1
|
Maier SH, Schönecker S, Anagnostatou V, Garny S, Nitschmann A, Fleischmann DF, Büttner M, Kaul D, Imhoff D, Fokas E, Seidel C, Hau P, Kölbl O, Popp I, Grosu AL, Haussmann J, Budach W, Celik E, Kahl KH, Hoffmann E, Tabatabai G, Paulsen F, Holzgreve A, Albert NL, Mansmann U, Corradini S, Belka C, Niyazi M, Bodensohn R. Dummy run for planning of isotoxic dose-escalated radiation therapy for glioblastoma used in the PRIDE trial (NOA-28; ARO-2024-01; AG-NRO-06). Clin Transl Radiat Oncol 2024; 47:100790. [PMID: 38765202 PMCID: PMC11101689 DOI: 10.1016/j.ctro.2024.100790] [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: 03/12/2024] [Revised: 05/02/2024] [Accepted: 05/02/2024] [Indexed: 05/21/2024] Open
Abstract
Background The PRIDE trial (NOA-28; ARO-2024-01; AG-NRO-06; NCT05871021) is designed to determine whether a dose escalation with 75.0 Gy in 30 fractions can enhance the median overall survival (OS) in patients with methylguanine methyltransferase (MGMT) promotor unmethylated glioblastoma compared to historical median OS rates, while being isotoxic to historical cohorts through the addition of concurrent bevacizumab (BEV). To ensure protocol-compliant irradiation planning with all study centers, a dummy run was planned and the plan quality was evaluated. Methods A suitable patient case was selected and the computed tomography (CT), magnetic resonance imaging (MRI) and O-(2-[18F]fluoroethyl)-L-tyrosine (FET) positron emission tomography (PET) contours were made available. Participants at the various intended study sites performed radiation planning according to the PRIDE clinical trial protocol. The treatment plans and dose grids were uploaded as Digital Imaging and Communications in Medicine (DICOM) files to a cloud-based platform. Plan quality and protocol adherence were analyzed using a standardized checklist, scorecards and indices such as Dice Score (DSC) and Hausdorff Distance (HD). Results Median DSC was 0.89, 0.90, 0.88 for PTV60, PTV60ex (planning target volume receiving 60.0 Gy for the standard and the experimental plan, respectively) and PTV75 (PTV receiving 75.0 Gy in the experimental plan), respectively. Median HD values were 17.0 mm, 13.9 mm and 12.1 mm, respectively. These differences were also evident in the volumes: The PTV60 had a volume range of 219.1-391.3 cc (median: 261.9 cc) for the standard plans, while the PTV75 volumes for the experimental plans ranged from 71.5-142.7 cc (median: 92.3 cc). The structures with the largest deviations in Dice score were the pituitary gland (median 0.37, range 0.00-0.69) and the right lacrimal gland (median 0.59, range 0.42-0.78). Conclusions The deviations revealed the necessity of systematic trainings with appropriate feedback before the start of clinical trials in radiation oncology and the constant monitoring of protocol compliance throw-out the study. Trial registration NCT05871021.
Collapse
Affiliation(s)
- Sebastian H. Maier
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Stephan Schönecker
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Vasiliki Anagnostatou
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Sylvia Garny
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Alexander Nitschmann
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Daniel F. Fleischmann
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, a partnership between DKFZ and LMU University Hospital, Munich, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Marcel Büttner
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - David Kaul
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Detlef Imhoff
- Department of Radiotherapy of Oncology, University of Frankfurt, Frankfurt, Germany
| | - Emmanouil Fokas
- Department of Radiotherapy of Oncology, University of Frankfurt, Frankfurt, Germany
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Clemens Seidel
- Department of Radiation Oncology, University Hospital Leipzig, University of Leipzig, Leipzig, Germany
| | - Peter Hau
- Department of Neurology and Wilhelm Sander-NeuroOncology Unit, Regensburg University Hospital, Regensburg, Germany
| | - Oliver Kölbl
- Department of Radiotherapy, University Medical Center Regensburg, Regensburg, Germany
| | - Ilinca Popp
- Department of Radiation Oncology, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Jan Haussmann
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Eren Celik
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
- Dept. of Radiation Oncology, Faculty of Medicine and University Hospital Ruhr-University Bochum, Marien Hospital Herne, Herne, Germany
| | - Klaus-Henning Kahl
- Department of Radiooncology, University Hospital Augsburg, Augsburg, Germany
| | - Elgin Hoffmann
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
| | - Ghazaleh Tabatabai
- Department of Neurology and Interdisciplinary Neuro-Oncology, University Hospital Tübingen, Hertie Institute for Clinical Brain Research, Tübingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
| | - Adrien Holzgreve
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
- Ahmanson Translational Theranostics Division, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, USA
| | - Nathalie L. Albert
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), partner site Tübingen, a partnership between DKFZ and University Hospital Tübingen, Tübingen, Germany
| | - Raphael Bodensohn
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
| |
Collapse
|
2
|
Prezado Y, Grams M, Jouglar E, Martínez-Rovira I, Ortiz R, Seco J, Chang S. Spatially fractionated radiation therapy: a critical review on current status of clinical and preclinical studies and knowledge gaps. Phys Med Biol 2024; 69:10TR02. [PMID: 38648789 DOI: 10.1088/1361-6560/ad4192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/22/2024] [Indexed: 04/25/2024]
Abstract
Spatially fractionated radiation therapy (SFRT) is a therapeutic approach with the potential to disrupt the classical paradigms of conventional radiation therapy. The high spatial dose modulation in SFRT activates distinct radiobiological mechanisms which lead to a remarkable increase in normal tissue tolerances. Several decades of clinical use and numerous preclinical experiments suggest that SFRT has the potential to increase the therapeutic index, especially in bulky and radioresistant tumors. To unleash the full potential of SFRT a deeper understanding of the underlying biology and its relationship with the complex dosimetry of SFRT is needed. This review provides a critical analysis of the field, discussing not only the main clinical and preclinical findings but also analyzing the main knowledge gaps in a holistic way.
Collapse
Affiliation(s)
- Yolanda Prezado
- Institut Curie, Université PSL, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, F-91400, Orsay, France
- Université Paris-Saclay, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, F-91400, Orsay, France
- New Approaches in Radiotherapy Lab, Center for Research in Molecular Medicine and Chronic Diseases (CIMUS), Instituto de investigación Sanitaria de Santiago de Compostela (IDIS), University of Santiago de Compostela, Santiago de Compostela, A Coruña, E-15706, Spain
- Oportunius Program, Galician Agency of Innovation (GAIN), Xunta de Galicia, Santiago de Compostela, A Coruña, Spain
| | - Michael Grams
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America
| | - Emmanuel Jouglar
- Institut Curie, PSL Research University, Department of Radiation Oncology, F-75005, Paris and Orsay Protontherapy Center, F-91400, Orsay, France
| | - Immaculada Martínez-Rovira
- Physics Department, Universitat Auto`noma de Barcelona, E-08193, Cerdanyola del Valle`s (Barcelona), Spain
| | - Ramon Ortiz
- University of California San Francisco, Department of Radiation Oncology, 1600 Divisadero Street, San Francisco, CA 94143, United States of America
| | - Joao Seco
- Division of Biomedical physics in Radiation Oncology, DKFZ-German Cancer Research Center, Heidelberg, Germany
- Department of Physics and Astronomy, Heidelberg University, Heidelberg, Germany
| | - Sha Chang
- Dept of Radiation Oncology and Department of Biomedical Engineering, University of North Carolina School of Medicine, United States of America
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolin State University, United States of America
| |
Collapse
|
3
|
Latreche A, Dissaux G, Querellou S, Mazouz Fatmi D, Lucia F, Bordron A, Vu A, Touati R, Nguyen V, Hamya M, Dissaux B, Bourbonne V. Correlation between rCBV Delineation Similarity and Overall Survival in a Prospective Cohort of High-Grade Gliomas Patients: The Hidden Value of Multimodal MRI? Biomedicines 2024; 12:789. [PMID: 38672146 PMCID: PMC11048661 DOI: 10.3390/biomedicines12040789] [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: 03/08/2024] [Revised: 03/18/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
PURPOSE The accuracy of target delineation in radiation treatment planning of high-grade gliomas (HGGs) is crucial to achieve high tumor control, while minimizing treatment-related toxicity. Magnetic resonance imaging (MRI) represents the standard imaging modality for delineation of gliomas with inherent limitations in accurately determining the microscopic extent of tumors. The purpose of this study was to assess the survival impact of multi-observer delineation variability of multiparametric MRI (mpMRI) and [18F]-FET PET/CT. MATERIALS AND METHODS Thirty prospectively included patients with histologically confirmed HGGs underwent a PET/CT and mpMRI including diffusion-weighted imaging (DWI: b0, b1000, ADC), contrast-enhanced T1-weighted imaging (T1-Gado), T2-weighted fluid-attenuated inversion recovery (T2Flair), and perfusion-weighted imaging with computation of relative cerebral blood volume (rCBV) and K2 maps. Nine radiation oncologists delineated the PET/CT and MRI sequences. Spatial similarity (Dice similarity coefficient: DSC) was calculated between the readers for each sequence. Impact of the DSC on progression-free survival (PFS) and overall survival (OS) was assessed using Kaplan-Meier curves and the log-rank test. RESULTS The highest DSC mean values were reached for morphological sequences, ranging from 0.71 +/- 0.18 to 0.84 +/- 0.09 for T2Flair and T1Gado, respectively, while metabolic volumes defined by PET/CT achieved a mean DSC of 0.75 +/- 0.11. rCBV variability (mean DSC0.32 +/- 0.20) significantly impacted PFS (p = 0.02) and OS (p = 0.002). CONCLUSIONS Our data suggest that the T1-Gado and T2Flair sequences were the most reproducible sequences, followed by PET/CT. Reproducibility for functional sequences was low, but rCBV inter-reader similarity significantly impacted PFS and OS.
Collapse
Affiliation(s)
- Amina Latreche
- Radiation Oncology Department, University Hospital, 29200 Brest, France; (A.L.); (G.D.); (F.L.); (A.B.); (A.V.); (V.N.); (M.H.)
| | - Gurvan Dissaux
- Radiation Oncology Department, University Hospital, 29200 Brest, France; (A.L.); (G.D.); (F.L.); (A.B.); (A.V.); (V.N.); (M.H.)
| | - Solène Querellou
- Nuclear Medicine Department, University Hospital, 29200 Brest, France;
- Groupe d’Etude de la Thrombose Occidentale GETBO (INSERM UMR 1304), Université de Bretagne Occidentale, 29200 Brest, France
| | | | - François Lucia
- Radiation Oncology Department, University Hospital, 29200 Brest, France; (A.L.); (G.D.); (F.L.); (A.B.); (A.V.); (V.N.); (M.H.)
- LaTIM UMR 1101, INSERM, Université de Bretagne Occidentale, 29200 Brest, France
| | - Anais Bordron
- Radiation Oncology Department, University Hospital, 29200 Brest, France; (A.L.); (G.D.); (F.L.); (A.B.); (A.V.); (V.N.); (M.H.)
| | - Alicia Vu
- Radiation Oncology Department, University Hospital, 29200 Brest, France; (A.L.); (G.D.); (F.L.); (A.B.); (A.V.); (V.N.); (M.H.)
| | - Ruben Touati
- Radiation Oncology Department, University Hospital, 29200 Brest, France; (A.L.); (G.D.); (F.L.); (A.B.); (A.V.); (V.N.); (M.H.)
| | - Victor Nguyen
- Radiation Oncology Department, University Hospital, 29200 Brest, France; (A.L.); (G.D.); (F.L.); (A.B.); (A.V.); (V.N.); (M.H.)
| | - Mohamed Hamya
- Radiation Oncology Department, University Hospital, 29200 Brest, France; (A.L.); (G.D.); (F.L.); (A.B.); (A.V.); (V.N.); (M.H.)
| | - Brieg Dissaux
- Groupe d’Etude de la Thrombose Occidentale GETBO (INSERM UMR 1304), Université de Bretagne Occidentale, 29200 Brest, France
- Radiology Department, University Hospital, 29200 Brest, France;
| | - Vincent Bourbonne
- Radiation Oncology Department, University Hospital, 29200 Brest, France; (A.L.); (G.D.); (F.L.); (A.B.); (A.V.); (V.N.); (M.H.)
- LaTIM UMR 1101, INSERM, Université de Bretagne Occidentale, 29200 Brest, France
| |
Collapse
|
4
|
Bodensohn R, Fleischmann DF, Maier SH, Anagnostatou V, Garny S, Nitschmann A, Büttner M, Mücke J, Schönecker S, Unger K, Hoffmann E, Paulsen F, Thorwarth D, Holzgreve A, Albert NL, Corradini S, Tabatabai G, Belka C, Niyazi M. Dosimetric feasibility analysis and presentation of an isotoxic dose-escalated radiation therapy concept for glioblastoma used in the PRIDE trial (NOA-28; ARO-2022-12). Clin Transl Radiat Oncol 2024; 45:100706. [PMID: 38116137 PMCID: PMC10726217 DOI: 10.1016/j.ctro.2023.100706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
Background and purpose The PRIDE trial (NOA-28; ARO-2022-12; NCT05871021) is scheduled to start recruitment in October 2023. Its primary objective is to enhance median overall survival (OS), compared to historical median OS rates, in patients with methylguanine methlyltransferase (MGMT) promotor unmethylated glioblastoma by incorporating isotoxic dose escalation to 75 Gy in 30 fractions. To achieve isotoxicity and counteract the elevated risk of radiation necrosis (RN) associated with dose-escalated regimens, the addition of protective concurrent bevacizumab (BEV) serves as an innovative approach. The current study aims to assess the dosimetric feasibility of the proposed concept. Materials and methods A total of ten patients diagnosed with glioblastoma were included in this dosimetric analysis. Delineation of target volumes for the reference plans adhered to the ESTRO-EANO 2023 guideline. The experimental plans included an additional volume for the integrated boost. Additionally, the 60 Gy-volume was reduced by using a margin of 1.0 cm instead of 1.5 cm. To assess the risk of symptomatic RN, the Normal Tissue Complication Probability (NTCP) was calculated and compared between the reference and experimental plans. Results Median NTCP of the reference plan (NTCPref) and of the experimental plan (NTCPex) were 0.24 (range 0.11-0.29) and 0.42 (range 0.18-0.54), respectively. NTCPex was a median of 1.77 (range 1.60-1.99) times as high as the NTXPref. In a logarithmic comparison, the risk of RN is enhanced by a factor of median 2.00 (range 1.66-2.35). The defined constraints for the organs at risk were feasible. Conclusion When considering the potential protective effect of BEV, which we hypothesized might reduce the risk of RN by approximately two-fold, achieving isotoxicity with the proposed dose-escalated experimental plan for the PRIDE trial seems feasible.
Collapse
Affiliation(s)
- Raphael Bodensohn
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Daniel F. Fleischmann
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, a partnership between DKFZ and LMU University Hospital, Munich, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sebastian H. Maier
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Vasiliki Anagnostatou
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Sylvia Garny
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Alexander Nitschmann
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Marcel Büttner
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Johannes Mücke
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Stephan Schönecker
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Kristian Unger
- Helmholtz Zentrum Munich, Neuherberg, Germany
- Faculty of Medicine, LMU Munich, Munich Germany
| | - Elgin Hoffmann
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, Germany
- German Cancer Consortium (DKTK), partner site Tübingen, a partnership between DKFZ and University Hospital, Tübingen, Germany
| | - Adrien Holzgreve
- Department of Nuclear Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Nathalie L. Albert
- Department of Nuclear Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Ghazaleh Tabatabai
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Neurology and Interdisciplinary Neuro-Oncology, University Hospital Tübingen, Hertie Institute for Clinical Brain Research, Tübingen, Germany
- German Cancer Consortium (DKTK), partner site Tübingen, a partnership between DKFZ and University Hospital, Tübingen, Germany
| | - Claus Belka
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Tübingen, a partnership between DKFZ and University Hospital, Tübingen, Germany
| |
Collapse
|
5
|
Pucci G, Minafra L, Bravatà V, Calvaruso M, Turturici G, Cammarata FP, Savoca G, Abbate B, Russo G, Cavalieri V, Forte GI. Glut-3 Gene Knockdown as a Potential Strategy to Overcome Glioblastoma Radioresistance. Int J Mol Sci 2024; 25:2079. [PMID: 38396757 PMCID: PMC10889562 DOI: 10.3390/ijms25042079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
The hypoxic pattern of glioblastoma (GBM) is known to be a primary cause of radioresistance. Our study explored the possibility of using gene knockdown of key factors involved in the molecular response to hypoxia, to overcome GBM radioresistance. We used the U87 cell line subjected to chemical hypoxia generated by CoCl2 and exposed to 2 Gy of X-rays, as single or combined treatments, and evaluated gene expression changes of biomarkers involved in the Warburg effect, cell cycle control, and survival to identify the best molecular targets to be knocked-down, among those directly activated by the HIF-1α transcription factor. By this approach, glut-3 and pdk-1 genes were chosen, and the effects of their morpholino-induced gene silencing were evaluated by exploring the proliferative rates and the molecular modifications of the above-mentioned biomarkers. We found that, after combined treatments, glut-3 gene knockdown induced a greater decrease in cell proliferation, compared to pdk-1 gene knockdown and strong upregulation of glut-1 and ldha, as a sign of cell response to restore the anaerobic glycolysis pathway. Overall, glut-3 gene knockdown offered a better chance of controlling the anaerobic use of pyruvate and a better proliferation rate reduction, suggesting it is a suitable silencing target to overcome radioresistance.
Collapse
Affiliation(s)
- Gaia Pucci
- Institute of Molecular Bioimaging and Physiology (IBFM)-National Research Council (CNR), Cefalù Secondary Site, C/da Pietrapollastra-Pisciotto, 90015 Cefalù, Italy; (G.P.); (V.B.); (M.C.); (F.P.C.); (G.R.); (G.I.F.)
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STeBiCeF), University of Palermo, Viale delle Scienze Bld.17, 90128 Palermo, Italy;
| | - Luigi Minafra
- Institute of Molecular Bioimaging and Physiology (IBFM)-National Research Council (CNR), Cefalù Secondary Site, C/da Pietrapollastra-Pisciotto, 90015 Cefalù, Italy; (G.P.); (V.B.); (M.C.); (F.P.C.); (G.R.); (G.I.F.)
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STeBiCeF), University of Palermo, Viale delle Scienze Bld.17, 90128 Palermo, Italy;
| | - Valentina Bravatà
- Institute of Molecular Bioimaging and Physiology (IBFM)-National Research Council (CNR), Cefalù Secondary Site, C/da Pietrapollastra-Pisciotto, 90015 Cefalù, Italy; (G.P.); (V.B.); (M.C.); (F.P.C.); (G.R.); (G.I.F.)
| | - Marco Calvaruso
- Institute of Molecular Bioimaging and Physiology (IBFM)-National Research Council (CNR), Cefalù Secondary Site, C/da Pietrapollastra-Pisciotto, 90015 Cefalù, Italy; (G.P.); (V.B.); (M.C.); (F.P.C.); (G.R.); (G.I.F.)
| | - Giuseppina Turturici
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STeBiCeF), University of Palermo, Viale delle Scienze Bld.17, 90128 Palermo, Italy;
| | - Francesco P. Cammarata
- Institute of Molecular Bioimaging and Physiology (IBFM)-National Research Council (CNR), Cefalù Secondary Site, C/da Pietrapollastra-Pisciotto, 90015 Cefalù, Italy; (G.P.); (V.B.); (M.C.); (F.P.C.); (G.R.); (G.I.F.)
| | - Gaetano Savoca
- Radiation Oncology, ARNAS-Civico Hospital, 90100 Palermo, Italy; (G.S.); (B.A.)
| | - Boris Abbate
- Radiation Oncology, ARNAS-Civico Hospital, 90100 Palermo, Italy; (G.S.); (B.A.)
| | - Giorgio Russo
- Institute of Molecular Bioimaging and Physiology (IBFM)-National Research Council (CNR), Cefalù Secondary Site, C/da Pietrapollastra-Pisciotto, 90015 Cefalù, Italy; (G.P.); (V.B.); (M.C.); (F.P.C.); (G.R.); (G.I.F.)
| | - Vincenzo Cavalieri
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STeBiCeF), University of Palermo, Viale delle Scienze Bld.17, 90128 Palermo, Italy;
| | - Giusi I. Forte
- Institute of Molecular Bioimaging and Physiology (IBFM)-National Research Council (CNR), Cefalù Secondary Site, C/da Pietrapollastra-Pisciotto, 90015 Cefalù, Italy; (G.P.); (V.B.); (M.C.); (F.P.C.); (G.R.); (G.I.F.)
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STeBiCeF), University of Palermo, Viale delle Scienze Bld.17, 90128 Palermo, Italy;
| |
Collapse
|
6
|
Colopi A, Fuda S, Santi S, Onorato A, Cesarini V, Salvati M, Balistreri CR, Dolci S, Guida E. Impact of age and gender on glioblastoma onset, progression, and management. Mech Ageing Dev 2023; 211:111801. [PMID: 36996926 DOI: 10.1016/j.mad.2023.111801] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/06/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023]
Abstract
Glioblastoma (GBM) is the most common primary malignant brain tumor in adults, while its frequency in pediatric patients is 10-15%. For this reason, age is considered one of the major risk factors for the development of GBM, as it correlates with cellular aging phenomena involving glial cells and favoring the process of tumor transformation. Gender differences have been also identified, as the incidence of GBM is higher in males than in females, coupled with a worse outcome. In this review, we analyze age- and gender- dependent differences in GBM onset, mutational landscape, clinical manifestations, and survival, according to the literature of the last 20 years, focusing on the major risk factors involved in tumor development and on the mutations and gene alterations most frequently found in adults vs young patients and in males vs females. We then highlight the impact of age and gender on clinical manifestations and tumor localization and their involvement in the time of diagnosis and in determining the tumor prognostic value.
Collapse
Affiliation(s)
- Ambra Colopi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Serena Fuda
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Samuele Santi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Angelo Onorato
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Valeriana Cesarini
- Department of Biomedicine, Institute of Translational Pharmacology-CNR, Rome, Italy
| | - Maurizio Salvati
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Carmela Rita Balistreri
- Cellular and Molecular Laboratory, Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, Corso Tukory 211, 90134 Palermo, Italy
| | - Susanna Dolci
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
| | - Eugenia Guida
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
| |
Collapse
|
7
|
Kotecha R, Odia Y, Khosla AA, Ahluwalia MS. Key Clinical Principles in the Management of Glioblastoma. JCO Oncol Pract 2023; 19:180-189. [PMID: 36638331 DOI: 10.1200/op.22.00476] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Glioblastoma is the most common and aggressive primary brain tumor in the adult population and leads to considerable morbidity and mortality. It has a dismal prognosis with average survival of 15-18 months, and the current standard-of-care treatment paradigm includes maximal surgical resection and postoperative concurrent chemoradiotherapy and maintenance chemotherapy, with consideration of Tumor Treating Fields. There is a major emphasis to enroll patients onto ongoing clinical trials to further improve treatment outcomes, given the aggressive nature of the disease course and poor patient survival. Recent research efforts have focused on radiotherapy dose intensification, regulation of the tumor microenvironment, and exploration of immunotherapeutic approaches to overcome the barriers to treatment. This review article outlines the current evidence-based management principles as well as reviews recent clinical trial data and ongoing clinical studies evaluating novel therapeutic options.
Collapse
Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Yazmin Odia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL.,Division of Neuro-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Atulya A Khosla
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Manmeet S Ahluwalia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL.,Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| |
Collapse
|
8
|
Brighi C, Verburg N, Koh ES, Walker A, Chen C, Pillay S, de Witt Hamer PC, Aly F, Holloway LC, Keall PJ, Waddington DE. Repeatability of radiotherapy dose-painting prescriptions derived from a multiparametric magnetic resonance imaging model of glioblastoma infiltration. Phys Imaging Radiat Oncol 2022; 23:8-15. [PMID: 35734265 PMCID: PMC9207284 DOI: 10.1016/j.phro.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 12/03/2022] Open
Abstract
Magnetic resonance imaging was used to derive dose-painting prescriptions in glioma. Dose prescriptions derived from magnetic resonance imaging are highly repeatable. Dose-painting plans are more repeatable than their dose prescriptions.
Background and purpose Glioblastoma (GBM) patients have a dismal prognosis. Tumours typically recur within months of surgical resection and post-operative chemoradiation. Multiparametric magnetic resonance imaging (mpMRI) biomarkers promise to improve GBM outcomes by identifying likely regions of infiltrative tumour in tumour probability (TP) maps. These regions could be treated with escalated dose via dose-painting radiotherapy to achieve higher rates of tumour control. Crucial to the technical validation of dose-painting using imaging biomarkers is the repeatability of the derived dose prescriptions. Here, we quantify repeatability of dose-painting prescriptions derived from mpMRI. Materials and methods TP maps were calculated with a clinically validated model that linearly combined apparent diffusion coefficient (ADC) and relative cerebral blood volume (rBV) or ADC and relative cerebral blood flow (rBF) data. Maps were developed for 11 GBM patients who received two mpMRI scans separated by a short interval prior to chemoradiation treatment. A linear dose mapping function was applied to obtain dose-painting prescription (DP) maps for each session. Voxel-wise and group-wise repeatability metrics were calculated for parametric, TP and DP maps within radiotherapy margins. Results DP maps derived from mpMRI were repeatable between imaging sessions (ICC > 0.85). ADC maps showed higher repeatability than rBV and rBF maps (Wilcoxon test, p = 0.001). TP maps obtained from the combination of ADC and rBF were the most stable (median ICC: 0.89). Conclusions Dose-painting prescriptions derived from a mpMRI model of tumour infiltration have a good level of repeatability and can be used to generate reliable dose-painting plans for GBM patients.
Collapse
|
9
|
Waqar M, Trifiletti DM, McBain C, O'Connor J, Coope DJ, Akkari L, Quinones-Hinojosa A, Borst GR. Early Therapeutic Interventions for Newly Diagnosed Glioblastoma: Rationale and Review of the Literature. Curr Oncol Rep 2022; 24:311-324. [PMID: 35119629 PMCID: PMC8885508 DOI: 10.1007/s11912-021-01157-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Glioblastoma is the commonest primary brain cancer in adults whose outcomes are amongst the worst of any cancer. The current treatment pathway comprises surgery and postoperative chemoradiotherapy though unresectable diffusely infiltrative tumour cells remain untreated for several weeks post-diagnosis. Intratumoural heterogeneity combined with increased hypoxia in the postoperative tumour microenvironment potentially decreases the efficacy of adjuvant interventions and fails to prevent early postoperative regrowth, called rapid early progression (REP). In this review, we discuss the clinical implications and biological foundations of post-surgery REP. Subsequently, clinical interventions potentially targeting this phenomenon are reviewed systematically. RECENT FINDINGS Early interventions include early systemic chemotherapy, neoadjuvant immunotherapy, local therapies delivered during surgery (including Gliadel wafers, nanoparticles and stem cell therapy) and several radiotherapy techniques. We critically appraise and compare these strategies in terms of their efficacy, toxicity, challenges and potential to prolong survival. Finally, we discuss the most promising strategies that could benefit future glioblastoma patients. There is biological rationale to suggest that early interventions could improve the outcome of glioblastoma patients and they should be investigated in future trials.
Collapse
Affiliation(s)
- Mueez Waqar
- Department of Academic Neurological Surgery, Geoffrey Jefferson Brain Research Centre, Salford Royal Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health and Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Mayo 1N, Jacksonville, FL, 32224, USA
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Catherine McBain
- Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Dept 58, Floor 2a, Room 21-2-13, Wilmslow Road, Manchester, M20 4BX, UK
| | - James O'Connor
- Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Dept 58, Floor 2a, Room 21-2-13, Wilmslow Road, Manchester, M20 4BX, UK
| | - David J Coope
- Department of Academic Neurological Surgery, Geoffrey Jefferson Brain Research Centre, Salford Royal Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health and Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| | - Leila Akkari
- Division of Tumour Biology and Immunology, The Netherlands Cancer Institute, Oncode Institute, Amsterdam, The Netherlands
| | - Alfredo Quinones-Hinojosa
- Department of Radiation Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Mayo 1N, Jacksonville, FL, 32224, USA
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Gerben R Borst
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health and Manchester Cancer Research Centre, University of Manchester, Manchester, UK.
- Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Dept 58, Floor 2a, Room 21-2-13, Wilmslow Road, Manchester, M20 4BX, UK.
| |
Collapse
|
10
|
Brighi C, Keall PJ, Holloway LC, Walker A, Whelan B, de Witt Hamer PC, Verburg N, Aly F, Chen C, Koh ES, Waddington DEJ. An investigation of the conformity, feasibility, and expected clinical benefits of multiparametric MRI-guided dose painting radiotherapy in glioblastoma. Neurooncol Adv 2022; 4:vdac134. [PMID: 36105390 PMCID: PMC9466270 DOI: 10.1093/noajnl/vdac134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background New technologies developed to improve survival outcomes for glioblastoma (GBM) continue to have limited success. Recently, image-guided dose painting (DP) radiotherapy has emerged as a promising strategy to increase local control rates. In this study, we evaluate the practical application of a multiparametric MRI model of glioma infiltration for DP radiotherapy in GBM by measuring its conformity, feasibility, and expected clinical benefits against standard of care treatment. Methods Maps of tumor probability were generated from perfusion/diffusion MRI data from 17 GBM patients via a previously developed model of GBM infiltration. Prescriptions for DP were linearly derived from tumor probability maps and used to develop dose optimized treatment plans. Conformity of DP plans to dose prescriptions was measured via a quality factor. Feasibility of DP plans was evaluated by dose metrics to target volumes and critical brain structures. Expected clinical benefit of DP plans was assessed by tumor control probability. The DP plans were compared to standard radiotherapy plans. Results The conformity of the DP plans was >90%. Compared to the standard plans, DP (1) did not affect dose delivered to organs at risk; (2) increased mean and maximum dose and improved minimum dose coverage for the target volumes; (3) reduced minimum dose within the radiotherapy treatment margins; (4) improved local tumor control probability within the target volumes for all patients. Conclusions A multiparametric MRI model of GBM infiltration can enable conformal, feasible, and potentially beneficial dose painting radiotherapy plans.
Collapse
Affiliation(s)
- Caterina Brighi
- ACRF Image X Institute, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney , Sydney , Australia
- Ingham Institute for Applied Medical Research , Sydney , Australia
| | - Paul J Keall
- ACRF Image X Institute, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney , Sydney , Australia
- Ingham Institute for Applied Medical Research , Sydney , Australia
| | - Lois C Holloway
- Ingham Institute for Applied Medical Research , Sydney , Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres , Liverpool , Australia
- Centre for Medical Radiation Physics, University of Wollongong , Wollongong, Australia
| | - Amy Walker
- Ingham Institute for Applied Medical Research , Sydney , Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres , Liverpool , Australia
- Centre for Medical Radiation Physics, University of Wollongong , Wollongong, Australia
| | - Brendan Whelan
- ACRF Image X Institute, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney , Sydney , Australia
- Ingham Institute for Applied Medical Research , Sydney , Australia
| | - Philip C de Witt Hamer
- Brain Tumor Center Amsterdam , Amsterdam UMC, Amsterdam , The Netherlands
- Department of Neurosurgery , Amsterdam UMC, Amsterdam , The Netherlands
| | - Niels Verburg
- Brain Tumor Center Amsterdam , Amsterdam UMC, Amsterdam , The Netherlands
- Department of Neurosurgery , Amsterdam UMC, Amsterdam , The Netherlands
| | - Farhannah Aly
- Ingham Institute for Applied Medical Research , Sydney , Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres , Liverpool , Australia
| | - Cathy Chen
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres , Liverpool , Australia
| | - Eng-Siew Koh
- Ingham Institute for Applied Medical Research , Sydney , Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres , Liverpool , Australia
| | - David E J Waddington
- ACRF Image X Institute, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney , Sydney , Australia
- Ingham Institute for Applied Medical Research , Sydney , Australia
| |
Collapse
|
11
|
Sarria GR, Smalec Z, Muedder T, Holz JA, Scafa D, Koch D, Garbe S, Schneider M, Hamed M, Vatter H, Herrlinger U, Giordano FA, Schmeel LC. Dosimetric Comparison of Upfront Boosting With Stereotactic Radiosurgery Versus Intraoperative Radiotherapy for Glioblastoma. Front Oncol 2021; 11:759873. [PMID: 34778080 PMCID: PMC8581360 DOI: 10.3389/fonc.2021.759873] [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: 08/17/2021] [Accepted: 10/13/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose To simulate and analyze the dosimetric differences of intraoperative radiotherapy (IORT) or pre-operative single-fraction stereotactic radiosurgery (SRS) in addition to post-operative external beam radiotherapy (EBRT) in Glioblastoma (GB). Methods Imaging series of previously treated patients with adjuvant radiochemotherapy were analyzed. For SRS target definition, pre-operative MRIs were co-registered to planning CT scans and a pre-operative T1-weighted gross target volume (GTV) plus a 2-mm planning target volume (PTV) were created. For IORT, a modified (m)GTV was expanded from the pre-operative volume, in order to mimic a round cavity as during IORT. Dose prescription was 20 Gy, homogeneously planned for SRS and calculated at the surface for IORT, to cover 99% and 90% of the volumes, respectively. For tumors > 2cm in maximum diameter, a 15 Gy dose was prescribed. Plan assessment was performed after calculating the 2-Gy equivalent doses (EQD2) for both boost modalities and including them into the EBRT plan. Main points of interest encompass differences in target coverage, brain volume receiving 12 Gy or more (V12), and doses to various organs-at-risk (OARs). Results Seventeen pre-delivered treatment plans were included in the study. The mean GTV was 21.72 cm3 (SD ± 19.36) and mGTV 29.64 cm3 (SD ± 25.64). The mean EBRT and SRS PTV were 254.09 (SD ± 80.0) and 36.20 cm3 (SD ± 31.48), respectively. Eight SRS plans were calculated to 15 Gy according to larger tumor sizes, while all IORT plans to 20 Gy. The mean EBRT D95 was 97.13% (SD ± 3.48) the SRS D99 99.91% (SD ± 0.35) and IORT D90 83.59% (SD ± 3.55). Accounting for only-boost approaches, the brain V12 was 49.68 cm3 (SD ± 26.70) and 16.94 cm3 (SD ± 13.33) (p<0.001) for SRS and IORT, respectively. After adding EBRT results respectively to SRS and IORT doses, significant lower doses were found in the latter for mean Dmax of chiasma (p=0.01), left optic nerve (p=0.023), right (p=0.008) and left retina (p<0.001). No significant differences were obtained for brainstem and cochleae. Conclusion Dose escalation for Glioblastoma using IORT results in lower OAR exposure as conventional SRS.
Collapse
Affiliation(s)
- Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Zuzanna Smalec
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Thomas Muedder
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Jasmin A Holz
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Davide Scafa
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - David Koch
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Stephan Garbe
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | | | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Ulrich Herrlinger
- Department of Neurology, Division of Neuro-Oncology, University Hospital Bonn, Bonn, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | | |
Collapse
|
12
|
Hessen ED, Makocki S, van der Heide UA, Jasperse B, Lutkenhaus LJ, Lamers E, Damen E, Troost EGC, Borst GR. The impact of anatomical changes during photon or proton based radiation treatment on tumor dose in glioblastoma dose escalation trials. Radiother Oncol 2021; 164:202-208. [PMID: 34592361 DOI: 10.1016/j.radonc.2021.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/16/2021] [Accepted: 09/20/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE/OBJECTIVE Most dose-escalation trials in glioblastoma patients integrate the escalated dose throughout the standard course by targeting a specific subvolume. We hypothesize that anatomical changes during irradiation may affect the dose coverage of this subvolume for both proton- and photon-based radiotherapy. MATERIAL AND METHODS For 24 glioblastoma patients a photon- and proton-based dose escalation treatment plan (of 75 Gy/30 fr) was simulated on the dedicated radiotherapy planning MRI obtained before treatment. The escalated dose was planned to cover the resection cavity and/or contrast enhancing lesion on the T1w post-gadolinium MRI sequence. To analyze the effect of anatomical changes during treatment, we evaluated on an additional MRI that was obtained during treatment the changes of the dose distribution on this specific high dose region. RESULTS The median time between the planning MRI and additional MRI was 26 days (range 16-37 days). The median time between the planning MRI and start of radiotherapy was relatively short (7 days, range 3-11 days). In 3 patients (12.5%) changes were observed which resulted in a substantial deterioration of both the photon and proton treatment plans. All these patients underwent a subtotal resection, and a decrease in dose coverage of more than 5% and 10% was observed for the photon- and proton-based treatment plans, respectively. CONCLUSION Our study showed that only for a limited number of patients anatomical changes during photon or proton based radiotherapy resulted in a potentially clinically relevant underdosage in the subvolume. Therefore, volume changes during treatment are unlikely to be responsible for the negative outcome of dose-escalation studies.
Collapse
Affiliation(s)
- Eline D Hessen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Sebastian Makocki
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, and Helmholtz-Zentrum Dresden-Rossendorf, Germany
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Bas Jasperse
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Lotte J Lutkenhaus
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Emmy Lamers
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Eugène Damen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Esther G C Troost
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, and Helmholtz-Zentrum Dresden-Rossendorf, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Helmholtz Association/Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Germany
| | - Gerben R Borst
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom; The Christie NHS Foundation Trust, Department of Radiotherapy Related Research, The Christie National Health Trust, Manchester, United Kingdom.
| |
Collapse
|
13
|
Abstract
The standard of care treatment for glioblastoma is surgical resection followed by radiotherapy to 60 Gy with concurrent and adjuvant temozolomide with or without tumor-treating fields. Advanced imaging techniques are under evaluation to better guide radiotherapy target volume delineation and allow for dose escalation. Particle therapy, in the form of protons, carbon ions, and boron neutron capture therapy, are being assessed as strategies to improve the radiotherapeutic ratio. Stereotactic, hypofractionated, pulsed-reduced dose-rate, and particle radiotherapy are re-irradiation techniques each uniquely suited for different clinical scenarios. Novel radiotherapy approaches, such as FLASH, represent promising advancements in radiotherapy for glioblastoma.
Collapse
Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
| | - Martin C Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| |
Collapse
|
14
|
Mathen P, Smart DK. Reimagining external beam radiotherapy for glioblastoma: "old beam, new trick". Neuro Oncol 2021; 23:345-346. [PMID: 33618364 PMCID: PMC7992895 DOI: 10.1093/neuonc/noab008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Peter Mathen
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - DeeDee K Smart
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| |
Collapse
|
15
|
Seidlitz A, Beuthien-Baumann B, Löck S, Jentsch C, Platzek I, Zöphel K, Linge A, Kotzerke J, Petr J, van den Hoff J, Steinbach J, Krex D, Schmitz-Schackert G, Falk M, Baumann M, Krause M. Final Results of the Prospective Biomarker Trial PETra: [ 11C]-MET-Accumulation in Postoperative PET/MRI Predicts Outcome after Radiochemotherapy in Glioblastoma. Clin Cancer Res 2021; 27:1351-1360. [PMID: 33376095 DOI: 10.1158/1078-0432.ccr-20-1775] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/24/2020] [Accepted: 12/22/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE This prospective trial investigates the association of time to recurrence (TTR) in glioblastoma with [11C]methionine (MET) tracer uptake before postoperative radiochemotherapy (RCT) aiming to guide radiotherapy boost regions. EXPERIMENTAL DESIGN Between 2013 and 2016, 102 patients with glioblastoma were recruited. RCT was performed with concurrent and adjuvant temozolomide to a total dose of 60 Gy. Tumor residues in postresection PET and MRI were together defined as gross tumor volumes for radiotherapy treatment planning. [11C]methionine (MET)-PET/MRI was performed before RCT and at each follow-up. RESULTS The primary hypothesis of a longer TTR for patients without increased tracer accumulation in postoperative MET-PET was confirmed in 89 patients. With 18.9 months (95% confidence interval, 9.3-28.5 months), median TTR was significantly (P < 0.001) longer for patients without (n = 29, 32.6%) as compared with 6.3 months (3.6-8.9) for patients with MET accumulation (n = 60, 67.4%) in pre-RCT PET. Although MRI often did not detect all PET-positive regions, an unfavorable impact of residual tumor in postsurgical MRI (n = 38, 42.7%) on TTR was observed [4.6 (4.2-5.1) vs. 15.5 months (6.0-24.9), P < 0.001]. Significant multivariable predictors for TTR were MRI positivity, PET-positive volume, and O6-methylguanine DNA methyltransferase (MGMT) hypermethylation. CONCLUSIONS Postsurgical amino acid PET has prognostic value for TTR after RCT in glioblastoma. Because of the added value of the metabolic beyond the pure structural information, it should complement MRI in radiotherapy planning if available with reasonable effort, at least in the context of maximal therapy. Furthermore, the spatial correlation of regions of recurrence with PET-positive volumes could provide a bioimaging basis for further trials, for example, testing local radiation dose escalation.
Collapse
Affiliation(s)
- Annekatrin Seidlitz
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. .,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site, Dresden, Germany
| | - Bettina Beuthien-Baumann
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,German Cancer Research Center (DKFZ), Department of Radiology, Heidelberg, Germany
| | - Steffen Löck
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site, Dresden, Germany
| | - Christina Jentsch
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | - Ivan Platzek
- Institute of Radiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Klaus Zöphel
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Annett Linge
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site, Dresden, Germany
| | - Jörg Kotzerke
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jan Petr
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany.,Department of Biomedical Engineering, Rochester Institute of Technology, Rochester, New York
| | - Jörg van den Hoff
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Jörg Steinbach
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany.,Department of Chemistry and Food Chemistry, TU Dresden, Dresden, Germany
| | - Dietmar Krex
- Department of Neurosurgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Gabriele Schmitz-Schackert
- Department of Neurosurgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Monique Falk
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site, Dresden, Germany
| | - Michael Baumann
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology, Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mechthild Krause
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology, Dresden, Germany
| |
Collapse
|
16
|
Ferro M, Ferro M, Macchia G, Cilla S, Buwenge M, Re A, Romano C, Boccardi M, Picardi V, Cammelli S, Cucci E, Mignogna S, Di Lullo L, Valentini V, Morganti AG, Deodato F. Post-Operative Accelerated-Hypofractionated Chemoradiation With Volumetric Modulated Arc Therapy and Simultaneous Integrated Boost in Glioblastoma: A Phase I Study (ISIDE-BT-2). Front Oncol 2021; 10:626400. [PMID: 33692944 PMCID: PMC7937791 DOI: 10.3389/fonc.2020.626400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 12/31/2020] [Indexed: 11/24/2022] Open
Abstract
Background Glioblastoma Multiforme (GBM) is the most common primary brain cancer and one of the most lethal tumors. Theoretically, modern radiotherapy (RT) techniques allow dose-escalation due to the reduced irradiation of healthy tissues. This study aimed to define the adjuvant maximum tolerated dose (MTD) using volumetric modulated arc RT with simultaneous integrated boost (VMAT-SIB) plus standard dose temozolomide (TMZ) in GBM. Methods A Phase I clinical trial was performed in operated GBM patients using VMAT-SIB technique with progressively increased total dose. RT was delivered in 25 fractions (5 weeks) to two planning target volumes (PTVs) defined by adding a 5-mm margin to the clinical target volumes (CTVs). The CTV1 was the tumor bed plus the MRI enhancing residual lesion with 10-mm margin. The CTV2 was the CTV1 plus 20-mm margin. Only PTV1 dose was escalated (planned dose levels: 72.5, 75, 77.5, 80, 82.5, 85 Gy), while PTV2 dose remained unchanged (45 Gy/1.8 Gy). Concurrent and sequential TMZ was prescribed according to the EORTC/NCIC protocol. Dose-limiting toxicities (DLTs) were defined as any G ≥ 3 non-hematological acute toxicity or any G ≥ 4 acute hematological toxicities (RTOG scale) or any G ≥ 2 late toxicities (RTOG-EORTC scale). Results Thirty-seven patients (M/F: 21/16; median age: 59 years; median follow-up: 12 months) were enrolled and treated as follows: 6 patients (72.5 Gy), 10 patients (75 Gy), 10 patients (77.5 Gy), 9 patients (80 Gy), 2 patients (82.5 Gy), and 0 patients (85 Gy). Eleven patients (29.7%) had G1-2 acute neurological toxicity, while 3 patients (8.1%) showed G ≥ 3 acute neurological toxicities at 77.5 Gy, 80 Gy, and 82.5 Gy levels, respectively. Since two DLTs (G3 neurological: 1 patient and G5 hematological toxicity: 1 patient) were observed at 82.5 Gy level, the trial was closed and the 80 Gy dose-level was defined as the MTD. Two asymptomatic histologically proven radionecrosis were recorded. Conclusions According to the results of this Phase I trial, 80 Gy in 25 fractions accelerated hypofractionated RT is the MTD using VMAT-SIB plus standard dose TMZ in resected GBM.
Collapse
Affiliation(s)
- Marica Ferro
- Radiation Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Milena Ferro
- Radiation Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Gabriella Macchia
- Radiation Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Milly Buwenge
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,DIMES, Alma Mater Studiorum Bologna University, Bologna, Italy
| | - Alessia Re
- Radiation Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Carmela Romano
- Medical Physics Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Mariangela Boccardi
- Radiation Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Vincenzo Picardi
- Radiation Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Silvia Cammelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,DIMES, Alma Mater Studiorum Bologna University, Bologna, Italy
| | - Eleonora Cucci
- Radiology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Samantha Mignogna
- Medical Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Liberato Di Lullo
- Medical Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Vincenzo Valentini
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Roma, Italy.,Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Alessio Giuseppe Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,DIMES, Alma Mater Studiorum Bologna University, Bologna, Italy
| | - Francesco Deodato
- Radiation Oncology Unit, Gemelli Molise Hospital - Università Cattolica del Sacro Cuore, Campobasso, Italy.,Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy
| |
Collapse
|
17
|
Guo L, Li X, Chen Y, Liu R, Ren C, Du S. The efficacy of hypofractionated radiotherapy (HFRT) with concurrent and adjuvant temozolomide in newly diagnosed glioblastoma: A meta-analysis. Cancer Radiother 2021; 25:182-190. [PMID: 33436285 DOI: 10.1016/j.canrad.2020.08.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/06/2020] [Accepted: 08/28/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE The efficacy of hypofractionated radiotherapy (HFRT) in glioblastoma (GBM) without age restrictions remains unclear. The aim of this meta-analysis is to access the survival outcomes of HFRT in these patients. METHODS A comprehensive electronic literature search of PubMed, Web of Science and Cochrane Library was conducted up to June 1, 2020. The main evaluation data were the overall survival (OS) rate at 12 months and 24 months and the progression-free survival (PFS) rate at 6 and 12 months. The secondary evaluation data was the incidence of radionecrosis and adverse events. The study was performed using R "meta" package. RESULTS Eleven studies met the inclusion criteria, which totally contained 484 participants. The 12-month OS and 24-month OS rate of HFRT in GBM were 71.3% and 34.8%, while the 6-month PFS and 12-month rate were 74.0% and 40.8%. Compared to low-BED (biological equivalent dose) schedules (<78Gy), high-BED schedules may increase survival benefit both in PFS-6 (P=0.003) and PFS-12 (P=0.011), while the difference did not show on OS. Different dose per fraction had no significant effect on both OS and PFS. Incidence of radionecrosis was 14.2%. Although the overall incidence of adverse reactions cannot be quantified, the toxicity of HFRT was acceptable. CONCLUSIONS Compared with survival data for standard treatment, HFRT seemed to improve overall survival and progression-free survival, while high BED schedules may future increase benefit on PFS. Meanwhile, the toxicity of HFRT was tolerable. Further randomised controlled clinical studies are needed to confirm these findings.
Collapse
Affiliation(s)
- Longbin Guo
- Department of radiation oncology, Nanfang hospital, Southern medical university, 1838, North Guangzhou avenue, 510515 Guangzhou, China
| | - Xuanzi Li
- Department of radiation oncology, Nanfang hospital, Southern medical university, 1838, North Guangzhou avenue, 510515 Guangzhou, China
| | - Yulei Chen
- Department of radiation oncology, Nanfang hospital, Southern medical university, 1838, North Guangzhou avenue, 510515 Guangzhou, China
| | - Rongping Liu
- Department of radiation oncology, Nanfang hospital, Southern medical university, 1838, North Guangzhou avenue, 510515 Guangzhou, China
| | - Chen Ren
- Department of radiation oncology, Nanfang hospital, Southern medical university, 1838, North Guangzhou avenue, 510515 Guangzhou, China.
| | - Shasha Du
- Department of radiation oncology, Nanfang hospital, Southern medical university, 1838, North Guangzhou avenue, 510515 Guangzhou, China.
| |
Collapse
|
18
|
Zhang Y, Wang J. Research progress on radiotherapy technology and dose fraction scheme for advanced gliomas. Transl Cancer Res 2020; 9:7642-7651. [PMID: 35117363 PMCID: PMC8799171 DOI: 10.21037/tcr-20-1891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/28/2020] [Indexed: 11/06/2022]
Abstract
Glioma is the most common central malignant tumor. High-grade glioma (HGG) has high malignancy and a short median survival. Complete surgical resection and comprehensive treatment with postoperative radiotherapy and chemotherapy is the recommended treatment for HGGs at present in clinic. Postoperative radiotherapy can reduce the local recurrence rate and prolong the survival time of patients. In recent years, researchers have made some progress on different radiotherapy technologies and dose fraction schemes. With the continuous development of medical technology, different groups of people should choose different dose fraction schemes, in order to realize the individualization of treatment schemes, and provide more benefits to patients. At present, the optimal radiotherapy dose, the fraction model, and how to achieve individualized radiotherapy remains unclear. In view of the poor prognosis of this disease, patients should be encouraged to participate in properly conducted experimental studies.
Collapse
Affiliation(s)
- Yu Zhang
- Department of Radiation Oncology, Peking University International Hospital, Beijing, China
| | - Junjie Wang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| |
Collapse
|
19
|
Farrell C, Shi W, Bodman A, Olson JJ. Congress of neurological surgeons systematic review and evidence-based guidelines update on the role of emerging developments in the management of newly diagnosed glioblastoma. J Neurooncol 2020; 150:269-359. [PMID: 33215345 DOI: 10.1007/s11060-020-03607-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/23/2020] [Indexed: 12/12/2022]
Abstract
TARGET POPULATION These recommendations apply to adult patients with newly diagnosed or suspected glioblastoma. IMAGING Question What imaging modalities are in development that may be able to provide improvements in diagnosis, and therapeutic guidance for individuals with newly diagnosed glioblastoma? RECOMMENDATION Level III: It is suggested that techniques utilizing magnetic resonance imaging for diffusion weighted imaging, and to measure cerebral blood and magnetic spectroscopic resonance imaging of N-acetyl aspartate, choline and the choline to N-acetyl aspartate index to assist in diagnosis and treatment planning in patients with newly diagnosed or suspected glioblastoma. SURGERY Question What new surgical techniques can be used to provide improved tumor definition and resectability to yield better tumor control and prognosis for individuals with newly diagnosed glioblastoma? RECOMMENDATIONS Level II: The use of 5-aminolevulinic acid is recommended to improve extent of tumor resection in patients with newly diagnosed glioblastoma. Level II: The use of 5-aminolevulinic acid is recommended to improve median survival and 2 year survival in newly diagnosed glioblastoma patients with clinical characteristics suggesting poor prognosis. Level III: It is suggested that, when available, patients be enrolled in properly designed clinical trials assessing the value of diffusion tensor imaging in improving the safety of patients with newly diagnosed glioblastoma undergoing surgery. NEUROPATHOLOGY Question What new pathology techniques and measurement of biomarkers in tumor tissue can be used to provide improved diagnostic ability, and determination of therapeutic responsiveness and prognosis for patients with newly diagnosed glioblastomas? RECOMMENDATIONS Level II: Assessment of tumor MGMT promoter methylation status is recommended as a significant predictor of a longer progression free survival and overall survival in patients with newly diagnosed with glioblastoma. Level II: Measurement of tumor expression of neuron-glia-2, neurofilament protein, glutamine synthetase and phosphorylated STAT3 is recommended as a predictor of overall survival in patients with newly diagnosed with glioblastoma. Level III: Assessment of tumor IDH1 mutation status is suggested as a predictor of longer progression free survival and overall survival in patients with newly diagnosed with glioblastoma. Level III: Evaluation of tumor expression of Phosphorylated Mitogen-Activated Protein Kinase protein, EGFR protein, and Insulin-like Growth Factor-Binding Protein-3 is suggested as a predictor of overall survival in patients with newly diagnosed with glioblastoma. RADIATION Question What radiation therapy techniques are in development that may be used to provide improved tumor control and prognosis for individuals with newly diagnosed glioblastomas? RECOMMENDATIONS Level III: It is suggested that patients with newly diagnosed glioblastoma undergo pretreatment radio-labeled amino acid tracer positron emission tomography to assess areas at risk for tumor recurrence to assist in radiation treatment planning. Level III: It is suggested that, when available, patients be with newly diagnosed glioblastomas be enrolled in properly designed clinical trials of radiation dose escalation, altered fractionation, or new radiation delivery techniques. CHEMOTHERAPY Question What emerging chemotherapeutic agents or techniques are available to provide better tumor control and prognosis for patients with newly diagnosed glioblastomas? RECOMMENDATION Level III: As no emerging chemotherapeutic agents or techniques were identified in this review that improved tumor control and prognosis it is suggested that, when available, patients with newly diagnosed glioblastomas be enrolled in properly designed clinical trials of chemotherapy. MOLECULAR AND TARGETED THERAPY Question What new targeted therapy agents are available to provide better tumor control and prognosis for individuals with newly diagnosed glioblastomas? RECOMMENDATION Level III: As no new molecular and targeted therapies have clearly provided better tumor control and prognosis it is suggested that, when available, patients with newly diagnosed glioblastomas be enrolled in properly designed clinical trials of molecular and targeted therapies IMMUNOTHERAPY: Question What emerging immunotherapeutic agents or techniques are available to provide better tumor control and prognosis for patients with newly diagnosed glioblastomas? RECOMMENDATION Level III: As no immunotherapeutic agents have clearly provided better tumor control and prognosis it is suggested that, when available, patients with newly diagnosed glioblastomas be enrolled in properly designed clinical trials of immunologically-based therapies. NOVEL THERAPIES Question What novel therapies or techniques are in development to provide better tumor control and prognosis for individuals with newly diagnosed glioblastomas? RECOMMENDATIONS Level II: The use of tumor-treating fields is recommended for patients with newly diagnosed glioblastoma who have undergone surgical debulking and completed concurrent chemoradiation without progression of disease at the time of tumor-treating field therapy initiation. Level II: It is suggested that, when available, enrollment in properly designed studies of vector containing herpes simplex thymidine kinase gene and prodrug therapies be considered in patients with newly diagnosed glioblastoma.
Collapse
Affiliation(s)
- Christopher Farrell
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA.
| |
Collapse
|
20
|
Unger K, Fleischmann DF, Ruf V, Felsberg J, Piehlmaier D, Samaga D, Hess J, Suresh MP, Mittelbronn M, Lauber K, Budach W, Sabel M, Rödel C, Reifenberger G, Herms J, Tonn JC, Zitzelsberger H, Belka C, Niyazi M. Improved risk stratification in younger IDH wild-type glioblastoma patients by combining a 4-miRNA signature with MGMT promoter methylation status. Neurooncol Adv 2020; 2:vdaa137. [PMID: 33305269 PMCID: PMC7712804 DOI: 10.1093/noajnl/vdaa137] [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] [Indexed: 12/18/2022] Open
Abstract
Background The potential benefit of risk stratification using a 4-miRNA signature in combination with MGMT promoter methylation in IDH1/2 wild-type glioblastoma patients was assessed. Methods Primary tumors from 102 patients with comparable treatment from the LMU Munich (n = 37), the University Hospital Düsseldorf (n = 33), and The Cancer Genome Atlas (n = 32) were included. Risk groups were built using expressions of hsa-let-7a-5p, hsa-let-7b-5p, hsa-miR-615-5p, and hsa-miR-125a-5p to assess prognostic performance in overall survival (OS). MGMT promoter methylation and age were considered as cofactors. Integrated miRNA, DNA methylome, and transcriptome analysis were used to explore the functional impact of signature miRNAs. Results The 4-miRNA signature defined high-risk (n = 46, median OS: 15.8 months) and low-risk patients (n = 56, median OS: 20.7 months; univariable Cox proportional hazard analysis: hazard ratio [HR]: 1.8, 95% confidence interval [CI]: 1.14–2.83, P = .01). The multivariable Cox proportional hazard model including the 4-miRNA signature (P = .161), MGMT promoter methylation (P < .001), and age (P = .034) significantly predicted OS (Log-rank P < .0001). Likewise to clinical routine, analysis was performed for younger (≤60 years, n = 50, median OS: 20.2 months) and older patients (>60 years, n = 52, median OS: 15.8) separately. In younger patients, the 4-miRNA signature had prognostic value (HR: 1.92, 95% CI: 0.93–3.93, P = .076). Particularly, younger, MGMT methylated, 4-miRNA signature low-risk patients (n = 18, median OS: 37.4 months) showed significantly improved survival, compared to other younger patients (n = 32, OS 18.5 months; HR: 0.33, 95% CI: 0.15–0.71, P = .003). Integrated data analysis revealed 4-miRNA signature-associated genes and pathways. Conclusion The prognostic 4-miRNA signature in combination with MGMT promoter methylation improved risk stratification with the potential for therapeutic substratification, especially of younger patients.
Collapse
Affiliation(s)
- Kristian Unger
- Research Unit Radiation Cytogenetics, Helmholtz Zentrum München, German Research Center for Environmental Health GmbH, Neuherberg, Germany.,Clinical Cooperation Group "Personalized Radiotherapy in Head and Neck Cancer," Helmholtz Zentrum München, German Research Center for Environmental Health GmbH, Neuherberg, Germany.,Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Daniel F Fleischmann
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Viktoria Ruf
- Center for Neuropathology and Prion Research LMU Munich, Munich, Germany
| | - Jörg Felsberg
- Institute for Neuropathology, University Hospital Düsseldorf (UKD), Heinrich Heine University, Düsseldorf, Germany.,German Cancer Consortium (DKTK), Partner Site Essen/Düsseldorf, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Daniel Piehlmaier
- Research Unit Radiation Cytogenetics, Helmholtz Zentrum München, German Research Center for Environmental Health GmbH, Neuherberg, Germany
| | - Daniel Samaga
- Research Unit Radiation Cytogenetics, Helmholtz Zentrum München, German Research Center for Environmental Health GmbH, Neuherberg, Germany
| | - Julia Hess
- Research Unit Radiation Cytogenetics, Helmholtz Zentrum München, German Research Center for Environmental Health GmbH, Neuherberg, Germany.,Clinical Cooperation Group "Personalized Radiotherapy in Head and Neck Cancer," Helmholtz Zentrum München, German Research Center for Environmental Health GmbH, Neuherberg, Germany
| | - Marian Preetham Suresh
- Department of Neurosurgery, University Hospital Düsseldorf (UKD), Heinrich Heine University, Düsseldorf, Germany
| | - Michel Mittelbronn
- National Center of Pathology (NCP), Laboratoire National de Santé (LNS), Dudelange, Luxembourg.,Luxembourg Centre for Systems Biomedicine (LCSB), University of Luxembourg, Esch-sur-Alzette, Luxembourg.,Department of Oncology (DONC), Luxembourg Institute of Health (LIH), Luxembourg, Luxembourg.,Luxembourg Center of Neuropathology (LCNP), Luxembourg, Luxembourg
| | - Kirsten Lauber
- Clinical Cooperation Group "Personalized Radiotherapy in Head and Neck Cancer," Helmholtz Zentrum München, German Research Center for Environmental Health GmbH, Neuherberg, Germany.,Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Wilfried Budach
- Department of Radiotherapy and Radiation Oncology, University Hospital Düsseldorf (UKD), Heinrich Heine University, Düsseldorf, Germany
| | - Michael Sabel
- Department of Neurosurgery, University Hospital Düsseldorf (UKD), Heinrich Heine University, Düsseldorf, Germany
| | - Claus Rödel
- Department of Radiation Oncology, University Hospital, Frankfurt, Germany
| | - Guido Reifenberger
- Institute for Neuropathology, University Hospital Düsseldorf (UKD), Heinrich Heine University, Düsseldorf, Germany.,German Cancer Consortium (DKTK), Partner Site Essen/Düsseldorf, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jochen Herms
- Center for Neuropathology and Prion Research LMU Munich, Munich, Germany
| | - Jörg-Christian Tonn
- Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
| | - Horst Zitzelsberger
- Research Unit Radiation Cytogenetics, Helmholtz Zentrum München, German Research Center for Environmental Health GmbH, Neuherberg, Germany.,Clinical Cooperation Group "Personalized Radiotherapy in Head and Neck Cancer," Helmholtz Zentrum München, German Research Center for Environmental Health GmbH, Neuherberg, Germany.,Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Clinical Cooperation Group "Personalized Radiotherapy in Head and Neck Cancer," Helmholtz Zentrum München, German Research Center for Environmental Health GmbH, Neuherberg, Germany.,Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| |
Collapse
|
21
|
Stewart J, Sahgal A, Lee Y, Soliman H, Tseng CL, Detsky J, Husain Z, Ho L, Das S, Maralani PJ, Lipsman N, Stanisz G, Perry J, Chen H, Atenafu EG, Campbell M, Lau AZ, Ruschin M, Myrehaug S. Quantitating Interfraction Target Dynamics During Concurrent Chemoradiation for Glioblastoma: A Prospective Serial Imaging Study. Int J Radiat Oncol Biol Phys 2020; 109:736-746. [PMID: 33068687 DOI: 10.1016/j.ijrobp.2020.10.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/18/2020] [Accepted: 10/05/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Magnetic resonance image (MRI) guided radiation therapy has the potential to improve outcomes for glioblastoma by adapting to tumor changes during radiation therapy. This study quantifies interfraction dynamics (tumor size, position, and geometry) based on sequential magnetic resonance imaging scans obtained during standard 6-week chemoradiation. METHODS AND MATERIALS Sixty-one patients were prospectively imaged with gadolinium-enhanced T1 (T1c) and T2/FLAIR axial sequences at planning (Fx0), fraction 10 (Fx10), fraction 20 (Fx20), and 1 month after the final fraction of chemoradiation therapy (P1M). Gross tumor volumes (GTVs) and clinical target volumes (CTVs) were contoured at all time points. Target dynamics were quantified by absolute volume (V), volume relative to Fx0 (Vrel), and the migration distance (dmigrate; the linear displacement of the GTV or CTV relative to Fx0). Temporal changes were assessed using a linear mixed-effects model. RESULTS Median volumes at Fx0, Fx10, Fx20, and P1M for the GTV were 18.4 cm3 (range, 1.1-110.5 cm3), 14.7 cm3 (range, 0.9-115.1 cm3), 13.7 cm3 (range, 0.6-174.2 cm3), and 13.0 cm3 (range, 0.9-76.3 cm3), respectively, with corresponding median Vrel of 0.88 at Fx10, 0.77 at Fx20, and 0.71 at P1M relative to Fx0 (P < .001 for all). The GTV (CTV) migration distances were greater than 5 mm in 46% (54%) of patients at Fx10, 50% (58%) of patients at Fx20, and 52% (57%) of patients at P1M. Dynamic tumor morphologic changes were observed, with 40% of patients exhibiting a decreased GTV (Vrel ≤1) with a dmigrate >5 mm during chemoradiation therapy. CONCLUSIONS Clinically meaningful tumor dynamics were observed during chemoradiation therapy for glioblastoma, supporting evaluation of daily MRI guided radiation therapy and treatment plan adaptation.
Collapse
Affiliation(s)
- James Stewart
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Young Lee
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ling Ho
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Sunit Das
- Division of Neurosurgery and Centre for Ethics, St. Michael's Hospital, Toronto, Canada; The Arthur and Sonia Labatt Brain Tumour Research Centre, SickKids Hospital, Toronto, Canada; Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Nir Lipsman
- Division of Neurosurgery, University of Toronto, Toronto, Canada; Department of Physical Sciences, Sunnybrook Research Institute, Toronto, Canada; Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Greg Stanisz
- Department of Physical Sciences, Sunnybrook Research Institute, Toronto, Canada; Department of Medical Biophysics University of Toronto, Toronto, Canada; Department of Neurosurgery and Pediatric Neurosurgery, Medical University, Lublin, Poland
| | - James Perry
- Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, Canada
| | - Mikki Campbell
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Angus Z Lau
- Department of Physical Sciences, Sunnybrook Research Institute, Toronto, Canada; Department of Medical Biophysics University of Toronto, Toronto, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada.
| |
Collapse
|
22
|
Ali MY, Oliva CR, Noman ASM, Allen BG, Goswami PC, Zakharia Y, Monga V, Spitz DR, Buatti JM, Griguer CE. Radioresistance in Glioblastoma and the Development of Radiosensitizers. Cancers (Basel) 2020; 12:E2511. [PMID: 32899427 PMCID: PMC7564557 DOI: 10.3390/cancers12092511] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/24/2020] [Accepted: 08/28/2020] [Indexed: 02/07/2023] Open
Abstract
Ionizing radiation is a common and effective therapeutic option for the treatment of glioblastoma (GBM). Unfortunately, some GBMs are relatively radioresistant and patients have worse outcomes after radiation treatment. The mechanisms underlying intrinsic radioresistance in GBM has been rigorously investigated over the past several years, but the complex interaction of the cellular molecules and signaling pathways involved in radioresistance remains incompletely defined. A clinically effective radiosensitizer that overcomes radioresistance has yet to be identified. In this review, we discuss the current status of radiation treatment in GBM, including advances in imaging techniques that have facilitated more accurate diagnosis, and the identified mechanisms of GBM radioresistance. In addition, we provide a summary of the candidate GBM radiosensitizers being investigated, including an update of subjects enrolled in clinical trials. Overall, this review highlights the importance of understanding the mechanisms of GBM radioresistance to facilitate the development of effective radiosensitizers.
Collapse
Affiliation(s)
- Md Yousuf Ali
- Interdisciplinary Graduate Program in Human Toxicology, University of Iowa, Iowa City, IA 52242, USA;
- Free Radical & Radiation Biology Program, Department of Radiation Oncology, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA 52242, USA; (C.R.O.); (B.G.A.); (P.C.G.); (D.R.S.)
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| | - Claudia R. Oliva
- Free Radical & Radiation Biology Program, Department of Radiation Oncology, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA 52242, USA; (C.R.O.); (B.G.A.); (P.C.G.); (D.R.S.)
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| | - Abu Shadat M. Noman
- Department of Biochemistry and Molecular Biology, The University of Chittagong, Chittagong 4331, Bangladesh;
- Department of Pathology, McGill University, Montreal, QC H3A 2B4, Canada
| | - Bryan G. Allen
- Free Radical & Radiation Biology Program, Department of Radiation Oncology, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA 52242, USA; (C.R.O.); (B.G.A.); (P.C.G.); (D.R.S.)
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| | - Prabhat C. Goswami
- Free Radical & Radiation Biology Program, Department of Radiation Oncology, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA 52242, USA; (C.R.O.); (B.G.A.); (P.C.G.); (D.R.S.)
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| | - Yousef Zakharia
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA; (Y.Z.); (V.M.)
| | - Varun Monga
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA; (Y.Z.); (V.M.)
| | - Douglas R. Spitz
- Free Radical & Radiation Biology Program, Department of Radiation Oncology, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA 52242, USA; (C.R.O.); (B.G.A.); (P.C.G.); (D.R.S.)
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| | - John M. Buatti
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| | - Corinne E. Griguer
- Free Radical & Radiation Biology Program, Department of Radiation Oncology, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA 52242, USA; (C.R.O.); (B.G.A.); (P.C.G.); (D.R.S.)
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| |
Collapse
|
23
|
Neurologic Complications of Cranial Radiation Therapy and Strategies to Prevent or Reduce Radiation Toxicity. Curr Neurol Neurosci Rep 2020; 20:34. [DOI: 10.1007/s11910-020-01051-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
24
|
Shieh LT, Guo HR, Ho CH, Lin LC, Chang CH, Ho SY. Survival of glioblastoma treated with a moderately escalated radiation dose-Results of a retrospective analysis. PLoS One 2020; 15:e0233188. [PMID: 32413077 PMCID: PMC7228055 DOI: 10.1371/journal.pone.0233188] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/29/2020] [Indexed: 11/18/2022] Open
Abstract
Glioblastoma (GBM) has the highest fatality rate among primary malignant brain tumors and typically tends to recur locally just adjacent to the original tumor site following surgical resection and adjuvant radiotherapy. We conducted a study to evaluate the survival outcomes between a standard dose (≤ 60 Gy) and moderate radiation dose escalation (>60 Gy), and to identify prognostic factors for GBM. We retrospectively reviewed the medical records of primary GBM patients diagnosed between 2005 and 2016 in two referral hospitals in Taiwan. They were identified from the cancer registry database and followed up from the date of diagnosis to October 2018. The progression-free survival (PFS) and overall survival (OS) were compared between the two dose groups, and independent factors for survival were analyzed through Cox proportional hazard model. We also affirmed the results using Cox regression with least absolute shrinkage and selection operator (LASSO) approach. From our cancer registry database, 142 GBM patients were identified, and 84 of them fit the inclusion criteria. Of the 84 patients, 52 (62%) were males. The radiation dose ranged from 50.0 Gy to 66.6 Gy, but their treatment volumes were similar to the others. Fifteen (18%) patients received an escalated dose boost >60.0 Gy. The escalated group had a longer median PFS (15.4 vs. 7.9 months, p = 0.01 for log-rank test), and a longer median OS was also longer in the escalation group (33.8 vs. 12.5 months, p <0.001) than the reference group. Following a multivariate analysis, the escalated dose was identified as a significant predictor for good prognosis (PFS: hazard ratio [HR] = 0.48, 95% confidence interval [95%CI]: 0.23-0.98; OS: HR = 0.40, 95%CI: 0.21-0.78). Using the LASSO approach, we found age > 70 (HR = 1.55), diagnosis after 2010 (HR = 1.42), and a larger radiation volume (≥ 250ml; HR = 0.81) were predictors of PFS. The escalated dose (HR = 0.47) and a larger radiation volume (HR = 0.76) were identified as predictors for better OS. Following detailed statistical analysis, a moderate radiation dose escalation (> 60 Gy) was found as an independent factor affecting OS in GBM patients. In conclusion, a moderate radiation dose escalation (> 60 Gy) was an independent predictor for longer OS in GBM patients. However, prospective studies including more patients with more information, such as molecular markers and completeness of resection, are needed to confirm our findings.
Collapse
Affiliation(s)
- Li-Tsun Shieh
- Department of Radiation Oncology, Chi Mei Medical Center, Liouying, Tainan, Taiwan, Republic of china
| | - How-Ran Guo
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan, Republic of china
- Department of Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, Republic of china
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan, Republic of china
- Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan, Republic of china
| | - Li-Ching Lin
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan, Republic of china
| | - Chin-Hong Chang
- Department of Neurosurgery, Chi Mei Medical Center, Tainan, Taiwan, Republic of china
| | - Sheng-Yow Ho
- Department of Radiation Oncology, Chi Mei Medical Center, Liouying, Tainan, Taiwan, Republic of china
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan, Republic of china
- Graduate Institute of Medical Science, Chang Jung Christian University, Tainan, Taiwan, Republic of china
- * E-mail:
| |
Collapse
|
25
|
Lipkova J, Angelikopoulos P, Wu S, Alberts E, Wiestler B, Diehl C, Preibisch C, Pyka T, Combs SE, Hadjidoukas P, Van Leemput K, Koumoutsakos P, Lowengrub J, Menze B. Personalized Radiotherapy Design for Glioblastoma: Integrating Mathematical Tumor Models, Multimodal Scans, and Bayesian Inference. IEEE TRANSACTIONS ON MEDICAL IMAGING 2019; 38:1875-1884. [PMID: 30835219 PMCID: PMC7170051 DOI: 10.1109/tmi.2019.2902044] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Glioblastoma (GBM) is a highly invasive brain tumor, whose cells infiltrate surrounding normal brain tissue beyond the lesion outlines visible in the current medical scans. These infiltrative cells are treated mainly by radiotherapy. Existing radiotherapy plans for brain tumors derive from population studies and scarcely account for patient-specific conditions. Here, we provide a Bayesian machine learning framework for the rational design of improved, personalized radiotherapy plans using mathematical modeling and patient multimodal medical scans. Our method, for the first time, integrates complementary information from high-resolution MRI scans and highly specific FET-PET metabolic maps to infer tumor cell density in GBM patients. The Bayesian framework quantifies imaging and modeling uncertainties and predicts patient-specific tumor cell density with credible intervals. The proposed methodology relies only on data acquired at a single time point and, thus, is applicable to standard clinical settings. An initial clinical population study shows that the radiotherapy plans generated from the inferred tumor cell infiltration maps spare more healthy tissue thereby reducing radiation toxicity while yielding comparable accuracy with standard radiotherapy protocols. Moreover, the inferred regions of high tumor cell densities coincide with the tumor radioresistant areas, providing guidance for personalized dose-escalation. The proposed integration of multimodal scans and mathematical modeling provides a robust, non-invasive tool to assist personalized radiotherapy design.
Collapse
|
26
|
Kosztyla R, Raman S, Moiseenko V, Reinsberg SA, Toyota B, Nichol A. Dose-painted volumetric modulated arc therapy of high-grade glioma using 3,4-dihydroxy-6-[ 18F]fluoro-L-phenylalanine positron emission tomography. Br J Radiol 2019; 92:20180901. [PMID: 31017449 DOI: 10.1259/bjr.20180901] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine whether dose painting with volumetric modulated arc therapy for high-grade gliomas using 3,4-dihydroxy-6-[18F]fluoro-l-phenylalanine (18F-FDOPA) positron emission tomography (PET) could achieve dose-escalated coverage of biological target volumes (BTVs) without increasing the dose to cranial organs at risk (OARs). METHODS 10 patients with high-grade gliomas underwent CT, MRI, and 18F-FDOPA PET/CT images for post-operative radiation therapy planning. Two volumetric modulated arc therapy plans were retrospectively generated for each patient: a conventional plan with 60 Gy in 30 fractions to the planning target volume delineated on MRI and a dose-escalated plan with a maximum dose of 80 Gy in 30 fractions to BTVs. BTVs were created by thresholding 18F-FDOPA PET/CT uptake using a linear quadratic model that assumed tracer uptake was linearly related to tumour cell density. The maximum doses and equivalent uniform doses of OARs were compared. RESULTS The median volume of the planning target volume receiving at least 95% of the prescribed dose (V 95%) was 99.6% with and 99.5% without dose painting. The median V 95% was >99.2% for BTVs. The maximum doses and equivalent uniform doses to the OARs did not differ significantly between the conventional and dose-painted plans. CONCLUSION Using commercially available treatment planning software, dose painting for high-grade gliomas was feasible with good BTV coverage and no significant change in the dose to OARs. ADVANCES IN KNOWLEDGE A novel treatment planning strategy was used to achieve dose painting for gliomas with BTVs obtained from 18F-FDOPA PET/CT using a radiobiological model.
Collapse
Affiliation(s)
- Robert Kosztyla
- 1 Department of Medical Physics, BC Cancer - Vancouver , Vancouver, British Columbia , Canada.,2 Department of Physics and Astronomy, University of British Columbia , Vancouver, British Columbia , Canada
| | - Srinivas Raman
- 3 Department of Radiation Oncology, BC Cancer - Vancouver , Vancouver, British Columbia , Canada
| | - Vitali Moiseenko
- 4 Department of Radiation Medicine and Applied Sciences, University of California San Diego , La Jolla, California , US
| | - Stefan A Reinsberg
- 2 Department of Physics and Astronomy, University of British Columbia , Vancouver, British Columbia , Canada
| | - Brian Toyota
- 5 Division of Neurosurgery, University of British Columbia , Vancouver, British Columbia , Canada
| | - Alan Nichol
- 3 Department of Radiation Oncology, BC Cancer - Vancouver , Vancouver, British Columbia , Canada
| |
Collapse
|
27
|
Wegner RE, Abel S, Horne ZD, Hasan S, Verma V, Ranjan T, Williamson RW, Karlovits SM. National trends in radiation dose escalation for glioblastoma. Radiat Oncol J 2019; 37:13-21. [PMID: 30947476 PMCID: PMC6453808 DOI: 10.3857/roj.2019.00017] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 02/11/2019] [Indexed: 01/04/2023] Open
Abstract
Purpose Glioblastoma (GBM) carries a high propensity for in-field failure despite trimodality management. Past studies have failed to show outcome improvements with dose-escalation. Herein, we examined trends and outcomes associated with dose-escalation for GBM. Materials and Methods The National Cancer Database was queried for GBM patients who underwent surgical resection and external-beam radiation with chemotherapy. Patients were excluded if doses were less than 59.4 Gy; dose-escalation referred to doses ≥66 Gy. Odds ratios identified predictors of dose-escalation. Univariable and multivariable Cox regressions determined potential predictors of overall survival (OS). Propensity-adjusted multivariable analysis better accounted for indication biases. Results Of 33,991 patients, 1,223 patients received dose-escalation. Median dose in the escalation group was 70 Gy (range, 66 to 89.4 Gy). The use of dose-escalation decreased from 8% in 2004 to 2% in 2014. Predictors of escalated dose were African American race, lower comorbidity score, treatment at community centers, decreased income, and more remote treatment year. Median OS was 16.2 months and 15.8 months for the standard and dose-escalated cohorts, respectively (p = 0.35). On multivariable analysis, age >60 years, higher comorbidity score, treatment at community centers, decreased education, lower income, government insurance, Caucasian race, male gender, and more remote year of treatment predicted for worse OS. On propensity-adjusted multivariable analysis, age >60 years, distance from center >12 miles, decreased education, government insurance, and male gender predicted for worse outcome. Conclusion Dose-escalated radiotherapy for GBM has decreased over time across the United States, in concordance with guidelines and the available evidence. Similarly, this large study did not discern survival improvements with dose-escalation.
Collapse
Affiliation(s)
- Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Stephen Abel
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Zachary D Horne
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Shaakir Hasan
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Vivek Verma
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Tulika Ranjan
- Division of Medical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | | | - Stephen M Karlovits
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| |
Collapse
|
28
|
Patterns of Care and Outcomes of Hypofractionated Chemoradiation Versus Conventionally Fractionated Chemoradiation for Glioblastoma in the Elderly Population. Am J Clin Oncol 2019; 41:167-172. [PMID: 29369825 DOI: 10.1097/coc.0000000000000417] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE This study evaluated practice patterns, outcomes, and predictors of survival for elderly patients with glioblastoma (GBM) receiving definitive chemoradiotherapy (CRT) with either hypofractionated radiotherapy or conventionally fractionated radiotherapy. MATERIALS AND METHODS The National Cancer Data Base was queried for patients age 65 years and above diagnosed with GBM between 2006 and 2012 that received definitive CRT with either hypofractionated radiotherapy (hCRT) or conventionally fractionated radiotherapy (cCRT). Patient, tumor, and treatment parameters were extracted. Statistics included Kaplan-Meier analysis to evaluate overall survival (OS) as well as Cox proportional hazards modeling to determine variables associated with OS. Propensity score matching was performed in order to assess groups in a balanced manner while reducing indication biases. RESULTS Altogether, 5126 patients met inclusion criteria; 126 (2.5%) underwent hCRT, while 5000 (97.5%) received cCRT. Temporal trends revealed that the use of hCRT is rising, especially in more recent years. Patients undergoing hCRT were older, with worse performance status, treated with biopsy only, and more likely to receive treatment at an academic facility. cCRT was associated with improved median OS (10.7 vs. 6.2 mo, P<0.001). This persisted in both Cox multivariate analysis (hazard ratio, 0.59; 95% confidence interval, 0.49-0.72; P=<0.001) and on propensity-matched analysis (median OS 8.7 vs. 6.2 mo; hazard ratio, 0.69; 95% confidence intervcal, 0.53-0.89; P=0.005). CONCLUSIONS This is the first study to directly evaluate hCRT versus cCRT for patients with GBM. The use of hCRT is rising over time; practice patterns of hCRT administration are evaluated. Delivery of hCRT independently predicted for poorer OS. Prospective data is recommended to validate the findings herein.
Collapse
|
29
|
Zschaeck S, Wust P, Graf R, Misch M, Onken J, Ghadjar P, Badakhshi H, Florange J, Budach V, Kaul D. Locally dose-escalated radiotherapy may improve intracranial local control and overall survival among patients with glioblastoma. Radiat Oncol 2018; 13:251. [PMID: 30567592 PMCID: PMC6299982 DOI: 10.1186/s13014-018-1194-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/27/2018] [Indexed: 05/02/2023] Open
Abstract
Background The dismal overall survival (OS) prognosis of glioblastoma, even after trimodal therapy, can be attributed mainly to the frequent incidence of intracranial relapse (ICR), which tends to present as an in-field recurrence after a radiation dose of 60 Gray (Gy). In this study, molecular marker-based prognostic indices were used to compare the outcomes of radiation with a standard dose versus a moderate dose escalation. Methods This retrospective analysis included 156 patients treated between 2009 and 2016. All patients were medically fit for postoperative chemoradiotherapy. In the dose-escalation cohort a simultaneous integrated boost of up to 66 Gy (66 Gy RT) within small high-risk volumes was applied. All other patients received daily radiation to a total dose of 60 Gy or twice daily to a total dose of 59.2 Gy (60 Gy RT). Results A total of 133 patients received standard 60 Gy RT, while 23 received 66 Gy RT. Patients in the 66 Gy RT group were younger (p < 0.001), whereas concomitant temozolomide use was more frequent in the 60 Gy RT group (p < 0.001). Other intergroup differences in known prognostic factors were not observed. Notably, the median time to ICR was significantly prolonged in the 66 Gy RT arm versus the 60 Gy RT arm (12.2 versus 7.6 months, p = 0.011), and this translated to an improved OS (18.8 versus 15.3 months, p = 0.012). A multivariate analysis revealed a strong association of 66 Gy RT with a prolonged time to ICR (hazard ratio = 0.498, p = 0.01) and OS (hazard ratio = 0.451, p = 0.01). These differences remained significant after implementing molecular marker-based prognostic scores (ICR p = 0.008, OS p = 0.007) and propensity-scored matched pairing (ICR p = 0.099, OS p = 0.023). Conclusion Radiation dose escalation was found to correlate with an improved time to ICR and OS in this cohort of glioblastoma patients. However, further prospective validation of these results is warranted. Electronic supplementary material The online version of this article (10.1186/s13014-018-1194-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Sebastian Zschaeck
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Peter Wust
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Reinhold Graf
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Martin Misch
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Pirus Ghadjar
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Harun Badakhshi
- Department of Radiation Oncology, Ernst von Bergmann Medical Center, Potsdam, Germany
| | - Julian Florange
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Volker Budach
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - David Kaul
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| |
Collapse
|
30
|
Giordano FA, Brehmer S, Mürle B, Welzel G, Sperk E, Keller A, Abo-Madyan Y, Scherzinger E, Clausen S, Schneider F, Herskind C, Glas M, Seiz-Rosenhagen M, Groden C, Hänggi D, Schmiedek P, Emami B, Souhami L, Petrecca K, Wenz F. Intraoperative Radiotherapy in Newly Diagnosed Glioblastoma (INTRAGO): An Open-Label, Dose-Escalation Phase I/II Trial. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy018] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Stefanie Brehmer
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Bettina Mürle
- Department of Neuroradiology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Grit Welzel
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Anke Keller
- Clinical Trials Coordination Center of the Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Yasser Abo-Madyan
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Elisabeth Scherzinger
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Sven Clausen
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Frank Schneider
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Carsten Herskind
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Martin Glas
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Essen, Essen, Germany
| | - Marcel Seiz-Rosenhagen
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Christoph Groden
- Department of Neuroradiology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Peter Schmiedek
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Bahman Emami
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois
| | - Luis Souhami
- Division of Radiation Oncology, McGill University Health Centre, Montreal, Canada
| | - Kevin Petrecca
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, Montreal, Canada
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
31
|
Donato V, Caruso C, Bressi C, Pressello MC, Salvati M, Delitala A, Delfini R. Evaluation of Helical Tomotherapy in the Treatment of High-Grade Gliomas near Critical Structures. TUMORI JOURNAL 2018; 98:636-42. [DOI: 10.1177/030089161209800515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Our purpose was to investigate the role of helical tomotherapy using a simultaneous integrated boost technique for the treatment of high-grade gliomas near intracranial critical structures. Methods and materials Of 27 patients treated with helical tomotherapy, 11 were eligible. Only patients whose tumors were within 0.5 cm of the optic chiasm, the optic nerve or the brainstem were included. The therapeutic approach was a simultaneous integrated boost, prescribing 66 and 60 Gy to the PTV1 and PTV2, respectively, in 30 fractions. All patients received concomitant temozolomide at a dose of 75 mg/m2 daily during radiation therapy. Results Of the 11 patients considered, 3 patients (27%) died after 4 months from the completion of the combined treatment. Three patients (27%) presented local progression, and the median time to disease progression was 6 months (range, 1–12). Five patients (45%), at the time of this evaluation, did not have signs or symptoms of recurrence or progression of the disease. Acute toxicity, evaluated during radiochemotherapy, was minimal, with all patients experiencing RTOG grade 0 and grade 1 toxicity. Conclusions Helical tomotherapy proved to be an effective and safe treatment modality, with an improvement of accuracy in delivery of highdose radiotherapy despite the presence of nearby critical structures.
Collapse
Affiliation(s)
- Vittorio Donato
- Department of Radiation Oncology, S Camillo-Forlanini Hospital, Rome
| | - Cristina Caruso
- Department of Radiation Oncology, S Camillo-Forlanini Hospital, Rome
| | | | | | | | - Alberto Delitala
- Department of Neurosurgery, S Camillo-Forlanini Hospital, Rome, Italy
| | | |
Collapse
|
32
|
Navarria P, Pessina F, Franzese C, Tomatis S, Perrino M, Cozzi L, Simonelli M, Bello L, Clerici E, Riva M, Santoro A, Scorsetti M. Hypofractionated radiation therapy (HFRT) versus conventional fractionated radiation therapy (CRT) for newly diagnosed glioblastoma patients. A propensity score matched analysis. Radiother Oncol 2017; 127:108-113. [PMID: 29291951 DOI: 10.1016/j.radonc.2017.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 11/14/2017] [Accepted: 12/03/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The current treatment for newly diagnosed glioblastoma consists of surgery followed by conventional radiotherapy (CRT) with concomitant and adjuvant chemotherapy. Hypofractionated radiation therapy (HFRT) has been investigated and it resulted feasible and safe. The aim of this study was to evaluate whether HFRT can be comparable to CRT. MATERIALS AND METHODS The analysis included newly diagnosed glioblastoma patients treated with CRT 60 Gy/30 fractions or HFRT 60 Gy/15 fractions. A propensity score matching analysis (PSM) was performed using a logistic regression that considered age, KPS, extent of surgery, MGMT and IDH status. RESULTS A total of 267 patients were included; before PSM 169 were in CRT-group and 98 in HRFT-group. After 1:1 matching, 82 patients resulted in each group. The median OS time was 17.9 months for the CRT-group and 16.7 months for the HFRT-group; the 1, 2, 3-year OS rates were 75.6%, 32.7%, and 15.5% for the CRT-group, and 75.6%, 33.3%, and 18.9% for the HFRT-group (p value = 0.8). No statistically significant differences were recorded between the two radiation therapy treatments performed. CONCLUSIONS A short course of radiation therapy would seem comparable to CRT in terms of outcome and less burdensome for these poor prognosis patients.
Collapse
Affiliation(s)
- Pierina Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy.
| | - Federico Pessina
- Neurosurgical Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Ciro Franzese
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Matteo Perrino
- Hematology and Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Luca Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Matteo Simonelli
- Hematology and Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Lorenzo Bello
- Neurosurgical Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Marco Riva
- Neurosurgical Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Armando Santoro
- Hematology and Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| |
Collapse
|
33
|
Navarria P, Pessina F, Tomatis S, Soffietti R, Grimaldi M, Lopci E, Chiti A, Leonetti A, Casarotti A, Rossi M, Cozzi L, Ascolese AM, Simonelli M, Marcheselli S, Santoro A, Clerici E, Bello L, Scorsetti M. Are three weeks hypofractionated radiation therapy (HFRT) comparable to six weeks for newly diagnosed glioblastoma patients? Results of a phase II study. Oncotarget 2017; 8:67696-67708. [PMID: 28978064 PMCID: PMC5620204 DOI: 10.18632/oncotarget.18809] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 05/14/2017] [Indexed: 11/25/2022] Open
Abstract
Background The current standard of care for newly diagnosed glioblastoma (GBM) is surgical resection, followed by radiation therapy (RT) with concurrent and adjuvant temozolomide chemotherapy (TMZ-CHT). The patients outcome is still poor. In this study we evaluated hypofractionated radiation therapy (HFRT), instead of standard fractionated radiation therapy, with concomitant and adjuvant TMZ chemotherapy, in terms of safety and effectiveness. Methods Patients with newly diagnosed GBM, Karnofsky performance scale (KPS) ≥70, and tumor up to 10 cm underwent maximal feasible surgical resection were treated. HFRT consisted of 60 Gy, in daily fractions of 4 Gy given 5 days per week for 3 weeks. The primary endpoints were overall survival (OS), progression free survival (PFS), and incidence of radiation induced brain toxicity. Secondary endpoint was the evaluation of neurocognitive function. Results A total of 97 patients were included in this phase II study. The median age was 60.5 years (range 23-77 years). Debulking surgery was performed in 83.5% of patients, HFRT was completed in all 97 patients, concurrent and adjuvant TMZ in 93 (95.9%). The median number of TMZ cycles was six (range 1-12 cycles). No severe toxicity occurred and the neuropsychological evaluation remained stable. At a median follow up time of 15.2 months the median OS time, 1,2-year OS rate were 15.9 months (95% CI 14-18), 72.2% (95% CI 62.1-80) and 30.4% (95% CI 20.8-40.6). Age, KPS, MGMT methylation status, and extent of surgical resection were significant factors influencing the outcome. Conclusion HFRT with concomitant and adjuvant TMZ chemotherapy is an effective and safe treatment.
Collapse
Affiliation(s)
- Pierina Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Federico Pessina
- Neurosurgical Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Riccardo Soffietti
- Consultant of Neurosurgical Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Marco Grimaldi
- Neuroradiology Unit, Radiology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Egesta Lopci
- Nuclear Medicine Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Arturo Chiti
- Nuclear Medicine Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Antonella Leonetti
- Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, Milan University, Milan, Italy
| | - Alessandra Casarotti
- Neurosurgical Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Marco Rossi
- Neurosurgical Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Luca Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Anna Maria Ascolese
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Matteo Simonelli
- Hematology and Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Simona Marcheselli
- Department of Neurology, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Armando Santoro
- Hematology and Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Lorenzo Bello
- Neurosurgical Oncology Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| |
Collapse
|
34
|
Choi SH, Kim JW, Chang JS, Cho JH, Kim SH, Chang JH, Suh CO. Impact of Including Peritumoral Edema in Radiotherapy Target Volume on Patterns of Failure in Glioblastoma following Temozolomide-based Chemoradiotherapy. Sci Rep 2017; 7:42148. [PMID: 28176884 PMCID: PMC5296913 DOI: 10.1038/srep42148] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 01/04/2017] [Indexed: 12/25/2022] Open
Abstract
We assessed the impact of including peritumoral edema in radiotherapy volumes on recurrence patterns among glioblastoma multiforme (GBM) patients treated with standard chemoradiotherapy (CRT). We analyzed 167 patients with histologically confirmed GBM who received temozolomide (TMZ)-based CRT between May 2006 and November 2012. The study cohort was divided into edema (+) (n = 130) and edema (−) (n = 37) groups, according to whether the entire peritumoral edema was included. At a median follow-up of 20 months (range, 2–99 months), 118 patients (71%) experienced progression/recurrence (infield: 69%; marginal: 26%; outfield: 16%; CSF seeding: 12%). The median overall survival and progression-free survival were 20 months and 15 months, respectively. The marginal failure rate was significantly greater in the edema (−) group (37% vs. 22%, p = 0.050). Among 33 patients who had a favorable prognosis (total resection and MGMT-methylation), the difference in the marginal failure rates was increased (40% vs. 14%, p = 0.138). Meanwhile, treatment of edema did not significantly increase the incidence of pseudoprogression/radiation necrosis (edema (−) 49% vs. (+) 37%, p = 0.253). Inclusion of peritumoral edema in the radiotherapy volume can reduce marginal failures following TMZ-based CRT without increasing pseudoprogression/radiation necrosis.
Collapse
Affiliation(s)
- Seo Hee Choi
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Ho Cho
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Se Hoon Kim
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
35
|
Niyazi M, Harter PN, Hattingen E, Rottler M, von Baumgarten L, Proescholdt M, Belka C, Lauber K, Mittelbronn M. Bevacizumab and radiotherapy for the treatment of glioblastoma: brothers in arms or unholy alliance? Oncotarget 2016; 7:2313-28. [PMID: 26575171 PMCID: PMC4823037 DOI: 10.18632/oncotarget.6320] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 10/13/2015] [Indexed: 01/05/2023] Open
Abstract
Glioblastoma (GBM) represents the most frequent primary brain tumor in adults and carries a dismal prognosis despite aggressive, multimodal treatment regimens involving maximal resection, radiochemotherapy, and maintenance chemotherapy. Histologically, GBMs are characterized by a high degree of VEGF-mediated vascular proliferation. In consequence, new targeted anti-angiogenic therapies, such as the monoclonal anti-VEGF-A antibody bevacizumab, have proven effective in attenuating tumor (neo)angiogenesis and were shown to possess therapeutic activity in several phase II trials. However, the role of bevacizumab in the context of multimodal therapy approaches appears to be rather complex. This review will give insights into current concepts, limitations, and controversies regarding the molecular mechanisms and the clinical benefits of bevacizumab treatment in combination with radio(chemo)therapy - particularly in face of the results of recent phase III trials, which failed to demonstrate convincing improvements in overall survival (OS).
Collapse
Affiliation(s)
- Maximilian Niyazi
- Department of Radiation Oncology, University of Munich, Germany.,German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Patrick N Harter
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Institute of Neurology (Edinger Institute), Goethe University, Frankfurt, Germany
| | - Elke Hattingen
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Maya Rottler
- Department of Radiation Oncology, University of Munich, Germany.,German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Martin Proescholdt
- Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Claus Belka
- Department of Radiation Oncology, University of Munich, Germany.,German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Kirsten Lauber
- Department of Radiation Oncology, University of Munich, Germany.,German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Michel Mittelbronn
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Institute of Neurology (Edinger Institute), Goethe University, Frankfurt, Germany
| |
Collapse
|
36
|
Ahmed KA, Chinnaiyan P, Fulp WJ, Eschrich S, Torres-Roca JF, Caudell JJ. The radiosensitivity index predicts for overall survival in glioblastoma. Oncotarget 2016; 6:34414-22. [PMID: 26451615 PMCID: PMC4741462 DOI: 10.18632/oncotarget.5437] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 09/21/2015] [Indexed: 12/16/2022] Open
Abstract
We have previously developed a multigene expression model of tumor radiosensitivity (RSI) with clinical validation in multiple cohorts and disease sites. We hypothesized RSI would identify glioblastoma patients who would respond to radiation and predict treatment outcomes. Clinical and array based gene expression (Affymetrix HT Human Genome U133 Array Plate Set) level 2 data was downloaded from the cancer genome atlas (TCGA). A total of 270 patients were identified for the analysis: 214 who underwent radiotherapy and temozolomide and 56 who did not undergo radiotherapy. Median follow-up for the entire cohort was 9.1 months (range: 0.04–92.2 months). Patients who did not receive radiotherapy were more likely to be older (p < 0.001) and of poorer performance status (p < 0.001). On multivariate analysis, RSI is an independent predictor of OS (HR = 1.64, 95% CI 1.08–2.5; p = 0.02). Furthermore, on subset analysis, radiosensitive patients had significantly improved OS in the patients with high MGMT expression (unmethylated MGMT), 1 year OS 84.1% vs. 53.7% (p = 0.005). This observation held on MVA (HR = 1.94, 95% CI 1.19–3.31; p = 0.008), suggesting that RT has a larger therapeutic impact in these patients. In conclusion, RSI predicts for OS in glioblastoma. These data further confirm the value of RSI as a disease-site independent biomarker.
Collapse
Affiliation(s)
- Kamran A Ahmed
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Prakash Chinnaiyan
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48073, USA
| | - William J Fulp
- Department of Biostatistics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Steven Eschrich
- Department of Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Javier F Torres-Roca
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Jimmy J Caudell
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| |
Collapse
|
37
|
Kelley K, Knisely J, Symons M, Ruggieri R. Radioresistance of Brain Tumors. Cancers (Basel) 2016; 8:cancers8040042. [PMID: 27043632 PMCID: PMC4846851 DOI: 10.3390/cancers8040042] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 03/10/2016] [Accepted: 03/24/2016] [Indexed: 12/21/2022] Open
Abstract
Radiation therapy (RT) is frequently used as part of the standard of care treatment of the majority of brain tumors. The efficacy of RT is limited by radioresistance and by normal tissue radiation tolerance. This is highlighted in pediatric brain tumors where the use of radiation is limited by the excessive toxicity to the developing brain. For these reasons, radiosensitization of tumor cells would be beneficial. In this review, we focus on radioresistance mechanisms intrinsic to tumor cells. We also evaluate existing approaches to induce radiosensitization and explore future avenues of investigation.
Collapse
Affiliation(s)
- Kevin Kelley
- Radiation Medicine Department, Hofstra Northwell School of Medicine, Northwell Health, Manhasset, NY 11030, USA.
| | - Jonathan Knisely
- Radiation Medicine Department, Hofstra Northwell School of Medicine, Northwell Health, Manhasset, NY 11030, USA.
| | - Marc Symons
- The Feinstein Institute for Molecular Medicine, Hofstra Northwell School of Medicine, Northwell Health, Manhasset, NY 11030, USA.
| | - Rosamaria Ruggieri
- Radiation Medicine Department, Hofstra Northwell School of Medicine, Northwell Health, Manhasset, NY 11030, USA.
- The Feinstein Institute for Molecular Medicine, Hofstra Northwell School of Medicine, Northwell Health, Manhasset, NY 11030, USA.
| |
Collapse
|
38
|
Jia A, Pannullo SC, Minkowitz S, Taube S, Chang J, Parashar B, Christos P, Wernicke AG. Innovative Hypofractionated Stereotactic Regimen Achieves Excellent Local Control with No Radiation Necrosis: Promising Results in the Management of Patients with Small Recurrent Inoperable GBM. Cureus 2016; 8:e536. [PMID: 27096136 PMCID: PMC4835149 DOI: 10.7759/cureus.536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Management of recurrent glioblastoma multiforme (GBM) remains a challenge. Several institutions reported that a single fraction of ≥ 20 Gy for small tumor burden results in excellent local control; however, this is at the expense of a high incidence of radiation necrosis (RN). Therefore, we developed a hypofractionation pattern of 33 Gy/3 fractions, which is a radiobiological equivalent of 20 Gy, with the aim to lower the incidence of RN. We reviewed records of 21 patients with recurrent GBM treated with hypofractionated stereotactic radiation therapy (HFSRT) to their 22 respective lesions. Sixty Gy fractioned external beam radiotherapy was performed as first-line treatment. Median time from primary irradiation to HFSRT was 9.6 months (range: 3.1 – 68.1 months). In HFSRT, a median dose of 33 Gy in 11 Gy fractions was delivered to the 80% isodose line that encompassed the target volume. The median tumor volume was 1.07 cm3 (range: 0.11 – 16.64 cm3). The median follow-up time after HFSRT was 9.3 months (range: 1.7 – 33.6 months). Twenty-one of 23 lesions treated (91.3%) achieved local control while 2/23 (8.7%) progressed. Median time to progression outside of the treated site was 5.2 months (range: 2.2 – 9.6 months). Progression was treated with salvage chemotherapy. Five of 21 patients (23.8%) were alive at the end of this follow-up; two patients remain disease-free. The remaining 16/21 patients (76.2%) died of disease. Treatment was well tolerated by all patients with no acute CTC/RTOG > Grade 2. There was 0% incidence of RN. A prospective trial will be underway to validate these promising results.
Collapse
Affiliation(s)
- Angela Jia
- Stich Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center
| | - Susan C Pannullo
- Neurological Surgery, NewYork-Presbyterian/Weill Cornell Medical Center
| | | | - Shoshana Taube
- Stich Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center
| | - Jenghwa Chang
- Stich Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center
| | - Bhupesh Parashar
- Stich Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center
| | - Paul Christos
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, NewYork-Presbyterian/Weill Cornell Medical Center
| | | |
Collapse
|
39
|
Park JY, Suh TS, Lee JW, Ahn KJ, Park HJ, Choe BY, Hong S. Dosimetric Effects of Magnetic Resonance Imaging-assisted Radiotherapy Planning: Dose Optimization for Target Volumes at High Risk and Analytic Radiobiological Dose Evaluation. J Korean Med Sci 2015; 30:1522-30. [PMID: 26425053 PMCID: PMC4575945 DOI: 10.3346/jkms.2015.30.10.1522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 07/07/2015] [Indexed: 01/26/2023] Open
Abstract
Based on the assumption that apparent diffusion coefficients (ADCs) define high-risk clinical target volume (aCTVHR) in high-grade glioma in a cellularity-dependent manner, the dosimetric effects of aCTVHR-targeted dose optimization were evaluated in two intensity-modulated radiation therapy (IMRT) plans. Diffusion-weighted magnetic resonance (MR) images and ADC maps were analyzed qualitatively and quantitatively to determine aCTVHR in a high-grade glioma with high cellularity. After confirming tumor malignancy using the average and minimum ADCs and ADC ratios, the aCTVHR with double- or triple-restricted water diffusion was defined on computed tomography images through image registration. Doses to the aCTVHR and CTV defined on T1-weighted MR images were optimized using a simultaneous integrated boost technique. The dosimetric benefits for CTVs and organs at risk (OARs) were compared using dose volume histograms and various biophysical indices in an ADC map-based IMRT (IMRTADC) plan and a conventional IMRT (IMRTconv) plan. The IMRTADC plan improved dose conformity up to 15 times, compared to the IMRTconv plan. It reduced the equivalent uniform doses in the visual system and brain stem by more than 10% and 16%, respectively. The ADC-based target differentiation and dose optimization may facilitate conformal dose distribution to the aCTVHR and OAR sparing in an IMRT plan.
Collapse
Affiliation(s)
- Ji-Yeon Park
- Department of Radiation Oncology, University of Florida, FL, USA
| | - Tae Suk Suh
- Department of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeong-Woo Lee
- Department of Radiation Oncology, Konkuk University Medical Center, Seoul, Korea
| | - Kook-Jin Ahn
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hae-Jin Park
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon, Korea
| | - Bo-Young Choe
- Department of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Semie Hong
- Department of Radiation Oncology, Konkuk University Medical Center, Seoul, Korea
| |
Collapse
|
40
|
Ryzhova MV, Shishkina LV. [Molecular methods in diagnosis of poorly differentiated malignant brain tumors in children]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2015; 79:10-20. [PMID: 26146040 DOI: 10.17116/neiro201579210-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The histological diagnosis of malignant brain tumors in children is a complex process. In some cases, glioblastoma, primitive neuroectodermal tumor of the central nervous system, and atypical teratoid/rhabdoid tumor have a histological type similar to that of small blue round cell malignant tumor. Despite the similar histology, biological properties and approaches to treatment, these neoplasms are completely different and require their own treatment protocols. We retrospectively reviewed the most malignant types of childhood tumors and analyzed our own experience to propose a diagnostic algorithm for intracerebral small blue round cell malignant tumors in children based on the use of immunohistochemistry and fluorescence in situ hybridization.
Collapse
Affiliation(s)
- M V Ryzhova
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | |
Collapse
|
41
|
Standardization and quality assurance of radiation therapy volumes for adults with high-grade gliomas. Semin Radiat Oncol 2015; 24:259-64. [PMID: 25219810 DOI: 10.1016/j.semradonc.2014.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Standard treatment for Glioblastoma Multiforme (GBM) consists of a combination of chemotherapy and radiation therapy followed by adjuvant chemotherapy. While the optimal dose of radiation therapy has been established, significant variability in volume of tissue irradiated exists. In this article we review the current guidelines, patterns of care, patterns of failure, imaging advances and toxicity related to radiation therapy volumes in the treatment of GBM.
Collapse
|
42
|
Mizumoto M, Yamamoto T, Takano S, Ishikawa E, Matsumura A, Ishikawa H, Okumura T, Sakurai H, Miyatake SI, Tsuboi K. Long-term survival after treatment of glioblastoma multiforme with hyperfractionated concomitant boost proton beam therapy. Pract Radiat Oncol 2015; 5:e9-16. [DOI: 10.1016/j.prro.2014.03.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 03/24/2014] [Accepted: 03/25/2014] [Indexed: 01/21/2023]
|
43
|
Giordano FA, Brehmer S, Abo-Madyan Y, Welzel G, Sperk E, Keller A, Schneider F, Clausen S, Herskind C, Schmiedek P, Wenz F. INTRAGO: intraoperative radiotherapy in glioblastoma multiforme—a phase I/II dose escalation study. BMC Cancer 2014; 14:992. [PMID: 25535398 PMCID: PMC4364103 DOI: 10.1186/1471-2407-14-992] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 12/16/2014] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Glioblastoma multiforme (GBM) is the most frequent primary malignant brain tumor in adults. Despite multimodal therapies, almost all GBM recur within a narrow margin around the initial resected lesion. Thus, novel therapeutic intensification strategies must target both, the population of dispersed tumor cells around the cavity and the postoperative microenvironment. Intraoperative radiotherapy (IORT) is a pragmatic and effective approach to sterilize the margins from persistent tumor cells, abrogate post-injury proliferative stimuli and to bridge the therapeutic gap between surgery and radiochemotherapy. Therefore, we have set up INTRAGO, a phase I/II dose-escalation study to evaluate the safety and tolerability of IORT added to standard therapy in newly diagnosed GBM. In contrast to previous approaches, the study involves the application of isotropic low-energy (kV) x-rays delivered by spherical applicators, providing optimal irradiation properties to the resection cavity. METHODS/DESIGN INTRAGO includes patients aged 50 years or older with a Karnofsky performance status of at least 50% and a histologically confirmed (frozen sections) supratentorial GBM. Safety and tolerability (i.e., the maximum tolerated dose, MTD) will be assessed using a classical 3 + 3 dose-escalation design. Dose-limiting toxicities (DLT) are wound healing deficits or infections requiring surgical intervention, IORT-related cerebral bleeding or ischemia, symptomatic brain necrosis requiring surgical intervention and early termination of external beam radiotherapy (before the envisaged dose of 60 Gy) due to radiotoxicity. Secondary end points are progression-free and overall survival. TRIAL REGISTRATION The study is registered with clinicaltrials.gov, number: NCT02104882 (Registration Date: 03/26/2014).
Collapse
Affiliation(s)
- Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Lévy S, Chapet S, Mazeron JJ. [Management of gliomas]. Cancer Radiother 2014; 18:461-7. [PMID: 25201633 DOI: 10.1016/j.canrad.2014.07.147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 07/14/2014] [Indexed: 01/28/2023]
Abstract
Gliomas are the most frequent primary brain tumors. Their care is difficult because of the proximity of organs at risk. The treatment of glioblastoma includes surgery followed by chemoradiation with the protocol of Stupp et al. The addition of bevacizumab allows an increase in progression-free survival by 4 months but it does not improve overall survival. This treatment is reserved for clinical trials. Intensity modulation radiotherapy may be useful to reduce the neurocognitive late effects in different types of gliomas. In elderly patients an accelerated radiotherapy 40 Gy in 15 fractions allows a similar survival to standard radiotherapy. O(6)-methylguanine-DNA methyltransferase (MGMT) status may help to choose between chemotherapy and radiotherapy. There is no standard for the treatment of recurrent gliomas. Re-irradiation in stereotactic conditions allows a median survival of 8 to 12.4 months. Anaplastic gliomas with 1p19q mutation have a greater sensibility to chemotherapy by procarbazine, lomustine and vincristine. Chemoradiotherapy in these patients has become the standard treatment. Many studies are underway testing targeted therapies, their place in the therapeutic management and new radiotherapy techniques.
Collapse
Affiliation(s)
- S Lévy
- Service de radiothérapie oncologique, centre Henry-Kaplan, université François-Rabelais, CHRU de Tours, 2, boulevard Tonnelé, 37000 Tours, France
| | - S Chapet
- Service de radiothérapie oncologique, centre Henry-Kaplan, université François-Rabelais, CHRU de Tours, 2, boulevard Tonnelé, 37000 Tours, France
| | - J-J Mazeron
- Service de radiothérapie oncologique, groupe hospitalier Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75651 Paris cedex, France; Université Paris VI, 75651 Paris cedex, France.
| |
Collapse
|
45
|
|
46
|
Clinical radiobiology of glioblastoma multiforme. Strahlenther Onkol 2014; 190:925-32. [DOI: 10.1007/s00066-014-0638-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 02/05/2014] [Indexed: 12/29/2022]
|
47
|
Iuchi T, Hatano K, Kodama T, Sakaida T, Yokoi S, Kawasaki K, Hasegawa Y, Hara R. Phase 2 trial of hypofractionated high-dose intensity modulated radiation therapy with concurrent and adjuvant temozolomide for newly diagnosed glioblastoma. Int J Radiat Oncol Biol Phys 2014; 88:793-800. [PMID: 24495592 DOI: 10.1016/j.ijrobp.2013.12.011] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Revised: 12/05/2013] [Accepted: 12/10/2013] [Indexed: 01/10/2023]
Abstract
PURPOSE/OBJECTIVES To assess the effect and toxicity of hypofractionated high-dose intensity modulated radiation therapy (IMRT) with concurrent and adjuvant temozolomide (TMZ) in 46 patients with newly diagnosed glioblastoma multiforme (GBM). METHODS AND MATERIALS All patients underwent postsurgical hypofractionated high-dose IMRT. Three layered planning target volumes (PTVs) were contoured. PTV1 was the surgical cavity and residual tumor on T1-weighted magnetic resonance images with 5-mm margins, PTV2 was the area with 15-mm margins surrounding the PTV1, and PTV3 was the high-intensity area on fluid-attenuated inversion recovery images. Irradiation was performed in 8 fractions at total doses of 68, 40, and 32 Gy for PTV1, PTV2, and PTV3, respectively. Concurrent TMZ was given at 75 mg/m(2)/day for 42 consecutive days. Adjuvant TMZ was given at 150 to 200 mg/m(2)/day for 5 days every 28 days. Overall and progression-free survivals were evaluated. RESULTS No acute IMRT-related toxicity was observed. The dominant posttreatment failure pattern was dissemination. During a median follow-up time of 16.3 months (range, 4.3-80.8 months) for all patients and 23.7 months (range, 12.4-80.8 months) for living patients, the median overall survival was 20.0 months after treatment. Radiation necrosis was diagnosed in 20 patients and was observed not only in the high-dose field but also in the subventricular zone (SVZ). Necrosis in the SVZ was significantly correlated with prolonged survival (hazard ratio, 4.08; P=.007) but caused deterioration in the performance status of long-term survivors. CONCLUSIONS Hypofractionated high-dose IMRT with concurrent and adjuvant TMZ altered the dominant failure pattern from localized to disseminated and prolonged the survival of patients with GBM. Necrosis in the SVZ was associated with better patient survival, but the benefit of radiation to this area remains controversial.
Collapse
Affiliation(s)
- Toshihiko Iuchi
- Division of Neurological Surgery, Chiba Cancer Center, Chiba, Japan.
| | - Kazuo Hatano
- Division of Radiation Oncology, Chiba Cancer Center, Chiba, Japan
| | - Takashi Kodama
- Division of Radiation Oncology, Chiba Cancer Center, Chiba, Japan
| | - Tsukasa Sakaida
- Division of Neurological Surgery, Chiba Cancer Center, Chiba, Japan
| | - Sana Yokoi
- Division of Gene Diagnosis, Chiba Cancer Center, Chiba, Japan
| | | | - Yuzo Hasegawa
- Division of Neurological Surgery, Chiba Cancer Center, Chiba, Japan
| | - Ryusuke Hara
- Division of Radiation Oncology, Chiba Cancer Center, Chiba, Japan
| |
Collapse
|
48
|
Improved outcomes with intensity modulated radiation therapy combined with temozolomide for newly diagnosed glioblastoma multiforme. Neurol Res Int 2014; 2014:945620. [PMID: 24563782 PMCID: PMC3915916 DOI: 10.1155/2014/945620] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 10/14/2013] [Accepted: 10/16/2013] [Indexed: 11/22/2022] Open
Abstract
Purpose. Glioblastoma multiforme (GBM) is optimally treated by maximal debulking followed by combined chemoradiation. Intensity modulated radiation therapy (IMRT) is gaining widespread acceptance in other tumour sites, although evidence to support its use over three-dimensional conformal radiation therapy (3DCRT) in the treatment of gliomas is currently lacking. We examined the survival outcomes for patients with GBM treated with IMRT and Temozolomide. Methods and Materials. In all, 31 patients with GBM were treated with IMRT and 23 of these received chemoradiation with Temozolomide. We correlated survival outcomes with patient functional status, extent of surgery, radiation dose, and use of chemotherapy. Results. Median survival for all patients was 11.3 months, with a median survival of 7.2 months for patients receiving 40.05 Gray (Gy) and a median survival of 17.4 months for patients receiving 60 Gy. Conclusions. We report one of the few series of IMRT in patients with GBM. In our group, median survival for those receiving 60 Gy with Temozolomide compared favourably to the combined therapy arm of the largest randomised trial of chemoradiation versus radiation to date (17.4 months versus 14.6 months). We propose that IMRT should be considered as an alternative to 3DCRT for patients with GBM.
Collapse
|
49
|
Waters JD, Rose B, Gonda DD, Scanderbeg DJ, Russell M, Alksne JF, Murphy K, Carter BS, Lawson J, Chen CC. Immediate post-operative brachytherapy prior to irradiation and temozolomide for newly diagnosed glioblastoma. J Neurooncol 2013; 113:467-77. [PMID: 23673513 DOI: 10.1007/s11060-013-1139-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Accepted: 04/27/2013] [Indexed: 10/26/2022]
Abstract
To determine whether immediate post-operative brachytherapy can be safely applied to newly diagnosed glioblastomas to retard tumor progression prior to initiation of external beam radiation therapy (EBRT) and temozolomide. Between 1996 and 2011, eleven patients underwent implantation of GliaSite (n = 9) or MammoSite (n = 2) at the time of surgical resection. Brachytherapy was carried out on post-operative day 2-3, with 45-60 Gy delivered to a 1 cm margin. All patients underwent subsequent standard radiation/temozolomide treatment 4-5 weeks post-irradiation. There were no wound related complications. Toxicity was observed in two patients (2/11 or 18 %), including one post-operative seizure and one case of cerebral edema that resolved after a course of steroid treatment. Immediate post-operative and pre-irradiation/temozolomide magnetic resonance imaging assessment was available for 9 of the 11 patients. Two of these nine patients (22 %) developed new regions of contrast enhancement prior to irradiation/temozolomide. This compares favorably to historical data where 53 % of patient suffer such tumor progression. While there was a trend toward improved 6 month progression free survival in the brachytherapy/temozolomide/radiation treated patients, the overall survival of these patients were comparable to historical controls. This case series demonstrates the safety of immediate post-operative brachytherapy when applied prior to EBRT and temozolomide in the treatment of newly diagnosed glioblastomas.
Collapse
Affiliation(s)
- J Dawn Waters
- Division of Neurosurgery, Center for Theoretic and Applied Neuro-Oncology, University of California, San Diego, 3855 Health Science Drive #0987, La Jolla, CA 92093-0987, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Choi Y, Song YJ, Lee HS, Hur WJ, Sung KH, Kim KU, Choi SS, Kim SJ, Kim DC. Epidermal growth factor receptor is related to poor survival in glioblastomas: single-institution experience. Yonsei Med J 2013; 54:101-7. [PMID: 23225805 PMCID: PMC3521249 DOI: 10.3349/ymj.2013.54.1.101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PURPOSE There are conflicting results surrounding the prognostic significance of epidermal growth factor receptor (EGFR) status in glioblastoma (GBM) patients. Accordingly, we attempted to assess the influence of EGFR expression on the survival of GBM patients receiving postoperative radiotherapy. MATERIALS AND METHODS Thirty three GBM patients who had received surgery and postoperative radiotherapy at our institute, between March 1997 and February 2006, were included. The evaluation of EGFR expression with immunohistochemistry was available for 30 patients. Kaplan-Meier survival analysis and Cox regression were used for statistical analysis. RESULTS EGFR was expressed in 23 patients (76.7%), and not expressed in seven (23.3%). Survival in EGFR expressing GBM patients was significantly less than that in non-expressing patients (median survival: 12.5 versus 17.5 months, p=0.013). Patients who received more than 60 Gy showed improved survival over those who received up to 60 Gy (median survival: 17.0 versus 9.0 months, p=0.000). Negative EGFR expression and a higher radiation dose were significantly correlated with improved survival on multivariate analysis. Survival rates showed no differences according to age, sex, and surgical extent. CONCLUSION The expression of EGFR demonstrated a significantly deleterious effect on the survival of GBM patients. Therefore, approaches targeting EGFR should be considered in potential treatment methods for GBM patients, in addition to current management strategies.
Collapse
Affiliation(s)
- Youngmin Choi
- Department of Radiation Oncology, Dong-A University School of Medicine, Busan, Korea
| | - Young-Jin Song
- Department of Neurosurgery, Dong-A University School of Medicine, Busan, Korea
| | - Hyung-Sik Lee
- Department of Radiation Oncology, Dong-A University School of Medicine, Busan, Korea
| | - Won-Joo Hur
- Department of Radiation Oncology, Dong-A University School of Medicine, Busan, Korea
| | - Ki-Han Sung
- Department of Radiation Oncology, Dong-A University School of Medicine, Busan, Korea
| | - Ki-Uk Kim
- Department of Neurosurgery, Dong-A University School of Medicine, Busan, Korea
| | - Sun-Seob Choi
- Department of Radiology, Dong-A University School of Medicine, Busan, Korea
| | - Su-Jin Kim
- Department of Pathology, Dong-A University School of Medicine, Busan, Korea
| | - Dae-Cheol Kim
- Department of Pathology, Dong-A University School of Medicine, Busan, Korea
| |
Collapse
|