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Schwarz SB, Thon N, Nikolajek K, Niyazi M, Tonn JC, Belka C, Kreth FW. Iodine-125 brachytherapy for brain tumours--a review. Radiat Oncol 2012; 7:30. [PMID: 22394548 PMCID: PMC3354996 DOI: 10.1186/1748-717x-7-30] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 03/06/2012] [Indexed: 11/10/2022] Open
Abstract
Iodine-125 brachytherapy has been applied to brain tumours since 1979. Even though the physical and biological characteristics make these implants particularly attractive for minimal invasive treatment, the place for stereotactic brachytherapy is still poorly defined.An extensive review of the literature has been performed, especially concerning indications, results and complications. Iodine-125 seeds have been implanted in astrocytomas I-III, glioblastomas, metastases and several other tumour entities. Outcome data given in the literature are summarized. Complications are rare in carefully selected patients.All in all, for highly selected patients with newly diagnosed or recurrent primary or metastatic tumours, this method provides encouraging survival rates with relatively low complication rates and a good quality of life.
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Affiliation(s)
- Silke B Schwarz
- Department of Radiation Oncology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Niklas Thon
- Department of Neurosurgery, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Katharina Nikolajek
- Department of Radiation Oncology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Joerg-Christian Tonn
- Department of Neurosurgery, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Friedrich-Wilhelm Kreth
- Department of Neurosurgery, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
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Niyazi M, Söhn M, Schwarz SB, Lang P, Belka C, Ganswindt U. Radiation treatment parameters for re-irradiation of malignant glioma. Strahlenther Onkol 2012; 188:328-33. [PMID: 22349710 DOI: 10.1007/s00066-011-0055-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Accepted: 10/20/2011] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Most patients with malignant glioma ultimately fail locally or loco-regionally after the first treatment, with re-irradiation being a reasonable treatment option. However, only limited data are presently available allowing for a precise selection of patients suitable for re-treatment with regard to safety and efficacy. MATERIAL AND METHODS Using the department database, 39 patients with a second course of radiation were identified. Doses to gross tumor volume (GTV), planning target volume (PTV), and relevant organs at risk (OARs; brainstem, optic chiasm, optic nerves, brain) were retrospectively analyzed and correlated to outcome parameters. Relevant treatment parameters including D(max), D(min), D(mean), and volume (ml) were obtained. Equivalent uniform dose (EUD) values were calculated for the tumor and OARs. To address the issue of radiation necrosis/leukoencephalopathy posttherapeutic MRI images were routinely examined every 3 months. RESULTS Median follow-up was 147 days. The time interval between first and second irradiation was regularly greater than 6 months. Median EUDs to the OARs were 11.9 Gy (range 0.7-27.4 Gy) to the optic chiasm, 17.6 Gy (range 0.7-43.0 Gy) to the brainstem, 4.9/2.1 Gy (range 0.3-24.5 Gy) to the right/left optic nerve, and 29.4 Gy (range 25.2-32.5 Gy) to the brain. No correlation between treated volume and survival was observed. Cold spots and dose did not correlate with survival. Re-irradiated volumes were treated with on average lower doses if they were larger and vice versa. CONCLUSION In general, re-irradiation is a safe and feasible re-treatment option. No relevant toxicity was observed after re-irradiation in our patient cohort during follow-up. In this regard, this analysis provides baseline data for the selection of putative patients. EUD values are derived and may serve as reference for further studies, including intensity-modulated radiotherapy (IMRT) protocols.
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Affiliation(s)
- M Niyazi
- Department of Radiation Oncology, Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany.
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Niyazi M, Ganswindt U, Schwarz SB, Kreth FW, Tonn JC, Geisler J, la Fougère C, Ertl L, Linn J, Siefert A, Belka C. Irradiation and Bevacizumab in High-Grade Glioma Retreatment Settings. Int J Radiat Oncol Biol Phys 2012; 82:67-76. [DOI: 10.1016/j.ijrobp.2010.09.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Revised: 09/09/2010] [Accepted: 09/15/2010] [Indexed: 02/06/2023]
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Reirradiation of relapsed brain tumors in children. Rep Pract Oncol Radiother 2011; 17:32-7. [PMID: 24376994 DOI: 10.1016/j.rpor.2011.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 09/06/2011] [Accepted: 10/07/2011] [Indexed: 11/21/2022] Open
Abstract
AIM The aim of this study was to evaluate toxicity and response to fractionated reirradiation (FR) of relapsed primary brain tumors in children. BACKGROUND The treatment options for recurrent brain tumors in children previously irradiated are limited. Reirradiation is performed with fear due to the cumulative late CNS toxicity and the lack of a significant chance of cure. MATERIALS AND METHODS Between 2008 and 2009, eight children with a median age of 14.5 years with a diagnosis of a recurrent brain tumor underwent reirradiation. Initially, all patients were treated with surgery, chemotherapy and radiotherapy. The median time to the first recurrence after the initial treatment was 19.5 months. Intervals between radiotherapy courses were in the range of 5-51 mos. All retreatments were carried out with 3D image-based conformal methods. The total prescription dose was 40 Gy in a fraction of 5 × 2 Gy/week. The total cumulative dose ranged from 65 to 95 Gy (median: 75 Gy). The median cumulative biologically effective dose was 144 Gy (range: 126-181 Gy). RESULTS The median overall survival and progression free survival measured from the beginning of reirradiation was 17.5 and 6.5 months, respectively. During the first evaluation, four patients showed a complete or partial response, two did not respond radiologically. Two children were progressive at the time of reirradiation. Among children with progression that occurred during the first year after reirradiation, only two progressed in the treatment area. The repeated irradiation was well tolerated by all patients. No late complications have been observed. CONCLUSION In the absence of other treatment possibilities, the fractionated reirradiation with highly conformal three-dimensional planning could be a therapeutic choice in case of recurrent brain tumors in children. The control of craniospinal dissemination remains to be the main problem.
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Geletneky K, Hartkopf AD, Krempien R, Rommelaere J, Schlehofer JR. Therapeutic implications of the enhanced short and long-term cytotoxicity of radiation treatment followed by oncolytic parvovirus H-1 infection in high-grade glioma cells. Bioeng Bugs 2011; 1:429-33. [PMID: 21468212 DOI: 10.4161/bbug.1.6.12943] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2010] [Revised: 07/03/2010] [Accepted: 07/09/2010] [Indexed: 11/19/2022] Open
Abstract
The prognosis of malignant brain tumors remains extremely bad in spite of moderate improvements of conventional treatments. A promising alternative approach is the use of oncolytic viruses. Strategies to improve viral toxicity include the combination of oncolytic viruses with standard therapies. Parvovirus H-1 (H-1PV) is an oncolytic virus with proven toxicity in glioma cells. Recently it has been demonstrated that the combination of ionizing radiation (IR) with H-1PV showed promising results. Previously irradiated glioma cells remained fully permissive for H-1PV induced cytotoxicity supporting the use of H-1PV for recurrent gliomas, which typically arise from irradiated cell clones. When glioma cells were infected with H-1PV shortly (24 h) after IR, cell killing improved and only the combination of both treatments lead to complete long-term tumor cell killing. The latter finding raises the question whether IR in combination with H-1PV exerts an additional therapeutic effect on highly resistant glioma stem cells. A likely translation into current clinical treatment protocols is to use stereotactic radiation of non-resectable recurrent gliomas followed by intratumoral injection of H-1PV to harvest the synergistic effects of combination treatment.
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Affiliation(s)
- Karsten Geletneky
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany.
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Abstract
OPINION STATEMENT Opinions vary on the best treatment options for recurrent high-grade glioma. Some argue that bevacizumab should become standard of care for patients with recurrent glioblastoma, especially in light of recent FDA approval for this indication. However, this opinion is not uniformly accepted. Age, performance status, histology, tumor size and location, O6-methylguanine-DNA methyltransferase (MGMT) methylation status for glioblastoma, 1p/19q status for oligodendroglial tumors, and the number and types of prior therapies are important considerations. In addition, recurrent disease must be distinguished from "pseudoprogression" due to treatment effects. Enrollment in a clinical trial is the optimal choice for most patients with recurrent high-grade glioma after failure of radiation therapy and temozolomide. For patients who are ineligible or do not have access to clinical trials, then either bevacizumab monotherapy or bevacizumab in combination with a second agent such as irinotecan is recommended. Involved-field external beam radiation should be considered for patients with anaplastic gliomas who have not received radiation. For patients with anaplastic astrocytoma who progress after radiotherapy, temozolomide may be used. For patients with anaplastic oligodendroglioma who progress after radiotherapy, PCV chemotherapy and temozolomide are options. Oligodendroglial tumors with 1p/19q deletions are more likely to respond to treatment. In the past, carmustine was commonly used to treat recurrent high-grade glioma, but the utility of carmustine in the modern era is unknown because most studies were performed prior to the widespread use of temozolomide. High-precision re-irradiation such as stereotactic radiosurgery is another option in high-grade glioma, especially for patients with poor bone marrow reserve or inability to tolerate chemotherapy, but there is a paucity of studies with adequate controls. Surgery may be useful as adjuvant treatment for patients with symptoms due to mass effect or for patients requiring definitive histopathology, but it generally should be combined with another treatment modality. Emerging therapies, including dose-intense temozolomide regimens, targeted molecular inhibitors, other antiangiogenic therapies, viral gene therapies, immunotherapies, and convection-enhanced delivery of targeted immunotoxins, are still under investigation.
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Affiliation(s)
- Eudocia C Quant
- Center for Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center, SW430B, 44 Binney Street, Boston, MA, 02115, USA,
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Combs SE, Kalbe A, Nikoghosyan A, Ackermann B, Jäkel O, Haberer T, Debus J. Carbon ion radiotherapy performed as re-irradiation using active beam delivery in patients with tumors of the brain, skull base and sacral region. Radiother Oncol 2010; 98:63-7. [PMID: 21112107 DOI: 10.1016/j.radonc.2010.10.010] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Revised: 10/09/2010] [Accepted: 10/14/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION To asses carbon ion radiation therapy (RT) performed as re-irradiation in 28 patients with recurrent tumors. MATERIALS AND METHODS Twenty-eight patients were treated with carbon ion RT as re-irradiation for recurrent chordoma and chondrosarcoma of the skull base (n=16 and n=2), one chordoma and one chondrosarcoma of the os sacrum, high-risk meningioma (n=3), adenoid-cystic carcinoma (n=4) as well as one SCCHN. All patients were treated using active raster scanning, and treatment planning was performed on CT- and MRI-basis. All patients were followed prospectively during follow-up. RESULTS In all patients re-irradiation could be applied safely without interruptions. For skull base tumors, local tumor control after re-irradiation was 92% at 24 months and 64% at 36 months. Survival after re-irradiation was 86% at 24 months, and 43% at 60 months. In all three meningiomas treated with C12 for re-irradiation, the tumor recurrence was located within the former RT-field. Two patients developed tumor progression at 6 months, and in one patient the tumor remained stable for 67 months. In patients with head-and-neck tumors, three patients developed local tumor progression at 12, 24 and 29 months after re-irradiation. Median local progression-free survival was 24 months. For sacral tumors, re-irradiation offered palliation with tumor control for 24 and 36 months. CONCLUSION Due to the physical characteristics particle therapy offers a new treatment modality in cases with tumor recurrences. With carbon ions, the additional biological benefits may be exploited for long-term tumor control. Further evaluation in a larger patients' cohort will be performed in the future.
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Affiliation(s)
- Stephanie E Combs
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany.
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Combs SE, Burkholder I, Edler L, Rieken S, Habermehl D, Jäkel O, Haberer T, Haselmann R, Unterberg A, Wick W, Debus J. Randomised phase I/II study to evaluate carbon ion radiotherapy versus fractionated stereotactic radiotherapy in patients with recurrent or progressive gliomas: the CINDERELLA trial. BMC Cancer 2010; 10:533. [PMID: 20925951 PMCID: PMC2958944 DOI: 10.1186/1471-2407-10-533] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Accepted: 10/06/2010] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Treatment of patients with recurrent glioma includes neurosurgical resection, chemotherapy, or radiation therapy. In most cases, a full course of radiotherapy has been applied after primary diagnosis, therefore application of re-irradiation has to be applied cauteously. With modern precision photon techniques such as fractionated stereotactic radiotherapy (FSRT), a second course of radiotherapy is safe and effective and leads to survival times of 22, 16 and 8 months for recurrent WHO grade II, III and IV gliomas.Carbon ions offer physical and biological characteristics. Due to their inverted dose profile and the high local dose deposition within the Bragg peak precise dose application and sparing of normal tissue is possible. Moreover, in comparison to photons, carbon ions offer an increased relative biological effectiveness (RBE), which can be calculated between 2 and 5 depending on the GBM cell line as well as the endpoint analyzed. Protons, however, offer an RBE which is comparable to photons.First Japanese Data on the evaluation of carbon ion radiation therapy for the treatment of primary high-grade gliomas showed promising results in a small and heterogeneous patient collective. METHODS DESIGN In the current Phase I/II-CINDERELLA-trial re-irradiation using carbon ions will be compared to FSRT applied to the area of contrast enhancement representing high-grade tumor areas in patients with recurrent gliomas. Within the Phase I Part of the trial, the Recommended Dose (RD) of carbon ion radiotherapy will be determined in a dose escalation scheme. In the subsequent randomized Phase II part, the RD will be evaluated in the experimental arm, compared to the standard arm, FSRT with a total dose of 36 Gy in single doses of 2 Gy.Primary endpoint of the Phase I part is toxicity. Primary endpoint of the randomized part II is survival after re-irradiation at 12 months, secondary endpoint is progression-free survival. DISCUSSION The Cinderella trial is the first study to evaluate carbon ion radiotherapy for recurrent gliomas, and to compare this treatment to photon FSRT in a randomized setting using an ion beam delivered by intensity modulated rasterscanning. TRIAL REGISTRATION NCT01166308.
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Affiliation(s)
- Stephanie E Combs
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.
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Improved killing of human high-grade glioma cells by combining ionizing radiation with oncolytic parvovirus H-1 infection. J Biomed Biotechnol 2010; 2010:350748. [PMID: 20224643 PMCID: PMC2833303 DOI: 10.1155/2010/350748] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Revised: 10/06/2009] [Accepted: 11/19/2009] [Indexed: 11/18/2022] Open
Abstract
Purpose. To elucidate the influence of ionizing radiation (IR) on
the oncolytic activity of Parvovirus H-1 (H-1PV) in human
high-grade glioma cells. Methods. Short term cultures of human
high-grade gliomas were irradiated at different doses and infected
with H-1PV. Cell viability was assessed by determining relative
numbers of surviving cells. Replication of H-1PV was measured by
RT-PCR of viral RNA, fluorescence-activated cell sorter (FACS)
analysis and the synthesis of infectious virus particles. To
identify a possible mechanism for radiation induced change in the
oncolytic activity of H-1PV we performed cell cycle analyses.
Results. Previous irradiation rendered glioma cells fully
permissive to H-1PV infection. Irradiation 24 hours prior to H-1PV
infection led to increased cell killing most notably in
radioresistant glioma cells. Intracellular levels of NS-1, the
main effector of H-1PV induced cytotoxicity, were elevated after
irradiation. S-phase levels were increased one day after
irradiation improving S-phase dependent viral replication and
cytotoxicity. Conclusion. This study demonstrates intact
susceptibility of previously irradiated glioma-cells for H-1PV
induced oncolysis. The combination of ionizing radiation followed
by H-1PV infection increased viral cytotoxicity, especially in
radioresistant gliomas. These findings support the ongoing
development of a clinical trial of H-1PV in patients with
recurrent glioblastomas.
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Liu BL, Cheng JX, Zhang X, Zhang W. Controversies concerning the application of brachytherapy in central nervous system tumors. J Cancer Res Clin Oncol 2010; 136:173-85. [PMID: 19956971 DOI: 10.1007/s00432-009-0741-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2009] [Accepted: 11/19/2009] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Brachytherapy (BRT) is defined as a therapy technique where a radioactive source is placed a short distance from or within the tumor being treated. Much expectation has been placed on its efficacy to improve the outcome for patients with central nervous system (CNS) tumors due to the initial promising results from single institution retrospective studies. However, these optimistic findings have been highly debated since the selection criteria itself is preferable to other therapeutic modalities. The fact that BRT demonstrated no significant survival advantage in two prospective studies, together with the emerging role of stereotactic convergence therapy as a promising alternative, has further decreased the enthusiasm for BRT. Despite all the negative aspects, BRT continues to be conducted for the management of CNS tumors including gliomas, meningiomas and brain metastases. MATERIAL AND METHODS As many controversies have been aroused concerning the experience and future application of BRT, this article reviews the existing heterogeneities in terms of implants choice, optimal dose rate, targeting volume, timing of BRT, patients selection, substantial efficacy, BRT in comparison with stereotactic convergence therapy techniques and BRT in combination with other treatment modalities (data were identified by Pubmed searches). RESULTS AND CONCLUSION Though it is inconvincible to argue for the routine use of BRT, BRT may provide a choice for patients with large recurrent or inoperable deep-seated tumors, especially with the Glia-site technique. Radiotherapies including BRT may hold more promise if biologic mechanisms of radiation could be better understand and biologic modifications could be added in clinical trials.
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Affiliation(s)
- Bo-Lin Liu
- Department of Neurosurgery, Xijing Institute of Clinical Neuroscience, Xijing Hospital, Fourth Military Medical University, West Changle Road, Shaanxi Province, People's Republic of China
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