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Arrillaga-Romany I, Gardner SL, Odia Y, Aguilera D, Allen JE, Batchelor T, Butowski N, Chen C, Cloughesy T, Cluster A, de Groot J, Dixit KS, Graber JJ, Haggiagi AM, Harrison RA, Kheradpour A, Kilburn LB, Kurz SC, Lu G, MacDonald TJ, Mehta M, Melemed AS, Nghiemphu PL, Ramage SC, Shonka N, Sumrall A, Tarapore RS, Taylor L, Umemura Y, Wen PY. ONC201 (Dordaviprone) in Recurrent H3 K27M-Mutant Diffuse Midline Glioma. J Clin Oncol 2024; 42:1542-1552. [PMID: 38335473 DOI: 10.1200/jco.23.01134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/20/2023] [Accepted: 12/11/2023] [Indexed: 02/12/2024] Open
Abstract
PURPOSE Histone 3 (H3) K27M-mutant diffuse midline glioma (DMG) has a dismal prognosis with no established effective therapy beyond radiation. This integrated analysis evaluated single-agent ONC201 (dordaviprone), a first-in-class imipridone, in recurrent H3 K27M-mutant DMG. METHODS Fifty patients (pediatric, n = 4; adult, n = 46) with recurrent H3 K27M-mutant DMG who received oral ONC201 monotherapy in four clinical trials or one expanded access protocol were included. Eligible patients had measurable disease by Response Assessment in Neuro-Oncology (RANO) high-grade glioma (HGG) criteria and performance score (PS) ≥60 and were ≥90 days from radiation; pontine and spinal tumors were ineligible. The primary end point was overall response rate (ORR) by RANO-HGG criteria. Secondary end points included duration of response (DOR), time to response (TTR), corticosteroid response, PS response, and ORR by RANO low-grade glioma (LGG) criteria. Radiographic end points were assessed by dual-reader, blinded independent central review. RESULTS The ORR (RANO-HGG) was 20.0% (95% CI, 10.0 to 33.7). The median TTR was 8.3 months (range, 1.9-15.9); the median DOR was 11.2 months (95% CI, 3.8 to not reached). The ORR by combined RANO-HGG/LGG criteria was 30.0% (95% CI, 17.9 to 44.6). A ≥50% corticosteroid dose reduction occurred in 7 of 15 evaluable patients (46.7% [95% CI, 21.3 to 73.4]); PS improvement occurred in 6 of 34 evaluable patients (20.6% [95% CI, 8.7 to 37.9]). Grade 3 treatment-related treatment-emergent adverse events (TR-TEAEs) occurred in 20.0% of patients; the most common was fatigue (n = 5; 10%); no grade 4 TR-TEAEs, deaths, or discontinuations occurred. CONCLUSION ONC201 monotherapy was well tolerated and exhibited durable and clinically meaningful efficacy in recurrent H3 K27M-mutant DMG.
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Affiliation(s)
| | | | - Yazmin Odia
- Miami Cancer Institute, part of Baptist Health South Florida, Miami, FL
| | - Dolly Aguilera
- Children's Healthcare of Atlanta, Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, GA
| | | | | | | | - Clark Chen
- University of Minnesota Medical Center, Minneapolis, MN
| | | | | | | | - Karan S Dixit
- Northwestern Medical Lou and Jean Malnati Brain Tumor Institute, Chicago, IL
| | | | | | | | | | | | | | | | - Tobey J MacDonald
- Children's Healthcare of Atlanta, Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, GA
| | - Minesh Mehta
- Miami Cancer Institute, part of Baptist Health South Florida, Miami, FL
| | | | | | | | | | | | | | - Lynne Taylor
- University of Washington Medical Center, Seattle, WA
| | | | - Patrick Y Wen
- Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
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Santos-Pinheiro F, Graber JJ. Neuro-oncology Treatment Strategies for Primary Glial Tumors. Semin Neurol 2023; 43:889-896. [PMID: 38096849 DOI: 10.1055/s-0043-1776764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Primary brain tumors underwent reclassification in the 2021 World Health Organization update, relying on molecular findings (especially isocitrate dehydrogenase mutations and chromosomal changes in 1p, 19q, gain of chromosome 7 and loss of chromosome 10). Newer entities have also been described including histone 3 mutant midline gliomas. These updated pathologic classifications improve prognostication and reliable diagnosis, but may confuse interpretation of prior clinical trials and require reclassification of patients diagnosed in the past. For patients over seventy, multiple studies have now confirmed the utility of shorter courses of radiation, and the risk of post-operative delirium. Ongoing studies are comparing proton to photon radiation. Long term follow up of prior clinical trials have confirmed the roles and length of chemotherapy (mainly temozolomide) in different tumors, as well as the wearable novottf device. New oral isocitrate dehydrogenase inhibitors have also shown efficacy in clinical trials.
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Affiliation(s)
| | - Jerome J Graber
- Department of Neurology and Neurosurgery, University of Washington, Alvord Brain Tumor Center, Seattle, Washington
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Graber JJ. Paraneoplastic Neurologic Syndromes. Continuum (Minneap Minn) 2023; 29:1779-1808. [PMID: 38085898 DOI: 10.1212/con.0000000000001357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
OBJECTIVE Progress is ongoing in understanding paraneoplastic neurologic disorders, with new syndromes and antibodies being described and more detailed evidence available to guide workup for diagnosis and treatment to improve outcomes. Many excellent reviews have summarized the molecular features of different antibodies, but this article emphasizes the clinical features of each syndrome that may help guide initial diagnosis and treatment, which often should occur before an antibody or cancer is found to confirm the diagnosis. LATEST DEVELOPMENTS Recent findings include updated diagnostic criteria with validated sensitivity and specificity, discovery of novel antibodies, and clinical findings that increase the likelihood of an underlying paraneoplastic disorder. Suggestive syndromes that have been recently identified include faciobrachial dystonic seizures and pilomotor auras in anti-leucine-rich glioma inactivated protein 1 encephalitis, extreme delta brush on EEG in N-methyl-d-aspartate (NMDA)-receptor encephalitis, déjà vu aura in anti-glutamic acid decarboxylase 65 (GAD65) encephalitis, and sleep disturbances in several disorders. In addition, there is confirmed utility of brain positron emission tomography (PET) and CSF markers, including carcinoembryonic antigen and oligoclonal bands, as well as improved tests for the presence of leptomeningeal cancer cells in CSF. Associations of cancer immunotherapies with paraneoplastic syndromes and herpes simplex virus encephalitis (and COVID-19) with NMDA-receptor encephalitis have been described. ESSENTIAL POINTS All neurologists should be aware of advances regarding paraneoplastic neurologic syndromes, as patients can present with a wide variety of neurologic symptoms and earlier diagnosis and treatment can improve outcomes.
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Bonm AV, Menghini A, Drolet CE, Graber JJ. Temporalis muscle thickness predicts early relapse and short survival in primary CNS lymphoma. Neurooncol Pract 2023; 10:162-168. [PMID: 36970167 PMCID: PMC10037939 DOI: 10.1093/nop/npac087] [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: 11/22/2022] Open
Abstract
Background Most patients with primary CNS lymphoma (PCNSL) achieve durable remission whereas a minority die in the first year. Sarcopenia is a powerful predictor of mortality in the brain and systemic cancers. Temporalis muscle thickness (TMT) is a validated radiographic measure of sarcopenia. We hypothesized that patients with thin TMT at diagnosis would have early progression and short survival. Methods Two blinded operators retrospectively measured TMT in 99 consecutive brain MRIs from untreated patients with PCNSL. Results We generated a receiver operator characteristic curve and chose a single threshold defining thin TMT in all patients as <5.65 mm, at which specificity and sensitivity for 1-year progression were 98.4% and 29.7% and for 1-year mortality were 97.4% and 43.5% respectively. Those with thin TMT were both more likely to progress (P < .001) and had higher rates of mortality (P < .001). These effects were independent of the effect of age, sex, and Eastern Cooperative Oncology Group performance status in a cox regression. Memorial Sloan Kettering Cancer Center score did not predict progression-free survival or overall survival as well as TMT. Patients with thin TMT received fewer cycles of high-dose methotrexate and were less likely to receive consolidation but neither variable could be included in the Cox regression due to violation of the proportional hazards assumption. Conclusions We conclude that PCNSL patients with thin TMT are at high risk for early relapse and short survival. Future trials should stratify patients by TMT to avoid confounding.
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Affiliation(s)
- Alipi V Bonm
- Department of Neurology, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Anthony Menghini
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Caroline E Drolet
- Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Jerome J Graber
- Departments of Neurology and Neurosurgery, Alvord Brain Tumor Center, University of Washington, Seattle, Washington, USA
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Bakouny Z, Labaki C, Grover P, Awosika J, Gulati S, Hsu CY, Alimohamed SI, Bashir B, Berg S, Bilen MA, Bowles D, Castellano C, Desai A, Elkrief A, Eton OE, Fecher LA, Flora D, Galsky MD, Gatti-Mays ME, Gesenhues A, Glover MJ, Gopalakrishnan D, Gupta S, Halfdanarson TR, Hayes-Lattin B, Hendawi M, Hsu E, Hwang C, Jandarov R, Jani C, Johnson DB, Joshi M, Khan H, Khan SA, Knox N, Koshkin VS, Kulkarni AA, Kwon DH, Matar S, McKay RR, Mishra S, Moria FA, Nizam A, Nock NL, Nonato TK, Panasci J, Pomerantz L, Portuguese AJ, Provenzano D, Puc M, Rao YJ, Rhodes TD, Riely GJ, Ripp JJ, Rivera AV, Ruiz-Garcia E, Schmidt AL, Schoenfeld AJ, Schwartz GK, Shah SA, Shaya J, Subbiah S, Tachiki LM, Tucker MD, Valdez-Reyes M, Weissmann LB, Wotman MT, Wulff-Burchfield EM, Xie Z, Yang YJ, Thompson MA, Shah DP, Warner JL, Shyr Y, Choueiri TK, Wise-Draper TM, Gandhi R, Gartrell BA, Goel S, Halmos B, Makower DF, O' Sullivan D, Ohri N, Portes M, Shapiro LC, Shastri A, Sica RA, Verma AK, Butt O, Campian JL, Fiala MA, Henderson JP, Monahan RS, Stockerl-Goldstein KE, Zhou AY, Bitran JD, Hallmeyer S, Mundt D, Pandravada S, Papaioannou PV, Patel M, Streckfuss M, Tadesse E, Gatson NTN, Kundranda MN, Lammers PE, Loree JM, Yu IS, Bindal P, Lam B, Peters MLB, Piper-Vallillo AJ, Egan PC, Farmakiotis D, Arvanitis P, Klein EJ, Olszewski AJ, Vieira K, Angevine AH, Bar MH, Del Prete SA, Fiebach MZ, Gulati AP, Hatton E, Houston K, Rose SJ, Steve Lo KM, Stratton J, Weinstein PL, Garcia JA, Routy B, Hoyo-Ulloa I, Dawsey SJ, Lemmon CA, Pennell NA, Sharifi N, Painter CA, Granada C, Hoppenot C, Li A, Bitterman DS, Connors JM, Demetri GD, Florez (Duma) N, Freeman DA, Giordano A, Morgans AK, Nohria A, Saliby RM, Tolaney SM, Van Allen EM, Xu WV, Zon RL, Halabi S, Zhang T, Dzimitrowicz H, Leighton JC, Graber JJ, Grivas P, Hawley JE, Loggers ET, Lyman GH, Lynch RC, Nakasone ES, Schweizer MT, Vinayak S, Wagner MJ, Yeh A, Dansoa Y, Makary M, Manikowski JJ, Vadakara J, Yossef K, Beckerman J, Goyal S, Messing I, Rosenstein LJ, Steffes DR, Alsamarai S, Clement JM, Cosin JA, Daher A, Dailey ME, Elias R, Fein JA, Hosmer W, Jayaraj A, Mather J, Menendez AG, Nadkarni R, Serrano OK, Yu PP, Balanchivadze N, Gadgeel SM, Accordino MK, Bhutani D, Bodin BE, Hershman DL, Masson C, Alexander M, Mushtaq S, Reuben DY, Bernicker EH, Deeken JF, Jeffords KJ, Shafer D, Cárdenas AI, Cuervo Campos R, De-la-Rosa-Martinez D, Ramirez A, Vilar-Compte D, Gill DM, Lewis MA, Low CA, Jones MM, Mansoor AH, Mashru SH, Werner MA, Cohen AM, McWeeney S, Nemecek ER, Williamson SP, Peters S, Smith SJ, Lewis GC, Zaren HA, Akhtari M, Castillo DR, Cortez K, Lau E, Nagaraj G, Park K, Reeves ME, O'Connor TE, Altman J, Gurley M, Mulcahy MF, Wehbe FH, Durbin EB, Nelson HH, Ramesh V, Sachs Z, Wilson G, Bardia A, Boland G, Gainor JF, Peppercorn J, Reynolds KL, Rosovsky RP, Zubiri L, Bekaii-Saab TS, Joyner MJ, Riaz IB, Senefeld JW, Shah S, Ayre SK, Bonnen M, Mahadevan D, McKeown C, Mesa RA, Ramirez AG, Salazar M, Shah PK, Wang CP, Bouganim N, Papenburg J, Sabbah A, Tagalakis V, Vinh DC, Nanchal R, Singh H, Bahadur N, Bao T, Belenkaya R, Nambiar PH, O’Cearbhaill RE, Papadopoulos EB, Philip J, Robson M, Rosenberg JE, Wilkins CR, Tamimi R, Cerrone K, Dill J, Faller BA, Alomar ME, Chandrasekhar SA, Hume EC, Islam JY, Ajmera A, Brouha SS, Cabal A, Choi S, Hsiao A, Jiang JY, Kligerman S, Park J, Razavi P, Reid EG, Bhatt PS, Mariano MG, Thomson CC, Glace M(G, Knoble JL, Rink C, Zacks R, Blau SH, Brown C, Cantrell AS, Namburi S, Polimera HV, Rovito MA, Edwin N, Herz K, Kennecke HF, Monfared A, Sautter RR, Cronin T, Elshoury A, Fleissner B, Griffiths EA, Hernandez-Ilizaliturri F, Jain P, Kariapper A, Levine E, Moffitt M, O'Connor TL, Smith LJ, Wicher CP, Zsiros E, Jabbour SK, Misdary CF, Shah MR, Batist G, Cook E, Ferrario C, Lau S, Miller WH, Rudski L, Santos Dutra M, Wilchesky M, Mahmood SZ, McNair C, Mico V, Dixon B, Kloecker G, Logan BB, Mandapakala C, Cabebe EC, Jha A, Khaki AR, Nagpal S, Schapira L, Wu JTY, Whaley D, Lopes GDL, de Cardenas K, Russell K, Stith B, Taylor S, Klamerus JF, Revankar SG, Addison D, Chen JL, Haynam M, Jhawar SR, Karivedu V, Palmer JD, Pillainayagam C, Stover DG, Wall S, Williams NO, Abbasi SH, Annis S, Balmaceda NB, Greenland S, Kasi A, Rock CD, Luders M, Smits M, Weiss M, Chism DD, Owenby S, Ang C, Doroshow DB, Metzger M, Berenberg J, Uyehara C, Fazio A, Huber KE, Lashley LN, Sueyoshi MH, Patel KG, Riess J, Borno HT, Small EJ, Zhang S, Andermann TM, Jensen CE, Rubinstein SM, Wood WA, Ahmad SA, Brownfield L, Heilman H, Kharofa J, Latif T, Marcum M, Shaikh HG, Sohal DPS, Abidi M, Geiger CL, Markham MJ, Russ AD, Saker H, Acoba JD, Choi H, Rho YS, Feldman LE, Gantt G, Hoskins KF, Khan M, Liu LC, Nguyen RH, Pasquinelli MM, Schwartz C, Venepalli NK, Vikas P, Zakharia Y, Friese CR, Boldt A, Gonzalez CJ, Su C, Su CT, Yoon JJ, Bijjula R, Mavromatis BH, Seletyn ME, Wood BR, Zaman QU, Kaklamani V, Beeghly A, Brown AJ, Charles LJ, Cheng A, Crispens MA, Croessmann S, Davis EJ, Ding T, Duda SN, Enriquez KT, French B, Gillaspie EA, Hausrath DJ, Hennessy C, Lewis JT, Li X(L, Prescott LS, Reid SA, Saif S, Slosky DA, Solorzano CC, Sun T, Vega-Luna K, Wang LL, Aboulafia DM, Carducci TM, Goldsmith KJ, Van Loon S, Topaloglu U, Moore J, Rice RL, Cabalona WD, Cyr S, Barrow McCollough B, Peddi P, Rosen LR, Ravindranathan D, Hafez N, Herbst RS, LoRusso P, Lustberg MB, Masters T, Stratton C. Interplay of Immunosuppression and Immunotherapy Among Patients With Cancer and COVID-19. JAMA Oncol 2023; 9:128-134. [PMID: 36326731 PMCID: PMC9634600 DOI: 10.1001/jamaoncol.2022.5357] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 08/11/2022] [Indexed: 11/06/2022]
Abstract
Importance Cytokine storm due to COVID-19 can cause high morbidity and mortality and may be more common in patients with cancer treated with immunotherapy (IO) due to immune system activation. Objective To determine the association of baseline immunosuppression and/or IO-based therapies with COVID-19 severity and cytokine storm in patients with cancer. Design, Setting, and Participants This registry-based retrospective cohort study included 12 046 patients reported to the COVID-19 and Cancer Consortium (CCC19) registry from March 2020 to May 2022. The CCC19 registry is a centralized international multi-institutional registry of patients with COVID-19 with a current or past diagnosis of cancer. Records analyzed included patients with active or previous cancer who had a laboratory-confirmed infection with SARS-CoV-2 by polymerase chain reaction and/or serologic findings. Exposures Immunosuppression due to therapy; systemic anticancer therapy (IO or non-IO). Main Outcomes and Measures The primary outcome was a 5-level ordinal scale of COVID-19 severity: no complications; hospitalized without requiring oxygen; hospitalized and required oxygen; intensive care unit admission and/or mechanical ventilation; death. The secondary outcome was the occurrence of cytokine storm. Results The median age of the entire cohort was 65 years (interquartile range [IQR], 54-74) years and 6359 patients were female (52.8%) and 6598 (54.8%) were non-Hispanic White. A total of 599 (5.0%) patients received IO, whereas 4327 (35.9%) received non-IO systemic anticancer therapies, and 7120 (59.1%) did not receive any antineoplastic regimen within 3 months prior to COVID-19 diagnosis. Although no difference in COVID-19 severity and cytokine storm was found in the IO group compared with the untreated group in the total cohort (adjusted odds ratio [aOR], 0.80; 95% CI, 0.56-1.13, and aOR, 0.89; 95% CI, 0.41-1.93, respectively), patients with baseline immunosuppression treated with IO (vs untreated) had worse COVID-19 severity and cytokine storm (aOR, 3.33; 95% CI, 1.38-8.01, and aOR, 4.41; 95% CI, 1.71-11.38, respectively). Patients with immunosuppression receiving non-IO therapies (vs untreated) also had worse COVID-19 severity (aOR, 1.79; 95% CI, 1.36-2.35) and cytokine storm (aOR, 2.32; 95% CI, 1.42-3.79). Conclusions and Relevance This cohort study found that in patients with cancer and COVID-19, administration of systemic anticancer therapies, especially IO, in the context of baseline immunosuppression was associated with severe clinical outcomes and the development of cytokine storm. Trial Registration ClinicalTrials.gov Identifier: NCT04354701.
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Affiliation(s)
- Ziad Bakouny
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Chris Labaki
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Punita Grover
- Division of Hematology/Oncology, University of Cincinnati Cancer Center, Cincinnati, Ohio
| | - Joy Awosika
- Division of Hematology/Oncology, University of Cincinnati Cancer Center, Cincinnati, Ohio
| | - Shuchi Gulati
- Division of Hematology/Oncology, University of Cincinnati Cancer Center, Cincinnati, Ohio
| | - Chih-Yuan Hsu
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Saif I Alimohamed
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, North Carolina
| | - Babar Bashir
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Mehmet A Bilen
- Winship Cancer Institute, Emory University, Atlanta, Georgia
| | | | | | - Aakash Desai
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Arielle Elkrief
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Omar E Eton
- Hartford Healthcare Cancer Institute, Hartford, Connecticut
| | | | | | | | | | | | | | | | | | | | | | - Mohamed Hendawi
- Aurora Cancer Center, Advocate Aurora Health, Milwaukee, Wisconsin
| | - Emily Hsu
- Hartford Healthcare Cancer Institute, Hartford, Connecticut
| | - Clara Hwang
- Henry Ford Cancer Institute, Detroit, Michigan
| | - Roman Jandarov
- Division of Hematology/Oncology, University of Cincinnati Cancer Center, Cincinnati, Ohio
| | | | | | - Monika Joshi
- Penn State Cancer Institute, Hershey, Pennsylvania
| | - Hina Khan
- Brown University and Lifespan Cancer Institute, Providence, Rhode Island
| | - Shaheer A Khan
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Natalie Knox
- Loyola University Medical Center, Maywood, Illinois
| | - Vadim S Koshkin
- UCSF, Helen Diller Comprehensive Cancer Center, San Francisco
| | | | - Daniel H Kwon
- UCSF, Helen Diller Comprehensive Cancer Center, San Francisco
| | - Sara Matar
- Hollings Cancer Center, MUSC, Charleston
| | - Rana R McKay
- Moores Cancer Center, UCSD, San Diego, California
| | - Sanjay Mishra
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Feras A Moria
- McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Nora L Nock
- Case Comprehensive Cancer Center, Department of Population and Quantitative Health Sciences, Cleveland, Ohio
| | | | - Justin Panasci
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | | | | | | | | - Yuan J Rao
- George Washington University, Washington, DC
| | | | | | - Jacob J Ripp
- University of Kansas Medical Center, Kansas City
| | - Andrea V Rivera
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Andrew L Schmidt
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Gary K Schwartz
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | | | - Justin Shaya
- Moores Cancer Center, UCSD, San Diego, California
| | - Suki Subbiah
- Stanley S. Scott Cancer Center, LSU, New Orleans, Louisiana
| | - Lisa M Tachiki
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | | | | | | | - Zhuoer Xie
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Michael A Thompson
- Aurora Cancer Center, Advocate Aurora Health, Milwaukee, Wisconsin.,Tempus Labs, Chicago, Illinois
| | - Dimpy P Shah
- Mays Cancer Center, UT Health, San Antonio, Texas
| | | | - Yu Shyr
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Toni K Choueiri
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Trisha M Wise-Draper
- Division of Hematology/Oncology, University of Cincinnati Cancer Center, Cincinnati, Ohio
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Omar Butt
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ang Li
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Eric Lau
- for the COVID-19 and Cancer Consortium
| | | | - Kyu Park
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ting Bao
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ji Park
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Erin Cook
- for the COVID-19 and Cancer Consortium
| | | | - Susie Lau
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Anup Kasi
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Li C Liu
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | - Chris Su
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Tan Ding
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | - Sara Saif
- for the COVID-19 and Cancer Consortium
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Singer J, Daum C, Baker KK, Uy NF, McLean E, Boekankamp D, Lavell L, Hnida J, Sofie K, Cruz J, Graber JJ, King SDW, Urban RR, Taylor LP, Rodriguez CP, Shen MJ, Loggers ET. Use of medical aid in dying by individuals with cancer at a comprehensive cancer center. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e24073] [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: 11/20/2022] Open
Abstract
e24073 Background: Understanding the experience of individuals with cancer (pts) who utilize Medical Aid in Dying (MAID) is important given growing access and limited research in the U.S. Methods: Chart review from January 1, 2014-October 1, 2020, of all pts who inquired (but did not initiate completion of all legal requirements), initiated (but did not complete all legal requirements to obtain access to the medications), or completed all legal requirements and could have had access to medications (whether or not they were obtained or used) at Seattle Cancer Care Alliance/University of Washington. Chi-square tests were used to compare differences in pt characteristics between the inquired/initiated versus completed group. Results: Of 498 total pts, 116 (23.3%) inquired, 127 (25.5%) initiated, and 255 (51.2%) completed the MAID process, of which, 45.9% (117/255) were known to have used the medications. At time of first inquiry (FI), mean age was 66 years (standard deviation [SD] = 11.9)/median 67.3/range 22-94; 206 (41.4%) were female; and 40 (8.0%) were non-white, while 11 (2.2%) were Hispanic/Latino and 14 (2.8%) were non-English speaking. At FI, 292 (58.6%) pts were married or had a significant other; 152 (30.5%) had a religious affiliation; 23 (4.6%) were uninsured; and 282 (56.6%) had Medicare. Mean months from the original cancer diagnosis and FI was 36.5 (SD = 50.3, range 0.1-366.1). 461 (92.6%) pts had solid/central nervous system (CNS) tumors, of which 231 (46.4%) had presented with metastatic disease. At FI, 84 (16.9%) were currently hospitalized; in total, 236 (47.4%) pts had been hospitalized within the 3 months prior to FI. A total of 71.9% (358/498) had not yet initiated hospice at FI; 51.8% (258/498) had evidence of advance care planning (ACP), including 41.5% (107/258) with a Physician Order for Life Sustaining Treatment on file. Overall, 152 (30.5%) and 166 (33.3%) of pts had seen social work or palliative care in the 30 days prior to FI, while 62 (12.4%) had met with a spiritual health clinician. Statistically significant differences were found between those who inquired/initiated versus completed with the following pt characteristics: non-white (ꭓ2= 6.596, p = .010); Medicaid versus all other insured (ꭓ2= 9.489, p = .002); those hospitalized at FI (ꭓ2= 6.101, p = .014); and those without evidence of ACP (ꭓ2= 17.090, p < .001). Pts with a hematologic malignancy (HM, n = 37/498, 7.4%) were less likely to complete the MAID process compared to pts with solid/CNS tumors (ꭓ2= 7.378, p = .007); 43.2% (16/37) of HM pts did not complete due to rapid decline. Conclusions: Less than half of pts who initially inquired about MAID completed the process. Recent hospitalizations and evidence of ACP were relatively common compared to current utilization of hospice or prior use of supportive care services. Future research should investigate why non-white pts, those with Medicaid and those with HM may be less likely to complete the MAID process.
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7
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Bhatt PS, Jani C, Shah D, Ahmed A, Mariano M, Singh H, Graber JJ, Salciccioli JD. Trends in incidence and mortality of brain cancer: An observational study of the Global Burden of Disease database from 1990 to 2019. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e18720] [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: 11/20/2022] Open
Abstract
e18720 Background: Brain cancer is relatively rare accounting for approximately 1.3% of all cancer diagnoses in the US annually, however it has a particularly poor prognosis with 5-year survival at 33%. The morbidity and mortality associated with brain cancer is high, while global epidemiological data relating to it remains scarce. This study investigates brain cancer incidence, mortality and disability-adjusted life years (DALYs) in the EU 15+ countries and six WHO world regions. Methods: We extracted data for 19 countries, including the EU nations as well as other selected high-income countries including the UK and USA from the Global Burden of Disease (GBD) database. This data included age-standardized incidence ratio (ASIR), age-standardized mortality ratio (ASMR) and DALY from brain cancer (ICD 10 codes C70-C72, D42-D43.9, D44.3-D44.5) between 1990 and 2019. Joinpoint analyses were used to describe trends further. Results: Greece was noted to have the highest DALY for both sexes with 252/100,000 and 174/100,000 respectively for males and females. The majority of countries saw a drop in DALY during the study period (14/19 for males and 19/19 for females). Greece also reported the highest ASMR over the study period for both sexes at 7.8/100,000 and 5.3/100,000 respectively for males and females. The majority of countries also saw a decline in ASMR (12/19 for males and 16/19 for females) with Belgium noting the largest decline for males and females at -27.2% and -34.3% respectively. Denmark was noted to have the highest ASIR in 2019 for both sexes with 17.9/100,000 and 16.4/100,000 respectively for males and females. Most countries reported an increase in ASIR over the study period (17/19 for males and 15/19 for females). Denmark displayed the greatest increase in incidence for both sexes with an 84.5% and 64.3% increase, respectively, for males and females. Notably, the countries with the highest incidences and DALYs, Denmark, Luxembourg, and Greece, also had the highest mortality. All countries saw a decline in the mortality-to-incidence ratio over the study period, with Denmark and Ireland showing the greatest drop for both sexes. Conclusions: Over the study period, the burden of brain cancer has decreased in most countries as measured by DALY, ASMR, and mortality-to-incidence ratios. However, incidence rates have increased. The reduced disease burden may be due to the use of temazolamide which has improved outcomes in MGMT methylated and IDH mutated gliomas, with PCV chemotherapy with radiation therapy having similar effects for high risk low grade gliomas. The preferential use of bevacizumab may explain some of the differing trends between European and other developed countries. Future work is required to delineate the diverging trends between global disease burden and incidence while highlighting the etiology of these changes.
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Affiliation(s)
| | | | - Darshil Shah
- Temple University School of Medicine, Philadelphia, PA
| | | | - Melissa Mariano
- University of New England College of Osteopathic Medicine, Portland, ME
| | - Harpreet Singh
- Froedtert and Medical College of Wisconsin, Milwaukee, WI
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8
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Schroeder BA, Cuevas E, Graber JJ. Multidisciplinary tumor boards present technical and financial challenges in the COVID-19 era. Ann Oncol 2021; 32:933. [PMID: 33737120 PMCID: PMC8010380 DOI: 10.1016/j.annonc.2021.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- B A Schroeder
- Clinical Cancer Research Division, Fred Hutchinson Cancer Research Center, Seattle, USA.
| | - E Cuevas
- Army Medical School, Uniformed Services University, Bethesda, USA
| | - J J Graber
- Department of Neurology and Neurosurgery, University of Washington, Seattle, USA
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9
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Affiliation(s)
- Jerome J Graber
- Associate Professor of Neurology and Neurosurgery, University of Washington, Seattle Cancer Care Alliance, Alvord Brain Tumor Center, Seattle, Washington, USA.
| | - Hany Soliman
- Assistant Professor, Department of Radiation Oncology, University of Toronto, Sunnybrook Odette Cancer Center, Toronto, Canada.
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10
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Bonm AV, Gibson AW, Holmberg LA, Mielcarek M, McGranahan T, Taylor LP, Graber JJ. A single-center retrospective analysis of outcome measures and consolidation strategies for relapsed and refractory primary CNS lymphoma. J Neurooncol 2021; 151:193-200. [PMID: 33398532 DOI: 10.1007/s11060-020-03648-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 08/07/2020] [Accepted: 10/10/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Relapsed or refractory primary CNS lymphoma (rrPCNSL) is a rare and challenging malignancy for which better evidence is needed to guide management. METHODS We present a retrospective cohort of 66 consecutive patients with rrPCNSL treated at the University of Washington between 2000 and 2020. Immunosuppressed and secondary CNS lymphoma patients were excluded. RESULTS During a median follow-up of 40.5 months from initial diagnosis, median OS for relapsed disease was 14.1 (0.2-88.5) months and median PFS was 11.0 (0.2-73.9) months. At diagnosis (r2 = 0.85, p < 0.001), first relapse (r2 = 0.69, p < 0.001), multiple relapses (r2 = 0.97, p < 0.001) PFS was highly correlated with OS. In contrast, there was no correlation between the duration of subsequent progression-free intervals. No difference in PFS or OS was seen between CSF or intraocular relapse and parenchymal relapse. Patients reinduced with high-dose methotrexate-based (HD-MTX) regimens had an overall response rate (ORR) of 86.7%. Consolidation with autologous stem cell transplant (ASCT) was associated with longer PFS compared to either no consolidation (p = 0.01) and trended to longer PFS when compared to other consolidation strategies (p = 0.06). OS was similarly improved in patients consolidated with ASCT compared with no consolidation (p = 0.04), but not compared with other consolidation (p = 0.22). Although patients receiving ASCT were younger, KPS, sex, and number of recurrences were similar between consolidation groups. A multivariate analysis confirmed an independent effect of consolidation group on PFS (p = 0.01), but not OS. CONCLUSIONS PFS may be a useful surrogate endpoint which predicts OS in PCNSL. Consolidation with ASCT was associated with improved PFS in rrPCNSL.
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Affiliation(s)
- Alipi V Bonm
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Alec W Gibson
- Medical Scientist Training Program, University of Washington, Seattle, WA, USA
| | - Leona A Holmberg
- Department of Medicine, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Marco Mielcarek
- Department of Medicine, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Tresa McGranahan
- Departments of Neurology and Neurosurgery, Alvord Brain Tumor Center, University of Washington Medical Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Lynne P Taylor
- Departments of Neurology and Neurosurgery, Alvord Brain Tumor Center, University of Washington Medical Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Jerome J Graber
- Departments of Neurology and Neurosurgery, Alvord Brain Tumor Center, University of Washington Medical Center, 1959 NE Pacific St, Seattle, WA, 98195, USA.
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11
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Abstract
Gliomas represent the majority of malignant central nervous system tumors, with the most aggressive subtype, glioblastoma, accounting for almost 57% of this entity. Type of glioma and its incidence can vary depending on the age of presentation. In turn, outcomes can vary significantly based on the actual type of glioma (histologically and molecularly) and age of the patient, as well as various tumor specific factors such as size, location, comorbidities, etc. In the last decade we have been able to identify key molecular features that have provided us with greater insight into the behavior of these tumors, but the spectrum of treatment options remains limited. In addition, ultimate causes of death in patients with gliomas are variable and stochastic in nature. Given these complicated factors, prognostication for gliomas remains extremely difficult. This review aims to discuss prognostication in low grade versus high grade gliomas, variability in treatment of these tumors, clinical features of poor prognosis, and differences in prognostic understanding between patients, caregivers, and providers. We will also make some general recommendations where appropriate on how to approach this subject from a palliative care perspective.
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Affiliation(s)
- Akanksha Sharma
- Hospice and Palliative Medicine, University of Washington Medical Center, Seattle, WA, USA.
| | - Jerome J Graber
- Department of Neurology and Neurosurgery, University of Washington Alvord Brain Tumor Center, Seattle, WA, USA
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12
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Isenberg-Grzeda E, Sofie K, Larrivee EJ, Graber JJ. Legal assistance in dying for people with brain tumors. Ann Palliat Med 2020; 10:893-898. [PMID: 32787350 DOI: 10.21037/apm-20-756] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 07/04/2020] [Indexed: 11/06/2022]
Abstract
The number of countries and states that have legalized assistance in dying under various names (Medical Assistance in Dying, Death with Dignity, etc.) has continued to grow in recent years, allowing this option for more patients. Most of these laws include restrictions for eligibility based on a terminal diagnosis and estimated prognosis, as well as asking certifying providers to attest to the cognitive and psychiatric competence and capacity of patients requesting access. Some laws also require that patients must be able to 'self-administer' the regimen, though details vary. Such determinations can be vague and difficult to clearly apply to patients with neurologic conditions and primary or metastatic brain tumors. There is currently a lack of rigorous studies guiding providers on how to apply these important legal criteria to this special and common patient population. As access to legal assistance in dying expands, more research is needed on how to ethically apply the laws and guide patients, families and providers through the process.
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Affiliation(s)
| | - Katie Sofie
- Department of Social Work, University of Washington, Seattle, WA, USA
| | | | - Jerome J Graber
- Department of Neurology, University of Washington/Seattle Cancer Care Alliance, Seattle, WA, USA.
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13
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Gibson AW, Graber JJ. Distinguishing and treating depression, anxiety, adjustment, and post-traumatic stress disorders in brain tumor patients. Ann Palliat Med 2020; 10:875-892. [PMID: 32692231 DOI: 10.21037/apm-20-509] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 07/13/2020] [Indexed: 11/06/2022]
Abstract
Cancer patients often suffer from psychiatric disorders as a result of their disease and its treatment. Rates of depression, anxiety, adjustment, and post-traumatic stress disorders are particularly high for individuals with cancer and differentiating between these conditions is important for providing both appropriate and high-quality care. Patients with primary and metastatic brain tumors are particularly susceptible to psychiatric morbidities as a result of direct neuropsychiatric effects from the tumor itself, as well as psychological distress stemming from their diagnosis, prognosis, or treatment. However, these morbidities are often underdiagnosed, misdiagnosed, and undertreated. Many tools exist for screening, diagnosing, and treating psychiatric disorders in brain tumor patients, and palliative care settings are well suited to both identify and treat psychiatric disorders in brain tumor patients. This review summarizes our current knowledge of psychiatric disorders in patients in patients with brain tumors, highlights the susceptibility of brain tumor patients to psychiatric conditions, provides recommendations for differentiating and treating these conditions, and emphasizes the need for further research. The goal of this review is to inform healthcare providers of the opportunities to address psychiatric morbidities in patients with primary and metastatic brain tumors, particularly in palliative care settings, and identify areas in need of additional research.
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Affiliation(s)
- Alec W Gibson
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA; School of Medicine, University of Washington, Seattle, WA, USA
| | - Jerome J Graber
- Department of Neurology, University of Washington, Seattle, WA, USA; Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
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14
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Throckmorton P, Graber JJ. T2-FLAIR mismatch in isocitrate dehydrogenase mutant astrocytomas: Variability and evolution. Neurology 2020; 95:e1582-e1589. [PMID: 32690782 DOI: 10.1212/wnl.0000000000010324] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 03/30/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the predictive value of T2 appearance as a defining criterion of T2-fluid-attenuated inversion recovery (FLAIR) mismatch sign (T2FM), further characterize tumors that display the marker, and describe its radiographic evolution. METHODS Records from 64 patients with astrocytomas were assessed for age at diagnosis, sex, tumor characteristics on pretreatment CT, MRI, and pathology, documentation of T2FM, treatment course, and temporal changes in tumor appearance. Cases were divided into those meeting classic criteria (homogenous T2, hyperintense FLAIR rim), those considered geographic (heterogeneous T2, hyperintense FLAIR rim), and those that were negative (no FLAIR rim). Groups were compared using χ2, estimate of effect, and qualitative analyses. RESULTS Including geographic tumors increased T2FM sensitivity 30% among astrocytomas without decreased specificity for IDH mutation. Tumors with T2FM characteristics were more cystic, less enhancing, and affected younger patients. T2FM persisted in residual tumors following subtotal resection and disappeared with radiotherapy, persisted in 5/8 recurrent tumors that were originally T2FM-positive, and was identified in tumors with high-grade characteristics. T2FM was able to predict IDH mutation status on sequencing when antibody testing was negative. CONCLUSIONS The presence of a hyperintense FLAIR rim, regardless of T2 appearance, is a reliable indicator of IDH mutation among astrocytomas. Tumors with a FLAIR rim are more cystic and this may lend to their characteristic appearance on MRI. T2FM demonstrates distinctive temporal radiographic changes, may be seen in high-grade gliomas, and may be used in combination with other variables to strengthen prediction of IDH status.
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Affiliation(s)
- Patrick Throckmorton
- From the School of Medicine (P.T.) and Departments of Neurology and Neurosurgery at the Alvord Brain Tumor Center (J.J.G.), the University of Washington; and Seattle Cancer Care Alliance (J.J.G.), WA
| | - Jerome J Graber
- From the School of Medicine (P.T.) and Departments of Neurology and Neurosurgery at the Alvord Brain Tumor Center (J.J.G.), the University of Washington; and Seattle Cancer Care Alliance (J.J.G.), WA.
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15
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Abstract
Background Primary CNS lymphoma is a rare and aggressive cancer that can develop in immunocompetent individuals, but little is known about risk factors and causes of disease. Previous studies have demonstrated seasonal patterns for lymphomas and brain tumors. This study examined the seasonal incidence pattern for primary CNSlymphoma. Methods A retrospective review was performed for patients diagnosed with primary CNS lymphoma from 2000 through 2018 at our tertiary referral center. A total of 156 patients were categorized based on month of symptom onset, month of diagnosis, and month of recurrence if they experienced a relapse of their disease. The distributions were then analyzed for seasonal patterns. Results There was a significant, bimodal seasonal incidence pattern based on month of symptom onset (P < .001), with peaks in July (n = 19) and December (n = 23) and troughs in March (n = 4) and September (n = 5). There were no significant differences in patients' sex, age at presentation, length of follow-up, and progression-free survival across months. There were no seasonal patterns based on month of diagnosis (P = .450) or month of disease recurrence (P = .572). Conclusion The incidence of primary CNS lymphoma has bimodal peaks in midsummer and early winter, which could provide insight into causative agents and mechanisms of disease.
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Affiliation(s)
- Alec W Gibson
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Alipi V Bonm
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Jerome J Graber
- Department of Neurology, University of Washington, Seattle, Washington, USA.,Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
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16
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Eastman BM, Venur VA, Lo SS, Graber JJ. Stereotactic radiosurgery in the treatment of adults with metastatic brain tumors. J Neurosurg Sci 2020; 64:272-286. [PMID: 32270945 DOI: 10.23736/s0390-5616.20.04952-8] [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: 11/08/2022]
Abstract
Brain metastasis is the most common type of intracranial tumor affecting a significant proportion of advanced cancer patients. In recent years, stereotactic radiosurgery (SRS) has become commonly utilized. It has contributed significantly to decreased toxicity, prolonged quality of life and general improvement in outcomes of patients with brain metastases. Frequent imaging and advanced treatment techniques have allowed for the treatment of more patients with large and numerous metastases extending their overall survival. The addition of targeted therapy and immunotherapy to SRS has introduced novel treatment paradigms and has further improved our ability to effectively treat brain lesions. In this review, we examined in detail the available evidence for the use of SRS alone or in combination with surgery and systemic therapies. Given our developing understanding of the importance of primary tumor histology, the use of different treatment strategies for different metastasis is evolving. Combining SRS with immunotherapy and targeted therapy in breast cancer, lung cancer and melanoma as well as the use of preoperative SRS have shown significant promise in recent years and are investigated in multiple ongoing prospective trials. Further research is needed to guide the optimal sequence of therapies and to identify specific patient subgroups that may benefit the most from aggressive, combined treatment approaches.
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Affiliation(s)
- Boryana M Eastman
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Vyshak A Venur
- Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Jerome J Graber
- Department of Neurology and Neurosurgery, Alvord Brain Tumor Center, University of Washington School of Medicine, Seattle, WA, USA -
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17
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Affiliation(s)
- Jerome J Graber
- Department of Neurology, Benjamin and Catherine Ivy Center for Advanced Brain Tumor Treatment, Swedish Neuroscience Institute, Seattle, WA, USA.,Alvord Brain Tumor Center, University of Washington, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Benjamin Plato
- Department of Neurology, Benjamin and Catherine Ivy Center for Advanced Brain Tumor Treatment, Swedish Neuroscience Institute, Seattle, WA, USA.,Alvord Brain Tumor Center, University of Washington, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Raya Mawad
- Department of Medical Oncology, Swedish Cancer Institute, Seattle, WA, USA
| | - Daniel J Moore
- Department of Community Oncology, Evergreen Health, Seattle Cancer Care Alliance, Seattle, WA, USA
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18
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Bonm AV, Ritterbusch R, Throckmorton P, Graber JJ. Clinical Imaging for Diagnostic Challenges in the Management of Gliomas: A Review. J Neuroimaging 2020; 30:139-145. [PMID: 31925884 DOI: 10.1111/jon.12687] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 09/24/2019] [Revised: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 02/06/2023] Open
Abstract
Neuroimaging plays a critical role in the management of patients with gliomas. While conventional magnetic resonance imaging (MRI) remains the standard imaging modality, it is frequently insufficient to inform clinical decision-making. There is a need for noninvasive strategies for reliably distinguishing low-grade from high-grade gliomas, identifying important molecular features of glioma, choosing an appropriate target for biopsy, delineating target area for surgery or radiosurgery, and distinguishing tumor progression (TP) from pseudoprogression (PsP). One recent advance is the identification of the T2/fluid-attenuated inversion recovery mismatch sign on standard MRI to identify isocitrate dehydrogenase mutant astrocytomas. However, to meet other challenges, neuro-oncologists are increasingly turning to advanced imaging modalities. Diffusion-weighted imaging modalities including diffusion tensor imaging and diffusion kurtosis imaging can be helpful in delineating tumor margins and better visualization of tissue architecture. Perfusion imaging including dynamic contrast-enhanced MRI using gadolinium or ferumoxytol contrast agents can be helpful for grading as well as distinguishing TP from PsP. Positron emission tomography is useful for measuring tumor metabolism, which correlates with grade and can distinguish TP/PsP in the right setting. Magnetic resonance spectroscopy can identify tissue by its chemical composition, can distinguish TP/PsP, and can identify molecular features like 2-hydroxyglutarate. Finally, amide proton transfer imaging measures intracellular protein content, which can be used to identify tumor grade/progression and distinguish TP/PsP.
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Affiliation(s)
- Alipi V Bonm
- Department of Neurology, University of Washington, Seattle, WA
| | | | | | - Jerome J Graber
- Department of Neurology, University of Washington, Seattle, WA.,Departments of Neurology and Neurosurgery, Alvord Brain Tumor Center, University of Washington, Seattle, WA
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19
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Graber JJ, Cobbs CS, Olson JJ. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Use of Stereotactic Radiosurgery in the Treatment of Adults With Metastatic Brain Tumors. Neurosurgery 2019; 84:E168-E170. [PMID: 30629225 DOI: 10.1093/neuros/nyy543] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/18/2018] [Indexed: 11/14/2022] Open
Abstract
TARGET POPULATION These recommendations apply to adult patients with new or recurrent solitary or multiple brain metastases from solid tumors as detailed in each section. QUESTION 1 Should patients with newly diagnosed metastatic brain tumors undergo stereotactic radiosurgery (SRS) compared with other treatment modalities? RECOMMENDATIONS Level 3: SRS is recommended as an alternative to surgical resection in solitary metastases when surgical resection is likely to induce new neurological deficits, and tumor volume and location are not likely to be associated with radiation-induced injury to surrounding structures. Level 3: SRS should be considered as a valid adjunctive therapy to supportive palliative care for some patients with brain metastases when it might be reasonably expected to relieve focal symptoms and improve functional quality of life in the short term if this is consistent with the overall goals of the patient. QUESTION 2 What is the role of SRS after open surgical resection of brain metastasis? RECOMMENDATION Level 3: After open surgical resection of a solitary brain metastasis, SRS should be used to decrease local recurrence rates. QUESTION 3 What is the role of SRS alone in the management of patients with 1 to 4 brain metastases? RECOMMENDATIONS Level 3: For patients with solitary brain metastasis, SRS should be given to decrease the risk of local progression. Level 3: For patients with 2 to 4 brain metastases, SRS is recommended for local tumor control, instead of whole brain radiotherapy, when their cumulative volume is < 7 mL. QUESTION 4 What is the role of SRS alone in the management of patients with more than 4 brain metastases? RECOMMENDATION Level 3: The use of stereotactic radiosurgery alone is recommended to improve median overall survival for patients with more than 4 metastases having a cumulative volume < 7 mL. The full guideline can be found at: https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_4.
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Affiliation(s)
- Jerome J Graber
- Ben and Catherine Ivy Center for Advanced Brain Tumor Treatment, Department of Neurology, Swedish Neuroscience Institute, University of Washington Department of Neurology, Alvord Brain Tumor Center, Seattle, Washington
| | - Charles S Cobbs
- Ben and Catherine Ivy Center for Advanced Brain Tumor Treatment, Swedish Neuroscience Institute, Seattle, Washington
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
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20
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Abstract
OPINION STATEMENT Treatment options for leptomeningeal metastases are expanding with greater tolerability and efficacy than in the past. Improved knowledge of molecular subtypes of some cancers can guide in choosing more effective therapeutic options; however, physicians should be mindful that these molecular types can be different in the central nervous system compared to the rest of the body. This is particularly true in breast and lung cancer, in which some patients now can live for many months or even years after diagnosis of leptomeningeal metastases. Options for intrathecal therapies are expanding, but physicians should be mindful that this is a passive delivery system that relies on normal CSF flow, so therapies will not penetrate bulky or parenchymal disease sites, especially in the presence of abnormal CSF flow. When chemotherapeutic options are lacking or unsuccessful, focal radiosurgery which can provide symptomatic relief and proton craniospinal radiation remain effective options. Hopefully more formal studies will be conducted in the future to verify which treatments are indeed most effective for particular types of cancer.
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Affiliation(s)
- Jerome J Graber
- Department of Neurology, Ben and Catherine Ivy Center for Advanced Brain Tumor Treatment, Swedish Neuroscience Institute, Seattle, WA, 98122-4470, USA.
| | - Santosh Kesari
- Department of Translational Neurosciences and Neurotherapeutics, John Wayne Cancer Institute, Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, CA, 90404, USA.
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Choi EY, Gomes WA, Haigentz M, Graber JJ. Association between malignancy and non-alcoholic Wernicke's encephalopathy: a case report and literature review. Neurooncol Pract 2015; 3:196-207. [PMID: 31386087 DOI: 10.1093/nop/npv036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [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: 05/14/2015] [Indexed: 12/29/2022] Open
Abstract
Background Wernicke's encephalopathy is a serious medical condition associated with high morbidity and mortality caused by deficiency of thiamine. This disease is classically associated with alcoholism, but is underappreciated in the nonalcoholic population. There is growing acknowledgement of the development of Wernicke's encephalopathy in patients with malignancies. Methods We conducted a literature review in PubMed for cases of Wernicke's encephalopathy occurring in patients with malignancy. We also present the case of a 47-year-old woman with recurrent laryngeal cancer and multiple hospital admissions for malnutrition. Neurological examination was notable for pendular nystagmus, severe gait ataxia, confusion, and poor memory consolidation. MRI of the brain was significant for T2-weighted fluid-attenuated inversion recovery hyperintensities in periaqueductal regions, medial thalami, and the tectal plate, typical for Wernicke's encephalopathy. She was treated with thiamine repletion, and had marked improvement in her mental status and some improvement in her vision problems and ataxia, although some nystagmus and significant short-term memory impairment persisted. Results The literature review yielded dozens of case reports of Wernicke's encephalopathy in patients with malignancy, dominated by cases of patients with malignancies of the gastrointestinal system, followed by those with hematologic malignancies. Conclusions Malignancy is an important risk factor for the development of Wernicke's encephalopathy. This diagnosis is underappreciated and difficult for the clinician to discern from multifactorial delirium. Clinicians should be aware to treat at-risk patients with thiamine immediately, especially if multiple risk factors are present.
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Affiliation(s)
- Evan Y Choi
- Department of Neurology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY (E.Y.C, J.J.G.); Assistant Professor, Department of Radiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY (W.A.G.); Associate Professor of Clinical Medicine, Department of Medicine (Oncology), Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY (M.H.)
| | - William A Gomes
- Department of Neurology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY (E.Y.C, J.J.G.); Assistant Professor, Department of Radiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY (W.A.G.); Associate Professor of Clinical Medicine, Department of Medicine (Oncology), Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY (M.H.)
| | - Missak Haigentz
- Department of Neurology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY (E.Y.C, J.J.G.); Assistant Professor, Department of Radiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY (W.A.G.); Associate Professor of Clinical Medicine, Department of Medicine (Oncology), Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY (M.H.)
| | - Jerome J Graber
- Department of Neurology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY (E.Y.C, J.J.G.); Assistant Professor, Department of Radiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY (W.A.G.); Associate Professor of Clinical Medicine, Department of Medicine (Oncology), Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY (M.H.)
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Glover RL, DeNiro LV, Lasala PA, Weidenheim KM, Graber JJ, Boro A. ILAE type 3 hippocampal sclerosis in patients with anti-GAD-related epilepsy. Neurol Neuroimmunol Neuroinflamm 2015; 2:e122. [PMID: 26161431 PMCID: PMC4484895 DOI: 10.1212/nxi.0000000000000122] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 05/05/2015] [Indexed: 11/17/2022]
Abstract
Objective: To describe the neuropathologic findings and clinical course of 2 patients who underwent temporal lobectomy for medically refractive epilepsy and were later found to have high anti–glutamic acid decarboxylase (GAD) concentrations. Methods: Small case series. Results: Neuropathologic examination of both patients revealed International League Against Epilepsy (ILAE) type 3 hippocampal sclerosis. Following surgery, both developed signs and symptoms of stiff person syndrome and later cerebellar ataxia. Laboratory studies demonstrated high concentrations of anti-GAD antibodies in both patients. Conclusions: These cases suggest that ILAE type 3 hippocampal sclerosis may be immunologically related to and may exist as part of a broader anti-GAD–related neurologic syndrome in some instances.
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Affiliation(s)
- Robert L Glover
- Department of Neurology (R.L.G., L.V.D., K.M.W., J.J.G., A.B.), Department of Neurological Surgery (P.A.L., K.M.W.), and Department of Pathology (K.M.W.), Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Lauren V DeNiro
- Department of Neurology (R.L.G., L.V.D., K.M.W., J.J.G., A.B.), Department of Neurological Surgery (P.A.L., K.M.W.), and Department of Pathology (K.M.W.), Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Patrick A Lasala
- Department of Neurology (R.L.G., L.V.D., K.M.W., J.J.G., A.B.), Department of Neurological Surgery (P.A.L., K.M.W.), and Department of Pathology (K.M.W.), Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Karen M Weidenheim
- Department of Neurology (R.L.G., L.V.D., K.M.W., J.J.G., A.B.), Department of Neurological Surgery (P.A.L., K.M.W.), and Department of Pathology (K.M.W.), Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Jerome J Graber
- Department of Neurology (R.L.G., L.V.D., K.M.W., J.J.G., A.B.), Department of Neurological Surgery (P.A.L., K.M.W.), and Department of Pathology (K.M.W.), Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Alexis Boro
- Department of Neurology (R.L.G., L.V.D., K.M.W., J.J.G., A.B.), Department of Neurological Surgery (P.A.L., K.M.W.), and Department of Pathology (K.M.W.), Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
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Affiliation(s)
- Jerome J. Graber
- Department of Neurology, Montefiore-Einstein Medical Center, Bronx, New York
| | - Suhayl Dhib-Jalbut
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Affiliation(s)
- Jerome J Graber
- Departments of Neurology (JJG, YK) and Pediatrics (NAK, YK), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nancy A Kernan
- Departments of Neurology (JJG, YK) and Pediatrics (NAK, YK), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yasmin Khakoo
- Departments of Neurology (JJG, YK) and Pediatrics (NAK, YK), Memorial Sloan Kettering Cancer Center, New York, NY
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25
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Young RJ, Gupta A, Shah AD, Graber JJ, Schweitzer AD, Prager A, Shi W, Zhang Z, Huse J, Omuro AMP. Potential role of preoperative conventional MRI including diffusion measurements in assessing epidermal growth factor receptor gene amplification status in patients with glioblastoma. AJNR Am J Neuroradiol 2013; 34:2271-7. [PMID: 23811973 DOI: 10.3174/ajnr.a3604] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Epidermal growth factor receptor amplification is a common molecular event in glioblastomas. The purpose of this study was to examine the potential usefulness of morphologic and diffusion MR imaging signs in the prediction of epidermal growth factor receptor gene amplification status in patients with glioblastoma. MATERIALS AND METHODS We analyzed pretreatment MR imaging scans from 147 consecutive patients with newly diagnosed glioblastoma and correlated MR imaging features with tumor epidermal growth factor receptor amplification status. The following morphologic tumor MR imaging features were qualitatively assessed: 1) border sharpness, 2) cystic/necrotic change, 3) hemorrhage, 4) T2-isointense signal, 5) restricted water diffusion, 6) nodular enhancement, 7) subependymal enhancement, and 8) multifocal discontinuous enhancement. A total of 142 patients had DWI available for quantitative analysis. ADC maps were calculated, and the ADCmean, ADCmin, ADCmax, ADCROI, and ADCratio were measured. RESULTS Epidermal growth factor receptor amplification was present in 60 patients (40.8%) and absent in 87 patients (59.2%). Restricted water diffusion correlated with epidermal growth factor receptor amplification (P = .04), whereas the other 7 morphologic MR imaging signs did not (P > .12). Quantitative DWI analysis found that all ADC measurements correlated with epidermal growth factor receptor amplification, with the highest correlations found with ADCROI (P = .0003) and ADCmean (P = .0007). CONCLUSIONS Our results suggest a role for diffusion MR imaging in the determination of epidermal growth factor receptor amplification status in glioblastoma. Additional work is necessary to confirm these results and isolate new imaging biomarkers capable of noninvasively characterizing the molecular status of these tumors.
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Gupta A, Prager A, Young RJ, Shi W, Omuro AMP, Graber JJ. Diffusion-weighted MR imaging and MGMT methylation status in glioblastoma: a reappraisal of the role of preoperative quantitative ADC measurements. AJNR Am J Neuroradiol 2012; 34:E10-1. [PMID: 23275590 DOI: 10.3174/ajnr.a3467] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Orange D, Frank M, Tian S, Dousmanis A, Marmur R, Buckley N, Parveen S, Graber JJ, Blachère N, Darnell RB. Cellular immune suppression in paraneoplastic neurologic syndromes targeting intracellular antigens. ACTA ACUST UNITED AC 2012; 69:1132-40. [PMID: 22566506 DOI: 10.1001/archneurol.2012.595] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Tumor treatment is the mainstay of therapy for paraneoplastic neurologic disorders (PNDs), but it is only effective in some cases and other treatment options are limited. OBJECTIVE To evaluate the short-term use of a combination of prednisone and tacrolimus for acute neurologic worsening in PND in which intracellular antigens are targeted. DESIGN Retrospective single-center case series of patients with PND treated with tacrolimus. SETTING The Rockefeller University Hospital, a research hospital in New York, New York. PATIENTS Twenty-six patients with PND with high titer (≥1:1000) anti-HuD, anti-Yo, or anti-CRMP5 autoantibodies were enrolled. Patients were referred from Memorial Sloan Kettering Cancer Center or self-referred. Two patients discontinued intervention owing to adverse events. INTERVENTIONS Patients were treated with tacrolimus, 0.15-0.30 mg/kg per day, in 2 divided oral doses with 60 mg per day of oral prednisone, tapered off during 1 to 4 weeks. MAIN OUTCOME MEASURES The primary outcome measure was median survival. Neurologic examinations before and after treatment as well as adverse events are described. RESULTS Median survival time was 52 months from time of diagnosis. Some patients experienced neurologic improvement that was functionally meaningful. The incidence of adverse events was similar to that generally reported with tacrolimus. CONCLUSIONS A short course of prednisone and tacrolimus to target central nervous system T cells in patients with PND with acute neurologic decline in which intracellular antigens are targeted was well tolerated and warrants further study. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00378326.
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Affiliation(s)
- Dana Orange
- The Rockefeller University, 1230 York Ave, New York, NY 10065, USA
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Becker JG, Pastores GM, Di Rocco A, Ferraris M, Graber JJ, Sathe S. Parkinson's disease in patients and obligate carriers of Gaucher disease. Parkinsonism Relat Disord 2012; 19:129-31. [PMID: 22940477 DOI: 10.1016/j.parkreldis.2012.06.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Revised: 06/19/2012] [Accepted: 06/26/2012] [Indexed: 12/01/2022]
Abstract
BACKGROUND Gaucher disease is an autosomal recessive disorder caused by glucocerebrosidase gene mutations. Accumulating evidence from several Parkinson's disease cohorts of varying ethnicities suggests that glucocerebrosidase mutations even in the heterozygous state (carriers) may be a susceptibility factor for Parkinson's. Very few studies have analyzed the frequency of Parkinson's in carriers and individuals with Gaucher disease. OBJECTIVE To determine frequency of Parkinson's in patients with Gaucher disease and obligate carriers of glucocerebrosidase mutations and compare it with a control group. METHODS A questionnaire was completed by 100 Ashkenazi Jewish Gaucher patients followed at our center and 109 ethnicity-matched controls with no personal or family history of Gaucher disease. RESULTS Frequency of Parkinson's was higher in Gaucher patients (8/100) than in controls (0/109; P = 0.0024). Frequency of Parkinson's in obligate carriers (11/200) was higher than controls (6/218), but the difference was not statistically significant (P = 0.215). Average age of onset of Parkinson's was earlier in Gaucher patients (57.2) than the general population and in obligate carriers (60) when compared with controls (76.8; P = 0.01). The L444P genotype was more frequent in Gaucher patients who reported a parent with Parkinson's (36.40%) than those who did not (4.50%). CONCLUSION Our study suggests that the risk for developing Parkinson's may be higher in affected versus carriers of glucocerebrosidase mutations and suggests that L444P may pose a higher risk of developing Parkinson's than other mutations. It also confirms previous findings that the age of onset of Parkinson's associated with glucocerebrosidase mutations is earlier than in the general population.
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Affiliation(s)
- Joanna G Becker
- New York University School of Medicine, New York, NY 10016, USA
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29
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Young RJ, Gupta A, Shah AD, Graber JJ, Chan TA, Zhang Z, Shi W, Beal K, Omuro AM. MRI perfusion in determining pseudoprogression in patients with glioblastoma. Clin Imaging 2012; 37:41-9. [PMID: 23151413 DOI: 10.1016/j.clinimag.2012.02.016] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 02/12/2012] [Accepted: 02/16/2012] [Indexed: 11/24/2022]
Abstract
We examine the role of dynamic susceptibility contrast (DSC) magnetic resonance imaging (MRI) perfusion in differentiating pseudoprogression from progression in 20 consecutive patients with treated glioblastoma. MRI perfusion was performed, and relative cerebral blood volume (rCBV), relative peak height (rPH), and percent signal recovery (PSR) were measured. Pseudoprogression demonstrated lower median rCBV (P=.009) and rPH (P<.001), and higher PSR (P=.039) than progression. DSC MRI perfusion successfully identified pseudoprogression in patients who did not require a change in treatment despite radiographic worsening following chemoradiotherapy.
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Affiliation(s)
- Robert J Young
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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30
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Gupta A, Omuro AMP, Shah AD, Graber JJ, Shi W, Zhang Z, Young RJ. Continuing the search for MR imaging biomarkers for MGMT promoter methylation status: conventional and perfusion MRI revisited. Neuroradiology 2011; 54:641-3. [PMID: 22006425 DOI: 10.1007/s00234-011-0970-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 10/07/2011] [Indexed: 11/25/2022]
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Young RJ, Gupta A, Shah AD, Graber JJ, Zhang Z, Shi W, Holodny AI, Omuro AMP. Potential utility of conventional MRI signs in diagnosing pseudoprogression in glioblastoma. Neurology 2011; 76:1918-24. [PMID: 21624991 DOI: 10.1212/wnl.0b013e31821d74e7] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the potential utility of conventional MRI signs in differentiating pseudoprogression (PsP) from early progression (EP). METHODS This retrospective study reviewed initial postradiotherapy MRI scans of 321 patients with glioblastoma undergoing chemotherapy and radiotherapy. A total of 93 patients were found to have new or increased enhancing mass lesions, raising the possibility of PsP. Final diagnosis of PsP or EP was established upon review of surgical specimens from a second resection or by clinical and radiologic follow-up. A total of 11 MRI signs potentially helpful in the differentiation between PsP and EP were examined on the initial post-RT MRI and were correlated with the final diagnosis through χ(2) or Fisher exact test. RESULTS Sixty-three (67.7%) of the 93 patients had EP, of which 22 (34.9%) were diagnosed by pathology. Thirty patients (32.3%) had PsP; 6 (16.7% of the 30) were diagnosed by pathology. Subependymal enhancement was predictive for EP (p = 0.001) with 38.1% sensitivity, 93.3% specificity, and 41.8% negative predictive value. The other 10 signs had no predictive value (p = 0.06-1.0). CONCLUSIONS Conventional MRI signs have limited utility in diagnosing PsP in patients with recently treated glioblastomas and worsening enhancing lesions. We did not find a sign with a high negative predictive value for PsP that would have been the most useful for the clinical physician. When present, subependymal spread of the enhancing lesion is a useful MRI marker in identifying EP rather than PsP.
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Affiliation(s)
- R J Young
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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Abstract
Studies conducted in the 1990s have established that high-dose methotrexate-based chemotherapy added to whole-brain radiotherapy improves survival in primary CNS lymphoma (PCNSL). However, radiotherapy-related delayed neurotoxicity has emerged as a serious complication of chemo-radiotherapy, particularly in the elderly. Unfortunately, omitting radiotherapy results in decreased progression-free survival, and therefore establishing more effective chemotherapy regimens is necessary in order to improve the number of long-term remissions. Recent studies have suggested that a combination of drugs is superior to single-agent methotrexate, but the optimal chemotherapy combination and the role of alternative consolidation treatments such as reduced-dose radiotherapy and high-dose chemotherapy with stem cell rescue remain to be defined. In this article, we review the multiple chemotherapy options reported in newly diagnosed and in progressive/refractory PCNSL, including recently reported and ongoing clinical trials, as well as future perspectives.
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Affiliation(s)
- Jerome J Graber
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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33
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Graber JJ, Dhib-Jalbut S. Biomarkers of disease activity in multiple sclerosis. J Neurol Sci 2011; 305:1-10. [DOI: 10.1016/j.jns.2011.03.026] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Revised: 02/25/2011] [Accepted: 03/01/2011] [Indexed: 12/15/2022]
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Graber JJ, Nayar A, Zagzag D. Metastatic cerebral malignant fibrous histiocytoma masquerading as neurocysticercosis. J Neurooncol 2011; 105:437-9. [PMID: 21544703 DOI: 10.1007/s11060-011-0583-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 04/08/2011] [Indexed: 11/25/2022]
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Abstract
Contemporary cancer research has led to unparalleled advances in therapeutics and improved survival. Even as treatment options continue to improve, quality of life should remain a priority. Headache drastically impacts the quality of life of patients with cancer and has a wide etiological scope, making diagnosis a challenge. Intracranial mass lesions are only one cause; others include extracranial tumors, paraneoplastic processes, and the consequences of diagnostic and therapeutic interventions used in cancer care. Fortunately, cancer-related headache is treatable, but a sound understanding of the variable etiologies is crucial to appropriate diagnostic evaluation and treatment. In this review, we highlight the important causes of headache in the patient with cancer, and consider the epidemiology, pathophysiology, clinical course, and treatment options for each.
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Affiliation(s)
- Samuel A Goldlust
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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36
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Graber JJ, Sherman FT, Kaufmann H, Kolodny EH, Sathe S. Vitamin B12-responsive severe leukoencephalopathy and autonomic dysfunction in a patient with "normal" serum B12 levels. J Neurol Neurosurg Psychiatry 2010; 81:1369-71. [PMID: 20587489 DOI: 10.1136/jnnp.2009.178657] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Leukoencephalopathy and autonomic dysfunction have been described in individuals with very low serum B(12) levels (<200 pg/ml), in addition to psychiatric changes, neuropathy, dementia and subacute combined degeneration. Elevated homocysteine and methylmalonic acid levels are considered more sensitive and specific for evaluating truly functional B(12) deficiency. A previously healthy 62-year-old woman developed depression and cognitive deficits with autonomic dysfunction that progressed over the course of 5 years. The patient had progressive, severe leukoencephalopathy on multiple MRI scans over 5 years. Serum B(12) levels ranged from 267 to 447 pg/ml. Homocysteine and methylmalonic acid levels were normal. Testing for antibody to intrinsic factor was positive, consistent with pernicious anaemia. After treatment with intramuscular B(12) injections (1000 μg daily for 1 week, weekly for 6 weeks, then monthly), she made a remarkable clinical recovery but remained amnesic for major events of the last 5 years. Repeat MRI showed partial resolution of white matter changes. Serum B(12), homocysteine and methylmalonic acid levels are unreliable predictors of B(12)-responsive neurologic disorders, and should be thoroughly investigated and presumptively treated in patients with unexplained leukoencephalopathy because even long-standing deficits may be reversible.
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Affiliation(s)
- J J Graber
- Department of Neuro-oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Graber JJ, Lau H, Sathe S. Teaching NeuroImages: Molar tooth sign with hypotonia, ataxia, and nystagmus (Joubert syndrome) and hypothyroidism. Neurology 2009; 73:e106. [PMID: 20018634 DOI: 10.1212/wnl.0b013e3181c679ba] [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: 11/15/2022] Open
Affiliation(s)
- Jerome J Graber
- Department of Neurology, New York University School of Medicine, New York 10016, USA
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Abstract
Acquired cerebellar tonsillar herniation is a known complication of lumboperitoneal shunt (LPS) for any indication, including idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri.(1) While the underlying pathophysiology of IIH remains unknown, increasing body mass index is a clear risk factor for the development of IIH. We describe an obese patient with IIH unresponsive to LPS who developed symptoms of intracranial hypotension and cerebellar tonsillar herniation after bariatric surgery and a 50-kg weight loss.
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Affiliation(s)
- Jerome J Graber
- NYU School of Medicine, Department of Neurology, Bellevue Hospital Center (BH), New York, NY, USA
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40
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Affiliation(s)
- Jerome J Graber
- Department of Neurology, New York University School of Medicine, NBV7W11, 462 First Avenue, New York, NY 10016, USA.
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Affiliation(s)
- Jerome J Graber
- Department of Neurology, New York University, Bellevue Hospital Center, 462 First Ave, Ste NBV7W11, New York, NY 10016, USA.
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Abstract
The immune system can play both detrimental and beneficial roles in the nervous system. Multiple arms of the immune system, including T cells, B cells, NK cells, mast cells, macrophages, dendritic cells, microglia, antibodies, complement and cytokines participate in limiting damage to the nervous system during toxic, ischemic, hemorrhagic, infective, degenerative, metabolic and immune-mediated insults and also assist in the process of repair after injury has occurred. Immune cells have been shown to produce neurotrophic growth factors and interact with neurons and glial cells to preserve them from injury and stimulate growth and repair. The immune system also appears to participate in proliferation of neural progenitor stem cells and their migration to sites of injury. Neural stem cells can also modify the immune response in the central and peripheral nervous system to enhance neuroprotective effects. Evidence for protective and reparative functions of the immune system has been found in diverse neurologic diseases including traumatic injury, ischemic and hemorrhagic stroke, multiple sclerosis, infection, and neurodegenerative diseases (Alzheimer's disease, Parkinson's disease and amyotrophic lateral sclerosis). Existing therapies including glatiramer acetate, interferon-beta and immunoglobulin have been shown to augment the protective and regenerative aspects of the immune system in humans, and other experimental interventions such as vaccination, minocycline, antibodies and neural stem cells, have shown promise in animal models of disease. The beneficent aspects of the immune response in the nervous system are beginning to be appreciated and their potential as pharmacologic targets in neurologic disease is being explored.
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Affiliation(s)
- Jerome J Graber
- New York University School of Medicine, Department of Neurology, New York, NY, USA
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Rueff L, Graber JJ, Bernbaum M, Kuzniecky RI. Voltage-gated potassium channel antibody-mediated syndromes: a spectrum of clinical manifestations. Rev Neurol Dis 2008; 5:65-72. [PMID: 18660738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Immune-related neurologic disorders have long been recognized. A number of specific targets have been identified, including neurons, Purkinje cells, and pre- and postsynaptic receptors. Over the past decade, antibodies against voltage-gated potassium channels (VGKCs) have been reported in a number of neurologic syndromes, such as neuromyotonia, limbic encephalitis, and Morvan's syndrome. Recent advances have supported the pathologic mechanism of VGKC in these disorders, their response to therapy, and the possible mechanisms of peripheral, central, and autonomic dysfunctions seen in these disorders. We present a patient with 1 of these syndromes and review the literature of these disorders.
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Affiliation(s)
- Laura Rueff
- Department of Neurology and Comprehensive Epilepsy Center, New York University School of Medicine, New York, NY, USA
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Graber JJ, Ford D, Zhan M, Francis G, Panitch H, Dhib-Jalbut S. Cytokine changes during interferon-beta therapy in multiple sclerosis: correlations with interferon dose and MRI response. J Neuroimmunol 2007; 185:168-74. [PMID: 17328965 PMCID: PMC1894687 DOI: 10.1016/j.jneuroim.2007.01.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [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: 11/27/2006] [Revised: 01/22/2007] [Accepted: 01/22/2007] [Indexed: 02/04/2023]
Abstract
We investigated serum (IL-10 and IL-12p70) and cellular cytokine levels (IL-10, IL-12p40, IL-12p70, IFN-gamma) in stimulated PBMC over 24 weeks in 15 relapsing-remitting multiple sclerosis (MS) patients randomized to receive once-weekly (qw) IFN-beta-1a 30 microg intramuscularly (IM) (n=8) or three-times-weekly (tiw) IFN-beta-1a 44 microg subcutaneously (SC) (n=7). Overall, IFN-beta treatment increased cellular IL-10 (p<0.01) levels and the ratios of cellular IL-10/IL-12p40 (p<0.01) and IL-10/IL-12p70 (p<0.02) while cellular IFN-gamma levels were reduced (p<0.01). Serum IL-10 levels were decreased in non-responders to therapy based on MRI-defined criteria (p<0.01) but did not change in responders over the course of treatment. In addition, non-responders demonstrated a decrease in serum IL-10/IL-12p70 ratio (p=0.031) and a decrease in cellular IL-12p70 (p<0.02). A decrease in cellular IFN-gamma was observed in responders (p=0.013). This is the first study that compares cytokine changes between the two IFN-beta regimes and demonstrates that serum IL-10 levels decrease in those patients who continue to have active MRI lesions while on interferon-beta therapy.
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Affiliation(s)
- Jerome J Graber
- University of Maryland School of Medicine, Department of Neurology, MD, USA
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Abstract
BACKGROUND/PURPOSE Infants with very low birth weight are at increased risk for both intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC). IVH often progresses in severity after initial diagnosis and causes severe neurological morbidity and mortality. The authors examined the role of NEC in the progression of IVH in these infants. METHODS The authors conducted a retrospective case-control study using data from the University of Maryland neonatal intensive care unit database between 1991 and 2003. From a cohort of 957 infants with very low birth weight, 53 pairs of infants labeled as IVH progression versus controls were selected and closely matched in respect to their gestational age and birth weight. Charts from these infants were reviewed to identify risk factors contributing to IVH progression. RESULTS Infants with IVH progression were significantly more likely to suffer from NEC (odds ratio, 3.6), whereas infants with surgical NEC showed a greater association with IVH progression (odds ratio, 5.33). Association with thrombocytopenia was also seen (odds ratio, 3.33). Sepsis showed trend toward significance (odds ratio, 1.9; P = .095) for progression of IVH. CONCLUSION Surgical NEC showed the greatest risk for IVH progression. NEC and thrombocytopenia also appear to be risk factors for IVH progression.
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Affiliation(s)
- Howard C Jen
- Division of Pediatric Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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