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Winograd E, Germano I, Wen P, Olson JJ, Ormond DR. Congress of Neurological Surgeons systematic review and evidence-based guidelines update on the role of targeted therapies and immunotherapies in the management of progressive glioblastoma. J Neurooncol 2022; 158:265-321. [PMID: 34694567 PMCID: PMC8543777 DOI: 10.1007/s11060-021-03876-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/11/2021] [Indexed: 11/20/2022]
Abstract
The following questions and recommendations are pertinent to the following: TARGET POPULATION: These recommendations apply to adults with progressive GBM who have undergone standard primary treatment with surgery and/or chemoradiation. QUESTION 1: In adults with progressive glioblastoma is the use of bevacizumab as monotherapy superior to standard salvage cytotoxic chemotherapy as measured by progression free survival and overall survival? RECOMMENDATION Level III: Treatment with bevacizumab is suggested in the treatment of progressive GBM, as it provides improved disease control compared to historical controls as measured by best imaging response and progression free survival at 6 months, while not providing evidence for improvement in overall survival. QUESTION 2: In adults with progressive glioblastoma is the use of bevacizumab as combination therapy with cytotoxic agents superior to standard salvage cytotoxic chemotherapy as measured by progression free survival and overall survival? RECOMMENDATION Level III: There is insufficient evidence to show benefit or harm of bevacizumab in combination with cytotoxic therapies in progressive glioblastoma due to a lack of evidence supporting a clearly defined benefit without significant toxicity. QUESTION 3: In adults with progressive glioblastoma is the use of bevacizumab as a combination therapy with targeted agents superior to standard salvage cytotoxic chemotherapy as measured by progression free survival and overall survival? RECOMMENDATION There is insufficient evidence to support a recommendation regarding this question. QUESTION 4: In adults with progressive glioblastoma is the use of targeted agents as monotherapy superior to standard salvage cytotoxic chemotherapy as measured by progression free survival and overall survival? RECOMMENDATION There is insufficient evidence to support a recommendation regarding this question. QUESTION 5: In adults with progressive glioblastoma is the use of targeted agents in combination with cytotoxic therapies superior to standard salvage cytotoxic chemotherapy as measured by progression free survival and overall survival? RECOMMENDATION There is insufficient evidence to support a recommendation regarding this question. QUESTION 6: In adults with progressive glioblastoma is the use of immunotherapy monotherapy superior to standard salvage cytotoxic chemotherapy as measured by progression free survival and overall survival? RECOMMENDATION There is insufficient evidence to support a recommendation regarding this question. QUESTION 7: In adults with progressive glioblastoma is the use of immunotherapy in combination with targeted agents superior to standard salvage cytotoxic chemotherapy as measured by progression free survival and overall survival? RECOMMENDATION There is insufficient evidence to support a recommendation regarding this question. QUESTION 8: In adults with progressive glioblastoma is the use of immunotherapy in combination with bevacizumab superior to standard salvage cytotoxic chemotherapy as measured by progression free survival and overall survival? RECOMMENDATION There is insufficient evidence to support a recommendation regarding this question.
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Affiliation(s)
- Evan Winograd
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Isabelle Germano
- Department of Neurosurgery, The Mount Sinai Hospital, New York, NY, USA
| | - Patrick Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - D Ryan Ormond
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA.
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, 12631 E. 17th Ave., Mail Stop C307, Aurora, CO, 80045, USA.
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2
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Guan Y, Xiong J, Pan M, Shi W, Li J, Zhu H, Gong X, Li C, Mei G, Liu X, Pan L, Dai J, Wang Y, Wang E, Wang X. Safety and efficacy of Hypofractionated stereotactic radiosurgery for high-grade Gliomas at first recurrence: a single-center experience. BMC Cancer 2021; 21:123. [PMID: 33546642 PMCID: PMC7863415 DOI: 10.1186/s12885-021-07856-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 01/11/2021] [Indexed: 12/20/2022] Open
Abstract
Background The optimal treatment for recurrent high-grade gliomas (rHGGs) remains uncertain. This study aimed to investigate the efficacy and safety of hypofractionated stereotactic radiosurgery (HSRS) as a first-line salvage treatment for in-field recurrence of high-grade gliomas. Methods Between January 2016 and October 2019, 70 patients with rHGG who underwent HSRS were retrospectively analysed. The primary endpoint was overall survival (OS), and secondary endpoints included both progression-free survival (PFS) and adverse events, which were assessed according to Common Toxicity Criteria Adverse Events (CTCAE) version 5. The prognostic value of key clinical features (age, performance status, planning target volume, dose, use of bevacizumab) was evaluated. Results A total of 70 patients were included in the study. Forty patients were male and 30 were female. Forty-nine had an initial diagnosis of glioblastoma (GBM), and the rest (21) were confirmed to be WHO grade 3 gliomas. The median planning target volume (PTV) was 16.68 cm3 (0.81–121.96 cm3). The median prescribed dose was 24 Gy (12–30 Gy) in 4 fractions (2–6 fractions). The median baseline of Karnofsky Performance Status (KPS) was 70 (40–90). With a median follow-up of 12.1 months, the median overall survival after salvage treatment was 17.6 months (19.5 and 14.6 months for grade 3 and 4 gliomas, respectively; p = .039). No grade 3 or higher toxicities was recorded. Multivariate analysis showed that concurrent bevacizumab with radiosurgery and KPS > 70 were favourable prognostic factors for grade 4 patients with HGG. Conclusions Salvage HSRS showed a favourable outcome and acceptable toxicity for rHGG. A prospective phase II study (NCT04197492) is ongoing to further investigate the value of hypofractionated stereotactic radiosurgery (HSRS) in rHGG. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-07856-y.
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Affiliation(s)
- Yun Guan
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Ji Xiong
- Department of pathology, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Mingyuan Pan
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jing Li
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Huaguang Zhu
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Xiu Gong
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Chao Li
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Guanghai Mei
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Xiaoxia Liu
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Li Pan
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Jiazhong Dai
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Yang Wang
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China
| | - Enmin Wang
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China. .,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China. .,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China. .,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China.
| | - Xin Wang
- CyberKnife Center, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China. .,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, China. .,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, China. .,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, China.
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3
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Dobi Á, Darázs B, Fodor E, Cserháti A, Együd Z, Maráz A, László S, Dodd L, Reisz Z, Barzó P, Oláh J, Hideghéty K. Low Fraction Size Re-irradiation for Large Volume Recurrence of Glial Tumours. Pathol Oncol Res 2020; 26:2651-2658. [PMID: 32648211 PMCID: PMC7471107 DOI: 10.1007/s12253-020-00868-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/30/2020] [Indexed: 11/26/2022]
Abstract
The aim of the present study was to evaluate the efficacy of re-irradiation (re-RT) in patients with advanced local relapses of glial tumours and to define the factors influencing the result of the hyper-fractionated external beam therapy on progression after primary management. We have analysed the data of 55 patients with brain tumours (GBM: 28) on progression, who were re-irradiated between January 2007 and December 2018. The mean volume of the recurrent tumour was 118 cm3, and the mean planning target volume (PTV) was 316 cm3, to which 32 Gy was delivered in 20 fractions at least 7.7 months after the first radiotherapy, using 3D conformal radiotherapy (CRT) or intensity modulated radiotherapy (IMRT). The median overall survival (mOS) from the re-RT was 8.4 months, and the 6-month and the 12-month OS rate was 64% and 31%, respectively. The most important factors by univariate analysis, which significantly improved the outcome of re-RT were the longer time interval between the diagnosis and second radiotherapy (p = 0.029), the lower histology grade (p = 0.034), volume of the recurrent tumour (p = 0.006) and Karnofsky performance status (KPS) (p = 0.009) at the re-irradiation. Our low fraction size re-irradiation ≥ 8 months after the first radiotherapy proved to be safe and beneficial for patients with large volume recurrent glial tumours.
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Affiliation(s)
- Ágnes Dobi
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary.
| | - Barbara Darázs
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Emese Fodor
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Adrienne Cserháti
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Zsófia Együd
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Anikó Maráz
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Szilvia László
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Leopold Dodd
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Zita Reisz
- Department of Pathology, University of Szeged, Állomás utca 1, Szeged, H-6725, Hungary
| | - Pál Barzó
- Department of Neurosurgery, University of Szeged, Semmelweis utca 6, Szeged, H-6725, Hungary
| | - Judit Oláh
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Katalin Hideghéty
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
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4
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Targets for improving tumor response to radiotherapy. Int Immunopharmacol 2019; 76:105847. [DOI: 10.1016/j.intimp.2019.105847] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/18/2019] [Accepted: 08/20/2019] [Indexed: 02/06/2023]
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5
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The Brain Penetrating and Dual TORC1/TORC2 Inhibitor, RES529, Elicits Anti-Glioma Activity and Enhances the Therapeutic Effects of Anti-Angiogenetic Compounds in Preclinical Murine Models. Cancers (Basel) 2019; 11:cancers11101604. [PMID: 31640252 PMCID: PMC6826425 DOI: 10.3390/cancers11101604] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 10/07/2019] [Accepted: 10/17/2019] [Indexed: 12/13/2022] Open
Abstract
Background. Glioblastoma multiforme (GBM) is a devastating disease showing a very poor prognosis. New therapeutic approaches are needed to improve survival and quality of life. GBM is a highly vascularized tumor and as such, chemotherapy and anti-angiogenic drugs have been combined for treatment. However, as treatment-induced resistance often develops, our goal was to identify and treat pathways involved in resistance to treatment to optimize the treatment strategies. Anti-angiogenetic compounds tested in preclinical and clinical settings demonstrated recurrence associated to secondary activation of the phosphatidylinositol 3-kinase (PI3K)/AKT/mTOR pathway. Aims. Here, we determined the sensitizing effects of the small molecule and oral available dual TORC1/TORC2 dissociative inhibitor, RES529, alone or in combination with the anti-VEGF blocking antibody, bevacizumab, or the tyrosine kinase inhibitor, sunitinib, in human GBM models. Results. We observed that RES529 effectively inhibited dose-dependently the growth of GBM cells in vitro counteracting the insurgence of recurrence after bevacizumab or sunitinib administration in vivo. Combination strategies were associated with reduced tumor progression as indicated by the analysis of Time to Tumor Progression (TTP) and disease-free survival (DSF) as well as increased overall survival (OS) of tumor bearing mice. RES529 was able to reduce the in vitro migration of tumor cells and tubule formation from both brain-derived endothelial cells (angiogenesis) and tumor cells (vasculogenic mimicry). Conclusions. In summary, RES529, the first dual TORC1/TORC2 dissociative inhibitor, lacking affinity for ABCB1/ABCG2 and having good brain penetration, was active in GBM preclinical/murine models giving credence to its use in clinical trial for patients with GBM treated in association with anti-angiogenetic compounds.
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6
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Efficacy and Safety of Hypofractionated Stereotactic Radiotherapy for Recurrent Malignant Gliomas: A Systematic Review and Meta-analysis. World Neurosurg 2019; 127:176-185. [DOI: 10.1016/j.wneu.2019.03.297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/29/2019] [Accepted: 03/30/2019] [Indexed: 02/07/2023]
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7
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Reynaud T, Bertaut A, Farah W, Thibouw D, Crehange G, Truc G, Vulquin N. Hypofractionated Stereotactic Radiotherapy as a Salvage Therapy for Recurrent High-Grade Gliomas: Single-Center Experience. Technol Cancer Res Treat 2019; 17:1533033818806498. [PMID: 30343637 PMCID: PMC6198395 DOI: 10.1177/1533033818806498] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and Purpose: The aim of this study was to investigate the survival outcomes and safety of hypofractioned stereotactic radiotherapy as a salvage treatment for recurrent high-grade glioma. Patients and Methods: Between March 2012 and March 2017, 32 consecutive patients (12 women, 20 men) treated in a single center were retrospectively included in this study. Grade III gliomas were diagnosed in 14 patients and grade IV in 18 patients. Thirty-four lesions were treated with hypofractionated stereotactic radiotherapy on a linear accelerator. Hypofractionated stereotactic radiotherapy delivered a median dose of 30 Gy (27-30) in 6 fractions (3-6) of 5 Gy (5-9). The treatment plans were normalized to 100% at the isocenter and prescribed to the 80% isodose line. Clinical outcomes and prognostic factors were analyzed. Results: Median follow-up was 20.9 months. Median overall survival following hypofractionated stereotactic radiotherapy was 15.6 months (median overall survival for patients with glioblastoma and grade III glioma was 8.2 and 19.5 months, respectively; P = .0496) and progression-free survival was 3.7 months (median progression-free survival for patients with glioblastoma and grade III glioma was 3.6 and 4.5 months, respectively; P = .2424). In multivariate analysis, tumor grade III (P = .0027), an Eastern Cooperative Oncology Group status <2 at the time of reirradiation (P = .0023), and a mean dose >35 Gy (P = .0055) significantly improved overall survival. A maximum reirradiation dose above 38 Gy (P = .0179) was significantly associated with longer progression-free survival. Conclusion: Hypofractionated stereotactic radiotherapy is well tolerated and offers an effective salvage option for the treatment of recurrent high-grade gliomas with encouraging overall survival. Our results suggest that the dose distribution had an impact on survival.
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Affiliation(s)
- Thomas Reynaud
- 1 Department of Radiotherapy, Georges François Leclerc Center, Dijon, France
| | - Aurélie Bertaut
- 2 Department of Epidemiology and Biostatistics, Georges François Leclerc Center, Dijon, France
| | - Walid Farah
- 3 Department of Neurosurgery, CHU, Dijon, France
| | - David Thibouw
- 1 Department of Radiotherapy, Georges François Leclerc Center, Dijon, France
| | - Gilles Crehange
- 1 Department of Radiotherapy, Georges François Leclerc Center, Dijon, France
| | - Gilles Truc
- 1 Department of Radiotherapy, Georges François Leclerc Center, Dijon, France
| | - Noémie Vulquin
- 1 Department of Radiotherapy, Georges François Leclerc Center, Dijon, France
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8
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Combs SE, Niyazi M, Adeberg S, Bougatf N, Kaul D, Fleischmann DF, Gruen A, Fokas E, Rödel CM, Eckert F, Paulsen F, Oehlke O, Grosu AL, Seidlitz A, Lattermann A, Krause M, Baumann M, Guberina M, Stuschke M, Budach V, Belka C, Debus J, Kessel KA. Re-irradiation of recurrent gliomas: pooled analysis and validation of an established prognostic score-report of the Radiation Oncology Group (ROG) of the German Cancer Consortium (DKTK). Cancer Med 2018; 7:1742-1749. [PMID: 29573214 PMCID: PMC5943421 DOI: 10.1002/cam4.1425] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 02/08/2018] [Accepted: 02/09/2018] [Indexed: 12/28/2022] Open
Abstract
The heterogeneity of high‐grade glioma recurrences remains an ongoing challenge for the interdisciplinary neurooncology team. Response to re‐irradiation (re‐RT) is heterogeneous, and survival data depend on prognostic factors such as tumor volume, primary histology, age, the possibility of reresection, or time between primary diagnosis and initial RT and re‐RT. In the present pooled analysis, we gathered data from radiooncology centers of the DKTK Consortium and used it to validate the established prognostic score by Combs et al. and its modification by Kessel et al. Data consisted of a large independent, multicenter cohort of 565 high‐grade glioma patients treated with re‐RT from 1997 to 2016 and a median dose of 36 Gy. Primary RT was between 1986 and 2015 with a median dose of 60 Gy. Median age was 54 years; median follow‐up was 7.1 months. Median OS after re‐RT was 7.5, 9.5, and 13.8 months for WHO IV, III, and I/II gliomas, respectively. All six prognostic factors were tested for their significance on OS. Aside from the time from primary RT to re‐RT (P = 0.074) and the reresection status (P = 0.101), all factors (primary histology, age, KPS, and tumor volume) were significant. Both the original and new score showed a highly significant influence on survival with P < 0.001. Both prognostic scores successfully predict survival after re‐RT and can easily be applied in the routine clinical workflow. Now, further prognostic features need to be found to even improve treatment decisions regarding neurooncological interventions for recurrent glioma patients.
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Affiliation(s)
- Stephanie E Combs
- Department of Radiation Oncology, Technical University Munich (TUM), Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Neuherberg, Germany.,Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany
| | - Maximilian Niyazi
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Adeberg
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology, Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg University, Heidelberg, Germany
| | - Nina Bougatf
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology, Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg University, Heidelberg, Germany
| | - David Kaul
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology, Charité-University Hospital Berlin, Berlin, Germany
| | - Daniel F Fleischmann
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Arne Gruen
- Department of Radiation Oncology, Charité-University Hospital Berlin, Berlin, Germany
| | - Emmanouil Fokas
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Claus M Rödel
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Franziska Eckert
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology, Faculty of Medicine, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Frank Paulsen
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany
| | - Oliver Oehlke
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology, University Medical Center Freiburg, Freiburg, Germany
| | - Anca-Ligia Grosu
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology, University Medical Center Freiburg, Freiburg, Germany
| | - Annekatrin Seidlitz
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology and OncoRay, National Center for Radiation Research in Oncology (NCRO), Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Annika Lattermann
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology and OncoRay, National Center for Radiation Research in Oncology (NCRO), Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Institute of Radiooncology, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Mechthild Krause
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology and OncoRay, National Center for Radiation Research in Oncology (NCRO), Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Institute of Radiooncology, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Michael Baumann
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology and OncoRay, National Center for Radiation Research in Oncology (NCRO), Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Institute of Radiooncology, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Partner site Dresden, National Center for Tumor Diseases (NCT), Dresden, Germany.,Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Maja Guberina
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Martin Stuschke
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Volker Budach
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology, Charité-University Hospital Berlin, Berlin, Germany
| | - Claus Belka
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Jürgen Debus
- Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany.,Department of Radiation Oncology, Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg University, Heidelberg, Germany
| | - Kerstin A Kessel
- Department of Radiation Oncology, Technical University Munich (TUM), Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Neuherberg, Germany.,Partner sites Munich, Heidelberg, Berlin, Frankfurt, Tübingen, Freiburg, Dresden, Essen, German Cancer Consortium (DKTK), Berlin, Germany
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9
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Lee J, Ahn SS, Chang JH, Suh CO. Hypofractionated Re-irradiation after Maximal Surgical Resection for Recurrent Glioblastoma: Therapeutic Adequacy and Its Prognosticators of Survival. Yonsei Med J 2018; 59:194-201. [PMID: 29436186 PMCID: PMC5823820 DOI: 10.3349/ymj.2018.59.2.194] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 11/20/2017] [Accepted: 12/15/2017] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To evaluate the adequacy of retreatment, including hypofractionated re-irradiation (HFReRT), after surgery for recurrent glioblastoma (GBM) and related prognosticators of outcomes. MATERIALS AND METHODS From 2011 to 2014, 25 consecutive patients with recurrent (n=17) or secondary (n=7) disease underwent maximal surgery and subsequent HFReRT after meeting the following conditions: 1) confirmation of recurrent or secondary GBM after salvage surgery; 2) Karnofsky performance score (KPS) ≥60; and 3) interval of ≥12 months between initial radiotherapy and HFReRT. HFReRT was delivered using a simultaneous integrated boost technique, with total dose of 45 Gy in 15 fractions to the gross tumor volume (GTV) and 37.5 Gy in 15 fractions to the clinical target volume. RESULTS During a median follow-up of 13 months, the median progression-free and overall survival (OS) were 13 and 16 months, respectively. A better KPS (p=0.026), no involvement of the eloquent area at recurrence (p=0.030), and a smaller GTV (p=0.005) were associated with better OS. Additionally, OS differed significantly between risk groups stratified by the National Institutes of Health Recurrent GBM Scale (low-risk vs. high-risk, p=0.025). Radiologically suspected radiation necrosis (RN) was observed in 16 patients (64%) at a median of 9 months after HFReRT, and 8 patients developed grade 3 RN requiring hospitalization. CONCLUSION HFReRT after maximal surgery prolonged survival in selected patients with recurrent GBM, especially those with small-sized recurrences in non-eloquent areas and good performance.
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Affiliation(s)
- Jeongshim Lee
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
- Department of Radiation Oncology, Inha University Hospital, Incheon, Korea
| | - Sung Soo Ahn
- Department of Radiology, 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.
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10
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Ho A, Jena R. Re-irradiation in the Brain: Primary Gliomas. Clin Oncol (R Coll Radiol) 2018; 30:124-136. [DOI: 10.1016/j.clon.2017.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/02/2017] [Accepted: 11/06/2017] [Indexed: 02/07/2023]
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11
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Lévy S, Chapet S, Scher N, Debbi K, Ruffier A, Bernadou G, Pointreau Y, Calais G. Reirradiation of gliomas under stereotactic conditions: Prognostic factors for survival without relapse or side effects, a retrospective study at Tours regional university hospital (France). Cancer Radiother 2017; 21:759-765. [PMID: 29128197 DOI: 10.1016/j.canrad.2017.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 05/06/2017] [Accepted: 05/16/2017] [Indexed: 01/18/2023]
Abstract
PURPOSE To search for factors correlated with relapse-free survival following stereotactic reirradiation in patients with recurrent glioma following radiochemotherapy and evaluate tolerance to this treatment. PATIENTS AND METHODS Initial radiotherapy was given according to the protocol of Stupp and al. Reirradiation was performed using the CyberKnife® system. Patients could have had surgical resection initially and at the time of recurrence. We analysed 13 patients treated between July 2010 and September 2014. The median age was 55 years. The doses delivered ranged from 20 to 36Gy, in one to ten fractions. RESULTS Median survival after stereotactic radiotherapy was 14 months. Survival without relapse was 3.7 months. Factors significantly influencing duration of relapse-free survival were: age (P=0.04), total dose (P=0.02), dose per fraction (P=0.04) and number of fractions (P=0.01). We found no correlation between gross tumour volume, clinical target volume, grade of tumour or prescription isodose and relapse-free survival following radiochemotherapy. Three patients developed radionecrosis. CONCLUSION Reirradiation under stereotactic conditions is well tolerated. A dose of more than 30Gy delivered in 5 or more fractions seems to prolong relapse-free survival.
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Affiliation(s)
- S Lévy
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France.
| | - S Chapet
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France
| | - N Scher
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France
| | - K Debbi
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France
| | - A Ruffier
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France
| | - G Bernadou
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France
| | - Y Pointreau
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France; Institut interrégional de cancérologie centre Jean-Bernard, clinique Victor-Hugo, 9, rue Beauverger, 72000 Le Mans, France
| | - G Calais
- Radiotherapy Department, CHRU de Tours, Corad, 2, boulevard Tonnelé, 37000 Tours, France
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12
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Clarke J, Neil E, Terziev R, Gutin P, Barani I, Kaley T, Lassman AB, Chan TA, Yamada J, DeAngelis L, Ballangrud A, Young R, Panageas KS, Beal K, Omuro A. Multicenter, Phase 1, Dose Escalation Study of Hypofractionated Stereotactic Radiation Therapy With Bevacizumab for Recurrent Glioblastoma and Anaplastic Astrocytoma. Int J Radiat Oncol Biol Phys 2017; 99:797-804. [PMID: 28870792 DOI: 10.1016/j.ijrobp.2017.06.2466] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/20/2017] [Accepted: 06/27/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE To establish the maximum tolerated dose of a 3-fraction hypofractionated stereotactic reirradiation schedule when delivered with concomitant bevacizumab to treat recurrent high-grade gliomas. METHODS AND MATERIALS Patients with recurrent high-grade glioma with Karnofsky performance status ≥60, history of standard fractionated initial radiation, tumor volume at recurrence ≤40 cm3, and absence of brainstem or corpus callosum involvement were eligible. A standard 3+3 phase 1 dose escalation trial design was utilized, with dose-limiting toxicities defined as any grade 3 to 5 toxicities possibly, probably, or definitely related to radiation. Bevacizumab was given at a dose of 10 mg/kg every 2 weeks. Hypofractionated stereotactic reirradiation was initiated after 2 bevacizumab doses, delivered in 3 fractions every other day, starting at 9 Gy per fraction. RESULTS A total of 3 patients were enrolled at the 9 Gy × 3 dose level cohort, 5 in the 10 Gy × 3 cohort, and 7 in the 11 Gy × 3 cohort. One dose-limiting toxicity of grade 3 fatigue and cognitive deterioration possibly related to hypofractionated stereotactic reirradiation was observed in the 11 Gy × 3 cohort, and this dose was declared the maximum tolerated dose in combination with bevacizumab. Although no symptomatic radionecrosis was observed, substantial treatment-related effects and necrosis were observed in resected specimens. The intent-to-treat median overall survival was 13 months. CONCLUSIONS Reirradiation using a 3-fraction schedule with bevacizumab support is feasible and reasonably well tolerated. Dose-escalation was possible up to 11 Gy × 3, which achieves a near doubling in the delivered biological equivalent dose to normal brain, in comparison with our previous 6 Gy × 5 schedule. Promising overall survival warrants further investigation.
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Affiliation(s)
- Jennifer Clarke
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Elizabeth Neil
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Robert Terziev
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Philip Gutin
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Igor Barani
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Thomas Kaley
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Andrew B Lassman
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York; Department of Neurology & Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York
| | - Timothy A Chan
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Josh Yamada
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Lisa DeAngelis
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ase Ballangrud
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Robert Young
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Katherine S Panageas
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Antonio Omuro
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York.
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13
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Miller JA, Balagamwala EH, Angelov L, Suh JH, Rini B, Garcia JA, Ahluwalia M, Chao ST. Spine stereotactic radiosurgery with concurrent tyrosine kinase inhibitors for metastatic renal cell carcinoma. J Neurosurg Spine 2016; 25:766-774. [DOI: 10.3171/2016.4.spine16229] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECT
Systemic control of metastatic renal cell carcinoma (mRCC) has substantially improved with the development of VEGF, mTOR, and checkpoint inhibitors. The current first-line standard of care is a VEGF tyrosine kinase inhibitor (TKI). In preclinical models, TKIs potentiate the response to radiotherapy. Such improved efficacy may prolong the time to salvage therapies, including whole-brain radiotherapy or second-line systemic therapy.
As the prevalence of mRCC has increased, the utilization of spine stereotactic radiosurgery (SRS) has also increased. However, clinical outcomes following concurrent treatment with SRS and TKIs remain largely undefined. The purpose of this investigation was to determine the safety and efficacy of TKIs when delivered concurrently with SRS. The authors hypothesized that first-line TKIs delivered concurrently with SRS significantly increase local control compared with SRS alone or TKIs alone, without increased toxicity.
METHODS
A retrospective cohort study of patients undergoing spine SRS for mRCC was conducted. Patients undergoing SRS were divided into 4 cohorts: those receiving concurrent first-line TKI therapy (A), systemic therapy–naïve patients (B), and patients who were undergoing SRS with (C) or without (D) concurrent TKI treatment after failure of first-line therapy. A negative control cohort (E) was also included, consisting of patients with spinal metastases managed with TKIs alone. The primary outcome was 12-month local failure, defined as any in-field radiographic progression. Multivariate competing risks regression was used to determine the independent effect of concurrent first-line TKI therapy upon local failure.
RESULTS
One hundred patients who underwent 151 spine SRS treatments (232 vertebral levels) were included. At the time of SRS, 46% were receiving concurrent TKI therapy. In each SRS cohort, the median prescription dose was 16 Gy in 1 fraction. Patients in Cohort A had the highest burden of epidural disease (96%, p < 0.01).
At 12 months, the cumulative incidence of local failure was 4% in Cohort A, compared with 19%–27% in Cohorts B–D and 57% in Cohort E (p < 0.01). Multivariate competing risks regression demonstrated that concurrent first-line TKI treatment (Cohort A) was independently associated with a local control benefit (HR 0.21, p = 0.04). In contrast, patients treated with TKIs alone (Cohort E) experienced an increased rate of local failure (HR 2.43, p = 0.03). No toxicities of Grade 3 or greater occurred following SRS with concurrent TKI treatment, and the incidence of post-SRS vertebral fracture (overall 21%) and pain flare (overall 17%) were similar across cohorts.
CONCLUSIONS
The prognosis for patients with mRCC has significantly improved with TKIs. The present investigation suggests a local control benefit with the addition of concurrent first-line TKI therapy to spine SRS. These results have implications in the oligometastatic setting and support a body of preclinical radiobiological research.
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Affiliation(s)
| | | | - Lilyana Angelov
- 3Neurosurgery and
- 4Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - John H. Suh
- Departments of 2Radiation Oncology,
- 4Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Brian Rini
- 5Medical Oncology, Taussig Cancer Institute; and
| | | | - Manmeet Ahluwalia
- 4Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
- 5Medical Oncology, Taussig Cancer Institute; and
| | - Samuel T. Chao
- Departments of 2Radiation Oncology,
- 4Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
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14
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Yang Y, Bu P. Progress on the cardiotoxicity of sunitinib: Prognostic significance, mechanism and protective therapies. Chem Biol Interact 2016; 257:125-31. [PMID: 27531228 DOI: 10.1016/j.cbi.2016.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 07/23/2016] [Accepted: 08/05/2016] [Indexed: 12/15/2022]
Abstract
Tyrosine kinase inhibitors (TKIs) are multi-targeted anti-cancer agents effective in the treatment of renal cell carcinoma (RCC), imatinib-resistant gastrointestinal stromal tumor (GIST) and pancreatic cancer (PC). Targeting and inhibiting a wide range of oncogenically relevant receptor tyrosine kinases (RTKs), TKIs have been the golden standard treatment of several types of cancer. The cardiotoxicity of TKIs, however, has also emerged alongside their anti-cancer potencies and has attracted research attention. Over the past few years significant progress has been made in developing a deeper understanding of aspects such as extent of cardiotoxicity, prognostic implications and survival predictions, toxicological mechanisms, and potential cardioprotective therapies. In this review we focus on a typical TKI sunitinib and summarize the up-to-date knowledge of sunitinib-induced cardiac abnormalities reported in clinical studies, weighing their implications of prognostic values. We also examine recent findings in underlying mechanisms, and development of potential cardioprotective agents.
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Affiliation(s)
- Yi Yang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Peili Bu
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, Shandong, China.
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15
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Dong Y, Fu C, Guan H, Zhang T, Zhang Z, Zhou T, Li B. Re-irradiation alternatives for recurrent high-grade glioma. Oncol Lett 2016; 12:2261-2270. [PMID: 27703519 PMCID: PMC5038913 DOI: 10.3892/ol.2016.4926] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 03/01/2016] [Indexed: 12/28/2022] Open
Abstract
Despite advances in the fields of surgery, chemotherapy and radiotherapy, the prognosis for high-grade glioma (HGG) remains unsatisfactory. The majority of HGG patients experience disease recurrence. To date, no standard treatments have been established for recurrent HGG. Repeat surgery and chemotherapy demonstrate moderate efficacy. As recurrent lesions are usually located within the previously irradiated field, a second course of irradiation was once considered controversial, as it was considered to exhibit unsatisfactory efficacy and radiation-related toxicities. However, an increasing number of studies have indicated that re-irradiation may present an efficacious treatment for recurrent HGG. Re-irradiation may be delivered via conventionally fractionated stereotactic radiotherapy, hypofractionated stereotactic radiation therapy, stereotactic radiosurgery and brachytherapy techniques. In the present review, the current literature regarding re-irradiation treatment for recurrent HGG is summarized with regard to survival outcome and side effects.
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Affiliation(s)
- Yuanli Dong
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China; School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong 250014, P.R. China
| | - Chengrui Fu
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Hui Guan
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China; School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong 250014, P.R. China
| | - Tianyi Zhang
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Zicheng Zhang
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Tao Zhou
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Baosheng Li
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
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16
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Carlisle B, Demko N, Freeman G, Hakala A, MacKinnon N, Ramsay T, Hey S, London AJ, Kimmelman J. Benefit, Risk, and Outcomes in Drug Development: A Systematic Review of Sunitinib. J Natl Cancer Inst 2016; 108:djv292. [PMID: 26547927 PMCID: PMC5943825 DOI: 10.1093/jnci/djv292] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 05/19/2015] [Accepted: 09/22/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Little is known about the total patient burden associated with clinical development and where burdens fall most heavily during a drug development program. Our goal was to quantify the total patient burden/benefit in developing a new drug. METHODS We measured risk using drug-related adverse events that were grade 3 or higher, benefit by objective response rate, and trial outcomes by whether studies met their primary endpoint with acceptable safety. The differences in risk (death rate) and benefit (overall response rate) between industry and nonindustry trials were analyzed with an inverse-variance weighted fixed effects meta-analysis implemented as a weighted regression analysis. All statistical tests were two-sided. RESULTS We identified 103 primary publications of sunitinib monotherapy, representing 9092 patients and 3991 patient-years of involvement over 10 years and 32 different malignancies. In total, 1052 patients receiving sunitinib monotherapy experienced objective tumor response (15.7% of intent-to-treat population, 95% confidence interval [CI] = 15.3% to 16.0%), 98 died from drug-related toxicities (1.08%, 95% CI = 1.02% to 1.14%), and at least 1245 experienced grade 3-4 drug-related toxicities (13.7%, 95% CI = 13.3% to 14.1%). Risk/benefit worsened as the development program matured, with several instances of replicated negative studies and almost no positive trials after the first responding malignancies were discovered. CONCLUSIONS Even for a successful drug, the risk/benefit balance of trials was similar to phase I cancer trials in general. Sunitinib monotherapy development showed worsening risk/benefit, and the testing of new indications responded slowly to evidence that sunitinib monotherapy would not extend to new malignancies. Research decision-making should draw on evidence from whole research programs rather than a narrow band of studies in the same indication.
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Affiliation(s)
- Benjamin Carlisle
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, QC, Canada (BC, ND, GF, AH, NM, SH, JK); University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada (TR); Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (SH); Department of Philosophy and Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, PA (AJL)
| | - Nadine Demko
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, QC, Canada (BC, ND, GF, AH, NM, SH, JK); University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada (TR); Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (SH); Department of Philosophy and Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, PA (AJL)
| | - Georgina Freeman
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, QC, Canada (BC, ND, GF, AH, NM, SH, JK); University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada (TR); Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (SH); Department of Philosophy and Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, PA (AJL)
| | - Amanda Hakala
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, QC, Canada (BC, ND, GF, AH, NM, SH, JK); University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada (TR); Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (SH); Department of Philosophy and Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, PA (AJL)
| | - Nathalie MacKinnon
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, QC, Canada (BC, ND, GF, AH, NM, SH, JK); University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada (TR); Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (SH); Department of Philosophy and Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, PA (AJL)
| | - Tim Ramsay
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, QC, Canada (BC, ND, GF, AH, NM, SH, JK); University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada (TR); Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (SH); Department of Philosophy and Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, PA (AJL)
| | - Spencer Hey
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, QC, Canada (BC, ND, GF, AH, NM, SH, JK); University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada (TR); Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (SH); Department of Philosophy and Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, PA (AJL)
| | - Alex John London
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, QC, Canada (BC, ND, GF, AH, NM, SH, JK); University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada (TR); Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (SH); Department of Philosophy and Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, PA (AJL)
| | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, QC, Canada (BC, ND, GF, AH, NM, SH, JK); University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada (TR); Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (SH); Department of Philosophy and Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, PA (AJL).
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17
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Salama JK, Gu L, Wang X, Pang HH, Bogart JA, Crawford J, Schild SE, Vokes EE, Ready NE. Positive Interaction between Prophylactic Cranial Irradiation and Maintenance Sunitinib for Untreated Extensive-Stage Small Cell Lung Cancer Patients After Standard Chemotherapy: A Secondary Analysis of CALGB 30504 (ALLIANCE). J Thorac Oncol 2015; 11:361-9. [PMID: 26723241 DOI: 10.1016/j.jtho.2015.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 11/06/2015] [Accepted: 11/09/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Prophylactic cranial irradiation (PCI) has become a standard option for patients with extensive-stage small cell lung cancer (ES-SCLC). The Cancer and Leukemia Group B 30504 trial was a randomized phase II study of the effect of sunitinib versus placebo in ES-SCLC patients responding to platinum-based systemic therapy. The study required preenrollment brain imaging. PCI was provided at the discretion of treating physicians. We performed a secondary analysis of the Cancer and Leukemia Group B trial to determine the impact of PCI on patients with ES-SCLC. METHODS Fisher's exact test and the Wilcoxon rank-sum test were conducted to identify the differences between patients receiving PCI and patients not receiving PCI. Kaplan-Meier analyses described progression-free survival (PFS) and overall survival (OS) for patients in the PCI and non-PCI groups. RESULTS A total of 85 patients received maintenance therapy (41 received placebo and 44 received sunitinib). Patient characteristics were balanced between the PCI and non-PCI groups. The patients receiving PCI plus sunitinib had a nonsignificant 2.7-month improvement in PFS (5.0 months versus 2.3 months, p = 0.14, hazard risk [HR] = 0.62, 95% confidence interval [CI]: 0.33-1.18) trending toward improved OS (8.9 months versus 5.4 months, p = 0.053, HR = 0.47, 95% CI: 0.22-1.03). PCI was associated with a trend toward improved median PFS (2.9 months versus 2.2 months, p = 0.096, HR = 0.69, 95% CI: 0.45-1.07) but not median OS (8.3 months in the PCI group versus 8.7 months in the non-PCI group, p = 0.76, HR = 1.07, 95% CI: 0.67-1.71). The patients receiving placebo had no improvement in PFS or OS with PCI. CONCLUSIONS Trends toward improved PFS and OS were seen in patients receiving PCI and sunitinib, thus supporting the need for further prospective research evaluating the integration of maintenance systemic therapy and PCI for patients with ES-SCLC. Improved outcomes for patients with ES-SCLC after induction chemotherapy may require PCI, thoracic radiotherapy, and maintenance systemic therapy to achieve control of both intracranial and extracranial disease.
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Affiliation(s)
- Joseph K Salama
- Department of Radiation Oncology, Duke University, Durham, NC, USA.
| | - Lin Gu
- Alliance Statistics and Data Center, Duke University, Durham, NC, USA
| | - Xiaofei Wang
- Alliance Statistics and Data Center, Duke University, Durham, NC, USA
| | - Herbert H Pang
- Alliance Statistics and Data Center, Duke University, Durham, NC, USA; School of Public Health, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pok Fu Lam, Hong Kong SAR, People's Republic of China
| | - Jeffrey A Bogart
- Department of Radiation Oncology, SUNY Upstate Medical Center, Syracuse, NY, USA
| | - Jeffrey Crawford
- Section of Medical Oncology, Department of Medicine, Duke University, Durham, NC, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, USA
| | - Everett E Vokes
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Neal E Ready
- Section of Medical Oncology, Department of Medicine, Duke University, Durham, NC, USA
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Kleibeuker EA, Ten Hooven MA, Verheul HM, Slotman BJ, Thijssen VL. Combining radiotherapy with sunitinib: lessons (to be) learned. Angiogenesis 2015. [PMID: 26202788 PMCID: PMC4596900 DOI: 10.1007/s10456-015-9476-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
To improve the efficacy of radiotherapy (RTx), there is a growing interest in combining RTx with drugs that inhibit angiogenesis, i.e., the process of neo-vessel formation out of preexisting capillaries. A frequently used drug to inhibit angiogenesis is sunitinib (Sutent, SU11248), a receptor tyrosine kinase inhibitor that is currently FDA approved for the treatment of several cancer types. The current review presents an overview of the preclinical studies and clinical trials that combined sunitinib with RTx. We discuss the findings from preclinical and clinical observations with a focus on dose scheduling and commonly reported toxicities. In addition, the effects of combination therapy on tumor response and patient survival are described. Finally, the lessons learned from preclinical and clinical studies are summarized and opportunities and pitfalls for future clinical trials are presented.
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Affiliation(s)
- Esther A Kleibeuker
- Department of Medical Oncology, VU University Medical Center, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - Matthijs A Ten Hooven
- Department of Medical Oncology, VU University Medical Center, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - Henk M Verheul
- Department of Medical Oncology, VU University Medical Center, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - Ben J Slotman
- Department of Radiation Oncology, VU University Medical Center, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - Victor L Thijssen
- Department of Medical Oncology, VU University Medical Center, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands. .,Department of Radiation Oncology, VU University Medical Center, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands.
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