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Wu Y, Song Y, Wang R, Wang T. Molecular mechanisms of tumor resistance to radiotherapy. Mol Cancer 2023; 22:96. [PMID: 37322433 PMCID: PMC10268375 DOI: 10.1186/s12943-023-01801-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 06/03/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Cancer is the most prevalent cause of death globally, and radiotherapy is considered the standard of care for most solid tumors, including lung, breast, esophageal, and colorectal cancers and glioblastoma. Resistance to radiation can lead to local treatment failure and even cancer recurrence. MAIN BODY In this review, we have extensively discussed several crucial aspects that cause resistance of cancer to radiation therapy, including radiation-induced DNA damage repair, cell cycle arrest, apoptosis escape, abundance of cancer stem cells, modification of cancer cells and their microenvironment, presence of exosomal and non-coding RNA, metabolic reprogramming, and ferroptosis. We aim to focus on the molecular mechanisms of cancer radiotherapy resistance in relation to these aspects and to discuss possible targets to improve treatment outcomes. CONCLUSIONS Studying the molecular mechanisms responsible for radiotherapy resistance and its interactions with the tumor environment will help improve cancer responses to radiotherapy. Our review provides a foundation to identify and overcome the obstacles to effective radiotherapy.
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Affiliation(s)
- Yu Wu
- Department of Radiotherapy, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Cancer Hospital of Dalian University of Technology, No.44 Xiaoheyan Road, Dadong District, Shenyang, 110042 Liaoning Province China
- School of Graduate, Dalian Medical University, Dalian, 116044 China
| | - Yingqiu Song
- Department of Radiotherapy, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Cancer Hospital of Dalian University of Technology, No.44 Xiaoheyan Road, Dadong District, Shenyang, 110042 Liaoning Province China
| | - Runze Wang
- Department of Radiotherapy, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Cancer Hospital of Dalian University of Technology, No.44 Xiaoheyan Road, Dadong District, Shenyang, 110042 Liaoning Province China
- School of Graduate, Dalian Medical University, Dalian, 116044 China
| | - Tianlu Wang
- Department of Radiotherapy, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Cancer Hospital of Dalian University of Technology, No.44 Xiaoheyan Road, Dadong District, Shenyang, 110042 Liaoning Province China
- Faculty of Medicine, Dalian University of Technology, Dalian, 116024 China
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Vilaplana-Lopera N, Besh M, Moon EJ. Targeting Hypoxia: Revival of Old Remedies. Biomolecules 2021; 11:1604. [PMID: 34827602 PMCID: PMC8615589 DOI: 10.3390/biom11111604] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 12/14/2022] Open
Abstract
Tumour hypoxia is significantly correlated with patient survival and treatment outcomes. At the molecular level, hypoxia is a major driving factor for tumour progression and aggressiveness. Despite the accumulative scientific and clinical efforts to target hypoxia, there is still a need to find specific treatments for tumour hypoxia. In this review, we discuss a variety of approaches to alter the low oxygen tumour microenvironment or hypoxia pathways including carbogen breathing, hyperthermia, hypoxia-activated prodrugs, tumour metabolism and hypoxia-inducible factor (HIF) inhibitors. The recent advances in technology and biological understanding reveal the importance of revisiting old therapeutic regimens and repurposing their uses clinically.
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Affiliation(s)
| | | | - Eui Jung Moon
- Department of Oncology, MRC Oxford Institute for Radiation Oncology, University of Oxford, Headington OX3 7DQ, UK; (N.V.-L.); (M.B.)
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Beg U, Snyder BM, Madhani SI, Hamidi N, Padmanaban V, Tuanquin LC, Kruser TJ, Connor J, Mansouri A. Current Landscape and Future Prospects of Radiation Sensitizers for Malignant Brain Tumors: A Systematic Review. World Neurosurg 2021; 151:e839-e856. [PMID: 33974987 DOI: 10.1016/j.wneu.2021.04.134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Radiation therapy (RT) is the cornerstone of management of malignant brain tumors, but its efficacy is limited in hypoxic tumors. Although numerous radiosensitizer compounds have been developed to enhance the effect of RT, progress has been stagnant. Through this systematic review, we provide an overview of radiosensitizers developed for malignant brain tumors, summarize their safety and efficacy, and evaluate areas for possible improvement. METHODS Following PRISMA guidelines, PubMed, EMBASE, Cochrane, and Web of Science were searched using terminology pertaining to radiosensitizers for brain tumor RT. Articles reporting clinical evidence of nonantineoplastic radiosensitizers with RT for malignant central nervous system tumors were included. Data of interest were presumed mechanism of action, median overall survival (OS), progression-free survival (PFS), and adverse events. RESULTS Twenty-two unique radiosensitizers were identified. Only 2/22 agents (fluosol with oxygen, and efaproxiral) showed improvement in OS in patients with glioblastoma and brain metastasis, respectively. A larger study was not able to confirm the latter. Improved PFS was reported with use of metronidazole, sodium glycididazole, and chloroquine. There was a wide range of toxicities, which prompted change of schedule or complete discontinuation of 9 agents. CONCLUSIONS Progress in radiosensitizers for malignant CNS tumors has been limited. Only 2 radiosensitizers have shown limited improvement in survival. Alternative strategies such as synthetic drug design, based on a mechanism of action that is independent of crossing the blood-brain barrier, may be necessary. Use of drug development strategies using new technologies to overcome past challenges is necessary.
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Affiliation(s)
- Usman Beg
- Midwestern University Arizona College of Osteopathic Medicine, Glendale, Arizona, USA
| | | | | | - Nima Hamidi
- Midwestern University Arizona College of Osteopathic Medicine, Glendale, Arizona, USA
| | - Varun Padmanaban
- Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | | | | | - James Connor
- Penn State Cancer Institute, Hershey, Pennsylvania, USA; Penn State Department of Neurosurgery, Hershey, Pennsylvania, USA
| | - Alireza Mansouri
- Penn State Cancer Institute, Hershey, Pennsylvania, USA; Penn State Department of Neurosurgery, Hershey, Pennsylvania, USA.
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Shen H, Cook K, Gee HE, Hau E. Hypoxia, metabolism, and the circadian clock: new links to overcome radiation resistance in high-grade gliomas. J Exp Clin Cancer Res 2020; 39:129. [PMID: 32631383 PMCID: PMC7339573 DOI: 10.1186/s13046-020-01639-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/01/2020] [Indexed: 02/07/2023] Open
Abstract
Radiotherapy is the cornerstone of treatment of high-grade gliomas (HGGs). It eradicates tumor cells by inducing oxidative stress and subsequent DNA damage. Unfortunately, almost all HGGs recur locally within several months secondary to radioresistance with intricate molecular mechanisms. Therefore, unravelling specific underlying mechanisms of radioresistance is critical to elucidating novel strategies to improve the radiosensitivity of tumor cells, and enhance the efficacy of radiotherapy. This review addresses our current understanding of how hypoxia and the hypoxia-inducible factor 1 (HIF-1) signaling pathway have a profound impact on the response of HGGs to radiotherapy. In addition, intriguing links between hypoxic signaling, circadian rhythms and cell metabolism have been recently discovered, which may provide insights into our fundamental understanding of radioresistance. Cellular pathways involved in the hypoxic response, DNA repair and metabolism can fluctuate over 24-h periods due to circadian regulation. These oscillatory patterns may have consequences for tumor radioresistance. Timing radiotherapy for specific times of the day (chronoradiotherapy) could be beneficial in patients with HGGs and will be discussed.
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Affiliation(s)
- Han Shen
- Translational Radiation Biology and Oncology Laboratory, Centre for Cancer Research, Westmead Institute for Medical Research, Westmead, New South Wales, 2145, Australia.
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia.
| | - Kristina Cook
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health & Charles Perkins Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Harriet E Gee
- Translational Radiation Biology and Oncology Laboratory, Centre for Cancer Research, Westmead Institute for Medical Research, Westmead, New South Wales, 2145, Australia
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, New South Wales, Australia
| | - Eric Hau
- Translational Radiation Biology and Oncology Laboratory, Centre for Cancer Research, Westmead Institute for Medical Research, Westmead, New South Wales, 2145, Australia
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, New South Wales, Australia
- Blacktown Hematology and Cancer Centre, Blacktown Hospital, Blacktown, New South Wales, Australia
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Hanna C, Lawrie TA, Rogozińska E, Kernohan A, Jefferies S, Bulbeck H, Ali UM, Robinson T, Grant R. Treatment of newly diagnosed glioblastoma in the elderly: a network meta-analysis. Cochrane Database Syst Rev 2020; 3:CD013261. [PMID: 32202316 PMCID: PMC7086476 DOI: 10.1002/14651858.cd013261.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND A glioblastoma is a fatal type of brain tumour for which the standard of care is maximum surgical resection followed by chemoradiotherapy, when possible. Age is an important consideration in this disease, as older age is associated with shorter survival and a higher risk of treatment-related toxicity. OBJECTIVES To determine the most effective and best-tolerated approaches for the treatment of elderly people with newly diagnosed glioblastoma. To summarise current evidence for the incremental resource use, utilities, costs and cost-effectiveness associated with these approaches. SEARCH METHODS We searched electronic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase to 3 April 2019, and the NHS Economic Evaluation Database (EED) up to database closure. We handsearched clinical trial registries and selected neuro-oncology society conference proceedings from the past five years. SELECTION CRITERIA Randomised trials (RCTs) of treatments for glioblastoma in elderly people. We defined 'elderly' as 70+ years but included studies defining 'elderly' as over 65+ years if so reported. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for study selection and data extraction. Where sufficient data were available, treatment options were compared in a network meta-analysis (NMA) using Stata software (version 15.1). For outcomes with insufficient data for NMA, pairwise meta-analysis were conducted in RevMan. The GRADE approach was used to grade the evidence. MAIN RESULTS We included 12 RCTs involving approximately 1818 participants. Six were conducted exclusively among elderly people (either defined as 65 years or older or 70 years or older) with newly diagnosed glioblastoma, the other six reported data for an elderly subgroup among a broader age range of participants. Most participants were capable of self-care. Study quality was commonly undermined by lack of outcome assessor blinding and attrition. NMA was only possible for overall survival; other analyses were pair-wise meta-analyses or narrative syntheses. Seven trials contributed to the NMA for overall survival, with interventions including supportive care only (one trial arm); hypofractionated radiotherapy (RT40; four trial arms); standard radiotherapy (RT60; five trial arms); temozolomide (TMZ; three trial arms); chemoradiotherapy (CRT; three trial arms); bevacizumab with chemoradiotherapy (BEV_CRT; one trial arm); and bevacizumab with radiotherapy (BEV_RT). Compared with supportive care only, NMA evidence suggested that all treatments apart from BEV_RT prolonged survival to some extent. Overall survival High-certainty evidence shows that CRT prolongs overall survival (OS) compared with RT40 (hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.56 to 0.80) and low-certainty evidence suggests that CRT may prolong overall survival compared with TMZ (TMZ versus CRT: HR 1.42, 95% CI 1.01 to 1.98). Low-certainty evidence also suggests that adding BEV to CRT may make little or no difference (BEV_CRT versus CRT: HR 0.83, 95% CrI 0.48 to 1.44). We could not compare the survival effects of CRT with different radiotherapy fractionation schedules (60 Gy/30 fractions and 40 Gy/15 fractions) due to a lack of data. When treatments were ranked according to their effects on OS, CRT ranked higher than TMZ, RT and supportive care only, with the latter ranked last. BEV plus RT was the only treatment for which there was no clear benefit in OS over supportive care only. One trial comparing tumour treating fields (TTF) plus adjuvant chemotherapy (TTF_AC) with adjuvant chemotherapy alone could not be included in the NMA as participants were randomised after receiving concomitant chemoradiotherapy, not before. Findings from the trial suggest that the intervention probably improves overall survival in this selected patient population. We were unable to perform NMA for other outcomes due to insufficient data. Pairwise analyses were conducted for the following. Quality of life Moderate-certainty narrative evidence suggests that overall, there may be little difference in QoL between TMZ and RT, except for discomfort from communication deficits, which are probably more common with RT (1 study, 306 participants, P = 0.002). Data on QoL for other comparisons were sparse, partly due to high dropout rates, and the certainty of the evidence tended to be low or very low. Progression-free survival High-certainty evidence shows that CRT increases time to disease progression compared with RT40 (HR 0.50, 95% CI 0.41 to 0.61); moderate-certainty evidence suggests that RT60 probably increases time to disease progression compared with supportive care only (HR 0.28, 95% CI 0.17 to 0.46), and that BEV_RT probably increases time to disease progression compared with RT40 alone (HR 0.46, 95% CI 0.27 to 0.78). Evidence for other treatment comparisons was of low- or very low-certainty. Severe adverse events Moderate-certainty evidence suggests that TMZ probably increases the risk of grade 3+ thromboembolic events compared with RT60 (risk ratio (RR) 2.74, 95% CI 1.26 to 5.94; participants = 373; studies = 1) and also the risk of grade 3+ neutropenia, lymphopenia, and thrombocytopenia. Moderate-certainty evidence also suggests that CRT probably increases the risk of grade 3+ neutropenia, leucopenia and thrombocytopenia compared with hypofractionated RT alone. Adding BEV to CRT probably increases the risk of thromboembolism (RR 16.63, 95% CI 1.00 to 275.42; moderate-certainty evidence). Economic evidence There is a paucity of economic evidence regarding the management of newly diagnosed glioblastoma in the elderly. Only one economic evaluation on two short course radiotherapy regimen (25 Gy versus 40 Gy) was identified and its findings were considered unreliable. AUTHORS' CONCLUSIONS For elderly people with glioblastoma who are self-caring, evidence suggests that CRT prolongs survival compared with RT and may prolong overall survival compared with TMZ alone. For those undergoing RT or TMZ therapy, there is probably little difference in QoL overall. Systemic anti-cancer treatments TMZ and BEV carry a higher risk of severe haematological and thromboembolic events and CRT is probably associated with a higher risk of these events. Current evidence provides little justification for using BEV in elderly patients outside a clinical trial setting. Whilst the novel TTF device appears promising, evidence on QoL and tolerability is needed in an elderly population. QoL and economic assessments of CRT versus TMZ and RT are needed. More high-quality economic evaluations are needed, in which a broader scope of costs (both direct and indirect) and outcomes should be included.
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Affiliation(s)
- Catherine Hanna
- University of GlasgowDepartment of OncologyBeatson West of Scotland Cancer CentreGreat Western RoadGlasgowScotlandUKG4 9DL
| | - Theresa A Lawrie
- The Evidence‐Based Medicine Consultancy Ltd3rd Floor Northgate HouseUpper Borough WallsBathUKBA1 1RG
| | - Ewelina Rogozińska
- The Evidence‐Based Medicine Consultancy Ltd3rd Floor Northgate HouseUpper Borough WallsBathUKBA1 1RG
| | - Ashleigh Kernohan
- Newcastle UniversityInstitute of Health & SocietyBaddiley‐Clark Building, Richardson RoadNewcastle upon TyneUKNE2 4AA
| | - Sarah Jefferies
- Addenbrooke's HospitalDepartment of OncologyHills RoadCambridgeUKCB2 0QQ
| | - Helen Bulbeck
- brainstrustDirector of Services4 Yvery CourtCastle RoadCowesIsle of WightUKPO31 7QG
| | - Usama M Ali
- University of OxfordNuffield Department of Population HealthRoosevelt DriveOld Road CampusOxfordOxfordshireUKOX3 7LF
| | - Tomos Robinson
- Newcastle UniversityInstitute of Health & SocietyBaddiley‐Clark Building, Richardson RoadNewcastle upon TyneUKNE2 4AA
| | - Robin Grant
- Western General HospitalEdinburgh Centre for Neuro‐Oncology (ECNO)Crewe RoadEdinburghScotlandUKEH4 2XU
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Jackson RK, Liew LP, Hay MP. Overcoming Radioresistance: Small Molecule Radiosensitisers and Hypoxia-activated Prodrugs. Clin Oncol (R Coll Radiol) 2019; 31:290-302. [PMID: 30853148 DOI: 10.1016/j.clon.2019.02.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 02/12/2019] [Indexed: 12/25/2022]
Abstract
The role of hypoxia in radiation resistance is well established and many approaches to overcome hypoxia in tumours have been explored, with variable success. Two small molecule strategies for targeting hypoxia have dominated preclinical and clinical efforts. One approach has been the use of electron-affinic nitroheterocycles as oxygen-mimetic sensitisers. These agents are best exemplified by the 5-nitroimidazole nimorazole, which has limited use in conjunction with radiotherapy in head and neck squamous cell carcinoma. The second approach seeks to leverage tumour hypoxia as a tumour-specific address for hypoxia-activated prodrugs. These prodrugs are selectively activated by reductases under hypoxia to release cytotoxins, which in some instances may diffuse to kill surrounding oxic tumour tissue. A number of these hypoxia-activated prodrugs have been examined in clinical trial and the merits and shortcomings of recent examples are discussed. There has been an evolution from delivering DNA-interactive cytotoxins to molecularly targeted agents. Efforts to implement these strategies clinically continue today, but success has been elusive. Several issues have been identified that compromised these clinical campaigns. A failure to consider the extravascular transport and the micropharmacokinetic properties of the prodrugs has reduced efficacy. One key element for these 'targeted' approaches is the need to co-develop biomarkers to identify appropriate patients. Hypoxia-activated prodrugs require biomarkers for hypoxia, but also for appropriate activating reductases in tumours, as well as markers of intrinsic sensitivity to the released drug. The field is still evolving and changes in radiation delivery and the impact of immune-oncology will provide fertile ground for future innovation.
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Affiliation(s)
- R K Jackson
- Auckland Cancer Society Research Centre, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - L P Liew
- Auckland Cancer Society Research Centre, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Maurice Wilkins Centre for Molecular Biodiscovery, University of Auckland, Auckland, New Zealand
| | - M P Hay
- Auckland Cancer Society Research Centre, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Maurice Wilkins Centre for Molecular Biodiscovery, University of Auckland, Auckland, New Zealand.
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Yasui H, Kubota N, Nishizumi J, Sakai Y, Yamamori T, Inanami O. Preclinical study on hypoxic radiosensitizing effects of glycididazole in comparison with those of doranidazole in vitro and in vivo. Oncol Lett 2018; 15:1993-1998. [PMID: 29434899 DOI: 10.3892/ol.2017.7481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 11/20/2017] [Indexed: 11/06/2022] Open
Abstract
To overcome the radioresistance of hypoxic cells in solid tumor, numerous types of radiosensitizers specifically against them have been developed. Glycididazole has a chemical structure in which two metronidazole forms are combined, and is widely used as a hypoxic radiosensitizer in China. However, a detailed investigation of its radiosensitizing properties has not been performed. The present study reported a comparative assessment of glycididazole and doranidazole, another hypoxic radiosensitizer. All experiments were performed using the murine squamous cell carcinoma cell line SCCVII. Prior to X-irradiation, the cells were treated with the test drugs at concentrations of 10 mM and 200 mg/kg in vitro and in vivo, respectively. Uptake and their intratumor chemical forms were analyzed by high performance liquid chromatography (HPLC). Both drugs enhanced the reproductive cell death induced by X-irradiation under hypoxia. However, the growth delay assay of the transplanted tumor revealed the combination of X-irradiation and glycididazole showed a similar antitumor effect to that of X-irradiation alone, whereas doranidazole significantly sensitized the cells to X-irradiation. HPLC analysis revealed that incorporated glycididazole was decomposed to metronidazole and was therefore present at a lower concentration compared with that of doranidazole. The decomposition of glycididazole to metronidazole reduced its radiosensitizing efficiency in vivo. Elucidation of the kinetics of drugs containing metabolizable chemical forms is necessary for the optimization of clinical treatment.
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Affiliation(s)
- Hironobu Yasui
- Laboratory of Radiation Biology, Department of Applied Veterinary Sciences, Division of Veterinary Medicine, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido 060-0818, Japan.,Central Institute of Isotope Science, Hokkaido University, Sapporo, Hokkaido 060-0815, Japan
| | - Nobuo Kubota
- R&D Laboratories, Pola Pharma Inc., Yokohama, Kanagawa 244-0812, Japan
| | - Junko Nishizumi
- R&D Laboratories, Pola Pharma Inc., Yokohama, Kanagawa 244-0812, Japan
| | - Yuri Sakai
- Laboratory of Radiation Biology, Department of Applied Veterinary Sciences, Division of Veterinary Medicine, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido 060-0818, Japan
| | - Tohru Yamamori
- Laboratory of Radiation Biology, Department of Applied Veterinary Sciences, Division of Veterinary Medicine, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido 060-0818, Japan
| | - Osamu Inanami
- Laboratory of Radiation Biology, Department of Applied Veterinary Sciences, Division of Veterinary Medicine, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido 060-0818, Japan
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8
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Mistry IN, Thomas M, Calder EDD, Conway SJ, Hammond EM. Clinical Advances of Hypoxia-Activated Prodrugs in Combination With Radiation Therapy. Int J Radiat Oncol Biol Phys 2017; 98:1183-1196. [PMID: 28721903 DOI: 10.1016/j.ijrobp.2017.03.024] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 02/24/2017] [Accepted: 03/14/2017] [Indexed: 12/29/2022]
Abstract
With the increasing incidence of cancer worldwide, the need for specific, effective therapies is ever more urgent. One example of targeted cancer therapeutics is hypoxia-activated prodrugs (HAPs), also known as bioreductive prodrugs. These prodrugs are inactive in cells with normal oxygen levels but in hypoxic cells (with low oxygen levels) undergo chemical reduction to the active compound. Hypoxia is a common feature of solid tumors and is associated with a more aggressive phenotype and resistance to all modes of therapy. Therefore, the combination of radiation therapy and bioreductive drugs presents an attractive opportunity for synergistic effects, because the HAP targets the radiation-resistant hypoxic cells. Hypoxia-activated prodrugs have typically been precursors of DNA-damaging agents, but a new generation of molecularly targeted HAPs is emerging. By targeting proteins associated with tumorigenesis and survival, these compounds may result in greater selectivity over healthy tissue. We review the clinical progress of HAPs as adjuncts to radiation therapy and conclude that the use of HAPs alongside radiation is vastly underexplored at the clinical level.
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Affiliation(s)
- Ishna N Mistry
- Cancer Research UK/Medical Research Council Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Matthew Thomas
- Cancer Research UK/Medical Research Council Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Ewen D D Calder
- Chemistry Research Laboratory, Department of Chemistry, University of Oxford, Oxford, United Kingdom
| | - Stuart J Conway
- Chemistry Research Laboratory, Department of Chemistry, University of Oxford, Oxford, United Kingdom
| | - Ester M Hammond
- Cancer Research UK/Medical Research Council Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom.
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Gzell C, Back M, Wheeler H, Bailey D, Foote M. Radiotherapy in Glioblastoma: the Past, the Present and the Future. Clin Oncol (R Coll Radiol) 2017; 29:15-25. [DOI: 10.1016/j.clon.2016.09.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 08/22/2016] [Accepted: 08/25/2016] [Indexed: 10/25/2022]
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Efficient Protocol for the Identification of Hypoxic Cell Radiosensitisers. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 899:269-90. [DOI: 10.1007/978-3-319-26666-4_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Alexander BM, Ligon KL, Wen PY. Enhancing radiation therapy for patients with glioblastoma. Expert Rev Anticancer Ther 2013; 13:569-81. [PMID: 23617348 DOI: 10.1586/era.13.44] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Radiation therapy has been the foundation of therapy following maximal surgical resection in patients with newly diagnosed glioblastoma for decades and the primary therapy for unresected tumors. Using the standard approach with radiation and temozolomide, however, outcomes are poor, and glioblastoma remains an incurable disease with the majority of recurrences and progression within the radiation treatment field. As such, there is much interest in elucidating the mechanisms of resistance to radiation therapy and in developing novel approaches to overcoming this treatment resistance.
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Affiliation(s)
- Brian M Alexander
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, 75 Francis Street, ASB1-L2, Boston, MA 02115, USA.
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Brown JM, Diehn M, Loo BW. Stereotactic ablative radiotherapy should be combined with a hypoxic cell radiosensitizer. Int J Radiat Oncol Biol Phys 2010; 78:323-7. [PMID: 20832663 DOI: 10.1016/j.ijrobp.2010.04.070] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Revised: 04/26/2010] [Accepted: 04/27/2010] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate the effect of tumor hypoxia on the expected level of cell killing by regimens of stereotactic ablative radiotherapy (SABR) and to determine the extent to which the negative effect of hypoxia could be prevented using a clinically available hypoxic cell radiosensitizer. RESULTS AND DISCUSSION We have calculated the expected level of tumor cell killing from regimens of SABR, both with and without the assumption that 20% of the tumor cells are hypoxic, using the standard linear quadratic model and the universal survival curve modification. We compare the results obtained with our own clinical data for lung tumors of different sizes and with published data from other studies. We also have calculated the expected effect on cell survival of adding the hypoxic cell sensitizer etanidazole at clinically achievable drug concentrations. Modeling tumor cell killing with any of the currently used regimens of SABR produces results that are inconsistent with the majority of clinical findings if tumor hypoxia is not considered. However, with the assumption of tumor hypoxia, the expected level of cell killing is consistent with clinical data. For only some of the smallest tumors are the clinical data consistent with no tumor hypoxia, but there could be other reasons for the sensitivity of these tumors. The addition of etanidazole at clinically achievable tumor concentrations produces a large increase in the expected level of tumor cell killing from the large radiation doses used in SABR. CONCLUSIONS The presence of tumor hypoxia is a major negative factor in limiting the curability of tumors by SABR at radiation doses that are tolerable to surrounding normal tissues. However, this negative effect of hypoxia could be overcome by the addition of clinically tolerable doses of the hypoxic cell radiosensitizer etanidazole.
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Affiliation(s)
- J Martin Brown
- Department of Radiation Oncology, Stanford University School of Medicine, California 94305, USA.
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Adamson C, Kanu OO, Mehta AI, Di C, Lin N, Mattox AK, Bigner DD. Glioblastoma multiforme: a review of where we have been and where we are going. Expert Opin Investig Drugs 2009; 18:1061-83. [DOI: 10.1517/13543780903052764] [Citation(s) in RCA: 370] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Cory Adamson
- Duke Medical Center, MSRB 1 Box 2624, Durham, NC 27712, USA ;
- Neurosurgery Section, Durham VA Medical Center, Durham, NC, USA
| | | | - Ankit I Mehta
- Duke Medical Center, MSRB 1 Box 2624, Durham, NC 27712, USA ;
| | - Chunhui Di
- Duke Medical Center, MSRB 1 Box 2624, Durham, NC 27712, USA ;
| | - Ningjing Lin
- Peking University School of Oncology, Beijing Cancer Hospital, Department of Oncology, Beijing, China
| | - Austin K Mattox
- Duke Medical Center, MSRB 1 Box 2624, Durham, NC 27712, USA ;
| | - Darell D Bigner
- Duke Medical Center, MSRB 1 Box 2624, Durham, NC 27712, USA ;
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14
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Lim SH, Lee JY, Park SH, Kim YH, Suh HS, Park JB, Lee J. Effect of Combination of Anticancer Agents and Nitroimidazoles on the Survival of Human Hepatocellular Carcinoma Cells under Hypoxic Conditions. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2009. [DOI: 10.4174/jkss.2009.76.6.337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sun Ha Lim
- Department of Biochemistry, College of Medicine, Catholic University of Daegu, Korea
| | | | - Sung Hwan Park
- Department of Surgery, College of Medicine, Catholic University of Daegu, Korea
| | - You Hee Kim
- Department of Biochemistry, College of Medicine, Keimyung University, Daegu, Korea
| | - Hun Suk Suh
- Department of Laboratory Medicine, College of Medicine, Catholic University of Daegu, Korea
| | - Jae Bok Park
- Department of Pathology, College of Medicine, Catholic University of Daegu, Korea
| | - Jongwon Lee
- Department of Biochemistry, College of Medicine, Catholic University of Daegu, Korea
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15
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Anderson E, Grant R, Lewis SC, Whittle IR. Randomized Phase III controlled trials of therapy in malignant glioma: where are we after 40 years? Br J Neurosurg 2008; 22:339-49. [PMID: 18568722 DOI: 10.1080/02688690701885603] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The objective of this study was to review the results of randomized Phase III controlled trials (RCTs) that involve initial treatments of malignant glioma and determine changes in median survival times (MST) over the last 40 years. An electronic database search identified RCTs for patients undergoing initial treatment for supratentorial high-grade malignant glioma. MSTs were analysed with respect to the date that patient accrual to the trial started, to identify the time course of changes in MST. Linear regression was used for statistical analysis. The review included 44 clinical trials that recruited patients between 1966 and 2004. Overall, there was a steady significant improvement in MST for the novel treatment cohorts over this period (r(2) = 0.43, p < 0.001), with MST increasing from around 8 to 15 months. There was also consistent improvement in the MST of the control cohorts, from around 7 months to 14 months, that reached statistical significance (r(2) = 0.41, p < 0.001). However, analysis including a quadratic term revealed a trend towards the rate of improvement in MST decreasing in the last two decades in the control, but not novel treatment, groups. The differences, either positive or negative, in MSTs between the control and novel treatment cohorts, and number of trials performed have all decreased with time. Subgroup analysis of the three most recent clinical trials report statistically significant better outcomes in MST after either >90% or 'complete' tumour resection. Despite tremendous advances in both the understanding of the biology of malignant gliomas and treatments in neuro-oncology, the prognosis for patients with malignant gliomas, although improved, remains very poor. The limitations of this type of analysis, including how trial design can bias outcomes and militate against comparison of trials are discussed.
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Affiliation(s)
- E Anderson
- Department of Clinical Neuroscience and Edinburgh Centre for Neuro-oncology, Western General Hospital, University of Edinburgh, UK
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Tsien C, Gomez-Hassan D, Ten Haken RK, Tatro D, Junck L, Chenevert TL, Lawrence T. Evaluating changes in tumor volume using magnetic resonance imaging during the course of radiotherapy treatment of high-grade gliomas: Implications for conformal dose-escalation studies. Int J Radiat Oncol Biol Phys 2005; 62:328-32. [PMID: 15890571 DOI: 10.1016/j.ijrobp.2004.10.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2004] [Revised: 08/31/2004] [Accepted: 10/14/2004] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine whether changes in tumor volume occur during the course of conformal 3D radiotherapy of high-grade gliomas by use of magnetic resonance imaging (MRI) during treatment and whether these changes had an impact on tumor coverage. METHODS AND MATERIALS Between December 2000 and January 2004, 21 patients with WHO Grades 3 to 4 supratentorial malignant gliomas treated with 3D conformal radiotherapy (median dose, 70 Gy) were enrolled in a prospective clinical study. All patients underwent T1-weighted contrast-enhancing and T2-weighted and fluid-attenuated inversion recovery (FLAIR) imaging at approximately 1 to 2 weeks before radiotherapy, during radiotherapy (Weeks 1 and 3), and at routine intervals thereafter. All MRI scans were coregistered to the treatment-planning CT. Gross tumor volume (GTV Pre-Rx) was defined from a postoperative T1-weighted contrast-enhancing MRI performed 1 to 2 weeks before start of radiotherapy. A second GTV (GTV Week 3) was defined by use of an MRI performed during Week 3 of radiotherapy. A uniform 0.5 cm expansion of the respective GTV, PTV (Pre-Rx), and PTV (Week 3) was applied to the final boost plan. Dose-volume histograms (DVH) were used to analyze any potential adverse changes in tumor coverage based on Week 3 MRI. RESULTS All MRI scans were reviewed independently by a neuroradiologist (DGH). Two patients were noted to have multifocal disease at presentation and were excluded from analysis. In 19 cases, changes in the GTV based on MRI at Week 3 during radiotherapy were as follows: 2 cases had an objective decrease in GTV (> or =50%); 12 cases revealed a slight decrease in the rim enhancement or changes in cystic appearance of the GTV; 2 cases showed no change in GTV; and 3 cases demonstrated an increase in tumor volume. Both cases with objective decreases in GTV during treatment were Grade 3 tumors. No cases of tumor progression were noted in Grade 3 tumors during treatment. In comparison, three of 12 Grade 4 tumors had tumor progression, based on MRI obtained during Week 3 of radiotherapy. Median increase in GTV (Week 3) was 11.7 cc (range, 9.8-21.3). Retrospective DVH analysis of PTV (Pre-Rx) and PTV (Week 3) demonstrated a decrease in V(95%)(PTV volume receiving 95% of the prescribed dose) in those 3 cases. CONCLUSIONS Routine MR imaging during radiotherapy may be essential in ensuring tumor coverage if highly conformal radiotherapy techniques such as stereotactic boost and intensity-modulated radiotherapy are used in dose-escalation trials that utilize smaller treatment margins.
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Affiliation(s)
- Christina Tsien
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, USA.
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17
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Arafat WO, Buchsbaum DJ, Gómez-Navarro J, Tawil SA, Olsen C, Xiang J, El-Akad H, Salama AM, Badib AO, Stackhouse MA, Curiel DT. An adenovirus encoding proapoptotic Bax synergistically radiosensitizes malignant glioma. Int J Radiat Oncol Biol Phys 2003; 55:1037-50. [PMID: 12605984 DOI: 10.1016/s0360-3016(02)04488-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE We explore the utility of the adenovirus-mediated delivery of proapoptotic Bax for enhancing the cytotoxicity of radiotherapy (RT) in RT-refractory glioma cells. MATERIALS AND METHODS Cell lines D54 MG and U87 MG (p53 wild-type), and U251 MG and U373 MG (p53 mutant), and patient-derived astrocytes were evaluated. Cells were irradiated and infected with an inducible adenovirus encoding Bax. Cell proliferation, colony formation assay, quantification of early apoptotic alteration in the plasma membrane by fluorescence-activated cell sorter using annexin V, and nuclear staining with H33258 were used to evaluate apoptosis. The capacity of the combined treatment to induce regression of subcutaneous D54 MG tumors was tested in nude mice. A dose of 5 Gy was administered every other day, four times, for a total dose of 20 Gy. One day after each irradiation, tumors were injected with 1 x 10(9) plaque-forming units (PFU). RESULTS Apoptotic death was enhanced by the combination of Ad/Bax and RT. In D54 MG, levels of apoptosis after RT alone, Ad/Bax alone, or the combination were, respectively, 12.3%, 32.1%, and 78.5%. In contrast, treatment of astrocytes did not significantly induce apoptosis. A colony-formation assay showed a 2-log inhibition with respect to controls after combined treatment, irrespective of the endogenous levels of p53. The other apoptosis assays also showed the defining characteristics of apoptosis in the combination group. Remarkably, combined treatment induced regression of tumors in mice. CONCLUSIONS Ad/Bax synergistically radiosensitizes glioma, with a seemingly favorable therapeutic index.
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Affiliation(s)
- Waleed O Arafat
- Division of Human Gene Therapy, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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18
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Knisely JPS, Rockwell S. Importance of hypoxia in the biology and treatment of brain tumors. Neuroimaging Clin N Am 2002; 12:525-36. [PMID: 12687909 DOI: 10.1016/s1052-5149(02)00032-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The resistance of gliomas to treatment with radiation and antineoplastic drugs may result in part from the effects of the extensive, severe hypoxia that is present in these tumors. It is clear that brain tumors contain extensive regions in which the tumor cells are subjected to unphysiological levels of hypoxia. Hypoxic cells are resistant to radiation. Hypoxia and the perfusion deficits and metabolic changes that accompany hypoxia in vivo also produce resistance to many commonly used anticancer drugs. The resistance of cells that are hypoxic at the time of therapy may influence the efficacy of the treatment of these tumors with radiation, chemotherapy, and combined modality regimens. Moreover, it is becoming increasingly evident from laboratory studies that exposure of cells to adverse microenvironments produces transient changes in gene expression, induces mutations, and selects for cells with altered genotypes, thus driving the evolution of the cell population toward increasing malignancy and increasingly aggressive phenotypes. Hypoxia may therefore be involved in the evolution of cells in low-grade malignancies to the resistant, aggressive phenotype characteristic of glioblastomas. During the past 50 years, many attempts have been made to circumvent the therapeutic resistance induced by hypoxia, by improving tumor oxygenation, by using oxygen-mimetic radiosensitizers, by adjuvant therapy with drugs that are preferentially toxic to hypoxic cells, by using hyperthermia, or by devising radiation sources and regimens that are less affected by hypoxia. Past clinical trials have provided tantalizing suggestions that the outcome of therapy can be improved by many of these approaches, but none has yet produced a significant, reproducible improvement in the therapeutic ratio, which would be needed for any of these approaches to become the standard therapy for these diseases. Several ongoing clinical trials are addressing other, hopefully better regimens; it will be interesting to see the results of these studies.
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Affiliation(s)
- Jonathan P S Knisely
- Department of Therapeutic Radiology, Yale University School of Medicine, P.O. Box 208040, New Haven, CT 06520-8040, USA.
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19
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Laperriere N, Zuraw L, Cairncross G. Radiotherapy for newly diagnosed malignant glioma in adults: a systematic review. Radiother Oncol 2002; 64:259-73. [PMID: 12242114 DOI: 10.1016/s0167-8140(02)00078-6] [Citation(s) in RCA: 257] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE A systematic review was conducted to develop guidelines for radiotherapy in adult patients with newly diagnosed malignant glioma. METHODS MEDLINE, CANCERLIT, the Cochrane Library, and relevant conference proceedings were searched to identify randomized trials and meta-analyses. RESULTS Pooling of six randomized trials detected a significant survival benefit favouring post-operative radiotherapy compared with no radiotherapy (risk ratio, 0.81; 95% confidence interval, 0.74 to 0.88, P<0.00001). Two randomized trials demonstrated no significant difference in survival rates for whole brain radiation versus more local fields that encompass the enhancing primary plus a 2 cm margin. A randomized trial detected a small improvement in survival with 60 Gy in 30 fractions over 45 Gy in 20 fractions. Radiation dose intensification and radiation sensitizer approaches have not demonstrated superior survival rates compared with conventionally fractionated doses of 50-60 Gy. CONCLUSIONS Post-operative external beam radiotherapy is recommended as standard therapy for patients with malignant glioma. The high-dose volume should incorporate the enhancing tumour plus a limited margin (e.g. 2 cm) for the planning target volume, and the total dose delivered should be in the range of 50-60 Gy in fraction sizes of 1.8-2.0 Gy. Radiation dose intensification and radiation sensitizer approaches are not recommended as standard care. For patients older than age 70, preliminary data suggest that the same survival benefit can be achieved with less morbidity using a shorter course of radiotherapy. Supportive care alone is a reasonable therapeutic option in patients older than age 70 with a poor performance status.
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Affiliation(s)
- Normand Laperriere
- Department of Radiation Oncology, Princess Margaret Hospital/University Health Network, University of Toronto, ON, Canada
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Steinmetz MP, Barnett GH, Kim BS, Chidel MA, Suh JH. Metastatic seeding of the stereotactic biopsy tract in glioblastoma multiforme: case report and review of the literature. J Neurooncol 2001; 55:167-71. [PMID: 11859971 DOI: 10.1023/a:1013873431159] [Citation(s) in RCA: 31] [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
OBJECTIVE AND IMPORTANCE The first case was recently reported of tumor seeding by glioblastoma multiforme (GBM) after stereotactic biopsy. This occurred despite radiosurgical treatment of the lesion post-biopsy. We report the first case of metastatic seeding along the needle biopsy tract of a GBM in which the tract was within the treatment field of subsequent fractionated radiation therapy. CLINICAL PRESENTATION A 56-year-old man presented with left-sided focal motor seizures. An MRI showed an enhancing right cingulate gyrus lesion. INTERVENTION A stereotactic biopsy of the lesion disclosed GBM. Radiation therapy was begun 25 days after biopsy and was completed 39 days thereafter. The biopsy tract received a minimum of 60 Gy. Subsequent magnetic resonance scanning showed the lesion to have doubled in size and evidence of enhancement along the biopsy tract. At surgery, specimens obtained from the biopsy tract, as determined using surgical navigation, revealed GBM. CONCLUSION Seeding of the biopsy tract, radioresistance and the time interval until radiotherapy are the most likely explanations for tumor growth along the biopsy tract in this case. Consideration should be given for an early start to radiotherapy among those who undergo stereotactic biopsy for GBM. Further research will allow one to determine the radiosensitivity of these tumors and determine which patients may benefit from a radiosurgical or fractionated radiotherapy boost to the biopsy tract.
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Affiliation(s)
- M P Steinmetz
- Department of Neurosurgery, Brain Tumor and Neuro-Oncology Center, The Cleveland Clinic, OH 44195, USA
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21
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Jansen EP, Dewit LG, van Herk M, Bartelink H. Target volumes in radiotherapy for high-grade malignant glioma of the brain. Radiother Oncol 2000; 56:151-6. [PMID: 10927133 DOI: 10.1016/s0167-8140(00)00216-4] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Delineation of the clinical target volume (CTV) in radiation treatment planning of high-grade glioma is a controversial issue. The use of computerized tomography (CT) and magnetic resonance imaging (MRI) has greatly improved the accuracy of tumor localization in three-dimensional planning. This review aims at critically analyzing available literature data in which tumor extent of high-grade glioma has been assessed using CT and/or MRI and relating this to postmortem observations. Attention is given to the pattern of tumor spread at initial presentation and to tumor recurrence pattern after external beam irradiation. Special emphasis is given to the site of tumor regrowth after radiation treatment in relation to the boundaries of the CTV. Guidelines for delineating CTV will be inferred from this information, taking data on radiation effects on the normal brain into account.
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Affiliation(s)
- E P Jansen
- Department of Radiotherapy, The Netherlands Cancer Institute/Antonie van Leeuwenhoekhuis, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
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22
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Groves MD, Maor MH, Meyers C, Kyritsis AP, Jaeckle KA, Yung WK, Sawaya RE, Hess K, Bruner JM, Peterson P, Levin VA. A phase II trial of high-dose bromodeoxyuridine with accelerated fractionation radiotherapy followed by procarbazine, lomustine, and vincristine for glioblastoma multiforme. Int J Radiat Oncol Biol Phys 1999; 45:127-35. [PMID: 10477016 DOI: 10.1016/s0360-3016(99)00122-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To conduct a Phase II study to evaluate the long-term efficacy and safety of high-dose 5'-bromodeoxyuridine (BrdU) and accelerated radiotherapy followed by procarbazine, lomustine (CCNU), and vincristine (PCV) chemotherapy in patients with glioblastoma multiforme. METHODS AND MATERIALS Between 1994 and 1996, 88 patients were enrolled to receive 1.9 Gy of radiation three times a day for two 5-day cycles separated by 2 weeks; each 5-day cycle was preceded by a continuous 96-hour infusion of BrdU at a dose of 2.1 g/m2/day. After radiotherapy, patients received PCV chemotherapy. RESULTS Median survival for all 88 patients was 50 weeks. Seventy (79.5 %) received one or more courses of PCV; their median survival was 57 weeks. Covariates predictive of improved survival were gross total versus subtotal resection or biopsy (p = 0.0048) and radiation dose > or = 56 Gy (p = 0.019). While receiving BrdU, 47 patients (53%) suffered grade 3 or 4 thrombocytopenia or leukopenia; 22 patients (25%) suffered grade 3 or 4 dermatologic toxicity. CONCLUSION Survival was not extended in patients with glioblastoma or gliosarcoma who received BrdU at the dose and administration schedule used in this study. The BrdU dose used in this study resulted in substantial myelosuppressive and dermatologic toxicity.
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Affiliation(s)
- M D Groves
- The Brain Tumor Center, Department of Neuro-Oncology, The University of Texas M.D. Anderson Cancer Center, Houston 77030, USA
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de Crevoisier R, Pierga JY, Dendale R, Feuvret L, Noël G, Simon JM, Mazeron JJ. [Radiotherapy of glioblastoma]. Cancer Radiother 1997; 1:194-207. [PMID: 9295873 DOI: 10.1016/s1278-3218(97)89765-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Glioblastoma cells appear to be inherently radioresistant and to present a significant fraction of hypoxic cells. The most significant prognostic factors to compare results achieved in several series of patients are the age, performance status and quality of surgical resection. Several randomized trials have provided evidence supporting the efficacy of radiation therapy in the treatment of glioblastoma. Prescription of a 60-Gy dose delivered according to a conventional dose-fractionation scheme (single daily fractions of 1.7 to 2 Gy five times per week) in a target volume with a 2-3 cm margin of tissue surrounding the perimeter of the contrast enhancing lesion on computerized tomography and magnetic resonance imaging is derived from observations made in several retrospective and prospective studies. Evidence of improvement in survival was observed neither in patients receiving hyperfractioned and accelerated radiotherapy, nor in patients for whom radiation sensitizers such as nitroimidazole compounds or halogenated pyrimidine analogs were associated to radiation therapy. The addition of nitrosourea to radiotherapy increases the 2-year survival rate by about 10%. Combination of full-dose external beam radiotherapy and brachytherapy or radiosurgery boost in selected patients with glioblastoma leads to an increase in the median survival, while external beam radiation alone in patients with similar prognosis does not.
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Affiliation(s)
- R de Crevoisier
- Centre des tumeurs, groupe hospitalier Pitié-Salpêtrière, Paris, France
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Abstract
Gliomas are the most frequent primary brain tumours. They include astrocytic gliomas, oligodendrocytic gliomas, ependymomas and gliomas with mixed cell populations. Each glioma type consists of both low-grade and malignant atypical varieties. The low-grade tumours occur predominantly in children and young adults, and the malignant forms in older people. The presenting symptoms are epileptic seizures, headache and mental confusion. Focal neurological symptoms and findings, such as hemiparesis, are mostly associated with the malignant forms. Magnetic resonance imaging (MRI) scan of the brain with and without gadolinium contrast demonstrates the tumour. However, stereotactic biopsy or surgical resection is necessary to obtain the correct pathological diagnosis, except for diffuse pontine astrocytomas, which have an unmistakeable imaging appearance and for which biopsy has substantial risks. Treatment depends on the pathological diagnosis. Complete surgical resection may be curative for low-grade tumours. Postoperative radiotherapy is recommended for partially resected tumours. Most malignant gliomas require aggressive combination therapy with radiotherapy and chemotherapy after maximal surgery. The standard initial regimens are nitrosourea-based chemotherapies, such as carmustine alone, a combination of procarbazine, lomustine and vincristine, or a combination of thioguanine, procarbazine, lomustine and hydroxycarbamide (hydroxyurea). Unfortunately, the prognosis of malignant gliomas is generally poor despite aggressive treatment, because of their infiltrative nature and high relapse rate.
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Affiliation(s)
- S E Kaba
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA
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Fatigante L, Ducci F, Cartei F, Colosimo S, Marini C, Prediletto R, Danesi R, Laddaga M, Del Tacca M, Caciagli P. Carbogen and nicotinamide combined with unconventional radiotherapy in glioblastoma multiforme: a new modality treatment. Int J Radiat Oncol Biol Phys 1997; 37:499-504. [PMID: 9112444 DOI: 10.1016/s0360-3016(96)00605-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE A new radiotherapy schedule to treat glioblastoma multiforme after surgery, combining nicotinamide and carbogen. METHODS AND MATERIALS We analyzed 36 patients with glioblastoma multiforme treated after surgery with radiotherapy, Nicotinamide and Carbogen as follows: 7 patients were treated with accelerated fractionation: two fractions/day, 1.5 cGy/fraction, 6 h interval, 5 days/week, total dose 60 Gy in 4 weeks; 8 patients were treated with the same irradiation scheduling plus Nicotinamide at the dose of 4 g and 2 g in capsules, respectively, 1 h before the first and the second irradiation fraction; 21 patients were treated with accelerated radiotherapy, Nicotinamide, and Carbogen (inhaled 10 min before radiotherapy and during the whole course of irradiation). On the basis of surgical removal our patients were subdivided in three groups: totally resected, with residual tumor <50%, or >50%. Radiotherapy with accelerated fractionation was completed in the scheduled time without side effects on the whole group of patients and Carbogen inhalation did not cause significant change of cardiopulmonar parameters. The toxicity observed was predominant in the gastrointestinal tract and was related to Nicotinamide. RESULTS The median survival time (M.S.T.) was 10 months, as reported by others authors with conventional treatment, but in patients without surgical residual tumor and submitted to the complete treatment schedule, the survival at 35 months was around 25%. CONCLUSIONS We conclude that this method is feasible with acceptable toxicity; analyzing the survival curves appears to be a trend towards an improvement in survival in the subgroup of patients with gross total removal treated with the combination of Carbogen, Nicotinamide, and accelerated fractionation.
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Affiliation(s)
- L Fatigante
- Cattedra di Radioterapia, Universita di Pisa, Italy
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Saunders M, Dische S. Clinical results of hypoxic cell radiosensitisation from hyperbaric oxygen to accelerated radiotherapy, carbogen and nicotinamide. THE BRITISH JOURNAL OF CANCER. SUPPLEMENT 1996; 27:S271-S278. [PMID: 8763896 PMCID: PMC2149999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The 40-year history of hypoxic cell sensitisation can be traced from hyperbaric oxygen to the present clinical studies with carbogen, nicotinamide and accelerated radiotherapy. A meta-analysis by Overgaard (1995) included 10703 cases entered into 83 randomised controlled trials and showed an overall improvement in local tumour control of 4.6% (P = 0.00001) and in survival of 2.8% (P = 0.005). Hyperbaric oxygen gave a 6.6% (P = 0.003) improvement in local control and hypoxic cell sensitisers 3.9% (P = 0.04). Despite this, the only hypoxic cell-sensitising method in routine clinical use is the giving of nimorazole in supraglottic and pharyngeal carcinomas. Acute, as well as chronic hypoxia has been recognised and nicotinamide, the amide derivative of B3 is believed to prevent the former. Thus ARCON (accelerated radiotherapy, carbogen and nicotinamide) has been introduced in the clinic in an effort to overcome tumour proliferation, chronic and acute hypoxia, respectively. The success of future randomised controlled trials would be improved greatly if methods were available to measure the concentration of hypoxic cells in tumours before treatment and thus select those where benefit may be gained. The use of ARCON recognises that tumour cell proliferation is an important cause of failure in addition to hypoxia. However, intrinsic radiosensitivity may also need to be taken into account in the future. Clinical trials aim to improve the therapeutic ratio and thus the study of morbidity is as important as local tumour control. International collaboration is essential if randomised controlled trials are to be carried out within reasonable periods of time.
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Affiliation(s)
- M Saunders
- Marie Curie Research Wing, Mount Vernon Hospital, Northwood, Middlesex, UK
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Levin VA, Maor MH, Thall PF, Yung WK, Bruner J, Sawaya R, Kyritsis AP, Leeds N, Woo S, Rodriguez L. Phase II study of accelerated fractionation radiation therapy with carboplatin followed by vincristine chemotherapy for the treatment of glioblastoma multiforme. Int J Radiat Oncol Biol Phys 1995; 33:357-64. [PMID: 7673023 DOI: 10.1016/0360-3016(95)00160-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE To conduct a Phase II one-arm study to evaluate the long-term efficacy and safety of accelerated fractionated radiotherapy combined with intravenous carboplatin for patients with previously untreated glioblastoma multiforme tumors. METHODS AND MATERIALS Between 1988 and 1992, 83 patients received 1.9-2.0 Gy radiation three times a day with 2-h infusions of 33 mg/m2 carboplatin for two 5-day cycles separated by 2 weeks; following radiotherapy, patients received procarbazine, lomustine (CCNU), and vincristine (PCV) for 1 year or until tumor progressed. RESULTS Eighty-three patients were evaluable for analysis. Seventy-four of the 83 patients (89%) received one or more courses of PCV; their median survival was 55 weeks. Total resection was performed in 20% (15 of 74), subtotal resection in 69% (51 of 74), and biopsy in 11% (8 of 74); reoperation (total or subtotal resection) was performed in 28 patients (37%). Survival was worst for those > or = 61 year old (median 35 weeks). Fits of the Cox proportional hazards regression model showed covariates individually predictive of improved survival were younger age (p < 0.01), smaller log of radiation volume (p = 0.008), total or subtotal resection vs. biopsy (p = 0.056), and higher Karnofsky performance status (p = 0.055). A multivariate analysis showed that age (p = 0.013) and extent of initial surgery (p = 0.003) together were predictive of a better survival with no other variables providing additional significance. Only 8.4% (7 of 83) of patients had clinically documented therapy-associated neurotoxicity ("radiation necrosis"). CONCLUSION When comparable selection criteria were applied, the survival in this study is similar to the results currently attainable with other chemoradiation approaches. The relative safety of accelerated fractionated radiotherapy, as used in this study with carboplatin, enables concomitant full-dose administration of chemotherapy or radiosensitizing agents in glioblastoma multiforme patients.
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Affiliation(s)
- V A Levin
- Department of Neuro-Oncology, University of Texas M. D. Anderson Cancer Center, Houston 77030, USA
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Levin VA, Prados MR, Wara WM, Davis RL, Gutin PH, Phillips TL, Lamborn K, Wilson CB. Radiation therapy and bromodeoxyuridine chemotherapy followed by procarbazine, lomustine, and vincristine for the treatment of anaplastic gliomas. Int J Radiat Oncol Biol Phys 1995; 32:75-83. [PMID: 7721642 DOI: 10.1016/0360-3016(94)00488-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE To conduct a Phase II study to evaluate the long-term efficacy and safety of radiotherapy combined with intravenous bromodeoxyuridine for patients with anaplastic glioma tumors. METHODS AND MATERIALS Between 1983 and 1987, study patients received 1.7-1.8 Gy radiation once a day, Monday through Friday, to a total dose of 60 Gy. On the Thursday prior to beginning radiotherapy and for the next 5 weeks (6 weeks total), patients received a continuous 96 h intravenous infusion of bromodeoxyuridine at 0.8 g/m2/24 h; following radiotherapy, patients received procarbazine, lomustine (CCNU), and vincristine (PCV) for 1 year or until tumor progressed. RESULTS One-hundred thirty eight patients (median age, 43 years) were evaluable for analysis. Estimated 4-year survival for the anaplastic astrocytoma (AA) stratum (n = 116) is 46%. For the astrocytoma (ASTRO) stratum (n = 22), the 6-year survival is estimated at 79%. Estimated 4-year progression-free survival for AAs is 42%, and for ASTROs, 68%. Whole brain irradiation was used in 23% and limited-field irradiation in 77%; patients receiving limited-field irradiation had a better survival rate (p = 0.07). Total tumor resection was performed in 15%, partial resection in 53%, and biopsy only in 32%. For the 81 patients with tumor recurrence, 34 (42%) are known to have received additional treatment(s). For AA, fits of the Cox proportional hazards regression model showed that covariates individually predictive of survival were younger age (p < 0.001), Karnofsky performance score (p = 0.10). Major toxicities were rash during Weeks 1 through 6 requiring dose modification in 14%, Grade > or = III leukopenia in 18%, and Grade > or = III thrombocytopeni in 9%. CONCLUSION The study suggests that the bromodeoxyuridine-radiotherapy-PCV, compared with other published therapies, can improve progression-free survival, and aggressive treatment of ASTRO patients can lead to substantial increases in survival compared to published survival data.
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Affiliation(s)
- V A Levin
- Northern California Cancer Center, Union City, USA
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Mehta MP, Masciopinto J, Rozental J, Levin A, Chappell R, Bastin K, Miles J, Turski P, Kubsad S, Mackie T. Stereotactic radiosurgery for glioblastoma multiforme: report of a prospective study evaluating prognostic factors and analyzing long-term survival advantage. Int J Radiat Oncol Biol Phys 1994; 30:541-9. [PMID: 7928484 DOI: 10.1016/0360-3016(92)90939-f] [Citation(s) in RCA: 120] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE Prospective evaluation of the toxicity and efficacy of radiosurgery with external beam radiotherapy in the management of newly diagnosed glioblastoma. METHODS AND MATERIALS From 5/89 to 12/92, 31 out of 51 patients with glioblastoma multiforme underwent radiosurgery, in addition to 54 Gy in 1.8 Gy/fraction following biopsy (n = 12) or resection (n = 19). Eligibility required supratentorial glioblastoma, tumor not > 4 cm in > 1 axis, age > 18 years, and location > 1 cm from optic chiasm. Patient characteristics were: age 20-78 years (median = 57); 22 male, 9 female; Karnofsky score 20-90 (m = 70), and volume of 2.3-59.7 c.c. (m = 17.4). Eighteen patients were treated with 1 collimator, 5 with 2, 7 with 3, and 1 with 4; peripheral isodoses were 40-90% (m = 72.5) and minimum and maximum tumor dose ranges were 10-20 (m = 12) and 15-35 Gy (m = 18.75). Patients were followed clinically and radiographically every 8-12 weeks to analyze survival, quality of life, and toxicity. RESULTS With a follow-up of 12-171 weeks, 8 out of 31 (26%) patients are alive. Median survival is 42 weeks. Twelve and 24-month actuarial survival are 38 and 28%. Comparison of the 2-year survival with previous Radiation Therapy Oncology Group patients was carried out using a nonparametric recursive partitioning technique and the observed vs. expected values are 28 vs. 9.7% (p < 0.05). Extent of resection and performance status were associated with improved survival in a multivariate analysis. No significant acute toxicity was encountered. Four patients (13%) developed clinically significant necrosis verified by biopsy or positron emission tomography scan at 9-59 weeks after radiosurgery. CONCLUSION The improvement in median survival in broadly selected glioblastoma patients treated with radiosurgery is difficult to determine, but the 2-year survival may be superior. Future randomized trials of radiosurgery are recommended, and ad hoc use of this modality should be discouraged.
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Affiliation(s)
- M P Mehta
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison 53792
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32
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Abstract
High grade (or malignant) astrocytomas remain a formidable therapeutic challenge. The main prognostic factors are patient age, patient performance status, tumor grade, the extent of surgical resection and the presence of fits. These factors could help to identify different groups of patients and should be an advantage in deciding on treatment strategies. Modern imaging techniques provide a more precise idea of tumor volume. The study of tumor recurrence shows that they occur in the immediate vicinity of the primary site. Surgery aside, radiotherapy remains the most important treatment modality. Currently, its standards concerning optimal dose and target volume appear to be accepted overall. There is no doubt that a dose-response relation exists; however, doses exceeding 60 Gy increase morbidity. Therefore 60 Gy is the dose most often cited in the literature. Furthermore, as whole brain irradiation does not decrease the risk of recurrence, a focal irradiation including a defined mean volume is generally used today. Radiosensitizers and heavy particles have not fulfilled their initial promise. Brachytherapy remains an interesting alternative for a limited number of patients. Nevertheless, it seems to increase recurrence at a distance from the primary site and to lead to severe focal lesions. Interstitial thermoradiotherapy may minimize local doses and thus help avoid serious local necrosis. Amongst the other therapeutic alternatives, intravenous chemotherapy using nitrosoureas provides a certain but modest benefit. Other administration modalities are currently undergoing evaluation. These include intra-arterial chemotherapy or high dose chemotherapy with auto-bone marrow transplantation. The interest of this latter is concerned mainly with anaplastic astrocytomas. Finally, among the future alternatives, gene therapy appears to hold the most promise. Intensive therapies, combined modality treatments, with the recent help of biological innovations, should be proposed to favorable groups of patients.
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Affiliation(s)
- F Mornex
- Département de Radiothérapie, Centre Léon Bérard, Lyon, France
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Gaspar LE, Fisher BJ, MacDonald DR, LeBer DV, Halperin EC, Schold SC, Cairncross JG. Malignant glioma--timing of response to radiation therapy. Int J Radiat Oncol Biol Phys 1993; 25:877-9. [PMID: 8478239 DOI: 10.1016/0360-3016(93)90318-p] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE The response of malignant gliomas to radiation was examined retrospectively in 71 patients with newly diagnosed supratentorial malignant gliomas. Questions asked included frequency, timing and clinical significance of response. METHODS AND MATERIALS After surgery, all were treated with whole brain plus boost radiotherapy followed 8 weeks later by chemotherapy. The rate, degree, and timing of response to radiation were determined by comparing postoperative, end of radiation, and prechemotherapy CT scans on each patient. RESULTS Postoperative residual tumor was evident on 63/71 postoperative scans. Twenty-two of 63 tumors (35%) had a partial or complete response to radiation. Twenty (32%) had responded by the end of radiation; 17 maximally. Six to 8 weeks later, three responding tumors had responded further and two previously stable ones had begun to respond. Only three tumors (5%) responded completely. A greater proportion of anaplastic gliomas than glioblastomas responded to radiation (52% vs. 26%). Protracted or delayed responses were only observed in patients with anaplastic glioma. Patients who responded to radiation did not live significantly longer than non-responders. However, tumor progression prior to chemotherapy was associated with significantly shorter survival. CONCLUSION This CT scan-based analysis demonstrates that malignant gliomas are only moderately radioresponsive tumors and also demonstrates that response to radiation, if it is going to occur, is usually evident by the end of treatment.
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Affiliation(s)
- L E Gaspar
- Department of Oncology, University of Western Ontario
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Gaspar LE, Fisher BJ, Macdonald DR, LeBer DV, Halperin EC, Schold SC, Cairncross JG. Supratentorial malignant glioma: patterns of recurrence and implications for external beam local treatment. Int J Radiat Oncol Biol Phys 1992; 24:55-7. [PMID: 1512163 DOI: 10.1016/0360-3016(92)91021-e] [Citation(s) in RCA: 210] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Pre- and postoperative computerized tomography scans, simulator films, and computerized tomography scans documenting tumor recurrence were analyzed on 70 patients with supratentorial malignant glioma treated with whole brain plus boost radiation therapy to determine sites of recurrence in relation to the boost. The boost was planned using the postoperative computerized tomography scan. Tumor recurred in 53 patients--within the boost in 38 (72%), partly outside the boost in 12 (23%), outside the boost but within the brain in one (2%), in the boost and in the spinal cord in one (2%), and in the spinal cord only in one (2%). All recurrences confined to the brain were found within 4 cm of the enhancing tumor as defined by the preoperative computerized tomography scan. Recurrences outside the boost were more common with inadequate boost margins, small boost volumes, temporal lobe tumors, and homolateral wedge pair technique. Survival was not adversely affected by recurrence outside the boost. We recommend that patients with malignant glioma be treated by parallel opposed fields with a margin that is 4 cm beyond the edge of the preoperative enhancing tumor, as seen on computerized tomography scan.
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Affiliation(s)
- L E Gaspar
- Department of Oncology, University of Western Ontario, London, Canada
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35
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The management of malignant gliomas with radiation therapy: Therapeutic results and research strategies. Semin Radiat Oncol 1991. [DOI: 10.1016/1053-4296(91)90007-t] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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36
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Mahaley MS. Neuro-oncology index and review (adult primary brain tumors). Radiotherapy, chemotherapy, immunotherapy, photodynamic therapy. J Neurooncol 1991; 11:85-147. [PMID: 1744686 DOI: 10.1007/bf02390173] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- M S Mahaley
- Division of Neurological Surgery, University of Alabama, Birmingham
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37
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Wong KH, Wallen CA, Wheeler KT. 2-Nitroimidazole potentiation of nitrosourea induced cytotoxicity in subcutaneous implants of rat 9L brain tumor cells. J Neurooncol 1991; 11:17-25. [PMID: 1833513 DOI: 10.1007/bf00166993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
To determine if the 2-nitroimidazole (2-NI) and the nitrosourea (NU) in a brain tumor chemopotentiation trial should be selected on the basis of known structure-activity relationships (electron affinity, lipophilicity, alkylating activity, carbamoylating activity), s.c. implants of rat 9L brain tumor cells were treated with combinations of misonidazole (MISO) or etanidazole (SR-2508) administered under oxic and hypoxic conditions, and BCNU, CCNU or chlorozotocin (CLZ) administered under oxic conditions. Cell kill was assessed by an in vivo to in vitro colony formation assay. To mimic the 'preincubation effect', the 2-NI was injected i.p., and 30 min later the tumor was clamped. After 2 hr, the clamp was released, and the NU administered immediately. MISO (2.5 mmole/kg) and SR-2508 (3.75 mmole/kg) reached the same peak tumor concentration in 30 min. Both 2-NIs were metabolized at the same rate in the clamped tumors; however, metabolism of the 2-NIs by hypoxic cells over the 2 hr clamping period did not produce any measurable s.c. 9L cell kill. The relative effectiveness of the NUs for killing oxic s.c. 9L tumor cells was: BCNU greater than CCNU greater than CLZ. Clamping the tumor prior to NU administration did not change the NU cytotoxicity. No potentiation of the NU cytotoxicity by the 2-NIs was observed in oxic tumors. Although metabolism of MISO by hypoxic cells did not result in potentiation of CLZ cytotoxicity at any dose, it resulted in potentiation of BCNU cytotoxicity at all doses and CCNU cytotoxicity at high doses.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- K H Wong
- Department of Radiology, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC 27103
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38
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Shenouda G, Souhami L, Freeman CR, Hazel J, Lehnert S, Joseph L. Accelerated fractionation for high-grade cerebral astrocytomas. Preliminary treatment results. Cancer 1991; 67:2247-52. [PMID: 2013030 DOI: 10.1002/1097-0142(19910501)67:9<2247::aid-cncr2820670906>3.0.co;2-q] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A Phase I/II accelerated fractionation study for high-grade cerebral astrocytomas began in October 1987. Forty-two patients, 25 men and 17 women, were entered in the study. Median age was 58.5 years of age (range, 32 to 78 years). Performance status was 0, 1, 2, and 3 on Eastern Cooperative Oncology Group (ECOG) scale for 13, 19, 9, and 1 patients, respectively. Thirty-six patients had undergone partial resection, and six had stereotactic biopsy only. All patients had histologically proven astrocytomas (6 Grade 3, and 36 Grade 4). Treatment consisted of radiation therapy doses of 4400 cGy in 22 daily fractions to the whole brain plus a boost of 1600 cGy in 8 fractions given concomitantly with the last 8 whole-brain treatments using a twice daily schedule with an interfraction interval of 8 hours. Median survival time was 57 weeks from the date of starting irradiation. Survival was 50% and 28% at 1 and 2 years, respectively. Alopecia and scalp erythema were seen in all patients; nine patients had localized areas of moist desquamation in the retroauricular region. Decreased hearing and serous otitis media were seen in five patients within 1 to 2 months from the end of treatment. Increasing somnolence was marked in eight patients with progressive deterioration of performance status; computerized axial tomography (CAT) scan studies in all eight patients showed evidence of disease recurrence with associated brain edema and mass effect. Three patients had a second resection for a recurrent tumor with no evidence of brain necrosis at craniotomy. To date, the accelerated fractionation schedule appears to be well tolerated with valuable shortening of overall treatment time. The preliminary results are encouraging, and longer follow-up time is required to evaluate tumor control and toxicity.
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Affiliation(s)
- G Shenouda
- Division of Radiation Oncology, McGill University, Montréal, Québec, Canada
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39
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Hypoxic Cell Sensitizers in the Management of Brain Tumours. GLIOMA 1991. [DOI: 10.1007/978-3-642-84127-9_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
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40
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Laperriere NJ. Critical appraisal of experimental radiation modalities for malignant astrocytomas. Can J Neurol Sci 1990; 17:199-208. [PMID: 2192790 DOI: 10.1017/s0317167100030456] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The management of patients with supratentorial malignant astrocytomas has remained a major problem. Patients continue to die from a lack of local control in 90% of cases despite an improvement of median survival seen with the use of postoperative radiation therapy. Because of this, there has been considerable interest in exploring novel ways of possibly improving results. This paper reviews the rationale and clinical results with the use of altered fractionation schemes, brachytherapy, radiation sensitizers, hyperthermia, particle therapy, and radiosurgery in the treatment of these patients. Currently, there is no demonstrated advantage with the use of these experimental modalities in the initial management of patients. There would appear to be some benefit for selected patients who are treated with brachytherapy at recurrence, but its efficacy as part of initial management remains to be determined determined in ongoing randomized prospective trials.
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Affiliation(s)
- N J Laperriere
- Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada
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41
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Abstract
A brief review of attempts in the United Kingdom to improve the results of treatment of high grade (grade 3, 4) supra-tentorial astrocytomas is presented. The radiosensitizer misonidazole failed to improve the results of post-surgical radiotherapy, however, multivariate analysis of data from these patients has provided a prognostic index of use in defining good and poor prognosis patients. An overview study of adjuvant nitrosourea therapy trials has shown a small significant advantage for the chemotherapy. A study of chemosensitization by benznidazole of CCNU treatment of patients in relapse failed to demonstrate any effect.
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Affiliation(s)
- N M Bleehen
- University Department, Addenbrookes Hospital, Cambridge, U.K
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42
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Abstract
This presentation will review recent data on the treatment of high grade gliomas. It deals primarily with results of radiotherapy even though several of the clinical trials to be considered also included chemotherapy. Present emphasis will be on, but not limited to, the larger prospective randomized trials conducted by various cooperative clinical groups in the United States, the United Kingdom and on the continent.
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Affiliation(s)
- G E Sheline
- Dept. of Radiation Oncology, University of California, San Francisco 94143
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43
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Davis LW. Malignant glioma--a nemesis which requires clinical and basic investigation in radiation oncology. Int J Radiat Oncol Biol Phys 1989; 16:1355-65. [PMID: 2656598 DOI: 10.1016/0360-3016(89)90936-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Malignant gliomas account for 40% of all central nervous system malignancies. These are essentially localized neoplastic tumors that have defied most treatment. In spite of improved techniques, surgery is unlikely to increase survival further since true cancer operations cannot be performed. Radiation therapy has made a significant difference in outcome. Investigation in radiation oncology is essential for further improvement in the treatment of these tumors. The pattern of failure is local tumor recurrence, but the method to overcome this resistance to treatment is not clear. Radiation therapy techniques and inherent radio-resistance have been considered as possible reasons for failure. With newer imaging procedures, the extent of tumor can be more accurately defined allowing improved treatment planning. Identifying an effective treatment program is more difficult. Studies have documented the beneficial effect of radiation therapy, but the optimal dose or fractionation schedule has not been determined. Whereas some studies have reported improved survival using higher radiation doses, others have reported no benefit. More recently, studies of multiple daily fractionation schedules have been conducted using two or three daily fractions. Equally confusing results have been reported. Histologically, these tumors have necrotic areas and may be radioresistant due to hypoxic cells. Treatment methods designed to overcome the radioprotective effect of hypoxia have yielded disappointing results. The addition of hypoxic cell sensitizers has not produced the expected improvement in outcome. Studies using neutron radiation therapy report tumor control but not improved survival. Radiobiologic information is now available which may contribute to our understanding of the response of these tumors to radiation. Further laboratory and clinical investigation is required. Carefully designed clinical trials are needed to test new treatment concepts, and all radiation oncologists should be prepared to participate in such clinical studies.
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Affiliation(s)
- L W Davis
- Department of Radiation Oncology, Albert Einstein College of Medicine, Bronx, NY
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Newman HF, Bleehen NM, Ward R, Workman P. Hypoxic cell radiosensitizers in the treatment of high grade gliomas: a new direction using combined Ro 03-8799 (pimonidazole) and SR 2508 (etanidazole). Int J Radiat Oncol Biol Phys 1988; 15:677-84. [PMID: 2843488 DOI: 10.1016/0360-3016(88)90311-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The hypoxic cell radiosensitizers Ro 03-8799 (pimonidazole) and SR 2508 (etanidazole) have been evaluated for their simultaneous penetration into human brain tumors and surrounding normal tissue. Thirteen patients received a dose of 1 g of each agent, infused over a 10 minute period during neurosurgery. Samples of glioma (20), brain (10) and cerebrospinal fluid (1) were obtained at a mean time (+/- SD) of 31 +/- 18 min from the end of infusion. A 24 hr plasma time course was measured in six patients. Nitroimidazole concentrations were determined by HPLC. For a mean dose of 0.55 g/m2 of each agent, the mean tumor concentrations (+/- SD) were 17.0 +/- 12.0 micrograms/g for Ro 03-8799 and 13.5 +/- 10.9 micrograms/g for SR 2508. The tumor/plasma ratios were 279 +/- 230% and 47 +/- 34% respectively. For adjacent 'normal' brain tissue, the radiosensitizer concentrations were 29.9 +/- 13.1 micrograms/g for Ro 03-8799, and 4.0 +/- 1.7 micrograms/g for SR 2508, and the brain/plasma ratios were 430 +/- 29% and 14 +/- 8% respectively. There was a significant trend towards increasing accumulation of both agents with time, in both tumor and normal brain. Concentrations in cerebrospinal fluid were very low. Plasma pharmacokinetics for Ro 03-8799 were similar to previous experience, but for SR 2508 the terminal half-life was greater in this series by a factor of 1.3. The results confirm that Ro 03-8799 is distributed widely in the central nervous system, and demonstrate that SR 2508 can achieve high tumor concentrations when the blood-brain barrier is compromised. The concentrations achieved with the combination are indicative of a significant advantage over metronidazole, misonidazole, or either agent alone, and normalized to the therapeutic dose of 0.75 g/m2 plus 2.0 g/m2 SR 2508 are consistent with those giving additive sensitization in an in vivo mouse tumor model.
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Affiliation(s)
- H F Newman
- University Department MRC Unit of Clinical Oncology, and Radiotherapeutics, Cambridge, U.K
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45
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Abstract
The effectiveness and complications of radiation therapy for brain neoplasms are reviewed. While the available data suggest a favorable influence and outcome, randomized studies are needed to further optimize radiation therapy techniques and to integrate new therapeutic modalities.
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47
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Roberts JT, Bleehen NM, Walton MI, Workman P. A clinical phase I toxicity study of Ro 03-8799: plasma, urine, tumour and normal brain pharmacokinetics. Br J Radiol 1986; 59:107-16. [PMID: 3947818 DOI: 10.1259/0007-1285-59-698-107] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Ro 03-8799 is a lipophilic, basic 2-nitroimidazole of greater potency than misonidazole, which we have administered to 52 patients. The dose-limiting toxicity is an acute central nervous system toxicity with symptoms which include nausea, disorientation, sweating, a feeling of heat and, in one extreme case, coma. Pharmacokinetic analysis was carried out in 31 patients. The mean distribution phase half-life was 44 min and the mean elimination half-life was 6.1 h. Peak concentration was linearly related to dose over the range 0.25 g/m2 to 3 g/m2 with a mean at 1 g/m2 of 15.7 micrograms/ml. Area under the curve was also linearly related to dose and the average whole body clearance was 20.1 l/h. Urinary recovery at 24 h was 31% for the parent compound and 28% for the N-oxide metabolite. The drug is concentrated in normal brain, brain tumour and non-brain tumour to a similar extent, the respective mean tissue/plasma ratios being 381%, 329% and 355%. For a dose of 1 g/m2, tumour concentrations were 1.5 times as high as for misonidazole, and the available in vivo and in vitro sensitisation data predict as improvement of 1.8 and 3.3 times respectively.
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48
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49
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50
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Abstract
The clinical work with chemical agents to restore the radiosensitivity of hypoxic cells began in 1973 with metronidazole, misonidazole was first given in 1974. The results so far recorded of the clinical trials with misonidazole have been generally disappointing. Only in 5 of 32 studies analyzed have significant benefits been shown to suggest real advantage with the use of misonidazole. Hypoxic cells must exist in all human tumours presenting for treatment and it is, however, probable that the oxygen effect is an important one at all dose fractionation regimes employed in radiotherapy but, after conventional fractionated radiotherapy, hypoxia may be a reason for failure in only a proportion of cases. The most important factor underlying the failure of misonidazole to achieve useful advantage is undoubtedly the low radiosensitizing concentrations achievable with the permitted dose of this neurotoxic drug. New drugs are under development and some have different dose-limiting toxicity. Those showing promise at this time are the Stanford compound, SR-2508, which is being extensively studied in the United States and the Roche compound, Ro 03-8799, which is being studied in the United Kingdom. It is possible that the greatest sensitization with the greatest tolerance will be achieved by a combination of drugs.
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