Journal of Neuro-Oncology

, Volume 137, Issue 2, pp 417–427 | Cite as

Tumor microenvironment after biodegradable BCNU wafer implantation: special consideration of immune system

  • Ichiyo ShibaharaEmail author
  • Mitsuto Hanihara
  • Takashi Watanabe
  • Mitsuru Dan
  • Sumito Sato
  • Hiroki Kuroda
  • Akinori Inamura
  • Madoka Inukai
  • Atsuko Hara
  • Yoshie Yasui
  • Toshihiro Kumabe
Clinical Study


Biomaterials to treat cancers hold therapeutic potential; however, their translation to bedside treatment requires further study. The carmustine (1,3-bis (2-chloroethyl)-1-nitrosourea; BCNU) wafer, a biodegradable polymer, currently is the only drug that is able to be placed at the surgical site to treat malignant tumors. However, how this wafer affects the surrounding tumor microenvironment is not well understood to date. We retrospectively reviewed all patients with glioblastoma treated with and without BCNU wafers who underwent repeat resection at tumor recurrence. We investigated radiological imaging; the interval between the two surgeries; and immunohistochemistry of CD3, CD4, CD8, CD20, CD68, FOXP3, and PD1. We implanted BCNU wafers in 41 newly diagnosed glioblastoma patients after approval of the wafer in Japan. Of them, 14 underwent surgery at recurrence and tissue was obtained from around the wafers. The interval between the first and second surgeries ranged from 63 to 421 days. The wafer could be observed on magnetic resonance imaging at up to 226 days, whereas intraoperatively the biodegraded material of the wafer could be found at up to 421 days after the initial surgery. Immunohistochemical analysis demonstrated that CD8+ and CD68+ cells were significantly increased, but FOXP3+ cells did not increase, after wafer implantation compared to tissue from cases without wafer implantation. MRI data and immune cells, as well as interval between surgeries and immune cells, demonstrated positive correlation. These results helped us to understand the bioactivity of bioengineered materials and to establish a new approach for immunotherapy.


BCNU wafer Gliadel Bioengineering CD8 FOXP3 



We would like to thank Enago ( for the English language review. This study was founded by Japan Brain Foundation.

Compliance with ethical standards

Conflict of interest

The authors declare no potential conflict of interest.

Supplementary material

11060_2017_2733_MOESM1_ESM.docx (23 kb)
Supplementary material 1 (DOCX 23 KB)
11060_2017_2733_MOESM2_ESM.pptx (10.4 mb)
Supplementary material 2: Supplementary Figure S1. Representative MRI for Volumetric analysis. T1Gd and FLAIR from initial and pre-second surgery of Case 9 were demonstrated. The area of high intensity in FLAIR and T1Gd was measured using axial imaging by OsiriX software (Pixmeo SARL, Bernex, Switzerland). FLAIR volume and T1Gd volume were quantified based on the sum of axial area, and the ratio of FLAIR volume/T1Gd volume (F/G ratio) was used for the analysis. Supplementary Figure S2. MRI and intraoperative findings of the BCNU wafer group (Cases 1–8, 10–14). Supplementary Figure S3. The number of CD8+ VIL, CD8+ TIL, and FOXP3+ cells obtained from immunohistochemical staining of Case 17. This case underwent BCNU wafer implantation at the second surgery, but there was no increase of CD8+ VIL, and TIL at the third surgery. (PPTX 10604 KB)


  1. 1.
    Westphal M, Hilt DC, Bortey E, Delavault P, Olivares R, Warnke PC, Whittle IR, Jaaskelainen J, Ram Z (2003) A phase 3 trial of local chemotherapy with biodegradable carmustine (BCNU) wafers (Gliadel wafers) in patients with primary malignant glioma. Neuro Oncol 5(2):79–88. CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Aoki T, Nishikawa R, Sugiyama K, Nonoguchi N, Kawabata N, Mishima K, Adachi J, Kurisu K, Yamasaki F, Tominaga T, Kumabe T, Ueki K, Higuchi F, Yamamoto T, Ishikawa E, Takeshima H, Yamashita S, Arita K, Hirano H, Yamada S, Matsutani M, group NPCs (2014) A multicenter phase I/II study of the BCNU implant (Gliadel((R)) Wafer) for Japanese patients with malignant gliomas. Neurol Med Chir (Tokyo) 54 (4):290–301CrossRefGoogle Scholar
  3. 3.
    Pallud J, Audureau E, Noel G, Corns R, Lechapt-Zalcman E, Duntze J, Pavlov V, Guyotat J, Hieu PD, Le Reste PJ, Faillot T, Litre CF, Desse N, Petit A, Emery E, Voirin J, Peltier J, Caire F, Vignes JR, Barat JL, Langlois O, Dezamis E, Parraga E, Zanello M, Nader E, Lefranc M, Bauchet L, Devaux B, Menei P, Metellus P, Club de Neuro-Oncologie of the Societe Francaise de N (2015) Long-term results of carmustine wafer implantation for newly diagnosed glioblastomas: a controlled propensity-matched analysis of a French multicenter cohort. Neuro Oncol 17(12):1609–1619. CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    McGirt MJ, Than KD, Weingart JD, Chaichana KL, Attenello FJ, Olivi A, Laterra J, Kleinberg LR, Grossman SA, Brem H, Quinones-Hinojosa A (2009) Gliadel (BCNU) wafer plus concomitant temozolomide therapy after primary resection of glioblastoma multiforme. J Neurosurg 110(3):583–588. CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Affronti ML, Heery CR, Herndon JE 2nd, Rich JN, Reardon DA, Desjardins A, Vredenburgh JJ, Friedman AH, Bigner DD, Friedman HS (2009) Overall survival of newly diagnosed glioblastoma patients receiving carmustine wafers followed by radiation and concurrent temozolomide plus rotational multiagent chemotherapy. Cancer 115(15):3501–3511. CrossRefPubMedGoogle Scholar
  6. 6.
    Bock HC, Puchner MJ, Lohmann F, Schutze M, Koll S, Ketter R, Buchalla R, Rainov N, Kantelhardt SR, Rohde V, Giese A (2010) First-line treatment of malignant glioma with carmustine implants followed by concomitant radiochemotherapy: a multicenter experience. Neurosurg Rev 33(4):441–449. CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Pan E, Mitchell SB, Tsai JS (2008) A retrospective study of the safety of BCNU wafers with concurrent temozolomide and radiotherapy and adjuvant temozolomide for newly diagnosed glioblastoma patients. J Neurooncol 88(3):353–357. CrossRefPubMedGoogle Scholar
  8. 8.
    Noel G, Schott R, Froelich S, Gaub MP, Boyer P, Fischer-Lokou D, Dufour P, Kehrli P, Maitrot D (2012) Retrospective comparison of chemoradiotherapy followed by adjuvant chemotherapy, with or without prior gliadel implantation (carmustine) after initial surgery in patients with newly diagnosed high-grade gliomas. Int J Radiat Oncol Biol Phys 82(2):749–755. CrossRefPubMedGoogle Scholar
  9. 9.
    Sonoda Y, Shibahara I, Matsuda KI, Saito R, Kawataki T, Oda M, Sato Y, Sadahiro H, Nomura S, Sasajima T, Beppu T, Kanamori M, Sakurada K, Kumabe T, Tominaga T, Kinouchi H, Shimizu H, Ogasawara K, Suzuki M (2017) Opening the ventricle during surgery diminishes survival among patients with newly diagnosed glioblastoma treated with carmustine wafers: a multi-center retrospective study. J Neurooncol. CrossRefPubMedGoogle Scholar
  10. 10.
    Koshy ST, Mooney DJ (2016) Biomaterials for enhancing anti-cancer immunity. Curr Opin Biotechnol 40:1–8. CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Kim J, Li WA, Choi Y, Lewin SA, Verbeke CS, Dranoff G, Mooney DJ (2015) Injectable, spontaneously assembling, inorganic scaffolds modulate immune cells in vivo and increase vaccine efficacy. Nat Biotechnol 33(1):64–72. CrossRefPubMedGoogle Scholar
  12. 12.
    Stephan SB, Taber AM, Jileaeva I, Pegues EP, Sentman CL, Stephan MT (2015) Biopolymer implants enhance the efficacy of adoptive T-cell therapy. Nat Biotechnol 33(1):97–101. CrossRefPubMedGoogle Scholar
  13. 13.
    Gammon JM, Dold NM, Jewell CM (2016) Improving the clinical impact of biomaterials in cancer immunotherapy. Oncotarget 7(13):15421–15443. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Swartz MA, Hirosue S, Hubbell JA (2012) Engineering approaches to immunotherapy. Sci Transl Med 4(148):148rv149. CrossRefGoogle Scholar
  15. 15.
    Goldberg MS (2015) Immunoengineering: how nanotechnology can enhance cancer immunotherapy. Cell 161(2):201–204. CrossRefPubMedGoogle Scholar
  16. 16.
    Sampath P, Hanes J, DiMeco F, Tyler BM, Brat D, Pardoll DM, Brem H (1999) Paracrine immunotherapy with interleukin-2 and local chemotherapy is synergistic in the treatment of experimental brain tumors. Cancer Res 59(9):2107–2114PubMedGoogle Scholar
  17. 17.
    Sato K, Dan M, Yamamoto D, Miyajima Y, Hara A, Kumabe T (2015) Chronic phase intracranial hemorrhage caused by ruptured pseudoaneurysm induced by carmustine wafer implantation for insulo-opercular anaplastic astrocytoma: a case report. Neurol Med Chir (Tokyo) 55(11):848–851. CrossRefGoogle Scholar
  18. 18.
    Saito K, Yamasaki K, Yokogami K, Ivanova A, Takeishi G, Sato Y, Takeshima H (2016) Eosinophilic meningitis triggered by implanted Gliadel wafers: case report. J Neurosurg. CrossRefPubMedGoogle Scholar
  19. 19.
    Han S, Zhang C, Li Q, Dong J, Liu Y, Huang Y, Jiang T, Wu A (2014) Tumour-infiltrating CD4(+) and CD8(+) lymphocytes as predictors of clinical outcome in glioma. Br J Cancer 110(10):2560–2568. CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Sato E, Olson SH, Ahn J, Bundy B, Nishikawa H, Qian F, Jungbluth AA, Frosina D, Gnjatic S, Ambrosone C, Kepner J, Odunsi T, Ritter G, Lele S, Chen YT, Ohtani H, Old LJ, Odunsi K (2005) Intraepithelial CD8+ tumor-infiltrating lymphocytes and a high CD8+/regulatory T cell ratio are associated with favorable prognosis in ovarian cancer. Proc Natl Acad Sci USA 102(51):18538–18543. CrossRefPubMedGoogle Scholar
  21. 21.
    Berghoff AS, Kiesel B, Widhalm G, Rajky O, Ricken G, Wohrer A, Dieckmann K, Filipits M, Brandstetter A, Weller M, Kurscheid S, Hegi ME, Zielinski CC, Marosi C, Hainfellner JA, Preusser M, Wick W (2015) Programmed death ligand 1 expression and tumor-infiltrating lymphocytes in glioblastoma. Neuro Oncol 17(8):1064–1075. CrossRefPubMedGoogle Scholar
  22. 22.
    Chaichana KL, Jusue-Torres I, Navarro-Ramirez R, Raza SM, Pascual-Gallego M, Ibrahim A, Hernandez-Hermann M, Gomez L, Ye X, Weingart JD, Olivi A, Blakeley J, Gallia GL, Lim M, Brem H, Quinones-Hinojosa A (2014) Establishing percent resection and residual volume thresholds affecting survival and recurrence for patients with newly diagnosed intracranial glioblastoma. Neuro Oncol 16(1):113–122. CrossRefPubMedGoogle Scholar
  23. 23.
    Eseonu CI, ReFaey K, Garcia O, Raghuraman G, Quinones-Hinojosa A (2017) Volumetric Analysis of extent of resection, survival, and surgical outcomes for insular Gliomas. World Neurosurg 103:265–274. CrossRefPubMedGoogle Scholar
  24. 24.
    Kim H, Zheng S, Amini SS, Virk SM, Mikkelsen T, Brat DJ, Grimsby J, Sougnez C, Muller F, Hu J, Sloan AE, Cohen ML, Van Meir EG, Scarpace L, Laird PW, Weinstein JN, Lander ES, Gabriel S, Getz G, Meyerson M, Chin L, Barnholtz-Sloan JS, Verhaak RG (2015) Whole-genome and multisector exome sequencing of primary and post-treatment glioblastoma reveals patterns of tumor evolution. Genome Res 25(3):316–327. CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Spainhour JC, Qiu P (2016) Identification of gene-drug interactions that impact patient survival in TCGA. BMC Bioinform 17(1):409. CrossRefGoogle Scholar
  26. 26.
    Lawson HC, Sampath P, Bohan E, Park MC, Hussain N, Olivi A, Weingart J, Kleinberg L, Brem H (2007) Interstitial chemotherapy for malignant gliomas: the Johns Hopkins experience. J Neurooncol 83(1):61–70. CrossRefPubMedGoogle Scholar
  27. 27.
    Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, Belanger K, Brandes AA, Marosi C, Bogdahn U, Curschmann J, Janzer RC, Ludwin SK, Gorlia T, Allgeier A, Lacombe D, Cairncross JG, Eisenhauer E, Mirimanoff RO (2005) Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352(10):987–996. CrossRefPubMedGoogle Scholar
  28. 28.
    Gu L, Mooney DJ (2016) Biomaterials and emerging anticancer therapeutics: engineering the microenvironment. Nat Rev Cancer 16(1):56–66. CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Colen RR, Zinn PO, Hazany S, Do-Dai D, Wu JK, Yao K, Zhu JJ (2011) Magnetic resonance imaging appearance and changes on intracavitary Gliadel wafer placement: a pilot study. World J Radiol 3(11):266–272. CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Prager JM, Grenier Y, Cozzens JW, Chiowanich P, Gorey MT, Meyer JR (2000) Serial CT and MR imaging of carmustine wafers. AJNR Am J Neuroradiol 21(1):119–123PubMedGoogle Scholar
  31. 31.
    Brem H, Ewend MG, Piantadosi S, Greenhoot J, Burger PC, Sisti M (1995) The safety of interstitial chemotherapy with BCNU-loaded polymer followed by radiation therapy in the treatment of newly diagnosed malignant gliomas: phase I trial. J Neurooncol 26(2):111–123CrossRefGoogle Scholar
  32. 32.
    Brem H, Tamargo RJ, Olivi A, Pinn M, Weingart JD, Wharam M, Epstein JI (1994) Biodegradable polymers for controlled delivery of chemotherapy with and without radiation therapy in the monkey brain. J Neurosurg 80(2):283–290. CrossRefPubMedGoogle Scholar
  33. 33.
    Kim YH, Jung TY, Jung S, Jang WY, Moon KS, Kim IY, Lee MC, Lee JJ (2012) Tumour-infiltrating T-cell subpopulations in glioblastomas. Br J Neurosurg 26(1):21–27. CrossRefPubMedGoogle Scholar
  34. 34.
    Sayour EJ, McLendon P, McLendon R, De Leon G, Reynolds R, Kresak J, Sampson JH, Mitchell DA (2015) Increased proportion of FoxP3+ regulatory T cells in tumor infiltrating lymphocytes is associated with tumor recurrence and reduced survival in patients with glioblastoma. Cancer Immunol Immunother 64(4):419–427. CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Rutledge WC, Kong J, Gao J, Gutman DA, Cooper LA, Appin C, Park Y, Scarpace L, Mikkelsen T, Cohen ML, Aldape KD, McLendon RE, Lehman NL, Miller CR, Schniederjan MJ, Brennan CW, Saltz JH, Moreno CS, Brat DJ (2013) Tumor-infiltrating lymphocytes in glioblastoma are associated with specific genomic alterations and related to transcriptional class. Clin Cancer Res 19(18):4951–4960. CrossRefPubMedGoogle Scholar
  36. 36.
    Aarntzen EH, Srinivas M, Radu CG, Punt CJ, Boerman OC, Figdor CG, Oyen WJ, de Vries IJ (2013) In vivo imaging of therapy-induced anti-cancer immune responses in humans. Cell Mol Life Sci 70(13):2237–2257. CrossRefPubMedGoogle Scholar
  37. 37.
    Mahmoud SM, Paish EC, Powe DG, Macmillan RD, Grainge MJ, Lee AH, Ellis IO, Green AR (2011) Tumor-infiltrating CD8+ lymphocytes predict clinical outcome in breast cancer. J Clin Oncol 29(15):1949–1955. CrossRefPubMedGoogle Scholar
  38. 38.
    Reits EA, Hodge JW, Herberts CA, Groothuis TA, Chakraborty M, Wansley EK, Camphausen K, Luiten RM, de Ru AH, Neijssen J, Griekspoor A, Mesman E, Verreck FA, Spits H, Schlom J, van Veelen P, Neefjes JJ (2006) Radiation modulates the peptide repertoire, enhances MHC class I expression, and induces successful antitumor immunotherapy. J Exp Med 203(5):1259–1271. CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Merlo A, Casalini P, Carcangiu ML, Malventano C, Triulzi T, Menard S, Tagliabue E, Balsari A (2009) FOXP3 expression and overall survival in breast cancer. J Clin Oncol 27(11):1746–1752. CrossRefPubMedGoogle Scholar
  40. 40.
    Perrone G, Ruffini PA, Catalano V, Spino C, Santini D, Muretto P, Spoto C, Zingaretti C, Sisti V, Alessandroni P, Giordani P, Cicetti A, D’Emidio S, Morini S, Ruzzo A, Magnani M, Tonini G, Rabitti C, Graziano F (2008) Intratumoural FOXP3-positive regulatory T cells are associated with adverse prognosis in radically resected gastric cancer. Eur J Cancer 44(13):1875–1882. CrossRefPubMedGoogle Scholar
  41. 41.
    Yue Q, Zhang X, Ye HX, Wang Y, Du ZG, Yao Y, Mao Y (2014) The prognostic value of Foxp3+ tumor-infiltrating lymphocytes in patients with glioblastoma. J Neurooncol 116(2):251–259. CrossRefPubMedGoogle Scholar
  42. 42.
    Chowdhary SA, Ryken T, Newton HB (2015) Survival outcomes and safety of carmustine wafers in the treatment of high-grade gliomas: a meta-analysis. J Neurooncol 122(2):367–382. CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Chaichana KL, Zadnik P, Weingart JD, Olivi A, Gallia GL, Blakeley J, Lim M, Brem H, Quinones-Hinojosa A (2013) Multiple resections for patients with glioblastoma: prolonging survival. J Neurosurg 118(4):812–820. CrossRefPubMedGoogle Scholar
  44. 44.
    Ringel F, Pape H, Sabel M, Krex D, Bock HC, Misch M, Weyerbrock A, Westermaier T, Senft C, Schucht P, Meyer B, Simon M, group SNs (2016) Clinical benefit from resection of recurrent glioblastomas: results of a multicenter study including 503 patients with recurrent glioblastomas undergoing surgical resection. Neuro Oncol 18 (1):96–104. CrossRefPubMedGoogle Scholar
  45. 45.
    Anderson JM, Rodriguez A, Chang DT (2008) Foreign body reaction to biomaterials. Semin Immunol 20(2):86–100. CrossRefPubMedGoogle Scholar
  46. 46.
    Klopfleisch R, Jung F (2017) The pathology of the foreign body reaction against biomaterials. J Biomed Mater Res A 105(3):927–940. CrossRefPubMedGoogle Scholar
  47. 47.
    Domb AJ, Rock M, Schwartz J, Perkin C, Yipchuk G, Broxup B, Villemure JG (1994) Metabolic disposition and elimination studies of a radiolabelled biodegradable polymeric implant in the rat brain. Biomaterials 15(9):681–688CrossRefGoogle Scholar
  48. 48.
    Kleinberg L (2012) Polifeprosan 20, 3.85% carmustine slow-release wafer in malignant glioma: evidence for role in era of standard adjuvant temozolomide. Core Evid 7:115–130. CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Ichiyo Shibahara
    • 1
    Email author return OK on get
  • Mitsuto Hanihara
    • 1
  • Takashi Watanabe
    • 2
  • Mitsuru Dan
    • 1
  • Sumito Sato
    • 1
  • Hiroki Kuroda
    • 1
  • Akinori Inamura
    • 1
  • Madoka Inukai
    • 3
  • Atsuko Hara
    • 3
  • Yoshie Yasui
    • 1
  • Toshihiro Kumabe
    • 1
  1. 1.Department of NeurosurgeryKitasato University School of MedicineSagamiharaJapan
  2. 2.Department of General Internal MedicineJCHO Sendai HospitalSendaiJapan
  3. 3.Department of PathologyKitasato University School of MedicineSagamiharaJapan

Personalised recommendations