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Stadler C, Gramatzki D, Le Rhun E, Hottinger AF, Hundsberger T, Roelcke U, Läubli H, Hofer S, Seystahl K, Wirsching HG, Weller M, Roth P. Glioblastoma in the oldest old: Clinical characteristics, therapy, and outcome in patients aged 80 years and older. Neurooncol Pract 2024; 11:132-141. [PMID: 38496908 PMCID: PMC10940826 DOI: 10.1093/nop/npad070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024] Open
Abstract
Background Incidence rates of glioblastoma in very old patients are rising. The standard of care for this cohort is only partially defined and survival remains poor. The aims of this study were to reveal current practice of tumor-specific therapy and supportive care, and to identify predictors for survival in this cohort. Methods Patients aged 80 years or older at the time of glioblastoma diagnosis were retrospectively identified in 6 clinical centers in Switzerland and France. Demographics, clinical parameters, and survival outcomes were annotated from patient charts. Cox proportional hazards modeling was performed to identify parameters associated with survival. Results Of 107 patients, 45 were diagnosed by biopsy, 30 underwent subtotal resection, and 25 had gross total resection. In 7 patients, the extent of resection was not specified. Postoperatively, 34 patients did not receive further tumor-specific treatment. Twelve patients received radiotherapy with concomitant temozolomide, but only 2 patients had maintenance temozolomide therapy. Fourteen patients received temozolomide alone, 35 patients received radiotherapy alone, 1 patient received bevacizumab, and 1 took part in a clinical trial. Median progression-free survival (PFS) was 3.3 months and median overall survival (OS) was 4.2 months. Among patients who received any postoperative treatment, median PFS was 3.9 months and median OS was 7.2 months. Karnofsky performance status (KPS) ≥70%, gross total resection, and combination therapy were associated with better outcomes. The median time spent hospitalized was 30 days, accounting for 23% of the median OS. End-of-life care was mostly provided by nursing homes (n = 20; 32%) and palliative care wards (n = 16; 26%). Conclusions In this cohort of very old patients diagnosed with glioblastoma, a large proportion was treated with best supportive care. Treatment beyond surgery and, in particular, combined modality treatment were associated with longer OS and may be considered for selected patients even at higher ages.
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Affiliation(s)
- Christina Stadler
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Dorothee Gramatzki
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Emilie Le Rhun
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Zurich
- Inserm, University of Lille, Lille, France
- Neuro-Oncology, General and Stereotaxic Neurosurgery Service, University Hospital of Lille, Lille, France
| | - Andreas F Hottinger
- Departments of Oncology & Clinical Neurosciences, Lundin Family Brain Tumor Research Center, Lausanne University Hospital & University of Lausanne, Lausanne, Switzerland
| | - Thomas Hundsberger
- Department of Neurology and Department of Medical Oncology and Haematology, Cantonal Hospital, St. Gallen, Switzerland
| | | | - Heinz Läubli
- Division of Oncology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Silvia Hofer
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Katharina Seystahl
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Hans-Georg Wirsching
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Patrick Roth
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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Li X, Shao Y, Wang Z, Zhu J. Risk prediction and treatment assessment in glioma patients using SEER database: a prospective observational study. BMJ Open 2023; 13:e079341. [PMID: 38070919 PMCID: PMC10729083 DOI: 10.1136/bmjopen-2023-079341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/25/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES To use a nomogram to predict the risk of mortality and estimate the impact of current treatment on the prognosis of glioma patients. METHODS A total of 3798 cases were obtained from the Surveillance Epidemiology and End Results database according to the selection criteria. A nomogram was built on the independent clinical factors screened by the variance inflation factor, univariate analyses and a multivariate Cox regression model. Then, categorising the overall population into high-risk, medium-risk and low-risk groups using nomogram-derived risk scores, to study the impact of treatment on different subgroups' survival outcomes. Furthermore, based on the postmatch cohorts, the influences of treatment on survival outcomes were assessed by the log-rank test. RESULT Age, race, stage of disease, histological type, histological grade, surgery, radiotherapy and chemotherapy were identified as the independent prognostic factors. A nomogram with good discrimination and consistency was built. Generally, the patients who underwent surgery, radiotherapy and chemotherapy were more likely to achieve better prognosis than those who did not, except for those who received radiotherapy in the low-risk cohort and those who underwent surgery in the high-risk cohort. Furthermore, the isocitrate dehydrogenase 1/2 (IDH1/2) wild-type patients with surgery, radiotherapy or chemotherapy tended to have higher survival probabilities, while some inconsistent results were observed in the IDH mutant-type cohort. CONCLUSION Surgery, radiotherapy and chemotherapy improved the prognosis, while appropriate selection of topical treatment for the low-risk or high-risk patients deserves further consideration. IDH status gene might be a reliable indicator of therapeutic effectiveness.
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Affiliation(s)
- XinRong Li
- Department of Integrative Medicine and Medical Oncology, Shengzhou People's Hospital (the First Affiliated Hospital of Zhejiang University Shengzhou Branch), Shengzhou, Zhejiang, People's Republic of China
| | - Yan Shao
- Department of Pharmacy, Shengzhou People's Hospital (the First Affiliated Hospital of Zhejiang University Shengzhou Branch), Shengzhou, Zhejiang, People's Republic of China
| | - ZeMing Wang
- Department of Integrative Medicine and Medical Oncology, Shengzhou People's Hospital (the First Affiliated Hospital of Zhejiang University Shengzhou Branch), Shengzhou, Zhejiang, People's Republic of China
| | - JunQuan Zhu
- Department of Integrative Medicine and Medical Oncology, Shengzhou People's Hospital (the First Affiliated Hospital of Zhejiang University Shengzhou Branch), Shengzhou, Zhejiang, People's Republic of China
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Cao W, Xiong L, Meng L, Li Z, Hu Z, Lei H, Wu J, Song T, Liu C, Wei R, Shen L, Hong J. Prognostic analysis and nomogram construction for older patients with IDH-wild-type glioblastoma. Heliyon 2023; 9:e18310. [PMID: 37519736 PMCID: PMC10372674 DOI: 10.1016/j.heliyon.2023.e18310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/06/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023] Open
Abstract
As many countries face an ageing population, the number of older patients with glioblastoma (GB) is increasing. Thus, there is an urgent need for prognostic models to aid in treatment decision-making and life planning. A total of 98 patients with isocitrate dehydrogenase (IDH)-wild-type GB aged ≥65 years were analysed from January 2012 to January 2020. Independent prognostic factors were identified by prognostic analysis. Using the independent prognostic factors for overall survival (OS), a nomogram was constructed by R software to predict the prognosis of older patients with IDH-wild-type GB. The concordance index (C-index) and receiver operating characteristic (ROC) curve were used to assess model discrimination, and the calibration curve was used to assess model calibration. Prognostic analysis showed that the extent of resection (EOR), adjusted Charlson comorbidity index (ACCI), O6-methylguanine-DNA methyltransferase (MGMT) methylation status, postoperative radiotherapy, and postoperative temozolomide (TMZ) chemotherapy were independent prognostic factors for OS. MGMT methylation status and subventricular zone (SVZ) involvement were independent prognostic factors for progression-free survival (PFS). A nomogram was constructed based on EOR, ACCI, MGMT methylation status, postoperative radiotherapy and postoperative TMZ chemotherapy to predict the 6-month, 12-month and 18-month OS of older patients with IDH-wild-type GB. The C-index of the nomogram was 0.72, and the ROC curves showed that the areas under the curve (AUCs) at 6, 12 and 18 months were 0.874, 0.739 and 0.779, respectively. The calibration plots showed that the nomogram was in good agreement with the actual observations in predicting the OS of older patients with IDH-wild-type GB. Older patients with IDH-wild-type GB can benefit from gross total resection (GTR), postoperative radiotherapy and postoperative TMZ chemotherapy. A high ACCI score and MGMT nonmethylation are poor prognostic factors. We constructed a nomogram including the ACCI to facilitate clinical decision-making and follow-up interval selection.
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Affiliation(s)
- Wenjun Cao
- Department of Hematology and Oncology, The First Hospital of Changsha, People's Republic of China
| | - Luqi Xiong
- Department of Oncology, Xiangya Hospital, Central South University, People's Republic of China
| | - Li Meng
- Department of Radiology, Xiangya Hospital, Central South University, People's Republic of China
| | - Zhanzhan Li
- Department of Oncology, Xiangya Hospital, Central South University, People's Republic of China
| | - Zhongliang Hu
- Department of Pathology, Xiangya Hospital, Central South University, People's Republic of China
| | - Huo Lei
- Department of Neurosurgery, Xiangya Hospital, Central South University, People's Republic of China
| | - Jun Wu
- Department of Neurosurgery, Xiangya Hospital, Central South University, People's Republic of China
| | - Tao Song
- Department of Neurosurgery, Xiangya Hospital, Central South University, People's Republic of China
| | - Chao Liu
- Department of Oncology, Xiangya Hospital, Central South University, People's Republic of China
| | - Rui Wei
- Department of Oncology, Xiangya Hospital, Central South University, People's Republic of China
| | - Liangfang Shen
- Department of Oncology, Xiangya Hospital, Central South University, People's Republic of China
| | - Jidong Hong
- Department of Oncology, Xiangya Hospital, Central South University, People's Republic of China
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Zhao R, Zeng J, DeVries K, Proulx R, Krauze AV. Optimizing management of the elderly patient with glioblastoma: Survival prediction online tool based on BC Cancer Registry real-world data. Neurooncol Adv 2022; 4:vdac052. [PMID: 35733517 PMCID: PMC9209750 DOI: 10.1093/noajnl/vdac052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Glioblastoma (GBM) is associated with fatal outcomes and devastating neurological presentations especially impacting the elderly. Management remains controversial and representation in clinical trials poor. We generated 2 nomograms and a clinical decision making web tool using real-world data. METHODS Patients ≥60 years of age with histologically confirmed GBM (ICD-O-3 histology codes 9440/3, 9441/3, and 9442/3) diagnosed 2005-2015 were identified from the BC Cancer Registry (n = 822). Seven hundred and twenty-nine patients for which performance status was captured were included in the analysis. Age, performance and resection status, administration of radiation therapy (RT), and chemotherapy were reviewed. Nomograms predicting 6- and 12-month overall survival (OS) probability were developed using Cox proportional hazards regression internally validated by c-index. A web tool powered by JavaScript was developed to calculate the survival probability. RESULTS Median OS was 6.6 months (95% confidence interval [CI] 6-7.2 months). Management involved concurrent chemoradiation (34%), RT alone (42%), and chemo alone (2.3%). Twenty-one percent of patients did not receive treatment beyond surgical intervention. Age, performance status, extent of resection, chemotherapy, and RT administration were all significant independent predictors of OS. Patients <80 years old who received RT had a significant survival advantage, regardless of extent of resection (hazard ratio range from 0.22 to 0.60, CI 0.15-0.95). A nomogram was constructed from all 729 patients (Harrell's Concordance Index = 0.78 [CI 0.71-0.84]) with a second nomogram based on subgroup analysis of the 452 patients who underwent RT (Harrell's Concordance Index = 0.81 [CI 0.70-0.90]). An online calculator based on both nomograms was generated for clinical use. CONCLUSIONS Two nomograms and accompanying web tool incorporating commonly captured clinical features were generated based on real-world data to optimize decision making in the clinic.
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Affiliation(s)
- Rachel Zhao
- University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Jonathan Zeng
- University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Kimberly DeVries
- Cancer Surveillance & Outcomes, BC Cancer, Vancouver, British Columbia, Canada
| | - Ryan Proulx
- Safe Software, Surrey, British Columbia, Canada
| | - Andra Valentina Krauze
- University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
- Radiation Oncology Branch, National Cancer Institute, Bethesda, Maryland, USA
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5
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Krauze AV, Camphausen K. Molecular Biology in Treatment Decision Processes-Neuro-Oncology Edition. Int J Mol Sci 2021; 22:13278. [PMID: 34948075 PMCID: PMC8703419 DOI: 10.3390/ijms222413278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 11/30/2022] Open
Abstract
Computational approaches including machine learning, deep learning, and artificial intelligence are growing in importance in all medical specialties as large data repositories are increasingly being optimised. Radiation oncology as a discipline is at the forefront of large-scale data acquisition and well positioned towards both the production and analysis of large-scale oncologic data with the potential for clinically driven endpoints and advancement of patient outcomes. Neuro-oncology is comprised of malignancies that often carry poor prognosis and significant neurological sequelae. The analysis of radiation therapy mediated treatment and the potential for computationally mediated analyses may lead to more precise therapy by employing large scale data. We analysed the state of the literature pertaining to large scale data, computational analysis, and the advancement of molecular biomarkers in neuro-oncology with emphasis on radiation oncology. We aimed to connect existing and evolving approaches to realistic avenues for clinical implementation focusing on low grade gliomas (LGG), high grade gliomas (HGG), management of the elderly patient with HGG, rare central nervous system tumors, craniospinal irradiation, and re-irradiation to examine how computational analysis and molecular science may synergistically drive advances in personalised radiation therapy (RT) and optimise patient outcomes.
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Affiliation(s)
- Andra V. Krauze
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, 9000 Rockville Pike, Building 10, Bethesda, MD 20892, USA;
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Ali S, Borin TF, Piranlioglu R, Ara R, Lebedyeva I, Angara K, Achyut BR, Arbab AS, Rashid MH. Changes in the tumor microenvironment and outcome for TME-targeting therapy in glioblastoma: A pilot study. PLoS One 2021; 16:e0246646. [PMID: 33544755 PMCID: PMC7864405 DOI: 10.1371/journal.pone.0246646] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/22/2021] [Indexed: 12/12/2022] Open
Abstract
Glioblastoma (GBM) is a hypervascular and aggressive primary malignant tumor of the central nervous system. Recent investigations showed that traditional therapies along with antiangiogenic therapies failed due to the development of post-therapy resistance and recurrence. Previous investigations showed that there were changes in the cellular and metabolic compositions in the tumor microenvironment (TME). It can be said that tumor cell-directed therapies are ineffective and rethinking is needed how to treat GBM. It is hypothesized that the composition of TME-associated cells will be different based on the therapy and therapeutic agents, and TME-targeting therapy will be better to decrease recurrence and improve survival. Therefore, the purpose of this study is to determine the changes in the TME in respect of T-cell population, M1 and M2 macrophage polarization status, and MDSC population following different treatments in a syngeneic model of GBM. In addition to these parameters, tumor growth and survival were also studied following different treatments. The results showed that changes in the TME-associated cells were dependent on the therapeutic agents, and the TME-targeting therapy improved the survival of the GBM bearing animals. The current GBM therapies should be revisited to add agents to prevent the accumulation of bone marrow-derived cells in the TME or to prevent the effect of immune-suppressive myeloid cells in causing alternative neovascularization, the revival of glioma stem cells, and recurrence. Instead of concurrent therapy, a sequential strategy would be better to target TME-associated cells.
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Affiliation(s)
- Sehar Ali
- Laboratory of Tumor Angiogenesis Initiative, Georgia Cancer Center, Augusta University, Augusta, Georgia, United States of America
| | - Thaiz F. Borin
- Laboratory of Tumor Angiogenesis Initiative, Georgia Cancer Center, Augusta University, Augusta, Georgia, United States of America
| | - Raziye Piranlioglu
- Laboratory of Tumor Angiogenesis Initiative, Georgia Cancer Center, Augusta University, Augusta, Georgia, United States of America
| | - Roxan Ara
- Laboratory of Tumor Angiogenesis Initiative, Georgia Cancer Center, Augusta University, Augusta, Georgia, United States of America
| | - Iryna Lebedyeva
- Department of Chemistry and Physics, Augusta University, Augusta, Georgia, United States of America
| | - Kartik Angara
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, Michigan, United States of America
| | - Bhagelu R. Achyut
- Winship Cancer Institute, Emory University, Atlanta, Georgia, United States of America
| | - Ali Syed Arbab
- Laboratory of Tumor Angiogenesis Initiative, Georgia Cancer Center, Augusta University, Augusta, Georgia, United States of America
- * E-mail: (ASA); (MHR)
| | - Mohammad H. Rashid
- Laboratory of Tumor Angiogenesis Initiative, Georgia Cancer Center, Augusta University, Augusta, Georgia, United States of America
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
- * E-mail: (ASA); (MHR)
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Nunna RS, Khalid SI, Patel S, Sethi A, Behbahani M, Mehta AI, Adogwa O, Byrne RW. Outcomes and Patterns of Care in Elderly Patients with Glioblastoma Multiforme. World Neurosurg 2021; 149:e1026-e1037. [PMID: 33482415 DOI: 10.1016/j.wneu.2021.01.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Glioblastoma multiforme (GBM) is the most common primary malignant brain tumor in adults, with an increased incidence among the elderly. However, the optimal treatment strategy in elderly patients remains unclear. This study seeks to investigate the effect of patient selection and treatment strategies on survival trends in these patients. METHODS Patients with diagnosis codes specific for GBM were queried from the National Cancer Database during 2004-2016. Univariate and multivariate Cox regression analysis was performed to investigate outcomes. Survival curves and 5-year survival were also generated based on patient-specific factors. RESULTS Among 104,456 patients with GBM identified, elderly patients were less likely to receive radiotherapy (61.3% vs. 77.8%; P < 0.001) or chemotherapy (47.2% vs. 62.9%; P < 0.001) or to undergo surgical resection (68.3% vs. 81.8; P < 0.001). Mean overall survival was 9.1 months (standard deviation, 10.0) and 5-year survival was 5.3%. Multivariate analysis showed age 75-84 years (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.12-1.73; P = 0.003) and lower Karnofsky Performance Status (50-70: HR, 1.68, 95% CI, 1.35-2.08, P < 0.001; ≤40: HR, 1.79, 95% CI 1.18-2.72, P = 0.006) were associated with decreased overall survival, whereas surgical resection (subtotal resection: HR, 0.52, 95% CI, 0.38-0.71, P < 0.001; gross total resection: HR, 0.29, 95% CI, 0.21-0.41, P < 0.001), radiotherapy (HR, 0.65; 95% CI, 0.47-0.91; P = 0.012), and chemotherapy (HR, 0.65; 95% CI, 0.48-0.88; P = 0.006) were associated with increased overall survival in elderly patients. CONCLUSIONS In an analysis of 104,456 patients with GBM, all treatment modalities were found to be used less frequently in elderly patients. Increasing age and poor performance status were associated with worsened survival. Gross total resection was associated with the greatest survival benefit, and chemotherapy and radiotherapy also improved survival outcomes. These treatment options improved outcomes regardless of performance status. Although maximal treatment strategies may improve survival in elderly patients with GBM, these treatment strategies must be balanced against patient-specific factors and quality-of-life concerns.
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Affiliation(s)
- Ravi S Nunna
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA.
| | - Syed I Khalid
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Saavan Patel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Abhishek Sethi
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Mandana Behbahani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Owoicho Adogwa
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Richard W Byrne
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
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Renovanz M, Hickmann AK, Nadji-Ohl M, Keric N, Weimann E, Wirtz CR, Singer S, Ringel F, Coburger J. Health-related quality of life and distress in elderly vs. younger patients with high-grade glioma-results of a multicenter study. Support Care Cancer 2020; 28:5165-5175. [PMID: 32060706 PMCID: PMC7546979 DOI: 10.1007/s00520-020-05354-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/06/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Half of all newly diagnosed patients with glioblastoma are > 65 years still with a poor prognosis. Preserving quality of life is of high importance. However, patient reported outcome (PRO) data in this patient group is rare. The aim was to compare health-related quality of life (HRQoL) and distress between elderly and younger patients with high-grade glioma (HGG). METHODS We used baseline data of a prospective study where HGG patients were enrolled from 4 hospitals. Distress was measured using the distress thermometer (DT), HRQoL using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30) plus brain module (BN20). We compared distress and HRQoL by age (≥ 65 vs. < 65 years), gender, performance score, and time since diagnosis using multivariate linear and logistic regressions. RESULTS A total of n = 93 (30%) out of n = 309 patients were ≥ 65 years (mean 70 years, range 65-86 years). Mean DT score of elderly patients (5.2, SD 2.6) was comparable with younger patients (4.9, SD 2.6). Elderly patients reported significantly lower global health (GHS, mean elderly vs. younger; 50.8 vs. 60.5, p = 0.003), worse physical (56.8 vs. 73.3, p < 0.001) and lower cognitive functioning (51.1 vs. 63.2, p = 0.002), worse fatigue (52.5 vs. 43.5, p = 0.042), and worse motor dysfunction (34.9 vs. 23.6, p = 0.030). KPS and not age was consistently associated with HRQoL. CONCLUSION Physical functioning was significantly reduced in the elderly compared with younger HGG patients, and at the same time, emotional functioning and DT scores were comparable. KPS shows a greater association with HRQoL than with calendric age in HGG patients reflecting the particular importance for adequate assessment of HRQoL and general condition in elderly patients.
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Affiliation(s)
- Mirjam Renovanz
- Department of Neurosurgery, University Medical Center, Mainz, Germany.
- Division of Neuro-Oncology, University Medical Center Tubingen, Tübingen, Germany.
| | | | - Minou Nadji-Ohl
- Department of Neurosurgery, Klinikum Stuttgart, Stuttgart, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Medical Center, Mainz, Germany
| | - Elke Weimann
- Department of Neurology, RKH Kliniken Ludwigsburg, Ludwigsburg, Germany
| | | | - Susanne Singer
- Division of Epidemiology and Health Services Research, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center, Mainz, Germany
| | - Jan Coburger
- Department of Neurosurgery, University Medical Center Ulm, Ulm, Germany
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9
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Han Q, Liang H, Cheng P, Yang H, Zhao P. Gross Total vs. Subtotal Resection on Survival Outcomes in Elderly Patients With High-Grade Glioma: A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:151. [PMID: 32257941 PMCID: PMC7093492 DOI: 10.3389/fonc.2020.00151] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/28/2020] [Indexed: 01/22/2023] Open
Abstract
Background: The optimal strategy for the management of high-grade glioma in the elderly (≥60.0 years) remains controversial, especially regarding the effects of surgical extent on survival outcomes. The purpose of this study was to compare gross total resection (GTR) with subtotal resection (STR) for treatment effects in elderly patients with high-grade glioma. Methods: Three electronic databases were systematically searched, including PubMed, EmBase, and the Cochrane library, from inception to August 2018. Hazard ratios (HRs) or odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were used to express summary effect estimates using the random-effects model. Nineteen retrospective observational studies involving a total of 10,815 elderly patients with high-grade glioma were included in this meta-analysis. Results: The summary results indicated that GTR was associated with a significant improvement in overall survival (OS) compared with STR (HR = 0.70, 95% CI = 0.64–0.77). In addition, elderly patients administered GTR showed lower risk of 3-month mortality (OR = 0.47, 95% CI = 0.24–0.93), 6-month mortality (OR = 0.38, 95% CI = 0.26–0.56), 9-month mortality (OR = 0.35, 95% CI = 0.25–0.49), and 1-year mortality (OR = 0.40, 95% CI = 0.29–0.56). Pooled OS data differed when stratified by publication year, country, sample size, disease status, and study quality. Conclusion: GTR seems to be more effective than STR in achieving longer survival in elderly patients with high-grade glioma.
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Affiliation(s)
- Qian Han
- Department of Radiotherapy, Henan Provincial People's Hospital, Zhengzhou, China
| | - Hengpo Liang
- Department of Radiotherapy, Henan Provincial People's Hospital, Zhengzhou, China
| | - Peng Cheng
- Department of Radiotherapy, Henan Provincial People's Hospital, Zhengzhou, China
| | - Hongjie Yang
- Department of Radiotherapy, Henan Provincial People's Hospital, Zhengzhou, China
| | - Pingfan Zhao
- Department of Outpatient, Henan Provincial People's Hospital, Zhengzhou, China
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Risks and Benefits of Glioblastoma Resection in Older Adults: A Retrospective Austrian Multicenter Study. World Neurosurg 2020; 133:e583-e591. [DOI: 10.1016/j.wneu.2019.09.097] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/17/2019] [Accepted: 09/18/2019] [Indexed: 01/26/2023]
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Giaccherini L, Galaverni M, Renna I, Timon G, Galeandro M, Pisanello A, Russo M, Botti A, Iotti C, Ciammella P. Role of multidimensional assessment of frailty in predicting outcomes in older patients with glioblastoma treated with adjuvant concurrent chemo-radiation. J Geriatr Oncol 2019; 10:770-778. [DOI: 10.1016/j.jgo.2019.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 01/30/2019] [Accepted: 03/13/2019] [Indexed: 12/13/2022]
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12
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Kamada K, Anei R, Kodama K, Kitajima Y, Ishizuka M, Hiroshima S, Ogawa H, Tamura Y, Takeuchi F. Real-time spectrum quantification of tumor-related fluorescence during neurosurgery: A preliminary report. Clin Neurol Neurosurg 2019; 181:89-97. [PMID: 31026714 DOI: 10.1016/j.clineuro.2019.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/02/2019] [Accepted: 04/08/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The fluorescent dye, 5-aminolevulinic acid (5-ALA), is currently applied for fluorescence-guided resections of high-grade gliomas. Present limitations of this technique are qualitative and subjective analyses, which show little of the background structures. This paper describes the intraoperative quantitative analysis of fluorescence intensity, hot-spot enhancement by frame averaging, and observation of surrounding structures by using 1000-nm lighting in real time. PATIENTS AND METHODS A sample of diluted protoporphyrin IX (PpIX) in a bottle and 37 samples from nine patients with brain lesions were involved in this study. In this preliminary study, we determined appropriate conditions for image averaging and filters and selected the most sensitive spectrometer. In addition, we utilized a 1000-nm lighting system to visualize surrounding structures with no interference from PpIX fluorescence. RESULTS The novel system permitted the real-time quantitative analysis of PpIX fluorescence in operative fields by illuminating structures with 1000-nm-lighting. The real-time quantification provided subjective evaluations for surgical decision-making. We found good correlations between the fluorescence and PpIX contents in brain tissue. Furthermore, 1000-nm lighting visualized the anatomical structures and PpIX fluorescence simultaneously. CONCLUSION The combination of spectroscopy and a 1000-nm lighting system could enable surgeons to create a spectrogram of targets of interest while observing background structures. The spectrometer that we selected is highly sensitive to PpIX fluorescence and enables us to perform intraoperative real-time tissue mapping. By using a real-time system, we can perform quantitative and objective evaluations to achieve maximal tumor resection.
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Affiliation(s)
| | - Ryogo Anei
- Department of Neurosurgery, Asahikawa, Hokkaido, Japan.
| | - Ken Kodama
- SBI Pharmaceuticals Co., Ltd., Kobe, Hyogo, Japan.
| | | | | | | | - Hiroshi Ogawa
- Department of Neurosurgery, Asahikawa, Hokkaido, Japan.
| | - Yukie Tamura
- Department of Neurosurgery, Asahikawa, Hokkaido, Japan.
| | - Fumiya Takeuchi
- Educational Center, Asahikawa Medical University, Asahikawa, Hokkaido, Japan.
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13
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Guan Y, He Y, Lv S, Hou X, Li L, Song J. Overexpression of HOXC10 promotes glioblastoma cell progression to a poor prognosis via the PI3K/AKT signalling pathway. J Drug Target 2018; 27:60-66. [PMID: 29768063 DOI: 10.1080/1061186x.2018.1473408] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The HOX gene is expressed in neoplasias occurred in multiple tissues, such as the colon, lung and breast. However, the effects of the HOX gene on glioblastoma (GBM) remain poorly understood. We examined HOXC10 expression in GBM tissues and cells, analysed its effect on GBM prognosis, and finally assessed its possible underlying mechanisms in this study. METHODS HOXC10 expression levels and its prognostic effects on GBM tissues were analysed based on The Cancer Genome Atlas (TCGA) and ONCOMINE database. Overall survival (OS) analysis was performed using the Kaplan-Meier method and log rank test. Then, the expression of HOXC10 was detected in four GBM cell lines using quantitative real-time reverse transcription-PCR (qRT-PCR). In addition, small interfering RNA (si-RNA) was utilised in the U87 cell line with the highest HOXC10 expression to facilitate subsequent in vitro cell experiment. Cell proliferation, migration and invasion were assessed using the Cell Counting Kit-8 (CCK-8) and colony formation assay, wound healing, Transwell assay, respectively in GBM U87 cell after HOXC10 knockdown. Key proteins related to the phosphatidylinositol-3-kinase (PI3K)/protein kinase B (AKT) signalling pathway were measured by western blotting. RESULTS HOXC10 expression was significantly increased in GBM tissues and cell lines, leading a poor OS in GBM patients. Knockdown of HOXC10 could inhibit the GBM U87 cells proliferation, migration and invasion, as well as decreased expression levels of key proteins in PI3K/AKT signalling pathway. CONCLUSION HOXC10 was overexpressed in GBM tissues and cells, and associated with poor prognosis in GBM patients. Moreover, HOXC10 knockdown inhibited U87 cell proliferation, migration and invasion, which were potentially related to PI3K/AKT signalling pathway activation. Our findings revealed that HOXC10 represent a promising biological target for GBM treatment in the future.
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Affiliation(s)
- Yong Guan
- a Department of Neurosurgery , Qingdao Minicipal Hospital , Qingdao , Shandong , PR China
| | - Yajie He
- a Department of Neurosurgery , Qingdao Minicipal Hospital , Qingdao , Shandong , PR China
| | - Shaoping Lv
- b Department of Rehabilitation , Qingdao Central Hospital , Qingdao , Shandong , PR China
| | - Xiaoqun Hou
- a Department of Neurosurgery , Qingdao Minicipal Hospital , Qingdao , Shandong , PR China
| | - Luo Li
- a Department of Neurosurgery , Qingdao Minicipal Hospital , Qingdao , Shandong , PR China
| | - Jianjun Song
- a Department of Neurosurgery , Qingdao Minicipal Hospital , Qingdao , Shandong , PR China
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14
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Heiland DH, Haaker G, Watzlawick R, Delev D, Masalha W, Franco P, Machein M, Staszewski O, Oelhke O, Nicolay NH, Schnell O. One decade of glioblastoma multiforme surgery in 342 elderly patients: what have we learned? J Neurooncol 2018; 140:385-391. [PMID: 30076585 DOI: 10.1007/s11060-018-2964-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 07/06/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Glioblastoma multiforme (GBM) is the most common malignant primary brain tumor in adults with peak incidence in patients older than 65 years. These patients are mostly underrepresented in clinical trials and often undertreated due to concomitant diseases. Recently, different therapeutic approaches for elderly patients with GBM were discussed. To date, there is no defined standard treatment. The aim of the present study is to evaluate the functional and oncological outcome in surgical treatment of elderly patients. MATERIALS AND METHODS A total of 342 elderly patients aged ≥ 65 years were retrospectively analyzed in our neurosurgical center. Surgical therapy, adjuvant treatment, overall survival (OS) and functional outcome using Karnofsky performance scale (KPS) and Neurological assessment of neuro-oncology-score were analyzed. RESULTS The median age at GBM diagnosis was 73.4 (IQR 9.28) years. Median overall survival was 7.5 (CI 95% 6.0-9.1) months and median preoperative or postoperative KPS was 80 (IQR 20). Surgical resection was performed in 216 (63.2%) patients, in 125 patients (36.5%) patients a stereotactic biopsy was performed. The median OS was significantly higher in patients with gross total resection (GTR) compared to partial resection and biopsy (10.8 months; CI 95% 9.5-12.3). Patients with combined radio- and chemo-therapy (RCT) showed significant longer OS, particularly MGMT-negative GBM. Higher preoperative KPS was found to be associated with improved overall survival. CONCLUSION GTR and adjuvant combined RCT provides benefits for overall survival in elderly patients. Therapy decision should be made in regard to preoperative functional status instead of biological age.
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Affiliation(s)
- Dieter Henrik Heiland
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Gerrit Haaker
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralf Watzlawick
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Delev
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Waseem Masalha
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Pamela Franco
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marcia Machein
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ori Staszewski
- Institute of Neuropathology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Oliver Oelhke
- Radiation Clinic, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nils Henrik Nicolay
- Radiation Clinic, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Oliver Schnell
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
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15
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Sun L, Zhang C, Yang Z, Wu Y, Wang H, Bao Z, Jiang T. KIF23 is an independent prognostic biomarker in glioma, transcriptionally regulated by TCF-4. Oncotarget 2017; 7:24646-55. [PMID: 27013586 PMCID: PMC5029730 DOI: 10.18632/oncotarget.8261] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 03/04/2016] [Indexed: 02/01/2023] Open
Abstract
Kinesin family member 23 (KIF23), a nuclear protein and a key regulator of cellular cytokinesis, has been found to be overexpressed as an oncogene in glioma. However, the prognostic and clinicopathological features of glioma with KIF23 expression was not clear yet. Here, we analyzed KIF23 expression pattern by using whole genome mRNA expression microarray data from Chinese Glioma Genome Atlas (CGGA) database (http://www.cgga.org.cn), and found that KIF23 overexpression was significantly associated with high grade glioma as well as the higher mortality in survival analysis (log-rank test, p<0.01). The results of the three other validation datasets showed similar findings. Furthermore, KIF23 also served as an independent prognostic biomarker in glioma patients. Finally, functional assay showed that reduction of KIF23 suppressed glioma cell proliferation both in vivo and vitro. Additionally, we found that KIF23 was regulated by TCF-4 at transcriptionally level. Therefore, this evidence indicates KIF23 over-expression is associated with glioma malignancy and conferred a worse survival time in glioma, which suggests KIF23 is a new novel prognostic biomarker with potential therapeutic implications in glioma.
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Affiliation(s)
- Lihua Sun
- Department of Molecular Neuropathology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Neurosurgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Chuanbao Zhang
- Department of Molecular Neuropathology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Zhengxiang Yang
- Department of Neurosurgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Yiping Wu
- Department of Neurosurgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Hongjun Wang
- Department of Neurosurgery, 2nd Affiliated hospital of Harbin Medical University, Harbin, China
| | - Zhaoshi Bao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tao Jiang
- Department of Molecular Neuropathology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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16
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Arbab AS, Rashid MH, Angara K, Borin TF, Lin PC, Jain M, Achyut BR. Major Challenges and Potential Microenvironment-Targeted Therapies in Glioblastoma. Int J Mol Sci 2017; 18:ijms18122732. [PMID: 29258180 PMCID: PMC5751333 DOI: 10.3390/ijms18122732] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 12/13/2017] [Accepted: 12/15/2017] [Indexed: 02/07/2023] Open
Abstract
Glioblastoma (GBM) is considered one of the most malignant, genetically heterogeneous, and therapy-resistant solid tumor. Therapeutic options are limited in GBM and involve surgical resection followed by chemotherapy and/or radiotherapy. Adjuvant therapies, including antiangiogenic treatments (AATs) targeting the VEGF–VEGFR pathway, have witnessed enhanced infiltration of bone marrow-derived myeloid cells, causing therapy resistance and tumor relapse in clinics and in preclinical models of GBM. This review article is focused on gathering previous clinical and preclinical reports featuring major challenges and lessons in GBM. Potential combination therapies targeting the tumor microenvironment (TME) to overcome the myeloid cell-mediated resistance problem in GBM are discussed. Future directions are focused on the use of TME-directed therapies in combination with standard therapy in clinical trials, and the exploration of novel therapies and GBM models for preclinical studies. We believe this review will guide the future of GBM research and therapy.
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Affiliation(s)
- Ali S Arbab
- Tumor Angiogenesis laboratory, Georgia Cancer Center, Department of Biochemistry and Molecular Biology, Augusta University, Augusta, GA 30912, USA.
| | - Mohammad H Rashid
- Tumor Angiogenesis laboratory, Georgia Cancer Center, Department of Biochemistry and Molecular Biology, Augusta University, Augusta, GA 30912, USA.
| | - Kartik Angara
- Tumor Angiogenesis laboratory, Georgia Cancer Center, Department of Biochemistry and Molecular Biology, Augusta University, Augusta, GA 30912, USA.
| | - Thaiz F Borin
- Tumor Angiogenesis laboratory, Georgia Cancer Center, Department of Biochemistry and Molecular Biology, Augusta University, Augusta, GA 30912, USA.
| | - Ping-Chang Lin
- Tumor Angiogenesis laboratory, Georgia Cancer Center, Department of Biochemistry and Molecular Biology, Augusta University, Augusta, GA 30912, USA.
| | - Meenu Jain
- Tumor Angiogenesis laboratory, Georgia Cancer Center, Department of Biochemistry and Molecular Biology, Augusta University, Augusta, GA 30912, USA.
| | - Bhagelu R Achyut
- Tumor Angiogenesis laboratory, Georgia Cancer Center, Department of Biochemistry and Molecular Biology, Augusta University, Augusta, GA 30912, USA.
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Abstract
OPINION STATEMENT Newly diagnosed elderly patients (age > 65-70 years) with glioblastoma should be treated with a patient-centred approach by a multi-disciplinary team. Chronological age alone should not be considered as a contraindication to treatment with maximal safe surgical resection. A 3-week course of adjuvant radiation and chemotherapy is appropriate in selected elderly patients with favourable Karnofsky performance status (KPS) who cannot tolerate a longer 6-week course of fractionated radiotherapy. The presence or absence of 06-methylguanine-DNA methyltransferase (MGMT) promoter methylation can be used to guide clinical decision-making as both prognostic and predictive biomarkers. This review provides an update and summary of the available evidence for treating newly diagnosed elderly patients with glioblastoma.
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18
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Harris G, Jayamanne D, Wheeler H, Gzell C, Kastelan M, Schembri G, Brazier D, Cook R, Parkinson J, Khasraw M, Louw S, Back M. Survival Outcomes of Elderly Patients With Glioblastoma Multiforme in Their 75th Year or Older Treated With Adjuvant Therapy. Int J Radiat Oncol Biol Phys 2017; 98:802-810. [DOI: 10.1016/j.ijrobp.2017.02.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 01/01/2017] [Accepted: 02/14/2017] [Indexed: 10/20/2022]
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19
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Cysteinyl Leukotriene Receptor Antagonists Inhibit Migration, Invasion, and Expression of MMP-2/9 in Human Glioblastoma. Cell Mol Neurobiol 2017; 38:559-573. [DOI: 10.1007/s10571-017-0507-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 06/06/2017] [Indexed: 12/21/2022]
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20
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Amsbaugh MJ, Yusuf MB, Gaskins J, Burton EC, Woo SY. Patterns of care and predictors of adjuvant therapies in elderly patients with glioblastoma: An analysis of the National Cancer Data Base. Cancer 2017; 123:3277-3284. [DOI: 10.1002/cncr.30730] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/16/2017] [Accepted: 03/17/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Mark J. Amsbaugh
- Department of Radiation Oncology; University of Louisville; Louisville Kentucky
| | - Mehran B. Yusuf
- Department of Radiation Oncology; University of Louisville; Louisville Kentucky
| | - Jeremy Gaskins
- Department of Bioinformatics and Biostatistics; University of Louisville; Louisville Kentucky
| | - Eric C. Burton
- Division of Neuro-Oncology, Department of Neurology; University of Louisville; Louisville Kentucky
| | - Shiao Y. Woo
- Department of Radiation Oncology; University of Louisville; Louisville Kentucky
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21
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Morgan ER, Norman A, Laing K, Seal MD. Treatment and outcomes for glioblastoma in elderly compared with non-elderly patients: a population-based study. ACTA ACUST UNITED AC 2017; 24:e92-e98. [PMID: 28490931 DOI: 10.3747/co.24.3424] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Elderly patients make up a large percentage of the individuals newly diagnosed with glioblastoma (gbm), but they face particular challenges in tolerating standard therapy, and compared with younger patients, they experience significantly shorter survival. We set out to compare clinical characteristics, treatment patterns, and outcomes in a non-elderly group (<65 years) and an elderly group (≥65 years) of patients diagnosed with gbm. METHODS This retrospective population-based study used a province-wide cancer registry to identify patients with a new diagnosis of gbm within a 6-year period (2006-2012). Of the 138 patients identified, 56 (40.6%) were 65 years of age or older. Demographic characteristics, treatment patterns, and overall survival (os) in the elderly and non-elderly groups were compared. Predictors of os were determined using multivariate analysis. RESULTS Elderly patients were more likely to present with a poor performance status (Eastern Cooperative Oncology Group ≥ 2), to undergo biopsy without resection, and to receive whole-brain or hypofractionated radiotherapy. Compared with non-elderly patients, the elderly patients were less likely to receive adjuvant temozolomide. Survival time was significantly shorter in the elderly than in the non-elderly patients (7.2 months vs. 11.2 months). In multivariate analysis, surgical resection, hypofractionated radiotherapy (compared with whole-brain or conventional radiotherapy), and chemotherapy were predictive of os in older patients. Among elderly patients receiving radiation, survival was improved with the use of combined therapy compared with the use of radiation only (11.3 months vs. 4.6 months). CONCLUSIONS Overall survival was shorter for elderly patients with gbm than for non-elderly patients; the elderly patients were also less likely to receive intensive surgical or adjuvant therapy. Our population-based analysis demonstrated improved os with surgical resection, hypofractionated radiotherapy, and temozolomide, and supports the results of recent clinical trials demonstrating a benefit for combination chemoradiotherapy in older patients.
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Affiliation(s)
- E R Morgan
- Gerry and Nancy Pencer Brain Tumour Centre, Princess Margaret Hospital Cancer Centre, Toronto, ON
| | - A Norman
- Cancer Care Program, Dr. H. Bliss Murphy Cancer Centre, St. John's, NL
| | - K Laing
- Cancer Care Program, Dr. H. Bliss Murphy Cancer Centre, St. John's, NL
| | - M D Seal
- Cancer Care Program, Dr. H. Bliss Murphy Cancer Centre, St. John's, NL
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22
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Cloney M, D'Amico R, Lebovic J, Nazarian M, Zacharia BE, Sisti MB, Bruce JN, McKhann GM, Iwamoto FM, Sonabend AM. Frailty in Geriatric Glioblastoma Patients: A Predictor of Operative Morbidity and Outcome. World Neurosurg 2016; 89:362-7. [DOI: 10.1016/j.wneu.2015.12.096] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 12/23/2015] [Accepted: 12/29/2015] [Indexed: 11/30/2022]
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23
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Ohtaki S, Wanibuchi M, Kataoka-Sasaki Y, Sasaki M, Oka S, Noshiro S, Akiyama Y, Mikami T, Mikuni N, Kocsis JD, Honmou O. ACTC1 as an invasion and prognosis marker in glioma. J Neurosurg 2016; 126:467-475. [PMID: 27081897 DOI: 10.3171/2016.1.jns152075] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Glioma is a major class of brain tumors, and glioblastoma (GBM) is the most aggressive and malignant type. The nature of tumor invasion makes surgical removal difficult, which results in remote recurrence. The present study focused on glioma invasion and investigated the expression of actin, alpha cardiac muscle 1 (ACTC1), which is 1 of 6 actin families implicated in cell motility. METHODS mRNA expression of ACTC1 expression was analyzed using quantitative real-time polymerase chain reaction (qRT-PCR) in 47 formalin-fixed, paraffin-embedded glioma tissues that were graded according to WHO criteria: Grade I (n = 4); Grade II (n = 12); Grade III (n = 6); and Grade IV (n = 25). Survival was analyzed using the Kaplan-Meier method. The relationships between ACTC1 expression and clinical features such as radiological findings at the time of diagnosis and recurrence, patient age, Karnofsky Performance Scale status (KPS), and the MIB-1 index were evaluated. RESULTS The incidence of ACTC1 expression as a qualitative assessment gradually increased according to WHO grade. The hazard ratio for the median overall survival (mOS) of the patients with ACTC1-positive high-grade gliomas as compared with the ACTC1-negative group was 2.96 (95% CI, 1.03-8.56). The mOS was 6.28 years in the ACTC1-negative group and 1.26 years in the positive group (p = 0.037). In GBM patients, the hazard ratio for mOS in the ACTC1-positive GBMs as compared with the ACTC1-negative group was 2.86 (95% CI 0.97-8.45). mOS was 3.20 years for patients with ACTC1-negative GBMs and 1.08 years for patients with ACTC1-positive GBMs (p = 0.048). By the radiological findings, 42.9% of ACTC1-positive GBM patients demonstrated invasion toward the contralateral cerebral hemisphere at the time of diagnosis, although no invasion was observed in ACTC1-negative GBM patients (p = 0.013). The recurrence rate of GBM was 87.5% in the ACTC1-positive group; in contrast, none of the ACTC1-negative patients demonstrated distant recurrence (0.007). No remarkable relationship was demonstrated among ACTC1 expression and patient age, KPS, and the MIB-1 index. CONCLUSIONS ACTC1 may serve as a novel independent prognostic and invasion marker in GBM.
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Affiliation(s)
- Shunya Ohtaki
- Departments of 1 Neurosurgery and.,Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Masahiko Wanibuchi
- Departments of 1 Neurosurgery and.,Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Yuko Kataoka-Sasaki
- Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Masanori Sasaki
- Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan.,Department of Neurology, Yale University School of Medicine, New Haven; and.,Center for Neuroscience and Regeneration Research, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Shinichi Oka
- Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Shouhei Noshiro
- Departments of 1 Neurosurgery and.,Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | | | - Takeshi Mikami
- Departments of 1 Neurosurgery and.,Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | | | - Jeffery D Kocsis
- Department of Neurology, Yale University School of Medicine, New Haven; and.,Center for Neuroscience and Regeneration Research, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Osamu Honmou
- Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan.,Department of Neurology, Yale University School of Medicine, New Haven; and.,Center for Neuroscience and Regeneration Research, VA Connecticut Healthcare System, West Haven, Connecticut
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24
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Wang Y, Xing D, Zhao M, Wang J, Yang Y. The Role of a Single Angiogenesis Inhibitor in the Treatment of Recurrent Glioblastoma Multiforme: A Meta-Analysis and Systematic Review. PLoS One 2016; 11:e0152170. [PMID: 27007828 PMCID: PMC4805294 DOI: 10.1371/journal.pone.0152170] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 03/09/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Currently, the standard treatment for newly diagnosed glioblastoma multiforme (GBM) is maximal safe surgical resection followed by radiation therapy with concurrent and adjuvant temozolomide. However, disease recurs in almost all patients, and the optimal salvage treatment for recurrent GBM remains unclear. We conducted a systematic review and meta-analysis of published clinical trials to assess the efficacy and toxicities of angiogenesis inhibitors alone as salvage treatment in these patients. METHODS Trials published between 1994 and 2015 were identified by an electronic search of public databases (MEDLINE, EMBASE, Cochrane library). Demographic data, treatment regimens, objective response rate (ORR), median progression-free survival (PFS), median overall survival (OS), 6-months PFS rate, 1-year OS and grade 3/4 toxicities were extracted. We also compared the main outcomes of interest between bevacizumab and other angiogenesis inhibitors. All analyses were performed using Comprehensive Meta Analysis software (Version 2.0). RESULTS A total of 842 patients were included for analysis: 343 patients were treated with bevacizumab, 386 with other angiogenesis inhibitors and 81 with thalidomide. The pooled ORR, 6-months PFS, and 1-year OS for recurrent GBM patients receiving angiogenesis inhibitors was 20.1%, 19.5% and 29.3%, respectively. The use of single agent bevacizumab in recurrent GBM significantly improved ORR and 6-months PFS when compared to other angiogenesis inhibitors [relative risk (RR) 2.93, 95% CI 1.38-6.21; p = 0.025; and RR 2.36 95% CI 1.46-3.82; p<0.001, respectively], while no significant difference in 1-year OS was found between the two groups (p = 0.07). when compared to thalidomide, bevacizumab treatment in recurrent GBM significantly improved ORR (RR 6.8, 95%CI: 2.64-17.6, p<0.001), but not for 6-months PFS (p = 0.07) and 1-year OS (p = 0.31). As for grade 3/4 toxicities, the common toxicity was hypertension with pooled incidence of 12.1%, while high-grade thromboembolic events (2.2%), hemorrhage (5.1%) and GI perforation (2.8%) associated with angiogenesis inhibitors were relatively low. CONCLUSIONS In comparison with other angiogenesis inhibitors and thalidomide, the use of single agent bevacizumab as salvage treatment for recurrent GBM patients improve ORR and 6-months PFS, but not for 1-year OS.
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Affiliation(s)
- Yawei Wang
- Department of Electromyography, Tianjin Hospital, Tianjin, China
| | - Dan Xing
- Arthritis Clinic & Research Center, Peking University People's Hospital, Peking University, Beijing, China
| | - Meng Zhao
- Clinical laboratory, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Jie Wang
- Department of Orthopedics, Tianjin Hospital, Tianjin, China
| | - Yang Yang
- Department of Orthopedics, Tianjin Hospital, Tianjin, China
- * E-mail:
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Pereira AF, Carvalho BF, Vaz RM, Linhares PJ. Glioblastoma in the elderly: Therapeutic dilemmas. Surg Neurol Int 2015; 6:S573-82. [PMID: 26664927 PMCID: PMC4653331 DOI: 10.4103/2152-7806.169542] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 08/31/2015] [Indexed: 12/04/2022] Open
Abstract
Background: Glioblastoma (GBM) is commonly diagnosed in patients older than 60 years, but the treatment protocols are mostly based on trials in patients aged up to 70 years. These lead to little consensus and to an absence of protocols regarding the standard treatments. The objective of this study is to analyze the prognostic factors, treatment efficacy, and adverse events in a cohort of elderly patients. Methods: A retrospective observational study of all patients aged ≥65 with histologically confirmed GBM followed at Centro Hospitalar S. João between 2005 and 2013. Demographic, clinical, radiographic, treatment, and outcome data were evaluated. Univariate and multivariate analyses were performed. Results: A total of 126 patients were reviewed. Median progression-free survival was 5 months (95% confidence interval [CI], 4.138 to 5.862 months). Median overall survival (OS) was 8 months (95% CI, 5.950 to 10.050 months). Univariate analysis showed the statistically significant associations between the higher OS and age <70 (P = 0.046), Karnofsky performance status ≥70 (P = 0.001), single lesions (P = 0.007), lesions affecting one lobe (P = 0.007), total resection (P = 0.048), and Charlson age-comorbidity index ≤5. Multivariate analysis identified the completion of 60 Gy radiotherapy and completion of 6 or more cycles of temozolomide chemotherapy as independent prognostic factors positively correlated with increased survival. Conclusions: Maximal resection and radiochemotherapy treatment completion are associated with longer OS, and age alone should not preclude elderly patients from receiving surgery and adjuvant treatment. However, only a few patients were able to finish the proposed treatments. Poor performance and high comorbidity index status might compromise the benefit of treatment aggressiveness and must be considered in therapeutic decision.
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Affiliation(s)
- André F Pereira
- Department of Clinical Neurosciences and Mental Health, Medical Faculty of Porto University, Porto, Portugal
| | - Bruno F Carvalho
- Department of Clinical Neurosciences and Mental Health, Medical Faculty of Porto University, Porto, Portugal ; Department of Neurosurgery, Centro Hospitalar S. João, Porto, Portugal
| | - Rui M Vaz
- Department of Clinical Neurosciences and Mental Health, Medical Faculty of Porto University, Porto, Portugal ; Department of Neurosurgery, Centro Hospitalar S. João, Porto, Portugal
| | - Paulo J Linhares
- Department of Clinical Neurosciences and Mental Health, Medical Faculty of Porto University, Porto, Portugal ; Department of Neurosurgery, Centro Hospitalar S. João, Porto, Portugal
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Abdel-Rahman O, Fouad M. Irinotecan-based regimens for recurrent glioblastoma multiform: a systematic review. Expert Rev Neurother 2015; 15:1255-70. [DOI: 10.1586/14737175.2015.1101346] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Mason M, Laperriere N, Wick W, Reardon DA, Malmstrom A, Hovey E, Weller M, Perry JR. Glioblastoma in the elderly: making sense of the evidence. Neurooncol Pract 2015; 3:77-86. [PMID: 31386084 DOI: 10.1093/nop/npv027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Indexed: 11/14/2022] Open
Abstract
Glioblastoma is a highly malignant neoplasm, notorious for its poor prognosis. The median age of diagnosis is 64 years, with an increasing number of patients diagnosed over the age of seventy. Managing elderly patients with this condition is challenging. Management pathways may include surgery, radiotherapy, chemotherapy, and best supportive care. Many clinical trials in oncology exclude elderly patients, including some of those for malignant brain tumors, leaving less evidence to guide treatment in these patients. Recent advances in molecular diagnostics and biomarkers, such as 06-methylguanine-DNA-methyltransferase (MGMT) promoter methylation status, may help guide optimal treatment selection. Focusing on available randomized data, this review provides a practical overview of the evidence for treating newly diagnosed glioblastoma in the elderly, including management recommendations.
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Affiliation(s)
- Matthew Mason
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada (M.M., N.L.); Neurology Clinic and National Center for Tumor Disease and Neurology Clinic, Heidelberg University Medical Center and DKFZ, Heidelberg, Germany (W.W); Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA(D.A.R.); Department of Advanced Home Care and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden (A.M.); Department of Medical Oncology, Prince of Wales Hospital, Randwick NSW, Australia (E.H.); Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, Zürich, Switzerland (M.W.); Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (J.R.P.)
| | - Normand Laperriere
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada (M.M., N.L.); Neurology Clinic and National Center for Tumor Disease and Neurology Clinic, Heidelberg University Medical Center and DKFZ, Heidelberg, Germany (W.W); Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA(D.A.R.); Department of Advanced Home Care and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden (A.M.); Department of Medical Oncology, Prince of Wales Hospital, Randwick NSW, Australia (E.H.); Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, Zürich, Switzerland (M.W.); Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (J.R.P.)
| | - Wolfgang Wick
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada (M.M., N.L.); Neurology Clinic and National Center for Tumor Disease and Neurology Clinic, Heidelberg University Medical Center and DKFZ, Heidelberg, Germany (W.W); Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA(D.A.R.); Department of Advanced Home Care and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden (A.M.); Department of Medical Oncology, Prince of Wales Hospital, Randwick NSW, Australia (E.H.); Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, Zürich, Switzerland (M.W.); Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (J.R.P.)
| | - David A Reardon
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada (M.M., N.L.); Neurology Clinic and National Center for Tumor Disease and Neurology Clinic, Heidelberg University Medical Center and DKFZ, Heidelberg, Germany (W.W); Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA(D.A.R.); Department of Advanced Home Care and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden (A.M.); Department of Medical Oncology, Prince of Wales Hospital, Randwick NSW, Australia (E.H.); Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, Zürich, Switzerland (M.W.); Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (J.R.P.)
| | - Annika Malmstrom
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada (M.M., N.L.); Neurology Clinic and National Center for Tumor Disease and Neurology Clinic, Heidelberg University Medical Center and DKFZ, Heidelberg, Germany (W.W); Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA(D.A.R.); Department of Advanced Home Care and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden (A.M.); Department of Medical Oncology, Prince of Wales Hospital, Randwick NSW, Australia (E.H.); Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, Zürich, Switzerland (M.W.); Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (J.R.P.)
| | - Elizabeth Hovey
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada (M.M., N.L.); Neurology Clinic and National Center for Tumor Disease and Neurology Clinic, Heidelberg University Medical Center and DKFZ, Heidelberg, Germany (W.W); Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA(D.A.R.); Department of Advanced Home Care and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden (A.M.); Department of Medical Oncology, Prince of Wales Hospital, Randwick NSW, Australia (E.H.); Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, Zürich, Switzerland (M.W.); Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (J.R.P.)
| | - Michael Weller
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada (M.M., N.L.); Neurology Clinic and National Center for Tumor Disease and Neurology Clinic, Heidelberg University Medical Center and DKFZ, Heidelberg, Germany (W.W); Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA(D.A.R.); Department of Advanced Home Care and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden (A.M.); Department of Medical Oncology, Prince of Wales Hospital, Randwick NSW, Australia (E.H.); Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, Zürich, Switzerland (M.W.); Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (J.R.P.)
| | - James R Perry
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada (M.M., N.L.); Neurology Clinic and National Center for Tumor Disease and Neurology Clinic, Heidelberg University Medical Center and DKFZ, Heidelberg, Germany (W.W); Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA(D.A.R.); Department of Advanced Home Care and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden (A.M.); Department of Medical Oncology, Prince of Wales Hospital, Randwick NSW, Australia (E.H.); Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, Zürich, Switzerland (M.W.); Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (J.R.P.)
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