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Pöhlmann J, Weller M, Marcellusi A, Grabe-Heyne K, Krott-Coi L, Rabar S, Pollock RF. High costs, low quality of life, reduced survival, and room for improving treatment: an analysis of burden and unmet needs in glioma. Front Oncol 2024; 14:1368606. [PMID: 38571509 PMCID: PMC10987841 DOI: 10.3389/fonc.2024.1368606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 02/28/2024] [Indexed: 04/05/2024] Open
Abstract
Gliomas are a group of heterogeneous tumors that account for substantial morbidity, mortality, and costs to patients and healthcare systems globally. Survival varies considerably by grade, histology, biomarkers, and genetic alterations such as IDH mutations and MGMT promoter methylation, and treatment, but is poor for some grades and histologies, with many patients with glioblastoma surviving less than a year from diagnosis. The present review provides an introduction to glioma, including its classification, epidemiology, economic and humanistic burden, as well as treatment options. Another focus is on treatment recommendations for IDH-mutant astrocytoma, IDH-mutant oligodendroglioma, and glioblastoma, which were synthesized from recent guidelines. While recommendations are nuanced and reflect the complexity of the disease, maximum safe resection is typically the first step in treatment, followed by radiotherapy and/or chemotherapy using temozolomide or procarbazine, lomustine, and vincristine. Immunotherapies and targeted therapies currently have only a limited role due to disappointing clinical trial results, including in recurrent glioblastoma, for which the nitrosourea lomustine remains the de facto standard of care. The lack of treatment options is compounded by frequently suboptimal clinical practice, in which patients do not receive adequate therapy after resection, including delayed, shortened, or discontinued radiotherapy and chemotherapy courses due to treatment side effects. These unmet needs will require significant efforts to address, including a continued search for novel treatment options, increased awareness of clinical guidelines, improved toxicity management for chemotherapy, and the generation of additional and more robust clinical and health economic evidence.
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Affiliation(s)
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Andrea Marcellusi
- Economic Evaluation and HTA (EEHTA)-Centre for Economic and International Studies (CEIS), Faculty of Economics, University of Rome “Tor Vergata”, Rome, Italy
| | | | | | - Silvia Rabar
- Covalence Research Ltd, Harpenden, United Kingdom
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2
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Williamson C, Williamson S, Jiang R, Sudmeier L, Esiashvili N, Eaton BR. The impact of radiation therapy variables on pediatric high-grade glioma outcomes: A National Cancer Database analysis. Pediatr Blood Cancer 2024; 71:e30751. [PMID: 37937991 DOI: 10.1002/pbc.30751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 09/23/2023] [Accepted: 10/17/2023] [Indexed: 11/09/2023]
Abstract
PURPOSE The purpose of this analysis is to report patterns of care for pediatric patients with high-grade glioma (pHGG) and evaluate the impact of radiotherapy (RT) variables on outcomes using the National Cancer Database (NCDB). METHODS Eligibility criteria included age < 22 years, histologically diagnosed WHO grade III-IV gliomas treated with ≥50 Gy and < 76 Gy RT between 2004 and 2013, and RT initiation within 90 days of diagnosis. RT variables including RT dose, RT timing, and RT modality were analyzed along with baseline demographic, tumor, and treatment variables to assess the impact on overall survival. RESULTS A total of 498 pHGG patients were included. The median age was 15 years (range, 0-21), common diagnoses were astrocytoma (55%) and glioblastoma (30%), 73.5% underwent surgical resection and 90.2% received chemotherapy. The median RT dose was 59.4 Gy (SD 2.9 Gy) starting at a median of 4.4 weeks from diagnosis (SD 2.5 weeks). Fourteen patients were treated with proton therapy. Median follow-up was 19.6 months with 1- and 3-year overall survival of 78.4% and 40.4%, respectively. On multivariable analysis, female gender, older age, and RT delay of ≥6 weeks were significantly associated with a lower rate of death; glioblastoma histology, no surgical resection/biopsy only, and earlier RT initiation < 6 weeks from diagnosis were associated with a higher rate of death. There was no relationship between RT dose or proton versus photon therapy and overall survival. CONCLUSIONS Outcomes for pHGG are poor. There was no benefit to early RT timing when RT is initiated within 90 days of diagnosis or higher RT dose in this dataset.
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Affiliation(s)
- Christopher Williamson
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Shayla Williamson
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Renjian Jiang
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Lisa Sudmeier
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
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Dejonckheere CS, Thelen A, Simon B, Greschus S, Köksal MA, Schmeel LC, Wilhelm-Buchstab T, Leitzen C. Impact of Postoperative Changes in Brain Anatomy on Target Volume Delineation for High-Grade Glioma. Cancers (Basel) 2023; 15:2840. [PMID: 37345177 DOI: 10.3390/cancers15102840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 06/23/2023] Open
Abstract
High-grade glioma has a poor prognosis, and radiation therapy plays a crucial role in its management. Every step of treatment planning should thus be optimised to maximise survival chances and minimise radiation-induced toxicity. Here, we compare structures needed for target volume delineation between an immediate postoperative magnetic resonance imaging (MRI) and a radiation treatment planning MRI to establish the need for the latter. Twenty-eight patients were included, with a median interval between MRIs (range) of 19.5 (8-50) days. There was a mean change in resection cavity position (range) of 3.04 ± 3.90 (0-22.1) mm, with greater positional changes in skull-distant (>25 mm) resection cavity borders when compared to skull-near (≤25 mm) counterparts (p < 0.001). The mean differences in resection cavity and surrounding oedema and FLAIR hyperintensity volumes were -32.0 ± 29.6% and -38.0 ± 25.0%, respectively, whereas the mean difference in midline shift (range) was -2.64 ± 2.73 (0-11) mm. These data indicate marked short-term volumetric changes and support the role of an MRI to aid in target volume delineation as close to radiation treatment start as possible. Planning adapted to the actual anatomy at the time of radiation limits the risk of geographic miss and might thus improve outcomes in patients undergoing adjuvant radiation for high-grade glioma.
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Affiliation(s)
| | - Anja Thelen
- Faculty of Medicine, University Bonn, 53127 Bonn, Germany
| | - Birgit Simon
- Department of Radiology, University Hospital Bonn, 53127 Bonn, Germany
| | | | - Mümtaz Ali Köksal
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | | | | | - Christina Leitzen
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
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4
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Gao S, Jin L, Moliterno J, Corbin ZA, Bindra RS, Contessa JN, Yu JB, Park HS. Impact of radiotherapy delay following biopsy for patients with unresected glioblastoma. J Neurosurg 2023; 138:610-620. [PMID: 35907197 DOI: 10.3171/2022.5.jns212761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 05/19/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Because of the aggressive nature of glioblastoma, patients with unresected disease are encouraged to begin radiotherapy within approximately 1 month after craniotomy. The aim of this study was to investigate the potential association between time interval from biopsy to radiotherapy with overall survival in patients with unresected glioblastoma. METHODS Patients with unresected glioblastoma diagnosed between 2010 and 2014 who received adjuvant radiotherapy and concurrent chemotherapy were identified in the National Cancer Database. Demographic and clinical data were compared using chi-square and Wilcoxon rank-sum tests. Survival was analyzed using the Kaplan-Meier method and Cox proportional hazards regression modeling. RESULTS Among 3456 patients with unresected glioblastoma, initiation of radiotherapy within 3 weeks of biopsy was associated with a higher hazard of death compared with later initiation of radiotherapy. After excluding patients who received radiotherapy within 3 weeks of biopsy to minimize the effects of confounders associated with short time intervals from biopsy to radiotherapy, the median interval from biopsy to radiotherapy was 32 days (IQR 27-39 days). Overall, 1782 (66.82%) patients started radiotherapy within 5 weeks of biopsy, and 885 (33.18%) patients started radiotherapy beyond 5 weeks of biopsy. On multivariable analysis, there was no significant difference in overall survival between these two groups (HR 0.96, 95% CI 0.88-1.50; p = 0.374). CONCLUSIONS In patients with unresected glioblastoma, a longer time interval from biopsy to radiotherapy does not appear to be associated with worse overall survival. However, external validation of these findings is necessary given that selection bias is a significant limitation of this study.
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Affiliation(s)
- Sarah Gao
- 1Department of Therapeutic Radiology, Yale School of Medicine, New Haven
| | - Lan Jin
- 2Department of Neurosurgery, Yale School of Medicine, New Haven
| | | | | | - Ranjit S Bindra
- 1Department of Therapeutic Radiology, Yale School of Medicine, New Haven
| | - Joseph N Contessa
- 1Department of Therapeutic Radiology, Yale School of Medicine, New Haven
| | - James B Yu
- 4Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut; and.,5Department of Radiation Oncology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Henry S Park
- 1Department of Therapeutic Radiology, Yale School of Medicine, New Haven.,4Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut; and
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5
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Colopi A, Fuda S, Santi S, Onorato A, Cesarini V, Salvati M, Balistreri CR, Dolci S, Guida E. Impact of age and gender on glioblastoma onset, progression, and management. Mech Ageing Dev 2023; 211:111801. [PMID: 36996926 DOI: 10.1016/j.mad.2023.111801] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/06/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023]
Abstract
Glioblastoma (GBM) is the most common primary malignant brain tumor in adults, while its frequency in pediatric patients is 10-15%. For this reason, age is considered one of the major risk factors for the development of GBM, as it correlates with cellular aging phenomena involving glial cells and favoring the process of tumor transformation. Gender differences have been also identified, as the incidence of GBM is higher in males than in females, coupled with a worse outcome. In this review, we analyze age- and gender- dependent differences in GBM onset, mutational landscape, clinical manifestations, and survival, according to the literature of the last 20 years, focusing on the major risk factors involved in tumor development and on the mutations and gene alterations most frequently found in adults vs young patients and in males vs females. We then highlight the impact of age and gender on clinical manifestations and tumor localization and their involvement in the time of diagnosis and in determining the tumor prognostic value.
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Affiliation(s)
- Ambra Colopi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Serena Fuda
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Samuele Santi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Angelo Onorato
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Valeriana Cesarini
- Department of Biomedicine, Institute of Translational Pharmacology-CNR, Rome, Italy
| | - Maurizio Salvati
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Carmela Rita Balistreri
- Cellular and Molecular Laboratory, Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, Corso Tukory 211, 90134 Palermo, Italy
| | - Susanna Dolci
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
| | - Eugenia Guida
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
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Śledzińska P, Bebyn M, Furtak J, Koper A, Koper K. Current and promising treatment strategies in glioma. Rev Neurosci 2022:revneuro-2022-0060. [PMID: 36062548 DOI: 10.1515/revneuro-2022-0060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/30/2022] [Indexed: 12/14/2022]
Abstract
Gliomas are the most common primary central nervous system tumors; despite recent advances in diagnosis and treatment, glioma patients generally have a poor prognosis. Hence there is a clear need for improved therapeutic options. In recent years, significant effort has been made to investigate immunotherapy and precision oncology approaches. The review covers well-established strategies such as surgery, temozolomide, PCV, and mTOR inhibitors. Furthermore, it summarizes promising therapies: tumor treating fields, immune therapies, tyrosine kinases inhibitors, IDH(Isocitrate dehydrogenase)-targeted approaches, and others. While there are many promising treatment strategies, none fundamentally changed the management of glioma patients. However, we are still awaiting the outcome of ongoing trials, which have the potential to revolutionize the treatment of glioma.
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Affiliation(s)
- Paulina Śledzińska
- Molecular Oncology and Genetics Department, Innovative Medical Forum, The F. Lukaszczyk Oncology Center, 85-796 Bydgoszcz, Poland
| | - Marek Bebyn
- Molecular Oncology and Genetics Department, Innovative Medical Forum, The F. Lukaszczyk Oncology Center, 85-796 Bydgoszcz, Poland
| | - Jacek Furtak
- Department of Neurosurgery, 10th Military Research Hospital and Polyclinic, 85-681 Bydgoszcz, Poland.,Department of Neurooncology and Radiosurgery, The F. Lukaszczyk Oncology Center, 85-796 Bydgoszcz, Poland
| | - Agnieszka Koper
- Department of Oncology, Nicolaus Copernicus University in Torun, Ludwik Rydygier Collegium Medicum, 85-067 Bydgoszcz, Poland.,Department of Oncology, Franciszek Lukaszczyk Oncology Centre, 85-796 Bydgoszcz, Poland
| | - Krzysztof Koper
- Department of Oncology, Franciszek Lukaszczyk Oncology Centre, 85-796 Bydgoszcz, Poland.,Department of Clinical Oncology, and Nursing, Departament of Oncological Surgery, Nicolaus Copernicus University in Torun, Ludwik Rydygier Collegium Medicum, 85-067 Bydgoszcz, Poland
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7
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Mini-craniotomy for intra-axial brain tumors: a comparison with conventional craniotomy in 306 patients harboring non-dural based lesions. Neurosurg Rev 2022; 45:2983-2991. [PMID: 35585468 DOI: 10.1007/s10143-022-01811-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/14/2022] [Accepted: 05/04/2022] [Indexed: 10/18/2022]
Abstract
The use of a mini-craniotomy approach involving linear skin incision and a bone flap of about 3 cm has been reported for several neurosurgical diseases, such as aneurysms or cranial base tumors. More superficial lesions, including intra-axial tumors, may occasionally raise concerns due to insufficient control of the tumor boundaries. The convenience of a minimally invasive approach to intrinsic brain tumors was evaluated by comparing 161 patients who underwent mini-craniotomy (MC) for intra-axial brain tumors with a group of 145 patients operated on by the same surgical team through a conventional craniotomy (CC). Groups were propensity-matched for age, preoperative condition, size and location of the tumor, and pathological diagnosis. Results were analyzed focusing on operative time, the extent of resection, clinical outcome, hospitalization time, and time to start adjuvant therapy. Mini-craniotomy was equally effective in terms of extent of resection (GTR: 70.9% in the MC group vs 70.5% in the CC group) but had shorter operative time (average: 165 min in the MC group vs 205 min in the CC group p < 0.001) and lower rate of postoperative complications both superficial (1.03% vs 6.5% in the CC group p = 0.009) and deep (4% in the MC group vs 5.5% in the CC group p = 0,47). No relationship was found between the size or location of the tumor and resection rate. The MC group had reduced hospitalization time (average: 5.8 days vs 7.6 in CC group p < 0.001) and faster access to adjuvant therapies. 92.5% of the MC patients, which were scheduled for treatment, started radiotherapy within 8 weeks after surgery as opposed to 84.1% in the CC group (p = 0.04). These findings support the increasing use of mini-craniotomy for intra-axial brain tumors.
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8
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Tang L, Zhang M, Liu C. Advances in Nanotechnology-Based Immunotherapy for Glioblastoma. Front Immunol 2022; 13:882257. [PMID: 35651605 PMCID: PMC9149074 DOI: 10.3389/fimmu.2022.882257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/31/2022] [Indexed: 12/14/2022] Open
Abstract
Glioblastoma (GBM) is the most aggressive type of brain tumor. Despite the multimodal therapies, the effectiveness of traditional treatments is not much satisfying. In recent years, immunotherapy has become the focus of tumor treatment. Unlike traditional treatments that directly target tumor cells, immunotherapy uses the body’s immune system to kill tumors. However, due to the severe immunosuppressive microenvironment of GBM, it generally has a poor response to immunotherapy. In addition, the existence of the blood-brain barrier (BBB) also compromises the immunotherapeutic efficacy. Therefore, effective immunotherapy of GBM requires the therapeutic agents to not only efficiently cross the BBB but also relieve the strong immunosuppression of the tumor microenvironment of GBM. In this review, we will first introduce the CNS immune system, immunosuppressive mechanism of GBM, and current GBM immunotherapy strategies. Then, we will discuss the development of nanomaterials for GBM immunotherapy based on different strategies, roughly divided into four parts: immune checkpoint therapy, targeting tumor-associated immune cells, activating immune cells through immunogenic cell death, and combination therapy, to provide new insights for future GBM immunotherapy.
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Affiliation(s)
- Lin Tang
- Beijing Advanced Innovation Center for Soft Matter Science and Engineering, Beijing University of Chemical Technology, Beijing, China
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing, China
| | - Ming Zhang
- Department of Pathology, Peking University International Hospital, Beijing, China
- *Correspondence: Chaoyong Liu, ; Ming Zhang,
| | - Chaoyong Liu
- Beijing Advanced Innovation Center for Soft Matter Science and Engineering, Beijing University of Chemical Technology, Beijing, China
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing, China
- *Correspondence: Chaoyong Liu, ; Ming Zhang,
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9
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Yaghi NK, Radu S, Nugent JG, Mazur-Hart DJ, Pang BW, Bowden SG, Murphy B, Han SJ. Optimal timing of radiotherapy following brain metastases surgery. Neurooncol Pract 2022; 9:133-141. [PMID: 35371524 PMCID: PMC8965066 DOI: 10.1093/nop/npac007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Background There is growing evidence supporting the need for a short time delay before starting radiotherapy (RT) treatment postsurgery for most optimal responses. The timing of RT initiation and effects on outcomes have been evaluated in a variety of malignancies, but the relationship remains to be well established for brain metastasis. Methods Retrospective study of 176 patients (aged 18-89 years) with brain metastases at a single institution (March 2009 to August 2018) who received RT following surgical resection. Time interval (≤22 and >22 days) from surgical resection to initiation of RT and any potential impact on patient outcomes were assessed. Results Patients who underwent RT >22 days after surgical resection had a decreased risk for all-cause mortality of 47.2% (95% CI: 8.60, 69.5%). Additionally, waiting >40 days for RT after surgical resection more than doubled the risk of tumor progression; adjusted hazard ratio 2.02 (95% CI: 1.12, 3.64). Conclusions Findings indicate that a short interval delay (>22 days) following surgical resection is required before RT initiation for optimal treatment effects in brain metastasis. Our timing of RT postsurgical resection data adds definition to current heterogeneity in RT timing, which is especially important for standardized clinical trial design and patient outcomes.
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Affiliation(s)
- Nasser K Yaghi
- Neurological Surgery, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Stephanie Radu
- Neurological Surgery, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Joseph G Nugent
- Neurological Surgery, Oregon Health & Sciences University, Portland, Oregon, USA
| | - David J Mazur-Hart
- Neurological Surgery, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Brandi W Pang
- Neurological Surgery, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Stephen G Bowden
- Neurological Surgery, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Blair Murphy
- Radiation Medicine, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Seunggu J Han
- Corresponding Author: Seunggu J. Han, MD, Neurosurgery, Stanford Health Care, 300 Pasteur Drive, Stanford, CA 94304, USA ()
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10
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Malhotra AK, Karthikeyan V, Zabih V, Landry A, Bennett J, Bartels U, Nathan PC, Tabori U, Hawkins C, Das S, Gupta S. Adolescent and young adult glioma: systematic review of demographic, disease, and treatment influences on survival. Neurooncol Adv 2022; 4:vdac168. [PMID: 36479061 PMCID: PMC9721387 DOI: 10.1093/noajnl/vdac168] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND Prognostic factors in adolescent and young adult (AYA) glioma are not well understood. Though clinical and molecular differences between pediatric and adult glioma have been characterized, their application to AYA populations is less clear. There is a major need to develop more robust evidence-based practices for managing AYA glioma patients. METHODS A systematic review using PRISMA methodology was conducted using multiple databases with the objective of identifying demographic, clinical, molecular and treatment factors influencing AYA glioma outcomes. RESULTS 40 Studies met inclusion criteria. Overall survival was highly variable across studies depending on glioma grade, anatomic compartment and cohort characteristics. Thirty-five studies suffered from high risk of bias in at least one domain. Several studies included older adults within their cohorts; few captured purely AYA groups. Despite study heterogeneity, identified favorable prognosticators included younger age, higher functional status at diagnosis, low-grade pathology, oligodendroglioma histology and increased extent of surgical resection. Though isocitrate dehydrogenase (IDH) mutant status was associated with favorable prognosis, validity of this finding within AYA was compromised though may studies including older adults. The prognostic influence of chemotherapy and radiotherapy on overall survival varied across studies with conflicting evidence. CONCLUSION Existing literature is heterogenous, at high risk of bias, and rarely focused solely on AYA patients. Many included studies did not reflect updated pathological and molecular AYA glioma classification. The optimal role of chemotherapy, radiotherapy, and targeted agents cannot be determined from existing literature and should be the focus of future studies.
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Affiliation(s)
- Armaan K Malhotra
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Veda Zabih
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alexander Landry
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Julie Bennett
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ute Bartels
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul C Nathan
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Uri Tabori
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cynthia Hawkins
- Division of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sunit Das
- Division of Neurosurgery, St. Michael’s Hospital, University of Toronto, Toronto, OntarioCanada
| | - Sumit Gupta
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
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11
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Rationally designed drug delivery systems for the local treatment of resected glioblastoma. Adv Drug Deliv Rev 2021; 177:113951. [PMID: 34461201 DOI: 10.1016/j.addr.2021.113951] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/26/2021] [Accepted: 08/24/2021] [Indexed: 02/08/2023]
Abstract
Glioblastoma (GBM) is a particularly aggressive brain cancer associated with high recurrence and poor prognosis. The standard of care, surgical resection followed by concomitant radio- and chemotherapy, leads to low survival rates. The local delivery of active agents within the tumor resection cavity has emerged as an attractive means to initiate oncological treatment immediately post-surgery. This complementary approach bypasses the blood-brain barrier, increases the local concentration at the tumor site while reducing or avoiding systemic side effects. This review will provide a global overview on the local treatment for GBM with an emphasis on the lessons learned from past clinical trials. The main parameters to be considered to rationally design fit-of-purpose biomaterials and develop drug delivery systems for local administration in the GBM resection cavity to prevent the tumor recurrence will be described. The intracavitary local treatment of GBM should i) use materials that facilitate translation to the clinic; ii) be characterized by easy GMP effective scaling up and easy-handling application by the neurosurgeons; iii) be adaptable to fill the tumor-resected niche, mold to the resection cavity or adhere to the exposed brain parenchyma; iv) be biocompatible and possess mechanical properties compatible with the brain; v) deliver a therapeutic dose of rationally-designed or repurposed drug compound(s) into the GBM infiltrative margin. Proof of concept with high translational potential will be provided. Finally, future perspectives to facilitate the clinical translation of the local perisurgical treatment of GBM will be discussed.
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12
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Bander ED, Yuan M, Reiner AS, Panageas KS, Ballangrud ÅM, Brennan CW, Beal K, Tabar V, Moss NS. Durable 5-year local control for resected brain metastases with early adjuvant SRS: the effect of timing on intended-field control. Neurooncol Pract 2021; 8:278-289. [PMID: 34055375 DOI: 10.1093/nop/npab005] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Adjuvant stereotactic radiosurgery (SRS) improves the local control of resected brain metastases (BrM). However, the dependency of long-term outcomes on SRS timing relative to surgery remains unclear. Methods Retrospective analysis of patients treated with metastasectomy-plus-adjuvant SRS at Memorial Sloan Kettering Cancer Center (MSK) between 2013 and 2016 was conducted. Kaplan-Meier methodology was used to describe overall survival (OS) and cumulative incidence rates were estimated by type of recurrence, accounting for death as a competing event. Recursive partitioning analysis (RPA) and competing risks regression modeling assessed prognostic variables and associated events of interest. Results Two hundred and eighty-two patients with BrM had a median OS of 1.5 years (95% CI: 1.2-2.1) from adjuvant SRS with median follow-up of 49.8 months for survivors. Local surgical recurrence, other simultaneously SRS-irradiated site recurrence, and distant central nervous system (CNS) progression rates were 14.3% (95% CI: 10.1-18.5), 4.9% (95% CI: 2.3-7.5), and 47.5% (95% CI: 41.4-53.6) at 5 years, respectively. Median time-to-adjuvant SRS (TT-SRS) was 34 days (IQR: 27-39). TT-SRS was significantly associated with surgical site recurrence rate (P = 0.0008). SRS delivered within 1 month resulted in surgical site recurrence rate of 6.1% (95% CI: 1.3-10.9) at 1-year, compared to 9.2% (95% CI: 4.9-13.6) if delivered between 1 and 2 months, or 27.3% (95% CI: 0.0-55.5) if delivered >2 months after surgery. OS was significantly lower for patients with TT-SRS >~2 months. Postoperative length of stay, discharge to a rehabilitation facility, urgent care visits, and/or disease recurrence between surgery and adjuvant SRS associated with increased TT-SRS. Conclusions Adjuvant SRS provides durable local control. However, delays in initiation of postoperative SRS can decrease its efficacy.
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Affiliation(s)
- Evan D Bander
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Neurosurgery, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, New York
| | - Melissa Yuan
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne S Reiner
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine S Panageas
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Åse M Ballangrud
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cameron W Brennan
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nelson S Moss
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
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EANO guidelines on the diagnosis and treatment of diffuse gliomas of adulthood. Nat Rev Clin Oncol 2020; 18:170-186. [PMID: 33293629 PMCID: PMC7904519 DOI: 10.1038/s41571-020-00447-z] [Citation(s) in RCA: 728] [Impact Index Per Article: 182.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 01/16/2023]
Abstract
In response to major changes in diagnostic algorithms and the publication of mature results from various large clinical trials, the European Association of Neuro-Oncology (EANO) recognized the need to provide updated guidelines for the diagnosis and management of adult patients with diffuse gliomas. Through these evidence-based guidelines, a task force of EANO provides recommendations for the diagnosis, treatment and follow-up of adult patients with diffuse gliomas. The diagnostic component is based on the 2016 update of the WHO Classification of Tumors of the Central Nervous System and the subsequent recommendations of the Consortium to Inform Molecular and Practical Approaches to CNS Tumour Taxonomy — Not Officially WHO (cIMPACT-NOW). With regard to therapy, we formulated recommendations based on the results from the latest practice-changing clinical trials and also provide guidance for neuropathological and neuroradiological assessment. In these guidelines, we define the role of the major treatment modalities of surgery, radiotherapy and systemic pharmacotherapy, covering current advances and cognizant that unnecessary interventions and expenses should be avoided. This document is intended to be a source of reference for professionals involved in the management of adult patients with diffuse gliomas, for patients and caregivers, and for health-care providers. Herein, the European Association of Neuro-Oncology (EANO) provides recommendations for the diagnosis, treatment and follow-up of adult patients with diffuse gliomas. These evidence-based guidelines incorporate major changes in diagnostic algorithms based on the 2016 update of the WHO Classification of Tumors of the Central Nervous System as well as on evidence from recent large clinical trials.
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Le Rhun E, Weller M. Sex-specific aspects of epidemiology, molecular genetics and outcome: primary brain tumours. ESMO Open 2020; 5:e001034. [PMID: 33234601 PMCID: PMC7689067 DOI: 10.1136/esmoopen-2020-001034] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 11/16/2022] Open
Abstract
Recent years have seen a great interest in sex-specific aspects of many diseases, including cancer, in part because of the assumption that females have often not been adequately represented in early drug development and determination of safety, tolerability and efficacy in clinical trials. Brain tumours represent a highly heterogeneous group of neoplastic diseases with strong variation of incidence by age, but partly also by sex. Most gliomas are more common in men whereas meningiomas, the most common primary intracranial tumours, are more common in females. Potential sex-specific genetic risk factors and specific sex biology have been reported in a tumour-specific manner. Several small studies have indicated differences in tolerability and safety of, as well as benefit from, treatment by sex, but no conclusive data have been generated. Exploring sex-specific aspects of neuro-oncology should be studied more systematically and in more depth in order to uncover the biological reasons for known sex differences in this disease.
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Affiliation(s)
- Emilie Le Rhun
- Departments of Neurology and Neurosurgery, Clinical Neuroscience Center and Brain Tumor Center, University Hospital Zurich, Zurich, Switzerland.
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
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