Pre-radiation chemotherapy in glioma patients with poor prognostic factors

Clinical Determinants of Long-Term Survival in Patients with Glioblastoma Multiforme

Repeated reports of more than ten years postoperative survival in patients with glioblastoma multiforme (GM) have appeared in the literature over the last decades. Authors have tried to identify the clinical, therapeutic and histological features determining long-term survival. We present two patients in whom, after radical removal of the tumor followed by conventional radiation, there has been no recurrence for at least ten years. The young age of the patients and the radical surgical approach were in accordance with previous reports of long-term survival. Nevertheless, one tumor originated from the thalamus, a location considered to be of unfavorable prognosis. We therefore further discuss the value of clinical signs as determinants in the prognosis of GM.

Neoadjuvant phase II multicentre study of new agents in patients with malignant glioma after minimal surgery. Report of a cohort of 187 patients treated with temozolomide

BACKGROUND

The aim of this study was to assess the efficacy of new agents in patients with malignant glioma in a neoadjuvant setting not confounded by surgery. The first study of neoadjuvant temozolomide aimed to provide a benchmark for future evaluation of new treatments.

PATIENTS AND METHODS

This was a multicentre phase II study of chemotherapy in patients with histologically verified glioblastoma multiforme (GBM) and anaplastic astrocytoma (AA) who had undergone biopsy alone. Patients were planned to receive two cycles of temozolomide at 200 mg/m(2) orally daily for 5 days at a 28-day interval prior to radiotherapy. Response was assessed by two central observers on pre- and post-chemotherapy enhanced scans using bi-dimensional criteria and as progression-free survival (PFS) at the time of second assessment prior to radiotherapy. Withdrawal from the study due to worsening clinical condition was, in the absence of second imaging, assessed as progressive disease. Survival and quality of life (QOL) were secondary endpoints.

RESULTS

Between August 1999 and June 2002, 188 patients from 15 UK and two Italian centres were entered into the study and 187 were analysed. Overall, 162 patients were assessable for response; seven had partial and 25 had minimal response. The objective response rate was 20% [95% confidence interval (CI) 14-26%] and PFS prior to commencing radiotherapy was 64% (95% CI 57-72%). The median survival was 10 months, and 1-year survival 41%. The median survival of responders was 16 months compared to 3 months in patients with progressive disease (P <0.001 on multivariate analysis).

CONCLUSION

The phase II study design of primary chemotherapy in patients with malignant glioma following biopsy alone is feasible and provides as objective a method of assessment of efficacy as is currently available. The baseline data on temozolomide provide a benchmark for assessment of efficacy of other agents and combinations.

Neoadjuvant gemcitabine/treosulfan chemotherapy for newly diagnosed glioblastoma: a phase II study

The median survival for patients with glioblastoma is 12 months. The authors evaluated whether preirradiation gemcitabine/treosulfan (GeT) chemotherapy followed by standard radiotherapy improved outcome in patients with glioblastoma. Seventeen patients with newly diagnosed glioblastoma were enrolled in a prospective, unicenter trial of preirradiation GeT chemotherapy. Chemotherapy included up to 4 cycles of intravenous gemcitabine (1000 mg/m2 body surface) and treosulfan (3500 mg/m2 body surface) on days 1 and 8 of 28 days treatment cycles. Involved field radiotherapy (60 Gy in 30 fractions) was given after chemotherapy or earlier in the case of disease progression or drug intolerance. There was no specific treatment-related neurotoxicity reported, but in 3 of 17 patients (18%) chemotherapy was stopped because of World Health Organization (WHO) IV hematological toxicity. With GeT chemotherapy alone, there was a median progression-free survival of 12 weeks and a progression-free survival rate at 4 months of 29%. In 16 of 17 patients who subsequently received a full course of radiotherapy, the median progression-free survival from the time of diagnosis was 8 months, and the progression-free survival rate at 12 months was 25% (4 of 16 patients). The median overall survival was 12 months. Neither age nor extent of the residual postoperative tumor predicted the duration of progression-free survival after chemotherapy alone or after chemotherapy followed by radiotherapy. The combination of gemcitabine and treosulfan produced significant hematological toxicity in patients with newly diagnosed glioblastoma. The schedule used in the present study did not confer any significant survival advantage compared with standard involved field radiotherapy alone.

Brain tumors in the older person

BACKGROUND

The incidence of brain tumors is increasing rapidly, particularly in the older population. Advances in molecular biology help to explain differences in biologic behavior and response to therapy of brain tumors in the elderly compared with younger patients. The number of elderly patients who desire and receive therapy for brain tumors and are included in clinical trials is increasing.

METHODS

This article reviews the literature on the epidemiology, clinical aspects, and therapy of brain tumors, with emphasis on the older patient population.

RESULTS

The increased incidence of brain tumors in the elderly is principally due to the increasing number of people who comprise the older population. Age and performance status are important independent prognostic indicators, together with tumor histology. Surgery, radiation therapy, and chemotherapy can benefit elderly patients with brain tumors with favorable histologies, tumor location, and good performance status. The response rates to available therapies are less favorable than in younger patients, and only a small number of elderly patients are enrolled in clinical studies addressing new treatment modalities.

CONCLUSIONS

Brain tumors in the elderly have specific characteristics that determine their biologic behavior and response to therapy. There is a need for clinical studies designed for treatment of brain tumors in older patients, and requirements for rehabilitation and support systems for the elderly need to be addressed.

Interstitial chemotherapy plus systemic chemotherapy for glioblastoma patients: improved survival in sequential studies

We investigated the efficacy of 3 different systemic chemotherapy regimes in 122 patients with histologically confirmed glioblastoma, KPS > 60, age < 65. Locoregional chemotherapy was delivered to 22 patients from all three systemic chemotherapy groups. Chemotherapy was given before and during radiotherapy, which was the same for all patients consisting of unconventional fractionation with a break between courses. Survival (Kaplan-Meier) was significantly longer in the subgroup receiving cisplatinum plus BCNU compared to those receiving cisplatinum plus etoposide or carboplatinum plus BCNU with median survival time 21.5 months, 15 months and 15 months respectively (log rank test p = 0.01). Survival was also significantly longer in patients who received locoregional therapy compared to those who received only systemic chemotherapy (21 vs 15 months, p = 0.01). Univariate analysis showed that age, postoperative Karnofsky status and extent of resection were not predictive of survival in the series, although there were trends to better outcome in younger patients and those undergoing total/subtotal resection. Age, systemic chemotherapy type and interstitial treatment were included in a multivariate analysis, and both locoregional treatment and chemotherapy with cisplatinum plus BCNU were significantly predictive of survival [P = 0.01]. These encouraging preliminary results suggest that further trials with locoregional and systemic therapy prior to radiotherapy are worth pursuing.

Pre-radiation chemotherapy for malignant glioma in adults

PURPOSE

To review our experience with pre-radiation chemotherapy for malignant glioma.

METHODS

Consecutive adults with newly diagnosed glioblastoma, anaplastic astrocytoma, anaplastic oligodendroglioma and anaplastic mixed glioma with a Karnofsky Performance Score of 60 or greater were treated with one cycle of procarbazine, lomustine and vincristine or lomustine alone, prior to radiation. Computed tomographic scans were obtained soon after surgery, eight weeks later, after radiation, and at regular intervals thereafter. The effects of chemotherapy and subsequent radiation and durations of tumor control and survival were assessed in this single arm, single center, prospective trial.

RESULTS

Thirty-seven patients started chemotherapy, 36 were rescanned eight weeks after diagnosis. Five patients (16%) responded to the first cycle of chemotherapy, three had glioblastoma and two anaplastic oligodendroglioma. Seven (19%) progressed during the first cycle, 6 had glioblastoma; with the addition of radiation one progressive case responded, three stabilized, and three continued to progress. Median times to progression and median durations of survival were 26 weeks and 60 weeks for the entire group, 24 weeks and 44 weeks for glioblastoma, and greater than 104 weeks for anaplastic astrocytoma.

CONCLUSIONS

Most patients with glioblastoma do not respond to one cycle of nitrosourea-based chemotherapy given prior to radiation, but patients with anaplastic oligodendroglioma sometimes do. Patients with anaplastic astrocytoma may not respond to one cycle of chemotherapy, but often respond to subsequent radiation. Judging by survival results, radiation can be delayed eight weeks without appearing to compromise patient outcome.

IMPLICATIONS

Pre-radiation chemotherapy with newer agents can be evaluated more fully in the future knowing that brief delays in radiation are unlikely to yield substantially inferior results.

Supratentorial glioblastoma: neuroradiological findings and survival after surgery and radiotherapy

Few studies have attempted to correlate neuroimaging with outcome in patients with glioblastoma. Our aim was to evaluate the relationship between neuroradiological findings and survival in these patients. We studied 18 consecutive patients with glioblastoma who had undergone surgery and radiotherapy. We assessed the following features, using preoperative CT and/or MRI: tumour size, extent of necrotic area within the mass, extent of perifocal oedema and contrast enhancement. The mean survival was 14.2 +/- 5 months (range 6-22). The extent of radiological evidence of necrosis within the mass correlated significantly with survival time, whereas tumour size, perifocal oedema and contrast enhancement did not.