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Fleischmann DF, Gajdi L, Corradini S, Schönecker S, Marschner S, Bodensohn R, Hofmaier J, Garny S, Forbrig R, Thon N, Belka C, Niyazi M. Re-irradiation treatment regimens for patients with recurrent glioma - Evaluation of the optimal dose and best concurrent therapy. Radiother Oncol 2024; 199:110437. [PMID: 39013502 DOI: 10.1016/j.radonc.2024.110437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 07/10/2024] [Accepted: 07/11/2024] [Indexed: 07/18/2024]
Abstract
PURPOSE Re-irradiation (reRT) is an effective treatment modality for patients with recurrent glioma. Data on dose escalation, the use of simulated integrated boost and concomitant therapy to reRT are still scarce. In this monocentric cohort of n = 223 patients we investigated the influence of reRT dose escalation as well as the concomitant use of bevacizumab (BEV) with regard to post-recurrence survival (PRS) and risk of radionecrosis (RN). PATIENTS AND METHODS Patients with recurrent glioma treated between July 2008 and August 2022 with reRT with BEV, reRT with temozolomide (TMZ) and reRT without concomitant systemic therapy were retrospectively analyzed. PRS and RN-free survival (RNFS) were calculated for all patients using the Kaplan-Meier estimator. Univariable and multivariable cox regression was performed for PRS and for RNFS. The reRT Risk Score (RRRS) was calculated for all patients. RESULTS Good, intermediate and poor risk of the RRRS translated into 11 months, 9 months and 7 months of median PRS (univariable: p = 0.008, multivariable: p = 0.013). ReRT was applied with a dose of ≤36 Gy (n = 140) or >36 Gy (n = 83). Concomitant bevacizumab (BEV) therapy was performed in n = 122 and concomitant temozolomide (TMZ) therapy in n = 32 patients. Median PRS was 10 months in patients treated with >36 Gy and 8 months in patients treated with ≤36 Gy (univariable: p = 0.032, multivariable: p = 0.576). Regarding concomitant TMZ therapy, median PRS was 14 months vs. 9 months for patients treated with or without TMZ (univariable: p = 0.041, multivariable: p = 0.019). No statistically significant influence on PRS was seen for concomitant BEV therapy in this series. RN was less frequent for reRT with concomitant BEV, (17/122; 13.9 %) than for reRT without BEV (30/101; 29.7 %). Regarding RNFS, the hazard ratio for reRT with BEV was 0.436 (univariable; p = 0.006) and 0.479 (multivariable; p = 0.023), respectively. ReRT dose did not show statistical significance in regards to RN (univariable: p = 0.073, multivariable: p = 0.404). RNFS was longer for patients receiving concomitant BEV to reRT than for patients treated with reRT only (mean 31.7 vs. 30.9 months, p = 0.004). CONCLUSION In this cohort, in patients treated with concomitant BEV therapy RN was less frequently detected and in patients treated with concomitant TMZ longer PRS was observed. Based on these results, the best concomitant therapy and the optimal dose should be decided on a patient-by-patient basis.
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Affiliation(s)
- Daniel F Fleischmann
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Laura Gajdi
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Stephan Schönecker
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Marschner
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Raphael Bodensohn
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany; Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Jan Hofmaier
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Sylvia Garny
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Robert Forbrig
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Niklas Thon
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany; Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany; Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany; German Cancer Consortium (DKTK), Partner Site Tübingen, Tübingen, Germany
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Tong E, Horsley P, Wheeler H, Wong M, Venkatesha V, Chan J, Kastelan M, Back M. Hypofractionated re-irradiation with bevacizumab for relapsed chemorefractory glioblastoma after prior high dose radiotherapy: a feasible option for patients with large-volume relapse. J Neurooncol 2024; 168:69-76. [PMID: 38551747 DOI: 10.1007/s11060-024-04643-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/11/2024] [Indexed: 05/15/2024]
Abstract
PURPOSE There remains no standard of care for patients with recurrent and chemorefractory glioblastoma. Re-irradiation (reRT) provides an additional management option. However, published series predominantly focus on small reRT volumes utilizing stereotactic hypofractionated regimens. Concerns regarding toxicity have limited utilisation of reRT for larger recurrences, however this may be mitigated with use of bevacizumab (BEV). METHODS AND MATERIALS A prospective database of patients managed with the EORTC-NCIC (Stupp) protocol 60 Gy chemoradiotherapy protocol for glioblastoma between 2007 and 2021 was reviewed for those patients receiving reRT for chemorefractory relapse. Serial MRI and PET were used to establish true progression and exclude patients with pseudoprogression or radionecrosis from reRT. The primary endpoint was overall survival (OS) from date of reRT. Prognostic factors were also assessed. RESULTS 447 patients managed for glioblastoma under the Stupp protocol were identified, of which 372 had relapsed and were thus eligible for reRT. 71 patients underwent reRT. Median relapse-free survival from diagnosis for the reRT and overall cohorts were similar at 11.6 months (95%CI:9.4-14.2) and 11.8 months (95%CI:9.4-14.2) respectively. 60/71 (85%) reRT patients had received BEV prior to reRT and continued concurrent BEV during reRT. Of the 11 patients not managed with BEV during reRT, 10 required subsequent salvage BEV. ReRT patients were younger (median 53 vs. 59 years, p < 0.001), had better performance status (86% vs. 69% ECOG 0-1, p = 0.002) and more commonly had MGMT promoter-methylated tumours (54% vs. 40%, p = 0.083) compared to non-reRT patients. Median reRT PTV volume was 135cm3 (IQR: 69-207cm3). Median OS from reRT to death was 7.1 months (95%CI:6.3-7.9). Patients aged < 50, 50-70 and > 70 years had post-reRT median OS of 7.7, 6.4 and 6.0 months respectively (p = 0.021). Median post-reRT survival was longer for patients with ECOG performance status 0-1 compared to 2-3 (8.1 vs. 6.3 months, p = 0.039). PTV volume, site of relapse, MGMT promoter-methylation status and extent of initial surgical resection were not associated with post-reRT survival. ReRT was well-tolerated. Out of the 6 patients (8%) admitted to hospital after reRT, only one was for reRT toxicity. This was a CTCAE grade 3 radiation necrosis event in a patient managed without prior BEV. CONCLUSION Patients with recurrent glioblastoma who have been previously treated with 60 Gy radiotherapy have a meaningful survival benefit from large volume re-irradiation which is well tolerated. ReRT should not be ignored as a salvage treatment option in patients with chemorefractory progressive disease.
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Affiliation(s)
- Elissa Tong
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia.
| | - Patrick Horsley
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
| | - Helen Wheeler
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
- The Brain Cancer Group, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Matthew Wong
- Central Coast Cancer Centre, Gosford Hospital, Gosford, NSW, Australia
| | - Venkatesha Venkatesha
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
| | - Joseph Chan
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
| | - Marina Kastelan
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
- The Brain Cancer Group, St Leonards, NSW, Australia
| | - Michael Back
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
- The Brain Cancer Group, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Central Coast Cancer Centre, Gosford Hospital, Gosford, NSW, Australia
- GenesisCare, Sydney, NSW, Australia
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3
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Knisely JPS, Fine HA. Reirradiation for Recurrent Glioblastoma: What We Know and What We Do Not. J Clin Oncol 2023; 41:1183-1188. [PMID: 36260825 DOI: 10.1200/jco.22.01785] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.
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Affiliation(s)
| | - Howard A Fine
- Department of Neurology, Weill Cornell Medicine, New York, NY.,Meyer Cancer Center, Weill Cornell Medicine, New York, NY
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4
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She L, Su L, Liu C. Bevacizumab combined with re-irradiation in recurrent glioblastoma. Front Oncol 2022; 12:961014. [PMID: 36046037 PMCID: PMC9423039 DOI: 10.3389/fonc.2022.961014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 07/04/2022] [Indexed: 11/18/2022] Open
Abstract
Background Glioblastoma is characterized by rich vasculature and abnormal vascular structure and function. Currently, there is no standard treatment for recurrent glioblastoma (rGBM). Bevacizumab (BEV) has established role of inhibiting neovascularization, alleviating hypoxia in the tumor area and activating the immune microenvironment. BEV may exert synergistic effects with re-irradiation (re-RT) to improve the tumor microenvironment for rGBM. Purpose The purpose of this study was to evaluate the safety, tolerability, and efficacy of a combination of BEV and re-RT for rGBM treatment. Methods In this retrospective study, a total of 26 rGBM patients with surgical pathologically confirmed glioblastoma and at least one event of recurrence were enrolled. All patients were treated with re-RT in combination with BEV. BEV was administered until progression or serious adverse events. Results Median follow-up was 21.9 months for all patients, whereas median progression-free survival (PFS) was 8.0 months (95% confidence interval [CI]: 6.5–9.5 months). In addition, the 6-month and 1-year PFS rates were 65.4% and 28.2%, respectively. The median overall survival (OS), 6-month OS rate, and 1-year OS rate were 13.6 months (95% CI: 10.2–17.0 months), 92.3%, and 67.5%, respectively. The patient showed good tolerance during the treatment with no grade > 3 grade side event and radiation necrosis occurrence rate of 0%. Combined treatment of gross total resection (GTR) before re-RT and concurrent temozolomide during re-RT was an independent prognostic factor that affected both OS and PFS in the whole cohort (OS: 0.067, 95% CI: 0.009–0.521, p = 0.010; PFS: 0.238, 95% CI: 0.076–0.744, p = 0.038). Conclusion In this study, re-RT combined with concurrent and maintenance BEV treatment was safe, tolerable, and effective in rGBM patients. Moreover, GTR before re-RT and selective concurrent temozolomide could further improve patient PFS and OS.
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Affiliation(s)
- Lei She
- Department of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacology, Engineering Research Center for Applied Technology of Pharmacogenomics of Ministry of Education, Central South University, Changsha, China.,Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Lin Su
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Chao Liu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
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5
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Stiefel I, Schröder C, Tanadini-Lang S, Pytko I, Vu E, Klement R, Guckenberger M, Andratschke N. High-dose re-irradiation of intracranial lesions - Efficacy and safety including dosimetric analysis based on accumulated EQD2Gy dose EQD calculation. Clin Transl Radiat Oncol 2021; 27:132-138. [PMID: 33659717 PMCID: PMC7890358 DOI: 10.1016/j.ctro.2021.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 01/30/2021] [Indexed: 01/05/2023] Open
Abstract
Re-irradiation of the brain is feasible with an encouraging overall survival. Treatment related toxicity was low within the reported dose range. EQD2 cumulative dose distributions were calculated using rigid registration. Dose-Response-Modelling with logistic regression showed a correlation of the D1cc brain with any grade of acute toxicity.
Introduction The use of cranial re-irradiation is growing with improving overall survival and the advent of high-precision radiotherapy techniques. Still the value of re-irradiation needs careful evaluation regarding safety and efficacy. We analyzed dosimetric and clinical data of patients receiving cranial re-irradiation using EQD2 sum plans. Methods and material We retrospectively analyzed the data of 76 patients who received repeated cranial radiotherapy from 02/2013 to 09/2016. 34 patients suffered from recurrent primary brain tumors, 42 from brain metastases. Dosimetric analysis was performed accumulating EQD2 dose distributions based on rigid image registration. Clinical and radiological data was collected at follow-ups including toxicity, local control and overall survival. Results In total 76 patients had at least 2 courses of intracranial radiotherapy. The median accumulated prescription EQD2 dose was 96.5 Gy2 for all radiation courses combined. The median D(0.1 cc) of the brain for patients receiving more than 100 Gy2 was 114 Gy2 with a highest dose of 161.5 Gy2. 74% of patients suffered from low grade (G1–G2) acute toxicity, only two high grade (>G3) toxicities were recorded. Median overall survival from the time of first re-irradiation was 57 weeks (range 4–186 weeks). The median time to local failure for patients with a primary brain tumor was not reached and 24 weeks (range 1–77 weeks) for patients with brain metastases. Conclusion Repeated radiotherapy appears both safe and efficient in patients with recurrent primary or secondary brain tumors with doses to the brain up to 120 Gy2 EQD2, doses below 100 Gy2 for brainstem and doses below 75 Gy2 EQD2 to chiasm and optic nerves.
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Affiliation(s)
- I. Stiefel
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - C. Schröder
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
- Center for Proton Therapy, Paul Scherrer-Institut, Villigen, Switzerland
| | - S. Tanadini-Lang
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - I. Pytko
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - E. Vu
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - R.J. Klement
- Department of Radiation Oncology, Leopoldina Hospital, Schweinfurt, Germany
- University of Zurich, Zurich, Switzerland
| | - M. Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - N. Andratschke
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
- Corresponding author at: Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
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Gupta T, Maitre M, Maitre P, Goda JS, Krishnatry R, Chatterjee A, Moiyadi A, Shetty P, Epari S, Sahay A, Patil V, Jalali R. High-dose salvage re-irradiation for recurrent/progressive adult diffuse glioma: healing or hurting? Clin Transl Oncol 2021; 23:1358-1367. [PMID: 33528810 DOI: 10.1007/s12094-020-02526-0] [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: 10/24/2020] [Accepted: 11/13/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE To report survival outcomes and identify prognostic factors of salvage re-irradiation (re-RT) in recurrent/progressive glioma. METHODS Medical records of patients treated with high-dose re-RT as part of multi-modality salvage therapy for recurrence/progression of adult diffuse glioma from 2010 to 2019 were analyzed retrospectively. RESULTS A total of 111 patients developing recurrent/progressive high-grade glioma after adequate upfront treatment at initial diagnosis were included. The first course of radiotherapy (RT) had been delivered to a median dose of 59.4 Gy with an inter-quartile range (IQR) of 54-60 Gy. Median time to recurrence/progression was 4.3 years (IQR = 2.3-7.4 years) while the median time to re-RT was 4.8 years (IQR = 3.6-7.9 years). Re-RT was delivered with intensity-modulated radiation therapy (IMRT) using 1.8 Gy/fraction to a median dose of 54 Gy (IQR = 50.4-55.8 Gy) for a cumulative median equivalent dose in 2-Gy fractions (EQD2) of 104.3 Gy (IQR = 102.6-109.4 Gy). At a median follow-up of 14 months after re-RT, the 1-year Kaplan-Meier estimates of post-re-RT progression-free survival (PFS) and overall survival (OS) were 42.8 and 61.8%, respectively. Univariate analysis identified histological grade at recurrence/progression; histological subtype; disease-free interval (DFI) and time interval between both courses of RT; performance status at re-RT; dose at re-RT and cumulative EQD2; isocitrate dehydrogenase (IDH) mutation; and O6-methyl-guanine DNA methyl transferase (MGMT) gene promoter methylation as significant prognostic factors. Preserved performance status, longer DFI, prolonged time interval between both courses of RT, and presence of IDH mutation were associated with significantly improved PFS on multi-variate analysis. However, only performance status retained independent prognostic significance for OS on multi-variate analysis. Post-treatment changes were seen in 33 (30%) patients on follow-up imaging, with higher cumulative dose (EQD2 ≥ 104.3 Gy) being associated with increased risk of post-re-RT pseudo-progression. CONCLUSION This clinical audit reports encouraging survival outcomes and identifies key prognostic factors associated with high-dose salvage re-RT in recurrent/progressive glioma.
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Affiliation(s)
- T Gupta
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer (ACTREC)/Tata Memorial Hospital (TMH), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Kharghar, Navi Mumbai, 410210, India.
| | - M Maitre
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer (ACTREC)/Tata Memorial Hospital (TMH), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Kharghar, Navi Mumbai, 410210, India
| | - P Maitre
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer (ACTREC)/Tata Memorial Hospital (TMH), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Kharghar, Navi Mumbai, 410210, India
| | - J S Goda
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer (ACTREC)/Tata Memorial Hospital (TMH), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Kharghar, Navi Mumbai, 410210, India
| | - R Krishnatry
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer (ACTREC)/Tata Memorial Hospital (TMH), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Kharghar, Navi Mumbai, 410210, India
| | - A Chatterjee
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer (ACTREC)/Tata Memorial Hospital (TMH), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Kharghar, Navi Mumbai, 410210, India
| | - A Moiyadi
- Department of Neuro-Surgical Oncology, Advanced Centre for Treatment Research and Education in Cancer (ACTREC)/Tata Memorial Hospital (TMH), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Kharghar, Navi Mumbai, 410210, India
| | - P Shetty
- Department of Neuro-Surgical Oncology, Advanced Centre for Treatment Research and Education in Cancer (ACTREC)/Tata Memorial Hospital (TMH), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Kharghar, Navi Mumbai, 410210, India
| | - S Epari
- Department of Pathology, Advanced Centre for Treatment Research and Education in Cancer (ACTREC)/Tata Memorial Hospital (TMH), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Kharghar, Navi Mumbai, 410210, India
| | - A Sahay
- Department of Pathology, Advanced Centre for Treatment Research and Education in Cancer (ACTREC)/Tata Memorial Hospital (TMH), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Kharghar, Navi Mumbai, 410210, India
| | - V Patil
- Department of Medical Oncology, Advanced Centre for Treatment Research and Education in Cancer (ACTREC)/Tata Memorial Hospital (TMH), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Kharghar, Navi Mumbai, 410210, India
| | - R Jalali
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer (ACTREC)/Tata Memorial Hospital (TMH), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Kharghar, Navi Mumbai, 410210, India
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Prospective Longitudinal Assessment of Quality of Life and Activities of Daily Living as Patient-Reported Outcome Measures in Recurrent/Progressive Glioma Treated with High-dose Salvage Re-irradiation. Clin Oncol (R Coll Radiol) 2020; 33:e155-e165. [PMID: 32917486 DOI: 10.1016/j.clon.2020.08.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/13/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022]
Abstract
AIMS To evaluate quality of life (QOL) and activities of daily living (ADL) longitudinally in patients treated with salvage re-irradiation for recurrent/progressive glioma. Secondary end points included post-re-irradiation survival. MATERIALS AND METHODS Patients with diffuse glioma, aged 18-70 years with preserved performance status and unequivocal evidence of recurrence/progression with a minimum 2-year time interval from index radiation therapy were eligible. QOL was assessed by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core-30 (QLQ-C30) and brain cancer module (BN20). ADL was assessed using a modified Barthel's index. Assessments were carried out longitudinally, first before re-irradiation, at completion of re-irradiation and subsequently periodically on follow-up. Summary scores were calculated from raw scores as per the EORTC scoring manual; higher functional scores and lower symptom scores indicating better QOL. Summary mean scores for the modified Barthel's index were also calculated, with lower scores indicating higher disability. Differences between the summary scores at different time points were tested using the Friedman test. RESULTS In total, 225 assessments were carried out in 60 patients accrued on the study. A significant improvement in scores was noted for physical function (P < 0.001), emotional function (P = 0.002), cognitive function (P = 0.009) and social functioning (P = 0.047) over time. Role function scores (P = 0.182) and global health status scores (P = 0.074) remained stable. Among symptom scores, fatigue showed a statistically significant improvement over time (P = 0.01), whereas other symptom scores remained largely stable. There was a significant increase in the modified Barthel's index score over time (P = 0.001), suggesting greater functional independence. At a median follow-up of 12.9 months, the 1-year Kaplan-Meier estimates with 95% confidence intervals of post-re-irradiation progression-free survival and overall survival were 45.1% (31.5-58.7%) and 62.2% (49.2-75.2%), respectively. CONCLUSIONS High-dose salvage re-irradiation in carefully selected patients with recurrent/progressive glioma is associated with stable QOL (preserved functional domains and reduced symptom burden) and improvement in ADL (greater functional independence) over time with encouraging survival outcomes.
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Chan J, Jayamanne D, Wheeler H, Khasraw M, Wong M, Kastelan M, Guo L, Back M. The role of large volume re-irradiation with Bevacizumab in chemorefractory high grade glioma. Clin Transl Radiat Oncol 2020; 22:33-39. [PMID: 32195378 PMCID: PMC7075764 DOI: 10.1016/j.ctro.2020.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/06/2020] [Accepted: 03/06/2020] [Indexed: 02/06/2023] Open
Abstract
Large volume reRT is a viable treatment for refractory recurrent high-grade glioma. Bevacizumab facilitates large volume reRT by reducing the risk of CNS radionecrosis. Patient selection for reRT needs more work but should be guided by performance status.
Background and purpose Current practice in re-irradiation (reRT) of previously treated high-grade gliomas (HGG) has generally been limited to small volume reRT with stereotactic procedures. Less evidence exists for large volume reRT involving treatment volumes equivalent to that used at initial diagnosis. The primary aim of this study was to investigate the outcome of large volume reRT delivered in combination with Bevacizumab (BEV) in patients with recurrent chemorefractory HGG. Methods and materials Patients with HGG managed with reRT were entered prospectively into a database. Clinicopathological features were recorded including timing of reRT, use of BEV and Dosimetric data. Median survival following reRT was the primary endpoint and association with clinicopathological factors was assessed with cox regression models. Results Sixty seven patients in total were managed with reRT, 51 patients had glioblastoma and 16 had anaplastic glioma. The median PTV was 145.3 cm3. Median OS post reRT was 7.8 months (95% CI 6.3–9.2 months) in the total cohort and 7.5 months (95% CI: 6.6–8.3 months) for GBM patients. In multivariate analysis of the whole cohort, IDH1 mutation status (p = 0.041) and ECOG status prior to reRT (<0.001) were significantly associated with OS. In terms of safety and toxicity, the majority of patients (66.5%) were ECOG 0–2 three months after treatment. In total, four episodes of suspected radiation necrosis occurred, all in patients treated without upfront BEV. Conclusion Large volume reRT with bevacizumab is a feasible late salvage option in patients with recurrent HGG and offers meaningful prolongation of survival with low toxicity.
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Affiliation(s)
- Joseph Chan
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia
| | - Dasantha Jayamanne
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Helen Wheeler
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia.,The Brain Cancer Group, Sydney, Australia
| | - Mustafa Khasraw
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia.,The Brain Cancer Group, Sydney, Australia
| | - Matthew Wong
- Central Coast Cancer Centre, Gosford Hospital, Gosford, Australia
| | - Marina Kastelan
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia.,The Brain Cancer Group, Sydney, Australia
| | - Lesley Guo
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia
| | - Michael Back
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia.,Central Coast Cancer Centre, Gosford Hospital, Gosford, Australia.,Genesis Cancer Care, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia.,The Brain Cancer Group, Sydney, Australia
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Tsang DS, Oliveira C, Bouffet E, Hawkins C, Ramaswamy V, Yee R, Tabori U, Bartels U, Huang A, Millar BA, Crooks B, Bowes L, Zelcer S, Laperriere N. Repeat irradiation for children with supratentorial high-grade glioma. Pediatr Blood Cancer 2019; 66:e27881. [PMID: 31207154 DOI: 10.1002/pbc.27881] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/10/2019] [Accepted: 05/31/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND There are very few studies about the role of repeat irradiation (RT2) for children with recurrent supratentorial high-grade glioma (HGG). It was the aim of this study to assess the effectiveness and safety of RT2 in this population. PROCEDURE This was a retrospective cohort study of 40 children age 18 years and under with recurrent supratentorial HGG who had received at least one course of RT. In-field reirradiation volumes included focal or whole brain RT, with doses ranging from 30 to 54 Gy. The primary endpoint was overall survival (OS) from the first day of RT2. RESULTS Fourteen patients underwent RT2. The median survival of these patients was 6.5 months. Patients with ≥12 months elapsed time between RT1 and RT2 experienced longer OS than patients who had < 12 months (P = 0.009). There was no difference in OS between patients with or without germline mutations (e.g., Lynch, Li-Fraumeni, or constitutional mismatch-repair deficiency, P = 0.20). Ten patients received RT2 that overlapped with RT1 volumes for locally recurrent disease. Of this group, 80% experienced clinical benefit from in-field RT2, defined as clinical/radiologic response or stable disease. Ninety-three percent completed the prescribed course of RT2, with one patient developing grade 3 radiation necrosis four months after RT2. When compared with 26 patients who were not offered reirradiation, those selected for RT2 had improved median survival from the time of first disease progression (9.4 vs 3.8 months, P = 0.005). CONCLUSIONS Reirradiation for children with recurrent supratentorial HGG is a safe, effective treatment that provides short-term disease control.
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Affiliation(s)
- Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Carol Oliveira
- Division of Radiation Oncology, Queen's University, Kingston, Ontario, Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cynthia Hawkins
- Paediatric Laboratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ryan Yee
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Uri Tabori
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ute Bartels
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Annie Huang
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Barbara-Ann Millar
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Bruce Crooks
- Division of Hematology-Oncology, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Lynette Bowes
- Janeway Child Health Centre, St. John's, Newfoundland, Canada
| | - Shayna Zelcer
- London Health Sciences Centre, London, Ontario, Canada
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
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Cuncannon M, Wong M, Jayamanne D, Guo L, Cove N, Wheeler H, Back M. Role of delayed salvage bevacizumab at symptomatic progression of chemorefractory glioblastoma. BMC Cancer 2019; 19:445. [PMID: 31088401 PMCID: PMC6518639 DOI: 10.1186/s12885-019-5678-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 05/03/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Assess benefit of salvage bevacizumab (BEV) at time of symptomatic progression in patients with refractory glioblastoma (GBM). METHODS Patients managed with adjuvant long course chemo-radiation therapy for GBM were entered into a prospective database. At chemorefractory symptomatic progression, patients were offered BEV or best supportive care. Re-irradiation (ReRT) was used with BEV in selected patients. BEV continued indefinitely until deterioration limited hospital based infusion. The primary endpoint was median survival calculated from date of decision for BEV to proceed (BEVstart), or decision to decline BEV (BEVreject). RESULTS Fifty-five patients were managed of which 48 patients have relapsed disease. The median survival post relapse was 6 months (95%CI: 4.6-7.4). At relapse, 28 patients received BEV with only 14% delivered at first relapse. The median number of BEV cycles was 8 (range 1-25). ReRT was subsequently used in 16 (33%) relapsed patients. BEV treated patients were associated with improved median survival post relapse with 9 months vs 3 months (p < 0.01). The median survival from BEV related decision-making at symptomatic refractory progression to death was 4 months (95%CI: 2.0-6.0). BEVstart was associated with improved survival from this date with median survival of 6 months vs 1 month with BEVreject (p < 0.01). Median survival with ReRT from this date was 8 months vs 3 months without ReRT (p = 0.01). In the BEV patients at eventual progression, death occurred at a median of 30 days post BEV cessation. CONCLUSION In this clinic managing selected patients with chemorefractory progressive glioblastoma, delayed salvage bevacizumab, often in combination with re-irradiation, may provide an increase in survival duration compared with best supportive care.
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Affiliation(s)
- Moire Cuncannon
- Central Coast Cancer Centre, Gosford Hospital, Gosford, NSW, 2250, Australia
| | - Matthew Wong
- Central Coast Cancer Centre, Gosford Hospital, Gosford, NSW, 2250, Australia
| | - Dasantha Jayamanne
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
| | - Linxin Guo
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
| | - Nicola Cove
- Central Coast Cancer Centre, Gosford Hospital, Gosford, NSW, 2250, Australia
| | - Helen Wheeler
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia.,Sydney Neuro-Oncology Group, Sydney, NSW, Australia.,Sydney Medical School, University of Sydney, Camperdown, NSW, 2006, Australia
| | - Michael Back
- Central Coast Cancer Centre, Gosford Hospital, Gosford, NSW, 2250, Australia. .,Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia. .,Sydney Neuro-Oncology Group, Sydney, NSW, Australia. .,Sydney Medical School, University of Sydney, Camperdown, NSW, 2006, Australia.
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11
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Tsang D, Laperriere N. Re-irradiation for Paediatric Tumours. Clin Oncol (R Coll Radiol) 2019; 31:191-198. [DOI: 10.1016/j.clon.2018.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 05/29/2018] [Accepted: 06/11/2018] [Indexed: 12/25/2022]
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12
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Nieder C. Second re-irradiation: A delicate balance between safety and efficacy. Phys Med 2019; 58:155-158. [DOI: 10.1016/j.ejmp.2019.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/20/2018] [Accepted: 01/04/2019] [Indexed: 12/16/2022] Open
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13
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Windsor P. Re-irradiation of the Brain. Clin Oncol (R Coll Radiol) 2018; 30:456-457. [DOI: 10.1016/j.clon.2018.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 03/22/2018] [Indexed: 02/02/2023]
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Ho ALK, Jena R. Glioma Re-irradiation and Neurocognitive Dysfunction. Clin Oncol (R Coll Radiol) 2018; 30:457. [PMID: 29680735 DOI: 10.1016/j.clon.2018.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 03/22/2018] [Indexed: 12/21/2022]
Affiliation(s)
- A L K Ho
- Department of Oncology, University of Cambridge, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK
| | - R Jena
- Department of Oncology, University of Cambridge, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK
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Muirhead R, Jones B. Re-irradiation is Now a Real Option – But How Do We Take it Forward? Clin Oncol (R Coll Radiol) 2018; 30:65-66. [DOI: 10.1016/j.clon.2017.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 11/22/2017] [Indexed: 12/20/2022]
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