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Coutinho JM, van de Munckhof A, Aguiar de Sousa D, Poli S, Aaron S, Arauz A, Conforto AB, Krzywicka K, Hiltunen S, Lindgren E, Sánchez van Kammen M, Shu L, Bakchoul T, Belder R, van den Berg R, Boumans E, Cannegieter S, Cano-Nigenda V, Field TS, Fragata I, Heldner MR, Hernández-Pérez M, Klok FA, Leker RR, Lucas-Neto L, Molad J, Nguyen TN, Saaltink DJ, Saposnik G, Sharma P, Stam J, Thijs V, van der Vaart M, Werring DJ, Wong Ramos D, Yaghi S, Yeşilot N, Tatlisumak T, Putaala J, Jood K, Arnold M, Ferro JM. Reducing the global burden of cerebral venous thrombosis: An international research agenda. Int J Stroke 2024; 19:599-610. [PMID: 38494462 PMCID: PMC11292977 DOI: 10.1177/17474930241242266] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/04/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Due to the rarity of cerebral venous thrombosis (CVT), performing high-quality scientific research in this field is challenging. Providing answers to unresolved research questions will improve prevention, diagnosis, and treatment, and ultimately translate to a better outcome of patients with CVT. We present an international research agenda, in which the most important research questions in the field of CVT are prioritized. AIMS This research agenda has three distinct goals: (1) to provide inspiration and focus to research on CVT for the coming years, (2) to reinforce international collaboration, and (3) to facilitate the acquisition of research funding. SUMMARY OF REVIEW This international research agenda is the result of a research summit organized by the International Cerebral Venous Thrombosis Consortium in Amsterdam, the Netherlands, in June 2023. The summit brought together 45 participants from 15 countries including clinical researchers from various disciplines, patients who previously suffered from CVT, and delegates from industry and non-profit funding organizations. The research agenda is categorized into six pre-specified themes: (1) epidemiology and clinical features, (2) life after CVT, (3) neuroimaging and diagnosis, (4) pathophysiology, (5) medical treatment, and (6) endovascular treatment. For each theme, we present two to four research questions, followed by a brief substantiation per question. The research questions were prioritized by the participants of the summit through consensus discussion. CONCLUSIONS This international research agenda provides an overview of the most burning research questions on CVT. Answering these questions will advance our understanding and management of CVT, which will ultimately lead to improved outcomes for CVT patients worldwide.
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Affiliation(s)
- Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Aguiar de Sousa
- Stroke Center, Centro Hospitalar Universitário Lisboa Central, Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, and L Lopes Lab, Instituto de Medicina Molecular JLA, Lisbon, Portugal
| | - Sven Poli
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | | | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Adriana B Conforto
- LIM-44, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Sini Hiltunen
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Liqi Shu
- Brown University, Providence, RI, USA
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Rosalie Belder
- Netherlands Thrombosis Foundation, Voorschoten, The Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Suzanne Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vanessa Cano-Nigenda
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Isabel Fragata
- Stroke Center, Centro Hospitalar Universitário Lisboa Central, Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, and L Lopes Lab, Instituto de Medicina Molecular JLA, Lisbon, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Mirjam R Heldner
- Inselspital Bern, University Hospital and University of Bern, Bern, Switzerland
| | | | - Frederikus A Klok
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Ronen R Leker
- Hadassah—Hebrew University Medical Center, Jerusalem, Israel
| | - Lia Lucas-Neto
- North Lisbon University Hospital Center and Lisbon Medical School, Lisbon, Portugal
| | | | | | | | - Gustavo Saposnik
- Stroke Outcomes & Decision Neuroscience Research Unit, University of Toronto, Toronto, ON, Canada
| | - Pankaj Sharma
- Royal Holloway University of London, London, United Kingdom
| | - Jan Stam
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | | | - David J Werring
- UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Diana Wong Ramos
- Portugal AVC-União de Sobreviventes, Familiares e Amigos, Portugal
| | | | - Nilüfer Yeşilot
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Jukka Putaala
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Marcel Arnold
- Inselspital Bern, University Hospital and University of Bern, Bern, Switzerland
| | - José M Ferro
- Hospital da Luz, University of Lisbon, Lisbon, Portugal
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2
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Segura PP, Quintela NV, García MM, del Barco Berrón S, Sarrió RG, Gómez JG, Castaño AG, Martín LMN, Rubio OG, Losada EP. SEOM-GEINO clinical guidelines for high-grade gliomas of adulthood (2022). Clin Transl Oncol 2023; 25:2634-2646. [PMID: 37540408 PMCID: PMC10425506 DOI: 10.1007/s12094-023-03245-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 08/05/2023]
Abstract
High-grade gliomas (HGG) are the most common primary brain malignancies and account for more than half of all malignant primary brain tumors. The new 2021 WHO classification divides adult HGG into four subtypes: grade 3 oligodendroglioma (1p/19 codeleted, IDH-mutant); grade 3 IDH-mutant astrocytoma; grade 4 IDH-mutant astrocytoma, and grade 4 IDH wild-type glioblastoma (GB). Radiotherapy (RT) and chemotherapy (CTX) are the current standard of care for patients with newly diagnosed HGG. Several clinically relevant molecular markers that assist in diagnosis and prognosis have recently been identified. The treatment for recurrent high-grade gliomas is not well defined and decision-making is usually based on prior strategies, as well as several clinical and radiological factors. Whereas the prognosis for GB is grim (5-year survival rate of 5-10%) outcomes for the other high-grade gliomas are typically better, depending on the molecular features of the tumor. The presence of neurological deficits and seizures can significantly impact quality of life.
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Affiliation(s)
- Pedro Pérez Segura
- Medical Oncology Department, Hospital Clínico San Carlos, IdISCC, Madrid, Spain
| | - Noelia Vilariño Quintela
- Medical Oncology Department, Catalan Institute of Oncology, Barcelona, Spain
- Preclinical and Experimental Research in Thoracic Tumors (PReTT) Group, Oncobell Program, IDIBELL, L’Hospitalet, Barcelona, Spain
| | - María Martínez García
- Medical Oncology Department, Hospital del Mar, Barcelona, Spain
- Cancer Research Program, Hospital del Mar Research Institute, Barcelona, Spain
| | - Sonia del Barco Berrón
- Medical Oncology Department, Unidad Cáncer de Mama y Tumores Cerebrales, Instituto Catalán de Oncologia, Hospital Universitario Doctor Josep Trueta, Girona, Spain
| | - Regina Gironés Sarrió
- Medical Oncology Department. Hospital, Univeristari i Politècnic La Fe, Valencia, Spain
| | - Jesús García Gómez
- Medical Oncology Department, Complejo Hospitalario Universitario de Orense, Orense, Spain
| | | | | | - Oscar Gallego Rubio
- Medical Oncology Department, Hospital de Sant Pau i La Santa Creu, Barcelona, Spain
| | - Estela Pineda Losada
- Medical Oncology Department, Hospital Clinic and Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, Barcelona, Spain
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3
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A Hypoxia Molecular Signature-Based Prognostic Model for Endometrial Cancer Patients. Int J Mol Sci 2023; 24:ijms24021675. [PMID: 36675190 PMCID: PMC9866886 DOI: 10.3390/ijms24021675] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 01/19/2023] Open
Abstract
Endometrial cancer has the highest incidence of uterine corpus cancer, the sixth most typical cancer in women until 2020. High recurrence rate and frequent adverse events were reported in either standard chemotherapy or combined therapy. Hence, developing precise diagnostic and prognostic approaches for endometrial cancer was on demand. Four hypoxia-related genes were screened for the EC prognostic model by the univariate, LASSO, and multivariate Cox regression analysis from the TCGA dataset. QT-PCR and functional annotation analysis were performed. Associations between predicted risk and immunotherapy and chemotherapy responses were investigated by evaluating expressions of immune checkpoint inhibitors, infiltrated immune cells, m6a regulators, and drug sensitivity. The ROC curve and calibration plot indicated a fair predictability of our prognostic nomogram model. NR3C1 amplification, along with IL-6 and SRPX suppressions, were detected in tumor. High stromal score and enriched infiltrated aDCs and B cells in the high-risk group supported the hypothesis of immune-deserted tumor. Hypoxia-related molecular subtypes of EC were then identified via the gene signature. Cluster 2 patients showed a significant sensitivity to Vinblastine. In summary, our hypoxia signature model accurately predicted the survival outcome of EC patients and assessed translational and transcriptional dysregulations to explore targets for precise medical treatment.
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Nassar A, Smolanka V, Smolanka A, Chaulagain D, Devinyak O. Sphenoid wing meningiomas: peritumoral brain edema as a prognostic factor in surgical outcome. Neurosurg Rev 2022; 45:2951-2959. [PMID: 35624342 DOI: 10.1007/s10143-022-01816-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/03/2022] [Accepted: 05/17/2022] [Indexed: 11/29/2022]
Abstract
Sphenoidal meningiomas constitute 18% of intracranial masses, and still present a difficult surgical challenge. PTBE has been associated with several complications and future recurrence. This study aims to evaluate the outcome of the operatively treated sphenoid wing meningiomas in relation to PTBE as a prognostic factor in a series of 65 patients. The clinical materials of 65 patients with SWM treated microsurgically between 2007 and 2020 were analyzed retrospectively. Follow-up ranged from 6 to 156 months (median, 86). Clinical outcomes include postoperative major neurological deficit, quality of life using KPS, recurrence, and mortality rates. The mean age of patients was 53.9 years (range 20-74), males 24.6% and females75.4%. An edema index (EI) of 1 (40%) was considered as absent edema, and EI > 1 (60%) indicated present edema. Total resection (Simpson I-II) was achieved in 64.6% and subtotal (Simpson IV) in 13.8%. Postoperative complications included vision impairment in 3 patients, motor weakness 6, third nerve palsy 6, intraoperative bleeding and edema 5, and MCA infarct 2, recurrence in 17% and 7.7% died. In univariate analysis, we found that the PTBE is one of the serious risk factors in the immediate surgical outcomes and complication, though more data is needed to support this claim, while having a negative effect on postoperative KPS at short-term follow up (χ2 = 6.44, p = 0.011). PTBE was associated with decline in KPS and quality of life in the early postoperative period (three months) while showing no significant effect at long-term outcomes.
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Affiliation(s)
- Abdalrahman Nassar
- Uzhhorod Regional Center of Neurosurgery and Neurology, Uzhhorod National University, Uzhhorod, Ukraine.
| | - Volodymyr Smolanka
- Uzhhorod Regional Center of Neurosurgery and Neurology, Uzhhorod National University, Uzhhorod, Ukraine
| | - Andriy Smolanka
- Uzhhorod Regional Center of Neurosurgery and Neurology, Uzhhorod National University, Uzhhorod, Ukraine
| | - Dipak Chaulagain
- Uzhhorod Regional Center of Neurosurgery and Neurology, Uzhhorod National University, Uzhhorod, Ukraine
| | - Oleg Devinyak
- Department of Pharmacy, Uzhhorod National University, Uzhhorod, Ukraine
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5
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Keats MR, Grandy SA, Blanchard C, Fowles JR, Neyedli HF, Weeks AC, MacNeil MV. The Impact of Resistance Exercise on Muscle Mass in Glioblastoma in Survivors (RESIST): Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2022; 11:e37709. [PMID: 35507403 PMCID: PMC9118089 DOI: 10.2196/37709] [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: 03/03/2022] [Revised: 03/17/2022] [Accepted: 03/23/2022] [Indexed: 11/25/2022] Open
Abstract
Background Glioblastoma is the most common primary brain malignancy in adults, accounting for approximately 48% of all brain tumors. Standard treatment includes radiation and temozolomide chemotherapy. Glioblastomas are highly vascular and can cause vasogenic brain edema and mass effect, which can worsen the neurologic symptoms associated with the disease. The steroid dexamethasone (DEX) is the treatment of choice to reduce vasogenic edema and intracranial pressure associated with glioblastoma. However high-dose DEX or long-term use can result in muscle myopathy in 10%-60% of glioblastoma patients, significantly reducing functional fitness and quality of life (QOL). There is a wealth of evidence to support the use of exercise as an adjuvant therapy to improve functional ability as well as help manage treatment-related symptoms. Specifically, resistance training has been shown to increase muscle mass, strength, and functional fitness in aging adults and several cancer populations. Although studies are limited, research has shown that exercise is safe and feasible in glioblastoma populations. However, it is not clear whether resistance training can be successfully used in glioblastoma to prevent or mitigate steroid-induced muscle myopathy and associated loss of function. Objective The primary purpose of this study is to establish whether an individualized circuit-based program will reduce steroid-induced muscle myopathy, as indicated by maintained or improved functional fitness for patients on active treatment and receiving steroids. Methods This is a 2-armed, randomized controlled trial with repeated measures. We will recruit 38 adult (≥18 years) patients diagnosed with either primary or secondary glioblastoma who are scheduled to receive standard radiation and concurrent and adjuvant temozolomide chemotherapy postsurgical debulking and received any dose of DEX through the neurooncology clinic and the Nova Scotia Health Cancer Center. Patients will be randomly allocated to a standard of care waitlist control group or standard of care + circuit-based resistance training exercise group. The exercise group will receive a 12-week individualized, group and home-based exercise program. The control group will be advised to maintain an active lifestyle. The primary outcome, muscle myopathy (functional fitness), will be assessed using the Short Physical Performance Battery and hand grip strength. Secondary outcome measures will include body composition, cardiorespiratory fitness, physical activity, QOL, fatigue, and cognitive function. All measures will be assessed pre- and postintervention. Participant accrual, exercise adherence, and safety will be assessed throughout the study. Results This study has been funded by the Canadian Cancer Society Atlantic Cancer Research Grant and the J.D. Irving Limited–Excellence in Cancer Research Fund (grant number 707182). The protocol was approved by the Nova Scotia Health and Acadia University’s Research Ethics Boards. Enrollment is anticipated to begin in March 2022. Conclusions This study will inform how individualized circuit-based resistance training may improve functional independence and overall QOL of glioblastoma patients. Trial Registration ClinicalTrails.gov NCT05116137; https://www.clinicaltrials.gov/ct2/show/NCT05116137 International Registered Report Identifier (IRRID) DERR1-10.2196/37709
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Affiliation(s)
- Melanie R Keats
- Division of Kinesiology, School of Health and Human Performance, Dalhousie University, Halifax, NS, Canada.,Division of Medical Oncology, Department of Medicine, Dalhousie University, Halifax, NS, Canada.,Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
| | - Scott A Grandy
- Division of Kinesiology, School of Health and Human Performance, Dalhousie University, Halifax, NS, Canada.,Division of Medical Oncology, Department of Medicine, Dalhousie University, Halifax, NS, Canada.,Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
| | - Christopher Blanchard
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | | | - Heather F Neyedli
- Division of Kinesiology, School of Health and Human Performance, Dalhousie University, Halifax, NS, Canada.,Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
| | - Adrienne C Weeks
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Mary V MacNeil
- Division of Medical Oncology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
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6
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Makwana M, Hussain H, Merola JP, Zaben M, Jesurasa AR, Patel C, Leach P. Pre-operative dosing of dexamethasone for the management of children with posterior fossa tumours: are we getting it right? Br J Neurosurg 2022; 36:609-612. [PMID: 35176921 DOI: 10.1080/02688697.2022.2040948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Posterior fossa (PF) tumours are associated with vasogenic oedema causing symptoms of raised intracranial pressure. Preoperatively this is managed with dexamethasone. To minimise steroid related complications, the lowest effective dose should be administered. No neurosurgical guidelines exist for pre-operative dosing of dexamethasone in PF tumours. METHODS A retrospective review was performed of surgically managed cases for patients under 16 years of age between 2013 and 2018 to ascertain the initial dose of dexamethasone with symptomatic PF tumours. RESULTS Thirty-six patients were identified of which 30 notes were available. Sixteen were male. Median age was 6 years (range 10 months - 15 years). Twenty-two (73%) were referrals from DGH and 8 (27%) presented to our neurosurgical centre. All patients presented with symptomatic PF tumours including headache (97%), vomiting (93%), gait disturbance (43%), and nystagmus (17%). Four (13%) had papilloedema. Average initial stat dexamethasone dose was 9.15 mg; 0.31 mg/kg (range 1-16.7 mg; 0.05 - 1.77 mg/kg). Stratified according to weight, average dose (and range) was 8.8 mg; 0.94 mg/kg (1-16.6 mg; 0.13 - 1.77 mg/kg) in those weighing <10 kg; 9.7 mg; 0.66 mg/kg (4-16.7 mg; 0.21 - 1.35 mg/kg) in 10-20 kg; 12.3 mg;0.52 mg/kg (8-16.7 mg; 0.27 - 0.73mg/kg) in 20-30 kg and 7.8 mg; 0.17mg/kg (2-16.7 mg; 0.0 - 0.39 mg/kg) in >30 kg up to a maximum of 16.6 mg in any 24h period. These results suggest that dosage was higher in those children weighing less. PPI was used in 24 (80%) of cases. All doses were reduced after review by the neurosurgical team and a PPI added. CONCLUSION Pre-operative dexamethasone dosing does not always reflect the severity of clinical symptoms for PF tumours. Guidelines are required to correlate clinical symptoms with a suggested suitable dose of dexamethasone to prevent overdose and complications associated with corticosteroid use. We recommend a weight-based regimen as provided by the Food and Drug Administration. The current advice is for 0.02-0.3mg/kg/day in 3-4 divided doses.
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Affiliation(s)
- Milan Makwana
- Department of Paediatric Neurosurgery, University Hospital of Wales & Noah's Ark Children's Hospital, Cardiff, United Kingdom.,School of Medicine, Neuroscience and Mental Health Research Institute, Institute of Psychological Medicine and Clinical Neurosciences, University Hospital Wales, Cardiff University, Cardiff, United Kingdom
| | - Humaira Hussain
- Department of Paediatric Neurosurgery, University Hospital of Wales & Noah's Ark Children's Hospital, Cardiff, United Kingdom
| | - Joseph P Merola
- Department of Paediatric Neurosurgery, University Hospital of Wales & Noah's Ark Children's Hospital, Cardiff, United Kingdom.,School of Medicine, Neuroscience and Mental Health Research Institute, Institute of Psychological Medicine and Clinical Neurosciences, University Hospital Wales, Cardiff University, Cardiff, United Kingdom
| | - Malik Zaben
- Department of Paediatric Neurosurgery, University Hospital of Wales & Noah's Ark Children's Hospital, Cardiff, United Kingdom.,School of Medicine, Neuroscience and Mental Health Research Institute, Institute of Psychological Medicine and Clinical Neurosciences, University Hospital Wales, Cardiff University, Cardiff, United Kingdom
| | - Anthony R Jesurasa
- Department of Paediatric Neurosurgery, University Hospital of Wales & Noah's Ark Children's Hospital, Cardiff, United Kingdom
| | - Chirag Patel
- Department of Paediatric Neurosurgery, University Hospital of Wales & Noah's Ark Children's Hospital, Cardiff, United Kingdom
| | - Paul Leach
- Department of Paediatric Neurosurgery, University Hospital of Wales & Noah's Ark Children's Hospital, Cardiff, United Kingdom
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7
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Jessurun CAC, Hulsbergen AFC, Lamba N, Nandoe Tewarie RDS, Smith TR, Broekman MLD. Practice variation in perioperative steroid dosing for brain tumor patients: an international survey. World Neurosurg 2021; 159:e431-e441. [PMID: 34958992 DOI: 10.1016/j.wneu.2021.12.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Steroids are commonly used against peritumoral edema and increased intracranial pressure in brain tumor patients. Despite the widespread use of steroids, relatively little evidence is available about their optimal perioperative dosing scheme. This study aims to increase insight into practice variation of perioperative steroid dosing and tapering schedules used in the neurosurgical community. METHODS An electronic survey consisting of 27 questions regarding steroid dosing, tapering schedules, and adverse events was conducted among neurosurgeons between December 6th, 2019 and June 1st, 2020. The survey was distributed through the European Association of Neurosurgical Societies and social media platforms. Collected data were assessed for quantitative and qualitative analysis. RESULTS The survey obtained 175 responses from 55 countries across six continents, including 30 from low- or middle-income countries; 152 (87%) respondents completed all questions. In total, 130 respondents (80%) indicated prescribing perioperative steroids. Reported doses ranged from 2 to 64 mg/day in schedules ranging from one to four times daily. The most prescribed steroid was dexamethasone in a dose of 16 mg/day (n = 49; 31%), followed by 12 mg/day (n = 31; 20%) and 8 mg/day (n = 18; 12%). No significant association was found between prescribed dose and physician and institutional characteristics. CONCLUSION Steroids are commonly prescribed perioperatively in brain tumor patients. However, there is a great practice variation in dosing and schedules among neurosurgeons. Future investigation in a prospective and preferably randomized manner is needed to identify an optimal dosing scheme and implement (inter)national guidelines for steroid use.
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Affiliation(s)
- Charissa A C Jessurun
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School; 75 Francis Street, 02115, Boston, Massachusetts, United States; Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, Zuid-Holland, The Netherlands; Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, Zuid-Holland, The Netherlands
| | - Alexander F C Hulsbergen
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School; 75 Francis Street, 02115, Boston, Massachusetts, United States; Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, Zuid-Holland, The Netherlands; Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, Zuid-Holland, The Netherlands
| | - Nayan Lamba
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School; 75 Francis Street, 02115, Boston, Massachusetts, United States
| | - Rishi D S Nandoe Tewarie
- Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, Zuid-Holland, The Netherlands; Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, Zuid-Holland, The Netherlands
| | - Timothy R Smith
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School; 75 Francis Street, 02115, Boston, Massachusetts, United States
| | - Marike L D Broekman
- Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, Zuid-Holland, The Netherlands; Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, Zuid-Holland, The Netherlands; Department of Neurology, Massachusetts General Hospital, Harvard Medical School; 55 Fruit Street, 02114, Boston, Massachusetts, United States.
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8
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Medikonda R, Patel K, Jackson C, Saleh L, Srivastava S, Feghali J, Mohan A, Pant A, Jackson CM, Weingart J, Mukherjee D, Bettegowda C, Gallia GL, Brem H, Lim M. The safety and efficacy of dexamethasone in the perioperative management of glioma patients. J Neurosurg 2021; 136:1062-1069. [PMID: 34560653 DOI: 10.3171/2021.4.jns204127] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In this single-institution retrospective cohort study, the authors evaluated the effect of dexamethasone on postoperative complications and overall survival in patients with glioma undergoing resection. METHODS A total of 435 patients who underwent resection of a primary glioma were included in this retrospective cohort study. The inclusion criterion was all patients who underwent resection of a primary glioma at a tertiary medical center between 2014 and 2019. RESULTS The use of both pre- and postoperative dexamethasone demonstrated a trend toward the development of postoperative wound infections (3% vs 0% in single use or no use, p = 0.082). No association was detected between dexamethasone use and the development of new-onset hyperglycemia (p = 0.149). On multivariable Cox proportional hazards analysis, dexamethasone use was associated with a greater hazard of death (overall p = 0.017); this effect was most pronounced for preoperative (only) dexamethasone use (hazard ratio 3.0, p = 0.062). CONCLUSIONS Combined pre- and postoperative dexamethasone use may increase the risk of postoperative wound infection, and dexamethasone use, specifically preoperative use, may negatively impact survival. These findings highlight the potential for serious negative consequences with dexamethasone use.
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Affiliation(s)
- Ravi Medikonda
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kisha Patel
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christina Jackson
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura Saleh
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Siddhartha Srivastava
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James Feghali
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aditya Mohan
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ayush Pant
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher M Jackson
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jon Weingart
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Debraj Mukherjee
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chetan Bettegowda
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gary L Gallia
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Henry Brem
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael Lim
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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9
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Pracucci E, Pillai V, Lamers D, Parra R, Landi S. Neuroinflammation: A Signature or a Cause of Epilepsy? Int J Mol Sci 2021; 22:6981. [PMID: 34209535 PMCID: PMC8267969 DOI: 10.3390/ijms22136981] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/11/2021] [Accepted: 06/23/2021] [Indexed: 12/21/2022] Open
Abstract
Epilepsy can be both a primary pathology and a secondary effect of many neurological conditions. Many papers show that neuroinflammation is a product of epilepsy, and that in pathological conditions characterized by neuroinflammation, there is a higher probability to develop epilepsy. However, the bidirectional mechanism of the reciprocal interaction between epilepsy and neuroinflammation remains to be fully understood. Here, we attempt to explore and discuss the relationship between epilepsy and inflammation in some paradigmatic neurological and systemic disorders associated with epilepsy. In particular, we have chosen one representative form of epilepsy for each one of its actual known etiologies. A better understanding of the mechanistic link between neuroinflammation and epilepsy would be important to improve subject-based therapies, both for prophylaxis and for the treatment of epilepsy.
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Affiliation(s)
- Enrico Pracucci
- National Enterprise for Nanoscience and Nanotechnology (NEST), Istituto Nanoscienze Consiglio Nazionale delle Ricerche (CNR) and Scuola Normale Superiore Pisa, 56127 Pisa, Italy; (E.P.); (V.P.); (D.L.); (R.P.)
| | - Vinoshene Pillai
- National Enterprise for Nanoscience and Nanotechnology (NEST), Istituto Nanoscienze Consiglio Nazionale delle Ricerche (CNR) and Scuola Normale Superiore Pisa, 56127 Pisa, Italy; (E.P.); (V.P.); (D.L.); (R.P.)
| | - Didi Lamers
- National Enterprise for Nanoscience and Nanotechnology (NEST), Istituto Nanoscienze Consiglio Nazionale delle Ricerche (CNR) and Scuola Normale Superiore Pisa, 56127 Pisa, Italy; (E.P.); (V.P.); (D.L.); (R.P.)
| | - Riccardo Parra
- National Enterprise for Nanoscience and Nanotechnology (NEST), Istituto Nanoscienze Consiglio Nazionale delle Ricerche (CNR) and Scuola Normale Superiore Pisa, 56127 Pisa, Italy; (E.P.); (V.P.); (D.L.); (R.P.)
| | - Silvia Landi
- National Enterprise for Nanoscience and Nanotechnology (NEST), Istituto Nanoscienze Consiglio Nazionale delle Ricerche (CNR) and Scuola Normale Superiore Pisa, 56127 Pisa, Italy; (E.P.); (V.P.); (D.L.); (R.P.)
- Institute of Neuroscience CNR, 56127 Pisa, Italy
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10
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Zoccarato M, Nardetto L, Basile AM, Giometto B, Zagonel V, Lombardi G. Seizures, Edema, Thrombosis, and Hemorrhages: An Update Review on the Medical Management of Gliomas. Front Oncol 2021; 11:617966. [PMID: 33828976 PMCID: PMC8019972 DOI: 10.3389/fonc.2021.617966] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/04/2021] [Indexed: 12/21/2022] Open
Abstract
Patients affected with gliomas develop a complex set of clinical manifestations that deeply impact on quality of life and overall survival. Brain tumor-related epilepsy is frequently the first manifestation of gliomas or may occur during the course of disease; the underlying mechanisms have not been fully explained and depend on both patient and tumor factors. Novel treatment options derive from the growing use of third-generation antiepileptic drugs. Vasogenic edema and elevated intracranial pressure cause a considerable burden of symptoms, especially in high-grade glioma, requiring an adequate use of corticosteroids. Patients with gliomas present with an elevated risk of tumor-associated venous thromboembolism whose prophylaxis and treatment are challenging, considering also the availability of new oral anticoagulant drugs. Moreover, intracerebral hemorrhages can complicate the course of the illness both due to tumor-specific characteristics, patient comorbidities, and side effects of antithrombotic and antitumoral therapies. This paper aims to review recent advances in these clinical issues, discussing the medical management of gliomas through an updated literature review.
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Affiliation(s)
- Marco Zoccarato
- Neurology Unit, O.S.A., Azienda Ospedale-Università, Padua, Italy
| | - Lucia Nardetto
- Neurology Unit, O.S.A., Azienda Ospedale-Università, Padua, Italy
| | | | - Bruno Giometto
- Neurology Unit, Trento Hospital, Azienda Provinciale per i Servizi Sanitari (APSS) di Trento, Trento, Italy
| | - Vittorina Zagonel
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCSS, Padua, Italy
| | - Giuseppe Lombardi
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCSS, Padua, Italy
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11
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Roth P, Pace A, Le Rhun E, Weller M, Ay C, Cohen-Jonathan Moyal E, Coomans M, Giusti R, Jordan K, Nishikawa R, Winkler F, Hong JT, Ruda R, Villà S, Taphoorn MJB, Wick W, Preusser M. Neurological and vascular complications of primary and secondary brain tumours: EANO-ESMO Clinical Practice Guidelines for prophylaxis, diagnosis, treatment and follow-up. Ann Oncol 2021; 32:171-182. [PMID: 33246022 DOI: 10.1016/j.annonc.2020.11.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 02/08/2023] Open
Affiliation(s)
- P Roth
- Department of Neurology and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - A Pace
- Neuroncology Unit, IRCCS Regina Elena Cancer Institute, Rome, Italy
| | - E Le Rhun
- Department of Neurology and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland; Université Lille, U-1192, Lille, France; Inserm, U-1192, Lille, France; Centre Hospitalier Universitaire CHU, Lille, General and Stereotaxic Neurosurgery Service, Lille, France; Oscar Lambret Center, Breast Cancer Department, Lille, France
| | - M Weller
- Department of Neurology and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - C Ay
- Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Vienna, Austria
| | - E Cohen-Jonathan Moyal
- Radiation Oncology Department, Institut Claudius Regaud, Université Paul Sabatier, Toulouse, France; Institut Universitaire du Cancer de Toulouse IUCT Oncopole, Toulouse, France
| | - M Coomans
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - R Giusti
- Medical Oncology Unit, Azienda Ospedaliero Universitaria Sant'Andrea, Rome, Italy
| | - K Jordan
- Department of Medicine V, Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - R Nishikawa
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - F Winkler
- Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany; Clinical Cooperation Unit Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK), Heidelberg, Germany
| | - J T Hong
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, Seoul, The Catholic University of Korea, Republic of Korea
| | - R Ruda
- Department of Neuro-Oncology, City of Health and Science and University of Turin, Turin, Italy
| | - S Villà
- Catalan Institute of Oncology, HU Germans Trias, Badalona, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M J B Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - W Wick
- Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - M Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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12
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Muhsen BA, Joshi KC, Lee BS, Thapa B, Borghei-Razavi H, Jia X, Barnett GH, Chao ST, Mohammadi AM, Suh JH, Vogelbaum MA, Angelov L. The effect of Gamma Knife radiosurgery on large posterior fossa metastases and the associated mass effect from peritumoral edema. J Neurosurg 2021; 134:466-474. [PMID: 31978879 DOI: 10.3171/2019.11.jns191485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 11/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKRS) as monotherapy is an option for the treatment of large (≥ 2 cm) posterior fossa brain metastases (LPFMs). However, there is concern regarding possible posttreatment increase in peritumoral edema (PTE) and associated compression of the fourth ventricle. This study evaluated the effects and safety of GKRS on tumor and PTE control in LPFM. METHODS The authors performed a single-center retrospective review of 49 patients with 51 LPFMs treated with GKRS. Patients with at least 1 clinical and radiological follow-up visit were included. Tumor, PTE, and fourth ventricle volumetric measurements were used to assess efficacy and safety. Overall survival was a secondary outcome. RESULTS Fifty-one lesions in 49 consecutive patients were identified; 57.1% of patients were male. At the time of GKRS, the median age was 61.5 years, and the median Karnofsky Performance Status score was 90. The median number of LPFMs and overall brain metastases were 1 and 2, respectively. The median overall tumor, PTE, and fourth ventricle volumes at diagnosis were 4.96 cm3 (range 1.4-21.1 cm3), 14.98 cm3 (range 0.6-71.8 cm3), and 1.23 cm3 (range 0.3-3.2 cm3), respectively, and the median lesion diameter was 2.6 cm (range 2.0-5.07 cm). The median follow-up time was 7.3 months (range 1.6-57.2 months). At the first follow-up, 2 months posttreatment, the median tumor volume decreased by 58.66% (range -96.95% to +48.69%, p < 0.001), median PTE decreased by 78.10% (range -99.92% to +198.35%, p < 0.001), and the fourth ventricle increased by 24.97% (range -37.96% to +545.6%, p < 0.001). The local control rate at first follow-up was 98.1%. The median OS was 8.36 months. No patient required surgical intervention, external ventricular drainage, or shunting between treatment and first follow-up. However, 1 patient required a ventriculoperitoneal shunt at 23 months from treatment. Posttreatment, 65.30% received our general steroid taper, 6.12% received no steroids, and 28.58% required prolonged steroid treatment. CONCLUSIONS In this retrospective analysis, patients with LPFMs treated with GKRS had a statistically significant posttreatment reduction in tumor size and PTE and marked opening of the fourth ventricle (all p < 0.001). This study demonstrates that GKRS is well tolerated and can be considered in the management of select cases of LPFMs, especially in patients who are poor surgical candidates.
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Affiliation(s)
- Baha'eddin A Muhsen
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
| | - Krishna C Joshi
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
| | - Bryan S Lee
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
| | - Bicky Thapa
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
| | - Hamid Borghei-Razavi
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
| | - Xuefei Jia
- 2Quantitative Health Sciences, Taussig Cancer Institute, Cleveland Clinic, Cleveland
| | - Gene H Barnett
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
| | - Samuel T Chao
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
- 4Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alireza M Mohammadi
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
| | - John H Suh
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
- 4Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Vogelbaum
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
| | - Lilyana Angelov
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
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13
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Forst DA. Palliative and Supportive Care in Neuro-oncology. ACTA ACUST UNITED AC 2020; 26:1673-1685. [PMID: 33273177 DOI: 10.1212/con.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article reviews the supportive care needs of patients with primary brain tumors and their caregivers, outlines the management of selected common symptoms of patients with brain tumors, and describes challenges and opportunities in providing palliative care for this population. RECENT FINDINGS Patients with primary malignant brain tumors generally have a poor prognosis and experience progressive neurologic decline and significant physical and psychological symptoms. Management of these symptoms, including fatigue, mood disorders, and the manifestations of cerebral edema, can be challenging. Caregivers for these patients have high rates of psychological distress and report significant caregiving burden. Although the benefit of early palliative care for patients with other advanced solid tumors is well established, our understanding of the role of palliative care in neuro-oncology is incomplete, and thus palliative care and hospice services remain underutilized. SUMMARY Patients with brain tumors and their caregivers have significant supportive care needs, which often differ from the needs of patients with cancers outside of the nervous system. Clinicians face challenges associated with managing patients' symptoms and adequately facilitating prognostic understanding and decision making. Palliative care and hospice services may offer important benefits for this population.
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Abstract
OPINION STATEMENT Corticosteroids have been essential in the management of brain tumor patients for decades, primarily for the treatment of peritumoral cerebral edema and its associated neurologic deficits. Dexamethasone is the drug of choice with standard practice being administration up to four times per day, however, because of its long biologic half-life and high potency, once or twice a day dosing is likely adequate in patients without elevated intracranial pressure. The length of corticosteroid treatment should be limited to the shortest period of time to minimize the risk of potential toxicities that can significantly affect quality of life, as well as to avoid a possible detrimental impact on survival in high-grade glioma patients and abrogation of the effect of immunotherapy. Agents such as bevacizumab should be considered in patients who are unable to wean completely off of steroids as well as those who have symptomatic edema and are on immunotherapy. Several other agents have been studied without much success. An increased understanding of the complex pathophysiology of peritumoral vasogenic edema is critically needed to discover new agents that are safer and more effective.
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15
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Thakkar JP, Prabhu VC, Rouse S, Lukas RV. Acute Neurological Complications of Brain Tumors and Immune Therapies, a Guideline for the Neuro-hospitalist. Curr Neurol Neurosci Rep 2020; 20:32. [PMID: 32596758 DOI: 10.1007/s11910-020-01056-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE OF REVIEW Patients with brain tumors presenting to the emergency room with acute neurologic complications may warrant urgent investigations and emergent management. As the neuro-hospitalist will likely encounter this complex patient population, an understanding of the acute neurologic issues will have value. RECENT FINDINGS We discuss updated information and management regarding various acute neurologic complications among neuro-oncology patients and neurologic complications of immunotherapy. Understanding of the acute neurologic complications associated with central nervous system tumors and with common contemporary cancer treatments will facilitate the neuro-hospitalist management of these patient populations. While there are aspects analogous to the diagnosis and management in the non-oncologic population, a number of unique features discussed in this review should be considered.
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Affiliation(s)
- Jigisha P Thakkar
- Department of Neurology, Stritch School of Medicine, Loyola University Medical Center, 2160 S. 1st Avenue, Bldg 105, Room 2700, Maywood, IL, 60153, USA. .,Department of Neurosurgery, Stritch School of Medicine, Loyola University Chicago, 2160 S. 1st Avenue, Bldg 105, Room 1900, Maywood, IL, 60153, USA.
| | - Vikram C Prabhu
- Department of Neurosurgery, Stritch School of Medicine, Loyola University Chicago, 2160 S. 1st Avenue, Bldg 105, Room 1900, Maywood, IL, 60153, USA
| | - Stasia Rouse
- Department of Neurology, Stritch School of Medicine, Loyola University Medical Center, 2160 S. 1st Avenue, Bldg 105, Room 2700, Maywood, IL, 60153, USA
| | - Rimas V Lukas
- Department of Neurology, Northwestern University Feinberg School of Medicine, 710 N. Lake Shore Drive, Abbott Hall 1114, Chicago, IL, 60611, USA.,Lou and Jean Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, 60611, USA
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16
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Provider views on perioperative steroid use for patients with newly diagnosed pediatric brain tumors. J Neurooncol 2020; 147:205-212. [PMID: 32026434 DOI: 10.1007/s11060-020-03416-9] [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: 11/14/2019] [Accepted: 01/29/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Cerebral edema from brain tumors can cause neurological impairment. Steroids treat edema but with possible adverse effects. We surveyed providers regarding steroid use in newly diagnosed patients with brain tumors to determine if practices are standard or markedly variable. METHODS An anonymous voluntary online survey was sent to members of neuro-oncology consortiums. Four clinical scenarios were provided and questions regarding initiation of steroids, type, dose, formulation, and duration were asked. Demographic information was collected. RESULTS 369 providers received the survey, 76 responded (20.6% response rate). The proportion of providers who would start steroids significantly differed among scenarios (scenario 1 vs 2, p < 0.001; 2 vs 3, p < 0.001; 1 vs 3, p < 0.001). 75 (98.7%) providers would start steroids for vasogenic edema (scenario 1) and 55 (72.4%) for obstructive hydrocephalus (scenario 2). 16 (21.1%) would start steroids for vasogenic edema but not obstructive hydrocephalus. The odds of choosing to start steroids in patients with obstructive hydrocephalus were 7.59 times more (95% CI: 2.29, 25.13) if providers felt symptoms would improve within 24 h. All would use dexamethasone. A significant difference was seen between the proportion of providers who would give a loading dose if vasogenic edema with neurological deficits were noted versus vasogenic edema alone (57.9% vs 43.4%; p = 0.002). CONCLUSIONS These results suggest that providers recommend dexamethasone for patients with vasogenic edema and obstructive hydrocephalus. Variability remains with dosing schedule. Further studies are needed to identify the most appropriate use of steroids for newly diagnosed CNS tumor patients with the goal to create steroid management guidelines.
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17
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Jessurun CAC, Hulsbergen AFC, Cho LD, Aglio LS, Nandoe Tewarie RDS, Broekman MLD. Evidence-based dexamethasone dosing in malignant brain tumors: what do we really know? J Neurooncol 2019; 144:249-264. [PMID: 31346902 PMCID: PMC6700052 DOI: 10.1007/s11060-019-03238-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/13/2019] [Indexed: 12/19/2022]
Abstract
Purpose The present study aims to conduct a systematic review of literature reporting on the dose and dosing schedule of dexamethasone (DXM) in relation to clinical outcomes in malignant brain tumor patients, with particular attention to evidence-based practice. Methods A systematic search was performed in PubMed, Embase, Web of Science, Cochrane, Academic Search Premier, and PsycINFO to identify studies that reported edema volume reduction, symptomatic relief, adverse events and survival in relation to dexamethasone dose in glioma or brain metastasis (BM) patients. Results After screening 1812 studies, fifteen articles were included for qualitative review. Most studies reported a dose of 16 mg, mostly in a schedule of 4 mg four times a day. Due to heterogeneity of studies, it was not possible to perform quantitative meta-analysis. For BMs, best available evidence suggests that higher doses of DXM may give more adverse events, but may not necessarily result in better clinical condition. Some studies suggest that higher DXM doses are associated with shorter survival in the palliative setting. For glioma, DXM may lead to symptomatic improvement, yet no studies directly compare different doses. Results regarding edema reduction and survival in glioma patients are conflicting. Conclusions Evidence on the safety and efficacy of different DXM doses in malignant brain tumor patients is scarce and conflicting. Best available evidence suggests that low DXM doses may be noninferior to higher doses in certain circumstances, but more comparative research in this area is direly needed, especially in light of the increasing importance of immunotherapy for brain tumors. Electronic supplementary material The online version of this article (10.1007/s11060-019-03238-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Charissa A C Jessurun
- Faculty of Medicine, University of Amsterdam/Amsterdam University Medical Center, Location Academic Medical Center (AMC), Meibergdreef 9, 1105 AZ, Amsterdam, Noord-Holland, The Netherlands
| | - Alexander F C Hulsbergen
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, Zuid-Holland, The Netherlands.,Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, Zuid-Holland, The Netherlands
| | - Logan D Cho
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Brown University, 69 Brown Street, Providence, RI, 02912, USA
| | - Linda S Aglio
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Rishi D S Nandoe Tewarie
- Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, Zuid-Holland, The Netherlands.,Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, Zuid-Holland, The Netherlands
| | - Marike L D Broekman
- Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, Zuid-Holland, The Netherlands. .,Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, Zuid-Holland, The Netherlands. .,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
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18
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The Role of Brain Vasculature in Glioblastoma. Mol Neurobiol 2019; 56:6645-6653. [DOI: 10.1007/s12035-019-1561-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 03/13/2019] [Indexed: 01/16/2023]
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19
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Breshears JD, Haddad AF, Viner J, Rau J, Sankaran S, McDermott MW. A Reduced Exogenous Steroid Taper for Postoperative Brain Tumor Patients-A Case-Control Study. World Neurosurg 2019; 125:e44-e47. [PMID: 30639502 DOI: 10.1016/j.wneu.2018.12.173] [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: 09/13/2018] [Revised: 12/17/2018] [Accepted: 12/20/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Dexamethasone is a standard treatment for cerebral edema after brain tumor surgery. However, its side effects can negatively impact the quality and safety of care provided to patients. Sparse evidence exists in the literature regarding postoperative steroid dosing to guide clinicians. The objective of this study was to determine if a new reduced exogenous steroid taper (REST) protocol would effectively treat postoperative cerebral edema while reducing the incidence of steroid-related side effects including diabetes, hypertension, and insomnia. METHODS A REST protocol (dexamethasone 38.5 mg tapered over 10 days) was instituted for patients with postoperative brain tumor of a single surgeon. Historical controls treated with a high-dose taper (dexamethasone 117 mg taper over 17 days) were selected to match for baseline characteristics. Outcomes of new or worsened diabetes, hypertension, and insomnia, as well as length of stay (LOS) and 30-day readmission rates, were compared. RESULTS Twenty-five patients were included in each group. There were no significant differences in baseline characteristics. The REST group received a median of 34.5 mg (interquartile range, 32-41 mg) of dexamethasone, whereas controls received 43 mg (interquartile range, 16-91 mg) (P = 0.04). There was a significant reduction in the incidence of new or worsened hypertension in the REST group (0%) compared with controls (20%, P = 0.02). No difference was seen in the rates of diabetes mellitus, insomnia, LOS, or 30-day readmission rates. CONCLUSIONS A reduced steroid taper after brain tumor surgery significantly reduced the incidence of hypertension without increasing LOS or 30-day readmissions compared with controls treated with a high-dose taper.
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Affiliation(s)
- Jonathan D Breshears
- Department of Neurological Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alexander F Haddad
- School of Medicine, University of California San Francisco, San Francisco, California, USA.
| | - Jennifer Viner
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Johnny Rau
- Department of Pharmaceutical Services, University of California San Francisco, San Francisco, California, USA
| | - Sujatha Sankaran
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA; Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Michael W McDermott
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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20
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Wells E, Kambhampati M, Damsker JM, Gordish-Dressman H, Yadavilli S, Becher OJ, Gittens J, Stampar M, Packer RJ, Nazarian J. Vamorolone, a dissociative steroidal compound, reduces pro-inflammatory cytokine expression in glioma cells and increases activity and survival in a murine model of cortical tumor. Oncotarget 2018; 8:9366-9374. [PMID: 28030841 PMCID: PMC5354737 DOI: 10.18632/oncotarget.14070] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 12/13/2016] [Indexed: 11/25/2022] Open
Abstract
Corticosteroids, such as dexamethasone, are routinely used as palliative care in neuro-oncology for their anti-inflammatory benefits, however many patients experience dose limiting side effects caused by glucocorticoid response element (GRE)-mediated transcription. The purpose of this study was to use a murine model to investigate a new steroid alternative, vamorolone, which promises to reduce side effects through dissociating GRE-mediated transcription and NF-κB -mediated anti-inflammatory actions. To compare vamorolone to dexamethasone in reducing pro-inflammatory signals in vitro, murine glioma cells were treated with dexamethasone, vamorolone or vehicle control. Changes in mRNA expression were assessed using the nanostring inflammatory platform. Furthermore, drug efficacy, post-treatment behavioral activity and side effects were assessed by treating two cohorts of brain tumor bearing mice with dexamethasone, vamorolone, or vehicle control. Our investigation showed that treatment with vamorolone resulted in a reduction of pro-inflammatory signals in tumor cells in vitro similar to treatment with dexamethasone. Treatment with vamorolone resulted in a better safety profile in comparison to dexamethasone treatment. Vamorolone- treated mice showed similar or better activity and survival when compared to dexamethasone-treated mice. Our data indicate vamorolone is a potential steroid-sparing alternative for treating patients with brain tumors.
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Affiliation(s)
- Elizabeth Wells
- Research Center for Genetic Medicine, Children's National Health System, Washington, DC, USA.,Brain Tumor Institute, Center for Neuroscience and Behavioral Medicine, Children's National Health System, Washington, DC, USA
| | - Madhuri Kambhampati
- Research Center for Genetic Medicine, Children's National Health System, Washington, DC, USA
| | | | | | - Sridevi Yadavilli
- Research Center for Genetic Medicine, Children's National Health System, Washington, DC, USA
| | | | - Jamila Gittens
- Research Center for Genetic Medicine, Children's National Health System, Washington, DC, USA
| | - Mojca Stampar
- Research Center for Genetic Medicine, Children's National Health System, Washington, DC, USA
| | - Roger J Packer
- Brain Tumor Institute, Center for Neuroscience and Behavioral Medicine, Children's National Health System, Washington, DC, USA
| | - Javad Nazarian
- Research Center for Genetic Medicine, Children's National Health System, Washington, DC, USA.,Department of Integrative Systems Biology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Díez Valle R, Becerra Castro V, Marigil Sánchez M, Gállego Pérez-Larraya J, Núñez-Córdoba JM, Tejada Solis S. Results of a Policy of Fast Tapering of Steroids After Resection Surgery in Glioblastoma. World Neurosurg 2018; 109:e845-e852. [DOI: 10.1016/j.wneu.2017.10.110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 10/18/2017] [Accepted: 10/20/2017] [Indexed: 11/29/2022]
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Armstrong TS, Bishof AM, Brown PD, Klein M, Taphoorn MJB, Theodore-Oklota C. Determining priority signs and symptoms for use as clinical outcomes assessments in trials including patients with malignant gliomas: Panel 1 Report. Neuro Oncol 2016; 18 Suppl 2:ii1-ii12. [PMID: 26989127 DOI: 10.1093/neuonc/nov267] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Patients with primary brain tumors such as malignant gliomas are highly symptomatic, often from the time of diagnosis. Signs and symptoms (signs/symptoms) can cause functional limitations that often worsen over the disease trajectory and may impact patient quality of life. It is recognized that standard measurements of tumor response do not adequately measure this impact or the impact that a therapy may have to mitigate these signs/symptoms and potentially have clinical benefit. Identifying a core set of signs/symptoms and functional limitations is important for understanding their clinical impact and is the first step to including clinical outcomes assessment in primary brain tumor clinical trials.
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Affiliation(s)
- Terri S Armstrong
- The University of Texas Health Science Center at Houston and MD Anderson Cancer Center, Houston, Texas (T.S.A.); Patient Advocate, Bryn Mawr, Pennsylvania (A.M.B.); The University of Texas MD Anderson Cancer Center, Houston, Texas (P.D.B.); VU University Medical Center, Amsterdam, Netherlands (M.K.); VU University Medical Center, Amsterdam, and Medical Center Haaglanden, The Hague, Netherlands (M.J.B.T.); Genentech, South San Francisco, California (C.T.-O.)
| | - Allison M Bishof
- The University of Texas Health Science Center at Houston and MD Anderson Cancer Center, Houston, Texas (T.S.A.); Patient Advocate, Bryn Mawr, Pennsylvania (A.M.B.); The University of Texas MD Anderson Cancer Center, Houston, Texas (P.D.B.); VU University Medical Center, Amsterdam, Netherlands (M.K.); VU University Medical Center, Amsterdam, and Medical Center Haaglanden, The Hague, Netherlands (M.J.B.T.); Genentech, South San Francisco, California (C.T.-O.)
| | - Paul D Brown
- The University of Texas Health Science Center at Houston and MD Anderson Cancer Center, Houston, Texas (T.S.A.); Patient Advocate, Bryn Mawr, Pennsylvania (A.M.B.); The University of Texas MD Anderson Cancer Center, Houston, Texas (P.D.B.); VU University Medical Center, Amsterdam, Netherlands (M.K.); VU University Medical Center, Amsterdam, and Medical Center Haaglanden, The Hague, Netherlands (M.J.B.T.); Genentech, South San Francisco, California (C.T.-O.)
| | - Martin Klein
- The University of Texas Health Science Center at Houston and MD Anderson Cancer Center, Houston, Texas (T.S.A.); Patient Advocate, Bryn Mawr, Pennsylvania (A.M.B.); The University of Texas MD Anderson Cancer Center, Houston, Texas (P.D.B.); VU University Medical Center, Amsterdam, Netherlands (M.K.); VU University Medical Center, Amsterdam, and Medical Center Haaglanden, The Hague, Netherlands (M.J.B.T.); Genentech, South San Francisco, California (C.T.-O.)
| | - Martin J B Taphoorn
- The University of Texas Health Science Center at Houston and MD Anderson Cancer Center, Houston, Texas (T.S.A.); Patient Advocate, Bryn Mawr, Pennsylvania (A.M.B.); The University of Texas MD Anderson Cancer Center, Houston, Texas (P.D.B.); VU University Medical Center, Amsterdam, Netherlands (M.K.); VU University Medical Center, Amsterdam, and Medical Center Haaglanden, The Hague, Netherlands (M.J.B.T.); Genentech, South San Francisco, California (C.T.-O.)
| | - Christina Theodore-Oklota
- The University of Texas Health Science Center at Houston and MD Anderson Cancer Center, Houston, Texas (T.S.A.); Patient Advocate, Bryn Mawr, Pennsylvania (A.M.B.); The University of Texas MD Anderson Cancer Center, Houston, Texas (P.D.B.); VU University Medical Center, Amsterdam, Netherlands (M.K.); VU University Medical Center, Amsterdam, and Medical Center Haaglanden, The Hague, Netherlands (M.J.B.T.); Genentech, South San Francisco, California (C.T.-O.)
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Validating self-report and proxy reports of the Dexamethasone Symptom Questionnaire -Chronic for the evaluation of longer-term corticosteroid toxicity. Support Care Cancer 2015; 24:1209-18. [PMID: 26294320 DOI: 10.1007/s00520-015-2897-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 08/09/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE In brain tumours, brain metastases or advanced cancer; treatment with corticosteroids, side effects can add to symptoms. These are best assessed by patients, complementing clinical assessment. We assessed the feasibility and validity of the Dexamethasone Symptom Questionnaire-Chronic (DSQ-Chronic), patient and caregiver versions. METHODS A longitudinal cohort study was conducted, collecting clinician-rated toxicity, performance status, dexamethasone dose and DSQ-Chronic (patient and caregiver versions) at baseline, then 2, 4 and 8 weeks later. Patients had a primary malignant brain tumour, brain metastases, or advanced cancer; Karnofsky Performance Status ≥40 and predicted survival ≥8 weeks. Analysis included questionnaire completion rates, frequency and severity of dexamethasone-attributable side effects, agreement between patient and caregiver ratings, comparison with clinician-rated toxicity and correlation with performance status. RESULTS Sixty-six patients were recruited (mean age 60 years), with their caregivers. Completion of questionnaires was over 90% for the dyad at baseline but dropped over time, with caregiver completion rates higher at all timepoints. Agreement between patients and proxies was fair to moderate, and while proxies systematically overestimated symptom severity on DSQ-chronic total scores, the bias was less than 10 points. Patient and clinician agreement was higher for more objective symptoms. CONCLUSION The DSQ-Chronic is feasible when the patient is relatively well. As capacity to complete the DSQ-Chronic diminishes, caregivers can be proxy-raters. Clinicians capture corticosteroid toxicities, which may not be obvious to the patient. The DSQ-Chronic, patient and caregiver versions, are useful tools to be used with clinician assessment.
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Armstrong TS, Ying Y, Wu J, Acquaye AA, Vera-Bolanos E, Gilbert MR, Brown PD, Vardy J, Chung C. The relationship between corticosteroids and symptoms in patients with primary brain tumors: utility of the Dexamethasone Symptom Questionnaire-Chronic. Neuro Oncol 2015; 17:1114-1120. [PMID: 25862766 PMCID: PMC4490874 DOI: 10.1093/neuonc/nov054] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 03/11/2005] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Corticosteroids can have many side effects that impact the patient's quality of life and functional status. The Dexamethasone Symptom Questionnaire-Chronic (DSQ-C) was developed to report corticosteroid side effects. This study's objective was to evaluate the utility of the DSQ-C and report associated signs and symptoms in brain tumor patients. METHODS Data collection included demographic and disease characteristics and the DSQ-C. Descriptive statistics were used to report associations among variables. Linear regression models were applied to assess the effects of the cumulative daily dose (mg/d × total d) on DSQ-C scores. Psychometrics included factor analysis to assess construct validity and Cronbach's alpha for internal consistency. RESULTS Ninety-six adult patients with primary (77%) or metastatic (23%) brain tumors participated, with 74% on corticosteroids. Participants were primarily white (83%) males (65%) between 20 and 75 years of age (median, 53). Median corticosteroid dose duration was 4 mg/day for 1 month (range, 0-26 mo). The DSQ-C scores ranged from 17 to 54 (mean of 27), with 35% reporting increased appetite and trouble sleeping. Factor analysis indicated 6 underlying constructs explaining 53% of variance. DSQ-C internal consistency (reliability) was 0.77. The DSQ-C discriminated between patients who were on steroids and those who were not (P < .01), and cumulative dose predicted DSQ-C scores (P < .001). CONCLUSIONS This study demonstrated the potential use of the DSQ-C as a screening tool for side effects associated with corticosteroid use in brain tumor patients. Future analyses should include longitudinal evaluation of severity and biologic underpinnings of variability of timing and severity of symptoms.
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Affiliation(s)
- Terri S Armstrong
- University of Texas Health Science Center, Houston, Texas (T.S.A.); M.D. Anderson Cancer Center, Houston, Texas (T.S.A., Y.Y., J.W., A.A.A., E.V.-B., P.D.B.); National Institutes of Health, Bethesda, Maryland (M.R.G.); University of Sydney Concord Repatriation General Hospital, Concord, New South Wales, Australia (J.V.); Department of Radiation Oncology, University of Toronto/University Health Network-Princess Margaret Cancer Centre, Toronto, Ontario, Canada (C.C.)
| | - Yuan Ying
- University of Texas Health Science Center, Houston, Texas (T.S.A.); M.D. Anderson Cancer Center, Houston, Texas (T.S.A., Y.Y., J.W., A.A.A., E.V.-B., P.D.B.); National Institutes of Health, Bethesda, Maryland (M.R.G.); University of Sydney Concord Repatriation General Hospital, Concord, New South Wales, Australia (J.V.); Department of Radiation Oncology, University of Toronto/University Health Network-Princess Margaret Cancer Centre, Toronto, Ontario, Canada (C.C.)
| | - Jimin Wu
- University of Texas Health Science Center, Houston, Texas (T.S.A.); M.D. Anderson Cancer Center, Houston, Texas (T.S.A., Y.Y., J.W., A.A.A., E.V.-B., P.D.B.); National Institutes of Health, Bethesda, Maryland (M.R.G.); University of Sydney Concord Repatriation General Hospital, Concord, New South Wales, Australia (J.V.); Department of Radiation Oncology, University of Toronto/University Health Network-Princess Margaret Cancer Centre, Toronto, Ontario, Canada (C.C.)
| | - Alvina A Acquaye
- University of Texas Health Science Center, Houston, Texas (T.S.A.); M.D. Anderson Cancer Center, Houston, Texas (T.S.A., Y.Y., J.W., A.A.A., E.V.-B., P.D.B.); National Institutes of Health, Bethesda, Maryland (M.R.G.); University of Sydney Concord Repatriation General Hospital, Concord, New South Wales, Australia (J.V.); Department of Radiation Oncology, University of Toronto/University Health Network-Princess Margaret Cancer Centre, Toronto, Ontario, Canada (C.C.)
| | - Elizabeth Vera-Bolanos
- University of Texas Health Science Center, Houston, Texas (T.S.A.); M.D. Anderson Cancer Center, Houston, Texas (T.S.A., Y.Y., J.W., A.A.A., E.V.-B., P.D.B.); National Institutes of Health, Bethesda, Maryland (M.R.G.); University of Sydney Concord Repatriation General Hospital, Concord, New South Wales, Australia (J.V.); Department of Radiation Oncology, University of Toronto/University Health Network-Princess Margaret Cancer Centre, Toronto, Ontario, Canada (C.C.)
| | - Mark R Gilbert
- University of Texas Health Science Center, Houston, Texas (T.S.A.); M.D. Anderson Cancer Center, Houston, Texas (T.S.A., Y.Y., J.W., A.A.A., E.V.-B., P.D.B.); National Institutes of Health, Bethesda, Maryland (M.R.G.); University of Sydney Concord Repatriation General Hospital, Concord, New South Wales, Australia (J.V.); Department of Radiation Oncology, University of Toronto/University Health Network-Princess Margaret Cancer Centre, Toronto, Ontario, Canada (C.C.)
| | - Paul D Brown
- University of Texas Health Science Center, Houston, Texas (T.S.A.); M.D. Anderson Cancer Center, Houston, Texas (T.S.A., Y.Y., J.W., A.A.A., E.V.-B., P.D.B.); National Institutes of Health, Bethesda, Maryland (M.R.G.); University of Sydney Concord Repatriation General Hospital, Concord, New South Wales, Australia (J.V.); Department of Radiation Oncology, University of Toronto/University Health Network-Princess Margaret Cancer Centre, Toronto, Ontario, Canada (C.C.)
| | - Janette Vardy
- University of Texas Health Science Center, Houston, Texas (T.S.A.); M.D. Anderson Cancer Center, Houston, Texas (T.S.A., Y.Y., J.W., A.A.A., E.V.-B., P.D.B.); National Institutes of Health, Bethesda, Maryland (M.R.G.); University of Sydney Concord Repatriation General Hospital, Concord, New South Wales, Australia (J.V.); Department of Radiation Oncology, University of Toronto/University Health Network-Princess Margaret Cancer Centre, Toronto, Ontario, Canada (C.C.)
| | - Caroline Chung
- University of Texas Health Science Center, Houston, Texas (T.S.A.); M.D. Anderson Cancer Center, Houston, Texas (T.S.A., Y.Y., J.W., A.A.A., E.V.-B., P.D.B.); National Institutes of Health, Bethesda, Maryland (M.R.G.); University of Sydney Concord Repatriation General Hospital, Concord, New South Wales, Australia (J.V.); Department of Radiation Oncology, University of Toronto/University Health Network-Princess Margaret Cancer Centre, Toronto, Ontario, Canada (C.C.)
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Managing Disease and Therapy-Related Complications in Patients with Central Nervous System Tumors. Curr Treat Options Oncol 2015; 16:38. [DOI: 10.1007/s11864-015-0357-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Alan N, Seicean A, Seicean S, Neuhauser D, Benzel EC, Weil RJ. Preoperative steroid use and the incidence of perioperative complications in patients undergoing craniotomy for definitive resection of a malignant brain tumor. J Clin Neurosci 2015; 22:1413-9. [PMID: 26073371 DOI: 10.1016/j.jocn.2015.03.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/21/2015] [Indexed: 12/21/2022]
Abstract
We studied the impact of preoperative steroids on 30 day morbidity and mortality of craniotomy for definitive resection of malignant brain tumors. Glucocorticoids are used to treat peritumoral edema in patients with malignant brain tumors, however, prolonged (⩾ 10 days) use of preoperative steroids as a risk factor for perioperative complications following resection of brain tumors has not been studied comprehensively. Therefore, we identified 4407 patients who underwent craniotomy to resect a malignant brain tumor between 2007 and 2012, who were reported in the National Surgical Quality Improvement Program, a prospectively collected clinical database. Metastatic brain tumors constituted 37.5% (n=1611) and primary malignant gliomas 62.5% (n=2796) of the study population. We used logistic regression to assess the association between preoperative steroid use and perioperative complications before and after 1:1 propensity score matching. Patients who received steroids constituted 22.8% of the population (n=1009). In the unmatched cohort, steroid use was associated with decreased length of hospitalization (odds ratio [OR] 0.7; 95% confidence interval [CI] 0.6-0.8), however, the risk for readmission (OR 1.5; 95% CI 1.2-1.8) was increased. In the propensity score matched cohort (n=465), steroid use was not statistically associated with any adverse outcomes. Patients who received steroids were less likely to stay hospitalized for a protracted period of time, but were more likely to be readmitted after discharge following craniotomy. As an independent risk factor, preoperative steroid use was not associated with any observed perioperative complications. The findings of this study suggest that preoperative steroids do not independently compromise the short term outcome of craniotomy for resection of malignant brain tumors.
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Affiliation(s)
- Nima Alan
- School of Medicine, Case Western Reserve University, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - Andreea Seicean
- School of Medicine, Case Western Reserve University, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH, USA
| | - Sinziana Seicean
- Department of Pulmonary, Critical Care and Sleep Medicine, University Hospitals, Cleveland, OH, USA; Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Duncan Neuhauser
- Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH, USA
| | - Edward C Benzel
- Department of Neurosurgery, The Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Robert J Weil
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery, The Neurological Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Neurosurgery, Geisinger Health System, Danville, PA, USA
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Schiff D, Lee EQ, Nayak L, Norden AD, Reardon DA, Wen PY. Medical management of brain tumors and the sequelae of treatment. Neuro Oncol 2015; 17:488-504. [PMID: 25358508 PMCID: PMC4483077 DOI: 10.1093/neuonc/nou304] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 09/28/2014] [Indexed: 12/11/2022] Open
Abstract
Patients with malignant brain tumors are prone to complications that negatively impact their quality of life and sometimes their overall survival as well. Tumors may directly provoke seizures, hypercoagulable states with resultant venous thromboembolism, and mood and cognitive disorders. Antitumor treatments and supportive therapies also produce side effects. In this review, we discuss major aspects of supportive care for patients with malignant brain tumors, with particular attention to management of seizures, venous thromboembolism, corticosteroids and their complications, chemotherapy including bevacizumab, and fatigue, mood, and cognitive dysfunction.
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Affiliation(s)
| | - Eudocia Q. Lee
- Neuro-Oncology Center, University of Virginia Medical Center, Charlottesville, Virginia (D.S.); Center for Neuro-Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (E.Q.L., L.N., A.D.N., D.A.R., P.Y.W.)
| | - Lakshmi Nayak
- Neuro-Oncology Center, University of Virginia Medical Center, Charlottesville, Virginia (D.S.); Center for Neuro-Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (E.Q.L., L.N., A.D.N., D.A.R., P.Y.W.)
| | - Andrew D. Norden
- Neuro-Oncology Center, University of Virginia Medical Center, Charlottesville, Virginia (D.S.); Center for Neuro-Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (E.Q.L., L.N., A.D.N., D.A.R., P.Y.W.)
| | - David A. Reardon
- Neuro-Oncology Center, University of Virginia Medical Center, Charlottesville, Virginia (D.S.); Center for Neuro-Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (E.Q.L., L.N., A.D.N., D.A.R., P.Y.W.)
| | - Patrick Y. Wen
- Neuro-Oncology Center, University of Virginia Medical Center, Charlottesville, Virginia (D.S.); Center for Neuro-Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (E.Q.L., L.N., A.D.N., D.A.R., P.Y.W.)
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Dubois LG, Campanati L, Righy C, D'Andrea-Meira I, Spohr TCLDSE, Porto-Carreiro I, Pereira CM, Balça-Silva J, Kahn SA, DosSantos MF, Oliveira MDAR, Ximenes-da-Silva A, Lopes MC, Faveret E, Gasparetto EL, Moura-Neto V. Gliomas and the vascular fragility of the blood brain barrier. Front Cell Neurosci 2014; 8:418. [PMID: 25565956 PMCID: PMC4264502 DOI: 10.3389/fncel.2014.00418] [Citation(s) in RCA: 218] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 11/18/2014] [Indexed: 12/22/2022] Open
Abstract
Astrocytes, members of the glial family, interact through the exchange of soluble factors or by directly contacting neurons and other brain cells, such as microglia and endothelial cells. Astrocytic projections interact with vessels and act as additional elements of the Blood Brain Barrier (BBB). By mechanisms not fully understood, astrocytes can undergo oncogenic transformation and give rise to gliomas. The tumors take advantage of the BBB to ensure survival and continuous growth. A glioma can develop into a very aggressive tumor, the glioblastoma (GBM), characterized by a highly heterogeneous cell population (including tumor stem cells), extensive proliferation and migration. Nevertheless, gliomas can also give rise to slow growing tumors and in both cases, the afflux of blood, via BBB is crucial. Glioma cells migrate to different regions of the brain guided by the extension of blood vessels, colonizing the healthy adjacent tissue. In the clinical context, GBM can lead to tumor-derived seizures, which represent a challenge to patients and clinicians, since drugs used for its treatment must be able to cross the BBB. Uncontrolled and fast growth also leads to the disruption of the chimeric and fragile vessels in the tumor mass resulting in peritumoral edema. Although hormonal therapy is currently used to control the edema, it is not always efficient. In this review we comment the points cited above, considering the importance of the BBB and the concerns that arise when this barrier is affected.
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Affiliation(s)
- Luiz Gustavo Dubois
- Instituto Estadual do Cérebro Paulo Niemeyer, Rua do Rezende Rio de Janeiro, Brazil
| | - Loraine Campanati
- Laboratório de Morfogênese Celular, Instituto de Ciências Biomédicas da, Universidade Federal do Rio de Janeiro Rio de Janeiro, Brazil
| | - Cassia Righy
- Instituto Estadual do Cérebro Paulo Niemeyer, Rua do Rezende Rio de Janeiro, Brazil
| | | | | | | | - Claudia Maria Pereira
- Programa de Pós-Graduação em Odontologia, Escola de Ciências da Saúde (ECS), Universidade do Grande Rio (UNIGRANRIO) Duque de Caxias, Brazil
| | - Joana Balça-Silva
- Centro de Neurociência e Biologia Celular, Faculdade de Medicina, Universidade de Coimbra Coimbra, Portugal
| | - Suzana Assad Kahn
- Instituto Estadual do Cérebro Paulo Niemeyer, Rua do Rezende Rio de Janeiro, Brazil
| | - Marcos F DosSantos
- Laboratório de Morfogênese Celular, Instituto de Ciências Biomédicas da, Universidade Federal do Rio de Janeiro Rio de Janeiro, Brazil
| | | | - Adriana Ximenes-da-Silva
- Instituto de Ciências Biológicas e da Saúde, Universidade Federal de Alagoas, Maceió Alagoas, Brazil
| | - Maria Celeste Lopes
- Centro de Neurociência e Biologia Celular, Faculdade de Medicina, Universidade de Coimbra Coimbra, Portugal
| | - Eduardo Faveret
- Instituto Estadual do Cérebro Paulo Niemeyer, Rua do Rezende Rio de Janeiro, Brazil
| | | | - Vivaldo Moura-Neto
- Instituto Estadual do Cérebro Paulo Niemeyer, Rua do Rezende Rio de Janeiro, Brazil ; Laboratório de Morfogênese Celular, Instituto de Ciências Biomédicas da, Universidade Federal do Rio de Janeiro Rio de Janeiro, Brazil
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Paulsen Ø, Klepstad P, Rosland JH, Aass N, Albert E, Fayers P, Kaasa S. Efficacy of Methylprednisolone on Pain, Fatigue, and Appetite Loss in Patients With Advanced Cancer Using Opioids: A Randomized, Placebo-Controlled, Double-Blind Trial. J Clin Oncol 2014; 32:3221-8. [DOI: 10.1200/jco.2013.54.3926] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Corticosteroids are frequently used in cancer pain management despite limited evidence. This study compares the analgesic efficacy of corticosteroid therapy with placebo. Patients and Methods Adult patients with cancer receiving opioids with average pain intensity ≥ 4 (numeric rating scale [NRS], 0 to 10) in the last 24 hours were eligible. Patients were randomly assigned to methylprednisolone (MP) 16 mg twice daily or placebo (PL) for 7 days. Primary outcome was average pain intensity measured at day 7 (NRS, 0 to 10); secondary outcomes were analgesic consumption (oral morphine equivalents), fatigue and appetite loss (European Organisation for Research and Treatment of Cancer–Quality of Life Questionnaire C30, 0 to 100), and patient satisfaction (NRS, 0 to 10). Results A total of 592 patients were screened; 50 were randomly assigned, and 47 were analyzed. Baseline opioid level was 269.9 mg in the MP arm and 160.4 mg in the PL arm. At day-7 evaluation, there was no difference between the groups in pain intensity (MP, 3.60 v PL, 3.68; P = .88) or relative analgesic consumption (MP, 1.19 v PL, 1.20; P = .95). Clinically and statistically significant improvements were found in fatigue (−17 v 3 points; P .003), appetite loss (−24 v 2 points; P = .003), and patient satisfaction (5.4 v 2.0 points; P = .001) in favor of the MP compared with the PL group, respectively. There were no differences in adverse effects between the groups. Conclusion MP 32 mg daily did not provide additional analgesia in patients with cancer receiving opioids, but it improved fatigue, appetite loss, and patient satisfaction. Clinical benefit beyond a short-term effect must be examined in a future study.
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Affiliation(s)
- Ørnulf Paulsen
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Pål Klepstad
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Jan Henrik Rosland
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Nina Aass
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Eva Albert
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Peter Fayers
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Stein Kaasa
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
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Hou J, Kshettry VR, Selman WR, Bambakidis NC. Peritumoral brain edema in intracranial meningiomas: the emergence of vascular endothelial growth factor-directed therapy. Neurosurg Focus 2014; 35:E2. [PMID: 24289127 DOI: 10.3171/2013.8.focus13301] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Meningioma is the second most common type of adult intracranial neoplasm. A substantial subset of patients present with peritumoral brain edema (PTBE), which can cause significant morbidity via mass effect, complicate surgical management, and impact the safety of stereotactic radiosurgery. Recent studies suggest a close relationship between vascular endothelial growth factor-A (VEGF-A) expression and PTBE development in meningiomas. The authors performed a systematic review of the literature on the pathogenesis of PTBE in meningiomas, the effectiveness of steroid therapy, the role played by VEGF-A, and the current clinical evidence for antiangiogenic therapy to treat peritumoral brain edema. Mounting evidence suggests VEGF-A is secreted directly by meningioma cells to induce angiogenesis and edemagenesis of tumoral as well as peritumoral brain tissue. The VEGF-A cascade results in recruitment of cerebral-pial vessels and disruption of the tumor-brain barrier, which appear to be requisite for VEGF-A to have an edemagenic effect. Results of preliminary clinical studies suggest VEGF-directed therapy has modest activity against recurrent and progressive meningioma growth but can alleviate PTBE in some patients. A comprehensive understanding of the VEGF-A pathway and its modulators may hold the key to an effective therapeutic approach to treating PTBE associated with meningiomas. Further clinical trials with larger patient cohorts and longer follow-up periods are warranted to confirm the efficacy of VEGF-directed therapy.
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Affiliation(s)
- Jack Hou
- Department of Neurological Surgery, University Hospitals Case Medical Center; and
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Walbert T, Khan M. End-of-life symptoms and care in patients with primary malignant brain tumors: a systematic literature review. J Neurooncol 2014; 117:217-24. [DOI: 10.1007/s11060-014-1393-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 01/26/2014] [Indexed: 10/25/2022]
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Kellogg RG, Straus DC, Choi M, Chaudhry TA, Diaz AZ, Muñoz LF. Stereotactic radiosurgery boost to the resection cavity for cerebral metastases: Report of overall survival, complications, and corticosteroid protocol. Surg Neurol Int 2013; 4:S436-42. [PMID: 24349867 PMCID: PMC3858803 DOI: 10.4103/2152-7806.121632] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 08/21/2013] [Indexed: 11/25/2022] Open
Abstract
Background: This report focuses on the overall survival and complications associated with treatment of cerebral metastases with surgical resection followed by stereotactic radiosurgery (SRS). Management and complications of corticosteroid therapy are underreported in the literature but represent an important source of morbidity for patients. Methods: Fifty-nine consecutive patients underwent surgical resection of a cerebral metastasis followed by SRS to the cavity. Patient charts were reviewed retrospectively to ascertain overall survival, local control, surgical complications, SRS complications, and corticosteroid complications. Results: Our mean follow-up was 14.4 months (median 12.0 months, range 0.9-62.9 months). Median overall survival in this series was 15.25 months and local control was 98.3%. There was a statistically significant survival benefit conferred by Radiation Therapy Oncology Group recursive partitioning analysis Classes 1 and 2. The surgical complication rate was 6.8% while the SRS complication rate was 2.4%. Corticosteroid complications are reported and dependence at 1 month was 20.3%, at 3 months 6.8%, at 6 months 1.7%, and at 12 months no patients remained on corticosteroid therapy. Conclusions: Overall survival and local control with this treatment paradigm compare well to the other published literature. Complications associated with this patient population are low. A corticosteroid tapering protocol is proposed and demonstrated lower rates of steroid-related complications and dependence than previously reported.
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Affiliation(s)
- Robert G Kellogg
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - David C Straus
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Mehee Choi
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, USA
| | | | - Aidnag Z Diaz
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Lorenzo F Muñoz
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
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Roth P, Regli L, Tonder M, Weller M. Tumor-associated edema in brain cancer patients: pathogenesis and management. Expert Rev Anticancer Ther 2013; 13:1319-25. [PMID: 24152171 DOI: 10.1586/14737140.2013.852473] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The long-term treatment of peritumoral edema remains a major challenge in clinical neuro-oncology. Steroids have been and will remain the backbone of any anti-edematous therapy because of their striking activity, convenient oral administration and also because of their cost-effectiveness. Their side effects, however, can compromise quality of life, particularly upon continuous administration. Therapeutic alternatives which may replace or - at least - help to reduce the steroid dose are limited. However, with the development of new agents such as corticorelin acetate, there is a hope that steroid-induced side effects can be delayed and reduced. The administration of anti-angiogenic agents with steroid-sparing effects, for example, bevacizumab, is limited due to their costs. Increased knowledge on boswellic acids and cyclooxygenase-2 inhibitors which are available for clinical application may help to exploit their anti-edema activity more efficiently in the future.
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Affiliation(s)
- Patrick Roth
- Department of Neurology, University Hospital Zurich, Switzerland
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34
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Current World Literature. Curr Opin Anaesthesiol 2013; 26:244-52. [DOI: 10.1097/aco.0b013e32835f8a30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Deutsch MB, Panageas KS, Lassman AB, DeAngelis LM. Steroid management in newly diagnosed glioblastoma. J Neurooncol 2013; 113:111-6. [DOI: 10.1007/s11060-013-1096-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 02/22/2013] [Indexed: 01/24/2023]
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Gutiérrez-Aceves GA, Moreno-Jiménez S, Celis MÁ, Hernández-Bojórquez M. Radiosurgical third ventriculostomy: Technical note. Surg Neurol Int 2012; 3:121. [PMID: 23226607 PMCID: PMC3512342 DOI: 10.4103/2152-7806.102338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 08/29/2012] [Indexed: 12/25/2022] Open
Abstract
Background: We describe a minimally invasive technique to perform a radiosurgical third ventriculostomy in a patient with mild obstructive hydrocephalus secondary to malignant pathology. Methods: A 42 years old woman with diagnosis of clear cells renal carcinoma and with right nefrectomy performed last year. Cranial Magnetic Resonance Imaging showed two brain metastasis: one right temporal, and other in the pons with Sylvian aqueduct partial obliteration and mild ventricular enlargement. The patient received radiosurgical treatment for brain metastasis; after this procedure a new target was defined on the floor of the third ventricle, in the midpoint between the mamillary bodies and the infundibular recess where we delivered 100 Gy delivered by an isocentric multiple noncoplanar arcs technique, with a 6 MV Novalis® dedicated LINAC. A series of 21 arcs was arranged with a radiation field generated by a 4 mm circular collimator. Results: One week pos-irradiation in the head CT we did not find significant changes in the metastatic lesions; however the VSI diminished 4%, despite of persistent aqueduct obliteration. At three months we perform 3.0 T MRI where we confirmed the presence of the third ventriculostomy (2.63 mm diameter). Conclusion: This report demonstrates, for the first time, the ability of a dedicated LINAC to perform a precise third ventriculostomy without associate morbility in short term.
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Padovani L, André N, Constine LS, Muracciole X. Neurocognitive function after radiotherapy for paediatric brain tumours. Nat Rev Neurol 2012; 8:578-88. [DOI: 10.1038/nrneurol.2012.182] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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