A Retrospective Review of Re-irradiating Patients' Recurrent High-grade Gliomas

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

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.

Re-irradiation with stereotactic radiotherapy for recurrent high-grade glial tumors

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.

Fractionated stereotactic re-irradiation for recurrent glioblastoma: A systematic review and meta-analysis

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.

Impact of fractionated stereotactic radiotherapy on activity of daily living and performance status in progressive/recurrent glioblastoma: a retrospective study

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.

Radiosurgery and Stereotactic Brain Radiotherapy with Systemic Therapy in Recurrent High-Grade Gliomas: Is It Feasible? Therapeutic Strategies in Recurrent High-Grade Gliomas

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.

Simultaneously acquired PET and ASL imaging biomarkers may be helpful in differentiating progression from pseudo-progression in treated gliomas

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.

High-dose salvage re-irradiation for recurrent/progressive adult diffuse glioma: healing or hurting?

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.

Glioblastoma treatment guidelines: Consensus by the Spanish Society of Neurosurgery Tumor Section

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.

Low Fraction Size Re-irradiation for Large Volume Recurrence of Glial Tumours

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.

Stereotactic Radiotherapy in Recurrent Glioblastoma: A Valid Salvage Treatment Option

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.

Repeat irradiation for children with supratentorial high-grade glioma

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.

Appraisal of re-irradiation for the recurrent glioblastoma in the era of MGMT promotor methylation

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.