Computer-based assessment of cognitive functions in brain tumor patients

Social cognition and occupational reintegration in primary central nervous system lymphoma long-term survivors: a secondary analysis of a combined data set

OBJECTIVE

Although sociocognitive impairment is linked to failure of occupational reintegration in other clinical populations, less is known on the association of sociocognitive functioning and occupational reintegration in brain tumor patients such as primary central nervous system lymphoma (PCNSL).

METHODS

Twenty PCNSL patients with ongoing complete response to therapy for at least one year were evaluated of whom eight resumed work. The association between occupational status, empathy, alexithymia and social problem solving was analyzed.

RESULTS

Employed and non-employed patients were significantly different in their ability to provide appropriate solutions for social situations even when accounting for neurocognition. Decreased quality of life was associated with sociocognitive impairment.

CONCLUSIONS

Although the results must be replicated in larger, more representative populations, this exploratory analysis tentatively adds facets to the literature on occupational reintegration in brain tumor patients. Forthcoming psychosocial research and clinical practice may target sociocognitive impairment when addressing reintegration after neuro-oncological treatment.

Long-term neurocognitive function and quality of life after multimodal therapy in adult glioma patients: a prospective long-term follow-up

PURPOSE

Multimodal therapies have significantly improved prognosis in glioma. However, in particular radiotherapy may induce long-term neurotoxicity compromising patients' neurocognition and quality of life. The present prospective multicenter study aimed to evaluate associations of multimodal treatment with neurocognition with a particular focus on hippocampal irradiation.

METHODS

Seventy-one glioma patients (WHO grade 1-4) were serially evaluated with neurocognitive testing and quality of life questionnaires. Prior to (baseline) and following further treatment (median 7.1 years [range 4.6-11.0] after baseline) a standardized computerized neurocognitive test battery (NeuroCog FX) was applied to gauge psychomotor speed and inhibition, verbal short-term memory, working memory, verbal and non-verbal memory as well as verbal fluency. Mean ipsilateral hippocampal radiation dose was determined in a subgroup of 27 patients who received radiotherapy according to radiotherapy plans to evaluate its association with neurocognition.

RESULTS

Between baseline and follow-up mean performance in none of the cognitive domains significantly declined in any treatment modality (radiotherapy, chemotherapy, combined radio-chemotherapy, watchful-waiting), except for selective attention in patients receiving chemotherapy alone. Apart from one subtest (inhibition), mean ipsilateral hippocampal radiation dose > 50 Gy (Dmean) as compared to < 10 Gy showed no associations with long-term cognitive functioning. However, patients with Dmean < 10 Gy showed stable or improved performance in all cognitive domains, while patients with > 50 Gy numerically deteriorated in 4/8 domains.

CONCLUSIONS

Multimodal glioma therapy seems to affect neurocognition less than generally assumed. Even patients with unilateral hippocampal irradiation with > 50 Gy showed no profound cognitive decline in this series.

Perioperative levetiracetam for seizure prophylaxis in seizure-naive brain tumor patients with focus on neurocognitive functioning

INTRODUCTION

In seizure-naive brain tumor patients, the efficacy of perioperative prophylactic antiepileptic drug treatment remains controversial. In case of administration, the common preferred drug is levetiracetam (LEV) because of its favorable pharmacological profile. Research to date has not sufficiently determined how LEV affects cognition in the short term, as is the case in the perioperative period. The objective of this prospective study was to examine the neurocognitive functioning of seizure-naive brain tumor patients after receiving LEV perioperatively.

METHODS

Fortythree patients with supratentorial brain tumor scheduled for surgery received LEV three days before until six days after surgery as seizure prophylaxis. Cognitive functioning (NeuroCogFX), LEV plasma-levels, hematotoxicity, side-effects, as well as health-related quality of life (HRQoL, Qolie31), were recorded preoperatively before (Baseline) and after onset of LEV (Pre-Op), 4-6 days postoperatively (Post-Op) and 21 days postoperatively (Follow-Up).

RESULTS

No significant changes in cognitive functioning and HRQoL were seen after onset of preoperative LEV. There was a significant improvement of NeuroCogFX total-score at Follow-Up (p = 0.004) compared to Baseline. The overall-score Qolie31 showed simultaneous improvement patterns as cognitive functioning (p < 0.001). The most frequent side effect related to study drug was somnolence (in 28.6% of patients).

CONCLUSIONS

A significant improvement of cognitive functioning, as well as an improvement in HRQoL, were detected postoperatively. This is presumably due to the debulking effect of the surgery. Nevertheless, LEV has no detrimental effect on cognitive functioning in the perioperative phase in seizure-naive brain tumor patients.

TRIAL REGISTRATION

This study was registered prospectively (Date: 25/11/2015; EudraCT: 2015-003,916-19).

Mid-term treatment-related cognitive sequelae in glioma patients

Purpose

Cognitive functioning represents an essential determinant of quality of life. Since significant advances in neuro-oncological treatment have led to prolonged survival it is important to reliably identify possible treatment-related neurocognitive dysfunction in brain tumor patients. Therefore, the present study specifically evaluates the effects of standard treatment modalities on neurocognitive functions in glioma patients within two years after surgery.

Methods

Eighty-six patients with World Health Organization (WHO) grade 1–4 gliomas were treated between 2004 and 2012 and prospectively followed within the German Glioma Network. They received serial neuropsychological assessment of attention, memory and executive functions using the computer-based test battery NeuroCog FX. As the primary outcome the extent of change in cognitive performance over time was compared between patients who received radiotherapy, chemotherapy or combined radio-chemotherapy and patients without any adjuvant therapy. Additionally, the effect of irradiation and chemotherapy was assessed in subgroup analyses. Furthermore, the potential impact of the extent of tumor resection and histopathological characteristics on cognitive functioning were referred to as secondary outcomes.

Results

After a median of 16.8 (range 5.9–31.1) months between post-surgery baseline neuropsychological assessment and follow-up assessment, all treatment groups showed numerical and often even statistically significant improvement in all cognitive domains. The extent of change in cognitive functioning showed no difference between treatment groups. Concerning figural memory only, irradiated patients showed less improvement than non-irradiated patients (p = 0.029, η² = 0.06). Resected patients, yet not patients with biopsy, showed improvement in all cognitive domains. Compared to patients with astrocytomas, patients with oligodendrogliomas revealed a greater potential to improve in attentional and executive functions. However, the heterogeneity of the patient group and the potentially selected cohort may confound results.

Conclusion

Within a two-year post-surgery interval, radiotherapy, chemotherapy or their combination as standard treatment did not have a detrimental effect on cognitive functions in WHO grade 1–4 glioma patients. Cognitive performance in patients with adjuvant treatment was comparable to that of patients without.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11060-022-04044-1.

Improvement of functional outcome for patients with newly diagnosed grade 2 or 3 gliomas with co-deletion of 1p/19q - IMPROVE CODEL: the NOA-18 trial

Background

Given the young age of patients with CNS WHO grade 2 and 3 oligodendrogliomas and the relevant risk of neurocognitive, functional, and quality-of-life impairment with the current aggressive standard of care treatment, chemoradiation with PCV, of the tumour located in the brain optimizing care is the major challenge.

Methods

NOA-18 aims at improving qualified overall survival (qOS) for adult patients with CNS WHO grade 2 and 3 oligodendrogliomas by randomizing between standard chemoradiation with up to six six-weekly cycles with PCV and six six-weekly cycles with lomustine and temozolomide (CETEG) (n = 182 patients per group accrued over 4 years) thereby delaying radiotherapy and adding the chemoradiotherapy concept at progression after initial radiation-free chemotherapy, allowing for effective salvage treatment and delaying potentially deleterious side effects. QOS represents a new concept and is defined as OS without functional and/or cognitive and/or quality of life deterioration regardless of whether tumour progression or toxicity is the main cause. The primary objective is to show superiority of an initial CETEG treatment followed by partial brain radiotherapy (RT) plus PCV (RT-PCV) at progression over partial brain radiotherapy (RT) followed by procarbazine, lomustine, and vincristine (PCV) chemotherapy (RT-PCV) and best investigators choice (BIC) at progression for sustained qOS. An event concerning a sustained qOS is then defined as a functional and/or cognitive and/or quality of life deterioration after completion of primary therapy on two consecutive study visits with an interval of 3 months, tolerating a deviation of at most 1 month. Assessments are done with a 3-monthly MRI, assessment of the NANO scale, HRQoL, and KPS, and annual cognitive testing. Secondary objectives are evaluation and comparison of the two groups regarding secondary endpoints (short-term qOS, PFS, OS, complete and partial response rate). The trial is planned to be conducted at a minimum of 18 NOA study sites in Germany.

Discussion

qOS represents a new concept. The present NOA trial aims at showing the superiority of CETEG plus RT-PCV over RT-PCV plus BIC as determined at the level of OS without sustained functional deterioration for all patients with oligodendroglioma diagnosed according to the most recent WHO classification.

Trial registration

Clinicaltrials.govNCT05331521. EudraCT 2018–005027-16.

Multimodal assessment of disease activity in glioblastoma : A single center experience

BACKGROUND

Assessment of disease activity in glioblastoma (GBM) can be challenging due to several clinical and radiological pitfalls. Besides MRI, FET-PET and neurocognitive assessment (NA) are used in several neuro-oncological centers in order to improve the specificity of response assessment. We performed a retrospective study to investigate whether the assessment by RANO (Response Assessment in NeuroOncology) corresponds to FET-PET imaging and NA results. Moreover, the concordance of RANO with a final recommendation of an interdisciplinary neuro-oncological tumor board recommendation (TBR) was analyzed.

METHODS

We enrolled 25 consecutive patients with newly diagnosed histologically confirmed GBM in a pilot study, accounting for 81 multimodal test results. All patients were selected after undergoing consecutive follow-up comprising MRI, FET-PET, and NA with a subsequent TBR. Results were analyzed for correlations between RANO, FET-PET and NA. An additional consistency analysis was performed to elucidate the impact of RANO on decision making.

RESULTS

A highly statistically significant correlation was found between RANO and FET-PET and NA results (all P < 0.01); however, 26% of follow-up tests exhibited inconsistent results in multimodal assessment, among which RANO was only 48% in accordance with the final TBR. The concordance of NA and FET-PET with the final TBR was 67% and 86%, respectively.

CONCLUSION

The RANO proved its value in the context of multimodal assessment of disease activity in GBM; however, because the implementation of multimodal assessment showed a considerably high percentage of inconsistent results, further studies are required to investigate the relationship between different assessment techniques, in addition to their overall significance to response rating.

Longitudinal study of cognitive function in glioma patients treated with modern radiotherapy techniques and standard chemotherapy

Introduction: Cognitive function is an important outcome measure in patients with brain tumor, providing information about the patient's clinical situation, treatment effects and possible progressive disease. The aim of this longitudinal study was to evaluate effects of the currently used radiation and chemotherapy treatment on cognitive function and to investigate associations between cognitive function at baseline and progression as well as overall survival.Methods: 32 patients newly diagnosed with malignant glioma were evaluated at baseline with CNS Vital Signs (CNS-VS), a computerized standardized neuropsychological test battery, prior to arc-based radiotherapy and concomitant chemotherapy with Temozolomide. CNS-VS measures the cognitive functions known to be affected in patients with brain tumor, covering nine cognitive domains. Follow-up cognitive evaluations were performed in 26 patients after 3.5 months and in 13 patients 1 year after treatment start.Results: Overall cognitive scores were lower in the studied patient cohort at baseline compared to standardized domain scores. At 3.5 months follow-up cognitive functioning was slightly decreased, but only in 1/9 cognitive domains - visual memory - where significant changes were found compared to baseline test results. Similarly, at 12 months follow-up no significant changes in cognitive test results were seen compared to baseline examination, except for a decrease in the visual memory domain. In relation to early progression, the most significant cognitive deficits were dysfunctional visual memory and low executive functioning at baseline. Low executive function at baseline correlated most significantly with shorter overall survival.Conclusion: The present study suggests that the currently used arc-based radiotherapy and chemotherapy might affect cognitive function less negatively than previously described during treatment and in the first year after treatment in malignant glioma patients. In general, a high cognitive test score at baseline was associated with longer time to progression and with longer survival.

Complete response to therapy: why do primary central nervous system lymphoma patients not return to work?

PURPOSE

Although primary central nervous system lymphomas (PCNSL) represent extremely aggressive brain tumours, high-dose methotrexate in combination with other chemotherapeutic agents has resulted in long-term disease control in a substantial fraction of patients. Advances in treatment efficacy with longer survival resulted in a focus on additional outcome measures such as quality of life (QoL) and neurocognition. Despite recent evidence of return to work as an important aspect of patients' QoL, little is known about occupational reintegration in PCNSL long-term survivors. This study aimed to detect specific characteristics of patients who successfully resumed work after complete response to therapy.

METHODS

Patients with ongoing complete response to therapy completed a test battery capturing neurocognition, social integration, QoL and psychological burden. Of 25 patients who had been in regular employment before diagnosis only eight returned to work after treatment (32%).

RESULTS

Patients who resumed work rated important aspects of their QoL and social integration as higher and suffered less from symptoms affecting QoL than patients who did not resume work. Also, the subjective confidence in their ability to work was higher in patients who resumed work, but independent predictors of return to work were not found in logistic regression analyses.

CONCLUSION

Occupational (re)integration is of clinical relevance in PCNSL patients after complete response to therapy. Due to the small size of our cohort the present results should be considered an exploratory first step. Return to work might be a crucial aspect of QoL and (re)integration into society after cure of PCNSL.

Avaliação Neuropsicológica em Pacientes com Tumores Cerebrais: revisão sistemática da literatura

Os tumores cerebrais (TC) são causados pelo crescimento anormal de células. As consequências dos TC podem envolver prejuízos físicos, cognitivos e emocionais. Objetiva-se identificar e descrever os prejuízos cognitivos associados aos TC, através de uma revisão sistemática da literatura. As buscas realizaram-se nas bases de dados internacionais PubMed/MEDLINE, LILACS, e SCOPUS, incluindo abstracts de artigos publicados de 2006 a 2016. Encontrou-se 501 artigos desses, 31 cumpriram os critérios de inclusão. Os TC, representam 5% das neoplasias, sendo alguns mais agressivos que outros. Apresenta-se como sintomas severos: déficits cognitivos, motores. A avaliação neuropsicológica auxilia na identificação de possíveis alterações cognitivas e no acompanhamento dos efeitos do tratamento, contribuindo para melhor qualidade de vida desses pacientes. Os resultados encontrados indicaram as Escalas Wechsler de Inteligência; Matrizes Progressivas de Raven, Figuras Complexas de Rey, Teste de Retenção Visual de Benton, e Token Test como os mais utilizados, e que evidenciaram como prejuízos os envolvendo a memória, a atenção e funções executivas. A localização mais frequente destes TC eram as regiões frontais e temporais e os gliomas o tipo de tumor mais investigado.

Convergent and criterion validity of the CogState computerized brief battery cognitive assessment in women with and without breast cancer

OBJECTIVE

Computerized tests have increasingly garnered interest for assessing cognitive functioning due to their potential logistical and financial advantages over traditional 'pencil and-paper' neuropsychological tests. However, psychometric information is necessary to guide decisions about their clinical and research utility with varied populations. We explored the convergent construct validity and criterion validity of the CogState computerized tests in breast cancer survivors, a group known to present with mostly mild, subtle cognitive dysfunction.

METHOD

Fifty-three post-menopausal women (26 breast cancer survivors, 27 healthy controls) completed the CogState Brief Battery tests with passed performance checks, conceptually matched traditional neuropsychological tests, and a self-report measure of daily functioning, the Functional Activities Questionnaire.

RESULTS

Significant positive correlations were found between the CogState Brief Battery tests and traditional neuropsychological tests, although the traditional tests specifically hypothesized to correlate with CogState tests did not reach statistical significance. Analysis of Covariance results showed preliminary support for criterion validity, as the patient and control groups differed on the traditional test of working memory (Digits Backwards, p = .01), with a trend towards significance for the CogState test of working memory (One Back, p = .02), controlled for age, race, and mood.

CONCLUSIONS

The results provide preliminary support for further research to determine if the CogState tests are viable as screening tools to detect subtle cognitive differences between breast cancer survivors and healthy women. Our study was limited by the low base rate of cognitive impairment and small sample size. We recommend further research employing sufficiently powered sample sizes and a longitudinal, repeated measures study design.

CogState computerized memory tests in patients with brain metastases: secondary endpoint results of NRG Oncology RTOG 0933

Whole brain radiotherapy (WBRT) is associated with memory dysfunction. As part of NRG Oncology RTOG 0933, a phase II study of WBRT for brain metastases that conformally avoided the hippocampal stem cell compartment (HA-WBRT), memory was assessed pre- and post-HA-WBRT using both traditional and computerized memory tests. We examined whether the computerized tests yielded similar findings and might serve as possible alternatives for assessment of memory in multi-institution clinical trials. Adult patients with brain metastases received HA-WBRT to 30 Gy in ten fractions and completed Hopkins Verbal Learning Test-Revised (HVLT-R), CogState International Shopping List Test (ISLT) and One Card Learning Test (OCLT), at baseline, 2 and 4 months. Tests' completion rates were 52-53 % at 2 months and 34-42 % at 4 months. All baseline correlations between HVLT-R and CogState tests were significant (p ≤ 0.003). At baseline, both CogState tests and one component of HVLT-R differentiated those who were alive at 6 months and those who had died (p ≤ 0.01). At 4 months, mean relative decline was 7.0 % for HVLT-R Delayed Recall and 18.0 % for ISLT Delayed Recall. OCLT showed an 8.0 % increase. A reliable change index found no significant changes from baseline to 2 and 4 months for ISLT Delayed Recall (z = -0.40, p = 0.34; z = -0.68, p = 0.25) or OCLT (z = 0.15, p = 0.56; z = 0.41, p = 0.66). Study findings support the possibility that hippocampal avoidance may be associated with preservation of memory test performance, and that these computerized tests also may be useful and valid memory assessments in multi-institution adult brain tumor trials.

Glioma

Gliomas are primary brain tumours that are thought to derive from neuroglial stem or progenitor cells. On the basis of their histological appearance, they have been traditionally classified as astrocytic, oligodendroglial or ependymal tumours and assigned WHO grades I-IV, which indicate different degrees of malignancy. Tremendous progress in genomic, transcriptomic and epigenetic profiling has resulted in new concepts of classifying and treating gliomas. Diffusely infiltrating gliomas in adults are now separated into three overarching tumour groups with distinct natural histories, responses to treatment and outcomes: isocitrate dehydrogenase (IDH)-mutant, 1p/19q co-deleted tumours with mostly oligodendroglial morphology that are associated with the best prognosis; IDH-mutant, 1p/19q non-co-deleted tumours with mostly astrocytic histology that are associated with intermediate outcome; and IDH wild-type, mostly higher WHO grade (III or IV) tumours that are associated with poor prognosis. Gliomas in children are molecularly distinct from those in adults, the majority being WHO grade I pilocytic astrocytomas characterized by circumscribed growth, favourable prognosis and frequent BRAF gene fusions or mutations. Ependymal tumours can be molecularly subdivided into distinct epigenetic subgroups according to location and prognosis. Although surgery, radiotherapy and alkylating agent chemotherapy are still the mainstay of treatment, individually tailored strategies based on tumour-intrinsic dominant signalling pathways and antigenic tumour profiles may ultimately improve outcome. For an illustrated summary of this Primer, visit: http://go.nature.com/TXY7Ri.

Developing interventions for cancer-related cognitive dysfunction in childhood cancer survivors

Survivors of childhood cancer frequently experience cancer-related cognitive dysfunction, commonly months to years after treatment for pediatric brain tumors, acute lymphoblastic leukemia (ALL), or tumors involving the head and neck. Risk factors for cancer-related cognitive dysfunction include young age at diagnosis, treatment with cranial irradiation, use of parenteral or intrathecal methotrexate, female sex, and pre-existing comorbidities. Limiting use and reducing doses and volume of cranial irradiation while intensifying chemotherapy have improved survival and reduced the severity of cognitive dysfunction, especially in leukemia. Nonetheless, problems in core functional domains of attention, processing speed, working memory and visual-motor integration continue to compromise quality of life and performance. We review the epidemiology, pathophysiology and assessment of cancer-related cognitive dysfunction, the impact of treatment changes for prevention, and the broad strategies for educational and pharmacological interventions to remediate established cognitive dysfunction following childhood cancer. The increased years of life saved after childhood cancer warrants continued study toward the prevention and remediation of cancer-related cognitive dysfunction, using uniform assessments anchored in functional outcomes.

Monitoring the cognitive effects of antiepileptic pharmacotherapy--approaching the individual patient

Cognitive side effects of antiepileptic drugs are common and can negatively affect tolerability, compliance, and long-term retention of the treatment. Furthermore, adverse cognitive effects of pharmacotherapy significantly affect everyday functioning and quality of life. Consequently, preservation of cognitive functions is an important aspect of epilepsy therapy. Knowledge of the patient's neuropsychological status before and after pharmacological interventions can help to decide on the appropriate treatment and, thus, can potentially improve individual medical care. Here, we suggest that cognitive monitoring of antiepileptic pharmacotherapy--like the assessment of seizure frequency, blood serum levels, electroencephalography or structural imaging--should be carried out as a matter of routine. In contrast to subjective measures, there are only very few neuropsychological instruments explicitly validated for the assessment of cognition along with antiepileptic pharmacotherapy. This review (1.) outlines indications and requirements for individual cognitive monitoring, (2.) discusses available diagnostic tools, and (3.) discloses relevant pitfalls. Neuropsychology, as demonstrated, provides evidence-based methods for monitoring cognitive effects of individual pharmacological treatments and, therefore, serves as a valuable tool for the quality and outcome control of antiepileptic therapies.

Cognitive function testing in adult brain tumor trials: lessons from a comprehensive review

Neurocognitive function (NCF) impairment is an important component of primary and metastatic brain tumors and their therapeutic interventions. As a result, modern clinical trials of cranial irradiation for adult cancer patients have incorporated NCF testing as a primary or secondary end point. In doing so, these clinical trials have provided a novel insight into our understanding of the NCF effects of cranial irradiation and brain tumor progression. In this article, we review these clinical trials both in terms of the trial findings and in terms of the types of NCF tests used in these trials. We also provide an introduction to the strengths and limitations of these NCF tests, as well as expert commentary on the current status and future directions of NCF testing in brain tumor trials.

Pathogenesis and management of primary CNS lymphoma

Primary CNS lymphoma (PCNSL), a rare variant of extranodal non-Hodgkin's lymphoma, may cause various neurological symptoms and signs. The best therapeutic strategy is still a matter of debate. High-dose methotrexate (HD-MTX) is the most active compound and should be used as the backbone for any chemotherapy applied. Several other chemotherapeutic drugs have been assessed in combination with HD-MTX, but no standard has yet been defined. Whole-brain radiotherapy is active against PCNSL, but typically does not confer long-lasting remission and is associated with significant neurotoxicity in many patients. The recently published G-PCNSL-SG1 trial has shown that consolidating whole-brain radiotherapy after HD-MTX-based chemotherapy does not prolong overall survival and may therefore be deferred. Combined systemic and intraventricular polychemotherapy, or high-dose chemotherapy followed by stem cell transplantation may offer cures to younger patients. Improving treatment regimens without adding significant (neuro-)toxicity should be the focus of ongoing and future studies.