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[Proton magnetic resonance spectroscopic imaging and other types of metabolic imaging for radiotherapy planning in adult and pediatric high-grade gliomas]. Cancer Radiother 2009; 13:556-61. [PMID: 19766525 DOI: 10.1016/j.canrad.2009.07.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Revised: 06/15/2009] [Accepted: 07/01/2009] [Indexed: 11/23/2022]
Abstract
Radiation therapy improves survival in high-grade gliomas but most patients relapse and usually within radiation fields. This may be due to uncertainties in target delineation and difficulties in identifying radioresistant regions for dose escalation. The use of T1 and T2-weighted magnetic resonance imaging (MRI) coregistration on the planning CT improves the target volume definition but magnetic resonance spectroscopic imaging (MRSI) and other types of metabolic and functional imaging (perfusion MRI, diffusion-weighted MRI, positron emission tomography (PET) imaging) may give useful additional information for target delineation. This article focuses on the potential of each imaging modality: assessment of response to treatment, detection of abnormalities not seen on MRI, predictive value for the site of local relapse. The incorporation of such techniques may improve target volume definition.
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Survival following stereotactic radiosurgery for newly diagnosed and recurrent glioblastoma multiforme: a multicenter experience. Neurosurg Rev 2009; 32:417-24. [PMID: 19633875 DOI: 10.1007/s10143-009-0212-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 02/23/2009] [Accepted: 04/14/2009] [Indexed: 10/20/2022]
Abstract
Despite decades of clinical trials investigating new treatment modalities for glioblastoma multiforme (GBM), there have been no significant treatment advances since the 1980s. Reported median survival times for patients with GBM treated with current modalities generally range from 9 to 19 months. The purpose of the current study is to retrospectively review the ability of CyberKnife (Accuray Incorporated, Sunnyvale, CA, USA) radiosurgery to provide local tumor control of newly diagnosed or recurrent GBM. Twenty patients (43.5%) underwent CyberKnife treatment at the time of the initial diagnosis and/or during the first 3 months of their initial clinical management. Twenty-six patients (56.5%) were treated at the time of tumor recurrence or progression. CyberKnife was performed in addition to the traditional therapy. The median survival from diagnosis for the patients treated with CyberKnife as an initial clinical therapy was 11.5 months (range, 2-33) compared to 21 months (range, 8-96) for the patients treated at the time of tumor recurrence/progression. This difference was statistically significant (Kaplan-Meier analysis, P = 0.0004). The median survival from the CyberKnife treatment was 9.5 months (range, 0.25-31 months) and 7 months (range, 1-34 months) for patients in the newly diagnosed and recurrent GBM groups (Kaplan-Meier analysis, P = 0.79), respectively. Cox proportional hazards survival regression analysis demonstrated that survival time did not correlate significantly with treatment parameters (Dmax, Dmin, number of fractions) or target volume. Survival time and recursive partitioning analysis class were not correlated (P = 0.07). Patients with more extensive surgical interventions survived longer (P = 0.008), especially those who underwent total tumor resection vs. biopsy (P = 0.004). There is no apparent survival advantage in using CyberKnife in initial management of glioblastoma patients, and it should be reserved for patients whose tumors recur or progress after conventional therapy.
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Yamamoto T, Nakai K, Kageji T, Kumada H, Endo K, Matsuda M, Shibata Y, Matsumura A. Boron neutron capture therapy for newly diagnosed glioblastoma. Radiother Oncol 2009; 91:80-4. [DOI: 10.1016/j.radonc.2009.02.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 01/28/2009] [Accepted: 02/15/2009] [Indexed: 11/25/2022]
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Pouratian N, Crowley RW, Sherman JH, Jagannathan J, Sheehan JP. Gamma Knife radiosurgery after radiation therapy as an adjunctive treatment for glioblastoma. J Neurooncol 2009; 94:409-18. [PMID: 19330482 DOI: 10.1007/s11060-009-9873-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Accepted: 03/16/2009] [Indexed: 01/09/2023]
Abstract
Despite a randomized trial showing no benefit of stereotactic radiosurgery (SRS) prior to radiation therapy (RT), the benefits of SRS after RT and at the time of progression require further characterization. We retrospectively reviewed 48 patients with histopathological diagnoses of glioblastoma (GBM) that were treated with SRS over a 16-year period (1991-2007). Twenty-two were treated as part of their initial treatment paradigm and 26 were treated at the time of progression. The primary endpoints studied were overall survival (OS), survival after SRS and time-to-progression (TTP). Patients treated at the time of progression had significantly longer OS than those treated on initial presentation (17.4 vs. 15.1 months, P = 0.003). On multivariate analysis, Radiation Therapy Oncology Group (RTOG) class III patients, those with more extensive resections, and those who were not on steroids at the time of SRS had significantly improved OS. SRS margin dose was a significant prognostic factor for TTP on multivariate analysis (HR = 0.78, 95% CI: 0.62-0.98). In the subgroup of patients treated with GKS as part of their initial treatment, an increasing number of weeks between surgical resection and GKS was a poor prognostic factor on multivariate analysis (HR = 1.11, 95% CI: 1.01-1.23). In patients who were treated with SRS at the time of progression, chemotherapy was associated with a longer TTP (P = 0.028). Our results suggest that SRS provides a survival advantage when delivered after RT. This benefit may be best appreciated in RTOG class III patients. Moreover, SRS may be a viable alternative to open surgery for aggressive management of GBM at the time of recurrence. Prospective studies of SRS for GBM should focus on these two groups of patients.
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Affiliation(s)
- Nader Pouratian
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA 22908, USA.
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55
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Tsurubuchi T, Zaboronok A, Yamamoto T, Nakai K, Yoshida F, Shirakawa M, Matsuda M, Matsumura A. The optimization of fluorescence imaging of brain tumor tissue differentiated from brain edema—In vivo kinetic study of 5-aminolevulinic acid and talaporfin sodium. Photodiagnosis Photodyn Ther 2009; 6:19-27. [DOI: 10.1016/j.pdpdt.2009.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 03/29/2009] [Accepted: 03/30/2009] [Indexed: 11/17/2022]
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Smith KA, Ashby LS, Gonzalez LF, Gonzalez F, Brachman DG, Thomas T, Coons SW, Battaglia M, Scheck A. Prospective trial of gross-total resection with Gliadel wafers followed by early postoperative Gamma Knife radiosurgery and conformal fractionated radiotherapy as the initial treatment for patients with radiographically suspected, newly diagnosed glioblastoma multiforme. J Neurosurg 2009; 109 Suppl:106-17. [PMID: 19123896 DOI: 10.3171/jns/2008/109/12/s17] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was to determine whether increased local control and improved survival can be achieved in patients with glioblastoma multiformes (GBMs) who undergo aggressive resection, Gliadel wafer implantation, Gamma Knife radiosurgery (GKS), and fractionated radiotherapy (RT) as the initial treatment. METHODS Thirty patients with radiographically suspected GBMs were screened for enrollment in a Phase I/II prospective clinical trial. Twenty-seven patients were eligible and underwent gross-total resection and Gliadel wafer implantation. Gamma Knife radiosurgery (12 Gy at 50%) was administered to the resection cavity within 2 weeks of surgery. Patients then received standard fractionated RT (total dose 60 Gy over 6 weeks). Temozolomide was prescribed for patients at the time of recurrence. Surveillance MR imaging, neurological examination, and quality-of-life evaluations were performed at 2-month intervals. To estimate the potential effects on the DNA repair mechanism, tumor tissue was analyzed with methylation-specific polymerase chain reaction analysis and immunohistochemical assays for MGMT gene promoter methylation and protein expression. RESULTS The median survival for all patients was 50 weeks and the 2-year survival rate was 22%. When stratified into standard and high-risk patient groups, the median survivals were 76 and 33 weeks, respectively. Two patients remain alive at the time of this report with no clinical or radiographic evidence of disease at > 189 and 239 weeks posttreatment and excellent performance status. Local tumor control was achieved in 53% of patients, and local failure occurred in 47%. No acute early toxicity was noted; however, delayed symptomatic radionecrosis occurred in 47% of patients, which required repeated operations 9-24 months after the initial treatment. Delayed hydrocephalus requiring ventriculoperitoneal shunt placement occurred in 47% of patients. There was a significant difference in survival between patients whose tumors contained the methylated and unmethylated MGMT promoter, 103 versus 45 weeks, respectively (p = 0.0009, log-rank test). CONCLUSIONS The combination of aggressive resection, Gliadel wafer implantation, and GKS in addition to standard fractionated RT in selected patients resulted in increased local control and increased survival compared with a historical control group treated with surgery and involved-field RT alone. Delayed focal radionecrosis was increased to 47% in this series and was managed with steroids and repeated resection. Aggressive local tumor control with these multimodal therapies should be approached judiciously for a select group of high performance patients and the probability of developing symptomatic radionecrosis requiring surgery should be anticipated and fully disclosed to patients who undergo this treatment.
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Affiliation(s)
- Kris A Smith
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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57
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Lee IH, Piert M, Gomez-Hassan D, Junck L, Rogers L, Hayman J, Ten Haken RK, Lawrence TS, Cao Y, Tsien C. Association of 11C-methionine PET uptake with site of failure after concurrent temozolomide and radiation for primary glioblastoma multiforme. Int J Radiat Oncol Biol Phys 2008; 73:479-85. [PMID: 18834673 DOI: 10.1016/j.ijrobp.2008.04.050] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Revised: 04/16/2008] [Accepted: 04/22/2008] [Indexed: 11/15/2022]
Abstract
PURPOSE To determine whether increased uptake on 11C-methionine-PET (MET-PET) imaging obtained before radiation therapy and temozolomide is associated with the site of subsequent failure in newly diagnosed glioblastoma multiforme (GBM). METHODS Patients with primary GBM were treated on a prospective trial with dose- escalated radiation and concurrent temozolomide. As part of the study, MET-PET was obtained before treatment but was not used for target volume definition. Using automated image registration, we assessed whether the area of increased MET-PET activity (PET gross target volume [GTV]) was fully encompassed within the high-dose region and compared the patterns of failure for those with and without adequate high-dose coverage of the PET-GTV. RESULTS Twenty-six patients were evaluated with a median follow-up of 15 months. Nineteen of 26 had appreciable (>1 cm(3)) volumes of increased MET-PET activity before treatment. Five of 19 patients had PET-GTV that was not fully encompassed within the high-dose region, and all five patients had noncentral failures. Among the 14 patients with adequately covered PET-GTV, only two had noncentral treatment failures. Three of 14 patients had no evidence of recurrence more than 1 year after radiation therapy. Inadequate PET-GTV coverage was associated with increased risk of noncentral failures. (p < 0.01). CONCLUSION Pretreatment MET-PET appears to identify areas at highest risk for recurrence for patients with GBM. It would be reasonable to test a strategy of incorporating MET-PET into radiation treatment planning, particularly for identifying areas for conformal boost.
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Affiliation(s)
- Irwin H Lee
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
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Wakimoto N, Wolf I, Yin D, O'Kelly J, Akagi T, Abramovitz L, Black KL, Tai HH, Koeffler HP. Nonsteroidal anti-inflammatory drugs suppress glioma via 15-hydroxyprostaglandin dehydrogenase. Cancer Res 2008; 68:6978-86. [PMID: 18757412 DOI: 10.1158/0008-5472.can-07-5675] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Studies have conjectured that nonsteroidal anti-inflammatory drugs (NSAID) inhibit growth of various malignancies by inhibiting cyclooxygenase-2 (COX-2) enzyme activity. Yet, several lines of evidence indicate that a COX-2-independent mechanism may also be involved in their antitumor effects. Here, we report that NSAIDs may inhibit the growth of glioblastoma multiforme (GBM) cells through COX-2-independent mechanisms, including up-regulation of both 15-hydroxyprostaglandin dehydrogenase (15-PGDH, the key prostaglandin catabolic enzyme) and the cell cycle inhibitor p21. Using Western blot and real-time PCR analysis in various GBM cell lines, we observed up-regulation of 15-PGDH and p21 after NSAIDs treatment. To elucidate the role of 15-PGDH in GBM, transfection assays were conducted using the T98G GBM cell line. Overexpression of 15-PGDH suppressed cell growth and was associated with increased expression of p21. In an attempt to investigate the roles of COX-2, 15-PGDH, and p21 in the inhibition of growth of GBM, small interfering RNA (siRNA) against each of these proteins was transfected into T98G cells. Inhibition of growth mediated by NSAIDs was partially reversed after knockdown of either 15-PGDH or p21, but not after COX-2 knockdown. Moreover, expression level of p21 was not affected in COX-2 siRNA transfected cells. Our studies provide evidence that the up-regulation of 15-PGDH induced by NSAIDs has the potential to inhibit growth of GBM, in part, by up-regulation of p21 possibly independent from COX-2 enzymatic function.
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Affiliation(s)
- Naoki Wakimoto
- Division of Hematology/Oncology, Cedars-Sinai Medical Center/University of California at Los Angeles School of Medicine, USA
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Buatti J, Ryken TC, Smith MC, Sneed P, Suh JH, Mehta M, Olson JJ. Radiation therapy of pathologically confirmed newly diagnosed glioblastoma in adults. J Neurooncol 2008; 89:313-37. [DOI: 10.1007/s11060-008-9617-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Accepted: 05/19/2008] [Indexed: 11/30/2022]
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Korkolopoulou P, Levidou G, Saetta AA, El-Habr E, Eftichiadis C, Demenagas P, Thymara I, Xiromeritis K, Boviatsis E, Thomas-Tsagli E, Panayotidis I, Patsouris E. Expression of nuclear factor-kappaB in human astrocytomas: relation to pI kappa Ba, vascular endothelial growth factor, Cox-2, microvascular characteristics, and survival. Hum Pathol 2008; 39:1143-52. [PMID: 18495209 DOI: 10.1016/j.humpath.2008.01.020] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Revised: 01/03/2008] [Accepted: 01/22/2008] [Indexed: 01/04/2023]
Abstract
Although NF-kappaB has been reported to be constitutively activated in various neoplasms, little information is available about its clinical significance in astrocytomas. In this study, we investigated the association of NF kappa B1/p50 and pI kappa Ba immunohistochemical expression with clinicopathologic features, vascular endothelial growth factor, Cox-2, and microvascular parameters in paraffin-embedded tissue from 82 patients with astrocytomas. pI kappa Ba expression was positively correlated with nuclear (P = .0010) and negatively with cytoplasmic (P = .0008) NF kappa B1/p50 expression. Nuclear NF kappa B1/p50 and pI kappa Ba expression increased with tumor grade (P = .0001 and P < .0001). Nuclear NF kappa B1/p50 was associated with vascular endothelial growth factor (P = .0079), Cox-2 (P = .0500), and total vascular surface area (P = .0430), although the latter was significant only in grades II and III. pI kappa Ba was also positively correlated with microvessel caliber (pI kappa Ba/area; P = .0087). Multivariate analysis selected NF kappa B/p50 expression as an independent prognosticator not only for the entire cohort (P = .0220), but also for grades II and III (P = .0029) and grade IV cases (P = .0310). Our results suggest that nuclear NF kappa B1/p50 expression is dictated by its interaction with I kappa Ba in astrocytomas and is associated with tumor grade and angiogenic factors, denoting the importance of nuclear NF kappa B/p50 expression in patients' prognosis.
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Affiliation(s)
- Penelope Korkolopoulou
- First Department of Pathology, Medical School, Laiko Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
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61
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Pan E, Mitchell SB, Tsai JS. A retrospective study of the safety of BCNU wafers with concurrent temozolomide and radiotherapy and adjuvant temozolomide for newly diagnosed glioblastoma patients. J Neurooncol 2008; 88:353-7. [DOI: 10.1007/s11060-008-9576-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Accepted: 03/26/2008] [Indexed: 11/30/2022]
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Proton magnetic resonance spectroscopic imaging in newly diagnosed glioblastoma: predictive value for the site of postradiotherapy relapse in a prospective longitudinal study. Int J Radiat Oncol Biol Phys 2008; 70:773-81. [PMID: 18262090 DOI: 10.1016/j.ijrobp.2007.10.039] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Revised: 10/26/2007] [Accepted: 10/30/2007] [Indexed: 11/24/2022]
Abstract
PURPOSE To investigate the association between magnetic resonance spectroscopic imaging (MRSI)-defined, metabolically abnormal tumor regions and subsequent sites of relapse in data from patients treated with radiotherapy (RT) in a prospective clinical trial. METHODS AND MATERIALS Twenty-three examinations were performed prospectively for 9 patients with newly diagnosed glioblastoma multiforme studied in a Phase I trial combining Tipifarnib and RT. The patients underwent magnetic resonance imaging (MRI) and MRSI before treatment and every 2 months until relapse. The MRSI data were categorized by the choline (Cho)/N-acetyl-aspartate (NAA) ratio (CNR) as a measure of spectroscopic abnormality. CNRs corresponding to T1 and T2 MRI for 1,207 voxels were evaluated before RT and at recurrence. RESULTS Before treatment, areas of CNR2 (CNR > or =2) represented 25% of the contrast-enhancing (T1CE) regions and 10% of abnormal T2 regions outside T1CE (HyperT2). The presence of CNR2 was often an early indicator of the site of relapse after therapy. In fact, 75% of the voxels within the T1CE+CNR2 before therapy continued to exhibit CNR2 at relapse, compared with 22% of the voxels within the T1CE with normal CNR (p < 0.05). The location of new contrast enhancement with CNR2 corresponded in 80% of the initial HyperT2+CNR2 vs. 20.7% of the HyperT2 voxels with normal CNR (p < 0.05). CONCLUSION Metabolically active regions represented a small percentage of pretreatment MRI abnormalities and were predictive for the site of post-RT relapse. The incorporation of MRSI data in the definition of RT target volumes for selective boosting may be a promising avenue leading to increased local control of glioblastomas.
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63
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Starr P. Neurosurgery. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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64
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Ashamalla H, Zaki B, Mokhtar B, Lewis L, Lavaf A, Nasr H, Colella F, Dosik D, Krishnamurthy M, Saad N, Guriguis A. Fractionated stereotactic radiotherapy boost and weekly paclitaxel in malignant gliomas clinical and pharmacokinetics results. Technol Cancer Res Treat 2007; 6:169-76. [PMID: 17535024 DOI: 10.1177/153303460700600303] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Management of Malignant Gliomas continues to be a challenge. We prospectively studied the role of adding weekly Paclitaxel to Fractionated Stereotactic Radiation Therapy (FSRT) in the treatment of Malignant Gliomas. Twenty-three Glioblastoma Multiforme and two Anaplastic Astrocytoma were studied. Patients received 46 Gy at 2 Gy/fraction followed by a boost utilizing FSRT at a fraction of 2.5 Gy for 8 fractions. Paclitaxel is delivered concomitantly at 150 mg/m(2) weekly for six cycles. Eighteen patients had pharmacokinetic assays of Paclitaxel levels. All patients were followed until death or for a maximum of 36 months. The overall survival of the whole group was 14 months. The median survival for RPA prognostic classes III, IV, V, and VI were 20, 14, 12, and 11 months. Higher survival (14 months) was noted in the subtherapeutic phenytoin level group compared to 10 months in the therapeutic group (P=0.271). No grade 4 CTCAE (version 3.0) toxicities were observed. Enhanced survival was demonstrated with gross tumor resection (20.8 months), KPS > or =80 (18.7 months) and age < or =60 years (27 months) as compared to subtotal resection or biopsy (12.1 months, P< 0.005), KPS < or =70 (10.8 months, P=0. 005) and older age > 60 (10.46 months, P=0.006), respectively. Our study suggests that: i) the use of weekly Paclitaxel and FSRT in Gliomas is well tolerated with a survival of 14 months; ii) the regimen resulted in improvement of survival of RPA classes IV, V, VI; and iii) the use of FSRT boost may be studied with other chemotherapeutic agents to see if superior results can be attained.
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Affiliation(s)
- H Ashamalla
- Radiation Oncology, New York Methodist Hospital, Weill Medical College of Cornell University, 506 6th Street, Brooklyn, NY 11215, USA.
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Stereotactic radiosurgery for patients with newly diagnosed glioblastoma multiforme (GBM): comparison with intra-operative radiotherapy and evaluation of prognostic factors. JOURNAL OF RADIOTHERAPY IN PRACTICE 2007. [DOI: 10.1017/s1460396907006073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractThe goals of this study were (1) to compare, in a single institute, the clinical results of patients with newly diagnosed glioblastoma multiforme (GBM) treated with stereotactic radiosurgery (SRS), which has been incorporated into the initial management approach, with thosein-patientstreated with intra-operative radiotherapy (IORT) and (2) to assess whether these local irradiation boost therapies are prognostic factors on survival analysis. One hundred and twenty adult patients with supratentorial GBM had undergone tumour resection or biopsy and had received external beam radiotherapy (EBRT). Of them, 31 underwent IORT, 29 underwent SRS, and the remaining 60 had no local high-dose irradiation boost. The local irradiation boost led to clearly better results on survival of GBM patients. Furthermore, SRS is less invasive and allows for meticulous target planning of the irradiation boost, and was superior to IORT in terms of survival prolongation as well as suppression of local tumour recurrence/progression at the primary site in this series. In addition, SRS was a significant, positive prognostic factor for survival as well as gross-total resection of the tumour, and could be an alternative therapeutic modality to IORT for GBM.
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66
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Ishikawa E, Tsuboi K, Yamamoto T, Muroi A, Takano S, Enomoto T, Matsumura A, Ohno T. Clinical trial of autologous formalin-fixed tumor vaccine for glioblastoma multiforme patients. Cancer Sci 2007; 98:1226-33. [PMID: 17517052 PMCID: PMC11158799 DOI: 10.1111/j.1349-7006.2007.00518.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
A pilot study was performed to investigate the safety and feasibility of autologous formalin-fixed tumor vaccines (AFTV) and the clinical responses to these vaccines by glioblastoma multiforme (GBM) patients. Twelve primary GBM patients were recruited. Eight had recurrent disease while four had been treated for primary disease but retained a visible tumor mass. AFTV were prepared from formalin-fixed and/or paraffin-embedded tumor tissue obtained upon surgery and premixed with original adjuvant materials. The patients were given three five-site intradermal inoculations at weekly intervals. A delayed-type hypersensitivity test was performed before and after each vaccination. In addition, the tumor tissues were subjected to immunohistochemical analysis to determine whether MIB-1, p53, and major histocompatibility complex (MHC) class-I complex expression could predict the response to the treatment. The treatment was well tolerated, with only local erythema, induration, and low-grade fever being reported. Of the 12 patients, one showed a complete response, one showed a partial response, two showed minor responses, one had stable disease, and seven exhibited progressive disease. The median survival period was 10.7 months from the initiation of the AFTV treatment but three of the five responders survived for 20 months or more after AFTV inoculation. Low p53 and high MHC class-I expression by the tumor may help predict the efficacy of this therapy. Thus, the AFTV is safe and feasible, and could significantly improve the outcome of GBM. Further clinical investigations to confirm this are highly desirable.
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Affiliation(s)
- Eiichi Ishikawa
- Department of Neurosurgery, Ibaraki Prefectural Central Hospital, Kasama, Ibaraki 309-1793, Japan
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Nagane M, Cavenee WK, Shiokawa Y. Synergistic cytotoxicity through the activation of multiple apoptosis pathways in human glioma cells induced by combined treatment with ionizing radiation and tumor necrosis factor–related apoptosis-inducing ligand. J Neurosurg 2007; 106:407-16. [PMID: 17367063 DOI: 10.3171/jns.2007.106.3.407] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Object
Malignant gliomas remain incurable despite modern multimodality treatments. Tumor necrosis factor (TNF)–related apoptosis-inducing ligand (TRAIL), also known as Apo2L, a member of the TNF family, preferentially induces apoptosis in human tumor cells through its cognate death receptors DR4 or DR5, suggesting that it may serve as a potential therapeutic agent for intractable malignant gliomas. Here, the authors show that genotoxic ionizing radiation synergistically enhances TRAIL-induced cell death in human glioma cells expressing DR5.
Methods
Combination treatment with soluble human TRAIL plus radiation induced robust cell death, while each of them singly led to only limited cytotoxicity. The combination resulted in cleavage and activation of the apoptotic initiator caspase-8 and the effector caspase-3 as well as cleavage of Bid and another initiator caspase-9, a downstream component of the apoptosome. Accordingly, it augmented the release of cytochrome c from the mitochondria into the cytosol, as well as apoptosis-inducing factor. Synergistic cell death was suppressed by TRAIL-neutralizing DR5-Fc, caspase inhibitors, expression of dominant-negative Fasassociated protein with death domain and CrmA, which selectively blocks caspase-8, and overexpression of Bcl-XL. Finally, combination treatment had no influence on the viability of normal human astrocytes.
Conclusions
These results suggest that combination treatment with TRAIL and ionizing radiation kills human glioma cells through the activation of DR5-mediated death receptor pathways. This therapy involves direct activation of effector caspases as well as mitochondria-mediated pathways and provides a novel strategy in which TRAIL could be synergistically combined with DNA-damaging radiation.
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Affiliation(s)
- Motoo Nagane
- Department of Neurosurgery, Kyorin University School of Medicine, Mitaka, Tokyo, Japan.
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Mineo JF, Bordron A, Baroncini M, Ramirez C, Maurage CA, Blond S, Dam-Hieu P. Prognosis factors of survival time in patients with glioblastoma multiforme: a multivariate analysis of 340 patients. Acta Neurochir (Wien) 2007; 149:245-52; discussion 252-3. [PMID: 17273889 DOI: 10.1007/s00701-006-1092-y] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2006] [Accepted: 12/11/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND The prognosis of glioblastoma multiforme remains poor despite recent therapeutic advances. Several clinical and therapeutic factors as well as tumour characteristics have been reported as significant to survival. A more efficient determination of the prognostic factors is required to optimize individual therapeutic management. The aim of our study was to evaluate by univariate then multivariate analysis the factors that influence prognosis and particularly survival. METHODS Data of 340 patients with newly-diagnosed GBM were retrospectively analyzed. Univariate analysis of prognosis factors of survival time was performed. Factors that seemed determinant were evaluated by Kaplan-Meier survival curves. Finally, the significant factors found in univariate analysis were tested in multivariate analysis using the COX regression method. FINDINGS Using multivariate analysis, the following factors were found to influence survival: radiotherapy was the predominant factor followed by radical surgery, tumour location, age and chemotherapy. Patients treated with temozolomide had a markedly better survival rate than patients treated with other chemotherapies (Log-rank test P < 0.005). The values of GBM type (de novo or secondary), as well as repeated surgery and partial surgery (vs. simple biopsy) were suggested by univariate analysis but not confirmed by the COX regression method. After radical surgery, progression-free survival was correlated to overall survival (r = 0.87, P < 10e-5). CONCLUSIONS; The influence of radiotherapy on survival was greater than the influence of age, an argument supporting the proposition of radiotherapy for patients until at least age 70. In the case of recurrence, the correlation between overall survival and progression-free survival is an important factor when considering the therapeutic options. Initial radical surgery and repeated procedures dramatically influence survival. The benefit of partial surgery remains difficult to evaluate. Partial surgery could be used to decrease intracranial pressure and to minimize residual tumours in order to enable treatment by chemotherapy and radiotherapy. The value of temozolomide treatment was confirmed.
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Affiliation(s)
- J-F Mineo
- Department of Neurosurgery, Hospital Roger Salengro, University Medical Centre, Lille, France.
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69
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Nawashiro H, Otani N, Shinomiya N, Fukui S, Ooigawa H, Shima K, Matsuo H, Kanai Y, Endou H. L-type amino acid transporter 1 as a potential molecular target in human astrocytic tumors. Int J Cancer 2006; 119:484-92. [PMID: 16496379 DOI: 10.1002/ijc.21866] [Citation(s) in RCA: 184] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
L-type amino acid transporter 1 (LAT1) is a Na+-independent neutral amino acid transport agency and essential for the transport of large neutral amino acids. LAT1 has been identified as a light chain of the CD98 heterodimer from C6 glioma cells. LAT1 also corresponds to TA1, an oncofetal antigen that is expressed primarily in fetal tissues and cancer cells. We have investigated for the first time, the expression of the transporter in the human primary astrocytic tumor tissue from 60 patients. LAT1 is unique because it requires an additional single membrane spanning protein, the heavy chain of 4F2 cell surface antigen (4F2hc), for its functional expression. 4F2hc expression was also determined by immunohistochemistry. Kaplan-Meier analyses demonstrated that high LAT1 expression correlated with poor survival for the study group as a whole (p<0.0001) and for those with glioblastoma multiforme in particular (p=0.0001). Cox regression analyses demonstrated that LAT1 expression was one of significant predictors of outcome, independent of all other variables. On the basis of these findings, we also investigated the effect of the specific inhibitor to LAT1, 2-aminobicyclo-2 (2,2,1)-heptane-2-carboxylic acid (BCH), on the survival of C6 glioma cells in vitro and in vivo using a rat C6 glioma model. BCH inhibited the growth of C6 glioma cells in vitro and in vivo in a dose-dependent manner. Kaplan-Meier survival data of rats treated with BCH were significant. These findings suggest that LAT1 could be one of the molecular targets in glioma therapy.
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Affiliation(s)
- Hiroshi Nawashiro
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan.
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Perdiki M, Korkolopoulou P, Thymara I, Agrogiannis G, Piperi C, Boviatsis E, Kotsiakis X, Angelidakis D, Diamantopoulou K, Thomas-Tsagli E, Patsouris E. Cyclooxygenase-2 expression in astrocytomas. Relationship with microvascular parameters, angiogenic factors expression and survival. Mol Cell Biochem 2006; 295:75-83. [PMID: 16868662 DOI: 10.1007/s11010-006-9275-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2006] [Accepted: 06/26/2006] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Cyclooxygenase-2 (COX-2) is the enzyme isoform involved in the synthesis of prostaglandins (PGs) and thromboxane from arachidonic acid. The role of the up-regulation of COX-2 in the formation and progression of gliomas has been dealt with in earlier reports, which describe increased levels of PGs within gliomas. In the present study, we examined the expression of COX-2 in diffuse gliomas of astrocytic origin in relation to microvascular parameters, angiogenic factors and survival. MATERIALS AND METHODS A total of 83 cases of diffuse astrocytomas (grade II-IV) were analyzed by immunohistochemistry for the presence of COX-2. RESULTS COX-2 expression was detected in 79 cases (95%) with an increased expression in grade IV as compared to grades II/III (p=0.024). A positive correlation occurred between COX-2 and angiogenic factors such as vascular endothelial growth factor (VEGF) (p<0.0001) and hypoxia inducible factor (HIF)-1alpha (p=0.005), as well as the tumours' proliferative activity (expressed as the percentage of Ki-67 positive cells) (p=0.032), and total vascular area (TVA) (p=0.040). In univariate analysis, COX-2 was associated with shortened survival (p = 0.050). Multivariate survival analysis showed that the interaction model of COX-2 with grade along with age were the only significant prognostic indicators. CONCLUSION These results implicate COX-2 in the angiogenesis and biological aggressiveness of diffuse astrocytomas, and suggest that it would be worthwhile to examine how the inhibition of COX-2 expression may influence astrocytoma patients' survival.
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Affiliation(s)
- Marina Perdiki
- Department of Pathology, National and Kapodistrian University of Athens, Athens, Greece.
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Biassoni V, Casanova M, Spreafico F, Gandola L, Massimino M. A Case of Relapsing Glioblastoma Multiforme Responding to Vinorelbine. J Neurooncol 2006; 80:195-201. [PMID: 16670944 DOI: 10.1007/s11060-006-9176-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2005] [Accepted: 04/07/2006] [Indexed: 10/24/2022]
Abstract
Childhood malignant gliomas are rare and their clinical behavior is almost as aggressive as in adults: they resist treatment, progress rapidly and often spread. Therapeutic strategies at relapse deserve an experimental approach, since none of the conventional-dose treatments have demonstrated a clear superiority over the others and no randomized trials have proved that high-dose chemotherapy is better than conventional treatment. Vinorelbine is a semi-synthetic vinca alkaloid with an in vitro and in vivo experimentally proven broad spectrum of activity, including against malignant brain glioma. We report our experience with a 19-year-old girl with glioblastoma multiforme (GBM) of the deep temporal region recurring 6 months after completing an intensive treatment that included preradiation chemotherapy (chemotherapy as a preradiation "sandwich" phase) with a myeloablative course of thiotepa, tumor bed radiotherapy and postradiation maintenance chemotherapy. The GBM proved fully responsive to intravenous vinorelbine, with a subsequent progression-free interval lasting more than 24 months. This case report suggests that vinorelbine is effective against high-grade pediatric glioma and, since this evidence has only one precedent in the literature (and given the generally poor prognosis for this tumor), even this single success seems worth reporting.
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Affiliation(s)
- V Biassoni
- Department of Pediatric, Istituto Nazionale per lo Studio e la Cura dei Tumori, 20133, Milan, Italy.
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Abstract
Despite the implementation of increasingly aggressive surgery, chemotherapy, and fractionated radiotherapy for the treatment of glioblastoma multiforme (GBM), most therapeutic regimens have resulted in only modest improvements in patient survival. Gamma knife surgery (GKS) has become an indispensable tool in the primary and adjuvant management of many intracranial pathologies, including meningiomas, pituitary tumors, and arteriovenous malformations. Although it would seem that radiosurgical techniques, which produce steep radiation dose fall-off around the target, would not be well suited to treat these infiltrative lesions, a limited number of institutional series suggest that GKS might provide a survival benefit when used as part of the comprehensive management of GBM. This may largely be attributed to the observation that tumors typically recur within a 2-cm margin of the tumor resection cavity. Despite these encouraging results, enthusiasm for radiosurgery as a primary treatment for GBM is significantly tempered by the failure of the only randomized trial that has been conducted to yield any benefit for patients with GBM who were treated with radiosurgery. In this paper, the authors review the pathophysiological mechanisms of GKS and its applications for GBM management.
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Affiliation(s)
- R Webster Crowley
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia 22908-0212, USA
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73
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Qi XS, Schultz CJ, Li XA. An estimation of radiobiologic parameters from clinical outcomes for radiation treatment planning of brain tumor. Int J Radiat Oncol Biol Phys 2006; 64:1570-80. [PMID: 16580506 DOI: 10.1016/j.ijrobp.2005.12.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2005] [Revised: 11/17/2005] [Accepted: 12/06/2005] [Indexed: 10/24/2022]
Abstract
PURPOSE To estimate a plausible set of radiobiologic parameters such as alpha, alpha/beta values, from clinical outcomes for biologically based radiation treatment planning of brain tumors. METHODS AND MATERIALS Linear-quadratic (LQ) formalism and the concept of equivalent uniform dose were used to analyze a series of published clinical data for malignant gliomas involving different forms of radiation therapy. RESULTS A plausible set of LQ parameters was obtained for gliomas: alpha = 0.06 +/- 0.05 Gy(-1), alpha/beta = 10.0 +/- 15.1 Gy, the tumor cell doubling time T(d) = 50 +/- 30 days, with the repair half-time of 0.5 h. The present estimated biologic parameters can reasonably predict the effectiveness of most of the recently reported clinical results employing either single or combined radiation therapy modalities. Different LQ parameters between Grade 3 and Grade 4 astrocytomas were found, implying the radiosensitivity for different grade tumors may be different. Smaller alpha, beta from in vivo was observed, indicating lower radiosensitivity occurred in vivo as compared with in vitro. CONCLUSIONS A plausible set of radiobiologic parameters for gliomas was estimated based on clinical data. These parameters can reasonably predict most of the clinical results. They may be used to design new treatment fractionation schemes and to evaluate and optimize treatment plans.
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Affiliation(s)
- X Sharon Qi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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74
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Rübel A, Handrick R, Lindner LH, Steiger M, Eibl H, Budach W, Belka C, Jendrossek V. The membrane targeted apoptosis modulators erucylphosphocholine and erucylphosphohomocholine increase the radiation response of human glioblastoma cell lines in vitro. Radiat Oncol 2006; 1:6. [PMID: 16722524 PMCID: PMC1475859 DOI: 10.1186/1748-717x-1-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2005] [Accepted: 03/29/2006] [Indexed: 12/16/2022] Open
Abstract
Background Alkylphosphocholines constitute a novel class of antineoplastic synthetic phospholipid derivatives that induce apoptosis of human tumor cell lines by targeting cellular membranes. We could recently show that the first intravenously applicable alkylphosphocholine erucylphosphocholine (ErPC) is a potent inducer of apoptosis in highly resistant human astrocytoma/glioblastoma cell lines in vitro. ErPC was shown to cross the blood brain barrier upon repeated intravenous injections in rats and thus constitutes a promising candidate for glioblastoma therapy. Aim of the present study was to analyze putative beneficial effects of ErPC and its clinically more advanced derivative erucylphosphohomocholine (erucyl-N, N, N-trimethylpropanolaminphosphate, ErPC3, Erufosine™ on radiation-induced apoptosis and eradication of clonogenic tumor cells in human astrocytoma/glioblastoma cell lines in vitro. Results While all cell lines showed high intrinsic resistance against radiation-induced apoptosis as determined by fluorescence microscopy, treatment with ErPC and ErPC3 strongly increased sensitivity of the cells to radiation-induced cell death (apoptosis and necrosis). T98G cells were most responsive to the combined treatment revealing highly synergistic effects while A172 showed mostly additive to synergistic effects, and U87MG cells sub-additive, additive or synergistic effects, depending on the respective radiation-dose, drug-concentration and treatment time. Combined treatment enhanced therapy-induced damage of the mitochondria and caspase-activation. Importantly, combined treatment also increased radiation-induced eradication of clonogenic T98G cells as determined by standard colony formation assays. Conclusion Our observations make the combined treatment with ionizing radiation and the membrane targeted apoptosis modulators ErPC and ErPC3 a promising approach for the treatment of patients suffering from malignant glioma. The use of this innovative treatment concept in an in vivo xenograft setting is under current investigation.
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Affiliation(s)
- Amelie Rübel
- Department of Radiation Oncology, Experimental Radiation Oncology, University of Tuebingen, Hoppe-Seyler-Str. 3, D-72076 Tuebingen, Germany
| | - René Handrick
- Department of Radiation Oncology, Experimental Radiation Oncology, University of Tuebingen, Hoppe-Seyler-Str. 3, D-72076 Tuebingen, Germany
| | - Lars H Lindner
- Department of Internal Medicine III, University Hospital Grosshadern, Marchioninistraße 15, D-81377 Munich, Germany
| | - Matthias Steiger
- Department of Internal Medicine III, University Hospital Grosshadern, Marchioninistraße 15, D-81377 Munich, Germany
| | - Hansjörg Eibl
- Max-Planck-Institute for Biophysical Chemistry, Am Fassberg 11, D-37077 Goettingen, Germany
| | - Wilfried Budach
- Department of Radiation Oncology, Moorenstrasse 5, D-40225 Duesseldorf, Germany
| | - Claus Belka
- Department of Radiation Oncology, Experimental Radiation Oncology, University of Tuebingen, Hoppe-Seyler-Str. 3, D-72076 Tuebingen, Germany
| | - Verena Jendrossek
- Department of Radiation Oncology, Experimental Radiation Oncology, University of Tuebingen, Hoppe-Seyler-Str. 3, D-72076 Tuebingen, Germany
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Ruben JD, Dally M, Bailey M, Smith R, McLean CA, Fedele P. Cerebral radiation necrosis: incidence, outcomes, and risk factors with emphasis on radiation parameters and chemotherapy. Int J Radiat Oncol Biol Phys 2006; 65:499-508. [PMID: 16517093 DOI: 10.1016/j.ijrobp.2005.12.002] [Citation(s) in RCA: 325] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2005] [Revised: 11/30/2005] [Accepted: 12/01/2005] [Indexed: 11/29/2022]
Abstract
PURPOSE To investigate radiation necrosis in patients treated for glioma in terms of incidence, outcomes, predictive and prognostic factors. METHODS AND MATERIALS Records were reviewed for 426 patients followed up until death or for at least 3 years. Logistic regression analysis was performed to identify predictive and prognostic factors. Multivariate survival analysis was conducted using Cox proportional hazards regression. Separate analyses were performed for the subset of 352 patients who received a biologically effective dose (BED) > or =85.5 Gy2 (> or =45 Gy/25 fractions) who were at highest risk for radionecrosis. RESULTS Twenty-one patients developed radionecrosis (4.9%). Actuarial incidence plateaued at 13.3% after 3 years. In the high-risk subset, radiation parameters confirmed as risk factors included total dose (p < 0.001), BED (p < 0.005), neuret (p < 0.001), fraction size (p = 0.028), and the product of total dose and fraction size (p = 0.001). No patient receiving a BED <96 Gy2 developed radionecrosis. Subsequent chemotherapy significantly increased the risk of cerebral necrosis (p = 0.001) even when adjusted for BED (odds ratio [OR], 5.8; 95% confidence interval [CI], 1.6-20.3) or length of follow-up (OR, 5.4; 95% CI, 1.5-19.3). Concurrent use of valproate appeared to delay the onset of necrosis (p = 0.013). The development of radionecrosis did not affect survival (p = 0.09). CONCLUSIONS Cerebral necrosis is unlikely at doses below 50 Gy in 25 fractions. The risk increases significantly with increasing radiation dose, fraction size, and the subsequent administration of chemotherapy.
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Affiliation(s)
- Jeremy D Ruben
- William Buckland Radiotherapy Centre, Melbourne, Australia
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Iizuka Y, Kojima H, Kobata T, Kawase T, Kawakami Y, Toda M. Identification of a glioma antigen, GARC-1, using cytotoxic T lymphocytes induced by HSV cancer vaccine. Int J Cancer 2006; 118:942-9. [PMID: 16152596 DOI: 10.1002/ijc.21432] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Despite several ongoing clinical trials of immunotherapies against glioma, few glioma-specific antigens recognized by cytotoxic T lymphocytes (CTLs) have been identified. We recently demonstrated that intratumoral inoculation with herpes simplex virus (HSV) as a cancer vaccine activates tumor-specific CTLs. To identify glioma antigens recognized by CTLs, we used the HSV cancer vaccine to vaccinate mice harboring a syngeneic mouse glioma cell line, GL261. From the splenocytes of the immunized mice, we generated an H-2Db-restricted CTL line, GCL-1, that was specific for GL261. Then, a cDNA expression library generated from GL261 was screened with GCL-1, and a new gene encoding glioma antigen, GARC-1, was isolated. Sequence analysis revealed that the GARC-1 gene isolated from GL261 had a point mutation causing an amino acid change (Asp to Asn at position 81). T-cell epitope analysis revealed that the mutated peptide GARC-1(77-85) (AALLNKLYA) but not the wild-type peptide (AALLDKLYA), was recognized by GCL-1. These results suggest that HSV cancer vaccination may be a useful method for inducing tumor-specific CTLs and identifying tumor antigens. Furthermore, this GL261/GARC-1 murine glioma model may be useful for the development of immunotherapy for brain tumors.
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Affiliation(s)
- Yukihiko Iizuka
- Neuroimmunology Research Group, Keio University School of Medicine, Tokyo, Japan
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Halatsch ME, Schmidt U, Behnke-Mursch J, Unterberg A, Wirtz CR. Epidermal growth factor receptor inhibition for the treatment of glioblastoma multiforme and other malignant brain tumours. Cancer Treat Rev 2006; 32:74-89. [PMID: 16488082 DOI: 10.1016/j.ctrv.2006.01.003] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2005] [Revised: 12/22/2005] [Accepted: 01/08/2006] [Indexed: 11/25/2022]
Abstract
Gliomas are the most common primary central nervous system tumours and about 55% are glioblastoma multiforme (GBM). Between 40% and 50% of GBM have dysregulated epidermal growth factor receptor (HER1/EGFR), and almost half of these co-express the mutant receptor subtype EGFRvIII, which may contribute to the aggressive and refractory course of GBM. Limited therapeutic options exist for GBM, and recurrence is common. Standard therapy is surgical resection, where possible, and radiotherapy. Adjuvant chemotherapy provides a modest survival benefit. New therapies are essential, and HER1/EGFR-targeted agents may provide a viable strategy. The HER1/EGFR tyrosine kinase inhibitors erlotinib and gefitinib are in advanced clinical development for glioma, and a number of trials are in progress, or have recently been completed. Preliminary results with gefitinib show no objective responses, but do provide evidence of disease control. In contrast, preliminary data with erlotinib appear more encouraging. Erlotinib inhibits wild-type HER1/EGFR and EGFRvIII, which may underlie its promising clinical activity. Other HER1/EGFR-targeted agents are also being investigated for glioma, including monoclonal antibodies, radio-immuno conjugates, ligand-toxin conjugates, antisense oligonucleotides and ribozymes. Further studies will define their clinical potential and hopefully provide new, effective treatments for GBM and other malignant brain tumours.
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Affiliation(s)
- Marc-Eric Halatsch
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany.
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Robe PA, Martin D, Albert A, Deprez M, Chariot A, Bours V. A phase 1-2, prospective, double blind, randomized study of the safety and efficacy of Sulfasalazine for the treatment of progressing malignant gliomas: study protocol of [ISRCTN45828668]. BMC Cancer 2006; 6:29. [PMID: 16448552 PMCID: PMC1368982 DOI: 10.1186/1471-2407-6-29] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2005] [Accepted: 01/31/2006] [Indexed: 11/23/2022] Open
Abstract
Background The prognosis of patients suffering from WHO grade 3 and 4 astrocytic glioma remains poor despite surgery, radiation therapy and the use of current chemotherapy regimen. Indeed, the median survival of glioblastoma multiforme (WHO grade 4) patients is at best 14.6 month with only 26.5 percents of the patients still alive after 2 years and the median survival of anaplastic astrocytomas (WHO grade 3) is 19.2 month. Recent evidence suggests that the transcription factor NF-kappaB is constitutively expressed in malignant gliomas and that its inhibition by drugs like Sulfasalazine may block the growth of astrocytic tumors in vitro and in experimental models of malignant gliomas. Design ULg_GBM_04/1 is a prospective, randomized, double blind single-center phase 1–2 study. A total of twenty patients with progressive malignant glioma despite surgery, radiation therapy and a first line of chemotherapy will be recruited and assigned to four dosage regimen of Sulfasalazine. This medication will be taken orally t.i.d. at a daily dose of 1.5–3–4 or 6 g, continuously until complete remission, evidence of progression or drug intolerance. Primary endpoints are drug safety in the setting of malignant gliomas and tumor response as measured according to MacDonald's criteria. An interim analysis of drug safety will be conducted after the inclusion of ten patients. The complete evaluation of primary endpoints will be conducted two years after the enrolment of the last patient or after the death of the last patient should this occur prematurely. Discussion The aim of this study is to evaluate the safety and efficacy of Sulfasalazine as a treatment for recurring malignant gliomas. The safety and efficacy of this drug are analyzed as primary endpoints. Overall survival and progression-free survival are secondary endpoint.
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Affiliation(s)
- Pierre A Robe
- Department of Neurosurgery, University of Liège, Domaine du Sart TIlman, B35, 4000 Liège, Belgium
- Human Genetics. University of Liège, Domaine du Sart TIlman, B35, 4000 Liège, Belgium
| | - Didier Martin
- Department of Neurosurgery, University of Liège, Domaine du Sart TIlman, B35, 4000 Liège, Belgium
| | - Adelin Albert
- Department of Medical Statistics, University of Liège, Domaine du Sart TIlman, B35, 4000 Liège, Belgium
| | - Manuel Deprez
- Department of Pathology (Neuropathology), University of Liège, Domaine du Sart TIlman, B35, 4000 Liège, Belgium
| | - Alain Chariot
- Department of Medical Chemistry University of Liège, Domaine du Sart TIlman, B35, 4000 Liège, Belgium
| | - Vincent Bours
- Human Genetics. University of Liège, Domaine du Sart TIlman, B35, 4000 Liège, Belgium
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Tanaka M, Ino Y, Nakagawa K, Tago M, Todo T. High-dose conformal radiotherapy for supratentorial malignant glioma: a historical comparison. Lancet Oncol 2005; 6:953-60. [PMID: 16321763 DOI: 10.1016/s1470-2045(05)70395-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although radiotherapy remains the main postoperative treatment for patients with malignant glioma, modifications to regimens have not improved the poor outlook of patients with this disease. We aimed to investigate whether high-dose conformal radiotherapy improves the survival of patients with supratentorial malignant glioma compared with conventional radiotherapy. METHODS 29 patients with anaplastic astrocytoma and 61 patients with glioblastoma who received high-dose conformal radiotherapy during 1990-2002 were compared with 34 patients with anaplastic astrocytoma and 60 patients with glioblastoma who received conventional 60 Gy radiotherapy during 1979-89. 77 of the 90 patients receiving high-dose radiotherapy were given 80 Gy; the remaining 13 patients, all with glioblastoma, received 90 Gy. Radiotherapy was planned on the basis of images taken before surgery, and doses were delivered in 2 Gy per fraction per day for 5 days a week. Hazard ratios for death were calculated with a Cox model, and were adjusted for age, Karnofsky performance scale, tumour size, and extent of resection. FINDINGS Patients who received high-dose radiotherapy had significantly longer overall survival compared with those who received conventional radiotherapy (adjusted hazard ratio 0.30 [95% CI 0.12-0.76], p=0.011 for anaplastic astrocytoma and 0.49 [0.28-0.87], p=0.014 for glioblastoma). Patients with anaplastic astrocytoma in the high-dose group have not yet reached median survival; median survival in the conventional radiotherapy group was 22.3 months (95% CI 20.6-24.0). 5-year survival was 51.3% (29.2-73.4) for the high-dose group and 14.7% (0.0-30.0) for the conventional group. Median survival in patients with glioblastoma was 16.2 months (12.8-19.6) for the high-dose group and 12.4 months (10.0-14.8) for the conventional group. 2-year survival was 38.4% (23.5-53.3) for the high-dose group and 11.4% (0.0-25.3) for the conventional group. Survival did not differ between those that received 80 Gy radiotherapy and those that received 90 Gy (hazard ratio 0.94 [95% CI 0.42-2.12]). The higher frequency of radiation-induced white matter abnormality in the high-dose group compared with the conventional radiotherapy group did not lead to increased disability. INTERPRETATION High-dose, standard-fractionated radiotherapy shows potential as the main postoperative treatment for patients with supratentorial malignant glioma.
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Affiliation(s)
- Minoru Tanaka
- Department of Neurosurgery, University of Tokyo, Tokyo, Japan
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Chakrabarti I, Cockburn M, Cozen W, Wang YP, Preston-Martin S. A population-based description of glioblastoma multiforme in Los Angeles County, 1974-1999. Cancer 2005; 104:2798-806. [PMID: 16288487 DOI: 10.1002/cncr.21539] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND There have been reports that the incidence rates of brain tumors have increased over the past few decades, but most have considered all brain tumors together. The authors analyzed the pattern of glioblastoma multiforme (GBM) occurrence in Los Angeles County, California to shed light on the incidence and descriptive epidemiology of this type of brain tumor. METHODS Data were obtained from the Los Angeles County Cancer Surveillance Program. Incidence rates were analyzed by gender, race, age at diagnosis, period of diagnosis (1974-1981, 1982-1988, or 1989-1999), and socioeconomic status (SES). In addition, data were stratified according to anatomic subsite. A multivariate model describing changes in rates by each of these variables was constructed. RESULTS Age-specific incidence rates (ASIR) rose sharply after age 30 years. The peak ASIR was at age 70-74 years in males and at age 75-79 years in females. The age-adjusted incidence rate (AAIR) of GBM increased from 1974 to 1999 by an estimated 2.4% per year among males and 2.8% per year among females. Overall, males had a 60% increased risk of brain tumors compared with females. Males had a higher incidence of GBM compared with females at each anatomic subsite except the posterior fossa. The largest male:female ratio occurred in the occipital lobes. Non-Latino whites had the highest incidence rates (2.5 per 100,000) followed by Latino whites (1.8 per 100,000), and blacks (1.5 per 100,000). After 1989, compared with the period before magnetic resonance imaging (MRI) was available, there was an increase in GBM incidence rates among those with of higher SES that was most pronounced in females. The incidence of GBM was highest for frontal lobe tumors and for tumors that involved two or more lobes (overlapping tumors), followed by tumors in the temporal and parietal lobes. In the multivariate analysis, year of diagnosis, SES, gender, race (Latino but not black), site, and age at diagnosis all were important predictors of incidence rate. CONCLUSIONS GBM incidence increased in Los Angeles County over the last 30 years and especially after 1989, suggesting that the introduction of MRI may have contributed to the increase. Individuals older than age 65 years experienced the greatest increase in incidence over time. Older age, male gender, higher SES, and non-Latino white race increased the risk of GBM. Previously unreported incidence rates for GBM among Latino whites were significantly lower than among non-Latino whites but were intermediate between non-Latino whites and blacks.
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Affiliation(s)
- Indro Chakrabarti
- Department of Neurosurgery, University of Southern California Keck School of Medicine, Los Angeles, 90032, USA.
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81
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Giller CA, Berger BD. New frontiers in radiosurgery for the brain and body. Proc (Bayl Univ Med Cent) 2005; 18:311-9; discussion 319-20. [PMID: 16252020 PMCID: PMC1255939 DOI: 10.1080/08998280.2005.11928087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Radiosurgery is defined as the use of highly focused beams of radiation to ablate a pathologic target, thus achieving a surgical objective by noninvasive means. Recent advances have allowed a wide variety of intracranial lesions to be effectively treated with radiosurgery, and radiosurgical treatment has been accepted as a standard part of the neurosurgical armamentarium. The advent of frameless radiosurgery now permits radiosurgical treatment to all parts of the body and is being actively explored by many centers. This article reviews some of the modern tools for radiosurgical treatment and discusses the current clinical practice of radiosurgery.
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Affiliation(s)
- Cole A Giller
- Baylor Radiosurgery Center, Baylor University Medical Center, Dallas, Texas 75246, USA.
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82
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Abstract
Over the past several decades neurooncologists have attempted to find an adjuvant treatment that prolongs survival for patients with malignant brain tumors. Brachytherapy, radiotherapy delivered by placing radioactive sources directly into the tumor, was initially thought to be the solution to this problem. Initial single institution studies showed very promising results; however, this technique has failed to show a significant survival advantage in two randomized studies. Despite this, brachytherapy continues to be used in a number of centers throughout the world for the treatment of various types of brain tumors including low-grade gliomas, anaplastic astrocytomas, glioblastomas, meningiomas and metastases. This article reviews brachytherapy's rationale, radiobiology, complications, indications, and results from numerous studies that have focused on its application for brain tumors with emphasis on its application for glial tumors.
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Affiliation(s)
- Todd W Vitaz
- Neurosurgical Service Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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Abstract
Glioblastoma multiforme (GBM) is a highly malignant brain tumor with limited therapeutic options, a high recurrence rate and mortality. Standard therapy is maximal surgical resection and radiotherapy (RT). Recent data suggest combining temozolomide with RT is better than RT alone. Adjuvant chemotherapy has a modest impact on survival. For relapsed patients there is no standard therapy, but options include chemotherapeutic agents or new agents in development. One approach to improve outcome is using targeted agents that interfere with cell-surface receptors or intracellular signaling pathways. Between 40% and 50% of GBM tumors show HER1/EGFR dysregulation, and almost half co-express the constitutively active mutant receptor subtype EGFRvIII, which may contribute to the aggressive and refractory course of GBM. Numerous studies show a relationship between aberrant HER1/EGFR biology and tumorigenicity in GBM cells. Two available HER1/EGFR tyrosine kinase inhibitors (TKIs) are gefitinib (Iressa) and erlotinib (Tarceva); both show antitumor and radiosensitization effects in vitro and in animal models of GBM. Clinical trials in patients with GBM and other gliomas are ongoing. Preliminary and published results from trials of gefitinib in recurrent GBM show no increased time to progression or overall survival (OS) compared with historical controls. Studies with erlotinib show greater antitumor activity in patients with GBM than with gefitinib, although the impact of both agents on OS remains unclear. GBM treatment with HER1/EGFR TKIs alone or combined with other targeted therapies and conventional modalities deserve further investigation and refinement, as does our understanding of their mechanisms of action and the role of genetics.
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Affiliation(s)
- Jeffrey J Raizer
- Northwestern University, Feinberg School of Medicine, Abbott Hall, Room 1123, 710 North Lake Shore Drive, Chicago, IL 60611, USA.
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84
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Grosu AL, Weber WA, Riedel E, Jeremic B, Nieder C, Franz M, Gumprecht H, Jaeger R, Schwaiger M, Molls M. L-(methyl-11C) methionine positron emission tomography for target delineation in resected high-grade gliomas before radiotherapy. Int J Radiat Oncol Biol Phys 2005; 63:64-74. [PMID: 16111573 DOI: 10.1016/j.ijrobp.2005.01.045] [Citation(s) in RCA: 198] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2004] [Revised: 11/22/2004] [Accepted: 01/11/2005] [Indexed: 11/15/2022]
Abstract
PURPOSE Using magnetic resonance imaging (MRI), residual tumor cannot be differentiated from nonspecific postoperative changes in operated patients with brain gliomas. The higher specificity and sensitivity of L-(methyl-11C)-labeled methionine positron emissions tomography (MET-PET) in gliomas has been demonstrated in previous studies and is the rationale for the integration of this investigation in gross tumor volume delineation. The goal of this trial was to quantify the affect of MET-PET vs. with MRI in gross tumor volume definition for radiotherapy planning of high-grade gliomas. METHODS AND MATERIALS The trial included 39 patients with resected malignant gliomas. MRI and MET-PET data were coregistered based on mutual information. The residual tumor volume on MET-PET and the volume of tissue abnormalities on T1-weighted MRI (gadolinium [Gd] enhancement) and T2-weighted MRI (hyperintensity areas) were compared using MET-PET/MRI fusion images. RESULTS The MET-PET vs. Gd-enhanced T1-weighted MRI analysis was performed on 39 patients. In 5 patients (13%), MET uptake corresponded exactly with Gd enhancement, and in 29 (74%) of 39 patients, the region of MET uptake was larger than that of the Gd enhancement. In 27 (69%) of the 39 patients, the Gd enhancement area extended beyond the MET enhancement. MET uptake was detected up to 45 mm beyond the Gd enhancement. MET-PET vs. T2-weighted MRI was investigated in 18 patients. MET uptake did not correspond exactly with the hyperintensity areas on T2-weighted MRI in any patient. In 9 (50%) of 18 patients, MET uptake extended beyond the hyperintensity area on the T2-weighted MRI, and in 18 (100%), at least some hyperintensity on the T2-weighted MRI was located outside the MET enhancement area. MET uptake was detected up to 40 mm beyond the hyperintensity area on T2-weighted MRI. CONCLUSION In operated patients with brain gliomas, the size and location of residual MET uptake differs considerably from abnormalities found on postoperative MRI. Because postoperative changes cannot be differentiated from residual tumor by MRI, MET-PET, with a greater specificity for tumor tissue, can help to outline the gross tumor volume with greater accuracy.
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Affiliation(s)
- Anca-Ligia Grosu
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.
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Lichy MP, Plathow C, Schulz-Ertner D, Kauczor HU, Schlemmer HP. Follow-up gliomas after radiotherapy: 1H MR spectroscopic imaging for increasing diagnostic accuracy. Neuroradiology 2005; 47:826-34. [PMID: 16142479 DOI: 10.1007/s00234-005-1434-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2004] [Accepted: 07/14/2005] [Indexed: 10/25/2022]
Abstract
We evaluated the value of magnetic resonance imaging (MRI) and the additional benefit of proton MR spectroscopic imaging (1H SI) in patients with a new suspicious lesion after fractionated stereotactic radiotherapy (FSRT) of a glioma. Thirty-four patients with histologically proven astrocytoma WHO II-IV after treatment by FSRT and a new suspect lesion in the follow-up were included in this study. Data were analysed by three independent radiologists with different experience in 1H SI: Data were verified by clinical follow-up (PT, progressive tumour; nPT, non-progressive tumour) and a kappa analysis was performed. Sensitivity and specificity of T1 weighted (w) and T2w MRI was compared (imaging at radiotherapy and follow-up) using further follow-up controls as gold standard and the additional benefit of 1H SI (imaging at follow-up) was calculated. Mean interval between last irradiation and detection of a suspicious lesion was 37 +/- 32 months. Time to clinical evaluation was 13 +/- 8 months. Interobserver agreement was significantly high in all analyses (kappa always >0.8, P < 0.05). T2w imaging proved to be superior to contrast enhanced T1w imaging in sensitivity (87.5 vs 81.25%) and specificity (85.7 vs 57.1%). Solitary 1H SI had similar results as T2w (sensitivity 87.5%, specificity 71.4%). Taking all techniques into account, all PT were correctly diagnosed. Radiologists' experience had no significant influence on correct interpretation of a suspicious lesion. We conclude that 1H SI is helpful in characterising new suspicious lesions in irradiated gliomas, particularly if pre-MRI is not available for evaluating follow-up.
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Tsao MN, Mehta MP, Whelan TJ, Morris DE, Hayman JA, Flickinger JC, Mills M, Rogers CL, Souhami L. The American Society for Therapeutic Radiology and Oncology (ASTRO) evidence-based review of the role of radiosurgery for malignant glioma. Int J Radiat Oncol Biol Phys 2005; 63:47-55. [PMID: 16111571 DOI: 10.1016/j.ijrobp.2005.05.024] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2005] [Accepted: 05/20/2005] [Indexed: 11/18/2022]
Abstract
PURPOSE To systematically review the evidence for the use of stereotactic radiosurgery or stereotactic fractionated radiation therapy in adult patients with malignant glioma. METHODS Key clinical questions to be addressed in this evidence-based review were identified. Outcomes considered were overall survival, quality of life or symptom control, brain tumor control or response and toxicity. MEDLINE (1990-2004 June Week 2), CANCERLIT (1990-2003), CINAHL (1990-2004 June Week 2), EMBASE (1990-2004 Week 25), and the Cochrane library (2004 issue 2) databases were searched using OVID. In addition, the Physician Data Query clinical trials database, the proceedings of the American Society of Clinical Oncology (1997-2004), ASTRO (1997-2004), and the European Society of Therapeutic Radiology and Oncology (ESTRO) (1997-2003) were searched. Data from the literature search were reviewed and tabulated. This process included an assessment of the level of evidence. RESULTS For patients with newly diagnosed malignant glioma, radiosurgery as boost therapy with conventional external beam radiation was examined in one randomized trial, five prospective cohort studies, and seven retrospective series. There is Level I evidence that the use of radiosurgery boost followed by external beam radiotherapy and carmustine (BCNU) does not confer benefit with respect to overall survival, quality of life, or patterns of failure as compared with external beam radiotherapy and BCNU. There is Level I-III evidence of toxicity associated with radiosurgery boost as compared with external beam radiotherapy alone. The results of the prospective and retrospective studies may be influenced by selection bias. Radiosurgery used as salvage for recurrent or progressive malignant glioma after conventional external beam radiotherapy failure was reported in zero randomized trials, three prospective cohort studies, and five retrospective series. The available data are sparse and insufficient to make absolute recommendations. Stereotactic fractionated radiation therapy has been reported as boost therapy with external beam radiotherapy for patients with newly diagnosed malignant glioma in only three prospective studies. As primary therapy alone without conventional external beam radiotherapy for newly diagnosed malignant glioma patients, stereotactic fractionated radiation therapy has been reported in only one prospective study. There were only three prospective series and two retrospective studies reported for patients with recurrent or progressive malignant glioma. CONCLUSIONS For patients with malignant glioma, there is Level I-III evidence that the use of radiosurgery boost followed by external beam radiotherapy and BCNU does not confer benefit in terms of overall survival, local brain control, or quality of life as compared with external beam radiotherapy and BCNU. The use of radiosurgery boost is associated with increased toxicity. For patients with malignant glioma, there is insufficient evidence regarding the benefits/harms of using radiosurgery at the time progression or recurrence. There is also insufficient evidence regarding the benefits/harms in the use of stereotactic fractionated radiation therapy for patients with newly diagnosed or progressive/recurrent malignant glioma.
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Affiliation(s)
- May N Tsao
- The American Society for Therapeutic Radiology and Oncology, Fairfax, VA 22033, USA
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87
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Hanissian SH, Teng B, Akbar U, Janjetovic Z, Zhou Q, Duntsch C, Robertson JH. Regulation of myeloid leukemia factor-1 interacting protein (MLF1IP) expression in glioblastoma. Brain Res 2005; 1047:56-64. [PMID: 15893739 DOI: 10.1016/j.brainres.2005.04.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2004] [Revised: 03/22/2005] [Accepted: 04/01/2005] [Indexed: 11/17/2022]
Abstract
The myelodysplasia/myeloid leukemia factor 1-interacting protein MLF1IP is a novel gene which encodes for a putative transcriptional repressor. It is localized to human chromosome 4q35.1 and is expressed in both the nuclei and cytoplasm of cells. Northern and Western blot analyses have revealed MLF1IP to be present at very low amounts in normal brain tissues, whereas a number of human and rat glioblastoma (GBM) cell lines demonstrated a high level expression of the MLF1IP protein. Immunohistochemical analysis of rat F98 and C6 GBM tumor models showed that MLF1IP was highly expressed in the tumor core where it was co-localized with MLF1 and nestin. Moreover, MLF1IP expression was elevated in the contralateral brain where no tumor cells were detected. These observations, together with previous data demonstrating a role for MLF1IP in erythroleukemias, suggest a possible function for this protein in glioma pathogenesis and potentially in other types of malignancies.
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Affiliation(s)
- Silva H Hanissian
- Department of Neurosurgery, The University of Tennessee Health Science Center, 847 Monroe, Memphis, TN 38163, USA.
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88
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Abstract
Current surgical treatment of malignant gliomas largely depends on mechanistic reasoning and data collected in non-randomised studies. Technological advance has enabled more accurate resection of tumours and preservation of eloquent brain areas but ethical considerations have restricted randomised trials on the efficacy of surgery to one small trial that found a 3 month survival advantage for patients over age 65 years who received surgery and interim analysis of a larger trial. There is an argument for surgery as a palliative measure in patients with symptoms caused by mechanisms that are surgically remediable. Whether there is any survival advantage from surgery in patients other than those with immediately life-threatening, surgically remediable complications, such as raised intracranial pressure, is unclear. The available data show that if such an advantage does exist, it is modest at best. Adjuvant treatments given surgically are being studied. Chemotherapy wafers are the most prominent of the adjuvant treatments but the evidence available is insufficient to recommend their use in routine practice. In this review we examine the prevailing mechanistic model and observational data; we assess how these are applied and the priorities they indicate for future research.
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89
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Mahajan A, McCutcheon IE, Suki D, Chang EL, Hassenbusch SJ, Weinberg JS, Shiu A, Maor MH, Woo SY. Case—control study of stereotactic radiosurgery for recurrent glioblastoma multiforme. J Neurosurg 2005; 103:210-7. [PMID: 16175848 DOI: 10.3171/jns.2005.103.2.0210] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The role of stereotactic radiosurgery (SRS) for recurrent glioblastoma multiforme (GBM) was evaluated in a case—control study.
Methods. All patients who underwent SRS for recurrent GBM before March 2003 formed the case group. A control group of patients who did not undergo SRS was created from an institutional database, and each case was matched for known prognostic factors in GBM. The medical and neuroimaging records of all the patients were reviewed, and survival and treatment outcomes were recorded.
The case and control groups were well matched with regard to demographics and pre-SRS interventions. In the control group, the date on which magnetic resonance imaging identified a recurrent lesion that would have been eligible for SRS was deemed the “SRS” date. The number of surgeries performed in the control group was statistically higher than that in the case group. The median duration of overall survival from diagnosis was 26 months in the case group and 23 months in the control group. From the date of SRS or “SRS”, the median duration of survival was 11 months in the case group and 10 months in the control group, a difference that was not statistically significant.
Conclusions. It appears that a subgroup of patients with GBMs has a higher than expected median survival duration despite the initial prognostic factors. In patients with localized recurrences, survival may be prolonged by applying aggressive local disease management by using either SRS or resection to equal advantage.
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Affiliation(s)
- Anita Mahajan
- Division of Radiation Oncology and the Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Vordermark D, Kölbl O. Lack of survival benefit after stereotactic radiosurgery boost for glioblastoma multiforme: Randomized comparison of stereotactic radiosurgery followed by conventional radiotherapy with carmustine to conventional radiotherapy with carmustine for patients with glioblastoma multiforme: Report of Radiation Therapy Oncology Group 93-05 protocol: In regard to Souhami et al. (Int J Radiat Oncol Biol Phys 2004;60:853–860). Int J Radiat Oncol Biol Phys 2005; 62:296-7; author reply 297. [PMID: 15850943 DOI: 10.1016/j.ijrobp.2005.01.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Polin RS, Marko NF, Ammerman MD, Shaffrey ME, Huang W, Anderson FA, Caputy AJ, Laws ER. Functional outcomes and survival in patients with high-grade gliomas in dominant and nondominant hemispheres. J Neurosurg 2005; 102:276-83. [PMID: 15739555 DOI: 10.3171/jns.2005.102.2.0276] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The goal of this study was to investigate survival and functional outcomes in patients with high-grade intracranial astrocytomas as a function of the location of the lesion in the dominant or nondominant hemisphere (DH and NDH, respectively), and to suggest management strategies for such patients based on these data.
Methods. Data were collected from the Glioma Outcomes Project database, a longitudinal database of demographic, clinical, and outcome data for patients with high-grade intracranial gliomas. From the entire database of 788 patients, a subset of all 280 right-handed patients with newly diagnosed, unilateral gliomas involving potentially eloquent cortex was selected as the sample population. Two cohorts were defined based on the location of the tumor in the right or left cerebral hemisphere. All other relevant demographic and clinical data were nearly identical between the cohorts. A Kaplan—Meier analysis was conducted to assess survival, and Karnofsky Performance Scale scores assigned at 6 and 12 months postoperatively were compared as a measure of functional outcome.
The analysis demonstrated no difference in survival between patients with lesions in the DH and those with tumors in the NDH. Additionally, no statistically significant difference in functional outcomes was observed between the two groups.
Conclusions. Laterality of high-grade gliomas is not an independent prognostic factor for predicting survival or functional outcome. The findings in this study demonstrate that fears of increased postoperative morbidity or mortality in otherwise resectable tumors of the DH are unfounded, and the authors therefore advocate that the surgeon's decision to operate be guided by validated outcome predictors and not biased by tumor lateralization.
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Affiliation(s)
- Richard S Polin
- Department of Neurosurgery, School of Medicine, The George Washington University, Washington, DC 20037, USA.
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92
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Rutkowski S, De Vleeschouwer S, Kaempgen E, Wolff JEA, Kühl J, Demaerel P, Warmuth-Metz M, Flamen P, Van Calenbergh F, Plets C, Sörensen N, Opitz A, Van Gool SW. Surgery and adjuvant dendritic cell-based tumour vaccination for patients with relapsed malignant glioma, a feasibility study. Br J Cancer 2004; 91:1656-62. [PMID: 15477864 PMCID: PMC2409960 DOI: 10.1038/sj.bjc.6602195] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Patients with relapsed malignant glioma have a poor prognosis. We developed a strategy of vaccination using autologous mature dendritic cells loaded with autologous tumour homogenate. In total, 12 patients with a median age of 36 years (range: 11–78) were treated. All had relapsing malignant glioma. After surgery, vaccines were given at weeks 1 and 3, and later every 4 weeks. A median of 5 (range: 2–7) vaccines was given. There were no serious adverse events except in one patient with gross residual tumour prior to vaccination, who repetitively developed vaccine-related peritumoral oedema. Minor toxicities were recorded in four out of 12 patients. In six patients with postoperative residual tumour, vaccination induced one stable disease during 8 weeks, and one partial response. Two of six patients with complete resection are in CCR for 3 years. Tumour vaccination for patients with relapsed malignant glioma is feasible and likely beneficial for patients with minimal residual tumour burden.
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Affiliation(s)
- S Rutkowski
- Department of Pediatric Oncology, Children's Hospital, University of Wuerzburg, Josef-Schneider-Str. 2, D-97080 Wuerzburg, Germany
| | - S De Vleeschouwer
- Laboratory of Experimental Immunology, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
- Department of Neurosurgery, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
| | - E Kaempgen
- Department of Dermatology, University of Erlangen, Hartmennstrasse 14, D-91052 Erlangen, Germany
| | - J E A Wolff
- Department of Pediatric Oncology, St Hedwig, University of Regensburg, Steinmetzstr. 1-3, D-93049 Regensburg, Germany
| | - J Kühl
- Department of Pediatric Oncology, Children's Hospital, University of Wuerzburg, Josef-Schneider-Str. 2, D-97080 Wuerzburg, Germany
| | - P Demaerel
- Department of Radiology, University Hospital Gasthuisberg, Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - M Warmuth-Metz
- Department of Neuroradiology, University of Wuerzburg, Josef-Schneider-Str. 11, D-97080 Wuerzburg, Germany
| | - P Flamen
- Department of Nuclear Medicine, Jules Bordet Institute, Héger-Bordetstraat 1, B-1000 Brussel, Belgium
| | - F Van Calenbergh
- Department of Neurosurgery, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
| | - C Plets
- Department of Neurosurgery, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
| | - N Sörensen
- Department of Pediatric Neurosurgery, University of Wuerzburg, Josef-Schneider-Str. 11, D-97080 Wuerzburg, Germany
| | - A Opitz
- Department of Transfusion Medicine, University of Wuerzburg, Josef-Schneider-Str. 2, D-97080 Wuerzburg, Germany
| | - S W Van Gool
- Laboratory of Experimental Immunology, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
- Department of Pediatrics, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
- University hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium. E-mail:
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Janabi N, Jensen PN, Major EO. Differential effects of interferon-γ on the expression of cyclooxygenase-2 in high-grade human gliomas versus primary astrocytes. J Neuroimmunol 2004; 156:113-22. [PMID: 15465602 DOI: 10.1016/j.jneuroim.2004.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2004] [Revised: 07/22/2004] [Accepted: 07/23/2004] [Indexed: 11/30/2022]
Abstract
We compared effects of interferon-gamma (IFNgamma) on cyclooxygenase-2 (COX-2) expression in malignant human glioma cell lines and cultured primary human astrocytes. While IFNgamma inhibited interleukin-1beta (IL1beta)-induced expression of COX-2 in the glioma cells, it enhanced expression in primary astrocytes. This differential effect correlated with the observed modulation of NFkappaB and AP-1 DNA binding activity; reduced in the glioma cells, increased in primary astrocytes. Furthermore, IFNgamma had a significantly greater anti-proliferative effect on the glioma cells than COX inhibitors. This inhibitory effect of IFNgamma on expression of COX-2 in human glioma cells may have relevance for immunotherapies directed against high-grade gliomas.
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Affiliation(s)
- Nazila Janabi
- Laboratory of Molecular Medicine and Neuroscience, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892-4164, USA. nazila @free.fr
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Lustig RA, Scott CB, Curran WJ. Does Stereotactic Eligibility for the Treatment of Glioblastoma Cause Selection Bias in Randomized Studies? Am J Clin Oncol 2004; 27:516-21. [PMID: 15596923 DOI: 10.1097/01.coc.0000135641.82026.c4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to evaluate the potential selection bias using stereotactic eligibility as a criteria for participation in studies of glioblastoma multiforme. Radiation Therapy Oncology Group (RTOG) 90-06 comparing 60 Gy in 30 fractions with BCNU and 72 Gy in 60 fractions with BCNU was analyzed based on eligibility criteria used to enter patients on RTOG 93-05 using a stereotactic boost for patients with glioblastoma. Five hundred nine patients with histopathologically confirmed glioblastoma multiforme were analyzed; of these, 137 met criteria for 93-05 and 372 did not. Recursive partitioning analysis (RPA) was used to evaluate for differences. The RPA distribution in stereotactic radiosurgery (SRS)-eligible and -ineligible patients was similar. The median survival for RPA class 3 SRS-eligible patients was 1.4 years and -ineligible patients 1.4 years. For RPA class 4, the median survival was 1.0 years for eligible patients and 0.9 years for ineligible patients (P = 0.0421). For class 5 patients, the median survival was 8.3 months versus 7.2 months (P = 0.09). RPA class 6 patients had a median survival of 1.7 months versus 2.7 months for ineligible patients (P = 0.199). By analyzing previously randomized patients in a study not using a stereotactic boost, there does not appear to be a survival benefit for those patients who fit the criteria for consideration of a stereotactic boost in patients with glioblastoma multiforme.
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Affiliation(s)
- Robert A Lustig
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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Jeremic B, Milicic B, Grujicic D, Dagovic A, Aleksandrovic J, Nikolic N. Clinical prognostic factors in patients with malignant glioma treated with combined modality approach. Am J Clin Oncol 2004; 27:195-204. [PMID: 15057161 DOI: 10.1097/01.coc.0000055059.97106.15] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The impact of various clinical pretreatment prognostic factors in patients with malignant glioma treated with a combined modality approach was investigated in 229 patients treated on four consecutive prospective phase II studies. The median survival time for all 229 patients is 14 months, and 2- and 5-year survival rates are 34%, and 9%, respectively. The median time to tumor progression is 14 months, and 2- and 5-year progression-free survival rates are 32%, and 9%, respectively. Females did better than males, while patients 55 years or less did better than those more than 55 years. Patients with Karnofsky performance status (KPS) 80 to 100 did better than those with KPS 50 to 70 as well as did patients having preoperative tumor sizes 4 cm or less when compared to those with larger tumors. Frontal tumor location as well as more extensive surgery favorably influenced survival. Patients harboring anaplastic astrocytoma fared significantly better than those with glioblastoma multiforme. Both univariate and multivariate Cox analyses confirmed independent influence of these prognosticators. When progression-free survival was used as an endpoint, all seven variables remained independent prognosticators. This study showed that sex, age, KPS, tumor size, tumor location, histology, and extent of surgery are independent prognosticators in patients with malignant glioma treated with combined modality approach.
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Ichioka T, Miyatake SI, Asai N, Kajimoto Y, Nakagawa T, Hayashi H, Kuroiwa T. Enhanced detection of malignant glioma xenograft by fluorescein-human serum albumin conjugate. J Neurooncol 2004; 67:47-52. [PMID: 15072447 DOI: 10.1023/b:neon.0000021783.62610.1b] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECT During the surgical resection of malignant gliomas, it is important to make clear the border zone between the tumor tissue and normal brain tissue. For this purpose, we conjugated fluorescein and human serum albumin (FLS-HSA) and compared its effectiveness against that of fluorescein-sodium (FLS-Na) alone in detecting human glioma xenografts in SCID mice through a fluorescence microscope. METHODS We made FLS-HSA conjugate using carbodiimide as a linking reagent. SCID mice, with U251MG cells transplanted subcutaneously, were prepared as tumor models. The animals were sacrificed 15, 30, 60, 180, 360, or 720 min after the intravenous administration of either the FLS-HSA conjugate or FLS-Na alone (n = 3). Fluorescence images were taken with a digital camera, and the brightness of the tumor and that of the peripheral tissue in each image were quantified. In the group of tumor-bearing mice that received FLS-Na, the fluorescence of tumor tissue disappeared 60 min after the reagent was administered, and there was no significant difference in brightness between the tumor and peripheral tissue at any time point. On the other hand, injection of FLS-HSA revealed relative tumor-selective brightness and sufficient contrast between the tumor and surrounding tissue 60 and 360 min after administration. CONCLUSION FLS-HSA has the advantages of specificity and persistence of fluorescence over FLS-Na for the purpose of identifying glioma nodules in xenogenic subcutaneous tumor transplantation models.
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97
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Cho KH, Hall WA, Lo SS, Dusenbery KE. Stereotactic radiosurgery versus fractionated stereotactic radiotherapy boost for patients with glioblastoma multiforme. Technol Cancer Res Treat 2004; 3:41-9. [PMID: 14750892 DOI: 10.1177/153303460400300105] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The aim of this study is to evaluate the efficacy of stereotactic radiotherapy boost (SRB) in patients with glioblastoma multiforme (GBM) by comparing two different regimens, single dose or fractionated treatment. Between December 1994 and January 2000, 24 patients with GBM were treated with SRB in conjunction with external beam radiotherapy (EBRT). Fourteen patients (58%) were treated with stereotactic radiosurgery (SRS) and 10 patients (42%) with fractionated stereotactic radiotherapy (FSRT). Median interval between EBRT and SRS or FSRT was 1.4 months (range -0.4-3.9 months). Actuarial survival rates of the entire 24 patients at one and two years following SRB were 63% and 34% respectively, with median survival time of 16 months. Variables predicting survival were age, extent of surgery, re-operation and the RTOG (Radiation Therapy Oncology Group) classes based on recursive partitioning analysis (RPA). In comparison to historical controls, improved survival benefit after SRB was observed. The median survival times for the RTOG classes 4, 5, and 6 were 28.3, 10.3, and 6.0 months following EBRT+SRB, respectively. Expected values for these classes after EBRT are 11.1, 8.9, and 4.6 months, respectively. This improvement in survival was seen predominantly for the RTOG class 4. There was no difference in survival between SRS and FSRT treated groups. Late complications developed in 4 patients in the SRS group and 1 patients in the FSRT group. Our retrospective data suggest that SRB in conjunction with EBRT may improve survival in patients with GBM with median survival time of 16 months, when compared to historical controls of the RTOG data following EBRT. The addition of SRB appeared to improve the median survival most demonstrably in RTOG RPA class 4 patients. SRS and FSRT are equally effective with similar median survival, but potentially less late complications associated with FSRT. Since this is a nonrandomized study, further investigation is needed to confirm this and to determine an optimal dose/fractionation scheme.
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Affiliation(s)
- Kwan H Cho
- Departments of Therapeutic Radiology and Radiation Oncology, Fairview University Medical Center, University of Minnesota, Minneapolis, MN, USA.
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98
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Chan MF, Schupak K, Burman C, Chui CS, Ling CC. Comparison of intensity-modulated radiotherapy with three-dimensional conformal radiation therapy planning for glioblastoma multiforme. Med Dosim 2004; 28:261-5. [PMID: 14684191 DOI: 10.1016/j.meddos.2003.08.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This study was designed to assess the feasibility and potential benefit of using intensity-modulated radiotherapy (IMRT) planning for patients newly diagnosed with glioblastoma multiforme (GBM). Five consecutive patients with confirmed histopathologically GBM were entered into the study. These patients were planned and treated with 3-dimensional conformal radiation therapy (3DCRT) using our standard plan of 3 noncoplanar wedged fields. They were then replanned with the IMRT method that included a simultaneous boost to the gross tumor volume (GTV). The dose distributions and dose-volume histograms (DHVs) for the planning treatment volume (PTV), GTV, and the relevant critical structures, as obtained with 3DCRT and IMRT, respectively, were compared. In both the 3DCRT and IMRT plans, 59.4 Gy was delivered to the GTV plus a margin of 2.5 cm, with doses to critical structures below the tolerance threshold. However, with the simultaneous boost in IMRT, a higher tumor dose of approximately 70 Gy could be delivered to the GTV, while still maintaining the uninvolved brain at dose levels of the 3DCRT technique. In addition, our experience indicated that IMRT planning is less labor intensive and time consuming than 3DCRT planning. Our study shows that IMRT planning is feasible and efficient for radiotherapy of GBM. In particular, IMRT can deliver a simultaneous boost to the GTV while better sparing the normal brain and other critical structures.
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Affiliation(s)
- Maria F Chan
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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99
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Oh J, Henry RG, Pirzkall A, Lu Y, Li X, Catalaa I, Chang S, Dillon WP, Nelson SJ. Survival analysis in patients with glioblastoma multiforme: Predictive value of choline-to-n-acetylaspartate index, apparent diffusion coefficient, and relative cerebral blood volume. J Magn Reson Imaging 2004; 19:546-54. [PMID: 15112303 DOI: 10.1002/jmri.20039] [Citation(s) in RCA: 152] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To investigate the potential value of pre-external-beam radiation therapy (XRT) choline-to-NAA (N-acetylaspartate) index (CNI), apparent diffusion coefficient (ADC), and relative cerebral blood volume (rCBV) for predicting survival in newly diagnosed patients with glioblastoma multiforme (GBM). MATERIALS AND METHODS Twenty-eight patients with GBM were studied using in vivo proton magnetic resonance spectroscopic imaging (1H MRSI) and diffusion- and perfusion-weighted imaging after surgery but prior to XRT. Patients were categorized on the basis of their volumes of morphologic and metabolic abnormalities (volume of CNI > or = 2 and CNI values), normalized ADC (nADC), or rCBV values within the T1 contrast-enhancing and T2 regions. The median survival time was compared. RESULTS A significantly shorter median survival time was observed for patients with a large volume of metabolic abnormality than for those with a small abnormality (12.0 and 17.1 months, respectively, P = 0.002). A similar pattern was observed for patients with a low mean nADC value compared to those with high mean nADC value within the T2 region (11.2 and 21.7 months, respectively, P = 0.004). A shorter median survival time was also observed for patients with contrast-enhancing residual disease than for those without the presence of contrast enhancement with marginal significance. CONCLUSION The pre-XRT volume of the metabolic abnormality and the nADC value within the T2 region may be valuable in predicting outcome for patients with GBM.
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Affiliation(s)
- Joonmi Oh
- Magnetic Resonance Science Center, Department of Radiology, University of California, San Francisco, California 94107, USA.
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Jeremic B, Milicic B, Grujicic D, Dagovic A, Aleksandrovic J. Multivariate analysis of clinical prognostic factors in patients with glioblastoma multiforme treated with a combined modality approach. J Cancer Res Clin Oncol 2003; 129:477-84. [PMID: 12884028 DOI: 10.1007/s00432-003-0471-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2003] [Accepted: 06/16/2003] [Indexed: 10/26/2022]
Abstract
We investigated the influence of various clinical prognostic factors in patients with glioblastoma multiforme (GBM) treated with a combined modality approach. A total of 175 patients with GBM was treated in four consecutive prospective phase II studies using surgery, hyperfractionated or accelerated hyperfractionated radiotherapy (RT) and either adjuvant or concurrent or pre-irradiation chemotherapy (CHT) between January 1988 and December 1993. The median survival time for all 175 patients was 14 months and 1-3-year survival (OS) rates were 57%, 34% and 24%, respectively. The median time to tumour progression was 12 months, and 1-3-year progression-free survival (PFS) rates were 43%, 11% and 7%, respectively. Survival analysis showed that of all investigated prognostic factors, only gender did not influence survival. Patients </=55 years did better than those >55 years; patients with KPS 80-100 did better than those with KPS 50-70; patients with frontal tumours did better than those with tumours in other locations; patients with tumours up to 4 cm did better than those with larger tumours, as did patients with either subtotal or gross total tumour resection when compared to those undergoing biopsy only. Multivariate analysis showed that gender and tumour location did not independently influence survival. When PFS was used as the endpoint, only gender did not influence PFS, as confirmed by multivariate analysis.
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Affiliation(s)
- Branislav Jeremic
- Department of Oncology, University Hospital, Kragujevac, Yugoslavia.
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