The Safety of Bevacizumab Administered Shortly after Laser Interstitial Thermal Therapy in Glioblastoma: A Case Series

Recent advances in laser interstitial thermal therapy in the treatment of brain metastases and radiation necrosis

PURPOSE

This manuscript reviews advancements in Laser Interstitial Thermal Therapy (LITT) for treating brain metastases and radiation necrosis, emphasizing its minimally invasive nature and precision in targeting deep-seated or eloquent area lesions. It analyzes studies from 2011 to 2024 to evaluate LITT's efficacy, safety, and complications while highlighting the need for standardized clinical endpoints. Despite its potential, LITT remains a secondary treatment due to limited high-level evidence, requiring further research and multidisciplinary collaboration.

METHODS

A systematic PubMed search identified 2,004 articles on LITT for brain metastases and radiation necrosis. Filtering for studies from 2011 to 2024 resulted in 60 selected articles: 4 clinical trials, 22 observational studies, 3 case reports, 2 case series, and the rest review articles. Relevant data were extracted, analyzed, and compiled for this review.

RESULTS

LITT is primarily used for lesions unsuitable for open craniotomy, such as deep-seated or eloquent-area tumors. Literature supports its increasing neuro-oncological applications, particularly in brain metastases, gliomas, meningiomas, and radiation necrosis.

CONCLUSION

The evolving landscape of brain metastasis treatment underscores the importance of a multidisciplinary approach incorporating standardized reporting, advanced imaging, and molecular diagnostics. Further innovation and collaboration are needed to optimize LITT's role in neuro-oncology and address treatment challenges in the era of personalized medicine.

The LITT Fit in neuro-oncology: indications, imaging, and adjunctive therapies

PURPOSE

There is an unmet need for new treatments for many central nervous system tumors. An expanding body of research supports the use of laser interstitial thermal therapy (LITT) in the treatment of gliomas, recurrent brain metastases, and radiation necrosis.

METHODS

In this review, we highlight emerging indications for LITT, including its use adjacent to eloquent structures, in the posterior fossa, and for meningioma and tumors of the vertebral column. We conclude by providing an overview of current research into post-LITT response assessment and adjunctive therapies.

RESULTS

Evidence has continued to accumulate regarding the safety of LITT in locations as varied as the motor cortex, posterior fossa, and vertebral column, as well as for novel pathologies such as meningioma. Regardless of disease histology, most patients leave the hospital within 12-48 h of LITT and can rapidly return to systemic and radiation therapies. Emerging data has allowed for a characterization of post-LITT imaging findings, and receipt of LITT should not preclude subsequent clinical trial enrollment, especially as hyperthermia modulates blood-brain barrier permeability and may synergize with immunotherapies.

CONCLUSION

As LITT is incorporated into neurosurgical oncology practice, novel use cases will continue to emerge. Given that laser ablation is associated with shortened length of stay and decreased debility relative to open resection, development of radiographic response assessment criteria for LITT-treated lesions is urgently needed so that patients may more rapidly receive definitive management or proceed to clinical trial enrollment. Prospective evaluation of LITT and adjunctive combination therapies is ongoing.

Device-assisted strategies for drug delivery across the blood-brain barrier to treat glioblastoma

The blood-brain barrier, essential for protecting the central nervous system, also restricts drug delivery to this region. Thus, delivering drugs across the blood-brain barrier is an active research area in immunology, oncology, and neurology; moreover, novel methods are urgently needed to expand therapeutic options for central nervous system pathologies. While previous strategies have focused on small molecules that modulate blood-brain barrier permeability or penetrate the barrier, there is an increased focus on biomedical devices-external or implanted-for improving drug delivery. Here, we review device-assisted drug delivery across the blood-brain barrier, emphasizing its application in glioblastoma, an aggressively malignant primary brain cancer in which the blood-brain barrier plays a central role. We examine the blood-brain barrier and its features in glioblastoma, emerging models for studying the blood-brain barrier, and device-assisted methods for crossing the blood-brain barrier. We conclude by presenting methods to monitor the blood-brain barrier and paradigms for combined cross-BBB drug delivery.

Consensus review on strategies to improve delivery across the blood-brain barrier including focused ultrasound

Drug delivery to the central nervous system (CNS) has been a major challenge for CNS tumors due to the impermeability of the blood-brain barrier (BBB). There has been a multitude of techniques aimed at overcoming the BBB obstacle aimed at utilizing natural transport mechanisms or bypassing the BBB which we review here. Another approach that has generated recent interest in the recently published literature is to use new technologies (Laser Interstitial Thermal Therapy, LITT; or Low-Intensity Focused Ultrasound, LIFU) to temporarily increase BBB permeability. This review overviews the advantages, disadvantages, and major advances of each method. LIFU has been a major area of research to allow for chemotherapeutics to cross the BBB which has a particular emphasis in this review. While most of the advances remain in animal studies, there are an increasing number of translational clinical trials that will have results in the next few years.

Safety and Efficacy of Laser Interstitial Thermal Therapy as Upfront Therapy in Primary Glioblastoma and IDH-Mutant Astrocytoma: A Meta-Analysis

Although primary studies have reported the safety and efficacy of LITT as a primary treatment in glioma, they are limited by sample sizes and institutional variation in stereotactic parameters such as temperature and laser power. The current literature has yet to provide pooled statistics on outcomes solely for primary brain tumors according to the 2021 WHO Classification of Tumors of the Central Nervous System (WHO CNS5). In the present study, we identify recent articles on primary CNS neoplasms treated with LITT without prior intervention, focusing on relationships with molecular profile, PFS, and OS. This meta-analysis includes the extraction of data from primary sources across four databases using the Covidence systematic review manager. The pooled data suggest LITT may be a safe primary management option with tumor ablation rates of 94.8% and 84.6% in IDH-wildtype glioblastoma multiforme (GBM) and IDH-mutant astrocytoma, respectively. For IDH-wildtype GBM, the pooled PFS and OS were 5.0 and 9.0 months, respectively. Similar to rates reported in the prior literature, the neurologic and non-neurologic complication rates for IDH-wildtype GBM were 10.3% and 4.8%, respectively. The neurologic and non-neurologic complication rates were somewhat higher in the IDH-mutant astrocytoma cohort at 33% and 8.3%, likely due to a smaller cohort size.

Laser interstitial thermal therapy for recurrent glioblastomas: a systematic review and meta-analysis

We aim to investigate the efficacy and safety of laser interstitial thermal therapy (LITT) in treating recurrent glioblastomas (rGBMs). A comprehensive search was conducted in four databases to identify studies published between January 2001 and June 2022 that reported prognosis information of rGBM patients treated with LITT as the primary therapy. The primary outcomes of interest were progression-free survival (PFS) and overall survival (OS) at 6 and 12 months after LITT intervention. Adverse events and complications were also evaluated. Eight eligible non-comparative studies comprising 128 patients were included in the analysis. Seven studies involving 120 patients provided data for the analysis of PFS. The pooled PFS rate at 6 months after LITT was 25% (95% CI 15-37%, I2 = 53%), and at 12 months, it was 9% (95% CI 4-15%, I2 = 24%). OS analysis was performed on 54 patients from six studies, with an OS rate of 92% (95% CI 84-100%, I2 = 0%) at 6 months and 42% (95% CI 13-73%, I2 = 67%) at 12 months after LITT. LITT demonstrates a favorable safety profile with low complication rates and promising tumor control and overall survival rates in patients with rGBMs. Tumor volume and performance status are important factors that may influence the effectiveness of LITT in selected patients. Additionally, the combination of LITT with immune-based therapy holds promise. Further well-designed clinical trials are needed to expand the application of LITT in glioma treatment.

Blood-Brain Barrier Disruption for the Treatment of Primary Brain Tumors: Advances in the Past Half-Decade

PURPOSE OF REVIEW

To review relevant advances in the past half-decade in the treatment of primary brain tumors via modification of blood-brain barrier (BBB) permeability.

RECENT FINDINGS

BBB disruption is becoming increasingly common in the treatment of primary brain tumors. Use of mannitol in BBB disruption for targeted delivery of chemotherapeutics via superselective intra-arterial cerebral infusion (SIACI) is the most utilized strategy to modify the BBB. Mannitol is used in conjunction with chemotherapeutics, oligonucleotides, and other active agents. Convection-enhanced delivery has become an attractive option for therapeutic delivery while bypassing the BBB. Other technologic innovations include laser interstitial thermal therapy (LITT) and focused ultrasound (FUS) which have emerged as prime modalities to directly target tumors and cause significant local BBB disruption. In the past 5 years, interest has significantly increased in studying modalities to disrupt the BBB in primary brain tumors to enhance treatment responses and improve clinical outcomes.

Meta-analysis of the impact of laser interstitial hyperthermia on wound healing complications in brain tumors

High-grade gliomas (HGGs) may be amenable to the neurosurgical technique known as laser interstitial thermal therapy (LITT), which delivers thermal energy to interstitial brain injuries and wounds with pinpoint accuracy. The purpose of this extensive meta-analysis was to evaluate the effects of LITT on wound complications among patients who have brain tumours. Diverse conclusions emerge from a systematic review of pertinent studies, necessitating a comprehensive examination. The meta-analysis, performed utilizing the meta library provided by the R package meta, reveals an initial significant overall effect (RR: -2.1262, 95% CI [-2.7466, -1.5059], p < 0.0001) accompanied by considerable heterogeneity among studies (I2  = 61.13%). Following analyses that specifically examined the incidence of wounds, a complex correlation was found (RR: 0.0471, 95% CI [0.0264, 0.0842], p < 0.0001), indicating that LITT has a discernible but insignificant effect on the occurrence of wounds. Although the meta-analysis emphasizes a notable decrease in wound complications subsequent to LITT treatment, additional research is warranted due to constraints in standardized reporting, data accessibility, and small sample sizes. The results of this study underscore the need for exhaustive protocols to analyse wound complications in patients with brain tumours undergoing LITT.

Laser Interstitial Thermal Therapy for the Treatment of Primary and Metastatic Brain Tumors: A Systematic Review and Meta-Analysis

BACKGROUND

Laser interstitial thermal therapy (LITT) is a minimally invasive treatment option for intracranial tumors that are challenging to treat via traditional methods; however, its safety and efficacy are not yet well validated in the literature. The objectives of the study were to assess the available evidence of the indications and adverse events (AEs) of LITT and 1-year progression-free survival and 1-year overall survival in the treatment of primary and secondary brain tumors.

METHODS

A comprehensive literature search was conducted through the databases PubMed, Embase, and the Cochrane Library until October 2021. Comparative and descriptive studies, except for case reports, were included in the meta-analysis. Separate analyses by tumor type (high-grade gliomas, including World Health Organization grade 4 astrocytomas [which include glioblastomas] as a specific subgroup; low-grade gliomas; and brain metastases) were conducted. Pooled effect sizes and their 95% confidence intervals (CI) were generated via random-effects models.

RESULTS

Forty-five studies met the inclusion criteria, yielding 826 patients for meta-analysis. There were 829 lesions in total, of which 361 were classified as high-grade gliomas, 116 as low-grade gliomas, 337 as metastatic brain tumors, and 15 as nonglial tumors. Indications for offering LITT included deep/inaccessible tumor (12 studies), salvage therapy after failed radiosurgery (9), failures of ≥2 treatment options (3), in pediatric patients (4), patient preference (1); indications were nonspecific in 12 studies. Pooled incidence of all (minor or major) procedure-related AEs was 30% (95% CI, 27%-40%) for all tumors. Pooled incidence of neurologic deficits (minor or major) was 16% (12%-22%); postprocedural edema 14% (8%-22%); seizure 6% (4%-9%); hematoma 20% (14%-29%); deep vein thrombosis 19% (11%-30%); hydrocephalus 8% (5%-12%); and wound infection 5% (3%-7%). One-year progression-free survival was 18.6% (11.3%-29.0%) in high-grade gliomas, 16.9% (11.6%-24.0%) among the grade 4 astrocytomas; and 51.2% (36.7%-65.5%) in brain metastases. One-year overall survival was 43.0% (36.0%-50.0%) in high-grade glioma, 45.9% (95% CI, 37.9%-54%) in grade 4 astrocytomas; 93.0% (42.3%-100%) in low-grade gliomas, and 56.3% (47.0%-65.3%) in brain metastases.

CONCLUSIONS

New neurologic deficits and postprocedural edema were the most reported AEs after LITT, albeit mostly transient. This meta-analysis provides the best statistical estimates of progression and survival outcomes based on the available information. LITT is generally a safe procedure for selected patients, and future well-designed comparative studies on its outcomes versus the current standard of care should be performed.

Laser Interstitial Thermal Therapy for Recurrent Glioblastoma: Pooled Analyses of Available Literature

OBJECTIVE/BACKGROUND

The efficacy of laser interstitial thermal therapy (LITT) in recurrent glioblastoma (rGBM) is unknown. The goal of this study was to conduct a systematic review and pooled analysis of the literature for outcomes on patients with rGBM undergoing LITT.

METHODS

A literature search was performed to retrieve all studies investigating overall survival, postprocedure survival, and progression-free survival outcomes of patients with rGBM undergoing LITT. Statistics were pooled together by meta-analysis of mean using a weighted random-effects or fixed-effect model.

RESULTS

Eleven studies were included in the final cohort, representing a total of 134 patients with rGBM. The pooled mean age of the cohort at the time of recurrence was 56.7 ± 4.56 years; 41% of the cohort were female. For delivery of LITT, 2 studies used neodymium-yttrium aluminum-garnet laser (Nd:YAG laser), 3 studies used the Visualase system, 5 studies used the NeuroBlate system, and 1 study used both the NeuroBlate and the Visualase system. A total of 8 studies with 107 patients had available data for overall median survival. The pooled overall survival was found to be 18.6 months (95% confidence interval [CI] 16.2-21.1). A total of 6 studies with 93 patients had available data for post-LITT survival. The pooled post-LITT survival was found to be 10.1 months (95% CI 8.8-11.6). A total of 8 studies with 119 patients had available data for progression-free survival. Pooled progression free survival was found to be 6 months (95% CI 5.3-6.7).

CONCLUSIONS

LITT is a novel minimally invasive procedure which, when used with optimal adjuvant therapy, may confer survival benefit for patients with rGBM.

Laser Interstitial Thermal Therapy Case Series: Choosing the Correct Number of Fibers Depending on Lesion Size

BACKGROUND

Laser interstitial thermal therapy (LITT) is being used for the treatment of recurrent glioblastoma multiforme (GBM). Lesions can be treated using 1 or multiple LITT fibers depending on the preference of surgeons. Usually, more fibers are needed for coverage of larger tumors.

OBJECTIVE

To investigate and analyze how tumor size affected the number of LITT fibers used.

METHODS

This is a retrospective review of patients undergoing treatment of recurrent GBM. Patients were treated with up to 4 LITT fibers for adequate tumor coverage. Patient demographics, tumor characteristics, length of stay, complications, and biopsy results were recorded.

RESULTS

A total of 43 cases were treated using LITT, and of these cases, 31 consisted of contiguous lesions. We used more fibers to treat larger tumor volumes. On average, for each 5 cc of tumor volume, a fiber was added for proper coverage (P = .554). Complications and length of stay were similar across the groups (P = .378, P = .941).

CONCLUSION

LITT can be used for the treatment of recurrent GBM. For each 5 cc of tumor volume, a LITT fiber can be added to the treatment plan.

In situ vaccination with laser interstitial thermal therapy augments immunotherapy in malignant gliomas

INTRODUCTION

Laser interstitial thermal therapy (LITT) remains a promising advance in the treatment of primary central nervous system malignancies. As indications for its use continue to expand, there has been growing interest in its ability to induce prolonged blood brain barrier (BBB) permeability through hyperthermia, potentially increasing the effectiveness of current therapeutics including BBB-impermeant agents and immunotherapy platforms.

METHODS

In this review, we highlight the mechanism of hyperthermic BBB disruption and LITT-induced immunogenic cell death in preclinical models and humans. Additionally, we summarize ongoing clinical trials evaluating a combination approach of LITT and immunotherapy, which will likely serve as the basis for future neuro-oncologic treatment paradigms.

RESULTS

There is evidence to suggest a highly immunogenic response to laser interstitial thermal therapy through activation of both the innate and adaptive immune response. These mechanisms have been shown to potentiate standard methods of oncologic care. There are only a limited number of clinical trials are ongoing to evaluate the utility of LITT in combination with immunotherapy.

CONCLUSION

LITT continues to be studied as a possible technique to bridge the gap between exciting preclinical results and the limited successes seen in the field of neuro-oncology. Preliminary data suggests a substantial benefit for use of LITT as a combination therapy in several clinical trials. Further investigation is required to determine whether or not this treatment paradigm can translate into long-term durable results for primary intracranial malignancies.

Laser Interstitial Thermal Therapy for Metastatic Melanoma After Failed Radiation Therapy: A Case Series

BACKGROUND

Laser interstitial thermal therapy (LITT) is a growing technology to treat a variety of brain lesions. It offers an alternative to treatment options, such as open craniotomy and stereotactic radiosurgery.

OBJECTIVE

To analyze our experience using LITT for metastatic melanoma.

METHODS

This is a retrospective chart review of the patients from our institution. Our case series involves 5 patients who had previously failed radiation treatment.

RESULTS

Our patients have low complication rates and short hospital stays. Both are considerably lower when compared to the literature for metastatic melanoma.

CONCLUSION

LITT is a safe therapy, with few complications and short hospital stays.

Survival outcomes in patients with recurrent glioblastoma treated with Laser Interstitial Thermal Therapy (LITT): A systematic review

OBJECTIVE

To study the role of laser interstitial thermal therapy in recurrent glioblastoma and to assess its effect in the overall survival and in progression-free survival.

METHODS

A MEDLINE and Pubmed search was performed for the key words "laser interstitial thermal therapy", "LITT" and "glioblastoma". Studies investigating overall survival and progression-free survival of recurrent glioblastoma after laser interstitial thermal therapy were selected.

RESULTS

A total of 17 studies met the selection criteria, accounting for 203 patients with recurrent glioblastoma who underwent 219 laser interstitial thermal therapy treatments. The median age was 57.4 years and there was male predominance (65.8 % male Vs 34.2 % female). The most common location resulted frontal lobe (29 %), followed by temporal (23.9 %), parietal (21.4 %) and occipital lobes (2.6 %). Additional locations included thalamus, corpus callosum and cerebellum (23.1 %). Pre-treatment median tumor size was 8.9 cm3. Morbidity was 6.4 % with a median hospital stay of 3.5 days. The most common complications were seizures (2%), motor deficits (1.5 %), wound infection (1.5 %), transient hemiparesis (1%) and hemorrhage (0.5 %). No deaths were reported due to LITT procedure. The median progression-free survival and the median overall survival after laser interstitial thermal therapy resulted 5.6 months and 10.2 months, respectively. The median overall survival from diagnosis was 14.7 months. All patients underwent adjuvant chemotherapy after treatment.

CONCLUSION

Laser interstitial thermal therapy provides an effective treatment with low morbidity for selected patients harboring recurrent glioblastoma. Laser interstitial thermal therapy should be included in the armamentarium of neurosurgical oncologist for treatment of recurrent glioblastomas.

Hyperthermia treatment advances for brain tumors

Hyperthermia therapy (HT) of cancer is a well-known treatment approach. With the advent of new technologies, HT approaches are now important for the treatment of brain tumors. We review current clinical applications of HT in neuro-oncology and ongoing preclinical research aiming to advance HT approaches to clinical practice. Laser interstitial thermal therapy (LITT) is currently the most widely utilized thermal ablation approach in clinical practice mainly for the treatment of recurrent or deep-seated tumors in the brain. Magnetic hyperthermia therapy (MHT), which relies on the use of magnetic nanoparticles (MNPs) and alternating magnetic fields (AMFs), is a new quite promising HT treatment approach for brain tumors. Initial MHT clinical studies in combination with fractionated radiation therapy (RT) in patients have been completed in Europe with encouraging results. Another combination treatment with HT that warrants further investigation is immunotherapy. HT approaches for brain tumors will continue to a play an important role in neuro-oncology.

Laser interstitial thermal therapy in gliomas

Laser interstitial thermal therapy (LITT) has been used for brain metastasis, epilepsy, and necrosis, as well as gliomas as a minimally invasive treatment for many years. With the improvement of the thermal monitoring and ablation precision, especially the application of magnetic resonance (MR) thermography in the procedure and the available two commercial laser systems nowadays, LITT is gradually accepted by more neurosurgical centers. Recently, some new concepts, for example the adjuvant chemotherapy or radiation following LITT, the combination of immunotherapy and LITT regarding the glioma treatment are proposed and currently being investigated. The aim of this study is to summarize the evolution of LITT especially for brain gliomas and a possible outlook of the future.

Laser interstitial thermal therapy

Background

Laser interstitial thermal therapy (LITT) is becoming an increasingly popular technique for the treatment of brain lesions. More minimally invasive that open craniotomy for lesion resection, LITT may be more appropriate for lesions that are harder to access through an open approach, deeper lesions, and for patients who may not tolerate open surgery.

Methods

A search of the current primary literature on LITT for brain lesions on PubMed was performed. These studies were reviewed and updates on the radiological, pathological, and long-term outcomes after LITT for brain metastases, primary brain tumors, and radiation necrosis as well as common complications are included.

Results

Larger extent of ablation and LITT as frontline treatment were potential predictors of favorable progression-free and overall survival for primary brain tumors. In brain metastases, larger extent of ablation was more significantly associated with survival benefit, whereas tumor size was a possible predictor. The most common complications after LITT are transient and permanent weakness, cerebral edema, hemorrhage, seizures, and hyponatremia.

Conclusions

Although the current literature is limited by small sample sizes and primarily retrospective studies, LITT is a safe and effective treatment for brain lesions in the correct patient population.