-determinant of the SHH molecular subgroup [11].
35.3.10 Gene Amplification
and Overexpression
Gene amplifications are relatively infrequent in medulloblas-
toma (<10 %), and typically involve the MYC and MYCN
proto-oncogenes [166]. Such amplifications have been
observed in the context of double minute chromosomes
[174]. Amplification and/or overexpression of MYC-family
genes are regularly observed in the large cell anaplastic vari-
ant of medulloblastoma, and correlate with poor clinical out-
come [175, 176]. In addition to gene amplifications, certain
genes are aberrantly overexpressed in medulloblastoma such
as ERBB2 [177]. Increased ERBB2 and ERBB4 expression
correlates with higher risk of metastasis and is associated
with a poor prognosis [178–180].
669
35.3.11 Gene Mutations and Deletions
Various mutations of tumor suppressor genes important in
developmental signaling pathways have been described in
medulloblastoma. Mutations in PTCH1, SMOH, Gli2, and
SUFU lead to loss of inhibitory factors and thus promote con-
stitutive activation of SHH pathways [181–184]. Germ-line
APC mutations as found in familial adenomatous polyposis
(FAP) syndrome or Turcot syndrome predispose to medullo-
blastoma formation [86]. The APC-protein is encoded on
chromosome 5 and is part of a protein complex inhibiting the
WNT signaling pathway. Loss of APC function results in
intranuclear accumulation of ß-catenin, which activates tran-
scription factors and promotes the pathogenesis of medullo-
blastoma. Overall, mutations involving the WNT pathway
occur in approximately 10 % of sporadic medulloblastoma
cases, including activating mutations in the CTNNB1 gene
[185–188]. In addition, TP53 mutations have been found in
10 % of medulloblastoma cases (16 % in WNT, 21 % in SHH,
virtually absent in Group 3 and 4) and are considered a risk
factor for poor outcome in the SHH subgroup [189].
35.3.12 Epigenetic Alterations
Epigenetic alterations such as modification of histone or
DNA methylation status are important factors in medullo-
blastoma pathogenesis and mostly recorded in Group 3 and 4
medulloblastoma [190, 191]. Large-scale genomic analyses
have identified OTX2, a developmentally regulated transcrip-
tion factor important for early brain morphogenesis, as a fre-
quently occurring focal genetic gain in medulloblastoma
(21 %) [168, 192, 193]. Overexpression of OTX2 results in
impaired demethylation activity of histone modifying pro-
teins. Consequently, levels of trimethylated histone H3 lysine
27 (H3K27me3) are increased which in turn leads to specific
chromatin condensation [194]. Medulloblastoma patients
with OTX2 gene amplification (mostly restricted to subgroup
3 and 4) exhibited poorer survival and were more likely to
have anaplastic tumors [193]. There is also epigenetic dereg-
ulation of DNA methylation as an underlying mechanism of
medulloblastoma formation. Subgroup specific patterns of
DNA methylation have already been proposed as a biomarker
for improving survival prediction in non-WNT medulloblas-
toma [195, 196].
35.3.13 Subgroups
Advances in next generation DNA sequencing and ultrahigh-
resolution genetic mapping over recent years have enabled
670 D. Coluccia et al.

Fig. 35.4 Medulloblastoma Subgroups. Infographic illustrating the incidence, gender ratio, survival, histology, cytogenetic alterations, and common
driver genes for each group. LCA large cell anaplastic, MBEN medulloblastoma with extensive nodularity.

remarkable insight into some of the underlying molecular
interactions leading to the observed heterogeneity in clinical
behavior. According to current consensus among investiga-
tors, four main subgroups can be distinguished: WNT, SHH,
Group 3, and Group 4 [11, 197, 198] (Fig. 35.4). The WNT
and the SHH group are marked by mutations in the WNT and
SHH pathway, respectively. For Group 3 and 4, no single
pathway alteration has been identified and the diagnosis
relies primarily on transcriptional profile clusters. However,
recent studies detected prevalent drivers in particular for
Group 3 [199]. These molecular subgroups typically do not
correlate with the histological phenotypes. The histopatho-
logical classic type occurs in all four medulloblastoma sub-
groups. The nodular desmoplastic or extensive nodular type
falls within the SHH subtype, although it should be men-
tioned that the SHH subgroup is the only subgroup that may
include all of the known major histological variants. Large
cell anaplastic tumors are also found in all four subgroups
but the majority will be classified to Group 3. The WNT sub-
group has mostly classic histology and accounts for 10 % of
35 Molecular Biology of Human Brain Tumors
all medulloblastomas and has the best prognosis with >90 %
long-term survivals. Alterations resulting in increased activity
of the WNT pathway results from sporadic somatic mutations
of CTNNB1 encoding ß-catenin or less common in germ-line
mutations of the APC gene as in Turcot or FAP syndrome.
Monosomy 6 and TP53 mutation are often found. The SHH
subgroup (30 %) has a good to intermediate prognosis; almost
half of the cases exhibit desmoplastic/nodular histology.
In sporadic SHH tumors, somatic mutation in PTCH,
SMO, and SUFU leads to increased SHH activity. In addi-
tion, amplifications of GLI1 and GLI2 can trigger this path-
way. Deletion of chromosome 9q, which includes the PTCH
gene, is primarily limited to SHH tumors. Hereditary SHH
medulloblastomas are found in Gorlin syndrome and are
characterized by germ-line mutation of the tumor suppressor
gene PTCH1. MYCN amplification and mutations at TP53
are regularly observed. Recently, small molecules targeting
smoothened (SMO), a positive regulator of the SHH path-
way, showed rapid (although transient due to acquired drug
resistance) regression of tumor volume in a subset of patients
with SHH medulloblastoma [200, 201]. Group 3 medullo-
blastomas (25 %) primarily demonstrate classic histology but
have a high incidence of large cell anaplastic types. They are
almost never observed in adults and harbor the worst progno-
sis of all subtypes. Metastases are frequently found and cou-
pled to poor prognosis. MYC and OTX2 amplification are
common features and some tumors show loss of both 5q and
10q and gain of chromosome 1q. Recently, somatic genomic
rearrangements resulting in GFI1 and GFI1B activation have
been found to occur in approximately one-third of Group 3
patients; thus enhancer hijacking is now considered a promi-
nent mechanism driving Group 3 medulloblastoma [199].
Group 4 is the most common medulloblastoma subgroup
(35 %), usually of classic histology and with an intermediate
prognosis. Isochromosome 17q is the major cytogenic altera-
tion observed (60–80 % of Group 4 samples). Amplification of
OTX2, CDK6, and MYCN are also frequently associated with
this subgroup, whereas structural variants associated with
GFI1 and GFI1B activation are detected in 5–10 % [199].
Molecular classification will have a large impact on future
treatment recommendations and strategies. Given the four
subgroups show distinct clinical behavior that does not cor-
relate with histological features, the use of histopathology
alone is considered inadequate for the classification of
medulloblastoma. It remains to be seen how the revealed
diversity in molecular patterns and clinical outcome will
influence the WHO Grade IV classification for medulloblas-
toma. The current treatment modality of surgery, radiation
and chemotherapy is highly toxic to the developing brain.
Complication and morbidity observed in patients with
tumors subgrouped into good prognosis, such as the WNT
subgroup, could correspond to a higher extent with iatro-
genic interventions than with the natural course of disease.
These patients may benefit from a reduction in radiation and
671
chemotherapy, whereas patient with tumors subgrouped into
more aggressive lesions may benefit from exhaustive thera-
peutic strategies.
35.3.14 Ependymoma
Ependymomas originate from the wall of the ventricular
system with possible manifestations along the entire cranio-
spinal axis of the CNS [202]. Radial glia cells are presumed
to constitute the progenitor cells [203]. In children, over
90 % of ependymomas occur intracranially with 70 % aris-
ing in the posterior fossa, whereas in adults the spinal mani-
festation is more common [204–206]. Based on
histopathological features, the WHO divides ependymomas
in grade I–III and recognizes four histological types: subep-
endymoma (grade I), myxopapillary (grade I, usually spi-
nal), classic (grade II), and anaplastic (grade III) [9, 202].
However, as for most tumors, molecular characteristics will
have to complement and specify future grading systems.
Recent studies indicate that ependymomas from different
compartments of the CNS display distinct genetic signa-
tures, reflecting their unique origins, despite appearing his-
tologically homogeneous [203, 207].
35.3.15 Chromosomal Alterations
Cytogenetic changes are seen in a significant proportion of
ependymomas and are overall more common in adults [206,
208, 209]. About 30 % of sporadic ependymomas have
monosomy 22, and deletions or translocations involving
chromosome 22 are also observed [210]. The NF2 gene is
located on chromosome 22 (22q12), and NF2 patients are
predisposed to develop spinal ependymomas in addition to
other CNS tumors [211]. In fact, NF2 mutations are almost
exclusively found in spinal ependymomas [212], thus another
tumor suppressor gene on chromosome 22 might be involved
in cranial ependymomas [210, 213]. Gain of chromosome 1q
is the most common genomic aberration in pediatric intra-
cranial ependymomas, possibly associated with anaplastic
histology [206, 214]. Besides numeric chromosomal altera-
tions within the ependymoma genome, translocations are
frequently reported to affect chromosomes 1, 11, and 22
[208]. The assumption that tumor location-specific genomic
alterations exist in ependymoma has been encouraged by
recent revelation of chromothripsis within chromosome
11q13.1 [215]. In more than two-thirds of supratentorial
ependymoma samples, a fusion of the oncogene RELA to an
uncharacterized gene involving 11q13.1 occurs, which is
absent in posterior fossa tumors. The aberrant RELA-fusion
proteins modulate activation of the transcription factor NF-
kB. The largest molecular analysis of ependymoma to date,
including 583 tissue samples, demonstrated that posterior
672
fossa ependymomas can be classified in to two subgroups,
Group A and B, which differ in their genomics, transcrip-
tomics, location and clinical outcome [209]. Group A epen-
dymomas affect younger patients, are more laterally located
and exhibit more frequent recurrence and metastasis with an
overall poorer prognosis compared with Group B. The
genome in Group A is more balanced, shows increased
occurrence of chromosome 1q gains, whereas in Group B the
genome is highly unstable with frequent segmental gains of
chromosomes 9, 15, 18, as well as losses of chromosomes 6
and 22 [209].
35.3.16 Gene Amplification, Overexpression,
Mutations, and Deletions
In ependymoma and especially in children, the overall
genetic mutation rate appears to be lower than astrocytic
tumors. Expression profiling by microarray analysis on
pediatric ependymomas have identified a subset of genes
abnormally expressed in this tumor, including increased
expression of EGFR, WNT5A, TP53, and many cell cycle,
cell adhesion, angiogenesis, and cell proliferation genes,
with downregulated genes including SCHIP-1 and EB1
[213]. EGFR overexpression has been recorded as a prog-
nostic marker in intracranial grade II ependymomas corre-
lating with reduced progression free and overall survival
[216, 217]. Amplification and rearrangement of the c-erb B
gene has been identified, as well as rearrangements of the
MEN1 gene (11q13) [212, 218]. A large genomic analysis
of ependymoma including tumors from 207 samples dem-
onstrated focal amplification of genes involved in stem cell
proliferation, pluripotency, and neuronal differentiation
such as THAP11, PSPH, EPHB2, KCNN1, RAB3A,
PTPRN2, PCDH cluster, and NOTCH1 [207]. This same
study identified focal deletions of known tumor suppressor
genes (PTEN, INK4A/ARF) and novel genes such as STAG1
and TNRC6B [207].
35.3.17 Epigenetic Alteration
Epigenetic modifiers involved in the formation of ependy-
momas have recently been identified. The methylation status
of CpG islands occurs more frequently in posterior fossa
Group A (PFA) tumors, leading to transcriptional silencing
of the histone methyltransferase Polycomb repressive com-
plex 2 (PRC2), which in turn results in repressive effect on
expression of cell differentiation genes [219]. This epigene-
tic mechanism predicts for the more aggressive behavior of
Group A tumors. Mice xenograft models implanted with
human PFA showed a decreased tumor volume and longer
survival after that PRC2 was reactivated through demethyl-
D. Coluccia et al.
ation by administration of established epigenetic drugs that
target either DNA or histone methylation [219].
35.4 Cell Cycle Dysregulation
and Mitogenic Factors in Human
Brain Tumors
The cell cycle can be conceptualized as a circle divided by a
number of discrete phases during which nuclear content
changes in preparation for cell division (Fig. 35.5). In healthy
neural tissue, with advancing differentiation and age, most cells
will become quiescent and do not express cell cycle genes due
to the presence of cell-type specific repression mechanisms. In
human brain tumors, the intrinsic machinery of the cell cycle is
the target of mutations or functional derangements leading to
release of repression mechanisms and rapid, uncontrolled pro-
liferation—a hallmark of cancer.
35.4.1 General Mechanisms of Cell Cycle
Dysregulation
Cyclins (A-E) are a group of proteins whose expression levels
are differentially and tightly regulated during the cell cycle.
When bound to their respective cyclin dependent kinases
(CDKs), an activated complex promotes transcription of
products required for a specific stage in the cell cycle [220].
The activity of the various CDKs are coupled to both binding
of the cyclins and a series of phosphorylations and dephos-
phorylations on specific residues by cyclin-dependent kinase
activating kinases (CAKs) and cyclin-dependent kinase
inhibitors (CKIs) [221, 222].
One of the most important cell cycle pathways known to
be perturbed in human brain tumors, especially astrocytomas,
is the cyclin D-CDK4-RB-E2F pathway, (RB-pathway)
(Fig. 35.5). Here, cyclin D forms an activated complex with
CDK4 and/or 6. This active complex partially phosphorylates
a previously hypophosphorylated retinoblastoma protein, RB
[221, 222]. Partial phosphorylation of RB liberates E2F-DP
such that it can act to upregulate target genes involved in the
continued regulation of cell cycle, such as cyclin E [221, 222].
Thus, the phosphorylation of RB is a key regulatory step of
the G1–S checkpoint.
Whereas the cyclins and CDKs could be termed accelerators
of the cell cycle, inhibitor of cyclin-dependent Kinase 4 (INK4)
and Cip/Kip could be termed the brakes of the cell cycle. INK4
is a family of four proteins A-D, p16INK4a, p15INK4B, p18INK4C, and
p19INK4D. INK4A is encoded from a gene on 9q21. Interestingly,
this gene also encodes for a novel second protein, using an alter-
native reading frame in exon 1 and splicing it to the common
exons 2 and 3. This protein is called ARF (p14ARF), alternative
reading frame, and is also involved in cycle arrest with p53.
35 Molecular Biology of Human Brain Tumors
Fig. 35.5 Dysregulation in cell cycle pathways involved in the pathogenesis of astrocytomas.
The Cip/Kip family of CDK inhibitors (p21CIP1, p27Kip1,
p57Kip2) can bind and inhibit the G1/S cyclin-CDK complexes,
and the mitotic cyclin B/A complexes. They can also act as
both positive and negative regulators of the cell cycle. In early
G1 phase Cip/Kip family members bind and aid in the forma-
tion of cyclin D/CDK4/6 complexes without inhibiting kinase
activity and therefore contribute to the formation of hyper-
phosphorylated RB and cell cycle progression [223]. Once RB
is partially phosphorylated and transcription of Cyclin E and
Cdk 2 are upregulated, the Cip/Kip members then bind with
higher affinity to Cyclin E/CDK 2 complexes and inhibit CDK
2 activity and halt cell cycle progression (Fig. 35.5).
35.4.2 The Importance of p53 and Cell Cycle
Control
The TP53 gene encodes the most well studied tumor sup-
pressor, p53 and to date has been implicated to play a role in
almost 50 % of human cancers, including human brain
tumors [224]. Mutations in the TP53 gene can lead to mis-
sense or loss of protein expression, whereas the missense
mutation is associated with earlier cancer onset and more
aggressive tumor profile [225, 226]. P53 has a multitude of
stress-induced effects on cellular homeostasis by blocking
673
cell cycle passage and promoting apoptosis. Several cell
cycle proteins interact as negative or positive regulators with
p53. One such mechanism of regulation of p53 is via the
Murine Double Minute-2 protein (MDM2) (Fig. 35.4),
which is able to repress p53 activity both at the transcrip-
tional and protein levels [227–229]. MDM2 binds and con-
ceals the p53 transactivating domain and blocks the basal
transcriptional machinery for p53. In response to DNA dam-
age both MDM2 and p53 are phosphorylated resulting in
conformational changes that incapacitate binding [230, 231].
This allows p53 to be stabilized in the nucleus where it is
able to upregulate genes involved in either cell cycle arrest
or apoptosis. The ability of MDM2 to block the p53 pathway
is reversed by ARF which binds to and sequesters MDM2 in
the nucleolus away from p53, as also impairs MDM2’s ubiq-
uitin ligase activity [232–234]. This allows for stabilization
of p53 levels and downstream activation of p21 and cell
cycle arrest.
35.4.3 Mitogenic Signals That Impact on Brain
Tumor Growth
The decision of the cell to divide is provided by both internal
stimuli and external conditions. External conditions favorable
674
to cell division, growth, and survival are conveyed via cell
membrane tyrosine kinase receptors that typically dimerize
upon ligand binding, phosphorylate their cytoplasmic tails
and activate downstream signaling molecules. One key
growth activator is the small GTPase Ras. It activates multi-
ple mitogenic pathways: RAF-MEF-MAPK, CDC42-RAC-
Rho, and PI3K-PTEN-AKT [235]. These downstream
signaling molecules subsequently activate cyclin/CDK com-
plexes triggering growth, demonstrating these pathways are
commonly targeted during tumor mutagenesis.
Epidermal growth factor receptor (EGFR), platelet
derived growth factor receptor (PDGFR), fibroblast growth
factor receptor (FGFR), C-Met, and C-kit are all tyrosine
kinases implicated in the formation of astrocytomas and
other neurological tumors.
35.4.4 Analysis of Cell Cycle and Mitogenic
Pathway Disturbances in Brain Tumors:
Low and High Grade Astrocytomas
Our understanding of the pathways involved in tumor initia-
tion and progression has been enhanced through molecular
genetic analyses of cell cycle and mitogenic stimulation
pathways. Genetic alterations of TP53 are present in low
grade, anaplastic and GBMs, and the genetic aberrations are
higher for the secondary GBM (up to 80 %) compared to the
primary GBM (around 30 %) suggesting a role in astrocy-
toma initiation [114, 123].
Mutations in the RB pathway of INK4A, CDK4, and RB
represent about 80 % of GBMs and only a small portion of
low-grade astrocytomas [109] [236]. There are also differ-
ences between primary and secondary GBMs. Deletion of the
CDKN2A locus leading to reduced CDK4 inhibition is found
in over 50 % of primary and 20 % of secondary GBMs [114,
130, 131]. This locus encodes both INK4A and ARF and there-
fore disrupts both the p53 and RB pathways indirectly, per-
haps contributing to the rapid rate of growth attributed to
primary GBMs. Alterations of RB itself are found in up to
14 % of GBMs [130, 131]. CDK4 amplification is present in
14 % of GBMs. Other mutations found to arise in GBMs have
been identified in CDK6, cyclin D, and cyclin E [237, 238].
EGFR is amplified or altered in up to 57 % of glioblasto-
mas, mainly detected in the primary and rarely in secondary
GBM, which is why this alteration might not be involved
early in tumor initiation [109, 239]. A mouse model express-
ing the mutated EGFR alone was insufficient to cause astro-
cytomas, but expressed in a background of TP53 +/− or
Ink4A/ARF−/− astrocytoma formation occurred rapidly
[240]. This suggests that EGFR may be responsible for
tumor progression but require additional mutations in other
genes for tumor initiation.
D. Coluccia et al.
PDGFRA is a surface tyrosine kinase receptor repeatedly
found to be altered in both high and low-grade human astro-
cytomas [109, 241]. As a growth factor it interacts with the
MAPK/RAS pathway, which is implicated in primary GBM
formation, however the role of PDGFR in tumor initiation or
progression has yet to be elucidated.
The tumor suppressor PTEN acts as a negative regulator of
the PI3K-AKT growth control pathway. PTEN mutations may
be found in 30 % of primary GBMs and up to 8 % of secondary
GBMs [114], however these numbers are inconsistent among
the different study groups to allow conclusive interpretation
regarding order in succession of tumorigenesis.
35.5 Brain Tumor Migration and Invasion
Brain invasion by infiltrative tumor cells is one of the most
sinister histopathological hallmarks of malignant brain
tumors. Brain tumor invasion is a complex cellular phenom-
enon including permissive changes in the extracellular milieu
and intracellular biomechanical systems. The spread of brain
tumor cells within the cerebral tissue involves changes in
cell/cell and cell/extracellular matrix (ECM) adhesion,
enzyme degradation of the ECM by proteases, and cell motil-
ity into normal brain parenchyma [252, 253]. Specifically,
cell migration requires a complex balance between extracel-
lular cues and responsive intracellular signals that lead to
dynamic regulation of the interactions between actin micro-
filaments, microtubules, intermediate filaments and associ-
ated adhesions [254, 255]. The driving force for cell
movement is normally provided by dynamic reorganization
of the actin cytoskeleton, which directs protrusions at the
front of the cell and retraction at the rear [254, 255]. For a
cell to move, it must establish polarity resulting in leading
and trailing edges with directionalized forces. One of the
first steps in cell migration is the formation of actin-rich
structures called lamellipodia at the leading edge of the
motile cell [256, 257]. Subsequent attachment of these pro-
trusive structures to the substratum followed by tension
across the cell, generated by myosin motor proteins, will
lead to the contractile force ultimately required for cell body
translocation [256, 257].
Ultimately, this interplay of contractile elements with
adhesive matrix increases metabolic demand and triggers
enzymes for enhanced glycolysis. As shown recently, GBM
cells overexpress glucose-6-phosphatase (G6P) to overcome
glycolytic inhibition [258]. By downregulating glucose-6-
phosphatase in human derived GBM cells the migration and
invasion rate was markedly reduced [258].
Migration along the tight extracellular space requires also
considerable adaptation in volume and shape of glioma cells
[253, 259], which is mediated by modulation of Cl− and K+
35 Molecular Biology of Human Brain Tumors
Fig. 35.6 Mechanisms involved in the migration and invasion of Glioblastoma (GBM) cells along the perivascular space and white matter tracts.
channels. The Na+-K+-Cl− co-transporter (NKCC1) is highly
expressed in glioma cells, which accumulates intracellular
Cl− leading to opening of Cl−channels (ClC3) and resulting
in volume shrinkage [260]. In recent studies, glioma migra-
tion and invasion could be decreased after inhibiting NKCC1
or ClC3 channels [261, 262].
In contrast to solid tumors of other organs, malignant
glioma cells usually do not spread through an intravascular
route but rather within the perivascular zone. Moreover, lym-
phatic channels do not exist in the brain. Despite their pro-
found parenchymal invasiveness, metastasis outside the
brain is negligible in primary malignant gliomas [263],
which is likely due to the blood–brain barrier and an unsuit-
able environment for growth in other organ systems. The
migration is mainly directed into two compartments: the
perivascular space and the brain parenchyma, which then
results in a spreading of glioma satellites at distant sites from
the main tumor mass [253] (Fig. 35.6). The alignment
towards existing structures such as white matter tracts, blood
675
vessels and meninges resembles the movement observed in
neural progenitor cells during tissue maturation [253].
There have been numerous reviews describing many of
the extracellular factors relating to invading brain tumor cells
such as the proteolytic degradation by various proteases
(MMPs, cathepsins, serine proteases, urokinase plasminogen
activator receptor), and ECM deposition and adhesion facili-
tated by matrix receptors [252, 264, 265]. The increased
release of glutamate by glioma cells additionally acts as an
autocrine and paracrine ligand supporting Ca2+ triggered cell
migration and invasion [266]. Indeed, blocking intracellular
glutamate uptake through sulfasalazine resulted in reduced
tumor spreading in a rodent model [266]. There are also
many well characterized genetic lesions in brain tumors
which have been shown to affect astrocytoma progression
[254, 267, 268], but the understanding of the intracellular
and molecular mechanisms that mediate brain tumor inva-
sion is still in its infancy. These molecular pathways include
signaling regulated by (1) the non-receptor tyrosine kinases
676
focal adhesion kinase (FAK) and proline-rich tyrosine kinase
2 (Pyk2), (2) members of the Rho family of small GTPases,
(RhoA and Rac1) including signaling by lysophosphatidic
acid (LPA) and sphingosine-1-phosphate (S1P), and (3) the
nuclear factor-kB (NF-kB) family of transcription factors.
The Rho family of small GTPases is essential in cellular
migration pathways. RhoA activation mediates formation
of stress fibers and focal adhesions in the trailing edge of
the cells and leads to a rounded amoeboid form of move-
ment, while Rac1 directs actin assembly in lamellipodia at
the leading edge of migrating cells which results in cells
moving in an elongated mesenchymal manner [269, 270].
Attempts to reduce cell motility by blocking migration
pathways have to take into account that cells can switch
between these different modes of migration. CDC42 is a
well-studied member of the Rho family and, while not
essential for cellular movement, aids in regulating filopodia
formation and cellular polarity [271, 272]. Inhibition of
Rac1 with siRNA leads to decreased lamellipodia forma-
tion and cellular movement [273, 274]. Using a dominant
negative Rac1 inhibitor induced death on GBM cells but
not normal astrocytes [275]. Additionally, it was shown that
downstream inhibition of Rho-Kinase (downstream of RhoA
activation) lead to increase motility through activation of
Rac1 [276]. Therefore, it may be a balance between RhoA
and Rac1 that regulates cellular migration and invasion in
astrocytoma cells.
The greatest limitation of brain tumor invasion research to
date has been the lack of a reliable and reproducible in vivo
animal model of brain invasion. Current applications of
existing animal models are currently not optimized or char-
acterized for use in brain tumor invasion research. Induction
of invasion in vivo, tracking infiltrative cells and quantitation
of brain invasion are the most critical considerations of a live
animal model of brain tumor invasion.
35.6 Brain Tumor Angiogenesis
Angiogenesis is defined as the formation of new blood ves-
sels from the sprouting of previously existing vessels. In the
fetal brain, angiogenesis begins during embryogenesis when
soluble angiogenic factors are secreted to cause capillary
sprouting from the extracerebral plexus and neovasculariza-
tion. In contrast, the adult brain shows very little angiogenic
activity due to expression of antiangiogenic factors.
Solid tumors beyond 2 mm in diameter require recruit-
ment of blood vessels for continued growth [277]. In patho-
logical states such as tumors, an angiogenic signaling switch
occurs that results in a cascade of events including enzymatic
degradation of basement membrane proteins, endothelial
migration, endothelial proliferation, and tubular vessel for-
D. Coluccia et al.
mation. The most important mitogen orchestrating vascular
neogenesis in brain tumors is vascular endothelial growth
factor, VEGF.
35.6.1 Mechanisms of Angiogenesis
in Human Astrocytomas
A distinguishing histopathological feature of astrocytoma is
endothelial proliferation, which can be 40 times higher than
in normal brain [278]. VEGF overexpression is central to the
neovascularization observed in these high-grade lesions such
as GBM [279–281]. Monoclonal antibodies directed against
VEGF in GBM mice xenografts and withdrawal of VEGF
from implanted GBM cell lines in mice resulted in vessel
regression underscoring the importance of VEGF in these
lesions [282, 283].
VEGF is a 34–45 kDa glycosylated homodimeric protein
that acts as a specific mitogen and chemotactic factor for
endothelial cells [284]. There are five other VEGF homologs,
VEGF-A, VEGF-B, VEGF-C, VEGF-D, VEGF-E, and pla-
cental growth factor (PGF) [285]. VEGF, itself, is composed
of five splice variants, which have equivalent effects in
regards to angiogenesis [286]. Expression of VEGF results in
increased permeability of the microvasculature, endothelial
production of proteases to break down basement membrane,
endothelial survival, and endothelial proliferation [287].
The effects of VEGF are exerted via the tyrosine kinase
receptors vascular endothelial growth factor receptor one and
two, VEGFR1-2, and neuropilin-1 (Nrp-1). Binding of VEGF
to VEGFR-2 promotes endothelial proliferation, whereas
binding to VEFGR-1 regulates endothelial cells [288].
VEGF-2 is considered a core driver in complete activation of
the angiogenic cascade and thus progression of neovascular-
ization observed in high grade astrocytomas [280].
Central to the expression of VEGF is hypoxia. Increased
transcription of VEGF mRNA in vitro can be efficiently
induced by hypoxic conditions and upon restoration of oxygen
levels, basal VEGF expression is returned [289]. Rapidly pro-
liferating tumors, such as GBMs, quickly outstrip their blood
supply creating a hypoxic and necrotic environment. Indeed,
VEGF expression of cells at the rim of necrosis shows 50
times basal VEGF expression [290, 291]. This is mediated
through hypoxia inducible factor, HIF-1 [292].
HIF-1 is a heterodimer consisting of an α and β subunit.
Under normal physiological conditions the α subunit is ubiq-
uitinated by the tumor suppressor von Hippel–Lindau, VHL
[293]. As a result of hypoxia, HIF-1α interacts with the
hypoxia-response element leading to the increased expression
and upregulation of pro-angiogenesis genes, such as VEGF
[292]. HIF-1 also cooperates in the stabilization of the VEGF
protein and increasing VEGF secretion [294]. VEGF expression
35 Molecular Biology of Human Brain Tumors 677

can also be upregulated by fibroblast growth factor (FGF),

PDGF, EGF, tumor necrosis factor α, (TNF-α), transforming
growth factor β (TGF-β), and interleukins 1 and 6 [287].
Angiopoietins are a four-member family of secreted ligands
that bind to the endothelial specific tyrosine kinase Tie-2.
The two best understood angiopoietins are angiopoietin 1
(Ang-1), and angiopoietin 2 (Ang-2), which act antagonisti-
cally at the Tie-2 receptor. In the presence of VEGF, Ang-2
promotes vessel destabilization in preparation for neovascu-
larization [295]. The combination of VEGF and Ang-2 is
found at the hypoxic rim of GBMs [296], whereas Ang-1
stimulation of Tie-2 results in vessel stabilization and is
found at the tumor periphery [287].
Bevacizumab, a human monoclonal antibody against
VEGF-A, leads to a marked reduction in tumor size and pro-
longation of progression-free and overall survival in GBM
patients in promising preclinical and clinical studies [297,
298]. Two highly awaited and large Phase III randomized
trials have been conducted recently (RTOG-0825 and
AVAGlio trial) [299, 300]; however neither study demon-
strated any benefit in overall survival, albeit a slight increase
in progression-free survival was observed.

35.7 Developmental Signaling Pathways

and Human Brain Tumors

During normal neuroembryogenesis multiple signaling path-

ways are active to allow fast proliferation and increased
migration of neural progenitor cells. The phase of differen-
tiation and maturation requires a precisely adapted regula-
tion of expression and silencing of the involved signaling
networks. In the past decade, an increasing number of genes
and pathways involved in this maturation process have been
discovered and characterized. As advanced molecular analy-
sis in human brain tumors recurrently revealed mutations
and other alterations in these genes, it is assumed that such
alterations are involved in the early phase of brain cancer
initiation and eventually enable tumor cells to acquire prolif-
Fig. 35.7 Notch signaling pathway.
eration and migration proprieties similarly found in primitive
neural cells. Here we discuss three developmental signaling
cascades with proven associations with formation of human growth factor-like ligand domain. When engaged with ligand
brain tumors. from the Jagged or Delta families, the extracellular compo-
nent gets cleaved by ADAM metalloproteases, which then
leads to a second cleavage at the transmembrane region by a
35.7.1 The Notch Signaling Pathway γ-secretase. This second proteolytic event releases the Notch
intracellular domain which promotes transcription of Hes
The Notch signaling pathway mediates cell–cell signaling family genes, among others [301] (Fig. 35.7).
and is a key developmental pathway regulating cell decisions The functions of the Notch genes (Notch1-4) are time-
regarding cell survival, maintenance of stem cell self- dependent and cellular context-dependent, and thus, they may
renewal, proliferation, differentiation, and apoptosis [301– act as an oncogene or a tumor suppressor [304–306].
303]. The Notch protein forms a transmembrane receptor, Activation of Notch signaling is known in various human neo-
whereas the extracellular region contains an epidermal plasms such as cervical carcinomas, T-cell leukemia, pancreatic
678
cancer, and mucoepidermoid carcinoma [307, 308]. In the
nervous system, Notch regulates stem cells in developing and
modeling the shape and cytoarchitecture of brain and spinal
cord [309, 310]. Notch upregulation was observed in glioma
cell lines and primary human glioblastomas resulting in stem
cell maintenance and tumor proliferation [311, 312].
Specifically, the self-renewal of stem cell-like GBM cells is
sustained in the perivascular stem cell niche by endothelial
cells, which provide Notch ligands, promoting radioresis-
tance [313, 314]. Notch inactivation by γ-secretase inhibitors
(GSI) resulted in increased radiosensitivity through regula-
tion of the PI3K/Akt pathway [314]. GSI induced suppres-
sion of Notch can also enhance the antitumoral effect of
temozolomide (TMZ) [315]. From the four GBM subgroups,
the proneural type particularly shows high Notch pathway
activation and sensitivity to GSI in the mouse model [316].
Notch signaling deregulation also occurs in medulloblas-
tomas, primarily within the SHH subgroup, where Notch 2
amplification and overexpression correlated with tumor pro-
gression and poor prognosis [317–319]. Interestingly, inhibit-
ing the Notch pathway in medulloblastoma cell lines using
inhibitors of GSI could decrease the number of CD133+ cells
and block in vivo engraftments [320]. The role of Notch in
medulloblastoma genesis and how the Notch pathway inter-
acts with the SHH pathway remains to be elucidated given
that recent studies demonstrate that Notch signaling may not
be crucial for SHH-driven medulloblastomas [321–323].
Several studies reported an upregulation of the Notch
pathway in ependymomas, supporting its potential role in the
pathogenesis of these tumors [203, 324, 325]. Taylor et al.
identified genetically distinct ependymomas by patterns of
gene expression that recapitulated those of radial glial cells
in corresponding regions of the CNS [203]. Specifically, it
was shown that supratentorial tumors expressed markedly
elevated levels of Notch family members.
35.7.2 The Sonic Hedgehog Signaling Pathway
The SHH signaling pathway plays a primary role in mor-
phogenic development of different organs during embryo-
genesis [326]. The secreted Sonic Hedgehog ligand, encoded
on chromosome 7q36, binds and inactivates the transmem-
brane receptor Patched (PTCH), which results in releasing
the inhibition of Smoothened (SMO) [304, 327]. SMO sub-
sequently acts to activate transcription factors of the GLI
family to express target genes, while SUFU (Suppressor of
Fused) regulates Gli (Gli1–4) proteins to inhibit the SHH
pathway [327, 328] A model of SHH signaling is shown in
Fig. 35.8.
Dysregulation of the SHH pathway is implicated in cancers
of different tissues, including the brain, lung, mammary gland,
prostate, and skin [329]. In the nervous system, SHH is crucial
D. Coluccia et al.
for pattering the midline structures in brain and spinal cord as
well as controlling of axonal spreading and stem cell prolifera-
tion [330]. Proper regulation of SHH is particularly critical for
normal development of the cerebellum, explaining the fre-
quent implication of this pathway in medulloblastomas
when one or more genes of this pathway are dysregulated
[331, 332]. Through analysis of gene expression in medul-
loblastomas, it has been shown that tumors with mutations
in SHH pathway express high levels of Gli1, as well as N-myc
and C-myc, cyclin D1 and D2 [333]. Interestingly, sporadic
Gorlin’s syndrome and medulloblastomas are often character-
ized by inactivation of Ptch1 gene or activation of SMO [80,
184, 334]. Bmi1, a polycomb group gene, is involved in the
clonal expansion of granule cell precursors, and its overex-
pression is linked to that of Ptch and is ultimately required for
SHH driven tumorigenesis [331, 332]. A recent genome
sequencing of SHH pathway medulloblastoma showed that
the most frequently detected gene mutations were found in
PTCH1 (45 %), SMO (14 %), and SUFU (8 %) [335].
Interestingly, while PTCH1 mutations were found at roughly
equal distribution in infants, children, and adults, SMO altera-
tions were markedly more frequent in adults, and SUFU
almost exclusively in infants under 3 years [335]. On the other
hand, children older than 3 years exhibited strong MYCN and
GLI2 amplification together with TP53 mutations (possibly in
correlation with Li–Fraumeni syndrome), while all of these
findings were rare in infants and adults [335].
SHH pathway is best studied for the pathogenesis of medul-
loblastoma, but there is increasing data revealing involvement
in glioma incurrence. Amplification and overexpression of
Gli1 has been associated with some low- and high-grade astro-
cytomas [336, 337], and is assumed that the SHH pathway
might have a stronger role in glioma initiation compared to
other developmental pathways such as Notch or WNT [338].
Furthermore, it has been demonstrated that CD133+ glioblas-
toma cancer stem cells (CSC) are promoted by endothelial
cells through SHH pathways and inhibition of SHH by SMO
knockdown in vitro and in vivo results in reduction of CSC
phenotype-appearance [337]. High expression of SHH and
Gli1 in glioma patient samples were correlated with both
increasing WHO grade and worse prognosis [337].
Therapeutic approaches targeting the SHH pathway have
mainly focused on SMO inhibition [335, 339]. Preclinical
and clinical studies appeared initially promising with evi-
dence of marked reduction in tumor growth; however, point
mutations in SMO and GLI2 amplifications eventually lead
to drug inefficacy [340, 341]. Recent xenograft models
revealed that SHH medulloblastomas with PTCH1 muta-
tions were responsive to SMO-inhibition, while tumors with
SUFU or MYNC mutations, which are often found in infants,
showed resistance [335]. The addition of PI3K inhibitors to
SMO antagonist therapy may be a strategy to delay the
development of resistance [340, 341].
35 Molecular Biology of Human Brain Tumors
Fig. 35.8 Sonic Hedgehog
(SHH) signaling pathway.
35.7.3 The Wingless Pathway
The Wingless (WNT) proteins form a family of secretory mol-
ecules that regulate cell–cell interactions during embryogene-
sis. To date, 19 WNT genes and more than 15 associated
receptors have been identified in the human genome [304,
342]. WNT binds to the G-protein-coupled receptor Frizzled,
which results in intracellular signaling carried out by the phos-
phoprotein Dishevelled (DSH) and leads to a release of inhibi-
tion of the transcription factor β-catenin [343]. With inactive
WNT signaling, the cytoplasmic concentration of β-catenin is
regulated and decreased by a destruction complex, which
mainly is formed by Axin, APC, GCK-3, and CKI [344].
A current model of WNT signaling is shown in Fig. 35.9.
Through its interactions with other families of secreted
growth factors, including EGFR, FGF, TGF-β, and the
Hedgehog proteins, WNT signaling can regulate diverse pro-
cesses including cell proliferation, migration, polarity and
679
differentiation [345–347]. The canonical WNT pathway is
also a critical regulator of stem cells properties, and its acti-
vation has been associated with various cancers [348].
Evidence for the involvement of the WNT signaling path-
way in brain tumors has come from studies of Turcot’s syn-
drome, characterized by the development of medulloblastomas
and astrocytomas resulting from a germ-line mutation in the
APC gene [188]. Since then it has been established that WNT
signaling influences the proliferation and the renewal of neu-
ral stem cells and progenitors [347]. There is increasing evi-
dence that aberrant activation of WNT signaling, resulting in
accumulation or increased activity of β-catenin, will lead to
the development of sporadic brain tumors, Notably, pediatric
medulloblastomas harbor mutations of β-catenin, APC, and
Axin [188, 329]. These point mutations are found in approxi-
mately 10–15 % of medulloblastomas but are mutually
exclusive. For instance, 4 % of sporadic medulloblastomas
harbor missense mutations in APC, and 1–5 % have Axin1
680
Fig. 35.9 Wingless/Int 1
(WNT) signaling pathway.
point mutations [186, 349]. Interestingly, there is evidence
of cross-talk between the WNT and SHH signaling path-
ways as SUFU has been shown to regulate the activity of
β-catenin [350]. SUFU mutations in medulloblastomas may
lead to the activation of the two pathways: WNT and SHH
[351]. The role of WNT signaling in brain tumor formation
has primarily been studied in the context of medulloblas-
toma, but there is increasing evidence that WNT signaling
may also modulate the early phase of tumorigenesis in some
gliomas [346, 347, 352].
So far, agents targeted against the WNT pathway in
medulloblastoma cells or tumors have only been explored in
preclinical setting [353, 354]; however given that medullo-
blastoma patients harboring mutations involving WNT sig-
naling show favorable outcome compared to other subgroups
[198], WNT targeted strategies seem to be of lower priority.
D. Coluccia et al.
35.8 Stem Cells in Brain Tumors
The cancer stem cell (CSC) hypothesis was initially derived
from the concept of CSCs giving rise to the hematopoietic
malignancies. Since then the CSC hypothesis attempts to
explain the development of solid tumors, such as brain
tumors. Furthermore, the CSC hypothesis provides impor-
tant concepts for future brain tumor treatment. The failure or
only short lived beneficial effect of chemotherapy drugs and
radiotherapy in addition to rapid tumor recurrence for most
malignant brain cancers lead to the assumption that actual
therapies might not adequately target a subset of dormant or
slow cycling cells with abilities of self-renewal and adaptation
[105]. Brain tumor stem cells are hypothesized to reside
within a nutritive perivascular niche [355] (Fig. 35.10).
35 Molecular Biology of Human Brain Tumors
Fig. 35.10 Glioblastoma
stem cells and perivascular
niche. GBM glioblastoma
multiforme.
As in normal tissue, tumors are organized in a cellular and
functional hierarchy based on stem cells. Neural stem cells
(NSC) are defined as cells that have the ability to perpetuate
themselves through self-renewal (symmetric division) and to
generate mature cells of a particular tissue through differen-
tiation (asymmetric division) [356, 357]. These cells have
been isolated from the embryonic brain of humans and per-
sist in the adult in the subventricular zone of the frontal lat-
eral ventricles and dentate gyrus of the hippocampus [105].
Different markers have been proposed to characterize the
NSC population, but none have proven to be specific enough
to ensure the identification of a pure population. The expres-
sion of Nestin is a widely used marker to delineate NSCs, as
is the cell surface marker CD133. Additionally, some NSCs
have characteristics of glial cells and will express on their
surface SSEA-1, CD44, α-6 integrin, BLBP, GLAST, RC2,
and GFAP markers [358–361].
Many genes that have been identified as regulators of neu-
ral stem cells properties are also known to be involved in
brain tumorigenesis [361]. For instance, Bmi-1 is important
for cell proliferation and maintenance, and PTEN acts as a
tumor suppressor and important negative regulator of cellu-
lar proliferation [362, 363]. The Notch, Sonic Hedgehog,
and Wingless pathways have also been implicated in regulat-
ing NSCs [348, 364–366]. Importantly, deregulation of these
pathways is also strongly implicated in the initiation and
progression of CNS cancers when they are deregulated.
To date, CSCs have been identified in many solid tumors,
including breast carcinoma, CNS tumors including astrocyto-
681
mas, ependymomas and medulloblastomas, skin malignancies,
and colon cancer [203, 367–373].
Evidence supporting the CSC hypothesis in brain tumors,
include finding that these cells have indefinite potential for
self-renewal, proliferation, differentiation, and have clono-
genic potential based on neurosphere assays. Several studies
demonstrate a close link between developmental biology,
stem cells and cancer cells. In vitro, CSCs have been shown
to express molecular markers of neural precursors as Sox2,
Bmi1, Musashi, Notch, Emx2, Pax6, and Jagged1 [374].
These findings suggest that CSCs may have been initially
derived from normal stem cells. Several proteins have been
proposed as markers of the CDC population in brain tumors
including CD133, CD15, α-6 integrin, and ATP-Binding
cassette transporters (ABCT) [371, 375–377]. However,
other studies have shown that the negative populations of
these markers can also give rise to tumors and therefore these
markers may only enrich for CSC and not define CSC [378].
Importantly, it is not clear yet if cancer-initiating events
occur in the NSC, progenitor cells, or terminally differenti-
ated cells, which reacquire a de-differentiated state [379].
Recent studies have suggested the microenvironment is
important in defining the CSC. In melanoma, for example,
the complete obliteration of the immune response of the
xenograft host lead to a larger fraction of the tumor popula-
tion exhibiting CSC properties [380].
Using a high-throughput drug screen, Diamandis et al.
demonstrated that the functional ground state of neural stem
cells may not only be dependent on developmental signaling
682 D. Coluccia et al.

Table 35.2 Pros and cons of common animal models of brain tumors
Brain tumor in vivo model Pros
Orthotopic xenograft Cell lines can be genetically
manipulated prior to transplantation in
order to explore specific genetic events
Large numbers of animals can be
generated in relatively short time and
at low breading costs
Relative consistent histology and
chromosomal profile supports
standardization
Chemically induced model Immune competent animals can be
used
Tumors show relative high degree of
invasive growth
Cons
Brain tumor cell lines generally
show genotypic deviation and
homogeneity compared to the
original patient tumor (applies
less to biopsy xenografts, at the
cost of longer engraftment time
and more variable tumor
histology)
Mostly demonstrate an expansive
growth with only limited
infiltration into the perivascular
space and occurrence of necrosis
or microvascular alterations
(better results with sphere cultures
compared to monolayer cell lines)
Inhibited immunological
tumor-host response
Genotype and phenotype of the
tumor is not reproducible
Histologically present more like
gliosarcomas or “glioma-like
tumors”

Genetically engineered Tumors arise de novo and in situ Time point of tumor initiation
mouse model (GEMM) within immune competent animals cannot be controlled
Induction of defined genetic alterations Biological differences of murine
allow to study the role of oncogenes and human malignancies
and tumor suppressors in Complex and expensive breading
tumorigenesis
Intact immune system and distinct
molecular characterization of induced
brain tumors improves validation of
drug testing
Transplantable, chemically induced, and genetically engineered mouse models (GEMM)

pathways such as Notch, SHH, and WNT, but also on path-
ways relating to neural transmission [381].
Although the cancer stem cell hypothesis remains some-
what controversial it offers a unique prospective to examine
and understand brain tumor biology. The properties required
for a population of cells to become tumorigenic requires a
dynamic interplay between genetic aberrations, tumor hier-
archy, and microenvironment.
35.9 Animal Models of Brain Tumors
The ideal animal model of a human brain tumor recapitulates
the molecular, genetic, histopathologic, and clinical features
that are found in the human tumor. While none of the current
animal models can fully achieve these requirements, these mod-
els are critically important as they can be used to investigate
tumor biology, screen novel molecular targets and pave the way
towards preclinical trials. In the past 10 years, great progress has
been made in establishing several relevant and reproducible ani-
mal models of human brain tumors that are based on the molec-
ular genetic alterations that characterize the human tumors. Here
we describe transplantable, chemically induced, and genetically
engineered models [242] (Table 35.2).
35.9.1 Transplantable Allograft
and Xenograft Models
Classic modeling involves transplantation of cultured rodent
(allograft) or human (xenograft) cell lines under the skin
(subcutaneous) or in the brain (orthotropic) of immunodefi-
cient/immunonaive rodents [382, 383]. These rodent models
are highly reproducible in terms of tumor formation, growth,
and survival pattern. The cell lines can be genetically manipu-
lated prior to transplantation in order to explore specific
genetic events. However, these tumors may not faithfully
recapitulate the original tumor histology, and pathobiology
[384]. Established brain tumor cell lines generally show
genotypic deviation and homogeneity compared to the origi-
nal patient tumor [385]. One strategy to overcome this is the
use of orthotopic serial passaging of primary human brain
tumors in mice, as these xenografts often retain the original
tumor phenotype. A common drawback of tumor transplants
35 Molecular Biology of Human Brain Tumors
is that they mostly demonstrate an expansive growth with
only limited infiltration into the perivascular space of the
brain and rare occurrence of necrosis or microvascular altera-
tions [242]. The advancement in cell selection and prepara-
tion of growth media now allows for cultivating cancer
stem-like cells which grow as spheres [242, 368]. These
sphere cultures closely retain the genetic profile of the patient
tumor and are highly tumorigenic, invasive, and angiogeneic
[242, 386]. However, EGFR amplification is rather rare in
neurosphere cultures and some cell populations lose glial and
gain mesenchymal features in a process known as mesenchy-
mal drift [387]. The retention of the initial chromosomal pro-
file and tissue architecture of the tumor can be improved
when biopsy tissue is directly cultivated as multicellular
organotypic spheroids and implanted into immunodeficient
rodents [388]. Biopsy xenograft models usually maintain
their heterogeneity and show invasiveness, necrotic areas and
frequently display EGFR amplification [242]. However given
that the tumor histology differs between animals and initial
engraftment may take up to 1 year, experimental planning
becomes problematic [242].
35.9.2 Induction of Brain Tumors
via Embryonic Mutagenesis
The second classical method of modeling is inducing tumor
formation in the developing brain of embryonic rodents with
early exposure to mutagenic alkylating agents (chemically
induced model) [389, 390]. These tumors, mostly estab-
lished in rats (e.g., 9L, C6), show some degree of invasion
and necrosis, but histologically present more like gliosarco-
mas or glioma-like tumors [242]. An advantage over trans-
planted tumors is that immunocompetent animals can be
used, which mimics the situation normally found in humans.
However, when cell lines from chemically induced tumors
are used as an allograft transplant, immunogenic tumor
rejection may still occur and interfere with the interpretation
of the effect of experimental antitumoral agents. An essential
disadvantage of chemically induced tumors in embryonic
animals is that the genotype and phenotype of the tumor is
not reproducible, given the inciting genetic event is unknown
and reveals little about the molecular etiology of brain
tumors in humans.
35.9.3 Genetically Engineered Mouse
Models (GEMM)
GEMMs are created by germ-line modifications or somatic
cell gene transfer techniques. An advantage over xenografts
is that the tumors arise de novo and in situ within immune
competent animals. GEMMs have allowed further insight
into the molecular events behind tumor initiation and main-
683
tenance, although mouse tumors that phenotypically resem-
ble human tumors still behave differently with respect to
their genetics and therapeutic response [391].
The generation of transgenic mice involves inserting a
DNA construct (usually an oncogene) downstream of a pro-
moter into a fertilized oocyte, which is then implanted into the
mouse [392, 393]. All cells of the resulting transgenic off-
spring homogenously contain the new genetic material.
Conditional expression can be conferred using tissue/develop-
mental stage specific promoters, drug response elements such
as tetracycline or doxycycline, or recombination techniques
(Cre/lox) [394, 395]. Strategies employing conditional expres-
sion allow the study of genes that would otherwise result in
embryonic lethality, and confer tissue and stage specificity.
Knock-out mice or loss-of-function models traditionally
involve using homologous recombination to substitute a
mutated gene with a selection marker (i.e., antibiotic resis-
tant gene) for a wild type gene. The cells of interest are then
selected for and placed into embryonic stem cells, which are
then transferred to mouse embryos and generate chimeric
mice, which can be mated to generate a homozygous mouse
with the inactivated gene [393, 396]. These mice as well as
transgenic mice can be mated for a combination of genetic
modifications.
Somatic cell transfer techniques allow the infection of
only a population of cells in an effort to more closely model
the spontaneous genetic events responsible for the majority
of brain tumors. These techniques employ the use of viral
vectors for the delivery of genetic information. One strategy
takes advantage of the Moloney Murine Leukemia Virus
(MMLV) and its wild-type helper virus to deliver genes to
dividing cells [397]. A second more specific system uses the
replication incompetent avian leukosis virus (ALV) to only
deliver genes to cells engineered to express the viral receptor
tv-a [398, 399]. The ability to study secondary mutations in
these systems is related to infection efficiency, as well, the
inclusion of large genes in the vectors decreases viral effi-
ciency. However, multiple viral constructs can be coinfected
to study multiple genetic hits.
35.9.4 Models of Astrocytoma
Alterations within the three core signaling pathways (p53,
RB, RTK/RAS) as characterized by the TCGA are often used
to induce astrocytoma formation in GEM models [391].
Transgenic mice with constitutively active H-RAS driven by
a GFAP promoter (astrocyte specific) develop Grade II–IV
astrocytomas in a dose dependent manner [400]. High H-RAS
expressors develop tumors characteristic of GBM and moder-
ate expressors develop low-grade or anaplastic astrocytomas
[393, 400].
Mice with tumors characteristic of GBMs can be created
by breeding mice with TP53 deletions with mice with Nf1
684
(the mouse form of the human NF1) deletions [401]. Nf1, as
in humans, is a RAS-GAP protein that downregulates RAS
activation, therefore, its loss would result in RAS activation.
Transgenic mice with v-src expression driven by a GFAP
promoter develop low grade or anaplastic astrocytomas
14.4 % of the time [393, 402]. The src receptor interacts with
the EGFR and PDGFR signaling pathways.
Anaplastic astrocytomas were modeled in mice engineered
to express the SV40 T-antigen late in development. SV40
inactivates RB and RB family member p107 and p103. These
mice develop anaplastic astrocytomas within 10 months in
almost 100 % of cases [393, 403]. Interestingly, mutating RB
alone does not result in astrocytomas suggesting redundancy
between RB family members.
Using the RCAS/tv-a retroviral somatic cell transfer tech-
nique to over express K-RAS and AKT in nestin positive
CNS progenitor cells results in the formation of tumors char-
acteristic of GBM [404]. Neither K-RAS nor AKT overex-
pression alone formed tumors. AKT over expression may be
analogous to PTEN deletions in human GBM as the inhibi-
tory effects of PTEN are immediately upstream of AKT acti-
vation [393]. Marumoto et al. transduced a small number of
GFAP+cells heterozygous for TP53 with lentivirus harboring
activated oncogenes H-RAS and AKT in the cortex, subven-
tricular zone and hippocampus of mice [405]. Tumors that
recapitulated human GBM arose only from transduced cells
in the subventricular zone or hippocampus [405].
Deletions and alterations in tumor suppressor or onco-
genes can be combined in order to generate mouse models of
GBM subgroups. For example, knocking down p53 and acti-
vating RAS signaling resulted in tumors harboring a molecu-
lar profile resembling the mesenchymal GBM subtype [104].
Furthermore, the first orthotopic xenograft model of anaplas-
tic oligodendroglioma with mutations in IDH1 and tumor
suppressor genes FUB1 and CIC (both involved in MYC
expression and RTK signaling repression) has been reported
recently [406].
35.9.5 Models of Oligodendroastrocytoma
Overactive PDGFR has been implicated in the pathogenesis
of human oligodendroastrocytoma tumors and as such
murine models of this tumor have focused on this abnormal-
ity. Holland et al. used the RCAS retroviral system to
express oncogenic PDGFB in either nestin or GFAP express-
ing cells [407]. The nestin group acquired mainly low grade
oligodendroastrocytomas approximately 60 % of the time,
whereas the GFAP group developed mixed oligoastrocyto-
mas or oligodendroastrocytomas 40 % of the time [407].
When the oncogenic PDGFB mice were crossed with mice
lacking the INK4A/ARF gene, the proportion of anaplastic
D. Coluccia et al.
tumors increased the latency to tumor formation [407].
Recently, oligodendroglioma cells from fresh human tissue
samples with co-deletion of chromosomes 1p and 19q have
been successfully cultivated as permanent cell lines (BT054
and BT088). BT088 was shown to engraft in the brain of
immunocompromised mice, and demonstrated extensive
infiltration and histology resembling anaplastic oligoden-
droglioma [408].
35.9.6 Models of Medulloblastoma
Mice heterozygous for mouse PTCH deletion develop
tumors similar to human medulloblastoma at a rate of 15 %
by 10 months [409]. This incidence can be increased to 98 %
by 12 weeks if the PTCH +/- mice are combined with p53
null mice [409]. Using the RCAS retroviral and inducing
Sonic Hedgehog mis-expression in the cerebellum of fetal or
newborn mice resulted in medulloblastoma formation at
high rates [410, 411]. The co-overexpression of C-MYC in
these mice enhanced the effect [393]. In murine transgenic
models, the overexpression of MYC in concert with loss of
TP53 resulted in medulloblastomas that expressed markers
typical of Group 3 medulloblastoma [412]. Interestingly,
while trying to create astrocytoma models in GFAP express-
ing cells of mice by deletion of both TP53 and RB, tumors
phenotypically similar to medulloblastoma developed in the
cerebellum [413]. The WNT subgroup could be recapitu-
lated in mice with activating mutations in the WNT pathway
effect protein CTNNB1 [414]. These WNT pathway tumors
in the mouse model revealed that this subgroup of medullo-
blastoma arise from regions in the dorsal brainstem as
opposed to other genetically distinct medulloblastoma
subgroups such as SHH which arise from the cerebellar
hemispheres [414].
35.9.7 Models of Ependymoma
For a long time, preclinical models of ependymoma were
lacking [415]. Johnson et al. introduced the first mouse
model in 2010 using genetic engineering techniques [207].
After transducing the oncogene EPHB2 in neural stem cells
that were INK4A/ARF−/− the mice developed tumors that
were histologically indistinguishable from human ependy-
momas at a rate of 50 %. Advances in optimum medium
preparation have permitted ependymoma cell culture derived
directly from primary patient material and to create ortho-
topic xenograft mice models for posterior fossa ependy-
moma [416]. Recently, an ependymoma stem cell line
(DKFZ-EP1NS) derived from a patient with metastasizing
supratentorial anaplastic ependymoma has been cultivated as
35 Molecular Biology of Human Brain Tumors
neurospheres and used to establish the first orthotopic animal
model for supratentorial ependymoma harboring homozy-
gous deletion for CDKN2A [417].
35.10 Conclusion
Continued pursuits in understanding the molecular and
genetic events in brain tumor initiation, maintenance and
progression will lead to improved therapies in the future. It
will one day be possible to analyze the molecular biology of
a particular patient’s brain tumor and tailor individual thera-
pies based on these findings. The goal of improving patient
outcomes in this devastating disease will only be accom-
plished through the continued application of the latest tech-
nologies to the field.
References
1. CBTRUS statistical report: primary brain and central nervous
system tumors diagnosed in the United States in 2005–2009 2011
(cited 2014 July); www.cbtrus.org.
2. Ohgaki H, Kleihues P. Epidemiology and etiology of gliomas.
Acta Neuropathol. 2005;109:93–108.
3. Ostrom QT, Bauchet L, Davis FG, et al. The epidemiology of gli-
oma in adults: a “state of the science” review. Neuro Oncol.
2014;16:896–913.
4. Malmer B, Iselius L, Holmberg E, et al. Genetic epidemiology of
glioma. Br J Cancer. 2001;84:429–34.
5. Institute NC. Cancer Stat Rev 1975–2011. (July 2014). http://seer.
cancer.gov.
6. de Martel C, Ferlay J, Franceschi S, et al. Global burden of can-
cers attributable to infections in 2008: a review and synthetic
analysis. Lancet Oncol. 2012;13:607–15.
7. Dziurzynski K, Chang SM, Heimberger AB, et al. Consensus on
the role of human cytomegalovirus in glioblastoma. Neuro Oncol.
2012;14:246–55.
8. Soderberg-Naucler C, Rahbar A, Stragliotto G. Survival in patients
with glioblastoma receiving valganciclovir. N Engl J Med.
2013;369:985–6.
9. Louis DN, Ohgaki H, Wiestler OD, et al. The 2007 WHO classifi-
cation of tumours of the central nervous system. Acta Neuropathol.
2007;114:97–109.
10. Weller M, Stupp R, Hegi ME, et al. Personalized care in neuro-
oncology coming of age: why we need MGMT and 1p/19q testing
for malignant glioma patients in clinical practice. Neuro Oncol.
2012;14 Suppl 4:iv100–8.
11. Northcott PA, Korshunov A, Pfister SM, Taylor MD. The clinical
implications of medulloblastoma subgroups. Nat Rev Neurol.
2012;8:340–51.
12. Dempfle A, Wudy SA, Saar K, et al. Evidence for involvement of
the vitamin D receptor gene in idiopathic short stature via a
genome-wide linkage study and subsequent association studies.
Hum Mol Genet. 2006;15:2772–83.
13. Friedman JM. Epidemiology of neurofibromatosis type 1. Am
J Med Genet. 1999;89:1–6.
14. National Institutes of Health Consensus Development Conference.
Neurofibromatosis. Conference statement. Arch Neurol. 1988;
45:575–8.
685
15. DeBella K, Szudek J, Friedman JM. Use of the national institutes
of health criteria for diagnosis of neurofibromatosis 1 in children.
Pediatrics. 2000;105:608–14.
16. Valero MC, Martin Y, Hernandez-Imaz E, et al. A highly sensitive
genetic protocol to detect NF1 mutations. J Mol Diagn. 2011;13:
113–22.
17. Listernick R, Ferner RE, Liu GT, Gutmann DH. Optic pathway
gliomas in neurofibromatosis-1: controversies and recommenda-
tions. Ann Neurol. 2007;61:189–98.
18. Easton DF, Ponder MA, Huson SM, Ponder BA. An analysis of
variation in expression of neurofibromatosis (NF) type 1 (NF1): evi-
dence for modifying genes. Am J Hum Genet. 1993;53:305–13.
19. Carey JC, Viskochil DH. Neurofibromatosis type 1: A model con-
dition for the study of the molecular basis of variable expressivity
in human disorders. Am J Med Genet. 1999;89:7–13.
20. Gutmann DH, Parada LF, Silva AJ, Ratner N. Neurofibromatosis
type 1: modeling CNS dysfunction. J Neurosci. 2012;32:
14087–93.
21. Marchuk DA, Saulino AM, Tavakkol R, et al. cDNA cloning of the
type 1 neurofibromatosis gene: complete sequence of the NF1
gene product. Genomics. 1991;11:931–40.
22. Cawthon RM, O’Connell P, Buchberg AM, et al. Identification
and characterization of transcripts from the neurofibromatosis 1
region: the sequence and genomic structure of EVI2 and mapping
of other transcripts. Genomics. 1990;7:555–65.
23. Xu GF, O’Connell P, Viskochil D, et al. The neurofibromatosis
type 1 gene encodes a protein related to GAP. Cell. 1990;62:
599–608.
24. Abulencia A, Acosta D, Adelman J, et al. Measurement of the tt
production cross section in pp collisions at square root of s = 1.96
TeV. Phys Rev Lett. 2006;97:082004.
25. Jett K, Friedman JM. Clinical and genetic aspects of neurofibro-
matosis 1. Genet Med. 2010;12:1–11.
26. Gutmann DH, Wood DL, Collins FS. Identification of the neurofi-
bromatosis type 1 gene product. Proc Natl Acad Sci U S A.
1991;88:9658–62.
27. Xu GF, Lin B, Tanaka K, et al. The catalytic domain of the neuro-
fibromatosis type 1 gene product stimulates ras GTPase and com-
plements ira mutants of S. cerevisiae. Cell. 1990;63:835–41.
28. Dasgupta B, Gutmann DH. Neurofibromatosis 1: closing the GAP
between mice and men. Curr Opin Genet Dev. 2003;13:20–7.
29. Dasgupta B, Gutmann DH. Neurofibromin regulates neural stem
cell proliferation, survival, and astroglial differentiation in vitro
and in vivo. J Neurosci. 2005;25:5584–94.
30. Kourea HP, Cordon-Cardo C, Dudas M, Leung D, Woodruff
JM. Expression of p27(kip) and other cell cycle regulators in
malignant peripheral nerve sheath tumors and neurofibromas: the
emerging role of p27(kip) in malignant transformation of neurofi-
bromas. Am J Pathol. 1999;155:1885–91.
31. Packer RJ, Gutmann DH, Rubenstein A, et al. Plexiform neurofi-
bromas in NF1: toward biologic-based therapy. Neurology.
2002;58:1461–70.
32. Korf BR. Malignancy in neurofibromatosis type 1. Oncologist.
2000;5:477–85.
33. Evans DG, Baser ME, McGaughran J, et al. Malignant peripheral
nerve sheath tumours in neurofibromatosis 1. J Med Genet.
2002;39:311–4.
34. Menon AG, Anderson KM, Riccardi VM, et al. Chromosome 17p
deletions and p53 gene mutations associated with the formation of
malignant neurofibrosarcomas in von Recklinghausen neurofibro-
matosis. Proc Natl Acad Sci U S A. 1990;87:5435–9.
35. Cichowski K, Shih TS, Schmitt E, et al. Mouse models of tumor devel-
opment in neurofibromatosis type 1. Science. 1999;286:2172–6.
36. Ward BA, Gutmann DH. Neurofibromatosis 1: from lab bench to
clinic. Pediatr Neurol. 2005;32:221–8.
686
37. Gutmann, D.H. (2014) Eliminating barriers to personalized medi-
cine: Learning from neurofibromatosis type 1. Neurology.
38. Gutmann DH, Blakeley JO, Korf BR, Packer RJ. Optimizing bio-
logically targeted clinical trials for neurofibromatosis. Expert
Opin Investig Drugs. 2013;22:443–62.
39. Study of RAD001 (everolimus) for children with NF1 and
chemotherapy-refractory radiographic progressive low grade glio-
mas. 2014 (cited 2014 July); http://clinicaltrials.gov.
40. Evans DG. Neurofibromatosis type 2 (NF2): a clinical and molec-
ular review. Orphanet J Rare Dis. 2009;4:16.
41. Asthagiri AR, Parry DM, Butman JA, et al. Neurofibromatosis
type 2. Lancet. 2009;373:1974–86.
42. Evans DG, Baser ME, O'Reilly B, et al. Management of the
patient and family with neurofibromatosis 2: a consensus confer-
ence statement. Br J Neurosurg. 2005;19:5–12.
43. Rouleau GA, Wertelecki W, Haines JL, et al. Genetic linkage of
bilateral acoustic neurofibromatosis to a DNA marker on chromo-
some 22. Nature. 1987;329:246–8.
44. Rouleau GA, Merel P, Lutchman M, et al. Alteration in a new gene
encoding a putative membrane-organizing protein causes neuro-
fibromatosis type 2. Nature. 1993;363:515–21.
45. Trofatter JA, MacCollin MM, Rutter JL, et al. A novel moesin-,
ezrin-, radixin-like gene is a candidate for the neurofibromatosis
2 tumor suppressor. Cell. 1993;72:791–800.
46. Cooper J, Giancotti FG. Molecular insights into NF2/Merlin
tumor suppressor function. FEBS Lett. 2014;588:2743–52.
47. Lim SH, Ardern-Holmes S, McCowage G, de Souza P. Systemic
therapy in neurofibromatosis type 2. Cancer Treat Rev.
2014;40:857–61.
48. McClatchey AI. Merlin and ERM proteins: unappreciated roles in
cancer development? Nat Rev Cancer. 2003;3:877–83.
49. Ammoun S, Cunliffe CH, Allen JC, et al. ErbB/HER receptor acti-
vation and preclinical efficacy of lapatinib in vestibular schwan-
noma. Neuro Oncol. 2010;12:834–43.
50. McClatchey AI, Saotome I, Ramesh V, Gusella JF, Jacks T. The
Nf2 tumor suppressor gene product is essential for extraembry-
onic development immediately prior to gastrulation. Genes Dev.
1997;11:1253–65.
51. Giovannini M, Robanus-Maandag E, van der Valk M, et al.
Conditional biallelic Nf2 mutation in the mouse promotes mani-
festations of human neurofibromatosis type 2. Genes Dev.
2000;14:1617–30.
52. Subbiah V, Slopis J, Hong DS, et al. Treatment of patients with
advanced neurofibromatosis type 2 with novel molecularly tar-
geted therapies: from bench to bedside. J Clin Oncol.
2012;30:e64–8.
53. Karajannis MA, Legault G, Hagiwara M, et al. Phase II trial of
lapatinib in adult and pediatric patients with neurofibromatosis
type 2 and progressive vestibular schwannomas. Neuro Oncol.
2012;14:1163–70.
54. Hippel E. Ueber eine sehr seltene Erkrankung der Netzhaut.
Albrecht von Graefes Archiv für Ophthalmologie.
1904;59:83–106.
55. Lindau A. Zur Frage der Angiomatosis Rentinae und Ihrer
Hirnkomplikationen. Acta Ophtalmologica. 1926;4:193–226.
56. Robinson CM, Ohh M. The multifaceted von Hippel-Lindau
tumour suppressor protein. FEBS Lett. 2014;588:2704–11.
57. Latif F, Tory K, Gnarra J, et al. Identification of the von Hippel-
Lindau disease tumor suppressor gene. Science.
1993;260:1317–20.
58. Maddock IR, Moran A, Maher ER, et al. A genetic register for von
Hippel-Lindau disease. J Med Genet. 1996;33:120–7.
59. Richards FM, Payne SJ, Zbar B, et al. Molecular analysis of de
novo germ-line mutations in the von Hippel-Lindau disease gene.
Hum Mol Genet. 1995;4:2139–43.
D. Coluccia et al.
60. Catapano D, Muscarella LA, Guarnieri V, et al. Hemangioblastomas
of central nervous system: molecular genetic analysis and clinical
management. Neurosurgery. 2005;56:1215–21.
61. Wanebo JE, Lonser RR, Glenn GM, Oldfield EH. The natural his-
tory of hemangioblastomas of the central nervous system in
patients with von Hippel-Lindau disease. J Neurosurg.
2003;98:82–94.
62. Pause A, Lee S, Lonergan KM, Klausner RD. The von Hippel-
Lindau tumor suppressor gene is required for cell cycle exit upon
serum withdrawal. Proc Natl Acad Sci U S A. 1998;95:993–8.
63. Koochekpour S, Jeffers M, Wang PH, et al. The von Hippel-
Lindau tumor suppressor gene inhibits hepatocyte growth factor/
scatter factor-induced invasion and branching morphogenesis in
renal carcinoma cells. Mol Cell Biol. 1999;19:5902–12.
64. Peruzzi B, Athauda G, Bottaro DP. The von Hippel-Lindau
tumor suppressor gene product represses oncogenic beta-catenin
signaling in renal carcinoma cells. Proc Natl Acad Sci U S A.
2006;103:14531–6.
65. An J, Liu H, Magyar CE, et al. Hyperactivated JNK is a therapeu-
tic target in pVHL-deficient renal cell carcinoma. Cancer Res.
2013;73:1374–85.
66. Chen L, Han L, Zhang K, et al. VHL regulates the effects of
miR-23b on glioma survival and invasion via suppression of HIF-
1alpha/VEGF and beta-catenin/Tcf-4 signaling. Neuro Oncol.
2012;14:1026–36.
67. Kwiatkowski DJ. Tuberous sclerosis: from tubers to mTOR. Ann
Hum Genet. 2003;67:87–96.
68. Jozwiak S, Schwartz RA, Janniger CK, Bielicka-Cymerman
J. Usefulness of diagnostic criteria of tuberous sclerosis complex
in pediatric patients. J Child Neurol. 2000;15:652–9.
69. Goodman M, Lamm SH, Engel A, et al. Cortical tuber count: a
biomarker indicating neurologic severity of tuberous sclerosis
complex. J Child Neurol. 1997;12:85–90.
70. Short MP, Richardson EP, Haines JL, Kwiatkowski DJ. Clinical,
neuropathological and genetic aspects of the tuberous sclerosis
complex. Brain Pathol. 1995;5:173–9.
71. Weiner DM, Ewalt DH, Roach ES, Hensle TW. The tuberous scle-
rosis complex: a comprehensive review. J Am Coll Surg.
1998;187:548–61.
72. Sancak O, Nellist M, Goedbloed M, et al. Mutational analysis of
the TSC1 and TSC2 genes in a diagnostic setting:
genotype--phenotype correlations and comparison of diagnostic
DNA techniques in Tuberous Sclerosis Complex. Eur J Hum
Genet. 2005;13:731–41.
73. Jones AC, Shyamsundar MM, Thomas MW, et al. Comprehensive
mutation analysis of TSC1 and TSC2-and phenotypic correlations
in 150 families with tuberous sclerosis. Am J Hum Genet.
1999;64:1305–15.
74. Huang J, Dibble CC, Matsuzaki M, Manning BD. The TSC1-
TSC2 complex is required for proper activation of mTOR com-
plex 2. Mol Cell Biol. 2008;28:4104–15.
75. Krueger DA, Care MM, Holland K, et al. Everolimus for subepen-
dymal giant-cell astrocytomas in tuberous sclerosis. N Engl
J Med. 2010;363:1801–11.
76. Krueger DA, Care MM, Agricola K, et al. Everolimus long-term
safety and efficacy in subependymal giant cell astrocytoma.
Neurology. 2013;80:574–80.
77. Evans DG, Farndon PA, Burnell LD, Gattamaneni HR, Birch
JM. The incidence of Gorlin syndrome in 173 consecutive cases of
medulloblastoma. Br J Cancer. 1991;64:959–61.
78. Jones EA, Sajid MI, Shenton A, Evans DG. Basal cell carcinomas
in gorlin syndrome: a review of 202 patients. J Skin Cancer.
2011;2011:217378.
79. Gorlin RJ. Nevoid basal cell carcinoma syndrome. Dermatol Clin.
1995;13:113–25.
35 Molecular Biology of Human Brain Tumors
80. Hahn H, Wicking C, Zaphiropoulous PG, et al. Mutations of the
human homolog of Drosophila patched in the nevoid basal cell
carcinoma syndrome. Cell. 1996;85:841–51.
81. Li FP, Fraumeni Jr JF. Rhabdomyosarcoma in children: epidemio-
logic study and identification of a familial cancer syndrome. J Natl
Cancer Inst. 1969;43:1365–73.
82. Achatz MI, Olivier M, Le Calvez F, et al. The TP53 mutation,
R337H, is associated with Li-Fraumeni and Li-Fraumeni-like syn-
dromes in Brazilian families. Cancer Lett. 2007;245:96–102.
83. Gonzalez KD, Noltner KA, Buzin CH, et al. Beyond Li Fraumeni
syndrome: clinical characteristics of families with p53 germ-line
mutations. J Clin Oncol. 2009;27:1250–6.
84. Bell DW, Varley JM, Szydlo TE, et al. Heterozygous germ line
hCHK2 mutations in Li-Fraumeni syndrome. Science.
1999;286:2528–31.
85. Watanabe T, Vital A, Nobusawa S, Kleihues P, Ohgaki H.
Selective acquisition of IDH1 R132C mutations in astrocytomas
associated with Li-Fraumeni syndrome. Acta Neuropathol.
2009;117:653–6.
86. Hamilton SR, Liu B, Parsons RE, et al. The molecular basis of
Turcot’s syndrome. N Engl J Med. 1995;332:839–47.
87. Turcot J, Despres JP, St Pierre F. Malignant tumors of the central
nervous system associated with familial polyposis of the colon:
report of two cases. Dis Colon Rectum. 1959;2:465–8.
88. van Meir E, de Tribolet N. Microsatellite instability in human
brain tumors. Neurosurgery. 1995;37:1231–2.
89. Hobert JA, Eng C. PTEN hamartoma tumor syndrome: an over-
view. Genet Med. 2009;11:687–94.
90. Lloyd 2nd KM, Dennis M. Cowden’s disease. A possible new
symptom complex with multiple system involvement. Ann Intern
Med. 1963;58:136–42.
91. Lhermitte D. Sur un ganglioneurome diffus du cortex du cervelet.
Bull Assoc Fr Etud Cancer. 1920;9:99–107.
92. Padberg GW, Schot JD, Vielvoye GJ, Bots GT, de Beer FC.
Lhermitte-Duclos disease and Cowden disease: a single phakoma-
tosis. Ann Neurol. 1991;29:517–23.
93. Eng C. PTEN: one gene, many syndromes. Hum Mutat.
2003;22:183–98.
94. Myers MP, Pass I, Batty IH, et al. The lipid phosphatase activity of
PTEN is critical for its tumor suppressor function. Proc Natl Acad
Sci U S A. 1998;95:13513–8.
95. Orloff MS, Eng C. Genetic and phenotypic heterogeneity in the
PTEN hamartoma tumour syndrome. Oncogene. 2008;27:5387–97.
96. Liaw D, Marsh DJ, Li J, et al. Germ-line mutations of the PTEN
gene in Cowden disease, an inherited breast and thyroid cancer
syndrome. Nat Genet. 1997;16:64–7.
97. Marsh DJ, Coulon V, Lunetta KL, et al. Mutation spectrum and
genotype-phenotype analyses in Cowden disease and Bannayan-
Zonana syndrome, two hamartoma syndromes with germ-line
PTEN mutation. Hum Mol Genet. 1998;7:507–15.
98. Tan MH, Mester J, Peterson C, et al. A clinical scoring system for
selection of patients for PTEN mutation testing is proposed on the
basis of a prospective study of 3042 probands. Am J Hum Genet.
2011;88:42–56.
99. Orloff MS, He X, Peterson C, et al. Germ-line PIK3CA and AKT1
mutations in Cowden and Cowden-like syndromes. Am J Hum
Genet. 2013;92:76–80.
100. Zhou XP, Marsh DJ, Morrison CD, et al. Germ-line inactivation of
PTEN and dysregulation of the phosphoinositol-3-kinase/Akt
pathway cause human Lhermitte-Duclos disease in adults. Am
J Hum Genet. 2003;73:1191–8.
101. Abel TW, Baker SJ, Fraser MM, et al. Lhermitte-Duclos disease:
a report of 31 cases with immunohistochemical analysis of the
PTEN/AKT/mTOR pathway. J Neuropathol Exp Neurol.
2005;64:341–9.
687
102. Backman SA, Stambolic V, Suzuki A, et al. Deletion of Pten in
mouse brain causes seizures, ataxia and defects in soma size
resembling Lhermitte-Duclos disease. Nat Genet. 2001;29:
396–403.
103. Kwon CH, Zhu X, Zhang J, et al. Pten regulates neuronal soma
size: a mouse model of Lhermitte-Duclos disease. Nat Genet.
2001;29:404–11.
104. Friedmann-Morvinski D, Bushong EA, Ke E, et al. Dedifferentiation
of neurons and astrocytes by oncogenes can induce gliomas in mice.
Science. 2012;338:1080–4.
105. Stiles CD, Rowitch DH. Glioma stem cells: a midterm exam.
Neuron. 2008;58:832–46.
106. Capelle L, Fontaine D, Mandonnet E, et al. Spontaneous and ther-
apeutic prognostic factors in adult hemispheric World Health
Organization Grade II gliomas: a series of 1097 cases: clinical
article. J Neurosurg. 2013;118:1157–68.
107. Sturm D, Bender S, Jones DT, et al. Paediatric and adult glioblas-
toma: multiform (epi)genomic culprits emerge. Nat Rev Cancer.
2014;14:92–107.
108. Ohgaki H, Dessen P, Jourde B, et al. Genetic pathways to glioblas-
toma: a population-based study. Cancer Res. 2004;64:6892–9.
109. Brennan CW, Verhaak RG, McKenna A, et al. The somatic
genomic landscape of glioblastoma. Cell. 2013;155:462–77.
110. Hirose Y, Sasaki H, Miwa T, et al. Whole genome analysis from
microdissected tissue revealed adult supratentorial grade II-III
gliomas are divided into clinically relevant subgroups by genetic
profile. Neurosurgery. 2011;69:376–90.
111. Hirose Y, Aldape K, Bollen A, et al. Chromosomal abnormalities
subdivide ependymal tumors into clinically relevant groups. Am
J Pathol. 2001;158:1137–43.
112. Hirose Y, Sasaki H, Abe M, et al. Subgrouping of gliomas on the
basis of genetic profiles. Brain Tumor Pathol. 2013;30:203–8.
113. Houillier C, Mokhtari K, Carpentier C, et al. Chromosome 9p and
10q losses predict unfavorable outcome in low-grade gliomas.
Neuro Oncol. 2010;12:2–6.
114. Ohgaki H, Kleihues P. The definition of primary and secondary
glioblastoma. Clin Cancer Res. 2013;19:764–72.
115. Sanborn JZ, Salama SR, Grifford M, et al. Double minute chro-
mosomes in glioblastoma multiforme are revealed by precise
reconstruction of oncogenic amplicons. Cancer Res. 2013;73:
6036–45.
116. Reifenberger J, Reifenberger G, Liu L, et al. Molecular genetic
analysis of oligodendroglial tumors shows preferential allelic
deletions on 19q and 1p. Am J Pathol. 1994;145:1175–90.
117. Bettegowda C, Agrawal N, Jiao Y, et al. Mutations in CIC and
FUBP1 contribute to human oligodendroglioma. Science.
2011;333:1453–5.
118. Yip S, Butterfield YS, Morozova O, et al. Concurrent CIC muta-
tions, IDH mutations, and 1p/19q loss distinguish oligodendro-
gliomas from other cancers. J Pathol. 2012;226:7–16.
119. Ren X, Cui X, Lin S, et al. Co-deletion of chromosome 1p/19q
and IDH1/2 mutation in glioma subsets of brain tumors in Chinese
patients. PLoS One. 2012;7:e32764.
120. Cairncross G, Wang M, Shaw E, et al. Phase III trial of chemora-
diotherapy for anaplastic oligodendroglioma: long-term results of
RTOG 9402. J Clin Oncol. 2013;31:337–43.
121. Iwadate Y, Matsutani T, Hasegawa Y, et al. Favorable long-term
outcome of low-grade oligodendrogliomas irrespective of 1p/19q
status when treated without radiotherapy. J Neurooncol.
2011;102:443–9.
122. van den Bent MJ, Brandes AA, Taphoorn MJ, et al. Adjuvant pro-
carbazine, lomustine, and vincristine chemotherapy in newly
diagnosed anaplastic oligodendroglioma: long-term follow-up of
EORTC brain tumor group study 26951. J Clin Oncol.
2013;31:344–50.
688
123. Bourne TD, Schiff D. Update on molecular findings, management
and outcome in low-grade gliomas. Nat Rev Neurol. 2010;
6:695–701.
124. Dunn GP, Rinne ML, Wykosky J, et al. Emerging insights into the
molecular and cellular basis of glioblastoma. Genes Dev.
2012;26:756–84.
125. Watanabe K, Tachibana O, Sata K, et al. Overexpression of the
EGF receptor and p53 mutations are mutually exclusive in the
evolution of primary and secondary glioblastomas. Brain Pathol.
1996;6:217–23. discussion 223–214.
126. Ekstrand AJ, James CD, Cavenee WK, et al. Genes for epidermal
growth factor receptor, transforming growth factor alpha, and epi-
dermal growth factor and their expression in human gliomas
in vivo. Cancer Res. 1991;51:2164–72.
127. Hegi ME, Rajakannu P, Weller M. Epidermal growth factor recep-
tor: a re-emerging target in glioblastoma. Curr Opin Neurol.
2012;25:774–9.
128. Contreras CM, Azamar-Arizmendi G, Saavedra M, Hernandez-
Lozano M. A five-day gradual reduction regimen of chlormadi-
none reduces premenstrual anxiety and depression: a pilot study.
Arch Med Res. 2006;37:907–13.
129. El Imam M, Omran M, Nugud F, et al. Obstructive uropathy in
Sudanese patients. Saudi J Kidney Dis Transpl. 2006;17:415–9.
130. Cancer Genome Atlas Research Network. Comprehensive
genomic characterization defines human glioblastoma genes and
core pathways. Nature. 2008;455:1061–8.
131. Parsons DW, Jones S, Zhang X, et al. An integrated genomic anal-
ysis of human glioblastoma multiforme. Science.
2008;321:1807–12.
132. Balss J, Meyer J, Mueller W, et al. Analysis of the IDH1 codon
132 mutation in brain tumors. Acta Neuropathol. 2008;116:
597–602.
133. Nobusawa S, Watanabe T, Kleihues P, Ohgaki H. IDH1 mutations
as molecular signature and predictive factor of secondary glioblas-
tomas. Clin Cancer Res. 2009;15:6002–7.
134. Yan H, Parsons DW, Jin G, et al. IDH1 and IDH2 mutations in
gliomas. N Engl J Med. 2009;360:765–73.
135. Dubbink HJ, Taal W, van Marion R, et al. IDH1 mutations in low-
grade astrocytomas predict survival but not response to temozolo-
mide. Neurology. 2009;73:1792–5.
136. Sanson M, Marie Y, Paris S, et al. Isocitrate dehydrogenase 1
codon 132 mutation is an important prognostic biomarker in glio-
mas. J Clin Oncol. 2009;27:4150–4.
137. van den Bent MJ, Dubbink HJ, Marie Y, et al. IDH1 and IDH2
mutations are prognostic but not predictive for outcome in ana-
plastic oligodendroglial tumors: a report of the European
Organization for Research and Treatment of Cancer Brain Tumor
Group. Clin Cancer Res. 2010;16:1597–604.
138. Weller M, Felsberg J, Hartmann C, et al. Molecular predictors of
progression-free and overall survival in patients with newly diag-
nosed glioblastoma: a prospective translational study of the
German Glioma Network. J Clin Oncol. 2009;27:5743–50.
139. Wick W, Hartmann C, Engel C, et al. NOA-04 randomized phase
III trial of sequential radiochemotherapy of anaplastic glioma with
procarbazine, lomustine, and vincristine or temozolomide. J Clin
Oncol. 2009;27:5874–80.
140. Ichimura K, Pearson DM, Kocialkowski S, et al. IDH1 mutations
are present in the majority of common adult gliomas but rare in
primary glioblastomas. Neuro Oncol. 2009;11:341–7.
141. Watanabe T, Nobusawa S, Kleihues P, Ohgaki H. IDH1 mutations
are early events in the development of astrocytomas and oligoden-
drogliomas. Am J Pathol. 2009;174:1149–53.
142. Kondo Y, Katsushima K, Ohka F, Natsume A, Shinjo K. Epigenetic
dysregulation in glioma. Cancer Sci. 2014;105:363–9.
143. Hegi ME, Diserens AC, Gorlia T, et al. MGMT gene silencing and
benefit from temozolomide in glioblastoma. N Engl J Med.
2005;352:997–1003.
D. Coluccia et al.
144. Wick W, Weller M, van den Bent M, et al. MGMT testing-the
challenges for biomarker-based glioma treatment. Nat Rev Neurol.
2014;10:372–85.
145. Yan H, Bigner DD, Velculescu V, Parsons DW. Mutant metabolic
enzymes are at the origin of gliomas. Cancer Res. 2009;69:9157–9.
146. Warburg O. On the origin of cancer cells. Science.
1956;123:309–14.
147. David CJ, Chen M, Assanah M, Canoll P, Manley JL. HnRNP pro-
teins controlled by c-Myc deregulate pyruvate kinase mRNA
splicing in cancer. Nature. 2010;463:364–8.
148. Wolf A, Agnihotri S, Micallef J, et al. Hexokinase 2 is a key medi-
ator of aerobic glycolysis and promotes tumor growth in human
glioblastoma multiforme. J Exp Med. 2011;208:313–26.
149. Sanoudou D, Tingby O, Ferguson-Smith MA, Collins VP,
Coleman N. Analysis of pilocytic astrocytoma by comparative
genomic hybridization. Br J Cancer. 2000;82:1218–22.
150. Zattara-Cannoni H, Gambarelli D, Lena G, et al. Are juvenile pilo-
cytic astrocytomas benign tumors? A cytogenetic study in 24
cases. Cancer Genet Cytogenet. 1998;104:157–60.
151. Bax DA, Mackay A, Little SE, et al. A distinct spectrum of copy
number aberrations in pediatric high-grade gliomas. Clin Cancer
Res. 2010;16:3368–77.
152. Paugh BS, Qu C, Jones C, et al. Integrated molecular genetic pro-
filing of pediatric high-grade gliomas reveals key differences with
the adult disease. J Clin Oncol. 2010;28:3061–8.
153. Rickert CH, Strater R, Kaatsch P, et al. Pediatric high-grade astro-
cytomas show chromosomal imbalances distinct from adult cases.
Am J Pathol. 2001;158:1525–32.
154. Sung T, Miller DC, Hayes RL, et al. Preferential inactivation of
the p53 tumor suppressor pathway and lack of EGFR amplifica-
tion distinguish de novo high grade pediatric astrocytomas from
de novo adult astrocytomas. Brain Pathol. 2000;10:249–59.
155. Verhaak RG, Hoadley KA, Purdom E, et al. Integrated genomic
analysis identifies clinically relevant subtypes of glioblastoma
characterized by abnormalities in PDGFRA, IDH1, EGFR, and
NF1. Cancer Cell. 2010;17:98–110.
156. Bar EE, Lin A, Tihan T, Burger PC, Eberhart CG. Frequent gains
at chromosome 7q34 involving BRAF in pilocytic astrocytoma.
J Neuropathol Exp Neurol. 2008;67:878–87.
157. Jones DTW, Kocialkowski S, Liu L, et al. Tandem duplication
producing a novel oncogenic BRAF fusion gene defines the
majority of pilocytic astrocytomas. Cancer Res. 2008;68:8673–7.
158. Jones DTW, Kocialkowski S, Liu L, et al. Oncogenic RAF1 rear-
rangement and a novel BRAF mutation as alternatives to
KIAA1549:BRAF fusion in activating the MAPK pathway in
pilocytic astrocytoma. Oncogene. 2009;28:2119–23.
159. Chen YH, Gutmann DH. The molecular and cell biology of pedi-
atric low-grade gliomas. Oncogene. 2014;33:2019–26.
160. Davies H, Bignell GR, Cox C, et al. Mutations of the BRAF gene
in human cancer. Nature. 2002;417:949–54.
161. Hudson TJ, Anderson W, Artez A, et al. International network of
cancer genome projects. Nature. 2010;464:993–8.
162. Phillips HS, Kharbanda S, Chen R, et al. Molecular subclasses of
high-grade glioma predict prognosis, delineate a pattern of disease
progression, and resemble stages in neurogenesis. Cancer Cell.
2006;9:157–73.
163. Noushmehr H, Weisenberger DJ, Diefes K, et al. Identification of
a CpG island methylator phenotype that defines a distinct sub-
group of glioma. Cancer Cell. 2010;17:510–22.
164. van den Bent MJ, Gravendeel LA, Gorlia T, et al. A hypermethyl-
ated phenotype is a better predictor of survival than MGMT meth-
ylation in anaplastic oligodendroglial brain tumors: a report from
EORTC study 26951. Clin Cancer Res. 2011;17:7148–55.
165. Wang J, Wechsler-Reya RJ. The role of stem cells and progenitors
in the genesis of medulloblastoma. Exp Neurol. 2012;260:69–73.
166. Kool M, Korshunov A, Remke M, et al. Molecular subgroups of
medulloblastoma: an international meta-analysis of transcriptome,
35 Molecular Biology of Human Brain Tumors
genetic aberrations, and clinical data of WNT, SHH, Group 3,
and Group 4 medulloblastomas. Acta Neuropathol. 2012;123:
473–84.
167. Bigner SH, Burger PC, Wong AJ, et al. Gene amplification in
malignant human gliomas: clinical and histopathologic aspects.
J Neuropathol Exp Neurol. 1988;47:191–205.
168. Northcott PA, Nakahara Y, Wu X, et al. Multiple recurrent genetic
events converge on control of histone lysine methylation in medul-
loblastoma. Nat Genet. 2009;41:465–72.
169. Giordana MT, Migheli A, Pavanelli E. Isochromosome 17q is a
constant finding in medulloblastoma. An interphase cytogenetic
study on tissue sections. Neuropathol Appl Neurobiol.
1998;24:233–8.
170. Pan E, Pellarin M, Holmes E, et al. Isochromosome 17q is a nega-
tive prognostic factor in poor-risk childhood medulloblastoma
patients. Clin Cancer Res. 2005;11:4733–40.
171. McDonald JD, Daneshvar L, Willert JR, et al. Physical mapping of
chromosome 17p13.3 in the region of a putative tumor suppressor
gene important in medulloblastoma. Genomics. 1994;23:229–32.
172. Ferretti E, De Smaele E, Di Marcotullio L, Screpanti I, Gulino
A. Hedgehog checkpoints in medulloblastoma: the chromosome
17p deletion paradigm. Trends Mol Med. 2005;11:537–45.
173. Shih DJ, Northcott PA, Remke M, et al. Cytogenetic prognostica-
tion within medulloblastoma subgroups. J Clin Oncol.
2014;32:886–96.
174. Aldosari N, Wiltshire RN, Dutra A, et al. Comprehensive molecular
cytogenetic investigation of chromosomal abnormalities in human
medulloblastoma cell lines and xenograft. Neuro Oncol.
2002;4:75–85.
175. Eberhart CG, Kratz J, Wang Y, et al. Histopathological and molec-
ular prognostic markers in medulloblastoma: c-myc, N-myc,
TrkC, and anaplasia. J Neuropathol Exp Neurol. 2004;63:441–9.
176. Eberhart CG, Kratz JE, Schuster A, et al. Comparative genomic
hybridization detects an increased number of chromosomal altera-
tions in large cell/anaplastic medulloblastomas. Brain Pathol.
2002;12:36–44.
177. Gilbertson RJ, Clifford SC, MacMeekin W, et al. Expression of
the ErbB-neuregulin signaling network during human cerebellar
development: implications for the biology of medulloblastoma.
Cancer Res. 1998;58:3932–41.
178. Lee CJ, Chan WI, Scotting PJ. CIC, a gene involved in cerebellar
development and ErbB signaling, is significantly expressed in
medulloblastomas. J Neurooncol. 2005;73:101–8.
179. Gilbertson R, Hernan R, Pietsch T, et al. Novel ERBB4 juxtamem-
brane splice variants are frequently expressed in childhood medul-
loblastoma. Genes Chromosomes Cancer. 2001;31:288–94.
180. Gajjar A, Hernan R, Kocak M, et al. Clinical, histopathologic, and
molecular markers of prognosis: toward a new disease risk strati-
fication system for medulloblastoma. J Clin Oncol.
2004;22:984–93.
181. Erez A, Ilan T, Amariglio N, et al. GLI3 is not mutated commonly
in sporadic medulloblastomas. Cancer. 2002;95:28–31.
182. Pietsch T, Koch A, Wiestler OD. Molecular genetic studies in
medulloblastomas: evidence for tumor suppressor genes at the
chromosomal regions 1q31-32 and 17p13. Klin Padiatr.
1997;209:150–5.
183. Reifenberger J, Wolter M, Weber RG, et al. Missense mutations in
SMOH in sporadic basal cell carcinomas of the skin and primitive
neuroectodermal tumors of the central nervous system. Cancer
Res. 1998;58:1798–803.
184. Taylor MD, Liu L, Raffel C, et al. Mutations in SUFU predispose
to medulloblastoma. Nat Genet. 2002;31:306–10.
185. Dahmen RP, Koch A, Denkhaus D, et al. Deletions of AXIN1, a
component of the WNT/wingless pathway, in sporadic medullo-
blastomas. Cancer Res. 2001;61:7039–43.
186. Huang H, Mahler-Araujo BM, Sankila A, et al. APC mutations in
sporadic medulloblastomas. Am J Pathol. 2000;156:433–7.
689
187. Kang DE, Soriano S, Xia X, et al. Presenilin couples the paired
phosphorylation of beta-catenin independent of axin: implications
for beta-catenin activation in tumorigenesis. Cell.
2002;110:751–62.
188. Zurawel RH, Chiappa SA, Allen C, Raffel C. Sporadic medullo-
blastomas contain oncogenic beta-catenin mutations. Cancer Res.
1998;58:896–9.
189. Zhukova N, Ramaswamy V, Remke M, et al. Subgroup-specific
prognostic implications of TP53 mutation in medulloblastoma.
J Clin Oncol. 2013;31:2927–35.
190. Hovestadt V, Jones DT, Picelli S, et al. Decoding the regulatory
landscape of medulloblastoma using DNA methylation sequenc-
ing. Nature. 2014;510:537–41.
191. Remke M, Ramaswamy V, Taylor MD. Medulloblastoma molecu-
lar dissection: the way toward targeted therapy. Curr Opin Oncol.
2013;25:674–81.
192. Di C, Liao S, Adamson DC, et al. Identification of OTX2 as a
medulloblastoma oncogene whose product can be targeted by all-
trans retinoic acid. Cancer Res. 2005;65:919–24.
193. Adamson DC, Shi Q, Wortham M, et al. OTX2 is critical for the
maintenance and progression of Shh-independent medulloblasto-
mas. Cancer Res. 2010;70:181–91.
194. Bunt J, Hasselt NA, Zwijnenburg DA, et al. OTX2 sustains a
bivalent-like state of OTX2-bound promoters in medulloblastoma
by maintaining their H3K27me3 levels. Acta Neuropathol.
2013;125:385–94.
195. Hovestadt V, Remke M, Kool M, et al. Robust molecular sub-
grouping and copy-number profiling of medulloblastoma from
small amounts of archival tumour material using high-density
DNA methylation arrays. Acta Neuropathol. 2013;125:913–6.
196. Schwalbe EC, Williamson D, Lindsey JC, et al. DNA methylation
profiling of medulloblastoma allows robust subclassification and
improved outcome prediction using formalin-fixed biopsies. Acta
Neuropathol. 2013;125:359–71.
197. Taylor MD, Northcott PA, Korshunov A, et al. Molecular sub-
groups of medulloblastoma: the current consensus. Acta
Neuropathol. 2012;123:465–72.
198. Northcott PA, Korshunov A, Witt H, et al. Medulloblastoma
comprises four distinct molecular variants. J Clin Oncol.
2011;29:1408–14.
199. Northcott PA, Lee C, Zichner T, et al. Enhancer hijacking activates
GFI1 family oncogenes in medulloblastoma. Nature.
2014;511:428–34.
200. Rudin CM, Hann CL, Laterra J, et al. Treatment of medulloblas-
toma with hedgehog pathway inhibitor GDC-0449. N Engl J Med.
2009;361:1173–8.
201. Kieran MW. Targeted treatment for Sonic Hedgehog-dependent
medulloblastoma. Neuro Oncol. 2014;16:1037–47.
202. Kleihues P, Louis DN, Scheithauer BW, et al. The WHO classifi-
cation of tumors of the nervous system. J Neuropathol Exp Neurol.
2002;61:215–25.
203. Taylor MD, Poppleton H, Fuller C, et al. Radial glia cells are
candidate stem cells of ependymoma. Cancer Cell.
2005;8:323–35.
204. Dolecek TA, Propp JM, Stroup NE, Kruchko C. CBTRUS statisti-
cal report: primary brain and central nervous system tumors diag-
nosed in the United States in 2005-2009. Neuro Oncol. 2012;14
Suppl 5:v1–49.
205. Ruda R, Gilbert M, Soffietti R. Ependymomas of the adult: molec-
ular biology and treatment. Curr Opin Neurol. 2008;21:754–61.
206. Kilday JP, Rahman R, Dyer S, et al. Pediatric ependymoma: bio-
logical perspectives. Mol Cancer Res. 2009;7:765–86.
207. Johnson RA, Wright KD, Poppleton H, et al. Cross-species
genomics matches driver mutations and cell compartments to
model ependymoma. Nature. 2010;466:632–6.
208. Mack SC, Taylor MD. The genetic and epigenetic basis of ependy-
moma. Childs Nerv Syst. 2009;25:1195–201.
690
209. Witt H, Mack SC, Ryzhova M, et al. Delineation of two clinically
and molecularly distinct subgroups of posterior fossa ependy-
moma. Cancer Cell. 2011;20:143–57.
210. Huang B, Starostik P, Kuhl J, Tonn JC, Roggendorf W. Loss of
heterozygosity on chromosome 22 in human ependymomas. Acta
Neuropathol. 2002;103:415–20.
211. Plotkin SR, O'Donnell CC, Curry WT, et al. Spinal ependymomas
in neurofibromatosis type 2: a retrospective analysis of 55 patients.
J Neurosurg Spine. 2011;14:543–7.
212. Lamszus K, Lachenmayer L, Heinemann U, et al. Molecular
genetic alterations on chromosomes 11 and 22 in ependymomas.
Int J Cancer. 2001;91:803–8.
213. Suarez-Merino B, Hubank M, Revesz T, et al. Microarray analysis
of pediatric ependymoma identifies a cluster of 112 candidate
genes including four transcripts at 22q12.1-q13.3. Neuro Oncol.
2005;7:20–31.
214. Ward S, Harding B, Wilkins P, et al. Gain of 1q and loss of 22 are
the most common changes detected by comparative genomic
hybridisation in paediatric ependymoma. Genes Chromosomes
Cancer. 2001;32:59–66.
215. Parker M, Mohankumar KM, Punchihewa C, et al. C11orf95-
RELA fusions drive oncogenic NF-kappaB signalling in ependy-
moma. Nature. 2014;506:451–5.
216. Mendrzyk F, Korshunov A, Benner A, et al. Identification of gains
on 1q and epidermal growth factor receptor overexpression as
independent prognostic markers in intracranial ependymoma. Clin
Cancer Res. 2006;12:2070–9.
217. Senetta R, Miracco C, Lanzafame S, et al. Epidermal growth fac-
tor receptor and caveolin-1 coexpression identifies adult supraten-
torial ependymomas with rapid unfavorable outcomes. Neuro
Oncol. 2011;13:176–83.
218. Diedrich U, Soja S, Behnke J, Zoll B. Amplification of the c-erbB
oncogene is associated with malignancy in primary tumours of
neuroepithelial tissue. J Neurol. 1991;238:221–4.
219. Mack SC, Witt H, Piro RM, et al. Epigenomic alterations define
lethal CIMP-positive ependymomas of infancy. Nature.
2014;506:445–50.
220. Dirks PB, Hubbard SL, Murakami M, Rutka JT. Cyclin and
cyclin-dependent kinase expression in human astrocytoma cell
lines. J Neuropathol Exp Neurol. 1997;56:291–300.
221. Malumbres M, Barbacid M. To cycle or not to cycle: a critical
decision in cancer. Nat Rev Cancer. 2001;1:222–31.
222. Ivanchuk SM, Rutka JT. The cell cycle: accelerators, brakes, and
checkpoints. Neurosurgery. 2004;54:692–9.
223. Malumbres M. Physiological relevance of cell cycle kinases.
Physiol Rev. 2011;91:973–1007.
224. Kandoth C, McLellan MD, Vandin F, et al. Mutational landscape
and significance across 12 major cancer types. Nature. 2013;
502:333–9.
225. Muller PA, Vousden KH. Mutant p53 in cancer: new functions and
therapeutic opportunities. Cancer Cell. 2014;25:304–17.
226. Zerdoumi Y, Aury-Landas J, Bonaiti-Pellie C, et al. Drastic effect
of germ-line TP53 missense mutations in Li-Fraumeni patients.
Hum Mutat. 2013;34:453–61.
227. Stewart CL, Soria AM, Hamel PA. Integration of the pRB and p53
cell cycle control pathways. J Neurooncol. 2001;51:183–204.
228. Malkin D. The role of p53 in human cancer. J Neurooncol.
2001;51:231–43.
229. Marine JC, Lozano G. Mdm2-mediated ubiquitylation: p53 and
beyond. Cell Death Differ. 2010;17:93–102.
230. Shieh SY, Ikeda M, Taya Y, Prives C. DNA damage-induced
phosphorylation of p53 alleviates inhibition by MDM2. Cell.
1997;91:325–34.
231. Siliciano JD, Canman CE, Taya Y, et al. DNA damage induces
phosphorylation of the amino terminus of p53. Genes Dev.
1997;11:3471–81.
D. Coluccia et al.
232. Kamijo T, Weber JD, Zambetti G, et al. Functional and physical
interactions of the ARF tumor suppressor with p53 and Mdm2.
Proc Natl Acad Sci U S A. 1998;95:8292–7.
233. Honda R, Yasuda H. Association of p19(ARF) with Mdm2 inhib-
its ubiquitin ligase activity of Mdm2 for tumor suppressor p53.
EMBO J. 1999;18:22–7.
234. Pomerantz J, Schreiber-Agus N, Liegeois NJ, et al. The Ink4a
tumor suppressor gene product, p19Arf, interacts with MDM2 and
neutralizes MDM2's inhibition of p53. Cell. 1998;92:713–23.
235. Besson A, Yong VW. Mitogenic signaling and the relationship to
cell cycle regulation in astrocytomas. J Neurooncol. 2001;
51:245–64.
236. Nakamura M, Yonekawa Y, Kleihues P, Ohgaki H. Promoter
hypermethylation of the RB1 gene in glioblastomas. Lab Invest.
2001;81:77–82.
237. Costello JF, Plass C, Arap W, et al. Cyclin-dependent kinase 6
(CDK6) amplification in human gliomas identified using two-
dimensional separation of genomic DNA. Cancer Res. 1997;
57:1250–4.
238. Riemenschneider MJ, Buschges R, Wolter M, et al. Amplification
and overexpression of the MDM4 (MDMX) gene from 1q32 in a
subset of malignant gliomas without TP53 mutation or MDM2
amplification. Cancer Res. 1999;59:6091–6.
239. Ohgaki H, Kleihues P. Genetic alterations and signaling pathways
in the evolution of gliomas. Cancer Sci. 2009;100:2235–41.
240. Holland EC, Hively WP, Gallo V, Varmus HE. Modeling muta-
tions in the G1 arrest pathway in human gliomas: overexpression
of CDK4 but not loss of INK4a-ARF induces hyperploidy in cul-
tured mouse astrocytes. Genes Dev. 1998;12:3644–9.
241. Huang H, Colella S, Kurrer M, et al. Gene expression profiling of
low-grade diffuse astrocytomas by cDNA arrays. Cancer Res.
2000;60:6868–74.
242. Huszthy PC, Daphu I, Niclou SP, et al. In vivo models of primary
brain tumors: pitfalls and perspectives. Neuro Oncol. 2012;14:
979–93.
243. Beier D, Hau P, Proescholdt M, et al. CD133(+) and CD133(-) glio-
blastoma-derived cancer stem cells show differential growth charac-
teristics and molecular profiles. Cancer Res. 2007;67:4010–5.
244. Burkhard C, Di Patre PL, Schuler D, et al. A population-based
study of the incidence and survival rates in patients with pilocytic
astrocytoma. J Neurosurg. 2003;98:1170–4.
245. Theeler BJ, Ellezam B, Sadighi ZS, et al. Adult pilocytic astrocy-
tomas: clinical features and molecular analysis. Neuro Oncol.
2014;16:841–7.
246. Ogiwara H, Bowman RM, Tomita T. Long-term follow-up of
pediatric benign cerebellar astrocytomas. Neurosurgery.
2012;70:40–7.
247. Jones DT, Ichimura K, Liu L, et al. Genomic analysis of pilocytic
astrocytomas at 0.97 Mb resolution shows an increasing tendency
toward chromosomal copy number change with age. J Neuropathol
Exp Neurol. 2006;65:1049–58.
248. Jones DT, Gronych J, Lichter P, Witt O, Pfister SM. MAPK path-
way activation in pilocytic astrocytoma. Cell Mol Life Sci.
2012;69:1799–811.
249. Jones DT, Hutter B, Jager N, et al. Recurrent somatic alterations
of FGFR1 and NTRK2 in pilocytic astrocytoma. Nat Genet.
2013;45:927–32.
250. Pfister S, Janzarik WG, Remke M, et al. BRAF gene duplication
constitutes a mechanism of MAPK pathway activation in low-
grade astrocytomas. J Clin Invest. 2008;118:1739–49.
251. Horbinski C, Nikiforova MN, Hagenkord JM, Hamilton RL,
Pollack IF. Interplay among BRAF, p16, p53, and MIB1 in pediat-
ric low-grade gliomas. Neuro Oncol. 2012;14:777–89.
252. Newton HB. Molecular neuro-oncology and the development of
targeted therapeutic strategies for brain tumors. Part 3: brain
tumor invasiveness. Expert Rev Anticancer Ther. 2004;4:803–21.
35 Molecular Biology of Human Brain Tumors
253. Cuddapah VA, Robel S, Watkins S, Sontheimer H. A neurocentric
perspective on glioma invasion. Nat Rev Neurosci.
2014;15:455–65.
254. Raftopoulou M, Etienne-Manneville S, Self A, Nicholls S, Hall
A. Regulation of cell migration by the C2 domain of the tumor
suppressor PTEN. Science. 2004;303:1179–81.
255. Ridley AJ, Schwartz MA, Burridge K, et al. Cell migration: inte-
grating signals from front to back. Science. 2003;302:1704–9.
256. Beadle C, Assanah MC, Monzo P, et al. The role of myosin II in
glioma invasion of the brain. Mol Biol Cell. 2008;19:3357–68.
257. Terakawa Y, Agnihotri S, Golbourn B, et al. The role of drebrin in
glioma migration and invasion. Exp Cell Res. 2013;319:517–28.
258. Abbadi S, Rodarte JJ, Abutaleb A, et al. Glucose-6-phosphatase is
a key metabolic regulator of glioblastoma invasion. Mol Cancer
Res. 2014;12:1547–59.
259. Watkins S, Sontheimer H. Hydrodynamic cellular volume changes
enable glioma cell invasion. J Neurosci. 2011;31:17250–9.
260. Garzon-Muvdi T, Schiapparelli P, ap Rhys C, et al. Regulation of
brain tumor dispersal by NKCC1 through a novel role in focal
adhesion regulation. PLoS Biol. 2012;10:e1001320.
261. Haas BR, Sontheimer H. Inhibition of the sodium-potassium-
chloride cotransporter isoform-1 reduces glioma invasion. Cancer
Res. 2010;70:5597–606.
262. Cuddapah VA, Sontheimer H. Molecular interaction and func-
tional regulation of ClC-3 by Ca2+/calmodulin-dependent protein
kinase II (CaMKII) in human malignant glioma. J Biol Chem.
2010;285:11188–96.
263. Preusser M, de Ribaupierre S, Wohrer A, et al. Current concepts
and management of glioblastoma. Ann Neurol. 2011;70:9–21.
264. Giese A, Westphal M. Glioma invasion in the central nervous sys-
tem. Neurosurgery. 1996;39:235–50.
265. Hsieh WT, Yeh WL, Cheng RY, et al. Exogenous endothelin-1
induces cell migration and matrix metalloproteinase expression in
U251 human glioblastoma multiforme. J Neurooncol. 2014;
118:257–69.
266. Lyons SA, Chung WJ, Weaver AK, Ogunrinu T, Sontheimer
H. Autocrine glutamate signaling promotes glioma cell invasion.
Cancer Res. 2007;67:9463–71.
267. Guha A, Mukherjee J. Advances in the biology of astrocytomas.
Curr Opin Neurol. 2004;17:655–62.
268. Rao RD, James CD. Altered molecular pathways in gliomas: an
overview of clinically relevant issues. Semin Oncol. 2004;31:
595–604.
269. Sahai E, Marshall CJ. Differing modes of tumour cell invasion
have distinct requirements for Rho/ROCK signalling and extracel-
lular proteolysis. Nat Cell Biol. 2003;5:711–9.
270. Seol HJ, Chang JH, Yamamoto J, et al. Overexpression of CD99
Increases the Migration and Invasiveness of Human Malignant
Glioma Cells. Genes Cancer. 2012;3:535–49.
271. Reymond N, Im JH, Garg R, et al. Cdc42 promotes transendothe-
lial migration of cancer cells through beta1 integrin. J Cell Biol.
2012;199:653–68.
272. Ridley AJ, Hall A. Distinct patterns of actin organization regulated
by the small GTP-binding proteins Rac and Rho. Cold Spring
Harb Symp Quant Biol. 1992;57:661–71.
273. Nobes CD, Hall A. Rho GTPases control polarity, protrusion,
and adhesion during cell movement. J Cell Biol. 1999;144:
1235–44.
274. Bouzahzah B, Albanese C, Ahmed F, et al. Rho family GTPases
regulate mammary epithelium cell growth and metastasis through
distinguishable pathways. Mol Med. 2001;7:816–30.
275. Senger DL, Tudan C, Guiot M-C, et al. Suppression of Rac activ-
ity induces apoptosis of human glioma cells but not normal human
astrocytes. Cancer Res. 2002;62:2131–40.
276. Salhia B, Rutten F, Nakada M, et al. Inhibition of Rho-kinase
affects astrocytoma morphology, motility, and invasion through
activation of Rac1. Cancer Res. 2005;65:8792–800.
691
277. Brem S. The role of vascular proliferation in the growth of brain
tumors. Clin Neurosurg. 1976;23:440–53.
278. Plate KH, Breier G, Risau W. Molecular mechanisms of develop-
mental and tumor angiogenesis. Brain Pathol. 1994;4:207–18.
279. Plate KH, Breier G, Weich HA, Risau W. Vascular endothelial
growth factor is a potential tumour angiogenesis factor in human
gliomas in vivo. Nature. 1992;359:845–8.
280. Jain RK, di Tomaso E, Duda DG, et al. Angiogenesis in brain
tumours. Nat Rev Neurosci. 2007;8:610–22.
281. Hicklin DJ, Ellis LM. Role of the vascular endothelial growth fac-
tor pathway in tumor growth and angiogenesis. J Clin Oncol.
2005;23:1011–27.
282. Yuan F, Chen Y, Dellian M, et al. Time-dependent vascular regres-
sion and permeability changes in established human tumor xeno-
grafts induced by an anti-vascular endothelial growth factor/
vascular permeability factor antibody. Proc Natl Acad Sci U S A.
1996;93:14765–70.
283. Benjamin LE, Keshet E. Conditional switching of vascular endo-
thelial growth factor (VEGF) expression in tumors: induction of
endothelial cell shedding and regression of hemangioblastoma-
like vessels by VEGF withdrawal. Proc Natl Acad Sci U S A.
1997;94:8761–6.
284. Leung DW, Cachianes G, Kuang WJ, Goeddel DV, Ferrara
N. Vascular endothelial growth factor is a secreted angiogenic
mitogen. Science. 1989;246:1306–9.
285. Harrigan MR. Angiogenic factors in the central nervous system.
Neurosurgery. 2003;53:639–60.
286. Jansen M, de Witt Hamer PC, Witmer AN, Troost D, van Noorden
CJF. Current perspectives on antiangiogenesis strategies in the
treatment of malignant gliomas. Brain Res Brain Res Rev.
2004;45:143–63.
287. Kargiotis O, Rao JS, Kyritsis AP. Mechanisms of angiogenesis in
gliomas. J Neurooncol. 2006;78:281–93.
288. Hiratsuka S, Minowa O, Kuno J, Noda T, Shibuya M. Flt-1 lacking
the tyrosine kinase domain is sufficient for normal development
and angiogenesis in mice. Proc Natl Acad Sci U S A.
1998;95:9349–54.
289. Shweiki D, Itin A, Soffer D, Keshet E. Vascular endothelial growth
factor induced by hypoxia may mediate hypoxia-initiated angio-
genesis. Nature. 1992;359:843–5.
290. Weindel K, Moringlane JR, Marme D, Weich HA. Detection and
quantification of vascular endothelial growth factor/vascular
permeability factor in brain tumor tissue and cyst fluid: the key to
angiogenesis? Neurosurgery. 1994;35:439–48.
291. Plate KH, Breier G, Weich HA, Mennel HD, Risau W. Vascular
endothelial growth factor and glioma angiogenesis: coordinate
induction of VEGF receptors, distribution of VEGF protein and
possible in vivo regulatory mechanisms. Int J Cancer.
1994;59:520–9.
292. Forsythe JA, Jiang BH, Iyer NV, et al. Activation of vascular endo-
thelial growth factor gene transcription by hypoxia-inducible fac-
tor 1. Mol Cell Biol. 1996;16:4604–13.
293. Semenza GL. HIF-1 and tumor progression: pathophysiology and
therapeutics. Trends Mol Med. 2002;8:62–7.
294. May D, Itin A, Gal O, et al. Ero1-L alpha plays a key role in a HIF-
1-mediated pathway to improve disulfide bond formation and
VEGF secretion under hypoxia: implication for cancer. Oncogene.
2005;24:1011–20.
295. Lobov IB, Brooks PC, Lang RA. Angiopoietin-2 displays VEGF-
dependent modulation of capillary structure and endothelial cell
survival in vivo. Proc Natl Acad Sci U S A. 2002;99:11205–10.
296. Koga K, Todaka T, Morioka M, et al. Expression of angiopoietin-
2 in human glioma cells and its role for angiogenesis. Cancer Res.
2001;61:6248–54.
297. Friedman HS, Prados MD, Wen PY, et al. Bevacizumab alone and
in combination with irinotecan in recurrent glioblastoma. J Clin
Oncol. 2009;27:4733–40.
692
298. Kreisl TN, Kim L, Moore K, et al. Phase II trial of single-agent beva-
cizumab followed by bevacizumab plus irinotecan at tumor progres-
sion in recurrent glioblastoma. J Clin Oncol. 2009;27:740–5.
299. Chinot OL, Wick W, Mason W, et al. Bevacizumab plus
radiotherapy-temozolomide for newly diagnosed glioblastoma. N
Engl J Med. 2014;370:709–22.
300. Gilbert MR, Dignam JJ, Armstrong TS, et al. A randomized trial
of bevacizumab for newly diagnosed glioblastoma. N Engl J Med.
2014;370:699–708.
301. Kopan R, Ilagan MX. The canonical Notch signaling pathway:
unfolding the activation mechanism. Cell. 2009;137:216–33.
302. Artavanis-Tsakonas S, Rand MD, Lake RJ. Notch signaling: cell
fate control and signal integration in development. Science.
1999;284:770–6.
303. Lasky JL, Wu H. Notch signaling, brain development, and human
disease. Pediatr Res. 2005;57:109.
304. Samsioe A, Feinstein R, Saade G, et al. Intrauterine death, fetal
malformation, and delayed pregnancy in Ljungan virus-infected
mice. Birth Defects Res B Dev Reprod Toxicol. 2006;77:251–6.
305. Purow BW, Sundaresan TK, Burdick MJ, et al. Notch-1 regulates
transcription of the epidermal growth factor receptor through p53.
Carcinogenesis. 2008;29:918–25.
306. Radtke F, Raj K. The role of Notch in tumorigenesis: oncogene or
tumour suppressor? Nat Rev Cancer. 2003;3:756–67.
307. Sjolund J, Manetopoulos C, Stockhausen M-T, Axelson H. The
Notch pathway in cancer: differentiation gone awry. Eur J Cancer.
2005;41:2620–9.
308. Weng AP, Aster JC. Multiple niches for Notch in cancer: context
is everything. Curr Opin Genet Dev. 2004;14:48–54.
309. Kageyama R, Ohtsuka T, Hatakeyama J, Ohsawa R. Roles of
bHLH genes in neural stem cell differentiation. Exp Cell Res.
2005;306:343–8.
310. Hatakeyama J, Sakamoto S, Kageyama R. Hes1 and Hes5 regulate
the development of the cranial and spinal nerve systems. Dev
Neurosci. 2006;28:92–101.
311. Kanamori M, Kawaguchi T, Nigro JM, et al. Contribution of
Notch signaling activation to human glioblastoma multiforme.
J Neurosurg. 2007;106:417–27.
312. Purow BW, Haque RM, Noel MW, et al. Expression of Notch-1
and its ligands, Delta-like-1 and Jagged-1, is critical for glioma
cell survival and proliferation. Cancer Res. 2005;65:2353–63.
313. Zhu TS, Costello MA, Talsma CE, et al. Endothelial cells create a
stem cell niche in glioblastoma by providing NOTCH ligands that
nurture self-renewal of cancer stem-like cells. Cancer Res.
2011;71:6061–72.
314. Wang J, Wakeman TP, Lathia JD, et al. Notch promotes radioresis-
tance of glioma stem cells. Stem Cells. 2010;28:17–28.
315. Gilbert CA, Daou MC, Moser RP, Ross AH. Gamma-secretase
inhibitors enhance temozolomide treatment of human gliomas by
inhibiting neurosphere repopulation and xenograft recurrence.
Cancer Res. 2010;70:6870–9.
316. Saito N, Fu J, Zheng S, et al. A high Notch pathway activation pre-
dicts response to gamma secretase inhibitors in proneural subtype of
glioma tumor-initiating cells. Stem Cells. 2014;32:301–12.
317. Fan X, Mikolaenko I, Elhassan I, et al. Notch1 and notch2 have
opposite effects on embryonal brain tumor growth. Cancer Res.
2004;64:7787–93.
318. Hallahan AR, Pritchard JI, Hansen S, et al. The SmoA1 mouse
model reveals that notch signaling is critical for the growth and
survival of Sonic Hedgehog-induced medulloblastomas. Cancer
Res. 2004;64:7794–800.
319. Ingram WJ, McCue KI, Tran TH, Hallahan AR, Wainwright
BJ. Sonic Hedgehog regulates Hes1 through a novel mechanism
that is independent of canonical Notch pathway signalling.
Oncogene. 2008;27:1489–500.
D. Coluccia et al.
320. Fan X, Matsui W, Khaki L, et al. Notch pathway inhibition
depletes stem-like cells and blocks engraftment in embryonal
brain tumors. Cancer Res. 2006;66:7445–52.
321. Wang Q, Li H, Liu N, et al. Correlative analyses of notch signaling
with resveratrol-induced differentiation and apoptosis of human
medulloblastoma cells. Neurosci Lett. 2008;438:168–73.
322. Hatton BA, Villavicencio EH, Pritchard J, et al. Notch signaling is
not essential in Sonic Hedgehog-activated medulloblastoma.
Oncogene. 2010;29:3865–72.
323. Julian E, Dave RK, Robson JP, Hallahan AR, Wainwright BJ.
Canonical Notch signaling is not required for the growth of
Hedgehog pathway-induced medulloblastoma. Oncogene. 2010;
29:3465–76.
324. Palm T, Figarella-Branger D, Chapon F, et al. Expression profiling
of ependymomas unravels localization and tumor grade-specific
tumorigenesis. Cancer. 2009;115:3955–68.
325. Puget S, Grill J, Valent A, et al. Candidate genes on chromosome
9q33-34 involved in the progression of childhood ependymomas.
J Clin Oncol. 2009;27:1884–92.
326. Villavicencio EH, Walterhouse DO, Iannaccone PM. The Sonic
Hedgehog-Patched-Gli pathway in human development and disease.
Am J Hum Genet. 2000;67:1047–54.
327. Varjosalo M, Taipale J. Hedgehog signaling. J Cell Sci.
2007;120:3–6.
328. Lee Y, Kawagoe R, Sasai K, et al. Loss of suppressor-of-fused
function promotes tumorigenesis. Oncogene. 2007;26:6442–7.
329. Dahmane N, Sanchez P, Gitton Y, et al. The Sonic Hedgehog-Gli
pathway regulates dorsal brain growth and tumorigenesis.
Development. 2001;128:5201–12.
330. Shahi MH, Rey JA, Castresana JS. The Sonic Hedgehog-GLI1
signaling pathway in brain tumor development. Expert Opin Ther
Targets. 2012;16:1227–38.
331. Leung C, Lingbeek M, Shakhova O, et al. Bmi1 is essential for
cerebellar development and is overexpressed in human medullo-
blastomas. Nature. 2004;428:337–41.
332. Wang X, Venugopal C, Manoranjan B, et al. Sonic Hedgehog
regulates Bmi1 in human medulloblastoma brain tumor-initiating
cells. Oncogene. 2012;31:187–99.
333. Pomeroy SL, Tamayo P, Gaasenbeek M, et al. Prediction of central
nervous system embryonal tumour outcome based on gene expres-
sion. Nature. 2002;415:436–42.
334. Bale AE, Yu KP. The hedgehog pathway and basal cell carcino-
mas. Hum Mol Genet. 2001;10:757–62.
335. Kool M, Jones DT, Jager N, et al. Genome sequencing of SHH
medulloblastoma predicts genotype-related response to smooth-
ened inhibition. Cancer Cell. 2014;25:393–405.
336. Kinzler KW, Bigner SH, Bigner DD, et al. Identification of an
amplified, highly expressed gene in a human glioma. Science.
1987;236:70–3.
337. Yan GN, Yang L, Lv YF, et al. Endothelial cells promote stem-like
phenotype of glioma cells through activating the Hedgehog path-
way. J Pathol. 2014;234:11–22.
338. Takezaki T, Hide T, Takanaga H, et al. Essential role of the
Hedgehog signaling pathway in human glioma-initiating cells.
Cancer Sci. 2011;102:1306–12.
339. Hadden MK. Hedgehog pathway inhibitors: a patent review
(2009--present). Expert Opin Ther Pat. 2013;23:345–61.
340. Yauch RL, Dijkgraaf GJ, Alicke B, et al. Smoothened mutation
confers resistance to a Hedgehog pathway inhibitor in medullo-
blastoma. Science. 2009;326:572–4.
341. Buonamici S, Williams J, Morrissey M, et al. Interfering with
resistance to smoothened antagonists by inhibition of the PI3K
pathway in medulloblastoma. Sci Transl Med. 2010;2:51ra70.
342. Niehrs C. The complex world of WNT receptor signalling. Nat
Rev Mol Cell Biol. 2012;13:767–79.
35 Molecular Biology of Human Brain Tumors
343. Klaus A, Birchmeier W. Developmental signaling in myocardial
progenitor cells: a comprehensive view of Bmp- and Wnt/beta-
catenin signaling. Pediatr Cardiol. 2009;30:609–16.
344. Li VS, Ng SS, Boersema PJ, et al. Wnt signaling through inhibi-
tion of beta-catenin degradation in an intact Axin1 complex. Cell.
2012;149:1245–56.
345. Anastas JN, Moon RT. WNT signalling pathways as therapeutic
targets in cancer. Nat Rev Cancer. 2013;13:11–26.
346. Paul I, Bhattacharya S, Chatterjee A, Ghosh MK. Current under-
standing on EGFR and Wnt/beta-catenin signaling in glioma and
their possible crosstalk. Genes Cancer. 2013;4:427–46.
347. Holland JD, Klaus A, Garratt AN, Birchmeier W. Wnt signaling in
stem and cancer stem cells. Curr Opin Cell Biol. 2013;25:
254–64.
348. Reya T, Clevers H. Wnt signalling in stem cells and cancer.
Nature. 2005;434:843–50.
349. Baeza N, Masuoka J, Kleihues P, Ohgaki H. AXIN1 mutations but
not deletions in cerebellar medulloblastomas. Oncogene.
2003;22:632–6.
350. Meng X, Poon R, Zhang X, et al. Suppressor of fused negatively
regulates beta-catenin signaling. J Biol Chem. 2001;276:40113–9.
351. Taylor MD, Zhang X, Liu L, et al. Failure of a medulloblastoma-
derived mutant of SUFU to suppress WNT signaling. Oncogene.
2004;23:4577–83.
352. Rathod SS, Rani SB, Khan M, Muzumdar D, Shiras A. Tumor
suppressive miRNA-34a suppresses cell proliferation and tumor
growth of glioma stem cells by targeting Akt and Wnt signaling
pathways. FEBS Open Bio. 2014;4:485–95.
353. Cimmino F, Scoppettuolo MN, Carotenuto M, et al. Norcantharidin
impairs medulloblastoma growth by inhibition of Wnt/beta-
catenin signaling. J Neurooncol. 2012;106:59–70.
354. Kahn M. Can we safely target the WNT pathway? Nat Rev Drug
Discov. 2014;13:513–32.
355. Calabrese C, Poppleton H, Kocak M, et al. A perivascular niche
for brain tumor stem cells. Cancer Cell. 2007;11:69–82.
356. Reya T, Morrison SJ, Clarke MF, Weissman IL. Stem cells, cancer,
and cancer stem cells. Nature. 2001;414:105–11.
357. Temple S. Stem cell plasticity—building the brain of our dreams.
Nat Rev Neurosci. 2001;2:513–20.
358. Son MJ, Woolard K, Nam DH, Lee J, Fine HA. SSEA-1 is an
enrichment marker for tumor-initiating cells in human glioblas-
toma. Cell Stem Cell. 2009;4:440–52.
359. Anido J, Saez-Borderias A, Gonzalez-Junca A, et al. TGF-beta
receptor inhibitors target the CD44(high)/Id1(high) glioma-
initiating cell population in human glioblastoma. Cancer Cell.
2010;18:655–68.
360. Lathia JD, Gallagher J, Heddleston JM, et al. Integrin alpha 6
regulates glioblastoma stem cells. Cell Stem Cell.
2010;6:421–32.
361. Nicolis SK. Cancer stem cells and “stemness” genes in neuro-
oncology. Neurobiol Dis. 2007;25:217–29.
362. Gargiulo G, Cesaroni M, Serresi M, et al. In vivo RNAi screen for
BMI1 targets identifies TGF-beta/BMP-ER stress pathways as
key regulators of neural- and malignant glioma-stem cell homeo-
stasis. Cancer Cell. 2013;23:660–76.
363. Dirks PB. Brain tumor stem cells: the cancer stem cell hypothesis
writ large. Mol Oncol. 2010;4:420–30.
364. Uchida H, Arita K, Yunoue S, et al. Role of Sonic Hedgehog sig-
naling in migration of cell lines established from CD133-positive
malignant glioma cells. J Neurooncol. 2011;104:697–704.
365. Turchi L, Debruyne DN, Almairac F, et al. Tumorigenic potential
of miR-18A* in glioma initiating cells requires NOTCH-1 signal-
ing. Stem Cells. 2013;31:1252–65.
366. Kim KH, Seol HJ, Kim EH, et al. Wnt/beta-catenin signaling is a
key downstream mediator of MET signaling in glioblastoma stem
cells. Neuro Oncol. 2013;15:161–71.
693
367. Al-Hajj M, Wicha MS, Benito-Hernandez A, Morrison SJ, Clarke
MF. Prospective identification of tumorigenic breast cancer cells.
Proc Natl Acad Sci U S A. 2003;100:3983–8.
368. Galli R, Binda E, Orfanelli U, et al. Isolation and characterization
of tumorigenic, stem-like neural precursors from human glioblas-
toma. Cancer Res. 2004;64:7011–21.
369. Gregorieff A, Pinto D, Begthel H, et al. Expression pattern of Wnt
signaling components in the adult intestine. Gastroenterology.
2005;129:626–38.
370. Hemmati HD, Nakano I, Lazareff JA, et al. Cancerous stem cells
can arise from pediatric brain tumors. Proc Natl Acad Sci U S A.
2003;100:15178–83.
371. Singh SK, Clarke ID, Hide T, Dirks PB. Cancer stem cells in nervous
system tumors. Oncogene. 2004;23:7267–73.
372. Tumbar T, Guasch G, Greco V, et al. Defining the epithelial stem
cell niche in skin. Science. 2004;303:359–63.
373. Yuan X, Curtin J, Xiong Y, et al. Isolation of cancer stem cells from
adult glioblastoma multiforme. Oncogene. 2004;23:9392–400.
374. Dirks P. Bmi1 and cell of origin determinants of brain tumor phe-
notype. Cancer Cell. 2007;12:295–7.
375. Read T-A, Fogarty MP, Markant SL, et al. Identification of CD15
as a marker for tumor-propagating cells in a mouse model of
medulloblastoma. Cancer Cell. 2009;15:135–47.
376. Ward RJ, Lee L, Graham K, et al. Multipotent CD15+ cancer stem
cells in patched-1-deficient mouse medulloblastoma. Cancer Res.
2009;69:4682–90.
377. Uchida N, Buck DW, He D, et al. Direct isolation of human central
nervous system stem cells. Proc Natl Acad Sci U S A.
2000;97:14720–5.
378. Prestegarden L, Enger PO. Cancer stem cells in the central ner-
vous system—a critical review. Cancer Res. 2010;70:8255–8.
379. Passegue E, Jamieson CHM, Ailles LE, Weissman IL. Normal and
leukemic hematopoiesis: are leukemias a stem cell disorder or a
reacquisition of stem cell characteristics? Proc Natl Acad Sci U S
A. 2003;100 Suppl 1:11842–9.
380. Quintana E, Shackleton M, Sabel MS, et al. Efficient tumour forma-
tion by single human melanoma cells. Nature. 2008;456:593–8.
381. Diamandis P, Wildenhain J, Clarke ID, et al. Chemical genetics
reveals a complex functional ground state of neural stem cells. Nat
Chem Biol. 2007;3:268–73.
382. Shapiro WR, Basler GA, Chernik NL, Posner JB. Human brain
tumor transplantation into nude mice. J Natl Cancer Inst.
1979;62:447–53.
383. Kobayashi N, Allen N, Clendenon NR, Ko LW. An improved rat
brain-tumor model. J Neurosurg. 1980;53:808–15.
384. Finkelstein SD, Black P, Nowak TP, et al. Histological character-
istics and expression of acidic and basic fibroblast growth factor
genes in intracerebral xenogeneic transplants of human glioma
cells. Neurosurgery. 1994;34:136–43.
385. Li A, Walling J, Kotliarov Y, et al. Genomic changes and gene
expression profiles reveal that established glioma cell lines are
poorly representative of primary human gliomas. Mol Cancer Res.
2008;6:21–30.
386. Gunther HS, Schmidt NO, Phillips HS, et al. Glioblastoma-
derived stem cell-enriched cultures form distinct subgroups
according to molecular and phenotypic criteria. Oncogene.
2008;27:2897–909.
387. Schulte A, Gunther HS, Phillips HS, et al. A distinct subset of
glioma cell lines with stem cell-like properties reflects the tran-
scriptional phenotype of glioblastomas and overexpresses CXCR4
as therapeutic target. Glia. 2011;59:590–602.
388. Bjerkvig R, Tonnesen A, Laerum OD, Backlund EO. Multicellular
tumor spheroids from human gliomas maintained in organ culture.
J Neurosurg. 1990;72:463–75.
389. Kleihues P, Lantos PL, Magee PN. Chemical carcinogenesis in the
nervous system. Int Rev Exp Pathol. 1976;15:153–232.
694
390. Swenberg JA, Koestner A, Wechsler W. The induction of tumors
of the nervous system in rats with intravenous methylnitrosourea
(MNU). J Neuropathol Exp Neurol. 1971;30:122.
391. Simeonova I, Huillard E. In vivo models of brain tumors: roles of
genetically engineered mouse models in understanding tumor
biology and use in preclinical studies. Cell Mol Life Sci.
2014;71:4007–26.
392. Aguzzi A, Brandner S, Isenmann S, Steinbach JP, Sure
U. Transgenic and gene disruption techniques in the study of neu-
rocarcinogenesis. Glia. 1995;15:348–64.
393. Hesselager G, Holland EC. Using mice to decipher the molecular
genetics of brain tumors. Neurosurgery. 2003;53:685–94.
394. Rajewsky K, Gu H, Kuhn R, et al. Conditional gene targeting.
J Clin Invest. 1996;98:600–3.
395. Fomchenko EI, Holland EC. Mouse models of brain tumors and
their applications in preclinical trials. Clin Cancer Res.
2006;12:5288–97.
396. Thomas KR, Capecchi MR. Site-directed mutagenesis by gene
targeting in mouse embryo-derived stem cells. Cell.
1987;51:503–12.
397. Uhrbom L, Hesselager G, Nister M, Westermark B. Induction of
brain tumors in mice using a recombinant platelet-derived growth
factor B-chain retrovirus. Cancer Res. 1998;58:5275–9.
398. Holland EC, Hively WP, DePinho RA, Varmus HE. A constitu-
tively active epidermal growth factor receptor cooperates with
disruption of G1 cell-cycle arrest pathways to induce glioma-like
lesions in mice. Genes Dev. 1998;12:3675–85.
399. Srivastava S, Zou ZQ, Pirollo K, Blattner W, Chang EH. Germ-
line transmission of a mutated p53 gene in a cancer-prone family
with Li-Fraumeni syndrome. Nature. 1990;348:747–9.
400. Ding H, Roncari L, Shannon P, et al. Astrocyte-specific expression
of activated p21-ras results in malignant astrocytoma formation
in a transgenic mouse model of human gliomas. Cancer Res.
2001;61:3826–36.
401. Reilly KM, Loisel DA, Bronson RT, McLaughlin ME, Jacks
T. Nf1;Trp53 mutant mice develop glioblastoma with evidence of
strain-specific effects. Nat Genet. 2000;26:109–13.
402. Weissenberger J, Steinbach JP, Malin G, et al. Development and
malignant progression of astrocytomas in GFAP-v-src transgenic
mice. Oncogene. 1997;14:2005–13.
403. Xiao A, Wu H, Pandolfi PP, Louis DN, Van Dyke T. Astrocyte
inactivation of the pRb pathway predisposes mice to malignant
astrocytoma development that is accelerated by PTEN mutation.
Cancer Cell. 2002;1:157–68.
View publication stats
D. Coluccia et al.
404. Holland EC. A mouse model for glioma: biology, pathology, and
therapeutic opportunities. Toxicol Pathol. 2000;28:171–7.
405. Marumoto T, Tashiro A, Friedmann-Morvinski D, et al.
Development of a novel mouse glioma model using lentiviral vec-
tors. Nat Med. 2009;15:110–6.
406. Klink B, Miletic H, Stieber D, et al. A novel, diffusely infiltrative
xenograft model of human anaplastic oligodendroglioma with
mutations in FUBP1, CIC, and IDH1. PLoS One. 2013;8:e59773.
407. Dai C, Celestino JC, Okada Y, et al. PDGF autocrine stimulation
dedifferentiates cultured astrocytes and induces oligodendroglio-
mas and oligoastrocytomas from neural progenitors and astrocytes
in vivo. Genes Dev. 2001;15:1913–25.
408. Kelly JJ, Blough MD, Stechishin OD, et al. Oligodendroglioma
cell lines containing t(1;19)(q10;p10). Neuro Oncol. 2010;12:
745–55.
409. Wetmore C, Eberhart DE, Curran T. The normal patched allele is
expressed in medulloblastomas from mice with heterozygous
germ-line mutation of patched. Cancer Res. 2000;60:2239–46.
410. Weiner HL, Bakst R, Hurlbert MS, et al. Induction of medullo-
blastomas in mice by Sonic Hedgehog, independent of Gli1.
Cancer Res. 2002;62:6385–9.
411. Wechsler-Reya RJ, Scott MP. Control of neuronal precursor
proliferation in the cerebellum by Sonic Hedgehog. Neuron.
1999;22:103–14.
412. Kawauchi D, Robinson G, Uziel T, et al. A mouse model of the
most aggressive subgroup of human medulloblastoma. Cancer
Cell. 2012;21:168–80.
413. Marino S, Vooijs M, van Der Gulden H, Jonkers J, Berns
A. Induction of medulloblastomas in p53-null mutant mice by
somatic inactivation of Rb in the external granular layer cells of
the cerebellum. Genes Dev. 2000;14:994–991004.
414. Gibson P, Tong Y, Robinson G, et al. Subtypes of medulloblas-
toma have distinct developmental origins. Nature. 2010;468:
1095–9.
415. Witt H, Korshunov A, Pfister SM, Milde T. Molecular approaches
to ependymoma: the next step(s). Curr Opin Neurol. 2012;
25:745–50.
416. Guan S, Shen R, Lafortune T, et al. Establishment and character-
ization of clinically relevant models of ependymoma: a true
challenge for targeted therapy. Neuro Oncol. 2011;13:748–58.
417. Milde T, Kleber S, Korshunov A, et al. A novel human high-risk
ependymoma stem cell model reveals the differentiation-inducing
potential of the histone deacetylase inhibitor Vorinostat. Acta
Neuropathol. 2011;122:637–50.