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Demetz M, Krigers A, Moser P, Kerschbaumer J, Thomé C, Freyschlag CF. Same but different. Incidental and symptomatic lower grade gliomas show differences in molecular features and survival. J Neurooncol 2023; 162:397-405. [PMID: 37043120 PMCID: PMC10167120 DOI: 10.1007/s11060-023-04301-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/20/2023] [Indexed: 04/13/2023]
Abstract
PURPOSE Data on differences in overall survival and molecular characteristics between incidental (iLGG) and symptomatic lower grade Glioma (sLGG) are limited. The aim of this study was to investigate differences between patients with iLGG and sLGG. METHODS All adult patients with a histologically proven diffuse (WHO°II) or anaplastic (WHO°III) glioma who underwent their first surgery at the authors' institution between 2010 and 2019 were retrospectively included. Tumor volume on pre- and postoperative MRI scans was determined. Clinical and routine neuropathological data were gained from patients' charts. If IDH1, ATRX and EGFR were not routinely assessed, they were re-determined. RESULTS Out of 161 patients included, 23 (14%) were diagnosed as incidental findings. Main reasons for obtaining MRI were: headache(n = 12), trauma(n = 2), MRI indicated by other departments(n = 7), staging examination for cancer(n = 1), volunteering for MRI sequence testing(n = 1). The asymptomatic patients were significantly younger with a median age of 38 years (IqR28-48) vs. 50 years (IqR38-61), p = 0.011. Incidental LGG showed significantly lower preoperative tumor volumes in T1 CE (p = 0.008), FLAIR (p = 0.038) and DWI (p = 0.028). Incidental LGG demonstrated significantly lower incidence of anaplasia (p = 0.004) and lower expression of MIB-1 (p = 0.008) compared to sLGG. IDH1-mutation was significantly more common in iLGG (p = 0.024). Incidental LGG showed a significantly longer OS (mean 212 vs. 70 months, p = 0.005) and PFS (mean 201 vs. 61 months, p = 0.001) compared to sLGG. CONCLUSION Our study is the first to depict a significant difference in molecular characteristics between iLGG and sLGG. The findings of this study confirmed and extended the results of previous studies showing a better outcome and more favorable radiological, volumetric and neuropathological features of iLGG.
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Affiliation(s)
- Matthias Demetz
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, Innsbruck, AT-6020, Austria
| | - Aleksandrs Krigers
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, Innsbruck, AT-6020, Austria
| | - Patrizia Moser
- Department of Neuropathology, University Hospital Innsbruck, Tirol Kliniken, Innsbruck, Austria
| | - Johannes Kerschbaumer
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, Innsbruck, AT-6020, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, Innsbruck, AT-6020, Austria
| | - Christian F Freyschlag
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, Innsbruck, AT-6020, Austria.
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Deacu M, Popescu S, Docu Axelerad A, Topliceanu TS, Aschie M, Bosoteanu M, Cozaru GC, Cretu AM, Voda RI, Orasanu CI. Prognostic Factors of Low-Grade Gliomas in Adults. Curr Oncol 2022; 29:7327-7342. [PMID: 36290853 PMCID: PMC9600247 DOI: 10.3390/curroncol29100576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/22/2022] [Accepted: 09/29/2022] [Indexed: 11/22/2022] Open
Abstract
Adult low-grade gliomas are a rare and aggressive pathology of the central nervous system. Some of their characteristics contribute to the patient's life expectancy and to their management. This study aimed to characterize and identify the main prognostic factors of low-grade gliomas. The six-year retrospective study statistically analyzed the demographic, imaging, and morphogenetic characteristics of the patient group through appropriate parameters. Immunohistochemical tests were performed: IDH1, Ki-67, p53, and Nestin, as well as FISH tests on the CDKN2A gene and 1p/19q codeletion. The pathology was prevalent in females, with patients having an average age of 56.31 years. The average tumor volume was 41.61 cm3, producing a midline shift with an average of 7.5 mm. Its displacement had a negative impact on survival. The presence of a residual tumor resulted in decreased survival and is an independent risk factor for mortality. Positivity for p53 identified a low survival rate. CDKN2A mutations were an independent risk factor for mortality. We identified that a negative prognosis is influenced by the association of epilepsy with headache, tumor volume, and immunoreactivity to IDH1 and p53. Independent factors associated with mortality were midline shift, presence of tumor residue, and CDKN2A gene deletions and amplifications.
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Affiliation(s)
- Mariana Deacu
- Clinical Service of Pathology, Departments of Pathology, Sfantul Apostol Andrei Emergency County Hospital, 900591 Constanta, Romania
- Faculty of Medicine, “Ovidius” University of Constanta, 900470 Constanta, Romania
| | - Steliana Popescu
- Faculty of Medicine, “Ovidius” University of Constanta, 900470 Constanta, Romania
- Department of Radiology, Sfantul Apostol Andrei Emergency County Hospital, 900591 Constanta, Romania
| | - Any Docu Axelerad
- Faculty of Medicine, “Ovidius” University of Constanta, 900470 Constanta, Romania
- Department of Neurology, Sfantul Apostol Andrei Emergency County Hospital, 900591 Constanta, Romania
| | - Theodor Sebastian Topliceanu
- Center for Research and Development of the Morphological and Genetic Studyies of Malignant Pathology (CEDMOG), Ovidius University of Constanta, 900591 Constanta, Romania
| | - Mariana Aschie
- Clinical Service of Pathology, Departments of Pathology, Sfantul Apostol Andrei Emergency County Hospital, 900591 Constanta, Romania
- Faculty of Medicine, “Ovidius” University of Constanta, 900470 Constanta, Romania
- Academy of Medical Sciences of Romania, 030167 Bucharest, Romania
| | - Madalina Bosoteanu
- Clinical Service of Pathology, Departments of Pathology, Sfantul Apostol Andrei Emergency County Hospital, 900591 Constanta, Romania
- Faculty of Medicine, “Ovidius” University of Constanta, 900470 Constanta, Romania
| | - Georgeta Camelia Cozaru
- Center for Research and Development of the Morphological and Genetic Studyies of Malignant Pathology (CEDMOG), Ovidius University of Constanta, 900591 Constanta, Romania
- Clinical Service of Pathology, Departments of Genetics, Sfantul Apostol Andrei Emergency County Hospital, 900591 Constanta, Romania
| | - Ana Maria Cretu
- Clinical Service of Pathology, Departments of Pathology, Sfantul Apostol Andrei Emergency County Hospital, 900591 Constanta, Romania
- Center for Research and Development of the Morphological and Genetic Studyies of Malignant Pathology (CEDMOG), Ovidius University of Constanta, 900591 Constanta, Romania
| | - Raluca Ioana Voda
- Clinical Service of Pathology, Departments of Pathology, Sfantul Apostol Andrei Emergency County Hospital, 900591 Constanta, Romania
- Center for Research and Development of the Morphological and Genetic Studyies of Malignant Pathology (CEDMOG), Ovidius University of Constanta, 900591 Constanta, Romania
| | - Cristian Ionut Orasanu
- Clinical Service of Pathology, Departments of Pathology, Sfantul Apostol Andrei Emergency County Hospital, 900591 Constanta, Romania
- Center for Research and Development of the Morphological and Genetic Studyies of Malignant Pathology (CEDMOG), Ovidius University of Constanta, 900591 Constanta, Romania
- Correspondence: ; Tel.: +40-72-281-4037
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Axelson HW, Latini F, Jemstedt M, Ryttlefors M, Zetterling M. Continuous subcortical language mapping in awake glioma surgery. Front Oncol 2022; 12:947119. [PMID: 36033478 PMCID: PMC9416475 DOI: 10.3389/fonc.2022.947119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022] Open
Abstract
Repetitive monopolar short-train stimulation (STS) delivered from a suction probe enables continuous mapping and distance assessment of corticospinal tracts during asleep glioma resection. In this study, we explored this stimulation technique in awake glioma surgery. Fourteen patients with glioma involving language-related tracts were prospectively included. Continuous (3-Hz) cathodal monopolar STS (five pulses, 250 Hz) was delivered via the tip of a suction probe throughout tumor resection while testing language performance. At 70 subcortical locations, surgery was paused to deliver STS in a steady suction probe position. Monopolar STS influence on language performance at different subcortical locations was separated into three groups. Group 1 represented locations where STS did not produce language disturbance. Groups 2 and 3 represented subcortical locations where STS produced language interference at different threshold intensities (≥7.5 and ≤5 mA, respectively). For validation, bipolar Penfield stimulation (PS; 60 Hz for 3 s) was used as a “gold standard” comparison method to detect close proximity to language-related tracts and classified as positive or negative regarding language interference. There was no language interference from STS in 28 locations (Group 1), and PS was negative for all sites. In Group 2 (STS threshold ≥ 7.5 mA; median, 10 mA), there was language interference at 18 locations, and PS (median, 4 mA) was positive in only one location. In Group 3 (STS threshold ≤ 5 mA; median, 5 mA), there was language interference at 24 locations, and positive PS (median 4 mA) was significantly (p < 0.01) more common (15 out of 24 locations) compared with Groups 1 and 2. Despite the continuous stimulation throughout tumor resection, there were no seizures in any of the patients. In five patients, temporary current spread to the facial nerve was observed. We conclude that continuous subcortical STS is feasibly also in awake glioma surgery and that no language interference from STS or interference at ≥7.5 mA seems to indicate safe distance to language tracts as judged by PS comparisons. STS language interference at STS ≤ 5 mA was not consistently confirmed by PS, which needs to be addressed.
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Affiliation(s)
- Hans W. Axelson
- Department of Medical Sciences, Section of Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
- *Correspondence: Hans W. Axelson,
| | - Francesco Latini
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Malin Jemstedt
- Department of Medical Sciences, Speech-Language Pathology, Uppsala University, Uppsala, Sweden
| | - Mats Ryttlefors
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Maria Zetterling
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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Sierpowska J, Rofes A, Dahlslätt K, Mandonnet E, ter Laan M, Połczyńska M, Hamer PDW, Halaj M, Spena G, Meling TR, Motomura K, Reyes AF, Campos AR, Robe PA, Zigiotto L, Sarubbo S, Freyschlag CF, Broen MPG, Stranjalis G, Papadopoulos K, Liouta E, Rutten GJ, Viegas CP, Silvestre A, Perrote F, Brochero N, Cáceres C, Zdun-Ryżewska A, Kloc W, Satoer D, Dragoy O, Hendriks MPH, Alvarez-Carriles JC, Piai V. The Aftercare Survey: Assessment and intervention practices after brain tumor surgery in Europe. Neurooncol Pract 2022; 9:328-337. [PMID: 35855456 PMCID: PMC9290892 DOI: 10.1093/nop/npac029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background People with gliomas need specialized neurosurgical, neuro-oncological, psycho-oncological, and neuropsychological care. The role of language and cognitive recovery and rehabilitation in patients' well-being and resumption of work is crucial, but there are no clear guidelines for the ideal timing and character of assessments and interventions. The goal of the present work was to describe representative (neuro)psychological practices implemented after brain surgery in Europe. Methods An online survey was addressed to professionals working with individuals after brain surgery. We inquired about the assessments and interventions and the involvement of caregivers. Additionally, we asked about recommendations for an ideal assessment and intervention plan. Results Thirty-eight European centers completed the survey. Thirty of them offered at least one postsurgical (neuro)psychological assessment, mainly for language and cognition, especially during the early recovery stage and at long term. Twenty-eight of the participating centers offered postsurgical therapies. Patients who stand the highest chances of being included in evaluation and therapy postsurgically are those who underwent awake brain surgery, harbored a low-grade glioma, or showed poor recovery. Nearly half of the respondents offer support programs to caregivers, and all teams recommend them. Treatments differed between those offered to individuals with low-grade glioma vs those with high-grade glioma. The figure of caregiver is not yet fully recognized in the recovery phase. Conclusion We stress the need for more complete rehabilitation plans, including the emotional and health-related aspects of recovery. In respondents' opinions, assessment and rehabilitation plans should also be individually tailored and goal-directed (eg, professional reinsertion).
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Affiliation(s)
- Joanna Sierpowska
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, the Netherlands
- Department of Medical Psychology, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Adrià Rofes
- Department of Neurolinguistics, University of Groningen, Groningen, the Netherlands
| | | | | | - Mark ter Laan
- Department of Neurosurgery, Radboud Institute of Health Science, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Monika Połczyńska
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, California, USA
| | | | - Matej Halaj
- Department of Neurosurgery, University Hospital Olomouc, Olomouc, Czech Republic
| | | | - Torstein R Meling
- Department of Neurosurgery, Geneva University Hospital, Geneva, Switzerland
| | - Kazuya Motomura
- Department of Neurosurgery, Nagoya University School of Medicine, Nagoya, Japan
| | - Andrés Felipe Reyes
- Experimental Psychology Lab, Faculty of Psychology, Universidad El Bosque, Bogotá, Colombia
- Graduate School for the Humanities (GSH), University of Groningen, Groningen, the Netherlands
| | - Alexandre Rainha Campos
- Department of Neurosurgery, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Pierre A Robe
- Department of Neurology and Neurosurgery, University Medical Center of Utrecht, Utrecht, the Netherlands
| | - Luca Zigiotto
- Department of Neurosurgery, “S. Chiara” Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
- Structural and Functional Connectivity Lab Project, “S. Chiara” Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Silvio Sarubbo
- Department of Neurosurgery, “S. Chiara” Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
- Structural and Functional Connectivity Lab Project, “S. Chiara” Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | | | - Martijn P G Broen
- Department of Neurology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - George Stranjalis
- Department of Neurosurgery, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - Konstantinos Papadopoulos
- Department of Neurosurgery, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - Evangelia Liouta
- Department of Neurosurgery, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - Geert-Jan Rutten
- Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | | | - Ana Silvestre
- Department of Neurosurgery, Hospital Garcia de Orta, Lisbon, Portugal
| | - Federico Perrote
- Department of Neurosurgery and Neurology, Private University Hospital of Córdoba, Córdoba, Argentina
| | - Natacha Brochero
- Department of Neurosurgery and Neurology, Private University Hospital of Córdoba, Córdoba, Argentina
| | - Cynthia Cáceres
- Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Agata Zdun-Ryżewska
- Department of Quality-of-Life Research, Medical University of Gdansk, Gdansk, Poland
| | - Wojciech Kloc
- Department of Psychology and Sociology of Health and Public Health School of Public Health Collegium Medicum, University of Warmia—Mazury in Olsztyn, Olsztyn, Poland
- Department of Neurosurgery, Copernicus PL, Gdansk, Poland
| | - Djaina Satoer
- Department of Neurosurgery, Erasmus MC—University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Olga Dragoy
- Center for Language and Brain, HSE University, Moscow, Russia
| | - Marc P H Hendriks
- Academic Centre for Epileptology, Kempenhaeghe, Heeze, the Netherlands
- Department of Neurosurgery, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Juan C Alvarez-Carriles
- Clinical Neuropsychology Unit, Liaison Mental Health Service, Hospital Universitario Central de Asturias, Oviedo, Spain
- Department of Psychology, University of Oviedo, Oviedo, Spain
- ISPA, Health Research Institute of Principado de Asturias, Oviedo, Spain
| | - Vitória Piai
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, the Netherlands
- Department of Medical Psychology, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
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Booth TC, Wiegers EC, Warnert EAH, Schmainda KM, Riemer F, Nechifor RE, Keil VC, Hangel G, Figueiredo P, Álvarez-Torres MDM, Henriksen OM. High-Grade Glioma Treatment Response Monitoring Biomarkers: A Position Statement on the Evidence Supporting the Use of Advanced MRI Techniques in the Clinic, and the Latest Bench-to-Bedside Developments. Part 2: Spectroscopy, Chemical Exchange Saturation, Multiparametric Imaging, and Radiomics. Front Oncol 2022; 11:811425. [PMID: 35340697 PMCID: PMC8948428 DOI: 10.3389/fonc.2021.811425] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/28/2021] [Indexed: 01/16/2023] Open
Abstract
Objective To summarize evidence for use of advanced MRI techniques as monitoring biomarkers in the clinic, and to highlight the latest bench-to-bedside developments. Methods The current evidence regarding the potential for monitoring biomarkers was reviewed and individual modalities of metabolism and/or chemical composition imaging discussed. Perfusion, permeability, and microstructure imaging were similarly analyzed in Part 1 of this two-part review article and are valuable reading as background to this article. We appraise the clinic readiness of all the individual modalities and consider methodologies involving machine learning (radiomics) and the combination of MRI approaches (multiparametric imaging). Results The biochemical composition of high-grade gliomas is markedly different from healthy brain tissue. Magnetic resonance spectroscopy allows the simultaneous acquisition of an array of metabolic alterations, with choline-based ratios appearing to be consistently discriminatory in treatment response assessment, although challenges remain despite this being a mature technique. Promising directions relate to ultra-high field strengths, 2-hydroxyglutarate analysis, and the use of non-proton nuclei. Labile protons on endogenous proteins can be selectively targeted with chemical exchange saturation transfer to give high resolution images. The body of evidence for clinical application of amide proton transfer imaging has been building for a decade, but more evidence is required to confirm chemical exchange saturation transfer use as a monitoring biomarker. Multiparametric methodologies, including the incorporation of nuclear medicine techniques, combine probes measuring different tumor properties. Although potentially synergistic, the limitations of each individual modality also can be compounded, particularly in the absence of standardization. Machine learning requires large datasets with high-quality annotation; there is currently low-level evidence for monitoring biomarker clinical application. Conclusion Advanced MRI techniques show huge promise in treatment response assessment. The clinical readiness analysis highlights that most monitoring biomarkers require standardized international consensus guidelines, with more facilitation regarding technique implementation and reporting in the clinic.
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Affiliation(s)
- Thomas C. Booth
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St. Thomas’ Hospital, London, United Kingdom
- Department of Neuroradiology, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Evita C. Wiegers
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Kathleen M. Schmainda
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Frank Riemer
- Mohn Medical Imaging and Visualization Centre (MMIV), Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | - Ruben E. Nechifor
- Department of Clinical Psychology and Psychotherapy International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babes-Bolyai University, Cluj-Napoca, Romania
| | - Vera C. Keil
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location VUmc, Amsterdam, Netherlands
| | - Gilbert Hangel
- Department of Neurosurgery & High-Field MR Centre, Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Patrícia Figueiredo
- Department of Bioengineering and Institute for Systems and Robotics - Lisboa, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | | | - Otto M. Henriksen
- Department of Clinical Physiology, Nuclear medicine and PET, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Patient-Reported Quality of Life in Grade 2 and 3 Gliomas after Surgery, Can We Do More? Clin Neurol Neurosurg 2022; 214:107175. [DOI: 10.1016/j.clineuro.2022.107175] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/01/2022] [Accepted: 02/10/2022] [Indexed: 12/11/2022]
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Han Y, Wang ZJ, Li WH, Yang Y, Zhang J, Yang XB, Zuo L, Xiao G, Wang SZ, Yan LF, Cui GB. Differentiation Between Primary Central Nervous System Lymphoma and Atypical Glioblastoma Based on MRI Morphological Feature and Signal Intensity Ratio: A Retrospective Multicenter Study. Front Oncol 2022; 12:811197. [PMID: 35174088 PMCID: PMC8841723 DOI: 10.3389/fonc.2022.811197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/05/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives To investigate the value of morphological feature and signal intensity ratio (SIR) derived from conventional magnetic resonance imaging (MRI) in distinguishing primary central nervous system lymphoma (PCNSL) from atypical glioblastoma (aGBM). Methods Pathology-confirmed PCNSLs (n = 93) or aGBMs (n = 48) from three institutions were retrospectively enrolled and divided into training cohort (n = 98) and test cohort (n = 43). Morphological features and SIRs were compared between PCNSL and aGBM. Using linear discriminant analysis, multiple models were constructed with SIRs and morphological features alone or jointly, and the diagnostic performances were evaluated via receiver operating characteristic (ROC) analysis. Areas under the curves (AUCs) and accuracies (ACCs) of the models were compared with the radiologists’ assessment. Results Incision sign, T2 pseudonecrosis sign, reef sign and peritumoral leukomalacia sign were associated with PCNSL (training and overall cohorts, P < 0.05). Increased T1 ratio, decreased T2 ratio and T2/T1 ratio were predictive of PCNSL (all P < 0.05). ROC analysis showed that combination of morphological features and SIRs achieved the best diagnostic performance for differentiation of PCNSL and aGBM with AUC/ACC of 0.899/0.929 for the training cohort, AUC/ACC of 0.794/0.837 for the test cohort and AUC/ACC of 0.869/0.901 for the overall cohort, respectively. Based on the overall cohort, two radiologists could distinguish PCNSL from aGBM with AUC/ACC of 0.732/0.724 for radiologist A and AUC/ACC of 0.811/0.829 for radiologist B. Conclusion MRI morphological features can help differentiate PCNSL from aGBM. When combined with SIRs, the diagnostic performance was better than that of radiologists’ assessment.
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Affiliation(s)
- Yu Han
- Department of Radiology and Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Zi-Jun Wang
- Battalion of the First Regiment of cadets of Basic Medicine, Fourth Military Medical University, Xi’an, China
| | - Wen-Hua Li
- Battalion of the Second Regiment of cadets of Basic Medicine, Fourth Military Medical University, Xi’an, China
| | - Yang Yang
- Department of Radiology and Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Jian Zhang
- Department of Radiology, Xi’an XD Group Hospital, Shaanxi University of Chinese Medicine, Xi’an, China
| | - Xi-Biao Yang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lin Zuo
- Department of Radiology and Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Gang Xiao
- Department of Radiology and Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Sheng-Zhong Wang
- Department of Radiology and Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Lin-Feng Yan
- Department of Radiology and Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
- *Correspondence: Guang-Bin Cui, ; Lin-Feng Yan,
| | - Guang-Bin Cui
- Department of Radiology and Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
- *Correspondence: Guang-Bin Cui, ; Lin-Feng Yan,
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Svedung Wettervik T, Munkhammar ÅA, Jemstedt M, Ersson M, Latini F, Ryttlefors M, Zetterling M. Dynamics in cognition and health-related quality of life in grade 2 and 3 gliomas after surgery. Acta Neurochir (Wien) 2022; 164:3275-3284. [PMID: 36331612 PMCID: PMC9705489 DOI: 10.1007/s00701-022-05408-2] [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: 07/14/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The focus of clinical management and research in gliomas has been on survival, but the interest in the treatment effects on cognition and health-related quality of life (HRQoL) is emerging. The primary aim of this study was to investigate the dynamics in cognition after brain tumor surgery for astrocytomas and oligodendrogliomas grade 2 and 3. The secondary aim was to investigate the association of postoperative changes in cognition with changes HRQoL. METHODS In this observational study, 48 patients operated for an astrocytoma or oligodendrogliomas, grade 2 or 3, at the Department of Neurosurgery, Uppsala, Sweden, 2016-2021, were included. Cognitive and language skills were assessed with a selected test battery and HRQoL was patient-reported as assessed with RAND-36 pre- and approximately 3 months postoperatively. RESULTS There was a significant postoperative decrease in attention span and verbal learning, but the patients improved in the test for visual memory. There was no change in visual attention, executive function, verbal memory, visual organization and construction, verbal fluency, and confrontation naming. The RAND-36 variables physical function, role physical, general health, vitality, and social functioning decreased significantly after surgery. Patients operated for tumor recurrence exhibited greater deterioration in attention and a greater extent of resection correlated with a less pronounced decrease in verbal memory, but there were otherwise weak associations between the dynamics in cognition and patient-, tumor-, and treatment-variables. A decline in cognitive variables was not associated with worse HRQoL. CONCLUSIONS Although both several cognitive and HRQoL domains deteriorated postoperatively, these changes did not correlate with each other. This highlights the complexity of cognitive and HRQoL dynamics in the early postoperative phase.
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Affiliation(s)
- Teodor Svedung Wettervik
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Åsa A. Munkhammar
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Malin Jemstedt
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Marcus Ersson
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Francesco Latini
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Mats Ryttlefors
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Maria Zetterling
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
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Munkvold BKR, Solheim O, Bartek J, Corell A, de Dios E, Gulati S, Helseth E, Holmgren K, Jensdottir M, Lundborg M, Mireles EEM, Mahesparan R, Tveiten ØV, Milos P, Redebrandt HN, Pedersen LK, Ramm-Pettersen J, Sjöberg RL, Sjögren B, Sjåvik K, Smits A, Tomasevic G, Vecchio TG, Vik-Mo EO, Zetterling M, Salvesen Ø, Jakola AS. Variations in the management of diffuse low-grade gliomas-A Scandinavian multicenter study. Neurooncol Pract 2021; 8:706-717. [PMID: 34777840 PMCID: PMC8579093 DOI: 10.1093/nop/npab054] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Early extensive surgery is a cornerstone in treatment of diffuse low-grade gliomas (DLGGs), and an additional survival benefit has been demonstrated from early radiochemotherapy in selected “high-risk” patients. Still, there are a number of controversies related to DLGG management. The objective of this multicenter population-based cohort study was to explore potential variations in diagnostic work-up and treatment between treating centers in 2 Scandinavian countries with similar public health care systems. Methods Patients screened for inclusion underwent primary surgery of a histopathologically verified diffuse WHO grade II glioma in the time period 2012 through 2017. Clinical and radiological data were collected from medical records and locally conducted research projects, whereupon differences between countries and inter-hospital variations were explored. Results A total of 642 patients were included (male:female ratio 1:4), and annual age-standardized incidence rates were 0.9 and 0.8 per 100 000 in Norway and Sweden, respectively. Considerable inter-hospital variations were observed in preoperative work-up, tumor diagnostics, surgical strategies, techniques for intraoperative guidance, as well as choice and timing of adjuvant therapy. Conclusions Despite geographical population-based case selection, similar health care organizations, and existing guidelines, there were considerable variations in DLGG management. While some can be attributed to differences in clinical implementation of current scientific knowledge, some of the observed inter-hospital variations reflect controversies related to diagnostics and treatment. Quantification of these disparities renders possible identification of treatment patterns associated with better or worse outcomes and may thus represent a step toward more uniform evidence-based care.
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Affiliation(s)
- Bodil Karoline Ravn Munkvold
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
| | - Ole Solheim
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, NTNU, Trondheim, Norway.,Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Alba Corell
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eddie de Dios
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Sasha Gulati
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, NTNU, Trondheim, Norway.,Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Eirik Helseth
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Klas Holmgren
- Department of Clinical Sciences, Neuroscience, Umeå University, Umeå, Sweden.,Department of Neurosurgery, University Hospital of Northern Sweden, Umeå, Sweden
| | - Margret Jensdottir
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Mina Lundborg
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | | | - Ruby Mahesparan
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Øystein Vesterli Tveiten
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway.,Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Peter Milos
- Department of Neurosurgery, Linköping University Hospital, Sweden
| | - Henrietta Nittby Redebrandt
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| | | | | | - Rickard L Sjöberg
- Department of Clinical Sciences, Neuroscience, Umeå University, Umeå, Sweden.,Department of Neurosurgery, University Hospital of Northern Sweden, Umeå, Sweden
| | - Björn Sjögren
- Department of Neurosurgery, Linköping University Hospital, Sweden
| | - Kristin Sjåvik
- Department of Neurosurgery, University Hospital of North Norway, Tromsø, Norway
| | - Anja Smits
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Gregor Tomasevic
- Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| | - Tomás Gómez Vecchio
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Einar O Vik-Mo
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Maria Zetterling
- Department of Neuroscience, Uppsala University, Uppsala, Sweden.,Department of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden
| | - Øyvind Salvesen
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Asgeir S Jakola
- Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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10
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Gómez Vecchio T, Neimantaite A, Corell A, Bartek J, Jensdottir M, Reinertsen I, Solheim O, Jakola AS. Lower-Grade Gliomas: An Epidemiological Voxel-Based Analysis of Location and Proximity to Eloquent Regions. Front Oncol 2021; 11:748229. [PMID: 34621684 PMCID: PMC8490663 DOI: 10.3389/fonc.2021.748229] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/27/2021] [Indexed: 01/14/2023] Open
Abstract
Background Glioma is the most common intra-axial tumor, and its location relative to critical areas of the brain is important for treatment decision-making. Studies often report tumor location based on anatomical taxonomy alone since the estimation of eloquent regions requires considerable knowledge of functional neuroanatomy and is, to some degree, a subjective measure. An unbiased and reproducible method to determine tumor location and eloquence is desirable, both for clinical use and for research purposes. Objective To report on a voxel-based method for assessing anatomical distribution and proximity to eloquent regions in diffuse lower-grade gliomas (World Health Organization grades 2 and 3). Methods A multi-institutional population-based dataset of adult patients (≥18 years) histologically diagnosed with lower-grade glioma was analyzed. Tumor segmentations were registered to a standardized space where two anatomical atlases were used to perform a voxel-based comparison of the proximity of segmentations to brain regions of traditional clinical interest. Results Exploring the differences between patients with oligodendrogliomas, isocitrate dehydrogenase (IDH) mutated astrocytomas, and patients with IDH wild-type astrocytomas, we found that the latter were older, more often had lower Karnofsky performance status, and that these tumors were more often found in the proximity of eloquent regions. Eloquent regions are found slightly more frequently in the proximity of IDH-mutated astrocytomas compared to oligodendrogliomas. The regions included in our voxel-based definition of eloquence showed a high degree of association with performing biopsy compared to resection. Conclusion We present a simple, robust, unbiased, and clinically relevant method for assessing tumor location and eloquence in lower-grade gliomas.
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Affiliation(s)
- Tomás Gómez Vecchio
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Alice Neimantaite
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Alba Corell
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Margret Jensdottir
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Ingerid Reinertsen
- Department of Health Research, SINTEF Digital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
| | - Ole Solheim
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, NTNU, Trondheim, Norway.,Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Asgeir S Jakola
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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11
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Ntemou E, Ohlerth AK, Ille S, Krieg SM, Bastiaanse R, Rofes A. Mapping Verb Retrieval With nTMS: The Role of Transitivity. Front Hum Neurosci 2021; 15:719461. [PMID: 34539364 PMCID: PMC8442843 DOI: 10.3389/fnhum.2021.719461] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/31/2021] [Indexed: 11/25/2022] Open
Abstract
Navigated Transcranial Magnetic Stimulation (nTMS) is used to understand the cortical organization of language in preparation for the surgical removal of a brain tumor. Action naming with finite verbs can be employed for that purpose, providing additional information to object naming. However, little research has focused on the properties of the verbs that are used in action naming tasks, such as their status as transitive (taking an object; e.g., to read) or intransitive (not taking an object; e.g., to wink). Previous neuroimaging data show higher activation for transitive compared to intransitive verbs in posterior perisylvian regions bilaterally. In the present study, we employed nTMS and production of finite verbs to investigate the cortical underpinnings of transitivity. Twenty neurologically healthy native speakers of German participated in the study. They underwent language mapping in both hemispheres with nTMS. The action naming task with finite verbs consisted of transitive (e.g., The man reads the book) and intransitive verbs (e.g., The woman winks) and was controlled for relevant psycholinguistic variables. Errors were classified in four different error categories (i.e., non-linguistic errors, grammatical errors, lexico-semantic errors and, errors at the sound level) and were analyzed quantitatively. We found more nTMS-positive points in the left hemisphere, particularly in the left parietal lobe for the production of transitive compared to intransitive verbs. These positive points most commonly corresponded to lexico-semantic errors. Our findings are in line with previous aphasia and neuroimaging studies, suggesting that a more widespread network is used for the production of verbs with a larger number of arguments (i.e., transitives). The higher number of lexico-semantic errors with transitive compared to intransitive verbs in the left parietal lobe supports previous claims for the role of left posterior areas in the retrieval of argument structure information.
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Affiliation(s)
- Effrosyni Ntemou
- International Doctorate in Experimental Approaches to Language and Brain (IDEALAB, Universities of Groningen, Potsdam, Newcastle, Trento and Macquarie University), Sydney, NSW, Australia.,Centre for Language and Cognition Groningen (CLCG), University of Groningen, Groningen, Netherlands
| | - Ann-Katrin Ohlerth
- International Doctorate in Experimental Approaches to Language and Brain (IDEALAB, Universities of Groningen, Potsdam, Newcastle, Trento and Macquarie University), Sydney, NSW, Australia.,Centre for Language and Cognition Groningen (CLCG), University of Groningen, Groningen, Netherlands
| | - Sebastian Ille
- Department of Neurosurgery, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Roelien Bastiaanse
- Center for Language and Brain, National Research University Higher School of Economics, Moscow, Russia
| | - Adrià Rofes
- Centre for Language and Cognition Groningen (CLCG), University of Groningen, Groningen, Netherlands
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12
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Age is associated with unfavorable neuropathological and radiological features and poor outcome in patients with WHO grade 2 and 3 gliomas. Sci Rep 2021; 11:17380. [PMID: 34462493 PMCID: PMC8405625 DOI: 10.1038/s41598-021-96832-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 08/17/2021] [Indexed: 12/20/2022] Open
Abstract
With the rising life expectancy and availability of neuroimaging, increased number of older patients will present with diffuse and anaplastic gliomas. The aim of our study was therefore to investigate age-related prognostic clinical, neuropathological and radiological features of lower-grade gliomas. All consecutive patients with diffuse or anaplastic glioma WHO grade 2 and 3 who underwent first tumor resection between 2010 and 2018, were selected from the institutional neuro-oncological database and evaluated. The mean age of 55 males and 44 females was 46 years (SD ± 16). Wild-type IDH1 (p = 0.012), persistent nuclear ATRX expression (p = 0.012) and anaplasia (p < 0.001) were significantly associated with higher age. The CE volume before resection was found to be increased in older patients (r = 0.42, p < 0.0001), and CE rate was higher in the IDH wild-type population only (p = 0.02). The extent of resection did not differ with age. Overall, one year of life resulted in a PFS reduction of 9 days (p = 0.047); in IDH sub-group analysis, this dependency was confirmed only in wild-type tumors (p = 0.05). OS was significantly reduced in older patients (p = 0.033). In conclusion, behavior and prognosis of WHO grade 2 and 3 glioma were unfavorable in correlation to patient’s age, even if the extent of resection was comparable. Older age imparted a poorer PFS and higher CE rate only in the IDH wild-type population.
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13
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Silva LL, Tuncer MS, Vajkoczy P, Picht T, Rosenstock T. Distinct approaches to language pathway tractography: comparison of anatomy-based, repetitive navigated transcranial magnetic stimulation (rTMS)-based, and rTMS-enhanced diffusion tensor imaging-fiber tracking. J Neurosurg 2021; 136:589-600. [PMID: 34330091 DOI: 10.3171/2020.12.jns204028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Visualization of subcortical language pathways by means of diffusion tensor imaging-fiber tracking (DTI-FT) is evolving as an important tool for surgical planning and decision making in patients with language-suspect brain tumors. Repetitive navigated transcranial magnetic stimulation (rTMS) cortical language mapping noninvasively provides additional functional information. Efforts to incorporate rTMS data into DTI-FT are promising, but the lack of established protocols makes it hard to assess clinical utility. The authors performed DTI-FT of important language pathways by using five distinct approaches in an effort to evaluate the respective clinical usefulness of each approach. METHODS Thirty patients with left-hemispheric perisylvian lesions underwent preoperative rTMS language mapping and DTI. FT of the principal language tracts was conducted according to different strategies: Ia, anatomical landmark based; Ib, lesion-focused landmark based; IIa, rTMS based; IIb, rTMS based with postprocessing; and III, rTMS enhanced (based on a combination of structural and functional data). The authors analyzed the respective success of each method in revealing streamlines and conducted a multinational survey with expert clinicians to evaluate aspects of clinical utility. RESULTS The authors observed high usefulness and accuracy ratings for anatomy-based approaches (Ia and Ib). Postprocessing of rTMS-based tractograms (IIb) led to more balanced perceived information content but did not improve the usefulness for surgical planning and risk assessment. Landmark-based tractography (Ia and Ib) was most successful in delineating major language tracts (98% success), whereas rTMS-based tractography (IIa and IIb) frequently failed to reveal streamlines and provided less complete tractograms than the landmark-based approach (p < 0.001). The lesion-focused landmark-based (Ib) and the rTMS-enhanced (III) approaches were the most preferred methods. CONCLUSIONS The lesion-focused landmark-based approach (Ib) achieved the best ratings and enabled visualization of the principal language tracts in almost all cases. The rTMS-enhanced approach (III) was positively evaluated by the experts because it can reveal cortico-subcortical connections, but the functional relevance of these connections is still unclear. The use of regions of interest derived solely from cortical rTMS mapping (IIa and IIb) leads to cluttered images that are of limited use in clinical practice.
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Affiliation(s)
- Luca L Silva
- Departments of1Neurosurgery and.,2Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin
| | | | | | - Thomas Picht
- Departments of1Neurosurgery and.,3Cluster of Excellence: "Matters of Activity. Image Space Material"-Humboldt University, Berlin; and
| | - Tizian Rosenstock
- Departments of1Neurosurgery and.,4Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin, Germany
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14
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The advanced development of Cx43 and GAP-43 mediated intercellular networking in IDH1 wildtype diffuse and anaplastic gliomas with lower mitotic rate. J Cancer Res Clin Oncol 2021; 147:3003-3009. [PMID: 34173871 DOI: 10.1007/s00432-021-03711-6] [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: 04/25/2021] [Accepted: 06/23/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The biologic behavior and the therapeutic resistance of diffuse and anaplastic gliomas varies greatly. This may be explained by differences in cell-to-cell communication, determined by the Cx43-associated junctional activity and the microtubules-defined network, in which GAP-43 is the dominant structural component. We assessed the expression of these crucial communication proteins in samples of patients harboring WHO°II and III gliomas, graded according to the current 4th revised WHO classification. METHODS Tissue of adult patients with WHO°II and III gliomas, who underwent surgery between 2014 and 2018, were selected from our institutional biobank. GAP-43 and Cx43 expression was analyzed using IHC. Routine clinical and neuropathological findings were additionally retrieved from our institutional prospective database. RESULTS 43 (57%) males and 33 (43%) females with a median age of 47 (IqR: 35-61) years were selected. IDH1 wildtype tumors showed a significantly higher expression of Cx43 (p = 0.014) and a tendency for increased GAP-43 production. Advanced Cx43 expression significantly correlated with lower mitosis rate (p = 0.014): more in IDH1 wildtype (r = - 0.57, p = 0.003) than in mutated gliomas (r = - 0.37, p = 0.019). There was no difference in Cx43 or GAP-43 expression in relation to anaplastic phenotype, Gadolinum-contrasted enhancement (CE) on MRI and advanced EGFR or p53 expression. CONCLUSIONS Intercellular communication tends to be more relevant in slower proliferating, e.g. lower malignant tumors. They could have more time to establish this network, providing longitudinally acquired resistance against specific oncological therapy. This feature matches the unfavorable IDH1 wildtype status of glioma and supports the noted malignant behavior of these tumors in the upcoming 5th WHO classification of gliomas.
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15
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Latini F, Axelson H, Fahlström M, Jemstedt M, Alberius Munkhammar Å, Zetterling M, Ryttlefors M. Role of Preoperative Assessment in Predicting Tumor-Induced Plasticity in Patients with Diffuse Gliomas. J Clin Med 2021; 10:jcm10051108. [PMID: 33799925 PMCID: PMC7961995 DOI: 10.3390/jcm10051108] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 01/03/2023] Open
Abstract
When diffuse gliomas (DG) affect the brain’s potential to reorganize functional networks, patients can exhibit seizures and/or language/cognitive impairment. The tumor–brain interaction and the individual connectomic organization cannot be predicted preoperatively. We aimed to, first, investigate the relationship between preoperative assessment and intraoperative findings of eloquent tumors in 36 DG operated with awake surgery. Second, we also studied possible mechanisms of tumor-induced brain reorganization in these patients. FLAIR-MRI sequences were used for tumor volume segmentation and the Brain-Grid system (BG) was used as an overlay for infiltration analysis. Neuropsychological (NPS) and/or language assessments were performed in all patients. The distance between eloquent spots and tumor margins was measured. All variables were used for correlation and logistic regression analyses. Eloquent tumors were detected in 75% of the patients with no single variable able to predict this finding. Impaired NPS functions correlated with invasive tumors, crucial location (A4C2S2/A3C2S2-voxels, left opercular-insular/sub-insular region) and higher risk of eloquent tumors. Epilepsy was correlated with larger tumor volumes and infiltrated A4C2S2/A3C2S2 voxels. Language impairment was correlated with infiltrated A3C2S2 voxel. Peritumoral cortical eloquent spots reflected an early compensative mechanism with age as possible influencing factor. Preoperative NPS impairment is linked with high risk of eloquent tumors. A systematic integration of extensive cognitive assessment and advanced neuroimaging can improve our comprehension of the connectomic brain organization at the individual scale and lead to a better oncological/functional balance.
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Affiliation(s)
- Francesco Latini
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, 75185 Uppsala, Sweden; (M.Z.); (M.R.)
- Correspondence: ; Tel.: +46-764-244-653
| | - Hans Axelson
- Section of Clinical Neurophysiology, Department of Neuroscience, Uppsala University, 75185 Uppsala, Sweden;
| | - Markus Fahlström
- Section of Radiology, Department of Surgical Sciences, Uppsala University, 75185 Uppsala, Sweden;
| | - Malin Jemstedt
- Department of Neuroscience, Speech-Language Pathology, Uppsala University, 75185 Uppsala, Sweden;
| | | | - Maria Zetterling
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, 75185 Uppsala, Sweden; (M.Z.); (M.R.)
| | - Mats Ryttlefors
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, 75185 Uppsala, Sweden; (M.Z.); (M.R.)
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16
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Manfrini E, Smits M, Thust S, Geiger S, Bendella Z, Petr J, Solymosi L, Keil VC. From research to clinical practice: a European neuroradiological survey on quantitative advanced MRI implementation. Eur Radiol 2021; 31:6334-6341. [PMID: 33481098 PMCID: PMC8270851 DOI: 10.1007/s00330-020-07582-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/22/2020] [Accepted: 12/01/2020] [Indexed: 12/13/2022]
Abstract
Objective Quantitative MRI (qMRI) methods provide versatile neuroradiological applications and are a hot topic in research. The degree of their clinical implementation is however barely known. This survey was created to illuminate which and how qMRI techniques are currently applied across Europe. Methods In total, 4753 neuroradiologists from 27 countries received an online questionnaire. Demographic and professional data, experience with qMRI techniques in the brain and head and neck, usage, reasons for/against application, and knowledge of the QIBA and EIBALL initiatives were assessed. Results Two hundred seventy-two responders in 23 countries used the following techniques clinically (mean values in %): DWI (82.0%, n = 223), DSC (67.3%, n = 183), MRS (64.3%, n = 175), DCE (43.4%, n = 118), BOLD-fMRI (42.6%, n = 116), ASL (37.5%, n = 102), fat quantification (25.0%, n = 68), T2 mapping (16.9%, n = 46), T1 mapping (15.1%, n = 41), PET-MRI (11.8%, n = 32), IVIM (5.5%, n = 15), APT-CEST (4.8%, n = 13), and DKI (3.3%, n = 9). The most frequent usage indications for any qMRI technique were tissue differentiation (82.4%, n = 224) and oncological monitoring (72.8%, n = 198). Usage differed between countries, e.g. ASL: Germany (n = 13/63; 20.6%) vs. France (n = 31/40; 77.5%). Neuroradiologists endorsed the use of qMRI because of an improved diagnostic accuracy (89.3%, n = 243), but 50.0% (n = 136) are in need of better technology, 34.9% (n = 95) wish for more communication, and 31.3% need help with result interpretation/generation (n = 85). QIBA and EIBALL were not well known (12.5%, n = 34, and 11.0%, n = 30). Conclusions The clinical implementation of qMRI methods is highly variable. Beyond the aspect of readiness for clinical use, better availability of support and a wider dissemination of guidelines could catalyse a broader implementation. Key Points • Neuroradiologists endorse the use of qMRI techniques as they subjectively improve diagnostic accuracy. • Clinical implementation is highly variable between countries, techniques, and indications. • The use of advanced imaging could be promoted through an increase in technical support and training of both doctors and technicians. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-020-07582-2.
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Affiliation(s)
- Elia Manfrini
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany.,Facoltà di Medicina e Chirurgia, Università Politecnica delle Marche, Via Tronto 10, 60126, Ancona, Italy
| | - Marion Smits
- Department of Radiology and Nuclear Medicine (Ne-515), Erasmus MC, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.,National Hospital for Neurology and Neurosurgery, University College London Hospitals, London, UK
| | - Steffi Thust
- National Hospital for Neurology and Neurosurgery, University College London Hospitals, London, UK.,Department of Brain Rehabilitation and Repair, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Sergej Geiger
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Zeynep Bendella
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jan Petr
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Laszlo Solymosi
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Vera C Keil
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany. .,Department of Radiology, Section Neuroradiology, Amsterdam University Medical Center, VUmc, Amsterdam, The Netherlands.
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17
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Han Y, Yang Y, Shi ZS, Zhang AD, Yan LF, Hu YC, Feng LL, Ma J, Wang W, Cui GB. Distinguishing brain inflammation from grade II glioma in population without contrast enhancement: a radiomics analysis based on conventional MRI. Eur J Radiol 2020; 134:109467. [PMID: 33307462 DOI: 10.1016/j.ejrad.2020.109467] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/22/2020] [Accepted: 12/01/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE In populations without contrast enhancement, the imaging features of atypical brain parenchyma inflammations can mimic those of grade II gliomas. The aim of this study was to assess the value of the conventional MR-based radiomics signature in differentiating brain inflammation from grade II glioma. METHODS Fifty-seven patients (39 patients with grade II glioma and 18 patients with inflammation) were divided into primary (n = 44) and validation cohorts (n = 13). Radiomics features were extracted from T1-weighted images (T1WI) and T2-weighted images (T2WI). Two-sample t-test and least absolute shrinkage and selection operator (LASSO) regression were adopted to select features and build radiomics signature models for discriminating inflammation from glioma. The predictive performance of the models was evaluated via area under the receiver operating characteristic curve (AUC) and compared with the radiologists' assessments. RESULTS Based on the primary cohort, we developed T1WI, T2WI and combination (T1WI + T2WI) models for differentiating inflammation from glioma with 4, 8, and 5 radiomics features, respectively. Among these models, T2WI and combination models achieved better diagnostic efficacy, with AUC of 0.980, 0.988 in primary cohort and that of 0.950, 0.925 in validation cohort, respectively. The AUCs of radiologist 1's and 2's assessments were 0.661 and 0.722, respectively. CONCLUSION The signature based on radiomics features helps to differentiate inflammation from grade II glioma and improved performance compared with experienced radiologists, which could potentially be useful in clinical practice.
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Affiliation(s)
- Yu Han
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710038, PR China
| | - Yang Yang
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710038, PR China
| | - Zhe-Sheng Shi
- College of Basic Medicine, Fourth Military Medical University, Xi'an, Shaanxi, 710032, PR China
| | - An-Ding Zhang
- College of Basic Medicine, Fourth Military Medical University, Xi'an, Shaanxi, 710032, PR China
| | - Lin-Feng Yan
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710038, PR China
| | - Yu-Chuan Hu
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710038, PR China
| | - Lan-Lan Feng
- Department of Pathology, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, PR China
| | - Jiao Ma
- Department of Pathology, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, PR China
| | - Wen Wang
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710038, PR China.
| | - Guang-Bin Cui
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710038, PR China.
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18
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Eijgelaar RS, Visser M, Müller DMJ, Barkhof F, Vrenken H, van Herk M, Bello L, Conti Nibali M, Rossi M, Sciortino T, Berger MS, Hervey-Jumper S, Kiesel B, Widhalm G, Furtner J, Robe PAJT, Mandonnet E, De Witt Hamer PC, de Munck JC, Witte MG. Robust Deep Learning-based Segmentation of Glioblastoma on Routine Clinical MRI Scans Using Sparsified Training. Radiol Artif Intell 2020; 2:e190103. [PMID: 33937837 PMCID: PMC8082349 DOI: 10.1148/ryai.2020190103] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 04/10/2020] [Accepted: 04/16/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE To improve the robustness of deep learning-based glioblastoma segmentation in a clinical setting with sparsified datasets. MATERIALS AND METHODS In this retrospective study, preoperative T1-weighted, T2-weighted, T2-weighted fluid-attenuated inversion recovery, and postcontrast T1-weighted MRI from 117 patients (median age, 64 years; interquartile range [IQR], 55-73 years; 76 men) included within the Multimodal Brain Tumor Image Segmentation (BraTS) dataset plus a clinical dataset (2012-2013) with similar imaging modalities of 634 patients (median age, 59 years; IQR, 49-69 years; 382 men) with glioblastoma from six hospitals were used. Expert tumor delineations on the postcontrast images were available, but for various clinical datasets, one or more sequences were missing. The convolutional neural network, DeepMedic, was trained on combinations of complete and incomplete data with and without site-specific data. Sparsified training was introduced, which randomly simulated missing sequences during training. The effects of sparsified training and center-specific training were tested using Wilcoxon signed rank tests for paired measurements. RESULTS A model trained exclusively on BraTS data reached a median Dice score of 0.81 for segmentation on BraTS test data but only 0.49 on the clinical data. Sparsified training improved performance (adjusted P < .05), even when excluding test data with missing sequences, to median Dice score of 0.67. Inclusion of site-specific data during sparsified training led to higher model performance Dice scores greater than 0.8, on par with a model based on all complete and incomplete data. For the model using BraTS and clinical training data, inclusion of site-specific data or sparsified training was of no consequence. CONCLUSION Accurate and automatic segmentation of glioblastoma on clinical scans is feasible using a model based on large, heterogeneous, and partially incomplete datasets. Sparsified training may boost the performance of a smaller model based on public and site-specific data.Supplemental material is available for this article.Published under a CC BY 4.0 license.
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Affiliation(s)
- Roelant S Eijgelaar
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Martin Visser
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Domenique M J Müller
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Frederik Barkhof
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Hugo Vrenken
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Marcel van Herk
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Lorenzo Bello
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Marco Conti Nibali
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Marco Rossi
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Tommaso Sciortino
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Mitchel S Berger
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Shawn Hervey-Jumper
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Barbara Kiesel
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Georg Widhalm
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Julia Furtner
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Pierre A J T Robe
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Emmanuel Mandonnet
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Philip C De Witt Hamer
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Jan C de Munck
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
| | - Marnix G Witte
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (R.S.E., M.v.H., M.G.W.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.V., F.B., H.V., J.C.d.M.); Neurosurgical Center Amsterdam, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (D.M.J.M., P.C.D.W.H.); Institutes of Neurology & Healthcare Engineering, University College London, London, England (F.B.); Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, England (M.v.H.); Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Research Hospital, IRCCS, Milan, Italy (L.B., M.C.N., M.R., T.S.); Department of Neurologic Surgery, University of California-San Francisco, San Francisco, Calif (M.S.B., S.H.J.); Department of Neurosurgery, Medical University Vienna, Vienna, Austria (B.K., G.W.); Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria (J.F.); Department of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (P.A.J.T.R.); and Department of Neurologic Surgery, Hôpital Lariboisière, Paris, France (E.M.)
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Arzoine J, Levé C, Pérez-Hick A, Goodden J, Almairac F, Aubrun S, Gayat E, Freyschlag CF, Vallée F, Mandonnet E, Madadaki C. Anesthesia management for low-grade glioma awake surgery: a European Low-Grade Glioma Network survey. Acta Neurochir (Wien) 2020; 162:1701-1707. [PMID: 32128618 DOI: 10.1007/s00701-020-04274-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 02/20/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Awake surgery has become a key treatment of diffuse low-grade gliomas (DLGG) and is divided in three main phases: opening, tumor resection - during which the patient needs to be fully awake - and closure. The anesthetic management of awake neurosurgery is a challenge, and there are currently no guidelines. OBJECTIVE The objective of the survey was to explore differences and commonalities regarding the anesthetic management of awake DLGG surgery within the European Low-Grade Glioma Network (ELGGN) centers. METHODS A form that contained 14 questions about the anesthetic management was sent to 28 centers in May 2015. RESULTS Twenty centers responded. During the opening and closing non-awake periods, 56% of teams chose general anesthesia with mechanical ventilation for at least one period (asleep-awake-asleep, SAS protocol), and 44% monitored anesthesia care including sedation without mechanical ventilation (MAC protocol). In case of SAS, all the teams chose intravenous anesthesia, 82% used laryngeal mask instead of endotracheal intubation during the opening sequence, and 71% during closure. Local and regional anesthesia was practiced by all the teams. The most frequently reported cause of pain was dural and cerebral vessels manipulation (77%). Pain management was mostly based on paracetamol (70%) and remifentanil (55%). CONCLUSION Our survey showed that there was an equivalent proportion of centers using SAS or MAC protocols in the anesthetic management of awake surgery in ELGGN centers. The advantages and disadvantages of each anesthesia protocol were reviewed.
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Affiliation(s)
- Jeremy Arzoine
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
| | - Charlotte Levé
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
- INSERM UMR-942, Paris, France
| | | | - John Goodden
- Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
| | - Fabien Almairac
- Department of Neurosurgery, Hôpital Pasteur II, University Hospital of Nice, Nice, France
| | - Sylvie Aubrun
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
| | - Etienne Gayat
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
- University Paris 7, Paris, France
| | | | - Fabrice Vallée
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
- INSERM UMR-942, Paris, France
| | - Emmanuel Mandonnet
- University Paris 7, Paris, France.
- Department of Neurosurgery, Lariboisière Hospital, APHP, Paris, France.
- Frontlab, Institut du Cerveau et de la Moelle épinière, Inserm U 1127, CNRS UMR 7225, Paris, France.
| | - Catherine Madadaki
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
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20
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Latini F, Fahlström M, Hesselager G, Zetterling M, Ryttlefors M. Differences in the preferential location and invasiveness of diffuse low-grade gliomas and their impact on outcome. Cancer Med 2020; 9:5446-5458. [PMID: 32537906 PMCID: PMC7402839 DOI: 10.1002/cam4.3216] [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: 02/27/2020] [Revised: 05/14/2020] [Accepted: 05/16/2020] [Indexed: 12/16/2022] Open
Abstract
Background Low‐grade gliomas (LGGs) are primary diffuse slow‐growing brain tumors derived from glial cells. The management of these tumors is dependent on their location, which often harbors eloquent areas. We retrospectively recorded the location of diffuse gliomas to identify whether specific differences exist between the histological types. Methods We analyzed 102 patients with previous histological diagnosis of WHO‐II astrocytomas (62) and WHO‐II oligodendrogliomas (40) according to WHO‐2016 classification. MRI sequences (T2‐FLAIR) were used for tumor volume segmentation and to create a frequency map of their locations within the Montreal Neurological Institute (MNI) space. The Brain‐Grid (BG) system (standardized radiological tool of intersected lines according to anatomical landmarks) was created and merged with a tractography atlas for infiltration analysis. Results Astrocytomas frequently infiltrated association and projection white matter pathways within fronto‐temporo‐insular regions on the left side. Oligodendrogliomas infiltrated larger white matter networks (association‐commissural‐projection) of the frontal lobe bilaterally. A critical number of infiltrated BG voxels (7 for astrocytomas, 10 for oligodendrogliomas) significantly predicted shorter overall survival (OS) in both groups. Bilateral tumor extension in astrocytomas and preoperative tumor volume in oligodendrogliomas were independent prognostic factors for shorter OS. Conclusions Astrocytomas and oligodendrogliomas differ in preferential location, and this has an impact on the type and the extent of white matter involvement. The number of BG voxels infiltrated reflected different tumor invasiveness and its impact on OS in both groups. All this new information may be valuable in neurosurgical oncology to classify and plan treatment for patients with diffuse gliomas.
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Affiliation(s)
- Francesco Latini
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Markus Fahlström
- Department of Surgical Sciences, Radiology, Uppsala University, Uppsala, Sweden
| | - Göran Hesselager
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Maria Zetterling
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Mats Ryttlefors
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
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21
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Mellinghoff IK, Ellingson BM, Touat M, Maher E, De La Fuente MI, Holdhoff M, Cote GM, Burris H, Janku F, Young RJ, Huang R, Jiang L, Choe S, Fan B, Yen K, Lu M, Bowden C, Steelman L, Pandya SS, Cloughesy TF, Wen PY. Ivosidenib in Isocitrate Dehydrogenase 1 -Mutated Advanced Glioma. J Clin Oncol 2020; 38:3398-3406. [PMID: 32530764 PMCID: PMC7527160 DOI: 10.1200/jco.19.03327] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Diffuse gliomas are malignant brain tumors that include lower-grade gliomas (LGGs) and glioblastomas. Transformation of low-grade glioma into a higher tumor grade is typically associated with contrast enhancement on magnetic resonance imaging. Mutations in the isocitrate dehydrogenase 1 (IDH1) gene occur in most LGGs (> 70%). Ivosidenib is an inhibitor of mutant IDH1 (mIDH1) under evaluation in patients with solid tumors. METHODS We conducted a multicenter, open-label, phase I, dose escalation and expansion study of ivosidenib in patients with mIDH1 solid tumors. Ivosidenib was administered orally daily in 28-day cycles. RESULTS In 66 patients with advanced gliomas, ivosidenib was well tolerated, with no dose-limiting toxicities reported. The maximum tolerated dose was not reached; 500 mg once per day was selected for the expansion cohort. The grade ≥ 3 adverse event rate was 19.7%; 3% (n = 2) were considered treatment related. In patients with nonenhancing glioma (n = 35), the objective response rate was 2.9%, with 1 partial response. Thirty of 35 patients (85.7%) with nonenhancing glioma achieved stable disease compared with 14 of 31 (45.2%) with enhancing glioma. Median progression-free survival was 13.6 months (95% CI, 9.2 to 33.2 months) and 1.4 months (95% CI, 1.0 to 1.9 months) for the nonenhancing and enhancing glioma cohorts, respectively. In an exploratory analysis, ivosidenib reduced the volume and growth rates of nonenhancing tumors. CONCLUSION In patients with mIDH1 advanced glioma, ivosidenib 500 mg once per day was associated with a favorable safety profile, prolonged disease control, and reduced growth of nonenhancing tumors.
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Affiliation(s)
- Ingo K Mellinghoff
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Benjamin M Ellingson
- UCLA Brain Tumor Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Mehdi Touat
- Drug Development Department, Gustave Roussy Cancer Center, Villejuif, France
| | - Elizabeth Maher
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Macarena I De La Fuente
- Department of Neurology and Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
| | - Matthias Holdhoff
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Gregory M Cote
- Henri and Belinda Termeer Center for Targeted Therapies, Massachusetts General Hospital Cancer Center, Boston, MA
| | | | - Filip Janku
- Department of Investigational Cancer Therapeutics, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Robert J Young
- Radiology, Neuroradiology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Raymond Huang
- Department of Radiology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA
| | - Liewen Jiang
- Biostatistics, Agios Pharmaceuticals, Cambridge, MA
| | - Sung Choe
- Bioinformatics, Agios Pharmaceuticals, Cambridge, MA
| | - Bin Fan
- Pharmacology, Agios Pharmaceuticals, Cambridge, MA
| | - Katharine Yen
- Clinical Sciences, Agios Pharmaceuticals, Cambridge, MA
| | - Min Lu
- Clinical Sciences, Agios Pharmaceuticals, Cambridge, MA
| | | | | | | | - Timothy F Cloughesy
- Department of Neurology, Ronald Reagan UCLA Medical Center, University of California, Los Angeles, Los Angeles, CA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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22
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Röhrich M, Loktev A, Wefers AK, Altmann A, Paech D, Adeberg S, Windisch P, Hielscher T, Flechsig P, Floca R, Leitz D, Schuster JP, Huber PE, Debus J, von Deimling A, Lindner T, Haberkorn U. IDH-wildtype glioblastomas and grade III/IV IDH-mutant gliomas show elevated tracer uptake in fibroblast activation protein-specific PET/CT. Eur J Nucl Med Mol Imaging 2019; 46:2569-2580. [PMID: 31388723 DOI: 10.1007/s00259-019-04444-y] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 07/16/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE Targeting fibroblast activation protein (FAP) is a new diagnostic approach allowing the visualization of tumor stroma. Here, we applied FAP-specific PET imaging to gliomas. We analyzed the target affinity and specificity of two FAP ligands (FAPI-02 and FAPI-04) in vitro, and the pharmacokinetics and biodistribution in mice in vivo. Clinically, we used 68Ga-labeled FAPI-02/04 for PET imaging in 18 glioma patients (five IDH-mutant gliomas, 13 IDH-wildtype glioblastomas). METHODS For binding studies with 177Lu-radiolabeled FAPI-02/04, we used the glioblastoma cell line U87MG, FAP-transfected fibrosarcoma cells, and CD26-transfected human embryonic kidney cells. For pharmacokinetic and biodistribution studies, U87MG-xenografted mice were injected with 68Ga-labeled compounds followed by small-animal PET imaging and 177Lu-labeled FAPI-02/04, respectively. Clinical PET/CT scans were performed 30 min post intravenous administration of 68Ga-FAPI-02/04. PET and MRI scans were co-registrated. Immunohistochemistry was done on 14 gliomas using a FAP-specific antibody. RESULTS FAPI-02 and FAPI-04 showed high binding specificity to FAP. FAPI-04 demonstrated higher tumor accumulation and delayed elimination compared with FAPI-02 in preclinical studies. IDH-wildtype glioblastomas and grade III/IV, but not grade II, IDH-mutant gliomas showed elevated tracer uptake. In glioblastomas, we observed spots with increased uptake in projection on contrast-enhancing areas. Immunohistochemistry showed FAP-positive cells with mainly elongated cell bodies and perivascular FAP-positive cells in glioblastomas and an anaplastic IDH-mutant astrocytoma. CONCLUSIONS Using FAP-specific PET imaging, increased tracer uptake in IDH-wildtype glioblastomas and high-grade IDH-mutant astrocytomas, but not in diffuse astrocytomas, may allow non-invasive distinction between low-grade IDH-mutant and high-grade gliomas. Therefore, FAP-specific imaging in gliomas may be useful for follow-up studies although further clinical evaluation is required.
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Affiliation(s)
- Manuel Röhrich
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany.
| | - Anastasia Loktev
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Annika K Wefers
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Annette Altmann
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Daniel Paech
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Paul Windisch
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Hielscher
- Department of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Paul Flechsig
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Ralf Floca
- Division of Medical Image Computing, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Dominik Leitz
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Julius P Schuster
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Molecular Radiooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Peter E Huber
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Molecular Radiooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas von Deimling
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Thomas Lindner
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Uwe Haberkorn
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
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23
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Darlix A, Mandonnet E, Freyschlag CF, Pinggera D, Forster MT, Voss M, Steinbach J, Loughrey C, Goodden J, Banna G, Di Blasi C, Foroglou N, Hottinger AF, Baron MH, Pallud J, Duffau H, Rutten GJ, Almairac F, Fontaine D, Taillandier L, Pessanha Viegas C, Albuquerque L, von Campe G, Urbanic-Purkart T, Blonski M. Chemotherapy and diffuse low-grade gliomas: a survey within the European Low-Grade Glioma Network. Neurooncol Pract 2019; 6:264-273. [PMID: 31386080 PMCID: PMC6660823 DOI: 10.1093/nop/npy051] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Diffuse low-grade gliomas (DLGGs) are rare and incurable tumors. Whereas maximal safe, functional-based surgical resection is the first-line treatment, the timing and choice of further treatments (chemotherapy, radiation therapy, or combined treatments) remain controversial. METHODS An online survey on the management of DLGG patients was sent to 28 expert centers from the European Low-Grade Glioma Network (ELGGN) in May 2015. It contained 40 specific questions addressing the modalities of use of chemotherapy in these patients. RESULTS The survey demonstrated a significant heterogeneity in practice regarding the initial management of DLGG patients and the use of chemotherapy. Interestingly, radiation therapy combined with the procarbazine, CCNU (lomustine), and vincristine regimen has not imposed itself as the gold-standard treatment after surgery, despite the results of the Radiation Therapy Oncology Group 9802 study. Temozolomide is largely used as first-line treatment after surgical resection for high-risk DLGG patients, or at progression. CONCLUSIONS The heterogeneity in the management of patients with DLGG demonstrates that many questions regarding the postoperative strategy and the use of chemotherapy remain unanswered. Our survey reveals a high recruitment potential within the ELGGN for retrospective or prospective studies to generate new data regarding these issues.
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Affiliation(s)
- Amélie Darlix
- Department of Medical Oncology, Institut du Cancer de Montpellier, University of Montpellier, France
| | | | | | - Daniel Pinggera
- Department of Neurosurgery, Medical University of Innsbruck, Austria
| | | | - Martin Voss
- Dr. Senckenberg Institute of Neurooncology, Goethe University Hospital, Frankfurt, Germany
| | - Joachim Steinbach
- Dr. Senckenberg Institute of Neurooncology, Goethe University Hospital, Frankfurt, Germany
| | | | - John Goodden
- Leeds General Infirmary and North East Paediatric Neuroscience Network, Leeds, United Kingdom
| | - Giuseppe Banna
- Department of Neurosurgery and Gammaknife, Cannizzaro General Hospital, Catania, Italy
| | - Concetta Di Blasi
- Department of Neurosurgery and Gammaknife, Cannizzaro General Hospital, Catania, Italy
| | - Nicolas Foroglou
- Aristotle University of Thessaloniki, Department of Neurosurgery, AHEPA University Hospital, Greece
| | - Andreas F Hottinger
- Departments of Clinical Neurosciences and Oncology, Centre Hospitalier Universitaire Vaudois and Lausanne University, Switzerland
| | | | - Johan Pallud
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France, and Paris Descartes University, Sorbonne Paris Cité, France
| | - Hugues Duffau
- Inserm, U894, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
- Department of Neurosurgery, Montpellier University Hospital, France
| | - Geert-Jan Rutten
- Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Fabien Almairac
- Department of Neurosurgery, University Hospital of Nice, France
| | - Denys Fontaine
- Department of Neurosurgery, University Hospital of Nice, France
| | - Luc Taillandier
- Department of Neurooncology, Nancy Neurological Hospital, France
| | | | | | - Gord von Campe
- Department of Neurosurgery, Medical University of Graz, Austria
| | | | - Marie Blonski
- Department of Neurooncology, Nancy Neurological Hospital, France
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Radiological evaluation of low-grade glioma: time to embrace quantitative data? Acta Neurochir (Wien) 2019; 161:577-578. [PMID: 30693371 DOI: 10.1007/s00701-019-03816-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/19/2018] [Indexed: 01/21/2023]
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25
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Donner D, Rozzanigo U, Amelio D, Sarubbo S, Scartoni D, Picori L, Amichetti M, Chioffi F, Chierichetti F. PET in brain tumors. Clin Transl Imaging 2018. [DOI: 10.1007/s40336-018-0307-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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26
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Conti Nibali M, Rossi M, Sciortino T, Riva M, Gay LG, Pessina F, Bello L. Preoperative surgical planning of glioma: limitations and reliability of fMRI and DTI tractography. J Neurosurg Sci 2018; 63:127-134. [PMID: 30290696 DOI: 10.23736/s0390-5616.18.04597-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Brain mapping techniques (intraoperative neurophysiology and neuropsychology) represent the gold standard in glioma surgery, and particularly in glioma resection. Since the introduction of MRI in the clinical practice, several advanced applications have been developed, like functional MRI (fMRI) and diffusion imaging-based tractography (DTI), which both have an application in glioma surgery. fMRI allows to identify cortical areas related to a specific function, DTI allows to reconstruct a model of the sub-cortical connectivity. This paper describes the clinical application of fMRI and DTI, enlightening sensitivity and specificity in comparison to gold standard and underlining their limitations in surgical decision making.
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Affiliation(s)
- Marco Conti Nibali
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy -
| | - Marco Rossi
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy
| | - Tommaso Sciortino
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy
| | - Marco Riva
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy.,Department of Medical Biotechnology and Translational Medicine, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy
| | - Lorenzo G Gay
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy
| | - Federico Pessina
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Lorenzo Bello
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy
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