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Zhu Z, Gong G, Wang L, Su Y, Lu J, Dong G, Yin Y. Dose-Painting Proton Radiotherapy Guided by Functional MRI in Non-enhancing High-Grade Gliomas. Clin Oncol (R Coll Radiol) 2024; 36:552-561. [PMID: 38876805 DOI: 10.1016/j.clon.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 05/17/2024] [Accepted: 05/23/2024] [Indexed: 06/16/2024]
Abstract
AIMS This study aimed to demonstrate the feasibility and evaluate the dosimetric effect and clinical impact of dose-painting proton radiotherapy (PRT) guided by functional MRI in non-enhancing high-grade gliomas (NE-HGGs). MATERIALS AND METHODS The 3D-ASL and T2 FLAIR MR images of ten patients with NE-HGGs before radiotherapy were studied retrospectively. The hyperintensity on T2 FLAIR was used to generate the planning target volume (PTV), and the high-perfusion volume on 3D-ASL (PTV-ASL) was used to generate the simultaneous integrated boost (SIB) volume. Each patient received pencil beam scanning PRT and photon intensity-modulated radiotherapy (IMRT). There were five plans in each modality: (1) Uniform plans (IMRT60 vs. PRT60): 60Gy in 30 fractions to the PTV. (2)-(5) SIB plans (IMRT72, 84, 96, 108 vs. PRT72, 84, 96, 108): Uniform plan plus additional dose boost to PTV-ASL in 30 fractions to 72, 84, 96, 108 Gy. The dosimetric differences between various plans were compared. The clinical effects of target volume and organs at risk (OARs) were assessed using biological models for both tumor control probability (TCP) and normal tissue complication probability (NTCP). RESULTS Compared with the IMRT plan, the D2 and D50 of the PRT plans with the same prescription dose increased by 1.27-4.12% and 0.64-2.01%, respectively; the R30 decreased by > 32%; the dose of brainstem and chiasma decreased by > 27% and >32%; and the dose of normal brain tissue (Br-PTV), optic nerves, eyeballs, lens, cochlea, spinal cord, and hippocampus decreased by > 50% (P < 0.05). The maximum necessary dose was 96GyE to achieve >98% TCP for PRT, and it was 84Gy to achieve >91% TCP for IMRT. The average NTCP of Br-PTV was 1.30% and 1.90% for PRT and IMRT at the maximum dose escalation, respectively. The NTCP values of the remaining OARs approached zero in all PRT plans. CONCLUSION The functional MRI-guided dose escalation using PRT is feasible while sparing the OARs constraints and demonstrates a potential clinical benefit by improving TCP with no or minimal increase in NCTP for tissues outside the PTV. This retrospective study suggested that the use of PRT-based SIB guided by functional MRI may represent a strategy to provide benefits for patients with NE-HGGs.
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Affiliation(s)
- Z Zhu
- Harbin Medical University, No.157, Baojian Road, Nangang District, Harbin City, 150081, Heilongjiang Province, China; Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, No.440 Jiyan Road, Huaiyin District, Jinan City, 250117, Shandong Province, China
| | - G Gong
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, No.440 Jiyan Road, Huaiyin District, Jinan City, 250117, Shandong Province, China
| | - L Wang
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, No.440 Jiyan Road, Huaiyin District, Jinan City, 250117, Shandong Province, China
| | - Y Su
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, No.440 Jiyan Road, Huaiyin District, Jinan City, 250117, Shandong Province, China
| | - J Lu
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, No.440 Jiyan Road, Huaiyin District, Jinan City, 250117, Shandong Province, China
| | - G Dong
- Harbin Medical University, No.157, Baojian Road, Nangang District, Harbin City, 150081, Heilongjiang Province, China.
| | - Y Yin
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, No.440 Jiyan Road, Huaiyin District, Jinan City, 250117, Shandong Province, China.
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Takano S, Tomita N, Kuno M, Niwa M, Torii A, Takaoka T, Kita N, Okazaki D, Yamamoto S, Kawai T, Sugie C, Ogawa Y, Matsumoto K, Uchiyama K, Otsuka S, Matsui T, Miyakawa A, Mizuno T, Iida M, Tanikawa M, Mase M, Hiwatashi A. Simultaneous boost radiotherapy versus conventional dose radiotherapy for patients with newly diagnosed glioblastoma: a multi-institutional analysis. Sci Rep 2024; 14:9283. [PMID: 38654028 PMCID: PMC11039761 DOI: 10.1038/s41598-024-60154-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 04/19/2024] [Indexed: 04/25/2024] Open
Abstract
We compared survival outcomes of high-dose concomitant boost radiotherapy (HDCBRT) and conventional dose radiotherapy (CRT) for newly diagnosed glioblastoma (GB). Patients treated with intensity-modulated radiation therapy for newly diagnosed GB were included. In HDCBRT, specific targets received 69, 60, and 51 Gy in 30 fractions, while 60 Gy in 30 fractions was administered with a standard radiotherapy method in CRT. Overall survival (OS) and progression-free survival (PFS) were compared using the Log-rank test, followed by multivariate Cox analysis. The inverse probability of treatment weighting (IPTW) method was also applied to each analysis. Among 102 eligible patients, 45 received HDCBRT and 57 received CRT. With a median follow-up of 16 months, the median survival times of OS and PFS were 21 and 9 months, respectively. No significant differences were observed in OS or PFS in the Kaplan-Meier analyses. In the multivariate analysis, HDCBRT correlated with improved OS (hazard ratio, 0.49; 95% confidence interval, 0.27-0.90; P = 0.021), and this result remained consistent after IPTW adjustments (P = 0.028). Conversely, dose suppression due to the proximity of normal tissues and IMRT field correlated with worse OS and PFS (P = 0.008 and 0.049, respectively). A prospective study with a stricter protocol is warranted to validate the efficacy of HDCBRT for GB.
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Affiliation(s)
- Seiya Takano
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Natsuo Tomita
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan.
| | - Mayu Kuno
- Department of Radiation Oncology, Ichinomiya Municipal Hospital, 2-2-22 Bunkyo, Ichinomiya, Aichi, 491-8558, Japan
| | - Masanari Niwa
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Akira Torii
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Taiki Takaoka
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Nozomi Kita
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Dai Okazaki
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Shintaro Yamamoto
- Department of Radiology, Japan Community Health Care Organization Chukyo Hospital, 1-1-10 Sanjo, Minami-Ku, Nagoya, Aichi, 457-8510, Japan
| | - Tatsuya Kawai
- Department of Radiology, Nagoya City University Midori Municipal Hospital, 1-77 Shiomigaoka, Midori-Ku, Nagoya, Aichi, 458-0037, Japan
| | - Chikao Sugie
- Department of Radiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myoken-Cho, Showa-Ku, Nagoya, Aichi, 466-8650, Japan
| | - Yasutaka Ogawa
- Department of Radiation Oncology, Kasugai Municipal Hospital, 1-1-1 Takaki-Cho, Kasugai, Aichi, 486-8510, Japan
| | - Kenichi Matsumoto
- Department of Radiation Oncology, Hokuto Hospital, 7-5 Kisen, Inada-Cho, Obihiro, Hokkaido, 080-0833, Japan
| | - Kaoru Uchiyama
- Department of Radiology, Kariya Toyota General Hospital, 5-15 Sumiyoshi-Cho, Kariya, Aichi, 448-8505, Japan
| | - Shinya Otsuka
- Department of Radiology, Okazaki City Hospital, 3-1 Goshoai, Koryuji-Cho, Okazaki, Aichi, 444-8553, Japan
| | - Tooru Matsui
- Department of Radiology, Konan Kosei Hospital, 137 Oomatsubara, Takaya-Cho, Konan, Aichi, 483-8704, Japan
| | - Akifumi Miyakawa
- Department of Radiation Oncology, National Hospital Organization Nagoya Medical Center, 4-1-1, Sannomaru, Naka-Ku, Nagoya, Aichi, 460-0001, Japan
| | - Tomoki Mizuno
- Department of Radiation Oncology, Suzuka General Hospital, 1275-53 Yamanoue, Yasuzuka-Cho, Suzuka, Mie, 513-0818, Japan
| | - Masato Iida
- Department of Radiology, Toyokawa City Hospital, Yawata-Cho Noji 23, Toyokawa, Aichi, 442-8561, Japan
| | - Motoki Tanikawa
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Mitsuhito Mase
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Akio Hiwatashi
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
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Williamson C, Williamson S, Jiang R, Sudmeier L, Esiashvili N, Eaton BR. The impact of radiation therapy variables on pediatric high-grade glioma outcomes: A National Cancer Database analysis. Pediatr Blood Cancer 2024; 71:e30751. [PMID: 37937991 DOI: 10.1002/pbc.30751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 09/23/2023] [Accepted: 10/17/2023] [Indexed: 11/09/2023]
Abstract
PURPOSE The purpose of this analysis is to report patterns of care for pediatric patients with high-grade glioma (pHGG) and evaluate the impact of radiotherapy (RT) variables on outcomes using the National Cancer Database (NCDB). METHODS Eligibility criteria included age < 22 years, histologically diagnosed WHO grade III-IV gliomas treated with ≥50 Gy and < 76 Gy RT between 2004 and 2013, and RT initiation within 90 days of diagnosis. RT variables including RT dose, RT timing, and RT modality were analyzed along with baseline demographic, tumor, and treatment variables to assess the impact on overall survival. RESULTS A total of 498 pHGG patients were included. The median age was 15 years (range, 0-21), common diagnoses were astrocytoma (55%) and glioblastoma (30%), 73.5% underwent surgical resection and 90.2% received chemotherapy. The median RT dose was 59.4 Gy (SD 2.9 Gy) starting at a median of 4.4 weeks from diagnosis (SD 2.5 weeks). Fourteen patients were treated with proton therapy. Median follow-up was 19.6 months with 1- and 3-year overall survival of 78.4% and 40.4%, respectively. On multivariable analysis, female gender, older age, and RT delay of ≥6 weeks were significantly associated with a lower rate of death; glioblastoma histology, no surgical resection/biopsy only, and earlier RT initiation < 6 weeks from diagnosis were associated with a higher rate of death. There was no relationship between RT dose or proton versus photon therapy and overall survival. CONCLUSIONS Outcomes for pHGG are poor. There was no benefit to early RT timing when RT is initiated within 90 days of diagnosis or higher RT dose in this dataset.
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Affiliation(s)
- Christopher Williamson
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Shayla Williamson
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Renjian Jiang
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Lisa Sudmeier
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
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Seaberg MH, Kazda T, Youland RS, Laack NN, Pafundi DH, Anderson SK, Sarkaria JN, Galanis E, Brown PD, Brinkmann DH. Dosimetric patterns of failure in the era of novel chemoradiotherapy in newly-diagnosed glioblastoma patients. Radiother Oncol 2023; 188:109768. [PMID: 37385378 DOI: 10.1016/j.radonc.2023.109768] [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: 11/18/2022] [Revised: 06/09/2023] [Accepted: 06/21/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Patterns of failure (POF) may provide an alternative quantitative endpoint to overall survival for evaluation of novel chemoradiotherapy regimens with glioblastoma. MATERIALS AND METHODS POF of 109 newly-diagnosed glioblastoma patients per 2016 WHO classification who received conformal radiotherapy with concomitant and adjuvant temozolomide were reviewed. Seventy-five of those patients also received an investigational chemotherapy agent (everolimus, erlotinib, or vorinostat). Recurrence volumes were defined with MRI contrast enhancement. POF at protocol (POFp), initial (POFi), and RANO (POFRANO) progression timepoints were characterized by the percentage of recurrence volume within the 95% dose region. POFp, POFi, and POFRANO of each patient were categorized (central, non-central, or both). RESULTS POF of the temozolomide-only control cohort were unchanged (79% central, 12% non-central, and 9% both) across protocol, initial, and RANO progression timepoints. Unlike the temozolomide-only cohort, POF of the collective novel chemotherapy cohort appeared increasingly non-central when comparing POFi with POFp, with a non-central component increasing from 16% to 29% (p = 0.078). POF did not correlate with overall survival or time to progression. CONCLUSION POF of patients receiving a novel chemotherapy appeared to be influenced by the timepoint of analysis and were increasingly non-central at protocol progression as compared with initial recurrence, suggesting that recurrence originates from the central region. Addition of everolimus and vorinostat appeared to influence POF, despite similar survival outcomes with the temozolomide-only control group. In studies dealing with novel therapeutic agents, robust and properly-timed dosimetric POF analysis may be helpful to evaluate biologic aspects of novel agents.
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Affiliation(s)
- Maasa H Seaberg
- University of California San Francisco Medical Center, Department of Radiation Oncology, San Francisco, CA, USA
| | - Tomas Kazda
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | | | - Nadia N Laack
- Mayo Clinic, Department of Radiation Oncology, Rochester, MN, USA
| | - Deanna H Pafundi
- Mayo Clinic, Department of Radiation Oncology, Jacksonville, FL, USA
| | | | - Jann N Sarkaria
- Mayo Clinic, Department of Radiation Oncology, Rochester, MN, USA
| | | | - Paul D Brown
- Mayo Clinic, Department of Radiation Oncology, Rochester, MN, USA
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Laprie A, Tensaouti F, Cohen-Jonathan Moyal E. [Radiation dose intensification for glioblastoma]. Cancer Radiother 2022; 26:894-898. [PMID: 36085279 DOI: 10.1016/j.canrad.2022.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 10/14/2022]
Abstract
Glioblastoma is the most common brain tumor in adults; its treatment includes surgical excision or biopsy followed by radio-chemotherapy. Even if radiotherapy increases the survival of all patients regardless of their age or their general condition, there are always sources of radioresistance, where relapses occur and therefore treatment fails. Indeed, these foci result in a local relapse, which is observed in 95% of cases in the irradiation fields. We will describe here the current approaches to overcome this radioresistance by dose escalation, without or with guidance by metabolic and functional imaging (dose-painting). We will detail several prospective trials including the French phase III trial, SPECTRO-GLIO, randomizing the use of an integrated boost guided by spectrometric magnetic resonance imaging and similar trials developed across the Atlantic. We will also discuss approaches using different PET markers as well as diffusion or perfusion magnetic resonance imaging.
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Affiliation(s)
- A Laprie
- Département d'oncologie radiothérapie, institut universitaire du cancer de Toulouse-Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex, France; Inserm Toulouse neuroimaging center (Tonic), place Baylac, 31000 Toulouse, France.
| | - F Tensaouti
- Département d'oncologie radiothérapie, institut universitaire du cancer de Toulouse-Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex, France; Inserm Toulouse neuroimaging center (Tonic), place Baylac, 31000 Toulouse, France
| | - E Cohen-Jonathan Moyal
- Département d'oncologie radiothérapie, institut universitaire du cancer de Toulouse-Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex, France; Inserm Radopt, CRCT, Centre de recherche en cancérologie de Toulouse, 2, avenue Hubert-Curien, 31100 Toulouse, France
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Morrison C, Weterings E, Mahadevan D, Sanan A, Weinand M, Stea B. Expression Levels of RAD51 Inversely Correlate with Survival of Glioblastoma Patients. Cancers (Basel) 2021; 13:cancers13215358. [PMID: 34771522 PMCID: PMC8582387 DOI: 10.3390/cancers13215358] [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: 09/23/2021] [Revised: 10/17/2021] [Accepted: 10/23/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Identifying prognostic and predictive biomarkers for glioblastoma (GBM), a primary brain tumor, is essential in improving patient survival. We utilized gene expression profiling to investigate a uniform population of GBM patients who had been treated with surgery and adjuvant radiation therapy versus normal brain tissue, and identified high RAD51 expression as a poor prognostic marker that is amenable to therapeutic intervention. This observation was confirmed utilizing a publicly available gene expression dataset in a cohort of GBM patients. Abstract Treatment failures of glioblastoma (GBM) occur within high-dose radiation fields. We hypothesized that this is due to increased capacity for DNA damage repair in GBM. We identified 24 adult GBM patients treated with maximal safe resection followed by radiation with concurrent and adjuvant temozolomide. The mRNA from patients was quantified using NanoString Technologies’ nCounter platform and compared with 12 non-neoplastic temporal lobe tissue samples as a control. Differential expression analysis identified seven DNA repair genes significantly upregulated in GBM tissues relative to controls (>4-fold difference, adjusted p values < 0.001). Among these seven genes, Cox proportional hazards models identified RAD51 to be associated with an increased risk of death (HR = 3.49; p = 0.03). Kaplan–Meier (KM) analysis showed that patients with high RAD51 expression had significantly shorter OS compared to low levels (median OS of 10.6 mo. vs 20.1 mo.; log-rank p = 0.03). Our findings were validated in a larger external dataset of 162 patients using publicly available gene expression data quantified by the same NanoString technology (median OS of 13.8 mo. vs. 17.4 mo; log-rank p = 0.006). Within this uniformly treated GBM population, RAD51, in the homologous recombination pathway, was overexpressed (vs. normal brain) and inversely correlated with OS. High RAD51 expression may be a prognostic biomarker and a therapeutic target in GBM.
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Affiliation(s)
- Christopher Morrison
- Department of Radiation Oncology, University of Arizona, Tucson, AZ 85719, USA; (C.M.); (E.W.)
| | - Eric Weterings
- Department of Radiation Oncology, University of Arizona, Tucson, AZ 85719, USA; (C.M.); (E.W.)
| | - Daruka Mahadevan
- Mays Cancer Center, University of Texas Health, San Antonio, TX 78229, USA;
| | - Abhay Sanan
- Center for Neurosciences, Tucson, AZ 85718, USA;
| | - Martin Weinand
- Department of Neurosurgery, University of Arizona College of Medicine, Tucson, AZ 85724, USA;
| | - Baldassarre Stea
- Department of Radiation Oncology, University of Arizona, Tucson, AZ 85719, USA; (C.M.); (E.W.)
- Correspondence: ; Tel.: +1-(520)-694-0861
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Laack NN, Pafundi D, Anderson SK, Kaufmann T, Lowe V, Hunt C, Vogen D, Yan E, Sarkaria J, Brown P, Kizilbash S, Uhm J, Ruff M, Zakhary M, Zhang Y, Seaberg M, Wan Chan Tseung HS, Kabat B, Kemp B, Brinkmann D. Initial Results of a Phase 2 Trial of 18F-DOPA PET-Guided Dose-Escalated Radiation Therapy for Glioblastoma. Int J Radiat Oncol Biol Phys 2021; 110:1383-1395. [PMID: 33771703 DOI: 10.1016/j.ijrobp.2021.03.032] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 02/21/2021] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Our previous work demonstrated that 3,4-dihydroxy-6-[18F]-fluoro-L-phenylalanine (18F-DOPA) positron emission tomography (PET) is sensitive and specific for identifying regions of high density and biologically aggressive glioblastoma. The purpose of this prospective phase 2 study was to determine the safety and efficacy of biologic-guided, dose-escalated radiation therapy (DERT) using 18F-DOPA PET in patients with glioblastoma. METHODS AND MATERIALS Patients with newly diagnosed, histologically confirmed glioblastoma aged ≥18 years without contraindications to 18F-DOPA were eligible. Target volumes included 51, 60, and 76 Gy in 30 fractions with a simultaneous integrated boost, and concurrent and adjuvant temozolomide for 6 months. 18F-DOPA PET imaging was used to guide DERT. The study was designed to detect a true progression-free survival (PFS) at 6 months (PFS6) rate ≥72.5% in O6-methylguanine methyltransferase (MGMT) unmethylated patients (DE-Un), with an overall significance level (alpha) of 0.20 and a power of 80%. Kaplan-Meier analysis was performed for PFS and overall survival (OS). Historical controls (HCs) included 139 patients (82 unmethylated) treated on prospective clinical trials or with standard RT at our institution. Toxicities were evaluated with Common Terminology Criteria for Adverse Events v4.0. RESULTS Between January 2014 and December 2018, 75 evaluable patients were enrolled (39 DE-Un, 24 methylated [DE-Mth], and 12 indeterminate). PFS6 for DE-Un was 79.5% (95% confidence interval, 63.1%-90.1%). Median PFS was longer for DE-Un patients compared with historical controls (8.7 months vs 6.6 months; P = .017). OS was similarly longer, but the difference was not significant (16.0 vs 13.5 months; P = .13). OS was significantly improved for DE-Mth patients compared with HC-Mth (35.5 vs 23.3 months; P = .049) despite nonsignificant improvement in PFS (10.7 vs 9.0 months; P = .26). Grade 3 central nervous system necrosis occurred in 13% of patients, but treatment with bevacizumab improved symptoms in all cases. CONCLUSIONS 18F-DOPA PET-guided DERT appears to be safe, and it significantly improves PFS in MGMT unmethylated glioblastoma. OS is significantly improved in MGMT methylated patients. Further investigation of 18F-DOPA PET biologic guided DERT for glioblastoma is warranted.
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Affiliation(s)
| | - Deanna Pafundi
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | | | | | - Val Lowe
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Diane Vogen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Yan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Jann Sarkaria
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Paul Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sani Kizilbash
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Joon Uhm
- Department of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Michael Ruff
- Deptartment of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Mark Zakhary
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland
| | - Yan Zhang
- Department of Research, Mayo Clinic, Jacksonville, Florida
| | | | | | - Brian Kabat
- Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Bradley Kemp
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Debra Brinkmann
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Kim MM, Sun Y, Aryal MP, Parmar HA, Piert M, Rosen B, Mayo CS, Balter JM, Schipper M, Gabel N, Briceño EM, You D, Heth J, Al-Holou W, Umemura Y, Leung D, Junck L, Wahl DR, Lawrence TS, Cao Y. A Phase 2 Study of Dose-intensified Chemoradiation Using Biologically Based Target Volume Definition in Patients With Newly Diagnosed Glioblastoma. Int J Radiat Oncol Biol Phys 2021; 110:792-803. [PMID: 33524546 PMCID: PMC8920120 DOI: 10.1016/j.ijrobp.2021.01.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 01/14/2021] [Accepted: 01/21/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE We hypothesized that dose-intensified chemoradiation therapy targeting adversely prognostic hypercellular (TVHCV) and hyperperfused (TVCBV) tumor volumes would improve outcomes in patients with glioblastoma. METHODS AND MATERIALS This single-arm, phase 2 trial enrolled adult patients with newly diagnosed glioblastoma. Patients with a TVHCV/TVCBV >1 cm3, identified using high b-value diffusion-weighted magnetic resonance imaging (MRI) and dynamic contrast-enhanced perfusion MRI, were treated over 30 fractions to 75 Gy to the TVHCV/TVCBV with temozolomide. The primary objective was to estimate improvement in 12-month overall survival (OS) versus historical control. Secondary objectives included evaluating the effect of 3-month TVHCV/TVCBV reduction on OS using Cox proportional-hazard regression and characterizing coverage (95% isodose line) of metabolic tumor volumes identified using correlative 11C-methionine positron emission tomography. Clinically meaningful change was assessed for quality of life by the European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire C30, for symptom burden by the MD Anderson Symptom Inventory for brain tumor, and for neurocognitive function (NCF) by the Controlled Oral Word Association Test, the Trail Making Test, parts A and B, and the Hopkins Verbal Learning Test-Revised. RESULTS Between 2016 and 2018, 26 patients were enrolled. Initial patients were boosted to TVHCV alone, and 13 patients were boosted to both TVHCV/TVCBV. Gross or subtotal resection was performed in 87% of patients; 22% were O6-methylguanine-DNA methyltransferase (MGMT) methylated. With 26-month follow-up (95% CI, 19-not reached), the 12-month OS rate among patients boosted to the combined TVHCV/TVCBV was 92% (95% CI, 78%-100%; P = .03) and the median OS was 20 months (95% CI, 18-not reached); the median OS for the whole study cohort was 20 months (95% CI, 14-29 months). Patients whose 3-month TVHCV/TVCBV decreased to less than the median volume (3 cm3) had superior OS (29 vs 12 months; P = .02). Only 5 patients had central or in-field failures, and 93% (interquartile range, 59%-100%) of the 11C-methionine metabolic tumor volumes received high-dose coverage. Late grade 3 neurologic toxicity occurred in 2 patients. Among non-progressing patients, 1-month and 7-month deterioration in quality of life, symptoms, and NCF were similar in incidence to standard therapy. CONCLUSIONS Dose intensification against hypercellular/hyperperfused tumor regions in glioblastoma yields promising OS with favorable outcomes for NCF, symptom burden, and quality of life, particularly among patients with greater tumor reduction 3 months after radiation therapy.
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Affiliation(s)
- Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Yilun Sun
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Madhava P Aryal
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Hemant A Parmar
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Morand Piert
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Benjamin Rosen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Charles S Mayo
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - James M Balter
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Matthew Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Nicolette Gabel
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan
| | - Emily M Briceño
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan
| | - Daekeun You
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Jason Heth
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Wajd Al-Holou
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Yoshie Umemura
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Denise Leung
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Larry Junck
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Daniel R Wahl
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Theodore S Lawrence
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Radiology, University of Michigan, Ann Arbor, Michigan; Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
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9
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Seidlitz A, Beuthien-Baumann B, Löck S, Jentsch C, Platzek I, Zöphel K, Linge A, Kotzerke J, Petr J, van den Hoff J, Steinbach J, Krex D, Schmitz-Schackert G, Falk M, Baumann M, Krause M. Final Results of the Prospective Biomarker Trial PETra: [ 11C]-MET-Accumulation in Postoperative PET/MRI Predicts Outcome after Radiochemotherapy in Glioblastoma. Clin Cancer Res 2021; 27:1351-1360. [PMID: 33376095 DOI: 10.1158/1078-0432.ccr-20-1775] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/24/2020] [Accepted: 12/22/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE This prospective trial investigates the association of time to recurrence (TTR) in glioblastoma with [11C]methionine (MET) tracer uptake before postoperative radiochemotherapy (RCT) aiming to guide radiotherapy boost regions. EXPERIMENTAL DESIGN Between 2013 and 2016, 102 patients with glioblastoma were recruited. RCT was performed with concurrent and adjuvant temozolomide to a total dose of 60 Gy. Tumor residues in postresection PET and MRI were together defined as gross tumor volumes for radiotherapy treatment planning. [11C]methionine (MET)-PET/MRI was performed before RCT and at each follow-up. RESULTS The primary hypothesis of a longer TTR for patients without increased tracer accumulation in postoperative MET-PET was confirmed in 89 patients. With 18.9 months (95% confidence interval, 9.3-28.5 months), median TTR was significantly (P < 0.001) longer for patients without (n = 29, 32.6%) as compared with 6.3 months (3.6-8.9) for patients with MET accumulation (n = 60, 67.4%) in pre-RCT PET. Although MRI often did not detect all PET-positive regions, an unfavorable impact of residual tumor in postsurgical MRI (n = 38, 42.7%) on TTR was observed [4.6 (4.2-5.1) vs. 15.5 months (6.0-24.9), P < 0.001]. Significant multivariable predictors for TTR were MRI positivity, PET-positive volume, and O6-methylguanine DNA methyltransferase (MGMT) hypermethylation. CONCLUSIONS Postsurgical amino acid PET has prognostic value for TTR after RCT in glioblastoma. Because of the added value of the metabolic beyond the pure structural information, it should complement MRI in radiotherapy planning if available with reasonable effort, at least in the context of maximal therapy. Furthermore, the spatial correlation of regions of recurrence with PET-positive volumes could provide a bioimaging basis for further trials, for example, testing local radiation dose escalation.
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Affiliation(s)
- Annekatrin Seidlitz
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. .,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site, Dresden, Germany
| | - Bettina Beuthien-Baumann
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,German Cancer Research Center (DKFZ), Department of Radiology, Heidelberg, Germany
| | - Steffen Löck
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site, Dresden, Germany
| | - Christina Jentsch
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | - Ivan Platzek
- Institute of Radiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Klaus Zöphel
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Annett Linge
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site, Dresden, Germany
| | - Jörg Kotzerke
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jan Petr
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany.,Department of Biomedical Engineering, Rochester Institute of Technology, Rochester, New York
| | - Jörg van den Hoff
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Jörg Steinbach
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany.,Department of Chemistry and Food Chemistry, TU Dresden, Dresden, Germany
| | - Dietmar Krex
- Department of Neurosurgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Gabriele Schmitz-Schackert
- Department of Neurosurgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Monique Falk
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site, Dresden, Germany
| | - Michael Baumann
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology, Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mechthild Krause
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology, Dresden, Germany
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10
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Ferro M, Ferro M, Macchia G, Cilla S, Buwenge M, Re A, Romano C, Boccardi M, Picardi V, Cammelli S, Cucci E, Mignogna S, Di Lullo L, Valentini V, Morganti AG, Deodato F. Post-Operative Accelerated-Hypofractionated Chemoradiation With Volumetric Modulated Arc Therapy and Simultaneous Integrated Boost in Glioblastoma: A Phase I Study (ISIDE-BT-2). Front Oncol 2021; 10:626400. [PMID: 33692944 PMCID: PMC7937791 DOI: 10.3389/fonc.2020.626400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 12/31/2020] [Indexed: 11/24/2022] Open
Abstract
Background Glioblastoma Multiforme (GBM) is the most common primary brain cancer and one of the most lethal tumors. Theoretically, modern radiotherapy (RT) techniques allow dose-escalation due to the reduced irradiation of healthy tissues. This study aimed to define the adjuvant maximum tolerated dose (MTD) using volumetric modulated arc RT with simultaneous integrated boost (VMAT-SIB) plus standard dose temozolomide (TMZ) in GBM. Methods A Phase I clinical trial was performed in operated GBM patients using VMAT-SIB technique with progressively increased total dose. RT was delivered in 25 fractions (5 weeks) to two planning target volumes (PTVs) defined by adding a 5-mm margin to the clinical target volumes (CTVs). The CTV1 was the tumor bed plus the MRI enhancing residual lesion with 10-mm margin. The CTV2 was the CTV1 plus 20-mm margin. Only PTV1 dose was escalated (planned dose levels: 72.5, 75, 77.5, 80, 82.5, 85 Gy), while PTV2 dose remained unchanged (45 Gy/1.8 Gy). Concurrent and sequential TMZ was prescribed according to the EORTC/NCIC protocol. Dose-limiting toxicities (DLTs) were defined as any G ≥ 3 non-hematological acute toxicity or any G ≥ 4 acute hematological toxicities (RTOG scale) or any G ≥ 2 late toxicities (RTOG-EORTC scale). Results Thirty-seven patients (M/F: 21/16; median age: 59 years; median follow-up: 12 months) were enrolled and treated as follows: 6 patients (72.5 Gy), 10 patients (75 Gy), 10 patients (77.5 Gy), 9 patients (80 Gy), 2 patients (82.5 Gy), and 0 patients (85 Gy). Eleven patients (29.7%) had G1-2 acute neurological toxicity, while 3 patients (8.1%) showed G ≥ 3 acute neurological toxicities at 77.5 Gy, 80 Gy, and 82.5 Gy levels, respectively. Since two DLTs (G3 neurological: 1 patient and G5 hematological toxicity: 1 patient) were observed at 82.5 Gy level, the trial was closed and the 80 Gy dose-level was defined as the MTD. Two asymptomatic histologically proven radionecrosis were recorded. Conclusions According to the results of this Phase I trial, 80 Gy in 25 fractions accelerated hypofractionated RT is the MTD using VMAT-SIB plus standard dose TMZ in resected GBM.
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Affiliation(s)
- Marica Ferro
- Radiation Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Milena Ferro
- Radiation Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Gabriella Macchia
- Radiation Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Milly Buwenge
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,DIMES, Alma Mater Studiorum Bologna University, Bologna, Italy
| | - Alessia Re
- Radiation Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Carmela Romano
- Medical Physics Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Mariangela Boccardi
- Radiation Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Vincenzo Picardi
- Radiation Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Silvia Cammelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,DIMES, Alma Mater Studiorum Bologna University, Bologna, Italy
| | - Eleonora Cucci
- Radiology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Samantha Mignogna
- Medical Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Liberato Di Lullo
- Medical Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Vincenzo Valentini
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Roma, Italy.,Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Alessio Giuseppe Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,DIMES, Alma Mater Studiorum Bologna University, Bologna, Italy
| | - Francesco Deodato
- Radiation Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy.,Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy
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11
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Shieh LT, Guo HR, Ho CH, Lin LC, Chang CH, Ho SY. Survival of glioblastoma treated with a moderately escalated radiation dose-Results of a retrospective analysis. PLoS One 2020; 15:e0233188. [PMID: 32413077 PMCID: PMC7228055 DOI: 10.1371/journal.pone.0233188] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/29/2020] [Indexed: 11/18/2022] Open
Abstract
Glioblastoma (GBM) has the highest fatality rate among primary malignant brain tumors and typically tends to recur locally just adjacent to the original tumor site following surgical resection and adjuvant radiotherapy. We conducted a study to evaluate the survival outcomes between a standard dose (≤ 60 Gy) and moderate radiation dose escalation (>60 Gy), and to identify prognostic factors for GBM. We retrospectively reviewed the medical records of primary GBM patients diagnosed between 2005 and 2016 in two referral hospitals in Taiwan. They were identified from the cancer registry database and followed up from the date of diagnosis to October 2018. The progression-free survival (PFS) and overall survival (OS) were compared between the two dose groups, and independent factors for survival were analyzed through Cox proportional hazard model. We also affirmed the results using Cox regression with least absolute shrinkage and selection operator (LASSO) approach. From our cancer registry database, 142 GBM patients were identified, and 84 of them fit the inclusion criteria. Of the 84 patients, 52 (62%) were males. The radiation dose ranged from 50.0 Gy to 66.6 Gy, but their treatment volumes were similar to the others. Fifteen (18%) patients received an escalated dose boost >60.0 Gy. The escalated group had a longer median PFS (15.4 vs. 7.9 months, p = 0.01 for log-rank test), and a longer median OS was also longer in the escalation group (33.8 vs. 12.5 months, p <0.001) than the reference group. Following a multivariate analysis, the escalated dose was identified as a significant predictor for good prognosis (PFS: hazard ratio [HR] = 0.48, 95% confidence interval [95%CI]: 0.23-0.98; OS: HR = 0.40, 95%CI: 0.21-0.78). Using the LASSO approach, we found age > 70 (HR = 1.55), diagnosis after 2010 (HR = 1.42), and a larger radiation volume (≥ 250ml; HR = 0.81) were predictors of PFS. The escalated dose (HR = 0.47) and a larger radiation volume (HR = 0.76) were identified as predictors for better OS. Following detailed statistical analysis, a moderate radiation dose escalation (> 60 Gy) was found as an independent factor affecting OS in GBM patients. In conclusion, a moderate radiation dose escalation (> 60 Gy) was an independent predictor for longer OS in GBM patients. However, prospective studies including more patients with more information, such as molecular markers and completeness of resection, are needed to confirm our findings.
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Affiliation(s)
- Li-Tsun Shieh
- Department of Radiation Oncology, Chi Mei Medical Center, Liouying, Tainan, Taiwan, Republic of china
| | - How-Ran Guo
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan, Republic of china
- Department of Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, Republic of china
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan, Republic of china
- Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan, Republic of china
| | - Li-Ching Lin
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan, Republic of china
| | - Chin-Hong Chang
- Department of Neurosurgery, Chi Mei Medical Center, Tainan, Taiwan, Republic of china
| | - Sheng-Yow Ho
- Department of Radiation Oncology, Chi Mei Medical Center, Liouying, Tainan, Taiwan, Republic of china
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan, Republic of china
- Graduate Institute of Medical Science, Chang Jung Christian University, Tainan, Taiwan, Republic of china
- * E-mail:
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12
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Metabolic Tumor Volume Response Assessment Using (11)C-Methionine Positron Emission Tomography Identifies Glioblastoma Tumor Subregions That Predict Progression Better Than Baseline or Anatomic Magnetic Resonance Imaging Alone. Adv Radiat Oncol 2019; 5:53-61. [PMID: 32051890 PMCID: PMC7004943 DOI: 10.1016/j.adro.2019.08.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/05/2019] [Indexed: 02/08/2023] Open
Abstract
Purpose To evaluate whether response assessment of newly diagnosed glioblastoma at 3 months using 11C-methionine-positron emission tomography (MET-PET) is better associated with patient outcome compared with baseline MET-PET or anatomic magnetic resonance imaging alone. Methods and Materials Patients included were participants in a phase I/II trial of dose-escalated chemoradiation based on anatomic magnetic resonance imaging. Automated segmentation of metabolic tumor volume (MTV) was performed at a threshold of 1.5 times mean cerebellar uptake. Progression-free (PFS) and overall survival were estimated with the Kaplan-Meier method and compared with log-rank tests. Multivariate analysis for PFS and overall survival was performed using Cox proportional hazards, and spatial overlap between imaging and recurrence volumes were analyzed. Results Among 37 patients, 15 had gross total resection, of whom 10 (67%) had residual MTV, 16 subtotal resection, and 6 biopsy alone. Median radiation therapy dose was 75 Gy (range, 66-81). Median baseline T1 Gd-enhanced tumor volume (GTV-Gd) was 38.0 cm3 (range, 8.0-81.5). Median pre-CRT MTV was 4.9 cm3 (range, 0-43.8). Among 25 patients with 3-month MET-PET, MTV was only 2.4 cm3 (range, 0.004-18.0) in patients with uptake. Patients with MTV = 0 cm3 at 3 months had superior PFS (18.2 vs 10.1 months, P = .03). On multivariate analysis, larger 3-month MTV (hazard ratio [HR] 2.4, 95% confidence interval [CI], 1.4-4.3, P = .03), persistent MET-PET subvolume (overlap of pre-CRT and 3 month MTV; HR 2.0, 95% CI, 1.2-3.4, P = .06), and increase in MTV (HR 1.8, 95% CI, 1.1-3.1, P = .09) were the only imaging factors significant for worse PFS. GTV-Gd at recurrence encompassed 97% of the persistent MET-PET subvolume (interquartile range 72%-100%), versus 71% (interquartile range 39%-93%) of baseline MTV, 54% of baseline GTV-Gd (18%-87%), and 78% of 3-month MTV (47%-95%). Conclusions The majority of patients with apparent gross total resection of glioblastoma have measurable postoperative MTV. Total and persisting MTV 3 months post-CRT were significant predictors of PFS, and persistent MET-PET subvolume was the strongest predictor for localizing tumor recurrence.
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