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Saito A, Kitayama J, Nagai R, Aizawa K. Anatomical Targeting of Anticancer Drugs to Solid Tumors Using Specific Administration Routes: Review. Pharmaceutics 2023; 15:1664. [PMID: 37376112 DOI: 10.3390/pharmaceutics15061664] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/02/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023] Open
Abstract
Despite remarkable recent progress in developing anti-cancer agents, outcomes of patients with solid tumors remain unsatisfactory. In general, anti-cancer drugs are systemically administered through peripheral veins and delivered throughout the body. The major problem with systemic chemotherapy is insufficient uptake of intravenous (IV) drugs by targeted tumor tissue. Although dose escalation and treatment intensification have been attempted in order to increase regional concentrations of anti-tumor drugs, these approaches have produced only marginal benefits in terms of patient outcomes, while often damaging healthy organs. To overcome this problem, local administration of anti-cancer agents can yield markedly higher drug concentrations in tumor tissue with less systemic toxicity. This strategy is most commonly used for liver and brain tumors, as well as pleural or peritoneal malignancies. Although the concept is theoretically reasonable, survival benefits are still limited. This review summarizes clinical results and problems and discusses future directions of regional cancer therapy with local administration of chemotherapeutants.
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Affiliation(s)
- Akira Saito
- Department of Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0431, Japan
| | - Joji Kitayama
- Department of Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0431, Japan
- Division of Translational Research, Clinical Research Center, Jichi Medical University Hospital, Tochigi, Tochigi 329-0498, Japan
| | - Ryozo Nagai
- Department of Medicine, School of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
| | - Kenichi Aizawa
- Division of Translational Research, Clinical Research Center, Jichi Medical University Hospital, Tochigi, Tochigi 329-0498, Japan
- Division of Clinical Pharmacology, Department of Pharmacology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
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Niyazi M, Andratschke N, Bendszus M, Chalmers AJ, Erridge SC, Galldiks N, Lagerwaard FJ, Navarria P, Munck Af Rosenschöld P, Ricardi U, van den Bent MJ, Weller M, Belka C, Minniti G. ESTRO-EANO guideline on target delineation and radiotherapy details for glioblastoma. Radiother Oncol 2023; 184:109663. [PMID: 37059335 DOI: 10.1016/j.radonc.2023.109663] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND AND PURPOSE Target delineation in glioblastoma is still a matter of extensive research and debate. This guideline aims to update the existing joint European consensus on delineation of the clinical target volume (CTV) in adult glioblastoma patients. MATERIAL AND METHODS The ESTRO Guidelines Committee identified 14 European experts in close interaction with the ESTRO clinical committee and EANO who discussed and analysed the body of evidence concerning contemporary glioblastoma target delineation, then took part in a two-step modified Delphi process to address open questions. RESULTS Several key issues were identified and are discussed including i) pre-treatment steps and immobilisation, ii) target delineation and the use of standard and novel imaging techniques, and iii) technical aspects of treatment including planning techniques and fractionation. Based on the EORTC recommendation focusing on the resection cavity and residual enhancing regions on T1-sequences with the addition of a reduced 15 mm margin, special situations are presented with corresponding potential adaptations depending on the specific clinical situation. CONCLUSIONS The EORTC consensus recommends a single clinical target volume definition based on postoperative contrast-enhanced T1 abnormalities, using isotropic margins without the need to cone down. A PTV margin based on the individual mask system and IGRT procedures available is advised; this should usually be no greater than 3 mm when using IGRT.
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Affiliation(s)
- Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium (DKTK), partner site Munich, Munich, Germany; Bavarian Cancer Research Center (BZKF), Munich, Germany.
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Sara C Erridge
- Edinburgh Centre for Neuro-Oncology, University of Edinburgh, Western General Hospital, Edinburgh, EH4 1EU, UK
| | - Norbert Galldiks
- Department of Neurology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany; Institute of Neuroscience and Medicine (INM-3), Research Center Juelich, Juelich, Germany; Center for Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Duesseldorf, Germany
| | - Frank J Lagerwaard
- Department of Radiation Oncology, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, IRCCS, Humanitas Research Hospital, Rozzano (MI), Italy
| | - Per Munck Af Rosenschöld
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, and Lund University, Lund, Sweden
| | | | | | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium (DKTK), partner site Munich, Munich, Germany; Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Giuseppe Minniti
- Dept. of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy; IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy
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Minniti G, Tini P, Giraffa M, Capone L, Raza G, Russo I, Cinelli E, Gentile P, Bozzao A, Paolini S, Esposito V. Feasibility of clinical target volume reduction for glioblastoma treated with standard chemoradiation based on patterns of failure analysis. Radiother Oncol 2023; 181:109435. [PMID: 36529439 DOI: 10.1016/j.radonc.2022.11.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 11/02/2022] [Accepted: 11/27/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE To analyze recurrence patterns in patients with glioblastoma (GBM) after standard chemoradiation according to different target volume delineation strategies. METHODS AND MATERIALS Two hundred seven patients with GBM who recurred after standard chemoradiation were evaluated. According to ESTRO target volume delineation guideline, the CTV was generated by adding a 2-cm margin to the GTV, defined as the resection cavity plus residual tumor. Patterns of failure were analyzed using dose-volume histogram. Recurrent lesions were defined as in-field, marginal, or distant if > 80 %, 20-80 %, or < 20 % of the intersecting volume was included in the 95 % isodose line.For each patient, a theoretical plan consisting of reduced 1-cm GTV-to-CTV margin was created to compare patterns of failure and radiation doses to normal brain. RESULTS Median overall survival and progression-free survival times were 15.3 months and 7.8 months, respectively, from the date of surgery. Recurrences were in-field in 180, marginal in 5, and distant in 22 patients. According to MGMT promoter methylation, distant recurrences occurred in 18.6 % of methylated and 6 % of unmethylated tumors (p = 0.0046). Following replanning with 1-cm reduced margin, dosimetric analysis showed similar patterns of failure. Recurrences were in-field, marginal, and distant in 177, 3, and 27 plans, respectively, although radiation doses to the healthy brain and hippocampi were significantly lower compared with standard target delineation (p = 0.0001). CONCLUSION Current provide the rationale for evaluating GTV-to-CTV margin reduction in future clinical trials with the aim of limiting the cognitive sequelae of GBM irradiation while maintaining survival benefits of standard chemoradiation.
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Affiliation(s)
- Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Italy; IRCCS Neuromed, 86077 Pozzilli, IS, Italy.
| | - Paolo Tini
- Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Martina Giraffa
- UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Luca Capone
- UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Giorgio Raza
- UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Ivana Russo
- UPMC Hillman Cancer Center, Villa Maria, Mirabella Eclano, AV, Italy
| | - Elisa Cinelli
- Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | | | - Alessandro Bozzao
- Neuroradiology Unit, NESMOS Department, Sant'Andrea Hospital, La Sapienza University, Rome, Italy
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An Integrated Monte Carlo Model for Heterogeneous Glioblastoma Treated with Boron Neutron Capture Therapy. Cancers (Basel) 2023; 15:cancers15051550. [PMID: 36900341 PMCID: PMC10001318 DOI: 10.3390/cancers15051550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/16/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Glioblastomas (GBMs) are notorious for their aggressive features, e.g., intrinsic radioresistance, extensive heterogeneity, hypoxia, and highly infiltrative behaviours. The prognosis has remained poor despite recent advances in systemic and modern X-ray radiotherapy. Boron neutron capture therapy (BNCT) represents an alternative radiotherapy technique for GBM. Previously, a Geant4 BNCT modelling framework was developed for a simplified model of GBM. PURPOSE The current work expands on the previous model by applying a more realistic in silico GBM model with heterogeneous radiosensitivity and anisotropic microscopic extensions (ME). METHODS Each cell within the GBM model was assigned an α/β value associated with different GBM cell lines and a 10B concentration. Dosimetry matrices corresponding to various MEs were calculated and combined to evaluate cell survival fractions (SF) using clinical target volume (CTV) margins of 2.0 & 2.5 cm. SFs for the BNCT simulation were compared with external X-ray radiotherapy (EBRT) SFs. RESULTS The SFs within the beam region decreased by more than two times compared to EBRT. It was demonstrated that BNCT results in markedly reduced SFs for both CTV margins compared to EBRT. However, the SF reduction as a result of the CTV margin extension using BNCT was significantly lower than using X-ray EBRT for one MEP distribution, while it remained similar for the other two MEP models. CONCLUSIONS Although the efficiency of BNCT in terms of cell kill is superior to EBRT, the extension of the CTV margin by 0.5 cm may not increase the BNCT treatment outcome significantly.
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Chiesa S, Russo R, Beghella Bartoli F, Palumbo I, Sabatino G, Cannatà MC, Gigli R, Longo S, Tran HE, Boldrini L, Dinapoli N, Votta C, Cusumano D, Pignotti F, Lupattelli M, Camilli F, Della Pepa GM, D’Alessandris GQ, Olivi A, Balducci M, Colosimo C, Gambacorta MA, Valentini V, Aristei C, Gaudino S. MRI-derived radiomics to guide post-operative management of glioblastoma: Implication for personalized radiation treatment volume delineation. Front Med (Lausanne) 2023; 10:1059712. [PMID: 36744131 PMCID: PMC9892450 DOI: 10.3389/fmed.2023.1059712] [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: 10/01/2022] [Accepted: 01/03/2023] [Indexed: 01/20/2023] Open
Abstract
Background The glioblastoma's bad prognosis is primarily due to intra-tumor heterogeneity, demonstrated from several studies that collected molecular biology, cytogenetic data and more recently radiomic features for a better prognostic stratification. The GLIFA project (GLIoblastoma Feature Analysis) is a multicentric project planned to investigate the role of radiomic analysis in GB management, to verify if radiomic features in the tissue around the resection cavity may guide the radiation target volume delineation. Materials and methods We retrospectively analyze from three centers radiomic features extracted from 90 patients with total or near total resection, who completed the standard adjuvant treatment and for whom we had post-operative images available for features extraction. The Manual segmentation was performed on post gadolinium T1w MRI sequence by 2 radiation oncologists and reviewed by a neuroradiologist, both with at least 10 years of experience. The Regions of interest (ROI) considered for the analysis were: the surgical cavity ± post-surgical residual mass (CTV_cavity); the CTV a margin of 1.5 cm added to CTV_cavity and the volume resulting from subtracting the CTV_cavity from the CTV was defined as CTV_Ring. Radiomic analysis and modeling were conducted in RStudio. Z-score normalization was applied to each radiomic feature. A radiomic model was generated using features extracted from the Ring to perform a binary classification and predict the PFS at 6 months. A 3-fold cross-validation repeated five times was implemented for internal validation of the model. Results Two-hundred and seventy ROIs were contoured. The proposed radiomic model was given by the best fitting logistic regression model, and included the following 3 features: F_cm_merged.contrast, F_cm_merged.info.corr.2, F_rlm_merged.rlnu. A good agreement between model predicted probabilities and observed outcome probabilities was obtained (p-value of 0.49 by Hosmer and Lemeshow statistical test). The ROC curve of the model reported an AUC of 0.78 (95% CI: 0.68-0.88). Conclusion This is the first hypothesis-generating study which applies a radiomic analysis focusing on healthy tissue ring around the surgical cavity on post-operative MRI. This study provides a preliminary model for a decision support tool for a customization of the radiation target volume in GB patients in order to achieve a margin reduction strategy.
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Affiliation(s)
- S. Chiesa
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - R. Russo
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Institute of Radiology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - F. Beghella Bartoli
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - I. Palumbo
- Radiation Oncology Section, University of Perugia, Perugia, Italy,Perugia General Hospital, Perugia, Italy
| | - G. Sabatino
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy,Department of Neurosurgery, Agostino Gemelli University Polyclinic (IRCCS), Rome, Italy
| | - M. C. Cannatà
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy,*Correspondence: M. C. Cannatà,
| | - R. Gigli
- Medical Physics, Mater Olbia Hospital, Olbia, Italy
| | - S. Longo
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - H. E. Tran
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - L. Boldrini
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - N. Dinapoli
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - C. Votta
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - D. Cusumano
- Medical Physics, Mater Olbia Hospital, Olbia, Italy
| | - F. Pignotti
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy,Department of Neurosurgery, Agostino Gemelli University Polyclinic (IRCCS), Rome, Italy
| | | | - F. Camilli
- Radiation Oncology Section, University of Perugia, Perugia, Italy
| | - G. M. Della Pepa
- Department of Neurosurgery, Agostino Gemelli University Polyclinic (IRCCS), Rome, Italy
| | - G. Q. D’Alessandris
- Department of Neurosurgery, Agostino Gemelli University Polyclinic (IRCCS), Rome, Italy
| | - A. Olivi
- Department of Neurosurgery, Agostino Gemelli University Polyclinic (IRCCS), Rome, Italy
| | - M. Balducci
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - C. Colosimo
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Institute of Radiology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - M. A. Gambacorta
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - V. Valentini
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - C. Aristei
- Radiation Oncology Section, University of Perugia, Perugia, Italy,Perugia General Hospital, Perugia, Italy
| | - S. Gaudino
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Institute of Radiology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
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Convection Enhanced Delivery in the Setting of High-Grade Gliomas. Pharmaceutics 2021; 13:pharmaceutics13040561. [PMID: 33921157 PMCID: PMC8071501 DOI: 10.3390/pharmaceutics13040561] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/04/2021] [Accepted: 04/12/2021] [Indexed: 11/16/2022] Open
Abstract
Development of effective treatments for high-grade glioma (HGG) is hampered by (1) the blood–brain barrier (BBB), (2) an infiltrative growth pattern, (3) rapid development of therapeutic resistance, and, in many cases, (4) dose-limiting toxicity due to systemic exposure. Convection-enhanced delivery (CED) has the potential to significantly limit systemic toxicity and increase therapeutic index by directly delivering homogenous drug concentrations to the site of disease. In this review, we present clinical experiences and preclinical developments of CED in the setting of high-grade gliomas.
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Zheng L, Zhou ZR, Yu Q, Shi M, Yang Y, Zhou X, Li C, Wei Q. The Definition and Delineation of the Target Area of Radiotherapy Based on the Recurrence Pattern of Glioblastoma After Temozolomide Chemoradiotherapy. Front Oncol 2021; 10:615368. [PMID: 33692942 PMCID: PMC7937883 DOI: 10.3389/fonc.2020.615368] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/30/2020] [Indexed: 11/13/2022] Open
Abstract
Radiotherapy is an important treatment for glioblastoma (GBM), but there is no consensus on the target delineation for GBM radiotherapy. The Radiation Therapy Oncology Group (RTOG) and European Organisation for Research and Treatment of Cancer (EORTC) each have their own rules. Our center adopted a target volume delineation plan based on our previous studies. This study focuses on the recurrence pattern of GBM patients whose target delineations did not intentionally include the T2/fluid-attenuated inversion recovery (FLAIR) hyperintensity area outside of the gross tumor volume (GTV). We prospectively collected 162 GBM cases and retrospectively analysed the clinical data and continuous dynamic magnetic resonance images (MRI) of 55 patients with recurrent GBM. All patients received concurrent radiotherapy and chemotherapy with temozolomide (TMZ). The GTV that we defined includes the postoperative T1-weighted MRI enhancement area and resection cavity. Clinical target volume 1 (CTV1) and CTV2 were defined as GTVs with 1 and 2 cm margins, respectively. Planning target volume 1 (PTV1) and PTV2 were defined as CTV1 and CTV2 plus a 3 mm margin with prescribed doses of 60 and 54 Gy, respectively. The first recurrent contrast-enhanced T1-weighted MRI was introduced into the Varian Eclipse radiotherapy planning system and fused with the original planning computed tomography (CT) images to determine the recurrence pattern. The median follow-up time was 15.8 months. The median overall survival (OS) and progression-free survival (PFS) were 17.7 and 7.0 months, respectively. Among the patients, 44 had central recurrences, two had in-field recurrences, one had marginal recurrence occurred, 11 had distant recurrences, and three had subependymal recurrences. Five patients had multiple recurrence patterns. Compared to the EORTC protocol, target delineation that excludes the adjacent T2/FLAIR hyperintensity area reduces the brain volume exposed to high-dose radiation (P = 0.000) without an increased risk of marginal recurrence. Therefore, it is worthwhile to conduct a clinical trial investigating the feasibility of intentionally not including the T2/FLAIR hyperintensity region outside of the GTV.
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Affiliation(s)
- Lin Zheng
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Radiation Oncology, Taizhou Cancer Hospital, Wenling, China
| | - Zhi-Rui Zhou
- Radiation Oncology Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - QianQian Yu
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Minghan Shi
- Département de l'éducation aux adultes, Cégep Saint-Jean-sur-Richelieu, Brossard, QC, Canada
| | - Yang Yang
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaofeng Zhou
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chao Li
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qichun Wei
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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McAbee JH, Degorre-Kerbaul C, Valdez K, Wendler A, Shankavaram UT, Watts C, Camphausen K, Tofilon PJ. Detection of glioblastoma intratumor heterogeneity in radiosensitivity using patient-derived neurosphere cultures. J Neurooncol 2020; 149:383-390. [PMID: 33057920 DOI: 10.1007/s11060-020-03643-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/01/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Glioblastoma (GBM) is characterized by extensive clonal diversity suggesting the presence of tumor cells with varying degrees of treatment sensitivity. Radiotherapy is an integral part of glioblastoma treatment. Whether GBMs are comprised of spatially distinct cellular populations with uniform or varying degrees of radiosensitivity has not been established. METHODS Spatially distinct regions of three GBMs (J3, J7 and J14) were resected and unique cell lines were derived from each region. DNA from cell lines, corresponding tumor fragments, and patient blood was extracted for whole exome sequencing. Variants, clonal composition, and functional implications were compared and analyzed with superFreq and IPA. Limiting dilution assays were performed on cell lines to measure intrinsic radiosensitivity. RESULTS Based on WES, cell lines generated from different regions of the same tumor were more closely correlated with their tumor of origin than the other GBMs. Variant and clonal composition comparisons showed that cell lines from distinct tumors displayed increasing levels of ITH with J3 and J14 having the lowest and highest, respectively. The radiosensitivities of the cell lines generated from the J3 tumor were similar as were those generated from the J7 tumor. However, the radiosensitivities of the 2 cell lines generated from the J14 tumor (J14T3 and J14T6) were significantly different with J14T6 being more sensitive than J14T3. CONCLUSION Data suggest a tumor dependent ITH in radiosensitivity. The existence of ITH in radiosensitivity may impact not only the initial therapeutic response but also the effectiveness of retreatment protocols.
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Affiliation(s)
- Joseph H McAbee
- Radiation Oncology Branch, NCI, Bethesda, MD, USA.,Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | | | - Astrid Wendler
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - Colin Watts
- Department of Neurosurgery, Institute of Cancer Genome Sciences, University of Birmingham, Birmingham, UK
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Applications of radiomics and machine learning for radiotherapy of malignant brain tumors. Strahlenther Onkol 2020; 196:856-867. [PMID: 32394100 PMCID: PMC7498494 DOI: 10.1007/s00066-020-01626-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/22/2020] [Indexed: 12/12/2022]
Abstract
Background Magnetic resonance imaging (MRI) and amino acid positron-emission tomography (PET) of the brain contain a vast amount of structural and functional information that can be analyzed by machine learning algorithms and radiomics for the use of radiotherapy in patients with malignant brain tumors. Methods This study is based on comprehensive literature research on machine learning and radiomics analyses in neuroimaging and their potential application for radiotherapy in patients with malignant glioma or brain metastases. Results Feature-based radiomics and deep learning-based machine learning methods can be used to improve brain tumor diagnostics and automate various steps of radiotherapy planning. In glioma patients, important applications are the determination of WHO grade and molecular markers for integrated diagnosis in patients not eligible for biopsy or resection, automatic image segmentation for target volume planning, prediction of the location of tumor recurrence, and differentiation of pseudoprogression from actual tumor progression. In patients with brain metastases, radiomics is applied for additional detection of smaller brain metastases, accurate segmentation of multiple larger metastases, prediction of local response after radiosurgery, and differentiation of radiation injury from local brain metastasis relapse. Importantly, high diagnostic accuracies of 80–90% can be achieved by most approaches, despite a large variety in terms of applied imaging techniques and computational methods. Conclusion Clinical application of automated image analyses based on radiomics and artificial intelligence has a great potential for improving radiotherapy in patients with malignant brain tumors. However, a common problem associated with these techniques is the large variability and the lack of standardization of the methods applied.
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Ge X, Xue X, Liu H, Wang Y, Xiao Z, Tian L, Chang X, Lin Q, Yu J. Treatment of high-grade gliomas using escalating doses of hypofractionated simultaneous integrated boost-intensity-modulated radiation therapy in combination with temozolomide: A modified Phase I clinical trial. J Cancer Res Ther 2018; 14:1482-1491. [PMID: 30589027 DOI: 10.4103/jcrt.jcrt_51_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Recent studies have shown that hypofractionated simultaneous integrated boost-intensity-modulated radiation therapy (SIB-IMRT) provided certain survival benefits over other fractionation methods for high-grade gliomas. However, the best hypofractionation mode and its efficacy have not been confirmed. The purpose of this study was to investigate the maximum tolerated dose (MTD) of hypofractionated SIB-IMRT with stepwise escalating doses combined with temozolomide (TMZ) for treating malignant gliomas. Methods The patients received concurrent postoperative radiotherapy and chemotherapy. SIB-IMRT was adopted to increase the dose both in the surgical cavity and residual tumor (planning target volume 1). The dose at each fraction was gradually increased from 2.8 Gy/f (total of 20 times), with an escalating dose interval of 0.4 Gy. The planning target volume 2 involved the 2 cm region around surgical cavity, and residual tumor remained unchanged, with 2.5 Gy each time and a total of 50 Gy/20f. TMZ was administered with a dose of 75 mg/m2/day during radiotherapy. Adjuvant TMZ was given at 150-200 mg/m2/day for 5 days every 28 days. A total of 16 patients were enrolled. Results Three patients exhibited dose-limiting toxicity (DLT), two cases reported Grade 3 headache in the 3.6 Gy/f and 4 Gy/f dose groups, and one patient developed persistent seizures attacks in the 4 Gy/f dose group. Therefore, 4 Gy/f was considered the DLT and the lower dose level of 3.6 Gy/f was regarded as the MTD in the study, with tolerable adverse reactions. The median overall survival (OS) and median progression-free survival (PFS) in this study were 19 and 16 months, respectively. The 1- and 2-year OS and PFS were 86.7%, 31.0% and 73.7%, 26.7%, respectively. Conclusions It showed that the treatment of high-grade gliomas with hypofractionated SIB-IMRT combined with TMZ had an MTD of 3.6 Gy/f (72 Gy/20f). In addition, the results preliminarily showed improved survival.
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Affiliation(s)
- Xiaohui Ge
- Department of Radiotherapy, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Xiaoying Xue
- Department of Radiotherapy, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Huizhi Liu
- Department of Radiotherapy, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Yanqiang Wang
- Department of Radiotherapy, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Zhiqing Xiao
- Department of Radiotherapy, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Lei Tian
- Department of Radiotherapy, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Xiaojing Chang
- Department of Radiotherapy, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Qiang Lin
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, China
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, China
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11
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Can Early Postoperative O-(2- 18FFluoroethyl)-l-Tyrosine Positron Emission Tomography After Resection of Glioblastoma Predict the Location of Later Tumor Recurrence? World Neurosurg 2018; 121:e467-e474. [PMID: 30267942 DOI: 10.1016/j.wneu.2018.09.139] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 09/17/2018] [Accepted: 09/18/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Glioblastoma inevitably recurs despite aggressive therapy. Therefore, it would be helpful to predict the location of tumor recurrence from postoperative imaging to customize further treatment. O-(2-18Ffluoroethyl)-l-tyrosine (FET) positron emission tomography (PET) might be a helpful technique, because tumor tissue can be differentiated from normal brain tissue with high specificity. METHODS Thirty-two consecutive patients with perioperative and follow-up imaging data available were included. On postoperative FET-PET, the tumor/normal brain (TTB) ratio around the resection cavity borders was measured. Increased TTB ratios were recorded and anatomically correlated with the site of later tumor recurrence. On postoperative magnetic resonance imaging (MRI), residual contrast-enhancing tumor correlated with the site of later tumor recurrence. RESULTS Location of progression was predictable using MRI alone in 42% of patients by residual tumor on postoperative MRI. FET-PET was predictive in 25 patients by a clear hot spot at the site of later tumor recurrence. In 3 patients, it was partially predictive and in 4 was not predictive of the tumor recurrence location. One patient without any tracer uptake was recurrence free at the last follow-up examination. In contrast to the postoperative MRI results, tumor recurrence was found in 79% at a site of elevated TTB ratio on postoperative FET-PET. Therefore, the predictability of the tumor recurrence location using postoperative FET-PET was greater than that with MRI, and all cases predictable using MRI could have been predicted using FET-PET. CONCLUSIONS Postoperative FET-PET can be helpful for planning subsequent therapy, such as repeat resection or radiotherapy, because tumor recurrence can be predicted with relatively greater sensitivity than with MRI alone.
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12
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Late Effects of Radiation Prime the Brain Microenvironment for Accelerated Tumor Growth. Int J Radiat Oncol Biol Phys 2018; 103:190-194. [PMID: 30171879 DOI: 10.1016/j.ijrobp.2018.08.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/10/2018] [Accepted: 08/21/2018] [Indexed: 01/15/2023]
Abstract
PURPOSE Glioblastoma (GBM) remains incurable, despite state-of-the-art treatment involving surgical resection, chemotherapy, and radiation. GBM invariably recurs as a highly invasive and aggressive phenotype, with the majority of recurrences within the radiation therapy treatment field. Although a large body of literature reporting on primary GBM exists, comprehensive studies of how prior irradiation alters recurrent tumor growth are lacking. An animal model that replicates the delayed effects of radiation therapy on the brain microenvironment, and its impact on the development of recurrent GBM, would be a significant advance. METHODS AND MATERIALS Cohorts of mice received a single fraction of 0, 20, 30, or 40 Gy Gamma Knife irradiation. Naïve, nonirradiated mouse GBM tumor cells were implanted into the ipsilateral hemisphere 6 weeks postirradiation. Tumor growth was measured by magnetic resonance imaging, and animal survival was assessed by monitoring weight loss. Magnetic resonance imaging results were supported by hemotoxylin and eosin histology. RESULTS Tumorous lesions generated from orthotopic implantation of nonirradiated mouse GBM tumor cells into irradiated mouse brain grew far more aggressively and invasively than implantation of these same cells into nonirradiated brain. Lesions in irradiated brain tissue were significantly larger, more necrotic, and more vascular than those in control animals with increased invasiveness of tumor cells in the periphery, consistent with the histologic features commonly observed in recurrent high-grade tumors in patients. CONCLUSIONS Irradiation of normal brain primes the targeted cellular microenvironment for aggressive tumor growth when naïve (not previously irradiated) cancer cells are subsequently introduced. The resultant growth pattern is similar to the highly aggressive pattern of tumor regrowth observed clinically after therapeutic radiation therapy. The mouse model offers an avenue for determining the cellular and molecular basis for the aggressiveness of recurrent GBM.
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13
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Piper RJ, Senthil KK, Yan JL, Price SJ. Neuroimaging classification of progression patterns in glioblastoma: a systematic review. J Neurooncol 2018; 139:77-88. [PMID: 29603080 DOI: 10.1007/s11060-018-2843-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 03/21/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Our primary objective was to report the current neuroimaging classification systems of spatial patterns of progression in glioblastoma. In addition, we aimed to report the terminology used to describe 'progression' and to assess the compliance with the Response Assessment in Neuro-Oncology (RANO) Criteria. METHODS We conducted a systematic review to identify all neuroimaging studies of glioblastoma that have employed a categorical classification system of spatial progression patterns. Our review was registered with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) registry. RESULTS From the included 157 results, we identified 129 studies that used labels of spatial progression patterns that were not based on radiation volumes (Group 1) and 50 studies that used labels that were based on radiation volumes (Group 2). In Group 1, we found 113 individual labels and the most frequent were: local/localised (58%), distant/distal (51%), diffuse (20%), multifocal (15%) and subependymal/subventricular zone (15%). We identified 13 different labels used to refer to 'progression', of which the most frequent were 'recurrence' (99%) and 'progression' (92%). We identified that 37% (n = 33/90) of the studies published following the release of the RANO classification were adherent compliant with the RANO criteria. CONCLUSIONS Our review reports significant heterogeneity in the published systems used to classify glioblastoma spatial progression patterns. Standardization of terminology and classification systems used in studying progression would increase the efficiency of our research in our attempts to more successfully treat glioblastoma.
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Affiliation(s)
- Rory J Piper
- Cambridge Brain Tumour Imaging Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Hill's Road, Cambridge, CB2 0QQ, UK.
| | - Keerthi K Senthil
- Cambridge Brain Tumour Imaging Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Hill's Road, Cambridge, CB2 0QQ, UK
| | - Jiun-Lin Yan
- Cambridge Brain Tumour Imaging Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Hill's Road, Cambridge, CB2 0QQ, UK
| | - Stephen J Price
- Cambridge Brain Tumour Imaging Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Hill's Road, Cambridge, CB2 0QQ, UK
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14
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Jayamanne D, Wheeler H, Brazier D, Newey A, Kastelan M, Guo L, Back M. Predicting patterns of failure in temporal lobe GBMs: possible implications on radiotherapy treatment portals. Radiat Oncol 2018; 13:133. [PMID: 30029668 PMCID: PMC6053721 DOI: 10.1186/s13014-018-1078-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 07/12/2018] [Indexed: 12/25/2022] Open
Abstract
Background Characterise patterns of failure of Temporal Lobe (TL) Glioblastoma (GBM) following treatment with relation to normal temporal lobe anatomy and neural pathways. Methods 335 GBM patients received radiotherapy between 03/2007 and 07/2014, 100 were located in TL. Site of initial tumour and subsequent relapse were subdivided into 5 local TL sites (anterior, lateral, medial, posterior and superior); 5 adjacent regional sites (occipital lobe, inferior frontal lobe, caudate/thalamus/internal/external capsules, fornix/ventricular trigone), and 5 distant failure sites (ventricles, contralateral hemisphere, brainstem, leptomeninges and spine). Extension along major neuroanatomical pathways at initial presentation and at first documented Magnetic Resonance Imaging (MRI) failure were categorised into anterior, superior, medial and posterior pathways. Results Of the 100 patients, 86 had radiological progress with a median survival of 17.3 months. At initial diagnosis, 74% of tumours were linked to one TL site and 94% were confined to the TL. 19% had neural pathway disease at initial pre-treatment MRI. At first recurrence locoregional site failure was 74%. 26% failed within distant sites and 53% patients were noted to have neural pathway involvement. Initial tumour location predicted for local site recurrence (p < 0.0001), regional site recurrence (p = 0.004) and neural pathway recurrence pattern (p = 0.005), but not for distant sites (p = 0.081). Conclusion Most GBMs fail at local or adjacent regional sites. Many of the recurrences occurred in a predictable pattern within a local or regional site, unique to initial TL site with more than half involving neural pathways. Knowledge of tumour infiltration and failure may improve target definition and radiotherapy.
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Affiliation(s)
- Dasantha Jayamanne
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW, Australia. .,Central Coast Cancer Centre, Gosford Hospital, Gosford, NSW, Australia.
| | - Helen Wheeler
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW, Australia.,Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Sydney Neurooncology Group, Sydney, NSW, Australia
| | - David Brazier
- Department of Radiology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Allison Newey
- Department of Radiology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Marina Kastelan
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW, Australia.,Sydney Neurooncology Group, Sydney, NSW, Australia
| | - Linxin Guo
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Michael Back
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW, Australia.,Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Central Coast Cancer Centre, Gosford Hospital, Gosford, NSW, Australia.,Sydney Neurooncology Group, Sydney, NSW, Australia
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15
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Yasuda T, Muragaki Y, Nitta M, Miyamoto K, Oura Y, Henmi T, Noguchi S, Oda H, Saito T, Maruyama T, Atsuchi S, Miura N, Kawamata T. Effectiveness of Stereotactic Radiotherapy and Bevacizumab for Recurrent High-Grade Gliomas: A Potential Therapy for Isocitrate Dehydrogenase Wild-Type Recurrent High-Grade Gliomas. World Neurosurg 2018; 114:e1138-e1146. [PMID: 29614360 DOI: 10.1016/j.wneu.2018.03.161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 03/22/2018] [Accepted: 03/23/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE This study aimed to evaluate the efficacy of stereotactic radiotherapy combined with bevacizumab (SRT-Bv) compared with Bv treatment for recurrent high-grade gliomas (HGGs). METHODS Data for patients with recurrent HGGs who received SRT and Bv (n = 29) or Bv (n = 29) between June 2014 and September 2016 were retrospectively analyzed. All patients received conventional radiotherapy (total, 60 Gy) before this study. SRT was administered at a median dose of 42 Gy in 3-7 fractions. The recurrence pattern was classified into 3 groups: in-field, marginal, and out-field. RESULTS The median overall survival in the SRT-Bv group was significantly longer than that in the Bv group (10.4 vs. 5.6 months; P = 0.02). In patients with isocitrate dehydrogenase wild-type tumors, the SRT-Bv treatment significantly prolonged survival more than the Bv treatment (10.9 vs. 8.2 months; P = 0.01). The World Health Organization grade and presence or absence of SRT were significant prognostic factors in the univariate analysis. Besides brain edema in 2 cases and asymptomatic subdural hematoma in 1 case, no other severe adverse effect due to SRT-Bv treatment was recorded. The pattern of recurrence was as follows: in-field, 2 cases (7%); marginal, 8 cases (28%); out-field, 11 cases (38%); no recurrence on radiologic findings, 6 cases (21%); and uncertain, 2 cases (7%). CONCLUSIONS SRT-Bv treatment significantly prolonged survival duration more than Bv treatment and provides good local control in patients with recurrent HGGs, especially those with isocitrate dehydrogenase wild-type tumors.
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Affiliation(s)
- Takayuki Yasuda
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Yoshihiro Muragaki
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan; Faculty of Advanced Techno-Surgery, Institute of Biomedical Engineering and Science, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan.
| | - Masayuki Nitta
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan; Faculty of Advanced Techno-Surgery, Institute of Biomedical Engineering and Science, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Kazunari Miyamoto
- Department of Radiation therapy, Itabashi Chuo Medical Center, Itabashi-ku, Tokyo, Japan
| | - Yuko Oura
- Department of Radiation therapy, Itabashi Chuo Medical Center, Itabashi-ku, Tokyo, Japan
| | - Takuo Henmi
- Department of Pathology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Sanshiro Noguchi
- Department of Pathology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Hideaki Oda
- Department of Pathology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Taiichi Saito
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Takashi Maruyama
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan; Faculty of Advanced Techno-Surgery, Institute of Biomedical Engineering and Science, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Shoko Atsuchi
- Department of Neurosurgery, Itabashi Chuo Medical Center, Itabashi-ku, Tokyo, Japan
| | - Naohisa Miura
- Department of Neurosurgery, Itabashi Chuo Medical Center, Itabashi-ku, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
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16
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Rathore S, Akbari H, Doshi J, Shukla G, Rozycki M, Bilello M, Lustig R, Davatzikos C. Radiomic signature of infiltration in peritumoral edema predicts subsequent recurrence in glioblastoma: implications for personalized radiotherapy planning. J Med Imaging (Bellingham) 2018. [PMID: 29531967 DOI: 10.1117/1.jmi.5.2.021219] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Standard surgical resection of glioblastoma, mainly guided by the enhancement on postcontrast T1-weighted magnetic resonance imaging (MRI), disregards infiltrating tumor within the peritumoral edema region (ED). Subsequent radiotherapy typically delivers uniform radiation to peritumoral FLAIR-hyperintense regions, without attempting to target areas likely to be infiltrated more heavily. Noninvasive in vivo delineation of the areas of tumor infiltration and prediction of early recurrence in peritumoral ED could assist in targeted intensification of local therapies, thereby potentially delaying recurrence and prolonging survival. This paper presents a method for estimating peritumoral edema infiltration using radiomic signatures determined via machine learning methods, and tests it on 90 patients with de novo glioblastoma. The generalizability of the proposed predictive model was evaluated via cross-validation in a discovery cohort ([Formula: see text]) and was subsequently evaluated in a replication cohort ([Formula: see text]). Spatial maps representing the likelihood of tumor infiltration and future early recurrence were compared with regions of recurrence on postresection follow-up studies with pathology confirmation. The cross-validated accuracy of our predictive infiltration model on the discovery and replication cohorts was 87.51% (odds ratio = 10.22, sensitivity = 80.65, and specificity = 87.63) and 89.54% (odds ratio = 13.66, sensitivity = 97.06, and specificity = 76.73), respectively. The radiomic signature of the recurrent tumor region revealed higher vascularity and cellularity when compared with the nonrecurrent region. The proposed model shows evidence that multiparametric pattern analysis from clinical MRI sequences can assist in in vivo estimation of the spatial extent and pattern of tumor recurrence in peritumoral edema, which may guide supratotal resection and/or intensification of postoperative radiation therapy.
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Affiliation(s)
- Saima Rathore
- University of Pennsylvania, Center for Biomedical Image Computing and Analytics, Perelman School of Medicine, Philadelphia, Pennsylvania, United States.,University of Pennsylvania, Department of Radiology, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Hamed Akbari
- University of Pennsylvania, Center for Biomedical Image Computing and Analytics, Perelman School of Medicine, Philadelphia, Pennsylvania, United States.,University of Pennsylvania, Department of Radiology, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Jimit Doshi
- University of Pennsylvania, Center for Biomedical Image Computing and Analytics, Perelman School of Medicine, Philadelphia, Pennsylvania, United States.,University of Pennsylvania, Department of Radiology, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Gaurav Shukla
- University of Pennsylvania, Center for Biomedical Image Computing and Analytics, Perelman School of Medicine, Philadelphia, Pennsylvania, United States.,Thomas Jefferson University, Department of Radiation Oncology, Philadelphia, Pennsylvania, United States
| | - Martin Rozycki
- University of Pennsylvania, Center for Biomedical Image Computing and Analytics, Perelman School of Medicine, Philadelphia, Pennsylvania, United States.,University of Pennsylvania, Department of Radiology, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Michel Bilello
- University of Pennsylvania, Center for Biomedical Image Computing and Analytics, Perelman School of Medicine, Philadelphia, Pennsylvania, United States.,University of Pennsylvania, Department of Radiology, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Robert Lustig
- University of Pennsylvania, Department of Radiation Oncology, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Christos Davatzikos
- University of Pennsylvania, Center for Biomedical Image Computing and Analytics, Perelman School of Medicine, Philadelphia, Pennsylvania, United States.,University of Pennsylvania, Department of Radiology, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
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17
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Nagy M, Schulz-Ertner D, Bischof M, Welzel T, Hof H, Debus J, Combs SE. Long-Term Outcome of Postoperative Irradiation in Patients with Newly Diagnosed WHO Grade III Anaplastic Gliomas. TUMORI JOURNAL 2018; 95:317-24. [DOI: 10.1177/030089160909500308] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose Patients with anaplastic gliomas have a more favorable overall survival than patients with glioblastomas. In most analyses, WHO grade III and IV tumors are not analyzed separately. The present analysis reports outcome after postoperative radiotherapy in patients with WHO grade III gliomas. Patients and methods Between January 1988 and January 2007, 127 patients with WHO grade III tumors were treated with radiotherapy; the histological classification was pure astrocytoma in 104 patients, oligoastrocytoma in 12 and pure oligodendroglioma in 11 patients. Median age was 48 years. After the primary diagnosis, a biopsy had been performed in 72 patients; subtotal and total resections were performed in 37 and 18 patients, respectively. In all patients radiotherapy was applied with a median dose of 60 Gy in conventional fractionation. The median follow-up time was 18 months. Results Median overall survival was 17 months. Overall survival was significantly influenced by the extent of surgery. Median overall survival was 32 months after complete resection, 36 months after subtotal resection, and 12 months after biopsy. Median overall survival was 7 months for patients with anaplastic astrocytomas, 44 months for patients with mixed tumors, and 47 months for those with pure oligodendrogliomas. Age significantly influenced overall survival. Median progression-free survival was 9 months; the extent of neurosurgical resection significantly influenced progression-free survival. Conclusion Patients with WHO grade III anaplastic astrocytomas, oligodendrogliomas and oligoastrocytomas show favorable overall survival after postoperative radiotherapy compared with glioblastoma patients and should therefore be analyzed separately. Radiochemotherapy might further improve outcome.
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Affiliation(s)
- Monika Nagy
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Daniela Schulz-Ertner
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Marc Bischof
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Thomas Welzel
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Holger Hof
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
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18
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Gobitti C, Borsatti E, Arcicasa M, Roncadin M, Franchin G, Minatel E, Skrap M, Zanotti B, Tuniz F, Cimitan M, Capra E, Drigo A, Trovò MG. Treatment of recurrent high-grade gliomas with GliaSite brachytherapy: A prospective mono-institutional Italian experience. TUMORI JOURNAL 2018; 97:614-9. [DOI: 10.1177/030089161109700513] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background The present study evaluated toxicity, local control, and survival in patients with relapsed high-grade glioma after surgery and external beam radiation therapy and treated with re-operation and GliaSite brachytherapy. Methods Between 2006 and 2008, 15 patients with recurrent high-grade glioma underwent re-operation and GliaSite brachytherapy. Ten patients were males and 5 females. Median age was 40 years (range, 20–71). Karnofsky performance status was ≥70. All patients but one received GliaSite irradiation of the surgical cavity wall at the dose of 4500 cGy at a depth of 1 cm. Results No severe acute side effects were observed during GliaSite brachytherapy. Pathologically documented, symptomatic late radiation necrosis was observed in 3 patients (20%); 2 subsequently died of further complications. Two patients were alive at a median follow-up 13 months (range, 1–30). Median overall survival after GliaSite brachytherapy was 13 months. Conclusions Patients with recurrent high-grade glioma can be treated with additional surgery and GliaSite brachytherapy, delivering 4500 cGy at 1 cm depth without significant acute side effects but with a significant rate (20%) of late radiation necrosis, resulting in 13% of treatment-related deaths. Compared with the literature, survival results in our study appear to be satisfactory, but they may be related to patient selection criteria. Re-intervention followed by GliaSite brachytherapy should not be offered as a standard treatment for recurrent high-grade glioma, because of the high rate of late complications, treatment-related deaths, and high treatment costs.
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Affiliation(s)
- Carlo Gobitti
- Radiation Oncology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano
| | - Eugenio Borsatti
- Nuclear Medicine, Centro di Riferimento Oncologico, National Cancer Institute, Aviano
| | - Mauro Arcicasa
- Radiation Oncology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano
| | - Mario Roncadin
- Radiation Oncology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano
| | - Giovanni Franchin
- Radiation Oncology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano
| | - Emilio Minatel
- Radiation Oncology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano
| | - Miran Skrap
- Neurosurgery Department, University Hospital, Udine, Italy
| | - Bruno Zanotti
- Neurosurgery Department, University Hospital, Udine, Italy
| | | | - Marino Cimitan
- Nuclear Medicine, Centro di Riferimento Oncologico, National Cancer Institute, Aviano
| | - Elvira Capra
- Medical Physics Divisions, Centro di Riferimento Oncologico, National Cancer Institute, Aviano
| | - Annalisa Drigo
- Medical Physics Divisions, Centro di Riferimento Oncologico, National Cancer Institute, Aviano
| | - Mauro G Trovò
- Radiation Oncology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano
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19
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Harat M, Małkowski B, Wiatrowska I, Makarewicz R, Roszkowski K. Relationship between Glioblastoma Dose Volume Parameters Measured by Dual Time Point Fluoroethylthyrosine-PET and Clinical Outcomes. Front Neurol 2018; 8:756. [PMID: 29403428 PMCID: PMC5786516 DOI: 10.3389/fneur.2017.00756] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 12/29/2017] [Indexed: 12/03/2022] Open
Abstract
Glioblastoma multiforme (GBM) is highly invasive. Despite irradiation with wide margins, GBM usually recurs in-field. Recent in vitro data have suggested that progression might be promoted by sublethal irradiation. Fluoroethylthyrosine-PET (FET-PET) can be used to detect glioblastoma invasion not apparent on MRI. We therefore performed a retrospective analysis of a prospective clinical study to examine whether glioblastoma outcomes depend on dose volume parameters measured by MRI and FET-PET. Twenty-three patients were prospectively recruited to a study examining the role of dual time point FET-PET in the treatment planning of GBM radiotherapy. The dose delivered to the site of recurrence was subdivided into suboptimal-dose (SOD) and high-dose (HD) areas. Types of progression were defined for correlation with dosimetric parameters including V100% of gross tumor volume (GTV)PET, GTVPETMRI, and GTVMRI. The HD area did not cover the entire GTVPETMRI in any case. Recurrences were significantly more frequent in the SubD area (chi-squared test, p = 0.004). There was no relationship between increasing dose volume and progression. The V100% for GTVPET and progression-free survival (PFS) was positively correlated (Spearman’s rho 0.417; p = 0.038). Progression is more common in areas with suboptimal dosing. Dose heterogeneity within GTVPET may be responsible for shorter PFS.
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Affiliation(s)
- Maciej Harat
- Department of Radiotherapy, The Franciszek Lukaszczyk Oncology Centre, Bydgoszcz, Poland.,Department of Positron Emission Tomography and Molecular Imaging, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum, Bydgoszcz, Poland
| | - Bogdan Małkowski
- Department of Nuclear Medicine, The Franciszek Lukaszczyk Oncology Centre, Bydgoszcz, Poland.,Department of Medical Physics, The Franciszek Lukaszczyk Oncology Center, Bydgoszcz, Poland
| | - Izabela Wiatrowska
- Department of Oncology and Brachytherapy, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum, Bydgoszcz, Poland
| | - Roman Makarewicz
- Department of Positron Emission Tomography and Molecular Imaging, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum, Bydgoszcz, Poland.,Department of Oncology and Brachytherapy, The Franciszek Lukaszczyk Oncology Centre, Bydgoszcz, Poland
| | - Krzysztof Roszkowski
- Department of Radiotherapy, The Franciszek Lukaszczyk Oncology Centre, Bydgoszcz, Poland.,Department of Oncology, Radiotherapy and Ginecologic Oncology, Faculty of Health Sciences, Nicolaus Copernicus University Toruń, Bydgoszcz, Poland
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20
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Jensen MB, Guldberg TL, Harbøll A, Lukacova S, Kallehauge JF. Diffusion tensor magnetic resonance imaging driven growth modeling for radiotherapy target definition in glioblastoma. Acta Oncol 2017; 56:1639-1643. [PMID: 28893125 DOI: 10.1080/0284186x.2017.1374559] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The clinical target volume (CTV) in radiotherapy is routinely based on gadolinium contrast enhanced T1 weighted (T1w + Gd) and T2 weighted fluid attenuated inversion recovery (T2w FLAIR) magnetic resonance imaging (MRI) sequences which have been shown to over- or underestimate the microscopic tumor cell spread. Gliomas favor spread along the white matter fiber tracts. Tumor growth models incorporating the MRI diffusion tensors (DTI) allow to account more consistently for the glioma growth. The aim of the study was to investigate the potential of a DTI driven growth model to improve target definition in glioblastoma (GBM). MATERIAL AND METHODS Eleven GBM patients were scanned using T1w, T2w FLAIR, T1w + Gd and DTI. The brain was segmented into white matter, gray matter and cerebrospinal fluid. The Fisher-Kolmogorov growth model was used assuming uniform proliferation and a difference in white and gray matter diffusion of a ratio of 10. The tensor directionality was tested using an anisotropy weighting parameter set to zero (γ0) and twenty (γ20). The volumetric comparison was performed using Hausdorff distance, Dice similarity coefficient (DSC) and surface area. RESULTS The median of the standard CTV (CTVstandard) was 180 cm3. The median surface area of CTVstandard was 211 cm2. The median surface area of respective CTVγ0 and CTVγ20 significantly increased to 338 and 376 cm2, respectively. The Hausdorff distance was greater than zero and significantly increased for both CTVγ0 and CTVγ20 with respective median of 18.7 and 25.2 mm. The DSC for both CTVγ0 and CTVγ20 were significantly below one with respective median of 0.74 and 0.72, which means that 74 and 72% of CTVstandard were included in CTVγ0 and CTVγ20, respectively. CONCLUSIONS DTI driven growth models result in CTVs with a significantly increased surface area, a significantly increased Hausdorff distance and decreased overlap between the standard and model derived volume.
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Affiliation(s)
- Morten B. Jensen
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | | | - Anja Harbøll
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Slávka Lukacova
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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21
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Moghaddasi L, Bezak E. Development of an integrated Monte Carlo model for glioblastoma multiforme treated with boron neutron capture therapy. Sci Rep 2017; 7:7069. [PMID: 28765533 PMCID: PMC5539248 DOI: 10.1038/s41598-017-07302-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 06/27/2017] [Indexed: 12/04/2022] Open
Abstract
Glioblastomas (GBM) are notorious for their high fatality rate. Boron Neutron Capture Therapy (BNCT) being a biochemically targeted type of radiotherapy is a potent modality for GBM. In the current work, a BNCT treatment modelling framework for GBM was developed. Optimal Clinical Target Volume (CTV) margins for GBM-BNCT and the BNCT efficacy have been investigated. The model integrated a cell-based dosimetry model, an in-house-developed epithermal neutron beam model and previously-developed Microscopic Extension Probability (MEP) model. The system was defined as a cubic ICRP-brain phantom divided into 20 μm side voxels. The corresponding 10B concentrations in GBM and normal brain cells were applied. The in-silico model was irradiated with the epithermal neutron beam using 2 and 2.5 cm CTV margins. Results from the cell-based dosimetry and the MEP models were combined to calculate GBM cell survival fractions (SF) post BNCT and compared to x-ray radiotherapy (XRT) SFs. Compared to XRT, the SF within the beam decreased by five orders of magnitudes and the total SF was reduced three times following BNCT. CTV extension by 0.5 cm reduced the SF by additional (53.8 ± 0.3)%. In conclusion, BNCT results in a more efficient cell kill. The extension of the CTV margin, however, may not increase the treatment outcome significantly.
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Affiliation(s)
- Leyla Moghaddasi
- School of Physical Sciences, University of Adelaide, Adelaide, Australia. .,Department of Medical Physics, Adelaide Radiotherapy Centre, Adelaide, Australia.
| | - Eva Bezak
- School of Physical Sciences, University of Adelaide, Adelaide, Australia.,School of Health Sciences, University of South Australia, Adelaide, Australia.,Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
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22
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Boonzaier NR, Larkin TJ, Matys T, van der Hoorn A, Yan JL, Price SJ. Multiparametric MR Imaging of Diffusion and Perfusion in Contrast-enhancing and Nonenhancing Components in Patients with Glioblastoma. Radiology 2017; 284:180-190. [DOI: 10.1148/radiol.2017160150] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Natalie R. Boonzaier
- From the Cambridge Brain Tumour Imaging Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences (N.R.B., T.J.L., A.v.d.H., J.L.Y., S.J.P.), Wolfson Brain Imaging Centre, Department of Clinical Neurosciences (N.R.B., T.J.L., J.L.Y., S.J.P.), and Department of Radiology (T.M., A.v.d.H.), University of Cambridge, Cambridge, England; Cancer Trials Unit Department of Oncology, Addenbrooke’s Hospital, Cambridge, England (T.M.); Department of Radiology, University Medical Centre Groningen,
| | - Timothy J. Larkin
- From the Cambridge Brain Tumour Imaging Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences (N.R.B., T.J.L., A.v.d.H., J.L.Y., S.J.P.), Wolfson Brain Imaging Centre, Department of Clinical Neurosciences (N.R.B., T.J.L., J.L.Y., S.J.P.), and Department of Radiology (T.M., A.v.d.H.), University of Cambridge, Cambridge, England; Cancer Trials Unit Department of Oncology, Addenbrooke’s Hospital, Cambridge, England (T.M.); Department of Radiology, University Medical Centre Groningen,
| | - Tomasz Matys
- From the Cambridge Brain Tumour Imaging Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences (N.R.B., T.J.L., A.v.d.H., J.L.Y., S.J.P.), Wolfson Brain Imaging Centre, Department of Clinical Neurosciences (N.R.B., T.J.L., J.L.Y., S.J.P.), and Department of Radiology (T.M., A.v.d.H.), University of Cambridge, Cambridge, England; Cancer Trials Unit Department of Oncology, Addenbrooke’s Hospital, Cambridge, England (T.M.); Department of Radiology, University Medical Centre Groningen,
| | - Anouk van der Hoorn
- From the Cambridge Brain Tumour Imaging Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences (N.R.B., T.J.L., A.v.d.H., J.L.Y., S.J.P.), Wolfson Brain Imaging Centre, Department of Clinical Neurosciences (N.R.B., T.J.L., J.L.Y., S.J.P.), and Department of Radiology (T.M., A.v.d.H.), University of Cambridge, Cambridge, England; Cancer Trials Unit Department of Oncology, Addenbrooke’s Hospital, Cambridge, England (T.M.); Department of Radiology, University Medical Centre Groningen,
| | - Jiun-Lin Yan
- From the Cambridge Brain Tumour Imaging Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences (N.R.B., T.J.L., A.v.d.H., J.L.Y., S.J.P.), Wolfson Brain Imaging Centre, Department of Clinical Neurosciences (N.R.B., T.J.L., J.L.Y., S.J.P.), and Department of Radiology (T.M., A.v.d.H.), University of Cambridge, Cambridge, England; Cancer Trials Unit Department of Oncology, Addenbrooke’s Hospital, Cambridge, England (T.M.); Department of Radiology, University Medical Centre Groningen,
| | - Stephen J. Price
- From the Cambridge Brain Tumour Imaging Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences (N.R.B., T.J.L., A.v.d.H., J.L.Y., S.J.P.), Wolfson Brain Imaging Centre, Department of Clinical Neurosciences (N.R.B., T.J.L., J.L.Y., S.J.P.), and Department of Radiology (T.M., A.v.d.H.), University of Cambridge, Cambridge, England; Cancer Trials Unit Department of Oncology, Addenbrooke’s Hospital, Cambridge, England (T.M.); Department of Radiology, University Medical Centre Groningen,
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23
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Akbari H, Macyszyn L, Da X, Bilello M, Wolf RL, Martinez-Lage M, Biros G, Alonso-Basanta M, OʼRourke DM, Davatzikos C. Imaging Surrogates of Infiltration Obtained Via Multiparametric Imaging Pattern Analysis Predict Subsequent Location of Recurrence of Glioblastoma. Neurosurgery 2016; 78:572-80. [PMID: 26813856 DOI: 10.1227/neu.0000000000001202] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Glioblastoma is an aggressive and highly infiltrative brain cancer. Standard surgical resection is guided by enhancement on postcontrast T1-weighted (T1) magnetic resonance imaging, which is insufficient for delineating surrounding infiltrating tumor. OBJECTIVE To develop imaging biomarkers that delineate areas of tumor infiltration and predict early recurrence in peritumoral tissue. Such markers would enable intensive, yet targeted, surgery and radiotherapy, thereby potentially delaying recurrence and prolonging survival. METHODS Preoperative multiparametric magnetic resonance images (T1, T1-gadolinium, T2-weighted, T2-weighted fluid-attenuated inversion recovery, diffusion tensor imaging, and dynamic susceptibility contrast-enhanced magnetic resonance images) from 31 patients were combined using machine learning methods, thereby creating predictive spatial maps of infiltrated peritumoral tissue. Cross-validation was used in the retrospective cohort to achieve generalizable biomarkers. Subsequently, the imaging signatures learned from the retrospective study were used in a replication cohort of 34 new patients. Spatial maps representing the likelihood of tumor infiltration and future early recurrence were compared with regions of recurrence on postresection follow-up studies with pathology confirmation. RESULTS This technique produced predictions of early recurrence with a mean area under the curve of 0.84, sensitivity of 91%, specificity of 93%, and odds ratio estimates of 9.29 (99% confidence interval: 8.95-9.65) for tissue predicted to be heavily infiltrated in the replication study. Regions of tumor recurrence were found to have subtle, yet fairly distinctive multiparametric imaging signatures when analyzed quantitatively by pattern analysis and machine learning. CONCLUSION Visually imperceptible imaging patterns discovered via multiparametric pattern analysis methods were found to estimate the extent of infiltration and location of future tumor recurrence, paving the way for improved targeted treatment.
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Affiliation(s)
- Hamed Akbari
- Departments of ‡Radiology, §Neurosurgery, ¶Pathology and Laboratory Medicine, and ‖Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia, Pennsylvania; #Institute for Computational Engineering and Sciences, The University of Texas at Austin, Austin, Texas; **Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
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24
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Amino-acid PET versus MRI guided re-irradiation in patients with recurrent glioblastoma multiforme (GLIAA) - protocol of a randomized phase II trial (NOA 10/ARO 2013-1). BMC Cancer 2016; 16:769. [PMID: 27716184 PMCID: PMC5052714 DOI: 10.1186/s12885-016-2806-z] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/22/2016] [Indexed: 12/21/2022] Open
Abstract
Background The higher specificity of amino-acid positron emission tomography (AA-PET) in the diagnosis of gliomas, as well as in the differentiation between recurrence and treatment-related alterations, in comparison to contrast enhancement in T1-weighted MRI was demonstrated in many studies and is the rationale for their implementation into radiation oncology treatment planning. Several clinical trials have demonstrated the significant differences between AA-PET and standard MRI concerning the definition of the gross tumor volume (GTV). A small single-center non-randomized prospective study in patients with recurrent high grade gliomas treated with stereotactic fractionated radiotherapy (SFRT) showed a significant improvement in survival when AA-PET was integrated in target volume delineation, in comparison to patients treated based on CT/MRI alone. Methods This protocol describes a prospective, open label, randomized, multi-center phase II trial designed to test if radiotherapy target volume delineation based on FET-PET leads to improvement in progression free survival (PFS) in patients with recurrent glioblastoma (GBM) treated with re-irradiation, compared to target volume delineation based on T1Gd-MRI. The target sample size is 200 randomized patients with a 1:1 allocation ratio to both arms. The primary endpoint (PFS) is determined by serial MRI scans, supplemented by AA-PET-scans and/or biopsy/surgery if suspicious of progression. Secondary endpoints include overall survival (OS), locally controlled survival (time to local progression or death), volumetric assessment of GTV delineated by either method, topography of progression in relation to MRI- or PET-derived target volumes, rate of long term survivors (>1 year), localization of necrosis after re-irradiation, quality of life (QoL) assessed by the EORTC QLQ-C15 PAL questionnaire, evaluation of safety of FET-application in AA-PET imaging and toxicity of re-irradiation. Discussion This is a protocol of a randomized phase II trial designed to test a new strategy of radiotherapy target volume delineation for improving the outcome of patients with recurrent GBM. Moreover, the trial will help to develop a standardized methodology for the integration of AA-PET and other imaging biomarkers in radiation treatment planning. Trial registration The GLIAA trial is registered with ClinicalTrials.gov (NCT01252459, registration date 02.12.2010), German Clinical Trials Registry (DRKS00000634, registration date 10.10.2014), and European Clinical Trials Database (EudraCT-No. 2012-001121-27, registration date 27.02.2012).
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25
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Mujokoro B, Adabi M, Sadroddiny E, Adabi M, Khosravani M. Nano-structures mediated co-delivery of therapeutic agents for glioblastoma treatment: A review. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2016; 69:1092-102. [PMID: 27612807 DOI: 10.1016/j.msec.2016.07.080] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 07/10/2016] [Accepted: 07/31/2016] [Indexed: 11/18/2022]
Abstract
Glioblastoma is a malignant brain tumor and leads to death in most patients. Chemotherapy is a common method for brain cancer in clinics. However, the recent advancements in the chemotherapy of brain tumors have not been efficient enough. With the advancement of nanotechnology, the used drugs can enhance chemotherapy efficiency and increase the access to brain cancers. Combination of therapeutic agents has been recently attracted great attention for glioblastoma chemotherapy. One of the early benefits of combination therapies is the high potential to provide synergistic effects and decrease adverse side effects associated with high doses of single anticancer drugs. Therefore, brain tumor treatments with combination drugs can be considered as a crucial approach for avoiding tumor growth. This review investigates current progress in nano-mediated co-delivery of therapeutic agents with focus on glioblastoma chemotherapy prognosis.
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Affiliation(s)
- Basil Mujokoro
- Department of Medical Nanotechnology, School of Advanced Technologies in Medicine, International Campus, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Adabi
- Young Researchers and Elite Club, Roudehen Branch, Islamic Azad University, Roudehen, Iran
| | - Esmaeil Sadroddiny
- Department of Medical Biotechnology, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Adabi
- Department of Medical Nanotechnology, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran.
| | - Masood Khosravani
- Department of Medical Nanotechnology, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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26
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Piroth MD, Galldiks N, Pinkawa M, Holy R, Stoffels G, Ermert J, Mottaghy FM, Shah NJ, Langen KJ, Eble MJ. Relapse patterns after radiochemotherapy of glioblastoma with FET PET-guided boost irradiation and simulation to optimize radiation target volume. Radiat Oncol 2016; 11:87. [PMID: 27342976 PMCID: PMC4920983 DOI: 10.1186/s13014-016-0665-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 06/23/2016] [Indexed: 12/14/2022] Open
Abstract
Background O-(2-18 F-fluoroethyl)-L-tyrosine-(FET)-PET may be helpful to improve the definition of radiation target volumes in glioblastomas compared with MRI. We analyzed the relapse patterns in FET-PET after a FET- and MRI-based integrated-boost intensity-modulated radiotherapy (IMRT) of glioblastomas to perform an optimized target volume definition. Methods A relapse pattern analysis was performed in 13 glioblastoma patients treated with radiochemotherapy within a prospective phase-II-study between 2008 and 2009. Radiotherapy was performed as an integrated-boost intensity-modulated radiotherapy (IB-IMRT). The prescribed dose was 72 Gy for the boost target volume, based on baseline FET-PET (FET-1) and 60 Gy for the MRI-based (MRI-1) standard target volume. The single doses were 2.4 and 2.0 Gy, respectively. Location and volume of recurrent tumors in FET-2 and MRI-2 were analyzed related to initial tumor, detected in baseline FET-1. Variable target volumes were created theoretically based on FET-1 to optimally cover recurrent tumor. Results The tumor volume overlap in FET and MRI was poor both at baseline (median 12 %; range 0–32) and at time of recurrence (13 %; 0–100). Recurrent tumor volume in FET-2 was localized to 39 % (12–91) in the initial tumor volume (FET-1). Over the time a shrinking (mean 12 (5–26) ml) and shifting (mean 6 (1–10 mm) of the resection cavity was seen. A simulated target volume based on active tumor in FET-1 with an additional safety margin of 7 mm around the FET-1 volume covered recurrent FET tumor volume (FET-2) significantly better than a corresponding target volume based on contrast enhancement in MRI-1 with a same safety margin of 7 mm (100 % (54–100) versus 85 % (0–100); p < 0.01). A simulated planning target volume (PTV), based on FET-1 and additional 7 mm margin plus 5 mm margin for setup-uncertainties was significantly smaller than the conventional, MR-based PTV applied in this study (median 160 (112–297) ml versus 231 (117–386) ml, p < 0.001). Conclusions In this small study recurrent tumor volume in FET-PET (FET-2) overlapped only to one third with the boost target volume, based on FET-1. The shrinking and shifting of the resection cavity may have an influence considering the limited overlap of initial and relapse tumor volume. A simulated target volume, based on FET-1 with 7 mm margin covered 100 % of relapse volume in median and led to a significantly reduced PTV, compared to MRI-based PTVs. This approach may achieve similar therapeutic efficacy but lower side effects offering a broader window to intensify concomitant systemic treatment focusing distant failures.
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Affiliation(s)
- Marc D Piroth
- Department of Radiation Oncology, University Hospital RWTH Aachen, Aachen, Germany. .,Jülich-Aachen Research Alliance (JARA) - Section JARA-Brain, Research Center Jülich, Jülich, Germany. .,Department of Radiation Oncology, HELIOS University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany.
| | - Norbert Galldiks
- Institute of Neuroscience and Medicine, Research Center Jülich, Jülich, Germany.,Jülich-Aachen Research Alliance (JARA) - Section JARA-Brain, Research Center Jülich, Jülich, Germany.,Department of Neurology, University of Cologne, Cologne, Germany
| | - Michael Pinkawa
- Department of Radiation Oncology, University Hospital RWTH Aachen, Aachen, Germany.,Jülich-Aachen Research Alliance (JARA) - Section JARA-Brain, Research Center Jülich, Jülich, Germany
| | - Richard Holy
- Department of Radiation Oncology, University Hospital RWTH Aachen, Aachen, Germany.,Jülich-Aachen Research Alliance (JARA) - Section JARA-Brain, Research Center Jülich, Jülich, Germany.,Department of Radiation Oncology, HELIOS University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | - Gabriele Stoffels
- Institute of Neuroscience and Medicine, Research Center Jülich, Jülich, Germany.,Jülich-Aachen Research Alliance (JARA) - Section JARA-Brain, Research Center Jülich, Jülich, Germany
| | - Johannes Ermert
- Institute of Neuroscience and Medicine, Research Center Jülich, Jülich, Germany.,Jülich-Aachen Research Alliance (JARA) - Section JARA-Brain, Research Center Jülich, Jülich, Germany
| | - Felix M Mottaghy
- Department of Nuclear Medicine, University Hospital RWTH Aachen, Aachen, Germany.,Jülich-Aachen Research Alliance (JARA) - Section JARA-Brain, Research Center Jülich, Jülich, Germany
| | - N Jon Shah
- Department of Neurology, University Hospital RWTH Aachen, Aachen, Germany.,Institute of Neuroscience and Medicine, Research Center Jülich, Jülich, Germany.,Jülich-Aachen Research Alliance (JARA) - Section JARA-Brain, Research Center Jülich, Jülich, Germany
| | - Karl-Josef Langen
- Department of Nuclear Medicine, University Hospital RWTH Aachen, Aachen, Germany.,Institute of Neuroscience and Medicine, Research Center Jülich, Jülich, Germany.,Jülich-Aachen Research Alliance (JARA) - Section JARA-Brain, Research Center Jülich, Jülich, Germany
| | - Michael J Eble
- Department of Radiation Oncology, University Hospital RWTH Aachen, Aachen, Germany.,Jülich-Aachen Research Alliance (JARA) - Section JARA-Brain, Research Center Jülich, Jülich, Germany
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Manon R, Hui S, Chinnaiyan P, Suh J, Chang E, Timmerman R, Phan S, Das R, Mehta M. The Impact of Mid-Treatment MRI on Defining Boost Volumes in the Radiation Treatment of Glioblastoma Multiforme. Technol Cancer Res Treat 2016; 3:303-7. [PMID: 15161323 DOI: 10.1177/153303460400300308] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Radiation therapy is a central modality in the treatment of glioblastoma multiforme (GBM). Integral to adequate radiation therapy delivery is the appropriate determination of tumor volume and extent at the time treatment is being delivered. As a matter of routine practice, radiation therapy treatment fields are designed based on tumor volumes evident on preoperative or immediate post-operative MRIs; another MRI is generally not obtained for planning boost fields. In some instances the time interval from surgery to radiotherapy initiation is up to 5 weeks and the boost or “cone-down phase” commences 4–5 weeks later. The contrast enhanced T1 MRI may not be a totally reliable indicator of active tumor, especially in regions where such blood-brain barrier breakdown has not occurred. Moreover, these volumes may change during the course of treatment. This may lead to a geographic miss when mid-treatment boost volumes are designed based on a pre-radiotherapy MRI. The goal of this study is to examine how a mid-treatment MRI impacts the delineation and definition of the boost volume in GBM patients in comparison to the pre-treatment MRI scan, particularly when the tumor-specific agent Motexafin-Gadolinium is used.
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Affiliation(s)
- Rafael Manon
- University of Wisconsin, Department of Radiation Oncology, K4/B100, 600 Highland Ave, Madison, WI 53792, USA.
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Zhao F, Li M, Kong L, Zhang G, Yu J. Delineation of radiation therapy target volumes for patients with postoperative glioblastoma: a review. Onco Targets Ther 2016; 9:3197-204. [PMID: 27313465 PMCID: PMC4892826 DOI: 10.2147/ott.s104241] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Glioblastoma is the most aggressive and lethal primary malignancy of the brain, and radiotherapy (RT) is a fundamental part of its treatment. However, the optimal radiation treatment conditions are still a matter of debate, and there is no clear consensus concerning the inclusion of peritumoral edema in the clinical target volume calculation. Target delineation calculations that use postoperative residual tumor and cavity volumes plus 2 cm margins result in smaller volumes of normal brain receiving high-dose irradiation, compared to calculations that include expanded edema. Smaller RT fields may be more appropriate than larger RT fields, possibly reducing the risk of late neurological deterioration, especially in patients with significant peritumoral edema. This review focuses on the factors influencing target delineation, such as peritumoral edema, failure patterns, and prognostic factors (clinical and pathological characteristics) of patients with glioblastoma. Based on this information, we make three suggestions for radiation oncologists to refer to in daily practice. Further study is necessary to investigate the unresolved problems related to routine clinical application of RT.
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Affiliation(s)
- Fen Zhao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jinan, Shandong, People's Republic of China; Key Laboratory of Radiation Oncology Shandong Province, Jinan, Shandong, People's Republic of China
| | - Minghuan Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jinan, Shandong, People's Republic of China; Key Laboratory of Radiation Oncology Shandong Province, Jinan, Shandong, People's Republic of China
| | - Li Kong
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jinan, Shandong, People's Republic of China; Key Laboratory of Radiation Oncology Shandong Province, Jinan, Shandong, People's Republic of China
| | - Guoli Zhang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jinan, Shandong, People's Republic of China; Key Laboratory of Radiation Oncology Shandong Province, Jinan, Shandong, People's Republic of China
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jinan, Shandong, People's Republic of China; Key Laboratory of Radiation Oncology Shandong Province, Jinan, Shandong, People's Republic of China
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Compter I, Peerlings J, Eekers DBP, Postma AA, Ivanov D, Wiggins CJ, Kubben P, Küsters B, Wesseling P, Ackermans L, Schijns OEMG, Lambin P, Hoffmann AL. Technical feasibility of integrating 7 T anatomical MRI in image-guided radiotherapy of glioblastoma: a preparatory study. MAGNETIC RESONANCE MATERIALS IN PHYSICS BIOLOGY AND MEDICINE 2016; 29:591-603. [DOI: 10.1007/s10334-016-0534-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 02/03/2016] [Accepted: 02/10/2016] [Indexed: 10/22/2022]
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30
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Price SJ, Young AMH, Scotton WJ, Ching J, Mohsen LA, Boonzaier NR, Lupson VC, Griffiths JR, McLean MA, Larkin TJ. Multimodal MRI can identify perfusion and metabolic changes in the invasive margin of glioblastomas. J Magn Reson Imaging 2016; 43:487-94. [PMID: 26140696 PMCID: PMC5008200 DOI: 10.1002/jmri.24996] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 06/23/2015] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To use perfusion and magnetic resonance (MR) spectroscopy to compare the diffusion tensor imaging (DTI)-defined invasive and noninvasive regions. Invasion of normal brain is a cardinal feature of glioblastomas (GBM) and a major cause of treatment failure. DTI can identify invasive regions. MATERIALS AND METHODS In all, 50 GBM patients were imaged preoperatively at 3T with anatomic sequences, DTI, dynamic susceptibility perfusion MR (DSCI), and multivoxel spectroscopy. The DTI and DSCI data were coregistered to the spectroscopy data and regions of interest (ROIs) were made in the invasive (determined by DTI), noninvasive regions, and normal brain. Values of relative cerebral blood volume (rCBV), N-acetyl aspartate (NAA), myoinositol (mI), total choline (Cho), and glutamate + glutamine (Glx) normalized to creatine (Cr) and Cho/NAA were measured at each ROI. RESULTS Invasive regions showed significant increases in rCBV, suggesting angiogenesis (invasive rCBV 1.64 [95% confidence interval, CI: 1.5-1.76] vs. noninvasive 1.14 [1.09-1.18]; P < 0.001), Cho/Cr (invasive 0.42 [0.38-0.46] vs. noninvasive 0.35 [0.31-0.38]; P = 0.02) and Cho/NAA (invasive 0.54 [0.41-0.68] vs. noninvasive 0.37 [0.29-0.45]; P = < 0.03), suggesting proliferation, and Glx/Cr (invasive 1.54 [1.27-1.82] vs. noninvasive 1.3 [1.13-1.47]; P = 0.028), suggesting glutamate release; and a significantly reduced NAA/Cr (invasive 0.95 [0.85-1.05] vs. noninvasive 1.19 [1.06-1.31]; P = 0.008). The mI/Cr was not different between the three ROIs (invasive 1.2 [0.99-1.41] vs. noninvasive 1.3 [1.14-1.46]; P = 0.68). In the noninvasive regions, the values were not different from normal brain. CONCLUSION Combining DTI to identify the invasive region with perfusion and spectroscopy, we can identify changes in invasive regions not seen in noninvasive regions.
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Affiliation(s)
- Stephen J Price
- Neurosurgery Division, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Adam M H Young
- Neurosurgery Division, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - William J Scotton
- Neurosurgery Division, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Jared Ching
- Neurosurgery Division, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Laila A Mohsen
- University Department of Radiology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Natalie R Boonzaier
- Neurosurgery Division, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Victoria C Lupson
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - John R Griffiths
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Cambridge, UK
| | - Mary A McLean
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Cambridge, UK
| | - Timothy J Larkin
- Neurosurgery Division, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
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Niyazi M, Brada M, Chalmers AJ, Combs SE, Erridge SC, Fiorentino A, Grosu AL, Lagerwaard FJ, Minniti G, Mirimanoff RO, Ricardi U, Short SC, Weber DC, Belka C. ESTRO-ACROP guideline “target delineation of glioblastomas”. Radiother Oncol 2016; 118:35-42. [DOI: 10.1016/j.radonc.2015.12.003] [Citation(s) in RCA: 201] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 12/13/2015] [Indexed: 11/26/2022]
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Tryptophan PET predicts spatial and temporal patterns of post-treatment glioblastoma progression detected by contrast-enhanced MRI. J Neurooncol 2015; 126:317-25. [PMID: 26514361 DOI: 10.1007/s11060-015-1970-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 10/25/2015] [Indexed: 10/22/2022]
Abstract
Amino acid PET is increasingly utilized for the detection of recurrent gliomas. Increased amino acid uptake is often observed outside the contrast-enhancing brain tumor mass. In this study, we evaluated if non-enhancing PET+ regions could predict spatial and temporal patterns of subsequent MRI progression in previously treated glioblastomas. Twelve patients with a contrast-enhancing area suspicious for glioblastoma recurrence on MRI underwent PET scanning with the amino acid radiotracer alpha-[(11)C]-methyl-L-tryptophan (AMT). Brain regions showing increased AMT uptake in and outside the contrast-enhancing volume were objectively delineated to include high uptake consistent with glioma (as defined by previous studies). Volume and tracer uptake of such non-enhancing PET+ regions were compared to spatial patterns and timing of subsequent progression of the contrast-enhancing lesion, as defined by serial surveillance MRI. Non-enhancing PET+ volumes varied widely across patients and extended up to 24 mm from the edge of MRI contrast enhancement. In ten patients with clear progression of the contrast-enhancing lesion, the non-enhancing PET+ volumes predicted the location of new enhancement, which extended beyond the PET+ brain tissue in six. In two patients, with no PET+ area beyond the initial contrast enhancement, MRI remained stable. There was a negative correlation between AMT uptake in non-enhancing brain and time to subsequent progression (r = -0.77, p = 0.003). Amino acid PET imaging could complement MRI not only for detecting glioma recurrence but also predicting the location and timing of subsequent tumor progression. This could support decisions for surgical intervention or other targeted therapies for recurrent gliomas.
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Prognostic Value of MRS Metabolites in Postoperative Irradiated High Grade Gliomas. BIOMED RESEARCH INTERNATIONAL 2015; 2015:341042. [PMID: 26339606 PMCID: PMC4538329 DOI: 10.1155/2015/341042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 02/09/2015] [Indexed: 11/17/2022]
Abstract
Purpose. We studied the prognostic significance of Magnetic Resonance Spectroscopy (MRS) in operated high grade gliomas. Materials and Methods. Twelve patients were treated with radiotherapy and Temozolomide. The MRS data were taken four weeks after operation (before radiotherapy) and every six months after the completion of RT. The N-acetyl aspartate, choline, creatine, and myo-inositol parameters were quantified, analyzed, and correlated to recurrence-free survival (RFS). Results. The median RFS was 26.06 months. RFS was significantly worse in elderly patients (P = 0.001) along with the higher choline/creatine ratios at either baseline (P = 0.003) or six months post Radiotherapy (P = 0.042). Median RFS was 23 months in high choline/creatine levels ≥2 at 6 months after radiotherapy and 11 months for those with <2 choline/creatine levels. There was a significant correlation of maximum difference of choline/creatine ratio with RFS (rho = 0.64, P = 0.045). Conclusion. Age and choline/creatine ratio are strong independent prognostic factors in high grade gliomas.
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Navarria P, Reggiori G, Pessina F, Ascolese AM, Tomatis S, Mancosu P, Lobefalo F, Clerici E, Lopci E, Bizzi A, Grimaldi M, Chiti A, Simonelli M, Santoro A, Bello L, Scorsetti M. Investigation on the role of integrated PET/MRI for target volume definition and radiotherapy planning in patients with high grade glioma. Radiother Oncol 2014; 112:425-9. [PMID: 25308182 DOI: 10.1016/j.radonc.2014.09.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 09/08/2014] [Accepted: 09/09/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE To evaluate the impact of fluid-attenuated-inversion-recovery MRI (FLAIR/MRI) and Carbon-11-labeled-methionine PET (11C-MET-PET) on high grade glioma (HGG) tumor volume delineation for radiotherapy planning. MATERIAL AND METHODS Sixty-nine patients with HGG were evaluated. The clinical target volumes (CTV1, generated by adding a 10mm margin to FLAIRMRI area, CTV2 by adding a 20mm margin to enhanced T1MRI) and biological target volume (BTV) were delineated on pre-operative MRI images and 11CMETPET respectively. RESULTS The overlap between CTV1 and CTV2 showed a low correlation between the two volumes with CTV1 not always fully included into the CTV2. In all cases the whole BTV was included into the CTV1, while in 35/69 patients (50%) part of BTV was outside the CTV2 despite larger margins were added. In all cases recurrences were within the CTV1 volume and in 19/38 (50%) partially outside the CTV2. In all patients relapse corresponded to the BTV area. CONCLUSIONS Our data suggest that the target volume definition using FLAIR-MRI is more adequate compared to enhanced T1MRI. 11C-METPET uptake could help identify microscopic residual areas.
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Affiliation(s)
- Pierina Navarria
- Radiotherapy and Radiosurgery Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy.
| | - Giacomo Reggiori
- Radiotherapy and Radiosurgery Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy
| | - Federico Pessina
- Neurosurgical Oncology Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy
| | - Anna Maria Ascolese
- Radiotherapy and Radiosurgery Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy
| | - Pietro Mancosu
- Radiotherapy and Radiosurgery Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy
| | - Francesca Lobefalo
- Radiotherapy and Radiosurgery Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy
| | - Egesta Lopci
- Nuclear Medicine Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy
| | - Alberto Bizzi
- Neuroradiology Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy
| | - Marco Grimaldi
- Neuroradiology Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy
| | - Arturo Chiti
- Nuclear Medicine Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy
| | - Matteo Simonelli
- Oncology and Hematology Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy
| | - Armando Santoro
- Oncology and Hematology Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy
| | - Lorenzo Bello
- Neurosurgical Oncology Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Istituto Clinico Humanitas Cancer Center, Milan, Italy
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Parra NA, Maudsley AA, Gupta RK, Ishkanian F, Huang K, Walker GR, Padgett K, Roy B, Panoff J, Markoe A, Stoyanova R. Volumetric spectroscopic imaging of glioblastoma multiforme radiation treatment volumes. Int J Radiat Oncol Biol Phys 2014; 90:376-84. [PMID: 25066215 DOI: 10.1016/j.ijrobp.2014.03.049] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Revised: 02/27/2014] [Accepted: 03/28/2014] [Indexed: 11/19/2022]
Abstract
PURPOSE Magnetic resonance (MR) imaging and computed tomography (CT) are used almost exclusively in radiation therapy planning of glioblastoma multiforme (GBM), despite their well-recognized limitations. MR spectroscopic imaging (MRSI) can identify biochemical patterns associated with normal brain and tumor, predominantly by observation of choline (Cho) and N-acetylaspartate (NAA) distributions. In this study, volumetric 3-dimensional MRSI was used to map these compounds over a wide region of the brain and to evaluate metabolite-defined treatment targets (metabolic tumor volumes [MTV]). METHODS AND MATERIALS Volumetric MRSI with effective voxel size of ∼1.0 mL and standard clinical MR images were obtained from 19 GBM patients. Gross tumor volumes and edema were manually outlined, and clinical target volumes (CTVs) receiving 46 and 60 Gy were defined (CTV46 and CTV60, respectively). MTVCho and MTVNAA were constructed based on volumes with high Cho and low NAA relative to values estimated from normal-appearing tissue. RESULTS The MRSI coverage of the brain was between 70% and 76%. The MTVNAA were almost entirely contained within the edema, and the correlation between the 2 volumes was significant (r=0.68, P=.001). In contrast, a considerable fraction of MTVCho was outside of the edema (median, 33%) and for some patients it was also outside of the CTV46 and CTV60. These untreated volumes were greater than 10% for 7 patients (37%) in the study, and on average more than one-third (34.3%) of the MTVCho for these patients were outside of CTV60. CONCLUSIONS This study demonstrates the potential usefulness of whole-brain MRSI for radiation therapy planning of GBM and revealed that areas of metabolically active tumor are not covered by standard RT volumes. The described integration of MTV into the RT system will pave the way to future clinical trials investigating outcomes in patients treated based on metabolic information.
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Affiliation(s)
- N Andres Parra
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida
| | - Andrew A Maudsley
- Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida
| | - Rakesh K Gupta
- Department of Radiology & Imaging, Fortis Memorial Research Institute, Gurgaon, Haryana, India
| | - Fazilat Ishkanian
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida
| | - Kris Huang
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida
| | - Gail R Walker
- Biostatistics and Bioinformatics Core Resource, Sylvester Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Kyle Padgett
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida; Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida
| | - Bhaswati Roy
- Department of Radiology & Imaging, Fortis Memorial Research Institute, Gurgaon, Haryana, India
| | - Joseph Panoff
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida
| | - Arnold Markoe
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida
| | - Radka Stoyanova
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida.
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Hypofractionated stereotactic reirradiation for recurrent glioblastoma. J Neurooncol 2014; 120:117-23. [PMID: 25012955 DOI: 10.1007/s11060-014-1524-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 06/28/2014] [Indexed: 12/19/2022]
Abstract
Treatment choices for recurrent glioblastoma patients are sparse and the results are not satisfactory. In this retrospective analysis, we evaluated the results of re-irradiation of locally recurrent glioblastoma patients with an image-guided, fractionated, frameless stereotactic radiotherapy (SRT) technique. We treated 37 patients with the diagnosis of recurrent glioblastoma from September 2009 to December 2011. SRT was performed in a median five fractions (range, 1-5 fractions) with CyberKnife(®) (Accuray Incorporated, Sunnyvale, CA, USA). The dose given ranged from 14 to 32 Gy (median, 30 Gy). The median volume of the GTV was 24 cc (range, 2-81 cc). Median follow-up was 9.3 months. Five patients had regression in their lesions, 14 had stable disease, progression was observed in eight patients, and seven patients had pseudoprogression. The median survival following SRT was 10.6 months (range, 1.1-20 months) and overall survival following initial treatment was 35.5 months. The time to progression following SRT was 7.9 months in median. Patients with pseudoprogression had significantly longer survival after the first magnetic resonance imaging (MRI) compared to those with regression, stable or progressive disease (p = 0.012). The median survival after SRT for patients with pseudoprogression was 20 months. Patients who had GTV <24 cc had significantly longer survival following SRT compared to those with lesions ≥24 cc (p = 0.015). Patients who had chemotherapy after SRT had a median survival of 16.8 months. This was 9.7 months for patients who were not prescribed any chemotherapy (p = 0.062).
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37
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Whitfield GA, Kennedy SR, Djoukhadar IK, Jackson A. Imaging and target volume delineation in glioma. Clin Oncol (R Coll Radiol) 2014; 26:364-76. [PMID: 24824451 DOI: 10.1016/j.clon.2014.04.026] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 04/11/2014] [Indexed: 11/22/2022]
Abstract
Here we review current practices in target volume delineation for radical radiotherapy planning for gliomas. Current radiotherapy planning margins for glioma are informed by historic data of recurrence patterns using radiological imaging or post-mortem studies. Radiotherapy planning for World Health Organization grade II-IV gliomas currently relies predominantly on T1-weighted contrast-enhanced magnetic resonance imaging (MRI) and T2/fluid-attenuated inversion recovery sequences to identify the gross tumour volume (GTV). Isotropic margins are added empirically for each tumour type, usually without any patient-specific individualisation. We discuss novel imaging techniques that have the potential to influence radiotherapy planning, by improving definition of the tumour extent and its routes of invasion, thus modifying the GTV and allowing anisotropic expansion to a clinical target volume better reflecting areas at risk of recurrence. Identifying the relationships of tumour boundaries to important white matter pathways and eloquent areas of cerebral cortex could lead to reduced normal tissue complications. Novel magnetic resonance approaches to identify tumour extent and invasion include: (i) diffusion-weighted magnetic resonance metrics; (ii) diffusion tensor imaging; and (iii) positron emission tomography, using radiolabelled amino acids methyl-11C-L-methionine and 18F-fluoroethyltyrosine. Novel imaging techniques may also have a role together with clinical characteristics and molecular genetic markers in predicting response to therapy. Most significant among these techniques is dynamic contrast-enhanced MRI, which uses dynamic acquisition of images after injection of intravenous contrast. A number of studies have identified changes in diffusion and microvascular characteristics occurring during the early stages of radiotherapy as powerful predictive biomarkers of outcome.
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Affiliation(s)
| | - S R Kennedy
- The Christie NHS Foundation Trust, Manchester, UK
| | - I K Djoukhadar
- Wolfson Molecular Imaging Centre, University of Manchester, Manchester, UK
| | - A Jackson
- Wolfson Molecular Imaging Centre, University of Manchester, Manchester, UK
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38
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Hwang CS, Marymont MH, Muro K. Photon radiotherapy for the treatment of high-grade gliomas. Expert Rev Anticancer Ther 2014; 7:S37-43. [DOI: 10.1586/14737140.7.12s.s37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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39
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Ho J, Ondos J, Ning H, Smith S, Kreisl T, Iwamoto F, Sul J, Kim L, McNeil K, Krauze A, Shankavaram U, Fine HA, Camphausen K. Chemoirradiation for glioblastoma multiforme: the national cancer institute experience. PLoS One 2013; 8:e70745. [PMID: 23940635 PMCID: PMC3733728 DOI: 10.1371/journal.pone.0070745] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 06/28/2013] [Indexed: 12/02/2022] Open
Abstract
Purpose Standard treatment for glioblastoma (GBM) is surgery followed by radiation (RT) and temozolomide (TMZ). While there is variability in survival based on several established prognostic factors, the prognostic utility of other factors such as tumor size and location are not well established. Experimental Design The charts of ninety two patients with GBM treated with RT at the National Cancer Institute (NCI) between 1998 and 2012 were retrospectively reviewed. Most patients received RT with concurrent and adjuvant TMZ. Topographic locations were classified using preoperative imaging. Gross tumor volumes were contoured using treatment planning systems utilizing both pre-operative and post-operative MR imaging. Results At a median follow-up of 18.7 months, the median overall survival (OS) and progression-free survival (PFS) for all patients was 17.9 and 7.6 months. Patients with the smallest tumors had a median OS of 52.3 months compared to 16.3 months among patients with the largest tumors, P = 0.006. The patients who received bevacizumab after recurrence had a median OS of 23.3 months, compared to 16.3 months in patients who did not receive it, P = 0.0284. The median PFS and OS in patients with periventricular tumors was 5.7 and 17.5 months, versus 8.9 and 23.3 months in patients with non-periventricular tumors, P = 0.005. Conclusions Survival in our cohort was comparable to the outcome of the defining EORTC-NCIC trial establishing the use of RT+TMZ. This study also identifies several potential prognostic factors that may be useful in stratifying patients.
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Affiliation(s)
- Jennifer Ho
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - John Ondos
- Radiation Management Associates, Bethesda, Maryland, United States of America
| | - Holly Ning
- Radiation Management Associates, Bethesda, Maryland, United States of America
| | - Sharon Smith
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Teri Kreisl
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Fabio Iwamoto
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Joohee Sul
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Lyndon Kim
- Jefferson Medical College, Philadelphia, Pennsylvania, United States of America
| | - Kate McNeil
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Andra Krauze
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Uma Shankavaram
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Howard A. Fine
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Kevin Camphausen
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
- * E-mail:
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40
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Kim TG, Lim DH. Interfractional variation of radiation target and adaptive radiotherapy for totally resected glioblastoma. J Korean Med Sci 2013; 28:1233-7. [PMID: 23960453 PMCID: PMC3744714 DOI: 10.3346/jkms.2013.28.8.1233] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 05/14/2013] [Indexed: 12/27/2022] Open
Abstract
This study aimed to evaluate the effects of volume adapted re-planning for radiotherapy (RT) after gross total resection (GTR) for glioblastoma. Nineteen patients with glioblastoma who underwent GTR and postoperative RT were analyzed. The volumes of the surgical cavity on computed tomography (CT) obtained one day after GTR (CT0), the first RT simulation CT (sim-CT1), and the second simulation CT for the boost RT plan (sim-CT2) were compared. The boost RT plan was based on the surgical cavity observed on the sim-CT2 (boost RTP2) and was compared with that based on the surgical cavity observed on the sim-CT1 (boost RTP1). The volume reduction ratios were 14.4%-51.3% (median, 29.0%) between CT0 and sim-CT1 and -7.9%-71.9% (median, 34.9%) between sim-CT1 and sim-CT2 (P < 0.001). The normal brain volumes in boost RTP1 were significantly reduced in boost RTP2, especially at high dose levels. Target volume in sim-CT2 which was not covered with the boost RTP1, developed in five cases (26.3%). The surgical cavity volume was reduced following surgery in patients with glioblastoma who underwent GTR. The application of volume-adapted re-planning during RT could decrease the irradiated volume of normal brain and prevent a target miss for boost RT.
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Affiliation(s)
- Tae Gyu Kim
- Department of Radiation Oncology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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41
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Fiorentino A, Caivano R, Pedicini P, Fusco V. Clinical target volume definition for glioblastoma radiotherapy planning: magnetic resonance imaging and computed tomography. Clin Transl Oncol 2013; 15:754-8. [DOI: 10.1007/s12094-012-0992-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 12/20/2012] [Indexed: 11/29/2022]
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42
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Dörner L, Mustafa A, Rohr A, Mehdorn HM, Nabavi A. Growth pattern of tumor recurrence following bis-chloroethylnitrosourea (BCNU) wafer implantation in malignant glioma. J Clin Neurosci 2013; 20:429-34. [PMID: 23313517 DOI: 10.1016/j.jocn.2012.01.060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2011] [Revised: 01/04/2012] [Accepted: 01/06/2012] [Indexed: 10/27/2022]
Abstract
Bis-chloroethylnitrosourea (BCNU; Gliadel, Eisai, Tokyo, Japan) is the only therapeutic agent for local chemotherapy of malignant gliomas approved by the US Food and Drug Administration and the European Medicines Agency. In a small patient cohort, it has previously been shown that glioblastomas recur locally despite treatment with BCNU. This raises concern about local treatment with BCNU as a stand-alone measure. The goal of this study was to analyze the growth pattern of tumor recurrence in a larger patient group: 41 patients were included in this study. Tumor recurrences were morphologically categorized as: local, diffuse, distant or multilocular. Thirty-three of the tumors (80%) that recurred were local or diffuse. These results show that BCNU implantation does not provide lasting local tumor control. Our data support the need to incorporate BCNU in to multimodal therapy schemes. The improved survival rates of patients who receive concomitant local and systemic adjuvant treatment support using local therapy to bridge the therapy-free interval of the initial postoperative phase.
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Affiliation(s)
- Lutz Dörner
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein Campus, Kiel, Germany.
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Champ CE, Siglin J, Mishra MV, Shen X, Werner-Wasik M, Andrews DW, Mayekar SU, Liu H, Shi W. Evaluating changes in radiation treatment volumes from post-operative to same-day planning MRI in High-grade gliomas. Radiat Oncol 2012; 7:220. [PMID: 23259933 PMCID: PMC3552717 DOI: 10.1186/1748-717x-7-220] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 12/18/2012] [Indexed: 02/16/2023] Open
Abstract
Background Adjuvant radiation therapy (RT) with temozolomide (TMZ) is standard of care for high grade gliomas (HGG) patients. RT is commonly started 3 to 5 weeks after surgery. The deformation of the tumor bed and brain from surgery to RT is poorly studied. This study examined the magnitude of volume change in the postoperative tumor bed and the potential impact of RT planning. Method and materials This study includes 24 patients with HGG who underwent craniotomy and adjuvant RT with TMZ at our institution. All patients had immediate postoperative MRI and repeat MRI during the day of RT simulation. Gross tumor volumes (GTV), clinical target volumes (CTV) of initial 46 Gy (CTV1) and boost to 60 Gy (CTV2) were contoured on both sets of MRIs according to RTOG (Radiation Therapy Oncology Group) guidelines. For patients who recurred after RT, the recurrence pattern was evaluated. Results An average of 17 days elapsed between immediate and delayed MRIs. GTV1 (FLAIR abnormality and tumor bed) decreased significantly on the delayed MRI as compared to immediate post-operative MRI (mean = 30.96cc, p = 0.0005), while GTV2 (contrast-enhanced T1 abnormality and tumor bed) underwent a non-significant increase (mean = 6.82cc, p = 0.07). Such changes lead to significant decrease of CTV1 (mean decrease is 113.9cc, p<0.01), and significant increase of CTV2 (mean increase is 32.5cc, p=0.05). At a median follow-up of 13 months, 16 patients (67%) progressed, recurred, or died, with a progression-free survival time of 13.7 months. Twelve patients failed within all CTVs based on immediate and delayed MRIs, while one patient recurred outside of CTV2 based on immediate post-operative MRI, but within the CTV2 defined on delayed MRI. Conclusion The postoperative tumor bed of HGGs undergoes substantial volumetric changes after surgery. Treatment planning based on delayed MRI significantly reduces the volume of treated brain tissue without local control detriment. The marked reduction of volume treated to 46 Gy based on delayed MRI scan, could result in increased sparing of organs at risk. There may be a small risk of inadequate radiation field design if radiation planning is based on immediate post-operative MRI.
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Affiliation(s)
- Colin E Champ
- Department of Radiation Oncology, Kimmel Cancer Center and Jefferson Medical College of Thomas Jefferson University, 111 S, 11th Street, Philadelphia, PA 19107, USA.
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Massaccesi M, Ferro M, Cilla S, Balducci M, Deodato F, Macchia G, Valentini V, Morganti AG. Accelerated intensity-modulated radiotherapy plus temozolomide in patients with glioblastoma: a phase I dose-escalation study (ISIDE-BT-1). Int J Clin Oncol 2012; 18:784-91. [PMID: 22892797 DOI: 10.1007/s10147-012-0462-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 07/26/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND We performed a dose-escalation trial to determine the maximum tolerated dose (MTD) of intensity-modulated radiotherapy (IMRT) with standard concurrent and sequential-dose temozolomide (TMZ) in patients with glioblastoma multiforme. METHODS Histologically proven glioblastoma patients underwent IMRT dose escalation. IMRT was delivered over 5 weeks with the simultaneous integrated boost (SIB) technique to the two planning target volumes (PTVs) defined by adding 5-mm margin to the respective clinical target volumes (CTVs). CTV1 was the tumor bed plus the enhancing lesion with 10-mm margin; CTV2 was the area of perifocal edema with 20-mm margin. Only the PTV1 dose was escalated (planned dose escalation: 60, 62.5, 65, 67.5, 70 Gy) while the PTV2 dose remained the same (45 Gy). RESULTS Forty consecutive glioblastoma patients were treated. While no dose-limiting toxicity (DLT) was recorded during the dose escalation up to 67.5/2.7 Gy, two out of the first six consecutively enrolled patients on the highest dose level (70/2.8 Gy) experienced a DLT, and therefore a cohort expansion was required. 3/14 patients experienced a DLT on the highest planned dose level, and therefore the MTD was not exceeded. After a median follow-up time of 25 months no grade >2 late neurological toxicity was recorded. CONCLUSIONS By using a SIB IMRT technique, a radiation dose of 70 Gy in 25 fractions (biological effective dose--BED--of 92.8 Gy) can be delivered with concurrent and sequential standard dose TMZ, without unacceptable acute toxicity in patients with glioblastoma.
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Affiliation(s)
- Mariangela Massaccesi
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
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Gunjur A, Bressel M, Ryan G. The addition of temozolomide does not change the pattern of progression of glioblastoma multiforme post-radiotherapy. J Med Imaging Radiat Oncol 2012; 56:567-73. [DOI: 10.1111/j.1754-9485.2012.02414.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 02/23/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Ashray Gunjur
- Faculty of Medicine, Dentistry and Health Sciences; the University of Melbourne; Melbourne; Victoria; Australia
| | - Mathias Bressel
- Biostatistics and Clinical Trials, ; Peter MacCallum Cancer Centre; Melbourne; Victoria; Australia
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Taw BBT, Gorgulho AA, Selch MT, De Salles AA. Radiation Options for High-Grade Gliomas. Neurosurg Clin N Am 2012; 23:259-67, viii. [DOI: 10.1016/j.nec.2012.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Piroth MD, Pinkawa M, Holy R, Klotz J, Schaar S, Stoffels G, Galldiks N, Coenen HH, Kaiser HJ, Langen KJ, Eble MJ. Integrated boost IMRT with FET-PET-adapted local dose escalation in glioblastomas. Results of a prospective phase II study. Strahlenther Onkol 2012; 188:334-9. [PMID: 22349712 DOI: 10.1007/s00066-011-0060-5] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Accepted: 12/02/2011] [Indexed: 10/28/2022]
Abstract
PURPOSE Dose escalations above 60 Gy based on MRI have not led to prognostic benefits in glioblastoma patients yet. With positron emission tomography (PET) using [(18)F]fluorethyl-L-tyrosine (FET), tumor coverage can be optimized with the option of regional dose escalation in the area of viable tumor tissue. METHODS AND MATERIALS In a prospective phase II study (January 2008 to December 2009), 22 patients (median age 55 years) received radiochemotherapy after surgery. The radiotherapy was performed as an MRI and FET-PET-based integrated-boost intensity-modulated radiotherapy (IMRT). The prescribed dose was 72 and 60 Gy (single dose 2.4 and 2.0 Gy, respectively) for the FET-PET- and MR-based PTV-FET((72 Gy)) and PTV-MR((60 Gy)). FET-PET and MRI were performed routinely for follow-up. Quality of life and cognitive aspects were recorded by the EORTC-QLQ-C30/QLQ Brain20 and Mini-Mental Status Examination (MMSE), while the therapy-related toxicity was recorded using the CTC3.0 and RTOG scores. RESULTS Median overall survival (OS) and disease-free survival (DFS) were 14.8 and 7.8 months, respectively. All local relapses were detected at least partly within the 95% dose volume of PTV-MR((60 Gy)). No relevant radiotherapy-related side effects were observed (excepted alopecia). In 2 patients, a pseudoprogression was observed in the MRI. Tumor progression could be excluded by FET-PET and was confirmed in further MRI and FET-PET imaging. No significant changes were observed in MMSE scores and in the EORTC QLQ-C30/QLQ-Brain20 questionnaires. CONCLUSION Our dose escalation concept with a total dose of 72 Gy, based on FET-PET, did not lead to a survival benefit. Acute and late toxicity were not increased, compared with historical controls and published dose-escalation studies.
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Affiliation(s)
- M D Piroth
- Department of Radiation Oncology, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074, Aachen, Germany.
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KONISHI Y, MURAGAKI Y, ISEKI H, MITSUHASHI N, OKADA Y. Patterns of Intracranial Glioblastoma Recurrence After Aggressive Surgical Resection and Adjuvant Management: Retrospective Analysis of 43 Cases. Neurol Med Chir (Tokyo) 2012; 52:577-86. [DOI: 10.2176/nmc.52.577] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Yoshiyuki KONISHI
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University
| | - Yoshihiro MURAGAKI
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University
- Department of Neurosurgery, Tokyo Women's Medical University
| | - Hiroshi ISEKI
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University
- Department of Neurosurgery, Tokyo Women's Medical University
| | - Norio MITSUHASHI
- Department of Radiation Oncology, Tokyo Women's Medical University
| | - Yoshikazu OKADA
- Department of Neurosurgery, Tokyo Women's Medical University
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Price SJ, Gillard JH. Imaging biomarkers of brain tumour margin and tumour invasion. Br J Radiol 2011; 84 Spec No 2:S159-67. [PMID: 22433826 PMCID: PMC3473903 DOI: 10.1259/bjr/26838774] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Invasion of tumour cells into the normal brain is one of the major reasons of treatment failure for gliomas. Although there is a good understanding of the molecular and cellular processes that occur during this invasion, it is not possible to detect the extent of the tumour with conventional imaging. However, there is an understanding that the degree of invasion differs with individual tumours, and yet they are all treated the same. Newer imaging techniques that probe the pathological changes within tumours may be suitable biomarkers for invasion. Imaging methods are now available that can detect subtle changes in white matter organisation (diffusion tensor imaging), tumour metabolism and cellular proliferation (using MR spectroscopy and positron emission tomography) occurring in regions of tumour that cannot be detected by conventional imaging. The role of such biomarkers of invasion should allow better delineation of tumour margins, which should improve treatment planning (especially surgery and radiotherapy) and provide information on the invasiveness of an individual tumour to help select the most appropriate therapy and help stratify patients for clinical trials.
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Affiliation(s)
- S J Price
- Academic Neurosurgery Division, Department of Clinical Neuroscience, Addenbrooke's Hospital, Cambridge, UK.
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Lupo JM, Chuang CF, Chang SM, Barani IJ, Jimenez B, Hess CP, Nelson SJ. 7-Tesla susceptibility-weighted imaging to assess the effects of radiotherapy on normal-appearing brain in patients with glioma. Int J Radiat Oncol Biol Phys 2011; 82:e493-500. [PMID: 22000750 DOI: 10.1016/j.ijrobp.2011.05.046] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Revised: 05/19/2011] [Accepted: 05/20/2011] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate the intermediate- and long-term imaging manifestations of radiotherapy on normal-appearing brain tissue in patients with treated gliomas using 7T susceptibility-weighted imaging (SWI). METHODS AND MATERIALS SWI was performed on 25 patients with stable gliomas on a 7 Tesla magnet. Microbleeds were identified as discrete foci of susceptibility that did not correspond to vessels. The number of microbleeds was counted within and outside of the T2-hyperintense lesion. For 3 patients, radiation dosimetry maps were reconstructed and fused with the 7T SWI data. RESULTS Multiple foci of susceptibility consistent with microhemorrhages were observed in patients 2 years after chemoradiation. These lesions were not present in patients who were not irradiated. The prevalence of microhemorrhages increased with the time since completion of radiotherapy, and these lesions often extended outside the boundaries of the initial high-dose volume and into the contralateral hemisphere. CONCLUSIONS High-field SWI has potential for visualizing the appearance of microbleeds associated with long-term effects of radiotherapy on brain tissue. The ability to visualize these lesions in normal-appearing brain tissue may be important in further understanding the utility of this treatment in patients with longer survival.
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Affiliation(s)
- Janine M Lupo
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94158, USA.
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