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Chen ATC, Serante AR, Ayres AS, Tonaki JO, Moreno RA, Shih H, Gattás GS, Lopez RVM, Dos Santos de Jesus GR, de Carvalho IT, Marotta RC, Marta GN, Feher O, Neto HS, Ribeiro ISN, Vasconcelos KGMDC, Figueiredo EG, Weltman E. Prospective Randomized Phase 2 Trial of Hypofractionated Stereotactic Radiation Therapy of 25 Gy in 5 Fractions Compared With 35 Gy in 5 Fractions in the Reirradiation of Recurrent Glioblastoma. Int J Radiat Oncol Biol Phys 2024; 119:1122-1132. [PMID: 38232937 DOI: 10.1016/j.ijrobp.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 01/19/2024]
Abstract
PURPOSE The aim of this work was to investigate whether reirradiation of recurrent glioblastoma with hypofractionated stereotactic radiation therapy (HSRT) consisting of 35 Gy in 5 fractions (35 Gy/5 fx) compared with 25 Gy in 5 fractions (25 Gy/5 fx) improves outcomes while maintaining acceptable toxicity. METHODS AND MATERIALS We conducted a prospective randomized phase 2 trial involving patients with recurrent glioblastoma (per the 2007 and 2016 World Health Organization classification). A minimum interval from first radiation therapy of 5 months and gross tumor volume of 150 cc were required. Patients were randomized 1:1 to receive HSRT alone in 25 Gy/5 fx or 35 Gy/5 fx. The primary endpoint was progression-free survival (PFS). We used a randomized phase 2 screening design with a 2-sided α of 0.15 for the primary endpoint. RESULTS From 2011 to 2019, 40 patients were randomized and received HSRT, with 20 patients in each group. The median age was 50 years (range, 27-71); a new resection before HSRT was performed in 75% of patients. The median PFS was 4.9 months in the 25 Gy/5 fx group and 5.2 months in the 35 Gy/5 fx group (P = .23). Six-month PFS was similar at 40% (85% CI, 24%-55%) for both groups. The median overall survival (OS) was 9.2 months in the 25 Gy/5 fx group and 10 months in the 35 Gy/5 fx group (P = .201). Grade ≥3 necrosis was numerically higher in the 35 Gy/5 fx group (3 [16%] vs 1 [5%]), but the difference was not statistically significant (P = .267). In an exploratory analysis, median OS of patients who developed treatment-related necrosis was 14.1 months, and that of patients who did not was 8.7 months (P = .003). CONCLUSIONS HSRT alone with 35 Gy/5 fx was not superior to 25 Gy/5 fx in terms of PFS or OS. Due to a potential increase in the rate of clinically meaningful treatment-related necrosis, we suggest 25 Gy/5 fx as the standard dose in HSRT alone. During follow-up, attention should be given to differentiating tumor progression from potentially manageable complications.
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Affiliation(s)
- Andre Tsin Chih Chen
- Department of Radiation Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil.
| | - Alexandre Ruggieri Serante
- Department of Radiation Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil
| | - Aline Sgnolf Ayres
- Department of Radiology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da FMUSP, Sao Paulo, Brazil
| | - Juliana Ono Tonaki
- Division of Psychology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da FMUSP, Sao Paulo, Brazil
| | - Raquel Andrade Moreno
- Department of Radiology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da FMUSP, Sao Paulo, Brazil
| | - Helen Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Rossana Veronica Mendoza Lopez
- Oncology Translational Research Center, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da FMUSP, Sao Paulo, Brazil
| | - Gabriela Reis Dos Santos de Jesus
- Department of Radiation Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil
| | - Icaro Thiago de Carvalho
- Department of Radiation Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil
| | - Rodrigo Carvalho Marotta
- Department of Radiation Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil
| | - Gustavo Nader Marta
- Department of Radiation Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil
| | - Olavo Feher
- Department of Clinical Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da FMUSP, Sao Paulo, Brazil
| | - Hugo Sterman Neto
- Department of Neurosurgery, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da FMUSP, Sao Paulo, Brazil
| | - Iuri Santana Neville Ribeiro
- Department of Neurosurgery, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da FMUSP, Sao Paulo, Brazil
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Preusser M, Kazda T, Le Rhun E, Sahm F, Smits M, Gempt J, Koekkoek JA, Monti AF, Csanadi M, Pitter JG, Bulbek H, Fournier B, Quoilin C, Gorlia T, Weller M, Minniti G. Lomustine with or without reirradiation for first progression of glioblastoma, LEGATO, EORTC-2227-BTG: study protocol for a randomized phase III study. Trials 2024; 25:366. [PMID: 38849943 PMCID: PMC11157762 DOI: 10.1186/s13063-024-08213-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 05/30/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Chemotherapy with lomustine is widely considered as standard treatment option for progressive glioblastoma. The value of adding radiotherapy to second-line chemotherapy is not known. METHODS EORTC-2227-BTG (LEGATO, NCT05904119) is an investigator-initiated, pragmatic (PRECIS-2 score: 34 out of 45), randomized, multicenter phase III trial in patients with first progression of glioblastoma. A total of 411 patients will be randomized in a 1:1 ratio to lomustine (110 mg/m2 every 6 weeks) or lomustine (110 mg/m2 every 6weeks) plus radiotherapy (35 Gy in 10 fractions). Main eligibility criteria include histologic confirmation of glioblastoma, isocitrate dehydrogenase gene (IDH) wild-type per WHO 2021 classification, first progression at least 6 months after the end of prior radiotherapy, radiologically measurable disease according to RANO criteria with a maximum tumor diameter of 5 cm, and WHO performance status of 0-2. The primary efficacy endpoint is overall survival (OS) and secondary endpoints include progression-free survival, response rate, neurocognitive function, health-related quality of life, and health economic parameters. LEGATO is funded by the European Union's Horizon Europe Research program, was activated in March 2024 and will enroll patients in 43 sites in 11 countries across Europe with study completion projected in 2028. DISCUSSION EORTC-2227-BTG (LEGATO) is a publicly funded pragmatic phase III trial designed to clarify the efficacy of adding reirradiation to chemotherapy with lomustine for the treatment of patients with first progression of glioblastoma. TRIAL REGISTRATION ClinicalTrials.gov NCT05904119. Registered before start of inclusion, 23 May 2023.
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Affiliation(s)
- Matthias Preusser
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Tomáš Kazda
- Department of Radiation Oncology and Research Centre for Applied Molecular Oncology (RECAMO), Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Emilie Le Rhun
- Department of Medical Oncology and Hematology, University Hospital & University of Zurich, Zurich, Switzerland
| | - Felix Sahm
- Department of Neuropathology, University Hospital Heidelberg and CCU Neuropathology, DKFZ, Heidelberg, Germany
| | - Marion Smits
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Jens Gempt
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Johan Af Koekkoek
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Angelo F Monti
- Department of Medical Physics, ASST GOM Niguarda, Milano, Italy
| | | | | | - Helen Bulbek
- Brainstrust-the brain cancer people, Isle of Wight, Cowes, UK
| | | | | | | | - Michael Weller
- Department of Neurology, University Hospital & University of Zurich, Zurich, Switzerland
| | - Giuseppe Minniti
- Department of Radiological Sciences, Oncology and Anatomical Pathology and IRCCS Neuromed (IS), Sapienza University, Policlinico Umberto I, Rome, Italy
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Cuccia F, Jafari F, D’Alessandro S, Carruba G, Craparo G, Tringali G, Blasi L, Ferrera G. Preferred Imaging for Target Volume Delineation for Radiotherapy of Recurrent Glioblastoma: A Literature Review of the Available Evidence. J Pers Med 2024; 14:538. [PMID: 38793120 PMCID: PMC11122491 DOI: 10.3390/jpm14050538] [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: 03/12/2024] [Revised: 04/29/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Recurrence in glioblastoma lacks a standardized treatment, prompting an exploration of re-irradiation's efficacy. METHODS A comprehensive systematic review from January 2005 to May 2023 assessed the role of MRI sequences in recurrent glioblastoma re-irradiation. The search criteria, employing MeSH terms, targeted English-language, peer-reviewed articles. The inclusion criteria comprised both retrospective and prospective studies, excluding certain types and populations for specificity. The PICO methodology guided data extraction, and the statistical analysis employed Chi-squared tests via MedCalc v22.009. RESULTS Out of the 355 identified studies, 81 met the criteria, involving 3280 patients across 65 retrospective and 16 prospective studies. The key findings indicate diverse treatment modalities, with linac-based photons predominating. The median age at re-irradiation was 54 years, and the median time interval between radiation courses was 15.5 months. Contrast-enhanced T1-weighted sequences were favored for target delineation, with PET-imaging used in fewer studies. Re-irradiation was generally well tolerated (median G3 adverse events: 3.5%). The clinical outcomes varied, with a median 1-year local control rate of 61% and a median overall survival of 11 months. No significant differences were noted in the G3 toxicity and clinical outcomes based on the MRI sequence preference or PET-based delineation. CONCLUSIONS In the setting of recurrent glioblastoma, contrast-enhanced T1-weighted sequences were preferred for target delineation, allowing clinicians to deliver a safe and effective therapeutic option; amino acid PET imaging may represent a useful device to discriminate radionecrosis from recurrent disease. Future investigations, including the ongoing GLIAA, NOA-10, ARO 2013/1 trial, will aim to refine approaches and standardize methodologies for improved outcomes in recurrent glioblastoma re-irradiation.
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Affiliation(s)
- Francesco Cuccia
- Radiation Oncology, ARNAS Civico Hospital, 90100 Palermo, Italy (G.F.)
| | - Fatemeh Jafari
- Radiation Oncology Department, Imam-Khomeini Hospital Complex, Teheran University of Medical Sciences, Teheran 1416634793, Iran
| | | | - Giuseppe Carruba
- Division of Internationalization and Health Research (SIRS), ARNAS Civico Hospital, 90100 Palermo, Italy
| | | | | | - Livio Blasi
- Medical Oncology, ARNAS Civico Hospital, 90100 Palermo, Italy;
| | - Giuseppe Ferrera
- Radiation Oncology, ARNAS Civico Hospital, 90100 Palermo, Italy (G.F.)
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De Pietro R, Zaccaro L, Marampon F, Tini P, De Felice F, Minniti G. The evolving role of reirradiation in the management of recurrent brain tumors. J Neurooncol 2023; 164:271-286. [PMID: 37624529 PMCID: PMC10522742 DOI: 10.1007/s11060-023-04407-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 07/24/2023] [Indexed: 08/26/2023]
Abstract
Despite aggressive management consisting of surgery, radiation therapy (RT), and systemic therapy given alone or in combination, a significant proportion of patients with brain tumors will experience tumor recurrence. For these patients, no standard of care exists and management of either primary or metastatic recurrent tumors remains challenging.Advances in imaging and RT technology have enabled more precise tumor localization and dose delivery, leading to a reduction in the volume of health brain tissue exposed to high radiation doses. Radiation techniques have evolved from three-dimensional (3-D) conformal RT to the development of sophisticated techniques, including intensity modulated radiation therapy (IMRT), volumetric arc therapy (VMAT), and stereotactic techniques, either stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT). Several studies have suggested that a second course of RT is a feasible treatment option in patients with a recurrent tumor; however, survival benefit and treatment related toxicity of reirradiation, given alone or in combination with other focal or systemic therapies, remain a controversial issue.We provide a critical overview of the current clinical status and technical challenges of reirradiation in patients with both recurrent primary brain tumors, such as gliomas, ependymomas, medulloblastomas, and meningiomas, and brain metastases. Relevant clinical questions such as the appropriate radiation technique and patient selection, the optimal radiation dose and fractionation, tolerance of the brain to a second course of RT, and the risk of adverse radiation effects have been critically discussed.
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Affiliation(s)
- Raffaella De Pietro
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Lucy Zaccaro
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Francesco Marampon
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Paolo Tini
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Francesca De Felice
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Giuseppe Minniti
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy.
- IRCCS Neuromed, Pozzilli (IS), Isernia, Italy.
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Luo T, Feng J, Sun P. Fractionated stereotactic re-irradiation for recurrent glioblastoma: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 229:107728. [PMID: 37105068 DOI: 10.1016/j.clineuro.2023.107728] [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: 01/20/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND The clinical benefit and the safety of fractionated stereotactic re-irradiation in treating patients with recurrent glioblastoma are still disputed. Thus, we conducted a meta-analysis to explore the clinical benefit and the safety of fractionated stereotactic re-irradiation for patients with recurrent glioblastoma. MATERIALS AND METHODS We retrieved the eligible papers published up to Nov. 2022 through PubMed, Embase, Cochrane, Web of Science, and Clinical Trials. Gov, and other biomedical databases and evaluated the quality of the studies by Newcastle-Ottawa Scale. The random effect model was used to pool 12-month overall survival rates, 12-month progression-free survival rates, and radiational necrosis risk, and an interaction test was used to compare defined subgroups. RESULTS We identified eight eligible studies, including 307 patients. The overall survival rate of 12 months was 33.1 % (95 % CI 26.0 %-40.9 %), and the progression-free survival rate of 12 months was 13.4 % (95 % CI 8.0 %-21.3 %). Radiation necrosis was low in incidence in the included studies. Additionally, the subgroup analysis demonstrated that factors such as age, time interval (from the first radiation to the re-irradiation), total dose, and single dose, impacted the survival rate. CONCLUSION Fractionated stereotactic re-irradiation produces relative clinical benefit and safety for patients with recurrent glioblastoma.
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Affiliation(s)
- Tingfan Luo
- Department of Radiotherapy, Lanzhou University Second Hospital, Lanzhou 730030, Gansu Province, People's Republic of China
| | - Jin Feng
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, Guangdong Province, People's Republic of China
| | - Pengfei Sun
- Department of Radiotherapy, Lanzhou University Second Hospital, Lanzhou 730030, Gansu Province, People's Republic of China.
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Combined Hyperthermia and Re-Irradiation in Non-Breast Cancer Patients: A Systematic Review. Cancers (Basel) 2023; 15:cancers15030742. [PMID: 36765699 PMCID: PMC9913630 DOI: 10.3390/cancers15030742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 01/27/2023] Open
Abstract
PURPOSE This systematic literature review summarizes clinical studies and trials involving combined non-ablative hyperthermia and re-irradiation in locoregionally recurrent cancer except breast cancer. METHODS One database and one registry, MEDLINE and clinicaltrials.gov, respectively, were searched for studies on combined non-ablative hyperthermia and re-irradiation in non-breast cancer patients. Extracted study characteristics included treatment modalities and re-irradiation dose concepts. Outcomes of interest were tumor response, survival measures, toxicity data and palliation. Within-study bias assessment included the identification of conflict of interest (COI). The final search was performed on 29 August 2022. RESULTS Twenty-three articles were included in the final analysis, reporting on 603 patients with eight major tumor types. Twelve articles (52%) were retrospective studies. Only one randomized trial was identified. No COI statement was declared in 11 studies. Four of the remaining twelve studies exhibited significant COI. Low study and patient numbers, high heterogeneity in treatment modalities and endpoints, as well as significant within- and across-study bias impeded the synthesis of results. CONCLUSION Outside of locoregionally recurrent breast cancer, the role of combined moderate hyperthermia and re-irradiation can so far not be established. This review underscores the necessity for more clinical trials to generate higher levels of clinical evidence for combined re-irradiation and hyperthermia.
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Impact of fractionated stereotactic radiotherapy on activity of daily living and performance status in progressive/recurrent glioblastoma: a retrospective study. Radiat Oncol 2022; 17:201. [PMID: 36474245 PMCID: PMC9727986 DOI: 10.1186/s13014-022-02169-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The prognosis of recurrent glioblastoma (GBM) is poor, with limited options of palliative localized or systemic treatments. Survival can be improved by a second localized treatment; however, it is not currently possible to identify which patients would benefit from this approach. This study aims to evaluate which factors lead to a lower Karnofsky performance status (KPS) score after fractionated stereotactic RT (fSRT). METHODS We retrospectively collected data from patients treated with fSRT for recurrent GBM at the Institut de Cancérologie de Lorraine between October 2010 and November 2017 and analyzed which factors were associated with a lower KPS score. RESULTS 59 patients received a dose of 25 Gy in 5 sessions spread over 5-7 days (80% isodose). The median time from the end of primary radiotherapy to the initiation of fSRT was 10.7 months. The median follow-up after fSRT initiation was 8.8 months. The incidence of KPS and ADL impairment in all patients were 51.9% and 37.8% respectively with an adverse impact of PTV size on KPS (HR = 1.57 [95% CI 1.19-2.08], p = 0.028). Only two patients showed early grade 3 toxicity and none showed grade 4 or late toxicity. The median overall survival time, median overall survival time after fSRT, median progression-free survival and institutionalization-free survival times were 25.8, 8.8, 3.9 and 7.7 months, respectively. Initial surgery was associated with better progression-free survival (Hazard ratio (HR) = 0.48 [95% CI 0.27-0.86], p = 0.013). CONCLUSIONS A larger PTV should predicts lower KPS in the treatment of recurrent GBM using fSRT.
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Lautenschlaeger FS, Dumke R, Schymalla M, Hauswald H, Carl B, Stein M, Keber U, Jensen A, Engenhart-Cabillic R, Eberle F. Comparison of carbon ion and photon reirradiation for recurrent glioblastoma. Strahlenther Onkol 2022; 198:427-435. [PMID: 34523017 PMCID: PMC9038837 DOI: 10.1007/s00066-021-01844-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 07/25/2021] [Indexed: 12/03/2022]
Abstract
PURPOSE Purpose of this study was to investigate overall survival in recurrent glioblastoma treated with either carbon ion reirradiation or photon reirradiation. MATERIALS AND METHODS In this retrospective study we evaluated 78 consecutive patients with recurrent IDH (Isocitrate dehydrogenase)-wildtype glioblastoma (38 patients carbon ion re-radiotherapy, 40 patients photon re-radiotherapy) treated with either carbon ion reirradiation or stereotactic photon reirradiation. 45 Gy (RBE; 15 fractions) carbon ion reirradiation (CIRT) or 39 Gy (13 fractions) photon reirradiation (FSRT) was administered, respectively. Overall survival was investigated with respect to histological, clinical, and epidemiological features. Kaplan-Meier and multivariate Cox statistics were calculated. A propensity score-matched analysis of the FSRT and CIRT groups using variables from a validated prognosis score was carried out. RESULTS The type of reirradiation (CIRT vs. FSRT) significantly influenced overall survival-8.0 months vs. 6.5 months (univariate: p = 0.046)-and remained an independent prognostic factor in multivariate analysis (p = 0.017). Propensity score-adjusted analysis with CIRT versus FSRT as the dependent variable yielded a significant overall survival advantage for the CIRT group (median OS 8.9 versus 7.2 months, p = 0.041, 1‑year survival 29 versus 10%). Adverse events (AE) were evaluated for both subgroups. For the FSRT group no toxicity ≥ grade 4 occurred. For the CIRT subgroup no grade 5 AE occurred, but 1 patient developed a grade 4 radionecrosis. We encountered 4 grade 3 toxicities. One patient developed a zoster at the trunk, 2 progressed in their paresis, and 1 featured progressive dysesthesia. CONCLUSION In conclusion, carbon ion treatment is a safe and feasible treatment option for recurrent glioblastoma. Due to the retrospective nature of the study and two different dose levels for CIRT or FSRT, the improved outcome in CIRT reirradiation might be an effect of higher biological impact from carbon ions or a simple dose-escalation effect. This hypothesis needs prospective testing in larger patient cohorts. A prospective phase III randomized trial is in preparation at our center.
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Affiliation(s)
- F S Lautenschlaeger
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Marburg, Marburg, Germany.
- Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany.
| | - R Dumke
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Marburg, Marburg, Germany
| | - M Schymalla
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Marburg, Marburg, Germany
| | - H Hauswald
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Marburg, Marburg, Germany
- Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
- RNS Gemeinschaftspraxis, St. Josefs-Hospital, Wiesbaden, Germany
- Klinik für Radio-Onkologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - B Carl
- Klinik für Neurochirurgie, Helios Dr. Horst Schmidt Kliniken Wiesbaden, Wiesbaden, Germany
- Klinik für Neurochirurgie, Universitätsklinikum Marburg, Marburg, Germany
| | - M Stein
- Klinik für Neurochirurgie, Universitätsklinikum Gießen, Gießen, Germany
| | - U Keber
- Institut für Neuropathologie, Universitätsklinikum Marburg, Marburg, Germany
| | - A Jensen
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Marburg, Marburg, Germany
- Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Gießen, Gießen, Germany
| | - R Engenhart-Cabillic
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Marburg, Marburg, Germany
- Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Gießen, Gießen, Germany
| | - F Eberle
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Marburg, Marburg, Germany
- Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
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Intermittent radiotherapy as alternative treatment for recurrent high grade glioma: a modeling study based on longitudinal tumor measurements. Sci Rep 2021; 11:20219. [PMID: 34642366 PMCID: PMC8511136 DOI: 10.1038/s41598-021-99507-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 09/20/2021] [Indexed: 12/30/2022] Open
Abstract
Recurrent high grade glioma patients face a poor prognosis for which no curative treatment option currently exists. In contrast to prescribing high dose hypofractionated stereotactic radiotherapy (HFSRT, [Formula: see text] Gy [Formula: see text] 5 in daily fractions) with debulking intent, we suggest a personalized treatment strategy to improve tumor control by delivering high dose intermittent radiation treatment (iRT, [Formula: see text] Gy [Formula: see text] 1 every 6 weeks). We performed a simulation analysis to compare HFSRT, iRT and iRT plus boost ([Formula: see text] Gy [Formula: see text] 3 in daily fractions at time of progression) based on a mathematical model of tumor growth, radiation response and patient-specific evolution of resistance to additional treatments (pembrolizumab and bevacizumab). Model parameters were fitted from tumor growth curves of 16 patients enrolled in the phase 1 NCT02313272 trial that combined HFSRT with bevacizumab and pembrolizumab. Then, iRT +/- boost treatments were simulated and compared to HFSRT based on time to tumor regrowth. The modeling results demonstrated that iRT + boost(- boost) treatment was equal or superior to HFSRT in 15(11) out of 16 cases and that patients that remained responsive to pembrolizumab and bevacizumab would benefit most from iRT. Time to progression could be prolonged through the application of additional, intermittently delivered fractions. iRT hence provides a promising treatment option for recurrent high grade glioma patients for prospective clinical evaluation.
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García-Cabezas S, Rivin del Campo E, Solivera-Vela J, Palacios-Eito A. Re-irradiation for high-grade gliomas: Has anything changed? World J Clin Oncol 2021; 12:767-786. [PMID: 34631441 PMCID: PMC8479348 DOI: 10.5306/wjco.v12.i9.767] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/21/2021] [Accepted: 07/30/2021] [Indexed: 02/06/2023] Open
Abstract
Optimal management after recurrence or progression of high-grade gliomas is still undefined and remains a challenge for neuro-oncology multidisciplinary teams. Improved radiation therapy techniques, new imaging methods, published experience, and a better radiobiological knowledge of brain tissue have positioned re-irradiation (re-RT) as an option for many of these patients. Decisions must be individualized, taking into account the pattern of relapse, previous treatment, and functional status, as well as the patient’s preferences and expected quality of life. Many questions remain unanswered with respect to re-RT: Who is the most appropriate candidate, which dose and fractionation are most effective, how to define the target volume, which imaging technique is best for planning, and what is the optimal timing? This review will focus on describing the most relevant studies that include re-RT as salvage therapy, with the aim of simplifying decision-making and designing the best available therapeutic strategy.
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Affiliation(s)
- Sonia García-Cabezas
- Department of Radiation Oncology, Reina Sofia University Hospital, Cordoba 14004, Spain
| | | | - Juan Solivera-Vela
- Department of Neurosurgery, Reina Sofia University Hospital, Cordoba 14004, Spain
| | - Amalia Palacios-Eito
- Department of Radiation Oncology, Reina Sofia University Hospital, Cordoba 14004, Spain
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Kayalı FI, Habiboğlu R. CAN HYPOFRACTIONATED REIRRADIATION PLUS TEMOZOLAMIDE BE A WISE CHOICE FOR RECURRENT HIGH AND LOW GRADE BRAIN TUMORS? JOURNAL OF RADIATION RESEARCH AND APPLIED SCIENCES 2021. [DOI: 10.1080/16878507.2021.1935131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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12
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McAleenan A, Kelly C, Spiga F, Kernohan A, Cheng HY, Dawson S, Schmidt L, Robinson T, Brandner S, Faulkner CL, Wragg C, Jefferies S, Howell A, Vale L, Higgins JPT, Kurian KM. Prognostic value of test(s) for O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation for predicting overall survival in people with glioblastoma treated with temozolomide. Cochrane Database Syst Rev 2021; 3:CD013316. [PMID: 33710615 PMCID: PMC8078495 DOI: 10.1002/14651858.cd013316.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Glioblastoma is an aggressive form of brain cancer. Approximately five in 100 people with glioblastoma survive for five years past diagnosis. Glioblastomas that have a particular modification to their DNA (called methylation) in a particular region (the O6-methylguanine-DNA methyltransferase (MGMT) promoter) respond better to treatment with chemotherapy using a drug called temozolomide. OBJECTIVES To determine which method for assessing MGMT methylation status best predicts overall survival in people diagnosed with glioblastoma who are treated with temozolomide. SEARCH METHODS We searched MEDLINE, Embase, BIOSIS, Web of Science Conference Proceedings Citation Index to December 2018, and examined reference lists. For economic evaluation studies, we additionally searched NHS Economic Evaluation Database (EED) up to December 2014. SELECTION CRITERIA Eligible studies were longitudinal (cohort) studies of adults with diagnosed glioblastoma treated with temozolomide with/without radiotherapy/surgery. Studies had to have related MGMT status in tumour tissue (assessed by one or more method) with overall survival and presented results as hazard ratios or with sufficient information (e.g. Kaplan-Meier curves) for us to estimate hazard ratios. We focused mainly on studies comparing two or more methods, and listed brief details of articles that examined a single method of measuring MGMT promoter methylation. We also sought economic evaluations conducted alongside trials, modelling studies and cost analysis. DATA COLLECTION AND ANALYSIS Two review authors independently undertook all steps of the identification and data extraction process for multiple-method studies. We assessed risk of bias and applicability using our own modified and extended version of the QUality In Prognosis Studies (QUIPS) tool. We compared different techniques, exact promoter regions (5'-cytosine-phosphate-guanine-3' (CpG) sites) and thresholds for interpretation within studies by examining hazard ratios. We performed meta-analyses for comparisons of the three most commonly examined methods (immunohistochemistry (IHC), methylation-specific polymerase chain reaction (MSP) and pyrosequencing (PSQ)), with ratios of hazard ratios (RHR), using an imputed value of the correlation between results based on the same individuals. MAIN RESULTS We included 32 independent cohorts involving 3474 people that compared two or more methods. We found evidence that MSP (CpG sites 76 to 80 and 84 to 87) is more prognostic than IHC for MGMT protein at varying thresholds (RHR 1.31, 95% confidence interval (CI) 1.01 to 1.71). We also found evidence that PSQ is more prognostic than IHC for MGMT protein at various thresholds (RHR 1.36, 95% CI 1.01 to 1.84). The data suggest that PSQ (mainly at CpG sites 74 to 78, using various thresholds) is slightly more prognostic than MSP at sites 76 to 80 and 84 to 87 (RHR 1.14, 95% CI 0.87 to 1.48). Many variants of PSQ have been compared, although we did not see any strong and consistent messages from the results. Targeting multiple CpG sites is likely to be more prognostic than targeting just one. In addition, we identified and summarised 190 articles describing a single method for measuring MGMT promoter methylation status. AUTHORS' CONCLUSIONS PSQ and MSP appear more prognostic for overall survival than IHC. Strong evidence is not available to draw conclusions with confidence about the best CpG sites or thresholds for quantitative methods. MSP has been studied mainly for CpG sites 76 to 80 and 84 to 87 and PSQ at CpG sites ranging from 72 to 95. A threshold of 9% for CpG sites 74 to 78 performed better than higher thresholds of 28% or 29% in two of three good-quality studies making such comparisons.
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Affiliation(s)
- Alexandra McAleenan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Claire Kelly
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Francesca Spiga
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hung-Yuan Cheng
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration West (ARC West) , University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Lena Schmidt
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Tomos Robinson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sebastian Brandner
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK
- Division of Neuropathology, The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Claire L Faulkner
- Bristol Genetics Laboratory, Pathology Sciences, Southmead Hospital, Bristol, UK
| | - Christopher Wragg
- Bristol Genetics Laboratory, Pathology Sciences, Southmead Hospital, Bristol, UK
| | - Sarah Jefferies
- Department of Oncology, Addenbrooke's Hospital, Cambridge, UK
| | - Amy Howell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration West (ARC West) , University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Kathreena M Kurian
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Medical School: Brain Tumour Research Centre, Public Health Sciences, University of Bristol, Bristol, UK
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13
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Minniti G, Niyazi M, Alongi F, Navarria P, Belka C. Current status and recent advances in reirradiation of glioblastoma. Radiat Oncol 2021; 16:36. [PMID: 33602305 PMCID: PMC7890828 DOI: 10.1186/s13014-021-01767-9] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/11/2021] [Indexed: 12/12/2022] Open
Abstract
Despite aggressive management consisting of maximal safe surgical resection followed by external beam radiation therapy (60 Gy/30 fractions) with concomitant and adjuvant temozolomide, approximately 90% of WHO grade IV gliomas (glioblastomas, GBM) will recur locally within 2 years. For patients with recurrent GBM, no standard of care exists. Thanks to the continuous improvement in radiation science and technology, reirradiation has emerged as feasible approach for patients with brain tumors. Using stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT), either hypofractionated or conventionally fractionated schedules, several studies have suggested survival benefits following reirradiation of patients with recurrent GBM; however, there are still questions to be answered about the efficacy and toxicity associated with a second course of radiation. We provide a clinical overview on current status and recent advances in reirradiation of GBM, addressing relevant clinical questions such as the appropriate patient selection and radiation technique, optimal dose fractionation, reirradiation tolerance of the brain and the risk of radiation necrosis.
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Affiliation(s)
- Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico le Scotte, 53100, Siena, Italy. .,IRCCS Neuromed, Pozzilli, IS, Italy.
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Filippo Alongi
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, VR, Italy
| | - Piera Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Hospital-IRCCS, Rozzano, MI, Italy
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
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14
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Giambattista J, Omene E, Souied O, Hsu FH. Modern Treatments for Gliomas Improve Outcome. CURRENT CANCER THERAPY REVIEWS 2020. [DOI: 10.2174/1573394715666191017153045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Glioma is the most common type of tumor in the central nervous system (CNS). Diagnosis
is through history, physical examination, radiology, histology and molecular profiles. Magnetic
resonance imaging is a standard workup for all CNS tumors. Multidisciplinary team management
is strongly recommended. The management of low-grade gliomas is still controversial
with regards to early surgery, radiotherapy, chemotherapy, or watchful waiting watchful waiting.
Patients with suspected high-grade gliomas should undergo an assessment by neurosurgeons for
the consideration of maximum safe resection to achieve optimal tumor debulking, and to provide
adequate tissue for histologic and molecular diagnosis. Post-operative radiotherapy and/or chemotherapy
are given depending on disease grade and patient performance. Glioblastoma are mostly
considered incurable. Treatment approaches in the elderly, pediatric population and recurrent
gliomas are discussed with the latest updates in the literature. Treatment considerations include
performance status, neurocognitive functioning, and co-morbidities. Important genetic mutations,
clinical trials and guidelines are summarized in this review.
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Affiliation(s)
| | - Egiroh Omene
- Vancouver Cancer Centre, BC Cancer Agency, Columbia, Vancouver, BC, Canada
| | - Osama Souied
- Vancouver Cancer Centre, BC Cancer Agency, Columbia, Vancouver, BC, Canada
| | - Fred H.C. Hsu
- Vancouver Cancer Centre, BC Cancer Agency, Columbia, Vancouver, BC, Canada
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15
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Minniti G, Paolini S, Rea MLJ, Isidori A, Scaringi C, Russo I, Osti MF, Cavallo L, Esposito V. Stereotactic reirradiation with temozolomide in patients with recurrent aggressive pituitary tumors and pituitary carcinomas. J Neurooncol 2020; 149:123-130. [PMID: 32632895 DOI: 10.1007/s11060-020-03579-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/29/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To evaluate the efficacy of a second course of fractionated stereotactic radiotherapy (re-SRT) and temozolomide (TMZ) as salvage treatment option in patients with aggressive pituitary tumors (APTs) and pituitary carcinomas (PCs). PATIENTS AND METHODS Twenty-one patients with recurrent or progressive APTs (n = 17) and PCs (n = 4) who received combined TMZ and re-SRT, 36 Gy/18fractions or 37.5 Gy/15fractions, were retrospectively evaluated. TMZ was given at a dose of 75 mg/m2 given concurrently to re-SRT, and then 150-200 mg/m2/day for 5 days every 4 weeks or 50 mg/m2 daily for 12 months. Local control (LC) and overall survival (OS) were calculated from the time of re-SRT by Kaplan-Meier method. RESULTS With a median follow-up of 27 months (range 12-58 months), 2-year and 4-year LC rates were 73% and 65%, respectively; 2-year and 4-year survival rates were 82% and 66%, respectively. A complete response was achieved in 2 and partial response in 11 patients. Six patients recurred with a median time to progression of 14 months. O(6)-Methylguanine-DNA methyltransferase (MGMT) status and tumor volume emerged as prognostic factors. Grade 3 radiation-related toxicities occurred in 3 (14%) patients. Grade 2 or 3 hematologic toxicities during chemotherapy occurred in 8 (38%) patients. CONCLUSION Re-SRT and TMZ is a safe treatment offering high LC in patients with progressive APTs and PCs. The potential advantages of combined chemoradiation as up-front or salvage treatment need to be explored in prospective trials.
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Affiliation(s)
- Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, 53100, Siena, Italy. .,IRCCS Neuromed, Pozzilli, IS, Italy.
| | | | - Marie Lise Jaffrain Rea
- Biotechnological and Applied Clinical Sciences Department, University of L'Aquila, L'Aquila, Italy
| | - Andrea Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Claudia Scaringi
- UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Ivana Russo
- UPMC Hillman Cancer Center, Villa Maria, Mirabella, AV, Italy
| | | | - Luigi Cavallo
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
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16
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Eberle F, Lautenschläger S, Engenhart-Cabillic R, Jensen AD, Carl B, Stein M, Debus J, Hauswald H. Carbon Ion Beam Reirradiation in Recurrent High-Grade Glioma. Cancer Manag Res 2020; 12:633-639. [PMID: 32095084 PMCID: PMC6995286 DOI: 10.2147/cmar.s217824] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 10/23/2019] [Indexed: 12/30/2022] Open
Abstract
Background Patients with recurrent glioma after prior radiotherapy have a poor prognosis. Carbon ion beam radiotherapy offers highly conformal dose distributions and more complex biological radiation effects eventually resulting in optimized normal tissue sparing and improved outcome. The aim of this study was to analyze toxicity, local control and overall survival after reirradiation of recurrent high-grade glioma with carbon ion radiotherapy. Methods Between 10/2015 and 12/2018, 30 patients (median age: 59 years) with recurrent high-grade glioma were reirradiated with carbon ion beams and retrospectively analyzed. Diagnosis of recurrent glioma was based on magnetic resonance imaging. Thirteen patients had repeated resection prior to reirradiation and 24 patients underwent additional chemotherapy. The median initial radiation dose was 60 Gy and the median time interval between the initial and repeated radiotherapy was 10 months. The reirradiation dose was 45 Gy (relative biological effectiveness) applied in 15 fractions. All patients received regular follow-up imaging after reirradiation. Kaplan-Meier estimation, log rank test and Cox regression analysis were used for statistical assessment. Results Applying common toxicity criteria, there were no grade 5 or 4 adverse events, while 8 patients showed grade 3 adverse events. The median follow-up after reirradiation was 11 months and the median overall survival after diagnosis of recurrent high-grade glioma was 13 months. The 6-, 12- and 24-month overall survival rates after diagnosis of recurrent high-grade glioma were 76%, 50% and 19%, respectively. Upon multivariate Cox regression analysis, a Ki67 score of the initial tumor histology of less than 20% was prognostic. Repeated resection or chemotherapy for the recurrent disease did not result in significantly prolonged survival. Conclusion Carbon ion reirradiation in recurrent high-grade glioma is safe and feasible. No radiation-associated grade 4 toxicities were documented and treatment was tolerated well.
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Affiliation(s)
- Fabian Eberle
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Marburg Ion-Beam Therapy Center (MIT), Department of Radiation Oncology, Heidelberg University Hospital, Marburg, Germany.,Department of Radiation Oncology, Marburg University Hospital, Marburg, Germany
| | | | - Rita Engenhart-Cabillic
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Marburg Ion-Beam Therapy Center (MIT), Department of Radiation Oncology, Heidelberg University Hospital, Marburg, Germany.,Department of Radiation Oncology, Marburg University Hospital, Marburg, Germany
| | - Alexandra D Jensen
- Department of Radiation Oncology, Gießen University Hospital, Gießen, Germany
| | - Barbara Carl
- Department of Neurosurgery, Marburg University Hospital, Marburg, Germany
| | - Marco Stein
- Department of Neurosurgery, Gießen University Hospital, Gießen, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Marburg Ion-Beam Therapy Center (MIT), Department of Radiation Oncology, Heidelberg University Hospital, Marburg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Henrik Hauswald
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Marburg Ion-Beam Therapy Center (MIT), Department of Radiation Oncology, Heidelberg University Hospital, Marburg, Germany.,Department of Radiation Oncology, Marburg University Hospital, Marburg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
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17
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Abstract
PURPOSE OF REVIEW Recurrent glioblastoma (rGBM) has no standard treatment. Despite a better molecular knowledge, few therapies have brought changes in clinical practice so far. Here we will review the current data evaluating the re-radiation, re-resection, bevacizumab, and cytotoxic chemotherapy agents in this setting. We will also discuss the advances of immunotherapy and the possible benefit of this treatment for patients with rGBM. RECENT FINDINGS Next-generation sequencing is increasingly utilized in the clinical practice of neuro-oncologists, bringing gene mutations as targets for therapies. As in other solid tumors, immunotherapy has been also extensively studied in rGBM, with interesting results in phase I and II trials. The most promising therapies in the horizon are combinations including immune checkpoint inhibitors, virotherapy, vaccines, and monoclonal antibodies. Although re-radiation, re-resection, bevacizumab, and chemotherapy are still the most widely used therapies for treating rGBM, the clinical benefit from these treatments is still not well established. Preliminary results of studies with immune checkpoint inhibitors were disappointing, but virotherapy emerges as more promising immunotherapy in rGBM, especially in combination with other strategies. In addition to the gain in overall survival, the improvement in the quality of life of these patients is also expected.
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18
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Combs SE, Kessel KA, Hesse J, Straube C, Zimmer C, Schmidt-Graf F, Schlegel J, Gempt J, Meyer B. Moving Second Courses of Radiotherapy Forward: Early Re-Irradiation After Surgical Resection for Recurrent Gliomas Improves Efficacy With Excellent Tolerability. Neurosurgery 2019; 83:1241-1248. [PMID: 29462372 DOI: 10.1093/neuros/nyx629] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 12/27/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Generally, re-irradiation (Re-RT) is offered to patients with glioma recurrences with macroscopic lesions. Results are discussed controversially, and some centers postulate limited benefit of Re-RT. Re-RT is generally offered to tumors up to 4 cm in diameter. Re-resection is also discussed controversially; however, recent studies have shown significant benefit. OBJECTIVE To combine proactive re-resection and early Re-RT in patients with recurrent glioma. METHODS We included 108 patients treated between 2002 and 2016 for recurrent glioma. All patients underwent surgical resection for recurrence; Re-RT was applied with a median dose of 37.5 Gy (range 25 Gy-57Gy/equivalent dose in 2Gy fractions [EQD2]) with high-precision techniques. All patients were followed prospectively in an interdisciplinary follow-up program. RESULTS Median follow-up after Re-RT was 7 mo. Median survival after surgery and Re-RT was 12 mo (range 1-102 mo). Complete resection had a significant impact on the outcome (P = .03). The strongest predictors of outcome were MGMT-promotor methylation and Karnofsky Performance Score and time interval between primary and second RT. CONCLUSION Proactive resection of tumor recurrences combined with early Re-RT conveys into promising outcome in recurrent glioma. Complete resection and early Re-RT lead to improved survival. Thus, moving Re-RT to an earlier timepoint during the treatment of recurrent glioma, eg after complete macroscopic removal of the tumor, may be crucial for treatment optimization. Using advanced RT techniques, side effects are low. Currently, this concept is evaluated in the GLIOCAVE/NOA 17 trial.
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Affiliation(s)
- Stephanie E Combs
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany.,Institute of Innovative Radiotherapy ( i RT), Helmholtz Zentrum München, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (dktk), Partner Site Munich, Munich, Germany
| | - Kerstin A Kessel
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany.,Institute of Innovative Radiotherapy ( i RT), Helmholtz Zentrum München, Neuherberg, Germany
| | - Josefine Hesse
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
| | - Christoph Straube
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Technical University of Munich (TUM), Munich, Germany
| | | | - Jürgen Schlegel
- Department of Neuropathology, Technical University of Munich (TUM), Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Technical University of Munich (TUM), Ismaninger Straße 22, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich (TUM), Ismaninger Straße 22, Munich, Germany
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19
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Morris SAL, Zhu P, Rao M, Martir M, Zhu JJ, Hsu S, Ballester LY, Day AL, Tandon N, Kim DH, Shepard S, Blanco A, Esquenazi Y. Gamma Knife Stereotactic Radiosurgery in Combination with Bevacizumab for Recurrent Glioblastoma. World Neurosurg 2019; 127:e523-e533. [DOI: 10.1016/j.wneu.2019.03.193] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 01/17/2023]
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20
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Kim IH. Appraisal of re-irradiation for the recurrent glioblastoma in the era of MGMT promotor methylation. Radiat Oncol J 2019; 37:1-12. [PMID: 30947475 PMCID: PMC6453809 DOI: 10.3857/roj.2019.00171] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 03/21/2019] [Indexed: 12/23/2022] Open
Abstract
Despite recent innovation in treatment techniques and subsequently improved outcomes, the majority of glioblastoma (GBL) have relapses, especially in locoregional areas. Local re-irradiation (re-RT) has been established as a feasible option for recurrent GBL of all ages with safety, tolerability, and effectiveness both in survival and quality of life regardless of fractionation schedule. To keep adverse effects under acceptable range, cumulative dose limit in equivalent dose at 2 Gy fractions by the linear-quadratic model at α/β = 2 for normal brain tissue (EQD2) with narrow margin should be observed and single/hypofractionated re-RT should be undertaken very carefully to recurrent tumor with large volume or adjacent to the brainstem. Promising outcome of re-operation (re-Op) plus re-RT (re-Op/RT) need to be validated and result from re-RT with temozolomide/bevacizumab (TMZ/BV) or new strategy is expected. Development of new-concept prognostic scoring or risk group is required to select patients properly and make use of predictive biomarkers such as O(6)-methylguanine-DNA methyltransferase (MGMT) promotor methylation that influence outcomes of re-RT, re-Op/RT, or re-RT with TMZ/BV.
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Affiliation(s)
- Il Han Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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21
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Re-irradiation for recurrent glioblastoma (GBM): a systematic review and meta-analysis. J Neurooncol 2018; 142:79-90. [PMID: 30523605 DOI: 10.1007/s11060-018-03064-0] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 11/24/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE To determine the efficacy and toxicity of re-irradiation for patients with recurrent GBM. MATERIALS AND METHODS We searched various biomedical databases from 1998 to 2018, for eligible studies where patients were treated with re-irradiation for recurrent GBM. Outcomes of interest were 6 and 12-month overall survival (OS-6, OS-12), 6 and 12-month progression free survival (PFS-6, PFS-12) and serious (Grade 3 +) adverse events (AE). We used the random effects model to pool outcomes across studies and compared pre-defined subgroups using interaction test. Methodological quality of each study was assessed using the Newcastle-Ottawa scoring system. RESULTS We found 50 eligible non-comparative studies including 2095 patients. Of these, 42% were of good or fair quality. The pooled results were as follows: OS-6 rate 73% (95% confidence interval (CI) 69-77%), OS-12 rate 36% (95% CI 32-40%), PFS-6 rate 43% (95% CI 35-50%), PFS-12 rate 17% (95% CI 13-20%), and Grade 3 + AE rate 7% (95% CI 4-10%). Subgroup analysis showed that prospective studies reported higher toxicity rates, and studies which utilized brachytherapy to have a longer OS-12. Within the external beam radiotherapy group, there was no dose-response [above or below 36 Gy in 2 Gy equivalent doses (EQD2)]. However, a short fractionation regimen (≤ 5 fractions) seemed to provide superior PFS-6. CONCLUSION The available evidence, albeit mostly level III, suggests that re-irradiation provides encouraging disease control and survival rates. Toxicity was not uniformly reported, but seemed to be low from the included studies. Randomized controlled trials (RCT) are needed to establish the optimal management strategy for recurrent GBM.
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22
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Navarria P, Minniti G, Clerici E, Tomatis S, Pinzi V, Ciammella P, Galaverni M, Amelio D, Scartoni D, Scoccianti S, Krengli M, Masini L, Draghini L, Maranzano E, Borzillo V, Muto P, Ferrarese F, Fariselli L, Livi L, Pasqualetti F, Fiorentino A, Alongi F, di Monale MB, Magrini S, Scorsetti M. Re-irradiation for recurrent glioma: outcome evaluation, toxicity and prognostic factors assessment. A multicenter study of the Radiation Oncology Italian Association (AIRO). J Neurooncol 2018; 142:59-67. [PMID: 30515706 DOI: 10.1007/s11060-018-03059-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 11/21/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The prognosis of glioma is dismal, and almost all patients relapsed. At recurrence time, several treatment options are considered, but to date there is no a standard of care. The Neurooncology Study Group of the Italian Association of Radiation Oncology (AIRO) collected clinical data regarding a large series of recurrent glioma patients who underwent re-irradiation (re-RT) in Italy. METHODS Data regarding 300 recurrent glioma patients treated from May 2002 to November 2017, were analyzed. All patients underwent re-RT. Surgical resection, followed by re-RT with concomitant and adjuvant chemotherapy was performed. Clinical outcome was evaluated by neurological examination and brain MRI performed, 1 month after radiation therapy and then every 3 months. RESULTS Re-irradiation was performed at a median interval time (IT) of 16 months from the first RT. Surgical resection before re-RT was performed in 19% of patients, concomitant temozolomide (TMZ) in 16.3%, and maintenance chemotherapy in 29%. Total doses ranged from 9 Gy to 52.5 Gy, with a median biological effective dose of 43 Gy. The median, 1, 2 year OS were 9.7 months, 41% and 17.7%. Low grade glioma histology (p ≪ 0.01), IT > 12 months (p = 0.001), KPS > 70 (p = 0.004), younger age (p = 0.001), high total doses delivered (p = 0.04), and combined treatment performed (p = 0.0008) were recorded as conditioning survival. CONCLUSION our data underline re-RT as a safe and feasible treatment with limited rate of toxicity, and a combined ones as a better option for selected patients. The identification of a BED threshold able to obtain a greater benefit on OS, can help in designing future prospective studies.
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Affiliation(s)
- Pierina Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy.
| | | | - Elena Clerici
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Valentina Pinzi
- Radiotherapy Unit, Istituto Neurologico Fondazione "Carlo Besta", Milan, Italy
| | - Patrizia Ciammella
- Radiation Therapy Unit, Department of Oncology and Advanced Technology, Azienda Ospedaliera Arcispedale S Maria Nuova, Reggio Emilia, Italy
| | - Marco Galaverni
- Radiation Therapy Unit, Department of Oncology and Advanced Technology, Azienda Ospedaliera Arcispedale S Maria Nuova, Reggio Emilia, Italy
| | - Dante Amelio
- Proton Therapy Center, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Daniele Scartoni
- Proton Therapy Center, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Silvia Scoccianti
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Marco Krengli
- Radiotherapy Unit, Department of Translation Medicine, University of Piemonte Orientale, Novara, Italy
| | - Laura Masini
- Radiotherapy Unit, Department of Translation Medicine, University of Piemonte Orientale, Novara, Italy
| | - Lorena Draghini
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | | | - Valentina Borzillo
- UOC Radiation Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori -Fondazione "Giovanni Pascale", Naples, Italy
| | - Paolo Muto
- UOC Radiation Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori -Fondazione "Giovanni Pascale", Naples, Italy
| | - Fabio Ferrarese
- Radiation Therapy, Ospedale Ca' Foncello di Treviso, Treviso, Italy
| | - Laura Fariselli
- Radiotherapy Unit, Istituto Neurologico Fondazione "Carlo Besta", Milan, Italy
| | - Lorenzo Livi
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | | | - Alba Fiorentino
- Radiation Oncology, Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy
| | - Filippo Alongi
- Radiation Oncology, Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy
| | | | - Stefano Magrini
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Prelaj A, Rebuzzi SE, Grassi M, Giròn Berrìos JR, Pecorari S, Fusto C, Ferrara C, Salvati M, Stati V, Tomao S, Bianco V. Multimodal treatment for local recurrent malignant gliomas: Resurgery and/or reirradiation followed by chemotherapy. Mol Clin Oncol 2018; 10:49-57. [PMID: 30655977 PMCID: PMC6313879 DOI: 10.3892/mco.2018.1745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/05/2018] [Indexed: 01/26/2023] Open
Abstract
The therapeutic management of recurrent malignant gliomas (MGs) is not determined. Therefore, the efficacy of a multimodal approach and a combination systemic therapy was investigated. A retrospective analysis of 26 MGs patients at first relapse treated with multimodal therapy (chemotherapy plus surgery and/or reirradiation) or chemotherapy alone was performed. Second-line chemotherapy consisted of fotemustine (FTM) in combination with bevacizumab (BEV) (cFTM/BEV) or followed by third-line BEV (sFTM/BEV). Subgroup analyses were performed. Multimodal therapy provided a higher overall response rate (ORR) (73 vs. 47%), disease control rate (DCR) (82 vs. 67%), median progression-free survival (mPFS) (11 vs. 7 months; P=0.08) and median overall survival (mOS) (13 vs. 8 months; P=0.04) compared with chemotherapy. Concomitant FTM/BEV resulted in higher ORR (84 vs. 36%), DCR (92 vs. 57%), mPFS (10 vs. 5 months; P=0.22) and mOS (11 vs. 5.2 months; P=0.15) compared with sFTM/BEV. Methylated patients did not experience additional survival benefits with multimodality treatment but had higher mPFS (10 vs 7.1 months; P=0.33) and mOS (11 vs. 8 months; P=0.33) with cFTM/BEV. Unmethylated patients experienced the greatest survival benefit with the multimodal approach (mPFS: 10 vs. 5 months; mOS 11 vs 6 months; both P=0.02) and cFTM/BEV (mPFS: 5 vs. 2 months; mOS 6 vs. 3.2 months; both P=0.01). In conclusion, in recurrent MGs, multimodal therapy and cFTM/BEV provide survival and response benefits. Methylated patients benefit from a cFTM/BEV but not from a multimodal approach. Notably, unmethylated patients had the highest survival benefit with the two strategies.
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Affiliation(s)
- Arsela Prelaj
- Department of Medical Oncology Unit A, Policlinico Umberto I, 'Sapienza' University of Rome, I-00161 Rome, Italy
| | - Sara Elena Rebuzzi
- Department of Medical Oncology, Ospedale Policlinico San Martino IST, I-16132 Genoa, Italy
| | - Massimiliano Grassi
- Department of Medical Oncology, Ospedale Policlinico San Martino IST, I-16132 Genoa, Italy
| | - Julio Rodrigo Giròn Berrìos
- Department of Medical Oncology Unit A, Policlinico Umberto I, 'Sapienza' University of Rome, I-00161 Rome, Italy
| | - Silvia Pecorari
- Department of Medical Oncology Unit A, Policlinico Umberto I, 'Sapienza' University of Rome, I-00161 Rome, Italy
| | - Carmela Fusto
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, 'Sapienza' University of Rome, Policlinico Umberto I, I-00161 Rome, Italy
| | - Carla Ferrara
- Department of Public Health and Infectious Diseases, 'Sapienza' University of Rome, I-00185 Rome, Italy
| | - Maurizio Salvati
- Department of Neurosurgery, IRCCS Neuromed, I-86077 Pozzilli, Italy
| | - Valeria Stati
- Department of Medico-Surgical Sciences and Biotechnologies, 'Sapienza' University of Rome, I-00185 Rome, Italy
| | - Silverio Tomao
- Department of Medical Oncology Unit A, Policlinico Umberto I, 'Sapienza' University of Rome, I-00161 Rome, Italy.,Department of Radiological Sciences, Oncology and Pathology, 'Sapienza' University of Rome, I-04100 Latina, Italy
| | - Vincenzo Bianco
- Department of Medical Oncology Unit A, Policlinico Umberto I, 'Sapienza' University of Rome, I-00161 Rome, Italy
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Cheon YJ, Jung TY, Jung S, Kim IY, Moon KS, Lim SH. Efficacy of Gamma Knife Radiosurgery for Recurrent High-Grade Gliomas with Limited Tumor Volume. J Korean Neurosurg Soc 2018; 61:516-524. [PMID: 29991111 PMCID: PMC6046572 DOI: 10.3340/jkns.2017.0259] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/01/2018] [Indexed: 11/27/2022] Open
Abstract
Objective This study aims to determine whether gamma knife radiosurgery (GKR) improves survival in patients with recurrent highgrade gliomas. Methods Twenty nine patients with recurrent high-grade glioma underwent 38 GKR. The male-to-female ratio was 10 : 19, and the median age was 53.8 years (range, 20-75). GKR was performed in 11 cases of recurrent anaplastic oligodendrogliomas, five anaplastic astrocytomas, and 22 glioblastomas. The median prescription dose was 16 Gy (range, 10-24), and the median target volume was 7.0 mL (range, 1.1-15.7). Of the 29 patients, 13 (44.8%) received concurrent chemotherapy. We retrospectively analyzed the progression-free survival (PFS) and overall survival (OS) after GKR depending on the Eastern Cooperative Oncology Group (ECOG) performance status (PS), pathology, concurrent chemotherapy, radiation dose, and target tumor volume. Results Starting from when the patients underwent GKR, the median PFS and OS were 5.0 months (range, 1.1-28.1) and 13.0 months (range, 1.1-75.1), respectively. On univariate analysis, the median PFS was significantly long in patients with anaplastic oligodendroglioma, ECOG PS 1, and target tumor volume less than 10 mL (p<0.05). Meanwhile, on multivariate analysis, patients with ECOG PS 1 and target tumor volume less than 10 mL showed improved PFS (p=0.043 and p=0.007, respectively). The median OS was significantly increased in patients with ECOG PS 1 and tumor volume less than 10 mL on univariate and multivariate analyses (p<0.05). Conclusion GKR could be an additional treatment option in recurrent high-grade glioma, particularly in patients with good PS and limited tumor volume.
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Affiliation(s)
- Young-Jun Cheon
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, Korea
| | - Tae-Young Jung
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, Korea
| | - Shin Jung
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, Korea
| | - In-Young Kim
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, Korea
| | - Kyung-Sub Moon
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, Korea
| | - Sa-Hoe Lim
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, Korea
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Re-irradiation for malignant glioma: Toward patient selection and defining treatment parameters for salvage. Adv Radiat Oncol 2018; 3:582-590. [PMID: 30370358 PMCID: PMC6200913 DOI: 10.1016/j.adro.2018.06.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/25/2018] [Accepted: 06/28/2018] [Indexed: 12/23/2022] Open
Abstract
Purpose Reirradiation for recurrent glioma remains controversial without knowledge of optimal patient selection, dose, fractionation, and normal tissue tolerances. We retrospectively evaluated outcomes and toxicity after conventionally fractionated reirradiation for recurrent high-grade glioma, along with the impact of concurrent chemotherapy. Methods and materials We conducted a retrospective review of patients reirradiated for high-grade glioma recurrence between 2007 and 2016 (including patients with initial low-grade glioma). Outcome metrics included overall survival (OS), prognostic factors for survival, and treatment-related toxicity. Results Patients (n = 118; median age 47 years; median Karnofsky performance status score: 80) were re-treated at a median of 28 months (range, 5-214 months) after initial radiation therapy. The median reirradiation dose was 41.4 Gy (range, 12.6-54.0 Gy) to a median lesion volume of 202 cm3 (range, 20-901 cm3). The median cumulative (initial radiation and reirradiation combined) potential maximum brainstem dose was 76.9 Gy (range, 5.0-108.3 Gy) and optic apparatus dose was 56.0 Gy (range, 4.5-90.9 Gy). Of the patients, 56% received concurrent temozolomide, 14%, bevacizumab, and 11%, temozolomide plus bevacizumab; 19% had no chemotherapy. The planned reirradiation was completed by 90% of patients. Median OS from the completion of reirradiation was 9.6 months (95% confidence interval [CI], 7.5-11.7 months) for all patients and 14.0, 11.5, and 6.7 months for patients with initial grade 2, 3, and 4 glioma, respectively. On multivariate analysis, better OS was observed with a >24-month interval between radiation treatments (hazard ratio [HR]: 0.3; 95% CI, 0.2-0.5; P < .001), reirradiation dose >41.4 Gy (HR: 0.6; 95% CI, 0.4-0.9; P = .03), and gross total resection before reirradiation (HR: 0.6, 95% CI, 0.3-0.9; P = .02). Radiation necrosis and grade ≥3 late neurotoxicity were both minimal (<5%). No symptomatic persistent brainstem or optic nerve/chiasm injury was identified. Conclusions Salvage reirradiation, even at doses >41.4 Gy in conventional fractionation, along with chemotherapy, was safe and well tolerated with meaningful survival duration. These data provide information that may be useful in implementing safe reirradiation treatments for appropriately selected patients and guiding future studies to define optimal reirradiation doses, maximal safe doses to critical structures, and the role of systemic therapy.
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Chun SJ, Park SH, Park CK, Kim JW, Kim TM, Choi SH, Lee ST, Kim IH. Survival gain with re-Op/RT for recurred high-grade gliomas depends upon risk groups. Radiother Oncol 2018; 128:254-259. [PMID: 29937212 DOI: 10.1016/j.radonc.2018.05.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/19/2018] [Accepted: 05/22/2018] [Indexed: 12/23/2022]
Abstract
INTRODUCTION A majority of high-grade gliomas relapse despite combined surgery, radiotherapy and chemotherapy. There is no consensus on standard treatment for recurrent high-grade gliomas, or defined efficacy of adjuvant re-RT after re-Op. This retrospective study evaluated the benefit and safety of re-RT after re-Op (re-Op/RT). MATERIALS AND METHODS A total of 84 patients with recurrent high-grade gliomas who underwent reoperation from 2009 to 2015 were analyzed. All patients received neurosurgical intervention and adjuvant radiotherapy previously before recurrence. At recurrence and after reoperation, treatment options were discussed in multidisciplinary clinic or brain tumor joint conference. For re-RT, cumulative EQD2 (equivalent dose in 2 Gy fractions at α/β = 2) was below 106.9 Gy. RESULT Median progression free survival (PFS) was 6.5 months; 3.5 months with re-Op, 9.0 months with re-Op/RT (p = 0.025). Age <50, time interval to recur ≥12 months, WHO pathologic grade III, methylated MGMT promotor, and re-RT were factors enhancing PFS in the multivariate analysis. Median overall survival (OS) was 18.3 months: 12.7 months with re-Op, and 28.1 months with re-Op/RT (p = 0.066). Three risk factors (age >50, WHO grade IV, and unmethylated promoter of MGMT) were significantly associated with poor OS in multivariate analysis. Benefit of re-RT in both OS and PFS was established in patients carrying 2 or more risk factors. During re-RT, 4 patients (8%) had grade 2 or higher toxicity, and 3 patients (6%) did not complete re-RT. No radionecrosis was observed. CONCLUSION Re-RT after re-Op was tolerable with a cumulative median EQD2 of 99.3 Gy and resulted in clear benefit in PFS and marginal gain in OS. Survival gain with re-Op/RT was more prominent in patients with two or more risk factors (age ≥50, WHO pathologic grade IV, unmethylated MGMT promoter), and needs to be validated.
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Affiliation(s)
- Seok-Joo Chun
- Department of Radiation Oncology, Seoul National University College of Medicine, South Korea
| | - Sung-Hye Park
- Department of Pathology, Seoul National University College of Medicine, South Korea
| | - Chul-Kee Park
- Department of Neurosurgery, Seoul National University College of Medicine, South Korea; Cancer Research Institute, Seoul National University, South Korea
| | - Jin Wook Kim
- Department of Neurosurgery, Seoul National University College of Medicine, South Korea
| | - Tae Min Kim
- Department of Internal Medicine, Seoul National University College of Medicine, South Korea
| | - Seung Hong Choi
- Department of Radiology, Seoul National University College of Medicine, South Korea
| | - Soon-Tae Lee
- Department of Neurology, Seoul National University College of Medicine, South Korea
| | - Il Han Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, South Korea; Cancer Research Institute, Seoul National University, South Korea.
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Ganau M, Foroni RI, Gerosa M, Zivelonghi E, Longhi M, Nicolato A. Radiosurgical Options in Neuro-oncology: A Review on Current Tenets and Future Opportunities. Part I: Therapeutic Strategies. TUMORI JOURNAL 2018. [DOI: 10.1177/1636.17912] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Mario Ganau
- Department of Neurosciences, University Hospital, Azienda Ospedaliera Universitaria Integrata, Verona
- Department of Biomedical Engineering, University of Cagliari, Cagliari
| | - Roberto Israel Foroni
- Department of Pathology and Diagnosis, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Massimo Gerosa
- Department of Neurosciences, University Hospital, Azienda Ospedaliera Universitaria Integrata, Verona
| | - Emanuele Zivelonghi
- Department of Pathology and Diagnosis, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Michele Longhi
- Department of Neurosciences, University Hospital, Azienda Ospedaliera Universitaria Integrata, Verona
| | - Antonio Nicolato
- Department of Neurosciences, University Hospital, Azienda Ospedaliera Universitaria Integrata, Verona
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Re-irradiation as salvage treatment in recurrent glioblastoma: A comprehensive literature review to provide practical answers to frequently asked questions. Crit Rev Oncol Hematol 2018; 126:80-91. [PMID: 29759570 DOI: 10.1016/j.critrevonc.2018.03.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 02/11/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023] Open
Abstract
The primary aim of this review is to provide practical recommendations in terms of fractionation, dose, constraints and selection criteria to be used in the daily clinical routine. Based on the analysis of the literature reviewed, in order to keep the risk of severe side effects ≤3,5%, patients should be stratified according to the target volume. Thus, patients should be treated with different fractionation and total EQD2 (<12.5 ml: EQD2 < 65 Gy with radiosurgery; >12.5 ml and <35 ml: EQD2 < 50 Gy with hypofractionated stereotactic radiotherapy; >35 ml and <50 ml: EQD2 < 36 Gy with conventionally fractionated radiotherapy). Concurrent approaches with temozolomide or bevacizumab do not seem to improve the outcomes of reirradiation and may lead to a higher risk of toxicity but these findings need to be confirmed in prospective series.
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Zhao YH, Wang ZF, Cao CJ, Weng H, Xu CS, Li K, Li JL, Lan J, Zeng XT, Li ZQ. The Clinical Significance of O 6-Methylguanine-DNA Methyltransferase Promoter Methylation Status in Adult Patients With Glioblastoma: A Meta-analysis. Front Neurol 2018; 9:127. [PMID: 29619003 PMCID: PMC5873285 DOI: 10.3389/fneur.2018.00127] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 02/20/2018] [Indexed: 12/31/2022] Open
Abstract
Background and objective Promoter status of O6-methylguanine-DNA methyltransferase (MGMT) has been widely established as a clinically relevant factor in glioblastoma (GBM) patients. However, in addition to varied therapy schedule, the prognosis of GBM patients is also affected by variations of age, race, primary or recurrent tumor. This study comprehensively investigated the association between MGMT promoter status and prognosis in overall GBM patients and in different GBM subtype including new diagnosed patients, recurrent patients and elderly patients. Methods A comprehensive search was performed using PubMed, EMBASE, Cochrane databases to identify literatures (published from January 1, 2005 to April 1, 2017) that evaluated the associations between MGMT promoter methylation and prognosis of GBM patients. Results Totally, 66 studies including 7,886 patients met the inclusion criteria. Overall GBM patients with a methylated status of MGMT receiving temozolomide (TMZ)-containing treatment had better overall survival (OS) and progression-free survival (PFS) [OS: hazard ratio (HR) = 0.46, 95% confidence interval (CI): 0.41–0.52, p < 0.001, Bon = 0.017; PFS: HR = 0.48, 95% CI 0.40–0.57, p < 0.001, Bon = 0.014], but no significant advantage on OS or PFS in GBM patients with TMZ-free treatment was observed (OS: HR = 0.97, 95% CI 0.91–1.03, p = 0.08, Bon = 1; PFS: HR = 0.76, 95% CI 0.57–1.02, p = 0.068, Bon = 0.748). These different impacts of MGMT status on OS were similar in newly diagnosed GBM patients, elderly GBM patients and recurrent GBM. Among patients receiving TMZ-free treatment, survival benefit in Asian patients was not observed anymore after Bonferroni correction (Asian OS: HR = 0.78, 95% CI 0.64–0.95, p = 0.02, Bon = 0.24, I2 = 0%; PFS: HR = 0.69, 95% CI 0.50–0.94, p = 0.02, Bon = 0.24). No benefit was observed in Caucasian receiving TMZ-free therapy regardless of Bonferroni adjustment. Conclusion The meta-analysis highlights the universal predictive value of MGMT methylation in newly diagnosed GBM patients, elderly GBM patients and recurrent GBM patients. For elderly methylated GBM patients, TMZ alone therapy might be a more suitable option than radiotherapy alone therapy. Future clinical trials should be designed in order to optimize therapeutics in different GBM subpopulation.
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Affiliation(s)
- Yu-Hang Zhao
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Ze-Fen Wang
- Department of Physiology, School of Basic Medical Sciences, Wuhan University, Wuhan, China
| | - Chang-Jun Cao
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Hong Weng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Cheng-Shi Xu
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Kai Li
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Jie-Li Li
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Jing Lan
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Xian-Tao Zeng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Zhi-Qiang Li
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Wuhan, China
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Abstract
There is no standard treatment available for recurrent high-grade gliomas. This monoinstitutional retrospective analysis evaluates the differences in overall survival and progression-free survival in patients according to the timing of re-irradiation. Patients suffering from a glioblastoma who received re-irradiation for recurrence were evaluated retrospectively. The median overall survival (OS) and the median progression-free survival were compared with different treatment options and within various time periods. From January 2007 until March 2015, 41 patients suffering from recurrent high-grade gliomas received re-irradiation [median dose of 30.6 Gy (range 20-40 Gy) in median 4 Gy fractions (range 1.8-5 Gy)] in our institution after initial postoperative irradiation or combined radiochemotherapy. The OS in this population was 34 months, and the OS after recurrence (OS-R) was 13 months. After diagnosis of recurrence, patients underwent additional surgical resection after a median of 1.2 months, received a second-line systemic therapy after 2.2 months with or without re-irradiation after 5.7 months. Growth of the tumour was assessed 4.3 months after the start of re-irradiation. The OS after the second surgical resection was 12.2 months, 11.7 months after the start of the second-line systemic therapy, and 6.7 months after the start of re-irradiation. The OS-R was not significantly correlated with the start of re-irradiation after a diagnosis of recurrence or the time period after the previous surgery. At this institution, re-irradiation was performed later compared to other treatment options. However, select patients could benefit from irradiation at an earlier time point. A precise time point should still be evaluated on an individual basis due to the patient's diverse conditions.
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Lee J, Ahn SS, Chang JH, Suh CO. Hypofractionated Re-irradiation after Maximal Surgical Resection for Recurrent Glioblastoma: Therapeutic Adequacy and Its Prognosticators of Survival. Yonsei Med J 2018; 59:194-201. [PMID: 29436186 PMCID: PMC5823820 DOI: 10.3349/ymj.2018.59.2.194] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 11/20/2017] [Accepted: 12/15/2017] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To evaluate the adequacy of retreatment, including hypofractionated re-irradiation (HFReRT), after surgery for recurrent glioblastoma (GBM) and related prognosticators of outcomes. MATERIALS AND METHODS From 2011 to 2014, 25 consecutive patients with recurrent (n=17) or secondary (n=7) disease underwent maximal surgery and subsequent HFReRT after meeting the following conditions: 1) confirmation of recurrent or secondary GBM after salvage surgery; 2) Karnofsky performance score (KPS) ≥60; and 3) interval of ≥12 months between initial radiotherapy and HFReRT. HFReRT was delivered using a simultaneous integrated boost technique, with total dose of 45 Gy in 15 fractions to the gross tumor volume (GTV) and 37.5 Gy in 15 fractions to the clinical target volume. RESULTS During a median follow-up of 13 months, the median progression-free and overall survival (OS) were 13 and 16 months, respectively. A better KPS (p=0.026), no involvement of the eloquent area at recurrence (p=0.030), and a smaller GTV (p=0.005) were associated with better OS. Additionally, OS differed significantly between risk groups stratified by the National Institutes of Health Recurrent GBM Scale (low-risk vs. high-risk, p=0.025). Radiologically suspected radiation necrosis (RN) was observed in 16 patients (64%) at a median of 9 months after HFReRT, and 8 patients developed grade 3 RN requiring hospitalization. CONCLUSION HFReRT after maximal surgery prolonged survival in selected patients with recurrent GBM, especially those with small-sized recurrences in non-eloquent areas and good performance.
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Affiliation(s)
- Jeongshim Lee
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
- Department of Radiation Oncology, Inha University Hospital, Incheon, Korea
| | - Sung Soo Ahn
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.
| | - Chang Ok Suh
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea.
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Ho A, Jena R. Re-irradiation in the Brain: Primary Gliomas. Clin Oncol (R Coll Radiol) 2018; 30:124-136. [DOI: 10.1016/j.clon.2017.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/02/2017] [Accepted: 11/06/2017] [Indexed: 02/07/2023]
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Zygogianni A, Protopapa M, Kougioumtzopoulou A, Simopoulou F, Nikoloudi S, Kouloulias V. From imaging to biology of glioblastoma: new clinical oncology perspectives to the problem of local recurrence. Clin Transl Oncol 2018; 20:989-1003. [PMID: 29335830 DOI: 10.1007/s12094-018-1831-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 01/04/2018] [Indexed: 12/13/2022]
Abstract
GBM is one of the most common and aggressive brain tumors. Surgery and adjuvant chemoradiation have succeeded in providing a survival benefit. Although most patients will eventually experience local recurrence, the means to fight recurrence are limited and prognosis remains poor. In a disease where local control remains the major challenge, few trials have addressed the efficacy of local treatments, either surgery or radiation therapy. The present article reviews recent advances in the biology, imaging and biomarker science of GBM as well as the current treatment status of GBM, providing new perspectives to the problem of local recurrence.
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Affiliation(s)
- A Zygogianni
- Radiotherapy Unit, 1st Department of Radiology, Medical School, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - M Protopapa
- Radiotherapy Unit, 1st Department of Radiology, Medical School, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - A Kougioumtzopoulou
- Radiotherapy Unit, 2nd Department of Radiology, Medical School, ATTIKON University Hospital, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Greece
| | - F Simopoulou
- Radiotherapy Unit, 1st Department of Radiology, Medical School, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - S Nikoloudi
- Radiotherapy Unit, 1st Department of Radiology, Medical School, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - V Kouloulias
- Radiotherapy Unit, 2nd Department of Radiology, Medical School, ATTIKON University Hospital, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Greece.
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Krauze AV, Attia A, Braunstein S, Chan M, Combs SE, Fietkau R, Fiveash J, Flickinger J, Grosu A, Howard S, Nieder C, Niyazi M, Rowe L, Smart DD, Tsien C, Camphausen K. Expert consensus on re-irradiation for recurrent glioma. Radiat Oncol 2017; 12:194. [PMID: 29195507 PMCID: PMC5709844 DOI: 10.1186/s13014-017-0928-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 11/17/2017] [Indexed: 02/06/2023] Open
Abstract
Purpose To investigate radiation oncologists’ opinions on important considerations to offering re-irradiation (re-RT) as a treatment option for recurrent glioma. Materials and methods A survey was conducted with 13 radiation oncologists involved in the care of central nervous system tumor patients. The survey was comprised of 49 questions divided into 2 domains: a demographic section (10 questions) and a case section (5 re-RT cases with 5 to 6 questions representing one or several re-RT treatment dilemmas as may be encountered in the clinic). Respondents were asked to rate the relevance of various factors to offering re-RT, respond to the cases with a decision to offer re-RT vs. not, volume to be treated, margins to be employed, dose/fractionation suggested and any additional comments with respect to rationale in each scenario. Results Sixty nine percent of responders have been practicing for greater than 10 years and 61% have re-RT 20 to 100 patients to date, with 54% seeing 2–5 re-RT cases per month and retreating 1–2 patients per month. Recurrent tumor volume, time since previous radiation therapy, previously administered dose to organs at risk and patient performance status were rated by the majority of responders (85%, 92%, 77%, and 69% respectively) as extremely relevant or very relevant to offering re-RT as an option. Conclusion The experts’ practice of re-RT is still heterogeneous, reflecting the paucity of high-quality prospective data available for decision-making. Nevertheless, practicing radiation oncologists can support own decisions by referring to the cases found suitable for re-RT in this survey. Electronic supplementary material The online version of this article (10.1186/s13014-017-0928-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andra V Krauze
- Radiation Oncology Branch, National Cancer Institute NIH, Bethesda, MD, USA.
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Steve Braunstein
- Department of Radiation Oncology, University of California, San Francisco, USA
| | - Michael Chan
- Department of Radiation Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Size, Munich, Germany
| | | | - John Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Anca Grosu
- Department of Radiation Oncology, University of Freiburg, Freiburg, Germany
| | - Steven Howard
- Department of Human Oncology, University of Wisconsin, Madison, WI, USA
| | - Carsten Nieder
- Department of Oncology and Palliative Medicine, Hospital Trust, 8092, Bodø, Nordland, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, 9038, Tromsø, Norway
| | - Maximilian Niyazi
- Department of Radiation Oncology, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lindsay Rowe
- Radiation Oncology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Dee Dee Smart
- Radiation Oncology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Christina Tsien
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - Kevin Camphausen
- Radiation Oncology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
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Krauze AV, Peters C, Cheng J, Ning H, Mackey M, Rowe L, Cooley-Zgela T, Smart DD, Camphausen K. Re-irradiation for recurrent glioma- the NCI experience in tumor control, OAR toxicity and proposal of a novel prognostic scoring system. Radiat Oncol 2017; 12:191. [PMID: 29187219 PMCID: PMC5707810 DOI: 10.1186/s13014-017-0930-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 11/17/2017] [Indexed: 12/25/2022] Open
Abstract
Purpose/objectives Despite mounting evidence for the use of re-irradiation (re-RT) in recurrent high grade glioma, optimal patient selection criteria for re-RT remain unknown. We present a novel scoring system based on radiobiology principles including target independent factors, the likelihood of target control, and the anticipated organ at risk (OAR) toxicity to allow for proper patient selection in the setting of recurrent glioma. Materials/methods Thirty one patients with recurrent glioma who received re-RT (2008–2016) at NCI – NIH were included in the analysis. A novel scoring system for overall survival (OS) and progression free survival (PFS) was designed to include:1) target independent factors (age, KPS (Karnofsky Performance Status), histology, presence of symptoms), 2) target control, and 3) OAR toxicity risk. Normal tissue complication probability (NTCP) calculations were performed using the Lyman model. Kaplan-Meier analysis was performed for overall survival (OS) and progression free survival (PFS) for comparison amongst variables. Results No patient, including those who received dose to OAR above the published tolerance dose, experienced any treatment related grade 3–5 toxicity with a median PFS and OS from re-RT of 4 months (0.5–103) and 6 months (0.7–103) respectively. Based on cumulative maximum doses the average NTCP was 25% (0–99%) for the chiasm, 21% (0–99%) for the right optic nerve, 6% (0–92%) for the left optic nerve, and 59% (0–100%) for the brainstem. The independent factor and target control scores were each statistically significant for OS and the combination of independent factors plus target control was also significant for both OS (p = 0.02) and PFS (p = 0.006). The anticipated toxicity risk score was not statistically significant. Conclusion Our scoring system may represent a novel approach to patient selection for re-RT in recurrent high grade glioma. Further validation in larger patient cohorts including compilation of doses to tumor and OAR may help refine this further for inclusion into clinical trials and general practice. Electronic supplementary material The online version of this article (10.1186/s13014-017-0930-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andra Valentina Krauze
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, 9000 Rockville Pike, Building 10, CRC, Bethesda, MD, 20892, USA.
| | - Cord Peters
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, 9000 Rockville Pike, Building 10, CRC, Bethesda, MD, 20892, USA
| | - Jason Cheng
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, 9000 Rockville Pike, Building 10, CRC, Bethesda, MD, 20892, USA
| | - Holly Ning
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, 9000 Rockville Pike, Building 10, CRC, Bethesda, MD, 20892, USA
| | - Megan Mackey
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, 9000 Rockville Pike, Building 10, CRC, Bethesda, MD, 20892, USA
| | - Lindsay Rowe
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, 9000 Rockville Pike, Building 10, CRC, Bethesda, MD, 20892, USA
| | - Theresa Cooley-Zgela
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, 9000 Rockville Pike, Building 10, CRC, Bethesda, MD, 20892, USA
| | - Dee Dee Smart
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, 9000 Rockville Pike, Building 10, CRC, Bethesda, MD, 20892, USA
| | - Kevin Camphausen
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, 9000 Rockville Pike, Building 10, CRC, Bethesda, MD, 20892, USA
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Arvold ND, Shi DD, Aizer AA, Norden AD, Reardon DA, Lee EQ, Nayak L, Dunn IF, Golby AJ, Johnson MD, Claus EB, Chiocca EA, Ligon KL, Wen PY, Alexander BM. Salvage re-irradiation for recurrent high-grade glioma and comparison to bevacizumab alone. J Neurooncol 2017; 135:581-591. [PMID: 28975467 DOI: 10.1007/s11060-017-2611-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 08/20/2017] [Indexed: 11/27/2022]
Abstract
While salvage re-irradiation is often used for recurrent high-grade glioma (HGG), there have been few comparisons between various re-radiation dose/fractionation schedules or with bevacizumab alone. We analyzed patients with recurrent HGG who received re-irradiation at Dana-Farber Cancer Institute and Brigham and Women's Hospital from 2010 to 2014 (n = 67), as well as those who received bevacizumab alone (n = 177). Cox proportional hazards modeling was used to examine factors associated with overall survival (OS). Propensity score modeling was used to compare survival after re-irradiation vs. bevacizumab alone. Median time from initial diagnosis to re-irradiation was 31.4 months. The most common re-irradiation dose/fractionations used were 6 Gy × 5 (36%), 3.5 Gy × 10 (21%), 2.67 Gy × 15 (15%), and 18-20 Gy × 1 (15%). No early or late toxicities >grade 2 were observed. Median PFS and OS after re-irradiation were 4.8 and 10.7 months, respectively. Number of progressions prior to re-irradiation (adjusted hazard ratio [AHR] 1.6; 95% CI, 1.1-2.3; p = .007), and recurrence in a new brain location (vs. local-only; AHR 7.4; 95% CI, 2.4-23.1; p < .001) were associated with OS; dose/fractionation was not. Compared with bevacizumab alone, re-irradiated patients had a non-significant increase in OS (HR 0.80; 95% CI, 0.53-1.23; P = .31). Among patients with a local-only recurrence, there was a trend towards longer median OS after re-irradiation compared to bevacizumab alone (12.4 vs. 8.0 months; p = .12). Survival after re-irradiation for recurrent HGG appears independent of dose/fractionation and compares favorably with bevacizumab alone.
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Affiliation(s)
- Nils D Arvold
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, and Whiteside Institute for Clinical Research, University of Minnesota Duluth, Duluth, MN, USA
| | | | - Ayal A Aizer
- Harvard Medical School, Boston, MA, USA
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrew D Norden
- Harvard Medical School, Boston, MA, USA
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - David A Reardon
- Harvard Medical School, Boston, MA, USA
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Eudocia Q Lee
- Harvard Medical School, Boston, MA, USA
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Lakshmi Nayak
- Harvard Medical School, Boston, MA, USA
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ian F Dunn
- Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Alexandra J Golby
- Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Mark D Johnson
- Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Elizabeth B Claus
- Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham & Women's Hospital, Boston, MA, USA
- School of Public Health, Yale University, New Haven, CT, USA
| | - E Antonio Chiocca
- Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Keith L Ligon
- Harvard Medical School, Boston, MA, USA
- Department of Pathology, Dana-Farber Cancer Institute, Brigham & Women's Hospital, Boston, MA, USA
| | - Patrick Y Wen
- Harvard Medical School, Boston, MA, USA
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Brian M Alexander
- Harvard Medical School, Boston, MA, USA.
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.
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Fetcko K, Lukas RV, Watson GA, Zhang L, Dey M. Survival and complications of stereotactic radiosurgery: A systematic review of stereotactic radiosurgery for newly diagnosed and recurrent high-grade gliomas. Medicine (Baltimore) 2017; 96:e8293. [PMID: 29068998 PMCID: PMC5671831 DOI: 10.1097/md.0000000000008293] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 09/13/2017] [Accepted: 09/16/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Utilization of stereotactic radiosurgery (SRS) for treatment of high-grade gliomas (HGGs) has been slowly increasing with variable reported success rates. OBJECTIVE Systematic review of the available data to evaluate the efficacy of SRS as a treatment for HGG with regards to median overall survival (OS) and progression-free survival (PFS), in addition to ascertaining the rate of radiation necrosis and other SRS-related major neurological complications. METHODS Literature searches were performed for publications from 1992 to 2016. The pooled estimates of median PFS and median OS were calculated as a weighted estimate of population medians. Meta-analyses of published rates of radiation necrosis and other major neurological complications were also performed. RESULTS Twenty-nine studies reported the use of SRS for recurrent HGG, and 16 studies reported the use of SRS for newly diagnosed HGG. For recurrent HGG, the pooled estimates of median PFS and median OS were 5.42 months (3-16 months) and 20.19 months (9-65 months), respectively; the pooled radiation necrosis rate was 5.9% (0-44%); and the pooled estimates of major neurological complications rate was 3.3% (0-23%). For newly diagnosed HGG, the pooled estimates of median PFS and median OS were 7.89 months (5.5-11 months) and 16.87 months (9.5-33 months) respectively; the pooled radiation necrosis rate was 6.5% (0-33%); and the pooled estimates of other major neurological complications rate was 1.5% (0-25%). CONCLUSION Our results suggest that SRS holds promise as a relatively safe treatment option for HGG. In terms of efficacy at this time, there are inadequate data to support routine utilization of SRS as the standard of care for newly diagnosed or recurrent HGG. Further studies should be pursued to define more clearly the therapeutic role of SRS.
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Affiliation(s)
- Kaleigh Fetcko
- Department of Neurosurgery, Indiana University, Indianapolis, IN
| | - Rimas V. Lukas
- Department of Neurology, Northwestern University, Chicago, IL
| | - Gordon A. Watson
- Department of Radiation Oncology, Simon Cancer Center, Indiana University, Indianapolis, IN
| | - Lingjiao Zhang
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philidelphia, PA
| | - Mahua Dey
- Department of Neurosurgery, Indiana University, Indianapolis, IN
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Re-irradiation after gross total resection of recurrent glioblastoma : Spatial pattern of recurrence and a review of the literature as a basis for target volume definition. Strahlenther Onkol 2017; 193:897-909. [PMID: 28616821 DOI: 10.1007/s00066-017-1161-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 05/23/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Currently, patients with gross total resection (GTR) of recurrent glioblastoma (rGBM) undergo adjuvant chemotherapy or are followed up until progression. Re-irradiation, as one of the most effective treatments in macroscopic rGBM, is withheld in this situation, as uncertainties about the pattern of re-recurrence, the target volume, and also the efficacy of early re-irradiation after GTR exist. METHODS Imaging and clinical data from 26 consecutive patients with GTR of rGBM were analyzed. The spatial pattern of recurrences was analyzed according to the RANO-HGG criteria ("response assessment in neuro-oncology criteria for high-grade gliomas"). Progression-free (PFS) and overall survival (OS) were analyzed by the Kaplan-Meier method. Furthermore, a systematic review was performed in PubMed. RESULTS All but 4 patients underwent adjuvant chemotherapy after GTR. Progression was diagnosed in 20 of 26 patients and 70% of recurrent tumors occurred adjacent to the resection cavity. The median extension beyond the edge of the resection cavity was 20 mm. Median PFS was 6 months; OS was 12.8 months. We propose a target volume containing the resection cavity and every contrast enhancing lesion as the gross tumor volume (GTV), a spherical margin of 5-10 mm to generate the clinical target volume (CTV), and a margin of 1-3 mm to generate the planning target volume (PTV). Re-irradiation of this volume is deemed to be safe and likely to prolong PFS. CONCLUSION Re-irradiation is worth considering also after GTR, as the volumes that need to be treated are limited and re-irradiation has already proven to be a safe treatment option in general. The strategy of early re-irradiation is currently being tested within the GlioCave/NOA 17/Aro 2016/03 trial.
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The evolving role for re-irradiation in the management of recurrent grade 4 glioma. J Neurooncol 2017; 134:523-530. [PMID: 28386661 DOI: 10.1007/s11060-017-2392-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 02/24/2017] [Indexed: 01/14/2023]
Abstract
Although significant gains have been realized in the management of grade 4 glioma, the majority of these patients will ultimately suffer local recurrence within the prior field of treatment. Clearly, novel local treatment strategies are required to improve patient outcomes. Concerns of toxicity have limited enthusiasm for the utilization of re-irradiation as a treatment option. However, using modern imaging technology and precision radiotherapy delivery techniques re-irradiation has proven a feasible option achieving both a palliative benefit and prolongation of survival with low toxicity rates. The evolution of re-irradiation as a treatment modality for recurrent grade 4 glioma is reviewed. In addition, potential targeted radiosensitizers to be used in conjunction with re-irradiation are also discussed.
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Dong Y, Fu C, Guan H, Zhang T, Zhang Z, Zhou T, Li B. Re-irradiation alternatives for recurrent high-grade glioma. Oncol Lett 2016; 12:2261-2270. [PMID: 27703519 PMCID: PMC5038913 DOI: 10.3892/ol.2016.4926] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 03/01/2016] [Indexed: 12/28/2022] Open
Abstract
Despite advances in the fields of surgery, chemotherapy and radiotherapy, the prognosis for high-grade glioma (HGG) remains unsatisfactory. The majority of HGG patients experience disease recurrence. To date, no standard treatments have been established for recurrent HGG. Repeat surgery and chemotherapy demonstrate moderate efficacy. As recurrent lesions are usually located within the previously irradiated field, a second course of irradiation was once considered controversial, as it was considered to exhibit unsatisfactory efficacy and radiation-related toxicities. However, an increasing number of studies have indicated that re-irradiation may present an efficacious treatment for recurrent HGG. Re-irradiation may be delivered via conventionally fractionated stereotactic radiotherapy, hypofractionated stereotactic radiation therapy, stereotactic radiosurgery and brachytherapy techniques. In the present review, the current literature regarding re-irradiation treatment for recurrent HGG is summarized with regard to survival outcome and side effects.
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Affiliation(s)
- Yuanli Dong
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China; School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong 250014, P.R. China
| | - Chengrui Fu
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Hui Guan
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China; School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong 250014, P.R. China
| | - Tianyi Zhang
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Zicheng Zhang
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Tao Zhou
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Baosheng Li
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
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Mallick S, Benson R, Hakim A, Rath GK. Management of glioblastoma after recurrence: A changing paradigm. J Egypt Natl Canc Inst 2016; 28:199-210. [PMID: 27476474 DOI: 10.1016/j.jnci.2016.07.001] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 06/30/2016] [Accepted: 07/03/2016] [Indexed: 11/29/2022] Open
Abstract
Glioblastoma remains the most common primary brain tumor after the age of 40years. Maximal safe surgery followed by adjuvant chemoradiotherapy has remained the standard treatment for glioblastoma (GBM). But recurrence is an inevitable event in the natural history of GBM with most patients experiencing it after 6-9months of primary treatment. Recurrent GBM poses great challenge to manage with no well-defined management protocols. The challenge starts from differentiating radiation necrosis from true local progression. A fine balance needs to be maintained on improving survival and assuring a better quality of life. Treatment options are limited and ranges from re-excision, re-irradiation, systemic chemotherapy or a combination of these. Re-excision and re-irradiation must be attempted in selected patients and has been shown to improve survival outcomes. To facilitate the management of GBM recurrences, a treatment algorithm is proposed.
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Affiliation(s)
- Supriya Mallick
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India.
| | - Rony Benson
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Abdul Hakim
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Goura K Rath
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
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Lee J, Cho J, Chang JH, Suh CO. Re-Irradiation for Recurrent Gliomas: Treatment Outcomes and Prognostic Factors. Yonsei Med J 2016; 57:824-30. [PMID: 27189273 PMCID: PMC4951456 DOI: 10.3349/ymj.2016.57.4.824] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 09/11/2015] [Accepted: 10/23/2015] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The aim of this study was to evaluate the efficacy of re-irradiation in patients with recurrent gliomas and to identify subgroups for whom re-irradiation for recurrent gliomas is most beneficial. MATERIALS AND METHODS We retrospectively reviewed 36 patients with recurrent or progressive gliomas who received re-irradiation between January 1996 and December 2011. Re-irradiation was offered to recurrent glioma patients with good performance or at least 6 months had passed after initial radiotherapy (RT), with few exceptions. RESULTS Median doses of re-irradiation and initial RT were 45.0 Gy and 59.4 Gy, respectively. The median time interval between initial RT and re-irradiation was 30.5 months. Median overall survival (OS) and the 12-month OS rate were 11 months and 41.7%, respectively. In univariate analysis, Karnofsky performance status (KPS) ≥70 (p<0.001), re-irradiation dose ≥45 Gy (p=0.040), and longer time interval between initial RT and re-irradiation (p=0.040) were associated with improved OS. In multivariate analysis, KPS (p=0.030) and length of time interval between initial RT and re-irradiation (p=0.048) were important predictors of OS. A radiographically suspected mixture of radiation necrosis and progression after re-irradiation was seen in 5 patients. CONCLUSION Re-irradiation in conjunction with surgery could be a salvage treatment for selected recurrent glioma patients with good performance status and recurrence over a long time.
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Affiliation(s)
- Jeongshim Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jaeho Cho
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea.
| | - Chang Ok Suh
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea.
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Jia A, Pannullo SC, Minkowitz S, Taube S, Chang J, Parashar B, Christos P, Wernicke AG. Innovative Hypofractionated Stereotactic Regimen Achieves Excellent Local Control with No Radiation Necrosis: Promising Results in the Management of Patients with Small Recurrent Inoperable GBM. Cureus 2016; 8:e536. [PMID: 27096136 PMCID: PMC4835149 DOI: 10.7759/cureus.536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Management of recurrent glioblastoma multiforme (GBM) remains a challenge. Several institutions reported that a single fraction of ≥ 20 Gy for small tumor burden results in excellent local control; however, this is at the expense of a high incidence of radiation necrosis (RN). Therefore, we developed a hypofractionation pattern of 33 Gy/3 fractions, which is a radiobiological equivalent of 20 Gy, with the aim to lower the incidence of RN. We reviewed records of 21 patients with recurrent GBM treated with hypofractionated stereotactic radiation therapy (HFSRT) to their 22 respective lesions. Sixty Gy fractioned external beam radiotherapy was performed as first-line treatment. Median time from primary irradiation to HFSRT was 9.6 months (range: 3.1 – 68.1 months). In HFSRT, a median dose of 33 Gy in 11 Gy fractions was delivered to the 80% isodose line that encompassed the target volume. The median tumor volume was 1.07 cm3 (range: 0.11 – 16.64 cm3). The median follow-up time after HFSRT was 9.3 months (range: 1.7 – 33.6 months). Twenty-one of 23 lesions treated (91.3%) achieved local control while 2/23 (8.7%) progressed. Median time to progression outside of the treated site was 5.2 months (range: 2.2 – 9.6 months). Progression was treated with salvage chemotherapy. Five of 21 patients (23.8%) were alive at the end of this follow-up; two patients remain disease-free. The remaining 16/21 patients (76.2%) died of disease. Treatment was well tolerated by all patients with no acute CTC/RTOG > Grade 2. There was 0% incidence of RN. A prospective trial will be underway to validate these promising results.
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Affiliation(s)
- Angela Jia
- Stich Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center
| | - Susan C Pannullo
- Neurological Surgery, NewYork-Presbyterian/Weill Cornell Medical Center
| | | | - Shoshana Taube
- Stich Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center
| | - Jenghwa Chang
- Stich Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center
| | - Bhupesh Parashar
- Stich Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center
| | - Paul Christos
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, NewYork-Presbyterian/Weill Cornell Medical Center
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Taunk NK, Moraes FY, Escorcia FE, Mendez LC, Beal K, Marta GN. External beam re-irradiation, combination chemoradiotherapy, and particle therapy for the treatment of recurrent glioblastoma. Expert Rev Anticancer Ther 2016; 16:347-58. [PMID: 26781426 DOI: 10.1586/14737140.2016.1143364] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Glioblastoma is a common aggressive primary malignant brain tumor, and is nearly universal in progression and mortality after initial treatment. Re-irradiation presents a promising treatment option for progressive disease, both palliating symptoms and potentially extending survival. Highly conformal radiation techniques such as stereotactic radiosurgery and hypofractionated radiosurgery are effective short courses of treatment that allow delivery of high doses of therapeutic radiation with steep dose gradients to protect normal tissue. Patients with higher performance status, younger age, and longer interval between primary treatment and progression represent the best candidates for re-irradiation. Multiple studies are also underway involving combinations of radiation and systemic therapy to bend the survival curve and improve the therapeutic index. In the multimodal treatment of recurrent high-grade glioma, the use of surgery, radiation, and systemic therapy should be highly individualized. Here we comprehensively review radiation therapy and techniques, along with discussion of combination treatment and novel strategies.
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Affiliation(s)
- Neil K Taunk
- a Department of Radiation Oncology , Memorial Sloan Kettering Cancer Center , New York , New York , USA
| | - Fabio Y Moraes
- b Department of Radiation Oncology , Hospital Sírio-Libanês , São Paulo , Brazil
| | - Freddy E Escorcia
- a Department of Radiation Oncology , Memorial Sloan Kettering Cancer Center , New York , New York , USA
| | - Lucas Castro Mendez
- d Department of Radiation Oncology , Instituto de Radiologia - Faculdade de Medicina da Universidade de São Paulo (FMUSP) , São Paulo , Brazil
| | - Kathryn Beal
- a Department of Radiation Oncology , Memorial Sloan Kettering Cancer Center , New York , New York , USA
| | - Gustavo N Marta
- b Department of Radiation Oncology , Hospital Sírio-Libanês , São Paulo , Brazil.,c Department of Radiation Oncology , Instituto do Câncer do Estado de São Paulo (ICESP) - Faculdade de Medicina da Universidade de São Paulo (FMUSP) , São Paulo , Brazil
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Scorsetti M, Navarria P, Pessina F, Ascolese AM, D'Agostino G, Tomatis S, De Rose F, Villa E, Maggi G, Simonelli M, Clerici E, Soffietti R, Santoro A, Cozzi L, Bello L. Multimodality therapy approaches, local and systemic treatment, compared with chemotherapy alone in recurrent glioblastoma. BMC Cancer 2015; 15:486. [PMID: 26118437 PMCID: PMC4484625 DOI: 10.1186/s12885-015-1488-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 06/14/2015] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Long-term local control in Glioblastoma is rarely achieved and nearly all patients relapse. In this study we evaluated the clinical effect of different treatment approaches in recurrent patients. METHODS Forty-three patients, with median age of 51 years were evaluated for salvage treatment: re-resection and/or re-irradiation plus chemotherapy or chemotherapy alone. Response was recorded using the Response Assessment in Neuro-Oncology criteria. Hematologic and non-hematologic toxicities were graded according to Common Terminology Criteria for Adverse Events 4.0. Twenty-one patients underwent chemotherapy combined with local treatment, surgery and/or radiation therapy, and 22 underwent chemotherapy only. RESULTS The median follow up was 7 months (range 3-28 months). The 1 and 2-years Progression Free Survival was 65 and 10 % for combined treatment and 22 and 0 % for chemotherapy alone (p < 0.01). The 1 and 2-years overall survival was 69 and 29 % for combined and 26 and 0 % for chemotherapy alone (p < 0.01). No toxicity greater than grade 2 was recorded. CONCLUSION These data showed that in glioblastoma recurrence the combination of several approaches in a limited group of patients is more effective than a single treatment alone. This stress the importance of multimodality treatment whenever clinically feasible.
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Affiliation(s)
- Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Humanitas Cancer Center, Istituto Clinico Humanitas, Via Manzoni 56, 20089, Rozzano, Milano, Italy.
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Humanitas Cancer Center, Istituto Clinico Humanitas, Via Manzoni 56, 20089, Rozzano, Milano, Italy.
| | - Federico Pessina
- Neuro-oncological Surgery Department, Humanitas Cancer Center and Università degli Studi di Milano, Milan, Italy.
| | - Anna Maria Ascolese
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Humanitas Cancer Center, Istituto Clinico Humanitas, Via Manzoni 56, 20089, Rozzano, Milano, Italy.
| | - Giuseppe D'Agostino
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Humanitas Cancer Center, Istituto Clinico Humanitas, Via Manzoni 56, 20089, Rozzano, Milano, Italy.
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Humanitas Cancer Center, Istituto Clinico Humanitas, Via Manzoni 56, 20089, Rozzano, Milano, Italy.
| | - Fiorenza De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Humanitas Cancer Center, Istituto Clinico Humanitas, Via Manzoni 56, 20089, Rozzano, Milano, Italy.
| | - Elisa Villa
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Humanitas Cancer Center, Istituto Clinico Humanitas, Via Manzoni 56, 20089, Rozzano, Milano, Italy.
| | - Giulia Maggi
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Humanitas Cancer Center, Istituto Clinico Humanitas, Via Manzoni 56, 20089, Rozzano, Milano, Italy.
| | - Matteo Simonelli
- Oncology and Hematology Department, Humanitas Cancer Center, Milan, Italy.
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Humanitas Cancer Center, Istituto Clinico Humanitas, Via Manzoni 56, 20089, Rozzano, Milano, Italy.
| | | | - Armando Santoro
- Oncology and Hematology Department, Humanitas Cancer Center, Milan, Italy.
| | - Luca Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Humanitas Cancer Center, Istituto Clinico Humanitas, Via Manzoni 56, 20089, Rozzano, Milano, Italy.
| | - Lorenzo Bello
- Neuro-oncological Surgery Department, Humanitas Cancer Center and Università degli Studi di Milano, Milan, Italy.
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Galle JO, McDonald MW, Simoneaux V, Buchsbaum JC. Reirradiation with Proton Therapy for Recurrent Gliomas. Int J Part Ther 2015. [DOI: 10.14338/theijpt-14-00029.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Re-resection for recurrent high-grade glioma in the setting of re-irradiation: more is not always better. J Neurooncol 2015; 124:215-21. [PMID: 26024653 DOI: 10.1007/s11060-015-1825-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 05/23/2015] [Indexed: 10/23/2022]
Abstract
The optimal treatment for patients with recurrent high grade glioma (HGG) remains controversial. Available therapies include surgery, re-irradiation, alternating electric fields or systemic therapy. Here we investigate whether re-resection will improve survival in patients receiving repeat radiotherapy for tumor recurrence. 231 consecutive patients with recurrent HGG treated with re-irradiation between 1994 and 2012 were analyzed. 105 patients underwent re-resection. Re-irradiation was delivered using daily fractions of 3.5 Gy to a median total dose of 35 Gy. Survival was then analyzed comparing patients with and without re-resection. Overall survival (OS) and survival from the first recurrence are reported. Univariate and cox-proportional hazard modeling was performed in a step-wise multivariate analysis using known prognostic factors. The median follow-up time from initial diagnosis was 25.7 months. The median OS from initial diagnosis of the entire group was 22.5 months. There was no significant difference in median overall survival between patients who received re-resection versus no re-resection, 23 versus 21.9 months respectively (p = 0.6). Additionally, there was no difference in median survival from the time of first recurrence 10.5 months without re-resection versus 11.1 months with re-resection (p = 0.09). After adjusting for known prognostic variables, only age remained significant. Re-irradiation is an effective salvage therapy for patients with localized, progressive high grade glioma, achieving a median survival of 10-11 months from re-irradiation. Our data reveals no significant improvement in survival with the addition of re-resection to re-irradiated patients with HGG.
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Management of patients with recurrent glioblastoma using hypofractionated stereotactic radiotherapy. TUMORI JOURNAL 2015; 101:179-84. [PMID: 25791534 DOI: 10.5301/tj.5000236] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Glioblastoma (GBM) is the most common primary malignant brain tumor in adults. The chance of cure is very limited due to treatment-refractory disease course with frequent recurrences despite aggressive multimodality management. In this retrospective study, we evaluated treatment outcomes of hypofractionated stereotactic radiotherapy (HFSRT) in the management of recurrent GBM and report our single-center experience. METHODS Twenty-eight patients receiving HFSRT for recurrent GBM between September 2008 and February 2014 were retrospectively assessed. Total radiotherapy dose was 25 Gy delivered in 5 fractions over 5 consecutive days for all patients. High-precision, image-guided volumetric modulated arc therapy was delivered with a linear accelerator using 6-MV photons using the frameless technique. Analyzed prognostic factors were age, gender, Karnofsky performance status (KPS), tumor location, planning target volume (PTV) size, overall survival (OS), progression-free survival (PFS), time interval between completion of treatment with Stupp protocol at primary diagnosis and recurrence. RESULTS Median follow-up time was 42 months (range 2-68). Median time interval between primary chemoradiotherapy and HFSRT was 11.2 months (range 4-57.9). Median OS and PFS calculated from reirradiation was 10.3 months and 5.8 months, respectively. Longer interval between initial treatment and recurrence (p = 0.01), smaller PTV size (p = 0.001), KPS ≥70 (p = 0.005) and younger age (p = 0.004) were associated with longer OS on statistical analysis. CONCLUSION HFSRT offers a feasible and effective salvage treatment option for recurrent GBM management. Prognostic factors associated with longer OS in our study were longer interval between initial treatment and recurrence, smaller PTV size, KPS ≥70 and younger age.
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Hypofractionated stereotactic radiotherapy in combination with bevacizumab or fotemustine for patients with progressive malignant gliomas. J Neurooncol 2015; 122:559-66. [DOI: 10.1007/s11060-015-1745-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 02/16/2015] [Indexed: 01/16/2023]
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Kim HR, Kim KH, Kong DS, Seol HJ, Nam DH, Lim DH, Lee JI. Outcome of salvage treatment for recurrent glioblastoma. J Clin Neurosci 2015; 22:468-73. [PMID: 25595963 DOI: 10.1016/j.jocn.2014.09.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 09/05/2014] [Accepted: 09/13/2014] [Indexed: 01/30/2023]
Abstract
Most glioblastoma (GBM) cases recur within a year and almost all cases recur at some point. Standard treatment for recurrent GBM has not yet been established. We investigated the outcome of various salvage treatments for recurrent GBM. Retrospective analysis was undertaken in 144 patients who received salvage treatment at the time of first progression after maximum debulking surgery followed by concomitant chemoradiotherapy and adjuvant temozolomide (TMZ) chemotherapy. The median follow-up period was 18.2 months. We grouped these patients into five groups according to the salvage modalities: Gamma Knife radiosurgery (GKS) group (n=29), TMZ group (n=31), GKS+TMZ group (n=28), reoperation group (n=38) and "other treatment" group (n=18). The median time to first progression from initial diagnosis was 8.8 months. The median overall survival (OS) of the five different treatment groups; GKS, TMZ, GKS+TMZ, reoperation, and "other treatment", was 9.2, 5.6, 15.5, 13.2, and 8.0 months, respectively. Median progression-free survival (PFS) was 3.6, 2.3, 6.0, 4.3, and 2.6 months, respectively. Pairwise comparison of OS of the GKS+TMZ group with the other groups showed that the OS of the GKS+TMZ group was significantly better than all others except the reoperation group. Statistically significant prolongation of PFS was observed in the GKS+TMZ group compared with the TMZ group and the "other treatment" group. GKS followed by TMZ salvage treatment was a good prognostic factor for both PFS and OS in multivariate analysis. Retrospectively, GKS+TMZ as a salvage treatment, tended to provide a superior survival benefit at the time of recurrence.
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Affiliation(s)
- Hong Rye Kim
- Department of Neurosurgery, Konyang University Hospital, Konyang University School of Medicine, Daejeon, Republic of Korea
| | - Kyung Hwan Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea.
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