1
|
Mazarakis NK, Robinson SD, Sinha P, Koutsarnakis C, Komaitis S, Stranjalis G, Short SC, Chumas P, Giamas G. Management of glioblastoma in elderly patients: A review of the literature. Clin Transl Radiat Oncol 2024; 46:100761. [PMID: 38500668 PMCID: PMC10945210 DOI: 10.1016/j.ctro.2024.100761] [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: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 03/20/2024] Open
Abstract
High grade gliomas are the most common primary aggressive brain tumours with a very poor prognosis and a median survival of less than 2 years. The standard management protocol of newly diagnosed glioblastoma patients involves surgery followed by radiotherapy, chemotherapy in the form of temozolomide and further adjuvant temozolomide. The recent advances in molecular profiling of high-grade gliomas have further enhanced our understanding of the disease. Although the management of glioblastoma is standardised in newly diagnosed adult patients there is a lot of debate regarding the best treatment approach for the newly diagnosed elderly glioblastoma patients. In this review article we attempt to summarise the findings regarding surgery, radiotherapy, chemotherapy, and their combination in order to offer the best possible management modality for this group of patients. Elderly patients 65-70 with an excellent functional level could be considered as candidates for the standards treatment consisting of surgery, standard radiotherapy with concomitant and adjuvant temozolomide. Similarly, elderly patients above 70 with good functional status could receive the above with the exception of receiving a shorter course of radiotherapy instead of standard. In elderly GBM patients with poorer functional status and MGMT promoter methylation temozolomide chemotherapy can be considered. For elderly patients who cannot tolerate chemotherapy, hypofractionated radiotherapy is an option. In contrast to the younger adult patients, it seems that a careful individualised approach is a key element in deciding the best treatment options for this group of patients.
Collapse
Affiliation(s)
- Nektarios K. Mazarakis
- Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK
- School of Medicine RCSI, Royal College of Surgeons in Ireland, 123 St. Stephen’s Green, Dublin 2, Ireland
| | - Stephen D. Robinson
- Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK
- Department of Biochemistry and Biomedicine, School of Life Sciences, University of Sussex, Brighton BN1 9QG, UK
| | - Priyank Sinha
- Department of Neurosurgery, Leeds General Infirmary, Great George Street, LS1 3EX, UK
| | | | - Spyridon Komaitis
- Department of Neurosurgery, Evaggelismos Hospital, Ipsilantou 45-47, Athens, Greece
| | - George Stranjalis
- Department of Neurosurgery, Evaggelismos Hospital, Ipsilantou 45-47, Athens, Greece
| | - Susan C. Short
- Leeds Institute of Medical Research at St James’s Wellcome Trust Brenner Building St James’s University Hospital Leeds, LS9 7TF, UK
| | - Paul Chumas
- School of Medicine RCSI, Royal College of Surgeons in Ireland, 123 St. Stephen’s Green, Dublin 2, Ireland
| | - Georgios Giamas
- Department of Biochemistry and Biomedicine, School of Life Sciences, University of Sussex, Brighton BN1 9QG, UK
| |
Collapse
|
2
|
Chatterjee A, Bhadane M, Manjali JJ, Dasgupta A, Epari S, Sahay A, Patil V, Moiyadi A, Shetty P, Gupta T. Optimizing Postoperative Adjuvant Therapy in Elderly Patients with Newly Diagnosed Glioblastoma: Single-Institution Audit of Clinical Outcomes from a Tertiary-Care Comprehensive Cancer Center in India. World Neurosurg 2022; 161:e587-e595. [PMID: 35192971 DOI: 10.1016/j.wneu.2022.02.059] [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: 01/30/2022] [Revised: 02/12/2022] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND There is lack of consensus regarding optimal adjuvant therapy in elderly glioblastoma (GBM). We have been treating elderly (≥60 years) GBM patients with normofractionated or hypofractionated radiotherapy (RT) plus temozolomide (TMZ) based on Karnofsky performance status (KPS). Herein we report clinical outcomes in this cohort treated at our institute using this approach. METHODS Medical records of elderly GBM patients (≥60 years) treated between 2013 and 2017 with either normofractionated RT (59.4-60 Gy/30-33 fractions/6-6.5 weeks) or hypofractionated RT (35 Gy/10 fractions/2 weeks) plus TMZ were reviewed retrospectively. Outcomes of interest included progression-free survival (PFS), overall survival (OS), and ≥grade 3 myelotoxicity. Time-to-event outcomes were analyzed with Kaplan-Meier methods, compared using log-rank test, and reported as point estimates with 95% confidence interval (CI). RESULTS The normofractionated cohort (n = 126) was characterized by a higher proportion of patients younger than age 65 years, KPS ≥70, methylated O6-methylguanine DNA methyltransferase (MGMT), and receiving adjuvant TMZ including extended adjuvant TMZ (>6 cycles) compared with the hypofractionated cohort (n = 20), confirming selection bias. At a median follow-up of 13 months, 1-year Kaplan-Meier estimates of PFS and OS were 43% (95% CI: 36%-52%) and 56% (95% CI: 48%-64%), yielding median PFS and OS of 11.0 months and 13.1 months, respectively. Higher KPS, methylated MGMT, normofractionated RT, and extended adjuvant TMZ emerged as favorable prognostic factors. TMZ was well tolerated with a low risk of ≥grade 3 myelotoxicity. CONCLUSIONS Our single-institution clinical audit confirms poor survival in elderly GBM with suboptimal performance status but demonstrates acceptably fair outcomes in patients with preserved KPS comparable with the nonelderly cohort.
Collapse
Affiliation(s)
- Abhishek Chatterjee
- Department of Radiation Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Manish Bhadane
- Department of Radiation Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Jifmi Jose Manjali
- Department of Radiation Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Archya Dasgupta
- Department of Radiation Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Sridhar Epari
- Department of Pathology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Ayushi Sahay
- Department of Pathology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Vijay Patil
- Department of Medical Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Aliasgar Moiyadi
- Department of Neurosurgery, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Prakash Shetty
- Department of Neurosurgery, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Tejpal Gupta
- Department of Radiation Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| |
Collapse
|
3
|
Outcome of glioblastoma resection in patients 80 years of age and older. Acta Neurochir (Wien) 2022; 164:373-383. [PMID: 33660052 DOI: 10.1007/s00701-021-04776-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 02/17/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the role and possible complications of tumor resection in the management of glioblastoma (GBM) in a series of patients 80 years of age and older with review of literature. METHODS The authors retrospectively analyzed cases involving patients 80 years or older who underwent biopsy or initial resection of GBM at their hospital between 2007 and 2018. A total of 117 patients (mean age 82 years) met the inclusion criteria; 57 had resection (group A) and 60 had biopsy (group B). Functional outcomes and survival at follow-up were analyzed. RESULTS Group A differed significantly from group B at baseline in having better WHO performance status, better ASA scores, more right-sided tumors, and no basal ganglia or "butterfly" gliomas. Nevertheless, 56% of group A patients had an ASA score of 3. Median survival was 9.5 months (95% CI 8-17 months) in group A, 4 months (95% CI 3.5-6 months) in group B, and 17.5 months (95% CI 12-24 months) in the 56% of group A patients treated with resection and Stupp protocol. Rates of postoperative neurologic and medical complications were almost identical in the 2 groups, but the rate of surgical site complications was substantially greater in group A (12% vs 5%). There was no significant difference in mean preoperative and postoperative KPS scores (group A). CONCLUSIONS In selected patients 80 years or older, radical removal of GBM was associated with acceptable survival and a low perioperative complication rate which is comparable to that of a biopsy. Although the median survival of the whole group was lower than reported for younger patients, a subgroup amenable to radical surgery and Stupp protocol achieved a median survival of 17.5 months.
Collapse
|
4
|
Yin A, Shang Z, Etcheverry A, He Y, Aubry M, Lu N, Liu Y, Mosser J, Lin W, Zhang X, Dong Y. Integrative analysis identifies an immune-relevant epigenetic signature for prognostication of non-G-CIMP glioblastomas. Oncoimmunology 2021; 10:1902071. [PMID: 33854822 PMCID: PMC8018210 DOI: 10.1080/2162402x.2021.1902071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The clinical and molecular implications of DNA methylation alterations remain unclear among the majority of glioblastomas (GBMs) without glioma-CpGs island methylator phenotype (G-CIMP); integrative multi-level molecular profiling may provide useful information. Independent cohorts of non-G-CIMP GBMs or IDH wild type (wt) lower-grade gliomas (LGGs) from local and public databases with DNA methylation and gene expression microarray data were included for discovery and validation of a multimarker signature, combined using a RISK score model. Bioinformatic and in vitro functional analyses were employed for biological validation. Using a strict multistep selection approach, we identified eight CpGs, each of which was significantly correlated with overall survival (OS) of non-G-CIMP GBMs, independent of age, the O-6-methylguanine-DNA methyltransferase (MGMT) methylation status, treatments and other identified CpGs. An epigenetic RISK signature of the 8 CpGs was developed and validated to robustly and independently prognosticate prognosis in different cohorts of not only non-G-GIMP GBMs, but also IDHwt LGGs. It also showed good discriminating value in stratified cohorts by current clinical and molecular factors. Bioinformatic analysis revealed consistent correlation of the epigenetic signature to distinct immune-relevant transcriptional profiles of GBM bulks. Functional experiments showed that S100A2 appeared to be epigenetically regulated by one identified CpG and was associated with GBM cell proliferation, apoptosis, invasion, migration and immunosuppression. The prognostic 8-CpGs RISK score signature may be of promising value for refining current glioma risk classification, and its potential links to distinct immune phenotypes make it a promising biomarker candidate for predicting response to anti-glioma immunotherapy.
Collapse
Affiliation(s)
- Anan Yin
- Department of Neurosurgery, Xijing Institute of Clinical Neuroscience, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi Province, The People's Republic of China.,Department of Neurosurgery, The 960th Hospital of the People's Liberation Army, Taian, Shandong Province, The People's Republic of China
| | - Zhende Shang
- Department of Neurosurgery, The 960th Hospital of the People's Liberation Army, Taian, Shandong Province, The People's Republic of China.,Department of Neurosurgery, The Second Affiliated Hospital of Shandong First Medical University, Taian, Shandong Province, The People's Republic of China
| | - Amandine Etcheverry
- CNRS, UMR 6290, Institut de Génétique et Développement de Rennes (IGdR), Rennes, France.,Faculté de Médecine, Université Rennes1, UEB, UMS 3480 Biosit, Rennes, France.,CHU Rennes, Service de Génétique Moléculaire et Génomique, Rennes, France
| | - Yalong He
- Department of Neurosurgery, Xijing Institute of Clinical Neuroscience, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi Province, The People's Republic of China
| | - Marc Aubry
- CNRS, UMR 6290, Institut de Génétique et Développement de Rennes (IGdR), Rennes, France
| | - Nan Lu
- Department of Neurosurgery, The 960th Hospital of the People's Liberation Army, Taian, Shandong Province, The People's Republic of China
| | - Yuhe Liu
- Department of Neurosurgery, The 960th Hospital of the People's Liberation Army, Taian, Shandong Province, The People's Republic of China
| | - Jean Mosser
- CNRS, UMR 6290, Institut de Génétique et Développement de Rennes (IGdR), Rennes, France.,Faculté de Médecine, Université Rennes1, UEB, UMS 3480 Biosit, Rennes, France.,CHU Rennes, Service de Génétique Moléculaire et Génomique, Rennes, France
| | - Wei Lin
- Department of Neurosurgery, Xijing Institute of Clinical Neuroscience, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi Province, The People's Republic of China
| | - Xiang Zhang
- Department of Neurosurgery, Xijing Institute of Clinical Neuroscience, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi Province, The People's Republic of China
| | - Yu Dong
- Department of Stomatology, Xi'an No.3 Hospital, the Affiliated Hospital of Northwest University, Xi'an, Shaanxi Province, The People's Republic of China.,State Key Laboratory of Military Stomatology, School of Stomatology, Air Force Medical University, Xi'an, Shaanxi Province, The People's Republic of China
| |
Collapse
|
5
|
Gangwani K, Snigdha K, Kango-Singh M. Tep1 Regulates Yki Activity in Neural Stem Cells in Drosophila Glioma Model. Front Cell Dev Biol 2020; 8:306. [PMID: 32457905 PMCID: PMC7225285 DOI: 10.3389/fcell.2020.00306] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 04/07/2020] [Indexed: 12/18/2022] Open
Abstract
Glioblastoma Multiforme (GBM) is the most common form of malignant brain tumor with poor prognosis. Amplification of Epidermal Growth Factor Receptor (EGFR), and mutations leading to activation of Phosphatidyl-Inositol-3 Kinase (PI3K) pathway are commonly associated with GBM. Using a previously published Drosophila glioma model generated by coactivation of PI3K and EGFR pathways [by downregulation of Pten and overexpression of oncogenic Ras] in glial cells, we showed that the Drosophila Tep1 gene (ortholog of human CD109) regulates Yki (the Drosophila ortholog of human YAP/TAZ) via an evolutionarily conserved mechanism. Oncogenic signaling by the YAP/TAZ pathway occurs in cells that acquire CD109 expression in response to the inflammatory environment induced by radiation in clinically relevant models. Further, downregulation of Tep1 caused a reduction in Yki activity and reduced glioma growth. A key function of Yki in larval CNS is stem cell renewal and formation of neuroblasts. Other reports suggest different upstream regulators of Yki activity in the optic lobe versus the central brain regions of the larval CNS. We hypothesized that Tep1 interacts with the Hippo pathway effector Yki to regulate neuroblast numbers. We tested if Tep1 acts through Yki to affect glioma growth, and if in normal cells Tep1 affects neuroblast number and proliferation. Our data suggests that Tep1 affects Yki mediated stem cell renewal in glioma, as reduction of Tep significantly decreases the number of neuroblasts in glioma. Thus, we identify Tep1-Yki interaction in the larval CNS that plays a key role in glioma growth and progression.
Collapse
Affiliation(s)
- Karishma Gangwani
- Department of Biology, University of Dayton, Dayton, OH, United States
| | - Kirti Snigdha
- Department of Biology, University of Dayton, Dayton, OH, United States
| | - Madhuri Kango-Singh
- Department of Biology, University of Dayton, Dayton, OH, United States
- Center for Tissue Regeneration and Engineering at Dayton (TREND), University of Dayton, Dayton, OH, United States
- Premedical Programs, University of Dayton, Dayton, OH, United States
- Integrated Science and Engineering Center (ISE), University of Dayton, Dayton, OH, United States
| |
Collapse
|
6
|
Hanna C, Lawrie TA, Rogozińska E, Kernohan A, Jefferies S, Bulbeck H, Ali UM, Robinson T, Grant R. Treatment of newly diagnosed glioblastoma in the elderly: a network meta-analysis. Cochrane Database Syst Rev 2020; 3:CD013261. [PMID: 32202316 PMCID: PMC7086476 DOI: 10.1002/14651858.cd013261.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND A glioblastoma is a fatal type of brain tumour for which the standard of care is maximum surgical resection followed by chemoradiotherapy, when possible. Age is an important consideration in this disease, as older age is associated with shorter survival and a higher risk of treatment-related toxicity. OBJECTIVES To determine the most effective and best-tolerated approaches for the treatment of elderly people with newly diagnosed glioblastoma. To summarise current evidence for the incremental resource use, utilities, costs and cost-effectiveness associated with these approaches. SEARCH METHODS We searched electronic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase to 3 April 2019, and the NHS Economic Evaluation Database (EED) up to database closure. We handsearched clinical trial registries and selected neuro-oncology society conference proceedings from the past five years. SELECTION CRITERIA Randomised trials (RCTs) of treatments for glioblastoma in elderly people. We defined 'elderly' as 70+ years but included studies defining 'elderly' as over 65+ years if so reported. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for study selection and data extraction. Where sufficient data were available, treatment options were compared in a network meta-analysis (NMA) using Stata software (version 15.1). For outcomes with insufficient data for NMA, pairwise meta-analysis were conducted in RevMan. The GRADE approach was used to grade the evidence. MAIN RESULTS We included 12 RCTs involving approximately 1818 participants. Six were conducted exclusively among elderly people (either defined as 65 years or older or 70 years or older) with newly diagnosed glioblastoma, the other six reported data for an elderly subgroup among a broader age range of participants. Most participants were capable of self-care. Study quality was commonly undermined by lack of outcome assessor blinding and attrition. NMA was only possible for overall survival; other analyses were pair-wise meta-analyses or narrative syntheses. Seven trials contributed to the NMA for overall survival, with interventions including supportive care only (one trial arm); hypofractionated radiotherapy (RT40; four trial arms); standard radiotherapy (RT60; five trial arms); temozolomide (TMZ; three trial arms); chemoradiotherapy (CRT; three trial arms); bevacizumab with chemoradiotherapy (BEV_CRT; one trial arm); and bevacizumab with radiotherapy (BEV_RT). Compared with supportive care only, NMA evidence suggested that all treatments apart from BEV_RT prolonged survival to some extent. Overall survival High-certainty evidence shows that CRT prolongs overall survival (OS) compared with RT40 (hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.56 to 0.80) and low-certainty evidence suggests that CRT may prolong overall survival compared with TMZ (TMZ versus CRT: HR 1.42, 95% CI 1.01 to 1.98). Low-certainty evidence also suggests that adding BEV to CRT may make little or no difference (BEV_CRT versus CRT: HR 0.83, 95% CrI 0.48 to 1.44). We could not compare the survival effects of CRT with different radiotherapy fractionation schedules (60 Gy/30 fractions and 40 Gy/15 fractions) due to a lack of data. When treatments were ranked according to their effects on OS, CRT ranked higher than TMZ, RT and supportive care only, with the latter ranked last. BEV plus RT was the only treatment for which there was no clear benefit in OS over supportive care only. One trial comparing tumour treating fields (TTF) plus adjuvant chemotherapy (TTF_AC) with adjuvant chemotherapy alone could not be included in the NMA as participants were randomised after receiving concomitant chemoradiotherapy, not before. Findings from the trial suggest that the intervention probably improves overall survival in this selected patient population. We were unable to perform NMA for other outcomes due to insufficient data. Pairwise analyses were conducted for the following. Quality of life Moderate-certainty narrative evidence suggests that overall, there may be little difference in QoL between TMZ and RT, except for discomfort from communication deficits, which are probably more common with RT (1 study, 306 participants, P = 0.002). Data on QoL for other comparisons were sparse, partly due to high dropout rates, and the certainty of the evidence tended to be low or very low. Progression-free survival High-certainty evidence shows that CRT increases time to disease progression compared with RT40 (HR 0.50, 95% CI 0.41 to 0.61); moderate-certainty evidence suggests that RT60 probably increases time to disease progression compared with supportive care only (HR 0.28, 95% CI 0.17 to 0.46), and that BEV_RT probably increases time to disease progression compared with RT40 alone (HR 0.46, 95% CI 0.27 to 0.78). Evidence for other treatment comparisons was of low- or very low-certainty. Severe adverse events Moderate-certainty evidence suggests that TMZ probably increases the risk of grade 3+ thromboembolic events compared with RT60 (risk ratio (RR) 2.74, 95% CI 1.26 to 5.94; participants = 373; studies = 1) and also the risk of grade 3+ neutropenia, lymphopenia, and thrombocytopenia. Moderate-certainty evidence also suggests that CRT probably increases the risk of grade 3+ neutropenia, leucopenia and thrombocytopenia compared with hypofractionated RT alone. Adding BEV to CRT probably increases the risk of thromboembolism (RR 16.63, 95% CI 1.00 to 275.42; moderate-certainty evidence). Economic evidence There is a paucity of economic evidence regarding the management of newly diagnosed glioblastoma in the elderly. Only one economic evaluation on two short course radiotherapy regimen (25 Gy versus 40 Gy) was identified and its findings were considered unreliable. AUTHORS' CONCLUSIONS For elderly people with glioblastoma who are self-caring, evidence suggests that CRT prolongs survival compared with RT and may prolong overall survival compared with TMZ alone. For those undergoing RT or TMZ therapy, there is probably little difference in QoL overall. Systemic anti-cancer treatments TMZ and BEV carry a higher risk of severe haematological and thromboembolic events and CRT is probably associated with a higher risk of these events. Current evidence provides little justification for using BEV in elderly patients outside a clinical trial setting. Whilst the novel TTF device appears promising, evidence on QoL and tolerability is needed in an elderly population. QoL and economic assessments of CRT versus TMZ and RT are needed. More high-quality economic evaluations are needed, in which a broader scope of costs (both direct and indirect) and outcomes should be included.
Collapse
Affiliation(s)
- Catherine Hanna
- University of GlasgowDepartment of OncologyBeatson West of Scotland Cancer CentreGreat Western RoadGlasgowScotlandUKG4 9DL
| | - Theresa A Lawrie
- The Evidence‐Based Medicine Consultancy Ltd3rd Floor Northgate HouseUpper Borough WallsBathUKBA1 1RG
| | - Ewelina Rogozińska
- The Evidence‐Based Medicine Consultancy Ltd3rd Floor Northgate HouseUpper Borough WallsBathUKBA1 1RG
| | - Ashleigh Kernohan
- Newcastle UniversityInstitute of Health & SocietyBaddiley‐Clark Building, Richardson RoadNewcastle upon TyneUKNE2 4AA
| | - Sarah Jefferies
- Addenbrooke's HospitalDepartment of OncologyHills RoadCambridgeUKCB2 0QQ
| | - Helen Bulbeck
- brainstrustDirector of Services4 Yvery CourtCastle RoadCowesIsle of WightUKPO31 7QG
| | - Usama M Ali
- University of OxfordNuffield Department of Population HealthRoosevelt DriveOld Road CampusOxfordOxfordshireUKOX3 7LF
| | - Tomos Robinson
- Newcastle UniversityInstitute of Health & SocietyBaddiley‐Clark Building, Richardson RoadNewcastle upon TyneUKNE2 4AA
| | - Robin Grant
- Western General HospitalEdinburgh Centre for Neuro‐Oncology (ECNO)Crewe RoadEdinburghScotlandUKEH4 2XU
| | | |
Collapse
|
7
|
Werlenius K, Fekete B, Blomstrand M, Carén H, Jakola AS, Rydenhag B, Smits A. Patterns of care and clinical outcome in assumed glioblastoma without tissue diagnosis: A population-based study of 131 consecutive patients. PLoS One 2020; 15:e0228480. [PMID: 32053655 PMCID: PMC7017992 DOI: 10.1371/journal.pone.0228480] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/15/2020] [Indexed: 11/19/2022] Open
Abstract
Background Elderly patients with glioblastoma and an accumulation of negative prognostic factors have an extremely short survival. There is no consensus on the clinical management of these patients and many may escape histologically verified diagnosis. The primary aim of this study was to characterize this particular subgroup of patients with radiological glioblastoma diagnosis without histological verification. The secondary aim was to evaluate if oncological therapy was of benefit. Methods Between November 2012 and June 2016, all consecutive patients presenting with a suspected glioblastoma in the western region of Sweden were registered in a population-based study. Of the 378 patients, 131 (35%) met the inclusion criteria of the present study by typical radiological features of glioblastoma without histological verification. Results The clinical characteristics of the 131 patients (72 men, 59 women) were: age ≥ 75 (n = 99, 76%), performance status according to Eastern Cooperative Oncology Group ≥ 2 (n = 93, 71%), significant comorbidity (n = 65, 50%) and multilobular tumors (n = 90, 69%). The overall median survival rate was 3.6 months. A subgroup of 44 patients (34%) received upfront treatment with temozolomide, with an overall radiological response rate of 34% and a median survival of 6.8 months, compared to 2.7 months for those receiving best supportive care only. Good performance status and temozolomide treatment were statistically significant favorable prognostic factors, while younger age was not. Conclusion Thirty-five percent of patients with a radiological diagnosis of glioblastoma in our region lacked histological diagnosis. Apart from high age and poor performance status, they had more severe comorbidities and extensive tumor spread. Even for this poor prognostic group upfront treatment with temozolomide was shown of benefit in a subgroup of patients. Our data illustrate the need of non-invasive diagnostic methods to guide optimal individualized therapy for patients considered too fragile for neurosurgical biopsy.
Collapse
Affiliation(s)
- Katja Werlenius
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- * E-mail:
| | - Boglarka Fekete
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Malin Blomstrand
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Carén
- Sahlgrenska Cancer Center, Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Asgeir S. Jakola
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bertil Rydenhag
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anja Smits
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Neuroscience, Neurology, Uppsala University, Gothenburg, Sweden
| |
Collapse
|
8
|
Kalra B, Kannan S, Gupta T. Optimal adjuvant therapy in elderly glioblastoma: results from a systematic review and network meta-analysis. J Neurooncol 2020; 146:311-320. [PMID: 31894517 DOI: 10.1007/s11060-019-03375-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/18/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND There exists lack of consensus worldwide regarding the most optimal adjuvant therapy regimen in elderly patients with newly-diagnosed glioblastoma (GBM). PURPOSE To identify the most optimal adjuvant therapy regimen in elderly GBM patients through systematic review and network meta-analysis. METHODS Prospective trials randomly assigning elderly GBM patients post-operatively to any adjuvant therapy regimen were included. The primary outcome measure was overall survival. Numbers of events, patients at-risk, and censored patients for survival were estimated from Kaplan-Meier survival curves in the interval of 0-12 months. The total person-time at risk and the mortality × 100 person-months was also estimated. The relative ranking probability of each treatment and rankograms were used to estimate the hierarchy of each intervention in terms of overall survival. The mean rank values and the surface under the cumulative ranking (SUCRA) curves were also calculated. RESULTS A systematic literature search identified 1278 abstracts, that were screened to retrieve full-text manuscripts of potentially eligible articles. After detailed assessment, data from 1569 patients in 7 randomized controlled trials (RCTs) treated with one of following regimens was extracted and analyzed: normofractionated radiotherapy (RT) delivered over 5.5-6 weeks; moderately hypofractionated RT (2-3 weeks) either alone or in combination with temozolomide or bevacizumab; extremely hypofractionated RT (1-week); temozolomide monotherapy; and best supportive care alone. In terms of overall survival, moderately hypofractionated RT (3-weeks) with concurrent and adjuvant temozolomide emerged as the best and second-best adjuvant therapy option with 81% probability and 99.1% probability respectively. Using SUCRA, the surface area for moderately hypofractionated RT (3-weeks) with concurrent and adjuvant temozolomide reached almost 100%, confirming it as the best intervention. As expected, best supportive care alone was ranked as the worst treatment strategy. CONCLUSION Moderately hypofractionated RT (3-weeks) with concurrent and adjuvant temozolomide is the most optimal and preferred adjuvant therapeutic regimen in elderly GBM.
Collapse
Affiliation(s)
- Babusha Kalra
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Kharghar, Navi Mumbai, 410210, India
| | - Sadhana Kannan
- Clinical Research Secretariat, ACTREC, Tata Memorial Centre, HBNI, Kharghar, Navi Mumbai, India
| | - Tejpal Gupta
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Kharghar, Navi Mumbai, 410210, India.
| |
Collapse
|
9
|
Clinical and Molecular Recursive Partitioning Analysis of High-grade Glioma Treated With IMRT. Am J Clin Oncol 2019; 42:27-35. [PMID: 29912004 DOI: 10.1097/coc.0000000000000470] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Despite multimodal treatment for high-grade gliomas, prognosis remains grim. Prior Radiation Therapy Oncology Group-Recursive Partitioning Analysis (RTOG-RPA) reports indicate based on pretreatment and treatment-related factors, a subset of patients experience a significantly improved survival. Since the development of the RTOG-RPA, high-grade gliomas have seen the widespread introduction of temozolomide and tumor oncogenetics. Here we aimed to determine whether the RTOG-RPA retained prognostic significance in the context of modern treatment, as well as generate an updated RPA incorporating both clinical and genetic variables. METHODS Patients with histologically proven glioblastoma, gliosarcoma, anaplastic astrocytoma, and anaplastic oligodendroglioma treated with intensity-modulated radiation therapy (IMRT) between 2004 and 2017 were reviewed. The primary endpoint was overall survival from date of diagnosis. Primary analysis compared actual survival rates to that expected of corresponding RTOG-RPA class. Secondary analysis utilized the rpart function to recursively partition overall survival by numerous clinical and genetic pretreatment and treatment-related variables. A tertiary analysis recursively partitioned a subset of patients in which the status of all genetic markers were known. RESULTS We identified 878 patients with histologically proven high-grade glioma treated with IMRT and 291 patients in our genetic subset. Median overall survival for the entire cohort was 14.2 months (95% confidence interval, 13.1-15.3). Applying the RTOG-RPA to our cohort validated the relative prognostic ordering of the survival classes except class II. Generating our new RPA created 7 significantly different survival classes (P<0.001, χ=584) with median survival ranging from 96.4 to 2.9 months based on age, histology, O6-methylguanine-DNA methyltransferase methylation status, radiation fractions, tumor location, radiation dose, temozolomide status, and resection status. Our second RPA of our genetic subset generated 5 significantly different survival classes (P<0.001, χ=166) with survival ranging from 65.3 to 5.6 months based on age, isocitrate dehydrogenase 1 mutation status, O6-methylguanine-DNA methyltransferase methylation status, neurological functional classification, hospitalization during IMRT, temozolomide status, and Karnofsky performance status. CONCLUSIONS The RTOG-RPA retains partial prognostic significance, however, should be updated to reflect recent advancements. This series represents a large RPA analyzing both clinical and genetic factors and generated 7 distinct survival classes. Further assessment of patients with fully available genetic markers generated 5 distinct survival classes. These survival classifications need to be validated by a prospective data set and compared against the RTOG-RPA to determine whether they provide improved prognostic power.
Collapse
|
10
|
Lawrie TA, Hanna CR, Rogozińska E, Kernohan A, Vale L, Bulbeck H, Ali UM, Grant R. Treatment of newly diagnosed glioblastoma in the elderly. Hippokratia 2019. [DOI: 10.1002/14651858.cd013261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Theresa A Lawrie
- 1st Floor Education Centre, Royal United Hospital; Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group; Combe Park Bath UK BA1 3NG
| | - Catherine R Hanna
- University of Glasgow; Department of Oncology; Beatson West of Scotland Cancer Centre Great Western Road Glasgow Scotland UK G4 9DL
| | | | - Ashleigh Kernohan
- Newcastle University; Institute of Health & Society; Baddiley-Clark Building, Richardson Road Newcastle upon Tyne UK NE2 4AA
| | - Luke Vale
- Newcastle University; Institute of Health & Society; Baddiley-Clark Building, Richardson Road Newcastle upon Tyne UK NE2 4AA
| | - Helen Bulbeck
- brainstrust; Director of Services; 4 Yvery Court Castle Road Cowes Isle of Wight UK PO31 7QG
| | - Usama M Ali
- University of Oxford; Centre for Statistics in Medicine; 7 Dewsbury Road Luton Bedfordshire UK LU3 2HJ
| | - Robin Grant
- Western General Hospital; Edinburgh Centre for Neuro-Oncology (ECNO); Crewe Road Edinburgh Scotland UK EH4 2XU
| |
Collapse
|
11
|
Back M, Rodriguez M, Jayamanne D, Khasraw M, Lee A, Wheeler H. Understanding the Revised Fourth Edition of the World Health Organization Classification of Tumours of the Central Nervous System (2016) for Clinical Decision-making: A Guide for Oncologists Managing Patients with Glioma. Clin Oncol (R Coll Radiol) 2018; 30:556-562. [DOI: 10.1016/j.clon.2018.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/17/2018] [Accepted: 05/22/2018] [Indexed: 11/25/2022]
|
12
|
Asmaa A, Dixit S, Rowland-Hill C, Achawal S, Rajaraman C, O'Reilly G, Highley R, Hussain M, Baker L, Gill L, Morris H, Hingorani M. Management of elderly patients with glioblastoma-multiforme-a systematic review. Br J Radiol 2018; 91:20170271. [PMID: 29376741 DOI: 10.1259/bjr.20170271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The management of elderly patients with glioblastoma-multiforme (GBM) remains poorly defined with many experts in the past advocating best supportive care, in view of limited evidence on efficacy of more aggressive treatment protocols. There is randomised evidence (NORDIC and NA-O8 studies) to support the use of surgery followed by adjuvant monotherapy with either radiotherapy (RT) using hypofractionated regimes (e.g. 36 Gy in 6 fractions OR 40 Gy in 15 fractions) or chemotherapy with temozolomide (TMZ) in patients expressing methylation of promoter for O6-methylguanine-DNA methyltransferase enzyme. However, the role of combined-modality therapy involving the use of combined RT and TMZ protocols has remained controversial with data from the EORTC (European Organisation for Research and Treatment of Cancer)-NCIC (National Cancer Institute of Canada) studies indicating that patients more than 65 years of age may not benefit significantly from combining standard RT fractionation using 60 Gy in 30 fractions with concurrent and adjuvant TMZ. More recently, randomised data has emerged on combining hypofractionated RT with concurrent and adjuvant TMZ. We provide a comprehensive review of literature with the aim of defining an evidence-based algorithm for management of elderly glioblastoma-multiforme population.
Collapse
Affiliation(s)
- Almadani Asmaa
- 1 Faculty of Health Sciences, University of Hull , Hull , UK
| | - Sanjay Dixit
- 2 Queen centre of Oncology, Castle Hill hospital , Cottingham , UK
| | | | | | | | - Gerry O'Reilly
- 3 Department of Neurosurgery, Hull Royal Infirmary , Hull , UK
| | - Robin Highley
- 3 Department of Neurosurgery, Hull Royal Infirmary , Hull , UK
| | - Masood Hussain
- 3 Department of Neurosurgery, Hull Royal Infirmary , Hull , UK
| | - Louise Baker
- 3 Department of Neurosurgery, Hull Royal Infirmary , Hull , UK
| | - Lynne Gill
- 3 Department of Neurosurgery, Hull Royal Infirmary , Hull , UK
| | - Holly Morris
- 3 Department of Neurosurgery, Hull Royal Infirmary , Hull , UK
| | - Mohan Hingorani
- 4 Leeds Institue of Oncology, Leeds Teaching Hospitals NHS Trust , Leeds , UK
| |
Collapse
|
13
|
Abstract
OBJECTIVES Glioblastoma is a lethal disease in the elderly population. We aimed to evaluate disease and treatment outcomes in the oldest-old patients. METHODS Patients >80 years old with histologically confirmed glioblastoma treated between 2004 and 2009 were identified. We included patients managed with best supportive care (BSC), temozolomide (TMZ) alone, radiotherapy (RT) alone, or concomitantly with TMZ (CRT). Survival outcomes were analyzed using the Kaplan-Meier method. RESULTS Ultimately, 48 patients were analyzed. Median age and Eastern Cooperative Oncology Group (ECOG) Performance Status were 82 years and 2, respectively. The median Age-Adjusted Charlson Index (AAC) was 6. Gross total and subtotal resections were performed in 16.7% and 18.8% of patients, respectively. Biopsy followed by RT alone was the treatment modality for 23/48 (47.9%), while 17/48 (35.4%) received surgery followed by RT alone or CRT. A total of 8 (16.7%) were managed with BSC after biopsy. Median overall survival (OS) and progression-free survival (PFS) were 4.1 (95% confidence interval [95% CI] 3.3-4.9) and 2.7 (95% CI 1.5-3.9) months, respectively. Improved median OS was observed in those treated with surgical resection followed by RT alone or CRT (7.1 months), compared to biopsy followed by RT alone (4.2 months) or BSC (2.0 months; p=0.002). Surgical resection, age≤85, and AAC<6 were associated with better OS (p=0.032, p=0.031, and p=0.02, respectively). Cause of death was neurological progression in 56% of cases. RT was well-tolerated. CONCLUSIONS PFS and OS outcomes remain poor in the oldest-old patients (>80 years old). Younger age, lower AAC, surgical resection, and adjuvant treatment were associated with improved OS.
Collapse
|
14
|
Liu YL, Liu PF, Shao W, Du HP, Li ZZ, Guo C, Li ZF. Effect of temozolomide on survival in elderly patients with glioblastoma and impaired performance status: a propensity score-matching analysis. Onco Targets Ther 2017; 10:4029-4035. [PMID: 28860811 PMCID: PMC5565376 DOI: 10.2147/ott.s123473] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE At present, there is no consensus regarding the standard treatment for glioblastoma (GBM) in elderly patients with impaired Karnofsky performance status (KPS) scores. This study aimed to determine the effects of temozolomide (TMZ) versus best supportive care (BSC) in this population. MATERIALS AND METHODS We conducted a retrospective observational study of patients aged ≥65 years with histologically confirmed GBM and KPS scores ≤70 who were treated at our institution between January 2006 and July 2014. Demographic data, treatments, and outcomes were evaluated. Univariate and multivariate analyses were performed to identify the independent prognostic factors of overall survival (OS) and progression-free survival (PFS). The impact of TMZ on survival was analyzed by the application of propensity score matching of clinicopathological factors among patients who received TMZ vs BSC. RESULTS There were 153 patients (86 men, 56.2%) in this study. The median patient age was 70 years (range: 65-83 years). The median KPS score was 60 (range: 30-70). Seventy-eight patients (51.0%) received TMZ, whereas 75 (49.0%) received BSC. Median OS and PFS were 6.0 and 4.5 months, respectively. Compared with BSC, TMZ was associated with improved OS (hazard ratio [HR]: 0.38, 95% CI: 0.17-0.70; P=0.002) and PFS (HR: 0.41, 95% CI: 0.21-0.76; P=0.003) after propensity score matching. Factors independently associated with OS were KPS score (HR: 2.11, 95% CI: 1.48-7.67; P=0.016), extent of resection (HR: 1.98, 95% CI: 1.45-5.14; P=0.026), and treatment group (HR: 0.49, 95% CI: 0.23-0.87; P=0.019). The most frequent toxicity in the TMZ group was myelosuppression. CONCLUSION Compared with BSC, TMZ increased survival with acceptable toxicity in elderly GBM patients with KPS scores ≤70.
Collapse
Affiliation(s)
- Yong-Liang Liu
- Department of Neurosurgery, Affiliated Hospital of Binzhou Medical University, Binzhou, Shandong, Yantai, People’s Republic of China
| | - Peng-Fei Liu
- Department of Neurosurgery, Affiliated Hospital of Binzhou Medical University, Binzhou, Shandong, Yantai, People’s Republic of China
| | - Wei Shao
- Department of Neurosurgery, Affiliated Hospital of Binzhou Medical University, Binzhou, Shandong, Yantai, People’s Republic of China
| | - Hong-Peng Du
- Department of Neurosurgery, Affiliated Hospital of Binzhou Medical University, Binzhou, Shandong, Yantai, People’s Republic of China
| | - Zhen-Zhu Li
- Department of Neurosurgery, Affiliated Hospital of Binzhou Medical University, Binzhou, Shandong, Yantai, People’s Republic of China
| | - Chong Guo
- Department of Neurosurgery, Affiliated Hospital of Binzhou Medical University, Binzhou, Shandong, Yantai, People’s Republic of China
| | - Ze-Fu Li
- Department of Neurosurgery, Affiliated Hospital of Binzhou Medical University, Binzhou, Shandong, Yantai, People’s Republic of China
| |
Collapse
|
15
|
Elderly patients with newly diagnosed glioblastoma: can preoperative imaging descriptors improve the predictive power of a survival model? J Neurooncol 2017; 134:423-431. [PMID: 28674975 DOI: 10.1007/s11060-017-2544-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 06/25/2017] [Indexed: 12/16/2022]
Abstract
The purpose of this study was to identify independent prognostic factors among preoperative imaging features in elderly glioblastoma patients and to evaluate whether these imaging features, in addition to clinical features, could enhance the predictive power of survival models. This retrospective study included 108 patients ≥65 years of age with newly diagnosed glioblastoma. Preoperative clinical features (age and KPS), postoperative clinical features (extent of surgery and postoperative treatment), and preoperative MRI features were assessed. Univariate and multivariate cox proportional hazards regression analyses for overall survival were performed. The integrated area under the receiver operating characteristic curve (iAUC) was calculated to evaluate the added value of imaging features in the survival model. External validation was independently performed with 40 additional patients ≥65 years of age with newly diagnosed glioblastoma. Eloquent area involvement, multifocality, and ependymal involvement on preoperative MRI as well as clinical features including age, preoperative KPS, extent of resection, and postoperative treatment were significantly associated with overall survival on univariate Cox regression. On multivariate analysis, extent of resection and ependymal involvement were independently associated with overall survival and preoperative KPS showed borderline significance. The model with both preoperative clinical and imaging features showed improved prediction of overall survival compared to the model with preoperative clinical features (iAUC, 0.670 vs. 0.600, difference 0.066, 95% CI 0.021-0.121). Analysis of the validation set yielded similar results (iAUC, 0.790 vs. 0.670, difference 0.123, 95% CI 0.021-0.260), externally validating this observation. Preoperative imaging features, including eloquent area involvement, multifocality, and ependymal involvement, in addition to clinical features, can improve the predictive power for overall survival in elderly glioblastoma patients.
Collapse
|
16
|
Morgan ER, Norman A, Laing K, Seal MD. Treatment and outcomes for glioblastoma in elderly compared with non-elderly patients: a population-based study. ACTA ACUST UNITED AC 2017; 24:e92-e98. [PMID: 28490931 DOI: 10.3747/co.24.3424] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Elderly patients make up a large percentage of the individuals newly diagnosed with glioblastoma (gbm), but they face particular challenges in tolerating standard therapy, and compared with younger patients, they experience significantly shorter survival. We set out to compare clinical characteristics, treatment patterns, and outcomes in a non-elderly group (<65 years) and an elderly group (≥65 years) of patients diagnosed with gbm. METHODS This retrospective population-based study used a province-wide cancer registry to identify patients with a new diagnosis of gbm within a 6-year period (2006-2012). Of the 138 patients identified, 56 (40.6%) were 65 years of age or older. Demographic characteristics, treatment patterns, and overall survival (os) in the elderly and non-elderly groups were compared. Predictors of os were determined using multivariate analysis. RESULTS Elderly patients were more likely to present with a poor performance status (Eastern Cooperative Oncology Group ≥ 2), to undergo biopsy without resection, and to receive whole-brain or hypofractionated radiotherapy. Compared with non-elderly patients, the elderly patients were less likely to receive adjuvant temozolomide. Survival time was significantly shorter in the elderly than in the non-elderly patients (7.2 months vs. 11.2 months). In multivariate analysis, surgical resection, hypofractionated radiotherapy (compared with whole-brain or conventional radiotherapy), and chemotherapy were predictive of os in older patients. Among elderly patients receiving radiation, survival was improved with the use of combined therapy compared with the use of radiation only (11.3 months vs. 4.6 months). CONCLUSIONS Overall survival was shorter for elderly patients with gbm than for non-elderly patients; the elderly patients were also less likely to receive intensive surgical or adjuvant therapy. Our population-based analysis demonstrated improved os with surgical resection, hypofractionated radiotherapy, and temozolomide, and supports the results of recent clinical trials demonstrating a benefit for combination chemoradiotherapy in older patients.
Collapse
Affiliation(s)
- E R Morgan
- Gerry and Nancy Pencer Brain Tumour Centre, Princess Margaret Hospital Cancer Centre, Toronto, ON
| | - A Norman
- Cancer Care Program, Dr. H. Bliss Murphy Cancer Centre, St. John's, NL
| | - K Laing
- Cancer Care Program, Dr. H. Bliss Murphy Cancer Centre, St. John's, NL
| | - M D Seal
- Cancer Care Program, Dr. H. Bliss Murphy Cancer Centre, St. John's, NL
| |
Collapse
|
17
|
Pattern of care and outcome in elderly patients with glioblastoma: Data in 151 patients from 3 Lombardia Hospitals. J Neurol Sci 2017; 378:3-8. [PMID: 28566172 DOI: 10.1016/j.jns.2017.04.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 03/30/2017] [Accepted: 04/17/2017] [Indexed: 01/15/2023]
Abstract
The appropriate treatment approach for elderly patients with glioblastoma multiforme (GBM) is unclear, although different studies suggest survival benefit in fit patients treated with radiotherapy and chemiotherapy after surgery. We performed a retrospective analysis of 151 patients older than 65years with GBM treated in 3 Lombardia Hospitals. In univariate regression analysis higher KPS (p=0.02), macroscopical total resection (p<0.003), radiotherapy (p<0.0001), chemotherapy (p<0.0001) and second line chemotheraphy (p=0.02) were of positive prognostic value. On the contrary older age (>70years), presence of seizure at onset and additional resection after tumor recurrence did not influence OS. Multivariate analysis revealed radiotherapy (HR 0.2 p<0.0001) and extent of surgery (HR 0.3, p=0,0063) as positive independent prognostic factors. Patients receiving radio-chemiotherapy displayed more treatment-related toxicities with a slightly prolonged OS versus those receiving hypofractionated radiotherapy. With the limits of a retrospective study, our data suggest that in elderly fit patients extensive surgery should be considered, moreover adjuvant treatments led to an increase in OS. Randomized controlled study are needed to develop treatment guidelines for elderly GBM patients and to assess whether the combination of post-surgical radio and chemiotherapy may be superior to hypofractionated radiotherapy and chemiotherapy in fit patients.
Collapse
|
18
|
Yang LK, Zhu J, Chen YH, Wang DL, Li H, Zhang LJ, Zhou JR, Liu W. Knockdown of Angiopoietin-Like Protein 2 Inhibits Proliferation and Invasion in Glioma Cells via Suppressing the ERK/MAPK Signaling Pathway. Oncol Res 2017; 25:1349-1355. [PMID: 28247845 PMCID: PMC7841190 DOI: 10.3727/096504017x14874337324615] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Angiopoietin-like protein 2 (ANGPTL2), a member of the glycoprotein family, is mainly secreted by adipose tissues under normal conditions. Recently, ANGPTL2 has been found to be upregulated in some types of cancers and is considered to be a tumor promoter. However, the functional significance of ANGPTL2 in glioma has not yet been elucidated. In this study, we investigated the specific role of ANGPTL2 in glioma. The results showed that ANGPTL2 was highly expressed in glioma tissues and cell lines. Knockdown of ANGPTL2 reduced the proliferative and invasive abilities of glioma cells. Moreover, the tumorigenesis assay showed that ANGPTL2 knockdown inhibited glioma tumor growth in vivo. We also found that ANGPTL2 knockdown decreased the protein levels of p-ERK1/2 in glioma cells and thus blocked the activity of the ERK/MAPK signaling pathway. Taken together, our study provided the first evidence that ANGPTL2 played an oncogenic role in glioma development and might be considered as a new therapeutic target for glioma treatment.
Collapse
|
19
|
Feng E, Sui C, Wang T, Sun G. Temozolomide with or without Radiotherapy in Patients with Newly Diagnosed Glioblastoma Multiforme: A Meta-Analysis. Eur Neurol 2017; 77:201-210. [PMID: 28192785 DOI: 10.1159/000455842] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 01/04/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND/AIM The current meta-analysis evaluated the survival outcomes of newly diagnosed glioblastoma patients treated with radiotherapy (RT) alone and with RT + temozolomide (TMZ). METHODS Relevant studies were identified by an extensive literature search in Medline, Current Contents and Cochrane databases by 2 independent reviewers using the terms "glioblastoma multiforme/glioblastoma, TMZ, radiation therapy/RT and survival." RESULTS Results revealed a median survival of 13.41-19 months in the combined treatment group, as opposed to 7.7-17.1 months in the RT-alone group. Progression-free survival (PFS) was also significantly different between the 2 groups (RT + TMZ, 6.3-13 months; RT-alone, 5-7.6 months). While there was no significant difference in the 6-month survival and 6-month PFS rates between the RT + TMZ and RT groups (pooled OR 0.690; p = 0.057 and OR 0.429, p = 0.052, respectively), the 1-year survival and 1-year PFS rates showed significant difference (OR 0.469; p = 0.030 and OR 0.245, p < 0.001, respectively). CONCLUSIONS Concomitant RT + TMZ is more effective and improves the overall survival and PFS in patients with newly diagnosed glioblastoma.
Collapse
Affiliation(s)
- Enshan Feng
- Department of Neurosurgery, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | | | | | | |
Collapse
|
20
|
MiR-27a regulates Wnt/beta-catenin signaling through targeting SFRP1 in glioma. Neuroreport 2016; 26:695-702. [PMID: 26164457 DOI: 10.1097/wnr.0000000000000410] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Glioma is one of the most common intracranial tumors, and the prognosis is poor, although more and more treatments are employed. Wnt/beta-catenin signaling has been reported to be associated with glioma. SFRP1 acts as an antagonist and inhibits Wnt signaling by binding to Wnt molecules. In the present study, we aimed to investigate miRNA-27a as an antineoplastic factor that inhibits the Wnt/beta-catenin pathway by binding to the SFRP1 3'-UTR in glioma in vitro. We first showed that the expression of miR-27a was elevated in both glioma samples and cell lines. Furthermore, downregulation of miR-27a induced growth inhibition, cycle arrest, and apoptosis, and suppressed invasion/migration in glioma cell lines. Quantitative real-time PCR, western blot, and luciferase assay analysis showed that SFRP1 is a direct target of miR-27a. Overexpression of SFRP1 inhibited the malignancy of glioma cell lines. Our investigation showed that downregulation of miR-27a suppressed beta-catenin/TCF-4 transcription activity by targeting SFRP1. Our findings identify a role for miR-27a in glioma cell viability, cycle, apoptosis, and invasion/migration after activation of Wnt/beta-catenin signaling through SFRP1.
Collapse
|
21
|
Hau E, Shen H, Clark C, Graham PH, Koh ES, L McDonald K. The evolving roles and controversies of radiotherapy in the treatment of glioblastoma. J Med Radiat Sci 2016; 63:114-23. [PMID: 27350891 PMCID: PMC4914819 DOI: 10.1002/jmrs.149] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 08/25/2015] [Accepted: 10/06/2015] [Indexed: 12/22/2022] Open
Abstract
Numerous randomised controlled trials have demonstrated the benefit of radiation therapy in patients with newly diagnosed glioblastoma and it has been the cornerstone of treatment for decades. The aims of this review are to (1) Briefly outline the historical studies which resulted in radiation being the current standard of care as used in the Stupp et al. trial (2) Discuss the evolving role of radiation therapy in the management of elderly patients (3) Review the current evidence and ongoing studies of radiation use in the recurrent/salvage setting and (4) Discuss the continuing controversies of volume delineation in the planning of radiation delivery.
Collapse
Affiliation(s)
- Eric Hau
- Cure Brain Cancer Foundation Biomarkers and Translational Research Laboratory Prince of Wales Clinical School UNSW Sydney New South Wales Australia; Cancer Care Centre St George Hospital Sydney New South Wales Australia
| | - Han Shen
- Targeted Therapies Group Children's Cancer Institute Australia Lowy Cancer Research Centre Sydney New South Wales Australia
| | - Catherine Clark
- Cancer Care Centre St George Hospital Sydney New South Wales Australia
| | - Peter H Graham
- St George Cancer Care Centre Kogarah Sydney New South Wales Australia
| | - Eng-Siew Koh
- Liverpool Cancer Care Centre Liverpool Hospital Sydney New South Wales Australia; University of New South Wales Sydney New South Wales Australia
| | - Kerrie L McDonald
- Cure Brain Cancer Foundation Biomarkers and Translational Research Laboratory Prince of Wales Clinical School UNSW Sydney New South Wales Australia
| |
Collapse
|
22
|
Lapointe S, Florescu M, Nguyen DK, Djeffal C, Bélanger K. Prophylactic anticonvulsants for gliomas: a seven-year retrospective analysis. Neurooncol Pract 2015; 2:192-198. [PMID: 31386083 DOI: 10.1093/nop/npv018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Indexed: 11/14/2022] Open
Abstract
Background The American Academy of Neurology (AAN) does not recommend routine use of prophylactic antiepileptic drugs (pAEDs) in patients with newly diagnosed brain tumors. If used in the perioperative setting, discontinuation is suggested after the first postoperative week. It is unclear whether such recommendations are followed. Our objective was to compare our perioperative and long-term pAED use in glioma patients with AAN practice parameters. Methods Retrospective chart review was performed on 578 glioma patients from 2006 to 2013. Seizures and AED use were assessed at surgery, 3 months postoperatively and death, last visit or 16 months postoperatively. Patients were divided into three groups at surgery: seizure-free with pAED, seizure-free without pAED, and seizure patients. Long-term pAED use was defined as continued use at 3 months postsurgery without seizures. pAEDs efficacy, factors influencing its use, and survival were examined. Results Out of 578 patients identified, 330 (57.1%) were seizure-naïve preoperatively. There were no significant differences in age, histology, tumor location or resection status between seizure-free populations with and without prophylaxis. Of 330 seizure-naïve patients, 205 (62.1%) received pAEDs at surgery. Ninety-six (46.9%) of those patients were still on pAEDs 3 months postsurgery (median use = 58 days). Rate of long-term prophylaxis use decreased by 13.5% over 6 years (70.3% in 2006; 56.8% in 2012). Phenytoin was preferred in 2006 (98.2%) with increasing use of levetiracetam over 6 years (44.6% in 2012). The only predictive factor for pAED use was complete resection (P = .0069). First seizure prevalence was similar in both seizure-free populations (P = .91). The seizure population had more men (P = .007), younger patients (P < .0001), lower-grade gliomas (P = .0003) and survived longer (P = .001) compared with seizure-free populations. Conclusions In our center, long-term prophylactic AED use is high, deviating from current AAN Guidelines. Corrective measures are warranted.
Collapse
Affiliation(s)
- Sarah Lapointe
- Neurology Division, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal, CanadaH2L 4M1 (S.L., D.K.N.); Hematology and Oncology Department, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal, CanadaH2L 4M1 (M.F., C.D., K.B.)
| | - Marie Florescu
- Neurology Division, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal, CanadaH2L 4M1 (S.L., D.K.N.); Hematology and Oncology Department, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal, CanadaH2L 4M1 (M.F., C.D., K.B.)
| | - Dang K Nguyen
- Neurology Division, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal, CanadaH2L 4M1 (S.L., D.K.N.); Hematology and Oncology Department, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal, CanadaH2L 4M1 (M.F., C.D., K.B.)
| | - Chanez Djeffal
- Neurology Division, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal, CanadaH2L 4M1 (S.L., D.K.N.); Hematology and Oncology Department, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal, CanadaH2L 4M1 (M.F., C.D., K.B.)
| | - Karl Bélanger
- Neurology Division, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal, CanadaH2L 4M1 (S.L., D.K.N.); Hematology and Oncology Department, CHUM Notre-Dame Hospital, University of Montreal, 1560 Sherbrooke East, Montreal, CanadaH2L 4M1 (M.F., C.D., K.B.)
| |
Collapse
|
23
|
Predictors of survival and effect of short (40 Gy) or standard-course (60 Gy) irradiation plus concomitant temozolomide in elderly patients with glioblastoma: a multicenter retrospective study of AINO (Italian Association of Neuro-Oncology). J Neurooncol 2015; 125:359-67. [PMID: 26423801 DOI: 10.1007/s11060-015-1923-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 08/31/2015] [Indexed: 10/23/2022]
Abstract
The efficacy of temozolomide (TMZ) plus radiation therapy (RT) in elderly patients with glioblastoma is unclear. We performed a large multicenter retrospective study to analyze prognostic factors and clinical outcome in these patients. Inclusion criteria were age ≥65 years, newly histologically confirmed glioblastoma, ECOG PS 0-2, adjuvant treatment with RT plus TMZ. We enrolled 237 patients; the average age was 71 and ECOG PS was 0-1 in 196 patients; gross total resection was performed in 174 cases. MGMT was analyzed in 151 persons and was methylated in 56 %. IDH1 was assessed in 100 patients and was mutated in 6 %. Seventy-one patients were treated with RT 40 Gy and 166 with RT 60 Gy. Progression-free survival and overall survival (OS) were 11.3 and 17.3 months, respectively. Overall survival was 19.4 vs 13.8 months for patients treated with RT 60 Gy and 40 Gy (p = 0.02); OS was 17.7 versus 16.1 months for patients treated with gross total resection vs partial surgery (p = 0.02); OS was 21.2 versus 13.6 months for methylated and unmethylated MGMT (p < 0.001). On multivariate analysis, gross total resection, RT 60 Gy, methylated MGMT and ECOG PS 0-1 were independent predictors of longer survival. Twenty-five patients (10 %) had grade 3-4 haematological toxicity during the concomitant treatment. We showed that, in elderly patients in good clinical condition treated with concomitant treatment, standard-course irradiation might be more effective than short-course irradiation. Methylated MGMT remains the most important prognostic factor.
Collapse
|
24
|
Burton E, Ugiliweneza B, Woo S, Skirboll S, Boaky M. A Surveillance, Epidemiology and End Results-Medicare data analysis of elderly patients with glioblastoma multiforme: Treatment patterns, outcomes and cost. Mol Clin Oncol 2015; 3:971-978. [PMID: 26623036 DOI: 10.3892/mco.2015.590] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 05/15/2015] [Indexed: 11/06/2022] Open
Abstract
The Surveillance, Epidemiology and End Results (SEER) database was used to determine the treatment patterns, outcomes and cost of therapy in elderly patients with glioblastoma multiforme (GBM). The SEER-Medicare linked database was used to identify patients aged >66 years with GBM diagnosed between 1997 and 2009. The patients were stratified by initial treatment following diagnostic surgery (resection or biopsy) into 6 groups as follows: No treatment, standard radiation therapy (SRT) with and without concurrent temozolomide (TMZ), hypofractionated RT (HRT) with and without concurrent TMZ, or TMZ alone. The 3,759 patients identified had a median age of 74 years (range, 66-97 years). A total of ~48% of the patients received SRT without TMZ; ~10% received SRT with concurrent TMZ; ~29% received no treatment; ~10% received HRT without TMZ; ~1% received HRT with TMZ; and <1% received TMZ alone. Untreated patients had a median survival of 2 months (range, 0-89 months). Patients treated with SRT with and without concurrent TMZ had a median survival of 11 and 9 months, respectively (P=0.01). Patients treated with HRT with and without TMZ or TMZ alone had a median survivals of 3 months [adjusted hazard ratio (AHR)=0.48; 95% confidence interval (CI): 0.36-0.66], 4 months (AHR=0.55; 95% CI: 0.49-0.62) and 6 months (AHR=0.43; 95% CI: 0.29-0.62), respectively. The median post-surgery total treatment cost for patients receiving HRT with and without TMZ or TMZ alone was 63,915, 42,834 and 48,298 USD, respectively. Standard RT with concurrent TMZ was associated with improved survival, even in patients aged >75 years. HRT with and without concurrent TMZ and TMZ alone improved survival compared to the no treatment group. Therefore, in certain cases, HRT or TMZ alone may be more cost-effective, with similar survival outcomes. The various treatment options highlight the need for geriatric assessment tools to aid in therapeutic decision making.
Collapse
Affiliation(s)
- Eric Burton
- Department of Neurology, University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Beatrice Ugiliweneza
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Shiao Woo
- Department of Radiation Oncology, University of Louisville School of Medicine and James Graham Brown Cancer Center, Louisville, KY 4010, USA
| | - Stephen Skirboll
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA 94305, USA
| | - Maxwell Boaky
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, KY 40202, USA
| |
Collapse
|
25
|
Tsang D, Khan L, Perry J, Soliman H, Sahgal A, Keith J, Mainprize T, Das S, Zhang L, Tsao M. Survival Outcomes in Elderly Patients with Glioblastoma. Clin Oncol (R Coll Radiol) 2015; 27:176-83. [DOI: 10.1016/j.clon.2014.11.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 09/19/2014] [Accepted: 11/27/2014] [Indexed: 10/24/2022]
|
26
|
Biau J, Dalloz P, Durando X, Hager MO, Ouédraogo ZG, Khalil T, Lemaire JJ, Chautard E, Verrelle P. [Elderly patients with glioblastoma: state of the art]. Bull Cancer 2015; 102:277-86. [PMID: 25732048 DOI: 10.1016/j.bulcan.2015.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 01/27/2015] [Indexed: 11/18/2022]
Abstract
The incidence of glioblastoma increases with age, with a median age, at diagnosis, of 65 years. Indeed, the optimization of standard of care of elderly glioblastoma patients in an aging population in Western countries becomes crucial. The age remains the main prognostic factor of glioblastoma. Survival among elderly patients is significantly less than among younger patients. The median survival of elderly glioblastoma patients is generally inferior to 6 months. More aggressive tumor behavior, less aggressive treatments, increased toxicity of therapies and more unfavorable clinical factors and comorbidities could explain a higher severity of the disease in the elderly. The balance between treatment efficacy and quality of life is a major focus because of the shorter life expectancy of patients. The standard of care of glioblastoma in elderly patients remains controversial. Large optimal resection, when achievable, should be preferred to biopsy. Survival is longer after adjuvant radiotherapy, either normofractionated over 6-weeks course or hypofractionated over 3-weeks course, for patients with good clinical status. Hypofractionation is often preferred because of shorter procedure. Chemotherapy alone with temozolomide can be proposed to patients with methylated MGMT promoter. A phase III randomized study, testing short-course adjuvant radiotherapy with or without temozolomide in elderly patients with good clinical status, is ongoing.
Collapse
Affiliation(s)
- Julian Biau
- Clermont université, EA7283 CREaT, centre Jean-Perrin, département de radiothérapie, 58, rue Montalembert, 63011 Clermont-Ferrand, France; Institut Curie, UMR CNRS 3347/Inserm U1021, équipe recombinaison, réparation et cancer, 91400 Paris-Orsay, France.
| | - Pierre Dalloz
- Centre Jean-Perrin, département d'oncologie médicale, 63011 Clermont-Ferrand, France
| | - Xavier Durando
- Inserm U501, centre d'investigation clinique, Clermont université, EA7283 CREaT, centre Jean-Perrin, département d'oncologie médicale, 63011 Clermont-Ferrand, France
| | - Marie-Odile Hager
- CHU, département d'oncogériatrie, centre Jean-Perrin, département d'oncologie médicale , 63011 Clermont-Ferrand, France
| | - Zangbéwendé Guy Ouédraogo
- Clermont université, EA7283 CREaT, centre Jean-Perrin, département de radiothérapie, 58, rue Montalembert, 63011 Clermont-Ferrand, France
| | - Toufic Khalil
- Clermont université, CHU Gabriel-Montpied, service de neurochirurgie, EA7282, 63011 Clermont-Ferrand, France
| | - Jean-Jacques Lemaire
- Clermont université, CHU Gabriel-Montpied, service de neurochirurgie, EA7282, 63011 Clermont-Ferrand, France
| | - Emmanuel Chautard
- Clermont université, EA7283 CREaT, centre Jean-Perrin, département de radiothérapie, 58, rue Montalembert, 63011 Clermont-Ferrand, France
| | - Pierre Verrelle
- Clermont université, EA7283 CREaT, centre Jean-Perrin, département de radiothérapie, 58, rue Montalembert, 63011 Clermont-Ferrand, France
| |
Collapse
|
27
|
Abstract
Although glioblastoma occurs mostly in elderly patients, there is a paucity of trials addressing patients older than 70 years of age. Age, by itself, constitutes an unfavorable prognostic factor, which is probably due to unpropitious genetic features, but also due to iatrogenic defeatism. However, many retrospective studies report a survival benefit achieved by aggressive surgical resection seeking gross total removal of contrast-enhancing tumor according to preoperative MRI. Combined radiochemotherapy with concomitant and adjuvant temozolomide has not been investigated in prospective trials. Numerous retrospective studies and a meta-analysis suggest benefit from combined treatment. Prospective randomized trials only evaluated either temozolomide or radiotherapy. Single-treatment hypofractionated radiotherapy performed superior to conventional fractionation. In patients with methylated MGMT promoter, first-line dose-dense temozolomide facilitates prolonged survival. However, there is no comparison with combined radiochemotherapy as the standard-of-care in adult patients. Comorbidity is more frequent in elderly patients, but does not correlate with preterm termination of temozolomide treatment. This review article compiles data proposing a straightforward glioblastoma treatment, irrespective of age.
Collapse
Affiliation(s)
- Florian Stockhammer
- Department of Neurosurgery, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, 37075 Göttingen, Germany
| |
Collapse
|
28
|
Bauchet L, Zouaoui S, Darlix A, Menjot de Champfleur N, Ferreira E, Fabbro M, Kerr C, Taillandier L. Assessment and treatment relevance in elderly glioblastoma patients. Neuro Oncol 2014; 16:1459-68. [PMID: 24792440 DOI: 10.1093/neuonc/nou063] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Glioblastoma (GBM) is the most common malignant primary brain tumor. Its incidence continues to increase in the elderly because the older segment of the population is growing faster than any other age group. Most clinical studies exclude elderly patients, and "standards of care" do not exist for GBM patients aged >70 years. We review epidemiology, tumor biology/molecular factors, prognostic factors (clinical, imaging data, therapeutics), and their assessments as well as classic and specific endpoints plus recent and ongoing clinical trials for elderly GBM patients. This work includes perspectives and personal opinions on this topic. Although there are no standards of care for elderly GBM patients, we can hypothesize that (i) Karnofsky performance status (KPS), probably after steroid treatment, is one of the most important clinical factors for determining our oncological strategy; (ii) resection is superior to biopsy, at least in selected patients (depending on location of the tumor and associated comorbidities); (iii) specific schedules of radiotherapy yield a modest but significant improvement; (iv) temozolomide has an acceptable tolerance, even when KPS <70, and could be proposed for methylated elderly GBM patients; and (v) the addition of concomitant temozolomide to radiotherapy has not yet been validated but shows promising results in some studies, yet the optimal schedule of radiotherapy remains to be determined. In the future, specific assessments (geriatric, imaging, biology) and use of new endpoints (quality of life and toxicity measures) will aid clinicians in determining the balance of potential benefits and risks of each oncological strategy.
Collapse
Affiliation(s)
- Luc Bauchet
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
| | - Sonia Zouaoui
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
| | - Amélie Darlix
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
| | - Nicolas Menjot de Champfleur
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
| | - Ernestine Ferreira
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
| | - Michel Fabbro
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
| | - Christine Kerr
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
| | - Luc Taillandier
- Department of Neurosurgery and INSERM U1051, Hôpital Saint Eloi - Gui de Chauliac, Montpellier, France (L.B., S.Z.); French Brain Tumor DataBase, ICM, Montpellier, France (L.B., S.Z., A.D.); Department of Neuroradiology, CHU, Montpellier, France (N.M. deC.); Department of Geriatrics, CHU, Montpellier, France (E.F.); Department of Medical Oncology, ICM, Montpellier, France (A.D., M.F.); Department of Radiation Oncology, ICM, Montpellier, France (C.K.); Department of Neurology, CHU, Poitiers, France (L.T.)
| |
Collapse
|
29
|
Treatment of malignant gliomas in elderly patients: a concise overview of the literature. BIOMED RESEARCH INTERNATIONAL 2014; 2014:734281. [PMID: 24864257 PMCID: PMC4016934 DOI: 10.1155/2014/734281] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 03/20/2014] [Indexed: 12/03/2022]
Abstract
Gliomas are the most frequent primary brain tumors and the incidence data has increased in the elderly population. Unfortunately, prospective studies on this population are few and so the right treatment is unknown. In the elderly patients no standard treatment has been established and therefore the optimal treatment should be individualized. We performed a review analyzing the prognostic and predictive factors, the clinical studies, and the correct management of this population.
Collapse
|