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Mazarakis NK, Robinson SD, Sinha P, Koutsarnakis C, Komaitis S, Stranjalis G, Short SC, Chumas P, Giamas G. Management of glioblastoma in elderly patients: A review of the literature. Clin Transl Radiat Oncol 2024; 46:100761. [PMID: 38500668 PMCID: PMC10945210 DOI: 10.1016/j.ctro.2024.100761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 03/20/2024] Open
Abstract
High grade gliomas are the most common primary aggressive brain tumours with a very poor prognosis and a median survival of less than 2 years. The standard management protocol of newly diagnosed glioblastoma patients involves surgery followed by radiotherapy, chemotherapy in the form of temozolomide and further adjuvant temozolomide. The recent advances in molecular profiling of high-grade gliomas have further enhanced our understanding of the disease. Although the management of glioblastoma is standardised in newly diagnosed adult patients there is a lot of debate regarding the best treatment approach for the newly diagnosed elderly glioblastoma patients. In this review article we attempt to summarise the findings regarding surgery, radiotherapy, chemotherapy, and their combination in order to offer the best possible management modality for this group of patients. Elderly patients 65-70 with an excellent functional level could be considered as candidates for the standards treatment consisting of surgery, standard radiotherapy with concomitant and adjuvant temozolomide. Similarly, elderly patients above 70 with good functional status could receive the above with the exception of receiving a shorter course of radiotherapy instead of standard. In elderly GBM patients with poorer functional status and MGMT promoter methylation temozolomide chemotherapy can be considered. For elderly patients who cannot tolerate chemotherapy, hypofractionated radiotherapy is an option. In contrast to the younger adult patients, it seems that a careful individualised approach is a key element in deciding the best treatment options for this group of patients.
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Affiliation(s)
- Nektarios K. Mazarakis
- Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK
- School of Medicine RCSI, Royal College of Surgeons in Ireland, 123 St. Stephen’s Green, Dublin 2, Ireland
| | - Stephen D. Robinson
- Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK
- Department of Biochemistry and Biomedicine, School of Life Sciences, University of Sussex, Brighton BN1 9QG, UK
| | - Priyank Sinha
- Department of Neurosurgery, Leeds General Infirmary, Great George Street, LS1 3EX, UK
| | | | - Spyridon Komaitis
- Department of Neurosurgery, Evaggelismos Hospital, Ipsilantou 45-47, Athens, Greece
| | - George Stranjalis
- Department of Neurosurgery, Evaggelismos Hospital, Ipsilantou 45-47, Athens, Greece
| | - Susan C. Short
- Leeds Institute of Medical Research at St James’s Wellcome Trust Brenner Building St James’s University Hospital Leeds, LS9 7TF, UK
| | - Paul Chumas
- School of Medicine RCSI, Royal College of Surgeons in Ireland, 123 St. Stephen’s Green, Dublin 2, Ireland
| | - Georgios Giamas
- Department of Biochemistry and Biomedicine, School of Life Sciences, University of Sussex, Brighton BN1 9QG, UK
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Stadler C, Gramatzki D, Le Rhun E, Hottinger AF, Hundsberger T, Roelcke U, Läubli H, Hofer S, Seystahl K, Wirsching HG, Weller M, Roth P. Glioblastoma in the oldest old: Clinical characteristics, therapy, and outcome in patients aged 80 years and older. Neurooncol Pract 2024; 11:132-141. [PMID: 38496908 PMCID: PMC10940826 DOI: 10.1093/nop/npad070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024] Open
Abstract
Background Incidence rates of glioblastoma in very old patients are rising. The standard of care for this cohort is only partially defined and survival remains poor. The aims of this study were to reveal current practice of tumor-specific therapy and supportive care, and to identify predictors for survival in this cohort. Methods Patients aged 80 years or older at the time of glioblastoma diagnosis were retrospectively identified in 6 clinical centers in Switzerland and France. Demographics, clinical parameters, and survival outcomes were annotated from patient charts. Cox proportional hazards modeling was performed to identify parameters associated with survival. Results Of 107 patients, 45 were diagnosed by biopsy, 30 underwent subtotal resection, and 25 had gross total resection. In 7 patients, the extent of resection was not specified. Postoperatively, 34 patients did not receive further tumor-specific treatment. Twelve patients received radiotherapy with concomitant temozolomide, but only 2 patients had maintenance temozolomide therapy. Fourteen patients received temozolomide alone, 35 patients received radiotherapy alone, 1 patient received bevacizumab, and 1 took part in a clinical trial. Median progression-free survival (PFS) was 3.3 months and median overall survival (OS) was 4.2 months. Among patients who received any postoperative treatment, median PFS was 3.9 months and median OS was 7.2 months. Karnofsky performance status (KPS) ≥70%, gross total resection, and combination therapy were associated with better outcomes. The median time spent hospitalized was 30 days, accounting for 23% of the median OS. End-of-life care was mostly provided by nursing homes (n = 20; 32%) and palliative care wards (n = 16; 26%). Conclusions In this cohort of very old patients diagnosed with glioblastoma, a large proportion was treated with best supportive care. Treatment beyond surgery and, in particular, combined modality treatment were associated with longer OS and may be considered for selected patients even at higher ages.
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Affiliation(s)
- Christina Stadler
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Dorothee Gramatzki
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Emilie Le Rhun
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Zurich
- Inserm, University of Lille, Lille, France
- Neuro-Oncology, General and Stereotaxic Neurosurgery Service, University Hospital of Lille, Lille, France
| | - Andreas F Hottinger
- Departments of Oncology & Clinical Neurosciences, Lundin Family Brain Tumor Research Center, Lausanne University Hospital & University of Lausanne, Lausanne, Switzerland
| | - Thomas Hundsberger
- Department of Neurology and Department of Medical Oncology and Haematology, Cantonal Hospital, St. Gallen, Switzerland
| | | | - Heinz Läubli
- Division of Oncology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Silvia Hofer
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Katharina Seystahl
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Hans-Georg Wirsching
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Patrick Roth
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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Zhu E, Wang J, Shi W, Jing Q, Ai P, Shan D, Ai Z. Optimizing adjuvant treatment options for patients with glioblastoma. Front Neurol 2024; 15:1326591. [PMID: 38456152 PMCID: PMC10919147 DOI: 10.3389/fneur.2024.1326591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/09/2024] [Indexed: 03/09/2024] Open
Abstract
Background This study focused on minimizing the costs and toxic effects associated with unnecessary chemotherapy. We sought to optimize the adjuvant therapy strategy, choosing between radiotherapy (RT) and chemoradiotherapy (CRT), for patients based on their specific characteristics. This selection process utilized an innovative deep learning method. Methods We trained six machine learning (ML) models to advise on the most suitable treatment for glioblastoma (GBM) patients. To assess the protective efficacy of these ML models, we employed various metrics: hazards ratio (HR), inverse probability treatment weighting (IPTW)-adjusted HR (HRa), the difference in restricted mean survival time (dRMST), and the number needed to treat (NNT). Results The Balanced Individual Treatment Effect for Survival data (BITES) model emerged as the most effective, demonstrating significant protective benefits (HR: 0.53, 95% CI, 0.48-0.60; IPTW-adjusted HR: 0.65, 95% CI, 0.55-0.78; dRMST: 7.92, 95% CI, 7.81-8.15; NNT: 1.67, 95% CI, 1.24-2.41). Patients whose treatment aligned with BITES recommendations exhibited notably better survival rates compared to those who received different treatments, both before and after IPTW adjustment. In the CRT-recommended group, a significant survival advantage was observed when choosing CRT over RT (p < 0.001). However, this was not the case in the RT-recommended group (p = 0.06). Males, older patients, and those whose tumor invasion is confined to the ventricular system were more frequently advised to undergo RT. Conclusion Our study suggests that BITES can effectively identify GBM patients likely to benefit from CRT. These ML models show promise in transforming the complex heterogeneity of real-world clinical practice into precise, personalized treatment recommendations.
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Affiliation(s)
- Enzhao Zhu
- School of Medicine, Tongji University, Shanghai, China
| | - Jiayi Wang
- School of Medicine, Tongji University, Shanghai, China
| | - Weizhong Shi
- Shanghai Hospital Development Center, Shanghai, China
| | - Qi Jing
- Department of Anesthesiology and Perioperative Medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Pu Ai
- School of Medicine, Tongji University, Shanghai, China
| | - Dan Shan
- Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
| | - Zisheng Ai
- Department of Medical Statistics, School of Medicine, Tongji University, Shanghai, China
- Clinical Research Center for Mental Disorders, Chinese-German Institute of Mental Health, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, China
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Albrecht C, Baumgart L, Schroeder A, Wiestler B, Meyer B, Krieg SM, Ille S. Impact of function-guided glioma treatment on oncological outcome in the elderly. BRAIN & SPINE 2024; 4:102742. [PMID: 38510620 PMCID: PMC10951774 DOI: 10.1016/j.bas.2023.102742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/18/2023] [Accepted: 12/28/2023] [Indexed: 03/22/2024]
Abstract
Introduction Many patients with high-grade gliomas (HGG) are of older age. Research question We hypothesize that pre- and intraoperative mapping and monitoring preserve functional status in elderly patients while gross total resection (GTR) is the aim, resulting in overall survival (OS) rates comparable to the general population with HGG. Material and methods We subdivided a prospective cohort of 168 patients above 65 years with eloquent high-grade gliomas into four groups ([years/cases] 1: 65-69/58; 2: 70-74/47; 3: 75-79/43; 4: >79/20). All patients underwent preoperative noninvasive mapping, which was also used for decision-making, intraoperative neuromonitoring in 138 cases, direct cortical and/or subcortical motor mapping in 66 and 50 cases, and awake language mapping in 11 cases. Results GTR and subtotal resection (STR) could be achieved in 65% and 28%, respectively. Stereotactic biopsy was performed in 8% of cases. Postoperatively, we found transient and permanent functional deficits in 13% and 11% of cases. Postoperative Karnofsky Performance Scale (KPS) did not differ between subgroups. Patients with long-term follow-up (51%) had a progression-free survival of 5.5 (1-47) months and an overall survival of 10.5 (0-86) months. Discussion and conclusion The interdisciplinary glioma treatment in the elderly is less age-dependent but must be adjusted to the functional status. Function-guided surgical resections could be performed as usual, with maximal tumor resection being the primary goal. However, less network capacity in the elderly to compensate for deficits might cause higher rates of permanent deficits in this group of patients with more fast-growing malignant gliomas.
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Affiliation(s)
- Carolin Albrecht
- Department of Neurosurgery, Technical University of Munich, Germany
- School of Medicine, Klinikum Rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Lea Baumgart
- Department of Neurosurgery, Technical University of Munich, Germany
- School of Medicine, Klinikum Rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Axel Schroeder
- Department of Neurosurgery, Technical University of Munich, Germany
- School of Medicine, Klinikum Rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Benedikt Wiestler
- Section of Diagnostic and Interventional Neuroradiology Department of Radiology, Klinikum Rechts der Isar, School of Medicine, Technische Universität München, Germany
- School of Medicine, Klinikum Rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
- Department of Diagnostic and Interventional Neuroradiology, Technical University of Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich, Germany
- School of Medicine, Klinikum Rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, Technical University of Munich, Germany
- School of Medicine, Klinikum Rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Technical University of Munich, Germany
- School of Medicine, Klinikum Rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
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Weller J, Katzendobler S, Niedermeyer S, Harter PN, Herms J, Trumm C, Niyazi M, Thon N, Tonn JC, Stoecklein VM. Treatment benefit in patients aged 80 years or older with biopsy-proven and non-resected glioblastoma is dependent on MGMT promoter methylation status. J Neurooncol 2023:10.1007/s11060-023-04362-y. [PMID: 37289281 PMCID: PMC10322768 DOI: 10.1007/s11060-023-04362-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/01/2023] [Indexed: 06/09/2023]
Abstract
PURPOSE Glioblastoma is associated with especially poor outcome in the elderly. It is unclear if patients aged ≥80 years benefit from tumor-specific therapy as opposed to receiving best supportive care (BSC) only. METHODS Patients with IDH-wildtype glioblastoma (WHO 2021), aged ≥80 years, and diagnosed by biopsy between 2010 and 2022 were included. Patient characteristics and clinical parameters were assessed. Uni- and multivariate analyses were performed. RESULTS 76 patients with a median age of 82 (range 80-89) and a median initial KPS of 80 (range 50-90) were included. Tumor-specific therapy was initiated in 52 patients (68%). 22 patients (29%) received temozolomide monotherapy, 23 patients (30%) were treated with radiotherapy (RT) alone and 7 patients (9%) received combination therapies. In 24 patients (32%), tumor-specific therapy was omitted in lieu of BSC. Overall survival (OS) was longer in patients receiving tumor-specific therapy (5.4 vs. 3.3 months, p < 0.001). Molecular stratification showed that the survival benefit was owed to patients with MGMT promoter methylation (MGMTpos) who received tumor-specific therapy as opposed to BSC (6.2 vs. 2.6 months, p < 0.001), especially to those with better clinical status and no initial polypharmacy. Patients with unmethylated MGMT promoter (MGMTneg) did not benefit from tumor-specific therapy (3.6 vs. 3.7 months, p = 0.18). In multivariate analyses, better clinical status and MGMT promoter methylation were associated with prolonged survival (p < 0.01 and p = 0.01). CONCLUSION Benefit from tumor-specific treatment in patients with newly diagnosed glioblastoma aged ≥80 years might be restricted to MGMTpos patients, especially to those with good clinical status and no polypharmacy.
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Affiliation(s)
- Jonathan Weller
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, Munich, 81377, Germany
| | - Sophie Katzendobler
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, Munich, 81377, Germany
| | - Sebastian Niedermeyer
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, Munich, 81377, Germany
| | - Patrick N Harter
- Center for Neuropathology and Prion Research, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner site Munich and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jochen Herms
- Center for Neuropathology and Prion Research, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner site Munich and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Maximilian Niyazi
- Department of Radiotherapy and Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner site Munich and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Niklas Thon
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, Munich, 81377, Germany
- German Cancer Consortium (DKTK), Partner site Munich and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Joerg-Christian Tonn
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, Munich, 81377, Germany
- German Cancer Consortium (DKTK), Partner site Munich and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Veit M Stoecklein
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, Munich, 81377, Germany.
- German Cancer Consortium (DKTK), Partner site Munich and German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Josowitz AD, Bindra RS, Saltzman WM. Polymer nanocarriers for targeted local delivery of agents in treating brain tumors. NANOTECHNOLOGY 2022; 34:10.1088/1361-6528/ac9683. [PMID: 36179653 PMCID: PMC9940943 DOI: 10.1088/1361-6528/ac9683] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 09/30/2022] [Indexed: 06/16/2023]
Abstract
Glioblastoma (GBM), the deadliest brain cancer, presents a multitude of challenges to the development of new therapies. The standard of care has only changed marginally in the past 17 years, and few new chemotherapies have emerged to supplant or effectively combine with temozolomide. Concurrently, new technologies and techniques are being investigated to overcome the pharmacokinetic challenges associated with brain delivery, such as the blood brain barrier (BBB), tissue penetration, diffusion, and clearance in order to allow for potent agents to successful engage in tumor killing. Alternative delivery modalities such as focused ultrasound and convection enhanced delivery allow for the local disruption of the BBB, and the latter in particular has shown promise in achieving broad distribution of agents in the brain. Furthermore, the development of polymeric nanocarriers to encapsulate a variety of cargo, including small molecules, proteins, and nucleic acids, have allowed for formulations that protect and control the release of said cargo to extend its half-life. The combination of local delivery and nanocarriers presents an exciting opportunity to address the limitations of current chemotherapies for GBM toward the goal of improving safety and efficacy of treatment. However, much work remains to establish standard criteria for selection and implementation of these modalities before they can be widely implemented in the clinic. Ultimately, engineering principles and nanotechnology have opened the door to a new wave of research that may soon advance the stagnant state of GBM treatment development.
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Affiliation(s)
- Alexander D Josowitz
- Department of Biomedical Engineering, Yale University, New Haven, CT, United States of America
| | - Ranjit S Bindra
- Department of Therapeutic Radiology, Yale School of Medicine, United States of America
| | - W Mark Saltzman
- Department of Biomedical Engineering, Yale University, New Haven, CT, United States of America
- Department of Chemical & Environmental Engineering, Yale University, New Haven, CT, United States of America
- Department of Cellular & Molecular Physiology, Yale University, New Haven, CT, United States of America
- Department of Dermatology, Yale University, New Haven, CT, United States of America
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Abstract
Glioblastoma is the most aggressive primary brain tumor with a poor prognosis. The 2021 WHO CNS5 classification has further stressed the importance of molecular signatures in diagnosis although therapeutic breakthroughs are still lacking. In this review article, updates on the current and novel therapies in IDH-wildtype GBM will be discussed.
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Affiliation(s)
- Jawad M Melhem
- Division of Neurology, Department of Medicine, Faculty of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Mary Jane Lim-Fat
- Division of Neurology, Department of Medicine, Faculty of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - James R Perry
- Division of Neurology, Department of Medicine, Faculty of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.
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8
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Climans SA, Mason WP, Grunfeld E, Chan K. Clinical features of glioma patients who develop pneumocystis pneumonia with temozolomide chemoradiotherapy. J Neurooncol 2022; 159:665-674. [PMID: 35932358 DOI: 10.1007/s11060-022-04109-1] [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: 05/25/2022] [Accepted: 07/28/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The treatment of glioma with temozolomide chemoradiotherapy predisposes patients to pneumocystis pneumonia (PCP). Because PCP is a rare outcome, very little is known about specific clinical risk factors for its development in patients with glioma. METHODS We performed a population-based retrospective cohort study of glioma patients undergoing temozolomide chemoradiotherapy 2005 to 2019 in Ontario, Canada. We compared clinical features of patients who did not versus did develop PCP within one year of chemoradiotherapy. We examined the overall survival of patients by PCP status. RESULTS There were 5130 patients with glioma treated with temozolomide chemoradiotherapy. Ultimately, 38 patients (0.74%) were diagnosed with PCP within 1 year of chemoradiotherapy. Most (71%) infections occurred between 0-90 days and 29% occurred between 91-365 days. Median survival was 12.3 months in patients who did not develop PCP and 8.6 months in those who did develop PCP (P < 0.001). Trough 90-day lymphocyte counts were lower in the PCP group. When the lymphocytes fell below 0.19 × 109/L (or 0.25 × 109/L among patients without PCP prophylaxis), the risk of PCP was > 3.5%. CONCLUSIONS Pneumocystis pneumonia is rare in glioma patients who receive temozolomide chemoradiotherapy. Infection is associated with shorter survival and the development of lymphopenia. Reserving PCP prophylaxis for patients whose lymphocyte counts drop below 0.25 × 109/L may be a reasonable strategy.
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Affiliation(s)
- Seth A Climans
- Department of Oncology, Western University, London, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada. .,London Regional Cancer Program, 800 Commissioners Rd E, London, ON, N6A5W9, Canada.
| | - Warren P Mason
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Eva Grunfeld
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Kelvin Chan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Klingenschmid J, Krigers A, Kerschbaumer J, Thomé C, Pinggera D, Freyschlag CF. Surgical Management of Malignant Glioma in the Elderly. Front Oncol 2022; 12:900382. [PMID: 35692808 PMCID: PMC9181439 DOI: 10.3389/fonc.2022.900382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 04/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background The median age for diagnosis of glioblastoma is 64 years and the incidence rises with increasing age to a peak at 75-84 years. As the total number of high-grade glioma patients is expected to increase with an aging population, neuro-oncological surgery faces new treatment challenges, especially regarding aggressiveness of the surgical approach and extent of resection. In the elderly, aspects like frailty and functional recovery time have to be taken into account before performing surgery. Material & Methods Patients undergoing surgery for malignant glioma (WHO grade III and IV) at our institution between 2015 and 2020 were compiled in a centralized tumor database and analyzed retrospectively. Karnofsky Performance Scale (KPS) and Clinical Frailty Scale (CFS) were used to determine functional performance pre- and postoperatively. Overall survival (OS) was compared between age groups of 65-69 years, 70-74 years, 75-79 years, 80-84 years and >85 years in view of extent of resection (EOR). Furthermore, we performed a literature evaluation focusing on surgical treatment of newly diagnosed malignant glioma in the elderly. Results We analyzed 121 patients aged 65 years and above (range 65 to 88, mean 74 years). Mean overall survival (OS) was 10.35 months (SD = 11.38). Of all patients, only a minority (22.3%) received tumor biopsy instead of gross total resection (GTR, 61.2%) or subtotal resection (STR, 16.5%). Postoperatively, 52.9% of patients were treated according to the Stupp protocol. OS differed significantly between extent of resection (EOR) groups (4.0 months after biopsy vs. 8.3 after STR vs. 13.8 after GTR, p < 0.05 and p < 0.001 correspondingly). No significant difference was observed regarding EOR across different age groups. Conclusion GTR should be the treatment of choice also in elderly patients with malignant glioma as functional outcome and survival after surgery are remarkably better compared to less aggressive treatment. Elderly patients who received GTR of high-grade gliomas survived significantly longer compared to patients who underwent biopsy and STR. Age seems to have little influence on overall survival in selected surgically extensive treated patients, but high preoperative functional performance is mandatory.
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Arakawa Y, Mineharu Y, Uto M, Mizowaki T. Optimal managements of elderly patients with glioblastoma. Jpn J Clin Oncol 2022; 52:833-842. [PMID: 35552425 PMCID: PMC9841411 DOI: 10.1093/jjco/hyac075] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/19/2022] [Indexed: 01/21/2023] Open
Abstract
Optimizing the management of elderly patients with glioblastoma is an ongoing task in neuro-oncology. The number of patients with this tumor type is gradually increasing with the aging of the population. Although available data and practice recommendations remain limited, the current strategy is maximal safe surgical resection followed by radiotherapy in combination with temozolomide. However, survival is significantly worse than that in the younger population. Surgical resection provides survival benefit in patients with good performance status. Hypofractionated radiotherapy decreases toxicities while maintaining therapeutic efficacy, thus improving treatment adherence and subsequently leading to better quality of life. The intensity of these treatments should be balanced with patient-specific factors and consideration of quality of life. This review discusses the current optimal management in terms of efficacy and safety, as well as future perspectives.
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Affiliation(s)
- Yoshiki Arakawa
- For reprints and all correspondence: Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. E-mail: ; Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. E-mail:
| | - Yohei Mineharu
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Megumi Uto
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takashi Mizowaki
- For reprints and all correspondence: Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. E-mail: ; Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. E-mail:
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Elderly Gliobastoma Patients: The Impact of Surgery and Adjuvant Treatments on Survival: A Single Institution Experience. Brain Sci 2022; 12:brainsci12050632. [PMID: 35625018 PMCID: PMC9139732 DOI: 10.3390/brainsci12050632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/07/2022] [Accepted: 05/10/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction. Elderly glioblastoma (GBM) patients often show limited response to treatment and poor outcome. Here, we provide a case series of elderly GBM patients from our Institution, in whom we assessed the clinical characteristics, feasibility of surgical resection, response to adjuvant treatments, and outcome, along with the impact of comorbidities and clinical status on survival. Patients and Methods. We included patients ≥ 65-year-old. We collected information about clinical and molecular features, extent of resection, adjuvant treatments, treatment-related complications, and outcome. Results. We included 135 patients. Median age was 71 years. In total, 127 patients (94.0%) had a Karnofsky Performance Status (KPS) ≥70 and 61/135 (45.2%) a Charlson Comorbidity Score (CCI) > 3. MGMTp methylation was found in 70/135 (51.9%). Subtotal resections (STRs), gross-total resections (GTRs), and biopsies were 102 (75.6%), 10 (7.4%) and 23 (17.0%), respectively. Median progression-free survival and overall survival (mOS) were 8.0 and 10.5 months for the whole cohort. Notably, GTR and radio-chemotherapy with temozolomide in patients with MGMTp methylation were associated with significantly longer mOS (32.8 and 44.8 months, respectively). In a multivariable analysis, risk of death was affected by STR vs. GTR (HR 2.8, p = 0.002), MGMTp methylation (HR 0.55, p = 0.007), and KPS at baseline ≥70 (HR 0.43, p = 0.031). Conversely, CCI and post-surgical complications were not significant. Conclusions. Elderly GBM patients often have a dismal prognosis. However, it is possible to identify a subgroup with favourable clinical and molecular features, who benefit from GTR and radio-chemotherapy with temozolomide. A comprehensive prognostic score is needed to guide treatment modality and predict the outcome.
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Abstract
Purpose of Review Elderly patients with newly diagnosed glioblastoma (eGBM) carry a worse prognosis compared with their younger counterparts. eGBM garners special attention due to the unique challenges, including increased treatment-associated toxicity, less relative benefit from aggressive therapy, medical comorbidities, and immunosuppression. The pivotal GBM trials excluded patients > 70 years old and the optimal treatment approach remains unsettled for eGBM. In this review, we analyze the historical evidence-based data for treating eGBM and discuss the future direction for managing this vulnerable population. Recent Findings Treatment for eGBM continues to evolve. Therapy choice is guided by performance status and presence of O6-methylguanine-DNA-methyltransferase (MGMT) promoter methylation. For eGBM with good performance status, combinatorial hypofractionated radiation therapy (hRT) and temozolomide should be recommended. For those with poor performance status, further stratification based on MGMT promoter methylation test result is recommended. Single-agent temozolomide is a viable treatment option for MGMT methylated tumors (mMGMT); in particular, those classified with receptor tyrosine kinase II methylation. hRT alone can be considered in MGMT unmethylated (uMGMT) eGBM patients. As precision oncology continues to advance, effective targeted and immunotherapy may emerge as new treatment options for eGBM. Summary Management of elderly patients with newly diagnosed GBM carries a unique set of challenges. Progress has been made in defining the optimal therapeutic approach for these patients, but many questions remain to be answered.
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Affiliation(s)
- Carlen A. Yuen
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, 710 W 168th St, 9th Floor, New York, NY 10032 USA
| | - Marissa Barbaro
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, 710 W 168th St, 9th Floor, New York, NY 10032 USA
- Present Address: Perlmutter Cancer Center at NYU Langone Hematology Oncology Associates – Mineola, NYU Long Island School of Medicine, NYU Langone Health, Mineola, NY USA
| | - Aya Haggiagi
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, 710 W 168th St, 9th Floor, New York, NY 10032 USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY USA
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Osawa T, Tosaka M, Horiguchi K, Sugawara K, Yokoo H, Yoshimoto Y. Elderly patients aged over 75 years with glioblastoma: Preoperative status and surgical strategies. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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14
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McAleenan A, Kelly C, Spiga F, Kernohan A, Cheng HY, Dawson S, Schmidt L, Robinson T, Brandner S, Faulkner CL, Wragg C, Jefferies S, Howell A, Vale L, Higgins JPT, Kurian KM. Prognostic value of test(s) for O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation for predicting overall survival in people with glioblastoma treated with temozolomide. Cochrane Database Syst Rev 2021; 3:CD013316. [PMID: 33710615 PMCID: PMC8078495 DOI: 10.1002/14651858.cd013316.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Glioblastoma is an aggressive form of brain cancer. Approximately five in 100 people with glioblastoma survive for five years past diagnosis. Glioblastomas that have a particular modification to their DNA (called methylation) in a particular region (the O6-methylguanine-DNA methyltransferase (MGMT) promoter) respond better to treatment with chemotherapy using a drug called temozolomide. OBJECTIVES To determine which method for assessing MGMT methylation status best predicts overall survival in people diagnosed with glioblastoma who are treated with temozolomide. SEARCH METHODS We searched MEDLINE, Embase, BIOSIS, Web of Science Conference Proceedings Citation Index to December 2018, and examined reference lists. For economic evaluation studies, we additionally searched NHS Economic Evaluation Database (EED) up to December 2014. SELECTION CRITERIA Eligible studies were longitudinal (cohort) studies of adults with diagnosed glioblastoma treated with temozolomide with/without radiotherapy/surgery. Studies had to have related MGMT status in tumour tissue (assessed by one or more method) with overall survival and presented results as hazard ratios or with sufficient information (e.g. Kaplan-Meier curves) for us to estimate hazard ratios. We focused mainly on studies comparing two or more methods, and listed brief details of articles that examined a single method of measuring MGMT promoter methylation. We also sought economic evaluations conducted alongside trials, modelling studies and cost analysis. DATA COLLECTION AND ANALYSIS Two review authors independently undertook all steps of the identification and data extraction process for multiple-method studies. We assessed risk of bias and applicability using our own modified and extended version of the QUality In Prognosis Studies (QUIPS) tool. We compared different techniques, exact promoter regions (5'-cytosine-phosphate-guanine-3' (CpG) sites) and thresholds for interpretation within studies by examining hazard ratios. We performed meta-analyses for comparisons of the three most commonly examined methods (immunohistochemistry (IHC), methylation-specific polymerase chain reaction (MSP) and pyrosequencing (PSQ)), with ratios of hazard ratios (RHR), using an imputed value of the correlation between results based on the same individuals. MAIN RESULTS We included 32 independent cohorts involving 3474 people that compared two or more methods. We found evidence that MSP (CpG sites 76 to 80 and 84 to 87) is more prognostic than IHC for MGMT protein at varying thresholds (RHR 1.31, 95% confidence interval (CI) 1.01 to 1.71). We also found evidence that PSQ is more prognostic than IHC for MGMT protein at various thresholds (RHR 1.36, 95% CI 1.01 to 1.84). The data suggest that PSQ (mainly at CpG sites 74 to 78, using various thresholds) is slightly more prognostic than MSP at sites 76 to 80 and 84 to 87 (RHR 1.14, 95% CI 0.87 to 1.48). Many variants of PSQ have been compared, although we did not see any strong and consistent messages from the results. Targeting multiple CpG sites is likely to be more prognostic than targeting just one. In addition, we identified and summarised 190 articles describing a single method for measuring MGMT promoter methylation status. AUTHORS' CONCLUSIONS PSQ and MSP appear more prognostic for overall survival than IHC. Strong evidence is not available to draw conclusions with confidence about the best CpG sites or thresholds for quantitative methods. MSP has been studied mainly for CpG sites 76 to 80 and 84 to 87 and PSQ at CpG sites ranging from 72 to 95. A threshold of 9% for CpG sites 74 to 78 performed better than higher thresholds of 28% or 29% in two of three good-quality studies making such comparisons.
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Affiliation(s)
- Alexandra McAleenan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Claire Kelly
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Francesca Spiga
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hung-Yuan Cheng
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration West (ARC West) , University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Lena Schmidt
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Tomos Robinson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sebastian Brandner
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK
- Division of Neuropathology, The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Claire L Faulkner
- Bristol Genetics Laboratory, Pathology Sciences, Southmead Hospital, Bristol, UK
| | - Christopher Wragg
- Bristol Genetics Laboratory, Pathology Sciences, Southmead Hospital, Bristol, UK
| | - Sarah Jefferies
- Department of Oncology, Addenbrooke's Hospital, Cambridge, UK
| | - Amy Howell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration West (ARC West) , University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Kathreena M Kurian
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Medical School: Brain Tumour Research Centre, Public Health Sciences, University of Bristol, Bristol, UK
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15
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Barbaro M, Fine HA, Magge RS. Scientific and Clinical Challenges within Neuro-Oncology. World Neurosurg 2021; 151:402-410. [PMID: 33610863 DOI: 10.1016/j.wneu.2021.01.151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/25/2022]
Abstract
Both primary and metastatic brain tumors carry poor prognoses despite modern advances in medical therapy, radiation therapy, and surgical techniques. Gliomas, including glioblastoma (GBM), are particularly difficult to treat, and high-grade gliomas have poor outcomes. Treatment of brain tumors involves a unique set of scientific and clinical challenges, which are often not present in the treatment of systemic malignancies. With respect to scientific challenges, the anatomy and physiology of brain tumors (including the blood-brain barrier, blood-tumor barrier, and blood-cerebrospinal fluid barrier) prevent adequate drug delivery into the central nervous system. The unique nature of the immune system in the central nervous system as well as the immunosuppressive microenvironment of tumors such as GBM also create therapeutic roadblocks in the treatment of brain tumors. Tumor heterogeneity, particularly in GBM, has classically been believed to contribute to multitherapy resistance; however, recent data suggest that this may not be the case. Clinical challenges include neurologic and medical comorbidities of patients with brain tumor, as well as potential toxicity of tumor-directed treatment. Clinical trials investigating new treatment paradigms are needed, but several roadblocks exist to good and promising clinical trial availability.
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Affiliation(s)
- Marissa Barbaro
- Weill Cornell Brain Tumor Center, Department of Neurology, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Howard A Fine
- Weill Cornell Brain Tumor Center, Department of Neurology, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Rajiv S Magge
- Weill Cornell Brain Tumor Center, Department of Neurology, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA.
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16
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Navarria P, Pessina F, Franzese C, Loi M, Bellu L, Clerici E, Marco Marzo A, Simonelli M, Lorenzi E, Salvatore Politi L, Bello L, Fornari M, Rossini Z, Santoro A, Scorsetti M. The 70-year-old newly diagnosed glioblastoma patients are older than the 65-year-old? Outcome evaluation of the two categories in a matched case control study with propensity score balancing. Radiother Oncol 2020; 156:49-55. [PMID: 33245946 DOI: 10.1016/j.radonc.2020.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/14/2020] [Accepted: 11/16/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The standard of care for elderly, newly-diagnosed glioblastoma patients consists, if feasible, of surgical resection followed by a short course of radiation therapy (RT) with concomitant and adjuvant temozolomide chemotherapy (TMZCHT). To date, the literature lacks of consistence in the definition of elderly, if older than 65 years, or 70 years. Aim of this study was to explore whether differences exist between these two cohorts, comparing outcomes using a propensity score matched analysis (PSM). MATERIALS AND METHODS Two hundred twenty-one elderly newly diagnosed glioblastoma patients were included. All patients received surgery followed by RT with concurrent and adjuvant TMZCHT. The RT dose prescribed was 60 Gy/30 fractions for patients 65-69-year-old or 40.5 Gy/15 fractions for ≥70-year-old. After 1:1 matching there were 86 patients in each group. Distribution of covariates was adequately balanced in the matched data set. RESULTS After PSM median PFS time, 1,2,3-year PFS rates were 10 months, 33.3%, 13.1%, and 6.6% for the 65-69-year group, 9 months, 34.7%, 11% and 4.8% for the ≥70-year group (p = 0.530). Median OS time, and 1,2,3-year OS rates were 14 months, 54.1%, 23.4%, 13.9% for the 65-69-year old group, and 12 months, 49.3%, 21.5%, 10% for the ≥70-year group (p = 0.357). No differences were recorded in relation to different groups of age. CONCLUSIONS The PSM analyses showed a similar outcome in 65-69-year old patients compared to older ones notwithstanding a more burdensome RT schedule. Hypofractionated RT treatment has to be considered also in this group of younger elderly, newly-diagnosed GBM patients.
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Affiliation(s)
- Pierina Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy.
| | - Federico Pessina
- Neurosurgical Department, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele-Milan, Italy
| | - Ciro Franzese
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele-Milan, Italy
| | - Mauro Loi
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy
| | - Luisa Bellu
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy
| | - Antonio Marco Marzo
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy
| | - Matteo Simonelli
- Oncology and Hematology Department, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele-Milan, Italy
| | - Elena Lorenzi
- Oncology and Hematology Department, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy
| | - Letterio Salvatore Politi
- Neuroradiology Department, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele-Milan, Italy
| | - Lorenzo Bello
- Oncology and Hemato-oncology Department, University of Milan, Italy
| | - Maurizio Fornari
- Neurosurgical Department, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy
| | - Zefferino Rossini
- Neurosurgical Department, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy
| | - Armando Santoro
- Oncology and Hematology Department, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele-Milan, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele-Milan, Italy
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Conti Nibali M, Gay LG, Sciortino T, Rossi M, Caroli M, Bello L, Riva M. Surgery for Glioblastoma in Elderly Patients. Neurosurg Clin N Am 2020; 32:137-148. [PMID: 33223022 DOI: 10.1016/j.nec.2020.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The management of glioblastoma in the elderly population represents a field of growing interest owing a longer life expectancy. In this age group, more than in the young adult, biological age is much more important than chronologic one. The date of birth should not exclude a priori access of treatments. Maximal safe resection is proved to be the first option when performance status and general health is good. Adjuvant therapy and decision about management of recurrence should be choose in a multidisciplinary group according to performance of the patients and O6-methylguanine-DNA methyl-transferase methylation.
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Affiliation(s)
- Marco Conti Nibali
- Department of Oncology and Hemato-Oncology, Via Festa del Perdono 7, Milan 20122, Italy; IRCCS Istituto Ortopedico Galeazzi, Neurochirurgia Oncologica, Milan, Italy.
| | - Lorenzo G Gay
- Department of Oncology and Hemato-Oncology, Via Festa del Perdono 7, Milan 20122, Italy; IRCCS Istituto Ortopedico Galeazzi, Neurochirurgia Oncologica, Milan, Italy
| | - Tommaso Sciortino
- Department of Oncology and Hemato-Oncology, Via Festa del Perdono 7, Milan 20122, Italy; IRCCS Istituto Ortopedico Galeazzi, Neurochirurgia Oncologica, Milan, Italy
| | - Marco Rossi
- Department of Oncology and Hemato-Oncology, Via Festa del Perdono 7, Milan 20122, Italy; IRCCS Istituto Ortopedico Galeazzi, Neurochirurgia Oncologica, Milan, Italy
| | - Manuela Caroli
- Unit of Neurosurgery, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Bello
- Department of Oncology and Hemato-Oncology, Via Festa del Perdono 7, Milan 20122, Italy; IRCCS Istituto Ortopedico Galeazzi, Neurochirurgia Oncologica, Milan, Italy
| | - Marco Riva
- IRCCS Istituto Ortopedico Galeazzi, Neurochirurgia Oncologica, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, Universita` degli Studi di Milano, Via Festa del Perdono 7, Milan 20122, Italy
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Berger K, Turowski B, Felsberg J, Malzkorn B, Reifenberger G, Steiger HJ, Budach W, Haussmann J, Knipps J, Rapp M, Hänggi D, Sabel M, Mijderwijk HJ, Kamp MA. Age-stratified clinical performance and survival of patients with IDH-wildtype glioblastoma homogeneously treated by radiotherapy with concomitant and maintenance temozolomide. J Cancer Res Clin Oncol 2020; 147:253-262. [PMID: 32748120 PMCID: PMC7810639 DOI: 10.1007/s00432-020-03334-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/22/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Isocitrate dehydrogenase (IDH)-wildtype glioblastomas are the most malignant glial tumours. Median survival is only 14-16 months after diagnosis, with patients aged ≥ 65 years reportedly showing worse outcome. This study aimed to further evaluate the prognostic role of age in a homogenously treated patient cohort. METHODS The study includes 132 IDH-wildtype glioblastoma patients treated between 2013 and 2017 with open resection followed by radiotherapy with concomitant and maintenance temozolomide. Patients were dichotomized into a non-elderly (< 65 years) and an elderly (≥ 65 years) group. Extent of resection and the O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status were determined for each tumour. Clinical and radiological follow-up data were obtained at 6 weeks after the end of radiation therapy and thereafter in 3-month intervals. Progression-free survival (PFS) and overall survival (OS) were evaluated in univariate and multivariate cox regression analyses. RESULTS The elderly group consisted of 58 patients (median age: 70.5 years) and the non-elderly group of 74 patients (median age: 55 years). Median pre- and postoperative operative Karnofsky Performance Scale (KPS), Eastern Cooperative Oncology Group (ECOG) score and National Institutes of Stroke Scale (NIHSS) were not significantly different between the groups, but KPS and ECOG scores became significantly worse in the elderly group at 6 weeks after termination of radiation therapy. Neither PFS nor OS differed significantly between the age groups. Patients with MGMT promoter-methylated tumours survived longer. CONCLUSION Elderly patients in good pre- and postoperative clinical conditions may show similar outcome as younger patients when treated according to standard of care. However, elderly patients may suffer more frequently from clinical deterioration following chemoradiotherapy. In both age groups, MGMT promoter methylation was linked to longer PFS and OS.
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Affiliation(s)
- Kerstin Berger
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Bernd Turowski
- Institute for Diagnostic and Interventional Radiology, Frankfurt, Germany
| | | | | | | | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jan Haussmann
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Johannes Knipps
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Marion Rapp
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Michael Sabel
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Hendrik-Jan Mijderwijk
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Marcel A Kamp
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany.
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Korja M, Raj R, Seppä K, Luostarinen T, Malila N, Seppälä M, Mäenpää H, Pitkäniemi J. Glioblastoma survival is improving despite increasing incidence rates: a nationwide study between 2000 and 2013 in Finland. Neuro Oncol 2020; 21:370-379. [PMID: 30312433 DOI: 10.1093/neuonc/noy164] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND We assessed population-level changes in glioblastoma survival between 2000 and 2013 in Finland, with focus on elderly patients (>70 y) in order to assess if changes in treatment of glioblastoma are reflected also in population-based survival rates. METHODS We identified all patients (age ≥18 y) from the Finnish Cancer Registry (FCR) with a histopathological diagnosis of primary glioblastoma in 2000-2013. Patients were followed up until December 2015. The accuracy of register-based search of glioblastoma patients was internally validated. We report age-standardized relative survival ratios and relative excess risks (RERs) of death in 2000-2006 (pre-period) and 2007-2013 (post-period). RESULTS We identified 2045 glioblastoma patients from the FCR. The accuracy of the FCR-based search was 97%. Median age was 63.3 years, and 42% were women. Incidence increased on average by 1.6% (P = 0.004) and median age by 0.4 years per calendar year. Between the pre- and post-periods, the proportion of patients >70 years increased from 24% to 27%. In >70-year-old patients, the median survival time increased from 3.6 months in 2000-2006 to 4.5 months in 2007-2013 (RER 0.82, 95% CI: 0.68-0.98). In ≤70-year-old patients, the median survival time increased from 9.3 months in 2000-2006 to 11.7 months in 2007-2013 (RER 0.74, 95% CI: 0.67-0.82). CONCLUSION Despite the increased proportion of elderly glioblastoma patients, population-level survival of glioblastoma patients has improved since the year 2000. However, increasing incidence, increasing age of patients, and poor survival in elderly are alarming, and future studies should perhaps focus more on elderly.
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Affiliation(s)
- Miikka Korja
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Karri Seppä
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland
| | - Tapio Luostarinen
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland
| | - Nea Malila
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland
| | - Matti Seppälä
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Mäenpää
- Department of Oncology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Janne Pitkäniemi
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland
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20
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Hanna C, Lawrie TA, Rogozińska E, Kernohan A, Jefferies S, Bulbeck H, Ali UM, Robinson T, Grant R. Treatment of newly diagnosed glioblastoma in the elderly: a network meta-analysis. Cochrane Database Syst Rev 2020; 3:CD013261. [PMID: 32202316 PMCID: PMC7086476 DOI: 10.1002/14651858.cd013261.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND A glioblastoma is a fatal type of brain tumour for which the standard of care is maximum surgical resection followed by chemoradiotherapy, when possible. Age is an important consideration in this disease, as older age is associated with shorter survival and a higher risk of treatment-related toxicity. OBJECTIVES To determine the most effective and best-tolerated approaches for the treatment of elderly people with newly diagnosed glioblastoma. To summarise current evidence for the incremental resource use, utilities, costs and cost-effectiveness associated with these approaches. SEARCH METHODS We searched electronic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase to 3 April 2019, and the NHS Economic Evaluation Database (EED) up to database closure. We handsearched clinical trial registries and selected neuro-oncology society conference proceedings from the past five years. SELECTION CRITERIA Randomised trials (RCTs) of treatments for glioblastoma in elderly people. We defined 'elderly' as 70+ years but included studies defining 'elderly' as over 65+ years if so reported. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for study selection and data extraction. Where sufficient data were available, treatment options were compared in a network meta-analysis (NMA) using Stata software (version 15.1). For outcomes with insufficient data for NMA, pairwise meta-analysis were conducted in RevMan. The GRADE approach was used to grade the evidence. MAIN RESULTS We included 12 RCTs involving approximately 1818 participants. Six were conducted exclusively among elderly people (either defined as 65 years or older or 70 years or older) with newly diagnosed glioblastoma, the other six reported data for an elderly subgroup among a broader age range of participants. Most participants were capable of self-care. Study quality was commonly undermined by lack of outcome assessor blinding and attrition. NMA was only possible for overall survival; other analyses were pair-wise meta-analyses or narrative syntheses. Seven trials contributed to the NMA for overall survival, with interventions including supportive care only (one trial arm); hypofractionated radiotherapy (RT40; four trial arms); standard radiotherapy (RT60; five trial arms); temozolomide (TMZ; three trial arms); chemoradiotherapy (CRT; three trial arms); bevacizumab with chemoradiotherapy (BEV_CRT; one trial arm); and bevacizumab with radiotherapy (BEV_RT). Compared with supportive care only, NMA evidence suggested that all treatments apart from BEV_RT prolonged survival to some extent. Overall survival High-certainty evidence shows that CRT prolongs overall survival (OS) compared with RT40 (hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.56 to 0.80) and low-certainty evidence suggests that CRT may prolong overall survival compared with TMZ (TMZ versus CRT: HR 1.42, 95% CI 1.01 to 1.98). Low-certainty evidence also suggests that adding BEV to CRT may make little or no difference (BEV_CRT versus CRT: HR 0.83, 95% CrI 0.48 to 1.44). We could not compare the survival effects of CRT with different radiotherapy fractionation schedules (60 Gy/30 fractions and 40 Gy/15 fractions) due to a lack of data. When treatments were ranked according to their effects on OS, CRT ranked higher than TMZ, RT and supportive care only, with the latter ranked last. BEV plus RT was the only treatment for which there was no clear benefit in OS over supportive care only. One trial comparing tumour treating fields (TTF) plus adjuvant chemotherapy (TTF_AC) with adjuvant chemotherapy alone could not be included in the NMA as participants were randomised after receiving concomitant chemoradiotherapy, not before. Findings from the trial suggest that the intervention probably improves overall survival in this selected patient population. We were unable to perform NMA for other outcomes due to insufficient data. Pairwise analyses were conducted for the following. Quality of life Moderate-certainty narrative evidence suggests that overall, there may be little difference in QoL between TMZ and RT, except for discomfort from communication deficits, which are probably more common with RT (1 study, 306 participants, P = 0.002). Data on QoL for other comparisons were sparse, partly due to high dropout rates, and the certainty of the evidence tended to be low or very low. Progression-free survival High-certainty evidence shows that CRT increases time to disease progression compared with RT40 (HR 0.50, 95% CI 0.41 to 0.61); moderate-certainty evidence suggests that RT60 probably increases time to disease progression compared with supportive care only (HR 0.28, 95% CI 0.17 to 0.46), and that BEV_RT probably increases time to disease progression compared with RT40 alone (HR 0.46, 95% CI 0.27 to 0.78). Evidence for other treatment comparisons was of low- or very low-certainty. Severe adverse events Moderate-certainty evidence suggests that TMZ probably increases the risk of grade 3+ thromboembolic events compared with RT60 (risk ratio (RR) 2.74, 95% CI 1.26 to 5.94; participants = 373; studies = 1) and also the risk of grade 3+ neutropenia, lymphopenia, and thrombocytopenia. Moderate-certainty evidence also suggests that CRT probably increases the risk of grade 3+ neutropenia, leucopenia and thrombocytopenia compared with hypofractionated RT alone. Adding BEV to CRT probably increases the risk of thromboembolism (RR 16.63, 95% CI 1.00 to 275.42; moderate-certainty evidence). Economic evidence There is a paucity of economic evidence regarding the management of newly diagnosed glioblastoma in the elderly. Only one economic evaluation on two short course radiotherapy regimen (25 Gy versus 40 Gy) was identified and its findings were considered unreliable. AUTHORS' CONCLUSIONS For elderly people with glioblastoma who are self-caring, evidence suggests that CRT prolongs survival compared with RT and may prolong overall survival compared with TMZ alone. For those undergoing RT or TMZ therapy, there is probably little difference in QoL overall. Systemic anti-cancer treatments TMZ and BEV carry a higher risk of severe haematological and thromboembolic events and CRT is probably associated with a higher risk of these events. Current evidence provides little justification for using BEV in elderly patients outside a clinical trial setting. Whilst the novel TTF device appears promising, evidence on QoL and tolerability is needed in an elderly population. QoL and economic assessments of CRT versus TMZ and RT are needed. More high-quality economic evaluations are needed, in which a broader scope of costs (both direct and indirect) and outcomes should be included.
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Affiliation(s)
- Catherine Hanna
- University of GlasgowDepartment of OncologyBeatson West of Scotland Cancer CentreGreat Western RoadGlasgowScotlandUKG4 9DL
| | - Theresa A Lawrie
- The Evidence‐Based Medicine Consultancy Ltd3rd Floor Northgate HouseUpper Borough WallsBathUKBA1 1RG
| | - Ewelina Rogozińska
- The Evidence‐Based Medicine Consultancy Ltd3rd Floor Northgate HouseUpper Borough WallsBathUKBA1 1RG
| | - Ashleigh Kernohan
- Newcastle UniversityInstitute of Health & SocietyBaddiley‐Clark Building, Richardson RoadNewcastle upon TyneUKNE2 4AA
| | - Sarah Jefferies
- Addenbrooke's HospitalDepartment of OncologyHills RoadCambridgeUKCB2 0QQ
| | - Helen Bulbeck
- brainstrustDirector of Services4 Yvery CourtCastle RoadCowesIsle of WightUKPO31 7QG
| | - Usama M Ali
- University of OxfordNuffield Department of Population HealthRoosevelt DriveOld Road CampusOxfordOxfordshireUKOX3 7LF
| | - Tomos Robinson
- Newcastle UniversityInstitute of Health & SocietyBaddiley‐Clark Building, Richardson RoadNewcastle upon TyneUKNE2 4AA
| | - Robin Grant
- Western General HospitalEdinburgh Centre for Neuro‐Oncology (ECNO)Crewe RoadEdinburghScotlandUKEH4 2XU
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Werlenius K, Fekete B, Blomstrand M, Carén H, Jakola AS, Rydenhag B, Smits A. Patterns of care and clinical outcome in assumed glioblastoma without tissue diagnosis: A population-based study of 131 consecutive patients. PLoS One 2020; 15:e0228480. [PMID: 32053655 PMCID: PMC7017992 DOI: 10.1371/journal.pone.0228480] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/15/2020] [Indexed: 11/19/2022] Open
Abstract
Background Elderly patients with glioblastoma and an accumulation of negative prognostic factors have an extremely short survival. There is no consensus on the clinical management of these patients and many may escape histologically verified diagnosis. The primary aim of this study was to characterize this particular subgroup of patients with radiological glioblastoma diagnosis without histological verification. The secondary aim was to evaluate if oncological therapy was of benefit. Methods Between November 2012 and June 2016, all consecutive patients presenting with a suspected glioblastoma in the western region of Sweden were registered in a population-based study. Of the 378 patients, 131 (35%) met the inclusion criteria of the present study by typical radiological features of glioblastoma without histological verification. Results The clinical characteristics of the 131 patients (72 men, 59 women) were: age ≥ 75 (n = 99, 76%), performance status according to Eastern Cooperative Oncology Group ≥ 2 (n = 93, 71%), significant comorbidity (n = 65, 50%) and multilobular tumors (n = 90, 69%). The overall median survival rate was 3.6 months. A subgroup of 44 patients (34%) received upfront treatment with temozolomide, with an overall radiological response rate of 34% and a median survival of 6.8 months, compared to 2.7 months for those receiving best supportive care only. Good performance status and temozolomide treatment were statistically significant favorable prognostic factors, while younger age was not. Conclusion Thirty-five percent of patients with a radiological diagnosis of glioblastoma in our region lacked histological diagnosis. Apart from high age and poor performance status, they had more severe comorbidities and extensive tumor spread. Even for this poor prognostic group upfront treatment with temozolomide was shown of benefit in a subgroup of patients. Our data illustrate the need of non-invasive diagnostic methods to guide optimal individualized therapy for patients considered too fragile for neurosurgical biopsy.
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Affiliation(s)
- Katja Werlenius
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- * E-mail:
| | - Boglarka Fekete
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Malin Blomstrand
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Carén
- Sahlgrenska Cancer Center, Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Asgeir S. Jakola
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bertil Rydenhag
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anja Smits
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Neuroscience, Neurology, Uppsala University, Gothenburg, Sweden
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22
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Alassiri AH, Alkhaibary A, Al-Sarheed S, Alsufani F, Alharbi M, Alkhani A, Aloraidi A. O 6-methylguanine-DNA methyltransferase promoter methylation and isocitrate dehydrogenase mutation as prognostic factors in a cohort of Saudi patients with glioblastoma. Ann Saudi Med 2019; 39:410-416. [PMID: 31804140 PMCID: PMC6894451 DOI: 10.5144/0256-4947.2019.410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Treatment of glioblastoma (GB), the most common malignant primary brain tumor in adults, can include alkylating chemo-therapeutic agents. Two molecular biomarkers of treatment response are MGMT (O6-methylguanine-DNA methyltransferase) promoter methylation and IDH (isocitrate dehydrogenase) mutations, which prevent repair of tumor cell DNA damage caused by alkylating chemotherapy. The status of MGMT promoter methylation and IDH mutation are associated with longer survival and a better response to chemotherapy. OBJECTIVE Assess the prognostic value of MGMT methylation status and IDH mutation in adult Saudi glioblastoma patients. DESIGN Retrospective, comparative survival analysis. SETTING Tertiary care center. PATIENTS AND METHODS The status of the MGMT promoter methylation and IDH mutation was assessed in adult patients diagnosed with GB between 2006 and 2019. A PCR-based assay was used to analyze for methylation of the MGMT promoter. A qualitative assay combining PCR clamping and amplification refractory mutation system technology was used to search for any of the 12 most common mutations in IDH1 and IDH2. Differences in survival were compared between those with and without MGMT promoter methylation and IDH mutation and between other subgroups. MAIN OUTCOME MEASURES Survival of GB patients relative to MGMT promoter methylation and IDH mutation status. SAMPLE SIZE 146 patients (80 males and 66 females). RESULTS Of 43 (29.5%) cases tested for MGMT promoter methylation, 14 (32.5%) were positive. Of 65 (44.5%) cases screened for IDH mutation, 6 cases (9.2%) tested positive. The 36-month survival rate was 47% for the MGMT methylated cohort compared to 27% for their unmethylated counterparts. The 18-month survival rate for the IDH-mutant was 75% compared to 48% for their IDH-wildtype counterparts. CONCLUSION The findings confirm the positive impact of both MGMT promoter methylation and IDH mutation on the overall survival of Saudi GB patients. LIMITATIONS Single institute study with relatively few tested cases. CONFLICT OF INTEREST None.
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Affiliation(s)
- Ali H Alassiri
- From the College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,From the Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ali Alkhaibary
- From the College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Saud Al-Sarheed
- From the College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Fahd Alsufani
- From the Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Mohammed Alharbi
- From the Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ahmed Alkhani
- From the Department of Neurosurgery, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ahmed Aloraidi
- From the Department of Neurosurgery, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Hypofractionated versus standard radiation therapy in combination with temozolomide for glioblastoma in the elderly: a meta-analysis. J Neurooncol 2019; 143:177-185. [PMID: 30919157 DOI: 10.1007/s11060-019-03155-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 03/21/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is no clear consensus regarding the optimal treatment for glioblastoma (GBM) in the elderly. Hypofractionated radiation therapy (hRT) has emerged as a viable and comparable radiation regime compared to standard radiation therapy (sRT), however the survival effect of temozolomide (TMZ) with hRT is uncertain. The aim of this meta-analysis was to evaluate survival outcomes of hRT + TMZ vs sRT + TMZ in this specific demographic. METHODS Searches of 7 electronic databases from inception to January 2019 were conducted following the appropriate guidelines. Articles were screened against pre-specified criteria. The progression free survival (PFS) and overall survival (OS) metrics were then extracted and pooled by meta-analysis evaluating mean difference (MD). RESULTS A total of 7 individual comparative studies describing hRT + TMZ vs sRT + TMZ (n = 917) respectively satisfied inclusion criteria. Meta-analysis by random-effects modelling indicated that compared to sRT + TMZ, hRT + TMZ resulted in comparable PFS (MD 0.3 months; 95% CI - 2.4 to 2.9; I2 = 91.7%; P-effect = 0.85) and significantly shorter OS (MD - 3.5 months; 95% CI - 6.3 to - 0.6; I2 = 98.9%; P-effect = 0.02). Subgroup analysis between age definitions of elderly of > 65 vs > 70 years old both demonstrated the same significant trend with no statistical difference between the groups. CONCLUSION The combination of hRT + TMZ is feasible in well-selected elderly GBM cases, and appears to confer a statistically comparable PFS compared to sRT + TMZ. However, expectations that the OS with hRT + TMZ is comparable to that of sRT + TMZ in all elderly GBM presentations should be tempered. It is likely a specific subgroup of elderly GBM patients will benefit greatly from the addition of TMZ to hRT, and greater investigation is needed to identify their characteristics.
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Lawrie TA, Hanna CR, Rogozińska E, Kernohan A, Vale L, Bulbeck H, Ali UM, Grant R. Treatment of newly diagnosed glioblastoma in the elderly. Hippokratia 2019. [DOI: 10.1002/14651858.cd013261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Theresa A Lawrie
- 1st Floor Education Centre, Royal United Hospital; Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group; Combe Park Bath UK BA1 3NG
| | - Catherine R Hanna
- University of Glasgow; Department of Oncology; Beatson West of Scotland Cancer Centre Great Western Road Glasgow Scotland UK G4 9DL
| | | | - Ashleigh Kernohan
- Newcastle University; Institute of Health & Society; Baddiley-Clark Building, Richardson Road Newcastle upon Tyne UK NE2 4AA
| | - Luke Vale
- Newcastle University; Institute of Health & Society; Baddiley-Clark Building, Richardson Road Newcastle upon Tyne UK NE2 4AA
| | - Helen Bulbeck
- brainstrust; Director of Services; 4 Yvery Court Castle Road Cowes Isle of Wight UK PO31 7QG
| | - Usama M Ali
- University of Oxford; Centre for Statistics in Medicine; 7 Dewsbury Road Luton Bedfordshire UK LU3 2HJ
| | - Robin Grant
- Western General Hospital; Edinburgh Centre for Neuro-Oncology (ECNO); Crewe Road Edinburgh Scotland UK EH4 2XU
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25
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Navarria P, Pessina F, Cozzi L, Tomatis S, Reggiori G, Simonelli M, Santoro A, Clerici E, Franzese C, Carta G, Conti Nibali M, Bello L, Scorsetti M. Phase II study of hypofractionated radiation therapy in elderly patients with newly diagnosed glioblastoma with poor prognosis. TUMORI JOURNAL 2018; 105:47-54. [PMID: 30131010 DOI: 10.1177/0300891618792483] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE: To evaluate hypofractionated radiation therapy (HFRT) given at therapeutic effective doses in a phase II study. Endpoints were progression-free survival (PFS) rate, overall survival (OS), and incidence of toxicity. METHODS: Patients with newly diagnosed glioblastoma, age ⩾70 years, Karnofsky performance scale (KPS) score ⩽60, were enrolled. The total dose of HFRT was 52.5 Gy/15 fractions, corresponded to a biological effective dose to the tumor of 70.88 Gy. RESULTS: Thirty patients were treated, with a median age of 75 years. Concurrent and adjuvant temozolomide chemotherapy (TMZ-CHT) was administered in 7 (23.3%) and 11 (40.7%) patients received only adjuvant TMZ-CHT. The median, 6-month PFS, and 12-month PFS were 5.0 months, 43.3%, and 20%, respectively. The median, 6-month OS, and 12-month OS were 8 months, 90%, and 30%, respectively. At the last observation time, 26 patients (86.7%) were dead and 4 (13.3%) were alive. No increase in steroid drugs was required during radiotherapy treatment and a reduction was possible in 12 (40%). Patients with KPS=60, RPA V, MGMT methylated status, neurological status stable or improved after surgery and who underwent HFRT with concurrent and adjuvant CHT, had the better outcome. CONCLUSION: HFRT has proven to be feasible and effective, with limited morbidity, for selected elderly and frail patients with newly diagnosed glioblastoma. The primary objective of this study was not reached in the whole cohort but only in selected patients, who need more aggressive treatment.
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Affiliation(s)
- Pierina Navarria
- 1 Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Federico Pessina
- 2 Neurosurgical Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Luca Cozzi
- 1 Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy.,4 Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Stefano Tomatis
- 1 Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Giacomo Reggiori
- 1 Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Matteo Simonelli
- 3 Hematology and Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Armando Santoro
- 3 Hematology and Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy.,4 Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Elena Clerici
- 1 Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Ciro Franzese
- 1 Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Giulio Carta
- 1 Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Marco Conti Nibali
- 2 Neurosurgical Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Lorenzo Bello
- 2 Neurosurgical Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Marta Scorsetti
- 1 Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy.,4 Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
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26
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Treatment recommendations for elderly patients with newly diagnosed glioblastoma lack worldwide consensus. J Neurooncol 2018; 140:421-426. [PMID: 30088191 DOI: 10.1007/s11060-018-2969-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Glioblastoma predominantly occurs in the 6th and 7th decades of life. The optimal treatment paradigm for elderly patients is not well established. We sampled current worldwide management strategies for elderly patients with newly diagnosed glioblastoma. METHODS A web-based survey was developed and distributed to 168 radiation oncologists, neuro-oncologists and neurosurgeons identified through the United Council for Neurologic Subspecialties and the CNS committees for North American, European and Asian Organizations. Questions addressed treatment recommendations in order to determine whether management consensus exists in this patient subset. RESULTS There were 68 (40%) respondents. Across respondents, the most important factors directing treatment were KPS (94%) and MGMT methylation status (71%). Only 37% of respondents strictly factor in age when making treatment recommendations with 59% defining elderly as greater than 70 years-old. The most common treatment recommendations for MGMT-methylated elderly patients with KPS > 70 were as follows: standard chemoRT (49%), short course chemoRT (39%), and temozolomide alone (30%). The most common treatment recommendations for MGMT-unmethylated patients with KPS > 70 were as follows: short course RT alone (51%), standard chemoRT (38%), and short course chemoRT (28%). Treatment recommendations for patients with KPS < 50 were short course RT alone (40%), best supportive care (57%), or TMZ alone (17%). Individuals practicing in North America were significantly more likely to recommend standard chemoradiation for patients compared to their European counterparts. CONCLUSION Worldwide treatment recommendations for elderly patients with newly diagnosed GBM vary widely. Further randomized studies are needed to elucidate the optimal treatment strategy for this subset of patients.
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Yusuf MB, Gaskins J, Amsbaugh MJ, Woo S, Burton E. Survival impact of prolonged postoperative radiation therapy for patients with glioblastoma treated with combined-modality therapy. Neurooncol Pract 2018; 6:112-123. [PMID: 31386043 DOI: 10.1093/nop/npy027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Though conventionally fractionated chemoradiation (CRT) is well tolerated by selected patients with newly diagnosed glioblastoma (GBM), adverse health-related and nonhealth-related factors can lead to unplanned interruptions in treatment. The effects of prolonged time to completion (TTC) of radiation therapy (RT) on overall survival (OS) for these patients are unclear. Methods The National Cancer Database (NCDB) was queried for all adult patients with newly diagnosed GBM undergoing surgical resection followed by adjuvant CRT with conventionally fractionated RT (6000-6600 cGy in 30-33 fractions) from 2005 to 2012. TTC was defined as the interval from first to last fraction of RT. Recursive partitioning analysis (RPA) was used to determine a threshold for TTC of adjuvant RT. Cox proportional hazards modeling was used to identify covariates associated with OS. Results A total of 13489 patients were included in our cohort. Patients who completed adjuvant RT within the RPA-defined threshold of 46 days from initiation of RT (median OS: 14.0 months, 95% confidence interval (CI) 13.7 to 14.3 months) had significantly improved OS compared to patients with TTC of 47 days or greater (median OS: 12.0 months, 95% CI 11.4 to 12.6 months, P < .001). Delays in completing adjuvant RT were relatively common, with 15.0% of patients in our cohort having a TTC of RT of 47 days or greater. Conclusions Delays in completing adjuvant RT were associated with a worse survival outcome. Any unnecessary delays in completing adjuvant RT should be minimized while ensuring the safe delivery of therapy.
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Affiliation(s)
- Mehran B Yusuf
- Department of Radiation Oncology, University of Louisville Hospital, Kentucky, USA
| | - Jeremy Gaskins
- Department of Bioinformatics and Biostatistics, University of Louisville, Kentucky, USA
| | - Mark J Amsbaugh
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Shiao Woo
- Department of Radiation Oncology, University of Louisville Hospital, Kentucky, USA
| | - Eric Burton
- Division of Neuro-Oncology, Department of Neurology, University of Louisville, Kentucky, USA
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Pellerino A, Franchino F, Soffietti R, Rudà R. Overview on current treatment standards in high-grade gliomas. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2018; 62:225-238. [PMID: 29696949 DOI: 10.23736/s1824-4785.18.03096-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
High-grade gliomas (HGGs) are the most common primary tumors of the central nervous system, which include anaplastic gliomas (grade III) and glioblastomas (GBM, grade IV). Surgery is the mainstay of treatment in HGGs in order to achieve a histological and molecular characterization, as well as relieve neurological symptoms and improve seizure control. Combinations of some molecular factors, such as IDH 1-2 mutations, 1p/19q codeletion and MGMT methylation status, allow to classify different subtypes of gliomas and identify patients with different outcome. The SOC in HGGs consists in a combination of radiotherapy and chemotherapy with alkylating agents. Despite this therapeutic approach, tumor recurrence occurs in HGGs, and new surgical debulking, reirradiation or second-line chemotherapy are needed. Considering the poor results in terms of survival, several clinical trials have explored the efficacy and tolerability of antiangiogenic agents, targeted therapies against epidermal growth factor receptor (EGFR) and different immunotherapeutic approaches in recurrent and newly-diagnosed GBM, including immune checkpoint inhibitors (ICIs), and cell- or peptide-based vaccination with unsatisfactory results in term of disease control. In this review we describe the major updates in molecular biology of HGGs according to 2016 WHO Classification, the current management in newly-diagnosed and recurrent GBM and grade III gliomas, and the results of the most relevant clinical trials on targeted agents and immunotherapy.
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Affiliation(s)
- Alessia Pellerino
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy -
| | - Federica Franchino
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
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Yusuf M, Ugiliweneza B, Amsbaugh M, Boakye M, Williams B, Nelson M, Hattab EM, Woo S, Burton E. Interim Results of a Phase II Study of Hypofractionated Radiotherapy with Concurrent Temozolomide Followed by Adjuvant Temozolomide in Patients over 70 Years Old with Newly Diagnosed Glioblastoma. Oncology 2018; 95:39-42. [PMID: 29694955 DOI: 10.1159/000488395] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 03/12/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE In this phase II study, we investigate clinical outcomes and tolerability of hypofractionated radiotherapy (HRT) combined with temozolomide (TMZ) to treat elderly patients with glioblastoma (GBM). METHODS Patients 70 years of age or older with newly diagnosed GBM received HRT to a dose of 34 Gy given in ten fractions over 2 weeks, delivered with concurrent and adjuvant TMZ. RESULTS In this interim analysis, ten patients were enrolled on trial from 12/1/2015 to 4/5/2017. With a median follow-up of 9 months (range 3-12 months), median progression-free survival (PFS) was 6 months. The median overall survival (OS) has not been reached. Estimated 1-year OS and PFS rates were 53.3 and 44.4%, respectively. All patients completed the full course of RT, with no patients developing grade 3 or higher adverse events from treatment. CONCLUSIONS The preliminary results of our phase II trial suggest HRT delivered over 2 weeks with concurrent and adjuvant TMZ is well tolerated in elderly patients with GBM without compromising clinical outcomes.
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Affiliation(s)
- Mehran Yusuf
- Department of Radiation Oncology and the James Graham Brown Cancer Center, University of Louisville Hospital, Louisville, Kentucky, USA
| | | | - Mark Amsbaugh
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Brian Williams
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Megan Nelson
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Eyas M Hattab
- Department of Pathology, University of Louisville, Louisville, Kentucky, USA
| | - Shiao Woo
- Department of Radiation Oncology and the James Graham Brown Cancer Center, University of Louisville Hospital, Louisville, Kentucky, USA
| | - Eric Burton
- Division of Neuro-Oncology, Department of Neurology, University of Louisville Hospital, Louisville, Kentucky, USA
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30
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Yang P, Zhang C, Cai J, You G, Wang Y, Qiu X, Li S, Wu C, Yao K, Li W, Peng X, Zhang W, Jiang T. Radiation combined with temozolomide contraindicated for young adults diagnosed with anaplastic glioma. Oncotarget 2018; 7:80091-80100. [PMID: 27590514 PMCID: PMC5346774 DOI: 10.18632/oncotarget.11756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 08/22/2016] [Indexed: 12/21/2022] Open
Abstract
Purpose Age is a major prognostic factor for malignant gliomas. However, few studies have investigated the management of gliomas in young adults. We determined the role of survival and treatment in young adults with advanced gliomas in a large population from the Chinese Glioma Genome Atlas (CGGA). Methods This study included 726 adults (age ≥ 18) with histologically proven anaplastic glioma or glioblastoma multiforme (GBM). The overall and progression-free survival was determined in young (age < 50) and older groups (age ≥ 50). Results The study included an older group (OP) of 264 patients and a younger group (YP) of 462patients. In the OP group with GBM and anaplastic glioma, patients treated with RT combined with temozolomide (TMZ) manifested significantly longer OS and PFS compared with patients assigned to RT alone (P < 0.05). In contrast, the YP group diagnosed with anaplastic glioma failed to show any survival advantage with RT plus TMZ compared with RT alone. Conclusions We observed no survival benefit in young adults (age < 50) with anaplastic glioma when treated with TMZ combined with RT. Our findings warrant further investigation of younger patients diagnosed with anaplastic glioma treated with radiotherapy plus TMZ chemotherapy.
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Affiliation(s)
- Pei Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Chuanbao Zhang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Jinquan Cai
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Gan You
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Yinyan Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Xiaoguang Qiu
- Department of Radiation Therapy, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shouwei Li
- Department of Neurosurgery, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Chenxing Wu
- Department of Neurosurgery, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Kun Yao
- Department of Pathology, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Wenbin Li
- Department of Oncology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xiaoxia Peng
- Department of Epidemiology and Biostatistics, School of Public Health and Family Medicine, Capital Medical University, Beijing, China
| | - Wei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Tao Jiang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China
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31
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Lanzetta G, Minniti G. Treatment of Glioblastoma in Elderly Patients: An Overview of Current Treatments and Future Perspective. TUMORI JOURNAL 2018; 96:650-8. [DOI: 10.1177/030089161009600502] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Current treatment of glioblastoma in the elderly includes surgery, radiotherapy and chemotherapy, but the prognosis remains extremely poor, and its optimal management is still debated. Longer survival after extensive resection compared with biopsy only has been reported, although the survival advantage remains modest. Radiation in the form of standard (60 Gy in 30 fractions over 6 weeks) and abbreviated courses of radiotherapy (30–50 Gy in 6–20 fractions over 2–4 weeks) has been employed in elderly patients with glioblastoma, showing survival benefits compared with supportive care alone. Temozolomide is an alkylating agent recently employed in older patients with newly diagnosed glioblastoma. The addition of concomitant and/or adjuvant chemotherapy with temozolomide to radiotherapy, which is currently the standard treatment in adults with glioblastoma, is emerging as an effective therapeutic option for older patients with favorable prognostic factors. The potential benefits on survival, improvement in quality of life and toxicity of different schedules of radiotherapy plus temozolomide need to be addressed in future randomized studies. Free full text available at www.tumorionline.it
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Affiliation(s)
| | - Giuseppe Minniti
- Department of Neuroscience, Neuromed Institute, Pozzilli (IS)
- Radiotherapy Oncology, Sant'Andrea Hospital, University “Sapienza”, Rome, Italy
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32
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Muni R, Minniti G, Lanzetta G, Caporello P, Frati A, Enrici MM, Marchetti P, Enrici RM. Short-term Radiotherapy followed by Adjuvant Chemotherapy in Poor-Prognosis Patients with Glioblastoma. TUMORI JOURNAL 2018; 96:60-4. [DOI: 10.1177/030089161009600110] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives The optimal treatment for patients with glioblastoma with unfavorable prognostic factors, such as old age and low performance status, remains controversial. We conducted a prospective study to assess the effect of temozolomide and short-course radiation versus short-course radiation alone in the treatment of poor-prognosis patients with newly diagnosed glioblastoma. Patients and methods Forty-five patients with a newly diagnosed glioblastoma, older than 70 years or aged 50–70 years and with a Karnofsky performance score ≤70 were enrolled in this prospective study. Twenty-three patients were treated with an abbreviated course of radiotherapy (30 Gy in 6 fractions over 2 weeks) and 22 patients with the same radiotherapy schedule plus adjuvant temozolomide at the dose of 150–200 mg/m2 for 5 days every 28-day cycle. The primary end point was overall survival. Secondary end points included progression-free survival and toxicity. Results Median overall survival was 7.3 months in the radiotherapy group and 9.4 months in the radiotherapy plus temozolomide group (P = 0.003), with respective 6-month overall survivals of 78% and 95%, respectively. Median progression-free survival was 4.4 months in the radiotherapy group and 5.5 months in the radiotherapy plus temozolomide group (P = 0.01), and respective 6-month progression-free survival rates were 22% and 45%. In multivariate analysis, Karnofsky performance score was the only significant independent predictive factor of survival (P = 0.03). Adverse effects of radiotherapy were mainly represented by neurotoxicity (24%), which resolved in most cases with the use of steroids. Grade 3-4 hematologic toxicity occurred in 36% of patients treated with temozolomide. Conclusions The addition of temozolomide to short-term radiotherapy resulted in a statistically significant survival benefit with minimal additional toxicity in poor-prognosis patients with newly diagnosed glioblastoma. Future studies need to define the best combined regimens of radiotherapy and temozolomide on survival and quality of life in this subgroup of patients.
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Affiliation(s)
- Roberta Muni
- Department of Radiotherapy S. Andrea Hospital, University “Sapienza”, Rome, Italy
| | - Giuseppe Minniti
- Department of Radiotherapy S. Andrea Hospital, University “Sapienza”, Rome, Italy
- Department of Neurological Sciences, Neuromed Institute, Pozzilli (IS), Rome, Italy
| | - Gaetano Lanzetta
- Department of Neurological Sciences, Neuromed Institute, Pozzilli (IS), Rome, Italy
| | - Paola Caporello
- Department of Medical Oncology, S. Andrea Hospital, University “Sapienza”, Rome, Italy
| | - Alessandro Frati
- Department of Neurological Sciences, Neuromed Institute, Pozzilli (IS), Rome, Italy
| | | | - Paolo Marchetti
- Department of Medical Oncology, S. Andrea Hospital, University “Sapienza”, Rome, Italy
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Sim HW, Morgan ER, Mason WP. Contemporary management of high-grade gliomas. CNS Oncol 2018; 7:51-65. [PMID: 29241354 PMCID: PMC6001673 DOI: 10.2217/cns-2017-0026] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 10/02/2017] [Indexed: 01/01/2023] Open
Abstract
High-grade gliomas, including glioblastoma, are the most common malignant brain tumors in adults. Despite intensive efforts to develop new therapies for these diseases, treatment options remain limited and prognosis is poor. Recently, there have been important advances in our understanding of the molecular basis of glioma, leading to refinements in our diagnostic and management approach. There is new evidence to guide the treatment of elderly patients. A multitude of new agents have been investigated, including targeted therapies, immunotherapeutics and tumor-treating fields. This review summarizes the key findings from this research, and presents a perspective on future opportunities to advance the field.
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Affiliation(s)
- Hao-Wen Sim
- Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada
| | - Erin R Morgan
- Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada
| | - Warren P Mason
- Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada
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A Model to Predict the Feasibility of Concurrent Chemoradiotherapy With Temozolomide in Glioblastoma Multiforme Patients Over Age 65. Am J Clin Oncol 2017; 40:523-529. [PMID: 26017481 DOI: 10.1097/coc.0000000000000198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES It is controversial whether concurrent chemoradiotherapy (CRT) with temozolomide is feasible and beneficial in elderly patients with glioblastoma. MATERIALS AND METHODS Retrospective analysis of 74 elderly glioblastoma patients (65 y and above) treated with concurrent CRT with temozolomide. Factors influencing prognosis and feasibility of CRT were investigated. RESULTS The median overall survival was 11.3 months. Univariate analysis showed a significant difference in median overall survival for cumulative dose of concurrent temozolomide (optimal cutoff, 2655 mg/m; 13.9 mo for >2655 mg/m vs. 4.9 mo for ≤2655 mg/m; P=0.0216, adjusted for multiple testing). Furthermore, cumulative dose of concurrent temozolomide >2655 mg/m was a significant independent prognostic parameter in multivariate analysis (hazard ratio, 0.33; P=0.002). Hematotoxicity was the most common cause of treatment interruption or discontinuation in patients with an insufficient cumulative temozolomide dose. Prognostic factors for successful performance of CRT with a cumulative dose of concurrent temozolomide >2655 mg/m were female sex (odds ratio [OR], 0.174; P=0.006), age (OR, 0.826 per year; P=0.017), and pretreatment platelet count (OR, 1.013 per 1000 platelets/µL; P=0.001). For easy clinical application of the model an online calculator was developed, which is available at http://www.OldTMZ.com. CONCLUSIONS The probability of successful performance of concurrent CRT with temozolomide can be estimated based on the patient's age, sex, and pretreatment platelet count using the model developed in this study. Thus, a subgroup of elderly glioblastoma patients suitable for chemoradiation with temozolomide can be identified.
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Concurrent radiotherapy with temozolomide vs. concurrent radiotherapy with a cisplatinum-based polychemotherapy regimen : Acute toxicity in pediatric high-grade glioma patients. Strahlenther Onkol 2017; 194:215-224. [PMID: 29022050 DOI: 10.1007/s00066-017-1218-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/19/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE As the efficacy of all pediatric high-grade glioma (HGG) treatments is similar and still disappointing, it is essential to also investigate the toxicity of available treatments. METHODS Prospectively recorded hematologic and nonhematologic toxicities of children treated with radiochemotherapy in the HIT GBM-C/D and HIT-HGG-2007 trials were compared. Children aged 3-18 years with histologically proven HGG (WHO grade III and IV tumors) or unequivocal radiologic diagnosis of diffuse intrinsic pontine glioma (DIPG) were included in these trials. The HIT-HGG-2007 protocol comprised concomitant radiochemotherapy with temozolomide, while cisplatinum/etoposide (PE) and PE plus ifosfamide (PEI) in combination with weekly vincristine injections were applied during radiochemotherapy in the HIT GBM-C/D protocol. RESULTS Regular blood counts and information about cellular nadirs were available from 304 patients (leukocytes) and 306 patients (thrombocytes), respectively. Grade 3-4 leukopenia was much more frequent in the HIT GBM-C/D cohort (n = 88, 52%) vs. HIT-HGG-2007 (n = 13, 10%; P <0.001). Grade 3-4 thrombopenia was also more likely in the HIT GBM-C/D cohort (n = 21, 12% vs. n = 3,2%; P <0.001). Grade 3-4 leukopenia appeared more often in children aged 3-7 years (n = 38/85, 45%) than in children aged 8-12 years (n = 39/120, 33%) and 13-18 years (24/100, 24%; P =0.034). In addition, sickness was more frequent in the HIT GBM-C/D cohort (grade 1-2: 44%, grade 3-4: 6% vs. grade 1-2: 28%, grade 3-4: 1%; P <0.001). CONCLUSION Radiochemotherapy involving cisplatinum-based polychemotherapy is more toxic than radiotherapy in combination with temozolomide. Without evidence of differences in therapeutic efficacy, the treatment with lower toxicity, i. e., radiotherapy with temozolomide should be used.
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36
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Das S, Kim AH, Chang S, Berger MS. Management of Elderly Patients with Glioblastoma after CE.6. Front Oncol 2017; 7:196. [PMID: 28913179 PMCID: PMC5582080 DOI: 10.3389/fonc.2017.00196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 08/16/2017] [Indexed: 12/17/2022] Open
Affiliation(s)
- Sunit Das
- Division of Neurosurgery, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Kids, Toronto, ON, Canada
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine, Siteman Cancer Center, St. Louis, MO, United States
| | - Susan Chang
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, United States
| | - Mitchel S Berger
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, United States
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37
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Combined-modality hypofractionated radiotherapy for elderly patients with glioblastoma: setting a new standard. Future Sci OA 2017; 3:FSO210. [PMID: 28884007 PMCID: PMC5583694 DOI: 10.4155/fsoa-2017-0050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 04/20/2017] [Indexed: 12/25/2022] Open
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38
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Harris G, Jayamanne D, Wheeler H, Gzell C, Kastelan M, Schembri G, Brazier D, Cook R, Parkinson J, Khasraw M, Louw S, Back M. Survival Outcomes of Elderly Patients With Glioblastoma Multiforme in Their 75th Year or Older Treated With Adjuvant Therapy. Int J Radiat Oncol Biol Phys 2017; 98:802-810. [DOI: 10.1016/j.ijrobp.2017.02.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 01/01/2017] [Accepted: 02/14/2017] [Indexed: 10/20/2022]
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39
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Glioblastoma multiforme (GBM) in the elderly: initial treatment strategy and overall survival. J Neurooncol 2017; 134:107-118. [PMID: 28527010 DOI: 10.1007/s11060-017-2493-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 05/14/2017] [Indexed: 10/19/2022]
Abstract
The EORTC trial which solidified the role of external beam radiotherapy (EBRT) plus temozolomide (TMZ) in the management of GBM excluded patients over age 70. Randomized studies of elderly patients showed that hypofractionated EBRT (HFRT) alone or TMZ alone was at least equivalent to conventionally fractionated EBRT (CFRT) alone. We sought to investigate the practice patterns and survival in elderly patients with GBM. We identified patients age 65-90 in the National Cancer Data Base (NCDB) with histologically confirmed GBM from 1998 to 2012 and known chemotherapy and radiotherapy status. We analyzed factors predicting treatment with EBRT alone vs. EBRT plus concurrent single-agent chemotherapy (CRT) using multivariable logistic regression. Similarly, within the EBRT alone cohort we compared CFRT (54-65 Gy at 1.7-2.1 Gy/fraction) to HFRT (34-60 Gy at 2.5-5 Gy/fraction). Multivariable Cox proportional hazards model (MVA) with propensity score adjustment was used to compare survival. A total of 38,862 patients were included. Initial treatments for 1998 versus 2012 were: EBRT alone = 50 versus 10%; CRT = 6 versus 50%; chemo alone = 1.6% (70% single-agent) versus 3.2% (94% single-agent). Among EBRT alone patients, use of HFRT (compared to CFRT) increased from 13 to 41%. Numerous factors predictive for utilization of CRT over EBRT alone and for HFRT over CFRT were identified. Median survival and 1-year overall survival were higher in the CRT versus EBRT alone group at 8.6 months vs. 5.1 months and 36.0 versus 15.7% (p < 0.0005 by log-rank, multivariable HR 0.65 [95% CI = 0.61-0.68, p < 0.0005], multivariable HR with propensity adjustment 0.66 [95% CI = 0.63-0.70, p < 0.0005]). For elderly GBM patients in the United States, CRT is the most common initial treatment and appears to offer a survival advantage over EBRT alone. Adoption of hypofractionation has increased over time but continues to be low.
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40
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Binabaj MM, Bahrami A, ShahidSales S, Joodi M, Joudi Mashhad M, Hassanian SM, Anvari K, Avan A. The prognostic value of MGMT promoter methylation in glioblastoma: A meta-analysis of clinical trials. J Cell Physiol 2017; 233:378-386. [PMID: 28266716 DOI: 10.1002/jcp.25896] [Citation(s) in RCA: 204] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 03/06/2017] [Indexed: 01/16/2023]
Abstract
The DNA repair protein O6-Methylguanine-DNA methyltransferase (MGMT) is suggested to be associated with resistance to alkylating agents such as Temozolomide which is being used in treatment of patients with glioblastoma (GBM). Therefore, we evaluated the associations between MGMT promoter methylation and prognosis of patients with glioblastoma (GBM). Data were extracted from publications in Embase, PubMed, and the Cochrane Library. Data on overall survival (OS), progression-free survival (PFS), and MGMT methylation status were obtained and 4,097 subjects were enrolled. Data from 34 studies showed that MGMT methylated patients had better OS, compared to GBM unmethylated patients (pooled HRs, 0.494; 95%CI 0.412-0.591; p = 0.001). Meta-analysis of 10 eligible studies reporting on PFS, demonstrated that MGMT promoter methylation was not significantly associated with better PFS (pooled HRs, 0.653; 95%CI 0.414-1.030; p = 0.067). GBM patients with MGMT methylation were associated with longer overall survival, although this effect was not detected for PFS. Moreover, we performed further analysis in patients underwent a comprehensive imaging evaluation. This data showed a significant association with better OS and PFS, although further studies are warranted to assess the value of emerging marker in prospective setting in patients with glioblastoma as a risk stratification biomarker in clinical management of the patients.
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Affiliation(s)
- Maryam Moradi Binabaj
- Department of Medical Biochemistry, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Afsane Bahrami
- Department of Modern Sciences and Technology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.,Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Soodabeh ShahidSales
- Cancer Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Marjan Joodi
- Department of Pediatric Surgery, School of Medicine, Mashhad University of Medical Sciences, Sarvar Children's Hospital, Endoscopic and Minimally Invasive Surgery Research Center, Mashhad, Iran
| | - Mona Joudi Mashhad
- Cancer Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Mahdi Hassanian
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Kazem Anvari
- Cancer Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Avan
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Cancer Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Straube C, Scherb H, Gempt J, Bette S, Zimmer C, Schmidt-Graf F, Schlegel J, Meyer B, Combs SE. Does age really matter? Radiotherapy in elderly patients with glioblastoma, the Munich experience. Radiat Oncol 2017; 12:77. [PMID: 28454549 PMCID: PMC5408447 DOI: 10.1186/s13014-017-0809-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 04/14/2017] [Indexed: 08/30/2023] Open
Abstract
Background Glioblastoma is usually diagnosed around the age of 60–70 years. Patients older than 65 years are frequently described as “elderly”. Several trials with monotherapy have established treatment regimens that offer therapies with reduced side effects but reduced efficacy. We analysed the outcome of elderly glioblastoma patients treated at our facility. Methods We performed a retrospective analysis of 62 consecutive patients older than 65 years treated for a primary glioblastoma at our facility from 2009 to 2015. Results Median age was 69.6 years (range 65.1–85.6 years); median OS of the entire cohort was 10.9 months. ECOG, MGMT and extent of resection but not age and the time from surgery to radiotherapy were associated with longer survival. Patients treated with adjuvant chemotherapy had a significantly longer survival (20.5 vs. 7.8 months). Furthermore, salvage therapies were associated with significant improved survival when compared to Best Supportive Care (22.3 vs. 8.8 months). Conclusion Also elderly patients are likely to benefit from an aggressive treatment after primary diagnosis of glioblastoma.
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Affiliation(s)
- Christoph Straube
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany. .,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.
| | - Hagen Scherb
- Institute of Computational Biology, Helmholtz Zentrum München, Deutsches Forschungszentrum für Gesundheit und Umwelt (GmbH), Neuherberg, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany
| | - Stefanie Bette
- Department Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany
| | - Claus Zimmer
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.,Department Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany
| | - Jürgen Schlegel
- Department of Neuropathology, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.,Institute for Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Neuherberg, Germany
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42
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Amsbaugh MJ, Yusuf MB, Gaskins J, Burton EC, Woo SY. Patterns of care and predictors of adjuvant therapies in elderly patients with glioblastoma: An analysis of the National Cancer Data Base. Cancer 2017; 123:3277-3284. [DOI: 10.1002/cncr.30730] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/16/2017] [Accepted: 03/17/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Mark J. Amsbaugh
- Department of Radiation Oncology; University of Louisville; Louisville Kentucky
| | - Mehran B. Yusuf
- Department of Radiation Oncology; University of Louisville; Louisville Kentucky
| | - Jeremy Gaskins
- Department of Bioinformatics and Biostatistics; University of Louisville; Louisville Kentucky
| | - Eric C. Burton
- Division of Neuro-Oncology, Department of Neurology; University of Louisville; Louisville Kentucky
| | - Shiao Y. Woo
- Department of Radiation Oncology; University of Louisville; Louisville Kentucky
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43
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Morgan ER, Norman A, Laing K, Seal MD. Treatment and outcomes for glioblastoma in elderly compared with non-elderly patients: a population-based study. ACTA ACUST UNITED AC 2017; 24:e92-e98. [PMID: 28490931 DOI: 10.3747/co.24.3424] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Elderly patients make up a large percentage of the individuals newly diagnosed with glioblastoma (gbm), but they face particular challenges in tolerating standard therapy, and compared with younger patients, they experience significantly shorter survival. We set out to compare clinical characteristics, treatment patterns, and outcomes in a non-elderly group (<65 years) and an elderly group (≥65 years) of patients diagnosed with gbm. METHODS This retrospective population-based study used a province-wide cancer registry to identify patients with a new diagnosis of gbm within a 6-year period (2006-2012). Of the 138 patients identified, 56 (40.6%) were 65 years of age or older. Demographic characteristics, treatment patterns, and overall survival (os) in the elderly and non-elderly groups were compared. Predictors of os were determined using multivariate analysis. RESULTS Elderly patients were more likely to present with a poor performance status (Eastern Cooperative Oncology Group ≥ 2), to undergo biopsy without resection, and to receive whole-brain or hypofractionated radiotherapy. Compared with non-elderly patients, the elderly patients were less likely to receive adjuvant temozolomide. Survival time was significantly shorter in the elderly than in the non-elderly patients (7.2 months vs. 11.2 months). In multivariate analysis, surgical resection, hypofractionated radiotherapy (compared with whole-brain or conventional radiotherapy), and chemotherapy were predictive of os in older patients. Among elderly patients receiving radiation, survival was improved with the use of combined therapy compared with the use of radiation only (11.3 months vs. 4.6 months). CONCLUSIONS Overall survival was shorter for elderly patients with gbm than for non-elderly patients; the elderly patients were also less likely to receive intensive surgical or adjuvant therapy. Our population-based analysis demonstrated improved os with surgical resection, hypofractionated radiotherapy, and temozolomide, and supports the results of recent clinical trials demonstrating a benefit for combination chemoradiotherapy in older patients.
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Affiliation(s)
- E R Morgan
- Gerry and Nancy Pencer Brain Tumour Centre, Princess Margaret Hospital Cancer Centre, Toronto, ON
| | - A Norman
- Cancer Care Program, Dr. H. Bliss Murphy Cancer Centre, St. John's, NL
| | - K Laing
- Cancer Care Program, Dr. H. Bliss Murphy Cancer Centre, St. John's, NL
| | - M D Seal
- Cancer Care Program, Dr. H. Bliss Murphy Cancer Centre, St. John's, NL
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44
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Pretanvil JA, Salinas IQ, Piccioni DE. Glioblastoma in the elderly: treatment patterns and survival. CNS Oncol 2017; 6:19-28. [PMID: 28001088 PMCID: PMC6027939 DOI: 10.2217/cns-2016-0023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 09/07/2016] [Indexed: 11/21/2022] Open
Abstract
AIM The optimal treatment for elderly glioblastoma patients is unclear. We conducted a retrospective review of the California Cancer Registry to examine treatment patterns and survival by age. METHODS We identified 2670 adult patients from the California Cancer Registry with glioblastoma. We compared the extent of resection, treatment type and modality. RESULTS Elderly patients had the greatest overall survival (OS) with combined surgery, radiation and chemotherapy. However, they were more likely to undergo biopsy and less likely to receive combined radiation and chemotherapy than patients <70. CONCLUSION OS was maximized in elderly patients who were able to get some surgical resection and undergo combined radiation and chemotherapy. OS survival in some elderly patients may be improved by more extensive therapy.
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Affiliation(s)
- Jean-Aine Pretanvil
- Department of Neurosciences, UCSD Moores Cancer Center, University of California San Diego, 3855 Health Science Drive, La Jolla, CA 92093-0819, USA
| | - Isaac Q Salinas
- Department of Neurosciences, UCSD Moores Cancer Center, University of California San Diego, 3855 Health Science Drive, La Jolla, CA 92093-0819, USA
| | - David E Piccioni
- Department of Neurosciences, UCSD Moores Cancer Center, University of California San Diego, 3855 Health Science Drive, La Jolla, CA 92093-0819, USA
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Gzell C, Back M, Wheeler H, Bailey D, Foote M. Radiotherapy in Glioblastoma: the Past, the Present and the Future. Clin Oncol (R Coll Radiol) 2017; 29:15-25. [DOI: 10.1016/j.clon.2016.09.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 08/22/2016] [Accepted: 08/25/2016] [Indexed: 10/25/2022]
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Lapointe S, Florescu M, Simonyan D, Michaud K. Impact of standard care on elderly glioblastoma patients. Neurooncol Pract 2016; 4:4-14. [PMID: 31385982 DOI: 10.1093/nop/npw011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Indexed: 11/13/2022] Open
Abstract
Background Uncertainty persists about the survival advantage of concomitant and adjuvant temozolomide (TMZ) plus radiotherapy (RT) in elderly patients with newly diagnosed glioblastoma (GBM). We compared the clinical outcome of unselected elderly GBM patients treated with 4 adjuvant treatment modalities, including the Stupp protocol. Methods From 2010 to 2014, retrospective chart review was performed on 171 GBM patients aged ≥55 who received either concurrent chemoradiation therapy (CCRT) with standard 60 Gy/30 (SRT); CCRT with hypofractionated 40 Gy/15 (HRT); HRT alone; or TMZ alone. Stratification is by age (55-69, ≥70), KPS (<70, ≥70), and resection status (biopsy, resection). Results Out of 171 patients identified, 128(75%) had surgical resection, median age was 66(55-83), and median overall survival (mOS) 11.4mo. Majority (109/171) were treated according to the Stupp protocol (CCRT-SRT), and 106/171 received post-CCRT adjuvant TMZ (median of 3 cycles). In our population, age <70yo was a significant prognostic factor (mOS of patients aged 55-69 vs ≥70 yo = 13.3 vs 6.6 mo; P = .001). However, among the population receiving the Stupp regimen, there was no difference in survival between patients aged 55-69 and those ≥70 (respectively, 14.4 vs 13.2 mo; P = .798). Patients ≥70 yo had similar survival when treated with CCRT-HRT and CCRT-SRT (P = .248), although numbers were small. Conclusions Our data suggests that, despite having a worse global prognostic than their younger counterparts, GBM patients ≥70yo with a good performance status could be treated according to the Stupp protocol with similar survival. Theses results need prospective confirmation.
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Affiliation(s)
- Sarah Lapointe
- Neurology Division, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal H2L 4M1, Canada (S.L.); Hematology and Oncology Division, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal H2L 4M1, Canada (M.F.); Neurosurgery Division, CHU Enfant-Jésus Hospital, Laval University, 1401 18th street, Québec G1J1Z4, Canada (K.M.); Clinical and Evaluative Research Platform, CHU de Québec Research Center, 10 de l'Espinay, D6-747, Québec, QC, G1L 3L5, Canada (D.S.)
| | - Marie Florescu
- Neurology Division, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal H2L 4M1, Canada (S.L.); Hematology and Oncology Division, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal H2L 4M1, Canada (M.F.); Neurosurgery Division, CHU Enfant-Jésus Hospital, Laval University, 1401 18th street, Québec G1J1Z4, Canada (K.M.); Clinical and Evaluative Research Platform, CHU de Québec Research Center, 10 de l'Espinay, D6-747, Québec, QC, G1L 3L5, Canada (D.S.)
| | - David Simonyan
- Neurology Division, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal H2L 4M1, Canada (S.L.); Hematology and Oncology Division, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal H2L 4M1, Canada (M.F.); Neurosurgery Division, CHU Enfant-Jésus Hospital, Laval University, 1401 18th street, Québec G1J1Z4, Canada (K.M.); Clinical and Evaluative Research Platform, CHU de Québec Research Center, 10 de l'Espinay, D6-747, Québec, QC, G1L 3L5, Canada (D.S.)
| | - Karine Michaud
- Neurology Division, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal H2L 4M1, Canada (S.L.); Hematology and Oncology Division, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal H2L 4M1, Canada (M.F.); Neurosurgery Division, CHU Enfant-Jésus Hospital, Laval University, 1401 18th street, Québec G1J1Z4, Canada (K.M.); Clinical and Evaluative Research Platform, CHU de Québec Research Center, 10 de l'Espinay, D6-747, Québec, QC, G1L 3L5, Canada (D.S.)
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Putz F, Putz T, Goerig N, Knippen S, Gryc T, Eyüpoglu I, Rössler K, Semrau S, Lettmaier S, Fietkau R. Improved survival for elderly married glioblastoma patients : Better treatment delivery, less toxicity, and fewer disease complications. Strahlenther Onkol 2016; 192:797-805. [PMID: 27628965 DOI: 10.1007/s00066-016-1046-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 08/17/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Marital status is a well-described prognostic factor in patients with gliomas but the observed survival difference is unexplained in the available population-based studies. METHODS A series of 57 elderly glioblastoma patients (≥70 years) were analyzed retrospectively. Patients received radiotherapy or chemoradiation with temozolomide. The prognostic significance of marital status was assessed. Disease complications, toxicity, and treatment delivery were evaluated in detail. RESULTS Overall survival was significantly higher in married than in unmarried patients (median, 7.9 vs. 4.0 months; p = 0.006). The prognostic significance of marital status was preserved in the multivariate analysis (HR, 0.41; p = 0.011). Married patients could receive significantly higher daily temozolomide doses (mean, 53.7 mg/m² vs. 33.1 mg/m²; p = 0.020), were more likely to receive maintenance temozolomide (45.7 % vs. 11.8 %; p = 0.016), and had to be hospitalized less frequently during radiotherapy (55.0 % vs. 88.2 %; p = 0.016). Of the patients receiving temozolomide, married patients showed significantly lower rates of hematologic and liver toxicity. Most complications were infectious or neurologic in nature. Complications of any grade were more frequent in unmarried patients (58.8 % vs. 30.0 %; p = 0.041) with the incidence of grade 3-5 complications being particularly elevated (47.1 % vs. 15.0 %; p = 0.004). CONCLUSION We found poorer treatment delivery as well as an unexpected severe increase in toxicity and disease complications in elderly unmarried glioblastoma patients. Marital status may be an important predictive factor for clinical decision-making and should be addressed in further studies.
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Affiliation(s)
- Florian Putz
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitätsstraße 27, 91054, Erlangen, Germany.
| | - Tobias Putz
- Professorship of Demography, University of Bamberg, Feldkirchenstraße 21, 96052, Bamberg, Germany
| | - Nicole Goerig
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitätsstraße 27, 91054, Erlangen, Germany
| | - Stefan Knippen
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitätsstraße 27, 91054, Erlangen, Germany
| | - Thomas Gryc
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitätsstraße 27, 91054, Erlangen, Germany
| | - Ilker Eyüpoglu
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Karl Rössler
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitätsstraße 27, 91054, Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitätsstraße 27, 91054, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitätsstraße 27, 91054, Erlangen, Germany
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Zhang C, Wang X, Hao S, Su Z, Zhang P, Li Y, Song G, Yu L, Wang J, Ji N, Xie J, Gao Z. Analysis of Treatment Tolerance and Factors Associated with Overall Survival in Elderly Patients with Glioblastoma. World Neurosurg 2016; 95:77-84. [PMID: 27485530 DOI: 10.1016/j.wneu.2016.07.079] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 07/22/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND As the population ages, the proportion of elderly patients with glioblastomas has increased. Recently, many researchers have focused on the treatments available to and prognoses in elderly patients with glioblastomas. METHODS We conducted a retrospective study of glioblastoma patients aged 60 years old or older who were treated at the Neurosurgery Center at Beijing Tiantan Hospital from 2012 to 2014. Their clinical features, immunohistochemical characteristics, treatments, and outcomes were evaluated to determine treatment tolerance and identify prognostic factors. RESULTS Among the 70 included patients, the median survival time was 15 months. In the univariate analysis, patients who underwent a gross total resection had longer overall survival times than patients who had a subtotal resection (P < 0.05), and patients who received postoperative adjuvant therapy had longer overall survival times than those with no postoperative adjuvant therapy (P < 0.05). The expression of the p53 protein significantly affected overall survival. Patients with low p53 protein expression had a median survival of 17 months, whereas those who had high p53 protein expression had a median survival of 11.50 months (P < 0.05). Undergoing a gross total resection, receiving postoperative adjuvant therapy and having low p53 protein expression were factors that independently contributed to longer overall survival times in multivariate analysis. CONCLUSIONS Maximal safe surgical resection followed by radiotherapy with concurrent and adjuvant temozolomide significantly prolonged overall survival times and was well tolerated in elderly patients with glioblastomas. In addition, low p53 protein expression was a significant favorable prognostic indicator in this population.
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Affiliation(s)
- Chaocai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research for Neurological Diseases, Beijing, China
| | - Xingchao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research for Neurological Diseases, Beijing, China
| | - Shuyu Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research for Neurological Diseases, Beijing, China
| | - Zhaoping Su
- Department of Epidemiology and Health Statistics, Academy of Public Health and Management, Weifang Medical University, Weifang, China
| | - Peng Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research for Neurological Diseases, Beijing, China
| | - Yajie Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research for Neurological Diseases, Beijing, China
| | - Guidong Song
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research for Neurological Diseases, Beijing, China
| | - Lanbing Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research for Neurological Diseases, Beijing, China
| | - Jiangfei Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research for Neurological Diseases, Beijing, China
| | - Nan Ji
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research for Neurological Diseases, Beijing, China
| | - Jian Xie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research for Neurological Diseases, Beijing, China
| | - Zhixian Gao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research for Neurological Diseases, Beijing, China.
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Hau E, Shen H, Clark C, Graham PH, Koh ES, L McDonald K. The evolving roles and controversies of radiotherapy in the treatment of glioblastoma. J Med Radiat Sci 2016; 63:114-23. [PMID: 27350891 PMCID: PMC4914819 DOI: 10.1002/jmrs.149] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 08/25/2015] [Accepted: 10/06/2015] [Indexed: 12/22/2022] Open
Abstract
Numerous randomised controlled trials have demonstrated the benefit of radiation therapy in patients with newly diagnosed glioblastoma and it has been the cornerstone of treatment for decades. The aims of this review are to (1) Briefly outline the historical studies which resulted in radiation being the current standard of care as used in the Stupp et al. trial (2) Discuss the evolving role of radiation therapy in the management of elderly patients (3) Review the current evidence and ongoing studies of radiation use in the recurrent/salvage setting and (4) Discuss the continuing controversies of volume delineation in the planning of radiation delivery.
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Affiliation(s)
- Eric Hau
- Cure Brain Cancer Foundation Biomarkers and Translational Research Laboratory Prince of Wales Clinical School UNSW Sydney New South Wales Australia; Cancer Care Centre St George Hospital Sydney New South Wales Australia
| | - Han Shen
- Targeted Therapies Group Children's Cancer Institute Australia Lowy Cancer Research Centre Sydney New South Wales Australia
| | - Catherine Clark
- Cancer Care Centre St George Hospital Sydney New South Wales Australia
| | - Peter H Graham
- St George Cancer Care Centre Kogarah Sydney New South Wales Australia
| | - Eng-Siew Koh
- Liverpool Cancer Care Centre Liverpool Hospital Sydney New South Wales Australia; University of New South Wales Sydney New South Wales Australia
| | - Kerrie L McDonald
- Cure Brain Cancer Foundation Biomarkers and Translational Research Laboratory Prince of Wales Clinical School UNSW Sydney New South Wales Australia
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Jordan JT, Gerstner ER, Batchelor TT, Cahill DP, Plotkin SR. Glioblastoma care in the elderly. Cancer 2015; 122:189-97. [PMID: 26618888 DOI: 10.1002/cncr.29742] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/20/2015] [Accepted: 09/09/2015] [Indexed: 11/10/2022]
Abstract
Glioblastoma is common among elderly patients, a group in which comorbidities and a poor prognosis raise important considerations when designing neuro-oncologic care. Although the standard of care for nonelderly patients with glioblastoma includes maximal safe surgical resection followed by radiotherapy with concurrent and adjuvant temozolomide, the safety and efficacy of these modalities in elderly patients are less certain given the population's underrepresentation in many clinical trials. The authors reviewed the clinical trial literature for reports on the treatment of elderly patients with glioblastoma to provide evidence-based guidance for practitioners. In elderly patients with glioblastoma, there is a survival advantage for those who undergo maximal safe resection, which likely includes an incremental benefit with increasing completeness of resection. Radiotherapy extends survival in selected patients, and hypofractionation appears to be more tolerable than standard fractionation. In addition, temozolomide chemotherapy is safe and extends the survival of patients with tumors that harbor O(6)-methylguanine-DNA methyltransferase (MGMT) promoter methylation. The combination of standard radiation with concurrent and adjuvant temozolomide has not been studied in this population. Although many questions remain unanswered regarding the treatment of glioblastoma in elderly patients, the available evidence provides a framework on which providers may base individual treatment decisions. The importance of tumor biomarkers is increasingly apparent in elderly patients, for whom the therapeutic efficacy of any treatment must be weighed against its potential toxicity. MGMT promoter methylation status has specifically demonstrated utility in predicting the efficacy of temozolomide and should be considered in treatment decisions when possible. Cancer 2016;122:189-197. © 2015 American Cancer Society.
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Affiliation(s)
- Justin T Jordan
- Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Elizabeth R Gerstner
- Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Tracy T Batchelor
- Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel P Cahill
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Scott R Plotkin
- Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Boston, Massachusetts
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