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Matsuda R, Maeoka R, Tokuda N, Nakazawa T, Morimoto T, Kotsugi M, Takeshima Y, Tamura K, Yamada S, Nishimura F, Nakagawa I, Park YS, Nakase H. Intraoperative Ventricular Opening has No Effect on Complication Development Following BCNU Wafer Implantation for Malignant Glioma. World Neurosurg 2023; 171:e707-13. [PMID: 36574919 DOI: 10.1016/j.wneu.2022.12.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the safety profile of bis-chloroethyl-nitrosourea (BCNU) wafer implantation after malignant glioma resection with or without ventricular opening (VO). METHODS This single-center retrospective study included 66 consecutive patients with BCNU wafer implantation after malignant glioma resection between March 2013 and August 2021. The patients were categorized into 2 groups based on whether VO occurred during the malignant glioma resection. Fifty-eight patients had glioblastoma, and 8 had anaplastic astrocytoma or oligodendroglioma. Forty-eight patients underwent an initial treatment, and 18 underwent recurrent surgeries. Infection, hydrocephalus, subcutaneous fluid collection, chronic subdural hematoma, early seizure after surgery within 1 month, symptomatic edema surrounding the resected cavity, cyst formation, and postoperative hemorrhage were defined as adverse events (AEs). RESULTS Thirty-three patients underwent resection with VO, and 33 without. The median survival time was 28 months in the initial treatment group and 11.5 months in the recurrent treatment group. The with and without VO groups had similar median survival times. Postoperative AEs occurred in 7/33 patients (21.2%) with VO and 10/33 (30.3%) without VO, with no difference between them (P = 0.574). CONCLUSIONS This study showed that VO during surgery with BCNU wafer implantation might not influence the occurrence of postoperative AEs. If VO happens, BCNU wafer implantation can be performed safely with accurate closing of the ventricle.
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Waqar M, Trifiletti DM, McBain C, O'Connor J, Coope DJ, Akkari L, Quinones-Hinojosa A, Borst GR. Early Therapeutic Interventions for Newly Diagnosed Glioblastoma: Rationale and Review of the Literature. Curr Oncol Rep 2022; 24:311-324. [PMID: 35119629 PMCID: PMC8885508 DOI: 10.1007/s11912-021-01157-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Glioblastoma is the commonest primary brain cancer in adults whose outcomes are amongst the worst of any cancer. The current treatment pathway comprises surgery and postoperative chemoradiotherapy though unresectable diffusely infiltrative tumour cells remain untreated for several weeks post-diagnosis. Intratumoural heterogeneity combined with increased hypoxia in the postoperative tumour microenvironment potentially decreases the efficacy of adjuvant interventions and fails to prevent early postoperative regrowth, called rapid early progression (REP). In this review, we discuss the clinical implications and biological foundations of post-surgery REP. Subsequently, clinical interventions potentially targeting this phenomenon are reviewed systematically. RECENT FINDINGS Early interventions include early systemic chemotherapy, neoadjuvant immunotherapy, local therapies delivered during surgery (including Gliadel wafers, nanoparticles and stem cell therapy) and several radiotherapy techniques. We critically appraise and compare these strategies in terms of their efficacy, toxicity, challenges and potential to prolong survival. Finally, we discuss the most promising strategies that could benefit future glioblastoma patients. There is biological rationale to suggest that early interventions could improve the outcome of glioblastoma patients and they should be investigated in future trials.
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Affiliation(s)
- Mueez Waqar
- Department of Academic Neurological Surgery, Geoffrey Jefferson Brain Research Centre, Salford Royal Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health and Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Mayo 1N, Jacksonville, FL, 32224, USA
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Catherine McBain
- Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Dept 58, Floor 2a, Room 21-2-13, Wilmslow Road, Manchester, M20 4BX, UK
| | - James O'Connor
- Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Dept 58, Floor 2a, Room 21-2-13, Wilmslow Road, Manchester, M20 4BX, UK
| | - David J Coope
- Department of Academic Neurological Surgery, Geoffrey Jefferson Brain Research Centre, Salford Royal Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health and Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| | - Leila Akkari
- Division of Tumour Biology and Immunology, The Netherlands Cancer Institute, Oncode Institute, Amsterdam, The Netherlands
| | - Alfredo Quinones-Hinojosa
- Department of Radiation Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Mayo 1N, Jacksonville, FL, 32224, USA
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Gerben R Borst
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health and Manchester Cancer Research Centre, University of Manchester, Manchester, UK.
- Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Dept 58, Floor 2a, Room 21-2-13, Wilmslow Road, Manchester, M20 4BX, UK.
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Shibahara I, Miyasaka K, Sekiguchi A, Ishiyama H, Inukai M, Yasui Y, Watanabe T, Sato S, Hide T, Kumabe T. Long-term follow-up after BCNU wafer implantation in patients with newly diagnosed glioblastoma. J Clin Neurosci 2021; 86:202-210. [PMID: 33775329 DOI: 10.1016/j.jocn.2021.01.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 01/17/2021] [Accepted: 01/23/2021] [Indexed: 12/12/2022]
Abstract
1,3-Bis(2-chloroethyl)-1-nitrosourea (BCNU, or Carmustine) wafers are intraoperatively implantable wafers used to achieve local tumor control. There is scarce data about the behavior of wafers in the long-term follow-up of implanted cases. We reviewed the data of 64 patients with newly diagnosed glioblastoma treated by surgery, BCNU wafers, radiation therapy, and temozolomide administration. This cohort included 55 patients who presented first recurrence, and 49 of them showed tumor progression to death. The MR imaging of each patient at the terminal stage and an autopsy case were used to elucidate the tumor progression pattern after the wafer implantation. We subdivided the first recurrence pattern into local, distant, and multifocal based on MR imaging or into infield, outfield, and marginal based on the radiation field. The first recurrence pattern was 33 patients (60%) with local, 13 (24%) with distant, and nine (16%) with multifocal recurrence, or 38 patients (69%) with infield, 13 (24%) with outfield, and four (7%) with marginal. The median and mean time intervals between MR imaging at the terminal stage and death were 2.0 and 2.3 months, respectively. Of note, 13 patients with first distant recurrence had no obvious radiological local tumor progression even at the terminal stage. Long-term follow-up after BCNU wafer implantation revealed that patients with first distant recurrence had long-lasting local tumor control until the terminal stage.
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Affiliation(s)
- Ichiyo Shibahara
- Departments of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan.
| | - Kazuhiro Miyasaka
- Departments of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Akane Sekiguchi
- Radiology and Radiation Oncology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Hiromichi Ishiyama
- Radiology and Radiation Oncology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Madoka Inukai
- Departments of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan; Pathology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Yoshie Yasui
- Departments of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Takashi Watanabe
- Department of General Internal Medicine, JCHO Sendai Hospital, Sendai, Miyagi, Japan
| | - Sumito Sato
- Departments of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Takuichiro Hide
- Departments of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Toshihiro Kumabe
- Departments of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
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Salle F, Lahiani W, Spagnuolo E, Palfi S. Adverse Event with the Use of Carmustine Wafers and Postoperative Radiochemotherapy for the Treatment of High-grade Glioma. Asian J Neurosurg 2018; 13:1171-1174. [PMID: 30459887 PMCID: PMC6208266 DOI: 10.4103/ajns.ajns_235_16] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Randomized, controlled trials have shown significant improvement of survival after implantation of 1,3-bis(2-Chloroethyl)-1-nitrosourea (BCNU) wafers for patients suffering from high-grade glioma. A combination of local chemotherapy with BCNU and concomitant radiochemotherapy with temozolomide (TMZ) appears to be attractive to enhance the overall survival, even though these treatments may potentially cumulate their toxicity. We report a clinical case of a patient submitted to this combined treatment protocol. Severe brain edema and a cystic formation in the surgical cavity rapidly developed. Data supporting the use of Gliadel® combined with TMZ comes from small retrospective studies, and some series have shown a very high rate of adverse events (AEs) when this multimodality treatment is applied. Combined protocols of local and systemic chemotherapy might provide survival benefits, although AEs seem currently underestimated.
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Affiliation(s)
- Federico Salle
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Henri-Mondor Albert-Chenevier, PePsy Department, F-94010 Créteil, France.,U955 INSERM IMRB eq. 14 Université Paris 12 UPEC, Faculté de Médecine, F-94010 Créteil, France.,Department of Neurosurgery, Hospital Maciel-ASSE, Montevideo, Uruguay
| | - Wissem Lahiani
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Henri-Mondor Albert-Chenevier, PePsy Department, F-94010 Créteil, France
| | - Edgardo Spagnuolo
- Department of Neurosurgery, Hospital Maciel-ASSE, Montevideo, Uruguay
| | - Stéphane Palfi
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Henri-Mondor Albert-Chenevier, PePsy Department, F-94010 Créteil, France.,U955 INSERM IMRB eq. 14 Université Paris 12 UPEC, Faculté de Médecine, F-94010 Créteil, France
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Doishita S, Shimono T, Yoneda T, Yamada E, Tsukamoto T, Takemori D, Kimura D, Tatekawa H, Sakamoto S, Miki Y. In vitro Study of Serial Changes to Carmustine Wafers ( Gliadel) with MR Imaging and Computed Tomography. Magn Reson Med Sci 2017; 17:58-66. [PMID: 28867760 PMCID: PMC5760234 DOI: 10.2463/mrms.mp.2017-0035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Implantation of carmustine wafers (Gliadel) in vivo is accompanied by characteristic serial changes on MRI and CT, such as transient hyperintensity of the wafers on T1-weighted images (T1WIs) and considerable gas accumulation in surgical resection cavities. The purpose of this study was to evaluate intrinsic imaging changes to carmustine wafers in vitro. METHODS Three phantoms simulating a surgical resection cavity were constructed. Each contained either a carmustine wafer fixed with oxidized regenerated cellulose and fibrin sealant, an unfixed carmustine wafer, or a fixed polyethylene control disk, immersed in phosphate-buffered saline. Image acquisition of the phantoms was performed on MRI and CT until 182 days after construction. The radiological appearances of the object in each phantom were assessed by visual evaluation and quantification of the region of interest. The volume of gas around the objects at 24 h after constructing the phantoms was also measured. RESULTS The carmustine wafers showed low signal intensities on T1WIs and T2-weighted images (T2WIs), and high densities on CT images at 24 h. The signal intensities and CT densities gradually approximated those of saline over a period of months. However, the carmustine wafers never showed hyperintensity on T1WIs in vitro. The fixed carmustine wafer showed slower radiological changes, as compared to the unfixed wafer. The gas volume around the fixed carmustine wafer was greater than that around the fixed control disk. CONCLUSION Changes to the carmustine wafers probably reflected penetration of fluid inside and degradation of the hydrophobic matrix. Reported transient hyperintensity of wafers on T1WIs in vivo is regarded as the result of biological reactions, whereas the initial production of gas is considered as an intrinsic characteristic of wafers.
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Affiliation(s)
- Satoshi Doishita
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine
| | - Taro Shimono
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine
| | - Tetsuya Yoneda
- Department of Medical Physics in Advanced Biomedical Sciences, Faculty of Life Sciences, Kumamoto University
| | - Eiji Yamada
- Department of Radiological Technology, Osaka City University Hospital
| | - Taro Tsukamoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine
| | - Daichi Takemori
- Department of Radiological Technology, Osaka City University Hospital
| | - Daisuke Kimura
- Department of Radiological Technology, Osaka City University Hospital
| | - Hiroyuki Tatekawa
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine
| | - Shinichi Sakamoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine
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Ene CI, Nerva JD, Morton RP, Barkley AS, Barber JK, Ko AL, Silbergeld DL. Safety and efficacy of carmustine (BCNU) wafers for metastatic brain tumors. Surg Neurol Int 2016; 7:S295-9. [PMID: 27217968 PMCID: PMC4866053 DOI: 10.4103/2152-7806.181987] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 02/22/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Carmustine (BCNU) wafers (Gliadel) prolongs local disease control and progression-free survival (PFS) in patients with malignant gliomas. However, in metastatic brain tumors, there is a paucity of evidence in support of its safety and efficacy. The goal of this study was to assess the safety and efficacy of Gliadel wafers in patients with metastatic brain tumors. METHODS We retrospectively reviewed the University of Washington experience with Gliadel wafers for metastatic brain tumors between 2000 and 2015. RESULTS Gliadel wafers were used in 14 patients with metastatic brain tumors during the period reviewed. There were no postoperative seizures, strokes, or hemorrhages. There was one postoperative wound infection necessitating return to the operating room. The mean time to tumor progression (n = 7) and death (n = 5) after Gliadel wafer implantation was 2.5 and 2.9 years, respectively. Age was the only variable affecting PFS in patients receiving Gliadel wafers. Patients <53 years old (n = 7) had a PFS of 0.52 years, whereas patients >53 years old (n = 7) had a PFS of 4.29 years (P = 0.02). There was no significant difference in PFS in relation to presenting Karnofsky Performance Status (P = 0.26), number of brain metastasis (P = 0.82), tumor volume (P = 0.54), prior surgery (P = 0.57), or prior radiation (P = 0.41). There were no significant differences in the mean survival in relationship to any variable including age. CONCLUSIONS BCNU wafers are a safe and a potentially efficacious adjunct to surgery and radiation for improving local disease control in metastatic brain tumors. Larger studies, however, are needed to examine overall efficacy and tumor specific efficacy.
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Affiliation(s)
- Chibawanye I Ene
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - John D Nerva
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Ryan P Morton
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Ariana S Barkley
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Jason K Barber
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Andrew L Ko
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Daniel L Silbergeld
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
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Abstract
Glioblastoma (GBM) is the most common primary brain tumor and carries a grave prognosis. Despite years of research investigating potentially new therapies for GBM, the median survival rate of individuals with this disease has remained fairly stagnant. Delivery of drugs to the tumor site is hampered by various barriers posed by the GBM pathological process and by the complex physiology of the blood-brain and blood-cerebrospinal fluid barriers. These anatomical and physiological barriers serve as a natural protection for the brain and preserve brain homeostasis, but they also have significantly limited the reach of intraparenchymal treatments in patients with GBM. In this article, the authors review the functional capabilities of the physical and physiological barriers that impede chemotherapy for GBM, with a specific focus on the pathological alterations of the blood-brain barrier (BBB) in this disease. They also provide an overview of current and future methods for circumventing these barriers in therapeutic interventions. Although ongoing research has yielded some potential options for future GBM therapies, delivery of chemotherapy medications across the BBB remains elusive and has limited the efficacy of these medications.
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Affiliation(s)
- Benjamin K Hendricks
- Goodman Campbell Brain and Spine, Indiana University Department of Neurological Surgery; and
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Grossman R, Burger P, Soudry E, Tyler B, Chaichana KL, Weingart J, Olivi A, Gallia GL, Sidransky D, Quiñones-Hinojosa A, Ye X, Brem H. MGMT inactivation and clinical response in newly diagnosed GBM patients treated with Gliadel. J Clin Neurosci 2015; 22:1938-42. [PMID: 26249244 DOI: 10.1016/j.jocn.2015.07.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 07/01/2015] [Indexed: 11/17/2022]
Abstract
We examined the relationship between the O(6)-methylguanine-methyltransferase (MGMT) methylation status and clinical outcomes in newly diagnosed glioblastoma multiforme (GBM) patients who were treated with Gliadel wafers (Eisai, Tokyo, Japan). MGMT promoter methylation has been associated with increased survival among patients with GBM who are treated with various alkylating agents. MGMT promoter methylation, in DNA from 122 of 160 newly diagnosed GBM patients treated with Gliadel, was determined by a quantitative methylation-specific polymerase chain reaction, and was correlated with overall survival (OS) and recurrence-free survival (RFS). The MGMT promoter was methylated in 40 (32.7%) of 122 patients. The median OS was 13.5 months (95% confidence interval [CI] 11.0-14.5) and RFS was 9.4 months (95% CI 7.8-10.2). After adjusting for age, Karnofsky performance score, extent of resection, temozolomide (TMZ) and radiation therapy (RT), the newly diagnosed GBM patients with MGMT methylation had a 15% reduced mortality risk, compared to patients with unmethylated MGMT (hazard ratio 0.85; 95% CI 0.56-1.31; p=0.46). The patients aged over 70 years with MGMT methylation had a significantly longer median OS of 13.5 months, compared to 7.6 months in patients with unmethylated MGMT (p=0.027). A significant difference was also found in older patients, with a median RFS of 13.1 versus 7.6 months for methylated and unmethylated MGMT groups, respectively (p=0.01). Methylation of the MGMT promoter in newly diagnosed GBM patients treated with Gliadel, RT and TMZ, was associated with significantly improved OS compared to the unmethylated population. In elderly patients, methylation of the MGMT promoter was associated with significantly better OS and RFS.
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Affiliation(s)
- Rachel Grossman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Peter Burger
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Ethan Soudry
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Betty Tyler
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States.
| | - Kaisorn L Chaichana
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Jon Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Alessandro Olivi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - David Sidransky
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Alfredo Quiñones-Hinojosa
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Xiaobu Ye
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Henry Brem
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States; Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States; Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
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9
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Abstract
Question What is the safety and efficacy of interstitial chemotherapy with carmustine-loaded polymers (Gliadel wafers: MGI Pharma, Bloomington, MN, U.S.A.) in the treatment of newly diagnosed or recurrent malignant glioma (that is, glioblastoma multiforme, anaplastic astrocytoma, anaplastic oligoastrocytoma, and anaplastic oligodendroglioma)? Perspectives Malignant glioma is the most common type of primary brain tumour in adults. In general, efficacy of systemic therapy in this patient population has been disappointing, and novel treatment approaches are needed. Because several randomized controlled trials (rcts) investigating the safety and efficacy of Gliadel are available, the Neuro-oncology Disease Site Group of Cancer Care Ontario’s Program in Evidence-Based Care decided that a systematic review of the evidence was necessary. Outcomes The outcomes of interest for this review were overall survival, adverse events, and quality of life. Methodology Systematic searches of the medline, embase, and Cochrane Library databases were conducted for relevant evidence. Fully-published reports of rcts comparing treatment with Gliadel wafers to placebo or alternative treatment were selected for inclusion. Prospective cohort studies were also included. Results Two rcts that compared Gliadel to placebo in patients with newly diagnosed malignant glioma were obtained. Both rcts reported a significant survival benefit for patients who received Gliadel as compared with patients in the control group. One rct and one prospective cohort study were obtained that examined the role of Gliadel in patients with recurrent malignant glioma. The rct demonstrated a significant survival benefit for Gliadel only after adjustment for prognostic factors, and the prospective cohort study reported no survival benefit for Gliadel as compared with a historical control group. All three rcts reported similar rates of adverse events in the treatment and control groups. The most frequently reported adverse events were convulsions, confusion, brain edema, infection, hemiparesis, aphasia, and visual field defects. Conclusions Gliadel is an option for selected patients with newly diagnosed malignant glioma where a near gross total resection is possible. No evidence is available comparing Gliadel with systemic therapy, and a decision to combine Gliadel with systemic therapy should be made for patients individually. The patient population that would benefit from Gliadel (age, histology, and performance status) is unclear; further investigation is needed. Gliadel is also an option for patients with surgically resectable recurrent malignant glioma.
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Affiliation(s)
- J Perry
- Toronto-Sunnybrook Regional Cancer Centre, Toronto, Ontario
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