1
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Conrad K, Löber-Handwerker R, Hazaymeh M, Rohde V, Malinova V. Personalized prognosis stratification of newly diagnosed glioblastoma applying a statistical decision tree model. J Neurooncol 2024:10.1007/s11060-024-04683-6. [PMID: 38639854 DOI: 10.1007/s11060-024-04683-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
PURPOSE Glioblastoma (GBM) is the most frequent glioma in adults with a high treatment resistance resulting into limited survival. The individual prognosis varies depending on individual prognostic factors, that must be considered while counseling patients with newly diagnosed GBM. The aim of this study was to elaborate a risk stratification algorithm based on reliable prognostic factors to facilitate a personalized prognosis estimation early on after diagnosis. METHODS A consecutive patient cohort with confirmed GBM treated between 2010 and 2021 was retrospectively analyzed. Clinical, radiological, and molecular parameters were assessed and included in the analysis. Overall survival (OS) was the primary outcome parameter. After identifying the strongest prognostic factors, a risk stratification algorithm was elaborated with estimated odds of survival. RESULTS A total of 462 GBM patients were analyzed. The strongest prognostic factors were Charlson Comorbidity Index (CCI), extent of tumor resection, and adjuvant treatment. Patients with CCI ≤ 1 receiving tumor resection had the highest survival odds (88% for 10 months). On the contrary, patients with CCI > 3 receiving no adjuvant treatment had the lowest survival odds (0% for 10 months). The 10-months survival rate in patients with CCI > 3 receiving adjuvant treatment was 56% for patients younger than 70 years and 22% for patients older than 70 years. CONCLUSION A risk stratification algorithm based on significant prognostic factors allowed a personalized early prognosis estimation at the time of GBM diagnosis, that can contribute to a more personalized patient counseling.
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Affiliation(s)
- Katharina Conrad
- Department of Neurosurgery, University Medical Center Göttingen, Robert-Koch Straße 40, 37075, Göttingen, Germany
| | - Ronja Löber-Handwerker
- Department of Neurosurgery, University Medical Center Göttingen, Robert-Koch Straße 40, 37075, Göttingen, Germany
| | - Mohammad Hazaymeh
- Department of Neurosurgery, University Medical Center Göttingen, Robert-Koch Straße 40, 37075, Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Robert-Koch Straße 40, 37075, Göttingen, Germany
| | - Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, Robert-Koch Straße 40, 37075, Göttingen, Germany.
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2
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Rammeloo E, Schouten JW, Krikour K, Bos EM, Berger MS, Nahed BV, Vincent AJPE, Gerritsen JKW. Preoperative assessment of eloquence in neurosurgery: a systematic review. J Neurooncol 2023; 165:413-430. [PMID: 38095774 DOI: 10.1007/s11060-023-04509-x] [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: 08/23/2023] [Accepted: 11/12/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Tumor location and eloquence are two crucial preoperative factors when deciding on the optimal treatment choice in glioma management. Consensus is currently lacking regarding the preoperative assessment and definition of eloquent areas. This systematic review aims to evaluate the existing definitions and assessment methods of eloquent areas that are used in current clinical practice. METHODS A computer-aided search of Embase, Medline (OvidSP), and Google Scholar was performed to identify relevant studies. This review includes articles describing preoperative definitions of eloquence in the study's Methods section. These definitions were compared and categorized by anatomical structure. Additionally, various techniques to preoperatively assess tumor eloquence were extracted, along with their benefits, drawbacks and ease of use. RESULTS This review covers 98 articles including 12,714 participants. Evaluation of these studies indicated considerable variability in defining eloquence. Categorization of these definitions yielded a list of 32 brain regions that were considered eloquent. The most commonly used methods to preoperatively determine tumor eloquence were anatomical classification systems and structural MRI, followed by DTI-FT, functional MRI and nTMS. CONCLUSIONS There were major differences in the definitions and assessment methods of eloquence, and none of them proved to be satisfactory to express eloquence as an objective, quantifiable, preoperative factor to use in glioma decision making. Therefore, we propose the development of a novel, objective, reliable, preoperative classification system to assess eloquence. This should in the future aid neurosurgeons in their preoperative decision making to facilitate personalized treatment paradigms and to improve surgical outcomes.
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Affiliation(s)
- Emma Rammeloo
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Joost Willem Schouten
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Keghart Krikour
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Eelke Marijn Bos
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Mitchel Stuart Berger
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Brian Vala Nahed
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Jasper Kees Wim Gerritsen
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
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3
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A Comparative Analysis with Exoscope and Optical Microscope for Intraoperative Visualization and Surgical Workflow in 5-Aminolevulinic Acid-Guided Resection of High-Grade Gliomas. World Neurosurg 2023; 170:133-137. [PMID: 36400360 DOI: 10.1016/j.wneu.2022.11.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/10/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The exoscope has been proposed as a valid tool in 5-aminolevulinic acid-guided resection of high-grade gliomas. However, it is not clear if, beyond ergonomics, the exoscope provides a real benefit over the optical microscope (OM). The aim of this study was to compare the exoscope with the OM in terms of surgical visualization and workflow in 5-aminolevulinic acid-guided brain surgery. METHODS Surgical videos of patients diagnosed with histopathologically confirmed, Shinoda stage I, high-grade gliomas who underwent surgery in from January to April 2022 were studied. Visualization under a 5-aminolevulinic acid blue filter for vessels, parenchyma, surgical instruments, and fluorescence was categorized for both superficial and deep fields. The following data were also recorded: median number of switches between white light and blue filter, average duration per switch, and amount of work under blue filter. RESULTS There were 5 surgeries performed under OM guidance and 5 performed under exoscope guidance. Under a blue filter, the exoscope was significantly better than the OM in visualizing vessels, parenchyma, and surgical instruments for both superficial and deep surgical fields. The median number of switches between blue and white light was lower compared with the OM. Both median switch duration and percentage of work under the blue filter were superior when using the exoscope. CONCLUSIONS Within the limitations of a preliminary analysis, use of the exoscope in fluorescence-guided surgery for high-grade gliomas provided significant advantages in terms of visualization of the surgical field under a blue filter and linearity of surgical flow.
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4
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Soliman MA, Khan A, Azmy S, Gilbert O, Khan S, Goliber R, Szczecinski EJ, Durrani H, Burke S, Salem AA, Lubanska D, Ghannam MM, Hess RM, Lim J, Mullin JP, Davies JM, Pollina J, Snyder KV, Siddiqui AH, Levy EI, Plunkett RJ, Fenstermaker RA. Meta-analysis of overall survival and postoperative neurologic deficits after resection or biopsy of butterfly glioblastoma. Neurosurg Rev 2022; 45:3511-3521. [PMID: 36173528 DOI: 10.1007/s10143-022-01864-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/22/2022] [Accepted: 09/12/2022] [Indexed: 11/28/2022]
Abstract
Butterfly glioblastoma (bGBM) is a grade 4 glioma with a poor prognosis. Surgical treatment of these cancers has been reviewed in the literature with some recent studies supporting resection as a safe and effective treatment instead of biopsy and adjuvant therapy. This meta-analysis was designed to determine whether there are significant differences in overall survival (OS) and postoperative neurologic deficits (motor, speech, and cranial nerve) following intervention in patients who underwent tumor resection as part of their treatment, compared to patients who underwent biopsy without surgical resection. A literature search was conducted using PubMed (National Library of Medicine) and Embase (Elsevier) to identify articles from each database's earliest records to May 25, 2021, that directly compared the outcomes of biopsy and resection in bGBM patients and met predetermined inclusion criteria. A meta-analysis was conducted to compare the effects of the two management strategies on OS and postoperative neurologic deficits. Six articles met our study inclusion criteria. OS was found to be significantly longer for the resection group at 6 months (odds ratio [OR] 2.94, 95% confidence interval [CI] 1.23-7.05) and 12 months (OR 3.75, 95% CI 1.10-12.76) than for the biopsy group. No statistically significant differences were found in OS at 18 and 24 months. Resection was associated with an increased rate of postoperative neurologic deficit (OR 2.05, 95% CI 1.02-4.09). Resection offers greater OS up to 1 year postintervention than biopsy alone; however, this comes at the cost of higher rates of postoperative neurologic deficits.
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Affiliation(s)
- Mohamed Ar Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA.,Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Shady Azmy
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Olivia Gilbert
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Slah Khan
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Ryan Goliber
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Eric J Szczecinski
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Hamza Durrani
- Dow International Medical College, Karachi, Sindh, Pakistan
| | | | - Amany A Salem
- Department of Public Health and Community Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Dorota Lubanska
- Department of Biomedical Sciences, University of Windsor, Windsor, Ontario, Canada
| | - Moleca M Ghannam
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Ryan M Hess
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA.,Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA.,Jacobs Institute, Buffalo, NY, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA.,Jacobs Institute, Buffalo, NY, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA.,Jacobs Institute, Buffalo, NY, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA.,Jacobs Institute, Buffalo, NY, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Robert J Plunkett
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA.,Department of Neurosurgery, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, 14263, USA
| | - Robert A Fenstermaker
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA. .,Department of Neurosurgery, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, 14263, USA.
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Abstract
Whenever possible, maximal safe resection is the first intervention for management of glioblastoma. Resection offers tissue for diagnosis, decompression of the brain, cytoreduction, and has been associated with prolonged survival in numerous retrospective studies. In this review, we provide a critical overview of the literature associating glioblastoma resection with survival. We discuss techniques that enhance extent of resection, and the role of clinical and surgeon-variables. At last, we analyze the covariates and confounders that might influence the relationship between extent of resection and survival for glioblastoma, as these might ultimately also influence outcomes and other therapeutic interventions tested in trials.
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6
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Müller DMJ, Robe PA, Ardon H, Barkhof F, Bello L, Berger MS, Bouwknegt W, Van den Brink WA, Conti Nibali M, Eijgelaar RS, Furtner J, Han SJ, Hervey-Jumper SL, Idema AJS, Kiesel B, Kloet A, De Munck JC, Rossi M, Sciortino T, Vandertop WP, Visser M, Wagemakers M, Widhalm G, Witte MG, Zwinderman AH, De Witt Hamer PC. Quantifying eloquent locations for glioblastoma surgery using resection probability maps. J Neurosurg 2020; 134:1091-1101. [PMID: 32244208 DOI: 10.3171/2020.1.jns193049] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Decisions in glioblastoma surgery are often guided by presumed eloquence of the tumor location. The authors introduce the "expected residual tumor volume" (eRV) and the "expected resectability index" (eRI) based on previous decisions aggregated in resection probability maps. The diagnostic accuracy of eRV and eRI to predict biopsy decisions, resectability, functional outcome, and survival was determined. METHODS Consecutive patients with first-time glioblastoma surgery in 2012-2013 were included from 12 hospitals. The eRV was calculated from the preoperative MR images of each patient using a resection probability map, and the eRI was derived from the tumor volume. As reference, Sawaya's tumor location eloquence grades (EGs) were classified. Resectability was measured as observed extent of resection (EOR) and residual volume, and functional outcome as change in Karnofsky Performance Scale score. Receiver operating characteristic curves and multivariable logistic regression were applied. RESULTS Of 915 patients, 674 (74%) underwent a resection with a median EOR of 97%, functional improvement in 71 (8%), functional decline in 78 (9%), and median survival of 12.8 months. The eRI and eRV identified biopsies and EORs of at least 80%, 90%, or 98% better than EG. The eRV and eRI predicted observed residual volumes under 10, 5, and 1 ml better than EG. The eRV, eRI, and EG had low diagnostic accuracy for functional outcome changes. Higher eRV and lower eRI were strongly associated with shorter survival, independent of known prognostic factors. CONCLUSIONS The eRV and eRI predict biopsy decisions, resectability, and survival better than eloquence grading and may be useful preoperative indices to support surgical decisions.
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Affiliation(s)
- Domenique M J Müller
- 1Brain Tumor Center & Department of Neurosurgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Pierre A Robe
- 2Department of Neurology & Neurosurgery, University Medical Center Utrecht, The Netherlands
| | - Hilko Ardon
- 3Department of Neurosurgery, St. Elisabeth Hospital, Tilburg, The Netherlands
| | - Frederik Barkhof
- 4Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit, University Medical Center, Amsterdam, The Netherlands.,5Institutes of Neurology and Healthcare Engineering, University College London, United Kingdom
| | - Lorenzo Bello
- 6Neurosurgical Oncology Unit, Departments of Oncology and Remato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy
| | - Mitchel S Berger
- 7Department of Neurological Surgery, University of California, San Francisco, California
| | - Wim Bouwknegt
- 8Department of Neurosurgery, Medical Center Slotervaart, Amsterdam, The Netherlands
| | | | - Marco Conti Nibali
- 6Neurosurgical Oncology Unit, Departments of Oncology and Remato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy
| | - Roelant S Eijgelaar
- 10Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Julia Furtner
- 11Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Austria
| | - Seunggu J Han
- 12Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon
| | - Shawn L Hervey-Jumper
- 7Department of Neurological Surgery, University of California, San Francisco, California
| | - Albert J S Idema
- 13Department of Neurosurgery, Northwest Clinics, Alkmaar, The Netherlands
| | - Barbara Kiesel
- 14Department of Neurosurgery, Medical University Vienna, Austria
| | - Alfred Kloet
- 15Department of Neurosurgery, Medical Center Haaglanden, The Hague, The Netherlands
| | - Jan C De Munck
- 4Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit, University Medical Center, Amsterdam, The Netherlands
| | - Marco Rossi
- 6Neurosurgical Oncology Unit, Departments of Oncology and Remato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy
| | - Tommaso Sciortino
- 6Neurosurgical Oncology Unit, Departments of Oncology and Remato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy
| | - W Peter Vandertop
- 1Brain Tumor Center & Department of Neurosurgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Martin Visser
- 4Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit, University Medical Center, Amsterdam, The Netherlands
| | - Michiel Wagemakers
- 16Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands; and
| | - Georg Widhalm
- 14Department of Neurosurgery, Medical University Vienna, Austria
| | - Marnix G Witte
- 10Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Aeilko H Zwinderman
- 17Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, Amsterdam, The Netherlands
| | - Philip C De Witt Hamer
- 1Brain Tumor Center & Department of Neurosurgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
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7
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Yang Y, Yan R, Zhang L, Meng X, Sun W. Primary glioblastoma transcriptome data analysis for screening survival-related genes. J Cell Biochem 2019; 121:1901-1910. [PMID: 31633244 DOI: 10.1002/jcb.29425] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 10/08/2019] [Indexed: 01/27/2023]
Abstract
PURPOSE The aim of this study was to screen survival-related genes for glioblastoma (GBM). METHODS GSE53733 was downloaded from Gene Expression Omnibus (GEO) database, including 16 short-term (ST), 31 intermediate (IM), and 23 long-term (LT) survivors. Analysis of variance was used to analyze the expression in three groups. The genes with P < .01 were screened as differentially expressed genes (DEGs). Soft clustering was performed using Mfuzz to mine the expression patterns of differential genes in three groups of overall survival (OS) classification. The cytoscape plugin clueGO was used for functional enrichment analysis. The protein interaction between differential genes was extracted from the STRING V10 database, and the protein-protein interaction (PPI) network was constructed and displayed with cytoscape. The hub genes were verified by quantitative reverse-transcription polymerase chain reaction. RESULTS Total 662 DEGs were obtained among three groups and enriched in 12 clusters. The overlap analysis between clusters could classify these 12 clusters Cluster A and B. Total 264 OS.DEGs were contained in Cluter A and Cluster B, and enriched in 28 Gene Ontology terms, such as trophoblast giant cell differentiation (P value = 6.18E-04), muscle fiber development (P value = 9.09E-04), and negative regulation of stem cell differentiation (P value = 1.76E-03). The top five nodes with highest degree in OS.PPI were HDAC1, DECR1, RASL11A, PDIA3, and POLR2F. The expression of DECR1 and POLR2F was significantly lower, while the levels of HDAC1 and PDIA3 were highly expressed in GBM tissues. CONCLUSION DECR1, POLR2F, HDAC1, and PDIA3 might be potential key genes affected the overall survival time of patients with GBM.
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Affiliation(s)
- Ying Yang
- Intensive Care Unit, Affiliated Hospital of Jining Medical University, Jining, China
| | - Ranran Yan
- Intensive Care Unit, Affiliated Hospital of Jining Medical University, Jining, China
| | - Liwen Zhang
- Intensive Care Unit, Affiliated Hospital of Jining Medical University, Jining, China
| | - Xiangli Meng
- Nursing Department, Affiliated Hospital of Jining Medical University, Jining, China
| | - Wen Sun
- Teaching Administration Office, Affiliated Hospital of Jining Medical University, Jining, China
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8
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Gandía-González ML, Cerdán S, Barrios L, López-Larrubia P, Feijoó PG, Palpan A, Roda JM, Solivera J. Assessment of Overall Survival in Glioma Patients as Predicted by Metabolomic Criteria. Front Oncol 2019; 9:328. [PMID: 31134147 PMCID: PMC6524167 DOI: 10.3389/fonc.2019.00328] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 04/11/2019] [Indexed: 11/17/2022] Open
Abstract
Objective: We assess the efficacy of the metabolomic profile from glioma biopsies in providing estimates of postsurgical Overall Survival in glioma patients. Methods: Tumor biopsies from 46 patients bearing gliomas, obtained neurosurgically in the period 1992–1998, were analyzed by high resolution 1H magnetic resonance spectroscopy (HR- 1H MRS), following retrospectively individual postsurgical Overall Survival up to 720 weeks. Results: The Overall Survival profile could be resolved in three groups; Short (shorter than 52 weeks, n = 19), Intermediate (between 53 and 364 weeks, n = 19) or Long (longer than 365 weeks, n = 8), respectively. Classical histopathological analysis assigned WHO grades II–IV to every biopsy but notably, some patients with low grade glioma depicted unexpectedly Short Overall Survival, while some patients with high grade glioma, presented unpredictably Long Overall Survival. To explore the reasons underlying these different responses, we analyzed HR-1H MRS spectra from acid extracts of the same biopsies, to characterize the metabolite patterns associated to OS predictions. Poor prognosis was found in biopsies with higher contents of alanine, acetate, glutamate, total choline, phosphorylcholine, and glycine, while more favorable prognosis was achieved in biopsies with larger contents of total creatine, glycerol-phosphorylcholine, and myo-inositol. We then implemented a multivariate analysis to identify hierarchically the influence of metabolomic biomarkers on OS predictions, using a Classification Regression Tree (CRT) approach. The CRT based in metabolomic biomarkers grew up to three branches and split into eight nodes, predicting correctly the outcome of 94.7% of the patients in the Short Overall Survival group, 78.9% of the patients in the Intermediate Overall Survival group, and 75% of the patients in the Long Overall Survival group, respectively. Conclusion: Present results indicate that metabolic profiling by HR-1H MRS improves the Overall Survival predictions derived exclusively from classical histopathological gradings, thus favoring more precise therapeutic decisions.
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Affiliation(s)
| | - Sebastián Cerdán
- Institute of Biomedical Research "Alberto Sols" CSIC/UAM, Madrid, Spain
| | | | | | - Pablo G Feijoó
- Department of Neurosurgery, Hospital Universitario La Paz, Madrid, Spain
| | - Alexis Palpan
- Department of Neurosurgery, Hospital Universitario La Paz, Madrid, Spain
| | - José M Roda
- Department of Neurosurgery, Hospital Universitario La Paz, Madrid, Spain
| | - Juan Solivera
- Department of Neurosurgery, University Hospital Reina Sofía, Córdoba, Spain
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9
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Hendriks EJ, Idema S, Hervey-Jumper SL, Bernat AL, Zwinderman AH, Barkhof F, Vandertop WP, Mandonnet E, Duffau H, Berger MS, De Witt Hamer PC. Preoperative Resectability Estimates of Nonenhancing Glioma by Neurosurgeons and a Resection Probability Map. Neurosurgery 2018; 85:E304-E313. [DOI: 10.1093/neuros/nyy487] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 08/21/2018] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Preoperative interpretation of resectability of diffuse nonenhancing glioma is primarily based on individual surgical expertise.
OBJECTIVE
To compare the accuracy and precision between observed resections and preoperative estimates of neurosurgeons and a resection probability map (RPM). We hypothesize that the RPM estimates is as good as senior neurosurgeons.
METHODS
A total of 234 consecutive patients were included from 2 centers, who had resective surgery with functional mapping between 2006 and 2012 for a supra-tentorial nonenhancing glioma. Extent of resection (EOR) and residual tumor volume (RTV) were segmented and an RPM was constructed in standard brain space. Three junior and three senior neurosurgeons estimated EOR and RTV, blinded for postoperative results. We determined the agreement between the estimates and calculated the diagnostic accuracy of the neurosurgeons and the RPM to predict the observed resections.
RESULTS
Preoperative estimates of resection results by junior and senior neurosurgeons were significantly biased towards overestimation of EOR (4.2% and 11.2%) and underestimation of RTV (4.3 and 9.0 mL), whereas estimates of the RPM were unbiased (−2.6% and −.2 mL, respectively). The limits of agreement were wide for neurosurgeons and for the RPM. The RPM was significantly more accurate in identifying patients in whom an EOR >40% was observed than neurosurgeons.
CONCLUSION
Neurosurgeons estimate preoperative resectability before surgery of a nonenhancing glioma rather accurate–with a small bias–and imprecise–with wide limits of agreement. An RPM provides unbiased resectability estimates, which can be useful for surgical decision-making, planning, and education.
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Affiliation(s)
- Eef J Hendriks
- Department of Radiology & Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Sander Idema
- Neurosurgical Center Amsterdam, VU University Medical Center and Academic Medical Center, Amsterdam, The Netherlands
| | - Shawn L Hervey-Jumper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Anne-Laure Bernat
- Department of Neurosurgery, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, Amsterdam, The Netherlands
| | - Frederik Barkhof
- Department of Radiology & Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
- Institutes of Neurology & Healthcare Engineering, UCL, London, UK
| | - W Peter Vandertop
- Neurosurgical Center Amsterdam, VU University Medical Center and Academic Medical Center, Amsterdam, The Netherlands
| | - Emmanuel Mandonnet
- Department of Neurosurgery, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Hugues Duffau
- Department of Neurosurgery, Hôpital Gui de Chauliac, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Philip C De Witt Hamer
- Neurosurgical Center Amsterdam, VU University Medical Center and Academic Medical Center, Amsterdam, The Netherlands
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Capellades J, Puig J, Domenech S, Pujol T, Oleaga L, Camins A, Majós C, Diaz R, de Quintana C, Teixidor P, Conesa G, Plans G, Gonzalez J, García-Balañà N, Velarde JM, Balaña C. Is a pretreatment radiological staging system feasible for suggesting the optimal extent of resection and predicting prognosis in glioblastoma? An observational study. J Neurooncol 2017; 137:367-377. [DOI: 10.1007/s11060-017-2726-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 12/21/2017] [Indexed: 10/18/2022]
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Balaña C, Capellades J, Pineda E, Estival A, Puig J, Domenech S, Verger E, Pujol T, Martinez‐García M, Oleaga L, Velarde J, Mesia C, Fuentes R, Marruecos J, Del Barco S, Villà S, Carrato C, Gallego O, Gil‐Gil M, Craven‐Bartle J, Alameda F. Pseudoprogression as an adverse event of glioblastoma therapy. Cancer Med 2017; 6:2858-2866. [PMID: 29105360 PMCID: PMC5727237 DOI: 10.1002/cam4.1242] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/22/2017] [Accepted: 09/25/2017] [Indexed: 01/01/2023] Open
Abstract
We explored predictive factors of pseudoprogression (PsP) and its impact on prognosis in a retrospective series of uniformly treated glioblastoma patients. Patients were classified as having PsP, early progression (eP) or neither (nP). We examined potential associations with clinical, molecular, and basal imaging characteristics and compared overall survival (OS), progression-free survival (PFS), post-progression survival (PPS) as well as the relationship between PFS and PPS in the three groups. Of the 256 patients studied, 56 (21.9%) were classified as PsP, 70 (27.3%) as eP, and 130 (50.8%) as nP. Only MGMT methylation status was associated to PsP. MGMT methylated patients had a 3.5-fold greater possibility of having PsP than eP (OR: 3.48; 95% CI: 1.606-7.564; P = 0.002). OS was longer for PsP than eP patients (18.9 vs. 12.3 months; P = 0.0001) but was similar for PsP and nP patients (P = 0.91). OS was shorter-though not significantly so-for PsP than nP patients (OS: 19.5 vs. 27.9 months; P = 0.63) in methylated patients. PPS was similar for patients having PsP, eP or nP (PPS: 7.2 vs. 5.4 vs. 6.7; P = 0.43). Neurological deterioration occurred in 64.3% of cases at the time they were classified as PsP and in 72.8% of cases of eP (P = 0.14). PsP confounds the evaluation of disease and does not confer a survival advantage in glioblastoma.
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Affiliation(s)
- Carmen Balaña
- Medical OncologyInstitut Catala Oncologia (ICO)BadalonaBarcelonaSpain
| | | | | | - Anna Estival
- Medical OncologyInstitut Catala Oncologia (ICO)BadalonaBarcelonaSpain
| | - Josep Puig
- Imaging Research UnitInstitut de Diagnostic per la Imatge (IDI)Biomedical Research Institute (IDIBGI)Hospital Universitari Dr Josep TruetaGironaSpain
| | - Sira Domenech
- RadiologyInstitut Diagnòstic per la Imatge (IDI)BadalonaBarcelonaSpain
| | | | | | | | | | | | - Carlos Mesia
- Medical OncologyIDIBELLInstitut Catala Oncologia (ICO)Hospitalet de LLobregatBarcelonaSpain
| | - Rafael Fuentes
- Radiation OncologyInstitut Catala Oncologia (ICO)GironaSpain
| | - Jordi Marruecos
- Radiation OncologyInstitut Catala Oncologia (ICO)GironaSpain
| | | | - Salvador Villà
- Radiation Oncology, StatisticsInstitut Catala Oncologia (ICO)BadalonaBarcelonaSpain
| | | | | | - Miguel Gil‐Gil
- Medical OncologyIDIBELLInstitut Catala Oncologia (ICO)Hospitalet de LLobregatBarcelonaSpain
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Brown TJ, Brennan MC, Li M, Church EW, Brandmeir NJ, Rakszawski KL, Patel AS, Rizk EB, Suki D, Sawaya R, Glantz M. Association of the Extent of Resection With Survival in Glioblastoma: A Systematic Review and Meta-analysis. JAMA Oncol 2017; 2:1460-1469. [PMID: 27310651 DOI: 10.1001/jamaoncol.2016.1373] [Citation(s) in RCA: 602] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Importance Glioblastoma multiforme (GBM) remains almost invariably fatal despite optimal surgical and medical therapy. The association between the extent of tumor resection (EOR) and outcome remains undefined, notwithstanding many relevant studies. Objective To determine whether greater EOR is associated with improved 1- and 2-year overall survival and 6-month and 1-year progression-free survival in patients with GBM. Data Sources Pubmed, CINAHL, and Web of Science (January 1, 1966, to December 1, 2015) were systematically reviewed with librarian guidance. Additional articles were included after consultation with experts and evaluation of bibliographies. Articles were collected from January 15 to December 1, 2015. Study Selection Studies of adult patients with newly diagnosed supratentorial GBM comparing various EOR and presenting objective overall or progression-free survival data were included. Pediatric studies were excluded. Data Extraction and Synthesis Data were extracted from the text of articles or the Kaplan-Meier curves independently by investigators who were blinded to each other's results. Data were analyzed to assess mortality after gross total resection (GTR), subtotal resection (STR), and biopsy. The body of evidence was evaluated according to Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria and PRISMA guidelines. Main Outcome and Measures Relative risk (RR) for mortality at 1 and 2 years and progression at 6 months and 1 year. Results The search produced 37 studies suitable for inclusion (41 117 unique patients). The meta-analysis revealed decreased mortality for GTR compared with STR at 1 year (RR, 0.62; 95% CI, 0.56-0.69; P < .001; number needed to treat [NNT], 9) and 2 years (RR, 0.84; 95% CI, 0.79-0.89; P < .001; NNT, 17). The 1-year risk for mortality for STR compared with biopsy was reduced significantly (RR, 0.85; 95% CI, 0.80-0.91; P < .001). The risk for mortality was similarly decreased for any resection compared with biopsy at 1 year (RR, 0.77; 95% CI, 0.71-0.84; P < .001; NNT, 21) and 2 years (RR, 0.94; 95% CI, 0.89-1.00; P = .04; NNT, 593). The likelihood of disease progression was decreased with GTR compared with STR at 6 months (RR, 0.72; 95% CI, 0.48-1.09; P = .12; NNT, 14) and 1 year (RR, 0.66; 95% CI, 0.43-0.99; P < .001; NNT, 26). The quality of the body of evidence by the GRADE criteria was moderate to low. Conclusion and Relevance This analysis represents the largest systematic review and only quantitative systematic review to date performed on this subject. Compared with STR, GTR substantially improves overall and progression-free survival, but the quality of the supporting evidence is moderate to low.
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Affiliation(s)
- Timothy J Brown
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Matthew C Brennan
- Ann Barshinger Cancer Center, Lancaster General Health, Lancaster, Pennsylvania
| | - Michael Li
- Department of Neurosurgery, University of Rochester Medical Center, Pittsford, New York
| | - Ephraim W Church
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Nicholas J Brandmeir
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Kevin L Rakszawski
- Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Akshal S Patel
- Department of Neurosurgery, Swedish Cerebrovascular Institute, Seattle, Washington
| | - Elias B Rizk
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Dima Suki
- Division of Surgery, Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston
| | - Raymond Sawaya
- Division of Surgery, Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston
| | - Michael Glantz
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Results of a multicenter survey showing interindividual variability among neurosurgeons when deciding on the radicality of surgical resection in glioblastoma highlight the need for more objective guidelines. Clin Transl Oncol 2016; 19:727-734. [PMID: 28005261 DOI: 10.1007/s12094-016-1598-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 12/10/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE We assessed agreement among neurosurgeons on surgical approaches to individual glioblastoma patients and between their approach and those recommended by the topographical staging system described by Shinoda. METHODS Five neurosurgeons were provided with pre-surgical MRIs of 76 patients. They selected the surgical approach [biopsy, partial resection, or gross total resection (GTR)] that they would recommend for each patient. They were blinded to each other's response and they were told that patients were younger than 50 years old and without symptoms. Three neuroradiologists classified each case according to the Shinoda staging system. RESULTS Biopsy was recommended in 35.5-82.9%, partial resection in 6.6-32.9%, and GTR in 3.9-31.6% of cases. Agreement among their responses was fair (global kappa = 0.28). Nineteen patients were classified as stage I, 14 as stage II, and 43 as stage III. Agreement between the neurosurgeons and the recommendations of the staging system was poor for stage I (kappa = 0.14) and stage II (kappa = 0.02) and fair for stage III patients (kappa = 0.29). An individual analysis revealed that in contrast to the Shinoda system, neurosurgeons took into account T2/FLAIR sequences and gave greater weight to the involvement of eloquent areas. CONCLUSIONS The surgical approach to glioblastoma is highly variable. A staging system could be used to examine the impact of extent of resection, monitor post-operative complications, and stratify patients in clinical trials. Our findings suggest that the Shinoda staging system could be improved by including T2/FLAIR sequences and a more adequate weighting of eloquent areas.
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Jackson PR, Juliano J, Hawkins-Daarud A, Rockne RC, Swanson KR. Patient-specific mathematical neuro-oncology: using a simple proliferation and invasion tumor model to inform clinical practice. Bull Math Biol 2015; 77:846-56. [PMID: 25795318 PMCID: PMC4445762 DOI: 10.1007/s11538-015-0067-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 02/10/2015] [Indexed: 11/25/2022]
Abstract
Glioblastoma multiforme (GBM) is the most common malignant primary brain tumor associated with a poor median survival of 15–18 months, yet there is wide heterogeneity across and within patients. This heterogeneity has been the source of significant clinical challenges facing patients with GBM and has hampered the drive toward more precision or personalized medicine approaches to treating these challenging tumors. Over the last two decades, the field of Mathematical Neuro-oncology has grown out of desire to use (often patient-specific) mathematical modeling to better treat GBMs. Here, we will focus on a series of clinically relevant results using patient-specific mathematical modeling. The core model at the center of these results incorporates two hallmark features of GBM, proliferation \documentclass[12pt]{minimal}
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\begin{document}$$\rho $$\end{document}ρ and D to create patient-specific growth predictions. The PI model, its predictions, and parameters have been used in a number of ways to derive biological insight. Beyond predicting growth, the PI model has been utilized to identify patients who benefit from different surgery strategies, to prognosticate response to radiation therapy, to develop a treatment response metric, and to connect clinical imaging features and genetic information. Demonstration of the PI model’s clinical relevance supports the growing role for it and other mathematical models in routine clinical practice.
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Affiliation(s)
- Pamela R. Jackson
- Mathematical NeuroOncology Lab, Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 676 N St Clair Street, Suite 1300, Chicago, IL 60611 USA
| | - Joseph Juliano
- Mathematical NeuroOncology Lab, Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 676 N St Clair Street, Suite 1300, Chicago, IL 60611 USA
| | - Andrea Hawkins-Daarud
- Mathematical NeuroOncology Lab, Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 676 N St Clair Street, Suite 1300, Chicago, IL 60611 USA
| | - Russell C. Rockne
- Mathematical NeuroOncology Lab, Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 676 N St Clair Street, Suite 1300, Chicago, IL 60611 USA
| | - Kristin R. Swanson
- Mathematical NeuroOncology Lab, Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 676 N St Clair Street, Suite 1300, Chicago, IL 60611 USA
- Department of Engineering Sciences and Applied Mathematics, Northwestern University, Evanston, IL USA
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Abstract
Background:Assessing the impact of glioma location on prognosis remains elusive. We approached the problem using multivoxel proton magnetic resonance spectroscopic imaging (1H-MRSI) to define a tumor “metabolic epicenter”, and examined the relationship of metabolic epicenter location to survival and histopathological grade.Methods:We studied 54 consecutive patients with a supratentorial glioma (astrocytoma or oligodendroglioma, WHO grades II-IV). The metabolic epicenter in each tumor was defined as the 1H-MRSI voxel containing maximum intra-tumoral choline on preoperative imaging. Tumor location was considered the X-Y-Z coordinate position, in a standardized stereotactic space, of the metabolic epicenter. Correlation between epicenter location and survival or grade was assessed.Results:Metabolic epicenter location correlated significantly with patient survival for all tumors (r2 = 0.30, p = 0.0002) and astrocytomas alone (r2 = 0.32, p = 0.005). A predictive model based on both metabolic epicenter location and histopathological grade accounted for 70% of the variability in survival, substantially improving on histology alone to predict survival. Location also correlated significantly with grade (r2 = 0.25, p = 0.001): higher grade tumors had a metabolic epicenter closer to the midpoint of the brain.Conclusions:The concept of the metabolic epicenter eliminates several problems related to existing methods of classifying glioma location. The location of the metabolic epicenter is strongly correlated with overall survival and histopathological grade, suggesting that it reflects biological factors underlying glioma growth and malignant dedifferentiation. These findings may be clinically relevant to predicting patterns of local glioma recurrence, and in planning resective surgery or radiotherapy.
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Murphy M, Parney IF. Clinical trials in neurosurgical oncology. J Neurooncol 2014; 119:569-76. [PMID: 25106866 DOI: 10.1007/s11060-014-1569-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Accepted: 07/23/2014] [Indexed: 10/24/2022]
Abstract
Brain tumors such as diffuse infiltrating gliomas continue to represent a major clinical challenge. Overall survival for patients diagnosed with glioblastoma, the most common primary brain tumor, remains less than 2 years despite intensive multimodal therapy with surgery, radiation, and chemotherapy. However, advances have been made in standard therapies and novel treatments that are showing great potential. These advances reflect careful study performed in the context of clinical trials. Neurosurgeons have played and will continue to play key parts in these studies. In this manuscript, we review clinical trials in neuro-oncology from a neurosurgical point of view and discuss potential roles for neurosurgeons in advancing glioma therapy in the future.
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Affiliation(s)
- Meghan Murphy
- Department of Neurological Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Fluorescence-guided surgery and biopsy in gliomas with an exoscope system. BIOMED RESEARCH INTERNATIONAL 2014; 2014:207974. [PMID: 24971317 PMCID: PMC4055357 DOI: 10.1155/2014/207974] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 04/16/2014] [Accepted: 05/04/2014] [Indexed: 11/26/2022]
Abstract
Background. The introduction of fluorescence-guided resection allows a better identification of tumor tissue and its more radical resection. We describe our experience with a modified exoscope to detect 5 ALA-induced fluorescence in neuronavigation-guided brain surgery or biopsy of malignant brain tumors. Methods. Thirty-eight patients with a suspected preoperative diagnosis of high-grade astrocytoma were included. We used a neuronavigation device and a high-definition exoscope system with a built-in filter to detect 5-ALA fluorescence in all cases. Thirty patients underwent craniotomy with tumor resection and 8 underwent frameless stereotactic brain biopsy. Results. Histopathological diagnosis confirmed the presence of high-grade gliomas in 34 patients. Total resection was achieved in 23 cases and subtotal in 7. No relevant complications related to the administration of 5-ALA were detected. Conclusions. The use of the exoscope in 5-ALA fluorescence-guided tumor surgery has twofold implications: during brain tumor surgery it can be considered a valuable tool to achieve a more radical resection of the lesion, and when applied to a biopsy of a suspected brain high-grade glioma, it decreases the possibility of a negative biopsy.
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Fluorescence-guided surgery in high grade gliomas using an exoscope system. Acta Neurochir (Wien) 2014; 156:653-60. [PMID: 24468884 DOI: 10.1007/s00701-013-1976-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 12/04/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Fluorescence-guided microsurgical resections of high-grade gliomas using 5-aminolevulinic acid (5-ALA) is superior to conventional microsurgery. An optical device, usually a modified microscope, is needed for these procedures. However, an exoscope may be implemented for fluorescence techniques. We present the use of an exoscope to perform tumor resection guided by 5-ALA fluorescence in 21 consecutive patients with high-grade glioma and two neuronavigation-guided biopsies. METHODS Twenty-three patients underwent operations. Tumor volume and localization were quantified with pre- and postoperative volumetric MRI in non-biopsy cases. RESULTS In non-biopsy cases, the age range was 20 to 79 years, with a median of 56 (interquartile range = 45-66). Histological analysis indicated that 14 had glioblastoma multiforme, 2 grade-III oligodendrogliomas and 1 anaplastic astrocytoma, 3 metastases and 1 low-grade astrocytoma. Total resection was achieved in 15 cases; subtotal resection was performed in 5 patients. The result was partial resection in one case. There was no perioperative mortality. The median fluorescence intensity, on a scale of 1-5, was 4.5 in the GBM group (IQR = 4-5), 3 (IQR = 2.5-3.5) in anaplastic glioma, and 2.5 (IQR = 2.25-2.75) for oligodendrogliomas. Of the three metastases, one showed fluorescence level 4. As for the two biopsy cases, one was anaplastic astrocytoma and one glioblastoma multiforme. The samples obtained were fluorescent in both cases. CONCLUSIONS An exoscope can be also used for fluorescence-guided surgery with 5-aminolevulinic acid (5-ALA) and neuronavigation-guided biopsy. With an important advantage of low cost, this allows the surgeon to perform collaborative surgeries and adds agility to the procedure.
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Resection probability maps for quality assessment of glioma surgery without brain location bias. PLoS One 2013; 8:e73353. [PMID: 24039922 PMCID: PMC3765204 DOI: 10.1371/journal.pone.0073353] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 07/18/2013] [Indexed: 11/19/2022] Open
Abstract
Background Intraoperative brain stimulation mapping reduces permanent postoperative deficits and extends tumor removal in resective surgery for glioma patients. Successful functional mapping is assumed to depend on the surgical team's expertise. In this study, glioma resection results are quantified and compared using a novel approach, so-called resection probability maps (RPM), exemplified by a surgical team comparison, here with long and short experience in mapping. Methods Adult patients with glioma were included by two centers with two and fifteen years of mapping experience. Resective surgery was targeted at non-enhanced MRI extension and was limited by functional boundaries. Neurological outcome was compared. To compare resection results, we applied RPMs to quantify and compare the resection probability throughout the brain at 1 mm resolution. Considerations for spatial dependence and multiple comparisons were taken into account. Results The senior surgical team contributed 56, and the junior team 52 patients. The patient cohorts were comparable in age, preoperative tumor volume, lateralization, and lobe localization. Neurological outcome was similar between teams. The resection probability on the RPMs was very similar, with none (0%) of 703,967 voxels in left-sided tumors being differentially resected, and 124 (0.02%) of 644,153 voxels in right-sided tumors. Conclusion RPMs provide a quantitative volumetric method to compare resection results, which we present as standard for quality assessment of resective glioma surgery because brain location bias is avoided. Stimulation mapping is a robust surgical technique, because the neurological outcome and functional-based resection results using stimulation mapping are independent of surgical experience, supporting wider implementation.
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The influence of regional health system characteristics on the surgical management and receipt of post operative radiation therapy for glioblastoma multiforme. J Neurooncol 2013; 112:393-401. [PMID: 23412775 DOI: 10.1007/s11060-013-1068-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 02/06/2013] [Indexed: 02/02/2023]
Abstract
Despite a known optimal treatment protocol for the management of glioblastoma multiforme (GBM), many patients fail to receive complete surgical resection or post-operative radiation therapy (PORT). The underlying reasons behind this disparity are unclear. Our study investigates the influence of regional health system resources on the surgical management and PORT receipt in patients with GBM. Surgical intervention, PORT receipt and patient data for patients diagnosed with GBM were obtained from the years 2004 to 2008 from the NCI Surveillance, Epidemiology, and End Results database and combined with the health system data from the Area Resource File. Four logistic models were constructed to test the effect of health system characteristics on surgical treatment choice and PORT receipt among health service areas (HSAs). We found that younger, married patients in HSAs with higher median incomes were significantly more likely to receive both gross total resection (p < 0.001, p < 0.001, p = 0.002) and PORT (p < 0.001, p < 0.001, p = 0.008). The density of radiation oncology equipped hospitals was also a significant predictor of PORT receipt (p = 0.002). Our findings suggest regional variations in of neuro-oncology services and income may have impact on GBM management. Policies aimed at narrowing disparities in treatment may need to focus on addressing regional variations in oncology resources.
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Ahmadloo N, Kani AA, Mohammadianpanah M, Nasrolahi H, Omidvari S, Mosalaei A, Ansari M. Treatment outcome and prognostic factors of adult glioblastoma multiforme. J Egypt Natl Canc Inst 2012; 25:21-30. [PMID: 23499203 DOI: 10.1016/j.jnci.2012.11.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Revised: 11/08/2012] [Accepted: 11/12/2012] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION This study aimed to report the characteristics, prognostic factors and treatment outcome of 223 patients with glioblastoma multiforme (GBM). SUBJECTS AND METHOD This retrospective study was carried out by reviewing the medical records of 223 adult patients diagnosed at a tertiary academic hospital between 1990 and 2008. Patients' follow up ranged from 1 to 69 months (median 11 months). Surgery was attempted in all patients in whom complete resection in 15 patients (7%), subtotal resection in 77 patients (34%), partial resection in 73 patients (33%) and biopsy alone in 58 patients (26%) were done. In addition, we performed a literature review of PubMed to find out and analyze major related series. In all, we collected and analyzed the data of 33 major series including more than 11,000 patients with GBM. RESULTS There were 141 men and 82 women. The median progression free- and overall survival were 6 (95% CI=5.711-8.289) and 11 (95% CI=9.304-12.696) months respectively. In univariate analysis for overall survival, age (P=0.003), tumor size (P<0.013), performance status (P<0.001), the extent of surgical resection (P=0.009), dose of radiation (P<0.001), and adjuvant chemotherapy (P<0.001) were prognostic factors. However, in multivariate analysis, only radiation dose, extent of surgical resection, and adjuvant chemotherapy were independent prognostic factors for overall survival. CONCLUSION The prognosis of adult patients with GBM remains poor; however, complete surgical resection and adjuvant treatments improve progression-free and overall survival.
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Affiliation(s)
- Niloofar Ahmadloo
- Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Ansari M, Nasrolahi H, Kani AA, Mohammadianpanah M, Ahmadloo N, Omidvari S, Mosalaei A. Pediatric glioblastoma multiforme: A single-institution experience. Indian J Med Paediatr Oncol 2012; 33:155-60. [PMID: 23248421 PMCID: PMC3523472 DOI: 10.4103/0971-5851.103142] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Glioblastoma multiforme (GBM) is the most common astrocytoma in adults and has a poor prognosis, with a median survival of about 12 months. But, it is rare in children. We report our experience on the pediatric population (20 years or younger) with GBM. Patients and Methods: Twenty-three patients with GBM who were treated at our hospital during 1990–2008 were evaluated. Results: The mean age was 15.2 years, and the majority of them (14/23) were male. All had received radiotherapy and some had also received chemotherapy. The mean survival was 16.0 months. Two cases survived more than 5 years. Age, radiation dose and performance status were significantly related to survival. Conclusion: GBM in pediatric patients were not very common in our center, and prognosis was unfavorable.
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Affiliation(s)
- Mansour Ansari
- Department of Radiation Oncology, Student Research Committee, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Okumus NO, Gursel B, Meydan D, Ozdemir O, Odabas E, Gonullu G. Prognostic significance of concomitant radiotherapy in newly diagnosed glioblastoma multiforme: a multivariate analysis of 116 patients. Ann Saudi Med 2012; 32:250-5. [PMID: 22588435 PMCID: PMC6081031 DOI: 10.5144/0256-4947.2012.250] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Currently, radiotherapy with concomitant and adjuvant temozolomide has become the standard treatment for glioblastoma. The purpose of this study was to report our experience with radiation plus concomitant temozolomide in 116 patients with glioblastoma multiforme (GBM) and examine the value of different prognostic factors. DESIGN AND SETTING Retrospective analysis of 116 patients with newly diagnosed GBM, who were treated at our department between January 1994 and March 2009. PATIENTS AND METHODS Age, gender, Karnofsky performance scale (KPS) score, a preoperative history of seizures, extent of surgery, total radiotherapy dose, and use of concomitant and adjuvant temozolomide were evaluated in uni- and multivariate analyses. Survival was determined using the Kaplan-Meier method, and differences were compared using the log rank test. Cox regression analysis was conducted to identify the independent prognostic factors. RESULTS The median overall survival time was 9 months, and the 1- and 2-year survival rates were 41.9% and 9.6%, respectively. The univariate analysis revealed that age, KPS score, presence of seizures, radiation doses, and use of concomitant and adjuvant temozolomide were significant prognostic factors. The multivariate analysis confirmed that the age, KPS score, presence of seizures, radiation doses, and use of concomitant and adjuvant temozolomide were independent, significant prognostic factors. CONCLUSIONS The results of our analyses demonstrate that radiation with concomitant and adjuvant temozolomide yields encouraging outcomes in patients with GBM, validating the results published in research papers. In addition, age, KPS score, presence of seizures, and radiation doses were identified as prognostic factors.
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Affiliation(s)
- Nilgun Ozbek Okumus
- Department of Radiation Oncology, Ondokuz Mayis University, School of Medicine, Turkey.
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Chen B, Wang H, Ge P, Zhao J, Li W, Gu H, Wang G, Luo Y, Chen D. Gross total resection of glioma with the intraoperative fluorescence-guidance of fluorescein sodium. Int J Med Sci 2012; 9:708-14. [PMID: 23091408 PMCID: PMC3477680 DOI: 10.7150/ijms.4843] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 09/17/2012] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE High dose fluorescein sodium has been utilized for fluorescence-guided tumor resection with conflicting reports on the efficacy of this procedure. The aim of this study was to reevaluate the utility and clinical limitations of using fluorescein sodium for the treatment and resection of glioma brain tumors. METHODS Patients diagnosed with glioma were divided into two groups with a total of 22 patients enrolled in the study: 1) the study group (n=10), patients that received intravenous injection of fluorescein sodium and 2) the control group (n=12), patients that did not receive injections during surgical resection. Quality of life was evaluated according to Karnofsky Performance Scale (KPS) score and neurological status. Fluorescein sodium was intravenously injected at a dose of 15-20mg/kg of body weight. Glioma resection was evaluated preoperative and postoperatively with enhanced Magnetic Resonance Imaging (MRI). RESULTS Significant differences in the gross total resection (GTR) rates were observed between the two patient groups (Fisher's Exact Test p=0.047). Progressive free survival was significantly longer in the study group (Student's T-Test p=0.033) as well as in the GTR group (Student's T-Test p=0.0001) compared to the control and non-GTR groups, respectively. Three patients in the study group and four patients in the control group had transient neurological deterioration. One patient in the control group had permanent hemiplegia. CONCLUSION The intraoperative utility of using fluorescein sodium can significantly increase the GTR rate without obvious deterioration. In addition, we find that it is better to apply the fluorescein sodium in the cases with BBB (blood-brain barrier) disruption, which had been enhanced in preoperative MRI.
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Affiliation(s)
- Bo Chen
- Department of neurosurgery The First Hospital of Jilin University, Changchun, Jilin 130021, China
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Affiliation(s)
- Ian F Parney
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA.
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Abstract
Background: Patients with high-grade gliomas are treated with surgery followed by chemoradiation. The risk factors and implications of neurological side effects are not known. Methods: Acute and late ⩾ grade 3 neurological toxicities (NTs) were analysed among 2761 patients from 14 RTOG trials accrued from 1983 to 2003. The association between acute and late toxicity was analysed using a stepwise logistic regression model. The association between the occurrence of acute NT and survival was analysed as an independent variable. Results: There were 2610 analysable patients (86% glioblastoma, 10% anaplastic astrocytoma). All received a systemic agent during radiation (83% chemotherapy, 17% biological agents). Median radiation dose was 60 Gy. There were 182 acute and 83 late NT events. On univariate analysis, older age, poor performance status, aggressive surgery, pre-existing neurological dysfunction, poor mental status and twice-daily radiation were associated with increased acute NT. In a stepwise logistic regression model the occurrence of acute NT was significantly associated with late NT (OR=2.40; 95% CI=1.2–4.8; P=0.014). The occurrence of acute NT predicted poorer overall survival, independent of recursive partitioning analysis class (median 7.8 vs 11.8 months). Interpretation: Acute NT is significantly associated with both late NT and overall survival.
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High-field iMRI in glioblastoma surgery: improvement of resection radicality and survival for the patient? ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 109:103-6. [PMID: 20960328 DOI: 10.1007/978-3-211-99651-5_16] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Since the first patients underwent intracranial tumor removal with the radicality control of intraoperative MRI (ioMRI) in September 2005 in our department, the majority of operations performed in the ioMRI room have been indicated for high grade gliomas. In order to elucidate the role of ioMRI scanning in patients harboring high-grade gliomas (HGG) on their survival, one hundred ninety three patients with gliomas WHO grades III and IV were operated either in a standard microsurgical neuronavigated fashion or using additionally ioMRI and were included in a follow-up study. The series started with surgeries from September 2005 until October 2007. Patient attribution to the two groups was based on the logistical availability of the ioMRI on a scheduled surgery day, and on the assumed "difficulty" of the surgery based on the location of the glioma in or near to an eloquent area. Surgery was intended to be as radical as possible without reduction of quality of life. First surgery was performed in 103 patients (75 WHO IV and 28 WHO III) and will be the main topic of this paper. In 60 patients, ioMRI was used, while in 43 patients standard microsurgical neuronavigated resection techniques were applied. Patients were followed in regular intervals mostly until death. Statistical analysis showed a median survival time for patients in whom ioMRI had been used of 20, 37 months compared to 10, 3 months in the cohort who had undergone conventional microsurgical removal. Major influencing concomitants were WHO grades and age which were balanced in both groups.
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Hoover JM, Chang SM, Parney IF. Clinical Trials in Brain Tumor Surgery. Neuroimaging Clin N Am 2010; 20:409-24. [DOI: 10.1016/j.nic.2010.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fujii O, Soejima T, Kuwatsuka Y, Harada A, Ota Y, Tsujino K, Sasaki M, Kudo H, Nishihara M, Taomoto K. Supratentorial glioblastoma treated with radiotherapy: use of the Radiation Therapy Oncology Group recursive partitioning analysis grouping for predicting survival. Jpn J Clin Oncol 2010; 40:726-31. [PMID: 20410057 DOI: 10.1093/jjco/hyq051] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the usefulness of recursive partitioning analysis model established by the Radiation Therapy Oncology Group for predicting the survival of patients with supratentorial glioblastoma treated with radiotherapy and to determine prognostic factors for the subgroups of this prognostic model. METHODS A total of 108 glioblastoma patients treated with radiotherapy between January 1987 and December 2005 were retrospectively reviewed. Recursive partitioning analysis classes III, IV, V and VI included 8, 29, 32 and 39 patients, respectively. These classes were divided into two subgroups: a good prognostic group containing classes III-IV and a poor prognostic group containing classes V-VI. The median radiation dose was 60 Gy. Seventy-five patients received chemotherapy and/or immunotherapy. RESULTS The overall survival differed significantly among classes III, IV, V and VI, with median survival times of 34, 15, 11 and 7 months, respectively. Among the good prognostic group, patients with basal ganglia invasion showed poorer survival outcomes than patients without basal ganglia invasion. Among the poor prognostic group, patients with tumor sizes of <5 cm and patients treated with nimustine hydrochloride showed better survival outcomes than those with tumor sizes of > or =5 cm and those without treatment with nimustine hydrochloride, respectively. CONCLUSIONS This study confirms the prognostic value of the recursive partitioning analysis grouping. Basal ganglia invasion could be a useful predictive factor for survival in the good prognostic group, whereas tumor size and treatment with nimustine hydrochloride could be useful predictive factors in the poor prognostic group.
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Affiliation(s)
- Osamu Fujii
- Department of Radiation Oncology, Hyogo Cancer Center, 13-70 Kitaojicho, Akashi 673-8558, Japan.
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Reithmeier T, Graf E, Piroth T, Trippel M, Pinsker MO, Nikkhah G. BCNU for recurrent glioblastoma multiforme: efficacy, toxicity and prognostic factors. BMC Cancer 2010; 10:30. [PMID: 20122270 PMCID: PMC2837009 DOI: 10.1186/1471-2407-10-30] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Accepted: 02/02/2010] [Indexed: 11/23/2022] Open
Abstract
Background The prognosis for patients with recurrent glioblastoma is still poor with a median survival between 3 and 6 months. Reports about the application of carmustine (BCNU), one of the standard chemotherapeutic drugs in the treatment of newly diagnosed glioblastoma, in the recurrent situation are rare. Methods We performed a retrospective analysis of 35 patients with recurrent or progressive glioblastoma treated with 80 mg/m2 BCNU on days 1 on 3 intravenously at our department for efficacy, toxicity and prognostic factors. Progression free survival and overall survival were estimated by the Kaplan-Meier method. The influence of age, Karnofsky performance status (KPS), tumor burden, pretreatment with temozolomide (TMZ), type of surgery for initial diagnosis and number of previous relapses on outcome was analyzed in a proportional hazards regression model. Results The median age of the group was 53 years, median KPS was 70. Median progression free survival was 11 weeks (95% confidence interval [CI]: 8-15), median overall survival 22 weeks (95% CI: 18-27). The rate of adverse events, especially hematological toxicity, is relatively high, and in 3 patients treatment had to be terminated due to adverse events (one pulmonary embolism, one pulmonary fibrosis, and one severe bone marrow suppression). No influence of age, KPS, tumor burden, pre-treatment with TMZ and number of previous relapses on outcome could be demonstrated, while gross total resection prior to recurrence showed a borderline statistically significant negative impact on PFS and OS. These data compare well with historical survival figures. However prospective randomized studies are needed to evaluate BCNU efficacy against newer drugs like bevacizumab or the intensified temozolomide regime (one week on/one week off). Conclusion In summary, BCNU treatment appears to be a valuable therapeutic option for recurrent glioblastomas, where no other validated radio- and/or chemotherapy are available.
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Affiliation(s)
- Thomas Reithmeier
- Department of Stereotactic and Functional Neurosurgery, University Medical Center Freiburg, Breisacher Str, 64, 79106 Freiburg im Breisgau, Germany.
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Optimizing costs of intraoperative magnetic resonance imaging. A series of 29 glioma cases. Acta Neurochir (Wien) 2010; 152:27-33. [PMID: 19572102 DOI: 10.1007/s00701-009-0430-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Accepted: 05/27/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE The goal of this study was to develop a method to reduce the costs of intraoperative high-field magnet resonance imaging (iMRI). The results of a series of 29 gliomas removed with this technique are presented. METHODS A series of 29 patients with brain gliomas were operated on using a low-cost method of high-field intraoperative MRI (Signa 1.5 T. MR Excite, GE Inc.). The patients were transported during surgery to the neuroradiological department through a specially located lift in order to perform the intraoperative examinations ("outside iMRI"). The time required for the procedure as well as the possible related complications, such as infection, were analyzed. RESULTS After studying the intraoperative images, additional tumor resection was needed in 12 of the 29 patients. The median time required to perform the iMRI was 25 min. There was no infection or other complications related to the procedure in this series. CONCLUSIONS This method offers all clinical advantages of high-field iMRI inside of the operating room, with very low costs and additional advantage of integrating the neurosurgical/ neuroradiological teams. This strategy will give an alternative to several neurosurgical departments in the world to perform high-quality iMRI at very low cost.
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Ma X, Lv Y, Liu J, Wang D, Huang Q, Wang X, Li G, Xu S, Li X. Survival analysis of 205 patients with glioblastoma multiforme: clinical characteristics, treatment and prognosis in China. J Clin Neurosci 2009; 16:1595-8. [PMID: 19793663 DOI: 10.1016/j.jocn.2009.02.036] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Revised: 02/19/2009] [Accepted: 02/24/2009] [Indexed: 11/15/2022]
Abstract
To study the clinical characteristics, treatment and prognosis of patients with glioblastoma multiforme (GBM) in China, we retrospectively analyzed 205 Chinese patients with histologically proven GBM. A univariate analysis of prognosis factors for survival time was performed and significant factors were tested in a multivariate analysis using the Cox regression method. Median overall survival time was 12.0 months (95% confidence interval [CI] 11.0-13.1 months). Survival rates after diagnosis were 82% at 6 months, 52% at 12 months, 27% at 18 months and 17% at 24 months. Age, preoperative Karnofsky's performance status score and tumour location were independent preoperative predictors of prognosis and among the treatment methods of GBM, radiotherapy was the strongest predictor of prognosis followed by radical surgery and chemotherapy. The median survival time post diagnosis for Chinese patients is comparable to the 11.0-15.9 month range observed in western patients. The data suggest a lack of ethnic differences in GBM prognosis of Chinese and western patients.
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Affiliation(s)
- Xiangyu Ma
- Department of Neurosurgery, Qilu Hospital of Shandong University, 107 Wenhua West Road, Jinan 250012, China
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Combined modality treatment of newly diagnosed glioblastoma multiforme in a regional neurosurgical centre. J Clin Neurosci 2009; 16:1174-9. [DOI: 10.1016/j.jocn.2008.12.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 12/14/2008] [Accepted: 12/14/2008] [Indexed: 11/17/2022]
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Mangiola A, de Bonis P, Maira G, Balducci M, Sica G, Lama G, Lauriola L, Anile C. Invasive tumor cells and prognosis in a selected population of patients with glioblastoma multiforme. Cancer 2008; 113:841-6. [PMID: 18618580 DOI: 10.1002/cncr.23624] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND After surgical resection, the residual, invasive glioblastoma (GBM) cells give rise to a recurrent tumor, which, in 96% of patients, arises adjacent to the resection margin. METHODS In this study, the authors prospectively enrolled 25 patients with GBM who underwent gross total resection followed by adjuvant radiochemotherapy (with temozolomide). Tumor removal was achieved with resection margins that included the neighboring, apparently normal tissue (between 1 cm and 2 cm from the tumor border [B area]) and the tumor. RESULTS Patients who had an absence of tumor cells in the neighboring, apparently normal white matter (B area) had better survival than patients who had the presence of tumor cells in the B area (21 months vs 12 months). This difference was statistically significant in univariate analysis (P = .005) and in multivariate analysis (P = .01). CONCLUSIONS Aggressive tumor removal may improve survival, but the current results indicated that biologic commitment of 'penumbra' cells appear to be the most relevant factor for tumor recurrence and accounts for the fatal outcome of the disease.
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Affiliation(s)
- Annunziato Mangiola
- Department of Neurological Sciences, Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy
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Ryken TC, Frankel B, Julien T, Olson JJ. Surgical management of newly diagnosed glioblastoma in adults: role of cytoreductive surgery. J Neurooncol 2008; 89:271-86. [DOI: 10.1007/s11060-008-9614-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Accepted: 05/19/2008] [Indexed: 11/28/2022]
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Balaña C, Capellades J, Teixidor P, Roussos I, Ballester R, Cuello M, Arellano A, Florensa R, Rosell R. Clinical course of high-grade glioma patients with a "biopsy-only" surgical approach: a need for individualised treatment. Clin Transl Oncol 2008; 9:797-803. [PMID: 18158984 DOI: 10.1007/s12094-007-0142-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION 'Biopsy-only' high-grade glioma (HGG) patients get limited benefit from post-operative treatments, and as a group, negatively impact median survival outcomes. MATERIAL AND METHODS We retrospectively evaluated clinical characteristics, treatment and overall survival of HGG patients with a 'biopsy- only' surgical approach diagnosed between 1997 and 2005 at a University Hospital in Spain. RESULTS In 31% of 294 suspected gliomas, only a diagnostic biopsy was undertaken. Reasons for 'biopsy-only' for all patients were either location in eloquent areas: (motor area 18.7%, language area 25,3%, basal ganglia 7.7%, visual area 4.4%) or extension of the disease (corpus callosum invasion 14.3% and multicentricity/multifocality 28.6%). Seventy-four patients (80.4%) were HGG: 26% of all grade IV and 49% of all grade III tumours. For these patients, post-operative Karnofsky Performance Status of over 70%, median age and median survival were, respectively: 64 and 70%, 60.7 and 57 years old, and 23.1 and 42.7 weeks (p=0.0006). Patients lived longer if post-operative treatment was given, in all grades (p<0.0001). Nineteen patients (25.6%) died within 42 days after surgery. Only 60% of them initiated radiotherapy and 10% of them did not complete it. However, tumour grade, radiotherapy and temozolomide- based chemotherapy were independently associated with longer survival in multivariate analysis (p<0.05). CONCLUSION Almost one third of HGG patients can undergo only a biopsy and not debulking surgery. Although radiotherapy improves survival, only 50% of them complete the treatment. An individualised approach to these patients is needed to facilitate a correct analysis of therapy results. New therapies must be investigated in these patients.
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Affiliation(s)
- C Balaña
- Medical Oncology Service, Institut Català d'Oncologia, Germans Trias i Pujol, Badalona, Barcelona, Spain.
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Butowski N, Lamborn KR, Berger MS, Prados MD, Chang SM. Historical controls for phase II surgically based trials requiring gross total resection of glioblastoma multiforme. J Neurooncol 2007; 85:87-94. [PMID: 17457513 DOI: 10.1007/s11060-007-9388-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2007] [Accepted: 04/02/2007] [Indexed: 11/28/2022]
Abstract
New treatments for patients with glioblastoma multiforme (GBM) are frequently tested in phase II surgically based clinical trials that require gross total resection (GTR). In order to determine efficacy in such single-arm phase II clinical trials, the results are often compared to those from a historical control group that is not limited to patients with GTR. Recursive partitioning analysis (RPA) can define risk groups within historical control groups; however, RPA analyses to date included patients irrespective of whether a patient had a GTR or not. To provide a more appropriate historical control group for surgically based trials requiring a GTR, we sought to determine survival for a group of patients with newly diagnosed GBM, all of who underwent GTR and were treated on prospective clinical trials. GTR was defined as removal of >90% of the enhancing mass, determined by postoperative magnetic resonance imaging. Of 893 patients with GBM treated during these trials, 153 underwent GTR. The median survival for the GTR group was 71 weeks (95% CI 65-76) which was better than those who did not have a GTR. Within the GTR group, the median age was 54 years (range 25-77 years), and median Karnofsky Performance Score was 90 (range 60-100). Considering only patients with GTR, age at diagnosis continued to be a statistically significant prognostic factor. Patients treated during surgically based phase II studies should be matched with a historical control group restricted to patients with similar pretreatment variables, including GTR.
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Affiliation(s)
- Nicholas Butowski
- Neuro-Oncology Service, Department of Neurological Surgery, University of California, San Francisco, 400 Parnassus Avenue, A808, San Francisco, CA 94143-0350, USA.
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Mineo JF, Bordron A, Baroncini M, Ramirez C, Maurage CA, Blond S, Dam-Hieu P. Prognosis factors of survival time in patients with glioblastoma multiforme: a multivariate analysis of 340 patients. Acta Neurochir (Wien) 2007; 149:245-52; discussion 252-3. [PMID: 17273889 DOI: 10.1007/s00701-006-1092-y] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2006] [Accepted: 12/11/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND The prognosis of glioblastoma multiforme remains poor despite recent therapeutic advances. Several clinical and therapeutic factors as well as tumour characteristics have been reported as significant to survival. A more efficient determination of the prognostic factors is required to optimize individual therapeutic management. The aim of our study was to evaluate by univariate then multivariate analysis the factors that influence prognosis and particularly survival. METHODS Data of 340 patients with newly-diagnosed GBM were retrospectively analyzed. Univariate analysis of prognosis factors of survival time was performed. Factors that seemed determinant were evaluated by Kaplan-Meier survival curves. Finally, the significant factors found in univariate analysis were tested in multivariate analysis using the COX regression method. FINDINGS Using multivariate analysis, the following factors were found to influence survival: radiotherapy was the predominant factor followed by radical surgery, tumour location, age and chemotherapy. Patients treated with temozolomide had a markedly better survival rate than patients treated with other chemotherapies (Log-rank test P < 0.005). The values of GBM type (de novo or secondary), as well as repeated surgery and partial surgery (vs. simple biopsy) were suggested by univariate analysis but not confirmed by the COX regression method. After radical surgery, progression-free survival was correlated to overall survival (r = 0.87, P < 10e-5). CONCLUSIONS; The influence of radiotherapy on survival was greater than the influence of age, an argument supporting the proposition of radiotherapy for patients until at least age 70. In the case of recurrence, the correlation between overall survival and progression-free survival is an important factor when considering the therapeutic options. Initial radical surgery and repeated procedures dramatically influence survival. The benefit of partial surgery remains difficult to evaluate. Partial surgery could be used to decrease intracranial pressure and to minimize residual tumours in order to enable treatment by chemotherapy and radiotherapy. The value of temozolomide treatment was confirmed.
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Affiliation(s)
- J-F Mineo
- Department of Neurosurgery, Hospital Roger Salengro, University Medical Centre, Lille, France.
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Litofsky NS, Bauer AM, Kasper RS, Sullivan CM, Dabbous OH. Image-guided resection of high-grade glioma: patient selection factors and outcome. Neurosurg Focus 2006; 20:E16. [PMID: 16709021 DOI: 10.3171/foc.2006.20.4.10] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECT In patients with glioma, image-guided surgery helps to define the radiographic limits of the tumor to maximize safety and the extent of resection while minimizing damage to eloquent brain tissue. The authors hypothesize that image-guided resection (IGR) techniques are associated with improved outcomes in patients with malignant glioma. METHODS Data recorded in 486 patients enrolled in the Glioma Outcomes Project were analyzed in this study. Demographic data and outcomes in patients who underwent IGR were compared with those in patients who underwent resection without IGR. Univariate analysis performed with chi-square testing was used to compare patient presentation, tumor characteristics, and death rates. Multivariate logistic regression was used to predict various outcome parameters. Patients who underwent IGR were younger and had smaller, lower-grade tumors than those in whom IGR was not performed. They were more likely to present with seizure and normal consciousness. Unexpectedly, gross-total resection was performed in significantly fewer patients with IGR than in individuals without IGR. Patients with IGR were more likely to be discharged home with the ability to live independently, and they had a shorter duration of hospital stay than patients without IGR. Survival was significantly longer in patients who underwent IGR, but multivariate analysis showed that glioblastoma multiforme (GBM) and age accounted for these observations. CONCLUSIONS Selection bias occurs regarding patients who receive IGR; these biases include younger age, presentation with seizure and normal level of consciousness, tumor diameter less than 4 cm, and non-GBM on histopathological studies. Outcome appears to be improved in patients who undergo IGRs of high-grade gliomas. It is unclear if these improved outcomes are due to the selection of a more favorable patient population or to the IGR techniques themselves. It is likely that the full potential of image guidance in glioma surgery will not be realized until it is applied to a wider range of patients.
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Affiliation(s)
- N Scott Litofsky
- Division of Neurosurgery, University of Missouri-Columbia School of Medicine, Columbia, Missouri 65212, USA.
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Abstract
Following the seminal trial conducted by the European Organisation for Research and Treatment of Cancer (EORTC) and the National Cancer Institute of Canada (NCIC), concurrent temozolomide and radiotherapy has become the new standard of care for patients with newly diagnosed glioblastoma multiforme (GBM). Investigation of emerging therapies (which are now used as salvage therapy) such as small-molecule inhibitors (for example, epidermal growth factor receptor inhibitors) and convection-enhanced delivery (CED) of targeted toxins (for example, interleukin-13/pseudomonas exotoxin) is likely to build on the EORTC/NCIC treatment platform and will, it is hoped, improve survival rates in patients with GBM. The majority of adjuvant Phase I and II trials being conducted by the brain tumor consortia are based on the EORTC/NCIC treatment platform and have added a targeted therapy in an effort to find a promising synergistic treatment. Furthermore, researchers in the consortia are continuing to explore treatments for recurrent GBM, not otherwise eligible for local therapies, such as CED. The treatments under study include novel cytotoxic chemotherapy as well as small-molecule inhibitors; these are being assessed in a variety of Phase I or II trials.
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Affiliation(s)
- Marc C Chamberlain
- Department of Interdisciplinary Oncology, Moffitt Cancer Center and Research Institute, Tampa, Florida 33612-0804, USA.
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Kurimoto M, Asahi T, Shibata T, Takahashi C, Nagai S, Hayashi N, Matsui M, Endo S. Safe Removal of Glioblastoma Near the Angular Gyrus by Awake Surgery Preserving Calculation Ability-Case Report-. Neurol Med Chir (Tokyo) 2006; 46:46-50. [PMID: 16434827 DOI: 10.2176/nmc.46.46] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 67-year-old patient presented with progressive agraphia, alexia, and impaired ability to calculate persisting for 4 weeks. He showed preserved ability to do single-digit addition and subtraction. Magnetic resonance imaging demonstrated a tumor in the left parietal lobe. A malignant glioma was suspected, and awake craniotomy was performed to remove the tumor with functional cortical mapping to determine the cortices involved in calculation and language. His calculation ability was mapped on the angular gyrus, and partial resection of the tumor was achieved without deterioration of that ability. The histological diagnosis was glioblastoma multiforme. The patient's calculation ability improved dramatically after the operation.
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Klautke G, Schütze M, Bombor I, Benecke R, Piek J, Fietkau R. Concurrent chemoradiotherapy and adjuvant chemotherapy with Topotecan for patients with glioblastoma multiforme. J Neurooncol 2005; 77:199-205. [PMID: 16314953 DOI: 10.1007/s11060-005-9028-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2005] [Accepted: 07/28/2005] [Indexed: 11/24/2022]
Abstract
PURPOSE The prognosis for patients with glioblastoma multiforme remains poor. Phase II studies, meta-analyses and a phase III study show that concurrent chemoradiotherapy has an advantage over irradiation alone. In this study the effectiveness of concurrent chemoradiotherapy with Topotecan and an adjuvant chemotherapy with Topotecan was investigated. PATIENTS AND METHOD Forty-two patients with predominantly unfavourable prognosis factors were included in the study and treated as follows: hyperfractionated accelerated radiotherapy (2x1.75Gy to 45.5 + 12.25 Gy (RP)) with a concurrent, continuous infusion of Topotecan (0.5 mg/m(2)/d, days 1-21). On day 28 the adjuvant chemotherapy (three courses) was begun according to the same scheme. RESULT Haematological toxicities were 13/42 (30%) grade III leucopenia, 2/42 (4%) grade IV, as well as 5/42 (10%) grade III thrombopenias and 1/42 (2%) grade IV. 30/42 (71%) patients showed improvement or stabilisation of an existing neurological symptomatic complex. The median time to progression was 7.2 (+/- 0.8) months, the median total survival was 10 (+/- 1.2) months, the 2 year survival rate 4.7 (+/- 0.3)%. Prognostic factors were age, surgical radicality, performance status and the tumour volume before therapy. SUMMARY Concurrent chemoradiotherapy and an adjuvant chemotherapy with Topotecan is feasible at acceptable toxicity levels also for patients with a moderate performance status. The patients benefit from the improvement of the clinical symptomatic complex and, even with unfavourable prognosis factors, have a higher median survival in comparison to data published on similar groups of patients given only radiotherapy.
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Affiliation(s)
- G Klautke
- Department of Radiotherapy, University of Rostock, Südring 75, 18059, Rostock, Germany.
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Schneider JP, Trantakis C, Rubach M, Schulz T, Dietrich J, Winkler D, Renner C, Schober R, Geiger K, Brosteanu O, Zimmer C, Kahn T. Intraoperative MRI to guide the resection of primary supratentorial glioblastoma multiforme--a quantitative radiological analysis. Neuroradiology 2005; 47:489-500. [PMID: 15951997 DOI: 10.1007/s00234-005-1397-1] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2004] [Accepted: 12/11/2004] [Indexed: 10/25/2022]
Abstract
Patients with supratentorial high-grade glioma underwent surgery within a vertically open 0.5-T magnetic resonance (MR) system to evaluate the efficacy of intraoperative MR guidance in achieving gross-total resection. For 31 patients, preoperative clinical data and MR findings were consistent with the putative diagnosis of a high-grade glioma, in 23 cases in eloquent regions. Tumor resections were carried out within a 0.5-T MR SIGNA SP/i (GE Medical Systems, USA). The resection of the lesion was carried out using fully MR compatible neurosurgical equipment and was stopped at the point when the operation was considered complete by the surgeon viewing the operation field with the microscope. We repeated imaging to determine the residual tumor volume only visible with MRI. Areas of tissue that were abnormal on these images were localized in the bed of resection by using interactive MR guidance. The procedure of resection, imaging control and interactive image guidance was repeated where necessary. Almost all tissue with abnormal characteristics was resected, with the exception of tissue localized in eloquent brain areas. The diagnosis of glioblastoma was confirmed in all 31 cases. When comparing the tumor volume before resection and at the point where the neurosurgeon would otherwise have terminated surgery ("first control"), residual tumor tissue was detectable in 29/31 patients; the mean residual tumor volume was 30.7 +/- 24%. After repeated resections under interactive image guidance the mean residual tumor volume was 15.1%. At this step we found tumor remnants only in 20/31 patients. The perioperative morbidity (12.9%) was low. Twenty-seven patients underwent sufficient postoperative radiotherapy. We found a significant difference (log(rank)p = 0.0037) in the mean survival times of the two groups with complete resection (n = 10, median survival time 537 days) and incomplete resection (n = 17, median survival time 237 days). The resection of primary glioblastoma multiforme under intraoperative MR guidance as demonstrated is a possibility to achieve a more complete removal of the tumor than with conventional techniques. In our small but homogeneous patient group we found an increase in the median survival time in patients with MRI for complete tumor resection, and the overall surgical morbidity was low.
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Polin RS, Marko NF, Ammerman MD, Shaffrey ME, Huang W, Anderson FA, Caputy AJ, Laws ER. Functional outcomes and survival in patients with high-grade gliomas in dominant and nondominant hemispheres. J Neurosurg 2005; 102:276-83. [PMID: 15739555 DOI: 10.3171/jns.2005.102.2.0276] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The goal of this study was to investigate survival and functional outcomes in patients with high-grade intracranial astrocytomas as a function of the location of the lesion in the dominant or nondominant hemisphere (DH and NDH, respectively), and to suggest management strategies for such patients based on these data.
Methods. Data were collected from the Glioma Outcomes Project database, a longitudinal database of demographic, clinical, and outcome data for patients with high-grade intracranial gliomas. From the entire database of 788 patients, a subset of all 280 right-handed patients with newly diagnosed, unilateral gliomas involving potentially eloquent cortex was selected as the sample population. Two cohorts were defined based on the location of the tumor in the right or left cerebral hemisphere. All other relevant demographic and clinical data were nearly identical between the cohorts. A Kaplan—Meier analysis was conducted to assess survival, and Karnofsky Performance Scale scores assigned at 6 and 12 months postoperatively were compared as a measure of functional outcome.
The analysis demonstrated no difference in survival between patients with lesions in the DH and those with tumors in the NDH. Additionally, no statistically significant difference in functional outcomes was observed between the two groups.
Conclusions. Laterality of high-grade gliomas is not an independent prognostic factor for predicting survival or functional outcome. The findings in this study demonstrate that fears of increased postoperative morbidity or mortality in otherwise resectable tumors of the DH are unfounded, and the authors therefore advocate that the surgeon's decision to operate be guided by validated outcome predictors and not biased by tumor lateralization.
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Affiliation(s)
- Richard S Polin
- Department of Neurosurgery, School of Medicine, The George Washington University, Washington, DC 20037, USA.
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Jeremic B, Milicic B, Grujicic D, Dagovic A, Aleksandrovic J, Nikolic N. Clinical prognostic factors in patients with malignant glioma treated with combined modality approach. Am J Clin Oncol 2004; 27:195-204. [PMID: 15057161 DOI: 10.1097/01.coc.0000055059.97106.15] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The impact of various clinical pretreatment prognostic factors in patients with malignant glioma treated with a combined modality approach was investigated in 229 patients treated on four consecutive prospective phase II studies. The median survival time for all 229 patients is 14 months, and 2- and 5-year survival rates are 34%, and 9%, respectively. The median time to tumor progression is 14 months, and 2- and 5-year progression-free survival rates are 32%, and 9%, respectively. Females did better than males, while patients 55 years or less did better than those more than 55 years. Patients with Karnofsky performance status (KPS) 80 to 100 did better than those with KPS 50 to 70 as well as did patients having preoperative tumor sizes 4 cm or less when compared to those with larger tumors. Frontal tumor location as well as more extensive surgery favorably influenced survival. Patients harboring anaplastic astrocytoma fared significantly better than those with glioblastoma multiforme. Both univariate and multivariate Cox analyses confirmed independent influence of these prognosticators. When progression-free survival was used as an endpoint, all seven variables remained independent prognosticators. This study showed that sex, age, KPS, tumor size, tumor location, histology, and extent of surgery are independent prognosticators in patients with malignant glioma treated with combined modality approach.
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Shinoda J, Yano H, Yoshimura SI, Okumura A, Kaku Y, Iwama T, Sakai N. Fluorescence-guided resection of glioblastoma multiforme by using high-dose fluorescein sodium. Technical note. J Neurosurg 2003; 99:597-603. [PMID: 12959452 DOI: 10.3171/jns.2003.99.3.0597] [Citation(s) in RCA: 165] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors have recently performed a fluorescence-guided tumor resection procedure by using high-dose fluorescein sodium without any special surgical microscopes for the intraoperative visualization of glioblastoma multiforme (GBM), and they report on the actual procedure and clinicopathological findings. Thirty-two patients with GBMs underwent tumor resection during which this fluorescence-guided procedure was used. Fluorescein sodium (20 mg/kg) was intravenously injected after dural opening at the craniotomy site. The tumor was stained almost homogeneously yellow and the color was intense enough to be readily perceived for resection. The center of the solid lesion was stained a deep yellow and surrounded by a transition zone that was faintly stained. The colored lesion was clearly distinguishable from the unstained zone outside the GBM, particularly in the white matter. Both the deeply and faintly stained regions included endothelial proliferation and dense tumor cells. In the unstained region, less dense tumor cells were consistently revealed; however, no endothelial proliferation could be seen. Gross-total resection (GTR) was successful in 84.4% of the patients who received an injection of fluorescein sodium, which accounted for 100% of those in whom all the visible yellow color (both the deeply and faintly stained regions) was judged to have been resected during operation. Gross-total resection was performed in 100% of the patients who underwent the fluorescence-guided procedure and assigned to Stage I, a GBM stage in which, as a therapeutic policy, the tumor should be resected as radically as possible. The GTR rates in patients who received fluorescein sodium were significantly higher than those in patients who did not (73 patients with GBMs who underwent tumor resection without the fluorescence-guided procedure). Although the extent of surgery was revealed to be one of the significant and independent prognostic factors for GBM, the fluorescein sodium-guided resection procedure was not a significant or independent prognostic factor in this series. This surgical procedure does not require any special surgical microscopic equipment and is simple, safe, useful, readily accomplished, and universally available for resection of GBMs. Its efficacy simplifies the surgical procedure of navigating the stained lesion from the unstained area to achieve GTR of GBMs, which can be demonstrated on magnetic resonance images.
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Affiliation(s)
- Jun Shinoda
- Department of Neurosurgery, Gifu University School of Medicine, Gifu, Japan.
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Jeremic B, Milicic B, Grujicic D, Dagovic A, Aleksandrovic J. Multivariate analysis of clinical prognostic factors in patients with glioblastoma multiforme treated with a combined modality approach. J Cancer Res Clin Oncol 2003; 129:477-84. [PMID: 12884028 DOI: 10.1007/s00432-003-0471-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2003] [Accepted: 06/16/2003] [Indexed: 10/26/2022]
Abstract
We investigated the influence of various clinical prognostic factors in patients with glioblastoma multiforme (GBM) treated with a combined modality approach. A total of 175 patients with GBM was treated in four consecutive prospective phase II studies using surgery, hyperfractionated or accelerated hyperfractionated radiotherapy (RT) and either adjuvant or concurrent or pre-irradiation chemotherapy (CHT) between January 1988 and December 1993. The median survival time for all 175 patients was 14 months and 1-3-year survival (OS) rates were 57%, 34% and 24%, respectively. The median time to tumour progression was 12 months, and 1-3-year progression-free survival (PFS) rates were 43%, 11% and 7%, respectively. Survival analysis showed that of all investigated prognostic factors, only gender did not influence survival. Patients </=55 years did better than those >55 years; patients with KPS 80-100 did better than those with KPS 50-70; patients with frontal tumours did better than those with tumours in other locations; patients with tumours up to 4 cm did better than those with larger tumours, as did patients with either subtotal or gross total tumour resection when compared to those undergoing biopsy only. Multivariate analysis showed that gender and tumour location did not independently influence survival. When PFS was used as the endpoint, only gender did not influence PFS, as confirmed by multivariate analysis.
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Affiliation(s)
- Branislav Jeremic
- Department of Oncology, University Hospital, Kragujevac, Yugoslavia.
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Trantakis C, Winkler D, Lindner D, Strauss G, Nagel C, Schneider JP, Meixensberger J. Clinical results in MR-guided therapy for malignant gliomas. ACTA NEUROCHIRURGICA. SUPPLEMENT 2003; 85:65-71. [PMID: 12570139 DOI: 10.1007/978-3-7091-6043-5_9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
The prognostic impact of the extent of tumour resection in surgery of malignant glioma patients remains controversial. We report the results of cumulative survival of malignant glioma patients operated with MR-guidance. Patients with complete tumour removal were compared with a population of patients with incomplete tumour removal. A 0.5 T scanner was used to criticize the extent of resection during surgery. In total no significant difference could be found, however there is a tendency that complete tumour removal seems to be associated with a slightly increased median survival time.
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Affiliation(s)
- C Trantakis
- Department of Neurosurgery, University of Leipzig, Leipzig, Germany
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Beppu T, Kamada K, Nakamura R, Oikawa H, Takeda M, Fukuda T, Arai H, Ogasawara K, Ogawa A. A phase II study of radiotherapy after hyperbaric oxygenation combined with interferon-beta and nimustine hydrochloride to treat supratentorial malignant gliomas. J Neurooncol 2003; 61:161-70. [PMID: 12622455 DOI: 10.1023/a:1022169107872] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Hypoxic cells play a key role in the radioresistance of malignant glioma. Interferon-beta, ACNU as nimustine hydrochloride and radiotherapy (IAR) is a common therapy for malignant glioma in Japan. Since hyperbaric oxygenation (HBO) increases oxygen pressure in glioma tissue, we applied a modified IAR therapy, radiotherapy after HBO combined with interferon-beta and ACNU (HBO/IAR therapy), for supratentorial malignant gliomas. Daily radiation therapy was completed within 15 min after HBO. We assessed HBO/IAR with respect to toxicity, response rates and the time of tumor progression (TTP). We also examined the incidence of responses by some prognostic factors before HBO/IAR, namely, age, Karnofsky performance scale (KPS), histological type, tumor size, tumor site and operation type. Of 39 patients who participated in this study, 35 underwent a complete schedule of HBO/IAR therapy in which toxicity was permissible. Thirty patients (76.9%) either maintained or increased KPS during HBO/IAR with a mean duration of 68 +/- 14 days. The response rates (CR + PR%) for glioblastoma, anaplastic astrocytoma and overall were 50%, 30% and 43%, respectively. The incidence of therapeutic responses among all prognostic factors before HBO/IAR did not significantly differ. Median TTP for patients with glioblastoma, patients with anaplastic astrocytoma, and overall were 38, 56 and 43 weeks, respectively. The present study suggested that HBO/IAR therapy could be applied to especially patients with poor prognostic factors, because of its short treatment period, its permissible toxicity and identical response to patients with good prognostic factors.
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Affiliation(s)
- Takaaki Beppu
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan.
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Akman F, Cooper RA, Sen M, Tanriver Y, Kentli S. Validation of the Medical Research Council and a newly developed prognostic index in patients with malignant glioma: how useful are prognostic indices in routine clinical practice? J Neurooncol 2002; 59:39-47. [PMID: 12222837 DOI: 10.1023/a:1016353614525] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Although different prognostic indices for malignant gliomas have been developed, their validity outside of clinical trials has not been widely tested. The aim of this study was to determine whether the Medical Research Council (MRC) brain tumour prognostic index was able to stratify patients for survival managed in routine practice, and secondly to compare the results with our newly developed prognostic score which included tumour grade and only 3 prognostic groups. The MRC and the new prognostic index were calculated for a group of 119 adult patients with malignant glioma managed by surgical resection/biopsy and post-operative radiotherapy. For the MRC and new score, 6 and 3 prognostic groups were defined, respectively. For all patients median survival was 11 (2-66) months. The overall survival rate at 12 and 24 months were 43% and 18%, respectively. The MRC median and two-year survival rates were 14 months and 26% for a score of 1-10, 14 months and 27% for a score of 11-15, 13 months and 22% for a score of 16-20, 8 months and 10% for a score of 21-25, 8 months and 0% for those scoring 26-33. There was only one patient in the 34-38 group. For the new prognostic index, median and two-year survival rates were respectively 16 and 26%; 12 and 23%; 8 and 7% for the good, intermediate and poor prognostic groups. Both indices were significant factors for survival in univariate analysis (MRC index, p = 0.0089, new index p = 0.0002), but not in multivariate analysis. Both the MRC and our newly devised prognostic score were able to separate patients into good and poor prognostic groups, which may aid in treatment decisions, although there was less differentiation between the MRC groups especially over the first year. Both scores use routinely available factors. However, inclusion of tumour grade in the new score may be an advantage over the MRC index.
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Affiliation(s)
- Fadime Akman
- Department of Radiation Oncology, Dokuz Eylül University, Medical School, Izmir, Turkey.
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