Combined modality therapy of operated astrocytomas grade III and IV. Confirmation of the value of postoperative irradiation and lack of potentiation of bleomycin on survival time: a prospective multicenter trial of the Scandinavian Glioblastoma Study Group

Canadian recommendations for the treatment of glioblastoma multiforme

Recommendation 1

Management of patients with glioblastoma multiforme (gbm) should be highly individualized and should take a multidisciplinary approach involving neuro-oncology, neurosurgery, radiation oncology, and pathology, to optimize treatment outcomes. Patients and caregivers should be kept informed of the progress of treatment at every stage.

Recommendation 2

Sufficient tissue should be obtained during surgery for cytogenetic analysis and, whenever feasible, for tumour banking.

Recommendation 3

Surgery is an integral part of the treatment plan, to establish a histopathologic diagnosis and to achieve safe, maximal, and feasible tumour resection, which may improve clinical signs and symptoms.

Recommendation 4

The preoperative imaging modality of choice is magnetic resonance imaging (mri) with gadolinium as the contrast agent. Other imaging modalities, such as positron emission tomography with [¹⁸F]-fluoro-deoxy-d-glucose, may also be considered in selected cases. Postoperative imaging (mri or computed tomography) is recommended within 72 hours of surgery to evaluate the extent of resection.

Recommendation 5

Postoperative external-beam radiotherapy is recommended as standard therapy for patients with gbm. The recommended dose is 60 Gy in 2-Gy fractions. The recommended clinical target volume should be identified with gadolinium-enhanced T1-weighted mri, with a margin in the order of 2–3 cm. Target volumes should be determined based on a postsurgical planning mri. A shorter course of radiation may be considered for older patients with poor performance status.

Recommendation 6

During rt, temozolomide 75 mg/m² should be administered concurrently for the full duration of radio-therapy, typically 42 days. Temozolomide should be given approximately 1 hour before radiation therapy, and at the same time on the days that no radiotherapy is scheduled.

Recommendation 7

Adjuvant temozolomide 150 mg/m², in a 5/28-day schedule, is recommended for cycle 1, followed by 5 cycles if well tolerated. Additional cycles may be considered in partial responders. The dose should be increased to 200 mg/m² at cycle 2 if well tolerated. Weekly monitoring of blood count is advised during chemoradiation therapy in patients with a low white blood cell count. Pneumocystis carinii pneumonia has been reported, and prophylaxis should be considered.

Recommendation 8

For patients with stable clinical symptoms during combined radiotherapy and temozolomide, completion of 3 cycles of adjuvant therapy is generally advised before a decision is made about whether to continue treatment, because pseudo-progression is a common phenomenon during this time. The recommended duration of therapy is 6 months. A longer duration may be considered in patients who show continuous improvement on therapy.

Recommendation 9

Selected patients with recurrent gbm may be candidates for repeat resection when the situation appears favourable based on an assessment of individual patient factors such as medical history, functional status, and location of the tumour. Entry into a clinical trial is recommended for patients with recurrent disease.

Recommendation 10

The optimal chemotherapeutic strategy for patients who progress following concurrent chemoradiation has not been determined. Therapeutic and clinical–molecular studies with quality of life outcomes are needed.

Low-grade gliomas in older patients: long-term follow-up from Mayo Clinic

BACKGROUND

Low-grade gliomas (LGGs) are uncommon in older patients, and long-term clinical behavior and prognostic factors are not well defined in this group.

METHODS

The authors retrospectively searched their tumor registry for the records of adult patients (> or =18 years) diagnosed as having nonpilocytic LGG between 1960 and 1992 at Mayo Clinic. The Kaplan-Meier method was used to estimate progression-free survival and overall survival (OS) in patients aged 55 years and older.

RESULTS

Of 314 patients initially identified, 32 were aged at least 55 years, with a median age at diagnosis of 61 years (range, 55-74 years). Median follow-up was 17.3 years for survivors. Operative pathologic diagnoses comprised astrocytoma (n = 22, 69%), mixed oligoastrocytoma (n = 7, 22%), and oligodendroglioma (n = 3, 9%). Gross total resection was achieved in 1 patient, radical subtotal resection in 1, and subtotal resection in 14; 16 patients had biopsy only. Postoperative radiotherapy or chemotherapy was given to 23 (72%) patients and 1 (3%) patient, respectively. Median OS was 2.7 years for all patients: 3 years with resection and 2.2 years with biopsy only (P = .58). The 5- and 10-year OS rates were 31% and 18%, respectively. Factors adversely affecting OS on univariate analysis were enhancement on computed tomography (P < .001) and supratentorial location (P = .03).

CONCLUSIONS

This retrospective series of older patients suggests that intracranial LGG in this age group behaves aggressively. Pathologic sampling error failing to recognize higher-grade tumors does not seem to account for these poor outcomes. Aggressive management with maximally safe resection followed by adjuvant therapy should be strongly considered.

The potential of proton beam radiation therapy in intracranial and ocular tumours

A group of oncologists and hospital physicists have estimated the number of patients in Sweden suitable for proton beam therapy. The estimations have been based on current statistics of tumour incidence, number of patients potentially eligible for radiation treatment, scientific support from clinical trials and model dose planning studies and knowledge of the dose-response relations of different tumours and normal tissues. In intracranial benign and malignant tumours, it is estimated that between 130 and 180 patients each year are candidates for proton beam therapy. Of these, between 50 and 75 patients have malignant glioma, 30-40 meningeoma, 20-25 arteriovenous malformations, 20-25 skull base tumours and 10-15 pituitary adenoma. In addition, 15 patients with ocular melanoma are candidates.

Randomized Phase III controlled trials of therapy in malignant glioma: where are we after 40 years?

The objective of this study was to review the results of randomized Phase III controlled trials (RCTs) that involve initial treatments of malignant glioma and determine changes in median survival times (MST) over the last 40 years. An electronic database search identified RCTs for patients undergoing initial treatment for supratentorial high-grade malignant glioma. MSTs were analysed with respect to the date that patient accrual to the trial started, to identify the time course of changes in MST. Linear regression was used for statistical analysis. The review included 44 clinical trials that recruited patients between 1966 and 2004. Overall, there was a steady significant improvement in MST for the novel treatment cohorts over this period (r(2) = 0.43, p < 0.001), with MST increasing from around 8 to 15 months. There was also consistent improvement in the MST of the control cohorts, from around 7 months to 14 months, that reached statistical significance (r(2) = 0.41, p < 0.001). However, analysis including a quadratic term revealed a trend towards the rate of improvement in MST decreasing in the last two decades in the control, but not novel treatment, groups. The differences, either positive or negative, in MSTs between the control and novel treatment cohorts, and number of trials performed have all decreased with time. Subgroup analysis of the three most recent clinical trials report statistically significant better outcomes in MST after either >90% or 'complete' tumour resection. Despite tremendous advances in both the understanding of the biology of malignant gliomas and treatments in neuro-oncology, the prognosis for patients with malignant gliomas, although improved, remains very poor. The limitations of this type of analysis, including how trial design can bias outcomes and militate against comparison of trials are discussed.

Survival following CyberKnife radiosurgery and hypofractionated radiotherapy for newly diagnosed glioblastoma multiforme

Current therapeutic goals for treatment of Glioblastoma Multiforme (GBM) involve gross total resection followed by multifractionated focal external beam radiation therapy (EBRT). Patients treated with optimal therapy have a median survival of approximately 12-15 months. In the present study, we sought to determine whether a hypofractionated dosing schedule using CyberKnife is at least as effective as multifractionated focal EBRT. A retrospective analysis was conducted on 20 histopathologically confirmed GBM patients treated with CyberKnife at Okayama Kyokuto Hospital in Japan after gross total resection (n=11), subtotal resection (n=8), or biopsy (n=1). Eight patients also received adjuvant ACNU and Vincrisitine chemotherapy according to local protocol; however, no patient received any other form of radiation besides post surgical/biopsy CyberKnife treatment. The treated tumor volumes ranged from 9.62 cm(3)-185.81 cm(3) (mean: 86.08 cm(3)). The marginal dose (D90) ranged from 19.99 Gy-41.47 Gy (mean: 34.58 Gy) with a maximum mean dose of 43.99 Gy (range: 23.33 Gy-56.89 Gy). The prescribed isodose line ranged from 50.38%-85.68% with a mean of 79.25%. Treatment was delivered in 1-8 fractions (mean: 5.65). Patients were followed from 2-36 months (mean: 16.45 months). Overall median survival was 16 months with 55% of patients alive at 12 months and 34% of patients alive at 24 months. Median survival of patients in Recursive Partitioning Analysis (RPA) classes III or IV was 32 months versus 12 months for those in RPA class V. Median survival for patients who received gross total resection was 36 months versus 8 months for those who underwent subtotal resection or biopsy. The results of this study using CyberKnife stereotactic radiosurgery (SRS) and hypofractionated radiotherapy compared favorably to historic data using focal EBRT in newly diagnosed post surgical GBM patients. A larger prospective analysis that compares CyberKnife SRS and hypofractionated radiotherapy to focal EBRT is warranted.

Evaluation of E1A double mutant oncolytic adenovectors in anti-glioma gene therapy

Malignant glioma, in particular glioblastoma multiforme (GBM), represents one of the most devastating cancers currently known and existing treatment regimens do little to change patient prognosis. Conditionally replicating adenoviral vectors (CRAds) represent attractive experimental anti-cancer agents with potential for clinical application. However, early protein products of the wild type adenovirus backbone--such as E1A--limit CRAds' replicative specificity. In this study, we evaluated the oncolytic potency and specificity of CRAds in which p300/CPB and/or pRb binding capacities of E1A were ablated to reduce non-specific replicative cytolysis. In vitro cytopathic assays, quantitative PCR analysis, Western blot, and flow cytometry studies demonstrate the superior anti-glioma efficacy of a double-mutated CRAd, Ad2/24CMV, which harbors mutations that reduce E1A binding to p300/CPB and pRb. When compared to its single-mutated and wild type counterparts, Ad2/24CMV demonstrated attenuated replication and cytotoxicity in representative normal human brain while displaying enhanced replicative cytotoxicity in malignant glioma. These results have implications for the development of double-mutated CRAd vectors for enhanced GBM therapy.

[Should elderly patients with glioblastoma be proposed to radiotherapy?]

In glioblastoma multiform-patients, advanced age has been associated with poor prognosis and decreased tolerance to treatments. The optimal management, especially with irradiation, was not definitively determined in the eighth and ninth decades. The Association of French-speaking neuro-oncologists (Anocef) has recently conducted a randomized clinical trial comparing radiotherapy plus supportive care versus supportive care alone in such patients. Patients aged 70-years and older with newly diagnosed glioblastoma and a Karnofsky performance score of 70 or above were randomly assigned to receive focal irradiation in daily fraction of 1.8 Gy given five days per week for a total dose of 50 Gy plus supportive care or supportive care only. Radiotherapy resulted in a modest but significant improvement in overall survival without reducing quality of life or cognition. However, the optimal regimen of radiotherapy in this fragile population remains uncertain. Abbreviated course of radiotherapy (40 Gy in 15 fractions over 19 days) has been proposed. Analysis of preliminary results showed that efficacy and safety of this hypofractionated accelerated regimen compared favourably with those of classically fractionated treatments. Finally, the potential contribution of surgery and chemotherapy should be evaluated in prospective clinical trials.

Optimizing radiotherapy schedules for elderly glioblastoma multiforme patients

Glioblastoma is the most common malignant primary brain tumor. Despite recent advances, the overall prognosis remains poor with median survivals of approximately 1 year and 5-year survivals of less than 5%. Efforts at risk stratification have identified age and performance status as the most important prognostic features. It is well established that patients treated with postoperative radiation therapy have improved survival and functional capacity compared with unirradiated patients. Recent evidence suggests that the benefit of postoperative radiation persists even within the cohort aged 70 years or over. Some investigators have questioned whether the standard treatment schedule of 60 Gy delivered over a 6-week period is necessary for older patients with limited functional status. Alternative treatment schedules have been devised to reduce the inconvenience and morbidity of standard therapy. This review aims to evaluate the current state of knowledge on alternative radiotherapy schedules for elderly and poor-prognosis patients with glioblastoma.

Adjuvant chemotherapy for adults with malignant glioma: a systematic review

OBJECTIVE

This systematic review examines the role of chemotherapy following surgery and external beam radiotherapy for adults with newly diagnosed malignant glioma.

METHODS

MEDLINE, EMBASE, and the Cochrane Library databases were searched to August 2006 to identify relevant randomized controlled trials (RCTs) and meta-analyses. Proceedings from the 1997 to 2006 annual meetings of the American Society of Clinical Oncology were also searched.

RESULTS

Two RCTs reported a survival advantage in favour of radiotherapy with concomitant and adjuvant temozolomide compared with radiotherapy alone in patients with anaplastic astrocytoma or glioblastoma. Twenty-six RCTs and two meta-analyses detected either no advantage or a small survival advantage in favour of adjuvant chemotherapy.

CONCLUSION

Concomitant temozolomide during radiotherapy and post-radiation adjuvant temozolomide is recommended for all patients ages 18-70 with newly diagnosed glioblastoma multiforme who are fit for radical therapy (ECOG 0-1). Temozolomide may be considered in other situations (i.e., ECOG 2, biopsy only, age > 70, intermediate grade glioma), but there is no high-level evidence to support this decision. Moreover, there are few data on long-term toxicities or quality of life with temozolomide. Adjuvant chemotherapy may be an option for younger patients with anaplastic (grade 3) astrocytoma and patients with pure or mixed oligodendroglioma. However, there is no evidence of a survival advantage from adjuvant chemotherapy in these patients, and treatment-related adverse effects and their impact upon quality of life are poorly studied. The combination of procarbazine, lomustine, and vincristine (PCV) is not recommended for patients with anaplastic oligodendroglioma and oligoastrocytoma.

Application of the Naïve Bayesian Classifier to optimize treatment decisions

BACKGROUND AND PURPOSE

To study the accuracy, specificity and sensitivity of the Naïve Bayesian Classifier (NBC) in the assessment of individual risk of cancer relapse or progression after radiotherapy (RT).

MATERIALS AND METHODS

Data of 142 brain tumour patients irradiated from 2000 to 2005 were analyzed. Ninety-six attributes related to disease, patient and treatment were chosen. Attributes in binary form consisted of the training set for NBC learning. NBC calculated an individual conditional probability of being assigned to: relapse or progression (1), or no relapse or progression (0) group. Accuracy, attribute selection and quality of classifier were determined by comparison with actual treatment results, leave-one-out and cross validation methods, respectively. Clinical setting test utilized data of 35 patients. Treatment results at classification were unknown and were compared with classification results after 3 months.

RESULTS

High classification accuracy (84%), specificity (0.87) and sensitivity (0.80) were achieved, both for classifier training and in progressive clinical evaluation.

CONCLUSIONS

NBC is a useful tool to support the assessment of individual risk of relapse or progression in patients diagnosed with brain tumour undergoing RT postoperatively.

Clinical trial of autologous formalin-fixed tumor vaccine for glioblastoma multiforme patients

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.

Standard fractionation intensity modulated radiation therapy (IMRT) of primary and recurrent glioblastoma multiforme

BACKGROUND

Intensity-modulated radiation therapy (IMRT) affords unparalleled capacity to deliver conformal radiation doses to tumors in the central nervous system. However, to date, there are few reported outcomes from using IMRT, either alone or as a boost technique, for standard fractionation radiotherapy for glioblastoma multiforme (GBM).

METHODS

Forty-two patients were treated with IMRT alone (72%) or as a boost (28%) after 3-dimensional conformal radiation therapy (3D-CRT). Thirty-three patients with primary disease and 9 patients with recurrent tumors were included. Thirty-four patients (81%) had surgery, with gross tumor resection in 13 patients (36%); 22 patients (53%) received chemo-radiotherapy. The median total radiation dose for all patients was 60 Gy with a range from 30.6 to 74 Gy. Standard fractions of 1.8 Gy/day to 2.0 Gy/day were utilized.

RESULTS

Median survival was 8.7 months, with 37 patients (88%) deceased at last contact. Nonparametric analysis showed no survival difference in IMRT-boost vs. IMRT-only groups.

CONCLUSION

While technically feasible, preliminary results suggest delivering standard radiation doses by IMRT did not improve survival outcomes in this series compared to historical controls. In light of this lack of a survival benefit and the costs associated with use of IMRT, future prospective trials are needed to evaluate non-survival endpoints such as quality of life and functional preservation. Short of such evidence, the use of IMRT for treatment of GBM needs to be carefully rationalized.

Systematic review of the diagnostic accuracy of 201Tl single photon emission computed tomography in the detection of recurrent glioma

OBJECTIVE

To determine the diagnostic accuracy of 201Tl SPECT in the detection of tumour recurrence in patients with previous radiotherapy for supratentorial glioma.

METHODS

The databases of PubMed and Embase were searched for relevant studies. Two reviewers independently selected and extracted data on study characteristics, quality and accuracy of studies. Studies were included if they comprised at least six eligible patients who underwent 201Tl SPECT (index test) and in whom (histo)pathological confirmation (reference test) of the suspected brain lesion was obtained. Because of the methodological and statistical heterogeneity of the included studies, a quantitative meta-analysis was not performed. Instead, for every individual study, the sensitivity, specificity and diagnostic odds ratio of 201Tl SPECT was calculated.

RESULTS

Eight studies met the inclusion criteria. Only one was considered of high methodological quality. Methodological limitations referred most notably to blinding and patient selection. The diagnostic odds ratio was greater than 1 in all studies included, with a broad range (2-351), and relatively wide 95% confidence intervals. The sensitivity of 201Tl SPECT ranged from 0.43 to 1.00, and the specificity from 0.25 to 1.00.

CONCLUSION

201Tl SPECT seems a valuable method in the detection of tumour recurrence in patients treated with radiotherapy for supratentorial glioma. However, the evidence is not very robust because of the low quality and high heterogeneity of the studies included. Future studies are warranted to further explore the diagnostic potential of 201Tl SPECT, and to determine optimum thresholds for the detection of glioma recurrence.

Role of exclusive chemotherapy as first line treatment in oligodendroglioma

PURPOSE

The optimal therapy of oligodendrogliomas remains uncertain. Although chemosensitive, these tumors are not chemocurable. We investigated whether chemotherapy delays the need for radiation therapy (RT) without decreasing length and quality of survival.

METHODS AND MATERIALS

Among 89 patients treated for oligodendrogliomas at the Centre Léon Bérard of Lyon from 1982 to 1999, 59 patients fitted inclusion criteria, having had centrally reviewed pure oligodendroglioma requiring treatment. According to the WHO's classification 35 patients had Grade III and 24, Grade II oligodendrogliomas.

RESULTS

According to the intent to treat, patients were retrospectively classified in three groups as exclusive RT (Group 1), radio-chemotherapy (Group 2), or exclusive chemotherapy (Group 3). Median progression-free survival (PFS): was 47 months [95% confidence interval (CI) 39-56], and median overall survival (OS) was 109 months (95% CI 83-134). In univariate analysis, PFS was correlated with frontal location and WHO classification; OS was correlated with frontal location and Post-operative Karnosky performans status both appearing as independent prognostic factors for OS in multivariate analysis. There was no significant difference between the treatment groups with regard to PFS (P = 0.82) and OS (P = 0.64). In the group of patients treated with exclusive chemotherapy the 5-year PFS and OS rates were 44 and 71%, respectively.

CONCLUSION

Front-line exclusive chemotherapy results in prolonged OS in patients with confirmed pure oligodendroglioma. Whether this strategy improves quality of life remains debatable.

Management of Scalp Toxic Epidermal Necrolysis and Cranial Osteomyelitis With Serratus Anterior Myocutaneous Pedicle Flap: A Case Report

The aim of this report is to describe the management of scalp toxic epidermal necrolysis (TEN) and cranial osteomyelitis complicating malignant glioma therapy. A 21-year-old man developed TEN while being radiated and receiving antineoplastic and anticonvulsant therapies for a malignant intracranial glioma. The strategy used to manage the above situation included withdrawal of the medications causing TEN, meticulous dermatological wound care, resection of residual glioma, debridement of scalp and bone, and reconstruction of the scalp and calvarial defect with a myocutaneous vascularized free flap. The scalp wounds have healed completely in a cosmetically acceptable fashion and the patient remains free of tumor recurrence approximately 18 months after surgery, having completed a course of systemic chemotherapy. TEN may complicate the use of anticonvulsant and antineoplastic medications in malignant glioma patients. Withdrawal of the offending agent and immune suppressant medications, skin care and infection control, tumor resection to diminish steroid use, and reconstruction of scalp and calvarial defects with a vascularized myocutaneous flap facilitate wound healing and permit resumption of antineoplastic therapies.

Radiotherapy for glioblastoma in the elderly

BACKGROUND

There is no community standard for the treatment of glioblastoma in patients 70 years of age or older. We conducted a randomized trial that compared radiotherapy and supportive care with supportive care alone in such patients.

METHODS

Patients 70 years of age or older with a newly diagnosed anaplastic astrocytoma or glioblastoma and a Karnofsky performance score of 70 or higher were randomly assigned to receive supportive care only or supportive care plus radiotherapy (focal radiation in daily fractions of 1.8 Gy given 5 days per week, for a total dose of 50 Gy). The primary end point was overall survival; secondary end points were progression-free survival, tolerance of radiotherapy, health-related quality of life, and cognition.

RESULTS

We randomly assigned 85 patients from 10 centers to receive either radiotherapy and supportive care or supportive care alone. The trial was discontinued at the first interim analysis, which showed that with a preset boundary of efficacy, radiotherapy and supportive care were superior to supportive care alone. A final analysis was carried out for the 81 patients with glioblastoma (median age, 73 years; range, 70 to 85). At a median follow-up of 21 weeks, the median survival for the 39 patients who received radiotherapy plus supportive care was 29.1 weeks, as compared with 16.9 weeks for the 42 patients who received supportive care alone. The hazard ratio for death in the radiotherapy group was 0.47 (95% confidence interval, 0.29 to 0.76; P=0.002). There were no severe adverse events related to radiotherapy. The results of quality-of-life and cognitive evaluations over time did not differ significantly between the treatment groups.

CONCLUSIONS

Radiotherapy results in a modest improvement in survival, without reducing the quality of life or cognition, in elderly patients with glioblastoma. (ClinicalTrials.gov number, NCT00430911 [ClinicalTrials.gov].).

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

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.

Chemotherapeutic options for primary brain tumors

Malignant gliomas are the most common primary brain tumors. Despite intensive clinical investigation and many novel therapeutic approaches, treatment for most primary brain tumors remains inadequate. Most are associated with a high rate of recurrence after primary therapy and a dismal outcome following recurrence. Surgery and radiation remain the primary modalities of therapy for malignant brain tumors. The role of chemotherapy in malignant gliomas, especially glioblastoma multiforme, has been inconclusive. However, a recent trial by the European Organisation for Research and Treatment of Cancer and the National Cancer Institute of Canada combining radiation therapy with temozolomide for newly diagnosed glioblastoma patients showed a significantly improved survival benefit over radiation therapy alone. In addition to this encouraging progress, recent experience has shown that selected malignant brain tumors--for example, anaplastic oligodendrogliomas, primary central nervous system lymphomas, medulloblastomas, and intracranial germ cell tumors--are often highly responsive to chemotherapy. Molecular genetic studies are becoming indispensable aids in the diagnosis and treatment of the malignant gliomas. For example, we have learned that allelic loss of chromosome 1p is a significant predictor of chemosensitivity, whereas combined loss of chromosomes 1p and 19q is a strong predictor of chemosensitivity, progression-free survival, and overall survival in patients with anaplastic oligodendroglioma. Similarly, MGMT promoter methylation is associated with more frequent responses and longer survival in patients with glioblastoma multiforme receiving temozolomide-based therapy. These and other recent advances have led to the development and testing of several novel chemotherapeutic and molecular-targeted agents. Several different approaches and modalities to improve the efficacy of chemotherapy (eg, MGMT promoter methylation) are currently under way. Clinical trials implementing angiogenesis inhibitors, biologic modifiers, or molecular-targeted therapies are also actively being investigated.

Radiotherapy and sequential temozolomide compared with radiotherapy with concomitant and sequential temozolomide in the treatment of newly diagnosed glioblastoma multiforme

Our objective was to determine and compare effects of sequential temozolomide vs. concomitant plus sequential temozolomide with conventional radiotherapy, in patients with newly diagnosed glioblastoma multiforme, comparing two independent trials. Sixty-four patients were treated on two consecutive separate phase II studies that used identical eligibility criteria and the same radiotherapy (60 Gy, 2 Gy/day, after surgery) and adjuvant temozolomide (200 mg/m/day for 5 days/28 days until progression), but differed in the absence or presence of a concomitant treatment with temozolomide (75 mg/m/day) during radiotherapy. In the first protocol (1999-2002), 21 patients (median age of 64 years) received radiotherapy alone and sequential temozolomide; in the succeeding protocol (2002-2004), 43 patients (median age of 61 years) with similar characteristics received radiotherapy with concomitant and sequential temozolomide. Median number of adjuvant cycles was five in both trials. Median survival was similar in both studies (18 vs. 17.4 months); overall survival rates at 6, 12, 18 and 24 months of all the population were 89, 69, 45 and 24%. No statistically significant differences were found among prognostic factors considered. Hematologic toxicities were mild and similar, with grade 3-4 neutropenia in 5-7% and grade 3-4 thrombocytopenia in 7-10% of patients in the sequential phases, and grade 3-4 thrombocytopenia in 7% in the concomitant phase of temozolomide. We confirmed that temozolomide combined with radiotherapy is well tolerated and provides a survival advantage compared with historical data using radiotherapy alone. Nevertheless, a concomitant use of temozolomide during radiotherapy does not seem to improve survival, although it does not increase toxicity.

Genetic profiling of a distant second glioblastoma multiforme after radiotherapy: Recurrence or second primary tumor?

OBJECT

In nearly all patients with glioblastoma multiforme (GBM) a local recurrence develops within a short period of time. In this paper the authors describe two patients in whom a second GBM developed after a relatively long time interval at a site remote from the primary tumor. The genetic profiles of the tumors were compared to discriminate between distant recurrence and a second primary tumor.

METHODS

Both patients harboring a supratentorial GBM were treated with surgery and local high-dose radiotherapy. Local control of the disease at the primary tumor site was achieved. Within 2 years, a second GBM developed in both patients, not only outside the previously irradiated target areas but infratentorially in one patient and in the opposite hemisphere in the other. The tumors were examined for the presence of several genetic alterations that are frequently found in GBMs--a loss of heterozygosity at chromosome regions 1p36, 10pl5, 19q13, and 22q13, and at the CDKN2A, PTEN, DMBT1, and TP53 gene regions; a TP53 mutation; and EGFR amplification. In the first patient, genetic profiling revealed that the primary tumor had an allelic imbalance for markers in several chromosome regions for which the second tumor displayed a complete loss. In the second patient, genetic profiling demonstrated the presence of genetic changes in the second tumor that were identical with and additional to those found in the primary tumor.

CONCLUSIONS

Based on the similarities between the genetic profiles of the primary and the second tumors in these patients, the authors decided that in each case the second distant GBM was a distant recurrence rather than a second independent primary tumor.

Detrimental effects of tumor progression on cognitive function of patients with high-grade glioma

PURPOSE

There is growing recognition that the primary cause of cognitive deficits in adult patients with primary brain tumors is the tumor itself and more significantly, tumor progression. To assess the cognitive performance of high-grade glioma patients, prospectively collected cognitive performance data were analyzed.

PATIENTS AND METHODS

We studied 1,244 high-grade brain tumor patients entered onto eight consecutive North Central Cancer Treatment Group treatment trials that used radiation and nitrosourea-based chemotherapy. Imaging studies and Folstein Mini-Mental State Examination (MMSE) scores recorded at baseline, 6, 12, 18, and 24 months were analyzed to assess tumor status and cognitive function over time.

RESULTS

The proportion of patients without tumor progression who experienced clinically significant cognitive deterioration compared with baseline was stable at 6, 12, 18, and 24 months (18%, 16%, 14%, and 13%, respectively). In patients without radiographic evidence of progression, clinically significant deterioration in MMSE scores was a strong predictor of a more rapid time to tumor progression and death. At evaluations preceding interval radiographic evidence of progression, there was significant deterioration in MMSE scores for patients who were to experience progression, whereas the scores remained stable for the patients who did not have tumor progression.

CONCLUSION

The proportion of high-grade glioma patients with cognitive deterioration over time is stable, most consistent with the constant pressure of tumor progression over time. Although other factors may contribute to cognitive decline, the predominant cause of cognitive decline seems to be subclinical tumor progression that precedes radiographic changes.

Phase II trial of radiotherapy after hyperbaric oxygenation with chemotherapy for high-grade gliomas

We conducted a phase II trial to evaluate the efficacy and toxicity of radiotherapy immediately after hyperbaric oxygenation (HBO) with chemotherapy in adults with high-grade gliomas. Patients with histologically confirmed high-grade gliomas were administered radiotherapy in daily 2 Gy fractions for 5 consecutive days per week up to a total dose of 60 Gy. Each fraction was administered immediately after HBO with the period of time from completion of decompression to irradiation being less than 15 min. Chemotherapy consisted of procarbazine, nimustine (ACNU) and vincristine and was administered during and after radiotherapy. A total of 41 patients (31 patients with glioblastoma and 10 patients with grade 3 gliomas) were enrolled. All 41 patients were able to complete a total radiotherapy dose of 60 Gy immediately after HBO with one course of concurrent chemotherapy. Of 30 assessable patients, 17 (57%) had an objective response including four CR and 13 PR. The median time to progression and the median survival time in glioblastoma patients were 12.3 months and 17.3 months, respectively. On univariate analysis, histologic grade (P=0.0001) and Karnofsky performance status (P=0.036) had a significant impact on survival, and on multivariate analysis, histologic grade alone was a significant prognostic factor for survival (P=0.001). Although grade 4 leukopenia and grade 4 thrombocytopenia occurred in 10 and 7% of all patients, respectively, these were transient with no patients developing neutropenic fever or intracranial haemorrhage. No serious nonhaematological or late toxicities were seen. These results indicated that radiotherapy delivered immediately after HBO with chemotherapy was safe with virtually no late toxicity in patients with high-grade gliomas. Further studies are required to strictly evaluate the effectiveness of radiotherapy after HBO for these tumours.

Chemotherapy in the treatment of malignant gliomas

Malignant gliomas are one of the most difficult tumors to treat, with only modest advances being made in the past few decades. Surgery and radiation have had the greatest impact, increasing survival. Chemotherapy modestly increases survival. The use of chemotherapy in the treatment of malignant gliomas is the focus of this paper and the more commonly used agents at diagnosis and relapse are reviewed. Since most patients fail first-, second- and even third-line agents that are commercially available, some of the more relevant new biological compounds will also be discussed. As treatments for brain tumors evolve, it is likely that optimal therapies will come from combination therapies that incorporate target-specific and chemotherapeutic agents.

Patterns of practice and survival in a retrospective analysis of 1722 adult astrocytoma patients treated between 1985 and 2001 in 12 Italian radiation oncology centers

PURPOSE

To analyze the patterns of practice and survival in a series of 1722 adult astrocytoma patients treated in 12 Italian radiotherapy centers.

METHODS AND MATERIALS

A total of 1722 patients were treated with postoperative radiotherapy (90% World Health Organization [WHO] Grade 3-4, 62% male, 44% aged >60 years, 25% with severe neurologic deficits, 44% after gross total resection, 52% with high-dose radiotherapy, and 16% with chemotherapy). Variations in the clinical-therapeutic features in three subsequent periods (1985 through 2001) were evaluated, along with overall survival for the different subgroups.

RESULTS

The proportion of women, of older patients, of those with worse neurologic performance status (NPS), with WHO Grade 4, and with smaller tumors increased with time, as did the proportion of those treated with radical surgery, hypofractionated radiotherapy, and more sophisticated radiotherapy techniques, after staging procedures progressively became more accurate. The main prognostic factors for overall survival were age, sex, neurologic performance status, WHO grade, extent of surgery, and radiation dose.

CONCLUSIONS

Recently, broader selection criteria for radiotherapy were adopted, together with simpler techniques, smaller total doses, and larger fraction sizes for the worse prognostic categories. Younger, fit patients are treated more aggressively, more often in association with chemotherapy. Survival did not change over time. The accurate evaluation of neurologic status is therefore of utmost importance before the best treatment option for the individual patient is chosen.

Survival outcomes in glioblastoma multiforme, including the impact of adjuvant chemotherapy

Glioblastoma is an uncommon cancer, but one that is disproportionately represented in mortality rates. Recent developments in adjuvant chemotherapy have regenerated enthusiasm for the treatment of this tumor. Ongoing translational and clinical research has led to a greater understanding of the biologic and molecular behavior and heterogeneity of this tumor. Recent shifts in treatment standards, as well as further selective individualizing of therapies based on molecular information, promise progress for this difficult-to-treat neoplasm.

Cerebral radiation necrosis: incidence, outcomes, and risk factors with emphasis on radiation parameters and chemotherapy

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.

Changing Paradigms—An Update on the Multidisciplinary Management of Malignant Glioma

Treatment of malignant glioma requires a multidisciplinary team. Treatment includes surgery, radiotherapy, and chemotherapy. Recently developed agents have demonstrated activity against recurrent malignant glioma and efficacy if given concurrently with radiotherapy in the upfront setting. Oligodendroglioma with 1p/19q deletions has been recognized as a distinct pathologic entity with particular sensitivity to radiotherapy and chemotherapy. Randomized trials have shown that early neoadjuvant or adjuvant administration of procarbazine, lomustine, and vincristine chemotherapy prolongs disease-free survival; however, it has no impact on overall survival. Temozolomide, a novel alkylating agent, has shown modest activity against recurrent glioma. In combination with radiotherapy in newly diagnosed patients with glioblastoma, temozolomide significantly prolongs survival. Molecular studies have demonstrated that the benefit is mainly observed in patients whose tumors have a methylated methylguanine methyltransferase gene promoter and are thus unable to repair some of the chemotherapy-induced DNA damage. For lower-grade glioma, the use of chemotherapy remains limited to recurrent disease, and first-line administration is the subject of ongoing clinical trials. Irinotecan and agents like gefitinib, erlotinib, and imatinib targeting the epidermal growth factor receptor and platelet-derived growth factor receptor have shown some promise in recurrent malignant glioma. This review summarizes recent developments, focusing on the clinical management of patients in daily neuro-oncology practice.

Improvement of functional outcome after radical surgery in glioblastoma patients: the efficacy of a navigation-guided fence-post procedure and neurophysiological monitoring

This retrospective study investigated the functional outcomes of patient with glioblastoma receiving radical surgery before and after the adoption of the navigation-guided fence-post (NGFP) procedure and neurophysiological monitoring. We investigated 42 glioblastoma patients receiving radical surgery in our institute between 1980 and 2005. Of the 42 patients, 18 patients from 1980 to 1996 (1st term) underwent radical surgery without navigation system guidance, NGFP, or neurophysiological monitoring; 11 patients from 1997 to 2002 (2nd term) underwent surgery with simple navigation system guidance but without NGFP procedure or neurophysiological monitoring, and 13 patients from 2003 to 2005 (3rd term) underwent surgery with the NGFP procedure and neurophysiological monitoring as appropriate. There were no significance differences between any of the three term groups in age, gender, preoperative KPS score, or 'surgical staging for glioma' according to the difficulty of surgery. The rates of 95% or greater volume reduction in each term were 38.9%, 54.5% and 76.9%. The rates of morbidity were 38.9%, 18.1% and 0%. The change in KPS scores (delta KPS) before and after the perioperative period in each term were -16.1 +/- 6.6 SEM, -9.0 +/- 5.8 SEM and +8.5 +/- 3.7 SEM, respectively. The delta KPS in the 3rd term was significantly better than those of 1st and 2nd terms (P < 0.01, Kruskal-Wallis rank test). The rate of patients who were discharged to home and who resumed daily useful life without assistance was 38.9%, 63.6% and 84.6% in each term, respectively. The mean survival times in each term were 9.9, 14.0 and 16.8 months. The introduction of the NGFP procedure and neurophysiological monitoring in glioblastoma radical surgery improved the functional outcome of patients.

L-(methyl-11C) methionine positron emission tomography for target delineation in resected high-grade gliomas before radiotherapy

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.

Thallium-201 SPECT: the optimal prediction of response in glioma therapy

PURPOSE

The aim of this study was to estimate 201Tl SPECT and CT-MRI cut-off values that lead to a validated prognostic classification for the end-point overall survival, in order to discriminate glioma patients with good and poor prognosis at an early stage during chemotherapeutic treatment.

METHODS

We studied patients who underwent 201Tl SPECT and CT-MRI before and after two courses of chemotherapy. Cut-off values were retrieved from the Cox model. Patients were classified according to the computed cut-off values, creating subgroups of patients with different prognosis in terms of survival [tumour regression (TR); stable disease (SD); tumour progression (TP)]. The differences between the subgroups were assessed by Kaplan-Meier analyses. The predictive performance of the classification procedure was evaluated by a leave-one-out cross-validation method.

RESULTS

201Tl SPECT classified 41% of the patients as SD, 25% as TR and 34% as TP. CT-MRI classified 82% of the patients as SD, and only 4% and 14% as TR and TP, respectively. Of those patients with a relatively long overall survival (i.e. > or =16 months), cross-validation estimates of 201Tl SPECT classification rates were 50% TR and 50% SD, and cross-validation estimates of CT-MRI classification rates were 7% TR, 72% SD, and 21% TP.

CONCLUSION

We constructed a 201Tl SPECT model that makes it possible to identify glioma patients with a good or a poor prognosis at an early stage during chemotherapeutic treatment. With this model, accurate predictions can be made with regard to the expected duration of survival.

Radiothérapie des glioblastomes : de la radiobiologie à la chimiothérapie concomitante

The prognosis of glioblastoma remains extremely poor. Clinical research has been very active for thirty years, and has explored all the concepts developed in the laboratories of radiobiology. Radiosensitisation of hypoxic tumours, hyperfractioned radiotherapy, external beam radiotherapy plus stereotactic radiosurgery or brachytherapy boost, and intensity modulated radiation therapy failed to improve the results of the treatment of these patients. Concomitant chemoradiotherapy has just obtained a new success in the treatment of glioblastoma. The addition of temozolomide to radiotherapy resulted in a statistically significant survival benefit with minimal acute additional toxicity. The challenge remains to improve clinical outcomes further, and some new research pathways are open.

YKL-40 expression is associated with poorer response to radiation and shorter overall survival in glioblastoma

PURPOSE

YKL-40 is a secreted protein that has been reported to be overexpressed in epithelial cancers and gliomas, although its function is unknown. Previous data in a smaller sample set suggested that YKL-40 was a marker associated with a poorer clinical outcome and a genetically defined subgroup of glioblastoma. Here we test these findings in a larger series of patients with glioblastoma, and in particular, determine if tumor YKL-40 expression is associated with radiation response.

EXPERIMENTAL DESIGN

Patients (n=147) with subtotal resections were studied for imaging-assessed changes in tumor size in serial studies following radiation therapy. An additional set (n=140) of glioblastoma patients who underwent a gross-total resection was tested to validate the survival association and extend them to patients with minimal residual disease.

RESULTS

In the subtotal resection group, higher YKL-40 expression was significantly associated with poorer radiation response, shorter time to progression and shorter overall survival. The association of higher YKL-40 expression with poorer survival was validated in the gross-total resection group. In multivariate analysis with both groups combined (n = 287), YKL-40 was an independent predictor of survival after adjusting for patient age, performance status, and extent of resection. YKL-40 expression was also compared with genetically defined subsets of glioblastoma by assessing epidermal growth factor receptor amplification and loss at chromosome 10q, two of the common recurring aberrations in these tumors, using fluorescent in situ hybridization. YKL-40 was significantly associated with 10q loss.

CONCLUSIONS

The findings implicate YKL-40 as an important marker of therapeutic response and genetic subtype in glioblastomas and suggest that it may play an oncogenic role in these tumors.

Cost of temozolomide therapy and global care for recurrent malignant gliomas followed until death

Effectiveness and costs of care and treatment of recurrent malignant gliomas are largely unknown. In this study, 49 patients (32 males, 17 females; mean age, 49; age range, 23-79) were treated with temozolomide (TMZ) for recurrent or progressive malignant gliomas after standard radiation therapy. Cost assessment (payer's perspective) singled out treatment for first recurrence and all costs of care until death. We computed personnel costs as wages; drugs, imaging, and laboratory tests as prices; and hospitalizations as day rates. Patients were administered a median of five TMZ cycles at recurrence. Drug acquisition costs amounted to euro 2206 per cycle (76% of total costs). Seven patients showed no second recurrence (two are still alive), 16 received no further chemotherapy and died after 3.9 months, and 26 received second-line chemotherapy. After the second progression, median survival was 4.0 months (95% confidence interval, 1.8-6.1). Overall monthly costs of care varied between euro 2450 and euro 3242 among the different groups, and median cost-effectiveness and cost utility ranged from euro 28,817 to euro 38,450 and from euro 41,167 to euro 53,369 per life of year and per quality-adjusted life-year gained, respectively. We conclude that despite high TMZ drug acquisition costs, care of recurrent malignant gliomas is comparable to other accepted therapies.

Survival in high-grade glioma: a study of survival in patients unfit for or declining radiotherapy

AIMS

To determine the survival of patients with high-grade glioma (HGG) and a poor prognosis in terms of age or performance status managed with best supportive care alone.

METHODS

An analysis of survival was carried out on 123 patients with HGG declining or judged unfit to receive radiotherapy, on the basis of age or performance status, between February 1998 and October 2003. Karnofsky performance status (KPS), biopsy or resection or no surgery, attendance at clinic and reason for not receiving radiotherapy were prospectively recorded.

RESULTS

Of the 123 patients, three were excluded from the analysis, as no outcome data were available. Median age was 66 years (range 29-91 years), and median KPS was 50 (range 30-100). All 120 patients included had died at the time of analysis. Overall median survival was 68 days (95% CI 56-85), range 2-294 days and interquartile range 35-123 days. Median survival of 22 patients declining radiotherapy was 75 days (95% CI 53-123), of 98 patients unfit for radiotherapy 67 days (95% CI 48-88); non-significant difference P = 0.36. Median survival of 26 patients undergoing biopsy was 95 days (95% CI 66-123), of 56 undergoing surgical resection 74 days (95% CI 47-93), and of 38 receiving no surgical intervention 59 days (95% CI 47-70); non-significant difference P = 0.16.

CONCLUSION

For patients with HGG and a poor prognosis, in terms of age or performance status managed with best supportive care, survival is short. Survival may be too short to benefit from radiotherapy and possibly surgery.

Views of bereaved relatives about quality of survival after radiotherapy for malignant cerebral glioma

OBJECTIVE

To explore the views of bereaved relatives about quality of survival after radiotherapy for malignant cerebral glioma.

DESIGN

Semistructured interviews with the bereaved relatives of 56 previously studied patients with glioma.

SETTING

Patients treated at six London hospitals from 1990 to 1992 surviving between one and 46 months (median, eight).

SUBJECTS

Fifty six relatives (44 spouses, 12 others) seen four to six months after bereavement and 20 again at 13 months.

MAIN OUTCOME MEASURES

Views about quality of life and satisfaction with radiotherapy.

RESULTS

Relatives described quality of life as "good or acceptable" when patients carried on some normal activities or enjoyed social relationships. They described restricted and dependent states, constant deterioration, or loss of social interaction as giving "poor or unacceptable" quality of life. Length of time lived in such states also appeared important. Relatives' views of good or acceptable quality of life were independently related to low initial cognitive or personality change or low distress in the patient after diagnosis, and to their subsequent survival free from physical disability for at least one month. Satisfaction with radiotherapy was related to low initial distress, some degree of surgical resection, and overall length of survival longer than six months.

CONCLUSIONS

Carefully exploring the views of bereaved relatives can bring a useful perspective to difficult treatment decisions. Their values support including disability and distress in quality of life measures, but cast doubt on the QALY-type approach of using full years of survival or time free from disability to judge whether treatments are worthwhile.

Radiologic findings in patients treated with boron neutron capture therapy for glioblastoma multiforme within EORTC trial 11961

PURPOSE

To assess the occurrence and development of cerebral radiologic changes (cerebral atrophy and white matter lesions) in patients treated with boron neutron capture therapy (BNCT) for primary supratentorial glioblastoma multiforme within the European Organization for Research and Treatment of Cancer (EORTC) trial 11961.

METHODS AND MATERIALS

Magnetic resonance imaging (MRI) scans were performed before and after surgery and at 1 week and 2, 4.5, 6, 9, 12, 15, and 18 months after BNCT. For the current study, MRI scans of all assessable patients were analyzed, with emphasis on cerebral atrophy and white matter abnormalities.

RESULTS

Twenty-six patients had been treated with BNCT according to the EORTC trial 11961, of whom 24 were assessable for the current study. The development of possible BNCT-related cerebral changes was observed in 12 patients (50%), 10 of whom had cerebral atrophy (42%) and 10 white matter changes (42%) after a median interval of 7.5 and 4.5 months, respectively.

CONCLUSION

In this study, cerebral radiologic changes appeared in 50% of patients within the first year after BNCT. Although a clear correlation between the BNCT dose and the development of cerebral changes could not be demonstrated, a relationship between the occurrence of these radiologic abnormalities and BNCT seems likely.

Role of Tc-glucoheptonic acid brain single photon emission computed tomography in differentiation of recurrent brain tumour and post-radiation gliosis

Blood-brain barrier imaging of brain tumours is fast attracting interest now that it has been demonstrated that disruption of the blood-brain barrier is essential for uptake of all tumour-seeking agents. The aim of the present study was to differentiate recurrent tumour from post-radiation gliosis using (99m)technetium-glucoheptonate ((99m)Tc-GHA) as a tumour-seeking agent. Brain single photon emission computed tomography (SPECT) with (99m)Tc-GHA was performed in 73 patients with primary malignant brain tumours after radiotherapy, and the results were correlated with the clinical behaviour of the disease on follow up. The SPECT was suggestive of recurrent tumour in 55 patients. The clinical course was consistent with recurrence in 51 of the 55 patients. The clinical course was consistent with radiation necrosis in the remaining 21 patients, which included 17 patients with a negative SPECT and four patients with a positive SPECT study. Mean GHA index in recurrent tumour and post-radiation gliosis was 7.04 +/- 4.35 and 1.88 +/- 1.70, respectively (P = 0.0001). Mean GHA index in high-grade and low-grade glioma was 7.78 +/- 4.73 and 3.15 +/- 2.44, respectively (P = 0.001). (99m)Technetium-glucoheptonate brain SPECT is a sensitive and reliable diagnostic modality to differentiate recurrent tumour from post-radiation gliosis.

Anaplastic astrocytoma: diagnosis, prognosis, and management

The designation of a tumor as anaplastic astrocytoma (AA) reflects a distinct histologic classification of malignant glioma characterized by an abundance of pleomorphic astrocytes with evidence of mitosis. Although these tumors are malignant, they have a better prognosis and a higher likelihood of response to treatment than glioblastoma. Despite advances in brain tumor imaging, making an accurate diagnosis requires the evaluation of tumor tissue and is essential for treatment planning. Currently, most patients undergo maximal surgical debulking of tumor followed by external beam radiation, often with subsequent adjuvant chemotherapy. However, despite the use of these treatment modalities, most tumors recur within a few years and these recurrent tumors are more refractory to subsequent therapies. This review examines the diagnosis, prognosis, and treatment of AAs. Ongoing clinical research investigations are also summarized, reflecting advances in our knowledge of the molecular pathogenesis of these tumors and providing hope for significant improvements in patient outcomes.

Cognitive sequelae of brain radiation in adults

Radiotherapy (RT) is a proven curative and palliative therapeutic tool in the treatment of a wide variety of primary and metastatic brain tumors in adults. Recent advances in multimodality therapy have led to improvement in survival for many cancer patients. As survival has improved, more attention has been directed toward long-term treatment-related morbidity. Specifically, the effect of RT on the long-term cognitive performance of these patients is a major concern. This article reviews the neurocognitive effects of cranial RT on adult patients with brain tumors. Analyses of neurocognitive function are confounded by factors such as surgery, chemotherapy, tumor characteristics, tumor progression, concurrent medical illnesses, neurologic comorbidity, and medications that can contribute to neurocognitive deficits. Risk of deficits after cranial RT is associated with high RT dose, large fraction size, larger field size, and extremes of age at time of treatment. Using modern techniques with moderate total doses (50 to 54 Gy), conformal RT, conventional fractionation, and advanced planning imaging and software, the risks of neurocognitive deficits are quite small and greatly overshadowed by deficits caused by the tumor itself. Further studies need to be undertaken to elucidate the degree and cause of cognitive decline in adult patients undergoing multimodality therapy for cranial tumors.