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Hudson EM, Noutch S, Webster J, Brown SR, Boele FW, Al-Salihi O, Baines H, Bulbeck H, Currie S, Fernandez S, Hughes J, Lilley J, Smith A, Parbutt C, Slevin F, Short S, Sebag-Montefiore D, Murray L. Brain Re-Irradiation Or Chemotherapy: a phase II randomised trial of re-irradiation and chemotherapy in patients with recurrent glioblastoma (BRIOChe) - protocol for a multi-centre open-label randomised trial. BMJ Open 2024; 14:e078926. [PMID: 38458809 PMCID: PMC11145639 DOI: 10.1136/bmjopen-2023-078926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 02/15/2024] [Indexed: 03/10/2024] Open
Abstract
INTRODUCTION Glioblastoma (GBM) is the most common adult primary malignant brain tumour. The condition is incurable and, despite aggressive treatment at first presentation, almost all tumours recur after a median of 7 months. The aim of treatment at recurrence is to prolong survival and maintain health-related quality of life (HRQoL). Chemotherapy is typically employed for recurrent GBM, often using nitrosourea-based regimens. However, efficacy is limited, with reported median survivals between 5 and 9 months from recurrence. Although less commonly used in the UK, there is growing evidence that re-irradiation may produce survival outcomes at least similar to nitrosourea-based chemotherapy. However, there remains uncertainty as to the optimum approach and there is a paucity of available data, especially with regards to HRQoL. Brain Re-Irradiation Or Chemotherapy (BRIOChe) aims to assess re-irradiation, as an acceptable treatment option for recurrent IDH-wild-type GBM. METHODS AND ANALYSIS BRIOChe is a phase II, multi-centre, open-label, randomised trial in patients with recurrent GBM. The trial uses Sargent's three-outcome design and will recruit approximately 55 participants from 10 to 15 UK radiotherapy sites, allocated (2:1) to receive re-irradiation (35 Gy in 10 daily fractions) or nitrosourea-based chemotherapy (up to six, 6-weekly cycles). The primary endpoint is overall survival rate for re-irradiation patients at 9 months. There will be no formal statistical comparison between treatment arms for the decision-making primary analysis. The chemotherapy arm will be used for calibration purposes, to collect concurrent data to aid interpretation of results. Secondary outcomes include HRQoL, dexamethasone requirement, anti-epileptic drug requirement, radiological response, treatment compliance, acute and late toxicities, progression-free survival. ETHICS AND DISSEMINATION BRIOChe obtained ethical approval from Office for Research Ethics Committees Northern Ireland (reference no. 20/NI/0070). Final trial results will be published in peer-reviewed journals and adhere to the ICMJE guidelines. TRIAL REGISTRATION NUMBER ISRCTN60524.
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Affiliation(s)
- Eleanor M Hudson
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Samantha Noutch
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Joanne Webster
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sarah R Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Florien W Boele
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Helen Baines
- National Radiotherapy Trials QA (RTTQA) Group, Mount Vernon Cancer Centre, Northwood, UK
| | | | - Stuart Currie
- Department of Radiology, Leeds General Infirmary, Leeds, UK
| | - Sharon Fernandez
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Jane Hughes
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - John Lilley
- Department of Medical Physics, Leeds Cancer Centre, Leeds, UK
| | - Alexandra Smith
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Finbar Slevin
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
- Department of Clinical Oncology, Leeds Cancer Centre, Leeds, UK
| | - Susan Short
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
- Department of Clinical Oncology, Leeds Cancer Centre, Leeds, UK
| | | | - Louise Murray
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
- Department of Clinical Oncology, Leeds Cancer Centre, Leeds, UK
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Soykut ED, Odabasi E, Sahin N, Tataroglu H, Baran A, Guney Y. Re-irradiation with stereotactic radiotherapy for recurrent high-grade glial tumors. Rep Pract Oncol Radiother 2023; 28:361-369. [PMID: 37795399 PMCID: PMC10547398 DOI: 10.5603/rpor.a2023.0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/23/2023] [Indexed: 10/06/2023] Open
Abstract
Background Despite the radical treatments applied, recurrence is encountered in the majority of high-grade gliomas (HGG). There is no standard treatment when recurrence is detected, but stereotactic radiotherapy (SRT) is a preferable alternative. The aim of this retrospective study is to evaluate the efficacy of SRT for recurrent HGG, and to investigate the factors that affect survival. Materials and methods From 2013 to 2021, a total of 59 patients with 64 lesions were re-irradiated in a single center with the CyberKnife Robotic Radiosurgery System. The primary endpoints of the study were overall survival (OS), progression free survival (PFS) and local control rates (LCR). Results The median time to first recurrence was 13 (4-85) months. SRT was performed as a median prescription dose of 30 Gy (range 15-30), with a median of 5 fractions (1-5). The median follow-up time was 4 months (range 1-57). The median OS was 8 (95% CI: 4.66-11.33) months. Age, grade 3, tumor size were associated with better survival. The median PFS was 5 [95% confidence interval (CI): 3.39-6.60] months. Age, grade 3 and time to recurrence > 9 months were associated with improved PFS. Grade 3 gliomas (p = 0.027), size of tumor < 2 cm (p = 0.008) remained independent prognostic factors for OS in multivariate analysis. Conclusion SRT is a viable treatment modality with significant survival contribution. Since it may have a favorable prognostic effect on survival in patients with tumor size < 2 cm, we recommend early diagnosis of recurrence and a decision to re-irradiate a smaller tumor during follow-up.
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Affiliation(s)
- Ela Delikgoz Soykut
- Department of Radiation Oncology, Samsun Education and Research Hospital, Samsun, Türkiye
| | - Eylem Odabasi
- Department of Radiation Oncology, Samsun Education and Research Hospital, Samsun, Türkiye
| | - Nilgun Sahin
- Department of Radiation Oncology, Samsun Education and Research Hospital, Samsun, Türkiye
| | - Hatice Tataroglu
- Department of Radiation Oncology, Samsun Education and Research Hospital, Samsun, Türkiye
| | - Ahmet Baran
- Department of Medical Oncology, Samsun Education and Research Hospital, Samsun, Türkiye
| | - Yildiz Guney
- Department of Radiation Oncology, Memorial Ankara Hospital, Ankara, Türkiye
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Luo T, Feng J, Sun P. Fractionated stereotactic re-irradiation for recurrent glioblastoma: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 229:107728. [PMID: 37105068 DOI: 10.1016/j.clineuro.2023.107728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND The clinical benefit and the safety of fractionated stereotactic re-irradiation in treating patients with recurrent glioblastoma are still disputed. Thus, we conducted a meta-analysis to explore the clinical benefit and the safety of fractionated stereotactic re-irradiation for patients with recurrent glioblastoma. MATERIALS AND METHODS We retrieved the eligible papers published up to Nov. 2022 through PubMed, Embase, Cochrane, Web of Science, and Clinical Trials. Gov, and other biomedical databases and evaluated the quality of the studies by Newcastle-Ottawa Scale. The random effect model was used to pool 12-month overall survival rates, 12-month progression-free survival rates, and radiational necrosis risk, and an interaction test was used to compare defined subgroups. RESULTS We identified eight eligible studies, including 307 patients. The overall survival rate of 12 months was 33.1 % (95 % CI 26.0 %-40.9 %), and the progression-free survival rate of 12 months was 13.4 % (95 % CI 8.0 %-21.3 %). Radiation necrosis was low in incidence in the included studies. Additionally, the subgroup analysis demonstrated that factors such as age, time interval (from the first radiation to the re-irradiation), total dose, and single dose, impacted the survival rate. CONCLUSION Fractionated stereotactic re-irradiation produces relative clinical benefit and safety for patients with recurrent glioblastoma.
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Affiliation(s)
- Tingfan Luo
- Department of Radiotherapy, Lanzhou University Second Hospital, Lanzhou 730030, Gansu Province, People's Republic of China
| | - Jin Feng
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, Guangdong Province, People's Republic of China
| | - Pengfei Sun
- Department of Radiotherapy, Lanzhou University Second Hospital, Lanzhou 730030, Gansu Province, People's Republic of China.
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Impact of fractionated stereotactic radiotherapy on activity of daily living and performance status in progressive/recurrent glioblastoma: a retrospective study. Radiat Oncol 2022; 17:201. [PMID: 36474245 PMCID: PMC9727986 DOI: 10.1186/s13014-022-02169-1] [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: 09/22/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The prognosis of recurrent glioblastoma (GBM) is poor, with limited options of palliative localized or systemic treatments. Survival can be improved by a second localized treatment; however, it is not currently possible to identify which patients would benefit from this approach. This study aims to evaluate which factors lead to a lower Karnofsky performance status (KPS) score after fractionated stereotactic RT (fSRT). METHODS We retrospectively collected data from patients treated with fSRT for recurrent GBM at the Institut de Cancérologie de Lorraine between October 2010 and November 2017 and analyzed which factors were associated with a lower KPS score. RESULTS 59 patients received a dose of 25 Gy in 5 sessions spread over 5-7 days (80% isodose). The median time from the end of primary radiotherapy to the initiation of fSRT was 10.7 months. The median follow-up after fSRT initiation was 8.8 months. The incidence of KPS and ADL impairment in all patients were 51.9% and 37.8% respectively with an adverse impact of PTV size on KPS (HR = 1.57 [95% CI 1.19-2.08], p = 0.028). Only two patients showed early grade 3 toxicity and none showed grade 4 or late toxicity. The median overall survival time, median overall survival time after fSRT, median progression-free survival and institutionalization-free survival times were 25.8, 8.8, 3.9 and 7.7 months, respectively. Initial surgery was associated with better progression-free survival (Hazard ratio (HR) = 0.48 [95% CI 0.27-0.86], p = 0.013). CONCLUSIONS A larger PTV should predicts lower KPS in the treatment of recurrent GBM using fSRT.
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Gregucci F, Surgo A, Carbonara R, Laera L, Ciliberti MP, Gentile MA, Caliandro M, Sasso N, Bonaparte I, Fanelli V, Tortora R, Paulicelli E, Surico G, Lombardi G, Signorelli F, Fiorentino A. Radiosurgery and Stereotactic Brain Radiotherapy with Systemic Therapy in Recurrent High-Grade Gliomas: Is It Feasible? Therapeutic Strategies in Recurrent High-Grade Gliomas. J Pers Med 2022; 12:1336. [PMID: 36013284 PMCID: PMC9410141 DOI: 10.3390/jpm12081336] [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: 08/01/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE For recurrent high-grade gliomas (HGG), no standard therapeutic approach has been reported; thus, surgery, chemotherapy, and re-irradiation (re-RT) may all be proposed. The aim of the study was to evaluate safety and efficacy of re-RT by radiosurgery or fractionated stereotactic radiotherapy (SRS/FSRT) in association to chemotherapy in patients with recurrent HGG. MATERIAL/METHODS All patients with histological diagnosis of HGG that suffered by recurrent disease diagnosed by magnetic resonance imaging (MRI), according to Response Assessment in Neuro-Oncology (RANO) criteria, after primary/adjuvant chemo-radiotherapy treatment and underwent to re-RT by SRS/FSRT were included in the analysis. Second-line chemotherapy was administered. Outcomes were evaluated by neurological examination and brain MRI performed 1 month after re-RT and then every 2-3 months. RESULTS From November 2019 to September 2021, 30 patients presenting recurrent HGG underwent re-RT. Median dose was 24 Gy (range 15-36 Gy), and median fractions was 5 (range 1-6). Twenty-one patients (70%) had RPA class ≤ IV. One patient had a histological diagnosis of anaplastic oligodendroglioma, 24 patients (80%) were affected by glioblastoma (GBM) including 3 cases of multifocal form, and 5 patients (17%) by anaplastic astrocytoma. Median time between primary/adjuvant RT and disease recurrence was 8 months. In six cases (20%) re-operation was performed, and in most cases (87%), a second line of systemic therapy was administrated. At a median follow-up time from recurrence of 13 months (range 6-56 months), 10 patients (33%) were alive: 2 patients with partial response disease, 7 patients with stable disease, and 1 patient with out-field progression disease. Of the 20 patients who died (67%), 15 (75%) died for progression disease and 5 (25%) for other causes (3 due to septic event, 1 due to thrombo-embolic event, and 1 due to car accident). Median OS and PFS after recurrence were 12.1 and 11.2 months. Six-month and one-year OS were, respectively, 81% and 51%. No acute or late neurological side effects grade ≥ 2 and no case of radio-necrosis were reported. One patient experienced, after reintervention and during Regorafenib treatment (administered 40 days after surgery), dehiscence of the surgical wound. In three cases, grade 2 distal paresthesia was reported. Grade 3-4 hematologic toxicity occurred in seven cases. Three case of grade 5 toxicities during chemotherapy were reported: three septic events and one thrombo-embolic event. CONCLUSION Re-RT with SRT/FSRT in association with second-line systemic therapy is a safe and feasible treatment for patients with HGG recurrence. Validation of these results by prospective studies is needed.
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Affiliation(s)
- Fabiana Gregucci
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Alessia Surgo
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Roberta Carbonara
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Letizia Laera
- Department of Medical Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Maria Paola Ciliberti
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Maria Annunziata Gentile
- Department of Radiology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Morena Caliandro
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Nicola Sasso
- Department of Medical Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Ilaria Bonaparte
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Vincenzo Fanelli
- Department of Neurosurgery, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Romina Tortora
- Centro Orientamento Oncologico, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Eleonora Paulicelli
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Giammarco Surico
- Department of Medical Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Giuseppe Lombardi
- Department of Medical Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy
| | - Francesco Signorelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, Division of Neurosurgery, University “Aldo Moro”, 70124 Bari, Italy
| | - Alba Fiorentino
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
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Pellerin A, Khalifé M, Sanson M, Rozenblum-Beddok L, Bertaux M, Soret M, Galanaud D, Dormont D, Kas A, Pyatigorskaya N. Simultaneously acquired PET and ASL imaging biomarkers may be helpful in differentiating progression from pseudo-progression in treated gliomas. Eur Radiol 2021; 31:7395-7405. [PMID: 33787971 DOI: 10.1007/s00330-021-07732-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/21/2020] [Accepted: 01/29/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The aim of this work was investigating the methods based on coupling cerebral perfusion (ASL) and amino acid metabolism ([18F]DOPA-PET) measurements to evaluate the diagnostic performance of PET/MRI in glioma follow-up. METHODS Images were acquired using a 3-T PET/MR system, on a prospective cohort of patients addressed for possible glioma progression. Data were preprocessed with statistical parametric mapping (SPM), including registration on T1-weighted images, spatial and intensity normalization, and tumor segmentation. As index tests, tumor isocontour maps of [18F]DOPA-PET and ASL T-maps were created and metabolic/perfusion abnormalities were evaluated with the asymmetry index z-score. SPM map analysis of significant size clusters and semi-quantitative PET and ASL map evaluation were performed and compared to the gold standard diagnosis. Lastly, ASL and PET topography of significant clusters was compared to that of the initial tumor. RESULTS Fifty-eight patients with unilateral treated glioma were included (34 progressions and 24 pseudo-progressions). The tumor isocontour maps and T-maps showed the highest specificity (100%) and sensitivity (94.1%) for ASL and [18F]DOPA analysis, respectively. The sensitivity of qualitative SPM maps and semi-quantitative rCBF and rSUV analyses were the highest for glioblastoma. CONCLUSION Tumor isocontour T-maps and combined analysis of CBF and [18F]DOPA-PET uptake allow achieving high diagnostic performance in differentiating between progression and pseudo-progression in treated gliomas. The sensitivity is particularly high for glioblastomas. KEY POINTS • Applied separately, MRI and PET imaging modalities may be insufficient to characterize the brain glioma post-therapeutic profile. • Combined ASL and [18F]DOPA-PET map analysis allows differentiating between tumor progression and pseudo-progression.
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Affiliation(s)
- Arnaud Pellerin
- Service de Neuroradiologie Diagnostique et Interventionnelle, Centre Hospitalier Universitaire de Nantes, Hôpital Nord Laennec, Rez-de-chaussée Bas Aile Est, Boulevard Jacques-Monod, Saint-Herblain, 44093, Nantes Cedex 1, France.
- Service de Neuroradiologie Diagnostique et Fonctionnelle, Groupe Hospitalier Pitié-Salpêtrière C. Foix, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
| | - Maya Khalifé
- Centre de NeuroImagerie de Recherche (CENIR), Institut du Cerveau et de la Moelle épinière (ICM), CNRS UMR 7225 - Inserm U1127 - Sorbonne Université - UMR S1127, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Arterys, 34 av. des Champs-Elysées, 75008, Paris, France
| | - Marc Sanson
- Service de Neurologie, Groupe Hospitalier Pitié-Salpêtrière C. Foix, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Laura Rozenblum-Beddok
- Service de Médecine Nucléaire, Groupe Hospitalier Pitié-Salpêtrière C. Foix, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Marc Bertaux
- Service de Médecine Nucléaire, Groupe Hospitalier Pitié-Salpêtrière C. Foix, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Marine Soret
- Service de Médecine Nucléaire, Groupe Hospitalier Pitié-Salpêtrière C. Foix, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Damien Galanaud
- Service de Neuroradiologie Diagnostique et Fonctionnelle, Groupe Hospitalier Pitié-Salpêtrière C. Foix, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Centre de NeuroImagerie de Recherche (CENIR), Institut du Cerveau et de la Moelle épinière (ICM), CNRS UMR 7225 - Inserm U1127 - Sorbonne Université - UMR S1127, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Didier Dormont
- Service de Neuroradiologie Diagnostique et Fonctionnelle, Groupe Hospitalier Pitié-Salpêtrière C. Foix, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Aurélie Kas
- Service de Médecine Nucléaire, Groupe Hospitalier Pitié-Salpêtrière C. Foix, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Université Paris 6 UPMC, LIB Inserm U1146, 91-105 Boulevard de l'Hôpital, 75013, Paris, France
| | - Nadya Pyatigorskaya
- Service de Neuroradiologie Diagnostique et Fonctionnelle, Groupe Hospitalier Pitié-Salpêtrière C. Foix, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Centre de NeuroImagerie de Recherche (CENIR), Institut du Cerveau et de la Moelle épinière (ICM), CNRS UMR 7225 - Inserm U1127 - Sorbonne Université - UMR S1127, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
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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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Tejada Solís S, Plans Ahicart G, Iglesias Lozano I, de Quintana Schmidt C, Fernández Coello A, Hostalot Panisello C, Ley Urzaiz L, García Romero JC, Díez Valle R, González Sánchez J, Duque S. Glioblastoma treatment guidelines: Consensus by the Spanish Society of Neurosurgery Tumor Section. Neurocirugia (Astur) 2020; 31:289-298. [PMID: 32690400 DOI: 10.1016/j.neucir.2020.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/20/2020] [Accepted: 06/03/2020] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Glioblastoma (GBM) treatment starts in most patients with surgery, either resection surgery or biopsy, to reach a histology diagnose. Multidisciplinar team, including specialists in brain tumors diagnose and treatment, must make an individualize assessment to get the maximum benefit of the available treatments. MATERIAL AND METHODS Experts in each GBM treatment field have briefly described it based in their experience and the reviewed of the literature. RESULTS Each area has been summarized and the consensus of the brain tumor group has been included at the end. CONCLUSIONS GBM are aggressive tumors with a dismal prognosis, however accurate treatments can improve overall survival and quality of life. Neurosurgeons must know treatment options, indications and risks to participate actively in the decision making and to offer the best surgical treatment in every case.
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Affiliation(s)
- Sonia Tejada Solís
- Departamento de Neurocirugía, Hospital Universitario Fundación Jiménez Díaz, Madrid, España.
| | - Gerard Plans Ahicart
- Departamento de Neurocirugía, Hospital Universitari Bellvitge, L'Hospitalet de Llobregat (Barcelona), España
| | - Irene Iglesias Lozano
- Departamento de Neurocirugía, Hospital Universitario Puerta del Mar, Barcelona, España
| | | | - Alejandro Fernández Coello
- Departamento de Neurocirugía, Hospital Universitari Bellvitge, L'Hospitalet de Llobregat (Barcelona), España
| | | | - Luis Ley Urzaiz
- Departamento de Neurocirugía, Hospital Universitario Ramón y Cajal, Madrid, España
| | | | - Ricardo Díez Valle
- Departamento de Neurocirugía, Hospital Universitario Fundación Jiménez Díaz, Madrid, España
| | - Josep González Sánchez
- Departamento de Neurocirugía, Hospital Clínic y Provincial de Barcelona, Barcelona, España
| | - Sara Duque
- Departamento de Neurocirugía, Hospital Universitario HM Montepríncipe, Majadahonda (Madrid), España
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Dobi Á, Darázs B, Fodor E, Cserháti A, Együd Z, Maráz A, László S, Dodd L, Reisz Z, Barzó P, Oláh J, Hideghéty K. Low Fraction Size Re-irradiation for Large Volume Recurrence of Glial Tumours. Pathol Oncol Res 2020; 26:2651-2658. [PMID: 32648211 PMCID: PMC7471107 DOI: 10.1007/s12253-020-00868-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/30/2020] [Indexed: 11/26/2022]
Abstract
The aim of the present study was to evaluate the efficacy of re-irradiation (re-RT) in patients with advanced local relapses of glial tumours and to define the factors influencing the result of the hyper-fractionated external beam therapy on progression after primary management. We have analysed the data of 55 patients with brain tumours (GBM: 28) on progression, who were re-irradiated between January 2007 and December 2018. The mean volume of the recurrent tumour was 118 cm3, and the mean planning target volume (PTV) was 316 cm3, to which 32 Gy was delivered in 20 fractions at least 7.7 months after the first radiotherapy, using 3D conformal radiotherapy (CRT) or intensity modulated radiotherapy (IMRT). The median overall survival (mOS) from the re-RT was 8.4 months, and the 6-month and the 12-month OS rate was 64% and 31%, respectively. The most important factors by univariate analysis, which significantly improved the outcome of re-RT were the longer time interval between the diagnosis and second radiotherapy (p = 0.029), the lower histology grade (p = 0.034), volume of the recurrent tumour (p = 0.006) and Karnofsky performance status (KPS) (p = 0.009) at the re-irradiation. Our low fraction size re-irradiation ≥ 8 months after the first radiotherapy proved to be safe and beneficial for patients with large volume recurrent glial tumours.
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Affiliation(s)
- Ágnes Dobi
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary.
| | - Barbara Darázs
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Emese Fodor
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Adrienne Cserháti
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Zsófia Együd
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Anikó Maráz
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Szilvia László
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Leopold Dodd
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Zita Reisz
- Department of Pathology, University of Szeged, Állomás utca 1, Szeged, H-6725, Hungary
| | - Pál Barzó
- Department of Neurosurgery, University of Szeged, Semmelweis utca 6, Szeged, H-6725, Hungary
| | - Judit Oláh
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Katalin Hideghéty
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
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Yaprak G, Isık N, Gemici C, Pekyurek M, Ceylaner Bıcakcı B, Demircioglu F, Tatarlı N. Stereotactic Radiotherapy in Recurrent Glioblastoma: A Valid Salvage Treatment Option. Stereotact Funct Neurosurg 2020; 98:167-175. [PMID: 32248188 DOI: 10.1159/000505706] [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: 05/28/2019] [Accepted: 12/30/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Glioblastoma (GBM) is a dismal disease. Recurrence is inevitable despite initial surgery and postoperative temozolomide (TMZ) and radiotherapy. Salvage surgery is the standard treatment in selected patients. Chemotherapy, biological agents, and re-irradiation are other treatment approaches available. Stereotactic radiotherapy (SRT) is nowadays a common treatment as a salvage treatment option. MATERIALS AND METHODS We reviewed the files of 132 GBM cases treated between 2010 and 2018. All patients received TMZ and radiotherapy after surgery or biopsy. Among the patients who had recurrence, we identified 42 cases treated with salvage SRT. The CyberKnife robotic system was used to administer SRT. RESULTS While the median follow-up time for all patients was 16 months (range 1-123), the median follow-up time for patients treated with SRT after initial diagnosis was 26.5 months (range 9-123). The median follow-up time after SRT was 10 months (range 2-107). SRT was performed in a median of 3 fractions (range 2-5). The median prescription dose was 20 Gy (range 18-30). While the median actuarial survival after initial diagnosis for patients treated with salvage SRT was 30 months (range 9-123), it was only 14 months (range 1-111) for patients who could not be treated with salvage SRT (p = 0.001). The median survival time after SRT was 12 months, and 1- and 2-year survival rates were 48 and 9%, respectively. The time to progression after SRT was 5 months (range 1-62), and 6-month and 1-year progression-free survival rates were 50 and 22%, respectively. Patients with longer time to recurrence >12 months had longer overall survival with respect to the ones having recurrence <12 months (p < 0.001). Salvage surgery had been performed in 7 out of 42 patients before SRT. These reoperated patients had significantly worse survival after SRT when compared to the patients who underwent SRT alone (p = 0.02). SRT was well tolerated and there was no grade III/IV toxicity. CONCLUSIONS SRT is a viable salvage treatment option for recurrent GBM. SRT provides acceptable local control and survival benefit for recurrent GBM cases. SRT can be considered especially in patients with long time to recurrence.
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Affiliation(s)
- Gokhan Yaprak
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey,
| | - Naciye Isık
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Cengiz Gemici
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Melike Pekyurek
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Beyhan Ceylaner Bıcakcı
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Fatih Demircioglu
- Department of Radiation Oncology, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Necati Tatarlı
- Department of Neurosurgery, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
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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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12
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Kim IH. Appraisal of re-irradiation for the recurrent glioblastoma in the era of MGMT promotor methylation. Radiat Oncol J 2019; 37:1-12. [PMID: 30947475 PMCID: PMC6453809 DOI: 10.3857/roj.2019.00171] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 03/21/2019] [Indexed: 12/23/2022] Open
Abstract
Despite recent innovation in treatment techniques and subsequently improved outcomes, the majority of glioblastoma (GBL) have relapses, especially in locoregional areas. Local re-irradiation (re-RT) has been established as a feasible option for recurrent GBL of all ages with safety, tolerability, and effectiveness both in survival and quality of life regardless of fractionation schedule. To keep adverse effects under acceptable range, cumulative dose limit in equivalent dose at 2 Gy fractions by the linear-quadratic model at α/β = 2 for normal brain tissue (EQD2) with narrow margin should be observed and single/hypofractionated re-RT should be undertaken very carefully to recurrent tumor with large volume or adjacent to the brainstem. Promising outcome of re-operation (re-Op) plus re-RT (re-Op/RT) need to be validated and result from re-RT with temozolomide/bevacizumab (TMZ/BV) or new strategy is expected. Development of new-concept prognostic scoring or risk group is required to select patients properly and make use of predictive biomarkers such as O(6)-methylguanine-DNA methyltransferase (MGMT) promotor methylation that influence outcomes of re-RT, re-Op/RT, or re-RT with TMZ/BV.
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Affiliation(s)
- Il Han Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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