Radiotherapy of spinal cord gliomas : A retrospective mono-institutional analysis

A Nomogram for Predicting Overall Survival of Patients With Primary Spinal Cord Glioblastoma

OBJECTIVE

Primary spinal cord glioblastoma (PSCGBM) is a rare malignancy with a poor prognosis. To date, no prognostic nomogram for this rare disease was established. Hence, we aimed to develop a nomogram to predict overall survival (OS) of PSCGBM.

METHODS

Clinical data of patients with PSCGBM was retrospectively collected from the neurosurgery department of Soochow University Affiliated Second Hospital and the Surveillance Epidemiology and End Results database. Information including age, sex, race, tumor extension, extent of resection, adjuvant treatment, marital status, income, year of diagnosis and months from diagnosis to treatment were recorded. Univariate and multivariate Cox regression analyses were used to identify independent prognostic factors for PSCGBM. A nomogram was constructed to predict 1-year, 1.5-year, and 2-year OS of PSCGBM.

RESULTS

A total of 132 patients were included. The 1-year, 1.5-year, and 2-year OS were 45.5%, 29.5%, and 18.9%, respectively. Four variables: age groups, tumor extension, extent of resection, and adjuvant therapy, were identified as independent prognostic factors. The nomogram showed robust discrimination with a C-index value for the prediction of 1-year OS, 1.5-year OS, and 2-year of 0.71 (95% confidence interval [CI], 0.61-0.70), 0.72 (95% CI, 0.62-0.70), and 0.70 (95% CI, 0.61-0.70), respectively. The calibration curves exhibited high consistencies between the predicted and observed survival probability in this cohort.

CONCLUSION

We have developed and internally validated a nomogram for predicting the survival outcome of PSCGBM for the first time. The nomogram has the potential to assist clinicians in making individualized predictions of survival outcome of PSCGBM.

Associations between urbanicity and spinal cord astrocytoma management and outcomes

BACKGROUND

The management of spinal cord astrocytomas (SCAs) remains controversial and may include any combination of surgery, radiation, and chemotherapy. Factors such as urbanicity (metropolitan versus non-metropolitan residence) are shown to be associated with patterns of treatment and clinical outcomes in a variety of cancers, but the role urbanicity plays in SCA treatment remains unknown.

METHODS

The Central Brain Tumor Registry of the United States (CBTRUS) analytic dataset, which combines data from CDC's National Program of Cancer Registries (NPCR) and NCI's Surveillance, Epidemiology, and End Results Programs, was used to identify individuals with SCAs between 2004 and 2019. Individuals' county of residence was classified as metropolitan or non-metropolitan. Multivariable logistic regression models were used to evaluate associations between urbanicity and SCA. Cox proportional hazard models were constructed to assess the effect of urbanicity on survival using the NPCR survival dataset (2004-2018).

RESULTS

1697 metropolitan and 268 non-metropolitan SCA cases were identified. The cohorts did not differ in age or gender composition. The populations had different racial/ethnic compositions, with a higher White non-Hispanic population in the non-metropolitan cohort (86 % vs 66 %, p < 0.001) and a greater Black non-Hispanic population in the metropolitan cohort (14 % vs 9.9 %, p < 0.001). There were no significant differences in likelihood of receiving comprehensive treatment (OR=0.99, 95 % CI [0.56, 1.65], p = >0.9), or survival (hazard ratio [HR]=0.92, p = 0.4) when non-metropolitan and metropolitan cases were compared. In the metropolitan cohort, there were statistically significant differences in SCA treatment patterns when stratified by race/ethnicity (p = 0.002).

CONCLUSIONS

Urbanicity does not significantly impact SCA management or survival. Race/ethnicity may be associated with likelihood of receiving certain SCA treatments in metropolitan communities.

Independent Prognostic Factors and Nomogram Prediction of Cancer-Specific Survival in Postoperative Patients With Spinal Cord Astrocytoma

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Spinal cord astrocytoma (SCA) is a rare central nervous system malignancy that typically requires early surgical intervention. However, the substantial frequency of relapse and bad outcomes limit the surgical advantage for patients. Herein, we aimed to determine the independent prognostic factors of cancer-specific survival (CSS) in post-surgical patients with primary SCA and to develop a new method to estimate the chances of CSS in these patients at 3-, 5- and 10-year.

METHODS

A total of 364 postoperative patients with SCA were recruited from the Surveillance, Epidemiology, and End Results database and randomly assigned to the training and validation sets. Univariate and multivariate Cox regression assessments were used to identify independent prognostic indicators. Second, a nomogram was established by integrating these indicators to estimate 3-, 5-, and 10-year CSS in patients with SCA who underwent surgery. Subsequently, the discriminatory power and predictive performance of the nomogram were assessed using the receiver operating characteristic (ROC) curve, calibration curves, and decision curve analysis (DCA). Finally, a mortality risk stratification system was generated.

RESULTS

Age, tumor stage, histological type, and radiotherapy were recognized as potential predictive indicators of CSS for postoperative patients with SCA. The ROC curve and DCA indicate that the nomogram has good accuracy and high clinical utility. Furthermore, the mortality risk stratification system efficiently divides patients into 3 risk subgroups.

CONCLUSIONS

The nomogram could accurately anticipate the 3-, 5-, and 10-year percentages of CSS in postoperative patients with SCA. It could assist clinicians with personalized medical counseling, risk stratification management, and clinical decision-making, improving the clinical outcomes of these patients.

The Role of Cellular Immunity and Adaptive Immunity in Pathophysiology of Brain and Spinal Cord Tumors

Major advances have been made in our understanding of CNS tumors, especially glioma, however, the survival of patients with malignant glioma remains poor. While radiation and chemotherapy have increased overall survival, glioblastoma multiforme (GBM) still has one of the worst 5-year survival rates of all human cancers. Here, in this chapter, the authors review the abrogation of the immune system in the tumor setting, revealing many plausible targets for therapy and the current immunotherapy treatment strategies employed. Notably, glioma has also been characterized as a subset of primary spinal cord tumor and current treatment recommendations are outlined here.

Clinical outcomes and a therapeutic indication of intramedullary spinal cord astrocytoma

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Although intramedullary astrocytoma is associated with a high mortality rate, the optimal treatment has not reached a consensus. This study aimed at evaluating neurologic function and overall survival rate (OSR) in the treatment of this tumor.

SETTING

The single institution in Japan.

METHODS

This study enrolled 67 subjects who underwent surgical treatment for intramedullary astrocytoma. Demographic, imaging, and surgical information were collected from each participant. Tumors were histologically categorized using the World Health Organization classification, and subjects were divided into low-grade (I and II; n = 40) and high-grade (III and IV; n = 27) groups. Neurologic status was evaluated using the modified McCormick scale (MMS). OSR was assessed using Kaplan-Meier methods.

RESULTS

The OSR decreased when the pathological grade increased (p < 0.01). Regarding the therapeutic efficacy for low-grade astrocytomas, subjects who underwent gross total resection (GTR) showed a higher OSR than those who did not (p = 0.02). GTR prevented worsening of MMS score, while non-GTR increased the MMS score (p < 0.01). In the high-grade group, 19 and 10 underwent radiation therapy and chemotherapy, respectively. However, both treatments did not improve OSR. Cordotomy was performed for subjects whose lesional area was at the thoracic level, but the OSR did not significantly increase.

CONCLUSIONS

The most beneficial therapeutic strategy for low-grade astrocytomas was GTR, whereas that for the high-grade tumors was unclear. Further studies with a larger sample size are warranted to validate the effective treatment for malignant astrocytomas.

Clinical Therapy of Metastatic Spinal Tumors

Metastatic spinal tumors (MST) have high rates of morbidity and mortality. MST can destroy the vertebral body or compress the nerve roots, resulting in an increased risk of pathological fractures and intractable pain. Here, we elaborately reviewed the currently available therapeutic options for MST according to the following four aspects: surgical management, minimally invasive therapy (MIT), radiation therapy, and systemic therapy. In particular, these aspects were classified and introduced to show their developmental process, clinical effects, advantages, and current limitations. Furthermore, with the improvement of treatment concepts and techniques, we discovered the prevalent trend toward the use of radiation therapy and MIT in clinic therapies. Finally, the future directions of these treatment options were discussed. We hoped that along with future advances and study will lead to the improvement of living standard and present status of treatment in patients with MST.

Management, outcomes, and prognostic factors of adult primary spinal cord gliomas

PURPOSE

Primary spinal cord tumors are rare, particularly in the adult population, and national guidelines remain ambiguous with regard to management approaches. To address this knowledge gap, we evaluated management, outcomes, and prognostic factors of these neoplasms.

METHODS

The National Cancer Database was queried (2004-2016) for newly-diagnosed, histologically-confirmed WHO grades I-III astrocytomas and glioblastoma. Statistics included Kaplan-Meier overall survival (OS) analysis, along with Cox proportional hazards modeling.

RESULTS

Of 1,033 subjects, 196 (19%) were pilocytic astrocytomas (PAs), 539 (52%) were grade II/III astrocytomas, and 298 (29%) were glioblastomas (GBMs). Respectively, 11%, 30%, and 27% did not undergo resection (biopsy only). RT was delivered to 27%, 54%, and 73%; chemotherapy was given to 5%, 21%, and 37%, respectively. The median OS was not reached for PAs, but was 101.2 months for grade II/III astrocytomas, and 23.9 months for GBMs (p < 0.001). Neither chemotherapy nor RT (or dose thereof) was associated with increased OS for grade II/III astrocytomas (p > 0.05 for all), though there was a trend toward improved OS with the use of chemotherapy for patients with GBM. Surgical resection was associated with improved OS for grade II/III astrocytomas and GBM (p < 0.05). Independent prognostic factors for survival in this cohort included histologic classification and resection (compared to biopsy only) (p < 0.05 for both).

CONCLUSIONS

This study sheds light onto the management of these rare tumors; surgery was associated with OS benefit for patients with GBM and Grade II/III astrocytomas. Neither RT nor chemotherapy were associated with OS benefit. Although not implying causation, these data can be used to guide patient counseling and therapeutic approaches.

Primary Spinal Astrocytomas: A Literature Review

Primary spinal astrocytoma is a subtype of glioma, the most common spinal cord tumor found in the intradural intramedullary compartment. Spinal astrocytomas account for 6-8% of all spinal cord tumors and are primarily low grade (World Health Organization grade I (WHO I) or WHO II). They are seen in both the adult and pediatric population with the most common presenting symptoms being back pain, sensory dysfunction, or motor dysfunction. Magnetic Resonance Imaging (MRI) with and without gadolinium is the imaging of choice, which usually reveals a hypointense T1 weighted and hyperintense T2 weighted lesion with a heterogeneous pattern of contrast enhancement. Further imaging which may aid in surgical planning includes computerized tomography, diffusion tensor imaging, and tractography. Median survival in spinal cord astrocytomas ranges widely. The factors most significantly associated with poor prognosis and shorter median survival are older age at initial diagnosis, higher grade lesion based on histology, and extent of resection. The mainstay of treatment for primary spinal cord astrocytomas is surgical resection, with the goal of preservation of neurologic function, guided by intraoperative neuromonitoring. Adjunctive radiation has been shown beneficial and may increase overall survival. The role of adjunctive chemotherapy is employed, however, its benefit has not been clearly defined. Primary spinal cord astrocytomas are rare and challenging to treat. The gold standard treatment is surgical resection. Second-line treatments include radiation and chemotherapy, although, the optimal regimen for adjunctive therapy has not yet been clearly defined.

Eupatilin inhibits glioma proliferation, migration, and invasion by arresting cell cycle at G1/S phase and disrupting the cytoskeletal structure

Purpose: Eupatilin is a pharmacologically active flavonoid extracted from Asteraceae argyi that has been identified as having antitumor effects. Gliomas are the most common intracranial malignant tumors and are associated with high mortality and a poor postoperative prognosis. There are few studies on the therapeutic effects of eupatilin on glioma. Therefore, we explored the efficacy and the underlying molecular mechanism of eupatilin on glioma.

Methods: The effect of eupatilin on cell proliferation and viability was detected using Cell Counting Kit-8 assays. Cell migration was analyzed with a scratch wound healing assay and invasion was analyzed using transwell assays.

Results: We found that eupatilin significantly inhibits the viability and proliferation of glioma cells by arresting the cell cycle at the G1/S phase. In addition, eupatilin disrupts the structure of the cytoskeleton and affects F-actin depolymerization via the “P-LIMK”/cofilin pathway, thereby inhibiting the migration of glioma. We also found that eupatilin inhibits the invasion of gliomas. The underlying mechanism may be related to the destruction of epithelial–mesenchymal transition, with eupatilin also affecting the RECK/matrix metalloproteinase pathway. However, we did not observe the proapoptotic effect of eupatilin on glioma, which is inconsistent with other studies. Finally, we observed a significant inhibitory effect of eupatilin on U87MG glioma in xenograft nude mice.

Conclusion: Eupatilin inhibits the viability and proliferation of glioma cells, attenuates the migration and invasion, and inhibits tumor growth in vivo, but does not promote apoptosis. Therefore, due to the poor clinical efficacy of drug treatment of glioma and high drug resistance, the emergence of eupatilin brings a new dawn for glioma patients.

Spinal cord astrocytomas: progresses in experimental and clinical investigations for developing recovery neurobiology-based novel therapies

Spinal cord astrocytomas (SCAs) have discernibly unique signatures in regards to epidemiology, clinical oncological features, genetic markers, pathophysiology, and research and therapeutic challenges. Overall, there are presently very limited clinical management options for high grade SCAs despite progresses made in validating key molecular markers and standardizing tumor classification. The endeavors were aimed to improve diagnosis, therapy design and prognosis assessment, as well as to define more effective oncolytic targets. Efficacious treatment for high grade SCAs still remains an unmet medical demand. This review is therefore focused on research state updates that have been made upon analyzing clinical characteristics, diagnostic classification, genetic and molecular features, tumor initiation cell biology, and current management options for SCAs. Particular emphasis was given to basic and translational research endeavors targeting SCAs, including establishment of experimental models, exploration of unique profiles of SCA stem cell-like tumor survival cells, characterization of special requirements for effective therapeutic delivery into the spinal cord, and development of donor stem cell-based gene-directed enzyme prodrug therapy. We concluded that precise understanding of molecular oncology, tumor survival mechanisms (e.g., drug resistance, metastasis, and cancer stem cells/tumor survival cells), and principles of Recovery Neurobiology can help to create clinically meaningful experimental models of SCAs. Establishment of such systems will expedite the discovery of efficacious therapies that not only kill tumor cells but simultaneously preserve and improve residual neural function.

Treatment outcomes of radiotherapy for primary spinal cord glioma

PURPOSE

Spinal cord gliomas are rare, and there is no consensus on the optimal radiotherapy (RT) regimen. Herein, we investigated therapeutic outcomes in spinal cord gliomas to obtain clues for the optimal RT regimen.

METHODS

We assessed 45 patients who received RT for primary spinal cord non-ependymoma gliomas between 2005 and 2017: 37 (82%) received postoperative RT, 6 (13%) underwent definitive RT without surgery, and 2 (5%) received salvage RT for recurrent tumors. Craniospinal irradiation (CSI; median, 40 Gy) was administered in 4 patients with seeding at diagnosis; all other patients received local RT only (median, 50.4 Gy).

RESULTS

In all 23 failures occurred (20 in patients without initial seeding +3 in patients with initial seeding and CSI; median follow-up, 33 months). The 2‑year overall survival and progression-free survival rates were 74 and 54%, respectively. Overall, 13 (32%) new seeding events outside the local RT field developed either first or subsequently. Tumor grade was significantly associated with survival endpoints (p = 0.009, 0.028) and overall seeding rates (p = 0.042). In grade II tumors, seeding developed in 23%, with a dismal prognosis (median, 10 months after RT). In grade III tumors, seeding developed in 45% with diverse prognosis. In grade IV tumors, seeding developed in 45%. The survival of patients with newly developed seeding was significantly worse than the others (2-year 50%, p < 0.001).

CONCLUSION

To encompass a considerable rate of progressive disease seeding, aggressive treatment such as pre-emptive application of CSI needs to be considered for high-grade spinal cord gliomas with adverse features. Prophylactic CSI could be an option for survival prolongation and requires prospective validation.