The Neurologic Assessment in Neuro-Oncology (NANO) Scale as an Assessment Tool for Survival in Patients With Primary Glioblastoma

Translation and validation of the Neurological Assessment in Neuro-Oncology scale to Brazilian Portuguese

Introduction

The Neurological Assessment for Neuro-Oncology (NANO) scale was elaborated to assess neurologic function in integration with radiological criteria to evaluate neuro-oncological patients in clinical setting and enable the standardization of neurological assessment in clinical trials. The objective of this study is the translation to Brazilian Portuguese and transcultural adaptation of NANO scale in patients with the diagnosis of glioblastoma, brain metastasis and low-grade glioma.

Methods

Patients with diagnosis of glioblastoma, brain metastasis, and low-grade glioma were prospectively evaluated between July 2019 and July 2021. The process of translating and cross-culturally adapting the NANO scale included: translation from English to Portuguese, synthesis and initial revision by an expert committee, back-translation from Portuguese to English, a second revision by the expert committee, and the application of the NANO scale. Regarding the reliability of the NANO scale, Cronbach's alpha was employed to measure the internal consistency of all scale items and assess the impact of item deletion. Additionally, Spearman's correlation test was used to evaluate the convergent validity between the NANO scale and Karnofsky Performance Scale (KPS).

Results

One hundred and seventy-four patients were evaluated. A statistically significant inverse relation (p < 0.001) between KPS and NANO scale was founded. The Cronbach's alpha values founded for NANO scale were 0.803 for glioblastoma, 0.643 for brain metastasis, and 0.482 for low grade glioma.

Discussion

The NANO scale Brazilian Portuguese version proves to be reproducible and valid to evaluate neuro-oncological patients with glioblastoma and brain metastasis, presenting a strong correlation with KPS scale. Further studies are warranted to assess the validity and reliability of the scale in patients diagnosed with low-grade glioma.

A Systematic Review and Meta-Analysis of Supramarginal Resection versus Gross Total Resection in Glioblastoma: Can We Enhance Progression-Free Survival Time and Preserve Postoperative Safety?

To date, gross total resection (GTR) of the contrast-enhancing area of glioblastoma (GB) is the benchmark treatment regarding surgical therapy. However, GB infiltrates beyond those margins, and most tumors recur in close proximity to the initial resection margin. It is unclear whether a supramarginal resection (SMR) enhances progression-free survival (PFS) time without increasing the incidence of postoperative surgical complications. The aim of the present meta-analysis was to investigate SMR with regard to PFS and postoperative surgical complications. We searched for eligible studies comparing SMR techniques with conventional GTR in PubMed, Cochrane Library, Web of Science, and Medline databases. From 3158 initially identified records, 11 articles met the criteria and were included in our meta-analysis. Our results illustrate significantly prolonged PFS time in SMR compared with GTR (HR: 11.16; 95% CI: 3.07–40.52, p = 0.0002). The median PFS of the SMR arm was 8.44 months (95% CI: 5.18–11.70, p < 0.00001) longer than the GTR arm. The rate of postoperative surgical complications (meningitis, intracranial hemorrhage, and CSF leaks) did not differ between the SMR group and the GTR group. SMR resulted in longer median progression-free survival without a negative postoperative surgical risk profile. Multicentric prospective randomized trials with a standardized definition of SMR and analysis of neurologic functioning and health-related quality of life are justified and needed to improve the level of evidence.

Metabolomic analysis provides new insights into the heat-hardening response of Manila clam (Ruditapes philippinarum) to high temperature stress

The temperature has always been a key environmental factor in Manila clam (Ruditapes philippinarum) culture. In this study, the Manila clam was treated to different temperature pre-heat (28 °C, 30 °C) and gained heat tolerance after recover of 12 h, and a survival rate (14.7 %-49.1 %) advantage after high temperature challenge (30 and 32 °C). To further investigate the physiological and metabolism changes in Manila clam that had experienced a heat stress, non-targeted metabolomics (LC-MS/MS) was used to analyze the metabolic responses of gills in three group Manila clams during the heat challenge. Metabolic profiles revealed that high temperature caused changes in fatty acid composition, energy metabolism, antioxidant metabolites, hydroxyl compounds, and amino acids in heat-hardened clams compared to non-hardened clams. We found a number of significantly enriched pathways, including cAMP signaling pathway, serotonergic synapse, and biosynthesis of unsaturated fatty acids in heat-hardened Manila clam compared with non-hardened and untreated Manila clam. After a brief high temperature treatment, the physiological maintenance ability of Manila clam was improved. Combined with metabolomics analysis, heat hardening treatment may improve the energy metabolism and antioxidant ability of Manila clam. These results provide new insights into the cellular and metabolic responses of Manila clams following high temperature stress.

MRI Response Assessment in Glioblastoma Patients Treated with Dendritic-Cell-Based Immunotherapy

Introduction: In this post hoc analysis we compared various response-assessment criteria in newly diagnosed glioblastoma (GB) patients treated with tumor lysate-charged autologous dendritic cells (Audencel) and determined the differences in prediction of progression-free survival (PFS) and overall survival (OS). Methods: 76 patients enrolled in a multicenter phase II trial receiving standard of care (SOC, n = 40) or SOC + Audencel vaccine (n = 36) were included. MRI scans were evaluated using MacDonald, RANO, Vol-RANO, mRANO, Vol-mRANO and iRANO criteria. Tumor volumes (T1 contrast-enhancing as well as T2/FLAIR volumes) were calculated by semiautomatic segmentation. The Kruskal-Wallis-test was used to detect differences in PFS among the assessment criteria; for correlation analysis the Spearman test was used. Results: There was a significant difference in median PFS between mRANO (8.6 months) and Vol-mRANO (8.6 months) compared to MacDonald (4.0 months), RANO (4.2 months) and Vol-RANO (5.4 months). For the vaccination arm, median PFS by iRANO was 6.2 months. There was no difference in PFS between SOC and SOC + Audencel. The best correlation between PFS/OS was detected for mRANO (r = 0.65) and Vol-mRANO (r = 0.69, each p < 0.001). A total of 16/76 patients developed a pure T2/FLAIR progressing disease, and 4/36 patients treated with Audencel developed pseudoprogression. Conclusion: When comparing different response-assessment criteria in GB patients treated with dendritic cell-based immunotherapy, the best correlation between PFS and OS was observed for mRANO and Vol-mRANO. Interestingly, iRANO was not superior for predicting OS in patients treated with Audencel.

Hydrocephalus Shunting in Supratentorial Glioblastoma: Functional Outcomes and Management

Background

Glioblastoma is the most common and the most challenging to treat adult primary central nervous system tumor. Although modern management strategies modestly improved the overall survival, the prognosis remains dismal associated with poor life quality and the clinical course often dotted by treatment side effects and cognitive decline. Functional deterioration might be caused by obstructive or communicating hydrocephalus but due to poor overall prognosis surgical treatment options are often limited and its optimal management strategies remain elusive. We aimed to investigate risk factors, treatment options and outcomes for tumor-associated hydrocephalus in a contemporary 10 years cohort of glioblastoma patients.

Methods

We reviewed electronic health records of 1800 glioblastoma patients operated at the Department of Neurosurgery, Medical Center – University of Freiburg from 2009 to 2019. Demographics, clinical characteristics and radiological features were analyzed. Univariate analysis for nominal variables was performed either by Fisher’s exact test or Chi-square test, as appropriate.

Results

We identified 39 glioblastoma patients with symptomatic communicating hydrocephalus treated by ventricular shunting (incidence 2.1%). Opening of the ventricular system during a previous tumor resection was associated with symptomatic hydrocephalus (p<0.05). There was also a trend toward location (frontal and temporal) and larger tumor volume. Number of craniotomies before shunting was not considered as a risk factor. Shunting improved hydrocephalus symptoms in 95% of the patients and Karnofsky Performance Score (KPS) could be restored after shunting. Of note, 75% of the patients had a post-shunting oncological treatment such as radiotherapy or chemotherapy, most prevalently chemotherapy. Infection (7.7%) and over- or under drainage (17.9%) were the most common complications requiring shunt revision in ten patients (25.6%), No peritoneal metastasis was found. The median overall survival (OS) was 385 days and the median post shunting survival was 135 days.

Conclusion

Ventricular system opening was identified as a risk factor for communicating hydrocephalus in glioblastoma patients. Although glioblastoma treatment remains challenging, shunting improved hydrocephalus-related functional status and may be considered even in a palliative setting for symptom relief.

The Prognostic Value of NANO Scale Assessment in IDH-Wild-Type Glioblastoma Patients

Background

IDH-wild-type glioblastoma (GBM) is the most frequent brain-derived malignancy. Despite intense research efforts, it is still associated with a very poor prognosis. Several parameters were identified as prognostic, including general physical performance. In neuro-oncology (NO), special emphasis is put on focal deficits and cognitive (dys-)function. The Neurologic Assessment in Neuro-Oncology (NANO) scale was proposed in order to standardize the assessment of neurological performance in NO. This study evaluated whether NANO scale assessment provides prognostic information in a standardized collective of GBM patients.

Methods

The records of all GBM patients treated between 2014 and 2019 at our facility were retrospectively screened. Inclusion criteria were age over 18 years, at least 3 months postoperative follow-up, and preoperative and postoperative cranial magnetic resonance imaging. The NANO scale was assessed pre- and postoperatively as well as at 3 months follow-up. Univariate and multivariate survival analyses were carried to investigate the prognostic value.

Results

One hundred and thirty-one patients were included. In univariate analysis, poor postoperative neurological performance (HR 1.13, p = 0.004), poor neurological performance at 3 months postsurgery (HR 1.37, p < 0.001), and neurological deterioration during follow-up (HR 1.38, p < 0.001), all assessed via the NANO scale, were associated with shorter survival. In multivariate analysis including other prognostic factors such as the extent of resection, adjuvant treatment regimen, or age, NANO scale assessment at 3 months postoperative follow-up was independently associated with survival prediction (HR 1.36, p < 0.001). The optimal NANO scale cutoff for patient stratification was 3.5 points.

Conclusion

Neurological performance assessment employing the NANO scale might provide prognostic information in patients suffering from GBM.

A Microfluidics-Based Scalable Approach to Generate Extracellular Vesicles with Enhanced Therapeutic MicroRNA Loading for Intranasal Delivery to Mouse Glioblastomas

Extracellular vesicles (EVs), including exosomes and microvesicles derived from different cell sources, are used as promising nanovesicles for delivering therapeutic microRNAs (miRNAs) and drugs in cancer therapy. However, their clinical translation is limited by the quantity, size heterogeneity, and drug or small RNA loading efficiency. Herein, we developed a scalable microfluidic platform that can load therapeutic miRNAs (antimiRNA-21 and miRNA-100) and drugs while controlling the size of microfluidically processed EVs (mpEVs) using a pressure-based disruption and reconstitution process. We prepared mpEVs of optimal size using microvesicles isolated from neural stem cells engineered to overexpress CXCR4 receptor and characterized them for charge and miRNA loading efficiency. Since the delivery of therapeutic miRNAs to brain cancer is limited by the blood-brain barrier (BBB), we adopted intranasal administration of miRNA-loaded CXCR4-engineered mpEVs in orthotopic GBM mouse models and observed a consistent pattern of mpEVs trafficking across the nasal epithelia, bypassing the BBB into the intracranial compartment. In addition, the CXCR4-engineered mpEVs manifested selective tropism toward GBMs by stromal-derived factor-1 chemotaxis to deliver their miRNA cargo. The delivered miRNAs sensitized GBM cells to temozolomide, resulting in prominent tumor regression, and improved the overall survival of mice. A simple and efficient approach of packaging miRNAs in mpEVs using microfluidics, combined with a noninvasive nose-to-brain delivery route presents far-reaching potential opportunities to improve GBM therapy in clinical practice.

Assessment of neurological function using the National Institute of Health Stroke Scale in patients with gliomas

Background

The evaluation of treatment response in patients with gliomas is performed using the Response Assessment in Neuro-Oncology (RANO) criteria. These criteria are based on cerebral magnetic resonance imaging (MRI), steroid use, and neurological function. However, a standardized tool for evaluating neurological function was lacking. We compared changes in the National Institute of Health Stroke Scale (NIHSS) to changes in the RANO categories to determine the relationship between clinical and neuroradiological findings.

Methods

We reviewed data on all adult patients with supratentorial gliomas WHO grade II-IV who were treated at the Cantonal Hospital St. Gallen from 2008 to 2015. The NIHSS was performed prospectively at baseline and at 3-month intervals simultaneously to MRI. Associations between changes in the NIHSS and RANO categories were assessed using the Stuart-Maxwell test.

Results

Our cohort consisted of 61 patients from which 471 observations were analyzed. The most common histological diagnosis was glioblastoma (49.2%). In total, 74% of RANO categories and 81% of the NIHSS scores remained stable on follow-up. Statistically, contemporaneous changes in the RANO category did not correlate with changes in the NIHSS (P < .0001).

Conclusion

The application of the NIHSS is easy and feasible in the heterogeneous population of glioma patients. In our cohort, the RANO categories did not reflect contemporaneous changes in the NIHSS. A validated clinical outcome measure with a well-defined minimal clinically important difference is warranted in neuro-oncological research and clinical practice.

Surgical strategies for older patients with glioblastoma

Objective

While adjuvant treatment regimens have been modified for older patients with glioblastoma (GBM), surgical strategies have not been tailored.

Methods

Clinical data of 48 consecutive patients aged 70 years or older, who underwent surgical resection for GBM with intraoperative ultrasonography (IoUS) alone or combination with intraoperative MRI (IoMRI) at Yale New Haven Hospital were retrospectively reviewed. Variables were analyzed, and comparative analyses were performed.

Results

The addition of IoMRI was not superior to IoUS alone in terms of overall survival (OS) (P = 0.306), Karnofsky Performance Score (KPS) at postoperative 6 weeks (P = 0.704) or extent of resection (P = 0.263). Length of surgery (LOSx), however, was significantly longer (P = 0.0002) in the IoMRI group. LOSx (P = 0.015) and hospital stay (P = 0.025) were predictors of postoperative complications. Increased EOR (GTR or NTR) (P = 0.030), postoperative adjuvant treatment (P < 0.0001) and postoperative complications (P = 0.006) were predictive for OS. Patients with relatively lower preoperative KPS scores (<70) showed significant improvement at postoperative 6 weeks (P<0.0001). Patients with complications (P = 0.038) were more likely to have lower KPS at postoperative 6 weeks.

Conclusions

Aggressive management with surgical resection should be considered in older patients with GBM, even those with relatively poor KPS. The use of ioMRI in this population does not appear to confer any measurable benefit over ioUS in experienced hands, but prolongs the length of surgery significantly, which is a preventable prognostic factor for impeding care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11060-021-03862-z.

The Effects of Administrated Dexamethasone on Neurologic Assessment in Neuro-oncology Scale in Patients with Intracranial Tumors

BACKGROUND: In intracranial tumors, glucocorticoids are the main therapy to treat peritumoral edema. Neurologic Assessment in Neuro-Oncology (NANO) score is an instrument that can assess neurological function objectively and practically in patients with intracranial tumors. AIM: This study aims to determine the effect of dexamethasone administration on the NANO score of intracranial tumor patients. METHODS: This study was a pre-experimental study with a pre and post-test design at the H. Adam Malik General Hospital in Medan from March to September 2020. The study population was intracranial tumor patients. The research subject were 37 subjects taken consecutively. Treated with dexamethasone injection, then examined the NANO score before and after receiving dexamethasone injection on days 1, 2, and 3. Statistical analysis with Friedman test. RESULTS: Based on the demographic characteristics of the research subjects, the mean age was 53.29 ± 8.5 years. Most of the research subjects were male (54.1%) while female (45.9%). Most types of intracranial tumors were secondary tumors (59.5%) while primary tumors (40.5%). The significant effect of dexamethasone on NANO score in patients with intracranial tumors (p < 0.001). CONCLUSION: There is an effect of dexamethasone on the NANO score of patients with intracranial tumors.

New Enhancement beyond Radiation Field Improves Survival Prediction in Patients with Post-Treatment High-Grade Glioma

The imaging signs which can accurately predict survival prognosis after standard treatment of high-grade glioma (HGG) are highly desirable. This study aims to explore the role of new enhancement beyond radiation field (NERF) in the survival prediction in patients with post-treatment HGG. The present study included 142 pathologically confirmed HGG patients who had received standard treatment. NERF, as well as other conventional MR findings and clinical variables, were included in univariate and multivariate analyses for evaluating their impactions on progression-free survival (PFS) and overall survival (OS). Univariate analysis showed that histological grade (p=0.008) and NERF (p=0.001) were the prognostic variables for poor PFS, whereas histological grade (p=0.017), NERF (p=0.001), and new subventricular zone enhancement (nSVZE) (p=0.001) were prognostic variables for poor OS. The multivariate analysis showed that NERF (HR 3.93; 95% CI 1.93-8.01; p=0.001) and nSVZE (HR 3.92; 95% CI 1.95-7.89; p=0.001) were the prognostic variables for poor OS. However, only nSVZE was (HR 3.29; 95% CI 2.04-5.28; p=0.001) the prognostic variable for poor PFS. When combining the NERF with the clinical and other MR variables, the highest AUC (0.924) and specificity (0.899) for predicting poor OS were achieved. The location of new developed enhancements relevant to high dose radiation field appears to be the main determinant of their prognostic value. Our results suggest that the new enhancement beyond radiation field can improve the survival prediction in patients with HGG after standard treatment.

Prognostic value of modified Glasgow prognostic score in recurrent high-grade glial tumors treated with systemic treatment

OBJECTIVES

Malignant high-grade gliomas are the most common and aggressive type of primary brain tumor. We aimed to evaluate the prognostic value of modified Glasgow Prognostic Score (mGPS), which is combination of C-reactive protein (CRP) and albumin, in recurrent high-grade glioma patients treated with systemic treatment.

PATIENTS AND METHODS

Data of 85 patients with recurrent high-grade glioma who received systemic treatment and followed in our clinic between 2012 and 2018 was retrospectively collected and analyzed. Patients were grouped according to mGPS criteria: mGPS-0: CRP < 10 mg/L and albumin >3.5 g/dL; mGPS-1: CRP < 10 mg/L and albumin <3.5 g/dL or CRP > 10 mg/L and albumin >3.5 g/dL; and mGPS-2: CRP > 10 mg/L and albumin <3.5 mg/L. We investigated the prognostic role of mGPS groups, mutations and survival outcomes.

RESULTS

There were 42 (49.4 %), 25 (29.6 %), and 18 (21 %) patients in mGPS-0, mGPS-1, and mGPS-2 groups, respectively. Median follow-up duration was 10 months (1-70 months). Median OS was 8.1 months. According to mGPS-0, -1 and -2; median OS was 13.8 months, 7.3 months and 3.6 months respectively (p = 0.003). mGPS, ATRX and IDH-1 mutation status, and ECOG PS were found to be independent prognostic factors for OS.

CONCLUSION

In our study, mGPS was found to be an independent prognostic factor in patients with recurrent high-grade gliomas. If validated, mGPS can be used as an objective, easily calculated, cheap, and readily available prognostic model in routine practice.

The prognostic value of peri-operative neurological performance in glioblastoma patients

BACKGROUND

IDH-wild-type glioblastoma (GBM) is a disease with devastating prognosis. First-line therapy consists of gross total resection and adjuvant radiotherapy with concomitant temozolomide. Several clinical parameters have been identified to provide prognostic value. We investigated whether peri-operative overall neurological performance could also be used to evaluate patients' prognosis.

METHODS

All patients with histologically diagnosed GBM between 2014 and 2017 over 18 years and MRI within 72 h after surgery were reviewed. To quantify neurological performance, the medical research council neurological performance score (MRC-NPS) was used. Univariate analysis with Kaplan-Meier estimate and log-rank test was performed. Survival prediction and multivariate analysis were performed employing Cox proportional hazard regression.

RESULTS

One hundred thirty-nine patients were included. In univariate analysis, survival decreased with increasing post-operative MRC-NPS scale. Moreover, post-operative MRC-NPS of 4 was statistically significant associated with reduced overall survival when analyzed for complete (p = 0.027) and partial resection (p = 0.002) as well as unilobar (p = 0.003) and multilobar tumor location (p < 0.0005). In multivariate analysis, extent of resection (hazard ratio (HR) 3.142), adjuvant therapy regimen (HR 3.001), tumor location (HR 2.005), and post-operative MRC-NPS (HR 2.310) had significant influence on overall survival.

CONCLUSION

We propose the post-operative neurological performance as an independent prognostic factor for GBM patients.

Biopsy Confirmed Glioma Recurrence Predicted by Multi-Modal Neuroimaging Metrics

Histopathological verification is currently required to differentiate tumor recurrence from treatment effects related to adjuvant therapy in patients with glioma. To bypass the complications associated with collecting neural tissue samples, non-invasive classification methods are needed to alleviate the burden on patients while providing vital information to clinicians. However, uncertainty remains as to which tissue features on magnetic resonance imaging (MRI) are useful. The primary objective of this study was to quantitatively assess the reliability of combining MRI and diffusion tensor imaging metrics to discriminate between tumor recurrence and treatment effects in histopathologically identified biopsy samples. Additionally, this study investigates the noise adjuvant radiation therapy introduces when discriminating between tissue types. In a sample of 41 biopsy specimens, from a total of 10 patients, we derived region-of-interest samples from MRI data in the ipsilateral hemisphere that encompassed biopsies obtained during resective surgery. This study compares normalized intensity values across histopathology classifications and contralesional volumes reflected across the midline. Radiation makes noninvasive differentiation of abnormal-nontumor tissue to tumor recurrence much more difficult. This is because radiation exhibits opposing behavior on key MRI modalities: specifically, on post-contrast T1, FLAIR, and GFA. While radiation makes noninvasive differentiation of tumor recurrence more difficult, using a novel analysis of combined MRI metrics combined with clinical annotation and histopathological correlation, we observed that it is possible to successfully differentiate tumor tissue from other tissue types. Additional work will be required to expand upon these findings.