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Gerritsen JKW, Young JS, Krieg SM, Jungk C, Ille S, Schucht P, Nahed BV, Broekman MLD, Berger M, De Vleeschouwer S, Vincent AJPE. Resection versus biopsy in patients with glioblastoma (RESBIOP study): study protocol for an international multicentre prospective cohort study (ENCRAM 2202). BMJ Open 2024; 14:e081689. [PMID: 39260848 PMCID: PMC11409263 DOI: 10.1136/bmjopen-2023-081689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2024] Open
Abstract
INTRODUCTION There are no guidelines or prospective studies defining the optimal surgical treatment for glioblastomas in older patients (≥70 years), for those with a limited functioning performance at presentation (Karnofsky Performance Scale ≤70) or for those with tumours in certain locations (midline, multifocal). Therefore, the decision between resection and biopsy is varied, among neurosurgeons internationally and at times even within an institution. This study aims to compare the effects of maximal tumour resection versus tissue biopsy on survival, functional, neurological and quality of life outcomes in these patient subgroups. Furthermore, it evaluates which modality would maximise the potential to undergo adjuvant treatment. METHODS AND ANALYSIS This study is an international, multicentre, prospective, two-arm cohort study of an observational nature. Consecutive patients with glioblastoma will be treated with resection or biopsy and matched with a 1:1 ratio. Primary endpoints are (1) overall survival and (2) proportion of patients that have received adjuvant treatment with chemotherapy and radiotherapy. Secondary endpoints are (1) proportion of patients with National Institute of Health Stroke Scale deterioration at 6 weeks, 3 months and 6 months after surgery; (2) progression-free survival (PFS); (3) quality of life at 6 weeks, 3 months and 6 months after surgery and (4) frequency and severity of serious adverse events. The total duration of the study is 5 years. Patient inclusion is 4 years; follow-up is 1 year. ETHICS AND DISSEMINATION The study has been approved by the Medical Ethics Committee (METC Zuid-West Holland/Erasmus Medical Center; MEC-2020-0812). The results will be published in peer-reviewed academic journals and disseminated to patient organisations and media. TRIAL REGISTRATION NUMBER NCT06146725.
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Affiliation(s)
| | - Jacob S Young
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Sandro M Krieg
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Christine Jungk
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Technical University of Munich, Munich, Germany
| | - Philippe Schucht
- Department of Neurosurgery, Inselspital Universitätsspital Bern, Bern, Switzerland
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Mitchel Berger
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
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Brookes A, Jewell A, Feng W, Bradshaw TD, Butler J, Gershkovich P. Oral lipid-based formulations alter delivery of cannabidiol to different anatomical regions in the brain. Int J Pharm 2023; 635:122651. [PMID: 36720447 DOI: 10.1016/j.ijpharm.2023.122651] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 01/30/2023]
Abstract
Delivery to the brain is a challenging task due to its protection by the blood-brain barrier (BBB). Lipids and fatty acids are reported to affect the permeability of the BBB, although this has not been reported following oral administration. Cannabidiol (CBD) has high therapeutic potential in the brain, therefore, this work investigated CBD delivery to anatomical brain regions following oral administration in lipid-based and lipid-free vehicles. All formulations resulted in a short brain Tmax (1 h) and brain-plasma ratios ≥ 3.5, with retention up to 18 h post administration. The highest CBD delivery was observed in the olfactory bulb and striatum, and the medulla pons and cerebellum the lowest. The lipid-free vehicle led to the highest levels of CBD in the whole brain. However, when each anatomical region was assessed individually, the long chain triglyceride-rich rapeseed oil formulation commonly showed optimal performance. The medium chain triglyceride-rich coconut oil formulation did not result in the highest CBD concentration in any brain region. Overall, differences in CBD delivery to the whole brain and various brain regions were observed following administration in different formulations, indicating that the oral formulation selection may be important for optimal delivery to specific regions of the brain.
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Affiliation(s)
- Alice Brookes
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Adelaide Jewell
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Wanshan Feng
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Tracey D Bradshaw
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - James Butler
- GlaxoSmithKline Research and Development, Park Road, Ware, Hertfordshire SG12 0DP, UK
| | - Pavel Gershkovich
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK.
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A consensus definition of supratotal resection for anatomically distinct primary glioblastoma: an AANS/CNS Section on Tumors survey of neurosurgical oncologists. J Neurooncol 2022; 159:233-242. [PMID: 35913556 DOI: 10.1007/s11060-022-04048-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 05/26/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Supratotal resection (SpTR) of glioblastoma may be associated with improved survival, but published results have varied in part from lack of consensus on the definition and appropriate use of SpTR. A previous small survey of neurosurgical oncologists with expertise performing SpTR found resection 1-2 cm beyond contrast enhancement was an acceptable definition and glioblastoma involving the right frontal and bilateral anterior temporal lobes were considered most amenable to SpTR. The general neurosurgical oncology community has not yet confirmed the practicality of this definition. METHODS Seventy-six neurosurgical oncology members of the AANS/CNS Tumor Section were surveyed, representing 34.0% of the 223 members who were administered the survey. Participants were presented with 11 definitions of SpTR and rated each definition's appropriateness. Participants additionally reviewed magnetic resonance imaging for 10 anatomically distinct glioblastomas and assessed the tumor location's eloquence, perceived equipoise of enrolling patients in a randomized trial comparing gross total to SpTR, and their personal treatment plans. RESULTS Most neurosurgeons surveyed agree that gross total plus resection of some non-contrast enhancement (n = 57, 80.3%) or resection 1-2 cm beyond contrast enhancement (n = 52, 73.2%) are appropriate definitions for SpTR. Cases were divided into three anatomically distinct groups by perceived equipoise between gross total and SpTR. The best clinical trial candidates were thought to be right anterior temporal (n = 58, 76.3%) and right frontal (n = 55, 73.3%) glioblastomas. CONCLUSION Support exists among neurosurgical oncologists with varying familiarity performing SpTR to adopt the proposed consensus definition of SpTR of glioblastoma and to potentially investigate the utility of SpTR to treat right anterior temporal and right frontal glioblastomas in a clinical trial. A smaller proportion of general neurosurgical oncologists than SpTR experts would personally treat a left anterior temporal glioblastoma with SpTR.
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Gerritsen JKW, Broekman MLD, De Vleeschouwer S, Schucht P, Jungk C, Krieg SM, Nahed BV, Berger MS, Vincent AJPE. Global comparison of awake and asleep mapping procedures in glioma surgery: An international multicenter survey. Neurooncol Pract 2022; 9:123-132. [PMID: 35371523 PMCID: PMC8965050 DOI: 10.1093/nop/npac005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Mapping techniques are frequently used to preserve neurological function during glioma surgery. There is, however, no consensus regarding the use of many variables of these techniques. Currently, there are almost no objective data available about potential heterogeneity between surgeons and centers. The goal of this survey is therefore to globally identify, evaluate and analyze the local mapping procedures in glioma surgery. Methods The survey was distributed to members of the neurosurgical societies of the Netherlands (Nederlandse Vereniging voor Neurochirurgie-NVVN), Europe (European Association of Neurosurgical Societies-EANS), and the United States (Congress of Neurological Surgeons-CNS) between December 2020 and January 2021 with questions about awake mapping, asleep mapping, assessment of neurological morbidity, and decision making. Results Survey responses were obtained from 212 neurosurgeons from 42 countries. Overall, significant differences were observed for equipment and its settings that are used for both awake and asleep mapping, intraoperative assessment of eloquent areas, the use of surgical adjuncts and monitoring, anesthesia management, assessment of neurological morbidity, and perioperative decision making. Academic practices performed awake and asleep mapping procedures more often and employed a clinical neurophysiologist with telemetric monitoring more frequently. European neurosurgeons differed from US neurosurgeons regarding the modality for cortical/subcortical mapping and awake/asleep mapping, the use of surgical adjuncts, and anesthesia management during awake mapping. Discussion This survey demonstrates the heterogeneity among surgeons and centers with respect to their procedures for awake mapping, asleep mapping, assessing neurological morbidity, and decision making in glioma patients. These data invite further evaluations for key variables that can be optimized and may therefore benefit from consensus.
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Affiliation(s)
| | - Marike L D Broekman
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, the Netherlands
| | | | - Philippe Schucht
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
| | - Christine Jungk
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Technical University Munich, Munich, Germany
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mitchel S Berger
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
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5
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Trombetta-Lima M, Rosa-Fernandes L, Angeli CB, Moretti IF, Franco YM, Mousessian AS, Wakamatsu A, Lerario AM, Oba-Shinjo SM, Pasqualucci CA, Marie SKN, Palmisano G. Extracellular Matrix Proteome Remodeling in Human Glioblastoma and Medulloblastoma. J Proteome Res 2021; 20:4693-4707. [PMID: 34533964 DOI: 10.1021/acs.jproteome.1c00251] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Medulloblastomas (MBs) and glioblastomas (GBMs) are high-incidence central nervous system tumors. Different origin sites and changes in the tissue microenvironment have been associated with the onset and progression. Here, we describe differences between the extracellular matrix (ECM) signatures of these tumors. We compared the proteomic profiles of MB and GBM decellularized tumor samples between each other and their normal decellularized brain site counterparts. Our analysis revealed that 19, 28, and 11 ECM proteins were differentially expressed in MBs, GBMs, and in both MBs and GBMs, respectively. Next, we validated key findings by using a protein tissue array with 53 MB and 55 GBM cases and evaluated the clinical relevance of the identified differentially expressed proteins through their analysis on publicly available datasets, 763 MB samples from the GSE50161 and GSE85217 studies, and 115 GBM samples from RNAseq-TCGA. We report a shift toward a denser fibrillary ECM as well as a clear alteration in the glycoprotein signature, which influences the tumor pathophysiology. MS data have been submitted to the PRIDE repository, project accession: PXD023350.
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Affiliation(s)
- Marina Trombetta-Lima
- Cellular and Molecular Biology Laboratory (LIM 15), Neurology Department, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Sao Paulo 01246-903, Brazil.,Faculty of Science and Engineering, Department of Molecular Pharmacology, Groningen Research Institute of Pharmacy (GRIP), University of Groningen, Groningen 9713 AV, The Netherlands
| | - Livia Rosa-Fernandes
- Parasitology Department, Instituto de Ciências Biomédicas (ICBUSP), Universidade de Sao Paulo, Sao Paulo, Sao Paulo 05508-000, Brazil
| | - Claudia B Angeli
- Parasitology Department, Instituto de Ciências Biomédicas (ICBUSP), Universidade de Sao Paulo, Sao Paulo, Sao Paulo 05508-000, Brazil
| | - Isabele F Moretti
- Cellular and Molecular Biology Laboratory (LIM 15), Neurology Department, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Sao Paulo 01246-903, Brazil
| | - Yollanda M Franco
- Cellular and Molecular Biology Laboratory (LIM 15), Neurology Department, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Sao Paulo 01246-903, Brazil
| | - Adaliana S Mousessian
- Cellular and Molecular Biology Laboratory (LIM 15), Neurology Department, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Sao Paulo 01246-903, Brazil
| | - Alda Wakamatsu
- Hepatic Pathology Laboratory (LIM 14), Pathology Department, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Sao Paulo 01246-903, Brazil
| | - Antonio M Lerario
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Sueli M Oba-Shinjo
- Cellular and Molecular Biology Laboratory (LIM 15), Neurology Department, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Sao Paulo 01246-903, Brazil
| | - Carlos A Pasqualucci
- Brazilian Aging Brain Study Group, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Sao Paulo 01246-903, Brazil
| | - Suely K N Marie
- Cellular and Molecular Biology Laboratory (LIM 15), Neurology Department, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Sao Paulo 01246-903, Brazil
| | - Giuseppe Palmisano
- Parasitology Department, Instituto de Ciências Biomédicas (ICBUSP), Universidade de Sao Paulo, Sao Paulo, Sao Paulo 05508-000, Brazil
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Khalafallah AM, Rakovec M, Bettegowda C, Jackson CM, Gallia GL, Weingart JD, Lim M, Esquenazi Y, Zacharia BE, Goldschmidt E, Ziu M, Ivan ME, Venteicher AS, Nduom EK, Mamelak AN, Chu RM, Yu JS, Sheehan JP, Nahed BV, Carter BS, Berger MS, Sawaya R, Mukherjee D. A Crowdsourced Consensus on Supratotal Resection Versus Gross Total Resection for Anatomically Distinct Primary Glioblastoma. Neurosurgery 2021; 89:712-719. [PMID: 34320218 DOI: 10.1093/neuros/nyab257] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/16/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Gross total resection (GTR) of contrast-enhancing tumor is associated with increased survival in primary glioblastoma. Recently, there has been increasing interest in performing supratotal resections (SpTRs) for glioblastoma. OBJECTIVE To address the published results, which have varied in part due to lack of consensus on the definition and appropriate use of SpTR. METHODS A crowdsourcing approach was used to survey 21 neurosurgical oncologists representing 14 health systems nationwide. Participants were presented with 11 definitions of SpTR and asked to rate the appropriateness of each definition. Participants reviewed T1-weighed postcontrast and fluid-attenuated inversion-recovery magnetic resonance imaging for 22 anatomically distinct glioblastomas. Participants were asked to assess the tumor location's eloquence, the perceived equipoise of enrolling patients in a randomized trial comparing gross total to SpTR, and their personal treatment plans. RESULTS Most neurosurgeons surveyed (n = 18, 85.7%) agree that GTR plus resection of some noncontrast enhancement is an appropriate definition for SpTR. Overall, moderate inter-rater agreement existed regarding eloquence, equipoise, and personal treatment plans. The 4 neurosurgeons who had performed >10 SpTRs for glioblastomas in the past year were more likely to recommend it as their treatment plan (P < .005). Cases were divided into 3 anatomically distinct groups based upon perceived eloquence. Anterior temporal and right frontal glioblastomas were considered the best randomization candidates. CONCLUSION We established a consensus definition for SpTR of glioblastoma and identified anatomically distinct locations deemed most amenable to SpTR. These results may be used to plan prospective trials investigating the potential clinical utility of SpTR for glioblastoma.
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Affiliation(s)
- Adham M Khalafallah
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Maureen Rakovec
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jon D Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael Lim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Yoshua Esquenazi
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center, Houston, Texas, USA
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Ezequiel Goldschmidt
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mateo Ziu
- Inova Neuroscience and Spine Institute, University of Virginia Medical School-Inova Campus, Falls Church, Virginia, USA
| | - Michael E Ivan
- Sylvester Comprehensive Cancer Center, Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Andrew S Venteicher
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Edjah K Nduom
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ray M Chu
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - John S Yu
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bob S Carter
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Raymond Sawaya
- Division of Surgery, Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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7
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Gogos AJ, Young JS, Morshed RA, Avalos LN, Noss RS, Villanueva-Meyer JE, Hervey-Jumper SL, Berger MS. Triple motor mapping: transcranial, bipolar, and monopolar mapping for supratentorial glioma resection adjacent to motor pathways. J Neurosurg 2021; 134:1728-1737. [PMID: 32502996 DOI: 10.3171/2020.3.jns193434] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Maximal safe resection of gliomas near motor pathways is facilitated by intraoperative mapping. The authors and other groups have described the use of bipolar or monopolar direct stimulation to identify functional tissue, as well as transcranial or transcortical motor evoked potentials (MEPs) to monitor motor pathways. Here, the authors describe their initial experience using all 3 modalities to identify, monitor, and preserve cortical and subcortical motor systems during glioma surgery. METHODS Intraoperative mapping data were extracted from a prospective registry of glioma resections near motor pathways. Additional demographic, clinical, pathological, and imaging data were extracted from the electronic medical record. All patients with new or worsened postoperative motor deficits were followed for at least 6 months. RESULTS Between January 2018 and August 2019, 59 operations were performed in 58 patients. Overall, patients in 6 cases (10.2%) had new or worse immediate postoperative deficits. Patients with temporary deficits all had at least Medical Research Council grade 4/5 power. Only 2 patients (3.4%) had permanently worsened deficits after 6 months, both of which were associated with diffusion restriction consistent with ischemia within the corticospinal tract. One patient's deficit improved to 4/5 and the other to 4/5 proximally and 3/5 distally in the lower limb, allowing ambulation following rehabilitation. Subcortical motor pathways were identified in 51 cases (86.4%) with monopolar high-frequency stimulation, but only in 6 patients using bipolar stimulation. Transcranial or cortical MEPs were diminished in only 6 cases, 3 of which had new or worsened deficits, with 1 permanent deficit. Insula location (p = 0.001) and reduction in MEPs (p = 0.01) were the only univariate predictors of new or worsened postoperative deficits. Insula location was the only predictor of permanent deficits (p = 0.046). The median extent of resection was 98.0%. CONCLUSIONS Asleep triple motor mapping is safe and resulted in a low rate of deficits without compromising the extent of resection.
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Affiliation(s)
| | | | | | | | - Roger S Noss
- 3Neuromonitoring Service, University of California, San Francisco, California
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8
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Tabatabaei Yazdi SA, Safaei M, Gholamin M, Abdollahi A, Nili F, Jabbari Nooghabi M, Anvari K, Mojarrad M. Expression and Prognostic Significance of Cancer/Testis Antigens, MAGE-E1, GAGE, and SOX-6, in Glioblastoma: An Immunohistochemistry Evaluation. IRANIAN JOURNAL OF PATHOLOGY 2020; 16:128-136. [PMID: 33936223 PMCID: PMC8085292 DOI: 10.30699/ijp.2020.125038.2368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/31/2020] [Indexed: 11/13/2022]
Abstract
Background & Objective: Glioblastoma is the most common primary malignancy of the brain, the prognosis of which is poor. Immunotherapy with cancer/testis (CT) antigens is a novel therapeutic approach for glioblastoma. This study aimed to investigate the expression rate of MAGE-E1, GAGE, and SOX-6 in glioblastoma tumors using the method of immunohistochemistry (IHC). Methods: Expression of MAGE-E1, GAGE, and SOX-6 were determined by IHC in 50 paraffin blocks of glioblastoma. The results were compared between variables including age, gender, tumor location, and Karnofsky performance status (Kps) score. Survival analysis was also performed. Results: The expression levels of SOX-6, MAGE-E1, and GAGE were 82%, 78%, and 76%, respectively. The relationship between CT antigens and age, gender, and tumor location was not significant, while the association between MAGE-E1 expression and age was statistically significant (P=0.002). High expression levels of SOX-6 and MAGE-E1 were associated with low Kps scores (P=0.034 and P<0.001, respectively). Survival analysis showed that age >40 and Kps score <80 were associated with significant relationship with shorter survival rate. (P=0.005 and P=0.018, respectively). Expression of MAGE-E1 and GAGE was negatively associated with overall 2-year survival rate (P=0.001 and P=0.021, respectively). Conclusion: The expression of all the three CT antigens, especially MAGE-E1 and SOX-6, was high in patients with glioblastoma. It can be concluded that these markers could be ideal targets for immunotherapy in such patients. MAGE-E1 and SOX-6 can be considered as important markers in determining the prognosis of glioblastoma.
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Affiliation(s)
| | - Masoomeh Safaei
- Department of Pathology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehran Gholamin
- Department of Laboratory Sciences, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alireza Abdollahi
- Department of Pathology, School of Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Nili
- Department of Pathology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Kazem Anvari
- Cancer Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Majid Mojarrad
- Department of Medical Genetics, Mashhad University of Medical Sciences, Mashhad, Iran
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Mandal AS, Romero-Garcia R, Hart MG, Suckling J. Genetic, cellular, and connectomic characterization of the brain regions commonly plagued by glioma. Brain 2020; 143:3294-3307. [PMID: 33278823 PMCID: PMC7891236 DOI: 10.1093/brain/awaa277] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/26/2020] [Accepted: 07/12/2020] [Indexed: 12/21/2022] Open
Abstract
For decades, it has been known that gliomas follow a non-random spatial distribution, appearing more often in some brain regions (e.g. the insula) compared to others (e.g. the occipital lobe). A better understanding of the localization patterns of gliomas could provide clues to the origins of these types of tumours, and consequently inform treatment targets. Following hypotheses derived from prior research into neuropsychiatric disease and cancer, gliomas may be expected to localize to brain regions characterized by functional hubness, stem-like cells, and transcription of genetic drivers of gliomagenesis. We combined neuroimaging data from 335 adult patients with high- and low-grade glioma to form a replicable tumour frequency map. Using this map, we demonstrated that glioma frequency is elevated in association cortex and correlated with multiple graph-theoretical metrics of high functional connectedness. Brain regions populated with putative cells of origin for glioma, neural stem cells and oligodendrocyte precursor cells, exhibited a high glioma frequency. Leveraging a human brain atlas of post-mortem gene expression, we found that gliomas were localized to brain regions enriched with expression of genes associated with chromatin organization and synaptic signalling. A set of glioma proto-oncogenes was enriched among the transcriptomic correlates of glioma distribution. Finally, a regression model incorporating connectomic, cellular, and genetic factors explained 58% of the variance in glioma frequency. These results add to previous literature reporting the vulnerability of hub regions to neurological disease, as well as provide support for cancer stem cell theories of glioma. Our findings illustrate how factors of diverse scale, from genetic to connectomic, can independently influence the anatomic localization of brain dysfunction.
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Affiliation(s)
- Ayan S Mandal
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Rafael Romero-Garcia
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Michael G Hart
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge, UK
- Academic Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - John Suckling
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge, UK
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10
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Yesil Cinkir H, Colakoglu Er H. Is temporal muscle thickness a survival predictor in newly diagnosed glioblastoma multiforme? Asia Pac J Clin Oncol 2020; 16:e223-e227. [PMID: 32762134 DOI: 10.1111/ajco.13369] [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: 12/07/2019] [Indexed: 01/09/2023]
Abstract
AIM Glioblastoma multiforme (GBM) is the most common primary malignant brain tumor in adults. In this study, we aimed to show the relationship between temporal muscle thickness (TMT) measurement and survival in newly diagnosed patients with GBM. METHODS Forty-seven patients with newly diagnosed GBM were evaluated, retrospectively. TMT at diagnosis of GBM before any surgical procedure was measured on the contrast-enhanced axial longitudinal relaxation time (T1)-weighted magnetic resonance images. Overall survival (OS) was analyzed by the Kaplan-Meier method and log-rank test was used to determine the differences between the groups. The median TMT was used to determine the cutoff point. RESULTS The median TMT was 4.7 mm (range, 2.8-6.6) in females and 5.4 mm (range, 2.9-8.1) in males. Median survival for TMT < 4.9 mm was 12.9 ± 3.5 (95% CI, 6.0-19.8) months, and 39.4 ± 11.9 (95% CI, 16.0-62.8) months for TMT ≥ 4.9 (P = .023). In the multivariate Cox regression model, the TMT group (Hazard ratio [HR] = 2.07, 95% CI, 0.92-4.61, P = .032) and age group (HR = 2.18, 95% CI, 1.01-4.67, P = .014) showed statistically significant difference. CONCLUSION TMT is not an independent predictor of response but a predictor of sarcopenia and survival in newly diagnosed GBM. TMT measurement is an easy and practical method. Survival prediction will provide useful information in GBM patients having poor prognosis.
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Affiliation(s)
- Havva Yesil Cinkir
- Department of Medical Oncology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Hale Colakoglu Er
- Department of Radiology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
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11
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Natsume A, Aoki K, Ohka F, Maeda S, Hirano M, Adilijiang A, Motomura K, Sumi M, Nishikawa R, Narita Y, Muragaki Y, Maruyama T, Ito T, Beppu T, Nakamura H, Kayama T, Sato S, Nagane M, Mishima K, Nakasu Y, Kurisu K, Yamasaki F, Sugiyama K, Onishi T, Iwadate Y, Terasaki M, Kobayashi H, Matsumura A, Ishikawa E, Sasaki H, Mukasa A, Matsuo T, Hirano H, Kumabe T, Shinoura N, Hashimoto N, Aoki T, Asai A, Abe T, Yoshino A, Arakawa Y, Asano K, Yoshimoto K, Shibui S, Okuno Y, Wakabayashi T. Genetic analysis in patients with newly diagnosed glioblastomas treated with interferon-beta plus temozolomide in comparison with temozolomide alone. J Neurooncol 2020; 148:17-27. [PMID: 32367437 DOI: 10.1007/s11060-020-03505-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/17/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE This study aimed to explore the genetic alterations and to identify good responders in the experimental arm in the tumor samples from newly diagnosed glioblastoma (GBM) patients enrolled in JCOG0911; a randomized phase II trial was conducted to compare the efficacy of interferonβ (IFNβ) plus temozolomide (TMZ) with that of TMZ alone. EXPERIMENTAL DESIGN: Of 122 tumors, we performed deep targeted sequencing to determine the somatic mutations, copy number variations, and tumor mutation burden; pyrosequencing for O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation; Sanger sequencing for the telomerase reverse transcriptase (TERT) promoter; and microsatellite instability (MSI) testing in 95, 91, 91 and 72 tumors, respectively. We performed a multivariable Cox regression analysis using backward stepwise selection of variables including clinical factors (sex, age, performance status, residual tumor after resection, tumor location) and genetic alterations. RESULTS Deep sequencing detected an IDH1 mutation in 13 tumors (14%). The MGMT promoter methylation by quantitative pyrosequencing was observed in 41% of the tumors. A mutation in the TERT promoter was observed in 69% of the tumors. While high tumor mutation burden (> 10 mutations per megabase) was seen in four tumors, none of the tumors displayed MSI-high. The clinical and genetic factors considered as independent favorable prognostic factors were gross total resection (hazard ratio [HR]: 0.49, 95% confidence interval, 0.30-0.81, P = 0.0049) and MGMT promoter methylation (HR: 0.43, 0.21-0.88, P = 0.023). However, tumor location at the temporal lobe (HR: 1.90, 1.22-2.95, P = 0.0046) was an independent unfavorable prognostic factor. No predictive factors specific to the TMZ + IFNβ + Radiotherapy (RT) group were found. CONCLUSION This additional sub-analytical study of JCOG0911 among patients with newly diagnosed GBM showed that tumor location at the temporal lobe, gross total resection, and MGMT promoter methylation were significant prognostic factors, although no factors specific to IFNβ addition were identified.
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Affiliation(s)
- Atsushi Natsume
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Kosuke Aoki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumiharu Ohka
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Sachi Maeda
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaki Hirano
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Alimu Adilijiang
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuya Motomura
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Minako Sumi
- Radiation Oncology Department, Cancer Institute Hospital, Tokyo, Japan
| | - Ryo Nishikawa
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yoshitaka Narita
- Department of Neurosurgery and Neuro-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshihiro Muragaki
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takashi Maruyama
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Tamio Ito
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Takaaki Beppu
- Department of Neurosurgery, Iwate Medical University, Iwate, Japan
| | - Hideo Nakamura
- Department of Neurosurgery, Kumamoto University Graduate School of Medicine, Kumamoto, Japan
| | - Takamasa Kayama
- Department of Neurosurgery, Yamagata University Graduate School of Medicine, Yamagata, Japan
| | - Shinya Sato
- Department of Neurosurgery, Yamagata University Graduate School of Medicine, Yamagata, Japan
| | - Motoo Nagane
- Department of Neurosurgery, Faculty of Medicine, Kyorin University, Tokyo, Japan
| | - Kazuhiko Mishima
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yoko Nakasu
- Department of Neurosurgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kaoru Kurisu
- Department of Neurosurgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Fumiyuki Yamasaki
- Department of Neurosurgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazuhiko Sugiyama
- Department of Clinical Oncology & Neuro-Oncology Program, Hiroshima University Hospital, Hiroshima, Japan
| | - Takanori Onishi
- Department of Neurosurgery, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Yasuo Iwadate
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Mizuhiko Terasaki
- Department of Neurosurgery, Kurume University Graduate School of Medicine, Kurume, Japan
| | - Hiroyuki Kobayashi
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Akira Matsumura
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hikaru Sasaki
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Akitake Mukasa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Takayuki Matsuo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hirofumi Hirano
- Department of Neurosurgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Toshihiro Kumabe
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Nobusada Shinoura
- Department of Neurosurgery, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Naoya Hashimoto
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tomokazu Aoki
- Department of Neurosurgery, Kitano Hospital, Osaka, Japan
| | - Akio Asai
- Department of Neurosurgery, Kansai Medical University, Osaka, Japan
| | - Tatsuya Abe
- Department of Neurosurgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Atsuo Yoshino
- Department of Neurological Surgery, Nihon University Graduate School of Medicine, Tokyo, Japan
| | - Yoshiki Arakawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenichiro Asano
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Koji Yoshimoto
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyusyu University, Fukuoka, Japan
| | - Soichiro Shibui
- Department of Neurosurgery and Neuro-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yusuke Okuno
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Toshihiko Wakabayashi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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12
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Jayabalan S, Balaji A, Rajendran K, Balaji P, Mehtha S, Subramaniam R, Sairam RM. Single institutional study on treatment and prognosis of glioblastoma multiforme. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2019.100575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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13
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Liu L, Zhang H, Wu J, Yu Z, Chen X, Rekik I, Wang Q, Lu J, Shen D. Overall survival time prediction for high-grade glioma patients based on large-scale brain functional networks. Brain Imaging Behav 2020; 13:1333-1351. [PMID: 30155788 DOI: 10.1007/s11682-018-9949-2] [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] [Indexed: 12/19/2022]
Abstract
High-grade glioma (HGG) is a lethal cancer with poor outcome. Accurate preoperative overall survival (OS) time prediction for HGG patients is crucial for treatment planning. Traditional presurgical and noninvasive OS prediction studies have used radiomics features at the local lesion area based on the magnetic resonance images (MRI). However, the highly complex lesion MRI appearance may have large individual variability, which could impede accurate individualized OS prediction. In this paper, we propose a novel concept, namely brain connectomics-based OS prediction. It is based on presurgical resting-state functional MRI (rs-fMRI) and the non-local, large-scale brain functional networks where the global and systemic prognostic features rather than the local lesion appearance are used to predict OS. We propose that the connectomics features could capture tumor-induced network-level alterations that are associated with prognosis. We construct both low-order (by means of sparse representation with regional rs-fMRI signals) and high-order functional connectivity (FC) networks (characterizing more complex multi-regional relationship by synchronized dynamics FC time courses). Then, we conduct a graph-theoretic analysis on both networks for a jointly, machine-learning-based individualized OS prediction. Based on a preliminary dataset (N = 34 with bad OS, mean OS, ~400 days; N = 34 with good OS, mean OS, ~1030 days), we achieve a promising OS prediction accuracy (86.8%) on separating the individuals with bad OS from those with good OS. However, if using only conventionally derived descriptive features (e.g., age and tumor characteristics), the accuracy is low (63.2%). Our study highlights the importance of the rs-fMRI and brain functional connectomics for treatment planning.
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Affiliation(s)
- Luyan Liu
- Med-X Research Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030, China.,Department of Radiology and BRIC, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Han Zhang
- Department of Radiology and BRIC, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jinsong Wu
- Glioma Surgery Division, Neurosurgery Department of Huashan Hospital, Fudan University, Shanghai, 200040, China.,Shanghai Key Lab of Medical Image Computing and Computer-Assisted Intervention, Shanghai, 200040, China.,Neurosurgery Department of Huashan Hospital, 12 Wulumuqi Zhong Road, Shanghai, 200040, China
| | - Zhengda Yu
- Glioma Surgery Division, Neurosurgery Department of Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Xiaobo Chen
- Department of Radiology and BRIC, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Islem Rekik
- Department of Radiology and BRIC, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,BASIRA Lab, CVIP Group, School of Science and Engineering, Computing, University of Dundee, Dundee, UK
| | - Qian Wang
- Med-X Research Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030, China.
| | - Junfeng Lu
- Glioma Surgery Division, Neurosurgery Department of Huashan Hospital, Fudan University, Shanghai, 200040, China. .,Shanghai Key Lab of Medical Image Computing and Computer-Assisted Intervention, Shanghai, 200040, China. .,Neurosurgery Department of Huashan Hospital, 12 Wulumuqi Zhong Road, Shanghai, 200040, China.
| | - Dinggang Shen
- Department of Radiology and BRIC, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,Department of Brain and Cognitive Engineering, Korea University, Seoul, 02841, Republic of Korea.
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14
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Oberheim Bush NA, Hervey-Jumper SL, Berger MS. Management of Glioblastoma, Present and Future. World Neurosurg 2020; 131:328-338. [PMID: 31658576 DOI: 10.1016/j.wneu.2019.07.044] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 01/22/2023]
Abstract
Glioblastomas are the most common malignant brain tumor and despite extensive research have a dismal prognosis. This review focuses on the current treatment paradigms of glioblastoma and highlights current advances in surgical approaches, imaging techniques, molecular diagnostics, and translational efforts. Several promising clinical trials in immunotherapy and personalized medicine are discussed and the importance of quality of life in the patients and their caregivers both during active treatment and survivorship is also commented on.
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Affiliation(s)
- Nancy Ann Oberheim Bush
- Division of Neuro-Oncology, Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Shawn L Hervey-Jumper
- Division of Neuro-Oncology, Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, California, USA.
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15
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Gerritsen JKW, Klimek M, Dirven CMF, Hoop EOD, Wagemakers M, Rutten GJM, Kloet A, Hallaert GG, Vincent AJPE. The SAFE-trial: Safe surgery for glioblastoma multiforme: Awake craniotomy versus surgery under general anesthesia. Study protocol for a multicenter prospective randomized controlled trial. Contemp Clin Trials 2019; 88:105876. [PMID: 31676314 DOI: 10.1016/j.cct.2019.105876] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 10/18/2019] [Accepted: 10/24/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgery of GBM nowadays is usually performed under general anesthesia (GA) and resections are often not as aggressive as possible, due to the chance of seriously damaging the patient with a rather low life expectancy. A surgical technique optimizing resection of the tumor in eloquent areas but preventing neurological deficits is necessary to improve survival and quality of life in these patients. Awake craniotomy (AC) with the use of cortical and subcortical stimulation has been widely implemented for low-grade glioma resections (LGG), but not yet for GBM. AC has shown to increase resection percentage and preserve quality of life in LGG and could thus be of important value in GBM surgery. METHODS/DESIGN This study is a prospective, multicenter, randomized controlled trial (RCT). Consecutive patients with a glioblastoma in or near eloquent areas (Sawaya grading II/III) will be 1:1 randomized to awake craniotomy or craniotomy under general anesthesia. 246 patients will be included in neurosurgical centers in the Netherlands and Belgium. Primary end-points are: 1) Postoperative neurological morbidity and 2) Proportion of patients with gross-total resections. Secondary end-points are: 1) Health-related quality of life; 2) Progression-free survival (PFS); 3) Overall survival (OS) and 4) Frequency and severity of Serious Adverse Effects in each group. Also, a cost-benefit analysis will be performed. All patients will receive standard adjuvant treatment with concomitant chemoradiotherapy. DISCUSSION This RCT should demonstrate whether AC is superior to craniotomy under GA on neurological morbidity, extent of resection and survival for glioblastoma resections in or near eloquent areas. TRIAL REGISTRATION Clinicaltrials.gov: NCT03861299 Netherlands Trial Register (NTR): NL7589.
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Affiliation(s)
| | - Markus Klimek
- Erasmus Medical Center Rotterdam, Department of Anesthesiology, The Netherlands
| | - Clemens M F Dirven
- Erasmus Medical Center Rotterdam, Department of Neurosurgery, The Netherlands
| | | | - Michiel Wagemakers
- University Medical Center Groningen, Department of Neurosurgery, The Netherlands
| | - Geert Jan M Rutten
- Elisabeth-Tweesteden Hospital Tilburg, Department of Neurosurgery, The Netherlands
| | - Alfred Kloet
- Haaglanden Medical Center Den Haag, Department of Neurosurgery, The Netherlands
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16
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Grasso G, Torregrossa F, Leone L. Maximizing the Extent of Resection in High-Grade Glioma. World Neurosurg 2019; 123:256-258. [DOI: 10.1016/j.wneu.2018.12.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 11/29/2022]
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17
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Gerritsen JKW, Arends L, Klimek M, Dirven CMF, Vincent AJPE. Impact of intraoperative stimulation mapping on high-grade glioma surgery outcome: a meta-analysis. Acta Neurochir (Wien) 2019; 161:99-107. [PMID: 30465276 PMCID: PMC6331492 DOI: 10.1007/s00701-018-3732-4] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 11/07/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Intraoperative stimulation mapping (ISM) using electrocortical mapping (awake craniotomy, AC) or evoked potentials has become a solid option for the resection of supratentorial low-grade gliomas in eloquent areas, but not as much for high-grade gliomas. This meta-analysis aims to determine whether the surgeon, when using ISM and AC, is able to achieve improved overall survival and decreased neurological morbidity in patients with high-grade glioma as compared to resection under general anesthesia (GA). METHODS A systematic search was performed to identify relevant studies. Adult patients were included who had undergone craniotomy for high-grade glioma (WHO grade III or IV) using ISM (among which AC) or GA. Primary outcomes were rate of postoperative complications, overall postoperative survival, and percentage of gross total resections (GTR). Secondary outcomes were extent of resection and percentage of eloquent areas. RESULTS Review of 2049 articles led to the inclusion of 53 studies in the analysis, including 9102 patients. The overall postoperative median survival in the AC group was significantly longer (16.87 versus 12.04 months; p < 0.001) and the postoperative complication rate was significantly lower (0.13 versus 0.21; p < 0.001). Mean percentage of GTR was significantly higher in the ISM group (79.1% versus 47.7%, p < 0.0001). Extent of resection and preoperative patient KPS were indicated as prognostic factors, whereas patient KPS and involvement of eloquent areas were identified as predictive factors. CONCLUSIONS These findings suggest that surgeons using ISM and AC during their resections of high-grade glioma in eloquent areas experienced better surgical outcomes: a significantly longer overall postoperative survival, a lower rate of postoperative complications, and a higher percentage of GTR.
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Affiliation(s)
- Jasper Kees Wim Gerritsen
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| | - Lidia Arends
- Department of Biostatistics, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Markus Klimek
- Department of Anesthesiology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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18
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Deshpande RP, Y B V K C, Panigrahi M, Babu PP. Prognostic Significance of Anatomic Origin and Evaluation of Survival Statistics of Astrocytoma Patients-a Tertiary Experience. Indian J Surg Oncol 2018; 10:55-60. [PMID: 30948873 DOI: 10.1007/s13193-018-0820-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 10/17/2018] [Indexed: 11/30/2022] Open
Abstract
Astrocytoma constitutes the most noted malignancies of the central nervous system with worse clinical outcomes in grade IV astrocytoma or glioblastoma multiforme. Owing to poor clinical outcomes with existing therapeutic regime, there is a need to revisit the initial course of treatment. Statistical information of clinicopathological parameters could be used to understand the spread of disease and, in turn, to formulate updated treatment management. In the present study, we have seen anatomic distribution of astrocytoma subtypes in a group of 479 patients and correlated it with survival outcomes. Anatomic location was confirmed by MRI (magnetic resonance imaging) images. A registry of patients was maintained with clinicopathological details as tumor type, location, age/sex, and survival after surgery. We have observed overall survival particulars in patients diagnosed with astrocytoma. Our findings highlight that in total cases, tumor location was anatomically dominated by frontal and temporal lobes. Survival analysis in high-grade (grade III, p = 0.03; grade IV, p = 0.01) astrocytic tumors confirms poor outcomes with temporal, parietal, and occipital location as compared to frontal lobe. Overall survival study demonstrates glioblastoma multiforme (GBM) was associated with worse prognosis as compared to astrocytoma subtypes (p < 0.0001). In high-grade astrocytomas, anaplastic astrocytoma was found with 34 months of median survival age while 14 months in the case of patients with glioblastoma multiforme. In conclusion, we report dismal prognosis in parietal, temporal, and occipital lobes in grade II, grade III, and grade IV astrocytoma patients. Among astrocytoma subtypes, patients with glioblastoma multiforme were associated with worse survival outcomes. We uniquely feature the survival of astrocytoma patients for the first time and observe GBM patients have slightly longer survival.
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Affiliation(s)
- Ravindra Pramod Deshpande
- 1Department of Biotechnology and Bioinformatics, School of Life Sciences, University of Hyderabad, Hyderabad, Telangana State 500046 India
| | | | - Manas Panigrahi
- 2Krishna Institute of Medical Sciences, Secunderabad, Telangana State India
| | - Phanithi Prakash Babu
- 1Department of Biotechnology and Bioinformatics, School of Life Sciences, University of Hyderabad, Hyderabad, Telangana State 500046 India
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19
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Balaña C, Estival A, Teruel I, Hardy-Werbin M, Sepulveda J, Pineda E, Martinez-García M, Gallego O, Luque R, Gil-Gil M, Mesia C, Del Barco S, Herrero A, Berrocal A, Perez-Segura P, De Las Penas R, Marruecos J, Fuentes R, Reynes G, Velarde JM, Cardona A, Verger E, Panciroli C, Villà S. Delay in starting radiotherapy due to neoadjuvant therapy does not worsen survival in unresected glioblastoma patients. Clin Transl Oncol 2018; 20:1529-1537. [PMID: 29737461 DOI: 10.1007/s12094-018-1883-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/23/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE We retrospectively examined the potential effect on overall survival (OS) of delaying radiotherapy to administer neoadjuvant therapy in unresected glioblastoma patients. PATIENTS AND METHODS We compared OS in 119 patients receiving neoadjuvant therapy followed by standard treatment (NA group) and 96 patients receiving standard treatment without neoadjuvant therapy (NoNA group). The MaxStat package of R identified the optimal cut-off point for waiting time to radiotherapy. RESULTS OS was similar in the NA and NoNA groups. Median waiting time to radiotherapy after surgery was 13 weeks for the NA group and 4.2 weeks for the NoNA group. The longest OS was attained by patients who started radiotherapy after 12 weeks and the shortest by patients who started radiotherapy within 4 weeks (12.3 vs 6.6 months) (P = 0.05). OS was 6.6 months for patients who started radiotherapy before the optimal cutoff of 6.43 weeks and 19.1 months for those who started after this time (P = 0.005). Patients who completed radiotherapy had longer OS than those who did not, in all 215 patients and in the NA and NoNA groups (P = 0.000). In several multivariate analyses, completing radiotherapy was a universally favorable prognostic factor, while neoadjuvant therapy was never identified as a negative prognostic factor. CONCLUSION In our series of unresected patients receiving neoadjuvant treatment, in spite of the delay in starting radiotherapy, OS was not inferior to that of a similar group of patients with no delay in starting radiotherapy.
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Affiliation(s)
- C Balaña
- Medical Oncology Service, Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Ctra Canyet, s/n, 08916, Badalona (Barcelona), Spain.
| | - A Estival
- Medical Oncology Service, Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Ctra Canyet, s/n, 08916, Badalona (Barcelona), Spain
| | - I Teruel
- Medical Oncology Service, Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Ctra Canyet, s/n, 08916, Badalona (Barcelona), Spain
| | - M Hardy-Werbin
- Cancer Research Programm, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - J Sepulveda
- Medical Oncology Service, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - E Pineda
- Medical Oncology Service, Hospital Clinic Provincial, Barcelona, Spain
| | | | - O Gallego
- Medical Oncology Service, Hospital de Sant Pau, Barcelona, Spain
| | - R Luque
- Medical Oncology Service, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - M Gil-Gil
- Medical Oncology Service, Institut Català d'Oncologia-IDIBELL, Hospitalet de Llobregat, Spain
| | - C Mesia
- Medical Oncology Service, Institut Català d'Oncologia-IDIBELL, Hospitalet de Llobregat, Spain
| | - S Del Barco
- Medical Oncology Service, Institut Català d'Oncologia, Hospital Josep Trueta, Girona, Spain
| | - A Herrero
- Medical Oncology Service, Hospital Miguel Servet, Saragossa, Spain
| | - A Berrocal
- Medical Oncology Service, Hospital General Universitario de Valencia, Valencia, Spain
| | - P Perez-Segura
- Medical Oncology Service, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - R De Las Penas
- Medical Oncology Service, Hospital Provincial de Castellón, Castellón, Spain
| | - J Marruecos
- Radiation Oncology Service, Institut Català d'Oncologia, Hospital Josep Trueta, Girona, Spain
| | - R Fuentes
- Radiation Oncology Service, Institut Català d'Oncologia, Hospital Josep Trueta, Girona, Spain
| | - G Reynes
- Medical Oncology Service, Hospital Universitario La Fe, Valencia, Spain
| | - J M Velarde
- Institut Investigació Germans Trias i Pujol (IGTP), Hospital Germans Trias i Pujol, Badalona, Spain
| | - A Cardona
- Clinical and Translational Oncology Group, Clínica del Country, Bogotá, Colombia.,Foundation for Clinical and Applied Cancer Research, FICMAC, Bogotá, Colombia.,Biology Systems Department, Universidad el Bosque, Bogotá, Colombia
| | - E Verger
- Radiation Oncology Service, Hospital Clinic Provincial, Barcelona, Spain
| | - C Panciroli
- Institut Investigació Germans Trias i Pujol (IGTP), Hospital Germans Trias i Pujol, Badalona, Spain
| | - S Villà
- Radiation Oncology Service, Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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20
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Pollak L, Gur R, Walach N, Reif R, Tamir L, Schiffer J. Clinical Determinants of Long-Term Survival in Patients with Glioblastoma Multiforme. TUMORI JOURNAL 2018; 83:613-7. [PMID: 9226032 DOI: 10.1177/030089169708300228] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Repeated reports of more than ten years postoperative survival in patients with glioblastoma multiforme (GM) have appeared in the literature over the last decades. Authors have tried to identify the clinical, therapeutic and histological features determining long-term survival. We present two patients in whom, after radical removal of the tumor followed by conventional radiation, there has been no recurrence for at least ten years. The young age of the patients and the radical surgical approach were in accordance with previous reports of long-term survival. Nevertheless, one tumor originated from the thalamus, a location considered to be of unfavorable prognosis. We therefore further discuss the value of clinical signs as determinants in the prognosis of GM.
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Affiliation(s)
- L Pollak
- Department of Neurology, Assaf Harofeh Medical Center, Zerifin, Israel
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Ellingson BM, Wen PY, Cloughesy TF. Evidence and context of use for contrast enhancement as a surrogate of disease burden and treatment response in malignant glioma. Neuro Oncol 2018; 20:457-471. [PMID: 29040703 PMCID: PMC5909663 DOI: 10.1093/neuonc/nox193] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The use of contrast enhancement within the brain on CT or MRI has been the gold standard for diagnosis and therapeutic response assessment in malignant gliomas for decades. The use of contrast enhancing tumor size, however, remains controversial as a tool for accurately diagnosing and assessing treatment efficacy in malignant gliomas, particularly in the current, quickly evolving therapeutic landscape. The current article consolidates overwhelming evidence from hundreds of studies in the field of neuro-oncology, providing the necessary evidence base and specific contexts of use for consideration of contrast enhancing tumor size as an appropriate surrogate biomarker for disease burden and as a tool for measuring treatment response in malignant glioma, including glioblastoma.
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Affiliation(s)
- Benjamin M Ellingson
- UCLA Brain Tumor Imaging Laboratory, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
- UCLA Center for Computer Vision and Imaging Biomarkers, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
- UCLA Neuro-Oncology Program, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
- UCLA Brain Research Institute, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
- Department of Physics in Medicine and Biology, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
- Department of Bioengineering, Henry Samueli School of Engineering and Applied Science at UCLA, University of California Los Angeles, Los Angeles, California
| | - Patrick Y Wen
- Department of Neurooncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Timothy F Cloughesy
- UCLA Neuro-Oncology Program, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
- Department of Neurology, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
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Guérin B, Villena JF, Polimeridis AG, Adalsteinsson E, Daniel L, White JK, Rosen BR, Wald LL. Computation of ultimate SAR amplification factors for radiofrequency hyperthermia in non-uniform body models: impact of frequency and tumour location. Int J Hyperthermia 2018; 34:87-100. [PMID: 28540815 PMCID: PMC5681886 DOI: 10.1080/02656736.2017.1319077] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 04/10/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022] Open
Abstract
PURPOSE We introduce a method for calculation of the ultimate specific absorption rate (SAR) amplification factors (uSAF) in non-uniform body models. The uSAF is the greatest possible SAF achievable by any hyperthermia (HT) phased array for a given frequency, body model and target heating volume. METHODS First, we generate a basis-set of solutions to Maxwell's equations inside the body model. We place a large number of electric and magnetic dipoles around the body model and excite them with random amplitudes and phases. We then compute the electric fields created in the body model by these excitations using an ultra-fast volume integral solver called MARIE. We express the field pattern that maximises the SAF in the target tumour as a linear combination of these basis fields and optimise the combination weights so as to maximise SAF (concave problem). We compute the uSAFs in the Duke body models at 10 frequencies in the 20-900 MHz range and for twelve 3 cm-diameter tumours located at various depths in the head and neck. RESULTS For both shallow and deep tumours, the frequency yielding the greatest uSAF was ∼900 MHz. Since this is the greatest frequency that we simulated, we hypothesise that the globally optimal frequency is actually greater. CONCLUSIONS The uSAFs computed in this work are very large (40-100 for shallow tumours and 4-17 for deep tumours), indicating that there is a large room for improvement of the current state-of-the-art head and neck HT devices.
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Affiliation(s)
- Bastien Guérin
- a Martinos Center for Biomedical Imaging, Department of Radiology , Massachusetts General Hospital , Charlestown , MA , USA
- b Harvard Medical School , Boston , MA , USA
| | | | | | - Elfar Adalsteinsson
- e Research Laboratory of Electronics , Massachusetts Institute of Technology , Cambridge , MA , USA
- f Harvard-MIT Division of Health Sciences Technology , Cambridge , MA , USA
| | - Luca Daniel
- e Research Laboratory of Electronics , Massachusetts Institute of Technology , Cambridge , MA , USA
| | - Jacob K White
- e Research Laboratory of Electronics , Massachusetts Institute of Technology , Cambridge , MA , USA
| | - Bruce R Rosen
- a Martinos Center for Biomedical Imaging, Department of Radiology , Massachusetts General Hospital , Charlestown , MA , USA
- b Harvard Medical School , Boston , MA , USA
- f Harvard-MIT Division of Health Sciences Technology , Cambridge , MA , USA
| | - Lawrence L Wald
- a Martinos Center for Biomedical Imaging, Department of Radiology , Massachusetts General Hospital , Charlestown , MA , USA
- b Harvard Medical School , Boston , MA , USA
- f Harvard-MIT Division of Health Sciences Technology , Cambridge , MA , USA
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23
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Sonabend AM, Zacharia BE, Cloney MB, Sonabend A, Showers C, Ebiana V, Nazarian M, Swanson KR, Baldock A, Brem H, Bruce JN, Butler W, Cahill DP, Carter B, Orringer DA, Roberts DW, Sagher O, Sanai N, Schwartz TH, Silbergeld DL, Sisti MB, Thompson RC, Waziri AE, Ghogawala Z, McKhann G. Defining Glioblastoma Resectability Through the Wisdom of the Crowd: A Proof-of-Principle Study. Neurosurgery 2017; 80:590-601. [PMID: 27509070 DOI: 10.1227/neu.0000000000001374] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 05/26/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Extent of resection (EOR) correlates with glioblastoma outcomes. Resectability and EOR depend on anatomical, clinical, and surgeon factors. Resectability likely influences outcome in and of itself, but an accurate measurement of resectability remains elusive. An understanding of resectability and the factors that influence it may provide a means to control a confounder in clinical trials and provide reference for decision making. OBJECTIVE To provide proof of concept of the use of the collective wisdom of experienced brain tumor surgeons in assessing glioblastoma resectability. METHODS We surveyed 13 academic tumor neurosurgeons nationwide to assess the resectability of newly diagnosed glioblastoma. Participants reviewed 20 cases, including digital imaging and communications in medicine-formatted pre- and postoperative magnetic resonance images and clinical vignettes. The selected cases involved a variety of anatomical locations and a range of EOR. Participants were asked about surgical goal, eg, gross total resection, subtotal resection (STR), or biopsy, and rationale for their decision. We calculated a "resectability index" for each lesion by pooling responses from all 13 surgeons. RESULTS Neurosurgeons' individual surgical goals varied significantly ( P = .015), but the resectability index calculated from the surgeons' pooled responses was strongly correlated with the percentage of contrast-enhancing residual tumor ( R = 0.817, P < .001). The collective STR goal predicted intraoperative decision of intentional STR documented on operative notes ( P < .01) and nonresectable residual ( P < .01), but not resectable residual. CONCLUSION In this pilot study, we demonstrate the feasibility of measuring the resectability of glioblastoma through crowdsourcing. This tool could be used to quantify resectability, a potential confounder in neuro-oncology clinical trials.
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Affiliation(s)
- Adam M Sonabend
- Department of Neurological Surgery, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
| | - Michael B Cloney
- Department of Neurological Surgery, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
| | - Aarón Sonabend
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Christopher Showers
- Department of Neurological Surgery, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
| | - Victoria Ebiana
- Department of Neurological Surgery, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
| | - Matthew Nazarian
- Department of Neurological Surgery, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
| | - Kristin R Swanson
- Department of Neurological Surgery, Mayo Clinic, Scottsdale, Arizona
| | - Anne Baldock
- University California at San Diego School of Medicine, San Diego, California
| | - Henry Brem
- Department of Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey N Bruce
- Department of Neurological Surgery, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
| | - William Butler
- Department of Neurological Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel P Cahill
- Department of Neurological Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bob Carter
- Division of Neurosurgery, Department of Surgery, University California at San Diego School of Medicine, San Diego, California
| | - Daniel A Orringer
- Department of Neurological Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - David W Roberts
- Division of Neurosurgery, Dartmouth University, Lebanon, New Hampshire
| | - Oren Sagher
- Department of Neurological Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Nader Sanai
- Division of Neurosurgical Oncology, Barrow Neurological Institute, Phoenix, Arizona
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Daniel L Silbergeld
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Michael B Sisti
- Department of Neurological Surgery, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
| | - Reid C Thompson
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Zoher Ghogawala
- Alan and Jacqueline Stuart Spine Research Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Guy McKhann
- Department of Neurological Surgery, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
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Elderly patients with newly diagnosed glioblastoma: can preoperative imaging descriptors improve the predictive power of a survival model? J Neurooncol 2017; 134:423-431. [PMID: 28674975 DOI: 10.1007/s11060-017-2544-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 06/25/2017] [Indexed: 12/16/2022]
Abstract
The purpose of this study was to identify independent prognostic factors among preoperative imaging features in elderly glioblastoma patients and to evaluate whether these imaging features, in addition to clinical features, could enhance the predictive power of survival models. This retrospective study included 108 patients ≥65 years of age with newly diagnosed glioblastoma. Preoperative clinical features (age and KPS), postoperative clinical features (extent of surgery and postoperative treatment), and preoperative MRI features were assessed. Univariate and multivariate cox proportional hazards regression analyses for overall survival were performed. The integrated area under the receiver operating characteristic curve (iAUC) was calculated to evaluate the added value of imaging features in the survival model. External validation was independently performed with 40 additional patients ≥65 years of age with newly diagnosed glioblastoma. Eloquent area involvement, multifocality, and ependymal involvement on preoperative MRI as well as clinical features including age, preoperative KPS, extent of resection, and postoperative treatment were significantly associated with overall survival on univariate Cox regression. On multivariate analysis, extent of resection and ependymal involvement were independently associated with overall survival and preoperative KPS showed borderline significance. The model with both preoperative clinical and imaging features showed improved prediction of overall survival compared to the model with preoperative clinical features (iAUC, 0.670 vs. 0.600, difference 0.066, 95% CI 0.021-0.121). Analysis of the validation set yielded similar results (iAUC, 0.790 vs. 0.670, difference 0.123, 95% CI 0.021-0.260), externally validating this observation. Preoperative imaging features, including eloquent area involvement, multifocality, and ependymal involvement, in addition to clinical features, can improve the predictive power for overall survival in elderly glioblastoma patients.
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D’Amico RS, Englander ZK, Canoll P, Bruce JN. Extent of Resection in Glioma–A Review of the Cutting Edge. World Neurosurg 2017; 103:538-549. [DOI: 10.1016/j.wneu.2017.04.041] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/03/2017] [Accepted: 04/06/2017] [Indexed: 11/29/2022]
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Brown TJ, Brennan MC, Li M, Church EW, Brandmeir NJ, Rakszawski KL, Patel AS, Rizk EB, Suki D, Sawaya R, Glantz M. Association of the Extent of Resection With Survival in Glioblastoma: A Systematic Review and Meta-analysis. JAMA Oncol 2017; 2:1460-1469. [PMID: 27310651 DOI: 10.1001/jamaoncol.2016.1373] [Citation(s) in RCA: 648] [Impact Index Per Article: 92.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Importance Glioblastoma multiforme (GBM) remains almost invariably fatal despite optimal surgical and medical therapy. The association between the extent of tumor resection (EOR) and outcome remains undefined, notwithstanding many relevant studies. Objective To determine whether greater EOR is associated with improved 1- and 2-year overall survival and 6-month and 1-year progression-free survival in patients with GBM. Data Sources Pubmed, CINAHL, and Web of Science (January 1, 1966, to December 1, 2015) were systematically reviewed with librarian guidance. Additional articles were included after consultation with experts and evaluation of bibliographies. Articles were collected from January 15 to December 1, 2015. Study Selection Studies of adult patients with newly diagnosed supratentorial GBM comparing various EOR and presenting objective overall or progression-free survival data were included. Pediatric studies were excluded. Data Extraction and Synthesis Data were extracted from the text of articles or the Kaplan-Meier curves independently by investigators who were blinded to each other's results. Data were analyzed to assess mortality after gross total resection (GTR), subtotal resection (STR), and biopsy. The body of evidence was evaluated according to Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria and PRISMA guidelines. Main Outcome and Measures Relative risk (RR) for mortality at 1 and 2 years and progression at 6 months and 1 year. Results The search produced 37 studies suitable for inclusion (41 117 unique patients). The meta-analysis revealed decreased mortality for GTR compared with STR at 1 year (RR, 0.62; 95% CI, 0.56-0.69; P < .001; number needed to treat [NNT], 9) and 2 years (RR, 0.84; 95% CI, 0.79-0.89; P < .001; NNT, 17). The 1-year risk for mortality for STR compared with biopsy was reduced significantly (RR, 0.85; 95% CI, 0.80-0.91; P < .001). The risk for mortality was similarly decreased for any resection compared with biopsy at 1 year (RR, 0.77; 95% CI, 0.71-0.84; P < .001; NNT, 21) and 2 years (RR, 0.94; 95% CI, 0.89-1.00; P = .04; NNT, 593). The likelihood of disease progression was decreased with GTR compared with STR at 6 months (RR, 0.72; 95% CI, 0.48-1.09; P = .12; NNT, 14) and 1 year (RR, 0.66; 95% CI, 0.43-0.99; P < .001; NNT, 26). The quality of the body of evidence by the GRADE criteria was moderate to low. Conclusion and Relevance This analysis represents the largest systematic review and only quantitative systematic review to date performed on this subject. Compared with STR, GTR substantially improves overall and progression-free survival, but the quality of the supporting evidence is moderate to low.
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Affiliation(s)
- Timothy J Brown
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Matthew C Brennan
- Ann Barshinger Cancer Center, Lancaster General Health, Lancaster, Pennsylvania
| | - Michael Li
- Department of Neurosurgery, University of Rochester Medical Center, Pittsford, New York
| | - Ephraim W Church
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Nicholas J Brandmeir
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Kevin L Rakszawski
- Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Akshal S Patel
- Department of Neurosurgery, Swedish Cerebrovascular Institute, Seattle, Washington
| | - Elias B Rizk
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Dima Suki
- Division of Surgery, Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston
| | - Raymond Sawaya
- Division of Surgery, Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston
| | - Michael Glantz
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Grossman R, Shimony N, Shir D, Gonen T, Sitt R, Kimchi TJ, Harosh CB, Ram Z. Dynamics of FLAIR Volume Changes in Glioblastoma and Prediction of Survival. Ann Surg Oncol 2016; 24:794-800. [PMID: 27766560 DOI: 10.1245/s10434-016-5635-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The extent of tumor resection (EOTR) calculated by enhanced T1 changes in glioblastomas has been previously reported to predict survival. However, fluid-attenuated inversion recovery (FLAIR) volume may better represent tumor burden. In this study, we report the first assessment of the dynamics of FLAIR volume changes over time as a predictive variable for post-resection overall survival (OS). METHODS Contemporary data from 103 consecutive patients with complete imaging and clinical data who underwent resection of newly diagnosed glioblastoma followed by the Stupp protocol between 2010 and 2013 were analyzed. Clinical, radiographic, and outcome parameters were retrieved for each patient, including magnetic resonance imaging (MRI)-based volumetric tumor analysis before, immediately after, and 3 months post-surgery. RESULTS OS rate was 17.6 months. A significant incremental OS advantage was noted, with as little as 85 % T1-weighted gadolinium-enhanced (T1Gd)-EOTR measured on contrast-enhanced MRI. Pre- and immediate postoperative FLAIR-based EOTR was not predictive of OS; however, abnormal FLAIR volume measured 3 months post-surgery correlated significantly with outcome when FLAIR residual tumor volume (RTV) was <19.3 cm3 and <46 % of baseline volume (p < 0.0001 for both). Age and isocitrate dehydrogenase (IDH)-1 mutation were predictive of OS (p < 0.0001, Cox proportional hazards). CONCLUSIONS OS correlated with the immediate postoperative T1Gd-EOTR measured by enhanced T1 MRI, but not by FLAIR volume. Diminished abnormal FLAIR volume at 3 months post-surgery was associated with OS benefit when FLAIR-RTV was <19.3 cm3 or <46 % of baseline. These threshold values provide a new radiological variable that can be used for prediction of OS in patients with glioblastoma immediately after completion of standard chemoradiation.
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Affiliation(s)
- Rachel Grossman
- Department of Neurosurgery, Tel Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Nir Shimony
- Department of Neurosurgery, Tel Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dror Shir
- Department of Neurosurgery, Tel Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Gonen
- Functional Brain Center, Tel Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Razi Sitt
- Department of Neurosurgery, Tel Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tali Jonas Kimchi
- Diagnostic Neuroradiology Unit, Tel Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Carmit Ben Harosh
- Department of Neurosurgery, Tel Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Hervey-Jumper SL, Berger MS. Maximizing safe resection of low- and high-grade glioma. J Neurooncol 2016; 130:269-282. [PMID: 27174197 DOI: 10.1007/s11060-016-2110-4] [Citation(s) in RCA: 305] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 03/23/2016] [Indexed: 10/21/2022]
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Prognostic Value of MRS Metabolites in Postoperative Irradiated High Grade Gliomas. BIOMED RESEARCH INTERNATIONAL 2015; 2015:341042. [PMID: 26339606 PMCID: PMC4538329 DOI: 10.1155/2015/341042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 02/09/2015] [Indexed: 11/17/2022]
Abstract
Purpose. We studied the prognostic significance of Magnetic Resonance Spectroscopy (MRS) in operated high grade gliomas. Materials and Methods. Twelve patients were treated with radiotherapy and Temozolomide. The MRS data were taken four weeks after operation (before radiotherapy) and every six months after the completion of RT. The N-acetyl aspartate, choline, creatine, and myo-inositol parameters were quantified, analyzed, and correlated to recurrence-free survival (RFS). Results. The median RFS was 26.06 months. RFS was significantly worse in elderly patients (P = 0.001) along with the higher choline/creatine ratios at either baseline (P = 0.003) or six months post Radiotherapy (P = 0.042). Median RFS was 23 months in high choline/creatine levels ≥2 at 6 months after radiotherapy and 11 months for those with <2 choline/creatine levels. There was a significant correlation of maximum difference of choline/creatine ratio with RFS (rho = 0.64, P = 0.045). Conclusion. Age and choline/creatine ratio are strong independent prognostic factors in high grade gliomas.
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Hervey-Jumper SL, Li J, Lau D, Molinaro AM, Perry DW, Meng L, Berger MS. Awake craniotomy to maximize glioma resection: methods and technical nuances over a 27-year period. J Neurosurg 2015; 123:325-39. [DOI: 10.3171/2014.10.jns141520] [Citation(s) in RCA: 244] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Awake craniotomy is currently a useful surgical approach to help identify and preserve functional areas during cortical and subcortical tumor resections. Methodologies have evolved over time to maximize patient safety and minimize morbidity using this technique. The goal of this study is to analyze a single surgeon's experience and the evolving methodology of awake language and sensorimotor mapping for glioma surgery.
METHODS
The authors retrospectively studied patients undergoing awake brain tumor surgery between 1986 and 2014. Operations for the initial 248 patients (1986–1997) were completed at the University of Washington, and the subsequent surgeries in 611 patients (1997–2014) were completed at the University of California, San Francisco. Perioperative risk factors and complications were assessed using the latter 611 cases.
RESULTS
The median patient age was 42 years (range 13–84 years). Sixty percent of patients had Karnofsky Performance Status (KPS) scores of 90–100, and 40% had KPS scores less than 80. Fifty-five percent of patients underwent surgery for high-grade gliomas, 42% for low-grade gliomas, 1% for metastatic lesions, and 2% for other lesions (cortical dysplasia, encephalitis, necrosis, abscess, and hemangioma). The majority of patients were in American Society of Anesthesiologists (ASA) Class 1 or 2 (mild systemic disease); however, patients with severe systemic disease were not excluded from awake brain tumor surgery and represented 15% of study participants. Laryngeal mask airway was used in 8 patients (1%) and was most commonly used for large vascular tumors with more than 2 cm of mass effect. The most common sedation regimen was propofol plus remifentanil (54%); however, 42% of patients required an adjustment to the initial sedation regimen before skin incision due to patient intolerance. Mannitol was used in 54% of cases. Twelve percent of patients were active smokers at the time of surgery, which did not impact completion of the intraoperative mapping procedure. Stimulation-induced seizures occurred in 3% of patients and were rapidly terminated with ice-cold Ringer's solution. Preoperative seizure history and tumor location were associated with an increased incidence of stimulation-induced seizures. Mapping was aborted in 3 cases (0.5%) due to intraoperative seizures (2 cases) and patient emotional intolerance (1 case). The overall perioperative complication rate was 10%.
CONCLUSIONS
Based on the current best practice described here and developed from multiple regimens used over a 27-year period, it is concluded that awake brain tumor surgery can be safely performed with extremely low complication and failure rates regardless of ASA classification; body mass index; smoking status; psychiatric or emotional history; seizure frequency and duration; and tumor site, size, and pathology.
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Affiliation(s)
| | - Jing Li
- Departments of 1Neurological Surgery and
| | - Darryl Lau
- Departments of 1Neurological Surgery and
| | | | - David W. Perry
- 2Surgical Neurophysiology, University of California, San Francisco, California
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A phase II study of feasibility and toxicity of bevacizumab in combination with temozolomide in patients with recurrent glioblastoma. Clin Transl Oncol 2015; 17:743-50. [PMID: 26033428 DOI: 10.1007/s12094-015-1304-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 05/16/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this prospective and multicentric phase II study was to evaluate the efficacy and safety of temozolomide (TMZ) and bevacizumab (BV) in patients (pts) with recurrent glioblastoma (GB), previously treated with chemoradiotherapy and at least three cycles of adjuvant TMZ. PATIENTS AND METHODS Patients with GB at first relapse received BV 10 mg/kg day every 2 weeks and TMZ 150 mg/m(2) days 1-7 and 15-21, every 28 days. Patients underwent brain magnetic resonance imaging every 8 weeks. RESULTS Thirty-two evaluable pts were recruited in 8 sites. Fourteen pts (44%) had gross total resection. O(6)-methylguanine-DNA methyltransferase (MGMT) promoter was methylated in 12 pts, unmethylated in 6 pts, and missing in 14 pts. The estimated 6-month progression free survival (PFS) rate was 21.9% (95% CI 9.3-40.0%). The median PFS and overall survival (OS) were 4.2 months (95% CI 3.6-5.4 months) and 7.3 months (95% CI 5.8-8.8 months), respectively. No significant association with MGMT status was found in terms of OS or PFS. Six of 32 pts (19%; 95% CI 7.2-36.4) were long-term survivors, with a median PFS and OS (50% events) of 9.5 months (95% CI 7.9-23.6) and 15.4 (95% CI 8.9-NA), respectively: no differences in baseline characteristics were identified in comparison with total population. No unexpected toxicities or treatment-related deaths were observed. CONCLUSIONS This regimen showed to be feasible and well tolerated in pts with recurrent GB pretreated with TMZ. Further investigation is warranted to identify subpopulations that are more likely to benefit from addition of BV to GB therapy.
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Wang Y, Liu S, Fan X, Li S, Wang R, Wang L, Ma J, Jiang T, Ma W. Age-associated brain regions in gliomas: a volumetric analysis. J Neurooncol 2015; 123:299-306. [PMID: 25981802 DOI: 10.1007/s11060-015-1798-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 04/20/2015] [Indexed: 01/29/2023]
Abstract
Both age of patients and tumor location are associated with tumor origin, genetic characteristics, and prognosis. The objective of this study was to investigate the relationship between tumor location and age at diagnosis in a large cohort of patients with a primary diagnosis of glioma. We consecutively enrolled a cohort of 200 adults with glioblastoma and another cohort of 200 adults with diffuse low-grade gliomas. The magnetic resonance images of all tumors were manually segmented and then registered to a standard brain space. By using voxel-by-voxel regression analysis, specific brains regions associated with advanced age at tumor diagnosis were localized. In the low-grade gliomas cohort, the brain regions associated with advanced age at tumor diagnosis were mainly located in the right middle frontal region, while a region in the left temporal lobe, particularly at the subgranular zone, was associated with lower age at tumor diagnosis. In the glioblastoma cohort, the brain regions associated with advanced age at tumor diagnosis were mainly located in the temporal lobe, particularly at the posterior region of the subventricular zones. A region in the left inferior frontal region was associated with lower age at tumor diagnosis. Significant differences in the age of patients were found between tumors located in the identified regions and those located elsewhere in both cohorts. The current study demonstrated the correlation between tumor location and age at diagnosis, which implies differences in the origin of gliomas in young and older patients.
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Affiliation(s)
- Yinyan Wang
- Beijing Neurosurgical Institute, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, 100050, China
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Grigore F, Brehar FM, Gorgan MR. Current perspectives concerning the multimodal therapy in Glioblastoma. ROMANIAN NEUROSURGERY 2015. [DOI: 10.1515/romneu-2015-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
GBM (Glioblastoma) is the most common, malignant type of primary brain tumor. It has a dismal prognosis, with an average life expectancy of less than 15 months. A better understanding of the tumor biology of GBM has been achieved in the past decade and set up new directions in the multimodal therapy by targeting the molecular paths involved in tumor initiation and progression. Invasion is a hallmark of GBM, and targeting the complex invasive mechanism of the tumor is mandatory in order to achieve a satisfactory result in GBM therapy. The goal of this review is to describe the tumor biology and key features of GBM and to provide an up-to-date overview of the current identified molecular alterations involved both in tumorigenesis and tumor progression.
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Rhun EL, Taillibert S, Chamberlain MC. The future of high-grade glioma: Where we are and where are we going. Surg Neurol Int 2015; 6:S9-S44. [PMID: 25722939 PMCID: PMC4338495 DOI: 10.4103/2152-7806.151331] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 10/15/2014] [Indexed: 01/12/2023] Open
Abstract
High-grade glioma (HGG) are optimally treated with maximum safe surgery, followed by radiotherapy (RT) and/or systemic chemotherapy (CT). Recently, the treatment of newly diagnosed anaplastic glioma (AG) has changed, particularly in patients with 1p19q codeleted tumors. Results of trials currenlty ongoing are likely to determine the best standard of care for patients with noncodeleted AG tumors. Trials in AG illustrate the importance of molecular characterization, which are germane to both prognosis and treatment. In contrast, efforts to improve the current standard of care of newly diagnosed glioblastoma (GB) with, for example, the addition of bevacizumab (BEV), have been largely disappointing and furthermore molecular characterization has not changed therapy except in elderly patients. Novel approaches, such as vaccine-based immunotherapy, for newly diagnosed GB are currently being pursued in multiple clinical trials. Recurrent disease, an event inevitable in nearly all patients with HGG, continues to be a challenge. Both recurrent GB and AG are managed in similar manner and when feasible re-resection is often suggested notwithstanding limited data to suggest benefit from repeat surgery. Occassional patients may be candidates for re-irradiation but again there is a paucity of data to commend this therapy and only a minority of selected patients are eligible for this approach. Consequently systemic therapy continues to be the most often utilized treatment in recurrent HGG. Choice of therapy, however, varies and revolves around re-challenge with temozolomide (TMZ), use of a nitrosourea (most often lomustine; CCNU) or BEV, the most frequently used angiogenic inhibitor. Nevertheless, no clear standard recommendation regarding the prefered agent or combination of agents is avaliable. Prognosis after progression of a HGG remains poor, with an unmet need to improve therapy.
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Affiliation(s)
- Emilie Le Rhun
- Department of Neuro-oncology, Roger Salengro Hospital, University Hospital, Lille, and Neurology, Department of Medical Oncology, Oscar Lambret Center, Lille, France, Inserm U-1192, Laboratoire de Protéomique, Réponse Inflammatoire, Spectrométrie de Masse (PRISM), Lille 1 University, Villeneuve D’Ascq, France
| | - Sophie Taillibert
- Neurology, Mazarin and Radiation Oncology, Pitié Salpétrière Hospital, University Pierre et Marie Curie, Paris VI, Paris, France
| | - Marc C. Chamberlain
- Department of Neurology and Neurological Surgery, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Hoffermann M, Bruckmann L, Mahdy Ali K, Asslaber M, Payer F, von Campe G. Treatment results and outcome in elderly patients with glioblastoma multiforme – A retrospective single institution analysis. Clin Neurol Neurosurg 2015; 128:60-9. [DOI: 10.1016/j.clineuro.2014.11.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/14/2014] [Accepted: 11/09/2014] [Indexed: 10/24/2022]
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The Value of Extent of Resection of Glioblastomas: Clinical Evidence and Current Approach. Curr Neurol Neurosci Rep 2014; 15:517. [DOI: 10.1007/s11910-014-0517-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Thakkar JP, Dolecek TA, Horbinski C, Ostrom QT, Lightner DD, Barnholtz-Sloan JS, Villano JL. Epidemiologic and molecular prognostic review of glioblastoma. Cancer Epidemiol Biomarkers Prev 2014; 23:1985-96. [PMID: 25053711 DOI: 10.1158/1055-9965.epi-14-0275] [Citation(s) in RCA: 809] [Impact Index Per Article: 80.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Glioblastoma multiforme (GBM) is the most common and aggressive primary central nervous system malignancy with a median survival of 15 months. The average incidence rate of GBM is 3.19/100,000 population, and the median age of diagnosis is 64 years. Incidence is higher in men and individuals of white race and non-Hispanic ethnicity. Many genetic and environmental factors have been studied in GBM, but the majority are sporadic, and no risk factor accounting for a large proportion of GBMs has been identified. However, several favorable clinical prognostic factors are identified, including younger age at diagnosis, cerebellar location, high performance status, and maximal tumor resection. GBMs comprise of primary and secondary subtypes, which evolve through different genetic pathways, affect patients at different ages, and have differences in outcomes. We report the current epidemiology of GBM with new data from the Central Brain Tumor Registry of the United States 2006 to 2010 as well as demonstrate and discuss trends in incidence and survival. We also provide a concise review on molecular markers in GBM that have helped distinguish biologically similar subtypes of GBM and have prognostic and predictive value.
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Affiliation(s)
- Jigisha P Thakkar
- Department of Medicine, University of Kentucky, Lexington, Kentucky. Department of Neurology, University of Kentucky, Lexington, Kentucky
| | - Therese A Dolecek
- Division of Epidemiology and Biostatistics and Institute for Health Research and Policy, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Craig Horbinski
- Department of Pathology, University of Kentucky, Lexington, Kentucky
| | - Quinn T Ostrom
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Donita D Lightner
- Department of Neurology and Pediatrics, University of Kentucky, Lexington, Kentucky
| | - Jill S Barnholtz-Sloan
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - John L Villano
- Department of Medicine, University of Kentucky, Lexington, Kentucky. Department of Neurology, University of Kentucky, Lexington, Kentucky.
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Mohammadi AM, Hawasli AH, Rodriguez A, Schroeder JL, Laxton AW, Elson P, Tatter SB, Barnett GH, Leuthardt EC. The role of laser interstitial thermal therapy in enhancing progression-free survival of difficult-to-access high-grade gliomas: a multicenter study. Cancer Med 2014; 3:971-9. [PMID: 24810945 PMCID: PMC4303165 DOI: 10.1002/cam4.266] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 03/25/2014] [Accepted: 03/28/2014] [Indexed: 12/21/2022] Open
Abstract
Surgical extent-of-resection has been shown to have an impact on high-grade glioma (HGG) outcomes; however, complete resection is rarely achievable in difficult-to-access (DTA) tumors. Controlled thermal damage to the tumor may have the same impact in DTA-HGGs. We report our multicenter results of laser interstitial thermal therapy (LITT) in DTA-HGGs. We retrospectively reviewed 34 consecutive DTA-HGG patients (24 glioblastoma, 10 anaplastic) who underwent LITT at Cleveland Clinic, Washington University, and Wake Forest University (May 2011-December 2012) using the NeuroBlate(®) System. The extent of thermal damage was determined using thermal damage threshold (TDT) lines: yellow TDT line (43 °C for 2 min) and blue TDT line (43°C for 10 min). Volumetric analysis was performed to determine the extent-of-coverage of tumor volume by TDT lines. Patient outcomes were evaluated statistically. LITT was delivered as upfront in 19 and delivered as salvage in 16 cases. After 7.2 months of follow-up, 71% of cases demonstrated progression and 34% died. The median overall survival (OS) for the cohort was not reached; however, the 1-year estimate of OS was 68 ± 9%. Median progression-free survival (PFS) was 5.1 months. Thirteen cases who met the following two criteria-(1) <0.05 cm(3) tumor volume not covered by the yellow TDT line and (2) <1.5 cm(3) additional tumor volume not covered by the blue TDT line-had better PFS than the other 21 cases (9.7 vs. 4.6 months; P = 0.02). LITT can be used effectively for treatment of DTA-HGGs. More complete coverage of tumor by TDT lines improves PFS which can be translated as the extent of resection concept for surgery.
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Affiliation(s)
- Alireza M Mohammadi
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery, Neurological Institute, 9500 Euclid Avenue, S70, Cleveland Clinic, Cleveland, Ohio, 44195
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Hervey-Jumper SL, Berger MS. Role of surgical resection in low- and high-grade gliomas. Curr Treat Options Neurol 2014; 16:284. [PMID: 24595756 DOI: 10.1007/s11940-014-0284-7] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OPINION STATEMENT Central nervous system tumors are a major cause of morbidity and mortality in the United States. Outside of brain metastasis, low- and high-grade gliomas are the most common intrinsic brain tumors. Low-grade gliomas have a 5- and 10-year survival rate of 97 % and 91 %, respectively, when extent of resection is greater than 90 %. High-grade gliomas are extremely aggressive with the vast majority of patients experiencing recurrence and a median survival of 1 to 3 years. Survival of patients with both low- and high-grade gliomas is enhanced with maximal tumor resection. The pursuit of more aggressive extent of resection must be balanced with preservation of functional pathways. Several innovations in neurosurgical oncology have expanded our understanding of individualized patient neuroanatomy, physiology, and function. Emerging imaging technologies as well as intraoperative techniques have expanded our ability to resect maximal amounts of tumor while preserving essential function. Stimulation mapping of language and motor pathways is well-established for the safe resection of intrinsic brain lesions. Additional techniques including neuro-navigation, fluorescence-guided microsurgery using 5-aminolevulinic acid, intraoperative magnetic resonance imaging, and high-frequency ultrasonography can all be used to improve extent of resection in glioma patients.
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Affiliation(s)
- Shawn L Hervey-Jumper
- Department of Neurological Surgery, University of California, 505 Parnassus Avenue, M779, San Francisco, CA, 94143, USA
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Neoadjuvant cisplatin plus temozolomide versus standard treatment in patients with unresectable glioblastoma or anaplastic astrocytoma: a differential effect of MGMT methylation. J Neurooncol 2014; 117:77-84. [PMID: 24395350 DOI: 10.1007/s11060-013-1352-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 12/28/2013] [Indexed: 10/25/2022]
Abstract
Patients with unresectable glioblastoma or anaplastic astrocytoma have a dismal prognosis. The role of neoadjuvant chemotherapy prior to irradiation in these patients has been studied primarily in non-randomized studies. We have compared the effect of neoadjuvant chemotherapy plus radiotherapy versus concomitant radiotherapy plus temozolomide in a retrospective analysis of two consecutive series of patients in whom surgery consisted of biopsy only. From 2003 to 2005, 23 patients received two cycles of temozolomide plus cisplatin followed by radiotherapy (Cohort 1), and from 2006 to 2010, 23 additional patients received concomitant radiotherapy and temozolomide followed by adjuvant temozolomide (Cohort 2). In Cohort 1, 91.3 % of patients received all planned chemotherapy cycles. Progression-free and overall survival were 3.3 and 8.5 months, respectively. In Cohort 2, progression-free and overall survival were 5.1 and 11.2 months, respectively. No differences between the two groups were observed in rate of completion of radiotherapy, progression-free or overall survival. MGMT methylation was assessed in 91.3 % of patients. In Cohort 1, patients without MGMT methylation showed a trend towards shorter progression-free survival (P = 0.09), while in Cohort 2, patients without MGMT methylation had longer progression-free survival (P = 0.04). In the overall patient population, neoadjuvant temozolomide plus cisplatin had neither a positive nor negative influence on outcome. However, our findings indicate that patients with methylated MGMT may derive greater benefit from neoadjuvant temozolomide than those with unmethylated MGMT.
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Kumar N, Kumar P, Angurana SL, Khosla D, Mukherjee KK, Aggarwal R, Kumar R, Bera A, Sharma SC. Evaluation of outcome and prognostic factors in patients of glioblastoma multiforme: A single institution experience. J Neurosci Rural Pract 2013; 4:S46-55. [PMID: 24174800 PMCID: PMC3808062 DOI: 10.4103/0976-3147.116455] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Aims: We present retrospective analysis of patients of glioblastoma multiforme (GBM) and discuss clinical characteristics, various treatment protocols, survival outcomes, and prognostic factors influencing survival. Materials and Methods: From January 2002 to June 2009, 439 patients of GBM were registered in our department. The median age of patients was 50 years, 66.1% were males, and 75% underwent complete or near-total excision. We evaluated those 360 patients who received radiotherapy (RT). Radiotherapy schedule was selected depending upon pre-RT Karnofsky Performance Status (KPS). Patients with KPS < 70 (Group I, n = 48) were planned for RT dose of 30-35 Gy in 10-15 fractions, and patients with KPS ≥ 70 (Group II, n = 312) were planned for 60 Gy in 30 fractions. In group I, six patients and in group II, 89 patients received some form of chemotherapy (lomustine or temozolomide). Statistical Analysis Used: Statistical analysis was done using Statistical Package for Social Sciences, version 12.0. Overall survival (OS) was calculated using Kaplan-Meier method, and prognostic factors were determined by log rank test. The Cox proportional hazards model was used for multivariate analysis. Results: The median follow-up was 7.53 months. The median and 2-year survival rates were 6.33 months and 2.24% for group I and 7.97 months and 8.21% for group II patients, respectively (P = 0.001). In multivariate analysis, site of tumor (central vs. others; P = 0.006), location of tumor (parietal lobe vs. others; P = 0.003), RT dose (<60 Gy vs. 60 Gy; P = 0.0001), and use of some form of chemotherapy (P = 0.0001) were independent prognostic factors for survival. Conclusions: In patients with GBM, OS and prognosis remains dismal. Whenever possible, we should use concurrent and/or adjuvant chemotherapy to maximize the benefits of post-operative radiotherapy. Patients with poor performance status may be considered for hypofractionated RT schedules, which have similar median survival rates as conventional RT.
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Affiliation(s)
- Narendra Kumar
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Sector - 12, Chandigarh, India
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Park CK, Kim JH, Nam DH, Kim CY, Chung SB, Kim YH, Seol HJ, Kim TM, Choi SH, Lee SH, Heo DS, Kim IH, Kim DG, Jung HW. A practical scoring system to determine whether to proceed with surgical resection in recurrent glioblastoma. Neuro Oncol 2013; 15:1096-101. [PMID: 23800677 DOI: 10.1093/neuonc/not069] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND To determine the benefit of surgical management in recurrent glioblastoma, we analyzed a series of patients with recurrent glioblastoma who had undergone surgery, and we devised a new scale to predict their survival. METHODS Clinical data from 55 consecutive patients with recurrent glioblastoma were evaluated after surgical management. Kaplan-Meier survival analysis and Cox proportional hazards regression modeling were used to identify prognostic variables for the development of a predictive scale. After the multivariate analysis, performance status (P = .078) and ependymal involvement (P = .025) were selected for inclusion in the new prognostic scale. The devised scale was validated with a separate set of 96 patients from 3 different institutes. RESULTS A 3-tier scale (scoring range, 0-2 points) composed of additive scores for the Karnofsky performance status (KPS) (0 for KPS ≥ 70 and 1 for KPS < 70) and ependymal involvement (0 for no enhancement and 1 for enhancement of the ventricle wall in the magnetic resonance imaging) significantly distinguished groups with good (0 points; median survival, 18.0 months), intermediate (1 point; median survival, 10.0 months), and poor prognoses (2 points; median survival, 4.0 months). The new scale was successfully applied to the validation cohort of patients showing distinct prognosis among the groups (median survivals of 11.0, 9.0, and 4.0 months for the 0-, 1-, and 2-point groups, respectively). CONCLUSIONS We developed a practical scale to facilitate deciding whether to proceed with surgical management in patients with recurrent glioblastoma. This scale was useful for the diagnosis of prognostic groups and can be used to develop guidelines for patient treatment.
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Affiliation(s)
- Chul-Kee Park
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea.
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Abstract
PURPOSE OF REVIEW In recent years, the safety and efficacy of neurosurgical intervention has rapidly improved for brain tumor patients. Technological advances, combined with refined intraoperative techniques, now enable well tolerated surgical access to any region of the human brain. For patients with gliomas, these improvements have redefined the clinical possibilities, and here we review several emerging operative strategies that are essential for next-generation neurosurgical oncologists and major brain tumor centers. RECENT FINDINGS The value of glioma extent of resection remains controversial, but review of the modern literature reveals important opportunities for early neurosurgical intervention. Although microsurgical resection must be balanced by the risk of neurological compromise, improvements in intraoperative stimulation techniques now enable resection of highly eloquent tumors with minimal morbidity. Additionally, the emergence of fluorescence-guided surgery as a new operative paradigm provides a unique opportunity to resect tumors to the margins of microscopic infiltration. SUMMARY Neurosurgical intervention remains the first step in effective glioma management. With intraoperative mapping techniques, aggressive microsurgical resection can be safely pursued even when tumors occupy essential functional pathways. With the development of tumor-specific fluorophores, such as 5-aminolevulinic acid, real-time microscopic visualization of tumor infiltration can be surgically targeted prior to adjuvant therapy.
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Lou E, Peters KB, Sumrall AL, Desjardins A, Reardon DA, Lipp ES, Herndon JE, Coan A, Bailey L, Turner S, Friedman HS, Vredenburgh JJ. Phase II trial of upfront bevacizumab and temozolomide for unresectable or multifocal glioblastoma. Cancer Med 2013; 2:185-95. [PMID: 23634286 PMCID: PMC3639657 DOI: 10.1002/cam4.58] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 12/19/2012] [Accepted: 12/21/2012] [Indexed: 12/14/2022] Open
Abstract
Patients with unresectable glioblastomas have a poor prognosis, with median survival of 6–10 months. We conducted a phase II trial of upfront 5-day temozolomide (TMZ) and bevacizumab (BV) in patients with newly diagnosed unresectable or multifocal glioblastoma. Patients received up to four cycles of TMZ at 200 mg/m2 on days 1–5, and BV at 10 mg/kg on days 1 and 15 of a 28-day cycle. Brain magnetic resonance imaging (MRI) was performed monthly. Therapy was continued as long as there was no tumor progression, grade 4 nonhematologic toxicity, or recurrent grade 4 hematologic toxicity after dose reduction. The primary end point was best tumor response as measured on MRI. Forty-one patients were accrued over 12 months; 39 had a full set of MRI scans available for evaluation. Assessment for best radiographic responses was as follows: partial responses in 24.4%, stable disease in 68.3%, and progressive disease in 2.4%. Treatment-related toxicities included seven grade 4 toxicities and one grade 5 toxicity (myocardial infarction). From this study, it was concluded that an upfront regimen of TMZ and BV for unresectable glioblastoma was well tolerated and provided a significant level of disease stabilization. Therapeutic toxicities were consistent with those seen in the adjuvant setting using these agents. The upfront approach to treatment of glioblastoma in the unresectable population warrants further investigation in randomized controlled phase III trials.
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Affiliation(s)
- Emil Lou
- Preston Robert Tisch Brain Tumor Center at Duke, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
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Hardesty DA, Sanai N. The value of glioma extent of resection in the modern neurosurgical era. Front Neurol 2012; 3:140. [PMID: 23087667 PMCID: PMC3474933 DOI: 10.3389/fneur.2012.00140] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 09/23/2012] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE There remains no general consensus in the neurosurgical oncology literature regarding the role of extent of glioma resection in improving patient outcome. Although the value of resection in establishing a diagnosis and alleviating mass effect is clear, there is less certainty in ascertaining the influence of extent of resection (EOR). Here, we review the recent literature to synthesize a comprehensive review of the value of extent of resection for gliomas in the modern neurosurgical era. METHODS We reviewed every major peer-reviewed clinical publication since 1990 on the role of EOR in glioma outcome. RESULTS Thirty-two high-grade glioma articles and 11 low-grade glioma articles were examined in terms of quality of evidence, expected EOR, and survival benefit. CONCLUSION Despite limitations in the quality of data, mounting evidence suggests that more extensive surgical resection is associated with longer life expectancy for both low- and high-grade newly diagnosed gliomas.
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Affiliation(s)
- Douglas A Hardesty
- Division of Neurological Surgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute Phoenix, AZ, USA
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Sanai N, Berger MS. Recent Surgical Management of Gliomas. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 746:12-25. [DOI: 10.1007/978-1-4614-3146-6_2] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Affiliation(s)
- Ian F Parney
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA.
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Anatomic localization of O6-methylguanine DNA methyltransferase (MGMT) promoter methylated and unmethylated tumors: a radiographic study in 358 de novo human glioblastomas. Neuroimage 2011; 59:908-16. [PMID: 22001163 DOI: 10.1016/j.neuroimage.2011.09.076] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 09/27/2011] [Accepted: 09/29/2011] [Indexed: 11/23/2022] Open
Abstract
Promoter methylation of O6-methylguanine DNA methyltransferase (MGMT) is associated with a favorable prognosis in glioblastoma multiforme (GBM) and has been hypothesized to occur early in tumor transformation of glial cells. Thus, a possible link exists between the site of malignant transformation and MGMT promoter methylation status. Using the Analysis of Differential Involvement (ADIFFI) statistical mapping technique in a total of 358 patients with GBM, we demonstrate that human de novo GBMs occur in a high frequency contiguous with the posterior subventricular zone (SVZ); MGMT promoter methylated GBMs are lateralized to the left hemisphere, while MGMT unmethylated GBMs are lateralized to the right hemisphere; and tumors near the left temporal lobe have a significantly longer overall survival compared with tumors occurring elsewhere, independent of treatment or MGMT methylation status.
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Modeling Adult Gliomas Using RCAS/t-va Technology. Transl Oncol 2011; 2:89-95. [PMID: 19412424 DOI: 10.1593/tlo.09100] [Citation(s) in RCA: 200] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 01/13/2009] [Accepted: 01/14/2009] [Indexed: 01/05/2023] Open
Abstract
Malignant gliomas remain the most devastating childhood and adult tumors of the central nervous system. Although adult and pediatric gliomas are histologically indistinguishable, they differ in location, behavior, and molecular characteristics. This implies that the molecular pathways and pathophysiology of malignant gliomagenesis in these two populations are distinct. Such differences between adult and pediatric gliomas may predict different therapeutic responses. Therefore, accurate genetically engineered models of adult and pediatric gliomas may help understand the biology of these tumors and evaluate therapeutic agents in preclinical studies. It has been proposed that gliomas arise from the subventricular zone in mice during development. Here, we demonstrate that, in adult mice, gliomas may arise not only when injected in the subventricular zone but also when injected in the cortex and cerebellum. Our work demonstrates a versatile and highly reproducible adult mouse model of glioma, which can be easily incorporated into preclinical studies.
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High-field iMRI in glioblastoma surgery: improvement of resection radicality and survival for the patient? ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 109:103-6. [PMID: 20960328 DOI: 10.1007/978-3-211-99651-5_16] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Since the first patients underwent intracranial tumor removal with the radicality control of intraoperative MRI (ioMRI) in September 2005 in our department, the majority of operations performed in the ioMRI room have been indicated for high grade gliomas. In order to elucidate the role of ioMRI scanning in patients harboring high-grade gliomas (HGG) on their survival, one hundred ninety three patients with gliomas WHO grades III and IV were operated either in a standard microsurgical neuronavigated fashion or using additionally ioMRI and were included in a follow-up study. The series started with surgeries from September 2005 until October 2007. Patient attribution to the two groups was based on the logistical availability of the ioMRI on a scheduled surgery day, and on the assumed "difficulty" of the surgery based on the location of the glioma in or near to an eloquent area. Surgery was intended to be as radical as possible without reduction of quality of life. First surgery was performed in 103 patients (75 WHO IV and 28 WHO III) and will be the main topic of this paper. In 60 patients, ioMRI was used, while in 43 patients standard microsurgical neuronavigated resection techniques were applied. Patients were followed in regular intervals mostly until death. Statistical analysis showed a median survival time for patients in whom ioMRI had been used of 20, 37 months compared to 10, 3 months in the cohort who had undergone conventional microsurgical removal. Major influencing concomitants were WHO grades and age which were balanced in both groups.
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