1
|
Lucas Calduch A, Macià Garau M, Villà Freixa S, García Expósito N, Modolell Farré I, Majós Torró C, Pons Escoda A, Mesía Barroso C, Vilariño Quintela N, Rosselló Gómez A, Plans Ahicart G, Martínez García M, Esteve Gómez A, Bruna Escuer J. Salvage reirradiation for recurrent glioblastoma: a retrospective case series analysis. Clin Transl Oncol 2025; 27:2104-2112. [PMID: 39388047 DOI: 10.1007/s12094-024-03750-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 10/01/2024] [Indexed: 10/12/2024]
Abstract
PURPOSE To assess the clinical outcome of patients with recurrent glioblastoma treated with salvage reirradiation. METHODS Between 2005 and 2022, data from adult patients with glioblastoma treated with surgery and radio-chemotherapy Stupp regimen who developed a local in-field relapse and received stereotactic radiotherapy (SRT) were retrospectively reviewed. RESULTS The study population included 44 patients with recurrent glioblastoma (median of 9.5 months after the first radiotherapy). Reirradiation alone was given to 47.7% of patients. The median maximum diameter of the recurrence was 13.5 mm. The most common SRT regimen (52.3%) was 35 Gy in 10 fractions. Acute toxicity was mild, with transient worsening of previous neurological symptoms in only 15% of patients. After a median follow-up of 15 months, 40% presented radiological response, but a remarkable number of early distant progressions were recorded (32.5%). The median time to progression was 4.8 months, being the dose, the scheme, the size of the recurrence or the strategy (exclusive RT vs. combined) unrelated factors. The median overall survival (OS) was 14.9 months. Karnofsky index < 70 and the size of the recurrence (maximum diameter < 25 mm) were significant factors associated with OS. Radiological changes after reirradiation were commonly seen (> 50% of patients) hindering the response assessment. CONCLUSIONS Reirradiation is a feasible and safe therapeutic option to treat localized glioblastoma recurrences, able to control the disease for a few months in selected patients, especially those with good functional status and small lesions. Hypofractionated schemes provided a suitable toxicity profile. Radiological changes were common.
Collapse
Affiliation(s)
- Anna Lucas Calduch
- Radiation Oncology Service, Institut Català d'Oncologia (ICO)-Hospital Duran I Reynals, L'Hospitalet de Llobregat, Avda. Gran Via de L'Hospitalet 199-203, 08908, Barcelona, Spain.
| | - Miquel Macià Garau
- Radiation Oncology Service, Institut Català d'Oncologia (ICO)-Hospital Duran I Reynals, L'Hospitalet de Llobregat, Avda. Gran Via de L'Hospitalet 199-203, 08908, Barcelona, Spain
| | | | - Nagore García Expósito
- Radiation Oncology Service, Institut Català d'Oncologia (ICO)-Hospital Duran I Reynals, L'Hospitalet de Llobregat, Avda. Gran Via de L'Hospitalet 199-203, 08908, Barcelona, Spain
| | - Ignasi Modolell Farré
- Medical Physics, Institut Català de'Oncologia (ICO), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Carles Majós Torró
- Institut de Diagnòstic per la Imatge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Albert Pons Escoda
- Institut de Diagnòstic per la Imatge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Carlos Mesía Barroso
- Medical Oncology, Institut Català de'Oncologia (ICO)- L'Hospitalet de Llobregat, Barcelona, Spain
| | - Noelia Vilariño Quintela
- Medical Oncology, Institut Català de'Oncologia (ICO)- L'Hospitalet de Llobregat, Barcelona, Spain
| | - Aleix Rosselló Gómez
- Neurosurgery, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Gerard Plans Ahicart
- Neurosurgery, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Anna Esteve Gómez
- Badalona Applied Research Group in Oncology (B-ARGO), Badalona, Barcelona, Spain
| | - Jordi Bruna Escuer
- Neurology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| |
Collapse
|
2
|
Prajapati HP, Ansari A. Updates in the Management of Recurrent Glioblastoma Multiforme. J Neurol Surg A Cent Eur Neurosurg 2023; 84:174-187. [PMID: 35772723 DOI: 10.1055/s-0042-1749351] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Glioblastoma is the most aggressive and diffusely infiltrative primary brain tumor. Recurrence is almost universal even after all primary standard treatments. This article aims to review the literature and update the standard treatment strategies for patients with recurrent glioblastoma. METHODS A systematic search was performed with the phrase "recurrent glioblastoma and management" as a search term in PubMed central, Medline, and Embase databases to identify all the articles published on the subject till December 2020. The review included peer-reviewed original articles, clinical trials, review articles, and keywords in title and abstract. RESULTS Out of 513 articles searched, 73 were included in this review after screening for eligibility. On analyzing the data, most of the studies report a median overall survival (OS) of 5.9 to 11.4 months after re-surgery and 4.7 to 7.6 months without re-surgery. Re-irradiation with stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) result in a median OS of 10.2 months (range: 7.0-12 months) and 9.8 months (ranged: 7.5-11.0 months), respectively. Radiation necrosis was found in 16.6% (range: 0-24.4%) after SRS. Chemotherapeutic agents like nitrosourea (carmustine), bevacizumab, and temozolomide (TMZ) rechallenge result in a median OS in the range of 5.1 to 7.5, 6.5 to 9.2, and 5.1-13.0 months and six months progression free survival (PFS-6) in the range of 13 to 17.5%, 25 to 42.6%, and 23 to 58.3%, respectively. Use of epithelial growth factor receptor (EGFR) inhibitors results in a median OS in the range of 2.0 to 3.0 months and PFS-6 in 13%. CONCLUSION Although recurrent glioblastoma remains a fatal disease with universal mortality, the literature suggests that a subset of patients may benefit from maximal treatment efforts.
Collapse
Affiliation(s)
- Hanuman Prasad Prajapati
- Department of Neurosurgery, Uttar Pradesh University of Medical Sciences, Etawah, Uttar Pradesh, India
| | - Ahmad Ansari
- Department of Neurosurgery, Uttar Pradesh University of Medical Sciences, Safai, Uttar Pradesh, India
| |
Collapse
|
3
|
Ciammella P, Cozzi S, Botti A, Giaccherini L, Sghedoni R, Orlandi M, Napoli M, Pascarella R, Pisanello A, Russo M, Cavallieri F, Ruggieri MP, Cavuto S, Savoldi L, Iotti C, Iori M. Safety of Inhomogeneous Dose Distribution IMRT for High-Grade Glioma Reirradiation: A Prospective Phase I/II Trial (GLIORAD TRIAL). Cancers (Basel) 2022; 14:cancers14194604. [PMID: 36230525 PMCID: PMC9562035 DOI: 10.3390/cancers14194604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Glioblastoma multiforme (GBM) is the most frequent primary malignant brain tumor, and despite advances in imaging techniques and treatment options, the outcome remains poor and recurrence is inevitable. Salvage therapy presents a challenge, and re-irradiation can be a therapeutic option in recurrent GBM. The decision-making process for re-irradiation is a challenge for radiation oncologists due to the expected toxicity of a second course of radiotherapy and the limited radiation tolerance of normal tissue; nevertheless, it is being increasingly used, as several studies have demonstrated its feasibility. The current study aimed to investigate the safety of moderate–high-voxel-based dose escalation radiotherapy in recurrent GBM patients after conventional concurrent chemoradiation. Twelve patients were enrolled in this prospective single-center study. Retreatment consisted of re-irradiation with a total dose range of 30–50 Gy over 5 days using the IMRT (arc VMAT) technique using dose painting planning. The treatment was well tolerated. No toxicities greater than 3 were recorded; only one patient had severe G3 acute toxicity, characterized by muscle weakness and fatigue. Median overall survival (OS2) and progression-free survival (PFS2) from the time of re-irradiation were 10.4 months and 5.7 months, respectively. Our phase I study demonstrated an acceptable tolerance profile of this approach, and the future prospective phase II study will analyze the efficacy in terms of PFS and OS. Abstract Glioblastoma multiforme (GBM) is the most aggressive astrocytic primary brain tumor, and concurrent temozolomide (TMZ) and radiotherapy (RT) followed by maintenance of adjuvant TMZ is the current standard of care. Despite advances in imaging techniques and multi-modal treatment options, the median overall survival (OS) remains poor. As an alternative to surgery, re-irradiation (re-RT) can be a therapeutic option in recurrent GBM. Re-irradiation for brain tumors is increasingly used today, and several studies have demonstrated its feasibility. Besides differing techniques, the published data include a wide range of doses, emphasizing that no standard approach exists. The current study aimed to investigate the safety of moderate–high-voxel-based dose escalation in recurrent GBM. From 2016 to 2019, 12 patients met the inclusion criteria and were enrolled in this prospective single-center study. Retreatment consisted of re-irradiation with a total dose of 30 Gy (up to 50 Gy) over 5 days using the IMRT (arc VMAT) technique. A dose painting by numbers (DPBN)/dose escalation plan were performed, and a continuous relation between the voxel intensity of the functional image set and the risk of recurrence in that voxel were used to define target and dose distribution. Re-irradiation was well tolerated in all treated patients. No toxicities greater than G3 were recorded; only one patient had severe G3 acute toxicity, characterized by muscle weakness and fatigue. Median overall survival (OS2) and progression-free survival (PFS2) from the time of re-irradiation were 10.4 months and 5.7 months, respectively; 3-, 6-, and 12-month OS2 were 92%, 75%, and 42%, respectively; and 3-, 6-, and 12-month PFS2 were 83%, 42%, and 8%, respectively. Our work demonstrated a tolerable tolerance profile of this approach, and the future prospective phase II study will analyze the efficacy in terms of PFS and OS.
Collapse
Affiliation(s)
- Patrizia Ciammella
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Salvatore Cozzi
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
- Correspondence: ; Tel.: +39-3297317608
| | - Andrea Botti
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Lucia Giaccherini
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Roberto Sghedoni
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Matteo Orlandi
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Manuela Napoli
- Neuroradiology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Rosario Pascarella
- Neuroradiology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Anna Pisanello
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Marco Russo
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Francesco Cavallieri
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Maria Paola Ruggieri
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Silvio Cavuto
- Clinical Trials and Statistics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Luisa Savoldi
- Clinical Trials and Statistics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Cinzia Iotti
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Mauro Iori
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| |
Collapse
|
4
|
She L, Su L, Liu C. Bevacizumab combined with re-irradiation in recurrent glioblastoma. Front Oncol 2022; 12:961014. [PMID: 36046037 PMCID: PMC9423039 DOI: 10.3389/fonc.2022.961014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 07/04/2022] [Indexed: 11/18/2022] Open
Abstract
Background Glioblastoma is characterized by rich vasculature and abnormal vascular structure and function. Currently, there is no standard treatment for recurrent glioblastoma (rGBM). Bevacizumab (BEV) has established role of inhibiting neovascularization, alleviating hypoxia in the tumor area and activating the immune microenvironment. BEV may exert synergistic effects with re-irradiation (re-RT) to improve the tumor microenvironment for rGBM. Purpose The purpose of this study was to evaluate the safety, tolerability, and efficacy of a combination of BEV and re-RT for rGBM treatment. Methods In this retrospective study, a total of 26 rGBM patients with surgical pathologically confirmed glioblastoma and at least one event of recurrence were enrolled. All patients were treated with re-RT in combination with BEV. BEV was administered until progression or serious adverse events. Results Median follow-up was 21.9 months for all patients, whereas median progression-free survival (PFS) was 8.0 months (95% confidence interval [CI]: 6.5–9.5 months). In addition, the 6-month and 1-year PFS rates were 65.4% and 28.2%, respectively. The median overall survival (OS), 6-month OS rate, and 1-year OS rate were 13.6 months (95% CI: 10.2–17.0 months), 92.3%, and 67.5%, respectively. The patient showed good tolerance during the treatment with no grade > 3 grade side event and radiation necrosis occurrence rate of 0%. Combined treatment of gross total resection (GTR) before re-RT and concurrent temozolomide during re-RT was an independent prognostic factor that affected both OS and PFS in the whole cohort (OS: 0.067, 95% CI: 0.009–0.521, p = 0.010; PFS: 0.238, 95% CI: 0.076–0.744, p = 0.038). Conclusion In this study, re-RT combined with concurrent and maintenance BEV treatment was safe, tolerable, and effective in rGBM patients. Moreover, GTR before re-RT and selective concurrent temozolomide could further improve patient PFS and OS.
Collapse
Affiliation(s)
- Lei She
- Department of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacology, Engineering Research Center for Applied Technology of Pharmacogenomics of Ministry of Education, Central South University, Changsha, China.,Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Lin Su
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Chao Liu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
5
|
Matsui JK, Perlow HK, Ritter AR, Upadhyay R, Raval RR, Thomas EM, Beyer SJ, Pillainayagam C, Goranovich J, Ong S, Giglio P, Palmer JD. Small Molecules and Immunotherapy Agents for Enhancing Radiotherapy in Glioblastoma. Biomedicines 2022; 10:biomedicines10071763. [PMID: 35885067 PMCID: PMC9313399 DOI: 10.3390/biomedicines10071763] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/13/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022] Open
Abstract
Glioblastoma (GBM) is an aggressive primary brain tumor that is associated with a poor prognosis and quality of life. The standard of care has changed minimally over the past two decades and currently consists of surgery followed by radiotherapy (RT), concomitant and adjuvant temozolomide, and tumor treating fields (TTF). Factors such as tumor hypoxia and the presence of glioma stem cells contribute to the radioresistant nature of GBM. In this review, we discuss the current treatment modalities, mechanisms of radioresistance, and studies that have evaluated promising radiosensitizers. Specifically, we highlight small molecules and immunotherapy agents that have been studied in conjunction with RT in clinical trials. Recent preclinical studies involving GBM radiosensitizers are also discussed.
Collapse
Affiliation(s)
- Jennifer K. Matsui
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA;
| | - Haley K. Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (H.K.P.); (A.R.R.); (R.U.); (R.R.R.); (E.M.T.); (S.J.B.)
| | - Alex R. Ritter
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (H.K.P.); (A.R.R.); (R.U.); (R.R.R.); (E.M.T.); (S.J.B.)
| | - Rituraj Upadhyay
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (H.K.P.); (A.R.R.); (R.U.); (R.R.R.); (E.M.T.); (S.J.B.)
| | - Raju R. Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (H.K.P.); (A.R.R.); (R.U.); (R.R.R.); (E.M.T.); (S.J.B.)
| | - Evan M. Thomas
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (H.K.P.); (A.R.R.); (R.U.); (R.R.R.); (E.M.T.); (S.J.B.)
| | - Sasha J. Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (H.K.P.); (A.R.R.); (R.U.); (R.R.R.); (E.M.T.); (S.J.B.)
| | - Clement Pillainayagam
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (C.P.); (J.G.); (S.O.); (P.G.)
| | - Justin Goranovich
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (C.P.); (J.G.); (S.O.); (P.G.)
| | - Shirley Ong
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (C.P.); (J.G.); (S.O.); (P.G.)
| | - Pierre Giglio
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (C.P.); (J.G.); (S.O.); (P.G.)
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (H.K.P.); (A.R.R.); (R.U.); (R.R.R.); (E.M.T.); (S.J.B.)
- Correspondence:
| |
Collapse
|
6
|
Relapsing High—Grade Glioma from Peritumoral Zone: Critical Review of Radiotherapy Treatment Options. Brain Sci 2022; 12:brainsci12040416. [PMID: 35447948 PMCID: PMC9027370 DOI: 10.3390/brainsci12040416] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/15/2022] [Accepted: 03/18/2022] [Indexed: 11/17/2022] Open
Abstract
Glioblastoma (GBM) is the most common and aggressive brain tumor in adults, with a median survival of about 15 months. After the prior treatment, GBM tends to relapse within the high dose radiation field, defined as the peritumoral brain zone (PTZ), needing a second treatment. In the present review, the primary role of ionizing radiation in recurrent GBM is discussed, and the current literature knowledge about the different radiation modalities, doses and fractionation options at our disposal is summarized. Therefore, the focus is on the necessity of tailoring the treatment approach to every single patient and using radiomics and PET/MRI imaging to have a relatively good outcome and avoid severe toxicity. The use of charged particle therapy and radiosensitizers to overcome GBM radioresistance is considered, even if further studies are necessary to evaluate the effectiveness in the setting of reirradiation.
Collapse
|
7
|
Kayalı FI, Habiboğlu R. CAN HYPOFRACTIONATED REIRRADIATION PLUS TEMOZOLAMIDE BE A WISE CHOICE FOR RECURRENT HIGH AND LOW GRADE BRAIN TUMORS? JOURNAL OF RADIATION RESEARCH AND APPLIED SCIENCES 2021. [DOI: 10.1080/16878507.2021.1935131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
8
|
Cs-131 brachytherapy for patients with recurrent glioblastoma combined with bevacizumab avoids radiation necrosis while maintaining local control. Brachytherapy 2021; 19:705-712. [PMID: 32928486 DOI: 10.1016/j.brachy.2020.06.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 06/01/2020] [Accepted: 06/16/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Re-irradiation of recurrent glioblastoma (GBM) may delay further recurrence but re-irradiation increases the risk of radionecrosis (RN). Salvage therapy should focus on balancing local control (LC) and toxicity. We report the results of using intraoperative Cesium-131 (Cs-131) brachytherapy for recurrent GBM in a population of patients who also received bevacizumab. METHODS AND MATERIALS Twenty patients with recurrent GBM underwent maximally safe neurosurgical resection with Cs-131 brachytherapy between 2010 and 2015. Eighty Gy was prescribed to 0.5 cm from the surface of the resection cavity. All patients previously received adjuvant radiotherapy and temozolomide, and received bevacizumab before or after salvage brachytherapy. Seven of 20 (35%) tumors were multiply recurrent and had been previously salvaged with external beam radiotherapy. Patients received MRI scans every 2 months monitored for recurrence, progression, and RN. RESULTS Median tumor diameter was 4.65 cm (range, 1.2-6.3 cm). Median number of seeds pace was 41 (range, 20-74) with total seed activity 96.8U (range, 41.08-201.3U). At a median followup of 19 months, crude LC was 85% and median overall survival was 9 months (range, 5-26 months). There were two postoperative wound infections (10%), three seizures (15%), and 0% incidence of RN. CONCLUSIONS Our study demonstrates that while LC and survival are similar to other studies of postoperative external beam radiotherapy, no RN occurred in any of these patients, including 7 multiply re-irradiated patients. Of interest, there were patients with multiple recurrences whose survival extended beyond 20 months. These findings suggest that the use of highly conformal Cs-131 brachytherapy is a promising treatment for patients with recurrent GBM with minimal risk of development of RN.
Collapse
|
9
|
Minniti G, Niyazi M, Alongi F, Navarria P, Belka C. Current status and recent advances in reirradiation of glioblastoma. Radiat Oncol 2021; 16:36. [PMID: 33602305 PMCID: PMC7890828 DOI: 10.1186/s13014-021-01767-9] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/11/2021] [Indexed: 12/12/2022] Open
Abstract
Despite aggressive management consisting of maximal safe surgical resection followed by external beam radiation therapy (60 Gy/30 fractions) with concomitant and adjuvant temozolomide, approximately 90% of WHO grade IV gliomas (glioblastomas, GBM) will recur locally within 2 years. For patients with recurrent GBM, no standard of care exists. Thanks to the continuous improvement in radiation science and technology, reirradiation has emerged as feasible approach for patients with brain tumors. Using stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT), either hypofractionated or conventionally fractionated schedules, several studies have suggested survival benefits following reirradiation of patients with recurrent GBM; however, there are still questions to be answered about the efficacy and toxicity associated with a second course of radiation. We provide a clinical overview on current status and recent advances in reirradiation of GBM, addressing relevant clinical questions such as the appropriate patient selection and radiation technique, optimal dose fractionation, reirradiation tolerance of the brain and the risk of radiation necrosis.
Collapse
Affiliation(s)
- Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico le Scotte, 53100, Siena, Italy. .,IRCCS Neuromed, Pozzilli, IS, Italy.
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Filippo Alongi
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, VR, Italy
| | - Piera Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Hospital-IRCCS, Rozzano, MI, Italy
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
10
|
Scoccianti S, Perna M, Olmetto E, Delli Paoli C, Terziani F, Ciccone LP, Detti B, Greto D, Simontacchi G, Grassi R, Scoccimarro E, Bonomo P, Mangoni M, Desideri I, Di Cataldo V, Vernaleone M, Casati M, Pallotta S, Livi L. Local treatment for relapsing glioblastoma: A decision-making tree for choosing between reirradiation and second surgery. Crit Rev Oncol Hematol 2020; 157:103184. [PMID: 33307416 DOI: 10.1016/j.critrevonc.2020.103184] [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] [Received: 01/27/2020] [Revised: 05/21/2020] [Accepted: 11/23/2020] [Indexed: 12/22/2022] Open
Abstract
In case of circumscribed recurrent glioblastoma (rec-GBM), a second surgery (Re-S) and reirradiation (Re-RT) are local strategies to consider. The aim is to provide an algorithm to use in the daily clinical practice. The first step is to consider the life expectancy in order to establish whether the patient should be a candidate for active treatment. In case of a relatively good life expectancy (>3 months) and a confirmed circumscribed disease(i.e. without multiple lesions that are in different lobes/hemispheres), the next step is the assessment of the prognostic factors for local treatments. Based on the existing prognostic score systems, patients who should be excluded from local treatments may be identified; based on the validated prognostic factors, one or the other local treatment may be preferred. The last point is the estimation of expected toxicity, considering patient-related, tumor-related and treatment-related factors impacting on side effects. Lastly, patients with very good prognostic factors may be considered for receiving a combined treatment.
Collapse
Affiliation(s)
- Silvia Scoccianti
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy.
| | - Marco Perna
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Emanuela Olmetto
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Camilla Delli Paoli
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Francesca Terziani
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Lucia Pia Ciccone
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Beatrice Detti
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Daniela Greto
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Gabriele Simontacchi
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Roberta Grassi
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Erika Scoccimarro
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Pierluigi Bonomo
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Monica Mangoni
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Isacco Desideri
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Vanessa Di Cataldo
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Marco Vernaleone
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| | - Marta Casati
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", Medical Physics Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Stefania Pallotta
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", Medical Physics Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Lorenzo Livi
- Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology Department, University of Florence, Florence, Italy
| |
Collapse
|
11
|
Ali MY, Oliva CR, Noman ASM, Allen BG, Goswami PC, Zakharia Y, Monga V, Spitz DR, Buatti JM, Griguer CE. Radioresistance in Glioblastoma and the Development of Radiosensitizers. Cancers (Basel) 2020; 12:E2511. [PMID: 32899427 PMCID: PMC7564557 DOI: 10.3390/cancers12092511] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/24/2020] [Accepted: 08/28/2020] [Indexed: 02/07/2023] Open
Abstract
Ionizing radiation is a common and effective therapeutic option for the treatment of glioblastoma (GBM). Unfortunately, some GBMs are relatively radioresistant and patients have worse outcomes after radiation treatment. The mechanisms underlying intrinsic radioresistance in GBM has been rigorously investigated over the past several years, but the complex interaction of the cellular molecules and signaling pathways involved in radioresistance remains incompletely defined. A clinically effective radiosensitizer that overcomes radioresistance has yet to be identified. In this review, we discuss the current status of radiation treatment in GBM, including advances in imaging techniques that have facilitated more accurate diagnosis, and the identified mechanisms of GBM radioresistance. In addition, we provide a summary of the candidate GBM radiosensitizers being investigated, including an update of subjects enrolled in clinical trials. Overall, this review highlights the importance of understanding the mechanisms of GBM radioresistance to facilitate the development of effective radiosensitizers.
Collapse
Affiliation(s)
- Md Yousuf Ali
- Interdisciplinary Graduate Program in Human Toxicology, University of Iowa, Iowa City, IA 52242, USA;
- Free Radical & Radiation Biology Program, Department of Radiation Oncology, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA 52242, USA; (C.R.O.); (B.G.A.); (P.C.G.); (D.R.S.)
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| | - Claudia R. Oliva
- Free Radical & Radiation Biology Program, Department of Radiation Oncology, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA 52242, USA; (C.R.O.); (B.G.A.); (P.C.G.); (D.R.S.)
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| | - Abu Shadat M. Noman
- Department of Biochemistry and Molecular Biology, The University of Chittagong, Chittagong 4331, Bangladesh;
- Department of Pathology, McGill University, Montreal, QC H3A 2B4, Canada
| | - Bryan G. Allen
- Free Radical & Radiation Biology Program, Department of Radiation Oncology, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA 52242, USA; (C.R.O.); (B.G.A.); (P.C.G.); (D.R.S.)
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| | - Prabhat C. Goswami
- Free Radical & Radiation Biology Program, Department of Radiation Oncology, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA 52242, USA; (C.R.O.); (B.G.A.); (P.C.G.); (D.R.S.)
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| | - Yousef Zakharia
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA; (Y.Z.); (V.M.)
| | - Varun Monga
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA; (Y.Z.); (V.M.)
| | - Douglas R. Spitz
- Free Radical & Radiation Biology Program, Department of Radiation Oncology, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA 52242, USA; (C.R.O.); (B.G.A.); (P.C.G.); (D.R.S.)
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| | - John M. Buatti
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| | - Corinne E. Griguer
- Free Radical & Radiation Biology Program, Department of Radiation Oncology, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA 52242, USA; (C.R.O.); (B.G.A.); (P.C.G.); (D.R.S.)
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| |
Collapse
|
12
|
Yaprak G, Isık N, Gemici C, Pekyurek M, Ceylaner Bıcakcı B, Demircioglu F, Tatarlı N. Stereotactic Radiotherapy in Recurrent Glioblastoma: A Valid Salvage Treatment Option. Stereotact Funct Neurosurg 2020; 98:167-175. [PMID: 32248188 DOI: 10.1159/000505706] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 12/30/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Glioblastoma (GBM) is a dismal disease. Recurrence is inevitable despite initial surgery and postoperative temozolomide (TMZ) and radiotherapy. Salvage surgery is the standard treatment in selected patients. Chemotherapy, biological agents, and re-irradiation are other treatment approaches available. Stereotactic radiotherapy (SRT) is nowadays a common treatment as a salvage treatment option. MATERIALS AND METHODS We reviewed the files of 132 GBM cases treated between 2010 and 2018. All patients received TMZ and radiotherapy after surgery or biopsy. Among the patients who had recurrence, we identified 42 cases treated with salvage SRT. The CyberKnife robotic system was used to administer SRT. RESULTS While the median follow-up time for all patients was 16 months (range 1-123), the median follow-up time for patients treated with SRT after initial diagnosis was 26.5 months (range 9-123). The median follow-up time after SRT was 10 months (range 2-107). SRT was performed in a median of 3 fractions (range 2-5). The median prescription dose was 20 Gy (range 18-30). While the median actuarial survival after initial diagnosis for patients treated with salvage SRT was 30 months (range 9-123), it was only 14 months (range 1-111) for patients who could not be treated with salvage SRT (p = 0.001). The median survival time after SRT was 12 months, and 1- and 2-year survival rates were 48 and 9%, respectively. The time to progression after SRT was 5 months (range 1-62), and 6-month and 1-year progression-free survival rates were 50 and 22%, respectively. Patients with longer time to recurrence >12 months had longer overall survival with respect to the ones having recurrence <12 months (p < 0.001). Salvage surgery had been performed in 7 out of 42 patients before SRT. These reoperated patients had significantly worse survival after SRT when compared to the patients who underwent SRT alone (p = 0.02). SRT was well tolerated and there was no grade III/IV toxicity. CONCLUSIONS SRT is a viable salvage treatment option for recurrent GBM. SRT provides acceptable local control and survival benefit for recurrent GBM cases. SRT can be considered especially in patients with long time to recurrence.
Collapse
Affiliation(s)
- Gokhan Yaprak
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey,
| | - Naciye Isık
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Cengiz Gemici
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Melike Pekyurek
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Beyhan Ceylaner Bıcakcı
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Fatih Demircioglu
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Necati Tatarlı
- Department of Neurosurgery, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
13
|
Xu Y, Ma P, Xu Y, Dai J. Selection of prescription isodose line for brain metastases treated with volumetric modulated arc radiotherapy. J Appl Clin Med Phys 2019; 20:63-69. [PMID: 31833642 PMCID: PMC6909111 DOI: 10.1002/acm2.12761] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/26/2019] [Accepted: 09/23/2019] [Indexed: 12/13/2022] Open
Abstract
Purpose To exploit the optimal prescription isodose line (IDL) for brain metastases treated with volumetric modulated arc radiotherapy (VMAT) as there is no consensus on the selection of IDL with VMAT. Methods and materials Eighteen patients with 20 brain tumors, who were treated with VMAT, were enrolled in this study. For each tumor of every patient, five plans were designed with IDL ranging from 50% to 90% in 10% increments. Different IDLs were obtained through adjusting the constraint parameters during planning optimization. Prescription dose (10 × 5 Gy) were identical for all plans, and the plans were compared in terms of gradient index (GI), conformity Index (CI), V26 Gy/VPTV, and V32 Gy/VPTV in normal brain tissue, which correlate to radiation necrosis. Results IDL with lowest GI has a median value of 60.0% (ranging from 50% to 80%). Except for one tumor with volume larger than 10 cc, the IDL with lowest GI varies from 50% to 70%, which depends on the shape of PTV, location, and whether the target volume is adjacent to crucial OAR. Moreover, there is no significant difference for CI with varying IDL plans. The average V26 Gy/VPTV and V32 Gy/VPTV in normal brain tissue 60% IDL plans are 27.3%, 31.7% lower than 90% IDL plans separately (P < 0.05). However, by further decreasing IDL from 60% to 50%, the average V26 Gy/VPTV and V32 Gy/VPTV may increase comparing with 60% IDL plans (P > 0.05). Furthermore, a lower IDL is found to result in higher mean dose to the target volume (P < 0.05). Conclusions Plans using VMAT with PTV smaller than 10 cc tend to be optimal with IDL around 60–70% for lower GI, smaller V26 Gy/VPTV, V32 Gy/VPTV in normal brain tissue, and higher mean dose in tumor comparing with high IDL plans which have potential benefit in reducing risk of radiation necrosis and increasing the local control. However, IDL lower than 60% is not recommended for the disadvantage of increasing V26 Gy/VPTV and V32 Gy/VPTV in normal brain tissue.
Collapse
Affiliation(s)
- Yuan Xu
- Department of Radiation OncologyNational Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Pan Ma
- Department of Radiation OncologyNational Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Yingjie Xu
- Department of Radiation OncologyNational Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Jianrong Dai
- Department of Radiation OncologyNational Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| |
Collapse
|
14
|
Fractionated stereotactic radiosurgery for malignant gliomas: comparison with single session stereotactic radiosurgery. J Neurooncol 2019; 145:571-579. [DOI: 10.1007/s11060-019-03328-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 10/31/2019] [Indexed: 12/29/2022]
|
15
|
Efficacy and Safety of Hypofractionated Stereotactic Radiotherapy for Recurrent Malignant Gliomas: A Systematic Review and Meta-analysis. World Neurosurg 2019; 127:176-185. [DOI: 10.1016/j.wneu.2019.03.297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/29/2019] [Accepted: 03/30/2019] [Indexed: 02/07/2023]
|
16
|
Chapman CH, Hara JH, Molinaro AM, Clarke JL, Oberheim Bush NA, Taylor JW, Butowski NA, Chang SM, Fogh SE, Sneed PK, Nakamura JL, Raleigh DR, Braunstein SE. Reirradiation of recurrent high-grade glioma and development of prognostic scores for progression and survival. Neurooncol Pract 2019; 6:364-374. [PMID: 31555451 DOI: 10.1093/nop/npz017] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/25/2019] [Accepted: 03/04/2019] [Indexed: 12/17/2022] Open
Abstract
Background Optimal techniques and patient selection for salvage reirradiation of high-grade glioma (HGG) are unclear. In this study, we identify prognostic factors for freedom from progression (FFP) and overall survival (OS) after reirradiation, risk factors for high-grade toxicity, and validate clinical prognostic scores. Methods A total of 116 patients evaluated between 2000 and 2018 received reirradiation for HGG (99 WHO grade IV, 17 WHO grade III). Median time to first progression after initial therapy was 10.6 months. Salvage therapies before reirradiation included surgery (31%) and systemic therapy (41%). Sixty-five patients (56%) received single-fraction stereotactic radiosurgery (SRS) as reirradiation. The median biologically effective dose (BED) was 47.25 Gy, and the median planning target volume (PTV) was 4.8 cc for SRS and 95.0 cc for non-SRS treatments. Systemic therapy was given concurrently to 52% and adjuvantly to 74% of patients. Results Median FFP was 4.9 months, and median OS was 11.0 months. Significant multivariable prognostic factors for FFP were performance status, time to initial progression, and BED; for OS they were age, time to initial progression, and PTV volume at recurrence. High-grade toxicity was correlated to PTV size at recurrence. Three-level prognostic scores were generated for FFP and OS, with cross-validated receiver operating characteristic area under the curve (AUC) of 0.640 and 0.687, respectively. Conclusions Clinical variables at the time of reirradiation for HGG can be used to prognosticate FFP and OS.
Collapse
Affiliation(s)
| | - Jared H Hara
- John A. Burns School of Medicine, University of Hawaii, Honolulu
| | - Annette M Molinaro
- Department of Neurological Surgery, University of California San Francisco, USA.,Department of Epidemiology & Biostatistics, University of California San Francisco
| | - Jennifer L Clarke
- Department of Neurological Surgery, University of California San Francisco, USA.,Department of Neurology, University of California San Francisco
| | - Nancy Ann Oberheim Bush
- Department of Neurological Surgery, University of California San Francisco, USA.,Department of Neurology, University of California San Francisco
| | - Jennie W Taylor
- Department of Neurological Surgery, University of California San Francisco, USA.,Department of Neurology, University of California San Francisco
| | - Nicholas A Butowski
- Department of Neurological Surgery, University of California San Francisco, USA
| | - Susan M Chang
- Department of Neurological Surgery, University of California San Francisco, USA
| | - Shannon E Fogh
- Department of Radiation Oncology, University of California San Francisco
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco
| | - Jean L Nakamura
- Department of Neurology, University of California San Francisco
| | - David R Raleigh
- Department of Radiation Oncology, University of California San Francisco
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco
| |
Collapse
|
17
|
Kim IH. Appraisal of re-irradiation for the recurrent glioblastoma in the era of MGMT promotor methylation. Radiat Oncol J 2019; 37:1-12. [PMID: 30947475 PMCID: PMC6453809 DOI: 10.3857/roj.2019.00171] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 03/21/2019] [Indexed: 12/23/2022] Open
Abstract
Despite recent innovation in treatment techniques and subsequently improved outcomes, the majority of glioblastoma (GBL) have relapses, especially in locoregional areas. Local re-irradiation (re-RT) has been established as a feasible option for recurrent GBL of all ages with safety, tolerability, and effectiveness both in survival and quality of life regardless of fractionation schedule. To keep adverse effects under acceptable range, cumulative dose limit in equivalent dose at 2 Gy fractions by the linear-quadratic model at α/β = 2 for normal brain tissue (EQD2) with narrow margin should be observed and single/hypofractionated re-RT should be undertaken very carefully to recurrent tumor with large volume or adjacent to the brainstem. Promising outcome of re-operation (re-Op) plus re-RT (re-Op/RT) need to be validated and result from re-RT with temozolomide/bevacizumab (TMZ/BV) or new strategy is expected. Development of new-concept prognostic scoring or risk group is required to select patients properly and make use of predictive biomarkers such as O(6)-methylguanine-DNA methyltransferase (MGMT) promotor methylation that influence outcomes of re-RT, re-Op/RT, or re-RT with TMZ/BV.
Collapse
Affiliation(s)
- Il Han Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
18
|
Grauer O, Jaber M, Hess K, Weckesser M, Schwindt W, Maring S, Wölfer J, Stummer W. Combined intracavitary thermotherapy with iron oxide nanoparticles and radiotherapy as local treatment modality in recurrent glioblastoma patients. J Neurooncol 2018; 141:83-94. [PMID: 30506500 PMCID: PMC6341053 DOI: 10.1007/s11060-018-03005-x] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 09/13/2018] [Indexed: 12/17/2022]
Abstract
Background There is an increasing interest in local tumor ablative treatment modalities that induce immunogenic cell death and the generation of antitumor immune responses. Methods We report six recurrent glioblastoma patients who were treated with intracavitary thermotherapy after coating the resection cavity wall with superparamagnetic iron oxide nanoparticles (“NanoPaste” technique). Patients underwent six 1-h hyperthermia sessions in an alternating magnetic field and, if possible, received concurrent fractionated radiotherapy at a dose of 39.6 Gy. Results There were no major side effects during active treatment. However, after 2–5 months, patients developed increasing clinical symptoms. CT scans showed tumor flare reactions with prominent edema around nanoparticle deposits. Patients were treated with dexamethasone and, if necessary, underwent re-surgery to remove nanoparticles. Histopathology revealed sustained necrosis directly adjacent to aggregated nanoparticles without evidence for tumor activity. Immunohistochemistry showed upregulation of Caspase-3 and heat shock protein 70, prominent infiltration of macrophages with ingested nanoparticles and CD3+ T-cells. Flow cytometric analysis of freshly prepared tumor cell suspensions revealed increased intracellular ratios of IFN-γ to IL-4 in CD4+ and CD8+ memory T cells, and activation of tumor-associated myeloid cells and microglia with upregulation of HLA-DR and PD-L1. Two patients had long-lasting treatment responses > 23 months without receiving any further therapy. Conclusion Intracavitary thermotherapy combined with radiotherapy can induce a prominent inflammatory reaction around the resection cavity which might trigger potent antitumor immune responses possibly leading to long-term stabilization of recurrent GBM patients. These results warrant further investigations in a prospective phase-I trial.
Collapse
Affiliation(s)
- Oliver Grauer
- Department of Neurology, University Hospital of Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
| | - Mohammed Jaber
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - Katharina Hess
- Institute of Neuropathology, University Hospital of Münster, Münster, Germany
| | - Matthias Weckesser
- Department of Nuclear Medicine, University Hospital of Münster, Münster, Germany
| | - Wolfram Schwindt
- Institute of Radiology, University Hospital of Münster, Münster, Germany
| | - Stephan Maring
- Department of Radiation Oncology, University Hospital of Münster, Münster, Germany
| | - Johannes Wölfer
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany.,Competence Center for Neurosurgery, Hufeland Klinikum GmbH, Langensalzaer Landstraße 1, 99974, Mühlhausen, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| |
Collapse
|
19
|
Patterns of re-irradiation for recurrent gliomas and validation of a prognostic score. Radiother Oncol 2018; 130:156-163. [PMID: 30446315 DOI: 10.1016/j.radonc.2018.10.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/17/2018] [Accepted: 10/29/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE OR OBJECTIVE Re-irradiation is a generally accepted method for salvage treatment in patients with recurrent glioma. However, no standard radiation regimen has been defined. This study aims to compare the efficacy and safety of different treatment regimens and to independently externally validate a recently published reirradiation risk score. MATERIAL AND METHODS We retrospectively analyzed a cohort of patients with recurrent malignant glioma treated with salvage conventionally fractionated (CFRT), hypofractionated (HFRT) or stereotactic radiotherapy (SRT) between 2007 and 2017 at the University Medical Centers in Utrecht and Groningen. RESULTS Of the 121 patients included, 60 patients (50%) underwent CFRT, 22 (18%) HFRT and 39 (32%) SRT. The primary tumor was grade II-III in 52 patients and grade IV in 69 patients with median Overall Survival (mOS) since first surgery of 113 [Interquartile range: 53.2-137] and 39.7 [24.6-64.9] months respectively (p < 0.01). Overall, mOS from the first day of re-irradiation was 9.7 months [6.5-14.6]. No significant difference in mOS was found between the treatment groups. In multivariate analysis, the Karnofsky performance scale ≥70% (p < 0.01), re-irradiation for first recurrence (p = 0.02), longer time interval between RT start dates (p < 0.01) and smaller planning target volume (p < 0.05) were significant favorable prognostic factors. The reirradiation risk score was validated. CONCLUSION In our series, mOS after reirradiation was sufficient to justify use of this modality. Until a reliable treatment decision tool is developed based on larger retrospective research, the decision for re-irradiation schedule should remain personalized and based on a multidisciplinary evaluation of each patient.
Collapse
|
20
|
Gigliotti MJ, Hasan S, Karlovits SM, Ranjan T, Wegner RE. Re-Irradiation with Stereotactic Radiosurgery/Radiotherapy for Recurrent High-Grade Gliomas: Improved Survival in the Modern Era. Stereotact Funct Neurosurg 2018; 96:289-295. [PMID: 30404102 DOI: 10.1159/000493545] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 09/05/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy of stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (fSRT) as salvage therapy for recurrent high-grade glioma and to look at the overall efficacy of treatment with linear accelerator (LINAC)-based radiosurgery and fractionated radiotherapy. METHODS From 2010 to 2017, a total of 25 patients aged 23-74 years were re-irradiated with LINAC-based SRS and fSRT. Patients were treated to a median dose of 25 Gy in 5 fractions. RESULTS The median overall survival (OS) after (initial) diagnosis was 39 months with an actuarial 1-, 3-, and 5-year OS rate of 88, 56, and 30%, respectively. After treatment with SRS or fSRT, the median OS was 9 months with an actuarial 1-year OS rate of 29%. Local control, assessed for 28 tumors, after 6 months was 57%, while local control after 1 year was 39%. Three patients experienced local failure. There was no evidence of toxicity noted after SRS or fSRT throughout the follow-up period. CONCLUSION SRS and fSRT remain a safe, reasonable, effective treatment option for re-irradiation following recurrent glioblastoma. Additionally, treatment volume may predict local control in the salvage setting.
Collapse
Affiliation(s)
- Michael J Gigliotti
- Division of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Shaakir Hasan
- Division of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Stephen M Karlovits
- Division of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Tulika Ranjan
- Division of Medical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania, USA
| | - Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA,
| |
Collapse
|
21
|
Re-irradiation of recurrent glioblastoma as part of a sequential multimodality treatment concept. Clin Transl Oncol 2018; 21:582-587. [PMID: 30284233 DOI: 10.1007/s12094-018-1957-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/14/2018] [Indexed: 01/18/2023]
Abstract
PURPOSE The aim of this retrospective study was to evaluate survival outcomes in well-performing, mainly, young patients receiving a sequence of all available therapeutic options for relapsed glioblastoma, including re-irradiation. METHODS We performed a retrospective analysis of 27 patients irradiated twice for glioblastoma between 2008 and 2016. In the first line, all had surgical treatment of the tumor followed by radiotherapy with a total dose of 60 Gy and temozolomide. All re-irradiated patients were treated with a total dose of 36 Gy in 12 fractions. The endpoints were death from glioblastoma or any cause, and toxicity after re-irradiation. RESULTS The median follow-up of survivors was 35.6 months. At the time of analysis, 25 patients had died. The median time between first and second radiotherapy was 18.9 months (6.1-58.4). Re-irradiation was performed at different time points of first, second and third progression. The median overall survival after first diagnosis was 39.2 months. Five years after first surgery, nearly 20% of the patients were alive. CONCLUSION Carefully planned re-irradiation of the brain is a safe therapy for recurrent glioblastoma. Younger and well-performing patients benefit from all available therapy options. Every patient should be discussed in a multidisciplinary setting at each time point of tumor progression. Further prospective studies are needed to define the optimal time, dose and volume of re-irradiation.
Collapse
|
22
|
Sadik ZHA, Hanssens PEJ, Verheul JB, Beute GN, Te Lie S, Leenstra S, Ardon H. Gamma knife radiosurgery for recurrent gliomas. J Neurooncol 2018; 140:615-622. [PMID: 30191361 PMCID: PMC6267255 DOI: 10.1007/s11060-018-2988-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/21/2018] [Indexed: 11/06/2022]
Abstract
Objective In recent years, gamma knife radiosurgery (GKRS) has become increasingly more popular as a salvage treatment modality for patients diagnosed with recurrent gliomas. The goal of GKRS for recurrent glioma patients is to improve survival rates with minimal burden for these patients. The emphasis of this report is on local tumor control (TC), clinical outcome and survival analysis. Methods We performed a retrospective analysis of prospectively collected data of all patients who underwent GKRS for gliomas at the Gamma Knife Center Tilburg between 23-09-2002 and 21-05-2015. In total, 94 patients with glioma were treated with GKRS. Two patients were excluded because GKRS was used as a first stage treatment. The other 92 patients were included for analysis. Results TC was 37% for all tumors (TC was 50% in LGGs and 27% in HGGs). Local progression (LP) was 46% for all tumors (LP was 31% in LGGs and 58% in HGGs). New distant lesions were seen in 18% of all patients (in 5% of LGG patients and 31% of HGG patients). Median progression-free and overall survival (PFS and OS) for all patients were 10.5 and 34.4 months, respectively. Median PFS was 50.1 and 5.7 months for low and high grade tumors, respectively. Median OS was 86.6 and 12.8 months for low and high grade tumors, respectively. No serious adverse events were noted post-GKRS. Conclusion GKRS can safely be used as salvage treatment for recurrent glioma and seems to improve survival rates in (high grade) glioma patients with minimal burden.
Collapse
Affiliation(s)
- Zjiwar H A Sadik
- Gamma Knife Center, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands. .,Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands. .,Department of Neurosurgery, Amsterdam Medical Center, Amsterdam, The Netherlands.
| | | | - Jeroen B Verheul
- Gamma Knife Center, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Guus N Beute
- Gamma Knife Center, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Suan Te Lie
- Gamma Knife Center, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Sieger Leenstra
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Hilko Ardon
- Gamma Knife Center, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| |
Collapse
|
23
|
Re-irradiation for malignant glioma: Toward patient selection and defining treatment parameters for salvage. Adv Radiat Oncol 2018; 3:582-590. [PMID: 30370358 PMCID: PMC6200913 DOI: 10.1016/j.adro.2018.06.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/25/2018] [Accepted: 06/28/2018] [Indexed: 12/23/2022] Open
Abstract
Purpose Reirradiation for recurrent glioma remains controversial without knowledge of optimal patient selection, dose, fractionation, and normal tissue tolerances. We retrospectively evaluated outcomes and toxicity after conventionally fractionated reirradiation for recurrent high-grade glioma, along with the impact of concurrent chemotherapy. Methods and materials We conducted a retrospective review of patients reirradiated for high-grade glioma recurrence between 2007 and 2016 (including patients with initial low-grade glioma). Outcome metrics included overall survival (OS), prognostic factors for survival, and treatment-related toxicity. Results Patients (n = 118; median age 47 years; median Karnofsky performance status score: 80) were re-treated at a median of 28 months (range, 5-214 months) after initial radiation therapy. The median reirradiation dose was 41.4 Gy (range, 12.6-54.0 Gy) to a median lesion volume of 202 cm3 (range, 20-901 cm3). The median cumulative (initial radiation and reirradiation combined) potential maximum brainstem dose was 76.9 Gy (range, 5.0-108.3 Gy) and optic apparatus dose was 56.0 Gy (range, 4.5-90.9 Gy). Of the patients, 56% received concurrent temozolomide, 14%, bevacizumab, and 11%, temozolomide plus bevacizumab; 19% had no chemotherapy. The planned reirradiation was completed by 90% of patients. Median OS from the completion of reirradiation was 9.6 months (95% confidence interval [CI], 7.5-11.7 months) for all patients and 14.0, 11.5, and 6.7 months for patients with initial grade 2, 3, and 4 glioma, respectively. On multivariate analysis, better OS was observed with a >24-month interval between radiation treatments (hazard ratio [HR]: 0.3; 95% CI, 0.2-0.5; P < .001), reirradiation dose >41.4 Gy (HR: 0.6; 95% CI, 0.4-0.9; P = .03), and gross total resection before reirradiation (HR: 0.6, 95% CI, 0.3-0.9; P = .02). Radiation necrosis and grade ≥3 late neurotoxicity were both minimal (<5%). No symptomatic persistent brainstem or optic nerve/chiasm injury was identified. Conclusions Salvage reirradiation, even at doses >41.4 Gy in conventional fractionation, along with chemotherapy, was safe and well tolerated with meaningful survival duration. These data provide information that may be useful in implementing safe reirradiation treatments for appropriately selected patients and guiding future studies to define optimal reirradiation doses, maximal safe doses to critical structures, and the role of systemic therapy.
Collapse
|
24
|
Re-irradiation as salvage treatment in recurrent glioblastoma: A comprehensive literature review to provide practical answers to frequently asked questions. Crit Rev Oncol Hematol 2018; 126:80-91. [PMID: 29759570 DOI: 10.1016/j.critrevonc.2018.03.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 02/11/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023] Open
Abstract
The primary aim of this review is to provide practical recommendations in terms of fractionation, dose, constraints and selection criteria to be used in the daily clinical routine. Based on the analysis of the literature reviewed, in order to keep the risk of severe side effects ≤3,5%, patients should be stratified according to the target volume. Thus, patients should be treated with different fractionation and total EQD2 (<12.5 ml: EQD2 < 65 Gy with radiosurgery; >12.5 ml and <35 ml: EQD2 < 50 Gy with hypofractionated stereotactic radiotherapy; >35 ml and <50 ml: EQD2 < 36 Gy with conventionally fractionated radiotherapy). Concurrent approaches with temozolomide or bevacizumab do not seem to improve the outcomes of reirradiation and may lead to a higher risk of toxicity but these findings need to be confirmed in prospective series.
Collapse
|
25
|
Youland RS, Lee JY, Kreofsky CR, Brown PD, Uhm JH, Laack NN. Modern reirradiation for recurrent gliomas can safely delay tumor progression. Neurooncol Pract 2018; 5:46-55. [PMID: 31385961 PMCID: PMC6655388 DOI: 10.1093/nop/npx014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Despite advances in modern therapy, high-grade gliomas continue to portend a dismal prognosis and nearly all patients will experience relapse. Unfortunately, salvage options remain limited. In this study, we assessed outcomes for patients with recurrent gliomas treated with reirradiation. METHODS We retrospectively identified 48 glioma patients treated with reirradiation between 2013 and 2016. All had radiographic or pathologic evidence of recurrence. Prognostic factors were abstracted from the electronic medical record. RESULTS Initial surgery included biopsy in 15, subtotal resection in 21, and gross total resection in 12. Initial chemotherapy included temozolomide (TMZ) in 31, TMZ+dasatinib in 7, TMZ+vorinostat in 3, and procarbazine, lomustine, and vincristine in 2. The median dose of primary radiotherapy was 60 Gy delivered in 30 fractions. Median overall survival (OS) and progression-free survival (PFS) from initial diagnosis were 3.2 and 1.7 years, respectively. A total of 36 patients failed salvage bevacizumab before reirradiation. Salvage surgery was performed before reirradiation in 21 patients. Median time to reirradiation was 1.7 years. Median follow-up was 13.7 months from reirradiation. Concurrent systemic therapy was given in 33 patients (bevacizumab in 27, TMZ in 8, and lomustine in 2). Median PFS and OS after reirradiation were 3.2 and 6.3 months, respectively. Radionecrosis occurred in 4 patients and no radionecrosis was seen in patients receiving concurrent bevacizumab with reirradiation (0% vs 19%, P = .03). CONCLUSIONS Reirradiation may result in delayed tumor progression with acceptable toxicity. Prospective trials are needed to determine the impact of reirradiation on tumor progression and quality of life.
Collapse
Affiliation(s)
- Ryan S Youland
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - John Y Lee
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Cole R Kreofsky
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Joon H Uhm
- Division of Medical Oncology, Mayo Clinic, Rochester, MN
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| |
Collapse
|
26
|
Ho A, Jena R. Re-irradiation in the Brain: Primary Gliomas. Clin Oncol (R Coll Radiol) 2018; 30:124-136. [DOI: 10.1016/j.clon.2017.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/02/2017] [Accepted: 11/06/2017] [Indexed: 02/07/2023]
|
27
|
Maranzano E, Anselmo P, Casale M, Trippa F, Carletti S, Principi M, Loreti F, Italiani M, Caserta C, Giorgi C. Treatment of Recurrent Glioblastoma with Stereotactic Radiotherapy: Long-Term Results of a Mono-Institutional Trial. TUMORI JOURNAL 2018; 97:56-61. [DOI: 10.1177/030089161109700111] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and background Few clinical data exist concerning normal brain tissue tolerance to re-irradiation. The present study evaluated long-term outcome of 22 recurrent glioblastoma patients re-irradiated with radiosurgery or fractionated stereotactic radiotherapy. Methods Twenty-two patients were treated with radiosurgery (13, 59%) or fractionated stereotactic radiotherapy (9, 41%) for 24 lesions of recurrent glioblastoma. The male/female ratio was 14: 8, median age 55 years (range, 27–81), and median Karnofsky performance status 90 (range, 70–100). The majority of the cases (77%) was in recursive partitioning analysis classes III or IV. Radiosurgery or fractionated stereotactic radiotherapy was chosen according to lesion size and location. Results Median time between primary radiotherapy and re-irradiation was 9 months. Median doses were 17 Gy and 30 Gy, whereas median cumulative normalized total dose was 141 Gy and 98 Gy for radiosurgery and fractionated stereotactic radiotherapy, respectively. All patients submitted to radiosurgery had a cumulative normalized total dose of more than 100 Gy, whereas only a few (44%) of fractionated stereotactic radiotherapy patients had a cumulative normalized total dose exceeding 100 Gy. Median follow-up from re-irradiation was 54 months. At the time of analysis, all patients had died. After re-irradiation, 1 (4%) lesion was in partial remission, 16 (67%) lesions were stable, and the remaining 7 (29%) were in progression. Median duration of response was 6 months, and median survival from re-irradiation 11 months. Three of 13 (23%) patients submitted to radiosurgery developed asymptomatic brain radionecrosis. The cumulative normalized total dose for the 3 patients was 122 Gy, 124 Gy, and 141 Gy, respectively. In one case, the volume of the lesion was large (14 cc), and in the other 2 the interval between the first and second cycle of radiotherapy was short (5 months). Conclusions Re-irradiation with radiosurgery and fractionated stereotactic radiotherapy is feasible and effective in recurrent glioblastoma patients. Apart from the importance of an accurate patient selection, cumulative radiotherapy dose and a correct indication for radiosurgery or fractionated stereotactic radiotherapy must be taken into account to avoid brain toxicity. Free full text available at www.tumorionline.it
Collapse
|
28
|
Mann J, Ramakrishna R, Magge R, Wernicke AG. Advances in Radiotherapy for Glioblastoma. Front Neurol 2018; 8:748. [PMID: 29379468 PMCID: PMC5775505 DOI: 10.3389/fneur.2017.00748] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 12/27/2017] [Indexed: 11/13/2022] Open
Abstract
External beam radiotherapy (RT) has long played a crucial role in the treatment of glioblastoma. Over the past several decades, significant advances in RT treatment and image-guidance technology have led to enormous improvements in the ability to optimize definitive and salvage treatments. This review highlights several of the latest developments and controversies related to RT, including the treatment of elderly patients, who continue to be a fragile and vulnerable population; potential salvage options for recurrent disease including reirradiation with chemotherapy; the latest imaging techniques allowing for more accurate and precise delineation of treatment volumes to maximize the therapeutic ratio of conformal RT; the ongoing preclinical and clinical data regarding the combination of immunotherapy with RT; and the increasing evidence of cancer stem-cell niches in the subventricular zone which may provide a potential target for local therapies. Finally, continued development on many fronts have allowed for modestly improved outcomes while at the same time limiting toxicity.
Collapse
Affiliation(s)
- Justin Mann
- Department of Radiation Oncology, Weill Cornell Medical College, New York, NY, United States
| | - Rohan Ramakrishna
- Department of Neurological Surgery, Weill Cornell Medical College, New York, NY, United States
| | - Rajiv Magge
- Department of Neurology, Weill Cornell Medical College, New York, NY, United States
| | - A Gabriella Wernicke
- Department of Radiation Oncology, Weill Cornell Medical College, New York, NY, United States
| |
Collapse
|
29
|
Zygogianni A, Protopapa M, Kougioumtzopoulou A, Simopoulou F, Nikoloudi S, Kouloulias V. From imaging to biology of glioblastoma: new clinical oncology perspectives to the problem of local recurrence. Clin Transl Oncol 2018; 20:989-1003. [PMID: 29335830 DOI: 10.1007/s12094-018-1831-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 01/04/2018] [Indexed: 12/13/2022]
Abstract
GBM is one of the most common and aggressive brain tumors. Surgery and adjuvant chemoradiation have succeeded in providing a survival benefit. Although most patients will eventually experience local recurrence, the means to fight recurrence are limited and prognosis remains poor. In a disease where local control remains the major challenge, few trials have addressed the efficacy of local treatments, either surgery or radiation therapy. The present article reviews recent advances in the biology, imaging and biomarker science of GBM as well as the current treatment status of GBM, providing new perspectives to the problem of local recurrence.
Collapse
Affiliation(s)
- A Zygogianni
- Radiotherapy Unit, 1st Department of Radiology, Medical School, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - M Protopapa
- Radiotherapy Unit, 1st Department of Radiology, Medical School, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - A Kougioumtzopoulou
- Radiotherapy Unit, 2nd Department of Radiology, Medical School, ATTIKON University Hospital, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Greece
| | - F Simopoulou
- Radiotherapy Unit, 1st Department of Radiology, Medical School, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - S Nikoloudi
- Radiotherapy Unit, 1st Department of Radiology, Medical School, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - V Kouloulias
- Radiotherapy Unit, 2nd Department of Radiology, Medical School, ATTIKON University Hospital, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Greece.
| |
Collapse
|
30
|
Youland RS, Pafundi DH, Brinkmann DH, Lowe VJ, Morris JM, Kemp BJ, Hunt CH, Giannini C, Parney IF, Laack NN. Prospective trial evaluating the sensitivity and specificity of 3,4-dihydroxy-6-[18F]-fluoro-L-phenylalanine (18F-DOPA) PET and MRI in patients with recurrent gliomas. J Neurooncol 2018; 137:583-591. [PMID: 29330751 DOI: 10.1007/s11060-018-2750-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 01/07/2018] [Indexed: 12/11/2022]
Abstract
Treatment-related changes can be difficult to differentiate from progressive glioma using MRI with contrast (CE). The purpose of this study is to compare the sensitivity and specificity of 18F-DOPA-PET and MRI in patients with recurrent glioma. Thirteen patients with MRI findings suspicious for recurrent glioma were prospectively enrolled and underwent 18F-DOPA-PET and MRI for neurosurgical planning. Stereotactic biopsies were obtained from regions of concordant and discordant PET and MRI CE, all within regions of T2/FLAIR signal hyperintensity. The sensitivity and specificity of 18F-DOPA-PET and CE were calculated based on histopathologic analysis. Receiver operating characteristic curve analysis revealed optimal tumor to normal (T/N) and SUVmax thresholds. In the 37 specimens obtained, 51% exhibited MRI contrast enhancement (M+) and 78% demonstrated 18F-DOPA-PET avidity (P+). Imaging characteristics included M-P- in 16%, M-P+ in 32%, M+P+ in 46% and M+P- in 5%. Histopathologic review of biopsies revealed grade II components in 16%, grade III in 43%, grade IV in 30% and no tumor in 11%. MRI CE sensitivity for recurrent tumor was 52% and specificity was 50%. PET sensitivity for tumor was 82% and specificity was 50%. A T/N threshold > 2.0 altered sensitivity to 76% and specificity to 100% and SUVmax > 1.36 improved sensitivity and specificity to 94 and 75%, respectively. 18F-DOPA-PET can provide increased sensitivity and specificity compared with MRI CE for visualizing the spatial distribution of recurrent gliomas. Future studies will incorporate 18F-DOPA-PET into re-irradiation target volume delineation for RT planning.
Collapse
Affiliation(s)
- Ryan S Youland
- Department of Radiation Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Deanna H Pafundi
- Department of Radiation Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Debra H Brinkmann
- Department of Radiation Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Val J Lowe
- Division of Nuclear Medicine, Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jonathan M Morris
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Bradley J Kemp
- Division of Nuclear Medicine, Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Christopher H Hunt
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Caterina Giannini
- Department of Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ian F Parney
- Department of Neurosurgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| |
Collapse
|
31
|
Attal J, Chaltiel L, Lubrano V, Sol JC, Lanaspeze C, Vieillevigne L, Latorzeff I, Cohen-Jonathan Moyal E. Subventricular zone involvement at recurrence is a strong predictive factor of outcome following high grade glioma reirradiation. J Neurooncol 2017; 136:413-419. [PMID: 29273890 DOI: 10.1007/s11060-017-2669-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 11/11/2017] [Indexed: 11/26/2022]
Abstract
We aimed to assess the efficacy of stereotactic irradiation for patients with recurrent high-grade glioma (HGG) and identify predictive factors of progression-free survival (PFS) and overall survival (OS) following reirradiation. We identified 32 patients with recurrent brain HGG who had been treated with either single-dose (stereotactic radiosurgery) or fractionated stereotactic radiotherapy between April 2008 and October 2015. Median follow up was 21.4 months (range 12.9-23.2) and median PFS was and 3.3 months (95% CI [2.3-4.7]), respectively. OS was 90.40% (95% CI [73.09-96.80]) at 6 months and 79.55% (95% CI [59.9-90.29]) at 12 months. Univariate analysis showed that biological effective dose at isocenter ≤ 76 Gy was a poor prognostic factor for both OS (83.33 vs. 100% at 6 months, p = 0.032) and median PFS (2.7 vs. 4.7 months, p = 0.025), as was gross tumor volume (GTV) above 1 cm3 for OS (86.15 vs. 94.12% at 6 months, p = 0.043). Contact with the subventricular zone (SVZ) was also a poor prognostic factor for median PFS (2.3 vs. 4.7 months, p = 0.002). Multivariate analysis showed that SVZ contact remained a poor prognostic factor for PFS (hazard ratio = 3.44, 95% CI [1.21-9.82], p = 0.021). Results suggest that reirradiation is a safe and effective treatment option for recurrent HGG in patients with a good Karnosfsky Performance Scale score, a long progression-free interval since first radiation and limited GTV, and that contact to SVZ is a strong prognostic factor for PFS.
Collapse
Affiliation(s)
- J Attal
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse-Oncopôle, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France.
| | - L Chaltiel
- Department of Biostatistics, Institut Universitaire du Cancer de Toulouse-Oncopôle, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France
| | - V Lubrano
- Regional Center for Stereotactic Radiosurgery, CHU Rangueil, Avenue Jean-Poulhès, 31052, Toulouse, France
- Department of Neurosurgery, CHU de Toulouse, Université Paul-Sabatier, 31059, Toulouse, France
| | - J C Sol
- Department of Neurosurgery, CHU de Toulouse, Université Paul-Sabatier, 31059, Toulouse, France
| | - C Lanaspeze
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse-Oncopôle, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France
| | - L Vieillevigne
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse-Oncopôle, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France
| | - I Latorzeff
- Regional Center for Stereotactic Radiosurgery, CHU Rangueil, Avenue Jean-Poulhès, 31052, Toulouse, France
- Department of Oncology-Radiotherapy, Groupe ONCORAD Garonne, Clinique Pasteur, 31300, Toulouse, France
| | - E Cohen-Jonathan Moyal
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse-Oncopôle, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France
- INSERM U1037, Cancer Research Center of Toulouse (CRCT), 31000, Toulouse, France
- Université Toulouse III Paul Sabatier, 31300, Toulouse, France
| |
Collapse
|
32
|
Lévy S, Chapet S, Scher N, Debbi K, Ruffier A, Bernadou G, Pointreau Y, Calais G. Reirradiation of gliomas under stereotactic conditions: Prognostic factors for survival without relapse or side effects, a retrospective study at Tours regional university hospital (France). Cancer Radiother 2017; 21:759-765. [PMID: 29128197 DOI: 10.1016/j.canrad.2017.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 05/06/2017] [Accepted: 05/16/2017] [Indexed: 01/18/2023]
Abstract
PURPOSE To search for factors correlated with relapse-free survival following stereotactic reirradiation in patients with recurrent glioma following radiochemotherapy and evaluate tolerance to this treatment. PATIENTS AND METHODS Initial radiotherapy was given according to the protocol of Stupp and al. Reirradiation was performed using the CyberKnife® system. Patients could have had surgical resection initially and at the time of recurrence. We analysed 13 patients treated between July 2010 and September 2014. The median age was 55 years. The doses delivered ranged from 20 to 36Gy, in one to ten fractions. RESULTS Median survival after stereotactic radiotherapy was 14 months. Survival without relapse was 3.7 months. Factors significantly influencing duration of relapse-free survival were: age (P=0.04), total dose (P=0.02), dose per fraction (P=0.04) and number of fractions (P=0.01). We found no correlation between gross tumour volume, clinical target volume, grade of tumour or prescription isodose and relapse-free survival following radiochemotherapy. Three patients developed radionecrosis. CONCLUSION Reirradiation under stereotactic conditions is well tolerated. A dose of more than 30Gy delivered in 5 or more fractions seems to prolong relapse-free survival.
Collapse
Affiliation(s)
- S Lévy
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France.
| | - S Chapet
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France
| | - N Scher
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France
| | - K Debbi
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France
| | - A Ruffier
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France
| | - G Bernadou
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France
| | - Y Pointreau
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France; Institut interrégional de cancérologie centre Jean-Bernard, clinique Victor-Hugo, 9, rue Beauverger, 72000 Le Mans, France
| | - G Calais
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France
| |
Collapse
|
33
|
Imber BS, Kanungo I, Braunstein S, Barani IJ, Fogh SE, Nakamura JL, Berger MS, Chang EF, Molinaro AM, Cabrera JR, McDermott MW, Sneed PK, Aghi MK. Indications and Efficacy of Gamma Knife Stereotactic Radiosurgery for Recurrent Glioblastoma: 2 Decades of Institutional Experience. Neurosurgery 2017; 80:129-139. [PMID: 27428784 DOI: 10.1227/neu.0000000000001344] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 05/23/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The role of stereotactic radiosurgery (SRS) for recurrent glioblastoma and the radionecrosis risk in this setting remain unclear. OBJECTIVE To perform a large retrospective study to help inform proper indications, efficacy, and anticipated complications of SRS for recurrent glioblastoma. METHODS We retrospectively analyzed patients who underwent Gamma Knife SRS between 1991 and 2013. We used the partitioning deletion/substitution/addition algorithm to identify potential predictor covariate cut points and Kaplan-Meier and proportional hazards modeling to identify factors associated with post-SRS and postdiagnosis survival. RESULTS One hundred seventy-four glioblastoma patients (median age, 54.1 years) underwent SRS a median of 8.7 months after initial diagnosis. Seventy-five percent had 1 treatment target (range, 1-6), and median target volume and prescriptions were 7.0 cm 3 (range, 0.3-39.0 cm 3 ) and 16.0 Gy (range, 10-22 Gy), respectively. Median overall survival was 10.6 months after SRS and 19.1 months after diagnosis. Kaplan-Meier and multivariable modeling revealed that younger age at SRS, higher prescription dose, and longer interval between original surgery and SRS are significantly associated with improved post-SRS survival. Forty-six patients (26%) underwent salvage craniotomy after SRS, with 63% showing radionecrosis or mixed tumor/necrosis vs 35% showing purely recurrent tumor. The necrosis/mixed group had lower mean isodose prescription compared with the tumor group (16.2 vs 17.8 Gy; P = .003) and larger mean treatment volume (10.0 vs 5.4 cm 3 ; P = .009). CONCLUSION Gamma Knife may benefit a subset of focally recurrent patients, particularly those who are younger with smaller recurrences. Higher prescriptions are associated with improved post-SRS survival and do not seem to have greater risk of symptomatic treatment effect.
Collapse
Affiliation(s)
- Brandon S Imber
- University of California, San Francisco School of Medicine, San Francisco, California
| | | | - Steve Braunstein
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Igor J Barani
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Shannon E Fogh
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Jean L Nakamura
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | | | | | | | | | | | - Penny K Sneed
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | | |
Collapse
|
34
|
Lee I, Kalkanis S, Hadjipanayis CG. Stereotactic Laser Interstitial Thermal Therapy for Recurrent High-Grade Gliomas. Neurosurgery 2017; 79 Suppl 1:S24-S34. [PMID: 27861323 DOI: 10.1227/neu.0000000000001443] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The value of maximal safe cytoreductive surgery in recurrent high-grade gliomas (HGGs) is gaining wider acceptance. However, patients may harbor recurrent tumors that may be difficult to access with open surgery. Laser interstitial thermal therapy (LITT) is emerging as a technique for treating a variety of brain pathologies, including primary and metastatic tumors, radiation necrosis, and epilepsy. OBJECTIVE To review the role of LITT in the treatment of recurrent HGGs, for which current treatments have limited efficacy, and to discuss the possible role of LITT in the disruption of the blood-brain barrier to increase delivery of chemotherapy locoregionally. METHODS A MEDLINE search was performed to identify 17 articles potentially appropriate for review. Of these 17, 6 reported currently commercially available systems and as well as magnetic resonance thermometry to monitor the ablation and, thus, were thought to be most appropriate for this review. These studies were then reviewed for complications associated with LITT. Ablation volume, tumor coverage, and treatment times were also reviewed. RESULTS Sixty-four lesions in 63 patients with recurrent HGGs were treated with LITT. Frontal (n = 34), temporal (n = 14), and parietal (n = 16) were the most common locations. Permanent neurological deficits were seen in 7 patients (12%), vascular injuries occurred in 2 patients (3%), and wound infection was observed in 1 patient (2%). Ablation coverage of the lesions ranged from 78% to 100%. CONCLUSION Although experience using LITT for recurrent HGGs is growing, current evidence is insufficient to offer a recommendation about its role in the treatment paradigm for recurrent HGGs. ABBREVIATIONS BBB, blood-brain barrierFDA, US Food and Drug AdministrationGBM, glioblastoma multiformeHGG, high-grade gliomaLITT, laser interstitial thermal therapy.
Collapse
Affiliation(s)
- Ian Lee
- *Hermelin Brain Tumor Center, Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan; ‡Department of Neurosurgery, Mt. Sinai Beth Israel Hospital, New York City, New York
| | | | | |
Collapse
|
35
|
Fetcko K, Lukas RV, Watson GA, Zhang L, Dey M. Survival and complications of stereotactic radiosurgery: A systematic review of stereotactic radiosurgery for newly diagnosed and recurrent high-grade gliomas. Medicine (Baltimore) 2017; 96:e8293. [PMID: 29068998 PMCID: PMC5671831 DOI: 10.1097/md.0000000000008293] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 09/13/2017] [Accepted: 09/16/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Utilization of stereotactic radiosurgery (SRS) for treatment of high-grade gliomas (HGGs) has been slowly increasing with variable reported success rates. OBJECTIVE Systematic review of the available data to evaluate the efficacy of SRS as a treatment for HGG with regards to median overall survival (OS) and progression-free survival (PFS), in addition to ascertaining the rate of radiation necrosis and other SRS-related major neurological complications. METHODS Literature searches were performed for publications from 1992 to 2016. The pooled estimates of median PFS and median OS were calculated as a weighted estimate of population medians. Meta-analyses of published rates of radiation necrosis and other major neurological complications were also performed. RESULTS Twenty-nine studies reported the use of SRS for recurrent HGG, and 16 studies reported the use of SRS for newly diagnosed HGG. For recurrent HGG, the pooled estimates of median PFS and median OS were 5.42 months (3-16 months) and 20.19 months (9-65 months), respectively; the pooled radiation necrosis rate was 5.9% (0-44%); and the pooled estimates of major neurological complications rate was 3.3% (0-23%). For newly diagnosed HGG, the pooled estimates of median PFS and median OS were 7.89 months (5.5-11 months) and 16.87 months (9.5-33 months) respectively; the pooled radiation necrosis rate was 6.5% (0-33%); and the pooled estimates of other major neurological complications rate was 1.5% (0-25%). CONCLUSION Our results suggest that SRS holds promise as a relatively safe treatment option for HGG. In terms of efficacy at this time, there are inadequate data to support routine utilization of SRS as the standard of care for newly diagnosed or recurrent HGG. Further studies should be pursued to define more clearly the therapeutic role of SRS.
Collapse
Affiliation(s)
- Kaleigh Fetcko
- Department of Neurosurgery, Indiana University, Indianapolis, IN
| | - Rimas V. Lukas
- Department of Neurology, Northwestern University, Chicago, IL
| | - Gordon A. Watson
- Department of Radiation Oncology, Simon Cancer Center, Indiana University, Indianapolis, IN
| | - Lingjiao Zhang
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philidelphia, PA
| | - Mahua Dey
- Department of Neurosurgery, Indiana University, Indianapolis, IN
| |
Collapse
|
36
|
Re-irradiation after gross total resection of recurrent glioblastoma : Spatial pattern of recurrence and a review of the literature as a basis for target volume definition. Strahlenther Onkol 2017; 193:897-909. [PMID: 28616821 DOI: 10.1007/s00066-017-1161-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 05/23/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Currently, patients with gross total resection (GTR) of recurrent glioblastoma (rGBM) undergo adjuvant chemotherapy or are followed up until progression. Re-irradiation, as one of the most effective treatments in macroscopic rGBM, is withheld in this situation, as uncertainties about the pattern of re-recurrence, the target volume, and also the efficacy of early re-irradiation after GTR exist. METHODS Imaging and clinical data from 26 consecutive patients with GTR of rGBM were analyzed. The spatial pattern of recurrences was analyzed according to the RANO-HGG criteria ("response assessment in neuro-oncology criteria for high-grade gliomas"). Progression-free (PFS) and overall survival (OS) were analyzed by the Kaplan-Meier method. Furthermore, a systematic review was performed in PubMed. RESULTS All but 4 patients underwent adjuvant chemotherapy after GTR. Progression was diagnosed in 20 of 26 patients and 70% of recurrent tumors occurred adjacent to the resection cavity. The median extension beyond the edge of the resection cavity was 20 mm. Median PFS was 6 months; OS was 12.8 months. We propose a target volume containing the resection cavity and every contrast enhancing lesion as the gross tumor volume (GTV), a spherical margin of 5-10 mm to generate the clinical target volume (CTV), and a margin of 1-3 mm to generate the planning target volume (PTV). Re-irradiation of this volume is deemed to be safe and likely to prolong PFS. CONCLUSION Re-irradiation is worth considering also after GTR, as the volumes that need to be treated are limited and re-irradiation has already proven to be a safe treatment option in general. The strategy of early re-irradiation is currently being tested within the GlioCave/NOA 17/Aro 2016/03 trial.
Collapse
|
37
|
The evolving role for re-irradiation in the management of recurrent grade 4 glioma. J Neurooncol 2017; 134:523-530. [PMID: 28386661 DOI: 10.1007/s11060-017-2392-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 02/24/2017] [Indexed: 01/14/2023]
Abstract
Although significant gains have been realized in the management of grade 4 glioma, the majority of these patients will ultimately suffer local recurrence within the prior field of treatment. Clearly, novel local treatment strategies are required to improve patient outcomes. Concerns of toxicity have limited enthusiasm for the utilization of re-irradiation as a treatment option. However, using modern imaging technology and precision radiotherapy delivery techniques re-irradiation has proven a feasible option achieving both a palliative benefit and prolongation of survival with low toxicity rates. The evolution of re-irradiation as a treatment modality for recurrent grade 4 glioma is reviewed. In addition, potential targeted radiosensitizers to be used in conjunction with re-irradiation are also discussed.
Collapse
|
38
|
Benefit of re-operation and salvage therapies for recurrent glioblastoma multiforme: results from a single institution. J Neurooncol 2017; 132:419-426. [PMID: 28374095 DOI: 10.1007/s11060-017-2383-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 02/22/2017] [Indexed: 10/19/2022]
Abstract
The optimal management of recurrent glioblastoma (GBM) has yet to be determined. We aim to assess the benefits of re-operation and salvage therapies (chemotherapy and/or re-irradiation) for recurrent GBM and to identify prognostic factors associated with better survival. All patients who underwent surgery for GBM between January 2005 and December 2012 followed by adjuvant radiotherapy, and who developed GBM recurrence on imaging were included in this retrospective study. Univariate and multivariate analysis was performed using Cox models in order to identify factors associated with overall survival (OS). One hundred and eighty patients treated to a dose of 60 Gy were diagnosed with recurrent GBM. At a median follow-up time of 6.2 months, the median survival (MS) from time of recurrence was 6.6 months. Sixty-nine patients underwent repeat surgery for recurrence based on imaging. To establish the benefits of repeat surgery and salvage therapies, 68 patients who underwent repeat surgery were matched to patients who did not based on extent of initial resection and presence of subventricular zone involvement at recurrence. MS for patients who underwent re-operation was 9.6 months, compared to 5.3 months for patients who did not have repeat surgery (p < 0.0001). Multivariate analysis in the matched pairs confirmed that repeat surgery with the addition of other salvage treatment can significantly affect patient outcome (HR 0.53). Re-operation with additional salvage therapies for recurrent GBM provides survival prolongation at the time of progression.
Collapse
|
39
|
Nieder C, Langendijk JA, Guckenberger M, Grosu AL. Preserving the legacy of reirradiation: A narrative review of historical publications. Adv Radiat Oncol 2017; 2:176-182. [PMID: 28740929 PMCID: PMC5514242 DOI: 10.1016/j.adro.2017.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/16/2017] [Accepted: 02/21/2017] [Indexed: 12/09/2022] Open
Abstract
PURPOSE The purpose of this study is to illustrate the historical development of reirradiation during several decades of the 20th century, in particular between 1920 and 1960. METHODS AND MATERIALS We chose the format of a narrative review because the historical articles are heterogeneous. No systematic extraction of baseline data, treatment details, or follow-up care was possible in many cases. RESULTS Both hematological malignancies and solid tumors were treated with a second course of radiation therapy, and indications included local relapse, regional nodal recurrence, and second primary tumors developing in a previously treated region. The literature consists of retrospective single-institution analyses describing treatment approaches that included external beam radiation therapy, brachytherapy, or combinations thereof. Data on toxicities and survival were often provided. Breast cancer and gynecological, head and neck, brain, and skin tumors are among the entities included in this review. CONCLUSIONS The leading pioneers in the field are fully aware of many of the challenges we continue to debate today. These include the process of late tissue changes and development of personalized treatment approaches and better ways to select patients who are likely to benefit from a second course of radiation therapy.
Collapse
Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital Trust, Bodø, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Centre Groningen, Groningen, Netherlands
| | | | - Anca L Grosu
- Department of Radiation Oncology, University Hospital Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany
| |
Collapse
|
40
|
Dong Y, Fu C, Guan H, Zhang T, Zhang Z, Zhou T, Li B. Re-irradiation alternatives for recurrent high-grade glioma. Oncol Lett 2016; 12:2261-2270. [PMID: 27703519 PMCID: PMC5038913 DOI: 10.3892/ol.2016.4926] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 03/01/2016] [Indexed: 12/28/2022] Open
Abstract
Despite advances in the fields of surgery, chemotherapy and radiotherapy, the prognosis for high-grade glioma (HGG) remains unsatisfactory. The majority of HGG patients experience disease recurrence. To date, no standard treatments have been established for recurrent HGG. Repeat surgery and chemotherapy demonstrate moderate efficacy. As recurrent lesions are usually located within the previously irradiated field, a second course of irradiation was once considered controversial, as it was considered to exhibit unsatisfactory efficacy and radiation-related toxicities. However, an increasing number of studies have indicated that re-irradiation may present an efficacious treatment for recurrent HGG. Re-irradiation may be delivered via conventionally fractionated stereotactic radiotherapy, hypofractionated stereotactic radiation therapy, stereotactic radiosurgery and brachytherapy techniques. In the present review, the current literature regarding re-irradiation treatment for recurrent HGG is summarized with regard to survival outcome and side effects.
Collapse
Affiliation(s)
- Yuanli Dong
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China; School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong 250014, P.R. China
| | - Chengrui Fu
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Hui Guan
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China; School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong 250014, P.R. China
| | - Tianyi Zhang
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Zicheng Zhang
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Tao Zhou
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Baosheng Li
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| |
Collapse
|
41
|
Mallick S, Benson R, Hakim A, Rath GK. Management of glioblastoma after recurrence: A changing paradigm. J Egypt Natl Canc Inst 2016; 28:199-210. [PMID: 27476474 DOI: 10.1016/j.jnci.2016.07.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 06/30/2016] [Accepted: 07/03/2016] [Indexed: 11/29/2022] Open
Abstract
Glioblastoma remains the most common primary brain tumor after the age of 40years. Maximal safe surgery followed by adjuvant chemoradiotherapy has remained the standard treatment for glioblastoma (GBM). But recurrence is an inevitable event in the natural history of GBM with most patients experiencing it after 6-9months of primary treatment. Recurrent GBM poses great challenge to manage with no well-defined management protocols. The challenge starts from differentiating radiation necrosis from true local progression. A fine balance needs to be maintained on improving survival and assuring a better quality of life. Treatment options are limited and ranges from re-excision, re-irradiation, systemic chemotherapy or a combination of these. Re-excision and re-irradiation must be attempted in selected patients and has been shown to improve survival outcomes. To facilitate the management of GBM recurrences, a treatment algorithm is proposed.
Collapse
Affiliation(s)
- Supriya Mallick
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India.
| | - Rony Benson
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Abdul Hakim
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Goura K Rath
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
42
|
Jia A, Pannullo SC, Minkowitz S, Taube S, Chang J, Parashar B, Christos P, Wernicke AG. Innovative Hypofractionated Stereotactic Regimen Achieves Excellent Local Control with No Radiation Necrosis: Promising Results in the Management of Patients with Small Recurrent Inoperable GBM. Cureus 2016; 8:e536. [PMID: 27096136 PMCID: PMC4835149 DOI: 10.7759/cureus.536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Management of recurrent glioblastoma multiforme (GBM) remains a challenge. Several institutions reported that a single fraction of ≥ 20 Gy for small tumor burden results in excellent local control; however, this is at the expense of a high incidence of radiation necrosis (RN). Therefore, we developed a hypofractionation pattern of 33 Gy/3 fractions, which is a radiobiological equivalent of 20 Gy, with the aim to lower the incidence of RN. We reviewed records of 21 patients with recurrent GBM treated with hypofractionated stereotactic radiation therapy (HFSRT) to their 22 respective lesions. Sixty Gy fractioned external beam radiotherapy was performed as first-line treatment. Median time from primary irradiation to HFSRT was 9.6 months (range: 3.1 – 68.1 months). In HFSRT, a median dose of 33 Gy in 11 Gy fractions was delivered to the 80% isodose line that encompassed the target volume. The median tumor volume was 1.07 cm3 (range: 0.11 – 16.64 cm3). The median follow-up time after HFSRT was 9.3 months (range: 1.7 – 33.6 months). Twenty-one of 23 lesions treated (91.3%) achieved local control while 2/23 (8.7%) progressed. Median time to progression outside of the treated site was 5.2 months (range: 2.2 – 9.6 months). Progression was treated with salvage chemotherapy. Five of 21 patients (23.8%) were alive at the end of this follow-up; two patients remain disease-free. The remaining 16/21 patients (76.2%) died of disease. Treatment was well tolerated by all patients with no acute CTC/RTOG > Grade 2. There was 0% incidence of RN. A prospective trial will be underway to validate these promising results.
Collapse
Affiliation(s)
- Angela Jia
- Stich Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center
| | - Susan C Pannullo
- Neurological Surgery, NewYork-Presbyterian/Weill Cornell Medical Center
| | | | - Shoshana Taube
- Stich Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center
| | - Jenghwa Chang
- Stich Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center
| | - Bhupesh Parashar
- Stich Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center
| | - Paul Christos
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, NewYork-Presbyterian/Weill Cornell Medical Center
| | | |
Collapse
|
43
|
Hau E, Shen H, Clark C, Graham PH, Koh ES, L McDonald K. The evolving roles and controversies of radiotherapy in the treatment of glioblastoma. J Med Radiat Sci 2016; 63:114-23. [PMID: 27350891 PMCID: PMC4914819 DOI: 10.1002/jmrs.149] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 08/25/2015] [Accepted: 10/06/2015] [Indexed: 12/22/2022] Open
Abstract
Numerous randomised controlled trials have demonstrated the benefit of radiation therapy in patients with newly diagnosed glioblastoma and it has been the cornerstone of treatment for decades. The aims of this review are to (1) Briefly outline the historical studies which resulted in radiation being the current standard of care as used in the Stupp et al. trial (2) Discuss the evolving role of radiation therapy in the management of elderly patients (3) Review the current evidence and ongoing studies of radiation use in the recurrent/salvage setting and (4) Discuss the continuing controversies of volume delineation in the planning of radiation delivery.
Collapse
Affiliation(s)
- Eric Hau
- Cure Brain Cancer Foundation Biomarkers and Translational Research Laboratory Prince of Wales Clinical School UNSW Sydney New South Wales Australia; Cancer Care Centre St George Hospital Sydney New South Wales Australia
| | - Han Shen
- Targeted Therapies Group Children's Cancer Institute Australia Lowy Cancer Research Centre Sydney New South Wales Australia
| | - Catherine Clark
- Cancer Care Centre St George Hospital Sydney New South Wales Australia
| | - Peter H Graham
- St George Cancer Care Centre Kogarah Sydney New South Wales Australia
| | - Eng-Siew Koh
- Liverpool Cancer Care Centre Liverpool Hospital Sydney New South Wales Australia; University of New South Wales Sydney New South Wales Australia
| | - Kerrie L McDonald
- Cure Brain Cancer Foundation Biomarkers and Translational Research Laboratory Prince of Wales Clinical School UNSW Sydney New South Wales Australia
| |
Collapse
|
44
|
Bokstein F, Blumenthal DT, Corn BW, Gez E, Matceyevsky D, Shtraus N, Ram Z, Kanner AA. Stereotactic radiosurgery (SRS) in high-grade glioma: judicious selection of small target volumes improves results. J Neurooncol 2015; 126:551-7. [PMID: 26603164 DOI: 10.1007/s11060-015-1997-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 11/19/2015] [Indexed: 11/29/2022]
Abstract
We present a retrospective review of 55 Stereotactic Radiosurgery (SRS) procedures performed in 47 consecutive patients with high-grade glioma (HGG). Thirty-three (70.2%) patients were diagnosed with glioblastoma and 14 (29.8%) with grade III glioma. The indications for SRS were small (up to 30 mm in diameter) locally progressing lesions in 32/47 (68%) or new distant lesions in 15/47 (32%) patients. The median target volume was 2.2 cc (0.2-9.5 cc) and the median prescription dose was 18 Gy (14-24 Gy). Three patients (5.5% incidence in 55 treatments) developed radiation necrosis. In eight cases (17%) patients received a second salvage SRS treatment to nine new lesions detected during follow-up. In 22/55 SRS treatments (40.0%) patients received concurrent chemo- or biological therapy, including temozolamide (TMZ) (15 patients), bevacizumab (BVZ) (6 patients) and carboplatin in one patient. Median time to progression after SRS was 5.0 months (1.0-96.4). Median survival time after SRS was 15.9 months (2.3-109.3) overall median survival (since diagnosis) was 37.4 months (9.6-193.6 months). Long-lasting responses (>12 months) after SRS were observed in 25/46 (54.3%) patients. We compared a matched (histology, age, KPS) cohort of patients with recurrent HGG treated with BVZ alone with the current study group. Median survival was significantly longer for SRS treated patients compared to the BVZ only cohort (12.6 vs. 7.3 months, p = 0.0102). SRS may be considered an effective salvage procedure for selected patients with small volume, recurrent high-grade gliomas. Long-term radiological control was observed in more than 50% of the patients.
Collapse
Affiliation(s)
- Felix Bokstein
- Neuro-Oncology Unit, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Deborah T Blumenthal
- Neuro-Oncology Unit, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Benjamin W Corn
- Institute of Radiotherapy, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.,Stereotactic Radiosurgery Unit, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Eliahu Gez
- Institute of Radiotherapy, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.,Stereotactic Radiosurgery Unit, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Diana Matceyevsky
- Institute of Radiotherapy, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.,Stereotactic Radiosurgery Unit, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Natan Shtraus
- Institute of Radiotherapy, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.,Stereotactic Radiosurgery Unit, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Andrew A Kanner
- Stereotactic Radiosurgery Unit, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel. .,Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.
| |
Collapse
|
45
|
Huss M, Barsoum P, Dodoo E, Sinclair G, Toma-Dasu I. Fractionated SRT using VMAT and Gamma Knife for brain metastases and gliomas--a planning study. J Appl Clin Med Phys 2015; 16:3-16. [PMID: 26699547 PMCID: PMC5691017 DOI: 10.1120/jacmp.v16i6.5255] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 07/14/2015] [Accepted: 07/13/2015] [Indexed: 12/25/2022] Open
Abstract
Stereotactic radiosurgery using Gamma Knife (GK) or linear accelerators has been used for decades to treat brain tumors in one fraction. A new positioning system, Extend™, was introduced by Elekta AB for fractionated stereotactic radiotherapy (SRT) with GK. Another option for fractionated SRT is advanced planning and delivery using linacs and volumetric modulated arc therapy (VMAT). This project aims to assess the performance of GK Extend™ for delivering fractionated SRT by comparing GK treatments plans for brain targets performed using Leksell GammaPlan (LGP) with VMAT treatment plans. Several targets were considered for the planning: simulated metastasis‐ and glioma‐like targets surrounding an organ at risk (OAR), as well as three clinical cases of metastases. Physical parameters such as conformity, gradient index, dose to OARs, and brain volume receiving doses above the threshold associated with risk of damaging healthy tissue, were determined and compared for the treatment plans. The results showed that GK produced better dose distributions for target volumes below 15 cm3, while VMAT results in better dose conformity to the target and lower doses to the OARs in case of fractionated treatments for large or irregular volumes. The volume receiving doses above a threshold associated with increased risk of damage to normal brain tissue was also smaller for VMAT. The GK consistently performed better than VMAT in producing a lower dose‐bath to the brain. The above is subjected only to margin‐dependent fractionated radiotherapy (CTV/PTV). The results of this study could lead to clinically significant decisions regarding the choice of the radiotherapy technique for brain targets. PACS numbers: 87.53.Ly, 87.55.D‐
Collapse
|
46
|
The influence of different classification standards of age groups on prognosis in high-grade hemispheric glioma patients. J Neurol Sci 2015; 356:148-52. [DOI: 10.1016/j.jns.2015.06.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 05/26/2015] [Accepted: 06/17/2015] [Indexed: 11/24/2022]
|
47
|
Abstract
In almost all patients, malignant glioma recurs following initial treatment with maximal safe resection, conformal radiotherapy, and temozolomide. This review describes the many options for treatment of recurrent malignant gliomas, including reoperation, alternating electric field therapy, chemotherapy, stereotactic radiotherapy or radiosurgery, or some combination of these modalities, presenting the evidence for each approach. No standard of care has been established, though the antiangiogenic agent, bevacizumab; stereotactic radiotherapy or radiosurgery; and, perhaps, combined treatment with these 2 modalities appear to offer modest benefits over other approaches. Clearly, randomized trials of these options would be advantageous, and novel, more efficacious approaches are urgently needed.
Collapse
Affiliation(s)
- John P Kirkpatrick
- Department of Radiation Oncology, Duke Cancer Institute, Durham, NC; Department of Surgery, Duke Cancer Institute, Durham, NC.
| | - John H Sampson
- Department of Radiation Oncology, Duke Cancer Institute, Durham, NC; Department of Surgery, Duke Cancer Institute, Durham, NC
| |
Collapse
|
48
|
Galle JO, McDonald MW, Simoneaux V, Buchsbaum JC. Reirradiation with Proton Therapy for Recurrent Gliomas. Int J Part Ther 2015. [DOI: 10.14338/theijpt-14-00029.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
49
|
Hasan S, Chen E, Lanciano R, Yang J, Hanlon A, Lamond J, Arrigo S, Ding W, Mikhail M, Ghaneie A, Brady L. Salvage Fractionated Stereotactic Radiotherapy with or without Chemotherapy and Immunotherapy for Recurrent Glioblastoma Multiforme: A Single Institution Experience. Front Oncol 2015; 5:106. [PMID: 26029663 PMCID: PMC4432688 DOI: 10.3389/fonc.2015.00106] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 04/21/2015] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The current standard of care for salvage treatment of glioblastoma multiforme (GBM) is gross total resection and adjuvant chemoradiation for operable patients. Limited evidence exists to suggest that any particular treatment modality improves survival for recurrent GBM, especially if inoperable. We report our experience with fractionated stereotactic radiotherapy (fSRT) with and without chemo/immunotherapy, identifying prognostic factors associated with prolonged survival. METHODS From 2007 to 2014, 19 patients between 29 and 78 years old (median 55) with recurrent GBM following resection and chemoradiation for their initial tumor, received 18-35 Gy (median 25) in three to five fractions via CyberKnife fSRT. Clinical target volume (CTV) ranged from 0.9 to 152 cc. Sixteen patients received adjuvant systemic therapy with bevacizumab (BEV), temozolomide (TMZ), anti-epidermal growth factor receptor (125)I-mAb 425, or some combination thereof. RESULTS The median overall survival (OS) from date of recurrence was 8 months (2.5-61) and 5.3 months (0.6-58) from the end of fSRT. The OS at 6 and 12 months was 47 and 32%, respectively. Three of 19 patients were alive at the time of this review at 20, 49, and 58 months from completion of fSRT. Hazard ratios for survival indicated that patients with a frontal lobe tumor, adjuvant treatment with either BEV or TMZ, time to first recurrence >16 months, CTV <36 cc, recursive partitioning analysis <5, and Eastern Cooperative Oncology Group performance status <2 were all associated with improved survival (P < 0.05). There was no evidence of radionecrosis for any patient. CONCLUSION Radiation Therapy Oncology Group (RTOG) 1205 will establish the role of re-irradiation for recurrent GBM, however our study suggests that CyberKnife with chemotherapy can be safely delivered, and is most effective in patients with smaller frontal lobe tumors, good performance status, or long interval from diagnosis.
Collapse
Affiliation(s)
- Shaakir Hasan
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA
| | - Eda Chen
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA
| | - Rachelle Lanciano
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| | - Jun Yang
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| | - Alex Hanlon
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Nursing, University of Pennsylvania , Philadelphia, PA , USA
| | - John Lamond
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| | - Stephen Arrigo
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| | - William Ding
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| | - Michael Mikhail
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA
| | - Arezoo Ghaneie
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA
| | - Luther Brady
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| |
Collapse
|
50
|
Bir SC, Connor DE, Ambekar S, Wilden JA, Nanda A. Factors predictive of improved overall survival following stereotactic radiosurgery for recurrent glioblastoma. Neurosurg Rev 2015; 38:705-13. [PMID: 25864406 DOI: 10.1007/s10143-015-0632-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 01/23/2015] [Accepted: 01/25/2015] [Indexed: 10/23/2022]
Abstract
The currently accepted standard of care for primary glioblastoma (GBM) consists of maximal surgical resection followed by fractionated external beam radiotherapy (EBRT) with concomitant temozolomide chemotherapy. The role of stereotactic radiosurgery (SRS) in the treatment of GBM is not well defined, but SRS has typically been applied as a salvage therapy for GBM recurrence. This paper reviews our single institution experience using gamma knife radiosurgery (GKRS) for the treatment of GBM. Thirty-six patients treated with GKRS for pathologically proven GBM at LSU Health in Shreveport from February 2000 to December 2013 were identified and analyzed. Patient characteristics, treatment variables, and survival were correlated. Seven patients received GKRS in the immediate postoperative period for an average tumor volume of 10.9 cm(3), and 29 patients were treated for a recurrent average tumor volume of 11.4 cm(3) with a prescribed dose ranging from 10 to 20 Gy at the 50 % isodose line. The median overall survival was significantly higher in recurrence group compared to up-front group [7.9 months (0.77-32.1 months) vs. 3.5 months (range 0.23-11.7 months) respectively, (p = 0.018)]. The predictive factors for improved survival in the patients with GBM were as follows: Karnofsky performance scale (KPS) > 70 (p = 0.026), age ≤ 50 years (p = 0.006), absence of neurodeficits (p = 0.01), and initial postoperative treatment with EBRT (p = 0.042). Adjuvant therapy with GKRS following GBM recurrence demonstrates statistical superiority over immediate postoperative boost therapy.
Collapse
Affiliation(s)
- Shyamal C Bir
- Department of Neurosurgery, LSU Health-Shreveport, 1501 Kings Highway, Shreveport, LA, 71130-3932, USA
| | | | | | | | | |
Collapse
|