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Palavani LB, de Barros Oliveira L, Reis PA, Batista S, Santana LS, de Freitas Martins LP, Rabelo NN, Bertani R, Welling LC, Figueiredo EG, Paiva WS, Neville IS. Efficacy and Safety of Intraoperative Radiotherapy for High-Grade Gliomas: A Systematic Review and Meta-Analysis. Neurosurg Rev 2024; 47:47. [PMID: 38221545 DOI: 10.1007/s10143-024-02279-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/27/2023] [Accepted: 01/03/2024] [Indexed: 01/16/2024]
Abstract
BACKGROUND AND OBJECTIVES High-grade gliomas (HGGs) are aggressive tumors of the central nervous system that cause significant morbidity and mortality. Despite advances in surgery and radiation therapy (RT), HGG still has a high incidence of recurrence and treatment failure. Intraoperative radiotherapy (IORT) has emerged as a promising therapeutic approach to achieve local tumor control while sparing normal brain tissue from radiation-induced damage. METHODS A systematic review and meta-analysis were conducted following PRISMA guidelines to evaluate the use of IORT for HGG. Eligible studies were included based on specific criteria, and data were independently extracted. Outcomes of interest included complications, IORT failure, survival rates at 12 and 24 months, and mortality. RESULTS Sixteen studies comprising 436 patients were included. The overall complication rate after IORT was 17%, with significant heterogeneity observed. The IORT failure rate was 77%, while the survival rates at 12 and 24 months were 74% and 24%, respectively. The mortality rate was 62%. CONCLUSION This meta-analysis suggests that IORT may be a promising adjuvant treatment for selected patients with HGG. Despite the high rate of complications and treatment failures, the survival outcomes were comparable or even superior to conventional methods. However, the limitations of the study, such as the lack of a control group and small sample sizes, warrant further investigation through prospective randomized controlled trials to better understand the specific patient populations that may benefit most from IORT. However, the limitations of the study, such as the lack of a control group and small sample sizes, warrant further investigation. Notably, the ongoing RP3 trial (NCT02685605) is currently underway, with the aim of providing a more comprehensive understanding of IORT. Moreover, future research should focus on managing complications associated with IORT to improve its safety and efficacy in treating HGG.
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Affiliation(s)
| | | | - Pedro Abrahão Reis
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Savio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | | | | | - Nicollas Nunes Rabelo
- Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Raphael Bertani
- Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Eberval Gadelha Figueiredo
- Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Wellingson S Paiva
- Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Iuri Santana Neville
- Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Instituto do Câncer do Estado de São Paulo - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Bao H, Ai S, Wang G, Yi L, Lai J, Wang S, Lv Z, Li C, Liu Q, Zhao X, Wu C, Liu C, Mi S, Sun X, Hao C, Liang P. Intraoperative radiotherapy in recurrent IDH-wildtype glioblastoma with gross total resection: A single-center retrospective study. Clin Neurol Neurosurg 2024; 236:108103. [PMID: 38199118 DOI: 10.1016/j.clineuro.2023.108103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/08/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Isocitrate dehydrogenase-wildtype (IDHwt) glioblastoma (GBM) is one of the most aggressive primary brain tumors. The recurrence of GBM is almost inevitable. As an adjuvant option to surgery, intraoperative radiotherapy (IORT) is gaining increasing attention in the treatment of glioma. This study is aimed to evaluate the therapeutic efficacy of IORT on recurrent IDHwt GBM. METHODS In total, 34 recurrent IDHwt GBM patients who received a second surgery were included in the analysis (17 in the surgery group and 17 in the surgery + IORT group). RESULTS The progression-free survival and overall survival after the second surgery were defined as PFS2 and OS2, respectively. The median PFS2 was 7.3 months (95% CI: 6.3-10.5) and 10.6 months (95% CI: 9.3-14.6) for those patients who received surgery and surgery + IORT, respectively. Patients in the surgery + IORT group also had a longer OS2 (12.8 months, 95% CI: 11.4-17.2) than those in the surgery group (9.3 months, 95% CI: 8.9-12.9). The Kaplan-Meier survival curves, analyzed by log-rank test, revealed a statistically significant difference in PFS2 and OS2 between both groups, suggesting that IORT plays an active role in the observed benefits for PFS2 and OS2. The effects of IORT on PFS2 and OS2 were further confirmed by multivariate Cox hazards regression analysis. Two patients in the surgery group developed distant glioma metastases, and no radiation-related complications were observed in the IORT group. CONCLUSIONS This study suggests that low-dose IORT may improve the prognosis of recurrent IDHwt GBM patients. Future prospective large-scale studies are needed to validate the efficacy and safety of IORT.
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Affiliation(s)
- Hongbo Bao
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Siqi Ai
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China; Department of Neurosurgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Gang Wang
- Department of Radiotherapy, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Liye Yi
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Jiacheng Lai
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Shuai Wang
- Department of Imaging Center, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Zhonghua Lv
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Chenlong Li
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Qing Liu
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Xinyu Zhao
- Department of Radiotherapy, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Chou Wu
- Department of Radiotherapy, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Chang Liu
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Shan Mi
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Xiaoyang Sun
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Chuncheng Hao
- Department of Radiotherapy, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China.
| | - Peng Liang
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China.
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3
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Zhang H, Zhang H, Zhang Y, Zhou B, Wu L, Yang W, Lei Y, Huang B. Multiparametric MRI-based fusion radiomics for predicting telomerase reverse transcriptase (TERT) promoter mutations and progression-free survival in glioblastoma: a multicentre study. Neuroradiology 2024; 66:81-92. [PMID: 37978079 DOI: 10.1007/s00234-023-03245-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/29/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE This study evaluated the performance of multiparametric magnetic resonance imaging (MRI)-based fusion radiomics models (MMFRs) to predict telomerase reverse transcriptase (TERT) promoter mutation status and progression-free survival (PFS) in glioblastoma patients. METHODS We retrospectively analysed 208 glioblastoma patients from two hospitals. Quantitative imaging features were extracted from each patient's T1-weighted, T1-weighted contrast-enhanced, and T2-weighted preoperative images. Using a coarse-to-fine feature selection strategy, four radiomics signature models were constructed based on the three MRI sequences and their combination for TERT promoter mutation status and PFS; model performance was subsequently evaluated. Subgroup analyses were performed by the radiomics signature of TERT promoter mutation status and PFS to distinguish patients who could benefit from prolonged temozolomide chemotherapy cycles. RESULTS TERT promoter mutation status was best predicted by MMFR, with an area under the curve (AUC) of 0.816 and 0.812 for the training and internal validation sets, respectively. The external test set also achieved stable and optimal prediction results (AUC, 0.823). MMFR better predicted patient PFS compared with the single-sequence radiomics signature in the test set (C-index, 0.643 vs 0.561 vs 0.620 vs 0.628). Subgroup analyses showed that more than six cycles of postoperative temozolomide chemotherapy were associated with improved PFS for patients in class 2 (high TERT promoter mutation and high survival rates; HR, 0.222; 95% CI, 0.054 - 0.923; p = 0.025). CONCLUSION MMFR is an effective method to predict TERT promoter mutations and PFS in patients with glioblastoma. Moreover, subgroup analysis could differentiate patients who may benefit from prolonged TMZ chemotherapy cycles.
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Affiliation(s)
- Hongbo Zhang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Department of Radiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, #106 Zhongshan 2Nd Road, Guangzhou, 510080, China
- Department of Radiology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, 517108, China
| | - Hanwen Zhang
- Department of Radiology, The First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People's Hospital, #3002 SunGangXi Road, Shenzhen, 518035, China
| | - Yuze Zhang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Department of Radiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, #106 Zhongshan 2Nd Road, Guangzhou, 510080, China
| | - Beibei Zhou
- Department of Radiology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, 517108, China
| | - Lei Wu
- Department of Radiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, #106 Zhongshan 2Nd Road, Guangzhou, 510080, China
| | - Wanqun Yang
- Department of Radiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, #106 Zhongshan 2Nd Road, Guangzhou, 510080, China
| | - Yi Lei
- Department of Radiology, The First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People's Hospital, #3002 SunGangXi Road, Shenzhen, 518035, China.
| | - Biao Huang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China.
- Department of Radiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, #106 Zhongshan 2Nd Road, Guangzhou, 510080, China.
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Ji X, Ding W, Wang J, Zhou B, Li Y, Jiang W, Pan H, Gu J, Sun X. Application of intraoperative radiotherapy for malignant glioma. Cancer Radiother 2023; 27:425-433. [PMID: 37344258 DOI: 10.1016/j.canrad.2023.01.007] [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: 12/25/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 06/23/2023]
Abstract
Malignant glioma is characterized by rapid tumor cell proliferation and high recurrence risk. In terms of its treatment, the therapeutic effects of maximum resection and postoperative radiotherapy with adjuvant chemotherapy as well as many other new therapeutic techniques such as antiangiogenic therapy and immunotherapy remain poor. Glioma recurrence, especially local recurrence, is an important reason of glioma treatment failure. Intraoperative radiotherapy (IORT) enables exclusion of radiation-sensitive normal tissue from the radiation field in operation and then the application of a single high-dose precision irradiation to the residual tumor or tumor bed. IORT has great application potential in the control of local recurrence of malignant tumors. This paper thus aims to review the current status and prospects of IORT's application in malignant glioma treatment.
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Affiliation(s)
- Xiaoqin Ji
- Department of Radiation Oncology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Wei Ding
- Department of Radiation Oncology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jiasheng Wang
- Department of Radiation Oncology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Bin Zhou
- Department of Radiation Oncology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yikun Li
- Department of Radiation Oncology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Wanrong Jiang
- Department of Radiation Oncology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Hao Pan
- Department of Neurosurgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jun Gu
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xiangdong Sun
- Department of Radiation Oncology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
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Cifarelli CP, Vargo JA, Sener U, Cifarelli DT, Scoville D, Dabir A. Intracranial intraoperative radiotherapy (IORT): evaluation of electrocorticography and peri-operative seizure risk. J Neurooncol 2023; 164:423-430. [PMID: 37668944 DOI: 10.1007/s11060-023-04443-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/30/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Intra-operative radiotherapy (IORT) for brain metastases (BMs) and primary brain tumors has emerged as an adjuvant radiation modality that allows for consolidation of care into a single anesthetic episode with surgical resection. Yet, there is a paucity of data regarding the impact that IORT may have on peri-operative and long-term seizure risk. METHODS A retrospective analysis of patients receiving IORT during tumor resection was performed via registry including data regarding peri-operative anti-seizure medications and anesthetic agents. Intra-operative neuromonitoring was performed using electrocorticography (ECoG) captured before-, during-, and after-IORT then analyzed for evidence of seizure or significant baseline changes. Kaplan-Meir estimations were used for overall survival analysis relative to documented clinical seizure incidence post-IORT. RESULTS Of the 24 consecutive patients treated with IORT during tumor resection included, 18 (75%) patients were diagnosed with BMs while 6 (25%) had newly-diagnosed glioblastoma. Mean and median survival times were 487 and 372 days, respectively. Clinical seizures occurred in 3 patients post-IORT, 2 BMs patients within 9 months and 1 glioblastoma patient at 14 months. IORT time represented 9.5% of anesthetic time. ECoG recordings were available for 5 patients (4 BMs; 1 glioblastoma), with mean recording durations of 13% of the total anesthetic time and no evidence of high-frequency oscillations or seizure activity. CONCLUSIONS IORT is an option for delivery of definitive radiation in surgically resected brain tumors without increasing the peri-operative or long-term risk of seizure. ECoG data during the delivery of radiation fail to demonstrate any electrophysiological changes in response to ionizing radiation.
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Affiliation(s)
- Christopher P Cifarelli
- Department of Neurosurgery, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26506-9183, USA.
- Department of Radiation Oncology, West Virginia University, Morgantown, WV, USA.
| | - John A Vargo
- Department of Radiation Oncology, UPMC, Pittsburgh, PA, USA
| | - Ugur Sener
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Daniel T Cifarelli
- Department of Neurosurgery, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26506-9183, USA
| | - David Scoville
- Division of Surgical Services, WVU Medicine, Morgantown, WV, USA
| | - Aman Dabir
- Department of Neurology, West Virginia University, Morgantown, WV, USA
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6
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Layer JP, Hamed M, Potthoff AL, Dejonckheere CS, Layer K, Sarria GR, Scafa D, Koch D, Köksal M, Kugel F, Grimmer M, Holz JA, Zeyen T, Friker LL, Borger V, Schmeel FC, Weller J, Hölzel M, Schäfer N, Garbe S, Forstbauer H, Giordano FA, Herrlinger U, Vatter H, Schneider M, Schmeel LC. Outcome assessment of intraoperative radiotherapy for brain metastases: results of a prospective observational study with comparative matched-pair analysis. J Neurooncol 2023; 164:107-116. [PMID: 37477822 PMCID: PMC10462513 DOI: 10.1007/s11060-023-04380-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/20/2023] [Indexed: 07/22/2023]
Abstract
PURPOSE Intraoperative radiation therapy (IORT) is an emerging alternative to adjuvant stereotactic external beam radiation therapy (EBRT) following resection of brain metastases (BM). Advantages of IORT include an instant prevention of tumor regrowth, optimized dose-sparing of adjacent healthy brain tissue and immediate completion of BM treatment, allowing an earlier admission to subsequent systemic treatments. However, prospective outcome data are limited. We sought to assess long-term outcome of IORT in comparison to EBRT. METHODS A total of 35 consecutive patients, prospectively recruited within a study registry, who received IORT following BM resection at a single neuro-oncological center were evaluated for radiation necrosis (RN) incidence rates, local control rates (LCR), distant brain progression (DBP) and overall survival (OS) as long-term outcome parameters. The 1 year-estimated OS and survival rates were compared in a balanced comparative matched-pair analysis to those of our institutional database, encompassing 388 consecutive patients who underwent adjuvant EBRT after BM resection. RESULTS The median IORT dose was 30 Gy prescribed to the applicator surface. A 2.9% RN rate was observed. The estimated 1 year-LCR was 97.1% and the 1 year-DBP-free survival 73.5%. Median time to DBP was 6.4 (range 1.7-24) months in the subgroup of patients experiencing intracerebral progression. The median OS was 17.5 (0.5-not reached) months with a 1 year-survival rate of 61.3%, which did not not significantly differ from the comparative cohort (p = 0.55 and p = 0.82, respectively). CONCLUSION IORT is a safe and effective fast-track approach following BM resection, with comparable long-term outcomes as adjuvant EBRT.
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Affiliation(s)
- Julian P Layer
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany.
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | - Cas S Dejonckheere
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Katharina Layer
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Davide Scafa
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - David Koch
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Mümtaz Köksal
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Fabian Kugel
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Molina Grimmer
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jasmin A Holz
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Thomas Zeyen
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Lea L Friker
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany
- Institute of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - F Carsten Schmeel
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Johannes Weller
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Michael Hölzel
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany
| | - Niklas Schäfer
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Stephan Garbe
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | | | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Mannheim, Germany
- DKFZ-Hector Cancer Institute of the University Medical Center Mannheim, Mannheim, Germany
- Mannheim Institute of Intelligent Systems in Medicine (MIISM), Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ulrich Herrlinger
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | - L Christopher Schmeel
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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Kumari S, Gupta R, Ambasta RK, Kumar P. Multiple therapeutic approaches of glioblastoma multiforme: From terminal to therapy. Biochim Biophys Acta Rev Cancer 2023; 1878:188913. [PMID: 37182666 DOI: 10.1016/j.bbcan.2023.188913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/24/2023] [Accepted: 05/10/2023] [Indexed: 05/16/2023]
Abstract
Glioblastoma multiforme (GBM) is an aggressive brain cancer showing poor prognosis. Currently, treatment methods of GBM are limited with adverse outcomes and low survival rate. Thus, advancements in the treatment of GBM are of utmost importance, which can be achieved in recent decades. However, despite aggressive initial treatment, most patients develop recurrent diseases, and the overall survival rate of patients is impossible to achieve. Currently, researchers across the globe target signaling events along with tumor microenvironment (TME) through different drug molecules to inhibit the progression of GBM, but clinically they failed to demonstrate much success. Herein, we discuss the therapeutic targets and signaling cascades along with the role of the organoids model in GBM research. Moreover, we systematically review the traditional and emerging therapeutic strategies in GBM. In addition, we discuss the implications of nanotechnologies, AI, and combinatorial approach to enhance GBM therapeutics.
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Affiliation(s)
- Smita Kumari
- Molecular Neuroscience and Functional Genomics Laboratory, Department of Biotechnology, Delhi Technological University, India
| | - Rohan Gupta
- Molecular Neuroscience and Functional Genomics Laboratory, Department of Biotechnology, Delhi Technological University, India
| | - Rashmi K Ambasta
- Molecular Neuroscience and Functional Genomics Laboratory, Department of Biotechnology, Delhi Technological University, India
| | - Pravir Kumar
- Molecular Neuroscience and Functional Genomics Laboratory, Department of Biotechnology, Delhi Technological University, India.
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8
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Li L, Qin K, Pan Y, Mao C, Alafate W, Tan P, Zhang N, Tang K. The Efficacy and Safety of Intraoperative Radiotherapy in the Treatment of Recurrent High-Grade Glioma: A Single-Center Prospective Study. World Neurosurg 2023; 172:e453-e466. [PMID: 36682529 DOI: 10.1016/j.wneu.2023.01.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/15/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND High-grade gliomas are treated following a standard protocol; however, tumor recurrence is almost inevitable. Recurrent high-grade gliomas have an extremely poor prognosis, and there are no clear treatment guidelines. In this stud, we evaluated the safety and effectiveness of intraoperative radiotherapy (IORT) for recurrent high-grade glioma. METHODS In this prospective randomized study begun in April 2018, patients ≥18 years of age with a Karnofsky Performance Status >50 and recurrent high-grade glioma were randomly assigned in a 1:1 ratio to tumor resection and IORT or tumor resection alone. RESULTS Twenty-two patients were allocated to the IORT group and 21 to receive surgery only (operation group). Clinical data of 42 enrolled patients were involved in the analysis. The progression-free survival of the IORT group was 9.6 months and of the operation group was 7.3 months (P = 0.018), and the overall survival of the 2 groups was 13.5 months and 10.2 months, respectively (P = 0.054). Univariate and multivariate analysis indicated that preoperative Karnofsky Performance Status >70 and IORT were protective factors for patients with recurrent high-grade glioma. A patient who underwent conventional fractionated radiotherapy within 6 months of receiving IORT died on the ninth day after undergoing tumor resection and IORT because of severe cerebral edema. The total operation time was longer in the IORT group, but there were no differences in intraoperative bleeding or adverse events between the 2 groups. CONCLUSIONS IORT with low-energy radiography at a dose of 30-40 Gy is generally safe and effective for patients with recurrent glioma. However, IORT should not be performed for patients who have received conventional fractionated radiotherapy within 6 months.
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Affiliation(s)
- Liangbin Li
- Shantou University Medical College, Shantou, Guangdong, P.R. China; Department of Neurosurgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, P.R. China
| | - Kun Qin
- Department of Neurosurgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, P.R. China
| | - Yi Pan
- Department of Radiotherapy, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, P.R. China
| | - Chengliang Mao
- Department of Neurosurgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, P.R. China
| | - Wahafu Alafate
- Department of Neurosurgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, P.R. China
| | - Peixin Tan
- Department of Radiotherapy, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, P.R. China
| | - Ni Zhang
- Department of Rehabilitation Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, P.R. China
| | - Kai Tang
- Department of Neurosurgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, P.R. China.
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9
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Ius T, Sabatino G, Panciani PP, Fontanella MM, Rudà R, Castellano A, Barbagallo GMV, Belotti F, Boccaletti R, Catapano G, Costantino G, Della Puppa A, Di Meco F, Gagliardi F, Garbossa D, Germanò AF, Iacoangeli M, Mortini P, Olivi A, Pessina F, Pignotti F, Pinna G, Raco A, Sala F, Signorelli F, Sarubbo S, Skrap M, Spena G, Somma T, Sturiale C, Angileri FF, Esposito V. Surgical management of Glioma Grade 4: technical update from the neuro-oncology section of the Italian Society of Neurosurgery (SINch®): a systematic review. J Neurooncol 2023; 162:267-293. [PMID: 36961622 PMCID: PMC10167129 DOI: 10.1007/s11060-023-04274-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/20/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE The extent of resection (EOR) is an independent prognostic factor for overall survival (OS) in adult patients with Glioma Grade 4 (GG4). The aim of the neuro-oncology section of the Italian Society of Neurosurgery (SINch®) was to provide a general overview of the current trends and technical tools to reach this goal. METHODS A systematic review was performed. The results were divided and ordered, by an expert team of surgeons, to assess the Class of Evidence (CE) and Strength of Recommendation (SR) of perioperative drugs management, imaging, surgery, intraoperative imaging, estimation of EOR, surgery at tumor progression and surgery in elderly patients. RESULTS A total of 352 studies were identified, including 299 retrospective studies and 53 reviews/meta-analysis. The use of Dexamethasone and the avoidance of prophylaxis with anti-seizure medications reached a CE I and SR A. A preoperative imaging standard protocol was defined with CE II and SR B and usefulness of an early postoperative MRI, with CE II and SR B. The EOR was defined the strongest independent risk factor for both OS and tumor recurrence with CE II and SR B. For intraoperative imaging only the use of 5-ALA reached a CE II and SR B. The estimation of EOR was established to be fundamental in planning postoperative adjuvant treatments with CE II and SR B and the stereotactic image-guided brain biopsy to be the procedure of choice when an extensive surgical resection is not feasible (CE II and SR B). CONCLUSIONS A growing number of evidences evidence support the role of maximal safe resection as primary OS predictor in GG4 patients. The ongoing development of intraoperative techniques for a precise real-time identification of peritumoral functional pathways enables surgeons to maximize EOR minimizing the post-operative morbidity.
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Affiliation(s)
- Tamara Ius
- Division of Neurosurgery, Head-Neck and NeuroScience Department, University Hospital of Udine, Udine, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Pier Paolo Panciani
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
| | - Marco Maria Fontanella
- Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, 10094, Torino, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, 10094, Torino, Italy
- Neurology Unit, Hospital of Castelfranco Veneto, 31033, Castelfranco Veneto, Italy
| | - Antonella Castellano
- Department of Neuroradiology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giuseppe Maria Vincenzo Barbagallo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico - San Marco" University Hospital, University of Catania, Catania, Italy
- Interdisciplinary Research Center On Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Francesco Belotti
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Giuseppe Catapano
- Division of Neurosurgery, Department of Neurological Sciences, Ospedale del Mare, Naples, Italy
| | | | - Alessandro Della Puppa
- Neurosurgical Clinical Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi Hospital, University of Florence, Florence, Italy
| | - Francesco Di Meco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Johns Hopkins Medical School, Baltimore, MD, USA
| | - Filippo Gagliardi
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini," Neurosurgery Unit, University of Turin, Torino, Italy
| | | | - Maurizio Iacoangeli
- Department of Neurosurgery, Università Politecnica Delle Marche, Azienda Ospedali Riuniti, Ancona, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | | | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Milan, Italy
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Milan, Italy
| | - Fabrizio Pignotti
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giampietro Pinna
- Unit of Neurosurgery, Department of Neurosciences, Hospital Trust of Verona, 37134, Verona, Italy
| | - Antonino Raco
- Division of Neurosurgery, Department of NESMOS, AOU Sant'Andrea, Sapienza University, Rome, Italy
| | - Francesco Sala
- Department of Neurosciences, Biomedicines and Movement Sciences, Institute of Neurosurgery, University of Verona, 37134, Verona, Italy
| | - Francesco Signorelli
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, Neurosurgery Unit, University "Aldo Moro", 70124, Bari, Italy
| | - Silvio Sarubbo
- Department of Neurosurgery, Santa Chiara Hospital, Azienda Provinciale Per I Servizi Sanitari (APSS), Trento, Italy
| | - Miran Skrap
- Division of Neurosurgery, Head-Neck and NeuroScience Department, University Hospital of Udine, Udine, Italy
| | | | - Teresa Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | | | | | - Vincenzo Esposito
- Department of Neurosurgery "Giampaolo Cantore"-IRCSS Neuromed, Pozzilli, Italy
- Department of Human, Neurosciences-"Sapienza" University of Rome, Rome, Italy
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10
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Lehrer EJ, Kowalchuk RO, Ruiz-Garcia H, Merrell KW, Brown PD, Palmer JD, Burri SH, Sheehan JP, Quninoes-Hinojosa A, Trifiletti DM. Preoperative stereotactic radiosurgery in the management of brain metastases and gliomas. Front Surg 2022; 9:972727. [PMID: 36353610 PMCID: PMC9637863 DOI: 10.3389/fsurg.2022.972727] [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: 06/18/2022] [Accepted: 10/04/2022] [Indexed: 01/24/2023] Open
Abstract
Stereotactic radiosurgery (SRS) is the delivery of a high dose ionizing radiation in a highly conformal manner, which allows for significant sparing of nearby healthy tissues. It is typically delivered in 1-5 sessions and has demonstrated safety and efficacy across multiple intracranial neoplasms and functional disorders. In the setting of brain metastases, postoperative and definitive SRS has demonstrated favorable rates of tumor control and improved cognitive preservation compared to conventional whole brain radiation therapy. However, the risk of local failure and treatment-related complications (e.g. radiation necrosis) markedly increases with larger postoperative treatment volumes. Additionally, the risk of leptomeningeal disease is significantly higher in patients treated with postoperative SRS. In the setting of high grade glioma, preclinical reports have suggested that preoperative SRS may enhance anti-tumor immunity as compared to postoperative radiotherapy. In addition to potentially permitting smaller target volumes, tissue analysis may permit characterization of DNA repair pathways and tumor microenvironment changes in response to SRS, which may be used to further tailor therapy and identify novel therapeutic targets. Building on the work from preoperative SRS for brain metastases and preclinical work for high grade gliomas, further exploration of this treatment paradigm in the latter is warranted. Presently, there are prospective early phase clinical trials underway investigating the role of preoperative SRS in the management of high grade gliomas. In the forthcoming sections, we review the biologic rationale for preoperative SRS, as well as pertinent preclinical and clinical data, including ongoing and planned prospective clinical trials.
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Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Roman O. Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Kenneth W. Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Paul D. Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Joshua D. Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Stuart H. Burri
- Department of Radiation Oncology, Atrium Health, Charlotte, NC, United States
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | | | - Daniel M. Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States,Correspondence: Daniel M. Trifiletti
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11
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Dajani S, Hill VB, Kalapurakal JA, Horbinski CM, Nesbit EG, Sachdev S, Yalamanchili A, Thomas TO. Imaging of GBM in the Age of Molecular Markers and MRI Guided Adaptive Radiation Therapy. J Clin Med 2022; 11:jcm11195961. [PMID: 36233828 PMCID: PMC9572863 DOI: 10.3390/jcm11195961] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 12/03/2022] Open
Abstract
Glioblastoma (GBM) continues to be one of the most lethal malignancies and is almost always fatal. In this review article, the role of radiation therapy, systemic therapy, as well as the molecular basis of classifying GBM is described. Technological advances in the treatment of GBM are outlined as well as the diagnostic imaging characteristics of this tumor. In addition, factors that affect prognosis such as differentiating progression from treatment effect is discussed. The role of MRI guided radiation therapy and how this technology may provide a mechanism to improve the care of patients with this disease are described.
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12
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Surgical Treatment of Glioblastoma: State-of-the-Art and Future Trends. J Clin Med 2022; 11:jcm11185354. [PMID: 36143001 PMCID: PMC9505564 DOI: 10.3390/jcm11185354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/17/2022] [Accepted: 08/31/2022] [Indexed: 11/22/2022] Open
Abstract
Glioblastoma (GBM) is a highly aggressive disease and is associated with poor prognosis despite treatment advances in recent years. Surgical resection of tumor remains the main therapeutic option when approaching these patients, especially when combined with adjuvant radiochemotherapy. In the present study, we conducted a comprehensive literature review on the state-of-the-art and future trends of the surgical treatment of GBM, emphasizing topics that have been the object of recent study.
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13
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Advances in local therapy for glioblastoma - taking the fight to the tumour. Nat Rev Neurol 2022; 18:221-236. [PMID: 35277681 PMCID: PMC10359969 DOI: 10.1038/s41582-022-00621-0] [Citation(s) in RCA: 93] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2022] [Indexed: 12/21/2022]
Abstract
Despite advances in neurosurgery, chemotherapy and radiotherapy, glioblastoma remains one of the most treatment-resistant CNS malignancies, and the tumour inevitably recurs. The majority of recurrences appear in or near the resection cavity, usually within the area that received the highest dose of radiation. Many new therapies focus on combatting these local recurrences by implementing treatments directly in or near the tumour bed. In this Review, we discuss the latest developments in local therapy for glioblastoma, focusing on recent preclinical and clinical trials. The approaches that we discuss include novel intraoperative techniques, various treatments of the surgical cavity, stereotactic injections directly into the tumour, and new developments in convection-enhanced delivery and intra-arterial treatments.
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14
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Hamed M, Potthoff AL, Layer JP, Koch D, Borger V, Heimann M, Scafa D, Sarria GR, Holz JA, Schmeel FC, Radbruch A, Güresir E, Schäfer N, Schuss P, Garbe S, Giordano FA, Herrlinger U, Vatter H, Schmeel LC, Schneider M. Benchmarking Safety Indicators of Surgical Treatment of Brain Metastases Combined with Intraoperative Radiotherapy: Results of Prospective Observational Study with Comparative Matched-Pair Analysis. Cancers (Basel) 2022; 14:cancers14061515. [PMID: 35326666 PMCID: PMC8946541 DOI: 10.3390/cancers14061515] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/05/2022] [Accepted: 03/08/2022] [Indexed: 12/07/2022] Open
Abstract
Simple Summary Patients with brain metastasis (BM) are at advanced stages of metastatic cancer, and surgical resection is often required in order to avoid severe neurologic deficits. After surgery, patients are usually committed to postoperative radiotherapy. In recent years, intraoperative radiotherapy (IORT) has been proposed as an alternative to conventional postsurgical radiation approaches. This possibility has several advantages, e.g., as IORT is administered only once during the surgical procedure, patients do not have to attend several radiotherapy sessions afterward. However, the application of radiation therapy directly into the open brain during surgery might be accompanied by severe perioperative complications and, therefore, might negatively impact the overall benefit. In the present study, we show that patients who underwent surgery for BM combined with IORT do not suffer from elevated levels of perioperative complications compared to patients without IORT. Therefore, IORT constitutes a safe treatment strategy for cancer patients with BM. Abstract Intraoperative radiotherapy (IORT) of the operative cavity for surgically treated brain metastasis (BM) has gained increasing prominence with respect to improved local tumor control. However, IORT immediately performed at the time of surgery might be associated with increased levels of perioperative adverse events (PAEs). In the present study, we performed safety metric profiling in patients who had undergone surgery for BM with and without IORT in order to comparatively analyze feasibility of IORT as an adjuvant radiation approach. Between November 2020 and October 2021, 35 patients were surgically treated for BM with IORT at our neuro-oncological center. Perioperative complication profiles were collected in a prospective observational cohort study by means of patient safety indicators (PSIs), hospital-acquired conditions (HACs), and specific cranial-surgery-related complications (CSCs) as high-standard quality metric tools and compared to those of an institutional cohort of 388 patients with BM resection without IORT in a balanced comparative matched-pair analysis. Overall, 4 out of 35 patients (11%) with IORT in the course BM resection suffered from PAEs, accounting for 3 PSIs (9%) and 1 HAC (3%). Balanced matched-pair analysis did not reveal significant differences in the perioperative complication profiles between the cohorts of patients with and without IORT (p = 0.44). Thirty-day mortality rates were 6% for patients with IORT versus 8% for patients without IORT (p = 0.73). The present study demonstrates that IORT constitutes a safe and clinically feasible adjuvant treatment modality in patients undergoing surgical resection of BM.
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Affiliation(s)
- Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
| | - Anna-Laura Potthoff
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
- Correspondence: (A.-L.P.); (M.S.)
| | - Julian P. Layer
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | - David Koch
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
| | - Muriel Heimann
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
| | - Davide Scafa
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | - Gustavo R. Sarria
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | - Jasmin A. Holz
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | | | - Alexander Radbruch
- Department of Neuroradiology, University Hospital Bonn, 53127 Bonn, Germany; (F.C.S.); (A.R.)
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
| | - Niklas Schäfer
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany; (N.S.); (U.H.)
| | - Patrick Schuss
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
- Department of Neurosurgery, BG Klinikum Unfallkrankenhaus Berlin, 12683 Berlin, Germany
| | - Stephan Garbe
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | - Frank A. Giordano
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | - Ulrich Herrlinger
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany; (N.S.); (U.H.)
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
| | - Leonard Christopher Schmeel
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
- Correspondence: (A.-L.P.); (M.S.)
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15
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Waqar M, Trifiletti DM, McBain C, O'Connor J, Coope DJ, Akkari L, Quinones-Hinojosa A, Borst GR. Early Therapeutic Interventions for Newly Diagnosed Glioblastoma: Rationale and Review of the Literature. Curr Oncol Rep 2022; 24:311-324. [PMID: 35119629 PMCID: PMC8885508 DOI: 10.1007/s11912-021-01157-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Glioblastoma is the commonest primary brain cancer in adults whose outcomes are amongst the worst of any cancer. The current treatment pathway comprises surgery and postoperative chemoradiotherapy though unresectable diffusely infiltrative tumour cells remain untreated for several weeks post-diagnosis. Intratumoural heterogeneity combined with increased hypoxia in the postoperative tumour microenvironment potentially decreases the efficacy of adjuvant interventions and fails to prevent early postoperative regrowth, called rapid early progression (REP). In this review, we discuss the clinical implications and biological foundations of post-surgery REP. Subsequently, clinical interventions potentially targeting this phenomenon are reviewed systematically. RECENT FINDINGS Early interventions include early systemic chemotherapy, neoadjuvant immunotherapy, local therapies delivered during surgery (including Gliadel wafers, nanoparticles and stem cell therapy) and several radiotherapy techniques. We critically appraise and compare these strategies in terms of their efficacy, toxicity, challenges and potential to prolong survival. Finally, we discuss the most promising strategies that could benefit future glioblastoma patients. There is biological rationale to suggest that early interventions could improve the outcome of glioblastoma patients and they should be investigated in future trials.
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Affiliation(s)
- Mueez Waqar
- Department of Academic Neurological Surgery, Geoffrey Jefferson Brain Research Centre, Salford Royal Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health and Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Mayo 1N, Jacksonville, FL, 32224, USA
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Catherine McBain
- Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Dept 58, Floor 2a, Room 21-2-13, Wilmslow Road, Manchester, M20 4BX, UK
| | - James O'Connor
- Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Dept 58, Floor 2a, Room 21-2-13, Wilmslow Road, Manchester, M20 4BX, UK
| | - David J Coope
- Department of Academic Neurological Surgery, Geoffrey Jefferson Brain Research Centre, Salford Royal Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health and Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| | - Leila Akkari
- Division of Tumour Biology and Immunology, The Netherlands Cancer Institute, Oncode Institute, Amsterdam, The Netherlands
| | - Alfredo Quinones-Hinojosa
- Department of Radiation Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Mayo 1N, Jacksonville, FL, 32224, USA
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Gerben R Borst
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health and Manchester Cancer Research Centre, University of Manchester, Manchester, UK.
- Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Dept 58, Floor 2a, Room 21-2-13, Wilmslow Road, Manchester, M20 4BX, UK.
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16
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Cifarelli CP, Jacobson GM. Intraoperative Radiotherapy in Brain Malignancies: Indications and Outcomes in Primary and Metastatic Brain Tumors. Front Oncol 2021; 11:768168. [PMID: 34858846 PMCID: PMC8631760 DOI: 10.3389/fonc.2021.768168] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/14/2021] [Indexed: 12/22/2022] Open
Abstract
Despite the continued controversy over defining an optimal delivery mechanism, the critical role of adjuvant radiation in the management of surgically resected primary and metastatic brain tumors remains one of the universally accepted standards in neuro-oncology. Local disease control still ranks as a significant predictor of survival in both high-grade glioma and treated intracranial metastases with radiation treatment being essential in maximizing tumor control. As with the emergence and eventual acceptance of cranial stereotactic radiosurgery (SRS) following an era dominated by traditional radiotherapy, evidence to support the use of intraoperative radiotherapy (IORT) in brain tumors requiring surgical intervention continues to accumulate. While the clinical trial strategies in treating glioblastoma with IORT involve delivery of a boost of cavitary radiation prior to the planned standard external beam radiation, the use of IORT in metastatic disease offers the potential for dose escalation to the level needed for definitive adjuvant radiation, eliminating the need for additional episodes of care while providing local control equal or superior to that achieved with SRS in a single fraction. In this review, we explore the contemporary clinical data on IORT in the treatment of brain tumors along with a discussion of the unique dosimetric and radiobiological factors inherent in IORT that could account for favorable outcome data beyond those seen in other techniques.
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Affiliation(s)
- Christopher P Cifarelli
- Department of Neurosurgery, West Virginia University, Morgantown, WV, United States.,Department of Radiation Oncology, West Virginia University, Morgantown, WV, United States
| | - Geraldine M Jacobson
- Department of Radiation Oncology, West Virginia University, Morgantown, WV, United States
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17
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Sarria GR, Smalec Z, Muedder T, Holz JA, Scafa D, Koch D, Garbe S, Schneider M, Hamed M, Vatter H, Herrlinger U, Giordano FA, Schmeel LC. Dosimetric Comparison of Upfront Boosting With Stereotactic Radiosurgery Versus Intraoperative Radiotherapy for Glioblastoma. Front Oncol 2021; 11:759873. [PMID: 34778080 PMCID: PMC8581360 DOI: 10.3389/fonc.2021.759873] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/13/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose To simulate and analyze the dosimetric differences of intraoperative radiotherapy (IORT) or pre-operative single-fraction stereotactic radiosurgery (SRS) in addition to post-operative external beam radiotherapy (EBRT) in Glioblastoma (GB). Methods Imaging series of previously treated patients with adjuvant radiochemotherapy were analyzed. For SRS target definition, pre-operative MRIs were co-registered to planning CT scans and a pre-operative T1-weighted gross target volume (GTV) plus a 2-mm planning target volume (PTV) were created. For IORT, a modified (m)GTV was expanded from the pre-operative volume, in order to mimic a round cavity as during IORT. Dose prescription was 20 Gy, homogeneously planned for SRS and calculated at the surface for IORT, to cover 99% and 90% of the volumes, respectively. For tumors > 2cm in maximum diameter, a 15 Gy dose was prescribed. Plan assessment was performed after calculating the 2-Gy equivalent doses (EQD2) for both boost modalities and including them into the EBRT plan. Main points of interest encompass differences in target coverage, brain volume receiving 12 Gy or more (V12), and doses to various organs-at-risk (OARs). Results Seventeen pre-delivered treatment plans were included in the study. The mean GTV was 21.72 cm3 (SD ± 19.36) and mGTV 29.64 cm3 (SD ± 25.64). The mean EBRT and SRS PTV were 254.09 (SD ± 80.0) and 36.20 cm3 (SD ± 31.48), respectively. Eight SRS plans were calculated to 15 Gy according to larger tumor sizes, while all IORT plans to 20 Gy. The mean EBRT D95 was 97.13% (SD ± 3.48) the SRS D99 99.91% (SD ± 0.35) and IORT D90 83.59% (SD ± 3.55). Accounting for only-boost approaches, the brain V12 was 49.68 cm3 (SD ± 26.70) and 16.94 cm3 (SD ± 13.33) (p<0.001) for SRS and IORT, respectively. After adding EBRT results respectively to SRS and IORT doses, significant lower doses were found in the latter for mean Dmax of chiasma (p=0.01), left optic nerve (p=0.023), right (p=0.008) and left retina (p<0.001). No significant differences were obtained for brainstem and cochleae. Conclusion Dose escalation for Glioblastoma using IORT results in lower OAR exposure as conventional SRS.
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Affiliation(s)
- Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Zuzanna Smalec
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Thomas Muedder
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Jasmin A Holz
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Davide Scafa
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - David Koch
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Stephan Garbe
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | | | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Ulrich Herrlinger
- Department of Neurology, Division of Neuro-Oncology, University Hospital Bonn, Bonn, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
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18
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Intraoperative radiotherapy for glioblastoma: A systematic review of techniques and outcomes. J Clin Neurosci 2021; 93:36-41. [PMID: 34656258 DOI: 10.1016/j.jocn.2021.08.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/12/2021] [Accepted: 08/21/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Despite multimodality treatment, the prognosis of glioblastoma (GBM) has remained poor. Intraoperative radiation therapy (IORT) offers additional local control by directly applying a radiation source to the resection margin, where most recurrences occur. METHODS We performed a systematic review on the oncologic outcomes and toxicities of IORT for GBM in the era of modern external beam radiation therapy (EBRT) and chemotherapy with temozolamide. RESULTS Four studies representing 123 patients were included. Majority (81%) were newly diagnosed, and gross total resection was reported in 13-80% of cases. IORT modalities included electrons from a linear accelerator (LINAC) and photons from a 50-kV x-ray device. Median doses were from 12.5 to 20 Gy for electron-based studies and 10-25 Gy for photon-based studies. Adjuvant treatment consisted of 46-60 Gy post-operative EBRT in electron-based studies and the Stupp protocol in photon-based studies. Complications included radiation necrosis (2.8-33%), infection, hematoma, perilesional edema, and wound dehiscence. Median time to local recurrence was 9.9-16 months and the reported overall progression-free survival was 11.2-12.2 months. Median overall survival was 13-14.2 months for the electron-based studies and 13.8-18 months for the photon-based studies. CONCLUSION IORT resulted in improved local control and comparable overall survival rates with the Stupp protocol. Although photon-based IORT had better results than electron IORT, this may be due to improvements in other forms of adjuvant treatment rather than the IORT modality itself. The overall effect of IORT on GBM treatment is still inconclusive due to the small number of patients and heterogeneous reporting of data.
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19
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Cifarelli CP, Jacques A, Bobko A. Heterogeneity of radiation response in mesenchymal subtype glioblastoma: molecular profiling and reactive oxygen species generation. J Neurooncol 2021; 152:245-255. [PMID: 33566263 DOI: 10.1007/s11060-021-03707-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Radiotherapy-induced tumor death remains critical in the successful first-line management of glioblastoma, whereas resistance to radiation serves as a major factor in disease progression. Mesenchymal shift has been identified as a driver in GBM recurrence, with gene expression associated with enhanced repair of macromolecular damage caused by radiation. METHODS Using distinct mesenchymal subtype GBM cells lines, radiation response was assessed by clonogenic assay and orthotopic mouse tumor model. RNA-sequencing was performed in the setting of increasing radiation dosing while real-time assessment of ROS generation was achieved by the measurement of hydroxyl spin trap adducts via electron paramagnetic resonance. RESULTS Radiation-induced cell death determined by clonogenic assay was significantly different at low dose (4-8 Gy) between the resistant U3035 cells and the sensitive U3020 cells. Similar trends were present in the in vivo NSG mouse model following radiation dosing on post-implantation day 7-10, with the rate of reduction in tumor bioluminescence reversing between the U3020 and U3035 cells after the third dose of radiation. Changes in gene expression following radiation determined by RNA-sequencing indicate both U3035 and U3020 cells demonstrate a shift toward more mesenchymal profiles, with concurrent shift away from pro-neural subtype gene expression in the U3020 cells that appeared to develop resistance to radiation in vivo. Persistence of ROS generated following radiation was greater in U3020 cells shown to be more sensitive to radiation. CONCLUSIONS Despite the same molecular classification, distinct GBM cell lines can demonstrate differential response to radiation and potential for mesenchymal shift associated with radiation resistance.
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Affiliation(s)
- Christopher P Cifarelli
- Department of Neurosurgery, West Virginia University, 1 Medical Center Drive, Suite 4300, Morgantown, WV, 26506-9183, USA. .,Department of Radiation Oncology, West Virginia University, Morgantown, WV, USA.
| | - Angelica Jacques
- Department of Neurosurgery, West Virginia University, 1 Medical Center Drive, Suite 4300, Morgantown, WV, 26506-9183, USA
| | - Andrey Bobko
- Department of Biochemistry, West Virginia University, Morgantown, WV, USA
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