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Hoggarth AR, Muthukumar S, Thomas SM, Crowley J, Kiser J, Witcher MR. Clinical Theranostics in Recurrent Gliomas: A Review. Cancers (Basel) 2024; 16:1715. [PMID: 38730666 PMCID: PMC11083317 DOI: 10.3390/cancers16091715] [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: 03/30/2024] [Revised: 04/21/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
Gliomas represent the most commonly occurring tumors in the central nervous system and account for approximately 80% of all malignant primary brain tumors. With a high malignancy and recurrence risk, the prognosis of high-grade gliomas is poor, with a mean survival time of 12-18 months. While contrast-enhanced MRI serves as the standard diagnostic imaging modality for gliomas, it faces limitations in the evaluation of recurrent gliomas, failing to distinguish between treatment-related changes and tumor progression, and offers no direct therapeutic options. Recent advances in imaging modalities have attempted to address some of these limitations, including positron emission tomography (PET), which has demonstrated success in delineating tumor margins and guiding the treatment of recurrent gliomas. Additionally, with the advent of theranostics in nuclear medicine, PET tracers, when combined with therapeutic agents, have also evolved beyond a purely diagnostic modality, serving both diagnostic and therapeutic roles. This review will discuss the growing involvement of theranostics in diagnosing and treating recurrent gliomas and address the associated impact on quality of life and functional recovery.
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Affiliation(s)
- Austin R. Hoggarth
- Department of Neurosurgery, Carilion Clinic, 1906 Belleview Avenue, Roanoke, VA 24014, USA;
- Virginia Tech Carilion School of Medicine, 2 Riverside Circle, Roanoke, VA 24016, USA; (S.M.); (S.M.T.)
- School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA
| | - Sankar Muthukumar
- Virginia Tech Carilion School of Medicine, 2 Riverside Circle, Roanoke, VA 24016, USA; (S.M.); (S.M.T.)
| | - Steven M. Thomas
- Virginia Tech Carilion School of Medicine, 2 Riverside Circle, Roanoke, VA 24016, USA; (S.M.); (S.M.T.)
| | - James Crowley
- Carilion Clinic Radiology, Roanoke, VA 24016, USA; (J.C.); (J.K.)
| | - Jackson Kiser
- Carilion Clinic Radiology, Roanoke, VA 24016, USA; (J.C.); (J.K.)
| | - Mark R. Witcher
- Department of Neurosurgery, Carilion Clinic, 1906 Belleview Avenue, Roanoke, VA 24014, USA;
- Virginia Tech Carilion School of Medicine, 2 Riverside Circle, Roanoke, VA 24016, USA; (S.M.); (S.M.T.)
- School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA
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2
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Chohan MO, Flores RA, Wertz C, Jung RE. "Non-Eloquent" brain regions predict neuropsychological outcome in tumor patients undergoing awake craniotomy. PLoS One 2024; 19:e0284261. [PMID: 38300915 PMCID: PMC10833519 DOI: 10.1371/journal.pone.0284261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 03/28/2023] [Indexed: 02/03/2024] Open
Abstract
Supratotal resection of primary brain tumors is being advocated especially when involving "non-eloquent" tissue. However, there is extensive neuropsychological data implicating functions critical to higher cognition in areas considered "non-eloquent" by most surgeons. The goal of the study was to determine pre-surgical brain regions that would be predictive of cognitive outcome at 4-6 months post-surgery. Cortical reconstruction and volumetric segmentation were performed with the FreeSurfer-v6.0 image analysis suite. Linear regression models were used to regress cortical volumes from both hemispheres, against the total cognitive z-score to determine the relationship between brain structure and broad cognitive functioning while controlling for age, sex, and total segmented brain volume. We identified 62 consecutive patients who underwent planned awake resections of primary (n = 55, 88%) and metastatic at the University of New Mexico Hospital between 2015 and 2019. Of those, 42 (23 males, 25 left hemispheric lesions) had complete pre and post-op neuropsychological data available and were included in this study. Overall, total neuropsychological functioning was somewhat worse (p = 0.09) at post-operative neuropsychological outcome (Mean = -.20) than at baseline (Mean = .00). Patients with radiation following resection (n = 32) performed marginally worse (p = .036). We found that several discrete brain volumes obtained pre-surgery predicted neuropsychological outcome post-resection. For the total sample, these volumes included: left fusiform, right lateral orbital frontal, right post central, and right paracentral regions. Regardless of lesion lateralization, volumes within the right frontal lobe, and specifically right orbitofrontal cortex, predicted neuropsychological difference scores. The current study highlights the gaps in our current understanding of brain eloquence. We hypothesize that the volume of tissue within the right lateral orbital frontal lobe represents important cognitive reserve capacity in patients undergoing tumor surgery. Our data also cautions the neurosurgeon when considering supratotal resections of tumors that do not extend into areas considered "non-eloquent" by current standards.
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Affiliation(s)
- Muhammad Omar Chohan
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Ranee Ann Flores
- Department of Neurosurgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States of America
| | - Christopher Wertz
- Department of Neurosurgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States of America
| | - Rex Eugene Jung
- Department of Neurosurgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States of America
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3
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Tohidinezhad F, Di Perri D, Zegers CML, Dijkstra J, Anten M, Dekker A, Van Elmpt W, Eekers DBP, Traverso A. Prediction Models for Radiation-Induced Neurocognitive Decline in Adult Patients With Primary or Secondary Brain Tumors: A Systematic Review. Front Psychol 2022; 13:853472. [PMID: 35432113 PMCID: PMC9009149 DOI: 10.3389/fpsyg.2022.853472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/07/2022] [Indexed: 12/25/2022] Open
Abstract
Purpose Although an increasing body of literature suggests a relationship between brain irradiation and deterioration of neurocognitive function, it remains as the standard therapeutic and prophylactic modality in patients with brain tumors. This review was aimed to abstract and evaluate the prediction models for radiation-induced neurocognitive decline in patients with primary or secondary brain tumors. Methods MEDLINE was searched on October 31, 2021 for publications containing relevant truncation and MeSH terms related to “radiotherapy,” “brain,” “prediction model,” and “neurocognitive impairments.” Risk of bias was assessed using the Prediction model Risk Of Bias ASsessment Tool. Results Of 3,580 studies reviewed, 23 prediction models were identified. Age, tumor location, education level, baseline neurocognitive score, and radiation dose to the hippocampus were the most common predictors in the models. The Hopkins verbal learning (n = 7) and the trail making tests (n = 4) were the most frequent outcome assessment tools. All studies used regression (n = 14 linear, n = 8 logistic, and n = 4 Cox) as machine learning method. All models were judged to have a high risk of bias mainly due to issues in the analysis. Conclusion Existing models have limited quality and are at high risk of bias. Following recommendations are outlined in this review to improve future models: developing cognitive assessment instruments taking into account the peculiar traits of the different brain tumors and radiation modalities; adherence to model development and validation guidelines; careful choice of candidate predictors according to the literature and domain expert consensus; and considering radiation dose to brain substructures as they can provide important information on specific neurocognitive impairments.
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Affiliation(s)
- Fariba Tohidinezhad
- Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, Netherlands
| | - Dario Di Perri
- Department of Radiation Oncology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Catharina M L Zegers
- Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, Netherlands
| | - Jeanette Dijkstra
- Department of Medical Psychology, School for Mental Health and Neurosciences (MHeNS), Maastricht University Medical Center, Maastricht, Netherlands
| | - Monique Anten
- Department of Neurology, School for Mental Health and Neuroscience (MHeNS), Maastricht University Medical Center, Maastricht, Netherlands
| | - Andre Dekker
- Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, Netherlands
| | - Wouter Van Elmpt
- Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, Netherlands
| | - Daniëlle B P Eekers
- Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, Netherlands
| | - Alberto Traverso
- Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, Netherlands
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4
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Kasper G, Hart S, Samuel N, Fox C, Das S. Anxiety and depression in patients with intracranial meningioma: a mixed methods analysis. BMC Psychol 2022; 10:93. [PMID: 35395829 PMCID: PMC8994241 DOI: 10.1186/s40359-022-00797-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 03/29/2022] [Indexed: 12/05/2022] Open
Abstract
Background While diagnosis with a high-grade intracranial tumor is known to be associated with increased psychosocial burden, the burdens associated with meningioma are less well described. This study aimed to investigate the mental health burden in patients with meningiomas who have undergone surgical resection or serial observation, so as to identify and enhance awareness of gaps in care. Methods The Hospital Anxiety and Depression Scale (HADS) was administered to participants. Fisher’s Exact tests were performed to evaluate frequency distributions and t-tests were applied to compare postoperative and non-surgical patients’ HADS scores. Semi-structured interviews were completed on a subset of participants. Thematic analysis of interviews identified emerging themes. Results Thirty patients with intracranial meningiomas met inclusion criteria. The cohort’s mean age was 56.01 years and 66.67% were women (n = 20). Fourteen underwent surgery; sixteen were treated conservatively with observation. The average time since diagnosis of the sample was 37.6 months. Prevalence of mild to severe symptoms of anxiety was 28.6% amongst surgical management patients and 50% for active surveillance patients (p = 0.325). The prevalence of mild to severe symptoms of depression was 7.14% amongst surgical management patients and 6.25% for active surveillance patients (p = 0.533). Emerging themes from eight interviews reveal the influence of resilience, uncertainty and time, social support, interactions with medical experts, and difficulties during recovery on mental health. Conclusion The findings from the present study reveal that patients with meningiomas experience a significant mental health burden, illustrating the need for enhanced patient-centred care focusing on mental health. Supplementary Information The online version contains supplementary material available at 10.1186/s40359-022-00797-6.
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Affiliation(s)
- Graham Kasper
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shannon Hart
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Nardin Samuel
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Colleen Fox
- Person-Centred Care, Ontario Health (Cancer Care Ontario), Toronto, ON, Canada
| | - Sunit Das
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada. .,Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
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5
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Peters KB, Affronti ML, Woodring S, Lipp E, Healy P, Herndon JE, Miller ES, Freeman MW, Randazzo DM, Desjardins A, Friedman HS. Effects of low-dose naltrexone on quality of life in high-grade glioma patients: a placebo-controlled, double-blind randomized trial. Support Care Cancer 2022; 30:3463-3471. [PMID: 35001215 DOI: 10.1007/s00520-021-06738-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE At diagnosis and throughout the disease course, patients with high-grade glioma (HGG) experience a diminished quality of life (QOL) and increased fatigue. Naltrexone, an orally semisynthetic opiate antagonist, is FDA-approved for the treatment of heroin/alcohol addiction, and low-dose naltrexone (LDN) has been observed to improve QOL and lower fatigue in other neurological illnesses, such as multiple sclerosis. LDN is believed to function as a partial agonist and can lead to shifts in neurochemicals that reduce fatigue. Based on this, we sought to study whether LDN has an impact on QOL and fatigue in patients with HGG. METHODS In a placebo-controlled, double-blind study, we randomized 110 HGG patients to receive placebo (N = 56) or LDN 4.5 mg orally at night (N = 54). Subjects received LDN or placebo at day 1 of concurrent radiation and temozolomide therapy and continued for 16 weeks. Change from baseline in patient-reported outcomes of QOL (Functional Assessment of Cancer Therapy-Brain) and fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue) was assessed. RESULTS Demographics were WHO grade IV (85%), male (56%), KPS 90-100 (51%), grossly resected (55%), and mean age of 56 years. QOL and fatigue changes between baseline and post concurrent chemotherapy and radiation therapy were not significantly different between patients receiving LDN or placebo. The adverse event profiles for LDN and placebo were similar and attributed to concomitant use of temozolomide. CONCLUSIONS LDN has no effect on QOL and fatigue in HGG patients during concurrent chemotherapy and radiation therapy. TRIAL REGISTRATION United States National Library of Medicine Clinical Trials.gov NCT01303835, Date 2/25/2011.
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Affiliation(s)
- Katherine B Peters
- Department of Neurosurgery, Duke University Medical Center, PO Box 3624, Durham, NC, 27710, USA. .,Department of Neurology, Duke University Medical Center, Durham, NC, USA.
| | - Mary L Affronti
- Department of Neurosurgery, Duke University Medical Center, PO Box 3624, Durham, NC, 27710, USA.,Duke School of Nursing, Duke University Medical Center, Durham, NC, USA
| | - Sarah Woodring
- Department of Neurosurgery, Duke University Medical Center, PO Box 3624, Durham, NC, 27710, USA
| | - Eric Lipp
- Department of Neurosurgery, Duke University Medical Center, PO Box 3624, Durham, NC, 27710, USA
| | - Patrick Healy
- Department of Biostatistics and Informatics, Duke University Medical Center, Durham, NC, USA
| | - James E Herndon
- Department of Biostatistics and Informatics, Duke University Medical Center, Durham, NC, USA
| | - Elizabeth S Miller
- Department of Neurosurgery, Duke University Medical Center, PO Box 3624, Durham, NC, 27710, USA
| | - Maria W Freeman
- Department of Neurosurgery, Duke University Medical Center, PO Box 3624, Durham, NC, 27710, USA
| | - Dina M Randazzo
- Department of Neurosurgery, Duke University Medical Center, PO Box 3624, Durham, NC, 27710, USA.,Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Annick Desjardins
- Department of Neurosurgery, Duke University Medical Center, PO Box 3624, Durham, NC, 27710, USA.,Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Henry S Friedman
- Department of Neurosurgery, Duke University Medical Center, PO Box 3624, Durham, NC, 27710, USA
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6
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Effects of brain radiotherapy on cognitive performance in adult low-grade glioma patients: A systematic review. Radiother Oncol 2021; 160:202-211. [PMID: 33964327 DOI: 10.1016/j.radonc.2021.04.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/18/2021] [Accepted: 04/28/2021] [Indexed: 11/23/2022]
Abstract
Grade II gliomas are slow growing tumours that usually affect younger patients. The mainstream treatment modality at present is surgical. The role of radiation therapy in the management of grade II gliomas has been the subject of considerable debate. Radiation therapy has a proven potential to prolong progression free and overall survival in high-risk patients, but may also produce long-term cognitive deficits. Since grade II glioma patients are expected to live several years, retention of cognitive capacity and quality of life is an equally important endpoint as prolonging progression free survival. Our overarching goal is to critically review the available evidence on the possible neuropsychological effects of postoperative radiotherapy in adult grade II glioma patients. We performed a systematic literature search in Medline, Embase and Cochrane databases up to 1st of May 2020 for studies assessing the cognitive effects of radiation therapy on grade II glioma patients. Eleven studies meeting our inclusion criteria provide either negative or contradictory data regarding the cognitive domains affected, while major confounding variables remain incompletely addressed. The available evidence does not adequately support the notion that current radiation therapy protocols independently produce substantial cognitive decline in grade II glioma patients and therefore it would be premature to argue that radiation associated cognitive morbidity outweighs the benefit of prolonged survival. A large prospective study incorporating a full battery of neuropsychological testing, sufficiently long-term follow-up period and tight control of confounders is due to provide high quality data.
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7
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Reuter G, Moïse M, Roll W, Martin D, Lombard A, Scholtes F, Stummer W, Suero Molina E. Conventional and advanced imaging throughout the cycle of care of gliomas. Neurosurg Rev 2021; 44:2493-2509. [PMID: 33411093 DOI: 10.1007/s10143-020-01448-3] [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: 08/03/2020] [Revised: 11/18/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
Although imaging of gliomas has evolved tremendously over the last decades, published techniques and protocols are not always implemented into clinical practice. Furthermore, most of the published literature focuses on specific timepoints in glioma management. This article reviews the current literature on conventional and advanced imaging techniques and chronologically outlines their practical relevance for the clinical management of gliomas throughout the cycle of care. Relevant articles were located through the Pubmed/Medline database and included in this review. Interpretation of conventional and advanced imaging techniques is crucial along the entire process of glioma care, from diagnosis to follow-up. In addition to the described currently existing techniques, we expect deep learning or machine learning approaches to assist each step of glioma management through tumor segmentation, radiogenomics, prognostication, and characterization of pseudoprogression. Thorough knowledge of the specific performance, possibilities, and limitations of each imaging modality is key for their adequate use in glioma management.
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Affiliation(s)
- Gilles Reuter
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium. .,GIGA-CRC In-vivo Imaging Center, ULiege, Liège, Belgium.
| | - Martin Moïse
- Department of Radiology, University Hospital of Liège, Liège, Belgium
| | - Wolfgang Roll
- Department of Nuclear Medicine, University Hospital of Münster, Münster, Germany
| | - Didier Martin
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium
| | - Arnaud Lombard
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium
| | - Félix Scholtes
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium.,Department of Neuroanatomy, University of Liège, Liège, Belgium
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - Eric Suero Molina
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
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8
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van der Weide HL, Kramer MCA, Scandurra D, Eekers DBP, Klaver YLB, Wiggenraad RGJ, Méndez Romero A, Coremans IEM, Boersma L, van Vulpen M, Langendijk JA. Proton therapy for selected low grade glioma patients in the Netherlands. Radiother Oncol 2020; 154:283-290. [PMID: 33197495 DOI: 10.1016/j.radonc.2020.11.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 12/12/2022]
Abstract
Proton therapy offers an attractive alternative to conventional photon-based radiotherapy in low grade glioma patients, delivering radiotherapy with equivalent efficacy to the tumour with less radiation exposure to the brain. In the Netherlands, patients with favourable prognosis based on tumour and patient characteristics can be offered proton therapy. Radiation-induced neurocognitive function decline is a major concern in these long surviving patients. Although level 1 evidence of superior clinical outcome with proton therapy is lacking, the Dutch National Health Care Institute concluded that there is scientific evidence to assume that proton therapy can have clinical benefit by reducing radiation-induced brain damage. Based on this decision, proton therapy is standard insured care for selected low grade glioma patients. Patients with other intracranial tumours can also qualify for proton therapy, based on the same criteria. In this paper, the evidence and considerations that led to this decision are summarised. Additionally, the eligibility criteria for proton therapy and the steps taken to obtain high-quality data on treatment outcome are discussed.
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Affiliation(s)
- Hiska L van der Weide
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, the Netherlands.
| | - Miranda C A Kramer
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, the Netherlands
| | - Daniel Scandurra
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, the Netherlands
| | - Daniëlle B P Eekers
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, the Netherlands
| | | | | | - Alejandra Méndez Romero
- Holland Proton Therapy Center, Delft, the Netherlands; Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ida E M Coremans
- Department of Radiation Oncology, Leiden University Medical Center, the Netherlands
| | - Liesbeth Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, the Netherlands
| | - Marco van Vulpen
- Holland Proton Therapy Center, Delft, the Netherlands; Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Radiation Oncology, Leiden University Medical Center, the Netherlands
| | - Johannes A Langendijk
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, the Netherlands
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9
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Mitchell TJ, Seitzman BA, Ballard N, Petersen SE, Shimony JS, Leuthardt EC. Human Brain Functional Network Organization Is Disrupted After Whole-Brain Radiation Therapy. Brain Connect 2020; 10:29-38. [PMID: 31964163 DOI: 10.1089/brain.2019.0713] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Radiation therapy (RT) plays a vital role in the treatment of brain cancers, but it frequently results in cognitive decline in the patients who receive it. Because the underlying mechanisms for this decline remain poorly understood, the brain is typically treated as a single, uniform volume when evaluating the toxic effects of RT plans. This ignorance represents a significant deficit in the field of radiation oncology, as the technology exists to manipulate dose distributions to spare regions of the brain, but there exists no body of knowledge regarding what is critical to spare. This deficit exists due to the numerous confounding factors that are frequently associated with radiotherapy, including the tumors themselves, other treatments such as surgery and chemotherapy, and dose gradients across the brain. Here, we present a case in which a 57-year-old male patient received a uniform dose of radiation across the whole brain, did not receive concurrent chemotherapy, had minimal surgical intervention and a small tumor burden, and received resting-state functional magnetic resonance imaging (fMRI) scans both before and after RT. To our knowledge, this is the first study on the effects of whole-brain radiotherapy on functional network organization, and this patient's treatment regimen represents a rare and non-replicable opportunity to isolate the effects of radiation on functional connectivity. We observed substantial changes in the subject's behavior and functional network organization over a 12-month timeframe. Interestingly, the homogenous radiation dose to the brain had a heterogeneous effect on cortical networks, and the functional networks most affected correspond with observed cognitive behavioral deficits. This novel study suggests that the cognitive decline that occurs after whole-brain radiation therapy may be network specific and related to the disruption of large-scale distributed functional systems, and it indicates that fMRI is a promising avenue of study for optimizing cognitive outcomes after RT.
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Affiliation(s)
- Timothy J Mitchell
- Department of Radiation Oncology and Washington University in St. Louis-School of Medicine, St. Louis, Missouri
| | - Benjamin A Seitzman
- Department of Neurology, Washington University in St. Louis-School of Medicine, St. Louis, Missouri
| | - Nicholas Ballard
- Department of Radiation Oncology and Washington University in St. Louis-School of Medicine, St. Louis, Missouri
| | - Steven E Petersen
- Department of Neurology, Washington University in St. Louis-School of Medicine, St. Louis, Missouri.,Mallinckrodt Institute of Radiology, Washington University in St. Louis-School of Medicine, St. Louis, Missouri.,Department of Neuroscience, Washington University in St. Louis-School of Medicine, St. Louis, Missouri.,Department of Biomedical Engineering, Washington University in St. Louis-School of Engineering and Applied Science, St. Louis, Missouri.,Department of Psychological and Brain Sciences, Washington University in St. Louis, St. Louis, Missouri
| | - Joshua S Shimony
- Mallinckrodt Institute of Radiology, Washington University in St. Louis-School of Medicine, St. Louis, Missouri
| | - Eric C Leuthardt
- Department of Neuroscience, Washington University in St. Louis-School of Medicine, St. Louis, Missouri.,Department of Biomedical Engineering, Washington University in St. Louis-School of Engineering and Applied Science, St. Louis, Missouri.,Department of Mechanical Engineering and Materials Science, Washington University in St. Louis-School of Engineering and Applied Science, St. Louis, Missouri.,Center for Innovation in Neuroscience and Technology and Washington University in St. Louis-School of Medicine, St. Louis, Missouri.,Brain Laser Center, Washington University in St. Louis-School of Medicine, St. Louis, Missouri.,Department of Neurological Surgery, Washington University in St. Louis-School of Medicine, St. Louis, Missouri
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10
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Reuter G, Lommers E, Balteau E, Simon J, Phillips C, Scholtes F, Martin D, Lombard A, Maquet P. Multiparameter quantitative histological MRI values in high-grade gliomas: a potential biomarker of tumor progression. Neurooncol Pract 2020; 7:646-655. [PMID: 33304600 PMCID: PMC7716186 DOI: 10.1093/nop/npaa047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Conventional MRI poorly distinguishes brain parenchyma microscopically invaded by high-grade gliomas (HGGs) from the normal brain. By contrast, quantitative histological MRI (hMRI) measures brain microstructure in terms of physical MR parameters influenced by histochemical tissue composition. We aimed to determine the relationship between hMRI parameters in the area surrounding the surgical cavity and the presence of HGG recurrence. Methods Patients were scanned after surgery with an hMRI multiparameter protocol that allowed for estimations of longitudinal relaxation rate (R1) = 1/T1, effective transverse relaxation rate (R2)*=1/T2*, magnetization transfer saturation (MTsat), and proton density. The initial perioperative zone (IPZ) was segmented on the postoperative MRI. Once recurrence appeared on conventional MRI, the area of relapsing disease was delineated (extension zone, EZ). Conventional MRI showing recurrence and hMRI were coregistered, allowing for the extraction of parameters R1, R2*, MTsat, and PD in 3 areas: the overlap area between the IPZ and EZ (OZ), the peritumoral brain zone, PBZ (PBZ = IPZ - OZ), and the area of recurrence (RZ = EZ - OZ). Results Thirty-one patients with HGG who underwent gross-total resection were enrolled. MTsat and R1 were the most strongly associated with tumor progression. MTsat was significantly lower in the OZ and RZ, compared to PBZ. R1 was significantly lower in RZ compared to PBZ. PD was significantly higher in OZ compared to PBZ, and R2* was higher in OZ compared to PBZ or RZ. These changes were detected 4 to 120 weeks before recurrence recognition on conventional MRI. Conclusions HGG recurrence was associated with hMRI parameters' variation after initial surgery, weeks to months before overt recurrence.
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Affiliation(s)
- Gilles Reuter
- GIGA Cyclotron Research Centre-In Vivo Imaging, University of Liège, Liège, Belgium.,Department of Neurosurgery, University Hospital of Liège, Liège, Belgium
| | - Emilie Lommers
- GIGA Cyclotron Research Centre-In Vivo Imaging, University of Liège, Liège, Belgium.,Department of Neurology, University Hospital of Liège, Liège, Belgium
| | - Evelyne Balteau
- GIGA Cyclotron Research Centre-In Vivo Imaging, University of Liège, Liège, Belgium
| | - Jessica Simon
- Psychology and Neuroscience of Cognition-PsyNCogn, University of Liège, Liège, Belgium
| | - Christophe Phillips
- GIGA Cyclotron Research Centre-In Vivo Imaging, University of Liège, Liège, Belgium.,GIGA In Silico Medicine, University of Liège, Liège, Belgium
| | - Felix Scholtes
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium.,Laboratory of Developmental Neurobiology, GIGA-Neurosciences Research Center, University of Liège, Liège, Belgium.,Department of Neuroanatomy, University of Liège, Liège, Belgium
| | - Didier Martin
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium
| | - Arnaud Lombard
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium.,Laboratory of Developmental Neurobiology, GIGA-Neurosciences Research Center, University of Liège, Liège, Belgium
| | - Pierre Maquet
- GIGA Cyclotron Research Centre-In Vivo Imaging, University of Liège, Liège, Belgium.,Department of Neurology, University Hospital of Liège, Liège, Belgium
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11
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De Martino M, Santini B, Cappelletti G, Mazzotta A, Rasi M, Bulgarelli G, Annicchiarico L, Marcocci A, Talacchi A. The quality of measurement properties of neurocognitive assessment in brain tumor clinical trials over the last 30 years: a COSMIN checklist-based approach. Neurol Sci 2020; 41:3105-3121. [PMID: 32656714 DOI: 10.1007/s10072-020-04477-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 05/20/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To provide an exhaustive review of the neuropsychological examination as conducted in brain tumor clinical trials over the last 30 years and to provide objective ratings about the reliability and suitability of such tests in neurooncological research and clinical practice. METHODS Methodologies and tools provided by the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) were exploited in order to assess the measurement properties of questionnaires and performance-based instruments used to evaluate cognitive functioning in brain tumor clinical trials from 1997 to 2017. RESULTS Twenty-six brain tumor clinical trials were analyzed and an overall set of 10 neuropsychological tests was identified. A list of 24 studies concerning the reliability of such tests was analyzed. Reliability and level of evidence scores for each study and for each test were obtained. The results revealed relevant faults about the quality of measurements and the suitability of the neurocognitive assessment batteries most commonly used in brain tumor clinical trials. CONCLUSION Our findings suggest that the cognitive assessment in brain tumor clinical trials should be implemented according to specific endpoints and should be addressed to investigate all the cognitive domains known to be affected by brain tumor and treatment.
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Affiliation(s)
- Maria De Martino
- Department of Political and Communication Sciences, University of Salerno, Via Giovanni Paolo II, 132, (SA), 84084, Fisciano, Italy.
| | - Barbara Santini
- Section of Neurosurgery, Department of Neuroscience, Biomedicine and Movement, University of Verona, Piazzale Stefani, 1, 37126, Verona, Italy
| | - Giovanna Cappelletti
- Section of Neurosurgery, Department of Neuroscience, Biomedicine and Movement, University of Verona, Piazzale Stefani, 1, 37126, Verona, Italy
| | - Annapina Mazzotta
- Section of Neurosurgery, Department of Neuroscience, Biomedicine and Movement, University of Verona, Piazzale Stefani, 1, 37126, Verona, Italy
| | - Matteo Rasi
- Section of Neurosurgery, Department of Neuroscience, Biomedicine and Movement, University of Verona, Piazzale Stefani, 1, 37126, Verona, Italy
| | - Giorgia Bulgarelli
- Section of Neurosurgery, Department of Neuroscience, Biomedicine and Movement, University of Verona, Piazzale Stefani, 1, 37126, Verona, Italy
| | - Luciano Annicchiarico
- Section of Neurosurgery, Department of Neuroscience, Biomedicine and Movement, University of Verona, Piazzale Stefani, 1, 37126, Verona, Italy
| | - Alessandro Marcocci
- Unit of Othorinolaringology, Merano Hospital, Via Rossini, 5, 39012, Merano (BZ), Italy
| | - Andrea Talacchi
- Section of Neurosurgery, Department of Neuroscience, Biomedicine and Movement, University of Verona, Piazzale Stefani, 1, 37126, Verona, Italy
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12
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Keng A, Stewart DE, Sheehan KA. Examining the Neuropsychiatric Sequelae Postsurgical Resection of Adult Brain Tumors Through a Scoping Review. PSYCHOSOMATICS 2020; 61:209-219. [PMID: 32139084 DOI: 10.1016/j.psym.2019.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Improving brain tumor survival rates have drawn increasing focus on neuropsychiatric and psychological outcomes. OBJECTIVE This review characterizes the literature on neuropsychiatric sequelae after neurosurgical resection of adult brain tumors. METHODS Using a scoping method, we reviewed articles describing patients with adult brain tumor who underwent partial or total brain resection and examined major neuropsychiatric domains after intervention. RESULTS The initial search yielded 9903 articles. After duplicate removal, abstract screening, review, and hand searching, 81 articles were found: 63 empirical and 18 nonempirical. Most articles centered on survivorship within the first year. Cognition was most widely studied with a transient worsening during the first month and usually recovery or improvement thereafter. Depression increased in frequency during survivorship and was associated with frontotemporal location, time to survival, quality of life, cognitive and physical parameters, and functional status. Anxiety, independent of depression, related to tumor histology and grading and had a weaker association with cognition and quality of life. Obsessive-compulsive symptoms, psychosis, mania, and delirium received little attention. Most studies did not include preoperative neuropsychiatric assessment, and treatment was poorly addressed. CONCLUSION This review highlights key gaps, including preoperative and postoperative neuropsychiatric assessment and a short follow-up. A better understanding of postresection neuropsychiatric outcomes can inform our ability to prognosticate and tailor management for patients at risk for these life-impairing conditions.
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Affiliation(s)
- Alvin Keng
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
| | - Donna E Stewart
- University Health Network Centre for Mental Health, University of Toronto, Toronto, ON, Canada
| | - Kathleen Ann Sheehan
- University Health Network Centre for Mental Health, University of Toronto, Toronto, ON, Canada
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13
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Vogel J, Carmona R, Ainsley CG, Lustig RA. The Promise of Proton Therapy for Central Nervous System Malignancies. Neurosurgery 2020; 84:1000-1010. [PMID: 30476191 DOI: 10.1093/neuros/nyy454] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 08/28/2018] [Indexed: 11/15/2022] Open
Abstract
Radiation therapy plays a significant role in management of benign and malignant diseases of the central nervous system. Patients may be at risk of acute and late toxicity from radiation therapy due to dose deposition in critical normal structures. In contrast to conventional photon delivery techniques, proton therapy is characterized by Bragg peak dose deposition which results in decreased exit dose beyond the target and greater sparing of normal structure which may reduce the rate of late toxicities from treatment. Dosimetric studies have demonstrated reduced dose to normal structures using proton therapy as compared to photon therapy. In addition, clinical studies are being reported demonstrating safety, feasibility, and low rates of acute toxicity. Technical challenges in proton therapy remain, including full understanding of depth of proton penetration and the biological activity in the distal Bragg peak. In addition, longer clinical follow-up is required to demonstrate reduction in late toxicities as compared to conventional photon-based radiation techniques. In this review, we summarize the current clinical literature and areas of active investigation in proton therapy for adult central nervous system malignancies.
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Affiliation(s)
- Jennifer Vogel
- Department of Rad-iation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ruben Carmona
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania
| | - Christopher G Ainsley
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania
| | - Robert A Lustig
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania
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14
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Nasal Drug Delivery of Anticancer Drugs for the Treatment of Glioblastoma: Preclinical and Clinical Trials. Molecules 2019; 24:molecules24234312. [PMID: 31779126 PMCID: PMC6930669 DOI: 10.3390/molecules24234312] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 11/22/2019] [Accepted: 11/24/2019] [Indexed: 12/18/2022] Open
Abstract
Glioblastoma (GBM) is the most lethal form of brain tumor, being characterized by the rapid growth and invasion of the surrounding tissue. The current standard treatment for glioblastoma is surgery, followed by radiotherapy and concurrent chemotherapy, typically with temozolomide. Although extensive research has been carried out over the past years to develop a more effective therapeutic strategy for the treatment of GBM, efforts have not provided major improvements in terms of the overall survival of patients. Consequently, new therapeutic approaches are urgently needed. Overcoming the blood–brain barrier (BBB) is a major challenge in the development of therapies for central nervous system (CNS) disorders. In this context, the intranasal route of drug administration has been proposed as a non-invasive alternative route for directly targeting the CNS. This route of drug administration bypasses the BBB and reduces the systemic side effects. Recently, several formulations have been developed for further enhancing nose-to-brain transport, mainly with the use of nano-sized and nanostructured drug delivery systems. The focus of this review is to provide an overview of the strategies that have been developed for delivering anticancer compounds for the treatment of GBM while using nasal administration. In particular, the specific properties of nanomedicines proposed for nose-to-brain delivery will be critically evaluated. The preclinical and clinical data considered supporting the idea that nasal delivery of anticancer drugs may represent a breakthrough advancement in the fight against GBM.
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15
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Starnoni D, Berthiller J, Idriceanu TM, Meyronet D, d'Hombres A, Ducray F, Guyotat J. Returning to work after multimodal treatment in glioblastoma patients. Neurosurg Focus 2019; 44:E17. [PMID: 29852767 DOI: 10.3171/2018.3.focus1819] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although multimodal treatment for glioblastoma (GBM) has resulted in longer survival, uncertainties exist regarding health-related quality of life and functional performance. Employment represents a useful functional end point and an indicator of social reintegration. The authors evaluated the rate of patients resuming their employment and the factors related to work capacity. METHODS The authors performed a retrospective study of working-age patients treated with surgery and radiochemotherapy between 2012 and 2015. Data were collected before and after surgery and at 6, 12, 18, and 24 months. Employment was categorized according to the French Socio-Professional Groups and analyzed regarding demographic and clinical data, performance status, socio-professional category, radiological features, type, and quality of resection. RESULTS A total of 125 patients, mean age 48.2 years, were identified. The mean follow-up was 20.7 months with a median survival of 22.9 months. Overall, 21 patients (18.3%) went back to work, most on a part-time basis (61.9%). Of the patients who were alive at 6, 12, 18, and 24 months after diagnosis, 8.7%, 13.8%, 15.3%, and 28.2%, respectively, were working. Patients going back to work were younger (p = 0.03), had fewer comorbidities (p = 0.02), and had a different distribution of socio-professional groups, with more patients belonging to higher occupation categories (p = 0.02). Treatment-related symptoms (36.2%) represented one of the main factors that prevented the resumption of work. Employment was strongly associated with performance status (p = 0.002) as well as gross-total removal (p = 0.04). No statistically significant difference was found regarding radiological or molecular features and the occurrence of complications after surgery. CONCLUSIONS GBM diagnosis and treatment has a significant socio-professional impact with only a minority of patients resuming work, mostly on a part-time basis.
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Affiliation(s)
- Daniele Starnoni
- 1Neurosurgical Department, Oncological and Vascular Service, Pierre Wertheimer University Hospital, Lyon
| | - Julien Berthiller
- 2Clinical Investigation Centre CIC-INSERM 1407, EPICIME, Department of Clinical Pharmacology, Hospices Civils de Lyon
| | - Tania-Mihaela Idriceanu
- 1Neurosurgical Department, Oncological and Vascular Service, Pierre Wertheimer University Hospital, Lyon
| | - David Meyronet
- 4Université Claude Bernard Lyon 1, Lyon.,6Hospices Civils de Lyon, Groupe Hospitalier Est, Service de Neuropathologie, Lyon; and
| | - Anne d'Hombres
- 7Département de Radiothérapie, Centre Hospitalier Universitaire Lyon Sud, Pierre-Bénite, France
| | - François Ducray
- 3Hospices Civils de Lyon, Groupe Hospitalier Est, Service de Neuro-Oncologie, Lyon.,5Department of Cancer Cell Plasticity, Cancer Research Centre of Lyon, INSERM U1052, CNRS UMR5286, Lyon
| | - Jacques Guyotat
- 1Neurosurgical Department, Oncological and Vascular Service, Pierre Wertheimer University Hospital, Lyon
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Lawrie TA, Gillespie D, Dowswell T, Evans J, Erridge S, Vale L, Kernohan A, Grant R. Long-term neurocognitive and other side effects of radiotherapy, with or without chemotherapy, for glioma. Cochrane Database Syst Rev 2019; 8:CD013047. [PMID: 31425631 PMCID: PMC6699681 DOI: 10.1002/14651858.cd013047.pub2] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Gliomas are brain tumours arising from glial cells with an annual incidence of 4 to 11 people per 100,000. In this review we focus on gliomas with low aggressive potential in the short term, i.e. low-grade gliomas. Most people with low-grade gliomas are treated with surgery and may receive radiotherapy thereafter. However, there is concern about the possible long-term effects of radiotherapy, especially on neurocognitive functioning. OBJECTIVES To evaluate the long-term neurocognitive and other side effects of radiotherapy (with or without chemotherapy) compared with no radiotherapy, or different types of radiotherapy, among people with glioma (where 'long-term' is defined as at least two years after diagnosis); and to write a brief economic commentary. SEARCH METHODS We searched the following databases on 16 February 2018 and updated the search on 14 November 2018: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 11) in the Cochrane Library; MEDLINE via Ovid; and Embase via Ovid. We also searched clinical trial registries and relevant conference proceedings from 2014 to 2018 to identify ongoing and unpublished studies. SELECTION CRITERIA Randomised and non-randomised trials, and controlled before-and-after studies (CBAS). Participants were aged 16 years and older with cerebral glioma other than glioblastoma. We included studies where patients in at least one treatment arm received radiotherapy, with or without chemotherapy, and where neurocognitive outcomes were assessed two or more years after treatment. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias. We assessed the certainty of findings using the GRADE approach. MAIN RESULTS The review includes nine studies: seven studies were of low-grade glioma and two were of grade 3 glioma. Altogether 2406 participants were involved but there was high sample attrition and outcome data were available for a minority of people at final study assessments. In seven of the nine studies, participants were recruited to randomised controlled trials (RCTs) in which longer-term follow-up was undertaken in a subset of people that had survived without disease progression. There was moderate to high risk of bias in studies due to lack of blinding and high attrition, and in two observational studies there was high risk of selection bias. Paucity of data and risk of bias meant that evidence was of low to very low certainty. We were unable to combine results in meta-analysis due to diversity in interventions and outcomes.The studies examined the following five comparisons.Radiotherapy versus no adjuvant treatmentTwo observational studies contributed data. At the 12-year follow-up in one study, the risk of cognitive impairment (defined as cognitive disability deficits in at least five of 18 neuropsychological tests) was greater in the radiotherapy group (risk ratio (RR) 1.95, 95% confidence interval (CI) 1.02 to 3.71; n = 65); at five to six years the difference between groups did not reach statistical significance (RR 1.38, 95% CI 0.92 to 2.06; n = 195). In the other study, one subject in the radiotherapy group had cognitive impairment (defined as significant deterioration in eight of 12 neuropsychological tests) at two years compared with none in the control group (very low certainty evidence).With regard to neurocognitive scores, in one study the radiotherapy group was reported to have had significantly worse mean scores on some tests compared with no radiotherapy; however, the raw data were only given for significant findings. In the second study, there were no clear differences in any of the various cognitive outcomes at two years (n = 31) and four years (n = 15) (very low certainty evidence).Radiotherapy versus chemotherapyOne RCT contributed data on cognitive impairment at up to three years with no clear difference between arms (RR 1.43, 95% CI 0.36 to 5.70, n = 117) (low-certainty evidence).High-dose radiotherapy versus low-dose radiotherapyOnly one of two studies reporting this comparison contributed data, and at two and five years there were no clear differences between high- and low-dose radiotherapy arms (very low certainty evidence).Conventional radiotherapy versus stereotactic conformal radiotherapyOne study involving younger people contributed limited data from the subgroup aged 16 to 25 years. The numbers of participants with neurocognitive impairment at five years after treatment were two out of 12 in the conventional arm versus none out of 11 in the stereotactic conformal radiotherapy arm (RR 4.62, 95% CI 0.25 to 86.72; n = 23; low-certainty evidence).Chemoradiotherapy versus radiotherapyTwo RCTs tested for cognitive impairment. One defined cognitive impairment as a decline of more than 3 points in MMSE score compared with baseline and reported data from 2-year (110 participants), 3-year (91 participants), and 5-year (57 participants) follow-up with no clear difference between the two arms at any time point. A second study did not report raw data but measured MMSE scores over five years in 126 participants at two years, 110 at three years, 69 at four years and 53 at five years. Authors concluded that there was no difference in MMSE scores between the two study arms (P = 0.4752) (low-certainty evidence).Two RCTs reported quality of life (QoL) outcomes for this comparison. One reported no differences in Brain-QoL scores between study arms over a 5-year follow-up period (P = 0.2767; no raw data were given and denominators were not stated). The other trial reported that the long-term results of health-related QoL showed no difference between the arms but did not give the raw data for overall HRQoL scores (low-certainty evidence).We found no comparative data on endocrine dysfunction; we planned to develop a brief economic commentary but found no relevant economic studies for inclusion. AUTHORS' CONCLUSIONS Radiotherapy for gliomas with a good prognosis may increase the risk of neurocognitive side effects in the long term; however the magnitude of the risk is uncertain. Evidence on long-term neurocognitive side effects associated with chemoradiotherapy is also uncertain. Neurocognitive assessment should be an integral part of long-term follow-up in trials involving radiotherapy for lower-grade gliomas to improve the certainty of evidence regarding long-term neurocognitive effects. Such trials should also assess other potential long-term effects, including endocrine dysfunction, and evaluate costs and cost effectiveness.
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Affiliation(s)
- Theresa A Lawrie
- 1st Floor Education Centre, Royal United HospitalCochrane Gynaecological, Neuro‐oncology and Orphan Cancer GroupCombe ParkBathUKBA1 3NG
| | - David Gillespie
- Western General HospitalDepartment of Neuropsychology133 Grange LoanEdinburghUKEH9 2HL
| | - Therese Dowswell
- The University of LiverpoolC/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Jonathan Evans
- University of GlasgowSchool of Psychological MedicineGartnavel Royal Hospital1055 Great Western RoadGlasgowUKG12 0XH
| | - Sara Erridge
- NHS LothianEdinburgh Cancer CentreWestern General HospitalCrewe RoadEdinburghUKEH4 2XU
| | - Luke Vale
- Newcastle UniversityInstitute of Health & SocietyBaddiley‐Clarke Building, Richardson RoadNewcastle upon TyneUKNE2 4AX
| | - Ashleigh Kernohan
- Newcastle UniversityInstitute of Health & SocietyBaddiley‐Clarke Building, Richardson RoadNewcastle upon TyneUKNE2 4AX
| | - Robin Grant
- Western General HospitalEdinburgh Centre for Neuro‐Oncology (ECNO)Crewe RoadEdinburghUKEH4 2XU
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Rosenkranz E, Thissen A, Siegel S, Piroth M, Clusmann H, Gebauer J, Brabant G, Kreitschmann-Andermahr I. Melatonin secretion following brain midline irradiation is diminished, but not correlated with subjective sleep disturbances. Clin Endocrinol (Oxf) 2018; 89:870-877. [PMID: 30003589 DOI: 10.1111/cen.13814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 07/11/2018] [Accepted: 07/11/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Cranial irradiation for brain tumours or leukaemias has been related to cognitive, endocrine and psychosocial late effects as well as sleep disturbances and increased daytime sleepiness. Studies suggest that cranial irradiation might impact on pineal melatonin secretion. Melatonin is an important regulator in human circadian rhythms and the sleep-wake cycle. The objective of this study was to investigate melatonin secretion, subjective sleep parameters and their interplay in a cohort of cranially irradiated head and brain tumour and leukaemia survivors at least 3 years after radiotherapy. DESIGN Cross-sectional study. PATIENTS Thirty-eight adults. MEASUREMENTS Melatonin secretion was evaluated by measuring its metabolite 6-sulphatoxymelatonin in collected overnight urine. Subjective sleep quality and daytime sleepiness were assessed using the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale. The Beck Depression Inventory II was used to screen for depressive symptoms because of their impact on sleep. RESULTS Patients irradiated in the brain midline had significantly lower melatonin secretion (P = 0.008). Subjects exhibited a high prevalence of sleeping difficulties, daytime sleepiness and depression, with females and overweight subjects particularly affected. Melatonin values and subjective sleep parameters did not correlate with each other or with treatment and most patient variables. CONCLUSIONS Our data suggest that radiation exposure to the pineal gland negatively affects melatonin secretion. This lack of pineal melatonin does not influence subjective sleep quality. As melatonin has important antioxidant and cancer-protective effects, further research is necessary to elucidate whether these patients have an increased risk of developing secondary neoplasms and other radiation late effects.
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Affiliation(s)
- Esther Rosenkranz
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Andrea Thissen
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Sonja Siegel
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Marc Piroth
- Department of Radiation Oncology, University Hospital RWTH Aachen, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Judith Gebauer
- Experimental and Clinical Endocrinology, Medical Clinic I, University of Luebeck, Luebeck, Germany
| | - Georg Brabant
- Experimental and Clinical Endocrinology, Medical Clinic I, University of Luebeck, Luebeck, Germany
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Lawrie TA, Evans J, Gillespie D, Erridge S, Vale L, Kernohan A, Grant R. Long-term side effects of radiotherapy, with or without chemotherapy, for glioma. Hippokratia 2018. [DOI: 10.1002/14651858.cd013047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Theresa A Lawrie
- 1st Floor Education Centre, Royal United Hospital; Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group; Combe Park Bath UK BA1 3NG
| | - Jonathan Evans
- University of Glasgow; School of Psychological Medicine; Gartnavel Royal Hospital 1055 Great Western Road Glasgow UK G12 0XH
| | - David Gillespie
- Western General Hospital; Department of Neuropsychology; 133 Grange Loan Edinburgh UK EH9 2HL
| | - Sara Erridge
- NHS Lothian; Edinburgh Cancer Centre; Western General Hospital Crewe Road Edinburgh UK EH4 2XU
| | - Luke Vale
- Newcastle University; Institute of Health & Society; Baddiley-Clarke Building, Richardson Road Newcastle upon Tyne Tyne & Wear UK NE2 4AX
| | - Ashleigh Kernohan
- Newcastle University; Institute of Health & Society; Baddiley-Clarke Building, Richardson Road Newcastle upon Tyne Tyne & Wear UK NE2 4AX
| | - Robin Grant
- Western General Hospital; Edinburgh Centre for Neuro-Oncology (ECNO); Crewe Road Edinburgh Scotland UK EH4 2XU
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19
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Eekers DB, In 't Ven L, Roelofs E, Postma A, Alapetite C, Burnet NG, Calugaru V, Compter I, Coremans IEM, Høyer M, Lambrecht M, Nyström PW, Méndez Romero A, Paulsen F, Perpar A, de Ruysscher D, Renard L, Timmermann B, Vitek P, Weber DC, van der Weide HL, Whitfield GA, Wiggenraad R, Troost EGC. The EPTN consensus-based atlas for CT- and MR-based contouring in neuro-oncology. Radiother Oncol 2018; 128:37-43. [PMID: 29548560 DOI: 10.1016/j.radonc.2017.12.013] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/01/2017] [Accepted: 12/19/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE To create a digital, online atlas for organs at risk (OAR) delineation in neuro-oncology based on high-quality computed tomography (CT) and magnetic resonance (MR) imaging. METHODS CT and 3 Tesla (3T) MR images (slice thickness 1 mm with intravenous contrast agent) were obtained from the same patient and subsequently fused. In addition, a 7T MR without intravenous contrast agent was obtained from a healthy volunteer. Based on discussion between experienced radiation oncologists, the clinically relevant organs at risk (OARs) to be included in the atlas for neuro-oncology were determined, excluding typical head and neck OARs previously published. The draft atlas was delineated by a senior radiation oncologist, 2 residents in radiation oncology, and a senior neuro-radiologist incorporating relevant available literature. The proposed atlas was then critically reviewed and discussed by European radiation oncologists until consensus was reached. RESULTS The online atlas includes one CT-scan at two different window settings and one MR scan (3T) showing the OARs in axial, coronal and sagittal view. This manuscript presents the three-dimensional descriptions of the fifteen consensus OARs for neuro-oncology. Among these is a new OAR relevant for neuro-cognition, the posterior cerebellum (illustrated on 7T MR images). CONCLUSION In order to decrease inter- and intra-observer variability in delineating OARs relevant for neuro-oncology and thus derive consistent dosimetric data, we propose this atlas to be used in photon and particle therapy. The atlas is available online at www.cancerdata.org and will be updated whenever required.
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Affiliation(s)
- Daniëlle Bp Eekers
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands; Proton Therapy Department South-East Netherlands (ZON-PTC), Maastricht, The Netherlands.
| | - Lieke In 't Ven
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands
| | - Erik Roelofs
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands; The-D Lab: Decision Support for Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, The Netherlands
| | - Alida Postma
- Department of Radiology and Nuclear Medicine MUMC+, Maastricht, The Netherlands
| | - Claire Alapetite
- Institut Curie, Radiation Oncology Department, Paris & Proton Center, Orsay, France
| | - Neil G Burnet
- University of Cambridge Department of Oncology, Addenbrooke's Hospital, United Kingdom
| | - Valentin Calugaru
- Institute Curie, Paris, France; Institute Curie, Centre de Protonthérapie d'Orsay, Orsay, France
| | - Inge Compter
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands
| | - Ida E M Coremans
- Leiden University Medical Centre, Department of Radiotherapy, The Netherlands; Holland Proton Therapy Centre, Delft, The Netherlands
| | - Morton Høyer
- Danish Center for Particle Therapy, Aarhus, Denmark
| | - Maarten Lambrecht
- Department of Radiotherapy-Oncology, Leuven Kanker Instituut, UZ Gasthuisberg, Belgium
| | - Petra Witt Nyström
- The Skandion Clinic, Uppsala, Sweden; Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
| | - Alejandra Méndez Romero
- Holland Proton Therapy Centre, Delft, The Netherlands; Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Frank Paulsen
- Department of Radiation Oncology, Eberhard-Carls-Universität Tübingen, Germany
| | - Ana Perpar
- EBG MedAustron GmbH, Wiener Neustadt, Austria
| | - Dirk de Ruysscher
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands; Department of Radiotherapy-Oncology, Leuven Kanker Instituut, UZ Gasthuisberg, Belgium
| | - Laurette Renard
- Service de Radiothérapie Oncologique Cliniques universitaires St Luc, Brussels, Belgium
| | - Beate Timmermann
- Clinic for Particle Therapy, University Hospital Essen, West German Cancer Center (WTZ), Germany; West German Proton Therapy Center Essen (WPE), Germany; German Cancer Consortium (DKTK), partnersite Essen, Essen, Germany
| | - Pavel Vitek
- Proton Therapy Center Czech, Prague, Czech Republic
| | - Damien C Weber
- Paul Scherrer Institut med. Center for Proton Therapy, Switzerland
| | - Hiske L van der Weide
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Gillian A Whitfield
- The University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, United Kingdom; The Children's Brain Tumour Research Network, University of Manchester, Royal Manchester Children's Hospital, United Kingdom
| | - Ruud Wiggenraad
- Holland Proton Therapy Centre, Delft, The Netherlands; Haaglanden Medisch Centrum, Department of Radiotherapy, Leidschendam, The Netherlands
| | - Esther G C Troost
- Department of Radiation Oncology, Medical Faculty and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Institute of Radiooncology - OncoRay, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany; OncoRay - National Center for Radiation Research in Oncology, Dresden, Germany; German Cancer Consortium (DKTK), partnersite Dresden, Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; National Center for Tumor Diseases (NCT), partnersite Dresden, Dresden, Germany
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Lidocaine Did Not Reduce Neuropsychological-Cognitive Decline in Patients 6 Months After Supratentorial Tumor Surgery: A Randomized, Controlled Trial. J Neurosurg Anesthesiol 2016; 28:6-13. [PMID: 26083427 DOI: 10.1097/ana.0000000000000171] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED : There is equivocal evidence examining cognitive improvement in response to lidocaine during cardiac surgery; however, no study has examined its effect on postoperative neuropsychological-cognitive decline after supratentorial tumor surgery. METHODS Ninety-four patients scheduled for supratentorial craniotomy were enrolled. Patients received either a dose of lidocaine (2%) via an intravenous bolus (1.5 mg/kg) after induction followed by an infusion at a rate of 2 mg/kg/h until the end of surgery (Lidocaine group) or the same volume of normal saline. The neuropsychological-cognitive decline was evaluated using the following tests: the Mini-Mental State Examination, the Information-Memory-Concentration test, the Hamilton Rating Scale for Depression, and the Hamilton Rating Scale for Anxiety. The cerebral oxygen extraction ratio and the difference in lactic acid levels between the bulb of the jugular vein and a peripheral artery were measured. RESULTS Eighty patients completed the neuropsychological tests, with 40 patients in each group. The incidence of postoperative decline at up to 6 months in the Lidocaine group was not significantly different than that in the Normal saline group. When the 2 cognitive tests were examined independent of the other tests, there was no difference between groups at 6 months. The cerebral oxygen extraction ratio was significantly lower in the Lidocaine group after surgery (P<0.05), and the arteriovenous difference of lactic acid was lower in the Lidocaine group (P<0.05). CONCLUSIONS Intraoperative infusion of lidocaine does not significantly decrease the incidence of postoperative neuropsychological-cognitive decline in patients 6 months after supratentorial tumor surgery.
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Gross BA, Chiocca EA. Low-Grade Gliomas and Quality of Life. World Neurosurg 2014; 82:e133-4. [DOI: 10.1016/j.wneu.2014.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 05/02/2014] [Indexed: 11/28/2022]
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Komaki RU, Ghia AJ. Brain Metastasis from Lung Cancer. Lung Cancer 2014. [DOI: 10.1002/9781118468791.ch38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Management of low-grade gliomas: a review of patient-perceived quality of life and neurocognitive outcome. World Neurosurg 2014; 82:e299-309. [PMID: 24560709 DOI: 10.1016/j.wneu.2014.02.033] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 11/08/2013] [Accepted: 02/18/2014] [Indexed: 01/23/2023]
Abstract
Low-grade glioma (LGG) comprises nearly 20% of all central nervous system glial tumors, with approximately 2000-3000 patients diagnosed annually in the United States. Because of their infiltrative ability and aggressive nature, the average 10-year survival is 30% when <90% of the tumor is resected. Since the 1970s, prognosis for LGGs has improved significantly. This improvement is primarily attributable to earlier diagnoses via magnetic resonance imaging scanning, increased awareness of the more favorable oligo component, technical advances in intraoperative neurosurgery, and stratification for young age. Using a number of prognostic factors, LGGs have been classified into low-risk and high-risk subgroups. Optimal therapy for patients with low-risk, supratentorial grade II glioma remains a highly controversial issue in the neuro-oncology community. The concerns regarding the toxicity of therapy often outweigh the benefits of delaying tumor progression. The recommendation for observation is made without full prospective understanding of the impact of radiologic tumor progression on the quality of life (QOL), neurocognitive function (NCF), seizure control, and functional status of these patients. We present a review of the current knowledge of the management of LGG with emphasis upon patient-reported outcomes of QOL, NCF, and seizure control. We also discuss current clinical trials with proposals to evaluate QOL, NCF, and seizure control in patients undergoing observation alone after newly diagnosed low-risk LGG or treatment options for those patients in the high-risk group.
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Mark RE, Klarenbeek PL, Rutten GJM, Sitskoorn MM. Why Don’t Neurosurgery Patients Return for Neuropsychological Follow-Up? Predictors for Voluntary Appointment Keeping and Reasons for Cancellation. Clin Neuropsychol 2013; 28:49-64. [DOI: 10.1080/13854046.2013.854837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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A randomized trial of cognitive rehabilitation in cancer survivors. Life Sci 2013; 93:617-22. [PMID: 24012579 DOI: 10.1016/j.lfs.2013.08.011] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 08/15/2013] [Accepted: 08/19/2013] [Indexed: 11/18/2022]
Abstract
AIMS The second most frequently reported post-treatment symptom in cancer survivors are concerns about impaired cognition. Despite numerous studies demonstrating significant impairments in a portion of survivors, information on effective treatments remains an emerging area of research. This study examined the effectiveness of a group-based cognitive rehabilitation intervention in cancer survivors. MAIN METHODS This study was a randomized, controlled study of a 7-week cognitive rehabilitation intervention delivered in group format. Participants were evaluated with subjective symptom questionnaires and objective neurocognitive tests prior to and following treatment. KEY FINDINGS Twenty-eight participants (mean age 58 years) with a median of 3 years (± 6 years) post-primary/adjuvant treatment and various cancer sites (breast, bladder, prostate, colon, uterine) completed the study. Compared to baseline, the treatment group demonstrated improvements in symptoms of perceived cognitive impairments (p<.01), cognitive abilities (p<.01) and overall quality of life with regard to cognitive symptoms (p<.01) as measured by the FACT-Cog. The treatment group also improved on objective measures of attention (p<.05) and a trend toward improvement on verbal memory. Significant improvement was not observed on all cognitive tests. SIGNIFICANCE A group based cognitive rehabilitation intervention in cancer survivors was effective for improving attention abilities and overall quality of life related to cognition. Results suggest that group based cognitive rehabilitation may be an effective intervention for treating cognitive dysfunction in cancer patients and should be further studied in a larger trial with an active control condition.
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Yavas C, Zorlu F, Ozyigit G, Gurkaynak M, Yavas G, Yuce D, Cengiz M, Yildiz F, Akyol F. Prospective assessment of health-related quality of life in patients with low-grade glioma: a single-center experience. Support Care Cancer 2012; 20:1859-1868. [PMID: 21979904 DOI: 10.1007/s00520-011-1288-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 09/26/2011] [Indexed: 11/28/2022]
Abstract
PURPOSE The assessment of Health-Related Quality of Life (HRQoL) in cancer patients has become increasingly important during the past decades. The aim of this study was to evaluate the HRQoL in patients treated for low-grade glioma (LGG). METHODS AND MATERIALS Forty-three adult patients with LGG were evaluated prospectively between September 2006 and December 2010. We assessed HRQoL at baseline (after surgery before radiotherapy), at the end of radiotherapy and during follow-up (every 3 months for the first 2 years and every 6 months between 2 and 5 years), using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire 30 (EORTC-C30), Brain Cancer Module-20 (BN-20), Mini Mental State Examination (MMSE) and Hospital Anxiety and Depression Scale (HADS). RESULTS We demonstrated changes in global score (p = 0.004), and future uncertainty (p < 0.001), communication deficit (p = 0.007), headache (p < 0.001), drowsiness (p = 0.002) and hair loss (p < 0.001), and recall score (p = 0.0029) during follow-up. All complaints of LGG patients showed improvement, except for the hair loss. Although the baseline cognitive function scores was not significantly different, the third-year cognitive function scores of patients who used antiepileptic drugs had lower when compared to patients who did not use (p < 0.001). The baseline and follow-up anxiety and depression scores did not differ significantly. CONCLUSION Our results suggested that there were improvement in HRQoL in LGG patients during follow-up and antiepileptic drugs had negative effect on cognitive functions.
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Affiliation(s)
- Cagdas Yavas
- Faculty of Medicine, Department of Radiation Oncology, Hacettepe University, Ankara, Turkey.
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Giovagnoli AR. Investigation of cognitive impairments in people with brain tumors. J Neurooncol 2012; 108:277-83. [DOI: 10.1007/s11060-012-0815-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 01/27/2012] [Indexed: 10/28/2022]
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Changes in neurocognitive functioning and quality of life in adult patients with brain tumors treated with radiotherapy. J Neurooncol 2012; 108:291-308. [PMID: 22354791 DOI: 10.1007/s11060-012-0821-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 01/27/2012] [Indexed: 10/28/2022]
Abstract
This review aims to summarize what is currently known about neurocognitive outcome and quality of life in patients with brain tumors treated with radiotherapy. Whether potential tumor-controlling benefits of radiotherapy outweigh its potential toxicity in the natural history of brain tumors is a matter of debate. This review focuses on some of the adult main brain tumors, for which the issue of neurocognitive decline has been thoroughly studied: low-grade gliomas, brain metastases, and primary central nervous system lymphomas. The aims of this review are: (1) the analysis of existing data regarding the relationship between radiotherapy and neurocognitive outcome; (2) the identification of strategies to minimize radiotherapy-related neurotoxicity by reducing the dose or the volume; (3) the evidence-based data concerning radiotherapy withdrawal; and (4) the definition of patients subgroups that could benefit from immediate radiotherapy. For high grade gliomas, the main findings from literature are summarized and some strategies to reduce the neurotoxicity of the treatment are presented. Although further prospective studies with adequate neuropsychological follow-up are needed, this article suggests that cognitive deficits in patients with brain tumor have a multifactorial genesis: radiotherapy may contribute to the neurocognitive deterioration, but the causes of this decline include the tumor itself, disease progression, other treatment modalities and comorbidities. Treatment variables, such as total and fractional dose, target volume, and irradiation technique can dramatically affect the safety of radiotherapy: optimizing radiation parameters could be an excellent approach to improve outcome and to reduce neurotoxicity. At the same time, delayed radiotherapy could be a valid option for highly selected patients.
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Patrias LM, Klaver AC, Coffey MP, Finke JM, Digambaranath JL, Dang L, Martinez AA, Loeffler DA. Effects of External Beam Radiation onIn VitroFormation of Abeta1-42 Fibrils and Preformed Fibrils. Radiat Res 2011; 175:375-81. [DOI: 10.1667/rr2448.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Schellart NAM, Reits D, van der Kleij AJ, Stalpers LJA. Hyperbaric oxygen treatment improved neurophysiologic performance in brain tumor patients after neurosurgery and radiotherapy. Cancer 2011; 117:3434-44. [DOI: 10.1002/cncr.25874] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Revised: 11/09/2010] [Accepted: 11/30/2010] [Indexed: 11/08/2022]
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Rooney AG, Carson A, Grant R. Depression in cerebral glioma patients: a systematic review of observational studies. J Natl Cancer Inst 2010; 103:61-76. [PMID: 21106962 DOI: 10.1093/jnci/djq458] [Citation(s) in RCA: 157] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Depression is a common and important complication of primary cerebral glioma. However, observational studies of this relationship have not been systematically reviewed. METHODS We searched MEDLINE, EMBASE, and PsycINFO for all English-language cross-sectional, case-control, and cohort studies of depression in adults with primary glioma published between January 1, 1980, and September 16, 2009. We identified 42 eligible studies that recruited 4089 individual glioma patients. We conducted a narrative review of these studies regarding the heterogeneity in diagnostic methods, the frequency of depression and its clinical associations, and the quality of study reporting. RESULTS Most studies of depression in adults with glioma were small, cross-sectional, or retrospective. Depression was most often measured using the Hospital Anxiety and Depression Scale (HADS; n = 10 studies). The Beck Depression Inventory, another frequently used screening instrument, returned a higher frequency of depression (median = 39%, range = 38%-42%) than the Hospital Anxiety and Depression Scale (median = 16%, range = 0%-21%). At clinical interview, the median frequency of depression in glioma was 15% (range = 6%-28%). Depression was consistently associated with reduced physical function, cognitive impairment, and reduced quality of life. It may be associated with reduced survival, although evidence for this association was modest. There was an absence of clear associations between depression and many tumor-related variables. Few observational studies examined the treatment of depression in glioma patients. Multivariable analyses were rare, and study reporting was of variable quality. CONCLUSIONS In glioma, mild to moderate depressive symptoms may only rarely be due to tumor-associated structural or functional disruption of neuronal emotional networks. Improved methodological reporting would help clinicians better evaluate future studies, and facilitate improved evidence-based care of depressed glioma patients.
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Affiliation(s)
- Alasdair G Rooney
- Edinburgh Centre for Neuro-Oncology, Western General Hospital, Edinburgh, UK.
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Fliessbach K, Rogowski S, Hoppe C, Sabel M, Goeppert M, Helmstaedter C, Calabrese P, Schackert G, Tonn JC, Simon M, Schlegel U. Computer-based assessment of cognitive functions in brain tumor patients. J Neurooncol 2010; 100:427-37. [DOI: 10.1007/s11060-010-0194-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Accepted: 04/13/2010] [Indexed: 10/19/2022]
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Radiation dose-volume effects in the brain. Int J Radiat Oncol Biol Phys 2010; 76:S20-7. [PMID: 20171513 DOI: 10.1016/j.ijrobp.2009.02.091] [Citation(s) in RCA: 551] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Revised: 02/24/2009] [Accepted: 02/27/2009] [Indexed: 11/21/2022]
Abstract
We have reviewed the published data regarding radiotherapy (RT)-induced brain injury. Radiation necrosis appears a median of 1-2 years after RT; however, cognitive decline develops over many years. The incidence and severity is dose and volume dependent and can also be increased by chemotherapy, age, diabetes, and spatial factors. For fractionated RT with a fraction size of <2.5 Gy, an incidence of radiation necrosis of 5% and 10% is predicted to occur at a biologically effective dose of 120 Gy (range, 100-140) and 150 Gy (range, 140-170), respectively. For twice-daily fractionation, a steep increase in toxicity appears to occur when the biologically effective dose is >80 Gy. For large fraction sizes (>or=2.5 Gy), the incidence and severity of toxicity is unpredictable. For single fraction radiosurgery, a clear correlation has been demonstrated between the target size and the risk of adverse events. Substantial variation among different centers' reported outcomes have prevented us from making toxicity-risk predictions. Cognitive dysfunction in children is largely seen for whole brain doses of >or=18 Gy. No substantial evidence has shown that RT induces irreversible cognitive decline in adults within 4 years of RT.
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Abstract
The optimal management of supratentorial low-grade glioma remains controversial, and only limited definitive data is available to guide recommendations. Treatment decisions have to take into account both the management of symptoms and of tumour control, and must balance the benefits against the potential for treatment-related complications. Overall outcome is more dependent on patient and tumour-related characteristics such as age, tumour grade, histology and neurological function than treatment. From the pooled analysis of 2 randomized EORTC trials a prognostic score has been derived, median survival is varying from 3.2 to 7.8 years. Radiation therapy is usually the primary treatment modality; however its benefit on initial tumour control may be outweighed by potential late toxicity. To date only 4 large randomized trials in patients with low-grade glioma have been reported. It allows concluding that early radiotherapy does not improve overall survival and supports an initially expectative approach. Similarly, higher radiation doses above 45-50 Gy (fractions of 1.8-2.0 Gy) do not confer a better outcome but may be associated with increased toxicity. The adjuvant use of PCV-chemotherapy in high-risk patients also failed to improve progression-free and overall survival. An ongoing large randomized EORTC/NCIC trial is investigating the primary treatment with temozolomide chemotherapy versus standard radiotherapy in patients "at need for treatment". Tumour material will be collected in all patients, which ultimately may allow identifying on a molecular basis patients for whom one or another treatment strategy may fit best. Irrespective of new chemotherapeutic agents, radiotherapy is also evolving. Highly conformal techniques based on modern imaging as co-registered MRI scans, limiting the amount of normal tissue irradiated without compromising tumour control, will be the future approach in order to reduce neurotoxicity.
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Affiliation(s)
- B G Baumert
- Department of Radiation-Oncology (MAASTRO), Grow (School for Oncology and Developmental Biology), Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
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Hassler MR, Elandt K, Preusser M, Lehrner J, Binder P, Dieckmann K, Rottenfusser A, Marosi C. Neurocognitive training in patients with high-grade glioma: a pilot study. J Neurooncol 2009; 97:109-15. [DOI: 10.1007/s11060-009-0006-2] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Accepted: 08/26/2009] [Indexed: 11/24/2022]
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Maintenance of white matter integrity in a rat model of radiation-induced cognitive impairment. J Neurol Sci 2009; 285:178-84. [PMID: 19625028 DOI: 10.1016/j.jns.2009.06.031] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Revised: 06/18/2009] [Accepted: 06/19/2009] [Indexed: 11/23/2022]
Abstract
Radiation therapy is used widely to treat primary and metastatic brain tumors, but also can lead to delayed neurological complications. Since maintenance of myelin integrity is important for cognitive function, the present study used a rat model that demonstrates spatial learning and memory impairment 12 months following fractionated whole-brain irradiation (WBI) at middle age to investigate WBI-induced myelin changes. In this model, 12-month Fischer 344 x Brown Norway rats received 9 fractions of 5 Gy delivered over 4.5 weeks (WBI rats); Sham-IR rats received anesthesia only. Twelve months later, the brains were collected and measures of white matter integrity were quantified. Qualitative observation did not reveal white matter necrosis one year post-WBI. In addition, the size of major forebrain commissures, the number of oligodendrocytes, the size and number of myelinated axons, and the thickness of myelin sheaths did not differ between the two groups. In summary, both the gross morphology and the structural integrity of myelin were preserved one year following fractionated WBI in a rodent model of radiation-induced cognitive impairment. Imaging studies with advanced techniques including diffusion tensor imaging may be required to elucidate the neurobiological changes associated with the cognitive impairment in this model.
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Abstract
With the advent of effective treatment regimes increasing survival rates, delayed treatment-related cognitive dysfunction has been recognized as a significant problem. It is considered the most frequent complication among long-term survivors. WBRT may lead to deep brain atrophy and leukoencephalopathy associated with severe cognitive dysfunction, single-fraction dosages of greater than 2 Gy are related to an increased risk of late neurotoxicity, and other factors such as old age, concomitant chemotherapy and preexisting neurological disease increase this risk. However, the potential of focal radiotherapy (RT) with single dosages of 2 Gy or less to a maximal total dose of 60 Gy to produce significant neurotoxicity is less clear. There is a need for a concise neuropsychological test battery to be included in clinical trials, which should meet the following criteria: assess several domains found to be most sensitive to tumor and treatment effects, have standardized stimuli and administration procedures, have published normative data, have moderate to high test-retest reliability, have alternate forms or be relatively insensitive to practice effects, and therefore be suitable to monitor changes in cognitive function over time, include tests that have been translated into several Languages, which can be administered by a trained psychometrician or clinical research associate under supervision of a neuropsychologist, and have a relatively short total administration time. The neuropsychological domains to be evaluated should comprise the cognitive core deficit in brain-tumor patients, namely attention, executive functions (i.e., working memory, processing speed, sequencing abilities), verbal memory, and motor speed.
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Brandes AA, Franceschi E, Tosoni A, Reni M, Gatta G, Vecht C, Kortmann RD. Adult neuroectodermal tumors of posterior fossa (medulloblastoma) and of supratentorial sites (stPNET). Crit Rev Oncol Hematol 2009; 71:165-79. [PMID: 19303318 DOI: 10.1016/j.critrevonc.2009.02.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Revised: 01/28/2009] [Accepted: 02/13/2009] [Indexed: 11/26/2022] Open
Abstract
Medulloblastoma and supratentorial primitive neuroectodermal tumors are rare diseases in adults. Due to this rarity, few prospective clinical trials have been conducted on medulloblastoma in adults, investigations being based exclusively on retrospective studies; the populations considered in literature are small, and the different treatments given span decades, during which diagnostic procedures, neurosurgical skills and radiotherapy techniques have changed. Unlike pediatric patients, adult medulloblastoma patients have been treated according to risk-adapted therapeutic strategies in only a few series and despite risk-tailored treatments, 20-30% of patients experience recurrence. Although patients could respond to second line treatments, the prognosis of relapsed patients remains dismal. An important challenge for the future will be the biological characterization of medulloblastoma, with the identification of specific genetic patterns of patients with a better or a worse prognosis.
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Affiliation(s)
- Alba A Brandes
- Department of Medical Oncology, Azienda USL-Bellaria-Maggiore Hospital Bologna, Italy.
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Welzel G, Fleckenstein K, Mai SK, Hermann B, Kraus-Tiefenbacher U, Wenz F. Acute neurocognitive impairment during cranial radiation therapy in patients with intracranial tumors. Strahlenther Onkol 2008; 184:647-54. [PMID: 19107345 DOI: 10.1007/s00066-008-1830-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2008] [Accepted: 09/29/2008] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE The objective of the current study was to evaluate the acute effects of cranial radiation therapy (CNS-RT) using different radiation doses (0, 1.8, 2, 3, >or=20 Gy) on cognitive function with special emphasis on memory. We assessed patients with and without intracranial tumors to distinguish between direct and indirect radiation effects on brain tissue. MATERIALS AND METHODS Eighty-two patients were evaluated with neuropsychological testing before and acutely after radiotherapy (RT). Sixty-four patients received RT to the brain (55 with, 9 without intracranial tumor). Eighteen patients treated with RT to the breast served as controls. RESULTS Patients with intracranial tumor demonstrated attention (19-38th percentile) and verbal memory scores (34-46th percentile) below the population average at baseline. The average Verbal Memory score was significantly different between patients with intracranial tumor and controls both at baseline (38th vs. 58th percentile) and after irradiation (27th vs. 52th percentile). Patients with preexisting peritumoral edema performed worse than patients without edema and controls. Radiation dose-related deficits were seen for working memory performance in patients with intracranial tumor. CONCLUSION Our data indicate no measurable impairment of cognitive functioning acutely after prophylactic cranial irradiation. Patients with intracranial tumor show a deterioration of almost all memory functions with a dose-dependent impairment in working memory. Patients with preexisting peritumoral brain edema show the strongest deterioration.
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Affiliation(s)
- Grit Welzel
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.
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Dietrich J, Monje M, Wefel J, Meyers C. Clinical patterns and biological correlates of cognitive dysfunction associated with cancer therapy. Oncologist 2008; 13:1285-95. [PMID: 19019972 DOI: 10.1634/theoncologist.2008-0130] [Citation(s) in RCA: 249] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Standard oncological therapies, such as chemotherapy and cranial radiotherapy, frequently result in a spectrum of neurocognitive deficits that includes impaired learning, memory, attention, and speed of information processing. In addition to classical mechanisms of neurotoxicity associated with chemo- and radiotherapy, such as radiation necrosis and leukoencephalopathy, damage to dynamic progenitor cell populations in the brain is emerging as an important etiologic factor. Radiation- and chemotherapy-induced damage to progenitor populations responsible for maintenance of white matter integrity and adult hippocampal neurogenesis is now believed to play a major role in the neurocognitive impairment many cancer survivors experience.
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Affiliation(s)
- Jörg Dietrich
- Department of Neurology, Division of Neuro-Oncology, Stephen E and Catherine Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Liu R, Page M, Solheim K, Fox S, Chang SM. Quality of life in adults with brain tumors: current knowledge and future directions. Neuro Oncol 2008; 11:330-9. [PMID: 19001097 DOI: 10.1215/15228517-2008-093] [Citation(s) in RCA: 157] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Quality of life is an important area of clinical neurooncology that is increasingly relevant as survivorship increases and as patients experience potential morbidities associated with new therapies. This review of quality-of-life studies in the brain tumor population aims to summarize what is currently known about quality of life in patients with both low-grade and high-grade tumors and suggest how we may use this knowledge to direct future research. To date, reports on quality of life have been primarily qualitative and focused on specific symptoms such as fatigue, sleep disorders, and cognitive dysfunction, as well as some symptom clusters. However, the increasing interest in exploring quality of life as a primary end point for cancer therapy has established a need for prospective, controlled studies to assess baseline and serial quality-of-life parameters in brain tumor patients in order to plan and evaluate appropriate and timely interventions for their symptoms.
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Affiliation(s)
- Raymond Liu
- Department of Neurological Surgery, University of California, San Francisco, CA 94143-0350, USA
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Haris M, Kumar S, Raj MK, Das KJM, Sapru S, Behari S, Rathore RKS, Narayana PA, Gupta RK. Serial diffusion tensor imaging to characterize radiation-induced changes in normal-appearing white matter following radiotherapy in patients with adult low-grade gliomas. ACTA ACUST UNITED AC 2008; 26:140-50. [PMID: 18683569 DOI: 10.1007/s11604-007-0209-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE The aim of this study was to ascertain whether diffusion tensor imaging (DTI) metrics fractional anisotropy (FA), mean diffusivity (MD), linear case (CL), planar case (CP), spherical case (CS)-can characterize a threshold dose and temporal evolution of changes in normal-appearing white matter (NAWM) of adults with low-grade gliomas (LGGs) treated with radiation therapy (RT). METHODS AND MATERIALS Conventional and DTI imaging were performed before RT in 5 patients and subsequently, on average, at 3 months (n = 5), 8 months (n = 3), and 14 months (n = 5) following RT for a total of 18 examinations. Isodose distribution at 5-Gy intervals were visualized in all the slices of fluid attenuated inversion recovery (FLAIR) and the corresponding DTI images without diffusion sensitization (b0DTI). The latter were exported for relative quantitative analysis. RESULTS Compared to pre-RT values, FA and CL decreased, whereas CS increased at 3 and 8 months and recovered partially at 14 months for the dose bins >55 Gy and 50-55 Gy. For the 45 50 Gy bin, the FA and CL decreased with an increase in CS at 3 months; no further change was seen at 8 or 14 months. For the >55 Gy and 50-55 Gy bins, CP decreased and MD increased at 3 months and returned to baseline at 8 months following RT. CONCLUSION Radiation-induced changes in NAWM can be detected at 3 months after RT, with changes in FA, CL, and CS (but not CP or MD) values seen at a threshold dose of 45-50 Gy. A partial recovery was evident by 14 months to regions that received doses of 50-55 Gy and >55 Gy, thus providing an objective measure of radiation effect on NAWM.
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Affiliation(s)
- Mohammad Haris
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareily Road, Lucknow 226014, India
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Palese A, Lamanna F, Di Monte C, Calligaris S, Doretto M, Criveller M. Quality of life in patients with right- or left-sided brain tumours: literature review. J Clin Nurs 2008; 17:1403-10. [DOI: 10.1111/j.1365-2702.2007.02182.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Meningiomas are mostly benign tumours originating from the arachnoid cap cells, represent 13-26% of all intracranial tumours. They are more common in older age and in females. Deletion in NF2 gene and exposure to ionizing radiation are established risk factors, while the role of sex hormones is yet not clarified. Five-year survival for typical meningiomas exceeds 80%, but is poorer (5-year survival <60%) in malignant and atypical meningiomas. Papillary and haemangiopericytic morphology, large tumour size, high mitotic index, absence of progesterone receptors, deletions and loss of heterozygosity are poor prognostic factors. Complete surgical excision is the standard treatment. Radiotherapy is currently used in the clinical practice in atypical, malignant or recurrent meningioma at a total dose of 45-60Gy. However, the role of adjuvant irradiation is still controversial and has to be compared in a randomised prospective setting with a policy of watchful waiting. Radiosurgery has gained more and more importance in the management of meningiomas, especially in meningiomas that cannot be completely resected as for many skull base meningiomas. Medical therapy for patients with recurrent, progressive and symptomatic disease after repeated surgery, radiosurgery and radiotherapy is investigational. Hormonal therapy with progesterone antagonists has shown modest results, while chemotherapy with hydroxyurea appears moderately active.
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Stupp R, Reni M, Gatta G, Mazza E, Vecht C. Anaplastic astrocytoma in adults. Crit Rev Oncol Hematol 2007; 63:72-80. [PMID: 17478095 DOI: 10.1016/j.critrevonc.2007.03.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2007] [Accepted: 03/21/2007] [Indexed: 11/23/2022] Open
Abstract
Anaplastic astrocytoma is an uncommon disease in the adult population. Prognosis is influenced by age, symptom duration, mental status and Karnofsky performance status. A truly complete resection, which is a recognized independent prognostic factor, is not possible and recurrence in the surgical cavity is common. Based on randomized data available, chemotherapy has consistently failed to improve the outcome of patients with anaplastic astrocytoma, while a meta-analysis showed a small, but significant improvement in survival favouring the use of chemotherapy. Outside a clinical trial, postoperative radiotherapy (30 x 2 Gy) remains the standard adjuvant therapy for most patients. For elderly patients, the application of treatment is usually based on performance status and neurological function. In recurrent disease, chemotherapy with temozolomide has been proven to be active and well-tolerated in phase II trials, but no comparative phase III trials of other cytotoxic drugs have been conducted.
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Affiliation(s)
- Roger Stupp
- University Hospital (CHUV), Lausanne, Switzerland.
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47
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Abstract
Ependymomas are rare tumours of neuroectodermal origin classified as myxopapillary ependymoma and subependymoma (grade I), ependymoma (grade II) and anaplastic ependymoma (grade III). The more common location is infratentorial (60%). Age <40 years and extent of surgery appear related to better prognosis, while the role of other prognostic factors, such as tumour grade and tumour site are equivocal. This emphasizes the role of surgery as the standard treatment. Postoperative radiotherapy is indicated in high-grade ependymomas, and is recommended in low-grade ependymomas after subtotal or incomplete resection (confirmed by postoperative MR). Deferral of radiotherapy until recurrence may be considered on an individual basis for patients with MR confirmation of a radical resection. Recommended dose to involved fields is 45-54 Gy for low-grade (grade II) and 54-60 Gy for high-grade ependymomas (grade III). There is no proof that postoperative chemotherapy improves the outcome. At recurrence, platinum-, nitrosourea- or temozolomide-based chemotherapy can be administered, although there is no evidence of efficacy.
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Affiliation(s)
- Michele Reni
- Medical Oncology Unit, San Raffaele Scientific Institute, Milan, Italy.
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Brown PD, Jensen AW, Felten SJ, Ballman KV, Schaefer PL, Jaeckle KA, Cerhan JH, Buckner JC. Detrimental effects of tumor progression on cognitive function of patients with high-grade glioma. J Clin Oncol 2006; 24:5427-33. [PMID: 17135644 DOI: 10.1200/jco.2006.08.5605] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There is growing recognition that the primary cause of cognitive deficits in adult patients with primary brain tumors is the tumor itself and more significantly, tumor progression. To assess the cognitive performance of high-grade glioma patients, prospectively collected cognitive performance data were analyzed. PATIENTS AND METHODS We studied 1,244 high-grade brain tumor patients entered onto eight consecutive North Central Cancer Treatment Group treatment trials that used radiation and nitrosourea-based chemotherapy. Imaging studies and Folstein Mini-Mental State Examination (MMSE) scores recorded at baseline, 6, 12, 18, and 24 months were analyzed to assess tumor status and cognitive function over time. RESULTS The proportion of patients without tumor progression who experienced clinically significant cognitive deterioration compared with baseline was stable at 6, 12, 18, and 24 months (18%, 16%, 14%, and 13%, respectively). In patients without radiographic evidence of progression, clinically significant deterioration in MMSE scores was a strong predictor of a more rapid time to tumor progression and death. At evaluations preceding interval radiographic evidence of progression, there was significant deterioration in MMSE scores for patients who were to experience progression, whereas the scores remained stable for the patients who did not have tumor progression. CONCLUSION The proportion of high-grade glioma patients with cognitive deterioration over time is stable, most consistent with the constant pressure of tumor progression over time. Although other factors may contribute to cognitive decline, the predominant cause of cognitive decline seems to be subclinical tumor progression that precedes radiographic changes.
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Abstract
As effective treatment interventions have increased survival rates, there has been greater awareness that many brain tumor patients experience cognitive dysfunction despite adequate disease control. Cognitive difficulties often have an impact on quality of life and interfere with the patient's ability to function at premorbid levels; however, the incidence of cognitive dysfunction in brain tumor patients is unknown, because it has not been investigated systematically. Future prospective clinical trials in neuro-oncology should include cognitive outcome measures to increase understanding of the contribution of the tumor and the delayed effects of treatment to cognitive dysfunction.
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Affiliation(s)
- Denise D Correa
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
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Bosma I, Vos MJ, Heimans JJ, Taphoorn MJB, Aaronson NK, Postma TJ, van der Ploeg HM, Muller M, Vandertop WP, Slotman BJ, Klein M. The course of neurocognitive functioning in high-grade glioma patients. Neuro Oncol 2006; 9:53-62. [PMID: 17018697 PMCID: PMC1828106 DOI: 10.1215/15228517-2006-012] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We evaluated the course of neurocognitive functioning in newly diagnosed high-grade glioma patients and specifically the effect of tumor recurrence. Following baseline assessment (after surgery and before radiotherapy), neurocognitive functioning was evaluated at 8 and 16 months. Neurocognitive summary measures were calculated to detect possible deficits in the domains of (1) information processing, (2) psychomotor function, (3) attention, (4) verbal memory, (5) working memory, and (6) executive functioning. Repeated-measures analyses of covariance were used to evaluate changes over time. Thirty-six patients were tested at baseline only. Follow-up data were obtained for 32 patients: 14 had a follow-up at 8 months, and 18 had an additional follow-up at 16 months. Between baseline and eight months, patients deteriorated in information-processing capacity, psychomotor speed, and attentional functioning. Further deterioration was observed between 8 and 16 months. Of 32 patients, 15 suffered from tumor recurrence before the eight-month follow-up. Compared with recurrence-free patients, not only did patients with recurrence have lower information-processing capacity, psychomotor speed, and executive functioning, but they also exhibited a more pronounced deterioration between baseline and eight-month follow-up. This difference could be attributed to the use of antiepileptic drugs in the patient group with recurrence. This study showed a marked decline in neurocognitive functioning in HGG patients in the course of their disease. Patients with tumor progression performed worse on neurocognitive tests than did patients without progression, which could be attributed to the use of antiepileptic drugs. The possibility of deleterious effects is important to consider when prescribing antiepileptic drug treatment.
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Affiliation(s)
- Ingeborg Bosma
- Department of Neurology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
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