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Kahng JY, Kang BH, Lee ST, Choi SH, Kim TM, Park CK, Won JK, Park SH, Son J, Lee JH. Clinicogenetic characteristics and the effect of radiation on the neural stem cell niche in subventricular zone-contacting glioblastoma. Radiother Oncol 2023; 186:109800. [PMID: 37423479 DOI: 10.1016/j.radonc.2023.109800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 06/26/2023] [Accepted: 07/03/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND AND PURPOSE Neural stem cells (NSCs) in the subventricular zone (SVZ) are recognized as the cellular origin of glioblastoma (GBM) and a potential therapeutic target. However, the characteristics of SVZ contacting GBM (SVZ + GBM) and radiotherapeutic strategies for NSCs are still controversial. Here, we investigated the clinicogenetic features of SVZ + GBM and evaluated the dose effect of NSC irradiation depending on SVZ involvement. MATERIALS AND METHODS We identified 125 patients with GBM treated with surgery followed by chemoradiotherapy. The genomic profiles were obtained by next-generation sequencing targeting 82 genes. NSCs in the SVZ and hippocampus were contoured using standardized methods, and dosimetric factors were analyzed. SVZ + GBM was defined as GBM with SVZ involvement in a T1 contrast-enhanced image. Progression-free survival (PFS) and overall survival (OS) were used as endpoints. RESULTS The number of patients with SVZ + GBM was 95 (76%). SVZ + GBM showed lower PFS than GBM without SVZ involvement (SVZ-GBM) (median 8.6 vs. 11.5 months, p = 0.034). SVZ contact was not associated with any specific genetic profile but was an independent prognostic factor in multivariate analysis. In SVZ + GBM, patients receiving high doses to the ipsilateral NSC region showed significantly better OS (HR = 1.89, p = 0.011) and PFS (HR = 1.77, p = 0.013). However, in SVZ-GBM, high doses to the ipsilateral NSC region were associated with worse OS (HR = 0.27, p = 0.013) and PFS (HR = 0.37, p = 0.035) in both univariate and multivariate analyses. CONCLUSION SVZ involvement in GBM was not associated with distinct genetic features. However, irradiation of NSCs was associated with better prognosis in patients with tumors contacting the SVZ.
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Affiliation(s)
- Jee Ye Kahng
- Department of Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Byung-Hee Kang
- Department of Radiation Oncology, Ewha Womans University Medical Center Seoul Hospital, Seongnam, Republic of Korea
| | - Soon-Tae Lee
- Departments of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Hong Choi
- Departments of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae Min Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chul-Kee Park
- Departments of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae-Kyung Won
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sung-Hye Park
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jaeman Son
- Department of Radiation Oncology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Joo Ho Lee
- Department of Radiation Oncology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.
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2
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Li S, Dong L, Pan Z, Yang G. Targeting the neural stem cells in subventricular zone for the treatment of glioblastoma: an update from preclinical evidence to clinical interventions. Stem Cell Res Ther 2023; 14:125. [PMID: 37170286 PMCID: PMC10173522 DOI: 10.1186/s13287-023-03325-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 04/03/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Glioblastoma is one of the most common and aggressive adult brain tumors. The conventional treatment strategy, surgery combined with chemoradiotherapy, did not change the fact that the recurrence rate was high and the survival rate was low. Over the years, accumulating evidence has shown that the subventricular zone has an important role in the recurrence and treatment resistance of glioblastoma. The human adult subventricular zone contains neural stem cells and glioma stem cells that are probably a part of reason for therapy resistance and recurrence of glioblastoma. MAIN BODY Over the years, both bench and bedside evidences strongly support the view that the presence of neural stem cells and glioma stem cells in the subventricular zone may be the crucial factor of recurrence of glioblastoma after conventional therapy. It emphasizes the necessity to explore new therapy strategies with the aim to target subventricular zone to eradicate neural stem cells or glioma stem cells. In this review, we summarize the recent preclinical and clinical advances in targeting neural stem cells in the subventricular zone for glioblastoma treatment, and clarify the prospects and challenges in clinical application. CONCLUSIONS Although there remain unresolved issues, current advances provide us with a lot of evidence that targeting the neural stem cells and glioma stem cells in subventricular zone may have the potential to solve the dilemma of glioblastoma recurrence and treatment resistance.
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Affiliation(s)
- Sijia Li
- Jilin Provincial Key Laboratory of Radiation Oncology and Therapy, Department of Radiation Oncology and Therapy, The First Hospital of Jilin University, Changchun, 130021 China
| | - Lihua Dong
- Jilin Provincial Key Laboratory of Radiation Oncology and Therapy, Department of Radiation Oncology and Therapy, The First Hospital of Jilin University, Changchun, 130021 China
| | - Zhenyu Pan
- Department of Radiation Oncology, Huizhou Third People’s Hospital, Guangzhou Medical University, Huizhou, 516000 China
| | - Guozi Yang
- Jilin Provincial Key Laboratory of Radiation Oncology and Therapy, Department of Radiation Oncology and Therapy, The First Hospital of Jilin University, Changchun, 130021 China
- Department of Radiation Oncology, Huizhou Third People’s Hospital, Guangzhou Medical University, Huizhou, 516000 China
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3
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Ermiş E, Althaus A, Blatti M, Uysal E, Leiser D, Norouzi S, Riggenbach E, Hemmatazad H, Ahmadli U, Wagner F. Therapy Resistance of Glioblastoma in Relation to the Subventricular Zone: What Is the Role of Radiotherapy? Cancers (Basel) 2023; 15:cancers15061677. [PMID: 36980563 PMCID: PMC10046464 DOI: 10.3390/cancers15061677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/02/2023] [Accepted: 03/05/2023] [Indexed: 03/12/2023] Open
Abstract
Glioblastoma is a highly heterogeneous primary malignant brain tumor with marked inter-/intratumoral diversity and a poor prognosis. It may contain a population of neural stem cells (NSC) and glioblastoma stem cells that have the capacity for migration, self-renewal and differentiation. While both may contribute to resistance to therapy, NSCs may also play a role in brain tissue repair. The subventricular zone (SVZ) is the main reservoir of NSCs. This study investigated the impact of bilateral SVZ radiation doses on patient outcomes. We included 147 patients. SVZs were delineated and the dose administered was extracted from dose–volume histograms. Tumors were classified based on their spatial relationship to the SVZ. The dose and outcome correlations were analyzed using the Kaplan–Meier and Cox proportional hazards regression methods. Median progression-free survival (PFS) was 7 months (range: 4–11 months) and median overall survival (OS) was 14 months (range: 9–23 months). Patients with an ipsilateral SVZ who received ≥50 Gy showed significantly better PFS (8 versus 6 months; p < 0.001) and OS (16 versus 11 months; p < 0.001). Furthermore, lower doses (<32 Gy) to the contralateral SVZ were associated with improved PFS (8 versus 6 months; p = 0.030) and OS (15 versus 11 months; p = 0.001). Targeting the potential tumorigenic cells in the ipsilateral SVZ while sparing contralateral NSCs correlated with an improved outcome. Further studies should address the optimization of dose distribution with modern radiotherapy techniques for the areas surrounding infiltrated and healthy SVZs.
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Affiliation(s)
- Ekin Ermiş
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Correspondence:
| | - Alexander Althaus
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Marcela Blatti
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Emre Uysal
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Dominic Leiser
- Center for Proton Therapy, Paul Scherrer Institute, 5232 Villigen, Switzerland
| | - Shokoufe Norouzi
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Elena Riggenbach
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Hossein Hemmatazad
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Uzeyir Ahmadli
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Franca Wagner
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
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Bruil DE, David S, Nagtegaal SHJ, de Sonnaville SFAM, Verhoeff JJC. Irradiation of the subventricular zone and subgranular zone in high- and low-grade glioma patients: an atlas-based analysis on overall survival. Neurooncol Adv 2022; 4:vdab193. [PMID: 35128399 PMCID: PMC8809520 DOI: 10.1093/noajnl/vdab193] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Neural stem cells in the subventricular zone (SVZ) and subgranular zone (SGZ) are hypothesized to support growth of glioma. Therefore, irradiation of the SVZ and SGZ might reduce tumor growth and might improve overall survival (OS). However, it may also inhibit the repair capacity of brain tissue. The aim of this retrospective cohort study is to assess the impact of SVZ and SGZ radiotherapy doses on OS of patients with high-grade (HGG) or low-grade (LGG) glioma. METHODS We included 273 glioma patients who received radiotherapy. We created an SVZ atlas, shared openly with this work, while SGZ labels were taken from the CoBrA atlas. Next, SVZ and SGZ regions were automatically delineated on T1 MR images. Dose and OS correlations were investigated with Cox regression and Kaplan-Meier analysis. RESULTS Cox regression analyses showed significant hazard ratios for SVZ dose (univariate: 1.029/Gy, P < .001; multivariate: 1.103/Gy, P = .002) and SGZ dose (univariate: 1.023/Gy, P < .001; multivariate: 1.055/Gy, P < .001) in HGG patients. Kaplan-Meier analysis showed significant correlations between OS and high-/low-dose groups for HGG patients (SVZ: respectively 10.7 months (>30.33 Gy) vs 14.0 months (<30.33 Gy) median OS, P = .011; SGZ: respectively 10.7 months (>29.11 Gy) vs 15.5 months (<29.11 Gy) median OS, P < .001). No correlations between dose and OS were found for LGG patients. CONCLUSION Irradiation doses on neurogenic areas correlate negatively with OS in patients with HGG. Whether sparing of the SVZ and SGZ during radiotherapy improves OS, should be subject of prospective studies.
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Affiliation(s)
- Danique E Bruil
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Szabolcs David
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Steven H J Nagtegaal
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Joost J C Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
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Kim KH, Yoo J, Kim N, Moon JH, Byun HK, Kang SG, Chang JH, Yoon HI, Suh CO. Efficacy of Whole-Ventricular Radiotherapy in Patients Undergoing Maximal Tumor Resection for Glioblastomas Involving the Ventricle. Front Oncol 2021; 11:736482. [PMID: 34621677 PMCID: PMC8490925 DOI: 10.3389/fonc.2021.736482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/06/2021] [Indexed: 01/01/2023] Open
Abstract
Background and Purpose Patients with glioblastoma (GBM) involving the ventricles are at high risk of ventricle opening during surgery and potential ventricular tumor spread. We evaluated the effectiveness of whole-ventricular radiotherapy (WVRT) in reducing intraventricular seeding in patients with GBM and identified patients who could benefit from this approach. Methods and Materials We retrospectively reviewed the data of 382 patients with GBM who underwent surgical resection and temozolomide-based chemoradiotherapy. Propensity score matching was performed to compensate for imbalances in characteristics between patients who did [WVRT (+); n=59] and did not [WVRT (–); n=323] receive WVRT. Local, outfield, intraventricular, and leptomeningeal failure rates were compared. Results All patients in the WVRT (+) group had tumor ventricular involvement and ventricle opening during surgery. In the matched cohort, the WVRT (+) group exhibited a significantly lower 2-year intraventricular failure rate than the WVRT (–) group (2.1% vs. 11.8%; P=0.045), with no difference in other outcomes. Recursive partitioning analysis stratified the patients in the WVRT (–) group at higher intraventricular failure risk (2-year survival, 14.2%) due to tumor ventricular involvement, MGMT unmethylation, and ventricle opening. WVRT reduced the intraventricular failure rate only in high-risk patients (0% vs. 14.2%; P=0.054) or those with MGMT-unmethylated GBM in the matched cohort (0% vs. 17.3%; P=0.036). Conclusions WVRT reduced the intraventricular failure rate in patients with tumor ventricular involvement and ventricle opening during surgery. The MGMT-methylation status may further stratify patients who could benefit from WVRT. Further prospective evaluation of WVRT in GBM is warranted.
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Affiliation(s)
- Kyung Hwan Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jihwan Yoo
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ju Hyung Moon
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Hwa Kyung Byun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Seok-Gu Kang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Hong In Yoon
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea.,Department of Radiation Oncology, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
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6
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Hallaert G, Pinson H, Van den Broecke C, Sweldens C, Van Roost D, Kalala JP, Boterberg T. Survival impact of incidental subventricular zone irradiation in IDH-wildtype glioblastoma. Acta Oncol 2021; 60:613-619. [PMID: 33689536 DOI: 10.1080/0284186x.2021.1893899] [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: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE The subventricular zone (SVZ) is an important niche for neural stem cells but probably also for brain tumor propagating cells, including the glioblastoma stem cell. The SVZ may become a target for radiation therapy in glioblastoma patients. However, reports studying the effect of irradiation of the SVZ on glioblastoma patient survival show conflicting results. We studied the correlation between incidental SVZ radiation dose and survival in a cohort of isocitrate dehydrogenase-wildtype (IDHwt) glioblastoma patients with inclusion of important survival prognosticators. PATIENTS AND METHODS In this retrospective analysis, only adult patients with supratentorial IDHwt glioblastoma were included who were treated with temozolomide-based chemoradiotherapy after surgery. The SVZ was contoured on the radiotherapy planning imaging. Cox proportional regression overall survival (OS) analysis was used to study the correlation between SVZ dose and survival. Age, Karnofsky Performance Score, extent of resection and O6-methylguanine-methyl-DNA-transferase gene promoter (MGMTp) methylation were used as covariates in multivariate analysis. RESULTS In total, 137 patients were included. Median OS was 13.3 months. The MGMTp methylation was present in 40% of cases. Ipsilateral SVZ (iSVZ) mean dose was 44.4 Gy and 27.2 Gy for the contralateral SVZ (cSVZ). Univariate survival analysis showed an inverse relationship between cSVZ mean dose and OS (HR 1.029 (1.003-1.057); p= .032). However, there was no correlation between cSVZ mean dose and OS in multivariate analysis. iSVZ dose did not correlate with survival. CONCLUSION In this cohort of 137 IDHwt glioblastoma patients, iSVZ did not correlate with OS. Higher cSVZ dose was inversely correlated with OS in univariate survival analysis but lost its significance in multivariate analysis, including MGMTp-methylation. Hence, the correlation between SVZ radiation and glioblastoma patient survival remains unclear. Carefully designed prospective studies are needed to provide unequivocal results on this controversial topic.
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Affiliation(s)
- Giorgio Hallaert
- Department of Neurosurgery, Ghent University Hospital, Ghent, Belgium
| | - Harry Pinson
- Department of Neurosurgery, Ghent University Hospital, Ghent, Belgium
| | - Caroline Van den Broecke
- Department of Pathology, AZ St Lucas Gent, Gent, Belgium
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | | | - Dirk Van Roost
- Department of Neurosurgery, Ghent University Hospital, Ghent, Belgium
| | | | - Tom Boterberg
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
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7
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Bender K, Träger M, Wahner H, Onken J, Scheel M, Beck M, Ehret F, Budach V, Kaul D. What is the role of the subventricular zone in radiotherapy of glioblastoma patients? Radiother Oncol 2021; 158:138-145. [PMID: 33636228 DOI: 10.1016/j.radonc.2021.02.017] [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: 11/01/2020] [Revised: 01/28/2021] [Accepted: 02/13/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND PURPOSE Current glioblastoma (GBM) therapies prolong survival, but overall prognosis is still poor. Irradiation of the subventricular zone (SVZ) has recently been discussed as a promising concept as this tissue harbors stem cells which seem to play a role in the initiation and recurrence of GBM. In this study, we retrospectively examined the relationship of SVZ irradiation dose and survival in a large, homogeneous GBM patient cohort. MATERIALS AND METHODS We included 200 GBM patients who had been treated at our institution with trimodal therapy (surgery, radiotherapy and chemotherapy) between 2009 and 2020. The SVZ was delineated, and dose-volume histograms were calculated and extracted. Tumors were classified according to their contact with the SVZ. The Kaplan-Meier method was used for survival analysis, and univariable and multivariable Cox regression (MVA) were used to determine prognostic effects on progression-free survival (PFS) and overall survival (OS). RESULTS Median PFS of the study group was 7.2 months; median OS was 15.1 months. In MVA (with mean dose to the ipsilateral SVZ as a continuous covariable), PFS was significantly lower for patients with a Karnofsky performance status (KPS) < 70% and without MGMT promoter methylation. Factors prognostic for shorter OS were old age, lower KPS, unmethylated MGMT status, SVZ contact and biopsy instead of subtotal- or gross total resection. There was no significant correlation between survival and SVZ dose. CONCLUSION In this cohort, an increased mean dose to the ipsilateral or contralateral SVZ did not correlate with improved survival in irradiated GBM patients in MVA. Patients whose tumor directly involved the SVZ showed worse OS in MVA.
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Affiliation(s)
- Katja Bender
- Department of Radiation Oncology Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Malte Träger
- Department of Radiation Oncology Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Helena Wahner
- Department of Radiation Oncology Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; German Cancer Consortium (DKTK), partner site Berlin, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Marcus Beck
- Department of Radiation Oncology Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Felix Ehret
- Department of Radiation Oncology Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Volker Budach
- Department of Radiation Oncology Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - David Kaul
- Department of Radiation Oncology Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; German Cancer Consortium (DKTK), partner site Berlin, Germany.
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Lombard A, Digregorio M, Delcamp C, Rogister B, Piette C, Coppieters N. The Subventricular Zone, a Hideout for Adult and Pediatric High-Grade Glioma Stem Cells. Front Oncol 2021; 10:614930. [PMID: 33575218 PMCID: PMC7870981 DOI: 10.3389/fonc.2020.614930] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/09/2020] [Indexed: 12/23/2022] Open
Abstract
Both in adult and children, high-grade gliomas (WHO grades III and IV) account for a high proportion of death due to cancer. This poor prognosis is a direct consequence of tumor recurrences occurring within few months despite a multimodal therapy consisting of a surgical resection followed by chemotherapy and radiotherapy. There is increasing evidence that glioma stem cells (GSCs) contribute to tumor recurrences. In fact, GSCs can migrate out of the tumor mass and reach the subventricular zone (SVZ), a neurogenic niche persisting after birth. Once nested in the SVZ, GSCs can escape a surgical intervention and resist to treatments. The present review will define GSCs and describe their similarities with neural stem cells, residents of the SVZ. The architectural organization of the SVZ will be described both for humans and rodents. The migratory routes taken by GSCs to reach the SVZ and the signaling pathways involved in their migration will also be described hereafter. In addition, we will debate the advantages of the microenvironment provided by the SVZ for GSCs and how this could contribute to tumor recurrences. Finally, we will discuss the clinical relevance of the SVZ in adult GBM and pediatric HGG and the therapeutic advantages of targeting that neurogenic region in both clinical situations.
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Affiliation(s)
- Arnaud Lombard
- Laboratory of Nervous System Disorders and Therapy, Groupement Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-Neurosciences Research Centre, University of Liège, Liège, Belgium.,Department of Neurosurgery, CHU of Liège, Liège, Belgium
| | - Marina Digregorio
- Laboratory of Nervous System Disorders and Therapy, Groupement Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-Neurosciences Research Centre, University of Liège, Liège, Belgium
| | - Clément Delcamp
- Laboratory of Nervous System Disorders and Therapy, Groupement Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-Neurosciences Research Centre, University of Liège, Liège, Belgium
| | - Bernard Rogister
- Laboratory of Nervous System Disorders and Therapy, Groupement Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-Neurosciences Research Centre, University of Liège, Liège, Belgium.,Department of Neurology, CHU of Liège, Liège, Belgium
| | - Caroline Piette
- Laboratory of Nervous System Disorders and Therapy, Groupement Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-Neurosciences Research Centre, University of Liège, Liège, Belgium.,Department of Pediatrics, Division of Hematology-Oncology, CHU of Liège, Liège, Belgium
| | - Natacha Coppieters
- Laboratory of Nervous System Disorders and Therapy, Groupement Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-Neurosciences Research Centre, University of Liège, Liège, Belgium
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9
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Gui C, Vannorsdall TD, Kleinberg LR, Assadi R, Moore JA, Hu C, Quiñones-Hinojosa A, Redmond KJ. A Prospective Cohort Study of Neural Progenitor Cell-Sparing Radiation Therapy Plus Temozolomide for Newly Diagnosed Patients With Glioblastoma. Neurosurgery 2020; 87:E31-E40. [PMID: 32497183 DOI: 10.1093/neuros/nyaa107] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 02/16/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND In treating glioblastoma, irradiation of the neural progenitor cell (NPC) niches is controversial. Lower hippocampal doses may limit neurocognitive toxicity, but higher doses to the subventricular zones (SVZ) may improve survival. OBJECTIVE To prospectively evaluate the impact of limiting radiation dose to the NPC niches on tumor progression, survival, and cognition in patients with glioblastoma. METHODS Patients with glioblastoma received resection followed by standard chemoradiation. Radiation dose to the NPC niches, including the bilateral hippocampi and SVZ, was minimized without compromising tumor coverage. The primary outcome was tumor progression in the spared NPC niches. Follow-up magnetic resonance imaging was obtained bimonthly. Neurocognitive testing was performed before treatment and at 6- and 12-mo follow-up. Cox regression evaluated predictors of overall and progression-free survival. Linear regression evaluated predictors of neurocognitive decline. RESULTS A total of 30 patients enrolled prospectively. The median age was 58 yr. Median mean doses to the hippocampi and SVZ were 49.1 and 41.8 gray (Gy) ipsilaterally, and 16.5 and 19.9 Gy contralaterally. Median times to death and tumor progression were 16.0 and 7.6 mo, and were not significantly different compared to a matched historical control. No patients experienced tumor progression in the spared NPC-containing regions. Overall survival was associated with neurocognitive function (P ≤ .03) but not dose to the NPC niches. Higher doses to the hippocampi and SVZ predicted greater decline in verbal memory (P ≤ .01). CONCLUSION In treating glioblastoma, limiting dose to the NPC niches may reduce cognitive toxicity while maintaining clinical outcomes. Further studies are needed to confirm these results.
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Affiliation(s)
- Chengcheng Gui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Tracy D Vannorsdall
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Ryan Assadi
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Joseph A Moore
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Chen Hu
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland.,Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | | | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
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Ziu M, Kim BYS, Jiang W, Ryken T, Olson JJ. The role of radiation therapy in treatment of adults with newly diagnosed glioblastoma multiforme: a systematic review and evidence-based clinical practice guideline update. J Neurooncol 2020; 150:215-267. [PMID: 33215344 DOI: 10.1007/s11060-020-03612-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 08/31/2020] [Indexed: 12/20/2022]
Abstract
TARGET POPULATION These recommendations apply to adult patients diagnosed with newly diagnosed glioblastoma. QUESTION 1 : In adult patients (aged 65 and under) with newly diagnosed glioblastoma, is the addition of radiation therapy (RT) more beneficial than management without RT in improving survival? RECOMMENDATIONS Level I: Radiation therapy (RT) is recommended for the treatment of newly diagnosed malignant glioblastoma in adults. QUESTION 2 : In adult patients (aged 65 and under) with newly diagnosed glioblastoma, is the RT regimen of 60 Gy given in 2 Gy daily fractions more beneficial than alternative regimens in providing survival benefit while minimizing toxicity? RECOMMENDATIONS Level I: Treatment schemes should include dosage of up to 60 Gy given in 2 Gy daily fractions that includes the enhancing area. QUESTION 3 : In adult patients (aged 65 and under) with newly diagnosed glioblastoma, is a tailored target volume superior to regional RT for reduction of radiation-induced toxicity while maintaining efficacy? RECOMMENDATION Level II: It is recommended that radiation therapy planning include 1-2 cm margin around the radiographically T1 weighted contrast-enhancing tumor volume or the T2 weighted abnormality on MRI. Level III: Recalculation of the radiation volume during RT treatment may be necessary to reduce the radiated volume of normal brain since the volume of surgical defect will change during the long period of RT. QUESTION 4 : In adult patients (aged 65 and under) with newly diagnosed glioblastoma, does the addition of RT of the subventricular zone to standard tumor volume treatment improve tumor control and overall survival? RECOMMENDATION No recommendation can be formulated as there is contradictory evidence in favor of and against intentional radiation of the subventricular zone (SVZ) QUESTION 5 : In elderly (age > 65 years) and/or frail patients with newly diagnosed glioblastoma, does the addition of RT to surgical intervention improve disease control and overall survival? RECOMMENDATION Level I: Radiation therapy is recommended for treatment of elderly and frail patients with newly diagnosed glioblastoma to improve overall survival. QUESTION 6 : In elderly (age > 65 years) and/or frail patients with newly diagnosed glioblastoma, does modification of RT dose and fractionation scheme from standard regimens decrease toxicity and improve disease control and survival? RECOMMENDATION Level II: Short RT treatment schemes are recommended in frail and elderly patients as compared to conventional 60 Gy given in 2 daily fractions because overall survival is not different while RT risk profile is better for the short RT scheme. Level II: The 40.05 Gy dose given in 15 fractions or 25 Gy dose given in 5 fractions or 34 Gy dose given in 10 fractions should be considered as appropriate doses for Short RT treatments in elderly and/or frail patients. QUESTION 7 : In adult patients with newly diagnosed glioblastoma is there advantage to delaying the initiation of RT instead of starting it 2 weeks after surgical intervention in decreasing radiation-induced toxicity and improving disease control and survival? RECOMMENDATION Level III: It is suggested that RT for patients with newly diagnosed GBM starts within 6 weeks of surgical intervention as compared to later times. There is insufficient evidence to recommend the optimal specific post-operative day within the 6 weeks interval to start RT for adult patients with newly diagnosed glioblastoma that have undergone surgical resection. QUESTION 8 : In adult patients with newly diagnosed supratentorial glioblastoma is Image-Modulated RT (IMRT) or similar techniques as effective as standard regional RT in providing tumor control and improve survival? RECOMMENDATION Level III: There is no evidence that IMRT is a better RT delivering modality when compared to conventional RT in improving overall survival in adult patients with newly diagnosed glioblastoma. Hence, IMRT should not be preferred over the Conventional RT delivery modality. QUESTION 9 : In adult patients with newly diagnosed glioblastoma does the use of radiosensitizers with RT improve the efficacy of RT as determined by disease control and overall survival? RECOMMENDATION Level III: Iododeoxyuridine is not recommended to be used as radiosensitizer during RT treatment for patients with newly diagnosed GBM QUESTION 10 : In adult patients with newly diagnosed glioblastoma is the use of Ultrafractionated RT superior to standard fractionation regimens in improving disease control and survival? RECOMMENDATION There is insufficient evidence to formulate a recommendation regarding the use of ultrafractionated RT schemes and patient population that could benefit from it. QUESTION 11 : In patients with poor prognosis with newly diagnosed glioblastoma is hypofractionated RT indicated instead of a standard fractionation regimen as measured by extent of toxicity, disease control and survival? RECOMMENDATION Level I: Hypofractionated RT schemes may be used for patients with poor prognosis and limited survival without compromising response. There is insufficient evidence in the literature for us to be able to recommend the optimal hypofractionated RT scheme that will confer longest overall survival and/or confer the same overall survival with less toxicities and shorter treatment time. QUESTION 12 : In adult patients with newly diagnosed glioblastoma is the addition of brachytherapy to standard fractionated RT indicated to improve disease control and survival? RECOMMENDATION Level I: Brachytherapy as a boost to external beam RT has not been shown to be beneficial and is not recommended in the routine management of patients with newly diagnosed GBM. QUESTION 13 : In elderly patients (> 65 year old) with newly diagnosed glioblastoma under what circumstances is accelerated hyperfractionated RT indicated instead of a standard fractionation regimen as measured by extent of toxicity, disease control and survival? RECOMMENDATION Level III: Accelerated Hyperfractionated RT with a total RT dose of 45 Gy or 48 Gy has been shown to shorten the treatment time without detriment in survival when compared to conventional external beam RT and should be considered as an option for treatment of elderly patients with newly diagnosed GBM. QUESTION 14 : In adult patients with newly diagnosed glioblastoma is the addition of Stereotactic Radiosurgery (SRS) boost to conventional standard fractionated RT indicated to improve disease control and survival? RECOMMENDATION Level I: Stereotactic Radiosurgery boost to external beam RT has not been shown to be beneficial and is not recommended in patients undergoing routine management of newly diagnosed malignant glioma.
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Affiliation(s)
- Mateo Ziu
- Department of Neurosurgery, Inova Neuroscience and Spine Institute, 3300 Gallows Rd, NPT 2nd Floor, Suite 200, Falls Church, VA, USA.
| | - Betty Y S Kim
- Department of Neurosurgery, The UT at MD Anderson Cancer Center, Houston, TX, USA
| | - Wen Jiang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Timothy Ryken
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
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Valiyaveettil D, Malik M, Akram KS, Ahmed SF, Joseph DM. Prospective study to assess the survival outcomes of planned irradiation of ipsilateral subventricular and periventricular zones in glioblastoma. Ecancermedicalscience 2020; 14:1021. [PMID: 32256704 PMCID: PMC7105331 DOI: 10.3332/ecancer.2020.1021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose/objective(s) Retrospective evidence suggests that the irradiation of stem cells in the periventricular zone (PVZ), specifically the subventricular zone (SVZ), to higher doses may be associated with improved outcomes. Materials/methods This was a prospective study, done from 2012 to 2017 in glioblastoma patients to assess the efficacy of planned irradiation of ipsilateral PVZ and SVZ on survival outcomes. The clinical target volume included the tumour bed with a 1.5–2 cm margin, perilesional oedema and was expanded to encompass the ipsilateral PVZ (5 mm lateral expansion adjacent to the ventricles, including the SVZ, which was a 5 mm expansion lateral to lateral ventricle). The ipsilateral PVZ was planned to receive a dose of ≥50 Gy. Results 89 patients were recruited of which 74 patients were available for the analysis. Median age was 48 years. Mean doses to ipsilateral PVZ and SVZ were 56.2 and 55.1Gy, respectively. Median overall survival in the entire group was 13 months. There was no significant correlation between survival and doses to ipsilateral, contralateral, or bilateral PVZ and SVZ. Median survival was 16, 12 and 6 months for Eastern Cooperative Oncology Group (ECOG) PS 1, 2 and 3, respectively (p = 0.05). Conclusion Planned irradiation of potential stem cell niches in the ipsilateral cerebral hemisphere did not result in improved survival as suggested by retrospective studies. Doses to contralateral or bilateral PVZ or SVZ also did not influence survival.
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Affiliation(s)
- Deepthi Valiyaveettil
- Department of Radiation Oncology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad 500082, India
| | - Monica Malik
- Department of Radiation Oncology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad 500082, India
| | - Kothwal Syed Akram
- Department of Radiation Oncology, Yashoda Superspeciality Hospital, Malakpet, Hyderabad 500036, India
| | - Syed Fayaz Ahmed
- Department of Radiation Oncology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad 500082, India
| | - Deepa M Joseph
- Department of Radiation Oncology, All India Institute of Medical Sciences, Rishikesh, India
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12
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Darázs B, Ruskó L, Végváry Z, Ferenczi L, Dobi Á, Paczona V, Varga Z, Fodor E, Hideghéty K. Subventricular zone volumetric and dosimetric changes during postoperative brain tumor irradiation and its impact on overall survival. Phys Med 2019; 68:35-40. [PMID: 31733404 DOI: 10.1016/j.ejmp.2019.10.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/10/2019] [Accepted: 10/28/2019] [Indexed: 02/07/2023] Open
Abstract
PURPOSE The aim of this retrospective study was to investigate the relationship between the dose to the subventricular zone (SVZ) and overall survival (OS) of 41 patients with glioblastoma multiforme (GBM), who were treated with an adaptive approach involving repeated topometric CT and replanning at two-thirds (40 Gy) of their course of postoperative radiotherapy for planning of a 20 Gy boost. METHODS We examined changes in the ipsilateral lateral ventricle (LV) and SVZ (iLV and iSVZ), as well as in the contralateral LV and SVZ (cLV and cSVZ). We evaluated the volumetric changes on both planning CT scans (primary CT1 and secondary CT2). The survival of the GBM patients was analyzed using the Kaplan-Meier method; the multivariate Cox regression was also performed. RESULTS Median follow-up and OS were 34.5 months and 17.6 months, respectively. LV and SVZ structures exhibited significant volumetric changes on CT2, resulting in an increase of dose coverage. At a cut-off point of 58 Gy, a significant correlation was detected between the iSVZ2 mean dose and OS (27.8 vs 15.6 months, p = 0.048). In a multivariate analysis, GBM patients with a shorter time to postoperative chemoradiotherapy (<3.8 weeks), with good performance status (≥70%) and higher mean dose (≥58 Gy) to the iSVZ2 had significantly better OS. CONCLUSIONS Significant anatomical and dose distribution changes to the brain structures were observed, which have a relevant impact on the dose-effect relationship for GBM; therefore, involving the iSVZ in the target volume should be considered and adapted to the changes.
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Affiliation(s)
- Barbara Darázs
- Department of Oncotherapy, University of Szeged, Szeged, Korányi fasor 12, Zip Code: 6720, Hungary.
| | - László Ruskó
- General Electric Healthcare Company, Budapest, Bence u. 3, Zip Code: 1131, Hungary.
| | - Zoltán Végváry
- Department of Oncotherapy, University of Szeged, Szeged, Korányi fasor 12, Zip Code: 6720, Hungary.
| | - Lehel Ferenczi
- General Electric Healthcare Company, Budapest, Bence u. 3, Zip Code: 1131, Hungary.
| | - Ágnes Dobi
- Department of Oncotherapy, University of Szeged, Szeged, Korányi fasor 12, Zip Code: 6720, Hungary.
| | - Viktor Paczona
- Department of Oncotherapy, University of Szeged, Szeged, Korányi fasor 12, Zip Code: 6720, Hungary.
| | - Zoltán Varga
- Department of Oncotherapy, University of Szeged, Szeged, Korányi fasor 12, Zip Code: 6720, Hungary.
| | - Emese Fodor
- Department of Oncotherapy, University of Szeged, Szeged, Korányi fasor 12, Zip Code: 6720, Hungary.
| | - Katalin Hideghéty
- Department of Oncotherapy, University of Szeged, Szeged, Korányi fasor 12, Zip Code: 6720, Hungary.
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13
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Validation and optimization of a web-based nomogram for predicting survival of patients with newly diagnosed glioblastoma. Strahlenther Onkol 2019; 196:58-69. [PMID: 31489457 DOI: 10.1007/s00066-019-01512-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 08/08/2019] [Indexed: 01/05/2023]
Abstract
PURPOSE To optimize and validate a current (NRG [a newly constituted National Clinical Trials Network group through National Surgical Adjuvant Breast and Bowel Project [NSABP], the Radiation Therapy Oncology Group [RTOG] and the Gynecologic Oncology Group (GOG)]) nomogram for glioblastoma patients as part of continuous validation. METHODS We identified patients newly diagnosed with glioblastoma who were treated with temozolomide-based chemoradiotherapy between 2006 and 2016 at three large-volume hospitals. The extent of resection was determined via postoperative MRI. The discrimination and calibration abilities of the prediction algorithm were assessed; if additional factors were identified as independent prognostic factors, updated models were developed using the data from two hospitals and were externally validated using the third hospital. Models were internally validated using cross-validation and bootstrapping. RESULTS A total of 837 patients met the eligibility criteria. The median overall survival (OS) was 20.0 (95% CI 18.5-21.5) months. The original nomogram was able to estimate the 6‑, 12-, and 24-month OS probabilities, but it slightly underestimated the OS values. In multivariable Cox regression analysis, MRI-defined total resection had a greater impact on OS than that shown by the original nomogram, and two additional factors-IDH1 mutation and tumor contacting subventricular zone-were newly identified as independent prognostic values. An updated nomogram incorporating these new variables outperformed the original nomogram (C-index at 6, 12, 24, and 36 months: 0.728, 0.688, 0.688, and 0.685, respectively) and was well calibrated. External validation using an independent cohort showed C‑indices of 0.787, 0.751, 0.719, and 0.702 at 6, 12, 24, and 36 months, respectively, and was well calibrated. CONCLUSION An updated and validated nomogram incorporating the contemporary parameters can estimate individual survival outcomes in patients with glioblastoma with better accuracy.
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14
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Valiyaveettil D, Malik M, Joseph DM. Effect of radiation dose to the periventricular zone and subventricular zone on survival in anaplastic gliomas. Ecancermedicalscience 2019; 13:956. [PMID: 31645884 PMCID: PMC6759320 DOI: 10.3332/ecancer.2019.956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Indexed: 01/10/2023] Open
Abstract
Purpose Evidence suggests a correlation of subventricular zone (SVZ) irradiation on survival. Most of the data have been analysed in glioblastoma patients. The aim of this study is to analyse the dose to the subventricular and periventricular zone and its outcomes in anaplastic gliomas. Materials and methods A retrospective analysis of patients with anaplastic gliomas were admitted for post-chemoradiation from January 2010 to June 2016 was done from treatment records. SVZ was contoured as 5 mm expansion along the lateral margin of the lateral ventricles, and PVZ was contoured as 5 mm lateral expansion adjacent to ventricles. Dosimetric data were collected from the treatment planning system. Results Ninety-five patients were included in the analysis. The median age was 35 years. Two- and five-year overall survival (OS) for the entire group was 84% and 54.2%, respectively. Two- and five-year progression-free survival (PFS) was 79.8% and 50.6%, respectively. Patients receiving <54 Gy to the i/l SVZ showed a significantly better PFS and OS. 5-Year OS was 72.6% in this group compared to 37% for the group receiving ≥54 Gy (p = 0.01). Five-year PFS was 69.9% in this group compared to 31.9% for the group receiving ≥54 Gy (p = 0.02). However, this was not significant in multivariate analysis. Conclusion Increased dose to the ipsilateral SVZ does not correlate with improved survival in anaplastic gliomas. There is conflicting evidence regarding the benefit of irradiating the stem cell zones. Future studies should focus on optimizing doses to these areas to reduce detriment in neurocognition.
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Affiliation(s)
- Deepthi Valiyaveettil
- Department of Radiation Oncology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad 500082, India
| | - Monica Malik
- Department of Radiation Oncology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad 500082, India
| | - Deepa M Joseph
- Department of Radiation Oncology, All India Institute of Medical Sciences, Rishikesh 249203, India
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Şuşman S, Leucuţa DC, Kacso G, Florian ŞI. High dose vs low dose irradiation of the subventricular zone in patients with glioblastoma-a systematic review and meta-analysis. Cancer Manag Res 2019; 11:6741-6753. [PMID: 31410064 PMCID: PMC6645358 DOI: 10.2147/cmar.s206033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 06/06/2019] [Indexed: 01/19/2023] Open
Abstract
PURPOSE The published data indicate that the irradiation of the subventricular zone (SVZ) might play a role in the treatment of patients with glioblastoma (GBM). We aimed to determine whether radiation treatment doses (high vs low) applied to the SVZ can lead to an increase in progression free survival (PFS) and overall survival (OS). PATIENTS AND METHODS We undertook a systematic review and meta-analysis according to the PICOS research criteria of patients with glioblastoma which received high doses compared to low doses in order to determine if they have a better survival in observational and experimental studies. RESULTS Our survey of the literature yielded 2573 unique records. After screening, 17 were assessed for eligibility, and in the end 8 were included in the qualitative and 4 in the quantitative analysis. Subjects who received higher doses of ipsilateral SVZ (iSVZ) irradiation had a statistically significant better PFS than those receiving lower doses (HR 0.58 [95% CI 0.42-0.82], p=0.002). Subjects receiving higher doses of contralateral SVZ (cSVZ) irradiation did not have a statistically significant better PFS than those receiving lower doses (HR =0.89 [95% CI 0.35-2.26], p=0.81). Also for OS the subjects receiving higher doses to the iSVZ did not have a statistically significant better survival than those receiving lower doses (HR =0.75 [95% CI 0.51-1.11], p=0.15). CONCLUSION The data indicate a possible involvement of the SVZ in the onset and progression of the GBM, as well as a possible role of the SVZ in radiation therapy.
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Affiliation(s)
- Sergiu Şuşman
- Department of Morphological Sciences, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Neuropathology-Imogen Research Center, Emergency County Hospital, Cluj-Napoca, Romania
| | - Daniel-Corneliu Leucuţa
- Department of Medical Informatics and Biostatistics, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Gabriel Kacso
- Department of Oncology and Radiotherapy, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Amethyst Radiotherapy Center, Cluj-Napoca, Romania
| | - Ştefan Ioan Florian
- Department of Neurosciences, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Neurosurgery, Emergency County Hospital, Cluj-Napoca, Romania
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The Role of SVZ Stem Cells in Glioblastoma. Cancers (Basel) 2019; 11:cancers11040448. [PMID: 30934929 PMCID: PMC6521108 DOI: 10.3390/cancers11040448] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/22/2019] [Accepted: 03/26/2019] [Indexed: 12/27/2022] Open
Abstract
As most common primary brain cancer, glioblastoma is also the most aggressive and malignant form of cancer in the adult central nervous system. Glioblastomas are genetic and transcriptional heterogeneous tumors, which in spite of intensive research are poorly understood. Over the years conventional therapies failed to affect a cure, resulting in low survival rates of affected patients. To improve the clinical outcome, an important approach is to identify the cells of origin. One potential source for these are neural stem cells (NSCs) located in the subventricular zone, which is one of two niches in the adult nervous system where NSCs with the capacity of self-renewal and proliferation reside. These cells normally give rise to neuronal as well as glial progenitor cells. This review summarizes current findings about links between NSCs and cancer stem cells in glioblastoma and discusses current therapeutic approaches, which arise as a result of identifying the cell of origin in glioblastoma.
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Murchison SC, Wiksyk B, Gossman S, Jensen B, Sayers D, Lesperance M, Truong PT, Alexander A. Subventricular Zone Radiation Dose and Outcome for Glioblastoma Treated Between 2006 and 2012. Cureus 2018; 10:e3618. [PMID: 30697499 PMCID: PMC6347443 DOI: 10.7759/cureus.3618] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 11/20/2018] [Indexed: 12/18/2022] Open
Abstract
Objective Stem cells residing in the subventricular zone (SVZ) may be related to recurrence, potentially affecting outcome in glioblastoma (GBM). This study investigated the relationship of SVZ radiation dose and survival in a large cohort treated with surgery and chemoradiotherapy (CRT). Methods Patients with GBM treated between 2006 and 2012 (n = 370) were identified. SVZs were contoured from planning computed tomography (CT) with magnetic resonance imaging (MRI) registration where available. Dose was extracted from dose volume histograms. Kaplan-Meier (KM) progression-free survival (PFS) and overall survival (OS) estimates were compared with log-rank tests for SVZ doses. Multivariate analysis (MVA) identified clinical and treatment-related factors significantly associated with outcome. Results Median follow-up was 16.4 months, 48.1% underwent gross total resection (GTR), 37.5% subtotal resection, and 14.4% biopsy without resection. Median PFS was 8.9 months (95% CI: 8.3-9.8 months), and OS was 16.5 months (95% CI: 15.2-17.6 months). PFS was significantly lower for older age (>50 years, P = 0.045), poor Karnofsky performance status (KPS, P = 0.049), multifocality (P < 0.001), and incomplete adjuvant chemotherapy (P < 0.001). Worse OS was associated with poor KPS (P = 0.001), biopsy only (P = 0.003), multifocality (P = 0.009), and failure to complete adjuvant chemotherapy (P < 0.001). SVZ dose was not associated with outcome for any of the dose levels assessed. On MVA, multifocality was associated with worse PFS (P < 0.01). Poor performance status and biopsy only were associated with worse OS (both P < 0.01). Conclusion In this analysis of a large cohort of GBM treated with surgery and CRT, increased SVZ dose was not associated with improved survival.
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Affiliation(s)
- Sonja C Murchison
- Radiation Oncology, British Columbia Cancer Agency - Vancouver Island Centre, Victoria, CAN
| | - Bradley Wiksyk
- Internal Medicine, University of British Columbia, Vancouver, CAN
| | - Stacey Gossman
- Radiation Oncology, British Columbia Cancer Agency - Vancouver Island Centre, Victoria, CAN
| | - Brigit Jensen
- Radiation Oncology, British Columbia Cancer Agency - Vancouver Island Centre, Victoria, CAN
| | - Dorothy Sayers
- Radiation Oncology, British Columbia Cancer Agency - Vancouver Island Centre, Victoria, CAN
| | | | - Pauline T Truong
- Radiation Oncology, British Columbia Cancer Agency - Vancouver Island Centre, Victoria, CAN
| | - Abraham Alexander
- Radiation Oncology, British Columbia Cancer Agency - Vancouver Island Centre, Victoria, CAN
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Muracciole X, El-Amine W, Tabouret E, Boucekine M, Barlier A, Petrirena G, Harivony T, Solignac L, Chinot OL, Macagno N, Figarella-Branger D, Padovani L. Negative Survival Impact of High Radiation Doses to Neural Stem Cells Niches in an IDH-Wild-Type Glioblastoma Population. Front Oncol 2018; 8:426. [PMID: 30338243 PMCID: PMC6180179 DOI: 10.3389/fonc.2018.00426] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 09/12/2018] [Indexed: 12/17/2022] Open
Abstract
Aims: Assess the impact of radiation doses to neural stem cell (NSC) niches in patients with IDH-wild-type glioblastoma. Materials and Methods: Fifty patients were included in the study. NSC niches [SubVentricular Zone (SVZ) and Sub Granular Zone (SGZ)] were contoured by fusing CT scans and pre-therapy MRI, Tumor location defined ipsilateral and contralateral SVZ and SGZ. Prognostic significance of clinical, biological and dosimetric parameters were examined. We generated a Recursive Partitioning Analysis (RPA) model with independent prognostic classes. Results: Median follow-up: 23.8 months. Event free and overall survival (OS): 10 and 19.1 months. Incomplete surgery, PTV (planning target volume), ipsilateral SVZ or NSC niche mean dose > 57.4 Gy, contralateral NSC niche mean dose > 35 Gy and bilateral NSC niche mean dose > 44 Gy were significantly correlated with reduced OS. Only EGFR amplification was an independent prognostic factor (p = 0.019) for OS. RPA generated independent risk groups: 1 (low risk): [ipsilateral NSC mean dose (INMD) < 58.01 Gy and methylated MGMT promoter], 2: (INMD < 58.01 Gy and unmethylated MGMT promoter and contralateral SVZ mean dose < 18.6 Gy; p = 0.43), 3: (INMD < 58.01 Gy and unmethylated MGMT promoter and contralateral SVZ mean dose > 18.6 Gy; p = 0.002) and 4: (very high risk) (INMD > 58.01 Gy; p < 0.001). Conclusion: High radiation doses to ipsilateral NSC and contralateral SVZ could have a negative impact on overall survival in IDH-wild-type glioblastoma population.
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Affiliation(s)
- Xavier Muracciole
- Radiotherapy Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Wassim El-Amine
- Radiotherapy Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Emmeline Tabouret
- Neuro-Oncology Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France.,Angiogenesis and Micro Environnment UMR 911 CRO2, Aix-Marseille University, Marseille, France
| | - Mohamed Boucekine
- Unity of Research EA3279, Aix-Marseille Université, Marseille, France
| | - Anne Barlier
- Molecular Biology and Oncogenetics Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Gregorio Petrirena
- Neuro-Oncology Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Tovo Harivony
- Radiotherapy Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Laetitia Solignac
- Radiotherapy Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Olivier L Chinot
- Neuro-Oncology Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Nicolas Macagno
- Angiogenesis and Micro Environnment UMR 911 CRO2, Aix-Marseille University, Marseille, France.,Neuropathology Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Dominique Figarella-Branger
- Angiogenesis and Micro Environnment UMR 911 CRO2, Aix-Marseille University, Marseille, France.,Neuropathology Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Laetitia Padovani
- Radiotherapy Department, Assistance Publique des Hôpitaux de Marseille, Marseille, France.,CRCM INSERM UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
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19
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Location of subventricular zone recurrence and its radiation dose predicts survival in patients with glioblastoma. J Neurooncol 2018; 138:549-556. [PMID: 29546530 DOI: 10.1007/s11060-018-2822-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/03/2018] [Indexed: 01/05/2023]
Abstract
Glioblastomas are aggressive brain tumors that frequently recur in the subventricular zone (SVZ) despite maximal treatment. The purpose of this study was to evaluate imaging patterns of subventricular progression and impact of recurrent subventricular tumor involvement and radiation dose to patient outcome. Retrospective review of 50 patients diagnosed with glioblastoma and treated with surgery, radiation, and concurrent temozolomide from January 2012 to June 2013 was performed. Tumors were classified based on location, size, and cortical and subventricular zone involvement. Survival was compared based on recurrence type, distance from the initial enhancing tumor (local ≤ 2 cm, distant > 2 cm), and the radiation dose at the recurrence site. Progression of enhancing subventricular tumor was common at both local (58%) and distant (42%) sites. Median survival was better after local SVZ recurrence than distant SVZ recurrence (8.7 vs. 4.3 months, p = 0.04). Radiation doses at local SVZ recurrence sites recurrence averaged 57.0 ± 4.0 Gy compared to 44.7 ± 6.7 Gy at distant SVZ recurrence sites (p = 0.008). Distant subventricular progression at a site receiving ≤ 45 Gy predicted worse subsequent survival (p = 0.05). Glioblastomas frequently recurred in the subventricular zone, and patient survival was worse when enhancing tumor occurred at sites that received lower radiation doses. This recurrent disease may represent disease undertreated at the time of diagnosis, and further study is needed to determine if improved treatment strategies, such as including the subventricular zone in radiation fields, could improve clinical outcomes.
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Matsuda M, Kohzuki H, Ishikawa E, Yamamoto T, Akutsu H, Takano S, Mizumoto M, Tsuboi K, Matsumura A. Prognostic analysis of patients who underwent gross total resection of newly diagnosed glioblastoma. J Clin Neurosci 2018; 50:172-176. [PMID: 29396060 DOI: 10.1016/j.jocn.2018.01.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 11/18/2017] [Accepted: 01/05/2018] [Indexed: 01/12/2023]
Abstract
Despite cumulative evidence supporting the idea that gross total resection (GTR) contributes to prolonged survival of patients with glioblastoma (GBM), the survival outcome of such patients remains unsatisfactory. To develop more effective postoperative therapeutic strategies for patients who underwent GTR, identification of prognostic factors influencing survival is urgently needed. Here we retrospectively analyzed prognostic factors for patients who underwent GTR of newly diagnosed GBM, with a particular focus on the influence of the subventricular zone (SVZ) as the tumor location. Forty-eight consecutive patients with newly diagnosed GBM who underwent GTR during the initial operation were investigated. Tumor involvement of the SVZ was significantly associated with overall survival (OS). The SVZ-positive group had a significantly shorter median OS of 12.2 months, compared to 34.9 months for the SVZ-negative group. The occurrence of leptomeningeal dissemination was significantly influenced by tumor involvement of the SVZ, but was not significantly influenced by ventricular opening during surgery. We observed a statistically significant difference in OS according to radiation modality. The median OS was 36.9 months for patients treated with high-dose proton beam therapy, compared with 26.2 months for patients treated with conventional radiotherapy. We demonstrated that tumor involvement of the SVZ was associated with poor survival of patients who underwent GTR of newly diagnosed GBM, suggesting the potential need for therapeutic strategies that specifically target tumors in the SVZ. Further prospective studies to evaluate whether radiotherapy targeting the SVZ improves survival of patients with tumor involvement of the SVZ who had undergone GTR are warranted.
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Affiliation(s)
- Masahide Matsuda
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hidehiro Kohzuki
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroyoshi Akutsu
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Shingo Takano
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Masashi Mizumoto
- Department of Radiation Oncology, Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Koji Tsuboi
- Department of Radiation Oncology, Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Akira Matsumura
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.
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21
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Mann J, Ramakrishna R, Magge R, Wernicke AG. Advances in Radiotherapy for Glioblastoma. Front Neurol 2018; 8:748. [PMID: 29379468 PMCID: PMC5775505 DOI: 10.3389/fneur.2017.00748] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 12/27/2017] [Indexed: 11/13/2022] Open
Abstract
External beam radiotherapy (RT) has long played a crucial role in the treatment of glioblastoma. Over the past several decades, significant advances in RT treatment and image-guidance technology have led to enormous improvements in the ability to optimize definitive and salvage treatments. This review highlights several of the latest developments and controversies related to RT, including the treatment of elderly patients, who continue to be a fragile and vulnerable population; potential salvage options for recurrent disease including reirradiation with chemotherapy; the latest imaging techniques allowing for more accurate and precise delineation of treatment volumes to maximize the therapeutic ratio of conformal RT; the ongoing preclinical and clinical data regarding the combination of immunotherapy with RT; and the increasing evidence of cancer stem-cell niches in the subventricular zone which may provide a potential target for local therapies. Finally, continued development on many fronts have allowed for modestly improved outcomes while at the same time limiting toxicity.
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Affiliation(s)
- Justin Mann
- Department of Radiation Oncology, Weill Cornell Medical College, New York, NY, United States
| | - Rohan Ramakrishna
- Department of Neurological Surgery, Weill Cornell Medical College, New York, NY, United States
| | - Rajiv Magge
- Department of Neurology, Weill Cornell Medical College, New York, NY, United States
| | - A Gabriella Wernicke
- Department of Radiation Oncology, Weill Cornell Medical College, New York, NY, United States
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Attal J, Chaltiel L, Lubrano V, Sol JC, Lanaspeze C, Vieillevigne L, Latorzeff I, Cohen-Jonathan Moyal E. Subventricular zone involvement at recurrence is a strong predictive factor of outcome following high grade glioma reirradiation. J Neurooncol 2017; 136:413-419. [PMID: 29273890 DOI: 10.1007/s11060-017-2669-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 11/11/2017] [Indexed: 11/26/2022]
Abstract
We aimed to assess the efficacy of stereotactic irradiation for patients with recurrent high-grade glioma (HGG) and identify predictive factors of progression-free survival (PFS) and overall survival (OS) following reirradiation. We identified 32 patients with recurrent brain HGG who had been treated with either single-dose (stereotactic radiosurgery) or fractionated stereotactic radiotherapy between April 2008 and October 2015. Median follow up was 21.4 months (range 12.9-23.2) and median PFS was and 3.3 months (95% CI [2.3-4.7]), respectively. OS was 90.40% (95% CI [73.09-96.80]) at 6 months and 79.55% (95% CI [59.9-90.29]) at 12 months. Univariate analysis showed that biological effective dose at isocenter ≤ 76 Gy was a poor prognostic factor for both OS (83.33 vs. 100% at 6 months, p = 0.032) and median PFS (2.7 vs. 4.7 months, p = 0.025), as was gross tumor volume (GTV) above 1 cm3 for OS (86.15 vs. 94.12% at 6 months, p = 0.043). Contact with the subventricular zone (SVZ) was also a poor prognostic factor for median PFS (2.3 vs. 4.7 months, p = 0.002). Multivariate analysis showed that SVZ contact remained a poor prognostic factor for PFS (hazard ratio = 3.44, 95% CI [1.21-9.82], p = 0.021). Results suggest that reirradiation is a safe and effective treatment option for recurrent HGG in patients with a good Karnosfsky Performance Scale score, a long progression-free interval since first radiation and limited GTV, and that contact to SVZ is a strong prognostic factor for PFS.
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Affiliation(s)
- J Attal
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse-Oncopôle, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France.
| | - L Chaltiel
- Department of Biostatistics, Institut Universitaire du Cancer de Toulouse-Oncopôle, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France
| | - V Lubrano
- Regional Center for Stereotactic Radiosurgery, CHU Rangueil, Avenue Jean-Poulhès, 31052, Toulouse, France
- Department of Neurosurgery, CHU de Toulouse, Université Paul-Sabatier, 31059, Toulouse, France
| | - J C Sol
- Department of Neurosurgery, CHU de Toulouse, Université Paul-Sabatier, 31059, Toulouse, France
| | - C Lanaspeze
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse-Oncopôle, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France
| | - L Vieillevigne
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse-Oncopôle, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France
| | - I Latorzeff
- Regional Center for Stereotactic Radiosurgery, CHU Rangueil, Avenue Jean-Poulhès, 31052, Toulouse, France
- Department of Oncology-Radiotherapy, Groupe ONCORAD Garonne, Clinique Pasteur, 31300, Toulouse, France
| | - E Cohen-Jonathan Moyal
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse-Oncopôle, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France
- INSERM U1037, Cancer Research Center of Toulouse (CRCT), 31000, Toulouse, France
- Université Toulouse III Paul Sabatier, 31300, Toulouse, France
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Mistry AM. Clinical correlates of subventricular zone-contacting glioblastomas: a meta-analysis. J Neurosurg Sci 2017; 63:581-587. [PMID: 29205011 DOI: 10.23736/s0390-5616.17.04274-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The clinical and molecular correlates of glioblastomas (GBMs) contacting the subventricular zone (SVZ+ GBM) are unknown. This work aimed to reveal any such correlates that may help explain their increased GBM malignancy. EVIDENCE ACQUISITION A meta-analysis was, therefore, conducted to assess whether tumor's MGMT promoter methylation status, isocitrate dehydrogenase (IDH) mutation status, volume, and extent of resection as well as patients' age at diagnosis and preoperative Karnofsky performance status score (KPS) correlate with SVZ contact by GBM. In addition, available imaging of GBM patients in The Cancer Imaging Archive was assessed for SVZ contact and their corresponding clinical and molecular variables were obtained through The Cancer Genome Atlas (TCGA) database. EVIDENCE SYNTHESIS Twenty-one studies were identified through PubMed and EMBASE database search. This review included 257 patients identified from the TCIA/TCGA database. MGMT promoter methylation status (summary odds ratio [OD], 1.18 [0.84-1.66], P=0.34), IDH mutation status (OD: 0.63 [0.20-1.99], P=0.43), and patients' age of diagnosis (summary mean difference, MD, 0.10 years [-1.85, 2.05], P=0.92) did not associated with SVZ contact of the GBM. However, SVZ+ GBMs were significantly larger than SVZ- GBMs (MD: 17.3 cm3 [8.70-25.8], P<0.0001). SVZ+ GBM patients had lower KPS scores (MD: -3.33 [-5.31-(-1.35)], P=0.001) and were half as likely to receive a gross total resection (OD: 0.50 [0.40-0.64], P<0.00001). CONCLUSIONS Additional, large studies that rigorously control for all the known clinical and molecular prognosticators, especially extent of resection and preoperative KPS scores, are needed to evaluate whether SVZ contact by GBM independently influences survival.
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Affiliation(s)
- Akshitkumar M Mistry
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA -
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Khalifa J, Tensaouti F, Lusque A, Plas B, Lotterie JA, Benouaich-Amiel A, Uro-Coste E, Lubrano V, Cohen-Jonathan Moyal E. Subventricular zones: new key targets for glioblastoma treatment. Radiat Oncol 2017; 12:67. [PMID: 28424082 PMCID: PMC5397708 DOI: 10.1186/s13014-017-0791-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 02/24/2017] [Indexed: 12/19/2022] Open
Abstract
Background We aimed to identify subventricular zone (SVZ)-related prognostic factors of survival and patterns of recurrence among patients with glioblastoma. Methods Forty-three patients with primary diagnosed glioblastoma treated in our Cancer Center between 2006 and 2010 were identified. All patients received surgical resection, followed by temozolomide-based chemoradiation. Ipsilateral (iSVZ), contralateral (cSVZ) and bilateral (bSVZ) SVZs were retrospectively segmented and radiation dose-volume histograms were generated. Multivariate analysis using the Cox proportional hazards model was assessed to examine the relationship between prognostic factors and time to progression (TTP) or overall survival (OS). Results Median age was 59 years (range: 25–85). Median follow-up, OS and TTP were 22.7 months (range 7.5–69.7 months), 22.7 months (95% CI 14.5–26.2 months) and 6.4 months (95% CI 4.4–9.3 months), respectively. On univariate analysis, initial contact to SVZ was a poor prognostic factor for OS (18.7 vs 41.7 months, p = 0.014) and TTP (4.6 vs 12.9 months, p = 0.002). Patients whose bSVZ volume receiving at least 20 Gy (V20Gy) was greater than 84% had a significantly improved TTP (17.7 months vs 5.2 months, p = 0.017). This radiation dose coverage was compatible with an hippocampal sparing. On multivariate analysis, initial contact to SVZ and V20 Gy to bSVZ lesser than 84% remained poor prognostic factors for TTP (HR = 3.07, p = 0.012 and HR = 2.67, p = 0.047, respectively). Conclusion Our results suggest that contact to SVZ, as well as insufficient bSVZ radiation dose coverage (V20Gy <84%), might be independent poor prognostic factors for TTP. Therefore, targeting SVZ could be of crucial interest for optimizing glioblastoma treatment.
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Affiliation(s)
- J Khalifa
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse - Oncopôle/Institut Claudius Regaud, 1 avenue Irène Joliot-Curie, Toulouse Cedex, 31059, France.
| | - F Tensaouti
- Toulouse NeuroImaging Center, ToNIC, Université de Toulouse, INSERM, Université Paul Sabatier, Toulouse, France
| | - A Lusque
- Department of Biostatistics, Institut Universitaire du Cancer de Toulouse - Oncopôle/Institut Claudius Regaud, 1 avenue Irène Joliot-Curie, Toulouse Cedex, 31059, France
| | - B Plas
- Department of Neurosurgery, Institut Universitaire du Cancer de Toulouse - Purpan, Place du Docteur Baylac, Toulouse Cedex, 31059, France
| | - J-A Lotterie
- Toulouse NeuroImaging Center, ToNIC, Université de Toulouse, INSERM, Université Paul Sabatier, Toulouse, France.,Department of Nuclear Medicine, CHU Rangueil, 1 avenue du Pr Jean Poulhès TSA 50032, Toulouse Cedex, 31059, France
| | - A Benouaich-Amiel
- Department of Medical Oncology, Institut Universitaire du Cancer de Toulouse - Oncopôle/Institut Claudius Regaud, 1 avenue Irène Joliot-Curie, Toulouse Cedex, 31059, France
| | - E Uro-Coste
- Department of Pathology, Institut Universitaire du Cancer de Toulouse - Oncopôle/Institut Claudius Regaud, 1 avenue Irène Joliot-Curie, Toulouse Cedex, 31059, France.,Université Paul Sabatier, Toulouse III, 118 route de Narbonne, Toulouse, 31062, France.,INSERM U1037, Centre de Recherche contre le Cancer de Toulouse, 1 avenue Irène Joliot-Curie, Toulouse Cedex, 31059, France
| | - V Lubrano
- Toulouse NeuroImaging Center, ToNIC, Université de Toulouse, INSERM, Université Paul Sabatier, Toulouse, France.,Department of Neurosurgery, Institut Universitaire du Cancer de Toulouse - Purpan, Place du Docteur Baylac, Toulouse Cedex, 31059, France
| | - E Cohen-Jonathan Moyal
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse - Oncopôle/Institut Claudius Regaud, 1 avenue Irène Joliot-Curie, Toulouse Cedex, 31059, France.,Université Paul Sabatier, Toulouse III, 118 route de Narbonne, Toulouse, 31062, France.,INSERM U1037, Centre de Recherche contre le Cancer de Toulouse, 1 avenue Irène Joliot-Curie, Toulouse Cedex, 31059, France
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25
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Foro Arnalot P, Pera O, Rodriguez N, Sanz X, Reig A, Membrive I, Ortiz A, Granados R, Algara M. Influence of incidental radiation dose in the subventricular zone on survival in patients with glioblastoma multiforme treated with surgery, radiotherapy, and temozolomide. Clin Transl Oncol 2017; 19:1225-1231. [PMID: 28389881 DOI: 10.1007/s12094-017-1659-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/31/2017] [Indexed: 01/06/2023]
Abstract
PURPOSE To determine if there is an association between the incidental radiation dose to the subventricular zone and survival in patients with glioblastoma multiforme treated with surgery, radiotherapy and temozolomide. METHODS AND MATERIALS Sixty-five patients, treated between 2006 and 2015, were included in this retrospective study. The doses (75th percentile; p75) administered to the ipsilateral, contralateral and bilateral subventricular zone were compared to overall survival and progression-free survival using Cox proportional hazards models. Covariates included: age, sex, surgery, tumor location, and concomitant and adjuvant temozolomide. RESULTS Median progression-free survival and overall survival were 11.5 ± 9.96 and 18.8 ± 18.5 months, respectively. The p75 doses to the ipsilateral, contralateral and bilateral subventrivular zone were, respectively, 57.30, 48.8, and 52.7 Gy. Patients who received a dose ≥48.8 Gy in the contralateral subventricular zone had better progression-free survival than those who received lower doses (HR 0.46; 95% CI 0.23-0.91 P = 0.028). This association was not found for overall survival (HR 0.60; 95% CI 0.30-1.22 P = 0.16). Administration of adjuvant temozolomide was significantly associated with improved progression-free survival (HR 0.19; 95% CI 0.09-0.41 P < 0.0001) and overall survival (HR 0.11; 95% CI 0.05-0.24 P = 0.001). In the subgroup of 46 patients whose O6-methylguanine-DNA methyltransferase gene promoter status was known, the methylation had no effect on either progression-free survival (P = 0.491) or overall survival (P = 0.203). CONCLUSION High-dose radiation in the contralateral subventricular zone was associated with a significant improvement in progression-free survival but not overall survival in patients treated for glioblastoma multiforme.
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Affiliation(s)
- P Foro Arnalot
- Department of Radiation Oncology, Parc de Salut Mar, Sant Josep de la Montanya 12, 08024, Barcelona, Spain. .,IMIM (Hospital del Mar Medical Research Institute), Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain. .,Universitat Pompeu Fabra, Barcelona, Spain.
| | - O Pera
- Department of Radiation Oncology, Parc de Salut Mar, Sant Josep de la Montanya 12, 08024, Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain
| | - N Rodriguez
- Department of Radiation Oncology, Parc de Salut Mar, Sant Josep de la Montanya 12, 08024, Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain
| | - X Sanz
- Department of Radiation Oncology, Parc de Salut Mar, Sant Josep de la Montanya 12, 08024, Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain
| | - A Reig
- Department of Radiation Oncology, Parc de Salut Mar, Sant Josep de la Montanya 12, 08024, Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - I Membrive
- Department of Radiation Oncology, Parc de Salut Mar, Sant Josep de la Montanya 12, 08024, Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - A Ortiz
- Department of Radiation Oncology, Parc de Salut Mar, Sant Josep de la Montanya 12, 08024, Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - R Granados
- Department of Radiation Oncology, Parc de Salut Mar, Sant Josep de la Montanya 12, 08024, Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - M Algara
- Department of Radiation Oncology, Parc de Salut Mar, Sant Josep de la Montanya 12, 08024, Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain
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Krause M, Dubrovska A, Linge A, Baumann M. Cancer stem cells: Radioresistance, prediction of radiotherapy outcome and specific targets for combined treatments. Adv Drug Deliv Rev 2017; 109:63-73. [PMID: 26877102 DOI: 10.1016/j.addr.2016.02.002] [Citation(s) in RCA: 225] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 01/05/2016] [Accepted: 02/03/2016] [Indexed: 12/26/2022]
Abstract
Inactivation of cancer stem cells (CSCs) is of utmost importance for tumor cure after radiotherapy. An increasing body of evidence complies with a higher radioresistance of CSCs compared to the mass of tumor cells, supporting the use of CSC related biomarkers for prediction of radiotherapy outcome. Treatment individualization strategies for patient groups with vastly different risk of recurrence will most likely require application of more than one biomarker. Specifically, inclusion of established biomarkers like tumor size for primary radio(chemo)therapy or human papilloma virus (HPV) infection status in head and neck squamous cell carcinoma seems to be of very high relevance. The high heterogeneity of CSC subclones along with changes of the functional behavior of individual tumors under treatment underlines the importance of the selection of the optimal timepoint(s) of biomarker evaluation, but also provides a potential therapeutic target for combined treatment approaches with irradiation.
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Affiliation(s)
- Mechthild Krause
- German Cancer Consortium (DKTK) Dresden, Germany; Dept. of Radiation Oncology, Technische Universität Dresden, Germany; OncoRay, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Germany; German Cancer Research Center (DKFZ) Heidelberg, Germany.
| | - Anna Dubrovska
- German Cancer Consortium (DKTK) Dresden, Germany; OncoRay, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; German Cancer Research Center (DKFZ) Heidelberg, Germany
| | - Annett Linge
- German Cancer Consortium (DKTK) Dresden, Germany; Dept. of Radiation Oncology, Technische Universität Dresden, Germany; OncoRay, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; German Cancer Research Center (DKFZ) Heidelberg, Germany
| | - Michael Baumann
- German Cancer Consortium (DKTK) Dresden, Germany; Dept. of Radiation Oncology, Technische Universität Dresden, Germany; OncoRay, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Germany; German Cancer Research Center (DKFZ) Heidelberg, Germany
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Irradiating the Subventricular Zone in Glioblastoma Patients: Is there a Case for a Clinical Trial? Clin Oncol (R Coll Radiol) 2016; 29:26-33. [PMID: 27729188 DOI: 10.1016/j.clon.2016.09.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/05/2016] [Accepted: 07/07/2016] [Indexed: 11/20/2022]
Abstract
Glioblastoma is the most common and aggressive adult brain tumour. Over the last 10 years it has emerged that the subventricular zone (SVZ), the largest adult neural stem cell niche, has an important role in the disease. Converging evidence has implicated transformation of adult neural stems in gliomagenesis and the permissive stem cell niche in disease recurrence. Concurrently, clinical studies have suggested that SVZ involvement is a negative prognostic marker. It would follow that irradiating the SVZ may improve outcomes in glioblastoma by directly targeting this putative sanctuary site. To investigate this potential strategy, 11 retrospective studies and 1 prospective study examined the relationship between dose to the SVZ and survival outcomes in glioblastoma patients. This review summarises the theoretical underpinning of this strategy, provides a critical evaluation of the existing evidence and discusses the rationale for a clinical trial.
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28
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Influence of glioblastoma contact with the lateral ventricle on survival: a meta-analysis. J Neurooncol 2016; 131:125-133. [PMID: 27644688 DOI: 10.1007/s11060-016-2278-7] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 09/03/2016] [Indexed: 02/07/2023]
Abstract
The ventricular-subventricular zone (V-SVZ), which lies in the walls of the lateral ventricles (LV), is the largest neurogenic niche within the adult brain. Whether radiographic contact with the LV influences survival in glioblastoma (GBM) patients remains unclear. We assimilated and analyzed published data comparing survival in GBM patients with (LV+GBM) and without (LV-GBM) radiographic LV contact. PubMed, EMBASE, and Cochrane electronic databases were searched. Fifteen studies with survival data on LV+GBM and LV-GBM patients were identified. Their Kaplan-Meier survival curves were digitized and pooled for generation of median overall (OS) and progression free (PFS) survivals and log-rank hazard ratios (HRs). The log-rank and reported multivariate HRs after accounting for the common predictors of GBM survival were analyzed separately by meta-analyses. The calculated median survivals (months) from pooled data were 12.95 and 16.58 (OS), and 4.54 and 6.25 (PFS) for LV+GBMs and LV-GBMs, respectively, with an overall log-rank HRs of 1.335 [1.204-1.513] (OS) and 1.387 [1.225-1.602] (PFS). Meta-analysis of log-rank HRs resulted in summary HRs of 1.58 [1.35-1.85] (OS, 10 studies) and 1.41 [1.22-1.64] (PFS, 5 studies). Meta-analysis of multivariate HRs resulted in summary HRs of 1.35 [1.14-1.58] (OS, 6 studies) and 1.64 [0.88-3.05] (PFS, 3 studies). Patients with GBM contacting the LV have lower survival. This effect may be independent of the common predictors of GBM survival, suggesting a clinical influence of V-SVZ contact on GBM biology.
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Do Increased Doses to Stem-Cell Niches during Radiation Therapy Improve Glioblastoma Survival? Stem Cells Int 2016; 2016:8793462. [PMID: 27429623 PMCID: PMC4939331 DOI: 10.1155/2016/8793462] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 03/22/2016] [Accepted: 05/19/2016] [Indexed: 01/11/2023] Open
Abstract
Background and Purpose. The reasons for the inevitable glioblastoma recurrence are yet understood. However, recent data suggest that tumor cancer stem cells (CSCs) in the stem-cell niches, with self-renewing capacities, might be responsible for tumor initiation, propagation, and recurrence. We aimed to analyze the effect of higher radiation doses to the stem-cell niches on progression-free survival (PFS) and overall survival (OS) in glioblastoma patients. Materials and Methods. Sixty-five patients with primary glioblastoma treated with radiation therapy were included in this retrospective analysis. The SVZ and DG were segmented on treatment planning magnetic resonance imaging, and the dose distributions to the structures were calculated. The relationship of dosimetry data and survival was evaluated using the Cox regression analysis. Results. Conventionally fractionated patients (n = 54) who received higher doses (Dmean ≥ 40 Gy) to the IL SVZ showed improved PFS (8.5 versus 5.2 months; p = 0.013). Furthermore, higher doses (Dmean ≥ 30 Gy) to the CL SVZ were associated with increased PFS (10.1 versus 6.9 months; p = 0.025). Conclusion. Moderate higher IL SVZ doses (≥40 Gy) and CL SVZ doses (≥30 Gy) are associated with improved PFS. Higher doses to the DG, the second stem-cell niche, did not influence the survival. Targeting the potential cancer stem cells in the SVZ might be a promising treatment approach for glioblastoma and should be addressed in a prospective randomized trial.
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Neural stem cells, the subventricular zone and radiotherapy: implications for treating glioblastoma. J Neurooncol 2016; 128:207-16. [PMID: 27108274 DOI: 10.1007/s11060-016-2123-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 04/07/2016] [Indexed: 02/08/2023]
Abstract
Over the past decade, advances in neuroscience have suggested that neural stem cells resident in specific regions of the adult brain may be involved in development of both primary and recurrent glioblastoma. Neurogenesis and malignant transformation occurs in the subventricular zone adjacent to the lateral ventricles. This region holds promise as a potential target for therapeutic intervention with radiotherapy. However, irradiation of a larger brain volume is not without risk, and significant side effects have been observed. The current literature remains contradictory regarding the efficacy of deliberate intervention with radiation to the subventricular zone. This critical review discusses the connection between neural stem cells and development of glioblastoma, explores the behavior of tumors associated with the subventricular zone, summarizes the discordant literature with respect to the effects of irradiation, and reviews other targeted therapies to this intriguing region.
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Gupta T, Nair V, Jalali R. Stem cell niche irradiation in glioblastoma: providing a ray of hope? CNS Oncol 2015; 3:367-76. [PMID: 25363009 DOI: 10.2217/cns.14.39] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Glioblastomas are organized hierarchically with a small number of glioblastoma stem cells that have unique self-renewal capacity and multilineage potency. The subventricular zone (SVZ) constitutes the largest neural stem cell niche in the adult human brain; it may also act as a reservoir of glioblastoma stem cells that can initiate, promote or repopulate a tumor. Incidental irradiation of SVZ has been shown to potentially influence outcomes suggesting that aggressively targeting the stem cell niche may offer a ray of hope in glioblastoma. The following review provides a summary of the experimental evidence supporting the origin and location of the putative glioblastoma stem cell in the SVZ, and offers a critical appraisal of the growing body of clinical evidence correlating SVZ dosimetry with outcomes in glioblastoma.
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Affiliation(s)
- Tejpal Gupta
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre, Kharghar, Navi Mumbai 410210, India
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Should the subventricular zone be part of the “rad” zone? J Neurooncol 2014; 118:423-424. [DOI: 10.1007/s11060-014-1465-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 04/23/2014] [Indexed: 01/12/2023]
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