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Wu A, Wu JY, Lim M. Updates in intraoperative strategies for enhancing intra-axial brain tumor control. Neuro Oncol 2022; 24:S33-S41. [PMID: 36322098 PMCID: PMC9629479 DOI: 10.1093/neuonc/noac170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
To ensure excellent postoperative clinical outcomes while preserving critical neurologic function, neurosurgeons who manage patients with intra-axial brain tumors can use intraoperative technologies and tools to achieve maximal safe resection. Neurosurgical oncology revolves around safe and optimal extent of resection, which further dictates subsequent treatment regimens and patient outcomes. Various methods can be adapted for treating both primary and secondary intra-axial brain lesions. We present a review of recent advances and published research centered on different innovative tools and techniques, including fluorescence-guided surgery, new methods of drug delivery, and minimally invasive procedural options.
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Affiliation(s)
- Adela Wu
- Department of Neurosurgery, Stanford Health Care, Stanford, California, USA
| | | | - Michael Lim
- Department of Neurosurgery, Stanford Health Care, Stanford, California, USA
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Odia Y, Gutierrez AN, Kotecha R. Surgically targeted radiation therapy (STaRT) trials for brain neoplasms: A comprehensive review. Neuro Oncol 2022; 24:S16-S24. [PMID: 36322100 PMCID: PMC9629486 DOI: 10.1093/neuonc/noac130] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The mainstays of radiation therapy include external beam radiation therapy (EBRT) and internally implanted radiation, or brachytherapy (BT), all with distinct benefits and risks in terms of local or distant tumor control and normal brain toxicities, respectively. GammaTile® Surgically Targeted Radiation Therapy (STaRT) attempts to limit the drawbacks of other BT paradigms via a permanently implanted, bioresorbable, conformable, collagen tile containing four uniform intensity radiation sources, thus preventing deleterious direct contact with the brain and optimizing interseed spacing to homogenous radiation exposure. The safety and feasibility of GammaTile® STaRT therapy was established by multiple clinical trials encompassing the spectrum of primary and secondary brain neoplasms, both recurrent and newly-diagnosed. Implantable GT tiles were FDA approved in 2018 for use in recurrent intracranial neoplasms, expanded to newly-diagnosed malignant intracranial neoplasms by 2020. The current spectrum of trials focuses on better defining the relative efficacy and safety of non-GT standard-of-care radiation strategies for intracranial brain neoplasm. We summarize the key design and eligibility criteria for open and future trials of GT therapy, including registries and randomized trials for newly-diagnosed and recurrent brain metastases as well as recurrent and newly-diagnosed glioblastoma in combination with approved therapies.
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Affiliation(s)
- Yazmin Odia
- Corresponding Author: Yazmin Odia, MD MS FAAN, Chief of Neuro-Oncology, MCI, BHSF, Associate Faculty, HWCOM, FIU, 8900 North Kendall Drive, Miami, FL 33176, USA ()
| | - Alonso N Gutierrez
- Department of Radiation-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Rupesh Kotecha
- Department of Radiation-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA,Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
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3
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Brachytherapy for central nervous system tumors. J Neurooncol 2022; 158:393-403. [PMID: 35546384 DOI: 10.1007/s11060-022-04026-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
Abstract
Radiation is a mainstay of treatment for central nervous system (CNS) tumors. Brachytherapy involves the placement of a localized/interstitial radiation source into a tumor or resection bed and has distinct advantages that can make it an attractive form of radiation when used in the appropriate setting. However, the data supporting use of brachytherapy is clouded by variability in radiation sources, techniques, delivered doses, and trial designs. The goal of this manuscript is to identify consistent themes, review the highest-level evidence and potential indications for brachytherapy in CNS tumors, as well as highlight avenues for future work. Improved understanding of the underlying biology, indications, complications, and evolving industry-academic collaborations, place brachytherapy on the brink of a resurgence.
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Gessler DJ, Neil EC, Shah R, Levine J, Shanks J, Wilke C, Reynolds M, Zhang S, Özütemiz C, Gencturk M, Folkertsma M, Bell WR, Chen L, Ferreira C, Dusenbery K, Chen CC. GammaTile® brachytherapy in the treatment of recurrent glioblastomas. Neurooncol Adv 2021; 4:vdab185. [PMID: 35088050 PMCID: PMC8788013 DOI: 10.1093/noajnl/vdab185] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background GammaTile® (GT) is a recent U.S. Food and Drug Administration (FDA) cleared brachytherapy platform. Here, we report clinical outcomes for recurrent glioblastoma patients after GT treatment following maximal safe resection. Methods We prospectively followed twenty-two consecutive Isocitrate Dehydrogenase (IDH) wild-type glioblastoma patients (6 O6-Methylguanine-DNA methyltransferase methylated (MGMTm); sixteen MGMT unmethylated (MGMTu)) who underwent maximal safe resection of recurrent tumor followed by GT placement. Results The cohort consisted of 14 second and eight third recurrences. In terms of procedural safety, there was one 30-day re-admission (4.5%) for an incisional cerebrospinal fluid leak, which resolved with lumbar drainage. No other wound complications were observed. Six patients (27.2%) declined in Karnofsky Performance Score (KPS) after surgery due to worsening existing deficits. One patient suffered a new-onset seizure postsurgery (4.5%). There was one (4.5%) 30-day mortality from intracranial hemorrhage secondary to heparinization for an ischemic limb. The mean follow-up was 733 days (range 279–1775) from the time of initial diagnosis. Six-month local control (LC6) and twelve-month local control (LC12) were 86 and 81%, respectively. Median progression-free survival (PFS) was comparable for MGMTu and MGMTm patients (~8.0 months). Median overall survival (OS) was 20.0 months for the MGMTu patients and 37.4 months for MGMTm patients. These outcomes compared favorably to data in the published literature and an independent glioblastoma cohort of comparable patients without GT treatment. Conclusions This clinical experience supports GT brachytherapy as a treatment option in a multi-modality treatment strategy for recurrent glioblastomas.
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Affiliation(s)
- Dominic J Gessler
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Elizabeth C Neil
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Rena Shah
- Department of Oncology, North Memorial Health, Robbinsdale, Minnesota, USA
| | - Joseph Levine
- Department of Oncology, North Memorial Health, Robbinsdale, Minnesota, USA
| | - James Shanks
- Department of Oncology, Fairview Cancer Care, Minneapolis, Minnesota, USA
| | - Christopher Wilke
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Margaret Reynolds
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shunqing Zhang
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Can Özütemiz
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mehmet Gencturk
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mark Folkertsma
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - W Robert Bell
- Department of Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Liam Chen
- Department of Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Clara Ferreira
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
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Wu W, Klockow JL, Zhang M, Lafortune F, Chang E, Jin L, Wu Y, Daldrup-Link HE. Glioblastoma multiforme (GBM): An overview of current therapies and mechanisms of resistance. Pharmacol Res 2021; 171:105780. [PMID: 34302977 PMCID: PMC8384724 DOI: 10.1016/j.phrs.2021.105780] [Citation(s) in RCA: 159] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 12/21/2022]
Abstract
Glioblastoma multiforme (GBM) is a WHO grade IV glioma and the most common malignant, primary brain tumor with a 5-year survival of 7.2%. Its highly infiltrative nature, genetic heterogeneity, and protection by the blood brain barrier (BBB) have posed great treatment challenges. The standard treatment for GBMs is surgical resection followed by chemoradiotherapy. The robust DNA repair and self-renewing capabilities of glioblastoma cells and glioma initiating cells (GICs), respectively, promote resistance against all current treatment modalities. Thus, durable GBM management will require the invention of innovative treatment strategies. In this review, we will describe biological and molecular targets for GBM therapy, the current status of pharmacologic therapy, prominent mechanisms of resistance, and new treatment approaches. To date, medical imaging is primarily used to determine the location, size and macroscopic morphology of GBM before, during, and after therapy. In the future, molecular and cellular imaging approaches will more dynamically monitor the expression of molecular targets and/or immune responses in the tumor, thereby enabling more immediate adaptation of tumor-tailored, targeted therapies.
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Affiliation(s)
- Wei Wu
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, CA 94305, USA
| | - Jessica L Klockow
- Department of Radiation Oncology, Stanford University, Stanford, CA 94305, USA
| | - Michael Zhang
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, CA 94305, USA; Department of Neurosurgery, Stanford University, Stanford, CA 94305, USA
| | - Famyrah Lafortune
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, CA 94305, USA
| | - Edwin Chang
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, CA 94305, USA
| | - Linchun Jin
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
| | - Yang Wu
- Department of Neuropathology, Institute of Pathology, Technical University of Munich, Munich, Bayern 81675, Germany
| | - Heike E Daldrup-Link
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, CA 94305, USA.
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Receipt of brachytherapy is an independent predictor of survival in glioblastoma in the Surveillance, Epidemiology, and End Results database. J Neurooncol 2019; 145:75-83. [PMID: 31471790 DOI: 10.1007/s11060-019-03268-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 08/21/2019] [Indexed: 12/15/2022]
Abstract
INTRODUCTION There has been a resurgence of interest in brachytherapy as a treatment for glioblastoma, with several currently ongoing clinical trials. To provide a foundation for the analysis of these trials, we analyze the Surveillance, Epidemiology, and End Results (SEER) database to determine whether receipt of brachytherapy conveys a survival benefit independent of traditional prognostic factors. MATERIALS AND METHODS We identified 60,456 glioblastoma patients, of whom 362 underwent brachytherapy. We grouped patients based on receipt of brachytherapy and compared clinical and demographic variables between groups using Student's t-test and Pearson's chi-squared test. We assessed survival using Kaplan-Meier curves and Cox proportional hazards models. RESULTS Median overall survival was 16 months in patients who received brachytherapy compared to 9 months in those who did not (log-rank p < 0.001). Patients who underwent brachytherapy tended to be younger (p < 0.001), suffered from smaller tumors (< 4 cm, p < 0.001), and were more likely to have undergone gross total resection (GTR, p < 0.001). In univariable Cox models, these variables were independently associated with improved overall survival. Additionally, improved survival was associated with known receipt of chemotherapy (HR 0.459, p < 0.001), external beam radiation (HR 0.447, p < 0.001), and brachytherapy (HR 0.637, p < 0.001). The association between brachytherapy and improved survival remained robust (HR 0.859, p = 0.031) in a multivariable model that adjusted for patient age, tumor size, tumor location, GTR, receipt of chemotherapy, and receipt of external beam radiation. CONCLUSION Our SEER analysis indicates that brachytherapy is associated with improved survival in glioblastoma after controlling for age, tumor size/location, extent of resection, chemotherapy, and external beam radiation.
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Yi S, Yang F, Jie C, Zhang G. A novel strategy to the formulation of carmustine and bioactive nanoparticles co-loaded PLGA biocomposite spheres for targeting drug delivery to glioma treatment and nursing care. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2019; 47:3438-3447. [PMID: 31411066 DOI: 10.1080/21691401.2019.1652628] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Shufeng Yi
- Department of Neurosurgery, Jinan People's Hospital, Jinan, P. R. China
| | - Fan Yang
- EICU, Jinan People's Hospital, Jinan, P. R. China
| | - Cunle Jie
- Dialysis Room, Jinan People's Hospital, Jinan, Shandong Province, P. R. China
| | - Guiqin Zhang
- Department of Science and Education, Jinan People's Hospital, Jinan, P. R. China
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Guler OC, Yıldırım BA, Önal C, Topkan E. Retrospective comparison of standard and escalated doses of radiotherapy in newly diagnosed glioblastoma patients treated with concurrent and adjuvant temozolomide. Indian J Cancer 2019; 56:59-64. [PMID: 30950447 DOI: 10.4103/ijc.ijc_128_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND To compare the efficacies of standard dose-(SDRT) and escalated dose radiotherapy (EDRT) in newly diagnosed glioblastoma (GBM) with concurrent and adjuvant temozolomide (TMZ). MATERIALS AND METHODS Outcomes of 126 newly diagnosed GBM patients who received SDRT (60 Gy, 30 fractions) or EDRT (70 Gy, 30 fractions) with concurrent plus adjuvant TMZ were retrospectively analyzed. Both groups received concurrent TMZ (75 mg/m2) during the course of RT and at least one course of adjuvant TMZ (150-200 mg/m2), thereafter. Overall survival (OS) and local progression free survival (LPFS) constituted the primary and secondary endpoints, respectively. RESULTS At median 14.2 months follow-up, 26 (20.6%) patients were alive. Median LPFS and OS were 9.2 [95% confidence interval (CI); 8.4-10.0] and 15.4 months (95% CI; 12.1-18.8), respectively, for the entire cohort. Although the median OS was numerically superior in the EDRT this difference could not reach statistical significance (22.0 vs. 14.9 months; P = 0.45), Likewise, LPFS was also (9.9 vs. 8.9 months; P = 0.89) not different between the two treatment groups. In multivariate analysis, better recursive partitioning analysis class (3-4 vs. 5; P = 0.044) and extensive surgery (gross total resection vs. subtotal resection/biopsy only; P= 0.021) were identified to associate significantly with superior OS times, irrespective of the RT protocol. CONCLUSIONS Although the current median OS of 22 months of the EDRT group is promising, no statistically significant survival advantage for EDRT was observed even in the presence of TMZ. Randomized studies with larger population sizes and available genetic markers are warranted to conclude more reliably on the fate of EDRT plus TMZ.
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Affiliation(s)
- Ozan Cem Guler
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Berna Akkuş Yıldırım
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Cem Önal
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Erkan Topkan
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
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Kim MM, Speers C, Li P, Schipper M, Junck L, Leung D, Orringer D, Heth J, Umemura Y, Spratt DE, Wahl DR, Cao Y, Lawrence TS, Tsien CI. Dose-intensified chemoradiation is associated with altered patterns of failure and favorable survival in patients with newly diagnosed glioblastoma. J Neurooncol 2019; 143:313-319. [PMID: 30977058 DOI: 10.1007/s11060-019-03166-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/08/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE We evaluated whether dose-intensified chemoradiation alters patterns of failure and is associated with favorable survival in the temozolomide era. MATERIALS AND METHODS Between 2003 and 2015, 82 patients with newly diagnosed glioblastoma were treated with 66-81 Gy in 30 fractions using conventional magnetic resonance imaging. Progression-free (PFS) and overall survival (OS) were calculated using Kaplan-Meier methods. Factors associated with improved PFS, OS, and time to progression were assessed using multivariate Cox model and linear regression. RESULTS Median follow-up was 23 months (95% CI 4-124 months). Sixty-one percent of patients underwent subtotal resection or biopsy, and 38% (10/26) of patients with available data had MGMT promoter methylation. Median PFS was 8.4 months (95% CI 7.3-11.0) and OS was 18.7 months (95% CI 13.1-25.3). Only 30 patients (44%) experienced central recurrence, 6 (9%) in-field, 16 (23.5%) marginal and 16 (23.5%) distant. On multivariate analysis, younger age (HR 0.95, 95% CI 0.93-0.97, p = 0.0001), higher performance status (HR 0.39, 95% CI 0.16-0.95, p = 0.04), gross total resection (GTR) versus biopsy (HR 0.37, 95% CI 0.16-0.85, p = 0.02) and MGMT methylation (HR 0.25, 95% CI 0.09-0.71, p = 0.009) were associated with improved OS. Only distant versus central recurrence (p = 0.03) and GTR (p = 0.02) were associated with longer time to progression. Late grade 3 neurologic toxicity was rare (6%) in patients experiencing long-term survival. CONCLUSION Dose-escalated chemoRT resulted in lower rates of central recurrence and prolonged time to progression compared to historical controls, although a significant number of central recurrences were still observed. Advanced imaging and correlative molecular studies may enable targeted treatment advances that reduce rates of in- and out-of-field progression.
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Affiliation(s)
- Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
| | - Corey Speers
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Pin Li
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Matthew Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Larry Junck
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Denise Leung
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Daniel Orringer
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Jason Heth
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Yoshie Umemura
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Daniel R Wahl
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Theodore S Lawrence
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Christina I Tsien
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO, USA
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Central Nervous System Tumors. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-97145-2_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
Most diseases and disorders of the brain require long-term therapy and a constant supply of drugs. Implantable drug-delivery systems provide long-term, sustained drug delivery in the brain. The present review discusses different type of implantable systems such as solid implants, in situ forming implants, in situ forming microparticles, depot formulations, polymeric-lipid implants, sucrose acetate isobutyrate and N-stearoyl L-alanine methyl ester systems for continuous drug delivery into brain for various brain diseases including glioblastomas, medulloblastoma, epilepsy, stroke, schizophrenia and Alzheimer's diseases. Implantable neural probes and microelectrode array systems for brain are also discussed in brief.
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Giordano FA, Brehmer S, Mürle B, Welzel G, Sperk E, Keller A, Abo-Madyan Y, Scherzinger E, Clausen S, Schneider F, Herskind C, Glas M, Seiz-Rosenhagen M, Groden C, Hänggi D, Schmiedek P, Emami B, Souhami L, Petrecca K, Wenz F. Intraoperative Radiotherapy in Newly Diagnosed Glioblastoma (INTRAGO): An Open-Label, Dose-Escalation Phase I/II Trial. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy018] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Stefanie Brehmer
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Bettina Mürle
- Department of Neuroradiology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Grit Welzel
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Anke Keller
- Clinical Trials Coordination Center of the Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Yasser Abo-Madyan
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Elisabeth Scherzinger
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Sven Clausen
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Frank Schneider
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Carsten Herskind
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Martin Glas
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Essen, Essen, Germany
| | - Marcel Seiz-Rosenhagen
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Christoph Groden
- Department of Neuroradiology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Peter Schmiedek
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Bahman Emami
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois
| | - Luis Souhami
- Division of Radiation Oncology, McGill University Health Centre, Montreal, Canada
| | - Kevin Petrecca
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, Montreal, Canada
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
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Walicke P, Abosch A, Asher A, Barker FG, Ghogawala Z, Harbaugh R, Jehi L, Kestle J, Koroshetz W, Little R, Rubin D, Valadka A, Wisniewski S, Chiocca EA. Launching Effectiveness Research to Guide Practice in Neurosurgery: A National Institute Neurological Disorders and Stroke Workshop Report. Neurosurgery 2017; 80:505-514. [PMID: 28362926 DOI: 10.1093/neuros/nyw133] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 12/12/2016] [Indexed: 11/13/2022] Open
Abstract
This workshop addressed challenges of clinical research in neurosurgery. Randomized controlled clinical trials (RCTs) have high internal validity, but often insufficiently generalize to real-world practice. Observational studies are inclusive but often lack sufficient rigor. The workshop considered possible solutions, such as (1) statistical methods for demonstrating causality using observational data; (2) characteristics required of a registry supporting effectiveness research; (3) trial designs combining advantages of observational studies and RCTs; and (4) equipoise, an identified challenge for RCTs. In the future, advances in information technology potentially could lead to creation of a massive database where clinical data from all neurosurgeons are integrated and analyzed, ending the separation of clinical research and practice and leading to a new "science of practice."
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Affiliation(s)
- Patricia Walicke
- National Institute Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Aviva Abosch
- Department of Neurosurgery, University of Colorado-Anschutz Medical Campus, Aurora, Co-lorado
| | - Anthony Asher
- Department of Neurosurgery and Neuroscience Institute, Carolinas Healthcare System, Charlotte, North Caro-lina
| | - Fred G Barker
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Zoher Ghogawala
- Alan L. and Jacqueline B. Stuart Spine Research Center, Depart-ment of Neurosurgery, Lahey Hospital and Medical Center, Burlington, Massa-chusetts; Tufts University School of Medi-cine, Boston, Massachusetts
| | - Robert Harbaugh
- Depart-ment of Neurosurgery, Penn State University, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Lara Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, Ohio
| | - John Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Walter Koroshetz
- National Institute Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | | | - Donald Rubin
- Department of Statistics, Harvard University, Cam-bridge, Massachusetts
| | - Alex Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia
| | - Stephen Wisniewski
- Depart-ment of Epidemiology, University of Pittsburg, Pittsburgh, Pennsylvania
| | - E Antonio Chiocca
- Department of Neurosurgery, Brigham and Women's Hospital, Center for Neuro- Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Puente PDL, Fettig N, Luderer MJ, Jin A, Shah S, Muz B, Kapoor V, Goddu SM, Salama NN, Tsien C, Thotala D, Shoghi K, Rogers B, Azab AK. Injectable Hydrogels for Localized Chemotherapy and Radiotherapy in Brain Tumors. J Pharm Sci 2017; 107:922-933. [PMID: 29162424 DOI: 10.1016/j.xphs.2017.10.042] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/25/2017] [Accepted: 10/26/2017] [Indexed: 11/18/2022]
Abstract
Overall survival of patients with newly diagnosed glioblastoma (GBM) remains dismal at 16 months with state-of-the-art treatment that includes surgical resection, radiation, and chemotherapy. GBM tumors are highly heterogeneous, and mechanisms for overcoming tumor resistance have not yet fully been elucidated. An injectable chitosan hydrogel capable of releasing chemotherapy (temozolomide [TMZ]) while retaining radioactive isotopes agents (iodine, [131I]) was used as a vehicle for localized radiation and chemotherapy, within the surgical cavity. Release from hydrogels loaded with TMZ or 131I was characterized in vitro and in vivo and their efficacy on tumor progression and survival on GBM tumors was also measured. The in vitro release of 131I was negligible over 42 days, whereas the TMZ was completely released over the first 48 h. 131I was completely retained in the tumor bed with negligible distribution in other tissues and that when delivered locally, the chemotherapy accumulated in the tumor at 10-fold higher concentrations than when delivered systemically. We found that the tumors were significantly decreased, and survival was improved in both treatment groups compared to the control group. Novel injectable chemo-radio-hydrogel implants may potentially improve the local control and overall outcome of aggressive, poor prognosis brain tumors.
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Affiliation(s)
- Pilar de la Puente
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110
| | - Nicole Fettig
- Radiology and Biomedical Engineering Department, Preclinical PET/CT Imaging Facility, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110
| | - Micah J Luderer
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110
| | - Abbey Jin
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110; Department of Pharmaceutical and Administrative Sciences, St. Louis College of Pharmacy, St. Louis, Missouri 63110
| | - Shruti Shah
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110
| | - Barbara Muz
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110
| | - Vaishali Kapoor
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110
| | - Sreekrishna M Goddu
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110
| | - Noha Nabil Salama
- Department of Pharmaceutical and Administrative Sciences, St. Louis College of Pharmacy, St. Louis, Missouri 63110; Department of Pharmaceutics and Industrial Pharmacy, Cairo University Faculty of Pharmacy, Cairo, Egypt
| | - Christina Tsien
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110; Siteman Cancer Center, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110
| | - Dinesh Thotala
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110; Siteman Cancer Center, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110
| | - Kooresh Shoghi
- Radiology and Biomedical Engineering Department, Preclinical PET/CT Imaging Facility, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110; Siteman Cancer Center, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110
| | - Buck Rogers
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110; Siteman Cancer Center, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110
| | - Abdel Kareem Azab
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110; Siteman Cancer Center, Washington University in Saint Louis School of Medicine, St. Louis, Missouri 63110.
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15
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Tini P, Nardone V, Pastina P, Battaglia G, Miracco C, Sebaste L, Rubino G, Cerase A, Pirtoli L. Patients Affected by Unmethylated O(6)-Methylguanine-DNA Methyltransferase Glioblastoma Undergoing Radiochemotherapy May Benefit from Moderately Dose-Escalated Radiotherapy. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9461402. [PMID: 29159183 PMCID: PMC5660746 DOI: 10.1155/2017/9461402] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/09/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE To compare the therapeutic results of two radiotherapy (RT) dose schedules in combined temozolomide- (TMZ-) RT treatment in newly diagnosed glioblastoma (GB), according to the O(6)-methylguanine-DNA methyltransferase (MGMT) methylation status. MATERIAL AND METHOD Patients received either standard (60 Gy) or moderately escalated dose (70 Gy) radiotherapy (RT) with concomitant and adjuvant TMZ between June 2006 and October 2013. We retrospectively evaluated the therapeutic effectiveness of RT schedules in terms of Overall Survival (OS) and Progression-Disease Free Survival (PDFS) analyzing the MGMT methylation status. RESULTS One hundred and seventeen patients were selected for the present analysis. Seventy-two out of the selected cases received the standard RT-TMZ course (SDRT-TMZ) whereas the remaining 45 underwent the escalated schedule (HDRT-TMZ). The analysis according to the MGMT promoter methylation status showed that, in unmethylated-MGMT GB patients, HDRT-TMZ and SDRT-TMZ groups had different median OS (p = 0,01) and PDFS (p = 0,007), that is, 8 months and 5 months for the SDRT-TMZ group and 14 months and 9 months for the HDRT-TMZ group, respectively. No difference in survival outcomes was found in methylated MGMT patients according to the two RT schedules (p = 0,12). CONCLUSIONS In our experience, unmethylated-MGMT GB patients benefited from a moderately escalated dose of RT plus TMZ.
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Affiliation(s)
- Paolo Tini
- Sbarro Health Research Organization, Temple University, Philadelphia, PA, USA
- Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
| | - Valerio Nardone
- Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
| | - Pierpaolo Pastina
- Department of Medicine, Surgery and Neurological Sciences, University of Siena, Siena, Italy
| | - Giuseppe Battaglia
- Department of Medicine, Surgery and Neurological Sciences, University of Siena, Siena, Italy
| | - Clelia Miracco
- Department of Medicine, Surgery and Neurological Sciences, University of Siena, Siena, Italy
- Unit of Pathological Anatomy, Department of Medicine, Surgery and Neurological Sciences, University of Siena, Siena, Italy
| | - Lucio Sebaste
- Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
| | - Giovanni Rubino
- Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
| | - Alfonso Cerase
- Unit of Neuroradiology, University Hospital of Siena, Siena, Italy
| | - Luigi Pirtoli
- Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
- Department of Medicine, Surgery and Neurological Sciences, University of Siena, Siena, Italy
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16
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Wernicke AG, Hirschfeld CB, Smith AW, Taube S, Yondorf MZ, Parashar B, Nedialkova L, Kulidzhanov F, Trichter S, Sabbas A, Ramakrishna R, Pannullo S, Schwartz TH. Clinical Outcomes of Large Brain Metastases Treated With Neurosurgical Resection and Intraoperative Cesium-131 Brachytherapy: Results of a Prospective Trial. Int J Radiat Oncol Biol Phys 2017; 98:1059-1068. [DOI: 10.1016/j.ijrobp.2017.03.044] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 02/27/2017] [Accepted: 03/24/2017] [Indexed: 12/16/2022]
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17
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Management of GBM: a problem of local recurrence. J Neurooncol 2017; 134:487-493. [PMID: 28378194 DOI: 10.1007/s11060-016-2347-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 12/23/2016] [Indexed: 01/22/2023]
Abstract
Forty years ago, adjuvant treatment of patients with GBM using fractionated radiotherapy following surgery was shown to substantially improve survival compared to surgery alone. However, even with the addition of temozolomide to radiotherapy, overall survival is quite limited and local failure remains a fundamental problem, despite multiple attempts to increase dose to the tumor target. This review presents the historical background and clinical rationale leading to the current standard of care consisting of 60 Gy total dose in 2 Gy fractions to the MRI-defined targets in younger, high performance status patients and more hypofractionated regimens in elderly and/or debilitated patients. Particle therapies offer the potential to increase local control while reducing dose and, potentially, long-term neurocognitive toxicity. However, improvements in systemic therapies for GBM will need to be implemented before the full benefits of improved local control can be realized.
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18
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Gzell C, Back M, Wheeler H, Bailey D, Foote M. Radiotherapy in Glioblastoma: the Past, the Present and the Future. Clin Oncol (R Coll Radiol) 2017; 29:15-25. [DOI: 10.1016/j.clon.2016.09.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 08/22/2016] [Accepted: 08/25/2016] [Indexed: 10/25/2022]
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19
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Shenouda G, Souhami L, Petrecca K, Owen S, Panet-Raymond V, Guiot MC, Corredor AG, Abdulkarim B. A Phase 2 Trial of Neoadjuvant Temozolomide Followed by Hypofractionated Accelerated Radiation Therapy With Concurrent and Adjuvant Temozolomide for Patients With Glioblastoma. Int J Radiat Oncol Biol Phys 2016; 97:487-494. [PMID: 28011051 DOI: 10.1016/j.ijrobp.2016.11.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/31/2016] [Accepted: 11/08/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE We performed a phase 2 trial of neoadjuvant temozolomide (TMZ), followed by hypofractionated accelerated radiation therapy (HART) with concurrent TMZ, and adjuvant TMZ in patients with newly diagnosed glioblastoma to determine whether neoadjuvant TMZ would safely improve outcomes in this group of patients prior to subsequent cytotoxic therapy. METHODS AND MATERIALS Adult patients with newly diagnosed glioblastoma and a Karnofsky Performance Status >60 were eligible. Neoadjuvant TMZ administration started 2 to 3 weeks from surgery at a daily dose of 75 mg/m2 for 2 weeks prior to delivery of HART (60 Gy in 20 daily fractions) with concurrent and adjuvant TMZ. The primary endpoints were feasibility and toxicity. The secondary endpoints included overall survival (OS) and progression-free survival. RESULTS Fifty patients were accrued. The median follow-up period was 44.0 months for patients at risk and 22.3 months for all 50 patients. Except for 1 patient in whom infection developed and another patient with progression during HART, all patients completed protocol therapy as planned. The median OS and progression-free survival were 22.3 months (95% confidence interval, 14.6-42.7 months) and 13.7 months (95% confidence interval, 8.0-33.3 months), respectively. The 4-year OS rates were 30.4% for the entire cohort and 53.3% and 14.0% for patients with methylated (n=21) and unmethylated (n=27) MGMT gene promoter tumors, respectively. One patient had grade 5 pancytopenia during HART, and another patient had transient grade 4 hepatotoxicity. A second surgical procedure was performed in 13 patients: 2 had intracranial infection, 3 had recurrences, 4 had recurrences and radiation-induced damage, and 4 had only radiation-induced damage. CONCLUSIONS This novel approach of neoadjuvant TMZ is associated with an encouraging favorable long-term survival with acceptable toxicity. A future comparative trial of the efficacy of this regimen is warranted.
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Affiliation(s)
- George Shenouda
- Department of Radiation Oncology, McGill University Health Centre, Montréal, Québec, Canada.
| | - Luis Souhami
- Department of Radiation Oncology, McGill University Health Centre, Montréal, Québec, Canada
| | - Kevin Petrecca
- Department of Neurosurgery, Montreal Neurological Institute, Montréal, Québec, Canada
| | - Scott Owen
- Department of Medical Oncology, McGill University Health Centre, Montréal, Québec, Canada
| | - Valerie Panet-Raymond
- Department of Radiation Oncology, McGill University Health Centre, Montréal, Québec, Canada
| | | | | | - Bassam Abdulkarim
- Department of Radiation Oncology, McGill University Health Centre, Montréal, Québec, Canada
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20
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Suchorska B, Hamisch C, Treuer H, Mahnkopf K, Lehrke RE, Kocher M, Ruge MI, Voges J. Stereotactic brachytherapy using iodine 125 seeds for the treatment of primary and recurrent anaplastic glioma WHO° III. J Neurooncol 2016; 130:123-131. [PMID: 27422129 DOI: 10.1007/s11060-016-2214-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 07/06/2016] [Indexed: 10/21/2022]
Abstract
The current study analyzed the outcome after stereotactic brachytherapy (SBT) using iodine-125 seeds in anaplastic astrocytoma, oligoastrocytoma or oligodendroglioma not suitable for resection. Out of 223 patients harbouring a malignant glioma treated according to a prospective protocol, 172 patients were selected who received SBT to treat a WHO grade III de-novo/residual tumor (n = 99) or a tumor recurrence after multimodal treatment (n = 73). We assessed progression free survival (PFS), overall survival (OS), radiological and clinical outcome and determined prognostic factors using univariate and multivariate regression analyses. The median follow-up time was 38 months. Median OS and median PFS was 28.9 and 21.4 months in the de-novo group vs. 49.4 and 32.6 months in the recurrence group. Recurrent tumors had more frequently (p = 0.01) an oligodendroglial-component compared to de novo tumors. According to cohort-specific univariate analyses KPS at SBT had a significant (p = 0.008) impact on OS in the de-novo group. In the recurrence group, (Cox regression analysis) OS was significantly associated with histology subtype (oligoastro-/oligodendroglioma vs. astrocytoma, p = 0.043). Transient and permanent morbidity (~1 %) was low. For patients unable to undergo surgery due to eloquent tumour location or reduced general condition SBT is an effective treatment option, which does not foreclose additional therapeutic interventions.
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Affiliation(s)
- B Suchorska
- Department of Stereotactic Neurosurgery, Otto-von-Guericke University of Magdeburg, Magdeburg, Germany.,Department of Neurosurgery, Ludwig Maximilians University of Munich, Munich, Germany
| | - C Hamisch
- Department of Stereotaxy and Functional Neurosurgery, Centre of Neurosurgery, University of Cologne, Cologne, Germany.,Department of Neurosurgery, Centre of Neurosurgery, University of Cologne, Cologne, Germany
| | - H Treuer
- Department of Stereotaxy and Functional Neurosurgery, Centre of Neurosurgery, University of Cologne, Cologne, Germany
| | - K Mahnkopf
- Department of Stereotactic Neurosurgery, Otto-von-Guericke University of Magdeburg, Magdeburg, Germany
| | - R E Lehrke
- Department of Stereotactic Neurosurgery, St. Barbara Hospital, Hamm, Germany
| | - M Kocher
- Department of Radiation Oncology, University Hospital of Cologne, Cologne, Germany
| | - M I Ruge
- Department of Stereotaxy and Functional Neurosurgery, Centre of Neurosurgery, University of Cologne, Cologne, Germany
| | - J Voges
- Department of Stereotactic Neurosurgery, Otto-von-Guericke University of Magdeburg, Magdeburg, Germany. .,Leibniz Institute for Neurobiology, Magdeburg, Germany.
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21
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The role of brachytherapy in the treatment of glioblastoma multiforme. Neurosurg Rev 2016; 40:195-211. [PMID: 27180560 DOI: 10.1007/s10143-016-0727-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 03/06/2016] [Accepted: 03/07/2016] [Indexed: 12/12/2022]
Abstract
Brachytherapy (BT) for glioblastoma multiforme (GBM) involves the use of radioactive isotopes to deliver ionizing radiation directly into the tumor bed. Its application as a means to prolong survival in GBM patients over the past few decades has come with variable success. The objective of this review is to describe the utility of BT in GBM, and to report the outcomes and adverse events associated with its use in different multimodal treatment approaches. A search of the literature was conducted using the PubMed database. The most recent search was performed in September 2015. Thirty-two series involving 1571 patients were included in our review. The longest median overall survival (MOS) following BT for newly diagnosed GBM reached 28.5 months. Overall, 1-, 2-, and 3-year survival rates were 46-89 %, 20-57 %, and 14-27 %. For recurrent GBM, the longest reported MOS after BT was 15.9 months. One-, 2- and 3-year survival rates for recurrent GBM were 10-66 %, 3-23 %, and 9-15 %. Adverse events were reported in 27 % of patients. Reoperation for radiation necrosis occurred in 4 and 27 % of patients following low- and high-dose rate BT, respectively. BT is a feasible option for extending survival in carefully selected GBM patients. As patient outcomes and overall survival improve with more aggressive radiotherapy, so does the risk of radiation-related complications. The most effective use of BT is likely as a part of multimodal treatment with other novel therapies.
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22
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Survival in glioblastoma: a review on the impact of treatment modalities. Clin Transl Oncol 2016; 18:1062-1071. [PMID: 26960561 DOI: 10.1007/s12094-016-1497-x] [Citation(s) in RCA: 413] [Impact Index Per Article: 51.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/27/2016] [Indexed: 12/17/2022]
Abstract
Glioblastoma (GBM) is the most common and lethal tumor of the central nervous system. The natural history of treated GBM remains very poor with 5-year survival rates of 5 %. Survival has not significantly improved over the last decades. Currently, the best that can be offered is a modest 14-month overall median survival in patients undergoing maximum safe resection plus adjuvant chemoradiotherapy. Prognostic factors involved in survival include age, performance status, grade, specific markers (MGMT methylation, mutation of IDH1, IDH2 or TERT, 1p19q codeletion, overexpression of EGFR, etc.) and, likely, the extent of resection. Certain adjuncts to surgery, especially cortical mapping and 5-ALA fluorescence, favor higher rates of gross total resection with apparent positive impact on survival. Recurrent tumors can be offered re-intervention, participation in clinical trials, anti-angiogenic agent or local electric field therapy, without an evident impact on survival. Molecular-targeted therapies, immunotherapy and gene therapy are promising tools currently under research.
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23
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Barker FG. Editorial: Randomized clinical trials and neurosurgery. J Neurosurg 2016; 124:552-6; discussion 556-7. [DOI: 10.3171/2015.2.jns142960] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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24
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Hau E, Shen H, Clark C, Graham PH, Koh ES, L McDonald K. The evolving roles and controversies of radiotherapy in the treatment of glioblastoma. J Med Radiat Sci 2016; 63:114-23. [PMID: 27350891 PMCID: PMC4914819 DOI: 10.1002/jmrs.149] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 08/25/2015] [Accepted: 10/06/2015] [Indexed: 12/22/2022] Open
Abstract
Numerous randomised controlled trials have demonstrated the benefit of radiation therapy in patients with newly diagnosed glioblastoma and it has been the cornerstone of treatment for decades. The aims of this review are to (1) Briefly outline the historical studies which resulted in radiation being the current standard of care as used in the Stupp et al. trial (2) Discuss the evolving role of radiation therapy in the management of elderly patients (3) Review the current evidence and ongoing studies of radiation use in the recurrent/salvage setting and (4) Discuss the continuing controversies of volume delineation in the planning of radiation delivery.
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Affiliation(s)
- Eric Hau
- Cure Brain Cancer Foundation Biomarkers and Translational Research Laboratory Prince of Wales Clinical School UNSW Sydney New South Wales Australia; Cancer Care Centre St George Hospital Sydney New South Wales Australia
| | - Han Shen
- Targeted Therapies Group Children's Cancer Institute Australia Lowy Cancer Research Centre Sydney New South Wales Australia
| | - Catherine Clark
- Cancer Care Centre St George Hospital Sydney New South Wales Australia
| | - Peter H Graham
- St George Cancer Care Centre Kogarah Sydney New South Wales Australia
| | - Eng-Siew Koh
- Liverpool Cancer Care Centre Liverpool Hospital Sydney New South Wales Australia; University of New South Wales Sydney New South Wales Australia
| | - Kerrie L McDonald
- Cure Brain Cancer Foundation Biomarkers and Translational Research Laboratory Prince of Wales Clinical School UNSW Sydney New South Wales Australia
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Abstract
Although resection remains the mainstay in the treatment of gliomas, microscopically complete resection of most central nervous system tumors remains challenging, and is, in fact, rarely accomplished. Considering their invasive nature, gross total resections to clearly negative margins often do or would require removal or transection of functional brain, with likely serious neurologic deficits. Consequently, radiotherapy has emerged as an indispensable component of therapy. It is delivered primarily by external-beam radiotherapy or brachytherapy techniques. Herein, we present the biologic principles, techniques, and applications of radiotherapy in glioma treatment today.
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Affiliation(s)
- James W Snider
- Department of Radiation Oncology, Marlene and Stewart Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Minesh Mehta
- Department of Radiation Oncology, Marlene and Stewart Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, MD, USA.
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26
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Farzin M, Molls M, Astner S, Rondak IC, Oechsner M. Simultaneous integrated vs. sequential boost in VMAT radiotherapy of high-grade gliomas. Strahlenther Onkol 2015; 191:945-52. [PMID: 26340939 DOI: 10.1007/s00066-015-0888-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 08/07/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND In 20 patients with high-grade gliomas, we compared two methods of planning for volumetric-modulated arc therapy (VMAT): simultaneous integrated boost (SIB) vs. sequential boost (SEB). The investigation focused on the analysis of dose distributions in the target volumes and the organs at risk (OARs). METHOD After contouring the target volumes [planning target volumes (PTVs) and boost volumes (BVs)] and OARs, SIB planning and SEB planning were performed. The SEB method consisted of two plans: in the first plan the PTV received 50 Gy in 25 fractions with a 2-Gy dose per fraction. In the second plan the BV received 10 Gy in 5 fractions with a dose per fraction of 2 Gy. The doses of both plans were summed up to show the total doses delivered. In the SIB method the PTV received 54 Gy in 30 fractions with a dose per fraction of 1.8 Gy, while the BV received 60 Gy in the same fraction number but with a dose per fraction of 2 Gy. RESULTS All of the OARs showed higher doses (Dmax and Dmean) in the SEB method when compared with the SIB technique. The differences between the two methods were statistically significant in almost all of the OARs. Analysing the total doses of the target volumes we found dose distributions with similar homogeneities and comparable total doses. CONCLUSION Our analysis shows that the SIB method offers advantages over the SEB method in terms of sparing OARs.
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Affiliation(s)
- Mostafa Farzin
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany. .,Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Science, Tehran, Iran.
| | - Michael Molls
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany.
| | - Sabrina Astner
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany.
| | - Ina-Christine Rondak
- Institut für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany.
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27
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Hasan S, Chen E, Lanciano R, Yang J, Hanlon A, Lamond J, Arrigo S, Ding W, Mikhail M, Ghaneie A, Brady L. Salvage Fractionated Stereotactic Radiotherapy with or without Chemotherapy and Immunotherapy for Recurrent Glioblastoma Multiforme: A Single Institution Experience. Front Oncol 2015; 5:106. [PMID: 26029663 PMCID: PMC4432688 DOI: 10.3389/fonc.2015.00106] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 04/21/2015] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The current standard of care for salvage treatment of glioblastoma multiforme (GBM) is gross total resection and adjuvant chemoradiation for operable patients. Limited evidence exists to suggest that any particular treatment modality improves survival for recurrent GBM, especially if inoperable. We report our experience with fractionated stereotactic radiotherapy (fSRT) with and without chemo/immunotherapy, identifying prognostic factors associated with prolonged survival. METHODS From 2007 to 2014, 19 patients between 29 and 78 years old (median 55) with recurrent GBM following resection and chemoradiation for their initial tumor, received 18-35 Gy (median 25) in three to five fractions via CyberKnife fSRT. Clinical target volume (CTV) ranged from 0.9 to 152 cc. Sixteen patients received adjuvant systemic therapy with bevacizumab (BEV), temozolomide (TMZ), anti-epidermal growth factor receptor (125)I-mAb 425, or some combination thereof. RESULTS The median overall survival (OS) from date of recurrence was 8 months (2.5-61) and 5.3 months (0.6-58) from the end of fSRT. The OS at 6 and 12 months was 47 and 32%, respectively. Three of 19 patients were alive at the time of this review at 20, 49, and 58 months from completion of fSRT. Hazard ratios for survival indicated that patients with a frontal lobe tumor, adjuvant treatment with either BEV or TMZ, time to first recurrence >16 months, CTV <36 cc, recursive partitioning analysis <5, and Eastern Cooperative Oncology Group performance status <2 were all associated with improved survival (P < 0.05). There was no evidence of radionecrosis for any patient. CONCLUSION Radiation Therapy Oncology Group (RTOG) 1205 will establish the role of re-irradiation for recurrent GBM, however our study suggests that CyberKnife with chemotherapy can be safely delivered, and is most effective in patients with smaller frontal lobe tumors, good performance status, or long interval from diagnosis.
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Affiliation(s)
- Shaakir Hasan
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA
| | - Eda Chen
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA
| | - Rachelle Lanciano
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| | - Jun Yang
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| | - Alex Hanlon
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Nursing, University of Pennsylvania , Philadelphia, PA , USA
| | - John Lamond
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| | - Stephen Arrigo
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| | - William Ding
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
| | - Michael Mikhail
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA
| | - Arezoo Ghaneie
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA
| | - Luther Brady
- Philadelphia CyberKnife/Crozer Keystone Healthcare System , Philadelphia, PA , USA ; School of Medicine, Drexel University , Philadelphia, PA , USA
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Bir SC, Connor DE, Ambekar S, Wilden JA, Nanda A. Factors predictive of improved overall survival following stereotactic radiosurgery for recurrent glioblastoma. Neurosurg Rev 2015; 38:705-13. [PMID: 25864406 DOI: 10.1007/s10143-015-0632-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 01/23/2015] [Accepted: 01/25/2015] [Indexed: 10/23/2022]
Abstract
The currently accepted standard of care for primary glioblastoma (GBM) consists of maximal surgical resection followed by fractionated external beam radiotherapy (EBRT) with concomitant temozolomide chemotherapy. The role of stereotactic radiosurgery (SRS) in the treatment of GBM is not well defined, but SRS has typically been applied as a salvage therapy for GBM recurrence. This paper reviews our single institution experience using gamma knife radiosurgery (GKRS) for the treatment of GBM. Thirty-six patients treated with GKRS for pathologically proven GBM at LSU Health in Shreveport from February 2000 to December 2013 were identified and analyzed. Patient characteristics, treatment variables, and survival were correlated. Seven patients received GKRS in the immediate postoperative period for an average tumor volume of 10.9 cm(3), and 29 patients were treated for a recurrent average tumor volume of 11.4 cm(3) with a prescribed dose ranging from 10 to 20 Gy at the 50 % isodose line. The median overall survival was significantly higher in recurrence group compared to up-front group [7.9 months (0.77-32.1 months) vs. 3.5 months (range 0.23-11.7 months) respectively, (p = 0.018)]. The predictive factors for improved survival in the patients with GBM were as follows: Karnofsky performance scale (KPS) > 70 (p = 0.026), age ≤ 50 years (p = 0.006), absence of neurodeficits (p = 0.01), and initial postoperative treatment with EBRT (p = 0.042). Adjuvant therapy with GKRS following GBM recurrence demonstrates statistical superiority over immediate postoperative boost therapy.
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Affiliation(s)
- Shyamal C Bir
- Department of Neurosurgery, LSU Health-Shreveport, 1501 Kings Highway, Shreveport, LA, 71130-3932, USA
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Man J, Shoemake JD, Ma T, Rizzo AE, Godley AR, Wu Q, Mohammadi AM, Bao S, Rich JN, Yu JS. Hyperthermia Sensitizes Glioma Stem-like Cells to Radiation by Inhibiting AKT Signaling. Cancer Res 2015; 75:1760-9. [PMID: 25712125 DOI: 10.1158/0008-5472.can-14-3621] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 02/11/2015] [Indexed: 12/21/2022]
Abstract
Glioma stem-like cells (GSC) are a subpopulation of cells in tumors that are believed to mediate self-renewal and relapse in glioblastoma (GBM), the most deadly form of primary brain cancer. In radiation oncology, hyperthermia is known to radiosensitize cells, and it is reemerging as a treatment option for patients with GBM. In this study, we investigated the mechanisms of hyperthermic radiosensitization in GSCs by a phospho-kinase array that revealed the survival kinase AKT as a critical sensitization determinant. GSCs treated with radiation alone exhibited increased AKT activation, but the addition of hyperthermia before radiotherapy reduced AKT activation and impaired GSC proliferation. Introduction of constitutively active AKT in GSCs compromised hyperthermic radiosensitization. Pharmacologic inhibition of PI3K further enhanced the radiosensitizing effects of hyperthermia. In a preclinical orthotopic transplant model of human GBM, thermoradiotherapy reduced pS6 levels, delayed tumor growth, and extended animal survival. Together, our results offer a preclinical proof-of-concept for further evaluation of combined hyperthermia and radiation for GBM treatment.
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Affiliation(s)
- Jianghong Man
- Department of Stem Cell Biology and Regenerative Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Jocelyn D Shoemake
- Department of Stem Cell Biology and Regenerative Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Tuopu Ma
- Department of Stem Cell Biology and Regenerative Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Anthony E Rizzo
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Andrew R Godley
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Qiulian Wu
- Department of Stem Cell Biology and Regenerative Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | - Shideng Bao
- Department of Stem Cell Biology and Regenerative Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Jeremy N Rich
- Department of Stem Cell Biology and Regenerative Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Jennifer S Yu
- Department of Stem Cell Biology and Regenerative Medicine, Cleveland Clinic, Cleveland, Ohio. Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio.
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30
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Niranjan A, Kano H, Iyer A, Kondziolka D, Flickinger JC, Lunsford LD. Role of adjuvant or salvage radiosurgery in the management of unresected residual or progressive glioblastoma multiforme in the pre-bevacizumab era. J Neurosurg 2015; 122:757-65. [PMID: 25594327 DOI: 10.3171/2014.11.jns13295] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT After initial standard of care management of glioblastoma multiforme (GBM), relatively few proven options remain for patients with unresected progressive tumor. Numerous reports describe the value of radiosurgery, yet this modality appears to remain underutilized. The authors analyzed the outcomes of early adjuvant stereotactic radiosurgery (SRS) for unresected tumor or later salvage SRS for progressive GBM. Radiosurgery was performed as part of the multimodality management and was combined with other therapies. Patients continued to receive additional chemotherapy after SRS and prior to progression being documented. In this retrospective analysis, the authors evaluated factors that affected patient overall survival (OS) and progression-free survival. METHODS Between 1987 and 2008 the authors performed Gamma Knife SRS in 297 patients with histologically proven GBMs. All patients had received prior fractionated radiation therapy, and 66% had undergone one or more chemotherapy regimens. Ninety-six patients with deep-seated unresectable GBMs underwent biopsy only. Of those in whom excision had been possible, resection was considered to be gross total in 68 and subtotal in 133. The median patient age was 58 years (range 23-89 years) and the median tumor volume was 14 cm(3) (range 0.26-84.2 cm(3)). The median prescription dose delivered to the imaging-defined tumor margin was 15 Gy (range 9-25 Gy). The median follow-up duration was 8.6 months (range 1.1-173 months). Cox regression models were used to analyze survival outcomes. Variables examined included age, residual versus recurrent tumor, prior chemotherapy, time to first recurrence, SRS dose, and gross tumor volume. RESULTS The median survival times after radiosurgery and after diagnosis were 9.03 and 18.1 months, respectively. The 1-year and 2-year OS after SRS were 37.9% and 16.7%, respectively. The 1-year and 2-year OS after diagnosis were 76.2% and 30.8%, respectively. Using multivariate analysis, factors associated with improved OS after diagnosis were younger age (< 60 years) at diagnosis (p < 0.0001), tumor volume < 14 cm(3) (p < 0.001), use of prior chemotherapy (p = 0.001), and radiosurgery at the time of recurrence (p < 0.0001). Multivariate analysis showed that younger age (p < 0.0001) and smaller tumor volume (< 14 cm(3)) (p = 0.001) were significantly associated with increased OS after SRS. Adverse radiation effects were seen in 69 patients (23%). Fifty-eight patients (19.5%) underwent additional resection after SRS. The median survivals after diagnosis for recursive partitioning analysis Classes III, IV and V+VI were 31.6, 20.8, and 16.7 months, respectively. CONCLUSIONS In this analysis 30% of a heterogeneous cohort of GBM patients eligible for SRS had an OS of 2 years. Radiosurgery at the time of tumor progression was associated with a median survival of 21.8 months. The role of radiosurgery for GBMs remains controversial. The findings in this study support the need for a funded and appropriately designed clinical trial that will provide a higher level of evidence regarding the future role of SRS for glioblastoma patients in whom disease has progressed despite standard management.
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Radiation therapy for glioma stem cells. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2015; 853:85-110. [PMID: 25895709 DOI: 10.1007/978-3-319-16537-0_6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Radiation therapy is the most effective adjuvant treatment modality for virtually all patients with high-grade glioma. Its ability to improve patient survival has been recognized for decades. Cancer stem cells provide new insights into how tumor biology is affected by radiation and the role that this cell population can play in disease recurrence. Glioma stem cells possess a variety of intracellular mechanisms to resist and even flourish in spite of radiation, and their proliferation and maintenance appear tied to supportive stimuli from the tumor microenvironment. This chapter reviews the basis for our current use of radiation to treat high-grade gliomas, and addresses this model in the context of therapeutically resistant stem cells. We discuss the available evidence highlighting current clinical efforts to improve radiosensitivity, and newer targets worthy of further development.
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Dehdashti AR, Sharma S, Laperriere N, Bernstein M. Coincidence vs Cause: Cure in Three Glioblastoma Patients Treated with Brachytherapy. Can J Neurol Sci 2014; 34:339-42. [PMID: 17803034 DOI: 10.1017/s031716710000679x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background:Very long term survival after diagnosis of malignant glioma has been described in individual case reports. Survival of more than 10 years is extremely rare, especially when identified in 3 out of 71 patients assigned to one arm of a randomized controlled trial.Patients:Three patients survived 11, 16, and 18 years following the diagnosis of glioblastoma and treatment with surgery, conventional fractionated radiation, and high-activity iodine-125 boost brachytherapy as part of a randomized controlled trial.Conclusion:Despite this apparent cause and effect relationship, statistical analysis shows no relationship between these cures and treatment with brachytherapy. Cure of glioblastoma remains rare.
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Affiliation(s)
- Amir R Dehdashti
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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33
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Badiyan SN, Markovina S, Simpson JR, Robinson CG, DeWees T, Tran DD, Linette G, Jalalizadeh R, Dacey R, Rich KM, Chicoine MR, Dowling JL, Leuthardt EC, Zipfel GJ, Kim AH, Huang J. Radiation Therapy Dose Escalation for Glioblastoma Multiforme in the Era of Temozolomide. Int J Radiat Oncol Biol Phys 2014; 90:877-85. [DOI: 10.1016/j.ijrobp.2014.07.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 06/24/2014] [Accepted: 07/11/2014] [Indexed: 11/29/2022]
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34
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Low-dose rate stereotactic iodine-125 brachytherapy for the treatment of inoperable primary and recurrent glioblastoma: single-center experience with 201 cases. J Neurooncol 2014; 120:615-23. [DOI: 10.1007/s11060-014-1595-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 08/17/2014] [Indexed: 10/24/2022]
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Unkelbach J, Menze BH, Konukoglu E, Dittmann F, Ayache N, Shih HA. Radiotherapy planning for glioblastoma based on a tumor growth model: implications for spatial dose redistribution. Phys Med Biol 2014; 59:771-89. [PMID: 24440905 DOI: 10.1088/0031-9155/59/3/771] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Gliomas differ from many other tumors as they grow infiltratively into the brain parenchyma rather than forming a solid tumor mass with a well-defined boundary. Tumor cells can be found several centimeters away from the central tumor mass that is visible using current imaging techniques. The infiltrative growth characteristics of gliomas question the concept of a radiotherapy target volume that is irradiated to a homogeneous dose-the standard in current clinical practice. We discuss the use of the Fisher-Kolmogorov glioma growth model in radiotherapy treatment planning. The phenomenological tumor growth model assumes that tumor cells proliferate locally and migrate into neighboring brain tissue, which is mathematically described via a partial differential equation for the spatio-temporal evolution of the tumor cell density. In this model, the tumor cell density drops approximately exponentially with distance from the visible gross tumor volume, which is quantified by the infiltration length, a parameter describing the distance at which the tumor cell density drops by a factor of e. This paper discusses the implications for the prescribed dose distribution in the periphery of the tumor. In the context of the exponential cell kill model, an exponential fall-off of the cell density suggests a linear fall-off of the prescription dose with distance. We introduce the dose fall-off rate, which quantifies the steepness of the prescription dose fall-off in units of Gy mm(-1). It is shown that the dose fall-off rate is given by the inverse of the product of radiosensitivity and infiltration length. For an infiltration length of 3 mm and a surviving fraction of 50% at 2 Gy, this suggests a dose fall-off of approximately 1 Gy mm(-1). The concept is illustrated for two glioblastoma patients by optimizing intensity-modulated radiotherapy plans. The dose fall-off rate concept reflects the idea that infiltrating gliomas lack a defined boundary and are characterized by a continuous fall-off of the density of infiltrating tumor cells. The approach can potentially be used to individualize the prescribed dose distribution if better methods to estimate radiosensitivity and infiltration length on a patient by patient basis become available.
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Affiliation(s)
- Jan Unkelbach
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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36
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Hadziahmetovic M, Lo SS, Clarke JW, Farace E, Cavaliere R. Palliative treatment of poor prognosis patients with malignant gliomas. Expert Rev Anticancer Ther 2014; 8:125-32. [DOI: 10.1586/14737140.8.1.125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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37
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Wardak Z, Choe KS. Molecular pathways and potential therapeutic targets in glioblastoma multiforme. Expert Rev Anticancer Ther 2014; 13:1307-18. [DOI: 10.1586/14737140.2013.852472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Zabi Wardak
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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38
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Hwang CS, Marymont MH, Muro K. Photon radiotherapy for the treatment of high-grade gliomas. Expert Rev Anticancer Ther 2014; 7:S37-43. [DOI: 10.1586/14737140.7.12s.s37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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39
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Abstract
High-grade gliomas, in particular anaplastic astrocytoma and glioblastoma multiforme, represent two of the most devastating forms of brain cancer. In spite of the poor prognosis, new treatments and emerging therapies are making an impact on this disease. This review discusses the role of the surgical management of high-grade gliomas and provides an overview of the currently available therapies which depend on surgical intervention. At the same time, cutting-edge clinical trials for patients with malignant brain tumors are reviewed to provide further insights into potential future therapies.
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Affiliation(s)
- Joseph C Hsieh
- Section of Neurosurgery, The University of Chicago, 5841 S. Maryland Ave., Chicago, IL 60637, USA.
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40
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Cha J, Suh CO, Park K, Chang JH, Lee KS, Kim SH, Chang JS, Kim JH, Suh YG, Kim JW, Cho J. Feasibility and outcomes of hypofractionated simultaneous integrated boost-intensity modulated radiotherapy for malignant gliomas: a preliminary report. Yonsei Med J 2014; 55:70-7. [PMID: 24339289 PMCID: PMC3874925 DOI: 10.3349/ymj.2014.55.1.70] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The aim of this study was to assess the feasibility and efficacy of hypofractionated simultaneous integrated boost-intensity modulated radiotherapy (SIB-IMRT) using three-layered planning target volumes (PTV) for malignant gliomas. MATERIALS AND METHODS We conducted a retrospective analysis of 12 patients (WHO grade IV-10; III-2) postoperatively treated with SIB-IMRT with concurrent temozolomide. Three-layered PTVs were contoured based on gadolinium-enhanced magnetic resonance imaging as follows; high risk PTV (H-PTV) as the area of surgical bed including residual gross tumor with a 0.5 cm margin; low risk PTV (L-PTV) as the area surrounding the high risk PTV with 1.5 cm margin; moderate risk PTV (M-PTV) as a line at one-third the distance from high risk PTV to low risk PTV. Total dose to high risk PTV was 70 Gy in 8 and 62.5 Gy in 4 patients. RESULTS The median follow-up time was 52 months in surviving patients. The 2- and 5-year overall survival (OS) rates were 66.6% and 47.6%, respectively. The 2- and 5-year progression-free survival (PFS) rates were 57.1% and 45.7%, respectively. The median OS and PFS were 48 and 31 months, respectively. Six patients (50%) progressed: in-field only in one, out-field or disseminated in 4, and both in one patient. All patients completed planned treatments without a toxicity-related gap. Asymptomatic radiation necrosis was observed in 4 patients at post-radiotherapy 9-31 months. CONCLUSION An escalated dose of hypofractionated SIB-IMRT using three-layered PTVs can be safely performed in patients with malignant glioma, and might contribute to better tumor control and survival.
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Affiliation(s)
- Jihye Cha
- Department of Radiation Oncology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea.
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41
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Alexander BM, Ligon KL, Wen PY. Enhancing radiation therapy for patients with glioblastoma. Expert Rev Anticancer Ther 2013; 13:569-81. [PMID: 23617348 DOI: 10.1586/era.13.44] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Radiation therapy has been the foundation of therapy following maximal surgical resection in patients with newly diagnosed glioblastoma for decades and the primary therapy for unresected tumors. Using the standard approach with radiation and temozolomide, however, outcomes are poor, and glioblastoma remains an incurable disease with the majority of recurrences and progression within the radiation treatment field. As such, there is much interest in elucidating the mechanisms of resistance to radiation therapy and in developing novel approaches to overcoming this treatment resistance.
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Affiliation(s)
- Brian M Alexander
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, 75 Francis Street, ASB1-L2, Boston, MA 02115, USA.
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42
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Kruser TJ, Mehta MP, Robins HI. Pseudoprogression after glioma therapy: a comprehensive review. Expert Rev Neurother 2013; 13:389-403. [PMID: 23545054 DOI: 10.1586/ern.13.7] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the last decade, pseudoprogression as a clinically significant entity affecting both glioma patient management and the conduct of clinical trials has been recognized as a significant issue. The authors have summarized the literature relative to the incidence, chronological sequence, therapy-relatedness, impact of O-6-methylguanine-DNA methyltransferase methylation status and clinical features of pseudoprogression. Evidence regarding numerous neuroradiologic techniques to differentiate pseudoprogression from tumor recurrence is summarized. The implications of pseudoprogression on prognosis and clinical trial design are substantial, and are reviewed. Relative to this, the overlapping terms pseudoprogression and radiation necrosis are clarified to produce an appropriate basis for future consideration and research regarding this important biological phenomenon.
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Affiliation(s)
- Tim J Kruser
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
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43
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Nishikawa R. Standard therapy for glioblastoma--a review of where we are. Neurol Med Chir (Tokyo) 2013; 50:713-9. [PMID: 20885105 DOI: 10.2176/nmc.50.713] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Glioblastoma is the most common primary malignant brain tumor in adults and is a challenging disease to treat. The current standard therapy includes maximal safe surgical resection, followed by a combination of radiation and chemotherapy with temozolomide. However, recurrence is quite common, so we continue to search for more effective treatments both for initial therapy and at the time of recurrence. This article will review the current standard of care and recent advances in therapy for newly-diagnosed and recurrent glioblastomas, based on the most authoritative guidelines, the National Cancer Institute's comprehensive cancer database Physician Data Query (PDQ®), and the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology(TM) for central nervous system cancers (V.1.2010), to elucidate the current position and in what direction we are advancing.
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Affiliation(s)
- Ryo Nishikawa
- Department of Neuro-Oncology/Neurosurgery, International Medical Center, Saitama Medical University, 1397 Yamane, Saitama, Japan.
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44
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Kirkpatrick JP, Yin FF, Sampson JH. Radiotherapy and Radiosurgery for Tumors of the Central Nervous System. Surg Oncol Clin N Am 2013; 22:445-61. [DOI: 10.1016/j.soc.2013.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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45
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Waters JD, Rose B, Gonda DD, Scanderbeg DJ, Russell M, Alksne JF, Murphy K, Carter BS, Lawson J, Chen CC. Immediate post-operative brachytherapy prior to irradiation and temozolomide for newly diagnosed glioblastoma. J Neurooncol 2013; 113:467-77. [PMID: 23673513 DOI: 10.1007/s11060-013-1139-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Accepted: 04/27/2013] [Indexed: 10/26/2022]
Abstract
To determine whether immediate post-operative brachytherapy can be safely applied to newly diagnosed glioblastomas to retard tumor progression prior to initiation of external beam radiation therapy (EBRT) and temozolomide. Between 1996 and 2011, eleven patients underwent implantation of GliaSite (n = 9) or MammoSite (n = 2) at the time of surgical resection. Brachytherapy was carried out on post-operative day 2-3, with 45-60 Gy delivered to a 1 cm margin. All patients underwent subsequent standard radiation/temozolomide treatment 4-5 weeks post-irradiation. There were no wound related complications. Toxicity was observed in two patients (2/11 or 18 %), including one post-operative seizure and one case of cerebral edema that resolved after a course of steroid treatment. Immediate post-operative and pre-irradiation/temozolomide magnetic resonance imaging assessment was available for 9 of the 11 patients. Two of these nine patients (22 %) developed new regions of contrast enhancement prior to irradiation/temozolomide. This compares favorably to historical data where 53 % of patient suffer such tumor progression. While there was a trend toward improved 6 month progression free survival in the brachytherapy/temozolomide/radiation treated patients, the overall survival of these patients were comparable to historical controls. This case series demonstrates the safety of immediate post-operative brachytherapy when applied prior to EBRT and temozolomide in the treatment of newly diagnosed glioblastomas.
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Affiliation(s)
- J Dawn Waters
- Division of Neurosurgery, Center for Theoretic and Applied Neuro-Oncology, University of California, San Diego, 3855 Health Science Drive #0987, La Jolla, CA 92093-0987, USA
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46
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Sloan AE, Ahluwalia MS, Valerio-Pascua J, Manjila S, Torchia MG, Jones SE, Sunshine JL, Phillips M, Griswold MA, Clampitt M, Brewer C, Jochum J, McGraw MV, Diorio D, Ditz G, Barnett GH. Results of the NeuroBlate System first-in-humans Phase I clinical trial for recurrent glioblastoma: clinical article. J Neurosurg 2013; 118:1202-19. [PMID: 23560574 DOI: 10.3171/2013.1.jns1291] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Laser interstitial thermal therapy has been used as an ablative treatment for glioma; however, its development was limited due to technical issues. The NeuroBlate System incorporates several technological advances to overcome these drawbacks. The authors report a Phase I, thermal dose-escalation trial assessing the safety and efficacy of NeuroBlate in recurrent glioblastoma multiforme (rGBM). METHODS Adults with suspected supratentorial rGBM of 15- to 40-mm dimension and a Karnofsky Performance Status score of ≥ 60 were eligible. After confirmatory biopsy, treatment was delivered using a rigid, gas-cooled, side-firing laser probe. Treatment was monitored using real-time MRI thermometry, and proprietary software providing predictive thermal damage feedback was used by the surgeon, along with control of probe rotation and depth, to tailor tissue coagulation. An external data safety monitoring board determined if toxicity at lower levels justified dose escalation. RESULTS Ten patients were treated at the Case Comprehensive Cancer Center (Cleveland Clinic and University Hospitals-Case Medical Center). Their average age was 55 years (range 34-69 years) and the median preoperative Karnofsky Performance Status score was 80 (range 70-90). The mean tumor volume was 6.8 ± 5 cm(3) (range 2.6-19 cm(3)), the percentage of tumor treated was 78% ± 12% (range 57%-90%), and the conformality index was 1.21 ± 0.33 (range 1.00-2.04). Treatment-related necrosis was evident on MRI studies at 24 and 48 hours. The median survival was 316 days (range 62-767 days). Three patients improved neurologically, 6 remained stable, and 1 worsened. Steroid-responsive treatment-related edema occurred in all patients but one. Three had Grade 3 adverse events at the highest dose. CONCLUSIONS NeuroBlate represents new technology for delivering laser interstitial thermal therapy, allowing controlled thermal ablation of deep hemispheric rGBM. CLINICAL TRIAL REGISTRATION NO.: NCT00747253 ( ClinicalTrials.gov ).
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Affiliation(s)
- Andrew E Sloan
- Brain Tumor & Neuro-Oncology Center and Department of Neurosurgery, University Hospitals Case Medical Center, Seidman Cancer Center, Cleveland, Ohio, USA
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47
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Elder JB, Chiocca EA. Editorial: Glioblastoma multiforme and laser interstitial thermal therapy. J Neurosurg 2013; 118:1199-200; discussion 1200-1. [PMID: 23560576 DOI: 10.3171/2012.9.jns121563] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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48
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Rahmathulla G, Marko NF, Weil RJ. Cerebral radiation necrosis: a review of the pathobiology, diagnosis and management considerations. J Clin Neurosci 2013; 20:485-502. [PMID: 23416129 DOI: 10.1016/j.jocn.2012.09.011] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 09/14/2012] [Indexed: 10/27/2022]
Abstract
Radiation therapy forms one of the building blocks of the multi-disciplinary management of patients with brain tumors. Improved survival following radiation therapy may come with a cost, including the potential complication of radiation necrosis. Radiation necrosis impacts the quality of life in cancer survivors, and it is essential to detect and effectively treat this entity as early as possible. Significant progress in neuro-radiology and molecular pathology facilitate more straightforward diagnosis and characterization of cerebral radiation necrosis. Several therapeutic interventions, both medical and surgical, may halt the progression of radiation necrosis and diminish or abrogate its clinical manifestations, but there are still no definitive guidelines to follow explicitly that guide treatment of radiation necrosis. We discuss the pathobiology, clinical features, diagnosis, available treatment modalities, and outcomes in the management of patients with intracranial radiation necrosis that follows radiation used to treat brain tumors.
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Affiliation(s)
- Gazanfar Rahmathulla
- The Burkhardt Brain Tumor & Neuro-Oncology Center, Desk S-7, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Hu X, Qiu H, Zhang L, Zhang W, Ma Y, Qiao Z, Chen D, Han J, Duan G, Zhang F. Recurrent gliomas: comparison of computed tomography (CT)-guided 125I seed implantation therapy and traditional radiochemotherapy. Cancer Biol Ther 2012; 13:840-7. [PMID: 22797010 DOI: 10.4161/cbt.20834] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Primary brain tumors have always been associated with high morbidity and mortality. Glioma is the most common type of malignant brain tumors,with a high probability of recurrence after surgical excision and with poor prognosis.The purpose of this study was to compare the therapeutic efficacy of computed tomography (CT)-guided interstitial (125)I seed implantation with traditional radiochemotherapy for treatment of recurrent gliomas. RESULTS The response rate at 1, 3, 6 and 12 months after (125)I seed implantation was 68.6, 74.3, 77.1 and 62.8% respectively, which was significantly higher than the group treated with the conventional chemoradiation protocol (p < 0.05). Patients exposed to (125)I seed implantation had a median survival of 29.0 months, whereas the median survival of those treated with traditional radiochemotherapy was 19.0 months. The difference observed between the two groups was significant. There were no severe complications or mortality associated with either treatment, except for one case of intracerebral hemorrhage around the tumor area in the (125)I seed implants group. METHODS From November 2002 to May 2010, 73 consecutive patients with recurrent gliomas were treated with CT-guided (125)I seed implantation (35 cases) or traditional radiochemotherapy (38 cases). Patients were followed up after treatment and the therapeutic effect was evaluated by comparing the response and survival rates of the two groups. In particular, patients treated with (125)I seed implantation were monitored for adverse side effects. CONCLUSIONS CT-guided (125)I seed implantation is safe and well-tolerated and more importantly, shows superior efficacy compared with conventional radiochemotherapy. This suggests that CT-guided (125)I seed implantation could be an alternative approach for recurrent gliomas.
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Affiliation(s)
- Xiaokun Hu
- Department of Medical Imaging and Interventional Radiology, Cancer Center and State Key Laboratory of Oncology in South China, Sun Yat-sen University, Guangzhou, Guangdong, China
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Ruge MI, Kickingereder P, Grau S, Treuer H, Sturm V, Voges J. Stereotactic iodine-125 brachytherapy for brain tumors: temporary versus permanent implantation. Radiat Oncol 2012; 7:94. [PMID: 22713629 PMCID: PMC3405446 DOI: 10.1186/1748-717x-7-94] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 06/19/2012] [Indexed: 11/10/2022] Open
Abstract
Stereotactic brachytherapy (SBT) has been described in several publications as an effective, minimal invasive and safe highly focal treatment option in selected patients with well circumscribed brain tumors <4 cm. However, a still ongoing discussion about indications and technique is hindering the definition of a clear legitimation of SBT in modern brain tumor treatment. These controversies encompass the question of how intense the irradiation should be delivered into the target volume (dose rate). For instance, reports about the use of high does rate (HDR) implantation schemes (>40 cGy/h) in combination with adjuvant external beam radiation and/or chemotherapy for the treatment of malignant gliomas and metastases resulted in increased rates of radiation induced adverse tissue changes requiring surgical intervention. Vice versa, such effects have been only minimally observed in numerous studies applying low dose rate (LDR) regiments (3-8 cGy/h) for low grade gliomas, metastases and other rare indications. Besides these observations, there are, however, no data available directly comparing the long term incidences of tissue changes after HDR and LDR and there is, furthermore, no evidence regarding a difference between temporary or permanent LDR implantation schemes. Thus, recommendations for effective and safe implantation schemes have to be investigated and compared in future studies.
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Affiliation(s)
- Maximilian I Ruge
- Department for Stereotaxy and Functional Neurosurgery, University of Cologne, Cologne, Germany.
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