Stereotactic Radiosurgery and Hypofractionated Radiotherapy for Glioblastoma

Deep learning-based overall survival prediction in patients with glioblastoma: An automatic end-to-end workflow using pre-resection basic structural multiparametric MRIs

PURPOSE

Accurate and automated early survival prediction is critical for patients with glioblastoma (GBM) as their poor prognosis requires timely treatment decision-making. To address this need, we developed a deep learning (DL)-based end-to-end workflow for GBM overall survival (OS) prediction using pre-resection basic structural multiparametric magnetic resonance images (Bas-mpMRI) with a multi-institutional public dataset and evaluated it with an independent dataset of patients on a prospective institutional clinical trial.

MATERIALS AND METHODS

The proposed end-to-end workflow includes a skull-stripping model, a GBM sub-region segmentation model and an ensemble learning-based OS prediction model. The segmentation model utilizes skull-stripped Bas-mpMRIs to segment three GBM sub-regions. The segmented GBM is fed into the contrastive learning-based OS prediction model to classify the patients into different survival groups. Our datasets include both a multi-institutional public dataset from Medical Image Computing and Computer Assisted Intervention (MICCAI) Brain Tumor Segmentation (BraTS) challenge 2020 with 235 patients, and an institutional dataset from a 5-fraction SRS clinical trial with 19 GBM patients. Each data entry consists of pre-operative Bas-mpMRIs, survival days and patient ages. Basic clinical characteristics are also available for SRS clinical trial data. The multi-institutional public dataset was used for workflow establishing (90% of data) and initial validation (10% of data). The validated workflow was then evaluated on the institutional clinical trial data.

RESULTS

Our proposed OS prediction workflow achieved an area under the curve (AUC) of 0.86 on the public dataset and 0.72 on the institutional clinical trial dataset to classify patients into 2 OS classes as long-survivors (>12 months) and short-survivors (<12 months), despite the large variation in Bas-mpMRI protocols. In addition, as part of the intermediate results, the proposed workflow can also provide detailed GBM sub-regions auto-segmentation with a whole tumor Dice score of 0.91.

CONCLUSION

Our study demonstrates the feasibility of employing this DL-based end-to-end workflow to predict the OS of patients with GBM using only the pre-resection Bas-mpMRIs. This DL-based workflow can be potentially applied to assist timely clinical decision-making.

Updates for newly diagnosed and recurrent glioblastoma: a review of recent clinical trials

PURPOSE OF REVIEW

Glioblastoma (GBM) is the most common and devastating primary malignant brain tumor. We summarize recent advances in radiotherapy, immunotherapy, and targeted therapy approaches for the treatment of newly diagnosed and recurrent glioblastoma. We also introduce ongoing clinical trials.

RECENT FINDINGS

Recent clinical trials have explored multiple novel strategies to treat GBM including the use of oncoviruses, chimeric antigen receptor (CAR) T cell therapy, vaccines, radiotherapy, and novel drug delivery techniques to improves drug penetrance across the blood brain barrier. Approaches to improve drug delivery to brain tumors have the potential to expand treatment options of existing therapies that otherwise have poor brain tumor penetrance. Immunotherapy has been of keen interest in both newly diagnosed and recurrent glioblastoma. Vaccines SurVaxM and DCVax-L have shown initial promise in phase II and III trials, respectively. CAR T cell therapy trials are in their early phases but hold promise in both newly diagnosed and recurrent glioblastoma.

SUMMARY

Although progress to improve outcomes for GBM patients has been modest, multiple novel strategies utilizing combination therapies, focused ultrasound to improve drug delivery, and novel immunotherapies are underway.

Isolation of Tumour-Derived Extracellular Vesicles From the Plasma of Dogs Affected by Intracranial Tumours Showing Heterologous and Cross-Species Tropism: A Pilot Study

Canine and human brain tumours exhibit similar incidence rates and prognoses. Recent studies have demonstrated that extracellular vesicles derived from human patients (PDEVs) can be loaded with contrast agents and exhibit tumour tropism in murine models. We showed in a previous study that gadolinium-labelled EVs derived from canine gliomas (cPDEVs) can selectively targets murine glioblastoma cells in animal models. As a further step, we investigated the potential heterologous and cross-species tumour tropism of cPDEVs with brain tumours. With the perspective of imminent clinical application as both markers and drug delivery tools, we have successfully established the isolation protocol for cPDEVs and confirmed the aseptic conditions of the procedure and therefore the sterility of the isolated EVs. To assess the functionality of cPDEVs as drug delivery tool, they were loaded with indocyanine green (ICG) and injected into murine models of cancer for in vivo fluorescence biodistribution studies. Biodistribution analysis in mice revealed that ICG-loaded cPDEVs injected into murine models of subcutaneous tumours accumulated exclusively in the neoplastic tissue, even when evaluated 24 h post-injection, thus showing the cross-species and heterologous selective tumour tropism of the nanoparticles. With these tests, we have established a safe protocol for isolating and loading autologous cPDEVs with various markers, thereby paving the way for the clinical testing phase. These significant findings suggest the potential use of cPDEVs as a theranostic tool in the management of canine brain tumours, with promising implications for translational medicine applications in the future.

Protein Immobilization on Bacterial Cellulose for Biomedical Application

New carriers for protein immobilization are objects of interest in various fields of biomedicine. Immobilization is a technique used to stabilize and provide physical support for biological micro- and macromolecules and whole cells. Special efforts have been made to develop new materials for protein immobilization that are non-toxic to both the body and the environment, inexpensive, readily available, and easy to modify. Currently, biodegradable and non-toxic polymers, including cellulose, are widely used for protein immobilization. Bacterial cellulose (BC) is a natural polymer with excellent biocompatibility, purity, high porosity, high water uptake capacity, non-immunogenicity, and ease of production and modification. BC is composed of glucose units and does not contain lignin or hemicellulose, which is an advantage allowing the avoidance of the chemical purification step before use. Recently, BC-protein composites have been developed as wound dressings, tissue engineering scaffolds, three-dimensional (3D) cell culture systems, drug delivery systems, and enzyme immobilization matrices. Proteins or peptides are often added to polymeric scaffolds to improve their biocompatibility and biological, physical-chemical, and mechanical properties. To broaden BC applications, various ex situ and in situ modifications of native BC are used to improve its properties for a specific application. In vivo studies showed that several BC-protein composites exhibited excellent biocompatibility, demonstrated prolonged treatment time, and increased the survival of animals. Today, there are several patents and commercial BC-based composites for wounds and vascular grafts. Therefore, further research on BC-protein composites has great prospects. This review focuses on the major advances in protein immobilization on BC for biomedical applications.

Predictive potentials of glycosylation-related genes in glioma prognosis and their correlation with immune infiltration

Glycosylation is currently considered to be an important hallmark of cancer. However, the characterization of glycosylation-related gene sets has not been comprehensively analyzed in glioma, and the relationship between glycosylation-related genes and glioma prognosis has not been elucidated. Here, we firstly found that the glycosylation-related differentially expressed genes in glioma patients were engaged in biological functions related to glioma progression revealed by enrichment analysis. Then seven glycosylation genes (BGN, C1GALT1C1L, GALNT13, SDC1, SERPINA1, SPTBN5 and TUBA1C) associated with glioma prognosis were screened out by consensus clustering, principal component analysis, Lasso regression, and univariate and multivariate Cox regression analysis using the TCGA-GTEx database. A glycosylation-related prognostic signature was developed and validated using CGGA database data with significantly accurate prediction on glioma prognosis, which showed better capacity to predict the prognosis of glioma patients than clinicopathological factors do. GSEA enrichment analysis based on the risk score further revealed that patients in the high-risk group were involved in immune-related pathways such as cytokine signaling, inflammatory responses, and immune regulation, as well as glycan synthesis and metabolic function. Immuno-correlation analysis revealed that a variety of immune cell infiltrations, such as Macrophage, activated dendritic cell, Regulatory T cell (Treg), and Natural killer cell, were increased in the high-risk group. Moreover, functional experiments were performed to evaluate the roles of risk genes in the cell viability and cell number of glioma U87 and U251 cells, which demonstrated that silencing BGN, SDC1, SERPINA1, TUBA1C, C1GALT1C1L and SPTBN5 could inhibit the growth and viability of glioma cells. These findings strengthened the prognostic potentials of our predictive signature in glioma. In conclusion, this prognostic model composed of 7 glycosylation-related genes distinguishes well the high-risk glioma patients, which might potentially serve as caner biomarkers for disease diagnosis and treatment.

Brain diffusion MRI biomarkers after oncology treatments

In addition to providing a measurement of the tumor's size and dimensions, magnetic resonance imaging (MRI) provides excellent noninvasive radiographic detection of tumor location. The MRI technique is an important modality that has been shown to be useful in the prognosis, diagnosis, treatment planning, and evaluation of response and recurrence in solid cancers. Diffusion-weighted imaging (DWI) is an imaging technique that quantifies water mobility. This imaging approach is good for identifying sub-voxel microstructure of tissues, correlates with tumor cellularity, and has been proven to be valuable in the early assessment of cytotoxic treatment for a variety of malignancies. Diffusion tensor imaging (DTI) is an MRI method that assesses the preferred amount of water transport inside tissues. This enables precise measurements of water diffusion, which changes according to the direction of white matter fibers, their density, and myelination. This measurement corresponds to some related variables: fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), axial diffusivity (AD), and others. DTI biomarkers can detect subtle changes in white matter microstructure and integrity following radiation therapy (RT) or chemoradiotherapy, which may have implications for cognitive function and quality of life. In our study, these indices were evaluated after brain chemoradiotherapy.

Neural and Onconeural Autoantibodies and Blood-Brain Barrier Disruption Markers in Patients Undergoing Radiotherapy for High-Grade Primary Brain Tumour

Radiotherapy (RT) plays a key role in brain tumours but can negatively impact functional outcomes and quality of life. The aim of this study was to analyse anti-neural and onconeural autoantibodies and markers of blood-brain barrier (BBB) disruption in patients with primary brain cancer undergoing RT.

MATERIALS AND METHODS

A prospective study was conducted on 45 patients with a brain tumour scheduled for intensity-modulated radiotherapy. Assessments were performed at baseline, post-RT, and at three months. We measured serum levels of BBB disruption biomarkers and anti-neural, onconeural, and organ-specific antibodies.

RESULTS

Antibodies against nucleosome antigens and neuronal surface antigens were detected in 85% and 3% of cases, respectively; anti-neural and onconeural antibodies were observed in 47% and 5.8%. In 44% patients, ≥2 antibody types were detected. No significant changes in BBB biomarkers were observed.

CONCLUSION

The findings of this study show that a humoral immune response is common in patients undergoing RT for brain cancer. This response appears to be non-organ specific but rather directed against nucleosome antigens, but onconeural antibodies were uncommon, suggesting a low risk of a neurological paraneoplastic syndrome. Our data suggested that radiotherapy may not affect BBB integrity, but larger studies are needed to better characterise the pathophysiological effects of RT.

Stereotactic Radiosurgery for Contrast-Enhancing Satellite Nodules in Recurrent Glioblastoma: A Rare Case Series From a Single Institution

Introduction Glioblastoma (GBM) is the most common malignant adult brain tumor and is invariably fatal. The standard treatment for GBM involves resection where possible, followed by chemoradiation per Stupp's protocol. We frequently use stereotactic radiosurgery (SRS) as a single-fraction treatment for small (volume ≤ 1cc) nodular recurrent GBM to the contrast-enhancing target on T1 MRI scan. In this paper, we aimed to evaluate the safety and efficacy of SRS for patients with contrast-enhancing satellite nodules in recurrent GBM. Methods This retrospective study analyzed the clinical and radiological outcomes of five patients who underwent CyberKnife (Accuray Inc., Sunnyvale, California) SRS at the institute between 2013 and 2022. Results From 96 patients receiving SRS for GBM, five (four males, one female; median age 53) had nine distinct new satellite lesions on MRI, separate from their primary tumor beds. Those nine lesions were treated with a median margin dose of 20 Gy in a single fraction. The three-, six, and 12-month local tumor control rates were 77.8%, 66.7%, and 26.7%, respectively. Median progression-free survival (PFS) was seven months, median overall survival following SRS was 10 months, and median overall survival (OS) was 35 months. Interestingly, the only lesion that did not show radiological progression was separate from the T2-fluid attenuated inversion recovery (FLAIR) signal of the main tumor. Conclusion Our SRS treatment outcomes for recurrent GBM satellite lesions are consistent with existing findings. However, in a unique case, a satellite nodule distinct from the primary tumor's T2-FLAIR signal and treated with an enlarged target volume showed promising control until the patient's demise. This observation suggests potential research avenues, given the limited strategies for 'multicentric' GBM lesions.

Patterns of Progression in Patients With Newly Diagnosed Glioblastoma Treated With 5-mm Margins in a Phase 1/2 Trial of 5-Fraction Stereotactic Radiosurgery With Concurrent and Adjuvant Temozolomide

PURPOSE

In patients with newly diagnosed glioblastoma (GBM), tumor margins of at least 20 mm are the standard of care. We sought to determine the pattern of tumor progression in patients treated with 5-fraction stereotactic radiosurgery with 5-mm margins.

METHODS AND MATERIALS

Thirty adult patients with newly diagnosed GBM were treated with 5-fraction stereotactic radiosurgery in escalated doses from 25 to 40 Gy with a 5-mm total treatment margin. Progression was scored as "in-field" if the recurrent tumor was within or contiguous with the 5-mm margin, "marginal" if between 5 and 20 mm, and "distant" if entirely occurring greater than 20 mm. As geometric patterns of progression do not reflect the biologic dose received, we calculated the minimum equi-effective dose in 2 Gy (EQD2) per day at the site of tumor recurrence. Progression was "dosimetrically in-field" if covered by a minimum EQD2 per day of 48 Gy10.

RESULTS

From 2010 to 2016, 27 patients had progressed. Progression was in-field in 17 (63%), marginal in 3 (11%), and distant in 7 (26%) patients. In the 3 patients with marginal progression, the minimum EQD2 to recurrent tumor were 48 Gy10, 56 Gy10 (both considered dosimetrically in-field), and 7 Gy10 (ie, dosimetrically out-of-field). Median overall survival was 12.1 months for in-field (95% confidence interval [CI], 8.9-17.6), 15.1 months (95% CI, 10.1 to not achieved) for marginal, and 21.4 months (95% CI, 11.2-33.5) for distant progression. Patients with radiation necrosis were less likely to have in-field progression (1 of 7; 14%) compared with those without radiation necrosis (16 of 20; 80%; P = .003); those with necrosis had a median overall survival of 27.2 months (95% CI, 11.2-48.3) compared with 11.7 months (95% CI, 8.9-17.6) for patients with no necrosis (P = .077).

CONCLUSIONS

In patients with newly diagnosed GBM treated with a 5-mm clinical target volume margin, 3 patients (11%) had marginal progression within 5 to 20 mm; only 1 patient (4%) may have dosimetrically benefitted from conventional 20-mm margins. Radiation necrosis was associated with in-field tumor control.

Charged particle therapy for high-grade gliomas in adults: a systematic review

High-grade gliomas are the most common intracranial malignancies, and their current prognosis remains poor despite standard aggressive therapy. Charged particle beams have unique physical and biological properties, especially high relative biological effectiveness (RBE) of carbon ion beam might improve the clinical treatment outcomes of malignant gliomas. We systematically reviewed the safety, efficacy, and dosimetry of carbon-ion or proton radiotherapy to treat high-grade gliomas. The protocol is detailed in the online PROSPERO database, registration No. CRD42021258495. PubMed, EMBASE, Web of Science, and The Cochrane Library databases were collected for data analysis on charged particle radiotherapy for high-grade gliomas. Until July 2022, two independent reviewers extracted data based on inclusion and exclusion criteria. Eleven articles were eligible for further analysis. Overall survival rates were marginally higher in patients with the current standard of care than those receiving concurrent intensity-modulated radiotherapy plus temozolomide. The most common side effects of carbon-ion-related therapy were grade 1-2 (such as dermatitis, headache, and alopecia). Long-term toxicities (more than three to six months) usually present as radiation necrosis; however, toxicities higher than grade 3 were not observed. Similarly, dermatitis, headache, and alopecia are among the most common acute side effects of proton therapy treatment. Despite improvement in survival rates, the method of dose-escalation using proton boost is associated with severe brain necrosis which should not be clinically underestimated. Regarding dosimetry, two studies compared proton therapy and intensity-modulated radiation therapy plans. Proton therapy plans aimed to minimize dose exposure to non-target tissues while maintaining target coverage. The use of charged-particle radiotherapy seems to be effective with acceptable adverse effects when used either alone or as a boost. The tendency of survival outcome shows that carbon ion boost is seemingly superior to proton boost. The proton beam could provide good target coverage, and it seems to reduce dose exposure to contralateral organs at risk significantly. This can potentially reduce the treatment-related dose- and volume-related side effects in long-term survivors, such as neurocognitive impairment. High-quality randomized control trials should be conducted in the future. Moreover, Systemic therapeutic options that can be paired with charged particles are necessary.

Impact of MRI resolution for Linac-based stereotactic radiosurgery

Objective

Magnetic resonance imaging (MRI) is a standard imaging modality in intracranial stereotactic radiosurgery (SRS) for defining target volumes. However, wide disparities in MRI resolution exist, which could directly impact accuracy of target delineation. Here, sequences with various MRI resolution were acquired on phantoms to evaluate the effect on volume definition and dosimetric consequence for cranial SRS.

Materials/Methods

Four T1-weighted MR sequences with increasing 3D resolution were compared, including two Spin Echo (SE) 2D acquisitions with 5mm and 3mm slice thickness (SE5mm, SE3mm) and two gradient echo 3D acquisitions (TFE, BRAVO). The voxel sizes were 0.4×0.4×5.0, 0.5×0.5×3.0, 0.9×0.9×1.25, and 0.4×0.4×0.5 mm³, respectively. Four phantoms with simulated lesions of different shape and volume (range, 0.53-25.0 cm³) were imaged, resulting in 16 total sets of MRIs. Four radiation oncologists provided contours on individual MR image set. All observer contours were compared with ground truth, defined on CT image according to the absolute dimensions of the target structure, using Dice similarity coefficient (DSC), Hausdorff distance (HD), mean distance-to-agreement (MDA), and the ratio between reconstructed and true volume (Ratio_vol ). For dosimetric consequence, SRS plans targeting observer volumes were created. The true Paddick conformity index ( C I p a d d i c k t r u e ), calculated with true target volume, was correlated with quality of observer volume.

Results

All measures of observer contours improved as increasingly higher MRI resolution was provided from SE5mm to BRAVO. The improvement in DSC, HD and MDA was statistically significant (p<0.01). Dosimetrically, C I p a d d i c k t r u e   strongly correlated with DSC of the planning observer volume (Pearson's r=0.94, p<0.00001).

Conclusions

Significant improvement in target definition and reduced inter-observer variation was observed as the MRI resolution improved, which also improved the quality of SRS plans. Results imply that high resolution 3D MR sequences should be used to minimize potential errors in target definition, and multi-slice 2D sequences should be avoided.

Robotic CyberKnife Radiosurgery for the Treatment of Choroidal and Ciliary Body Melanoma

PURPOSE

To present the results of robotic-assisted radiosurgery in choroidal and ciliary body melanomas treated at the Department of Ophthalmology of Ludwig-Maximilians-University and the European CyberKnife Center in Munich, Germany.

DESIGN

Interventional case series METHODS: This retrospective study included 594 consecutive patients referred to our clinic for the treatment of choroidal and ciliary body melanomas with robotic radiosurgery (CyberKnife) from 2005 to 2019. Eye retention, local control and disease-specific survival rates were calculated as Kaplan-Meier and actuarial estimates. The impact of prescription dose, tumor size, and ciliary body involvement was assessed by likelihood ratio tests and Cox regression.

RESULTS

Among all patients who were staged according to the TNM classification system (8th edition), 22.7% were I, 57.9% were II, 18.9% were III, and 0.5% were IV. Median apical tumor height and base diameter were 5.8 and 11.4 mm. The mean follow-up was 41.7 months. Local control after 3 and 5 years was 92.0% (95% CI = 88.2%-94.7%) and 84.3% (95% CI = 77.9%-89.0%), respectively, for 21 to 22 Gy and 86.9% (95% CI = 79.7%-91.7%) and 77.7% (95% CI = 68.5%-84.6%), respectively, when treated with 20 Gy or less. Eye retention was achieved in 89.9% and 81.0% after 3 and 5 years with 21 to 22 Gy and 85.9% and 80.0% for 20 Gy or less. Disease-specific survival rates were 93.1% (95% CI = 90.2%-95.2%) after 3 years, 89.8% (95% CI = 86.0%-92.6%) after 5 years, and 87.8% (95% CI = 82.8%-91.4%) after 7 years.

CONCLUSIONS

This is the largest series of patients treated for choroidal and ciliary body melanomas with CyberKnife. Our results reflect an improvement in the outcome of CyberKnife therapy for patients with choroidal and ciliary body melanoma treated with single-session radiosurgery in the last decade.

Cathepsins Trigger Cell Death and Regulate Radioresistance in Glioblastoma

Treatment of glioblastoma (GBM) remains very challenging, and it is particularly important to find sensitive and specific molecular targets. In this work, we reveal the relationship between the expression of cathepsins and radioresistance in GBM. We analyzed cathepsins (cathepsin B, cathepsin D, cathepsin L, and cathepsin Z/X), which are highly associated with the radioresistance of GBM by regulating different types of cell death. Cathepsins could be potential targets for GBM treatment.

Comparable Long-Term Tumor Control for Hypofractionated FLASH Versus Conventional Radiation Therapy in an Immunocompetent Rat Glioma Model

Purpose

To ensure a clinical translation of FLASH radiation therapy (FLASH-RT) for a specific tumor type, studies on tumor control and toxicity within the same biological system are needed. In this study, our objective was to evaluate tumor control and toxicity for hypofractionated FLASH-RT and conventional radiation therapy (CONV-RT) in an immunocompetent rat glioma model.

Methods and Materials

Fisher 344 rats (N = 68) were inoculated subcutaneously with NS1 glioma cells and randomized into groups (n = 9-10 per group). CONV-RT (∼8 Gy/min) or FLASH-RT (70-90 Gy/s) was administered in 3 fractions of either 8 Gy, 12.5 Gy, or 15 Gy using a 10-MeV electron beam. The maximum tumor diameter was measured weekly, and overall survival was determined until day 100. Long-term tumor control was defined as no evident tumor on day 100. Animals were evaluated for acute dermal side effects at 2 to 5 weeks after completed RT and for late dermal side effects at 3 months after initiation of treatment.

Results

Survival was significantly increased in all irradiated groups compared with control animals (P < .001). In general, irradiated tumors started to shrink at 1 week post-completed RT. In 40% (23 of 58) of the irradiated animals, long-term tumor control was achieved. Radiation-induced skin toxic effects were mild and consisted of hair loss, erythema, and dry desquamation. No severe toxic effect was observed. There was no significant difference between FLASH-RT and CONV-RT in overall survival, acute side effects, or late side effects for any of the dose levels.

Conclusions

This study shows that hypofractionated FLASH-RT results in long-term tumor control rates similar to those of CONV-RT for the treatment of large subcutaneous glioblastomas in immunocompetent rats. Neither treatment technique induced severe skin toxic effects. Consequently, no significant difference in toxicity could be resolved, suggesting that higher doses may be required to detect a FLASH sparing of skin.

Circular RNA VPS18 Promotes Glioblastoma Progression by Regulating miR-1229-3p/BCAT1 Axis

Circular RNAs (circRNAs) have been verified to play important roles in malignant tumors, including glioblastoma. The aim of this study is to explore the biological roles and underlying mechanisms of circRNA vacuolar protein sorting 18 homolog (circVPS18) in glioblastoma. A quantitative real-time polymerase chain reaction (qRT-PCR) was performed to measure the expression of circVPS18, microRNA (miR)-1299-3p, and branched-chain amino acid transaminase 1 (BCAT1). In vitro experiments were conducted using 5-ethynyl-2'-deoxyuridine (EdU), flow cytometry, transwell, and tube formation assays, respectively. Western blot was conducted to examine all protein levels. Dual-luciferase reporter assay and RNA immunoprecipitation (RIP) assay were employed to confirm the interaction between miR-1229-3p and circVPS18 or BCAT1. The murine xenograft model was established to conduct in vivo assay. CircVPS18 and BCAT1 were highly expressed while miR-1229-3p was lowly expressed in glioblastoma tissues and cells. CircVPS18 knockdown inhibited glioblastoma progression by inhibiting cell proliferation, migration, invasion, and angiogenesis, and promoting cell apoptosis. Moreover, miR-1229-3p could be targeted by circVPS18; inhibition of miR-1229-3p could invert the suppressive effect of circVPS18 knockdown on glioblastoma tumorigenesis. Furthermore, BCAT1 was a target of miR-1229-3p; functionally, BCAT1 overexpression could reverse the inhibitory effects of miR-1229-3p upregulation on glioblastoma cell malignant phenotypes. Moreover, we also verified that circVPS18A could regulate BCAT1 expression by sponging miR-1229-3p. Additionally, circVPS18 silencing also restrained tumor growth and metastasis in vivo. CircVPS18 accelerated glioblastoma progression by miR-1229-3p/BCAT1 axis, providing a potential therapeutic target for glioblastoma.

Stereotactic radiosurgery of radioresistant glioblastomas. The ways of overcoming radioresistance of hypoxic tumors

Background. Taking into account high degree of resistance of glioblastoma to radiation therapy, and also low overall survival rates of patients, it is necessary to develop improved methods of treating this pathology, in particular, complex combined treatment with radiation therapy and radiosensitizers. Purpose – to assess the effectiveness of radiosensitization of hypoxic tumors in radiosurgical treatment of glioblastomas; to increase non-recurrent and overall survival rate of patients. Materials and methods. Stereotactic radiosurgery (SRS) of glioblastoma was performed in 106 patients (average age – 53 years), 66 males (62,26%) and 40 females (37,73%). The average dose was 18 Gy in a single-fraction SRS, and 32 Gy (7 Gy per fraction) in multi-fraction SRS. The average volume tumor was 29 cm3 . The treatment group consisted of 66 patients who underwent SRS with radiosensitization. 40 patients made up the control group and underwent SRS without radiosensitization. Results. Median overall survival (MOS) was 20 months in the group with radiosensitization, whereas in the control group it was 12 months. 10-month recurrence-free period after radiosurgery was observed in 95,4% of the patients of the group with radiosensitization and in 70,6% of the patients of the control group. MOS after SRS was similar between the patients with wild-type IDH tumors and patients with tumors with IDH mutation (10,0 months and 11,0 months respectively), and also between the patients with MGMT-methylated tumors and patients with MGMT-nonmethylated tumors (11,2 and 10,2 months respectively). Among all the treated patients, in 20 of them (16,6%) side radiation effects after SRS were observed, and in 9 patients (7,5%) radiation necrosis developed in 3 to 16 months after SRS. The signs of moderate toxicity in the form of vomiting were observed in 6,6% of the patients of the subgroup with metronidazole. There were no signs of toxicity in the subgroup with nimorazole. Conclusions. Radiosensitization improves rates of overall survival by 53,3% and recurrence-free survival by 24,8 % in performing SRS of hypoxic radioresistant glioblastomas. Nimorazole and metronidazole are powerful radiosensitizers which increase radiosensitivity of tumor cells through enhancing oxygen saturation of hypoxic cells. In order to determine indications for performing SRS with radiosensitization and periods for performing an SRS session we must take into consideration the result of an oxygen test (level of oxygen saturation of the tumor), the peak of signal intensity in the zone of active tumor growth and the peak of saturation of the whole tumor volume.

The effectiveness of gamma knife radiosurgery for the management of residual high-grade gliomas: A single institutional study

High-grade gliomas (HGGs) are presently managed via surgical resection, external beam radiation therapy (EBRT), and chemotherapy. Although Gamma Knife radiosurgery (GKRS) is currently used to manage HGGs, it has not been considered standard care. This paper aims to compare the contribution of GKRS to clinical outcomes in patients in which gross total resection (GTR) cannot be achieved. We retrospectively reviewed the data of 99 patients with HGG (World Health Organization (WHO) grade III and IV) from two groups: group 1 consisted of 68 patients for which only EBRT was administered, and group 2 consisted of 31 patients for which EBRT and GKRS were administered. Patient demographic data, the extent of resection, IDH mutation, radiation dosage, progression-free survival (PFS), overall survival (OS), and follow-up time were recorded and compared across groups. The grade III/IV tumor ratio was 10/58 and 10/21 in groups 1 and 2, respectively. In group 2, PFS and OS were higher than in group 1 (P = 0.030 and 0.021). The mean follow-up time was 15.02 ± 11.8 (3-52) and 18.9 ± 98.6 (7-43) months in groups 1 and 2, respectively. In addition to the standard management of HGGs in patients without GTR, boost GKRS during the early postoperative period is beneficial for increasing PFS and OS.

Stereotactic Radiosurgery for Recurrent Glioblastoma Multiforme: A Retrospective Multi-Institutional Experience

Introduction

Glioblastoma multiforme (GBM) is the most common and lethal primary malignancy of the central nervous system. Despite standard therapy protocols, such as aggressive surgical resection, radiotherapy, and chemotherapy, GBM's aggressive nature produces low survival rates. Tumor recurrence and progression are nearly universal. Stereotactic radiosurgery (SRS) has been studied as an alternative treatment for recurrent GBM as a minimally invasive option that might prolong survival. The objective of this retrospective study was to evaluate the efficacy of SRS as a treatment modality considering overall survival (OS) in patients with GBM who had tumor recurrence and were treated with SRS in three different institutions.

Materials and methods

We retrospectively reviewed patients who received SRS for recurrent GBM between 1992 and 2020. A total of 46 patients were included in this study. We recorded age at diagnosis, the extent of surgical resection, radiation treatment, chemotherapy regimen, Karnofsky Performance Status at the time of SRS and at last follow-up, use of adjuvant chemotherapy after SRS, and response evaluation criteria in solid tumors. Primary endpoints were OS after initial diagnosis and OS from the date of the SRS procedure.

Results

Patients received SRS at a median of 10 months (range, 1 to 94 months) after their initial diagnoses. Median follow-up was seven months from the time of SRS and 22.8 months since diagnosis. The estimated median OS for all patients was nine months (range, 1 to 42 months) after SRS and 23.8 months (range, 4 to 102 months) after diagnosis. Median OS after SRS was seven months for patients treated from 1992 to 2011 and nine months for those treated from 2012 to 2020 (p = 0.008; X² = 7.008). Median OS for younger patients (i.e., those aged <50 years) was 37.1 months compared to 18.6 months for older patients (i.e., those aged >50 years; p = 0.04; X² = 3.870). Patients who received SRS after 10 months since diagnosis had a median OS of 36.2 months versus those who received SRS sooner than 10 months, who had an OS of 15 months (p = 0.004; X² = 8.145). Radiosurgery doses larger than 15 Gy correlated with a median survival of nine months versus seven months in those treated with doses <15 Gy (p = 0.01; X² = 6.756). Lastly, patients who received adjuvant bevacizumab (BEV) and or chemotherapy after SRS had a median survival of 12 months versus seven months for patients who did not receive any additional therapy after SRS (p = 0.04; X² = 4.196).

Conclusion

SRS focal recurrent GBM in selected patients may improve OS, especially when combined with adjuvant therapy such as BEV and chemotherapy. Other prognostic variables proved relevant such as patients' age, the dose delivered, and surgery-to-SRS time that translates to the time of recurrence. Our results were consistent with the published literature and added to the accumulating evidence regarding SRS in recurrent GBM; however, extensive, multi-center studies are required to make definitive recommendations on this treatment approach.

Current emerging MRI tools for radionecrosis and pseudoprogression diagnosis

PURPOSE OF REVIEW

This review aims to cover current MRI techniques for assessing treatment response in brain tumors, with a focus on radio-induced lesions.

RECENT FINDINGS

Pseudoprogression and radionecrosis are common radiological entities after brain tumor irradiation and are difficult to distinguish from real progression, with major consequences on daily patient care. To date, shortcomings of conventional MRI have been largely recognized but morphological sequences are still used in official response assessment criteria. Several complementary advanced techniques have been proposed but none of them have been validated, hampering their clinical use. Among advanced MRI, brain perfusion measures increase diagnostic accuracy, especially when added with spectroscopy and susceptibility-weighted imaging. However, lack of reproducibility, because of several hard-to-control variables, is still a major limitation for their standardization in routine protocols. Amide Proton Transfer is an emerging molecular imaging technique that promises to offer new metrics by indirectly quantifying intracellular mobile proteins and peptide concentration. Preliminary studies suggest that this noncontrast sequence may add key biomarkers in tumor evaluation, especially in posttherapeutic settings.

SUMMARY

Benefits and pitfalls of conventional and advanced imaging on posttreatment assessment are discussed and the potential added value of APT in this clinicoradiological evolving scenario is introduced.

Over-expression of lncRNA TMEM161B-AS1 promotes the malignant biological behavior of glioma cells and the resistance to temozolomide via up-regulating the expression of multiple ferroptosis-related genes by sponging hsa-miR-27a-3p

A growing body of evidence suggests that long-chain non-coding RNA (lncRNA) plays an important role in the malignant biological behavior and drug resistance of glioblastoma (GBM) cells. In this study, we analyzed the role and potential mechanism of lncRNA TMEM161B-AS1 in the malignant biological behavior of GBM cells and temozolomide (TMZ) resistance. Studies have found that FANCD2 and CD44 are significantly related to the occurrence of GBM, TMZ resistance and the survival of GBM patients. Knockdown of TMEM161B-AS1 down-regulated the expression of FANCD2 and CD44 by sponging hsa-miR-27a-3p, inhibited the proliferation, migration, invasion and promoted apoptosis, ferroptosis of U87 cells and U251 cells. Down-regulation of lncRNA TMEM161B-AS1 and/or over-expression of hsa-miR-27a-3p down-regulated the expression of FANCD2 and CD44, and inhibited the tumor growth in nude mice. These results demonstrated that the lncRNA TMEM161B-AS1-hsa-miR-27a-3p-FANCD2/CD44 signal axis regulated the malignant biological behavior of GBM and TMZ resistance. These findings were expected to provide promising therapeutic targets for the treatment of glioma.

Novel Strategies for Nanoparticle-Based Radiosensitization in Glioblastoma

Radiotherapy (RT) is one of the cornerstones in the current treatment paradigm for glioblastoma (GBM). However, little has changed in the management of GBM since the establishment of the current protocol in 2005, and the prognosis remains grim. Radioresistance is one of the hallmarks for treatment failure, and different therapeutic strategies are aimed at overcoming it. Among these strategies, nanomedicine has advantages over conventional tumor therapeutics, including improvements in drug delivery and enhanced antitumor properties. Radiosensitizing strategies using nanoparticles (NP) are actively under study and hold promise to improve the treatment response. We aim to describe the basis of nanomedicine for GBM treatment, current evidence in radiosensitization efforts using nanoparticles, and novel strategies, such as preoperative radiation, that could be synergized with nanoradiosensitizers.

Genome-wide profiling of alternative splicing in glioblastoma and their clinical value

Background

Alternative splicing (AS), one of the main post-transcriptional biological regulation mechanisms, plays a key role in the progression of glioblastoma (GBM). Systematic AS profiling in GBM is limited and urgently needed.

Methods

TCGA SpliceSeq data and the corresponding clinical data were downloaded from the TCGA data portal. Survival-related AS events were identified through Kaplan–Meier survival analysis and univariate Cox analysis. Then, splicing correlation network was constructed based on these AS events and associated splicing factors. LASSO regression followed by multivariate Cox analysis was performed to validate independent AS biomarkers and to construct a risk prediction model. Enrichment analysis was subsequently conducted to explore potential signaling pathways of these AS events.

Results

A total of 132 TCGA GBM samples and 45,610 AS events were included in our study, among which 416 survival-related AS events were identified. An AS correlation network, including 54 AS events and 94 splicing factors, was constructed, and further functional enrichment was performed. Moreover, the novel risk prediction model we constructed displayed moderate performance (the area under the curves were > 0.7) at both one, two and three years.

Conclusions

Survival-related AS events may be vital factors of both biological function and prognosis. Our findings in this study can deepen the understanding of the complicated mechanisms of AS in GBM and provide novel insights for further study. Moreover, our risk prediction model is ready for preliminary clinical applications. Further verification is required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08681-z.

Trends in physician reimbursements and procedural volumes for radiosurgery versus open surgery in brain tumor care: an analysis of Medicare data from 2009 to 2018

OBJECTIVE

Given its minimally invasive nature and effectiveness, stereotactic radiosurgery (SRS) has become a mainstay for the multimodal treatment of intracranial neoplasm. However, no studies have evaluated recent trends in the use of SRS versus those of open resection for the management of brain tumor or trends in the involvement of neurosurgeons in SRS (which is primarily delivered by radiation oncologists). Here, the authors used publicly available Medicare data from 2009 to 2018 to elucidate trends in the treatment of intracranial neoplasm and to compare reimbursements between these approaches.

METHODS

By using CPT Professional 2019, the authors identified 10 open resection and 9 SRS codes (4 for neurosurgery and 5 for radiation oncology) for the treatment of intracranial neoplasm. Medicare payments (inflation adjusted) and allowed services (number of reimbursed procedures) for each code were abstracted from the Centers for Medicare and Medicaid Services Part B National Summary Data File (2009-2018). Payments per procedure and procedures per 100,000 Medicare enrollees were analyzed with linear regression and compared with tests for equality of slopes (α = 0.05). The average payment per procedure over the study period was compared by using the 2-tailed Welsh unequal variances t-test, and more granular comparisons were conducted by using ANOVA with post hoc Tukey honestly significant difference (HSD) tests.

RESULTS

From 2009 to 2018, the number of SRS treatments per 100,000 Medicare enrollees for intracranial neoplasm increased by 3.97 cases/year (R2 = 0.99, p < 0.001), while comparable open resections decreased by 0.34 cases/year (R2 = 0.85, p < 0.001) (t16 = 7.5, p < 0.001). By 2018, 2.6 times more SRS treatments were performed per 100,000 enrollees than open resections (74.9 vs 28.7 procedures). However, neurosurgeon involvement in SRS treatment declined over the study period, from 23.4% to 11.5% of SRS treatments; simultaneously, the number of lesions treated per session increased from 1.46 to 1.84 (R2 = 0.98, p < 0.001). Overall, physician payments from 2013 to 2018 averaged $1816.08 (95% CI $1788.71-$1843.44) per SRS treatment and $1565.59 (95% CI $1535.83-$1595.34) per open resection (t10 = 15.9, p < 0.001). For neurosurgeons specifically, reimbursements averaged $1566 per open resection, but this decreased to $1031-$1198 per SRS session; comparatively, radiation oncologists were reimbursed even less (average $359-$898) per SRS session (p < 0.05 according to the Tukey HSD test for all comparisons).

CONCLUSIONS

Over a decade, the number of open resections for intracranial neoplasm in Medicare enrollees declined slightly, while the number of SRS procedures increased greatly. This latter expansion is largely attributable to radiation oncologists; meanwhile, neurosurgeons have shifted their involvement in SRS toward sessions for the management of multiple lesions.

C-methionine-PET-guided Gamma Knife radiosurgery boost as adjuvant treatment for newly diagnosed glioblastomas

Background:

The most common glial tumor is the glioblastoma, and the prognosis remains dismal despite a multimodal therapeutic approach. The role of radiosurgery for the treatment of glioblastomas has been evaluated in several studies with some benefit at the recurrent stage. We evaluate the results of the protocol administered at the Gamma Knife unit administering radiosurgery as a boost to metabolic active parts of the tumor after the patient had completed traditional external beam radiotherapy (XBRT) as part of the Stupp protocol for high-grade gliomas.

Methods:

This is a retrospective analysis of seven patients with newly diagnosed glioblastomas who were treated with Gamma Knife radiosurgery as a boost after receiving XBRT as part of the Stupp protocol. The target of radiation was determined according to the findings of the C-methionine PET scan in relation to magnetic resonance images. The primary end point of this study was to determine the progression-free survival (PFS) from the time of diagnosis.

Results:

The median age of patients was 48.8 years and the mean Karnofsky performance score was 92.8%. The median PFS was 12.4 months. No radiation adverse effects were documented.

Conclusion:

Stereotactic radiosurgery is safe to use in the upfront treatment for these patients and appears to have a beneficial role in improving the PFS. This beneficial role seems to be conditioned not only by the time the treatment is administered but also where the radiation dose is targeted to.

Concise review of stereotactic irradiation for pediatric glial neoplasms: Current concepts and future directions

Brain tumors, which are among the most common solid tumors in childhood, remain a leading cause of cancer-related mortality in pediatric population. Gliomas, which may be broadly categorized as low grade glioma and high grade glioma, account for the majority of brain tumors in children. Expectant management, surgery, radiation therapy (RT), chemotherapy, targeted therapy or combinations of these modalities may be used for management of pediatric gliomas. Several patient, tumor and treatment-related characteristics including age, lesion size, grade, location, phenotypic and genotypic features, symptomatology, predicted outcomes and toxicity profile of available therapeutic options should be considered in decision making for optimal treatment. Management of pediatric gliomas poses a formidable challenge to the physicians due to concerns about treatment induced toxicity. Adverse effects of therapy may include neurological deficits, hemiparesis, dysphagia, ataxia, spasticity, endocrine sequelae, neurocognitive and communication impairment, deterioration in quality of life, adverse socioeconomic consequences, and secondary cancers. Nevertheless, improved understanding of molecular pathology and technological advancements may pave the way for progress in management of pediatric glial neoplasms. Multidisciplinary management with close collaboration of disciplines including pediatric oncology, surgery, and radiation oncology is warranted to achieve optimal therapeutic outcomes. In the context of RT, stereotactic irradiation is a viable treatment modality for several central nervous system disorders and brain tumors. Considering the importance of minimizing adverse effects of irradiation, radiosurgery has attracted great attention for clinical applications in both adults and children. Radiosurgical applications offer great potential for improving the toxicity profile of radiation delivery by focused and precise targeting of well-defined tumors under stereotactic immobilization and image guidance. Herein, we provide a concise review of stereotactic irradiation for pediatric glial neoplasms in light of the literature.

A phase I/II trial of 5-fraction stereotactic radiosurgery with 5-mm margins with concurrent temozolomide in newly diagnosed glioblastoma: primary outcomes

BACKGROUND

We sought to determine the maximum tolerated dose (MTD) of 5-fraction stereotactic radiosurgery (SRS) with 5-mm margins delivered with concurrent temozolomide in newly diagnosed glioblastoma (GBM).

METHODS

We enrolled adult patients with newly diagnosed glioblastoma to 5 days of SRS in a 3 + 3 design on 4 escalating dose levels: 25, 30, 35, and 40 Gy. Dose limiting toxicity (DLT) was defined as Common Terminology Criteria for Adverse Events grades 3-5 acute or late CNS toxicity, including adverse radiation effect (ARE), the imaging correlate of radiation necrosis.

RESULTS

From 2010 to 2015, thirty patients were enrolled. The median age was 66 years (range, 51-86 y). The median target volume was 60 cm3 (range, 14.7-137.3 cm3). DLT occurred in 2 patients: one for posttreatment cerebral edema and progressive disease at 3 weeks (grade 4, dose 40 Gy); another patient died 1.5 weeks following SRS from postoperative complications (grade 5, dose 40 Gy). Late grades 1-2 ARE occurred in 8 patients at a median of 7.6 months (range 3.2-12.6 mo). No grades 3-5 ARE occurred. With a median follow-up of 13.8 months (range 1.7-64.4 mo), the median survival times were: progression-free survival, 8.2 months (95% CI: 4.6-10.5); overall survival, 14.8 months (95% CI: 10.9-19.9); O6-methylguanine-DNA methyltransferase hypermethylated, 19.9 months (95% CI: 10.5-33.5) versus 11.3 months (95% CI: 8.9-17.6) for no/unknown hypermethylation (P = 0.03), and 27.2 months (95% CI: 11.2-48.3) if late ARE occurred versus 11.7 months (95% CI: 8.9-17.6) for no ARE (P = 0.08).

CONCLUSIONS

The per-protocol MTD of 5-fraction SRS with 5-mm margins with concurrent temozolomide was 40 Gy in 5 fractions. ARE was limited to grades 1-2 and did not statistically impact survival.

Glioblastoma Break-in; Try Something New

Context: Glioblastoma is the most invasive brain tumor with a poor prognosis and rapid progression. The standard therapy (surgical resection, adjuvant chemotherapy, and radiotherapy) ensures survival only up to 18 months. In this article, we focus on innovative types of radiotherapy, various combinations of temozolomide with novel substances, and methods of their administration and vector delivery to tumor cells. Evidence Acquisition: For a detailed study of the various options for chemotherapy and radiotherapy, Elsevier, NCBI MedLine, Scopus, Google Scholar, Embase, Web of Science, The Cochrane Library, EMBASE, Global Health, CyberLeninka, and RSCI databases were analyzed. Results: The most available method is oral or intravenous administration of temozolomide. More efficient is the combined chemotherapy of temozolomide with innovative drugs and substances such as lomustine, histone deacetylase inhibitors, and chloroquine, as well as olaparib. These combinations improve patient survival and are effective in the treatment of resistant tumors. Compared to standard fractionated radiotherapy (60 Gy, 30 fractions, 6 weeks), hypofractionated is more effective for elderly patients due to lack of toxicity; brachytherapy reduces the risk of glioblastoma recurrence, while radiosurgery with bevacizumab is more effective against recurrent or inoperable tumors. Currently, the most effective treatment is considered to be the intranasal administration of anti-Ephrin A3 (anti-EPHA3)-modified containing temozolomide butyl ester-loaded (TBE-loaded) poly lactide-co-glycolide nanoparticles (P-NPs) coated with N-trimethylated chitosan (TMC) to overcome nasociliary clearance. Conclusions: New radiotherapeutic methods significantly increase the survival rates of glioblastoma patients. With some improvement, it may lead to the elimination of all tumor cells leaving the healthy alive. New chemotherapeutic drugs show impressive results with adjuvant temozolomide. Anti-EPHA3-modified TBE-loaded P-NPs coated with TMC have high absorption specificity and kill glioblastoma cells effectively. A new “step forward” may become a medicine of the future, which reduces the specific accumulation of nanoparticles in the lungs, but simultaneously does not affect specific absorption by tumor cells.

The efficacy of hypofractionated radiotherapy (HFRT) with concurrent and adjuvant temozolomide in newly diagnosed glioblastoma: A meta-analysis

PURPOSE

The efficacy of hypofractionated radiotherapy (HFRT) in glioblastoma (GBM) without age restrictions remains unclear. The aim of this meta-analysis is to access the survival outcomes of HFRT in these patients.

METHODS

A comprehensive electronic literature search of PubMed, Web of Science and Cochrane Library was conducted up to June 1, 2020. The main evaluation data were the overall survival (OS) rate at 12 months and 24 months and the progression-free survival (PFS) rate at 6 and 12 months. The secondary evaluation data was the incidence of radionecrosis and adverse events. The study was performed using R "meta" package.

RESULTS

Eleven studies met the inclusion criteria, which totally contained 484 participants. The 12-month OS and 24-month OS rate of HFRT in GBM were 71.3% and 34.8%, while the 6-month PFS and 12-month rate were 74.0% and 40.8%. Compared to low-BED (biological equivalent dose) schedules (<78Gy), high-BED schedules may increase survival benefit both in PFS-6 (P=0.003) and PFS-12 (P=0.011), while the difference did not show on OS. Different dose per fraction had no significant effect on both OS and PFS. Incidence of radionecrosis was 14.2%. Although the overall incidence of adverse reactions cannot be quantified, the toxicity of HFRT was acceptable.

CONCLUSIONS

Compared with survival data for standard treatment, HFRT seemed to improve overall survival and progression-free survival, while high BED schedules may future increase benefit on PFS. Meanwhile, the toxicity of HFRT was tolerable. Further randomised controlled clinical studies are needed to confirm these findings.

Stereotactic radiosurgery training patterns across neurosurgical programs: a multi-national survey

INTRODUCTION

The field of neurosurgery has witnessed a dramatic increase in the use of stereotactic radiosurgery (SRS) as a modality to treat various cranial and spinal pathologies. However, studies have consistently demonstrated disparities in SRS training. Accordingly, the present study represents a cross-sectional analysis of current SRS training and practice patterns.

METHODS

An online survey was utilized to collect data from participants. Two-sided t-tests were used in order to compare frequency tables for statistically significant differences between groups. Qualitative analyses were performed by modified thematic analyses, employing open and axial coding.

RESULTS

A total of 67 participants completed the online survey (16.4% response rate). The majority of participants were neurosurgery attendings (58.2%), followed by neurosurgery residents (25.4%). The majority of participants reported that resident exposure to SRS was gained primarily through non-SRS focused rotations (52.2%). The survey found that exposure to tumor cases was most frequent, followed by functional, vascular, and spine indications. The majority of participants (49.3%) indicate that residents are not competent or exhibit a low level of competency in SRS at the completion of neurosurgical residency. Qualitative analyses demonstrated that respondents believe SRS is a critical modality in current cranial neurosurgical care and that increased training is needed.

CONCLUSIONS

This study provides a multi-national analysis of SRS residency training and practice patterns, and aims to stimulate improvement in SRS in training worldwide. Enhanced resident training in SRS must include wider exposure to vascular, neoplastic, functional and pediatric indications for SRS.

Advances in radiotherapy and comprehensive treatment of high-grade glioma: immunotherapy and tumor-treating fields

High-grade gliomas (HGGs) are the most common primary malignant brain tumors. They have a high degree of malignancy and show invasive growth. The personal treatment plan for HGG is based on the patient's age, performance status, and degree of tumor invasion. The basic treatment plan for HGG involves tumor resection, radiotherapy (RT) with concomitant temozolomide (TMZ), and adjuvant TMZ chemotherapy. The basic radiation technology includes conventional RT, three-dimensional conformal RT, intensity-modulated RT, and stereotactic RT. As our understanding of tumor pathogenesis has deepened, so-called comprehensive treatment schemes have attracted attention. These combine RT with chemotherapy, molecular targeted therapy, immunotherapy, or tumor-treating fields. These emerging treatments are expected to improve the prospects of patients with HGG. In the present article, we review the recent advances in RT and comprehensive treatment for patients with newly diagnosed and recurrent HGG.

FAM225B Is a Prognostic lncRNA for Patients with Recurrent Glioblastoma

Objective

The overall survival of patients with recurrent glioblastoma (rGBM) is quite different, so clinical outcome prediction is necessary to guide personalized clinical treatment for patients with rGBM. The expression level of lncRNA FAM225B was analyzed to determine its prognostic value in rGBMs.

Methods

We collected 109 samples of Chinese Glioma Genome Atlas (CGGA) RNA sequencing dataset and divided into training set and validation set. Then, we analyzed the expression of FAM225B, clinical characteristics, and overall survival (OS) information. Kaplan-Meier survival analysis was used to estimate the OS distributions. The prognostic value of FAM225B in rGBMs was tested by univariate and multivariate Cox regression analyses. Moreover, we analyzed the biological processes and signaling pathways of FAM225B.

Results

We found that FAM225B was upregulated in rGBMs (P = 0.0009). The expression of FAM225B increased with the grades of gliomas (P < 0.0001). The OS of rGBMs in the low-expression group was significantly longer than that in the high-expression group (P = 0.0041). Similar result was found in the training set (P = 0.0340) and verified in the validation set (P = 0.0292). In multivariate Cox regression analysis, FAM225B was identified to be an independent prognostic factor for rGBMs (P = 0.003). Biological process and KEGG pathway analyses implied FAM225B mainly played a functional role on transcription, regulation of transcription, cell migration, focal adhesion, etc.

Conclusions

FAM225B is expected to be as a new prognostic biomarker for the identification of rGBM patients with poor outcome. And our study provided a potential therapeutic target for rGBMs.

Disentangling the therapeutic tactics in GBM: From bench to bedside and beyond

Glioblastoma multiforme (GBM) is one of the most common and malignant form of adult brain tumor with a high mortality rate and dismal prognosis. The present standard treatment comprising surgical resection followed by radiation and chemotherapy using temozolomide can broaden patient's survival to some extent. However, the advantages are not palliative due to the development of resistance to the drug and tumor recurrence following the multimodal treatment approaches due to both intra- and intertumoral heterogeneity of GBM. One of the major contributors to temozolomide resistance is O⁶ -methylguanine-DNA methyltransferase. Furthermore, deficiency of mismatch repair, base excision repair, and cytoprotective autophagy adds to temozolomide obstruction. Rising proof additionally showed that a small population of cells displaying certain stem cell markers, known as glioma stem cells, adds on to the resistance and tumor progression. Collectively, these findings necessitate the discovery of novel therapeutic avenues for treating glioblastoma. As of late, after understanding the pathophysiology and biology of GBM, some novel therapeutic discoveries, such as drug repurposing, targeted molecules, immunotherapies, antimitotic therapies, and microRNAs, have been developed as new potential treatments for glioblastoma. To help illustrate, "what are the mechanisms of resistance to temozolomide" and "what kind of alternative therapeutics can be suggested" with this fatal disease, a detailed history of these has been discussed in this review article, all with a hope to develop an effective treatment strategy for GBM.

A systematic analysis of stereotactic radiosurgery surveys for residents in neurosurgery training programs

OBJECT

The use of stereotactic radiosurgery (SRS) has increased. SRS training has not risen congruently. Neurosurgeons have conducted surveys and advocated implementation of widespread, standardized radiosurgery training. Here we analyze the SRS surveys conducted throughout the past decade.

METHODS

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic literature review. A broad search of the literature was conducted in October 2018 through the PubMed, Scopus, Embase, and Web of Science databases. This study included surveys evaluating SRS training in neurosurgery and excluded those regarding other specialties.

RESULTS

An overview of surveys showed that neurosurgery residents possess gaps in SRS knowledge and procedural competency that have persisted through the past decade. There is an overwhelming sentiment that current radiosurgery training is not adequate to prepare residents for future practice. Our recommendation is for residency programs to integrate formal SRS training electives, with a movement towards creating more options for extended SRS fellowships post-residency.

CONCLUSIONS

We present data from SRS competency and current training surveys. Although resident SRS training still lags behind other subspecialties, we see indications for growth. To keep up with the role of SRS in neurosurgery, residencies need more formalized SRS rotations.

Yttrium-90 radioembolization as a possible new treatment for brain cancer: proof of concept and safety analysis in a canine model

Purpose

To evaluate the safety, feasibility, and preliminary efficacy of yttrium-90 (⁹⁰Y) radioembolization (RE) as a minimally invasive treatment in a canine model with presumed spontaneous brain cancers.

Materials

Three healthy research dogs (R1–R3) and five patient dogs with spontaneous intra-axial brain masses (P1–P5) underwent cerebral artery RE with ⁹⁰Y glass microspheres (TheraSphere). ⁹⁰Y-RE was performed on research dogs from the unilateral internal carotid artery (ICA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) while animals with brain masses were treated from the ICA. Post-treatment ⁹⁰Y PET/CT was performed along with serial neurological exams by a veterinary neurologist. One month after treatment, research dogs were euthanized and the brains were extracted and sent for microdosimetric and histopathologic analyses. Patient dogs received post-treatment MRI at 1-, 3-, and 6-month intervals with long-term veterinary follow-up.

Results

The average absorbed dose to treated tissue in R1–R3 was 14.0, 30.9, and 73.2 Gy, respectively, with maximum doses exceeding 1000 Gy. One month after treatment, research dog pathologic analysis revealed no evidence of cortical atrophy and rare foci consistent with chronic infarcts, e.g., < 2-mm diameter. Absorbed doses to masses in P1–P5 were 45.5, 57.6, 58.1, 45.4, and 64.1 Gy while the dose to uninvolved brain tissue was 15.4, 27.6, 19.2, 16.7, and 33.3 G, respectively. Among both research and patient animals, 6 developed acute neurologic deficits following treatment. However, in all surviving dogs, the deficits were transient resolving between 7 and 33 days post-therapy. At 1 month post-therapy, patient animals showed a 24–94% reduction in mass volume with partial response in P1, P3, and P4 at 6 months post-treatment. While P2 initially showed a response, by 5 months, the mass had advanced beyond pre-treatment size, and the dog was euthanized.

Conclusion

This proof of concept demonstrates the technical feasibility and safety of ⁹⁰Y-RE in dogs, while preliminary, initial data on the efficacy of ⁹⁰Y-RE as a potential treatment for brain cancer is encouraging.

Intravital imaging reveals synergistic effect of CAR T-cells and radiation therapy in a preclinical immunocompetent glioblastoma model

Recent advances in novel immune strategies, particularly chimeric antigen receptor (CAR)-bearing T-cells, have shown limited efficacy against glioblastoma (GBM) in clinical trials. We currently have an incomplete understanding of how these emerging therapies integrate with the current standard of care, specifically radiation therapy (RT). Additionally, there is an insufficient number of preclinical studies monitoring these therapies with high spatiotemporal resolution. To address these limitations, we report the first longitudinal fluorescence-based intravital microscopy imaging of CAR T-cells within an orthotopic GBM preclinical model to illustrate the necessity of RT for complete therapeutic response. Additionally, we detail the first usage of murine-derived CAR T-cells targeting the disialoganglioside GD2 in an immunocompetent tumor model. Cell culture assays demonstrated substantial GD2 CAR T-cell-mediated killing of murine GBM cell lines SB28 and GL26 induced to overexpress GD2. Complete antitumor response in advanced syngeneic orthotopic models of GBM was achieved only when a single intravenous dose of GD2 CAR T-cells was following either sub-lethal whole-body irradiation or focal RT. Intravital microscopy imaging successfully visualized CAR T-cell homing and T-cell mediated apoptosis of tumor cells in real-time within the tumor stroma. Findings indicate that RT allows for rapid CAR T-cell extravasation from the vasculature and expansion within the tumor microenvironment, leading to a more robust and lasting immunologic response. These exciting results highlight potential opportunities to improve intravenous adoptive T-cell administration in the treatment of GBM through concurrent RT. Additionally, they emphasize the need for advancements in immunotherapeutic homing to and extravasation through the tumor microenvironment.

Pattern of disease progression following stereotactic radiosurgery in malignant glioma patients

INTRODUCTION

The clinical benefit of stereotactic radiosurgery (SRS) in the treatment of malignant glioma remains controversial. We analyzed failure patterns of malignant gliomas following SRS to identify the clinical implications of SRS against these malignancies.

MATERIALS AND METHODS

We retrospectively reviewed 58 consecutive patients who received SRS with a gamma knife for their malignant glioma from January 2013 to December 2018. A total of 51 patients were available for analysis of failure patterns. Failure patterns were defined by the recurrent tumors' spatial relation to SRS target as follows: in-field local recurrence, remote recurrence, and leptomeningeal seeding. If patients demonstrated several types of failure patterns simultaneously, we categorized them as a combined failure pattern.

RESULTS

In-field local recurrence was found in 47.1% of patients. Other types of failure patterns were as follows: remote recurrence (19.6%), leptomeningeal seeding (13.7%), and combined failure pattern (19.6%). The majority of patients (52.9%) experienced disease progression beyond the radiation field of SRS, which implies limited efficacy of local therapy against these invasive tumors. The prognosis of patients differed according to failure pattern and patients with local recurrence had better survival outcomes compared to other types of disease progression (p-value = 0.0015, log-rank test).

CONCLUSIONS

This study illustrated that SRS could not improve survival of malignant gliomas significantly even when it had some effect within radiation field. Our findings support utilizing a multidisciplinary treatment strategy to improve the prognosis of malignant gliomas and suggest that SRS is one element of that treatment strategy.

Radiation Necrosis in Intracranial Lesions

Radiation necrosis (RN) is a challenging potential complication of cranial radiation therapy. Believed to result from a complex interplay of vascular, glial, and immunologic factors, the exact mechanism of RN remains unclear. Patients who develop RN typically have a history of treatment with stereotactic radiation surgery or some other form of radiation-based therapy. The time frame for its development is variable, but it most often occurs one to three years following radiation therapy. Reported treatment doses capable of inducing radiation necrosis are variable, with higher doses per fraction more likely to induce RN. Furthermore, RN remains a challenging diagnosis for clinicians to make, as its presentation is often nonspecific and imaging studies might not clearly differentiate RN from tumor recurrence or pseudoprogression. RN is initially managed with corticosteroids, followed by bevacizumab, surgical resection, or laser interstitial thermal therapy if symptoms persist. In this review, we examine the literature regarding pathophysiology, incidence, imaging characteristics, and management strategies for radiation necrosis.

Identification of Novel lncRNA Markers in Glioblastoma Multiforme and Their Clinical Significance: A Study Based on Multiple Sequencing Data

Background

Long non-coding RNAs (lncRNAs) have been verified to have a vital role in the progression of glioblastoma multiforme (GBM). Our research was about to identify the potential lncRNAs which was closely associated with the pathogenesis and prognosis of glioblastoma multiforme.

Methods

All RNA sequence profiling data from patients with GBM were obtained from The Genotype-Tissue Expression (GTEx) and The Cancer Genome Atlas (TCGA). Differently expressed genes identified from GBM and control samples were used to construct competing endogenous RNA (ceRNA) network and perform corresponding functional enrichment analysis. Univariate Cox regression followed by lasso regression and multivariate Cox was used to validate independent lncRNA factors and construct a risk prediction model. Quantitative polymerase chain reaction (qPCR) was performed to verify the expression levels of potential lncRNA biomarkers in human GBM clinical specimens. A gene set enrichment analysis (GSEA) was subsequently conducted to explore potential signaling pathways in which critical lncRNAs may be involved. Moreover, nomogram plot was applied based on our prediction model and significant clinical covariates to visualize the prognosis of GBM patients.

Results

A total of 2023 differentially expressed genes (DEGs) including 56 lncRNAs, 1587 message RNAs (mRNAs) and 380 other RNAs were included. Based on predictive databases, 16lncRNAs, 32 microRNAs (miRNAs) and 99 mRNAs were used to construct a ceRNA network. Moreover, we performed a novel risk prediction model with 5 potential prognostic lncRNAs, in which 4 of them were newly identified in GBM, to predict the prognosis of GBM patients. Finally, a nomogram plot was constructed to illustrate the potential relationship between the prognosis of GBM and our risk prediction model and significant clinical covariates.

Conclusion

In this study, we identified 4 novel potential lncRNA biomarkers and constructed a prediction model of GBM prognosis. A simple-to-use nomogram was provided for further clinical application.

The circ_VCAN with radioresistance contributes to the carcinogenesis of glioma by regulating microRNA-1183

Circular RNAs (circRNAs), a widespread type of noncoding RNA, are produced by reverse splicing with a circular loop structure. Circ_VCAN (hsa_circ_0073237) acts as a novel circRNA, although its roles in the progression and radioresistance of glioma remain unknown.Expressions of circ_VCAN and microRNA-1183 (miR-1183) were analyzed by quantitative real-time PCR, and the functions of circ_VCAN and irradiate in glioma cell proliferation, apoptosis, migration, and invasion were assessed using cell counting kit-8, flow cytometry, Wound healing, and Transwell assays. The interaction between circ_VCAN and miR-1183 was validated dual-luciferase reporter assay.Our results revealed that circ_VCAN was significantly upregulated in radioresistant glioma tissues compared with radiosensitive tissues, and that circ_VCAN expression was negatively correlated with miR-1183 expression in glioma tissues. We also determined that circ_VCAN expression was decreased and miR-1183 expression was increased in U87 and U251 cells after irradiation. Both knockdown of circ_VCAN and treatment with miR-1183 mimics inhibited proliferation, migration, and invasion, and accelerated apoptosis of the irradiated U87 and U251 cells. In addition, luciferase reporter assays revealed that circ_VCAN might function as a sponge for miR-1183. Finally, overexpression of circ_VCAN expedited carcinogenesis and reduced glioma radiosensitivity by regulating miR-1183.Circ_VCAN serves as a potential oncogene of glioma by regulating miR-1183, and plays an essential role in the radioresistance of glioma.

Feasibility of removable balloon implant for simultaneous magnetic nanoparticle heating and HDR brachytherapy of brain tumor resection cavities

AIM

Hyperthermia (HT) has been shown to improve clinical response to radiation therapy (RT) for cancer. Synergism is dramatically enhanced if HT and RT are combined simultaneously, but appropriate technology to apply treatments together does not exist. This study investigates the feasibility of delivering HT with RT to a 5-10mm annular rim of at-risk tissue around a tumor resection cavity using a temporary thermobrachytherapy (TBT) balloon implant.

METHODS

A balloon catheter was designed to deliver radiation from High Dose Rate (HDR) brachytherapy concurrent with HT delivered by filling the balloon with magnetic nanoparticles (MNP) and immersing it in a radiofrequency magnetic field. Temperature distributions in brain around the TBT balloon were simulated with temperature dependent brain blood perfusion using numerical modeling. A magnetic induction system was constructed and used to produce rapid heating (>0.2°C/s) of MNP-filled balloons in brain tissue-equivalent phantoms by absorbing 0.5 W/ml from a 5.7 kA/m field at 133 kHz.

RESULTS

Simulated treatment plans demonstrate the ability to heat at-risk tissue around a brain tumor resection cavity between 40-48°C for 2-5cm diameter balloons. Experimental thermal dosimetry verifies the expected rapid and spherically symmetric heating of brain phantom around the MNP-filled balloon at a magnetic field strength that has proven safe in previous clinical studies.

CONCLUSIONS

These preclinical results demonstrate the feasibility of using a TBT balloon to deliver heat simultaneously with HDR brachytherapy to tumor bed around a brain tumor resection cavity, with significantly improved uniformity of heating over previous multi-catheter interstitial approaches. Considered along with results of previous clinical thermobrachytherapy trials, this new capability is expected to improve both survival and quality of life in patients with glioblastoma multiforme.

Contrast-to-Dose Relationship of Gadopiclenol, an MRI Macrocyclic Gadolinium-based Contrast Agent, Compared with Gadoterate, Gadobenate, and Gadobutrol in a Rat Brain Tumor Model

Background Detection of cerebral lesions at MRI may benefit from a chemically stable and more sensitively detected gadolinium-based contrast agent (GBCA). Gadopiclenol, a macrocyclic GBCA with at least twofold higher relaxivity, is currently undergoing clinical trials in humans. Purpose To determine the relationship between MRI contrast enhancement and the injected dose of gadopiclenol in a glioma rat model compared with those of conventional GBCA at label dose. Materials and Methods Between April and July 2012, 32 rats implanted with C6 glioma received two intravenous injections at a 24-hour interval. The injections were randomly selected among five doses of gadopiclenol (0.025, 0.05, 0.075, 0.1, and 0.2 mmol/kg) and three reference GBCAs (gadoterate meglumine, gadobutrol, and gadobenate dimeglumine) at 0.1 mmol/kg. MRI tumor enhancement was assessed on T1-weighted images before and up to 30 minutes after injection. Two blinded radiologists visually and qualitatively scored contrast enhancement, border delineation, and visualization of tumor morphology. Quantitatively, variations in contrast-to-noise ratio (ΔCNR) between tumor and contralateral parenchyma were calculated at each time point and were compared for each treatment at 5 minutes by using a mixed model after normality test. Results A total of 24 rats underwent the complete protocol (n = 5-7 per group). A linear dose-dependent ΔCNR relationship was observed between 0.025 and 0.1 mmol/kg for gadopiclenol (R ² = 0.99). No difference in ΔCNR was observed between the three reference GBCAs (P ≥ .55). Gadopiclenol resulted in twofold higher ΔCNR at 0.1 mmol/kg (P < .001 vs gadobutrol and gadoterate, P = .002 vs gadobenate) and similar ΔCNR at 0.05 mmol/kg (P = .56, P > .99, and P = .44 compared with gadobutrol, gadobenate, and gadoterate, respectively). For both readers, 0.05 mmol/kg of gadopiclenol improved contrast enhancement, border delineation, and visualization of tumor morphology (scores > 3 compared with scores between 2 and 3 for the marketed GBCA). Conclusion Gadopiclenol at 0.05 mmol/kg yielded comparable change in contrast-to-noise ratio and morphologic characterization of brain tumors compared with gadobenate, gadoterate, or gadobutrol at 0.1 mmol/kg. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Tweedle in this issue.

Efficacy and Safety of Hypofractionated Radiotherapy for the Treatment of Newly Diagnosed Glioblastoma Multiforme: A Systematic Review and Meta-Analysis

Background: Hypofractionated radiotherapy (HFR) is sometimes used in the treatment of glioblastoma multiforme (GBM). The efficacy and safety of HFR is still under investigation. The aim of this systematic review and meta-analysis was to provide a comprehensive summary of the efficacy and safety of HFR, and to compare the efficacy and safety of HFR and conventional fraction radiotherapy (CFR) for the treatment of patients with GBM, based on the results of randomized controlled trials (RCTs).

Methods: A literature search was conducted to identify Phase II and III trials o comparing the efficacy and safety of HFR and CFR. Study selection, data extraction, and quality assessment, were conducted by two independent researchers. The analysis was performed using RevMan 5.3 and Stata 12.0.

Results: Sixteen Phase II and III trials were included in the systematic review, and four RCTs were included in the meta-analysis. Participants treated with HRF and CRF had comparable overall survival (OS) (hazard ratio [HR]: 0.94, 95% confidence interval [CI]: 0.72–1.22, P = 0.64) and progression-free survival (PFS) (HR: 1.09, 95% CI: 0.60–1.95, P = 0.79), and similar rates of adverse events. However, in participants aged >70 years, those who received HFR had a higher OS than those who received CFR (HR: 0.59, 95% CI: 0.37–0.93, P = 0.02).

Conclusions: HRF is efficacious and safe for the treatment of GBM. In individuals aged >70 years, treatment with HRF is superior to CFR in terms of OS. The role of HFR in the treatment of GBM in younger individuals and those with good prognostic factors requires further research.

Blocking lncRNA MALAT1/miR-199a/ZHX1 Axis Inhibits Glioblastoma Proliferation and Progression

Zinc fingers and homeoboxes 1 (ZHX1) is a transcription repressor that has been implicated in the tumorigenesis and progression of diverse tumors. The functional role and regulating mechanism of ZHX1 has not been elucidated in glioblastoma (GBM). Previous reports have suggested that a large number of non-coding RNAs play a vital role in glioma initiation and progression. This study aimed to investigate the functional role and co-regulatory mechanisms of the metastasis-associated lung adenocarcinoma transcript-1 (MALAT1)/ microRNA-199a (miR-199a)/ZHX1 axis in GBM. We analyzed the expression of the MALAT1/miR-199a/ZHX1 axis and its correlation with patients' overall survival using two different glioma gene-expression datasets. A series of in vitro and in vivo studies including dual luciferase reporter assay, fluorescence in situ hybridization (FISH), RNA immunoprecipitation, and pull-down experiments were completed to elucidate the biological significance of the MALAT1/miR-199a/ZHX1 axis in promoting glioma proliferation and progression. Elevated ZHX1 expression correlated with poor prognosis in GBM patients, and in vitro studies demonstrated that ZHX1 attenuated GBM cell apoptosis by downregulation of pro-apoptotic protein (Bax) and upregulation of anti-apoptotic protein (Bcl-2). Furthermore, knockdown of MALAT1 inhibited GBM proliferation and progression in vitro and reduced tumor volume and prolonged survival in an orthotopic GBM murine model. Finally, we demonstrated that MALAT1 promoted ZHX1 expression via acting as a competing endogenous RNA by sponging miR-199a. The MALAT1/miR-199a/ZHX1 axis promotes GBM cell proliferation and progression in vitro and in vivo, and its expression negatively correlates with GBM patient survival. Blocking the MALAT1/miR-199a/ZHX1 axis can serve as a novel therapeutic strategy for treating GBM.

Imaging-guided precision medicine in glioblastoma patients treated with immune checkpoint modulators: research trend and future directions in the field of imaging biomarkers and artificial intelligence

Immunotherapies that employ immune checkpoint modulators (ICMs) have emerged as an effective treatment for a variety of solid cancers, as well as a paradigm shift in the treatment of cancers. Despite this breakthrough, the median survival time of glioblastoma patients has remained at about 2 years. Therefore, the safety and anti-cancer efficacy of combination therapies that include ICMs are being actively investigated. Because of the distinct mechanisms of ICMs, which restore the immune system’s anti-tumor capacity, unconventional immune-related phenomena are increasingly being reported in terms of tumor response and progression, as well as adverse events. Indeed, immunotherapy response assessments for neuro-oncology (iRANO) play a central role in guiding cancer patient management and define a “wait and see strategy” for patients treated with ICMs in monotherapy with progressive disease on MRI. This article deciphers emerging research trends to ameliorate four challenges unaddressed by the iRANO criteria: (1) patient selection, (2) identification of immune-related phenomena other than pseudoprogression (i.e., hyperprogression, the abscopal effect, immune-related adverse events), (3) response assessment in combination therapies including ICM, and (4) alternatives to MRI. To this end, our article provides a structured approach for standardized selection and reporting of imaging modalities to enable the use of precision medicine by deciphering the characteristics of the tumor and its immune environment. Emerging preclinical or clinical innovations are also discussed as future directions such as immune-specific targeting and implementation of artificial intelligence algorithms.

Hypofractionated stereotactic radiotherapy combined with chemotherapy or not in the management of recurrent malignant gliomas: A systematic review and meta-analysis

Hypofractionated stereotactic radiotherapy (HFSRT) is a common salvage treatment for recurrent malignant glioma (MG). However, it remains controversial whether the combination of HFSRT and chemotherapy could improve survival for patients with recurrent MG compared to HFSRT alone. The present systematic review and meta-analysis aims to investigate this question, and tries to determine to what extent the addition of chemotherapy to HFSRT affects survival. A systematic review was performed to analyse the survival for patients treated with HFSRT combined with chemotherapy or not. Hazard ratios (HRs) with 95% confidence intervals (CIs) for overall survival (OS) were pooled with random effects; and standard mean difference (MD) with 95% CIs for OS were pooled using the same strategy. A total of 7 studies including 388 patients with recurrent MG were eligible for our study. The OS survival of patients receiving combination therapy ranged from 8.7 to 23 months, and the median OS of patients underwent HFSRT ranged from 3.9 to 12 months. The meta-analyses resulted in the pooled HR of 0.44 (95% CI 0.30-0.65, p < 0.0001) (Cochran Q statistic 4.70, P = 0.320, I² = 14.8%) and pooled standard MD of 0.80 months (95% CI 0.41-1.18, p < 0.001) (Cochran Q statistic 10.16, p = 0.71, I² = 50.8%). The present study suggests that HFSRT + chemotherapy confers a slight survival improvement for patients with recurrent MG as compared with sole HFSRT management. To draw a more solid conclusion, greater investigation is warranted.

Dose-painted volumetric modulated arc therapy of high-grade glioma using 3,4-dihydroxy-6-[18F]fluoro-L-phenylalanine positron emission tomography

OBJECTIVE

To determine whether dose painting with volumetric modulated arc therapy for high-grade gliomas using 3,4-dihydroxy-6-[¹⁸F]fluoro-l-phenylalanine (¹⁸F-FDOPA) positron emission tomography (PET) could achieve dose-escalated coverage of biological target volumes (BTVs) without increasing the dose to cranial organs at risk (OARs).

METHODS

10 patients with high-grade gliomas underwent CT, MRI, and ¹⁸F-FDOPA PET/CT images for post-operative radiation therapy planning. Two volumetric modulated arc therapy plans were retrospectively generated for each patient: a conventional plan with 60 Gy in 30 fractions to the planning target volume delineated on MRI and a dose-escalated plan with a maximum dose of 80 Gy in 30 fractions to BTVs. BTVs were created by thresholding ¹⁸F-FDOPA PET/CT uptake using a linear quadratic model that assumed tracer uptake was linearly related to tumour cell density. The maximum doses and equivalent uniform doses of OARs were compared.

RESULTS

The median volume of the planning target volume receiving at least 95% of the prescribed dose (V _95%) was 99.6% with and 99.5% without dose painting. The median V _95% was >99.2% for BTVs. The maximum doses and equivalent uniform doses to the OARs did not differ significantly between the conventional and dose-painted plans.

CONCLUSION

Using commercially available treatment planning software, dose painting for high-grade gliomas was feasible with good BTV coverage and no significant change in the dose to OARs.

ADVANCES IN KNOWLEDGE

A novel treatment planning strategy was used to achieve dose painting for gliomas with BTVs obtained from ¹⁸F-FDOPA PET/CT using a radiobiological model.

A new glioblastoma cell trap for implantation after surgical resection

Glioblastoma (GB) is a highly infiltrative tumor, recurring, in 90% of cases, within a few centimeters of the surgical resection cavity, even with adjuvant chemo/radiotherapy. Residual GB cells left in the margins or infiltrating the brain parenchyma shelter behind the extremely fragile and sensitive brain tissue and may favor recurrence. Tools for eliminating these cells without damaging the brain microenvironment are urgently required. We propose a strategy involving the implantation, into the tumor bed after resection, of a scaffold to concentrate and trap these cells, to facilitate their destruction by targeted therapies, such as stereotactic radiosurgery. We used bacterial cellulose (BC), an easily synthesized and modifiable random nanofibrous biomaterial, to make the trap. We showed that the structure of BC membranes was ideal for trapping tumor cells and that BC implants were biocompatible with brain parenchyma. We also demonstrated the visibility of BC on magnetic resonance imaging, making it possible to follow its fate in clinical situations and to define the target volume for stereotactic radiosurgery more precisely. Furthermore, BC membranes can be loaded with chemoattractants, which were released and attracted tumor cells in vitro. This is of particular interest for trapping GB cells infiltrating tissues within a few centimeters of the resection cavity. Our data suggest that BC membranes could be a scaffold of choice for implantation after surgical resection to trap residual GB cells. STATEMENT OF SIGNIFICANCE: Glioblastoma is a highly infiltrative tumor, recurring, in 90% of cases, within a few centimeters of the surgical resection cavity, even with adjuvant chemo/radiotherapy. Residual tumor cells left in the margins or infiltrating the brain parenchyma shelter behind the extremely fragile and sensitive brain tissue and contribute to the risk of recurrence. Finding tools to eliminate these cells without damaging the brain microenvironment is a real challenge. We propose a strategy involving the implantation, into the walls of the surgical resection cavity, of a scaffold to concentrate and trap the residual tumor cells, to facilitate their destruction by targeted therapies, such as stereotactic radiosurgery.

Survival of rats bearing advanced intracerebral F 98 tumors after glutathione depletion and microbeam radiation therapy: conclusions from a pilot project

Background

Resistance to radiotherapy is frequently encountered in patients with glioblastoma multiforme. It is caused at least partially by the high glutathione content in the tumour tissue. Therefore, the administration of the glutathione synthesis inhibitor Buthionine-SR-Sulfoximine (BSO) should increase survival time.

Methods

BSO was tested in combination with an experimental synchrotron-based treatment, microbeam radiation therapy (MRT), characterized by spatially and periodically alternating microscopic dose distribution. One hundred thousand F98 glioma cells were injected into the right cerebral hemisphere of adult male Fischer rats to generate an orthotopic small animal model of a highly malignant brain tumour in a very advanced stage. Therapy was scheduled for day 13 after tumour cell implantation. At this time, 12.5% of the animals had already died from their disease.

The surviving 24 tumour-bearing animals were randomly distributed in three experimental groups: subjected to MRT alone (Group A), to MRT plus BSO (Group B) and tumour-bearing untreated controls (Group C). Thus, half of the irradiated animals received an injection of 100 μM BSO into the tumour two hours before radiotherapy.

Additional tumour-free animals, mirroring the treatment of the tumour-bearing animals, were included in the experiment. MRT was administered in bi-directional mode with arrays of quasi-parallel beams crossing at the tumour location. The width of the microbeams was ≈28 μm with a center-to-center distance of ≈400 μm, a peak dose of 350 Gy, and a valley dose of 9 Gy in the normal tissue and 18 Gy at the tumour location; thus, the peak to valley dose ratio (PVDR) was 31.

Results

After tumour-cell implantation, otherwise untreated rats had a mean survival time of 15 days. Twenty days after implantation, 62.5% of the animals receiving MRT alone (group A) and 75% of the rats given MRT + BSO (group B) were still alive. Thirty days after implantation, survival was 12.5% in Group A and 62.5% in Group B. There were no survivors on or beyond day 35 in Group A, but 25% were still alive in Group B. Thus, rats which underwent MRT with adjuvant BSO injection experienced the largest survival gain.

Conclusions

In this pilot project using an orthotopic small animal model of advanced malignant brain tumour, the injection of the glutathione inhibitor BSO with MRT significantly increased mean survival time.