3. Typical Treatment Course for Gliomas 1. Surgery-biopsy or resection 2. Radiation with low dose temozolomide (TMZ) 3. High dose or metronomic TMZ alone 4. F/u with MRI scans every two months 5. If MRI documented progression: Avastin, repeat resection, radiosurgery, or clinical trials

7. Preop Axial T1 with Contrast

8. Pre-resection motor stimulation with Ojemann Stimulator

9. Post Resection: Motor Stimulation

10. Gliadel Wafers Placed

11. Glioblastoma: post-mortem

15. Targeting the Perinecrotic Rim in Glioblastoma Multiforme via Modulation of the Endoplasmic Reticulum Stress Response Vascularized Periphery Perinecrotic Rim (Pseudopalisades ) Necrotic Area Thrombotic Vessel

16. Targeting the Perinecrotic Rim in Glioblastoma Multiforme via Modulation of the Endoplasmic Reticulum Stress Response

19. Targeting the Perinecrotic Rim in Glioblastoma Multiforme via Modulation of the Endoplasmic Reticulum Stress Response

20. •

21. HIV-1 Protease Inhibitors Nelfinavir and Atazanavir Induce Malignant Glioma Death by Triggering Endoplasmic Reticulum Stress

22. GRP78 LEVELS IN GLIOBLASTOMA TISSUE SECTIONS

23. TMZ increases GRP78 in glioblastoma cell lines. GRP78 Actin GRP78 Actin

24. U87 glioblastoma cells transfected with different concentrations of GRP78 siRNA and GFP siRNA fused to rhodamine.

28. Glioma Cancer Stem Cells and ER Stress

29. Neural Stem Cells and the Origin of Gliomas Nader Sanai, M.D., Arturo Alvarez-Buylla, Ph.D., and Mitchel S. Berger, M.D.

31. x16 x48 Morphology of GCSC (D431)

32. TMZ treatment with 15% BSA Treatment in 6well plate and transfer to 96well plate for MTT analysis 2009-10-01 TMZ (uM) % O.D. at 490nm TMZ (uM) % O.D. at 490nm Conclusion: TMZ is not cytotoxic to CSC. U251 w/ 15% BSA CSC w/ 15% BSA 0 20 40 60 80 100 120 0 10 20 30 40 50 60 70 80 90 100 0 20 40 60 80 100 120 0 10 20 30 40 50 60 70 80

33. Is DMC Cytotoxic To Glioma Cancer Stem Cells (GCSC) ? U87 U251 CSC (single) CSC (sphere) DMC (uM) % O.D. at 490nm Condition: Medium +10% BSA, 48hr treatment 0 20 40 60 80 100 120 140 0 10 20 30 40 50 60 70 80 90 100

34. Does DMC Enduces ER Stress in Glioma Cancer Stem Cells (CSC) ? 1 2 3 4 5 GRP78 Chop Actin 1: No treatment 2: DMC 20uM 3: DMC 40uM 4: DMC 60uM 5: DMC 80uM

35. Does DMC Induce ER Stress in Glioma Cancer Stem Cells (CSC) ? 1 2 3 4 5 GRP78 Chop Actin Parp MGMT Conclusion: ER stress upregulated at DMC 60 uM in CSC. DMC at 60 uM reduces MGMT levels. 24hr treatment Cl. parp Parp 1: No treatment 2: DMC 20uM 3: DMC 40uM 4: DMC 60uM 5: DMC 80uM CSC-D431

40. May/2006 Dec/2006 Fibrillary Astrocytoma grade II ______________________________________________________________________________________________________________________________________ May/2008 Jun/2007

41. JAN / 2007 MAY / 2008 Recurrente Anaplastic Oligodendroglioma ______________________________________________________________________________________________________________________________________ NOV / 2008

42. Disease-free survival (6 months) ______________________________________________________________________________________________________________________________________ The median PFS rate was 48.2% for patients with GBM, 60% for patients with AA, and 66.6% for patients with AO.

46. Development of an Implantable Pump for Convection Enhanced Delivery

50. www.pharmaco-kinesis.com Convection Enhanced Trials 1. Some success in Phase I/II trials 2. No clear success in Phase III trials (Neopharm, Transmid) 3. Question: Lack of success from delivery or from drug?

55. 9/19/2008 Property of Pharmaco Kinesis Corp.

57. Fig. 8 www.pharmaco-kinesis.com Medication Storage and Delivery System Circulation pump Medication pump Medication Reservoirs Catheter Catheter Cross Section Fluid Circulation System

59. www.pharmaco-kinesis.com

60. www.pharmaco-kinesis.com

61. Fig. 3B www.pharmaco-kinesis.com

63. Cir. And Reservoir Pump ( Bartels ) Active Valve ( Bartels ) Flow Sensor ( Sensirion ) Pressure Sensor Temperature Sensor ( GE ) pH Sensor ( WPI ) Reservior ( Metal Bellows ) www.pharmaco-kinesis.com

64. www.pharmaco-kinesis.com Wireless Radio High level goals High level tasks Internal states Growth signal Intracranial pressure Tissue condition Tissue metabolism Table of parameters Circulate Inject 1 Inject 2 Inject 3 Pump Pump-valve Pump-valve Pump-valve VEGF Spectrometer Pressure sensor pH sensor Oxygen sensor Solid Tumor Microcontroller Medication Tumor Fluid

66. www.pharmaco-kinesis.com Avastin in 28-day pump Implantated IP CPT-11 D7 – D11 D14 – D118 D21 – D25 D28 – D32 1 st dose of Avastin 2nd dose of Avastin

70. U87 intra-cerebral glioma model for in vivo analysis of RCR vector-mediated suicide gene therapy Establishment of tumor 1 x 10 t.u. ACE-CD injected into tumor 4 Intraperitoneal injection of 5-FC H&E / IHC Survival analysis virus spread 2 x 10 U87 tumor cells injected into nude mice 5