1
|
Chaban A, Waschulzik B, Bernhardt D, Delbridge C, Schmidt-Graf F, Wagner A, Wiestler B, Weber W, Yakushev I. Amino acid PET vs. RANO MRI for prediction of overall survival in patients with recurrent high grade glioma under bevacizumab therapy. Eur J Nucl Med Mol Imaging 2024; 51:1698-1702. [PMID: 38228970 PMCID: PMC11043199 DOI: 10.1007/s00259-024-06601-4] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/01/2024] [Indexed: 01/18/2024]
Abstract
PURPOSE To summarize evidence on the comparative value of amino acid (AA) PET and conventional MRI for prediction of overall survival (OS) in patients with recurrent high grade glioma (rHGG) under bevacizumab therapy. METHODS Medical databases were screened for studies with individual data on OS, follow-up MRI, and PET findings in the same patient. MRI images were assessed according to the RANO criteria. A receiver operating characteristic curve analysis was used to predict OS at 9 months. RESULTS Five studies with a total of 72 patients were included. Median OS was significantly lower in the PET-positive than in the PET-negative group. PET findings predicted OS with a pooled sensitivity and specificity of 76% and 71%, respectively. Corresponding values for MRI were 32% and 82%. Area under the curve and sensitivity were significantly higher for PET than for MRI. CONCLUSION For monitoring of patients with rHGG under bevacizumab therapy, AA-PET should be preferred over RANO MRI.
Collapse
Affiliation(s)
- Artem Chaban
- Department of Nuclear Medicine, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Birgit Waschulzik
- Institute of AI and Informatics in Medicine, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Denise Bernhardt
- Department of Nuclear Medicine, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Claire Delbridge
- Department of Nuclear Medicine, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Pathology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Nuclear Medicine, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Neurology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Arthur Wagner
- Department of Nuclear Medicine, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Benedikt Wiestler
- Department of Nuclear Medicine, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Neuroradiology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Wolfgang Weber
- Department of Nuclear Medicine, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Igor Yakushev
- Department of Nuclear Medicine, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.
| |
Collapse
|
2
|
Vollmuth Y, Jungbäck N, Mögele T, Schmidt-Graf F, Wunderlich S, Schimmel M, Rothe C, Stark L, Schlegel J, Rieder G, Richter T, Schaller T, Tappe D, Märkl B, Matiasek K, Liesche-Starnecker F. Comparative Study of Virus and Lymphocyte Distribution with clinical Data suggests early high dose Immunosuppression as potential Key Factor for the Therapy of Patients with BoDV-1 Infection. Emerg Microbes Infect 2024:2350168. [PMID: 38687703 DOI: 10.1080/22221751.2024.2350168] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Borna disease virus 1 (BoDV-1) was just recently shown to cause predominantly fatal encephalitis in humans. Despite its rarity, bornavirus encephalitis (BVE) can be considered a model disease for encephalitic infections caused by neurotropic viruses and understanding its pathomechanism is of utmost relevance.Aim of this study was to compare the extent and distribution pattern of cerebral inflammation with the clinical course of disease, and individual therapeutic procedures.For this, autoptic brain material from seven patients with fatal BVE was included in this study. Tissue was stained immunohistochemically for pan-lymphocytic marker CD45, the nucleoprotein of BoDV-1, as well as glial marker GFAP and microglial marker Iba1. Sections were digitalized and counted for CD45-positive and BoDV-1-positive cells. For GFAP and Iba1, a semiquantitative score was determined. Furthermore, detailed information about the individual clinical course and therapy were retrieved and summarized in a standardized way.Analysis of the distribution of lymphocytes shows interindividual patterns. In contrast, when looking at the BoDV-1-positive glial cells and neurons, a massive viral involvement in the brain stem was noticeable. Three of the seven patients received early high-dose steroids, which led to a significantly lower lymphocytic infiltration of the central nervous tissue and a longer survival compared to the patients who were treated with steroids later in the course of disease.This study highlights the potential importance of early high-dose immunosuppressive therapy in BVE. Our findings hint at a promising treatment option which should be corroborated in future observational or prospective therapy studies.
Collapse
Affiliation(s)
- Yannik Vollmuth
- Pathology, Medical Faculty, University of Augsburg, Augsburg, Germany
- Institute of Pathology, School of Medicine and Health, Technical University of Munich, Munich, Germany
- Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Nicola Jungbäck
- Pathology, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Tatiana Mögele
- Pathology, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Mareike Schimmel
- Department of Pediatrics and Adolescent Medicine, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Camilla Rothe
- Division of Infectious Diseases and Tropical Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Leonhard Stark
- Institute of Pathology, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Jürgen Schlegel
- Pathology, Medical Faculty, University of Augsburg, Augsburg, Germany
- Institute of Pathology, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Georg Rieder
- Department of Neurology, InnKlinikum, Altötting, Germany
| | - Thomas Richter
- Clinic of Pathology, Pathology Rosenheim, Rosenheim, Germany
| | - Tina Schaller
- Pathology, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Dennis Tappe
- National Reference Laboratory for Bornaviruses, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Bruno Märkl
- Pathology, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Kaspar Matiasek
- Section of Clinical and Comparative Neuropathology, Centre for Clinical Veterinary Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | | |
Collapse
|
3
|
Straube C, Combs SE, Bernhardt D, Gempt J, Meyer B, Zimmer C, Schmidt-Graf F, Vajkoczy P, Grün A, Ehret F, Zips D, Kaul D. Adjuvant re-irradiation vs. no early re-irradiation of resected recurrent glioblastoma: pooled comparative cohort analysis from two tertiary centers. J Neurooncol 2024:10.1007/s11060-024-04633-2. [PMID: 38520571 DOI: 10.1007/s11060-024-04633-2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/04/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND The optimal management strategy for recurrent glioblastoma (rGBM) remains uncertain, and the impact of re-irradiation (Re-RT) on overall survival (OS) is still a matter of debate. This study included patients who achieved gross total resection (GTR) after a second surgery after recurrence, following the GlioCave criteria. METHODS Inclusion criteria include being 18 years or older, having histologically confirmed locally recurrent IDHwt or IDH unknown GBM, achieving MRI-proven GTR after the second surgery, having a Karnofsky performance status of at least 60% after the second surgery, having a minimum interval of 6 months between the first radiotherapy and the second surgery, and a maximum of 8 weeks from second surgery to the start of Re-RT. RESULTS A total of 44 patients have met the inclusion criteria. The median OS after the second surgery was 14 months. All patients underwent standard treatment after initial diagnosis, including maximum safe resection, adjuvant radiochemotherapy and adjuvant chemotherapy. Re-RT did not significantly impact OS. However, MGMT promoter methylation status and a longer interval (> 12 months) between treatments were associated with better OS. Multivariate analysis revealed the MGMT status as the only significant predictor of OS. CONCLUSION Factors such as MGMT promoter methylation status and treatment interval play crucial roles in determining patient outcomes after second surgery. Personalized treatment strategies should consider these factors to optimize the management of rGBM. Prospective research is needed to define the value of re-RT after second surgery and to inform decision making in this situation.
Collapse
Affiliation(s)
- Christoph Straube
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
- Department of Radiation Oncology and Radiotherapy, Klinikum Landshut, Landshut, Germany.
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Hamburg-Eppendorf, Hamburg, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Arne Grün
- Department of Radiation Oncology, Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Felix Ehret
- Department of Radiation Oncology, Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Charité- Universitätsmedizin Berlin, Berlin, Germany
- Partner Site Berlin, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Daniel Zips
- Department of Radiation Oncology, Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Charité- Universitätsmedizin Berlin, Berlin, Germany
- Partner Site Berlin, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - David Kaul
- Department of Radiation Oncology, Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Charité- Universitätsmedizin Berlin, Berlin, Germany
- Partner Site Berlin, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| |
Collapse
|
4
|
Hönikl LS, Lange S, Butenschoen VM, Delbridge C, Meyer B, Combs SE, Illert AL, Schmidt-Graf F. The role of molecular tumor boards in neuro-oncology: a nationwide survey. BMC Cancer 2024; 24:108. [PMID: 38243190 PMCID: PMC10797778 DOI: 10.1186/s12885-024-11858-x] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/09/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND In neuro-oncology, the inclusion of tumor patients in the molecular tumor board has only become increasingly widespread in recent years, but so far there are no standards for indication, procedure, evaluation, therapy recommendations and therapy implementation of neuro-oncological patients. The present work examines the current handling of neuro-oncological patients included in molecular tumor boards in Germany. METHODS We created an online based survey with questions covering the handling of neuro-oncologic patient inclusion, annotation of genetic analyses, management of target therapies and the general role of molecular tumor boards in neuro-oncology in Germany. We contacted all members of the Neuro-Oncology working group (NOA) of the German Cancer Society (DKG) by e-mail. RESULTS 38 responses were collected. The majority of those who responded were specialists in neurosurgery or neurology with more than 10 years of professional experience working at a university hospital. Molecular tumor boards (MTB) regularly take place once a week and all treatment disciplines of neuro-oncology patients take part. The inclusions to the MTB are according to distinct tumors and predominantly in case of tumor recurrence. An independently MTB member mostly create the recommendations, which are regularly implemented in the tumor treatment. Recommendations are given for alteration classes 4 and 5. Problems exist mostly within the cost takeover of experimental therapies. The experimental therapies are mostly given in the department of medical oncology. CONCLUSIONS Molecular tumor boards for neuro-oncological patients, by now, are not standardized in Germany. Similarities exists for patient inclusion and interpretation of molecular alterations; the time point of inclusion and implementation during the patient treatment differ between the various hospitals. Further studies for standardization and harmonisation are needed. In summary, most of the interviewees envision great opportunities and possibilities for molecular-based neuro-oncological therapy in the future.
Collapse
Affiliation(s)
- Lisa S Hönikl
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Str. 22, 81675, Munich, Germany.
- Center for Personalized Medicine (ZPM), Klinikum rechts der Isar, Technical Universitiy of Munich (TUM), Munich, Germany.
| | - Sebastian Lange
- Center for Personalized Medicine (ZPM), Klinikum rechts der Isar, Technical Universitiy of Munich (TUM), Munich, Germany
- Department of Medicine II, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Vicki M Butenschoen
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Str. 22, 81675, Munich, Germany
| | - Claire Delbridge
- Center for Personalized Medicine (ZPM), Klinikum rechts der Isar, Technical Universitiy of Munich (TUM), Munich, Germany
- Department of Neuropathology, Institute of Pathology, Technical University of Munich (TUM), Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Anna Lena Illert
- Center for Personalized Medicine (ZPM), Klinikum rechts der Isar, Technical Universitiy of Munich (TUM), Munich, Germany
- Department of Medicine III, Faculty of Medicine, Klinikum Rechts der Isar, Technical University Munich (TUM), Munich, Germany
| | - Friederike Schmidt-Graf
- Center for Personalized Medicine (ZPM), Klinikum rechts der Isar, Technical Universitiy of Munich (TUM), Munich, Germany
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| |
Collapse
|
5
|
Metz MC, Ezhov I, Peeken JC, Buchner JA, Lipkova J, Kofler F, Waldmannstetter D, Delbridge C, Diehl C, Bernhardt D, Schmidt-Graf F, Gempt J, Combs SE, Zimmer C, Menze B, Wiestler B. Toward image-based personalization of glioblastoma therapy: A clinical and biological validation study of a novel, deep learning-driven tumor growth model. Neurooncol Adv 2024; 6:vdad171. [PMID: 38435962 PMCID: PMC10907005 DOI: 10.1093/noajnl/vdad171] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
Background The diffuse growth pattern of glioblastoma is one of the main challenges for accurate treatment. Computational tumor growth modeling has emerged as a promising tool to guide personalized therapy. Here, we performed clinical and biological validation of a novel growth model, aiming to close the gap between the experimental state and clinical implementation. Methods One hundred and twenty-four patients from The Cancer Genome Archive (TCGA) and 397 patients from the UCSF Glioma Dataset were assessed for significant correlations between clinical data, genetic pathway activation maps (generated with PARADIGM; TCGA only), and infiltration (Dw) as well as proliferation (ρ) parameters stemming from a Fisher-Kolmogorov growth model. To further evaluate clinical potential, we performed the same growth modeling on preoperative magnetic resonance imaging data from 30 patients of our institution and compared model-derived tumor volume and recurrence coverage with standard radiotherapy plans. Results The parameter ratio Dw/ρ (P < .05 in TCGA) as well as the simulated tumor volume (P < .05 in TCGA/UCSF) were significantly inversely correlated with overall survival. Interestingly, we found a significant correlation between 11 proliferation pathways and the estimated proliferation parameter. Depending on the cutoff value for tumor cell density, we observed a significant improvement in recurrence coverage without significantly increased radiation volume utilizing model-derived target volumes instead of standard radiation plans. Conclusions Identifying a significant correlation between computed growth parameters and clinical and biological data, we highlight the potential of tumor growth modeling for individualized therapy of glioblastoma. This might improve the accuracy of radiation planning in the near future.
Collapse
Affiliation(s)
- Marie-Christin Metz
- Department of Diagnostic and Interventional Neuroradiology, Technical University of Munich, Munich, Germany
| | - Ivan Ezhov
- Department of Informatics, Technical University of Munich, Munich, Germany
- TranslaTUM—Central Institute for Translational Cancer Research, Technical University of Munich, Munich, Germany
| | - Jan C Peeken
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany
- Department of Radiation Sciences (DRS), Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Munich, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Josef A Buchner
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany
| | - Jana Lipkova
- Department of Pathology and Molecular Medicine, University of California, Irvine, Irvine, CA, USA
| | - Florian Kofler
- Department of Diagnostic and Interventional Neuroradiology, Technical University of Munich, Munich, Germany
- Department of Informatics, Technical University of Munich, Munich, Germany
- Helmholtz Artificial Intelligence Cooperation Unit, Helmholtz Zentrum Munich, Munich, Germany
- TranslaTUM—Central Institute for Translational Cancer Research, Technical University of Munich, Munich, Germany
| | | | - Claire Delbridge
- Department of Neuropathology, Institute of Pathology, Technical University of Munich, Munich, Germany
| | - Christian Diehl
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany
- Department of Radiation Sciences (DRS), Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Munich, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | | | - Jens Gempt
- Department of Neurosurgery, Technical University of Munich, Munich, Germany
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany
- Department of Radiation Sciences (DRS), Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Munich, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Technical University of Munich, Munich, Germany
| | - Bjoern Menze
- Department of Informatics, Technical University of Munich, Munich, Germany
- Department of Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
| | - Benedikt Wiestler
- Department of Diagnostic and Interventional Neuroradiology, Technical University of Munich, Munich, Germany
| |
Collapse
|
6
|
Lennartz P, Thölke D, Bashiri Dezfouli A, Pilz M, Lobinger D, Messner V, Zanth H, Ainslie K, Kafshgari MH, Rammes G, Ballmann M, Schlegel M, Foulds GA, Pockley AG, Schmidt-Graf F, Multhoff G. Biomarkers in Adult-Type Diffuse Gliomas: Elevated Levels of Circulating Vesicular Heat Shock Protein 70 Serve as a Biomarker in Grade 4 Glioblastoma and Increase NK Cell Frequencies in Grade 3 Glioma. Biomedicines 2023; 11:3235. [PMID: 38137456 PMCID: PMC10741018 DOI: 10.3390/biomedicines11123235] [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] [Received: 08/31/2023] [Revised: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
The presence of circulating Hsp70 levels and their influence on the immunophenotype of circulating lymphocyte subsets were examined as diagnostic/prognostic biomarkers for the overall survival (OS) in patients with IDH-mutant WHO grade 3 oligodendroglioma, astrocytoma, and IDH-wildtype grade 4 glioblastoma (GBM). Vesicular and free Hsp70 in the plasma/serum was measured using the Hsp70-exo and R&D Systems DuoSet® Hsp70 ELISAs. The immunophenotype and membrane Hsp70 status was determined by multiparameter flow cytometry on peripheral blood lymphocytes and single-cell suspensions of tumor specimens and cultured cells. Compared to healthy controls, circulating vesicular Hsp70 levels were significantly increased in patients with GBM, concomitant with a significant decrease in the proportion of CD3+/CD4+ helper T cells, whereas the frequency of NK cells was most prominently increased in patients with grade 3 gliomas. Elevated circulating Hsp70 levels and a higher prevalence of activated CD3-/CD56+/CD94+/CD69+ NK cells were associated with an improved OS in grade 3 gliomas, whereas high Hsp70 levels and low CD3+/CD4+ frequencies were associated with an adverse OS in GBM. It is assumed that a reduced membrane Hsp70 density on grade 4 versus grade 3 primary glioma cells and reduced CD3+/CD4+ T cell counts in GBM might drive an immunosuppressive tumor microenvironment.
Collapse
Affiliation(s)
- Philipp Lennartz
- Central Institute for Translational Cancer Research Technische Universität München (TranslaTUM), Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany; (P.L.); (D.T.); (A.B.D.); (V.M.); (H.Z.)
- Department of Radiation Oncology, Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany
| | - Dennis Thölke
- Central Institute for Translational Cancer Research Technische Universität München (TranslaTUM), Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany; (P.L.); (D.T.); (A.B.D.); (V.M.); (H.Z.)
- Department of Radiation Oncology, Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany
| | - Ali Bashiri Dezfouli
- Central Institute for Translational Cancer Research Technische Universität München (TranslaTUM), Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany; (P.L.); (D.T.); (A.B.D.); (V.M.); (H.Z.)
- Department of Otolaryngology, Head and Neck Surgery, Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany
| | - Mathias Pilz
- Central Institute for Translational Cancer Research Technische Universität München (TranslaTUM), Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany; (P.L.); (D.T.); (A.B.D.); (V.M.); (H.Z.)
- Department of Radiation Oncology, Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany
| | - Dominik Lobinger
- Department of Thoracic Surgery, München Klinik Bogenhausen, Lehrkrankenhaus der TUM, 81925 Munich, Germany;
| | - Verena Messner
- Central Institute for Translational Cancer Research Technische Universität München (TranslaTUM), Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany; (P.L.); (D.T.); (A.B.D.); (V.M.); (H.Z.)
- Department of Radiation Oncology, Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany
| | - Hannah Zanth
- Central Institute for Translational Cancer Research Technische Universität München (TranslaTUM), Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany; (P.L.); (D.T.); (A.B.D.); (V.M.); (H.Z.)
- Department of Radiation Oncology, Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany
| | - Karen Ainslie
- Central Institute for Translational Cancer Research Technische Universität München (TranslaTUM), Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany; (P.L.); (D.T.); (A.B.D.); (V.M.); (H.Z.)
- Department of Radiation Oncology, Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany
| | - Morteza Hasanzadeh Kafshgari
- Central Institute for Translational Cancer Research Technische Universität München (TranslaTUM), Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany; (P.L.); (D.T.); (A.B.D.); (V.M.); (H.Z.)
- Department of Biomedical Electronics, Central Instititute for Translational Cancer Research, Technische Universität München (TranslaTUM), Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany
| | - Gerhard Rammes
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany (M.S.)
| | - Markus Ballmann
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany (M.S.)
| | - Martin Schlegel
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany (M.S.)
| | - Gemma Ann Foulds
- John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham NG11 8NS, UK; (G.A.F.); (A.G.P.)
| | - Alan Graham Pockley
- John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham NG11 8NS, UK; (G.A.F.); (A.G.P.)
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany;
| | - Gabriele Multhoff
- Central Institute for Translational Cancer Research Technische Universität München (TranslaTUM), Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany; (P.L.); (D.T.); (A.B.D.); (V.M.); (H.Z.)
- Department of Radiation Oncology, Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany
| |
Collapse
|
7
|
Prokop G, Wiestler B, Hieber D, Withake F, Mayer K, Gempt J, Delbridge C, Schmidt-Graf F, Pfarr N, Märkl B, Schlegel J, Liesche-Starnecker F. Multiscale quantification of morphological heterogeneity with creation of a predictor of longer survival in glioblastoma. Int J Cancer 2023; 153:1658-1670. [PMID: 37501565 DOI: 10.1002/ijc.34665] [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: 04/24/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/29/2023]
Abstract
Intratumor heterogeneity is a main cause of the dismal prognosis of glioblastoma (GBM). Yet, there remains a lack of a uniform assessment of the degree of heterogeneity. With a multiscale approach, we addressed the hypothesis that intratumor heterogeneity exists on different levels comprising traditional regional analyses, but also innovative methods including computer-assisted analysis of tumor morphology combined with epigenomic data. With this aim, 157 biopsies of 37 patients with therapy-naive IDH-wildtype GBM were analyzed regarding the intratumor variance of protein expression of glial marker GFAP, microglia marker Iba1 and proliferation marker Mib1. Hematoxylin and eosin stained slides were evaluated for tumor vascularization. For the estimation of pixel intensity and nuclear profiling, automated analysis was used. Additionally, DNA methylation profiling was conducted separately for the single biopsies. Scoring systems were established to integrate several parameters into one score for the four examined modalities of heterogeneity (regional, cellular, pixel-level and epigenomic). As a result, we could show that heterogeneity was detected in all four modalities. Furthermore, for the regional, cellular and epigenomic level, we confirmed the results of earlier studies stating that a higher degree of heterogeneity is associated with poorer overall survival. To integrate all modalities into one score, we designed a predictor of longer survival, which showed a highly significant separation regarding the OS. In conclusion, multiscale intratumor heterogeneity exists in glioblastoma and its degree has an impact on overall survival. In future studies, the implementation of a broadly feasible heterogeneity index should be considered.
Collapse
Affiliation(s)
- Georg Prokop
- Pathology, Medical Faculty, University of Augsburg, Augsburg, Germany
- Institute of Pathology, School of Medicine, Technical University Munich, Munich, Germany
| | - Benedikt Wiestler
- Department of Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Daniel Hieber
- Pathology, Medical Faculty, University of Augsburg, Augsburg, Germany
- Institute DigiHealth, Neu-Ulm University of Applied Sciences, Neu-Ulm, Germany
- Bavarian Cancer Research Center (BZKF), Augsburg, Germany
| | - Fynn Withake
- Department of Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Karoline Mayer
- Institute of Pathology, School of Medicine, Technical University Munich, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Claire Delbridge
- Institute of Pathology, School of Medicine, Technical University Munich, Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Nicole Pfarr
- Institute of Pathology, School of Medicine, Technical University Munich, Munich, Germany
| | - Bruno Märkl
- Pathology, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Jürgen Schlegel
- Pathology, Medical Faculty, University of Augsburg, Augsburg, Germany
- Institute of Pathology, School of Medicine, Technical University Munich, Munich, Germany
| | - Friederike Liesche-Starnecker
- Pathology, Medical Faculty, University of Augsburg, Augsburg, Germany
- Institute of Pathology, School of Medicine, Technical University Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Augsburg, Germany
| |
Collapse
|
8
|
Griessmair M, Delbridge C, Ziegenfeuter J, Bernhardt D, Gempt J, Schmidt-Graf F, Kertels O, Thomas M, Meyer HS, Zimmer C, Meyer B, Combs SE, Yakushev I, Wiestler B, Metz MC. Imaging the WHO 2021 Brain Tumor Classification: Fully Automated Analysis of Imaging Features of Newly Diagnosed Gliomas. Cancers (Basel) 2023; 15:2355. [PMID: 37190283 PMCID: PMC10136825 DOI: 10.3390/cancers15082355] [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] [Received: 01/22/2023] [Revised: 03/13/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND The fifth version of the World Health Organization (WHO) classification of tumors of the central nervous system (CNS) in 2021 brought substantial changes. Driven by the enhanced implementation of molecular characterization, some diagnoses were adapted while others were newly introduced. How these changes are reflected in imaging features remains scarcely investigated. MATERIALS AND METHODS We retrospectively analyzed 226 treatment-naive primary brain tumor patients from our institution who received extensive molecular characterization by epigenome-wide methylation microarray and were diagnosed according to the 2021 WHO brain tumor classification. From multimodal preoperative 3T MRI scans, we extracted imaging metrics via a fully automated, AI-based image segmentation and processing pipeline. Subsequently, we examined differences in imaging features between the three main glioma entities (glioblastoma, astrocytoma, and oligodendroglioma) and particularly investigated new entities such as astrocytoma, WHO grade 4. RESULTS Our results confirm prior studies that found significantly higher median CBV (p = 0.00003, ANOVA) and lower median ADC in contrast-enhancing areas of glioblastomas, compared to astrocytomas and oligodendrogliomas (p = 0.41333, ANOVA). Interestingly, molecularly defined glioblastoma, which usually does not contain contrast-enhancing areas, also shows significantly higher CBV values in the non-enhancing tumor than common glioblastoma and astrocytoma grade 4 (p = 0.01309, ANOVA). CONCLUSIONS This work provides extensive insights into the imaging features of gliomas in light of the new 2021 WHO CNS tumor classification. Advanced imaging shows promise in visualizing tumor biology and improving the diagnosis of brain tumor patients.
Collapse
Affiliation(s)
- Michael Griessmair
- Department of Neuroradiology, Klinikum Rechts der Isar, TU Munich, 81675 Munich, Germany
| | - Claire Delbridge
- Department of Pathology, Klinikum Rechts der Isar, TU Munich, 81675 Munich, Germany
| | - Julian Ziegenfeuter
- Department of Neuroradiology, Klinikum Rechts der Isar, TU Munich, 81675 Munich, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU Munich, 81675 Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum Rechts der Isar, TU Munich, 81675 Munich, Germany
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | | | - Olivia Kertels
- Department of Neuroradiology, Klinikum Rechts der Isar, TU Munich, 81675 Munich, Germany
| | - Marie Thomas
- Department of Neuroradiology, Klinikum Rechts der Isar, TU Munich, 81675 Munich, Germany
| | - Hanno S. Meyer
- Department of Neurosurgery, Klinikum Rechts der Isar, TU Munich, 81675 Munich, Germany
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum Rechts der Isar, TU Munich, 81675 Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum Rechts der Isar, TU Munich, 81675 Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU Munich, 81675 Munich, Germany
| | - Igor Yakushev
- Department of Nuclear Medicine, Klinikum Rechts der Isar, TU Munich, 81675 Munich, Germany
| | - Benedikt Wiestler
- Department of Neuroradiology, Klinikum Rechts der Isar, TU Munich, 81675 Munich, Germany
- TranslaTUM, TU Munich, 81675 Munich, Germany
| | - Marie-Christin Metz
- Department of Neuroradiology, Klinikum Rechts der Isar, TU Munich, 81675 Munich, Germany
| |
Collapse
|
9
|
Heitmann H, Fischer E, Wagner P, Pötter D, Gartmeier M, Schmidt-Graf F. Flipping the classroom in neurological bedside teaching: a prospective controlled study. BMC Med Educ 2023; 23:164. [PMID: 36922824 PMCID: PMC10016155 DOI: 10.1186/s12909-023-04150-2] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 03/10/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Bedside teaching is essential to foster core clinical competences in medical education, especially in Neurology. However, bedside skills are declining and new concepts to enhance the effectiveness of bedside teaching are needed, also in view of limited in-person teaching possibilities in the ongoing pandemic situation. If theoretical knowledge is taught prior to in-person sessions this might allow to better focus on practical application aspects during bedside teaching. We thus aimed to answer the question to what extent such an approach can enhance the effectiveness of neurological bedside teaching. METHODS In this prospective controlled study, neurological bedside courses following a traditional and a flipped classroom (FC) approach were compared with regards to their effects on theoretical knowledge and practical skills of medical students. Evaluations were obtained from 161 students and their lecturers participating in a neurological bedside teaching course at a German university hospital between October 2020 and July 2021. Students were randomly assigned to course dates. However, the 74 students assigned to course dates from May to July 2021 completed a mandatory online preparation course prior to the bedside teaching. These students served as the interventional group (IG) and the remaining 87 students formed the control group (CG). Ratings of knowledge and skills provided by the students and their lecturers on numerical rating scales served as primary outcome measures. Moreover, the time needed to recapitulate theoretical contents during the in-person teaching session was assessed as a secondary outcome measure. Group comparisons were performed using t-statistics. RESULTS Theoretical knowledge upon entering the course was rated significantly higher in the IG by the students (p < 0.001) and lecturers (p = 0.003). Lecturers also rated the practical skills of students in the IG significantly higher (p < 0.001). Furthermore, significantly less time was needed to recapitulate theoretical contents during the in-person session in the IG (p = 0.03). CONCLUSIONS Using a FC approach enhances the effectiveness of in-person neurological bedside teaching. Thus, these concepts are particularly valuable in the ongoing pandemic situation. Moreover, they might allow to reuse e-learning contents developed during the pandemic and to develop future bedside teaching concepts.
Collapse
Affiliation(s)
- Henrik Heitmann
- Department of Neurology, School of Medicine, Technical University of Munich (TUM), Munich, Germany.
- Department of Psychosomatic Medicine and Psychotherapy, Technical University of Munich (TUM), Munich, Germany.
| | - Elisabeth Fischer
- Department of Neurology, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Philipp Wagner
- Department of Neurology, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Dennis Pötter
- Department of Anesthesiology and Operative Intensive Care Medicine, Klinikum Dortmund, Dortmund, Germany
- TUM Medical Education Center, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Martin Gartmeier
- TUM Medical Education Center, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| |
Collapse
|
10
|
Aftahy AK, Butenschoen VM, Hoenikl L, Liesche-Starnecker F, Wiestler B, Schmidt-Graf F, Meyer B, Gempt J. A rare case of H3K27-altered diffuse midline glioma with multiple osseous and spinal metastases at the time of diagnosis. BMC Neurol 2023; 23:87. [PMID: 36855102 PMCID: PMC9972747 DOI: 10.1186/s12883-023-03135-4] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/21/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND H3K27-altered diffuse midline gliomas are uncommon central nervous system tumors with extremely poor prognoses. CASE PRESENTATION We report the case of a 24-year-old man patient with multiple, inter alia osseous metastases who presented with back pain, hemi-hypoesthesia, and hemi-hyperhidrosis. The patient underwent combined radio-chemotherapy and demonstrated temporary improvement before deteriorating. CONCLUSIONS H3K27-altered diffuse midline glioma presents an infrequent but crucial differential diagnosis and should be considered in cases with rapid neurological deterioration and multiple intracranial and intramedullary tumor lesions in children and young adults. Combined radio-chemotherapy delayed the neurological deterioration, but unfortunately, progression occurred three months after the diagnosis.
Collapse
Affiliation(s)
- A. Kaywan Aftahy
- grid.6936.a0000000123222966Department of Neurosurgery, School of Medicine, Medical Faculty, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Vicki M. Butenschoen
- grid.6936.a0000000123222966Department of Neurosurgery, School of Medicine, Medical Faculty, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Lisa Hoenikl
- grid.6936.a0000000123222966Department of Neurosurgery, School of Medicine, Medical Faculty, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Friederike Liesche-Starnecker
- grid.6936.a0000000123222966Department of Neuropathology, School of Medicine, Institute of Pathology, Technical University of Munich, Munich, Germany
| | - Benedikt Wiestler
- grid.6936.a0000000123222966Department of Neuroradiology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Friederike Schmidt-Graf
- grid.6936.a0000000123222966Neurological Department, School of Medicine, Technical University of Munich, Munich, Germany
| | - Bernhard Meyer
- grid.6936.a0000000123222966Department of Neurosurgery, School of Medicine, Medical Faculty, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Jens Gempt
- grid.6936.a0000000123222966Department of Neurosurgery, School of Medicine, Medical Faculty, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| |
Collapse
|
11
|
Baki E, Scheidhauer K, Schmidt-Graf F. Bilateral mydriasis as first manifestation of Hodgkin's lymphoma: a case report. BMC Neurol 2022; 22:473. [PMID: 36503418 PMCID: PMC9743757 DOI: 10.1186/s12883-022-02941-6] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/27/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Bilateral mydriasis is usually associated with severe brain stem damage or drug-induced sympathomimetic stimulation. Herein we report it as a unique neurologic complication of Hodgkin's lymphoma. CASE PRESENTATION A 23-year-old woman presented at our emergency department with dilated pupils unresponsive to light stimuli. MRI and CT scans showed bilaterally enlarged lymph nodes in the mediastinum and supraclavicular compressing the carotid artery on both sides. The histologic examination of lymph node biopsy specimens confirmed the diagnosis of Hodgkin's lymphoma. CONCLUSION Pathologies around the carotid artery causing oculosympathetic spasm should be considered among the possible causes of a mydriasis, especially when other common causes like brain stem impairment are excluded.
Collapse
Affiliation(s)
- Enayatullah Baki
- grid.6936.a0000000123222966Department of Neurology, Klinikum rechts der Isar, Technical University, Ismaningerstrasse 22, 81675 Munich, Germany
| | - Klemens Scheidhauer
- grid.6936.a0000000123222966Department of Nuclear Medicine, Klinikum rechts der Isar, Technical University, Ismaningerstrasse 22, 81675 Munich, Germany
| | - Friederike Schmidt-Graf
- grid.6936.a0000000123222966Department of Neurology, Klinikum rechts der Isar, Technical University, Ismaningerstrasse 22, 81675 Munich, Germany
| |
Collapse
|
12
|
Weller J, Zeyen T, Schlegel U, Lazaridis L, Werner JM, Onken J, Zeiner P, Drexler R, Hau P, Seidel C, Grosse L, Clusmann H, Sabel M, Ringel F, Pichler J, Grauer O, Hundsberger T, Schnell O, Mair MJ, Uhl M, Schmidt-Graf F, Glas M, Galldiks N, Unteroberdörster M, Steinbach J, Ricklefs F, Renovanz M, Delev DI, Turgut MO, Flesch OR, Cipriani D, Preusser M, Kebir S, Misch M, Goldbrunner R, Westphal M, Tabatabai G, Schäfer N, Schneider M, Vatter H, Giordano F, Schaub C, Herrlinger U. CTNI-07. LOMUSTINE/TEMOZOLOMIDE CHEMOTHERAPY FOR NEWLY DIAGNOSED MGMT-METHYLATED IDHWT GLIOBLASTOMA ACCORDING TO CETEG/NOA-09: REAL-WORLD EXPERIENCE IN A MULTICENTER COHORT. Neuro Oncol 2022. [PMCID: PMC9660822 DOI: 10.1093/neuonc/noac209.274] [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
INTRODUCTION
The CeTeG/NOA-09 trial demonstrated superior median overall survival (mOS, 48.1 months) in MGMT-methylated glioblastoma treated with lomustine/temozolomide compared to temozolomide. We retrospectively analyzed an off-study cohort of patients treated with lomustine/temozolomide to gather real-world data on this new regimen.
METHODS
Adult patients from 20 centers in Germany, Austria and Switzerland were included. Inclusion criteria were MGMT-methylated IDHwt glioblastoma newly diagnosed prior to end of 2020, and lomustine/temozolomide treatment as part of first-line therapy.
RESULTS
321 patients with a median age of 57 years (range, 21-78) and a median follow-up of 19.9 months were included. In the whole cohort, mOS was 41.0 months (95%CI, 33.0 – not reached). In patients starting lomustine/temozolomide immediately upon initiation of radiotherapy strictly following the CeTeG protocol (88%), mOS was 52.8 months (35.8 – not reached) as compared to 24.6 months (17.6 – not reached) in patients starting lomustine/temozolomide after completion of radiotherapy/concomitant temozolomide (12%, logrank test: p = 0.06). Patients with a KPS < 80 had a shorter mOS of 19.7 months (95%CI, 16.6 – not reached) compared to 41.0 months (33.0 – not reached, p = 0.009) in KPS 80-100. Gross total resection (GTR, 53.9%) was associated with longer mOS (52.8 months, 95%CI 24.1 – not reached) compared to partial resection/biopsy (30.5 months, 95%CI 36.8 – not reached, p=0.004). Multivariable Cox regression analysis confirmed GTR (HR 0.66, p = 0.033) and younger age ( ≤ 50 years: HR 0.42, p = 0.001), but not KPS (80-100 vs. lower: HR 0.66, p = 0.12) as independent prognostic factors.
DISCUSSION
In this real-world multicenter cohort, survival was similar to the promising results of CeTeG/NOA-09. Further analyses should investigate a potentially reduced benefit from lomustine/temozolomide in patients with low KPS/no GTR and a possible detrimental effect from deferred lomustine/temozolomide initiation. The median follow-up is admittedly short, updated data will be presented.
Collapse
Affiliation(s)
- Johannes Weller
- Division of Neurooncology, Department of Neurology, University Hospital Bonn , Bonn , Germany
| | - Thomas Zeyen
- Division of Neurooncology, Department of Neurology, University Hospital Bonn , Bonn , Germany
| | - Uwe Schlegel
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr–University Bochum , Bochum , Germany
| | - Lazaros Lazaridis
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany , Essen , Germany
| | - Jan-Michael Werner
- Dept. of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne , Cologne , Germany
| | - Julia Onken
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin , Berlin , Germany
| | - Pia Zeiner
- Dr. Senckenberg Institute of Neurooncology , Frankfurt , Germany
| | - Richard Drexler
- University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Peter Hau
- Universitätsklinikum Regensburg , Regensburg , Germany
| | - Clemens Seidel
- Department of Radiotherapy, University Hospital Leipzig , Leipzig , Germany
| | - Lucia Grosse
- Department of Neurology & Interdisciplinary Neuro-Oncology, University Hospital Tübingen, Hertie Institute for Clinical Brain Research , Tübingen , Germany
| | - Hans Clusmann
- Department of Neurosurgery, Faculty of Medicine, RWTH Aachen University , Aachen , Germany
| | - Michael Sabel
- Department of Neurosurgery, University of Düsseldorf , Düsseldorf , Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz , Mainz , Germany
| | - Josef Pichler
- Department of Internal Medicine, Neuromed Campus Wagner-Jauregg, Kepler University Hospital, Johannes Kepler University of Linz , Linz , Austria
| | - Oliver Grauer
- Department of Neurology, University Hospital Münster , Münster , Germany
| | - Thomas Hundsberger
- Departments of Neurology and Hematology/Oncology, Kantonsspital St.Gallen , St. Gallen , Switzerland
| | - Oliver Schnell
- Department of Neurosurgery, University of Freiburg , Freiburg , Germany
| | - Maximilian J Mair
- Department of Medicine I, Medical University of Vienna , Vienna , Austria
| | - Martin Uhl
- Department of Neurology, University Hospital Erlangen , Erlangen , USA
| | | | - Martin Glas
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany , Essen , Germany
| | - Norbert Galldiks
- Institute of Neuroscience and Medicine (INM-3), Research Center Juelich (FZJ) , Juelich , Germany
| | | | | | - Franz Ricklefs
- Universitry Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Mirjam Renovanz
- Department of Neurology & Interdisciplinary Neuro-Oncology, University Hospital Tübingen, Hertie Institute for Clinical Brain Research , Tübingen , Germany
| | - Daniel Ivanov Delev
- Department of Neurosurgery, Faculty of Medicine, RWTH Aachen University , Aachen , Germany
| | - Merih O Turgut
- Department of Neurosurgery, University Medical Center Mainz , Mainz , Germany
| | - Oliver R Flesch
- Department of Neurosurgery, University of Düsseldorf , Düsseldorf , Germany
| | - Debora Cipriani
- Department of Neurosurgery, University of Freiburg , Freiburg , Germany
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna , Vienna , Austria
| | - Sied Kebir
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany , Essen , Germany
| | - Martin Misch
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin , Berlin , Germany
| | - Roland Goldbrunner
- Dept. of General Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne , Cologne , Germany
| | | | - Ghazaleh Tabatabai
- Department of Neurology & Interdisciplinary Neuro-Oncology, University Hospital Tübingen, Hertie Institute for Clinical Brain Research , Tübingen , Germany
| | - Niklas Schäfer
- Division of Neurooncology, Department of Neurology, University Hospital Bonn , Bonn , Germany
| | | | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn , Bonn , Germany
| | - Frank Giordano
- Department of Radiation Oncology, University Hospital Bonn , Bonn , Germany
| | - Christina Schaub
- Division of Neurooncology, Department of Neurology, University Hospital Bonn , Bonn , Germany
| | - Ulrich Herrlinger
- Division of Neurooncology, Department of Neurology, University Hospital Bonn , Bonn , Germany
| |
Collapse
|
13
|
Kempter J, Gempt J, Wiestler B, Combs SE, Schlegel J, Liesche-Starnecker F, Schmidt-Graf F. P11.22.A Prognostic and predictive relevance of immunohistochemically determined p53 mutation in glioblastoma. Neuro Oncol 2022. [DOI: 10.1093/neuonc/noac174.211] [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: 11/12/2022] Open
Abstract
Abstract
Background
It can be expected that molecular biomarkers will increasingly affect clinical decisions and lead to the development of more personalized therapies in glioblastoma (GBM) in the future. In several other tumor entities TP53 gene mutation or p53 immunoreactivity (IR) serve as a prognostic marker, significantly affecting overall survival (OS) and progression-free survival (PFS). Such an association has not yet sufficiently been demonstrated in GBM. However, there are known prognostic markers in GBM, notably MGMT promotor methylation (mMGMT) which also serves as an important predictive marker leading to a better response to temozolomide chemotherapy. Our aim was to evaluate retrospectively if p53 mutation determined via immunohistochemistry (IHC) could act as a prognostic or predictive marker in GBM.
Material and Methods
Tumor samples of 195 treatment-naïve patients with IDHwt GBM that had been stained with the p53 antibody DO-7 were subdivided into 2 different groups by p53 IHC. Samples were considered as p53mut when strong p53 IR was detected in ≥10% of all tumor cells and as p53wt when in <10%. Treatment, further molecular and survival data were gathered retrospectively for all patients. Statistical analyses were performed with SPSS.
Results
The frequency of p53mut was 36.4% (71/195). p53mut tumors showed a significantly higher IR with Ki-67 proliferation marker (p=0.005) and p53wt seemed to be associated with multifocal primary tumor localization, though not statistically significant (p=0.107). There was no significant difference between p53wt and p53mut regarding gender, age, extent of resection, adjuvant therapy, occurrence of seizures, mMGMT or ATRX loss. The p53 status was not associated with OS or PFS. Factors that univariately led to significantly longer OS and PFS were younger age, unilateral or unifocal primary tumor localization, gross-total resection, higher Karnofsky Performance Status (KPS), mMGMT and adjuvant treatment via Stupp regimen instead of radiotherapy alone, the latter being significantly better than best supportive care. In multivariate survival analyses only age <65 years, the Stupp regimen more than radiotherapy alone and KPS ≥80% significantly prolonged both OS and PFS. Unifocal primary tumor localization led to longer OS and mMGMT led to longer PFS independently. The p53 status did not significantly affect the response to different adjuvant therapy regimens neither concerning OS nor PFS.
Conclusion
Based on our study, p53 IR has no prognostic or predictive significance in IDHwt GBM. There have been previous studies with similar and others with contradicting results. Remarkable is the discordance of the used IR thresholds between different studies. Further studies should aim to revalidate the staining threshold and improve the concordance between TP53 gene sequencing and p53 IHC in IDHwt GBM.
Collapse
Affiliation(s)
- J Kempter
- Department of Neurology, School of Medicine, Technical University Munich , Munich , Germany
| | - J Gempt
- Department of Neurosurgery, School of Medicine, Technical University Munich , Munich , Germany
| | - B Wiestler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Technical University , Munich , Germany
| | - S E Combs
- Department of RadiationOncology, School of Medicine, Technical University Munich , Munich , Germany
| | - J Schlegel
- Department of Neuropathology, School of Medicine, Institute of Pathology, Technical University Munich , Munich , Germany
| | - F Liesche-Starnecker
- Department of Neuropathology, School of Medicine, Institute of Pathology, Technical University Munich , Munich , Germany
| | - F Schmidt-Graf
- Department of Neurology, School of Medicine, Technical University Munich , Munich , Germany
| |
Collapse
|
14
|
Mosene K, Heitmann H, Pötter D, Schmidt-Graf F. New concepts in neurology education: successful implementation of flipped classroom lectures. Neurol Res Pract 2022; 4:31. [PMID: 35934701 PMCID: PMC9358101 DOI: 10.1186/s42466-022-00196-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 05/31/2022] [Indexed: 11/22/2022] Open
Abstract
In order to inspire and attract young people to Neurology, we must offer high-quality and attractive teaching! To improve neurological education at our Medical School (Technical University of Munich), we converted the main lecture into an e-learning concept using a flipped classroom model. Students had to prepare with a video and a text as well as answering multiple choice questions before each lecture. As a further incentive, students with ≥ 80% right answers in multiple choice questions received a bonus for the final exam. During the lectures, predominantely patient cases were discussed to apply, improve and enhance the previously acquired knowledge. The realignment of the main lecture in Neurology into a flipped classroom model was very successful and was further optimized in the following semesters based on the evaluations obtained for the new concept. Moreover, this enabled us to quickly switch to remote teaching during the COVID-19 pandemic, while still offering lectures of high quality. In addition, this new teaching concept attracts students for Neurology. Furthermore, the exemplary conversion of the Neurology main lecture to a flipped classroom concept also serves as best practice and motivation to adapt other courses in our faculty and far beyond.
Collapse
|
15
|
Kram H, Prokop G, Haller B, Gempt J, Wu Y, Schmidt-Graf F, Schlegel J, Conrad M, Liesche-Starnecker F. Glioblastoma Relapses Show Increased Markers of Vulnerability to Ferroptosis. Front Oncol 2022; 12:841418. [PMID: 35530303 PMCID: PMC9071304 DOI: 10.3389/fonc.2022.841418] [Citation(s) in RCA: 10] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/22/2022] [Indexed: 01/08/2023] Open
Abstract
Background Despite the availability of various therapy options and being a widely focused research area, the prognosis of glioblastoma (GBM) still remains very poor due to therapy resistance, genetic heterogeneity and a diffuse infiltration pattern. The recently described non-apoptotic form of cell death ferroptosis may, however, offer novel opportunities for targeted therapies. Hence, the aim of this study was to investigate the potential role of ferroptosis in GBM, including the impact of treatment on the expression of the two ferroptosis-associated players glutathione-peroxidase 4 (GPX4) and acyl-CoA-synthetase long-chain family number 4 (ACSL4). Furthermore, the change in expression of the recently identified ferroptosis suppressor protein 1 (FSP1) and aldehyde dehydrogenase (ALDH) 1A3 was investigated. Methods Immunohistochemistry was performed on sample pairs of primary and relapse GBM of 24 patients who had received standard adjuvant treatment with radiochemotherapy. To identify cell types generally prone to undergo ferroptosis, co-stainings of ferroptosis susceptibility genes in combination with cell-type specific markers including glial fibrillary acidic protein (GFAP) for tumor cells and astrocytes, as well as the ionized calcium-binding adapter molecule 1 (Iba1) for microglial cells were performed, supplemented by double stains combining GPX4 and ACSL4. Results While the expression of GPX4 decreased significantly during tumor relapse, ACSL4 showed a significant increase. These results were confirmed by analyses of data sets of the Cancer Genome Atlas. These profound changes indicate an increased susceptibility of relapsed tumors towards oxidative stress and associated ferroptosis, a cell death modality characterized by unrestrained lipid peroxidation. Moreover, ALDH1A3 and FSP1 expression also increased in the relapses with significant results for ALDH1A3, whereas for FSP1, statistical significance was not reached. Results obtained from double staining imply that ferroptosis occurs more likely in GBM tumor cells than in microglial cells. Conclusion Our study implies that ferroptosis takes place in GBM tumor cells. Moreover, we show that recurrent tumors have a higher vulnerability to ferroptosis. These results affirm that utilizing ferroptosis processes might be a possible novel therapy option, especially in the situation of recurrent GBM.
Collapse
Affiliation(s)
- Helena Kram
- Department of Neuropathology, Institute of Pathology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Georg Prokop
- Department of Neuropathology, Institute of Pathology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Bernhard Haller
- Institute of AI and Informatics in Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, School of Medicine, Technical University of Munich, Munich, Germany
| | - Yang Wu
- Department of Neuropathology, Institute of Pathology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Jürgen Schlegel
- Department of Neuropathology, Institute of Pathology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Marcus Conrad
- Institute of Metabolism and Cell Death, Helmholtz Zentrum München, Neuherberg, Germany.,Laboratory of Experimental Oncology, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Friederike Liesche-Starnecker
- Department of Neuropathology, Institute of Pathology, School of Medicine, Technical University of Munich, Munich, Germany
| |
Collapse
|
16
|
Biesalski AS, Tönges L, von Kirchbauer I, Gülke E, Eisenberg H, Ippen FM, Schmidt-Graf F. Residents as teachers in Neurology: a Germany-wide survey on the involvement of neurological residents in clinical teaching. Neurol Res Pract 2022; 4:17. [PMID: 35527309 PMCID: PMC9080961 DOI: 10.1186/s42466-022-00170-3] [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: 11/16/2021] [Accepted: 01/03/2022] [Indexed: 11/28/2022] Open
Abstract
Background Residents play an important role in the clinical training of medical students, spending up to 25% of their daily work teaching. In the US medical curriculum didactic courses for residents already exist and their role as a teacher is firmly anchored. In Germany, there are no fixed regulations or residents-as-teachers-programs. The aim of this study was to evaluate the activities of neurological residents in clinical teaching.
Methods We conducted a prospective cross-sectional online survey among neurological residents in Germany. The evaluation was carried out descriptively and by means of text analysis. Results 138 residents from 39 German neurological university hospitals answered the survey. Nearly half of them needed the teaching activity as part of their career planning. The residents are mostly involved in practical courses. More than 80% stated, that they enjoy teaching. 64% stated that there were no preparatory courses for teaching at their hospital/university. 78.4% of the respondents received no or merely insufficient feedback for their own teaching and 62.5% had only little or even no knowledge about the university curriculum. Conclusions By teaching medical students, residents play an outstanding role in recruiting students for neurology and, simultaneously, teaching leads an improvement in the residents’ own learning. To encourage young neurologists as teachers and—at the same time as learners—Clinic directors and universities should promote residents-as-teachers programs in neurology and reward the residents’ teaching activities. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-022-00170-3.
Collapse
Affiliation(s)
- Anne-Sophie Biesalski
- Department of Neurology, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany.
| | - Lars Tönges
- Department of Neurology, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany.,Center for Protein Diagnostics (ProDi), Ruhr University Bochum, Bochum, Germany
| | | | - Eileen Gülke
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanna Eisenberg
- Department of Neurology, Universität Medical Center Göttingen, Göttingen, Germany
| | | | | |
Collapse
|
17
|
Heitmann H, Wagner P, Fischer E, Gartmeier M, Schmidt-Graf F. Effectiveness of non-bedside teaching during the COVID-19 pandemic: a quasi-experimental study. BMC Med Educ 2022; 22:73. [PMID: 35101016 PMCID: PMC8801559 DOI: 10.1186/s12909-022-03141-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/27/2022] [Indexed: 05/30/2023]
Abstract
BACKGROUND The COVID-19 pandemic poses a huge challenge for clinical teaching due to contact restrictions and social distancing. Medical teachers have to balance potential risks and benefits of bedside teaching, especially in course formats intended to foster practical clinical skills. In this context, we aimed to address the question, whether presence-based teaching formats without patient involvement are suitable to teach practical skills. METHODS In this quasi-experimental study, presence-based teaching formats with and without patient contact were retrospectively compared regarding their effects on medical students' theoretical knowledge and practical skills, i.e. the performance and clinical interpretation of the neurological exam. To this end, evaluations from 102 students and their lecturers participating in a neurological bedside teaching course at a German university hospital between October 2020 and April 2021 were obtained. Students were initially randomly assigned to course dates. However, 53 students assigned to courses in November and December 2020, were not able to go bedside due to contact restrictions. These students formed the interventional group and the remaining 49 students the control group. The primary outcome measures were students' overall grading of the course (school grades, 1-6) as well as ratings of knowledge and skills provided by the students themselves and their lecturers on a numerical rating scale (0-10). Comparison between groups was performed using frequentist and Bayesian t-statistics. RESULTS The teaching format without patient contact received a significantly poorer overall grade by the students (p = 0.018). However, improvements in the students' self-ratings of knowledge and skills did not differ between the two formats (all p > 0.05, BF10max = 0.42). Moreover, especially practical skills were even rated significantly better in the group without patient contact by the lecturers (p < 0.001). CONCLUSIONS Teaching formats without patient contact are less well-received by the students. However, they are able to teach practical skills regarding the performance and clinical interpretation of examination techniques. Still, the evaluations obtained might not adequately capture the importance of bedside teaching in preparing future physicians for their practice. Perspectively, hybrid teaching approaches including flipped-classroom concepts hold considerable potential to enhance effectiveness of bedside teaching in the present pandemic situation and in the future.
Collapse
Affiliation(s)
- Henrik Heitmann
- Department of Neurology, School of Medicine, Technical University of Munich (TUM), Munich, Germany.
| | - Philipp Wagner
- Department of Neurology, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Elisabeth Fischer
- Department of Neurology, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Martin Gartmeier
- TUM Medical Education Center, School of Medicine, TUM, Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| |
Collapse
|
18
|
Barz M, Gerhardt J, Bette S, Aftahy AK, Huber T, Combs SE, Ryang YM, Wiestler B, Skardelly M, Gepfner-Tuma I, Behling F, Schmidt-Graf F, Meyer B, Gempt J. Prognostic value of tumour volume in patients with a poor Karnofsky performance status scale - a bicentric retrospective study. BMC Neurol 2021; 21:446. [PMID: 34781889 PMCID: PMC8591917 DOI: 10.1186/s12883-021-02424-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 11/01/2020] [Accepted: 09/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKROUND Median overall survival (OS) after diagnosis of glioblastoma (GBM) remains 15 months amongst patients receiving aggressive surgical resection, chemotherapy and irradiation. Treatment of patients with a poor preoperative Karnofsky Performance Status Scale (KPSS) is still controversial. Therefore, we retrospectively assessed the outcome after surgical treatment in patients with a KPSS of ≤60%. METHODS We retrospectively included patients with a de-novo glioblastoma WHO °IV and preoperative KPSS ≤60%, who underwent surgery at two neurosurgical centres between September 2006 and March 2016. We recorded pre- and postoperative tumour volume, pre- and postoperative KPSS, OS, age and MGMT promoter status. RESULTS One hundred twenty-three patients (58 females/65 males, mean age 67.4 ± 13.4 years) met the inclusion criteria. Seventy-five of the 123 patients (61%) underwent surgical resection. 48/123 patients (39%) received a biopsy. The median preoperative and postoperative tumour volume of all patients was 33.0 ± 31.3 cm3 (IR 15.0-56.5cm3) and 3.1 ± 23.8 cm3 (IR 0.2-15.0 cm3), respectively. The median KPSS was 60% (range 20-60%) preoperatively and 50% (range 0-80%) postoperatively. Patients who received a biopsy showed a median OS for patients who received a biopsy only was 3.0 months (95% CI 2.0-4.0 months), compared to patients who had a resection and had a median OS of 8 months (95% CI 3.1-12.9 months). Age (p < 0.001, HR: 1.045 [95% CI 1.022-1.068]), postoperative tumour volume (p = 0.02, HR: 1.016 [95% CI 1.002-1.029]) and MGMT promotor status (p = 0.016, HR: 0.473 [95% CI 0.257-0.871]) were statistically significant in multivariate analysis. In subgroup analyses only age was shown as a significant prognostic factor in multivariate analyses for patients receiving surgery (p < 0.001, HR: 1.046 [95% CI 1.022-1.072]). In the biopsy group no significant prognostic factors were shown in multivariate analysis. CONCLUSION GBM patients with a preoperative KPSS of ≤60% might profit from surgical reduction of tumour burden.
Collapse
Affiliation(s)
- Melanie Barz
- Department of Neurosurgery, Technical University Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Julia Gerhardt
- Department of Neurosurgery, Helios Klinikum Berlin Buch, Berlin, Germany
| | - Stefanie Bette
- Department of Diagnostic and Interventional Radiology, Universitätsklinikum Augsburg, Augsburg, Germany.,Department of Neuroradiology, Technical University Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - A Kaywan Aftahy
- Department of Neurosurgery, Technical University Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Thomas Huber
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Stephanie E Combs
- Helmholtz Zentrum Munich (HMGU), Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK) (German Cancer Consortium), Partner Site Munich, Munich, Germany
| | - Yu-Mi Ryang
- Department of Neurosurgery, Helios Klinikum Berlin Buch, Berlin, Germany
| | - Benedikt Wiestler
- Department of Neuroradiology, Technical University Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Marco Skardelly
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | | | - Felix Behling
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Technical University Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Technical University Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| |
Collapse
|
19
|
Barbera L, Schmidt-Graf F, Delbdrige C, Gempt J. The influence of postoperative infections on the survival of glioma patients. J Neurol Sci 2021. [DOI: 10.1016/j.jns.2021.118456] [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: 10/20/2022]
|
20
|
Biesalski AS, von Kirchbauer I, Schmidt-Graf F. Neurological teaching in times of crisis. GMS J Med Educ 2020; 37:Doc69. [PMID: 33364348 PMCID: PMC7740022 DOI: 10.3205/zma001362] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/12/2020] [Accepted: 10/19/2020] [Indexed: 06/01/2023]
Abstract
Background/Objective: The changes to medical studies that became necessary as part of the Corona pandemic have also forced considerable adjustments in Neurology. Classroom teaching had to be converted almost entirely to digital formats within a short period of time. The present study provides an overview of the respective changes and associated complications as well as opportunities in teaching Neurology. Methodology: Lecturers in Neurology at all University hospitals in Germany were asked about their approach and the individual changes in their curriculum. Of a total of 39 locations, 23 answered the online questionnaire (see attachment 1). Results: While frontal teaching and lectures could be carried out digitally without any problems, difficulties arose especially in learning physical examination and bedside teaching. Most of the participants stated that they had not found satisfactory e-learning formats to replace teaching at the patients bed. Conclusion: The ad hoc changes in teaching Neurology resulted in significant additional effort for the part of lecturers, but were generally well accepted by students. The Corona pandemic thus ultimately offers an opportunity to enrich teaching in Neurology.
Collapse
Affiliation(s)
- Anne-Sophie Biesalski
- Ruhr-Universität Bochum, Neurologische Klinik St. Josef Hospital Bochum, Bochum, Germany
| | - Isabelle von Kirchbauer
- Technische Universität München, Klinikum rechts der Isar, TUM Medical Education Center, Munich, Germany
| | - Friederike Schmidt-Graf
- Technische Universität München, Klinikum rechts der Isar, Klinik und Poliklinik für Neurologie, Munich, Germany
| |
Collapse
|
21
|
Straube C, Kessel K, Antoni S, Gempt J, Meyer B, Schlegel J, Schmidt-Graf F, Combs S. PH-0358: score to predict survival of elderly patients newly diagnosed for Glioblastoma. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)00382-0] [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: 10/22/2022]
|
22
|
Liesche-Starnecker F, Mayer K, Kofler F, Baur S, Schmidt-Graf F, Kempter J, Prokop G, Pfarr N, Wei W, Gempt J, Combs SE, Zimmer C, Meyer B, Wiestler B, Schlegel J. Immunohistochemically Characterized Intratumoral Heterogeneity Is a Prognostic Marker in Human Glioblastoma. Cancers (Basel) 2020; 12:cancers12102964. [PMID: 33066251 PMCID: PMC7602025 DOI: 10.3390/cancers12102964] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 09/07/2020] [Revised: 10/02/2020] [Accepted: 10/09/2020] [Indexed: 12/17/2022] Open
Abstract
Simple Summary Intratumoral heterogeneity is believed to contribute to the immense therapy resistance and recurrence rate of glioblastoma. The aim of this retrospective study was to analyze the heterogeneity of 36 human glioblastoma samples on a morphological level by immunohistochemistry. We confirmed that this method is valid for heterogeneity detection. 115 Areas of Interest were labelled. By cluster analysis, we defined two subtypes (“classical” and “mesenchymal”). The results of epigenomic analyses corroborated the findings. Interestingly, patients with tumors that consisted of both subtypes (“subtype-heterogeneous”) showed a shorter overall survival compared to patients with tumor that were dominated by one subtype (“subtype-dominant”). Furthermore, the analysis of 21 corresponding pairs of primary and recurrent glioblastoma demonstrated that, additionally to an intratumoral heterogeneity, there is also a chronological heterogeneity with dominance of the mesenchymal subtype in recurrent tumors. Our study confirms the prognostic impact of intratumoral heterogeneity in glioblastoma and makes this hallmark assessable by routine diagnostics. Abstract Tumor heterogeneity is considered to be a hallmark of glioblastoma (GBM). Only more recently, it has become apparent that GBM is not only heterogeneous between patients (intertumoral heterogeneity) but more importantly, also within individual patients (intratumoral heterogeneity). In this study, we focused on assessing intratumoral heterogeneity. For this purpose, the heterogeneity of 38 treatment-naïve GBM was characterized by immunohistochemistry. Perceptible areas were rated for ALDH1A3, EGFR, GFAP, Iba1, Olig2, p53, and Mib1. By clustering methods, two distinct groups similar to subtypes described in literature were detected. The classical subtype featured a strong EGFR and Olig2 positivity, whereas the mesenchymal subtype displayed a strong ALDH1A3 expression and a high fraction of Iba1-positive microglia. 18 tumors exhibited both subtypes and were classified as “subtype-heterogeneous”, whereas the areas of the other tumors were all assigned to the same cluster and named “subtype-dominant”. Results of epigenomic analyses corroborated these findings. Strikingly, the subtype-heterogeneous tumors showed a clearly shorter overall survival compared to subtype-dominant tumors. Furthermore, 21 corresponding pairs of primary and recurrent GBM were compared, showing a dominance of the mesenchymal subtype in the recurrent tumors. Our study confirms the prognostic impact of intratumoral heterogeneity in GBM, and more importantly, makes this hallmark assessable by routine diagnostics.
Collapse
Affiliation(s)
- Friederike Liesche-Starnecker
- Department of Neuropathology, School of Medicine, Institute of Pathology, Technical University Munich, Trogerstraße 18, 81675 München, Germany; (K.M.); (S.B.); (G.P.); (W.W.); (J.S.)
- Correspondence: ; Tel.: +49-89-6145
| | - Karoline Mayer
- Department of Neuropathology, School of Medicine, Institute of Pathology, Technical University Munich, Trogerstraße 18, 81675 München, Germany; (K.M.); (S.B.); (G.P.); (W.W.); (J.S.)
| | - Florian Kofler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Technical University Munich, Ismaninger Str. 22, 81675 München, Germany; (F.K.); (C.Z.); (B.W.)
| | - Sandra Baur
- Department of Neuropathology, School of Medicine, Institute of Pathology, Technical University Munich, Trogerstraße 18, 81675 München, Germany; (K.M.); (S.B.); (G.P.); (W.W.); (J.S.)
| | - Friederike Schmidt-Graf
- Department of Neurology, School of Medicine, Technical University Munich, Ismaninger Str. 22, 81675 München, Germany; (F.S.-G.); (J.K.)
| | - Johanna Kempter
- Department of Neurology, School of Medicine, Technical University Munich, Ismaninger Str. 22, 81675 München, Germany; (F.S.-G.); (J.K.)
| | - Georg Prokop
- Department of Neuropathology, School of Medicine, Institute of Pathology, Technical University Munich, Trogerstraße 18, 81675 München, Germany; (K.M.); (S.B.); (G.P.); (W.W.); (J.S.)
| | - Nicole Pfarr
- Institute of Pathology, School of Medicine, Technical University Munich, Trogerstraße 18, 81675 München, Germany;
| | - Wu Wei
- Department of Neuropathology, School of Medicine, Institute of Pathology, Technical University Munich, Trogerstraße 18, 81675 München, Germany; (K.M.); (S.B.); (G.P.); (W.W.); (J.S.)
| | - Jens Gempt
- Department of Neurosurgery, School of Medicine, Technical University Munich, Ismaninger Str. 22, 81675 München, Germany; (J.G.); (B.M.)
| | - Stephanie E. Combs
- Department of RadiationOncology, School of Medicine, Technical University Munich, Ismaninger Str. 22, 81675 München, Germany;
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Technical University Munich, Ismaninger Str. 22, 81675 München, Germany; (F.K.); (C.Z.); (B.W.)
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Technical University Munich, Ismaninger Str. 22, 81675 München, Germany; (J.G.); (B.M.)
| | - Benedikt Wiestler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Technical University Munich, Ismaninger Str. 22, 81675 München, Germany; (F.K.); (C.Z.); (B.W.)
- TranslaTUM (Zentralinstitut für translationale Krebsforschung der Technischen Universität München), Einsteinstraße 25, 81675 München, Germany
| | - Jürgen Schlegel
- Department of Neuropathology, School of Medicine, Institute of Pathology, Technical University Munich, Trogerstraße 18, 81675 München, Germany; (K.M.); (S.B.); (G.P.); (W.W.); (J.S.)
| |
Collapse
|
23
|
Straube C, Kessel KA, Antoni S, Gempt J, Meyer B, Schlegel J, Schmidt-Graf F, Combs SE. A balanced score to predict survival of elderly patients newly diagnosed with glioblastoma. Radiat Oncol 2020; 15:97. [PMID: 32375830 PMCID: PMC7201994 DOI: 10.1186/s13014-020-01549-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 01/03/2020] [Accepted: 04/24/2020] [Indexed: 01/10/2023] Open
Abstract
Background Over the past years, several treatment regimens have been recommended for elderly patients with glioblastoma (GBM), ranging from ultrahypofractionated radiotherapy (RT) over monochemotherapy (ChT) to combined radiochemotherapy (RChT). The current guidelines recommend active treatment in elderly patients in cases with a KPS of at least 60%. We established a score for selecting patients with a very poor prognosis from patients with a better prognosis. Methods One hundred eighty one patients ≥65 years old, histologically diagnosed with GBM, were retrospectively evaluated. Clinical characteristics were analysed for their impact on the overall survival (OS). Factors which were significant in univariate analysis (log-rank test, p < 0.05) were included in a multi-variate model (multi-variate Cox regression analysis, MVA). The 9-month OS for the significant factors after MVA (p < 0.05) was included in a prognostic score. Score sums with a median OS of < and > 6 months were summarized as Group A and B, respectively. Results Age, KPS, MGMT status, the extent of resection, aphasia after surgery and motor dysfunction after surgery were significantly associated with OS on univariate analysis (p < 0.05). On MVA age (p 0.002), MGMT promotor methylation (p 0.013) and Karnofsky performance status (p 0.005) remained significant and were included in the score. Patients were divided into two groups, group A (median OS of 2.7 months) and group B (median OS of 7.8 months). The score was of prognostic significance, independent of the adjuvant treatment regimen. Conclusions The score distinguishes patients with a poor prognosis from patients with a better prognosis. Its inclusion in future retrospective or prospective trials could help enhance the comparability of results. Before its employment on a routine basis, external validation is recommended.
Collapse
Affiliation(s)
- Christoph Straube
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany. .,Deutsches Konsortium für translationale Krebsforschung (dktk), Partner Site Munich, Munich, Germany.
| | - Kerstin A Kessel
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Stefanie Antoni
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany.,Department of Neuropathology, Technical University of Munich, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Juergen Schlegel
- Department of Neuropathology, Technical University of Munich, Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany.,Deutsches Konsortium für translationale Krebsforschung (dktk), Partner Site Munich, Munich, Germany.,Department of Radiation Sciences (DRS), Institut für Strahlenmedizin (IRM), Helmholtz Zentrum München (HMGU), Neuherberg, Germany
| |
Collapse
|
24
|
Bette S, Barz M, Ly Nham H, Huber T, Berndt M, Sales A, Schmidt-Graf F, Meyer HS, Ryang YM, Meyer B, Zimmer C, Kirschke JS, Wiestler B, Gempt J. Image Analysis Reveals Microstructural and Volumetric Differences in Glioblastoma Patients with and without Preoperative Seizures. Cancers (Basel) 2020; 12:E994. [PMID: 32316566 PMCID: PMC7226080 DOI: 10.3390/cancers12040994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/06/2020] [Accepted: 04/09/2020] [Indexed: 01/05/2023] Open
Abstract
Purpose: Seizures related to tumor growth are common in glioma patients, especially in low-grade glioma patients this is often the first tumor manifestation. We hypothesize that there are associations between preoperative seizures and morphologic features (e.g., tumor size, location) and histogram features in patients with glioblastoma (GB). Methods: Retrospectively, 160 consecutive patients with initial diagnosis and surgery of GB (WHO IV) and preoperative MRI were analyzed. Preoperative MRI sequences were co-registered (T2-FLAIR, T1-contrast, DTI) and tumors were segmented by a neuroradiologist using the software ITK-snap blinded to the clinical data. Tumor volume (FLAIR, T1-contrast) and histogram analyses of ADC- and FA-maps were recorded in the contrast enhancing tumor part (CET) and the non-enhancing peritumoral edema (FLAIR). Location was determined after co-registration of the data with an atlas. Permutation-based multiple-testing adjusted t statistics were calculated to compare imaging variables between patients with and without seizures. Results: Patients with seizures showed significantly smaller tumors (CET, adj. p = 0.029) than patients without preoperative seizures. Less seizures were observed in patients with tumor location in the right cingulate gyrus (adj. p = 0.048) and in the right caudate nucleus (adj. p = 0.009). Significant differences of histogram analyses of FA in the contrast enhancing tumor part were observed between patients with and without seizures considering also tumor location and size. Conclusion: Preoperative seizures in GB patients are associated with lower preoperative tumor volume. The different histogram analyses suggest that there might be microstructural differences in the contrast enhancing tumor part of patients with seizures measured by fractional anisotropy. Higher variance of GB presenting without seizures might indicate a more aggressive growth of these tumors.
Collapse
Affiliation(s)
- Stefanie Bette
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany; (S.B.); (H.L.N.); (M.B.); (C.Z.); (J.S.K.); (B.W.)
- Department of Diagnostic and Interventional Radiology, Universitätsklinikum Augsburg, Stenglinstr. 2, 85156 Augsburg, Germany
| | - Melanie Barz
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany; (M.B.); (A.S.); (H.S.M.); (Y.-M.R.); (B.M.)
| | - Huong Ly Nham
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany; (S.B.); (H.L.N.); (M.B.); (C.Z.); (J.S.K.); (B.W.)
| | - Thomas Huber
- Department of Clinical Radiology and Nuclear Medicine, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1–3, 68167 Mannheim, Germany;
| | - Maria Berndt
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany; (S.B.); (H.L.N.); (M.B.); (C.Z.); (J.S.K.); (B.W.)
| | - Arthur Sales
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany; (M.B.); (A.S.); (H.S.M.); (Y.-M.R.); (B.M.)
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany;
| | - Hanno S. Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany; (M.B.); (A.S.); (H.S.M.); (Y.-M.R.); (B.M.)
| | - Yu-Mi Ryang
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany; (M.B.); (A.S.); (H.S.M.); (Y.-M.R.); (B.M.)
- Department of Neurosurgery, HELIOS Klinikum Berlin-Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany; (M.B.); (A.S.); (H.S.M.); (Y.-M.R.); (B.M.)
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany; (S.B.); (H.L.N.); (M.B.); (C.Z.); (J.S.K.); (B.W.)
| | - Jan S. Kirschke
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany; (S.B.); (H.L.N.); (M.B.); (C.Z.); (J.S.K.); (B.W.)
| | - Benedikt Wiestler
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany; (S.B.); (H.L.N.); (M.B.); (C.Z.); (J.S.K.); (B.W.)
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany; (M.B.); (A.S.); (H.S.M.); (Y.-M.R.); (B.M.)
| |
Collapse
|
25
|
Kessel KA, Diehl CD, Oechsner M, Meyer B, Gempt J, Zimmer C, Schmidt-Graf F, Combs SE. Patient-Reported Outcome (PRO) as an Addition to Long-Term Results after High-Precision Stereotactic Radiotherapy in Patients with Secreting and Non-Secreting Pituitary Adenomas: A Retrospective Cohort Study up to 17-Years Follow-Up. Cancers (Basel) 2019; 11:cancers11121884. [PMID: 31783579 PMCID: PMC6966568 DOI: 10.3390/cancers11121884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 09/30/2019] [Revised: 11/10/2019] [Accepted: 11/18/2019] [Indexed: 12/11/2022] Open
Abstract
High-precision radiotherapy has been established as a valid and effective treatment option in patients with pituitary adenomas. We report on outcome after fractionated stereotactic radiotherapy (FSRT) in correlation with patient-reported outcomes (PROs). We analyzed 69 patients treated between 2000 and 2019. FSRT was delivered with a median total dose of 54 Gy (single fraction: 1.8 Gy). PRO questionnaires were sent to 28 patients. Median overall survival was 17.2 years; mean local control was 15.6 years (median not reached). Median follow-up was 5.8 years. Twenty (71%) patients participated in the PRO assessment. Physicians reported symptoms grade ≥3 in 6 cases (9%). Of all, 35 (51%) patients suffered from hypopituitarism at baseline, and during follow-up, new or progressive hypopituitarism was observed in 11 cases (16%). Patients reported 10 cases of severe side effects. Most of these symptoms were already graded as CTCAE (Common Terminology Criteria for Adverse Events) grade 2 by a physician in a previous follow-up exam. PROs are an essential measure and only correlate to a certain extent with the physician-reported outcomes. For high-precision radiotherapy of pituitary adenomas, they confirm excellent overall outcomes and low toxicity. In the future, the integration of PROs paired with high-end treatment will further improve outcomes.
Collapse
Affiliation(s)
- Kerstin A. Kessel
- Department of Radiation Oncology, Technical University of Munich (TUM), 81675 Munich, Germany; (C.D.D.); (M.O.); (S.E.C.)
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany; (B.M.); (J.G.); (C.Z.)
- Correspondence: ; Tel.: +49-089-4140-4502
| | - Christian D. Diehl
- Department of Radiation Oncology, Technical University of Munich (TUM), 81675 Munich, Germany; (C.D.D.); (M.O.); (S.E.C.)
| | - Markus Oechsner
- Department of Radiation Oncology, Technical University of Munich (TUM), 81675 Munich, Germany; (C.D.D.); (M.O.); (S.E.C.)
| | - Bernhard Meyer
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany; (B.M.); (J.G.); (C.Z.)
- Department of Neurosurgery, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Jens Gempt
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany; (B.M.); (J.G.); (C.Z.)
- Department of Neurosurgery, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Claus Zimmer
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany; (B.M.); (J.G.); (C.Z.)
- Department of Neuroradiology, Technical University of Munich (TUM), 81675 Munich, Germany
| | | | - Stephanie E. Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), 81675 Munich, Germany; (C.D.D.); (M.O.); (S.E.C.)
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany; (B.M.); (J.G.); (C.Z.)
| |
Collapse
|
26
|
Combs SE, Kessel KA, Hesse J, Straube C, Zimmer C, Schmidt-Graf F, Schlegel J, Gempt J, Meyer B. Moving Second Courses of Radiotherapy Forward: Early Re-Irradiation After Surgical Resection for Recurrent Gliomas Improves Efficacy With Excellent Tolerability. Neurosurgery 2019; 83:1241-1248. [PMID: 29462372 DOI: 10.1093/neuros/nyx629] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 12/27/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Generally, re-irradiation (Re-RT) is offered to patients with glioma recurrences with macroscopic lesions. Results are discussed controversially, and some centers postulate limited benefit of Re-RT. Re-RT is generally offered to tumors up to 4 cm in diameter. Re-resection is also discussed controversially; however, recent studies have shown significant benefit. OBJECTIVE To combine proactive re-resection and early Re-RT in patients with recurrent glioma. METHODS We included 108 patients treated between 2002 and 2016 for recurrent glioma. All patients underwent surgical resection for recurrence; Re-RT was applied with a median dose of 37.5 Gy (range 25 Gy-57Gy/equivalent dose in 2Gy fractions [EQD2]) with high-precision techniques. All patients were followed prospectively in an interdisciplinary follow-up program. RESULTS Median follow-up after Re-RT was 7 mo. Median survival after surgery and Re-RT was 12 mo (range 1-102 mo). Complete resection had a significant impact on the outcome (P = .03). The strongest predictors of outcome were MGMT-promotor methylation and Karnofsky Performance Score and time interval between primary and second RT. CONCLUSION Proactive resection of tumor recurrences combined with early Re-RT conveys into promising outcome in recurrent glioma. Complete resection and early Re-RT lead to improved survival. Thus, moving Re-RT to an earlier timepoint during the treatment of recurrent glioma, eg after complete macroscopic removal of the tumor, may be crucial for treatment optimization. Using advanced RT techniques, side effects are low. Currently, this concept is evaluated in the GLIOCAVE/NOA 17 trial.
Collapse
Affiliation(s)
- Stephanie E Combs
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany.,Institute of Innovative Radiotherapy ( i RT), Helmholtz Zentrum München, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (dktk), Partner Site Munich, Munich, Germany
| | - Kerstin A Kessel
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany.,Institute of Innovative Radiotherapy ( i RT), Helmholtz Zentrum München, Neuherberg, Germany
| | - Josefine Hesse
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
| | - Christoph Straube
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Technical University of Munich (TUM), Munich, Germany
| | | | - Jürgen Schlegel
- Department of Neuropathology, Technical University of Munich (TUM), Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Technical University of Munich (TUM), Ismaninger Straße 22, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich (TUM), Ismaninger Straße 22, Munich, Germany
| |
Collapse
|
27
|
von Rosenstiel C, Wiestler B, Haller B, Schmidt-Graf F, Gempt J, Bettstetter M, Rihani L, Wu W, Meyer B, Schlegel J, Liesche-Starnecker F. Correlation of the quantitative level of MGMT promoter methylation and overall survival in primary diagnosed glioblastomas using the quantitative MethyQESD method. J Clin Pathol 2019; 73:112-115. [PMID: 31422371 DOI: 10.1136/jclinpath-2019-206104] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 07/16/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 12/30/2022]
Abstract
AIMS O(6)-methylguanine-DNA-methyltransferase (MGMT) promoter methylation is a high predictive factor for therapy results of temozolomide in patients with glioma. The objective of this work was to analyse the impact of MGMT promoter methylation in patients with primary diagnosed glioblastoma (GBM) relating to survival using a quantitative method (methylation quantification of endonuclease-resistant DNA, MethyQESD) by verifying a cut-off point for MGMT methylation provided by the literature (</≥10%) and calculating an optimal cut-off. METHODS 67 patients aged 70 years or younger, operated between January 2013 and December 2015, with newly diagnosed IDH wild-type GBM and clinical follow-up were retrospectively investigated in this study. A known MGMT promoter methylation status was the inclusion criteria. RESULTS Median overall survival (OS) was 16.9 months. Patients who had a methylated MGMT promoter region of ≥10% had an improved OS compared with patients with a methylated promoter region of <10% (p=0.002). Optimal cut-off point for MGMT promoter methylation was 11.7% (p=0.012). CONCLUSION The results confirm that the quantitative level of MGMT promoter methylation is a positive prognostic factor in newly diagnosed patients with GBM. The cut-off provided by the literature (</≥10%) and the calculated optimal cut-off value of 11.7% give a statistically significant separation. Hence, MethyQESD is a reliable method to calculate MGMT promoter methylation in GBM.
Collapse
Affiliation(s)
- Charlotte von Rosenstiel
- Department of Neuropathology, Institute of Pathology, Technical University Munich, School of Medicine, Munich, Germany
| | - Benedikt Wiestler
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Technical University Munich, School of Medicine, Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
| | | | - Laura Rihani
- Department of Neuropathology, Institute of Pathology, Technical University Munich, School of Medicine, Munich, Germany
| | - Wei Wu
- Department of Neuropathology, Institute of Pathology, Technical University Munich, School of Medicine, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
| | - Jürgen Schlegel
- Department of Neuropathology, Institute of Pathology, Technical University Munich, School of Medicine, Munich, Germany
| | - Friederike Liesche-Starnecker
- Department of Neuropathology, Institute of Pathology, Technical University Munich, School of Medicine, Munich, Germany
| |
Collapse
|
28
|
Straube C, Kessel KA, Zimmer C, Schmidt-Graf F, Schlegel J, Gempt J, Meyer B, Combs SE. A Second Course of Radiotherapy in Patients with Recurrent Malignant Gliomas: Clinical Data on Re-irradiation, Prognostic Factors, and Usefulness of Digital Biomarkers. Curr Treat Options Oncol 2019; 20:71. [PMID: 31324990 DOI: 10.1007/s11864-019-0673-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 02/07/2023]
Abstract
OPINION STATEMENT The treatment of malignant gliomas has undergone a significant intensification during the past decade, and the interdisciplinary treatment team has learned that all treatment opportunities, including surgery and radiotherapy (RT), also have a central role in recurrent gliomas. Throughout the decades, re-irradiation (re-RT) has achieved a prominent place in the treatment of recurrent gliomas. A solid body of evidence supports the safety and efficacy of re-RT, especially when modern techniques are used, and justifies the early use of this regimen, especially in the case when macroscopic disease is present. Additionally, a second adjuvant re-RT to the resection cavity is currently being investigated by several investigators and seems to offer promising results. Although advanced RT technologies, such as stereotactic radiosurgery (SRS), fractionated stereotactic radiotherapy (FSRT), intensity-modulated radiotherapy (IMRT), and image-guided radiotherapy (IGRT) have become available in many centers, re-RT should continue to be kept in experienced hands so that they can select the optimal regimen, the ideal treatment volume, and the appropriate techniques from their tool-boxes. Concomitant or adjuvant use of systemic treatment options should also strongly be taken into consideration, especially because temozolomide (TMZ), cyclohexyl-nitroso-urea (CCNU), and bevacizumab have shown a good safety profile; they should be considered, if available. Nonetheless, the selection of patients for re-RT remains crucial. Single factors, such as patient age or the progression-free interval (PFI), fall too short. Therefore, powerful prognostic scores have been generated and validated, and these scores should be used for patient selection and counseling.
Collapse
Affiliation(s)
- Christoph Straube
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
- Institute for Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany
| | - Kerstin A Kessel
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
- Institute for Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Jürgen Schlegel
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany.
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.
- Institute for Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany.
| |
Collapse
|
29
|
Straube C, Antoni S, Schaffer P, Gempt J, Zimmer C, Meyer B, Combs S, Schmidt-Graf F. EP-1214 Patterns of care: Treatment of glioblastoma in elderly patients. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)31634-2] [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: 11/25/2022]
|
30
|
Sales AHA, Bette S, Barz M, Huber T, Wiestler B, Ryang YM, Schmidt-Graf F, Liesche F, Combs SE, Meyer B, Gempt J. Role of postoperative tumor volume in patients with MGMT-unmethylated glioblastoma. J Neurooncol 2019; 142:529-536. [DOI: 10.1007/s11060-019-03124-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 02/08/2019] [Indexed: 01/02/2023]
|
31
|
Herrlinger U, Tzaridis T, Mack F, Steinbach JP, Schlegel U, Sabel M, Hau P, Kortmann RD, Krex D, Grauer O, Goldbrunner R, Schnell O, Bähr O, Uhl M, Seidel C, Tabatabai G, Kowalski T, Ringel F, Schmidt-Graf F, Suchorska B, Brehmer S, Weyerbrock A, Renovanz M, Bullinger L, Galldiks N, Vajkoczy P, Misch M, Vatter H, Stuplich M, Schäfer N, Kebir S, Weller J, Schaub C, Stummer W, Tonn JC, Simon M, Keil VC, Nelles M, Urbach H, Coenen M, Wick W, Weller M, Fimmers R, Schmid M, Hattingen E, Pietsch T, Coch C, Glas M. Lomustine-temozolomide combination therapy versus standard temozolomide therapy in patients with newly diagnosed glioblastoma with methylated MGMT promoter (CeTeG/NOA-09): a randomised, open-label, phase 3 trial. Lancet 2019; 393:678-688. [PMID: 30782343 DOI: 10.1016/s0140-6736(18)31791-4] [Citation(s) in RCA: 309] [Impact Index Per Article: 61.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/12/2018] [Accepted: 07/27/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is an urgent need for more effective therapies for glioblastoma. Data from a previous unrandomised phase 2 trial suggested that lomustine-temozolomide plus radiotherapy might be superior to temozolomide chemoradiotherapy in newly diagnosed glioblastoma with methylation of the MGMT promoter. In the CeTeG/NOA-09 trial, we aimed to further investigate the effect of lomustine-temozolomide therapy in the setting of a randomised phase 3 trial. METHODS In this open-label, randomised, phase 3 trial, we enrolled patients from 17 German university hospitals who were aged 18-70 years, with newly diagnosed glioblastoma with methylated MGMT promoter, and a Karnofsky Performance Score of 70% and higher. Patients were randomly assigned (1:1) with a predefined SAS-generated randomisation list to standard temozolomide chemoradiotherapy (75 mg/m2 per day concomitant to radiotherapy [59-60 Gy] followed by six courses of temozolomide 150-200 mg/m2 per day on the first 5 days of the 4-week course) or to up to six courses of lomustine (100 mg/m2 on day 1) plus temozolomide (100-200 mg/m2 per day on days 2-6 of the 6-week course) in addition to radiotherapy (59-60 Gy). Because of the different schedules, patients and physicians were not masked to treatment groups. The primary endpoint was overall survival in the modified intention-to-treat population, comprising all randomly assigned patients who started their allocated chemotherapy. The prespecified test for overall survival differences was a log-rank test stratified for centre and recursive partitioning analysis class. The trial is registered with ClinicalTrials.gov, number NCT01149109. FINDINGS Between June 17, 2011, and April 8, 2014, 141 patients were randomly assigned to the treatment groups; 129 patients (63 in the temozolomide and 66 in the lomustine-temozolomide group) constituted the modified intention-to-treat population. Median overall survival was improved from 31·4 months (95% CI 27·7-47·1) with temozolomide to 48·1 months (32·6 months-not assessable) with lomustine-temozolomide (hazard ratio [HR] 0·60, 95% CI 0·35-1·03; p=0·0492 for log-rank analysis). A significant overall survival difference between groups was also found in a secondary analysis of the intention-to-treat population (n=141, HR 0·60, 95% CI 0·35-1·03; p=0·0432 for log-rank analysis). Adverse events of grade 3 or higher were observed in 32 (51%) of 63 patients in the temozolomide group and 39 (59%) of 66 patients in the lomustine-temozolomide group. There were no treatment-related deaths. INTERPRETATION Our results suggest that lomustine-temozolomide chemotherapy might improve survival compared with temozolomide standard therapy in patients with newly diagnosed glioblastoma with methylated MGMT promoter. The findings should be interpreted with caution, owing to the small size of the trial. FUNDING German Federal Ministry of Education and Research.
Collapse
Affiliation(s)
- Ulrich Herrlinger
- Division of Clinical Neurooncology, Department of Neurology and Centre of Integrated Oncology, University Hospital Bonn, Bonn, Germany.
| | - Theophilos Tzaridis
- Division of Clinical Neurooncology, Department of Neurology and Centre of Integrated Oncology, University Hospital Bonn, Bonn, Germany
| | - Frederic Mack
- Division of Clinical Neurooncology, Department of Neurology and Centre of Integrated Oncology, University Hospital Bonn, Bonn, Germany
| | | | - Uwe Schlegel
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr-Universität Bochum, Bochum, Germany
| | - Michael Sabel
- Department of Neurosurgery, University of Düsseldorf, Düsseldorf, Germany
| | - Peter Hau
- Department of Neurology and Wilhelm Sander Neurooncology Unit, University Hospital Regensburg, Regensburg, Germany
| | | | - Dietmar Krex
- Department of Neurosurgery, University of Dresden, Dresden, Germany
| | - Oliver Grauer
- Department of Neurology, University of Münster, Münster, Germany
| | | | - Oliver Schnell
- Department of Neurosurgery, Ludwig Maximillian University of Munich and German Cancer Consortium, Partner Site Munich, Munich, Germany; Department of Neurosurgery, University of Freiburg, Freiburg, Germany
| | - Oliver Bähr
- Dr Senckenberg Institute of Neurooncology, University of Frankfurt, Frankfurt, Germany
| | - Martin Uhl
- Department of Neurology and Wilhelm Sander Neurooncology Unit, University Hospital Regensburg, Regensburg, Germany
| | - Clemens Seidel
- Department of Radiation Oncology, University of Leipzig, Leipzig, Germany
| | - Ghazaleh Tabatabai
- Interdisciplinary Division of Neurooncology, University of Tübingen, Tübingen, Germany
| | - Thomas Kowalski
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr-Universität Bochum, Bochum, Germany
| | - Florian Ringel
- Department of Neurosurgery, Technical University of Munich, Munich, Germany; Department of Neurosurgery, University of Mainz, Mainz, Germany
| | | | - Bogdana Suchorska
- Department of Neurosurgery, Ludwig Maximillian University of Munich and German Cancer Consortium, Partner Site Munich, Munich, Germany
| | - Stefanie Brehmer
- Department of Neurosurgery, University of Mannheim, Mannheim, Germany
| | - Astrid Weyerbrock
- Department of Neurosurgery, University of Freiburg, Freiburg, Germany
| | - Miriam Renovanz
- Department of Neurosurgery, University of Mainz, Mainz, Germany
| | - Lars Bullinger
- Department of Internal Medicine, University of Ulm, Ulm, Germany
| | - Norbert Galldiks
- Department of Neurology, University of Cologne, Cologne, Germany; Institute of Neuroscience and Medicine (INM-3), Juelich, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité University of Berlin, Berlin, Germany
| | - Martin Misch
- Department of Neurosurgery, Charité University of Berlin, Berlin, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Moritz Stuplich
- Division of Clinical Neurooncology, Department of Neurology and Centre of Integrated Oncology, University Hospital Bonn, Bonn, Germany
| | - Niklas Schäfer
- Division of Clinical Neurooncology, Department of Neurology and Centre of Integrated Oncology, University Hospital Bonn, Bonn, Germany
| | - Sied Kebir
- Division of Clinical Neurooncology, Department of Neurology and Centre of Integrated Oncology, University Hospital Bonn, Bonn, Germany
| | - Johannes Weller
- Division of Clinical Neurooncology, Department of Neurology and Centre of Integrated Oncology, University Hospital Bonn, Bonn, Germany
| | - Christina Schaub
- Division of Clinical Neurooncology, Department of Neurology and Centre of Integrated Oncology, University Hospital Bonn, Bonn, Germany
| | - Walter Stummer
- Department of Neurosurgery, University of Münster, Münster, Germany
| | - Jörg-Christian Tonn
- Department of Neurosurgery, Ludwig Maximillian University of Munich and German Cancer Consortium, Partner Site Munich, Munich, Germany
| | - Matthias Simon
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Vera C Keil
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Michael Nelles
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Horst Urbach
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany; Department of Neuroradiology, University of Freiburg, Freiburg, Germany
| | - Martin Coenen
- Study Centre Bonn, University Hospital Bonn, Bonn, Germany
| | - Wolfgang Wick
- Department of Neurology, University of Heidelberg and German Cancer Research Center, Heidelberg, Germany
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Rolf Fimmers
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Elke Hattingen
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Torsten Pietsch
- Institute of Neuropathology and DGNN Brain Tumor Reference Centre, University Hospital Bonn, Bonn, Germany
| | - Christoph Coch
- Study Centre Bonn, University Hospital Bonn, Bonn, Germany
| | - Martin Glas
- Division of Clinical Neurooncology, Department of Neurology and Centre of Integrated Oncology, University Hospital Bonn, Bonn, Germany; Division of Clinical Neurooncology, Department of Neurology and West German Cancer Center, German Cancer Consortium, Partner Site Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| |
Collapse
|
32
|
Straube C, Antoni S, Gempt J, Zimmer C, Meyer B, Schlegel J, Schmidt-Graf F, Combs SE. Re-irradiation in elderly patients with glioblastoma: a single institution experience. J Neurooncol 2019; 142:327-335. [PMID: 30659523 DOI: 10.1007/s11060-019-03101-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 10/10/2018] [Accepted: 01/11/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Re-Irradiation (Re-RT) is an established treatment option for young patients with recurrent glioblastoma (GBM). Multiple reports show a low risk of side-effects as well as a good efficacy resulting in median survival times ranging from 5 to 18 months. Elderly patients, however, are underrepresented in reports about Re-RT. Even in the elderly, with concomitant radiochemotherapy and adjuvant chemotherapy, progression-free survival times now are approaching 6 months or even longer. METHODS We report on 25 consecutive patients with at least 65 years of age treated with Re-RT for recurrent GBM. We analyzed the patient's files for the treatment regimens, side-effects and survival times. Survival times, as well as hazards, were calculated by the Kaplan Meier method as well as Cox-regression method, respectively. RESULTS The median overall survival was 6.9 months, treatment was well tolerated with only minor side effects. Use of systemic treatments as well as the length of the interval between 1st -line radiotherapy and re-irradiation were associated with a favorable prognosis. The latter remained significant after multivariate analysis. CONCLUSION Re-RT of elderly GBM patients should not be withheld based purely on age since the treatment is safe and results in comparable survival times to younger patients. When counseling elderly patients with recurrent GBM, especially the length of the interval since 1st line radiotherapy should be considered as a prognostic factor and an additional systemic treatment option should be considered.
Collapse
Affiliation(s)
- Christoph Straube
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany.
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.
| | - Stefanie Antoni
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Jürgen Schlegel
- Institut for Pathology, Department of Neuropathology, Technical University of Munich (TUM), Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
- Department of Radiation Sciences (DRS), Institute for Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany
| |
Collapse
|
33
|
Bette S, Barz M, Wiestler B, Huber T, Gerhardt J, Buchmann N, Combs SE, Schmidt-Graf F, Delbridge C, Zimmer C, Kirschke JS, Meyer B, Ryang YM, Ringel F, Gempt J. Correction to: Prognostic Value of Tumor Volume in Glioblastoma Patients: Size Also Matters for Patients with Incomplete Resection. Ann Surg Oncol 2018; 25:989. [DOI: 10.1245/s10434-018-6443-4] [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: 11/18/2022]
|
34
|
Straube C, Schmidt-Graf F, Wiestler B, Zimmer C, Meyer B, Combs SE. The algorithms of adjuvant therapy in gliomas and their effect on survival. J Neurosurg Sci 2018; 63:179-186. [PMID: 30421895 DOI: 10.23736/s0390-5616.18.04610-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The treatment of gliomas became more sophisticated during the last decades. As by now, adjuvant treatment after maximum safe resection is considered an important and effective treatment strategy in most gliomas, yet the decision is based on several factors. This review summarizes the available evidence for the current adjuvant treatment algorithms with a focus on the impact on the survival of glioma patients. The review is based on the current guidelines, but it also includes new insights which have not yet been included into the official guidelines.
Collapse
Affiliation(s)
- Christoph Straube
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany.,German Consortium for Translational Cancer Research (DKTK), Partner Site Munich, Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Benedikt Wiestler
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany - .,German Consortium for Translational Cancer Research (DKTK), Partner Site Munich, Munich, Germany.,Department of Radiation Sciences (DRS), Institute for Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Munich, Germany
| |
Collapse
|
35
|
Straube C, Kessel KA, Schmidt-Graf F, Krieg SM, Meyer B, Gempt J, Combs SE. A trend towards a more intense adjuvant treatment of low-grade-gliomas in tertiary centers in Germany after RTOG 9802 - results from a multi-center survey. BMC Cancer 2018; 18:907. [PMID: 30241469 PMCID: PMC6151028 DOI: 10.1186/s12885-018-4825-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/14/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The treatment recommendations for Low-grade Gliomas (LGG) underwent profound changes due to results from RTOG 9802 published in April 2016. This work aims to investigate whether the results from the trial were already incorporated into the treatment recommendations at German oncology centers before an update of the official guidelines. METHODS An online based questionnaire with questions covering all aspects of adjuvant treatments of LGGs was generated, including three cases with distinct clinical situations. We contacted all members of the neuro-oncologic working group (NOA) of the German Cancer Society (DKG) as well as all German-speaking members of the European Low-Grade Glioma Network via E-mail. RESULTS We collected 38 responses. All responders were at least specialists; they predominantly worked at tertiary hospitals with a high volume of LGGs treated annually (75% with more than 10 cases per year). All responders stated to consent treatment recommendation for LGGs within interdisciplinary oncologic boards. The treatment recommendations for LGGs changed profoundly between 2015 and 12/2016. There is a trend towards PCV-based multimodal treatments, especially for oligodendroglial LGGs, as well as a trend away from watchful-waiting-policies for astrocytic LGGs. CONCLUSION Neurooncologists do adapt results from clinical trials quickly. None the less, there is still an immense heterogeneity within the treatment recommendations, predominantly for astrocytic LGGs. Well planned clinical trials and concise treatment recommendations are warranted; additionally, individual counseling of patients is essential.
Collapse
Affiliation(s)
- Christoph Straube
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
- Deutsches Konsortium Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Kerstin A. Kessel
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
- Institut für Innovative Radiotherapie (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Munich, Germany
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
- Institut für Innovative Radiotherapie (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Munich, Germany
- Deutsches Konsortium Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| |
Collapse
|
36
|
Schaub C, Kebir S, Junold N, Hattingen E, Schäfer N, Steinbach JP, Weyerbrock A, Hau P, Goldbrunner R, Niessen M, Mack F, Stuplich M, Tzaridis T, Bähr O, Kortmann RD, Schlegel U, Schmidt-Graf F, Rohde V, Braun C, Hänel M, Sabel M, Gerlach R, Krex D, Belka C, Vatter H, Proescholdt M, Herrlinger U, Glas M. Tumor growth patterns of MGMT-non-methylated glioblastoma in the randomized GLARIUS trial. J Cancer Res Clin Oncol 2018; 144:1581-1589. [PMID: 29808316 DOI: 10.1007/s00432-018-2671-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/16/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND We evaluated patterns of tumor growth in patients with newly diagnosed MGMT-non-methylated glioblastoma who were assigned to undergo radiotherapy in conjunction with bevacizumab/irinotecan (BEV/IRI) or standard temozolomide (TMZ) within the randomized phase II GLARIUS trial. METHODS In 142 patients (94 BEV/IRI, 48 TMZ), we reviewed magnetic resonance imaging scans at baseline and first tumor recurrence. Based on contrast-enhanced T1-weighted and fluid-attenuated inversion recovery images, we assessed tumor growth patterns and tumor invasiveness. Tumor growth patterns were classified as either multifocal or local at baseline and recurrence; at first recurrence, we additionally assessed whether distant lesions appeared. Invasiveness was determined as either diffuse or non-diffuse. Associations with treatment arms were calculated using Fisher's exact test. RESULTS At baseline, 115 of 142 evaluable patients (81%) had a locally confined tumor. Between treatment arms, there was no significant difference in the fraction of tumors that changed from an initially local tumor growth pattern to a multifocal pattern (12 and 13%, p = 0.55). Distant lesions appeared in 17% (BEV/IRI) and 13% (TMZ) of patients (p = 0.69). 15% of patients in the BEV/IRI arm and 8% in the TMZ arm developed a diffuse growth pattern from an initially non-diffuse pattern (p = 0.42). CONCLUSIONS The tumor growth and invasiveness patterns do not differ between BEV/IRI and TMZ-treated MGMT-non-methylated glioblastoma patients in the GLARIUS trial. BEV/IRI was not associated with an increased rate of multifocal, distant, or highly invasive tumors at the time of recurrence.
Collapse
Affiliation(s)
- Christina Schaub
- Division of Clinical Neurooncology, Department of Neurology, University of Bonn Medical Center, Bonn, Germany
| | - Sied Kebir
- Division of Clinical Neurooncology, Department of Neurology, University of Bonn Medical Center, Bonn, Germany.,West German Cancer Center (WTZ), University Hospital Essen and German Cancer Consortium, Partner Site University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Division of Clinical Neurooncology, Department of Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Nina Junold
- Division of Clinical Neurooncology, Department of Neurology, University of Bonn Medical Center, Bonn, Germany
| | - Elke Hattingen
- Neuroradiology; Department of Radiology, University of Bonn Medical Center, Bonn, Germany
| | - Niklas Schäfer
- Division of Clinical Neurooncology, Department of Neurology, University of Bonn Medical Center, Bonn, Germany.,West German Cancer Center (WTZ), University Hospital Essen and German Cancer Consortium, Partner Site University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Joachim P Steinbach
- Dr. Senckenberg Institute of Neurooncology, University of Frankfurt, Frankfurt, Germany
| | - Astrid Weyerbrock
- Department of Neurosurgery, University of Freiburg, Freiburg, Germany
| | - Peter Hau
- Department of Neurology and Wilhelm Sander NeuroOncology Unit, University of Regensburg, Regensburg, Germany
| | | | - Michael Niessen
- Division of Clinical Neurooncology, Department of Neurology, University of Bonn Medical Center, Bonn, Germany
| | - Frederic Mack
- Division of Clinical Neurooncology, Department of Neurology, University of Bonn Medical Center, Bonn, Germany
| | - Moritz Stuplich
- Division of Clinical Neurooncology, Department of Neurology, University of Bonn Medical Center, Bonn, Germany
| | - Theophilos Tzaridis
- Division of Clinical Neurooncology, Department of Neurology, University of Bonn Medical Center, Bonn, Germany
| | - Oliver Bähr
- Dr. Senckenberg Institute of Neurooncology, University of Frankfurt, Frankfurt, Germany
| | | | - Uwe Schlegel
- Department of Neurology, Knappschaftskrankenhaus Klinikum der Ruhr-Universität Bochum, Bochum, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Veit Rohde
- Department of Neurosurgery, Georg-August-University, Göttingen, Germany
| | - Christian Braun
- Department of Neurology, University Hospital Tübingen, Tübingen, Germany
| | - Mathias Hänel
- Department of Internal Medicine III, Klinikum Chemnitz gGmbH, Chemnitz, Germany
| | - Michael Sabel
- Department of Neurosurgery, Medizinische Fakultät, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Rüdiger Gerlach
- Department of Neurosurgery, HELIOS Klinikum Erfurt, Erfurt, Germany
| | - Dietmar Krex
- Department of Neurosurgery, Technical University Dresden, Dresden, Germany
| | - Claus Belka
- Department of Radiation Oncology, LMU Munich, Munich, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University of Bonn Medical Center, Bonn, Germany
| | - Martin Proescholdt
- Department of Neurosurgery, University of Regensburg, Regensburg, Germany
| | - Ulrich Herrlinger
- Division of Clinical Neurooncology, Department of Neurology, University of Bonn Medical Center, Bonn, Germany
| | - Martin Glas
- Division of Clinical Neurooncology, Department of Neurology, University of Bonn Medical Center, Bonn, Germany. .,West German Cancer Center (WTZ), University Hospital Essen and German Cancer Consortium, Partner Site University Hospital Essen, University Duisburg-Essen, Essen, Germany. .,Division of Clinical Neurooncology, Department of Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
| |
Collapse
|
37
|
Bette S, Barz M, Huber T, Straube C, Schmidt-Graf F, Combs SE, Delbridge C, Gerhardt J, Zimmer C, Meyer B, Kirschke JS, Boeckh-Behrens T, Wiestler B, Gempt J. Retrospective Analysis of Radiological Recurrence Patterns in Glioblastoma, Their Prognostic Value And Association to Postoperative Infarct Volume. Sci Rep 2018. [PMID: 29540809 PMCID: PMC5852150 DOI: 10.1038/s41598-018-22697-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [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: 11/18/2022] Open
Abstract
Recent studies suggested that postoperative hypoxia might trigger invasive tumor growth, resulting in diffuse/multifocal recurrence patterns. Aim of this study was to analyze distinct recurrence patterns and their association to postoperative infarct volume and outcome. 526 consecutive glioblastoma patients were analyzed, of which 129 met our inclusion criteria: initial tumor diagnosis, surgery, postoperative diffusion-weighted imaging and tumor recurrence during follow-up. Distinct patterns of contrast-enhancement at initial diagnosis and at first tumor recurrence (multifocal growth/progression, contact to dura/ventricle, ependymal spread, local/distant recurrence) were recorded by two blinded neuroradiologists. The association of radiological patterns to survival and postoperative infarct volume was analyzed by uni-/multivariate survival analyses and binary logistic regression analysis. With increasing postoperative infarct volume, patients were significantly more likely to develop multifocal recurrence, recurrence with contact to ventricle and contact to dura. Patients with multifocal recurrence (Hazard Ratio (HR) 1.99, P = 0.010) had significantly shorter OS, patients with recurrent tumor with contact to ventricle (HR 1.85, P = 0.036), ependymal spread (HR 2.97, P = 0.004) and distant recurrence (HR 1.75, P = 0.019) significantly shorter post-progression survival in multivariate analyses including well-established prognostic factors like age, Karnofsky Performance Score (KPS), therapy, extent of resection and patterns of primary tumors. Postoperative infarct volume might initiate hypoxia-mediated aggressive tumor growth resulting in multifocal and diffuse recurrence patterns and impaired survival.
Collapse
Affiliation(s)
- Stefanie Bette
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
| | - Melanie Barz
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Thomas Huber
- Department of Radiology, University Hospital, LMU, Munich, Germany
| | - Christoph Straube
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,Institute of Innovativ Radiotherapy (iRt), Department of Radiation Sciences (DRS) Helmholtz Zentrum München, Ingolstädter Landstraße Neuherberg, Munich, Germany.,Deutsches Konsortium für Transnationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,Institute of Innovativ Radiotherapy (iRt), Department of Radiation Sciences (DRS) Helmholtz Zentrum München, Ingolstädter Landstraße Neuherberg, Munich, Germany.,Deutsches Konsortium für Transnationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Claire Delbridge
- Department of Neuropathology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Julia Gerhardt
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Jan S Kirschke
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Tobias Boeckh-Behrens
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Benedikt Wiestler
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| |
Collapse
|
38
|
Straube C, Oechsner M, Kampfer S, Scharl S, Schmidt-Graf F, Wilkens JJ, Combs SE. Dosimetric impact of tumor treating field (TTField) transducer arrays onto treatment plans for glioblastomas - a planning study. Radiat Oncol 2018; 13:31. [PMID: 29471879 PMCID: PMC5824562 DOI: 10.1186/s13014-018-0976-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 02/15/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Tumor-Treating Fields (TTFields) are a novel treatment strategy for glioblastoma (GBM) that is approved for the use concomitantly to adjuvant chemotherapy. Preclinical data suggest a synergistic interaction of TTFields and radiotherapy (RT). However, the dosimetric uncertainties caused by the highly dense arrays have led to caution of applying the TTF setup during RT. METHODS In a RW3 slab phantom we compared the MV- and kV-CT based planned dose with the measured dose. VMAT-plans were optimized on MV-CTs of an Alderson head phantom without TTF arrays and then re-calculated on the same phantom equipped with TTF arrays. Dose at organs at risk (OAR) and target volumes (PTVs) were compared. RESULTS Measurements at a depth of 2, 3 and 4 cm of a RW 3 slab phantom show an attenuation due to TTField arrays of 3.4, 3.7 and 2.7% respectively. This was in-line with calculated attenuations based on MV-CT (1.2, 2.5 and 2.5%) but not with the attenuation expected from kV-CT based calculations (7.1, 8.2 and 8.6%). Consecutive MV-CT based VMAT planning and re-calculation reveals, that the conformity and homogeneity are not affected by the presence of TTField arrays. The dose at organs at risk (OAR) can show increases or decreases by < 0.5 Gy, which should be considered especially in cases next to the scull base. CONCLUSION MV-CT based dose calculation results in reliable dose distributions also in the presence of TTField arrays. There is a small but clinically not relevant interaction between the TTField arrays and VMAT dose application. Thus, daily replacement of TTField arrays is not necessary in regard to deeply located OARs. RT is feasible, when a VMAT treatment plan is optimized to an array free planning CT. As the biologic effect of a concomitant treatment especially on OARs is currently unknown, a concomitant treatment should be performed only within clinical trials.
Collapse
Affiliation(s)
- Christoph Straube
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Severin Kampfer
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Sophia Scharl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Jan J. Wilkens
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Department of Radiation Sciences (DRS), Institute for Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
- Department of Radiation Sciences (DRS), Institute for Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Munich, Germany
| |
Collapse
|
39
|
Schliesser MG, Claus R, Hielscher T, Grimm C, Weichenhan D, Blaes J, Wiestler B, Hau P, Schramm J, Sahm F, Weiß EK, Weiler M, Baer C, Schmidt-Graf F, Schackert G, Westphal M, Hertenstein A, Roth P, Galldiks N, Hartmann C, Pietsch T, Felsberg J, Reifenberger G, Sabel MC, Winkler F, von Deimling A, Meisner C, Vajkoczy P, Platten M, Weller M, Plass C, Wick W. Prognostic relevance of miRNA-155 methylation in anaplastic glioma. Oncotarget 2018; 7:82028-82045. [PMID: 27880937 PMCID: PMC5347671 DOI: 10.18632/oncotarget.13452] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 05/09/2016] [Accepted: 09/13/2016] [Indexed: 02/03/2023] Open
Abstract
The outcome of patients with anaplastic gliomas varies considerably depending on single molecular markers, such as mutations of the isocitrate dehydrogenase (IDH) genes, as well as molecular classifications based on epigenetic or genetic profiles. Remarkably, 98% of the RNA within a cell is not translated into proteins. Of those, especially microRNAs (miRNAs) have been shown not only to have a major influence on physiologic processes but also to be deregulated and prognostic in malignancies.To find novel survival markers and treatment options we performed unbiased DNA methylation screens that revealed 12 putative miRNA promoter regions with differential DNA methylation in anaplastic gliomas. Methylation of these candidate regions was validated in different independent patient cohorts revealing a set of miRNA promoter regions with prognostic relevance across data sets. Of those, miR-155 promoter methylation and miR-155 expression were negatively correlated and especially the methylation showed superior correlation with patient survival compared to established biomarkers.Functional examinations in malignant glioma cells further cemented the relevance of miR-155 for tumor cell viability with transient and stable modifications indicating an onco-miRNA activity. MiR-155 also conferred resistance towards alkylating temozolomide and radiotherapy as consequence of nuclear factor (NF)κB activation.Preconditioning glioma cells with an NFκB inhibitor reduced therapy resistance of miR-155 overexpressing cells. These cells resembled tumors with a low methylation of the miR-155 promoter and thus mir-155 or NFκB inhibition may provide treatment options with a special focus on patients with IDH wild type tumors.
Collapse
Affiliation(s)
- Maximilian Georg Schliesser
- Department of Neurology, Heidelberg University Hospital and German Cancer Consortium, Clinical Cooperation Units, Germany.,Clinical Cooperation Unit of Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Rainer Claus
- Division of Epigenomics and Cancer Risk Factors, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Thomas Hielscher
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christiane Grimm
- Department of Neurology, Heidelberg University Hospital and German Cancer Consortium, Clinical Cooperation Units, Germany.,Clinical Cooperation Unit of Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Dieter Weichenhan
- Division of Epigenomics and Cancer Risk Factors, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jonas Blaes
- Clinical Cooperation Unit of Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Benedikt Wiestler
- Department of Neurology, Heidelberg University Hospital and German Cancer Consortium, Clinical Cooperation Units, Germany.,Clinical Cooperation Unit of Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Peter Hau
- Neurology Clinic, Regensburg University, Regensburg, Germany
| | - Johannes Schramm
- Neurosurgery Clinic, University of Bonn Medical Center, TU Munich, Munich, Germany
| | - Felix Sahm
- Department of Neuropathology, Heidelberg University Hospital and German Cancer Consortium, Clinical Cooperation Units, Germany.,Clinical Cooperation Unit of Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Elisa K Weiß
- Department of Neurology, Heidelberg University Hospital and German Cancer Consortium, Clinical Cooperation Units, Germany.,Clinical Cooperation Unit of Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Markus Weiler
- Department of Neurology, Heidelberg University Hospital and German Cancer Consortium, Clinical Cooperation Units, Germany.,Clinical Cooperation Unit of Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of General Neurology, University Hospital Tübingen, Germany
| | - Constance Baer
- Division of Epigenomics and Cancer Risk Factors, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Friederike Schmidt-Graf
- Department of General Neurology, University Hospital Tübingen, Germany.,Neurology Clinic, TU Munich, Munich, Germany
| | | | - Manfred Westphal
- Neurosurgery Clinic, University Clinic Hamburg, Eppendorf, Germany
| | - Anne Hertenstein
- Department of Neurology, Heidelberg University Hospital and German Cancer Consortium, Clinical Cooperation Units, Germany.,Clinical Cooperation Unit of Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Patrick Roth
- Department of General Neurology, University Hospital Tübingen, Germany.,Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | | | - Christian Hartmann
- Department of Neuropathology, Heidelberg University Hospital and German Cancer Consortium, Clinical Cooperation Units, Germany.,Clinical Cooperation Unit of Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department for Neuropathology, Institute of Pathology, Medical University of Hannover, Hannover, Germany
| | - Torsten Pietsch
- Department of Neuropathology, Heinrich-Heine-University, Germany
| | - Joerg Felsberg
- Department of Neurosurgery, Heinrich-Heine-University, Germany.,Neurosurgery Clinic, Charité, Berlin, Germany
| | - Guido Reifenberger
- Department of Neurosurgery, Heinrich-Heine-University, Germany.,Neurosurgery Clinic, Charité, Berlin, Germany
| | | | - Frank Winkler
- Department of Neurology, Heidelberg University Hospital and German Cancer Consortium, Clinical Cooperation Units, Germany.,Clinical Cooperation Unit of Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Andreas von Deimling
- Department of Neuropathology, Heidelberg University Hospital and German Cancer Consortium, Clinical Cooperation Units, Germany.,Clinical Cooperation Unit of Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Peter Vajkoczy
- Department Hematology, Oncology and Stem Cell Transplantation, University Hospital Freiburg, Germany
| | - Michael Platten
- Department of Neurology, Heidelberg University Hospital and German Cancer Consortium, Clinical Cooperation Units, Germany.,Clinical Cooperation Unit of Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of General Neurology, University Hospital Tübingen, Germany
| | - Michael Weller
- Department of General Neurology, University Hospital Tübingen, Germany.,Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Plass
- Division of Epigenomics and Cancer Risk Factors, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Wolfgang Wick
- Department of Neurology, Heidelberg University Hospital and German Cancer Consortium, Clinical Cooperation Units, Germany.,Clinical Cooperation Unit of Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of General Neurology, University Hospital Tübingen, Germany
| |
Collapse
|
40
|
Straube C, Scherb H, Gempt J, Kirschke J, Zimmer C, Schmidt-Graf F, Meyer B, Combs SE. Adjuvant stereotactic fractionated radiotherapy to the resection cavity in recurrent glioblastoma - the GlioCave study (NOA 17 - ARO 2016/3 - DKTK ROG trial). BMC Cancer 2018; 18:15. [PMID: 29298660 PMCID: PMC5753454 DOI: 10.1186/s12885-017-3928-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 03/23/2016] [Accepted: 12/15/2017] [Indexed: 12/23/2022] Open
Abstract
Background Glioblastoma relapses in the vast majority of cases within 1 year. Maximum safe resection of the recurrent glioblastoma can be offered in some cases. Re-irradiation has been established for the treatment of recurrent glioblastoma, too. In both cases, adjuvant treatment, mostly using temozolomide, can improve PFS and OS after these interventions. However, combining gross tumor resection and adjuvant re-radiotherapy to the resection cavity has not been tested so far. Methods/Design In the multicenter two-armed randomized Phase II GlioCave Study, fractionated stereotactic radiotherapy to the resection cavity, after gross tumor resection of recurrent glioblastoma, will be compared to observation. Depending on the size of the target volume, a total dose of 46 Gy in 2 Gy per fraction or a total dose if 36 Gy in 3 Gy per fraction will be applied. Progression free survival will be the primary endpoint of the study. Discussion Adjuvant treatment after gross tumor resection of recurrent glioblastoma is currently deemed to be limited to chemotherapy. However, re-irradiation has proven safety and tolerability in the treatment of macroscopic disease. Performing re-irradiation as an adjuvant measure after gross tumor resection has not been tested so far. The GlioCave Study will investigate the efficacy and the safety profile of this approach. Trial registration The trial was prospectively registered at clinicaltrials.gov (NCT02715297, registration date February 29th, 2016). The protocol presented hereby refers to the version 1.2 of the protocol (January 11th, 2017).
Collapse
Affiliation(s)
- Christoph Straube
- Klinik für RadioOnkologie und Strahlentherapie, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany. .,Deutsches Konsortium für Translationale Krebsforschung (DKTK) - Partner Site Munich, 81675, Munich, Germany.
| | - Hagen Scherb
- Institute of Computational Biology, Helmholtz Zentrum München, Deutsches Forschungszentrum fuer Gesundheit und Umwelt (GmbH), Ingolstaedter Landstr.1, 85764, Neuherberg, Germany
| | - Jens Gempt
- Neurochirurgische Klinik und Poliklinik, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Jan Kirschke
- Abteilung für diagnostische und interventionelle Neuroradiologie, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Claus Zimmer
- Abteilung für diagnostische und interventionelle Neuroradiologie, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Friederike Schmidt-Graf
- Neurologische Klinik und Poliklinik, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Neurochirurgische Klinik und Poliklinik, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Klinik für RadioOnkologie und Strahlentherapie, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany.,Institut für Innovative Radiotherapie (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK) - Partner Site Munich, 81675, Munich, Germany
| |
Collapse
|
41
|
Gempt J, Lange N, Bette S, Foreman SC, Cammardella JH, Albertshauser J, Gradtke C, Buchmann N, Ryang YM, Schmidt-Graf F, Meyer B, Ringel F. Factors influencing neurocognitive function in patients with neuroepithelial tumors. Sci Rep 2017; 7:17764. [PMID: 29259230 PMCID: PMC5736700 DOI: 10.1038/s41598-017-17833-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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] [Received: 06/01/2017] [Accepted: 11/14/2017] [Indexed: 11/09/2022] Open
Abstract
Though cognitive function is proven to be an independent predictor of survival in patients with intrinsic brain tumors, cognitive functions are still rarely considered. Aim of this study was to assess neurocognitive function and to identify risk factors for neurocognitive deficits. 103 patients with primary neuroepithelial tumors who received tumor resections or biopsies were included in this prospective study. The following data was acquired: mini-mental state examination, preoperative tumor volume, WHO grade, tumor entity and location, and the Karnofsky performance status scale. Furthermore, patients participated in extensive neuropsychological testing of attentional, memory and executive functions. General factors like age, clinical status, WHO grade, tumor volume and tumor location correlated with patients' neurocognitive functions. Affection of the parietal lobe resulted in significant impairment of attention and memory functions. Frontal lobe involvement significantly affected patients' abilities in planning complex actions and novel problem solving. Patients with temporal lesions were more likely to have impaired memory and executive functions. Comparing results among neuroepithelial tumor patients enables the identification of risk factors for cognitive impairment. General parameters such as age, KPS score, tumor size, and WHO grade are apart from the respective tumor location of high importance for neurocognitive function.
Collapse
Affiliation(s)
- Jens Gempt
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany.
| | - Nicole Lange
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Stefanie Bette
- Abteilung für Neuroradiologie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Sarah Charlotte Foreman
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany.,Abteilung für Neuroradiologie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Jasmin Hernandez Cammardella
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Jennifer Albertshauser
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Corinna Gradtke
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Niels Buchmann
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Yu-Mi Ryang
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Friederike Schmidt-Graf
- Neurologische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Bernhard Meyer
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Florian Ringel
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| |
Collapse
|
42
|
Bette S, Barz M, Wiestler B, Huber T, Gerhardt J, Buchmann N, Combs SE, Schmidt-Graf F, Delbridge C, Zimmer C, Kirschke JS, Meyer B, Ryang YM, Ringel F, Gempt J. Prognostic Value of Tumor Volume in Glioblastoma Patients: Size Also Matters for Patients with Incomplete Resection. Ann Surg Oncol 2017; 25:558-564. [PMID: 29159745 DOI: 10.1245/s10434-017-6253-0] [Citation(s) in RCA: 23] [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] [Received: 09/10/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Incomplete resection of glioblastoma is discussed controversially in the era of combined radiochemotherapy. OBJECTIVE The aim of this study was to analyze the benefit of subtotal tumor resection for glioblastoma patients as this was recently questioned in the era of radiochemotherapy. METHODS Overall, 209 patients undergoing surgery for newly diagnosed WHO grade IV gliomas were retrospectively analyzed, and pre- and postoperative tumor volumes were manually segmented (cm3). Survival analyses were performed, including prognostic factors such as age, Karnofsky performance score (KPS), O6-methylguanine-DNA-methyltransferase (MGMT) promoter methylation status, and adjuvant treatment regimen. RESULTS Pre- and postoperative tumor volume is significantly associated with pre- and postoperative KPS, as well as age (p < 0.001). Postoperative tumor volume remained a significant prognostic factor in a multivariate analysis, independent of other prognostic factors (hazard ratio 1.0365, 95% confidence interval 1.0235-1.0497, p < 0.001). CONCLUSIONS In the era of molecularly-driven radiochemotherapy, glioblastoma surgery remains a major prognostic factor. Even in situations in which a gross total resection cannot be achieved, maximum safe reduction of tumor burden should be attempted.
Collapse
Affiliation(s)
- Stefanie Bette
- Department of Neuroradiology, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Melanie Barz
- Department of Neurosurgery, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Benedikt Wiestler
- Department of Neuroradiology, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Thomas Huber
- Department of Radiology, Ludwig-Maximilians-University, Munich, Germany
| | - Julia Gerhardt
- Department of Neurosurgery, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Niels Buchmann
- Department of Neurosurgery, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany.,Institute for Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, 85764, Oberschleißheim, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Claire Delbridge
- Department of Neuropathology, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Jan S Kirschke
- Department of Neuroradiology, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Yu-Mi Ryang
- Department of Neurosurgery, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Florian Ringel
- Department of Neurosurgery, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar der Technischen Universitat, Munich, Germany.
| |
Collapse
|
43
|
Gempt J, Hofmann N, Bette S, Foreman S, Cammardella JH, Albertshauser J, Gradtke C, Buchmann N, Ryang YM, Schmidt-Graf F, Meyer B, Ringel F. NCOG-10. FACTORS INFLUENCING NEUROCOGNITIVE FUNCTION IN PATIENTS WITH NEUROEPITHELIAL TUMORS. Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox168.571] [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: 11/13/2022] Open
|
44
|
Herrlinger U, Tzaridis T, Mack F, Steinbach J, Schlegel U, Sabel M, Hau P, Kortman RD, Krex D, Grauer O, Goldbrunner R, Schnell O, Baehr O, Uhl M, Tabatabai G, Ringel F, Schmidt-Graf F, Brehmer S, Weyerbrock A, Bullinger L, Vajkoczy P, Vatter H, Schäfer N, Kebir S, Weller J, Stummer W, Simon M, Keil V, Nelles M, Fimmers R, Pietsch T, Hattingen E, Coch C, Glas M. ACTR-58. PHASE III TRIAL OF CCNU/TEMOZOLOMIDE (TMZ) COMBINATION THERAPY VS. STANDARD TMZ THERAPY FOR NEWLY DIAGNOSED MGMT-METHYLATED GLIOBLASTOMA PATIENTS: THE CeTeg/NOA-09 trial. Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox168.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
45
|
Straube C, Oechsner M, Kampfer S, Scharl S, Schmidt-Graf F, Wilkens J, Combs S. RTHP-26. FEASIBILITY OF A CONCOMITANT ADMINISTRATION OF ALTERNATING ELECTRIC FIELDS AND RADIOTHERAPY – A PLANNING STUDY. Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox168.908] [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: 11/13/2022] Open
|
46
|
Scharl S, Straube C, Meyer B, Schmidt-Graf F, Combs SE. [Critical consideration of the European Association for Neuro-Oncology (EANO) guideline on the diagnosis and treatment of adult astrocytic and oligodendroglial gliomas]. Strahlenther Onkol 2017; 193:984-988. [PMID: 28875328 DOI: 10.1007/s00066-017-1199-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Sophia Scharl
- Klinik und Poliklinik für RadioOnkologie und Strahlentherapie, Technische Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Deutschland
| | - Christoph Straube
- Klinik und Poliklinik für RadioOnkologie und Strahlentherapie, Technische Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Deutschland.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, München, Deutschland
| | - Bernhard Meyer
- Neurochirurgische Klinik und Poliklinik, Technische Universität München, München, Deutschland.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, München, Deutschland
| | - Friederike Schmidt-Graf
- Neurologische Klinik und Poliklinik, Technische Universität München, München, Deutschland.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, München, Deutschland
| | - Stephanie E Combs
- Klinik und Poliklinik für RadioOnkologie und Strahlentherapie, Technische Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Deutschland. .,Institut für Innovative Radiotherapie (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Oberschleißheim, Deutschland. .,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, München, Deutschland.
| |
Collapse
|
47
|
Kessel K, Vogel M, Schmidt-Graf F, Combs S. PO-1019: Mobile Oncology: Survey with Healthcare Professionals about Telemedicine, mHealth and mobile Apps. Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)31455-x] [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: 10/19/2022]
|
48
|
Straube C, Scherb H, Gempt J, Bette S, Zimmer C, Schmidt-Graf F, Schlegel J, Meyer B, Combs SE. Does age really matter? Radiotherapy in elderly patients with glioblastoma, the Munich experience. Radiat Oncol 2017; 12:77. [PMID: 28454549 PMCID: PMC5408447 DOI: 10.1186/s13014-017-0809-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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] [Received: 02/27/2017] [Accepted: 04/14/2017] [Indexed: 08/30/2023] Open
Abstract
Background Glioblastoma is usually diagnosed around the age of 60–70 years. Patients older than 65 years are frequently described as “elderly”. Several trials with monotherapy have established treatment regimens that offer therapies with reduced side effects but reduced efficacy. We analysed the outcome of elderly glioblastoma patients treated at our facility. Methods We performed a retrospective analysis of 62 consecutive patients older than 65 years treated for a primary glioblastoma at our facility from 2009 to 2015. Results Median age was 69.6 years (range 65.1–85.6 years); median OS of the entire cohort was 10.9 months. ECOG, MGMT and extent of resection but not age and the time from surgery to radiotherapy were associated with longer survival. Patients treated with adjuvant chemotherapy had a significantly longer survival (20.5 vs. 7.8 months). Furthermore, salvage therapies were associated with significant improved survival when compared to Best Supportive Care (22.3 vs. 8.8 months). Conclusion Also elderly patients are likely to benefit from an aggressive treatment after primary diagnosis of glioblastoma.
Collapse
Affiliation(s)
- Christoph Straube
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany. .,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.
| | - Hagen Scherb
- Institute of Computational Biology, Helmholtz Zentrum München, Deutsches Forschungszentrum für Gesundheit und Umwelt (GmbH), Neuherberg, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany
| | - Stefanie Bette
- Department Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany
| | - Claus Zimmer
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.,Department Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany
| | - Friederike Schmidt-Graf
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany
| | - Jürgen Schlegel
- Department of Neuropathology, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München (TUM), Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.,Institute for Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Neuherberg, Germany
| |
Collapse
|
49
|
Kessel KA, Hesse J, Straube C, Zimmer C, Schmidt-Graf F, Schlegel J, Meyer B, Combs SE. Validation of an established prognostic score after re-irradiation of recurrent glioma. Acta Oncol 2017; 56:422-426. [PMID: 28075197 DOI: 10.1080/0284186x.2016.1276621] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Re-irradiation (Re-RT) is offered widely in clinical routine, and has been established as a key element in the treatment of recurrent gliomas. At our center, generally re-resection is performed widely by an experienced neurosurgical team. Thus, Re-RT mostly offered to patients with macroscopic residuals or irresectable lesions, is applied later compared to other centers. Therefore, we sought to validate the Combs Prognostic Score developed in 2012 using our independent patient cohort. PATIENTS AND METHODS We included 199 patients treated from 2002 until April 2016 for recurrent glioma at the Department of Radiation Oncology at the Klinikum Rechts der Isar, Munich. Different concepts of Re-RT were applied. RESULTS Median follow-up after Re-RT was 2.5 months. Median overall survival (OS) after Re-RT was 7.9 months for WHO IV gliomas, 11.3 months for WHO III gliomas, and 13.6 months for low-grade gliomas (WHO I/II). Univariate analyses confirmed the prognostic factors primary histology (p = 0.001), age (p = 0.002), and time between primary radiotherapy and Re-RT (p < 0.001). We also tested Karnofsky Performance Score (KPS), gender, and neurological symptoms before Re-RT as well as planning target volume and found only KPS also significant at p < 0.001. Comparing the prognostic score groups, the outcome was highly statistically significant at p < 0.001. CONCLUSION In our analysis, we validated the Combs Prognostic Score. Validation in this independent large patient cohort confirms the significance of the score for glioma recurrences. Thus, the role of the Combs Prognostic Score might be an essential component of future clinical decision making and patient stratification.
Collapse
Affiliation(s)
- Kerstin A. Kessel
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
- Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Neuherberg, Germany
| | - Josefine Hesse
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
| | - Christoph Straube
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Technical University of Munich, Munich, Germany
| | | | - Jürgen Schlegel
- Department of Neuropathology, Technical University of Munich, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich, Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
- Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Neuherberg, Germany
| |
Collapse
|
50
|
Kessel KA, Vogel MME, Schmidt-Graf F, Combs SE. Mobile Apps in Oncology: A Survey on Health Care Professionals' Attitude Toward Telemedicine, mHealth, and Oncological Apps. J Med Internet Res 2016; 18:e312. [PMID: 27884810 PMCID: PMC5146327 DOI: 10.2196/jmir.6399] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 10/19/2016] [Accepted: 11/08/2016] [Indexed: 12/11/2022] Open
Abstract
Background Mobile apps are an evolving trend in the medical field. To date, few apps in an oncological context exist. Objective The aim was to analyze the attitude of health care professionals (HCPs) toward telemedicine, mHealth, and mobile apps in the field of oncology. Methods We developed and conducted an online survey with 24 questions evaluating HCPs’ general attitude toward telemedicine and patients using medical mobile apps. Specific questions on the possible functionality for patients and the resulting advantages and disadvantages for both the patients’ and HCPs’ daily clinical routine were evaluated. Results A total of 108 HCPs completed the survey. In all, 88.9% (96/108) considered telemedicine useful and 84.3% (91/108) supported the idea of an oncological app complementing classical treatment. Automatic reminders, timetables, and assessment of side effects and quality of life during therapy were rated as the most important functions. In contrast, uncertainty regarding medical responsibility and data privacy were reasons mostly named by critics. Most (64.8%, 70/108) were in favor of an alert function due to data input needing further clarification, and 94% (66/70) were willing to contact the patient after a critical alert. In all, 93.5% (101/108) supported the idea of using the collected data for scientific research. Moreover, 75.0% (81/108) believed establishing a mobile app could be beneficial for the providing hospital. Conclusions A majority of HCPs are in favor of telemedicine and the use of oncological apps by patients. Assessing side effects can lead to quicker response and thus lower inconvenience for patients. Clinical data, such as life quality and treatment satisfaction, could be used to evaluate and improve the therapy workflow. Eventually, a mobile app would enhance the patients’ relationship to their treating department because they are in permanent contact.
Collapse
Affiliation(s)
- Kerstin A Kessel
- Klinikum rechts der Isar, Department of Radiation Oncology, Technical University of Munich (TUM), Munich, Germany.,Institute for Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München (HMGU), Neuherberg, Germany
| | - Marco M E Vogel
- Klinikum rechts der Isar, Department of Radiation Oncology, Technical University of Munich (TUM), Munich, Germany.,Institute for Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München (HMGU), Neuherberg, Germany
| | - Friederike Schmidt-Graf
- Klinikum rechts der Isar, Department of Neurology, Technical University of Munich (TUM), Munich, Germany
| | - Stephanie E Combs
- Klinikum rechts der Isar, Department of Radiation Oncology, Technical University of Munich (TUM), Munich, Germany.,Institute for Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München (HMGU), Neuherberg, Germany
| |
Collapse
|