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McBriar JD, Schulder M, Skeie BS. First use of radiation for the treatment of arteriovenous malformation. J Neurosurg 2023; 139:1348-1353. [PMID: 37029680 DOI: 10.3171/2023.2.jns23306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 02/09/2023] [Accepted: 02/27/2023] [Indexed: 04/09/2023]
Abstract
In 1921, Norwegian neurosurgeon Vilhelm Magnus (1871-1929) described the first use of radiation for the treatment of an arteriovenous malformation (AVM) in his monograph, Bidrag til hjernechirurgiens klinik og resultater. Seeing as this monograph has never been widely translated nor digitized, the authors discuss the impact of Magnus' original work and the ethics surrounding its citation. The senior author of this paper gained access to and directly translated key sections of Magnus' publication. Without Norwegian language skills, reading and understanding Magnus' text would have been impossible. Magnus described the use of radiation therapy in a single patient found to have an AVM (or "angioma"). He states that she was "well" 8 years later. No other information on that treatment is given, but for good reason Magnus has been given credit in the literature for the first use of radiation of any kind to treat a person with AVM. Most papers that have referenced Magnus' monograph cite it even though it is probable that the authors did not see it, let alone read its contents. While it is appropriate that his innovation has been properly credited, the authors discuss the limits of citing publications sight unseen.
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Affiliation(s)
- Joshua D McBriar
- 1Department of Neurological Surgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York; and
| | - Michael Schulder
- 1Department of Neurological Surgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York; and
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Strømsnes TA, Lund-Johansen M, Skeie GO, Eide GE, Behbahani M, Skeie BS. Growth dynamics of incidental meningiomas: A prospective long-term follow-up study. Neurooncol Pract 2023; 10:238-248. [PMID: 37188168 PMCID: PMC10180371 DOI: 10.1093/nop/npac088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background There is no consensus on the management of incidental meningiomas. The literature on long-term growth dynamics is sparse and the natural history of these tumors remains to be illuminated. Methods We prospectively assessed long-term tumor growth dynamics and survival rates during active monitoring of 62 patients (45 female, mean age 63.9 years) harboring 68 tumors. Clinical and radiological data were obtained every 6 months for 2 years, annually until 5 years, then every second year. Results The natural progression of incidental meningiomas during 12 years of monitoring was growth (P < .001). However, mean growth decelerated at 1.5 years and became insignificant after 8 years. Self-limiting growth patterns were seen in 43 (63.2%) tumors, non-decelerating in 20 (29.4%) and 5 (7.4%) were inconclusive due to ≤ 2 measurements. Decelerating growth persisted once established. Within 5 years, 38 (97.4%) of 39 interventions were initiated. None developed symptoms prior to intervention. Large tumors (P < .001) involving venous sinuses (P = .039) grew most aggressively. Since inclusion 19 (30.6%) patients have died of unrelated causes and 2 (3%) from grade 2 meningiomas. Conclusion Active monitoring seems a safe and appropriate first-line management of incidental meningiomas. Intervention was avoided in > 40% with indolent tumors in this cohort. Treatment was not compromised by tumor growth. Clinical follow-up seems sufficient beyond 5 years if self-limiting growth is established. Steady or accelerating growth warrant monitoring until they reach a stable state or intervention is initiated.
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Affiliation(s)
- Torbjørn Austveg Strømsnes
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Morten Lund-Johansen
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Geir Olve Skeie
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Geir Egil Eide
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Maziar Behbahani
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
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Starck L, Skeie BS, Bartsch H, Grüner R. Arterial input functions in dynamic susceptibility contrast MRI (DSC-MRI) in longitudinal evaluation of brain metastases. Acta Radiol 2023; 64:1166-1174. [PMID: 35786055 DOI: 10.1177/02841851221109702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI) could be helpful to separate true disease progression from pseudo-progression in brain metastases when assessing the need for retreatment. However, the selection of arterial input functions (AIFs) is not standardized for analysis, limiting its use for this application. PURPOSE To compare population-based AIFs, AIFs specific to each patient, and AIFs specific to every visit in the longitudinal follow-up of brain metastases. MATERIAL AND METHODS Longitudinal data were collected from eight patients before treatment (6 of 8 patients) and after treatment (6-17 visits). Imaging was performed using a 1.5-T MRI system. Lesions were segmented by subtracting precontrast images from postcontrast images. Cerebral blood volume (rCBV) and cerebral blood flow (rCBF) were computed, and Pearson's product moment correlation coefficients were calculated to evaluate similarity of DSC parameters dependent on various AIF choices across time. AIF shape characteristics were compared. Parameter differences between white matter (WM) and gray matter (GM) were obtained to determine which AIF choice maximizes tissue differentiation. RESULTS Although DSC parameters follow similar patterns in time, the various AIF selections cause large parameter variations with relative standard deviations of up to ±60%. AIFs sampled in one patient across sessions more similar in shape than AIFs sampled across patients. Estimates of rCBV based on scan-specific AIFs differentiated better between perfusion in WM and GM than patient-specific or population-based AIFs (P ≤ 0.02). CONCLUSION Results indicate that scan-specific AIFs are the best choice for DSC-MRI parameter estimations in the longitudinal follow-up of brain metastases.
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Affiliation(s)
- Lea Starck
- Department of Physics and Technology, 1658University of Bergen, Bergen, Norway
- Mohn Medical Imaging and Visualization Centre, Bergen, Norway
| | - Bente Sandvei Skeie
- Department of Neurosurgery, 60498Haukeland University Hospital, Bergen, Norway
| | - Hauke Bartsch
- Mohn Medical Imaging and Visualization Centre, Bergen, Norway
- Department of Radiology, 60498Haukeland University Hospital, Bergen, Norway
| | - Renate Grüner
- Department of Physics and Technology, 1658University of Bergen, Bergen, Norway
- Mohn Medical Imaging and Visualization Centre, Bergen, Norway
- Department of Radiology, 60498Haukeland University Hospital, Bergen, Norway
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Skeie BS, Schulder M. Book Review. World Neurosurg 2023. [DOI: 10.1016/j.wneu.2023.02.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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Skeie BS, Bragstad S, Sarowar S, Behbahani M, Filippi C, Knisely J, Schulder M, Goplen D, Eide GE, Heggdal JI, Gruner R, Enger PØ. CTNI-40. PHASE I TRIAL OF SULFASALAZINE COMBINED WITH STEREOTACTIC RADIOSURGERY FOR RECURRENT GLIOBLASTOMA: STUDY PROTOCOL FOR NCT04205357. Neuro Oncol 2022. [PMCID: PMC9660770 DOI: 10.1093/neuonc/noac209.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Glioblastoma (GBM) is one of the most aggressive, radioresistant types of cancer with a dismal prognosis. Sulfasalazine (SAS) has shown tumor selective radiosensitizing properties in preclinical studies. The antioxidant glutathione (GSH) produced at high levels in glioma cells normally protects against radiation injury by scavenging reactive oxygen species produced during radiation therapy (RT). SAS blocks cysteine uptake through the xCT-channel, a rate-limiting step for GSH production. We have previously shown slowing of tumor growth and prolonged survival when SAS was combined with stereotactic radiosurgery (SRS) in vivo compared to either treatment alone. Our hypothesis is that SAS potentiates the efficacy of SRS for recurrent GBM with a low risk of adverse events (AE). The primary end-point is to establish the recommended dose for efficacy testing in phase II/III trials. This phase 1 dose-escalation trial utilizes a standard 3 + 3 design with 3-6 patients per cohort. Patients will be treated with oral SAS (1.5, 3.0, 4.5 or 6.0 g/day) 3 days prior to single session SRS. The SAS-dose will be escalated depending on the absence/presence of toxicity in the previous cohort of treated patients. If more than 1 of 3-6 patients ( ≥ 33 %) is experiencing grade 3 or higher toxicity levels, the study will be terminated. The dose below will be the recommended dose. Toxicity is graded using the Common Toxicity Criteria for Adverse Events (CTCAE) v5.0 recorded the first 30 days. Secondary end-points are assessments of 1) intratumoral GSH production (GSH-spectroscopy), 2) late AE utilizing 11C-MET-MRI-PET 3) changes in KPS/quality of life (FACT-Br), 4) need for steroidal treatment, 5) progression free and overall survival. Novel treatment modalities are urgently needed. This trial will establish the recommended dose for SAS repurposed as a radiosensitizer for a future phase 2/3 trial and may ultimately lead to improvement of current GBM treatment.
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Affiliation(s)
- Bente Sandvei Skeie
- Department of Neurosurgery, Haukeland University hospital, Bergen, Norway , Bergen , Norway
| | - Sidsel Bragstad
- Department of Neurosciences, Haukeland University hospital, Bergen, Norway , Bergen , Norway
| | - Shahin Sarowar
- Department of Neurosciences, Haukeland University hospital, Bergen, Norway , Bergen , Norway
| | - Maziar Behbahani
- Department of Neurosurgery, Stavanger University hospital, Stavanger, Norway , Stavanger , Norway
| | | | - Jonathan Knisely
- Department of Radiation Oncology, Weill Cornell Medical School , New York , USA
| | | | - Dorota Goplen
- Department of Oncology, Haukeland University hospital, Bergen, Norway , Bergen , Norway
| | - Geir Egil Eide
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway , Bergen , Norway
| | - Jan Ingemann Heggdal
- Department of Oncology, Haukeland University hospital, Bergen, Norway , Bergen , Norway
| | - Renate Gruner
- Centre for Clinical Research, Haukeland University Hospital, Norway , Bergen , Norway
| | - Per Øyvind Enger
- Department of Neurosurgery, Stavanger University hospital, Stavanger, Norway , Stavanger , Norway
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Santacroce A, Tuleasca C, Liščák R, Motti E, Lindquist C, Radatz M, Gatterbauer B, Lippitz BE, Martínez Álvarez R, Martínez Moreno N, Kamp MA, Sandvei Skeie B, Schipmann S, Longhi M, Unger F, Sabin I, Mindermann T, Bundschuh O, Horstmann GA, van Eck AJ, Walier M, Berres M, Nakamura M, Steiger HJ, Hänggi D, Fortmann T, Alsofy SZ, Régis J, Ewelt C. Stereotactic Radiosurgery for Benign Cavernous Sinus Meningiomas: A Multicentre Study and Review of the Literature. Cancers (Basel) 2022; 14:cancers14164047. [PMID: 36011041 PMCID: PMC9406912 DOI: 10.3390/cancers14164047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/17/2022] [Revised: 06/17/2022] [Accepted: 07/02/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Meningiomas are the most common tumours of the central nervous system (CNS). Despite their benign histology, proximity to critical neurovascular structures may lead to significant morbidity with tumour growth. This is the case for cavernous sinus meningiomas (CSMs), as their growth may surround critical neuro-vascular structures and cause significant morbidity. Radical microsurgical resection carries a high risk of additional neurological deficits, as well as the risk of death. Current management of these tumours, where treatment is indicated, has moved away from radical surgery towards radiotherapy/radiosurgery. This is particularly the case for patients who have residual or recurring tumours after previous surgery. There are many reports that describe the effectiveness of using stereotactic radiosurgery (SRS) for CSMs; however, large cohort analyses are lacking. This multicentre analysis reports the outcome data of over 1000 patients with CSMs who were treated with SRS. SRS shows a high local tumour control rate with few complications. These results agree with previous reports in the literature. SRS is a valuable primary or adjuvant treatment option for CSMs. Abstract Cavernous sinus meningiomas (CSMs) remain a surgical challenge due to the intimate involvement of their contained nerves and blood vessels. Stereotactic radiosurgery (SRS) is a safe and effective minimally invasive alternative for the treatment of small- to medium-sized CSMs. Objective: To assess the medium- to long-term outcomes of SRS for CSMs with respect to tumour growth, prevention of further neurological deterioration and improvement of existing neurological deficits. This multicentric study included data from 15 European institutions. We performed a retrospective observational analysis of 1222 consecutive patients harbouring 1272 benign CSMs. All were treated with Gamma Knife stereotactic radiosurgery (SRS). Clinical and imaging data were retrieved from each centre and entered into a common database. All tumours with imaging follow-up of less than 24 months were excluded. Detailed results from 945 meningiomas (86%) were then analysed. Clinical neurological outcomes were available for 1042 patients (85%). Median imaging follow-up was 67 months (mean 73.4, range 24–233). Median tumour volume was 6.2 cc (+/−7), and the median marginal dose was 14 Gy (+/−3). The post-treatment tumour volume decreased in 549 (58.1%), remained stable in 336 (35.6%) and increased in only 60 lesions (6.3%), yielding a local tumour control rate of 93.7%. Only 27 (2.8%) of the 60 enlarging tumours required further treatment. Five- and ten-year actuarial progression-free survival (PFS) rates were 96.7% and 90.1%, respectively. Tumour control rates were higher for women than men (p = 0.0031), and also for solitary sporadic meningiomas (p = 0.0201). There was no statistically significant difference in outcome for imaging-defined meningiomas when compared with histologically proven WHO Grade-I meningiomas (p = 0.1212). Median clinical follow up was 61 months (mean 64, range 6–233). Permanent morbidity occurred in 5.9% of cases at last follow-up. Stereotactic radiosurgery is a safe and effective method for treating benign CSM in the medium term to long term.
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Affiliation(s)
- Antonio Santacroce
- Department of Neurosurgery, St. Barbara-Klinik Hamm-Heessen, 59073 Hamm, Germany
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58455 Witten, Germany
- Correspondence:
| | - Constantin Tuleasca
- Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
- Faculté de Biologie et de Médecine (FBM), Université de Lausanne (Unil), 1005 Lausanne, Switzerland
- Signal Processing Laboratory (LTS 5), Swiss Federal Institute of Technology (EPFL), 1015 Lausanne, Switzerland
- Faculté de Médecine, Sorbonné Université, 70513 Paris, France
- Assisstance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Sud, Centre Hospitalier Universitaire Bicêtre, Service de Neurochirurgie, 94270 Le Kremlin-Bicêtre, France
| | - Roman Liščák
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, 15000 Prague, Czech Republic
| | - Enrico Motti
- Dipartimento di Neuroscienze, Neurochirurgia, Università degli Studi di Milano, 20122 Milano, Italy; Villa Maria Cecilia Hospital, 48033 Cotignola, Italy
| | | | - Matthias Radatz
- National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
| | | | - Bodo E. Lippitz
- Interdisciplinary Centre for Radiosurgery (ICERA), Radiological Alliance, 22767 Hamburg, Germany
| | | | | | - Marcel A. Kamp
- Department of Neurosurgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07747 Jena, Germany
| | - Bente Sandvei Skeie
- Department of Neurosurgery, Haukeland University Hospital, 5021 Bergen, Norway
| | - Stephanie Schipmann
- Department of Neurosurgery, Haukeland University Hospital, 5021 Bergen, Norway
| | - Michele Longhi
- Unit of Radiosurgery and Stereotactic Neurosurgery, Department of Neurosciences, Azienda Ospedaliera Universitaria, 37126 Verona, Italy
| | - Frank Unger
- Department of Neurosurgery, Medical University Graz, 8036 Graz, Austria
| | - Ian Sabin
- Gamma Knife Unit, Wellington Hospital (Platinum Medical Centre), London NW8 7JA, UK
| | - Thomas Mindermann
- Gamma Knife Center Zurich, Klinik Im Park Hirslanden, 8002 Zurich, Switzerland
| | | | | | | | - Maja Walier
- Institute of Medical Biometry, Epidemiology and Informatics, University Medical Center of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
- Department of Mathematics and Technology, University of Applied Sciences Koblenz, Joseph-Rovan-Allee 2, 53424 Remagen, Germany
| | - Manfred Berres
- Institute of Medical Biometry, Epidemiology and Informatics, University Medical Center of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
- Department of Mathematics and Technology, University of Applied Sciences Koblenz, Joseph-Rovan-Allee 2, 53424 Remagen, Germany
| | - Makoto Nakamura
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58455 Witten, Germany
- Department of Neurosurgery, Academic Hospital Köln-Merheim, 51058 Köln, Germany
| | - Hans Jakob Steiger
- Department of Neurosurgery, Heinrich-Heine-Universität Düsseldorf, 40225 Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, Heinrich-Heine-Universität Düsseldorf, 40225 Düsseldorf, Germany
| | - Thomas Fortmann
- Department of Neurosurgery, St. Barbara-Klinik Hamm-Heessen, 59073 Hamm, Germany
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58455 Witten, Germany
| | - Samer Zawy Alsofy
- Department of Neurosurgery, St. Barbara-Klinik Hamm-Heessen, 59073 Hamm, Germany
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58455 Witten, Germany
| | - Jean Régis
- Service de Neurochirurgie Fonctionnelle et Stereotaxique, Hôpital D’adulte de la Timone, 13354 Marseille, France
| | - Christian Ewelt
- Department of Neurosurgery, St. Barbara-Klinik Hamm-Heessen, 59073 Hamm, Germany
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, 48149 Munster, Germany
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Starck L, Skeie BS, Moen G, Grüner R. Dynamic Susceptibility Contrast MRI May Contribute in Prediction of Stereotactic Radiosurgery Outcome in Brain Metastases. Neurooncol Adv 2022; 4:vdac070. [PMID: 35673606 PMCID: PMC9167634 DOI: 10.1093/noajnl/vdac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 11/12/2022] Open
Abstract
Background Following stereotactic radiosurgery (SRS), predicting treatment response is not possible at an early stage using structural imaging alone. Hence, the current study aims at investigating whether dynamic susceptibility contrast (DSC)-MRI estimated prior to SRS can provide predictive biomarkers in response to SRS treatment and characterize vascular characteristics of pseudo-progression. Methods In this retrospective study, perfusion-weighted DSC-MRI image data acquired with a temporal resolution of 1.45 seconds were collected from 41 patients suffering from brain metastases. Outcome was defined based on lesion volume changes in time (determined on structural images) or death. Motion correction and manual lesion delineation were performed prior to semi-automated, voxel-wise perfusion analysis. Statistical testing was performed using linear regression and a significance threshold at P = .05. Age, sex, primary cancers (pulmonary cancer and melanoma), lesion volume, and dichotomized survival time were added as covariates in the linear regression models (ANOVA). Results Relative cerebral blood volume (rCBV) and relative cerebral blood flow (rCBF) were found to be significantly lower prior to SRS treatment in patients with increasing lesion volume or early death post-SRS (P ≤ .01). Conclusion Unfavorable treatment outcome may be linked to low perfusion prior to SRS. Pseudo-progression may be preceded by a transient rCBF increase post-SRS. However, results should be verified in different or larger patient material.
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Affiliation(s)
- Lea Starck
- Department of Physics and Technology, University of Bergen, Norway
- Mohn Medical Imaging and Visualization Centre, Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | | | - Gunnar Moen
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | - Renate Grüner
- Department of Physics and Technology, University of Bergen, Norway
- Mohn Medical Imaging and Visualization Centre, Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
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Strømsnes TA, Lund-Johansen M, Skeie GO, Skeie BS. NCOG-33. GROWTH DYNAMICS OF INCIDENTAL MENINGIOMAS - A 10-YEAR PROSPECTIVE STUDY. Neuro Oncol 2021. [DOI: 10.1093/neuonc/noab196.623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
There is no consensus for the management of incidental meningiomas. To evaluate the natural history, we assessed tumour growth dynamics during 10 years of active monitoring of 62 patients (45 female and mean age 63.9) harbouring 68 tumours. Radiological and clinical data was obtained was obtained biannually for two years, then annually the following eight. Thirty-six patients (38 tumours) were referred to treatment and/or died of unrelated causes (n=5) within 5 years. The remaining were monitored for up to 10 years. Mean overall survival was at 128 months (95% CI: 118.8-136.7). Median progression free survival was 34 months (95% CI: 14.7-53.3). Median time for growth requiring intervention was 46 months (95% CI: 23.5-68.5). All tumours with self-limiting growth at 5 years (57.9 %) were still stable or reducing in size at 10 years. Mean growth rate decreased from 0.27 cm3/year (95% CI: 0.10-0.43) during the early observation period (0-5 years) to 0.09 cm3/year (95% CI: -0.02-0.21) in the late observation period. No tumours were referred to treatment during the late observation period. Two patients, both with verified WHO2 grade meningiomas succumbed to the disease, seven and eight years after diagnosis. No other patients developed symptoms and none other of the 18 total mortalities were meningioma related. Most clinical and radiological events occur within 5 years after diagnosis. Our findings suggests that if tumour growth slows down during the first 5 years of monitoring, this trend will continue. Clinical follow-up should be sufficient when a self-limiting growth pattern has been established.
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Affiliation(s)
| | | | - Geir Olve Skeie
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Skeie BS, Enger PØ, Knisely J, Pedersen PH, Heggdal JI, Eide GE, Skeie GO. A simple score to estimate the likelihood of pseudoprogression vs. recurrence following stereotactic radiosurgery for brain metastases: The Bergen Criteria. Neurooncol Adv 2020; 2:vdaa026. [PMID: 32642686 PMCID: PMC7212847 DOI: 10.1093/noajnl/vdaa026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Indexed: 11/13/2022] Open
Abstract
Background A major challenge in the follow-up of patients treated with stereotactic radiosurgery (SRS) for brain metastases (BM) is to distinguish pseudoprogression (PP) from tumor recurrence (TR). The aim of the study was to develop a clinical risk assessment score. Methods Follow-up images of 87 of 97 consecutive patients treated with SRS for 348 BM were analyzed. Of these, 100 (28.7%) BM in 48 (53.9%) patients responded with either TR (n = 53, 15%) or PP (n = 47, 14%). Differences between the 2 groups were analyzed and used to develop a risk assessment score (the Bergen Criteria). Results Factors associated with a higher incidence of PP vs. TR were as follows: prior radiation with whole brain radiotherapy or SRS (P = .001), target cover ratio ≥98% (P = .048), BM volume ≤2 cm3 (P = .054), and primary lung cancer vs. other cancer types (P = .084). Based on the presence (0) or absence (1) of these 5 characteristics, the Bergen Criteria was established. A total score <2 points was associated with 100% PP, 2 points with 57% PP and 43% TR, 3 points with 57% TR and 43% PP, whereas >3 points were associated with 84% TR and 16% PP, P < .001. Conclusion Based on 5 characteristics at the time of SRS the Bergen Criteria could robustly differentiate between PP vs. TR following SRS. The score is user-friendly and provides a useful tool to guide the decision making whether to retreat or observe at appropriate follow-up intervals.
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Affiliation(s)
| | - Per Øyvind Enger
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
| | - Jonathan Knisely
- Department of Radiation Oncology, Weill Cornell Medical College, New York, NY, USA
| | | | - Jan Ingeman Heggdal
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Geir Egil Eide
- Department of Global Public Health and Primary Care, University of Bergen, Norway.,Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Geir Olve Skeie
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Skeie BS, Enger PØ, Pedersen PH, Skeie GO. RADI-23. CLINICAL RISK ASSESSMENT SCORE TO ESTIMATE THE LIKELIHOOD OF PSEUDOPROGRESSION VERSUS TUMOR RECURRENCE FOLLOWING STEREOTACTIC RADIOSURGERY FOR BRAIN METASTASES. Neurooncol Adv 2019. [PMCID: PMC7213319 DOI: 10.1093/noajnl/vdz014.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE: A major challenge in the follow-up of patients managed with stereotactic radiosurgery (SRS) for brain metastases (BM) is to differentiate pseudoprogression (PP) from tumor recurrence (TR). A clinical score based on tumor and treatment related factors would be valuable when selecting appropriate treatment. MATERIAL AND METHODS: Follow-up images of 97 consecutive patients treated with SRS for 406 BM were analyzed. Of these 100 (24.6 %) BM in 48 (49.5 %) patients responded either with TR (delayed growth; 53 (13.1 %) BM) or PP (temporary volume increase; 47 (11.6 %) BM). Differences between the 2 groups were analyzed and used to develop a PP risk assessment score (PP-RAS). RESULTS: Significant factors associated with a higher incidence of PP versus TR were: primary lung cancer vs. other primaries, BM volume ≤ 2cc (or BM ≤ 1.5 cm in diameter), Target cover ratio > 98 % and prior radiation SRS or WBRT. Based on the presence (0) or not (1) of these 5 parameters, a risk assessment score for PP versus TR was established. A PP-RAS score of 0 corresponds with high likelihood of PP vs. TR, whereas a score of 5 corresponds with a high risk of TR. A score of ≤ 1 point was associated with 100 % PP, 2 points with 57 % PP and 43 % TR, 3 points with 57 % TR and 43 % PP, whereas ≥ 4 points were associated with 84 % TR and 16 % PP, π=24.57, df =4, p < 0.001). CONCLUSION: Based on these 5 parameters at the time of SRS our risk assessment score could robustly differentiate between PP versus growth following SRS. The score is user-friendly and may be a useful tool to guide the decision making whether to retreat or observe at appropriate follow-up intervals.
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Behbahani M, Skeie GO, Eide GE, Hausken A, Lund-Johansen M, Skeie BS. A prospective study of the natural history of incidental meningioma-Hold your horses! Neurooncol Pract 2019; 6:438-450. [PMID: 31832214 DOI: 10.1093/nop/npz011] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [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: 01/07/2023] Open
Abstract
Background The number of incidental meningiomas has increased because of the increased availability of neuroimaging. Lack of prospective data on the natural history makes the optimal management unclear. We conducted a 5-year prospective study of incidental meningiomas to identify risk factors for tumor growth. Methods Sixty-four of 70 consecutive patients with incidental meningioma were included. Clinical and radiological status was obtained at 0, 0.5, 1, 1.5, 2, 3, 4, and 5 years. GammaPlan and mixed linear regression modeling were utilized for volumetric analysis with primary endpoint tumor growth. Results None of the patients developed tumor-related symptoms during the study period, although 48 (75%) tumors increased (>15%), 13 (20.3%) remained unchanged, and 3 (4.7%) decreased (>15%) in volume. Mean time to growth was 2.2 years (range, 0.5-5.0 years).The growth pattern was quasi-exponential in 26%, linear in 17%, sigmoidal in 35%, parabolic in 17%, and continuous reduction in 5%. There was significant correlation among growth rate, larger baseline tumor volume (P < .001), and age in years (<55 y: 0.10 cm3/y, 55-75 y: 0.24 cm3/y, and >75 y: 0.85 cm3/y). Conclusion The majority of meningiomas will eventually grow. However, more than 60% display a self-limiting growth pattern. Our study provides level-2 evidence that asymptomatic tumors can be safely managed utilizing serial imaging until persistent radiological and/or symptomatic growth.
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Affiliation(s)
- Maziar Behbahani
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
- Department of Neurosurgery, Stavanger University Hospital, Norway
| | - Geir Olve Skeie
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Geir Egil Eide
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Norway
| | - Annbjørg Hausken
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Morten Lund-Johansen
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Norway
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Bragstad S, Flatebø M, Natvig GK, Eide GE, Skeie GO, Behbahani M, Pedersen PH, Enger PØ, Skeie BS. Predictors of quality of life and survival following Gamma Knife surgery for lung cancer brain metastases: a prospective study. J Neurosurg 2018; 129:71-83. [DOI: 10.3171/2017.2.jns161659] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVELung cancer (LC) patients who develop brain metastases (BMs) have a poor prognosis. Estimations of survival and risk of treatment-related deterioration in quality of life (QOL) are important when deciding on treatment. Although we know of several prognostic factors for LC patients with BMs, the role of QOL has not been established. Authors of this study set out to evaluate changes in QOL following Gamma Knife surgery (GKS) for BMs in LC patients and QOL as a prognostic factor for survival.METHODSForty-four of 48 consecutive LC patients with BMs underwent GKS in the period from May 2010 to September 2011, and their QOL was prospectively assessed before and 1, 3, 6, 9, and 12 months after GKS by using the Functional Assessment of Cancer Therapy–Brain (FACT-BR) questionnaire. A mixed linear regression model was used to identify potential predictive factors for QOL and to assess the effect of GKS and the disease course on QOL at follow-up.RESULTSMean QOL as measured by the brain cancer subscale (BRCS) of the FACT-BR remained stable from baseline (score 53.0) up to 12 months post-GKS (57.1; p = 0.624). The BRCS score improved for 32 patients (72.3%) with a total BM volume ≤ 5 cm3. Mean improvement in these patients was 0.45 points each month of follow-up, compared to a decline of 0.50 points each month despite GKS treatment in patients with BM volumes > 5 cm3 (p = 0.04). Asymptomatic BMs (p = 0.01), a lower recursive partitioning analysis (RPA) classification (p = 0.04), and a higher Karnofsky Performance Scale (KPS) score (p < 0.01) at baseline were predictors for a high, stable QOL after GKS. After multivariate analysis, a high KPS score (p < 0.01) remained the only positive predictor of a high, stable QOL post-GKS.Median survival post-GKS was 5.6 months (95% CI 1.0–10.3). A higher BRCS score (p = 0.01), higher KPS score (p = 0.01), female sex (p = 0.01), and the absence of liver (p = 0.02), adrenal (p = 0.02), and bone metastases (p = 0.03) predicted longer survival in unadjusted models. However, in multivariate analyses, a higher BRCS score (p < 0.01), female sex (p = 0.01), and the absence of bone metastases (p = 0.02) at GKS remained significant predictors. Finally, the BRCS score’s predictive value for survival was compared with the values for the variables behind well-known prognostic indices: age, KPS score, extracranial disease status, and number and volume of BMs. Both BRCS score (p = 0.01) and BM volume (p = 0.05) remained significant predictors for survival in the final model.CONCLUSIONSPatient-reported QOL according to the BRCS is a predictor of survival in patients with BMs and may be helpful in deciding on the optimal treatment. Gamma Knife surgery is a safe and effective therapeutic modality that improves QOL for LC patients with a BM volume ≤ 5 cm3 at treatment. Careful follow-up and salvage therapy on demand seem to prevent worsening of QOL due to relapse of BMs.
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Affiliation(s)
- Sidsel Bragstad
- Departments of 1Neurosurgery,
- 2Department of Global Public Health and Primary Care
| | | | | | - Geir Egil Eide
- 2Department of Global Public Health and Primary Care
- 4Centre for Clinical Research, Haukeland University Hospital
| | | | - Maziar Behbahani
- Departments of 1Neurosurgery,
- 6Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
| | | | - Per Øyvind Enger
- Departments of 1Neurosurgery,
- 8Oncomatrix, Institute of Biomedicine, University of Bergen; and
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Abstract
Cancer is a major health issue worldwide, and the global burden of cancer is expected to increase in the coming years. Whereas the limited success with current therapies has driven huge investments into drug development, the average number of FDA approvals per year has declined since the 1990s. This unmet need for more effective anti-cancer drugs has sparked a growing interest for drug repurposing, i.e. using drugs already approved for other indications to treat cancer. As such, data both from pre-clinical experiments, clinical trials and observational studies have demonstrated anti-tumor efficacy for compounds within a wide range of drug classes other than cancer. Whereas some of them induce cancer cell death or suppress various aspects of cancer cell behavior in established tumors, others may prevent cancer development. Here, we provide an overview of promising candidates for drug repurposing in cancer, as well as studies describing the biological mechanisms underlying their anti-neoplastic effects.
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Affiliation(s)
- Linda Sleire
- Oncomatrix Research Group, Department of Biomedicine, University of Bergen, Jonas Lies vei 91 5009 Bergen, Norway
| | - Hilde Elise Førde
- Oncomatrix Research Group, Department of Biomedicine, University of Bergen, Jonas Lies vei 91 5009 Bergen, Norway
| | - Inger Anne Netland
- Oncomatrix Research Group, Department of Biomedicine, University of Bergen, Jonas Lies vei 91 5009 Bergen, Norway
| | - Lina Leiss
- Oncomatrix Research Group, Department of Biomedicine, University of Bergen, Jonas Lies vei 91 5009 Bergen, Norway
| | - Bente Sandvei Skeie
- Oncomatrix Research Group, Department of Biomedicine, University of Bergen, Jonas Lies vei 91 5009 Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Jonas Lies vei, 71, 5021 Bergen, Norway
| | - Per Øyvind Enger
- Oncomatrix Research Group, Department of Biomedicine, University of Bergen, Jonas Lies vei 91 5009 Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Jonas Lies vei, 71, 5021 Bergen, Norway.
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14
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Skeie BS, Eide GE, Flatebø M, Heggdal JI, Larsen E, Bragstad S, Pedersen PH, Enger PØ. Quality of life is maintained using Gamma Knife radiosurgery: a prospective study of a brain metastases patient cohort. J Neurosurg 2017; 126:708-725. [DOI: 10.3171/2015.10.jns15801] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE
Gamma Knife radiosurgery (GKRS) is increasingly used in the management of brain metastases (BMs), but few studies have evaluated how GKRS impacts quality of life (QOL). The aim of this study was to monitor QOL as the primary end point following GKRS in a patient cohort with BM.
METHODS
The study included 97 consecutive patients with 1–6 BMs treated with GKRS between May 2010 and September 2011. QOL was assessed at baseline and at 1, 3, 6, 9, and 12 months postoperatively using the Functional Assessment of Cancer Therapy–Brain (FACT-BR) questionnaire with the brain cancer subscale (BRCS) questionnaire. Factors predicting QOL were identified by mixed linear regression analyses. Local control and toxicity were evaluated according to Response Evaluation Criteria in Solid Tumors (RECIST) and the European Organisation for Research and Treatment/Radiation Therapy Oncology Group (EORTC/RTOG) criteria of late effects, respectively.
RESULTS
Compliance was high from baseline (97%) to 12-month follow-up (78%). Mean BRCS scores remained high during follow-up: they improved in 66% of patients and remained unchanged in 6% at 9 months. Local control (p = 0.018), improved symptoms (p = 0.005), and stable extracerebral disease (p = 0.001) correlated with high QOL-BRCS score. High baseline recursive partitioning analysis class predicted improved QOL (p = 0.031), whereas high Karnofsky Performance Scale score (p = 0.017), asymptomatic BMs (p = 0.001), and no cognitive deficits (p = 0.033) or seizures (p = 0.040) predicted high, stable QOL-BRCS during the 12-month follow-up.
CONCLUSIONS
QOL remained stable for up to 12 months following GKRS for the total cohort. High QOL was reported if local control occurred, cerebral symptoms improved/stabilized, or the need for steroids declined, which all reflected successful GKRS. Conversely, low QOL accompanied progression of intra- and extracerebral disease. Based on the study findings, GKRS appears to be a safe and effective treatment option for patients with BMs.
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Affiliation(s)
| | - Geir Egil Eide
- 5Global Public Health and Primary Care, University of Bergen, Norway
- 6Centre for Clinical Research, Haukeland University Hospital; and
| | | | | | | | | | | | - Per Øyvind Enger
- Departments of 1Neurosurgery and
- 3Biomedicine, Oncomatrix Research Lab, and
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15
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Netland IA, Førde HE, Sleire L, Leiss L, Rahman MA, Skeie BS, Gjerde CH, Enger PØ, Goplen D. Dactolisib (NVP-BEZ235) toxicity in murine brain tumour models. BMC Cancer 2016; 16:657. [PMID: 27542970 PMCID: PMC4992256 DOI: 10.1186/s12885-016-2712-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 09/28/2015] [Accepted: 08/11/2016] [Indexed: 12/11/2022] Open
Abstract
Background Glioblastomas (GBMs) are highly malignant brain tumours with a poor prognosis, and current cytotoxic regimens provide only a limited survival benefit. The PI3K/Akt/mTOR pathway has been an attractive target for therapy due to its high activation in GBMs as well as other cancers. The dual pan-PI3K/mTOR kinase inhibitor dactolisib (NVP-BEZ235) is an anti-neoplastic compound currently under investigation. However, little is known about its efficacy in human GBMs. We aimed at evaluating the efficacy of dactolisib in human glioblastoma cells, as well as in murine models carrying human GBM xenografts. Methods To assess the effect of dactolisib in vitro, MTS assay, manual cell count, BrdU incorporation and Annexin V staining experiments were used to observe growth and apoptosis. Furthermore, Akt phosphorylation (S473), a downstream target of PI3K, was explored by western blotting. Animal studies utilizing orthotopic xenograft models of glioblastoma were performed in nude rats and NOD/SCID mice to monitor survival benefit or inhibition of tumor growth. Results We found that dactolisib in vitro shows excellent dose dependent anti-growth properties and increase in apoptosis. Moreover, dose dependent inhibition of Akt phosphorylation (S473), a downstream effect of PI3K, was observed by western blotting. However, in two independent animal studies utilizing nude rats and NOD/SCID mice in orthotopic xenograft models of glioblastoma, we observed no survival benefit or inhibition of tumour growth. Severe side effects were observed, such as elevated levels of blood glucose and the liver enzyme alanine transaminase (ALT), in addition to diarrhoea, hair loss (alopecia), skin rash and accumulation of saliva in the oral cavity. Conclusion Taken together, our results suggest that despite the anti-neoplastic efficacy of dactolisib in glioma treatment in vitro, its utility in vivo is questionable due to toxicity.
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Affiliation(s)
- I A Netland
- Oncomatrix research lab, Department of Biomedicine, University of Bergen, Jonas Lies vei 91, 5009, Bergen, Norway
| | - H E Førde
- Oncomatrix research lab, Department of Biomedicine, University of Bergen, Jonas Lies vei 91, 5009, Bergen, Norway
| | - L Sleire
- Oncomatrix research lab, Department of Biomedicine, University of Bergen, Jonas Lies vei 91, 5009, Bergen, Norway
| | - L Leiss
- Oncomatrix research lab, Department of Biomedicine, University of Bergen, Jonas Lies vei 91, 5009, Bergen, Norway.,Neuro Clinic, Haukeland University Hospital, Jonas Lies vei 71, 5053, Bergen, Norway
| | - M A Rahman
- Oncomatrix research lab, Department of Biomedicine, University of Bergen, Jonas Lies vei 91, 5009, Bergen, Norway
| | - B S Skeie
- Department of Clinical Medicine, K1, University of Bergen, Jonas Lies vei 87, 5021, Bergen, Norway
| | - C H Gjerde
- Oncomatrix research lab, Department of Biomedicine, University of Bergen, Jonas Lies vei 91, 5009, Bergen, Norway
| | - P Ø Enger
- Oncomatrix research lab, Department of Biomedicine, University of Bergen, Jonas Lies vei 91, 5009, Bergen, Norway.,Department of Neurosurgery, Haukeland University Hospital, Jonas Lies vei 1, 5021, Bergen, Norway.,Kristian Gerhard Jebsen Brain Tumour Research Center, Department of Biomedicine, University of Bergen, Jonas Lies vei 91, 5009, Bergen, Norway
| | - D Goplen
- Kristian Gerhard Jebsen Brain Tumour Research Center, Department of Biomedicine, University of Bergen, Jonas Lies vei 91, 5009, Bergen, Norway. .,Department of Oncology, Haukeland University Hospital, Jonas Lies vei 65, 5021, Bergen, Norway.
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16
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Netland IA, Førde HE, Sleire L, Leiss L, Rahman MA, Skeie BS, Miletic H, Enger PØ, Goplen D. Treatment with the PI3K inhibitor buparlisib (NVP-BKM120) suppresses the growth of established patient-derived GBM xenografts and prolongs survival in nude rats. J Neurooncol 2016; 129:57-66. [PMID: 27283525 PMCID: PMC4972854 DOI: 10.1007/s11060-016-2158-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [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: 11/23/2015] [Accepted: 06/01/2016] [Indexed: 12/03/2022]
Abstract
Glioblastomas (GBMs) are aggressive brain tumours with a dismal prognosis, despite combined surgery, radio- and chemotherapy. Close to 90 % of all GBMs harbour a deregulated PI3K pathway, which is essential in regulating central cellular functions such as proliferation, cell growth, motility and survival. Thus, PI3K represents a potential target for molecular therapy in GBM. We investigated the anti-tumour efficacy of the PI3K inhibitor buparlisib (NVP-BKM120) in GBM cell lines in vitro and in vivo, when treatment was initiated after MRI-confirmed tumour engraftment. We found that buparlisib inhibited glioma cell proliferation in a dose dependent manner, demonstrated by MTS assay, manual cell count and BrdU incorporation. A dose dependent increase in apoptosis was observed through flow cytometric analysis. Furthermore, by immunocytochemistry and western blot, we found a dose dependent inhibition of Akt phosphorylation. Moreover, buparlisib prolonged survival of nude rats harboring human GBM xenografts in three independent studies and reduced the tumours’ volumetric increase, as determined by MRI. In addition, histological analyses of xenograft rat brains showed necrotic areas and change in tumour cell nuclei in buparlisib-treated animals. The rats receiving buparlisib maintained their weight, activity level and food- and water intake. In conclusion, buparlisib effectively inhibits glioma cell proliferation in vitro and growth of human GBM xenografts in nude rats. Moreover, the compound is well tolerated when administered at doses providing anti-tumour efficacy. Thus, buparlisib may have a future role in glioma therapy, and further studies are warranted to validate this compound for human use.
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Affiliation(s)
- I A Netland
- Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, Bergen, Norway
| | - H E Førde
- Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, Bergen, Norway
| | - L Sleire
- Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, Bergen, Norway
| | - L Leiss
- Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, Bergen, Norway.,Neuro Clinic, Haukeland University Hospital, Bergen, Norway
| | - M A Rahman
- Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, Bergen, Norway
| | - B S Skeie
- Department of Clinical Medicine, K1, University of Bergen, Bergen, Norway
| | - H Miletic
- Department of Biomedicine, Kristian Gerhard Jebsen Brain Tumour Research Center, University of Bergen, Bergen, Norway.,Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - P Ø Enger
- Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, Bergen, Norway.,Department of Biomedicine, Kristian Gerhard Jebsen Brain Tumour Research Center, University of Bergen, Bergen, Norway.,Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - D Goplen
- Department of Biomedicine, Kristian Gerhard Jebsen Brain Tumour Research Center, University of Bergen, Bergen, Norway. .,Department of Oncology, Haukeland University Hospital, Bergen, Norway.
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17
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Sleire L, Skeie BS, Netland IA, Førde HE, Dodoo E, Selheim F, Leiss L, Wang J, Heggdal J, Pedersen PH, Enger PØ. Abstract 1789: Drug repurposing: Sulfasalazine sensitizes gliomas to gamma knife surgery by blocking cystine uptake through System XC−, leading to gluthatione depletion. Cancer Res 2015. [DOI: 10.1158/1538-7445.am2015-1789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Glioblastomas (GBMs) are lethal cancers and inherently resistant to radiotherapy. Established treatments including surgery, radio- and chemotherapy have a limited efficacy, and the median survival is approximately 14.6 months. Thus, treatment resistance represents a major challenge in the clinical management of these patients, and new therapies are urgently needed.
We hypothesized that the Xc−-inhibitor sulfasalazine (SAS) could potentiate the efficacy of radiotherapy against gliomas. Expression of the catalytic subunit of system Xc−, xCT, was found in a panel of 30 human GBM biopsies. Sections from normal brain tissue displayed only weak immunopositivity, thus our findings therefore suggest that xCT expression is common to most GBMs, which together with its low expression in normal brain tissue could provide a therapeutic window. SAS treatment dramatically reduced cysteine-uptake and glutathione (GSH) levels in glioma cells in vitro and markedly increased the levels of reactive oxygen species (ROS). Furthermore, SAS and radiation synergistically increased DNA double-strand breaks and increased glioma cell death, whereas adding the antioxidant N-acetyl-L-cysteine (NAC) reversed cell death. Moreover, SAS and gamma knife radiosurgery (GKRS) synergistically prolonged survival in nude rats harboring human GBM xenografts, compared to controls or either treatment alone. In conclusion, SAS effectively blocks cystine uptake in glioma cells in vitro, leading to GSH depletion and increased ROS levels, DNA damage and cell death. Moreover, it potentiates the anti-tumor efficacy of GKRS in rats with human GBM xenografts, providing a survival benefit. Thus, SAS may have a role as a radiosensitizer to enhance the efficacy of current radiotherapies for glioma patients. We are currently preparing a clinical trial for patients with GBM recurrences combining pre-treatment with SAS and GKRS.
Citation Format: Linda Sleire, Bente Sandvei Skeie, Inger Anne Netland, Hilde Elise Førde, Ernest Dodoo, Frode Selheim, Lina Leiss, Jian Wang, Jan Heggdal, Paal-Henning Pedersen, Per Øyvind Enger. Drug repurposing: Sulfasalazine sensitizes gliomas to gamma knife surgery by blocking cystine uptake through System XC−, leading to gluthatione depletion. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1789. doi:10.1158/1538-7445.AM2015-1789
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Affiliation(s)
- Linda Sleire
- 1Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, Bergen, Norway
| | | | - Inger Anne Netland
- 1Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Hilde Elise Førde
- 1Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Ernest Dodoo
- 3Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Frode Selheim
- 4Proteomics Unit (PROBE), Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Lina Leiss
- 1Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Jian Wang
- 1Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Jan Heggdal
- 5Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | | | - Per Øyvind Enger
- 1Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, Bergen, Norway
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18
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Sleire L, Skeie BS, Netland IA, Førde HE, Dodoo E, Selheim F, Leiss L, Heggdal JI, Pedersen PH, Wang J, Enger PØ. Drug repurposing: sulfasalazine sensitizes gliomas to gamma knife radiosurgery by blocking cystine uptake through system Xc-, leading to glutathione depletion. Oncogene 2015; 34:5951-9. [PMID: 25798841 DOI: 10.1038/onc.2015.60] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 11/27/2014] [Accepted: 12/16/2014] [Indexed: 12/25/2022]
Abstract
Glioblastomas (GBMs) are aggressive brain tumors that always recur after radiotherapy. Cystine, mainly provided by the system X(c)(-) antiporter, is a requirement for glioma cell synthesis of glutathione (GSH) which has a critical role in scavenging free radicals, for example, after radiotherapy. Thus, we hypothesized that the X(c)(-)-inhibitor sulfasalazine (SAS) could potentiate the efficacy of radiotherapy against gliomas. Here, we show that the catalytic subunit of system X(c)(-), xCT, was uniformly expressed in a panel of 30 human GBM biopsies. SAS treatment significantly reduced cystine uptake and GSH levels, whereas it significantly increased the levels of reactive oxygen species (ROS) in glioma cells in vitro. Furthermore, SAS and radiation synergistically increased DNA double-strand breaks and increased glioma cell death, whereas adding the antioxidant N-acetyl-L-cysteine (NAC) reversed cell death. Moreover, SAS and gamma knife radiosurgery (GKRS) synergistically prolonged survival in nude rats harboring human GBM xenografts, compared with controls or either treatment alone. In conclusion, SAS effectively blocks cystine uptake in glioma cells in vitro, leading to GSH depletion and increased ROS levels, DNA damage and cell death. Moreover, it potentiates the anti-tumor efficacy of GKRS in rats with human GBM xenografts, providing a survival benefit. Thus, SAS may have a role as a radiosensitizer to enhance the efficacy of current radiotherapies for glioma patients.
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Affiliation(s)
- L Sleire
- Department of Biomedicine, Oncomatrix Research Lab, University of Bergen, Bergen, Norway
| | - B S Skeie
- Department of Clinical Medicine, K1, University of Bergen, Bergen, Norway.,Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - I A Netland
- Department of Biomedicine, Oncomatrix Research Lab, University of Bergen, Bergen, Norway
| | - H E Førde
- Department of Biomedicine, Oncomatrix Research Lab, University of Bergen, Bergen, Norway
| | - E Dodoo
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - F Selheim
- Department of Biomedicine, Proteomics Unit (PROBE), University of Bergen, Bergen, Norway
| | - L Leiss
- Department of Biomedicine, Oncomatrix Research Lab, University of Bergen, Bergen, Norway.,Neuro Clinic, Haukeland University Hospital, Bergen, Norway
| | - J I Heggdal
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - P-H Pedersen
- Department of Clinical Medicine, K1, University of Bergen, Bergen, Norway.,Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - J Wang
- Department of Biomedicine, Oncomatrix Research Lab, University of Bergen, Bergen, Norway
| | - P Ø Enger
- Department of Biomedicine, Oncomatrix Research Lab, University of Bergen, Bergen, Norway.,Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
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Skeie BS. Gammaknivbehandling av hjernesvulster. Tidsskriftet 2015. [DOI: 10.4045/tidsskr.14.1173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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20
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Sandvei Skeie B, Wang J, Dodoo E, Heggdal JI, Grønli J, Sleire L, Bragstad S, Ganz JC, Chekenya M, Mørk S, Pedersen PH, Enger PØ. Gamma knife surgery as monotherapy with clinically relevant doses prolongs survival in a human GBM xenograft model. Biomed Res Int 2013; 2013:139674. [PMID: 24312904 PMCID: PMC3842058 DOI: 10.1155/2013/139674] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Revised: 09/17/2013] [Accepted: 09/19/2013] [Indexed: 11/18/2022]
Abstract
OBJECT Gamma knife surgery (GKS) may be used for recurring glioblastomas (GBMs). However, patients have then usually undergone multimodal treatment, which makes it difficult to specifically validate GKS independent of established treatments. Thus, we developed an experimental brain tumor model to assess the efficacy and radiotoxicity associated with GKS. METHODS GBM xenografts were implanted intracerebrally in nude rats, and engraftment was confirmed with MRI. The rats were allocated to GKS, with margin doses of 12 Gy or 18 Gy, or to no treatment. Survival time was recorded, tumor sections were examined, and radiotoxicity was evaluated in a behavioral open field test. RESULTS In the first series, survival from the time of implantation was 96 days in treated rats and 72 days in controls (P < 0.001). In a second experiment, survival was 72 days in the treatment group versus 54 days in controls (P < 0.006). Polynuclear macrophages and fibrosis was seen in groups subjected to GKS. Untreated rats with GBM xenografts displayed less mobility than GKS-treated animals in the open field test 4 weeks after treatment (P = 0.04). CONCLUSION GKS administered with clinically relevant doses prolongs survival in rats harboring GBM xenografts, and the associated toxicity is mild.
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Affiliation(s)
- Bente Sandvei Skeie
- Department of Neurosurgery, Haukeland University Hospital, 5021 Bergen, Norway
- Institute of Surgical Sciences, Haukeland University Hospital, 5021 Bergen, Norway
- Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, 5021 Bergen, Norway
| | - Jian Wang
- Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, 5021 Bergen, Norway
| | - Ernest Dodoo
- Department of Neurosurgery, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Jan Ingeman Heggdal
- Department of Oncology and Medical Physics, Haukeland University Hospital, 5021 Bergen, Norway
| | - Janne Grønli
- Department of Biological and Medical Psychology, University of Bergen, 5021 Bergen, Norway
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, 5021 Bergen, Norway
| | - Linda Sleire
- Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, 5021 Bergen, Norway
| | - Sidsel Bragstad
- Department of Neurosurgery, Haukeland University Hospital, 5021 Bergen, Norway
| | - Jeremy C. Ganz
- Department of Neurosurgery, Haukeland University Hospital, 5021 Bergen, Norway
| | - Martha Chekenya
- Brain Tumor Immunology & Therapy Group, Department of Biomedicine, University of Bergen, 5021 Bergen, Norway
| | - Sverre Mørk
- Department of Neurosurgery, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Paal-Henning Pedersen
- Department of Neurosurgery, Haukeland University Hospital, 5021 Bergen, Norway
- Institute of Surgical Sciences, Haukeland University Hospital, 5021 Bergen, Norway
| | - Per Øyvind Enger
- Department of Neurosurgery, Haukeland University Hospital, 5021 Bergen, Norway
- Oncomatrix Research Lab, Department of Biomedicine, University of Bergen, 5021 Bergen, Norway
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Skeie BS, Enger PØ, Brøgger J, Ganz JC, Thorsen F, Heggdal JI, Pedersen PH. γ knife surgery versus reoperation for recurrent glioblastoma multiforme. World Neurosurg 2012; 78:658-69. [PMID: 22484078 DOI: 10.1016/j.wneu.2012.03.024] [Citation(s) in RCA: 80] [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] [Received: 11/18/2011] [Revised: 02/23/2012] [Accepted: 03/29/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND The optimal management of patients with recurrent glioblastoma multiforme (GBM) is a subject of controversy. These patients may be candidates for both reoperation and/or gamma knife surgery (GKS). Few studies have addressed the role of GKS for relapsing gliomas, and the results have not been compared with reoperation. To validate the efficacy and safety of GKS, we compared the survival and complication rates of GKS and reoperation for recurrent GBMs. METHODS This study retrospectively reviewed 77 consecutive patients with histopathologically confirmed GBMs retreated for recurrent GBM between 1996 and 2007. Thirty-two patients underwent GKS, 26 reoperation and 19 both procedures. RESULTS The median time from the second intervention to tumor progression was longer after GKS than after resection, P = 0.009. Median survival after retreatment was 12 months for the 51 patients receiving GKS compared with 6 months for reoperation only (P = 0.001, hazard ratio [HR] 2.4), and 19 months versus 16 months from the time of primary diagnosis (P = 0.021, HR 1.8). A multivariate analysis adjusted for possible confounding factors (tumor volume, recursive partitioning analysis class, neurological deficits, time to recurrence, adjuvant therapy, and tumor location) showed significantly longer survival for patients treated with GKS, both from retreatment (P = 0.013, HR 4.1) and from primary diagnosis (P = 0.002, HR 5.8). The adjusted results were still significant after separate analysis according to tumor volume <5 mL, 5 to 20 mL, and >20 mL. The complications rate was 9.8% after GKS and 25.2% after reoperation. CONCLUSIONS GKS may be an alternative to open surgery for small GBMs at the time of recurrences, with a significantly lower complication rate and a possible survival benefit compared with reoperation.
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Affiliation(s)
- Bente Sandvei Skeie
- Department of Surgical Sciences, Haukeland University Hospital, Bergen, Norway.
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Skeie BS, Skeie GO, Enger PØ, Ganz JC, Heggdal JI, Ystevik B, Hatteland S, Parr E, Pedersen PH. Gamma Knife Surgery in Brain Melanomas: Absence of Extracranial Metastases and Tumor Volume Strongest Indicators of Prolonged Survival. World Neurosurg 2011; 75:684-91; discussion 598-603. [DOI: 10.1016/j.wneu.2010.12.054] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 12/03/2010] [Accepted: 12/17/2010] [Indexed: 10/18/2022]
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Skeie BS, Enger PO, Skeie GO, Thorsen F, Pedersen PH. Gamma knife surgery of meningiomas involving the cavernous sinus: long-term follow-up of 100 patients. Neurosurgery 2010; 66:661-8; discussion 668-9. [PMID: 20305491 DOI: 10.1227/01.neu.0000366112.04015.e2] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Resection of meningiomas involving the cavernous sinus often is incomplete and associated with considerable morbidity. As a result, an increasing number of patients with such tumors have been treated with gamma knife surgery (GKS). However, few studies have investigated the long-term outcome for this group of patients. METHODS 100 patients (23 male/77 female) with meningiomas involving the cavernous sinus received GKS at the Department of Neurosurgery at Haukeland University Hospital, Bergen, Norway, between November 1988 and July 2006. They were followed for a mean of 82.0 (range, 0-243) months. Only 2 patients were lost to long-term follow-up. Sixty patients underwent craniotomy before radiosurgery, whereas radiosurgery was the primary treatment for 40 patients. RESULTS Tumor growth control was achieved in 84.0% of patients. Twelve patients required re-treatment: craniotomy (7), radiosurgery (1), or both (4). Three out of 5 patients with repeated radiosurgery demonstrated secondary tumor growth control. Excluding atypical meningiomas, the growth control rate was 90.4%. The 1-, 5-, and 10-year actuarial tumor growth control rates are 98.9%, 94.2%, and 91.6%, respectively. Treatment failure was preceded by clinical symptoms in 14 of 15 patients. Most tumor growths appeared within 2.5 years. Only one third grew later (range, 6-20 yr). The complication rate was 6.0%: optic neuropathy (2), pituitary dysfunction (3), worsening of diplopia (1), and radiation edema (1). Mortality was 0. At last follow-up, 88.0% were able to live independent lives. CONCLUSION GKS gives long-term growth control and has a low complication rate. Most tumor growths manifest within 3 years following treatment. However, some appear late, emphasizing the need for long-term follow-up.
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Affiliation(s)
- Bente Sandvei Skeie
- Department of Neurosurgery, Haukeland University Hospital, N-5021 Bergen, Norway.
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