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Young JS, Al-Adli NN, Muster R, Chandra A, Morshed RA, Pereira MP, Chalif EJ, Hervey-Jumper SL, Theodosopoulos PV, McDermott MW, Berger MS, Aghi MK. Does waiting for surgery matter? How time from diagnostic MRI to resection affects outcomes in newly diagnosed glioblastoma. J Neurosurg 2024; 140:80-93. [PMID: 37382331 PMCID: PMC11180214 DOI: 10.3171/2023.5.jns23388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/02/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE Maximal safe resection is the standard of care for patients presenting with lesions concerning for glioblastoma (GBM) on magnetic resonance imaging (MRI). Currently, there is no consensus on surgical urgency for patients with an excellent performance status, which complicates patient counseling and may increase patient anxiety. This study aims to assess the impact of time to surgery (TTS) on clinical and survival outcomes in patients with GBM. METHODS This is a retrospective study of 145 consecutive patients with newly diagnosed IDH-wild-type GBM who underwent initial resection at the University of California, San Francisco, between 2014 and 2016. Patients were grouped according to the time from diagnostic MRI to surgery (i.e., TTS): ≤ 7, > 7-21, and > 21 days. Contrast-enhancing tumor volumes (CETVs) were measured using software. Initial CETV (CETV1) and preoperative CETV (CETV2) were used to evaluate tumor growth represented as percent change (ΔCETV) and specific growth rate (SPGR; % growth/day). Overall survival (OS) and progression-free survival (PFS) were measured from the date of resection and were analyzed using the Kaplan-Meier method and Cox regression analyses. RESULTS Of the 145 patients (median TTS 10 days), 56 (39%), 53 (37%), and 36 (25%) underwent surgery ≤ 7, > 7-21, and > 21 days from initial imaging, respectively. Median OS and PFS among the study cohort were 15.5 and 10.3 months, respectively, and did not differ among the TTS groups (p = 0.81 and 0.17, respectively). Median CETV1 was 35.9, 15.7, and 10.2 cm3 across the TTS groups, respectively (p < 0.001). Preoperative biopsy and presenting to an outside hospital emergency department were associated with an average 12.79-day increase and 9.09-day decrease in TTS, respectively. Distance from the treating facility (median 57.19 miles) did not affect TTS. In the growth cohort, TTS was associated with an average 2.21% increase in ΔCETV per day; however, there was no effect of TTS on SPGR, Karnofsky Performance Status (KPS), postoperative deficits, survival, discharge location, or hospital length of stay. Subgroup analyses did not identify any high-risk groups for which a shorter TTS may be beneficial. CONCLUSIONS An increased TTS for patients with imaging concerning for GBM did not impact clinical outcomes, and while there was a significant association with ΔCETV, SPGR remained unaffected. However, SPGR was associated with a worse preoperative KPS, which highlights the importance of tumor growth speed over TTS. Therefore, while it is ill advised to wait an unnecessarily long time after initial imaging studies, these patients do not require urgent/emergency surgery and can seek tertiary care opinions and/or arrange for additional preoperative support/resources. Future studies are needed to explore subgroups for whom TTS may impact clinical outcomes.
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Affiliation(s)
- Jacob S. Young
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Nadeem N. Al-Adli
- Department of Neurological Surgery, University of California, San Francisco, California
- School of Medicine, Texas Christian University, Fort Worth, Texas
| | - Rachel Muster
- School of Medicine, University of California, San Francisco, California
| | - Ankush Chandra
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ramin A. Morshed
- Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Eric J. Chalif
- Department of Neurological Surgery, University of California, San Francisco, California
| | | | | | - Michael W. McDermott
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Mitchel S. Berger
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Manish K. Aghi
- Department of Neurological Surgery, University of California, San Francisco, California
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Bozzao A, Weber D, Crompton S, Braz G, Csaba D, Dhermain F, Finocchiaro G, Flannery T, Kramm C, Law I, Marucci G, Oliver K, Ostgathe C, Paterra R, Pesce G, Smits M, Soffietti R, Terkola R, Watts C, Costa A, Poortmans P. European Cancer Organisation Essential Requirements for Quality Cancer Care: Adult glioma. J Cancer Policy 2023; 38:100438. [PMID: 37634617 DOI: 10.1016/j.jcpo.2023.100438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/17/2023] [Indexed: 08/29/2023]
Abstract
European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCCs) are explanations of the organisation and actions necessary to provide high-quality care to patients with a specific cancer type. They are compiled by a working group of European experts representing disciplines involved in cancer care, and provide oncology teams, patients, policymakers and managers with an overview of the essential requirements in any healthcare system. The focus here is on adult glioma. Gliomas make up approximately 80% of all primary malignant brain tumours. They are highly diverse and patients can face a unique cognitive, physical and psychosocial burden, so personalised treatments and support are essential. However, management of gliomas is currently very heterogeneous across Europe and there are only few formally-designated comprehensive cancer centres with brain tumour programmes. To address this, the ERQCC glioma expert group proposes frameworks and recommendations for high quality care, from diagnosis to treatment and survivorship. Wherever possible, glioma patients should be treated from diagnosis onwards in high volume neurosurgical or neuro-oncology centres. Multidisciplinary team working and collaboration is essential if patients' length and quality of life are to be optimised.
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Affiliation(s)
- Alessandro Bozzao
- NESMOS (Neurosciences, Mental Health and Sensory Organs) Department, Rome, Italy; School of Medicine and Psychology, "Sapienza" University - Rome, Rome, Italy; European Society of Oncologic Imaging (ESOI), Rome, Italy
| | - Damien Weber
- Paul Scherrer Institute, Center for Proton Therapy, Villigen, Switzerland; European Society for Radiotherapy and Oncology (ESTRO), Villigen, Switzerland
| | | | - Graça Braz
- European Oncology Nursing Society (EONS), Oporto, Portugal; Portuguese Oncology Institute, Outpatient Clinic Department, Oporto, Portugal
| | - Dégi Csaba
- International Psycho-Oncology Society (IPOS), Babeș-Bolyai University, Cluj-Napoca, Romania
| | - Frederic Dhermain
- European Organisation for Research and Treatment of Cancer (EORTC) Brain Tumour Group, Villejuif, France; Head of the Brain Tumor Board, Gustave Roussy University Hospital, Radiation Oncology, Villejuif, France
| | - Gaetano Finocchiaro
- Organisation of European Cancer Institutes (OECI), Milano, Italy; IRCCS Ospedale San Raffaele, Department of Neurology, Milano, Italy
| | - Thomas Flannery
- European Cancer Leagues (ECL), Belfast, Ireland; Royal Victoria Hospital Belfast, Department of Neurosurgery, Belfast, Ireland
| | - Christof Kramm
- The European Society for Paediatric Oncology (SIOPE), Goettingen, Germany; University Medical Center Goettingen, Division of Pediatric Hematology and Oncology, Goettingen, Germany
| | - Ian Law
- European Association of Nuclear Medicine (EANM), Copenhagen, Denmark; Rigshospitalet, Dept of Clinical Physiology, Nuclear Medicine & PET, Copenhagen, Denmark
| | - Gianluca Marucci
- European Society of Pathology (ESP), Milan, Italy; European Confederation of Neuropathological Societies (Euro-CNS), Milan, Italy; Neuropathology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | | | - Rosina Paterra
- Fondazione IRCCS Istituto Neurologico Besta, Milano, Italy
| | - Gianfranco Pesce
- European School of Oncology (ESO), Bellinzona, Switzerland; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Marion Smits
- European Society of Radiology (ESR), Rotterdam, the Netherlands; Erasmus MC, Department of Radiology and Nuclear Medicine, University Hospital Rotterdam, Rotterdam, the Netherlands
| | - Riccardo Soffietti
- European Academy of Neurology (EAN), Turin, Italy; University and City of Health and Science Hospital, Department of Neuro-Oncology, Turin, Italy
| | - Robert Terkola
- European Society of Oncology Pharmacy (ESOP), the Netherlands; University of Groningen, University Medical Centre Groningen, the Netherlands; University of Florida College of Pharmacy, Department of Pharmacotherapy and Translational Research, Gainesville, USA
| | - Colin Watts
- European Association of Neurosurgical Societies, Birmingham, UK; Neurosurgical Oncology Section, Institute of Cancer and Genomic Sciences, Birmingham, UK
| | | | - Philip Poortmans
- European Society for Radiotherapy and Oncology (ESTRO), Antwerp, Belgium; Iridium Netwerk and University of Antwerp, Antwerp, Belgium
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Anokwute MC, Preda V, Di Ieva A. Determining Contemporary Barriers to Effective Multidisciplinary Team Meetings in Neurological Surgery: A Review of the Literature. World Neurosurg 2023; 172:73-80. [PMID: 36754351 DOI: 10.1016/j.wneu.2023.01.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 01/19/2023] [Indexed: 02/10/2023]
Abstract
OBJECTIVE The integration of multidisciplinary team meetings (MDTMs) for neurosurgical care has been accepted worldwide. Our objective was to review the literature for the limiting factors to MDTMs that may introduce bias to patient care. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analysis was used to perform a literature review of MDTMs for neuro-oncology, pituitary oncology, cerebrovascular surgery, and spine surgery and spine oncology. Limiting factors to productive MDTMs and factors that introduce bias were identified, as well as determining whether MDTMs led to improved patient outcomes. RESULTS We identified 1264 manuscripts from a PubMed and Ovid Medline search, of which 27 of 500 neuro-oncology, 4 of 279 pituitary, and 11 of 260 spine surgery articles met our inclusion criteria. Of 224 cerebrovascular manuscripts, none met the criteria. Factors for productive MDTMs included quaternary/tertiary referral centers, nonhierarchical environment, regularly scheduled meetings, concise inclusion of nonmedical factors at the same level of importance as patient clinical information, inclusion of nonclinical participants, and use of clinical guidelines and institutional protocols to provide recommendations. Our review did not identify literature that described the use of artificial intelligence to reduce bias and guide clinical care. CONCLUSIONS The continued implementation of MDTMs in neurosurgery should be recommended but cautioned by limiting bias.
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Affiliation(s)
- Miracle C Anokwute
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia; Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Veronica Preda
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Antonio Di Ieva
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia; Computational NeuroSurgery (CNS) Lab, Macquarie University, Sydney, New South Wales, Australia.
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Refining the Intraoperative Identification of Suspected High-Grade Glioma Using a Surgical Fluorescence Biomarker: GALA BIDD Study Report. J Pers Med 2023; 13:jpm13030514. [PMID: 36983696 PMCID: PMC10058333 DOI: 10.3390/jpm13030514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/09/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023] Open
Abstract
Background. Improving intraoperative accuracy with a validated surgical biomarker is important because identifying high-grade areas within a glioma will aid neurosurgical decision-making and sampling. Methods. We designed a multicentre, prospective surgical cohort study (GALA-BIDD) to validate the presence of visible fluorescence as a pragmatic intraoperative surgical biomarker of suspected high-grade disease within a tumour mass in patients undergoing 5-aminolevulinic acid (5-ALA) fluorescence-guided cytoreductive surgery. Results. A total of 106 patients with a suspected high-grade glioma or malignant transformation of a low-grade glioma were enrolled. Among the 99 patients who received 5-ALA, 89 patients were eligible to assess the correlation of fluorescence with diagnosis as per protocol. Of these 89, 81 patients had visible fluorescence at surgery, and 8 patients had no fluorescence. A total of 80 out of 81 fluorescent patients were diagnosed as high-grade gliomas on postoperative central review with 1 low-grade glioma case. Among the eight patients given 5-ALA who did not show any visible fluorescence, none were high-grade gliomas, and all were low-grade gliomas. Of the seven patients suspected radiologically of malignant transformation of low-grade gliomas and with visible fluorescence at surgery, six were diagnosed with high-grade gliomas, and one had no tissue collected. Conclusion. In patients where there is clinical suspicion, visible 5-ALA fluorescence has clinical utility as an intraoperative surgical biomarker of high-grade gliomas and can aid surgical decision-making and sampling. Further studies assessing the use of 5-ALA to assess malignant transformation in all diffuse gliomas may be valuable.
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Sun R, Sharma S, Benghiat H, Meade S, Sanghera P, Bramwell G, Nagaraju S, Pohl U, Dawson C, Petrik V, Ughratdar I, White A, Zisakis A, Ramalingam S, Sawlani V, Watts C, Wykes V. Reconfiguration from emergency to urgent elective neurosurgery for glioblastoma patients improves length of stay, surgical adjunct use and extent of resective surgery. Neurooncol Pract 2022; 9:420-428. [PMID: 36127892 PMCID: PMC9476969 DOI: 10.1093/nop/npac034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Glioblastoma (GB) is the most common intrinsic brain cancer and is notorious for its aggressive nature. Despite widespread research and optimization of clinical management, the improvement in overall survival has been limited. The aim of this study was to characterize the impact of service reconfiguration on GB outcomes in a single centre. Methods Patients with a histopathological confirmation of a diagnosis of GB between 01/01/2014 and 31/12/2019 were retrospectively identified. Demographic and tumour characteristics, survival, treatment (surgical and oncological), admission status, use of surgical adjunct (5-aminolevulinic acid, intra-operative neuro-monitoring), the length of stay, extent of resection, and surgical complications were recorded from the hospital databases. Results From August 2018 the neurosurgical oncology service was reconfigured to manage high-grade tumours on an urgent outpatient basis by surgeons specializing in oncology. We demonstrate that these changes resulted in an increase in elective admissions, greater use of intra-operative adjuncts resulting in the improved extent of tumour resection, and a reduction in median length of stay and associated cost-savings. Conclusions Optimizing neuro-oncology patient management through service reconfiguration resulted in increased use of intra-operative adjuncts, improved surgical outcomes, and reduced hospital costs. These changes also have the potential to improve survival and disease-free progression for patients with GB.
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Affiliation(s)
- Rosa Sun
- Department of Neurosurgery, University Hospitals Birmingham, Birmingham
| | - Shivam Sharma
- Department of General Surgery, Royal Wolverhampton NHS trust
| | - Helen Benghiat
- Hall-Edwards Radiotherapy Research Group, Cancer Centre, Queen Elizabeth Hospital, Birmingham
| | - Sara Meade
- Hall-Edwards Radiotherapy Research Group, Cancer Centre, Queen Elizabeth Hospital, Birmingham
| | - Paul Sanghera
- Hall-Edwards Radiotherapy Research Group, Cancer Centre, Queen Elizabeth Hospital, Birmingham
| | - Gregory Bramwell
- Department of Neurosurgery, University Hospitals Birmingham, Birmingham
| | - Santhosh Nagaraju
- Department of Cellular Pathology, University Hospitals Birmingham, Birmingham
| | - Ute Pohl
- Department of Cellular Pathology, University Hospitals Birmingham, Birmingham
| | - Camilla Dawson
- Department of Speech and Language, University Hospitals Birmingham, Birmingham
| | - Vladimir Petrik
- Department of Neurosurgery, University Hospitals Birmingham, Birmingham
| | - Ismail Ughratdar
- Department of Neurosurgery, University Hospitals Birmingham, Birmingham
| | - Anwen White
- Department of Neurosurgery, University Hospitals Birmingham, Birmingham
| | | | | | - Vijay Sawlani
- Department of Neuroradiology, University Hospitals Birmingham, Birmingham
| | - Colin Watts
- Department of Neurosurgery, University Hospitals Birmingham, Birmingham
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham
| | - Victoria Wykes
- Department of Neurosurgery, University Hospitals Birmingham, Birmingham
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham
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Systematic Review of Enhanced Recovery After Surgery in Patients Undergoing Cranial Surgery. World Neurosurg 2021; 158:279-289.e1. [PMID: 34740831 DOI: 10.1016/j.wneu.2021.10.176] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Enhanced Recovery after Surgery (ERAS) pathways are increasingly being integrated in neurosurgical patient management. The full extent of ERAS in cranial surgery is not well studied. We performed a systematic review examining ERAS in cranial surgery patients to 1) identify the extent to which ERAS is integrated in cranial neurosurgical procedures and 2) assess effectiveness of ERAS interventions for patients undergoing these procedures. METHODS A systematic review of MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Scopus, PsychInfo, and Google Scholar was conducted according to PRISMA guidelines (CRD42020197187). Studies eligible for inclusion assessed patients undergoing any cranial surgical procedure using an ERAS or ERAS-like pathway, defined by ≥2 ERAS protocol elements per the ERAS Society's RECOvER Checklist and the recommendations of Hagan et al. 2016 (not including patient education, criteria for discharge, or tracking of postdischarge outcomes). RESULTS Nine studies were included in qualitative synthesis, 2 of which were randomized controlled trials. All studies showed a moderate risk of bias. The most common ERAS elements used were screening and/or optimization and formal discharge criteria. The least common ERAS elements used were fasting/carbohydrate loading and antithrombotic prophylaxis. Complication rates were similar in studies comparing ERAS with non-ERAS groups. ERAS interventions were associated with reduced length of stay, with comparable and/or improved patient satisfaction. CONCLUSIONS ERAS is a safe and potentially favorable perioperative pathway for select patients undergoing cranial surgery. Future studies of ERAS in cranial surgery patients should emphasize postoperative optimizations and patient-reported outcome measures as key features.
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Sun R, Cuthbert H, Watts C. Fluorescence-Guided Surgery in the Surgical Treatment of Gliomas: Past, Present and Future. Cancers (Basel) 2021; 13:cancers13143508. [PMID: 34298721 PMCID: PMC8304525 DOI: 10.3390/cancers13143508] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Gliomas are aggressive central nervous system tumours. The emergence and recent widespread adoption of 5-aminolevulinic acid and fluorescence guided surgery have improved the extent of resection, with implications for improved survival and progression-free survival. This review describes the history, rationale and mechanism behind the use of 5-aminolevulinic acid and fluorescence-guided surgery. We also discuss current limitations and future directions for this important adjunct to glioma surgery. This review aims to provide readers with an up-to-date overview and evidence base on this important topic. Abstract Gliomas are central nervous systems tumours which are diffusely infiltrative and difficult to treat. The extent of surgical resection is correlated with improved outcomes, including survival and disease-free progression. Cancerous tissue can be directly visualised intra-operatively under fluorescence by administration of 5-aminolevulinic acid to the patient. The adoption of this technique has allowed surgeons worldwide to achieve greater extents of resection, with implications for improved prognosis. However, there are practical limitations to use of 5-aminolevulinic acid. New adjuncts in the field of fluorescence-guided surgery aim to improve recognition of the interface between tumour and brain with the objective of improving resection and patient outcomes.
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Affiliation(s)
- Rosa Sun
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham B15 2GW, UK;
- Correspondence: (R.S.); (H.C.)
| | - Hadleigh Cuthbert
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham B15 2GW, UK;
- Correspondence: (R.S.); (H.C.)
| | - Colin Watts
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham B15 2GW, UK;
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2SY, UK
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Foo JC, Jawin V, Yap TY, Ahmad Bahuri NF, Ganesan D, Mun KS, Loh J, Azman RR, Gottardo NG, Qaddoumi I, Moreira DC, Rajagopal R. Conduct of neuro-oncology multidisciplinary team meetings and closing the "gaps" in the clinical management of childhood central nervous system tumors in a middle-income country. Childs Nerv Syst 2021; 37:1573-1580. [PMID: 33580355 DOI: 10.1007/s00381-021-05080-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/06/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Multidisciplinary team meetings (MDTMs) are essential in the clinical management of pediatric central nervous system (CNS) tumors. Evaluations of the impact of MDTMs on childhood CNS tumors and clinicians' perspectives on their effectiveness are scarce. METHODS We retrospectively reviewed the clinical data of pediatric patients (aged <18 years) with CNS tumors diagnosed and treated in the Pediatric Hematology-Oncology Division at the University Malaya Medical Center from 2008 to 2019. We also conducted a web-based survey of the core members of the multidisciplinary team to evaluate the impact of the MDTMs. RESULTS During the pre-MDTM era (2008-2012), 29 CNS tumors were diagnosed and treated, and during the MDTM era (2014-2019), 49 CNS tumors were diagnosed and treated. The interval for histologic diagnosis was significantly shorter during the MDTM era (p=0.04), but the interval from diagnosis to chemotherapy or radiotherapy and the 5-year overall survival of the 78 patients did not improve (62.1% ± 9.0% vs. 68.8% ± 9.1%; p=0.184). However, the 5-year overall survival of patients with medulloblastoma or rare tumors significantly improved in the MDTM era (p=0.01). Key factors that contributed to delayed treatment and poor outcomes were postoperative complications, the facility's lack of infrastructure, poor parental education about early treatment, cultural beliefs in alternative medicine, and infection during chemotherapy. Eighteen clinicians responded to the survey; they felt that the MDTMs were beneficial in decision-making and enhanced the continuity of coordinated care. CONCLUSION MDTMs significantly reduced the diagnostic interval and improved the overall outcomes. However, delayed treatment remains a major challenge that requires further attention.
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Affiliation(s)
- Jen Chun Foo
- Division of Hematology-Oncology, Department of Pediatrics, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Vida Jawin
- Division of Hematology-Oncology, Department of Pediatrics, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Tsiao Yi Yap
- Division of Hematology-Oncology, Department of Pediatrics, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Nor Faizal Ahmad Bahuri
- Division of Neuro-Surgery, Department of Surgery, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Dharmendra Ganesan
- Division of Neuro-Surgery, Department of Surgery, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Kein Seong Mun
- Department of Pathology, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Jasmin Loh
- Department of Clinical Radiation Oncology, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Raja Rizal Azman
- Department of Radiology, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Nicholas G Gottardo
- Department of Pediatric and Adolescent Clinical Hematology and Oncology, Perth Children's Hospital, Nedlands, Australia
| | - Ibrahim Qaddoumi
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Daniel C Moreira
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Revathi Rajagopal
- Division of Hematology-Oncology, Department of Pediatrics, University Malaya Medical Center, Kuala Lumpur, Malaysia.
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Edney LC, Gray J, Karnon J. A scoping review of the economics of multidisciplinary teams in oncology care. J Cancer Policy 2020. [DOI: 10.1016/j.jcpo.2020.100257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Grant R, Dowswell T, Tomlinson E, Brennan PM, Walter FM, Ben-Shlomo Y, Hunt DW, Bulbeck H, Kernohan A, Robinson T, Lawrie TA. Interventions to reduce the time to diagnosis of brain tumours. Cochrane Database Syst Rev 2020; 9:CD013564. [PMID: 32901926 PMCID: PMC8082957 DOI: 10.1002/14651858.cd013564.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Brain tumours are recognised as one of the most difficult cancers to diagnose because presenting symptoms, such as headache, cognitive symptoms, and seizures, may be more commonly attributable to other, more benign conditions. Interventions to reduce the time to diagnosis of brain tumours include national awareness initiatives, expedited pathways, and protocols to diagnose brain tumours, based on a person's presenting symptoms and signs; and interventions to reduce waiting times for brain imaging pathways. If such interventions reduce the time to diagnosis, it may make it less likely that people experience clinical deterioration, and different treatment options may be available. OBJECTIVES To systematically evaluate evidence on the effectiveness of interventions that may influence: symptomatic participants to present early (shortening the patient interval), thresholds for primary care referral (shortening the primary care interval), and time to imaging diagnosis (shortening the secondary care interval and diagnostic interval). To produce a brief economic commentary, summarising the economic evaluations relevant to these interventions. SEARCH METHODS For evidence on effectiveness, we searched CENTRAL, MEDLINE, and Embase from January 2000 to January 2020; Clinicaltrials.gov to May 2020, and conference proceedings from 2014 to 2018. For economic evidence, we searched the UK National Health Services Economic Evaluation Database from 2000 to December 2014. SELECTION CRITERIA We planned to include studies evaluating any active intervention that may influence the diagnostic pathway, e.g. clinical guidelines, direct access imaging, public health campaigns, educational initiatives, and other interventions that might lead to early identification of primary brain tumours. We planned to include randomised and non-randomised comparative studies. Included studies would include people of any age, with a presentation that might suggest a brain tumour. DATA COLLECTION AND ANALYSIS Two review authors independently assessed titles identified by the search strategy, and the full texts of potentially eligible studies. We resolved discrepancies through discussion or, if required, by consulting another review author. MAIN RESULTS We did not identify any studies for inclusion in this review. We excluded 115 studies. The main reason for exclusion of potentially eligible intervention studies was their study design, due to a lack of control groups. We found no economic evidence to inform a brief economic commentary on this topic. AUTHORS' CONCLUSIONS In this version of the review, we did not identify any studies that met the review inclusion criteria for either effectiveness or cost-effectiveness. Therefore, there is no evidence from good quality studies on the best strategies to reduce the time to diagnosis of brain tumours, despite the prioritisation of research on early diagnosis by the James Lind Alliance in 2015. This review highlights the need for research in this area.
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Affiliation(s)
- Robin Grant
- Edinburgh Centre for Neuro-Oncology (ECNO), Western General Hospital, Edinburgh, UK
| | - Therese Dowswell
- C/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Eve Tomlinson
- Cochrane Gynaecological, Neuro-oncology and Orphan Cancers, 1st Floor Education Centre, Royal United Hospital, Bath, UK
| | - Paul M Brennan
- Translational Neurosurgery Department, Western General Hospital, Edinburgh, UK
| | - Fiona M Walter
- Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | - David William Hunt
- Foundation School/Dept of Clinical and Experimental Medicine, Royal Surrey County Hospital/University of Surrey, Guildford, UK
| | | | - Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tomos Robinson
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
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Al-Mayhani TF, Heywood RM, Vemireddy V, Lathia JD, Piccirillo SGM, Watts C. A non-hierarchical organization of tumorigenic NG2 cells in glioblastoma promoted by EGFR. Neuro Oncol 2020; 21:719-729. [PMID: 30590711 PMCID: PMC6765068 DOI: 10.1093/neuonc/noy204] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Expression of neuron-glial antigen 2 (NG2) identifies an aggressive malignant phenotype in glioblastoma (GBM). Mouse models have implicated NG2 in the genesis, evolution, and maintenance of glial cancers and have highlighted potential interactions between NG2 and epidermal growth factor receptor (EGFR). However, it is unknown whether the lineage relationship of NG2+ and NG2− cells follows a hierarchical or stochastic mode of growth. Furthermore, the interaction between NG2 and EGFR signaling in human GBM is also unclear. Methods Single GBM NG2+ and NG2− cells were studied longitudinally to assess lineage relationships. Short hairpin RNA knockdown of NG2 was used to assess the mechanistic role of NG2 in human GBM cells. NG2+ and NG2− cells and NG2 knockdown (NG2-KD) and wild type (NG2-WT) cells were analyzed for differential effects on EGFR signaling. Results Expression of NG2 endows an aggressive phenotype both at single cell and population levels. Progeny derived from single GBM NG2− or GBM NG2+ cells consistently establish phenotypic equilibrium, indicating the absence of a cellular hierarchy. NG2 knockdown reduces proliferation, and mice grafted with NG2-KD survive longer than controls. Finally, NG2 promotes EGFR signaling and is associated with EGFR expression. Conclusions These data support a dynamic evolution in which a bidirectional relationship exists between GBM NG2+ and GBM NG2− cells. Such findings have implications for understanding phenotypic heterogeneity, the emergence of resistant disease, and developing novel therapeutics.
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Affiliation(s)
| | | | - Vamsidhara Vemireddy
- Department of Internal Medicine, Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Justin D Lathia
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland, Ohio, USA
| | - Sara G M Piccirillo
- Brain Repair Centre, University of Cambridge, Cambridge, UK.,Department of Internal Medicine, Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Colin Watts
- Brain Repair Centre, University of Cambridge, Cambridge, UK.,Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
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12
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Fernández-Méndez R, Wong MY, Rastall RJ, Rebollo-Díaz S, Oberg I, Price SJ, Joannides AJ. Improvement of the Efficiency and Completeness of Neuro-Oncology Patient Referrals to a Tertiary Center Through the Implementation of an Electronic Referral System: Retrospective Cohort Study. J Med Internet Res 2020; 22:e15002. [PMID: 32134389 PMCID: PMC7082731 DOI: 10.2196/15002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 11/03/2019] [Accepted: 12/16/2019] [Indexed: 12/03/2022] Open
Abstract
Background Quality referrals to specialist care are key for prompt, optimal decisions about the management of patients with brain tumors. Objective This study aimed to determine the impact of introducing a Web-based, electronic referral (eReferral) system to a specialized neuro-oncology center, using a service-developed proforma, in terms of waiting times and information completeness. Methods We carried out a retrospective cohort study based on the review of medical records of referred adult patients, excluding follow-ups. Primary outcome measures were durations of three key phases within the referral pathway and completion rates of six referral fields. Results A total of 248 patients were referred to the specialist center during the study period. Median (IQR) diagnostic imaging to referral intervals were 3 (1-5) days with eReferrals, and 9 (4-19), 19 (14-49), and 8 (4-23) days with paper proforma, paper letter, and internal referrals, respectively (P<.001). Median (IQR) referral to multidisciplinary team decision intervals were 3 (2-7), 2 (1-3), 8 (2-24), and 3 (2-6) days respectively (P=.01). For patients having surgery, median (IQR) diagnostic imaging to surgery intervals were 28 (21-41), 34 (27-51), 104 (69-143), and 32 (15-89) days, respectively (P<.001). Proportions of complete fields differed significantly by referral type in all study fields (all with Ps <.001) except for details of presentation, which were present in all referrals. All study fields were always present in eReferrals, as these are compulsory for referral submission. Depending on the data field, level of completeness in the remaining referral types ranged within 69% (65/94) to 87% (82/94), 15% (3/20) to 65% (13/20), and 22% (8/41) to 63% (26/41) in paper proforma, paper letter, and internal referrals, respectively. Conclusions An electronic, Web-based, service-developed specific proforma for neuro-oncology referrals performs significantly better, with shorter waiting times and greater completeness of information than other referral types. A wider application of eReferrals is an important first step to streamlining specialist care pathways and providing excellent care. International Registered Report Identifier (IRRID) RR2-10.2196/10.2196/15002
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Affiliation(s)
- Rocío Fernández-Méndez
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,NIHR Brain Injury MedTech Co-operative, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Mei Yin Wong
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Rebecca J Rastall
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | | | - Ingela Oberg
- Neurosurgery Department, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
| | - Stephen J Price
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,NIHR Brain Injury MedTech Co-operative, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,Neurosurgery Department, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
| | - Alexis J Joannides
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,NIHR Brain Injury MedTech Co-operative, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,Obex Technologies, Cambridge, United Kingdom.,Neurosurgery Department, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
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13
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Sage W, Fernández-Méndez R, Crofton A, Gifford MJ, Bannykh A, Chrysaphinis C, Tingley E, Bulbeck H, Brahmbhatt M, Pickard JD, Walter FM, Brodbelt A, Price SJ, Joannides AJ. Defining unmet clinical need across the pathway of brain tumor care: a patient and carer perspective. Cancer Manag Res 2019; 11:2189-2202. [PMID: 30962709 PMCID: PMC6433107 DOI: 10.2147/cmar.s175886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of this study was to determine the experience of patients with brain tumors and their carers across distinct parts of their treatment pathway and identify their views on potential service gaps in need of addressing. Methods A structured survey was administered at patient workshops across the UK and online through a charity newsletter. Answers to closed questions were analyzed using descriptive statistics, and open questions were examined using techniques of inductive content analysis. Results A total of 136 survey responses were received, representing patients with a variety of diagnoses and geographical locations (30 counties). There was a wide range of opinions on the provision of current neuro-oncology services. Key themes identified included a perceived lack of information provision, a gap in postdischarge psychological and neuropsychological supports, and an unmet willingness for involvement in research. Conclusion This national survey enhances our knowledge of current patient and carer experience within neuro-oncology services. A number of areas of unmet clinical need are highlighted providing a basis for informing future patient-centered service improvements and research.
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Affiliation(s)
- William Sage
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,
| | | | - Anna Crofton
- Department of Neurosurgery, The Walton Centre, Liverpool, UK
| | | | | | | | | | | | - Mita Brahmbhatt
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,
| | - John D Pickard
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,
| | - Fiona M Walter
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Andrew Brodbelt
- Department of Neurosurgery, The Walton Centre, Liverpool, UK
| | - Stephen J Price
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,
| | - Alexis J Joannides
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,
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14
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Sage W, Guilfoyle M, Luney C, Young A, Sinha R, Sgubin D, McAbee JH, Ma R, Jefferies S, Jena R, Harris F, Allinson K, Matys T, Qian W, Santarius T, Price S, Watts C. Local alkylating chemotherapy applied immediately after 5-ALA guided resection of glioblastoma does not provide additional benefit. J Neurooncol 2017; 136:273-280. [PMID: 29139095 PMCID: PMC5770495 DOI: 10.1007/s11060-017-2649-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 10/22/2017] [Indexed: 11/12/2022]
Abstract
Grade IV glioma is the most common and aggressive primary brain tumour. Gross total resection with 5-aminolevulinic acid (5-ALA) guided surgery combined with local chemotherapy (carmustine wafers) is an attractive treatment strategy in these patients. No previous studies have examined the benefit carmustine wafers in a treatment programme of 5-ALA guided resection followed by a temozolomide-based chemoradiotherapy protocol. The objective of this study was to examine the benefit of carmustine wafers on survival in patients undergoing 5-ALA guided resection. A retrospective cohort study of 260 patients who underwent 5-ALA resection of confirmed WHO 2007 Grade IV glioma between July 2009 and December 2014. Survival curves were calculated using the Kaplan–Meier method from surgery. The log-rank test was used to compare survival curves between groups. Cox regression was performed to identify variables predicting survival. A propensity score matched analysis was used to compare survival between patients who did and did not receive carmustine wafers while controlling for baseline characteristics. Propensity matched analysis showed no significant survival benefit of insertion of carmustine wafers over 5-ALA resection alone (HR 0.97 [0.68–1.26], p = 0.836). There was a trend to higher incidence of wound infection in those who received carmustine wafers (15.4 vs. 7.1%, p = 0.064). The Cox regression analysis showed that intraoperative residual fluorescent tumour and residual enhancing tumour on post-operative MRI were significantly predictive of reduced survival. Carmustine wafers have no added benefit following 5-ALA guided resection. Residual fluorescence and residual enhancing disease following resection have a negative impact on survival.
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Affiliation(s)
- William Sage
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Mathew Guilfoyle
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Catriona Luney
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Adam Young
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Rohitashwa Sinha
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Donatella Sgubin
- Division of Neurosurgery, Azienda Ospedaliera Nazionale SS, Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Joseph H McAbee
- Department of Clinical Neurosciences, John van Geest Centre for Brain Repair, University of Cambridge, Cambridge, UK
| | - Ruichong Ma
- Department of Neurosurgery, John Radcliffe Hospital NHS Foundation Trust, Oxford, UK
| | - Sarah Jefferies
- Department of Oncology, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Rajesh Jena
- Department of Oncology, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Fiona Harris
- Department of Oncology, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Kieren Allinson
- Department of Histopathology, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Tomasz Matys
- Department of Radiology, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Wendi Qian
- Cambridge Cancer Trial Centre, Cambridge Clinical Trials Unit - Cancer Theme, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Thomas Santarius
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Stephen Price
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Colin Watts
- Division of Neurosurgery, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK.
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrookes Hospital, University of Cambridge, Hills Road, Box 167, Cambridge, CB2 0QQ, UK.
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15
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Has the survival of patients with glioblastoma changed over the years? Br J Cancer 2015; 114:146-50. [PMID: 26671748 PMCID: PMC4815808 DOI: 10.1038/bjc.2015.421] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 08/01/2015] [Accepted: 11/01/2015] [Indexed: 11/21/2022] Open
Abstract
Background: Over the last decade, the approach to the management of brain tumours and the understanding of glioblastoma tumour biology has advanced and a number of therapeutic interventions have evolved, some of which have shown statistically significant effects on overall survival (OS) and progression-free survival in glioblastoma. The aim of this study is to compare survival in glioblastoma patients over a 10-year period (1999–2000 and 2009–2010). Methods: A retrospective cohort study was performed. Identification of all histologically confirmed glioblastoma in a single centre in years 1999, 2000, 2009 and 2010, and production of survival analysis comparing 1999–2000 and 2009–2010 were achieved. Results: A total of 317 patients were included in the analysis (133 in year 1999–2000, and 184 in year 2009–2010). Cox regression analysis showed that the survival was significantly longer in patients in years 2009–2010 than those in 1999–2000 at P<0.001 with HR=0.56, confidence interval (CI) (0.45–0.71). The 1- and 3-year survival rates were 20.7% and 4.4%, respectively, for patients in 1999–2000, improving to 40.0% and 10.3%, respectively, for patients in 2009–2010. The comparisons between the two groups in survival at 1, 2 and 3 years are all statistically significant at P<0.001, respectively. The median OS was 0.36 and 0.74 in 1999–2000 and 2009–2010 groups, respectively. Conclusions: Over this period, OS from glioblastoma has increased significantly in our unit. We believe this is due to the institution of evidence-based surgical and oncological strategies practised in a multidisciplinary setting.
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Guidelines, "minimal requirements" and standard of care in glioblastoma around the Mediterranean Area: A report from the AROME (Association of Radiotherapy and Oncology of the Mediterranean arEa) Neuro-Oncology working party. Crit Rev Oncol Hematol 2015; 98:189-99. [PMID: 26626226 DOI: 10.1016/j.critrevonc.2015.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 09/08/2015] [Accepted: 10/27/2015] [Indexed: 11/25/2022] Open
Abstract
Glioblastoma is the most common and the most lethal primary brain tumor in adults. Although studies are ongoing, the epidemiology of glioblastoma in North Africa (i.e. Morocco, Algeria and Tunisia) remains imperfectly settled and needs to be specified for a better optimization of the neuro-oncology healthcare across the Mediterranean area and in North Africa countries. Over the last years significant therapeutic advances have been accomplished improving survival and quality of life of glioblastoma patients. Indeed, concurrent temozolomide-radiotherapy (temoradiation) and adjuvant temozolomide has been established as the standard of care associated with a survival benefit and a better outcome. Therefore, considering this validated strategy and regarding the means and some other North Africa countries specificities, we decided, under the auspices of AROME (association of radiotherapy and oncology of the Mediterranean area; www.aromecancer.org), a non-profit organization, to organize a dedicated meeting to discuss the standards and elaborate a consensus on the "minimal requirements" adapted to the local resources. Thus, panels of physicians involved in daily multidisciplinary brain tumors management in the two borders of the Mediterranean area have been invited to the AROME neuro-oncology working party. We report here the consensus, established for minimal human and material resources for glioblastoma diagnosis and treatment faced to the standard of care, which should be reached. If the minimal requirements are not reached, the patients should be referred to the closest specialized medical center where at least minimal requirements, or, ideally, the standard of care should be guaranteed to the patients.
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17
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Maus F, Sakry D, Binamé F, Karram K, Rajalingam K, Watts C, Heywood R, Krüger R, Stegmüller J, Werner HB, Nave KA, Krämer-Albers EM, Trotter J. The NG2 Proteoglycan Protects Oligodendrocyte Precursor Cells against Oxidative Stress via Interaction with OMI/HtrA2. PLoS One 2015; 10:e0137311. [PMID: 26340347 PMCID: PMC4560422 DOI: 10.1371/journal.pone.0137311] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 08/14/2015] [Indexed: 02/06/2023] Open
Abstract
The NG2 proteoglycan is characteristically expressed by oligodendrocyte progenitor cells (OPC) and also by aggressive brain tumours highly resistant to chemo- and radiation therapy. Oligodendrocyte-lineage cells are particularly sensitive to stress resulting in cell death in white matter after hypoxic or ischemic insults of premature infants and destruction of OPC in some types of Multiple Sclerosis lesions. Here we show that the NG2 proteoglycan binds OMI/HtrA2, a mitochondrial serine protease which is released from damaged mitochondria into the cytosol in response to stress. In the cytosol, OMI/HtrA2 initiates apoptosis by proteolytic degradation of anti-apoptotic factors. OPC in which NG2 has been downregulated by siRNA, or OPC from the NG2-knockout mouse show an increased sensitivity to oxidative stress evidenced by increased cell death. The proapoptotic protease activity of OMI/HtrA2 in the cytosol can be reduced by the interaction with NG2. Human glioma expressing high levels of NG2 are less sensitive to oxidative stress than those with lower NG2 expression and reducing NG2 expression by siRNA increases cell death in response to oxidative stress. Binding of NG2 to OMI/HtrA2 may thus help protect cells against oxidative stress-induced cell death. This interaction is likely to contribute to the high chemo- and radioresistance of glioma.
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Affiliation(s)
- Frank Maus
- Department of Biology, Molecular Cell Biology, Johannes Gutenberg University, Mainz, Germany
| | - Dominik Sakry
- Department of Biology, Molecular Cell Biology, Johannes Gutenberg University, Mainz, Germany
| | - Fabien Binamé
- Department of Biology, Molecular Cell Biology, Johannes Gutenberg University, Mainz, Germany
| | - Khalad Karram
- Department of Biology, Molecular Cell Biology, Johannes Gutenberg University, Mainz, Germany
- Institute for Molecular Medicine, University Medical Center of the Johannes-Gutenberg University, Mainz, Germany
| | - Krishnaraj Rajalingam
- Research Center for Immune Therapy, Institute for Immunology, Johannes Gutenberg University of Mainz, Medical Center Mainz, Mainz, Germany
| | - Colin Watts
- Cambridge University, Dept. Clinical Neurosciences, Division of Neurosurgery, Cambridge, United Kingdom
| | - Richard Heywood
- Cambridge University, Dept. Clinical Neurosciences, Division of Neurosurgery, Cambridge, United Kingdom
| | - Rejko Krüger
- Clinical and Experimental Neuroscience, Luxembourg Center for Systems Biomedicine, University of Luxembourg and Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
- Department of Neurodegenerative Diseases, Hertie-Institute for Clinical Brain Research, and German Center for Neurodegenerative Diseases (DZNE), University of Tübingen, Tübingen, Germany
| | - Judith Stegmüller
- Cellular and Molecular Neurobiology, Max Planck Institute of Experimental Medicine, Göttingen, Germany
| | - Hauke B. Werner
- Max Planck Institute of Experimental Medicine, Department of Neurogenetics, Göttingen, Germany
| | - Klaus-Armin Nave
- Max Planck Institute of Experimental Medicine, Department of Neurogenetics, Göttingen, Germany
| | - Eva-Maria Krämer-Albers
- Department of Biology, Molecular Cell Biology, Johannes Gutenberg University, Mainz, Germany
| | - Jacqueline Trotter
- Department of Biology, Molecular Cell Biology, Johannes Gutenberg University, Mainz, Germany
- * E-mail:
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Nichols L, Wright K. Implementing a Primary Healthcare Framework: The Importance of Nursing Leadership in Developing and Maintaining a Brain Tumor Support Group. Clin J Oncol Nurs 2015. [DOI: 10.1188/15.cjon.463-467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kushner DS, Amidei C. Rehabilitation of motor dysfunction in primary brain tumor patients †. Neurooncol Pract 2015; 2:185-191. [PMID: 31386049 DOI: 10.1093/nop/npv019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Indexed: 11/13/2022] Open
Abstract
In 2010 it was estimated that >688 000 Americans were living with a primary brain tumor (PBT) corresponding to a U.S. prevalence rate of approximately 221.8 per 100 000 people. Five-year survival is 96.1% in nonmalignant PBTs, 34% in malignant PBTs for all ages, and 71% in children [1985-2005]. Case fatality rates have decreased in the U.S. since the 1970's for nonmalignant PBTs and for medulloblastoma, oligodendroglioma, and astrocytoma. Statistics of increasing survival highlight the importance of rehabilitation interventions to improve function and quality of life in survivors. PBT motor dysfunction is multifactorial, occurring as a result of direct effects of tumor and/or swelling or as a result of treatments; etiologies include encephalopathy, myopathy, neuropathy, infection, poor nutrition, metabolic factors, emotional factors, impaired perception/vision/cognition and complications of immobility. Motor dysfunction may lead to: impaired mobility, impaired activities of daily living, risk for complications of immobility, falls, pain, anxiety/depression, and loss of functional independence and quality of life. Rehabilitation treatment strategies target specific causes of motor dysfunction to improve functional independence and quality of life. This article reviews current knowledge and controversy regarding the role of rehabilitation for motor disorders in PBT patients.
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Affiliation(s)
- David S Kushner
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, Florida (D.S.K.); Department of Neurology and Rehabilitation, University of Illinois, College of Medicine (C.A.)
| | - Christina Amidei
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, Florida (D.S.K.); Department of Neurology and Rehabilitation, University of Illinois, College of Medicine (C.A.)
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20
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Kenney-Herbert E, Al-Mayhani T, Piccirillo SGM, Fowler J, Spiteri I, Jones P, Watts C. CD15 Expression Does Not Identify a Phenotypically or Genetically Distinct Glioblastoma Population. Stem Cells Transl Med 2015; 4:822-31. [PMID: 26019225 DOI: 10.5966/sctm.2014-0047] [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: 03/10/2014] [Accepted: 02/23/2015] [Indexed: 12/13/2022] Open
Abstract
UNLABELLED : Recent research has focused on the hypothesis that the growth and regeneration of glioblastoma (GB) is sustained by a subpopulation of self-renewing stem-like cells. This has led to the prediction that molecular markers for cancer stem cells in GB may provide a treatment target. One candidate marker is CD15: we wanted to determine if CD15 represented a credible stem cell marker in GB. We first demonstrated that CD15-positive (CD15+) cells were less proliferative than their CD15-negative (CD15-) counterparts in 10 patient GB tumors. Next we compared the proliferative activity of CD15+ and CD15- cells in vitro using tumor-initiating primary GB cell lines (TICs) and found no difference in proliferative behavior. Furthermore, TICs sorted for CD15+ and CD15- were not significantly different cytogenetically or in terms of gene expression profile. Sorted single CD15+ and CD15- cells were equally capable of reconstituting a heterogeneous population containing both CD15+ and CD15- cells over time, and both CD15+ and CD15- cells were able to generate tumors in vivo. No difference was found in the phenotypic or genomic behavior of CD15+ cells compared with CD15- cells from the same patient. Moreover, we found that in vitro, cells were able to interconvert between the CD15+ and CD15- states. Our data challenge the utility of CD15 as a cancer stem cell marker. SIGNIFICANCE The data from this study contribute to the ongoing debate about the role of cancer stem cells in gliomagenesis. Results showed that CD15, a marker previously thought to be a cancer stem-like marker in glioblastoma, could not isolate a phenotypically or genetically distinct population. Moreover, isolated CD15-positive and -negative cells were able to generate mixed populations of glioblastoma cells in vitro.
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Affiliation(s)
- Emma Kenney-Herbert
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, Cambridge University, Cambridge, United Kingdom; MRC Cancer Unit, Hutchison/MRC Research Centre, University of Cambridge, Cambridge, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Talal Al-Mayhani
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, Cambridge University, Cambridge, United Kingdom; MRC Cancer Unit, Hutchison/MRC Research Centre, University of Cambridge, Cambridge, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Sara G M Piccirillo
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, Cambridge University, Cambridge, United Kingdom; MRC Cancer Unit, Hutchison/MRC Research Centre, University of Cambridge, Cambridge, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Joanna Fowler
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, Cambridge University, Cambridge, United Kingdom; MRC Cancer Unit, Hutchison/MRC Research Centre, University of Cambridge, Cambridge, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Inmaculada Spiteri
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, Cambridge University, Cambridge, United Kingdom; MRC Cancer Unit, Hutchison/MRC Research Centre, University of Cambridge, Cambridge, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Philip Jones
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, Cambridge University, Cambridge, United Kingdom; MRC Cancer Unit, Hutchison/MRC Research Centre, University of Cambridge, Cambridge, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Colin Watts
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, Cambridge University, Cambridge, United Kingdom; MRC Cancer Unit, Hutchison/MRC Research Centre, University of Cambridge, Cambridge, United Kingdom; The Institute of Cancer Research, London, United Kingdom
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Abstract
Neurosurgical oncology for intrinsic glioma is evolving rapidly. It must be patient-centered, consultant-led and research-orientated. The value of specialist neurosurgical engagement is becoming more widely recognized. Detailed evaluation tailored to each patient is essential before the surgical admission, in conjunction with clinical oncology input. Medical optimization, collation of magnetic resonance datasets for preoperative planning and providing an informed explanation of the proposed management and its alternatives are all part of the neurosurgeon's remit. Meticulous microsurgical technique during surgery utilizing modern neuronavigation and physiological monitoring are integral components of the specialist armamentarium. A clear understanding of the rationale for surgical intervention, including its place alongside radiotherapy and chemotherapy, informs surgical decision-making. Recognition and understanding of these issues are driving the evolution of neurosurgical management of high-grade glioma. New challenges are emerging and need to be critically evaluated in robustly designed clinical trials.
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Affiliation(s)
- Colin Watts
- University of Cambridge Department of Clinical Neurosciences, Division of Neurosurgery, Box 167 Addenbrookes Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
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22
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Walker D, Hamilton W, Walter FM, Watts C. Strategies to accelerate diagnosis of primary brain tumors at the primary-secondary care interface in children and adults. CNS Oncol 2015; 2:447-62. [PMID: 25054667 DOI: 10.2217/cns.13.36] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
This article presents a shared view from practitioners with special interests in diagnosing and managing primary brain tumors in both primary and secondary care, in adult and pediatric disciplines; it examines the complexity of identifying whether it would be of benefit and feasible to try to identify those with brain tumors earlier, how this could be achieved and what evidence exists to justify such an approach. The experience of the HeadSmart Campaign in childhood brain tumor, using awareness as a method for driving service change, is used to illustrate how diagnostic practice can be changed across the primary and secondary care interface. This article highlights the importance of focusing upon the needs of patients with primary brain tumors as they represent a significant set of life-threatening and disabling diseases with significant implications for cancer and palliative services.
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Affiliation(s)
- David Walker
- Children's Brain Tumor Research Centre, Queen's Medical Centre, Nottingham, NG7 2UH, UK.
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Piccirillo SGM, Spiteri I, Sottoriva A, Touloumis A, Ber S, Price SJ, Heywood R, Francis NJ, Howarth KD, Collins VP, Venkitaraman AR, Curtis C, Marioni JC, Tavaré S, Watts C. Contributions to drug resistance in glioblastoma derived from malignant cells in the sub-ependymal zone. Cancer Res 2015; 75:194-202. [PMID: 25406193 PMCID: PMC4286248 DOI: 10.1158/0008-5472.can-13-3131] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Glioblastoma, the most common and aggressive adult brain tumor, is characterized by extreme phenotypic diversity and treatment failure. Through fluorescence-guided resection, we identified fluorescent tissue in the sub-ependymal zone (SEZ) of patients with glioblastoma. Histologic analysis and genomic characterization revealed that the SEZ harbors malignant cells with tumor-initiating capacity, analogous to cells isolated from the fluorescent tumor mass (T). We observed resistance to supramaximal chemotherapy doses along with differential patterns of drug response between T and SEZ in the same tumor. Our results reveal novel insights into glioblastoma growth dynamics, with implications for understanding and limiting treatment resistance.
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Affiliation(s)
- Sara GM Piccirillo
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Inmaculada Spiteri
- Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Cambridge, UK
| | - Andrea Sottoriva
- Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Cambridge, UK
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Anestis Touloumis
- Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Cambridge, UK
- European Bioinformatics Institute (EMBL-EBI), Wellcome Trust Genome Campus, Hinxton, Cambridge, UK
| | - Suzan Ber
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Stephen J Price
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Richard Heywood
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Nicola-Jane Francis
- Department of Oncology and the Medical Research Council Cancer Cell Unit, Hutchison/MRC Research Centre, Cambridge, UK
| | - Karen D Howarth
- Hutchison/MRC Research Centre and Department of Pathology, University of Cambridge, Cambridge, UK
| | - Vincent P Collins
- Division of Molecular Histopathology, Department of Pathology, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ashok R Venkitaraman
- Department of Oncology and the Medical Research Council Cancer Cell Unit, Hutchison/MRC Research Centre, Cambridge, UK
| | - Christina Curtis
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - John C Marioni
- European Bioinformatics Institute (EMBL-EBI), Wellcome Trust Genome Campus, Hinxton, Cambridge, UK
| | - Simon Tavaré
- Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Cambridge, UK
| | - Colin Watts
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
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Choo T, Deb S, Wilkins J, Atiomo W. Evaluating the impact of the reconfiguration of gynaecology services at a University Hospital NHS trust in the United Kingdom. BMC Health Serv Res 2014; 14:428. [PMID: 25249035 PMCID: PMC4263049 DOI: 10.1186/1472-6963-14-428] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Accepted: 09/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The project aim was to investigate the impact of reconfiguring gynaecology services on the key performance indicators of a University Hospital NHS Trust in the UK. The reconfiguration involved the centralisation of elective gynaecology on one hospital site and emergency gynaecology on the other. METHODS Data measuring outcomes of the Trust's performance indicators (clinical outcomes, patient experience, staff satisfaction, teaching/training, research/development and value for money) were collected. Two time periods, 12 months before and after the reconfiguration in March 2011, were compared for all outcome measures except patient experience. Retrospective data from the hospitals audit department on clinical activity/outcomes and emergency gynaecology patient's feedback questionnaires were analysed. Staff satisfaction, teaching/training and research/development were measured through an online survey of gynaecology consultants. RESULTS Post reconfiguration, the total number of admissions reduced by 6% (6,867 vs 6,446). There was a 14% increase in elective theatre sessions available (902.29 vs 1030.57) and an 84% increase in elective theatre sessions cancelled (44.43 vs 81.71). However, the average number of elective operations performed during each theatre session remained similar (2.63 vs 2.5). There was a significant increase in medical devices related clinical incidents (2 vs 11). With patient experience, there was a significant reduction in patient's overall length of stay on the emergency gynaecology ward and waiting times for investigations. For staff satisfaction, Consultants were significantly more dissatisfied with workload (3.45 vs 2.85) and standards of care (3.75 vs 2.93). With research and development, consultants remained dissatisfied with time/funding/opportunities for research. No significant impact on undergraduate/postgraduate teaching was found. No financial data on gynaecology was provided for the assessment of value for money. CONCLUSIONS Reconfiguration of gynaecology services at this Trust may have resulted in a reduction in gynaecological activity and increased cancellation of elective operations but did not significantly reduce the number of elective operations performed. Although consultants expressed increased dissatisfaction with standards of clinical care, clinical incident reports did not significantly increase apart from medical devices incidents. Patient experience of emergency gynaecology services was improved. This manuscript provides a framework for similar exercises evaluating the impact of service redesign in the NHS.
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Affiliation(s)
- Teck Choo
- />Department of Obstetrics and Gynaecology, Nottingham University Hospitals, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Shilpa Deb
- />Department of Obstetrics and Gynaecology, Nottingham University Hospitals, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Joanne Wilkins
- />Department of Obstetrics and Gynaecology, Nottingham University Hospitals, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - William Atiomo
- />School of Clinical Sciences, Division of Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
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Ajaz M, Jefferies S, Brazil L, Watts C, Chalmers A. Current and investigational drug strategies for glioblastoma. Clin Oncol (R Coll Radiol) 2014; 26:419-30. [PMID: 24768122 DOI: 10.1016/j.clon.2014.03.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 03/27/2014] [Indexed: 11/21/2022]
Abstract
Medical treatments for glioblastoma face several challenges. Lipophilic alkylators remain the mainstay of treatment, emphasising the primacy of good blood-brain barrier penetration. Temozolomide has emerged as a major contributor to improved patient survival. The roles of procarbazine and vincristine in the procarbazine, lomustine and vincristine (PCV) schedule have attracted scrutiny and several lines of evidence now support the use of lomustine as effective single-agent therapy. Bevacizumab has had a convoluted development history, but clearly now has no major role in first-line treatment, and may even be detrimental to quality of life in this setting. In later disease, clinically meaningful benefits are achievable in some patients, but more impressively the combination of bevacizumab and lomustine shows early promise. Over the last decade, investigational strategies in glioblastoma have largely subscribed to the targeted kinase inhibitor paradigm and have mostly failed. Low prevalence dominant driver lesions such as the FGFR-TACC fusion may represent a niche role for this agent class. Immunological, metabolic and radiosensitising approaches are being pursued and offer more generalised efficacy. Finally, trial design is a crucial consideration. Progress in clinical glioblastoma research would be greatly facilitated by improved methodologies incorporating: (i) routine pharmacokinetic and pharmacodynamic assessments by preoperative dosing; and (ii) multi-stage, multi-arm protocols incorporating new therapy approaches and high-resolution biology in order to guide necessary improvements in science.
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Affiliation(s)
- M Ajaz
- Surrey Cancer Research Institute, University of Surrey, Guildford, UK.
| | - S Jefferies
- Oncology Centre, Addenbrooke's Hospital, Cambridge, UK
| | - L Brazil
- Guy's, St Thomas' and King's College Hospitals, London, UK
| | - C Watts
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - A Chalmers
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
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Burnet N, Jena R, Burton K, Tudor G, Scaife J, Harris F, Jefferies S. Clinical and Practical Considerations for the Use of Intensity-modulated Radiotherapy and Image Guidance in Neuro-oncology. Clin Oncol (R Coll Radiol) 2014; 26:395-406. [DOI: 10.1016/j.clon.2014.04.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 04/04/2014] [Indexed: 12/26/2022]
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Burnet N. Developments in the Management of Central Nervous System Tumours. Clin Oncol (R Coll Radiol) 2014; 26:361-3. [DOI: 10.1016/j.clon.2014.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 04/11/2014] [Indexed: 11/28/2022]
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Arvold ND, Wang Y, Zigler C, Schrag D, Dominici F. Hospitalization burden and survival among older glioblastoma patients. Neuro Oncol 2014; 16:1530-40. [PMID: 24778086 DOI: 10.1093/neuonc/nou060] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Half of all glioblastoma patients are at least 65 years old. The frequency and duration of hospitalization from disease- and treatment-related morbidity in this population are unknown. METHODS We performed a retrospective cohort study among patients aged 65 years and older with glioblastoma diagnosed between 1999 and 2007 using SEER-Medicare linked data. Diagnoses and procedures were identified using administrative claims data. Logistic regression was performed to identify predictors of high hospitalization burden. RESULTS Among the 5029 patients in the cohort, 52% were ages 65-74, and 52% were male. Twenty-six percent of patients underwent extensive resection, 72% received radiotherapy, and 18% received temozolomide. Median survival was 4.9 months. Among all patients, 21% were hospitalized at least 30 cumulative days between diagnosis and death, and 22% of all patients spent at least one-fourth of their remaining lives as inpatients. Higher comorbidity score (adjusted hazard ratio [AHR], 1.72; 95% CI, 1.42-2.07) and black race (AHR, 1.56; 95% CI, 1.11-2.18) were associated with an increased risk of being hospitalized for at least 25% of remaining life, whereas radiation (AHR, 0.49; 95% CI, 0.42-0.58), temozolomide (AHR, 0.31; 95% CI, 0.23-0.42), and extensive surgery (AHR, 0.83; 95% CI, 0.69-0.99) were associated with a decreased risk. CONCLUSIONS These data highlight the burden of hospitalization faced by a large proportion of older glioblastoma patients. In the setting of short survival, strategies to reduce the amount of time these patients spend hospitalized are urgently needed, to help maintain quality of life at the end of life.
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Affiliation(s)
- Nils D Arvold
- Department of Radiation Oncology, Dana-Farber/Brigham & Women's Hospital, Boston, Massachusetts (N.D.A.); Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts (Y.W., C.Z., F.D.); Department of Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts (D.S.)
| | - Yun Wang
- Department of Radiation Oncology, Dana-Farber/Brigham & Women's Hospital, Boston, Massachusetts (N.D.A.); Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts (Y.W., C.Z., F.D.); Department of Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts (D.S.)
| | - Cory Zigler
- Department of Radiation Oncology, Dana-Farber/Brigham & Women's Hospital, Boston, Massachusetts (N.D.A.); Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts (Y.W., C.Z., F.D.); Department of Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts (D.S.)
| | - Deborah Schrag
- Department of Radiation Oncology, Dana-Farber/Brigham & Women's Hospital, Boston, Massachusetts (N.D.A.); Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts (Y.W., C.Z., F.D.); Department of Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts (D.S.)
| | - Francesca Dominici
- Department of Radiation Oncology, Dana-Farber/Brigham & Women's Hospital, Boston, Massachusetts (N.D.A.); Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts (Y.W., C.Z., F.D.); Department of Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts (D.S.)
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Price SJ, Guilfoyle M, J Jefferies S, Harris F, Oberg I, G Burnet N, Santarius T, Watts C. Development of an Integrated Subspecialist Multidisciplinary Neuro-oncology Service. BMJ QUALITY IMPROVEMENT REPORTS 2013; 2:bmjquality_u201857_w981. [PMID: 26734207 PMCID: PMC4652738 DOI: 10.1136/bmjquality.u201857.w981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 08/07/2013] [Indexed: 12/05/2022]
Abstract
Traditionally, the poor outcome for patients with malignant brain tumours led to therapeutic nihilism. In turn, this resulted in lack of interest in neurosurgical oncology subspecialisation, and less than ideal patient pathways. One problem of concern was the low rate of tumour resection. Between 1997 and 2006, 685 treated glioblastomas were identified. In the first four years only 40% of patients underwent tumour resection, rising to 55% in the last four years. Before revision of the pathway, the median length of hospital stay was 8 days, and 35% of patients received the results of their histology outside of a clinic setting. A pathway of care was established, in which all patients were discussed pre-operatively in an MDT meeting and then directed into a new surgical neuro-oncology clinic providing first point of contact. This limited the number of surgeons operating on adult glioma patients and aided recruitment into research studies. Now, three consultant neurosurgeons run this service, easily fulfilling IOG requirement to spend >50% of programmed activities in neuro-oncology. Nursing support has been critical to provide an integrated service. This model has allowed increased recruitment to clinical trials. The introduction of this service led to an increase in patients discussed pre-operatively in an MDT (66% rising to 87%; P=0.027), an increase in the rate of surgical resection (from 40% to 80%) and more patients being admitted electively (from 25% to 80%; P<0.001). There was a reduction in the median length of stay (8 days reduced to 4.5 days; P<0.001). For the cohort of GBM patients that went on to have chemoradiotherapy we improved median survival to 18 months, with 35% of patients alive at two years, comparable to international outcomes. Implementing a specialist neurosurgical oncology service begins with understanding the patient care pathway. Our patients have benefitted from the culture of subspecialisation and the excellent inter-disciplinary working relationships that have been developed.
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Mohsen LA, Shi V, Jena R, Gillard JH, Price SJ. Diffusion tensor invasive phenotypes can predict progression-free survival in glioblastomas. Br J Neurosurg 2013; 27:436-41. [DOI: 10.3109/02688697.2013.771136] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Elmahdi A, Frary AJ, Scotton WJ, O'Donovan DG, Price SJ. Glioblastomas with oligodendroglial component have the same clinical phenotype as classical glioblastomas. Br J Neurosurg 2013; 27:419-24. [PMID: 23418780 DOI: 10.3109/02688697.2013.767315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Glioblastomas are the commonest primary brain tumour and are considered one of the most heterogeneous tumour types. The introduction of a glioblastoma with oligodendroglial component (GBM + O) in the latest WHO Classification of Tumours of the Central Nervous System (1) was to help with this. There has been conflicting evidence as to whether this tumour conferred a better prognosis than classical glioblastoma (GBM). The aim of this study was to study the clinical phenotype of these GBM + O tumours and compare it to the classical GBM. MATERIALS AND METHODS All patients with histological evidence of a glioblastoma between 1st January 2007 and 31st January 2011 were identified from the Neuropathology Database. Clinical and radiological details were obtained for all patients. The overall survival of patients who were treated with chemoradiotherapy was obtained and the GBM + O cohort compared to the classical GBM cohort. RESULTS Three hundred and ninety-six patients with newly diagnosed glioblastomas were identified: 294 (74.2%) had classical GBM and 102 (25.6%) had GBM + O. The two cohorts presented at a similar age (61.1 years GBM + O vs. 63.2 years GBM; P = 0.09) and were matched for sex and side of the tumour. GBM + O were more likely to be located in the frontal lobes (38.2% for GBM + O vs. 27.2% for GBM: P = 0.04). In the group that was treated with chemoradiotherapy the overall survival was similar (median survival GBM + O 361 days vs. 379 days GBM; Log Rank 0.61, P = 0.43). CONCLUSION The presence of an oligodendroglial component does not confer any improvement in survival and has a similar clinical phenotype to classical GBMs.
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Affiliation(s)
- Ashraf Elmahdi
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals Foundation Trust , Cambridge , UK
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Watts C, Dunn L, Ashkan K, Jenkinson M, Smith P. Establishing the efficacy of Gliadel wafers: progress towards a Phase III trial. Acta Neurochir (Wien) 2013; 155:61-2. [PMID: 23108559 DOI: 10.1007/s00701-012-1533-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Accepted: 10/16/2012] [Indexed: 10/27/2022]
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Catt S, Chalmers A, Critchley G, Fallowfield L. Supportive follow-up in patients treated with radical intent for high-grade glioma. CNS Oncol 2012; 1:39-48. [PMID: 25054299 PMCID: PMC6176810 DOI: 10.2217/cns.12.8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
UNLABELLED Ongoing supportive follow-up for patients with malignant glioma lacks good evidence to define and guide practice, and certain approaches have previously been criticized. In the UK, it commonly involves routine hospital visits with imaging to monitor treatment effects and detect disease progression. AIMS Through use of an observational study evaluate and compare oncologist-led follow-up with a multidisciplinary group follow-up method from the perspective of patients and caregivers. MATERIALS & METHODS A total of 40 patients, and 32 of their caregivers, were recruited 3 months after completing radical radiotherapy treatment. Face-to-face interviews conducted at home with patients gathered information about access to and experiences of follow-up services. Standardized questionnaires measured patients' quality of life and unmet care needs, and caregivers' psychological wellbeing. Assessment was repeated three times over a 6-month period. RESULTS Inevitable attrition left 26/40 patients and 19/32 caregivers with complete data. Most (65%) patients' quality of life improved or was maintained over the study period. However, psychological support for patients and caregivers was suboptimal, notably 56% of caregivers had probable psychiatric morbidity. Though few significant differences were found between the two follow-up methods, multidisciplinary follow-up provided better continuity of care and more efficient test result provision. CONCLUSION Innovative interventions are required to ameliorate psychological distress in patients and caregivers.
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Affiliation(s)
- Susan Catt
- Sussex Health Outcomes, Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Brighton, BN1 9QG, UK
- Sussex Health Outcomes, Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Brighton, BN1 9QG, UK
| | - Anthony Chalmers
- Institute of Cancer Sciences, University of Glasgow, G12 8QQ, UK
| | - Giles Critchley
- Hurstwood Park Neurological Centre, Haywards Heath, RH16 4EX, UK
| | - Lesley Fallowfield
- Sussex Health Outcomes, Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Brighton, BN1 9QG, UK
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Piccirillo SGM, Dietz S, Madhu B, Griffiths J, Price SJ, Collins VP, Watts C. Fluorescence-guided surgical sampling of glioblastoma identifies phenotypically distinct tumour-initiating cell populations in the tumour mass and margin. Br J Cancer 2012; 107:462-8. [PMID: 22722315 PMCID: PMC3405212 DOI: 10.1038/bjc.2012.271] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 05/22/2012] [Accepted: 05/23/2012] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Acquiring clinically annotated, spatially stratified tissue samples from human glioblastoma (GBM) is compromised by haemorrhage, brain shift and subjective identification of 'normal' brain. We tested the use of 5-aminolevulinic acid (5-ALA) fluorescence to objective tissue sampling and to derive tumour-initiating cells (TICs) from mass and margin. METHODS The 5-ALA was administered to 30 GBM patients. Samples were taken from the non-fluorescent necrotic core, fluorescent tumour mass and non-fluorescent margin. We compared the efficiency of isolating TICs from these areas in 5-ALA versus control patients. HRMAS (1)H NMR was used to reveal metabolic alterations due to 5-ALA. We then characterised TICs for self-renewal in vitro and tumorigenicity in vivo. RESULTS The derivation of TICs was not compromised by 5-ALA and the metabolic profile was similar between tumours from 5-ALA patients and controls. The TICs from the fluorescent mass were self-renewing in vitro and tumour-forming in vivo, whereas TICs from non-fluorescent margin did not self-renew in vitro but did form tumours in vivo. CONCLUSION Our data show that 5-ALA does not compromise the derivation of TICs. It also reveals that the margin contains TICs, which are phenotypically different from those isolated from the corresponding mass.
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Affiliation(s)
- S G M Piccirillo
- Department of Clinical Neurosciences, Cambridge Centre for Brain Repair, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0PY, UK
| | - S Dietz
- Cancer Research UK, Cambridge Research Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - B Madhu
- Cancer Research UK, Cambridge Research Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - J Griffiths
- Cancer Research UK, Cambridge Research Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - S J Price
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - V P Collins
- Division of Molecular Histopathology, Department of Pathology, University of Cambridge, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - C Watts
- Department of Clinical Neurosciences, Cambridge Centre for Brain Repair, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0PY, UK
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
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