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Abstract
Background Tumor Treating Fields (TTF) have entered clinical practice for newly diagnosed and recurrent glioblastoma (GGM). However, controversies remain unresolved with regard to appropriate usage. We sought to determine TTF usage in major academic neuro-oncology programs in New York City, USA and Heidelberg, Germany and understand current attitudes toward TTF usage among providers. Methods We retrospectively determined TTF usage among patients with GGM, before and since the publication of key clinical trial results and regulatory approvals. We also surveyed attendees of an educational session related to TTF during the 2019 American Society of Clinical Oncology annual meeting. Results TTF usage remains infrequent (3-12% of patients with newly diagnosed GBM, and 0-16% of patients with recurrent disease) in our practices, although it has increased over time. Among 30 survey respondents (77% of whom self-identified as neuro- or medical oncologists), 60% were convinced that TTF prolongs survival for newly diagnosed GGM despite published phase III data and regulatory approval, and only 30% viewed TTF as definitively part of the standard of care treatment. A majority (87%) opposed mandating TTF incorporation into the design of clinical trials. Conclusions Providers continue to view TTF with some level of skepticism, with a lack of additional supportive data and logistical concerns representing continued barriers to uptake.
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Affiliation(s)
- Andrew B Lassman
- Department of Neurology, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | | | - Peter C Pan
- Department of Neurology, New York, New York, USA.,New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Wolfgang Wick
- Neurology Clinic, Heidelberg University Medical Center and Clinical Cooperation Unit Neurooncology, German Cancer Research Center, Heidelberg, Germany
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2
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Kamarudin MNA, Parhar I. Emerging therapeutic potential of anti-psychotic drugs in the management of human glioma: A comprehensive review. Oncotarget 2019; 10:3952-77. [PMID: 31231472 DOI: 10.18632/oncotarget.26994] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 05/13/2019] [Indexed: 12/12/2022] Open
Abstract
Despite numerous advancements in the last decade, human gliomas such as astrocytoma and glioblastoma multiforme have the worst prognoses among all cancers. Anti-psychotic drugs are commonly prescribed to treat mental disorders among cancer patients, and growing empirical evidence has revealed their antitumor, anti-metastatic, anti-angiogenic, anti-proliferative, chemo-preventive, and neo-adjuvant efficacies in various in vitro, in vivo, and clinical glioma models. Anti-psychotic drugs have drawn the attention of physicians and researchers owing to their beneficial effects in the prevention and treatment of gliomas. This review highlights data on the therapeutic potential of various anti-psychotic drugs as anti-proliferative, chemopreventive, and anti-angiogenic agents in various glioma models via the modulation of upstream and downstream molecular targets involved in apoptosis, autophagy, oxidative stress, inflammation, and the cell cycle in in vitro and in vivo preclinical and clinical stages among glioma patients. The ability of anti-psychotic drugs to modulate various signaling pathways and multidrug resistance-conferring proteins that enhance the efficacy of chemotherapeutic drugs with low side-effects exemplifies their great potential as neo-adjuvants and potential chemotherapeutics in single or multimodal treatment approach. Moreover, anti-psychotic drugs confer the ability to induce glioma into oligodendrocyte-like cells and neuronal-like phenotype cells with reversal of epigenetic alterations through inhibition of histone deacetylase further rationalize their use in glioma treatment. The improved understanding of anti-psychotic drugs as potential chemotherapeutic drugs or as neo-adjuvants will provide better information for their use globally as affordable, well-tolerated, and effective anticancer agents for human glioma.
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3
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Reznik E, Smith AW, Taube S, Mann J, Yondorf MZ, Parashar B, Wernicke AG. Radiation and Immunotherapy in High-grade Gliomas: Where Do We Stand? Am J Clin Oncol 2018; 41:197-212. [PMID: 28906259 DOI: 10.1097/COC.0000000000000406] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
High-grade glioma is the most common primary brain tumor, with glioblastoma multiforme (GBM) accounting for 52% of all brain tumors. The current standard of care (SOC) of GBM involves surgery followed by adjuvant fractionated radiotherapy and chemotherapy. However, little progress has been made in extending overall survival, progression-free survival, and quality of life. Attempts to characterize and customize treatment of GBM have led to mitigating the deleterious effects of radiotherapy using hypofractionated radiotherapy, as well as various immunotherapies as a promising strategy for the incurable disease. A combination of radiotherapy and immunotherapy may prove to be even more effective than either alone, and preclinical evidence suggests that hypofractionated radiotherapy can actually prime the immune system to make immunotherapy more effective. This review addresses the complications of the current radiotherapy regimen, various methods of immunotherapy, and preclinical and clinical data from combined radioimmunotherapy trials.
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4
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Brastianos PK, Ippen FM, Hafeez U, Gan HK. Emerging Gene Fusion Drivers in Primary and Metastatic Central Nervous System Malignancies: A Review of Available Evidence for Systemic Targeted Therapies. Oncologist 2018; 23:1063-1075. [PMID: 29703764 PMCID: PMC6192601 DOI: 10.1634/theoncologist.2017-0614] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 02/07/2018] [Indexed: 12/11/2022] Open
Abstract
Primary and metastatic tumors of the central nervous system present a difficult clinical challenge, and they are a common cause of disease progression and death. For most patients, treatment consists primarily of surgery and/or radiotherapy. In recent years, systemic therapies have become available or are under investigation for patients whose tumors are driven by specific genetic alterations, and some of these targeted treatments have been associated with dramatic improvements in extracranial and intracranial disease control and survival. However, the success of other systemic therapies has been hindered by inadequate penetration of the drug into the brain parenchyma. Advances in molecular characterization of oncogenic drivers have led to the identification of new gene fusions driving oncogenesis in some of the most common sources of intracranial tumors. Systemic therapies targeting many of these alterations have been approved recently or are in clinical development, and the ability to penetrate the blood-brain barrier is now widely recognized as an important property of such drugs. We review this rapidly advancing field with a focus on recently uncovered gene fusions and brain-penetrant systemic therapies targeting them. IMPLICATIONS FOR PRACTICE Driver gene fusions involving receptor tyrosine kinases have been identified across a wide range of tumor types, including primary central nervous system (CNS) tumors and extracranial solid tumors that are associated with high rates of metastasis to the CNS (e.g., lung, breast, melanoma). This review discusses the systemic therapies that target emerging gene fusions, with a focus on brain-penetrant agents that will target the intracranial disease and, where present, also extracranial disease.
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Affiliation(s)
- Priscilla K Brastianos
- Department of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Franziska Maria Ippen
- Department of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Umbreen Hafeez
- Medical Oncology, Austin Hospital, Heidelberg, Melbourne, Australia
| | - Hui K Gan
- Medical Oncology, Austin Hospital, Heidelberg, Melbourne, Australia
- La Trobe University School of Cancer Medicine, Heidelberg, Victoria, Australia
- Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia
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5
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Korshoej AR, Hansen FL, Mikic N, von Oettingen G, Sørensen JCH, Thielscher A. Importance of electrode position for the distribution of tumor treating fields (TTFields) in a human brain. Identification of effective layouts through systematic analysis of array positions for multiple tumor locations. PLoS One 2018; 13:e0201957. [PMID: 30133493 PMCID: PMC6104980 DOI: 10.1371/journal.pone.0201957] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 07/25/2018] [Indexed: 12/30/2022] Open
Abstract
Tumor treating fields (TTFields) is a new modality used for the treatment of glioblastoma. It is based on antineoplastic low-intensity electric fields induced by two pairs of electrode arrays placed on the patient’s scalp. The layout of the arrays greatly impacts the intensity (dose) of TTFields in the pathology. The present study systematically characterizes the impact of array position on the TTFields distribution calculated in a realistic human head model using finite element methods. We investigate systematic rotations of arrays around a central craniocaudal axis of the head and identify optimal layouts for a large range of (nineteen) different frontoparietal tumor positions. In addition, we present comprehensive graphical representations and animations to support the users’ understanding of TTFields. For most tumors, we identified two optimal array positions. These positions varied with the translation of the tumor in the anterior-posterior direction but not in the left-right direction. The two optimal directions were oriented approximately orthogonally and when combining two pairs of orthogonal arrays, equivalent to clinical TTFields therapy, we correspondingly found a single optimum position. In most cases, an oblique layout with the fields oriented at forty-five degrees to the sagittal plane was superior to the commonly used anterior-posterior and left-right combinations of arrays. The oblique configuration may be used as an effective and viable configuration for most frontoparietal tumors. Our results may be applied to assist clinical decision-making in various challenging situations associated with TTFields. This includes situations in which circumstances, such as therapy-induced skin rash, scar tissue or shunt therapy, etc., require layouts alternative to the prescribed. More accurate distributions should, however, be based on patient-specific models. Future work is needed to assess the robustness of the presented results towards variations in conductivity.
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Affiliation(s)
- Anders Rosendal Korshoej
- Aarhus University Hospital, Department of Neurosurgery, Nørrebrogade, Aarhus C, Denmark
- Aarhus University, Department of Clinical Medicine, Palle Juul-Jensens Boulevard, Aarhus N, Denmark
- * E-mail:
| | - Frederik Lundgaard Hansen
- Aarhus University Hospital, Department of Neurosurgery, Nørrebrogade, Aarhus C, Denmark
- Aarhus University, Department of Clinical Medicine, Palle Juul-Jensens Boulevard, Aarhus N, Denmark
| | - Nikola Mikic
- Aarhus University Hospital, Department of Neurosurgery, Nørrebrogade, Aarhus C, Denmark
| | - Gorm von Oettingen
- Aarhus University Hospital, Department of Neurosurgery, Nørrebrogade, Aarhus C, Denmark
- Aarhus University, Department of Clinical Medicine, Palle Juul-Jensens Boulevard, Aarhus N, Denmark
| | - Jens Christian Hedemann Sørensen
- Aarhus University Hospital, Department of Neurosurgery, Nørrebrogade, Aarhus C, Denmark
- Aarhus University, Department of Clinical Medicine, Palle Juul-Jensens Boulevard, Aarhus N, Denmark
| | - Axel Thielscher
- Danish Research Center for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Kettegaards Allé, DK, Hvidovre, Denmark
- Department of Electrical Engineering, Technical University of Denmark, Ørsteds Plads, DK, Kgs. Lyngby, Denmark
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6
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Kim EH, Song HS, Yoo SH, Yoon M. Tumor treating fields inhibit glioblastoma cell migration, invasion and angiogenesis. Oncotarget 2018; 7:65125-65136. [PMID: 27556184 PMCID: PMC5323142 DOI: 10.18632/oncotarget.11372] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 08/10/2016] [Indexed: 11/25/2022] Open
Abstract
Treatment with alternating electric fields at an intermediate frequency (100–300 kHz), referred to as tumor treating fields (TTF) therapy, inhibits cancer cell proliferation. In the present study, we demonstrated that TTF application suppressed the metastatic potential of U87 and U373 glioblastoma cell lines via the NF-kB, MAPK and PI3K/AKT signaling pathways. Wound-healing and transwell assays showed that TTF suppressed cell migration and invasion compared with controls. Soft agar and three-dimensional culture assays showed that TTF inhibited both anchorage-dependent (cell proliferation) and anchorage-independent (colony formation) GBM cell growth. TTF dysregulated epithelial-to-mesenchymal transition-related genes, such as vimentin and E-cadherin, which partially accounted for TTF inhibition of cell migration and invasion. We further demonstrated that TTF application suppressed angiogenesis by downregulating VEGF, HIF1α and matrix metalloproteinases 2 and 9. TTF also inhibited NF-kB transcriptional activity. Collectively, our findings show that TTF represents a promising novel anti-invasion and anti-angiogenesis therapeutic strategy for use in GBM patients.
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Affiliation(s)
- Eun Ho Kim
- Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Hyo Sook Song
- Department of Bio-Convergence Engineering, Korea University, Seoul, Korea
| | - Seung Hoon Yoo
- Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Myonggeun Yoon
- Department of Bio-Convergence Engineering, Korea University, Seoul, Korea
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7
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Wenger C, Miranda PC, Salvador R, Thielscher A, Bomzon Z, Giladi M, Mrugala MM, Korshoej AR. A Review on Tumor-Treating Fields (TTFields): Clinical Implications Inferred From Computational Modeling. IEEE Rev Biomed Eng 2018; 11:195-207. [DOI: 10.1109/rbme.2017.2765282] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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8
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Wenger C, Bomzon Z, Salvador R, Basser PJ, Miranda PC. Simplified realistic human head model for simulating Tumor Treating Fields (TTFields). Annu Int Conf IEEE Eng Med Biol Soc 2017; 2016:5664-5667. [PMID: 28269540 DOI: 10.1109/embc.2016.7592012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Tumor Treating Fields (TTFields) are alternating electric fields in the intermediate frequency range (100-300 kHz) of low-intensity (1-3 V/cm). TTFields are an anti-mitotic treatment against solid tumors, which are approved for Glioblastoma Multiforme (GBM) patients. These electric fields are induced non-invasively by transducer arrays placed directly on the patient's scalp. Cell culture experiments showed that treatment efficacy is dependent on the induced field intensity. In clinical practice, a software called NovoTalTM uses head measurements to estimate the optimal array placement to maximize the electric field delivery to the tumor. Computational studies predict an increase in the tumor's electric field strength when adapting transducer arrays to its location. Ideally, a personalized head model could be created for each patient, to calculate the electric field distribution for the specific situation. Thus, the optimal transducer layout could be inferred from field calculation rather than distance measurements. Nonetheless, creating realistic head models of patients is time-consuming and often needs user interaction, because automated image segmentation is prone to failure. This study presents a first approach to creating simplified head models consisting of convex hulls of the tissue layers. The model is able to account for anisotropic conductivity in the cortical tissues by using a tensor representation estimated from Diffusion Tensor Imaging. The induced electric field distribution is compared in the simplified and realistic head models. The average field intensities in the brain and tumor are generally slightly higher in the realistic head model, with a maximal ratio of 114% for a simplified model with reasonable layer thicknesses. Thus, the present pipeline is a fast and efficient means towards personalized head models with less complexity involved in characterizing tissue interfaces, while enabling accurate predictions of electric field distribution.
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9
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Gan HK, van den Bent M, Lassman AB, Reardon DA, Scott AM. Antibody-drug conjugates in glioblastoma therapy: the right drugs to the right cells. Nat Rev Clin Oncol 2017; 14:695-707. [PMID: 28675164 DOI: 10.1038/nrclinonc.2017.95] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Glioblastomas are high-grade brain tumours with a poor prognosis and, currently, few available therapeutic options. This lack of effective treatments has been linked to diverse factors, including target selection, tumour heterogeneity and poor penetrance of therapeutic agents through the blood-brain barrier and into tumours. Therapies using monoclonal antibodies, alone or linked to cytotoxic payloads, have proved beneficial for patients with different solid tumours; these approaches are currently being explored in patients with glioblastoma. In this Review, we summarise clinical data regarding antibody-drug conjugates (ADCs) against a variety of targets in glioblastoma, and compare the efficacy and toxicity of targeting EGFR with ADCs versus naked antibodies in order to illustrate key aspects of the use of ADCs in this malignancy. Finally, we discuss the complex challenges related to the biology and mutational changes of glioblastoma that can affect the use of ADC-based therapies in patients with this disease, and highlight potential strategies to improve efficacy.
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Affiliation(s)
- Hui K Gan
- Austin Health and Olivia Newton-John Cancer Research Institute, 145 Studley Road, Heidelberg, Victoria 3084, Australia.,La Trobe University School of Cancer Medicine, 145 Studley Road, Heidelberg, Victoria 3084, Australia.,Department of Medicine, University of Melbourne, 145 Studley Road, Heidelberg, Victoria 3084, Australia
| | - Martin van den Bent
- Brain Tumour Centre, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 EA Rotterdam, Netherlands
| | - Andrew B Lassman
- Department of Neurology & Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, 161 Fort Washington Avenue, New York, New York 10032, USA
| | - David A Reardon
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Dana 2134, Boston, Massachusetts 02215, USA
| | - Andrew M Scott
- Austin Health and Olivia Newton-John Cancer Research Institute, 145 Studley Road, Heidelberg, Victoria 3084, Australia.,La Trobe University School of Cancer Medicine, 145 Studley Road, Heidelberg, Victoria 3084, Australia.,Department of Medicine, University of Melbourne, 145 Studley Road, Heidelberg, Victoria 3084, Australia
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10
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Makarov SN, Noetscher GM, Yanamadala J, Piazza MW, Louie S, Prokop A, Nazarian A, Nummenmaa A. Virtual Human Models for Electromagnetic Studies and Their Applications. IEEE Rev Biomed Eng 2017; 10:95-121. [PMID: 28682265 PMCID: PMC10502908 DOI: 10.1109/rbme.2017.2722420] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
Numerical simulation of electromagnetic, thermal, and mechanical responses of the human body to different stimuli in magnetic resonance imaging safety, antenna research, electromagnetic tomography, and electromagnetic stimulation is currently limited by the availability of anatomically adequate and numerically efficient cross-platform computational models or "virtual humans." The objective of this study is to provide a comprehensive review of modern human models and body region models available in the field and their important features.
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Affiliation(s)
- Sergey N. Makarov
- ECE Dept., Worcester Polytechnic Institute, Worcester, MA 01609; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 ()
| | - Gregory M. Noetscher
- ECE Dept., Worcester Polytechnic Institute, Worcester, MA 01609; Neva Electromagnetics, LLC., Yarmouth Port, MA 02675 ()
| | | | | | | | | | - Ara Nazarian
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02675 ()
| | - Aapo Nummenmaa
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 ()
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Macedo M, Wenger C, Salvador R, Fernandes SR, Miranda PC. Investigating an alternative ring design of transducer arrays for tumor treating fields (TTFields). Annu Int Conf IEEE Eng Med Biol Soc 2017; 2016:5168-5171. [PMID: 28269429 DOI: 10.1109/embc.2016.7591891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Tumor treating fields (TTFields) is a therapy that inhibits cell proliferation and has been approved by the U.S Food and Drug Administration (FDA) for the treatment of Glioblastoma Multiforme. This anti-mitotic technique works non-invasively and regionally, and is associated with less toxicity and a better quality of life. Currently a device called Optune™ is clinically used which works with two perpendicular and alternating array pairs each consisting of 3×3 transducers. The aim of this study is to investigate a theoretical alternative array design which consists of two rings of 16 transducers and thus permits various field directions. A realistic human head model with isotropic tissues was used to simulate the electric field distribution induced by the two types of array layouts. One virtual tumour was modelled as a sphere in the white matter close to one lateral ventricle. Four alternative ring design directions were evaluated by activating arrays of 2×2 transducers on opposite sides of the head. The same amount of current was passed through active transducer arrays of the Optune system and the ring design. The electric field distribution in the brain differs for the various array configurations, with higher fields between activated transducer pairs and lower values in distant areas. Nonetheless, the average electric field strength values in the tumour are comparable for the various configurations. Values between 1.00 and 1.91 V/cm were recorded, which are above the threshold for effective treatment. Increasing the amount of field directions could possibly also increase treatment efficacy, because TTFields' effect on cancer cells is highest when the randomly distributed cell division axis is aligned with the field. The results further predict that slightly changing transducer positions only has a minor effect on the electric field. Thus patients might have some freedom to adjust array positions without major concern for treatment efficacy.
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Bomzon Z, Hershkovich HS, Urman N, Chaudhry A, Garcia-Carracedo D, Korshoej AR, Weinberg U, Wenger C, Miranda P, Wasserman Y, Kirson ED. Using computational phantoms to improve delivery of Tumor Treating Fields (TTFields) to patients. Annu Int Conf IEEE Eng Med Biol Soc 2017; 2016:6461-6464. [PMID: 28269726 DOI: 10.1109/embc.2016.7592208] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This paper reviews the state-of-the-art in simulation-based studies of Tumor Treating Fields (TTFields) and highlights major aspects of TTFields in which simulation-based studies could affect clinical outcomes. A major challenge is how to simulate multiple scenarios rapidly for TTFields delivery. Overcoming this challenge will enable a better understanding of how TTFields distribution is correlated with disease progression, leading to better transducer array designs and field optimization procedures, ultimately improving patient outcomes.
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13
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Korshoej AR, Hansen FL, Thielscher A, von Oettingen GB, Sørensen JCH. Impact of tumor position, conductivity distribution and tissue homogeneity on the distribution of tumor treating fields in a human brain: A computer modeling study. PLoS One 2017; 12:e0179214. [PMID: 28604803 PMCID: PMC5467909 DOI: 10.1371/journal.pone.0179214] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 05/25/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Tumor treating fields (TTFields) are increasingly used in the treatment of glioblastoma. TTFields inhibit cancer growth through induction of alternating electrical fields. To optimize TTFields efficacy, it is necessary to understand the factors determining the strength and distribution of TTFields. In this study, we provide simple guiding principles for clinicians to assess the distribution and the local efficacy of TTFields in various clinical scenarios. METHODS We calculated the TTFields distribution using finite element methods applied to a realistic head model. Dielectric property estimates were taken from the literature. Twentyfour tumors were virtually introduced at locations systematically varied relative to the applied field. In addition, we investigated the impact of central tumor necrosis on the induced field. RESULTS Local field "hot spots" occurred at the sulcal fundi and in deep tumors embedded in white matter. The field strength was not higher for tumors close to the active electrode. Left/right field directions were generally superior to anterior/posterior directions. Central necrosis focally enhanced the field near tumor boundaries perpendicular to the applied field and introduced significant field non-uniformity within the tumor. CONCLUSIONS The TTFields distribution is largely determined by local conductivity differences. The well conducting tumor tissue creates a preferred pathway for current flow, which increases the field intensity in the tumor boundaries and surrounding regions perpendicular to the applied field. The cerebrospinal fluid plays a significant role in shaping the current pathways and funnels currents through the ventricles and sulci towards deeper regions, which thereby experience higher fields. Clinicians may apply these principles to better understand how TTFields will affect individual patients and possibly predict where local recurrence may occur. Accurate predictions should, however, be based on patient specific models. Future work is needed to assess the robustness of the presented results towards variations in conductivity.
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Affiliation(s)
- Anders Rosendal Korshoej
- Aarhus University Hospital, Department of Neurosurgery, Nørrebrogade 44, Aarhus C, Denmark
- Aarhus University, Department of Clinical Medicine, Palle Juul-Jensens Boulevard 100, Aarhus N, Denmark
- * E-mail:
| | - Frederik Lundgaard Hansen
- Aarhus University Hospital, Department of Neurosurgery, Nørrebrogade 44, Aarhus C, Denmark
- Aarhus University, Department of Clinical Medicine, Palle Juul-Jensens Boulevard 100, Aarhus N, Denmark
| | - Axel Thielscher
- Danish Research Center for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Kettegaards Allé 30, DK, Hvidovre, Denmark
- Biomedical Engineering, DTU Electro, Technical University of Denmark, Ørsteds Plads, Building 349, DK, Kgs. Lyngby, Denmark
- Max Planck Institute of Biological Cybernetics, Tübingen, Germany
| | - Gorm Burckhardt von Oettingen
- Aarhus University Hospital, Department of Neurosurgery, Nørrebrogade 44, Aarhus C, Denmark
- Aarhus University, Department of Clinical Medicine, Palle Juul-Jensens Boulevard 100, Aarhus N, Denmark
| | - Jens Christian Hedemann Sørensen
- Aarhus University Hospital, Department of Neurosurgery, Nørrebrogade 44, Aarhus C, Denmark
- Aarhus University, Department of Clinical Medicine, Palle Juul-Jensens Boulevard 100, Aarhus N, Denmark
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Mittal S, Klinger NV, Michelhaugh SK, Barger GR, Pannullo SC, Juhász C. Alternating electric tumor treating fields for treatment of glioblastoma: rationale, preclinical, and clinical studies. J Neurosurg 2017; 128:414-421. [PMID: 28298023 DOI: 10.3171/2016.9.jns16452] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Treatment for glioblastoma (GBM) remains largely unsuccessful, even with aggressive combined treatment via surgery, radiotherapy, and chemotherapy. Tumor treating fields (TTFs) are low-intensity, intermediate-frequency, alternating electric fields that have antiproliferative properties in vitro and in vivo. The authors provide an up-to-date review of the mechanism of action as well as preclinical and clinical data on TTFs. METHODS A systematic review of the literature was performed using the terms "tumor treating fields," "alternating electric fields," "glioblastoma," "Optune," "NovoTTF-100A," and "Novocure." RESULTS Preclinical and clinical data have demonstrated the potential efficacy of TTFs for treatment of GBM, leading to several pilot studies, clinical trials, and, in 2011, FDA approval for its use as salvage therapy for recurrent GBM and, in 2015, approval for newly diagnosed GBM. CONCLUSIONS Current evidence supports the use of TTFs as an efficacious, antimitotic treatment with minimal toxicity in patients with newly diagnosed and recurrent GBM. Additional studies are needed to further optimize patient selection, determine cost-effectiveness, and assess the full impact on quality of life.
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Affiliation(s)
- Sandeep Mittal
- Departments of1Neurosurgery.,2Oncology.,5Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | | | | | - Geoffrey R Barger
- 3Neurology, and.,5Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Susan C Pannullo
- 6Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York; and.,7Department of Biomedical Engineering, Cornell University, Ithaca, New York
| | - Csaba Juhász
- 3Neurology, and.,4Pediatrics.,5Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
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15
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Affiliation(s)
- Wolfgang Wick
- Neurology Clinic, University of Heidelberg and Clinical Cooperation Unit (CCU) Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany (W.W.)
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Clark PA, Gaal JT, Strebe JK, Pasch CA, Deming DA, Kuo JS, Robins HI. The effects of tumor treating fields and temozolomide in MGMT expressing and non-expressing patient-derived glioblastoma cells. J Clin Neurosci 2017; 36:120-4. [PMID: 27865821 DOI: 10.1016/j.jocn.2016.10.042] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 10/31/2016] [Indexed: 01/11/2023]
Abstract
A recent Phase 3 study of newly diagnosed glioblastoma (GBM) demonstrated the addition of tumor treating fields (TTFields) to temozolomide (TMZ) after combined radiation/TMZ significantly increased survival and progression free survival. Preliminary data suggested benefit with both methylated and unmethylated O-6-methylguanine-DNA methyl-transferase (MGMT) promoter status. To date, however, there have been no studies to address the potential interactions of TTFields and TMZ. Thus, the effects of TTFields and TMZ were studied in vitro using patient-derived GBM stem-like cells (GSCs) including MGMT expressing (TMZ resistant: 12.1 and 22GSC) and non-MGMT expressing (TMZ sensitive: 33 and 114GSC) lines. Dose-response curves were constructed using cell proliferation and sphere-forming assays. Results demonstrated a ⩾10-fold increase in TMZ resistance of MGMT-expressing (12.1GSCs: IC50=160μM; 22GSCs: IC50=44μM) compared to MGMT non-expressing (33GSCs: IC50=1.5μM; 114GSCs: IC50=5.2μM) lines. TTFields inhibited 12.1 GSC proliferation at all tested doses (50-500kHz) with an optimal frequency of 200kHz. At 200kHz, TTFields inhibited proliferation and tumor sphere formation of both MGMT GSC subtypes at comparable levels (12.1GSC: 74±2.9% and 38±3.2%, respectively; 22GSC: 61±11% and 38±2.6%, respectively; 33GSC: 56±9.5% and 60±7.1%, respectively; 114 GSC: 79±3.5% and 41±4.3%, respectively). In combination, TTFields (200kHz) and TMZ showed an additive anti-neoplastic effect with equal efficacy for TTFields in both cell types (i.e., ± MGMT expression) with no effect on TMZ resistance. This is the first demonstration of the effects of TTFields on cancer stem cells. The expansion of such studies may have clinical implications.
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Korshoej AR, Saturnino GB, Rasmussen LK, von Oettingen G, Sørensen JCH, Thielscher A. Enhancing Predicted Efficacy of Tumor Treating Fields Therapy of Glioblastoma Using Targeted Surgical Craniectomy: A Computer Modeling Study. PLoS One 2016; 11:e0164051. [PMID: 27695068 PMCID: PMC5047456 DOI: 10.1371/journal.pone.0164051] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 09/18/2016] [Indexed: 11/21/2022] Open
Abstract
Objective The present work proposes a new clinical approach to TTFields therapy of glioblastoma. The approach combines targeted surgical skull removal (craniectomy) with TTFields therapy to enhance the induced electrical field in the underlying tumor tissue. Using computer simulations, we explore the potential of the intervention to improve the clinical efficacy of TTFields therapy of brain cancer. Methods We used finite element analysis to calculate the electrical field distribution in realistic head models based on MRI data from two patients: One with left cortical/subcortical glioblastoma and one with deeply seated right thalamic anaplastic astrocytoma. Field strength was assessed in the tumor regions before and after virtual removal of bone areas of varying shape and size (10 to 100 mm) immediately above the tumor. Field strength was evaluated before and after tumor resection to assess realistic clinical scenarios. Results For the superficial tumor, removal of a standard craniotomy bone flap increased the electrical field strength by 60–70% in the tumor. The percentage of tissue in expected growth arrest or regression was increased from negligible values to 30–50%. The observed effects were highly focal and targeted at the regions of pathology underlying the craniectomy. No significant changes were observed in surrounding healthy tissues. Median field strengths in tumor tissue increased with increasing craniectomy diameter up to 50–70 mm. Multiple smaller burr holes were more efficient than single craniectomies of equivalent area. Craniectomy caused no significant field enhancement in the deeply seated tumor, but rather a focal enhancement in the brain tissue underlying the skull defect. Conclusions Our results provide theoretical evidence that small and clinically feasible craniectomies may provide significant enhancement of TTFields intensity in cerebral hemispheric tumors without severely compromising brain protection or causing unacceptable heating in healthy tissues. A clinical trial is being planned to validate safety and efficacy.
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Affiliation(s)
| | - Guilherme Bicalho Saturnino
- The Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Max Planck Institute for Biological Cybernetics, Tübingen, Germany
| | | | | | | | - Axel Thielscher
- The Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Max Planck Institute for Biological Cybernetics, Tübingen, Germany
- Biomedical Engineering, DTU Elektro, Technical University of Denmark, Kongens Lyngby, Denmark
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Bomzon Z, Urman N, Wenger C, Giladi M, Weinberg U, Wasserman Y, Kirson ED, Miranda PC, Palti Y. Modelling Tumor Treating Fields for the treatment of lung-based tumors. Annu Int Conf IEEE Eng Med Biol Soc 2016; 2015:6888-91. [PMID: 26737876 DOI: 10.1109/embc.2015.7319976] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tumor Treating Fields (TTFields), low-intensity electric fields in the frequency range of 100-500 kHz, exhibit antimitotic activity in cancer cells. TTFields were approved by the U. S. Food and Drug Administration for the treatment of recurrent glioblastoma in 2011. Preclinical evidence and pilot studies suggest that TTFields could be effective for treating certain types of lung cancer, and that treatment efficacy depends on the electric field intensity. To optimize TTFields delivery to the lungs, it is important to understand how TTFields distribute within the chest. Here we present simulations showing how TTFields are distributed in the thorax and torso, and demonstrate how the electric field distribution within the body can be controlled by personalizing the layout of the arrays used to deliver the field.
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Wenger C, Salvador R, Basser PJ, Miranda PC. Modeling Tumor Treating fields (TTFields) application within a realistic human head model. Annu Int Conf IEEE Eng Med Biol Soc 2016; 2015:2555-8. [PMID: 26736813 DOI: 10.1109/embc.2015.7318913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Tumor Treating Fields (TTFields) are an antimitotic treatment against brain and other tumors. They are applied regionally and non-invasively by inducing intermediate frequency (100-300 kHz) alternating electric field of intensities between 1 to 3 V/cm through transducer arrays placed on the patient's skin close to the tumor. All TTFields studies predicted variability in treatment response among patients, whereas in vitro experiments indicate that the magnitude and direction of the electric field in the tumor might be crucial determinants of efficacy. Differences in the field might arise from varying tumor positions or array placement. By investigating different scenarios within a realistic human head model we hope to advance our understanding of TTFields therapy in clinical practice. We constructed a model from MRI data to calculate the electric field distribution in the brain using the Finite Element Method. An anisotropic electrical conductivity tensor was estimated using diffusion tensor imaging data. The head model contained different tissue types: scalp, skull, cerebrospinal fluid, gray and white matter. Additionally a virtual spherical tumor was included, two positions for the tumor were considered. Transducer arrays were placed on the scalp to model the commonly used device for TTFields delivery. One additional setup of the two transducer pairs was specifically adapted to the second tumor position. The results predict that the electric field strength exceeds the assumed therapeutic threshold value of 1 V/cm in both tumors for both active array pairs. For the second tumor the adapted transducer layout improved field delivery. The average field strength in the tumor further depends on tumor electrical properties. Yet a cystic and a solid tumor experience the same average field strength when treated with TTFields. As a next step towards personalized TTFields therapy, we will explore possible benefits of individualized treatment planning.
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Wenger C, Salvador R, Basser PJ, Miranda PC. Improving Tumor Treating Fields Treatment Efficacy in Patients With Glioblastoma Using Personalized Array Layouts. Int J Radiat Oncol Biol Phys 2016; 94:1137-43. [DOI: 10.1016/j.ijrobp.2015.11.042] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 10/12/2015] [Accepted: 11/30/2015] [Indexed: 11/24/2022]
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Robins HI, Zhang P, Gilbert MR, Chakravarti A, de Groot JF, Grimm SA, Wang F, Lieberman FS, Krauze A, Trotti AM, Mohile N, Kee AYJ, Colman H, Cavaliere R, Kesari S, Chmura SJ, Mehta M. A randomized phase I/II study of ABT-888 in combination with temozolomide in recurrent temozolomide resistant glioblastoma: an NRG oncology RTOG group study. J Neurooncol 2016; 126:309-16. [PMID: 26508094 PMCID: PMC4720526 DOI: 10.1007/s11060-015-1966-z] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 10/21/2015] [Indexed: 11/28/2022]
Abstract
This study tested the hypothesis that ABT-888 (velparib), a poly (ADP-ribose) polymerase (PARP) inhibitor, can modulate temozolomide (TMZ) resistance in recurrent TMZ refractory glioblastoma patients. The combination regimen (TMZ/ABT-888) was tested using two randomized schedules (5 vs. 21 days), with 6-month progression free survival (PFS6) as the primary endpoint. The maximum tolerated dose (MTD) for TMZ using the 21 day of 28 TMZ schedule, in concert with 40 mg BID ABT-888 was determined in a phase I portion of this study, and previously reported to be 75 mg/m(2) (arm1). The MTD for ABT-888 (40 mg BID) and the 5 of 28 day TMZ (150-200 mg/m(2)) schedule was known from prior trials (arm2). Two cohorts were studied: bevacizumab (BEV) naïve (n = 151), and BEV refractory (n = 74). Overall ten patients were ineligible. The incidence rate of grade 3/4 myelosuppression over all was 20.0 %. For the BEV refractory cohort, the PFS 6 was 4.4 %; for the BEV naïve cohort, PFS6 was 17 %. Overall survival was similar for both arms in both the BEV naïve [median survival time (MST) 10.3 M; 95 % CI 8.4-12] and BEV refractory cohort (MST 4.7 M; 95 %CI 3.5-5.6). The median PFS was essentially the same for both arms and both cohorts at ~2.0 M (95 % CI 1.9-2.1).
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Affiliation(s)
- H Ian Robins
- Paul Carbone Comprehensive Cancer Center, University of Wisconsin, 600 Highland Avenue, Madison, WI, 53792, USA.
| | - Peixin Zhang
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA
| | - Mark R Gilbert
- National Cancer Institute at the National Institutes of Health, Bethesda, MD, USA
| | | | - John F de Groot
- University of Texas-MD Anderson Cancer Center, Houston, TX, USA
| | | | - Fen Wang
- University of Kansas, Kansas City, KS, USA
| | | | - Andra Krauze
- National Cancer Institute Radiation Oncology Branch, Bethesda, MD, USA
| | - Andy M Trotti
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | | | | | - Howard Colman
- University of Utah Health Science Center, Salt Lake City, UT, USA
| | | | - Santosh Kesari
- Departments of Neurosciences and Radiation Medicine & Applied Sciences, UC San Diego Health Sciences, La Jolla, CA, USA
| | | | - Minesh Mehta
- University of Maryland Medical Systems, Baltimore, MD, USA
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Abstract
Glioblastoma is the most common and aggressive primary brain tumor in adults. Defining histopathologic features are necrosis and endothelial proliferation, resulting in the assignment of grade IV, the highest grade in the World Health Organization (WHO) classification of brain tumors. The classic clinical term "secondary glioblastoma" refers to a minority of glioblastomas that evolve from previously diagnosed WHO grade II or grade III gliomas. Specific point mutations of the genes encoding isocitrate dehydrogenase (IDH) 1 or 2 appear to define molecularly these tumors that are associated with younger age and more favorable outcome; the vast majority of glioblastomas are IDH wild-type. Typical molecular changes in glioblastoma include mutations in genes regulating receptor tyrosine kinase (RTK)/rat sarcoma (RAS)/phosphoinositide 3-kinase (PI3K), p53, and retinoblastoma protein (RB) signaling. Standard treatment of glioblastoma includes surgery, radiotherapy, and alkylating chemotherapy. Promoter methylation of the gene encoding the DNA repair protein, O(6)-methylguanyl DNA methyltransferase (MGMT), predicts benefit from alkylating chemotherapy with temozolomide and guides choice of first-line treatment in elderly patients. Current developments focus on targeting the molecular characteristics that drive the malignant phenotype, including altered signal transduction and angiogenesis, and more recently, various approaches of immunotherapy.
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Abstract
Glioblastoma, a WHO grade IV astrocytoma, is the most common primary malignant brain tumor in adults. It is characterized by molecular heterogeneity and aggressive behavior. Glioblastoma is almost always incurable and most older patients survive less than 6 months. Supportive care with steroids and anti-epileptic drugs is critical to improving and maintain quality of life. Young age, good performance status and methylation of the methyl guanyl methyl transferase promoter are important positive prognostic factors. Several recent clinical trials suggest that there is a subset of the elderly with prolonged survival that is comparable to younger patients. Treatment of glioblastoma in older patients includes maximal safe resection followed by either radiation, chemotherapy or combined modality therapy. Recent advances suggest that some patients can avoid radiation entirely and be treated with chemotherapy alone. Decisions about therapy are individual and based on a patient's performance status, family support and molecular features. Future work needs to better determine the role for comprehensive geriatric assessments in this patient population to better identify patients who may most benefit from aggressive therapies.
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Affiliation(s)
- Nimish A Mohile
- Department of Neurology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 704, Rochester, NY 14642, USA.
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25
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Lok E, Swanson KD, Wong ET. Tumor treating fields therapy device for glioblastoma: physics and clinical practice considerations. Expert Rev Med Devices 2015; 12:717-26. [DOI: 10.1586/17434440.2015.1086641] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Wenger C, Salvador R, Basser PJ, Miranda PC. The electric field distribution in the brain during TTFields therapy and its dependence on tissue dielectric properties and anatomy: a computational study. Phys Med Biol 2015; 60:7339-57. [PMID: 26350296 DOI: 10.1088/0031-9155/60/18/7339] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Tumor treating fields (TTFields) are a non-invasive, anti-mitotic and approved treatment for recurrent glioblastoma multiforme (GBM) patients. In vitro studies have shown that inhibition of cell division in glioma is achieved when the applied alternating electric field has a frequency in the range of 200 kHz and an amplitude of 1-3 V cm(-1). Our aim is to calculate the electric field distribution in the brain during TTFields therapy and to investigate the dependence of these predictions on the heterogeneous, anisotropic dielectric properties used in the computational model. A realistic head model was developed by segmenting MR images and by incorporating anisotropic conductivity values for the brain tissues. The finite element method (FEM) was used to solve for the electric potential within a volume mesh that consisted of the head tissues, a virtual lesion with an active tumour shell surrounding a necrotic core, and the transducer arrays. The induced electric field distribution is highly non-uniform. Average field strength values are slightly higher in the tumour when incorporating anisotropy, by about 10% or less. A sensitivity analysis with respect to the conductivity and permittivity of head tissues shows a variation in field strength of less than 42% in brain parenchyma and in the tumour, for values within the ranges reported in the literature. Comparing results to a previously developed head model suggests significant inter-subject variability. This modelling study predicts that during treatment with TTFields the electric field in the tumour exceeds 1 V cm(-1), independent of modelling assumptions. In the future, computational models may be useful to optimize delivery of TTFields.
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Affiliation(s)
- Cornelia Wenger
- Institute of Biophysics and Biomedical Engineering, Faculdade de Ciências, Universidade de Lisboa, 1749-016 Lisboa, Portugal
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Lok E, Hua V, Wong ET. Computed modeling of alternating electric fields therapy for recurrent glioblastoma. Cancer Med 2015; 4:1697-9. [PMID: 26311253 PMCID: PMC4673996 DOI: 10.1002/cam4.519] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 08/03/2015] [Indexed: 11/30/2022] Open
Abstract
Tumor treating fields (TTFields) are alternating electric fields frequency tuned to 200 kHz for the treatment of recurrent glioblastoma. We report a patient treated with TTFields and determined the distribution of TTFields intracranially by computerized simulation using co-registered postgadolinium T1-weighted, T2, and MP RAGE images together with pre-specified conductivity and relative permittivity values for various cerebral structures. The distribution of the electric fields within the brain is inhomogeneous. Higher field intensities were aggregated near the ventricles, particularly at the frontal and occipital horns. The recurred tumor was found distant from the primary glioblastoma and it was located at a site of relatively lower electric field intensity. Future improvement in TTFields treatment may need to take into account the inhomogeneity of the electric field distribution within the brain.
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Affiliation(s)
- Edwin Lok
- Brain Tumor Center and Neuro-Oncology Unit, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Van Hua
- Brain Tumor Center and Neuro-Oncology Unit, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Massachusetts College of Pharmacy and Health Sciences University, Boston, Massachusetts
| | - Eric T Wong
- Brain Tumor Center and Neuro-Oncology Unit, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Physics, University of Massachusetts at Lowell, Lowell, Massachusetts
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Abstract
OPINION STATEMENT Glioblastoma is a deadly disease and even aggressive neurosurgical resection followed by radiation and chemotherapy only extends patient survival to a median of 1.5 years. The challenge in treating this type of tumor stems from the rapid proliferation of the malignant glioma cells, the diffuse infiltrative nature of the disease, multiple activated signal transduction pathways within the tumor, development of resistant clones during treatment, the blood brain barrier that limits the delivery of drugs into the central nervous system, and the sensitivity of the brain to treatment effect. Therefore, new therapies that possess a unique mechanism of action are needed to treat this tumor. Recently, alternating electric fields, also known as tumor treating fields (TTFields), have been developed for the treatment of glioblastoma. TTFields use electromagnetic energy at an intermediate frequency of 200 kHz as a locoregional intervention and act to disrupt tumor cells as they undergo mitosis. In a phase III clinical trial for recurrent glioblastoma, TTFields were shown to have equivalent efficacy when compared to conventional chemotherapies, while lacking the typical side effects associated with chemotherapies. Furthermore, an interim analysis of a recent clinical trial in the upfront setting demonstrated superiority to standard of care cytotoxic chemotherapy, most likely because the subjects' tumors were at an earlier stage of clonal evolution, possessed less tumor-induced immunosuppression, or both. Therefore, it is likely that the efficacy of TTFields can be increased by combining it with other anti-cancer treatment modalities.
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Affiliation(s)
- Eric T Wong
- Brain Tumor Center and Neuro-Oncology Unit, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA,
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Weller M, Wick W, Aldape K, Brada M, Berger M, Pfister SM, Nishikawa R, Rosenthal M, Wen PY, Stupp R, Reifenberger G. Glioma. Nat Rev Dis Primers 2015; 1:15017. [PMID: 27188790 DOI: 10.1038/nrdp.2015.17] [Citation(s) in RCA: 607] [Impact Index Per Article: 67.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gliomas are primary brain tumours that are thought to derive from neuroglial stem or progenitor cells. On the basis of their histological appearance, they have been traditionally classified as astrocytic, oligodendroglial or ependymal tumours and assigned WHO grades I-IV, which indicate different degrees of malignancy. Tremendous progress in genomic, transcriptomic and epigenetic profiling has resulted in new concepts of classifying and treating gliomas. Diffusely infiltrating gliomas in adults are now separated into three overarching tumour groups with distinct natural histories, responses to treatment and outcomes: isocitrate dehydrogenase (IDH)-mutant, 1p/19q co-deleted tumours with mostly oligodendroglial morphology that are associated with the best prognosis; IDH-mutant, 1p/19q non-co-deleted tumours with mostly astrocytic histology that are associated with intermediate outcome; and IDH wild-type, mostly higher WHO grade (III or IV) tumours that are associated with poor prognosis. Gliomas in children are molecularly distinct from those in adults, the majority being WHO grade I pilocytic astrocytomas characterized by circumscribed growth, favourable prognosis and frequent BRAF gene fusions or mutations. Ependymal tumours can be molecularly subdivided into distinct epigenetic subgroups according to location and prognosis. Although surgery, radiotherapy and alkylating agent chemotherapy are still the mainstay of treatment, individually tailored strategies based on tumour-intrinsic dominant signalling pathways and antigenic tumour profiles may ultimately improve outcome. For an illustrated summary of this Primer, visit: http://go.nature.com/TXY7Ri.
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Affiliation(s)
- Michael Weller
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Frauenklinikstrasse 26, CH-8091 Zurich, Switzerland
| | - Wolfgang Wick
- Neurology Clinic, University of Heidelberg and German Cancer Research Center, Heidelberg, Germany
| | - Ken Aldape
- Department of Pathology, University Health Network, Toronto, Ontario, Canada
| | - Michael Brada
- Department of Molecular and Clinical Cancer Medicine and Department of Radiation Oncology, University of Liverpool and Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
| | - Mitchell Berger
- Department of Neurological Surgery and Brain Tumor Research Center, University of California, San Francisco, California, USA
| | - Stefan M Pfister
- Division of Pediatric Neuro-Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Pediatric Haematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ryo Nishikawa
- Department of Neuro-Oncology and Neurosurgery, Saitama Medical University, Saitama, Japan
| | - Mark Rosenthal
- Department of Medical Oncology, The Royal Melbourne Hospital, Victoria 3050, Australia
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Roger Stupp
- Department of Oncology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Guido Reifenberger
- Department of Neuropathology, Heinrich Heine University Düsseldorf, and German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ) Heidelberg, partner site Essen/Düsseldorf, Germany
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Wong ET, Lok E, Gautam S, Swanson KD. Dexamethasone exerts profound immunologic interference on treatment efficacy for recurrent glioblastoma. Br J Cancer 2015; 113:232-41. [PMID: 26125449 PMCID: PMC4506397 DOI: 10.1038/bjc.2015.238] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/23/2015] [Accepted: 06/04/2015] [Indexed: 12/31/2022] Open
Abstract
Background: Patients with recurrent glioblastoma have a poor outcome. Data from the phase III registration trial comparing tumour-treating alternating electric fields (TTFields) vs chemotherapy provided a unique opportunity to study dexamethasone effects on patient outcome unencumbered by the confounding immune and myeloablative side effects of chemotherapy. Methods: Using an unsupervised binary partitioning algorithm, we segregated both cohorts of the trial based on the dexamethasone dose that yielded the greatest statistical difference in overall survival (OS). The results were validated in a separate cohort treated in a single institution with TTFields and their T lymphocytes were correlated with OS. Results: Patients who used dexamethasone doses >4.1 mg per day had a significant reduction in OS when compared with those who used ⩽4.1 mg per day, 4.8 vs 11.0 months respectively (χ2=34.6, P<0.0001) in the TTField-treated cohort and 6.0 vs 8.9 months respectively (χ2=10.0, P<0.0015) in the chemotherapy-treated cohort. In a single institution validation cohort treated with TTFields, the median OS of patients who used dexamethasone >4.1 mg per day was 3.2 months compared with those who used ⩽4.1 mg per day was 8.7 months (χ2=11.1, P=0.0009). There was a significant correlation between OS and T-lymphocyte counts. Conclusions: Dexamethasone exerted profound effects on both TTFields and chemotherapy efficacy resulting in lower patient OS. Therefore, global immunosuppression by dexamethasone likely interferes with immune functions that are necessary for the treatment of glioblastoma.
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Affiliation(s)
- E T Wong
- Brain Tumor Center and Neuro-Oncology Unit, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - E Lok
- Brain Tumor Center and Neuro-Oncology Unit, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - S Gautam
- Division of Biostatistics, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - K D Swanson
- Brain Tumor Center and Neuro-Oncology Unit, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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Lee ST, Park CK, Kim JW, Park MJ, Lee H, Lim JA, Choi SH, Kim TM, Lee SH, Park SH, Kim IH, Lee KM. Early cognitive function tests predict early progression in glioblastoma. Neurooncol Pract 2015; 2:137-143. [PMID: 31386094 DOI: 10.1093/nop/npv007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Indexed: 11/15/2022] Open
Abstract
Background Early progression of glioblastoma prevents patients from completing the standard chemoradiation protocol. Given that cognitive function is associated with prognosis in glioblastoma, we investigated the usefulness of preoperative cognitive function tests for predicting the early progression of glioblastoma. Methods Consecutive patients who underwent glioma surgery were preoperatively evaluated with cognitive function tests including the Mini Mental State Examination, digit span tests, the Controlled Oral Word Association Test, the Trail Making Tests (TMT, parts A, B, and C), and the Stroop test. Glioblastomas were treated with a standard protocol using radiation and temozolomide, and 6-month progression-free survival (PFS-6) was analyzed retrospectively. Results Among 126 patients who underwent glioma surgery, 55 patients were diagnosed with glioblastoma, and 50 patients were eligible for the PFS-6 analysis. Thirty-four patients (68%) achieved PFS-6. No significant differences were observed in demographics or tumor characteristics between patients without progression (PFS-6) or patients with progression (no-PFS-6). In the cognitive function tests, the PFS-6 patients exhibited better performance in TMT-A and TMT-B. In a multivariate logistic regression, TMT-B was the only independent predictor for PFS-6, whereas age, years of education, gross total or near total resection, concomitant chemoradiation, and TMT-A were not predictors. Patients with good TMT-B performance exhibited better early prognosis in the Kaplan-Meier survival analysis and had better recursive partitioning analysis classes. Conclusions Our results indicated that preoperative TMTs can be useful for rapid evaluation of early prognosis in patients with glioblastoma.
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Affiliation(s)
- Soon-Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea (S.-T.L., H.L., J.-A.L., K.-M.L.); Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea (C.-K.P., J.W.K., M.-J.P.); Department of Radiology, Seoul National University Hospital, Seoul, Korea (S.H.C.); Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea (T.M.K., S.-H.L.); Department of Pathology, Seoul National University Hospital, Seoul, Korea (S.-H.P.); Department of Radiation Oncology,Seoul National University Hospital, Seoul, Korea (I.H.K.)
| | - Chul-Kee Park
- Department of Neurology, Seoul National University Hospital, Seoul, Korea (S.-T.L., H.L., J.-A.L., K.-M.L.); Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea (C.-K.P., J.W.K., M.-J.P.); Department of Radiology, Seoul National University Hospital, Seoul, Korea (S.H.C.); Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea (T.M.K., S.-H.L.); Department of Pathology, Seoul National University Hospital, Seoul, Korea (S.-H.P.); Department of Radiation Oncology,Seoul National University Hospital, Seoul, Korea (I.H.K.)
| | - Jin Wook Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea (S.-T.L., H.L., J.-A.L., K.-M.L.); Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea (C.-K.P., J.W.K., M.-J.P.); Department of Radiology, Seoul National University Hospital, Seoul, Korea (S.H.C.); Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea (T.M.K., S.-H.L.); Department of Pathology, Seoul National University Hospital, Seoul, Korea (S.-H.P.); Department of Radiation Oncology,Seoul National University Hospital, Seoul, Korea (I.H.K.)
| | - Min-Jung Park
- Department of Neurology, Seoul National University Hospital, Seoul, Korea (S.-T.L., H.L., J.-A.L., K.-M.L.); Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea (C.-K.P., J.W.K., M.-J.P.); Department of Radiology, Seoul National University Hospital, Seoul, Korea (S.H.C.); Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea (T.M.K., S.-H.L.); Department of Pathology, Seoul National University Hospital, Seoul, Korea (S.-H.P.); Department of Radiation Oncology,Seoul National University Hospital, Seoul, Korea (I.H.K.)
| | - Hyon Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea (S.-T.L., H.L., J.-A.L., K.-M.L.); Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea (C.-K.P., J.W.K., M.-J.P.); Department of Radiology, Seoul National University Hospital, Seoul, Korea (S.H.C.); Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea (T.M.K., S.-H.L.); Department of Pathology, Seoul National University Hospital, Seoul, Korea (S.-H.P.); Department of Radiation Oncology,Seoul National University Hospital, Seoul, Korea (I.H.K.)
| | - Jung-Ah Lim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea (S.-T.L., H.L., J.-A.L., K.-M.L.); Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea (C.-K.P., J.W.K., M.-J.P.); Department of Radiology, Seoul National University Hospital, Seoul, Korea (S.H.C.); Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea (T.M.K., S.-H.L.); Department of Pathology, Seoul National University Hospital, Seoul, Korea (S.-H.P.); Department of Radiation Oncology,Seoul National University Hospital, Seoul, Korea (I.H.K.)
| | - Seung Hong Choi
- Department of Neurology, Seoul National University Hospital, Seoul, Korea (S.-T.L., H.L., J.-A.L., K.-M.L.); Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea (C.-K.P., J.W.K., M.-J.P.); Department of Radiology, Seoul National University Hospital, Seoul, Korea (S.H.C.); Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea (T.M.K., S.-H.L.); Department of Pathology, Seoul National University Hospital, Seoul, Korea (S.-H.P.); Department of Radiation Oncology,Seoul National University Hospital, Seoul, Korea (I.H.K.)
| | - Tae Min Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea (S.-T.L., H.L., J.-A.L., K.-M.L.); Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea (C.-K.P., J.W.K., M.-J.P.); Department of Radiology, Seoul National University Hospital, Seoul, Korea (S.H.C.); Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea (T.M.K., S.-H.L.); Department of Pathology, Seoul National University Hospital, Seoul, Korea (S.-H.P.); Department of Radiation Oncology,Seoul National University Hospital, Seoul, Korea (I.H.K.)
| | - Se-Hoon Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea (S.-T.L., H.L., J.-A.L., K.-M.L.); Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea (C.-K.P., J.W.K., M.-J.P.); Department of Radiology, Seoul National University Hospital, Seoul, Korea (S.H.C.); Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea (T.M.K., S.-H.L.); Department of Pathology, Seoul National University Hospital, Seoul, Korea (S.-H.P.); Department of Radiation Oncology,Seoul National University Hospital, Seoul, Korea (I.H.K.)
| | - Sung-Hye Park
- Department of Neurology, Seoul National University Hospital, Seoul, Korea (S.-T.L., H.L., J.-A.L., K.-M.L.); Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea (C.-K.P., J.W.K., M.-J.P.); Department of Radiology, Seoul National University Hospital, Seoul, Korea (S.H.C.); Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea (T.M.K., S.-H.L.); Department of Pathology, Seoul National University Hospital, Seoul, Korea (S.-H.P.); Department of Radiation Oncology,Seoul National University Hospital, Seoul, Korea (I.H.K.)
| | - Il Han Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea (S.-T.L., H.L., J.-A.L., K.-M.L.); Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea (C.-K.P., J.W.K., M.-J.P.); Department of Radiology, Seoul National University Hospital, Seoul, Korea (S.H.C.); Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea (T.M.K., S.-H.L.); Department of Pathology, Seoul National University Hospital, Seoul, Korea (S.-H.P.); Department of Radiation Oncology,Seoul National University Hospital, Seoul, Korea (I.H.K.)
| | - Kyoung-Min Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea (S.-T.L., H.L., J.-A.L., K.-M.L.); Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea (C.-K.P., J.W.K., M.-J.P.); Department of Radiology, Seoul National University Hospital, Seoul, Korea (S.H.C.); Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea (T.M.K., S.-H.L.); Department of Pathology, Seoul National University Hospital, Seoul, Korea (S.-H.P.); Department of Radiation Oncology,Seoul National University Hospital, Seoul, Korea (I.H.K.)
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32
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Affiliation(s)
- Jan C Buckner
- Mayo Clinic, Department of Oncology, Division of Medical Oncology, 200 First Street SW, Rochester, MN 55905
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33
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Abstract
OPINION STATEMENT Glioblastoma (GBM), the most common malignant primary tumor in adults, carries a dismal prognosis with an average median survival of 14-16 months. The current standard of care for newly diagnosed GBM consists of maximal safe resection followed by fractionated radiotherapy combined with concurrent temozolomide and 6 to 12 cycles of adjuvant temozolomide. The determination of treatment response and clinical decision-making in the treatment of GBM depends on accurate radiographic assessment. Differentiating treatment response from tumor progression is challenging and combines long-term follow-up using standard MRI, with assessing clinical status and corticosteroid dependency. At progression, bevacizumab is the mainstay of treatment. Incorporation of antiangiogenic therapies leads to rapid blood-brain barrier normalization with remarkable radiographic response often not accompanied by the expected survival benefit, further complicating imaging assessment. Improved radiographic interpretation criteria, such as the Response Assessment in Neuro-Oncology (RANO) criteria, incorporate non-enhancing disease but still fall short of definitely distinguishing tumor progression, pseudoresponse, and pseudoprogression. With new evolving treatment modalities for this devastating disease, advanced imaging modalities are increasingly becoming part of routine clinical care in a field where neuroimaging has such essential role in guiding treatment decisions and defining clinical trial eligibility and efficacy.
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Affiliation(s)
- Martha R Neagu
- Dana Farber Cancer Institute, G4200, 44 Binney St, Boston, MA, 02115, USA
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34
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Rhun EL, Taillibert S, Chamberlain MC. The future of high-grade glioma: Where we are and where are we going. Surg Neurol Int 2015; 6:S9-S44. [PMID: 25722939 PMCID: PMC4338495 DOI: 10.4103/2152-7806.151331] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 10/15/2014] [Indexed: 01/12/2023] Open
Abstract
High-grade glioma (HGG) are optimally treated with maximum safe surgery, followed by radiotherapy (RT) and/or systemic chemotherapy (CT). Recently, the treatment of newly diagnosed anaplastic glioma (AG) has changed, particularly in patients with 1p19q codeleted tumors. Results of trials currenlty ongoing are likely to determine the best standard of care for patients with noncodeleted AG tumors. Trials in AG illustrate the importance of molecular characterization, which are germane to both prognosis and treatment. In contrast, efforts to improve the current standard of care of newly diagnosed glioblastoma (GB) with, for example, the addition of bevacizumab (BEV), have been largely disappointing and furthermore molecular characterization has not changed therapy except in elderly patients. Novel approaches, such as vaccine-based immunotherapy, for newly diagnosed GB are currently being pursued in multiple clinical trials. Recurrent disease, an event inevitable in nearly all patients with HGG, continues to be a challenge. Both recurrent GB and AG are managed in similar manner and when feasible re-resection is often suggested notwithstanding limited data to suggest benefit from repeat surgery. Occassional patients may be candidates for re-irradiation but again there is a paucity of data to commend this therapy and only a minority of selected patients are eligible for this approach. Consequently systemic therapy continues to be the most often utilized treatment in recurrent HGG. Choice of therapy, however, varies and revolves around re-challenge with temozolomide (TMZ), use of a nitrosourea (most often lomustine; CCNU) or BEV, the most frequently used angiogenic inhibitor. Nevertheless, no clear standard recommendation regarding the prefered agent or combination of agents is avaliable. Prognosis after progression of a HGG remains poor, with an unmet need to improve therapy.
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Affiliation(s)
- Emilie Le Rhun
- Department of Neuro-oncology, Roger Salengro Hospital, University Hospital, Lille, and Neurology, Department of Medical Oncology, Oscar Lambret Center, Lille, France, Inserm U-1192, Laboratoire de Protéomique, Réponse Inflammatoire, Spectrométrie de Masse (PRISM), Lille 1 University, Villeneuve D’Ascq, France
| | - Sophie Taillibert
- Neurology, Mazarin and Radiation Oncology, Pitié Salpétrière Hospital, University Pierre et Marie Curie, Paris VI, Paris, France
| | - Marc C. Chamberlain
- Department of Neurology and Neurological Surgery, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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