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Ghaffari-Rafi A, Ghaffari-Rafi S, Leon-Rojas J. Role of Temozolomide Regimen on Survival Outcomes in Molecularly Stratified WHO Grade II Gliomas: A Systematic Review. Asian J Neurosurg 2021; 16:14-23. [PMID: 34211862 PMCID: PMC8202389 DOI: 10.4103/ajns.ajns_186_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/23/2020] [Accepted: 09/27/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE/INTRODUCTION Although a critical chemotherapeutic, temozolomide's optimal regimen for 2016 World Health Organization (WHO) Grade II gliomas remains elusive, hence there is utility in not only cataloging survival outcomes of Grade II glioma subtypes against the background of temozolomide regimens, but also quantifying differences in progression-free survival (PFS) and overall survival (OS). MATERIALS AND METHODS A systematic review of MEDLINE, Embase, and Cochrane Central Register of Controlled Trails was conducted by using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis and the Cochrane Handbook of Systemic Reviews of Interventions. RESULTS Each molecular subtype of WHO Grade II glioma had a different temozolomide regimen identified as optimal in prolonging PFS and OS. For PFS, with temozolomide, the 25th, 50th, and 75th percentiles, were as follows (in months), respectively-A-wt II: 6.90, 12.95, and 19.95; A-mt II: 34.45, 36.01, and 39.60; OD II: 37.90, 46.00, and 55.03 (P = 0.016). For OS, the first quartile (25%), median (50%), third quartile (75%), were respectively identified (in months-A-wt II: 21.6 (median; n = 1); A-mt II: 60.6, 85.2, and 109.8; OD II: 86.1, 96.2, and 106.3 (P = 0.37). CONCLUSION For each tumor molecular subtype, a different temozolomide regimen was identified as optimal for prolonging PFS and OS. Furthermore, regardless of temozolomide regimen, A-wt II had a significantly shorter PFS than A-mt II and OD-II. Overall, the data can provide useful prognostic insight to patients when making critical treatment decisions. Moreover, by cataloging and assessing survival outcomes per temozolomide regimen, such may facilitate future clinical trial design.
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Affiliation(s)
- Arash Ghaffari-Rafi
- John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawaii, USA
| | - Shadeh Ghaffari-Rafi
- Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Jose Leon-Rojas
- Universidad Internacional del Ecuador, Escuela de Medicina, Quito, Ecuador
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Choi BD, Grannan BL, Cahill DP, Curry WT. Commentary: The Glioma-Network Interface: A Review of the Relationship Between Glioma Molecular Subtype and Intratumoral Function. Neurosurgery 2020; 88:E273-E274. [PMID: 33370805 DOI: 10.1093/neuros/nyaa517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/10/2020] [Indexed: 11/12/2022] Open
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EANO guidelines on the diagnosis and treatment of diffuse gliomas of adulthood. Nat Rev Clin Oncol 2020; 18:170-186. [PMID: 33293629 PMCID: PMC7904519 DOI: 10.1038/s41571-020-00447-z] [Citation(s) in RCA: 814] [Impact Index Per Article: 203.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 01/16/2023]
Abstract
In response to major changes in diagnostic algorithms and the publication of mature results from various large clinical trials, the European Association of Neuro-Oncology (EANO) recognized the need to provide updated guidelines for the diagnosis and management of adult patients with diffuse gliomas. Through these evidence-based guidelines, a task force of EANO provides recommendations for the diagnosis, treatment and follow-up of adult patients with diffuse gliomas. The diagnostic component is based on the 2016 update of the WHO Classification of Tumors of the Central Nervous System and the subsequent recommendations of the Consortium to Inform Molecular and Practical Approaches to CNS Tumour Taxonomy — Not Officially WHO (cIMPACT-NOW). With regard to therapy, we formulated recommendations based on the results from the latest practice-changing clinical trials and also provide guidance for neuropathological and neuroradiological assessment. In these guidelines, we define the role of the major treatment modalities of surgery, radiotherapy and systemic pharmacotherapy, covering current advances and cognizant that unnecessary interventions and expenses should be avoided. This document is intended to be a source of reference for professionals involved in the management of adult patients with diffuse gliomas, for patients and caregivers, and for health-care providers. Herein, the European Association of Neuro-Oncology (EANO) provides recommendations for the diagnosis, treatment and follow-up of adult patients with diffuse gliomas. These evidence-based guidelines incorporate major changes in diagnostic algorithms based on the 2016 update of the WHO Classification of Tumors of the Central Nervous System as well as on evidence from recent large clinical trials.
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Schucht P, Lee HR, Mezouar HM, Hewer E, Raabe A, Murek M, Zubak I, Goldberg J, Kovari E, Pierangelo A, Novikova T. Visualization of White Matter Fiber Tracts of Brain Tissue Sections With Wide-Field Imaging Mueller Polarimetry. IEEE TRANSACTIONS ON MEDICAL IMAGING 2020; 39:4376-4382. [PMID: 32822294 DOI: 10.1109/tmi.2020.3018439] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Identification of white matter fiber tracts of the brain is crucial for delineating the tumor border during neurosurgery. A custom-built Mueller polarimeter was used in reflection configuration for the wide-field imaging of thick sections of fixed human brain and fresh calf brain. The maps of the azimuth of the fast optical axis of linear birefringent medium reconstructed from the experimental Mueller matrix images of the specimen by applying a non-linear data compression algorithm showed a strong correlation with the silver-stained sample histology image, which is the gold standard for ex-vivo brain fiber tract visualization. The polarimetric maps of fresh calf brain tissue demonstrated the same trends in the depolarization, the scalar retardance and the azimuth of the fast optical axis as seen in fixed human brain tissue. Thus, label-free imaging Mueller polarimetry shows promise as an efficient intra-operative modality for the visualization of healthy brain white matter fiber tracts, which could improve the accuracy of tumor border detection and, ultimately, patient outcomes.
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105
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Rijnen SJM, Kaya G, Gehring K, Verheul JB, Wallis OC, Sitskoorn MM, Rutten GJM. Cognitive functioning in patients with low-grade glioma: effects of hemispheric tumor location and surgical procedure. J Neurosurg 2020; 133:1671-1682. [PMID: 31731264 DOI: 10.3171/2019.8.jns191667] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors evaluated the cognitive performance of patients with low-grade glioma (LGG) before and after surgery, and specifically investigated 1) the effects of hemispheric tumor location and 2) the type of surgery (either with or without intraoperative stimulation mapping [ISM]). METHODS Patients underwent neuropsychological assessment 1 day before (T0) and 3 months after (T3) surgery. ISM targeted motor and/or language functions, but no other cognitive functions. Using 2-way mixed ANOVAs, differences between groups (i.e., for patients with right- vs left-sided lesions and normative controls [NCs], and also for patients operated on with vs without ISM and NCs), effects over time (T0-T3), and interaction effects in cognitive functioning were explored. Individual changes over time were assessed with reliable change indices for each neuropsychological test. RESULTS In total, 77 patients with LGG were included (38 and 39 patients with right- and left-sided lesions, respectively; and 42 patients with and 35 patients without ISM). The majority of patients who were operated on with ISM had left-sided lesions. Patients with right- and left-sided lesions scored significantly lower on 6 and 3 out of 8 tests, respectively, compared to NCs. No significant differences between hemispheric groups were found at T0 or at T3. Patients with left-sided lesions showed significant deterioration of performance on verbal memory and sustained attention over time. Patients who underwent operation with versus without ISM scored significantly lower on 6 and 3 out of 8 tests, respectively, compared to NCs. Patients in the ISM group scored significantly lower on the Stroop test, shifting attention test, and verbal fluency test than patients without ISM. Also, the ISM group showed a significant decline in mean cognitive flexibility and sustained attention performance over time. CONCLUSIONS Cognitive impairments were found in patients irrespective of hemispheric tumor location, whereby patients who were operated on with ISM performed slightly worse after surgery than patients without ISM. The authors conclude that there is room for improvement of cognitive functioning in surgically treated patients with LGG. The use of specific tests for higher cognitive functions during surgery may potentially improve functional outcome, but that is to be determined in future studies and balanced against oncological outcome. Implementation of neuropsychological assessments into the clinical management of patients with LGG should be encouraged, to inform and alert patients and clinicians on the status of cognitive functioning.
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Affiliation(s)
- Sophie J M Rijnen
- 1Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg
- 2Department of Cognitive Neuropsychology, Tilburg University, Tilburg; and
| | - Gülizar Kaya
- 1Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg
| | - Karin Gehring
- 1Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg
- 2Department of Cognitive Neuropsychology, Tilburg University, Tilburg; and
| | - Jeroen B Verheul
- 1Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg
| | - Olga C Wallis
- 3Department of Medical Psychology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
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Experience with awake throughout craniotomy in tumour surgery: technique and outcomes of a prospective, consecutive case series with patient perception data. Acta Neurochir (Wien) 2020; 162:3055-3065. [PMID: 33006649 DOI: 10.1007/s00701-020-04561-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/28/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Awake craniotomy is the standard of care in surgery of tumours located in eloquent parts of the brain. However, high variability is recorded in multiple parameters, including anaesthetic techniques, mapping paradigms and technology adjuncts. The current study is focused primarily on patients' level of consciousness, surgical technique, and experience based on a cohort of 50 consecutive cases undergoing awake throughout craniotomy (ATC). METHODS Data was collected prospectively for 46 patients undergoing 50 operations over 14-month period, by the senior author, including demographics, extent of resection (EOR), adverse intraoperative events, surgical morbidity, surgery duration, levels of O2 saturation and brain oedema. A prospective, patient experience questionnaire was delivered to 38 patients. RESULTS The ATC technique was well tolerated in all patients. Once TCI stopped, all patients were immediately assessable for mapping. Despite > 75% of cases being considered inoperable/high risk, gross total resection (GTR) was achieved in 68% patients and subtotal resection in 20%. The average duration of surgery was 220 min with no episodes of hypoxia. Early and late severe deficits recorded in 12% and 2%, respectively. No stimulation-induced seizures or failed ATCs were recorded. Patient-recorded data showed absent/minimal pain during (1) clamp placement in 95.6% of patients; (2) drilling in 94.7% of patients; (3) surgery in 78.9% of patients. Post-operatively, 92.3% of patients reported willingness to repeat the ATC, if necessary. CONCLUSIONS The current ATC paradigm allows immediate brain mapping, maximising patient comfort during self-positioning. Despite the cohort of challenging tumour location, satisfactory EOR was achieved with acceptable morbidity and no adverse intraoperative events.
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107
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Mair MJ, Geurts M, van den Bent MJ, Berghoff AS. A basic review on systemic treatment options in WHO grade II-III gliomas. Cancer Treat Rev 2020; 92:102124. [PMID: 33227622 DOI: 10.1016/j.ctrv.2020.102124] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/20/2020] [Accepted: 10/22/2020] [Indexed: 02/07/2023]
Abstract
WHO grade II-III gliomas are rare primary brain tumors occurring at a median age of about 35-55 years. Median survival is longer in WHO grade II-III glioma compared with WHO grade IV glioblastoma as survival times of up to 10 years and longer can be observed. Maximal safe resection and adjuvant therapies including chemotherapy and radiotherapy are the mainstay of treatment. Clinical trials in WHO grade II-III tumors are challenging due to the rarity and the long follow up times. The 2016 WHO Classification of Central Nervous Tumours introduced a new diagnostic framework relying on molecular characteristics, providing the definition of prognostically more homogenous subgroups compared to the histopathological analysis. Most available evidence on the adjuvant treatment of WHO II-III gliomas was generated in the pre-molecular era, challenging the interpretation of study results. The present review therefore summarizes the available data from prospective trials on systemic treatment options in WHO grade II-III glioma, considering molecular markers, recently published results and future outlooks in the field.
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Affiliation(s)
- Maximilian J Mair
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Marjolein Geurts
- The Brain Tumor Center at Erasmus Medical Center Cancer Institute, Dr.Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
| | - Martin J van den Bent
- The Brain Tumor Center at Erasmus Medical Center Cancer Institute, Dr.Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
| | - Anna S Berghoff
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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108
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Intraoperative brain mapping of language, cognitive functions, and social cognition in awake surgery of low-grade gliomas located in the right non-dominant hemisphere. Clin Neurol Neurosurg 2020; 200:106363. [PMID: 33203593 DOI: 10.1016/j.clineuro.2020.106363] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 10/24/2020] [Accepted: 11/07/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The aim of our study was to evaluate the usefulness of cortical-subcortical intraoperative brain mapping (ioBM) in resective awake surgery of low-grade gliomas (LGG) of the right non-dominant hemisphere (RndH). It was estimated how ioBM may affect both the extent of resection and postoperative outcome of language, spatial cognition, social cognition, and executive functions including attention and working memory. PATIENTS AND METHODS Fifteen patients that underwent ioBM in resective awake surgery of LGG located on the RndH, were included. A cohort of 15 patients with the same tumour location operated under general anaesthesia without brain mapping was used as control. Specific intraoperative tasks for each location were carried out and results registered. Neuropsychological assessment was performed preoperatively and at 6 months after surgery. RESULTS In the group of patients operated by using ioBM in awake surgery, an 86.66 % mean of resection was obtained compared to 60.33 % in the control group. Speech arrest and incorrect naming responses were elicited in higher proportion in frontal and insular locations. Parietal stimulation associated higher number of incorrect responses in social cognition task. Parietal and temporal stimulation were more frequently associated with incorrect performance of spatial cognition task. Parietal stimulation associated with higher frequency incorrect execution of attention and working memory tasks. After comparing clinical and neuropsychological results in both cohorts, worst outcome at 6 months was observed in the group of patients operated under general anaesthesia without brain mapping, especially in parietal and insular locations. CONCLUSIONS Intraoperative identification of language, cognitive functions, and social cognition of RndH by means of ioBM, can be of paramount importance in improving the extent of resection of low-grade gliomas and positively affects clinical and neuropsychological outcome at six months.
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109
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Abstract
The work of modern neurosurgical glioma practice combines securing accurate diagnoses, under the 2016 revised World Health Organization (WHO) Classification of Tumors of the Central Nervous System, with an aggressive and safe surgical pursuit of tumor removal. The evidence base that drives clinical decision-making has undergone a critical reevaluation with the incorporation of molecular classifiers into the updated WHO diagnoses including the 3 most common diffuse gliomas in adults: glioblastoma IDH wild-type, astrocytoma IDH mutant, and oligodendroglioma IDH mutant 1p/19q codeleted. The studies that form the foundation of modern practice, and the areas for future inquiry are reviewed.
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Affiliation(s)
- Daniel P Cahill
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey 9E, Boston, MA 02114, USA.
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110
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Kavouridis VK, Boaro A, Dorr J, Cho EY, Iorgulescu JB, Reardon DA, Arnaout O, Smith TR. Contemporary assessment of extent of resection in molecularly defined categories of diffuse low-grade glioma: a volumetric analysis. J Neurosurg 2020; 133:1291-1301. [PMID: 31653812 PMCID: PMC7348099 DOI: 10.3171/2019.6.jns19972] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 06/24/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While the effect of increased extent of resection (EOR) on survival in diffuse infiltrating low-grade glioma (LGG) patients is well established, there is still uncertainty about the influence of the new WHO molecular subtypes. The authors designed a retrospective analysis to assess the interplay between EOR and molecular classes. METHODS The authors retrospectively reviewed the records of 326 patients treated surgically for hemispheric WHO grade II LGG at Brigham and Women's Hospital and Massachusetts General Hospital (2000-2017). EOR was calculated volumetrically and Cox proportional hazards models were built to assess for predictive factors of overall survival (OS), progression-free survival (PFS), and malignant progression-free survival (MPFS). RESULTS There were 43 deaths (13.2%; median follow-up 5.4 years) among 326 LGG patients. Median preoperative tumor volume was 31.2 cm3 (IQR 12.9-66.0), and median postoperative residual tumor volume was 5.8 cm3 (IQR 1.1-20.5). On multivariable Cox regression, increasing postoperative volume was associated with worse OS (HR 1.02 per cm3; 95% CI 1.00-1.03; p = 0.016), PFS (HR 1.01 per cm3; 95% CI 1.00-1.02; p = 0.001), and MPFS (HR 1.01 per cm3; 95% CI 1.00-1.02; p = 0.035). This result was more pronounced in the worse prognosis subtypes of IDH-mutant and IDH-wildtype astrocytoma, for which differences in survival manifested in cases with residual tumor volume of only 1 cm3. In oligodendroglioma patients, postoperative residuals impacted survival when exceeding 8 cm3. Other significant predictors of OS were age at diagnosis, IDH-mutant and IDH-wildtype astrocytoma classes, adjuvant radiotherapy, and increasing preoperative volume. CONCLUSIONS The results corroborate the role of EOR in survival and malignant transformation across all molecular subtypes of diffuse LGG. IDH-mutant and IDH-wildtype astrocytomas are affected even by minimal postoperative residuals and patients could potentially benefit from a more aggressive surgical approach.
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Affiliation(s)
- Vasileios K. Kavouridis
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Alessandro Boaro
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jeffrey Dorr
- Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Elise Y. Cho
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - J. Bryan Iorgulescu
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - David A. Reardon
- Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Omar Arnaout
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Timothy R. Smith
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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111
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Brar K, Hachem LD, Badhiwala JH, Mau C, Zacharia BE, de Moraes FY, Pirouzmand F, Mansouri A. Management of Diffuse Low-Grade Glioma: The Renaissance of Robust Evidence. Front Oncol 2020; 10:575658. [PMID: 33117714 PMCID: PMC7560299 DOI: 10.3389/fonc.2020.575658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 08/31/2020] [Indexed: 12/20/2022] Open
Abstract
The surgical management of diffuse low-grade gliomas (DLGGs) has undergone a paradigm shift toward striving for maximal safe resection when feasible. While extensive observational data supports this transition, unbiased evidence in the form of high quality randomized-controlled trials (RCTs) is lacking. Furthermore, despite a high volume of molecular, genetic, and imaging data, the field of neuro-oncology lacks personalized care algorithms for individuals with DLGGs based on a robust foundation of evidence. In this manuscript, we (1) discuss the logistical and philosophical challenges hindering the development of surgical RCTs for DLGGs, (2) highlight the potential impact of well-designed international prospective observational registries, (3) discuss ways in which cutting-edge computational techniques can be harnessed to generate maximal insight from high volumes of multi-faceted data, and (4) outline a comprehensive plan of action that will enable a multi-disciplinary approach to future DLGG management, integrating advances in clinical medicine, basic molecular research and large-scale data mining.
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Affiliation(s)
- Karanbir Brar
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Laureen D Hachem
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Christine Mau
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States.,Penn State Cancer Institute, Hershey, PA, United States
| | - Fabio Ynoe de Moraes
- Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Farhad Pirouzmand
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States.,Penn State Cancer Institute, Hershey, PA, United States
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"Do I want to know it all?" A qualitative study of glioma patients' perspectives on receiving information about their diagnosis and prognosis. Support Care Cancer 2020; 29:3339-3346. [PMID: 33125538 PMCID: PMC8062391 DOI: 10.1007/s00520-020-05846-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/21/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE Glioma patients have poor prognosis. The amount of detail of disease-related information patients wish to receive is not known. The aim of this study was to explore glioma patients' experiences and preferences regarding receiving information on diagnosis and prognosis. METHODS Semi-structured interviews were performed with patients diagnosed with glioma. The interviews were analysed by qualitative content analysis without predefined categories by two independent coders. RESULTS Ten women and 15 men, with newly diagnosed grade II-IV glioma, age 25-76 years, were interviewed. Participants' experience on diagnosis communication was either indirect, meaning they found out their diagnosis unintentionally, e.g., from their electronic health record (EHR) instead of from their doctor, this causing anxiety and feelings of abandonment, insufficiently tailored: lacking in many aspects or individualised and compassionate. Participants generally wanted to know "the truth" about diagnosis and prognosis, but what they meant varied; some desired full honest information to allow for autonomous choices, others preferred general information without details, and some wanted no bad news at all, only positive information. Participants disclosed vulnerability after receiving their diagnosis, being cast into the unknown. They expressed a need for better everyday practical information to help create some control. Supportive staff could reduce participants' distress. CONCLUSION There is a need to further develop and implement individually tailored information to glioma patients, both in consultations and patient-accessed EHR systems, which should have safe guards for sensitive information. Not all patients want to know it all, one size does not fit all.
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113
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Obara T, Blonski M, Brzenczek C, Mézières S, Gaudeau Y, Pouget C, Gauchotte G, Verger A, Vogin G, Moureaux JM, Duffau H, Rech F, Taillandier L. Adult Diffuse Low-Grade Gliomas: 35-Year Experience at the Nancy France Neurooncology Unit. Front Oncol 2020; 10:574679. [PMID: 33194684 PMCID: PMC7656991 DOI: 10.3389/fonc.2020.574679] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/20/2020] [Indexed: 01/14/2023] Open
Abstract
Background To report survival, spontaneous prognostic factors, and treatment efficacy in a French monocentric cohort of diffuse low-grade glioma (DLGG) patients over 35 years of follow-up. Methods A monocentric retrospective study of 339 patients diagnosed with a new DLGG between 01/01/1982 and 01/01/2017 was created. Inclusion criteria were patient age ≥18 years at diagnosis and histological diagnosis of WHO grade II glioma (according to 1993, 2007, and 2016 WHO classifications). The survival parameters were estimated using the Kaplan-Meier method with a 95% confidence interval. Differences in survival were tested for statistical significance by the log-rank test. Factors were considered significant when p ≤ 0.1 and p ≤ 0.05 in the univariate and multivariate analyses, respectively. Results A total of 339 patients were included with a median follow-up of 8.7 years. The Kaplan-Meier median overall survival was 15.7 years. At the time of radiological diagnosis, Karnofsky Performance Status score and initial tumor volume were significant independent prognostic factors. Oncological prognostic factors were the extent of resection for patients who underwent surgery and the timing of radiotherapy for those concerned. In this study, patients who had delayed radiotherapy (provided remaining low grade) did not have worse survival compared with patients who had early radiotherapy. The functional capabilities of the patients were preserved enough so that they could remain independent during at least three quarters of the follow-up. Conclusion This large monocentric series spread over a long time clarifies the effects of different therapeutic strategies and their combination in the management of DLGG.
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Affiliation(s)
- Tiphaine Obara
- Centre de Recherche en Automatique Nancy France - UMR 7039 - BioSiS Department, Faculty of Medicine, Université de Lorraine, Vandoeuvre-lès-Nancy, France.,Neurology Departement, Neurooncology Unit, CHRU, Nancy, France
| | - Marie Blonski
- Centre de Recherche en Automatique Nancy France - UMR 7039 - BioSiS Department, Faculty of Medicine, Université de Lorraine, Vandoeuvre-lès-Nancy, France.,Neurology Departement, Neurooncology Unit, CHRU, Nancy, France
| | - Cyril Brzenczek
- Centre de Recherche en Automatique Nancy France - UMR 7039 - BioSiS Department, Faculty of Medicine, Université de Lorraine, Vandoeuvre-lès-Nancy, France
| | - Sophie Mézières
- Department of Mathematics, Elie Cartan Institute, Nancy, France.,INRIA Biology, Genetics and Statistics, Nancy, France
| | - Yann Gaudeau
- Centre de Recherche en Automatique Nancy France - UMR 7039 - BioSiS Department, Faculty of Medicine, Université de Lorraine, Vandoeuvre-lès-Nancy, France
| | - Celso Pouget
- Department of Pathology, CHRU, Nancy, France.,Centre de Ressources Biologiques, BB-0033-00035, CHRU Nancy, France
| | - Guillaume Gauchotte
- Department of Pathology, CHRU, Nancy, France.,Centre de Ressources Biologiques, BB-0033-00035, CHRU Nancy, France
| | - Antoine Verger
- Department of Nuclear Medicine and Nancyclotep Imaging Platform, CHRU Nancy, France.,IADI, INSERM U1254, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Guillaume Vogin
- UMR 7365 CNRS, IMoPA Biopole Lorraine University Faculty of Medicine, Université de Lorraine, Vandoeuvre-lès-Nancy, France.,Department of Radiation Therapy, Baclese Radiation Therapy Centre, Esch/Alzette, Luxembourg
| | - Jean-Marie Moureaux
- Centre de Recherche en Automatique Nancy France - UMR 7039 - BioSiS Department, Faculty of Medicine, Université de Lorraine, Vandoeuvre-lès-Nancy, France
| | - Hugues Duffau
- Department of Neurosurgery, Montpellier University Medical Center, Gui de Chauliac Hospital, Montpellier, France.,Team "Plasticity of Central Nervous System, Stem Cells and Glial Tumors", U1051 Laboratory, National Institute for Health and Medical Research (INSERM), Institute for Neurosciences of Montpellier, Montpellier University Medical Center, Montpellier, France
| | - Fabien Rech
- Department of Neurosurgery, CHRU, Nancy, France
| | - Luc Taillandier
- Centre de Recherche en Automatique Nancy France - UMR 7039 - BioSiS Department, Faculty of Medicine, Université de Lorraine, Vandoeuvre-lès-Nancy, France.,Neurology Departement, Neurooncology Unit, CHRU, Nancy, France
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114
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Solomons MR, Rees JH. Seizure outcomes and survival in adult low-grade glioma over 11 years: living longer and better. Neurooncol Pract 2020; 7:578-579. [PMID: 33016956 DOI: 10.1093/nop/npaa028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
| | - Jeremy H Rees
- National Hospital for Neurology and Neurosurgery, London, UK.,UCL Queen Square Institute of Neurology, London, UK
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115
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Darlix A, Rigau V, Duffau H. Neoformazioni intracraniche: gliomi di grado II. Neurologia 2020. [DOI: 10.1016/s1634-7072(20)44227-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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116
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Senft C, Behrens M, Lortz I, Wenger K, Filipski K, Seifert V, Forster MT. The ability to return to work: a patient-centered outcome parameter following glioma surgery. J Neurooncol 2020; 149:403-411. [PMID: 32960402 PMCID: PMC7609423 DOI: 10.1007/s11060-020-03609-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/31/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND With refinements in diagnosis and therapy of gliomas, the importance of survival time as the sole outcome parameter has decreased, and patient-centered outcome parameters have gained interest. Pursuing a profession is an indispensable component of human happiness. The aim of this study was to analyze the professional outcomes besides their neuro-oncological and functional evaluation after surgery for gliomas in eloquent areas. METHODS We assessed neuro-oncological and functional outcomes of patients with gliomas WHO grades II and III undergoing surgery between 2012 and 2018. All patients underwent routine follow-up and adjuvant treatment. Treatment and survival parameters were collected prospectively. Repercussions of the disease on the patients' professional status, socio-economic situation, and neurocognitive function were evaluated retrospectively with questionnaires. RESULTS We analyzed data of 58 patients with gliomas (WHO II: 9; III: 49). Median patient age was 35.8 years (range 21-63 years). Awake surgery techniques were applied in 32 patients (55.2%). Gross total and subtotal tumor resections were achieved in 33 (56.9%) and 17 (29.3%) patients, respectively, whereas in 8 patients (13.8%) resection had to remain partial. Most patients (n = 46; 79.3%) received adjuvant treatment. Median follow up was 43.8 months (range 11-82 months). After treatment 41 patients (70.7%) were able to resume a working life. Median time until returning to work was 8.0 months (range 0.2-22.0 months). To be younger than 40 at the time of the surgery was associated with a higher probability to return to work (p < .001). Multivariable regression analysis showed that patient age < 40 years as well as occupational group and self-reported fatigue were factors independently associated with the ability to return to work. CONCLUSION The ability to resume professional activities following brain tumor surgery is an important patient-oriented outcome parameter. We found that the majority of patients with gliomas were able to return to work following surgical and adjuvant treatment. Preservation of neurological function is of utmost relevance for individual patients´ quality of life.
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Affiliation(s)
- Christian Senft
- Department of Neurosurgery, Goethe-University Hospital, Schleusenweg 2-16, 60528, Frankfurt, Germany. .,University Cancer Center Frankfurt - UCT, Frankfurt, Germany.
| | - Marion Behrens
- Department of Neurology, Goethe-University Hospital, Frankfurt, Germany
| | - Irina Lortz
- Department of Neurosurgery, Goethe-University Hospital, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Katharina Wenger
- Institute of Neuroradiology, Goethe-University Hospital, Frankfurt, Germany.,University Cancer Center Frankfurt - UCT, Frankfurt, Germany
| | - Katharina Filipski
- Neurological Institute (Edinger-Institute), Goethe-University, Frankfurt, Germany.,University Cancer Center Frankfurt - UCT, Frankfurt, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Heidelberg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe-University Hospital, Schleusenweg 2-16, 60528, Frankfurt, Germany.,University Cancer Center Frankfurt - UCT, Frankfurt, Germany
| | - Marie-Thérèse Forster
- Department of Neurosurgery, Goethe-University Hospital, Schleusenweg 2-16, 60528, Frankfurt, Germany.,University Cancer Center Frankfurt - UCT, Frankfurt, Germany
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117
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Giambattista J, Omene E, Souied O, Hsu FH. Modern Treatments for Gliomas Improve Outcome. CURRENT CANCER THERAPY REVIEWS 2020. [DOI: 10.2174/1573394715666191017153045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Glioma is the most common type of tumor in the central nervous system (CNS). Diagnosis
is through history, physical examination, radiology, histology and molecular profiles. Magnetic
resonance imaging is a standard workup for all CNS tumors. Multidisciplinary team management
is strongly recommended. The management of low-grade gliomas is still controversial
with regards to early surgery, radiotherapy, chemotherapy, or watchful waiting watchful waiting.
Patients with suspected high-grade gliomas should undergo an assessment by neurosurgeons for
the consideration of maximum safe resection to achieve optimal tumor debulking, and to provide
adequate tissue for histologic and molecular diagnosis. Post-operative radiotherapy and/or chemotherapy
are given depending on disease grade and patient performance. Glioblastoma are mostly
considered incurable. Treatment approaches in the elderly, pediatric population and recurrent
gliomas are discussed with the latest updates in the literature. Treatment considerations include
performance status, neurocognitive functioning, and co-morbidities. Important genetic mutations,
clinical trials and guidelines are summarized in this review.
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Affiliation(s)
| | - Egiroh Omene
- Vancouver Cancer Centre, BC Cancer Agency, Columbia, Vancouver, BC, Canada
| | - Osama Souied
- Vancouver Cancer Centre, BC Cancer Agency, Columbia, Vancouver, BC, Canada
| | - Fred H.C. Hsu
- Vancouver Cancer Centre, BC Cancer Agency, Columbia, Vancouver, BC, Canada
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118
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Heiland DH, Ohle R, Cipriani D, Franco P, Delev D, Behriger SP, Kellner E, Petrova G, Neidert N, Mader I, Nuñez MF, Urbach H, Sankowski R, Beck J, Schnell O. Characterization of longitudinal transformation of T2-hyperintensity in oligodendroglioma. BMC Cancer 2020; 20:818. [PMID: 32854646 PMCID: PMC7450792 DOI: 10.1186/s12885-020-07290-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/11/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Oligodendroglioma (ODG) are CNS resistant tumors characterized by their unique molecular signature, namely a combined deletion of 1p and 19q simultaneously to an IDH1/2 mutation. These tumors have a more favorable clinical outcome compared to other gliomas and a long-time survival that ranges between 10 and 20 years. However, during the course of the disease, multiple recurrences occur and the optimal treatment at each stage of the disease remains unclear. Here we report a retrospective longitudinal observation study of 836 MRI examinations in 44 ODG patients. METHODS We quantified the volume of T2-hyperintensity to compute growth behavior in dependence of different treatment modalities, using various computational models. RESULTS The identified growth pattern revealed dynamic changes, which were found to be patient-specific an did not correlate with clinical parameter or therapeutic interventions. Further, we showed that, surgical resection is beneficial for overall survival regardless the WHO grad or timepoint of surgery. To improve overall survival, an extent of resection above 50% is required. Multiple resections do not generally improve overall survival, except a greater extent of resection than in previous surgeries was achieved. CONCLUSIONS Our data aids to improve the interpretation of MRI images in clinical practice.
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Affiliation(s)
- Dieter H Heiland
- Translational NeuroOncology Research Group, Medical Center, University of Freiburg, Freiburg, Germany. .,Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany. .,Medical Faculty, Freiburg University, Freiburg, Germany.
| | - Robin Ohle
- Translational NeuroOncology Research Group, Medical Center, University of Freiburg, Freiburg, Germany.,Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Medical Faculty, Freiburg University, Freiburg, Germany
| | - Debora Cipriani
- Translational NeuroOncology Research Group, Medical Center, University of Freiburg, Freiburg, Germany.,Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Medical Faculty, Freiburg University, Freiburg, Germany
| | - Pamela Franco
- Translational NeuroOncology Research Group, Medical Center, University of Freiburg, Freiburg, Germany.,Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Medical Faculty, Freiburg University, Freiburg, Germany
| | - Daniel Delev
- Department of Neurosurgery, University of Aachen, Aachen, Germany
| | - Simon P Behriger
- Translational NeuroOncology Research Group, Medical Center, University of Freiburg, Freiburg, Germany.,Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Medical Faculty, Freiburg University, Freiburg, Germany
| | - Elias Kellner
- Medical Physics, Department of Radiology, Medical Centre - University of Freiburg, Freiburg, Germany
| | - Gergana Petrova
- Translational NeuroOncology Research Group, Medical Center, University of Freiburg, Freiburg, Germany.,Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Medical Faculty, Freiburg University, Freiburg, Germany
| | - Nicolas Neidert
- Translational NeuroOncology Research Group, Medical Center, University of Freiburg, Freiburg, Germany.,Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Medical Faculty, Freiburg University, Freiburg, Germany
| | - Irina Mader
- Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and Adolescents, Schön Klinik, Vogtareuth, Germany
| | - Mateo Fariña Nuñez
- Translational NeuroOncology Research Group, Medical Center, University of Freiburg, Freiburg, Germany.,Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Medical Faculty, Freiburg University, Freiburg, Germany
| | - Horst Urbach
- Medical Faculty, Freiburg University, Freiburg, Germany.,Department of Neuroradiology, Medical Center - University of Freiburg, Freiburg, Germany
| | - Roman Sankowski
- Medical Faculty, Freiburg University, Freiburg, Germany.,Institute of Neuropathology, Medical Center - University of Freiburg, Freiburg, Germany.,Berta-Ottenstein-Programme for Clinician Scientists Medical Center, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Medical Faculty, Freiburg University, Freiburg, Germany
| | - Oliver Schnell
- Translational NeuroOncology Research Group, Medical Center, University of Freiburg, Freiburg, Germany.,Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Medical Faculty, Freiburg University, Freiburg, Germany
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119
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Scherer M, Ahmeti H, Roder C, Gessler F, Jungk C, Pala A, Mayer B, Senft C, Tatagiba M, Synowitz M, Wirtz CR, Unterberg AW, Coburger J. Surgery for Diffuse WHO Grade II Gliomas: Volumetric Analysis of a Multicenter Retrospective Cohort From the German Study Group for Intraoperative Magnetic Resonance Imaging. Neurosurgery 2020; 86:E64-E74. [PMID: 31574147 DOI: 10.1093/neuros/nyz397] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 07/18/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In diffuse WHO grade II gliomas (LGG), the extent of resection (EOR) required to achieve significant survival benefits remains elusive. OBJECTIVE To evaluate the association of residual volume (RV) and EOR with progression-free survival (PFS) or overall survival (OS) in LGG in a retrospective, multicenter series by the German study group of intraoperative MRI (GeSGIM). METHODS Consecutive cases were retrospectively assessed from 5 centers. Tumors were volumetrically quantified before and after surgery, and clinical data were analyzed, including IDH mutations and neurologic deficits. Kaplan-Meier estimates, accelerated failure time models (AFT), and multivariate Cox regression models were calculated to identify determinants of survival. RESULTS A total of 140 cases were analyzed. Gross total resection (GTR) was associated with significantly longer PFS compared to any incomplete resection (P = .009). A significant survival disadvantage was evident even for small (>0-5 ml) residuals and increased for moderate (>5-20 ml) and large remnants (>20 ml) P = .001). Accordingly, PFS increased continuously for 20% incremental steps of EOR (P < .001). AFT models supported the notion of a continuous association of RV and EOR with PFS. Multivariate Cox regression models confirmed RV (P = .01) and EOR (P = .005) as continuous prognosticators of PFS. Univariate analysis showed significant associations of RV and EOR with OS. CONCLUSION Our data support the hypothesis of a continuous relationship of RV and EOR with survival for LGG with superiority seen for GTR. Hence, GTR should be achieved whenever safely feasible, and resections should be maximized whenever tumor has to be left behind to spare function.
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Affiliation(s)
- Moritz Scherer
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Hajrulla Ahmeti
- Department of Neurosurgery, University of Schleswig-Holstein, Kiel, Germany
| | - Constantin Roder
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Florian Gessler
- Department of Neurosurgery, University of Frankfurt, Frankfurt, Germany
| | - Christine Jungk
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Andrej Pala
- Department of Neurosurgery, University of Ulm, Günzburg, Germany
| | - Benjamin Mayer
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Christian Senft
- Department of Neurosurgery, University of Frankfurt, Frankfurt, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Michael Synowitz
- Department of Neurosurgery, University of Schleswig-Holstein, Kiel, Germany
| | | | | | - Jan Coburger
- Department of Neurosurgery, University of Ulm, Günzburg, Germany
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120
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Albuquerque LAF, Almeida JP, de Macêdo Filho LJM, Joaquim AF, Duffau H. Extent of resection in diffuse low-grade gliomas and the role of tumor molecular signature-a systematic review of the literature. Neurosurg Rev 2020; 44:1371-1389. [PMID: 32770298 DOI: 10.1007/s10143-020-01362-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/20/2020] [Accepted: 07/28/2020] [Indexed: 01/06/2023]
Abstract
There is a lack of class I evidence concerning the impact of surgery in the treatment of diffuse low-grade glioma; the early maximal resection with preservation of eloquent brain areas has been accepted as the first therapeutic option. We performed a systematic review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and protocol. Inclusion criteria: only case series with at least 100 patients containing supratentorial hemispheric diffuse low-grade glioma (according to any of the WHO classification used in papers published between 2000 to 2019), with pre- and postoperative MRI study were included in the qualitative and quantitative analyses. The extent of resection should be defined based on MRI at least in two categories and correlated with patients' outcomes (with univariate or multivariate analyses) using overall survival (OS) or malignant progression-free survival (MPFS). A total of 18 series with 4386 patients, published in 20 papers, were included in this systematic review. All the series that evaluates the relation between the extent of resection (EOR) and OS showed a statistically significant improvement of OS at univariate and/or multivariate analyzes with a greater EOR. Six studies showed a statistically significant improvement of MPFS with a greater EOR. We demonstrate that when a more rigorous analysis of EOR is performed, a benefit of a more aggressive resection on OS and MPFS is observed. Our review about EOR in different molecular groups of DLGG also suggests a benefit of maximum safe resection for all different subtypes, even though "radical surgery" may be associated with better OS and MPFS in tumors with a more aggressive signature.
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Affiliation(s)
- Lucas Alverne F Albuquerque
- Department of Neurosurgery, General Hospital of Fortaleza, Fortaleza, Ceará, Brazil. .,Department of Neurology, University of Campinas, Campinas, São Paulo, Brazil.
| | - João Paulo Almeida
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Andrei F Joaquim
- Department of Neurology, University of Campinas, Campinas, São Paulo, Brazil
| | - Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
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121
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Galldiks N, Unterrainer M, Judov N, Stoffels G, Rapp M, Lohmann P, Vettermann F, Dunkl V, Suchorska B, Tonn JC, Kreth FW, Fink GR, Bartenstein P, Langen KJ, Albert NL. Photopenic defects on O-(2-[18F]-fluoroethyl)-L-tyrosine PET: clinical relevance in glioma patients. Neuro Oncol 2020; 21:1331-1338. [PMID: 31077276 DOI: 10.1093/neuonc/noz083] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND O-(2-[18F]-fluoroethyl)-L-tyrosine (FET) PET has a sensitivity of more than 90% to detect gliomas. In the remaining small fraction of gliomas without increased tracer uptake, some tumors even show photopenic defects whose clinical significance is unclear. METHODS Glioma patients with a negative FET PET scan prior to neuropathological confirmation were identified retrospectively. Gliomas were rated visually as (i) having indifferent FET uptake or (ii) photopenic, if FET uptake was below background activity. FET uptake in the area of signal hyperintensity on the T2/fluid attenuated inversion recovery-weighted MRI was evaluated by mean standardized uptake value (SUV) and mean tumor-to-brain ratio (TBR). The progression-free survival (PFS) of photopenic gliomas was compared with that of gliomas with indifferent FET uptake. RESULTS Of 100 FET-negative gliomas, 40 cases with photopenic defects were identified. Fifteen of these 40 cases (38%) had World Health Organization (WHO) grades III and IV gliomas. FET uptake in photopenic gliomas was significantly decreased compared with both the healthy-appearing brain tissue (SUV, 0.89 ± 0.26 vs 1.08 ± 0.23; P < 0.001) and gliomas with indifferent FET uptake (TBR, 0.82 ± 0.09 vs 0.96 ± 0.13; P < 0.001). Irrespective of the applied treatment, isocitrate dehydrogenase (IDH)-mutated WHO grade II diffuse astrocytoma patients with indifferent FET uptake (n = 25) had a significantly longer PFS than patients with IDH-mutated diffuse astrocytomas (WHO grade II) with photopenic defects (n = 11) (51 vs 24 mo; P = 0.027). The multivariate survival analysis indicated that photopenic defects predict an unfavorable PFS (P = 0.009). CONCLUSION Photopenic gliomas in negative FET PET scans should be managed more actively, as they seem to have a higher risk of harboring a higher-grade glioma and an unfavorable outcome.
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Affiliation(s)
- Norbert Galldiks
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany.,Institute of Neuroscience and Medicine (INM-3/-4), Reseach Center Juelich, Juelich, Germany.,Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, Germany
| | - Marcus Unterrainer
- Department of Nuclear Medicine, Ludwig-Maximilians-University of Munich (LMU), Munich, Germany
| | - Natalie Judov
- Institute of Neuroscience and Medicine (INM-3/-4), Reseach Center Juelich, Juelich, Germany
| | - Gabriele Stoffels
- Institute of Neuroscience and Medicine (INM-3/-4), Reseach Center Juelich, Juelich, Germany
| | - Marion Rapp
- Department of Neurosurgery, University of Düsseldorf, Düsseldorf, Germany
| | - Philipp Lohmann
- Institute of Neuroscience and Medicine (INM-3/-4), Reseach Center Juelich, Juelich, Germany
| | - Franziska Vettermann
- Department of Nuclear Medicine, Ludwig-Maximilians-University of Munich (LMU), Munich, Germany
| | - Veronika Dunkl
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | | | - Jörg C Tonn
- Department of Neurosurgery, LMU, Munich, Germany
| | | | - Gereon R Fink
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany.,Institute of Neuroscience and Medicine (INM-3/-4), Reseach Center Juelich, Juelich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, Ludwig-Maximilians-University of Munich (LMU), Munich, Germany
| | - Karl-Josef Langen
- Institute of Neuroscience and Medicine (INM-3/-4), Reseach Center Juelich, Juelich, Germany.,Department of Nuclear Medicine, University of Aachen, Aachen, Germany
| | - Nathalie L Albert
- Department of Nuclear Medicine, Ludwig-Maximilians-University of Munich (LMU), Munich, Germany
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122
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Ge C, Gu IYH, Jakola AS, Yang J. Deep semi-supervised learning for brain tumor classification. BMC Med Imaging 2020; 20:87. [PMID: 32727476 PMCID: PMC7391541 DOI: 10.1186/s12880-020-00485-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 07/13/2020] [Indexed: 12/01/2022] Open
Abstract
Background This paper addresses issues of brain tumor, glioma, classification from four modalities of Magnetic Resonance Image (MRI) scans (i.e., T1 weighted MRI, T1 weighted MRI with contrast-enhanced, T2 weighted MRI and FLAIR). Currently, many available glioma datasets often contain some unlabeled brain scans, and many datasets are moderate in size. Methods We propose to exploit deep semi-supervised learning to make full use of the unlabeled data. Deep CNN features were incorporated into a new graph-based semi-supervised learning framework for learning the labels of the unlabeled data, where a new 3D-2D consistent constraint is added to make consistent classifications for the 2D slices from the same 3D brain scan. A deep-learning classifier is then trained to classify different glioma types using both labeled and unlabeled data with estimated labels. To alleviate the overfitting caused by moderate-size datasets, synthetic MRIs generated by Generative Adversarial Networks (GANs) are added in the training of CNNs. Results The proposed scheme has been tested on two glioma datasets, TCGA dataset for IDH-mutation prediction (molecular-based glioma subtype classification) and MICCAI dataset for glioma grading. Our results have shown good performance (with test accuracies 86.53% on TCGA dataset and 90.70% on MICCAI dataset). Conclusions The proposed scheme is effective for glioma IDH-mutation prediction and glioma grading, and its performance is comparable to the state-of-the-art.
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Affiliation(s)
- Chenjie Ge
- Dept. of Electrical Engineering, Chalmers Univ. of Technoloogy, Gothenburg, 41296, Sweden.
| | - Irene Yu-Hua Gu
- Dept. of Electrical Engineering, Chalmers Univ. of Technoloogy, Gothenburg, 41296, Sweden
| | - Asgeir Store Jakola
- Sahlgrenska University Hospital and Inst. of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, 41345, Sweden
| | - Jie Yang
- Inst. of Image Processing and Pattern Recognition, Shanghai Jiao Tong Univ., Shanghai, 200240, China
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123
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Yahanda AT, Patel B, Shah AS, Cahill DP, Sutherland G, Honeycutt J, Jensen RL, Rich KM, Dowling JL, Limbrick DD, Dacey RG, Kim AH, Leuthardt EC, Dunn GP, Zipfel GJ, Leonard JR, Smyth MD, Shah MV, Abram SR, Evans J, Chicoine MR. Impact of Intraoperative Magnetic Resonance Imaging and Other Factors on Surgical Outcomes for Newly Diagnosed Grade II Astrocytomas and Oligodendrogliomas: A Multicenter Study. Neurosurgery 2020; 88:63-73. [DOI: 10.1093/neuros/nyaa320] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/24/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Few studies use large, multi-institutional patient cohorts to examine the role of intraoperative magnetic resonance imaging (iMRI) in the resection of grade II gliomas.
OBJECTIVE
To assess the impact of iMRI and other factors on overall survival (OS) and progression-free survival (PFS) for newly diagnosed grade II astrocytomas and oligodendrogliomas.
METHODS
Retrospective analyses of a multicenter database assessed the impact of patient-, treatment-, and tumor-related factors on OS and PFS.
RESULTS
A total of 232 resections (112 astrocytomas and 120 oligodendrogliomas) were analyzed. Oligodendrogliomas had longer OS (P < .001) and PFS (P = .01) than astrocytomas. Multivariate analyses demonstrated improved OS for gross total resection (GTR) vs subtotal resection (STR; P = .006, hazard ratio [HR]: .23) and near total resection (NTR; P = .02, HR: .64). GTR vs STR (P = .02, HR: .54), GTR vs NTR (P = .04, HR: .49), and iMRI use (P = .02, HR: .54) were associated with longer PFS. Frontal (P = .048, HR: 2.11) and occipital/parietal (P = .003, HR: 3.59) locations were associated with shorter PFS (vs temporal). Kaplan-Meier analyses showed longer OS with increasing extent of surgical resection (EOR) (P = .03) and 1p/19q gene deletions (P = .02). PFS improved with increasing EOR (P = .01), GTR vs NTR (P = .02), and resections above STR (P = .04). Factors influencing adjuvant treatment (35.3% of patients) included age (P = .002, odds ratio [OR]: 1.04) and EOR (P = .003, OR: .39) but not glioma subtype or location. Additional tumor resection after iMRI was performed in 105/159 (66%) iMRI cases, yielding GTR in 54.5% of these instances.
CONCLUSION
EOR is a major determinant of OS and PFS for patients with grade II astrocytomas and oligodendrogliomas. Intraoperative MRI may improve EOR and was associated with increased PFS.
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Affiliation(s)
- Alexander T Yahanda
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Bhuvic Patel
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Amar S Shah
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Daniel P Cahill
- Department of Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Garnette Sutherland
- Department of Neurological Surgery, University of Calgary School of Medicine, Calgary, Canada
| | - John Honeycutt
- Department of Neurological Surgery, Cook Children's Medical Center, Fort Worth, Texas
| | - Randy L Jensen
- Department of Neurological Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Joshua L Dowling
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - David D Limbrick
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ralph G Dacey
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Eric C Leuthardt
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Gavin P Dunn
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Jeffrey R Leonard
- Department of Neurological Surgery, Ohio State University College of Medicine, Columbus, Ohio
| | - Matthew D Smyth
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Mitesh V Shah
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Steven R Abram
- Department of Neurological Surgery, St. Thomas Hospital, Nashville, Tennessee
| | - John Evans
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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Lahiff MN, Ghali MGZ. The Ethical Dilemma in the Surgical Management of Low Grade Gliomas According to the Variable Availability of Resources and Surgeon Experience. Asian J Neurosurg 2020; 15:266-271. [PMID: 32656117 PMCID: PMC7335147 DOI: 10.4103/ajns.ajns_296_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 12/20/2019] [Indexed: 11/04/2022] Open
Abstract
Low grade gliomas (LGGs) affect young individuals in the prime of life. Management may alternatively include biopsy and observation or surgical resection. Recent evidence strongly favors maximal and supramaximal resection of LGGs in optimizing survival metrics. Awake craniotomy with cortical mapping and electrical stimulation along with other preoperative and intraoperative surgical adjuncts, including intraoperative magnetic resonance and diffusion tensor imaging, facilitates maximization of resection and eschews precipitating neurological deficits. Intraoperative imaging permits additional resection of identified residual to be completed within the same surgical session, improving extent of resection and consequently progression free and overall survival. These resources are available in only a few centers throughout the United States, raising an ethical dilemma as to where patients harboring LGGs should most appropriately be treated.
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Affiliation(s)
- Marshall Norman Lahiff
- School of Law, University of Miami, Miami, Florida, USA.,Walton Lantaff Schoreder and Carson LLP, Miami, Florida, USA
| | - Michael George Zaki Ghali
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, Philadelphia, Pennsylvania, USA.,Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
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Arzoine J, Levé C, Pérez-Hick A, Goodden J, Almairac F, Aubrun S, Gayat E, Freyschlag CF, Vallée F, Mandonnet E, Madadaki C. Anesthesia management for low-grade glioma awake surgery: a European Low-Grade Glioma Network survey. Acta Neurochir (Wien) 2020; 162:1701-1707. [PMID: 32128618 DOI: 10.1007/s00701-020-04274-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 02/20/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Awake surgery has become a key treatment of diffuse low-grade gliomas (DLGG) and is divided in three main phases: opening, tumor resection - during which the patient needs to be fully awake - and closure. The anesthetic management of awake neurosurgery is a challenge, and there are currently no guidelines. OBJECTIVE The objective of the survey was to explore differences and commonalities regarding the anesthetic management of awake DLGG surgery within the European Low-Grade Glioma Network (ELGGN) centers. METHODS A form that contained 14 questions about the anesthetic management was sent to 28 centers in May 2015. RESULTS Twenty centers responded. During the opening and closing non-awake periods, 56% of teams chose general anesthesia with mechanical ventilation for at least one period (asleep-awake-asleep, SAS protocol), and 44% monitored anesthesia care including sedation without mechanical ventilation (MAC protocol). In case of SAS, all the teams chose intravenous anesthesia, 82% used laryngeal mask instead of endotracheal intubation during the opening sequence, and 71% during closure. Local and regional anesthesia was practiced by all the teams. The most frequently reported cause of pain was dural and cerebral vessels manipulation (77%). Pain management was mostly based on paracetamol (70%) and remifentanil (55%). CONCLUSION Our survey showed that there was an equivalent proportion of centers using SAS or MAC protocols in the anesthetic management of awake surgery in ELGGN centers. The advantages and disadvantages of each anesthesia protocol were reviewed.
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Affiliation(s)
- Jeremy Arzoine
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
| | - Charlotte Levé
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
- INSERM UMR-942, Paris, France
| | | | - John Goodden
- Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
| | - Fabien Almairac
- Department of Neurosurgery, Hôpital Pasteur II, University Hospital of Nice, Nice, France
| | - Sylvie Aubrun
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
| | - Etienne Gayat
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
- University Paris 7, Paris, France
| | | | - Fabrice Vallée
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
- INSERM UMR-942, Paris, France
| | - Emmanuel Mandonnet
- University Paris 7, Paris, France.
- Department of Neurosurgery, Lariboisière Hospital, APHP, Paris, France.
- Frontlab, Institut du Cerveau et de la Moelle épinière, Inserm U 1127, CNRS UMR 7225, Paris, France.
| | - Catherine Madadaki
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
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Mansouri A, Brar K, Cusimano MD. Considerations for a surgical RCT for diffuse low-grade glioma: a survey. Neurooncol Pract 2020; 7:338-343. [PMID: 32537182 DOI: 10.1093/nop/npz058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Diffuse low-grade gliomas (DLGGs) are heterogeneous tumors that inevitably differentiate into malignant entities, leading to disability and death. Recently, a shift toward up-front maximal safe resection of DLGGs has been favored. However, this transition is not supported by randomized controlled trial (RCT) data. Here, we sought to survey the neuro-oncology community on considerations for a surgical RCT for DLGGs. Methods A 21-question survey focusing on a surgical RCT for DLGGs was developed and validated by 2 neurosurgeons. A sample case of a patient for whom management might be debatable was presented to gather additional insight. The survey was disseminated to members of the Society for Neuro-Oncology (SNO) and responses were collected from March 16 to July 10, 2018. Results A total of 131 responses were collected. Sixty-three of 117 (54%) respondents thought an RCT would not be ethical, 39 of 117 (33%) would consider participating, and 56 of 117 (48%) believed an RCT would be valuable for determining the differing roles of biopsy, surgery, and observation. This was exemplified by an evenly distributed selection of the latter management options for our sample case. Eighty-three of 120 (69.2%) respondents did not believe in equipoise for DLGG patients. Quality of life and overall survival were deemed equally important end points for a putative RCT. Conclusions Based on our survey, it is evident that management of certain DLGG patients is not well defined and an RCT may be justified. As with any surgical RCT, logistic challenges are anticipated. Robust patient-relevant end points and standardization of perioperative adjuncts are necessary if a surgical RCT is undertaken.
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Affiliation(s)
- Alireza Mansouri
- Department of Neurosurgery, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Karanbir Brar
- Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Michael D Cusimano
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada
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Rydén I, Carstam L, Gulati S, Smits A, Sunnerhagen KS, Hellström P, Henriksson R, Bartek J, Salvesen Ø, Jakola AS. Return to work following diagnosis of low-grade glioma: A nationwide matched cohort study. Neurology 2020; 95:e856-e866. [PMID: 32540938 PMCID: PMC7605502 DOI: 10.1212/wnl.0000000000009982] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/27/2020] [Indexed: 01/11/2023] Open
Abstract
Objective Return-to-work (RTW) following diagnosis of infiltrative low-grade gliomas is unknown. Methods Swedish patients with histopathologic verified WHO grade II diffuse glioma diagnosed between 2005 and 2015 were included. Data were acquired from several Swedish registries. A total of 381 patients aged 18–60 were eligible. A matched control population (n = 1,900) was acquired. Individual data on sick leave, compensations, comorbidity, and treatments assigned were assessed. Predictors were explored using multivariable logistic regression. Results One year before surgery/index date, 88% of cases were working, compared to 91% of controls. The proportion of controls working remained constant, while patients had a rapid increase in sick leave approximately 6 months prior to surgery. After 1 and 2 years, respectively, 52% and 63% of the patients were working. Predictors for no RTW after 1 year were previous sick leave (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.88–0.96, p < 0.001), older age (OR 0.96, 95% CI 0.94–0.99, p = 0.005), and lower functional level (OR 0.64 95% CI, 0.45–0.91 p = 0.01). Patients receiving adjuvant treatment were less likely to RTW within the first year. At 2 years, biopsy (as opposed to resection), female sex, and comorbidity were also unfavorable, while age and adjuvant treatment were no longer significant. Conclusions Approximately half of patients RTW within the first year. Lower functional status, previous sick leave, older age, and adjuvant treatment were risk factors for no RTW at 1 year after surgery. Female sex, comorbidity, and biopsy only were also unfavorable for RTW at 2 years.
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Affiliation(s)
- Isabelle Rydén
- From the Section of Clinical Neuroscience, Institute of Neuroscience and Physiology (I.R., L.C., A.S., K.S.S., P.H., A.S.J.), University of Gothenburg, Sahlgrenska Academy; Departments of Neurology (I.R., A.S., P.H.) and Neurosurgery (L.C., A.S.J.), Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Neurosurgery (S.G., A.S.J.), St. Olavs University Hospital HF; Institute of Neuroscience (S.G.) and Department of Public Health and Nursing (Ø.S.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neuroscience (A.S.), Uppsala University; Department of Radiation Sciences & Oncology (R.H.), University of Umeå; Department of Neurosurgery (J.B.), Karolinska University Hospital; Departments of Neuroscience and Medicine (J.B.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurosurgery (J.B.), Copenhagen University Hospital Rigshospitalet, Denmark
| | - Louise Carstam
- From the Section of Clinical Neuroscience, Institute of Neuroscience and Physiology (I.R., L.C., A.S., K.S.S., P.H., A.S.J.), University of Gothenburg, Sahlgrenska Academy; Departments of Neurology (I.R., A.S., P.H.) and Neurosurgery (L.C., A.S.J.), Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Neurosurgery (S.G., A.S.J.), St. Olavs University Hospital HF; Institute of Neuroscience (S.G.) and Department of Public Health and Nursing (Ø.S.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neuroscience (A.S.), Uppsala University; Department of Radiation Sciences & Oncology (R.H.), University of Umeå; Department of Neurosurgery (J.B.), Karolinska University Hospital; Departments of Neuroscience and Medicine (J.B.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurosurgery (J.B.), Copenhagen University Hospital Rigshospitalet, Denmark
| | - Sasha Gulati
- From the Section of Clinical Neuroscience, Institute of Neuroscience and Physiology (I.R., L.C., A.S., K.S.S., P.H., A.S.J.), University of Gothenburg, Sahlgrenska Academy; Departments of Neurology (I.R., A.S., P.H.) and Neurosurgery (L.C., A.S.J.), Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Neurosurgery (S.G., A.S.J.), St. Olavs University Hospital HF; Institute of Neuroscience (S.G.) and Department of Public Health and Nursing (Ø.S.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neuroscience (A.S.), Uppsala University; Department of Radiation Sciences & Oncology (R.H.), University of Umeå; Department of Neurosurgery (J.B.), Karolinska University Hospital; Departments of Neuroscience and Medicine (J.B.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurosurgery (J.B.), Copenhagen University Hospital Rigshospitalet, Denmark
| | - Anja Smits
- From the Section of Clinical Neuroscience, Institute of Neuroscience and Physiology (I.R., L.C., A.S., K.S.S., P.H., A.S.J.), University of Gothenburg, Sahlgrenska Academy; Departments of Neurology (I.R., A.S., P.H.) and Neurosurgery (L.C., A.S.J.), Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Neurosurgery (S.G., A.S.J.), St. Olavs University Hospital HF; Institute of Neuroscience (S.G.) and Department of Public Health and Nursing (Ø.S.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neuroscience (A.S.), Uppsala University; Department of Radiation Sciences & Oncology (R.H.), University of Umeå; Department of Neurosurgery (J.B.), Karolinska University Hospital; Departments of Neuroscience and Medicine (J.B.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurosurgery (J.B.), Copenhagen University Hospital Rigshospitalet, Denmark
| | - Katharina S Sunnerhagen
- From the Section of Clinical Neuroscience, Institute of Neuroscience and Physiology (I.R., L.C., A.S., K.S.S., P.H., A.S.J.), University of Gothenburg, Sahlgrenska Academy; Departments of Neurology (I.R., A.S., P.H.) and Neurosurgery (L.C., A.S.J.), Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Neurosurgery (S.G., A.S.J.), St. Olavs University Hospital HF; Institute of Neuroscience (S.G.) and Department of Public Health and Nursing (Ø.S.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neuroscience (A.S.), Uppsala University; Department of Radiation Sciences & Oncology (R.H.), University of Umeå; Department of Neurosurgery (J.B.), Karolinska University Hospital; Departments of Neuroscience and Medicine (J.B.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurosurgery (J.B.), Copenhagen University Hospital Rigshospitalet, Denmark
| | - Per Hellström
- From the Section of Clinical Neuroscience, Institute of Neuroscience and Physiology (I.R., L.C., A.S., K.S.S., P.H., A.S.J.), University of Gothenburg, Sahlgrenska Academy; Departments of Neurology (I.R., A.S., P.H.) and Neurosurgery (L.C., A.S.J.), Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Neurosurgery (S.G., A.S.J.), St. Olavs University Hospital HF; Institute of Neuroscience (S.G.) and Department of Public Health and Nursing (Ø.S.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neuroscience (A.S.), Uppsala University; Department of Radiation Sciences & Oncology (R.H.), University of Umeå; Department of Neurosurgery (J.B.), Karolinska University Hospital; Departments of Neuroscience and Medicine (J.B.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurosurgery (J.B.), Copenhagen University Hospital Rigshospitalet, Denmark
| | - Roger Henriksson
- From the Section of Clinical Neuroscience, Institute of Neuroscience and Physiology (I.R., L.C., A.S., K.S.S., P.H., A.S.J.), University of Gothenburg, Sahlgrenska Academy; Departments of Neurology (I.R., A.S., P.H.) and Neurosurgery (L.C., A.S.J.), Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Neurosurgery (S.G., A.S.J.), St. Olavs University Hospital HF; Institute of Neuroscience (S.G.) and Department of Public Health and Nursing (Ø.S.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neuroscience (A.S.), Uppsala University; Department of Radiation Sciences & Oncology (R.H.), University of Umeå; Department of Neurosurgery (J.B.), Karolinska University Hospital; Departments of Neuroscience and Medicine (J.B.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurosurgery (J.B.), Copenhagen University Hospital Rigshospitalet, Denmark
| | - Jiri Bartek
- From the Section of Clinical Neuroscience, Institute of Neuroscience and Physiology (I.R., L.C., A.S., K.S.S., P.H., A.S.J.), University of Gothenburg, Sahlgrenska Academy; Departments of Neurology (I.R., A.S., P.H.) and Neurosurgery (L.C., A.S.J.), Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Neurosurgery (S.G., A.S.J.), St. Olavs University Hospital HF; Institute of Neuroscience (S.G.) and Department of Public Health and Nursing (Ø.S.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neuroscience (A.S.), Uppsala University; Department of Radiation Sciences & Oncology (R.H.), University of Umeå; Department of Neurosurgery (J.B.), Karolinska University Hospital; Departments of Neuroscience and Medicine (J.B.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurosurgery (J.B.), Copenhagen University Hospital Rigshospitalet, Denmark
| | - Øyvind Salvesen
- From the Section of Clinical Neuroscience, Institute of Neuroscience and Physiology (I.R., L.C., A.S., K.S.S., P.H., A.S.J.), University of Gothenburg, Sahlgrenska Academy; Departments of Neurology (I.R., A.S., P.H.) and Neurosurgery (L.C., A.S.J.), Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Neurosurgery (S.G., A.S.J.), St. Olavs University Hospital HF; Institute of Neuroscience (S.G.) and Department of Public Health and Nursing (Ø.S.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neuroscience (A.S.), Uppsala University; Department of Radiation Sciences & Oncology (R.H.), University of Umeå; Department of Neurosurgery (J.B.), Karolinska University Hospital; Departments of Neuroscience and Medicine (J.B.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurosurgery (J.B.), Copenhagen University Hospital Rigshospitalet, Denmark
| | - Asgeir Store Jakola
- From the Section of Clinical Neuroscience, Institute of Neuroscience and Physiology (I.R., L.C., A.S., K.S.S., P.H., A.S.J.), University of Gothenburg, Sahlgrenska Academy; Departments of Neurology (I.R., A.S., P.H.) and Neurosurgery (L.C., A.S.J.), Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Neurosurgery (S.G., A.S.J.), St. Olavs University Hospital HF; Institute of Neuroscience (S.G.) and Department of Public Health and Nursing (Ø.S.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neuroscience (A.S.), Uppsala University; Department of Radiation Sciences & Oncology (R.H.), University of Umeå; Department of Neurosurgery (J.B.), Karolinska University Hospital; Departments of Neuroscience and Medicine (J.B.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurosurgery (J.B.), Copenhagen University Hospital Rigshospitalet, Denmark.
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Motomura K, Takeuchi H, Nojima I, Aoki K, Chalise L, Iijima K, Wakabayashi T, Natsume A. Navigated repetitive transcranial magnetic stimulation as preoperative assessment in patients with brain tumors. Sci Rep 2020; 10:9044. [PMID: 32493943 PMCID: PMC7270124 DOI: 10.1038/s41598-020-65944-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 05/13/2020] [Indexed: 12/11/2022] Open
Abstract
We aimed to investigate clinical parameters that affected the results of navigated repetitive transcranial magnetic stimulation (nrTMS) language mapping by comparing the results of preoperative nrTMS language mapping with those of direct cortical stimulation (DCS) mapping. In the prospective, non-randomized study, patients had to meet all of the following inclusion criteria: the presence of left- or right-side brain tumors in the vicinity of or inside the areas anatomically associated with language functions; awake brain surgery scheduled; and age >18 years. Sixty one patients were enrolled, and this study included 42 low-grade gliomas and 19 high-grade gliomas (39 men, 22 women; mean age, 41.1 years, range 18-72 years). The tumor was located in the left and right hemisphere in 50 (82.0%) and 11 (18.0%) patients, respectively. In the 50 patients with left-side gliomas, nrTMS language mapping showed 81.6% sensitivity, 59.6% specificity, 78.5% positive predictive value, and 64.1% negative predictive value when compared with the respective DCS values for detecting language sites in all regions. We then investigated how some parameters, including age, tumor type, tumor volume, and the involvement of anatomical language-related regions, affected different subpopulations. Based on the receiver operating curve statistics, subgroup analysis showed that the non-involvement of language-related regions afforded significantly better the area under the curve (AUC) values (AUC = 0.81, 95% confidence interval (CI): 0.74-0.88) than the involvement of language-related regions (AUC = 0.58, 95% CI: 0.50-0.67; p < 0.0001). Our findings suggest that nrTMS language mapping could be a reliable method, particularly in obtaining responses for cases without tumor-involvement of classical perisylvian language areas.
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Affiliation(s)
- Kazuya Motomura
- Department of Neurosurgery, Nagoya University School of Medicine, Nagoya, Japan.
| | - Hiroki Takeuchi
- Department of Neurosurgery, Higashinagoya National Hospital, Nagoya, Japan
| | - Ippei Nojima
- Department of Physical Therapy, School of Health Sciences, Shinshu University, Nagano, Japan
| | - Kosuke Aoki
- Department of Neurosurgery, Nagoya University School of Medicine, Nagoya, Japan
| | - Lushun Chalise
- Department of Neurosurgery, Nagoya University School of Medicine, Nagoya, Japan
| | - Kentaro Iijima
- Department of Neurosurgery, Nagoya University School of Medicine, Nagoya, Japan
| | | | - Atsushi Natsume
- Department of Neurosurgery, Nagoya University School of Medicine, Nagoya, Japan
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Motomura K, Chalise L, Ohka F, Aoki K, Tanahashi K, Hirano M, Nishikawa T, Yamaguchi J, Shimizu H, Wakabayashi T, Natsume A. Neurocognitive and functional outcomes in patients with diffuse frontal lower-grade gliomas undergoing intraoperative awake brain mapping. J Neurosurg 2020; 132:1683-1691. [PMID: 31100731 DOI: 10.3171/2019.3.jns19211] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 03/04/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Lower-grade gliomas (LGGs) are often observed within eloquent regions, which indicates that tumor resection in these areas carries a potential risk for neurological disturbances, such as motor deficit, language disorder, and/or neurocognitive impairments. Some patients with frontal tumors exhibit severe impairments of neurocognitive function, including working memory and spatial awareness, after tumor removal. The aim of this study was to investigate neurocognitive and functional outcomes of frontal LGGs in both the dominant and nondominant hemispheres after awake brain mapping. METHODS Data from 50 consecutive patients with diffuse frontal LGGs in the dominant and nondominant hemispheres who underwent awake brain surgery between December 2012 and September 2018 were retrospectively analyzed. The goal was to map neurocognitive functions such as working memory by using working memory tasks, including digit span testing and N-back tasks. RESULTS Due to awake language mapping, the frontal aslant tract was frequently identified as a functional boundary in patients with left superior frontal gyrus tumors (76.5%). Furthermore, functional boundaries were identified while evaluating verbal and spatial working memory function by stimulating the dorsolateral prefrontal cortex using the digit span and visual N-back tasks in patients with right superior frontal gyrus tumors (7.1%). Comparing the preoperative and postoperative neuropsychological assessments from the Wechsler Adult Intelligence Scale-Third Edition (WAIS-III) and Wechsler Memory Scale-Revised (WMS-R), significant improvement following awake surgery was observed in mean Perceptual Organization (Z = -2.09, p = 0.04) in WAIS-III scores. Postoperative mean WMS-R scores for Visual Memory (Z = -2.12, p = 0.03) and Delayed Recall (Z = -1.98, p = 0.04) were significantly improved compared with preoperative values for every test after awake surgery. No significant deterioration was noted with regard to neurocognitive functions in a comprehensive neuropsychological test battery. In the postoperative course, early transient speech and motor disturbances were observed in 30.0% and 28.0% of patients, respectively. In contrast, late permanent speech and motor disturbances were observed in 0% and 4.0%, respectively. CONCLUSIONS It is noteworthy that no significant postoperative deterioration was identified compared with preoperative status in a comprehensive neuropsychological assessment. The results demonstrated that awake functional mapping enabled favorable neurocognitive and functional outcomes after surgery in patients with diffuse frontal LGGs.
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Abstract
PURPOSE OF REVIEW Low-grade gliomas (LGG) are a group of primary brain tumors that arise from supporting glial cells. They are characterized by a mutation in the isocitrate dehydrogenase (IDH) enzyme and include astrocytomas and oligodendrogliomas. They usually affect young adults, and their main treatment consists of surgical resection, followed by radiation and chemotherapy in selected patients. This article reviews recent research on the clinical and molecular aspects of the disease and innovative therapeutic modalities in the process. RECENT FINDINGS Newly identified clinical and molecular features are currently used in the classification of LGG and applied in treatment-planning decisions. Advanced studies on the cellular level have an advanced understanding of the metabolic effects induced by IDH mutations, offering opportunities for specific targeted therapies that may improve patient outcomes. Such findings may lead to a paradigm shift in the treatment of these tumors. Although LGG are sensitive to radiation and chemotherapy, these therapies are not curative, and patient survival remains limited, raising the need for more creative and effective interventions.
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Affiliation(s)
- Gilbert Youssef
- Pappas Center for Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Julie J Miller
- Pappas Center for Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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Corell A, Ferreyra Vega S, Hoefling N, Carstam L, Smits A, Olsson Bontell T, Björkman-Burtscher IM, Carén H, Jakola AS. The clinical significance of the T2-FLAIR mismatch sign in grade II and III gliomas: a population-based study. BMC Cancer 2020; 20:450. [PMID: 32434559 PMCID: PMC7238512 DOI: 10.1186/s12885-020-06951-w] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 05/11/2020] [Indexed: 11/18/2022] Open
Abstract
Background The T2-FLAIR mismatch sign is an imaging finding highly suggestive of isocitrate dehydrogenase mutated (IDH-mut) 1p19q non-codeleted (non-codel) gliomas (astrocytomas). In previous studies, it has shown excellent specificity but limited sensitivity for IDH-mut astrocytomas. Whether the mismatch sign is a marker of a clinically relevant subtype of IDH-mut astrocytomas is unknown. Methods We included histopathologically verified supratentorial lower-grade gliomas (LGG) WHO grade II-III retrospectively during the period 2010–2016. In the period 2017–2018, patients with suspected LGG radiologically were prospectively included, and in this cohort other diagnoses than glioma could occur. Clinical, radiological and molecular data were collected. For clinical evaluation we included all patients with IDH-mut astrocytomas. In the 2010–2016 cohort DNA methylation analysis with Infinium MethylationEPIC BeadChip (Illumina) was performed for patients with an IDH-mut astrocytoma with available tissue. We aimed to examine the association of the T2-FLAIR mismatch sign with clinical factors and outcomes. Additionally, we evaluated the diagnostic reliability of the mismatch sign and its relation to methylation profiles. Results Out of 215 patients with LGG, 135 had known IDH-mutation and 1p19q codeletion status. Fifty patients had an IDH-mut astrocytoma and 12 of these (24.0%) showed a mismatch sign. The sensitivity and specificity of the mismatch sign for IDH-mut detection were 26.4 and 97.6%, respectively. There were no differences between patients with an IDH-mut astrocytoma with or without mismatch sign when grouped according to T2-FLAIR mismatch sign with respect to baseline characteristics, clinical outcomes and methylation profiles. The overall interrater agreement between neuroradiologist and clinical neurosurgeons for the T2-FLAIR mismatch sign was significant when all 215 MRI examination assessed (κ = 0.77, p < 0.001, N = 215). Conclusion The T2-FLAIR mismatch sign in patients with an IDH-mut astrocytoma is not associated with clinical presentation or outcome. It seems unlikely that the IDH-mut astrocytomas with mismatch sign represent a specific subentity. Finally, we have validated that the T2-FLAIR mismatch sign is a reliable and specific marker of IDH-mut astrocytomas.
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Affiliation(s)
- Alba Corell
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden. .,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden.
| | - Sandra Ferreyra Vega
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Nickoleta Hoefling
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Louise Carstam
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Anja Smits
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden.,Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Thomas Olsson Bontell
- Department of Clinical Pathology and Cytology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Physiology, Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Isabella M Björkman-Burtscher
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Carén
- Sahlgrenska Cancer Center, Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Asgeir Store Jakola
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden.,Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway
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Kiesel B, Thomé CM, Weiss T, Jakola AS, Darlix A, Pellerino A, Furtner J, Kerschbaumer J, Freyschlag CF, Wick W, Preusser M, Widhalm G, Berghoff AS. Perioperative imaging in patients treated with resection of brain metastases: a survey by the European Association of Neuro-Oncology (EANO) Youngsters committee. BMC Cancer 2020; 20:410. [PMID: 32398144 PMCID: PMC7216695 DOI: 10.1186/s12885-020-06897-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/23/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Neurosurgical resection represents an important treatment option in the modern, multimodal therapy approach of brain metastases (BM). Guidelines for perioperative imaging exist for primary brain tumors to guide postsurgical treatment. Optimal perioperative imaging of BM patients is so far a matter of debate as no structured guidelines exist. METHODS A comprehensive questionnaire about perioperative imaging was designed by the European Association of Neuro-Oncology (EANO) Youngsters Committee. The survey was distributed to physicians via the EANO network to perform a descriptive overview on the current habits and their variability on perioperative imaging. Chi square test was used for dichotomous variables. RESULTS One hundred twenty physicians worldwide responded to the survey. MRI was the preferred preoperative imaging method (93.3%). Overall 106/120 (88.3%) physicians performed postsurgical imaging routinely including MRI alone (62/120 [51.7%]), postoperative CT (29/120 [24.2%]) and MRI + CT (15/120 [12.5%]). No correlation of postsurgical MRI utilization in academic vs. non-academic hospitals (58/89 [65.2%] vs. 19/31 [61.3%], p = 0.698) was found. Early postoperative MRI within ≤72 h after resection is obtained by 60.8% of the participants. The most frequent reason for postsurgical imaging was to evaluate the extent of tumor resection (73/120 [60.8%]). In case of residual tumor, 32/120 (26.7%) participants indicated to adjust radiotherapy, 34/120 (28.3%) to consider re-surgery to achieve complete resection and 8/120 (6.7%) to evaluate both. CONCLUSIONS MRI was the preferred imaging method in the preoperative setting. In the postoperative course, imaging modalities and timing showed high variability. International guidelines for perioperative imaging with special focus on postoperative MRI to assess residual tumor are warranted to optimize standardized management and adjuvant treatment decisions for BM patients.
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Affiliation(s)
- Barbara Kiesel
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria.,Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Carina M Thomé
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Tobias Weiss
- Department of Neurology and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Asgeir S Jakola
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Amélie Darlix
- Department of Medical Oncology, Institut Régional Du Cancer Montpellier, University of Montpellier, Montpellier, France
| | - Alessia Pellerino
- Department of Neuro-Oncology, University and City of Health and Science Hospital of Turin, Turin, Italy
| | - Julia Furtner
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.,Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria
| | | | | | - Wolfgang Wick
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Neurology Clinic & National Center for Tumor Disease, University of Heidelberg, Heidelberg, Germany
| | - Matthias Preusser
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.,Department of Medicine I, Clinical Division of Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Georg Widhalm
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria.,Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Anna S Berghoff
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria. .,Department of Medicine I, Clinical Division of Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Dimou J, Kelly J. The biological and clinical basis for early referral of low grade glioma patients to a surgical neuro-oncologist. J Clin Neurosci 2020; 78:20-29. [PMID: 32381393 DOI: 10.1016/j.jocn.2020.04.119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 03/24/2020] [Accepted: 04/26/2020] [Indexed: 12/15/2022]
Abstract
The discovery of IDH1/2 (isocitrate dehydrogenase) mutation in large scale, genomewide mutational analyses of gliomas has led to profound developments in understanding tumourigenesis, and restructuring of the classification of both high and low grade gliomas. Owing to this progress made in the recognition of molecular markers which predict tumour behavior and treatment response, the increasing importance of adjuvant treatments such as chemo- and radiotherapy, and the tremendous advances in surgical technique and intraoperative monitoring which have facilitated superior extents of resection whilst preserving neurological functioning and quality of life, contemporary management of low grade glioma (LGG) has switched from a passive, observant approach to a more active, interventional one. Furthermore, this has implications for the manner in which patients with incidentally discovered and/or asymptomatic LGG are managed, and this review of the biological behaviour of LGG, as well as its clinical investigation and management, should act as a timely reminder to all clinicians of the importance of referring LGG patients early to a surgical neuro-oncologist who is not only familiar and acquainted with the vagaries of this disease process, but who, in addition, is devoted to delivering care to these patients with the support of a multi-disciplinary clinical decision-making unit, comprising medical neuro-oncologists, radiation oncologists and allied health professionals.
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Affiliation(s)
- James Dimou
- Department of Neurosurgery, University of Calgary, Alberta, Canada.
| | - John Kelly
- Department of Neurosurgery, University of Calgary, Alberta, Canada
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Ferraris C, Cavalli R, Panciani PP, Battaglia L. Overcoming the Blood-Brain Barrier: Successes and Challenges in Developing Nanoparticle-Mediated Drug Delivery Systems for the Treatment of Brain Tumours. Int J Nanomedicine 2020; 15:2999-3022. [PMID: 32431498 PMCID: PMC7201023 DOI: 10.2147/ijn.s231479] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 04/14/2020] [Indexed: 12/14/2022] Open
Abstract
High-grade gliomas are still characterized by a poor prognosis, despite recent advances in surgical treatment. Chemotherapy is currently practiced after surgery, but its efficacy is limited by aspecific toxicity on healthy cells, tumour cell chemoresistance, poor selectivity, and especially by the blood–brain barrier (BBB). Thus, despite the large number of potential drug candidates, the choice of effective chemotherapeutics is still limited to few compounds. Malignant gliomas are characterized by high infiltration and neovascularization, and leaky BBB (the so-called blood–brain tumour barrier); surgical resection is often incomplete, leaving residual cells that are able to migrate and proliferate. Nanocarriers can favour delivery of chemotherapeutics to brain tumours owing to different strategies, including chemical stabilization of the drug in the bloodstream; passive targeting (because of the leaky vascularization at the tumour site); inhibition of drug efflux mechanisms in endothelial and cancer cells; and active targeting by exploiting carriers and receptors overexpressed at the blood–brain tumour barrier. Within this concern, a suitable nanomedicine-based therapy for gliomas should not be limited to cytotoxic agents, but also target the most important pathogenetic mechanisms, including cell differentiation pathways and angiogenesis. Moreover, the combinatorial approach of cell therapy plus nanomedicine strategies can open new therapeutical opportunities. The major part of attempted preclinical approaches on animal models involves active targeting with protein ligands, but, despite encouraging results, a few number of nanomedicines reached clinical trials, and most of them include drug-loaded nanocarriers free of targeting ligands, also because of safety and scalability concerns.
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Affiliation(s)
- Chiara Ferraris
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Roberta Cavalli
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Pier Paolo Panciani
- Clinic of Neurosurgery, Spedali Civili and University of Brescia, Brescia, Italy
| | - Luigi Battaglia
- Department of Drug Science and Technology, University of Turin, Turin, Italy
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Harary M, Kavouridis VK, Torre M, Zaidi HA, Chukwueke UN, Reardon DA, Smith TR, Iorgulescu JB. Predictors and early survival outcomes of maximal resection in WHO grade II 1p/19q-codeleted oligodendrogliomas. Neuro Oncol 2020; 22:369-380. [PMID: 31538193 PMCID: PMC7442358 DOI: 10.1093/neuonc/noz168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Although surgery plays a crucial diagnostic role in World Health Organization (WHO) grade II 1p/19q-codeleted oligodendrogliomas, the role of maximal tumor surgical resection remains unclear, with early retrospective series limited by lack of molecular classification or appropriate control groups. METHODS The characteristics, management, and overall survival (OS) of patients ≥20 years old presenting with histology-proven WHO grade II 1p/19q-codeleted oligodendrogliomas during 2010-2016 were evaluated using the National Cancer Database and validated using multi-institutional data. Patients were stratified by watchful waiting (biopsy only) versus surgical resection. OS was analyzed using Kaplan-Meier methods and risk-adjusted proportional hazards. RESULTS Five hundred ninety adults met inclusion criteria, of whom 79.0% (n = 466) underwent surgical resection. Of patient and tumor characteristics, younger patients were more likely to be resected. Achieving gross total resection (GTR; n = 320) was significantly associated with smaller tumors, management at integrated network cancer programs (vs community cancer programs), and Medicare insurance (as compared with no, private, or Medicaid/other government insurance) and independent of other patient or tumor characteristics. In risk-adjusted analyses, GTR, but not subtotal resection (STR), demonstrated improved OS (vs biopsy only: hazard ratio 0.28, 95% CI: 0.09-0.85, P = 0.02). CONCLUSIONS WHO grade II 1p/19q-codeleted oligodendrogliomas amenable to resection demonstrated improved OS with GTR, but not STR, compared with biopsy-only watchful waiting. The OS benefits of GTR were independent of age, tumor size, or tumor location. Medicare-insured and integrated network cancer program patients were significantly more likely to have GTR than other patients, suggesting that insurance status and care setting may play important roles in access to timely diagnosis or innovations that improve maximal resection.
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Affiliation(s)
- Maya Harary
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Vasileios K Kavouridis
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Matthew Torre
- Harvard Medical School, Boston, Massachusetts
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hasan A Zaidi
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Ugonma N Chukwueke
- Harvard Medical School, Boston, Massachusetts
- Center for Neuro-Oncology, Department of Medical Oncology, Dana-Farber Cancer Center, Boston, Massachusetts
| | - David A Reardon
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Center for Neuro-Oncology, Department of Medical Oncology, Dana-Farber Cancer Center, Boston, Massachusetts
| | - Timothy R Smith
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - J Bryan Iorgulescu
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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136
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Jakola AS, Sagberg LM, Gulati S, Solheim O. Advancements in predicting outcomes in patients with glioma: a surgical perspective. Expert Rev Anticancer Ther 2020; 20:167-177. [PMID: 32114857 DOI: 10.1080/14737140.2020.1735367] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Diffuse glioma is a challenging neurosurgical entity. Although surgery does not provide a cure, it may greatly influence survival, brain function, and quality of life. Surgical treatment is by nature highly personalized and outcome prediction is very complex. To engage and succeed in this balancing act it is important to make best use of the information available to the neurosurgeon.Areas covered: This narrative review provides an update on advancements in predicting outcomes in patients with glioma that are relevant to neurosurgeons.Expert opinion: The classical 'gut feeling' is notoriously unreliable and better prediction strategies for patients with glioma are warranted. There are numerous tools readily available for the neurosurgeon in predicting tumor biology and survival. Predicting extent of resection, functional outcome, and quality of life remains difficult. Although machine-learning approaches are currently not readily available in daily clinical practice, there are several ongoing efforts with the use of big data sets that are likely to create new prediction models and refine the existing models.
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Affiliation(s)
- Asgeir Store Jakola
- Department of Clinical Neuroscience, Institute of Physiology and Neuroscience, Sahlgrenska Academy, Gothenburg, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway
| | - Lisa Millgård Sagberg
- Department of Neurosurgery, St.Olavs Hospital, Trondheim, Norway.,Department of Public Health and Nursing, NTNU, Trondheim, Norway
| | - Sasha Gulati
- Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway.,Department of Neurosurgery, St.Olavs Hospital, Trondheim, Norway
| | - Ole Solheim
- Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway.,Department of Neurosurgery, St.Olavs Hospital, Trondheim, Norway
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Skjulsvik AJ, Bø HK, Jakola AS, Berntsen EM, Bø LE, Reinertsen I, Myrmel KS, Sjåvik K, Åberg K, Berg T, Dai HY, Kloster R, Torp SH, Solheim O. Is the anatomical distribution of low-grade gliomas linked to regions of gliogenesis? J Neurooncol 2020; 147:147-157. [PMID: 31983026 PMCID: PMC7075820 DOI: 10.1007/s11060-020-03409-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/20/2020] [Indexed: 12/02/2022]
Abstract
INTRODUCTION According to the stem cell theory, two neurogenic niches in the adult human brain may harbor cells that initiate the formation of gliomas: The larger subventricular zone (SVZ) and the subgranular zone (SGZ) in the hippocampus. We wanted to explore whether defining molecular markers in low-grade gliomas (LGG; WHO grade II) are related to distance to the neurogenic niches. METHODS Patients treated at two Norwegian university hospitals with population-based referral were included. Eligible patients had histopathological verified supratentorial low-grade glioma. IDH mutational status and 1p19q co-deletion status was retrospectively assessed. 159 patients were included, and semi-automatic tumor segmentation was done from pre-treatment T2-weighted (T2W) or Fluid-Attenuated Inversion Recovery (FLAIR) images. 3D maps showing the anatomical distribution of the tumors were then created for each of the three molecular subtypes (IDH mutated/1p19q co-deleted, IDH mutated and IDH wild-type). Both distance from tumor center and tumor border to the neurogenic niches were recorded. RESULTS In this population-based cohort of previously untreated low-grade gliomas, we found that low-grade gliomas are more often found closer to the SVZ than the SGZ, but IDH wild-type tumors are more often found near SGZ. CONCLUSION Our study suggests that the stem cell origin of IDH wild-type and IDH mutated low-grade gliomas may be different.
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Affiliation(s)
- Anne Jarstein Skjulsvik
- Department of Pathology, St. Olavs University Hospital, Trondheim, Norway
- Departments of Clinical and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 7491 Trondheim, Norway
| | - Hans Kristian Bø
- Department of Diagnostic Imaging, Nordland Hospital Trust, Bodø, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 7491 Trondheim, Norway
| | - Asgeir Store Jakola
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Neuroscience and Movement Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 7491 Trondheim, Norway
| | - Erik Magnus Berntsen
- Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 7491 Trondheim, Norway
- Department of Radiology and Nuclear Medicine, St. Olavs University Hospital, Olav Kyrres Gate, 7006 Trondheim, Norway
| | - Lars Eirik Bø
- Department of Health Research, SINTEF Digital, Trondheim, Norway
| | | | | | - Kristin Sjåvik
- Department of Neurosurgery, University Hospital of North Norway, Tromsö, Norway
| | - Kristin Åberg
- Department of Clinical Pathology, University Hospital of North Norway, Tromsö, Norway
| | - Thomas Berg
- Department of Clinical Pathology, University Hospital of North Norway, Tromsö, Norway
| | - Hong Yan Dai
- Department of Pathology, St. Olavs University Hospital, Trondheim, Norway
| | - Roar Kloster
- Department of Neurosurgery, University Hospital of North Norway, Tromsö, Norway
| | - Sverre Helge Torp
- Department of Pathology, St. Olavs University Hospital, Trondheim, Norway
- Departments of Clinical and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 7491 Trondheim, Norway
| | - Ole Solheim
- Department of Neurosurgery, St. Olavs University Hospital, Olav Kyrres Gate, 7006 Trondheim, Norway
- Department of Neuroscience and Movement Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 7491 Trondheim, Norway
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Solomons MR, Jaunmuktane Z, Weil RS, El-Hassan T, Brandner S, Rees JH. Seizure outcomes and survival in adult low-grade glioma over 11 years: living longer and better. Neurooncol Pract 2020; 7:196-201. [PMID: 32206321 PMCID: PMC7081389 DOI: 10.1093/nop/npz056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND There has been a trend toward earlier and more aggressive resection for low-grade gliomas (LGGs). This study set out to compare seizure control and survival of adults with LGG seen in the same neuro-oncology clinic over 11 years and to determine whether a change in surgical philosophy has led to a corresponding improvement in outcomes. METHODS We conducted a retrospective analysis using case-note review of 153 adults with histologically verified or radiologically suspected LGG, collecting data on patient, tumor, and seizure characteristics between 2006 and 2017. RESULTS We studied 79 patients in 2006 and 74 patients in 2017. There was no significant difference between the 2 groups in age at presentation, tumor location, or integrated pathological diagnosis. The numbers of complete or partial resections increased from 21.5% in 2006 to 60.8% in 2017 (P < .05). Five- and 10-year overall survival increased from 81.8% and 51.7% in 2006 to 100% and 95.8% in 2017 (P < .001); similarly, 5- and 10-year progression-free survival increased from 47.0% and 30.7% in 2006 to 93.1% and 68.7% in 2017. The proportion of patients with intractable epilepsy declined from 72.2% in 2006 to 43.2% in 2017 (P < .05). The neurosurgical morbidity rate was identical in both groups (11.8% in 2006 vs 11.1% in 2017). CONCLUSION Management of LGG over the last 11 years has led to substantial improvements in survival and seizure control. This is most likely thanks to a change in surgical philosophy, with early resection now favored over watchful waiting where possible.
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Affiliation(s)
| | - Zane Jaunmuktane
- Division of Neuropathology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Rimona S Weil
- National Hospital for Neurology and Neurosurgery, London, UK,UCL Queen Square Institute of Neurology, London, UK,Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK
| | - Tedani El-Hassan
- Division of Neuropathology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK,Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK
| | - Sebastian Brandner
- Division of Neuropathology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jeremy H Rees
- National Hospital for Neurology and Neurosurgery, London, UK,UCL Queen Square Institute of Neurology, London, UK,Corresponding Author: JH Rees, BSc, MBBS, PhD, FRCP, Mailbox 99, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK ()
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139
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Schei S, Solheim O, Jakola AS, Sagberg LM. Perioperative fatigue in patients with diffuse glioma. J Neurooncol 2020; 147:97-107. [PMID: 31974804 PMCID: PMC7075831 DOI: 10.1007/s11060-020-03403-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/16/2020] [Indexed: 12/18/2022]
Abstract
Purpose Few studies have assessed fatigue in relation to glioma surgery. The purpose of this study was to explore the prevalence of pre- and postoperative high fatigue, perioperative changes, and factors associated with pre- and postoperative high fatigue in patients undergoing primary surgery for diffuse glioma. Methods A total of 112 adult patients were prospectively included. Patient-reported fatigue was assessed before and one month after surgery using the cancer-specific European Organization for Research and Treatment of Cancer questionnaire fatigue subscale. The scores were dichotomized as high fatigue (≥ 39) or low fatigue (< 39). A change in score of ≥ 10 was considered as a clinically significant change. Factors associated with pre- and postoperative high fatigue were explored in multivariable regression analyses. Results High fatigue was reported by 45% of the patients preoperatively and by 42% of the patients postoperatively. Female gender and low Karnofsky Performance Status (KPS) were associated with preoperative high fatigue, while postoperative complications, low KPS and low-grade histopathology were associated with postoperative high fatigue. In total 35/92 (38%) patients reported a clinically significant improvement of fatigue scores after surgery, 36/92 (39%) patients reported a clinically significant worsening of fatigue scores after surgery, and 21/92 (23%) patients reported no clinically significant change in fatigue scores after surgery. Patients with low-grade gliomas more often reported low fatigue before surgery and high fatigue after surgery, while patients with high-grade gliomas more often reported high fatigue before surgery and low fatigue after surgery. Conclusions Our findings indicate that fatigue is a common symptom in patients with diffuse glioma, both pre- and postoperatively. Perioperative changes were frequently seen. This is important knowledge when informing patients before and after surgery. Electronic supplementary material The online version of this article (10.1007/s11060-020-03403-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stine Schei
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Ole Solheim
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
| | - Asgeir Store Jakola
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Lisa Millgård Sagberg
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
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Darlix A, Rigau V, Fraisse J, Gozé C, Fabbro M, Duffau H. Postoperative follow-up for selected diffuse low-grade gliomas with WHO grade III/IV foci. Neurology 2020; 94:e830-e841. [PMID: 31969465 DOI: 10.1212/wnl.0000000000008877] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 08/28/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Diffuse low-grade gliomas (DLGG) are defined by continuous growth and an almost unavoidable malignant transformation. Foci of malignant glioma can be found within DLGG samples obtained from surgical resections. As the medical management of patients is classically based on the higher tumor grade, an immediate adjuvant treatment is usually proposed. To determine whether postponing the medical treatment in selected patients is feasible, we conducted a single-center retrospective study. METHODS This was a single-center retrospective analysis of a consecutive series of DLGG managed with this conservative strategy. Inclusion criteria were at least 1 focus of malignant tumor (grade III-IV, WHO 2016), no previous chemotherapy or radiotherapy, no less than a subtotal resection of the fluid-attenuated inversion recovery tumor volume, no intention of treating with immediate adjuvant therapy, and minimum 2 years of follow-up. The time interval to the following oncologic medical treatment was analyzed, as well as the functional and survival results. RESULTS Forty-four patients met the inclusion criteria (median age 36, median time interval from diagnosis 7 months). Most tumors (88%) were IDH-mutant and 1p19q intact (59%); 9 presented with grade IV foci. With a median follow-up of 6.7 years, 75% of patients received a subsequent medical treatment, after a median time of 3.4 years since surgery. At the time of analysis, 9 patients (20.0%) had died (5- and 7-year survival rates: 95% and 67.0%). Most surviving patients were still active professionally, without seizures. CONCLUSIONS Postponing the medical treatment in DLGG with foci of malignant tumor following total or subtotal resection should be considered in selected patients.
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Affiliation(s)
- Amélie Darlix
- From the Department of Medical Oncology (A.D., M.F.) and Biometrics Unit (J.F.), Institut du Cancer de Montpellier, University of Montpellier; INSERM U1051 (A.D., V.R., C.G., H.D.), Montpellier Neurosciences Institute; and Department of Pathology (V.R.), Pathology and Oncobiology Department, Laboratory of Solid Tumors Biology (C.G.), and Department of Neurosurgery (H.D.), Montpellier University Hospital, France.
| | - Valérie Rigau
- From the Department of Medical Oncology (A.D., M.F.) and Biometrics Unit (J.F.), Institut du Cancer de Montpellier, University of Montpellier; INSERM U1051 (A.D., V.R., C.G., H.D.), Montpellier Neurosciences Institute; and Department of Pathology (V.R.), Pathology and Oncobiology Department, Laboratory of Solid Tumors Biology (C.G.), and Department of Neurosurgery (H.D.), Montpellier University Hospital, France
| | - Julien Fraisse
- From the Department of Medical Oncology (A.D., M.F.) and Biometrics Unit (J.F.), Institut du Cancer de Montpellier, University of Montpellier; INSERM U1051 (A.D., V.R., C.G., H.D.), Montpellier Neurosciences Institute; and Department of Pathology (V.R.), Pathology and Oncobiology Department, Laboratory of Solid Tumors Biology (C.G.), and Department of Neurosurgery (H.D.), Montpellier University Hospital, France
| | - Catherine Gozé
- From the Department of Medical Oncology (A.D., M.F.) and Biometrics Unit (J.F.), Institut du Cancer de Montpellier, University of Montpellier; INSERM U1051 (A.D., V.R., C.G., H.D.), Montpellier Neurosciences Institute; and Department of Pathology (V.R.), Pathology and Oncobiology Department, Laboratory of Solid Tumors Biology (C.G.), and Department of Neurosurgery (H.D.), Montpellier University Hospital, France
| | - Michel Fabbro
- From the Department of Medical Oncology (A.D., M.F.) and Biometrics Unit (J.F.), Institut du Cancer de Montpellier, University of Montpellier; INSERM U1051 (A.D., V.R., C.G., H.D.), Montpellier Neurosciences Institute; and Department of Pathology (V.R.), Pathology and Oncobiology Department, Laboratory of Solid Tumors Biology (C.G.), and Department of Neurosurgery (H.D.), Montpellier University Hospital, France
| | - Hugues Duffau
- From the Department of Medical Oncology (A.D., M.F.) and Biometrics Unit (J.F.), Institut du Cancer de Montpellier, University of Montpellier; INSERM U1051 (A.D., V.R., C.G., H.D.), Montpellier Neurosciences Institute; and Department of Pathology (V.R.), Pathology and Oncobiology Department, Laboratory of Solid Tumors Biology (C.G.), and Department of Neurosurgery (H.D.), Montpellier University Hospital, France
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141
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Jakola AS, Bouget D, Reinertsen I, Skjulsvik AJ, Sagberg LM, Bø HK, Gulati S, Sjåvik K, Solheim O. Spatial distribution of malignant transformation in patients with low-grade glioma. J Neurooncol 2020; 146:373-380. [PMID: 31915981 PMCID: PMC6971181 DOI: 10.1007/s11060-020-03391-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 01/03/2020] [Indexed: 12/19/2022]
Abstract
Background Malignant transformation represents the natural evolution of diffuse low-grade gliomas (LGG). This is a catastrophic event, causing neurocognitive symptoms, intensified treatment and premature death. However, little is known concerning the spatial distribution of malignant transformation in patients with LGG. Materials and methods Patients histopathological diagnosed with LGG and subsequent radiological malignant transformation were identified from two different institutions. We evaluated the spatial distribution of malignant transformation with (1) visual inspection and (2) segmentations of longitudinal tumor volumes. In (1) a radiological transformation site < 2 cm from the tumor on preceding MRI was defined local transformation. In (2) overlap with pretreatment volume after importation into a common space was defined as local transformation. With a centroid model we explored if there were particular patterns of transformations within relevant subgroups. Results We included 43 patients in the clinical evaluation, and 36 patients had MRIs scans available for longitudinal segmentations. Prior to malignant transformation, residual radiological tumor volumes were > 10 ml in 93% of patients. The transformation site was considered local in 91% of patients by clinical assessment. Patients treated with radiotherapy prior to transformation had somewhat lower rate of local transformations (83%). Based upon the segmentations, the transformation was local in 92%. We did not observe any particular pattern of transformations in examined molecular subgroups. Conclusion Malignant transformation occurs locally and within the T2w hyperintensities in most patients. Although LGG is an infiltrating disease, this data conceptually strengthens the role of loco-regional treatments in patients with LGG.
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Affiliation(s)
- Asgeir S Jakola
- Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway. .,Department of Neurosurgery, Sahlgrenska University Hospital, Blå Stråket 5, vån 3, 41345, Gothenburg, Sweden. .,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Box 430, 40530, Gothenburg, Sweden.
| | - David Bouget
- Department of Health Research, SINTEF Digital, Trondheim, Norway
| | | | - Anne J Skjulsvik
- Department of Pathology, St. Olavs University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, 7491, Trondheim, Norway
| | - Lisa Millgård Sagberg
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU, Trondheim, Norway.,Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway
| | - Hans Kristian Bø
- Department of Diagnostic Imaging, Nordland Hospital Trust, Bodø, Norway
| | - Sasha Gulati
- Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway.,Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway
| | - Kristin Sjåvik
- Department of Neurosurgery, University Hospital of North Norway, Tromsö, Norway
| | - Ole Solheim
- Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway.,Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway
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Ghaffari-Rafi A, Samandouras G. Effect of Treatment Modalities on Progression-Free Survival and Overall Survival in Molecularly Subtyped World Health Organization Grade II Diffuse Gliomas: A Systematic Review. World Neurosurg 2020; 133:366-380.e2. [DOI: 10.1016/j.wneu.2019.08.111] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 08/16/2019] [Accepted: 08/17/2019] [Indexed: 12/20/2022]
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143
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Singh S, Mukundan H, Lohia N, Taneja S, Sarin A, Bhatnagar S, Jaiswal P, Trivedi G, Prasher M, Viswanath S. Gliomas: Analysis of disease characteristics, treatment timelines and survival rates from two tertiary care hospitals of India. CLINICAL CANCER INVESTIGATION JOURNAL 2020. [DOI: 10.4103/ccij.ccij_27_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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144
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Socioeconomic factors affect treatment delivery for patients with low grade glioma: a Swedish population-based study. J Neurooncol 2019; 146:329-337. [PMID: 31883050 PMCID: PMC6971149 DOI: 10.1007/s11060-019-03378-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 12/20/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Despite aspirations to achieve equality in healthcare we know that socioeconomic differences exist and may affect treatment and patient outcome, also in serious diseases such as cancer. We investigated disparities in neurosurgical care and outcome for patients with low-grade glioma (LGG). METHODS In this nationwide registry-based study, patients who had undergone surgery for LGG during 2005-2015 were identified (n = 547) through the Swedish Brain Tumor Registry. We linked data to multiple national registries with individual level data on income, education and comorbidity and analyzed the association of disease characteristics, surgical management and outcome, with levels of income, education and sex. RESULTS Patients with either low income, low education or female gender showed worse pre-operative performance status. Patients with low income or education also had more comorbidities and those with low education endured longer waiting times for surgery. Median time from radiological imaging to surgery was 51 days (Q1-3 27-191) for patients with low education, compared to 32 days (Q1-3 20-80) for patients with high education (p = 0.006). Differences in waiting time over educational levels remained significant after stratification for age, comorbidity, preoperative performance status, and tumor size. Overall survival was better for patients with high income or high education, but income- and education-related survival differences were not significant after adjustment for age and comorbidity. The type of surgical procedure or complications did not differ over socioeconomic groups or sex. CONCLUSION The neurosurgical care for LGG in Sweden, a society with universal healthcare, displays differences that can be related to socioeconomic factors.
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Yoshida A, Motomura K, Natsume A, Chalise L, Iijima K, Hara D, Kadono I, Wakai K, Wakabayashi T. Preoperative predictive factors affecting return to work in patients with gliomas undergoing awake brain mapping. J Neurooncol 2019; 146:195-205. [PMID: 31853839 DOI: 10.1007/s11060-019-03371-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 12/13/2019] [Indexed: 01/12/2023]
Abstract
PURPOSE This study aimed to investigate the preoperative predictive factors affecting return to work in patients with gliomas in the left cerebral hemisphere undergoing awake surgery. METHODS We retrospectively reviewed 50 consecutive glioma patients who underwent awake surgery from January 2012 to July 2017. Adult patients older than 18 years, who reported working prior to surgery, were recruited for this study. RESULTS Comparing sociodemographic, disease-related and preoperative neurocognitive variables of glioma patients who returned to work and those who did not, binomial logistic regression models for preoperative predictors affecting return to work revealed significant differences in age and sole breadwinner status as sociodemographic variables, tumour volume as a disease-related variable, and Verbal IQ, Performance IQ, general memory, attention/concentration, and working memory as neurocognitive variables. Multivariate logistic regression models demonstrated that the independent factors associated with propriety of returning to work 1 year after surgery was the sociodemographic variable sole breadwinner status (yes vs no; OR = 15.00, 95% CI 2.22-101.35, p = 0.01), the disease-related variable tumour volume (per 1 cm3; OR = 0.98, 95% CI 0.96-0.99, p = 0.04), and the preoperative neurocognitive variable general memory (≥ 100 vs < 100; OR = 21.70, 95% CI 2.60-183.94, p = 0.01). CONCLUSIONS Our results suggest that three predictive factors including sole breadwinner status, tumour volume and general memory that can be assessed in the preoperative stage substantially contribute to returning to work in patients with gliomas in the left cerebral hemisphere, 1 year after awake surgery.
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Affiliation(s)
- Akihito Yoshida
- Department of Rehabilitation Science, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
| | - Kazuya Motomura
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Atsushi Natsume
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Lushun Chalise
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kentaro Iijima
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daisuke Hara
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
| | - Izumi Kadono
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
| | - Kenji Wakai
- Department of Preventive Medicine, Nagoya University School of Medicine, Nagoya, Japan
| | - Toshihiko Wakabayashi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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146
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van der Voort SR, Incekara F, Wijnenga MM, Kapas G, Gardeniers M, Schouten JW, Starmans MP, Nandoe Tewarie R, Lycklama GJ, French PJ, Dubbink HJ, van den Bent MJ, Vincent AJ, Niessen WJ, Klein S, Smits M. Predicting the 1p/19q Codeletion Status of Presumed Low-Grade Glioma with an Externally Validated Machine Learning Algorithm. Clin Cancer Res 2019; 25:7455-7462. [DOI: 10.1158/1078-0432.ccr-19-1127] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/12/2019] [Accepted: 09/06/2019] [Indexed: 11/16/2022]
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147
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Santos-Pinheiro F, Park M, Liu D, Kwong LN, Cruz S, Levine NB, O'Brien BJ, Chen M. Seizure burden pre- and postresection of low-grade gliomas as a predictor of tumor progression in low-grade gliomas. Neurooncol Pract 2019; 6:209-217. [PMID: 31386048 DOI: 10.1093/nop/npy022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Low-grade gliomas (LGGs) are slow-growing, infiltrative tumors frequently associated with seizures. Predicting which patients will develop early tumor recurrence based on clinical indicators following initial surgical intervention remains a challenge. Seizure recurrence following surgery may be an early indicator of tumor recurrence, especially in patients presenting with increase in seizure frequency. Methods This study analyzed 148 patients meeting inclusion criteria (age >18 years, LGG diagnosis, at least 1 seizure event recorded before and after initial surgical intervention). All patients were treated at the Brain and Spine Center at The University of Texas MD Anderson Cancer Center from January 2000 to March 2013. Seizure frequency in a 6-month period before and after tumor resection was categorized as none, 1, few (2 to 3 seizures) or several (>3 seizures). Immediately postoperative seizures (up to 48 hours from surgery) were not included in the analysis. Results A total of 116 (78.4%) patients had seizures at initial presentation and most (95%) were started on antiepileptic drugs (AEDs). We found 2 clinical variables with a significant impact on progression-free survival (PFS): Higher seizure frequency during the 6-month postoperative period and seizure frequency increase between the 6-month pre- and the 6-month postoperative periods were both correlated to higher risk of early tumor recurrence (P = .007 and P = .004, respectively). Conclusion Seizure frequency following surgical resection of LGGs and the seizure frequency change between the 6-month preoperative and postoperative periods may serve as clinical predictors of early tumor recurrence in patients with LGGs who are also afflicted by seizures.
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Affiliation(s)
| | - Mingjeong Park
- University of Texas MD Anderson Cancer Center, Department of Biostatistics
| | - Diane Liu
- University of Texas MD Anderson Cancer Center, Department of Biostatistics
| | - Lawrence N Kwong
- University of Texas MD Anderson Cancer Center, Department of Translation Molecular Pathology
| | | | - Nicholas B Levine
- University of Texas MD Anderson Cancer Center, Department of Neurosurgery
| | - Barbara J O'Brien
- University of Texas MD Anderson Cancer Center, Department of Neuro-Oncology
| | - Merry Chen
- University of Texas MD Anderson Cancer Center, Department of Neuro-Oncology
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148
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Affiliation(s)
- Roberta Rudà
- Department of Neuro-Oncology, University Hospital, Turin, Italy
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149
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Darlix A, Mandonnet E, Freyschlag CF, Pinggera D, Forster MT, Voss M, Steinbach J, Loughrey C, Goodden J, Banna G, Di Blasi C, Foroglou N, Hottinger AF, Baron MH, Pallud J, Duffau H, Rutten GJ, Almairac F, Fontaine D, Taillandier L, Pessanha Viegas C, Albuquerque L, von Campe G, Urbanic-Purkart T, Blonski M. Chemotherapy and diffuse low-grade gliomas: a survey within the European Low-Grade Glioma Network. Neurooncol Pract 2019; 6:264-273. [PMID: 31386080 PMCID: PMC6660823 DOI: 10.1093/nop/npy051] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Diffuse low-grade gliomas (DLGGs) are rare and incurable tumors. Whereas maximal safe, functional-based surgical resection is the first-line treatment, the timing and choice of further treatments (chemotherapy, radiation therapy, or combined treatments) remain controversial. METHODS An online survey on the management of DLGG patients was sent to 28 expert centers from the European Low-Grade Glioma Network (ELGGN) in May 2015. It contained 40 specific questions addressing the modalities of use of chemotherapy in these patients. RESULTS The survey demonstrated a significant heterogeneity in practice regarding the initial management of DLGG patients and the use of chemotherapy. Interestingly, radiation therapy combined with the procarbazine, CCNU (lomustine), and vincristine regimen has not imposed itself as the gold-standard treatment after surgery, despite the results of the Radiation Therapy Oncology Group 9802 study. Temozolomide is largely used as first-line treatment after surgical resection for high-risk DLGG patients, or at progression. CONCLUSIONS The heterogeneity in the management of patients with DLGG demonstrates that many questions regarding the postoperative strategy and the use of chemotherapy remain unanswered. Our survey reveals a high recruitment potential within the ELGGN for retrospective or prospective studies to generate new data regarding these issues.
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Affiliation(s)
- Amélie Darlix
- Department of Medical Oncology, Institut du Cancer de Montpellier, University of Montpellier, France
| | | | | | - Daniel Pinggera
- Department of Neurosurgery, Medical University of Innsbruck, Austria
| | | | - Martin Voss
- Dr. Senckenberg Institute of Neurooncology, Goethe University Hospital, Frankfurt, Germany
| | - Joachim Steinbach
- Dr. Senckenberg Institute of Neurooncology, Goethe University Hospital, Frankfurt, Germany
| | | | - John Goodden
- Leeds General Infirmary and North East Paediatric Neuroscience Network, Leeds, United Kingdom
| | - Giuseppe Banna
- Department of Neurosurgery and Gammaknife, Cannizzaro General Hospital, Catania, Italy
| | - Concetta Di Blasi
- Department of Neurosurgery and Gammaknife, Cannizzaro General Hospital, Catania, Italy
| | - Nicolas Foroglou
- Aristotle University of Thessaloniki, Department of Neurosurgery, AHEPA University Hospital, Greece
| | - Andreas F Hottinger
- Departments of Clinical Neurosciences and Oncology, Centre Hospitalier Universitaire Vaudois and Lausanne University, Switzerland
| | | | - Johan Pallud
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France, and Paris Descartes University, Sorbonne Paris Cité, France
| | - Hugues Duffau
- Inserm, U894, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
- Department of Neurosurgery, Montpellier University Hospital, France
| | - Geert-Jan Rutten
- Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Fabien Almairac
- Department of Neurosurgery, University Hospital of Nice, France
| | - Denys Fontaine
- Department of Neurosurgery, University Hospital of Nice, France
| | - Luc Taillandier
- Department of Neurooncology, Nancy Neurological Hospital, France
| | | | | | - Gord von Campe
- Department of Neurosurgery, Medical University of Graz, Austria
| | | | - Marie Blonski
- Department of Neurooncology, Nancy Neurological Hospital, France
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Tom MC, Cahill DP, Buckner JC, Dietrich J, Parsons MW, Yu JS. Management for Different Glioma Subtypes: Are All Low-Grade Gliomas Created Equal? Am Soc Clin Oncol Educ Book 2019; 39:133-145. [PMID: 31099638 DOI: 10.1200/edbk_238353] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Following the identification of key molecular alterations that provided superior prognostication and led to the updated 2016 World Health Organization (WHO) Central Nervous System (CNS) Tumor Classification, the understanding of glioma behavior has rapidly evolved. Mutations in isocitrate dehydrogenase (IDH) 1 and 2 are present in the majority of adult grade 2 and 3 gliomas, and when used in conjunction with 1p/19q codeletion for classification, the prognostic distinction between grade 2 versus grade 3 is diminished. As such, the previously often used term of "low-grade glioma," which referred to grade 2 gliomas, has now been replaced by the phrase "lower-grade glioma" to encompass both grade 2 and 3 tumors. Additional molecular characterization is ongoing to even further classify this heterogeneous group of tumors. With such a colossal shift in the understanding of lower-grade gliomas, management of disease is being redefined in the setting of emerging molecular-genetic biomarkers. In this article, we review recent progress and future directions regarding the surgical, radiotherapeutic, chemotherapeutic, and long-term management of adult lower-grade gliomas.
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Affiliation(s)
- Martin C Tom
- 1 Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Daniel P Cahill
- 2 Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jan C Buckner
- 3 Department of Oncology, Mayo Clinic, Rochester, MN
| | - Jörg Dietrich
- 4 Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Michael W Parsons
- 4 Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Jennifer S Yu
- 1 Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.,5 Department of Cancer Biology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
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