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Kong BY, Sim HW, Barnes EH, Nowak AK, Hovey EJ, Jeffree R, Harrup R, Parkinson J, Gan HK, Pinkham MB, Yip S, Hall M, Tu E, Carter C, Koh ES, Lwin Z, Dowling A, Simes JS, Gedye C. Multi-Arm GlioblastoMa Australasia (MAGMA): protocol for a multiarm randomised clinical trial for people affected by glioblastoma. BMJ Open 2022; 12:e058107. [PMID: 36104135 PMCID: PMC10441685 DOI: 10.1136/bmjopen-2021-058107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 08/12/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Glioblastoma (GBM) is the most common malignant primary central nervous system cancer in adults. The objective of the Multi-Arm GlioblastoMa Australasia (MAGMA) trial is to test hypotheses in real world setting to improve survival of people with GBM. Initial experimental arms are evaluating the effectiveness of interventions in newly diagnosed GBM (ndGBM). This study will compare maximal surgical resection followed by chemoradiotherapy plus adjuvant chemotherapy for 6 months with the addition of (1) 'neoadjuvant' chemotherapy beginning as soon as possible after surgery and/or (2) adjuvant chemotherapy continued until progression within the same study platform. METHODS AND ANALYSIS MAGMA will establish a platform for open-label, multiarm, multicentre randomised controlled testing of treatments for GBM. The study began recruiting in September 2020 and recruitment to the initial two interventions in MAGMA is expected to continue until September 2023.Adults aged ≥18 years with ndGBM will be given the option of undergoing randomisation to each study intervention separately, thereby giving rise to a partial factorial design, with two separate randomisation time points, one for neoadjuvant therapy and one for extended therapy. Patients will have the option of being randomised at each time point or continuing on with standard treatment.The primary outcome for the study is overall survival from the date of initial surgery until death from any cause. Secondary outcomes include progression-free survival, time to first non-temozolomide treatment, overall survival from each treatment randomisation, clinically significant toxicity as measured by grade 3 or 4 adverse events and health-related quality-of-life measures. Tertiary outcomes are predictive/prognostic biomarkers and health utilities and incremental cost-effectiveness ratio.The primary analysis of overall survival will be performed separately for each study intervention according to the intention to treat principle on all patients randomised to each study intervention. ETHICS AND DISSEMINATION The study (Protocol version 2.0 dated 23 November 2020) was approved by a lead Human Research Ethics Committee (Sydney Local Health District: 2019/ETH13297). The study will be conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. TRIAL REGISTRATION NUMBER ACTRN12620000048987.
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Affiliation(s)
- Benjamin Y Kong
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
- Department of Medical Oncology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Hao-Wen Sim
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Medical Oncology, The Kinghorn Cancer Centre, Darlinghurst, NSW, Australia
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | | | - Anna K Nowak
- Medical School, The University of Western Australia, Crawley, Western Australia, Australia
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, Perth, Australia
| | - Elizabeth J Hovey
- Department of Medical Oncology, Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Rosalind Jeffree
- Department of Neurosurgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Rosemary Harrup
- Cancer and Blood Services, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Jonathon Parkinson
- Department of Neurosurgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Hui K Gan
- Olivia Newton-John Cancer Research Institute, Austin Health, Heidelberg, Victoria, Australia
- School of Cancer Medicine, La Trobe University, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia
- Department of Medical Oncology, Olivia Newton-John Cancer and Wellness Centre, Austin Health, Heidelberg, VIC, Australia
| | - Mark B Pinkham
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sonia Yip
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Merryn Hall
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Emily Tu
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Candace Carter
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Eng-Siew Koh
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Radiation Oncology, Liverpool Cancer Therapy Centre, Liverpool, New South Wales, Australia
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Zarnie Lwin
- Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Anthony Dowling
- Department of Medicine, University of Melbourne Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia
- Department of Medical Oncology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Victoria, Australia
| | - John S Simes
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Craig Gedye
- Department of Medical Oncology, Calvary Mater Newcastle, Waratah, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton, New South Wales, Australia
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The Next Frontier in Health Disparities—A Closer Look at Exploring Sex Differences in Glioma Data and Omics Analysis, from Bench to Bedside and Back. Biomolecules 2022; 12:biom12091203. [PMID: 36139042 PMCID: PMC9496358 DOI: 10.3390/biom12091203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Sex differences are increasingly being explored and reported in oncology, and glioma is no exception. As potentially meaningful sex differences are uncovered, existing gender-derived disparities mirror data generated in retrospective and prospective trials, real-world large-scale data sets, and bench work involving animals and cell lines. The resulting disparities at the data level are wide-ranging, potentially resulting in both adverse outcomes and failure to identify and exploit therapeutic benefits. We set out to analyze the literature on women’s data disparities in glioma by exploring the origins of data in this area to understand the representation of women in study samples and omics analyses. Given the current emphasis on inclusive study design and research, we wanted to explore if sex bias continues to exist in present-day data sets and how sex differences in data may impact conclusions derived from large-scale data sets, omics, biospecimen analysis, novel interventions, and standard of care management.
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Wu J, Li XY, Liang J, Fang DL, Yang ZJ, Wei J, Chen ZJ. Network pharmacological analysis of active components of Xiaoliu decoction in the treatment of glioblastoma multiforme. Front Genet 2022; 13:940462. [PMID: 36046228 PMCID: PMC9420933 DOI: 10.3389/fgene.2022.940462] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/29/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Glioblastoma multiforme (GBM) is the most aggressive primary nervous system brain tumor. There is still a lack of effective methods to control its progression and recurrence in clinical treatment. It is clinically found that Xiaoliu Decoction (XLD) has the effect of treating brain tumors and preventing tumor recurrence. However, its mechanism is still unclear. Methods: Search the Traditional Chinese Medicine System Pharmacology Database (TCSMP) for efficient substances for the treatment of XLD in the treatment of GBM, and target the targeted genes of the effective ingredients to construct a network. At the same time, download GBM-related gene expression data from the TCGA and GTEX databases, screen differential expression bases, and establish a drug target disease network. Through bioinformatics analysis, the target genes and shared genes of the selected Chinese medicines are analyzed. Finally, molecular docking was performed to further clarify the possibility of XLD in multiple GBMs. Results: We screened 894 differentially expressed genes in GBM, 230 XLD active ingredients and 169 predicted targets of its active compounds, of which 19 target genes are related to the differential expression of GBM. Bioinformatics analysis shows that these targets are closely related to cell proliferation, cell cycle regulation, and DNA synthesis. Finally, through molecular docking, it was further confirmed that Tanshinone IIA, the active ingredient of XLD, was tightly bound to key proteins. Conclusion: To sum up, the results of this study suggest that the mechanism of XLD in the treatment of GBM involves multiple targets and signal pathways related to tumorigenesis and development. This study not only provides a new theoretical basis for the treatment of glioblastoma multiforme with traditional Chinese medicine, but also provides a new idea for the research and development of targeted drugs for the treatment of glioblastoma multiforme.
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Affiliation(s)
- Ji Wu
- Department of Neurosurgery, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China
| | - Xue-Yu Li
- Department of Neurosurgery, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China
| | - Jing Liang
- Department of Pediatrics, The Second Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Da-Lang Fang
- Department of Breast and Thyroid Surgery, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China
- *Correspondence: Da-Lang Fang, ; Zhao-Jian Yang, ; Jie Wei, ; Zhi-Jun Chen,
| | - Zhao-Jian Yang
- Department of Neurosurgery, Red Cross Hospital of Yulin City, Yulin, China
- *Correspondence: Da-Lang Fang, ; Zhao-Jian Yang, ; Jie Wei, ; Zhi-Jun Chen,
| | - Jie Wei
- Department of Hematology, People’s Hospital of Baise, Baise, China
- *Correspondence: Da-Lang Fang, ; Zhao-Jian Yang, ; Jie Wei, ; Zhi-Jun Chen,
| | - Zhi-Jun Chen
- Department of Neurosurgery, Red Cross Hospital of Yulin City, Yulin, China
- *Correspondence: Da-Lang Fang, ; Zhao-Jian Yang, ; Jie Wei, ; Zhi-Jun Chen,
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Mohile NA, Messersmith H, Gatson NTN, Hottinger AF, Lassman AB, Morton J, Ney D, Nghiemphu PL, Olar A, Olson J, Perry J, Portnow J, Schiff D, Shannon A, Shih HA, Strowd R, van den Bent M, Ziu M, Blakeley J. Therapy for Diffuse Astrocytic and Oligodendroglial Tumors in Adults: ASCO-SNO Guideline. Neuro Oncol 2021. [DOI: 10.1093/neuonc/noab279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Purpose
To provide guidance to clinicians regarding therapy for diffuse astrocytic and oligodendroglial tumors in adults.
Methods
ASCO and the Society for Neuro-Oncology convened an Expert Panel and conducted a systematic review of the literature.
Results
Fifty-nine randomized trials focusing on therapeutic management were identified.
Recommendations
Adults with newly diagnosed oligodendroglioma, isocitrate dehydrogenase (IDH)–mutant, 1p19q codeleted CNS WHO grade 2 and 3 should be offered radiation therapy (RT) and procarbazine, lomustine, and vincristine (PCV). Temozolomide (TMZ) is a reasonable alternative for patients who may not tolerate PCV, but no high-level evidence supports upfront TMZ in this setting. People with newly diagnosed astrocytoma, IDH-mutant, 1p19q non-codeleted CNS WHO grade 2 should be offered RT with adjuvant chemotherapy (TMZ or PCV). People with astrocytoma, IDH-mutant, 1p19q non-codeleted CNS WHO grade 3 should be offered RT and adjuvant TMZ. People with astrocytoma, IDH-mutant, CNS WHO grade 4 may follow recommendations for either astrocytoma, IDH-mutant, 1p19q non-codeleted CNS WHO grade 3 or glioblastoma, IDH-wildtype, CNS WHO grade 4. Concurrent TMZ and RT should be offered to patients with newly diagnosed glioblastoma, IDH-wildtype, CNS WHO grade 4 followed by 6 months of adjuvant TMZ. Alternating electric field therapy, approved by the US Food and Drug Administration, should be considered for these patients. Bevacizumab is not recommended. In situations in which the benefits of 6-week RT plus TMZ may not outweigh the harms, hypofractionated RT plus TMZ is reasonable. In patients age ≥ 60 to ≥ 70 years, with poor performance status or for whom toxicity or prognosis are concerns, best supportive care alone, RT alone (for MGMTpromoter unmethylated tumors), or TMZ alone (for MGMT promoter methylated tumors) are reasonable treatment options. Additional information is available at www.asco.org/neurooncology-guidelines.
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Affiliation(s)
- Nimish A Mohile
- Department of Neurology and Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Na Tosha N Gatson
- Banner MD Anderson Cancer Center, Phoenix, AZ, USA
- Geisinger Neuroscience Institute, Danville, PA, USA
| | - Andreas F Hottinger
- Department of Clinical Neurosciences and Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Jordan Morton
- University of Oklahoma Health Sciences, Oklahoma City, OK, USA
| | - Douglas Ney
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Jeffery Olson
- Emory University, Atlanta, GA, USA
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - James Perry
- City of Hope National Medical Center, Duarte, CA, USA
| | - Jana Portnow
- City of Hope National Medical Center, Duarte, CA, USA
| | - David Schiff
- University of Virginia Medical Center, Charlottesville, VA, USA
| | | | | | - Roy Strowd
- Wake Forest Baptist Health Medical Center, Winston-Salem, NC, USA
| | - Martin van den Bent
- The Brain Tumor Center at Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mateo Ziu
- INOVA Neurosciences and Inova Schar Cancer Institute, Falls Church, VA, USA
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Mohile NA, Messersmith H, Gatson NT, Hottinger AF, Lassman A, Morton J, Ney D, Nghiemphu PL, Olar A, Olson J, Perry J, Portnow J, Schiff D, Shannon A, Shih HA, Strowd R, van den Bent M, Ziu M, Blakeley J. Therapy for Diffuse Astrocytic and Oligodendroglial Tumors in Adults: ASCO-SNO Guideline. J Clin Oncol 2021; 40:403-426. [PMID: 34898238 DOI: 10.1200/jco.21.02036] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To provide guidance to clinicians regarding therapy for diffuse astrocytic and oligodendroglial tumors in adults. METHODS ASCO and the Society for Neuro-Oncology convened an Expert Panel and conducted a systematic review of the literature. RESULTS Fifty-nine randomized trials focusing on therapeutic management were identified. RECOMMENDATIONS Adults with newly diagnosed oligodendroglioma, isocitrate dehydrogenase (IDH)-mutant, 1p19q codeleted CNS WHO grade 2 and 3 should be offered radiation therapy (RT) and procarbazine, lomustine, and vincristine (PCV). Temozolomide (TMZ) is a reasonable alternative for patients who may not tolerate PCV, but no high-level evidence supports upfront TMZ in this setting. People with newly diagnosed astrocytoma, IDH-mutant, 1p19q non-codeleted CNS WHO grade 2 should be offered RT with adjuvant chemotherapy (TMZ or PCV). People with astrocytoma, IDH-mutant, 1p19q non-codeleted CNS WHO grade 3 should be offered RT and adjuvant TMZ. People with astrocytoma, IDH-mutant, CNS WHO grade 4 may follow recommendations for either astrocytoma, IDH-mutant, 1p19q non-codeleted CNS WHO grade 3 or glioblastoma, IDH-wildtype, CNS WHO grade 4. Concurrent TMZ and RT should be offered to patients with newly diagnosed glioblastoma, IDH-wildtype, CNS WHO grade 4 followed by 6 months of adjuvant TMZ. Alternating electric field therapy, approved by the US Food and Drug Administration, should be considered for these patients. Bevacizumab is not recommended. In situations in which the benefits of 6-week RT plus TMZ may not outweigh the harms, hypofractionated RT plus TMZ is reasonable. In patients age ≥ 60 to ≥ 70 years, with poor performance status or for whom toxicity or prognosis are concerns, best supportive care alone, RT alone (for MGMT promoter unmethylated tumors), or TMZ alone (for MGMT promoter methylated tumors) are reasonable treatment options. Additional information is available at www.asco.org/neurooncology-guidelines.
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Affiliation(s)
- Nimish A Mohile
- Department of Neurology and Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY
| | | | - Na Tosha Gatson
- Banner MD Anderson Cancer Center, Phoenix, AZ.,Geisinger Neuroscience Institute. Danville, PA
| | - Andreas F Hottinger
- Departments of Clinical Neurosciences and Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Jordan Morton
- University of Oklahoma Health Sciences, Oklahoma City, OK
| | - Douglas Ney
- University of Colorado School of Medicine, Aurora, CO
| | | | | | | | - James Perry
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Jana Portnow
- City of Hope National Medical Center, Duarte, CA
| | - David Schiff
- University of Virginia Medical Center, Charlottesville, VA
| | | | | | - Roy Strowd
- Wake Forest Baptist Health Medical Center, Winston-Salem, NC
| | - Martin van den Bent
- The Brain Tumor Center at Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mateo Ziu
- INOVA Neurosciences and Inova Schar Cancer Institute, Falls Church, VA
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McAleenan A, Kelly C, Spiga F, Kernohan A, Cheng HY, Dawson S, Schmidt L, Robinson T, Brandner S, Faulkner CL, Wragg C, Jefferies S, Howell A, Vale L, Higgins JPT, Kurian KM. Prognostic value of test(s) for O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation for predicting overall survival in people with glioblastoma treated with temozolomide. Cochrane Database Syst Rev 2021; 3:CD013316. [PMID: 33710615 PMCID: PMC8078495 DOI: 10.1002/14651858.cd013316.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Glioblastoma is an aggressive form of brain cancer. Approximately five in 100 people with glioblastoma survive for five years past diagnosis. Glioblastomas that have a particular modification to their DNA (called methylation) in a particular region (the O6-methylguanine-DNA methyltransferase (MGMT) promoter) respond better to treatment with chemotherapy using a drug called temozolomide. OBJECTIVES To determine which method for assessing MGMT methylation status best predicts overall survival in people diagnosed with glioblastoma who are treated with temozolomide. SEARCH METHODS We searched MEDLINE, Embase, BIOSIS, Web of Science Conference Proceedings Citation Index to December 2018, and examined reference lists. For economic evaluation studies, we additionally searched NHS Economic Evaluation Database (EED) up to December 2014. SELECTION CRITERIA Eligible studies were longitudinal (cohort) studies of adults with diagnosed glioblastoma treated with temozolomide with/without radiotherapy/surgery. Studies had to have related MGMT status in tumour tissue (assessed by one or more method) with overall survival and presented results as hazard ratios or with sufficient information (e.g. Kaplan-Meier curves) for us to estimate hazard ratios. We focused mainly on studies comparing two or more methods, and listed brief details of articles that examined a single method of measuring MGMT promoter methylation. We also sought economic evaluations conducted alongside trials, modelling studies and cost analysis. DATA COLLECTION AND ANALYSIS Two review authors independently undertook all steps of the identification and data extraction process for multiple-method studies. We assessed risk of bias and applicability using our own modified and extended version of the QUality In Prognosis Studies (QUIPS) tool. We compared different techniques, exact promoter regions (5'-cytosine-phosphate-guanine-3' (CpG) sites) and thresholds for interpretation within studies by examining hazard ratios. We performed meta-analyses for comparisons of the three most commonly examined methods (immunohistochemistry (IHC), methylation-specific polymerase chain reaction (MSP) and pyrosequencing (PSQ)), with ratios of hazard ratios (RHR), using an imputed value of the correlation between results based on the same individuals. MAIN RESULTS We included 32 independent cohorts involving 3474 people that compared two or more methods. We found evidence that MSP (CpG sites 76 to 80 and 84 to 87) is more prognostic than IHC for MGMT protein at varying thresholds (RHR 1.31, 95% confidence interval (CI) 1.01 to 1.71). We also found evidence that PSQ is more prognostic than IHC for MGMT protein at various thresholds (RHR 1.36, 95% CI 1.01 to 1.84). The data suggest that PSQ (mainly at CpG sites 74 to 78, using various thresholds) is slightly more prognostic than MSP at sites 76 to 80 and 84 to 87 (RHR 1.14, 95% CI 0.87 to 1.48). Many variants of PSQ have been compared, although we did not see any strong and consistent messages from the results. Targeting multiple CpG sites is likely to be more prognostic than targeting just one. In addition, we identified and summarised 190 articles describing a single method for measuring MGMT promoter methylation status. AUTHORS' CONCLUSIONS PSQ and MSP appear more prognostic for overall survival than IHC. Strong evidence is not available to draw conclusions with confidence about the best CpG sites or thresholds for quantitative methods. MSP has been studied mainly for CpG sites 76 to 80 and 84 to 87 and PSQ at CpG sites ranging from 72 to 95. A threshold of 9% for CpG sites 74 to 78 performed better than higher thresholds of 28% or 29% in two of three good-quality studies making such comparisons.
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Affiliation(s)
- Alexandra McAleenan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Claire Kelly
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Francesca Spiga
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hung-Yuan Cheng
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration West (ARC West) , University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Lena Schmidt
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Tomos Robinson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sebastian Brandner
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK
- Division of Neuropathology, The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Claire L Faulkner
- Bristol Genetics Laboratory, Pathology Sciences, Southmead Hospital, Bristol, UK
| | - Christopher Wragg
- Bristol Genetics Laboratory, Pathology Sciences, Southmead Hospital, Bristol, UK
| | - Sarah Jefferies
- Department of Oncology, Addenbrooke's Hospital, Cambridge, UK
| | - Amy Howell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration West (ARC West) , University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Kathreena M Kurian
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Medical School: Brain Tumour Research Centre, Public Health Sciences, University of Bristol, Bristol, UK
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Chelliah SS, Paul EAL, Kamarudin MNA, Parhar I. Challenges and Perspectives of Standard Therapy and Drug Development in High-Grade Gliomas. Molecules 2021; 26:1169. [PMID: 33671796 PMCID: PMC7927069 DOI: 10.3390/molecules26041169] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/05/2021] [Accepted: 02/06/2021] [Indexed: 12/18/2022] Open
Abstract
Despite their low incidence rate globally, high-grade gliomas (HGG) remain a fatal primary brain tumor. The recommended therapy often is incapable of resecting the tumor entirely and exclusively targeting the tumor leads to tumor recurrence and dismal prognosis. Additionally, many HGG patients are not well suited for standard therapy and instead, subjected to a palliative approach. HGG tumors are highly infiltrative and the complex tumor microenvironment as well as high tumor heterogeneity often poses the main challenges towards the standard treatment. Therefore, a one-fit-approach may not be suitable for HGG management. Thus, a multimodal approach of standard therapy with immunotherapy, nanomedicine, repurposing of older drugs, use of phytochemicals, and precision medicine may be more advantageous than a single treatment model. This multimodal approach considers the environmental and genetic factors which could affect the patient's response to therapy, thus improving their outcome. This review discusses the current views and advances in potential HGG therapeutic approaches and, aims to bridge the existing knowledge gap that will assist in overcoming challenges in HGG.
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Affiliation(s)
- Shalini Sundramurthi Chelliah
- Brain Research Institute Monash Sunway, Jeffrey Cheah School of Medicine and Health Science, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (S.S.C.); (E.A.L.P.); (M.N.A.K.)
- School of Science, Monash University Malaysia, Bandar Sunway 47500, Malaysia
| | - Ervin Ashley Lourdes Paul
- Brain Research Institute Monash Sunway, Jeffrey Cheah School of Medicine and Health Science, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (S.S.C.); (E.A.L.P.); (M.N.A.K.)
| | - Muhamad Noor Alfarizal Kamarudin
- Brain Research Institute Monash Sunway, Jeffrey Cheah School of Medicine and Health Science, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (S.S.C.); (E.A.L.P.); (M.N.A.K.)
| | - Ishwar Parhar
- Brain Research Institute Monash Sunway, Jeffrey Cheah School of Medicine and Health Science, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (S.S.C.); (E.A.L.P.); (M.N.A.K.)
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Giambattista J, Omene E, Souied O, Hsu FH. Modern Treatments for Gliomas Improve Outcome. CURRENT CANCER THERAPY REVIEWS 2020. [DOI: 10.2174/1573394715666191017153045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Glioma is the most common type of tumor in the central nervous system (CNS). Diagnosis
is through history, physical examination, radiology, histology and molecular profiles. Magnetic
resonance imaging is a standard workup for all CNS tumors. Multidisciplinary team management
is strongly recommended. The management of low-grade gliomas is still controversial
with regards to early surgery, radiotherapy, chemotherapy, or watchful waiting watchful waiting.
Patients with suspected high-grade gliomas should undergo an assessment by neurosurgeons for
the consideration of maximum safe resection to achieve optimal tumor debulking, and to provide
adequate tissue for histologic and molecular diagnosis. Post-operative radiotherapy and/or chemotherapy
are given depending on disease grade and patient performance. Glioblastoma are mostly
considered incurable. Treatment approaches in the elderly, pediatric population and recurrent
gliomas are discussed with the latest updates in the literature. Treatment considerations include
performance status, neurocognitive functioning, and co-morbidities. Important genetic mutations,
clinical trials and guidelines are summarized in this review.
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Affiliation(s)
| | - Egiroh Omene
- Vancouver Cancer Centre, BC Cancer Agency, Columbia, Vancouver, BC, Canada
| | - Osama Souied
- Vancouver Cancer Centre, BC Cancer Agency, Columbia, Vancouver, BC, Canada
| | - Fred H.C. Hsu
- Vancouver Cancer Centre, BC Cancer Agency, Columbia, Vancouver, BC, Canada
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Abstract
BACKGROUND Clinical practice guidelines suggest that magnetic resonance imaging (MRI) of the brain should be performed at certain time points or intervals distant from diagnosis (interval or surveillance imaging) of cerebral glioma, to monitor or follow up the disease; it is not known, however, whether these imaging strategies lead to better outcomes among patients than triggered imaging in response to new or worsening symptoms. OBJECTIVES To determine the effect of different imaging strategies (in particular, pre-specified interval or surveillance imaging, and symptomatic or triggered imaging) on health and economic outcomes for adults with glioma (grades 2 to 4) in the brain. SEARCH METHODS The Cochrane Gynaecological, Neuro-oncology and Orphan Cancers (CGNOC) Group Information Specialist searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase up to 18 June 2019 and the NHS Economic Evaluation Database (EED) up to December 2014 (database closure). SELECTION CRITERIA We included randomised controlled trials, non-randomised controlled trials, and controlled before-after studies with concurrent comparison groups comparing the effect of different imaging strategies on survival and other health outcomes in adults with cerebral glioma; and full economic evaluations (cost-effectiveness analyses, cost-utility analyses and cost-benefit analyses) conducted alongside any study design, and any model-based economic evaluations on pre- and post-treatment imaging in adults with cerebral glioma. DATA COLLECTION AND ANALYSIS We used standard Cochrane review methodology with two authors independently performing study selection and data collection, and resolving disagreements through discussion. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included one retrospective, single-institution study that compared post-operative imaging within 48 hours (early post-operative imaging) with no early post-operative imaging among 125 people who had surgery for glioblastoma (GBM: World Health Organization (WHO) grade 4 glioma). Most patients in the study underwent maximal surgical resection followed by combined radiotherapy and temozolomide treatment. Although patient characteristics in the study arms were comparable, the study was at high risk of bias overall. Evidence from this study suggested little or no difference between early and no early post-operative imaging with respect to overall survival (deaths) at one year after diagnosis of GBM (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.61 to 1.21; 48% vs 55% died, respectively; very low certainty evidence) and little or no difference in overall survival (deaths) at two years after diagnosis of GBM (RR 1.06, 95% CI 0.91 to 1.25; 86% vs 81% died, respectively; very low certainty evidence). No other review outcomes were reported. We found no evidence on the effectiveness of other imaging schedules. In addition, we identified no relevant economic evaluations assessing the efficiency of the different imaging strategies. AUTHORS' CONCLUSIONS The effect of different imaging strategies on survival and other health outcomes remains largely unknown. Existing imaging schedules in glioma seem to be pragmatic rather than evidence-based. The limited evidence suggesting that early post-operative brain imaging among GBM patients who will receive combined chemoradiation treatment may make little or no difference to survival needs to be further researched, particularly as early post-operative imaging also serves as a quality control measure that may lead to early re-operation if residual tumour is identified. Mathematical modelling of a large glioma patient database could help to distinguish the optimal timing of surveillance imaging for different types of glioma, with stratification of patients facilitated by assessment of individual tumour growth rates, molecular biomarkers and other prognostic factors. In addition, paediatric glioma study designs could be used to inform future research of imaging strategies among adults with glioma.
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Affiliation(s)
- Gerard Thompson
- University of EdinburghCentre for Clinical Brain SciencesChancellor’s Building FU201a49 Little France CrescentEdinburghScotlandUKEH16 4SB
| | - Theresa A Lawrie
- The Evidence‐Based Medicine Consultancy Ltd3rd Floor Northgate HouseUpper Borough WallsBathUKBA1 1RG
| | - Ashleigh Kernohan
- Newcastle UniversityInstitute of Health & SocietyBaddiley‐Clark Building, Richardson RoadNewcastle upon TyneUKNE2 4AA
| | - Michael D Jenkinson
- Institute of Translational MedicineUniversity of Liverpool & Department of NeurosurgeryThe Walton Centre NHS Foundation TrustLiverpoolMerseysideUK
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Malmström A, Łysiak M, Kristensen BW, Hovey E, Henriksson R, Söderkvist P. Do we really know who has an MGMT methylated glioma? Results of an international survey regarding use of MGMT analyses for glioma. Neurooncol Pract 2019; 7:68-76. [PMID: 32025325 PMCID: PMC6993038 DOI: 10.1093/nop/npz039] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Glioma O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status informs clinical decision making. Worldwide different methods and cutoff levels are used, which can lead to discordant methylation results. Methods We conducted an international survey to clarify which methods are regularly used and why. We also explored opinions regarding international consensus on methods and cutoff. Results The survey had 152 respondents from 25 countries. MGMT methylation status is determined for all glioblastomas in 37% of laboratories. The most common methods are methylation-specific polymerase chain reaction (msPCR) (37%) and pyrosequencing (34%). A method is selected for simplicity (56%), cost-effectiveness (50%), and reproducibility of results (52%). For sequencing, the number of CpG sites analyzed varies from 1–3 up to more than 16. For 50% of laboratories, the company producing the kit determines which CpG sites are examined, whereas 33% select the sites themselves. Selection of cutoff is equally distributed among a cutoff defined in the literature, by the local laboratory, or by the outside laboratory performing the analysis. This cutoff varies, reported from 1% to 30%, and in 1 laboratory tumor is determined as methylated in case of 1 methylated CpG site of 17 analyzed. Some report tumors as unmethylated or weakly vs highly methylated. An international consensus on MGMT methylation method and cutoff is warranted by 66% and 76% of respondents, respectively. The method preferred would be msPCR (45%) or pyrosequencing (42%), whereas 18% suggest next-generation sequencing. Conclusion Although analysis of MGMT methylation status is routine, there is controversy regarding laboratory methods and cutoff level. Most respondents favor development of international consensus guidelines.
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Affiliation(s)
- Annika Malmström
- Department of Advanced Home Care, Linköping University, Sweden.,Department of Clinical and Experimental Medicine, Linköping University, Sweden
| | - Małgorzata Łysiak
- Department of Clinical and Experimental Medicine, Linköping University, Sweden
| | - Bjarne Winther Kristensen
- Department of Pathology, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark
| | - Elizabeth Hovey
- Department of Medical Oncology, Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, Sydney, NSW, Australia.,University of New South Wales, Sydney, Australia
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Lawrie TA, Gillespie D, Dowswell T, Evans J, Erridge S, Vale L, Kernohan A, Grant R. Long-term neurocognitive and other side effects of radiotherapy, with or without chemotherapy, for glioma. Cochrane Database Syst Rev 2019; 8:CD013047. [PMID: 31425631 PMCID: PMC6699681 DOI: 10.1002/14651858.cd013047.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Gliomas are brain tumours arising from glial cells with an annual incidence of 4 to 11 people per 100,000. In this review we focus on gliomas with low aggressive potential in the short term, i.e. low-grade gliomas. Most people with low-grade gliomas are treated with surgery and may receive radiotherapy thereafter. However, there is concern about the possible long-term effects of radiotherapy, especially on neurocognitive functioning. OBJECTIVES To evaluate the long-term neurocognitive and other side effects of radiotherapy (with or without chemotherapy) compared with no radiotherapy, or different types of radiotherapy, among people with glioma (where 'long-term' is defined as at least two years after diagnosis); and to write a brief economic commentary. SEARCH METHODS We searched the following databases on 16 February 2018 and updated the search on 14 November 2018: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 11) in the Cochrane Library; MEDLINE via Ovid; and Embase via Ovid. We also searched clinical trial registries and relevant conference proceedings from 2014 to 2018 to identify ongoing and unpublished studies. SELECTION CRITERIA Randomised and non-randomised trials, and controlled before-and-after studies (CBAS). Participants were aged 16 years and older with cerebral glioma other than glioblastoma. We included studies where patients in at least one treatment arm received radiotherapy, with or without chemotherapy, and where neurocognitive outcomes were assessed two or more years after treatment. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias. We assessed the certainty of findings using the GRADE approach. MAIN RESULTS The review includes nine studies: seven studies were of low-grade glioma and two were of grade 3 glioma. Altogether 2406 participants were involved but there was high sample attrition and outcome data were available for a minority of people at final study assessments. In seven of the nine studies, participants were recruited to randomised controlled trials (RCTs) in which longer-term follow-up was undertaken in a subset of people that had survived without disease progression. There was moderate to high risk of bias in studies due to lack of blinding and high attrition, and in two observational studies there was high risk of selection bias. Paucity of data and risk of bias meant that evidence was of low to very low certainty. We were unable to combine results in meta-analysis due to diversity in interventions and outcomes.The studies examined the following five comparisons.Radiotherapy versus no adjuvant treatmentTwo observational studies contributed data. At the 12-year follow-up in one study, the risk of cognitive impairment (defined as cognitive disability deficits in at least five of 18 neuropsychological tests) was greater in the radiotherapy group (risk ratio (RR) 1.95, 95% confidence interval (CI) 1.02 to 3.71; n = 65); at five to six years the difference between groups did not reach statistical significance (RR 1.38, 95% CI 0.92 to 2.06; n = 195). In the other study, one subject in the radiotherapy group had cognitive impairment (defined as significant deterioration in eight of 12 neuropsychological tests) at two years compared with none in the control group (very low certainty evidence).With regard to neurocognitive scores, in one study the radiotherapy group was reported to have had significantly worse mean scores on some tests compared with no radiotherapy; however, the raw data were only given for significant findings. In the second study, there were no clear differences in any of the various cognitive outcomes at two years (n = 31) and four years (n = 15) (very low certainty evidence).Radiotherapy versus chemotherapyOne RCT contributed data on cognitive impairment at up to three years with no clear difference between arms (RR 1.43, 95% CI 0.36 to 5.70, n = 117) (low-certainty evidence).High-dose radiotherapy versus low-dose radiotherapyOnly one of two studies reporting this comparison contributed data, and at two and five years there were no clear differences between high- and low-dose radiotherapy arms (very low certainty evidence).Conventional radiotherapy versus stereotactic conformal radiotherapyOne study involving younger people contributed limited data from the subgroup aged 16 to 25 years. The numbers of participants with neurocognitive impairment at five years after treatment were two out of 12 in the conventional arm versus none out of 11 in the stereotactic conformal radiotherapy arm (RR 4.62, 95% CI 0.25 to 86.72; n = 23; low-certainty evidence).Chemoradiotherapy versus radiotherapyTwo RCTs tested for cognitive impairment. One defined cognitive impairment as a decline of more than 3 points in MMSE score compared with baseline and reported data from 2-year (110 participants), 3-year (91 participants), and 5-year (57 participants) follow-up with no clear difference between the two arms at any time point. A second study did not report raw data but measured MMSE scores over five years in 126 participants at two years, 110 at three years, 69 at four years and 53 at five years. Authors concluded that there was no difference in MMSE scores between the two study arms (P = 0.4752) (low-certainty evidence).Two RCTs reported quality of life (QoL) outcomes for this comparison. One reported no differences in Brain-QoL scores between study arms over a 5-year follow-up period (P = 0.2767; no raw data were given and denominators were not stated). The other trial reported that the long-term results of health-related QoL showed no difference between the arms but did not give the raw data for overall HRQoL scores (low-certainty evidence).We found no comparative data on endocrine dysfunction; we planned to develop a brief economic commentary but found no relevant economic studies for inclusion. AUTHORS' CONCLUSIONS Radiotherapy for gliomas with a good prognosis may increase the risk of neurocognitive side effects in the long term; however the magnitude of the risk is uncertain. Evidence on long-term neurocognitive side effects associated with chemoradiotherapy is also uncertain. Neurocognitive assessment should be an integral part of long-term follow-up in trials involving radiotherapy for lower-grade gliomas to improve the certainty of evidence regarding long-term neurocognitive effects. Such trials should also assess other potential long-term effects, including endocrine dysfunction, and evaluate costs and cost effectiveness.
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Affiliation(s)
- Theresa A Lawrie
- 1st Floor Education Centre, Royal United HospitalCochrane Gynaecological, Neuro‐oncology and Orphan Cancer GroupCombe ParkBathUKBA1 3NG
| | - David Gillespie
- Western General HospitalDepartment of Neuropsychology133 Grange LoanEdinburghUKEH9 2HL
| | - Therese Dowswell
- The University of LiverpoolC/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Jonathan Evans
- University of GlasgowSchool of Psychological MedicineGartnavel Royal Hospital1055 Great Western RoadGlasgowUKG12 0XH
| | - Sara Erridge
- NHS LothianEdinburgh Cancer CentreWestern General HospitalCrewe RoadEdinburghUKEH4 2XU
| | - Luke Vale
- Newcastle UniversityInstitute of Health & SocietyBaddiley‐Clarke Building, Richardson RoadNewcastle upon TyneUKNE2 4AX
| | - Ashleigh Kernohan
- Newcastle UniversityInstitute of Health & SocietyBaddiley‐Clarke Building, Richardson RoadNewcastle upon TyneUKNE2 4AX
| | - Robin Grant
- Western General HospitalEdinburgh Centre for Neuro‐Oncology (ECNO)Crewe RoadEdinburghUKEH4 2XU
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12
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Lawrie TA, Kernohan A, Jenkinson MD, Thompson G. Interval brain imaging for adults with cerebral glioma. Hippokratia 2018. [DOI: 10.1002/14651858.cd013137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Theresa A Lawrie
- 1st Floor Education Centre, Royal United Hospital; Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group; Combe Park Bath UK BA1 3NG
| | - Ashleigh Kernohan
- Newcastle University; Institute of Health & Society; Baddiley-Clark Building, Richardson Road Newcastle upon Tyne UK NE2 4AA
| | - Michael D Jenkinson
- Institute of Translational Medicine; University of Liverpool & Department of Neurosurgery The Walton Centre NHS Foundation Trust Liverpool Merseyside UK
| | - Gerard Thompson
- University of Edinburgh; Centre for Clinical Brain Sciences; Chancellor’s Building FU201a 49 Little France Crescent Edinburgh Scotland UK EH16 4SB
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