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Abstract
Radiation therapy is used postoperatively as adjunctive therapy to decrease local failure; to delay tumor progression and prolong survival; as a curative treatment; as a therapy that halts further tumor growth; to alter function; and for palliation. Registration of MRI scan data sets with the treatment-planning CT scan is essential for accurate definition of the tumor and surrounding organs at risk. Integrating additional imaging studies that reflect the biologic characteristics of central nervous system tumors is an area of active research. Conformal treatment delivery is used to spare adjacent normal tissue from receiving unnecessary dose. In the dose range used when treating these tumors, the probability of causing serious late toxicity is relatively low and secondary malignancies are rare.
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Affiliation(s)
- Volker W Stieber
- Department of Radiation Oncology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1030, USA.
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352
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Stupp R, Hottinger AF. Management of Malignant Glioma – Quo Vadis? ACTA ACUST UNITED AC 2008; 31:300-2. [DOI: 10.1159/000134024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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353
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Yaman E, Buyukberber S, Uner A, Coskun U, Akmansu M, Benekli M, Yamac D, Ozturk B, Kaya AO, Yıldız R, Ozkan S, Gunel N. Temozolomide in Newly Diagnosed Malignant Gliomas: Administered Concomitantly with Radiotherapy, and Thereafter as Consolidation Treatment. ACTA ACUST UNITED AC 2008; 31:309-13. [DOI: 10.1159/000127252] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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354
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Gorlia T, van den Bent MJ, Hegi ME, Mirimanoff RO, Weller M, Cairncross JG, Eisenhauer E, Belanger K, Brandes AA, Allgeier A, Lacombe D, Stupp R. Nomograms for predicting survival of patients with newly diagnosed glioblastoma: prognostic factor analysis of EORTC and NCIC trial 26981-22981/CE.3. Lancet Oncol 2007; 9:29-38. [PMID: 18082451 DOI: 10.1016/s1470-2045(07)70384-4] [Citation(s) in RCA: 385] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND A randomised trial published by the European Organisation for Research and Treatment of Cancer (EORTC) and the National Cancer Institute of Canada (NCIC) Clinical Trials Group (trial 26981-22981/CE.3) showed that addition of temozolomide to radiotherapy in the treatment of patients with newly diagnosed glioblastoma significantly improved survival. We aimed to undertake an exploratory subanalysis of the EORTC and NCIC data to confirm or identify new prognostic factors for survival in adult patients with glioblastoma, derive nomograms that predict an individual patient's prognosis, and suggest stratification factors for future trials. METHODS Data from 573 patients with newly diagnosed glioblastoma who were randomly assigned to radiotherapy alone or to the same radiotherapy plus temozolomide in the EORTC and NCIC trial were included in this subanalysis. Survival modelling was done in three patient populations: intention-to-treat population of all randomised patients (population 1); patients assigned temozolomide and radiotherapy (population 2, n=287); and patients assigned temozolomide and radiotherapy who had assessment of MGMT promoter methylation status and who had undergone tumour resection (population 3, n=103). Cox proportional hazards models were fitted with and without O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status. Nomograms were developed to predict an individual patient's median and 2-year survival probabilities. No nomogram was developed in the radiotherapy-alone group because combined treatment is now the new standard of care. FINDINGS Independent of the MGMT promoter methylation status, analysis in all randomised patients (population 1) identified combined treatment with temozolomide, more extensive tumour resection, younger age, Mini-Mental State Examination (MMSE) score of 27 or higher, and no corticosteroid treatment at baseline as independent prognostic factors correlated with improved survival outcome. In patients assigned temozolomide and radiotherapy (population 2), younger age, better performance status, more extensive tumour resection, and MMSE score of 27 or higher were associated with better survival. In patients who had tumours resected, who were assigned temozolomide and radiotherapy, and who had available MGMT promoter methylation status (population 3), methylated MGMT, better performance status, and MMSE score of 27 or higher were associated with improved survival. Nomograms were developed and are available at http://www.eortc.be/tools/gbmcalculator. INTERPRETATION MGMT promoter methylation status, age, performance status, extent of resection, and MMSE are suggested as eligibility or stratification factors for future trials in patients with newly diagnosed glioblastoma. Stratifying by MGMT promoter methylation status should be mandatory in all glioblastoma trials that use alkylating chemotherapy. Nomograms can be used to predict an individual patient's prognosis, and they integrate pertinent molecular information that is consistent with a paradigm shift towards individualised patient management.
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355
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Affiliation(s)
- John P Kirkpatrick
- Department of Radiation Oncology and the Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, North Carolina 27710, USA.
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356
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Abstract
For 30 years, nitrosourea was the only adjuvant treatment available for aggressive glioma patients, despite its severe side effects; and, therefore, radiotherapy was often the therapy of choice. Survival prospect in these patients was, however, low with generally few patients surviving beyond 2 years. Recently, temozolomide was successfully tested in a number of randomised clinical trials and showed an increased survival. As many countries are considering reimbursement or have granted a market authorisation for temozolomide, a number of studies have been published in various countries in order to assess the cost-effectiveness of temozolomide for glioma patients in first- or second-line treatment. These studies show that in general, the incremental cost-effectiveness of temozolomide as adjuvant treatment, albeit at the higher end of commonly accepted thresholds, falls in line with other accepted cancer treatments.
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Affiliation(s)
- Ralph Crott
- Cliniques Universitaires St-Luc, Brussels, Belgium.
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357
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Moyal ECJ, Laprie A, Delannes M, Poublanc M, Catalaa I, Dalenc F, Berchery D, Sabatier J, Bousquet P, De Porre P, Alaux B, Toulas C. Phase I Trial of Tipifarnib (R115777) Concurrent With Radiotherapy in Patients with Glioblastoma Multiforme. Int J Radiat Oncol Biol Phys 2007; 68:1396-401. [PMID: 17570606 DOI: 10.1016/j.ijrobp.2007.02.043] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Revised: 02/02/2007] [Accepted: 02/05/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE To conduct a Phase I trial to determine the maximally tolerated dose (MTD) of tipifarnib in combination with conventional three-dimensional conformal radiotherapy (RT) for patients with glioblastoma multiforme. METHODS AND MATERIALS After resection or biopsy, tipifarnib was given 1 week before and then continuously during RT (60 Gy), followed by adjuvant administration until progression. The tipifarnib dose during RT was escalated in cohorts of 3 starting at 200 mg/day. RESULTS Thirteen patients were enrolled, and 12 were evaluable for MTD. Of these patients, 7 had undergone biopsy, 4 had partial resection, and 1 had gross total resection. No dose-limiting toxicity (DLT) was observed during the concomitant treatment at 200 mg. All 3 patients at 300 mg experienced DLT during the concomitant treatment: 1 with sudden death and 2 with acute pneumonitis. The MTD was reached at 300 mg. The adjuvant treatment was suppressed from the protocol after a case of pneumonitis during this treatment. Six additional patients were included at 200 mg/day of the new protocol, confirming the safety of this treatment. Of the 9 evaluable patients, 1 had partial response, 4 had stable disease, and 3 had rapid progression; the patient with gross total resection was relapse-free after 21 months. Median survival of the evaluable patients was 12 months (range, 5.2-21 months). CONCLUSION Tipifarnib (200 mg/day) concurrent with standard radiotherapy is well tolerated in patients with glioblastoma. Preliminary efficacy results are encouraging.
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358
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Mauer M, Stupp R, Taphoorn MJB, Coens C, Osoba D, Marosi C, Wong R, de Witte O, Cairncross JG, Efficace F, Mirimanoff RO, Forsyth P, van den Bent MJ, Weller M, Bottomley A. The prognostic value of health-related quality-of-life data in predicting survival in glioblastoma cancer patients: results from an international randomised phase III EORTC Brain Tumour and Radiation Oncology Groups, and NCIC Clinical Trials Group study. Br J Cancer 2007; 97:302-7. [PMID: 17609661 PMCID: PMC2360328 DOI: 10.1038/sj.bjc.6603876] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This is one of the few studies that have explored the value of baseline symptoms and health-related quality of life (HRQOL) in predicting survival in brain cancer patients. Baseline HRQOL scores (from the EORTC QLQ-C30 and the Brain Cancer Module (BN 20)) were examined in 490 newly diagnosed glioblastoma cancer patients for the relationship with overall survival by using Cox proportional hazards regression models. Refined techniques as the bootstrap re-sampling procedure and the computation of C-indexes and R2-coefficients were used to try and validate the model. Classical analysis controlled for major clinical prognostic factors selected cognitive functioning (P=0.0001), global health status (P=0.0055) and social functioning (P<0.0001) as statistically significant prognostic factors of survival. However, several issues question the validity of these findings. C-indexes and R2-coefficients, which are measures of the predictive ability of the models, did not exhibit major improvements when adding selected or all HRQOL scores to clinical factors. While classical techniques lead to positive results, more refined analyses suggest that baseline HRQOL scores add relatively little to clinical factors to predict survival. These results may have implications for future use of HRQOL as a prognostic factor in cancer patients.
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Affiliation(s)
- M Mauer
- European Organisation for Research and Treatment of Cancer, Quality of Life Unit, Data Center, Avenue Mounier 83/11, 1200 Brussels, Belgium.
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359
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Soffietti R, Rudà R, Trevisan E. New chemotherapy options for the treatment of malignant gliomas. Anticancer Drugs 2007; 18:621-32. [PMID: 17762390 DOI: 10.1097/cad.0b013e32801476fd] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This review focuses on the recent advances in chemotherapy of malignant gliomas, with special emphasis on the most common primary brain tumor in adults, glioblastoma. The demonstration of the superiority of concomitant and adjuvant temozolomide with standard radiotherapy over radiotherapy alone in patients with newly diagnosed glioblastomas by means of phase III international trial has been the major advance in the care of these patients so far. Moreover, patients whose tumors display the hypermethylation of the promoter of the gene for the repairing enzyme O-methylguanine-DMA methyltransferase are most likely to benefit from the combination regimen. The advantage of a postsurgical local administration of carmustine by slow-release polymers ('gliadel wafers') is more modest, and the efficacy and safety of a sequence of carmustine wafers followed by temozolomide combined with radiotherapy remain to be defined. Different DNA repair modulation strategies are being investigated to further improve the results: dose-dense regimens of temozolomide, combination of temozolomide with specific inhibitors of O-methylguanine-DMA methyltransferase and combination of temozolomide with specific inhibitors of base excision repair [poly(ADP-ribose) polymerase inhibitors]. Other developments include the combination of cytotoxic, cytostatic and targeted therapies. Multitargeted compounds that simultaneously affect multiple signaling pathways, such as those involving epidermal growth factor receptor, platelet-derived growth factor receptor and vascular endothelial growth factor receptor, are increasingly employed. In the future, innovative trial designs (factorial and adaptative designs), pretreatment molecular profiling of individual tumors and the adoption of biological end-points (changes in serum tumor markers, measures of target inhibition), in addition to the traditional clinical and radiographic end-points, will be needed to achieve further advances.
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Affiliation(s)
- Riccardo Soffietti
- Division of Neuro-Oncology, Departments of Neuroscience and Oncology, University and San Giovanni Battista Hospital, Turin, Italy.
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360
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Boulay JL, Miserez AR, Zweifel C, Sivasankaran B, Kana V, Ghaffari A, Luyken C, Sabel M, Zerrouqi A, Wasner M, Meir EV, Tolnay M, Reifenberger G, Merlo A. Loss of NOTCH2 positively predicts survival in subgroups of human glial brain tumors. PLoS One 2007; 2:e576. [PMID: 17593975 PMCID: PMC1892807 DOI: 10.1371/journal.pone.0000576] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2007] [Accepted: 06/01/2007] [Indexed: 11/22/2022] Open
Abstract
The structural complexity of chromosome 1p centromeric region has been an obstacle for fine mapping of tumor suppressor genes in this area. Loss of heterozygosity (LOH) on chromosome 1p is associated with the longer survival of oligodendroglioma (OD) patients. To test the clinical relevance of 1p loss in glioblastomas (GBM) patients and identifiy the underlying tumor suppressor locus, we constructed a somatic deletion map on chromosome 1p in 26 OG and 118 GBM. Deletion hotspots at 4 microsatellite markers located at 1p36.3, 1p36.1, 1p22 and 1p11 defined 10 distinct haplotypes that were related to patient survival. We found that loss of 1p centromeric marker D1S2696 within NOTCH2 intron 12 was associated with favorable prognosis in OD (P = 0.0007) as well as in GBM (P = 0.0175), while 19q loss, concomitant with 1p LOH in OD, had no influence on GBM survival (P = 0.918). Assessment of the intra-chromosomal ratio between NOTCH2 and its 1q21 pericentric duplication N2N (N2/N2N-test) allowed delineation of a consistent centromeric breakpoint in OD that also contained a minimally lost area in GBM. OD and GBM showed distinct deletion patterns that converged to the NOTCH2 gene in both glioma subtypes. Moreover, the N2/N2N-test disclosed homozygous deletions of NOTCH2 in primary OD. The N2/N2N test distinguished OD from GBM with a specificity of 100% and a sensitivity of 97%. Combined assessment of NOTCH2 genetic markers D1S2696 and N2/N2N predicted 24-month survival with an accuracy (0.925) that is equivalent to histological classification combined with the D1S2696 status (0.954) and higher than current genetic evaluation by 1p/19q LOH (0.762). Our data propose NOTCH2 as a powerful new molecular test to detect prognostically favorable gliomas.
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Affiliation(s)
- Jean-Louis Boulay
- Laboratory of Molecular Neuro-Oncology, Department of Research, University Hospital, Basel, Switzerland
| | | | - Christian Zweifel
- Laboratory of Molecular Neuro-Oncology, Department of Research, University Hospital, Basel, Switzerland
- Neurosurgical Clinic, University Hospital, Basel, Switzerland
| | | | - Veronika Kana
- Laboratory of Molecular Neuro-Oncology, Department of Research, University Hospital, Basel, Switzerland
| | - Anthony Ghaffari
- Laboratory of Molecular Neuro-Oncology, Department of Research, University Hospital, Basel, Switzerland
- Neurosurgical Clinic, University Hospital, Basel, Switzerland
| | - Cordelia Luyken
- Departments of Neuropathology, and Neurosurgery, Heinrich-Heine-University, Düsseldorf, Germany
| | - Michael Sabel
- Departments of Neuropathology, and Neurosurgery, Heinrich-Heine-University, Düsseldorf, Germany
| | - Abdessamad Zerrouqi
- Laboratory of Molecular Neuro-Oncology, Department of Neurosurgery, Emory University, Atlanta, Georgia, United States of America
| | - Morten Wasner
- Neurosurgical Clinic, University Hospital, Basel, Switzerland
| | - Erwin Van Meir
- Laboratory of Molecular Neuro-Oncology, Department of Neurosurgery, Emory University, Atlanta, Georgia, United States of America
| | - Markus Tolnay
- Institute of Pathology, University Hospital, Basel, Switzerland
| | - Guido Reifenberger
- Departments of Neuropathology, and Neurosurgery, Heinrich-Heine-University, Düsseldorf, Germany
| | - Adrian Merlo
- Laboratory of Molecular Neuro-Oncology, Department of Research, University Hospital, Basel, Switzerland
- Neurosurgical Clinic, University Hospital, Basel, Switzerland
- * To whom correspondence should be addressed. E-mail:
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361
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Olson MV, Johnson DG, Jiang H, Xu J, Alonso MM, Aldape KD, Fuller GN, Bekele BN, Yung WKA, Gomez-Manzano C, Fueyo J. Transgenic E2F1 expression in the mouse brain induces a human-like bimodal pattern of tumors. Cancer Res 2007; 67:4005-9. [PMID: 17483310 DOI: 10.1158/0008-5472.can-06-2973] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The Rb/E2F pathway is deregulated in most human brain tumors, and the finding that loss of E2F1 reduced pituitary tumorigenesis in Rb(+/-) mice suggests that loss of pRb induces brain tumors by activating E2F1. We therefore investigated the role of E2F1 in the development and maintenance of brain cancer using a transgenic mouse model engineered to express E2F1 specifically within glial cells (GFAP-tgE2F1). GFAP-tgE2F1 mice developed a highly penetrant phenotype characterized by neurologic defects, and examination of the brains revealed the presence of brain tumors in 20% of these animals. Importantly, the distribution of tumors according to mouse age suggests the existence of a bimodal pattern of tumor development, forcing a comparison with the human disease. Mice, at an early age, with deregulated E2F1 show the formation of embryonal brain tumors such as medulloblastoma, choroid plexus carcinoma, and primary neuroectodermal tumor. Conversely, at an older age, mice escaping embryonal tumor formation present with malignant gliomas, which are typically identified in the human adult population. Thus, this study offers the first evidence for a global role of E2F1 in the formation and maintenance of multilineage brain tumors, irrefutably establishing E2F1 as an oncogene in the brain.
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Affiliation(s)
- Melissa V Olson
- Department of Neuro-Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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362
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Ford JM, Seiferheld W, Alger JR, Wu G, Endicott TJ, Mehta M, Curran W, Phan SC. Results of the phase I dose-escalating study of motexafin gadolinium with standard radiotherapy in patients with glioblastoma multiforme. Int J Radiat Oncol Biol Phys 2007; 69:831-8. [PMID: 17560737 DOI: 10.1016/j.ijrobp.2007.04.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2006] [Revised: 04/04/2007] [Accepted: 04/13/2007] [Indexed: 11/27/2022]
Abstract
PURPOSE Motexafin gadolinium (MGd) is a putative radiation enhancer initially evaluated in patients with brain metastases. This Phase I trial studied the safety and tolerability of a 2-6-week course (10-22 doses) of MGd with radiotherapy for glioblastoma multiforme. METHODS AND MATERIALS A total of 33 glioblastoma multiforme patients received one of seven MGd regimens starting at 10 doses of 4 mg/kg/d MGd and escalating to 22 doses of 5.3 mg/kg/d MGd (5 or 10 daily doses then three times per week). The National Cancer Institute Cancer Therapy Evaluation Program toxicity and stopping rules were applied. RESULTS The maximal tolerated dose was 5.0 mg/kg/d MGd (5 d/wk for 2 weeks, then three times per week) for 22 doses. The dose-limiting toxicity was reversible transaminase elevation. Adverse reactions included rash/pruritus (45%), chills/fever (30%), and self-limiting vesiculobullous rash of the thumb and fingers (42%). The median survival of 17.6 months prompted a case-matched analysis. In the case-matched analysis, the MGd patients had a median survival of 16.1 months (n = 31) compared with the matched Radiation Therapy Oncology Group database patients with a median survival of 11.8 months (hazard ratio, 0.43; 95% confidence interval, 0.20-0.94). CONCLUSION The maximal tolerated dose of MGd with radiotherapy for glioblastoma multiforme in this study was 5 mg/kg/d for 22 doses (daily for 2 weeks, then three times weekly). The baseline survival calculations suggest progression to Phase II trials is appropriate, with the addition of MGd to radiotherapy with concurrent and adjuvant temozolomide.
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Affiliation(s)
- Judith M Ford
- Department of Radiation Oncology, University of California, Los Angeles, School of Medicine, Los Angeles, CA 90095-6951, USA.
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363
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Back MF, Ang ELL, Ng WH, See SJ, Lim CCT, Chan SP, Yeo TT. Improved Median Survival for Glioblastoma Multiforme Following Introduction of Adjuvant Temozolomide Chemotherapy. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2007. [DOI: 10.47102/annals-acadmedsg.v36n5p338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Introduction: The use of adjuvant temozolomide (TMZ) in patients managed with surgery and adjuvant radiation therapy (RT) for glioblastoma multiforme (GBM) has been demonstrated to improve median and 2-year survival in a recent large international multicentre study. To confirm this result in routine clinical practice, an audit of the management and outcome of patients with GBM at The Cancer Institute Radiation Oncology was performed.
Materials and Methods: All patients with GBM managed radically at The Cancer Institute Radiation Oncology from May 2002 to 2006 were entered into a prospective database. Patient, tumour and treatment factors were analysed for association with the outcome of median survival (MS). Survival was calculated using the Kaplan-Meier technique and correlation was assessed using Cox proportional hazards regression.
Results: Forty-one patients with GBM were managed with radical intent over the 4year period. The median age was 54 years and 66% were Eastern Cooperative Oncology Group (ECOG) 0-1 performance status. Macroscopic, subtotal and biopsy alone procedures were performed in 61%, 29% and 10% of patients, respectively. The median time from surgery to RT was 26 days. Adjuvant TMZ was used in 44% of patients (n = 18). The MS of the total group was 13.6 months, with a 24% 2-year overall survival. The use of TMZ was associated with improved MS (19.6 versus 12.8 months; P = 0.035) and improved 2-year survival (43% versus 0%). A requirement of dexamethasone dose greater than 4 mg at the end of RT (P = 0.012) was associated with worse survival, but there was no association of MS with age, ECOG, tumour size or extent of surgery.
Conclusion: The median and 2-year survival outcomes are comparable to the results of the European Multicentre Study and justify the continued use of TMZ in routine clinical practice.
Key words: Adjuvant, Glioblastoma, Temozolomide
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364
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Zalutsky MR, Reardon DA, Pozzi OR, Vaidyanathan G, Bigner DD. Targeted alpha-particle radiotherapy with 211At-labeled monoclonal antibodies. Nucl Med Biol 2007; 34:779-85. [PMID: 17921029 DOI: 10.1016/j.nucmedbio.2007.03.007] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2007] [Accepted: 03/20/2007] [Indexed: 11/28/2022]
Abstract
An attractive feature of targeted radionuclide therapy is the ability to select radionuclides and targeting vehicles with characteristics that are best suited for a particular clinical application. One combination that has been receiving increasing attention is the use of monoclonal antibodies (mAbs) specifically reactive to receptors and antigens that are expressed in tumor cells to selectively deliver the alpha-particle-emitting radiohalogen astatine-211 (211At) to malignant cell populations. Promising results have been obtained in preclinical models with multiple 211At-labeled mAbs; however, translation of the concept to the clinic has been slow. Impediments to this process include limited radionuclide availability, the need for suitable radiochemistry methods operant at high activity levels and lack of data concerning the toxicity of alpha-particle emitters in humans. Nonetheless, two clinical trials have been initiated to date with 211At-labeled mAbs, and others are planned for the near future.
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Affiliation(s)
- Michael R Zalutsky
- Department of Radiology, Duke University Medical Center, Durham, NC 27710, USA.
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365
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Chinot OL, Barrié M, Fuentes S, Eudes N, Lancelot S, Metellus P, Muracciole X, Braguer D, Ouafik L, Martin PM, Dufour H, Figarella-Branger D. Correlation Between O6-Methylguanine-DNA Methyltransferase and Survival in Inoperable Newly Diagnosed Glioblastoma Patients Treated With Neoadjuvant Temozolomide. J Clin Oncol 2007; 25:1470-5. [PMID: 17442989 DOI: 10.1200/jco.2006.07.4807] [Citation(s) in RCA: 160] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose This phase II study evaluated the efficacy and safety of a 7-day on/7-day off regimen of temozolomide before radiotherapy (RT) in patients with inoperable newly diagnosed glioblastoma. Patients and Methods Patients received temozolomide (150 mg/m2/d on days 1 to 7 and days 15 to 21 every 28 days; 7 days on/7 days off) for up to four cycles before conventional RT (2-Gy fractions to a total of 60 Gy) and for four cycles thereafter or until disease progression. The primary end point was tumor response. Tumor tissue from 25 patients was analyzed for O6-methylguanine-DNA methyltransferase (MGMT) expression. Results Twenty-nine patients with a median age of 60 years were treated, and 28 were assessable for response. Seven (24%) of 29 patients had a partial response, nine patients (31%) had stable disease, and 12 patients (41%) had progressive disease. Median progression-free survival (PFS) time was 3.8 months, and median overall survival (OS) time was 6.1 months. Patients with low MGMT expression, compared with patients with high MGMT expression, had a significantly higher response rate (55% v 7%, respectively; P = .004) and improved PFS (median, 5.5 v 1.9 months, respectively; P = .009) and OS (median, 16 v 5 months, respectively; P = .003). The most common grade 3 and 4 toxicities were thrombocytopenia (20%) and neutropenia (17%). Conclusion This dose-dense temozolomide regimen resulted in modest antitumor activity with an acceptable safety profile in the neoadjuvant setting, and expression of MGMT correlated with response to temozolomide. However, this treatment approach seems to be inferior to standard concomitant RT plus temozolomide.
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Affiliation(s)
- Olivier L Chinot
- Unité de Neuro-Oncologie, Service de Neurochirurgie, Centre Hospitalier Universitaire Timone, Assistance Publique-Hôpitaux de Marseille, and Université de la Méditérranée, Faculté de Médecine de Marseille, Marseille, France.
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366
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Ducray F, Honnorat J. [What type of adjuvant chemotherapy should be proposed for the initial treatment of glioblastoma?]. Presse Med 2007; 36:1249-54. [PMID: 17350791 DOI: 10.1016/j.lpm.2007.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Carmustine wafers (Gliadel) and temozolomide (Temodal) were recently approved for initial management of glioblastoma. Gliadel) is a polymer wafer containing carmustine. These wafers are designed to be placed in the surgical cavity after glioblastoma resection to deliver local chemotherapy. This treatment is intended for tumors for which gross total resection is possible. Temozolomide is administered concomitantly with radiotherapy for six weeks followed by six cycles of adjuvant temozolomide (EORTC 26981, also known as "Stupp's protocol"). Temozolomide administered according to this protocol produced a median survival benefit of 2 months in glioblastomas, and carmustine a similar benefit in high-grade gliomas. The two-year survival rate was 26.5% with radiotherapy plus temozolomide compared with 10.4% with radiotherapy alone. In patients with complete resection, two-year survival reached 38%. These two new treatments are essentially intended for patients younger than 70 years and with a Karnofsky index>70. Ongoing studies are evaluating the possible value of combining these two treatments.
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Affiliation(s)
- François Ducray
- Service de neurologie B, Hôpital neurologique Pierre Wertheimer, Lyon
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367
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Bay JO, Jacques-Olivier B, Linassier C, Claude L, Biron P, Pierre B, Durando X, Xavier D, Verrelle P, Pierre V, Kwiatkowski F, Fabrice K, Rosti G, Giovanni R, Demirer T, Taner D. Does high-dose carmustine increase overall survival in supratentorial high-grade malignant glioma? An EBMT retrospective study. Int J Cancer 2007; 120:1782-6. [PMID: 17230505 DOI: 10.1002/ijc.22305] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Radiotherapy plus concomitant and adjuvant temozolomide have demonstrated improved survival for glioblastoma. However, prognosis remains poor. High-doses chemotherapy with carmustine is another way to improve response and survival by increasing the dose delivered. Myelotoxicity imposes autologous stem cell rescue. European Group for Blood and Marrow Transplantation experience of this treatment in patients with high-grade glioma was reported here. A retrospective analysis of 217 patients from European Group for Blood and Marrow Transplantation database was realized. Ninety-six patients underwent complete surgical resection while the 121 others had partial resection or only biopsy and were evaluable for an antitumor effect. Patients received 800 mg/m2 of carmustine intravenously at least 1 month after neurosurgery. Forty-eight to 72 hr after chemotherapy, 108 patients received autologous hematopoietic stem cells from bone marrow harvest and 109 patients autologous hematopoietic stem cells from peripheral blood. Radiotherapy was started approximately 40 days after transplantation. Ten deaths were related to the treatment. Of the 121 patients evaluable for tumor response, 64 (53%) presented an objective response. This protocol appear feasible, but with toxicity-related mortality of 4.5%. Median overall survival was 20 months and median time to treatment failure was 7 months. Overall survival and time to treatment were correlated with age, quality of resection and histological subtypes. In glioblastoma multiforme, age and surgery quality appeared to be prognostic factors. Compared with Stupp et al.'s recent study, this study did not favor high-dose carmustine for patients with glioblastoma multiforme with complete surgical resection.
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Affiliation(s)
- Jacques-Olivier Bay
- Unité de transplantation médullaire et département de radiothérapie, Centre Jean Perrin, Clermont-Ferrand, France.
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368
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Toler SM, Noe D, Sharma A. Selective enhancement of cellular oxidative stress by chloroquine: implications for the treatment of glioblastoma multiforme. Neurosurg Focus 2006; 21:E10. [PMID: 17341043 DOI: 10.3171/foc.2006.21.6.1] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Chloroquine is used in the treatment of malaria, a disease caused by infection with the parasite Plasmodium. Although chloroquine appears to possess diverse pharmacological activity, its plasmodicidal activity results from augmentation of parasite oxidative stress. Chloroquine also appears to augment oxidative stress in metabolically active mammalian cells, including human astroglial cells. The authors propose that chloroquine may augment oxidative stress induced by radiotherapy in the treatment of glioblastoma multiforme, enhancing therapeutic efficacy. Such an effect would be consistent with the known pharmacological effects of chloroquine observed in Plasmodium. Other selective redox agents, such as tempol and artemisinin, should be investigated clinically for therapeutic benefit when coadministered with combined radio- and chemotherapy for cancer.
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Affiliation(s)
- Steven M Toler
- Department of Clinical Pharmacology, Pfizer, Incorporated, 50 Pequot Avenue, New London, Connecticut 06320, USA.
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369
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Chamberlain MC, Chalmers L. A pilot study of primary temozolomide chemotherapy and deferred radiotherapy in elderly patients with glioblastoma. J Neurooncol 2006; 82:207-9. [PMID: 17019532 DOI: 10.1007/s11060-006-9269-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2006] [Accepted: 09/11/2006] [Indexed: 11/29/2022]
Abstract
There is no standard of care for elderly patients (age>or=70 years) with newly diagnosed glioblastoma (GBM). In 15 consecutive patients (median age 79 years) treated with temozolomide (TMZ) (42 days on; 14 days off), median survival was 6 months (range 4-14 months). This pilot study suggests that low dose daily TMZ may represent an alternative and equally effective treatment to more traditionally administered radiotherapy.
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Affiliation(s)
- Marc C Chamberlain
- Department of Interdisciplinary Oncology, Moffitt Cancer Center and Research Institute, 12902 Magnolia Avenue, Tampa, FL 33612-0804, USA.
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