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Tseng CL, Zeng KL, Mellon EA, Soltys SG, Ruschin M, Lau AZ, Lutsik NS, Chan RW, Detsky J, Stewart J, Maralani PJ, Sahgal A. Evolving concepts in margin strategies and adaptive radiotherapy for glioblastoma: A new future is on the horizon. Neuro Oncol 2024; 26:S3-S16. [PMID: 38437669 PMCID: PMC10911794 DOI: 10.1093/neuonc/noad258] [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] [Indexed: 03/06/2024] Open
Abstract
Chemoradiotherapy is the standard treatment after maximal safe resection for glioblastoma (GBM). Despite advances in molecular profiling, surgical techniques, and neuro-imaging, there have been no major breakthroughs in radiotherapy (RT) volumes in decades. Although the majority of recurrences occur within the original gross tumor volume (GTV), treatment of a clinical target volume (CTV) ranging from 1.5 to 3.0 cm beyond the GTV remains the standard of care. Over the past 15 years, the incorporation of standard and functional MRI sequences into the treatment workflow has become a routine practice with increasing adoption of MR simulators, and new integrated MR-Linac technologies allowing for daily pre-, intra- and post-treatment MR imaging. There is now unprecedented ability to understand the tumor dynamics and biology of GBM during RT, and safe CTV margin reduction is being investigated with the goal of improving the therapeutic ratio. The purpose of this review is to discuss margin strategies and the potential for adaptive RT for GBM, with a focus on the challenges and opportunities associated with both online and offline adaptive workflows. Lastly, opportunities to biologically guide adaptive RT using non-invasive imaging biomarkers and the potential to define appropriate volumes for dose modification will be discussed.
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Affiliation(s)
- Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - K Liang Zeng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Radiation Oncology, Simcoe Muskoka Regional Cancer Program, Royal Victoria Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eric A Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Angus Z Lau
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Natalia S Lutsik
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Rachel W Chan
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - James Stewart
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman J Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Mallick S, Gupta S, Amariyil A, Kunhiparambath H, Laviraj MA, Sharma S, Sagiraju HKR, Julka PK, Sharma D, Rath GK. Hypo-fractionated accelerated radiotherapy with concurrent and maintenance temozolomide in newly diagnosed glioblastoma: updated results from phase II HART-GBM trial. J Neurooncol 2023; 164:141-146. [PMID: 37452916 DOI: 10.1007/s11060-023-04391-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Glioblastoma (GBM) patients have poor survival outcomes despite treatment advances and most recurrences occur within the radiation field. Survival outcomes after dose escalation through hypofractionated accelerated RT(HART) were evaluated in this study. We previously reported the study's initial results showing similar survival outcomes with acceptable toxicities. Updated results after 5 years are being analysed to determine long-term survival trends. PATIENTS AND METHODS 89 patients of newly diagnosed GBM after surgery were randomized to conventional radiotherapy (CRT) or HART. CRT arm received adjuvant RT 60 Gy in 30 fractions over 6 weeks and the HART arm received 60 Gy in 20 fractions over 4 weeks, both with concurrent and adjuvant temozolomide. RESULTS 83 patients were eligible for analysis. After a median follow-up of 18.9 months, the median OS was 26.5 months and 22.4 months in the HART and CRT arms respectively. 5 year OS was 18.4% in the HART arm versus 3.8% in the CRT arm. This numerical difference in overall survival between the two arms was not statistically significant. The median PFS was not significantly different. CONCLUSION The long-term results of the trial support HART as a promising treatment option with comparable survival outcomes to the current standard of care. Phase III trials are required for further validation of this regimen which has the potential to become the new standard of care in GBM.
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Affiliation(s)
- Supriya Mallick
- Department of Radiation Oncology, National Cancer Institute, All India Institute of Medical Sciences, New Delhi, India.
| | - Subhash Gupta
- Department of Radiation Oncology, National Cancer Institute, All India Institute of Medical Sciences, New Delhi, India
| | - Adila Amariyil
- Department of Radiation Oncology, National Cancer Institute, All India Institute of Medical Sciences, New Delhi, India
| | - Haresh Kunhiparambath
- Department of Radiation Oncology, National Cancer Institute, All India Institute of Medical Sciences, New Delhi, India
| | - M A Laviraj
- Department of Radiation Oncology, National Cancer Institute, All India Institute of Medical Sciences, New Delhi, India
| | - Seema Sharma
- Department of Radiation Oncology, National Cancer Institute, All India Institute of Medical Sciences, New Delhi, India
| | | | - Pramod Kumar Julka
- Department of Radiation Oncology, National Cancer Institute, All India Institute of Medical Sciences, New Delhi, India
| | - Dayanand Sharma
- Department of Radiation Oncology, National Cancer Institute, All India Institute of Medical Sciences, New Delhi, India
| | - Goura Kishor Rath
- Department of Radiation Oncology, National Cancer Institute, All India Institute of Medical Sciences, New Delhi, India
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Schültke E, Jaekel F, Bartzsch S, Bräuer-Krisch E, Requardt H, Laissue JA, Blattmann H, Hildebrandt G. Good Timing Matters: The Spatially Fractionated High Dose Rate Boost Should Come First. Cancers (Basel) 2022; 14:cancers14235964. [PMID: 36497446 PMCID: PMC9738329 DOI: 10.3390/cancers14235964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/26/2022] [Accepted: 11/30/2022] [Indexed: 12/07/2022] Open
Abstract
Monoplanar microbeam irradiation (MBI) and pencilbeam irradiation (PBI) are two new concepts of high dose rate radiotherapy, combined with spatial dose fractionation at the micrometre range. In a small animal model, we have explored the concept of integrating MBI or PBI as a simultaneously integrated boost (SIB), either at the beginning or at the end of a conventional, low-dose rate schedule of 5x4 Gy broad beam (BB) whole brain radiotherapy (WBRT). MBI was administered as array of 50 µm wide, quasi-parallel microbeams. For PBI, the target was covered with an array of 50 µm × 50 µm pencilbeams. In both techniques, the centre-to-centre distance was 400 µm. To assure that the entire brain received a dose of at least 4 Gy in all irradiated animals, the peak doses were calculated based on the daily BB fraction to approximate the valley dose. The results of our study have shown that the sequence of the BB irradiation fractions and the microbeam SIB is important to limit the risk of acute adverse effects, including epileptic seizures and death. The microbeam SIB should be integrated early rather than late in the irradiation schedule.
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Affiliation(s)
- Elisabeth Schültke
- Department of Radiooncology, Rostock University Medical Center, 18059 Rostock, Germany
- Correspondence:
| | - Felix Jaekel
- Department of Radiooncology, Rostock University Medical Center, 18059 Rostock, Germany
| | - Stefan Bartzsch
- Department of Radiooncology, Technical University of Munich, 81675 Munich, Germany
- Institute for Radiation Medicine, Helmholtz Center Munich, 85764 Munich, Germany
| | - Elke Bräuer-Krisch
- Biomedical Beamline ID 17, European Synchrotron Radiation Facility (ESRF), 38043 Grenoble, France
| | - Herwig Requardt
- Biomedical Beamline ID 17, European Synchrotron Radiation Facility (ESRF), 38043 Grenoble, France
| | | | - Hans Blattmann
- Independent Researcher, 5417 Untersiggenthal, Switzerland
| | - Guido Hildebrandt
- Department of Radiooncology, Rostock University Medical Center, 18059 Rostock, Germany
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Harat M, Blok M, Miechowicz I, Wiatrowska I, Makarewicz K, Małkowski B. Safety and efficacy of irradiation boost based on 18F-FET-PET in patients with newly diagnosed glioblastoma. Clin Cancer Res 2022; 28:3011-3020. [PMID: 35552391 DOI: 10.1158/1078-0432.ccr-22-0171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/05/2022] [Accepted: 05/10/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE Dual timepoint FET-PET acquisition (10 and 60 minutes after FET injection) improves the definition of glioblastoma location and shape. Here we evaluated the safety and efficacy of simultaneous integrated boost (SIB) planned using dual FET-PET for postoperative glioblastoma treatment. EXPERIMENTAL DESIGN In this prospective pilot study (March 2017-December 2020), 17 patients qualified for FET-PET-based SIB intensity-modulated radiotherapy after resection. The prescribed dose was 78 and 60 Gy (2.6 and 2.0 Gy per fraction, respectively) for the FET-PET- and MR-based target volumes. Eleven patients had FET-PET within nine months to precisely define biological responses. Progression-free survival (PFS), overall survival (OS), toxicities, and radiation necrosis were evaluated. Six patients (35%) had tumors with MGMT promoter methylation. RESULTS The one- and two-year OS and PFS rates were 73% and 43% and 53% and 13%, respectively. The median OS and PFS were 24 (95%CI 9-26) and 12 (95%CI 6-18) months, respectively. Two patients developed uncontrolled seizures during radiotherapy and could not receive treatment per protocol. In patients treated per protocol, 7/15 presented with new or increased neurological deficits in the first month after irradiation. Radiation necrosis was diagnosed by MRI three months after SIB in five patients and later in another two patients. In two patients, the tumor was larger in FET-PET images after six months. CONCLUSIONS Survival outcomes using our novel dose escalation concept (total 78 Gy) were promising, even within the MGMTunmethylated subgroup. Excessive neurotoxicity was not observed, but radionecrosis was common and must be considered in future trials.
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Affiliation(s)
- Maciej Harat
- Franciszek Lukaszczyk Oncology Center, Bydgoszcz, Poland
| | - Maciej Blok
- Franciszek Lukaszczyk Oncology Center, Bydgoszcz, Poland
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Perlow HK, Prasad RN, Yang M, Klamer B, Matsui J, Marrazzo L, Detti B, Scorsetti M, Clerici E, Arnett A, Beyer S, Ammirati M, Chakravarti A, Raval RR, Brown PD, Navarria P, Scoccianti S, Grecula JC, Palmer JD. Accelerated hypofractionated radiation for elderly or frail patients with a newly diagnosed glioblastoma: A pooled analysis of patient-level data from 4 prospective trials. Cancer 2022; 128:2367-2374. [PMID: 35315512 DOI: 10.1002/cncr.34192] [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: 12/15/2021] [Revised: 02/14/2022] [Accepted: 02/28/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The standard of care for elderly or frail patients with glioblastoma (GBM) is 40 Gy in 15 fractions of radiotherapy. However, this regimen has a lower biological effective dose (BED) compared with the Stupp regimen of 60 Gy in 30 fractions. It is hypothesized that accelerated hypofractionated radiation of 52.5 Gy in 15 fractions (BED equivalent to Stupp) is safe and efficacious. METHODS Elderly or frail patients with GBM treated with 52.5 Gy in 15 fractions were pooled from 3 phase 1/2 studies and a prospective observational study. Overall survival (OS) and progression-free survival (PFS) were defined time elapsing between surgery/biopsy and death from any cause or progression of disease. RESULTS Sixty-two newly diagnosed patients were eligible for this pooled analysis of individual patient data. The majority (66%) had a Karnofsky performance status (KPS) score <70. The median age was 73 years. The median OS and PFS were 10.3 and 6.9 months, respectively. Patients with KPS scores ≥70 and <70 had a median OS of 15.3 and 9.5 months, respectively. Concurrent chemotherapy was an independent prognostic factor for improved PFS and OS. Grade 3 neurologic toxicity was seen in 2 patients (3.2%). There was no grade 4/5 toxicity. CONCLUSIONS This is the only analysis of elderly/frail patients with GBM prospectively treated with a hypofractionated radiation regimen that is isoeffective to the Stupp regimen. Treatment was well tolerated and demonstrated excellent OS and PFS compared with historical studies. This regimen gives the elderly/frail population an alternative to regimens with a lower BED. Randomized trials are needed to validate these results.
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Affiliation(s)
- Haley K Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Rahul N Prasad
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mike Yang
- Ohio State University School of Medicine, Columbus, Ohio
| | - Brett Klamer
- Center for Biostatistics, The Ohio State University, Columbus, Ohio
| | | | - Livia Marrazzo
- Department of Medical Physics, Azienda Ospedaliera Universitaria, Florence, Italy
| | - Beatrice Detti
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria, Florence, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Andrea Arnett
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sasha Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mario Ammirati
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Raju R Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Silvia Scoccianti
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria, Florence, Italy
| | - John C Grecula
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Perlow HK, Yaney A, Yang M, Klamer B, Matsui J, Raval RR, Blakaj DM, Arnett A, Beyer S, Elder JB, Ammirati M, Lonser R, Hardesty D, Ong S, Giglio P, Pillainayagam C, Goranovich J, Grecula J, Chakravarti A, Gondi V, Brown PD, Palmer JD. Dose-escalated accelerated hypofractionation for elderly or frail patients with a newly diagnosed glioblastoma. J Neurooncol 2022; 156:399-406. [PMID: 35013838 DOI: 10.1007/s11060-021-03925-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/06/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND The standard of care for elderly glioblastoma patients is 40 Gy in 15 fraction radiotherapy with temozolomide (TMZ). However, this regimen has a lower biologic equivalent dose (BED) compared to the Stupp regimen of 60 Gy in 30 fractions. We hypothesize that accelerated hypofractionated radiation of 52.5 Gy in 15 fractions (BED equivalent to Stupp) will have superior survival compared to 40 Gy in 15 fractions. METHODS Elderly patients (≥ 65 years old) who received hypofractionated radiation with TMZ from 2010 to 2020 were included in this analysis. Overall survival (OS) and progression free survival were defined as the time elapsed between surgery/biopsy and death from any cause or progression. Baseline characteristics were compared between patients who received 40 and 52.5 Gy. Univariable and multivariable analyses were performed. RESULTS Sixty-six newly diagnosed patients were eligible for analysis. Thirty-nine patients were treated with 40 Gy in 15 fractions while twenty-seven were treated with 52.5 Gy in 15 fractions. Patients had no significant differences in age, sex, methylation status, or performance status. OS was superior in the 52.5 Gy group (14.1 months) when compared to the 40 Gy group (7.9 months, p = 0.011). Isoeffective dosing to 52.5 Gy was shown to be an independent prognostic factor for improved OS on multivariable analysis. CONCLUSIONS Isoeffective dosing to 52.5 Gy in 15 fractions was associated with superior OS compared to standard of care 40 Gy in 15 fractions. These hypothesis generating data support accelerated hypofractionation in future prospective trials.
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Affiliation(s)
- Haley K Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Alexander Yaney
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Michael Yang
- Ohio State University School of Medicine, Columbus, OH, USA
| | - Brett Klamer
- Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | | | - Raju R Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Dukagjin M Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Andrea Arnett
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Sasha Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - James B Elder
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mario Ammirati
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Russell Lonser
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Douglas Hardesty
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Shirley Ong
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Pierre Giglio
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Clement Pillainayagam
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Justin Goranovich
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - John Grecula
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville, Northwestern Medicine Proton Center, Warrenville, IL, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Cinic, Rochester, MN, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA.
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Moderately hypofractionated versus conventionally fractionated radiation therapy with temozolomide for young and fit patients with glioblastoma: an institutional experience and meta-analysis of literature. J Neurooncol 2022; 160:361-374. [PMID: 36355260 PMCID: PMC9648463 DOI: 10.1007/s11060-022-04151-z] [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: 07/21/2022] [Accepted: 09/28/2022] [Indexed: 11/12/2022]
Abstract
PURPOSE Shorter hypofractionated radiation therapy (HF-RT) schedules may have radiobiological, patient convenience and healthcare resource advantages over conventionally fractionated radiation therapy (CF-RT) in glioblastoma (GBM). We report outcomes of young, fit GBM patients treated with HF-RT and CF-RT during the COVID-19 pandemic, and a meta-analysis of HF-RT literature in this patient subgroup. METHODS Hospital records of patients with IDH-wildtype GBM treated with HF-RT (50 Gy/20 fractions) and CF-RT (60 Gy/30 fractions) between January 2020 and September 2021 were reviewed. Overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method. Univariable analysis was performed using Cox regression analysis. A systematic search and meta-analysis of studies from January 2000 to January 2022 was performed. RESULTS 41 patients were treated (HF-RT:15, CF-RT:26). For both HF-RT and CF-RT groups, median age was 58 years and 80-90% were ECOG 0-1. There were more methylated tumours in the HF-RT group. All patients received concurrent/adjuvant temozolomide. At 19.2 months median follow-up, median OS was 19.8 months and not-reached for HF-RT and CF-RT (p = 0.5), and median PFS was 7.7 and 5.8 months, respectively (p = 0.8). HF-RT or CF-RT did not influence OS/PFS on univariable analysis. Grade 3 radionecrosis rate was 6.7% and 7.7%, respectively. 15 of 1135 studies screened from a systematic search were eligible for meta-analysis. For studies involving temozolomide, pooled median OS and PFS with HF-RT were 17.5 and 9.9 months (927 and 862 patients). Studies using shortened HF-RT schedules reported 0-2% Grade 3 radionecrosis rates. CONCLUSION HF-RT may offer equivalent outcomes and reduce treatment burden compared to CF-RT in young, fit GBM patients.
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Gregucci F, Surgo A, Bonaparte I, Laera L, Ciliberti MP, Carbonara R, Gentile MA, Giraldi D, Calbi R, Caliandro M, Sasso N, D’Oria S, Somma C, Martinelli G, Surico G, Lombardi G, Fiorentino A. Poor-Prognosis Patients Affected by Glioblastoma: Retrospective Study of Hypofractionated Radiotherapy with Simultaneous Integrated Boost and Concurrent/Adjuvant Temozolomide. J Pers Med 2021; 11:jpm11111145. [PMID: 34834497 PMCID: PMC8619413 DOI: 10.3390/jpm11111145] [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: 09/06/2021] [Revised: 10/23/2021] [Accepted: 10/30/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Glioblastoma (GBM) is a very poor-prognosis brain tumor. To date, maximal excision followed by radiochemotherapy, in 30 fractions, is the standard approach. Limited data are present in the literature about hypofractionated radiotherapy (hypo-RT) in GBM poor prognosis patients. Thus, this retrospective study was conducted to evaluate efficacy and toxicity of hypo-RT with simultaneous integrated boost (SIB) in association with temozolomide (TMZ) in this patient setting. METHODS Poor-prognosis GBM patients underwent surgery (complete, subtotal or biopsy) followed by SIB-hypo-RT and concomitant/adjuvant TMZ. The prescription dose was 40.05 Gy (15 fractions) with a SIB of 52.5 Gy (3.5 Gy/fraction) on surgical cavity/residual/macroscopic disease. Volumetric modulated arc therapy was performed. RESULTS From July 2019 to July 2021, 30 poor-prognosis patients affected by GBM were treated by SIB-hypo-RT; 25 were evaluated in the present analysis due to a minimum follow up of 6 months. The median age and KPS were 65 years and 60%, respectively. At the median follow-up time of 15 months (range 7-24), median and 1-year overall survival and progression-free survival were 13 months and 54%, and 8.4 months and 23%, respectively. No acute or late neurological side effects of grade ≥ 2 were reported. Grade 3-4 hematologic toxicity occurred in three cases. CONCLUSION SIB-hypo-RT associated with TMZ in poor-prognosis patients affected by GBM is an effective and safe treatment. Prospective studies could be warranted.
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Affiliation(s)
- Fabiana Gregucci
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (F.G.); (A.S.); (I.B.); (M.P.C.); (R.C.); (M.C.)
| | - Alessia Surgo
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (F.G.); (A.S.); (I.B.); (M.P.C.); (R.C.); (M.C.)
| | - Ilaria Bonaparte
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (F.G.); (A.S.); (I.B.); (M.P.C.); (R.C.); (M.C.)
| | - Letizia Laera
- Department of Medical Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (L.L.); (N.S.); (G.S.)
| | - Maria Paola Ciliberti
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (F.G.); (A.S.); (I.B.); (M.P.C.); (R.C.); (M.C.)
| | - Roberta Carbonara
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (F.G.); (A.S.); (I.B.); (M.P.C.); (R.C.); (M.C.)
| | - Maria Annunziata Gentile
- Department of Radiology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (M.A.G.); (R.C.); (G.M.)
| | - David Giraldi
- Department of Neurosurgery, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (D.G.); (S.D.); (C.S.)
| | - Roberto Calbi
- Department of Radiology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (M.A.G.); (R.C.); (G.M.)
| | - Morena Caliandro
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (F.G.); (A.S.); (I.B.); (M.P.C.); (R.C.); (M.C.)
| | - Nicola Sasso
- Department of Medical Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (L.L.); (N.S.); (G.S.)
| | - Salvatore D’Oria
- Department of Neurosurgery, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (D.G.); (S.D.); (C.S.)
| | - Carlo Somma
- Department of Neurosurgery, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (D.G.); (S.D.); (C.S.)
| | - Gaetano Martinelli
- Department of Radiology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (M.A.G.); (R.C.); (G.M.)
| | - Giammarco Surico
- Department of Medical Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (L.L.); (N.S.); (G.S.)
| | - Giuseppe Lombardi
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, 35128 Padua, Padova, Italy;
| | - Alba Fiorentino
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti, Bari, Italy; (F.G.); (A.S.); (I.B.); (M.P.C.); (R.C.); (M.C.)
- Correspondence: ; Tel.: +39-0803054608
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Singh R, Lehrer EJ, Wang M, Perlow HK, Zaorsky NG, Trifiletti DM, Bovi J, Navarria P, Scoccianti S, Gondi V, Brown PD, Palmer JD. Dose Escalated Radiation Therapy for Glioblastoma Multiforme: An International Systematic Review and Meta-Analysis of 22 Prospective Trials. Int J Radiat Oncol Biol Phys 2021; 111:371-384. [PMID: 33991621 DOI: 10.1016/j.ijrobp.2021.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/06/2021] [Accepted: 05/01/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Limited evidence is available on the utility of dose-escalated radiation therapy (DE-RT) with or without temozolomide (TMZ) versus standard-of-care radiation therapy (SoC-RT) for patients with newly diagnosed glioblastoma multiforme. We performed a systematic review/meta-analysis to compare overall survival (OS) and progression-free survival (PFS) between DE-RT and SoC-RT. METHODS AND MATERIALS We used a Population, Intervention, Control, Outcomes, Study Design/Preferred Reporting Items for Systematic Reviews and Meta-analyses/Meta-analysis of Observational Studies in Epidemiology selection criterion to identify studies. The primary and secondary outcomes were 1-year OS and 1-year PFS, respectively. Outcomes and comparisons were subdivided based on receipt of TMZ and MGMT status. DE-RT was defined based on equivalent dose calculations. Random effects meta-analyses using the Knapp-Hartung correction, arcsine transformation, and restricted maximum likelihood method were conducted. Meta-regression was used to compare therapeutic (eg, DE-RT or TMZ) and pathologic characteristics (eg, MGMT methylation status) using the Wald-type test. RESULTS Across 22 published studies, 2198 patients with glioblastoma multiforme were included; 507 received DE-RT. One-year OS after DE-RT alone was higher than SoC-RT alone (46.3% vs 23.4%; P = .02) as was 1-year PFS (17.9% vs 5.3%; P = .02). No significant difference in 1-year OS (73.2% vs 64.4%; P = .23) or 1-year PFS (44.5% vs 44.3%; P = .33) between DE-RT + TMZ and SoC-RT + TMZ was noted. No difference in 1-year OS was noted between DE-RT + TMZ and SoC-RT + TMZ in either MGMT methylated (83.2% vs 73.2%; P = .23) or MGMT unmethylated (72.6% vs 50.6%; P = .16) patients. CONCLUSIONS DE-RT alone resulted in superior PFS and OS versus SoC-RT alone. DE-RT + TMZ did not lead to improved outcomes versus SoC-RT + TMZ. No differential benefit based on MGMT status was found. Future studies are warranted to define which subgroups benefit most from DE-RT.
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Affiliation(s)
- Raj Singh
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ming Wang
- Department of Public Health Sciences, Penn State University, Hershey, Pennsylvania
| | - Haley K Perlow
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nicholas G Zaorsky
- Department of Public Health Sciences, Penn State University, Hershey, Pennsylvania; Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | | | - Joseph Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Hospital-IRCCS, Rozzano (MI), Italy
| | - Silvia Scoccianti
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Joshua D Palmer
- Department of Radiation Oncology and Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, Virginia.
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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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Guo L, Li X, Chen Y, Liu R, Ren C, Du S. The efficacy of hypofractionated radiotherapy (HFRT) with concurrent and adjuvant temozolomide in newly diagnosed glioblastoma: A meta-analysis. Cancer Radiother 2021; 25:182-190. [PMID: 33436285 DOI: 10.1016/j.canrad.2020.08.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/06/2020] [Accepted: 08/28/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE The efficacy of hypofractionated radiotherapy (HFRT) in glioblastoma (GBM) without age restrictions remains unclear. The aim of this meta-analysis is to access the survival outcomes of HFRT in these patients. METHODS A comprehensive electronic literature search of PubMed, Web of Science and Cochrane Library was conducted up to June 1, 2020. The main evaluation data were the overall survival (OS) rate at 12 months and 24 months and the progression-free survival (PFS) rate at 6 and 12 months. The secondary evaluation data was the incidence of radionecrosis and adverse events. The study was performed using R "meta" package. RESULTS Eleven studies met the inclusion criteria, which totally contained 484 participants. The 12-month OS and 24-month OS rate of HFRT in GBM were 71.3% and 34.8%, while the 6-month PFS and 12-month rate were 74.0% and 40.8%. Compared to low-BED (biological equivalent dose) schedules (<78Gy), high-BED schedules may increase survival benefit both in PFS-6 (P=0.003) and PFS-12 (P=0.011), while the difference did not show on OS. Different dose per fraction had no significant effect on both OS and PFS. Incidence of radionecrosis was 14.2%. Although the overall incidence of adverse reactions cannot be quantified, the toxicity of HFRT was acceptable. CONCLUSIONS Compared with survival data for standard treatment, HFRT seemed to improve overall survival and progression-free survival, while high BED schedules may future increase benefit on PFS. Meanwhile, the toxicity of HFRT was tolerable. Further randomised controlled clinical studies are needed to confirm these findings.
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Affiliation(s)
- Longbin Guo
- Department of radiation oncology, Nanfang hospital, Southern medical university, 1838, North Guangzhou avenue, 510515 Guangzhou, China
| | - Xuanzi Li
- Department of radiation oncology, Nanfang hospital, Southern medical university, 1838, North Guangzhou avenue, 510515 Guangzhou, China
| | - Yulei Chen
- Department of radiation oncology, Nanfang hospital, Southern medical university, 1838, North Guangzhou avenue, 510515 Guangzhou, China
| | - Rongping Liu
- Department of radiation oncology, Nanfang hospital, Southern medical university, 1838, North Guangzhou avenue, 510515 Guangzhou, China
| | - Chen Ren
- Department of radiation oncology, Nanfang hospital, Southern medical university, 1838, North Guangzhou avenue, 510515 Guangzhou, China.
| | - Shasha Du
- Department of radiation oncology, Nanfang hospital, Southern medical university, 1838, North Guangzhou avenue, 510515 Guangzhou, China.
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12
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Uysal B, Gamsiz H, Sager O, Dincoglan F, Demiral S, Ozcan F, Colak O, Beyzadeoglu M. Comparative outcomes of short-term and long-term fractionation with temozolomide in older glioblastoma patients: Single-center experience. J Cancer Res Ther 2021; 18:1610-1615. [DOI: 10.4103/jcrt.jcrt_984_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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13
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Farrell C, Shi W, Bodman A, Olson JJ. Congress of neurological surgeons systematic review and evidence-based guidelines update on the role of emerging developments in the management of newly diagnosed glioblastoma. J Neurooncol 2020; 150:269-359. [PMID: 33215345 DOI: 10.1007/s11060-020-03607-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/23/2020] [Indexed: 12/12/2022]
Abstract
TARGET POPULATION These recommendations apply to adult patients with newly diagnosed or suspected glioblastoma. IMAGING Question What imaging modalities are in development that may be able to provide improvements in diagnosis, and therapeutic guidance for individuals with newly diagnosed glioblastoma? RECOMMENDATION Level III: It is suggested that techniques utilizing magnetic resonance imaging for diffusion weighted imaging, and to measure cerebral blood and magnetic spectroscopic resonance imaging of N-acetyl aspartate, choline and the choline to N-acetyl aspartate index to assist in diagnosis and treatment planning in patients with newly diagnosed or suspected glioblastoma. SURGERY Question What new surgical techniques can be used to provide improved tumor definition and resectability to yield better tumor control and prognosis for individuals with newly diagnosed glioblastoma? RECOMMENDATIONS Level II: The use of 5-aminolevulinic acid is recommended to improve extent of tumor resection in patients with newly diagnosed glioblastoma. Level II: The use of 5-aminolevulinic acid is recommended to improve median survival and 2 year survival in newly diagnosed glioblastoma patients with clinical characteristics suggesting poor prognosis. Level III: It is suggested that, when available, patients be enrolled in properly designed clinical trials assessing the value of diffusion tensor imaging in improving the safety of patients with newly diagnosed glioblastoma undergoing surgery. NEUROPATHOLOGY Question What new pathology techniques and measurement of biomarkers in tumor tissue can be used to provide improved diagnostic ability, and determination of therapeutic responsiveness and prognosis for patients with newly diagnosed glioblastomas? RECOMMENDATIONS Level II: Assessment of tumor MGMT promoter methylation status is recommended as a significant predictor of a longer progression free survival and overall survival in patients with newly diagnosed with glioblastoma. Level II: Measurement of tumor expression of neuron-glia-2, neurofilament protein, glutamine synthetase and phosphorylated STAT3 is recommended as a predictor of overall survival in patients with newly diagnosed with glioblastoma. Level III: Assessment of tumor IDH1 mutation status is suggested as a predictor of longer progression free survival and overall survival in patients with newly diagnosed with glioblastoma. Level III: Evaluation of tumor expression of Phosphorylated Mitogen-Activated Protein Kinase protein, EGFR protein, and Insulin-like Growth Factor-Binding Protein-3 is suggested as a predictor of overall survival in patients with newly diagnosed with glioblastoma. RADIATION Question What radiation therapy techniques are in development that may be used to provide improved tumor control and prognosis for individuals with newly diagnosed glioblastomas? RECOMMENDATIONS Level III: It is suggested that patients with newly diagnosed glioblastoma undergo pretreatment radio-labeled amino acid tracer positron emission tomography to assess areas at risk for tumor recurrence to assist in radiation treatment planning. Level III: It is suggested that, when available, patients be with newly diagnosed glioblastomas be enrolled in properly designed clinical trials of radiation dose escalation, altered fractionation, or new radiation delivery techniques. CHEMOTHERAPY Question What emerging chemotherapeutic agents or techniques are available to provide better tumor control and prognosis for patients with newly diagnosed glioblastomas? RECOMMENDATION Level III: As no emerging chemotherapeutic agents or techniques were identified in this review that improved tumor control and prognosis it is suggested that, when available, patients with newly diagnosed glioblastomas be enrolled in properly designed clinical trials of chemotherapy. MOLECULAR AND TARGETED THERAPY Question What new targeted therapy agents are available to provide better tumor control and prognosis for individuals with newly diagnosed glioblastomas? RECOMMENDATION Level III: As no new molecular and targeted therapies have clearly provided better tumor control and prognosis it is suggested that, when available, patients with newly diagnosed glioblastomas be enrolled in properly designed clinical trials of molecular and targeted therapies IMMUNOTHERAPY: Question What emerging immunotherapeutic agents or techniques are available to provide better tumor control and prognosis for patients with newly diagnosed glioblastomas? RECOMMENDATION Level III: As no immunotherapeutic agents have clearly provided better tumor control and prognosis it is suggested that, when available, patients with newly diagnosed glioblastomas be enrolled in properly designed clinical trials of immunologically-based therapies. NOVEL THERAPIES Question What novel therapies or techniques are in development to provide better tumor control and prognosis for individuals with newly diagnosed glioblastomas? RECOMMENDATIONS Level II: The use of tumor-treating fields is recommended for patients with newly diagnosed glioblastoma who have undergone surgical debulking and completed concurrent chemoradiation without progression of disease at the time of tumor-treating field therapy initiation. Level II: It is suggested that, when available, enrollment in properly designed studies of vector containing herpes simplex thymidine kinase gene and prodrug therapies be considered in patients with newly diagnosed glioblastoma.
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Affiliation(s)
- Christopher Farrell
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA.
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14
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Trone JC, Vallard A, Sotton S, Ben Mrad M, Jmour O, Magné N, Pommier B, Laporte S, Ollier E. Survival after hypofractionation in glioblastoma: a systematic review and meta-analysis. Radiat Oncol 2020; 15:145. [PMID: 32513205 PMCID: PMC7278121 DOI: 10.1186/s13014-020-01584-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/25/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Glioblastoma multiforme (GBM) has a poor prognosis despite a multi modal treatment that includes normofractionated radiotherapy. So, various hypofractionated alternatives to normofractionated RT have been tested to improve such prognosis. There is need of systematic review and meta-analysis to analyse the literature properly and maybe generalised the use of hypofractionation. The aim of this study was first, to perform a meta-analysis of all controlled trials testing the impact of hypofractionation on survival without age restriction and secondly, to analyse data from all non-comparative trials testing the impact of hypofractionation, radiosurgery and hypofractionated stereotactic RT in first line. MATERIALS/METHODS We searched Medline, Embase and Cochrane databases to identify all publications testing the impact of hypofractionation in glioblastoma between 1985 and March 2020. Combined hazard ratio from comparative studies was calculated for overall survival. The impact of study design, age and use of adjuvant temozolomide was explored by stratification. Meta-regressions were performed to determine the impact of prognostic factors. RESULTS 2283 publications were identified. Eleven comparative trials were included. No impact on overall survival was evidenced (HR: 1.07, 95%CI: 0.89-1.28) without age restriction. The analysis of non-comparative literature revealed heterogeneous outcomes with limited quality of reporting. Concurrent chemotherapy, completion of surgery, immobilization device, isodose of prescription, and prescribed dose (depending on tumour volume) were poorly described. However, results on survival are encouraging and were correlated with the percentage of resected patients and with patients age but not with median dose. CONCLUSIONS Because few trials were randomized and because the limited quality of reporting, it is difficult to define the place of hypofactionation in glioblastoma. In first line, hypofractionation resulted in comparable survival outcome with the benefit of a shortened duration. The method used to assess hypofractionation needs to be improved.
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Affiliation(s)
- Jane-Chloe Trone
- Department of Radiation Oncology, Lucien Neuwirth Cancer Institute, 108 Bis, Avenue Albert Raimond, 42270, Saint-Priest-en-Jarez, France.
| | - Alexis Vallard
- Department of Radiation Oncology, Lucien Neuwirth Cancer Institute, 108 Bis, Avenue Albert Raimond, 42270, Saint-Priest-en-Jarez, France
| | - Sandrine Sotton
- University Departement of Research and Teaching, Lucien Neuwirth Cancer Institute, Saint-Priest-en-Jarez, France
| | - Majed Ben Mrad
- Department of Radiation Oncology, Lucien Neuwirth Cancer Institute, 108 Bis, Avenue Albert Raimond, 42270, Saint-Priest-en-Jarez, France
| | - Omar Jmour
- Department of Radiation Oncology, Lucien Neuwirth Cancer Institute, 108 Bis, Avenue Albert Raimond, 42270, Saint-Priest-en-Jarez, France
| | - Nicolas Magné
- University Departement of Research and Teaching, Lucien Neuwirth Cancer Institute, Saint-Priest-en-Jarez, France
| | - Benjamin Pommier
- Department of Neurosurgery, University Hospital, Saint-Etienne, France
| | - Silvy Laporte
- SAINBIOSE U1059, Jean Monnet University, Saint-Etienne, France
| | - Edouard Ollier
- SAINBIOSE U1059, Jean Monnet University, Saint-Etienne, France
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15
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Xiao J, Ma Y. Adaptive hypofractionated radiotherapy combined with chemotherapy and anti-angiogenic therapy for residual and recurrent glioblastoma after surgery: A case report. GLIOMA 2020. [DOI: 10.4103/glioma.glioma_26_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Liao G, Zhao Z, Yang H, Li X. Efficacy and Safety of Hypofractionated Radiotherapy for the Treatment of Newly Diagnosed Glioblastoma Multiforme: A Systematic Review and Meta-Analysis. Front Oncol 2019; 9:1017. [PMID: 31681570 PMCID: PMC6802705 DOI: 10.3389/fonc.2019.01017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 09/20/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Hypofractionated radiotherapy (HFR) is sometimes used in the treatment of glioblastoma multiforme (GBM). The efficacy and safety of HFR is still under investigation. The aim of this systematic review and meta-analysis was to provide a comprehensive summary of the efficacy and safety of HFR, and to compare the efficacy and safety of HFR and conventional fraction radiotherapy (CFR) for the treatment of patients with GBM, based on the results of randomized controlled trials (RCTs). Methods: A literature search was conducted to identify Phase II and III trials o comparing the efficacy and safety of HFR and CFR. Study selection, data extraction, and quality assessment, were conducted by two independent researchers. The analysis was performed using RevMan 5.3 and Stata 12.0. Results: Sixteen Phase II and III trials were included in the systematic review, and four RCTs were included in the meta-analysis. Participants treated with HRF and CRF had comparable overall survival (OS) (hazard ratio [HR]: 0.94, 95% confidence interval [CI]: 0.72–1.22, P = 0.64) and progression-free survival (PFS) (HR: 1.09, 95% CI: 0.60–1.95, P = 0.79), and similar rates of adverse events. However, in participants aged >70 years, those who received HFR had a higher OS than those who received CFR (HR: 0.59, 95% CI: 0.37–0.93, P = 0.02). Conclusions: HRF is efficacious and safe for the treatment of GBM. In individuals aged >70 years, treatment with HRF is superior to CFR in terms of OS. The role of HFR in the treatment of GBM in younger individuals and those with good prognostic factors requires further research.
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Affiliation(s)
- Guixiang Liao
- Department of Radiation Oncology, Second Clinical Medicine Centre, Shenzhen People's Hospital, Jinan University, Shenzhen, China
| | - Zhihong Zhao
- Department of Nephrology, Second Clinical Medicine Centre, Shenzhen People's Hospital, Jinan University, Shenzhen, China
| | - Hongli Yang
- Department of Radiation Oncology, Second Clinical Medicine Centre, Shenzhen People's Hospital, Jinan University, Shenzhen, China
| | - Xianming Li
- Department of Radiation Oncology, Second Clinical Medicine Centre, Shenzhen People's Hospital, Jinan University, Shenzhen, China
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17
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Zhong L, Chen L, Lv S, Li Q, Chen G, Luo W, Zhou P, Li G. Efficacy of moderately hypofractionated simultaneous integrated boost intensity-modulated radiotherapy combined with temozolomide for the postoperative treatment of glioblastoma multiforme: a single-institution experience. Radiat Oncol 2019; 14:104. [PMID: 31196126 PMCID: PMC6567425 DOI: 10.1186/s13014-019-1305-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/24/2019] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Despite recent advances in multimodal treatments, the prognosis of patients with glioblastoma multiforme (GBM) remains poor. The aim of this study was to evaluate the efficacy of moderately hypofractionated simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) combined with temozolomide (TMZ) for the postoperative treatment of GBM. MATERIALS AND METHODS From February 2012 to February 2018, 80 patients with newly diagnosed and histologically confirmed GBM in our institute were reviewed retrospectively. All patients underwent complete resection or partial resection surgery and then received hypofractionated SIB-IMRT with concomitant TMZ followed by adjuvant TMZ. A total dose of 64 Gy over 27 fractions was delivered to the gross tumor volume (GTV), clinical target volume 1 (CTV1) received 60 Gy over 27 fractions, and CTV2 received 54 Gy over 27 fractions. The progression-free survival (PFS) and overall survival (OS) rates and the toxicities were evaluated. Prognostic factors were analyzed using univariate and multivariate Cox models. RESULTS The median follow-up was 16 months (range, 5~72 months). The median PFS was 15 months, and the 1-, 2-, and 3-year PFS rates were 56.0, 27.6, and 19.5%, respectively. The median OS was 21 months, and the 1-, 2-, 3-, and 5-year OS rates were 77.6, 41.6, 32.8, and 13.4%, respectively. The toxicities were mild and acceptable. Age, KPS scores and the total number of TMZ cycles were significant factors influencing patient survival. CONCLUSION Moderately hypofractionated SIB-IMRT combined with TMZ is a feasible and safe treatment option with mild toxicity and good PFS and OS.
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Affiliation(s)
- Liangzhi Zhong
- Cancer Research Institute of the Chinese People's Liberation Army, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Lu Chen
- Cancer Research Institute of the Chinese People's Liberation Army, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Shengqing Lv
- Department of neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Qingrui Li
- Biobank, Southwest Hospital, Army Medical University, Chongqing, 400038, China
| | - Guangpeng Chen
- Cancer Research Institute of the Chinese People's Liberation Army, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Wen Luo
- Cancer Research Institute of the Chinese People's Liberation Army, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Pu Zhou
- Cancer Research Institute of the Chinese People's Liberation Army, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Guanghui Li
- Cancer Research Institute of the Chinese People's Liberation Army, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China.
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