Somnolence syndrome in patients receiving radical radiotherapy for primary brain tumours: a prospective study

Palliative Care and Care Partner Support in Neuro-oncology

ABSTRACT

The journey for a patient with a brain tumor and their loved ones can be extremely challenging due to the high burden of physical symptoms and the emotional distress caused by the diagnosis. Optimizing quality of life by addressing symptoms and reducing this emotional distress can improve treatment tolerance and outcomes and alleviate care partner distress and burden. Symptoms in patients with central nervous system (CNS) tumors can vary in onset and intensity, ranging from headaches, seizures, and focal weakness to emotional distress and cognitive dysfunction. Additionally, care partners may demonstrate distress due to the high burden of care and need appropriate support structures and access to resources to alleviate this stress. Evidence-based recommendations are unfortunately limited given the lack of high-quality research in this area, but patients living with CNS tumors and their loved ones can benefit from early and routine symptom identification and management, compassionate and transparent communication, and practical guidance for the future. These principles are part of palliative care, a field of medicine focused on alleviating suffering in patients with serious, chronic illness. Clinicians involved in the care of patients with CNS tumors must be educated in these important primary palliative care principles. This article focuses on key symptom management, strategies for high-quality communication, a discussion of advance care planning, and an overview of end-of-life care.

The Correlation of Sleep Disturbance and Location of Glioma Tumors: A Narrative Review

Sleep disturbance can occur when sleep centers of the brain, regions that are responsible for coordinating and generating healthy amounts of sleep, are disrupted by glioma growth or surgical resection. Several disorders cause disruptions to the average duration, quality, or patterns of sleep, resulting in sleep disturbance. It is unknown whether specific sleep disorders can be reliably correlated with glioma growth, but there are sufficient numbers of case reports to suggest that a connection is possible. In this manuscript, these case reports and retrospective chart reviews are considered in the context of the current primary literature on sleep disturbance and glioma diagnosis to identify a new and useful connection which warrants further systematic and scientific examination in preclinical animal models. Confirmation of the relationship between disruption of the sleep centers in the brain and glioma location could have significant implications for diagnostics, treatment, monitoring of metastasis/recurrence, and end-of-life considerations.

Symptom management in adult brain tumours: A literature review

AIM

To review the literature related to symptom management, clinical significance and related theoretical framework systems in adult patients with brain tumours.

BACKGROUND

As understanding of symptoms or symptom clusters and underlying biologic mechanisms has grown, it is apparent that symptom science is moving forward. Although some progress has been made in the symptom science of solid tumours such as breast and lung neoplasms, insufficient attention has been paid to symptom management for patients suffering from brain tumours. Further research is needed to achieve effective symptom management for these patients.

DESIGN

A literature review with a systematic search of symptom management in adult brain tumours.

METHODS

Electronic data bases were searched to obtain relevant published literature on symptom management in adults with brain tumours. This was then analysed and a synthesis of relevant findings is presented.

FINDINGS

Four significant general themes relating to symptom management of brain tumours in adults were identified: (1) The potential theoretical foundation related to symptom management was revealed. (2) Widely accepted validated scales or questionnaires for the assessment of single symptoms or symptom clusters were recommended. (3) Several symptom clusters and the underlying biologic mechanisms have been reported. (4) Specific symptom interventions for adults with brain tumours were collected and classified as evidence-based or insufficient evidence.

CONCLUSION

There are still many challenges in the effective management of symptoms in adults with brain tumours. The guiding role of theoretical frameworks or models related to symptom management should be utilized in future research. Using the concept of symptom clustering for research into symptoms found in patients with brain tumours, exploring common biological mechanisms for specific symptom clusters and making full use of modern big data resources to build a strong evidence base for an effective intervention or management program may inform the management of symptoms among these patients leading to better results.

NO PATIENT OR PUBLIC CONTRIBUTION

This is a literature review.

IMPLICATIONS FOR SYMPTOM MANAGEMENT

The ultimate goal is obviously not only improving the survival rate of patients with brain tumours, but also enhancing their quality of life. Several important findings from our review include the theoretical foundations, validated assessment tools, the assessment of symptom clusters and the underlying biologic mechanism, and the identification of the evidence base for symptom interventions. These are of relevance for managers, researchers and practitioners and may function as a reference to help the effective symptom management for adults with brain tumours.

Sleep disturbance in adults with untreated primary brain tumors: prevalence and impact on quality of life

Purpose

To investigate the frequency of sleep disturbance and its effects on quality of life in adults with untreated primary brain tumors.

Methods

This cross-sectional study recruited 68 and 35 patients with newly diagnosed benign and malignant brain tumors, respectively. All participants completed the Chinese versions of the Athens Insomnia Scale, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Hospital Anxiety and Depression Scale, Brief Fatigue Inventory, and EORTC-QLQ-BN20 for quality-of-life assessment. An actigraph was used to measure sleep parameters [e.g., dichotomy index (I < O)], for at least 3 consecutive days in untreated status.

Results

The majority of the patients with benign and malignant tumors had meningioma (57.4%) and glioblastoma (40%), respectively. The prevalence of insomnia, poor sleep quality, and excessive daytime sleepiness was 59.2%, 77.7%, and 4.9%, respectively. The prevalence rates of sleep disturbances were not affected by tumor locations (suprasellar vs. non-suprasellar tumors) and tumor types (benign vs. malignant tumors). Only 36 participants completed actigraphy assessments (I < O = 95.4) due to having a tight schedule, actigraph malfunction, or not having the habit of wearing a wristwatch; 61% of them experienced circadian rhythm disruption (I < O ≤ 97.5). Insomnia was the only sleep parameter that significantly affected quality of life after controlling for potential confounders (B = 0.54, p = 0.03, adjusted R2 = 0.60).

Conclusion

More than 60% of the patients with primary malignant and benign brain tumors experienced insomnia, poor sleep quality, and circadian rhythm disruption. Insomnia was independently correlated with quality of life in untreated status. Health-care providers can apply these findings to design effective interventions targeting sleep disturbance to improve quality of life in this population.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41105-022-00436-y.

Palliative care in brain tumors

The diagnosis of a brain tumor is a life-changing event for patients and families. High-grade gliomas (especially glioblastomas) are incurable, and long-term survival is limited. Metastatic brain lesions comprise the majority of intracranial neoplasms and are a significant source of morbidity and mortality in patients with systemic cancer. Response to treatment, prognosis, and survival depends not only on the underlying pathology, but more importantly on recently defined molecular features. Other crucial predictors of survival include age and performance status. Among patients with primary brain tumors, neurologic decline and psychological distress contribute to a high symptom burden and impaired quality of life (QoL) throughout the disease trajectory. While many symptoms in central nervous system (CNS) and non-CNS cancers overlap, others predominate in the brain tumor population, including seizures, headaches, depression, fatigue, and treatment-induced toxicity, all of which can be addressed with palliative interventions. Patients, families, and caregivers also report disproportionately high supportive care needs, which frequently differ from those of other systemic cancers. In addition, progressive neurologic decline often results in impaired communication and decision-making capacity at the end of life. Early palliative care (PC) integration has become more common in systemic cancers, but remains limited in neuro-oncology. These factors combined contribute to a uniquely challenging disease course that may benefit from a multidisciplinary approach with early involvement of specialized (PC) to address tumor-related symptoms and improve QoL. We review how to approach patients with brain tumors and address prognosis, symptom management, and advance care planning with the goal of improving QoL for patients, families, and caregivers.

The sex-dependent impact of PER2 polymorphism on sleep and activity in a novel mouse model of cranial-irradiation-induced hypersomnolence

Background

Hypersomnolence is a common and disruptive side effect of cranial radiotherapy and is associated with fatigue and disturbances in mood and cognition in primary brain tumor (PBT) patients. The biological underpinnings of this effect are not understood. Our laboratory has previously found that the presence of a single nucleotide polymorphism (rs934945, G-E mutation) in the PERIOD2 (PER2) clock gene was associated with a decreased likelihood of fatigue in PBT patients. Here, we aim to understand the effects of PER2 polymorphism on radiation susceptibility within a murine model of cranial-irradiation-induced hypersomnolence (C-RIH).

Methods

Male and female transgenic mice were generated using CRISPR-Cas9, replacing the endogenous mouse PER2:CRY1 binding domain with its human isoform with (hE1244 KI) or without the SNP rs934945 (hG1244 KI). Activity and sleep were monitored continuously 10 days before and after cranial irradiation (whole brain, 15Gy, single fraction). Behavioral assessments measuring anxiety, depression, and working memory were used to assess mood and cognitive changes 2 months postradiation.

Results

During their active phase, hE1244 knock-ins (KIs) had less radiation-induced suppression of activity relative to hG1244 KIs and female hE1244 KIs saw a reduction of hypersomnolence over 10 days. hE1244 KIs displayed less anxiety behavior and were more ambulatory within all behavioral tests.

Conclusions

The PER2 rs934945 polymorphism had long-lasting behavioral effects associated with radiation toxicity, particularly in sleep in females and the activity of all animals. Our findings shed light on biological mechanisms underlying C-RIH.

Exploring the prevalence and burden of sleep disturbance in primary brain tumor patients

BACKGROUND

Sleep disturbance (SD) is common in patients with cancer and has been associated with worse clinical outcomes. This cross-sectional study explored the prevalence of SD in a primary brain tumor (PBT) population, identified associated demographic and clinical characteristics, and investigated co-occurrence of SD with other symptoms and mood disturbance.

METHODS

Demographic, clinical characteristics, MD Anderson Symptom Inventory-Brain Tumor, and Patient Reported Outcome Measurement Information System Depression and Anxiety Short-Forms were collected from PBT patients at study entry. Descriptive statistics, Chi-square tests, and independent t-tests were used to report results.

RESULTS

The sample included 424 patients (58% male, 81% Caucasian) with a mean age of 49 years (range 18-81) and 58% with high-grade gliomas. Moderate-severe SD was reported in 19% of patients and was associated with younger age, poor Karnofsky Performance Status, tumor progression on MRI, and active corticosteroid use. Those with moderate-severe SD had higher overall symptom burden and reported more moderate-severe symptoms. These individuals also reported higher severity in affective and mood disturbance domains, with 3 to 4 times higher prevalence of depressive and anxiety symptoms, respectively. The most frequently co-occurring symptoms with SD were, drowsiness, and distress, though other symptoms typically associated with tumor progression also frequently co-occurred.

CONCLUSIONS

PBT patients with moderate-severe SD are more symptomatic, have worse mood disturbance, and have several co-occurring symptoms. Targeting interventions for sleep could potentially alleviate other co-occurring symptoms, which may improve life quality for PBT patients. Future longitudinal work examining objective and detailed subjective sleep reports, as well as underlying genetic risk factors, will be important.

Keep Your Mask On: The Benefits of Masking for Behavior and the Contributions of Aging and Disease on Dysfunctional Masking Pathways

Environmental cues (e.g., light-dark cycle) have an immediate and direct effect on behavior, but these cues are also capable of “masking” the expression of the circadian pacemaker, depending on the type of cue presented, the time-of-day when they are presented, and the temporal niche of the organism. Masking is capable of complementing entrainment, the process by which an organism is synchronized to environmental cues, if the cues are presented at an expected or predictable time-of-day, but masking can also disrupt entrainment if the cues are presented at an inappropriate time-of-day. Therefore, masking is independent of but complementary to the biological circadian pacemaker that resides within the brain (i.e., suprachiasmatic nucleus) when exogenous stimuli are presented at predictable times of day. Importantly, environmental cues are capable of either inducing sleep or wakefulness depending on the organism’s temporal niche; therefore, the same presentation of a stimulus can affect behavior quite differently in diurnal vs. nocturnal organisms. There is a growing literature examining the neural mechanisms underlying masking behavior based on the temporal niche of the organism. However, the importance of these mechanisms in governing the daily behaviors of mammals and the possible implications on human health have been gravely overlooked even as modern society enables the manipulation of these environmental cues. Recent publications have demonstrated that the effects of masking weakens significantly with old age resulting in deleterious effects on many behaviors, including sleep and wakefulness. This review will clearly outline the history, definition, and importance of masking, the environmental cues that induce the behavior, the neural mechanisms that drive them, and the possible implications for human health and medicine. New insights about how masking is affected by intrinsically photosensitive retinal ganglion cells, temporal niche, and age will be discussed as each relates to human health. The overarching goals of this review include highlighting the importance of masking in the expression of daily rhythms, elucidating the impact of aging, discussing the relationship between dysfunctional masking behavior and the development of sleep-related disorders, and considering the use of masking as a non-invasive treatment to help treat humans suffering from sleep-related disorders.

Memantine in the Prevention of Radiation-Induced Brain Damage: A Narrative Review

Simple Summary

Decline in cognitive function is a major problem for patients undergoing whole-brain radiotherapy (WBRT). Scientific interest has increased due to the high dropout rate of patients in the first months after WBRT and the early onset of cognitive decline. Therefore, the study of antiglutamatergic pharmacological prophylaxis and hippocampal-sparing WBRT techniques has been deepened based on the knowledge of the mechanisms of hyperglutamatergic neurotoxicity and the role of some hippocampal areas in cognitive decline. In order to provide a summary of the evidence in this field, and to foster future research in this setting, this literature review presents current evidence on the prevention of radiation-induced cognitive decline and particularly on the role of memantine.

Abstract

Preserving cognitive functions is a priority for most patients with brain metastases. Knowing the mechanisms of hyperglutamatergic neurotoxicity and the role of some hippocampal areas in cognitive decline (CD) led to testing both the antiglutamatergic pharmacological prophylaxis and hippocampal-sparing whole-brain radiotherapy (WBRT) techniques. These studies showed a relative reduction in CD four to six months after WBRT. However, the failure to achieve statistical significance in one study that tested memantine alone (RTOG 0614) led to widespread skepticism about this drug in the WBRT setting. Moreover, interest grew in the reasons for the strong patient dropout rates in the first few months after WBRT and for early CD onset. In fact, the latter can only partially be explained by subclinical tumor progression. An emerging interpretation of the (not only) cognitive impairment during and immediately after WBRT is the dysfunction of the limbic and hypothalamic system with its immune and hormonal consequences. This new understanding of WBRT-induced toxicity may represent the basis for further innovative trials. These studies should aim to: (i) evaluate in greater detail the cognitive effects and, more generally, the quality of life impairment during and immediately after WBRT; (ii) study the mechanisms producing these early effects; (iii) test in clinical studies, the modern and advanced WBRT techniques based on both hippocampal-sparing and hypothalamic-pituitary-sparing, currently evaluated only in planning studies; (iv) test new timings of antiglutamatergic drugs administration aimed at preventing not only late toxicity but also acute effects.

Sleep disturbance in primary brain tumor: prevalence, risk factors, and patient preferences

PURPOSE

Primary brain tumor (PBT) patients report sleep disturbance due to their disease and treatment, yet few studies have utilized validated measures to understand the extent of patients' concerns and preferences for treatment. The purpose of this quality improvement project was to determine the prevalence and associated risk factors of sleep disturbance among PBT patients in our clinic and to evaluate interest in treatment for sleep disturbance.

METHODS

PBT patients completed validated measures of sleep disturbance and health during routine neuro-oncology visits. Patients also reported on sleep-related symptom management and their preferences for pharmacological and/or behavioral treatment.

RESULTS

Sleep disturbance was common, with 61.5% of PBT patients (N = 119; M_age = 52.60 years; 50% male) reporting poor sleep quality and 21.5% endorsing symptoms of insomnia. Insomnia could be explained by increased fatigue and corticosteroid use; sleep quality could be explained by fatigue. Patients in our clinic with higher grade tumors, significant sleep disturbance, of minority racial/ethnic status, and those not already taking sleep medications were more likely to report their symptoms and were not well-addressed by their medical team. Patients indicated a similar interest in pharmacological and behavioral treatment, warranting the availability of both in our clinic.

CONCLUSIONS

Findings indicate a high prevalence of sleep disturbance in PBT patients, highlighting the need for increased screening, monitoring, and treatment in our neuro-oncology clinic. Future research would benefit from assessing the efficacy of behavioral treatments for sleep disturbance in this population.

Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome: A Comprehensive Review

PURPOSE OF REVIEW

SMART syndrome is a delayed complication of cranial irradiation that can be misconstrued as tumor recurrence or some other intracranial neurological disease. Recognition of this clinical syndrome is imperative as it can obviate the need for invasive diagnostic testing and can provide reassurance to both the patient and their loved ones.

RECENT FINDINGS

SMART syndrome is generally considered a reversible clinical syndrome; however, neurological deficits may become permanent. Pathophysiology of SMART syndrome may involve cerebrovascular autoregulation impairment, neuronal dysfunction leading to trigeminovascular system impairment and/or cortical spreading depression, and seizures. In addition to MRI brain with gadolinium, other imaging modalities, such as CT perfusion, MR perfusion, MR spectroscopy, and FDG PET/CT, aid in arriving to the diagnosis sooner. Patients should also undergo electroencephalogram in order to promptly identify and treat seizures. There are currently no clear guidelines on how to effectively treat SMART syndrome, but treatment may involve anti-seizure medication, anti-hypertensives, anti-platelet, and steroid therapy. This review provides a comprehensive understanding of the clinical characteristics of SMART syndrome from presentation to diagnostic evaluation. We also discuss radiographic features and treatment strategies for this rare disease. With increased radiotherapy utilization, prompt clinical recognition of SMART syndrome and further development of a comprehensive diagnostic approach to SMART syndrome utilizing newer radiographic modalities as well as treatment algorithms to effectively treat this clinical condition will be imperative.

Excessive daytime sleepiness in cancer patients

PURPOSE

Excessive daytime sleepiness (EDS) is commonly reported in patients with cancer, and it is also a cardinal feature of central disorders of hypersomnolence. Multiple sleep latency testing (MSLT) is used for objective assessment.

METHODS

A retrospective review of patients with cancer history who underwent formal sleep evaluation and MSLT from 2006 to 2019 was performed. Clinical characteristics, sleep-related history, and polysomnographic data were reviewed.

RESULTS

Of 16 patients with cancer history, 9 were women (56%) and median age was 49. Cancer diagnoses included 4 central nervous system, 3 breast, 1 lymphoma, and 9 other solid malignancies, and 31% were undergoing active treatment. Comorbid conditions included depression, obstructive sleep apnea, and cancer-related fatigue. Daytime fatigue (94%), daily naps (81%), and EDS (69%) were the most common symptoms. Hypnopompic and hypnogogic hallucinations, sleep paralysis, sleep attacks, and cataplexy were present in a few. Epworth Sleepiness Scale scores were consistent with EDS in 88%, and mean sleep latency was less than 8 min in 69%. Only 31% had more than 2 sleep-onset REM periods. MSLT supported diagnoses of central disorders of hypersomnolence in 5 patients (4 narcolepsy, 1 idiopathic hypersomnia); 5 hypersomnia due to a medical disorder, psychiatric condition, or medication; and 6 with normal results. Pharmacotherapy was prescribed in 5 patients.

CONCLUSIONS

EDS in patients with cancer may be multifactorial, but persistent symptoms may indicate an underlying disorder of hypersomnolence. Sleep referral and polysomnography to exclude other sleep disorders may be indicated. MSLT can help confirm the diagnosis. In those with normal MSLT, further evaluation for mood disorder should be considered.

Surgery and Evidence-based Treatments in Patients with Newly Diagnosed High-grade Glioma

OBJECTIVE

To describe the currently accepted standard-of-care practice for surgical and medical management of newly diagnosed high-grade glioma.

DATA SOURCES

Peer-reviewed journals, nationally accepted guidelines, and personal experience of the authors.

CONCLUSION

There is a widely accepted standard-of-care treatment protocol for patients with newly diagnosed high-grade glioma that includes maximal safe resection followed by radiation therapy with concurrent and adjuvant temozolomide. The regimen is well-tolerated and side effects are manageable.

IMPLICATIONS FOR NURSING PRACTICE

Nurses who are involved in the care of patients with newly diagnosed high-grade glioma should be familiar with the regimen and its side effects to provide crucial patient and caregiver education in an accurate and beneficial manner.

Sleep disturbance of adults with a brain tumor and their family caregivers: a systematic review

The high incidence and psychophysiological morbidities of sleep disturbance in cancer have been increasingly recognized. Yet, more detailed understanding of sleep disturbance and options for management have been neglected areas in both clinical care and research. Brain tumor patients have been particularly overlooked. A systematic search of the literature from 1990 to 2015 was performed to review sleep disturbance in adults with primary or secondary brain tumor and their family caregivers. Fifty eligible studies were identified, of which 12 focused on sleep, 37 reported sleep items within a health-related quality of life measure and 1 reported caregivers' sleep. No sleep intervention has been developed or tested for brain tumor patients. Sleep disturbance and somnolence were frequently reported as the most severely rated symptoms within health-related quality of life across the disease course or treatments, along with fatigue. However, sleep-focused studies yielded inconsistent results in small samples of mostly benign brain tumors in long-term remission from total tumor resection. The research using standardized, multifaceted sleep assessments, particularly in patients with malignant brain tumor and caregivers who are undergoing treatment, is seriously lacking. A more systematic examination of sleep disturbance is warranted to inform the development of better symptom management programs in this population.

Brain metastasis: clinical manifestations, symptom management, and palliative care

Patients who have brain metastases can suffer from a medley of symptoms, including headaches, seizures, cognitive impairment, fatigue, and focal deficits. As therapies have evolved, so has the management of these symptoms as patients survive longer. This chapter focuses on the clinical presentation of brain metastases, the treatment of those symptoms, and palliation in end-of-life management. Brain metastases are the most common cerebral malignancy. They can present with various symptoms, which can have significant impact on patients' quality of life throughout the course of their disease. Most of these symptoms are related to direct brain compression from the tumor or from edema. The location of the metastases will determine the focal deficits incurred and most patients will be on a course of steroids tapered according to their clinical status. The chapter includes a list of potential side-effects and considerations for management. Palliative care is an essential and important part of approaching patients with metastases. Early and clear communication about end-of-life decision making is encouraged with multiple easily accessible tools. For patients near the end of life, comfort is the ultimate goal in providing a good quality of life.

Health-related quality of life of cranial WHO grade I meningioma patients: are current questionnaires relevant?

BACKGROUND

The clinical relevance of Health-Related Quality of Life (HRQoL) in meningioma patients has been increasingly acknowledged in recent years. Various questionnaires have been used. However, almost none of these questionnaires has been particularly developed for and/or validated in this patient group. Therefore, the aim of this study was to assess the relevance and comprehensiveness of existing HRQoL questionnaires used in meningioma research and to assess the agreement between patients and health care professionals (HCPs) on the most relevant and important HRQoL issues.

METHODS

A systematic literature search, following the PRISMA statement, was conducted to identify all HRQoL questionnaires used in meningioma research. Semi-structured interviews were organized with patients and HCPs to (1) assess the relevance of all issues covered by the questionnaires (score 0-3: not relevant-highly relevant), (2) assess the ten most important issues, and (3) identify new relevant HRQoL issues.

RESULTS

Fourteen different questionnaires were found in the literature, comprising 140 unique issues. Interviews were conducted with 20 patients (median age 57, 71% female) and 10 HCPs (4 neurosurgeons, 2 neurologists, 2 radiotherapists, 1 rehabilitation specialist, 1 neuropsychologist; median experience 13 years). Meningioma patients rated 17-80% of the issues in each of the questionnaires as relevant, HCPs 90-100%. Patients and HCPs agreed on the relevance of only 49 issues (35%, Cohen's kappa: 0.027). Both patients and HCPs considered lack of energy the most important issue. Patients and HCPs suggested five additional relevant issues not covered by current HRQoL questionnaires.

CONCLUSIONS

Existing HRQoL questionnaires currently used in meningioma patients do not fully cover all relevant issues to these patients. Agreement between patients and HCPs on the relevance of issues was poor. Both findings support the need to develop and validate a meningioma-specific HRQoL questionnaire.

Association of genetic variants with fatigue in patients with malignant glioma

Background

Fatigue is a consistently reported, severe symptom among patients with gliomas throughout the disease trajectory. Genomic pathways associated with fatigue in glioma patients have yet to be identified.

Methods

Clinical factors (performance status, tumor details, age, gender) were collected by chart review on glioma patients with fatigue ("I have lack of energy" on Functional Assessment of Cancer Therapy-Brain), as well as available genotyping data. Candidate genes in clock and inflammatory pathways were identified from a literature review, of which 50 single nucleotide polymorphisms (SNPs) in 7 genes were available. Clinical factors and SNPs identified by univariate analyses were included in a multivariate model for moderate-severe fatigue.

Results

The study included 176 patients (median age = 47 years, 67% males). Moderate-severe fatigue was reported by 43%. Results from multivariate analysis revealed poor performance status and 2 SNPs were associated with fatigue severity. Moderate-severe fatigue was more common in patients with poor performance status (OR = 3.52, P < .01). For each additional copy of the minor allele in rs934945 (PER2) the odds of fatigue decreased (OR = 0.51, P < .05). For each additional copy of the minor allele in rs922270 (ARTNL2) the odds of fatigue increased (OR = 2.38, P < .01). Both of these genes are important in the circadian clock pathway, which has been implicated in diurnal preference, and duration and quality of sleep. No genes in the inflammatory pathway were associated with fatigue in the current study.

Conclusions

Identifying patients at highest risk for fatigue during treatment allows for improved clinical monitoring and enrichment of patient selection for clinical trials.

Frontline Systemic Therapy With Pemetrexed-Platinum in Nonsquamous Non-Small-Cell Lung Cancer With Asymptomatic Brain Metastases

The incidence of brain metastases from nonsquamous non-small-lung cancer is increasing as a result of superior imaging techniques for early detection of distant metastases. Although whole-brain radiation therapy and stereotactic radiosurgery along with systemic chemotherapy have shown to be effective in alleviating symptoms and improving outcomes, the approach to patients with asymptomatic brain metastases remains elusive. We explored the literature for a possible role of frontline systemic chemotherapy in asymptomatic brain metastases from nonsquamous non-small-lung cancer and found promising evidence that upfront systemic therapy with pemetrexed-platinum regimens might be a reasonable option for these patients and would forestall the need for upfront brain radiation therapy. More large-scale phase II and phase III clinical trials are needed to further investigate the frontline use of pemetrexed-platinum regimens in this setting.

Sleep-wake disturbance in patients with brain tumors

Sleep-wake disturbances are defined as perceived or actual alterations in sleep that result in impaired daytime functioning. Unlike other cancers, there is limited information about sleep-wake disturbances in adults with primary brain tumors throughout the illness trajectory. Sleep-wake disturbance is among the most severe and common symptoms reported by primary brain-tumor patients, particularly those undergoing radiation therapy. As with other cancers and neurologic illness, sleep-wake disturbance may also be clustered or related to other symptoms such as fatigue, depression, and cognitive impairment. There is increasing evidence for a genetic basis of normal sleep and sleep regulation in healthy adults. Specific mutations and single nucleotide variants have been reported to be associated with both fatigue and sleep-wake disorders, and both inflammation and alterations in circadian rhythms have been postulated to have a potential role. Guidelines for assessment and interventions have been developed, with cognitive behavioral therapy, exercise, and sleep hygiene demonstrating benefit in patients with other solid tumors. Further research is needed to identify risk and appropriate treatment in the brain-tumor patient population.

Determining priority signs and symptoms for use as clinical outcomes assessments in trials including patients with malignant gliomas: Panel 1 Report

Patients with primary brain tumors such as malignant gliomas are highly symptomatic, often from the time of diagnosis. Signs and symptoms (signs/symptoms) can cause functional limitations that often worsen over the disease trajectory and may impact patient quality of life. It is recognized that standard measurements of tumor response do not adequately measure this impact or the impact that a therapy may have to mitigate these signs/symptoms and potentially have clinical benefit. Identifying a core set of signs/symptoms and functional limitations is important for understanding their clinical impact and is the first step to including clinical outcomes assessment in primary brain tumor clinical trials.

Comprehensive assessment of Somnolence Syndrome in patients undergoing radiation to the brain

AIM

The aim of this prospective study was to assess Somnolence Syndrome (SS) in patients undergoing radiation to the brain.

BACKGROUND

SS is one of the sequelae of radiation to the brain, which is observed within three months of radiation. This is a self-limiting condition and a failure to diagnose leads to unnecessary investigations. This study was undertaken to objectively and subjectively analyze the occurrence, clinical presentation and severity of SS.

MATERIALS AND METHODS

Thirty-three patients receiving radiation to the brain were included in the study. Visual Analog Scale (VAS) was used for subjective assessment and the Littman Somnolence Syndrome (LSS) scale was used for objective assessment of SS. Sleep Latency Test (SLT) was used to quantify SS.

RESULTS

VAS scores showed an initial fall until week 3, followed by a plateau and a sudden increase after week 10. LSS scale at week 11 and 12 showed that 13 patients (43.3%) had grade 2, 5 (16.7%) had grade 3; and 2 (6.7%) had grade 4 SS. SLT revealed a shift of predominant sleep pattern from NREM 1 to NREM 2 at 6 weeks after radiation with a p value of 0.0412.

CONCLUSIONS

An insight into SS, its features, frequency of occurrence and self limiting nature can prevent anxiety and unwarranted investigations in the immediate post radiation period.

Neurocognitive Deficits and Neurocognitive Rehabilitation in Adult Brain Tumors

OPINION STATEMENT

Neurocognitive deficits are common with brain tumors. If assessed at presentation using detailed neurocognitive tests, problems are detected in 80 % of cases. Neurocognition may be affected by the tumor, its treatment, associated medication, mood, fatigue, and insomnia. Interpretation of neurocognitive problems should be considered in the context of these factors. Early post-operative neurocognitive rehabilitation for brain tumor patients will produce rehabilitation outcomes (e.g., quality of life, improved physical function, subjective neurocognition) equivalent to stroke, multiple sclerosis, and head injury, but the effect size and duration of benefit needs further research. In stable patients treated with radiotherapy +/- chemotherapy, the most frequent causes of distress include neurocognitive problems, psychological factors of anxiety, depression, fatigue, and sleep. Exercise, neurocognitive training, neurocognitive behavioral therapy, and medications to treat fatigue, behavior, memory, mood, and removal of drugs that may be associated with neurocognitive side effects (e.g., anti-epileptic drugs) all show promise in helping patients to manage the effects of their neurocognitive impairments better. As these are complex symptoms, multidisciplinary expertise is necessary to evaluate the influence of each variable to plan appropriate support and intervention. Neurocognitive rehabilitation should therefore occur in parallel with disease-centered, medical management from the outset. It should not occur in series, as a restricted phase in a patient's pathway. It should be considered in the pre- and post-operative period where there are good prospects of recovery, as one would for any brain-injured patient, so that the person may reach their optimal physical, sensory, intellectual, psychological, and social functional level. Yet the identification and selection of patients for early neurological rehabilitation and routine evaluation of cognition is uncommon in neurosurgical wards.

Rehabilitation of motor dysfunction in primary brain tumor patients†

In 2010 it was estimated that >688 000 Americans were living with a primary brain tumor (PBT) corresponding to a U.S. prevalence rate of approximately 221.8 per 100 000 people. Five-year survival is 96.1% in nonmalignant PBTs, 34% in malignant PBTs for all ages, and 71% in children [1985-2005]. Case fatality rates have decreased in the U.S. since the 1970's for nonmalignant PBTs and for medulloblastoma, oligodendroglioma, and astrocytoma. Statistics of increasing survival highlight the importance of rehabilitation interventions to improve function and quality of life in survivors. PBT motor dysfunction is multifactorial, occurring as a result of direct effects of tumor and/or swelling or as a result of treatments; etiologies include encephalopathy, myopathy, neuropathy, infection, poor nutrition, metabolic factors, emotional factors, impaired perception/vision/cognition and complications of immobility. Motor dysfunction may lead to: impaired mobility, impaired activities of daily living, risk for complications of immobility, falls, pain, anxiety/depression, and loss of functional independence and quality of life. Rehabilitation treatment strategies target specific causes of motor dysfunction to improve functional independence and quality of life. This article reviews current knowledge and controversy regarding the role of rehabilitation for motor disorders in PBT patients.

Central Hypersomnia

Sleepiness is not uncommon in the pediatric population. Although the etiology can be multifactorial, sleepiness due to increased sleep drive, also called central hypersomnia, is a common cause. The third edition of the International Classification of Sleep Disorders updated the diagnostic criteria for several of the central disorders of hypersomnolence, most notably narcolepsy. Although the International Classification Of Sleep Disorders-3 is not specific to pediatric patients, the peak incidence for many of the included disorders occurs during childhood or adolescence. As a result, recognition of these lifelong and potentially debilitating disorders is imperative for providers who evaluate pediatric patients. This review provides an update on recent advances in the field and highlights some of the diagnostic dilemmas, unique clinical features, and variable presentations associated with central disorders of hypersomnolence within the pediatric population.

Symptom management and quality of life in glioma patients

Symptoms of fatigue, cognitive deficits, depression and changes in personality and behavior are frequently reported in patients with glioma. These symptoms have a large impact on the everyday life of patients and their partners and can contribute to a decrease in quality of life. While guidelines are available for managing most of these symptoms, these guidelines are often not suitable for the brain tumor patient population, as this population has very specific problems and needs. Obtaining more evidence on the effectiveness of existing and new interventions targeting fatigue, cognitive deficits, depression, and changes in personality and behavior in this population is advised. Screening combined with adequate referral to supportive care professionals has the potential to decrease the disease burden of glioma patients and their partners.

Prevalence and predictors of fatigue in glioblastoma: a prospective study

BACKGROUND

The main goal of this study was to assess frequency, clinical correlates, and independent predictors of fatigue in a homogeneous cohort of well-defined glioblastoma patients at baseline prior to combined radio-chemotherapy.

METHODS

We prospectively included 65 glioblastoma patients at postsurgical baseline and assessed fatigue, sleepiness, mean bedtimes, mood disturbances, and clinical characteristics such as clinical performance status, presenting symptomatology, details on neurosurgical procedure, and tumor location and diameter as well as pharmacological treatment including antiepileptic drugs, antidepressants, and use of corticosteroids. Data on fatigue and sleepiness were measured with the Fatigue Severity Scale and the Epworth Sleepiness Scale, respectively, and compared with 130 age- and sex-matched healthy controls.

RESULTS

We observed a significant correlation between fatigue and sleepiness scores in both patients (r = 0.26; P = .04) and controls (r = 0.36; P < .001). Only fatigue appeared to be more common in glioblastoma patients than in healthy controls (48% vs 11%; P < .001) but not the frequency of sleepiness (22% vs 19%; P = .43). Female sex was associated with increased fatigue frequency among glioblastoma patients but not among control participants. Multiple linear regression analyses identified depression, left-sided tumor location, and female sex as strongest associates of baseline fatigue severity.

CONCLUSIONS

Our findings indicate that glioblastoma patients are frequently affected by fatigue at baseline, suggesting that factors other than those related to radio- or chemotherapy have significant impact, particularly depression and tumor localization.

Radiation therapy in neurologic disease

Radiotherapy is a primary mode of treatment of many of the disease entities seen by the neurologist. Therefore knowledge of how ionizing radiation works and when it is indicated is a crucial part of the field of Neurology. The neurologist may also be confronted with some of the side effects and complications or radiotherapy treatment. This chapter attempts to serve as a review of the current day process of radiotherapy, a brief review of biology and physics of radiation, and how it is used in the treatment diseases which are common to the Neurologist. In addition we review the more commonly seen side effects and complications of treatment which may be seen by the neurologist.

Is current technology improving outcomes with radiation therapy for gliomas?

Radiotherapy (RT) remains the principal component of glioma treatment, and three-dimensional conformal RT (3DCRT) is the current standard of RT delivery. Advances in imaging and in RT technology have enabled more precise treatment to defined targets combined with better means of avoiding critical normal structures, and this is complemented by intensive quality assurance, which includes on-treatment imaging. The refinements of 3DCRT include intensity modulated RT (IMRT), arcing IMRT, and high-precision conformal RT, formerly described as "stereotactic," which can be delivered using a linear accelerator or other specialized equipment. Although proton therapy uses heavy charged particles, the principal application can also be considered as refinement of 3DCRT. The technologies generally improve the dose differential between the tumor and normal tissue and enable more dose-intensive treatments. However, these have not translated into improved survival outcome in patients with low- and high-grade gliomas. More intensive altered fractionation regimens have also failed to show survival benefit. Nevertheless, novel technologies enable better sparing of normal tissue and selective avoidance of critical structures, and these need to be explored further to improve the quality of life of patients with gliomas. Principal clinical advance in RT has been the recognition that less intensive treatments are beneficial for patients with adverse prognosis high-grade gliomas. We conclude that the principal gain of modern RT technology is more likely to emerge as a reduction in treatment related toxicity rather than as an improvement in overall survival; the optimal avoidance strategies remain to be defined.

The effect of modafinil on fatigue, cognitive functioning, and mood in primary brain tumor patients: a multicenter randomized controlled trial

BACKGROUND

Fatigue, cognitive deficits, and depression are frequently reported but often undertreated symptoms that can profoundly affect daily life in patients with primary brain tumors (PBTs). To evaluate the effects of the psychostimulant modafinil on fatigue, depression, health-related quality of life (HRQOL), and cognitive functioning in PBT patients, we performed a multicenter, double-blind placebo-controlled crossover trial.

METHODS

Patients randomly received either 6 weeks of treatment with modafinil (up to 400 mg/day) or 6 weeks with placebo. After a 1-week washout period, the opposite treatment was provided. Assessments took place at baseline and immediately after the first and second condition. Patients completed self-report questionnaires on fatigue (Checklist Individual Strength [CIS]), depression (Center for Epidemiologic Studies Depression Scale [CES-D]), HRQOL (Short-Form Health Survey [SF-36]), and self-perceived cognitive functioning (Medical Outcomes Study [MOS]). They also underwent comprehensive neurocognitive testing.

RESULTS

In total, 37 patients participated. Relative to baseline, patients reported lower fatigue severity (CIS) and better motivation (CIS) in both the modafinil (P = .010 and P = .021, respectively) and the placebo condition (P < .001 and P = .027, respectively). The same held for physical health (SF-36 Physical Component Summary score; P = .001 and P = .008, respectively), working memory (P = .040 and P = .043), and information processing capacity (P = .036 and P = .040). No improvement in depressive symptoms was found in either condition.

CONCLUSIONS

Modafinil did not exceed the effects of placebo with respect to symptom management. Patient accrual was slow, and relatively many patients dropped out during the trial, due mostly to side effects. Other, preferably nonpharmacologic intervention studies should be considered to improve symptom management of PBT patients.

Prophylactic cranial irradiation for small-cell lung cancer: how, when and for whom?

Prophylactic cranial irradiation (PCI) reduces the incidence of brain metastases and improves overall survival in both limited disease (LD) and extensive disease (ED) small-cell lung cancer (SCLC), in complete and good responders to initial chemo(radio)therapy. In LD-SCLC, a standard dose of 25 Gy given in ten fractions is recommended, whereas in ED-SCLC a shorter schedule of 20 Gy in five fractions could be used. The issues of acute neurotoxicity (NT) and the potential impact of PCI on quality of life are of particular concern in ED-SCLC patients, as their expected survival is short. In LD-SCLC late neurologic sequelae may worsen quality-adjusted life expectancy for long-term survivors, as the pronounced effect of NT becomes apparent after several years. Some novel potential approaches to reduce the PCI-related late NT have recently been investigated. Despite the growing incidence of lung cancer in elderly people, there are no established standards of treatment for this subset of the population.